Post Polio Syndrome - Management & Treatment in Primary

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Physiotherapy and Post Polio Syndrome 21 Figure 1: Diagram showing the neuromuscular effects of polio and post-polio syndrome A B C D E (a) Normal motor units showing healthy motorneurons, their axons and the muscle fibres they innervate. (b) Initial polio virus with varying numbers of motorneuron death and denervation of their muscle fibres (dotted line). (c) Recovery from polio. Axons from surviving motorneurons sprout new fibres to innervate the denervated muscle fibres. (d) Early post-polio syndrome. New loss of nerve fibres and muscle fibre denervation. (e) Late post-polio syndrome with further loss of nerve fibres and muscle fibre denervation. Reduced muscular capacity in prior polio patients leads to a higher relative effort during daily activities and higher requirements of energy expenditure. 9 The energy cost of walking has been shown to be significantly higher in subjects with PPS than in healthy subjects and is strongly related to the extent of muscle weakness in the lower extremities. PPS subjects can use up to 40% more energy than healthy controls per distance covered. 10 Manual muscle testing using the MRC (Oxford) grading of skeletal muscle should be performed periodically. 11 More objective examination of muscle force using a dynamometer or similar device is highly desirable. This provides much more sensitive information and allows more early detection of muscle weakness. 12 Some systems such as isokinetic dynamometers and strain gauge tensiometers also allow detailed examination of muscle endurance (motor fatigue) which may be required if the patient complains of fatigue. Care should be taken when assessing muscle strength not to over fatigue the patient or induce muscle cramp. Also the physiotherapist should pay particular attention to trick PPS Mngt and Treat.indb 21 02/07/2007 16:07:50
22 Post Polio Syndrome movements that might occur secondary to muscle weakness, and note surgical procedures such as joint fusion or tendon transfers that may have occurred in the past and affect strength testing. Musculoskeletal A standard musculoskeletal examination should be performed with assessment of areas of pain identified in the subjective assessment. Range of movement of joints should be recorded objectively and a detailed postural examination performed as deformity can change with time. A detailed biomechanical evaluation should be incorporated as complex biomechanical problems are frequent. Pain is one of the most commonly described symptoms in prior polio patients with 38% to 86% reporting muscle pain and 42% to 80% joint pain. Risk factors for pain are summarised in Box 3. box 3: risk FaCtors For Pain Female gender Weaker lower extremities Weaker at time of onset Younger at time of onset Higher activity / mobility levels Higher exertion on activity Nerve compression syndromes, including carpal tunnel syndrome commonly occur. 6 Muscle pain (myalgia) is more frequently reported in the lower limbs 13 and can be due to cramps, fasiculations or muscle overuse. It can occur at rest but is mostly reported on activity. 14 Those with muscle pain have been shown to have higher severity and duration of fatigue, and lower scores on the SF-36. 15 Joint pain can be due to overuse of joints, the use of mobility aids and abnormal biomechanics. Conditions associated with chronic musculoskeletal wear and tear such as osteoarthritis, bursitis, tendonitis and myofascial pain are common. Pain in the legs and low back occurs more commonly in patients who are independently ambulating, while upper limb pain affects those who use crutches or manual wheelchairs. 6, 16 The shoulders, knees, lower back, and ankles /feet are the most frequently reported sites of pain. 17 Pain is more commonly reported in those with higher activity intensity levels and higher perceived exertion ratings suggesting that polio survivors who are more active experience more pain. 17 Many also experience significant PPS Mngt and Treat.indb 22 02/07/2007 16:07:50
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