Poliomyelitis & its Physiotherapeutic Management

Polio

1. Poliomyelitisandits
Physiotherapeutic
Management
DR. SANJIBKUMARDAS,PhD

2. INTRODUCTION
•Poliomyelitis,isanacuteinfectiousdiseasecausedbythe
poliovirus.Thetypesofvirusresponsibleforcausing
poliomyelitisare:TypeI-Brunhilde,TypeII-Lansing,TypeII-
Leon.
•Theinfectionmaymanifestasanepisodeofdiarrhoeaormay
affecttheanteriorhorncellsofthespinalcordandleadto
extensiveparalysisofthemuscles.
•Inextremeforms,theparalysismayinvolverespiratorymuscles,
andmayleadtodeath.

3. AETIOPATHOLOGY
•Thepoliovirusentersthebodyeitherthroughthefaeco-oral
routeorbyinhalationofdroplets.
•Paralysismaybeprecipitatedafterstrenuousphysicalactivity,
byanintramuscularinjectionorinachildoncortisone
therapy.
•Atonsillectomy,adenoidectomyortoothextraction
predisposestoparalysisduringpolioepidemics.
•Theinfectionoccurscommonlyinsummer.

4. PATHOGENESIS
•Thevirusmultipliesintheintestine.Fromhereit
travelstoenterthebloodcirculation.
•Ifthedefensemechanismofthebodyispoor,the
virusreachesthenervoussystem(anteriorhorncells)
viathebloodorperipheralnerves.
•Theneuronsundergovaryingdegreeofdamage–
somemaypermanentlydie,othersmaybe
temporarilydamaged,othersmayundergoonly
functionalimpairmentduetotissueoedema.

5. PATHOGENESIS
•Theneurons,whicharepermanentlydamaged,
leadtopermanentparalysis;whiletheothersmay
regenerate,sothatpartialrecoveryofthe
paralysismayoccur.
•Itisthisresidualparalysis(calledpost-polio
residualparalysis–PPRP)whichisresponsible
forthehostofproblemsassociatedwitha
paralyticlimb(deformities,weaknessetc.).

6. CLINICALFEATURES
•Thepatientisachildaroundtheageof9months.The
mothergivesahistorythatthechilddevelopedmild
pyrexiaassociatedwithdiarrhoea,followedby
inabilitytomoveapartorwholeofthelimb.
•Thelowerlimbsareaffectedmostcommonly.
Paralysisisofvaryingseverityandasymmetricalin
distribution.
•Inextremecases,therespiratorymusclesmayalsobe
paralyzed.

7. CLINICALFEATURES
•Intheearlystages,thechildisseenbyapaediatrician
andthenreferredtoanorthopaedicsurgeon.
•Bythistimetheparalysismayalreadybeonitsway
torecovery.
•Recoveryofpower,ifitoccurs,maycontinuefora
periodof2years.Mostoftherecoveryoccurswithin
thefirst6months.
•Anyresidualweaknesspersistingafter2yearsis
permanent,andwillnotrecover.

8. GeneralPatternofParalysisandExpectedRecovery
FollowingAcuteEpisode
Vigorousconcentratedphysiotherapyfromweek3orassoonastenderness
subsidesupto6monthsiscrucial.Maximumadvantagecanbederivedatthis
stage.

9. EXAMINATION
•Intheearlystage,thechildisfebrile,oftenwithrigidityof
theneckandtendermuscles.
•Thismaybeassociatedwithdiffusemuscleparalysis.The
followingaresomeofthetypicalfeaturesofaparalysis
resultingfrompolio:
Itisasymmetrici.e.,theinvolvementoftheaffected
musclesishaphazard.
Itoccurscommonlyinthelowerlimbsbecausetheanterior
horncellsofthelumbarenlargementofthespinalcordare
affectedmostoften.
Themuscleaffectedmostcommonlyisthequadriceps,
althoughinmostcasesitisonlypartiallyparalyzed.

10. EXAMINATION
Themusclewhichmostoftenundergoescomplete
paralysisisthetibialisanterior.
Themuscleinthehandaffectedmostcommonlyisthe
opponenspollicis.
Themotorparalysisisnotassociatedwithanysensory
loss.
Bulbarorbulbo-spinalpolio:Thisisararebutlife
threateningpolio(themotorneuronsofthemedullaare
affected).Thisresultsininvolvementofrespiratoryand
cardiovascularcentres,andmaycausedeath.

11. EXAMINATION
•Inlatestage(PPRP),theparalysismayresultin
wasting,weakness,anddeformitiesofthelimbs.
•Thedeformitiesresultfromimbalancebetween
musclesofoppositegroupsatajoint,ordueto
theactionofthegravityontheparalyzedlimb.
•Thecommondeformityatthehipisflexion-
abduction-externalrotation.

12. EXAMINATION
•Attheknee,flexiondeformityiscommon.
•Atthefoot,equino-varusdeformityisthecommonest;
othersbeingequino-valgus,calcaneo-valgusand
calcaneocavus.
•Intheupperlimbs,polioaffectsshoulderandelbow
muscles.
•Musclesofthehandareusuallyspared.
•Withtime,thedeformitiesbecomepermanentdueto
contractureofthesofttissuesandmal-developmentofthe
bonesinthedeformedposition.

13. COMMONCAUSATIVEFACTORSFORDEVELOPING
CONTRACTURES

14. PROGNOSIS
•Ofthetotalnumberofcasesinfectedwiththepoliovirus,50
percentdonotdevelopparalysisatall(non-paralytic
polio).
•40percentdevelopparalysisofavaryingdegree(mild,
moderateorsevere).
•10percentpatientsdiebecauseofrespiratorymuscle
paralysis.
•Ofthepatientswithparalyticpolio,33percentrecover
fully,33percentcontinuetohavemoderateparalysis,while
another33percentremainwithsevereparalysis.

15. PROGNOSISOFRECOVERYINRELATIONTOTHE
INITIALASSESSMENTOFMUSCLEPOWER
•Allthemusclegroupsoftheaffectedlimbshouldbedividedinto
twogroups:
•GroupI–musclesthatarepartiallyparalyzed(MMTgrade=1to
3)
•GroupII–musclesthataretotallyparalyzed(MMTgrade=0)

16. DIFFERENTIALDIAGNOSIS

17. MEDICALTREATMENT
•Poliocanbepreventedbyimmunization.
•Itisimportanttoimmunizepatientsevenafteranattack
ofacutepoliomyelitis.Thisisbecausetherearethree
strainsofthevirus,andthepatientcouldstillget
paralyticpoliobyanotherstrain.
•Thetreatmentprinciplesare:
(i)Toprovidesupportivetreatmentduringthestageof
paralysisorrecovery
(ii)Topreventthedevelopmentofdeformitiesduringthis
period
(iii)Touse,inamoreefficientway,whatevermusclesare
functioning.

18. TREATMENT
Stageofonset:Itisgenerallynotpossibletodiagnosepolioat
thisstage.Inanendemicarea,ifachildissuspectedofhaving
polio,intramuscularinjectionsandexcessivephysicalactivity
shouldbeavoided.
Stageofmaximumparalysis:Inthisstage,thechildneeds
mainlysupportivetreatment.
•Aclosewatchiskeptforsignssuggestiveofbulbarpolio.
Thesearesignsofparalysisofthevagusnerve,causing
weaknessofthesoftpalate,pharynxandthevocalcords–
henceproblemindeglutition,andspeech.Arespiratormaybe
necessarytosavelifeiftherespiratorymusclesareparalyzed.
•Paralyticlimbsmayhavetobesupportedbysplintstoprevent
thedevelopmentofcontractures.
•Allthejointsshouldbemovedthroughthefullrangeof
motionseveraltimesaday.
•Musclepainmaybeeasedbyapplyinghotpacks.

19. Stageofrecovery:Theprinciplesoftreatment
duringthisstageareasfollows:
•Preventionofdeformitybypropersplintage,and
jointmobilizingexercises.
•Correctionofthedeformitythatmayhavealready
occurred.
•Retrainingofmusclesthatarerecoveringby
exercises.Progressevaluatedbyrepeated
examinationofthemotorpoweroftheparalyzed
limb.
•Encouragewalkingwiththehelpofappliances,
whereverpossible.

20. TREATMENT
Stageofresidualparalysis:Itconsistsofthefollowing:
•Detailedevaluationofthepatient:Mostpatientswithresidualpolio
(PPRP)walkwithalimp,withorwithoutcalipers.Anassessmentis
madewhetherfunctionalstatusofthepatientcanbeimproved.
•Forthis,anevaluationofthedeformitiesandmuscleweaknessis
made.
•Preventionorcorrectionofdeformities:Themainemphasisison
preventionofdeformity.
•Splintingtheparalyzedpartinsuchawaythattheeffectofmuscle
imbalanceandgravityisnegated.
•Anoperationmayberequiredtopreventthedeformity.Forexample,
inafootwithseveremuscleimbalancebetweenoppositegroupof
muscles,atendontransferoperationisdone.A‘balanced’foot
produceslesspossibilityofdeformity

21. TREATMENT
•Tendontransfers:Itisnotdonebefore5yearsofage,asthechildhastobe
manageableenoughtobetaughtproperexercises.Morecommonly
performedtendontransfersareasfollows:
•Transferofextensorhallucislongus(EHL)fromthedistalphalanxofgreat
toetotheneckofthefirstmetatarsal.Thisisdonetocorrectfirstmetatarsal
dropincaseoftibialisanteriormuscleweakness.
•Transferofperoneuslongusandbrevismusclestothedorsumofthefoot.
Thetransferisrequiredinafootwithdorsiflexorweakness.Evertorscan
besparedformoreusefulfunctionofdorsiflexionofthefoot.
•Hamstring(kneeflexors)transfertothequadricepsmuscletosupporta
weakkneeextensor.

22. Principlesoftendontransfers
Donor tendon
•Shouldbe expandable
•Minimumpower 4/5
•Amplitudeof excursion to match that of therecipient muscle
•Preferablya synergistic muscle
Recipient site
•Rangeof movements of the joints on whichthe transferredmuscle is expected to work
should be good
•Noscarring at the bed of the transferred tendon
Technical considerations
•Transferredtendon should take a straight route
•Itshould be placed in subcutaneous space
•Fixationmust be under adequate tension
Patient considerations
•Age–minimum 5 years*
•Thedisease should be non-progressive
*Minimumage when a child can be trained in usingthe transferredmuscle.

23. TREATMENT
•Stabilizationofflailjoints:Jointswithseveremuscle
paralysisthatthebodylosescontroloverthemarecalled
flailjoints.
•Stabilizationofthesejointsisnecessaryforwalking.This
canbeachievedbyoperativeornon-operativemethods.
Non-operativemethodsconsistofcalipers,shoesetc.
•Operativemethodsconsistoffusionofthejoints(e.g.,triple
arthrodesisforstabilizationofthefoot).
•Leglengthequalization:Incaseswherealegisshortby
morethan4cm,aleglengtheningproceduremaybe
required.

24. PRINCIPLESOFPHYSIOTHERAPYMANAGEMENT

25. PRINCIPLESOFPHYSIOTHERAPYMANAGEMENT

26. PRINCIPLESOFPHYSIOTHERAPYMANAGEMENT

27. CORRECTION OF DEFORMITYDUETO SOFTTISSUECONTRACTURES

28. Lowerlimb:Releaseofsofttissuecontractures
•Hip:TheflexioncontractureatthehipiscorrectedbySoutter’soperationin
whichthetightstructuresalongtheanterioriliaccrestarereleasedandthe
deformityiscorrected.Theabductioncontractureiscorrectedbyreleaseof
abductors,fascialataandtheiliotibialband.Postoperatively,thepatientisgiven
aPOPhipspica,inthecorrectedposition,forabout4–6weeks.Thejointsare
thenmobilizedbutthecorrectionismaintainedinacaliper.
•Knee:Mildflexioncontracturesaregenerallyduetotightiliotibialbandthatis
divided.Moderatedegreesofflexioncontracturecanbetreatedbylengtheningof
thehamstrings.Severeflexioncontracturesrequirelengtheningofhamstringsand
posteriorcapsulotomyoftheknee(Wilson’soperation).Postoperatively,an
above-kneeplastercastfor4–6weeksfollowedbymobilizationistheusual
regime.Thecorrectionismaintainedinacaliper.

29. •Ankle:Thecommonestdeformityisequinus,whichresultsfromcontractureof
thetendoachilles.LengtheningofthetendoachillesbyZ-plastyisundertaken.
Anabove-kneeplastercastfor3–6weeksisgivenafteroperation.Abelow-
kneecaliperisusuallywornfor3–6monthstopreventrecurrence.
•Foot:Contractureoftheplantarfasciaproducesacavusdeformityofthefoot.
Thetightplantarfasciaisstrippedfromitsattachmenttothecalcaneus
(Steindler’soperation).Inthepostoperativeperiod,abelow-kneeplasteris
givenfor2–4weeks,afterwhichanightsplintisusedfor2–4months.
Lowerlimb:Releaseofsofttissue
contractures

30. JOINTARTHRODESIS:FUSION

31. PHYSIOTHERAPYFOLLOWINGSURGERY
•Thebasicapproachofphysiotherapyvariesaccordingtothetypeofthe
surgicalprocedure:
1.Afterreleaseofthesofttissuecontractures,measuresshouldbetakento
avoidrecurrenceofcontracture.
2.Followingtendontransplants,theemphasisshouldbeonre-educationof
thetransplantedmuscletoitsnewrole.
3.Followingthejointarthrodesis,theemphasisshouldbeoneducatingthe
functionaluseofthelimbinwhichthejointisarthrodesed.

32. RELEASEOFTHESOFTTISSUECONTRACTURES
•1.Positioning:ProperPositioningoftheoperatedlimbandofthebodywillnot
facilitaterecurrenceofthecontracture.
•Longperiodsofpronelyingareimportanttopreventrecurrenceofhipflexion
contracturefollowingSoutter’srelease.
•Maintainingoptimalextensionatthekneeafterreleaseoftheiliotibialbandandthe
hamstringsareimportant.
•Maintainingneutraldorsiflexionismandatoryinthereleaseoftendoachilles.
•TheshellofPOPorsuitableorthosesisnecessarytoretaintillthepositionof
correctionismaintainedwithactiveeffortsbythepatient.
•2.Mobilization:GradedmobilizingproceduresareusedtoregainearlyfullROMat
thejointrelatedtothesofttissuerelease.
•Relaxedpassivemovementsfollowingsoothingheatisalsoideal.

33. •3.Musclestrengtheningandenduranceexercises:Exercises should begiven to improve
strength and endurance of the musclegroups antagonisticto the ones thatwere
releasedsurgically, to maintainthe corrected position of the jointconcerned.
Therefore, gluteusmaximusin the release of hip flexion contractureand quadricepsin
the release of knee flexion contractureneeds attention.
•Agonisticcontrol aswell as overall strengthening ofthe othermuscle groups of the limb
should notbe neglected.
•Surgical scarshouldbe mobilized by friction massageorultrasoundto avoidit getting
adherent.
•4.Re-education:Re-educationofthe proper use of the joint,weightbearingand gait is
done to avoid recurrence of softtissue contractures.
•5.Hometreatmentprogram:Simple regularregime ofcorrect positioningand exercises
need to be continued athome.
RELEASEOFTHESOFTTISSUECONTRACTURES

34. TENDONTRANSFERS
•InPreoperativemanagementandtraining,fourfactorsneedspecial
consideration:
•1.Duetoimbalancedmuscularaction,theconcernedjointismostlikelyto
getstiffinthedirectionoftheweakermuscle,e.g.,limitationofinversionin
dorsiflexionwhenanteriortibialgroupisparalysedandperoneiarestrong.
ThetransplantcanneverbeeffectiveunlessfullROMisachievedatthe
concernedjointinthedirectionoftheproposedactionofthetransplant.
•2.Themuscletobetransplantedisboundtogetweakafterthe
transpositionandthereforeitshouldbestrongerbeforesurgery.
•Therefore,concentratedsessionsofpreoperativetrainingofstrengthening
andisometricholdingofthemuscletobetransplantedisamust.

35. •3.Thereisatendencyforthetransplantedmuscletocontinueitsprevious
actionevenaftertransposition.Thisisavoidedbyadequatetrainingofthe
patientonthecontralaterallimb,e.g.,correctgrooveofdorsiflexionwith
inversionisrepeatedlypracticedonthecontralaterallimbbefore
undertakingperonealtransplantfortheparalysedanteriortibialgroup.
•4.Specificstrengtheningproceduresaregiventotheassociatedmuscle
groupsofthemovementforwhichthetransplantisplanned.
•Thesemusclegroupsareinstrumentalinassistingtheperformanceofthe
transplantedmuscle.Forexample,extensordigitorumandhallucislongus
arestrengthenedwhentheperonealtransplanttothedorsumofthefootis
plannedtoassistdorsiflexion.
TENDONTRANSFERS

36. SEGMENTALASSOCIATIONOFMAJORMUSCLEGROUPSOFTHE
LOWERLIMB

37. •Postoperatively:Re-educationof the transplanted muscle isimportant.
•Begin withguided passive full-range movementin the exactgrooveofthe expected arc of
movement.
•Graduallyprogresstoassisted movementby encouraging the patientto actively contract
the transplantedmuscle.
•Electrical stimulationsynchronized with the patient’s effortis extremelyusefulin re-
education.Biofeedbackalso providesan excellentmeansof re-education.
•The sessionsofmuscle re-education and strengtheningshouldbe continuedand
progressedtill strong and controlled movementsbythe transplantedmuscle are
achieved.
•Guidedfunctional traininghastens therecovery.
•Dynamicorthosismay sometimes become necessary toprovide assistanceand to avoid
unwanted movements.
TENDONTRANSFERS

38. ARTHRODESIS
•Thisis a joint stabilizing procedurewhere immobilizationis usually done for a long
period.
Preoperativetraining
•The patient is taughtthe procedures of functionally using thelimb effectively,e.g.,non–
weight-bearing crutchwalking.
•Exercisesare givento strengthen the movementsof the joints adjacentto the jointto be
arthrodesed.
•Mobilization of the shoulder girdle and pelvic girdle aregiven whenthe arthrodesis is
planned for shoulderand hip, respectively.Ithelpsin the functional useof the limb
following stabilization.
Duringimmobilization:
•Vigorousexercises are given to the jointsfree fromimmobilization.
•Gaittraining is started as soon as the pain recedes.

39. Mobilization:
•Asthe initialweightbearingis painful,weighttransferstothe limb;single legbalanceand
ambulationare done ina graduatedmanner.
•Adequatewalkingaid may benecessaryinitially,but it shouldbe waned gradually.
•Functionaluse of the operatedjoint is emphasizedby teachingcompensatorymechanisms
by usingadjacentjoints.
•The exerciseprogramisthen madevigorous,emphasizingendurancetraining.
CORRECTION OFTHELIMBLENGTHDISPARITY
•Theperiodof immobilizationis longand thereforestrengthening andendurance exercises
are emphasized toall the free joints.
•Properpositioningof the limb is ensured inthe externalfixator.
•Isometricsto the glutei and quadricepsare givenon removal ofthe externalfixator orPOP.
•Gradualtraining inweight bearing,weight transfers,balanceand gait is initiatedand
progressed tonormaluse.
ARTHRODESIS

40. Thanks
Dr.SanjibKumar Das,MPT(Musculoskeletal)
Fellow PhD (Ergonomics & Human Factors)
ContactNo. [phone] /8169951520
Email: [email protected] / [email protected]
GoogleScholar:https://scholar.google.com/citations?user=rdOq9r8AAAAJ&hl=en&oi=ao
Linkedin:https://www.linkedin.com/in/dr-sanjib-kumar-das-75950936/