Clinical Problem Solving 2: Increasing Strength In A Patient With Post Polio Syndrome

Transcription

1 Clinical Problem Solving 2: Increasing Strength In A Patient With Post Polio Syndrome By Caroline Owen October 3 rd 2016

2 Purpose 1. To present the physical therapy evaluation and treatment of a patient presenting with post polio syndrome in an outpatient orthopedic clinic. 2. To examine evidence for weight bearing lower extremity strength training in a male diagnosed with post polio syndrome

3 Polio Viral disease which mainly affected children under 5 y.o. In some cases, the virus causes involvement of the spinal cord, brainstem or both Symptoms: Loss of reflexes, severe muscle aches or weakness, flaccid paralysis (often unilateral) Recovery: Some cell bodies do not recover! decreased motor units Some cells loose function temporarily and recover in 4-6 weeks Nerve terminal sprouting occurs to reinnervare denervated muscles

4 Post-Polio Syndrome Those who have recovered from paralytic polio develop symptoms years after recovering Symptoms: Muscular pain, progressive muscular weakness of affected muscles and fatigue Neural Fatigue Theory- cell bodies of enlarged motor neurons begin to fail due to added metabolic stress to nourish additional fibers.

5 The Patient Age 58 Gender Race Tobacco Occupation Living Situation Prior Level of Function Male BMI 35.5 Caucasian Non Smoker Retired Navy Pilot Two story home One flight of stairs with railings Lives with wife who is able to help when necessary Sedentary, Independent with all mobility Wears lift in R shoe Past Medical History Pt diagnosed with poliomyelitis at 1.5 Diagnosed with post-polio syndrome at 45 y.o

6 The Patient: History of Present Illness Fatigue Pt reports recent increase in fatigue with walking > 5 min Left Shoulder Pain Onset 1 month ago Progressive increase in pain Left Low Back Pain 10 year history of SIJ dysfunction 5 cm leg length discrepancy Has previously seen PT and improved. Has since not been compliant with HEP.

7 PT Exam: Shoulder Pain: R shoulder 5/10 pain Posture: rounded shoulders, forward head, bilateral inferior scapular angle winging ROM: decreased glenohumeral flexion, extension, abduction and IR. Scapular dumping and winging noted. Strength: Generalized weakness in R UE Special Tests: Ruled out instability and RC pathology Special Tests +/- Scapular Assist + Neer s + Hawkins Kennedy +

8 PT Exam: Sacroiliac Joint Pain: R SIJ 7/10 pain Gait: Compensated trendelenburg gait Strength: Generalized strength deficit on R side ROM: Deficits in - bilateral hip flexion, extension & abduction - thoracolumbar flexion, extension, side bending & rotation Special Tests +/- Distraction - Compression + Thigh Thrust + Sacral Thrust + Thomas Test + SLR + (R 60, L 70) 3+ pain provoking tests positive = 78% specificity, 91% sensitivity of SIJ Dysfunction (Laslett, 2008)

9 PT Exam: PT Diagnosis and Prognosis Shoulder: Decreased shoulder flexion, extension and IR ROM Generalized R shoulder weakness Scapular dyskinesia due to tight pec and impaired firing pattern of RC resulting in impingement SI Joint: Decreased spinal ROM secondary to pain Decreased LE flexibility Generalized strength deficits Muscular imbalances of R LE leading to SI dysfunction Prognosis: Fair May have short term improvement but long term gains are unlikely due to progressive diagnosis

10 The Patient: Goals Fatigue: In 4 weeks, the pt will be able to walk on the treadmill at 2.5 mph for 12 min without symptoms of LE muscular fatigue. Shoulder: In 2 weeks, the pt will increase active UE flexion to 130 in order to perform overhead ADLs without pain. In 4 weeks, the pt will display appropriate scapular kinematics during UE elevation in order to have pain free over head ROM. SI Joint: In 2 weeks, the pt will increase hip flexion ROM to 100 deg in order to climb stairs. In 4 weeks, the pt will increase hip extension strength to 4/5 MMT to decrease fatigue during ambulation.

11 The Patient: Physical Therapy Intervention Frequency: 3x/wk for 12 weeks Warm Up: Recumbent bike 5 min Stretching: LE: quads, hamstring, adductors, gastroc soleus UE: upper traps, pecs Strengthening: LE: mini lunges, side steps, heel raises, step ups, dips, mini squats UE: AAROM, punches, wall push ups, IR/ER, Ws, bird dog Neuromuscular Re-education: UE: Scapular assisted ROM, Kinesio taping Alternating muscle groups and frequent rest brakes used to prevent muscular fatigue

12 Outcomes: Shoulder ROM Initial 4 weeks Flexion 120 p! 180 Extension Internal Rot External Rot Abduction 90 p! 120 MMT Initial 4 weeks Flexion 3 4+ Extension 3 4 Internal Rot 3 4 External Rot 4 4+ Abduction 4 4+ Decrease in pt reported pain 0/10 No pain with overhead ROM Normal Scapular rhythm observed

13 Outcomes: SI Joint HIP ROM Initial 4 weeks Extension Flexion Abduction Hip MMT Initial 4 Weeks Extension 4 4+ Flexion 3+ 4 Abduction 3 4 Decrease in pt reported pain 3/10 Decrease in pt reported fatigue in climbing a flight of stairs Walked on treadmill for 10 min at 2.0 mph before muscular fatigue

14 Question Are exercise programs emphasizing weight bearing activities effective in improving lower extremity strength for a 58 year old male with PPS?

15 Evidence on Post Polio Significant amount on pharmacological treatment and multidisciplinary approach PT is a component of many studies but not the only intervention being tested No studies looked specifically at weight bearing strength training Studies examined strength gains from isokinetic and isometric contractions

16 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Cohort 12 polio survivors: 5 men, 7 women, y.o years post onset of polio Inclusion Criteria " Between y.o. " Polio history exceeding 25 years " Resisted full knee extension in sitting

17 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Methods: Measurements Knee flexion and extension muscle strength measurements were taken 1. Before training program 2. After training program 3. 6 months post training program months post training program # Used knee flexion strength as control cybex II muscle dynamometer

18 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Methods: Measurements Muscle biopsy s from the vastus lateralis were taken before and after the training program to determine fiber cross sectional area Subjects self reported Symptoms during exercise Feeling of strength in the trained leg General physical strength General well being Performance climbing stairs

19 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Methods: Muscle training All participants performed the training program for 3 times per week for 6 weeks Warm Up: bicycle ergometer for 5 min at 30W 12 sets of 8 isokinetic knee extension contractions 12 sets of 4 second max isometric knee extension contractions Alternated between isokinetic and isometirc contractions with rest brakes in between

20 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Results: Strength Significant increase in isometric (29%) and isokinetic (24%) knee extension torques post training program Muscle Biopsy Cross sectional fiber areas increased with training Changes in muscle strength did not correlate to changes in fiber size

21 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Results: Subject reports No increased discomfort during training program 10/12 reported feeling increased strength in trained leg 9/12 reported increased feeling of well being 4/12 reported better performance climbing one flight of stairs

22 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991) Limitations of the study Small cohort No control group, used knee flexion strength as control Published 1991 Application to Patient Cohort similar demographics to pt Met all inclusion criteria Isometric and isokinetic strengthening exercises may increase strength in a 58 y.o. male with PPS

23 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Cohort 10 individuals with PPS 5 in training group, 5 in control 8 healthy elderly individuals 4 training group, 4 in control Inclusion Criteria " History of poliomyelitis " One or both upper limbs affected o Moderate motor neuron loss in the thenar muscles

24 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Methods: Evaluations Maximum voluntary contractions (MVC): taken of the thumb 3-5 s, at 45 deg flexion Voluntary Activation Index (VAI): The subject performs a MVC, impulse delivered to the median and ulnar nerves. Additional twitch evoked represents a deficiency in voluntary activation Motor Unit Number Estimation (MUNE): Analyzing EMG during stimulation of the median nerve Measures were taken at baseline and repeated once every 4 weeks

25 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Methods: Training Supervised progressive resistance training 3x/ week for 12 weeks Three sets of eight voluntary contractions 3-5s Initial training load 50%, MVC increasing 10% each week up to 70% Five min rest between sets to prevent fatigue

26 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Results: Training Response MVC increased by 41% for PPS training group, 2% for PPS control group Those with PPS can make strength gains similar to healthy elderly subjects.

27 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Results: Training Response Mean VAI increased from 77% at baseline to 93% at end of training

28 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Results: Training Response The MUNE did not change significantly during training

29 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. (2003) Limitations Small cohort Training and control groups not matched for physical attributes (age, gender) Looked at thenar muscles only Inadequate information on how MVC and MUNE were obtained Unclear if VAI and MUNE directly correlate to increases in strength Unclear if MVC translates to increases in function Application Cohort similar demographics to pt Met all inclusion criteria Progressive resistance training may increase strength in a 58 y.o. male with PPS.

30 Are exercise programs emphasizing weight bearing activities effective in improving lower extremity strength for a 58 year old male with PPS? Maybe.

31 Conclusions Based on the evidence we cannot make a conclusion about weight bearing exercises Conclusions cannot be made on changes in participation restrictions/activity limitations # Future research needed! We can conclude that Pts with PPS can make strength gains. Pts with PPS can have strength adaptations in their muscle physiology. Progressive strength training does not have a harmful effect on cell bodies.

32 Conclusions Based off of the evidence looked at Begin with open chain isometric and isokinetic strengthening for 2 weeks Progress to weight bearing strength training in 25% of full ROM for 2 weeks Progress to weight bearing strength training in 50% of full ROM for 2 weeks This would allow for neural strength adaptation before increasing load while focusing on functional exercises

33 References Agre, James C., Arthur A. Rodriquez, and Todd M. Franke. "Strength, endurance, and work capacity after muscle strengthening exercise in postpolio subjects." Archives of physical medicine and rehabilitation 78.7 (1997): Willén, Carin, and Gunnar Grimby. "Pain, physical activity, and disability in individuals with late effects of polio." Archives of physical medicine and rehabilitation 79.8 (1998): Farbu, E., et al. "EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force." European Journal of Neurology13.8 (2006): Chan, K. Ming, et al. "Randomized controlled trial of strength training in post-polio patients." Muscle & nerve 27.3 (2003): Einarsson, Gisli. "Muscle conditioning in late poliomyelitis." Arch Phys Med Rehabil 72.1 (1991):

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35 M Wave

36 Randomized Control Trial of Strength Training in Post-Polio Patients Chan, K. et al. Purpose: To test the hypotheses that 1. After moderate intensity strength training, post-polio patients would show strength improvement comparable to that in a healthy individual 2. Such training does not have a harmful effect on MU survival 3. Part of the strength improvement is due to an increase in voluntary motor drive

37 Muscle Conditioning in Late Poliomyelitis Einarsson, G. (1991)