Post-polio syndrome (PPS) Mayo Clinic

By Mayo Clinic staff  Post-polio syndrome (PPS) is a condition that some people who had polio at a young age may experience years later.
Polio was once one of the most feared diseases in America, responsible for paralysis and death. Shortly after polio reached its peak in the early 1950s, the inactivated polio vaccine was introduced and greatly reduced polio's spread. Today, few people in developed countries get paralytic polio, thanks to the polio vaccine.

But some people who had polio at a young age may experience certain late effects of the disease many years later — post-polio syndrome. The exact cause of post-polio syndrome is unknown.
Treatment focuses on managing the signs and symptoms of post-polio syndrome and improving your quality of life.
Symptoms By Mayo Clinic staff 
Post-polio syndrome refers to a cluster of disabling signs and symptoms that appear decades — an average of 30 to 40 years — after the initial illness. Common signs and symptoms include:
  • Progressive muscle and joint weakness and pain
  • General fatigue and exhaustion with minimal activity
  • Muscle atrophy
  • Breathing or swallowing problems
  • Sleep-related breathing disorders, such as sleep apnea
  • Decreased tolerance of cold temperatures
In most people, post-polio syndrome tends to progress slowly, with new signs and symptoms followed by periods of stability.
When to see a doctor
If you're experiencing weakness or fatigue that seems to be slowly getting worse, see your doctor. It's important to rule out other causes of your signs and symptoms that may require different therapy from what's currently advised for post-polio syndrome.
Causes By Mayo Clinic staff

Risk factors By Mayo Clinic staff

Factors that may increase your risk of developing post-polio syndrome include:
  • Severity of initial polio infection. The more severe the initial infection, the more likely that you'll have signs and symptoms of post-polio syndrome.
  • Age at onset of initial illness. If you acquired polio as an adolescent or adult, rather than as a young child, your chances of developing post-polio syndrome increase.
  • Recovery. The greater your recovery after acute polio, the more likely it seems that post-polio syndrome will develop. This may be because greater recovery places additional stress on motor neurons.
  • Physical activity. If you often perform physical activity to the point of exhaustion or fatigue, this may overwork already stressed-out motor neurons and increase your risk of post-polio syndrome.
Nobody knows exactly what causes the signs and symptoms of post-polio syndrome to appear so many years after the first episode of polio. Currently, the most accepted theory regarding the cause of post-polio syndrome rests on the idea of degenerating nerve cells.
When poliovirus infects your body, it affects nerve cells called motor neurons — particularly those in your spinal cord — that carry messages (electrical impulses) between your brain and your muscles.Each neuron consists of three basic components:A cell body
  • A major branching fiber (axon)
  • Numerous smaller branching fibers (dendrites)
A polio infection often leaves many of these motor neurons destroyed or damaged. To compensate for the resulting neuron shortage, the remaining neurons sprout new fibers, and the surviving motor units become enlarged. This promotes recovery of the use of your muscles, but it also places added stress on the nerve cell body to nourish the additional fibers. Over the years, this stress may be more than the neuron can handle, leading to the gradual deterioration of the sprouted fibers and, eventually, the neuron itself.
Another theory is that the initial illness may have created an autoimmune reaction, causing the body's immune system to attack normal cells as if they were foreign substances. Some experts believe that the poliovirus may persist in the body and reactivate years later.
Complications By Mayo Clinic staff
Generally, post-polio syndrome is rarely life-threatening, but severe muscle weakness can lead to complications:
  • Falls. Weakness in your leg muscles makes it easier for you to lose your balance and fall. A fall may result in a broken bone, such as a hip fracture, leading to other complications.
  • Malnutrition, dehydration, pneumonia. People who've had bulbar polio, which affects nerves leading to muscles involved in chewing and swallowing, often have difficulty with these activities as well as other signs of post-polio syndrome. Chewing and swallowing problems can lead to inadequate nutrition and to dehydration, as well as aspiration pneumonia, which is caused by inhaling (aspirating) food particles into your lungs.
  • Acute respiratory failure. Weakness in your diaphragm and chest muscles makes it harder to take deep breaths and cough, which can ultimately lead to accumulation of fluid and mucus in your lungs. Obesity, curvature of the spine, anesthesia, prolonged immobility and certain medications can further decrease breathing ability, possibly leading to acute respiratory failure. This is characterized by a sharp drop in blood-oxygen levels and may require you to receive treatment to help you breathe (ventilation therapy).
  • Osteoporosis. Prolonged inactivity and immobility are often accompanied by loss of bone density and osteoporosis, in both men and women. If you have post-polio syndrome, you may wish to be screened for osteoporosis

Preparing for your appointment By Mayo Clinic staff

You're likely to start by first seeing your family doctor or a general practitioner when you first notice your symptoms. However, you'll probably be referred to a doctor who specializes in nervous system disorders (neurologist).
Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared for your appointment. Here's some information to help you get ready for your appointment, and what to expect from your doctor.
What you can do?
  • Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
  • Write down key personal information, including any major stresses or recent life changes.
  • Make a list of all medications, vitamins and supplements that you're taking.
  • Write down questions to ask your doctor.
Your time with your doctor is limited, so preparing a list of questions ahead of time will help you make the most of your time together. List your questions from most important to least important in case time runs out. For post-polio syndrome, some basic questions to ask your doctor include:
  • What is likely causing my symptoms?
  • Are there other possible causes for my symptoms?
  • What kinds of tests, if any, do I need? What will these tests tell you? What's involved in the test?
  • Is my condition likely temporary or chronic?
  • What treatments are available? Which do you recommend?
  • Are there alternatives to the primary approach that you're suggesting?
  • I have these other health conditions. How can I best manage them together?
  • Are there any activity restrictions that I need to follow?
  • Will I become incapacitated?
  • Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?
In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.
What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:
  • Have you ever had polio? If so, when?
  • How severe was your polio infection?
  • What areas of your body were affected by polio?
  • What types of symptoms are you now experiencing?
  • When did you first begin experiencing these symptoms?
  • Have your symptoms been continuous, or occasional?
  • What, if anything, seems to improve your symptoms?
  • Does anything appear to worsen your symptoms?
  • Tests and diagnosis By Mayo Clinic staff
  • To arrive at a diagnosis of post-polio syndrome, doctors look for three indicators:Previous diagnosis of polio. This may require finding old medical records or getting information from older family members, because acute polio primarily occurs during childhood. The late effects of polio usually occur in people who were adolescents or older during the initial attack of polio and whose symptoms were severe.
  • Long interval after recovery. People who recover from the initial attack of polio often live for many years without further signs or symptoms. The onset of late effects varies widely, but typically begins at least 15 years after the initial diagnosis.
  • Gradual onset. Weakness often isn't noticeable until it interferes with daily activities. You may awaken refreshed, but feel exhausted by the early afternoon, tiring after activities that were once easy.
In addition, because the signs and symptoms of post-polio syndrome are similar to those commonly associated with other disorders, your doctor will attempt to exclude other possible causes, such as arthritis, fibromyalgia, chronic fatigue syndrome and scoliosis.
Some people with post-polio syndrome worry that they may be getting amyotrophic lateral sclerosis (ALS), also called Lou Gehrig's disease. But the late effects of polio are not a form of ALS.
Some of the tests your doctor may use to rule out alternative diagnoses include:
  • Electromyography (EMG) and nerve conduction studies.Electromyography measures the tiny electrical discharges produced in muscles. A thin-needle electrode is inserted into the muscles your doctor wants to study. An instrument records the electrical activity in your muscle at rest and as you contract the muscle. In a variation of EMG called nerve conduction studies, two electrodes are taped to your skin above a nerve to be studied. A small shock is passed through the nerve to measure the speed of nerve signals. These tests help identify and exclude conditions such as neuropathy, an abnormal condition of your nerves, and myopathy, a muscle tissue disorder.
  • Imaging. You may undergo tests, such as magnetic resonance imaging (MRI) or computerized tomography (CT), to produce images of your brain and spinal cord. These tests can help exclude spinal disorders, such as spondylosis, a degenerative spine condition, or spinal stenosis, a narrowing of your spinal column that puts pressure on your nerves.
  • Blood tests. People with post-polio syndrome usually have normal blood samples. Abnormal blood test results may indicate another underlying problem that's causing your symptoms.
  • Treatments and drugs By Mayo Clinic staff
  • Because the signs and symptoms often vary, there's no one specific treatment for post-polio syndrome. The goal of treatment is to manage your symptoms and help make you as comfortable and independent as possible:

    • Energy conservation. This involves pacing your physical activity and combining it with frequent rest periods to reduce fatigue. Assistive devices, such as a cane, walker, wheelchair or motor scooter, also can help you conserve energy. A therapist can even show you ways to breathe that help conserve energy.
    • Physical therapy. Your doctor or therapist may prescribe exercises for you that strengthen your muscles without you experiencing muscle fatigue. These usually include less strenuous activities, such as swimming or water aerobics, that you perform every other day at a relaxed pace. Exercising to maintain fitness is important, but be cautious in your exercise routine and daily activities. Avoid overusing your muscles and joints and attempting to exercise beyond the point of pain or fatigue. Otherwise, you may need significant rest to regain your strength.
    • Occupational therapy. A physical therapist or occupational therapist can help you modify your home environment so that it's safe and convenient for you. This may include installation of grab bars in the shower or a raised toilet seat. Your therapist may also help you rearrange furniture or rethink certain household or work-related tasks, decreasing the number of steps you must take and increasing your efficiency.
    • Speech therapy. A speech therapist can show you ways to compensate for swallowing difficulties.
    • Sleep apnea treatment. Treatment for sleep apnea, which is common among people with post-polio syndrome, may involve changing your sleeping patterns, such as avoiding sleeping on your back, or using a device that helps open up a blocked airway.
    • Medications. Medications, including aspirin and other nonsteroidal anti-inflammatory drugs, may ease muscle and joint pain. Numerous drugs — including pyridostigmine (Mestinon), amantadine (Symmetrel), modafinil (Provigil), insulin-like growth factor-I (IGF-I) and alpha-2 recombinant interferon — have been studied as treatments for post-polio syndrome, but no clear benefit has been found for any of them. Early studies of intravenous immunoglobulin suggest that it may reduce pain, boost strength and improve quality of life for people with post-polio syndrome.
  • Lifestyle and home remedies By Mayo Clinic staff
  • Having to deal again with an illness you thought was in the past can be discouraging, even overwhelming at times. Recovering from the initial illness required drive and determination on your part, but now the late effects of polio require you to rest and conserve your energy. Moving from one frame of mind to another can be a difficult switch. Here are some suggestions that may help:
  • Limit activities that cause pain or fatigue. Moderation is key. Overdoing it on a good day can lead to several subsequent bad days.
  • Be smart. Conserving your energy through lifestyle modifications and assistive devices doesn't mean you're giving in to the illness. It just means you've found a smarter way to deal with it.
  • Stay warm. Cold increases muscle fatigue. Keep your home at a comfortable temperature and dress in layers, especially when you go out.
  • Avoid falls. Get rid of throw rugs and loose clutter on the floor, wear good shoes, and avoid slippery or icy surfaces.
  • Maintain a healthy lifestyle. Eat a balanced diet, stop smoking and decrease caffeine intake to keep fit, breathe easier and sleep better.
  • Protect your lungs. If your breathing is impaired, watch for signs of a developing respiratory infection, which can make breathing problems worse, and have it treated promptly. Also, avoid smoking and stay current with your flu and pneumonia vaccines
  • .References

  1. Shefner JM, et al. Post-polio syndrome. http://www.uptodate.com/home/index.html. Accessed Jan. 9, 2009.
  2. Polio disease - questions and answers. Centers for Disease Control and Prevention. http://www.cdc.gov/vaccines/vpd-vac/polio/dis-faqs.htm. Accessed Jan. 16, 2009.
  3. Post-polio syndrome fact sheet, National Institute of Neurological Disorders and Stroke. http://www.ninds.nih.gov/disorders/post_polio/detail_post_polio.htm. Accessed Jan. 15, 2009.
  4. Howard RS. Poliomyelitis and the postpolio syndrome. British Medical Journal. 2005;330:1314.


  •    Causes y Mayo Clinic staff

    The strength of your bones depends on their size and density; bone density depends in part on the amount of calcium, phosphorus and other minerals bones contain. When your bones contain fewer minerals than normal, they're less strong and eventually lose their internal supporting structure.
    The process of bone remodeling
    Scientists have yet to learn all the reasons why this occurs, but the process involves how bone is made. Bone is continuously changing — new bone is made and old bone is broken down — a process called remodeling, or bone turnover.
    A full cycle of bone remodeling takes about two to three months. When you're young, your body makes new bone faster than it breaks down old bone, and your bone mass increases. You reach your peak bone mass in your mid-30s. After that, bone remodeling continues, but you lose slightly more than you gain. At menopause, when estrogen levels drop, bone loss in women increases dramatically. Although many factors contribute to bone loss, the leading cause in women is decreased estrogen production during menopause.
    Your risk of developing osteoporosis depends on how much bone mass you attained between ages 25 and 35 (peak bone mass) and how rapidly you lose it later. The higher your peak bone mass, the more bone you have "in the bank" and the less likely you are to develop osteoporosis as you age. Not getting enough vitamin D and calcium in your diet may lead to a lower peak bone mass and accelerated bone loss later.
    What keeps bones healthy
    Three factors that you can influence are essential for keeping your bones healthy throughout your life:
    • Regular exercise
    • Adequate amounts of calcium
    • Adequate amounts of vitamin D, which is essential for absorbing calcium
    • A number of factors can increase the likelihood that you'll develop osteoporosis, including:

    • Risk factors By Mayo Clinic staff

    • Your sex. Fractures from osteoporosis are about twice as common in women as they are in men. That's because women start out with lower bone mass and tend to live longer. They also experience a sudden drop in estrogen at menopause that accelerates bone loss. Slender, small-framed women are particularly at risk. Men who have low levels of the male hormone testosterone also are at increased risk. The risk of osteoporosis in men is greatest from age 75 on.
    • Age. The older you get, the higher your risk of osteoporosis. Your bones become weaker as you age.
    • Race. You're at greatest risk of osteoporosis if you're white or of Southeast Asian descent. Black and Hispanic men and women have a lower, but still significant, risk.
    • Family history. Osteoporosis runs in families. For that reason, having a parent or sibling with osteoporosis puts you at greater risk, especially if you also have a family history of fractures.
    • Frame size. Men and women who are exceptionally thin or have small body frames tend to have higher risk because they may have less bone mass to draw from as they age.
    • Tobacco use. The exact role tobacco plays in osteoporosis isn't clearly understood, but researchers do know that tobacco use contributes to weak bones.
    • Lifetime exposure to estrogen. The greater a woman's lifetime exposure to estrogen, the lower her risk of osteoporosis. For example, you have a lower risk if you have a late menopause or you began menstruating at an earlier than average age. But your risk of osteoporosis is increased if your lifetime exposure to estrogen has been deficient, such as from infrequent menstrual periods or menopause before age 45.
    • Eating disorders. Women and men with anorexia nervosa or bulimia are at higher risk of lower bone density in their lower backs and hips.
    • Corticosteroid medications. Long-term use of corticosteroid medications, such as prednisone, cortisone, prednisolone and dexamethasone, is damaging to bone. These medications are common treatments for chronic conditions, such as asthma, rheumatoid arthritis and psoriasis. If you need to take a steroid medication for long periods, your doctor should monitor your bone density and recommend other drugs to help prevent bone loss.

    • Thyroid hormone. Too much thyroid hormone also can cause bone loss. This can occur either because your thyroid is overactive (hyperthyroidism) or because you take excess amounts of thyroid hormone medication to treat an underactive thyroid (hypothyroidism).
    • Selective serotonin reuptake inhibitors (SSRIs). Research published in 2007 showed lower bone mineral density among both men and women currently using SSRIs compared with study participants not taking these antidepressants. However, these results don't necessarily mean that SSRIs cause bone loss or osteoporosis. More research is needed to fully understand the association between SSRI use and low bone density. Evidence does not currently indicate that you should stop using SSRIs because of concerns about bone loss.
    • Other medications. Long-term use of the blood-thinning medication heparin, the cancer treatment drug methotrexate, some anti-seizure medications, diuretics and aluminum-containing antacids also can cause bone loss.
    • Breast cancer. Postmenopausal women who have had breast cancer are at increased risk of osteoporosis, especially if they were treated with chemotherapy or aromatase inhibitors such as anastrozole and letrozole, which suppress estrogen. This isn't true for women treated with tamoxifen, which may reduce the risk of fractures.
    • Low calcium intake. A lifelong lack of calcium plays a major role in the development of osteoporosis. Low calcium intake contributes to poor bone density, early bone loss and an increased risk of fractures.
    • Medical conditions and procedures that decrease calcium absorption. Stomach surgery (gastrectomy) can affect your body's ability to absorb calcium. So can conditions such as Crohn's disease, celiac disease, vitamin D deficiency, anorexia nervosa and Cushing's disease — a rare disorder in which your adrenal glands produce excessive corticosteroid hormones.
    • Sedentary lifestyle. Bone health begins in childhood. Children who are physically active and consume adequate amounts of calcium-containing foods have the greatest bone density. Any weight-bearing exercise is beneficial, but jumping and hopping seem particularly helpful for creating healthy bones. Exercise throughout life is important, but you can increase your bone density at any age.
    • Excess soda consumption. The link between osteoporosis and caffeinated sodas isn't clear, but caffeine may interfere with calcium absorption and its diuretic effect may increase mineral loss. In addition, the phosphoric acid in soda may contribute to bone loss by changing the acid balance in your blood. If you do drink caffeinated soda, be sure to get adequate calcium and vitamin D from other sources in your diet or from supplements.
    • Chronic alcoholism. For men, alcoholism is one of the leading risk factors for osteoporosis. Excess consumption of alcohol reduces bone formation and interferes with the body's ability to absorb calcium.
    • Depression. People who experience serious depression have increased rates of bone loss.

    • When to seek medical advice By Mayo Clinic staff

      Early detection is important in osteoporosis. Consider your risk factors, then discuss your prevention strategy with your doctor. If you're a woman, it's best to do this well before menopause.Osteoporosis  By Mayo Staff.Osteoporosis, which means "porous bones," causes bones to become weak and brittle — so brittle that even mild stresses like bending over, lifting a vacuum cleaner or coughing can cause a fracture. In most cases, bones weaken when you have low levels of calcium, phosphorus and other minerals in your bones.A common result of osteoporosis is fractures — most of them in the spine, hip or wrist. Although it's often thought of as a women's disease, osteoporosis also affects many men. And aside from people who have osteoporosis, many more have low bone density.

      Tests and diagnosis By Mayo Clinic staff
      Osteopenia refers to mild bone loss that isn't severe enough to be called osteoporosis, but that increases your risk of osteoporosis. Doctors can detect osteopenia or early signs of osteoporosis using a variety of devices to measure bone density.

      Dual energy X-ray absorptiometry
      The best screening test is dual energy X-ray absorptiometry (DEXA). This procedure is quick, simple and gives accurate results. It measures the density of bones in your spine, hip and wrist — the areas most likely to be affected by osteoporosis — and it's used to accurately follow changes in these bones over time.
      Other tests that can accurately measure bone density include:Ultrasound
      Quantitative computerized tomography (CT) scanning
      Should you have a test?
      If you're a woman, the National Osteoporosis Foundation recommends that you have a bone density test if you aren't taking estrogen and any of the following conditions apply to you:
      You're older than age 65, regardless of risk factors.
      • You're postmenopausal and have at least one risk factor for osteoporosis, including having fractured a bone.
      • You have a vertebral abnormality.
    You use medications, such as prednisone, that can cause osteoporosis.You have type 1 diabetes, liver

     disease, kidney disease, thyroid disease or a family history of osteoporosis.

    Complications By Mayo Clinic staff

    • Fractures are the most frequent and serious complication of osteoporosis. They often occur in your spine or hips — bones that directly support your weight. Hip fractures usually result from a fall. Although most people do relatively well with modern surgical treatment, hip fractures can result in disability and even death from postoperative complications, especially in older adults. Wrist fractures from falls also are common.
      In some cases, spinal fractures can occur without any fall or injury simply because the bones in your back (vertebrae) become so weakened that they begin to compress. Compression fractures can cause severe pain and require a long recovery. If you have many such fractures, you can lose several inches of height as your posture becomes stooped.Doctors don't generally recommend osteoporosis screening for men because the disease is less common in men than it is in women.It's never too late — or too early — to do something about osteoporosis. You can take steps to keep bones strong and healthy throughout life.
      Symptoms By Mayo Clinic staff
      In the early stages of bone loss, you usually have no pain or other symptoms. But once bones have been weakened by osteoporosis, you may have osteoporosis symptoms that include:
      • Back pain, which can be severe if you have a fractured or collapsed vertebra
      • Loss of height over time, with an accompanying stooped posture
      • Fracture of the vertebrae, wrists, hips or other bones

      Treatments and drugs
      By Mayo Clinic staff

      Hormone therapy
      Hormone therapy (HT) was once the mainstay of treatment for osteoporosis. But because of concerns about its safety and because other treatments are available, the role of hormone therapy in managing osteoporosis is changing. Most problems have been linked to certain oral types of HT, either taken in combination with progestin or alone. If you're interested in hormone therapy, other forms are available, including patches, creams and the vaginal ring.Discuss the various options with your doctor to determine which might be best for you.
      Prescription medications
      If HT isn't for you, and lifestyle changes don't help control your osteoporosis, prescription drugs can help slow bone loss and may even increase bone density over time. They included
      Bisphosphonates. Much like estrogen, this group of drugs can inhibit bone breakdown, preserve bone mass, and even increase bone density in your spine and hip, reducing the risk of fractures.
      Bisphosphonates may be especially beneficial for men, young adults and people with steroid-induced osteoporosis. They're also used to prevent osteoporosis in people who require long-term steroid treatment for a disease such as asthma or arthritis.
      Side effects, which can be severe, include nausea, abdominal pain, and the risk of an inflamed esophagus or esophageal ulcers, especially if you've had acid reflux or ulcers in the past. Bisphosphonates that can be taken once a week or once a month may cause fewer stomach problems. If you can't tolerate oral bisphosphonates, your doctor may recommend periodic intravenous infusions of bisphosphonate preparations.
      In 2007, the Food and Drug Administration (FDA) approved the first once-yearly drug for postmenopausal women with osteoporosis. The medication, zoledronic acid (Reclast), is given intravenously at your doctor's office. It takes about 15 minutes to get your annual dose. One published study found that zoledronic acid reduces the risk of spine fracture by 70 percent and of hip fracture by 41 percent.A small number of cases of osteonecrosis of the jaw have been reported in people taking bisphosphonates for osteoporosis. These cases have primarily occurred after trauma to the jaw, such as a tooth extraction, or cancer treatment. Risk appears to be higher in people who have received bisphosphonates intravenously. While there is currently no clear evidence that you should stop taking bisphosphonates before dental surgery, let your dentist know what medications you're taking and discuss your concerns.
      • Raloxifene (Evista). This medication belongs to a class of drugs called selective estrogen receptor modulators (SERMs). Raloxifene mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen, such as increased risk of uterine cancer and, possibly, breast cancer. Hot flashes are a common side effect of raloxifene, and you shouldn't use this drug if you have a history of blood clots. This drug is approved only for women with osteoporosis and is not currently approved for use in men.
      • Calcitonin. A hormone produced by your thyroid gland, calcitonin reduces bone resorption and may slow bone loss. It may also prevent spine fractures, and may even provide some pain relief from compression fractures. It's usually administered as a nasal spray and causes nasal irritation in some people who use it, but it's also available as an injection. Because calcitonin isn't as potent as bisphosphonates, it's normally reserved for people who can't take other drugs.
      • Teriparatide (Forteo). This powerful drug, an analog of parathyroid hormone, treats osteoporosis in postmenopausal women and men who are at high risk of fractures. Unlike other available therapies for osteoporosis, it works by stimulating new bone growth, as opposed to preventing further bone loss. Teriparatide is given once a day by injection under the skin on the thigh or abdomen. Long-term effects are still being studied, so the FDA recommends restricting therapy to two years or less.
      • Tamoxifen. This synthetic hormone is used to treat breast cancer and is given to certain high-risk women to help reduce their chances of developing breast cancer. Although tamoxifen blocks estrogen's effect on breast tissue, it has an estrogen-like effect on other cells in your body, including your bone cells. As a result, tamoxifen appears to reduce the risk of fractures, especially in women older than 50. Possible side effects of tamoxifen include hot flashes, stomach upset, and vaginal dryness or discharge.
      Emerging therapies
      A new physical therapy program has been shown to significantly reduce back pain, improve posture and reduce the risk of falls in women with osteoporosis who also have curvature of the spine. The program combines the use of a device called a spinal weighted kypho-orthosis (WKO) — a harness with a light weight attached — and specific back extension exercises. The WKO is worn daily for 30 minutes in the morning and 30 minutes in the afternoon and while performing 10 repetitions of back extension exercises.
      Getting adequate calcium and vitamin D is an important factor in reducing your risk of osteoporosis. If you already have osteoporosis, getting adequate calcium and vitamin D, as well as taking other measures, can help prevent your bones from becoming weaker. In some cases you may even be able to replace bone you've lost.

      The amount of calcium you need to stay healthy changes over your lifetime. Your body's demand for calcium is greatest during childhood and adolescence, when your skeleton is growing rapidly, and during pregnancy and breast-feeding. Postmenopausal women and older men also need to consume more calcium. As you age, your body becomes less efficient at absorbing calcium, and you're more likely to take medications that interfere with calcium absorption.
      How much calcium and vitamin D?
      Premenopausal women and postmenopausal women who use HT should consume at least 1,000 milligrams (mg) of elemental calcium and a minimum of 800 international units (IU) of vitamin D every day. Postmenopausal women not using HT, anyone at risk of steroid-induced osteoporosis, and all men and women older than 65 should aim for 1,500 mg of elemental calcium and at least 800 IU of vitamin D daily.
      Getting enough vitamin D is just as important as getting adequate amounts of calcium. Not only does vitamin D improve bone health by helping calcium absorption, but it also may improve muscle strength. Scientists are continuing to study vitamin D — which may also protect against certain types of cancer — to determine the optimal daily dose, but it's safe to take up to 2,000 IU a day.
      Although many people get adequate amounts of vitamin D from sunlight, this may not be a good source if you live in high latitudes, if you're housebound, or if you regularly use sunscreen or you avoid the sun entirely because of the risk of skin cancer. Although vitamin D is present in oily fish such as tuna and sardines and in egg yolks, you probably don't eat these on a daily basis. Calcium supplements with added vitamin D are a good alternative.
      As for calcium, dairy products are one, but by no means the only, source. Almonds, broccoli, cooked kale, canned salmon with the bones, oats and soy products such as tofu also are rich in calcium. If you find it difficult to get enough calcium from your diet, consider calcium supplements. Supplements are inexpensive and generally are well tolerated and well absorbed if taken properly. Sometimes calcium supplements can cause constipation. If this is a problem for you, drink more water and try using a fiber supplement. In addition, check the type of calcium you're using. Calcium phosphate and calcium citrate tend to be less constipating.
      Calcium and vitamin D supplements are most effective taken together in divided doses with food.Other tips for prevention
      These measures also may help you prevent bone loss:
      • Exercise. Exercise can help you build strong bones and slow bone loss. Exercise will benefit your bones no matter when you start, but you'll gain the most benefits if you start exercising regularly when you're young and continue to exercise throughout your life. Combine strength training exercises with weight-bearing exercises. Strength training helps strengthen muscles and bones in your arms and upper spine, and weight-bearing exercises — such as walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports — mainly affect the bones in your legs, hips and lower spine. Swimming, cycling and machines such as elliptical trainers can provide a good cardiovascular workout, but because they're low impact, they're not as helpful for improving bone health as weight-bearing exercises are.
      • Add soy to your diet. The plant estrogens found in soy help maintain bone density and may reduce the risk of fractures.
      • Don't smoke. Smoking increases bone loss, perhaps by decreasing the amount of estrogen a woman's body makes and by reducing the absorption of calcium in your intestine. The effects on bone of secondhand smoke aren't yet known.
      • Consider hormone therapy. Hormone therapy can reduce a woman's risk of osteoporosis during and after menopause. But because of the risk of side effects, discuss the options with your doctor and decide what's best for you. Testosterone replacement therapy works only for men with osteoporosis caused by low testosterone levels. Taking it when you have normal testosterone levels won't increase bone mass.
      • Avoid excessive alcohol. Consuming more than two alcoholic drinks a day may decrease bone formation and reduce your body's ability to absorb calcium. There's no clear link between moderate alcohol intake and osteoporosis.
      • Limit caffeine. Moderate caffeine consumption — about two to three cups of coffee a day — won't harm you as long as your diet contains adequate calcium.
      Lifestyle and home remedies By Mayo Clinic staff

      These suggestions may help relieve symptoms and maintain your independence if you have osteoporosis:
      • Maintain good posture. Good posture — which involves keeping your head held high, chin in, shoulders back, upper back flat and lower spine arched — helps you avoid stress on your spine. When you sit or drive, place a rolled towel in the small of your back. Don't lean over while reading or doing handwork. When lifting, bend at your knees, not your waist, and lift with your legs, keeping your upper back straight.
      • Prevent falls. Wear low-heeled shoes with nonslip soles and check your house for electrical cords, area rugs and slippery surfaces that might cause you to trip or fall. Keep rooms brightly lit, install grab bars just inside and outside your shower door, and make sure you can get in and out of your bed easily.
      • Manage pain. Discuss pain management strategies with your doctor. Don't ignore chronic pain. Left untreated, it can limit your mobility and cause even more pain.

      • Slide Shows




      The Polio Crusade

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      Erradicación de La poliomielitis

      Polio Tricisilla Adaptada

      March Of Dimes Polio History

      Dr. Bruno




      A 41-year-old man developed an acute illness at the age of 9 months during which, following a viral illness with headache, he developed severe weakness and wasting of the limbs of the left side. After several months he began to recover, such that he was able to walk at the age of 2 years and later was able to run, although he was never very good at sports. He had stable function until the age of 18 when he began to notice greater than usual difficulty lifting heavy objects. By the age of 25 he was noticing progressive difficulty walking due to weakness of both legs, and he noticed that the right calf had become larger. The symptoms became more noticeable over the course of the next 10 years and ultimately both upper as well as both lower limbs had become noticeably weaker.

      On examination there was wasting of the muscles of upper and lower limbs on the left, and massively hypertrophied gastrocnemius, soleus and tensor fascia late on the right. The calf circumference on the right exceeded that on the left by 10 cm (figure1). The right shoulder girdle, triceps, thenar eminence and small muscles of the hand were wasted and there was winging of both scapulae. The right quadriceps was also wasted. The wasted muscles were also weak but the hypertrophied right ankle plantar flexors had normal power. The tendon reflexes were absent in the lower limbs and present in the upper limbs, although the right triceps was reduced. The remainder of the examination was normal.

      Figure 1

      The patient's legs, showing massive enlargement of the right calf and wasting on the left


      What is that nature of the acute illness in infancy?
      What is the nature of the subsequent deterioration?
      What investigations should be performed?
      What is the differential diagnosis of the cause of the progressive calf hypertrophy?


      QUESTION 1

      An acute paralytic illness which follows symptoms of a viral infection with or without signs of meningitis is typical of poliomyelitis. Usually caused by one of the three polio viruses, it may also occur following vaccination and following infections with other enteroviruses.1 Other disorders which would cause a similar syndrome but with upper motor neurone signs would include acute vascular lesions, meningoencephalitis and acute disseminated encephalomyelitis.

      QUESTION 2

      A progressive functional deterioration many years after paralytic poliomyelitis is well known, although its pathogenesis is not fully understood.2 It is a diagnosis of exclusion; a careful search for alternative causes, for example, orthopaedic deformities such as osteoarthritis or worsening scoliosis, superimposed neurological disorders such as entrapment neuropathies or coincidental muscle disease or neuropathy, and general medical causes such as respiratory complications and endocrinopathies.3

      QUESTION 3

      Investigations revealed normal blood count and erythrocyte sedimentation rate and normal biochemistry apart from a raised creatine kinase at 330 IU/l (normal range 60–120 IU/l), which is commonly seen in cases of ongoing denervation. Electromyography showed evidence of denervation in the right APB and FDI with polyphasic motor units and complex repetitive discharges, no spontaneous activity in the left calf and large polyphasic units in the right calf consistent with chronic partial denervation. Motor and sensory conduction velocities were normal. A lumbar myelogram was normal. Magnetic resonance imaging (MRI) scan of the calves is shown in figure2.

      Figure 2

      Axial T1 weighted MRI scan (TR 588 ms, TE 15 ms) of the calves, showing gross muscle atrophy and replacement by adipose tissue on the left, and hypertrophy of the muscles on the right, with only minor adipose tissue deposition

      QUESTION 4

      The differential diagnosis of the progressive calf hypertrophy is given in the box.

      Causes of calf muscle hypertrophy

      Chronic partial denervation

      • radiculopathy

      • peripheral neuropathy

      • hereditary motor and sensory neuropathy

      • spinal muscular atrophy

      • following paralytic poliomyelitis

        Neuromyotonia and myokymia

      • Isaac's syndrome

      • generalised myokymia

      • neurotonia

      • continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis

        Muscular dystrophies



      • tumours

      • amyloidosis

      • cysticercosis

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