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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

Strategies Help Manage Post-Polio Symptoms

Even though no specific treatment is currently available for post-polio syndrome (PPS), strategies are available to help improve symptoms such as weakness, pain, respiratory dysfunction, dysphagia, and fatigue. A variety of techniques were outlined by Daria A. Trojan, MD, MSc, Assistant Professor at McGill University's Montreal Neurological Institute and Hospital, Montreal, Quebec, Canada, and Robert Miller, MD, Chairman of the Department of Neurology at California Pacific Medical Center, San Francisco.

Exercise for PPS patients has long been a topic of controversy, Dr. Trojan noted. In recent years, however, numerous studies have shown that judicious exercise can have a beneficial impact on weakness. Weakness may lessen in response to non-fatiguing strengthening exercises (isometric, isotonic, or isokinetic) and aerobic exercises. Improvements in muscle strength, power, work capacity, and economy of movement have been reported. Stretching exercises to decrease or prevent contractures may also be useful in patients with weakness.

Nevertheless, patients must be careful to avoid overuse of muscles during exercise, she said. Furthermore, exercise should be avoided altogether in those who are extremely weak and fatigued. "Just the activities of daily living take all of their energy, and these patients should not be subjected to additional exercise," she explained.

Weight loss can also help in the management of weakness, Dr. Trojan noted. Excess weight increases stress on post-polio muscles and joints, necessitating greater energy expenditure to perform activities of daily living.

Orthoses, or braces, offer another method of managing weakness. These devices can be used to compensate for joint instability secondary to weak muscles; to correct gait deviations; to control joint deformities secondary to weak muscles; and to reduce pain. Studies have shown that appropriate orthoses may improve the patient's ability to walk and their perception of walking safety, and may also relieve pain. Assistive devices such as canes, crutches, wheelchairs, and scooters may be useful as well.

Techniques Reduce Pain

PPS patients can experience pain as the result of muscular, joint or biomechanical, or neurologic problems. Dr. Trojan advised that muscular pain may be reduced by using pacing strategies, including taking rest periods during activities; using moist heat, ice and/or stretching; using assistive devices; and instituting lifestyle modifications.

Fibromyalgia, which occurs relatively frequently in post-polio patients, can be treated with amitriptyline, cyclobenzaprine or fluoxetine, Dr. Trojan said. Also potentially helpful are aerobic exercise, relaxation techniques, heat, massage and injection of local anesthetics. Pain resulting from joint and soft tissue abnormalities may improve with modification of extremity use, physiotherapy, orthoses, assistive devices, nonsteroidal anti-inflammatory drugs, steroid injections or surgery.

Another potential concern in PPS is respiratory dysfunction. Preventive measures (such as pneumococcal and influenza vaccinations) should be provided, she said, and reversible causes should be treated. Ventilatory assistance may be necessary in some cases; however, noninvasive methods are preferred due to an enhanced quality of life and decreased incidence of complications.

For dysphagia, Dr. Trojan recommended dietary alterations, special breathing and swallowing techniques, eating larger meals earlier in the day, and avoiding eating when fatigued.

Managing Fatigue

Dr. Miller described several strategies for improving the common symptom of fatigue in patients with PPS. He explained that fatigue may manifest itself as a low energy state; as mental fatigue; as reduced muscular endurance; or as delayed recovery after exercise. Patients frequently experience all types.

Healthcare professionals should help patients assess the ways in which energy is currently being expended, Dr. Miller said. It may be possible in many cases to identify methods of conserving energy, he noted. Judicious use of antidepressant medications may be appropriate for some, but not all, patients. Because sleep disturbances can play a major role in fatigue, efforts should be made to normalize sleep patterns. Amitriptyline may be useful in this regard, Dr. Miller said.

As in the case of muscle weakness, fatigue symptoms can also be improved through therapeutic exercise. Studies have shown that patients who exercise enjoy better endurance, greater work capability, and improved recovery after fatiguing activities. However, patients must be cautioned to start slowly. "The general caveat is if exercise produces fatigue, you have gone too far, and if the next day you have muscular pain, you have done too much," Dr. Miller said. "The 'no pain, no gain' aphorism that applies to normal, healthy athletes does not apply to PPS patients."

Pharmacologic Therapies Assessed

Dr. Trojan noted that several pharmacologic agents have recently been evaluated or are under evaluation for the treatment of weakness and/or fatigue in PPS patients (see Table). To date, small trials have found no significant effects of amantadine, prednisone or human growth hormone. Conversely, some improvement has been evident with bromocriptine, selegiline, insulin-like growth factor I (IGF-1), and pyridostigmine. An open-label trial in 17 PPS patients found that improvement in fatigue with pyridostigmine was significantly associated with amelioration in neuromuscular junction transmission with edrophonium (a similar, short-acting intravenous agent). This suggests that fatigue in some patients with PPS is due to anticholinesterase-responsive neuromuscular junction transmission defects. In an open-label trial of pyridostigmine in 27 PPS patients, 64% reported an improvement in fatigue. A double-blind, placebo-controlled, crossover trial in 27 PPS patients concluded that pyridostigmine produced an improvement in some measures of fatigue and strength. Because of these encouraging results, a multicenter trial of pyridostigmine in 126 PPS patients is currently underway.

"Thus far, pyridostigmine seems to be most promising," Dr. Trojan said. "However, other medications, such as IGF-1 and selegiline, should probably be investigated further."

Whenever possible, PPS patients should not receive medications that have fatiguing effects or potential inhibitory actions at the neuromuscular junction, she noted. Agents that should be avoided include beta-blockers, benzodiazepines, certain anesthetics, some antibiotics (such as tetracycline and aminoglycosides), certain anticonvulsants (such as phenytoin), some antipsychotics (such as lithium and phenothiazines), and barbiturates.

Table. Pharmacotherapy of Post-Polio Syndrome: Recent Trials
Drug Category Type of Trial N Results in PPS
Amantadine Anti-viral Randomized, placebo-controlled trial 25 No significant improvement in fatigue1
Prednisone (high dose) Steroid, anti-inflammatory Randomized, placebo-controlled trial 17 No significant improvemen tin strength or fatigue2
Human growth hormone Hormone Open trial 5 Little or no improvement in muscle strength3
Bromocriptine Dopamine receptor agonist Placebo-controlled, cross-over trial 5 Improvement in fatigue symptoms in three patients4
Selegiline Neuroprotective agent Case studies 2 Improvement in PPS symptoms5
Pyridostigmine Anticholinesterase Open trials

Placebo-controlled, cross-over trial

17, 27


Improvement in fatigue6, 7

Improvement in fatigue, strength8

Insulin-like growth factor I (IGF-1) Growth factor Randomized, placebo-controlled trial 22 Improvement in recovery after exercise, no change in strength, fatigability9

1. Stein DP et al. A double-blind, placebo-controlled trial of amantadine for the treatment of fatigue in patients with the post-polio syndrome. Ann NY Acad Sci 1995;753:296­302.

2. Dinsmore S et al. A double-blind, placebo-controlled trial of high-dose prednisone for the treatment of post-poliomyelitis syndrome. Ann NY Acad Sci 1995; 753:303­313.

3. Gupta KL et al. Human growth hormone effect on serum IGF-1 and muscle function in poliomyelitis survivors. Arch Phys Med Rehabil 1994;75:889-894.

4. Bruno RL et al. Bromocriptine in the treatment of post-polio fatigue. Am J Phys Med Rehabil 1996;75:340­347.

5. Bamford CR et al. Postpolio syndrome response to deprenyl (selegiline). Int J Neurosci 1993;71:183-188.

6. Trojan DA et al. Anticholinesterase-responsive neuromuscular junction transmission defects in post-poliomyelitis fatigue. J Neurol Sci 1993;114:170-177.

7. Trojan DA, Cashman NR. An open trial of pyridostigmine in post-poliomyelitis syndrome. Can J Neurol Sci 1995;22:223-227.

8. Seizert BP et al. Pyridostigmine effect on strength, endurance, and fatigue in post-polio patients (Abstract). Arch Phys Med Rehabil 1994;75:1049.

9. Miller RG et al. The effect of recombinant insulin-like growth factor 1 upon exercise-induced fatigue and recovery in patients with post polio syndrome (Abstract). Neurology 1997 (in press).

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