Polio survivors: falls and subsequent injuries

Femoral Shaft Fracture in Post-polio Syndrome Patients: Case Series from a Level-I Trauma Center and Review of Literature

BACKGROUND

Femoral shaft fracture in patients of post-polio syndrome (PPS) represents an uncommon yet complex injury pattern. Poorly developed soft-tissue envelope, decreased muscle bulk, reduced vascularity, regional osteopenia, joint contractures, and altered bony anatomy impose significant surgical challenges. Thorough pre-operative planning is imperative as each case requires individualized approach and method of fixation. The aim of the study was to analyze the clinical outcomes in such patients following fracture fixation and to assess the surgical challenges encountered and provide solutions.

MATERIALS AND METHODS

A retrospective case series of 33 patients with femoral shaft fracture in PPS limbs was undertaken. Mode of injury, method of fixation, surgical time, intra-operative blood loss, union time, and complications were recorded.

RESULTS

Low-energy fall was the most common mechanism of injury (73%). Thirty-three patients underwent fixation with intramedullary nailing being the most common mode (79%). Femoral canal diameter, femoral bow, fracture location and morphology and clinical deformities of the patients are key governing factors that determine the choice of implant. Locking plates, pre-contoured anatomical plates, and titanium elastic nailing system offer an alternative in patients unsuitable for nailing. With no difference between various implants, average time for bone healing was 13.8 ± 4.4 weeks. All patients resumed full weight-bearing mobilization and returned to pre-injury activity status at the end of 6 months post-surgery.

CONCLUSION

With detailed pre-operative work-up, contemplating intra-operative difficulties, individualized surgical plan, careful handling of soft tissues, and availability of back-up implants, good clinical outcomes can be achieved in femur fractures in PPS patients.

Measurement properties of the Falls Efficacy Scale-International (FES-I) in persons with late effects of polio: a cross-sectional study

BACKGROUND

Fear of falling (FoF) is very common in persons with late effects of polio (LEoP). An internationally recognized rating scale to assess FoF is the Falls Efficacy Scale-International (FES-I). Yet, there is limited knowledge about its measurement properties in persons with LEoP.

OBJECTIVE

To investigate the measurement properties of FES-I (16-item version) and short FES-I (7-item version) in persons with LEoP.

DESIGN

Explorative factor analysis and Rasch model analysis of cross-sectional data.

SETTING

University Hospital.

PARTICIPANTS

A total of 321 persons with LEoP (mean age 70 ± 10 years, 173 women).

MAIN OUTCOME MEASUREMENT

The FES-I and short FES-I, comprising four response options about concerns of falling ranging from 1 (not at all concerned) to 4 (very concerned).

METHODS

Data were collected by a postal survey. First, a factor analysis was performed to investigate unidimensionality of the scale. Thereafter, a Rasch model analysis was used to further analyze the measurement properties of FES-I and short FES-I, such as local dependency, targeting, hierarchical order of items, Differential Item Functioning (DIF), response category functioning and reliability (Person Separation Index, PSI). Raw score transformation to interval measurements was also performed.

RESULTS

The factor analysis revealed that FES-I was unidimensional, even though the Rasch analysis showed some misfit to the Rasch model and local dependency. Targeting for FES-I and short FES-I was somewhat suboptimal as the participants on average reported less FoF than expected. A negligible gender DIF was found for two items in FES-I and for one item in short FES-I. Reliability was high (PSI >0.86), and the response category thresholds worked as intended for both FES-I, and short FES-I.

CONCLUSION

The FES-I and the short FES-I have sufficient measurement properties in persons with LEoP. Both versions can be used to assess fear of falling in this population. This article is protected by copyright. All rights reserved.

Falls in Post-Polio Patients: Prevalence and Risk Factors

Simple Summary

People with post-polio syndrome (PPS) suffer frequent falls due to muscle weakness and problems with their balance. In order for a rehabilitation clinician to fit the patient with the optimal treatment plan to prevent imbalance and falls, we performed a simple 10-min walking test with 50 PPS patients. We also asked the patients how many falls they had experienced in the last year and they filled out a questionnaire regarding their balance confidence. We found that we can predict the occurrence of falls in PPS patients based on the consistency of their walking pattern. Since it is very easy to measure the walking pattern, our results may help rehabilitation clinicians to identify individuals at risk of fall and reduce the occurrence of falls in this population.

Abstract

Individuals with post-polio syndrome (PPS) suffer from falls and secondary damage. Aim: To (i) analyze the correlation between spatio-temporal gait data and fall measures (fear and frequency of falls) and to (ii) test whether the gait parameters are predictors of fall measures in PPS patients. Methods: Spatio-temporal gait data of 50 individuals with PPS (25 males; age 65.9 ± 8.0) were acquired during gait and while performing the Timed Up-and-Go test. Subjects filled the Activities-specific Balance Confidence Scale (ABC Scale) and reported number of falls during the past year. Results: ABC scores and number of falls correlated with the Timed Up-and-Go, and gait cadence and velocity. The number of falls also correlated with the swing duration symmetry index and the step length variability. Four gait variability parameters explained 33.2% of the variance of the report of falls (p = 0.006). The gait velocity was the best predictor of the ABC score and explained 24.8% of its variance (p = 0.001). Conclusion: Gait variability, easily measured by wearables or pressure-sensing mats, is an important predictor of falls in PPS population. Therefore, gait variability might be an efficient tool before devising a patient-specific fall prevention program for the PPS patient.

Fall-Related Activity Avoidance among Persons with Late Effects of Polio and Its Influence on Daily Life: A Mixed-Methods Study

Falls are common among persons with late effects of polio (LEoP), which may lead to fear of falling and activity avoidance in everyday life. Here, we assessed the occurrence of fall-related activity avoidance among persons with LEoP and explored how these experiences influenced daily life. Fourteen ambulatory persons (seven women; mean age 70 years) with LEoP participated. They responded to the modified Survey of Activities and Fear of Falling in the Elderly (mSAFFE) and participated in individual interviews, which were analysed by systematic text condensation. Each quotation was deductively analysed from its representation with regard to mSAFFE. We found that many persons often avoided activities related to standing and walking, for example, taking a bath, performing household chores, walking outdoors, attending social events if there were stairs in the building and travelling by public transport, due to fear of falling, increased pain and fatigability. To facilitate the performance of daily activities participants expressed that strategic thinking and aids were important to use. In conclusion, fall-related activity avoidance is common in persons with LEoP, which negatively influence daily life and social participation. To increase daily functioning in this population, fall-related activity avoidance should be included in a multifaceted fall management program.

Minimally invasive removal of a deep-positioned cannulated screw from the femoral neck: A case report

BACKGROUND

Clinical femoral neck fracture is common. Based on patient age and fracture type, different surgical methods can be selected, including cannulated screw fixation of the femoral neck and artificial total hip joint or semi-hip joint replacement. When patients with femoral neck fracture are treated with cannulated screw fixation, a cannulated screw may be positioned too deep. The excessively deep-placed screw is difficult to remove and causes major trauma to the patient.

CASE SUMMARY

A patient with poliomyelitis and femoral neck fracture was treated with a cannulated screw that was placed too deep. A self-made auxiliary tool (made of a steel sternal wire) was used to remove the cannulated screw near the pelvic cavity.

CONCLUSION

The depth of the cannulated screw can be estimated before screw placement using an improved hollow screwdriver with a scale mark, thus improving the safety of screw placement and facilitating clinical use.

Polio survivors have poorer walking adaptability than healthy individuals

BACKGROUND

Falling is a major health problem in polio survivors, often occurring as a result of tripping, slipping or misplaced steps. Therefore, reduced walking adaptability possibly plays an important role.

RESEARCH QUESTION

Does walking adaptability, assessed on an interactive treadmill, differ between polio survivors and healthy individuals?

METHODS

In this cross-sectional study, 48 polio survivors with at least one reported fall in the past year and/or fear of falling and 25 healthy individuals of similar age walked at self-selected comfortable fixed speed on an instrumented treadmill. Walking adaptability was measured as i) target-stepping accuracy (determined as variable error [VE] in mm independent of speed) in three conditions; 0 %, 20 % and 30 % variation in step length and width, and ii) anticipatory and reactive obstacle avoidance (ObA and ObR, in percentage successfully avoided). All trials were checked for valid step detection.

RESULTS

46 polio survivors (mean ± SD age: 63.2 ± 8.7 years) and 25 healthy individuals (64.3 ± 6.6 years, p = 0.585) showed valid step detection. Compared to healthy individuals (mean±SE VE: 30.6±1.2 mm), polio survivors stepped less accurately onto targets (36.4±0.9 mm, p = 0.001), especially with their least-affected leg. Polio survivors avoided fewer obstacles successfully (mean±SE ObA: 83±3 %, ObR: 59±4 %) than healthy individuals (100±0.3 %, p < 0.001 and 94±3 %, p < 0.001, respectively), with a stronger decline in success rates from anticipatory to reactive obstacle avoidance for polio survivors (p < 0.001).

SIGNIFICANCE

Polio survivors reporting falls and/or fear of falling had a demonstrably reduced walking adaptability, especially so for reactive obstacle avoidance, which requires step adjustments under high time-pressure demands. Future research should study the merit of walking-adaptability assessment to currently used clinical methods of fall-risk assessment within this population.

Medical Comorbidities and Complications Associated with Poliomyelitis and Its Sequelae

Survivors of poliomyelitis may experience long-term sequelae that put them at increased risk for injury, pain, cardiovascular deconditioning, and functional decline. Osteoporotic fractures and entrapment neuropathies, in particular, may result in greater impairments in one's mobility and ability to perform activities of daily living. Dysphagia may necessitate the use of compensatory swallow strategies to minimize aspiration risk. Comorbid conditions, including hypertension, dyslipidemia, obesity, and stroke, are also very prevalent in this population. Risk factor modification, including diet, exercise, and medication compliance, is essential to achieve optimal health and function among survivors of poliomyelitis.

Management Options and Outcomes for Patients with Femoral Fractures with Post-Polio Syndrome of the Lower Extremity: A Critical Analysis Review

Post-polio syndrome is characterized by a late functional deterioration (usually after >=15 years from the initial infection) in patients with a history of paralytic poliomyelitis infection, and it is defined by the March of Dimes criteria. Patients with post-polio syndrome are at increased risk for falls and associated hip and femoral fractures as a result of lower bone mineral density, decreased lean muscle mass, and musculoskeletal deformities. Current evidence suggests that treatment modalities for femoral fractures should emphasize fixation that allows early progressive weight-bearing and ambulation to optimize functional outcomes. Good results after hip arthroplasty have been described with both cemented and uncemented implants in patients who have been treated for osteoarthritis, but there has been little evidence guiding hip fracture management. Anatomic challenges that are encountered are osteoporotic bone, a valgus neck-shaft angle, increased femoral anteversion, and a small femoral canal diameter. Intramedullary nailing of hip and femoral fractures can be challenging due to the small femoral canal diameter that frequently is encountered. Alternative methods of fixation have shown promising results. These include the use of sliding hip screws for hip fracture management and fixed-angle locking plates for hip and femoral fracture management.

Fractures in patients with poliomyelitis: Past or current challenge?

Fractures in poliomyelitic limbs are a challenge to surgeons, due to polio's sequelae and morphological disorders, which make conventional osteosynthesis difficult. We present a retrospective study of 62 patients and 73 non-simultaneous fractures in their lower limbs. Average age was 61,7 years and 53,2% were females. We analyzed the preinjury functional level, etiology of the fracture, fracture pattern, treatment used (be conservative or surgical), and implant used in surgical cases. We treated 85,1% of them surgically and 37,9% of them maintained the same functional situation as before the fracture. 55,4% of them experienced the need to add some mechanical aids after the lesion and 6,8% lost the ability to walk. Most of the surgical treatments employed were similar as the ones used in non-poliomyelitic patients, although some cases required atypical implants, such as a Multiloc (® DePuy Synthes) humeral nail for a tibial shaft fracture, due to narrow bone. Mortality along the 1st year was 2.7%. We found similar functional and radiological results as those described in non-poliomyelitic limbs.

Is Intervention to Prevent Falls Necessary in Prior Polio Patients?

Objective

To investigate whether intervention to prevent falls is necessary in prior polio patients, by identifying the frequency, circumstances and consequences of falls among patients in Sweden with prior polio.

Subjects

Patients with prior polio diagnosis.

Methods

A falls history questionnaire was completed by patients with prior polio visiting the outpatient clinic at the Department of Rehabilitation Medicine, Danderyd University Hospital, Stock-holm, Sweden, or participating in group activities organized by the patient organization.

Results

A total of 80 patients answered the questionnaire; 32 men and 48 women. Eighty-one percent (n = 63/77) of respondents walked outdoors, but rarely more than 1 km, or only inside and near the house. Three-quarters of patients had fallen one or more times over the past year and one-quarter of patients had fallen 5 times or more. The falls often occurred during daytime in an environment known to the patient. Sixty-nine percent (n = 40/58) of respondents had been injured due to falling during the past year. The most common injuries were minor injuries.

Conclusion

Falls are common in patients in Sweden with prior polio. Interventions to prevent falls in people with prior polio are therefore clinically relevant.

Adults with polio are at risk of hip fracture from middle age: A nationwide population-based cohort study

BACKGROUND

Having motor impairment since childhood and being at risk of osteoporosis and falls, adults with polio would be more likely to suffer a hip fracture (HF) and may experience different epidemiological characteristics from the general population.

OBJECTIVE

To estimate the risk and incidence of HF in adults with polio.

DESIGN

Using a national database, we conducted a population-based cohort study. We identified patients with polio using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code of 138. For each patient with polio, we randomly selected five age- and sex-matched control subjects. Those subjects aged <40 years were excluded. We analyzed participants aged 40˜64 years (middle-aged) and subjects aged ≥65 years (elderly) separately and recognized subjects who had an HF (ICD-9-CM code, 820) only when they received hospitalization to care for the illness from January 1, 2003 to December 31, 2008.

RESULTS

We identified 403 adults with polio (mean age ± standard deviation, 47.2 ± 8.6 years). Compared to the controls, patients with polio had a higher incidence of HF (all, 4.1 vs. 1.1/1000 person-years, p = 0.002; middle-aged, 2.3 vs. 0.3/1000 person-years, p < 0.001; male, 6.2 vs. 0.9/1000 person-years, p < 0.001); had a younger mean age (±standard deviation) of fracturing a hip (61.0±14.9 vs. 74.4±9.3 years, p = 0.015); had a lower cumulative HF-free probability (±standard error) before the age of 65 years (0.970±0.017 vs. 0.988±0.007, p<0.001) and throughout the study duration (0.415 ± 0.296 vs. 0.682 ± 0.158, p<0.001); and had a higher risk of HF, yielding an adjusted hazard ratio (95% confidence interval) of 3.58 (1.45˜8.79, p = 0.006). Patients with polio aged >48.2 years were likely to experience an HF.

CONCLUSIONS

Adults with polio are at risk of HF. A customized HF prevention program is important for people with polio. The program should be started early in middle-age and should include men.

Factors associated with falls in Japanese polio survivors

Purpose: To identify factors associated with falls in Japanese polio survivors and assess the extent of their impact.Materials and methods: Subjects were 128 polio survivors. Fall history and fear of falling, lower limb muscle strength, gait ability (determined by walking speed and number of steps per day), post-polio syndrome incidence, and orthosis or walking aid use were assessed, and factors associated with falls were identified using logistic regression analysis.Results: The fall rate was 64%. Fallers (subjects with one or more falls in the preceding 12 months) had low lower limb muscle strength, slow walking speed, high total scores on the Fall Efficacy Scale-International, which assesses fear of falling, and a high orthosis use rate. Knee extension muscle strength on the weaker side was identified as a main factor influencing risk of falls (odds ratio: 0.72, 95% confidence interval: 0.56-0.96). Receiver operating characteristic curve analysis gave a cutoff value for knee extension muscle strength on the weaker side of 0.42 N/kg or lower.Conclusion: Low knee extension muscle strength on the weaker side was associated with falls, but predictive ability using a single internal factor might be poor. It appears that a comprehensive examination, including other factors, is required.Implications for rehabilitationAs polio survivors age, their risk of falling increases.To identify polio survivors who are at risk of falls, it is important to determine the factors associated with falls and their influence on fall risk.The results of this study showed that reduced knee extension muscle strength on the weaker side was a risk factor for falls in polio survivors.To precisely predict the risk of falls in polio survivors, a comprehensive evaluation of both internal and external factors is required.

Technical aspects and complications in the surgical treatment of poliomyelitis-affected lower limb fractures

OBJECTIVE

Post-polio patients present problems such as small and deformed bones, with narrow intramedullary canal and osteoporosis, affecting surgical treatment. The aim of this article is to describe the main preoperative and intraoperative complications of the surgical treatment of fractures in this population.

MATERIAL AND METHODS

A retrospective analysis was conducted between 1995 and 2014. Data obtained from the medical records included patient age, fracture pattern (AO/OTA), device used, technical aspects of the surgery that changed compared to a standard procedure, and the presence of intraoperative skeletal complications.

RESULTS

Sixty-four patients with 78 fractures were included in the study. Forty-seven percent of the fractures were at the proximal femur. The main complications of hip arthroplasty (14 patients) were absent hip abductors and intraoperative instability (3), bad cup fixation (3) and intraoperative periprosthetic fracture (2). The main problems of intramedullary nailing were due to a narrow canal and previous bone deformity. Main problems reported when plating included difficulty to fit a precontoured plate, and oversized hardware.

CONCLUSION

Given the large number of intraoperative complications, in preoperative planning we must include nails of small diameter and length, locking plates and external fixators, and, in the case of hip arthroplasty, long and thin stems and restrictive or dual mobility acetabular systems.

Poliomyelitis

Poliomyelitis, often termed "polio," is an acute infectious disease caused by an enterovirus which damages the anterior horn cells of the spinal cord and brainstem. Progress to lower motor neurone cell death leads to disruption of motor units and subsequent muscle weakness or complete paralysis. Although the virus is mostly eradicated from the Western world, postpolio decline is prevalent among people aged 60 years and over. It is characterized primarily by fatigability and muscle weakness, but pain is also common. Reductions in lower-limb muscle strength, voluntary drive, and endurance are likely to contribute to the impaired balance control, slow gait, and dysfunctional lower-limb kinematics reported in polio survivors. Given these significant risk factors, polio survivors fall up to four times more often than their age-matched healthy peers. Interventions to improve function, reduce disability, and prevent falls in polio survivors are therefore clinically relevant but studies are lacking, limiting the evidence base. Balance training, cognitive behavioral therapy, and orthoses prescription might be recommended. Muscle-strengthening programs should be carefully designed and delivered due to their potential detrimental effects related to excessive use and potential dysfunction of motor neurones and their axons.

Reverse Less Invasive Stabilization System (LISS) Plating for Proximal Femur Fractures in Poliomyelitis Survivors: A Report of Two Cases

Case series

Patient: Female, 50 • Male, 60

Final Diagnosis: Proximal femur fractures

Symptoms: Hip pain

Medication: —

Clinical Procedure: Internal fixation surgery

Specialty: Orthopedics and Traumatology

Relationship of depression and medications on incidence of falls among people with late effects of polio

The purpose of this study was to determine if falls in polio survivors, with or without post-polio syndrome (PPS), are related to number of medications taken, use of anti-depressant or psychoactive medications, or self-report of depression. A survey was sent to 300 members of a regional polio support group, asking them to document their fall history, medications used, and the presence of depression. Depression was measured by self-report and with the Geriatric Depression Scale, short form (GDS-15). One hundred and seventy-two usable surveys were returned with 146 of those completing the medication list. Sixty-two percent reported at least one fall in the past year. The multiple logistic regression was significant (p = 0.023), and it indicated depression to be a significant predictor (p = 0.012) of falls in polio survivors with and without PPS. The number of total medications or anti-depressant or psychoactive medications used was not related to fall incidence. Routine screening and treatment for depression may be one aspect of fall prevention which can be implemented through primary care.

The effects of different types of ankle-foot orthoses on postural responses in individuals with walking impairments

The aim of this study was to examine the immediate and long-term effects of different ankle-foot orthosis (AFO) types on postural responses in patients with various pathological conditions who, because of their walking disorders, wore an AFO. A total of 37 patients with different pathological conditions who visited the outpatient clinic for orthotics because of walking problems, already used or were referred for an AFO and had no other impairments that may influence balance were included in the study. The participants were divided into four groups according to the type of AFO that they wore. The postural responses were assessed with and without AFO using two force-plates following perturbations in different directions at the level of the pelvis. The centre of pressure was examined in the sagittal and frontal plane and compared with the normative data from healthy individuals. The results showed an improvement in postural responses to the lateral and backward perturbation directions when wearing the AFO, particularly responses in the anterior-posterior direction. The best results were achieved with the custom-made posterior leaf spring AFO for correction of equinovarus deformity. The time of wearing the AFO had an impact on postural responses in perturbation directions where the patients could not rely only on AFO. The custom-made AFO improved overall postural responses, especially dynamic stability, in lateral directions, whereas all stiff AFOs contributed towards an improvement in responses to all perturbations to the affected side. Results showed that long-term use of an AFO can be important for the overall improvement of postural responses.

The influence of a powered knee-ankle-foot orthosis on walking in poliomyelitis subjects: A pilot study

BACKGROUND

Traditionally, the anatomical knee joint is locked in extension when walking with a conventional knee-ankle-foot orthosis. A powered knee-ankle-foot orthosis was developed to provide restriction of knee flexion during stance phase and active flexion and extension of the knee during swing phase of gait.

OBJECTIVE

The purpose of this study was to determine differences of the powered knee-ankle-foot orthosis compared to a locked knee-ankle-foot orthosis in kinematic data and temporospatial parameters during ambulation.

STUDY DESIGN

Quasi-experimental design.

METHODS

Subjects with poliomyelitis (n = 7) volunteered for this study and undertook gait analysis with both the powered and the conventional knee-ankle-foot orthoses. Three trials per orthosis were collected while each subject walked along a 6-m walkway using a calibrated six-camera three-dimensional video-based motion analysis system.

RESULTS

Walking with the powered knee-ankle-foot orthosis resulted in a significant reduction in both walking speed and step length (both 18%), but a significant increase in stance phase percentage compared to walking with the conventional knee-ankle-foot orthosis. Cadence was not significantly different between the two test conditions (p = 0.751). There was significantly higher knee flexion during swing phase and increased hip hiking when using the powered orthosis.

CONCLUSION

The new powered orthosis permitted improved knee joint kinematic for knee-ankle-foot orthosis users while providing knee support in stance and active knee motion in swing in the gait cycle. Therefore, the new powered orthosis provided more natural knee flexion during swing for orthosis users compared to the locked knee-ankle-foot orthosis.

CLINICAL RELEVANCE

This orthosis has the potential to improve knee joint kinematics and gait pattern in poliomyelitis subjects during walking activities.

Falls in Korean Polio Survivors: Incidence, Consequences, and Risk Factors

Falls and fall-related injuries are important issue among polio survivors. The purpose of this study was to determine the incidence of, and consequences and factors associated with falls among Korean polio survivors. A total of 317 polio survivors participated in this study. All participants completed a questionnaire including fall history, symptoms related to post-polio syndrome and other information through a telephone interview. Among them, 80 participants visited our clinic for additional physical measurements and tests. Of the 317 respondents, 68.5% reported at least one fall in the past year. Of the fallers, 42.5% experienced at least one fall during one month. Most falls occurred during ambulation (76.6%), outside (75.2%) and by slipping down (29.7%). Of fallers, 45% reported any injuries caused by falls, and 23.3% reported fractures specifically. Female sex, old age, low bone mineral density, the presence of symptoms related to post-polio syndrome (PPS), poor balance confidence, short physical performance battery and weak muscle strength of knee extensor were not significantly associated with falls. Only leg-length discrepancy using spine-malleolar distance (SMD) was a significant factor associated with falls among Korean polio survivors. Our findings suggest that malalignment between the paralytic and non-paralytic limb length should be addressed in polio survivors for preventing falls.

Comprehensive review of challenges associated with management of lower limb fractures in poliomyelitis patients

Poliomyelitis is on the verge of eradication. But the survivors of polio are still living with its consequences in different parts of the world and so will continue to be seen for almost a century. Fractures in the polio-affected limb are a common entity in these patients and are difficult to manage using the common fracture management protocols. This article gives a comprehensive review of the challenges faced in fixation of fractures in polio affected limbs and possible solutions to overcome them. Knowledge of treating these fractures is important to a trauma surgeon as such scenarios are not uncommon in daily practice.

Post-polio syndrome and risk factors in korean polio survivors: a baseline survey by telephone interview

Objective

To obtain information on the socioeconomic, medical, and functional status of polio survivors, and to use these results as the preliminary data for establishing the middle-aged cohort of polio survivors.

Methods

The subjects were recruited based on the medical records of multiple hospitals and centers. They were assessed through a structured questionnaire over the phone. Post-poliomyelitis syndrome (PPS) was identified according to the specified diagnostic criteria. Differences between polio survivors with or without PPS were evaluated, and the risk factors for PPS were analyzed by the odds ratio (OR).

Results

Majority of polio survivors were middle-aged and mean age was 51.2±8.3 years. A total of 188 out of 313 polio survivors met the adopted criteria for PPS based on the symptoms, yielding a prevalence of 61.6%. Mean interval between acute poliomyelitis and the development of PPS was 38.5±11.6 years. Female gender (OR 1.82; confidence interval [CI] 1.09-3.06), the age at onset of poliomyelitis (OR 1.75; CI 1.05-2.94), the use of orthoses or walking aids (OR 2.46; CI 1.44-4.20), and the history of medical treatment for paralysis, pain or gait disturbance (OR 2.62; CI 1.52-4.51) represented independent risk factors for PPS.

Conclusion

We found that the majority of Korean polio survivors entered middle age with many medical, functional, and social problems. Female gender, early age of onset of poliomyelitis, the use of orthoses or walking aids, and the history of medical treatment for paralysis, pain or gait disturbance were identified as the significant risk factors for PPS. A comprehensive and multidisciplinary plan should be prepared to manage polio survivors considering their need for health care services and the risk factors for late effects, such as PPS.

Bilateral custom-fit total knee arthroplasty in a patient with poliomyelitis

In limbs affected by poliomyelitis, total knee arthroplasty results in satisfactory pain relief. However, the risk of failure is high, especially if the preoperative quadriceps power is low. Therefore, treating osteoarthritis in the current patient represented a challenging procedure. A 66-year-old man presented with tricompartmental osteoarthritis of both knees, with valgus deformity of 14° on the left knee and 11° on the right knee. He walked with a bilateral knee recurvatum of 30° and a grade 1 quadriceps power. The authors treated both knees with cemented custom-fit hinged total knee arthroplasty with 30° of recurvatum in the tibial keel. Clinical scores showed good results 1 year postoperatively, especially on the subjective data of quality of life and function. At follow-up, radiographs showed good total knee arthroplasty positioning on the right side and a small mechanical loosening at the end of the tibial keel on the left side. Only 5 studies (Patterson and Insall; Moran; Giori and Lewallen; Jordan et al; and Tigani et al) have reported total knee arthroplasty results in patients with poliomyelitis. This study reports an original case of bilateral custom-fit hinged total knee arthroplasty in a patient with poliomyelitis. To the authors' knowledge, this is the first report of this type of procedure in the literature. The key point is the degree of recurvatum that is needed to allow walking, avoiding excessive constraints on the implants that can lead to early mechanical failure.

Total hip arthroplasty performed in patients with residual poliomyelitis: does it work?

BACKGROUND

Patients with residual poliomyelitis can have advanced degenerative arthritis of the hip in the paralytic limb or the nonparalytic contralateral limb. Although THA is a treatment option for some of these patients, there are few studies regarding THA in this patient population.

QUESTIONS/PURPOSES

We therefore reviewed a group of patients with residual poliomyelitis who underwent cementless THA on either their paralytic limb or nonparalytic limb to assess (1) Harris hip scores, (2) radiographic results, including implant loosening, (3) complications, including dislocation, and (4) limb length discrepancy after recovery from surgery.

METHODS

From January 2000 to December 2009, 10 patients with residual poliomyelitis (10 hips, four paralytic limbs and six nonparalytic contralateral limbs) underwent THA using cementless prostheses. Harris hip scores, complications, and leg length discrepancy were determined by chart review, and confirmed by questionnaire and examination; radiographs were reviewed by two observers for this study. Followup was available for all 10 patients at a minimum of 3 years (median, 7 years; range, 3.4-13 years). Surgery was done at the same side of the paralytic limb in four hips and contralateral to the paralytic limb in six.

RESULTS

All patients had pain relief and improvement in function; the Harris hip score improved from mean of 68 preoperatively to 92 at last followup (p = 0.043). However, only three patients had complete pain relief. One hip dislocated, which was treated successfully with closed reduction and a hip spica cast for 2 months. There was no loosening or osteolysis in this series. Leg length discrepancy improved after the index operation, but only in the THAs performed in the paralytic limbs.

CONCLUSIONS

Cementless THA may be suitable for painful hips in adult patients with residual poliomyelitis. Nonetheless, these patients should be informed of the possibility of mild residual pain and persistent leg length discrepancy, particularly patients whose THA is performed on the limb that was not affected by polio (ie, the nonparalytic contralateral limb).

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Distal femoral fractures in post-poliomyelitis patients treated with locking compression plates

OBJECTIVE

Treatment of distal femoral fracture in post-polio patients is difficult because the bone is usually osteopenic, small and deformed. This retrospective study aimed to investigate the outcomes of distal femoral fracture in post-polio patients treated by locking compression plates (LCP).

METHODS

The medical records of 19 post-polio patients (mean age 49 years at time of surgery) were reviewed and intraoperative data retrieved. Fracture union and callus formation were evaluated on radiographs taken at each postoperative visit. Functional outcome assessments included range of motion and Hospital for Special Surgery (HSS) score of the ipsilateral knee joint.

RESULTS

Sixteen femoral fractures occurred in the poliomyelitis-affected limbs. The mean duration of operation was 86 min and mean blood loss 120 mL. All fractures healed (mean, four months) but union was delayed in one. At the final follow-up 2 yrs after surgery, the mean range of knee flexion was 105° (range, 90°-130°), and mean HSS score 76 points (range, 60-93). There were no cases of nonunion, implant cutout, or other complications.

CONCLUSIONS

LCP provides stable fixation of distal femoral fractures in post-polio patients. Bony union and good functional outcomes are achieved, but delayed union and minimal callus may occur.

A candidate core set of outcome measures based on the International Classification of Functioning, Disability and Health for clinical studies on lower limb orthoses

BACKGROUND

Although many core sets of measurement concepts have been published in the literature, this has not been done for the field of lower limb orthoses.

OBJECTIVES

This paper provides an overview of the measurement concepts that are relevant in lower limb orthotic evaluations, and it proposes a candidate Core Set of outcome measures to be used in clinical studies on ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs).

STUDY DESIGN

Literature review.

METHODS

The International Classification of Functioning, Disability and Health (ICF) was used as framework to select relevant concepts.

RESULTS AND CONCLUSION

Measurement concepts covering all ICF levels of functioning were identified as relevant for the Core Set, including functions of the joints and bones (b710-b729), muscle functions (b730-b749), gait pattern functions (b770), walking (b450), moving around in different locations (d460), and daily-life functioning (d5-d9). Further validation of this candidate Core Set through a formal decision-making process is needed to obtain consensus among experts in the field. Based on such a consensus, the next step will be to systematically review the literature and identify those measurement instruments that are best suited to assess the proposed concepts, based on their psychometric properties in a given sample and context. Thereafter, we suggest that this ICF Core Set of measurement instruments should be applied in orthotic studies on AFOs and KAFOs in ambulatory patients with gait problems.

CLINICAL RELEVANCE

Although many ICF Core Sets have been published, this has not been done for the field of lower limb orthoses. We feel that such a Core Set is urgently needed, to enable comparison of results, and establish evidence on the efficacy of orthotic treatment, which will improve patient care.

Femoral neck bone mineral density in ambulatory men with poliomyelitis

We evaluated bilateral femoral neck bone mineral densities (FNBMDs) in 32 men with poliomyelitis and their matched controls. Men with poliomyelitis had significantly lower FNBMD in both legs, and FNBMD was lowest in their shorter legs. Knee extensor strength and regular exercise were important predictive factors associated with decreased FNBMD.

INTRODUCTION

People with poliomyelitis (polio) are prone to leg fractures after mild trauma. The flaccid paralysis, asymmetric involvement, and underdeveloped growth of afflicted legs may lead to osteoporosis of either leg, characterized by different patterns. This study aimed to measure their femoral FNBMD and to explore the factors associated with changes in FNBMD in either leg.

METHODS

We did a prospective study to evaluate bilateral FNBMD with dual-energy X-ray absorptiometry in 32 men with polio (age range, 41-57 years; mean, 47 years) and 32 age- and body mass index-matched controls. Measuring the difference in leg length, we classified the legs of each polio subject as "longer" or "shorter." In addition, we chose the right leg of each control as a reference leg. We then used the Mann-Whitney U test to compare FNBMD of these three groups of legs and searched for the factors associated with FNBMD using stepwise multiple regression analyses.

RESULTS

Compared to the reference leg, men with polio had significantly lower FNBMD in both their longer and shorter legs, by 13% and 23%, respectively. The difference in FNBMD between the two legs of polio subjects was significant. Knee extensor strength and regular exercise were two important factors associated with bilateral FNBMD in men with polio.

CONCLUSIONS

Men with polio had lower bilateral FNBMD. FNBMD of the shorter leg should be the choice for predicting the risk of hip fracture in men with polio because on average, the shorter leg has lower BMD.

Locked plating for femoral fractures in polio patients

BACKGROUND

Femoral fractures in polio survivors present unique challenges; the bone is often small, deformed, osteoporotic and hypovascularized. Locked compression plating aided in achieving a better construct stability of osteoporotic fractures.

METHODS

A total of 13 unilateral femoral fractures in adult polio patients were fixed with locked compression plating in a prospective study. Mean age was 49.8 years (range 34-62). In 6 cases, the small size of the bone matched only narrow plates, and in 6 cases the plate was contoured to fit the cortex. Average follow-up period was 18.4 months (range 12-24).

RESULTS

Radiological evidence of union was apparent in 12 cases after 12-20 weeks (mean 16.3). One case was considered ununited after 28 weeks and progressed to union with bone grafting after another 12 weeks. At the end of the follow-up period, 12 patients returned to their prefracture Vignos disability scale, only the case that experienced nonunion showed functional deterioration.

CONCLUSION

The locked compression plate withstood fixing femoral fractures in polio patients, addressing the challenges of a smaller, osteoporotic, less vascularized and sometimes deformed femur.

Fear of falling, balance confidence and health-related quality of life in individuals with postpolio syndrome

The purposes of this study were to examine prevalence of fear of falling (FOF) and decreased balance confidence in individuals with postpolio syndrome (PPS) and to determine whether balance confidence was correlated with health-related quality of life (HRQOL) in this population. A survey, which included demographic questions, the Activities-specific Balance Confidence (ABC) Scale, and the MOS SF-36v2, was made available by mail and electronically to individuals with PPS. Descriptive and correlation statistics were used to analyze the responses. Fear of falling was reported in 95% of respondents, with 80% indicating that FOF affected their quality of life. Median ABC score (42 of 100), physical component score (27 of 100), and mental component score (47 of 100) were below average compared with the general population. A moderate correlation (r = 0.4; p < 0.001) was found between balance confidence and the physical component score of HRQOL in PPS. There was an overwhelming presence of FOF and severely impaired balance confidence in the majority of those with PPS. A fair correlation between the physical functioning component of HRQOL and balance confidence was noted in this population.

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.

Postural control in persons with late effects of polio

BACKGROUND

Persons who have suffered from acute poliomyelitis may decades later experience reduction of balance and gait capacity due to muscle weakness, fatigue and/or pain. This may affect the activity level in daily life of these persons.

AIMS OF THE STUDY

The aim of this study was to describe observer assessed and subjectively perceived postural control in persons with late effects of polio and to evaluate the correlation between postural control and gait velocity for this population.

METHOD

50 persons (mean age 59.8 yrs) with diagnosed polio disease and without other causes of mobility disorders were included. Balance was tested with the Timed Up and Go test (TUG), the Functional Reach test (FR) and the Falls Efficacy Scale (FES) (Swedish Version). Gait velocity over 30 m was measured for convenient and maximal velocity.

RESULTS

The subjects had reduced balance (TUG mean 9.0 sec, FR mean 23.5 cm) and perceived balance problems in ADL items (FES(S) median 119.5, normal value 130). They also showed reduced gait velocity compared to healthy persons of the same age (mean 1.01 m/s compared to 1.30 m/s, convenient speed). Correlations were demonstrated between the reduced balance and decreased convenient and maximal gait velocity (TUG/gait velocity: r = -0.7 (convenient), r = -0.8 (maximal), p <or= 0.01).

CONCLUSIONS

The knowledge of reduced balance and gait velocity in persons with late effects of polio may have an impact on how to provide service to this group to ensure safety in activities in daily life, including gait.

A pilot study of falls, fear of falling, activity levels and fall prevention actions in older people with polio

BACKGROUND AND AIMS

Polio survivors are ageing, and reporting new complications including falls. The aims of this study were: 1) to determine the frequency of falls, circumstances surrounding them, and the consequences of falls in older people who have polio; and 2) to investigate the range of fall prevention interventions undertaken to reduce the individual's risk of falling.

METHODS

A survey was conducted of members of the Eastern Polio Support Group of Victoria. Twenty-eight respondents (70%; 7 male, 21 female) had a mean age of 66 years and an average duration of 57 years since the onset of polio. The survey addressed demographic data, mobility, frequency and description of falls over the last 12 months, their consequences, and community services utilized. The Modified Falls Efficacy Scale (MFES) and Human Activity Profile (HAP) were also completed. Comparative data on the MFES and HAP were obtained from age- and gender-matched healthy community-dwelling older people.

RESULTS

Fourteen respondents (50%) reported one or more falls over the past 12 months, half reporting multiple falls. Two-thirds of falls occurred while walking. Of those who fell, 67% did not require medical attention. The highest percentage of injuries were bruises or grazes (44%), with one fracture reported. Sixty-one percent reported being fearful of falling, with an average MFES of 7.4 (+/-2.0), compared with the average of 9.7 (+/-0.5) for the age- and gender-matched controls (p<0.05). Only 5 of the respondents reported changing their level of activity as the result of a fall. A significant difference was identified on the Adjusted Activity Score (AAS) of the HAP between polio non-fallers (mean 56.3+/-19.1), polio fallers (mean 40.1+/-15.6) and age- and gender-matched controls (mean 73.5+/-10.3) (F2,46=25.5, p=0.000). The median number of fall prevention activities undertaken in the previous 12 months was one, 11 of the 28 respondents undertaking two or more. The most common interventions implemented were vision checks (42%) and review of medications by a doctor (25%).

CONCLUSIONS

A high rate of falling, fear of falling and low activity levels exist in older people with polio. There is a need for further research and clinical programs to reduce falls and injuries in this group.