Poliomyelitis

It is a viral infection affecting the Anterior Horn cell of Spinal cord and Brainstem producing a flaccid motor paralysis.

It is also know as Infantile Paralysis.

1. Poliomyelitis DR. Darshan Parmar (MPT-NEURO)

2. Definition It is a viral infection affecting the Anterior Horn cell of Spinal cord and Brainstem producing a flaccid motor paralysis . It is also know as Infantile Paralysis .

3. Etiology Causative Organism : Enterovirus (Poliovirus) Other types are Type I – Brunhilde Type II – Lanchi Type III – Leon

4. Mode of Transmission This disease is highly infectious and it spreads via, Orofecal route (in countries where hygiene is poor) Droplet Infection Carrier mode

5. Incubation Period of Virus It varies from 3-30 days; while 7-14 days is most common. Incubation period decreases on provocation like injection pricks, stenosis, physical activity, massage or minor operation. In infant below 6 months the involvement maybe transplacentally transmitted if the maternal immunity is very low.

6. Pathology (3 stages) 1) Alimentary stage : From Environment  Nasopharynx  GIT (virus multiplies in the epithelial cell of intestinal mucosa) 2) Viremic stage : Virus enters Blood Stream. If the virus gets victory against Antibodies then it enters stage III. 3) Neural stage : Virus finds its way to Anterior Horn cell of Spinal cord and Brainstem. It causes damage to the cell which results in flaccid paralysis of that muscle. However if the cells are killed the it leads to permanent paralysis.

7. Clinical features with Treatment The course of disease is divided into 4 stages and each with iths own clinicopathological pictures and varied treatment. 1. Prodromal/ pre-paralytic stage 2. Acute stage and Convalescent stage 3. Stage of Recovery 4. Stage of Residual Paralysis

8. PREDROMAL / PRE-PARALYTIC STAGE It is non specific and mimic any viral infection. Last 1-3 days on average Injections or Operations, Exercise may precipitate severe paralysis in limbs exercised or traumatized. Signs & Symptoms : Headache Sore Throat Malaise Slight Cough Diarrhoea/ Constipation Backache Joint pain Fever Mild neck stiffness

9. PREDROMAL / PRE-PARALYTIC STAGE Treatment : Rest Chances of infection should be avoided Additional booster dose should be given to the affected and unaffected children.

10. ACUTE STAGE If the infection does not resolve in prodromal stage it enters the acute stage which is the early stage of paralysis. Signs & Symptoms : Remains similar to Prodromal stage but more pronounced, especially Fever Diarrhoea, Nausea, Vomiting Limb and Joint pain Muscle tenderness (it is the most important sign in this stage) Duration : 3-6 weeks from onset of Poliomyelitis.

11. ACUTE STAGE Treatment : Rest : Minimal handling of child Physical activity should be discouraged Affected child should be isolated. Booster dose : Affected and unaffected children are given booster dose. Nutrition : Protein rich diet should be given Correct handling technique : Child should not be lifted by one hand . Child should be held in front with hip extended without hip abduction when carried.

12. ACUTE STAGE - TREATMENT Splinting and correct positioning : Splinting to Lower limb to prevent any damage to muscle. Splints also reduces pain arising from muscle Splint also prevents muscle from going to contracture Sister Kenny’s bath : It’s a form of moist heat. Towel is dipped and wringed and placed on limbs and spine of patient. This form of wet, moist heat helps to decrease inflammation Massage is contraindicated.

13. ACUTE STAGE - TREATMENT Gentle Passive Movement : 2-3 times/day to keep muscle and joint flexible as well as to improve circulation.

14. CONVALESCENT STAGE This is a stage where there is true or actual paralysis. Duration : 3 months Sign & Symptoms vary in both duration and severity. Paralysis can be of 1) Spinal (Most common type) 2) Bulbar 3) Spinobulbar/Bulbospinal 4) Post Encephalitic type (most fatal type)

15. CONVALESCENT STAGE 1) Spinal Type : Anterior horn cells are affected LMN type of paralysis : Asymmetrical flaccid paralysis and sensation are normal. LL > UL (affection) Contractures can lead to deformity Flexor contractures of hip, knee and equines deformity of ankle are likely to occur.

16. CONVALESCENT STAGE 2) Bulbar Type : most important sign is inability to swallow due to pharyngeal paralysis. patient chokes on both solid and liquid food. patient cannot cough properly due to paralysis of larynx difficulty in speaking due to paralysis of palate Respiratory muscle are affected Early sign of Respiratory involves : Breathlessness, feeling of suffocation, slight cyanosis, use of SCM for breathing.

17. CONVALESCENT STAGE 3) Spinobulbar Type : Combination of both spinal and bulbar type of polio Predominant spinal and less bulbar involvement  Spinobulbar type. Predominant bulbar and less spinal involvement  Bulbospinal type. 4) Post Encephalitic type : It is rare and usually associated with bulbar paralysis Mental disturbances and even coma may occur Paralysis of facial muscle is present Symptoms : Headache, Vomiting, Neck stiffness.

18. CONVALESCENT STAGE - TREATMENT Continuous splinting : AK splint (to prevent knee flexion and equines deformity) BK splint (to prevent equines deformity) Abdominal corset (for Abdominal weakness) Muscle charting : As soon as muscle tenderness subsides, MMT should be taken It usually subsides after 3-4 weeks from the onset of paraklysis .

19. CONVALESCENT STAGE - TREATMENT Positioning : Do not carry child in Indian position (it can increase IT band contracture) While sleeping Prone position is given Paralysis arms are supported on pillow with slight degree of Abduction In UL deltoid is most common muscle to get paralysed Towel rolls (under axilla  to prevent shoulder subluxation. It is given for 3 months)

20. CONVALESCENT STAGE - TREATMENT Changing the position : Severely paralysed patient should be turned every 2-4 hours , day and night to prevent bed sores and to keep skin dry. Stretching of Contractures : Gentle but consistent stretch should be given to prevent the chances of gross deformity.

21. STAGE OF RECOVERY It is also called Late Convalescent stage . Extends upto 2 years Muscle of polio patient can be strengthened to their maximum capacity upto 2 years, after this it won’t be possible to activate any paralysed muscle. Treatment : Strengthening technique 1) ES 2) Resisted Exercise with springs / pulley 3) Hydrotherapy and Suspension Therapy 4) Play therapy 5) Mat Exercise and weight bearing exercise (for contractures)

22. STAGE OF RESIDUAL PARALYSIS It is also called Post-polio residual palsy (PPRP) Paralysis or weakness persisting after 2 years is permenant The extent of Residual paralysis ranges between mild insignificant local weakness to almost gross paralysis of trunk and limb musculature giving rise to severe disability and functional dependency Weakness and wasting of muscle causes impaired growth of bone which gets shortened. Gross muscular imbalance + LLD maybe present.

23. STAGE OF RESIDUAL PARALYSIS - TREATMENT Combination of stretching, strengthening is given Serial casting in combination with exercise is used to correct the deformity Tailor made calliper is given according to deformity Tailor made calliper also prevent deformity from aggravation If conservative mode of treatment fails then surgical intervention is approached Soft tissue release / lengthening osteotomies Tendon transfer Arthrodesis

24. REFERANCE Glady

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