A NOTE FROM DR. RICHARD L.
BRUNO:
Please forward to your local
newsletter editor: Feel free to reprint
with this note:
This column is for information
purposes only and is not
intended as a substitute for
professional medical advice.
(Dr. Richard Bruno is Chairperson of the
International Post-Polio Task Force and Director of The Post-Polio Institute
and International Centre for Post-Polio Education and Research at Englewood
(NJ) Hospital and Medical Center. His
new e-Book, How to STOP Being Vampire Bait: Your Personal Stress Annihilation
Program, is now available through PostPolioInfo@aol.com.)
_______________________________________________________________
T'N'T: Tips and Techniques for Polio Survivors
by Dr.
Richard L. Bruno
Not from
Tennessee? You may not know the name
Steve Cohen. If you don’t, write it
down. Because, if you’re a polio
survivor anywhere in these the United States, freshman Democratic
Representative and polio survivor Stephen Cohen has just become your
Congressman.
“Delayed
gratification,” was Cohen’s reply when I asked how he felt about winning. “I’m excited about going to Washington,
where I’ve wanted to be my entire life.”
Cohen has
been trying to get to DC for forty years.
At sixteen, he applied to be a Congressional page. “Over the years, I applied to be a
Congressional intern, a government lawyer, and for jobs in Democratic
administrations.” Cohen was never
hired. He also lost a 1996
Congressional bid.
But, although
Washington was always on his mind, Cohen was working hard in Tennessee. A practicing lawyer, Cohen was elected to
served as a Shelby County commissioner, where he helped to create “The Med,” a
community-funded regional hospital.
Cohen was elected to the Tennessee State Senate in 1982, where he served
for twenty-four years and supported expanding healthcare access, voting rights
and the medical use of marijuana.
Some of
Cohen’s passion for public service and health care can be related to polio,
which he had at age five in under particularly disturbing circumstances. “My father was a pediatrician, participating
in the 1954 Salk vaccine trials. The
protocol was to give vaccine to second graders, like my brother Martin, who got
the shot. My father thought about
taking some vaccine home to give to me.
He didn’t do it.”
Cohen isn’t
sure why his father withheld the vaccine.
One notion is that his father thought there was a small chance Cohen
could get polio from the vaccine. “The
other story is that my father didn’t give me the vaccine because it wasn’t
right, my not being in the study group.
I got polio in fall of ‘54, an ironic situation.”
Cohen was
hospitalized in isolation and then in a rehabilitation facility for about 3
months. “My left leg and back were
affected.” He got the usual treatment
-- hot packs, water therapy and PT -- and uused crutches for all of first
grade. “I wore a cast sophomore year in
high school to stretch my achilles tendon, which didn’t work. So, I had tendon lengthening surgery my
junior year.”
Cohen is one
of not even a handful of polio survivors in the public eye who admits to having
Post-Polio Sequelae. “I limp more than
I used to. The past year, when I’m
standing, I feel like I’m going to lose my balance.”
Cohen also
says he gets more tired than he used to.
“But, I drive myself. I go way
beyond warp, and I always have.” Based
on the theory of conserving to preserve poliovirus-damaged neurons, Cohen says,
“I probably took five to seven years off my leg during the campaign, because I
was going every minute. I was hustling
like when I was 20 year-old!”
But, Cohen
knows what he has to do now. “Take two
rest periods, sit when you can and save your neurons... which is the opposite
of what I’ve always been thinking: Exercise, Exercise, Exercise.” A PT had given Cohen exercises -- muscle
resistance, quad strengthening by squatting and balancing on one foot -- which he hasn’t done.
What’s more,
Cohen was planning to manage his PPS even before he was sworn in. He asked for a ground floor suite in the
House office building closest to the Capitol, right next to the escalator going
to the subway that travels to the Capitol building. Cohen is also thinking of getting a Segway.
Cohen is
already planning to help polio survivors and promote polio vaccination during
2007, declared by Congress as “The Year of Polio Awareness.” He has already talked to Rhode Island
Representative and quad Jim Langevin, who asked Cohen to join the Disability
Caucus with another polio survivor, Missouri Congressman Ike Skelton.
“Polio is
part of my life. I want to do whatever
I can to help polio survivors and encourage vaccination in Africa and in
America. I am a testimonial to what
vaccination could do.”
Delayed
gratification and persistence. A
winning combination for one polio survivor from Tennessee and 1.63 million
polio survivors across the US.
________________________________________________________________
T'N'T: Tips and Techniques for Polio
Survivors
by Dr.
Richard L. Bruno
Drug companies are now reporting that statins
can cause muscle pain anywhere in the body without causing muscle breakdown.
I have been taking a statin drug to lower
my cholesterol for several years. I recently started to have muscle pain in
both arms and went to my doctor. He did
blood tests and said the statin wasn’t causing the pain. But, he stopped the
drug and, after a few days, the pain went away. Was the statin causing the pain or was it a coincidence?
Problems with
cholesterol lowering drugs in polio survivors redux...again!
I’ve written
two columns about cholesterol-lowering drugs potentially causing unique
problems in polio survivors. The first column was published five years ago. The
buzz in the post-polio community then was that rhabdomyolysis – a very serious
condition where kidney and muscle tissues breakdown – occurred more frequently
in polio survivors who take statins, the then newish cholesterol-lowering
drugs. There have been no specific studies of cholesterol-lowering drugs in
polio survivors, but there seemed to be no reason polio survivors would be more
prone to rhabdomyolysis. Only about one-half of 1% of anyone who takes a
statin, such as Lipitor, develops rhabdomyolysis, which can indeed cause muscle
pain (usually in the calves), muscle weakness and possibly even kidney failure.
With rhabdomyolysis, the enzyme creatine phosphokinase (CK, also called CPK) is
released as muscle breaks down, CK sometimes increasing to
more than ten
times the normal limit.
You should be
aware that polio survivors can have an elevated CK without taking a statin. Two
studies have found that 40% of polio survivors had abnormally elevated CK, with
men having significantly higher CK than did women. In one
study, CK
increased with the number of steps polio survivors walked in a day. In 50
Post-Polio Institute patients who were not taking statins, 21% had an
abnormally elevated CK of about 225, which is one-third higher than normal, but
not ten times higher. Still, an elevated CK may mean that polio survivors are
making their muscles work too hard and causing the fibers to break down, but
isn’t evidence of rhabdomyolysis.
Regardless,
your CK was normal and you had arm muscle pain -- not calf pain -- that went
away when you stopped the statin. Drug companies are now reporting that statins
can cause muscle pain anywhere in the body, not just in the calves, without
causing muscle breakdown or elevating CK. An exception is Zocor, which,
although it can cause rhabdomyolysis, is reported by its manufacturer to cause
muscle pain no more frequently than in those taking placebo.
Newer
cholesterol-lowering drugs, the fibrates (Tricor and Lopid), also can cause
rhabdomyolysis, elevated CK and “diffuse muscle pain, tenderness and weakness.”
Even one of the oldest cholesterol-lowering drugs, the bile-acid sequestrant
Welcol, is reported to cause muscle pain in 2% of patients versus none of those
on placebo. What’s more, the cholesterol lowering B vitamin, Niacin, has also
been reported to cause “pain,” although no more frequently than in those taking
a placebo.
The good news
is that the newest cholesterol-lowering drug, Zetia, is said to produce “no
excess” rhabdomyolysis or increase in CK, and produced only slightly more
(.04%) muscle pain than did placebo. Whatever drug you chose with your doctor,
remember that rhabdomyolysis and muscle pain are more likely if you’re taking a
combination of cholesterol-lowering drugs, calcium channel blockers, immune
system inhibitors, certain antibiotics or antifungal drugs, have kidney
disease, diabetes, a slow thyroid or drink more than a quart of grapefruit
juice a day. If you’re taking a cholesterol-lowering drug and feel muscle pain,
even if you’ve been on the medication for a while, stop the drug immediately
and call your doctor.
Also,
remember that there is more to managing cholesterol than taking a pill.
Reducing saturated fat and eating foods high in soluble fiber -- such as cereal
grains, beans, peas, legumes, fruits and vegetables -- can help lower
triglycerides
and the "bad" low-density cholesterol (LDL) while raising the
"good" high-density (HDL) cholesterol. It is also recommended that
you lose weight, decrease stress, treat high blood pressure, stop smoking and
have a five-ounce glass of wine with dinner. By following these suggestions and
The Post-Polio Institute “Diet” (that recommends eating more protein,
especially at breakfast) and reducing carbs and portion size -- you can lose
weight, fuel your neurons to feel less fatigue and muscle weakness, while
keeping your plumbing clear of cholesterol.
Dr. Richard Bruno is Chairperson of the International
Post-Polio Task Force and Director of The Post-Polio Institute and
International Centre for Post-Polio Education and Research at Englewood (NJ)
Hospital and Medical Center. His new
e-Book, How to STOP Being Vampire Bait: Your Personal Stress Annihilation Program, is now available through
PostPolioInfo@aol.com.
Exercise: Use it and Lose it
by Dr.
Richard L. Bruno
I
read that you don't recommend exercise for polio survivors who are getting
weaker. But if I stop exercising and do
nothing, won't I lose muscle tone, get flabby and become deconditioned and
become weaker still?
You're asking
a good question but are using buzzwords that Americans hear on
infomercials. It's vital that polio
survivors understand what the research really says about exercise for newly
weakened muscles and know the definitions of "muscle tone" and "deconditioned."
We never tell
polio survivors to "do nothing."
Both The Post-Polio Institute and Warm Springs long-term follow-up
studies find the same thing. All PPS
symptoms, fatigue, pain and muscle weakness, decrease when polio survivors stop
exercising and follow The Golden Rule: If anything causes fatigue, weakness or
pain, DON'T DO IT! (Or do much less of it.)
Unfortunately,
those who recommend strengthening exercise to polio survivors quote from the
conclusions of a half-dozen small studies of leg muscle strengthening,
apparently without having read them critically. The studies' conclusions say
that exercise programs "lead to significant gains in strength." However, when you look at the responses of
individual subjects the "significant gains in strength" are hard to
find. Just over half of the studies’
subjects had an increase in upper leg muscle strength of about 26%. One quarter
had no change in strength while 21% actually had a decrease in strength of
about 10%. So almost as often as not
exercise either had no effect or actually decreased muscle strength.
What's more,
only two studies asked whether exercise affected polio survivors' fatigue and
their ability to function in their daily lives. In one study, strength increased by 36% but muscle fatigue also
increased by 21%. In the other study,
although muscle strength increased by 30%, there was no improvement in polio
survivors' ability to do daily activities, and muscle fatigue increased as much
as 300%! You have to ask what good
comes from any small percentage increase in muscle strength that is not related
to improved functional ability and that actually increases muscle fatigue more
than strength.
And what of
"muscle "tone"? Most people think that muscle tone means muscles
that are firm and have a nice shape.
Muscle tone actually means that muscle fibers are ready to contract.
Muscle tone is lost when motor neurons are damaged and can't turn on muscle
fibers. Loss of tone can happen when
polio survivors exercise too much and muscles become weaker when
poliovirus-damaged motor neurons fail.
Remember, PPS researcher Alan McComas found that polio survivors who
have muscle weakness lose at least 7% of their motor neurons each year (see PPS
Forum June 2001). This is why he concluded that "polio survivors should
not engage in fatiguing exercise or activities that further stress
metabolically damaged neurons that are already overworking."
Polio
survivors' muscles get smaller lose tone if they're overused and the motor
neurons that turn on the muscle fibers die.
Arms and legs get flabby because of increased fat deposits, not a loss
of muscle tone. Exercise does burn fat
and at first causes muscles to increase in size. But polio survivors don't want
bigger muscle fibers because they "further stress metabolically damaged
neurons that are already overworking." The best way to prevent flabby arms
and legs is to stop overusing and abusing your motor neurons and to follow the
higher protein, low fat and lower carb Post-Polio Diet (see PPS Forum July,
2002).
And what does
"deconditioned" mean? Many
polio survivors believe that there are only two ways to live: overusing and
abusing or being a couch potato and becoming "deconditioned."
Deconditioning is something that happens when astronauts live in space or you
put someone to bed for weeks, removing the pull of gravity and causing a
decrease in blood volume and blood pressure.
Deconditioning can only happen if polio survivors never leave the couch,
not if they take two daily rest breaks on the couch, take a ninety minute nap,
stop strengthening exercising or use a power wheelchair.
However,
polio survivors may need to "condition" their hearts, especially if
they have had a heart attack.
Cardiopulmonary conditioning" uses exercise to strengthen the heart
muscle (which was not affected by polio) and make it work more
efficiently. However, there is no
benefit to running on a treadmill or riding a bicycle to exercise the heart if
you thereby stress and kill off poliovirus-damaged motor neurons. Many polio
survivors can do heart conditioning by using their less affected limbs, usually
their arms, in a carefully monitored program of paced and non-fatiguing
exercise (see PPS Forum May 2001).
Dr. Richard Bruno is Chairperson of the International
Post-Polio Task Force and Director of The Post-Polio Institute and
International Centre for Post-Polio Education and Research at Englewood (NJ)
Hospital and Medical Center. His book, THE POLIO PARADOX: UNCOVERING THE HIDDEN
HISTORY OF POLIO TO UNDERSTAND TREAT "POST-POLIO SYNDROME" AND
CHRONIC FATIGUE, is published by Warner Books. (AOL Keyword POLIO PARADOX.)
E-mail questions to him at PostPolioInfo@aol.com.
________________________________________________________________
The Post-Polio Institute Protein
Power "Diet"
by Dr.
Richard L. Bruno
CHECK WITH YOUR DOCTOR BEFORE CHANGING OR STARTING ANY DIET!
"Breakfast? Sorry, don't have the time. In the morning there's too much to do, like
showering and dressing and getting to work.
I grab a cup of coffee (or two or three) and maybe a donut at
work..."
"Lunch? Don't think so. I'm
still catching up from my late start in morning. I grab a cup of coffee (or two or three) and maybe wolf down half
a Big Mac..."
"Dinner? I'm either too tired or hungry as Patton's Third Army. I either defrost a piece of pizza and drag
myself into bed or eat everything that isn't nailed down!
"So why am I totally exhausted but can't
stop gaining weight?"
Polio
Survivors vs. Breakfast. Americans are
not very good at taking care of
themselves. American's with
disabilities are no better, and maybe a little worse, at self-care because it
takes so much time to do things non-disabled folk do in a flash, like showering
and dressing. There's hardly any time
or energy left for planning meals, shopping, cooking . . . or even eating.
One group of
people with disabilities shows the consequences of poor eating habits: North
America's 1.8 million polio survivors.
Nearly 76 percent of polio survivors are experience Post-Polio Sequelae
(PPS). PPS are requiring polio
survivors to
use new assistive devices or aids they discarded years ago, like braces, canes,
crutches, wheelchairs and scooters, to slow down and to rest during the
day. The problem is, polio survivors
are Type A, hard working, pressured, perfectionistic super-achievers, who have
pushed themselves beyond their physical limits and allow no time for
self-indulgent luxuries, like food.
Polio survivors don't want to slow down or rest, not only because
they're afraid if they are less Type A people won't like them, but also because
they are afraid of gaining weight if they become more sedentary. But they shouldn't be afraid. Food is good! Eating properly doesn't lead to becoming fat; it actually reduces
PPS symptoms.
Dr. Susan
Creange at The Post-Polio Institute discovered that polio survivors with blood
sugar levels in the low normal range have as much difficulty paying attention
and concentrating as would diabetics with blood sugars as low as if they had
taken too much insulin. "Polio survivors' 'Type A diet' -- three cups of
coffee for breakfast, skipping lunch and eating pizza for dinner -- is actually
starving their nervous systems' and causing PPS symptoms," says Creange. The relationship between diet and PPS was
seen in the 1998 National Post-Polio Survey: the less protein polio survivors
had at breakfast the more severe were their daily weakness and fatigue.
Why do polio
survivors function as if they have low blood sugar and report more symptoms
when they don't eat protein at breakfast?
Because polio survivors are running their nervous systems on "half
a tank of gas." About 50 percent
of all brain stem and motor neurons were killed decades ago by the
poliovirus. What's worse, the metabolic
apparatus, the internal power plant, of the neurons that survived the original
poliovirus infection was severely damaged.
So polio survivors have been running their full-tilt, Type A lives on
half the normal number of neurons, neurons that are less able to use their only
source of fuel, blood sugar. Dr.
Creange found that even normal levels of blood sugar were not enough to fuel
the remaining poliovirus-damaged, metabolically impaired neurons. And that's where protein at breakfast comes
in.
Protein: The
fuel that keeps on giving. Protein
provides a long-lasting, "slow-release" supply of blood sugar
throughout
the day. Polio survivors who had
protein for breakfast reported less PPS symptoms because their fuel tank stayed
full longer. They didn't need to
"fill up" throughout the day with short-lasting sugar fixes, like
soda or candy bars.
Mom was right
about one thing: breakfast is the most important meal of the day. Since many polio survivors use more energy
just getting showered and dressed than does a non-disabled person who runs a
marathon, you need protein early and often.
It's a good idea to eat breakfast before showering to "break your
fast" and fill your tank before your neurons need the fuel. When we ask
our post-polio patients to eat protein every day at breakfast, and have small,
non-carbohydrate snacks throughout the day, they report an almost immediate
reduction in nearly all the symptoms of PPS, especially fatigue. But the "protein power" diet is
neither a fad nor a miracle: it's just common sense. No engine can be expected to run without fuel!
Our patients
worry that using a wheelchair, resting more and having breakfast will cause
them to get fat and have more PPS symptoms.
A four-year follow-up study found that U.S. and Swedish polio survivors,
living their typical Type A, "use it or loose it" lifestyles without
using new assistive devices or resting, lost equal amounts of leg muscle
strength, about 2% per year. However,
when subjects from the two countries were looked at separately, the Swedes
gained only 6 ounces per year, while the Americans gained over 2 pounds; that's
220% more weight! Although weight gain alone is not responsible for the
progression of muscle weakness in polio survivors, it is Americans' high fat,
Big Mac diet that causes them to get fat.
You can fuel your neurons, feel stronger and less fatigued without
gaining weight, if you choose low fat, low cholesterol sources of protein. In
fact many of our patients, even as they slow down, sit down more, and use a
scooter, lose weight (about a pound per week) if they eat more protein, reduce
portion size and limit carbohydrates.
We aren't
recommending one of those "all protein, no carbohydrate" diets. We aren't recommending a "diet" at
all, but a method for eating healthy everyday.
We suggest 16 grams of protein at breakfast; that's about 1/4 of the
daily protein requirement (70 grams) for a 150-pound person. (Always check with your doctor, especially
if you have kidney problems, before changing your diet and ask to have your
cholesterol measured at your yearly check up.)
Look at the
list protein-rich foods and select different breakfasts so you can have a
variety throughout the week. In general
one ounce of meat or fish contains about 7 grams of protein: Remember, you want foods that have many more
grams of protein than they do fat.
The Protein Power "Diet"
Great!
Cottage
Cheese (Lite) (1 cup) = 28.0g Protein and 2.3g Fat
Salmon
(3 ounces) = 17.0g Protein and 5.4g Fat
Yogurt
(8 ounces) = 12.0g Protein and 4.0g Fat
Tofu
(6 ounces) = 10.0g Protein and 5.9g Fat
Milk (8 ounces = 1 cup)
Skim Plus Milk = 11.0g Protein and 0g Fat
2% Milk = 8.0g Protein and 3.0g Fat
Soy Milk = 7.0g Protein and 5.0g Fat
2 Egg Whites = 6.8g Protein and 0g Fat
Bagel (Lenders) = 6.0g Protein and 1.4g Fat
Egg Beaters (1/4 cup) = 5.0g Protein and 0g
Fat
Snack Bars:
MET-Rx
Fudge Brownie = 26g Protein and 2.5g Fat
Source One = 15.0g Protein and 3.0g Fat
GeniSoy Bar = 14.0g Protein and 3.5g Fat
Balance Bar = 14.0g Protein and 6.0g Fat
Cliff (Luna) Bar = 10.0g Protein and 5.0g
Fat
Protein
Drinks:
Boost
High Protein = 15.0g Protein and 6.0g Fat
Met-Rx in 2% Milk = 46.0g Protein and 5.5g
Fat
Designer Protein Powder in 2% Milk = 25.5g
Protein and 3.0g Fat
Carnation Instant Breakfast in 2% Milk = 12.0g
Protein and 3.0g Fat
Higher Fat:
Swiss Cheese (1 ounces) = 8.1g Protein and
7.8g Fat
Lite 'n' Lively Cheese (1 ounces) = 6.4g
Protein and 4.3g Fat
Hard Boiled Egg = 6.1g Protein and 5.6g Fat
Cream Cheese (Lite) (1 ounces) = 2.9g
Protein and 4.7g Fat
Peanut Butter (1 TBS) = 3.5g Protein and
4.0g Fat
Lower
Protein:
Quaker Life = 5.2g Protein and 1.8g Fat
English Muffin = 4.5g Protein and 1.1g Fat
Oatmeal (1 package) = 4.4g Protein and 1.7g
Fat
Cheerios (1 1/2 cups = 1 oz) = 4.3g Protein
and 1.8g Fat
Shredded Wheat (1 ounces) = 3.1g Protein and 0.6g Fat
Total
(1 cup) = 2.8g Protein and 0.6g Fat
Not Good:
Egg McMuffin = 17.0g Protein and 32.0g Fat
Bacon (3 strips) = 5.8g Protein and 9.4g Fat
Coffee = 0.1g
Protein and 0.0g Fat
POLIO SURVIVOR'S POWER BREAKFASTS:
12
minute breakfast: 2 hard boiled eggs (12 g) and an English Muffin (4.5 g)
8 minute breakfast: 3 scrambled egg whites (10 g) and a bagel (6 g)
6 minute breakfast: Toasted bagel (6 g), lite cream cheese (3 g) and 1 glass 2% milk
(8 g)
4 minute breakfast: Yogurt (12 g) and 1 ounces of low-fat cheese (6 g)
2 minute breakfast: 1/2 cup low-fat cottage cheese (14 g)
________________________________________________________________
T'N'T: Tips and Techniques for Polio
Survivors
by Dr.
Richard L. Bruno
Recently I
had a fever with muscle and chest pain. The only abnormal blood tests showed
high C-reactive protein and high creatine kinase. My blood pressure and
cholesterol are normal, I have never smoked, and I'm thin. Because of the chest
pain I had an angiogram, which was normal. Could high CRP and high CK be
related to PPS?
C-reactive
protein is a blood marker for inflammation somewhere in the body. High CRP can
be seen with type 2 diabetes, autoimmune diseases and cancers. Could inflammation somewhere in your body,
as indicated by your elevated CRP, be related to PPS? Fifty consecutive patients evaluated at The Post-Polio Institute
had CRP measured. The patients were on average 59 years old and 55% were women.
Thirteen percent had an elevated CRP, 66% of
whom were
men. CRP was on average nearly three times the normal value. However, there was
no significant difference between those with high and normal CRP on
self-ratings of daily fatigue, difficulty with self-care or ability to perform
activities inside or outside of the home.
So, there is no evidence that elevated CRP or inflammation is related to
PPS, either to post-polio fatigue or difficulty in functioning.
Recent
studies have found that elevated CRP is related to having a heart attack or
stroke. The theory is that a bacterial or viral infection (although definitely
not a poliovirus infection) somehow inflames arteries and causes them to clog.
Our 1985 National Survey found no more heart disease or high blood pressure in
polio survivors than in the general
population.
But two studies found that 5% more male post-polio patients had abnormally
elevated cholesterol as compared to the general population. In one of the
studies, only 33% of those with high cholesterol had been given a
cholesterol
screening test by their doctor and not even 25% were on cholesterol-lowering
medications, like the statin drugs such as Lipitor, Pravachol and Zocor. This
is not good, since reducing cholesterol reduces heart attack risk. What's more,
research has shown that taking statins to reduce cholesterol can also lower CRP
and may thereby increase survival even after having a first heart attack.
Statin drugs
provide a connection between CRP and CK--in polio survivors. CK is an enzyme
released when muscle is damaged. One half of one percent of anyone taking a
statin develops muscle breakdown, which causes muscle
pain
(especially in the calves), muscle weakness and an increase in CK. Even without
muscle breakdown or an elevated CK, some polio survivors report muscle pain or
weakness when taking a statin, usually one of the older statins like Lipitor.
And polio survivors can have an elevated CK without taking a statin. Two
studies found that 40% of polio survivors had abnormally elevated CK, with men
having significantly higher CK than did women. In one study, CK increased with
the number of steps polio survivors walked in a day. In our fifty Post-Polio
Institute patients, 21% had
abnormally
elevated CK levels (on average about 33% higher than normal) with men also
having higher CK than did women. But,
as with CRP, there was no significant difference between those with high and
normal CK on self-ratings
of daily
fatigue, difficulty with self-care or the ability to perform activities inside
or outside of the home. However, an elevated CK may mean that polio survivors
are making their muscles work too hard and are causing them to break down.
So, neither
CRP nor CK is related to fatigue or loss of functional abilities in polio
survivors. However, all polio survivors need to have their cholesterol and CRP
measured to assess heart disease risk. And since an elevated CK indicates
muscle breakdown, either from taking a statin or from muscle overuse, polio
survivors should have CK measured before taking a statin. If you are worried
about possible muscle weakness or breakdown with the statins, or the newer
cholesterol-lowering drugs like Zetia and Vytorin, ask your doctor about using
older medications like slow-acting niacin or bile acid sequestrants. Besides
medication, polio survivors need to eat high fiber foods, reduce saturated fat,
treat high blood pressure and stop smoking to keep their tickers ticking.
________________________________________________________________
T'N'T: Tips and Techniques for Polio
Survivors
by Dr.
Richard L. Bruno
“People
who survive polio in childhood will not suffer further effects later in life,”
say US researchers. That was the headline in the newspaper.
Are we
making up our muscle weakness, fatigue and pain? Is Post-Polio Sequelae all in
our minds?
No, PPS is
not in your mind. But, let’s start at
the beginning, 1987, when Mayo Clinic researchers began a study of 46 polio survivors.
The 46 were not a random sample of the 300 survivors of paralytic polio in
Olmstead County, Minnesota from 1935 to 1960, but were “representative” -- in
terms of the number of limbs involved and severity of polio, “bulbar” involvement and using a ventilator, age at polio,
current age, years since polio, and gender – but not because they had PPS or
“ongoing symptoms.”
Muscle
strength was measured subjectively by manual muscle testing in 27 muscles
(including face, tongue, diaphragm, arm, hand and leg muscles) to calculate a
strange measure called the “Neurologic Disability Score” (NDS).
The NDS is
scored from “0,” normal muscle strength, to “4,” a muscle that is totally
paralyzed. I say the NDS is strange
because it doesn’t make much sense in the real world. A polio survivor with mild weakness in the jaw, face and neck
muscles, moderate weakness in the abdominal muscles and in one toe, would get
the same NDS score as a polio survivor who had both thigh muscles totally
paralyzed. Muscle strength around the
elbows, knees and ankles was measured objectively using a machine, and hand and
finger dexterity were measured using standardized tests. The number of remaining motor units -- the
motor neurons available to run the muscles --
were measured using an EMG.
Cut to
2006. In an issue of the obscure
Journal of the Peripheral Nervous System, the Mayo researchers published a 15-
year follow-up of 38 of the 46 original subjects. Now, 15 years later, 82% subjects reported “progressive muscle
weakness,” had an 18% decrease in muscle strength on the NDS and lost 45% of
their remaining motor neurons.
The authors
state that “a normal age- and gender-matched control group” -- in which they
should have measured both muscle strength and remaining motor neurons -– “was
not included,” and therefore “one cannot reliably compare the
changes in
the polio group with those in a normal again population.”
But, their
lack of a control group didn’t stop them from concluding that polio survivors
“did not age any differently than a normal population” because they lost a
“normal” number of motor neurons. Thus, the authors concluded that “the most
likely cause” for “progressive muscle weakness” and the 18% decrease in muscle
strength ”in our polio survivors is aging alone.”
Somehow, when
the media got hold of the Mayo press release about the study, they focused only
on the “normal” loss of motor neurons and the headlines became, “People who
survive polio in childhood will not suffer further effects later in life.”
Of all the
problems with this study, this biggest is the assumption that the death of a
“normal” number of motor neurons in polio survivors is, well, normal. These researchers apparently aren’t aware
that David Bodian discovered in 1949 that the poliovirus killed on average 50%
of motor neurons, and that you had to lose at least 60% to have any muscle
weakness, let alone paralysis. So, if
polio survivors start out with one-half the “normal” number of motor neurons,
the loss of an additional 45% would mean that have lost 73% of their motor
neurons over 15 years, which is hardly normal, more than enough to cause
“progressive muscle weakness” and an 18% decrease in muscle strength. Inexplicably, the Mayo researchers acknowledge,
but then ignore, their not having a matched non-polio control group and their
own findings of progressive muscle weakness in their post-polio subjects. Apparently, at the Mayo Clinic, polio
survivors are merely the sum of their dying motor neurons.
I would argue
with the researchers that polio survivors are absolutely not merely the sum of
their dying motor neurons, that their
methods are faulty, their logic is flawed and their conclusions are
unfounded. But, I don’t have to argue
with the researchers. They argue with
themselves. Next month -- the rest off
the story.
__________________________________________________________
T'N'T: Tips and Techniques for Polio
Survivors
by Dr.
Richard L. Bruno
Last month, I
described the upset caused by the publication of a Mayo Clinic 2006 press
release and paper describing a 15-year follow-up study of 38 polio survivors
that generated the media headline, “People who survive polio in childhood will
not suffer further effects later in life.”
In spite of admittedly failing to include a control group of non-polio
survivors of the same age, post-polio subjects were said to lose a “normal”
number of motor neurons over 15
years, that
is 45%. Because of that “normal” loss
of neurons, the authors concluded that post-polio subjects’ reports of
progressive muscle weakness and a measured 18% decrease in muscle strength were
cause by “aging alone” and that polio survivors therefore “did not age any
differently than a normal population.”
What the Mayo
press release and paper didn’t tell you was that the 2006 article was the last
of three articles by the same authors.
The first paper was published in March 2005 in the journal,
Neurology. That paper also noted the
18% increase
in muscle weakness on subjective muscle strength tests and their 45% loss of
motor neurons. But, also reported were
the results of quantitative tests of muscle strength, measured objectively by
machine, and hand and finger dexterity measured using standardized tests. Those tests found polio survivors had an
overall decrease in muscle strength of 21%:
8% in the thighs, 14% in the muscles the lift the feet, 25% in the upper
arms, and 31% in grip strength. What’s
more, subjects had a 25% decrease in hand dexterity and a 55% decrease in
finger dexterity.
The authors
admitted, “We did not include a normal control group.” But, as opposed to the 2006 article, the
March 2005 paper stated, “In the absence of a normal control population, the
effects of aging… cannot be commented
on. How the changes identified in our
polio (subjects) compare with those of a normal aging population remains
unknown.” The study did not conclude
that “the decline in our polio survivors is aging alone” or that “people who
survive polio in childhood will not suffer further effects later in life.” In fact, the authors stated “The syndrome of
progressive weakness late after paralytic poliomyelitis was quite common.”
Then, in
September 2005, the authors published a second study of the same subjects in
Neurology, this time describing “adaptive equipment use.” In 1987, 13% reported using a brace or “gait
aid” (cane or crutch), 16% had been forced to change jobs and 13% had modified
their homes due to muscle weakness.
Fifteen years later, an additional 12% had to modify their homes or move
because of weakness and there had been a 100% increase in subjects using a
brace or aid. What’s more, forty
percent of those originally using just brace or aid are now using wheelchairs.
The 2005
studies, presenting objective findings of progressive muscle weakness, loss of
function and increased assistive device
use, certainly do not support the 2006 declaration that polio survivors “will
not suffer further effects later in life.”
Why did the authors erase their own findings of muscle weakness and loss
of ability from the 2006 paper and change their conclusion from how polio
survivors bodies’ “compare with those of a normal aging population remains
unknown” to “our polio survivors did not age any differently than a normal
population?” I haven’t a clue. And I don’t think it’s important to
know. What is important is the fact
that PPS are real and are not “normal”
aging. Studies of thousands of polio survivors –
not just “the Mayo 38” – have shown that.
It’s also
important, in this age of the 24 hour news cycle and the Internet, that we
become extremely cautious when medical research is “published” via press
release and the media. Medical “facts”
change in the media from week to week.
Chocolate causes obesity, then it fights cancer; a daily glass of wine
causes alcoholism, then it prevents heart disease. For PPS -- for or any condition -- we need to do the hard work of
reading the actual research studies, not just newspaper articles or press
releases, to understand what’s really happening to our bodies and know how to
care for ourselves.