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MRI of Neurogenic Human Motor Units Following Poliomyelitis

Muscle & Nerve, 2026; 73:403–411

https://doi.org/10.1002/mus.70107

403

Muscle & Nerve

CLINICAL RESEARCH ARTICLE OPEN ACCESS

MRI of Neurogenic Human Motor Units Following Poliomyelitis

1Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK | 2Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, UK | 3Ageing, Sarcopenia and Multimorbidity Theme, NIHR Newcastle Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, Cumbria Northumberland Tyne and Wear NHS Foundation Trust and Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK

Correspondence: Roger G. Whittaker (roger.whittaker@newcastle.ac.uk)

Received: 14 May 2025 | Revised: 27 November 2025 | Accepted: 4 December 2025

Keywords: electromyography | magnetic resonance imaging | motor unit | poliomyelitis | reinnervation

ABSTRACT

Introduction/Aims: Surviving motor units in neurogenic diseases demonstrate collateral reinnervation. Scanning electromyography (EMG) reveals normal motor unit corridor length, but with “silent regions,” suggesting that reinnervation does not result in increased motor unit size but may increase motor unit complexity. Motor unit magnetic resonance imaging (MUMRI) pairs MR imaging with electrical nerve stimulation to visualize individual motor units. This study aimed to assess the motor unit dimensions and complexity in patients with previous poliomyelitis compared to healthy controls.

Methods: Patients with a history of polio were recruited from the British Polio Fellowship, compared to a retrospective cohort of healthy controls. They underwent medical history and examination of lower limb power, fatigue assessment (fatigue severity score, FSS), and a 3 T MUMRI scan of the less-affected lower limb. The cross-sectional area, maximum, and minimum Feret diameter of the motor unit territories in tibialis anterior were calculated. Motor unit complexity was computed using the Hausdorff box-counting method.

Results: Of 12 polio survivors, n = 8 (6 female) were suitable for analysis and were compared to 19 controls. The mean motor unit maximum Feret diameter was 10.3 ± 3.1 mm compared to 8.4 ± 5.2 mm in controls (p = 0.34). The mean shape complexity was 0.59 ± 0.12 compared to 0.45 ± 0.2 in controls (p = 0.03).

Discussion: Polio survivors demonstrate motor units with normal dimensions but increased shape complexity, indicating nonuniform collateral reinnervation largely limited to existing territories. The size and shape of motor units could help in understanding the physiological processes behind reinnervation, both in polio and other neurogenic diseases such as amyotrophic lateral sclerosis.

1 | Introduction

Understanding the neurogenic remodeling process is key to understanding the changes seen in altered motor unit potential (MUP) morphology in neurogenic diseases that form the basis of clinical electromyography (EMG) interpretation. However,

it remains unclear whether reinnervation increases the spatial territory of a motor unit, or if it occurs exclusively within the original boundary.

While concentric EMG shows neurogenic MUPs are characterized by increased amplitude and duration, this is largely a

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product of the closest ~10 fibers [1] and reflects increased fiber density in the 1 mm around the needle [1] rather than the whole 10–20 mm motor unit territory [2–4].

While macro-MUP amplitude increases in neurogenic diseases [5–8] indicating an increased total fiber count for the whole motor unit, and single-fiber EMG confirms increased fiber density in polio survivors and other neurogenic conditions [9, 10], these methods do not measure spatial extent.

Attempts to measure territory directly have been contradictory. Scanning EMG has shown only minimal increases in motor unit dimensions in polio [11] or other neurogenic disorders [4], but with “silent regions” suggesting an increased complexity of the motor unit structure [12] whereas multielectrode EMG has shown significant increases in territory [13]. This variability may be explained in part by the random path of the electrode, which will tend to underestimate motor unit dimensions, especially those with complex profiles [14].

Animal studies using the glycogen depletion technique [15] have shown either a decrease in territory [15–17], a modest increase [18], or inconsistent results [19]. It therefore remains unclear whether the characteristic changes seen in neurogenic disease reflect an expanded motor unit territory or are solely due to increased fiber density.

We recently developed a magnetic resonance imaging (MRI)- based technique (motor unit MRI or MUMRI) capable of imaging the size and shape of human motor units in vivo [20]. MUMRI uses a pulsed gradient spin echo (PGSE) sequence, which is inherently sensitive to the movement of water molecules. When combined with in-scanner electrical nerve stimulation, the contraction of the muscle fibers in a given motor unit results in a localized signal void in the MR image. This in turn allows the quantification of the motor unit dimensions, crosssectional area, and shape [21]. The technique has been used to image single motor units in healthy controls [2], as well as to track the motor units through multiple axial slices of the lower leg, producing a 3D image of the motor unit [22].

In this study, we compared the motor unit dimensions of polio survivors who exhibit significant loss of motor units [23–26], extensive motor unit re-modeling [10] and very high amplitude MUPs [27], against a cohort of previously studied healthy controls. Our primary research question was whether or not compensatory reinnervation is limited to or extends beyond the normal territory of a human motor unit.

2 | Methods

Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee (2603/34701). Participants were recruited via the British Polio Fellowship through local meetings and email newsletters.

Our inclusion criteria were participants with a self-identified history of polio, defined as a febrile illness associated with acute muscle weakness followed by recovery with at least 15 years of stability [28]. Exclusion criteria were a contraindication to MRI

scan including a pacemaker or implanted medical devices or metallic fragments, severe claustrophobia, and those with confounding neurological diagnoses. We did not exclude those with implanted orthopedic metalwork as some polio survivors have internal joint fixation to enable locomotion, and the scans could continue safely with these in place [29]. Participants were prescreened against inclusion and exclusion criteria via telephone and were invited to take part in the study. During the study visit, further medical history was obtained, and a neurological examination was performed of the lower limbs by an experienced consultant neurophysiologist to assess tone, power (using MRC grading 0–5), and degree and pattern of wasting. The fatigue severity score (FSS) questionnaire validated on patients with neurological disease [30] was completed by participants, consisting of agreement with nine statements on a scale from 1 to 7, giving a score from 9 to 63.

For comparison of motor unit sizes to healthy controls, we used historically acquired data from a study involving healthy older participants collected 2–3 years prior using the same protocol and scan system. For that study, ethical approval was obtained from Newcastle University Faculty of Medical Sciences Ethics Committee (1852/525/2020). All polio survivors and healthy controls gave written informed consent prior to participation.

2.1 | Motor Unit MRI

The protocol for MUMRI has been described previously [2, 22]. Briefly, fibular nerve stimulation was paired with timed acquisition of PGSE images of the leg, with the slices centred at the thickest part of the calf. A 3 T Philips Achieva MR system (Best, the Netherlands) was combined with a flexible (FlexM, Philips) receiver coil pair positioned on either side of the leg. Several scans were performed (for detailed parameters see Table S1):

T1-weighted scan to assess muscle structure.
Dixon sequences [31] to obtain the fat fraction in the lower legs bilaterally.
MUMRI (PGSE) sequence setup scan during progressively increased stimulation strength through the range of muscle activation from subthreshold to supramaximal stimulation.
MUMRI “single motor unit scan” using a narrower stimulation current range to target the activation of a single motor unit (alternation) as assessed by visual inspection during the scan. This was then repeated twice at an even narrower stimulation current range in two stacks of 12 slices each (no slice gap). The overlap between the stacks was two slices and, in each stack, the most distal slice was unstimulated, resulting in 21 stimulated slices, imaging a continuous volume extending 210 mm along the lower limb.

Poliomyelitis is an asymmetric, patchy process, and subclinical changes can be found even in less-affected legs [32]. Based upon inspection of the structural T1-weighted scan, we targeted for motor unit imaging the side that showed neurogenic change in

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Muscle & Nerve, 2026 405

the anterior compartment indicating involvement of poliomyelitis, but avoided a side if it had been completely replaced by fat leaving no muscle for investigation.

Peripheral nerve stimulation was performed using a pair of stimulating electrodes placed over the common fibular nerve at the fibular head. The electrodes were connected to a programmable stimulator (DS5; Digitimer, Ft. Lauderdale, Florida, USA) via coaxial cables with low pass filters (Minicircuits, New York, USA) at the Faraday cage. In all cases, the stimulator cathode was placed distal to the anode. The stimulus frequency was 1 Hz, with a bipolar square pulse of 0.3 ms duration. Stimulation current was progressively increased until a visible leg twitch was achieved. An initial MUMRI survey scan was then performed around this stimulation current in increments of 0.5 mA until a region of signal dropout was visible indicating the first recruitment of motor units, up to the point where the entire muscle image was seen to be saturated. This provided the current range required for initial motor unit recruitment through to stimulation of all available motor units. Detailed MU mapping scans were then conducted, focused on stimulation strengths where periods of alternation were seen during this setup scan. MUMRI scans were collected with 360 stimulated sequences, decrementing by increments of 0.03 mA over a total current range of 10.8 mA to identify single motor units on a single axial slice. To produce a map of the longitudinal extent of that motor unit, 125 stimulated sequences, decrementing by 0.03 mA (current range: 3.75 mA) were performed at 22 axial slices.

Motor units were identified based on alternation characteristics as described previously [2]. Regions of muscle were selected that exhibited “all or nothing” recruitment and did not have multiple levels of activation to suggest they were compounds of multiple motor units. The maximum and minimum Feret diameter (the maximum and minimum distance between two parallel lines restricting the motor unit outline) and crosssectional area were computed from single-slice acquisitions, and the shape complexity was calculated using the Hausdorff box-counting method using a MATLAB (Mathworks version r2021a) script [33]. To produce motor unit recruitment curves, the average brightness of the voxels in the anterior compartment of a single slice was measured across all stimulation strengths.

The Hausdorff box-counting method is a technique used to quantify the complexity of a shape by estimating its fractal dimension. This method involves overlaying a grid of boxes of a certain size over the shape and counting the number of boxes that contain part of the shape. The process is repeated with boxes of different sizes, and the relationship between the number of boxes and the size of the boxes is analyzed. This dimension provides a measure of the shape’s complexity, with higher values indicating more intricate structures [34].

Motor unit diameters and shape complexity scores were measured using previously described methods [2]. Motor unit diameters and shape complexity scores were compared to healthy participants aged > 65 using the two-sample t test (MATLAB ttest2 function). These were selected from existing unpublished data collected using the same scanning protocol.

2.2 | Structural Analysis

Dixon-sequence scans were segmented manually using ITKsnap, version 4.20 [35] into anterior (muscles supplied by the fibular nerve including tibialis anterior and extensor digitorum longus) and posterior (muscles supplied by the tibial nerve including gastrocnemius, soleus, and tibialis posterior) compartments. Segmentation was confirmed by a clinical radiologist (L.B.). The fat-free contractile muscle volume was calculated from Dixon sequences using ITKsnap.

Contractile muscle volume was correlated with MRC power grading for each lower limb by performing ordinal regression using Spearman’s ρ in SPSS v29 (IBM, Armonk, NY, USA).

3 | Results

Twelve participants were recruited based upon the inclusion criteria. Of these: one participant could not be scanned due to a flexion deformity preventing their leg safely fitting into the bore of the scanner; two showed no reliable motor unit activation at all; and one in whom data were lost prior to analysis. This left eight participants for analysis, with a mean age of 75 years (range 68–80), six of whom were female (Table 1). The mean FSS was 44.1 (27–55). Examination of lower limb MRC power rating ranged from 0 to 5 (Table 1).

The motor unit data were compared to 19 adults aged 65 years or older (n = 6 female, mean age 73.7, range 67–82). MRC and fatigue score measurements were not available in this retrospective comparison cohort.

3.1 | Muscle MRI Features

The structural images of the participants were heterogenous in appearance, with varying patterns of fat infiltration within, and across, different muscles of the anterior and posterior compartments (Figure 1). The degree of fatty infiltration was highly variable between and within subjects, with almost normal appearing muscles or muscle regions alongside areas of almost complete fatty infiltration.

Contractile muscle volume was also variable, with mean anterior compartment volume of 79 cm3, and ranging from 6.9 to 184 cm3. The muscle volume was moderately to strongly correlated with MRC power scores for the anterior (Spearman’s ρ 0.828 p < 0.0001) and posterior compartments (Spearman’s ρ 0.663 p = 0.001). Visual inspection of MRC power scores versus contractile muscle volume showed that while there was an association, there was overlap of contractile muscle volumes at different MRC power grading (Figure S1).

3.2 | Motor Unit Characteristics

The recruitment curves appeared continuous and sigmoid in three participants (P04, P05, P09) and discrete with large step increments in the remaining five (P03, P06, P07, P11, P12) (Figure 2). Alternation of single motor unit activity was seen in stimulation currents between 9.6 and 21.3 mA. Visual inspection

406 Muscle & Nerve, 2026

indicated there was no clear relationship between the shape of the recruitment curve and the MRC strength scores.

A single motor unit was identified in the anterior compartment of six participants, with two individuals demonstrating two and four units with distinct and noncontiguous patterns of recruitment, respectively (Figure 3). In healthy controls, a single motor unit was identified for each participant.

In the single-slice (two-dimensional) imaging, the mean and standard deviation (SD) of the motor unit maximum Feret diameter was 10.3 ± 3.1 mm (range 7.2–16.8 mm) compared to 8.4 ± 5.2 mm (range 2.8–20.5 mm) in controls (p = 0.34). The mean and SD of the motor unit minimum Feret diameter was 5.5 ± 2 mm (range 2.5–10.6 mm), compared to 3.7 ± 1.9 mm (range 2–6.8 mm) in controls (p = 0.01). The mean and SD motor unit area was 28.2 ± 18.8 mm2,

FIGURE 1 | T1-weighted muscle MRI of less-affected legs of participants at the level of mid-calf. (A) P03 demonstrating diffuse fatty infiltration throughout the muscle with neuromuscular “islands” of sparing in tibialis anterior (arrow). (B) P04—extensive fatty replacement in the posterior compartment with patchy fatty infiltration in the anterior compartment. (C) P05—relatively normal muscle with little fatty infiltration. (D) P06—extensive fatty infiltration and neuromuscular islands (arrow) throughout anterior compartment with relative sparing of medial head of gastrocnemius.

TABLE 1 | Participant characteristics.

Participant Age (years) Sex Side scanned

Ankle strength (MRC)

FSS sum

Left Right

DF PF DF PF

P03 80 F L 3 5 0 0 42

P04 78 F L 4 4 1 1 39

P05 77 F L 5 5 0 0 42

P06 68 F R 0 4 2 4 52

P07 74 M L 4 4 0 0 45

P09 76 F L 4 4 4 3 55

P11 73 F R 5 5 4 2 51

P12 79 M L 2 4 5 5 27

Abbreviations: DF, dorsiflexion; FSS, fatigue severity score; MRC, Medical Research Council strength grading out of 5; PF, plantarflexion.

Muscle & Nerve, 2026 407

compared to 19.7 ± 16.2 mm2 in healthy controls (p = 0.24) (Table 2).

The mean and SD motor unit shape complexity as computed using the Hausdorff metric was 0.59 ± 0.12 compared to 0.45 ± 0.2 in controls. There was a significant difference when comparing polio survivors to the controls (p = 0.03).

To further explore the relationship between the motor unit morphologies and the macroscopic tissue volume of the limb in polio survivors, we assessed the correlation between contractile muscle volume and the motor unit shape complexity measure, and no correlation was found (Spearman’s ρ = 0.51, p = 0.09).

In the 22-slice (three-dimensional) imaging, six participants were excluded from analysis. Two of these showed excessive spontaneous activity at rest, one showed multiple motor units

that overlapped in activation current and territory, and in three more the motor unit showed insufficient activations to produce a consistent motor unit profile between slices. Of the remaining two participants, one showed two discrete motor units while another showed a single motor unit (Figure 4). Motor units extended between 6 and 10 cm longitudinally and the maximum Feret dimensions across all slices ranged from 3.6 to 16.1 mm (Table 3).

4 | Discussion

Using motor unit MRI combined with in-scanner nerve stimulation we show that the motor units in survivors of polio have a similar maximum Feret diameter and cross-sectional area to controls, but both the minimum Feret diameter and shape complexity were significantly increased. This suggests that

FIGURE 2 | Relative pulsed gradient spin echo (PGSE) recruitment curves, demonstrating the progressive increase in signal intensity across a single slice of the segmented anterior compartment, associated with increased activation of motor units via higher stimulation currents. This shows a continuous recruitment pattern in some individuals, and a discrete recruitment with large step sizes and alternation in others. Legend indicates participant ID and the MRC force grading of ankle dorsiflexion for that limb.

FIGURE 3 | (A) Axial single-slice motor unit profiles in the anterior compartment of the leg. (B) Each image is a single motor unit, with participant ID and motor unit number indicated.

408 Muscle & Nerve, 2026

reinnervation occurs within the original motor unit territory, results in an increased fiber density, and that this process is not uniform across the motor unit.

The implication of this limited spatial area within which reinnervation occurs is clear. As motor units are lost in a neurogenic disease, the surviving units are able to extend collateral nerve

TABLE 2 | Single axial slice motor unit dimensions and Hausdorff box-counting shape complexity of polio survivors and grouped healthy controls.

Participant MU number

Max Feret diameter (mm)

Min Feret diameter (mm)

Cross-sectional area (mm2)

Hausdorff complexity

P03 1 14.2 5.3 27 0.6074

P04 1 13.0 4.2 26 0.7114

P05 1 7.8 4.9 18 0.5113

P06 1 7.2 4.9 22 0.5198

P07 1 8.9 3.9 21 0.553

P09 1 7.6 4 26 0.5407

2 5.8 2.5 8 0.3333

3 14.9 6 44 0.6293

4 10.8 6.5 37 0.5879

P11 1 14.3 10.6 83 0.8301

2 9.9 6.8 37 0.6393

P12 1 8.6 6.4 27 0.6001

Controls (mean ± SD)

8.4 ± 5.2 3.7 ± 1.9 19.7 ± 16.2 0.45 ± 0.2

Abbreviation: MU = motor unit.

FIGURE 4 | Motor unit profiles through sequential axial sections of the lower leg numbered from proximal (1) to distal (22), and zoomed in on the relevant area. (A and B) Subject P09 showing a motor unit at slices 1–6 and another at slices 9–18. (C) Subject P11 showing a single large motor unit in slices 1–10.

Muscle & Nerve, 2026 409

branches to reinnervate fibers within their immediate territory, but these do not extend to reinnervate distant fibers. With limited motor unit loss there is sufficient overlap that all of the denervated fibers lie within a surviving motor unit’s territory, and potentially can be reinnervated. However, with further motor unit loss, regions of muscle containing no overlapping survivors will occur, and further motor unit loss will result in permanent muscle fiber denervation and ultimately fatty replacement. This insular remodeling phenomenon may be the reason that neurogenic “islands” have been shown in a number of muscle MRI studies of neurogenic (but not myopathic) diseases [36]. We have highlighted a number of muscle MRI scans with patchy, heterogenous changes across muscle groups, including some with the same pattern of neuromuscular “islands.” Indeed one of the participants showed a single motor unit which alternated with no overlapping motor units (Figure 4C), demonstrating that all of the muscle fibers in that region belonged to a single motor unit. Despite this, the level of wasting of a muscle, representing the likely degree of polio involvement, was not correlated with measures of motor unit shape complexity.

This technique reveals an important research direction in assessing the neurogenic motor unit. Since we are able to reliably activate a motor unit and detect its location and shape within the muscle, MUMRI may be useful as a longitudinal assessment of a motor unit’s health [20, 37].

We were able to obtain 3D images of only three motor units in two participants, which was a lower yield than our previous study in healthy participants [22]. Partly this was due to the difficulty in identifying discrete, non-overlapping motor units in a given slice, and partly due to difficulties in identifying the same motor unit in adjacent slices. This may be due to the activation characteristics of neurogenic motor units, which show a higher relative spread of threshold variability compared to healthy units [38], and therefore will alternate over a wider current range than healthy units, producing fewer activations. Despite the low yield, the longitudinal extent of the imaged units is comparable to those in healthy controls (mean 8.0 ± 3.8 cm).

Our study has important limitations. While we identified our polio survivor cohort from the British Polio Fellowship and selected according to established criteria, these diagnoses are historical by 60 or more years. Polio itself is a heterogenous disease, and the intervening duration will further contribute to the

heterogeneity of this population. This was seen in the variability of involvement on structural MRI sequences, showing differing degrees of fatty infiltration in different compartments, resulting in reduced contractile muscle volume which in turn was associated with reduced power rating.

There were important sex differences between our polio survivors and control cohort, with a greater proportion of female participants in the polio cohort (6/8) than controls (6/18). Important differences in muscle properties are seen between sexes, with females showing lower MUP amplitudes and higher firing rates than males [39], as well as a higher motor unit count [40], and this may have had a bearing on the differences between cohorts.

While we were able to identify single motor units in 8 out of 12 participants, a fixed-flexion deformity prevented one individual from fitting into the bore of the scanner, and no motor unit activity could be found in two participants, potentially limiting the utility of this technique in late-stage neurogenic diseases.

Despite longstanding efforts to eradicate the disease, polio remains prevalent in several regions of the world, most notably Pakistan and Afghanistan. With increasing global migration and vaccine hesitancy, the number of polio cases is likely to rise [41]. While our study population was exclusively UK patients who had contracted the disease during the polio outbreaks in the 1950s and 60s, a new group of far younger survivors of polio is being recognized who also need accurate diagnosis and monitoring. We believe that MUMRI may have a role alongside conventional EMG in achieving this.

Author Contributions

Stuart Maitland: conceptualization, investigation, writing – original draft, methodology, writing – review and editing, software, formal analysis, project administration, and data curation. Matthew Birkbeck: conceptualization, methodology, writing – review and editing, formal analysis, and data curation. Ian Schofield: conceptualization, investigation, methodology, writing – review and editing, formal analysis, project administration. Lawrence Best: formal analysis, writing – review and editing. James Scott: writing – review and editing, formal analysis. Andrew Blamire: conceptualization, investigation, funding acquisition, writing – review and editing, supervision. Roger G. Whittaker: conceptualization, investigation, funding acquisition, writing – review and editing, formal analysis, project administration, supervision, and resources.

Acknowledgments

The authors would like to acknowledge the British Polio Fellowship for their assistance with recruitment and dissemination of results. They would also like to acknowledge the Newcastle University AGE research group for recruitment of control subjects.

Funding

This work was funded by the NIHR Newcastle Biomedical Research Centre. The NIHR Newcastle Biomedical Research Centre is a partnership between Newcastle University and Newcastle Hospitals, funded by the National Institute for Health and Care Research (NIHR). This work presents independent research funded and supported by the NIHR Newcastle Biomedical Research Centre. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.

TABLE 3 | Multiple-slice (three-dimensional) measurements of

motor units.

Participant

Motor unit number

Max Feret diameters, range (median)

Number of slices

P09 1 3.6–9.1 mm (7.62)

2 6.7–11.2 mm (9.35)

P11 1 4.5–16.1 mm (11.3)

410 Muscle & Nerve, 2026

Ethics Statement

We confirm that we have read the Journal’s position on issues involved in ethical publication and affirm that this report is consistent with those guidelines. Ethical approval was obtained from the Newcastle University Faculty of Medical Sciences Ethics Committee (references 2603/34701 and 1852/525/2020).

Consent

All participants were provided with information and materials prior to recruitment and freely provided consent to take part in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Supporting Information

Additional supporting information can be found online in the Supporting Information section. Figure S1: Fat-free contractile muscle volume versus MRC power. Table S1: Scan parameters for various sequences.

MRI of Neurogenic Human Motor Units Following Poliomyelitis Read More »

Living Well With Post Polio As We Age

LIVING WELL WITH POST-POLIO AS WE AGE Nikki Wingerson, MSW, Ph.D., October 26, 2023

I. Introduction At the Ohio Polio Network 30th Anniversary and 2023 Conference, I was asked, as a mental health professional and member of the OPN Advisory Board, to write an article for OPN. I am an aging 77-year-old who has lived 38 years with Post-Polio Syndrome, so I decided to selectively explore evidence-based literature on both polio and aging to ultimately address living well with Post-Polio as we age. This article provides what I hope is relevant information for any reader about polio and its impacts; physiological changes that come with normal aging; challenges of aging with Post-Polio; suggested adaptations to aging and PostPolio; and a few reflections derived from this exploration.

II. Poliomyelitis

Poliomyelitis is the virus that causes the disease called polio. The virus is capable of attacking nerves in the spinal cord or brain stem, paralyzing muscles related to breathing, speaking, swallowing, and moving one’s limbs. The virus attacks nerves with a shotgun scatter effect, such that the resulting physical symptoms manifest unevenly: One leg might be capable of climbing stairs, the other not. Vaccination against polio since 1955 has eradicated the disease in the United States and in virtually much of the world.

III. Late Effects of Polio and Post-Polio Syndrome: Definitions, Causation, Diagnosis

The Late Effects of Polio (LEoP) is the term for symptoms related to a person having had polio. These symptoms include fatigue; decreased muscle strength and endurance; pain; breathing or swallowing or speech problems; sleep problems; and physical symptoms, such as joint problems and scoliosis. [1]

The LEoP are not associated with re-infection by the polio virus, but rather, with a greater loss of motor neurons than is typical in the normal aging process. Loss of motor neurons leads to increased muscle weakness. Reduced muscle tissue leads to muscle fatigue and pain. Weakened limbs can lead to reduced weight-bearing activity and reduced bone density. Postural abnormalities resulting from polio can lead to pain, and/or sleep or breathing problems. Increased stress on joints can lead to arthritis and pain. [1]

Post-Polio Syndrome (PPS) is a sub-category of LEoP and is a diagnosable neurological condition for those who have had polio, with or without paralysis. PPS is diagnosed 1) when new pain and/or weakness occurs following recovery from the acute illness and 10+ years without new symptoms; 2) when these new symptoms continue for at least one year; and 3) when there is no other clinical explanation for the new symptoms. [1] Nerve Conduction Studies and EMG tests, which measure muscle electrical activity, are sometimes useful in identifying the bases for new symptoms. [6]

The symptoms of Post-Polio Syndrome typically appear 15 to 30 years after recovery from the acute illness. [9] PPS symptoms have been “associated with the degree of residual weakness immediately following [patient] polio infections.” [11] However, PPS symptoms usually are not as severe as those experienced following the acute illness. [6] Along with the symptoms of LEoP noted above, other reported symptoms of PPS include cold intolerance and restless leg syndrome. [9]

The prevalence of PPS among polio survivors is estimated to be 25% – 40%, according to the CDC. [2] Risk factors for PPS include female sex, permanent disability caused by motor neuron damage, respiratory symptoms, muscle overuse and underuse, aging, and “immunologic mechanisms.” [9] The severity of, and degree of recovery from, symptoms caused by the acute illness determine the risk of developing PPS. [9] “As deficits at the end of the disease increase, the probability of experiencing post-polio symptoms increases.” [11]

There are three major theories for the cause of PPS. [8] The prevailing theory for the origin of PPS is based on the fact that recovery from polio involves the body creating new connections between surviving nerve cells and muscles, this to compensate for nerves damaged by the virus. [6] Over time, these compensatory nerve cells or extra nerve branches breakdown due to inflammation, injury, illness, one’s immune system, periods of inactivity, and normal aging. [6] This breakdown can occur anytime [11]

A second theory for the existence of PPS is the persistence of polio infection in the brain and spinal cord. [6] Several studies have shown the existence of polio virus genome fragments in the cerebrospinal fluid of PPS patients. [8]

A third theory for the cause of PPS is delayed immune response to the polio virus, leading to chronic inflammation and, thus, persistent symptoms of polio. [8] One study explicitly states that PPS symptoms were attributed to neuronal loss over time with inflammatory mechanisms, but “without any convincing evidence of viral reactivation.” [9]

IV. Normal Physiological Changes with Aging

With the increased experience of increased age comes wisdom. At the same time, normal aging also poses physiologic limitations apart from those experienced due to PPS. [5]

The Washington Post on October 15, 2023 included an online article by Judith Graham, “What’s normal for the body and brain as we age? An expert weighs in.” The information Graham provides is based on an evidence-based new book by Rosanne Leipzig, “Honest Aging: An Insider’s Guide to the Second Half of Life.” Leipzig is a physician and vice chair for education at the Brookdale Department of Geriatrics and Palliative Medicine at the Ichan School of Medicine at Mount Sinai in New York. Graham describes Leipzig’s book as “the most comprehensive examination of what to expect in later life I’ve come across in a dozen years covering aging.” [3]

In her article, Graham notes that explaining how we change with aging is difficult, because the aging process is gradual, decadeslong, and influenced by one’s behaviors, as well as one’s economic and social circumstances, and the like. There are common and predictable physiological changes, but the sequence and timing of these changes vary from one person to the next. [3]

Graham delineates some of the age-related issues that Leipzig describes in her book. Importantly, she includes why these changes occur, not covered here due to space constraints. Older people often present with different symptoms than do younger people when they have the same illness, and they often react differently to the same medication. Indeed, due to physiologic changes with aging, older people often require lower doses of medications which they have taken for years. Older people more frequently experience cognitive changes related to medications and illness than do younger people. These cognitive changes are normal and not a sign of dementia. Also, due to physiologic changes with aging, older people experience less musculoskeletal flexibility; weakened tendons and ligaments; reduced joint range-of-motion; reduced height; decreased muscle mass, strength, and energy; and reduced sense of hunger, thirst, taste, smell, and appetite. Older people require more energy for daily tasks and more protein for maintaining and building muscle. [3]

With aging, balance is compromised due to changes in the inner ear, the brain, and the vestibular system. Compromised balance, along with reduced bone density, leads to more frequent falls and fractures among the aging. Older people require more light to read, and more time to adjust to changes in available light. They experience difficulty in hearing, especially higher-frequency sounds and rapid speech. They find it more difficult to fall or stay asleep. Finally, people’s information-processing and reaction times slow with aging, while new learning, multitasking, and word-finding become more difficult. [3]

V. Aging with Post-Polio

In general, conditions which impact the aging population, including age-related chronic diseases, such as high blood pressure, diabetes, heart disease, COPD, and osteoporosis, may occur “more frequently, and at younger ages” among those who are physically disabled. [10] This is because health issues and barriers to maintaining health are often increased in the physically disabled population. Thus, those who are aging as well as physically disabled “need preventive services and at younger ages.” [10]

New symptoms in aging polio survivors might include pain at rest; cold intolerance; issues related to standing, walking, and climbing stairs, which increase both fall risk and accessibility issues. [4] PPS patients lament the lack of accessible public spaces, new lack of accessibility to friends’ homes, and the cost of purchasing assistive technology and services. [2] In one study, research participants were surprised at the nature of their fatigue, as it seemed unrelated to their physical effort. Some expressed surprise that they could no longer rely on parts of their body which they had previously relied upon. [4] All of these new symptoms and issues can lead to greater social isolation.

Psychological features might include reliving original polio trauma; recognition that former coping behaviors, such as “blending in,” no longer work; shame; lack of motivation; and fear of injury. [4] Fatigue due to PPS must be distinguished from fatigue due depression. Risk factors for depression include one’s previous illness experience, attitude towards disability, previous coping style, nature of physical changes, and degree of increased impairment, as well as the quality of one’s support. [12]

Interestingly, one study of aging post-polios found “modest increased weakness which may be commensurate with normal age.” These researchers found a discrepancy between patient experience with growing weakness and actual measurements of strength and neuronal loss, the measurements indicating “modest declines.” This discrepancy was considered likely due to “increased sensitivity due to their disease experiences… they lost so much strength at the time of their illness that any change is very noticeable to them.” [11]

VI. Adaptations to Aging and Post-Polio Syndrome

According to Graham, Rosanne Leipzig, in her evidence-based new book, recommends the following for adapting to age-related changes: Seek medical attention for sudden changes in functioning. Regularly ask your physician what each of your medications is for, and whether or not continued usage and dosages are currently appropriate. Engage in physical activity and in balance and resistance exercises. Stay well-hydrated – “Drink liquids even when you aren’t thirsty” – and eat sufficient protein. Have your eyes checked annually. Use hearing aids, if you find keeping up with conversation difficult. Two to 3 hours before bedtime, avoid exercise, alcohol, and heavy meals. Reduce multitasking and pace yourself. [3]

Post-Polio Syndrome management includes energy conservation; pacing of physical activities to avoid overuse; frequent rest periods; avoidance of stress; avoidance of cold temperatures; avoidance of pain with exercise; use of assistive devices; surgeries for joint repair; respiratory, occupational, and/or speech therapies; exercise physiology; podiatric care; dietetic consultation for weight management; use of mental health specialists and support groups to meet emotional needs; and planning ahead for one’s every move. [1] [2] [4]

The theory of PPS causation as an immune response to the polio virus leading to chronic inflammation proposes “treatment with immune modulators as means of combating the chronic inflammation.” [8] Management might include immunoglobulin to reduce “proinflammatory cytokines present in the cerebrospinal fluid of the spinal cord.” [9]

Aging is “often seen through the lens of the biomedical model of health, which focuses on preventing and curing medical problems causing disability.” Disability is often seen through the lens of the “social model of health, which focuses on building inclusive environments and eliminating systemic barriers.” [2] Both lenses are needed for clear vision towards patient quality of life. Living well with Post-Polio as we age requires an individualized, goal-oriented, comprehensive, interdisciplinary approach, with focus on empowerment and positive self-evaluation. [4]

VII. A Few Reflections

Undoubtedly, there is overlap in symptoms of PPS and aging. Either may aggravate the other. Both PPS and aging populations may experience an increased sense of vulnerability and difficulty accepting help. We aging Post-Polios must trust and honor what our bodies tell us about our need to make adaptations, regardless of how others perceive or judge our capabilities, or what tests might indicate about our strength.

Likewise, there is overlap in adaptations to PPS and aging. The good news is that those with PPS likely have already devised ways to adapt to changes in their physical function prior to experiencing the effects of advanced aging. In fact, they might consider themselves expert at adaptation.

As a polio survivor, I used to be able to conceal my left arm paralysis, the only polio residual I had for years. I was encouraged to find ways to do physically most everything that my peers could do. I was fortunate, for the most part, to be able to “blend in.” Then, at the age of 39, about 35 years after I had polio, I began having trouble climbing stairs. An orthopedic specialist described my legs as “misaligned,” in that polio had impacted muscular function in each leg differently. I had not known my legs were impacted at all.

I was informed that I had Post-Polio Syndrome. I gradually made adjustments. While I had to make adaptations that my non-polio peers did not have to make, I was exceedingly fortunate in having much remaining physical ability, adequate supports, and the financial means to hire help or buy equipment as needed.

Now I use a railing and climb stairs one at a time, since only one particular leg can lift me up each stair. I use a sling to support my limp arm. I’ve had to ask for assistance like never before. The difference for me now is that as I look around, I see that I have company among my aging non-polio friends in the use of assistive devices and asking for assistance. I “blend in,” but in a different way now. Aging has become a common leveler.

If age makes common bedfellows of us all, then I am in good company. Perhaps I can let go of past capacities with a bit more grace, if I view my increasing limitations from that perspective.

Living well with Post-Polio as we age requires that each of us find our own unique way to capitalize on our strengths and move forward, just as we always have. We need to take seriously suggested adaptations to PPS and aging, such as those noted above. That said, I rest my case and will adjourn for my regularly scheduled nap.

VIII. References

1 Better Health Channel, 2021, Victoria State Government Dept. of Health. Polio Australia. Retrieved October, 2023. https://www.betterhealth.vic.gov.au/health/conditionsandtreatments|polio-and-post-polio|syndrome

2 Duncan, Andrea and Batliwalla, Zinnia, “Growing old0er with post-polio syndrome: Social and quality-of-life implications,” NIH National Library of Medicine, National Center for Biotechnology Information. Retrieved October, 2023. Sage Open Med. 2018; 6: 2050312118793563 . Published online Sep 3.2018.

doi: 10.1177/2050312118793563 PMCID: PMC6122244 | PMID: 30202523

3 Graham, Judith, “What’s normal for the body and brain as we age? An expert weighs in,” The Washington Post. Published online October 15, 2023. Retrieved October 15, 2023.

4 Hammarlund, Catherina Sjodahl, Lexell, Jan, and Brogardh, Christina, “Perceived consequences of aging with late effects of polio and strategies for managing daily life: a qualitative study,” BMC Geriatrics. 17, Article No. 179, 2017. Retrieved October, 2023. https://doi.org/10.1186/s12877-017-0563-8

5 Jensen, Mark P., Ph.D., Department of Rehabilitation Medicine, Hughes M. and Katherine G. Blake Endowed Professor in Health Psychology, University of Washington, Seattle, Washington, “Aging Well with Post-Polio Syndrome,” Post-Polio Health. Vol. 25, No. 1, Winter, 2009. Retrieved October, 2023.

6 LeWine, Howard E., MD, Reviewer as Chief Medical Editor, Harvard Health Publishing, “Post-Polio Syndrome,” Harvard Health. March 24, 2023. Retrieved October, 2023.

7 Li Hi Shing, Stacey, Chipika, R.H., Finegan, Eoin, Murray, Deirdre, Hardiman, Orla, and Bede, Peter, Computational Neuroimaging Group, Academic Unit of Neurology, Biomedical Sciences Institute, Trinity College Dublin, Dublin, Ireland, “Post-polio Syndrome: More Than Just a Lower Motor Neuron Disease,” Frontiers Neurol. 16 July 2019, Sec. Neurodegeneration Vol. 10, 2019. Retrieved October, 2023.

10:773. doi: 10.3389/fneur.2019.0073. PMID: 31379723; PMCID: PMC6646725

8 Morolake, Amole and Khouzam-Skelton, Nadine, with Lobmann, Raif, Academic Editor, “Diagnosing Post-Polio Syndrome in the Elderly, a Case Report,” Geriatrics (Basel). Jun; 2 (2): 14, 2017. Published online 2017 Apr. 30. Retrieved October, 2023. doi:10.3390/geriatrics 20 200 14 PMCID: PMC 637 1137\PMID: 310 11024 https://doi.org/10.3390/geriatrics2020014.

9 Oiuwasanmi, Oiuwaseyi Jacob, McKenzie, Devaunna Adrene, Adewale, Idowu Oluwasegun, Aluka Christian O, Iyasse, James, Olunu, Esther, and Fakoya, Adegbenro Omotuyi, “Postpolio Syndrome: A Review of Lived Experiences of Patients,” Int J Appl Basic Med Res. 2019 July-Sep; 9 (3): 129-134. Retrieved October, 2023. doi 10.4103/ijabmr.lJABMR 333 18 PMCID: PMC665 2271 | PMID: 31392174

Living Well With Post Polio As We Age Read More »

Precision Vaccinations Polio Outbreaks 2023

POLIO OUTBREAKS 2023

Authored by Staff

Last reviewedMarch 12, 2023

Fact checked by Robert Carlson, MD

Fact checked by Holly Lutmer PharmD

CONTENT OVERVIEW

Poliovirus detection in Montreal, New York, London, Israel in wastewater continue in 2023. Polio outbreak information is fact-checked by medical professionals.

Polio Outbreaks March 2023

Poliovirus (Poliomyelitis) has been recently confirmed in wastewater and ground samples in non-endemic countries in Africa, the Americas, Asia, Canada, Europe, India, Israel, the United Kingdom, and New York (NY).

To notify the international community, the U.S. Centers for Disease Control and Prevention (CDC) issued an updated Global Polio Alert – Level 2, Practice Enhanced Precautions notice on March 7, 2023, regarding polio outbreaks and poliovirus detections in various countries. As of March 10, 2023, the New York Department of Health informed New Yorkers planning to visit Israel in 2023 and other countries with circulating poliovirus to confirm their polio immunization status prior to traveling abroad.

On September 13, 2022, the U.S. was added to a list of about thirty countries where circulating vaccine-derived poliovirus (cVDPV) was recently identified. On September 1, 2022, the CDC’s Clinician Outreach and Communication Activity Call presented: How to Recognize and Report Polio and Reinforce Routine Childhood Polio Vaccination.

As of March 2, 2023, there has been 1 confirmed polio (acute flaccid paralysis) case and 7 reports of patients under investigation in the U.S. (Washington) during 2023. There have been 723 confirmed polio cases in the U.S. since August 2014. An interactive timeline traces polio outbreaks from 1580 B.C. to 2022.

WHO Polio Public Health Emergency of International Concern 2023

On February 2, 2023, the World Health Organization (WHO) confirmed the spread of poliovirus remained a Public Health Emergency of International Concern (PHEIC) concerning Wild poliovirus type 1 (WPV1) and Circulating vaccine-derived poliovirus and recommended the extension of Temporary Recommendations for three months. This WHO issued a report (EB152/19, Dec. 2022) on implementing the Strategic Action Plan on Polio Vaccine Transition (2018–2023). In addition, the polio-endemic countries of Afghanistan and Pakistan have been associated with recent polio outbreaks in other countries, according to the Global Polio Eradication Initiative (GPEI).

Poliovirus Wastewater Detections 2023

Related poliovirus type 2 (PV2) isolates were identified in sewage samples collected in Canada, London, Israel, and New York in 2022. As a result, the U.S. CDC announced on November 30, 2022, that it would expand wastewater testing in the U.S. Dr. José R. Romero, Director of CDC’s National Center for Immunization and Respiratory Diseases, indicated that poliovirus testing would continue into early 2023.

Poliovirus Detroit, Michigan

The U.S. CDC announced plans to collect wastewater samples in communities near Detroit, Michigan. Preliminary testing will last at least four months. Oakland County, Michigan’s population is about 1.2 million. On August 23, 2022, Michigan reported 31% of young children were overdue for routine vaccinations, including polio.

Poliovirus Philadelphia, Pennsylvania

The U.S. CDC announced it would begin collecting wastewater samples from Chester County, with a population of about 500,000 near Philadelphia, PA, for analysis at CDC’s polio laboratory.

Poliovirus New York March 2023

As of March 8, 2023, the U.S. Centers for Disease Control and Prevention (CDC) and the State of New York confirmed sequencing analysis confirmed the presence of circulating vaccine-derived poliovirus (cVDPV2) in 100 samples collected genetically linked to a polio patient (Acute flaccid myelitis) identified in July 2022 in Rockland County, NY, signaling its continued circulation and a health risk to residents.

To enhance local detections, the New York State Department of Health announced on January 23, 2023, that it received $21.6 million in funding to expand its wastewater surveillance and infectious disease monitoring capabilities. NY’s wastewater network reaches all 62 New York counties and, during 2023, will increase the number of participating sewer sheds from 125 to over 215, reaching 16 million New Yorkers, about 81% of the population served by public sewer systems.

Beginning in April 2022, genetically related poliovirus has been detected in wastewater samples collected in Rockland County, Orange County, Sullivan County, Nassau County, Brooklyn (Kings County), and Queens County. On September 28, 2022, a ‘Declaration of an Imminent Threat to Public Health for poliovirus’ was issued by Mary T. Bassett, M.D., M.P.H. Commissioner of Health, NY.

In response to these poliovirus wastewater findings, the Governor of NY, Kathy Hochul, announced on October 9, 2022, she extended Executive Order 21.1, expanding the vaccination authorities for certain NY health providers. And New York State issued HEALTH ADVISORY Update #3 Regarding Poliovirus, which says unvaccinated New Yorkers or those not up to date with immunizations who live, work, go to school in or visit Rockland County, Orange County, New York City, Sullivan County, and Nassau County are at risk of contracting the paralytic disease and should speak with their healthcare provider regarding polio vaccination options.

As of March 2023, the New York Health Department states that under specific situations, a one-lifetime booster dose of IPV should be offered to adults who have previously completed their polio vaccination series and are at the highest risk of infection. Areas considered to have community transmission of poliovirus include those where poliovirus has been repeatedly detected in wastewater. As of January 27, 2023, polio booster doses are not recommended for individuals traveling to the New York City metropolitan area, including Rockland, Orange, or Sullivan Counties, merely because of their travel status.

Local polio vaccination resources: Nassau County, NY, webpage, New York City locations; Orange County, NY, webpage, Rockland County, NY, areas, Sullivan County, NY, Public Health at 845-513-2249, and Cattaraugus County, (NY) Public Health.

Polio in the Americas

As of March 2023, the Pan American Health Organization (PAHO) published AFP Surveillance Data segmented by Country for 2022.

Poliovirus Montreal Canada

On December 23, 2022, the Canada IHR National Focal Point reported detecting a vaccine-derived poliovirus type 2 (VDPV2) in various wastewater samples collected in August 2022 from a wastewater treatment plant and a target site in the city of Montreal, Quebec. Genetic sequencing confirmed it was linked to the cVDPV2 recently detected in New York. Additionally, in January 2023, two cVDPV2-positive environmental samples were collected in Canada. As of January 30, 2023, there have been no confirmed or suspected cases of acute flaccid paralysis (AFP) being investigated in the affected Canadian jurisdiction in 2022 – 2023.

Polio Israel 2023

As of March 10, 2023, Israel has been confirmed with both cVDPV2 and cVDPV3, and there is evidence of the continued existence of poliovirus in the wastewater sewage of many localities. In early March 2023, JPost reported the Health Ministry announced that an unvaccinated child from the Safed region in Galilee arrived at Ziv Medical Center and was found positive for (cVDPV2) acute flaccid paralysis (AFP). On March 2, 2023, the Times of Israel reported the Health Ministry confirmed three other children tested positive for poliovirus.

Poliovirus London

The UK Health Security Agency (UKHSA) declared a “national incident” in June 2022 after poliovirus detection in sewage in London, England. Detection of 118 genetically linked poliovirus isolates related to the serotype 2 Sabin vaccine strain collected in 2022, reported The BMJ and The Lancet. In addition, vaccine-derived poliovirus type 2 isolates environmental samples were found in several north and east London boroughs that were genetically linked to a polio case reported in New York and Israel.

Acute Flaccid Myelitis Polio-Like Virus

The U.S. CDC reported on March 2, 2023, there has been one confirmed AFM case in 2023 out of 7 reports of patients under investigation. AFM is an uncommon but serious neurologic condition caused by viruses, including enteroviruses (EV-D68). It affects the nervous system, specifically the area of the spinal cord called gray matter, which causes the muscles and reflexes in the body to become weak.

During 2022, the CDC reported 43 confirmed AFM cases in 24 states, indicating about a 35% increase from 2021. There have been 723 confirmed cases (children) since the CDC began tracking AFM in August 2014.

Acute Flaccid Paralysis

Acute Flaccid Paralysis (AFP) surveillance is the standard for detecting cases of poliomyelitis in anyone under 15 years of age. For AFP surveillance standards, please visit the WHO-recommended surveillance standard of poliomyelitis. Date of last update: 10/09/2022.

Post-Polio Syndrome

As polio survivors progress through life, a significant proportion develops neurological symptoms known as Post-Polio Syndrome (PPS), says the U.S. NIH. Characterized by new, gradual, and progressive muscle weakness and wasting, difficulty swallowing, joint or muscle pain, and general fatigue after being stable for many years, the non-contagious PPS typically develops 15 to 40 years after people have recovered from polio.

The first medical reports of PPS appeared in France in 1875. Further research published in the 1950s identified significant damage to nerve cells within the spinal cord. However, as the UK-based Polio Survivors Network concludes, PPS has no set pattern of nerve damage. The U.S. CDC posts additional clinical and diagnostic information about poliovirus infection as of August 10, 2022.

Poliovirus Shedding

The WHO, the UK Health Services Agency, the European CDC, and the U.S. National Institutes of Health (NIH) say three types of vaccines can prevent polio but they may indirectly enable virus shedding. However, research demonstrates that poliovirus transmission predominantly follows the oral-fecal route. In addition, concerns remain about the potential for persistent transmission of OPV viruses, as these viruses are known to revert toward wild-type neurovirulence.

Polio Vaccines Approved

Polio is a vaccine-preventable disease, says the U.S. CDC. For the latest polio vaccine information, visit this PrecisionVaccinations webpage.

Polio Outbreak News 2023

March 10, 2023 – New York issued a travel advisory for anyone visiting Israel.

February 23, 2023 – Wastewater sequencing analysis by the CDC confirmed the presence of poliovirus in a total of 100 positive samples of concern in New York.

December 23, 2022 – Canada reported detections of VDPV2 in wastewater samples.

December 19, 2022 – The WHO announced polio had become a high-risk disease in Indonesia.

December 7, 2022 – The WHO reported 2.61 million under-five children were immunized with the trivalent oral polio vaccine in Somalia.

November 30, 2022 – “Wastewater testing can be an important tool to help us understand if poliovirus may be circulating in communities in certain circumstances,” said Dr. José R. Romero, Director of CDC’s National Center for Immunization and Respiratory Diseases. “Vaccination remains the best way to prevent another case of paralytic polio.

November 17, 2022 – The latest Annenberg Science Knowledge national panel survey finds that a sizable portion of the U.S. public is unfamiliar with the risks of polio. Only a third of U.S. adults know there is no cure for polio, and over 22% of adults do not know whether they’ve been vaccinated against polio.

October 27, 2022 – New York State Health Department issued a Polio Letter to Providers & Polio Publication Request Form – Notification ID: 109528 – This is an urgent plea: as the most trusted source of medical guidance for your patients and their families, we need your help to make sure that any child who is not vaccinated or up to date with polio immunizations gets all the recommended doses immediately. This is particularly urgent for providers and patients in Rockland, Orange, and Sullivan Counties, where poliovirus has been detected in wastewater repeatedly.

October 19, 2022 – The UK Health Security Agency is investigating the extent of poliovirus transmission across north-east and north-central London. Based on recent sampling, poliovirus is considered present in sub-areas of the Beckton plant covering all or parts of the following London boroughs: Barnet, Brent, Camden, Enfield, Hackney, Haringey, Islington, and Waltham Forest. The sampling has also detected the virus in lower concentrations and frequency in areas adjacent to the Beckton catchment area to the South (immediately below the Thames) and the East.

October 12, 2022 – The Lancet published: Sustained detection of type 2 poliovirus in London sewage between February and July 2022. Interpretation: Environmental surveillance allowed early detection of poliovirus importation and circulation in London, including whole-genome sequences generated through nanopore sequencing, established linkage of isolates and confirmed transmission of a unique recombinant poliovirus lineage that has now been detected in Israel and the USA.

October 9, 2022 – New York state extends and expands Executive Order 21.1 – Continuing the Declaration of a Statewide Disaster Emergency Due to the Ongoing Spread of Polio in the State of New York.

September 28, 2022 – New York State Department of Health issued Advisory #3 regarding poliovirus detections. It recommended polio-preventive vaccinations, and the Commission issued a Declaration of an Imminent Threat to Public Health for poliovirus.

September 9, 2022 – NY State Health Department confirmed that of the 50 wastewater samples, 31 poliovirus samples were collected in Rockland County, 13 in Orange County, 6 in Sullivan County, and 1 in Nassau County. In response, NY’s governor declared a State of Disaster Emergency.

September 2, 2022 – The UKHSA reported following advice from the Joint Committee on Vaccination and Immunisation that all children aged 1 to 9 years in London need to have a dose of polio vaccine now – whether it’s an extra booster dose or to catch up.

September 1, 2022 – The U.S. CDC is investigating a case of poliomyelitis, or paralytic polio, in New York state.

August 26, 2022 – The New York State Department of Health confirmed that sequencing analysis performed by CDC has now detected poliovirus in four samples from Sullivan County, two collected in July and two collected in August, which are genetically linked to the case of paralytic polio previously identified in Rockland County. Already, poliovirus had been identified in samples collected in Rockland County, Orange County, and NYC, the types of poliovirus that can cause paralysis in humans.

August 25, 2022 – The JAMA Network published a Perspective: What Physicians Need to Know About the Polio Resurgence in New York State.

August 19, 2022 – New York Department of Health HEALTH ADVISORY: Update #2 Regarding Poliovirus in New York State: All children, adolescents, and adults who are unvaccinated or under-vaccinated should be brought up to date with all routine CDC-recommended IPV doses. This is particularly important and urgent if they live, work, attend school, or have frequent social interactions with Rockland and Orange Counties communities.

August 19, 2022 – The U.S. CDC published: Public Health Response to a Case of Paralytic Poliomyelitis in an Unvaccinated Person and Detection of Poliovirus in Wastewater — New York, June–August 2022. Twenty specimens from wastewater samples collected during May, June, and July were genetically linked to viruses from the patient’s stool samples. This case highlights the risk of paralytic disease among unvaccinated persons.

August 17, 2022 – Long-Term Immunogenicity of Inactivated and Oral Polio Vaccines: An Italian Retrospective Cohort Study. Protective antibodies against all three polioviruses persisted for at least 18 years after administration of the last vaccine dose.

August 16, 2022 – The U.S. CDC issued an MMWR – Public Health Response to a Case of Paralytic Poliomyelitis in an Unvaccinated Person and Detection of Poliovirus in Wastewater — New York, June–August 2022.

August 12, 2022 – Poliovirus Confirmed in NYC’s wastewater by the New York State Department of Health. and NYC Health issued: 2022 Health Alert #20: Update on Poliovirus in New York City.

August 4, 2022 – “Based on earlier polio outbreaks, New Yorkers should know that for every one case of paralytic polio observed, there may be hundreds of other people infected,” State Health Commissioner Dr. Mary T. Bassett said. HEALTH ADVISORY #1: Update Regarding Poliomyelitis in Rockland County, New York State.

July 13, 2022 – Israel’s Ministry of Health published updated polio vaccination guidelines #6.

July 3, 2022 – Israel’s Operation Two Drops 2022 polio vaccine program reached over two million children.

April 2, 2022 – Israel reported potentially eight polio cases in 2022.

March 15, 2022 – The Israeli Ministry of Health, under guidance from the Consultant Committee on Poliovirus, launched a nationwide vaccine operation, ‘Two-Drops 2022,’ for additional vaccination against polio for children.

1997 – Duration of Poliovirus Excretion and Its Implications for Acute Flaccid Paralysis Surveillance: A Review of the Literature.

https://www.precisionvaccinations.com/polio-outbreaks-2023

Precision Vaccinations Polio Outbreaks 2023 Read More »

Covid Vaccines The Polio Survivor

Covid-19 vaccines & the polio survivor

The recent pandemic has thrown into sharp relief the crucial part that vaccines can play in subduing / mitigating and halting the spread of viruses whether that be the polio virus, yellow fever or in this case the corona virus COVID-19. However, with the availability of social media many untruths, falsehood and lies are spreading regarding who should or not be vaccinated. This paper draws on medical sources and journals around the world and sets out to help explain where polio Survivors fall, in whether they should be vaccinated or not. It purely applies to the polio Survivor but does make reference to those who may have co

morbidity.

In researching this paper and contacting medical authorities one thing has become abundantly clear – the power of the pharma companies and the fear of running foul of them or being sued.

The one clear fact, from all the regulatory bodies, European Medical Agency (EU), Medical Regulatory Health Authority (UK), Centre for Disease Control (EU/USA) Federal Food & Drug Administration (USA) and the equivalent bodies in Australasia is that whatever the risk from some vaccines might be, remaining unvaccinated and contracting COVID-19 is far more dangerous and in 1:800 cases will lead to death. Many Covid Survivors will go on to having serious long term affects that in many instances will be life changing.

The Process for Regulatory Approval:-

All medicines must be approved by the medical/drug licensing authority of the country or group of countries before they can be widely used in either oral or injectable solution, there are some exceptions to this in certain cases where fast tracking is needed. The Covid vaccines are no different. A pharma company will develop a new treatment and then submit it together with all supporting documentation for scrutiny by the licensing authority. Part of the documentation will be the results of trials in the tertiary stage for human volunteers. In certain cases, such as cancers the pharma company will recruit those suffering from the disease and put these volunteers through a double-blind test, meaning some will get the drugs, others not. In both cases neither the doctors involved, nor patients will know which they received until results are revealed. This same double-blind procedure has been used in all the COVID-19 vaccines currently licensed. However, there was one important difference these volunteers were recruited by self referral and were drawn from across a cross section of society. Medical histories of the volunteers were taken to ensure their safety but from what has been reported no specific groups were targeted for inclusion – although some such as pregnant women were excluded. Our enquiries have failed to reveal whether the tests included any polio Survivors. However, statistically if taking a cross section of society, one would have thought it would have done.

Post Regulatory Approval

After approval procedure and the drug / vaccine etc goes into use a reporting system, called the yellow card system, is initiated so that doctors, medical authorities and others may report adverse effects. This how the blood clotting instances came to light and which have attracted so much attention. It should be noted that 2 cases of blood clotting have also been reported with the Pfizer vaccine, but the majority are among those who received the AstraZeneca Oxford (now renamed Vaxzevria vaccine) and the Johnson & Johnson (branded Janssen in Europe) vaccine. What are the facts?

Blood Clots – The Facts:

Blood clots, including the extremely rare cerebral sinus thrombosis (CST), occur in unvaccinated people as well as those who have had Covid and/or a Covid vaccine.

Cases that may be linked to vaccination typically occur 5 to 28 days after the first dose of Oxford/AZ . The risk of dying from one is in the order of one in a million. There have been 6 cases among the Johnson & Johnson cohort out of 6.8 million doses administered, including one death and one still critically ill. The incidence rate in the AZ vaccine is statistically similar. All those who have been affected, to date (14/5/21), are female under the age of 50. Interestingly these two vaccines are produced on the same technology and micro biology as the Polio vaccines that have been administered to tens of millions around the world with no apparent side effects reported in decades.

Symptoms of CST include a headache lasting more than four days after vaccination that is persistent, worse on coughing and straining and not relieved by simple painkillers. Others include blurred vision, stroke-like symptoms and pain in the ear/face.

Clots outside the brain (deep vein thrombosis and pulmonary embolus) can cause swelling of the leg, calf pain, shortness of breath, chest discomfort and coughing up blood. Low platelet levels (another rare side effect associated with CST) may cause unusual bruising and a characteristic pinprick reddish/purplish rash that does not blanch with pressure (use the side of a glass).

The fact that these side effects have been reported does not show the vaccines are failing, according to medical sources, rather it demonstrates how robust the “yellow card” reporting system is in flagging up problems.

Who should and should not get the COVID-19 vaccine? – Yale Medical School

COVID-19 can cause severe medical complications and lead to death. There is no way to know how COVID-19 will affect individuals. A person who contracts COVID-19, can spread the disease to family, friends, and others, especially the elderly with the risk of much higher mortality, 1:800, than from vaccine complications.

Getting a COVID-19 vaccine helps protect the recipient and others around them from COVID-19, particularly people at increased risk of severe illness from COVID-19.

Can people with allergies get the COVID-19 vaccine? Yes, with 2 exceptions:

∙ People with a severe allergic reaction (anaphylaxis) to any component of the COVID-19 vaccine should NOT receive the vaccine.

∙ People with a severe allergic reaction (anaphylaxis) to any vaccine or injectable (intramuscular or intravenous) medication should consult with their caring physician, or the providing authority to assess risk before receiving any COVID-19 vaccine.

Everyone else with severe allergic reactions to foods, oral medications, latex, pets, insects, and environmental triggers may get vaccinated.

People with severe allergies require a 30-minute observation period after vaccination, while all others must be observed for 15 minutes. Vaccine clinics have safety protocols in place to respond to any adverse reactions, i.e. Epipens/Adrenaline.

If I am pregnant or breastfeeding? A pregnant or breastfeeding person may choose to be vaccinated against COVID-19. The American College of Obstetricians and Gynaecologists (ACOG) recommends that the COVID-19 vaccine should not be withheld from pregnant or breastfeeding individuals.

There are limited data about the safety of COVID-19 vaccines for people who are pregnant. Pregnant people are at increased risk for severe illness from COVID-19 and may be at risk for adverse pregnancy outcomes. If pregnant and in work places, the individual is at a high risk for COVID-19 infection, the benefits and risks of the vaccine should be discussed with the relevant healthcare provider.

Currently, there are no data on the safety of COVID-19 vaccines in breastfeeding people or on the effects of mRNA vaccines on the breastfed infant or on milk production/excretion, however mRNA vaccines are not thought to be a risk to the breastfeeding infant. Although definitive data are not yet available, maternal antibodies passed to the infant via breastmilk may provide protection as seen with antibodies to other viruses. Breastfeeding people should discuss the benefits and risks of the vaccine with their healthcare provider.

Is the vaccine as effective in people with suppressed immune systems? Specific efficacy and safety data are not yet available for people with immunosuppression due to medications or chronic illness. People with autoimmune conditions or who are immunocompromised are not excluded from getting the vaccine. Those who are vaccinated should be guided on the potential for reduced immune responses and the need to continue to follow all current guidance to protect themselves against COVID-19. If an individual is immunocompromised or has an autoimmune disease, this is a matter for discussion and decision between the individual and their doctor or other healthcare provider.

A paper published on 13^thApril 2021 by APNEN (a Portuguese medical body) states:- “It is not uncommon for patients with autoimmune disease to have doubts about vaccination. Should I get vaccinated? Is any type of vaccine compatible? What are the recommendations? To address these and other doubts we spoke with Dr. Herval Ribeiro Soares Neto, who explained the importance of vaccination in those dealing with a chronic disease or condition such as Multiple Sclerosis (MS), an autoimmune progressive disease in which the immune system attacks the central nervous system (brain & spinal cord).

He said “There are several myths and arguments against vaccination. And when it comes to immunisation in autoimmune diseases, the misinformation is usually greater. Therefore, first of all, we need to reinforce that the gain with immunisation, in general, is very large, exceeding individual prevention.”

Can children get the COVID-19 vaccine? Not yet. No vaccine can be widely given to children until it has been tested in them. The current mRNA COVID-19 vaccines were not studied or approved in children younger than 16 years of age.

The Pfizer mRNA vaccine is authorized for people 16 years and older. The Moderna mRNA vaccine is authorized for people 18 years and older.

Should I get the COVID-19 vaccine even if I’ve already had COVID-19? The extent to which antibodies that develop in response to COVID-19 infection are protective is still under study. If these antibodies are protective, it’s not known what antibody levels are needed to protect against reinfection. Therefore, even those who previously had COVID-19 can and should receive the COVID 19 vaccine.

I was recently diagnosed with COVID-19 can I receive the vaccine? Yes, for Dose #1 you can be vaccinated four weeks after onset of symptoms or a positive test (whichever is earlier). For Dose #2 you may be vaccinated after you have completed your isolation period.

Isolation is for 10 days or 10 days plus 24 hours with no fever and an improvement in symptoms.

OTHER OPINIONS: –

As stated above the majority of those approached did not want their opinions either quoted or attributable. However, Dr Peter Brauer, an honorary EPU Member and author for many years on Post-Polio Sequalae (ICD10-CM-B91) and Post-Polio Myellitic Syndrome (ICD10-CM-G14) has informed us that “ According to my continual research into vaccines I , according to my opinion, do not recommend vector vaccines such as Astra Zeneca, Sputnik V and

Johson & Johnson for polio survivors, The alternatives would be mRNA vaccines such as Biontech-Pfizer and Moderna. Permission for the mRNA vaccine of Curevac is pending.”

Dr Richard Bruno, another long-standing researcher and author on the subject said “I reviewed the manufacturer’s data bases and the Centre for Disease Control (USA), and then did a survey of the Post Polio Coffee House. No adverse effects with Pfizer or Moderna in polio Survivors. Just sore arm, some fever. .Polio Survivors not more likely to get blood clots so at same risk as general population re AstraZeneca”

Peter Thwaites who runs Polio Warriors and spends large part of his time in the Philippines said “I gather from a conversation I had with a PPS specialist that any of the vaccines are suitable for polio Survivors and the fuss about the Johnson/AstraZeneca vaccines is completely unnecessary but the EMA/MHRA won’t commit.”

CONCLUSION:-

When it was realised that vaccines were not years away but months, bodies such as the European Commission, European Medical Agency, Centres for Disease Control, Federal Drug Administration said they would run co-ordinated and co-ordinating roles. For example, in Europe central purchasing and distribution, this has fallen apart for many reasons, part political, part logistical, part nationalistic. The fact is that all the bodies have declared these vaccines safe and effective and it is only now in these extremely rare blood clotting events that restrictions have been imposed. Even then different national opinions and maybe prejudices come into play. For example, in Ireland the AstraZeneca vaccine will only be given to those over 60, in the UK over 30.

As far as polio Survivors are concerned there is little or no evidence either way as to which vaccine suits them best. In the main opinion is extremely scarce and divided. From our research, and opinions submitted we can find no greater risk to polio Survivors from the vaccines than to the general population, including blood clotting.

UPDATE – 15^thApril 2021 – Denmark stops all use of Oxford AZ Vaccine – Source The Times, London

Denmark has become the first country to stop using the Oxford-AstraZeneca vaccine in all age groups because of a putative link to a blood disease that the government believes to affect

about one in 40,000 recipients.

https://www.thetimes.co.uk/article/85e10178-9d49-11eb-a908-ec96e110073e?shareToken=93cbac453be6ee1b8ed17ca732d4563b

UPDATE – 16^thApril 2021 – CDC USA scotch rumours on social media that vaccines cause women to become infertile and re-activate the Polio Virus, Types 1,2, & 3 – Source Washington Post, New York Times

UPDATE -17^thApril 2021 – Paper published by Oxford University following study on rare blood clotting events estimate chances are 4:1,00,000 for Vector vaccine (i.e. AZ / Johnson & Johnson) and 5:1,000,000 for mRNA vaccines(i.e. Pfizer & others) – Source Oxford University Research Website

Update – 17^thApril 2021 – Centre for Disease Control – announces mRNA vaccines approved for pregnant women following examination of records for results and yellow card system on 70,000 pregnant women vaccinated without problem – Source: Centre for Disease Control, Washington

UPDATE – 17^thApril 2021 – CEO of Pfizer Pharmaceutical reported as saying he anticipates 3^rdjab of their vaccine will be required 6-12 months after first round as no definite data on how long vaccine created antibodies last – CNN.

UPDATE – 17^thApril 2021 – BBC reports that UK Dept. of Health to start giving 3^rdjab to first recipients of vaccine given in December/January 2021. Campaign expected to cover 4 most at risk cohorts and commence in October. Might be undertaken at same time as flu campaign.

Issued for and on behalf of the European Polio Union 19^thApril 2021

All material checked and verified but the EPU is a support group without medical authority. Errors and Omissions excepted

Covid Vaccines The Polio Survivor Read More »

Variant of COVID Virus

Variant of Covid Virus

– Kindly shared with us by Eddie Bollenbach M.A. biology

You have probably heard of the new variant of COVID

virus in the United Kingdom and also another mutant

strain in South Africa with similar mutations to the UK

variant. Let’s constrain ourselves to the UK mutant.

The reproductive number or Ro of the wild strain is

1.1 which means 10 infected people will typically

infect 11 others. It is believed that the reproductive

number Ro of the mutant strain is 1.5, which by division you can find that the new virus seems 70% more infectious. 10 people will most commonly infect 15 people.

The difference in infectivity is not enough to mean we cannot control the virus by mask-wearing, social distancing, and hand washing. It can be handled.

Now, since the genetic code of the new variant differs in 6 places in the spike protein, but USA Today says 8 places, the result is that two amino acids in the spike protein are different from the wild type. A protein is a long chain of amino acids linearly bonded to one another. Then this long line of amino acids folds a couple of times to give us the shape of the protein. A change of 2 amino acids in the spike protein will result in a slightly different shape for the spike protein. In this new variant, there are a whopping 17 new mutations altogether.

Since the shape of the spike protein matters because it is the target of antibodies induced by vaccination the concern arises regarding the antibody shape combining with the new spike protein shape.

The good news is vaccinologists believe the vaccines will still be effective and work. Continuing research is going on now in Britain to measure this.

This variant will soon be all over the world if its Ro is higher than that of the wild strain. The US hasn’t closed its border to people from the UK because the strain is probably here already and it will be treated the same way as our original wild-type strain.

In the foreseeable future we will learn more about this variant so stay tuned.

Variant of COVID Virus Read More »

COVID Vaccine info BPF

https://www.britishpolio.org.uk/covid-19-vaccination-advice

COVID 19 VACCINATION

INFORMATION

Be aware that information on COVID-19 and vaccines is changing daily. Your own GP can give you up to date advice on whether a vaccine is right for you based on your personal health circumstances. This information has been published on 07/12/2020 please ensure you are following our most up to date information. The purpose of this publication is for information only. The British Polio Fellowship disclaims all liability for any claims, losses, damages, costs and expenses incurred as a result of reliance on this information. It is not a substitute for advice from your doctor, physiotherapist or other health care professional

Pfizer vaccine roll out and polio

The trials to date have reported very few safety issues and no evidence to suggest that people who have had polio or have PPS should not take the COVID 19 vaccine if offered. Most people in the UK who had polio are over 65 and are at higher risk of serious illness from COVID-19, so the clinical experts advising the BPF believe that they should have the vaccine unless advised otherwise by their health care professional.

The NHS expect to offer the Pfizer vaccine first to people who live in care homes and care home workers, to people over 80 yrs, and to health and social care workers.

Younger women should be aware that there is no safety data as yet for those who are pregnant or breastfeeding or planning a pregnancy within three months of the first dose and they are advised not to come forward for vaccination until at least 2 months after the vaccine. If they have received the first dose inadvertently while pregnant, the 2nd dose should be given after pregnancy.

Does having had polio or the polio vaccine give immunity?

You may have heard reports suggesting that having had polio gives immunity to COVID 19 – this is not backed by any clinical evidence.

You may have also heard reports that the polio vaccine gives immunity – again, this has no clinical backing. (In fact, most people in the UK are given the polio vaccine , so if the polio vaccine did give immunity – there would have been no COVID 19 epidemic in the UK). What has been discussed is that receiving live vaccines might possibly give protection against other diseases, but this has not been proven. The World Health Organisation does not recommend the live oral polio vaccine (OPV) for the prevention of COVID-19.

Will I be given priority because I had polio?

Polio/PPS is not specifically on the list of conditions that is considered to make people clinically extremely vulnerable to COVID-19 and the BPF will continue to advocate for this to happen. However, members may be offered the Pfizer virus sooner as they may fall in the priority vaccine list , such as is they live in a care home or are over 80yrs.

Some people who had polio will have significant respiratory (breathing) problems or other health conditions not related to polio which may make them clinically vulnerable or clinically extremely vulnerable. For advice on your individual suitability for or benefit from the vaccine, you should consult your GP or pharmacist ensuring they understand your polio and other medical history. They will be able to take into account your personal health risk and will have the latest information on the vaccine.

Do we still need to take precautions?

The government advice still is in place to take precautions around ‘Hands, Face, Space’. Even after the vaccine is rolled out, it will take time for an immune response to build up and for the NHS to determine how long the protection lasts. Everyone should continue to practice due care and everyone must continue to follow whatever measures are in places locally (such as the Tier system).

Sources: NHS, Joint Committee for Vaccine and Immunisation, the UK government website for information on priority groups and the Pfizer BioNTech vaccine information – accessed 4/12/2020

The British Polio Fellowship

CP House, Otterspool Way, Watford, WD25 8HR

COVID Vaccine info BPF Read More »

PHI Covid Vaccine

COVID-19 Vaccine

Information for Polio

Survivors

As the COVID-19 vaccines are approved for use and

begin to be given to Americans and others, PHI has

begun receiving questions from our constituents.

Remember our knowledge about the COVID-19 virus

is only about one year old and is continually being

updated which means information and

recommendations sometime change from month to

month. Your primary care physician, especially one

that has worked with you for some time, is the best source of information of what will be recommended for YOU and your particular situation.

At this time, December 2020, here is how our Medical Advisory Committee is responding to these questions:

Does having had polio or having received the polio vaccine give immunity to COVID 19? There has been a “theory” circulating that recent expose to some viral diseases or vaccines to those viral diseases might “boost” the immune system and provide some protection against COVID-19 but that is not backed by any clinical evidence. (If a history of receiving the polio vaccine did provide protection against COVID-19, then the older people living in the developed world, most of whom have been immunized against polio, would have a very low incidence of novel coronavirus infections, and that is clearly not the case!)

Will I be given priority because I had polio? No, a history of polio does not in itself make a person more likely to get COVID-19 or get sicker than others of similar age and other medical conditions. So, a history of polio and/or PPS does not move an individual up the priority list. On the other hand, most people who contracted polio in the United States or Canada are over age 65 and several even over 80 years old. Therefore, they are already in the “high risk” group, which generally places them in the second tier of people slated to be offered the vaccine. Polio survivors with respiratory compromise may rise up one level over others of a similar age group due to their underlying respiratory condition; likewise for the polio survivor living in a nursing home or other senior living situation. In the US, each state, with input from the national health authorities, determined their own priority list, so where you fall in the priority tier system may vary slightly from state to state.

After I get the vaccine, even the first dose, can I stop with all these “precautions”? We don’t know all the particulars, but studies have shown less than 50% immunity two weeks after the first dose which rises to greater than 90% protection two weeks after the second dose. Our colleagues in the British Polio Fellowship summarize the precautions as “Hands, Face, Space,” and the recommendation is to continue these precautions until enough people have received the vaccine to minimize the risk of exposure from the general public.

Why do I need two doses? Because tests to date with the vaccines that are currently available have shown only partial protection after the first dose and a much better immune response after the second. This is not unusual for vaccines—to get full immunity from polio a minimum of three (3) doses are recommended and four (4) are usually given; the shingles vaccine is a series of two

shots as are the measles, mumps, and rubella vaccine and the chickenpox vaccine. As new

COVID-19 vaccines are developed and approved it is possible that, at some point, we will have a single dose COVID-19 vaccine that is safe and effective, but not yet.

Can I get COVID-19 from the vaccine? No, the technology used to make the COVID-19 vaccine does NOT use any live virus or even part of the virus particle. All the new vaccines were made by breaking and then artificially duplicating part of the genetic code contained in the spikes on the surface of the COVID-19 virus. They work by blocking the virus from attaching to your cells and then invading your cells and causing infection.

When all the vaccines become available which one(s) should I get? THE FIRST ONE THAT BECOMES AVAILABLE TO YOU, REGARDLESS OF WHETHER ONE OR TWO DOSES!

Who should not get the vaccine? For now, it has not been adequately tested in youngsters under the age of 16 years or in pregnant women, so it is recommended that the vaccine not be given to those individuals until studies show the vaccines to be safe and effective in these groups.

There have been a few cases of severe allergic reactions in people with multiple significant allergies to other substances, so, for now, persons with allergies severe enough to carry an Epi Pen should discuss with their physician before being immunized.

-PHI Medical Advisory Committee

Taken from:

https://post-polio.org/covid-19-vaccine/

PHI Covid Vaccine Read More »

Late Effects of Polio a guide to management for medical professionals

Late effects of polio

A guide to management for medical professionals

ON YOUR TRUSTED TEAM FOR LIFEBackground

The World Health Organisation estimates there are 20 million people worldwide currently

living with some degree of disability caused by poliomyelitis (1). Not all polio survivors were

diagnosed with paralytic polio. However, 99% of all polio survivors may have experienced

sub-clinical damage that becomes more evident with age.

The late effects of polio is a neuromuscular condition that can occur in a high percentage

of people with prior exposure to polio. In Australia, it is estimated there are tens of thousands

of polio survivors. International surveys indicate there is up to 80% prevalence of late effects

of polio in polio survivors.

As late polio symptoms progressively worsen, patient coping mechanisms used for many

years may no longer be effective. Over time, partners and carers of polio survivors may

find themselves providing more assistance to the polio survivor. As the progression may

be gradual, the polio survivor and carers may not initially understand or appreciate the

magnitude of the impact of the late effects of polio on their lives.

Impact of polio

In the acute disease, the polio virus attacks the motor neurons resulting in varying degrees

of muscle paralysis and weakness. The brainstem is also involved in the initial infection,

particularly the reticular formation, vestibular nuclei, cerebella nuclei, hypothalamus and

thalamus, and the cranial nerves. Recovery involves the reinnervation of orphaned muscle

fibres by nearby neurons, resulting in enlarged motor units and muscle fibre hypertrophy.

Muscles that appear unaffected can have significant subclinical denervation, the effects

of which usually emerge as the polio survivor ages. Beyond the acute phase there is a period

of stable non-progressive level of disability for several decades.

Impact of the late effects of polio

Pathology: The leading causal hypothesis is that excessive metabolic stress on the remaining

motor neurons, possibly due to long term muscle overuse, results in distal degeneration

of terminal axons and eventually loss of motor neurons. The rate of loss is about twice that

of normal aging. After polio ongoing denervation and reinnervation occurs, but with time the

ability to reinnervate orphaned fibres diminishes. This can occur many years later in muscles

that appear normal but have subclinical denervation.

Treatment: There are no medications currently available to prevent or reverse muscular

atrophy, improve neuromuscular strength or relieve the neuromuscular fatigue of late effects

of polio.

The late effects of polio:

a gradual or sudden onset of progressive and persistent new muscle weakness or

abnormal muscle fatigability (decreased endurance), with or without generalised

fatigue, muscle atrophy, or muscle and joint pain. Sudden onset may follow a period

of inactivity, trauma, or surgery. Less commonly, symptoms attributed to late effects

of polio include new problems with swallowing or breathing.Presentation

Polio survivors may present with new weaknesses, pain, neuromuscular and/or general

fatigue, respiratory difficulties, or sleeplessness. Although affected patients may refer to their

prior episode of polio, many do not willingly disclose past exposure due to past significant

stigma they may have experienced due to polio infection.

As early symptoms of the late effects of polio, such as fatigue, are commonly experienced

by the general population, polio survivors may live with significant and worsening problems

for a considerable time before seeking medical help.

New symptoms may also reawaken the emotional distress experienced during the initial

disease, making discussion difficult for patients. This emotional distress may extend

to traumatic experiences in hospitals and health care facilities, and a general wariness

or mistrust of medical advice.

Diagnosis

The diagnosis of late effects of polio relies nearly entirely on clinical information. There are

no laboratory tests specific for this condition and symptoms vary greatly among individuals.

An extensive work-up including laboratory tests, imaging studies, cerebrospinal fluid

sampling, detailed electrophysiological evaluation, and muscle biopsies may be required

to exclude alternative diagnoses. The diagnostic criteria for Post-Polio Syndrome was first

proposed by Halstead in 1991 (3) and evolved over time to the current March of Dimes

diagnostic criteria (4, 5) which include:

Prior paralytic poliomyelitis with evidence of motor neuron loss, as confirmed

by history of the acute paralytic illness, signs of residual weakness and muscle atrophy

on examination, or signs of denervation on EMG.

A period of partial or complete functional recovery after acute paralytic poliomyelitis,

followed by an interval (usually 15 years or more) of stable neuromuscular function.

Gradual onset (rarely abrupt) progressive and persistent new muscle weakness or

abnormal muscle fatigability (decreased endurance), with or without generalised fatigue,

muscle atrophy, or muscle and joint pain. Onset may at times

follow trauma, surgery, or a period of inactivity. Less

commonly, bulbar dysfunction or respiratory weakness occurs.

Symptoms that persist for at least a year.
Exclusion of alternative neuromuscular, medical, and orthopaedic problems as causes

of symptoms.

Suggested recommendations for GPs include:

› Including a ‘tick box’ on the new patient registration form for your practice

promoting patients about their polio history

› Conduct an annual health check to review mobility, swallowing and respiratory

problems of polio survivors

› Check current psychological status of polio survivors.Diagnostic considerations:

Anaemia
Chronic infection
Collagen disorders
Deconditioning
Depression
Hypothyroidism
Infectious myopathy
Myasthenia gravis
Deconditioning and weakness

with the ageing process

Weight gain

Differential Diagnoses 5

› Amyotrophic Lateral Sclerosis in Physical Medicine and Rehabilitation

› Hypothyroid Myopathy

› Multiple Sclerosis

History Checklist

Polio infection and treatment

(if known)

› Age at onset, severity and progression

› Respiratory impact in acute phase

› Acute management

› Age at best recovery

› Maximum functional recovery

History since polio › Change in functional ability, degree,

speed and nature of change

Present status › Recent changes in activity levels,

employment, environment, nutritional

status, general health and lifestyle

Assessment

Effective assessment requires a full history and review of symptoms, including:

› Early experiences of polio. Explore the physical and psychological impact on their lives.

Identify areas affected in the original polio episode and extent of recovery. Document

any residual long-term effects of initial polio episodes, individuals who have very severe

residual weakness, individuals who had early bulbar respiratory difficulty in the acute

illness, and persons who were older when they contracted acute polio. Late polio

symptoms also tend to occur first in weaker muscles.

› Natural history of presentation. Document and differentiate symptoms of late polio,

including their pattern and progression.Pattern and impact of physical activity

Chronic overuse of affected or unaffected muscles can trigger or exacerbate symptoms.

Health professionals need to make enquiries into activity levels in paid or unpaid work,

sports/fitness training or daily living.

Enquiries need to include any changes to levels or intensity of physical activity.

Fatigue, weakness and pain. Exclude other possible causes of fatigue. The presentation

of fatigue in a polio survivor patient may resemble other conditions and risk potential

misdiagnosis.

Commonly used assessment tools such as manual muscle testing can give a false impression

of strength as one-off movements may be strong. However, polio survivors often show poor

endurance over repeated movements or during sustained activity.

Respiratory insufficiency may develop insidiously, initially at night, in individuals who

appeared previously unaffected, although respiratory disorders are most prevalent in

patients with residual muscle weakness. Symptoms may include unrefreshing sleep, frequent

wakening, waking with headaches, daytime sleepiness, waking gasping or difficulties lying

flat. Obstructive sleep apnoea is also common in polio survivors.

These complications are most prevalent when there is an additional strain on the respiratory

muscles such as respiratory infections, periods of immobility, surgery or obesity. Assessment

for respiratory complications should be considered both for those with night-time symptoms

or daytime effort-related shortness of breath.

Difficulty with swallowing is a potentially serious problem for people living with late effects

of polio. Common symptoms include increased swallowing time and food catching in the

throat. Weakness in pharyngeal constrictor muscles are common in late polio, even in the

absence of symptoms. Patients should also be assessed for risk of aspiration pneumonia.

If swallowing difficulties are suspected, referral to a speech therapist is strongly

recommended. The referral should advise that any tests involving observing muscle action

need to involve several repetitions to assess the impact

of abnormal neuromuscular fatigue.

Cold intolerance is common but underreported

and can affect motor function and comfort.

Walking and postural disturbances.

Difficulty in walking can be due to progressive

weaknesses and joint instability. Walking

problems are more common in people

who have used mobility assistance devices

in the past and have discarded them.

Postural problems can be related

to spinal malformations and weaknesses

in truncal muscles.Recommended management interventions

A multidisciplinary approach:  The ideal approach involves coordinated

multidisciplinary treatment often involving rehabilitation specialist doctors, GPs,

physiotherapists, occupational therapists, orthotists, other medical specialists and allied

health professionals as required (see referral criteria).

Energy management techniques: Successful energy management techniques, best taught

through referral to a specialist physiotherapist or occupational therapist, can help alleviate

the symptoms of neuromuscular and general fatigue and reduce pain. Techniques include:

› Pacing activity  Effective in reducing neuromuscular fatigue and pain and may

improve performance for some.

› Energy conservation  Adapting, simplifying and prioritising daily tasks can

preserve energy and avoid neuromuscular fatigue and pain.

› Aids and appliances  These can help in energy management. Late effects

of polio patients may need encouragement to use aids, which may remind them

of the original polio.

Orthotics:  An orthotics review by an experienced specialist can help reduce overuse

and misuse and reduce energy cost of walking by optimising orthoses and footwear.

Optimised orthotics may help reduce falls.

Respiratory management:  For respiratory insufficiency, confirmed by a respiratory

specialist, due to weak respiratory muscles or scoliosis, respiratory support in the form of

non-invasive ventilation, normally bilevel positive pressure (BiPAP), usually only at night,

is the recommended treatment. Continuous positive airway pressure (CPAP) is used for

obstructive sleep apnoea. If secretion retention is an issue, a respiratory physiotherapist can

advise on positions of treatment and devices such as cough assist that might be useful in the

case of a persistently weak cough.

Exercise and physical activity:  Once good energy management is established, these

can be considered under the guidance of a specialist physiotherapist with experience in

management of neurological conditions, to strengthen muscles where possible and help

improve cardiovascular health.

Caution: safe effective exercise for people with late effects of polio requires an individually

tailored non-fatiguing, pain-free program and careful monitoring to avoid overuse.

Pharmacological management:  As there is no medication proven to reverse the progress

of late effects of polio, pharmaceutical interventions are aimed at alleviating symptoms such

as fatigue, pain and poor sleep. To date, none have been proven to reduce the fatigue and

neurological weakness of late effects of polio. Some medications can alleviate pain and are

used after energy management techniques have been tried.

Psychological therapies:  May be helpful in treating symptoms such as depression

and anxiety. They may also enhance the efficacy of physical interventions by promoting

behaviour change and improving the ability to cope with physical symptoms.

The strength of the evidence is indicated:

 very strong.  strong.  for some.  may help, caution advised!Side effects of some medications can worsen symptoms of late effects of polio including

increased weakness, fatigue, respiratory depression or muscle pain/cramps:

› Anabolic steroids: Steroids are not recommended to improve muscle bulk as the risks

due to side effects greatly outweigh the potential benefits. Metabolic stimulants such

as L-Carnitine and Coenzyme Q10 have been studied and used in some parts of Australia

but have not been proven to be effective.

› Intravenous immunoglobulin: The efficacy and safety of intravenous immunoglobulin

is currently the subject of a multi-centre randomised controlled trial.

› Statins: Many polio survivors have read that some medication classes are bad for

them, including statins. While some statins may lead to muscle fatigue and pain, health

professionals are best placed to provide advice to patients with late effects of polio and

to monitor any potential side effects of statins.

› Anaesthetics: Anaesthetics can cause gastro-oesophageal reflux, tachyarrhythmia and,

sometimes, difficulty maintaining blood pressure.

› Sedatives: Patients with the late effects of polio are nearly always very sensitive to

sedative medications, and emergence can be prolonged. This is probably due to central

neuronal changes, especially in the Reticular Activating System, from the original disease.

› Analgesics: People with late effects of polio may experience breathing problems.

As opioid based analgesics can depress breathing, precaution should be taken when

prescribing them in a patient with the late effects of polio.

› Vaccination: Pneumococcal and influenza vaccinations are recommended.

Nutrition and weight management:  Dietary advice to optimise nutritional status may

also support functional status of the person with the late effects of polio. Weight loss may

help reduce neuromuscular fatigue and pain, taking account of probable low proportion of

lean mass and low mobility. A person being underweight may be due to poor diet, swallowing

issues or difficulty shopping/cooking and may impact late effects of polio symptoms.

Caution: if advising exercise, ensure you recommend a safe and effective program.

Other conditions: Management also needs to include treatment of other conditions which

occur more commonly in polio survivors such as osteoporosis and peripheral neuropathies.

Smoking cessation advice and support may help prevent worsening respiratory function

and vascular complications in a person with the late effects of polio.

Regular monitoring: As the polio survivor with features of the late effects of poliomyelitis

will potentially decline functionally with time, regular annual review helps identify changing

and progressive symptoms and early opportunities to intervene and adapt the individual’s

management program accordingly.

Criteria for referral to secondary care

› Development of new neurological symptoms

› Progression or deterioration of longstanding neurological symptoms

› Uncertainty regarding the diagnosis of late effects of polio

› Advice about symptom management of late effects of polio, especially where respiratory

complications or dysphagia are suspected

› Need for advice on failure of treatment that was previously effective in late effects of polio

› Need for specialist advice on orthotics, biomechanics and orthopaedic problems.1300 774 625

enquiries@spinal.com.au

spinal.com.au

Resources and References

Orthotic Management of Polio and Postpolio Syndrome (2019). William Lovegreen,

Michael, Kwasniewski, Preeti Panchang, Marcus J.Smith Atlas of Orthoses and Assistive

Devices (Fifth Edition) 2019, Pages 277-288.e2

Front. Neurol., 16 July 2019 Post-polio Syndrome: More Than Just a Lower Motor Neuron

Disease. Stacey Li Hi Shing, Rangariroyashe H. Chipika, Eoin Finegan, Deirdre Murray,

Orla Hardiman and Peter Bede https://doi.org/10.3389/fneur.2019.00773

Halstead LS. Assessment and differential diagnosis for post-polio syndrome. Orthopedics.

(1991) 14:1209–17.

March of Dimes. Post-polio Syndrome: Identifying Best Practices in Diagnosis and Care.

(2001). Available online at: post-polio.org/edu/pps.html

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

Ther. Clin. Risk Manag. (2010) 6:307–13. doi: 10.2147/TCRM.S4440

Postpolio Syndrome: emedicine.medscape.com/article/306920-overview. (Updated:

Jun 24, 2019) Author: Divakara Kedlaya, MBBS; Chief Editor: Stephen Kishner, MD, MHA

This Post Polio booklet has been officially

recognised as an Accepted Clinical Resource

by The Royal Australian College of General Practitioners.

Supported by

19212.04.2020

Late Effects of Polio a guide to management for medical professionals Read More »

Common Misconceptions PPS

Common Misconceptions Concerning the Post-Polio Syndrome

Peter Brauer MD

“Someone once said that everyone has the right to their own opinion but not to those based on their own facts.” John Robbins

Currently, over 99% of physicians do not possess the knowledge required to treat polio survivors for a polio encephalic-myelitis and the Post-polio syndrome (PPS). The general level of knowledge ranges from strongly predominant ignorance to superficial perceptions and half-truths masked with misjudgement, even though the poliomyelitis disease, also known as infantile paralysis, is one of the best studied infections in the world. Due to professional ignorance, the state of recognition and the state of knowledge differ catastrophically. This is clearly at the expense of the affected patients, most of whom are misdiagnosed and subsequently wrongly treated.

For PPS patients, a misdiagnosis rate of more than 99 percent must be assumed, including asymptomatic and abortive infection courses with their sequelae. Even under the exclusive consideration of paralytic illness cases, the polio survivors still have approximately the same magnitude of misdiagnosis.

With a few exceptions, the condition PPS exceeds the imagination of those who are not affected to a point of complete incomprehension. This lack of understanding ranges from family members, friends, acquaintances, work colleagues, doctors, health insurance companies, medical services, physiotherapists, health and social services, expert ascertainment services, right up to the social courts. The patient affected has to explain countlessly everywhere, whereby encountering unbelief and ignorance and is accused of being a know-all if he is a disease related informed patient and also not infrequently discredited even to the extent of being regarded as psychosomatic, depressive or even as a simulant.

Just a few errors or opinions offered as facts repeatedly in everyday practice prevent an adequate PPS diagnosis. These are referred to below:

* Poliomyelitis is a disease of the anterior horns of the spinal cord

This statement consists of several half-truths.

Poliomyelitis is not just an illness, but already disease-worthy as an infection, since as such, it leaves permanent damage to the central nervous system (CNS), under which the spinal cord and brain are to be understood. 2. On infection, the spinal cord is mostly affected. The brain on the contrary is always affected. So it is strictly speaking, a polio-encephalic-myelitis disease.
Infection and illness lead to damage in the CNS. It usually occurs in the spinal cord, but always causes consequential damage to the brain. Strictly speaking, the brain is “preferentially” infested, which means that during the incubation phase it is reached the fastest through the blood stream by the most massive of the polio viruses. 4. Not only the anterior horns of the spinal cord, but also the side horns and hind horns, as well as the dorsal root ganglia, may be affected.

* Poliomyelitis is a disease of the alpha motor neuron

This statement is imperfect.

It is strictly speaking a polio-encephalic-myelitis (see above)
Not only alpha motor neurons, but nerve cells, which innervate the muscular fibres of voluntary movement and nearly all neuro-regulatory brain areas such as brain activation, motor skills, pain regulation, the temperature regulation, respiratory regulation, stress regulation, sensitivity, cardiac circulatory regulation, hormone regulation and emotion regulation, can be affected.

* The bulbpontine and the encephalitic form of polio infection are extreme rare

This statement is incorrect in its incompleteness.

All polio infections are encephalitic and can damage the whole brain, mostly functional depending on the functional load for a more or less long period, as a result of the ability of the brain to compensate (equalization = neurogenic plasticity), which remains hidden (subclinical) to the outside. About 5 – 10% of course forms with visible (clinical) symptoms show involvement of the central nervous system (CNS). Thus, according to general understanding, the abortive, the aparalytic and paralytic forms are meant, of which the paralytic form in about 1% of cases of infection can

be found. With regard to the Post-polio syndrome, the subclinical bulbopontine and encephalitic infectious history are virtually always given, only the clinical proportion is relatively rare.

* The polio disease follows a stable phase after recovery

This statement is imperfect.

It is not a real stable phase, but a clinically stable phase with a subclinical unstable background. The losses of destroyed nerve cells are compensated through previously damaged and / or healthy nerve cells. The functional and structural compensation process is subject to constant reconstruction and decomposition with a limited durational magnitude. This is only clinically visible after a loss of about 50% of the nerve cells in a functional area due to functional impairment or functional failure. Even before this limit is exceeded, a subclinical PPS degenerative process may exist, which always emanates from the brain.

* The stable phase lasts at least 10, 15 or even 20 years

This statement is incorrect.

PPS is a degenerative disease of the overburdened balancing nerve cells of the brain and spinal cord. Transient processes in the musculature are also affected. The period up to their overload failure depends on the magnitude of the previous damage and the duration and extent of the relative or absolute load / overload. This can last from a few years, rarely months, up to several decades, without an upper time limit.

* A polio illness must be known for a PPS diagnosis

This statement is incorrect.

98% of polio infections go unnoticed without disease or are uncharacteristic but also carry a PPS risk. On clinically and / or epidemiologically probable infections on diagnosis, is also at least a possible post viral late effect to be taken into consideration.

* A PPS after an aparalytic polio is not credibly proven

This statement is incorrect.

A PPS can be expected with the aparalytic, the abortive and the inapparent (asymptomatic) infection course. A credible verification being the same as a proof of claim does not exist for the paralytic course of infection. Clinical and para-clinical findings are generally unspecific with PPS, or otherwise even mainly inconspicuous. Decisive is a compulsory thorough medical case history. This applies for all infection courses of polio-encephalic-myelitis. Polio related damage to the central nervous system (CNS) is proven in all infections of the asymptomatic, the abortive, aparalytic and paralytic courses. In any case, this results with the risk of a later PPS.

* For a PPS diagnosis disease consequences must be apparent

This statement is incorrect.

Visible sequelae such as muscle paralysis and muscle atrophy need not exist. 99% of polio infections occur without paralysis and their consequences such as muscular dystrophy, however not without a PPS risk. Also, paralysis may have regressed in the recovery phase after the disease.

* A preserved sensitivity is required for a PPS diagnosis

This statement is incorrect.

During the polio infection, areas of sensitivity such as in the dorsal root ganglia or in the brain can also be damaged and later lead to PPS symptoms.

* At least two or more characteristic symptoms must exist for a PPS diagnosis

This statement is incorrect.

The requirement for at least two or more existing symptoms is par excellence medical nonsense. Any indicative symptom of over 100 possibilities may or may not be required to exist. The virus infestation of nerve cells is irregular in location and extent, therefore also the late effects. In addition, weak symptoms are often not perceived or not registered as disease worthy. One mostly initially unique indicative symptom is sufficient for the suspected diagnosis.

Proofing symptoms do not exist. All possible indicative symptoms may be single or in different combinational occurrence. They may or may not be constantly present. Their occurrence can be timely, vary locally and in strength.

* The symptoms must have persisted for at least 1 year for a PPS diagnosis

This statement is incorrect.

The PPS usually begins insidiously creeping, but can also be suddenly noticeable. A diagnosis is obligatory on its beginning. The probability of a different causative disease with the same symptoms or additionally causative disease is always possible. However, the PPS diagnosis never excludes parallel diseases as indicative symptoms. Consequently, the diagnosis PPS is not limited in time tied to a minimum duration of its symptoms. It is also mandatory with changing symptoms.

* Other diseases must be excluded for a PPS diagnosis

This statement is incorrect.

The exclusion of other diseases serves to prevent their treatment not to be missed out and not just purely a PPS confirmation. Their presence does not exclude the PPS, because an exclusion diagnosis cannot be excludable as such. Parallel diseases are possible. In the presence of corresponding symptoms, the PPS diagnosis has to be kept independent from other illnesses. The suspected diagnosis thus remains.

* A new increasing muscle weakness must be present for a PPS diagnosis

This statement is incorrect.

Although new muscle weaknesses are common, they are not a condition for a PPS diagnosis. Predominantly the first, most frequent and main symptoms are states of fatigue, which often register very late as disease-grade with slow onset and progression. In addition to exhaustion, for example, pain, as an indicative symptom, occurs without evidence of apparent muscle weakness.

* Clinically ill conditions with polio survivors should not automatically suggest a PPS This statement is misleading.

Without exception and in addition to other illnesses with polio survivors, PPS should always be considered automatically.

* The causes of the PPS are still unknown

This statement is incorrect.

PPS is the result of a chronic relative as well as absolute overload, caused by a polio infection with or without disease of previously damaged and diminished healthy nerve cells, which depending on the strength and duration and result of overloading, after a more or less long period of time, die-off. It is therefore as in sports medicine defined described as an overtraining syndrome. Only the molecular sequence of event processes are not yet known, which do not matter for the diagnosis and the required symptomatic treatment

* The Post-polio syndrome is very rare

This statement is incorrect.

When only 1% to 1%o of polio infections have a paralysis, but all the infection courses have the risk of a later PPS, the reported cases of paralysis are multiplied by 100 to 1,000 to reach the approximate real number of polio-infected. According to the official risk profile gained from the proportion of the population, this results in the fact that there are actually always more PPS patients as defined under the definition for rare disease. A rare disease is considered to be less than 1 patient in 2,000 inhabitants.

* Post-polio syndrome is not a disease

This statement is incorrect.

The term syndrome is used to describe “… the simultaneous presence of various symptoms, so called symptoms” (Wikipedia) with known cause and unknown development. Only with known cause and known development is the term

syndrome usually avoided and generally described as clinical picture. In that sense, it is an unfortunate choice of the consensus to call the polio late effects term a Post-polio syndrome, as this is a disease where cause and development – with the exception of molecular biology processes – are known. On the other hand, this term refers to the characteristic variety of possible symptoms and the complexity of the disease, which is quite an advantage for primary diagnostic understanding. This is also followed by the WHO in their classification of diseases ICD 10 with the code G 14 Post-polio syndrome as a name for an independent disease.

* Post-polio syndrome is an immunological disorder

This statement is incorrect.

With PPS, nerve cells die-off as a result of chronic overload. The cellular decomposition process leads to the release of cell components, some of which are protein molecules that activate the immune system. This has a local inflammatory reaction resulting in the framework of cell debris removal. In some cases, it can also release poliovirus fragments from cell-inactivated and fragmented polio viruses, which lead to this nonspecific reaction. Freed virus genetic material (RNA) in the form of fragments can therefore also directly trigger an immune response. This is secondary non-causative to the PPS immune process. Immunological inflammatory processes can also be primarily triggered through chronic stress without structural degenerative processes. Chronic stress is one of the main causes of the Post-polio syndrome. The brain is also affected by this process.

Conclusion

As long as the polio-encephalic-myelitis is considered just to be polio-myelitis with almost exclusive limitation to the consequences of the body motor system in the form of pitiable paralysis and skeletal deformities, whereby other consequences of the infection to the spinal cord and especially to the brain, are not considered, then the late effects, the Post-polio syndrome cannot be understood and thus not properly diagnosed and treated. As long as clinical proof and para-clinical symptoms or finding requirements for a diagnosis are continuously being sought, where in any exclusion diagnosis, as even in this case only naturally indicative, which do not exclude such a disease and parallel diseases from the outset, misdiagnosis and mistreatment are inevitable. The basis for the detection of a Post-polio syndrome is the medical case history. No diagnosis in the case of a suspected Post-polio syndrome is already a misdiagnosis!

Updated version of an article in the German publication: ” Supplement zu Aspekte des Post-Polio-Syndroms“ pages. 22-27 Published through the Polio Initiative Europa e.V. (ed.) 2016 New stand: 07/2019 Translation: German to English by: Thomas House-Arno (Tom House) on the 23/7/2019

Common Misconceptions PPS Read More »

Links to Medical Articles regarding Post Polio Syndrome

Article Title	Authors	Link or Journal
A Brief History of Post-Polio Syndrome in The United States	Halstead, L	https://www.archives-pmr.org/article/S0003-9993(11)00135-3/fulltext
A Comparison of Fatigue Scales in Post-Poliomyelitis Syndrome	Vasconcelos, Om; Prokhorenko, Oa; Kelley, Kf; Vo, Ah; Olsen, Ch; Dalakas, Mc; Marinos C; Halstead, Ls; Jabbari, B; Campbell, Ww	https://www.archives-pmr.org/article/S0003-9993(06)00533-8/fulltext
A Comparison of Symptoms Between Swedish and American Post-Polio Individuals and Assessment of Lower-Limb Strength – A Four-Year Cohort Study	Agre, J, Grimby, G, Rodriquez, A, Einarsson, G, Swiggum, E, & Franke, T	https://www.ncbi.nlm.nih.gov/pubmed/8602481
A Double – Blind, Placebo – Controlled Trial of Amantadine for The Treatment of Fatigue in Patients with The Post – Polio Syndrome	Stein Dp , Dambrosia Jm , Dalakas Mc	https://www.ncbi.nlm.nih.gov/pubmed/7611638
A Long-Term Follow-Up Study of Patients with Post-Poliomyelitis Neuromuscular Symptoms	Dalakas Mc, Elder G, Hallett M, Ravits J, Baker M, Papadopoulos N, Albrecht P, Sever	https://www.ncbi.nlm.nih.gov/pubmed/3007983
A Multicenter, Randomized, Double-Blinded Trial of Pyridostigmine In Post-Polio Syndrome	Trojan, D; Collet, J; Shapiro, S; Jubelt, B; Miller, R; Agre, J; Munsat, T; Hollander, D; Tandan, R; Granger, C; Robinson, A; Finch, L; Ducruet, T; Cashman, N	https://www.ncbi.nlm.nih.gov/pubmed/10522877
A Personality Profile of Patients Diagnosed with Post-Polio Syndrome	Clark, K; Dinsmore, S; Grafman, J; Dalakas, M	https://www.ncbi.nlm.nih.gov/pubmed/7936226
A Pilot Study to Determine the Effi Ciency Of Lightweight Carbon Fibre Orthoses in The Management of Patients Suffering from Post – Poliomyelitis Syndrome	Heim M , Yaacobi E , Azaria M	https://www.ncbi.nlm.nih.gov/pubmed/9408670
A Postoperative Respiratory Arrest in A Post Poliomyelitis Patient	Magi E, Recine C, Klockenbusch B, Cascianini E	https://www.ncbi.nlm.nih.gov/pubmed/12492689
A Preliminary Report on the 1952 Epidemic of Poliomyelitis in Copenhagen With Special Reference to The Treatment of Acute Respiratory Insufficiency	Lassen, H	https://www.ncbi.nlm.nih.gov/pubmed/13011944
A Statement About Exercise for Survivors of Polio	Post-Polio Health	https://www.papolionetwork.org/uploads/2/7/7/2/27726699/statement_about_exercise_for_polio_survivors.pdf
A Survey of Post-Poliomyelitis Sequelae: Manifestations, Effects on People’s Lives and Responses to Treatment	Westbrook MT	https://www.ncbi.nlm.nih.gov/pubmed/25026393
Abnormal Movements in Sleep as A Post-Polio Sequela	Dr Richard L Bruno	http://www.postpolioinfo.com/library/grm.pdf
Activity and Post – Polio Fatigue	Packer Tl , Martins I , Krefting L , Brouwer B	https://www.ncbi.nlm.nih.gov/pubmed/1758789
Aging and People Who Have Had Polio	International Journal of Rehabilitation Research	https://journals.lww.com/intjrehabilres/toc/1983/03000
An 8-Year Longitudinal Study of Muscle Strength, Muscle Fiber Size, and Dynamic Electromyogram in Individuals with Late Polio	Grimby, G, Stalberg E, Sandberg A, Sunnerhagen K	https://www.ncbi.nlm.nih.gov/pubmed/9771666
An Association Between the Flat Back and Post-Polio Syndrome	Ring D, Vaccaro Ar, Scuderi G, Klein G, Green D, Garfin Sr	https://www.ncbi.nlm.nih.gov/pubmed/9084358
An Explanatory Model of Health Promotion and Quality of Life for Persons with Post-Polio Syndrome	Stuifbergen Ak, Seraphine A, Harrison T, Adachi E	https://www.ncbi.nlm.nih.gov/pubmed/15522493
An Open Trial of Pyridostigmine In Post – Poliomyelitis Syndrome	Trojan Da , Cashman Nr	https://www.ncbi.nlm.nih.gov/pubmed/8529175
Anaesthetic Implications of Post-Polio Syndrome: New Concerns for An Old Disease	Allan Schwartz, Lisa M, Bosch, B	https://www.papolionetwork.org/uploads/2/7/7/2/27726699/anes-imp-postpolio-1012-p356-361.pdf
Anaesthetic Management for Patients with Post-Polio Syndrome Receiving Electroconvulsive Therapy	Liu S, Modell J	https://www.ncbi.nlm.nih.gov/pubmed/11575559
Ankle-Foot Orthoses That Restrict Dorsiflexion Improve Walking in Polio Survivors with Calf Muscle Weakness	Ploeger, H, Bus, S, Brehm, M, Nollet, F	https://www.sciencedirect.com/science/article/abs/pii/S0966636214005487
Antibody Titer To Poliovirus in Blood and Cerebro- Spinal of Patients with Post-Polio Syndrome	Jubelt B, Salazar-Grueso E, Roos R, Cashman N	https://www.ncbi.nlm.nih.gov/pubmed/7611629
Anticholinesterase – Responsive Neuromuscular Junction Transmission Defects in Post – Poliomyelitis Fatigue	Trojan Da , Gendron D , Cashman N	https://www.ncbi.nlm.nih.gov/pubmed/8383188
Anticholinesterases in Post-Poliomyelitis Syndrome	Trojan Da, Cashman Nr	https://www.ncbi.nlm.nih.gov/pubmed/7611637
Antiganglioside Antibodies in Patients with Acute Polio and Post-Polio Syndrome	Illa, I; Leonmonzon, M; Agboatwalla, M; Ilyas, A; Latov, N; Dalakas, Mc	https://www.ncbi.nlm.nih.gov/pubmed/7611648
Are Polioviruses Playing A Pathogenic Role in The Late Consequences of Polio? Video	Antonio Toniolo, Md, Famh	http://polioplace.org/polioviruses-pathogenic-role
Assessment and Differential Diagnosis for Post-Polio Syndrome	Halstead LS	https://www.ncbi.nlm.nih.gov/pubmed/1758788
Avoiding PPS: “A Pound of Prevention Is Worth A Ton of Therapy”	Dr Richard L Bruno	http://www.postpolioinfo.com/library/ton.pdf
Beneficial Effect of Medical Cannabis in The Treatment of a Pharmacoresistant Nausea Associated with A Somatoform Disorder in A Patient with Post-Polio Syndrome	Bleckwenn, M, Weckbecker, K, Voss, S	https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0043-123897
Biomechanical Abnormalities of Post-Polio Patients and The Implications for Orthotic Management	Perry, J; Clark, D	https://www.ncbi.nlm.nih.gov/pubmed/24525982
Bromocriptine in The Treatment of Post-Polio Fatigue: A Pilot Study with Implications for The Pathophysiology of Fatigue	Bruno Rl, Zimmerman Jr, Creange Sj, Lewis T, Molzen T, Frick Nm	https://www.ncbi.nlm.nih.gov/pubmed/8873700
Cardiac Drugs, High Blood Pressure and Polio Survivors	Dr Richard L Bruno	http://www.postpolioinfo.com/library/CardiacDrugs.pdf
Cardiorespiratory Responses to Aerobic Training by Patients with Post-Poliomyelitis Sequelae	Jones Dr, Speier J, Canine K, Owen R, Stull G	https://www.ncbi.nlm.nih.gov/pubmed/2654435
Cardiorespiratory Responses to Upper Extremity Aerobic Training by Post-Polio Subject	Kriz Jl, Jones Dr, Speier Jl, Canine Jk, Owen Rr, Serfass R	https://www.ncbi.nlm.nih.gov/pubmed/1729974
Case-Studies – Orthotic Management of The Adult Post-Polio Patient	Clark, Dr; Perry, J; Lunsford, T	http://www.oandplibrary.org/op/pdf/1986_01_043.pdf
Characteristics and Management of Post-Polio Syndrome	Jubelt B, Agre Jc.	https://www.ncbi.nlm.nih.gov/pubmed/10904484
Cholesterol Medications and Muscle Pain in Polio Survivors	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/Cholesterol.pdf
Chronic Fatigue, Fainting and Autonomic Dysfunction: Further Similarities Between Post-Polio Fatigue and Chronic Fatigue Syndrome?	Bruno, R.L.	https://www.papolionetwork.org/uploads/9/9/7/0/99704804/chronic_fatigue_-_fainting_and_autonomic_dysfunction.pdf
Cold Intolerance and “Polio Feet” As Post-Polio Sequelae	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/gcold.pdf
Comment on The Description of The Polio Epidemic in Copenhagen	Kristensen, H.	https://www.ncbi.nlm.nih.gov/pubmed/8904275
Comparative Study of Spinal Cord Ubiquitin Expression in Post-Poliomyelitis and Sporadic Amyotrophic Lateral Sclerosis	Ito, H, Hirano, A	https://www.researchgate.net/publication/314508471_Comparative_study_of_spinal_cord_ubiquitin_expression_in_post-poliomyelitis_and_sporadic_amyotrophic_lateral_sclerosis http://dx.doi.org/10.1007/s004010050106
Complications and Outcomes of Complex Spine Reconstructions in Poliomyelitis-Associated Spinal Deformities: A Single-Institution Experience	Godzik, J., Lenke, L., Holekamp, T., Sides, B. And Kelly, M.	https://journals.lww.com/spinejournal/Abstract/2014/07010/Complications_and_Outcomes_of_Complex_Spine.13.aspx
Computed Tomographic Study of The Skeletal Musculature of The Lower Body In 45 Post-Polio Patients	Ivanyi B , Redekop W , De Jongh R , De Visser M .	https://www.ncbi.nlm.nih.gov/pubmed/9533792
Controlled Trial of Modafinil For the Treatment of Fatigue in Post-Polio Syndrome	Vasconcelos, Om; Prokhorenko, Oa; Vo, Ah; Kelley, Kf ; Dalakas, Mc; Lauro, Hs; Jabbari, B; Campbell, Ww	https://www.ncbi.nlm.nih.gov/pubmed/17502549
Correlation of Creatinine Kinase and Gait Measurement in The Post-Polio Population: A Corrected Version	Waring, WP And Mclaurin, TM.	https://www.ncbi.nlm.nih.gov/pubmed/1580772
Correlation of Electrophysiology with Pathology, Pathogenesis, and Anticholinesterase Therapy in Post-Polio Syndrome. Annals of The New York Academy of Sciences	Cashman, N. And Trojan, D.	https://nyaspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1749-6632.1995.tb27540.x
Currents Issues in Cardiorespiratory Care of Patients with Post-Polio Syndrome	Orsini, M et al	http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0004-282X2016000700574
Depression and Life Satisfaction in Aging Polio Survivors Versus Age-Matched Controls: Relation to Post-Polio Syndrome, Family Functioning and Attitude Toward Disability	Bryan J. Kemp, Brad M. Adams, Margaret L. Campbell	https://www.archives-pmr.org/article/S0003-9993(97)90262-8/fulltext
Determining the Anaerobic Threshold in Post-Polio Syndrome: Comparison with Current Guidelines for Training Intensity Prescription	Eric L. Voorn, Msc, Karin H. Gerrits, Phd, Fieke S. Koopman, MD, Frans Nollet, MD, Phd, Anita Beelen, Phd	https://pubmed.ncbi.nlm.nih.gov/24491465/
Diagnosing Post-Polio Syndrome in The Elderly A Case Report	Morolake Amole, And Nadine Khouzam-Skelton	https://www.papolionetwork.org/uploads/9/9/7/0/99704804/diagnosing_post-polio_syndrome_in_the_elderly_-_a_case_study.pdf
Diagnosing Post-Polio Syndrome: Inclusion and Exclusion Criteria	Halstead, L	https://www.researchgate.net/publication/279430632_Diagnosing_Postpolio_Syndrome_Inclusion_and_Exclusion_Criteria
Dieting and PPS: Red Herrings and Low Blood Sugar	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/DietingAndPPS.pdf
Disability and Functional Assessment in Former Polio Patients with and Without Post-Polio Syndrome	Nollet F, Beelen A, Prins MH, et al	https://www.ncbi.nlm.nih.gov/pubmed/10025486
Discussion Paper on The Late Effects of Polio/Post-Polio Syndrome	Georganas, S	https://www.aph.gov.au/parliamentary_business/committees/House_of_Representatives_Committees?url=haa/./leop%20pps/report/index.htm
Dysphagia and Dysphonia Among Persons with Post-Polio Syndrome – A Challenge in Neurorehabilitation	Soderholm, S., Lehtinen, A., Valtonen, K. And Ylinen, A	https://onlinelibrary.wiley.com/doi/full/10.1111/j.1600-0404.2009.01315.x
Dysphagia and Post-Polio Syndrome: Past, Present and Future	Sonies, B	https://www.ncbi.nlm.nih.gov/pubmed/9112316 https://doi.org/10.1055/s-2008-1040995
Dysphagia in Patients with The Post-Polio Syndrome	Sonies Bc, Dalakas Mc	https://www.nejm.org/doi/full/10.1056/NEJM199104253241703
Early and Late Losses of Motor Units After Poliomyelitis	Mccomas AJ, Quartly C, Griggs RC	https://www.ncbi.nlm.nih.gov/pubmed/9278631
Effect of Aquatic Exercise Training in Persons with Poliomyelitis Disability	Prins JH, Hartung H, Merritt DJ, Blancq RJ, Goe- Bert DA	https://www.tandfonline.com/doi/abs/10.1080/15438629409511999
Effect of Intravenous Immunoglobulin in Patients with Post – Polio Syndrome – An Uncontrolled Pilot Study	Kaponides G , Gonzalez H , Olsson T , Borg K	https://www.ncbi.nlm.nih.gov/pubmed/16546773
Effect of Treatment and Noncompliance on Post-Polio Sequelae	Peach, Pe; Olejnik, S	https://www.ncbi.nlm.nih.gov/pubmed/1758787
Effects of Lamotrigine on The Symptoms and Life Qualities of Patients with Post-Polio Syndrome: A Randomized, Controlled Study	On Ay , Oncu J , Uludag B , Ertekin C	https://www.ncbi.nlm.nih.gov/pubmed/16403993
Effects of Resistance Training in Combination with Coenzyme Q10 Supplementation in Patients with Post-Polio: A Pilot Study	Skough K, Krossén C, Heiwe S, Theorell H, Borg K.	https://medicaljournals.se/jrm/content/abstract/10.2340/16501977-0245
Effort-Limited Treadmill Walk Test – Reliability and Validity in Subjects with Post-Polio Syndrome	Finch, Le; Venturini, A; Mayo, Ne; Trojan, Da	https://www.ncbi.nlm.nih.gov/pubmed/15277963
EFNS Guideline on Diagnosis and Management of Post-Polio Syndrome. Report of An EFNS Task Force	Farbu, E., Gilhus, N., Barnes, M., Borg, K., De Visser, M., Driessen, A., Howard, R., Nollet, F., Opara, J. And Stalberg, E.	https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1468-1331.2006.01385.x
Electrophysiologic and Histologic Studies in Clinically Unaffected Muscles of Patients with Prior Paralytic Poliomyelitis	Luciano, Ca; Sivakumar, K; Spector, Sa; Dalakas, Mc	https://www.ncbi.nlm.nih.gov/pubmed/8874398
Electrophysiologic Study of The Quadriceps Muscles During Fatiguing Fatiguing Exercise and Recovery: A Comparison of Symptomatic and Asymptomatic Post-Polio Patients and Controls	Rodriquez, AA And Agre, JC.	https://www.ncbi.nlm.nih.gov/pubmed/1953324?dopt=Abstract
Electrophysiology and Electrodiagnosis of the Post-Polio Motor Unit	Trojan, Da; Gendron, D; Cashman, Nr	https://www.ncbi.nlm.nih.gov/pubmed/1784551
Elevated Plasma Prolactin and EEG Slow Wave Power in Post-Polio Fatigue	Richard L. Bruno, Susan Creange, Jerald R. Zimmerman & Nancy M. Frick	https://www.tandfonline.com/doi/abs/10.1300/J092v04n02_06
Elevated Serum Inflammatory Markers in Post-Poliomyelitis Syndrome	Fordyce CB , Gagne D , Jalili F , Et Al .	https://www.ncbi.nlm.nih.gov/pubmed/18474371
Emotional Stress in Polio Survivors.	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/gstress.pdf
Endurance Training Effect on Individuals with Post-Poliomyelitis	Ernstoff, B., Wetterqvist, H., Kvist, H., & Grimby, G.	https://pubmed.ncbi.nlm.nih.gov/8822672/
Endurance Training In PPS: How to Target Intensity?	Koopman FS, Et Al.	https://www.papolionetwork.org/uploads/2/7/7/2/27726699/voorn_-_endurance_training.pdf
Energy Conservation, Occupational Therapy and The Treatment of Post-Polio Sequelae	Young G.	https://www.ncbi.nlm.nih.gov/pubmed/1758790
Epidemiology of The Post-Polio Syndrome	Ramlow J, Alexander M, Laporte R, Kaufmann C, Kuller L.	https://www.ncbi.nlm.nih.gov/pubmed/1442743
Evaluation, Treatment, and Follow-Up Results of Post-Polio Patients with Dysphagia	Silbergleit Ak, Waring Wp, Sullivan Mj, Maynard Fm	https://pubmed.ncbi.nlm.nih.gov/1902934/
Excessive Muscular Fatigue in The Post- Poliomyelitis Syndrome	Sharma Kr, Braun-Kent J, Mynhier Ma, Weiner Mw, Miller Rg.	https://n.neurology.org/content/44/4/642
Exercise Therapy and Cognitive Behavioural Therapy to Improve Fatigue, Daily Activity Performance and Quality of Life in Post-Poliomyelitis Syndrome: The Protocol of the FACTS-2-PPS Trial	Koopman, F., Beelen, A., Gerrits, K., Bleijenberg, G., Abma, T., De Visser, M. And Nollet, F.	https://www.ncbi.nlm.nih.gov/pubmed/20082714
Experience with Younger Patients in a Post-Polio Clinic: A Case Series	Glaser, J.A. And Halstead, L.S.	http://www.post-polio.org/res/AAPMR2010glaser.pdf
Experiences and Perspectives of Patients with Post-Polio Syndrome and Therapists with Exercise and Cognitive Behavioural Therapy	Bakker, M., Schipper, K., Koopman, F., Nollet, F. And Abma, T.	https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-016-0544-0
Fatigue and Functional Capacity in Persons with Post-Polio Syndrome: Short-Term Effects of Exercise and Lifestyle Modification Compared to Lifestyle Modification Alone	Srishti Sanat Sharma, Megha Sandeep Sheth, Neeta Jayprakash Vyas	http://dcidj.org/article/view/335
Fatigue in Post-Poliomyelitis Syndrome: Association with Disease-Related, Behavioral and Psychosocial Factors	Trojan, Da ; Arnold, Dl ; Shapiro, S; Bar-Or, A; Robinson, A; Le Cruguel, Jp; Narayanan, S; Tartaglia, Mc; Caramanos, Z; Da Costa, D	https://www.ncbi.nlm.nih.gov/pubmed/19627931
Fibromyalgia Is Common in A Post-Poliomyelitis Clinic	Trojan, Da; Cashman, Nr	https://www.ncbi.nlm.nih.gov/pubmed/7763212
Findings in Post-Poliomyelitis Syndrome – Weakness of Muscles of The Calf as A Source of Late Pain and Fatigue of Muscles of The Thigh After Poliomyelitis	Perry, J; Fontaine, Jd; Mulroy, S	https://www.ncbi.nlm.nih.gov/pubmed/7642658
Function and Ultrastructure of The Neuromuscular Junction in Post-Polio Syndrome.	Maselli R, Wollmann R, Roos R.	https://www.ncbi.nlm.nih.gov/pubmed/7611622
Functional Recovery: A Major Risk Factor for The Development of Post-Poliomyelitis Muscular Atrophy	Klingman J, Chui H, Corgiat M, Perry J	https://www.ncbi.nlm.nih.gov/pubmed/3369971
Growing Older with Post-Polio Syndrome: Social and Quality-Of-Life Implications	Duncan, A., Batliwalla, Z.	https://journals.sagepub.com/doi/10.1177/2050312118793563
Handbook on The Late Effects of Poliomyelitis for Physicians and Survivors	Edited by Frederick M. Maynard, MD, And Joan L. Headley, MS with 47 contributing authors	https://www.amazon.co.uk/Handbook-Effects-Poliomyelitis-Physicians-Survivors/dp/0931301041
High Prevalence of Vitamin D Deficiency Across the Board in Neuromuscular Disease	News Article (Not Journal)	https://www.newswise.com/articles/high-prevalence-of-vitamin-d-deficiency-across-the-board-in-neuromuscular-disease#.VFetti4u1pA.facebook
Histopathological Basis of Clinical Findings in Poliomyelitis	Bodian D	https://www.ncbi.nlm.nih.gov/pubmed/18119382
How to Design A Therapeutic Study in Patients with The Post-Polio Syndrome – Methodological Concerns and Status of Present Therapies	Dalakas, Mc	https://www.ncbi.nlm.nih.gov/pubmed/7611640
Illness Narratives of Persons with Post-Polio Syndrome	Wenneberg S1, Ahlström G.	https://www.ncbi.nlm.nih.gov/pubmed/10672093
Improvement in Exercise Capacity After Nocturnal Positive Pressure Ventilation and Tracheostomy	Vaz Fragoso Ca , Kacmarek Rm , Systrom Dm	https://www.ncbi.nlm.nih.gov/pubmed/1729078
Influence of Appropriate Lower Extremity Orthotic Management on Ambulation, Pain and Fatigue in A Post-Polio Population	Waring Wp, Maynard F,Grady W, Grady R, Boyles C	https://www.ncbi.nlm.nih.gov/pubmed/2719540
Intermittent Isometric Activity: Its Effect on Muscle Fatigue in Post-Polio Subjects	James C. Agre, Arthur A. Rodriquez	https://www.archives-pmr.org/article/0003-9993(91)90138-9/fulltext
Intravenous Immunoglobulin for Post-Polio Syndrome: A Systematic Review and Meta-Analysis	Huang, Y., Chen, H., Huang, K., Chen, P., Hu, C., Tsai, C., Tam, K. And Kuan, Y.	https://bmcneurol.biomedcentral.com/track/pdf/10.1186/s12883-015-0301-9
Laryngeal Function in Post-Polio Patients	Driscoll Bp, Gracco C, Coelho C, Goldstein J, Oshima K, Tierney E, Sasaki Ct	https://www.ncbi.nlm.nih.gov/pubmed/7837911
Laryngeal Manifestations of Post-Poliomyelitis Syndrome	Abaza, M., Sataloff, R., Hawkshaw, M. And Mandel, S	https://www.jvoice.org/article/S0892-1997(01)00030-3/fulltext
Late Denervation in Patients with Antecedent Paralytic Poiomyelitis	Cashman NR, Maselli R, Wollman RL et al	https://pubmed.ncbi.nlm.nih.gov/3587319/
Late Effects of Paralytic Poliomyelitis in Olmsted County, Minnesota	Windebank AJ, Litchy WJ, Daube JR, et al	https://n.neurology.org/content/41/4/501 https://doi.org/10.1212/WNL.41.4.501
Late Effects of Polio	House of Representatives Standing Committee on Health and Ageing Friday, 30 March 2012 Members in Attendance: Mr Coulton, Mr Georganas, Ms Hall and Mr Irons	http://www.poliohealth.org.au/wp-content/uploads/delightful-downloads/Final-Transcript-Melbourne-Friday-30-March-2012.pdf
Late Effects of Polio: Managing Muscles and Mobility	Polio Australia	https://www.poliohealth.org.au/?download=361
Late Functional Deterioration Following Paralytic Poliomyelitis	Kidd D1, Howard Rs, Williams Aj, Heatley Fw, Panayiotopoulos Cp, Spencer Gt	https://www.ncbi.nlm.nih.gov/pubmed/9093596
Late Onset Polio Sequelae: Disabilities and Handicaps in A Population-Based Cohort of the 1956 Poliomyelitis Outbreak in The Netherlands	Ivanyi B, Nollet F, Redekop WK, De Haan R, Wohlgemuht M, Van Wijngaarden JK, De Visser M	https://www.ncbi.nlm.nih.gov/pubmed/10378496
Late Post-Polio Functional Deterioration	Howard R	https://pn.bmj.com/content/3/2/66
Late Post-Poliomyelitis Muscular Atrophy: Clinical, Virologic and Immunologic Studies	Dalakas Mc, Sever Jl, Madden Dl, Papadopoulos Nm, Shekarchi Ic, Albrecht P, Krezlewicz A	https://www.ncbi.nlm.nih.gov/pubmed/6330854?dopt=Abstract
Late Progression of Poliomyelitis or Forme Fruste Amyotrophic Lateral Sclerosis?	Mulder Dw, Rosenbaum Ra, Layton Dd Jr	https://www.ncbi.nlm.nih.gov/pubmed/4635567
Low-Intensity, Alternate-Day Exercise Improves Muscle Performance Without Apparent Adverse Effect in Post-Polio Patients	Agre, J., Rodriquez, A., Franke, T., Swiggum, E., Harmon, R., & Curt, J.	https://www.ncbi.nlm.nih.gov/pubmed/8645440
Management Alternatives for Post-Polio Respiratory Insufficiency – Assisted Ventilation by Nasal or Oral-Nasal Interface	Bach, Jr; Alba, As; Shin, D	https://pubmed.ncbi.nlm.nih.gov/2686715/
Management of A Patient with Post‐Polio Syndrome	Lcdr Terry Halbritter Rn, Msn	https://doi.org/10.1111/j.1745-7599.2001.tb00325.x
Management of Post-Polio Respiratory Sequelae	Bach JR.	https://pubmed.ncbi.nlm.nih.gov/7611664/
Management of Post-Polio Syndrome	Thorsteinsson G	https://www.ncbi.nlm.nih.gov/pubmed/9212764
Management of Post-Polio Syndrome	Trojan, Da; Finch, L	dx.doi.com/10.1016/S1053-8135(96)00214-4
Management of Post-Polio Syndrome	Gonzalez, H, Olsson, T, Borg, K	https://pubmed.ncbi.nlm.nih.gov/20494327/
Managing Post-Polio Syndrome Pain	Gevirtz, Clifford Md, Mph	https://journals.lww.com/nursing/Fulltext/2006/12000/Managing_postpolio_syndrome_pain.13.aspx
Modafinil For Treatment of Fatigue in Post-Polio Syndrome – A Randomized Controlled Trial	O. M. Vasconcelos, O. A. Prokhorenko, M. K. Salajegheh, K. F. Kelley, K. Livornese, C. H. Olsen, A. H. Vo, M. C. Dalakas, L. S. Halstead, B. Jabbari, W. W. Campbell	https://n.neurology.org/content/68/20/1680.short
Morphologic Changes in the Muscles of Patients with Post-Poliomyelitis Neuromuscular Symptoms	Marinos C. Dalakas, MD	https://www.ncbi.nlm.nih.gov/pubmed/3336469
Muscle Strength Is Only a Weak to Moderate Predictor of Gait Performance in Persons with Late Effects of Polio	Flansbjer Ub, Brogårdh C, Lexell J.	https://content.iospress.com/articles/neurorehabilitation/nre978 dx.doi/10.3233/NRE-130978.
Muscular Function in Late Polio and the Role of Exercise in Post-Polio Patients	Agre, J.C., Rodriquez, A.A	https://pubmed.ncbi.nlm.nih.gov/24525981/
National Rehabilitation Hospital Limb Classification for Exercise, Research and Clinical Trials in Post-Polio Patients	Halstead Ls , Gawne Ac , Pham Bt	https://www.ncbi.nlm.nih.gov/pubmed/7611643
Neurological Manifestations of the Post-Polio Syndrome	Jubelt, B; Cashman, Nr	https://pubmed.ncbi.nlm.nih.gov/9710162/
No Effects of Whole-Body Vibration Training on Muscle Strength and Gait Performance in Persons with Late Effects of Polio: A Pilot Study	Brogårdh, C., Flansbjer, U. And Lexell, J.	https://doi.org/10.1016/j.apmr.2010.06.024
Non-Fatiguing General Conditioning Exercise Program (The 20% Rule)	Stanley K. Yarnell, Md, Saint Mary’s Medical Center, Sun Francisco, California	http://www.polioplace.org/sites/default/files/files/PNN14-2pg7-8.pdf
Non-Paralytic Polio as Prelude to Post-Polio Sequelae	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/npp.pdf
Osteoarthritis of The Hand and Wrist in the Post Poliomyelitis Population	Robert A. Werner, William Waring, Frederick Maynard	https://www.archives-pmr.org/article/0003-9993(92)90173-T/fulltext
Osteoporosis in A Post-Polio Clinic Population	Haziza, M; Kremer, R; Benedetti, A; Trojan, Da	https://www.archives-pmr.org/article/S0003-9993(07)00353-X/fulltext
Outcomes: Post-Poliomyelitis Syndrome (PPS)	Ventilamed And Breathenvs.Com	https://www.breathenvs.com/outcomes-post-polio
Overcoming Barriers to Work Participation for Patients with Post-Poliomyelitis Syndrome	Ten Katen, K., Beelen, A., Nollet, F., Frings-Dresen, M. And Sluiter, J.	www.tandfonline.com/doi/abs/10.3109/09638288.2010.503257?journalCode=idre20
Overwork Weakness with Evidence of Muscle Damage in a Patient with Residual Paralysis from Polio	Peach, Pe	https://pubmed.ncbi.nlm.nih.gov/2317146/
Pain in Persons with Post-Polio Syndrome: Frequency, Intensity and Impact	Brenda L. Stoelb, Phd, Gregory T. Carter, MD, Richard T. Abresch, MS, Sophia Purekal, BA, Craig M. Mcdonald, MD, And Mark P. Jensen, Phd	http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC2651567&blobtype=pdf
Pain, Physical Activity, And Disability in Individuals with Late Effects of Polio	Willen C, Grimby G	https://pubmed.ncbi.nlm.nih.gov/9710162/
Parallels Between Post-Polio Fatigue and Chronic Fatigue Syndrome	Bruno Rl, Creange Sj, Frick Nm.	https://www.ncbi.nlm.nih.gov/pubmed/9790485
Paralytic Versus “Non-Paralytic” Polio: A Distinction Without A Difference?	Dr. Richard L. Bruno	https://www.papolionetwork.org/uploads/9/9/7/0/99704804/paralytic_vs_non-paralytic_polio_-_a_distinction_without_a_difference.pdf
Parasympathetic Abnormalities as Post-Polio Sequelae: Vagus Caveat OR Stress and “Type A” Behaviour As Precipitants of Post-Polio Sequelae	Drs. Richard L. Bruno And Nancy M. Frick	http://www.postpolioinfo.com/library/typea.pdf
Pathogenetic Mechanisms of Post – Polio Syndrome: Morphological, Electrophysiological, Virological and Immunological Correlations	Dalakas MC	https://www.ncbi.nlm.nih.gov/pubmed/7611626
Perceived Consequences of Ageing with Late Effects of Polio and Strategies for Managing Daily Life: A Qualitative Study	Sjödahl Hammarlund, C., Lexell, J. And Brogårdh, C.	bmcgeriatr.biomedcentral.com/track/pdf/10.1186/s12877-017-0563-8
Perceived Disability, Fatigue, Pain and Measured Isometric Muscle Strength in Patients with Post – Polio Symptoms	Hildegunn L, Jones K, Grenstad T, Dreyer V, Farbu E, Rekand T	https://www.ncbi.nlm.nih.gov/pubmed/17432393
Perimalleolar Tendon Transfer to The Os Calcis For Triceps Surae Insufficiency in Patients with Post-Polio Syndrome	Dicesare, Pe; Young, S; Perry, J; Baumgarten, M	https://www.researchgate.net/publication/15558580_Perimalleolar_Tendon_Transfer_to_the_Os_Calcis_for_Triceps_Surae_Insufficiency_in_Patients_With_Postpolio_Syndrome
Physical Performance and The Effects of Dynamic Exercise in Water in Individuals with Late Polio	Willen C	www.ncbi.nlm.nih.gov/pubmed/11239288 https://doi.org/10.1053/apmr.2001.9626
Physiologic Events Initiating REM Sleep in Patients with The Post-Polio Syndrome	Siegel, H; Mccutchen, C; Dalakas, MC; Freeman, A; Graham, B; Alling, D; Sato, S	https://n.neurology.org/content/52/3/516
Physiologic Parameters and Perceived Exertion with Local Muscle Fatigue in Post-Polio Subjects	Rodriquez, AA And Agre, JC	https://www.ncbi.nlm.nih.gov/pubmed/2009046?dopt=Abstract
Physiotherapy for Poliomyelitis: A Descriptive Study in The Republic of Congo	Mancini, S., Coldiron, M., Nicholas, S., Llosa, A., Mouniaman-Nara, I., Ngala, J., Grais, R. and Porten, K	https://www.researchgate.net/publication/267730979_Physiotherapy_for_poliomyelitis_A_descriptive_study_in_the_Republic_of_Congo
Pivotal Moments: Florence Kendall and the Facts About “Sister” Kenny	Elizabeth Kendall Mccreary	http://www.postpolioinfo.com/library/kendall.pdf
Polio – Long-Term Problems	Perry, J; Fleming, C	https://pubmed.ncbi.nlm.nih.gov/4095015/
Polio and Post-Polio Syndrome, Viewed by Patients and Health Professionals in Primary Care	Francisca Muñoz Cobos, María Luisa Morales Sutil, María Carmen Faz García, Marta Ariza González, José Andrés Salazar Agulló, And María Luz Burgos Varo	https://europepmc.org/abstract/med/29938691
Polio Initiative Europa E.V. Clarifies Little-Known Post-Polio Syndrome	Kurz, Marisa	https://www.thieme-connect.de/products/ejournals/abstract/10.1055/a-0774-3549
Polio Redux – Decades After Frightening Epidemics of the 1940s and 1950s, Some Polio Survivors Are Haunted by A Troubling New Afflictions – Post-Polio Syndrome	Dalakas, Mc; Bartfeld, H; Kurland, Lt	https://go.gale.com/ps/anonymous?id=GALE%7CA17381746&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=0036861X&p=AONE&sw=w
Polio Survivors Exercise? No Way!	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/NoExercise.pdf
Polioencephalitis and the Brain Fatigue Generator Model of Post-Viral Fatigue Syndromes	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/bromo.pdf
Polioencephalitis, Stress and The Etiology Of Post-Polio Sequelae	Richard L. Bruno, Nancy M. Frick, And Jesse Cohen.	http://www.postpolioinfo.com/library/enceph.pdf
Poliomyelitis and The Post-Polio Syndrome	Howard, R	http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC558211&blobtype=pdf
Post-Polio Respiratory Failure. New Manifestations of a Forgotten Disease	Bergholtz B , Mollestad So , Refsum H .	https://www.ncbi.nlm.nih.gov/pubmed/3206457
Post-Polio Syndrome Patients Treated with Intravenous Immunoglobulin: A Double-Blinded Randomized Controlled Pilot Study	Farbu E , Rekand T , Vik – Mo E , Lygren H , Gilhus Ne , Aarli Ja .	https://www.ncbi.nlm.nih.gov/pubmed/17222115
Post-Polio Syndrome – Management and Treatment in Primary Care	Latham, J; The Site of Post-Polio Support Group Ireland.	http://www.ppsg.ie/dloads/PostPolioBooklet.pdf
Post-Polio Syndrome and Total Health Status in A Prospective Hospital Study	Farbu E , Rekand T , Gilhus Ne	https://www.ncbi.nlm.nih.gov/pubmed/12823493
Post-Polio Syndrome and Weaning Failure 40 Years After the Last Polio Epidemic	Gaul, C, Winterholler, M	https://www.ncbi.nlm.nih.gov/pubmed/12125309?dopt=Abstract
Postoperative Respiratory Insufficiency in Patients After Poliomyelitis	Janda A	https://www.ncbi.nlm.nih.gov/pubmed/464249
Post-Polio Dysphagia: Alarm or Caution	Buchholz Dw, Jones B	https://www.ncbi.nlm.nih.gov/pubmed/1784546
Post-Polio Fatigue	Borg, K	https://www.researchgate.net/publication/279433680_Postpolio_Fatigue
Post-Polio Muscle Dysfunction	Borg, K	https://www.ncbi.nlm.nih.gov/pubmed/8845722?dopt=Abstract
Post-Polio Muscular Atrophy: Diagnostic Utility of Macroelectromyography	Lange, D, Smith, T, Lovelace, R	https://www.ncbi.nlm.nih.gov/pubmed/2712746
Post-Polio Protein Power: Eat Well, Be Well	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/prodiet.pdf
Post-Polio Sequelae and Sleep-Related Disordered Breathing	Hsu Aa, Staats Ba	https://pubmed.ncbi.nlm.nih.gov/9511778/
Post-Polio Sequelae and The Paradigms of the 50s: Newtie, Ozzie and Harriet Versus Paradigms of Caring and A Future for Rehabilitation in America	Bruno, R	https://www.archives-pmr.org/article/S0003-9993(95)80115-4/fulltext
Post-Polio Sequelae and The Psychology of Second Disability	Frick N	https://www.ncbi.nlm.nih.gov/pubmed/4095012?dopt=Abstract
Post-Polio Sequelae: Physiological and Psychological Overview	Dr. Nancy M. Frick, Dr Richard L. Bruno	Rehabilitation Literature; 1986 http://postpolioinfo.com/library/lit.pdf
Post-Polio Sequelae: Preventing Ultimate Burnout and/or Ultimate Burnout: Post-Polio Sequelae	Dr. Richard L. Bruno	http://www.ppsr.com/Ultimate_Burnout.html
Post-Polio Sequalae: Research and Treatment in The Second Decade	Bruno RL	https://www.ncbi.nlm.nih.gov/pubmed/1661890
Post-Polio Syndrome	Nollet F , De Visser M	https://www.ncbi.nlm.nih.gov/pubmed/15262753
Post-Polio Syndrome	Authored by Dr Colin Tidy, Reviewed by Dr Helen Huins on 24 June 2016 Certified by The Information Standard	https://patient.info/doctor/post-polio-syndrome
Post-Polio Syndrome	By T.L. Munsat. Published by Butterworth-Heinemann.	https://doi.org/10.1017/S0317167100032376 126 pages. $50 Cdn. approx
Post-Polio Syndrome	By Julie K. Silver, MD, And Anne C. Gawne, MD, With 25 Contributing Authors.	http://post-polio.org/edu/pphnews/pph20-1p6-7.pdf
Post-Polio Syndrome 12 Years Later: How It All Started, The Post-Polio Syndrome: Advances in The Pathogenesis and Treatment	Dalakas MC	https://nyaspubs.onlinelibrary.wiley.com/doi/abs/10.1111/j.1749-6632.1995.tb27527.x
Post-Polio Syndrome and Anaesthesia	David A. Lambert, M.D.; Eleni Giannouli, M.D.; Brian J. Schmidt, M.D.	https://anesthesiology.pubs.asahq.org/article.aspx?articleid=2026110
Post-Polio Syndrome and Risk Factors in Korean Polio Survivors: A Baseline Survey by Telephone Interview	Hyun Bang, MD, Jee Hyun Suh, MD, Seung Yeol Lee, MD, Keewon Kim, MD, Eun Joo Yang, MD, Se Hee Jung, MD, Soong-Nang Jang, MD, Soo Jeong Han, MD, Wan-Ho Kim, MD, Min-Gyun Oh, MD, Jeong-Hwan Kim, MD, Sam-Gyu Lee, MD, And Jae-Young Lim, MD	https://dx.doi.org/10.5535%2Farm.2014.38.5.637
Post-Polio Syndrome and The Late Effects of Poliomyelitis. Part 1. Pathogenesis, Biomechanical Considerations, Diagnosis and Investigations	Lo, Julian K; Robinson, Lawrence R	https://onlinelibrary.wiley.com/doi/abs/10.1002/mus.26168
Post-Polio Syndrome and The Late Effects of Poliomyelitis: Part 2. Treatment, Management, and Prognosis	Lo, Julian .; Robinson, Lawrence R	https://onlinelibrary.wiley.com/doi/full/10.1002/mus.26167
Post-Polio Syndrome in Twins and Their Siblings	Nee, L., Dambrosia, J., Bern, E., Eldridge, R. And Dalakas, M	https://eurekamag.com/research/032/880/032880856.php dx.doi.org/10.1111/j.1749-6632.1995.tb27566.x
Post-Polio Syndrome in Twins and Their Siblings – Evidence That Post-Polio Syndrome Can Develop in Patients with Nonparalytic Polio	Nee, L; Dambrosia, J; Bern, E; Eldridge, R; Dalakas, Mc	https://pubmed.ncbi.nlm.nih.gov/7611649/
Post-Polio Syndrome. Neurologic and Psychiatric Aspects	Weber Ma1, Schönknecht P, Pilz J, Storch-Hagenlocher B.	https://pubmed.ncbi.nlm.nih.gov/15088090/
Post-Polio Syndrome: A Guide for Polio Survivors & Their Families	Julie K. Silver	https://www.amazon.com/Post-Polio-Syndrome-Guide-Survivors-Families/dp/0300088086
Post-Polio Syndrome: A New Challenge for The Survivors of Polio		http://www.post-polio.org/edu/hpros/task/cd/index.html
Post-Polio Syndrome: An Update	Jubelt B, Drucker J	https://pubmed.ncbi.nlm.nih.gov/8272600/
Post-Polio Syndrome: Clinical Experience With 132 Consecutive Outpatients	Halstead L, Rossi D	https://www.ncbi.nlm.nih.gov/pubmed/3620612
Post-Polio Syndrome: Epidemiology, Pathogenesis and Management	Abdulraheem, I; Saka, M; Saka, A	https://academicjournals.org/article/article1379692396_ABDULRAHEEM%20et%20al.pdf
Post-Polio Syndrome: Identifying Best Practices in Diagnosis & Care and Guidelines for People Who Had Polio (March of Dimes)	Michael Katz, Md	https://www.polioplace.org/sites/default/files/files/MOD-%20Identifying.pdf
Post-Polio Syndrome: More Than Just a Lower Motor Neuron Disease	Li Hi Shing S, Chipika Rh, Finegan E, Murray D, Hardiman O, Bede P	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6646725/
Post-Polio Syndrome: Poliovirus Persistence Is Involved in the Pathogenesis	Julien J, Leparc-Goffart I, Lina B	https://www.ncbi.nlm.nih.gov/pubmed/10431774
Post-Polio Syndrome-Response to Deprenyl (Selegiline)	Bamford Cr, Montgomery Eb Jr, Muñoz Je, Stumpf C, Pry S, Namerow Ns.	https://www.ncbi.nlm.nih.gov/pubmed/8407144
Post-Poliomyelitis Syndrome as A Possible Viral Disease	Andreina Baj, Martina Colombo, Joan L. Headley, John R. Mcfarlane, Mary-Ann Liethof, Antonio Toniolo; Corresponding Editor: Eskild Petersen	https://doi.org/10.1016/j.ijid.2015.04.018
Post-Poliomyelitis Syndrome: Clinical Features and Management	Ramaraj R.	https://www.ncbi.nlm.nih.gov/pubmed/18186398
Predictive Factors and Correlates for Pain in Post-Poliomyelitis Syndrome Patients	Vasiliadis, Hm; Collet, Jp; Shapiro, S; Venturini, A; Trojan, Da	https://www.sciencedirect.com/science/article/abs/pii/S0003999302000345
Predictive Factors for Post-Poliomyelitis Syndrome	Daria A. Trojan, Neil R. Cashman, Stanley Shapiro, Catherine M. Tansey, John M. Esdaile	https://www.archives-pmr.org/article/0003-9993(94)90134-1/fulltext
Prevalence of Post – Polio Syndrome Based on A Cross – Sectional Survey in Kitakyushu, Japan	Takemura J , Saeki S , Hachisuka K , Aritome K	https://www.ncbi.nlm.nih.gov/pubmed/15074431
Prevalence Of Vitamin D Deficiency In Spring and Summer Months In Central Pennsylvania Neuromuscular Clinic	Bandyopadhyay, S. And Buchman, S.	https://www.ncbi.nlm.nih.gov/pubmed/27224439 Journal of Clinical Neuromuscular Disease . 2016
Preventing Complications in Polio Survivors Undergoing Dental Procedures	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/dental.pdf
Pro-Inflammatory Cytokines and Motor Neuron Dysfunction: Is There A Connection in Post-Polio Syndrome?	Dalakas, Mc	https://pubmed.ncbi.nlm.nih.gov/12409176/
Prolonged Benefit in Post-Polio Syndrome from Comprehensive Rehabilitation: A Pilot Study	Davidson, A, Auyeung, V, Luff, R, Holland, M., Hodgkiss, A, Weinman, J	www.tandfonline.com/doi/abs/10.1080/09638280801973206?journalCode=idre20
Psychologic Characteristics of Polio Survivors: A Preliminary Report	Linda J. Conrady, Joel R. Wish, Phd, James C. Agre, MD, Phd, Arthur A. Rodriquez, MD, Keith B. Sperling, MD.	https://www.archives-pmr.org/article/0003-9993(89)90007-5/pdf
Psychological Resilience and Depressive Symptoms in Older Adults Diagnosed with Post-Polio Syndrome	Pierini D, Stuifbergen Ak.	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3432643/
Psychometric Properties of Three Fatigue Rating Scales in Individuals with Late Effects of Polio	Lexell, J., Jonasson, S. And Brogardh, C.	https://www.e-arm.org/journal/view.php?doi=10.5535/arm.2018.42.5.702
Psychosocial Adjustment of Post-Poliomyelitis Ventilator Assisted Individuals	John R. Bach, Denise I. Campagnolo	https://www.archives-pmr.org/article/0003-9993(92)90265-X/fulltext
Pulmonary Dysfunction and Its Management in Post-Polio Patients	Bach, Jr; Tilton, M	https://content.iospress.com/articles/neurorehabilitation/nre8-2-07
Pulmonary Function in Individuals with A History of Poliomyelitis	Dean, E, Ross, J, Road, Jd, Courtenay, L, Madill, Kj.	https://www.ncbi.nlm.nih.gov/pubmed/2060329?dopt=Abstract
Pyridostigmine In Post-Polio Syndrome: No Decline in Fatigue and Limited Functional Improvement	Horemans HLD , Nollet F , Beelen A , Et Al .	https://jnnp.bmj.com/content/74/12/1655
Randomized Controlled Trial of Strength Training in Post – Polio Patients	Chan Km , Amirjani N , Sumrain M , Clarke A , Strohschein Fj .	https://www.ncbi.nlm.nih.gov/pubmed/12635120
Rimmed Vacuoles with Beta-Amyloid and Ubiquitinated Filamentous Deposits in The Muscles of Patients with Long-Standing Denervation (Post-Poliomyelitis Muscular Atrophy): Similarities with Inclusion Body Myositis	Seminomora, C; Dalakas, MC	https://pubmed.ncbi.nlm.nih.gov/9781653/
Rehabilitation for Post-Polio Sequelae	Khan F. With Comment in Victorian Polio Service (White C, 2005)	https://www.ncbi.nlm.nih.gov/pubmed/15373379 Aust Fam Physician. 2004
Relationship Between Self-Reported Walking Ability and Objectively Assessed Gait Performance in Persons with Late Effects of Polio	Brogårdh, Christina; Flansbjer, Ulla-Britt; Espelund, Christina; Lexell, Jan	https://content.iospress.com/articles/neurorehabilitation/nre936
Response of Post-Poliomyelitis Patients to Bisphosphonate Treatment	Alvarez, A; Kremer, R; Weiss, Dr ; Benedetti, A; Haziza, M; Trojan, D	https://www.sciencedirect.com/science/article/abs/pii/S1934148210011093
Restless Legs Syndrome in Patients with Sequelae of Poliomyelitis	Kumru, H., Portell, E., Barrio, M. And Santamaria, J.	https://www.prd-journal.com/article/S1353-8020(14)00234-X/fulltext
Review of Secondary Health Conditions in Post-Polio Syndrome Prevalence and Effects of Aging	Mcnalley, T., Yorkston, K., Jensen, M., Truitt, A., Schomer, K., Baylor, C. And Molton, I.	http://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC4289114&blobtype=pdf
Risk of Symptoms Related to Late Effects of Poliomyelitis	Rekand, T., Albrektsen, G., Langeland, N. And Aarli, J	https://onlinelibrary.wiley.com/doi/abs/10.1034/j.1600-0404.2000.101003153.x
Serum Insulin Like Growth Factor-I (IGF-I) Does Not Correlate with Fatigue and Physical Domains of Quality of Life in Post-Polio Syndrome	Trojan, Da; Collet, Jp; Pollack, M; Shapiro, S; Jubelt, B; Miller, Rg; Agre, Jc; Munsat, Tl; Hollander, D; Tandan, R; Robinson, A; Finch, L; Ducruet, T; Cashman, Nr	https://europepmc.org/article/med/11137515
Short-Term Effects of Aerobic Exercise on Functional Capacity, Fatigue and Quality of Life in Patients with Post-Polio Syndrome	Oncu, J., Durmaz, B. And Karapolat, H.	https://doi.org/10.1177/0269215508098893
Sleep Apnoea In Patients with Post-Polio Syndrome	Dean Ac, Graham Ba, Dalakas M, Sato S	https://pubmed.ncbi.nlm.nih.gov/9585362/
Sleep Complaints in Post-Polio Syndrome	Van Kralingen KW, Ivany B, Van Keimpema AR, Venmans BJ, De Visser M, Postmus PE:	https://www.ncbi.nlm.nih.gov/pubmed/8831481
Sleep in Post-Polio Syndrome	Steljes Dg , Kryger Mh , Kirk Bw , Millar Tw .	https://www.ncbi.nlm.nih.gov/pubmed/2361379
Sleep-Disordered Breathing in Fatigued Post-Poliomyelitis Clinic Patients	Dahan, V; Kimoff, Rj; Petrof, Bj; Benedetti, A; Diorio, D; Trojan, Da	https://www.sciencedirect.com/science/article/abs/pii/S0003999306008422
Sleep-Disordered Breathing in Neuromuscular Disease	Loutfi S. Aboussouan	https://doi.org/10.1164/rccm.201412-2224CI
Slow Guts and Polio Survivors	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/SlowGuts.pdf
Spinal Fluid Findings in Acute Anterior Poliomyelitis (The Epidemic in Copenhagen in 1950)	Bentzon, J. And Hilden, T.	https://pubmed.ncbi.nlm.nih.gov/13091716/
Stimulation Frequency-Dependent Neuromuscular-Junction Transmission Defects in Patients with Prior Poliomyelitis	Trojan, Da; Gendron, D; Cashman, Nr	https://doi.org/10.1016/0022-510X(93)90104-7
Strength Gains Without Muscle Injury After Strength Training in Patients with Post-Polio Muscular Atrophy	Spector Sa, Gordon Pl, Feuerstein Im, Sivakumar K, Hurley Bf, Dalakas Mc.	https://pubmed.ncbi.nlm.nih.gov/8808654/
Strength, Endurance and Work Capacity After Muscle Strengthening Exercise in Post-Polio Subjects	Agre Jc, Rodriquez Aa, Franke Tm.	https://www.ncbi.nlm.nih.gov/pubmed/9228868
Stress, Coping and Psychological Adaptation of Individuals with Post-Polio Sequelae	Sanchez DI.	https://shareok.org/bitstream/handle/11244/33843/Thesis-1996D-S211s.pdf?sequence=1
Subjective Recovery Time After Exhausting Muscular Activity in Post- Polio and Control Subjects	Agre Jc, Rodriquez Aa, Franke Tm	https://pubmed.ncbi.nlm.nih.gov/9558015/
Summary of Anaesthesia Issues for The Post-Polio Patient	Selma H. Calmes, MD	http://www.post-polio.org/edu/hpros/sum-anes.html
Surviving Polio in A Post-Polio World	Groce, N., Banks, L. And Stein, M.	https://doi.org/10.1016/j.socscimed.2014.02.024
Symptoms and Clinical Impressions of Patients Seen in A Post-Polio Clinic	Agre Jc, Rodriquez Aa, Sperling Kb.	https://www.ncbi.nlm.nih.gov/pubmed/11239288
The Anæsthetist’s Viewpoint on The Treatment of Respiratory Complications in Poliomyelitis During the Epidemic in Copenhagen, 1952	Dr. B Ibsen	https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1918820/ Proceedings of the royal society of medicine; Blegdam Hospital, Copenhagen, Denmark;1952
The Analysis of a Biopsychosocial Model to Assess Polio Survivors’ Likelihood of Diagnosis with Post-Polio Syndrome	Myers, N.A.	https://search.proquest.com/openview/ebbcf7ce6d642568befe5543f7c2fb33/1?pq-origsite=gscholar&cbl=18750&diss=y
The Challenge of Diagnosing ALS In Patients with Prior Poliomyelitis	Salajegheh, M; Bryan, Ww; Dalakas, Mc	https://n.neurology.org/content/67/6/1078.short
The Contribution of Childhood Physical and Emotional Trauma to The Development of The Post-Polio Personality	Dr. Nancy M. Frick	http://www.postpolioinfo.com/library/frick.pdf
The Effects of a Home-Based Arm Ergometry Exercise Programme on Physical Fitness, Fatigue and Activity in Polio Survivors: Protocol for A Randomised Controlled Trial	Deirdre Murray Dara Meldrum, Roisin Moloney, Anna Campion, Frances Horgan And Orla Hardiman	https://doi.org/10.1186/1471-2377-12-157
The First Intensive Care Unit in The World: Copenhagen 1953	Berthelsen, P. G. And Cronqvist, M.	https://www.researchgate.net/publication/9010703_The_first_intensive_care_unit_in_the_world_Copenhagen_1953
The Influence of Post-Polio Syndrome on Independence and Life Satisfaction	Helena Burger, Crt Marincek	www.tandfonline.com/doi/abs/10.1080/096382800296674
The Neuroanatomy of Post-Polio Fatigue	Bruno Rl, Cohen Jm, Galski T, Frick Nm.	https://www.ncbi.nlm.nih.gov/pubmed/8185440
The Neuropsychology of Post-Polio Fatigue	Bruno RL, Galski T, Deluca J.	https://pubmed.ncbi.nlm.nih.gov/8215857/
The Pathophysiology of a Central Cause of Post-Polio Fatigue	Bruno Rl, Sapolsky R, Zimmerman Jr, Frick Nm.	https://www.ncbi.nlm.nih.gov/pubmed/7611635
The Polio Paradox	Richard L. Bruno, Phd.	https://www.goodreads.com/book/show/226432.The_Polio_Paradox
The Polioviruses Live On and On	International Post-Polio Task Force;	https://www.papolionetwork.org/uploads/2/7/7/2/27726699/polio_viruses_live_on_and_on.pdf
The Post-Polio Experience: Psychological Insights and Coping Strategies for Polio Survivors and Their Families	Margaret E. Backman	https://www.amazon.co.uk/Post-Polio-Experience-Psychological-Strategies-Survivors/dp/0595386393
The Post-Polio Syndrome as An Evolved Clinical Entity	Dalakas MC	https://www.ncbi.nlm.nih.gov/pubmed/7611661
The Post-Polio Syndrome. An Overuse Phenomenon	Perry J, Barnes G, Gronley Jk	https://www.ncbi.nlm.nih.gov/pubmed/3402120
The Post-Polio Syndrome: Advances in The Pathogenesis and Treatment	Dalakas, M., Bartfeld, H. And Kurland, L.	https://www.amazon.co.uk/Post-polio-Syndrome-Advances-Pathogenesis-Treatment/dp/0897669177
The Post-Polio Syndrome: No Evidence for Poliovirus Persistence	Melchers W, Devisser, M, Jongen P, Van Loon A, Nibbeling R, Oostvogel P, Willemse D, Galama J	https://www.ncbi.nlm.nih.gov/pubmed/1335224
The Psychological Aspects of Polio Survivors Through Their Life Experience	Yelnik, A. And Laffont, I	https://pubmed.ncbi.nlm.nih.gov/20022578/
The Psychology of Polio as Prelude to Post-Polio Sequelae: Behaviour Modification and Psychotherapy	Dr. Richard L. Bruno, Dr Nancy M. Frick	http://www.postpolioinfo.com/library/psych.pdf
The Ten Commandments of PPS	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/tencom.pdf
Trauma and Illness as Precipitants of Post-Polio Sequelae	Dr. Richard L. Bruno	http://www.postpolioinfo.com/library/trauma.pdf
Treatment for Post-Polio Syndrome	Fieke Sophia Koopman, Anita Beelen, Nils Erik Gilhus, Marianne De Visser, Frans Nollet	https://pubmed.ncbi.nlm.nih.gov/25984923/
Treatment of Patients with Post-Polio Syndrome in A Warm Climate	Strumse Yas , Stanghelle Jk , Utne L , Ahlvin P, Svendsby Ek	https://www.ncbi.nlm.nih.gov/pubmed/12554382
Ultrasound-Guided Carpal Tunnel Release Using Dynamic Expansion of The Transverse Safe Zone in A Patient with Post-Polio Syndrome: A Case Report	Troy Henning Do Daniel Lueders Md Kate Chang Lynda Yang Md	https://onlinelibrary.wiley.com/doi/full/10.1016/j.pmrj.2018.02.016
Varied Clinical Patterns, Physical Activities, Muscle Enzymes, Electromyographic and Histologic Findings in Patients with Post – Polio Syndrome in Taiwan	Chang Cw , Huang Sf	https://www.ncbi.nlm.nih.gov/pubmed/11641796
Vocational Implications of Post-Polio Syndrome	Elrod, Lisa M; Jabben, Merten; Oswald, Gina; Szirony, Gary Michael	https://www.ncbi.nlm.nih.gov/pubmed/16131745
What Internists Need to Know About Post-Polio Syndrome	Silver, J., Aiello, D.	https://www.ncbi.nlm.nih.gov/pubmed/12222974 dx.doi/10.3949/ccjm.69.9.704
Why Drugs Fail in Post-Polio Syndrome: Lessons from Another Clinical Trial	Dalakas MC.	https://pubmed.ncbi.nlm.nih.gov/10522866/

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