Original Article
THE RISK OF BONE FRACTURES IN POST-POLIOMYELITIS
PATIENTS TRANSITIONING TO MIDDLE ADULTHOOD
Rutie Mamlok Sherf, MD1; Dror Cantrell, MD2,3; Karen Or, MD1,2;
Efrat Marcus, MD2; Alex Shapira, MD4; Carlos Benbassat, MD2,5;
Sophia Ish-Shalom, MD6; Ronit Koren, MD2,5
ABSTRACT
Objective: While osteoporotic fractures are reported
in up to 40% of adults with post-poliomyelitis syndrome
(PPS), clinical guidelines regarding bone mineral density
(BMD) and indications for treatment are scarce. We inves-
tigated the characteristics of PPS patients, focusing on
fractures and osteoporosis as the primary outcomes.
Methods: A cross-sectional retrospective data analy-
sis from medical records of 204 PPS patients regarding
their clinical characteristics and long-term outcome, with
emphasis on bone metabolism status.
Results: Our cohort included 53% women; mean age
was 65 years at study entry and 1.7 years at the diagnosis of
acute poliomyelitis. The lower limb was involved in 97.5%
of patients, and the BMD in the affected limb tended to be
lower than the unaffected, with a mean T-score of −1.64 vs.
−1.19, respectively (P = .06). Recurrent falls were docu-
mented in 39.2% of patients, and osteoporosis in 20.6%,
being more frequent in women (P = .003) and patients with
Submitted for publication February 25, 2020
Accepted for publication June 1, 2020
From 1Internal Medicine A, 2Endocrine Institute, 3Internal Medicine C,
4Polio Clinic Department of Orthopedics, Shamir Medical Center (formerly
Assaf Harofeh), Zerifin, 5Sackler Faculty of Medicine, Tel-Aviv University,
Tel Aviv, and 6Lin Endocrine Research Center, Haifa, Israel.
Address correspondence to Dr. Carlos Benbassat, Endocrine Institute,
Shamir Medical Center (Assaf Harofeh), Beer Yaakov, Zerifin 70300, Israel.
E-mail: carlosb@netvision.net.il.
Published as a Rapid Electronic Article in Press at http://www.endocrine
practice.org on June 23, 2020. DOI: 10.4158/EP-2020-0102
To purchase reprints of this article, please visit: https://www.aace.com/
publications/journal-reprints-copyrights-permissions.
Copyright © 2020 AACE.
Copyright © 2020 AACE
fractures (P = .002). At least one fracture occurred in 52.2%
of patients, and more than one in 40.3%. The median age
for the first fracture was 57.5 years (range, 30 to 83 years),
and most fractures occurred in the affected limb (73.2%).
Conclusion: Underdiagnosis and delayed treatment of
osteoporosis in late-adulthood post-poliomyelitis patients
underlie the need for comprehensive clinical guidelines
to manage these patients, including recommendations
on bone health assessment, medical treatment, and their
inclusion as a high-risk group for bone fractures. (Endocr
Pract. 2020;26:1277-1285)
Abbreviations:
aBMD = areal BMD; APP = acute paralytic poliomy-
elitis; BMD = bone mineral density; BMI = body mass
index; BP = bisphosphonate; PBM = peak bone mass;
PPS = post-poliomyelitis syndrome; Tsc = T-score;
vBMD = volumetric BMD
INTRODUCTION
Acute paralytic poliomyelitis (APP) is a degenerative
process of the muscle fibers caused by the poliovirus. As a
result, flaccid asymmetric paresis/plegia and muscle atro-
phy may evolve, leading to reduced mobility and an elevat-
ed risk for falls (1-6). In the United States, it has been esti-
mated that nearly 1 million people have been affected by
APP, with half of them later developing a progressive and
chronic condition known as post-poliomyelitis syndrome
(PPS) (4). During the mid-20th century, there were several
large outbreaks of APP in Israel (7). According to the Israeli
Ministry of Health (8), 6,540 cases of APP were recorded
in Israel between 1950-1961 (Fig. 1). Vaccinations against
APP were introduced in 1957 (Salk inactivated vaccine-
IPV) and 1961 (Sabin attenuated oral vaccine-OPV). In
1988, the use of the conjoined OPV + IPV vaccination
ENDOCRINE PRACTICE Vol 26 No. 11 November 2020 1277
1278 Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11)
regimen eliminated the disease occurrence (7). Although
APP is now a rare condition in developed countries, it is
still a relevant problem in less developed areas (9).
Osteoporosis is a systemic disease characterized by
low bone mass and microarchitectural deterioration, lead-
ing to compromised bone strength and increased risk of
fragility fractures, which account for significant morbidity
and mortality in the general population. As with any multi-
factorial disease, several risk factors have been identified,
such as advanced age, female sex, familial predisposition,
early menopause, smoking, heavy alcohol intake, reduced
physical activity, and muscle weakness (10,11).
It is estimated that between 20 and 85% of APP survi-
vors develop PPS, a specific neurologic disorder charac-
terized by new weakness and muscle fatigue occurring
many years after the initial paralytic illness (1,2,5,6).
These symptoms expose the patients to an increased risk of
falls with its consequent injuries, including fragility frac-
tures (12,13). The wide range in the reported prevalence
of PPS stems probably from different diagnostic criteria
(5,6). Most medical care of PPS patients is directed to skel-
etal deformities, muscle weakness, and gait disorders and
carried out mainly at orthopedic clinics. However, nearly
60 years later, it seems that osteoporosis and bone fractures
have been neglected in this population that are now reach-
ing the age range where osteoporosis becomes prevalent
among the general population (6,10).
At the Shamir Medical Center (formerly Assaf
Harofeh), there is a large and active orthopedic post-polio-
myelitis outpatient clinic with a long follow-up period,
providing a unique opportunity to study the impact of PPS
on osteoporosis and osteoporotic fractures. To the best of
our knowledge, no research has been conducted in Israel
that examined bone quality in adult PPS patients, and the
available data on this topic is quite scarce in the general
medical literature.
Fig. 1. Acute paralytic poliomyelitis outbreak in Israel.
Copyright © 2020 AACE
METHODS
This was an observational, retrospective cross-
sectional study of PPS patients followed up at the ortho-
pedic post-poliomyelitis outpatient clinic in the Shamir
Medical Center (formerly Assaf Harofeh), a university-
affiliated tertiary hospital. Since this is not a multidisci-
plinary clinic, endocrinologists or other bone metabolism
specialists are not directly or indirectly involved in the care
of these patients. The study followed a review-of-charts
design and was approved by the local institutional ethics
board. Medical charts of 204 patients visiting the PPS clin-
ic between August 2017 and April 2019 were reviewed.
Inclusion criteria were history and physical examination
consistent with PPS diagnosis as defined by the European
Federation of Neurological Societies (6), age above 40
years, and enough data for analysis. The variables collect-
ed for the study were: general characteristics such as age
at study entry, sex, height, weight, body mass index (BMI),
comorbidities, and chronic medications; data regarding
poliomyelitis status such as age at APP diagnosis, limb
affected, ambulatory state; and information on bone health
status such as history of fractures, recurrent falls, diagno-
sis and treatment of osteoporosis, bone mineral density
(BMD) examinations, and other related risk factors.
Because of its retrospective design, there was no
uniform protocol in this study. BMD was done at the
lumbar spine, femoral neck, and total hip, using dual-ener-
gy X-ray absorptiometry (DEXA) from Hologic or Lunar
manufacturer, according to the health insurance company
preference. It should be pointed out that (1) a signifi-
cant proportion of patients had their BMD performed at
the unaffected hip only; (2) BMD by DEXA is an areal
measurement (aBMD) that does not consider bone size. In
fact, as a variance from volumetric BMD (vBMD), aBMD
tends to underestimate the true BMD of small bones (14).
Copyright © 2020 AACE Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11) 1279

Statistical Analysis Table 1

Continuous variables are presented as means and Baseline Characteristics of Post-Poliomyelitis Patients
standard deviations or median and ranges, while categori- Women 109/204 (53.4%)
cal variables are presented as percentages. Between-group
Age at entry, mean ± SD, years 65 ± 6.1
differences were analyzed using the chi-square or Fisher’s
exact test for categorical variables and independent median (range) 66 (42-85)
Student t test or Mann-Whitney test for continuous vari- Age at polio diagnosis, months an = 65
ables. Quality control was performed by data verification mean ± SD 21.2 ± 21.4
on several occasions.
median (range) 12 (1-120)
The frequency of every given variable was adjusted
on a 100% basis and expressed as percentages and raw Height, cm an = 48
numbers to adjust for missing data. Statistical analysis was mean ± SD 163.5 ± 8.6
performed with the Sigma Stat 2.03 (Systat Software Inc., median (range) 160 (150-183)
Point Richmond, CA) computer program. A P value of less Weight, kg an = 49
than .05 was considered significant.
mean ± SD 71.3 ± 15.8
RESULTS median (range) 69 (48-110)
Body mass index, kg/m2 an = 48
The clinical characteristics of our cohort are shown mean ± SD 27.0 ± 5.0
in Table 1. The mean age at study entry was 65 years,
median (range) 25.8 (20-44)
height 163.5 cm, and BMI 27 kg/m2. Women accounted
for 53.4% of the cohort, and almost all (98.1%) were post- Menopausal status an = 107
menopausal. The mean age at APP diagnosis was 1.7 years. Postmenopausal 105/107 (98.1%)
The lower extremities were affected in 97.5% of patients HRT anytime 17/71 (23.9%)
and the upper extremities in 20%. Normal functional
Age at menopause, years an = 42
status with no need for any ambulation aid was recorded
for 23.5% of our patients. Past medical history included: mean ± SD 50.8 ± 4.4
smoking 32.8% (32 current smokers at entry), sporadic use median (range) 51 (40-59)
of glucocorticoids 34.4% (35 intra-articular, 8 inhaled, and Limb affected an = 204
8 systemic use), vitamin D insufficiency 22.8%, diabetes Upper limb 41/204
mellitus 26.7%, hyperthyroidism 2.6%, primary hyper-
Lower limb 199/204
parathyroidism 2.6%, hypogonadism 0.6%, and other
comorbidities 9.8% (prolactinoma, breast cancer, Behcet Both upper and lower limb 38/204
disease, Parkinson disease, ulcerative colitis, polymyalgia Abbreviation: HRT = hormone replacement therapy.
rheumatica, chronic obstructive pulmonary disease, s/p aPatients with available data.

bariatric surgery).
BMD and Osteoporosis in
Post-Poliomyelitis Patients
BMD was evaluated in only 25.8% of our cohort. In
36.6% of them, BMD was done only after experiencing
the first fracture. The mean age at first BMD evaluation
was 61.9 years. As shown in Table 2, a diagnosis of osteo-
porosis was recorded for only 20.6% of PPS patients with
available data. As expected, the mean BMD T-score (Tsc)
tended to be lower in the femoral neck of the affected limb
(Tsc −1.64) compared to the unaffected one (Tsc −1.19),
with an intra-individual difference (delta Tsc) of −0.45,
lower in the affected limb (P = .06).
Bone Fractures in Post-Poliomyelitis Patients
Data regarding bone fractures are shown in Table 2.
A history of bone fractures was recorded in 52.2% of PPS
patients with available data, for a total of 131 fractures and
an average of 1.59 fractures per patient. The mean age at
first fracture was 57 years. The rate of recurrent falls was
39.2%, and up to 62.8% of PPS patients with recurrent falls
sustained at least one fracture. From the 82 patients expe-
riencing bone fractures, the affected limb was the fracture
site in 73.2%, compared to 26.8% fractures in the unaffect-
ed (P = .001). The distribution of fractures by site was as
follows: femoral neck 16.4%, ankle 13.2%, radius 11.7%,
tibia 10.1%, foot 10.1%, femur other than neck 7.8%, knee
7.8%, ribs 5.4%, spine 4.6%, pelvis 4.6%, hands 4.6%, and
humerus 3.1%. Antiresorptive medications were given to
22 of 31 patients having been diagnosed with osteoporosis;
however, it was initiated only after their first fracture in
47.3% of them. Four patients experienced their first frac-
ture while already on treatment, all of whom were post-
menopausal women taking bisphosphonates for an aver-
age of 2.7 years. In 3 patients, the time interval between
treatment initiation and first fracture was not available. No
fractures occurred in the remaining 31.5% of osteoporotic
treated PPS patients.
1280 Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11) Copyright © 2020 AACE

Gender Differences in Bone Health
Among Post-Poliomyelitis Patients
When comparing clinical characteristics and fractures
by gender (Table 3), the height and weight of men were
not surprisingly higher as compared to women (P<.001);
however, BMI was similar among both sexes. As expected,
there were more BMD data available for women (36.7%
vs. 12.5%; P = .002), which was performed at a younger
age compared with men (60.9 years vs. 65.5 years; P =
.042). No significant differences were seen in BMD at the

Table 2
Osteoporosis and Fractures in Post-Poliomyelitis Patients
1st Bone Mineral Density an = 37 P value
Age 1st assessment, mean ± SD (years) 61.9 ± 6.6
median (range) 62 (49-74)
Lumbar Spine, T-score an = 34
mean ± SD −1.03 ± 1.35
median (range) −0.9 (−3.6 to +1.7)
FN affected, T-score an = 30
mean ± SD −1.64 ± 1.10
median (range) −1.4 (−3.5 to +0.4)
FN unaffected, T-score an = 19
mean ± SD −1.19 ± 0.77
median (range) −1.0 (−2.2 to +0.4)
FN affected vs. unaffected, T-score (delta) −0.45 .065
Bone Fractures
Patients with recurrent falls, n (%) 80/204 (39.2%)
Osteoporosis, n (%) 31/150 (20.6%)
Patients with fractures, n (%) 82/157 (52.2%)
All fractures (average per patient) 131/82 (1.59)
one Fx, n (%) 49/82 (59.7%)
more than 1 Fx, n (%) 33/82 (40.3%)
with 2 Fx, n (%) 19/82 (23.1%)
with 3 Fx, n (%) 12/82 (14.6%)
with 4 Fx, n (%) 2/82 (2.4%)
Patients with Fx of affected limb 60/82 (73.2%) b.001

Patients with Fx of unaffected limb 22/82 (26.8%)

Age at 1st Fracture, years an = 74
mean ± SD 57.0 ± 8.6
median (range) 57.5 (30-83)
Site of Bone Fracture an = 131
Lower limb, n (%) 90/131 (68.7%)
Upper limb, n (%) 25/131 (19.0%)
Spine, n (%) 6/131 (4.5%)
Ribs, n (%) 7/131 (5.3%)
Unknown, n (%) 3/131 (2.3%)
Abbreviations: FN = femoral neck; Fx = fracture.
aPatients with available data.
bComparison of Fx incidence between affected and unaffected limb.
Copyright © 2020 AACE Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11) 1281

femoral neck and lumbar spine among sexes. Interestingly,
the age at first BMD examination in men was younger
than expected.
Women were diagnosed with osteoporosis more
frequently than men (30.1% vs. 8.9%; P = .003) and were
more prone to recurrent falls (44.9% vs. 32.6%; P>.05) and
fractures (57.4% vs. 45.7%; P>.05). The average number
of fractures per patient was similar between sexes, as was
the age at first fracture (56.8 and 57.1 years, men and
women, respectively). There was no difference between

Table 3
Comparison of Post-Poliomyelitis Patients by Gender
Women, n = 109 (53.4%) Men, n = 95 (46.5%) P value
Age at polio diagnosis, mean ± SD (months) 24.8 ± 25.7 (an = 27) 18.7 ± 17.6 (an = 38) >.05
Age at study entry, mean ± SD (years) 64.8 ± 6.0 65.0 ± 6.2 >.05
Height, mean ± SD (cm) 158.1 ± 5.9 (an = 30) 169.8 ± 7.4 (an = 18) <.001
Weight, mean ± SD (kg) 65.5 ± 13.0 (an = 31) 81.4 ± 15.4 (an = 18) <.001
Body mass index, mean ± SD 26.5 ± 5.2 (an = 30) 28.0 ± 4.7 (an = 18) >.05
Bone Mineral Density an = 29 an =8 .002
Age at 1st BMD
mean ± SD 60.9 ± 5.9 65.5 ± 7.9 .042
Lumbar Spine, T-score an = 28 an =6
mean ± SD −1.09 ± 1.0 −0.75 ± 1.87 >.05
FN affected FN, T-score an = 22 an =8
mean ± SD −1.56 ± 1.20 −1.85 ± 0.84 >.05
FN unaffected FN, T-score an = 15 an =4
mean ± SD −1.24 ± 0.86 −1.02 ± 0.21 >.05
FN affected-unaffected, T-score, deltab −0.32 (P>.05) −0.83 (P = .076) >.05c
Bone Fractures
Patients with fractures, n (%) 50/87 (57.4%) 32/70 (45.7%) >.05
Age 1st fracture, mean ± SD (years) 57.1 ± 8.9 56.8 ± 8.4 >.05
Recurrent falls, n (%) 49/109 (44.9%) 31/95 (32.6%) .098
Osteoporosis, n (%) 25/83 (30.1%) 6/67 (8.9%) .003
Fractures per patient, average 82/50 (1.64) 49/32 (1.53) >.05
1 Fx, n (%) 28/50 (56%) 21/32 (65.6%) >.05
>1 Fx, n (%) 22/50 (44%) 11/32 (34.3%) >.05
with 2 Fx 13/50 (26%) 6/32 (18.7%)
with 3 Fx 8/50 (16%) 4/32 (12.5%)
with 4 Fx 1/50 (2%) 1/32 (3.1%)
Fractures of affected limb, n (%) 51/80 (63.7%) 34/48 (71%) >.05
Patients with Fx of affected limb, n (%) 35/50 (70.0%) 25/32 (78.1%) >.05
Site of fracture, n (%) an = 82 an = 49 −
Lower limb 55 (67%) 35 (71.4%) >.05
Upper limb 18 (21.9%) 7 (14.2%) >.05
Spine 3 (3.6%) 3 (6.1%) >.05
Ribs 5 (6.1%) 2 (4%) >.05
Unknown 1 (1.2%) 2 (4%) >.05
Abbreviations: BMD = bone mineral density; FN = femoral neck; Fx = fracture.
aPatients with available data.
bDelta, intra-individual affected vs. unaffected BMD differences.
cComparison of delta between women and men.
1282 Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11)
sexes regarding the incidence of bone fractures except for
a higher, but not significant, tendency in men to have more
fractures in the affected limb (71% vs. 63.7%; P>.05). As
seen in Table 3, this could be partially explained by men
having a larger intra-individual delta BMD between affect-
ed and unaffected limbs, compared to women (delta-Tsc
−0.83 vs. −0.32, respectively; P>.05).
Post-Poliomyelitis Patients
With and Without Bone Fractures
The clinical characteristics of PPS patients with and
without fractures are shown in Table 4. As expected, the
fracture group had higher rates of recurrent falls (53.6%
vs. 34.6%; P = .05) and osteoporosis (30.9% vs. 9.4%; P =
.002). The tendency to a much lower BMD in the affected
limb compared to the unaffected one within the fracture
group (Tsc −1.9 vs. −1.2; P = .06) could partially explain
the higher risk of breaking the affected limb (73.2%) that
was discussed before.
Post-Poliomyelitis Patients
According to Functional Status
While comparing patients according to their function-
al status, patients with assisted ambulation (76.4%) had
higher rates of recurrent falls as compared to those with
nonassisted ambulation (45.4% vs. 19.0%, respectively; P
= .002). Although BMD was similar between the assisted
and nonassisted ambulation groups, the assisted group
showed a tendency to a higher intra-individual difference
between affected and unaffected limbs, compared to the
nonassisted group (delta Tsc −0.6 vs. −0.02, respective-
ly; P>.05). Surprisingly, the difference in fracture events
between groups was not statistically significant (55.6% vs.
38.2%; P>.05). Nevertheless, a trend towards fractures at
an earlier age was nearly significant in the assisted-ambu-
lation group (56.4 years vs. 59.8 years; P = .065).
DISCUSSION
In this study, we analyzed the clinical characteris-
tics of 204 Israeli patients with PPS to estimate the risk
of osteoporosis and bone fractures. Most studies on PPS
patients addressed the issue of neuromuscular weakness,
its functional and skeletal deformities consequences, and
treatment (1-6), but very few investigated the connection
between poliomyelitis, osteoporosis, and bone fractures
(15-17). We noticed that bone metabolism profession-
als in real practice play a marginal role in the care of PPS
patients, at least within the Israeli PPS population. We also
found that the only guidelines published do not address the
risk of bone fractures but rather focus on muscle weakness,
ambulatory balance, and skeletal deformities (6). Under
these circumstances, physicians are challenged by the
specific characteristics inherent to this population regard-
ing bone health assessment, indications and timing of treat-
ment, and the prevention of bone fractures.
Copyright © 2020 AACE
Bone formation occurs during childhood and adoles-
cence until reaching peak bone mass (PBM) up to the
beginning of the third decade of life (18). We assumed that
PPS patients who suffered from APP at a young age would
not have reached an optimal PBM in the affected limb.
Furthermore, we expected the unaffected limb to have a
higher BMD due to compensatory overuse; however, a
poor functional status could affect bones at all sites (10,15).
With this background, BMD and osteoporosis in PPS
patients may differ significantly from that of the general
population in pathogenesis, fracture risk, and therapeutic
approach. Accordingly, their limited mobility, advanced
age, and low PBM may lead to a higher incidence of osteo-
porosis and osteoporotic fractures (19).
The assessment of BMD in PPS patients is quite prob-
lematic. On the one hand, aBMD tends to underestimate
the small femurs of the affected limb (17); on the other
hand, muscle weakness, poor ambulation, and skeletal
deformities impact all bones, irrespective of the affected
limb. As previously mentioned, the use of vBMD would
be more appropriate in these patients. Because this was a
retrospective study, bone density was measured following
real-world practice, where aBMD is routinely used; there-
fore, our results should be taken cautiously. We could have
applied the Katzman formula (20) to convert aBMD into
bone mineral apparent density, but besides its poor preci-
sion, we are not aware of any validated reference values.
A different approach could have been to use qCT machines
(14), but qCT is not routinely available in clinical practice.
Furthermore, we are not aware of any study investigating
the usefulness of trabecular bone score in PPS patients
(21). All the above makes it easy to understand the pecu-
liarities and difficulties to be confronted when assessing
the true BMD in PPS patients, which remains a subject
of research.
Although some studies examined the prevalence of
osteoporosis in the PPS population (15-17), very little is
known about its prevalence in Israel. We found that BMD
in the affected limb tended to be lower compared to the
unaffected. Similar results were reported by others (4,15).
A cross-sectional study from Montréal found that lower
BMD in the affected limb correlated to lower muscle
strength (16). Chang et al (22) found BMD in PPS men to
be 23% lower in the affected limb and 13% lower in the
unaffected limb, compared to healthy controls. This data
suggests that in PPS men, a low BMD is not exclusive for
the affected site, although it was 11.3% lower in the affect-
ed versus unaffected PPS limb.
In the present study, more than half of our PPS patients
experienced at least one fracture at an early age, with multi-
ple fractures reported in 40.3% of them. Of the overall 131
fractures recorded among 82 PPS patients, 68.7% occurred
in the lower limbs (16.4% at the femoral neck). Though our
study did not include a control group, the 52.2% incidence
of fractures in our cohort was much higher than the 31.4%
reported by Goerss et al (19), with a total of 161 fractures
Copyright © 2020 AACE Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11) 1283

recorded among 277 PPS patients. In a case-control study,
Wu et al (23) corroborated Goers’ results, showing a frac-
ture incidence of 26.3% (106/403) among PPS patients.
Interestingly, Wu et al compared PPS patients to healthy
controls and found that PPS men had a 6-times higher inci-
dence of fractures than expected, while it was only mildly
elevated among PPS women. Furthermore, fractures in
PPS men occurred 13 years earlier than healthy controls.
Though the prevalence of fractures among the general
Israeli population has not been well established, one study
in healthy Israelis reported the fracture rate at 80/1,000 in
women and 20/1,000 in men; thus, by extrapolation, PPS
men in our cohort showed a higher incidence of fractures
than expected. Also, the first fracture in men occurred at a
much younger age (56.8 years) than expected (24). To the
best of our knowledge, this is the first study comparing the
risk of bone fracture in PPS patients according to gender.
Our finding that most PPS patients who suffered from
bone fractures broke the affected limb (73.2%) is in line
with previous studies (15,19). Though this may seem obvi-
ous, considering the lower PBM of the affected limb, we
found these facts and their consequences to be frequently
overlooked, with more focus put on the muscle weak-
ness and gait disorder, as well as the degenerative skeletal
changes (1-6).
Fall risk is an important issue because it represents a
significant health problem, especially among the elderly.
At least one self-reported fall has been reported in 62 to

Table 4
Characteristics of Post-Polio Patients With and Without Fractures
  Fractures, n = 82 No fractures, n = 75 P value
Women, n (%) 50 (60.9%) 43 (57.3%) >.05
Age at entry, mean ± SD (years) 65.7 ± 5.9 63.5 ± 6.6 .061
Age at polio diagnosis, month an = 22 an = 29
mean ± SD 19.9 ± 21.1 19.2 ± 17.3 >.05
Height, cm an = 29 an = 18
mean ± SD 161.6 ± 7.8 164.1 ± 10 >.05
Weight, kg an = 30 an = 18
mean ± SD 71 ± 16.2 72.9 ± 15.4 >.05
Body mass index, kg/m2 an = 29 an = 18
mean ± SD 27 ± 4.3 27.5 ± 6.1 >.05
Menopausal status -
Postmenopausal, n (%) 49/49 (100%) 35/37 (94.6%) >.05
HRT anytime, n (%) 11/41 (26.8%) 6/29 (20.6%) >.05
Age at menopause, years an = 24 an = 18 -
mean ± SD 50.7 ± 4.8 51 ± 3.9 >.05
1st Bone Mineral Density
Age at 1st BMD, years an = 19 an = 15 -
mean ± SD 61.7 ± 7.2 61.7 ± 5.9 >.05
Lumbar Spine T-score an = 20 an = 13 -
mean ± SD −1.13 ± 1.23 −1.0 ± 1.5 >.05
FN affected T-score an = 15 an = 13 -
mean ± SD −1.90 ± 1.10 −1.2 ± 0.9 .062
FN unaffected T-score an =8 an =9
mean ± SD −1.25 ± 0.84 −1.18 ± 0.84 >.05
FN affected-unaffected T-score, deltab −0.65 (P = .09) −0.02 (P = .417) .071c
Recurrent falls, n (%) 44/82 (53.6%) 26/75 (34.6%) .052
Osteoporosis, n (%) 22/71 (30.9%) 7/74 (9.4%) .002
Abbreviations: BMD = bone mineral density; FN = femoral neck; HRT = hormone replacement
therapy.
aPatients with available data.
bDelta, intra-individual affected vs. unaffected BMD differences.
cComparison of delta between fracture and no-fracture groups.
1284 Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11)
68% of PPS patients during a time-span of 1 year (12,13).
However, in our study, recurrent falls were much lower
(39.2%). The discrepancy may be explained by having
our research based on medical records rather than self-
questionnaires. Data from the U.S. show that up to 25%
of people older than 65 sustain a fall each year, with 20
to 30% of them suffering moderate to severe injuries
such as bruises, hip fractures, or head trauma (25,26).
The increased morbidity and poor prognosis associated
with hip fractures make these findings even more rele-
vant (27,28). Furthermore, it has been reported that PPS
patients with femoral fractures have a worse prognosis for
regaining their pre-injury ambulatory capacity and a higher
re-operation rate (29).
Only a few studies have been published addressing
the treatment of osteoporosis in PPS patients. Mohammad
et al (15) studied 50 PPS patients, in whom 28 carried a
diagnosis of osteoporosis, with 19 having a history of bone
fractures. Of these 19 patients, only 6 were receiving anti-
resorptive therapy. The authors concluded that this popula-
tion should be considered at high risk for fragility fractures
requiring an appropriate correction of other risk factors, an
early BMD evaluation, and a timely initiation of treatment.
We found only one retrospective study investigating
the response to bisphosphonates (BPs) on 144 PPS patients
with over 5 years of follow-up (30). In that study, 54
BP-treated PPS patients were compared to 94 untreated PPS
patients. A control group was composed of 75 BP-treated
and 37 nontreated typical osteoporotic patients. Results
revealed that BP treatment in PPS patients was noninferior
compared to the control group. A subanalysis of 32 treated
PPS patients with bone fracture history showed that two-
thirds of fractures occurred before and one-third during BP
treatment. The benefit of preventing bone fractures in PPS
patients was borderline significant on a conditional logistic
regression model (P = .046) but nonsignificant on Poisson
regression analysis (P = .183). Based on their data, the
authors concluded that in PPS patients, BPs might improve
BMD; however, their benefit in preventing fractures needs
further research.
Comparing PPS patients by gender, we confirmed
the expected higher incidence of osteoporosis in women
(24,31,32). However, the age and frequency of bone health
assessment in our cohort showed no differences among
sexes. Also, we found no differences in the incidence of
fractures, expected to occur 10 years later in healthy men.
Although osteoporosis appeared to be delayed in our PPS
male group compared to women, it was diagnosed earlier
than expected for the healthy male population (33), with
their first BMD performed at a similar age as women.
When comparing potential risk factors between
the fracture and nonfracture groups, only the higher
rate of recurrent falls reached statistical significance
(P = .05). Assessment of BMD impact on bone frac-
ture was precluded due to the few available data, which
Copyright © 2020 AACE
may not have happened were endocrinologists and bone
metabolism specialists more involved in the care of PPS
patients. Nevertheless, our study suggests that in osteo-
porotic PPS patients, treatment should be considered at
an early stage. Whether anabolic agents could be more
effective than antiresorptive agents has yet to be investi-
gated. The low PBM in this specific population suggests
that anabolic agents may have a role as first-line treat-
ment, including the recently approved sclerostin anti-
body drugs, which might add some improvement in bone
microarchitecture (34).
The higher bone fracture risk, the lack of proper clini-
cal guidelines (35), and the fact that 47.3% of osteoporotic
PPS patients started treatment only after the first fracture
is good evidence of the current unawareness regarding the
poor bone health and elevated risk in this population.
The early age and higher risk for fractures in the PPS
population should be a driving factor to put together clini-
cal guidelines for timely detection and intervention, irre-
spective of a normal BMD at unaffected skeletal sites.
However, the best time to start treatment remains uncer-
tain and is challenged by the differences in BMD among
skeletal sites and the low PBM of this population, on top
of the evolving high bone turnover. It also poses the ques-
tion of which medication should be a first-line anabolic or
antiresorptive agent.
Our study has some strengths and limitations. The
main limitation is the scarce data on BMD examinations
precluding us from performing an appropriate statistical
analysis in this regard. On the other hand, it emphasizes
the need for more involvement of bone metabolic special-
ists. Other limitations inherent to the retrospective nature
of our study were the lack of a control group and the fact
that many BMDs were performed at the unaffected limb
only. Unfortunately, due to the few available data, we
could not use the Z-scores as a surrogate for the control
group. As a retrospective study in a real-world scenario,
selection bias for more-severe PPS patients seeking treat-
ment at the outpatient clinic cannot be excluded; thus, our
results may not represent the whole PPS population. The
study’s strengths include being the first hospital-based
study to investigate bone health in PPS Israeli patients with
access to extensive individual data, specifically related to
bone fractures.
CONCLUSION
We conclude that PPS patients are at high risk for
fragility fractures, which seems to be overlooked, especial-
ly in men. A significant delay in diagnosis and treatment of
osteoporosis and higher rates of recurrent falls with early
age fractures all support having PPS patients included
as a high-risk group for bone fractures, together with the
compelling need for comprehensive clinical guidelines and
better awareness among the endocrine community.
Copyright © 2020 AACE Bone Fragility and Poliomyelitis, Endocr Pract. 2020;26(No. 11) 1285

DISCLOSURE 18. Weaver CM, Gordon CM, Janz KF, et al. The National
Osteoporosis Foundation’s position statement on peak bone mass
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The authors have no multiplicity of interest to disclose. mentation recommendations. Osteoporos Int. 2016;27:1281-1386.
19. Goerss JB, Atkinson EJ, Windebank AJ, O’Fallon WM,
Melton LJ 3rd. Fractures in an aging population of poliomy-
elitis survivors: a community-based study in Olmsted County,
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