Polio and Post-Polio Syndrome (PPS): Summary and Key Insights

By SWA

 


In the human body, poliovirus can survive and replicate for varying durations depending on the phase of infection and the individual's immune response:

  1. Incubation Period: After entering the body, poliovirus can begin replicating in the throat and intestines within a few hours. The typical incubation period lasts 7 to 10 days (but can range from 3 to 35 days), during which the virus is actively multiplying.

  2. Shedding in Feces: Even after symptoms have resolved or in asymptomatic cases, poliovirus can be excreted in the feces for an extended period.

    • In most individuals, the virus is shed in feces for 4 to 8 weeks after infection.
    • In rare cases, especially in individuals with compromised immune systems, the virus may persist in the gut and be shed for months or even years (a condition called chronic excretion).

  3. Bloodstream: If the virus enters the bloodstream and causes viremia, it may persist there for a few days before being cleared by the immune system or progressing to infect the central nervous system (CNS).

In summary, while poliovirus typically persists in the human body for a few weeks to a few months, prolonged persistence is possible in immunocompromised individuals.

During the 1950s and 1960s, many polio infections were mistakenly diagnosed as the flu due to overlapping symptoms and limited diagnostic tools. At the time, the critical role of stool testing in identifying poliovirus was not widely understood or utilized by doctors. However, with the advent of reliable cell culture systems (like the HeLa cell line) and advancements in laboratory techniques, stool testing became a standard and crucial method for accurately diagnosing poliovirus infections. This development marked a turning point in differentiating polio from other illnesses and understanding its transmission. Nevertheless, this neglect has lead to what we see today: Post-Polio Syndrome (PPS)

Poliovirus does not leave a specific genetic or epigenetic marker in the host. Its effects are primarily due to physical damage caused during the acute phase of infection, such as motor neuron damage, rather than lasting alterations to the genome or epigenome. Post-polio syndrome (PPS) is a secondary condition that arises years or decades after the initial infection, affecting some polio survivors. It is characterized by progressive muscle weakness, fatigue, and pain, stemming from the long-term degeneration of motor neurons and their compensatory mechanisms. Between 1955 and 1963, some polio vaccine batches were inadvertently contaminated with SV40 (Simian Virus 40), a virus derived from monkey kidney cells used in vaccine production. Although SV40 has been detected in human tissues and studied for potential links to cancer, there is no conclusive evidence directly associating it with PPS. Nevertheless, the absence of evidence does not equate to evidence of absence, and unless science definitively rules it out, the possibility of SV40’s involvement in PPS cannot be entirely dismissed.
Below is a concise overview based on the detailed information provided:

Pathophysiology of PPS


 

  1. Motor Neuron Degeneration:

    • During the acute phase of poliovirus infection, motor neurons in the spinal cord and brainstem are damaged or destroyed.
    • Surviving neurons compensate by sprouting new terminal branches (collateral sprouting) to reinnervate the affected muscle fibers, forming "giant motor units."

  2. Progressive Decline:

    • Decades after recovery, these overburdened motor neurons gradually lose their function, leading to renewed denervation of muscle fibers.
    • The degeneration surpasses the body's ability to regenerate (synthesis of acetylcholine and sprouting), resulting in muscle weakness and fatigue.

  3. Neuromuscular Complications:

    • Dysfunction in acetylcholine release or receptor activity at the neuromuscular junction contributes to variable weakness and fatigue.

  4. Degeneration Timeline:

    • Muscle stability may persist for 15–40 years before symptoms emerge.
    • Progression varies among individuals and muscle groups.

Clinical Features

  • Muscle Weakness:
    • Both previously affected and unaffected muscles can weaken.
    • Uncontrollable muscle twitching
    • Often asymmetric and progressive.
  • Fatigue:
    • Generalized fatigue or localized muscle fatigue after minimal exertion.
  • Pain:
    • Muscle and joint pain due to compensatory overuse, postural imbalances, and joint degeneration.
  • Other Symptoms:
    • Cold intolerance, difficulty breathing, and swallowing (bulbar involvement in severe cases).

Diagnosis

  1. Clinical Criteria:

    • History of polio infection.
    • Gradual onset of new neuromuscular symptoms after a stable period.
    • Exclusion of other neuromuscular disorders (e.g., ALS, myasthenia gravis).

  2. Electromyography (EMG):

    • Confirms denervation and reinnervation in affected muscles.
    • Identifies ongoing motor unit loss.

  3. Creatine Phosphokinase (CPK):

    • Elevated CPK may indicate muscle injury or overuse, common in PPS patients.
     
    What are the symptoms of CPK?
    • Why do I need a CK test?
    • Muscle pain and/or cramps.
    • Muscle weakness.
    • Balance problems and/or falling a lot.
    • Numbness or tingling.
    • Dark colored urine (pee)
    • Swollen legs or feet.
     
    What are the symptoms of myositis?
    • Symptoms
    • Difficulty standing up from a seated position.
    • Difficulty climbing stairs.
    • Difficulty lifting the arms.
    • Fatigue after standing or walking a long time.
    • Trouble swallowing or breathing.
    • Muscle pain that does not subside within a few weeks.
    • A red or purple colored rash on the eyelids, elbows, knees and knuckles.
     
    If your CK levels increase or stay at a persistently high level, it may indicate that you have ongoing muscle damage or muscle degeneration.

  4. Exclusion of Active Poliovirus:

    • PPS is not caused by active viral infection; stool or serology tests are unnecessary unless infection is suspected.

Causes of PPS

  1. Primary Cause:
  2. Neuromuscular Imbalance:
    • Disturbed acetylcholine synthesis/release exacerbates symptoms.
  3. Age-Related Changes:
    • Natural aging accelerates neuron loss and weakens muscles.

Acetylcholine and PPS

  • Role of Acetylcholine:
    • Critical neurotransmitter for muscle contraction and neuromuscular communication.
    • Dysregulation may worsen muscle fatigue in PPS.
  • Testing for Acetylcholine Function:
    • Direct acetylcholine measurement is not feasible due to its transient nature, but indirect assessments (e.g., EMG or response to acetylcholinesterase inhibitors) may be useful.

Management of PPS

  1. Lifestyle Modifications:

    • Energy Conservation: Avoid overuse of affected muscles. Rest is essential to prevent fatigue.
    • Exercise:
      • Tailored low-impact exercises (e.g., swimming) to maintain strength and flexibility.
      • Avoid intense or high-resistance exercises that can accelerate muscle damage.
    • Weight Management: Reduces stress on weakened muscles and joints.

  2. Physical Therapy:

    • Preserves joint mobility and prevents contractures.
    • Improves posture and gait with braces or orthotic devices.

  3. Pain Management:

    • NSAIDs or acetaminophen for musculoskeletal pain only with caution.
    • Physical therapy modalities (e.g., massage, heat therapy).

  4. Assistive Devices:

    • Canes, walkers, or wheelchairs may be necessary as mobility decreases.

  5. Pharmacological Treatment:

    • Acetylcholinesterase inhibitors (e.g., pyridostigmine) have been explored but are not consistently effective.
    • Pain relievers and antidepressants for symptom management.

  6. Psychological Support:

    • Counseling or support groups help patients cope with the emotional impact of PPS.

  7. Preventive Measures:

    • Avoid overexertion and activities that strain already compromised motor units.

Polio Vaccination and PPS

  • Not Recommended for Most PPS Patients:
    • PPS is not caused by active poliovirus, and survivors typically have lifelong immunity.
  • Exceptions:
    • Travel to polio-endemic areas.
    • Incomplete vaccination history.

Research and Studies

  • Emerging Findings:
    • Increased CPK levels in PPS suggest ongoing muscle damage, reflecting overuse or chronic degeneration.
    • New therapeutic options aim to preserve motor function and slow progression.
  • Key Studies:
    • Research articles on PubMed provide valuable insights into PPS pathophysiology and treatment strategies.

    Medications Poorly Tolerated by PPS (Post-Polio Syndrome) Patients:

        Narcotics
        Muscle relaxants
        Psychotropic drugs
        Beta blockers
        Non-steroidal anti-inflammatory drugs (NSAIDs)
        Certain antibiotics (e.g., aminoglycosides, tetracyclines, gyrase inhibitors)
        Fibrates
        Statins
        Antiallergic drugs
        Novalgin

     Notes:

         These medications can still be prescribed but require a critical risk-benefit analysis.

    The "Rule of Two" for PPS Patients:

         Medication dosages should generally be halved.
        Postoperative ventilation should last twice as long as usual.
        Postoperative recovery time is calculated as twice the usual duration.
        Pain management will likely be needed for twice the normal duration.
        Rehabilitation stays (e.g., in clinics) should be planned for twice the usual length.
        Recovery at home and the time to return to work or feeling "normal" again should also take twice as long.

Prognosis

  • PPS is a progressive but variable condition. While it cannot be cured, proper management can significantly improve quality of life by minimizing symptoms and preserving independence.

By understanding the long-term effects of polio and the underlying mechanisms of PPS, patients and healthcare providers can work together to implement effective strategies for maintaining health and function.

Read also: Muscle and Nerve Disorders Related to Different Illnesses

Post-Polio Syndrome Revisited: https://pmc.ncbi.nlm.nih.gov/articles/PMC10123742/

Describing post-polio syndrome https://pubmed.ncbi.nlm.nih.gov/35672121/

Post-polio syndrome and rehabilitation
https://pubmed.ncbi.nlm.nih.gov/20044320/

Post-polio syndrome and the late effects of poliomyelitis: Part 2. treatment, management, and prognosis https://pubmed.ncbi.nlm.nih.gov/29752826/

Characteristics and Management of Postpolio Syndrome
https://jamanetwork.com/journals/jama/article-abstract/192910

Late Effects of Polio https://post-polio.org/education/late-effects-of-polio/

More information https://pubmed.ncbi.nlm.nih.gov/?term=Post+polio

Additional information: https://pubmed.ncbi.nlm.nih.gov/?term=Post+polio

Post-poliomyelitis syndrome- Video abstract [ID 219481]
https://www.youtube.com/watch?v=c0XVX_xPOhE

Germany:
Very detailed Video: Poliomyelitis die Spätfolgen und das Post-Polio-Syndrom (PPS)

Der Bundesverband: https://www.polio-selbsthilfe.de/de/Der-Verband/Bundesverband

© 2000-2025 Sieglinde W. Alexander. All writings by Sieglinde W. Alexander have a fife year copy right.
Library of Congress Card Number: LCN 00-192742
ISBN: 0-9703195-0-9

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