Polio Place

Muscle stretching and joint range-of-motion exercises are important whenever there is muscle weakness. Preventing tightness, where muscles are weak, is important to maximize function and is particularly important in the chest wall and abdominal musculature if there is a limitation of breathing capacity. Preventing tightness in the hip and knee is important to maximize walking ability when there is significant weakness of the hip and thigh musculature.

General conditioning exercises or aerobic exercises, specifically to maintain or improve cardiovascular endurance, are good for many polio survivors and have been shown to be effective (Owen & Jones, 1985; Kriz et al., 1992). The best endurance exercise is swimming, because it minimizes mechanical stress on tendons and joints, but beneficially stresses the cardiovascular system.

Conditioning exercises or any repetitive activity, including walking, which causes pain or a sense of excessive muscle fatigue and increased weakness should be discontinued. The primary focus of any exercise program should be on building endurance, not strength (Agre et al., 1997; Ernstoff et al., 1996).

In general, muscles that are significantly weakened by previous polio respond poorly to vigorous strengthening exercise programs. Very gradual strengthening exercises which are guided in intensity and duration by the individual’s level of fatigue and/or pain can lead to modest but significant improvements in strength (Agre et al., 1996). Exercise should be focused on functionally important muscles.

An appropriate exercise program will help to maintain the strength of previously involved muscles, and also avoid overloading those muscles which previously were not recognized as having been affected. An adequate exercise program will help to minimize loss in strength and endurance associated with the aging process. Professional advice may be needed to design a feasible and effective personalized exercise program.

Excerpt from PHI's "Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors." © 1999

Basic Beginning Exercise for Polio Survivors and More

“Exercise admonitions: Take these exercises to your doctor and ask your doctor if it is all right for you to complete this routine. Do not exercise within one hour of a meal (before or after). Do not exercise within two hours of the time you plan to go to bed. Do not continue to exercise if you feel very tired or are unable to talk easily. Remember that if you are more fatigued after exercises you should not increase the frequency of exercises and you may want to break up the exercises so that you complete five of the exercises in the morning and five in the afternoon. Stop any exercise that causes any sharp pain. If possible, exercise when someone else is close by. Start by completing the exercises once daily. After two weeks of daily exercises, and depending on how tired you are after exercising, you may increase the exercises to twice daily.” David Guy, MS, CPT USA (ret). Guy is a retired physical therapist who has worked in multiple settings from the Army to universities. He has worked with polio survivors throughout his career. He now helps out with a polio support group in Arizona.

Beginning Exercise

1. Seated on a chair with arms, place your hands on your knees, then, simultaneously, raise your arms overhead and breathe in deeply. Lower your arms and exhale. Complete five repetitions.

2. Seated in a chair with arms, stretch your arms straight in front of you and then, slowly twist your arms and your body to the left and then, to the right. Complete five repetitions.

3. Seated in a chair with arms, grasp the arm rests, lean forward and pushing down on your hands on the chair arms, try to lift your bottom off the chair. Complete five repetitions.

4. Seated in a chair with arms, lean back into the chair and try to lift your right knee up. Lower the right knee and do the same with the left knee. Complete five repetitions with each leg.

5. Seated in a chair with arms, lean back and try to straighten out your right knee and lift your foot up as high as you can. Lower the right foot and do the same exercise with your left leg. Complete five repetitions with each leg.

6. Rest for 20 to 30 minutes after completing the exercises.

Additional Exercises 

1. Lying on your bed, lift one leg straight up as you are able without bending the knee

2. Lying on your bed, place a small rolled towel behind your knee and then try to straighten that knee.

3. Lying on your bed, bend both legs and place your feet so that they are flat on the bed. Reach with your hands up toward your knees and lift your head and shoulders.

4. Lying on your bed, bend both legs and place your feet so that they are flat on the bed. Move both knees as far as possible to the left and then to the right as far as possible.

5. Lying on your bed, bend both legs and place your feet so that they are flat on the bed. Reach with your hands up toward the left and twist your body to the left also. Do the same to the right.

6. Turn over and lie on your stomach. Put your arms at your sides and try to lift your head and shoulders up as far as possible.

7. Seated, pick up your leg and hold it up and then try to move your foot to the left and then to the right. If possible, keep your knee up without holding it up.

8. Seated move your knees apart and then together but keep your feet together and in place as you move your knees.

9. Standing and holding onto a counter, move the right leg as far as possible to the right. Make sure that the toes are pointing straight forward throughout the exercise. Do the same the left leg.

10. Standing and holding onto a counter, bend both knees about 30 degrees and no further. Straighten both knees.

Do all the exercises above 20 times, twice daily if you can. Remember to not get fatigued.

In addition, try to lie on your stomach and up on your elbows. Keep your hips down and in contact with the bed. Stay in this position for 20 minutes.

Flexibility and Breathing Exercises for Polio Survivors

1. Seated, reach first as far forward as possible and, then, simultaneously exhale and bend forward as far as possible. After bending forward, simultaneously reach up overhead and breathe in as deeply as possible. Very slowly complete 5 repetitions.

2. Seated reach up toward the ceiling and simultaneously inhale as deeply as possible. Exhale and bend to the right as far as you can. Straighten up again inhaling as you reach up. Then, exhale and bend to the left as far as possible. Complete three repetitions resting between each repetition.

3. Place both hands on your right knee. Keeping your hands together and elbows straight, reach with both hands up and out to the left side twisting your body to the left as far as possible. Lower your hands to your left knee and then, complete the exercise moving to the right. Complete three repetitions resting between each repetition.

4. Fold a tissue in half and then in thirds. Grasp the tissue at the top and hold the tissue three inches in front of the mouth. Purse your lips and blow out as hard as possible against the tissue attempting to bend the tissue 90 degrees and to keep it bent at 90 degrees for a count of six. Complete 5 repetitions of this exercise and then rest for several minutes.

5. Place your hands below the ribs across the upper abdomen. Simultaneously exhale and compress the upper abdomen. Then, breathe in as deeply as possible and attempt to force your hands out. Release pressure on your abdomen as the downward movement of the diaphragm is felt. Complete 5 repetitions and rest for several minutes.

6. Seated fold your arms across your chest. Rotate your body to the right as far as possible and then to the left. Complete 10 repetitions.

7. Seated, pull your chin straight back and flatten the back of your neck pulling the ears directly over the shoulder joints. Relax after each repetition. Complete 10 repetitions.

8. Seated hold both arms straight ahead with the elbows slightly bent. Pinch your shoulder blades together toward your spine. Hold for a count of five and then relax. Complete 10 repetitions.

9. Sit in a chair with arms. Place both your hands on the arms of the chair and holding the head, neck and trunk still, straighten your arms and lift your buttocks 2-3 inches above the seat of the chair. Relax. Complete 5 repetitions.

10. Seated, try to blow up a balloon.

Non-Fatiguing General Conditioning Exercise Program
(The 20% Rule)
Stanley K. Yarnell, MD (retired), California

The non-fatiguing general conditioning exercise program using the 20% rule was designed to restore stamina or endurance for those individuals who have continued to be bothered by profound fatigue following surgery, illness or trauma.

The program begins by determining the polio survivor's maximum exercise capability with the help of the clinic physical therapist. The type of exercise can be in a pool or on dry land, using an arm erqometer or an exercise bicycle, depending on the individual's abilities and preferences. If one prefers swimming, the maximum number of laps that the patient can swim is used as the maximum exercise capability. If the survivor has considerable residual weakness and is only able to swim one lap in half an hour, then the amount of time actively swimming can be used as the maximum exercise capability rather than the number of laps.

Having established the maximum exercise capability, the polio survivor is instructed to begin his aerobic swimming program at 20% of the determined maximum exercise capability. He can swim three to four times per week at that level for one month, and then he is instructed to increase by 10%. For example, if an individual is able to actively swim in a pool for half an hour, then one-half hour would be his maximum exercise capability. He would begin swimming just six minutes per session three to four times per week for a month before increasing the amount of time actively swimming to nine minutes three to four times per week for another month. Then he would increase by 10% once again so that he was actively swimming 12 minutes per session three to four times per week for another month, and so on. After three to four months, our patients have reported that they feel an increase in their general stamina or endurance.

Alternatively, if an arm ergometer or exercise bicycle is used, the same basic principle can be utilized, calculating distance pedaled or time spent actively pedaling. The individual begins his aerobic or non-fatiguing general conditioning exercise program at 20% of maximum exercise capability three to four times per week for one month before increasing the distance by 10%. He continues with that level of activity for another month before increasing by another 10%, so that he is exercising at 40% of maximum exercise capability.

For example, if an individual is able to pedal an exercise bicycle for one mile or is able to actively pedal the bicycle for up to 20 minutes, then that is his maximum exercise capability. He is instructed to begin his exercise program at one-fifth of a mile (or, if time is used, then four minutes is the beginning exercise time). This is repeated three to four times per week for a month before increasing the distance to one-third of a mile or six minutes. Our patients are encouraged to maintain that for an additional month before increasing by another 10%, and so on.

Individuals are cautioned to stop if they become fatigued during their exercise program, or if they experience pain or aches in their muscles. Most polio survivors are able to continue increasing their exercise program to nearly the maximum exercise capability, though it clearly would take a full nine months if this program were strictly followed. Conditioning or aerobic exercise at this submaximal level allows the individual to regain a healthier sense of stamina without damaging delicate old motor units.

It is imperative to incorporate the concept of pacing and spacing within the non-fatiguing general conditioning exercise program, meaning that rests are to be taken every few minutes.

The 20% rule is sometimes also applied to polio survivors when they are given instructions in a home flexibility and stretching program so they do not exercise too vigorously.

This exercise program can be modified with the supervision of a physical therapist, depending on the progress made by the polio survivor. This program may not eliminate fatigue, but we have found it effective for those who have a significant element of deconditioning contributing to their sense of fatigue.

©Post-Polio Health (ISSN 1066-5331), Vol. 7, No. 3, Summer 1991

Ejercicio

Los ejercicios de estiramiento muscular y los de movimiento articular son importantes siempre que hay debilidad muscular. Para prevenir la rigidez, donde los músculos son débiles, es importante aumentar al máximo la función y es particularmente importante en los músculos de la pared del pecho y el abdomen si existe una limitación en la capacidad respiratoria. Para prevenir la rigidez en la cadera y la rodilla es importante aumentar al máximo la habilidad ambulatoria cuando hay significativa debilidad en la musculatura de la cadera y el muslo.

Los ejercicios de acondicionamiento general o los ejercicios aeróbicos, específicamente para mantener o mejorar la capacidad de resistencia cardiovascular, son buenos para muchos sobrevivientes de la polio y han demostrado ser eficaces. El mejor ejercicio de resistencia es la natación, porque minimiza la tensión mecánica en los tendones y articulaciones, y le da una beneficiosa tensión al sistema cardiovascular.

Los ejercicios de acondicionamiento o cualquier actividad repetitiva, incluyendo la caminata, si causa dolor o sensación de fatiga muscular excesiva y debilidad aumentada, debe discontinuarse. El enfoque primario de cualquier programa de ejercicio debe estar en construir la resistencia, no la fuerza.

En general, músculos que están significativamente debilitados con anterioridad por la polio, responden pobremente a los programas de vigorosos ejercicios de fortalecimiento. Los ejercicios de fortalecimiento muy gradual, cuya intensidad y duración se guían por los niveles de fatiga y/o dolor del individuo, pueden llevar a modestas, pero significativas mejoras en la fuerza. El ejercicio debe enfocarse en los músculos funcionalmente importantes.

Un programa apropiado de ejercicios ayuda a mantener la fuerza de los músculos previamente comprometidos, y también evita sobrecargar esos músculos que previamente no se reconoció que fueron afectados. Un programa adecuado de ejercicios ayudará a minimizar la pérdida de fuerza y resistencia asociada con el proceso de envejecimiento. Se puede requerir el consejo de un profesional para diseñar un programa de ejercicios personalizado, factible y eficaz.

Excerpt from PHI's "Handbook on the Late Effects of Poliomyelitis for Physicians and Survivors." © 1999

Una Exposición sobre el Ejercicio para los Sobrevivientes de Polio

El aconsejar a todos los sobrevivientes de polio de no realizar ejercicios resulta tan irresponsable como aconsejarles de sí hacerlo.

Para los sobrevivientes de polio, la actual evidencia sugiere que muchas veces el ejercicio es de beneficio siempre y cuando el programa de ejercicios sea diseñado de manera individual y sea seguido por una minuciosa evaluación del paciente y que inicialmente sea supervisado por versados profesionales de la salud. Tanto los sobrevivientes de polio como sus profesionales de la salud quienes poseen un completo entendimiento sobre el estatus de salud del sobreviviente individual en su totalidad, deberán de tomar la decisión final relacionada con la asesoría y el protocolo que el programa de ejercicios deberá seguir.

Los estudios clínicos respaldan los programas de ejercicios recetados y supervisados por profesionales para muchos sobrevivientes de polio, inclusive para aquellos que presentan el síndrome de post polio * (Ver Referencias).

Cuando la infección viral conlleve a la muerte de las células de asta anteriores (CAA) en la médula espinal, la polio paralítica aguda puede resultar en un debilitamiento muscular permanente. Se cree que la recuperación de la parálisis se debe al rebrote de las terminaciones de los nervios de las fibras musculares órfanas, creando así unidades motrices expandidas. La recuperación también se atribuye al ejercicio que facilita la expansión de las fibras musculares ennervadas. Como ejemplo tenemos que algunos de los sobrevivientes de polio recobraron el uso de los brazos y así han podido caminar con muletas por años. Otros recobraron la habilidad de caminar sin la ayuda de soportes, muletas, etc. y han continuado caminando así durante décadas.

Se cree que el aumento del debilitamiento muscular, identificado en aquellas personas con el síndrome de polio, ocurre a partir de la degeneración de los brotes de las unidades motrices expandidas. Se especula que la muerte prematura de algunas de las CAA afectadas por el virus de la polio también cause nuevos debilitamientos, siendo estos nuevos debilitamientos causados por una práctica errónea o una disminución en la actividad o el ejercicio.

Se concuerda de que el uso repetitivo puede causar daños a los músculos y a las articulaciones, pero ¿podría así el uso repetitivo o la excesiva actividad física acelerar la degeneración de los nervios o su muerte? Esto justamente es el meollo del debate entre los temas de la actividad física y el ejercicio.

La actividad física se concibe como el movimiento que ocurre dentro de las actividades diarias. El ejercicio está definido como un movimiento corporal previsto, estructurado y repetitivo.

El ejercicio terapéutico se realiza para generar un beneficio para la salud, generalmente para reducir el dolor, aumentar la fuerza y la resistencia y/o aumentar la capacidad de la actividad física.

Los sobrevivientes de polio quienes ejercitan demasiado sus músculos experimentan una fatiga excesiva que muchas veces se entiende de mejor manera como un agotamiento del abastecimiento de energía hacia los músculos. Sin embargo, la debilidad de algunos de los sobrevivientes de polio se puede explicar por la falta de ejercicio y actividad física que claramente conlleva al debilitamiento de la fibra muscular y a la falta de acondicionamiento cardiovascular.

Las investigaciones apoyan el hecho de que muchos sobrevivientes podrían elevar tanto el nivel de su salud óptima, el rango de sus movimientos y así como su capacidad para la actividad a través del emprendimiento de un programa de ejercicios sensato y que se distinga de las típicas actividades físicas cotidianas. Estos mismos sobrevivientes de polio no necesitan temer la "destrucción" de las células nerviosas restantes, mas bien, necesitan reconocer que efectivamente el deterioro y la posible muerte de algunas de las células nerviosas puede que sea parte del proceso normal de envejecimiento luego de haber contraído la polio.

Los programas de ejercicio deberán ser diseñados y supervisados por doctores, fisioterapistas y/o cualquier otro profesional del cuidado la salud que esté familiarizado con la patofisiología singular del síndrome de post polio y los riesgos del ejercicio excesivo. Por lo general, los profesionales crean un programa de ejercicios individualizado específicamente para el paciente y que se mantiene bajo supervisión durante un período de dos a cuatro meses. Durante este período ellos controlarán el grado de dolor, fatiga y debilidad del individuo y efectuarán las correcciones debidas al protocolo para identificar un programa de ejercicios que pueda ser seguido por el sobreviviente de polio de manera independiente al profesional médico.

Para alcanzar las metas específicas y/o los niveles de mantenimiento a la hora de diseñar un programa, deben de tomarse en cuenta las siguientes normas generales:

La intensidad del ejercicio debe de ser de moderada a baja.

El progreso del ejercicio debe ser lento, en particular sobre aquellos músculos que no se han ejercitado por un período de tiempo y/o que presenten una obvia debilidad crónica producida por una poliomelitis aguda.

El tomar pasos de manera progresiva se incorpora dentro del programa detallado como actividad.

El plan deberá de incluir una rotación de diferentes tipos de ejercicios como el estiramiento, el acondicionamiento general (aeróbico), el fortalecimiento, la resistencia o ejercicios para mantener el rango de movimiento de las articulaciones.

Aquellos sobrevivientes de polio que experimenten un dolor muy marcado o una fatiga luego de realizar algún ejercicio, deberán suspender ese ejercicio hasta que se pongan en contacto con su profesional médico.

Los médicos investigadores y clínicos no podrán hacer una exposición de manera más definida hasta que estudios adicionales relacionados tanto sobre los efectos del ejercicio a largo plazo como sobre los efectos del ejercicio relacionados con la función y calidad de vida, hayan sido realizados.

co y el Cuidado. March of Dimes, 2001.

References
Agre, J., Grimby, G., Rodriquez, A., Einarsson, G., Swiggum, E., & Franke, T. (1995). A comparison of symptoms between Swedish and American post-polio individuals and assessment of lower-limb strength – a four-year cohort study. Scandinavian Journal of Rehabilitation Medicine, 27, 183-192.

Agre, J., Rodriquez, A., & Franke, T. (1997). Strength, endurance, and work capacity after muscle strengthening exercise in postpolio subjects. Archives of Physical Medicine & Rehabilitation, 78, 681-685.

Agre, J., Rodriquez, A., & Franke, T. (1998). Subjective recovery time after exhausting muscular activity in postpolio and control subjects. American Journal of Physical Medicine & Rehabilitation, 77, 140-144.

Agre, J., Rodriquez, A., Franke, T., Swiggum, E., Harmon, R., & Curt, J. (1996). Low-intensity, alternate-day exercise improves muscle performance without apparent adverse affect in postpolio patients. American Journal of Physical Medicine & Rehabilitation, 75, 50-58.

Agre, J.C., Rodriquez, A.A. (1997). Muscular function in late polio and the role of exercise in post-polio patients. Neurorehabilitation, 8, 107-118.

Ernstoff, B., Wetterqvist, H., Kvist, H., & Grimby, G. (1996). Endurance training effect on individuals with postpoliomyelitis. Archives of Physical Medicine & Rehabilitation, 77, 843-848.

Grimby, G., Stalberg, E., Sandberg, A., Sunnerhagen, KS. (1998). An 8-year longitudinal study of muscle strength, muscle fiber size, and dynamic electromyogram in individuals with late polio. Muscle & Nerve, 21, 1428-1437.

Jones, D.R., et al. (1989). Cardiorespiratory responses to aerobic training by patients with post-poliomyelitis sequelae. Journal of the American Medical Association, 261(22), 3255-3258.

Kriz, J.L., Jones, D.R., Speier, J.L., Canine, J.K., Owen, R.R., Serfass, R.C. (1992). Cardiorespiratory responses to upper extremity aerobic training by post-polio subjects. Archives of Physical Medicine & Rehabilitation, 73, 49-54.

Prins, J.H., Hartung, H., Merritt, D.J., Blancq, R.J., Goebert, D.A., (1994). Effect of aquatic exercise training in persons with poliomyelitis disability. Sports Medicine, Training and Rehabilitation, 5, 29-39.

Spector, S.A., et al. (1996). "Strength gains without muscle injury after strength training in patients with postpolio muscular atrophy. Muscle & Nerve, 19, 1282-1290.

©Post-Polio Health (ISSN 1066-5331), Vol. 19, No. 2, Spring 2003