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Although the Post-Polio Task Force disbanded in 1999 because the research was concluded, the information that was developed for this section of the PHI website remains relevant to this date.

Highlights of 1997 Roundtable Meetings

Differential Diagnosis of Post-Polio Syndrome Requires Knowledge, Skill and Persistence

Diagnosing post-polio syndrome (PPS) is a challenging process. There are no pathognomonic tests for the condition, and a definitive diagnosis can be achieved only through exclusion of other conditions that may be responsible for causing PPS-like symptoms, such as pain, new weakness and fatigue. A successful exclusionary diagnosis of PPS depends on the knowledge, skill, and persistence of the examining physician, according to Frederick M. Maynard, MD, Professor and Chairperson of Physical Medicine and Rehabilitation at Case Western Reserve University/MetroHealth Medical Center in Cleveland, Ohio.

"Persistence is particularly important when it comes to diagnosing PPS, because it is not always possible to get to the bottom of the situation during just a few visits with the patient," Dr. Maynard said. " One diagnostic difficulty stems from the fact that a patient's symptoms may result from a synergy between post-polio residual neuromuscular dysfunction, orthopedic dysfunction and other comorbid medical conditions."

Diagnostic Algorithm

The process of "teasing apart" synergistic dysfunctions in a patient can be simplified through the use of a diagnostic algorithm, according to Dr. Maynard (see Table below).

Diagnostic Algorithm for Post-Polio Syndrome

  • Verify an original diagnosis of acute paralytic polio (APP).
  • Evaluate the extent and severity of APP residua.
  • Develop a differential diagnosis of the presenting symptom complex.
  • Conduct diagnostic tests to exclude other conditions considered in the differential diagnosis.
  • (If no other conditions are found): Establish the patient's baseline function and develop a rehabilitation plan.
  • (If other conditions are found): Treat them and re-evaluate the patient later for rehabilitation needs.

The first step of this algorithm was summarized during the roundtable discussion led by Drs. Lauro Halstead and Burk Jubelt. The second step requires the development of a comprehensive functional history, which allows the examining physician to quantify increasing weakness. Potential tests of a patient's physical abilities include manual muscle testing; isometric strength measurement; joint range-of-motion measurements; gait evaluation; and pulmonary function tests.

The third step in the diagnostic algorithm - developing a differential diagnosis - involves not only defining the basic characteristics of each symptom, but also considering the symptoms in relation to the individual's overall health and specific lifestyle. Once this is accomplished, a diagnostic plan can be developed. In general, Dr. Maynard said, diagnostic planning can be ap- proached by examining the primary symptoms of pain, new weakness and fatigue, and using appropriate evaluation tests to exclude conditions other than PPS.

In Dr. Maynard's algorithm, possible causes for new weakness that should be ruled out can be categorized according to their association with one or more of the following conditions: new superimposed neurological conditions, disuse atrophy, overuse/chronic strain and systemic comorbid medical conditions. The category of new superimposed neurological conditions includes entrapment neuropathies (such as those affecting the median nerve at the wrist and the ulnar nerve in the hand), generalized motor and/or sensory neuropathies, radiculopathies, spinal stenosis and other neurological diseases (e.g., amyotrophic lateral sclerosis [ALS], multiple sclerosis [MS], myasthenia gravis). The most appropriate evaluation tests for these conditions, according to Dr. Maynard, are electrodiagnostic tests (electromyography and nerve conduction studies); x-rays and imaging studies; blood chemistries, including creatine kinase and thyroid function tests; and toxic metals screening. The algorithm follows a similar step-by-step process for the differential diagnosis of pain and fatigue in PPS.

Practical Concerns

Some roundtable participants expressed concern that this algorithm may require expertise beyond the range of many practicing physicians, most of whom rarely see polio survivors. Dr. Maynard agreed that such concerns were valid, but also pointed out that the emphasis of the algorithm was not turning clinicians into "instant experts" on PPS. "The real issue is, how do we help doctors recognize possible PPS in the first place, and how should it be distinguished from other conditions?" Dr. Maynard said. "Some physicians may not feel comfortable in diagnosing specific orthopedic problems associated with PPS, while others may feel less comfortable diagnosing neurological difficulties. One benefit of this algorithm is that it can assist examining physicians in knowing when to refer their patients to outside experts."

Once other conditions have been excluded through differential diagnosis, the examining physician can begin to establish a functional baseline for the patient in order to measure the progress of rehabilitation, Dr. Maynard said. A patient's baseline can be established through manual muscle testing, quantitative strength training, electromyography and limb circumference measurements. The examining physician can also record the time it takes a patient to walk a given distance or to complete an activity of daily living, so that these times can be compared to those achieved after the patient has begun a rehabilitation program. A subjective measurement of baseline function can also be established by videotaping movements and functional activities of the patient.

"PPS is a complex syndrome that does not lend itself to easy evaluation, and itfollows that rehabilitation of a patient requires considerable attention and persistence on the part of the physician," Dr. Maynard concluded. "To be effective, rehabilitation must address issues relating to general health,symptom reduction, and functional enhancement, as well as those relating to the prevention of secondary disability."

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