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Symptoms resurface in polio survivors.
However, a common obstacle to addressing this health issue is the minimization of polio survivors' complaints by health care providers who are frequently unfamiliar with PPS.2 Very few nurses practicing today have ever cared for patients with acute paralytic poliomyelitis, and the symptoms of PPS are sometimes confused with those of age-related conditions. PPS is not a reinfection with the poliomyelitis virus but a secondary condition that people with a history of polio can develop. Those who suffer from PPS don't have flu-like symptoms or fever, and they don't experience sudden paralysis.
Annual polio epidemics became increasingly severe during the first half of the 20th century. The biggest epidemic occurred in 1952 and involved more than 50,000 reported cases in the United States alone.3 The majority of polio infections resembled mild flu, yet 1% to 2% of cases resulted in respiratory paralysis. Although some patients who suffered from respiratory paralysis survived with iron lungs, many died. The poliomyelitis virus enters through the mouth and multiplies in the intestines. By crossing into the bloodstream, it can eventually invade the nervous system, destroying motor neurons in the anterior horn of the spinal cord, which leads to weakness or paralysis of the skeletal muscles. During the acute phase of polio infection, 95% of the spinal motor neurons are infected, leaving the patient with residual weakness or paralysis if more than 50% of the affected neurons don't survive.3 FIGURE 2
Survivors who made either a partial or complete recovery from an acute paralytic polio episode with a period of functional stability of at least 10 years can develop PPS. Symptoms include new weakness in previously affected or clinically unaffected muscles,4 muscle and joint pain, fatigue, dyspnea (difficulty in breathing), dysphagia (difficulty in swallowing), and cold intolerance, with equal risk in both men and women. Other conditions like arthritis, stroke, cardiac or pulmonary disease, and Parkinson's disease that could produce similar symptoms must be ruled out.5 Predictive factors include age, severity of weakness during the acute polio episode, muscle and joint pain on activity, and recent weight gain.6
PPS can go unnoticed at first, and it's frequently exacerbated by a stressful event such as a fall or surgery that requires bed rest.3
ASSESSMENT OF SYSTEMS AND SYMPTOMS^
"Hitting the polio wall." Sixty percent to 90% of patients feel profoundly fatigued on minimal exertion. This fatigue, the most common symptom of PPS, should not be confused with similar symptoms such as daytime sleepiness caused by obstructive sleep apnea (which causes overproduction of urine during sleep) or the lassitude often seen in patients with depression.
Musculoskeletal changes. These include muscle atrophy, fasciculation, decreased limb and trunk strength, and aching musculoskeletal pain after light activities. Muscles and joints that weren't affected by polio are frequently strained because of overuse in compensation for affected muscles. No exercise should be performed without the approval of a physician or physical therapist with knowledge of polio; this individual can write a limb-specific prescription such as exercise with an upper extremity exercycle or swimming with a floater to support weak limbs.7
Difficulty in breathing. This is associated with chronic alveolar hypoventilation caused by respiratory muscle weakness and fatigue. Patients often develop a shallow breathing pattern with a limited ability to take deep breaths. This ultimately leads to the retention of secretions in the lungs because of the impaired ability to cough. In addition, obesity, kyphoscoliosis (the lateral and posterior curvature of the spine), anesthesia, prolonged immobility, and medication that depresses respiratory function increase the risk of respiratory difficulty.8 Acute respiratory failure occurs when respiratory muscles weaken, causing a reduction in vital capacity, compliance, and tidal volume.
Poor quality of sleep. Inadequate sleep may be the result of pain, restless legs, or nocturia. There is also a high incidence of sleep-related breathing disorders (including central sleep apnea, obstructive sleep apnea, and hypoventilation) among patients with a history of acute bulbar polio, especially those who required mechanical respiratory support during the acute polio episode and those with coexisting pulmonary diseases.8,9 Decreased diaphragm and chest wall muscle strength can result in hypoventilation that becomes severe during sleep. Overnight assessment in a sleep laboratory by polysomnography (simultaneous and continuous monitoring of physiologic activity during sleep) can determine the nature and extent of sleep disturbance. Daytime symptoms of sleep-related breathing disturbances include headaches upon awakening and excessive sleepiness, which could either exacerbate PPS or be misinterpreted as fatigue related to PPS.
Difficulty in swallowing. Survivors of acute bulbar polio will develop difficulty swallowing because of the affected nerves that innervated the muscles used for swallowing and chewing. Patients with PPS can develop laryngospasm (spasmodic closure of the glottic aperture) and have difficulty chewing and swallowing liquid and solid foods. This can cause malnutrition, dehydration, and aspiration pneumonia. Facial, oropharyngeal, and vocal cord weakness impairs phonation and vocal modulation and can cause vocal hoarseness. Patients may experience such difficulty with speech that communication itself is impaired.10
Urologic symptoms. These may include difficulty emptying the bladder, increased severity of urinary incontinence, and nocturia. A chronically weak detrusor muscle often causes hesitancy, decreased force of the urinary stream, and incomplete bladder emptying. Incontinence is related to weakened pelvic floor muscles or the inability to get to the bathroom in time.11
Psychological symptoms. Patients with PPS will likely regain their independence.10 Polio survivors have attained educational and socioeconomic levels higher than those of the general population, and studies show that the same hard work and discipline these patients put into rehabilitation fueled their professional and educational endeavors.3, 10 But, of course, the recurrence of weakness, pain, and fatigue takes an emotional toll on these patients.
Polio survivors are recognized, broadly, as either "passers," "minimizers," or "identifiers," with coping mechanisms that vary according to the degree of residual disability. Passers recovered completely or almost completely from the acute polio episode, acting as if they were never afflicted by the condition and regarding the episode as something that occurred years ago that no longer affects their lives. Minimizers were left with moderate residual disability that continues to affect their daily lives. They are able to achieve the functional level of a person without disabilities with the use of assistive devices, or they compensate with energy conservation techniques. Identifiers have severe disabilities that continue to profoundly affect their lives necessitating, for instance, the use of a wheelchair.12 Regardless of their level of recovery, polio survivors may express anger or be depressed about the need to redevelop techniques to cope with the resurfaced polio symptoms.13
CARING FOR PATIENTS WITH PPS^
Although PPS results in progressive loss of muscle strength, well-conceived nursing interventions can retard this effect and assist in maintaining the individual's physical, psychological, and social well-being.10, 14
Energy conservation to reduce fatigue. Patients should plan and coordinate activities. For example, they should allow for a rest period between the morning bath and physical or respiratory therapy. Activity and rest should be balanced with one or two daily planned naps or rest periods lasting at least 15 minutes. Assistive devices such as canes, crutches, manual wheelchairs, and motorized scooters can reduce weakness and fatigue.10
Pain reduction techniques. These include resting muscles and joints, using braces to reduce strain, using a transcutaneous electrical nerve stimulation unit, and applying ice or heat. Nonpharmacologic techniques to reduce pain, such as biofeedback, relaxation, distraction, and massage, may also be helpful.
Airway management for respiration. Frequently auscultate breath sounds to monitor retained secretions and ensure adequate fluid intake to prevent mucus plugs. Deep breathing, incentive spirometry, and intermittent positive pressure breathing treatments help maintain clear breath sounds. Pulmonary function testing and arterial blood gas levels determine CO2 retention.
Sleep improvement. Patients should avoid foods and beverages that contain caffeine. Help make the patient's environment more conducive to sleep and encourage warm nighttime baths. If the patient has sleep-related breathing disturbances, mechanical ventilation during sleep will rest the respiratory muscles. This is an intervention that often results in improved daytime functioning as well. Obstructive sleep apnea is most effectively treated with continuous positive airway pressure, which uses pneumatic pressure to splint open the airway. Ventilation with bilevel assisted positive airway pressure is an alternative if hypoventilation or central apnea predominate. The effectiveness of older treatments to support ventilation, such as the rocking bed, a device that rhythmically shifts the abdominal contents against the diaphragm, needs to be evaluated in a sleep laboratory setting.15
Improvement in food intake. Problems in swallowing may be reduced by encouraging the patient to take small mouthfuls of food and sips of liquids. The risk of aspiration can be reduced by sitting the patient upright and eschewing the use of straws. If fatigue is causing inadequate nutritional intake, encourage frequent small, high-protein meals. A feeding tube may be indicated if the individual is unable to obtain adequate intake orally or if a study demonstrates possible aspiration while swallowing.
Urinary problems. Intermittent catheterization may be necessary if the patient has a high post-void residual volume overflow incontinence, or frequent urinary tract infections caused by incomplete emptying of the bladder. Persons who void two or more times a night need to be assessed for obstructive sleep disorder.1 A bedside commode or urinal may be used if there is a risk of falling.
Patient and family involvement. Encourage the patient to express concerns and to be involved in the planning of care. Include family members and significant others in discussions and decisions, if appropriate.
Medications. Patients with PPS frequently have strong reactions to many medications such as narcotic analgesics and anesthesia. Therefore, start with a low dose and increase if necessary. Sedatives and hypnotic medications should not be given because they can exacerbate hypoventilation. Although there are currently no drugs that reverse the physiologic changes that occur in PPS, several clinical studies are investigating drugs that may relieve some of the condition's symptoms.
RECOMMENDATIONS^
• Remind your patient to limit any activity that causes pain, fatigue, or weakness. Important activities should be planned for the morning because fatigue often increases in the afternoon and evening.
• Lifestyle modifications that compensate for reduced energy, such as sitting rather than standing during meal preparation and using a shower chair or a motorized scooter can increase the level of activity.
• Cold should be avoided because it increases muscle fatigue. Resist the temptation to lower the thermostat in the winter. Although the indoor temperature might be moderate, it is important to dress patients as if it were 20° colder, with warm vests, hats, socks, and gloves.
• Problems in keeping balance can precipitate falling. Teach your patient to reduce the risk by decreasing floor clutter, installing grab bars in the bathtub and handrails on staircases, wearing shoes that fit properly and have nonskid soles, and avoiding icy or slippery surfaces when going outdoors.
RESOURCES^
Contact the following organizations for additional information on support groups, health care providers, and hospitals specializing in PPS.
The Gazette International Network Institute; 4207 Lindell Boulevard, #110; St. Louis, MO 63108-2915; (314) 534-0475; www.post-polio.org
Lincolnshire Post-Polio Network in England; 69 Woodvale Ave.; Lincoln, Lincolnshire, LN63RD; United Kingdom; www.eskimo.com/~dempt/polio.html
REFERENCES^
1. Umlauf MG, et al. Nocturia and nocturnal urine production in obstructive sleep apnea. Appl Nurs Res 1997;10(4):198-201. [Context Link]
2. Aston JW, Jr. Post-polio syndrome. An emerging threat to polio survivors. Postgrad Med 1992;92(1):249-56, 60. [Context Link]
3. Halstead LS. Post-polio syndrome. Sci Am 1998;278(4):42-7. Bibliographic Links [Context Link]
4. Jubelt B, Agre JC. Characteristics and management of post-polio syndrome. JAMA 2000;284(4):412-4. [Context Link]
5. Dalakas MC. Post-polio syndrome 12 years later. How it all started. Ann N Y Acad Sci 1995;753:11-8. Bibliographic Links [Context Link]
6. Trojan DA, et al. Predictive factors for post-poliomyelitis syndrome. Arch Phys Med Rehabil 1994;75(7):770-7. Bibliographic Links [Context Link]
7. Halstead L, Gawne AC. NRH proposal for limb classification and exercise prescription. Disabil Rehabil 1996;18(6):311-6. Bibliographic Links [Context Link]
8. Dolmage TE, et al. Respiratory function during wakefulness and sleep among survivors of respiratory and non-respiratory poliomyelitis. Eur Respir J 1992;5(7):864-70. Bibliographic Links [Context Link]
9. Dean AC, et al. Sleep apnea in patients with postpolio syndrome. Ann Neurol 1998;43(5):661-4. [Context Link]
10. LeCompte CM. Post polio syndrome: an update for the primary health care provider. Nurse Pract 1997;22(6):133-6, 9, 42-6 passim. [Context Link]
11. Johnson VY, et al. Urologic manifestations of postpolio syndrome. J Wound Ostomy Continence Nurs 1996;23(4):218-23. Bibliographic Links [Context Link]
12. Maynard FM, Roller S. Recognizing typical coping styles of polio survivors can improve re-rehabilitation. Polio Survivors' Page. http://www.eskimo.com/~dempt/coping.htm . [Context Link]
13. Maynard FM. Managing the late effects of polio from a life-course perspective. Ann N Y Acad Sci 1995;753:354-60. Bibliographic Links [Context Link]
14. McCloskey JC, et al. Nursing interventions classification (NIC): Iowa Intervention Project. 2nd ed. St. Louis: Mosby; 1996. [Context Link]
15. Steljes DG, et al. Sleep in postpolio syndrome. Chest 1990;98(1):133-40. [Context Link]
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