Medscape is available in 5 Language Editions – Choose your Edition here.


Postpolio Syndrome Clinical Presentation

  • Author: Divakara Kedlaya, MBBS; Chief Editor: Stephen Kishner, MD, MHA  more...
Updated: Sep 15, 2015


Symptoms of postpolio syndrome (PPS) usually appear earlier in patients who have very severe residual weakness, individuals who had early bulbar respiratory difficulty in the acute illness, and persons who were older when they contracted acute polio. PPS symptoms tend to occur first in the weaker muscles.


In individuals without polio or PPS, the functional consequences of aging and loss of motor units may be unnoticeable until a very advanced age. In the individual with PPS, any further loss of strength may be more readily apparent. In contrast to patients with chronic fatigue syndrome, postpolio fatigue is prominent in the early hours of the afternoon and decreases after brief periods of rest and is exacerbated by minimal physical exercise. PPS-related fatigue usually does not prevent patients from working. Fatigue in PPS usually occurs on a daily basis, increases in severity as the day progresses, and is usually associated with physical weakness.[9]

Fatigue in PPS is multidimensional. Different types of fatigue, such as general fatigue, physical fatigue, and mental fatigue, are determined by different variables. Potentially modifiable factors such as stress, depression, pain, and physical activity account for a portion of fatigue in PPS.[10]

Central pain pathogenesis can include chronic pain, type A personality, depression, dysfunctional reticular-activated system, sleep disorders, and respiratory dysfunction. PPS produces somnolence and difficulty in concentrating and remembering.

Peripheral pain pathogenesis may be metabolic exhaustion of the enlarged motor units, neuromuscular junction transmission defects, scarring within the motor neurons, or loss of motor units due to aging. PPS produces decreased muscular endurance and increased muscular fatigability.

A study by Romigi et al found a high prevalence of restless legs syndrome (RLS) in patients with PPS, with RLS possibly being a significant factor in fatigue. The investigators suggested that a link exists between neuroanatomic and inflammatory mechanisms in RLS and PPS.[11]

Muscle weakness

In PPS, muscle weakness and atrophy can be permanent, because of loss of motor units, or transient, because of muscle fatigue.[12, 13]

A number of functional etiologies for weakness have been hypothesized, including disuse, overuse, and chronic weakness, as well as weight gain.

Asymmetrical and scattered weakness may be present. Progression of muscle weakness is faster than in normal ageing.[14]

Some authors have found evidence that previously unaffected muscles later become weak; in these cases, they discovered that the patient was unaware of or had not been told that the particular muscle had been affected during the acute episode.

A systematic review conducted by Stolwijk-Swüste et al[15] concluded that the rate of decline in muscle strength in PPS is slow, and prognostic factors have not yet been identified. They suggested that long-term follow-up studies with unselected study populations and age-matched control individuals are needed to shed further light on this question.

Muscle pain [3, 16]

Deep aching pain may be a component of a myofascial pain syndrome or fibromyalgia.

This feature is extremely prevalent in PPS. Using a retrospective, cross-sectional survey, Stoelb et al investigated the frequency and most common sites of pain in patients with postpolio syndrome.[17] Pain symptoms were reported by 57 (90.5%) of the 63 study participants; pain was reported most often in the shoulders, legs, hips, and lower back, with the most intense pain occurring in the legs, knees, wrists, head, and lower back.

In a Swedish study, 68% of patients with PPS experienced pain at the examination. Pain was found to have a significant impact on their quality of life.[18]

Gait disturbance

Difficulty with gait is caused by progressive weakness, pain, osteoarthritis, or joint instability; it is common in patients who previously used assistive devices but later discarded them. The gait pattern of PPS patients is related to numerous intrinsic and extrinsic factors.[19] . Using 6-minute walk test, it was shown that walking speed was negatively correlated with the increased hip flexion, but not with the ankle plantar-flexion at foot-off in the patients with PPS.[20]

Respiratory problems

Respiratory disorders are most prevalent in patients with residual respiratory muscle weakness.

These changes cause chronic microatelectasis, diminished pulmonary compliance, increased chest wall tightness, chronic alveolar hypoventilation, decreased cough and expiratory flow, and decreased clearing of secretions.

The new respiratory difficulties are not only related to new respiratory muscle weakness but also to scoliosis, pulmonary emphysema, cardiovascular insufficiency, or poor posture.

A central component also may occur because acute bulbar polio often affects the medullary structures, including the reticular formation and sleep regulatory system.

Nonetheless, a study by Lira et al found that on spirometric evaluation, the only significant difference in lung function between patients with PPS and controls was an approximately 27% lower value in mean maximal voluntary ventilation.[21]

Swallowing problems (dysphagia)

Dysphagia can occur in patients with bulbar and nonbulbar postpolio.

Subclinical asymmetrical weakness in the pharyngeal constrictor muscles is almost always present in all postpolio muscular atrophy patients, including those who do not complain of new swallowing difficulties.

In one Finnish study of 51 people with PPS who were admitted to a rehabilitation center, 15 people reported daily problems with swallowing or voice production. The most commonly observed deficits in swallowing included decreased pharyngeal transit and food catching in the throat.[22]

Autonomic dysfunction

The cause is unclear; the peripheral component could include muscular atrophy and, therefore, diminished heat production.

Sleep apnea

This disorder is not uncommon in patients left with residual bulbar dysfunction or severe respiratory compromise. Patients with bulbar involvement had more frequent sleep apnea than patients without. They also had significantly more central apnea.[23]

Sleep apnea appears to be due to a combination of the following:

  • Central apnea, due to a residual dysfunction of the surviving bulbar reticular neurons
  • Obstructive apnea, due to pharyngeal weakness and increased musculoskeletal deformities from scoliosis or emphysema
  • Postpolio muscular atrophy, resulting in diminished muscle strength of the respiratory, intercostal, and abdominal muscle groups

Flat-back syndrome

Another possible symptom in some patients with postpolio syndrome is the flat-back syndrome, which consists of the inability to stand erect because of forward flexion of the trunk and pain in the low back and legs.[24]

The flat-back syndrome typically occurs in patients with diminished lumbar lordosis as a result of instrumentation of the spine for scoliosis, vertebral fracture, or degenerative joint disease.

The trunk extensor musculature plays an essential role in maintaining upright posture, and it may be that PPS-related weakness in this musculature represents a major contributing factor to the flat-back syndrome in these patients.



In persons with postpolio syndrome, progressive weakness and atrophy may be observed in muscles that were affected initially by the poliovirus or in muscles that were spared clinically, which tends to happen in an asymmetrical distribution. Fasciculations sometimes can be observed in atrophic muscles, as a result of the lower motor neuron injury.

Obesity is widespread in postpolio survivors. A study by Chang indicates that the current body mass index (BMI) underestimates the total body fat mass percentage for those with poliomyelitis, leading the authors to suggest that a population-specific BMI should be used instead.[25]

Contributor Information and Disclosures

Divakara Kedlaya, MBBS Clinical Associate Professor, Department of Physical Medicine and Rehabilitation, Loma Linda University School of Medicine; Medical Director, Physical Medicine and Rehabilitation and Pain Management, St Mary Corwin Medical Center

Divakara Kedlaya, MBBS is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, Colorado Medical Society, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Kat Kolaski, MD Assistant Professor, Departments of Orthopedic Surgery and Pediatrics, Wake Forest University School of Medicine

Kat Kolaski, MD is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, American Academy of Physical Medicine and Rehabilitation

Disclosure: Nothing to disclose.

Chief Editor

Stephen Kishner, MD, MHA Professor of Clinical Medicine, Physical Medicine and Rehabilitation Residency Program Director, Louisiana State University School of Medicine in New Orleans

Stephen Kishner, MD, MHA is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Association of Neuromuscular and Electrodiagnostic Medicine

Disclosure: Nothing to disclose.


Martin K Childers, DO, PhD Professor, Department of Neurology, Wake Forest University School of Medicine; Professor, Rehabilitation Program, Institute for Regenerative Medicine, Wake Forest Baptist Medical Center

Martin K Childers, DO, PhD is a member of the following medical societies: American Academy of Physical Medicine and Rehabilitation, American Congress of Rehabilitation Medicine, American Osteopathic Association, Christian Medical & Dental Society, and Federation of American Societies for Experimental Biology

Disclosure: Allergan pharma Consulting fee Consulting

Gerald J Herbison, MD Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University

Disclosure: Nothing to disclose.

Flor M Muñiz, MD Assistant Professor, Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario

Flor M Muñiz, MD is a member of the following medical societies: American Medical Association, Canadian Association of Physical Medicine and Rehabilitation, and Canadian Medical Association

Disclosure: Nothing to disclose.

  1. Halstead LS. Assessment and differential diagnosis for post-polio syndrome. Orthopedics. 1991 Nov. 14(11):1209-17. [Medline].

  2. March of Dimes Birth Defects Foundation. Post-polio syndrome: identifying best practices in diagnosis and care. Available at Accessed: November 15, 2013.

  3. Gonzalez H, Ottervald J, Nilsson KC, et al. Identification of novel candidate protein biomarkers for the post-polio syndrome - implications for diagnosis, neurodegeneration and neuroinflammation. J Proteomics. 2009 Jan 30. 71(6):670-81. [Medline].

  4. Bouza C, Munoz A, Amate JM. Postpolio syndrome: a challenge to the health-care system. Health Policy. 2005 Jan. 71(1):97-106. [Medline].

  5. Ramlow J, Alexander M, LaPorte R, Kaufmann C, Kuller L. Epidemiology of the post-polio syndrome. Am J Epidemiol. 1992 Oct 1. 136(7):769-86. [Medline].

  6. Quadros AA, Conde MT, Marin LF, Silva HC, Silva TM, Paula MB, et al. Frequency and clinical manifestations of post-poliomyelitis syndrome in a Brazilian tertiary care center. Arq Neuropsiquiatr. 2012 Aug. 70(8):571-3. [Medline].

  7. Ragonese P, Fierro B, Salemi G, Randisi G, Buffa D, D'Amelio M, et al. Prevalence and risk factors of post-polio syndrome in a cohort of polio survivors. J Neurol Sci. 2005 Sep 15. 236(1-2):31-5. [Medline].

  8. Bertolasi L, Acler M, dall'Ora E, Gajofatto A, Frasson E, Tocco P, et al. Risk factors for post-polio syndrome among an Italian population: a case-control study. Neurol Sci. 2012 Dec. 33(6):1271-5. [Medline].

  9. Berlly MH, Strauser WW, Hall KM. Fatigue in postpolio syndrome. Arch Phys Med Rehabil. 1991 Feb. 72(2):115-8. [Medline].

  10. Trojan DA, Arnold DL, Shapiro S, Bar-Or A, Robinson A, Le Cruguel JP, et al. Fatigue in post-poliomyelitis syndrome: association with disease-related, behavioral, and psychosocial factors. PM R. 2009 May. 1(5):442-9. [Medline].

  11. Romigi A, Pierantozzi M, Placidi F, et al. Restless legs syndrome and post polio syndrome: a case-control study. Eur J Neurol. 2015 Mar. 22 (3):472-8. [Medline].

  12. Trojan DA, Cashman NR. Post-poliomyelitis syndrome. Muscle Nerve. 2005 Jan. 31(1):6-19. [Medline].

  13. Bickerstaffe A, Beelen A, Nollet F. Change in physical mobility over 10 years in post-polio syndrome. Neuromuscul Disord. 2015 Mar. 25 (3):225-30. [Medline].

  14. Klein MG, Whyte J, Keenan MA, Esquenazi A, Polansky M. Changes in strength over time among polio survivors. Arch Phys Med Rehabil. 2000 Aug. 81(8):1059-64. [Medline].

  15. Stolwijk-Swüste JM, Beelen A, Lankhorst GJ, Nollet F. The course of functional status and muscle strength in patients with late-onset sequelae of poliomyelitis: a systematic review. Arch Phys Med Rehabil. 2005 Aug. 86(8):1693-701. [Medline].

  16. Fordyce CB, Gagne D, Jalili F, et al. Elevated serum inflammatory markers in post-poliomyelitis syndrome. J Neurol Sci. 2008 Aug 15. 271(1-2):80-6. [Medline].

  17. Stoelb BL, Carter GT, Abresch RT, et al. Pain in persons with postpolio syndrome: frequency, intensity, and impact. Arch Phys Med Rehabil. 2008 Oct. 89(10):1933-40. [Medline].

  18. Werhagen L, Borg K. Impact of pain on quality of life in patients with post-polio syndrome. J Rehabil Med. 2013 Feb. 45(2):161-3. [Medline].

  19. Portnoy S, Schwartz I. Gait characteristics of post-poliomyelitis patients: Standardization of quantitative data reporting. Ann Phys Rehabil Med. 2013 Oct. 56(7-8):527-41. [Medline].

  20. Vreede KS, Henriksson J, Borg K, Henriksson M. Gait characteristics and influence of fatigue during the 6-minute walk test in patients with post-polio syndrome. J Rehabil Med. 2013 Sep. 45(9):924-8. [Medline].

  21. Lira CA, Minozzo FC, Sousa BS, et al. Lung function in post-poliomyelitis syndrome: a cross-sectional study. J Bras Pneumol. 2013 Jun-Aug. 39 (4):455-60. [Medline].

  22. Söderholm S, Lehtinen A, Valtonen K, Ylinen A. Dysphagia and dysphonia among persons with post-polio syndrome - a challenge in neurorehabilitation. Acta Neurol Scand. 2010 Nov. 122(5):343-9. [Medline].

  23. Dean AC, Graham BA, Dalakas M, Sato S. Sleep apnea in patients with postpolio syndrome. Ann Neurol. 1998 May. 43(5):661-4. [Medline].

  24. Ring D, Vaccaro AR, Scuderi G, Klein G, Green D, Garfin SR. An association between the flat back and postpolio syndromes: a report of three cases. Arch Phys Med Rehabil. 1997 Mar. 78(3):324-6. [Medline].

  25. Chang KH, Lai CH, Chen SC, Hsiao WT, Liou TH, Lee CM. Body composition assessment in taiwanese individuals with poliomyelitis. Arch Phys Med Rehabil. 2011 Jul. 92(7):1092-7. [Medline].

  26. Correa JC, Rocco CC, de Andrade DV, et al. Electromyographic and neuromuscular analysis in patients with post-polio syndrome. Electromyogr Clin Neurophysiol. 2008 Nov-Dec. 48(8):329-33. [Medline].

  27. Davidson AC, Auyeung V, Luff R, Holland M, Hodgkiss A, Weinman J. Prolonged benefit in post-polio syndrome from comprehensive rehabilitation: a pilot study. Disabil Rehabil. 2009. 31(4):309-17. [Medline].

  28. Tersteeg IM, Koopman FS, Stolwijk-Swuste JM, Beelen A, Nollet F. A 5-year longitudinal study of fatigue in patients with late-onset sequelae of poliomyelitis. Arch Phys Med Rehabil. 2011 Jun. 92(6):899-904. [Medline].

  29. Atwal A, Giles A, Spiliotopoulou G, Plastow N, Wilson L. Living with polio and postpolio syndrome in the United Kingdom. Scand J Caring Sci. 2013 Jun. 27(2):238-45. [Medline].

  30. Koopman FS, Voorn EL, Beelen A, et al. No Reduction of Severe Fatigue in Patients With Postpolio Syndrome by Exercise Therapy or Cognitive Behavioral Therapy: Results of an RCT. Neurorehabil Neural Repair. 2015 Aug 7. [Medline].

  31. Skough K, Krossen C, Heiwe S, et al. Effects of resistance training in combination with coenzyme Q10 supplementation in patients with post-polio: a pilot study. J Rehabil Med. 2008 Oct. 40(9):773-5. [Medline].

  32. Skough K, Broman L, Borg K. Test-retest reliability of the 6-min walk test in patients with postpolio syndrome. Int J Rehabil Res. 2013 Jun. 36(2):140-5. [Medline].

  33. Chan KM, Amirjani N, Sumrain M, Clarke A, Strohschein FJ. Randomized controlled trial of strength training in post-polio patients. Muscle Nerve. 2003 Mar. 27(3):332-8. [Medline].

  34. Bertelsen M, Broberg S, Madsen E. Outcome of physiotherapy as part of a multidisciplinary rehabilitation in an unselected polio population with one-year follow-up: an uncontrolled study. J Rehabil Med. 2009 Jan. 41(1):85-7. [Medline].

  35. Stein DP, Dambrosia JM, Dalakas MC. A double-blind, placebo-controlled trial of amantadine for the treatment of fatigue in patients with the post-polio syndrome. Ann N Y Acad Sci. 1995 May 25. 753:296-302. [Medline].

  36. Dinsmore S, Dambrosia J, Dalakas MC. A double-blind, placebo-controlled trial of high-dose prednisone for the treatment of post-poliomyelitis syndrome. Ann N Y Acad Sci. 1995 May 25. 753:303-13. [Medline].

  37. Vasconcelos OM, Prokhorenko OA, Salajegheh MK, Kelley KF, Livornese K, Olsen CH, et al. Modafinil for treatment of fatigue in post-polio syndrome: a randomized controlled trial. Neurology. 2007 May 15. 68(20):1680-6. [Medline].

  38. Chan KM, Strohschein FJ, Rydz D, Allidina A, Shuaib A, Westbury CF. Randomized controlled trial of modafinil for the treatment of fatigue in postpolio patients. Muscle Nerve. 2006 Jan. 33(1):138-41. [Medline].

  39. Koopman FS, Uegaki K, Gilhus NE, Beelen A, de Visser M, Nollet F. Treatment for postpolio syndrome. Cochrane Database Syst Rev. 2011 Feb 16. CD007818. [Medline].

  40. Ostlund G, Broman L, Werhagen L, Borg K. Immunoglobulin treatment in post-polio syndrome: Identification of responders and non-responders. J Rehabil Med. 2015 Sep 3. 47 (8):727-33. [Medline].

  41. Bertolasi L, Frasson E, Turri M, Gajofatto A, Bordignon M, Zanolin E, et al. A randomized controlled trial of IV immunoglobulin in patients with postpolio syndrome. J Neurol Sci. 2013 Jul 15. 330(1-2):94-9. [Medline].

  42. Trojan DA, Collet JP, Shapiro S, Jubelt B, Miller RG, Agre JC, et al. A multicenter, randomized, double-blinded trial of pyridostigmine in postpolio syndrome. Neurology. 1999 Oct 12. 53(6):1225-33. [Medline].

  43. Gonzalez H, Sunnerhagen KS, Sjoberg I, et al. Intravenous immunoglobulin for post-polio syndrome: a randomised controlled trial. Lancet Neurol. 2006 Jun. 5(6):493-500. [Medline].

  44. On AY, Oncu J, Uludag B, et al. Effects of lamotrigine on the symptoms and life qualities of patients with post polio syndrome: a randomized, controlled study. NeuroRehabilitation. 2005. 20(4):245-51. [Medline].

  45. Diseases of the motor unit. DeLisa J, Gans B, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott-Raven; 1998. 1554-6.

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.