Post-Polio Syndrome

Post-polio syndrome

unBy Susanra A. LaRocco, PhD, MBA,ve RN ling

MRS. M, 69, IS ADMITTED to the unit with bilateral pneumonia. As you review her health history, you note that she had polio in 1951 and was diagnosed with 2.0 post-polio syndrome (PPS) in 1998. You’ve never provided care for anyone who had ANCC polio; none of the nurses on your unit have either. As you assist Mrs. M into bed, CONTACT HOURS you wonder what PPS is all about and how it will affect patient care. Polio survivors can experience effects of the disease many years after they have recovered. Collectively known as PPS, characteristic signs and symptoms—progressive weakness, fatigue, myalgia, arthralgia, and muscle atrophy—can occur decades after the polio diagnosis. As survivors of polio age, you’re likely to see more of them in acute care hospitals, both for problems related to PPS and for unrelated illnesses such as cardiac problems and complications of diabetes. This article reviews the basics of PPS, how it affects patients later in life, and what you can do to provide them with the most appropriate, up-to-date care.

Dangerous disease PPS affects some patients with a history of poliomyelitis, a highly infectious viral disease usually spread by contact with the stool or nasal/oral secretions of an infected person.1 Initially, most patients infected with polio were asymptomatic or experienced flulike symptoms; most recovered without further complications and developed lifelong immunity. Less than 1% developed paralysis.1 Although about 95% of patients infected with the polio virus were asymptomatic or developed only mild symptoms, they could still spread the disease. Of patients who developed paralytic polio, 5% to 10% died from respiratory paralysis.1 But most of them sur- vived, so you’re likely to see patients with PPS in your facility. Before the Salk inactivated polio vaccine was used routinely in 1956, polio was the most feared childhood disease in the United States. In 1952, more than 21,000 paralytic cases were reported; after widespread immunization, only 61 cases were reported in 1965.1 The oral polio vaccine, developed by Albert Sabin in the late 1950s, was commonly used during the 1960s because it was easier to administer. Since then, however, it’s been associated with a small incidence of vaccine-associated paralytic polio and hasn’t been used in the United States for 10 years.1

Long-term effects PPS typically develops 20 to 40 years after the onset of acute polio.2 It’s not contagious and usually not life-threatening.3 For some patients, weakness of respiratory muscles due to

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. PPS can impair ventilation, and • myalgia • a nonfatiguing exercise program weakness of muscles involved in • arthralgia • psychologic interventions to im- swallowing can lead to dysphagia, • muscle atrophy prove body image and coping. aspiration, and aspiration pneumonia.3 • gait disturbances No one knows exactly how many • sleep disturbances, including sleep Psychologic considerations Americans have PPS. The National apnea Because PPS signs and symptoms Center for Health Statistics estimates • respiratory problems are often mistaken for other prob- that the number of polio survivors • difficulty swallowing lems, patients may suffer significant may exceed 440,000, and that 25% • cold intolerance.2,6,7 emotional distress from a misdiag- to 60% of them may have PPS.3 It’s Muscle weakness may affect mus- nosis of another neurologic disease, likely that many cases are undiag- cles that were severely affected by such as amyotrophic lateral sclero- nosed, with their signs and symp- polio and muscles that were seem- sis, or a lack of diagnosis in light of toms misinterpreted as part of the ingly unaffected.6 Some patients also the vagueness of the symptoms. You normal aging process. develop visible muscle atrophy. Re- can help patients to cope by encour- The cause of PPS is unknown.3 spiratory problems are most com- aging them to verbalize their concerns A generally accepted theory is that mon in patients who had difficulty and assuring them that there was neurons begin to degenerate during breathing during the acute illness. nothing that could have been done the acute polio attack, resulting in The signs and symptoms of PPS to prevent PPS. a lack of innervation to the muscle. progress slowly, often with periods Opioids, anesthetics, sedatives, The surviving nerve cells in the of stability followed by further pro- and other medications that depress brainstem and spinal cord grow gression. Myalgia is often described the respiratory system should be sprouts to compensate for the loss as a deep, aching pain.7 used with caution in patients with (reinnervation). This burdens the Diagnosis of PPS is called a diagnosis PPS because they may be more remaining nerve cells with an in- of exclusion because signs and symp- susceptible to them. creased workload as they supply toms can indicate various diseases, more muscle fibers than normal. including osteoarthritis, fibromyalgia, Caring for Mrs. M These sprouts may degenerate over or multiple sclerosis.8 Depression can Upon admission, Mrs. M is withdrawn time because they become over- also be associated with fatigue and and prefers to be left alone. When she whelmed, eventually causing a new, must be ruled out or treated.3 See does speak, she says she’s discouraged late-onset weakness, or PPS.4 Other Diagnosing PPS for a list of criteria and fearful. She’s been feeling very theories include a reactivation of that can help in diagnosis. tired lately and is having difficulty persistent poliovirus in the nervous swallowing. She knows that these are system and inflammation and induc- Managing PPS clinical manifestations of PPS. You tion of autoimmunity.5 Although PPS isn’t curable, many acknowledge her concerns and assure treatment strategies can help pa- her that you’ll work with her and Recognizing PPS tients manage signs and symptoms. the rest of the healthcare team to Common signs and symptoms of Because each patient presents differ- address and manage her signs and PPS include: ently, provide an individualized plan symptoms. • progressive weakness of care for each patient.4 The most For patients such as Mrs. M, • fatigue effective care is provided by a multi- energy conservation is of primary disciplinary team that includes a importance. Make sure your patients neurologist, a physiatrist, physical with PPS receive uninterrupted rest 5 Diagnosing PPS and occupational therapists, and periods throughout the day. Limit The following criteria can help estab- nurses with expertise in rehabilita- visits from therapists, social workers, lish a diagnosis of PPS: tion and the psychiatric aspects of case managers, dietary workers, and • a prior episode of poliomyelitis with long-term disability. housekeeping personnel. Ask them evidence of residual motor neuron loss Care for the patient with PPS to group their activities so patients • a period of at least 15 years after the focuses on alleviating or mitigating can have several uninterrupted rest acute onset of polio with neurologic specific signs and symptoms. Inter- periods. Visitors can also be tiring; and functional stability ventions include: discuss this with your patients and • a gradual (or rarely abrupt) onset of • energy conservation strategies to encourage visitors to limit the length new weakness and abnormal mus- reduce fatigue of their visits. Make sure patients cle fatigability that persists for at • pain management take rest periods before and after least 1 year • strengthening exercises and appro- therapy so they can participate fully. • exclusion of other medical conditions that cause similar symptoms. priate assistive devices to improve Watch for nonverbal cues that mobility patients are experiencing pain and

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. decrease stress on their joints and receive. Knowing they have this syn- On the Web improve their mobility. drome and taking the proper steps to Post-Polio Health International: Swallowing difficulties are com- manage their signs and symptoms www.post-polio.org mon in patients with PPS and can will help keep PPS under control. ■ Post-Polio Syndrome Central: lead to aspiration pneumonia. Ob- www.skally.net/ppsc tain an evaluation by a speech thera- REFERENCES pist, who will teach them techniques 1. Centers for Disease Control and Prevention. Polio disease—questions and answers. http://www. to minimize aspiration, such as cdc.gov/vaccines/vpd-vac/polio/dis-faqs.htm. encourage them to determine a pain turning the head to one side while 2. Mayo Clinic. Post-polio syndrome. http://www. management goal and plan that’s swallowing. Food consistency may mayoclinic.com/health/post-polio-syndrome/ DS00494. acceptable to them. Therapeutic need to be modified for safety. Help 3. Postpolio syndrome fact sheet. National Institute interventions include nonsteroidal patients sit fully upright for meals, of Neurological Disorders and Stroke. http://www. anti-inflammatory drugs and acet- preferably out of bed. ninds.nih.gov/disorders/post_polio/detail_post_ polio.htm?css=print. aminophen, as well as massage, re- Some patients with PPS develop 4. Headley JL. What is post-polio syndrome? http:// laxation, and applications of cold sleep apnea, so they should be evalu- www.post-polio.org/edu/pps.html. and heat.7 These interventions will ated for this disorder. If diagnosed, 5. Simionescu L, Jubelt B. UpToDate: post-polio syndrome. http://www.uptodate.com/patients/ let them participate more thoroughly it’s treated with continuous or bilevel content/topic.do?topicKey=~WjhtvOIE.0lh. in therapy sessions and improve positive airway pressure ventilation. 6. Pountney D. Identifying and managing post- their overall functioning. Advise Support groups can help patients polio syndrome. Br J Neurosci Nurs. 2009;5(11): 508-510. patients to regularly perform the with PPS feel they’re not alone. For 7. Gevirtz C. Managing postpolio syndrome pain. strengthening exercises prescribed patients who have limited mobility Nursing. 2006;36(12 pt 1):17. by the physical therapist. or live in rural areas, online groups 8. Wise HH. Effective intervention strategies for management of impaired posture and fatigue with Assistive devices such as walkers and chat rooms may allow them to post-polio syndrome: a case report. Physiother and canes or orthotics such as connect with others. (See On the Theory Pract. 2006;22(5):279-287. braces and splints can help decrease Web for resources.) Susan A. LaRocco is a professor at Curry College in mechanical stress on joints. Some Milton, Mass. patients may benefit from installing Know your syndrome The author has discolosed that she has no financial a chair lift in their homes. Encourage PPS can complicate comorbidities relationships pertaining to this article. obese patients to lose weight to and affect the care your patients DOI-10.1097/01.NURSE.0000392917.84035.be