The Post-Polio Clinic at the University of Alberta Hospitals, Edmonton, Alberta, is dedicated solely to the treatment of patients diagnosed as having Post-Polio Syndrome (PPS). This Clinic, which has been in existence since 1985, operates under the guidance of a physiatrist with expertise in the field of PPS. Patients are treated by a physical therapist using the protocol described by the Clinical Director.
This article will expand on the treatment protocol that is used in the hopes that other physical therapists will be able to obtain the same results with PPS patients as have been achieved in Edmonton.
Clinically, individuals suspected of having PPS, present themselves to their physicians with the same complaints:
The majority of patients will also complain of generalized fatigue, which usually occurs in the early afternoon. Often, they will describe it as "hitting the wall". All of these changes occur 25 to 40 years after the recovery from the initial episode of acute poliomyelitis.
Patients who are referred to the PPS Clinic have been diagnosed as having PPS. This diagnosis is based on clinical and electromyographic (EMG) criteria. The physical therapist receives a copy of the consultant's report which includes a past medical and surgical history (particularly as it pertains to the old polio), the results of manual muscle testing, as well as the results of the EMG studies. These studies identify which muscles are PPS muscles, which are weak because of incomplete recovery (IR) from old polio, as well as those muscles that are normal.
The patient's first visit to the Post-Polio Clinic is for assessment only, and lasts for approximately one hour. The first half-hour consists of an informal interview session, wherein the patients's subjective complaints are noted. These may include specific limb weakness, general weakness and/or fatigue, pain and /or inability to cope with work/daily/leisure activities. The patient is then questioned as to his current physical function, i.e. stairs management (one, two or no handrails; one step at a time or one step after another; inability to manage stairs), transfers (tub, toilet, bed, chair, car), and endurance (including walking distance before fatigue).
The second half of the examination consists of complete range of motion (ROM) testing and a manual muscle test of all muscle groups. Those muscles identified as being less than full strength (MRC grade 5/5) are further tested with a Microfet Muscle Tester. Gait assessment is also done at this time.
The results of the assessment are used to design an individual exercise program for each patient. Wherever possible, the program is designed so as to have the patient move into each exercise position once and only once, so as to minimize the energy cost to the patient. For instance, a patient will exercise in high sitting first, then do all the necessary exercises in supine before returning to high sitting again. As well, an effort is made to alternate exercises from each side of the body, or from upper and lower extremities, again to reduce energy cost to the patient.
All muscles found to be less than full strength on initial assessment are exercised. Muscles showing better than antigravity strength (MRC grade >3) but which are thought to be unaffected by old polio ("normal" muscles) as well as IR muscles with the same strength characteristics may be set up on a regular strengthening program (i.e. three sets of ten repetitions) without regard for fatigue. If the normal or IR muscle has barely antigravity strength (grade 3 to 3+) and the patient cannot complete three sets of ten repetitions, then that muscle is treated as a PPS muscle (see below). Should the normal or IR muscle have less than antigravity strength initially, then it is exercised in slings or on a powderboard, gravity eliminated.
Post-Polio muscles, if grade 3+ to 4+, are exercised using non-fatiguing strengthening exercises (NFSE). The PPS muscle is tested to determine the Five Repetition Maximum (5RM) weight i.e. the weight with which the patient can do only five repetitions without sign of fatigue. The physical therapist observes the patient closely for any sign of fatigue: a decrease in the quality of movement, wavering or quivering of the muscle being exercised, the use of synergistic or gross body movements to help with the muscle contractions or facial grimacing of the patient while exercising. It is important not to fatigue a PPS muscle.
Once the 5RM weight has been identified for that particular muscle (and it may take several exercise sessions with different weights), the exercise for that muscle is commenced at the next exercise session using 50% of the 5RM weight. Successive repetitions of the muscle movement are performed with that weight, working up to thirty repetitions, although exercise is always stopped at the first sight of fatigue. There should be no lengthy breaks between repetitions, although a patient should always completely relax the muscle between repetitions. The number of repetitions done is recorded. When the patient has reached thirty repetitions during two successive exercise sessions, the weight used for that muscle is increased to 75% of the 5RM weight. Progression of resistance continues in this fashion, until the patient reaches a plateau and then the last weight used becomes the maintenance weight upon completion of the program.
If the PPS muscle being exercised is grade 3 to 3+ initially, and the patient cannot do more than twenty repetitions without resistance against gravity, then the patient works up to thirty repetitions against gravity first, before any resistance is added. Once the goal of thirty repetitions is reached without any sign of fatigue, then weight may be added, in 1/4 lb. increments, working up to the weight at which that muscle reaches a plateau.
When exercising a PPS muscle of less than antigravity strength, slings or a powderboard are utilized, to allow the patient to exercise with gravity eliminated, using the method described in the previous paragraph. If the patient can do twenty or more repetitions, gravity eliminated, then the 5RM protocol is used.
Patients attend the Post-Polio Clinic for exercise three times a week, as it is important for the PPS muscles to have a day of rest between clinic sessions. Once the exercise program has been established, the physical therapist endeavours to teach the patient to recognize the signs of fatigue as they appear in his PPS muscles. This is important not only to insure the patient can properly continue his exercise program at home upon discharge, but also to teach the patient to become aware of fatigue in his PPS muscles during his daily activities, so that he may recognize the point at which he should stop an activity.
By paying close attention to the number of repetitions of each exercise done by the patient at each exercise session, the physical therapist is able to identify the patient who may be pushing through his fatigue limit in the course of his daily activities. If a majority of the muscles being exercised showed a dramatic decrease in repetition number during an exercise session, it is likely that muscle use beyond fatigue has occurred recently. Careful questioning of the patient regarding his activities on the day before the exercise session or on the morning of the exercise session, will likely reveal too much work/activity done with too little rest.
A major part of the PPS program is designed to provide the patient with advice regarding the planning of his high-intensity activities. The patient should allow a day of rest before and after a heavy activity day. An activity should be stopped when muscle fatigue is perceived in the PPS muscles. This often allows patients to maintain their current lifestyles, with only minor changes, while avoiding fatigue which require them to reduce their usual function for a few days. The patient who experiences the generalized fatigue that usually occurs in the afternoon is also advised to incorporate a rest period into his daily schedule.
When the maintenance weight has been identified for all muscles being exercised, the patient is discharged from the Clinic on a home exercise program. Weights and other equipment are purchased by the patient. These are necessary to enable the patient to carry out the exercise program at home. The patient is then advised and expected to follow this maintenance program at home, three times weekly, for life. Prior to the patients's discharge from the Clinic, gait is reassessed and any problems that remain are dealt with by gait training and/or orthotic management as indicated.
The patient is evaluated during treatment by both the Clinic Director and the physical therapist after approximately eight weeks of treatment. The progress that has been made is assessed and a decision is made as to the readiness of the patient for discharge. Evaluations are done every eight to twelve weeks thereafter, until the patient is deemed ready for discharge. Then, the patient is followed by the physiatrist at three to six month intervals, to ensure that the patient maintains the strength achieved at discharge.
Twenty-four new PPS patients have completed a course of treatment at the Post-Polio Clinic over the past twenty-five months (this therapist's term of employment at the Clinic). The average length of treatment has been four and one-half months, with eight weeks being the shortest stay and eight and one half months the longest.
There was a total of 252 weak muscles treated. Ninety-seven were identified as PPS muscles, sixty as IR muscles and the remaining 95 were neither PPS nor IR (i.e. normal) muscles. Of the 97 PPS muscles, twelve maintained their initial strength while twenty-five made only a minimal gain in strength (one-half a grade, MRC 1 to 5 scale), for a total of 38%. The remaining 60 muscles improved in strength by at least one grade (62%). Forty-seven of the PPS muscles (48%) achieved a rating of 5/5 (full strength). None of the PPS muscles lost strength during the course of the treatment.
Of the 60 IR muscles, 14 maintained their strength, while a further 16 only achieved a minimal (one-half grade) increase in strength, for a total of 50%. The remaining 30 muscles (50%) improved by at least one grade. Fifty percent of the IR muscles achieved full strength. None of the IR muscles lost strength.
Of the "normal" muscles exercised, 11 maintained their strength, while 26 improved minimally, for a total of 38%. The remaining 62% attained at least a one grade improvement in strength. Sixty-six percent attained full strength. Again, none of these muscles lost strength.
In summary - this report describes the results obtained by the use of exercise in the treatment of Post-Polio Syndrome patients. Prescription of exercise is guided by the accurate differentiation, by EMG studies, between normal muscles, those which have signs of Incomplete Recover (IR) and muscles showing EMG characteristics of Post-Polio Syndrome (PPS). While regular strengthening exercises may be used for both normal and IR muscles, care must be taken to avoid fatigue in exercising the PPS muscles by the use of non-fatiguing strengthening exercises. These exercises are carried out three times weekly, under supervision in the Clinic, until all muscles have attained peak strength, at which time the patient is discharged on a home exercise program, to be done three times weekly, indefinitely.
Patients are also given advice regarding the planning of high-intensity activities as well as energy-saving techniques. Most patients are able to avoid fatigue while enjoying only a slightly altered lifestyle.
A nine-year follow-up of Clinic patients who have continued their exercise programs following discharge shows a maintenance of post-treatment strength. This is favourable in comparison to the natural course of Post-Polio Syndrome, which invariably results in a gradual decline in muscle strength and endurance.
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