Other medications typically used for chronic pain may also be tried, such as tricyclic antidepressants and anticonvulsants. Tricyclic antidepressants have cholinergic side effects; the most serious is the possibility of acute urinary retention in men, especially if underlying prostate problems are present.

Injections with local anesthetics or corticosteroids or both may be effective for specific conditions that are often associated with postpolio syndrome, such as myofascial pain, trochanteric bursitis, carpal tunnel syndrome, lateral epicondylitis, or rotator cuff tendonitis.

Physical and occupational therapy
From a quality-of-life perspective, perhaps the most important thing a physician can do is to help patients preserve mobility and avoid falls and resultant injuries.

Physical and occupational therapists can be extremely helpful in treating patients with musculoskeletal pain, weakness, decreased endurance, impaired balance, and difficulty walking. They can recommend appropriate adaptive equipment, such as shower grab bars, a raised toilet seat, sturdy and lightweight braces, assistive devices such as canes and crutches, and footwear modifications such as heel lifts and lateral wedges. Therapists can also advise patients on how to pace themselves, which is especially important for polio survivors. Home safety, work simplification, falls prevention, and proper exercise are also strategies that can enhance function.

Exercise
One of the most common questions polio survivors ask is, “How should I exercise?” This has been much debated. General guidelines for patients:

• Maintain an active exercise program to avoid deconditioning and cardiovascular sequelae
• Avoid overly aggressive exercise (fatiguing)
• Resist the impulse to exercise through pain.

Muscle fibers of polio survivors have very limited endurance because of the loss of aerobic enzyme activity and greater reliance on anaerobic metabolic capacity.16 Cross-training programs, such as alternating cycling with swimming and walking, are a good way to involve different muscle groups, but such programs should be consistent in terms of repetitions, resistance, and time. For most people, using daily activities as a primary way to exercise is too erratic and may lead to overuse, fatigue, and further weakness.

Is a wheelchair needed?
For patients who are having difficulty with walking or who may be at risk for falls, a motorized wheelchair or scooter can be useful, either full-time or part-time. Such vehicles can improve functional mobility, decrease risk of falls, and help conserve energy.

Manual wheelchairs have the advantage over motorized wheelchairs of being lighter and easily folded for transport. However, manual wheelchairs tend to promote overuse syndromes in the arms and are generally recommended only when another person will push the patient.

Ancillary health care
Referral to other appropriate health care providers can markedly improve the quality of
life for polio survivors. For example, speech and language pathologists can be extremely helpful in teaching patients compensatory mechanisms for swallowing. Referral to a mental health counselor, with pharmacologic intervention if needed, should be considered for patients who are depressed or have other psychological sequelae.

AVOIDING COMPLICATIONS
Osteoporosis. Patients with significant paralysis often have associated loss of bone density. Recent studies indicate that male polio survivors are at risk for osteopenia and osteoporosis, and may be at higher risk for fracture.8,16,17 We recommend that all polio survivors be screened for bone density loss and be appropriately treated.

Falls. Polio survivors are also at greater
risk of tripping and falling due to poor balance and weak arms or legs, and are less likely to be able to protect themselves as they fall.18–21 Since the complications of a fall can be serious, interventions for fall prevention are crucial. Both physical and occupational therapists typically address fall prevention.

Upper extremity injuries. Because polio survivors tend to overuse their arms, they are also at risk for upper extremity injuries, including carpal tunnel syndrome and ulnar neuropathy.8,22–24

REFERENCES

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Frick NM. Bromocriptine in the treatment of post-polio fatigue: a pilot study with implications for the Pathophysiology of fatigue. Am J Phys Med Rehabil 1996; 75:340–347.

14. Kingshott RN, Vennelle M, Coleman EL, Engleman HM,
Mackay TW, Douglas NJ. Randomized, double-blind, placebo-controlled crossover trial of modafinil in the treatment of residual excessive daytime sleepiness in the sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 2001; 163:918–923.

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with narcolepsy. Sleep Med 2000; 1:231–243.

16. Silver JK, Aiello DD. Bone density and fracture risk in
male polio survivors [abstract]. Arch Phys Med Rehabil
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17. Silver JK, MacNeil JR, Aiello DD. Effect of Fosamax on
bone density in a male polio survivor: a case report [abstract]. Arch Phys Med Rehabil 2001; 82:1329.

18. Silver JK, Aiello DD. Fall prevention strategies in a polio
survivor: a case report [abstract]. Arch Phys Med Rehabil
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19. Silver JK, Aiello DD. Polio survivors’ attitudes regarding
falls [abstract]. Arch Phys Med Rehabil 2000; 81:1296.

20. Silver JK, Aiello DD. Risk of falls in polio survivors
[abstract]. Arch Phys Med Rehabil 2000; 81:1272.

21. Silver JK, Aiello DD. Polio survivors: falls and subsequent
injuries. Am J Phys Med Rehabil. In press 2002.

22. Veerendrakumar M, Taly AB, Nagaraja D. Ulnar nerve
palsy due to axillary crutch. Neurol India 2001; 49:67–70.

23. Waring WP, Werner RA. Clinical management of carpal
tunnel syndrome in patients with long term sequelae of
poliomyelitis. J Hand Surg 1989; 14:865–869.

24. Slowman LS, Silver JK. Prevalence of median and ulnar
neuropathy in post-polio patients [abstract]. Arch Phys Med Rehabil 2001; 82:1312–1313.

Reprint with permission
ADDRESS: Julie K. Silver, MD,
Spaulding-Framingham
Outpatient Center,
570 Worcester Road, Framingham, MA
01702;
e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it .