Polio: managing its late effects in the nursing home; Are you capturing the rehabilitative minutes you earn for post-polio syndrome?

For most Americans today, polio is a vaccine, not a crippling disease. However, in the 1940s and '50s poliomyelitis was an epidemic across the country. In 1952 alone, approximately 50,000 Americans contracted polio, with 12% dying. (1) Today an estimated 1.6 million Americans have survived polio's acute infectious stage with disabilities ranging from weakness to paralysis. (2)

Today, six decades after the polio epidemic, survivors are reporting new and unexpected symptoms related to the disease. Many people who conquered earlier disabilities are now facing the challenges of late-appearing symptoms, called post-polio syndrome (PPS). This received official acknowledgment in 2003, when the Social Security Administration issued a new ruling (SSR 03-lp) defining post-polio sequelae. (3)

Polio survivors are now entering nursing homes for treatment of comorbidities, such as heart disease and stroke, and injuries such as hip fractures. Understanding PPS symptoms can help nursing home staff capture RUG minutes for therapy while treating this previously underserved population. It is important that facilities specifically ensure consistency between sections G and P of the Minimum Data Set (MDS).

Etiology and Early Effects

Polio is a contagious disease caused by one of three types of polio viruses. Paralysis results in one out of every 200 infections. (4) Polio viruses are spread through direct hand-to-hand or hand-to-mouth contact after the virus is excreted in the feces of infected persons. The virus enters humans via the gastrointestinal tract, where it multiplies and spreads through the bloodstream. (5)

Polio viruses have a special ability to damage anterior horn cells of nerves serving muscle fibers. The nerve may recover. But when a nerve cell dies, the corresponding muscle fiber that it innervated becomes weak or paralyzed. Leg nerves are more often damaged than those in the arm. Muscle wasting is seen as soon as a week after the virus infects a person. (6)

Muscle fibers infected by polio viruses change internally. Fibers convert from type II, fast-twitching to type I, slow-twitching. In normal people, slow movement, such as walking, requires type I fibers. Faster movement, such as running, demands type II fibers. People whose muscles were affected by polio use both type I and type II fibers for ordinary walking. Those who had polio therefore experience excessive taxing of their muscle fibers. (6)

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Late Effects

As mentioned, people affected by polio decades earlier are increasingly seeking medical attention for a variety of clinical conditions related either to acute infection or its residual deficits. (3) PPS symptoms appear from 15-54 years after acute infection. The average reported onset of PPS is 28.8 years. Some PPS symptoms are exhibited in 50-80% of people who had polio. (5,6)

The most frequently reported late effects of polio are weakness and excessive fatigue, followed by pain, breathing difficulties, swallowing problems, intolerance to cold, cognitive changes, and sleep disturbances. (3,5-8)

Here's more information about each of these effects:

Weakness. The normal functional losses of aging are heightened for persons with PPS. Motor neurons already impaired decrease at a rate of 2% every decade after age 20 and 5% every decade after age 60. (2) Muscles affected by polio have a delay in recovery time after exercise. (6)

Excessive fatigue. "Hitting the polio wall" is a phrase commonly used to describe PPS fatigue. Polio survivors report that they are exhausted at the end of the day and more so at the end of the workweek. They need the weekend to regain enough strength to return to work on Monday.

Pain. The most commonly reported precipitant to PPS musculoskeletal pain is physical activity. Overuse of muscles leads to pain. (7) This is a catch-22 situation where exercise can lead to pain and muscle fatigue which, in turn, necessitates a more sedentary lifestyle that can easily lead to weight gain. Muscles in people with PPS must then work harder when they gain weight. Weight gain also adversely affects joints. In addition, the polio survivor has often compensated for a weakened limb by favoring a stronger one, leading to degenerative joint disease and osteoarthritis in the overused limb. (7)

Breathing difficulties/sleep disorders/swallowing and speech difficulties. Dysphagia (difficulty swallowing) or respiratory insufficiency occur mainly in polio survivors if breathing and swallowing problems were present in the acute polio attack. (7) Dysphagia most often occurs later in the day as the polio survivor tires. When muscles used for breathing lose strength, the ability to breathe is impaired. Muscle weakness caused by polio may lead to sleep disorders and the inability to fully inflate the lungs. For those survivors who suffered respiratory or bulbar polio, baseline pulmonary function testing is recommended. (9) Ventilatory assistance may range from CPAP (continuous positive airway pressure) and BiPAP (bilevel positive airways pressure) for sleep disorders to ventilator use. (7) Preventing infection is important. All polio survivors should receive pneumococcal vaccine and a yearly influenza vaccine. (7,9)

Intolerance to cold. Cold often precipitates pain in previously paralyzed or weakened extremities. Polio survivors should layer their clothing to ensure that limbs are adequately covered when exposed to cool, ambient air, such as that found in restaurants and theaters. Many people with PPS find warm baths, heat packs, and hot tubs to be comforting. (10)

Inattention/impaired concentration and memory deficits. Polio survivors report "brain tiredness." Symptoms include difficulty with concentrating, word-finding, thinking clearly, and staying awake. (2) Neurons related to sleepiness, inattention, and fatigue may have been damaged by the polio virus. Damage, combined with a natural lessening of these neurons with age, causes increased sleepiness and fatigue when survivors reach middle age. (8)

Gearing Up for Care

Survivors of polio report difficulty finding primary care providers who are knowledgeable about PPS. (3,7) They are most often cared for by doctors and nurses who have never seen an acute case of polio. Nursing home staff, well-versed in PPS, can partner with residents, individualizing interventions to bring symptom relief and improved functioning on a day-to-day basis.

Whereas individuals with PPS had to work hard to overcome the early effects of polio, now they must do smart work so that they do not stress muscle groups. People who had polio must learn to live within their disability.

Key Players

Nurses are on the front line, gathering data from residents about their histories with polio and current clinical conditions. Sometimes it is the nurse who first learns of a resident's bout with polio. Nurses can draw on the inherent strengths of residents who had polio. Survivors have more formal education than other disabled and nondisabled groups and score higher on spiritual values. Additionally, most people who have lived through the ups and downs of the disease have an internal locus of control orientation; they take control and adapt well to new situations. (1,2,8) Nurses should encourage these strengths. They can ensure that polio survivors experience decreased physical and emotional strain and intersperse rest with rehabilitation each day. (7)

Physical therapists can set up mild and judicious exercise programs that work around the fine line between over-and underuse of weakened muscle groups. (6,7,11,13) Exercise may vary from gentle stretching and yoga to aerobic exercises. (10) Special attention must be paid to providing weight-bearing exercises to lessen bone density loss. (7) Isometric and isokinetic training, along with progressive resistive exercises, are recommended. Moderate walking and swimming are good conditioning exercises for residents with PPS. Swimming, however, must be done in warm water because of the survivor's intolerance for cold. (5,6)

Occupational therapists can coach polio survivors to pace themselves and conserve energy. Regular rest periods and guaranteed nighttime sleep are essential. (7)

Speech therapists become involved as swallowing and breathing issues arise. Special swallowing techniques such as chin-tuck or head-turning can be taught. (7) Food consistency may need to be altered, especially as the resident with PPS tires later in the day. Devices to assist with coughing may be warranted. (7,9)

Gearing Up for Polio Survivors

The medical community once believed that people who had polio, after working hard to recover, reached a stable plateau. Each survivor believed polio was conquered and left behind. Today, persons affected by polio outnumber people with multiple sclerosis, amyotrophic lateral sclerosis, and spinal cord injury (paraplegia and quadriplegia). (1) With the development of late symptoms, the march against polio must reconvene. Nursing home staff play a pivotal role in helping residents with PPS remain strong, with maximum functioning unimpeded by the resurgence of their childhood disease.