May 29, 2017

Global Polio Eradication


Poliomyelitis (polio) is a highly infectious viral disease, which mainly affects young children. The virus is transmitted through contaminated food and water, and multiplies in the intestine, from where it can invade the nervous system. Many infected people have no symptoms, but do excrete the virus in their faeces, hence transmitting infection to others. Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in the neck and pain in the limbs. In a small proportion of cases, the disease causes paralysis, which is often permanent. Polio can only be prevented by immunization.

Global Polio Eradication

There are only three polio-endemic countries in the world: Afghanistan, Nigeria and Pakistan (data as of September 2014). In the past 12 months importations of wild poliovirus were detected in seven countries which were previously polio-free: Cameroon, Equatorial Guinea, Ethiopia, Iraq, Pakistan, Somalia and Syria (updated September 2014). In 2013, a total of 416 cases of paralysis due to wild poliovirus were reported globally. 

Polio Eradication in the  

The last indigenous case of wild poliovirus in the Western Pacific Region was reported in Cambodia in 1997. The Western Pacific Region was certified polio free on 29 October 2000. Since certification in 2000, the Region has experienced three wild poliovirus importations. Due to the efforts of public health workers, the transmission of wild poliovirus following the importation was rapidly stopped. 

The Polio Endgame

An unprecedented intensity of polio eradication activities between 2010 and 2012 resulted in significant progress towards the global eradication of poliomyelitis. Acknowledging the progress, in May 2012, the World Health Assembly declared the completion of polio eradication a programmatic emergency for global public health and requested the WHO Director-General to rapidly finalize a comprehensive eradication and endgame strategy. The Global Polio Eradication Initiative (GPEI) developed the Polio Eradication and Endgame Strategic Plan 2013–2018, a comprehensive, long-term strategy for the eradication and containment of all polioviruses (wild and vaccine-related). At the Sixty-sixth session of the World Health Assembly, Member States reviewed and endorsed the Polio Eradication and Endgame Strategic Plan 2013–2018.

The Polio Endgame in the Western Pacific Region

Unlike previous global polio plans, the Polio Eradication and Endgame Strategic Plan 2013–2018 has implications for countries and areas in polio-free regions. Recognizing the need to tailor the plan to the Western Pacific Region, the Polio Endgame in the Western Pacific Region 2013–2018 was developed. This document refines activities from the global polio endgame to provide technical guidance to countries and areas on the content of national polio endgame plans, explain the role of the WHO Regional Office for the Western Pacific, the financial implications and the key implementation challenges of the polio endgame.

Polio Endgame Toolkit

For resources related to the Polio Endgame in the Western Pacific Region, please visit . The Polio Endgame Toolkit contains useful resources for the Western Pacific Region including briefs, fact sheets, communications resources, poster infographics and inactivated polio vaccine (IPV) introduction training modules related to the polio endgame and IPV introduction.

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May 22, 2017

Rehabilitation for postpolio sequelae.

Author information

Department of Medicine, University of Melbourne, and Melbourne Extended Care and Rehabilitation Centre, Royal Melbourne Hospital, Victoria.



Postpolio sequelae (PPS) are new, late manifestations that occur many years after the initial poliomyelitis infection. Recurrence of symptoms and fear of reactivation of the polio virus is particularly distressing to polio survivors.


This article outlines the diagnosis, pathophysiology, and management of PPS disabilities using a case vignette.


Clinical features of PPS include fatigue, joint and muscle pain, new muscular weakness and bulbar symptoms. Diagnosis can be complicated particularly in nonparalytic cases of poliomyelitis.
Disabilities in PPS may not be obvious to the observer but significantly affect the quality of life of the PPS patient. 
Previous rehabilitation intervention focussed on physical effort and determination to overcome disability at all costs. The treatment in PPS is now modified, and aggressive physical measures that may exacerbate muscle weakness are avoided. 
Most disabilities in PPS can be well managed with rehabilitation interventions that address limitations in patient activities of daily living, mobility and cardiopulmonary fitness.

May 21, 2017

I Tried to Get Off Ativan

Harriet Brown

And learned some dark shit in the process.

In 2006 I had a really, really bad year. My older daughter got sick and nearly died, my younger daughter got depressed, and my beloved mother-in-law developed terminal lung cancer. For weeks all I could do was cry and panic and cry some more. 
When a psychiatrist suggested I take a small dose of lorazepam (the generic name for Ativan) three times a day, I said yes please. The relief was immediate: I could sleep. I could think. I could cope with the multiple traumas our family was facing. 
I was in good company. According to a new report based on government data, one in five American women (and one in ten men) has taken at least one psychiatric medication, mostly antidepressants or anti-anxiety drugs like Ativan. And most of these patients take the meds regularly, many for years and years. Like me. 

Our annus horribilis eventually came to an end: My daughters got better and my mother-in-law died. But eight years later I was still slipping a tiny white pill under my tongue three times a day, and I wanted to stop. I asked my doctor if he could help me get off it, and his response, more or less, was "If it ain't broke, don't fix it." 
The thing was, it was sort of broke. My once-excellent memory had become unreliable. I felt dull and stupid. My balance got so wobbly I tripped over nothing one day and face-planted myself into a broken nose. The doc reassured me that the class of medications known as benzodiazepines were benign, but I was reading research linking benzos with dementiamemory lossfalls, and overdoses.
Some percentage of people who've taken benzos for more than a few weeks can stop cold turkey and have no problems. But I knew I wasn't one of them. Whenever I was late with a dose I'd feel my anxiety spike and my heart pound. After eight years I'd become physically dependent on the drugs. Getting off them wasn't going to be easy.
When you can't sleep or eat or breathe without feeling like you're about to die, you'll do pretty much anything to make it stop. Benzos really are a miracle drug in that moment.
Benzodiazepines were the pharmaceutical miracle of the 1960s. Librium, Valium, and other benzos were prescribed for everything from insomnia to seizures, and by the late 1970s they were the most prescribed medication in the world

"There are plenty of appropriate uses for them," says Joseph Lee, medical director of the Hazelden Betty Ford Foundation Youth Continuum. He names seizure disorders, catatonia, and life-threatening withdrawal from alcohol and other sedatives.
But by far the most common reason benzos are prescribed is for anxiety. And I get why. When you've gone a week or two with your body and brain in panic mode, when you can't sleep or eat or breathe without feeling like you're about to die, you'll do pretty much anything to make it stop. Benzos really are a miracle drug in that moment.
Unfortunately, for most people those miraculous anti-anxiety effects last only a few weeks or, if you're lucky, months. In one of the few studies ever done on the long-term effectiveness of benzos, people who took Xanax to manage anxiety did worse after eight weeks than people who took a placebo. "That finding has never been repeated because nobody will fund it," says Reid Finlayson, an associate professor of clinical psychiatry and behavioral sciences at Vanderbilt University in Nashville. 
People who took Xanax to manage anxiety did worse after eight weeks than people who took a placebo. 
Doctors keep right on writing scrips for benzos for years, even decades, despite the fact that they're linked to treatment-resistant depressionsuicidecognitive impairmentAlzheimer's disease and other dementias, and traffic accidents. The number of benzodiazepine prescriptions in the US has tripled in the past two decades. A 2015 study showed that more than 5 percent of the US population filled prescriptions for benzos; up to a third of them were long-term users (this despite the fact that the label usually recommends otherwise). 

When I contacted Pfizer, makers of Xanax, with questions about the longterm use of their drug, a rep there offered this bland statement: "When prescribed and taken as indicated, Xanax is an important treatment option for patients. As with all our medicines, Xanax should be administered in accordance with local product labeling. Patients who have questions should speak with their healthcare provider."
Ideally, says, Thomas L. Schwartz, a professor of psychiatry at SUNY Upstate Medical University in Syracuse, New York, benzodiazepines aren't the go-to treatment for treating anxiety. "Classically a patient is treated with psychotherapy, an SSRI, or an SNRI," he explains. "After these three things fail, a benzo is allowed per most treatment guidelines for many of the anxiety disorders."  
Schwartz feels that for some people, benzos remain effective long term. "I have some patients I have seen since 2000 and their [anti-anxiety effects] have not worn off," he says. My question is, how can you tell? My doctor certainly thought benzos were still working for me. But after eight years I wasn't so sure. 
I felt a deep sense of shame about using lorazepam, despite the fact that I'd taken it only as prescribed. I'd never upped my dose or popped a handful for fun or gone doctor-shopping for more. I didn't particularly like the way it made me feel. I didn't think it was doing much for my anxiety, either; an antidepressant now took care of that.

I went online to find out how to get off the meds, and what I read freaked me out. There were whole websites devoted to supporting people who were tapering themselves off the drug because no doctor could or would help. Some of them had been at it for months or years. Many struggled with such profound symptoms they'd become disabled. "It's incredibly hard to get off benzos, and it has nothing to do with addiction," Lee says. "It just has to do with physiologic dependence."
One of those long-term patients was Christy Huff, a cardiologist in Fort Worth, Texas. Huff was prescribed daily Xanax after dry eye syndrome made it impossible for her to sleep. It worked for a few weeks, but then she started to develop anxiety during the day, which she'd never had before. She needed more and more Xanax; she thought she was going crazy. She had no idea what was going on until a psychologist asked her to stop the Xanax for 12 hours before a biofeedback session. "My whole chest clamped down," remembers Huff. "I couldn't breathe. Suddenly it was like, Wait a second, this is not anxiety—I'm dependent on this stuff." 

May 14, 2017

Cannabis Company Designs Pain Patch For Fibromyalgia And Nerve Pain

Cannabis has been used as an all-purpose homeopathic remedy for centuries. Over time, evidence suggests that the plant was an herbal remedy for psycho-neurological disorders, breast cancer, rheumatism,  sexual disorders, and painful complications related to childbirth. Now, this ancient tool has a new, modern application. A cannabis patch is now available for patients with fibromyalgia and diabetic nerve pain.

Cannabis for fibromyalgia & nerve pain

Cannabis Company Designs 1 Cannabis Company Designs Pain Patch For Fibromyalgia And Nerve Pain
Photo credit
Fibromyalgia and diabetic neuropathy have a couple of things in common. Both conditions involve seemingly unexplainable pain, tingling, and can drastically reduce your quality of life.
Early research suggests that cannabis may have powerful therapeutic effects for both conditions, and this new pain patch offers a novel new approach for conditions that are incredibly difficult to treat.
2014 survey from the National Pain Foundations found that cannabis was considered the most effective pain medication by fibromyalgia patients who were willing to experiment with the herb.
Not all survey respondents had consumed cannabis. However, those that had suggested that the herb worked better at managing pain than the leading prescriptions for fibromyalgia, including Savella, Cymbalta, and Lyrica.
Small human trials of cannabis for diabetic neuropathy have also been successful. A study of 16 patients with diabetic neuropathy of the feet found the herb successfully reduced pain symptoms in a dose-dependant manner. The cannabis plant has successfully reduced nerve pain associated with conditions like multiple sclerosis as well.
While expensive cannabis-based pharmaceuticals are already available in some countries for the treatment of nervous disorders, most canna-curious patients are stuck with topical creams and oral cannabis options, which can be a little strong for the daytime.
Now, one innovative company, Cannabis Science, has released a revolutionary new topical application of cannabis medicines.

Cannabis Science designs an infused pain patch

Cannabis Company Designs 2 Cannabis Company Designs Pain Patch For Fibromyalgia And Nerve Pain
Photo credit
Cannabis Science, Inc. is a pharmaceutical research company that works to develop innovative new cannabis medicines. In November of 2016, they announced their most recent project, a transdermal patch that delivers powerful pain-fighting medicine through the skin and into the bloodstream.
The company has two new patches in mind, one for fibromyalgia and one for diabetic neuropathy. While both of these patches will contain cannabinoids, each formulation and delivery method will be designed to most effectively manage symptoms of the respective illness.
In a press release announcing the new pain patch, Cannabis Science CEO Raymond Dabney explains,
The development of these two new pharmaceutical medicinal applications are just the tip of the iceberg for what we see as the future for Cannabis Science.
While we strive to increase our land capacity for growth and facilities to produce our own product to supply our scientists with proprietary materials to make these formulations, we are also busy researching more potential needs for Cannabis related medical applications and developing the methods for delivery of these medications.
Earlier in 2016, Cannabis Science began recruiting for a study on inhaled cannabis preparations for patients with asthma and lung diseases like COPD.
Cannabis Science is also not the first company to look into the transdermal applications of cannabis. Mary’s Medicinals got there first, offering cannabis-infused pain patches to medical cannabis patients in Colorado, Arizona, Nevada, Washington, Michigan, and Oregon. The company also hopes to offer their patches in California soon.


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May 11, 2017

Rory Cooper: The Man Behind the Technology

Rory Cooper couldn’t have known what to expect as he and his team from the Human Engineering Research Laboratories at the University of Pittsburgh prepared to test their state-of-the-art power chair at October’s inaugural Cybathlon in Kloten, Switzerland.
The Cybathlon was conceived as a chance for the world’s leading assistive technology researchers to show off their latest and greatest innovations in several different events: a virtual race using brain control interface, a bicycle race using FES, obstacle courses for people with arm and leg prostheses, an obstacle course for robotic exoskeletons, and the event Cooper was competing in, an extreme obstacle course for power wheelchairs.
That might sound like fun to someone like Cooper, HERL’s founder and director and one of the preeminent researchers and engineers when it comes to assistive technology, but no one knew if people would fill up the hockey arena where the competition was being held — or if the general public even cared.
Photo courtesy of University of Pittsburgh
When Cooper strapped on his helmet and rolled into the arena, the response caught him off guard. “The size of the turnout was amazing,” he recalls. Not only was the arena mostly filled with raucous fans, but a large media contingent was on hand to broadcast the event live across Europe and the internet. “I’ve competed in a lot of athletic competitions — I was a Paralympian in 1988 and I’ve been a coach a number of times — but rolling out there, it felt almost like I was a gladiator.”
In many ways, Cooper is a gladiator for those who rely on assistive technology. Ever since he was paralyzed in 1980, Cooper has devoted himself to pushing assistive technology forward by inventing and improving the products people with disabilities rely on and fighting to raise the public’s awareness of their needs. If you use a wheelchair or any other sort of assistive technology, the chances are extremely high that he has had some direct or indirect influence on its design.
With a list of awards, accomplishments and honors almost as long as the list of patents he has secured, Cooper didn’t need the adulation of the Cybathlon crowd, but its significance was not lost on him. “Hopefully the enthusiasm that was there will drive more people to study science and engineering and help continue the progress that we’ve made,” he says. “If I want anything, I want to grow the positive impact that we can have on people with disabilities.”

Building the Wheelchair Capital

Cooper’s quest to elevate assistive technology began July 23, 1980, when he was paralyzed in a biking accident while stationed in Germany with the U.S. Army. He eventually made it home to California where he completed his rehab and married the German woman he had fallen in love with. As he studied electrical engineering at California Polytechnic State University, San Luis Obispo, he grew increasingly aware of the obstacles facing people with disabilities and his knack for solving them. He was particularly interested in the repetitive stress injuries many people suffered from pushing wheelchairs. He earned his bachelor’s, master’s and got a Ph.D. in electrical and computer engineering. He completed a fellowship in rehabilitation engineering and science and then taught at California State University in Sacramento. In 1990 he was appointed director of the school’s Human Engineering Laboratory and coordinator of the Rehabilitation Engineering Program. The University of Pittsburgh hired him away in 1994 and soon after he founded HERL.
“It started in my living room and dining room at home with me and two graduate students. My wife kicked us out and the VA gave us an old locker room,” he says. “Literally one of my students got an award last week, and he mentioned that there was a sign over his desk that said  ‘Please flush after using.’ I reminded him that my office was the towel cage.”
Even Cooper has trouble reconciling those humble beginnings with the program’s current setup. Six years ago HERL moved into a custom-built space in a swanky Pittsburgh research park alongside Google, Ford and other industry giants. The space is big enough to accommodate the 70 to 100 students, faculty and interns that regularly pass through, and it holds all the design and manufacturing equipment for researchers to see their projects through from inception to completion.
Rory Cooper pilots the MEBot in the 2016 Cybathlon.
Rory Cooper pilots the MEBot in the 2016 Cybathlon. Photo courtesy of HERL.

“It is kind of unique in that everything’s housed at one place,” says Jonathan Duvall, a C6 quad completing his Ph.D. at HERL. “You can design something using 3-D CAD software and as soon as you’re done designing it, you go down to the basement to the machine shop and actually build it yourself. We don’t outsource any of our production. We have all the machines there to do it ourselves. So we go from concept and idea to prototyping to testing in the field — and even doing human subject testing to see how people feel about the technology that we develop and how effective it is.”
That unique setup, combined with a dedicated team of researchers and medical professionals, has helped make HERL into the “wheelchair capital” for researchers, according to Jonathan Pearlman, the associate director for product innovation and translation. “I don’t think I’ve ever seen a shop like we have,” he says. “Even our engineering schools here at Pitt — their jaws just drop when they see the resources we have. … Our setup helps create the kinds of synergies that happen less frequently elsewhere.”
The 70 or so projects going on at any one time run the gamut. Beyond wheelchairs and orthoses, you might catch a glimpse of robots preparing meals, researchers testing home environmental control units or something else you’ve never seen before.
“You really never know what’s going to be talked about the next day,” says Brandon Daveler, a C4-5 quad who completed his master’s at HERL and is now working on his Ph.D.
Brandon Daveler and Jonathan Duvall are both grad students at HERL
Brandon Daveler and Jonathan Duvall are both grad students at HERL. Photo by Lawrence Roffee Photography.

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May 6, 2017

Polio survivor group talks of legacy and a new battle

At six-years-old, Bobby Doherty from Belfast wasn't playing or riding his bike - he was lying entombed in plaster from head-to-foot in Musgrave Park Hospital after contracting polio. 
More than half a century after the infection first struck, he and a group of fellow polio survivors still meet up each week in the Short Strand Recreation Centre. 
They play games, reminisce over a cup of tea and support each other in coping with the effects of a disease, which many people think doesn't exist anymore. 
Now in his 70s, Mr Doherty still vividly recalls falling ill. 

Bobby Doherty
Image captionMr Doherty still uses leg braces to get about

"It was September 1949, a lovely sunny Friday evening and I remember my father taking me to the GP but when we got there the surgery was closed," he said. 
"The doctor turned up at my house on Monday morning, tickled my left foot and said 'I'll be back in an hour with an ambulance or a consultant.'
"An hour later I was in an ambulance heading to the Purdysburn Fever Hospital."

'Fear of wasps'

Mr Doherty was to remain in hospital for more than a year with the serious viral infection, which causes muscles to shrink, paralysis and in some cases, death. 
When he was discharged, polio had left a permanent mark. He was paralysed in both legs and was fitted with leg braces, known then as calipers, which he still uses to get about. 
Another long-standing member of the NI Polio Fellowship is Eddie McCrory, who contracted the disease in 1957, aged five, during its largest outbreak in Northern Ireland. 

Eddie McCrory
Image captionMr McCrory was completely paralysed at first

For him too, the memories are sharp. 
"My father said I would only be in hospital for the night - and I remember falling out with him when I had to stay much longer than that," he said.
"I was in an isolation ward with three others, and my mother and father would come to the window and look in. She would cry and run away. 
"I was completely paralysed at first and I remember a wasp coming into the ward. The other children could cover themselves with their sheets but I couldn't. 
"It was terrible and I've had a fear of wasps ever since."
Mr McCrory, who is originally from Belfast's Short Strand but now lives in Carryduff, was left with a severe curvature of the spine. 

A young Eddie McCrory

Polio is now all but eradicated in the UK thanks to a highly-effective vaccine introduced in the 1960s. 
Polio does still exist worldwide, although polio cases have decreased by more than 99% since 1988, from an estimated more than 350,000 cases to 74 reported cases in 2015. 
Only two countries in the world have never stopped transmission of polio - Pakistan and Afghanistan.

Polio Fellowship Group meeting
Image captionThe NI Polio Fellowship playing some sport

But for the friends who still gather in east Belfast, the legacy of the disease lives on, not only in their disabilities but in a new battle with what's known as post-polio syndrome. 
Mr McCrory explains that while polio was once considered a static disease, it is now thought fresh symptoms can emerge up to 60 years later. 
"I have a diagnosis of post-polio syndrome - I can feel tired, really fatigued and then there are aches," he said.
"Not awful aches but in the parts where I didn't ever have polio. I'm very sensitive to cold. My feet and legs are like blocks of ice because the body doesn't respond quickly enough to changes in body temperature."

'Contented life'

He says there's a lack of awareness of the condition - not helped by the fact many polio experts are retired or deceased.
"Young doctors would have no idea," he said. "When I go to see the neurologist and he sends me to the physiotherapist, she'll often bring in her students and say - this is someone who had polio."
Dr Ultan Power, a molecular virology specialist from Queen's University Belfast, says post-polio syndrome is a neurological disease evident in people who had polio.

Dr Ultan Power
Image captionDr Ultan Power says no treatments are currently available for post-polio syndrome

"I've asked a few of my colleagues had they heard about post-polio syndrome and they all said no," he said. 
"My understanding is it is not well-known because of the virtual eradication of polio in society."
There are no treatments available but some clinical trials are ongoing, he added.
"One involves using antibodies from people who have the polio virus, which is pretty much everybody as we are all vaccinated," he said.
"They take them from healthy individuals and transfuse them into people who are suffering from post-polio syndrome. 
"The hope is that it will have an impact on the residual virus, help eliminate it and improve function for individuals - i.e. their ability to walk - and live a generally contented life."

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May 2, 2017

On the brink of eradication: Why polio research matters

Poliovirus research offers insights into other viruses that impact global health

In the decades since Dr. Jonas Salk developed the first polio vaccine, cases of polio have exponentially declined. Though once widespread epidemic, the highly infectious childhood disease is now close to global eradication. 

The question remains: why would researchers spend time and resources studying a virus already on the brink of total eradication? 
In a new Research Matters article, PLOS Pathogens author and microbiologist at the University of Texas Southwestern Medical Center, Julie K. Pfeiffer discusses why she studies poliovirus, and shares how her research has affected the study of other viruses. 
For Dr. Pfeiffer, there are several benefits to studying poliovirus. Poliovirus "grows like a weed", able to produce immense stocks that are easy and safe to work with since its genome can be targeted, mutations can be made within days, and a vaccine already exists for it. 
Most importantly, because poliovirus has already been exhaustively studied, it can serve as a useful model system, a virus that can be studied to understand the workings of other similar viruses.
Early in her career, Dr. Pfeiffer showed that RNA viruses such as poliovirus, benefited from a "sloppy replication strategy". As RNA viruses replicated, they produced genetic mutations, some of which benefited them. This discovery was later used show that other RNA viruses including chikungunya, also relied on sloppy replication strategies. 
In addition, Dr. Pfeiffer's research has shown that poliovirus "sticks to bacteria", aiding its infection and transmission. Her work, along that of other research groups, has shown that many gut viruses rely on intestinal bacteria to infect humans. Dr. Pfeiffer's findings were applied to human norovirus, a virus that can lead to severe infections with explosive vomiting and diarrhea, opening the door to prevention strategies. 
By studying an eradicated virus like poliovirus, scientists like Dr. Pfeiffer can learn more about other viruses that pose a threat to public health such as Ebola, Zika, and influenza. This type of basic research could potentially lead to new treatments and vaccines for these viruses. 
In your coverage please use this URL to provide access to the freely available article in PLOS Pathogens
Citation: Pfeiffer JK (2017) The importance of model systems: Why we study a virus on the brink of global eradication. PLoS Pathog 13(4): e1006330. doi:10.1371/journal.ppat.1006330
Funding: Dr. Pfeiffer's work is supported by NIH R01 AI74668, NIH R21 AI114927, a Burroughs Wellcome Fund Investigators in the Pathogenesis of Infectious Diseases Award, and a Faculty Scholar grant from the Howard Hughes Medical Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing Interests: The author has declared that no competing interests exist.
Disclaimer: AAAS and EurekAlert! are not responsible for the accuracy of news releases posted to EurekAlert! by contributing institutions or for the use of any information through the EurekAlert system.

May 1, 2017

Postpolio Syndrome Symptoms

Postpolio Syndrome

Synonyms and related keywords: PPS
  • Central 
    • Pathogenesis can include chronic pain, type A personality, depression, dysfunctional reticular-activated system, sleep disorders, and respiratory dysfunction. 
    • PPS produces somnolence and difficulty in concentrating and remembering.
  • Peripheral 
    • Pathogenesis may be metabolic exhaustion of the enlarged motor units, neuromuscular junction transmission defects, scarring within the motor neurons, or loss of motor units due to aging. 
    • PPS produces decreased muscular endurance and increased muscular fatigability.
  • Weakness 
    • A number of functional etiologies for weakness have been hypothesized, including disuse, overuse, and chronic weakness, as well as weight gain. 
    • Asymmetric and scattered weakness may be present. 
    • Some authors have found evidence that previously unaffected muscles later become weak; in these cases, they discovered that the patient was unaware or had not been told that the particular muscle had been affected during the acute episode.
  • Muscle pain 
    • Deep aching pain may be a component of a myofascial pain syndrome or fibromyalgia. 
    • This feature is extremely prevalent in PPS.
  • Gait disturbance: Difficulty with gait is caused by progressive weakness, pain, osteoarthritis, or joint instability; it is common in patients who previously used assistive devices but later discarded them.
  • Respiratory problems 
    • Respiratory disorders are most prevalent in patients with residual respiratory muscle weakness. 
    • These changes cause chronic microatelectasis, diminished pulmonary compliance, increased chest wall tightness, chronic alveolar hypoventilation, decreased cough and expiratory flow, and decreased clearing of secretions. 
    • The new respiratory difficulties are not only related to new respiratory muscle weakness but also to scoliosis, pulmonary emphysema, cardiovascular insufficiency, or poor posture. 
    • A central component also may occur because acute bulbar polio often affects the medullary structures, including the reticular formation and sleep regulatory system.
  • Swallowing problems 
    • These difficulties can occur in patients with bulbar and nonbulbar postpolio. 
    • Subclinical asymmetrical weakness in the pharyngeal constrictor muscles is almost always present in all postpolio muscular atrophy (PPMA) patients, including those who do not complain of new swallowing difficulties.
  • Autonomic dysfunction: The cause is unclear; the peripheral component could include muscular atrophy and, therefore, diminished heat production.
  • Sleep apnea
  • This disorder is not uncommon in patients left with residual bulbar dysfunction or severe respiratory compromise.
  • Sleep apnea appears to be due to a combination of the following:
    • Central apnea, due to a residual dysfunction of the surviving bulbar reticular neurons 
    • Obstructive apnea, due to pharyngeal weakness and increased musculoskeletal deformities from scoliosis or emphysema 
    • PPMA, resulting in diminished muscle strength of the respiratory, intercostal, and abdominal muscle groups
  • Flat back syndrome
  • Another possible symptom in some patients with PPS is the flat back syndrome, which consists of the inability to stand erect because of forward flexion of the trunk and pain in the low back and legs.
  • The flat back syndrome typically occurs in patients with diminished lumbar lordosis as a result of instrumentation of the spine for scoliosis, vertebral fracture, or degenerative joint disease.
  • The trunk extensor musculature plays an essential role in maintaining upright posture, and it may be that PPS-related weakness in this musculature represents a major contributing factor to the flat back syndrome in these patients.

Author: Flor M Muñiz, MD, Staff Physician, Department of Physical Medicine and Rehabilitation, Thomas Jefferson UniversityCoauthor(s): Gerald Herbison, MD, Clinical Professor, Department of Physical Medicine and Rehabilitation, Thomas Jefferson University
Flor M Muñiz, MD, is a member of the following medical societies: American Medical Association
Editor(s): Martin K Childers, DO, Associate Professor, Department of Physical Medicine and Rehabilitation, University of Missouri School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Kat Kolaski, MD, Adjunct Clinical Assistant Professor, Department of Pediatrics, University of North Carolina; Director, Pediatric and Adolescent Rehabilitation, Charlotte Institute of Rehabilitation; Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center; and Denise I Campagnolo, MD, MS, Clinical Director of Spinal Cord Injury Program, Associate Professor, Department of Physical Medicine and Rehabilitation, New Jersey Medical School

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