LIVING WITH POLIO

“These are my braces,

they set me free

but, these are my braces,

they are not me.

Without my braces,

I sit in my chair

without my braces,

life is not fair.

But, put on my braces

and I am just like the others.

Put on my braces,

and I run like my brother.

Well, not exactly,

I’ll have to admit, no.

Well, not exactly,

‘Cause, I had polio.”

INTRODUCTION :

This is a poem written by Richard L. Daggett, in 1954 from, Los Angeles, California. This blog I am dedicating to all the Polio survivors in India and all over the country and for the people who have seen and heard a lot but still are marginally unaware of this world of Poliomyeitis.

Poliomyelitis or infantile paralysis was first recorded in Egypt in 1300 BC. It is mainly a disease of children and young adults caused by polio enterovirus type 1, 2 or 3 of high infectivity whose main route of infection is via the human gastrointestinal tract. Infection is oral and the virus multiplies in the gut for one to three weeks when it is either contained by an immune response or a viraemic phase occurs. The virus is excreted in the feces for a number of weeks and in saliva for some days.

PolioEradication

(Image Courtesy : Global Polio Eradication Initiative)

INCUBATION PERIOD & PHASES :

Incubation period is of 3 – 30 days.

Phases :

    1. Initial incubation period
    2. Prodromal or non-paralytic stage
    3. Definitive paralytic stage.

PATHOLOGY : 

Primarily the virus attacks & destroys the anterior horn cells. It may attack the grey matter of the brain stem and also the motor cells of the cerebral cortex. Virus passes along the axons of the nerves, reaches the spinal cord & attacks the AHC. There is presence of engorged & inflamed blood vessels. Degeneration of AHC begins with the loss of Nissil’s granules & the nucleus, followed by complete disappearance of the cell. There is rapid cell death with disappearance of motor fibers arising from the destroyed cell, muscles are cut from the tropic centers and show signs of degeneration. Later they become flaccid and atrophy sets early.

FORMS OF POLIO :

ABORTIVE FORM OR NON PARALYTIC POLIOMYELITIS :

      • Flu-like illness with no neurological sequelae.

BULBAR FORM :

      • Involvement of grey matter of higher centers.
      • Involvement of cranial nerves – particularly the facial nerve & Abducens nerve.
      • If nerves of larynx & pharynx are affected, mortality is high.

SPINAL/ PARALYTIC FORM :

Here the course of disease is sub-divided into acute, convalescent and chronic phases. The acute phase, lasting from 5-10 days is the period of acute illness when paralysis may occur. It is further sub-divided into Pre-paralytic stage and Paralytic stage. The acute phase is ordinarily considered to terminate 48 hours following the return to normal temperature.

The convalescent phase encompasses the 16-month period following the acute phase. During this time a varying degree of spontaneous recovery in muscle power takes place. This phase is also sub-divided into the sensitive phase (lasting from 2 weeks to several months), characterized by hypersensitivity of muscles, which are tender and “in spasm”; and the insensitive phase , in which the muscles are no longer sensitive but are still in period of recovery. The chronic or residual phase is the final stage of the disease after the recovery of muscle power has taken place. It encompasses the rest of the patient’s life following the termination of the convalescent period.

POST-POLIO RESIDUAL PARALYSIS & POST-POLIO SYNDROME :

Polio was considered to be a chronic but stable disease once the acute phase was over and rehabilitation had restored a lesser or greater degree of function. However, in the 1970s and 1980s increasing numbers of people with a history of poliomyelitis began to have new weakness in both their polio muscles and muscles they thought were unaffected by the poliovirus.  They had what was called the late effects of poliomyelitis, postpolio sequelae, or postpolio muscular atrophy. Now the condition is usually referred to as post polio syndrome. The term post polio syndrome (PPS) was first used at the first International Post-Polio Conference at Warm Springs Georgia in 1984.

Presently, the countries with complete eradication of the polio viruses and no new acute cases are dealing with two residual conditions namely the POST-POLIO RESIDUAL PARALYSIS (PPRP or chronic stage) and the POST-POLIO SYNDROME (PPS). The purposes of treatment in permanent paralysis stage or (PPRP) stage are to enable the patient to attain maximal function and to obtain the greatest amount of productive activity in spite of residual weakness. The residual stage is a dynamic, not a static, period. With continued growth and use of the limb, progressive deformities develop that ultimately cause loss of function. Major task in chronic stage is to prevent deformities and to correct them if present.

Here I would like to list some common deformities around lower and upper extremity joints and the spine. Around ankle and foot we equinus or plantarflexion can observe deformity, calcaneus or fixed dorsiflexion deformity, varus or fixed eversion deformity and valgus or fixed inversion deformity. When Combined these are seen as equinovalgus calcaneocavovarus or equinivarus. Around knee flexion, extension, varus or valgus attitude may develop. Most commonly flexion- abduction contractures can be seen around the hip. Rarely flexion-adduction contractures with strong hip flexors and adductors and paretic glutei may lead to subluxation or even dislocation of the hip joint.

In the upper limbs, flexion deformity at the elbows, rotary deformity at the fore arm, extension deformity at the wrists and clawing of fingers can be seen. In the spine, scoliosis is one of the most severe deformities seen with PPRP. In the PPRP stage physical therapy regimen is directed towards preventing or correcting deformities by passive stretching, increasing motor strength by active or hypertrophy exercises for marginal muscles which have some power left in them and achieving maximum functional activity.

Post-Polio Syndrome (PPS) is a neurologic disorder that produces a cluster of symptoms in individuals who had paralytic poliomyelitis many years earlier. Because these symptoms tend to occur together, they are called a syndrome. Typically, these problems occur after a period of functional and neurological stability of at least 15 years following the initial episode of poliomyelitis. PPS adds the secondary impairments of a unique type of fatigue, deep muscle pain, new muscle weakness along with muscle cramps, fasciculations, cold intolerance, swallowing difficulties, hypoventilation and sleep disorders. The cardinal symptom is new weakness.

CRITERIA FOR THE DIAGNOSIS OF PPS :

Mulder, Rosenbaum and Layton initially proposed specific criteria for the diagnosis of PPS in 1972.  These criteria were further refined by Halstead in 1991.

    1. A prior episode of paralytic polio confirmed by history, physical examination and typical findings on EMG.
    2. Standard EMG evaluation demonstrated changes consistent with prior anterior horn cell disease.
    3. Characteristic pattern of recovery – a period of neurological recovery followed by an extended interval of neurological  and functional stability preceding the onset of new weakness, the interval of neurological and  functional stability usually lasts 15 years or more.
    4. The gradual or abrupt onset of new weakness in polio-affected muscles. This weakness may or may not be accompanied by new problems such as generalised fatigue, muscle atrophy, joint and muscle pain, decreased endurance and diminished function.
    5. Exclusion of medical, orthopaedic and neurological conditions that may be causing the health problems listed in number 4 above.

Joint pain is not used as a diagnostic criterion for PPS because pain is an injury phenomenon from local abnormal joint joint and muscle forces.

AETIOLOGY :

There is no definite explanation for the new symptoms associated with PPS. Several theories have been proposed and developed over the years.

PROPOSED AETIOLOGIES OF PPS :

    1. Motor unit dysfunction – degenerative changes within motor units.
    2. Muscle overuse.
    3. Muscle disuse.
    4. Loss of motor units with ageing.
    5. Predisposition to motor neuron degeneration because of glial, vascular, and lymphatic changes caused by acute polio.
    6. Chronic poliovirus infection or virus reactivation.
    7. An immune mediated syndrome.
    8. The effect of growth hormone.
    9. The combined effects of disuse, overuse, pain, weight gain or other illnesses.

But the most widely accepted theory is that of neuronal fatigue. In this theory it is assumed that many motor neurons were destroyed by the original infection, leaving small numbers of overworked neurons to innervate many (orphaned) muscle fibers. With time and overuse, these few working neurons simply wear out leaving muscles denervated. 

PHYSIOTHERAPY & POST POLIO SYNDROME :

MANAGEMENT OF NEW WEAKNESS :

Appropriate and carefully monitored, exercise programs can be of benefit to post polio patients.

GUIDELINES ON THE USE OF STRENGTHENING EXERCISES :

      1. Prior Polio subjects can increase muscle strength with appropriate individualized exercise programs.
      2. An individually prescribed exercise program should be monitored for deterioration in muscle strength, increased pain or increased fatigue.
      3. Individuals should learn to monitor and manage weakness and fatigue prior to commencing an exercise program.
      4.  Muscle overuse, manifested as an aching on exertion should be avoided.

AEROBIC EXERCISE :

Dean and Ross reported an improvement in energy cost and movement economy following modified low intensity (55-70% of age predicted maximum heart rates) aerobic training on a treadmill 30-40 minutes, 3 times a week for 6 weeks.

MANAGEMENT OF PAIN :

The pain or fatigue in PPS is unusual because it usually does not occur at the time of activity but rather 2-3 days later. Treatment should be directed towards :

      • Identification of the cause of pain
      • Modification of activity levels
      • Weight reduction
      • Use of aids and appliances to relieve or support weak muscles and joints
      • Electrophysical agents
      • Stretching exercises / Strengthening exercises
      •  Postural re-education
      • Correction of gait problems
      • Hydrotherapy.

Examples of life style changes include avoiding stairs, low chairs and encouraging use of elevators, elevated chairs, bathtub bench of shower stool, reserved parking and weight control. For the neck and upper extremities include seating and workstation corrections support of books, and newspaper for reading, use of rolling carts for carrying, telephone headsets and computer wristrests.

MANAGEMENT OF CARDIO RESPIRATORY OF PROBLEMS :

Chest physiotherapy can be provided to assist with the removal of secretions, and teach manual and assisted cough techniques.

In conclusion, patients with PPRP and POST POLIO SYNDROME present with complex physical problems which require different treatment approaches. Physical therapy evaluation and interventions help to alleviate the distress related to these conditions and enhance the quality of life.

“ LET’S END THE SUFFERING, JUST TWO DROPS CAN SAVE YOUR CHILD FROM A LIFELONG CURSE”.