What Is Post-polio Syndrome?

  • Rukhsar Jabbar Masters in Physiotherapy, Jamia Millia Islamia, India

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In the domain of health struggles, imagine defeating the initial enemy only to find out there's an unexpected aftermath of the condition. Post-polio syndrome (PPS) is that unforeseen condition that emerges years after recovering from polio, bringing with it a new set of challenges.

Let's understand the complexities of PPS and shine a light on this often-overlooked chapter in the journey of polio survivors.

Introduction

It was shown that anywhere from 25% to 40% of patients who healed completely or partially from poliomyelitis went on to acquire symptoms that bore similarities to sporadic motor neuron diseases (MNDs) many years post-polio pandemic. It was difficult to make links with previous histories of poliomyelitis because it was thought that if the early childhood disease had been fully recovered from, the motor dysfunction would have been an aggravation of already present poliomyelitis-related pathology, and if not, the symptoms in later life aligned to a new disease entity. The two ideas eventually came to be combined by agreement and is referred to as "post-polio syndrome" (PPS).1

In the 1970s and 1980s, paralytic poliomyelitis, or polio, was eradicated in the majority of affluent nations. It was thought that survivors of acute paralytic poliomyelitis would have stable physical conditions for the remainder of their lives after recovering. Nonetheless, the eradication of polio does not signify the termination of medical intervention for the disease. Worldwide, many thousands of polio survivors remain vulnerable to the disease's late consequences.2

Definition of post-polio syndrome (PPS)

The symptoms of the post-poliomyelitis syndrome include an initial period of neurological and functional stability followed by a rapid or gradual loss of muscle strength, atrophy, pain, weariness, and hypersensitivity to colds. The illness occurs at least 15 years after the acute poliovirus infection.3

Understanding the poliovirus (PV)

A member of the human enterovirus species C is the poliovirus (PV). Every enterovirus is quite resilient to its surroundings. Toddlers below the age of five are the major target of poliomyelitis, which typically spreads through the fecal-oral route. The disease's severity is primarily determined by the location of the viral target, even though it is highly contagious. The virus inhibits cellular protein production by rerouting the translation machinery to work to its advantage as soon as it enters human systems.

Most infections (90–95%) are limited to the gastrointestinal system, and those who contract the poliovirus frequently have minimal or no symptoms (sometimes referred to as subclinical polio). Poliomyelitis, also known as paralytic poliomyelitis, occurs in a fraction of 1% of PV infections. This particular strain of the virus causes floppy paralysis and weakness in the muscles by attacking the motor neurons in the brainstem and spinal anterior horn.2 

Definition and history of polio

Poliomyelitis was thought to be a neurologically stable illness with potential functional aftereffects beyond the acute phase until quite recently. In the decade of the 1970s, patients with a history of poliomyelitis started to exhibit new symptoms that were worsening their functional state.4

 The phrase "post-polio syndrome" was first used in the 1980s to refer to this new, delayed polio symptom that appeared several decades after the original recovery. Although the exact pathophysiology of PPS is unknown, it is most likely complex. There have been several theories put forth to explain the new symptoms, including inflammatory alterations in the central nervous system and serum, overuse of the motor units, degeneration of the neuromuscular functions, and general ageing. Furthermore, PPS may resemble or exacerbate the late symptoms of polio, such as arthritic conditions, tendonitis, muscle wear, osteoporosis, and fractures. These complications are frequently the result of biomechanical abnormalities. This population of patients requires interdisciplinary care.2

Polio vaccination and eradication efforts

Since the development of the injectable Salk vaccine (1955) and the oral Sabin vaccine (1962), polio has all but disappeared from industrialized nations.2 The World Health Organization declared that poliomyelitis had been eradicated in Western nations in 1994 after the last case was reported in America, in the Pacific in 2000, and in Europe in 2002. However, a 2015 WHO report states that poliomyelitis is still endemic in Afghanistan and Pakistan.3

Prevalence and demographics

The implementation of poliovirus immunisation practically eliminated wild poliovirus in the United States, reducing the yearly incidence rate from over 10,000 cases to roughly 10. Worldwide, the number of cases of acute paralytic illness decreased from over 600,000 in the year before the polio campaign to less than 1000 by the year 2000 as a result of vaccination campaigns. However, due to inadequate availability to or adherence to immunization, low endemic rates continue to exist in some geographical pockets.1

Common symptoms of PPS

Patients first experience fever, exhaustion, headaches, nausea, and stiffness. A few hours later, they start to lose strength. The World Health Organization (WHO) reports that 5% to 10% of patients pass away from respiratory failure and that one in every 200 infected people exhibits an irreversible form of paralysis.3

One potential pathophysiological explanation for newly developed weakness is the weariness of the motor units, or reinforcement mechanisms that developed following the attack. Because of their weakness from the prior incident and the abandoned muscle fibres' long-term compensation for the denervated neurons, the surviving neurons may age prematurely.

Joint pain can also be quite severe, usually brought on by abnormal biomechanics, leg length inequality, muscle atrophy, joint stiffness, and age-related changes. Muscle pain is very common and is believed to be caused by overusing weak muscles or other muscle groups that are adjusting for the weakened polio-affected muscles. Neuropathic pain is experienced by several survivors and is primarily brought on by nerve impingement or disc herniation.2

Causes of post-polio syndrome

The dysfunction, degeneration, or death of motor neurons in the brainstem and spinal cord of PPS is relatively specific and resembles MND. However, uncertainty surrounds the PPS mechanism.

 Potential explanations include:

  1. Ageing-related neuronal and fibre attrition that affects  previously repaired and recovered underlying pathologiesEpigenetic modifications brought on by previous poliomyelitis that heighten susceptibility to spontaneous MND1

Diagnosis of post-polio syndrome

The purpose of the diagnosis is to rule out all other potential explanations for the new symptoms and clinical decline. PPS is an exclusion diagnosis, meaning it does not require a specific test or analysis.

It appears that everyone agrees with the EFNS (European Federation of Neurological Societies) criteria. The following criteria apply:

  1. Verified history of acute paralytic polio with an electromyogram showing denervation
  2. A minimum of fifteen years of sustained neurologic function following partial or whole recovery from acute paralytic poliomyelitis
  3. Abnormal muscle fatigability or progressive, persistent muscle weakening that develops gradually or suddenly
  4. The symptoms last for a minimum of a year
  5. Elimination of the possibility that other orthopedic, medical, and neuromuscular disorders are the root of the issues2

Managing post-polio syndrome

For patients with PPS, interdisciplinary care is the most effective approach. The cornerstone of PPS management is conservative treatment. The effects of tailored rehabilitation, which includes water treatment, endurance training, and muscle strengthening, have been demonstrated to be highly beneficial for pain alleviation, physical exertion, and endurance.

Post-polio muscle pain is treated with an array of pharmaceuticals (including benzodiazepines, opioids, and acetaminophen), but the results are mixed. Tricyclic antidepressants, particularly amitriptyline, are effective in treating both pain and fatigue.

Orthoses that fit properly can save energy and enhance the biomechanical movement pattern. Reducing or eliminating biomechanical pain and building stronger muscles for sitting, standing, walking, and other activities are frequently achieved by treating postural abnormalities.

In rare cases, treating polio survivors may include orthopaedic surgery. Pain alleviation, deformity correction, muscle transfers to counterbalance muscular force imbalance, securing unstable joints, and facilitating more efficient use of braces and orthoses are among the objectives of surgery.2

The only approach to reduce functional deficiency is through rehabilitation programs using physical-kinetic therapy, which includes massage, kinesiotherapy, thermotherapy, hydrotherapy, and occupational therapy. These therapies are crucial to the long-term treatment and care of patients. The long-term prognosis is not good, so it's critical to follow up with patients frequently and enrol them in comprehensive medical rehabilitation initiatives to maximize their autonomy and improve their quality of life. The process of rehabilitation is intricate and expensive both socially and personally, on a psycho-emotional level.4

FAQs

Post-polio syndrome (PPS): what is it?

People who previously had polio are susceptible to post-polio syndrome. It includes symptoms such as weariness, new muscle weakness, and other side effects that appear years after the initial polio infection has healed.

What is the cause of the syndrome?

A: Although the precise origin is unknown, it is thought to be connected to the deterioration of nerve cells that the poliovirus initially destroyed.

What PPS symptoms are present?

Weariness, joint pain, weakness in the muscles, and trouble doing tasks requiring strength in the muscles are common symptoms.

Is it possible to avoid PPS?

Regrettably, post-polio syndrome cannot be specifically prevented. However, leading a healthy lifestyle and controlling your stress can assist in reducing symptoms.

How can one diagnose post-polio syndrome?

Physical examination, medical history, and ruling out other potential explanations of symptoms are usually used to make a diagnosis. To confirm the diagnosis, a muscle biopsy and electromyography (EMG) may be performed.

Is there a way to treat PPS? 

Post-polio syndrome does not have a treatment. The goals of treatment are to improve the quality of life and manage symptoms. This could involve medicines, assistive technology, and physical therapy.

Can physical activity aid with PPS?

A: It is frequently advised to maintain muscle strength and flexibility with suitable exercise. However, before beginning any fitness regimen, it's crucial to speak with a healthcare professional.

Are there PPS support groups available? 

It is possible to get both practical information and emotional assistance by joining a support group. It makes it possible for people with PPS to interact with people who can relate to their experiences.

What is a person with PPS likely to face in the long run? 

Each person's PPS progresses differently. While some people only have modest effects, symptoms may get worse over time. To control symptoms and preserve general health, it's critical to collaborate closely with healthcare professionals.

Bear in mind that while this is a basic guideline, personal experiences may differ. Consult a healthcare provider at all times.

Summary

To sum up, post-polio syndrome (PPS) is a complicated illness that poses fresh difficulties to people who have recovered from polio. Although there is no known treatment for PPS, individuals who are impacted can greatly enhance their quality of life by being aware of its symptoms, getting a correct diagnosis, and implementing a thorough management plan. Stressing the value of routine physical examinations, customized exercise regimens, and a caring support system can enable people to successfully manage the distinctive path of living with post-polio syndrome.

References

  1. Punsoni M, Lakis NS, Mellion M, Monte SM de la. Post-polio syndrome revisited. Neurology International [Internet]. 2023 Apr 13 [cited 2023 Nov 6];15(2):569–79. Available from: https://www.mdpi.com/2035-8377/15/2/35
  2. Chu EC, Lam KK. Post-poliomyelitis syndrome. International Medical Case Reports Journal [Internet]. 2019 [cited 2023 Nov 6]; 261-4. Available from: https://www.tandfonline.com/doi/full/10.2147/IMCRJ.S219481
  3. Dogaru GB, Stănescu I. Role of medical rehabilitation in postpoliomyelitis syndrome. A case report. Clujul Medical [Internet]. 2013 [cited 2023 Nov 9];86(2):150-2. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462434/
  4. Sáinz MP, Pelayo R, Laxe S, Castaño B, Capdevilla E, Portell E. Describing post-polio syndrome. Neurología (English Edition) [Internet]. 2022 Jun 1 [cited 2023 Nov 8];37 (5):346–54. Available from: https://www.sciencedirect.com/science/article/pii/S2173580821000614

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Rukhsar Jabbar

Masters in Physiotherapy, Jamia Millia Islamia, India

Rukhsar Jabbar is a physiotherapist specializing in neurology, having attained her master's degree in the field. She is particularly passionate about research-based medical content writing, demonstrating a commitment to promoting health awareness. Her dedication lies in bridging the gap between evidence-based scientific information to accessible content, catering to individuals of diverse backgrounds. Looking ahead, Rukhsar aspires to make significant contributions to the field of research, further enhancing the understanding and application of evidence-based information in healthcare.

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