Changes in strength over time among polio survivors

Two-year course of walking adaptability in persons living with late effects of polio

OBJECTIVE

To evaluate the 2-year course of walking adaptability in persons with late effects of polio.

DESIGN

Prospective cohort study.

PATIENTS

A total of 48 persons with late effects of polio (69% female, mean age 63.1 years) with a fall history and/or fear of falling.

METHODS

Walking adaptability (i.e. variable target-stepping and reactive obstacle-avoidance) was assessed on an interactive treadmill at baseline, 1 year and 2 years. Further, leg-muscle strength and balance were assessed at baseline. The course of walking adaptability was analysed with linear mixed models. Based on median values, subgroups were defined for low vs high baseline walking-adaptability and for clinical characteristics. Tme by subgroup interactions were analysed.

RESULTS

Variable target-stepping and reactive obstacle-avoidance did not change (p > 0.285). Reactive obstacle-avoidance improved for persons with a high balance score at baseline (p = 0.037), but not for those with lower scores (p = 0.531). No other time by subgroup interactions were found (p > 0.126).

CONCLUSION

Walking adaptability did not change in persons with late effects of polio over 2 years, and walking adaptability course did not differ between subgroups stratified for walking adaptability determinants, except for balance. Since falls are a major problem among persons with late effects of polio, future studies should investigate whether walking adaptability declines over a longer time and which persons are most at risk.

Total Hip Arthroplasty in the Nonparalytic Limb of Residual Poliomyelitis Patients: A Propensity Score Matched Study

OBJECTIVE

Poliomyelitis is a rare neuromuscular disease that can cause hip osteoarthritis on the contralateral side due to an abnormal mechanical weight-bearing state, making some residual poliomyelitis patients candidates for total hip arthroplasty (THA). The aim of this study was to investigate the clinical outcome of THA in the nonparalytic limbs of these patients compared with those of non-poliomyelitis patients.

METHODS

Patients treated between January 2007 and May 2021 were retrospectively identified in a single center arthroplasty database. Eight residual poliomyelitis cases that met the inclusion criteria were matched to non-poliomyelitis cases in a ratio of 1:2 based on age, sex, body mass index (BMI), age-adjusted Charlson comorbidity index (aCCI), surgeon, and operation date. The hip function, health-related quality of life, radiographic outcomes, and complications were analyzed with unpaired Student's t test, Mann-Whitney test, Fisher's exact test or analysis of covariance (ANCOVA). Survivorship analysis was determined using the Kaplan-Meier estimator analysis and Gehan-Breslow-Wilcoxon test.

RESULTS

After a mean follow-up of about 5 years, patients with residual poliomyelitis had worse postoperative mobility outcomes(P < 0.05), but there was no difference in total modified Harris hip score (mHHS) or European quality of life-visual analogue scale (EQ-VAS) between the two groups (P > 0.05). There was no difference in radiographic outcomes or complications between the two groups, and patients had similar postoperative satisfaction (P > 0.05). No readmission or reoperation occurred in the poliomyelitis group (P > 0.05), but the postoperative limb length discrepancy (LLD) in the residual poliomyelitis group was greater than that in the control group (P < 0.05).

CONCLUSION

Functional outcomes, health-related quality of life improvement were similarly significantly improved in the nonparalytic limb of residual poliomyelitis patients after THA compared with conventional osteoarthritis patients. However, the residual LLD and weak muscle strength of the affected side will still influence mobility, so residual poliomyelitis patients should be fully informed of this outcome before surgery.

Evaluating the Influence of Gravity on Shoulder Strength Measures Assessed via Handheld Dynamometry

CONTEXT

Handheld dynamometry is a feasible, reliable, and cost-effective method for assessing shoulder strength. One limitation to this tool is the lack of standardized testing protocols and specified shoulder strength test positions. Although it is recommended that strength tests be performed in a gravity-eliminated position, this may not always be a feasible or practical testing protocol. There is limited research on the influence of gravity on strength measures; to our knowledge, no study has compared handheld dynamometry shoulder strength assessments based on body position and gravity. Therefore, the purpose of this study was to compare shoulder flexion, extension, and abduction strength assessed via handheld dynamometry between a gravity-eliminated and a gravity-influenced test position.

DESIGN

This study was a comparison of shoulder strength based on test position. The test position was the independent variable, and the dependent variables were shoulder flexion, extension, and abduction strength.

METHODS

Supine (gravity-eliminated) and seated (gravity-influenced) strength measures were assessed in 20 healthy adults (19.4 [1.2] y) on the dominant arm. Paired t tests were used to determine differences between body positions for each test. Significance was accepted at P ≤ .05.

RESULTS

There were no differences between supine and seated flexion and extension measures. Absolute supine shoulder abduction scores (152.5 [58.4] N) were significantly higher than seated scores (139.9 [55.6] N).

CONCLUSIONS

Findings show that gravity should be considered when using handheld dynamometry scores as indicators of abductor shoulder strength and function.

Post-polio Syndrome: More Than Just a Lower Motor Neuron Disease

Post-polio syndrome (PPS) is a neurological condition that affects polio survivors decades after their initial infection. Despite its high prevalence, the etiology of PPS remains elusive, mechanisms of progression are poorly understood, and the condition is notoriously under-researched. While motor dysfunction is a hallmark feature of the condition, generalized fatigue, sleep disturbance, decreased endurance, neuropsychological deficits, sensory symptoms, and chronic pain are also often reported and have considerable quality of life implications in PPS. The non-motor aspects of PPS are particularly challenging to evaluate, quantify, and treat. Generalized fatigue is one of the most distressing symptoms of PPS and is likely to be multifactorial due to weight-gain, respiratory compromise, poor sleep, and polypharmacy. No validated diagnostic, monitoring, or prognostic markers have been developed in PPS to date and the mainstay of therapy centers on symptomatic relief and individualized rehabilitation strategies such as energy conservation and muscle strengthening exercise regimes. Despite a number of large clinical trials in PPS, no effective disease-modifying pharmacological treatments are currently available.

Post-polio syndrome and the late effects of poliomyelitis: Part 2. treatment, management, and prognosis

Post-polio syndrome (PPS) is characterized by new muscle weakness and/or muscle fatigability that occurs many years after the initial poliomyelitis illness. An individualized approach to rehabilitation management is critical. Interventions may include rehabilitation management strategies, adaptive equipment, orthotic equipment, gait/mobility aids, and a variety of therapeutic exercises. The progression of muscle weakness in PPS is typically slow and gradual; however, there is also variability in both the natural history of weakness and functional prognosis. Further research is required to determine the effectiveness of selected medical treatment. Muscle Nerve 58:760-769, 2018.

Outcomes of total hip replacement in limbs affected by poliomyelitis

INTRODUCTION

The outcomes of total hip replacement in patients suffering from residual poliomyelitis are poorly covered in the literature. In this retrospective study we posed the question of whether total hip replacement performed for degenerative hip diseases in limbs with residual poliomyelitis could determine satisfactory mid-term clinical and radiographic results, with a reasonable complication rate.

METHODS

A retrospective study was carried out to assess the results of 14 total hip replacements performed on 14 patients with residual poliomyelitis on the involved limb from June 1999 to September 2011. Average age at the time of surgery was 51 years (range 26-66 years). Mean duration of follow-up was 92 months (range 52-156 months). Surgery was performed through a direct lateral approach on all hips. All but one were cementless implants.

RESULTS

2 implants failed, 1 due to traumatic acetabular fracture 6 days after surgery, and 1 due to aseptic cup loosening 13 years after surgery. Surgery was uneventful in all patients except 1 (7%), who experienced a transient sensory sciatic nerve palsy. At the latest follow up Harris Hip Score was 83.3 (range 72-91) with a marked improvement when compared to preoperative score (average 52, range 32-78). No dislocations had occurred.

CONCLUSIONS

Total hip replacement can be considered a feasible option for hip osteoarthritis in patients with limbs affected by residual poliomyelitis. Longer follow-up studies are needed to assess the effectiveness of unconstrained total hip replacement in polio patients.

Poliomyelitis sequels in France and the clinical and social needs of survivors: a retrospective study of 200 patients

INTRODUCTION

Polio survivors in France are estimated at 50,000. This study aimed at describing their needs from their clinical and vocational conditions.

METHOD

A retrospective study of our physical and rehabilitation medicine (PRM) consultation activity.

RESULTS

One hundred and fifteen women/85 men, with a mean age of 51years±14.3 (17 to 82). Paralysis involved only one lower limb in 108 patients, the two lower limbs in 56 patients and only one upper limb in 4. At the time of the first consultation 137 patients had experienced functional worsening. The complaints were pain (105 subjects), fatigue (59) and new paresis (58). Only 25% had retired. Post-polio syndrome criteria were present in 46 subjects (23%). Patients who had contracted poliomyelitis in France (56%) differed from the other subjects with regard to age (58.4 versus 41.5), professional status and frequency of PPS (30.9% versus 12.6%).

CONCLUSION

These polio survivors were not particularly aged and they had often experienced functional worsening. The evolution of their disease shall represent a public health issue over the decades to come.

Development of the Activity Effort Scale for women aging with paralytic polio

The purpose of this study was to develop and psychometrically test the Activity Effort Scale among women aging with the affects of paralytic polio. On the basis of prior qualitative research, six items were generated. Two researchers with expertise in disability were consulted for examination of the items, which led to the addition of two more items to the scale. Next, a survey was sent to 500 women with a history of paralytic polio. Data from participants were subjected to psychometric testing: factor analysis, reliability testing, and correlation with existing measures. Useable surveys were returned by 299 women aged 49 to 75 years. Mean age of infection with polio was 7.6 years, and 54% had spinal polio. Principal component analysis of the 8-item scale resulted in one component with an eigenvalue above 1, explaining 74% of the variance. The Cronbach's alpha was .92. Correlations between variables supported content validity. Data suggest that the Activity Effort Scale is a valid and reliable tool consisting of one component measuring frequency of effort exerted beyond levels of discomfort, pain, and fatigue among women aging with paralytic polio.

Physical therapist management following rotator cuff repair for a patient with postpolio syndrome

BACKGROUND AND PURPOSE

Postpoliomyelitis sequelae, such as gait instability and progressive weakness, predispose people with postpolio syndrome to secondary disabilities. With aging, people who depend on their upper extremities to accommodate lower-extremity deficits may anticipate overuse injuries. The purpose of this case report is to describe the use of mobilization and exercise in postoperative rehabilitation of rotator cuff surgery on a patient with postpolio syndrome.

CASE DESCRIPTION

A 48-year-old woman with postpolio syndrome had rotator cuff surgical repair followed by physical therapy intervention. Maitland mobilization and mild functional exercises were chosen to avoid triggering fatigue.

OUTCOMES

Measurements taken preoperatively, before and after physical therapy intervention, and 2 years after intervention showed return to independent status with excellent retention.

DISCUSSION

No fatigue or overuse weakness was encountered. This is the first case report to document physical therapy following rotator cuff repair in a patient with postpolio syndrome.

The Relation Between Walking Capacity and Clinical Correlates in Survivors of Chronic Spinal Poliomyelitis

OBJECTIVES

To examine (1) common clinical measures that may influence walking performance in the six-minute walk test (6MWT) in people with chronic poliomyelitis and (2) the test-retest reliability of the 6MWT distance, lower-extremity muscle strength, balance, and balance confidence on separate trials.

DESIGN

A prospective quasi-experimental study.

SETTING

University-based postpolio clinic.

PARTICIPANTS

Nineteen survivors of poliomyelitis (mean age, 62.2+/-1.9y; time since polio onset, 54.4+/-8.79y).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

6MWT distance, rate-pressure product (RPP), Physiological Cost Index (PCI), ratings of perceived exertion (RPE), pain, fatigue, strength, standing balance, balance confidence, limb-length discrepancy, and lung function.

RESULTS

The 6MWT distance correlated with PCI, pretest pain, lower-extremity muscle strength, balance, balance confidence, corrected leg-length discrepancy, and lung function but not with RPP, RPE, posttest pain, or pretest and posttest fatigue. The PCI correlated with balance confidence and lung function. About 68% of the variance in 6MWT distance was accounted for by balance and pretest pain. The P value was set at .05.

CONCLUSIONS

With stringent standardization of the 6MWT applied to survivors of poliomyelitis (a neuromuscular condition with a musculoskeletal component), reproducibility was high; hence, test validity and interpretation were enhanced. The 6MWT distance was useful in elucidating the relation between impairment and a functional activity-namely, walking-in survivors of poliomyelitis.

Interexaminer reliability of the deltoid and psoas muscle test

OBJECTIVE

To determine if 2 practitioners of differing skill levels could reliably agree on the presence of a weak or strong deltoid or psoas muscle.

STUDY DESIGN

Interexaminer reliability study of 2 common muscle tests.

MAIN OUTCOME MEASURES

Cohen kappa (unweighted) scores, observer agreement, and 95% confidence intervals (CIs).

RESULTS

The results showed that an experienced and a novice practitioner have good agreement when using repeated muscle test procedures on the deltoid ( kappa 0.62) and the psoas ( kappa 0.67).

CONCLUSIONS

The manual muscle test procedures using the anterior deltoid or psoas showed good interexaminer reliability when used by an experienced and a novice user. These techniques may be used between practitioners in multidoctor assessment/management programs.

Strength and endurance of knee extensors in subjects after paralytic poliomyelitis

PURPOSE

To compare the strength and endurance of knee extensors in subjects after paralytic poliomyelitis as well as to extend the comparison to healthy subjects.

METHOD

Twenty subjects after poliomyelitis with new symptoms (SYM group), 10 without new symptoms (ASYM group) and 15 healthy controls were included. To determine strength, isometric maximal voluntary contraction (MVC) torque of knee extensors in both legs was determined by Biodex dynamometer at 60 degrees knee angle. To determine endurance, the subjects were asked to maintain force in the knee extensors in the same position, in the range between 40-45% of MVC torque, as long as possible. The 'tensiomyography' method was applied to measure the radial displacement of m. rectus femoris during submaximal continuous electrical stimulation until recording a flat response.

RESULTS

No significant difference in MVC torque and endurance was found between SYM and ASYM group, as well between the duration of m. rectus femoris response of both groups to submaximal electrical stimulation. MVC torque and endurance of knee extensors with 'normal' strength was significantly lower in post-polio subjects compared to healthy controls.

CONCLUSION

Endurance of knee extensor muscles in post-polio subjects is generally and significantly lower than that of knee extensors in healthy subjects, regardless of the implication of normal strength and subjective observations of post-polio subjects.

The Course of Functional Status and Muscle Strength in Patients With Late-Onset Sequelae of Poliomyelitis: A Systematic Review

OBJECTIVES

To review systematically studies of late-onset polio sequelae on the course of functional status and muscle strength over time and to identify prognostic factors of change.

DATA SOURCES

We conducted a computerized literature search up to July 2004 in MEDLINE, EMBASE, CINAHL, Web of Science, PsychInfo, and the Cochrane controlled trial register using the key words: postpolio, postpoliomyelitis, postpoliomyelitis syndrome, post poliomyelitis muscular atrophy, and poliomyelitis.

STUDY SELECTION

Reports were selected by 1 reviewer if the study involved subjects with a history of poliomyelitis, the outcome measures described functional status or muscle strength, and follow-up was for at least 6 months.

DATA EXTRACTION

Studies were summarized with regard to population, design, sample size, outcome measures, results, and methodologic scores. Overlap in populations between studies was checked.

DATA SYNTHESIS

Of 71 potentially relevant studies, 19 were included (2 on functional status, 15 on muscle strength, 2 on both muscle strength and functional status). Two studies on the course of functional status had sufficient quality and reported inconsistent results. Four studies on the course of muscle strength had sufficient quality. Two studies reported a decline in strength and 2 reported no change. Decline in strength was only reported in studies with a follow-up period longer than 2 years. One study reported extent of paresis as a prognostic factor for change in perceived physical mobility.

CONCLUSIONS

Conclusions cannot be drawn from the literature with regard to the functional course or prognostic factors in late-onset polio sequelae. The rate of decline in muscle strength is slow, and prognostic factors have not yet been identified. Long-term follow-up studies with unselected study populations and age-matched controls are needed, with specific focus on prognostic factors.

Post-Polio Syndrome

Post-polio syndrome (PPS) is the term used for the new late manifestations that occur in patients 30 to 40 years after the occurrence of acute poliomyelitis. PPS has been recognized for over 100 years, but is more common at the present time because of the large epidemics of poliomyelitis in the 1940s and 1950s. PPS is manifested by neurologic, musculoskeletal, and general manifestations. Neurologic manifestations include new weakness, muscle atrophy, dysphagia, dysphonia, and respiratory failure. Musculoskeletal manifestations include muscle pain, joint pain, spinal spondylosis and scoliosis, and secondary root and peripheral nerve compression. General manifestations include generalized fatigue and cold intolerance. New muscle weakness of a mild-to-moderate degree responds well to a nonfatiguing exercise program and pacing of activity with rest periods to avoid muscle overuse. Generalized fatigue may be treated with energy conservation and weight loss programs and lower extremity orthoses. Pharmacologic agents also may be helpful, but have not been beneficial in controlled trials. Bulbar muscle weakness includes dysphagia, dysphonia, sleep disorders, and chronic respiratory failure. Dysphagia may be improved with instruction on compensatory swallowing techniques. Dysphonia is treated with voice exercise therapy and voice amplification devices. Sleep disorders are treated similarly to sleep disorders in non-PPS patients. Respiratory failure may be treated with continuous positive airway pressure, bilevel positive airway pressure, and nasal ventilation, or tracheotomy and permanent ventilation if necessary. Musculoskeletal (muscle and joint) pain is treated with weight loss, pacing of activities, use of assistive devices, and prescribing anti-inflammatory medications and physical therapy techniques. Cardiopulmonary conditioning can be improved without muscle overuse with cycle or arm ergometer exercise or dynamic aquatic exercise.

Randomized controlled trial of strength training in post-polio patients

Many post-polio patients develop new muscle weakness decades after the initial illness. However, its mechanism and treatment are controversial. The purpose of this study was to test the hypotheses that: (1) after strength training, post-polio patients show strength improvement comparable to that seen in the healthy elderly; (2) such training does not have a deleterious effect on motor unit (MU) survival; and (3) part of the strength improvement is due to an increase in voluntary motor drive. After baseline measures including maximum voluntary contraction force, voluntary activation index, motor unit number estimate, and the tetanic tension of the thumb muscles had been determined, 10 post-polio patients with hand involvement were randomized to either the training or control group. The progressive resistance training program consisted of three sets of eight isometric contractions, three times weekly for 12 weeks. Seven healthy elderly were also randomized and trained in a similar manner. Changes in the baseline parameters were monitored once every 4 weeks throughout the training period. The trained post-polio patients showed a significant improvement in their strength (P < 0.05). The magnitude of gain was greater than that seen in the healthy elderly (mean +/- SE, 41 +/- 16% vs. 29 +/- 8%). The training did not adversely affect MU survival and the improvement was largely attributable to an increase in voluntary motor drive. We therefore conclude that moderate intensity strength training is safe and effective in post-polio patients.

A comparison of the effects of exercise and lifestyle modification on the resolution of overuse symptoms of the shoulder in polio survivors: a preliminary study

OBJECTIVE

To compare the effectiveness of exercise and lifestyle modification therapy in treating shoulder symptoms in polio survivors with lower-extremity weakness.

DESIGN

A randomized parallel group study.

SETTING

Research laboratory.

PARTICIPANTS

Twenty-three subjects recruited from a cohort of 194 polio survivors who had participated in a previous study had bilateral hip-extensor and knee-extensor weakness and reported experiencing shoulder pain on a regular basis with daily activity.

INTERVENTIONS

Subjects were randomly assigned to 1 of 3 treatment groups. Members of group 1 were placed on a home exercise program that focused on strengthening their hip and knee extensors. Members of group 2 were instructed in lifestyle modification techniques designed to avoid shoulder overuse. Members of group 3 received both interventions.

MAIN OUTCOME MEASURES

Shoulder symptoms were quantified in terms of number and severity. Isometric strength of bilateral hip and knee extensors was measured with a hand-held dynamometer.

RESULTS

Symptoms improved in all 3 groups. However, members of the exercise-only group (group 1) were the only ones to show a significant difference in both number and severity of symptoms when pre- and posttreatment values were compared.

CONCLUSIONS

Both exercise and lifestyle modification therapies that focus on reducing the stress related to lower-extremity weakness are effective in treating shoulder overuse symptoms in polio survivors. A trend toward greater improvement in shoulder symptoms in subjects who participated in the exercise program and who also showed a trend toward increased knee-extensor strength supports muscle strength and/or endurance as a key factor.