The late effects of Polio Information for Health Care Providers
Charlotte Leboeuf

12 DIAGNOSTIC CONSIDERATIONS IN PATIENTS WHO HAVE HAD POLIO

1. Has the patient had polio?
2. If yes -
   What was the approximate localisation and severity of the disease?
3. What degree of post-convalescent recovery took place?
4. Are the symptoms clearly related to polio?
5. If no -
   Can the symptoms be caused by a progression of residual polio?
6. Are the symptoms consistent with those ascribed to the late effects of polio?
7. If yes -
   Are the symptoms due to a combination of causes?
8. How severe is the condition and what is its rate of progression?

QUESTION 1:
HAS THE PATIENT HAD POLIO?

A previous history of polio is often not clear. Investigate the following:

Patients may be unaware of a past history of polio because they:

• were to young to remember the acute infection;
• may not have been told by the parents;
• may not have been diagnosed as such because the attack was mild or atypical, or because it occured during a time period or in an area where polio was uncommon.

Some people may also have been incorrectly diagnosed as having polio.

QUESTION 2:
IF YES - WHAT WAS THE APPROXIMATE LOCALISATION AND SEVERITY OF THE DISEASE?

Investigate the following:

It may be difficult to establish the extent of the acute paralytic disease because:

• medical records may be unavailable or imprecise;
• patients may not have been informed of details of their disease;
• patients may have been informed of the full extent of their disease but were unable to retain the information
• parents and relatives may no longer be available to provide further information.

QUESTION 3:
WHAT DEGREE OF POST-CONVALESCENT RECOVERY TOOK PLACE

A careful history is necessary to establish at what level the individual functioned after the recovery stage peaked. Investigate the following:

It may be difficult to establish the amount of recovery which took place because:

• medical records may be unavailable or imprecise;
• the amount of recovery may not have been objectively measured. Muscles which were thought to have made full or near full recovery on the basis of manual muscle testing are likely to have reatined a considerable residual weakness (up to 50%);
• atrophy is not always visable, although asymmetry may be noticable. Look for signs if slightly differently developed limbs such as differently-sized shoes.

In order to obtain objective measures of the neuromuscular integrity it may be necessary to perform EMG studies, Cybex dynamometer tests and measurement of the grip strength. The vital capacity of the lungs can be established through spirometry.

QUESTION 4:
ARE THE SYMPTOMS CLEARLY UNRELATED TO POLIO?

Investigate other possible causes, such as:

QUESTION 5:
IF NO - CAN THE SYMPTOMS BE CAUSED BY A PROGRESSION OF RESIDUAL POLIO?

Is it possible that residual problems may have developed into further disturbances, such as:

Useful reading:
1. Hodges DL, Kumar VN. Postpolio syndrome. Orthopedic Review 1986;15:51-5. [PubMed Abstract]
2. Frustace SJ. Poliomyelitis: Late and unusual sequelae. Am J Phys Med 1988;66:328-37. [PubMed Abstract]
3. Jackson RP, Simmons EH, Stripinis D. Coronal and sagittal plane spinal deformities correlating with back pain and pulmonary function in adult idiopathic scoliosis. Spine 1989;14:1391-7. [PubMed Abstract]
4. Einarsson G, Grimby G. Disability and handicap in late poliomyelitis. Scand J Rehab Med 1990;22:113-21. [PubMed Abstract]
5. Bruno RL, Johnson JC, Berman WS. Vasomotor abnormalities as post-polio sequelae: Functional and clinical implications. Orthopedics 1985;8:865-9. [PubMed Abstract]

QUESTION 6:
ARE THE SYMPTOMS CONSISTENT WITH THOSE ASCRIBED TO THE LATE EFFECTS OF POLIO?

New symptoms, commonly ascribed to the late effects of polio, may occur following a period of post-convalescent stability (commonly 20-30 years). It appears that a combination of at least two of the following symptoms is most common (1):

• weakness:
  • general lack of endurance;
  • new weakness in muscles of limbs and trunk.
• fatigue:
  • unrelated to activity;
  • long-lasting following activity.
• pain:
  • following seemingly moderate activities;
  • spontaneous, unpredictable in muscles and joints;
  • headaches;
  • muscle cramps.
• swallowing/speech difficulties.
• respiratory problems:
  • shallow, laboured breathing due to voluntary muscle insufficiency;
  • increased respiratory distress in the supine position;
  • breathlessness with or without activity;
  • depressed central respiration resulting in daytime respiratory insufficiency and/or sleep apnoea;
  • other possible symptoms are:
    • chest infections (due to respiratory insufficiency);
    • headaches (due to hypoxia and hypercarbia);
    • insomnia, sleep disturbancies, nightmares, confusion (due to hypoxia);
    • daytime sleepiness and irritability (due to lack of sleep).

Sleep apnoea of central origin may not be detected unless sleep surveillance is undertaken. During the day the voluntary action of respiratory and ancillary muscles may conceal this effect (2). Sleep apnoea is often associated with excessive snoring.

All these symptoms may be intermittent, often associated with overuse.

References:
1. Castle House Medical Research Group. The late effects of polio: A descriptive survey of the postpolio syndrome in British Columbia. Prepared for the Post Polio Awareness and Support Society of British Columbia, 1989.
2. Saltzstein RJ, Melvin JL. Abdominal distension as an indication of post-polio ventilatory insufficiency. Clinical note. Am J Phys Med Rehab 1988;85-6. [PubMed Abstract]

QUESTION 7:
IF YES - ARE THE SYMPTOMS DUE TO A COMBINATION OF CAUSES?

It is possible that a combination of underlying causes results in recurrent or chronic symptoms in people who previously had polio. Consider the following:

Useful reading:
1. Frustace SJ. Poliomyelitis: late and unusual sequelae. Am J Phys Med 1988;66:328-37. [PubMed Abstract]
2. Hodges DL, Kumar VN. Postpolio syndrome. Orthopaedic Review 1986;15:51-5. [PubMed Abstract]

QUESTION 8:
HOW SEVERE IS THE PRESENT CONDITION AND WHAT IS ITS RATE OF PROGRESSION>

Investigate the following:

A drawing may be useful to keep track of many symptoms, using different colours or codes for areas of paralysis, weakness and pain.

A pain scale or disability index provides a practical and reliable measure of discomfort and lifestyle impairment. The rating can also be used as a reference for further re-assessments.

Objective tests may be required to evaluate:

• lung function (spirometry, blood gases, sleep tests (1));
• dysphagia (videofluoroscopic swallowing exam (2));
• strength and endurance (Cybex dynamometer, test bike);
• extent of previous nerve destruction (EMG).

The progression of the condition can be assessed in the following manner:

References:
1. Hill R, Robbins AW, Messing R, Arora NS. Sleep apnea syndrome after poliomyelitis. Am Rev Respir Dis 1983;127:129-31 (abstract).
2. Coelho CA, Ferrento R. Dysphagia in postpolio sequelae: Report of three cases. Arch Phys Med Rehabil 1988;69:634-6.

© Copyright The Lincolnshire Post-Polio Network 1997 1998 1999 2000 2001 2002

This document comprises an index, foreword, introduction and seventeen other sections or subdocuments. Permission for printing copies is granted only on the basis that ALL sections are printed in their entirety and kept together as a single document.

Document preparation: Chris Salter, Original Think-tank, Cornwall, United Kingdom.
Primary Document Reference: <URL:http://www.ott.zynet.co.uk/polio/lincolnshire/library/australia/leop/sectn_12.html>
Alternate Document Reference: <URL:http://www.zynet.co.uk/ott/polio/lincolnshire/library/australia/leop/sectn_12.html>
Created: 7th July 1997
Last modification: 9th January 2002
Last information content change: 6th June 2000