A Brief presentation about Occupational Therapy management for Post polio syndrome (PPS)

1. Phinoj K Abraham
IInd MOTh Student
All India Institute of Physical Medicine & Rehabilitation,
(AIIPM&R) Mumbai

2. 
Acute Paralytic Polio
 Stages
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Post Polio Syndrome (PPS)
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Definition
Epidemiology
Causes
Risk factors
Path physiology
Clinical Features
Management
Prognosis
2

3. 
Virus [ Burnhilde, Lansing & Leon]
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Contaminated water / food
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Affinity for motor (muscle) nerves
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Kills / Injures motor nerves
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Results in weakness / paralysis
3

4. 
There are four recognized stages:
 Acute Paralysis and/or weakness
 Recovery and Rehabilitation
 Neurological Stability
 Post Polio Syndrome / Sequelae
4

5. 
A Neurological condition
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New symptoms many years after acute polio typically 30-50 yrs.
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New symptoms appear after a period of
neurological stability
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Major sxs- New weakness, loss of function, intense
fatigue, pain in muscles / joints
5

6. Confirmed history of polio
Partial or fairly complete neurological and functional
recovery after the acute episode.
 Period of at least 15 years with neurological and functional
stability
 Two or more of the following health problems occurring
after the stable period:
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Extensive fatigue
Muscle and or joint pain
New weakness in muscles previously affected or unaffected
New muscle atrophy
Functional loss
Cold intolerance
No other medical explanation found
Halstead LS. 1991
6

7. 
The frequency of PPS ranges between 15%-80%,
Natural history data from post-polio clinic in Houston, Texas. A =
birth; B = onset of polio; C = maximum recovery; D = onset of new
health problems; E = time of evaluation; F = death. (Halstead, L. S. and
Rossi, C. D 1987)
7

8. 
The pathological changes that cause the
symptoms of PPS are not well understood

There are four different theories on the cause of
PPS:
 Disintegration of overused motor units
 Reactivation of Polio virus
 Immune system dysfunction
 Neural loss due to ageing
8

9. Accelerated natural ageing
Falling nerve to muscle motor unit ratio
Inflammation and active immune response
Co-morbidity:
 Orthopaedic problems
 Radiculopathy and entrapment neuropathy
 Respiratory failure
 General medical problems
 PPS is more likely with
 Increasing age;
 The more severe the initial weakness was
 The more time that elapses after the attack of polio
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9

10. 10
Halstead, L. S 1988

11. 
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Higher age at onset of poliomyelitis
The association with other diseases may indicate
that a chronic physical stress, particularly in
already weak motor units, can contribute to the
development of signs and symptoms of PPS
Poor Socio-economic conditions (Ragonese P et
al)
Individuals who had polio exhibit "Type A"
behavior and experience chronic stress (Richard
L. Bruno et al)
11

12. Theories:
Remaining healthy
motor neurons can no
longer maintain new
sprouts
 Decompensation /
chronic denervation
and reinervation
process.
 Denervation exceeds
reinervation
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Dalakas, M. C., et al 1985
12

13. 
Motor neuronal loss
due to reactivation of a
persistent latent virus.

Infection of the polio
survivor’s motor
neuron by a different
enterovirus

Loss of strength
associated with
aging, in already
weakened muscles
Dalakas, M. C., et al 1985
13

14. Common
 Fatigue
 New Weakness
 Decreased endurance
 Muscle & joint pain
 Loss of function
Less common
 Muscle atrophy
 Respiratory problems
 Swallowing problems
 Cold intolerance
 Sleep apnoea
 Gait disturbance
 Climbing Stairs
 Dressing
 (Activities that require
repetitive muscular
contraction)
Julie K Silver, Anne C Gawne 2004
14

15. 
Post Polio Fatigue
 Central (evolved from CNS)
▪ Difficulty regarding cognition, concentration, memory
attention, maintaining wakefulness (because of the
affectation of RAS, Basal Ganglia etc..)
 Peripheral (evolving from the peripheral nerves i.e.,
the motor unit.)
▪ Muscle weakness
 According to Schanke and Stanghelle (2001),
physical, peripheral fatigue was greater problem for
the patients than mental, central Fatigue
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16. 
Extremely prevalent in PPS
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Deep aching pain
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Myofascial pain syndrome / Fibromyalgia
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Small number of patients have muscle
tenderness on palpation
Julie K Silver, Anne C Gawne 2004
16

17. 
Weakness and Functional Loss.
 focal neurological disease such as a radiculopathy, focal
compressive neuropathy, or spinal cord lesion and
medical causes of neuropathy such as diabetes, thyroid
disease, uremia, alcohol, toxins, and, uncommonly, heredi
tary neuromuscular disease.
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Fatigue.
 anemia, chronic infections, collagen disorders, thyroid
disease, diabetes, cancer, depression .
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Pain.
 osteoarthritis, bursitis, tendinitis, and myofascial pain
polymyalgia rheumatica, fibromyalgia, polymyositis, and
rheumatoid arthritis
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18. Medical management
 Evaluation
 Confirmation of previous Paralytic Polio
 Exclusion of other causes of new symptoms
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Medications
 No well-proven pharmacologic treatment for this
▪ Pyridostigmine – fatigue (effectiveness ?)
▪ Amantadine (Anti viral agent) effectiveness ?
▪ High dose Prednisone (no significant improvement in M
Strength, however a trend to an increse in isometric strength)
 Other symptomatic management
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19. 
Rehabilitative
 Interdisciplinary team
assessment
▪ Physician, OT, PT,
SLP,P&O, SW, Respiratory
Therapist
 Goal setting
 Treat ment Planning &
intervention
▪ Management of Weakness
▪ Management of Fatigue
▪ Management of Pain
For the assessment of Fatigue
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20. 
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OT interventions are tasks or activities that
promote health and improve occupational
performance .
Role of OT in PPS
 Exercise program that involves the U/E
 Prevention of overuse injuries
 Treatment of any existing arm problems
 Education about the principles of energy
conservation
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21. 
Interventions are
 Orthoses for the U/E (e.g. splints )
 Assistive technology
 Modifications at home and work
 Lifestyle modification
 Exercise program
 Discharge and follow-up
MOYERS P et al .AJOT 53:251-289,1999
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22. 
Energy conservation techniques
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Life style changes
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Regular rest periods or naps during the day
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Pacing (rest periods during activity)
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Improvement of sleep ( e. g relaxation
techniques)
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Avoidance of excessive fatigue
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23. 
Most effective treatments for pain include:
 Heat
 Massage
 Gentle exercise
 Education
 Stretching
 Orthoses and Walking aids
 Re-education of Movement
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24. 
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Post-polio syndrome is not life-threatening
unless there is severe pulmonary involvement
or a swallowing disorder.
The symptoms are manageable and with
proper measures quality of life can remain
good.
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25. 1.
2.
3.
4.
5.
Halstead LS. 1991. Assessment and differential diagnosis for
post-polio syndrome. Orthopedics. 14(11):1209.
Halstead, L. S. and Rossi, C. D., Post-polio syndrome: clinical
experience with 132 consecutive outpatients, in Research and
Clinical Aspects of the Late Effects of Poliomyelitis, Halstead, L. S.
and Weichers, D. O., Eds., March of Dimes Birth Defects
Foundation, 23(4), White Plains, NY, 1987, 13-26.
Halstead, L. S., Late complications of poliomyelitis, in
Rehabilitation Medicine, Goodgold, J., Ed., CV.
Mosby, Washington, D.C., 1988, 328-340.
Dalakas, M. C., Sever, J. L., Fletcher, M., Madden, D.
L., Papadopoulos, N., Shekarchi, I., and
Albrecht, P., Neuromuscular symptoms in patients with old
poliomyelitis: clinical, virological and immunological studies, in
Late Effects of Poliomyelitis, Halstead, L. S. and Weichers, D.
O., Eds., Symposia Foundation, Miami, FL, 1985, 73-90.
Julie K Silver, Anne C Gawne 2004 Post Polio Syndrome p 5 25

26. 

Ragonese P, Fierro B, Salemi G, Randisi G, Buffa D, D'Amelio
M, Aloisio A, Savettieri G. Prevalence and risk factors of postpolio syndrome in a cohort of polio survivors. J Neurol
Sci. 2005 Sep 15;236(1-2):31-5.
Stress and "Type A" Behavior as Precipitants of Post-Polio
Sequelae: The Felician/Columbia Survey Richard L.
Bruno, PhD, and Nancy M. Frick, MDiv, LhD
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