Role of medical rehabilitation in postpoliomyelitis syndrome. A case report

Abstract

Postpoliomyelitis syndrome is characterized by a sudden or progressive loss of muscle strength, muscle atrophy, muscle pain, fatigue, intolerance to cold, after a period of at least 15 years from the acute polio virus infection, a period of neurological and functional stability. No therapeutic benefit of the evaluated drug agents (pyridostigmine, steroids, amantadine) has been reported. The reason for this presentation results from the fact that clinical studies have demonstrated that isokinetic and isometric muscle training can prevent the loss of muscle strength and reduce muscle fatigue. Rehabilitation programs through physical-kinetic therapy are the only way to limit functional deficit, playing an important role in the long-term management and care of patients. The particularity of this case is the fact that the symptoms occurred after a 40 year period of neurological stability. The regular monitoring and inclusion of the patient in complex medical rehabilitation programs are important in order to limit the functional deficit and increase the quality of life of these patients.

Full text

150
Clinical cases
Clujul Medical 2013 Vol. 86 - no. 2
ROLE OF MEDICAL REHABILITATION
IN POSTPOLIOMYELITIS SYNDROME. A CASE REPORT

Clinical Rehabilitation Hospital Cluj-Napoca, Romania


Postpoliomyelitis syndrome is characterized by a sudden or progressive loss of
muscle strength, muscle atrophy, muscle pain, fatigue, intolerance to cold, after a period
of at least 15 years from the acute polio virus infection, a period of neurological and
functional stability. No therapeutic benet of the evaluated drug agents (pyridostigmine,
steroids, amantadine) has been reported. The reason for this presentation results
from the fact that clinical studies have demonstrated that isokinetic and isometric
muscle training can prevent the loss of muscle strength and reduce muscle fatigue.
Rehabilitation programs through physical-kinetic therapy are the only way to limit
functional decit, playing an important role in the long-term management and care
of patients. The particularity of this case is the fact that the symptoms occurred after a
40 year period of neurological stability. The regular monitoring and inclusion of the
patient in complex medical rehabilitation programs are important in order to limit the
functional decit and increase the quality of life of these patients.
 post-polio syndrome, medical rehabilitation, treatment,
kinesitherapy.
Manuscript received: 12.02.2013
Received in revised form: 16.03.2013
Accepted: 29.03.2013
Address for correspondence: anagabicata@yahoo.com

The term post polio syndrome (PPS) was introduced
in 1985 by Halstead. It is characterized by a sudden or
progressive loss of muscle strength, new muscle atrophy,
muscle pain, fatigue, functional impotence, intolerance to
cold after a period of at least 15 years from acute polio
virus infection, a period of neurological and functional
stability, in the absence of other medical explanation [1].
The reported prevalence of PPS is between 15% and 80%
of all patients with previous poliomyelitis virus infections
[2,3]. The few studies available regarding drug therapy have
reported no efciency of the studied drug agents: steroids,
pyridostigmine, amantadine in the management of fatigue
and muscle strength [4,5,6]. Non-randomized studies with
kinesitherapy programs with a duration between 6 weeks
and 7 months, involving isokinetic and isometric endurance
muscle training, demonstrated an increase of muscle strength
in patients with mild and moderate loss of muscle strength
and a reduction of muscle fatigue [7,8,9]. In a randomized
study, a signicant reduction in pain, depression, fatigue,
as well as an improvement of walking following hydro-
thermotherapy were described [10]. Rehabilitation pro-
grams through physical-kinetic therapy are the only way
to limit functional decit, playing an important role in the
long-term management and care of patients. The aim of the
study is to clinically and functionally assess the efciency
of an individualized rehabilitation program in the case of a
patient with PPS.

DV, aged 57 years, with a history of poliomyelitis
since the age of 2, had walked with crutches with armpit
support since the age of 5. In October 2012, he sought
medical attention for a progressive loss of muscle strength,
particularly in the lower limbs, fatigue, muscle atrophy,
intolerance to cold, impossible standing and walking,
symptoms occurring a year before, and worsening in the
last month. At the age of 30, he had a right tibial fracture,
operated with osteosynthesis material. Since the age of 50,
he had had high blood pressure values, currently receiving
drug treatment and a low sodium diet. The objective
examination of the osteoarticular system revealed marked
dorso-lumbar scoliosis, scapula alata, scapulo-humeral (SH)
pain, left SH stiffness (joint testing shows 120° exion, 30°
extension, 90° abduction, 50° internal rotation, 50° external
rotation), reducible exum of the knee, bilateral hollow
foot, lower limb muscle atrophy, impossible orthostatism
and walking. Active segmental movements absent in the

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Clujul Medical 2013 Vol. 86 - no. 2
right lower limb, diminished to the left. Muscle strength:
1/5 right lower limb, 3/5 left lower limb, 4/5 bilateral upper
limbs. Loss of osteotendinous reexes, normal sensory
examination, imperative micturition and dyspnea were
observed. Paraclinical investigations showed biological
tests within normal limits, moderate restrictive ventilatory
dysfunction at functional respiratory tests. EKG was
normal. EMG examination evidenced chronic denervation
and rare fasciculations, without any nervous conduction
abnormalities. X-rays of the cervico-dorso-lumbar spine
showed spondylarthrosis changes. Computed tomography
(CT-scan) of the cervical spine showed cervical arthrosis
without stenosis.
CT-scan cervical spine - Cervical arthrosis.
 CT-scan cervical spine - Cervical arthrosis.
Drug treatment used included NSAIDs, antispastics,
vitamins. Clinical and functional assessment were performed
at the beginning of the rehabilitation treatment and after
the two weeks of treatment. Pain on the visual analogue
scale (VAS), articular mobility using joint evaluation,
muscle strength using muscle testing, and transfers were
monitored. Rehabilitation treatment consisted of sedative
paravertebral massage and toning massage of the upper
and lower limbs, posturing with the upper limbs in slight
abduction, the elbows and knees in extension, in order to
prevent tendinous retractions and joint stiffness. Parafn
packing with analgesic and myorelaxant effect was used for
the left shoulder. Passive mobilizations of the lower limbs
were performed in order to prevent potential complications
of the immobilization syndrome, such as joint stiffness,
increase in muscle hypotrophy, immobilization osteoporosis
and thrombophlebitis; active mobilizations of the upper
limbs were aimed at increasing the range of joint motion.
Transfers in bed, as well as from bed to wheelchair, postures
facilitating respiration, and respiratory gymnastics for the
improvement of respiratory function were also carried out.
Isotonic and isometric muscle training for preventing the
loss of muscle strength was monitored for exercise duration
and the rest period. Stretching exercises and muscle relaxing
exercises were also performed. The ergotherapy program
consisted of techniques for the improvement of ADLs.
The agreement of Ethic Commission of research
of the Clinical Rehabilitation Hospital Cluj-Napoca was
obtained.
Results
After two weeks of drug treatment and rehabilitation,
the intensity of pain in the shoulder decreased (VAS before
treatment 9 and after treatment 5). The patient was able
to perform by himself transfers in bed and also, from bed
to wheelchair, having a higher degree of independence in
the wheelchair. Mobility in the left scapulo humeral joint
signicantly improved (150° exion, 70° extension, 120°
abduction, 70° external rotation, 70° internal rotation).
Muscle testing also improved: 2/5 right lower limb,
3/5 left lower limb, 4/5 bilateral upper limbs.
Discussion
Post-polio syndrome (PPS) may be difcult to
diagnose in some people because both neurological diseases
and other medical conditions can explain aggravation of
a previous stable motor decit. It is important to clearly
establish the origin and potential causes for declining
strength and to assess progression of weakness not
explained by other health problems. Magnetic resonance
imaging (MRI) and computed tomography (CT) of the
spinal cord, electrophysiological studies, and other tests
(muscle biopsy or a spinal uid analysis) are frequently
used for the differential diagnosis. Neurological conditions
that involve progressive aggravation of a motor decit are

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cervical myelopathy, syringomyelia, amyotrophic lateral
sclerosis, motor neuropathies and myopathies. In our
case, the CT scan of the cervical spine (MRI could not be
performed due to metallic implants) ruled out the spinal
cord compression; the lack of sensory signs at clinical
and electrophysiological studies excluded radiculo- and
neuropathies, and also myopathies, which have a typical
EMG aspect. Other medical conditions can mimic motor
decit with fatigue: shoulder osteoarthritis from walking
with crutches, a chronic rotator cuff tear, or a progressive
scoliosis causing breathing insufciency. Pain, weakness,
and fatigue can result from the overuse or disuse of muscles
and joints.
Rehabilitation treatment’s complexity depends on
the goals established after osteoarticular and muscular
system examination. To obtain the best efcacy, association
between different physical methods of treatment is
necessary (massage, kinetotherapy, hydrothermotherapy
and occupational therapy).
The study reveales the benets of physical-kinetic
therapy for the maintenance and increase of joint mobility,
the improvement of pain, muscle strength and respiratory
function. The data in literature show that the excessive
use of muscles and training can aggravate PPS symptoms
and decrease muscle strength [11]. However, there are no
prospective studies demonstrating that increased muscle
activity or training can induce a decrease of muscle strength
compared to no training or minimal muscle activity. Patients
with regular physical exercise had fewer symptoms and
an increased functional level compared to physically
inactive patients. The majority of the studies based on
physical exercise were conducted under monitoring, with
submaximal exercise, intermittent pauses and rest periods
in order to prevent overstrain effects [11,12].
Conclusions
Rehabilitation programs through physical-kinetic
therapy: massage, kinesitherapy, thermotherapy, hydro-
thermotherapy, occupational therapy are the only way to
limit functional decit, playing an important role in the
long-term management and care of patients. Long-term
prognosis is unfavorable, and the regular follow-up of
patients and their inclusion in complex medical rehabili-
tation programs are important for ensuring the highest
possible autonomy and increasing the quality of life of
these patients. Rehabilitation is a complex process, which
involves high costs at an individual, psycho-emotional
level, as well as at the social level.

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