PSN Library Files – Page 5 – Polio Survivors Network

Exercise What Is Right For You

EXERCISE – WHAT IS RIGHT FOR YOU

Mavis J. Matheson. MD.

April 1995 (updated 2005).

Many people with a history of polio can improve muscle strength and cardiovascular conditioning with an exercise program. [1], [2] One of the problems that people with Post-polio Syndrome face is how much exercise they should be doing. We have all been told to conserve our energy. We know that too much exercise will further damage already weak muscles. We also know that if a muscle is not exercised it will lose strength. So what should we be doing?

Determining how much we should do isn’t easy. We must learn to recognize fatigue. We must learn which pains mean overworked muscle. We need to pay attention to our bodies and use pain and fatigue as signals. We have to let go of the ‘no pain; no gain’; philosophy we learned while we were recovering from polio. We must also learn to use how we feel today to assess activity yesterday or even the day before and plan for tomorrow.

The key to exercise for people with Post-polio syndrome is to suit the activity to the amount of damage to the muscle. This damage may be a result of the original polio and from Post-polio overuse. Different researchers use different methods of determining just how much a muscle or group of muscles is damaged and what exercises are appropriate. [1], [4], [6]

After consulting with our doctors to assure ourselves that we don’t have some disease process other than PPS causing our problems, we must decide how much to do. What can we do when we don’t have a Post polio Clinic and physicians willing and able to do four limb specialized EMG techniques? We can still look at our histories and we can feel how we are doing now. Using this information we can try to set up or get the physiotherapists (who may or may not have knowledge of post-polio syndrome) to set up appropriate exercise programs for us. I suggest you try to figure out what each of your limbs should do based on your experience with that limb.

Dr. Agre and Dr. Rodriquez have shown that polio survivors can assess their own muscle fatigue. [3] For each limb, ask yourself “Which is the most severely involved muscle in this limb?” “Is that muscle weak?” and “Am I noticing signs of increasing weakness in that muscle?” Increased pain in the muscle, twitching, decrease in quality of movement, being able to walk shorter distances, having more trouble with stairs, more difficulty standing, muscle wasting, difficulty holding your arm up, driving, dressing and tiring with fewer and fewer repetitions during your regular exercise routine are common signs of increased weakness in a muscle or limb.

A limb that does not have any weakness is classed as no clinical polio [1] and you may be able to use it like any normal limb. These are the limbs you may be able to use to get a good workout for your heart and

lungs (cardiovascular workout). It is sensible to increase the amount of exercise you do gradually. If you notice any signs of increasing weakness, you must reevaluate you limb and your exercise program for that limb. Even muscles with no clinical polio may have silently lost up to 40 percent of their neurons. [6] If you don’t have any signs of damage, you can gradually try to work up to being active 3-4 times a week for at least 20 minutes getting your heart rate up to 60%-80% of maximum.

If your muscle is mild to moderately weak but shows no signs of increasing weakness, the limb would be classed as clinically stable polio. [1] You can exercise these muscles with care. They should not be significantly fatigued. Try exercising 3 times per week for periods of no more than 10-20 minutes with frequent rests. Progressive resistance exercises (also called non-fatiguing strengthening exercises) with gradually increasing weights may be used to maintain and possibly gain strength. In a study by Chan et al, the progressive resistance training program [7] consisted of three sets of eight isometric contractions starting at 50% of maximum voluntary contractions, three times weekly for 12 weeks. Feldman et al [4] increased weight by less than half a pound at a time. Monitor yourself carefully while you exercise and if you notice any signs of increasing weakness, you must reevaluate your limb and your exercise program for that limb.

If your muscle is severely weak, the limb is probably appropriately classed as severely atrophic polio. [1] Active exercise of the limb is likely impossible. Passive range of motion exercises may be used to maintain flexibility.

If your muscle is weak and showing increasing weakness, ask yourself “Am I doing too much or too little?” Unless the limb has been immobilized recently (for example, in a cast or on bed rest) you are probably doing too much. The limb should be classed as having clinically unstable polio. [1] You should decrease the amount of activity that limb is doing, use energy conservation, and get your rests. These are the muscles that are being damaged by overuse. You must not fatigue them. It is probably a good idea to stretch to maintain flexibility and range of motion. (If you are sure the limb has been getting too little activity, you can try a carefully graduated program of non-fatiguing exercises.) Monitor yourself carefully while you exercise and if you notice any signs of increasing weakness, reevaluate your exercise program for that limb.

Whatever your exercise program, continue to make changes to help you conserve energy. Paying attention to fatigue in your exercise program may help you to realize how much activity overworks each limb. As you go through your day, be aware of fatigue and rest when you are tired (before you are exhausted). Dr. Peach and Dr. Olejnik found that patients who successfully control the factors responsible for neuromuscular overuse did not lose muscle strength. [5]

Resources.

Gawne AC: Strategies for Exercise Prescription in Post-Polio Patients. In Halstead LS, Grimby G (eds). Post Polio Syndrome (1995) pp 141 – 164. [Lincolnshire Library Full Text] 2. Fillyaw MS, Badger GJ, Goodwin GD, Bradley WG, Fries TJ, Shukla A: The effects of Long -Term Non Fatiguing Resistance Exercises in Subjects with Post-Polio Syndrome. Orthopedics (1991) vol. 14: 1253 – 1256. [PubMed Abstract]
Agre JC, Rodriquez AA: Neuromuscular Function in Polio Survivors. Orthopedics (1991) vol. 14 No. 12: 1343 – 1347. [PubMed Abstract]
Feldman RM: The use of EMG in the differential Diagnosis of muscle weakness in post-polio syndrome. Electromyogr. Clin. Neurophysiol., (1988) 28: 269 – 272. [PubMed Abstract] 5. Peach PE, Olejnik S: Effect of treatment and non-compliance on Post Polio Sequelae. Orthopedics

(1991) vol 14. 1199 – 1203. [Lincolnshire Library Full Text]

McComas AJ, Quartly C, Griggs RC. Early and late losses of motor units after poliomyelitis. Brain , 1997; 120:1415-1421. [Pub Med Abstract]
Chan KM, Amirjani N, Sumrain M, Clarke A, Strohschein FJ, Randomized controlled trial of strength training in post-polio patients . Muscle Nerve. 2003 Mar;27(3):332-8. [Pub Med Abstract]

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The Lincolnshire Post-Polio Network takes great care in the transcription of all information that appears at this site. However, we do not accept liability for any damage resulting directly or otherwise from any errors introduced in the transcription. Neither do we accept liability for any damage resulting directly or otherwise from the information available at this site. The opinions expressed in the documents available at this site are those of the individual authors and do not necessarily constitute endorsement or approval by the Lincolnshire Post-Polio Network.

Copyright is retained by The Lincolnshire Post-Polio Network and/or original author(s). Permission is granted to print copies of individual articles for personal use provided they are printed in their entirety. Links from other Internet WWW sites are welcome and encouraged. We only ask that you let us know so that we can in future notify you of critical changes. Reproduction and redistribution of any articles via any media, with the exception of the aforementioned, requires permission from The Lincolnshire Post-Polio Network and where applicable, the original author(s).

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Document Reference: <URL:http://www.ott..zynet.co.uk/polio/lincolnshire/library/usa/exercise.html> Created: 28th January 1997

Last modification: 31st January 2010.

Exercise What Is Right For You Read More »

Save Our Shoulders

S.O.S. Save Our Shoulders A Guide for Polio Survivor’s

Jennifer Kuehl, MPT Roberta Costello, MSN, RN

Janet Wechsler, PT

Funding for the production of this manual was made possible by: The National Institute for Disability and Rehabilitation Research

Grant #H133A000101

and The U.S. Department of the Army

Grant #DAMD17-00-1-0533

Investigators:

Mary Klein, PhD Mary Ann Keenan, MD Alberto Esquenazi, MD

Acknowledgements We gratefully acknowledge the contributions and input provided from all of those who participated in our research. The time and effort

of our participants was instrumental in the creation of this manual.

Jennifer Kuehl, MPT Moss Rehabilitation Research Institute, Philadelphia

Roberta Costello, MSN, RN Moss Rehabilitation Research Institute, Philadelphia

Janet Wechsler, PT Moss Rehabilitation Research Institute, Philadelphia

Mary Klein, PhD Moss Rehabilitation Research Institute, Philadelphia

Mary Ann Keenan, MD University of Pennsylvania, Philadelphia

Alberto Esquenazi, MD MossRehab Hospital, Philadelphia

Cover and manual design by

Ron Kalstein, MED Albert Einstein Medical Center, Philadelphia

Table of Contents

Introduction ……….

……5

General Information About the Shoulder ………………
Facts About Shoulder Problems ………..

….8

Treatment Options …..

…..13

About Exercise ……….

…..16

Stretching Exercises…….

…..19

Cane Stretches………….

…..22

Strengthening Exercises…..

…..25

Tips to Avoid Shoulder Problems …..
Conclusion………

…..31

Resources ….

…3

The information contained within this manual is for reference only

and is not a substitute for professional medical advice. Before beginning any exercise program consult your physician.

Save Our Shoulders: A Guide for Polio Survivors • 4

Introduction

Many polio survivors report new symptoms as they age. Some of the more common symptoms include loss of strength, fatigue, muscle twitching, cramping, and muscle or joint pain. These

symptoms, combined with the muscle weakness caused by the polio virus, often lead to problems with activities like climbing stairs or getting up from a chair or sofa.

When muscle weakness and/or pain is present in one area of the body, people often compensate by putting more stress on another area of the body. For example, polio survivors who have weak leg muscles often rely on their arms to assist with mobility-related tasks, such as pushing off of the armrests of a chair when getting up or pulling up on the railing when going up a flight of stairs. This behavior can increase the risk for symptoms of shoulder overuse. These symptoms can include pain, swelling, weakness, and loss of motion or function in one or both the shoulders.

The purpose of this manual is to help polio survivors become more aware of the behaviors that can cause shoulder overuse

and some of the treatment options that are available. While the information included in this manual is targeted to polio survivors, it will be useful to anyone with shoulder problems. Shoulder dysfunction is an orthopedic problem with similar symptoms in people with and without a history of polio. Treatment approaches are individualized and focus on minimizing or eliminating pain while maximizing function.

Save Our Shoulders: A Guide for Polio Survivors

General Information About The Shoulder The shoulder is made up of many muscles, bones, tendons, ligaments, and nerves that work together to help with movement of the arms. The shoulder joint is the only joint in the body that allows movement in a complete circle.

The bones that are part of the shoulder include the scapula, the clavicle, and the humerus.

– CLAVICLE

– HUMERUS

SCAPULA

Illustration by A. Simone

Save Our Shoulders: A Guide for Polio Survivors • 6

The scapula is the bone that makes up the back of the shoulder. The clavicle is located in the front of the shoulder, and the humerus is the long bone in the upper arm that inserts into the shoulder socket. These bones all work together to make the shoulder a functional unit.

Many muscles support the shoulder by helping to keep the bones in proper position and aiding in moving the arms. The major muscles

o keep proper bone position are known as the rotator cuff. These muscles are called a cuff because they give support to the shoulder joint.

A rotator cuff tear is the most common shoulder problem and is found in almost half of the people who seek help for a shoulder injury.

MUSCLES OF THE ROTATOR CUFF

Illustration by A. Simone

Save Our Shoulders: A Guide for Polio Survivors

Facts About Shoulder Problems

Shoulder problems are one of the most frequent complaints in

the post-polio population.

Shoulder issues are also common among older adults without

a history of polio, occurring in about 30% of people who are 60 years and older.

Shoulder problems can increase with age and changing levels of

physical activity.

People who are involved in sports are not the only ones to suffer

from shoulder problems.

Shoulder problems are common in those with long standing medical conditions, such as post-polio syndrome, arthritis,

spinal cord injury, stroke (CVA), or multiple sclerosis.

Our research has shown that polio survivors who have weakness in their legs or who are overweight are at high risk for developing shoulder problems.

Save Our Shoulders: A Guide for Polio Survivors

Risks For Developing Shoulder Problems

You may be at risk for developing shoulder problems if you:

Have had polio
Are over 60 years old
Use your arms to compensate for weakness in other areas
Use an assistive device such as a cane or walker
Are overweight
Had previous injury or trauma to your shoulder(s)
Perform tasks that involve repetitive shoulder motion
Perform activities that require frequent reaching overhead
Feel pain, discomfort, or muscle fatigue in your arms when doing

your normal activities

Use improper lifting techniques or poor body mechanics when

performing tasks at home or at work

Do not do proper warm-up or stretching before physical activity

Improper Lifting

Proper Lifting

Save Our Shoulders: A Guide for Polio Survivors

Common Shoulder Problems And Possible Causes

Pain may result from:

Fractures (broken bones) caused by a fall, bone disease such

as osteoporosis, or medications

Impingement Syndrome (pain in the shoulder due to incorrect

shoulder movement) caused by overuse, trauma, poor posture, weakness in some muscles of the shoulder, or bony changes

Poor Posture

Poor Positioning

Tendonitis (swelling of the structure that joins muscle to bone)

caused by overuse, trauma, or a disease process such as a stroke or polio

Weakness may result from:

Disease processes such as polio, stroke, or nerve damage
Inactivity

Save Our Shoulders: A Guide for Polio Survivors • 10

Movement Difficulty may result from:

Frozen Shoulder (unable to move arm because of severe pain which leads to stiffness in the joint) caused by an infection,

injury, lack of movement in arm, or severe pain in shoulder

Bony changes caused by arthritis, fractures, calcium deposits, or birth defects
Swelling caused by surgery, trauma, lack of motion, or a disease

process such as a stroke

Pain, weakness and movement difficulty frequently develop due to a cycle of symptoms. Individuals limit their use of a painful shoulder, which results in stiffness and loss of strength. This leads to increased pain and continues the cycle of pain, weakness, and loss of motion. An effective treatment program will focus on breaking this cycle.

Pain

Weakness

Movement Difficulty

11 • Save Our Shoulders: A Guide for Polio Survivors

What To Do If You Have A Shoulder Problem

It is important that you seek the care and advice of a medical professional qualified to diagnose and treat shoulder problems. Depending on the problem that you are having, you may be referred to a specialist. Regardless of who evaluates your shoulder, information will be collected about your specific shoulder problem. If you are a polio survivor, it is important to seek the help of a healthcare provider who is informed about polio and its effects on your treatment and recovery. In order to get the most helpful information, you may be asked questions such as:

Tell me your medical and polio history, and medicine you

are taking.

Tell me about your shoulder problem.
Have you ever had this problem before?

-what did you do for it then? … Did you have any tests done?

Have you had therapy, surgery, or other treatments for the

same problem?

Does anything make your shoulder feel better? …Worse?
Does your shoulder bother you more at a particular time of

the day? …When?

Does your shoulder problem wake you from sleep?
Does the problem affect different areas of your body?…Where?
Do you need help with getting washed, dressed, or

household chores?

Do you use assistive devices such as a reacher or a long

handled sponge because of shoulder problems?

If you need to take medication for your shoulder problem,

how often are you taking it?…Does it help?

Save Our Shoulders: A Guide for Polio Survivors • 12

Shoulder Problem Treatment Options

Many approaches can be used to treat shoulder problems. Some

examples of treatment options are:

O Rest

Cold Pack or Hot Pack 3 Massage

Ultrasound 6 Aquatic Therapy 6 Electric Stimulation O Anti-inflammatory medicines or cortisone injections * Pain Management at a pain clinic 9 Modifications (home/work; adaptive devices or equipment;

lifestyle changes) 10 Surgery

The most common treatment for a shoulder problem begins with rest, ice, and heat, and the use of anti-inflammatory medicines. If these conservative treatment options do not help, the doctor usually recommends cortisone injections to the painful area. After injections, the physician will often refer you to physical therapy for evaluation and treatment.
In physical therapy there are several treatment techniques that can be combined to relieve the pain, and increase the strength and use of the arm. Physical therapists may use exercise, stretching, ice, heat, ultrasound (a deep heat), massage, electric stimulation (electrical current used to decrease pain or increase movement), water therapy, or hands on techniques to help your shoulder problem.
The final option recommended by the doctor is usually surgery. Most doctors will try non-invasive options before recommending

surgery.

The success of treatment lies with the patient and the health care provider working together so that the greatest benefit of the treatment goals can be reached.

Save Our Shoulders: A Guide for Polio Survivors

The Importance of Education And Exercise

Most treatment plans will include education and exercise.

Why Education?

Learning about the problem you are having with your shoulder

and how it is affecting you will make you more aware of things that can aggravate the problem.

Understanding why a treatment plan has been chosen, and how to follow it will improve your ability to get the most benefit from

the plan.

Involving you in the treatment process is important so that further injury can be minimized and proper treatment of the current problem can be set up based on your needs.

Why Exercise?

It is inexpensive.
It is easy.
It doesn’t take much time.
It helps to maintain or increase your

flexibility, balance, coordination, and stability.

It helps to maintain or increase your strength

and endurance.

It helps keep you independent with

daily activities.

It helps you control weight and body fat.
It helps to reduce stress.
It helps increase energy levels.

Save Our Shoulders: A Guide for Polio Survivors

It is important to work with a health care provider who is educated in the effects of polio and exercise.

Before beginning your exercise program it is important to remember:

Exercise is not always appropriate

for every shoulder problem or every

individual.

In some cases, some exercises can actually do more harm than good.
Some medical problems can influence which exercises are

appropriate for you to perform. . It is important to get clearance from your doctor

BEFORE you begin any exercise program.

Save Our Shoulders: A Guide for Polio Survivors

General Information On Exercise Programs

The benefits of exercise can be achieved by doing as little as 30 minutes of moderate physical

activity three to five times a week.

An exercise program can help you feel better physically, and emotionally. Exercise can be a source of enjoyment for many individuals. Exercise can be performed in a group or alone.

Before you begin an exercise program you should always get approval from your doctor to participate. This is especially important if you have any medical problems.

About Exercise Programs In General

O An exercise program consists of three key phases.

Warm up
Exercise
Cool Down The warm-up and cool down involve stretching, getting your blood flowing, and your heart pumping.

The warm-up gets your body ready for exercise because

it increases the blood flow, preparing the heart and body

for exercise. b. Stretching prepares your muscles for exercise. C. Stretching involves moving your body part to the point of

feeling a pull in the muscles. It is important not to stretch your muscle beyond the point of pain. If you feel pain, stop the stretching motion.

Save Our Shoulders: A Guide for Polio Survivors. 16

Most stretches are held for 30 seconds for 3 repetitions. e. The cool down slows your body down from the exercise

and prepares your body for rest. It slows your heart down gradually, instead of rapidly ending the session after strenuous activity.

3 There are many different ways of exercising. There are

aerobic, strengthening, range of motion, and flexibility

exercises. @ For the best results, follow recommended precautions.

Polio survivors need to pace themselves

STOP

SLOW

Stop exercising if you are tired

or have increased pain

Exercise slowly

One of the most important tips for polio survivors is to

respect their body signals, and adapt their lifestyle to minimize their limitations. . It is important for polio survivors to respect their fatigue

and take frequent rest breaks when performing an exercise program.

Save Our Shoulders: A Guide for Polio Survivors

Exercise Tips:

Exercise slowly and take breaks between each exercise.
Do not hold your breath while exercising (count out loud to

encourage breathing).

Do not continue to exercise if you get sharp or new pain in the

area you are exercising.

If the exercise increases your pain, stop the exercise, or perform

the exercise in a pain free range of motion.

Do not push to perform the extreme of the motion or exercise.
Stop exercising if you have muscle twitching, muscle cramping,

or muscle fatigue that does not go away after 2 minutes rest.

Polio survivors should not exercise to the point of fatigue. . It is important to recognize that your fatigue may not appear

immediately. It may show up at the end of the day or the following day. You should look at your recent activities and modify them if your fatigue increases or occurs at the end of the day or the next day.

It is very important to listen to your body for signs of tiredness, pain, unusual muscle twitching, inability to perform a task that you can normally do, or the need for help with a task that you can usually do without help. These are signs suggesting muscle fatigue or overuse, and continuing activities that cause these signs could be harmful.

Most individuals who have a history of polio will have a system that works for them; some prefer to exercise in the morning

ey have the most energy, others exercise at the end of their day because they can rest after the program, and still others may ‘split’ their exercise program into two sessions a day.

Everyone will have his or her own way to do things, and when

it comes to exercising, each person needs to find a system that works best for them.

However, it is crucial to prevent fatigue because it may do

irreversible harm to your muscles

Save Our Shoulders: A Guide for Polio Survivors • 18

Sample Stretching Exercises

These stretches should be performed on each arm. While stretching do not continue if you feel sharp pain in your arms. You should only stretch until a pull is felt.

Corner Stretch

Stand facing a corner or open door, with your arms at shoulder

level and elbows bent.

Lean forward from your ankles, with your knees slightly bent.
Hold for 30 seconds and slowly return to the starting position.
Repeat 3 times for each arm.
Take a 1 minute rest break.

Save Our Shoulders: A Guide for Polio Survivors

Shoulder Flexion

Lie on your back.
Put your arm at your side and turn your palm toward your body.
Keeping your elbow straight, bring your arm up toward your

head and ear.

Hold for 30 seconds, and slowly return to the starting position.
Repeat 3 times for each arm.
Take a 1 minute rest break.

Shoulder Abduction

Lie on your back with your arm at your side and your palm up. . Keep your elbow straight and your arm down flat.
Slide your arm out to the side and up toward your ear.
Hold for 30 seconds, and slowly return to the starting position.
Repeat 3 times for each arm.
Take a 1 minute rest break.

Save Our Shoulders: A Guide for Polio Survivors. 20

Shoulder Internal Rotation

. You need a bath towel before you begin this exercise.

Stand straight with the towel resting on your right shoulder.
Put your left hand on your low back with your palm facing out.

Grab the towel with your left hand. With your right hand grab the towel in front of your right shoulder.

Gently pull down on the towel with your right arm until a stretch

is felt in your left shoulder. Hold for 30 seconds and slowly return to the starting position.

Repeat 3 times with each arm.

Save Our Shoulders: A Guide for Polio Survivors

Cane Stretches The following exercises require the use of a cane, dowel, yardstick, or broom handle to stretch your shoulders. They can be performed sitting, lying down, or standing. You should perform each exercise for your right and left arms.

Shoulder Flexion

Lift the cane above your shoulders until you feel a stretch.
Hold for 5 seconds.
Slowly return to the starting position.
Repeat 10 times.

Standing

Sitting

Save Our Shoulders: A Guide for Polio Survivors • 22

Shoulder Rotation

Sit, stand, or lie on your back with the cane in your hands and

your elbows against your side, with the cane above your chest.

Rotate the cane out to the right side, while keeping your elbows

against your side. Hold the stretch for 30 seconds.

Rotate the cane out to the left side, while keeping your elbows

against your side.

Hold for 30 seconds.
Repeat 3 times to each side.

Moving to the Right

Moving to the Left

Save Our Shoulders: A Guide for Polio Survivors

Shoulder Abduction

Lie on your back with the cane in your hands, with your right palm facing the ceiling and the left palm facing down. Put your right palm over the end of the cane, and the left hand at the

opposite end of the cane.

Push the end of the cane out to the right side until you feel

a stretch.

Hold for 30 seconds.
Repeat 3 times to each side.

Standing

Lying Down

Save Our Shoulders: A Guide for Polio Survivors. 24

Sample Strengthening Exercises

The following exercises involve the use of a resistive elastic band to increase strength. These bands can be obtained from a healthcare provider. The purpose of this type of exercise is to increase strength by moving the bands through a range of motion with resistance. The bands come in various colors that relate to different levels of resistance. Exercising with these bands is a safe and effective method to work specific muscle groups in individuals with, or without, a history of polio.

You should always perform exercises to a count of five (1-2-3-4-5) in a pain free range. Polio survivors should perform gentle non fatiguing exercises to strengthen the shoulder muscles. If you have any concerns or questions about the exercises you should consult your healthcare provider.

Some of the benefits of using a resistive elastic band are:

It is inexpensive.
It is easily portable.
It does not require heavy equipment.
It is easy to use.
You can use different levels of resistance for each exercise

if necessary.

It does not involve a lot of setup.

Save Our Shoulders: A Guide for Polio Survivors

Shoulder External Rotation

Anchor elastic band to doorknob at waist level.
Stand with elbow bent as shown holding band taut in your hand.
Place a towel between your upper arm and body.
Rotate arm outward, keeping elbow bent.
Slowly bring arm back to original position.

Save Our Shoulders: A Guide for Polio Survivors . 26

Shoulder Internal Rotation

Anchor elastic band to doorknob at waist level.
Stand with elbow bent as shown holding band taut in your hand.
Place a towel between your upper arm and body.
Rotate arm inward toward body keeping elbow bent.
Slowly bring arm back to original position.

27 • Save Our Shoulders: A Guide for Polio Survivors

Shoulder Wide Rows

Sit forward in a chair without arms, facing a desk or bed, with

your feet on the floor.

Loop the elastic band around the leg of a desk or bed and hold

the band with both hands so there are no wrinkles.

Start with your arms outstretched in front of you, shoulder

width apart, elbows slightly bent, palms facing each other.

Keeping your hands in the same position, slowly bring your hands toward your chest and return to the starting position.

Save Our Shoulders: A Guide for Polio Survivors

Tips To Avoid Making Your Shoulder Problem Worse

There are many changes that you can make in your normal activities that may help decrease problems you may be having with your shoulder(s). Below are examples of simple things that can be done to reduce the stress placed on your shoulders. REMEMBER: you are the one who knows your body best. Respect and learn to listen to your body’s signals or limits.

Rest or take a break from any sporting or leisure activity that

aggravates your arm or causes shoulder pain.

. Limit prolonged activities by taking frequent rest breaks.

Avoid excessive overhead activities with your painful arm.
Avoid activities or movements that increase your pain,

Take pain and anti-inflammatory medicine as prescribed by your doctor to control the pain and allow you to function.

When you enter a room take a minute to look at the chairs

and choose the highest one with armrests so that you do not have to put so much pressure on your shoulders when rising.

Avoid regular stalls in public bathrooms, as most of the toilets

are very low; handicap stalls have higher toilets and grab bars.

Save Our Shoulders: A Guide for Polio Survivors

Tips (cont’d):

Modify or seek help with work or home settings to avoid improper positioning and poor body mechanics.
Keep items used most frequently in cabinets below your

shoulder level.

When possible sit in a chair with armrests to keep your arms

supported and to lessen the amount of stress on your shoulders when you ‘push up’ to stand.

When doing tasks at a table sit on a cushion to raise your body.

When doing a sitting job, try to have every thing you need at hand

to avoid pushing yourself out of the chair more than necessary.

. Do not push a vacuum or lawn mower if you can get someone

else to do it.

Ask for help with heavy lifting tasks to prevent injuries.
Use adaptive equipment to perform your activities of daily living,

such as a reacher for getting items from a high shelf, or a long handled sponge to wash hard to reach body areas.

Put your shirt, blouse, or jacket on your painful arm first.

Do not sleep on your painful shoulder.
Put a pillow between your arm and body while lying on your non-painful side.

. While lying on your back, put a pillow under your painful

shoulder to support your arm.

Save Our Shoulders: A Guide for Polio Survivors. 30

Conclusion

Most people can easily identify what tasks are difficult for them to do or what activities cause a problem with their shoulders. For instance, many people have trouble climbing stairs or getting up from a chair. However, many do not realize just how much stress and strain is placed on the shoulders when doing these activities.

It is our hope that the information in this manual has helped you learn about your shoulders and has improved your awareness of some of the things that can increase the stress and strain placed on them. We think knowing this information is important because keeping your shoulders as healthy as possible can help you maintain your independence. The information provided is a basic guide for shoulder problems. If you have a shoulder problem, you should be evaluated by a healthcare professional that can work with you to develop a plan that best meets your needs.

Resources for Polio Information and Education

Helpful Websites for Post-Polio Information:

The Lincolnshire Post Polio Network

http://www.ott.zynet.co.uk/polio/lincolnshire

PICO: Introduction and Contents (The Polio Information Center Online)

http://cumicro2.cpmc.columbia.edu/PICO/PICO.html

Post Polio Syndrome Resources

Home

International Polio Network

Home

Englewood Hospital and Medical Center

http://www.postpolioinfo.com

31 . Save Our Shoulders: A Guide for Polio Survivors

Addresses of Post-Polio Clinics:

Post-Polio Walking Program Dr. Alberto Esquenazi MOSSREHAB HOSPITAL 1200 West Tabor Road Philadelphia, PA 19141 Phone: 215-456-9900

The New Jersey Polio Network PO Box 537 Martinsville, NJ 00836

Phone: 201-845-6860

Penn Post-Polio Program Mary Ann Keenan, MD Department of Orthopedic Surgery UNIVERSITY OF PENNSYLVANIA 3400 Spruce Street 2 Silverstein Philadelphia, PA 19104 Phone: 215-662-3340

Bacharach Institute for Rehabilitation Dr. Jacinth Reid-Artist 61 W. Jimmie Leeds Rd. Pomona, NJ 08240-0723 Phone: 609-748-5470

Saint Vincent’s Hospital & Medical Center Dr. Howard Sander 153 W. 11th St. Cronin 462 New York, NY 10011 Phone: 212-604-7453

Healthsouth Rehabilitation Hospital

of Reading Dr. Patti Brown

1623 Morgantown Rd. Reading, PA 19607-9455 Phone: 610-796-6354

SUNY Upstate Post-Polio Clinic Dr. Burk Jubelt Department of Neurology SUNY HEALTH SCIENCE CENTER 750 E. Adams St. Syracuse, NY 13210-2399 Phone: 315-464-4627

315-464-5356 Email: JubeltB@upstate.edu

The Post-Polio Institute Dr. Richard Bruno Phone: 201-894-3724 Dr. Jerald Zimmerman Phone: 201-894-3707 Physical Medicine and Rehabilitation ENGLEWOOD HOSPITAL AND MEDICAL CENTER 350 Engle St. Englewood, NJ 07631 Phone: 877-Post-Polio

National Rehab Hospital Dr. Lauro Halstead Dr. Michael Kvo 102 Irving St. NW Washington, DC 20010-2949

Phone: 202-877-1711 Email: Ish1@mhg.edu

Save Our Shoulders: A Guide for Polio Survivors. 32

For more information on post-polio research

please contact:

Mobility Research Office MOSS REHABILITATION RESEARCH INSTITUTE

Korman Bldg., Suite 213 Philadelphia, PA 19141

215-456-4993

Save Our Shoulders Read More »

Polio and CFS ME

Polio and CFS/ME

Dr. Richard L. Bruno

Dr. Bruno’s response to people who write about “poliovirus causing CFS”.

…have you heard of a Dr. William Campbell Douglas, editor of a publication called “Second Opinion,” and his contention that polio “may be with us again in a disguised form.”

I have read Dr. Douglas’s writings on this. But the idea that polio “may be with us again in a disguised form”, this is not true. I don’t think this is really what he’s saying.

“We may be mistakenly calling it chronic fatigue syndrome (U.S.) or myalgic encephalomyelitis (England). According to him, polio is more common than ever and may actually be caused by the polio vaccination.

Polio is NOT more common than ever and is NOT caused by the polio vaccination. [Dr. Bruno is commenting on the above, not on Vaccine Associated Polio (VAP) resulting from Oral Polio Vaccine (OPV)] There is no evidence that any of the polioviruses cause CFS.

“Dr. Douglas argues that the Salk and Sabin vaccines did not eliminate polio at all but forced it to change. While the vaccines suppressed the polio virus, it was replaced by genetically similar ones, such as Coxsackie virus often found in elevated levels in chronic fatigue syndrome patients.

Poliovirus being replaced by OTHER similar viruses is very different than polio being “with us again in a disguised form,” polio being more common than ever, being caused by the polio vaccination” or poliovirus “changing.” There is no consistent evidence of ANY virus, even the Coxsackie viruses, being “found in elevated levels in chronic fatigue syndrome patients.” However, “replacing” the poliovirus with a similar virus is a different story and may be what’s happening in CFS.

A British infectious disease specialist, Dr. Betty Dowsett, has been collaborating with us on our new studies of the links between PPS and CFS. She has sent me data showing that CFS cases rose significantly in the 1950s when the polio vaccines came on the scene. Her idea, repeated by Dr. Campbell, is that, like when one flock of birds takes over the territory of another flock when the first flock dies, other enteroviruses (especially the Coxsackie viruses) “took over” the territory of the 3 polioviruses when the polio vaccines reduced their number. There are several Coxsackie viruses that damage the brain activating system and could cause fatigue like that seen in CFS and PPS. There is even a Coxsackie virus (Coxsackie A7) that causes a condition identical to traditional paralytic polio, so similar in fact that it has even been called Russian Polio and even Poliovirus Type IV. There is nothing unique about the polioviruses’ ability to chew up the spinal cord and the brain stem.

We have a new paper on the parallels between PPS and CFS, describing the viral links between Coxsackie and other viruses and brain activating system damage, out in September in the American Journal of Medicine. The article is on the Harvest Center Web Page with our other articles on viral damage to the brain a post-viral fatigue.

Dr. Richard L. Bruno

Chairperson International Post-Polio Task Force and Director The Post-Polio Institute Englewood Hospital and Medical Center

Englewood, New Jersey 07631

Phone: (201) 894-3724 Toll Free: 1-877-POST- POLIO Fax: (201) 894-0324 PPSENG@AOL.COM

Many of Dr. Bruno’s papers are also available in the Lincolnshire Post-Polio Library and can be found listed under the catalogue entry for Bruno, Richard L., Ph.D..

The Lincolnshire Post-Polio Network

Registered Charity No. 1064177

An Information Service for Polio Survivors and Medical Professionals

All enquiries, book requests, medical article requests, membership fees, items for newsletters and donations to

The Secretary, Lincolnshire Post-Polio Network

PO Box 954, Lincoln, Lincolnshire, LN5 5ER United Kingdom Telephone: +44 (0)1522 888601

Facsimile: +44 (0)870 1600840

Email: info@lincolnshirepostpolio.org.uk Web Site: www.lincolnshirepostpolio.org.uk

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Created: 22nd October 1998

Last modification: 22nd January 2010.

Polio and CFS ME Read More »

Dr Henry writes as a retired physician-psychiatrist with Post-Polio

Dr. Henry writes as a retired physician-psychiatrist with PPS

My name is Henry Holland. I am a retired (on disability due to PPS) physician-psychiatrist. I have learned a lot from reading the postings to the Post-Polio Mailing Lists. I have noticed considerable questioning about medical matters in regard to PPS, various pros. and cons. of medications, and a variety of alternative and non-traditional treatments for PPS which may help some but not others. As a physician, I have observed a fair amount of doctor bashing, much of which may be justified. I have decided to begin posting to possibly be of some help to other PPSers and hopefully to provide some medical balance. I will begin by telling you my abbreviated polio history. I had polio at the age of eleven in 1950 in Richmond, Virginia, where I still reside. I had a severe paralytic case involving motor function damage from the neck down, the right side more severe than the left. After a three month hospitalization and a year of intensive exercise and hot bath treatments at home, I recovered enough function to only require a long leg locking brace on my right leg. During my college and medical school years, I could climb flights of steps, one at a time without a railing and alternating with both legs with a railing. I could walk an 18 hole golf course and ride a bicycle. I could pick myself off the ground when I fell. Towards the end of medical school, my main interests were internal medicine and psychiatry because I enjoyed patient contact. My interest in a medical career was a direct result of my polio experience. I should mention that during my adolescent growing years, I developed scoliosis of the spine with the curvature to the right, my weaker side.

During my rotating internship, I contracted a severe case of hospital resistant staph pneumonia, was trached, and almost died. I did recover but my lungs were never the same after that. I decided to do my residency in psychiatry because this speciality was mostly mental, could be practiced sitting down, and involved patient contact. However, I continued my interest in internal medicine, attended medical conferences, read medical and psychiatric journals as well as being on the clinical faculty of the Medical College of Virginia for 27 years. During my residency, I experienced repeated episodes of respiratory failure requiring intubation (just as in ‘ER’ every week) because my arterial C02 would increase during sleep due to exhausted respiratory muscles. In 1970, I agreed to a permanent tracheostomy, managed to get a cumbersome Bennett MA-I ventilator at home and my life almost miraculously turned round. I engaged in an active practice for 20 years until I experienced the first signs of PPS. During those 20 years, like many of you, I was a workaholic, had 12-14 hour days, was a dept. chairman, served on executive committees and taught med students and supervised residents. I loved my work. My wife and I had two children before my permanent trach was done and we had another daughter in 1979. If she had been a boy, we might have named her Bennett because that ventilator had extended my life. In 1990 I began to experience unexplained fatigue. I had numerous tests with no new findings. A lady at my church had heard about PPS and told me about a support group that met in Richmond. I went to my first meeting in 1991 and the first meeting was an amazing insight and I discovered an explanation for my problem when I heard the experiences of the other members. I educated my three doctors and they somewhat reluctantly agreed that my fatigue was probably somehow related to PPS. I cut back my hours, bought a scooter and van with a hoist to carry the scooter, my symptoms of fatigue remitted, and I resumed my workaholic practice for another five years. This past summer, the fatigue returned with intensity and was debilitating.

I was hospitalized, had $8,000 worth of tests in two days and nothing new was found. My doctors (the same ones as before) now believed that I had post-polio fatigue. Dr. Richard Bruno’s excellent article on the pathophysiology of central fatigue in PPS was most helpful to these doctors. I have retired on disability and was fairly quickly approved for SSDI. At the worst, the fatigue was so severe that I could not stand, only sit for a few minutes, yet my legs would hold me up and did not feel much weaker motorwise.

I just simply felt like I did not have the energy to walk ten feet. Tom Walter in California has been of immense help to me when I went on-line. The polio chat group on aol, the list services, and my own local support group have shown me that I am not alone, and that there are numerous polio warriors out there.

I still have my brain and can communicate. Yes, I do have some word finding problems at times. At lot of daily rest has restored some energy to where I can leave the house for a few hours depending on the temperature outside. I am convinced that the original polio infection involved areas of the brain (particularly the Reticular Activating System) in the spinal and bulbar-spinal types that probably went undetected unless the patient died and evidence was found at autopsy. Now this area and probably other areas have worn out, contributing to central fatigue. The theories on motor neuron fatigue and related muscle or joint pain make sense and are more easily accepted in medical centres as being related to PPS. I find that the central fatigue when it is debilitating causes sleep disturbance, a feeling of being constantly tired even when one wakes up and tends to become more severe in the late afternoon. Everyone with PPS has tried to find what works best for them, and there is much variety. I remind myself that the polio virus was very specific in where it did its damage, but no two cases of acute polio were exactly alike. Consequently, although there are many similarities in the symptoms of PPS (that is why it is called a ‘syndrome’), the manifestations of PPS are never EXACTLY the same in any two of us. As a result, the medical profession is puzzled as to what to do even when medical people are knowledgeable about PPS. Do you exercise or not? Do you prescribe pain meds and contribute to someone attempting to resume activity and further weaken motor function? Do you prescribe antidepressants since some surveys indicate 1/4 to 1/3rd of PPSers meet the diagnostic criteria for Major Depression? But what dose do you prescribe since most PPSers respond to lower doses if they respond, and it seem most PPSers are more sensitive to side effects than just depressed patients. Is the PPS itself causing a depletion of serotonin and catacholamines leading to biological depression or is the depression simply secondary to the sense of loss of purpose and usefulness that many PPSers experience. I think many of us have used denial and are prone to be so called type A personalities. A better term might be driven obsessive-compulsive overachievers who find it difficult to change and deal with anger. I think PPS has stirred up both our repressed anger (from the past) and allowed our conscious anger about PPS to be felt. I have noticed as a group that most of us are perceptive, but also sensitive to the reactions of others and even project our anger onto others. This usually indicates that the individual is angry with himself or herself. But we also seem to be equally caring, apologetic, and forgiving. We are all in this together. If not for PPS, we would have had no reason to find each other. If there is a blessing in all of this for us, it is that we have rediscovered ourselves and each other through a variety of interpersonal methods. Until 1991, I knew only one other person who showed a residual of polio. Now, I know hundreds, and the potential is thousands. During my professional career, I treated the usual mental disorders that most psychiatrists treat, but I maintained an interest in the emotional problems or defenses of people with chronic medical illnesses (diabetes, colitis, arthritis, chronic pulmonary disease, cerebral palsy, chronic fatigue syndrome, fibromyalgia, etc.) I also tried to stay abreast of psychopharmocology and the interaction of drugs. I have learned a lot about ventilators since I have used one for 27 years. I found that many times the least treatment is the best, especially with the elderly and chronic disorders, but I also believe in relieving pain. I can confess that doctors are fearful of state boards of medicine and their power, fearful of losing their federal narcotic license, and are under scrutiny from review by private insurance companies, Medicare, Medicaide and HMO’s (Health Money

Organizations — only joking), who will punish you if you happen to have a ‘sick’ practice, meaning a lot of patients with chronic disorders.

We often do order unnecessary tests in defensive fear of malpractice claims. It used to be that if something had happened, you could deal with it when you knew that you had done nothing wrong, but now the doctor gets a letter in the mail for his records from a lawyer or a subpoena for records from the court over something that may have happened over a year before. I can tell you that such an event can distract your attention and attitude towards our many grateful patients.

I have said enough, I would like to respond to inquiries about PPS, medications, various treatments, and yes, I am interested in alternative treatments and have tried a few myself. Ironically, the Salk Vaccine put an abrupt end to all the research on the natural course of polio. Now, we, hopefully, the last polio generation in the USA, will perhaps renew some research and provide answers about the natural course of polio, and hopefully, in time to be of some help to ourselves. I graduated from med school in 1966, and my class did get a one hour lecture on polio, now it is mentioned in much the same way the bubonic plague or leprosy is mentioned. You need to know about it to answer quiz questions, but you do not expect ever to see a case of it.

What I have said in regard to medical and psyche dynamic issues is only my opinion, just that. I have had vast experience as a doctor and a patient. I do not claim to be an expert, I am one of you, but I am willing to be of any help I can.

Henry Holland, Richmond., Virginia, USA. Henry4FDR@aol.com

The Lincolnshire Post-Polio Network

Registered Charity No. 1064177

An Information Service for Polio Survivors and Medical Professionals

All enquiries, book requests, medical article requests, membership fees, items for newsletters and donations to

The Secretary, Lincolnshire Post-Polio Network

PO Box 954, Lincoln, Lincolnshire, LN5 5ER United Kingdom

Telephone: +44 (0)1522 888601

Facsimile: +44 (0)870 1600840

Email: info@lincolnshirepostpolio.org.uk

Web Site: www.lincolnshirepostpolio.org.uk

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Created: 3rd February 1997

Last modification: 22nd January 2010.

Dr Henry writes as a retired physician-psychiatrist with Post-Polio Read More »

The Late Effects of Polio Information for GP

The Late Effects of Polio Information for GP Read More »

Nutrition and Post Polio Syndrome

Nutrition and Post Polio Syndrome

Janice Hartman

This article was originally written in 1997, but the nutrition information is still as valid today as it was then. Additional information on PPS Nutrition is now on my website:

http://www.reocities.com/arojann.geo/ppsnutrition.html

Janice Hartman, February 2001.

Let me first say that I am no expert here, but my training is in Nutrition and Education. I must caution all of you trying to lose weight to please do it sensibly. A low fat diet (with portion control) and exercise (to whatever degree you can do) works the best. Jane Brody recommends in her Nutrition Book a diet high in fiber, but balanced with all foods. A weight loss of one to two pounds a week is recommended. With fast

weight loss muscle tissue is diminished, and even worse when you regain weight it is added as fat, not muscle tissue. Thus, yo-yo dieting where you lose – gain, lose – gain is not recommended. If you fall into the category of morbidly obese, you should be under a doctor’s care for more options.

Diet pills are dangerous. Protein diets are dangerous. Be very careful.

Seek out a knowledgeable doctor. A multivitamin might be advisable, if you can tolerate it. Megavitamins can be a problem and ought to only be attempted under a doctor’s care. Some studies with vitamin B-6 have proven mega doses of this vitamin can help certain rare disorders, but people who self treat with mega doses of B-6 risk severe NERVE damage. Be cautious. Excesses of water soluble vitamins are also excreted from the body and sometimes only create a placebo effect.

FYI: Vitamins are either water soluble (8 B vitamins and C) or fat soluble (vitamins A, D, E, and K). Since the fat soluble are stored in the body, they can build up to toxic levels. The water soluble vitamins are not generally stored and the excess are washed out of the body through urine or sweat. They need to be replaced daily.

Be aware of the salt you use in and on your foods. Salt is a combination of sodium and chloride (NaCl). Sodium (Na) occurs naturally in foods. However, in natural unprocessed foods, sodium is low and phosphorus is high. In processed foods, they are generally high in sodium (or even salt) and low in phosphorus.

Try to eat foods in as close to their natural state as possible. Fresh fruits and vegetables (high in fiber), grains like oatmeal instead of processed sugar (or honey) ladened foods. Read labels: for cereals look under Total Carbohydrates in Nutrition Facts, the Sugars should be 0 g (grams) to not more than 6 g. Also, change to lower fat (or low fat) dairy products. You can save many fat calories by switching to a lower fat

milk . If you drink whole milk switch to 2% , if your drinking 2% try 1%, etc. You still get all the calcium and added vit A and D in low fat. I don’t advocate raw meats, fish, as a natural food. Trim the visible fat, take the skin off the chicken and bake, don’t fry whenever possible.

Vegetarianism may prove to be beneficial to some people. Just remember that you need to include other sources of protein if you eliminate meats entirely. Vegetarians can get protein if they eat dairy or eggs. If not, protein is found in nuts and nut butters, beans and vegetables. There are web sites for vegetarian foods that are worth checking out.

I am not trying to add to the “well, what can we eat now?” syndrome. If your eating habits are terrible, just try to change a little at a time. If fresh fruit is too expensive (but look for bargains) buy canned. Just try to read labels. Enjoy treats even if you are eating well. I like cookies, but generally make my own or buy low fat as treats (mine are better).

Use medications that work for you, but only try one at a time to see its effects. Use the lowest dosage that works. Be careful with drug interactions. Drugs have side effects depending on the person. The question is: do the benefits outweigh the risks? Like nausea, does it go away? You decide if it is working for you.

I have been taking note of the many medications than can help PPS pain so I will know what I can try if my present meds don’t work anymore. Hope no one is attempting to try them all, unless your need is great and you have doctors advise. Henry has given very sound information on the use of low dosages of anti depressants that are helping some people. Keep an open mind, learn to hear what your body is trying to tell you, practice pacing yourself, and learn to say no.

Janice Hartman, Baltimore, Maryland, USA

jannhartman@juno.com

Credentials:

I am first and foremost the mother of three boys. Post Polio Survivor from 1953. B.S.in Home Economics Education.

International Board Certified Lactation Consultant (IBCLC).

Former:

Home Economics Teacher.

Home Economist with PA State Cooperative Extension.

Ass’t Dietitian.

Ass’t Nutritionist with Woman, Infants, and Children Program (WIC).

Editorial Ass’t for “Whole Foods for the Whole Family” Cookbook.

Lecturer at workshops for Family and Children Conferences for over 20 years.

The Lincolnshire Post-Polio Network

Registered Charity No. 1064177

An Information Service for Polio Survivors and Medical Professionals

All enquiries, book requests, medical article requests, membership fees, items for newsletters and

donations to

The Secretary, Lincolnshire Post-Polio Network

PO Box 954, Lincoln, Lincolnshire, LN5 5ER United Kingdom

Telephone: +44 (0)1522 888601

Facsimile: +44 (0)870 1600840

Email: info@lincolnshirepostpolio.org.uk

Web Site: www.lincolnshirepostpolio.org.uk

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Primary Document Reference: <URL:http://www.ott.zynet.co.uk/polio/lincolnshire/library/usa/nutri.html> Alternate Document Reference: <URL:http://www.zynet.co.uk/ott/polio/lincolnshire/library/usa/nutri.html> Created: 21st March 1997

Last minor modification: 6th February 2010.

Reviewed February 2001

Nutrition and Post Polio Syndrome Read More »

Late Effects of ME Can They be Distinguished From Post-Polio

THE LATE EFFECTS OF ME

Can they be distinguished from the Post-polio syndrome?

Dr. E.G. Dowsett MBChB, Dip Bact.

Honorary Consultant Microbiologist

Basildon and Thurrock Hospitals NHS Trust.

Originally a Presentation to the All Party Group of MPs on ME/PPS on 31st January 2001. This Lincolnshire Post-Polio Library Publication February 2001.

INTRODUCTION:

Few people would dispute that ME (Myalgic encephalomyelitis), an illness which blights the hopes and aspirations of all sufferers, especially the young, is denied equal treatment in respect of diagnostic facilities, medical coverage and welfare provision. Comparable chronic and unpredictably disabling neurological conditions, for example Multiple Sclerosis, which was formerly ascribed to “hysteria” and similarly neglected, now receive government recognition, facilities within the NHS, and more generous research funding – though the potential cost of effective treatment can still arouse bitter debate.

WHAT IS ME?[1,2,3]

ONSET:

It is a syndrome (a group of linked symptoms) initiated by one or more of a related group of enteroviruses which circulate annually in the community in summer and autumn in temperate climates, but all the year round in tropical areas.

MINOR ILLNESS:

The majority of encounters with these viruses are asymptomatic but some subjects, more commonly teenagers and adults, suffer a seemingly trivial minor illness, usually described as a non specific summer ‘flu accompanied by gastrointestinal upset, sore throat and occasionally by generalised glandular enlargment.

SECONDARY PHASE:

The minor illness is self limiting in 90% of adults. However, some 5-10% of all age groups exposed, may progress to a more significant episode with severe headaches and vertigo, a stiff neck and back and

generalised muscle pain, signifying that the central nervous system has now become involved with a possible progression to viral meningitis and encephalitis[3]. Clinical recovery at this stage is normally possible, but does not preclude further effects of the illness in later years. It has to he remembered that ME is a life-long disability where relapse is always possible.

FINAL STAGE[1,2]:

After a variable interval, a multi-system syndrome may develop, involving permanent damage to skeletal or cardiac muscle and to other “end organs” such as the liver, pancreas, endocrine glands and lymphoid tissues, signifying the further development of a lengthy chronic, mainly neurological condition with evidence of metabolic dysfunction in the brain stem. Yet, stabilisation, albeit at a low level, can still be achieved by appropriate management and support. The death rate of 10% occurs almost entirely from end organ damage within this group (mainly from cardiac or pancreatic failure). It has to be said that suicide in younger patients and in earlier stages of the disability is related to the current climate of disbelief, rejection of welfare support and loss of educational and employment prospects. It is an additional and potentially avoidable factor.

WHAT ARE THE LATE EFFECTS OF ME?

Most doctors with substantial experience of examining these patients would agree that the outlook for any individual is unpredictable. Case records need to be kept up to date for prolonged periods because patients who have remained clinically stable over 40 years or more and have worked normally for most of their lives are still subject to significant late effects. These include: overwhelming fatigue both physical and mental; cognitive disturbances; muscular and joint pain; muscular weakness and wasting; difficulty with breathing; episodes of hypothermia and low blood pressure; problems with swallowing and voice production as well as sudden attacks of breathlessness while sleeping. The similarities of these symptoms to those complained of by sufferers from the Post-polio syndrome, is striking and requires further explanation.

WHICH GROUP OF ME SUFFERERS ARE CHIEFLY AT RISK OF THE LATE EFFECTS?[4]

The majority of ME patients contract their illness in the 3rd and 4th decade (50%) with secondary peak at puberty (18%). The incidence at the extremes of age (below 10 years and above 50 years) has, until recently, been low (about 10% in each group). Epidemiological surveys made between 1988 and 1998, in 2 Essex hospital clinics dedicated to ME, indicate that the percentage of patients over 50 years of age attending with new illness has risen from 6% in 1988 to 16% in 1995 and 18% in 1998. Some patients indeed, present with paralysis. Others have a vague past history of illness in childhood. Some years of “weakness” or “growing pains”; recovery, but always poor at sport; possibly a stable work record for 25 years or more, followed by a decline in walking ability; unusual fatigue after simple tasks; problems with climbing stairs, dressing and with short term memory. The current age range of these patients is from 40- 92 years, so it is not easy to dismiss their symptoms as due solely to “ageing”. Their social and medical problems are especially severe, as they share all the difficulties of access to remedial and support services complained of by other disabled people in the same age group. However, in the UK, there is almost nowhere to refer patients with suspected post-polio symptoms as the medical profession has largely forgotten or never experienced the many manifestations of that disease. Successful immunisation against only 3 polio viruses among some 69 enteroviruses currently in circulation is deemed to have solved all problems!

WHAT IS THE POST-POLIO SYNDROME?[5,6,7]

Poliomyelitis is an acute enteroviral infection with a wide range of clinical manifestations and multi-organ involvement (a fact which was frequently overlooked by physicians dealing with large numbers of dangerously paralysed patients, between 1940 and 1950). 95% of people who contract the infection remain symptom free or suffer only a trivial non-specific respiratory or gastrointestinal illness as in ME.

Some 5% of those contracting the minor illness develop muscle weakness or paralysis before more serious or fatal complications supervene. The diagnostic distinction between “paralytic” and “non-paralytic polio” was entirely arbitrary in the days of the big epidemics. In fact, the category of “non-paralytic polio” contained many patients with mild or temporary paralysis and with encephalitis, which occurs in patients reaching the later stages of this illness. Modern studies indicate that overt paralysis in these patients depends entirely on the percentage of spinal nerve cells destroyed. For damage to be visible as weakness or paralysis at least 50%-60% of the nerves controlling muscular action must be damaged or destroyed. Thus, patients with less damage who may only have had a minor illness, and some who were asymptornatic can still present many years later with a classic Post-polio syndrome.

Recent publication[6,8] of this information (originally derived from studies made in 1955) has resulted in a re-definition of the post-polio syndrome and will certainly include many patients currently seen in ME clinics.

SUGGESTED NEW CRITERIA FOR THE DIAGNOSIS AND ASSESSMENT OF THE POST-POLIO SYNDROME[7].

A history of remote paralytic or non-paralytic polio, or findings on history, physical examination or laboratory and other technical studies compatible with damage to the central nervous system in earlier life.
A period of recovery.
A period of stable functioning for 10-50 years.
New symptoms for which no other explanation can be found. Many patients and research workers point out that the assessment of sufferers will now have to become more holistic, that standard electrical tests of muscle function (EMG) will have to be more widespread (and repeated), and that manual muscle testing must refer to repetitive activity and daily tasks rather than a single examination on the couch[16].

IS IT POSSIBLE THAT MANY PATIENTS DIAGNOSED AS HAVING ME ARE SUFFERERS FROM AN ILLNESS CLINICALLY IDENTICAL TO “NON PARALYTIC” POLIO?[6,8]

Yes, undoubtedly! This is an important question with fundamental implications for further research into the diagnosis, treatment and prevention of both disabilities.

Modern research published currently in a dedicated supplement of the American Journal of Physical and Medical Rehabilitation by the Editor and 3 leading research teams[6,8], indicates that part of the current difficulty in obtaining a clear diagnosis of the post-polio syndrome lies in the error of dividing acute poliomyelitis into “paralytic”, “non-paralytic”, “abortive” and “sub clinical” categories. It has to be recognised that there is a wide range of nerve damage in every patient. The Post-polio syndrome may

therefore include:

Patients whose nervous system damage was not clinically obvious at the time of diagnosis. b. Those who had minimal paralysis for a short period and were misdiagnosed as non-paralytic polio.
Those patients suffering from infection due to non polio enteroviruses with potential to cause nervous system damage and the “Post polio” syndrome, equal to that of polio viruses e.g. Coxsackie viruses A9, A7; Coxsackie B viruses 1-6; ECHO virus 9; Enteroviruses 70, 71 – all of which have been implicated in outbreaks of ME or epidemics clinically identical to paralytic poliomyelitis.
Patients with symptoms clinically identical to the Post-polio syndrome whose nerve damage arises from some other cause, for example, local muscle problems due to metabolic dysfunction, the effects of persistent virus infection, immune reaction to fragments of viral genetic material etc.

It is essential that patients with clinical symptoms suggestive of Post-polio syndrome should be referred to a Physician to exclude other nervous diseases (eg, Motor Neurone Disease), and especially those which are treatable.

IS IT NECESSARY TO DIFFERENTIATE BETWEEN THE LATE EFFECTS OF ME AND THE POST-POLIO SYNDROME?[8,9,10]

Not really, even if it were useful or practicable to do so at present, as the two conditions are clinically identical and similar in respect of neuroanatomical, neuroendocrine, neuropsychological electroencephalographic and other techniques, including brain imaging and molecular biology, as indicated by a remarkable series of research papers published by Bruno and colleagues over the past 20 years.

WHAT IS THE EVIDENCE THAT THE LATE EFFECTS OF ME AND THE POST POLIO SYNDROME CAN BE CAUSED BY ENTEROVIRUSES OTHER THAN POLIO VIRUSES 1-3?

[11] In 1948, the year in which polio viruses were first cultured, specimens from 2 children with clinical poliomyelitis, yielded a non-polio enterovirus, (eponymously called Coxsackie after the neighbourhood in which they lived). This finding opened a Pandora’s box of some 70 previously undiscovered enteroviruses of which 14 strains were later found to have neurogenic potential equal to that of polio viruses.
[12] From the late 1940s, studies in the USA indicated that outbreaks of major or minor enteroviral illness (eg. Paralytic or non-paralytic and non specific “summer ‘flu”) could be caused by varying proportions of virulent and non virulent polio viruses combined with other neurogenic enteroviruses, for example in Akron and Cincinnati [Table 1], Ohio (1947) Delaware and Connecticut (1949).
[13] In the UK, an outbreak of poliomyelitis affecting an Edinburgh housing estate from August 1961-February 1962 (a period when polio immunisation with the Salk (injectable) vaccine had recently been introduced) provided evidence that a “mosaic” of enteroviruses, including Polio type 3, Coxsackie viruses B2 and B4, Echo viruses 5 and 15 could act in combination to enhance virulence in individual patients, to block the spread of polio virus type 3 and to interfere with vaccine efficiency. Each virus type appeared sequentially until the arrival of Echo virus 5 in November which ended the outbreak by the following February (as indicated by serial sampling of

the local school sewer). It has to be remembered that a sudden change in the virulence and spread of enteroviruses in the 20th century has been due to alterations in human hygienic behaviour rather than to viral mutations.

TABLE 1. 1947 OUTBREAK OF SUMMER ‘FLU, CINCINNATI, USA [12]
DIAGNOSIS	CASE No	CSF CELL COUNT	VIRULENCE OF POLIO VIRUS	3 LABORATORY TESTS FOR COXSACKI VIRUS (NON POLIO ENTEROVIRUS)			SUMMARY OF LABORATORY FINDINGS
Summer Flu	1	0	Polio HV	–	–	–	High virulence polio virus only
	2	40*	Non paralytic polio LV	–	–	–	Low virulence polio virus & infection of CSF
	3	3	“	+	+	+	Low virulence polio virus & coxsackie virus
	4	150*	“	+	+	+	Infection of CSF & low virulence polio virus & Coxsackie virus
Non Paralytic Polio	5	734*	Polio HV	–	–	–	Only high virulence polio virus & infection of CSF
	6	27	Polio HV	–	–	–	Only high virulence polo virus
	7	70*	–	–	–	–	Only Coxsackie virus & infection of CSF
Paralytic Polio	8	107*	Polio HV	–	–	–	Only high virulence polio virus and infection of CSF

KEY * Raised cell count in cerebro-spinal fluid indicates infection in the central nervous system Polio HV – Polio type one, virulent.

Polio LV – Possibly polio type two, low virulence (non paralytic)

Coxsackie is a neurovirulent, non polio enterovirus

HOW MAY SYMPTOMS OF THE LATE EFFECTS OF ME AND POLIO BE EXPLAINED?[9,10]

It has to be accepted that some degree of encephalitis has occurred in all these cases and that the areas chiefly affected include the upper spinal motor and sensory nerve roots and the spinal nerve networks traversing the adjacent brain stem (a nerve centre controlling all vital bodily functions which is always damaged). The most troublesome symptoms of both conditions are progressive muscle weakness, fatigue and pain, and the commonest cause of relapse over use of repaired nerve networks and an inappropriate response to physical or mental stress in combination with the increasing effect of normal aging.

FATIGUE:

This is almost always central and due to damage affecting the Reticular activating system (which keeps the brain awake and alert as well as maintaining some control over muscular activity). Fatigue is characteristically intermittent, but profound and incapacitating and related even to minor activity.

[14]MUSCLE WEAKNESS AND WASTING:

This may have a central cause (as above) or a local origin due to loss of motor units controlling individual muscles (including the breakdown of repair to these over time). Metabolic, immune or ongoing viral injury to muscle fibres, are other possibilities where infection persists.

PAIN:

This is a severe symptom which is difficult to treat and is usually due to dysfunction of the thalamus, an important sensory relay station in the brain stem. Failure to produce natural painkillers (e.g. endorphins and encephalins), may be an additional factor.

INAPPROPRIATE REACTION TO PHYSICAL OR MENTAL STRESS:

This also arises from injury to the brain stem which normally controls the production of cortisol (a steroid required for stress control) via the hypothalamus, pituitary and adrenal glands . In the absence of an efficient response, even minor stress can cause catastrophic collapse in these patients. NB. Because of the many and varied symptoms arising from encephalitic damage to the brain, all symptoms reported, however bizarre they may seem, must be taken as possible evidence of organic disease.

MANAGEMENT:

Despite promising reports from the USA of anti-enteroviral agents[18], and of Dopamine receptor agonists[9] (to correct some deficiencies in neurotransmission) no specific medical treatment is yet available in the UK and the main principles of management rely upon conservation of energy, reduction of stress, and simplification of manual tasks at home or at work. These objectives cannot possibly be achieved without financial and social support, aids to mobility, house conversions and suitable rehabilitation facilities. In the USA it is claimed that (with counselling, if necessary, for those who find

such adjustments to life style difficult) 91% of patients will stabilise in view of the fact that, at this stage, the disability is only slowly progressive. Patients have to be cautious about drugs, especially those acting on the central nervous system including psycho-active preparations and alcohol. In general, these patients

need less anaesthetic but higher doses of pain killers than usual and more time to convalesce from surgery. There are now many new options for muscle problems including modern orthoses and corrective surgery.

COMMENT.[15]

There has been little government interest or support for patients suffering from the late effects of ME or from the post-polio syndrome. It is generally expected that survivors of polio will gradually disappear because of successful immunisation of the UK population 40 years ago. However the fact that “Post-polio”, by any other name, can arise from currently circulating enteroviruses has not been taken into account. The Chief Medical Officer’s Working Party on ME (set up in 1999 and funded privately by the Linbury Trust) has made it clear that its remit is only with management, and that all discussion about the cause, epidemiology and social benefit requirements of these patients is ruled out. It seems that it will be difficult to advise on rational management in the absence of such vital information.
The potential size and cost of the problem. This is impossible to assess in the UK because no official epidemiological surveys have been made. However, increasing numbers of patient support groups and individual research workers have been making their own calculations. In the case of ME, prevalence appears to range from 300/100,000 to 500/100,000 in occupations at high risk of infection[2], but no information is yet available about the number likely to suffer late effects (except that it may have trebled in the last 10 years)[4].

The number likely to be affected by the post-polio syndrome has been calculated as between 200- 270/100,000 currently[7], but no account has been taken of survivors from non-paralytic polio which could easily double that figure. Possible costing for ME support has been based on 3 times the cost of maintenance for multiple sclerosis on the supposition that ME is 3 times as common[4]. The only costs that we can be sure of are those derived from the failure of appropriate management, and of inappropriate assessments which waste vast sums of money and medical time while allowing patients to deteriorate unnecessarily.[16]

Some Immediate Steps that Could Be Taken[7,17,18,19,20]. These patients could be referred to NHS rehabilitation clinics and welfare facilities as for any other chronic neurological disease but physiotherapy must include exercise suitable for patients with some damaged muscle fibres which have been overused while others are normal and liable to deconditioning[7]. Separate “ME” and “Post-polio Clinics” are more expensive and often inaccessible. We should be educating doctors and paramedics now about the very common and seriously disabling effects of neglect[7]. Rapid diagnostic tests for enteroviruses, anti-enteroviral drugs and possible vaccines are already in preparation here, or in use (in the USA) to deal with the tremendous burden of circulating enteroviral infections, (for example, leading to febrile respiratory infections, viral meningitis and myocarditis, let alone unnecessary admissions to hospital and inappropriate prescription of antibiotics in children)[17,18]. These methods could well be employed for the benefit of young people in the UK and to prevent the rising tide of ME in schools – the commonest cause of long term absence and subsequent educational deficit![19,20]
Research workers must be encouraged and appropriately funded to work in this field. However they should first be directed to papers published before 1988, the time at which all specialised experience about poliomyelitis and associated infections seem to have vanished

mysteriously![11,12,13]

Address for correspondence:

47 Drewsteignton

Shoeburyness

Essex SS3 8BA.

United Kingdom.

REFERENCES.

RICHARDSON J. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome and Enteroviral – Mediated Organ Pathology. The Haworth Press Inc. New York, London Oxford. ISBN 0-7890- 1127-1 (in press).
DOWSETT EG, RICHARDSON J. The Epidemiology of Myalgic Encephalomyelitis (ME) in the UK – 1919-1999. Evidence submitted to the All Party Parliamentary Group of MPs on ME 23.11.99.
Echo Viruses and Meningitis. Scottish Centre for Infection and Environmental Health, Weekly Report, 7.11.2000.
RAMSAY AM, DOWSETT EG. – Then and Now. An epidemiological introduction (in the Clinical and Scientific Basis of Myalgic encephalomyelitis/Chronic Fatigue Syndrome. HYDE BM, GOLDSTEIN J, LEVINE P. Eds): The Nightingale Research Foundation, Ottawa, Ontario, Canada, 1992 Chapter 7 : 81-84.
DALAKAS MC. Post-polio Syndrome 12 years later (in the Post-polio Syndrome – advances in the pathogenisis and treatment. DALAKAS MC, BARTFIELD H, KURLAND LT. Eds) Annals of the New York Academy of Sciences: 1995; 753: 11-18. [PubMed Abstract]
FALCONER M, BOLLENBACH E. Late Functional Loss in Nonparalytic Polio. American Journal of Physical Medicine and Rehabilitation. 2000; 79(1) 19-23. [PubMed Abstract] 7. Basic information leaflet for health professionals on Post-polio syndrome/late effects of polio. Lincolnshire Post-polio Network, 69 Woodvale Avenue, Lincoln, LN6 3RD, UK. October 2000 8. JOHNSON EW: A Clarification of “nonparalytic” polio: 3

BRUNO RL : Paralytic vs. “Nonparalytic” Polio. Distinction Without a Difference?: 4-12. [PubMed Abstract]

HALSTEAD LS, SILVER JK: Nonparalytic Polio and Postpolio Syndrome: 13-18. [PubMed Abstract]

(see opus cit. reference 6)

BRUNO RL, SAPOLSKI R, ZIMMERMAN JR, FRICK NM. Pathophysiology of a Central Cause of Post-polio Fatigue. (in the Post-polio syndrome — advances in pathogenesis and treatment. DALAKAS MC, BARTFIELD H, KURLAND LT: eds.) Annals of the New York Academy of Sciences. 1995; 753 : 257-275. [Lincolnshire Library Full Text]
BRUNO RL, FRICK NM, CREANGE MA, ZIMMERMAN JR, LEWIS T. Polio Encephalitis and the Brain Generator Model of Post-Viral Fatigue syndromes. Journal of Chronic Fatigue Syndrome. 1996; 2 (2,3): 5-27. [Lincolnshire Library Full Text]
DALLDORF G, SICKLES GM, PLAGER H, GIFFORD R. A virus recovered from the faeces of “poliomyelitis” patients. Pathogenic for suckling mice. Journal of Experimental Medicine. 1949; 89: 567-582.
MELNICK JL, LEDINKO N, KAPLAN A, KRAFT E. Ohio Strains of a Virus Pathogenic for Infant Mice (Coxsackie Group). Simultaneous occurrence with poliomyelitis virus in patients with “summer grippe”. Journal of Experimental Medicine. 1950 : 91: 185-195.
SELWYN S, HOWITT LF. A Mosaic of Enteroviruses. Polio, Coxsackie and Echo infection in a

group of families. The Lancet. 1962; 2 : 548-551.

LANE RJM, BARRETT MC, WOODROW D. Muscle Fibre Characteristics and Lactate Responses to Exercise in CFS. Journal of Neurology Neurosurgery and Psychiatry. 1998; 64: 362-367. [PubMed Abstract]
Letter from Parliamentary Under Secretary of State, Department of Health (Yvette Cooper) to Matthew Taylor MP 20.6.2000 re. Post-polio Syndrome in UK.
HALLAM H. Polio Survivors need holistic multidisciplinary assessment because the standard physical assessment is not adequate. LincPIN Newsletter June 19, 1999.
ROTBART H, MCCRACKEN GH, WHITELY RJ. et al. Clinical significance of enteroviruses in serious summer febrile illnesses of children. Paediatric infectious diseases. 1999; 18 : 869-74. [PubMed Abstract]
ROTBART HA, O’CONNELL JF, McKINLAY MA. Treatment of Human Enterovirus Infection, Antiviral Research. 1998; 38 : 1-14. [PubMed Abstract]
DOWSETT EG, COLBY J. Long Term Sickness Absence due to ME/CSF in UK Schools – an epidemiological study with medical and educational implications. Journal of Chronic Fatigue Syndrome 1997; 3 (2) : 29-42.
RANGEL L, GARALDA ME, LEVIN M, LEVIN M, ROBERTS H. The course of severe chronic fatigue in childhood. Journal of the Royal Society of Medicine. 2000; 93 : 129-134. [PubMed Abstract]

The Lincolnshire Post-Polio Network

Registered Charity No. 1064177

An Information Service for Polio Survivors and Medical Professionals

All enquiries, book requests, medical article requests, membership fees, items for newsletters and donations to

The Secretary, Lincolnshire Post-Polio Network

PO Box 954, Lincoln, Lincolnshire, LN5 5ER United Kingdom

Telephone: +44 (0)1522 888601

Facsimile: +44 (0)870 1600840

Email: info@lincolnshirepostpolio.org.uk

www.lincolnshirepostpolio.org.uk

and encouraged. We only ask that you let us know so that we can in future notify you of critical changes. Reproduction and redistribution of any articles via any media, with the exception of the aforementioned, requires permission from The Lincolnshire Post-Polio Network and where applicable, the original author(s).

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Created: 19th February 2001

Last Minor Modification: 22nd January 2010.

Late Effects of ME Can They be Distinguished From Post-Polio Read More »

Late Effects of Polio – Overview 2000

FLORIDA EAST COAST POST POLIO SUPPORT GROUP

LATE EFFECTS OF POLIO — OVERVIEW 2000

December 8th – 10th, 2000

SWALLOWING, BREATHING, ARTIFICIAL VENTILATION

Augusta S. Alba, MD, DPM&R, DNP-N

Director Rehabilitation Medicine Coler Goldwater Memorial Hospital

Clinical Associate Professor Rusk Institute of Rehabilitation Medicine

New York University Medical Center

Oral Peripheral Examination: (An intact examination from the neurological point of view depends on five pairs of cranial nerves: V, VII, IX, X and XII located in the brainstem)

Labial (lips), lingual (tongue), palatal (soft, and uvula): range of motion (ROM), rate and strength. Dentition: within functional limits (WFL), missing teeth, edentulous, or dentures (upper/lower). Vocal Quality: clear, wet, or hoarse. Cervical Auscultation: clear, wet, and/ or stridor. Volitional Cough and Volitional Throat Clear: present, absent, or weak. Volitional Swallow: present, or absent. Gag: present, absent, or reduced.

Oral Stage of Swallow For the following phases: preparation, propulsion, residual, and for the following seven consistencies: honey thick, nectar thick, thin liquid, puree, mechanical soft, soft and regular, note the number of trials, and whether the phase was WFL.

There are a minimum of 21 observations if all consistencies are tested.

Pharyngeal Stage of Swallow Phases:

> Beginning of the pharyngeal stage: Pharyngeal swallow is initiated.

► Pharyngeal passage: The bolus passes through the pharynx.

► The epiglottis tilts down and the bolus enters the hypopharynx. Larynx

elevates and closes. > Entry of the bolus through the esophagopharyngeal sphincter. Larynx

remains elevated and closed. → Bolus enters cervical esophagus.

► Completion of pharyngeal stage.

Late Effects of Polio Overview – December 2000

Page 2

For each of the seven consistencies note: ✓ Swallow Response: present, delayed, or absent. ✓ Laryngeal Excursion: present or absent. ✓ Vocal Quality: clear, wet and/or stridor. ✓ Cervical Auscultation: clear, wet and/or stridor. ✓ Cough: present or absent. ✓ Throat clear: present or absent.

Esophageal Stage of Swallow Tongue, epiglottis and larynx return to normal position. Prognosis for improvement is good, fair or poor.

Recommendations:

► Feeding procedures: positioning, presentation, compensatory strategies.

Further diagnostic techniques: ENT referral; modified barium swallow with

video-fluoroscopy.

► Dysphagia treatment program.

GERD (gastroesophageal reflux disease): Common with aging, hiatus hernia, and abdominal obesity. GERD causes recurrent respiratory infection, cough, asthma, hoarseness and sore throat. If the pharyngeal stage of swallowing is weakened, there will be a greater degree of aspiration during reflux and Increased symptoms. Severe GERD may require antireflux surgery.

OSA (Obstructive sleep apnea) and mixed sleep apnea (with an additional central component where there is a cessation of breathing for more than 10 sec) are more common when the muscles of swallowing are weak.

Since 1998 human growth hormone is being used in patients with post polio syndrome to improve muscle strength. One individual described dramatic improvement in his sleep apnea. This may have occurred either from increased strength in the muscles of the mouth and pharynx and/ or the respiratory muscles. Further studies are necessary.

BREATHING

Causes of decline in breathing reserve: The vital capacity (VC or deepest breath possible) and maximum voluntary ventilation (MW) decrease with aging. This natural aging process, which is somewhat accelerated in post polio, leads to a decrease in breathing reserve. During rest or activity the breathing reserve index for that particular state is defined as the MV/MW. The MV is the minute ventilation or amount of air required by the person during one minute. The MW

Late Effects of Polio Overview –December 2000

page 3.

is the greatest amount of air the person can exchange during one minute with maximal effort.

Most post polio individuals have a decrease in breathing reserve but do not require artificial ventilation for respiratory insufficiency.

Late onset of respiratory insufficiency: after poliomyelitis first described by Dr. Lane in England in 1974 with the following findings:

Respiratory insufficiency correlated with severe kyphoscoliosis and/or

diaphragmatic paralysis.

► If either of these conditions were present, the size of the lungs, functional

residual capacity (FRC), was under 75% of predicted normal. Otherwise, the size of the lungs was normal.

The VC was reduced to 20-40% of predicted normal. > There was no obstruction on spirometric studies. The amount of air

expired during the first second (FEV1) in a forced vital capacity (FVC) was over 90%. This is indicative of a restrictive pulmonary problem as opposed to an obstructive pulmonary problem when this ratio (FEV1/FVC) is under 70%. Persons who have smoked or have asthma can have a concomitant

obstructive problem. > Response to inhaled CO2 was diminished in proportion to the reduced

vital capacity. This means there was no indication of central apnea or a

reduced brainstem response to the blood gases.

► Arterial partial pressure of oxygen (PaO2) was normal in more than 1/2 of

the patients.

The normal age-related rate of decline for muscle groups is 1.5 3%. The predicted annual percentage decrease in this group of polio survivors varied from 11.2% in those in their early 40s to 17.5 % per year for those in their late 60s and early 70s. Since the innervation of shoulder and elbow flexor groups is at a similar level in the cervical spinal cord as the innervation of the diaphragm, it would be of importance to measure the rate of decreasing diaphragm strength in this same cohort of survivors.

Late Effects of Polio Overview -December 2000

page 4.

Breathing Exercises

A recent study has shown that patients with prior polio using daily part-time noninvasive assisted ventilation (NIPPV) are able to perform inspiratory muscle training (IMT) with no adverse effects. IMT increased inspiratory muscle endurance with improvement in ADL and well-being in the patients. The patient breathed through an inspiratory threshold training device for 5 minutes with a resistance which was rated as “15” or hard on the Borg’s rating of perceived exertion scale (RPE). Resistance tolerated after 10 weeks of training improved from 10.7 to 16.7cm H20. Those patients who could only tolerate a resistance which was less than 4 cmH20 were not able to participate in training. Patients used their own ventilator for at least 30 minutes before and after very training session. It has already been reported in the literature that subjective recovery time after exhausting muscular activity in post polio patients with declining muscle strength is longer, and may take a few days as compared to 12 to 2 days

in the stable post polio patient and normal persons. Therefore, it was considered necessary to rest the breathing muscles immediately after training.

For abdominal muscle strengthening, expiratory resistance breathing must be used.’ From a study of spinal cord injury complete tetraplegics it has been learned that the shoulder girdle muscles, pectoralis major and latissium dorsi, both of which have innervation from the cervical spinal cord, can be activated as accessory expiratory muscles during coughing. 8 When there is severe abdominal muscle weakness in the post polio survivor with reasonable strength in these muscles, emphasis should be placed on further increasing their strength to assist in coughing.

ARTIFICIAL VENTILATION

Cough: The critical level for peak cough flow (PCF) is at least 2.7 L/sec. Studies were carried out on ninety patients, twelve of whom had post polio syndrome. For those patients with a VC < 1500 ml, it is necessary to further inflate the lungs by glossopharyngeal breathing, or use of a manual resuscitator or ventilator to provide a maximal insufflation capacity (MIC). Lungs are inflated to 85-90% of inspiratory capacity so that high thoracoabdominal expiratory pressures can be generated on unassisted or assisted coughing. These pressures are needed to mobilize mucus. The InExsufflator cough machine by Emerson produces the necessary insufflation followed by negative pressure or suctioning of the airway.

CPAP/BIPAP (continuous or bi-level positive air pressure)

Sleep apnea: obstructive, central, mixed

Late Effects of Polio Overview –December 2000

page 3.

is the greatest amount of air the person can exchange during one minute with maximal effort.

Most post polio individuals have a decrease in breathing reserve but do not require artificial ventilation for respiratory insufficiency.

Late onset of respiratory insufficiency: after poliomyelitis first described by Dr. Lane in England in 1974 with the following findings:

> Respiratory insufficiency correlated with severe kyphoscoliosis and/or

diaphragmatic paralysis. If either of these conditions were present, the size of the lungs, functional residual capacity (FRC), was under 75% of predicted normal. Otherwise,

the size of the lungs was normal. → The VC was reduced to 20-40% of predicted normal. > There was no obstruction on spirometric studies. The amount of air

obstructive problem. > Response to inhaled CO2 was diminished in proportion to the reduced

vital capacity. This means there was no indication of central apnea or a

reduced brainstem response to the blood gases.

► Arterial partial pressure of oxygen (PaO2) was normal in more than 72 of

the patients.

A more recent study of strength in polio survivors over time showed a decrease in strength in all upper extremity muscles with the decrease ranging from large to small in both those aware of increasing weakness and those who were asymptomatic 4 Age, time since polio, gender, symptom status and weight were analyzed as possible factors. It was determined that there was a increasing rate of deterioration of strength with increasing age. The initial level of upper extremity strength was not age-dependent. Time since polio and history of residual weakness were not significant factors. All survivors were at least 34 years post polio. The normal age-related rate of decline for muscle groups is 1.5 3%. The predicted annual percentage decrease in this group of polio survivors varied from 11.2% in those in their early 40s to 17.5 % per year for those in their late 60s and early 70s. Since the innervation of shoulder and elbow flexor groups is at a similar level in the cervical spinal cord as the innervation of the diaphragm, it would be of importance to measure the rate of decreasing diaphragm strength in this same cohort of survivors.

Late Effects of Polio Overview – December 2000

page 5.

Mechanism of obstructive sleep apnea: The oropharynx is held open by the tongue-protruding muscles and the small muscles attached to the hyoid bone in the throat. The lateral tips of this bone can be palpated below the angles of the jaw and above the larynx. These muscles dilate the pharynx a fraction of a second before inspiration occurs, and hold it open during inspiration. If they are weakened by polio, the individual may experience swallowing difficulty as well. Further neurological involvement from Parkinson’s disease, strokes, or head injury, anesthesia, head flexion, obesity in the region of the head and neck, alcohol or other sedating psychotropic medications, hypothryoidism, congenital or acquired small airway size, and rapid eye movement (REM) or dream sleep are factors in producing OSA. The orophyarnx in a sleep apneic person may close with a negative pressure from inspiratory effort as small as ** minus 0.5 cm. H20 whereas a normal person will maintain patency to a minus 27 cm H20. Lying on the side helps to prevent airway collapse. Central sleep apnea is absence of airflow associated with failure of respiratory effort. It can be caused by pathology of the brainstem. It is also caused by the presence of upper airway closure in OSA, and when it is seen with OSA, mixed apnea is said to be present. CPAP is used as an “air splint” both in the nasopharynx and throat and in the lungs. BIPAP can be used for the same purpose. At a higher inspiratory pressure, BIPAP can be used as a ventilator.

Positive Pressure Ventilation: > Use for deep breathing by air stacking in order to improve compliance or

provide a deep inspiration for an adequate cough. > Use as the most versatile form of artificial ventilation

HOME MECHANICAL VENTILATION

Patient education: A respiratory care practitioner (RCP), a respiratory R.N., a nurse practitioner or physician’s assistant specializing in respiratory problems, and a chest physical therapist are all capable of providing patient education, in addition to the physician. Information is available on the Internet and from t American Lung Association, including its local chapters.

Bronchial hygiene regimens: Nebulization, use of metered dose inhalers (MDIs), postural drainage, assisted coughing can be taught by the RCP, a respiratory R.N. or a chest physical therapist. The medications for nebulization are prescribed by the physician.

Late Effects of Polio Overview -December 2000

page 6.

Relaxation techniques: These are always of value to relieve stress when an individual is breathing on his own with little reserve. However, the individual must recognize when it is necessary to use the ventilator.

Diaphragmatic retraining: A client with absent diaphragmatic function can not retrain the diaphragm as can be done in chronic obstructive pulmonary disease of moderate degree. See above for retraining if the diaphragm and other inspiratory muscles are weak, but not paralyzed.

Support and coaching: This is necessary when a client is learning noninvasive ventilation by nasal mask or by mouth. It is also important when a client learns to synchronize his breathing with a rocking bed or other body ventilator. If the client has a tracheostomy with no cuff, a deflated cuff, or a fenestration, he must be trained to use the air flow from the ventilator for breathing or for speaking.

Arterial blood gases, invasive and noninvasive: Arterial blood must be placed on ice and tested for 02 and CO2 within a matter of minutes for accuracy, Generally noninvasive oximetry to measure oxygen saturation of the capillary blood and capnography to measure the end-tidal carbon dioxide are done in the home. The client may have his own portable oximeter.

Pulmonary function tests: Generally the only study done in the home is a vital capacity or a peak flow. For more comprehensive studies the client is expected to go to a PFT laboratory at a local hospital.

Sputum cultures and sensitivities: In the presence of chronic bronchitis, which is more common with a tracheostomy, it may be necessary to determine the organisms responsible for a flare-up (acute bronchitis), and the antibiotics to which they are sensitive. A recent retrospective study of 684 ventilator users, including 371 post-polio survivors, was carried out on the effect of home mechanical ventilator use versus oxygen therapy on pneumonia and hospitalization rates. 10 Pneumonia and hospitalization rates were significantly higher for ventilator users with gastrostomy tubes. For persons with neuromuscular ventilatory insufficiency without gastrostomy tubes, more than 90% of the pneumonias and hospitalizations were triggered by otherwise benign intercurrent upper respiratory tract infections. Oxygen therapy, when assisted ventilation for ventilatory insufficiency was needed, was associated with a significantly higher rate of pneumonias and hospitalizations.

Late Effects of Polio Overview –December 2000

page 7.

Mobile electrocardiograms: These can be ordered by the pulmonologist/internist/general practitioner caring for the client if th

ing for the client if there is any suspicion that chest pain or shortness of breath is related to the heart.

Ventilator management: A registered respiratory care practitioner (RCP) visits on a regular basis and when an emergency related to the equipment occurs. He is instrumental in teaching those in the home care setting how to use the ventilator.

Tracheostomy care: The tracheostomy tube is usually replaced once every 6 wks. by an ENT specialist. At times the client’s family doctor may replace it or the person may go to a local ER or diagnostic and treatment center for it to be done. The client may replace it himself with the assistance of a family member, if needed. Tracheostomy care on a daily basis is performed by the client or caregivers. Suctioning in some states can be performed by caregivers who have been trained by a licensed professional. A client with the use of his hands is taught to suction himself.

LATE EFFECTS OF POLIO OVERVIEW – DECEMBER 2000

REFERENCES:

Bedside Dysphagia Evaluation Form, Coler Goldwater Specialty Hospital and

Nursing Facility, 10/99.

Bulbar and Spinal Polio. Holland, H.Florida East Coast Post-Polio Support

Group-Vol. 8, #1, July/August 2000.

New Hope in Post-Polio Syndrome. Perlmutter, D. Florida East Coast Post

Polio Support Group-Vol. 8, #1, July/August 2000.

Changes in Strength Over Time Among Polio Survivors. Klein, MG et al. Arch

Phys Med Rehabil 81: 1059-1064, August, 2000.

Inspiratory Muscle Training in Patients With Prior Polio Who Use Part-Time

Assisted Ventilation. Klefbeck, B et al. Arch Phys Med Rehabil 81: 1065 1071. August, 2000.

Subjective Recovery Time After Exhausting Muscular Activity in Postpolio and

Control Subjects. Agre, JC et al. Am J Phys Med Rehabil 77 (2) 140-144, March/April, 1998.

Abdominal Muscle Activity During Inspiratory and Expiratory Resistance

Breathing. Ugalde, V et al. Arch Phys Med Rehabil 81, p 1262, Sept, 2000.

Expiratory Function in Complete Tetraplegics: Study of Spirometry, Maximal

Expiratory Pressure, and Muscle Activity of Pectoralis Major and Latissimus Dorsi Muscles. Fujiwara, T et al. Am J Phys Med Rehabil 78 (5): 464-469, Sept/Oct, 1999.

Maximum Insufflation Capacity: Vital Capacity and Cough Flows in

Neuromuscular Disease. Kang, SW, Bach, JR. Am J Phys Med Rehabil 79 (3):222-227, May/June, 2000.

Neuromuscular Ventilatory Insufficiency: Effect of Home Mechanical

Ventilator Use v Oxygen Therapy on Pneumonia and Hospitalization Rates. Bach, JR, et al. Am J Phys Med Rehabil77 (1) 8-19, Jan/Feb, 1998.

Late Effects of Polio – Overview 2000 Read More »

Bollenbach Polio Biology 11

Polio Biology XI

The Biology of Fatigue

Eddie Bollenbach

A Lincolnshire Post-Polio Library Publication

6th August 2000

William Shakespeare, Sonnet XXVII: ‘Weary with toil, I haste me to my bed.’

Everyone has experienced fatigue, even Shakespeare. It is a reaction the body has evolved to maintain a healthy steady-state. It is a countermeasure to overuse and acts to avoid damage to muscles and nerves. If our bodies, sculpted through millions of years of evolution, had no way to tell us that it is time to shut down, we wouldn’t have gotten this far. So my first point in this essay is to emphasize that fatigue is not just the province of people living with post-polio syndrome. Everyone in the human family has experienced fatigue.

One area of the biomedical literature which has examined fatigue, and its components, is the discipline of sports medicine. The 2000 Sydney Olympics is on the docket and you can be sure that trainers and sport’s physicians are studying every aspect of fatigue that can effect their athletes. Why? Fatigue degrades performance. An understanding of all of its manifestations allows athletes to take steps to avoid and minimize the likelihood of a poor performance.

Of course we with post-polio syndrome live with fatigue. It is a much more common state for us and does not abate easily and normally as it does for an athlete. We have to be especially careful about it and also knowledgeable about it if we are to improve our lives.

Elite athletes know about fatigue to win medals, we must know about fatigue to improve our lives. Who knows more about the biology of fatigue, the elite athlete or the post-polio survivor? I hope this essay can help improve our general knowledge, from the biological perspective, and allow us to intelligently use this information to improve our lives.

Biology of Fatigue.

Throughout this series we have mentioned the motor unit. This is the nerve/voluntary muscle unit of contraction. The nerve depolarizes (that means the charge on the outside of the cell membrane (+) rushes inside (-) resulting in the charge on either side canceling). This depolarization moves along the nerve away from the Central Nervous System eventually to a voluntary muscle. When an activity requiring muscle contraction begins (running is a good example) the rate of depolarization and re-polarization (which requires energy) is rapid in the motor unit. The nerve cell depolarization triggers depolarization in the muscle cell membrane. The muscle cell depolarizes and the muscle fiber contracts (shortens) due to

the activity of proteins inside the muscle fiber. The muscle and nerve quickly recover and re-polarize. This uses nutrient energy. Then they fire again. If this rapid firing is not interrupted, either by other motor units taking over (which we lack- see Polio Biology X), or because of maximum intensity exercise over a long period, the nerve, nerve/muscle junction, and/or the muscle fiber itself will fatigue.

Inside the nerve the energy used to re-polarize the membrane is derived from specialized molecules, nutrients, and enzymes. As they become depleted waste products accumulate. If the waste products interfere with normal energy production and utilization we have metabolic fatigue inside the cell. The same can happen in the muscle fiber where chemicals like lactic acid, ammonia, and creatine build up faster than they can be excreted. All of this biochemistry, which may manifest as a feeling of burning inside a muscle, cramping, weakness, pain, or creepy crawly feelings are the result of fatigue, specifically localized fatigue. Any fatigue in the nerve, muscle fiber, or entire motor unit (muscle and nerve) constitutes localized fatigue.

If fatigue occurs in any nerves above the motor unit it is called Central Fatigue. It too is a common protective mechanism for the muscles and nerves below it and athletes experience it mostly as a consequence of over training. I get the sense that many polio survivors think that Central Fatigue is reserved for them and is a unique and disturbing symptom not known to others. This is not so.

There is a way to measure the magnitude of subtypes of Central fatigue. If you use a small electric shock to stimulate a muscle and measure the maximum force of contraction you can use this as a baseline of strength of contraction. If you then prompt a person to contract the same muscle as vigorously as possible you can measure the difference between tetanic contraction (of the unit with the electric pulse) and the maximum voluntary force possible. This is one measure of one subtype of Central Fatigue. We don’t know a lot about Central Fatigue at the molecular level but it manifests itself, often, as a loss of drive or motivation to perform. Again, one can appreciate the role of Central Fatigue in protecting the nerves and muscles by inhibiting their over work at the level of the Central Nervous System.

There is a part of the human brain you may have heard about: The Reticular Formation. Nerve cell firing there keeps us awake. Some say, or have said, that polio damage has affected the reticular formation and that this is why some of us sleep so much and cannot easily rouse. I think this would be a very difficult idea to prove because of the complexity of the arousal system and the role of Central Fatigue in overwork, blood gases, and other factors. If you experience a blow to the head the neurons of the Reticular Formation can all depolarize and you will be rendered unconscious. If re-polarization occurs (hopefully in a short while) you will awaken. Anyway, this depolarization and re-polarization is how all neurons work.

Let’s get back to Central Fatigue. Any negative effect on muscular performance, which is generated above the motor unit, is Central Fatigue. This includes inhibitory processes arising in the brain. We know less about this but we do know that it occurs in athletes as well as in polio survivors. The Central Nervous System is involved to a large extent in the regulation of muscular activity. (Bompa 1990)[1]. Elements within the Central Nervous System result in a number of psychological factors, and emotions, which can degrade muscle performance and result in a loss of drive due to Central Fatigue. (McComas 1996)[3].

During prolonged exercise in an athlete, or during any activity which exceeds the fatigue point for a polio survivor, the blood chemistry changes. Amino acids, which make up proteins, change with respect to their relative abundances. Those amino acids with branched chains decrease and fatty acids increase. Examples of branched chain amino acids are leucine, isoleucine, and valine. Tryptophan is an amino acid but is not a

branched chain amino acid. The ratio or Tryptophan/BCAA rises during fatigue, which results in a biochemical alteration of tryptophan to 5-hydroxytryptamine (5-HT) in the brain. You may know (5-HT) by its more commonly used name of serotonin.

To make a very complicated story short serotonin can act on serotonin receptors in the brain to cause sleep and also increase the mental effort (motivation) needed to maintain muscular activity. It’s all rather complicated chemically, and this is but one theoretical biochemical pathway of many that helps explain Central Fatigue.

We’ve also heard of dysfunction of the hypothalamus and pituitary to explain Central Fatigue in post-polio syndrome. As is to be expected, these areas are implicated in Central Fatigue for elite athletes too. Possible indicators of Central Fatigue, cited by Lehman et.al. (1993)[2] include an impaired neurotransmitter metabolism, with increased cerebral 5-hydroxyrtyptamine (5-HT) concentration, partial hypothalamic and pituitary dysfunction, with resultant dysfunction of the neuro-endocrine axes.

It has been observed that over-training in athletes (which happens often for our normal activities) results in faulty prolactin metabolism as well as adrenocortical insufficiency. Well, enough of the biochemistry.

Suffice it to say that fatigue is a complicated phenomenon which involves motor units and the CNS and regulates the body by preventing overuse on many levels. There is not much difference in the CNS aspects of fatigue comparing elite athletes and polio survivors in my opinion. We just must do more with less and get to fatigue sooner.

I’ve never heard of anyone trying Branched Chain Amino Acids to help with Central Fatigue but I believe they are available at health food stores. To do any good (and they may not) you probably need 10 to 20 grams. Ask a physician before you try this. The fatigue is there for a purpose. If you reduce it without addressing the root of it you could hurt yourself.

References.

Bompa TO (1990): Theory and methodology of training: The key to athletic performance. (2nd ed.) Dubuque: Kendall/Hunt Publishing Company.
Lehmann, M., C. Foster, and J. Keul. Overtraining in Endurance Athletes: A Brief Review. Medicine and Science in Sports and Exercise. 25(7):854-862, 1993.
McComas AJ, Stuart DG, Thomas CK and Pierce PA (Eds) (1996): Fatigue: Neural and muscular mechanisms. New York: Plenum Press, pp. 457-469.

The Lincolnshire Post-Polio Network

Registered Charity No. 1064177

An Information Service for Polio Survivors and Medical Professionals

All enquiries, book requests, medical article requests, membership fees, items for newsletters and donations to

The Secretary, Lincolnshire Post-Polio Network

PO Box 954, Lincoln, Lincolnshire, LN5 5ER United Kingdom

Telephone: +44 (0)1522 888601

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Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Created: 6th August 2000

Last modification: 21st January 2010.

Last information content change: 7th August 2000

Bollenbach Polio Biology 11 Read More »

Dr Henry writes about the Virginia Polio Epidemic of 1950

Dr. Henry writes about the Virginia Polio Epidemic of 1950.

I contracted polio on Sunday, September 17, 1950, entered the polio isolation ward on the ninth floor, south wing of the Medical College of Virginia Hospital on Saturday, September 23 and was discharged almost three months later on Monday, December 18. In addition to the isolation ward, I spent time on nine west during post isolation, and the majority of my hospitalization on five south and five west in convalescence and rehabilitation. The event of polio changed my life thereafter. Until recently, I had little interest in the polio events of that year. With help from the Virginia Health Department, Division of Immunization, and newspaper records from Richmond Newspapers, I have learned that 1950 was a record year for polio in Virginia and that Virginia ranked second in the nation in the incidence of polio per capita in 1950.

During most of the first half of the twentieth century, the Virginia State Health Department’s Bureau of Communicable Diseases kept records about every reported case of polio in regard to confirmed diagnosis, location of each case, and the age, sex, and race of each individual. In the Richmond area, information was published identifying the section of the city that each case originated. Health officials used these numbers to track the disease throughout the epidemic years. As cases were reported in any given year, comparisons were made to previous years as one way of predicting whether a particular year might be a light year or a year of high incidence of polio. At the end of a year, the accumulated data would reveal the numbers of cases in each city and county in Virginia.

Virginia was one of the leading States in its efforts to prepare for each polio season. There were five designated hospitals for polio cases in Virginia. They were Children’s Hospital in Washington DC for cases in northern Virginia, DePaul and Maryview Hospitals in the Hampton Roads area, Roanoke Memorial and Crippled Children’s Hospital in Roanoke for southwestern Virginia cases, and the Medical College of Virginia Hospitals in Richmond. St Phillip Hospital of the MCV Hospitals accepted almost all of the African American polio patients. Racial segregation was a reality in Virginia in the epidemic years. MCV typically handled approximately 40 to 50 per cent of Virginia’s polio cases. Combined efforts from physicians, nurses, the State Health Department, the March of Dimes, the Red Cross, local rescue squads, and even the Virginia Air National Guard were instrumental in providing necessary trained staff, hot pack machines, and iron lungs where the need was the greatest. The year 1950 was the greatest challenge for teamwork and proper allocation of therapeutic resources.

How did 1950 differ in numbers of polio cases to other years? The data on polio from 1910 to 1960 would indicate that polio cases would occur in greater numbers about every five years until the disease became more consistently epidemic around 1948. Prior to 1948, the years with the greatest polio cases were as follows:

Year	Polio Cases
1910	679
1911	387
1929	325
1935	685
1944	756

During the 1920s, there were five years in which the number of polio cases was below 100 with a low of 67 in 1926. Throughout the 1930s, there were less than 100 cases per year except for 1935 when there were 685 cases. The lowest year on record prior to the development of the Salk and Sabin vaccines was 1942 with only 43 cases. Two years later in 1944, the second highest total on record occurred. There were 756 polio cases that year. Thus, it is easy to conclude that the polio virus was unpredictable and a constant challenge to public health officials. Beginning in 1948, these rather extreme fluctuations seemed to be less frequent with a pattern of more cases occurring each year. It has been theorized that the virus was becoming more virulent during the late 1940s and 1950s. Below are the annual case numbers for 1948 to 1965.

Year	Polio Cases
1948	567
1949	337
1950	1200
1951	267
1952	690
1953	740
1954	613
1955	336
1956	237
1957	107
1958	159
1959	290

1960	58
1961	17
1962	8
1963	22
1964	4
1965	0

The introduction of the Salk vaccine in 1955 and the Sabin vaccine a few years later began to bring the polio case numbers down considerably by 1960.

A reflection on the above numbers reveals that 1950, with 1200 cases of polio, was by far the greatest epidemic year in Virginia history. What happened that year to set it apart from other years? First there was an epidemic within the overall epidemic. Wythe County, particularly the little town of Wytheville (population 5,500) accounted for 184 cases. Small town and rural southwestern Virginia accounted for one-third of polio cases in 1950. Among the 1200 cases, there were 62 deaths or a death rate of 5%. In Wythe County, there were 17 deaths or a death rate of almost 10%. This data would indicate that the wild poliovirus in Wythe County was more virulent than most other regions of Virginia. Newspaper reports during July and August reported the daily increase of polio cases. Public hysteria was avoided by rational precautions and reassurance from the State Health Department. However, a state of alarm existed in Wythe County. Swimming pools were closed. The movie theater was closed due to lack of business. Church Sunday schools and camps were closed. The summer semipro baseball team canceled their remaining games. Even the local draft board temporarily closed its doors. Traffic through Wytheville on Route 11 was detoured around the town to avoid a possible polio contact. The State Health Department sent investigators to Wythe County, but was unable to uncover any common source of the poliovirus. The virus was apparently centered in Wytheville in Wythe County, but the distribution within this relatively small area was random.

No urban area ever had as many polio cases as the Wythe County count of 1950. Below are some of the higher urban polio statistics in Virginia

	1910 Roanoke	65
	1935 Richmond 60
	1950 Richmond 52
	1953 Norfolk	66
	1954 Norfolk	55

Thus, Wythe County had nearly triple the number of polio cases in 1950 than any urban area in any other year. Because of this unexpected concentration of cases in southwest Virginia, the Roanoke Memorial and Crippled Children’s Hospital was overwhelmed. MCV admitted and treated 410 cases in 1950. One of those cases was Mrs. Sidney Culver of Clarke County. She was the 24-year-old adult married daughter of

Basil O’Connor, the executive director of the National Foundation for Infantile Paralysis or the March of Dimes. After a week at MCV Hospital, she was transferred to Warm Springs Georgia for continued care.

When the need for an iron lung became immediately necessary, rescue squads would often transport the iron lungs or the Virginia Air National Guard could provide even more rapid transportation. The spirit of cooperation was evident in the news reports. When the need for polio nurses increased, nurses were recruited from other Virginia cities and from nearby States. The March of Dimes spent more money in Virginia in 1950 than expected, but the request for voluntary contributions usually exceeded the goals set. The public was well informed and aware that the vast majority of polio cases were children. In the daily news reports, the age, sex, race, and location of each victim was published. Usually, when a child or adult died from polio, his/her name was printed in the newspaper.

Thankfully, fifty years later, the wild poliovirus has been eradicated from Virginia, the United States, and the Western Hemisphere. The Virginia Polio Epidemic of 1950 is now past history. Hopefully, such an event will never be repeated. If anyone reading this article contracted polio in Wythe County Virginia in 1950, I would appreciate hearing from you.

References:

Records from the Virginia Department of Health, Division of Immunization. Special thanks to Jackson Milton, Jr., Deputy Director, Epidemiologist.
Richmond Newspapers Library, news articles from 1950. Special thanks to William McKelway, Reporter, Richmond Times-Dispatch.

Henry Holland, Richmond., Virginia, USA. Henry4FDR@aol.com

August 2000.

Originally published in the Central Va PPS Support Group (PPSG)‘s newsletter, The Deja View, in the August/September 2000 issue.

The Lincolnshire Post-Polio Network

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An Information Service for Polio Survivors and Medical Professionals

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The Secretary, Lincolnshire Post-Polio Network

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Telephone: +44 (0)1522 888601

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errors introduced in the transcription. Neither do we accept liability for any damage resulting directly or otherwise from the information available at this site. The opinions expressed in the documents available at this site are those of the individual authors and do not necessarily constitute endorsement or approval by the Lincolnshire Post-Polio Network.

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.

Created: 13th August 1999

Last modification: 24th January 2010.

Dr Henry writes about the Virginia Polio Epidemic of 1950 Read More »