There is a lot of information around these days on exercising for polio survivors. It is generally acknowledged that we all need some exercise but that care should be taken to not over-exercise.
There is consensus that exercise should be non-fatiguing aerobic interval training. ie enough to increase the pulse rate, not wear us out, and have frequent rest periods built in.
Before we go into this any further we should perhaps recap on what we have to work with.
POLIO destroys nerve cells that activate muscle
cells. If we look at the individual cells we can see what happened
then and what is happening now.
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In the diagram above (A) shows a good mix of type
1 and type 2 nerves with nerve supply to type 1 and type 2 muscle cells.
Type 1 muscle cells are black and type 2 are white. (B) Then comes
the polio virus and knocks out (in this case) half of what we can see in
this particular part of the spinal column. So the muscles activated
by these nerve cells are left with no life-line. (C) As part of the
recovery process, over the next few months and years as we improve, surviving
nerve cells send out extra shoots to pick up some of the orphaned muscle
cells. Some are lost but we don't necessarily notice, because we
don't register weakness until we are falling below 50% capacity.
(D) Now 30-40 years later, these nerves that have been working with an
extra load are unable to sustain this extra work and some may be lost again.
Additionally we are starting to run into normal loss with aging as well
so we lose some of the unaffected life-lines too. Now we have many
less muscle cells working and we notice we are getting weaker. There
are also more black spots (type 1) left than there are white spots (type
2).
This reflects the pattern seen in muscle biopsies
in polio research in USA, where a dominance of type 1 muscles is recorded
and the fact that they are abnormal type 1 ie larger and with less blood
supply, a feature of type 2 muscle cells. When the nerve supply to
a cell is changed, the fuel requirements of that cell change to that of
the activating nerve. ie the type 2 muscle cell changed to a type
1 runs better on fatty acid metabolism which requires carnitine.
(This fuel change is recorded in modern physiology books.)
This probably explains why our WA research is finding supplemental carnitine beneficial in energy production needed for exercising muscles
If we consider these diagrams again for a minute, there are other areas that may need additional support, where we have been using our bodies as if we had 6 instead of the remaining 3 nerves. They have been working harder because there are fewer left to do the work. Now they need some TLC (tender loving care) to keep going.
This means looking at all that is necessary for normal function. The vitamins, minerals, amino acids that they use to work. The nerve may need extra B6, nerve transmission may need more choline to make enough acetylcholine (the neurotransmitter or message bearer), the muscle - carnitine to transport fatty acids, magnesium to relax the muscle after contraction, glutamine, taurine and a host of others that are used by muscles and nerves to operate. There are usually signs and symptoms sent out by the body indicating particular deficiencies. Don't just take them without having a valid reason to do so. (See information in other WA Polio Clinic booklets.)
Right, back to exercising. As we saw in the diagram we don't have as many cells left now, so we shouldn't try to do more than what the nerves left are capable of doing. How do we know what is left? We don't really, until we are dead and they do an autopsy. But that is too late. EMG testing by a neurologist can determine what is happening as far as nerve function and distribution goes (and should certainly be done if you are contemplating surgery such as knee or hip replacement). But it is painful, involved and expensive. There are some simple ways of evaluating yourself or have it done by a physio.
SCALES FOR GRADING
There are 2 scales you might like to use.
The first has to do with polio and your muscles.
| GRADE | DISABILITY from POLIO | EXERCISE |
| 1 | no history of polio affecting | as normal |
| 2 | polio but no weakness now | normal with caution |
| 3 | polio leaving some weakness | 20% of capacity |
| 4 | polio with new weakness now | 20% with caution |
| 5 | polio - severe muscle wastage4 | with caution |
The second is the Beasely scale which converts
the Physio Muscle Grading Scale for polio affected muscles.
| GRADE | NON POLIO | % if POLIO | POTENTIAL |
| 5 | Normal | 50% - 60% | some strength improvement |
| 4 | Good | 40% | slight strength improvement |
| 3 | Fair | 20% | little strength improvement |
| 2 | Poor | 10% | no gain likely |
| 1 | Trace | 1% | preserve it |
| 0 | Paralysed | 0% | impossible |
Be careful - these scales run in opposite ways.
So we can scale our ability to exercise according to the effect of polio on a limb or muscle and we can scale our strength as to likelihood of being able to improve it or build it up.
You may be familiar with the saying "Use it or Lose it!" This is particularly true with polio but it doesn't mean "abuse it". When we are immobilised for a time as happens with the flu, surgery or fractures, we de-condition rapidly. If you are confined to bed, try to move around a little, frequently, to keep the muscle tone up.
"No pain, no gain!" however is out. Pain and fatigue are the body's warning systems that things are not right. Ignore at your peril.
It is very difficult to prescribe an exercise
program for polio survivors because we each have different amounts we are
capable of and different parts of the body weakened. No two people
are exactly the same. Our aim is cardiovascular conditioning and
preservation of existing muscle capacity. So a number of suggestions
or rules have evolved.
| 1. Adjust your exercise to your
capabilities. ie no pain, no fatigue
2. Find your own "happy medium". too much or too little can cause further deterioration. 3. Use your best muscles for cardiovascular exercise ie to raise your pulse rate. 4. Recognise your limitations. Pain or fatigue indicate you have gone too far. 5. Exercise at 20% of fatigue capacity. Try increasing by 10% monthly. 6. Build frequent rest periods into your exercise program eg 2-3 mins exercise to 1 min rest |
| TYPE OF EXERCISE
Obviously, if you have problems walking, you wouldn't try to walk for miles as a form of exercise. Similarly if arms and shoulders are causing you problems you wouldn't try to swim overarm. Any exercise 1. should not use body areas already compromised by polio. 2. should avoid fatigue in the muscles you use. 3. should avoid generalised fatigue or feeling "wiped out".
Here is what we are aiming for - Resistance - target pulse rise
(220 minus age X 60% - 70%)
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 Cycling, walking, sailing, golf, swimming, pool walking, water aerobics, exercise bike, arm pedalling, mini trampoline, passive body exerciser, stretching exercises, yoga, tai-chi, specific exercises for problem areas (usually set by a physio).
Physiological fatigue - if when you start exercising it gets harder by the minute. "Lead in the butt" fatigue - if feel tired when start but feel better and it gets easier as you get going.  |
So we've chosen our type of exercise, maybe sought some professional advice, we've started gradually, have a few minutes on and 1 off, only do 3 - 4 days per week so we have a day to recover in between, we are doing 30 minutes each session and we have raised the pulse rate to around the correct levels. And we feel good afterwards, not worn out ...or do we?
EXERCISING PROBLEMS
When we ran a trial this year with the passive
aerobic exerciser, participants reported back that initially they felt
OK or better. As the amount of time spent exercising increased, one
by one they dropped out. Pain starts to appear in various places,
the back, the shoulders, the hips - and eager to do more we inch the time
up hoping to get back to better days. It doesn't work. We must
be aware of our limitations.
In normal muscle exercise, only 20% is activated at any one time and the rest time is 4 in every 5 cycles. However, most of us are running at somewhere between 40% - 65% of normal so rest time is 1 in 2 or 1 in 3 cycles. In other words, we are literally running all the time instead of walking. Then we say let's exercise, increase the running rate to 100% with no rest time and wonder why we can't keep it up. The muscles run out of fuel, seize up and stay tight. How do we get energy?
MUSCLE ENERGY
Muscles have 2 energy sources. The glucose
cycle and the fatty acid cycle. They run in tandem, side by side
and assist each other. We start moving, glucose, insulin and oxygen
fuel the quick action type 2 muscles and as the glucose is used up the
endurance type 1 muscles come into action with fatty acids, carnitine and
oxygen. Breathing and blood flow increases to bring in more oxygen
and glucose and fatty acids. Immediate stocks are running low so
the muscles revert to anaerobic (no oxygen) glucose metabolism temporarily
while oxygen builds up again.
When this happens, lactic acid is formed and build up of lactic acid causes muscle pain. Oxygen arrives, muscles return to aerobic energy production and so on until carnitine and/or magnesium levels drop. Fatigue sets in, muscles tighten and become painful, the muscle goes to jelly. We have to stop and have a rest. While we are resting the body is busy speeding more supplies to used up areas. Breathing is rapid until the oygen debit has been repaid. Energy returns when fuel supplies, including carnitine, have been restored.
CARNITINE
Many of our members have had their carnitine
levels done and a large proportion have recorded low levels. Supplemental
carnitine boosts available supplies in the body, enabling us to exercise
without the exhaustion that takes days to recover from. And without
the pain from overuse. Subsequent serum carnitine levels show a rise
in available and used carnitine together with improved performance.
Supplemental carnitine is self-limiting. If we take more than we require, it is eliminated within a few hours, giving diarrhoea, the sign of excess to requirements. A number of our members are using a little extra carnitine immediately before extra exertion or exercise to enable them to exercise without fatigue pain or damage One member who needs 6 capsules can say that at 5 he is still tired, at 6 he is fine, 7 has diarrhoea, but needs that extra 1 later to play a game of golf or to go out in the evening. This is making it work for you. You are in control. The same applies to magnesium. If your muscles are tight or sore, your body is pleading for more magnesium to enable the muscle to relax.
EVALUATION
Am I doing it right? We should record everything
we do. We may need those records later and we won't remember accurately.
We need some yard-sticks that can be reproduced simply - like measuring
the circumference of limbs at a given point with a tape measure to detect
muscle wastage later. Your scale needs to be suited to what you can
easily do.
| EXAMPLES
1. Distance I can walk in a given time. 2. Number of steps I can climb in given time. 3. How high I can step up. 4. Number of seconds I can balance on each leg. 5. Weight I can lift from floor or table eg full kettle. 6. How often I fall or trip, flat or uneven surface. 7. Can I reach my toes or how far can I reach. 8. How long till I get short of breath. |
We still have our limitations - as seen by the nerve and muscle loss diagram. We still need to keep our activities within our capabilities and this will vary from person to person. Exercise is good for us but we need to make sure we have the right ingredients for successful muscular activity.
COMPLIANCE
How stickable am I? One study shows that
less than 40% of people may keep up an exercise program. One important
rule for sticking with it is to enjoy what
you are doing. If you need peer pressure
to keep at it, do it with a friend, join a group, make it a "regular thing"
you do. Choose a time, place and exercise that you are comfortable
with and enjoy doing. If not, find an enjoyable distraction to ocupy
you while you do it, like watching TV on the exercise bike, or mini tramp.
Listening to music or the radio while you do leg raises. A letterbox
drop while you walk. Walk the dog. But don't set yourself impossible
goals.
BENEFITS
1. Improved circulation - better
heart function, better cell nutrition, better elimination ie bowel habits,
warmer limbs, improved venous return, less oedema.
2. Respiratory stimulation - greater
oxygen intake, lung expansion, moves build-up in lungs.
3. Mental clarity - greater awareness,
increased hormone and enzyme levels, less depression.
4. Osteoporosis reduction - weight
bearing muscle pull on bones maintains bone density (body weight for legs,
lifting weights for arms)
5. Weight loss - mobilising of fatty
reserves for energy fuels.
6. Joint mobility - extra movement
keeps joints from seizing up, maintains joint fluid viscosity, lessens
calcium deposits and arthritis.
7. Improves muscle tone - in many
areas of body including bowel, bladder incontinence, pelvic floor.
8. Maintains muscle function - slows
age-related deterioration and in post polio if not excessive.
So there are many advantages to doing a bit of exercise. Be careful not to overstress areas of the body already working at maximum capacity. For some of us, just our normal daily living activities, use all our exercise potential. We may still benefit from some passive exercise - massage, deep breathing, stretching, someone else doing range of movement sessions, a passive electrical exerciser and even crosswords, cards and general knowledge quiz shows. The brain is a muscle needing exercise too.
References
Uriadka C, PT "Physiotherapy
Management of LEOP" 1997 Post Polio Clinic, West Park Hospital
Toronto, Ontario
Grimby G, MD et al "Endurance
Training Effect on Individuals with Post Polio" Arch Phys Med
Rehab. 1996; 77:843-8
Yarnell S, MD "Sydney Polio
Conference" 1996 Nov
Stoner E, PT "Northwest Polio
Conference Paper" 1995 May
Halstead L, MD;Grimby G,
Post Polio Syndrome Philadelphia, Hanley & Belfus,
1995
Martini F, Fundamentals of Anatomy
& Physiology NJ USA Prentice-Hall 1995
Moffett D, Moffett, S, Schauf C
Human Physiology Missouri USA Mosby 1993
Pons R, MD, de Vivo D, MD, "Primary
& Secondary Carnitine Deficiency Syndromes" J Child Neur 1995;
10 (Supp) 2S8-2S24
Lehmann T, MD "L-Carnitine
& Post Polio Syndrome" 1994 Dept Ventilators &
Post Polio Bern Switzerland
Perry J, "Manual Muscle Testing
Grading" Rancho Polio Clinic
