POST POLIO SYNDROME:
WHAT DOES IT MEAN ORTHOTICALLY?

What is post polio syndrome? This becomes a complex question that may have many answers depending on the specifics of a patient's complaints and problems. There was a time that some feared the dreaded disease was coming back and that it would cause additional paralysis in what muscles were left. These issues puzzled patients and physicians alike. Many physicians practicing today have not had the experience of working with the polio population, as many polio patients have been stable for some time. However, after many years of use, muscles and joints seem to be screaming out, "I've had enough, I need relief, I need some rest!" These symptoms, consisting of muscle and joint pain, come from different parts of the body depending on the affected areas.

First of all, we need to describe exactly what polio is. After entering the body through the gastro-intestinal tract and an incubation period of two weeks, the virus attacks the anterior horn cell of the spinal cord or the brainstem (1). The ventral root, which synapses with a motor nerve, is damaged to the point that it is unable to send messages to the muscle cell through the terminal axon sprouts. This lack of innervation causes muscle weakness or paralysis. If enough damage is done, partial or total paralysis of the lower or upper limbs will result as well as complications and paralysis of the respiratory system. It is believed that some of the terminal axon sprouts are able to branch out to muscle cells, which have been affected and help in innervation (2). This will allow function of the muscle cell, however, that particular muscle probably will be much weaker than a normal group of cell innervation.

There are five main stages of polio. These consist of a prodromal phase lasting two days, an acute illness lasting approximately two months, a recovery or convalescence period lasting up to two years, a stable disability or stage of chronicity and then a post polio syndrome (3), (4) which includes symptoms of muscle pain, joint pain fatigue accompanied by additional weakness and atrophy of muscle tissue. Usually the stage of stable disability lasts for 20 to 30 years. These chronic disabilities become increasingly challenging for polio patients trying to keep up a normal pace. The exacerbation of symptoms of the polio patient is classified as "Post Polio Syndrome," a condition composing of a "…cluster of symptoms in individuals who had paralytic polio many years earlier" (5).

From a survey conducted in 1987 by the National Commission on Health Statistics, there were 1.63 million polio survivors with 641,000 having some type of paralysis (6). If you divide this by the approximately 1,000 ABC facilities, there are about 600 patients per facility who will need some manner of care. Even if this number were cut in half, there would still be a substantial population for each facility. A recent problem that has arisen from this group is that many of them who require orthotic care have felt reluctant to confide in their orthotist. Many orthotic professionals have told them that they (polio patients) are hard to deal with, they are set in their ways and take a considerable amount of time to provide care. The orthotic profession must be careful not to prejudge these patients as all difficult type "A" personalities (7). Many of them have expressed offense as they have shared their feeling in the many seminars and support groups which I have had the privilege of presenting. We, as professional practitioners, need to take the time to listen and to properly evaluate these patients' conditions. It is imperative that orthotic practitioners become familiar with the polio patient's history. Practitioners need to understand exactly what they are dealing with. Polio survivors are the type of patients that practitioners need to evaluate hands-on and to know "firsthand" the muscle weakness and range of motion and how the patient is substituting for the weakness to be able to function.

The polio patient is the most important member of this/her rehabilitation team. He/she must be allowed to assist in the design of the orthosis. He/she needs to understand that orthotic practitioners are not sentencing them to 24-hour orthotic wear but are trying to provide a system that will protect and stabilize. Be flexible with these patients. Leave options in the treatment plan. Provide patients with a choice and lead them in the right direction. Let them know that your abilities and expertise can help eliminate unwanted range of motion and allow for a more normal function. By all means, don't lock their joints unless you absolutely have to. If you do, you may find that your carefully designed orthosis will end up in their closet, not because of your design, but because you have taken away form them the simple motions that they use to substitute for muscle weakness and joint deformity.

When assessing a post polio orthotic patient, consider all design options which are available. Some of these options may be a combination of two or more orthotic designs. For example, you may have a patient that needs additional knee stability due to weakened quadriceps but is unable to tolerate the weight of conventional designs. One idea is to provide a hybrid orthosis consisting of a leaf spring design orthosis with a pre-tibial shell which provides minimum quadricep support and give just enough feedback to prevent the knee form buckling. Younger and stronger patients [40-60] can accept more aggressive designs and seem to have a willingness to try harder in allowing time for adjustment to new designs. They seem to have a better understanding of what the intended outcome is and will work to make it happen if possible. Older polio ambulatory [60-75] are often more complicated due to additional muscle and joint fatigue. They seem to be more apprehensive about change. Orthotic practitioners need to realize that these older patients have experienced much in dealing with past orthotic challenges. These patients need to lead the way in their orthotic care and are the ones who need options to choose from. Elderly ambulators [75 +] usually need lightweight orthoses. They want little change and practitioner listening skills need to be especially keen for this group. You must let these elderly patients know that you care about them and you also must learn to take their criticism with a smile.

What drives many of these patients to their physicians and eventually to orthotic facilities is pain. Polio patients with post-polio syndrome will have pain. There is a reason for this pain. Pain is good; it is a tool by which a patient can be protected from further damage if he/she respects it (8). Pain is the "Personal Awareness of Internal Notification" system. It is important to identify the source of the pain. Orthotic professionals need to focus on the musculoskeletal issues. If possible, joints need to be protected to prevent further damage while allowing the patient to continue to have mobility. By providing stability and more normal biomechanical function, joint destruction and muscle fatigue and stress can be reduced.

Many new and amazing materials are becoming available to orthotic professionals. This allows for lighter and stronger orthotic designs. New techniques are also available through modern technology by surgeons. Some joint deformities can now be improved dramatically, relieving stress and pain around joints and surrounding tissue. Keep your polio patients informed and don't be afraid of the challenges. Many of you have been trained professionally to handle these types of conditions. Please remember that your area of expertise is greatly needed and polio survivors will be relying more on your professional services.

Reference:

1. Atlas of Orthotics, Second Edition, The C.V. Mosby Company, 1985:94.

2. Halstead, LS. Managing Post Polio: A guide to living well with Post-Polio syndrome. Washington, D.C. NRH Press, 1998:9.

3. Salter, RB. Testbook of disorders and injuries of the musculoskeletal system. Baltimore, Md. Williams & Williams, 1982:266.

4. Halstead, LS. Opcit, 5.

5. ibid, 7.

6. ibid, 11.

7. Halstead LS, & Grimby. Post-Polio Syndrome, Philadelphia: Hanley & Belfus, Inc. 1994: 179.

8. Halstead, LS. Opcit, 122.