Post Polio Syndrome - Case Study

Original Editor - Matthew Kowalczyk Top Contributors - Matthew Kowalczyk, Aaron Hart, Christopher Siemaszko, Justin Achat, Kim Jackson and Nupur Smit Shah

Intervention

Gait Aid Fitting

Our patient has indicated that he would rather not use a cane due to the associated stigma of being perceived as “old”, however, we will need to convince him to use it on a temporary basis to improve his functional abilities by allowing him to walk faster and decrease his risk of falling given his recent perceived instability. Canes have been recommended for PPS to maximize mobility and reduce fatigue (Lo and Robinson, 2018), especially considering our patient likely experiences a higher cognitive demand for maintaining his balance which likely contributes to his fatigue. Our long-term goal for our patient is to limit the use of the cane only when ambulating longer distances such as for 15 minutes or longer, or in unfamiliar environments with difficult terrain or open environments including navigating around other people in crowded shopping malls 6 months into our physiotherapy treatment. In the short-term, we will encourage the use of the cane as much as possible given the initial weakness of the right knee extensors, right ankle dorsiflexors, and mild balance impairment.

Using an AFO for the first two months of our therapy with our patient will also be important to compensate for his weak ankle dorsiflexion in his right leg. Our goal is to increase strength in his right ankle dorsiflexor from a 3/5 at baseline to 4/5 in two months. Thus, during time in between the AFO will be helpful in compensating and improving gait speed and overall balance by preventing our patient from tripping over his toes (Lo and Robinson, 2018).

Hydrotherapy

An excellent way to attenuate the effect of fatigue from prolonged standing while allowing increased energy to be focused on performing the stretching, strengthening and aerobic fitness exercises is using water (Howard, 2005). Water based activities have been shown to decrease fatigue and improve exercise endurance (Davidson et al, 2009). Furthermore, exercising in warm water is effective at reducing the pain experienced for patients with post-polio syndrome (Howard, 2005; Li Hi Shing et al, 2019). As such, once a week our patient will attend an aquafit session at his local community centre for 20 minutes, with a 5 minute break in the middle of the session to allow time for rest to reduce fatigue. We will reserve time once a week during our PT sessions to discuss how he is tolerating the water based exercise and adjust the work and rest times accordingly. The goal will be to increase the time of aquafit training by 5 minutes each week, eventually reaching a level where our patient can attend an entire aquafit session (typically 50 minutes) with two short breaks during the session by the 6 month follow-up. Our long-term goal is to leave our patient with this activity as a new tool to enable him to maintain his aerobic capacity over his lifespan.

Strength Training

Based on the patients reported levels of fatigue as well as weakness noted in the right knee extensors and right ankle dorsiflexors,  a measured approach to lower body strengthening should be used in treatment planning. All treatment will take place within a clinic setting, and efforts will be made to have the patient perform these exercises in a context that’s significant to the patient. Evidence suggests that  performing sub-maximal bouts of strength exercises should be done to avoid excessive fatigue in post-polio patients (lo & robinson 2018; Li Hi Shing, 2019). As a result, general guideline parameters for exercise prescription will be kept at lower intensities and at fewer repetitions per set, but more sets. We will begin with isometric knee extension and ankle dorsiflexion (5 secs x 2-3 sets). If well tolerated, treatment will progress  to gravity-eliminated isotonic single limb exercises  including both concentric and eccentric contractions (5-6 reps at 2-3 sets) and eventually working towards functional exercises that will be performed in full weight bearing (that may or may not include the use of an assistive device). Aside from improving levels of strength, the patient’s goals related to participation in being a coach for his son’s soccer team will be important to keep in mind throughout the rehabilitation process. As such, we will incorporate sessions of passing a ball back and forth once a week or as tolerated, beginning with 2 minutes,  increasing weekly by 1 minute, in order to keep our patient engaged and performing activities relevant to his hobbies.

Additionally exercises for right rotator cuff strengthening and range of motion will also be prescribed to address shoulder pain. By strengthening his rotator cuff, we may be able to positively affect limitations to his participation at work as a substitute teacher, as well as with IADLS (i.e. his woodworking hobby). The same stepwise approach to stretching will be taken, beginning with isometric exercises and gradually working towards functional activities (reaching overhead) without pain.

Aerobic Exercise

The specific parameters regarding aerobic exercises are not well documented in the literature and there is conflicting evidence regarding the intensity of aerobic exercise beneficial to PPS patients, though a recent study notes that high-intensity aerobic exercise should be avoided (Li Hi Shing et al, 2019). It has been suggested to perform aerobic training using large muscle groups less affected by the effects of PPS (Lo and Robinson, 2018), and in the case of our patient his lower limbs are more affected than the upper limbs. Thus, aerobic training may involve the use of  an arm ergometer, modified rowing equipment, or functional exercises that are closely related to his hobby of woodworking. Similarly to the prescribed intensities for his strength training exercises, sub-maximal efforts will be encouraged in an effort to avoid excessive fatigue (Lo& Robinson 2018). Training a muscle group that is involved in ADLs, in the case of our patient his hobby of woodworking, helping put dishes away to overhead cupboards at home, and writing on an overhead board at work in his classroom, will allow him to maintain the training benefits of our aerobic exercises (Lo and Robinson, 2018). Effort will be measured using the RPE scale and will target a score of 12/20 as RPE is a reliable measure of intensity (lo and Robinson, 2018). In addition to upper extremity based aerobic activity, we will aim to incorporate a graded walking exercise program to this patient's home exercise routine. A hypothetical starting point  of two 5-minute bouts per day could be prescribed, depending on his tolerance and fatigue. Progress will also be tracked using the 6MWT to evaluate improvements in aerobic capacity and walking tolerance.  Finally, to address our patient’s functional goal of standing for 30 minutes while woodworking by two months of treatment, we will introduce a graded activity plan that will involve weekly incremental increases in his continue standing time while woodworking in his shed twice a week. He will start with standing for 10 minutes, and adding 2 minutes of standing time every week until he can achieve 30 minutes of standing time.

Education

An important component in establishing our patient’s ability to self-manage his pain and fatigue is to educate him on the nature of post-polio syndrome. We will explain that the condition involves a slow progression of muscle weakness that may be attenuated with regular exercise at non-fatiguing levels, and that avoiding overexertion will be crucial to avoid muscle damage and limit functional disability (Lo and Robinson, 2018). Accordingly, we will need to equip our patient with some specific tools to structure his daily life to balance his functional demands and the nature of the PPS. One such tool is pacing, which involves scheduling time for rest throughout the day, and during activities such as prolonged standing or walking (Lo and Robinson, 2018). Another method to managing fatigue associated with PPS is alternating activities that involve different muscle groups and energy requirements every 15-20 minutes (Lo and Robinson, 2018). This will allow our patient to perform a specific activity without experiencing fatigue, and alternate between the activities, until the required daily tasks are complete (Lo and Robinson, 2018). For example, for 15 minutes our patient may stock the shelves in the kitchen with plates from the sink, alternating to performing standing woodworking for another 15 minutes, and for 15 minutes walking around his house and dusting, with a 15 minute break allocated for watching the news on the television. Likewise at work in the school, our patient can structure his lesson by allocating 15 minutes to writing on the board and teaching the class directly, followed by 15 minutes of independent study or working through problems, followed by 15 minutes of student presentations, as an example. Overall, fatigue management through these strategies will be important in limiting functional disability and attenuating the negative effects of PPS.

Outcome

Overall our patient was able to make significant impacts on key indicators including fatigue, levels of pain and disability, and improvements in upper and lower extremity strength.

Using a graded approach for exercise intervention,the patient was able to double his standing tolerance from 10 minutes to 30 minutes after 6 months. Additionally, the walking program increased his overall walking speed as indicated by significant improvements in the Timed Up and Go test (decrease from 18 seconds to 11 seconds, MCID 3.4 seconds (Gautschi, 2016). A large part of this success can be attributed to the patients proficiency in using the prescribed assistive devices, as he was able to graduate from the AFO to using the cane for longer distances  after the first 8 weeks of treatment. To date, the patient now reports not having to rely on the cane when ambulating short distances around the house or when navigating his property. Moreover, his ABC score improved from a 40.62% to a 12%, which is a clinically significant improvement in his balance based on the MCID score of 18.5 (Beauchamp et al, 2016). Regarding strength improvements, we were able to achieve success in progressing the right knee extensors from 3- to 4/5, and right dorsiflexors  from 3 to ⅘ . The shoulder strengthening interventions were successful in both decreasing reported levels of pain (as noted from a decrease in VAS from 6-2/10) as well as an overall decrease in reported levels of disability in the right shoulder (as noted from a significant decrease in DASH scores from 75 to 10/100, considering the MCID is 10.83 (Franchignoni et al, 2014). After regularly attending aquafit sessions for 6 months, the patient had reported being able to perform the recommended exercises for 25 minutes before needing to stop for a rest, in addition to reporting decreased levels of fatigue following sessions. He has since stated that he intends to continue participating in weekly aquafit sessions for the remainder of the year. His fatigue severity scale has decreased from a 48 to a 20, which is a clinically significant decrease in this outcome measure as the MCID is 20.2 (pouchot et al, 2008).

We will refer our patient to an Occupational Therapist for an assessment of how they may adapt his workplace to enable him to write on the board for longer periods of time, as well as for a home assessment which may involve incorporating additional seating areas such as a stool in his shed to enable him to continue working without having to stand.

Furthermore, we recognize that explaining the progressive nature of post-polio syndrome and accepting this difficult reality will be difficult for our patient. As such, we will enrol him in a post-polio syndrome support group ran by the March of Dimes Canada with weekly sessions to ensure that our patient establishes a solid social support network and continues to learn about tools and information to enable him to live his life to an optimal capacity.

Based on our patient meeting his treatment goals and achieving safe and independent functional abilities to perform his ADLs and IADLs, we will discharge him from our current intensive physiotherapy treatment consisting of two sessions per week. Given the progressive nature of PPS, we will follow-up with him over the phone monthly for brief status updates and addressing questions, and have in person follow-ups every 3 months to assess the progression of the disease and revise goals and refine his home exercise program to more accurately reflect his functional abilities.