A double-blind, placebo-controlled trial of amantadine for the treatment of fatigue in patients with the post-polio syndrome

Increased cerebral integrity metrics in poliomyelitis survivors: putative adaptation to longstanding lower motor neuron degeneration

BACKGROUND

Post-polio syndrome (PPS) has been traditionally considered a slowly progressive condition that affects poliomyelitis survivors decades after their initial infection. Cerebral changes in poliomyelitis survivors are poorly characterised and the few existing studies are strikingly conflicting.

OBJECTIVE

The overarching aim of this study is the comprehensive characterisation of cerebral grey and white matter alterations in poliomyelitis survivors with reference to healthy- and disease-controls using quantitative imaging metrics.

METHODS

Thirty-six poliomyelitis survivors, 88 patients with ALS and 117 healthy individuals were recruited in a prospective, single-centre neuroimaging study using uniform MRI acquisition parameters. All participants underwent standardised clinical assessments, T1-weighted structural and diffusion tensor imaging. Whole-brain and region-of-interest morphometric analyses were undertaken to evaluate patterns of grey matter changes. Tract-based spatial statistics were performed to evaluate diffusivity alterations in a study-specific whiter matter skeleton.

RESULTS

In contrast to healthy controls, poliomyelitis survivors exhibited increased grey matter partial volumes in the brainstem, cerebellum and occipital lobe, accompanied by increased FA in the corticospinal tracts, cerebellum, bilateral mesial temporal lobes and inferior frontal tracts. Polio survivors exhibited increased integrity metrics in the same anatomical regions where ALS patients showed degenerative changes.

CONCLUSIONS

Our findings indicate considerable cortical and white matter reorganisation in poliomyelitis survivors which may be interpreted as compensatory, adaptive change in response to severe lower motor neuron injury in infancy.

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.

A randomized controlled trial of coenzyme Q10 for fatigue in the late-onset sequelae of poliomyelitis

OBJECTIVE

To determine if coenzyme Q(10) alleviates fatigue in the late-onset sequelae of poliomyelitis.

DESIGN

Parallel-group, randomized, placebo-controlled trial.

BACKGROUND SETTING

Coenzyme Q(10) has been shown to boost muscle energy metabolism in post-polio subjects but it does not promote muscle strength, endurance or function in polio survivors with post-poliomyelitis syndrome. However, the collective increased energy metabolism might contribute to a reduction in post-polio fatigue.

PARTICIPANTS

Polio survivors from the Australian post-polio networks in Queensland and New South Wales who attribute a moderate to high level of fatigue to their diagnosed late-onset sequelae of poliomyelitis. Those with fatigue-associated comorbidities of diabetes, anaemia, hypothyroidism and fibromyalgia were excluded.

METHOD

Participants were assigned (1:1), with stratification of those who use energy-saving mobility aids, to receive 100 mg coenzyme Q(10) or matching placebo daily for 60 days. Participants and investigators were blinded to group allocation. Fatigue was assessed by the Multidimensional Assessment of Fatigue as the primary outcome and the Fatigue Severity Scale as secondary outcome.

RESULTS

Of 103 participants, 54 were assigned to receive coenzyme Q(10) and 49 to receive the placebo. The difference in the mean score reductions between the two groups was not statistically significant for either fatigue measure. Oral supplementation with coenzyme Q(10) was safe and well-tolerated.

CONCLUSION

A daily dose of 100 mg coenzyme Q(10) for 60 days does not alleviate the fatigue of the late-onset sequelae of poliomyelitis. The registration number for the clinical trial is ACTRN 12612000552886.

Pharmacological treatments for fatigue associated with palliative care

BACKGROUND

This review updates the original review, 'Pharmacological treatments for fatigue associated with palliative care' and also incorporates the review 'Drug therapy for the management of cancer-related fatigue'.In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients' fatigue can be severely debilitating and is often not counteracted with rest, thereby impacting daily activity and quality of life. Fatigue frequently occurs in patients with advanced disease (e.g. cancer-related fatigue) and modalities used to treat cancer can often contribute. Further complicating issues are the multidimensionality, subjective nature and lack of a consensus definition of fatigue. The pathophysiology is not fully understood and evidence-based treatment approaches are needed.

OBJECTIVES

To evaluate the efficacy of pharmacological treatments for fatigue in palliative care, with a focus on patients at an advanced stage of disease, including patients with cancer and other chronic diseases.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO and EMBASE, and a selection of cancer journals up to 28 April 2014. We searched the references of identified articles and contacted authors to obtain unreported data. To validate the search strategy we selected sentinel references.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) concerning adult palliative care with a focus on pharmacological treatment of fatigue compared to placebo, application of two drugs, usual care or a non-pharmacological intervention. The primary outcome had to be non-specific fatigue (or related terms such as asthenia). We did not include studies on fatigue related to antineoplastic treatment (e.g. chemotherapy, radiotherapy, surgical intervention). We also included secondary outcomes that were assessed in fatigue-related studies (e.g. exhaustion, tiredness).

DATA COLLECTION AND ANALYSIS

Two review authors (MM and MC) independently assessed trial quality and extracted data. We screened the search results and included studies if they met the selection criteria. If we identified two or more studies that investigated a specific drug with the same dose in a population with the same disease and using the same assessment instrument or scale, we conducted meta-analysis. In addition, we compared the type of drug investigated in specific populations, as well as the frequent adverse effects of fatigue treatment, by creating overview tables.

MAIN RESULTS

For this update, we screened 1645 publications of which 45 met the inclusion criteria (20 additional studies to the previous reviews). In total, we analysed data from 18 drugs and 4696 participants. There was a very high degree of statistical and clinical heterogeneity in the trials and we discuss the reasons for this in the review. There were some sources of potential bias in the included studies, including a lack of description of the methods of blinding and allocation concealment, and the small size of the study populations. We included studies investigating pemoline and modafinil in participants with multiple sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue in meta-analysis. Treatment results pointed to weak and inconclusive evidence for the efficacy of amantadine, pemoline and modafinil in multiple sclerosis and for carnitine and donepezil in cancer-related fatigue. Methylphenidate and pemoline seem to be effective in patients with HIV, but this is based only on one study per intervention, with only a moderate number of participants in each study. Meta-analysis shows an estimated superior effect for methylphenidate in cancer-related fatigue (standardised mean difference (SMD) 0.49, 95% confidence interval (CI) 0.15 to 0.83). Therapeutic effects could not be described for dexamphetamine, paroxetine or testosterone. There were a variety of results for the secondary outcomes in some studies. Most studies had low participant numbers and were heterogeneous. In general, adverse reactions were mild and had little or no impact.

AUTHORS' CONCLUSIONS

Based on limited evidence, we cannot recommend a specific drug for the treatment of fatigue in palliative care patients. Fatigue research in palliative care seems to focus on modafinil and methylphenidate, which may be beneficial for the treatment of fatigue associated with palliative care although further research about their efficacy is needed. Dexamethasone, methylprednisolone, acetylsalicylic acid, armodafinil, amantadine and L-carnitine should be further examined. Consensus is needed regarding fatigue outcome parameters for clinical trials.

Treatment for postpolio syndrome

BACKGROUND

Postpolio syndrome (PPS) may affect survivors of paralytic poliomyelitis and is characterised by a complex of neuromuscular symptoms leading to a decline in physical functioning. The effectiveness of pharmacological treatment and rehabilitation management in PPS is not yet established. This is an update of a review first published in 2011.

OBJECTIVES

To systematically review the evidence from randomised and quasi-randomised controlled trials for the effect of any pharmacological or non-pharmacological treatment for PPS compared to placebo, usual care or no treatment. 

SEARCH METHODS

We searched the following databases on 21 July 2014: Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PsycINFO and CINAHL Plus. We also checked reference lists of all relevant articles, searched the Database of Abstracts of Reviews of Effects (DARE), the Health Technology Assessment (HTA) Database and trial registers and contacted investigators known to be involved in research in this area.

SELECTION CRITERIA

Randomised and quasi-randomised trials of any form of pharmacological or non-pharmacological treatment for people with PPS. The primary outcome was self perceived activity limitations and secondary outcomes were muscle strength, muscle endurance, fatigue, pain and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 10 pharmacological (modafinil, intravenous immunoglobulin (IVIg), pyridostigmine, lamotrigine, amantadine, prednisone) and three non-pharmacological (muscle strengthening, rehabilitation in a warm climate (that is temperature ± 25°C, dry and sunny) and a cold climate (that is temperature ± 0°C, rainy or snowy), static magnetic fields) studies with a total of 675 participants with PPS in this review. None of the included studies were completely free from any risk of bias, the most prevalent risk of bias being lack of blinding.There was moderate- and low-quality evidence that IVIg has no beneficial effect on activity limitations in the short term and long term, respectively, and inconsistency in the evidence for effectiveness on muscle strength. IVIg caused minor adverse events in a substantial proportion of the participants. Results of one trial provided very low-quality evidence that lamotrigine might be effective in reducing pain and fatigue, resulting in fewer activity limitations without generating adverse events. Data from two single trials suggested that muscle strengthening of thumb muscles (very low-quality evidence) and static magnetic fields (moderate-quality evidence) are safe and beneficial for improving muscle strength and pain, respectively, with unknown effects on activity limitations. Finally, there was evidence varying from very low quality to high quality that modafinil, pyridostigmine, amantadine, prednisone and rehabilitation in a warm or cold climate are not beneficial in PPS.

AUTHORS' CONCLUSIONS

Due to insufficient good-quality data and lack of randomised studies, it was impossible to draw definite conclusions about the effectiveness of interventions for PPS. Results indicated that IVIg, lamotrigine, muscle strengthening exercises and static magnetic fields may be beneficial but need further investigation to clarify whether any real and meaningful effect exists.

Speech-related fatigue and fatigability in Parkinson's disease

This study tested the assumption that speech is more susceptible to fatigue than normal in persons with dysarthria. After 1 h of speech-like exercises, participants with Parkinson's disease (PD) were expected to report increased perceptions of fatigue and demonstrate fatigability by producing less precise speech with corresponding acoustic changes compared to neurologically normal participants. Twelve adults with idiopathic PD and 13 neurologically normal adults produced sentences with multiple lingual targets before and after six 10-min blocks of fast syllable or word productions. Both groups reported increasing self-perceived fatigue over time, but trained listeners failed to detect systematic differences in articulatory precision or speech naturalness between sentences produced before and after speech-related exercises. Similarly, few systematic acoustic differences occurred. These findings do not support the hypothesis that dysarthric speakers are particularly susceptible to speech-related fatigue; instead, speech articulation generally appears to be resistant to fatigue induced by an hour of moderate functional exercises.

Treatment for postpolio syndrome

BACKGROUND

Postpolio syndrome (PPS) may affect survivors of paralytic poliomyelitis and is characterised by a complex of neuromuscular symptoms leading to a decline in physical functioning. The effectiveness of pharmacological treatment and rehabilitation management in PPS is not yet established.

OBJECTIVES

To review systematically the effects of any treatment for PPS compared to placebo, usual care or no treatment.  

SEARCH STRATEGY

We searched the following databases on 1 October 2010: Cochrane Neuromuscular Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO and CINAHL Plus from inception to September 2010.

SELECTION CRITERIA

Randomised and quasi-randomised trials of any form of pharmacological or non-pharmacological treatment for people with PPS. The primary outcome was self-perceived activity limitations and secondary outcomes were muscle strength, muscle endurance, fatigue, pain and adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected eligible studies, assessed risk of bias and extracted data.

MAIN RESULTS

Nine pharmacological (modafinil, intravenous immunoglobulin, pyridostigmine, lamotrigine, amantadine, prednisone) and three non-pharmacological (muscle strengthening, rehabilitation in a warm climate (i.e. temperature ± 25°C, dry and sunny) and a cold climate (i.e. temperature ± 0°C, rainy or snowy), static magnetic fields) studies were included in this review. None of the included studies was completely free from any risk of bias and the most prevalent risk of bias was lack of blinding.There is moderate quality evidence that intravenous immunoglobulin has no beneficial effect on activity limitations and there is inconsistency in the evidence for effectiveness on muscle strength and pain. Results of one trial provide very low quality evidence that lamotrigine might be effective in reducing pain and fatigue, resulting in fewer activity limitations. Data from two single trials suggest that muscle strengthening of thumb muscles (very low quality evidence) and static magnetic fields (moderate quality evidence) are beneficial for improving muscle strength and pain, respectively, with unknown effects on activity limitations. Finally, there is evidence varying from very low quality to high quality that modafinil, pyridostigmine, amantadine, prednisone and rehabilitation in a warm or cold climate are not beneficial in PPS.

AUTHORS' CONCLUSIONS

Due to insufficient good quality data and lack of randomised studies it is impossible to draw definite conclusions on the effectiveness of interventions for PPS. Results indicate that IVIG, lamotrigine, muscle strengthening exercises and static magnetic fields may be beneficial but need further investigation.

Pharmacological treatments for fatigue associated with palliative care

BACKGROUND

In healthy individuals, fatigue is a protective response to physical or mental stress, often relieved by rest. By contrast, in palliative care patients fatigue can be severely debilitating, thereby impacting daily activity and quality of life, often with rest not counteracting fatigue. Fatigue frequently occurs in patients with advanced disease and modalities treating cancer often contribute or cause fatigue. Further complicating issues are its multidimensionality, subjective nature, and lack of a consensus definition of fatigue. Pathophysiology is not fully understood and evidence-based treatment approaches are needed.

OBJECTIVES

The objective was to determine efficacy of pharmacological treatments on non-specific fatigue in palliative care. The focus was on patients at an advanced stage of disease, including cancer and other chronic diseases associated with fatigue, aiming to relieve fatigue. Studies aiming at curative treatment (e.g. surgical intervention for early breast cancer) were not included.

SEARCH STRATEGY

We searched EMBASE; Psych Lit, CENTRAL and MEDLINE to June 2009.

SELECTION CRITERIA

We considered randomised controlled trials (RCTs) concerning adult palliative care with focus on pharmacological treatment of fatigue. The primary outcome had to be non-specific fatigue (or related terms such as asthenia).

DATA COLLECTION AND ANALYSIS

Results were screened and included if they met the selection criteria. If two or more studies were identified that investigated a specific drug in a population with the same disease, meta-analysis was conducted. In addition, comparison of type of drug investigated in a specific population as well as comparison of frequent adverse effects of fatigue treatment was done by creating overview tables.

MAIN RESULTS

More than 2000 publications were screened, and 22 met inclusion criteria. In total, data from 11 drugs and 1632 participants were analysed. Studies investigating amantadine, pemoline, and modafinil in participants with Multiple Sclerosis (MS)-associated fatigue and methylphenidate in patients suffering from advanced cancer and fatigue could be used for meta-analysis. Amantadine in MS and methylphenidate in cancer patients showed a superior effect. Most studies had low participant numbers and were heterogenous.

AUTHORS' CONCLUSIONS

Based on limited evidence, we cannot recommend a specific drug for treatment of fatigue in palliative care patients. Surprisingly, corticosteroids have not been a research focus for fatigue treatment, although these drugs are frequently used. Recent fatigue research seems to focus on modafinil, which may be beneficial although there is no evidence currently. Amantadine and methylphenidate should be further examined. Consensus regarding fatigue assessment in advanced disease is needed.

Update on current and emerging treatment options for post-polio syndrome

Post-polio syndrome (PPS) refers to the clinical deterioration experienced by many polio survivors several decades after their acute illness. The symptoms are new muscle weakness, decreased muscle endurance, fatigue, muscle pain, joint pain, cold intolerance, and this typical clinical entity is reported from different parts of the world. The pathophysiology behind PPS is not fully understood, but a combination of distal degeneration of enlarged motor units caused by increased metabolic demands and the normal aging process, in addition to inflammatory mechanisms, are thought to be involved. There is no diagnostic test for PPS, and the diagnosis is based on a proper clinical workup where all other possible explanations for the new symptoms are ruled out. The basic principle of management of PPS lies in physical activity, individually tailored training programs, and lifestyle modification. Muscle weakness and muscle pain may be helped with specific training programs, in which training in warm water seems to be particularly helpful. Properly fitted orthoses can improve the biomechanical movement pattern and be energy-saving. Fatigue can be relieved with lifestyle changes, assistive devices, and training programs. Respiratory insufficiency can be controlled with noninvasive respiratory aids including biphasic positive pressure ventilators. Pharmacologic agents like prednisone, amantadine, pyridostigmine, and coenzyme Q10 are of no benefit in PPS. Intravenous immunoglobulin (IVIG) has been tried in three studies, all having positive results. IVIG could probably be a therapeutic alternative, but the potential benefit is modest, and some important questions are still unanswered, in particular to which patients this treatment is useful, the dose, and the therapeutic interval.

Effective intervention strategies for management of impaired posture and fatigue with post-polio syndrome: A case report

This case report describes effective intervention strategies that included gait training with the use of an acceptable, assistive device for the management of impaired posture and fatigue associated with post-polio syndrome. Review of videotaped gait-training sessions enhanced patient compliance with the assistive device, a single forearm crutch. The 49-year-old female acquired childhood polio with resulting leg length discrepancy, lower extremity weakness, and complaints of fatigue. She walked with a right ankle foot orthosis and increased right lateral trunk flexion during right stance. Interventions consisted of patient education regarding the diagnosis and management of post-polio syndrome, health promotion, and energy conservation strategies that included gait training with a single forearm crutch. An outcome measure not previously documented in the post-polio literature was used to measure the patient's perceived fatigue. Six-month and 18-month reexaminations found that the patient was compliant with the assistive device, reported a 30% reduction in fatigue, and walked with a more upright posture for longer distances in a shorter period of time. Patient education, health promotion, and energy conservation strategies that included walking with a properly fitting assistive device reduced perceived fatigue and improved posture and function in an individual with post-polio syndrome.

Pain in persons with postpolio syndrome: frequency, intensity, and impact

OBJECTIVE

To describe the frequency, intensity, and impact of pain in persons with postpoliomyelitis syndrome (PPS).

DESIGN

Retrospective, cross-sectional survey.

SETTING

Community-based survey.

PARTICIPANTS

Convenience sample of people with PPS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Overall intensity and duration of pain, pain sites, pain interference, pain treatments, and relief provided by pain treatments.

RESULTS

A total of 91% (n=57) of the study participants (N=63) reported pain. The most frequently reported pain sites were the shoulders, lower back, legs, and hips. Participants reported pain intensity to be the greatest in the knees, legs, wrists, lower back, and head. Pain interfered most with sleep and with activities requiring a high level of musculoskeletal involvement. Respondents also reported pain problems that were more severe than those of the general population and than those of a sample of people with multiple sclerosis. Many treatments had been tried previously for pain, but continued use of treatments was reported by relatively few participants at the time of the survey.

CONCLUSIONS

The findings indicate that pain is a persistent and common problem in persons with PPS, highlighting the need for effective and accessible pain treatments for this population.

Amantadine: Postpoliomyelitis Syndrome—Related Fatigue

Off-Label Drug Uses — This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a quarterly 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 (FDA). This new guide to the literature will enable 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. A summary of the most relevant data is provided, including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations. 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 hospitalpharmacy@drugfacts.com .

Post-polio syndrome: clinical manifestations and cerebrospinal fluid markers

Post-polio syndrome (PPS) refers to a constellation of new neurological, musculoskeletal and general symptoms occurring in survivors of poliomyelitis decades after acute paralytic and nonparalytic disease. The common manifestations of PPS include generalized, central and peripheral fatigue, muscle weakness and musculoskeletal pain. The pathogenesis of PPS remains obscure. Three prevailing hypotheses have been advanced: stress-induced degeneration of surviving neurons, persistent poliovirus replication or virus reactivation and immune-mediated damage. The diagnosis of PPS is based on medical history and clinical examination, since no specific diagnostic tests are available. In the light of recent studies demonstrating a partial beneficial effect of intravenous immunoglobulin, this article will focus on cerebrospinal fluid biomarkers reflecting disease activity and pathogenic processes in PPS.

A Comparison of Fatigue Scales in Postpoliomyelitis Syndrome

OBJECTIVE

To examine the applicability and validity of traditional fatigue questionnaires in postpoliomyelitis syndrome (PPS) patients with disabling fatigue.

DESIGN

Cross-sectional study. PPS and disabling fatigue were ascertained according to published criteria. Descriptiveness was determined using the McNemar test, and interscale z-score agreement was estimated with Pearson's coefficients.

SETTING

PPS clinic.

PARTICIPANTS

Fifty-six survivors of poliomyelitis: 39 met criteria for PPS, 25 of whom met criteria for disabling fatigue.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Fatigue Severity Scale (FSS), visual analog scale (VAS) for fatigue, and Fatigue Impact Scale (FIS).

RESULTS

Twenty-four patients scored 50% or higher on the scale range for FSS, compared with 19 patients for VAS for fatigue (P=.042), and 7 patients for FIS (P<.001). Scores for patients with disabling fatigue averaged 81.5%, 62%, and 40.9% of the scale range for FSS, VAS for fatigue, and FIS, respectively. Agreement was moderate between the FSS and VAS for fatigue (r=.45, P=.02), but low between FSS and FIS (r=.29, P=.15), and FIS and VAS for fatigue (r=.20, P=.33). Two sample t tests showed significant differences between those with disabling fatigue and those without, based on FSS scores (t=3.8, P<.001), but not for VAS for fatigue or FIS scores.

CONCLUSIONS

FSS was the most descriptive of the instruments tested. Scores generated by the scales were not interchangeable. Of the 3 scales, FFS seemed to be the most informative for the clinical assessment of fatigue in patients with PPS.

EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force

Post-polio syndrome (PPS) is characterized by new or increased muscular weakness, atrophy, muscle pain and fatigue several years after acute polio. The aim of the article is to prepare diagnostic criteria for PPS, and to evaluate the existing evidence for therapeutic interventions. The Medline, EMBASE and ISI databases were searched. Consensus in the group was reached after discussion by e-mail. We recommend Halstead's definition of PPS from 1991 as diagnostic criteria. Supervised, aerobic muscular training, both isokinetic and isometric, is a safe and effective way to prevent further decline for patients with moderate weakness (Level B). Muscular training can also improve muscular fatigue, muscle weakness and pain. Training in a warm climate and non-swimming water exercises are particularly useful (Level B). Respiratory muscle training can improve pulmonary function. Recognition of respiratory impairment and early introduction of non-invasive ventilatory aids prevent or delay further respiratory decline and the need for invasive respiratory aid (Level C). Group training, regular follow-up and patient education are useful for the patients' mental status and well-being. Weight loss, adjustment and introduction of properly fitted assistive devices should be considered (good practice points). A small number of controlled studies of potential-specific treatments for PPS have been completed, but no definitive therapeutic effect has been reported for the agents evaluated (pyridostigmine, corticosteroids, amantadine). Future randomized trials should particularly address the treatment of pain, which is commonly reported by PPS patients. There is also a need for studies evaluating the long-term effects of muscular training.

Cognitive functioning in post-polio patients with and without general fatigue

OBJECTIVE AND DESIGN

This study examined 2 main hypotheses. First, whether patients with post-polio suffering from general fatigue (n=10) demonstrate cognitive deficits compared with patients with post-polio without general fatigue (n=10). Secondly, by systematically varied test order administration we examined whether such differences varied as a function of increasing cognitive load during cognitive testing.

SUBJECTS

Twenty patients diagnosed with post-polio syndrome, 10 with general fatigue and 10 without fatigue.

RESULTS

Neither of the 2 hypotheses were confirmed. The group with general fatigue reported elevated levels of depression. However, no systematic association between level of depression and cognitive performance could be detected.

CONCLUSION

The results of this study provide no evidence that general fatigue or cognitive load affects cognitive functioning in post-polio.

Aging in polio

For a disease that was "conquered" some 40 years ago with the onset of effective vaccination, the issues of long-term survivors of paralytic polio as they age continue to present challenges to rehabilitation specialists. Aging with polio is a definition of PPS. There are over a million patients with PPS in the United States. Management has to include the appropriate use of exercises, appropriate bracing and support, and, in the case of bulbar and respiratory symptoms, the appropriate use of speech therapy services and ventilatory support. There are no prospective randomized trials studying the treatment of weakness and fatigue in PPS. Pharmacologic interventions are limited at this time but include anticholinergics for muscle weakness and dopaminergic agents or amantadine to control central fatigue. The pathophysiology of aging with polio is consistent with neuronal loss and denervation lying at the heart of the developing disorder, whereas the central nervous system components of the fatigue syndrome may be related to central changes with neuronal loss in the basal ganglia and reticular-activating system. Many of the survivors of the polio epidemics are in their later retirement years, and their needs will increase as they have other disabilities due to natural aging. Sensitivity to some of the special issues in PPS may help to avoid complications. Polio is an active infection in the third world. Although great strides have been made, the disease is endemic in eight nations and is threatening to spread. The lessons learned in treating PPS now will be useful in years to come as these individuals age and manifest PPS in the future.

Postpolio syndrome: a challenge to the health-care system

The practical eradication of poliomyelitis in industrialized countries marks one of the most important achievements of world health policy. Yet, disability induced by polio not only continues to exist among survivors with paralytic sequelae, but may also be further accentuated in a considerable number of affected subjects by the development of postpolio syndrome (PPS). PPS aggravates the motor sequelae already present in such subjects and reduces their functional capacity to the point where it affects their activities of daily living and worsens their quality of life. Inasmuch as development of PPS questions the concept of poliomyelitis as a static disease it poses a challenge not only to health professionals but also to policy-makers tasked with providing the necessary health-care measures and appropriate resources. This study sought to review research on this syndrome and to draw up some recommendations that might prove useful to the health authorities for decision-making purposes.

Fatigue in neurological disorders

Chronic fatigue is a typical symptom of neurological diseases, and is most disabling in multiple sclerosis, postpoliomyelitis, poststroke, and in chronic fatigue syndrome. Disorders of neuromuscular junction transmission and metabolic diseases cause muscle fatigability, which is characterised by failure to sustain the force of muscle contraction (peripheral fatigue). Fatigue is also seen in diseases that affect the central, peripheral, and autonomic nervous systems (central fatigue). Enhanced perception of effort and limited endurance of sustained physical and mental activities are the main characteristics of central fatigue. Metabolic and structural lesions that disrupt the usual process of activation in pathways interconnecting the basal ganglia, thalamus, limbic system, and higher cortical centre are implicated in the pathophysiological process of central fatigue. A state of pre-existing relative hypocortisolaemia might sensitise the hypothalamic-pituitary-adrenal axis to development of persistent central fatigue after stress. The contributions of physiological, cognitive, and affective changes underlying fatigue are variable, and treatment is largely symptomatic and rehabilitative.

A comparison of 4 questionnaires to measure fatigue in postpoliomyelitis syndrome

OBJECTIVE

To assess the comparability and reproducibility of 4 questionnaires used to measure fatigue in postpoliomyelitis syndrome (PPS).

DESIGN

Repeated-measures at a 3-week interval.

SETTING

University hospital.

PARTICIPANTS

Convenience sample of 65 patients with PPS.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Fatigue Severity Scale (FSS), the Nottingham Health Profile (NHP) energy category, the Polio Problem List (PPL) fatigue item, and the Dutch Short Fatigue Questionnaire (SFQ).

RESULTS

Correlations of scores between questionnaires were all significant (P<.01) and ranged from.43 (between the NHP energy category and the PPL fatigue item) to.68 (between the PPL fatigue item and the SFQ). Scores on the second visit, normalized to a 0 to 100 scale, were: FSS, 78+/-15; NHP energy category, 47+/-35; PPL fatigue item, 81+/-17; and SFQ, 65+/-22. Except for the difference between the FSS and the PPL fatigue item, the differences in scores between the questionnaires were significant (P<.01). Scale analysis indicated that all questionnaires measured the same unidimensional construct. The reproducibility of the FSS, the PPL fatigue item, and the SFQ was moderate. The smallest detectable change was 1.5 points for the FSS, 2.0 points for the PPL fatigue item, and 1.9 points for the SFQ.

CONCLUSIONS

Although the questionnaires measure the same fatigue construct in PPS, the results are not interchangeable because the ranges of measurement differ. The NHP energy category, in particular, appeared to have a high detection threshold. The moderate reproducibility of the questionnaires indicates a lack of precision, especially when applied at the individual patient level.

Le syndrome post-poliomyélitique

Postpoliomyelitis syndrome is a clinical syndrome characterized by late progression of symptoms, neuromuscular weakness, fatigue and pain, several (more than 20) Years after acute anterior poliomyelitis. In the United States, where it has been mainly described, frequency is estimated between 20 and 30p.100 in patients with sequelae of poliomyelitis. Although the cause is still unknown, postpoliomyelitis syndrome is likely due to degeneration and dysfunction of terminal axons of enlarged post-polio units, with a possible role of inflammatory reaction driven by persistence of the polio virus. Due to lack of specific therapy, rational therapeutic approaches are symptomatic, including exercise, reassurance and life-strategies for fatigue.

Applicability, validity, and reliability of the Piper Fatigue Scale in postpolio patients

OBJECTIVE

To identify a scale that is potentially applicable for measuring the fatigue in postpolio patients and to evaluate its validity and reliability in this population.

DESIGN

Interview survey of 64 individuals with postpolio syndrome and 25 healthy controls of similar age range, with retest in a subset of postpolio patients. The sample was recruited from a postpolio support group, a postpolio clinic, and the general community. Subjects completed the Piper Fatigue Scale, the Beck Depression Inventory, and the Chalder Fatigue Questionnaire during the interview.

RESULTS

Face and content validity of the Piper Fatigue Scale was established by a team of experts and by a group of postpolio patients. The postpolio subjects had significantly higher Piper Fatigue Scale scores than the healthy control subjects (P < 0.001), demonstrating extreme groups validity. Convergent validity was shown with a strong positive correlation between Piper Fatigue Scale scores and Chalder Fatigue Questionnaire scores (r = 0.80). Reliability was also demonstrated with the Piper Fatigue Scale's high internal consistency (alpha = 0.98) and strong test-retest agreement (intraclass correlation coefficient = 0.98).

CONCLUSIONS

The Piper Fatigue Scale is a valid and reliable tool for measuring postpolio fatigue. This scale may be useful in other studies of postpolio fatigue, including those gauging the effectiveness of various treatments for this fatigue.

Treatment of fatigue in fibromyalgia

Clearly, fatigue is a large and challenging problem for those suffering from fibromyalgia. It adds greatly to the morbidity and disability associated with the disease. In the management of this specific symptom in fibromyalgia, attention should first be focused on identifying comorbidities that may be present and contribute to fatigue. As with other symptoms of fibromyalgia, education is a critical component of management. This can be done by the practitioner, with available free resources, or with specialized cognitive behavioral programs. This education process can be augmented with a variety of other nonpharmacologic therapies, especially very gradually increasing, low-impact, aerobic exercise programs. Numerous pharmacologic therapies may also be helpful as an adjunct to treatment. Classes of compounds that raise central levels of norepinephrine or dopamine appear to be the most specific for management of fatigue. There are also many medications used to combat fatigue in other disorders that have not yet been adequately explored as to the possible benefits in alleviating the fatigue of fibromyalgia. Advances in the management of fatigue in fibromyalgia are likely to come from a variety of directions. Easier access to well designed nonpharmacologic therapies is essential, because these treatments are underutilized in clinical practice at present. Improvements in pharmacologic therapies will come from new insights into mechanisms, especially those that might only be present in subsets of patients and would respond to more targeted therapies.

Management of postpolio syndrome

Recent research has shed light on the pathogenesis of the postpolio syndrome and has helped explain its symptoms and the rationale for management. The aim of this article is to familiarize physicians with this syndrome. The history, acute infection, definition, and diagnosis are discussed, as well as the various symptoms and their management. People with postpolio syndrome can educate health professionals about this condition and can help others inflicted with this syndrome. Thus far, no cure is available. A correct diagnosis is important, and the physician must realize that severe comorbidities tend to afflict people with this syndrome. Numerous management options are available to help these people enjoy a high quality of life.

Bromocriptine in the treatment of post-polio fatigue: a pilot study with implications for the pathophysiology of fatigue

Fatigue is the most commonly reported and most disabling of all post-polio sequelae (PPS). Bromocriptine mesylate (Parlodel) was employed in a placebo-controlled trial in five survivors of paralytic polio who continued to report moderate to severe daily fatigue after complying with the conservative treatments prescribed for PPS. Placebo was given for 4 wk followed by increasing doses of bromocriptine mesylate, administered at 12:00 pm for 28 days, which reached a total dose of 12.5 mg/day. Three subjects reported marked symptom improvement on bromocriptine but not on placebo. Their reported difficulty with attention, concentration, word finding, mind wandering, memory, thinking clearly, and fatigue on awakening was significantly negatively correlated with days on bromocriptine but not with days on placebo. Before the drug trial began, responders had clinically impaired performance on neuropsychologic tests of attention and information processing speed, more than twice as many hyperintensities on magnetic resonance imaging of the brain, abnormally low fasting adrenocorticotropic hormone levels, and nearly double the mean plasma prolactin level compared with nonresponders. The implications of these findings for the pathophysiology of fatigue are discussed. A double-blind, placebo-controlled, multicenter study will be needed to confirm bromocriptine's efficacy in treating attentionally and neurophysiologically impaired polio survivors whose severe and disabling fatigue does not respond to conservative therapies.