('''PPS''') is a condition that affects survivors of
Poliomyelitis , a
Viral Infection of the
Nervous System , after recovery from an initial paralytic attack of the virus. Typically the symptoms appear 20-40 years after the original infection, at an age of 35 to 60. Symptoms include new or increased
Muscular Weakness ,
Pain in the
Muscle s, and
Fatigue .
1
The precise mechanism that causes post-polio syndrome is unknown. It shares many features in common with
Myalgic Encephalomyelitis , a form of
Chronic Fatigue Syndrome that is apparently caused by viral infections, but unlike those disorders it tends to be progressive, and can cause tangible loss of muscle strength.
Treatment generally is limited to supportive measures, primarily
Leg Braces and energy-saving devices such as powered wheelchairs, plus pain relievers, sleep aids, etc.
Diagnosis of post-polio syndrome can be difficult, since the symptoms are hard to separate from the original symptoms of polio and from the normal infirmities of
Aging . There is no laboratory test for post-polio syndrome, nor is there any other specific diagnostic, and diagnosis is usually a "diagnosis of exclusion" whereby other possible causes of the symptoms are eliminated.
2
PPS may be difficult to diagnose in some because it is hard to determine what component of a neuromuscular deficit is old and what is new: Neurological examination aided by other laboratory studies can help to exclude all other possible diagnoses. Objective assessment of muscle strength in PPS patients may not be easy. Changes in muscle strength are determined in specific muscle groups sing various muscle scales which
Quantify strength, such as the
Medical Research Council (MRC) scale.
Magnetic Resonance Imaging (MRI),
Neuroimaging , and
Electrophysiological studies, muscle
Biopsies , or
Spinal Fluid Analysis may also be used in establishing a PPS diagnosis.
In general, PPS is not life-threatening. The only exception is in patients left with severe residual respiratory difficulties, who may experience new severe respiratory impairment. Studies have proven that, compared to control populations, PPS patients lack any elevation of
Antibodies against the
Poliovirus , and because no poliovirus is excreted in the feces, it is not considered a recurrence of the original polio. Further, there is no evidence that the poliovirus can cause a persistent infection in humans. PPS can be confused with
Amyotrophic Lateral Sclerosis (ALS), which progressively weakens muscles. PPS patients do not have an elevated risk of ALS.
Symptoms include new or increased
Muscular Weakness ,
Pain in the
Muscle s, and
Fatigue .
3 Fatigue is often the most disabling symptom, as often even slight exertion can produce disabling fatigue and also increase other symptoms.
4
Some post-polio patients report having
Memory problems, or various other
Cognitive difficulties that are difficult to distinguish from normal aging. Some physicians have suspected that post-polio patients have an increased sensitivity to
Anesthetic s, but rigorous work on the subject remains to be done. Weight gain is also a frequently noted symptom, though it is hard to tell if this is due to the disorder directly or due to the decreased level of physical activity that usually accompanies the disorder.
Several theories have been proposed to explain post-polio symptoms. One theory of the mechanism behind the disorder is that it is due to "neural fatigue" from overworked
Neuron s. The original polio infection generally results in the death of a substantial fraction of the
Motor Neuron s controlling
Skeletal Muscle s, and the theory is that the remaining neurons are thus overworked and eventually wear out.
Another theory holds that the original viral infection damages portions of the lower
Brain , possibly including the
Thalamus and
Hypothalamus . This somehow upsets the hormones that control muscle metabolism, and the result is a
Metabolic Disorder similar to
Mitochondrial Disorder that causes muscle pain and injury (via
Rhabdomyolysis ) and also causes the fatigue. Some also believe that the original polio caused the
Atrophy ing of some muscles and as the person ages the weakness caused by loss of muscle mass due to aging is accelerated due to the person starting off with less muscle. It will likely turn out that post-polio symptoms are due to some combination of mechanisms.
The most widely accepted theory is the "neural fatigue" one.
Motor Neuron fibers were originally damaged by the polio virus and were subsequently over-stressed because too few surviving neurons activated too many muscles. Eventually these neurons become fatigued and die, leading to the slowly advancing loss of muscle function that is typical of post-polio. This scenario may be accelerated by the fall-off in production of
Nerve Growth Factor (NGF) that occurs with
Menopause /
Andropause .
This theory assumes that the major symptoms of PPS are a result of some interference with the action of
Mitochondria in the muscles and possibly the nerves. Failure of the mitochondria to produce sufficient energy would result in the muscle pain typical of PPS, and would, over time, cause muscle death (
Rhabdomyolysis ) due to exerting the muscle beyond its ability to recover. The cause of this interference with mitochondrial action is presumably a change in the body's
Hormone balance, as mediated by the
Hypothalamus and other lower
Brain areas that control hormones (and which were, presumably, damaged by the original polio virus infection). As with the ''neural fatigue'' theory, menopause/andropause accelerates the process, though this time by most likely disrupting the
NOTCH Pathway that controls cell differentiation and damage repair.
One significant argument in favor of the mitochondrial disruption theory is that it explains the fatigue and
Cognitive difficulties ("brain fog") symptoms that usually accompany post-polio better than the neural fatigue theory does.
Damage to the
Reticular Activating System and related areas such as the
Thalamus can also produce most of the fatigue, "brain fog", and
Dysautonomia symptoms of post-polio, and may be able to cause hormonal changes that result in progressive muscle weakness.
Post-mortem Examination s of polio patients have shown damage to these areas, and some PPS patients show lesions in these areas when examined by MRI. Many authorities believe that these areas are damaged by the initial polio infection, either as a direct result of the polio virus, or due to an
Autoimmune reaction following the polio infection.
One problem with this theory, though, is that it doesn't easily explain the delayed onset of PPS. It may be that this theory needs to be combined with one of the others to explain delayed onset.
The stresses placed on nerves, muscles, and joints in a polio survivor are in many cases several times those experienced by other people. Problems with
Gait , in particular, can greatly over-stress joints and the surviving muscles, and the polio survivor is also likely to compensate for weakened arms by jerking more when lifting/pulling something. Over time (and again with menopause/andropause), this results in fatigue and damage.
An early theory stated that PPS is caused by reactivation of latent polio virus in the body, similar to the way that
Shingles is a reactivation of the
Chicken Pox virus. This theory has been discredited by laboratory studies that show no active polio virus in the body.
Treatment for post-polio is primarily
Palliative , as no reliable therapy to reverse symptoms is known. Palliative treatment includes:
Very often fatigue is the most disabling symptom of PPS, and many of those with the disease have discovered that by carefully managing energy expenditure they can prevent or reduce the worst fatigue episodes. Further, for many this "energy management" approach appears to reduce pain. Though most authorities agree that rest is an important component of post-polio treatment, there is significant disagreement as to how much rest is necessary. Some hold that the best approach is to expend the absolute minimum amount of energy necessary to enjoy a reasonable lifestyle, while others feel that there is some threshold below which energy conservation is not helpful and may in fact be harmful (due to the general effects caused by lack of exercise).
Leg Braces and other
Orthotics can reduce the stress on joints and, in some cases, muscles, and so may slow the progression of joint and muscle damage related to PPS. However, some authorities feel that many PPS patients rely on such items too much and for too long when they should be graduating to a wheelchair.
Wheelchair s (particularly powered wheelchairs) and "scooters" (small battery-powered vehicles) are useful both to conserve energy and to reduce the stress on weakened joints and muscles. Non-powered wheelchairs, however, are not generally recommended since they place too much stress on arm muscles and joints and may take too much energy to operate. In some cases even the scooters are not recommended since operating the "tiller" of the typical scooter can be tiring to arm muscles. A
Standing Frame can be used in conjunction with the wheelchair to provide alternative positioning and prevent secondary complications.
Post-polio syndrome often causes significant levels of pain, sometimes in specific muscles or joints, and sometimes body-wide. Various forms of
Narcotic and non-narcotic
Pain-reliever s,
Muscle Relaxant s,
Tranquilizer s, and sleep medications may help to deal with the pain and related sleep problems. In some cases surgery can be used to repair joint deformities, or to fuse joints (as in the back or ankle) that have become too weak.
Very few non-palliative treatments for post-polio syndrome have shown any promise, and none have been subjected to any sort of rigorous clinical testing. There are, however, a few treatments that have developed some "following" in the PPS community:
The
Amino Acid ,
L-carnitine has several functions in the body, one of the most important being the transport of
Fatty Acid s into the mitochondria. Researchers in Australia have had some success using doses of several grams per day.
Coenzyme Q10 is a general
Antioxidant , but it also plays a critical role in the function of the mitochondria, transporting electrons between the "complexes" that participate in the energy conversion cycle. A shortage of CoQ10 can cause the fatigue and muscle pain much like that experienced with PPS. Some PPS patients have reported significant improvements in their symptoms when taking several hundred milligrams of CoQ10 per day.
The
Pentose sugar
D-
Ribose is the "R" in
RNA and a critical component of
DNA , RNA, and
Enzyme s. It is also a component of
ATP , the energy-transporting molecule produced by the mitochondria. A shortage of
D-ribose can produce fatigue and muscle pain. Some PPS patients have reported significant improvement in pain and fatigue symptoms when taking on the order of 20 grams/day of
D-ribose.
- Maynard, F.M., & Headley, J.H. (Eds.) (1999). ''Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors.'' Saint Louis, MO: GINI (now Post-Polio Health International). Information on 90 post-polio topics; a compilation of the research and experience of over 40 experts.
- March of Dimes Birth Defects Foundation. (1999). ''Identifying Best Practices in Diagnosis & Care.'' Warm Springs, GA: March of Dimes International Conference on Post-Polio Syndrome
- Nollet F. "Perceived health and physical functioning in postpoliomyelitis syndrome". Vrije Universiteit Amsterdam, 2002.
- Nollet, F. "Post-polio syndrome". Orphanet Ecyclopaedia, 2003
- Silver, Julie K. (2001). ''Post-Polio Syndrome: A Guide for Polio Survivors and Their Families.'' New Haven: Yale University Press. (Dr. Silver is Medical Director, Spaulding-Framingham Outpatient Center; Assistant Professor, Department of Physical Medicine and Rehabilitation, Harvard Medical School.)
