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Post-Polio Clinic Medical Report 2022
The McGill University-affiliated Post-Polio Program continues to provide clinical care for post-polio patients, education and clinical research on post-polio syndrome (PPS) and the late effects of polio.
The Post-Polio Clinic is currently based at both the Montreal Neurological Hospital Institute and the Central West Montreal Integrated University Health and Social Services Network (Lethbridge-Layton-Mackay Rehabilitation Centre, Constance-Lethbridge site), and is directed by Dr. Daria Trojan, Physiatrist. Dr. Diane Diorio is the clinic's neurologist. Ms. Beatrice Stoklas is our clinic secretary at the Montreal Neurological Hospital, and Ms. Shannia Seebaran is the clinic secretary at the Lethbridge-Layton-Mackay Rehabilitation Centre. The Clinic is held on Fridays. Both physicians work in the same area of the Centre at that time. Both physicians also see some of their patients at other times.
Dr. Trojan sees post-polio patients at the Montreal Neurological Hospital and Dr. Diorio also sees his patients in the affiliated McGill outpatient clinics. The last two years have been very difficult because of the pandemic, but we are now regularly assessing new patients, about 2-3 per month, mainly at the Lethbridge-Layton-Mackay Rehabilitation Centre. Many patients are followed up on a regular basis, approximately every 6-12 months.
Clinicians from the Neuro Musculoskeletal Program at the Lethbridge-Layton-Mackay Rehabilitation Centre are involved in rehabilitation, and some physiotherapists work with us to assess new patients at the Lethbridge-Layton-Mackay Rehabilitation Centre. Following the assessment, patients may be referred to their local rehabilitation center for treatment and rehabilitation programs. Patients can also be referred to other physicians and health care professionals if necessary. These include neurologists and electromyographers for electromyography (EMG) studies at the Montreal Neurological Institute or the Neurology Clinic at Brunswick@Glen Medical Centre, pulmonary and sleep medicine specialists for respiratory disorders and sleep assessment at the Royal Victoria Hospital (Glen site) the Bone Metabolism Unit (Osteoporosis Clinic) for osteoporosis at the Royal Victoria Hospital (Glen site), occupational therapists, orthotists and psychologists for psychological difficulties. Due to the pandemic, our standard operating procedures have changed since mid-March 2020. Many patients being followed were seen by phone at the beginning of the pandemic, but with the advent of effective vaccination, many are seen in person. Most new patients are seen in person.
Participation in the education of health care professionals, patients and the general population.
Due to the pandemic, we have had fewer trainees in our clinics over the past two years. Dr. Trojan supervised a 3rd year medical student from McGill in a post-polio clinic, and four physiatry residents from the University of Montreal in post-polio clinics this past year. She also presented a lecture on post-polio syndrome to physiatry residents at the University of Montreal. In addition, physiotherapists and occupational therapists from both centers teach physiotherapy and occupational therapy students from McGill University and the Université de Montréal.
We are involved in clinical studies on the subject of PPS and the late effects of polio. We are part of an international, multi-center, randomized, placebo-controlled clinical trial of intravenous immunoglobulin for post-polio syndrome. This is a potential treatment for post-polio syndrome. The study was initiated at the Montreal Neurological Institute-Hospital in August 2014. To date, twenty-five patients have been included at our center, and a total of at least 130 patients have been included at all study centers. We have three patients currently being treated in the study at the Montreal Neurological Institute-Hospital. The study includes approximately 20 centers in Canada, the United States and Europe.
We are the only study center in Canada.
The study was to be conducted in two parts. The first part of the study with data analysis has been completed and the second part was initiated at our center in October 2018. Recruitment of study subjects is currently halted for data analysis. We are also in the process of completing a study entitled "Markers of Bone Metabolism in Post-Polio Clinic Patients" with Dr. Pejman Madani (former fellow), Dr. Richard Kremer, and Dr. Amichai Grunbaum. Data collection for this project has been completed and some data analyses have been performed.
Researchers The studies described above and already conducted involve or have involved the collaboration of many researchers. These include Dr. Andrea Benedetti, Dr. Diane Diorio, Dr. Angela Genge and members of the Clinical Research Unit of the Montreal Neurological Hospital Institute, Dr. Marta Kaminska, Dr. John Kimoff, Dr. Richard Kremer, Dr. Erin O'Ferrall, Dr. Pejman Madani, Dr. Rami Massie, Dr. Basil Petrof and Ms. Ann Robinson.
Acknowledgements
We are very grateful to all the people who gave their time and energy to participate in our studies. They made these studies possible. The continued help and support of the Polio Quebec Association in the many aspects of our work is, as always, greatly appreciated. Thank you!
Research from the post-polio clinic
The following is a summary of recent published research from the Post-Polio Clinic at the Montreal Neurological Institute and Hospital. Thanks to Dr.re Trojan and Dre Kaminska for sending us these summaries:
Some people who have had polio may have decreased respiratory function. This problem affects those who have a deformity of the rib cage or weakness of the breathing muscles (such as the diaphragm) as a result of polio. These people may not have any respiratory problems for a long time. However, with age, respiratory function deteriorates and difficulties may occur. In addition, people with post-polio syndrome may have an accelerated loss of muscle strength, potentially including the respiratory muscles.
A team of researchers from the Montreal Neurological Institute and the Royal Victoria Hospital (McGill University Health Centre), attached to the post-polio clinic of the Montreal Neurological Hospital, is currently conducting a research project aimed at improving the lung health of people with post-polio syndrome who show early loss of lung function. Two other diseases are also being studied: Steinert's dystrophy and amyotrophic lateral sclerosis. This project focuses on an exercise for the respiratory system - the "manual hyperinflation technique". This involves blowing a certain amount of air into the lungs with a balloon (similar to the one used for resuscitation), as if the person were taking a deep breath. The amount of air blown in exceeds somewhat the volume that the person could breathe in on their own due to muscle weakness. This allows the person to "recruit" maximum lung capacity. It is in a way physiotherapy for the lungs. The goal of the exercises is to maintain or increase the flexibility of the lungs and the thoracic cage. The lungs and rib cage tend to become ankylosed when they are not fully utilized, which is the case when there is some weakness in the respiratory muscles.
These exercises are very safe. Their main drawback is the time required to do them - for optimal effect three to four sessions per day are suggested. People with more severe impairment of respiratory muscle strength with various neurological diseases already routinely practice these exercises. In addition to increasing the flexibility of the lungs and rib cage and thus making breathing easier, they improve the strength of the cough, which allows secretions to be cleared more easily and potentially reduces the risk of pneumonia in these patients. Until now, these exercises have never been formally studied to see if they can help prevent breathing deterioration. The current study is groundbreaking because its goal is to demonstrate a beneficial effect for people with only mild impairment of their respiratory function. Ultimately, it is possible that these exercises could slow the progression of respiratory deterioration. When there is a greater loss of strength and respiratory disability, nighttime breathing assistance is required using a ventilator, which is a machine that pushes air through a nasal or nasal-oral mask, similar to the machines used for sleep apnea (CPAP). The ventilator allows for adequate oxygen and CO2 exchange by assisting the patient's weakened muscles with each breath. The "manual hyperinflation technique" may delay the need for nighttime ventilator use by maintaining better lung health.
The people who participated in this study generally enjoyed the experience. It is too early to draw conclusions about the effectiveness of the exercises on physiological measures, but the preliminary results are encouraging. At least some people are noticing an improvement in their breath and endurance, and it seems that the reported benefits are greater in those with post-polio syndrome compared to the other two diseases studied. No complications were observed. The researchers are therefore confident that these exercises can actually have a positive impact on people with weakened respiratory muscles, especially those with post-polio syndrome. They continue to seek candidates for this project.
Researchers Physicians collaborating on this project are Dr. Daria Trojan, Dr. Angela Genge, Dr. Basil Petrof and Dr. Marta Kaminska. The respiratory therapist who specializes in this technique and supervises its teaching is Franceen Browman. The research coordinator is Christine Kupka.
Written by Marta Kaminska MD, FRCP(C), McGill University Health Centre, Respiratory Division, Montreal. Originally published in Folio Polio, no45, Winter 2010-2011.
Sleep-disordered breathing in post-polio clinic patients with fatigue
The objective of this study was to determine the frequency, predictive factors, as well as symptoms that may predict sleep-disordered breathing in post-polio clinic patients.
This study involved a review of 590 records available at the post-polio clinic. We concluded that sleep-disordered breathing, particularly obstructive sleep apnea-hypopnea, was very common in post-polio clinic patients who were referred for sleep evaluation. This condition often occurred even in patients who had no history of polio-related breathing difficulties. Snoring was the only symptom that could predict a sleep-disordered breathing condition. This disorder is best diagnosed when we perform an all-night sleep study in the laboratory. With proper treatment, people with sleep-disordered breathing can experience significant improvement in symptoms. Although the effects of treatment were not evaluated in our study, our clinical experience suggests that treatment may decrease fatigue in patients with a history of paralytic poliomyelitis.
If an individual who has had polio experiences fatigue or drowsiness that is atypical (unusual) for post-polio syndrome as well as other symptoms suggestive of a sleep-disordered breathing disorder, we recommend that they discuss their symptoms with their doctor. An evaluation at a sleep clinic may be necessary.
Reference: Dahan V, Kimoff J, Petrof B, Benedetti A, Diorio D, Trojan DA. Sleep disordered breathing in fatigued post-polio clinic patients. Archives of Physical Medicine and Rehabilitation 2006;87:1352-1356.
Osteoporosis in post-polio clinic patients
The purpose of this research was to determine the frequency of osteoporosis in the hip and lumbar spine (lower back) in post-polio clinic patients, and to evaluate the relationship between muscle strength and other factors with hip bone density.
The study involved a review of the medical records of 379 patients in the post-polio clinic at our institution. Of these, 164 patients met the study criteria, including the results of a bone densitometry. From this preliminary study, we concluded that osteoporosis and osteopenia at the hip occur frequently in patients of the post-polio clinic who were referred for bone densitometry. In the patients included in our study, osteoporosis and osteopenia of the hip occurred frequently in men as well as in pre- and postmenopausal women. We found a relationship between hip bone density and muscle strength of the leg for which bone density was assessed: the weaker the leg, the greater the chance that the patient would have osteoporosis at the hip for that leg.
Based on these findings, we recommend that all patients with a history of paralytic poliomyelitis be evaluated for osteoporosis at both hips (or preferably the hip of the weaker extremity) and at the lumbar spine. It is possible that appropriate treatment may increase bone mineral density, although this was not part of our study and has not been specifically evaluated in patients with a history of paralytic poliomyelitis. Further research on this issue is ongoing.
Reference Haziza M, Kremer R, Benedetti A, Trojan DA. Osteoporosis in a post-polio clinic population. Archives of Physical Medicine and Rehabilitation. 2007;88:1030-1035.
Elevated inflammation markers in serum in people with post-polio syndrome
The purpose of this study was to determine whether inflammation markers in serum are increased in patients with post-polio syndrome compared to a healthy control group. We also wanted to know if there is an association between elevated inflammation markers and clinical symptoms.
In this cross-sectional study, we compared 51 individuals with post-polio syndrome with 26 individuals in the control group. We found that the serum (blood) inflammation markers TNF-α, IL-6, and leptin were increased in patients with post-polio syndrome compared with individuals in the control group. We also found a relationship between TNF-α levels and pain, specifically muscle pain, in patients with post-polio syndrome.
Because of the nature of our study, which included only one assessment, we cannot conclude that inflammation markers are a cause of pain in patients with post-polio syndrome. However, our results allow us to see the possibility that inflammation markers may become important for the study of clinical symptoms of post-polio syndrome. We recommend that further studies be conducted on the role of inflammation markers in the pathophysiology of post-polio syndrome.
Reference : Fordyce CB. Gagne D, Jalili F, Alatab S, Arnold DL, Da Costa D, Sawoczczuk S, Bodner C, Shapiro S, Collet J-P, Le Cruguel J-P, Robinson A, Lapierre Y, Bar-Or A, Trojan DA. Elevated serum inflammatory markers in post-poliomyelitis syndrome. Journal of the Neurological Sciences 2008;271:80-86.)
Fatigue in post-polio syndrome: relationship between disease-associated, behavioral, and psychosocial factors
The objective of this study was to determine which factors are associated with general, physical, and mental fatigue in patients with post-polio syndrome, and to evaluate the influence of possibly modifiable factors on fatigue. Several factors related to the disease, behavior and psychosocial factors were considered.
This study of 52 outpatients with post-polio syndrome was cross-sectional. We found that in several multivariate statistical models, important factors predicting general fatigue were reduced respiratory muscle strength, presence of fibromyalgia, decreased extremity muscle strength, and increased stress and depression. Important predictors of physical fatigue are decreased respiratory muscle strength, decreased extremity muscle strength, increased age, decreased time since polio, decreased physical activity and increased pain. An important indicator of mental fatigue is an increase in stress.
We concluded that there are different types of fatigue in patients with post-polio syndrome and that different variables are important for different types of fatigue. Potentially modifiable factors (such as stress, depression, pain, and physical activity) account for some of the fatigue in patients with post-polio syndrome.
Because this study was cross-sectional, we cannot conclude that these factors are causes of fatigue. However, because many of the identified factors are amenable to treatment, our results suggest that with appropriate treatment, it is possible to improve the state of fatigue. Because several potentially modifiable factors were identified as being important for both general and physical fatigue, our results suggest that an interdisciplinary rehabilitation program that focuses on the factors contributing to these types of fatigue would be very helpful in treating these types of fatigue.
Reference : Trojan DA, Arnold D, Collet J-P, Shapiro S, Bar-Or A, Robinson A, Le Cruguel J-P, Ducruet T, Narayanan S, Arcelin K, Tartaglia MC, Caramanos Z, Da Costa D. Fatigue in post-poliomyelitis syndrome: association with disease-related, behavioral, and psychosocial factors. Physical Medicine and Rehabilitation 2009;1:442-449.
Brain volume and fatigue in patients with post-polio syndrome
The objective of this study was to determine whether patients with post-polio syndrome (PPS) have a smaller brain volume than normal subjects. We also wanted to determine if there is an association between brain volume and fatigue in PPS patients.
Acute polio is associated with encephalitis (or inflammation of the brain). It is possible that inflammation of the brain at a young age can produce permanent neuronal damage with loss of brain volume resulting in symptoms such as fatigue. Brain volume loss in other neurological diseases has been associated with clinical symptoms such as decreased cognitive function and fatigue. The project was a cross-sectional study of 49 patients with PPS, 28 controls and 53 patients with multiple sclerosis (MS). The MS patients were the positive control for the research protocol, as brain volume has already been shown to decrease with MS. All study subjects underwent magnetic resonance imaging (MRI) of their brains and the calculation of their brain volume was done by an automated software program: "Structured Image Evaluation, using Normalization, of Atrophy method (SIENAx)". This assessment method may not detect brain volume loss in a region such as the brainstem. Subjects also completed the Fatigue Severity Scale (FSS). Imaging of adequate quality was available for 42 patients with PPS, 27 in the control group, and 49 patients with MS.
We found that the volume of patients with PPS was not significantly different from the control group. As demonstrated by previous research, we found a significant loss of brain volume in patients with PPS. We found no association between brain volume and fatigue in patients with PPS. Our results indicate that brain atrophy is not a significant problem for patients with PPS and is probably not a contributing factor to the symptom of fatigue in patients with this syndrome.
Reference Trojan DA, Narayanan S, Francis SJ, Caramanos Z, Robinson A, Cardoso M, Arnold DL. Brain volume and fatigue in post-poliomyelitis syndrome patients. Physical Medicine and Rehabilitation 2013 doi: 10.1016/j.pmrj.2013.09.009 (Epub ahead of print)
Acknowledgements
These studies were supported by the Polio Quebec Association, the Multiple Sclerosis Society of Canada (operational funds) and the Montreal Neurological Institute (salary). We are grateful to the patients and members of the control group who gave their time to participate in these studies.
