Patient with Post-Polio Syndrome (PPS)

It had been a rewarding 4 weeks of musculoskeletal outpatient placement – filled with different kinds of learning experiences and fun!

Saw a variety of cases. One particular case which I found quite challenging at first was a lady with history of post-polio syndrome. She presented with 4/12 history of persistent medial ankle pain and swelling. On objective examination, she had significant asymmetrical LL atrophy (L), and leg length discrepancy (L< R). It was challenging because besides treating her (L) ankle, I had to take into consideration:

1) a holistic approach – not just looking at the ankle as 1 entity,
2) type and dosage of strengthening exercises, without resulting in overuse and fatigue of the weakened muscle,
3) psychosocial issues (recall: neuro exam question in last yr’s neuro written paper? >.<)

As such, I decided to use this case as my in-service presentation as I had no idea how much strengthening is “too much” or “too little”. Initially I was prescribing exercise based on “not to the point of fatigue”, and observing closely that she did not do any trick movements after a certain no. of reps (= a sign of fatigue), and not prescribing too many exercises at 1 time.

From my readings, most studies involved training programmes consisting of isokinetic and isometric exercises. Endurance and/or aerobic training were also equally important in maintaining/ improving cardiovascular sufficiency. Below are a few key points I’ve learnt:

- Mild to moderate weakness can be improved with nonfatiguing exercises

- Specific exercise prescription is dependent on several factors such as current level of function, other presenting symptoms, client’s interest *Individualized therapy program!*

- Encourage short periods of activity, adequate rest between bouts of activity, rotate between different muscle groups

- 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 5-minute rest between sets. The patient should perform about 3 sets of 5-10 repetitions.

- Body alignment during exercise and functional activities, incorporate postural exercises and correction to address malalignments and unnecessary use of muscles and joints

- Do not exercise to point of fatigue or pain

Most PPS patients also have the philosophy of “not giving in”. Hence, when prescribed with orthotics, they seldom use the orthotics. Some of them believed that by using the orthotics, they’re accepting defeat. Not sure whether this was the case for my patient coz she had a pair of closed-in built up shoe to correct her leg length discrepancy. She had not been wearing it for 3-4 yrs because she felt peculiar wearing them and felt that they did not fit well. Initially, it took me a while to convince her to wear the shoes for gait re-education. I realized.. getting her to stand in front of the mirror, show her that the shoes were of correct height by showing that the hips are level.. helped in convincing her to wear the shoes. In addition, also explaining the rationale behind wearing the shoes helped: preventing malalignment, unnecessary use of muscles. Aim: maintain/improve strength => improve quality of life.

Hopefully, the above information is useful to anyone who, by any chance, has a patient with PPS =)