Post-polio syndrome: Pathophysiological hypotheses, diagnosis criteria, medication therapeutics

Quality appraisal of clinical practice guidelines for motor neuron diseases or related disorders using the AGREE II instrument

Objectives

This study aimed to systematically assess the quality of CPGs for motor neuron diseases (MNDs) or related disorders and identify the gaps that limit evidence-based practice.

Methods

Four scientific databases and six guideline repositories were searched for eligible CPGs. Three researchers assessed the eligible CPGs using the Appraisal of Guidelines Research and Evaluation II instrument. The distribution of the level of evidence and strength of recommendation of these CPGs were determined. The univariate regression analysis was used to explore the characteristic factors affecting the quality of CPGs.

Results

Fifteen CPGs met the eligibility criteria: 10 were for MND and 5 were for spinal muscular atrophy. The mean overall rating score was 44.5%, and only 3 of 15 CPGs were of high quality. The domains that achieved low mean scores were applicability (24.4%), rigor of development (39.9%), and stakeholder involvement (40.3%). Most recommendations were based on low-quality evidence and had a weak strength. The CPGs that were updated, meant for adults, and evidence based, and used a CPG quality tool and a grading system were associated with higher scores in certain specific domains and overall rating.

Conclusion

The overall quality of CPGs for MNDs or related disorders was poor and recommendations were largely based on low-quality evidence. Many areas still need improvement to develop high-quality CPGs, and the use of CPG quality tools should be emphasized. A great deal of research on MNDs or related disorders is still needed to fill the large evidence gap.

Combating a resurgence of poliomyelitis through public health surveillance and vaccination

Poliomyelitis, or polio, is a highly infectious disease and can result in permanent flaccid paralysis of the limbs. Singapore was certified polio-free by the World Health Organization (WHO) on 29 October 2000, together with 36 other countries in the Western Pacific Region. The last imported case of polio in Singapore was in 2006. Fortunately, polio is vaccine-preventable—the world saw the global eradication of wild poliovirus types 2 and 3 achieved in 2015 and 2019, respectively. However, in late 2022, a resurgence of paralytic polio cases from vaccine-derived poliovirus (VDPV) was detected in countries like Israel and the US (specifically, New York); VDPV was also detected during routine sewage water surveillance with no paralysis cases in London, UK. Without global eradication, there is a risk of re-infection from importation and spread of wild poliovirus or VDPV, or new emergence and circulation of VDPV. During the COVID-19 pandemic, worldwide routine childhood vaccination coverage fell by 5% to 81% in 2020–2021. Fortunately, Singapore has maintained a constantly high vaccination coverage of 96% among 1-year-old children as recorded in 2021. All countries must ensure high poliovirus vaccination coverage in their population to eradicate poliovirus globally, and appropriate interventions must be taken to rectify this if the coverage falters. In 2020, WHO approved the emergency use listing of a novel oral polio vaccine type 2 for countries experiencing circulating VDPV type 2 outbreaks. Environmental and wastewater surveillance should be implemented to allow early detection of “silent” poliovirus transmission in the population, instead of relying on clinical surveillance of acute flaccid paralysis based on case definition alone. Keywords: Acute flaccid paralysis, infectious diseases, polio vaccine, poliovirus, surveillance

The Influence of Walking Limitations on Daily Life: A Mixed-Methods Study of 14 Persons with Late Effects of Polio

Reduced walking ability is common in persons with late effects of polio (LEoP). Here, we explored how many walking limitations persons with LEoP perceive, and how these limitations influence daily life, by using a mixed-methods design. Fourteen persons (mean age 70 years, whereof 7 women) with LEoP responded to the Walking Impact Scale (Walk-12), and were interviewed individually. Qualitative data were analysed by systematic text condensation, and each quotation was deductively analysed in relation to the items in Walk-12. Running was perceived as most limited, whereas walking indoors without using support was perceived as least limited. A majority (>70%) were moderately to extremely limited in standing or walking, in walking speed and distance, which affected concentration and effort, as well as gait quality aspects. The limited walking ability intruded on many everyday activities, both indoors and outdoors, which affected social participation negatively. To increase safety when walking and reduce the fall risk, various strategies were adopted such as using aids, walking carefully, and avoiding risky activities. In conclusion, LEoP-related walking limitations influence participants’ activity and participation greatly. By using both the Walk-12 scale and face-to-face interviews, an increased understanding of how walking limitations influence everyday life was achieved.

Sense of coherence and coping behaviours in persons with late effects of polio

BACKGROUND

Sense of coherence (SOC), comprising "comprehensibility", "manageability" and "meaningfulness", is important for successful adaptation in persons with late effects of polio (LEoP) and can be used as an estimate of the ability to cope with stressors. Coping behaviours are the actions a person performs to reduce stress and can be divided into problem-focused coping, emotion-focused coping and less useful coping. Our knowledge is very limited of what coping behaviours persons with LEoP use to manage their life situation as well as the association between SOC and coping behaviours.

OBJECTIVE

The aims of this cross-sectional study were to assess coping behaviours and to explore the association between SOC and coping behaviours in persons with LEoP.

METHODS

In total, 93 ambulant persons (52% women, mean [SD] age 74 [8] years) with clinically and electromyographically verified LEoP responded to a postal survey with the Sense of Coherence Scale 13 items (SOC-13) and the Brief Cope Scale. Three linear regression analyses were used to explore the association between SOC and problem-focused coping, emotion-focused coping and less useful coping, controlling for age and sex.

RESULTS

The most-used coping behaviours belonged to the categories problem-focused and emotion-focused coping. We found a significant negative association between SOC and less useful coping; less useful coping explained 34% of the variance of SOC (adj R2 = 0.34, p < 0.001), whereas age and sex were not significant in the analyses.

CONCLUSIONS

Persons with LEoP primarily use problem-focused and emotion-focused coping behaviours, which suggests that generally they have adapted well to their disability. Regardless of age and sex, persons with lower SOC scores use less useful coping behaviours, which suggests that they are not as well adapted. These results can facilitate the development of rehabilitation interventions that help persons with LEoP adapt to their situation with a life-long disability.

Nerve Conduction Study/Electromyography: Common Neuropathies and Considerations for Patients with Polio

Acute poliomyelitis is now extremely rare in the United States. Worldwide there are still sporadic outbreaks, which are typically treated with acute inoculation programs. Although polio has effectively been eradicated, the full scope of the disease and its myriad manifestations both in the acute phase and in the postpolio syndrome phase, remain areas of fertile research, debate, and stimulating topics.

Recommendations for Therapy following Nerve Transfer for Children with Acute Flaccid Myelitis

AIM

To provide recommendations for pre- and post-operative occupational and physical therapy for children with acute flaccid myelitis (AFM).

METHODS

Writing panel members consisted of an interdisciplinary team of seven healthcare professionals specializing in the care of children with AFM. The panel reviewed background material on AFM, nerve transfer, and rehabilitation principles applied to pediatrics. Recommendations were prioritized if evidence was available. Where there was no known evidence to support a recommendation, this was noted.

RECOMMENDATIONS

Communication and coordination among interprofessional team members are vital to a comprehensive family-centered rehabilitation program. Surgical planning should include team preparation accounting for frequency, duration, and timing of treatment, as well as individual characteristics and developmental status of the child. Recommendations for pre-operative and six phases of post-operative therapy address assessment, strengthening, range of motion, orthoses, performance of functional activity, and support of the family.

CONCLUSION

Rehabilitation following nerve transfer in children with AFM requires interdisciplinary collaboration and a multisystem approach to assessment and treatment. As new evidence becomes available, recommendations may be revised or replaced accordingly.

Molecular Pathogenicity of Enteroviruses Causing Neurological Disease

Enteroviruses are single-stranded positive-sense RNA viruses that primarily cause self-limiting gastrointestinal or respiratory illness. In some cases, these viruses can invade the central nervous system, causing life-threatening neurological diseases including encephalitis, meningitis and acute flaccid paralysis (AFP). As we near the global eradication of poliovirus, formerly the major cause of AFP, the number of AFP cases have not diminished implying a non-poliovirus etiology. As the number of enteroviruses linked with neurological disease is expanding, of which many had previously little clinical significance, these viruses are becoming increasingly important to public health. Our current understanding of these non-polio enteroviruses is limited, especially with regards to their neurovirulence. Elucidating the molecular pathogenesis of these viruses is paramount for the development of effective therapeutic strategies. This review summarizes the clinical diseases associated with neurotropic enteroviruses and discusses recent advances in the understanding of viral invasion of the central nervous system, cell tropism and molecular pathogenesis as it correlates with host responses.

Life Satisfaction in Persons With Late Effects of Polio: A Test-Retest Reliability Study

BACKGROUND

The Life Satisfaction Questionnaire (LiSat-11), including one global item and 10 domain-specific items, is used to evaluate life satisfaction in persons with the late effects of polio (LEoPs). However, there is a lack of knowledge about its psychometric properties.

OBJECTIVE

To evaluate the test-retest reliability of the LiSat-11 and the associations between the global and domain-specific items in persons with LEoPs.

DESIGN

A test-retest design, where data were collected by a postal survey.

SETTING

University Hospital, Outpatient Clinic.

PARTICIPANTS

A cross-sectional sample of persons (20 women and 31 men; mean age 72 years) with LEoPs.

MAIN OUTCOME MEASUREMENTS

LiSat-11, assessing how satisfied a person is with different aspects of life, such as life as a whole, vocation, economy, leisure, contacts with friends and acquaintances, sexual life, activities of daily living (ADLs), family life, partner relationship, somatic health, and psychological health.

METHODS

LiSat-11 was administered on two occasions, 2 weeks apart. The test-retest reliability was evaluated by Kappa statistics, the percent agreement (PA), and the Svensson rank-invariant method. The association between the items was evaluated with the Spearman rank correlation coefficient (rho).

RESULTS

The Kappa coefficients showed good to excellent agreement (0.64-0.90) and the PA ≤1 point was high (>92%) for all items. No items showed any systematic or random disagreements according to the Svensson method. All domain-specific items correlated significantly with the global item "Life as a whole" (P < .01; rhos 0.41 to 0.75).

CONCLUSIONS

LiSat-11 is reliable for assessing life satisfaction in persons with LEoPs. The global item "Life as a whole" is useful as an overall measure but cannot fully replace the information obtained from the domain-specific items of LiSat-11.

Lower-limb muscle strength, static and dynamic postural stabilities, risk of falling and fear of falling in polio survivors and healthy subjects

INTRODUCTION

This study investigated the association between preserved lower-limb muscle strength, dynamic and static postural stability, risk of falling, and fear of falling in polio survivors. We also investigated whether these clinical features differ between polio survivors and healthy controls. Methods: This quasi-experimental study enrolled 16 polio survivors (13 underwent a complete-case analysis) and 12 age- and sex-matched healthy controls. Participants were assessed by the manual muscle test, Berg Balance Scale, force platform posturography, and Falls Efficacy Scale. Between-group mean differences with confidence intervals (MD, CI 95%) and Spearman's ρ are reported. Results: Compared to healthy controls, polio survivors presented reduced muscle strength (MD = -13, CI 95% -16 to -9 points), lower dynamic postural stability (MD = -14, CI 95% -19 to -8 points), and increased fear of falling (MD = 14, CI 95% 10-18 points) (all P < 0.001). In polio survivors, lower-limb muscle strength was correlated with dynamic (ρ = 0.760) and static postural stability (ρ = 0.738-0.351), risk of falling (ρ = -0.746), and fear of falling (ρ = -0.432). Dynamic postural stability was correlated with risk of falling (ρ = -0.841), fear of falling (ρ = -0.277), and static postural stability (ρ = -0.869 to -0.435; ρ = -0.361 to -0.200, respectively). Risk and fear of falling were also correlated (ρ = 0.464). Discussion: Polio survivors exhibited impaired dynamic postural stability but preserved static stability and increased risk of falling and fear of falling. Preserved lower-limb muscle strength, postural stability, fear of falling, and risk of falling are associated clinical features in this population.

Predictors of changes in gait performance over four years in persons with late effects of polio

BACKGROUND

Reduced gait performance is common in persons with late effects of polio.

OBJECTIVE

To identify predictors of change in gait performance over four years in persons with late effects of polio.

METHODS

Gait performance was assessed annually in 51 ambulatory persons (mean age 64 years, SD 6) by the Timed "Up & Go" (TUG), Comfortable and Fast Gait Speed (CGS, FGS), and 6-Minute Walk Test (6MWT). Isokinetic knee extensor and flexor muscle strength was measured with a Biodex dynamometer. Mixed Linear Models were used to analyze changes in gait performance and to identify any predictors of change among the covariates gender, age, body mass index, time with new symptoms, baseline reduction in gait performance and knee muscle strength.

RESULTS

There were significant linear effects over time (reduction per year) for three gait performance tests; CGS (0.8%; p < 0.05), FGS (1.7%; p < 0.001), and 6MWT (0.7%; p < 0.05) with significant random effects for all tests. The strongest predictor of a change in gait performance was the individual variations in the knee flexor strength (p < 0.001).

CONCLUSION

The small gradual reduction in gait performance over time in persons with late effects of polio is primarily determined by the individual variations in the knee flexor strength.

Comparison of activity and fatigue of the respiratory muscles and pulmonary characteristics between post-polio patients and controls: A pilot study

OBJECTIVES

To compare pulmonary function measures, maximal respiratory pressure and fatigue of respiratory muscles between patients with Post-Polio Syndrome (PPS) and controls.

DESIGN

Cross-sectional study.

PATIENTS

Patients with PPS (N = 12; age 62.1±11.6 years) able to walk for 6 minutes without human assistance; age-matched controls with no history of polio or pulmonary dysfunction (N = 12; age 62.2±6.5 years).

MEASUREMENTS

A body plethysmograph was used to quantify Residual Volume (RV), Total Lung Capacity (TLC), and Thoracic Gas Volume (TGV) etc. A manometer was used to measure Maximal Inspiratory Pressure (MIP) and Maximal Expiratory Pressure. A spirometer was used to measure Maximal Voluntary Ventilation (MVV). Surface electromyography (sEMG) recorded diaphragmatic muscle activity while performing MVV.

RESULTS

The control group had significantly higher TGV and showed improvement in MIP following the effort (difference of 5.5±4.0cmH2O) while the PPS group showed deterioration in MIP (difference of -2.5±5.0cmH2O). Subjects with scoliosis had significantly higher RV/TLC values compared with subjects without scoliosis. The 25th frequency percentile of the sEMG signal acquired during MVV was reduced in the PPS group.

CONCLUSIONS

Maximal respiratory pressure test and sEMG measurements may identify fatigue of respiratory muscles in patients with PPS. Early diagnosis of respiratory impairment may delay respiratory decline and future need of invasive respiratory aids.

Progressive Muscular Atrophy

Progressive muscular atrophy (PMA) is a rare, sporadic, adult-onset motor neuron disease, clinically characterized by isolated lower motor neuron features; however, clinically evident upper motor neuron signs may emerge in some patients. Subclinical upper motor neuron involvement is identified pathologically, radiologically, and neurophysiologically in a substantial number of patients with PMA. Patients with subclinical upper motor neuron involvement do not fulfill the revised El Escorial criteria to participate in amyotrophic lateral sclerosis clinical trials. Intravenous immunoglobulin therapy is only marginally beneficial in a small subgroup of patients with lower motor neuron syndrome without conduction block.

Pyridostigmine: Postpoliomyelitis Syndrome

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu .

Construct validity of a new rating scale for self-reported impairments in persons with late effects of polio

OBJECTIVE

To evaluate the construct validity of a new rating scale for self-reported impairments in persons with late effects of polio.

DESIGN

Psychometric analysis of data on self-perceived impairments in persons with prior polio.

PARTICIPANTS

Two hundred seventy-three persons with prior polio (119 men and 154 women; mean age, 63.5 years).

METHOD

Rasch analysis of a 13-item rating scale with 5 response categories, in which the participants rated how much they have been bothered by various post-polio-related impairments during the past 2 weeks.

RESULTS

The initial analysis showed disordered categories, misfit with some of the items, multidimensionality, and local dependency. After adjustment of the categories, which resulted in a 4-category rating scale, fit to the model was achieved, but the scale still showed signs of multidimensionality. Analyses of local dependency revealed correlations among some of the items, which resulted in a 5 testlet solution, which gave fit to the model and unidimensionality.

CONCLUSION

After adjustment of the categories and local dependency, this new rating scale, Self-Reported Impairments in Persons With Late Effects of Polio, can be considered as unidimensional. The good psychometric properties implies that the Self-Reported Impairments in Persons With Late Effects of Polio scale could be a useful rating scale that would increase our understanding of the impairments that persons with late effects of polio can experience. With further refinements, this scale may assist in the planning and evaluation of appropriate rehabilitation interventions.