Exercise in Post-Polio Syndrome

A New Classification• Anne C. Gawne,

MD• Director Post-

polio Program• Roosevelt Warm

Springs Institute for Rehabilitation

Benefits of Exercise

• Increase strength• Increase

Cardiovascular Fitness

• Decrease Weight and Cholesterol

• Improve sense of Well being

Rationale/Problems in PPS

• Exercise may be harmful

• Not all limbs are affected equally

• Current protocols don’t quantify involvement

• Need to enhance communication between doctor and therapists

How to use Classification

• Determine Classification for each limb

• Prescribe individualized limb-specific exercise program, using the least affected limbs

• Follow-up periodically to assess strength and function, modifying exercise program as needed

Classification Elements

• Remote history- Extent of original polio• Recent History-New neurological Symptoms• Physical Exam-

Musculoskeletal,Neurological• EMG/NCS- Standard Protocol• Exercise- Limb Specific

Recommendations• Note-Classification refers to limbs not to

person

NRH Limb Classification For Exercise • 1 No Polio• 2 Subclinical Polio• 3 Clinically Stable Polio• 4 Clinically Unstable Polio• 5 Atrophic Polio

Class 1 - No Polio

• Remote history No weakness• Recent history No new weakness• Physical Exam Good to Normal

strength normal sensation

and reflexes• EMG/NCS Normal

Class 2- Subclinical Polio

• Remote history No weakness or if weak, full recovery

• Recent history No new weakness• Physical Exam Good to

normal strength, sensation

and reflexes• EMG/NCS Evidence of old

Polio

Class 3 -Clinically Stable Polio• Remote history Weakness with

variable recovery• Recent history No new weakness• Physical Exam Poor to good

strength, normal sensation normal to decreased reflexes

• EMG/NCS Evidence of old polio

Class 4- Clinically Unstable Polio• Remote history Weakness with

variable recovery• Recent history New weakness• Physical Exam Poor to good

strength, normal sensation and normal to decreased reflexes

• EMG/NCS Evidence of old polio

Class 5- Atrophic Polio

• Remote history Weakness with little recovery

• Recent history May have new weakness• Physical Exam Trace to poor strength,

atrophy normal sensation and decreased reflexes

• EMG/NCS Evidence of old polio decreased insertional activity, few motor units

Class of Polio

Remote History

Recent History

Physical Examination

Neurological Examination

I Noclinical

No weakness

No new weakness

Good-to-normal strength, normal sensation and reflexes, no atrophy.

Normal using standard screening examination.

IISub-clinical

No weakness or, if affected, full clinical recovery.

Chronic denervation consistent with anterior horn cell disease, no evidence of acute denervation

IIIClinically stable Weakness

with variable recovery.

Poor-to-good strength, normal sensation, normal-to-decreased reflexes, may have atrophy.

Chronic denervation consistent with anterior horn cell disease, may have evidence of acute denervation.

IV Clinically unstable

New weakness

VSeverely Atrophic

Weakness with little recovery.

May have new weakness

Trace-to-poor strength, normal sensation, areflexic, severe atrophy.

Decreased insertional activity, few to no motor unit action potentials, may have acute denervation.

Summary

General Exercise Recommendations

• Stretching-Active Range of Motion(AROM) or Passive Range of Motion (PROM)

• Warm up• Strengthening Exercises• Aerobic Exercises• Cool Down

ACSM Exercise Recommendations• Frequency 3-5 X /Week• Duration 15-30 Minutes• Intensity 60-90% Of

Maximum Heart Rate ( 220-age)

Class 1 Exercises

• Active ROM/Passive ROM• Warm Up• Strengthening Exercises- 3 sets of 10

at 10reps max• Aerobic exercises 3-5 days/week• 15-30 min at 60-80 % of maximum

HR• Cool down

Class 1 Sample Exercises

• Swimming 25-35 yards/minute

• Walking 5-6 MPH• Bicycle Riding 12-

14 MPH

Class 2 Exercises

• Warm Up• Strengthening Exercises- Use modified

Class 1 program• Active ROM/Passive ROM• Aerobic exercises 3 days/week 15-20 min

at 80 % of maximum HR • Pacing- Perform 4-5 minutes, rest 1

minute• Cool down• Modify if new weakness fatigue or pain

Class 2 Sample Exercises

• Swimming 25 yards/Min

• Walking 4-5 MPH• Bicycle riding 10-

12 MPH

Class 3 Exercises

• Warm Up• Active ROM/Passive ROM• Strengthening Exercises-Non

fatigueing/paced • Aerobic exercises 3 days/week(alternate)

15 min at 60 % of maximum HR• Pacing- Perform2-3 minutes rest 1 minute• Cool down• Modify if new weakness fatigue or pain

Class 3 Sample Exercises

• Swimming 20 Yds/min

• Walking 4MPH• Bicycle Riding

10MPH

Class 4 Exercises

• Passive ROM• Trial of rest to exclude overuse

weakness• Aerobic exercises only in Activities

of Daily Living (ADLS)• If overuse is excluded, trial of

nonfatiguing, paced exercise ( like class 3)

Class 4 Sample Exercises

• No cardiopulmonary aerobic exercise

• Use of brace, Wheel chair, Scooter

• If overuse weakness excluded trial of nonfatigueing exercise

Class 5 Exercises

• PROM• Usually Bracing, Wheelchair is

needed

Results of NRH classification of 100 consecutive patientsNRH Class Upper

ExtremityLowerExtremity

Total

I 84 10 94II 42 46 88III 42 53 95IV 25 50 75V 7 41 48Total 200 200 400

NRH Classification of 100 Patients

NRH Classification of 100 Patients

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20

40

60

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100

I II III IV V

NRH Class

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Upper extremity Lower Extremity