• I~cliahlc Isokinctic Evaluation of Strength and Neuromuscular .'atigue to Determine the Effects of Pyridostigminc in Subjects with l'ost-poliomyelitis Syndrome Submitted by: Monica Roscmondc Kilfoil, BSc.PT. School of l'hysical & Occupational Therapy McGiII University, Montreal • Datc Submittcd: August, 1992 A thcsis submittcd to the Faculty of Graduate Studies and Rcscarch in partial fliifillmcnt of the rcquirements for the dcgree of Masters in Rehabilitation Science. © Monica R. Kilfoil, 1992 • ACKNO'VLEJ)(;EMENTS • This thesl~ \\ork L'ould not havl' hl'cn c01l1pkted without thl' .l'SISt.\IlU' nt 111\' advisors. Drs. DMt.,,1 St-PICITC, NR Cashman. DA TIOpn and pwr 1':' D.IIIIIl'l1h.1l1ll1. tu whol11 1 am grateful for t!lei! guidancc. utlllO:-.t patll'ncl', and ullsl'lli-.h 'Uppllll To aIl the subJccts who 1).\1 tiCIpah.'d 111 ll1y ~Iud it':-'. 1 .llll l'Ilt \1 cl" gl.ltcf III .l1ld wish to ex tend to you aIl a SlIlCCIC Ùlank.-yoll fOl yOlll tmlt' and l'Ill'I~!y 1 acknowledge ail fellow graduate ~tlldenh bUI. in paltllul.U. l'ailla Mattlll'\\'-'. Kathleen Nomlan and Sandy Chambers for thelr assistance in data rollel'tloll, alld ail ancillary activities related to surviving graduate school. 1 acknowledge the trell1endOllS sccretarial, Icchnical, and above ail hlll1lorolls support provided by Colleen, Joyce, Sylvain and FI ank • DEDICATION 1 dedicate this research thesis to rny family, in particulm ln Mattha, who plovl<kd me with unimaginable support and love during me pcriod of Illy graduatc stll(!Ics. " Resiliency is an important factor in livlll~ 'l'hl' wlfuls of lift' mav /)('lId Il.\, huI ifwe have resilience of spirit, they canllat breaA. U,\ To cofiragl'(I/(.\[Y .1I1(/[glll('11 agalll after our heads have been bowed by defl'al or dl.\apfJolflll/'/('lIf, 1.\ 1IU' .\'II/)I·t'II/(' It'sl 01 character. "1 1. Author unknown, from PClty, J. Applcs of Gold 19X2 P 71 C.R Glh~()11 COlllpany ('OII1I1':CIJUII • 0TATEMENT (W AllTIIOHSIIIP • 1 hel ehy LCI tif y that 1 am the malll author of ail the manuscripts ll1 this thesls. aho c1alll1 full re~p()Il~JhJllty for the content and style of aIl text\ not specifically indicated a\ heing "1l1 preparation" . • • ii TABLE OF CONTENTS • ACKNO\VLEJ)<;EMENTS DEIHCATH)N STATEMENT OF Al JTIIORSIIIP Il TARLE OF CONTENTS III LIST OF TARLES " LIST OF FIGURES ,'1 AHSTRACT AHRÉGf~ 1.0 INTROI>UCTION 2.0 REVIEW OF THE LITERATUIU: S 2.1 Poliomyelitis (Polio) S • 2.1 a) Etiology 7 2.1 b) Pathogenesis 7 2.1 c) Pathology X 2.2 Post-poliomyelitis Syndroffi:! (PI)S) lU 2.2 a) Definition and Epidemiology lU 2.2 b) Signs and symptoms 12 1) Psychological: 12 2) Systemic: 12 3) Respiratory: B 4) Neurological: B • iii 5) M U-'llllo.,helcfal: J.3 • 2.2 c) Efilllllgy 14 ( 1) Chronic polioviru-. infection 14 (2) Imrmmological mcchani~111 ]4 (3) Early agin~ or o"cruse 15 2.2 d) Pat ho~cne~is of IJPS ]8 2.2 c) (:Jinkal Managcment of PPS 24 2.2 n ('Iinical Mc •• .,urclllcnt of Fatigue: 27 23 Met ho<l-., I{CSlllfs, J)jscll~~iun 30 J.U i) Ar,jdl' 1 31 J.O ii) ArtÎclt' Il 44 4.0 ( '()nchrsion 62 • 5.0 Limitations and Rccmnmendations: 64 (dt Appendices 66 A) '''urld IIcalth Organizatiun (WHO) Polio Statistics Il) Consent Forms C) Medical Chart Review Form D) Visual Analog Scale of Pain 1 Clinical Status Questionnaire E) Borg Seille uf Perceived Exertion 7.0 References 67 • iv LIST OF TABLES • Article 1 Table 1. Il1tr.l-cla~ ... COli l'lai 1011 CncnlL'lt'llh lI( 'C) 101 the \1Ullllllll' \ ,lll,lllle ... pl peak. 100qul'. all~k ut IW,Ik. IOllllll', IUlque dl" t'lllPl'd ,II 1\\ Il 'P"I11Il .loi nt angle ... l() 7'), 1 0) 1.ldl,lIl"') hy tht' k.:Wl' C\Il'INlI' .lIld Ilnlll', aeras:-- fOUI te:-.I Vt'lIlClllt':-. Table 2. Intla-c1a:-.:-. ('ollt'laIIllIl (\lt'tlllICl1h (I( '( ') tOI Ihl' (luit (lI Il,' V,\ll,lhk\ 01 total work, aVL'ra~t' and 1l1.1'IIllUIll powel of the k.lll'" t':\ll'n"'lIl ... ,1IId flexor~, acro:-.\ four le\t Wllllllle<; Table 3. Intra-c1ass COllrlatlon ('oetfICH'I1I\ (1('(') tOI Ihl' llulllllllt' V:lIl,lhk 01 peak torque of the knl'l' e"lL'n~or:-- .lIld Ikxor" l'valll,llL'd al 10111 Il',1 velocitIes A L'Ompall'>llll nt 1dlahlllly aLl 0\\ Day ... 1 alld 2 \,,'1 \11\ 1la\'\ 2 and 3 Article 2 Table 1. Subject of Charactenstlls Table 2. Visual Analogue PaIll Score:-- • Table 3. Ratings of Perceiyrd Exertlon Table 4. Intra-Class Correlation (,()eflll'lent~. (1('(') lor the Olltl (li Ill' val J,lhll'~ of peak torque, and torque devcloped at Iwo :-,pt'rllil IOIllI .1Il}'It'~ (079, 1.05 radians) by the knee exten<;ors and llexor:-. A lOlllp.III\1l11 01 reliabilJty acro:--:-- Ddy\ 1 and 2 ver<;l!'> 1)ay\ l, 2 and ~ Table 5. Intra-Chlss Correlation Cocft IClent~ (1('(') 101 the OlltUlIl1I' Viii Jahlt-s of total contractile work and average power 01 Ihe km'(' l'xtl'n\()I~ and flexors. A comparison ot Ichahlltty aelO\~ U.ly:-' 1 and 2 V('I\II~ J )ay<, l, 2 and 3 . • y • A ,,'ic/t, 1 l'i~lIre 1. Torqlll'-ve!OLlty curvc,> 01 the knce cxtenllor and f1exor muscles II1 PPS "llhJl'Ch Fi~ure 2. A veragc power a!'> a 1unctfon of vclocity in PPS subject'\. Artide 2 Fi~lIre la. Total contractIle work of knee extensor muscles of PPS versus nonnal control !'>ub,CCh, rllc<I,>ured aeros!'> three test clay'> Fi~lIrl' 1 h. A Vl'I age power uf the knee ext'~nsor muscles of PPS ver!'>us nannal conll 01 "'lIblect~, I1lca ... urcd acro~'i three test day~. Figllre 2a. Ab,>olutc torque of the knce extellsor mu~c1es of PPS versus nonnal control ,>uhwct:-- dUfing the fatigue I1rotocol. Figllre 2b. NOImall/cd turque of the knee exten'ior muscles af PPS versus nonnal control :--uhWct 'i ch" II1g the fatIgue pmtocol • Figllre J:I. Total contI ,let rie work of the knee extensor muscles of PPS subJects whilc ()N pyr Idll,>tlgmIl1t' for four cI,tY'> versu ... OFF far one day. Figllre Jh. A ver age powl'r of knee extensor muscles of PPS subJects while ON pyndo!'>tlgrmnc for four days versus OFF for one day. Figure 4a. Angle-speCIfie torlJue of knee extensor musdes while PPS subjects were ON vcr :--us (>FF the pyl ICiOlltIgmIl1e. Representation of responders to the drug III term:-. of an effect on strength. Figure 4b. Angle-speci1ïe tOlque of knee extensor muscles while PPS subjects were ON versus OFf· the pyndostIgmine. Representation of single male rl'sponde) to the dllrg III tenm of fatlgability. Figure 5. Angle-specifie tOique of knee extensor muscles while PPS subjects were ON versu:-- OFF the pyndostigmine. Representation of non-responders to the <il lIg . • vi ABSTHACT • T",o .. ubJl"ct gwup", :-.t'Vl"l1 PPS (4 malc:-., -' Iem,lIe,,) and 1." Illlllll,tllllll!llll-; (1) females, 6 males) welt' matched on the ha\ls of age, IWlght and wl'l!!h! and pal!lllp.I!t'd in this stucty. Three repeatl'd meaSlIll'lllellls weIl' cOlldul ted tll t'vaIUal\' Ihl' ll'lrahllllV (lI isokinetic measurement of strength (at 4 veloc!tle:-.) and fatlgahrllly (~') Il'llplPlal contractions at 3.14 rad" S-I) Data from t",o suhsequent !t'sI day:-. \WIC u\l'd l(lev,tlualt' the fatIgue responses of the PPS suhJect:-. whlle ON 01 OFF pyrido"llgllllIH' Si/'nilil alli st! ength ctlfferences weI e ~een hetween the 1wo gInUp:-', hnwl'vl'I Ihelt' wa\ IlO Ilh\t'I vcd difference 111 the 1 ate of ckvel op Illl' III 01 LltlgUl' Rl'Ilahrllly 01 "'Ill'Ilglh \\',1\ d\'I\\()I\..,II:llcd for the knee exlensor:-. and flexOl:-' 01 Ihe PPS \uhll'L"I\ allci Ihll'l' l\1II\t', \l11Vl' Inl da v... Fatigabihty of thc knee extensors 111 J>J>S subll'CIS could hl' Il,,,led Il'II,l Illy allt'l 1hic\' le\1 days but more lime would be reqUlred for rchable performalLl' 01 the hUel' lIl'xOIS • Reliability of strength and fatigabihty wa:-. :-.ecn 10r hoth the knet.' extensO! and IkxOlS ni the nonnal controls after only twC! con~eclltlve tl'~( days. A hl'Iwltclal d'kcl 01 IIll' dlIIg on fatigability was not seen in the three fcmale PPS subfccts, huI wa:-. c!e\llon<,llaled III Ollt' male subject. The drug appeared to have a hencflclal clfec! on strcnglh in Ille relllallllli/' three male subjects. • • ('l'tll: {-(ude utdl..,e deux groupe~ dc su/eh, :-.cpt ~uJ('t:-. ayant le SPP (4 homme~, 3 kIlIIllC..,) l't J) LontrÔJe.., normaux (l) femmc.." 6 hOl11me<;) comparable.., en âge, grandeur et pOld.., 'l'roi'i lépétitIOm cIe.., mc~ures ont été faite\ pour évaluer la reprodlllsihilité des ll1e~un.:~ Isoklllé!1411eS de force (à 4 vitesses angulaires) et de fatIgabilité (25 contractions altl:rnatlves à 3.14 rad.s- '). Les donnés de deux JOUI~ de test suhséquents ont été utilisées pOlU évalucr les répon:-.e ..., de fatIgue de:-. ~uleh PPS alor~ qu'ils prenaient du PYIlc!O:-'IIJ!I11IIlt' ou Ilon. De'i (lJfft~rellle\ ~lgnitlcatlVC\ ont été oh\ervée~ au nIveau de la lo/Cl' l'IIIle k:-. deux gJOupe.., l'OUI ce qui e:-.t du taux de dévéloppement de la fatigue, !oUldOlS, aucune dIfférence n'a été obtenue. La reprodulslbilité de la force a été c!{-montlée pmll 1(':-.