eMedicine Specialties > Physical Medicine and Rehabilitation > Disorders of the Motor Unit

Postpolio Syndrome: Treatment & Medication

Author: Flor M Muñiz, MD, Assistant Professor, Department of Physical Medicine and Rehabilitation, McMaster University, Hamilton, Ontario
Coauthor(s): Gerald J Herbison, MD, Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University
Contributor Information and Disclosures

Updated: May 6, 2009

Treatment

Rehabilitation Program

Physical Therapy

The basic management principles for individuals with postpolio syndrome include energy conservation and pacing one's activities. Although basic, these activity modifications may be difficult for some patients to accept.

Reports on exercises are conflicting, but the key factor seems to be exercise intensity. Strengthening exercises should be nonfatiguing. A specific suggestion is to exercise every other day, and the perceived rate of exertion should be less than "very hard." Loads should be held for only 4-5 seconds, and there should be a 10-second rest between bouts and a 5-minute rest between sets. The patient should perform about 3 sets of 5-10 repetitions.6

In addition to specifying exercises for those body areas experiencing the deleterious effects of disuse, the exercise prescription also should consider how to protect (1) muscles and joints that are experiencing the adverse effects of overuse and (2) body areas with very significant chronic weakness (generally, areas where the muscles have less than antigravity strength on manual muscle testing).

Results of these exercises vary. Strengthening programs performed as described show a 60% increase on isokinetic strength, improved cardiorespiratory status, no decline in strength in 6-12 months, and 5% increase in isometric strength.

Electrical stimulation has been used to strengthen weakened muscles or to reeducate muscles weakened through disuse, as well as to decrease pain.

For myofascial pain, consider heat, electrical stimulation, trigger point injections, stretching exercises, biofeedback, muscle relaxation exercises, or static magnetic fields for trigger points.

For gait disturbances, assistive devices can be used, but sometimes patients refuse because of the philosophy of "not giving in." Treatment also can involve limitation of ambulation to shorter distances and the use of orthotics for joint protection.

Occupational Therapy

Patients with postpolio syndrome usually benefit from different adaptive techniques and equipment to perform any activities of daily living, as well as education and energy conservation techniques.

Speech Therapy

Speech evaluation in persons with postpolio syndrome usually is recommended with any suggestion of swallowing problems. The therapist teaches the patient about different techniques to improve his/her swallowing function.

Consultations

  • Pulmonologists
    • When the patient with postpolio syndrome reports respiratory problems, a full pulmonary evaluation may be required.
    • Sometimes, the patient may even need mechanical respiratory support.
    • A sleep evaluation may be necessary for suspected sleep apnea.
  • Orthopedists - The patient may present with various joint deformities that may require orthoses and sometimes even surgery.

Medication

Medications, most of which address fatigue, have been used with only partial success in patients with postpolio syndrome. Contradictory information is reported on the use of antivirals. Some authors have found no significant improvement with antivirals as compared with placebo. Amantadine may act to release dopamine from dopaminergic terminals and other central sites. Corticosteroids have been studied, but with no good results.

Anticholinesterases

Some authors have reported that one of the mechanisms for production of fatigue may be related to neuromuscular junction transmission deficits; however, treatment with anticholinesterases has been successful in only half of the cases; this low success rate has been attributed to the variety of neuromuscular junction defects believed to be present in postpolio syndrome. The mechanism of response to anticholinesterases also is unclear because some patients experience improvement in muscular strength, rather than improvement in fatigability.


Pyridostigmine (Mestinon)

Acts in smooth muscle, the CNS, and secretory glands where it blocks action of acetylcholine at parasympathetic sites and facilitates transmission of impulses across the myoneural junction.

Adult

60 mg PO tid (in experimentation)

Pediatric

Not established

Pyridostigmine increases effects of depolarizing neuromuscular blockers; increases toxicity of edrophonium

Documented hypersensitivity; GI or GU obstruction; cardiac arrhythmia, asthma, and increased bronchial secretions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in bronchial asthma and those receiving a cardiac glycoside; overdose may cause cholinergic crisis, which may be fatal; atropine IV should be readily available for treatment of cholinergic reactions

Immunoglobulins

Modulate activity of immune system.7


Immunoglobulin intravenous (Gammagard, Sandoglobulin)

Intravenous immunoglobulin has been recently studied in the treatment of symptoms related to postpolio syndrome. Results show that it could be a supportive treatment option for subgroups of patients with postpolio syndrome. Further studies are needed to investigate this in more detail.
Features that may be relevant to its efficacy include neutralization of circulating myelin antibodies through anti-idiotypic antibodies; down-regulation of proinflammatory cytokines, including IFN-gamma; blockade of Fc receptors on macrophages; suppression of inducer T and B cells and augmentation of suppressor T cells; blockade of the complement cascade; promotion of remyelination; 10% increase in CSF IgG.

Adult

2 g/kg IV over 2-5 d

Pediatric

Administer as in adults

Globulin preparation may interfere with immune response to live virus vaccine (MMR) and reduce efficacy (do not administer within 3 mo of vaccine)

Documented hypersensitivity; IgA deficiency

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Check serum IgA before IVIG (use an IgA-depleted product, eg, Gammagard S/D); infusions may increase serum viscosity and thromboembolic events; infusions may increase risk of migraine attacks, aseptic meningitis (10%), urticaria, pruritus, or petechiae (2-30 d postinfusion)
Increases risk of renal tubular necrosis in elderly patients and in patients with diabetes, volume depletion, and preexisting kidney disease; lab result changes associated with infusions include elevated antiviral or antibacterial antibody titers for 1 mo, 6-fold increase in ESR for 2-3 wk, and apparent hyponatremia

Anticonvulsant agents

May reduce morbidity of the disease.8


Lamotrigine (Lamictal)

Some preliminary studies suggest the efficacy of lamotrigine in enhancing the quality of life and symptoms of patients with postpolio syndrome. Further studies are needed.

Inhibits release of glutamate and inhibits voltage-sensitive sodium channels, leading to stabilization of neuronal membrane.

Adult

Monotherapy: Initial: 50-100 mg/d PO bid
Maintenance: 100-400 mg/d PO qd or divided bid, not to exceed 500 mg/d
Adjunct therapy with valproic acid: Initial dose: 25 mg PO qod
Maintenance: 50-200 mg/d PO in 1-2 divided doses, not to exceed 200 mg/d

Pediatric

<2 years: Not established
2-12 years:
Added to regimens not containing valproic acid:
Weeks 1-2: 0.6 mg/kg/d PO divided q12h, rounded down to nearest 5 mg
Weeks 3-4: 1.2 mg/kg/d PO divided q12h, rounded down to nearest 5 mg
Maintenance: 5-15 mg/kg/d PO; not to exceed 400 mg/d PO divided q12h
To achieve maintenance dose, increase doses q1-2wk as follows: Calculate 1.2 mg/kg/d and round down to nearest 5 mg; add this amount to previously administered daily dose

Concomitant therapy with valproic acid: Weeks 1-2: 0.15 mg/kg/d PO qd or divided bid, rounded down to nearest 5 mg
If initial calculated daily dose is 2.5-5 mg, take 5 mg on alternate days for first 2 wk
Weeks 3-4: 0.3 mg/kg/d PO qd or divided bid, rounded down to nearest 5 mg
Maintenance: 1-5 mg/kg/d PO qd or divided bid, not to exceed 200 mg/d
To achieve maintenance dose, increase doses q1-2wk as follows: Calculate 0.3 mg/kg/d, and round down to nearest 5 mg, and add amount to previously administered qd dose

>12 years: Regimens not containing valproic acid:
Weeks 1-2: 50 mg/d PO
Weeks 3-4: 100 mg/d PO divided bid
Maintenance: 300-500 mg/d PO divided bid; to achieve
maintenance, increase doses by 100 mg/d q1-2wk
Concomitant therapy with valproic acid:
Weeks 1-2: 25 mg PO qod
Weeks 3-4: 25 mg PO qd
Maintenance: 100-400 mg/d PO qd or divided bid
To achieve maintenance dose, may increase by 25-50 mg/d q1-2 wk

Acetaminophen increases renal clearance of medication, decreasing effects; similarly, phenobarbital and phenytoin increase lamotrigine metabolism causing a decrease in lamotrigine levels; administration of valproic acid with lamotrigine increases half-life; succinimide anticonvulsants (eg, methsuximide, phensuximide) decrease lamotrigine levels

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in impaired renal or hepatic function

More on Postpolio Syndrome

Overview: Postpolio Syndrome
Differential Diagnoses & Workup: Postpolio Syndrome
Treatment & Medication: Postpolio Syndrome
Follow-up: Postpolio Syndrome
References
Further Reading
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References

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

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

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

  6. 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. Oct 2008;40(9):773-5. [Medline].

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

  8. 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].

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Further Reading

Clinical guidelines:
EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force.
European Federation of Neurological Societies - Medical Specialty Society.  2006 Aug.  7 pages.  NGC:005488

Clinical trials:
Study of Mental Fatigue in Polio Survivors

Related eMedicine topics:
 Acute Poliomyelitis
Breathing-Related Sleep Disorder
Central Sleep Apnea
Enteroviral Infections
Enteroviruses
Focal Muscular Atrophies
Obstructive Sleep Apnea-Hypopnea Syndrome
Poliomyelitis [Orthopedic Surgery]
Poliomyelitis [Pediatrics: General Medicine]
Swallowing Disorders

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Keywords

postpolio syndrome, polio, poliomyelitis, muscle atrophy, post polio, post polio syndrome, sleep apnea, neuromuscular junction, enterovirus, polio virus, poliovirus, denervation, post-polio syndrome, polio complications

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Contributor Information and Disclosures

Author

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.

Coauthor(s)

Gerald J Herbison, MD, Professor, Department of Rehabilitation Medicine, Jefferson Medical College, Thomas Jefferson University
Disclosure: Nothing to disclose.

Medical Editor

Martin K Childers, DO, PhD, Associate Professor, Department of Neurology, Wake Forest University Health Services
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

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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 and American Academy of Physical Medicine and Rehabilitation
Disclosure: Nothing to disclose.

CME Editor

Kelly L Allen, MD, Regional Medical Director, IMX-Medical Management Services
Disclosure: Nothing to disclose.

Chief Editor

Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers
Denise I Campagnolo, MD, MS is a member of the following medical societies: Alpha Omega Alpha, American Association of Neuromuscular and Electrodiagnostic Medicine, American Paraplegia Society, Association of Academic Physiatrists, and Consortium of Multiple Sclerosis Centers
Disclosure: Teva Neuroscience Honoraria Speaking and teaching; Serono-Pfizer Honoraria Speaking and teaching

 
 
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