Christine Uriadka, Physiotherapist
Post Polio Clinic, West Park Hospital, Toronto, Ontario.
Revised transcript of presentation given by the author
in Winnipeg, Canada April, 1997
Lincolnshire Post-Polio Library copy by kind permission of the author.
Janice Hartman
This article was originally written in 1997, but the nutrition information is still as valid today as it was then. Additional information on PPS Nutrition is now on my
website: http://www.reocities.com/arojann.geo/ppsnutrition.html
Janice Hartman, February 2001.
Let me first say that I am no expert here, but my training is in Nutrition and Education. I must caution all of you trying to lose weight to please do it sensibly. A low fat diet (with portion
control) and exercise (to whatever degree you can do) works the best. Jane Brody recommends in her Nutrition Book a diet high in fiber, but balanced with all foods. A weight loss of one to two
pounds a week is recommended. With fast weight loss muscle tissue is diminished, and even worse when you regain weight it is added as fat, not muscle tissue. Thus, yo-yo dieting where you lose -
gain, lose - gain is not recommended. If you fall into the category of morbidly obese, you should be under a doctor's care for more options.
Diet pills are dangerous. Protein diets are dangerous. Be very careful.
Seek out a knowledgeable doctor. A multivitamin might be advisable, if you can tolerate it. Megavitamins can be a problem and ought to only be attempted under a doctor's care. Some studies with
vitamin B-6 have proven mega doses of this vitamin can help certain rare disorders, but people who self treat with mega doses of B-6 risk severe NERVE damage. Be
cautious. Excesses of water soluble vitamins are also excreted from the body and sometimes only create a placebo effect.
FYI: Vitamins are either water soluble (8 B vitamins and C) or fat soluble (vitamins A, D, E, and K). Since the fat soluble are stored in the body, they can build up to toxic levels. The water
soluble vitamins are not generally stored and the excess are washed out of the body through urine or sweat. They need to be replaced daily.
Be aware of the salt you use in and on your foods. Salt is a combination of sodium and chloride (NaCl). Sodium (Na) occurs naturally in foods.
However, in natural unprocessed foods, sodium is low and phosphorus is high. In processed foods, they are generally high in sodium (or even salt) and low in phosphorus.
Try to eat foods in as close to their natural state as possible. Fresh fruits and vegetables (high in fiber), grains like oatmeal instead of processed sugar (or honey) ladened foods. Read labels:
for cereals look under Total Carbohydrates in Nutrition Facts, the Sugars should be 0 g (grams) to not more than 6 g. Also, change to lower fat (or low fat) dairy products. You can save many fat
calories by switching to a lower fat milk . If you drink whole milk switch to 2% , if your drinking 2% try 1%, etc. You still get all the calcium and added vit A and D in low fat. I don't
advocate raw meats, fish, as a natural food. Trim the visible fat, take the skin off the chicken and bake, don't fry whenever possible.
Vegetarianism may prove to be beneficial to some people. Just remember that you need to include other sources of protein if you eliminate meats entirely. Vegetarians can get protein if they eat
dairy or eggs. If not, protein is found in nuts and nut butters, beans and vegetables. There are web sites for vegetarian foods that are worth checking out.
I am not trying to add to the "well, what can we eat now?" syndrome. If your eating habits are terrible, just try to change a little at a time. If fresh fruit is too expensive (but look for
bargains) buy canned. Just try to read labels. Enjoy treats even if you are eating well. I like cookies, but generally make my own or buy low fat as treats (mine are better).
Use medications that work for you, but only try one at a time to see its effects. Use the lowest dosage that works. Be careful with drug interactions. Drugs have side effects depending on the
person. The question is: do the benefits outweigh the risks? Like nausea, does it go away? You decide if it is working for you.
I have been taking note of the many medications than can help PPS pain so I will know what I can try if my present meds don't work anymore. Hope no one is attempting to try them all, unless your
need is great and you have doctors advise. Henry has given very sound information on the use of low
dosages of anti-depressants that are helping some people. Keep an open mind, learn to hear what your body is trying to tell you, practice pacing yourself, and learn to say no.
Janice Hartman, Baltimore, Maryland, USA
jannhartman@juno.com
Credentials:
I am first and foremost the mother of three boys. Post Polio Survivor from 1953.
B.S.in Home Economics Education.
International Board Certified Lactation Consultant (IBCLC).
Former:
Home Economics Teacher.
Home Economist with PA State Cooperative Extension.
Ass't Dietitian.
Ass't Nutritionist with Woman, Infants, and Children Program (WIC).
Editorial Ass't for "Whole Foods for the Whole Family" Cookbook.
Lecturer at workshops for Family and Children Conferences for over 20 years.
Management of Post-Polio Symptoms
Now that I have outlined a general profile of a person experiencing the late effects of polio, I would like to go on to discuss some essential components of symptom management, primarily focusing
on the role of the physiotherapist. Before I continue, I would like to make two comments. First of all, you will notice that many of the management strategies intermesh, and can be difficult to
separate into mutually exclusive categories. For example, when a rollator walker is prescribed for a client to facilitate their ambulation, it is also contributing the additional benefits of
providing postural support, alleviating muscle fatigue, and minimizing mechanical stress on the joints, thus relieving pain. Secondly, I'd like to emphasize the point that there is also extensive
overlap between the roles of the different disciplines. To illustrate this idea, let's look at the example of a client who is having difficulty transferring in and out of their bathtub. The
occupational therapist may be involved in prescribing the specific bathroom equipment needed to ensure a safe and efficient transfer. The physiotherapist may focus on providing exercises to
strengthen particular muscles that are essential to the activity of transferring. The social worker may play a role in helping the client develop effective coping skills, so that they can adjust
to and accept the changes that they are facing, as well as directing the client in locating funding sources for the equipment that they need. In this manner, the roles of the different health
care clinicians very often complement and facilitate each other.
At this point, I will be describing six symptom management approaches for the post-polio population that particularly relate to physiotherapy. They include: exercise prescription, energy
conservation, correction of postural alignment, prescription of assistive devices such as braces and ambulation aids, pain management and client education.
Exercise Guidelines for the Post-Polio Population
Let's talk about exercise guidelines first. When prescribing exercise to an individual with a history of polio, the physiotherapist needs to consider the client's description of their fatigue,
pain, postural deformities, muscle imbalances, and previous surgical procedures. The therapist is challenged to find activities that help to prevent deconditioning and atrophy of the relatively
unaffected muscles that are underused, while at the same time avoiding the risk of placing additional demands on weaker muscles that are already overworked beyond their capacity. As I prescribe
exercise for the post-polio population, I generally have two goals in mind. The first goal is to improve the individual's cardiovascular conditioning. This serves to increase the overall
efficiency of muscle function and oxygen transport. As the energy cost of movement is decreased, a person is left with less fatigue, and a greater energy reserve to apply towards other
activities. The second goal of exercise prescription is to maximize the strength and endurance of specific muscles that are underused. As these muscles are strengthened, they can help to achieve
appropriate compensations in movement and posture. As a result, harmful compensations that lead to joint degeneration and pain are avoided.
Prescription of Cardiovascular Exercise
Recent literature published by researchers such as Owen and by Dean and Ross, indicates that a modified, low-intensity regime of aerobic conditioning exercise within the individual's fatigue
tolerance is beneficial in the post-polio population for maintaining or improving overall endurance and functional work capacity.
Dean and Ross feel that by optimizing both cardiovascular fitness and the biomechanical efficiency of movement, aerobic training is effective for post-polio clients in reducing muscle fatigue and
joint stresses. Rather than being singled out, use of the affected muscles is integrated into a more general whole-body activity. Therefore, the affected muscles are subjected to a lesser degree
of chronic overuse. For most of the post-polio clients that I see, I normally recommend low-resistance activities that are least likely to fatigue the compromised muscles. They include walking or
bicycling on a level surface, pedaling a stationary bicycle or arm ergometer set on a minimal tension, swimming, and performing gentle conditioning pool exercises. Regardless of the type of
cardiovascular activity that is prescribed, I always emphasize to a client who has had polio the importance of pacing. Because many post-polio individuals have typically conditioned themselves to
disregard any discomfort and to push through it, a lot of time is spent educating the client about how to recognize muscle fatigue, and how to listen to their bodies. Clients have to be taught to
be aware of indications of fatigue, such as muscle cramping or twitching, burning pain, diminished range of movement, and shaking or heaviness of the limb. As soon as they begin to experience any
of these symptoms, I direct the person to stop and rest for several minutes until the discomfort subsides, rather than continuing to force themselves through the exercise. Once the muscle gets
tired, it is generally not advantageous to continue the exercise, as the individual starts to do use compensatory movements and do the exercise incorrectly, causing it to be more detrimental than
beneficial. The general rule of thumb that I give to many of my clients is that if the discomfort persists after resting for 5 minutes, they should end their exercise session for the day. If
however, any indications of fatigue are alleviated by several minutes of resting, they can resume their activity, continuing as long as the exercise does not exacerbate any pain or muscle
cramping. In most situations, I encourage individuals to adhere to the generally recommended parameters for cardiovascular conditioning: 20-30 minutes of exercise, three times a week. If the
client has not previously been exercising regularly, it is advisable for them to begin with a shorter duration of 5-10 minutes, and to gradually progress the duration within their fatigue
tolerance. Spacing is equally essential in avoiding excessive overuse of the affected muscles. By scheduling the activity on alternate days, the individual allows their body ample rest time
between exercise sessions.
Please note that the exercise guidelines previously outlined represent a general approach. However, each person's exercise routine must be tailored to the specific individual, according to their
fatigue level, activity tolerance and to the extent and distribution of muscle weakness. Some people encountering the late effects of polio experience such debilitating fatigue, that the effort
involved in exercising renders a conditioning exercise program unfeasible and counterproductive. The exercise program for any polio survivor should be prescribed to meet their specific needs. It
is essential that the type, intensity, frequency and duration of exercise activity be modified appropriately to correspond with the individual's level of physical function. It is recommended that
the exercise program be re-evaluated on a regular basis.
Benefits of Aquatic Exercise
I would like to take a moment now to talk specifically about aquatic exercises. The benefits of pool exercises are many. Exercising in water gives one the opportunity to exercise in positions
that allow any particular movement to be either assisted, supported, or resisted by the buoyancy of water. Depending on the level of immersion, a person standing in water is required to support
only a portion of their total weight. This reduction of weight bearing dramatically decreases the mechanical stress placed on the lower limb joints. As well, the warmth of the water helps to
promote improved circulation and muscle relaxation. For these reasons, many post-polio clients, especially those who are minimally ambulatory, find that they are able to enjoy activities in the
water that they are not able to perform on land. I have encountered a number of people who have never considered exercising in a pool because they don't swim. There is a wide variety of pool
activities that can be suggested to these clients that do not involve swimming, such as aquafit exercises, walking or marching in the water, kicking or pedaling the legs.
Considerations regarding Aquatic Exercise
Before referring a client to a community aquatic exercise program, there are several factors that the therapist needs to consider. Because of their cold intolerance, post-polio individuals find
the temperature of many community pools uncomfortably cold. They may need to be referred to a therapeutic pool where the water temperature is kept within the range of 90-95 degrees Fahrenheit.
Accessibility of the pool is also a factor that needs to be considered. To this end, it helps to investigate the distance from the parking lot to the change room, and between the change room and
the pool. Does the pool provide a wheelchair that individuals can use to get to the pool? Can the client wear their brace to the pool deck? Are there stairs in the way? Does the pool have stairs
or a lift for entering the water? Is any assistance available at the poolside? Are any specific hours or programs offered for individuals with special needs? All of these issues can determine
whether a person would be able to and interested in participating in a pool exercise program.
Before referring a client to a hydrotherapy or aquafit program, the physiotherapist must be aware of any aspects of the individual's medical history that may be considered a contraindication or
precaution to pool exercise. Such conditions include unstable cardiac status, hypertension, open skin lesions, sensitivity to chlorine, seizures, and incontinence. The instructor of a community
pool exercise class would likely have limited knowledge about the late effects of polio and the exercise approach that is appropriate for this population. Therefore, it is important for the
referring therapist to act as an information resource for the instructor, perhaps even sending along some general literature or handout materials about the late effects of polio.
Prescription of Strengthening Exercises
Now that we have talked about aerobic conditioning, let's go on to discuss the use of resistive strengthening exercises for specific muscles. At present, prescribing aggressive strengthening
exercises for the post-polio population poses some unanswered questions. It has indeed been demonstrated that a progressive, high-intensity strengthening regime for specific muscles is effective
in maintaining or improving functional strength and endurance, as long as they do not increase the individual's level of discomfort. However, these exercises must be approached with caution.
Activities that are isolated to a particular affected muscle may bring about the detrimental effects of chronic overuse, particularly if training is done against maximal resistance. Such constant
excessive demands placed on partially denervated muscles may contribute to fatigue and promote overuse atrophy. I have personally maintained a relatively conservative approach to prescribing
strengthening exercise for my post-polio clients, particularly as they go on to do the exercises without regular supervision of a physiotherapist. Generally, I limit the exercises to isometric
and non-resisted activities, and I am careful to provide the client with the necessary education to enable them to safely modify their program. When performing more high-intensity resisted
exercises, I feel that it is advisable for the individual to be monitored regularly by a physiotherapist.
Prescription of Stretching Exercises
The last component of exercise prescription that I would like to touch upon is stretching. Because of their muscle imbalances and postural deformities, it is fairly common for a post-polio client
to develop tightness and shortening of certain trunk and lower extremity muscles, particularly if they are non-ambulatory. This muscle shortening further contributes to pain, joint instability,
and inefficiency of movement. In the post-polio population, hip and knee flexion contractures, as well as ankle plantarflexion deformity, are the most common to develop. It is usually appropriate
to prescribe specific stretches for localized joint contractures and muscle tightness. However, the therapist must be aware that in some situations a restriction in range may be functionally
useful in assisting mobility. For example, I have encountered a large number of clients whose ankle has been fused to minimize footdrop and facilitate their ambulation. In such cases, it would
obviously not be advisable to try to improve the range of motion of the joint. The approach to stretching for post-polio individuals needs to be gentle and slow. Because they tend to be so prone
to cramping if the muscle is overstretched, I direct my clients to stretch within the range where only a slight pulling is felt.
Energy Conservation
The next area of management that I would like to briefly speak about is energy conservation. In our Post-Polio Clinic, it is primarily within the occupational therapist's role to instruct a
client in appropriate energy conservation and pacing strategies. However, because energy conservation approaches are such an integral part of general lifestyle adjustments that are recommended
for this population, and because pacing is always incorporated into the client's exercise program and pain control strategies, energy conservation is one area that truly overlaps across all of
the disciplines. I'll just review some sample energy conservation techniques that are frequently recommended. One aspect of energy conservation involves scheduling. This includes such suggestions
as planning two 20-minute rest breaks during the day before the onset of fatigue, spreading activities out over the course of the day or the week, breaking up strenuous activities into smaller
components, and alternating between light and heavy tasks. Once a person is tired, it takes much longer to build up their energy reserve. Therefore, they need to take a break before their energy
supplies are depleted and they are running on empty. Next, it is important for the individual to modify activities that are particularly fatiguing. For example, strenuous activities such as
vacuuming or shoveling snow can be delegated to others. Arrangements can be made to have groceries delivered. Tasks that involve standing or walking should be limited in duration, and minimizing
any unnecessary use of stairs is encouraged. Proper positioning is also essential to energy conservation. A person should sit in a supportive chair with their arms supported to perform activities
whenever possible, maintaining correct posture. Arranging the workspace so that the working surface is at a comfortable height can be very helpful. Assistive devices also go a long way in making
activities less tiring. Such adaptive aids can include items such as tap turners, jar openers, stocking aids, barbecue tongs for removing clothes from the dryer, and a trolley for transporting
heavy loads. Perhaps the most difficult aspect of energy conservation can be setting priorities. It is not always easy to weed out nonessential activities and eliminate them to save energy for
activities that are more important to ones self-image, and this process can involve making some difficult choices. I also would like to include the comment that, for people who are working, it is
usually more challenging to follow energy conservation principles on the job. People don't have as much control over their environment, the pace that is expected, and scheduling of work hours and
rest breaks at their place of employment. Finding energy conservation strategies that can be implemented even at work can require a lot of resourcefulness, open-mindedness, and imagination.
Postural Correction
I'll go on now to speak about the third area of symptom management for post-polio individuals: that of postural correction. Asymmetrical postural alignment can most frequently be attributed to
muscle imbalance. As well as often being implicated in the etiology of pain, postural deformities can dramatically impact on an individual's energy efficiency during various activities. Again,
this is where postural exercises can play an important role. With respect to alignment of the trunk, the most common remarkable finding encountered in the post-polio population is spinal
scoliosis. The scoliosis that is noted may be a true fixed scoliosis that has developed due to weakness of the trunk and paraspinal muscles over one side of the body. More frequently, it is an
apparent scoliosis, associated with unequal height of the two halves of the pelvis, that is secondary to a leg length discrepancy. This type of scoliosis is correctable by placing a lift of the
appropriate height under the client's shorter leg to compensate for the leg length discrepancy. Post-polio individuals often also present with upper thoracic kyphosis and forward head posture,
with a compensatory hyperlordotic curve. With regards to the lower extremities, some of the postural malalignments that are frequently encountered include:
- genu valgus and recurvatum deformities
- pelvic obliquity
- uneven weight distribution between the limbs, and also through the soles of the feet
- calcaneal valgus or varus
Strategies to Correct Postural Alignment
I've already referred to some examples of interventions related to the posture of a post-polio client, that are aimed at relieving muscle tension and preventing unnecessary joint stresses. As I
have mentioned, the strategies that are recommended by the physiotherapist should include toning and/or stretching exercises for the paraspinal and abdominal muscles, as well as postural
exercises for the neck and shoulder girdle region. The exercises should always be accompanied by education regarding general back protection and the use of correct body mechanics. Some clients
may even benefit from being referred to an outpatient facility for a comprehensive back care program. Appropriate resting positions should be suggested for persons who have back pain related to
poor posture. Adaptive aids such as contoured therapeutic pillows, neck collars, and abdominal belts can be considered, to provide adequate postural support. In addition, the use of orthotics,
shoe lifts, or bracing to promote more symmetrical postural alignment is an option that is sometimes suggested as appropriate.
While we're on the topic of posture, I just want to again touch upon the issue of weight management. It is undeniable that excess weight and abdominal obesity do contribute to poor posture. Once
more, the benefits of aerobic exercise in promoting a higher metabolic rate and burning off calories come into play. Despite the client's residual muscle weakness or functional impairments, the
therapist can usually work together with the client to find some forms of cardiovascular conditioning activities that are feasible and enjoyable for them to do, which may facilitate weight loss.
To this end, some clients benefit from being referred to a dietitian for nutritional counseling.
Adaptive Equipment: Benefits of Orthotic Prescription
The fourth management strategy that I would like to address is that of adaptive equipment, specifically bracing and the use of ambulation aids. In the post-polio population, an orthosis can be
used during ambulation as a means of facilitating the client's mobility and reducing the effort involved in walking by compensating for muscle weakness. An orthosis may be recommended for the
purposes of ensuring correct position and stability of the joint, providing more equal weight distribution, and supporting the weaker leg, thereby indirectly also alleviating the load on the
stronger leg.
Factors Affecting Bracing Requirements
The physiotherapist may be called upon to provide input in establishing the client's need for a brace. Whether an individual requires an ankle-foot orthosis or a knee-ankle-foot orthosis is
determined by several factors, such as the degree and location of muscle weakness, gait deviations, extent of joint instability and alignment deformities, and their daily functional requirements.
In general, clients that demonstrate extensive instability of the knee joint and an overall lower extremity strength less than grade 2 tend to require a KAFO. However, the benefits and
disadvantages related to bracing need to be weighed in each specific situation. When considering prescription of an orthosis, one must take into account the weight of the brace, the risk of
aggravating lower back strain, whether the person has sufficient muscular function at the level of the hip to be able to maneuver the braced leg, and whether the client would have difficulty
managing stairs while wearing a brace. Having said that, I also want to draw your attention to the fact that braces are now being made of stronger compounds, allowing them to provide the
necessary support while being less bulky and conspicuous. Many clients are pleasantly surprised by how light and uncumbersome their orthosis is, compared to their earlier experiences. Certainly,
becoming accustomed to walking with a brace requires an adjustment period, during which modifications may need to be made to the brace. This process of getting used to the orthosis and learning
to use it should be approached gradually. The success of bracing is greatly influenced by the client's receptiveness to the orthosis, and willingness to endure the adjustment period.
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meningitis evolucionará con rigidez en la nuca y parálisis de los nervioscraneales.
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que por lo general ocurren sólo cuando las áreas son presionadas. (Algunas personas pueden tener menos que 11 puntos sensibles, pero
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cuando las áreas son presionadas. Ahora es reconocido que algunas personas con fibromialgia tendrán menos de 11 ofrecen / provocan puntos, pero tendrán la mayor parte de otros
síntomas sabidos(conocidos).
son presionados. Empujando con cuidado sobre estos puntos de gatillo específicos durante un examen causan la incomodidad o el dolor agudo.