*******************************************
A
CORNUCOPIA WITH THANKSGIVING GOODIES
A
LIGHT-FILLED CHANUKAH
and
the
MERRIEST
OF CHRISTMASES!!
********************************************
November 9th,
2008
– Two therapists from Florida Hospital Pt. Orange Rehab
Services David Manestar, Manager
and Kristen Hanak, certified
Lymphedema Therapist.
January 18th, 2009 – Dr. MaryAnn
Keenan, head of
Orthopedic Surgery Department, will talk on both surgery and
bracing.
Michael
Kossove,
Professor of Microbiology at
about Polio 101.
*********************************************
CONTENTS
From Barbara
An Approach to the Patient with
Suspected Post-Polio
Syndrome
Isn’t This the Truth????
6 Super-Healthy Snacks
This is Happening Right Here in
Our Own Country
Various Types of Pain Defined
A Keeper
Calendar Watch
*********************************************
FROM
BARBARA
Please
be sure to note that our meeting this month is the second Sunday –
NOVEMBER 9th
– the reason for this is very simple…. I am cruising from November
16th to the 23rd. This time
it’s on a Holland America ship, the Westerdam, I have not been on this
line before and will let you know how it was in the next newsletter.
Last newsletter I told
you how I knew Professor Kossove – now I’ll tell you about Dr.
Keenan. I first met Dr. Mary Ann
Keenan at one of the Post-Polio International Conferences in
When I told my family,
they immediately wanted to know if the brace that I would be given would wind
up in the closet with the rest of the braces that I had tried the previous few
years. This time I told them I
would have to wear it because after the surgery my leg would not be strong enough
to support me without the brace.
The only time it would be off me was when I was sleeping.
The surgery was done
in November 1995. The knee on
November 10th and the ankle on November 21st – the delay due to the hope
that maybe, somehow, after the knee was done it would line up with the ankle. Of course, it wasn’t to be.
The
day after the ankle was done a brace was fitted and made for me –
I’ve been wearing that brace every day since then. I stayed at Moss Rehab (connected to
Dr.
Keenan was there giving me support the entire time. I still go to
We’ve
had two conferences here in
If
you have never heard Dr. Keenan give a talk on surgery and bracing, this is the
time to do so.
********************************************
The following article is from the
Michigan Polio Network’s Polio Perspectives, Volume 23 No 2, Summer
2008. It was very kindly e-mailed
to us by their Editor, Vera Hazel.
Thank you, Vera.
AN APPROACH TO THE PATIENT WITH SUSPECTED POST POLIO
SYNDROME
Polio survivors
are at risk for the occurrence of certain physiologic changes in the nervous
system which result in a characteristic set of symptoms now known as Post Polio
Syndrome. In addition to these unexpected physiological changes there are
anticipated complications such as arthritis, scoliosis, and entrapment
syndromes that frequently accompany paralytic conditions. These anticipated
complications are not the problems that distinguish PPS from other diseases of
the nervous system. Post Polio Syndrome (PPS) is a major chronic illness and
one which poses unique problems to its survivors and their physicians.
No Diagnostic
test exists for PPS, so clinical criteria must be used to establish the
diagnosis. Many Physicians lack training in the diagnosis and management of a
syndrome only recently acknowledged as existing. Patients are often
uncomfortable with physicians they feel do not understand their problems. They
also fear increased disability, often at the same time they are coping with
limitations of aging. Patients are often trapped in a "conquer the
disease" mentality derived from the experience of recovering from the
acute episode an average of 25 years earlier. This is incompatible with the
lifestyle adjustments necessary for optimal results in PPS rehabilitation.
I. INTRODUCTION
A. DEFINITION
OF POST POLIO SYNDROME
An otherwise
unexplained constellation of symptoms which may include weakness, fatigue,
pain, heat or cold intolerance, and swallowing, breathing, or sleep disturbance
developing in a patient who had paralytic polio. Post Polio Muscle Atrophy
(PPMA) has been used as the label for the above symptoms when they include
progressive muscle atrophy.
B. SCOPE OF THE
PROBLEM
1987 National
Health Interview Survey estimated 1.63 million American polio survivors
(=0.625% of population), 50% with some Post Polio Syndrome symptoms.
C. DIAGNOSTIC
CRITERIA
1. PPS is a
diagnosis of exclusion and should be based on a thorough history and physical
exam.
2. Evidence of
prior paralytic polio: via EMG, an appropriate history, or characteristic
residual atrophy.
3. Period of
apparent stability before any new symptoms. New symptoms may often be seen
after an illness or injury.
4. Exclusion of
other conditions (especially motor neuron diseases and overuse syndromes).
II. PATHOLOGY:
PHYSIOLOGIC AND CLINICAL CONSEQUENCES
A. EXTENSIVE
NEURONAL INVOLVEMENT IN THE ACUTE POLIO INFECTION
1. The extent
of central nervous system infection by polio virus is not well appreciated.
Infection is far more widespread than anterior horn cells alone. Often anterior
horn cell infection is largely subclinical due to residual capacity of
uninfected and surviving neurons. Infection outside the anterior horns is
likely to be largely subclinical also, but may help to explain the disabling
symptoms of fatigue and pain which are subjective and controversial (because
the physiologic basis is uncertain).
2. Ninety-five
percent (95%) of motor neurons are infected in an average acute infection, with
a 50% neuronal fatality rate.
3. There is
frequent segmental involvement, accounting for the lack of symmetry of
weakness.
4. In addition
to the anterior horns in the spinal cord, infection involves inter-mediolateral
horns and dorsal root ganglia.
5. Infection
also involves motor cortex, hypothalamus, and globus pallidus, brain-stem
nuclei, reticular formation, cerebellar roof nuclei, and vermis.
B. MOTOR UNIT
REMODELING IN THE POST RECOVERY PHASE
1. A normal
quadriceps has, on average, 200 muscle fibers/anterior horn cell and a normal
anterior horn cell can adopt as many as 1,000 orphaned muscle fibers.
2. Over 50 % of
motor units may be lost without symptoms. (Normal walking uses only 15-20% of
maximum muscle strength.)
3. Clinical
improvement occurs acutely through recovery of mildly affected neurons,
collateral sprouting, and strengthening (hypertrophy) of intact musculature.
4. Increased
demand on surviving motor units results in increased firing frequency which in
turn produces a change in fiber type to predominantly aerobic "slow
twitch" fibers with increased vascularity.
C.
DECOMPENSATION THEN PRODUCES POST POLIO SYNDROME
While a single underlying
etiology for PPS has not been proven, several theories exist:
1. There is an
increased metabolic burden on surviving anterior horn cells (even in
asymptomatic muscles) as they direct more muscle fibers to contract, more
often, to achieve the same force of contraction. This leads to anterior horn
cell fatigue and can lead to premature metabolic injury, perhaps even cell
loss. Fatigued neurons may be unable to continue to trophically support as many
muscle fibers. The collateral sprouts to some muscle fibers will degenerate.
The strength of these muscle fibers will be lost to the motor unit, and a
spiral of decline may set in. This mode of decompensation augured by fatigue,
may be anterior horn cell based. This appears not to be a static process and
there may be dynamic denervation and reinervation.
2. Another mode
of decompensation is muscle fiber based: Rapidly firing muscle fibers produce
more lactic acid which may not be adequately dissipated. This is especially
true with any degree of isometric contraction. Muscle fiber fatigue may, lead
to muscle fiber injury, lost function, and a spiral of decline.
3. Any increase
in mechanical load (such as would result from increased weight or increased
physical activity) or decrease in force generating capacity (such as would
result from inactivity following illness or injury) may trigger metabolic
failure in motor units or in muscle fibers functioning close to their capacity.
4. The
resulting relative weakness may lead to joint and muscle misuse and overuse.
This may lead in turn to both arthritis and overuse syndromes.
5. In addition
to anterior horn cell and muscle fiber modes of fatigue, central fatigue may
also be a factor. Polio virus infection of the motor strip and the reticular
activating system is well described. A working definition for central fatigue
is: "Increased mental effort necessary to perform a fixed amount of muscle
contraction". This is very much how Post Polio Syndrome patients describe
their feelings of fatigue, many report hitting a "post polio wall".
III. PATIENT
PRESENTATION
A. PRIME
SYMPTOMS
A common
presentation is a polio survivor who previously had lower extremity involvement
in a well defined polio episode. The patient may have restricted ambulation
from hiking or jogging, lived a sedentary life, and did not feel disabled.
After a period of relatively stability he or she may begin to notice unusual
fatigue and discomfort and may further restrict activity. Denial of decreased
functional capacity may lead to a crisis as the patient can no longer can meet
occupational, social, and family commitments. Persistence and attempts to
continue at a previous activity level may lead to a downward spiral of
decreasing functional capacity with resulting depression and despair. On
examination, relative obesity may be present and weakness is easily
demonstrated, often in the "good" leg; limbs considered unaffected
are often subclinically affected with polio and may present with
"new" polio. A statistical summary of the clinical characteristics of
several series of PPS patients is as follows:
1. Fatigue,
Pain, and Weakness are almost always present. Fatigue (89%); Pain in Muscle
or Joint (86%); New weakness (83%) in previously symptomatic (69%) or
asymptomatic (50%) muscles.
2.
New Atrophy (28%); This equates to Post Polio Muscular Atrophy (PPMA).
3.
Activities of daily living difficulties (78%) = functional loss. Walking
(64%); Climbing Stairs (61%); Dressing (17%).
B. ADDITIONAL
PRESENTING PROBLEMS
1. Pulmonary
dysfunction:
Patients with
Post Polio Syndrome may suffer from weakness of the breathing muscles, namely
the diaphragm and ribcage. Occasionally, this can be severe enough to cause
symptoms of dyspnea on exertion and even at rest, poor clearance of respiratory
secretions increasing the risk of pneumonia, and elevations in the resting
arterial CO2 level. Measurement of pulmonary function tests in these patients
usually shows a significant restrictive pattern (small lung volumes) on the
basis on neuromuscular weakness.
If respiratory
muscle weakness is severe enough mechanical ventilation may be required. Small
mechanical ventilators have been developed which deliver breaths through a
comfortable plastic nose mask. This is often performed while the patient is
asleep at night and results in improved daytime function.
2. Sleep
Disorders:
Patients with
Post Polio Syndrome have a high incidence of sleep disturbances with poor sleep
quality and frequent awakenings which may be due to several factors. However,
the most important etiology to rule out is central, obstructive and mixed sleep
apneas. Nocturnal hypoxemia and hypercarbia can lead to worsening of daytime
function of the breathing muscles. Nocturnal non invasive ventilation can be
used in these patients to improve sleep quality and reduce symptoms of daytime
sleepiness, and perhaps improve daytime respiratory muscle function.
3. Dysphagia:
Many PPS
patients reported some new difficulty with eating or swallowing more commonly
in those with bulbar polio. Video fluoroscopy has been used for evaluation and
has frequently revealed pharyngeal constrictor weakness. Laryngeal penetration
and loss of the cough reflex may occur without symptoms, suggesting an
underestimation of the presence and severity of dysphagia in this population.
Many patients have already employed compensation such as altering diet, cutting
solids into small pieces, chewing it thoroughly, taking small sips of liquids,
eating slowly, and using postural maneuvers. Most patients with dysphagia had
also experienced some progressive speech difficulty such as increased
hoarseness, weakness, or slurring.
4. Cold
intolerance (29%):
Limbs may be
cold and cold exposure produces weakness. This is thought to be due to
intermediolateral column involve-ment resulting is vasoparesis, venous pooling,
and excessive heat loss.
5. Degenerative
arthritis:
A joint that is
biomechanically disadvantaged may develop degenerative arthritis.
6. Social and
psychological problems:
Long term
disability and denial may result in social and psychological problems.
C. PAST HISTORY
1. Average age
of polio onset is 7 years. Median time to maximum recovery is 8 years. Median
period of stable neurologic and functional status is 25 years. Median post
polio symptom duration before patient presents for evaluation is 5 years.
2. Variables
associated with shorter interval to PPS: greater severity and greater age.
3. Initial
symptoms are most frequent in the lower limb most affected in the acute
illness. (Upper extremity weakness is easier to compensate for without overuse
resulting.)
4. The onset is
usually insidious but is frequently precipitated by injury, illness, bed rest,
or weight gain.
IV. EVALUATION
PROCESS
A. IDENTIFY AREAS OF DYSFUNCTION
1. The history
is especially useful in identifying fatigue, dysphagia, sleep disorders, and
alteration in activities of daily living.
2. The
Neurologic exam will identify atrophy or weakness and verify that reflexes are
not increased. Pay special attention to the "good" limb as
significant weakness may be present of which the patient has never been aware.
With leg muscles, functional tests must be used because manual testing may not
detect quadriceps weakened to 30% of normal even though this is sufficient
strength for routine daily activities. Seek a mechanical advantage in manual muscle
testing: Test the triceps or quadriceps with the elbow or knee flexed more than
90 degrees. Test the psoas in the supine position.
3. The general
physical exam and biomechanical exam note obesity, joint deformity, overuse
syndromes, and scoliosis.
4. Electromyography
may be requested when needed to document previous anterior horn cell disease
(especially when the previous history of polio is in doubt). EMG can also be
used to rule out other neuromuscular pathologies or to identify subclinically
involved muscles.
5. CK elevation
may be seen in patients but may not correlate with progressive weakness.
B. FORMALIZE
TREATMENT GOALS
After the
diagnosis of PPS is established, a patient conference is a convenient way to
formalize treatment goals and begin patient education. These areas should be
addressed:
1. Lifestyle
Modifications:
This item is
the "sine qua non" of all attempts at successful management of PPS.
At the time of formal diagnosis, patients are often desperate, yet imbued with
a belief in their own ability to overcome their disability through the "no
pain, no gain" approach. This approach may have served them very well
after their acute attack of polio many years ago but is now actually self
destructive.
Persistence in
this approach of "over-coming" illness has led to a spiral of
deteriorating function and frequently a parallel decline in self worth.
Patients must understand the concept of "living with" PPS in order to
lead the fullest life possible. An understanding of the need for lifestyle
modification is rarely achieved at the first visit and is often best
reintroduced by a knowledgeable Occu-pational or Physical Therapist and
reinforced and monitored at subsequent physician office visits.
2. Increase
Muscle Capacity:
a. Muscular
capacity can be increased by achieving increased strength or endurance.
Strength can be increased through isometric exercise. However, muscles must be
carefully selected for isometric exercises. Some muscles will already be
functioning at their maximum. Exercise may actually have a deleterious effect
by forcing these muscles beyond their metabolic capacity and producing injury.
b. Endurance
may be increased, susceptibility to fatigue decreased, and long term
deterioration minimized through appropriate exercise supervised by a physical
therapist experienced with post polio patients. Almost all patients have
initial difficulties with exercise programs resulting from overdoing. They may
also equate fatiguing daily activities (which challenge the weakest musculature
and do not provide an effective aerobic training level) to exercise. This can
be an instructive opportunity for the patient in understanding the
"Lifestyle modification" and to experience its benefits. Goals in
aerobic exercise are:
(1) Educate the
patient to avoid potentially harmful exercise-induced fatigue. A reasonable
approach would be to establish the level of peak performance by patient
history. Then start at 50% of peak performance and slowly increase performance
as tolerated.
(2) Select
exercises which can create a training effect in the patient with weakened,
atrophic musculature and overuse syndromes. Exercise intervals with intervening
rests are necessary, just as is pacing of daily activities. A knowledgeable
Physical Therapist can be crucial to this aspect of management.
c. Muscle
capacity can also be increased by bracing, orthotics, or other aids which
extend, amplify or substitute for muscles.
d.
Pharmacologic treatment of fatigue: Some medications seem to raise the
threshold for fatigue. These observations are, as yet, anecdotal and await
confirmation from clinical trials.
(1) Amantadine:
up to 100 mg BID as tolerated.
(2) Deprenyl:
up to 5 mg BID as tolerated.
(3) Mestinon:
up to 60 mg TID when careful monitoring is available.
Medications for
the amelioration of fatigue must be understood as aids which can give a running
start to the rehabilitation process. However, if they are perceived by the
patient as a form of curative treatment, they will only forestall the day of
reckoning.
3. Decrease Muscle
Load To Less Than Muscle Capacity:
a. PACING of
activity is the logical consequence of a successful LIFESTYLE MODIFICATION.
Implementing of PACING requires that patients identify for each of the
activities of daily living the length of time they may participate before
experiencing fatigue. They must then break up their activities into smaller
modules of time, each of which is of less duration than the time required to
produce fatigue. A corollary concept to PACING is ENERGY BUDGETING which
imagines that one has a fixed expenditure of energy for each day and that this
sum should be "spent" on activities of the highest personal priority.
(Exceeding this daily limit may be conceptualized as spending principle or
acquiring debt but probably correlates to metabolic injury of the motor unit
through overuse.)
b. Other means
of decreasing muscle load are diet when overweight, use of orthotics to improve
mechanical efficiency, use of wheelchairs or scooters to save energy
expenditure, and treatment of chronic overuse syndromes.
4. Treat
Specific Complications:
a. Attention to
specific complications such as dysphagia, pulmonary dysfunction and sleep
disturbances may require specific referrals. The goals of these referrals can
be addressed with the patient at this first conference.
b. Functional
consequences also result from overuse syndromes which can lead to joint
deformity. Physiatry consultation can be helpful here and orthopedic
intervention is occasionally required. Evaluate need for orthotic prescriptions
(i.e., splints, braces, AFO's)
c.
Somatization, depression, anxiety, and self worth problems may occur as
capacity decreases. Referral for counseling should be considered (MSW,
psychologist) or polio support group (see reference section).
d. Evaluate
and/or modify work duties through referral to occupational therapist or
vocational counselor.
C. PROGNOSIS
Patients often
present during a period of decompensation. Decompensation may be caused by even
slight embarrassment in strength due to inactivity or injury superimposed upon
aging. It may also result from slight increase in muscular work resulting from
weight gain or increase in activities. In either case, a spiral of
deterioration may result from potential overuse injury to the motor unit and
subsequent decrease in functional capacity can result. Patients may easily
become fearful and depressed at this ominous decline in their previously
stable, if compromised, neuromuscular status.
It is important
to clarify for the patient the difference between deterioration in function and
deterioration from disease progression. In fact, there is little evidence that
any loss of function experienced by PPS patients is due to progression or
recurrence of polio virus infection. If patients can understand that opposing
forces of muscle strength versus muscle load are acting near a capacity
threshold, they will be quicker to accept PACING concepts, to employ an
appropriate exercise program, and to utilize other elements of rehabilitation.
In most cases, this will allow the patient to return to or approach the
previous functional baseline. It is not difficult for patients to then minimize
deterioration in function over the years by:
1. Achieving an
optimal balance between muscle strength and endurance (achieved and maintained
by exercise) versus muscle burden (resulting from body weight, mechanical
inefficiencies, and activity level).
2. Utilizing
PACING and restriction of activities after the point of fatigue so that muscle
work is kept within the limits of muscle capacity and decompensation does not
occur.
3. Gradually
decreasing total daily energy expenditure over the years much as a non PPS
individual might do. This rarely results in much loss of individual activities
or functions, only in the amount of each that is performed each day.
V. RESOURCES IN
PATIENT MANAGE-MENT
The patient
with PPS is best served by having a physician who has experience evaluating
post polio symptoms, formalizing treatment goals, and making the appropriate
referrals such as those listed below:
A. NEUROLOGY
CONSULTATION
When the
Diagnosis is in question.
B. PHYSIATRY
(PHYSICAL MEDICINE AND REHABILITATION)
A Physiatrist
is a physician with expertise in the orchestration of the rehabilitation
process. Especially when disability is severe, complex, or when biomechanical
problems are prominent, physiatry consultation can help with the initial
planning and selection of specific exercise programs, physical therapy,
orthotics, and adaptive equipment.
C. PHYSICAL
THERAPY
A Physical
Therapist who is experienced regarding PPS will be of tremendous value in
introducing and customizing the lifestyle modifications and in introducing the
useful concepts of pacing and energy budgeting. Physical Therapists can also
screen for inefficiency in movement resulting from deformity or weakness,
assist in establishing your patient on a safe exercise program, and monitor for
the almost inevitable initial over indulgence in that program.
D. OCCUPATIONAL
THERAPY
Occupational
Therapists are trained to assess the home environment and the patient's daily
activities in order to restructure tasks, introduce mechanical aids like grab
bars, and provide devices such as sock lifters which make possible physical
activities otherwise compromised by disability. Instruction in PACING of
routine daily activities and associated lifestyle modification can also be
provided by an Occupational Therapist.
E. SPEECH
PATHOLOGY
A speech
pathologist can help in the evaluation and treatment of swallowing and speech
problems.
F. PULMONOLOGY
A Pulmonologist
can evaluate and manage respiratory dysfunction and sleep dysfunction.
G. PSYCHOLOGY
A psychologist
or MSW can evaluate and counsel regarding reactive depression, coping
strategies, pain management and life style adjustment. This is especially
important to help the post-polio survivor deal with the "reemergence"
of a neuromuscular disorder they thought had been previously conquered.
H. SUPPORT
GROUPS
Local
education/support groups meet on a monthly basis in various locales, offering
education, support, and social opportunities for polio survivors and their
families.
I. OTHER
Orthopedics,
nutrition, and social work referrals for evaluation will occasionally be useful
in specific circumstances.
VI.
BIBLIOGRAPHY
Dalakas, et al.
A Long Term Followup Study of Patients with Post Poliomyelitis Neuromuscular
Symptoms. NEJM 1986; 314:949-63.
Klingman, et
al. Functional Recovery: A Major Risk Factor for the Development of PPMA.
Arch Neurol '88; 45:645- 7.
Pezeshkpour
& Dalakas. Long Term Changes in the Spinal Cords of Patients with Old
Polio. Arch Neurol '88; 45:505-8.
Sonies and
Dalakas. Dysphagia in Patients with the Post-Polio Syndrome. NEJM 1991;
324:1162-7.
Steljes, et al.
Sleep in Postpolio Syndrome. Chest 1990; 98:133-139.
Jones, et al. Cardiorespiratory
Responses to Aerobic Training by Patients with Polio Sequelae. JAMA '89;
261:3255- 8.
Agre, et al. Late
Effects of Polio: Critical Review of the Literature on NM Fxn. Arch Phys
Med Rehab '91;72:923- 31.
Munsat, ed. Post-Polio
Syndrome. Butterworth-Heinemann, 1990.
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This too, was e-mailed to me by another
one of our members. Thanks, Caryle.
ISN'T
THIS THE TRUTH??????
You
may need to stop at the women's restroom . . . be prepared!
When you have to visit a public
bathroom, you usually find a line of women, so you smile politely and take your
place. Once it's your turn, you check for feet under the stall doors. Every
stall is occupied.
Finally, a door opens and you dash
in, nearly knocking down the woman leaving the stall.
You get in to find the door won't
latch. It doesn't matter, the wait has been so long you are about to wet your
pants! The dispenser for the modern 'seat covers' (invented by someone's Mom,
no doubt) is handy, but empty. You would hang your purse on the door hook, if
there was one, but there isn't - so you carefully, but quickly drape it around
your neck, (Mom would turn over in her grave if you put it on the FLOOR!) yank down your pants, and
assume 'The Stance.'
In this position your aging, toneless
thigh muscles begin to shake. You'd love to sit down, but you certainly hadn't
taken time to wipe the seat or lay toilet paper on it, so you hold 'The
Stance.'
To take your mind off your trembling
thighs, you reach for what you discover to be the empty toilet paper dispenser.
In your mind, you can hear your mother's voice saying, 'Honey, if you had tried
to clean the seat, you would have KNOWN
there was no toilet paper!' Your thighs shake more.
You remember the tiny tissue that
you blew your nose on yesterday - the one that's still in your purse. (Oh yeah,
the purse around your neck, that now, you have to hold up trying not to
strangle yourself at the same time). That would have to do. You crumple it in
the puffiest way possible. It's still smaller than your thumbnail.
Someone pushes your door open
because the latch doesn't work. The door hits your purse, which is hanging
around your neck in front of your chest, and you and your purse topple backward
against the tank of the toilet. 'Occupied!' you scream, as you reach for the
door, dropping your precious, tiny, crumpled tissue in a puddle on the floor,
lose your footing altogether, and slide down directly onto the TOILET SEAT. It is wet of course.
You bolt up, knowing all too well that it's too late. Your bare bottom has made
contact with every imaginable germ and life form on the uncovered seat because
YOU never laid down toilet paper - not that there was any, even if you had
taken time to try. You know that your mother would be utterly appalled if she
knew, because, you're certain her bare bottom never touched a public toilet
seat because, frankly, dear, 'You just don't KNOW what kind of diseases you could get.'
By this time, the automatic sensor
on the back of the toilet is so confused that it flushes, propelling a stream
of water like a fire hose against the inside of the bowl that sprays a fine
mist of water that covers your butt and runs down your legs and into your
shoes. The flush somehow sucks everything down with such force that you grab
onto the empty toilet paper dispenser for fear of being dragged in too.
At this point, you give up. You're
soaked by the spewing water and the wet toilet seat. You're exhausted. You try to wipe with a
gum wrapper you found in your pocket and then slink out incon-spicuously to the
sinks.
You can't figure out how to operate
the faucets with the automatic sensors, so you wipe your hands with spit and a
dry paper towel and walk past the line of women still waiting.
You are no longer able to smile politely
to them. A kind soul at the very end of the line points out a piece of toilet
paper trailing from your shoe. (Where was that when you NEEDED it??) You yank the paper from your shoe, plunk it in the
woman's hand and tell her warmly, 'Here, you just might need this.'
As you exit, you spot your hubby,
who has long since entered, used, and left the men's restroom. Annoyed, he
asks, 'What took you so long, and why is your purse hanging around your neck?'
This is dedicated to women
everywhere who deal with a public restrooms (rest??? you've GOT to be kidding!!). It finally
explains to the men what really does take us so long. It also answers their
other commonly asked questions about why women go to the restroom in pairs.
It's so the other gal can hold the door, hang onto your purse and hand you
Kleenex under the door!
This HAD to be written by a woman! No one else could describe it so accurately!
********************************************
The following is reprinted from the EatSmart column by Jean Carper in the
Daytona Beach News Journal.
6
Super-Healthy Snacks
Eating
the wrong kind of snacks is a major cause of obesity in children and
adults. My favorite good ones:
Popcorn: It’s whole grain, fiber rich and low glycemic (less likely
to spike blood sugar and cause hunger and weight gain). Whole grains help fight heart disease,
diabetes and cancer. When
air-popped, three cups of popcorn has only 93 calories.
Dark Chocolate: It’s rich in antioxidants, can lower blood pressure and
might help protect your heart.
Surprise: It does not spike
blood sugar. My choice –
three pieces of Dove dark chocolate (about an ounce has 126 calories).
Prunes: Sugary, yes, but low among dried fruits in boosting blood
sugar (at half the rate of raisins, for example). New evidence suggests that prunes might
help fight colon cancer. Three
prunes have 69 calories.
Hard-Boiled Egg: A nutritional bargain at 80 calories each, eggs are packed
with filling protein and are rich in choline for optimal brain functioning.
Almonds: A handful with antioxidant-rich skins is filling and rich in
fiber and protein. Almonds are good
for cholesterol and might cut risk of lung cancer in smokers and heart disease.
Peanut Butter: High in fat, yes, but studies show that snacking on peanuts
and peanut butter helps to suppress appetite. I like a couple of tablespoons on an
apple.
********************************************
The following was e-mailed to me by one of our
members, Marion Schoeller. Thanks,
THIS IS HAPPENING RIGHT HERE IN OUR OWN COUNTRY!
We Must Stop This Immediately!
Have you
noticed that stairs are getting steeper. Groceries are heavier . And, everything
is farther away. Yesterday I walked
to the corner and I was dumbfounded to discover how long our street had become!
And, you know, people are less considerate
now, especially the young ones. They speak in whispers all the time! If you ask them to speak up they just
keep repeating themselves, endlessly mouthing the same silent message until they're red in the face!
What do they think I am, a lip reader?
I also think they are
much younger than I was at the same age. On the other hand, people my own
age are so much older than
I am. I ran into an old friend the other day and she has aged so much
that she didn't even recognize me!
I got to thinking
about the poor dear while I was combing my hair this morning, and in doing so,
I glanced at my own reflection. Well, REALLY NOW – even mirrors are not made the way they used to be!
Another thing,
everyone drives so fast these days!
You're risking life and limb if you happen to pull onto the freeway in
front of them. All I can say is, their brakes must wear out awfully fast,
the way I see them screech and swerve in my rear view
mirror.
Clothing manufacturers
are less civilized these days. Why else would they suddenly start
labeling a size 10 or 12 dress as 18 or 20? Do they think no one notices?
The people who make bathroom scales are
pulling the same prank. Do they think I actually 'believe' the number I
see on that dial? HA! I would never let myself weigh that much!
Just who do these people think they're fooling?
I'd like to call up
someone in authority to report what's going on--but the telephone company is in on the conspiracy too: they've printed
the phone books in such small type that no one could
ever find a number in there!
All I can do is pass
along this warning:
WE ARE UNDER ATTACK!
Unless something drastic
happens, pretty soon everyone will have to suffer these awful indignities.
PS: I am
sending this to you in a larger font size, because something has happened to my
computer's fonts – they are smaller than they once were.
********************************************
Reprinted from San
Joaquin CFIDS/ME/FMS Support Group, August, September 2008 newsletter.
Various
Types of Pain Defined
Pain:
The International Association for the Study of Pain describes pain as,
“An unpleasant sensory and emotional experience associated with actual or
potential tissue damage, or described in terms of such damage”. Pain is a subjec-tive condition which
includes personal experiences and emotions. Therefore, no one patient with pain can
be treated with exactly the same methods or medications as another patient.
Acute Pain: This usually has a sudden onset and a foreseeable end. It is most often associated with trauma
or acute disease such as a broken limb or, for example, appendicitis.
Chronic Pain: This is usually described as pain which has lasted for 3 or more
months. However, it also applies to
pain which has lasted longer than the expected normal healing time.
Pain terminologies and definitions that you may have read about or heard from your doctor are listed
below.
Allodynia: Pain caused by a stimulus
which does not normally provoke pain.
Eg. Lightly touching uninjured skin causing pain.
Analgesia: Absence of pain in response to stimulation which would normally be
painful. Eg – Not feeling a
pin prick to the skin.
Dysaesthesia: An unpleasant abnormal
sensation, whether spontaneous or evoked.
Hyperaesthesia: An increased sensitivity to stimulation. Eg – A light touch is per-ceived
as strong.
Hyperalgesia: An increased response to a stimulus which is normally painful. Eg – A pin prick is felt more
painful than is normal.
Hyperpathia: A painful syndrome characterized by an abnormally painful reaction to a
stimulus, especially a repetitive stimulus, as well as an increased threshold.
Hypoalgesia: Reduced feeling of pain to normally painful stimulus.
Hypoaesthesia: Decreased sensitivity to stimulation, excluding the special senses.
Causalgia: A syndrome of sustained burning pain, allodynia and hyperpathia after
traumatic nerve lesion, often combined with vasomotor dysfunction.
Central Pain: Pain initiated or caused by
a primary lesion or dysfunction in the central nervous system. (Brain and spinal cord).
Neuralgia: Pain in the distribution of a nerve or nerves.
Neuritis: Inflammation of a nerve or nerves.
Neuropathic pain: Pain initiated or caused by a primary lesion or dysfunction in the
nervous system.
Neuropathy: A disturbance of function or pathological change in a nerve. Mononeuropathy = in one nerve. Mono-neuropathy Multiplex = in several
nerves. Polyneuropathy = diffuse
and bilateral.
Complex Regional Pain Syndrome
I: CPRS I was formerly known as
reflex sympathetic dystrophy, it consists of continuous pain (allodynia or
hyper-algesia) in part of an extremity after a trauma. However the pain does not correspond to
the distribution of a single peripheral nerve. The pain is worse with movement and
associated with sympathetic hyperactivity.
==============
Balance of this article in next newsletter.
********************************************
Another e-mail to me by one of our members, Barbara Kidd –
Thanks, Barbara… If you agree
with it, please send it on to those who you
believe are “Keepers.”
A
Keeper
Their marriage was good, their
dreams focused. Their best friends lived barely a wave away. I can see them now, Dad in trousers,
work shirt and a hat; and Mom in a house dress, lawn mower in one hand, and
dish-towel in the other. It was the time for fixing things: a curtain
rod, the kitchen radio, screen door, the oven door, the hem in a dress. Things
we keep.
It was a way of life, and sometimes it made me crazy. All that re-fixing,
re-heating leftovers, renewing; I wanted just once to be wasteful. Waste
meant affluence. Throwing things away meant you knew there'd always be more.
But when my mother died, and I was standing in that clear morning light in the
warmth of the hospital room, I was struck with the pain of learning that
sometimes there isn't any more.
Sometimes, what we care about most
gets all used up and goes away... never to return. Sooo, while we have it, it's
best we love it... And care for it... And fix it when it's broken... And heal
it when it's sick.
This is true: For marriage.... And
old cars.... And children with bad report cards. Dogs and cats with bad
hips... And aging parents... And
grandparents. We keep them because they are worth it... because we are worth it. Some things we
keep, like a best friend that moved away or a classmate we grew up with.
There are just some things that make life important, like people we know who
are special.... And so, we keep them close!
I received this from someone who thinks I am a 'keeper,' so I've sent it to the
people I think of in the same way...
Now it's your turn to send this to those people that are 'keepers' in
your life. Good friends are like stars... You don't always see them, but
you know they are always there!
********************************************
CALENDAR WATCH
January 18, 2009 – Our very own 1 day seminar with Dr.
Mary Ann Keenan, head of Univ of PA Orthopedic Surgery Dept, will be talking on surgery
and bracing. Also, Michael Kossove,
a Professor of Microbiology at
April 23 - 25, 2009 – Post-Polio Health International’s 10th
International Confer-ence, Living with
Polio in the 21st Century, will be hosted by the Roosevelt Warm Springs
Institute for Rehabilitation in
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FLORIDA EAST COAST POST-POLIO SUPPORT GROUP
12 ECLIPSE TRAIL -
386 676-2435 e-mail:- bgold@iag.net
SEMINAR MEETING FORM
DATE: Sunday, January 18th, 2009
TIME: 10:00 AM - Registration -- 5:00 PM
PLACE: Daytona Beach Hampton Inn
1715 W International
386-257-4030
SPEAKERS: MICHAEL KOSSOVE, Professor of Microbiology at Touro
College, NY, will talk about Polio 101.
DR. MARY ANN KEENAN, Chief Neuro-Orthopedic Department
of
Dr. Keenan will be speaking on surgery and bracing.
EARLY REGISTRATION: $20.00 includes meeting material and lunch.
LATE REGISTRATION: $25.00
For Early Registration please send in by December 15, 2008.
Please feel free to make copies of this form to give to others.
Any questions, call Barbara at 386-676-2435.
==============================
The Hampton Inn, 386-257-4030, has put aside a block of 8 handicapped rooms for us, in addition to 10 non-handicap rooms at the special rate of $99.00 per night (that includes their Continental Breakfast). When calling to reserve a room, make sure to tell them that you will be attending the Post-Polio Conference so that you will get the special rate.
This Hampton Inn is right outside of
the
In order to make it easy for you to choose your lunch, here is a description of the various choices:-
Chicken Cordon Bleu:- Grilled chicken breast with baked ham and melted Swiss
cheese. Served open face with lettuce, tomato, and pickle spear.
Mediterranean Wrap:- Vegetarian with Hummus or Albacore Tuna with feta
cheese, lettuce, chopped tomatoes, Greek olives and roasted peppers.
With a light lemon yogurt and cucumber dressing served on the side.
Chicken Ranch Salad:- Grilled chicken breast over garden greens with crispy
bacon, shredded Monterrey Jack cheese, hard boiled eggs, tomato
wedges and cucumbers, served with Ranch dressing.
Chef Salad:- Strips of tender turkey breast, baked ham, Swiss and cheddar
cheese, garnished with carrot strips, ripe tomatoes and hard boiled
eggs. Served over fresh greens with our own House Vinaigrette, Ranch
or Bleu Cheese.
==============================================================
January 18, 2009 Seminar Registration
Name: _______________________________ Phone No.: _________________
Address: __________________________________________________________
Number of People Attending: ______ Number in Wheelchair(s):- _______
Lunch Choice: Chicken Cordon Bleu ___ Mediterranean Wrap ___
Chicken Ranch Salad ___ Chef Salad ___
Please make check payable to FL East Coast PPSG and send to:
FLORIDA EAST COAST POST-POLIO SUPPORT GROUP
12 Eclipse Trail -
11/2008
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FLORIDA EAST COAST POST-POLIO SUPPORT GROUP
12 Eclipse Trail
/
386-676-2435 / e-mail address: bgold@iag.net
DATE: Sunday, November 9th, 2008
TIME: 1:00 – 4:00 PM
PLACE: Red Lobster Restaurant
Right off I-95 – Exit
261–
(head EAST for about 1/4 mile)
PROGRAM:
Two therapists from Florida Hospital Pt. Orange Rehab
Services
David Manestar, Manager and Kristen Hanak, certified
Lymphedema Therapist.
Cost of the Luncheon is $13.00 all inclusive. As usual we will have a choice of several different menu items.
Please send in your reservation tear sheet and check
no later than November 5th, 2008
Any questions call Barbara at 386-676-2435.
===============================================================================
R
E S E R V A T I O N F O R M
November 9th, 2008 Luncheon Meeting
Name:- _______________________________ Phone No.:- _________________
Number of People Coming:- _________ Number in Wheelchair(s):- ___________
Amount of Check Enclosed:- ________________ @ $10.00 per person
Make check payable to and mail same to:
FLORIDA EAST COAST POST-POLIO SUPPORT GROUP
12 Eclipse Trail --
11/2008
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The World Congress
on Disabilities will be having a two day Expo in
This sounds like a
great opportunity to see what’s happening in some of the new technology
today. Unfortunately, I’ll be
on my cruise and won’t be able to attend. For further information you can go to
their website:-
www.wcdexpo.com
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DUES FOR 2008- Please take a look
at your mailing label - on it you’ll see the month and year
we received your 2007 dues, i.e., 01/2007 means it was received in January
2007, so your 2008 dues was due in January 2008. If your mailing label
has the year first and then the month, i.e., 2007/01 it means that you
indicated to us in January 2007 that you wanted to receive the newsletter but
paid no dues. That’s OK as we still believe that anyone who wants information
should receive it – but we do need you to return the tear sheet with
either the “Dues” box checked or the “Keep me on the Mailing
List” box checked.
Your dues covers the supplies we need to send out the information packets to
all inquiring about Post-Polio Syndrome, any other correspondence we do, and
postage for publicity and for the out-of-country (25) newsletters that we send
out. We’re fortunate in that the “Free Matter for the Blind
and Physically Handicapped” status takes care of the postage for the over
450 newsletters sent out within the United States. We network with
approximately 60 other support groups throughout the
*****************
WHEN YOU
MOVE PLEASE be sure to send us your new address.
Sometimes the post-office will return the newsletter to us with a
“forwarding period expired” notice on the front with your new
address but most of the time they are just returned to us with “address
unknown” on it. SO, if you want to continue receiving the
newsletter it is UP TO YOU to make sure we have your new address.
===============================================
2008 DUES/MAILING LIST
____ Dues Enclosed ____ Keep me on mailing list
If sending dues, please make Check ($5.00) Payable to and Mail to:-
FLORIDA EAST COAST POST-POLIO SUPPORT GROUP
12 Eclipse Trail,
NAME:- _____________________________________________________________
ADDRESS:- _________________________________________________________
E-MAIL ADDRESS:-__________________________ FAX #:- ___________________
TELEPHONE NO:- Home _______________________ Office ___________________
Date of Birth:-_________________ Wedding Anniversary:- _____________________
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