From Fifth International Polio & Independent Living Conference in Saint Louis
Suggestions for Exercise
Polio survivor, Nancy Caverly, Saint Louis, Missouri, introduced the topic of exercise and energy conservation by sharing her experiences.
About 15 years ago, with my youngest child securely placed in school, I decided to become a jock and take part in one of the major exercise programs in Saint Louis. The first day of the class, I was impressed by my size, which was larger than all of the thin women who had signed up to become super-jocks. Also, I was impressed by my inability to perform most of the exercises. Nevertheless, on my little pad on the floor, I pursued all of the exercises I could possibly do. I went home after an hour of a rigorous workout, took a hot bath, and went to bed for the rest of the day. I did finish the six-week course, because I had paid for it, but after the first day I did only the exercises that my body would allow me to do comfortably and without strain. I chalked the experience up as one major mistake in my personal quest for how best to maintain my body for the years to come – this was not the way.
The other exercise I tried doing, because I had done it extensively before polio at age 17, was swimming. My first morning included walking down a long flight of steps, changing clothes and getting into the pool, and swimming with businessmen who came to do 50 laps on their lunch hour. That day, I did 36 laps, or 1/2 mile, and again went to bed for the day. This time I did not wipe swimming off of my list of acceptable exercises, because I knew that swimming had many positive points for exercising. I decided to start low and build up my laps to find out the reasonable number for my body. Now, I swim two days a week, between 8 and 10 o'clock in the morning. The reasonable number for me is 20 laps in the 100% accessible 25-meter pool at a local school. I do ten laps of freestyle or crawl stroke, two laps of back stroke, two laps of elementary back stroke, two laps of breast stroke, two laps of side stroke, and a few stretching exercises. For the last two laps, I do whatever makes me feel the best, I check my pulse rate after about ten laps and it usually is about 112 to 118 a minute, the minimum necessary for cardiovascular conditioning. It takes me approximately 20 to 25 minutes to do that number of laps. The cardiovascular stimulation that I am getting from swimming is great; I am unable to exercise in any other way (walking, cycling, etc.) for that length of time.
On the Tuesdays and Thursdays after swimming, my energy level during the day is much higher. I do not go to sleep at 8 o'clock watching a movie on television. I am still moving at 10 o'clock that night, not with energy that I should not have, but with energy that is available to be used.
After swimming for five years, I was telling our local pharmacist that I was having some low-back pain from an old diving injury. He suggested I try swimming with fins. With fins, I get faster movement so that it takes me less time and fewer strokes, but I get more resistance. The low back pain decreased within a three-month period and has not recurred. As a polio survivor, I know I am going to find a year-round swimming pool where I can swim at least two times a week, wherever I live in the future. That is where my body and I are with exercise.
Non-Fatiguing General Conditioning Exercise Program (The 20% Rule)
Stanley K. Yarnell, MD (now retired), San Francisco, California
The non-fatiguing general conditioning exercise program using the 20% rule was designed to restore stamina or endurance for those individuals who have continued to be bothered by profound fatigue following surgery, illness or trauma.
The program begins by determining the polio survivor's maximum exercise capability with the help of the clinic physical therapist. The type of exercise can be in a pool or on dry land, using an arm erqometer or an exercise bicycle, depending on the individual's abilities and preferences. If one prefers swimming, the maximum number of laps that the patient can swim is used as the maximum exercise capability. If the survivor has considerable residual weakness and is only able to swim one lap in half an hour, then the amount of time actively swimming can be used as the maximum exercise capability rather than the number of laps.
Having established the maximum exercise capability, the polio survivor is instructed to begin his aerobic swimming program at 20% of the determined maximum exercise capability. He can swim three to four times per week at that level for one month, and then he is instructed to increase by 10%. For example, if an individual is able to actively swim in a pool for half an hour, then one-half hour would be his maximum exercise capability. He would begin swimming just six minutes per session three to four times per week for a month before increasing the amount of time actively swimming to nine minutes three to four times per week for another month. Then he would increase by 10% once again so that he was actively swimming 12 minutes per session three to four times per week for another month, and so on. After three to four months, our patients have reported that they feel an increase in their general stamina or endurance.
Alternatively, if an arm ergometer or exercise bicycle is used, the same basic principle can be utilized, calculating distance pedaled or time spent actively pedaling. The individual begins his aerobic or non-fatiguing general conditioning exercise program at 20% of maximum exercise capability three to four times per week for one month before increasing the distance by 10%. He continues with that level of activity for another month before increasing by another 10%, so that he is exercising at 40% of maximum exercise capability.
For example, if an individual is able to pedal an exercise bicycle for one mile or is able to actively pedal the bicycle for up to 20 minutes, then that is his maximum exercise capability. He is instructed to begin his exercise program at one-fifth of a mile (or, if time is used, then four minutes is the beginning exercise time). This is repeated three to four times per week for a month before increasing the distance to one-third of a mile or six minutes. Our patients are encouraged to maintain that for an additional month before increasing by another 10%, and so on.
Individuals are cautioned to stop if they become fatigued during their exercise program, or if they experience pain or aches in their muscles. Most polio survivors are able to continue increasing their exercise program to nearly the maximum exercise capability, though it clearly would take a full nine months if this program were strictly followed. Conditioning or aerobic exercise at this submaximal level allows the individual to regain a healthier sense of stamina without damaging delicate old motor units.
It is imperative to incorporate the concept of pacing and spacing within the non-fatiguing general conditioning exercise program, meaning that rests are to be taken every few minutes.
The 20% rule is sometimes also applied to polio survivors when they are given instructions in a home flexibility and stretching program so they do not exercise too vigorously.
This exercise program can be modified with the supervision of a physical therapist, depending on the progress made by the polio survivor. This program may not eliminate fatigue, but we have found it effective for those who have a significant element of deconditioning contributing to their sense of fatigue.
THE POLIO CRUSADE IN AMERICAN EXPERIENCE A GOOD VIDEO
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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.
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?
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.
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
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.
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
The differential diagnosis of the progressive calf hypertrophy is given in the box.
Causes of calf muscle hypertrophy
Chronic partial denervation
hereditary motor and sensory neuropathy
spinal muscular atrophy
following paralytic poliomyelitis
Neuromyotonia and myokymia
continuous muscle fibre activity due to: chronic inflammatory demyelinating polyradiculopathy, Guillain Barre syndrome, myasthenia gravis, thymoma, thyrotoxicosis, thyroiditis