TREATMENT OF YOUNG POLIO SURVIVORS IN TURKEY Prof.Dr .Arzu Yağız On Ege University Medical Faculty Department of PM&R, TURKEY
Ege University Hospital Over 4000 inpatient beds 125,000 inpatient /year 450,000 inpatient / year
Department of Physical Medicine and Rehabilitation 80 inpatient beds 700 inpatient /year 15,000 outpatient / year
• 1997 : Fellow-ship in Uppsala University Hospital, Department of Clinical Neurophysiology (Arne Sandberg, Erik Stålberg ) • 2001: Post-Polio Clinic was established in Ege University Hospital, Department of Physical Medicine and Rehabilitation
Turkey is a Transcontinental Country (Eurasia) The modern convention of the Europe-Asia boundary
Istanbul is a transcontinental city
Cultural influences in Turkey originate from both Asia and Europe EUROPE ASIA
Inter-regional differences in terms of development and welfare Most developed Least developed Development status of Turkey
cases of wild poliomyelitis in 1998 Development status of Turkey Most developed Least developed
History of polio eradication in Turkey
Immunization campaigns Polio eradication program National immunization days 1963: vaccination started with a coverage rate of 20%
Polio cases % 100 100 80 80 National immunization days 60 60 40 40 20 20 0 0
Europe’s last case of wild poliomyelitis AĞRI -TURKEY 26 NOV 1998 MELİK MİNAS
Now, he is 16 years old. All our efforts are to keep him as the last child suffering from polio in Turkey.
• Eradicating polio is still a publich health priority in Turkey. • Insufficient attention has been paid to the patients living with polio sequela, and their health and rehabilitation, social, financial and psychological needs …
Current situation of polio survivors in Turkey??? • Global number? • Regional distribution? • Age distribution ? Challenges in accurately diagnosing and reporting the cases during epidemics
reported morbidity mortality exes year population cases rate rate year reported cases 1961 361 1962 1193 1963 954 1964 244 1965 629 1966 1975 1967 814 1968 2206 1969 384 TOTAL NUMBER OF REPORTED CASES BETWEEN 1961-1999 12.953
Developed countries Developing countries Polio largely eradicated by the early eliminated the disease in the late 1990s / 1980s still not eradicated Polio survivors mostly older than 50 Polio survivors are often younger Secondary conditions different needs and challenges to; Worsening disability due to PPS Health-care and rehabilitation Education Social integration Economic self- sufficiency
The degree to which polio affected …. • Education • Employement • Life satisfaction
Onset of PPS creates further challenges • Employement • Psychosocial situation • Independence • Social participation • Life satisfaction
Ege University PMR Post-polio clinic Team members • Physiatrist • Physioterapist • Orthotist • Access to dietitian and speech therapist • Access to specialists in psychiatry, pulmonary medicine, neurology and orthopedic surgery • occupational therapist • recreational therapist • rehabilitation psychologist • rehabilitation social worker • rehabilitation nurse • vocational counselor
original illness and subsequent sequel, use of orthotics and/or walking aids Assessment Previous surgeries medical history social situation and life style new neuromuscular and musculoskeletal information sheet symptoms (Pain, Fatigue, Weakness, Changes in functional status Physiatrist Physiotherapist • • Neurologic and ROM • musculoskeletal exam Strength • • Assessment of fatigue Mobility status (VAS, FIS, FSS) • Assessment of quality of life Orthotist • (NHP) Need for orthosis, • Four limbs needle EMG ambulatory aids • Further evaluations and referral • Confirmation of poliomyelitis • Extent of subclinical involvement • Diagnosis of PPS
International Journal of Rehabilitation Research. 2013. Vol 36 No 4
174 patients with a history of poliomyelitis admitted to our clinic between 1997-2014 Confirmation of poliomyelitis by clinical and EMG examinations n 158 (90%) Misdiagnosis of polio n 16 (10%) Encephalitis Upper motor neuron syndromes Stroke
Demographic characteristics of 158 polio survivors admitted to our clinic between 1997-2014 Age (min-max) Educational level mean 37 low 35 (22%) min-max 19-65 mid 71 (45%) Gender high 52 (33%) women 112 ( 71%) Employment status men 46 (29%) employed 52 (33%) Marital status self-employed 11 (7%) married 72 (46%) student 21 (13%) single 48 (30%) retired 12 (8%) divorced 26 (16%) not employed 62 (39%) widowed 12 (8%)
Region of origin Access route West 121 (77%) Internet / e-mail 92 (58%) Middle 23 (14%) referral 43 (27%) East-South East 14 (9%) other 22 (14%) Turk Fiz Rehab Derg 2004;36:112-116 Turk J Phys Med Rehab 2004;36:112-116
Clnical characteristics of 158 polio survivors admitted to our clinic between 1997-2014 Diagnosis of PPS n 82 % 54 women 53 (65%) men 29 (35%) Concominant diseases n 36 % 23 neurologic 4 rheumatologic 28 cardiovascular 2 endocrine 2
Clinical management program • Late effects of polio, PPS, associated problems Education • Instruction in energy conservation techniques Individual and family and work simplification • Suggestions for adaptive techniques and counselling equipment • Assistance in learning to adjust necessary lifestyle changes • Repairing or modifiying older orthosis Modification of orthosis • Fabrication of new custom orthosis • Providing therapeutic or weight-reduction diets Nutritional counseling • Specifically tailored to the individual’s functional Personalized exercise program status and needs • Emphasis the prevention of overuse • Supervision for two months • Close monitoring, modifications
Education Handbook • Late effects of polio • Work simplification • Energy conservation EL KİTABI • Home exercise programs Prof.Dr . Arzu Yağız On • Orthoses 2004
Clinical management program • Treatment of other disorders unrelated with polio Medical treatment • Treatment of PPS symptoms (lamotrigine)
Follow-up (one to two months) • Success of the program • Efficacy of the medical treatment • Side/advers effects of medicine • Modification or update of exercise program • Further evaluation and treatment
Lacking members in our team … • Rehabilitation nurse Home visits • Suggestions to make patient’s home accessible and functional • Rehabilitation social worker Inform about community resources available • Vocational counselor Vocational counseling and work evaluation • Job training to return former job • Alternate job training and placement
Future needs regarding polio survivors in Turkey
Future needs regarding polio survivors in Turkey • The lack of accurate data has profound implications for national policy- making. • Situation of polio survivors should be documented. – more accurate estimates of regional prevalence – the degree of residual disability • Polio survivors will continue to be a major concern – educational, social and economic needs of young- middle aged adults must be met – PPS will make additional demands on national health systems
Future needs regarding polio survivors in Turkey • Care strategies for polio survivors should involve coordination of multiple skilled professionals. – Adaptations of these strategies for resource-poor areas
Healthcare workers are largely unaware of PPS • Currently, education among health professionals is almost wholly on vaccination efforts. • Education of healthcare professionals and patients – Giving lectures – Publishing reviews – Joining the online support groups • A more widespread effort combining support from government with financial investments from global health organizations is needed
Future needs regarding polio survivors in Turkey • Overdiagnosis of PPS should be prevented
Future needs regarding polio survivors in Turkey • Despite polio survivors have been leaders in disabled people’s organizations, there is no organization or patients support group in Turkey specific to polio .
Positive note: • Strong social support, especially from family!! • General health insurance covers all rehabilitation services and equipments.
Thank you very much
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