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From:         TOM WALTER 
To:           Multiple recipients of list POLIO 
Date:         Sat, 17 Jun 1995 01:09:50 EDT
Subject:      PPS PERSPECTIVE BY PERRY
From the March Newsletter of the (Downey, CA) Rancho Los Amigos Post-Polio
Support Group
POLIO IN PERSPECTIVE FOR 1995 With Dr. Jacquelin Perry
Reported by Mary Clarke Atwood; Posted by Tom Walter
Jacquelin Perry, M.D., Chief of Pathokinesiology and Polio Services at Rancho
Los Amigos Medical Center was the featured speaker at the Rancho Los Amigos
Post-Polio Support Group meeting in Downey, CA on December 10, 1994.
During the beginning portion of this lecture, Dr. Perry reviewed some basic
medical questions regarding post-polio syndrome, such as: who gets PPS; what
causes it; how is it diagnosed. She went on to explain muscle weakness in 
ore
detail before discussing lifestyle modification, tips for saving your 
shoulders
and exercise guidelines. She concluded by telling us what we can do, along 
with
some cautions.
POST-POLIO GROUPINGS
Many people assume that post-polio syndrome (PPS) is inevitable but it's
not. Although 95% of the people who come to the Rancho Polio Clinic do
have a problem, there are a curious 5% of clinic patients who ask, "Do
I have a problem?" Since people who do not have a problem do not come
to the clinic, Dr. Perry divides polio survivors into three groups.
Group 1 - ASYMPTOMATIC (History of polio with no current symptoms).
These people can continue their activities as usual. But if they start
having problems, they need to cut back on their activity level.
Group 2 - POST-POLIO SYNDROME (new symptoms of pain, fatigue, or
function). These patients say, "My leg hurts," or "My thighs hurt," or
"My calves ache". For this group, the patient's lifestyle has exceeded
their physical capacity so they must make a change.
Group 3 - POST-POLIO SEQUELAE (Post-Polio joint degeneration from
overuse). These people may experience joint tenderness, joint pain,
deformity, and/or degeneration that can be seen on x-rays. They say,
"My ankle hurts," or "My foot hurts."
WHY DID THIS HAPPEN?
During the acute phase of polio, 95% of the patient's anterior horn cells
were either injured or destroyed by the polio virus. (These are the nerve
cells that ultimately control muscles.) Within a month, 12% to 91% of
these cells began to  cover. Although many people seemed to "recover," the
majority do not have as many motor nerve cells as normal. Therefore, their
motor system is not as strong as normal. So with fewer motor units, the
muscles have been working harder than normal trying to meet regular demands.
This results in overuse of the system and weakness develops, regardless if
it is due to a nerve problem or a muscle problem. "If you cannot relate
your symptoms to weakness of the breathing muscles, or weakness of the arm
muscles, etc., then it is something else." So when you visit your doctor,
don't try to bias him by saying the cause of all your problems is PPS. Be
sure your doctor rules out other problems because there is no one sign,
examination, or laboratory test that will confirm a diagnosis of PPS.
Since a lot of physicians do not understand PPS, the patient must put what
they say in perspective. Nevertheless, it has been Dr. Perry's experience
that the patients who come to see her and announce that they have PPS are
usually the ones who do not!
DIAGNOSING PPS
Dr. Perry bases a diagnosis of PPS on three things:
1. a history of polio;
2. a period of some recovery followed by new loss of function;
3. a physical examination that reveals:
        A. scattered muscle weakness (observed during an extensive manual
        muscle test from head to toe);
        B. normal sensations;
        C. reflexes that are normal (2+) for strong muscles and depressed
        for weak muscles.
MUSCLE MATTERS
*  Recovered muscles (post-polio) are less efficient since there are
   fewer motor units as well as larger motor units.
*  If muscle weakness is revealed on a manual muscle test of the upper
   leg, probably 1/3 to 1/2 of that muscle has been lost.
*  The weaker the muscle, the less frequently it should be used.
*  Every muscle can be overused - even those of athletes and marathoners!
*  If you do not have strong enough muscles for normal activities you
   cannot do the same activities as people with normal muscle.
For normal muscles only 20% of the fibers are at work at any one time so
there is less fatigue. For polios, some muscles' fibers may be working
100% at any given time so they get no rest and fatigue very quickly. If
less than 20% of the muscle fiber is working at a given time, the muscle
gets full oxygenation and works fine. As the percentage of muscle fiber
in use increases "the less rest they get, the less oxygen they get, the
less they have a capacity to repair themselves."
LIFESTYLE MODIFICATION
*  "If you have symptoms and you've overused your muscles, what do you
do about it? You modify your lifestyle and remove the strain."
*  Find ways to make tasks easier or get rid of the tasks.
*  Break up activities with rest periods.
*  Stop doing heavy tasks.
*  Look at the number of activities you have per day. Many people feel
   better with fewer activities.
*  Polio survivors "do not have enough muscles to live the usual vigorous
   lifestyle. So you have to make your lifestyle match your muscle
   strength."
*  Extra body weight is like carrying around a spare tire. The recommend-
   ation is to reduce body weight by re-educating your taste buds. Dr.
   Perry compares this to visiting a new country and learning to eat new
   food. She suggests convincing yourself there are other flavors in life!
SAVING SHOULDERS
*  The shoulder is the most mobile joint in the body. It must have muscle
   to support it: The deltoid muscle lifts up the arm; the rotator cuff
   stabilizes the shoulder.
*  Polio patients activate twice as much of the muscle as a normal person
   to lift up an arm, so the muscle has less rest and fatigues more easily.
   You must find ways to rest your shoulder and not use it all the time.
*  The arm is heavy; it weighs about 5% of your body weight (3.5 kg or
   about 8 pounds). It is like having an eight pound weight hanging from
   each shoulder. You can take pressure off your shoulders by bending
   your elbow and bringing your arm and hand closer to your body.
*  Leaning on your arm is like leaning on your shoulder. When you push
   yourself up with your hands you push through the wrist, push through
   the elbows, push through the shoulders. This can cause impingement.
*  When you push yourself up with your hands the pectoral muscles are
   involved. The pectoral muscles are a new area of focus that have not
   had much attention in the past.
*  People who use crutches can wear out their shoulders. Their rotator
   cuff can be repaired and will be ok if the person quits using the
   crutches and rides thereafter. (It's like wearing out a sock and
   then darning it. But you don't get a new pair of socks.)
*  So how can you save your shoulders?
1.  Reduce reaching;
2.  Support your arms;
3.  Lean back about 10 degrees when sitting (with back support) and
    bring the work up to you.
4.  Get others to do the job.
EXERCISE
*  When your lifestyle gives you a margin of muscle capacity that is
   not being used, then exercise can be considered. If there is no
   margin, there should be no exercise.
*  Muscles that test as 3+ are markedly hypertrophied (enlarged). They
   have to work double time for normal activities so they tire easily.
   These 3+ muscles are very good for short periods but they do not
   need more exercise.
*  Only muscles that test grade 4 or 5 should be considered for exercise.
   Even some grade 4 muscles are questionable - you must be sure your
   lifestyle gives a margin of muscle that is not being used before
   considering exercise for it.
*  If a muscle qualifies for exercise, it should be done for only 5
   repetitions at 50% to 70% of capacity.
*  "Remember, all exercise is overload" so don't push or make muscles
   sore. Polio muscles will never be normal.
WHAT CAN A POLIO SURVIVOR DO?
*  Dr. Perry says you can do anything as long as it causes no pain or
   fatigue that lasts more than ten minutes.
*  When injured, tell the doctors you don't have any muscles and need
   to start "teasing" the muscles right away in order to regain movement.
*  Be aware that people who use electric carts or scooters can develop
   shoulder and wrist problems. (Some vehicles can be retrofitted to
   avoid having to extend an arm to reach the control piece; the vehicle
   can then be operated with a person's arm remaining next to his body.)
*  Keep in mind that recovery from fatigue is slow if you have "pushed"
   yourself.
*  "The more you face the facts and make your lifestyle planned, the
   more comfortable you will be."
*  Remember, that all polios have the same perception of fatigue,
   whether they have PPS or not. Polios are "not hypersensitive to
   pain. When you hurt, you hurt! So don't talk yourself out of it -
   protect yourself instead."
*  Don't forget that PPS is due to accumulated strain from chronic
   overuse. "So get rid of the chronic overuse."
*  Dr. Perry's motto: "Be an Intelligent Hypochondriac!"
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