Article

Coping with a Second Disability: Implications of the Late Effects of Poliomyelitis for Occupational Therapists

Authors:
  • Macquarie University, Sydney. Australia
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Abstract

The long term effects of many physical disabilities have only recently begun to be appreciated. For people who have lived for years with what they thought to be stable conditions, the onset of secondary disabilities may be associated with considerable problems and distress. A questionnaire survey of 324 people with poliomyelitis revealed the occurrence of late effects in 94% of respondents. The majority reported increased weakness, pain and fatigue, problems in carrying out daily living activities and difficulties in obtaining appropriate health care. Although occupational therapists were less likely to be consulted than other professionals, they received one of the highest satisfaction ratings from clients. Discussion of case studies indicates ways in which occupational therapists can provide symptom relief and enable clients to maintain valued roles. As the survival rates of people with disabilities increase there is a need for greater awareness of, and research into, the late effects of disability.

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... Previous studies on disability in polio survivors have indi- cated that the impact of PPS has mainly been on mobility- related activities, such as walking on level surfaces and stair- climbing. 22,23 Halstead and Rossi 24 reported that 82% of postpolio patients with new symptoms report progressive loss of ability to ambulate and 81% have more difficulty with stairs. Progressive mobility impairments and disabilities may affect polio survivors' abilities to perform various activities of daily living. ...
Article
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To examine factors associated with daily step activity, perceived activity, maximum walking speed, and walking speed reserve over time in polio survivors and older adults with no history of polio. Longitudinal study. A research clinic and the community. Polio survivors (n=96; 65 in postpolio syndrome [PPS] group, 31 in non-PPS group) and older adults (n=112) with no history of polio. Not applicable. Daily step activity, perceived activity, maximum walking speed, and walking speed reserve. Results showed decreases in perceived activity over time in the PPS group. However, there was no change in average daily walking activity. Overall, polio survivors walk less and have a smaller walking speed reserve than controls. Knee strength was positively associated with maximum walking speed and walking speed reserve in all groups. Weight and age were associated with daily step activity in controls but not polio survivors. Daily walking activity did not change statistically over the 3-year study period, although perceived activity and the walking speed reserve decreased among polio survivors with PPS. On average, polio survivors appear to function with minimal functional reserve, as their preferred walking speed was close to their maximum speed.
Article
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Article
The aim of this study was to provide a description of pain and its relationship to the effects of polio, physical activity, and disability. Assessment instruments used were: a pain questionnaire, a pain drawing, a visual analogue scale (VAS), a 30-m walk indoors, isokinetic muscle strength, serum creatine kinase concentration, the Physical Activity Scale for the Elderly, and the Nottingham Health Profile (NHP). A university hospital department. Thirty-two consecutive individuals with late effects of polio. More than 50% of the individuals had pain every day, mostly during physical activity. The mean VAS score for daily pain intensity was 55mm, range 0 to 93mm. In the lower limbs cramping pain was the most common pain characteristic in both polio-affected and non-polio-affected limbs. In the upper limbs and in the trunk, aching pain was the most common pain characteristic, especially in the polio-affected areas. The degree of muscle weakness had no correlation to pain experience. The walking test demonstrated a relatively small difference between spontaneous and maximal walking speed. The NHP questionnaire demonstrated that all six dimensions (energy, pain, physical mobility, sleep, emotional reactions, and social isolation) were affected. The dimensions pain and physical mobility both strongly correlated with energy. There is a relationship between physical activity in daily life and experience of pain. In many postpolio individuals who experience a high level of pain, spontaneous and maximal walking speed are approximately the same. It is strongly recommended that individuals with late effects of polio, experiencing aching and especially cramping pain, modify their level of physical activity.
Article
Full-text available
This communication is in response to the article by Michael T Gross and Charles P Schuch entitled "Exercise Programs for Patients with Post-Polio Syndrome: A Case Report" published in the January 1989 issue of Physical Therapy. The investigators examined the effects of a rigorous isokinetic training program on peak torque of the knee flexor and extensor muscles of a post-polio patient. The literature on post-polio syndrome, however, does not support the use of either conventional muscle strengthening regimens or rigorous isokinetic exercise programs in the management of post-polio syndrome. In addition, based on the observation that there was no appreciable increase in muscle strength in either the affected or the apparently unaffected leg, the investigators concluded that their rigorous exercise program was not deleterious. The lack of a normal training response, however, is consistent with bilateral muscle fatigue secondary to overuse rather than muscle weakness secondary to disuse. This result is consistent with the need for a balance between rest and low-intensity exercise, which will help to maintain or enhance function while slowing rather than hastening further deterioration. We hope that this rejoinder clarifies some of the misconceptions that may arise from the Gross and Schuch article and that physical therapists consider very carefully the rationale for any type of exercise program for post-polio patients.
Article
• In a retrospective study, we reviewed sections from the spinal cords from eight patients, aged 36 to 61 years, who had had poliomyelitis and who died of nonneurologic diseases nine months to 44 years (mean, 20.7 years) after the acute poliomyelitis infection. Five patients had stable postpoliomyelitis deficits without new symptoms, and three patients had new slowly progressive muscle weakness defined as postpoliomyelitis progressive muscular atrophy (PPMA). Representative spinal cord sections matched the patients' clinical involvement in both groups. Control tissues from ten patients with amyotrophic lateral sclerosis and five with spinocerebellar degeneration were examined simultaneously. The spinal cord segments from all patients who had had poliomyelitis showed loss or atrophy of motor neurons, severe reactive gliosis (disproportional to the neuronal loss), and a surprising mild to moderate perivascular and interparenchymal inflammation. There was no difference in these pathologic changes between the patients with stable postpoliomyelitis deficits and those with PPMA. Additional findings were axonal spheroids (dystrophic axons) and occasional chromatolytic neurons in the spinal cord of patients with PPMA. Corticospinal tracts were spared.
Conference Paper
This book contains 32 selections. Some of the titles are: Late effects of Polio: Historical Perspectives; Sleep-Disordered Breathing as a Late Effect of Poliomyelitis; Clinical Subtypes, DNA Repair Efficiency, and Therapeutic Trials in the Post-Polio Syndromes; and Post-Polio Muscle Function.
Article
Questionnaires from 156 people with scleroderma, a serious, progressive, chronic disease, were used to investigate factors in patients' medical histories associated with belief in ability to control relapses, a variable previously found to be related to adjustment to illness. The 80 subjects who perceived themselves as having the ability to control relapses were more likely to have had initial contact with a helpful general practitioner and to have experienced remission of symptoms in the last year. They did not differ significantly from the 76 helpless patients in time since onset of illness, time taken to diagnose the disease, severity of symptoms, handicaps experienced, or having had contact with helpful specialist physicians. Evaluative processes postulated by Taylor (1983) as methods of coping with threatening events were used more frequently by the perceived control group. These involved making causal attributions regarding the illness, construing benefits from the event, focusing on attributes that made them appear advantaged, creating hypothetically worse worlds and finding meaning in their illness.
Article
Approximately 75,000 polio survivors are experiencing new weakness, pain, and fatigue that are related to their initial disease. These problems affect their functional ability; therefore, they are of concern to occupational therapists. Overwork of a weakened neuromuscular system is believed to be the cause of these late symptoms. This article reviews current writings on the late effects of poliomyelitis. An understanding of the symptoms, causality, and psychosocial ramifications of this phenomenon facilitates effective occupational therapy intervention. Guidelines for occupational therapy assessment and treatment are included.
Article
The immunologic status of patients with prior poliomyelitis was studied using two-color flow cytometric analyses. Ten lymphocyte subsets including subsets of CD4+ T cells, CD8+ T cells, B cells, and natural killer cells were examined. Eighteen patients presented with clinical symptoms compatible with the postpolio syndrome. This group was compared with 18 asymptomatic postpolio survivors and 22 age-matched healthy controls. The results demonstrated significant alterations in CD4+ subsets in the postpolio group as a whole when compared with normal controls. These findings reveal definite alterations in the immune status of postpolio survivors and raise the possibility that immunologic factors may contribute to late disease progression.
Article
An outbreak of 9 cases of paralytic poliomyelitis and 1 non-paralytic case occurred in Finland between August, 1984, and January, 1985, after two decades of freedom from the disease attributable to a successful immunisation programme. During the outbreak poliovirus type 3 was isolated from the patients, from about 15% of healthy persons tested, and from sewage water. At least 100 000 persons were estimated to have been infected. With 1.5 million extra doses of inactivated poliovirus vaccine to children under 18 years of age and an oral poliovirus vaccine campaign covering about 95% of the entire population in February-March, 1985, the outbreak was halted in February, 1985. Impaired herd immunity to the epidemic strain of poliovirus type 3, which differed from the type 3 vaccine strains in both immunological and molecular properties, was important in the emergence of this outbreak. The inactivated poliovaccine that had been used in the vaccination programme was relatively weakly immunogenic, especially as regards the type 3 component. Whether continuous antigenic variation of poliovirus type 3 has wider epidemiological implications is not known.
Article
A "post-polio" syndrome characterized by new neuromuscular symptoms, including muscle weakness, may develop years after recovery from acute paralytic poliomyelitis. We studied 27 patients (mean age, 50.6 years) in whom new muscle weakness developed a mean of 28.8 years after recovery from acute polio. We reevaluated these patients during a mean follow-up period of 8.2 years (range, 4.5 to 20) after they were originally studied at the National Institutes of Health. The total mean follow-up period after the onset of new weakness was 12.2 years (range, 6 to 29). The patients were assessed with quantitative muscle testing, muscle biopsy, electromyography, and virologic and immunologic examination of the cerebrospinal fluid. Muscle strength had declined in all patients. The rate of decline averaged 1 percent per year. The decrease was irregular, with subjective plateau periods that ranged from 1 to 10 years. None of the patients had amyotrophic lateral sclerosis. Oligoclonal bands (IgG) were found in the cerebrospinal fluid of 7 of 13 patients studied, but no specific elevation of antibodies to poliovirus was observed in the cerebrospinal fluid. The newly affected muscles that were evaluated longitudinally with follow-up muscle biopsies and electromyography showed signs of chronic and new denervation. Groups of atrophic muscle fibers (group atrophy) and "neurogenic jitter" were not present. New post-polio muscle weakness is not a life-threatening form of motor-neuron deterioration. It appears that this weakness is not due to a loss of whole motor neurons, as in amyotrophic lateral sclerosis, but that it is due to a dysfunction of the surviving motor neurons that causes a slow disintegration of the terminals of individual nerve axons.
Article
In a retrospective study, we reviewed sections from the spinal cords from eight patients, aged 36 to 61 years, who had had poliomyelitis and who died of nonneurologic diseases nine months to 44 years (mean, 20.7 years) after the acute poliomyelitis infection. Five patients had stable postpoliomyelitis deficits without new symptoms, and three patients had new slowly progressive muscle weakness defined as postpoliomyelitis progressive muscular atrophy (PPMA). Representative spinal cord sections matched the patients' clinical involvement in both groups. Control tissues from ten patients with amyotrophic lateral sclerosis and five with spinocerebellar degeneration were examined simultaneously. The spinal cord segments from all patients who had had poliomyelitis showed loss or atrophy of motor neurons, severe reactive gliosis (disproportional to the neuronal loss), and a surprising mild to moderate perivascular and interparenchymal inflammation. There was no difference in these pathologic changes between the patients with stable postpoliomyelitis deficits and those with PPMA. Additional findings were axonal spheroids (dystrophic axons) and occasional chromatolytic neurons in the spinal cord of patients with PPMA. Corticospinal tracts were spared.
Article
A retrospective study was undertaken to identify potential risk factors for the development of progressive postpoliomyelitis muscular atrophy (PPMA). Patients with PPMA (n = 57) were compared with patients with a history of poliomyelitis but without a history of progressive weakness (n = 49). Patients who later developed PPMA had histories of more widespread acute paralysis, but relatively greater functional recovery. They were less disabled, and reported higher recent activity levels. Seventy-nine percent of the total variance between the PPMA and control groups could be accounted for by recovery alone (ie, severity minus disability). Functional recovery is generally attributed to reinnervation of sarcomeres by collateral sprouting from surviving lower motor neurons. Since degree of recovery predicts the risk of developing PPMA, our findings suggest that enlarged motor units may carry an increased susceptibility for dysfunction and/or degeneration.
Article
Persons with good recovery of function following their initial poliomyelitis are now, more than 30 years later, experiencing new weakness, fatigue, and muscle pain. The likelihood of muscle overuse being the cause of this late functional loss was investigated by dynamic electromyography (EMG) and foot-switch stride analysis in 34 symptomatic patients. Manual testing grouped the muscles, with strong (S) encompassing Grades Good (G) and Normal (N) while weak (W) included Fair plus (F+) to zero (0). After testing quadriceps and calf strength, the patients fell into one of four classes: strong quadriceps and calf (SQ/SC), strong quadriceps and weak calf (SQ/WC), weak quadriceps and strong calf (WQ/SC), or combined weak quadriceps and calf (WQ/WC). Quantified EMG (normalized by the manual muscle test EMG) defined the mean duration and intensity of the quadriceps, soleus, lower gluteus maximus, and long head of the biceps femoris during walking. Overuse was defined as values greater than the laboratory normal (mean + 1 SD). Each muscle exhibited instances of overuse, normalcy, and sparing. The biceps femoris was the only muscle with dominant overuse (82%). Quadriceps overuse was next in frequency (53%). Soleus activity infrequently exceeded normal function (34%), but this still represented more than twice the intensity and duration of the other muscles. Gluteus maximus action was also seldom excessive (34%). The patients averaged two muscles with excessive use during walking. Gait velocity of the SQ/SC strong group was highest (71% of normal) while the three categories that included weak muscles had walking speeds in the range of 50% of normal. The finding of muscle overuse during a single free-speed walking test that does not attain normal velocity supports the concept of muscle overuse being the cause of the patient's dysfunction.
Article
How many of the thousands who contracted polio during the epidemics 30 and 40 years ago will experience post-polio syndrome? What causes these delayed effects, and how quickly will they progress? None of these questions can be answered with certainty. At present, several factors appear to be at work. Patients are generally in one of two groups: The first group has deterioration in the function of muscles that were affected by the disease. This muscle weakness may be caused by a loss of motor neurons, due to aging, from an already depleted neuron pool. The remaining motor units then become stressed from overuse. The second group has problems in new muscle groups or those thought to be recovered from the disease. Problems in the second group appear to have a cause other than simple aging, possibly autoimmune, but longer follow-up is required to assess these patients. Evaluation of post-polio patients should be based on differentiating new neuromuscular disorders from exacerbations of the original disability. Although changes associated with aging cannot be halted, once post-polio syndrome is diagnosed, patients can be encouraged to follow appropriate dietary and exercise programs to maintain their present function, and they can be reassured of the relatively benign course of their problems.
Article
Presented are the results of a questionnaire survey on new health problems in 539 polio survivors. The most common new problems were fatigue, weakness in previously affected and unaffected muscles, muscle pain, and joint pain. The median time from polio to the onset of these problems ranged from 30 to 40 years. Factors at onset of polio most strongly associated with developing these new health problems were: being hospitalized, being over 10 years old, being on a ventilator, and having paralytic involvement of all four limbs. The differential diagnoses of these new problems, implications for treatment and areas for future research are discussed.
Article
Thousands of persons who had poliomyelitis are reporting new physical symptoms that are eroding physical abilities, regained only after strenuous and lengthy rehabilitation, that were thought to have been permanently restored. These symptoms are causing persons to feel they are becoming disabled for a second time by the same disease. These new symptoms are psychologically traumatic also because they are unexpected, their cause is unknown and there is a lack of knowledge and understanding concerning them within the medical community. Society's negative and pejorative attitude toward the disabled is discussed to explain the psychological trauma associated with any first or second disability. Psychological processes that promote acceptance of disability are outlined with special emphasis on the post-polio experience. Post-polio support groups are described as one means to obtain the resources necessary to surmount the physical and psychological difficulties associated with post-polio sequelae.
Article
This paper is based on a Canadian study which is examining the long term impact of disability among people who developed respiratory or non-respiratory polio during the epidemics of the 1950s and who were admitted to the same Manitoba hospital, the centralized treatment centre for the Province. This research is exploring change in the lives of these individuals by focusing on three conceptually distinct, although empirically overlapping areas or dimensions. The first is called the 'trajectory of disability' and refers to changes in functional status. The second includes those changes which are the product of the interaction between the normal processes of aging and the long term impact of poliomyelitis. The third is changes in the context of disability. This refers not only to changes in medical and technological knowledge, but sociopolitical developments including the emergence of a Disabled Rights Consumer Movement. This paper discusses the methodological and conceptual issues involved in the study, particularly its combination of different methods of data collection and the value of its historical-prospective design for capturing the effects of change over time in each of these different dimensions.
Article
To test hypotheses derived from theories regarding sex differences in illness behavior, health care received, and psychological development across the life span, patients' descriptions of their current life situations were content analyzed using nine scales that measure patterns of anxiety, depression, anger, helplessness, competence, sociability and positive feelings. Patients had chronic diseases or were awaiting surgery. Two-way analyses of variance were used to compare the responses of 261 males and 318 females of four age groups: young adult (18 to 30 years), adult (31 to 45), middle-aged (46 to 60), and elderly (61 to 85). Women expressed greater separation anxiety and sociability than men. Elderly patients experienced less anxiety, fewer feelings of competence and of helplessness, and fewer positive feelings than did young adults. Older patients reported as many social interactions, but these were more likely to be solidarity interactions in which they were reactors. Results seem best interpreted in terms of developmental theories regarding women's greater affiliation needs and abilities.
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