Musculoskeletal Physiotherapy Management in Poliomyelitis

Musculoskeletal Physiotherapy Management in
Poliomyelitis
Dr Sreeraj S R, Ph.D.

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POLIOMYELITIS
⬢ Viral infection of the anterior horn cell of the spinal cord and
brainstem, resulting in temporary or permanent paralysis.
⬢ Common in children < 5 years, also in young adults.
⬢ India rolled out the Pulse Polio Immunization Program on 2nd
October 1994, when the country accounted for around 60% of the
global polio cases.
⬢ The last polio case being reported in Howrah in West Bengal on 13th
January 2011.
⬢ On 27th March 2014, India received ‘Polio-free certification’ from
World Health Organization.

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Virology
⬢ The Picornavirus group (25-27 mm in diameter) causes
poliomyelitis:
1. Brunhilde (type I)
2. Leon (type II)
3. Lansing (type III).

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Pathology
⬢ The virus is transmitted by droplet infection and through the
faeco-oral route.
1. Alimentary Stage: After gaining access to the body through
the nasopharynx on the GIT, the virus multiplies in the
epithelial cells of the intestinal mucosa.
2. Viremic Stage: The virus then spreads through the blood
stream and enter its third stage.
3. Neural Stage: It then finds its way to the anterior horn cells of
the spinal cord and nerve cells in the brain stem.

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Stages
1. Prodromal or Invasion Stage
2. Acute Stage
3. Convalescent Stage
4. Stage of Recovery
5. Stage of Residual Paralysis
⬢ Post Polio Syndrome (PPS)

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Prodromal or Invasion Stage
⬢ Invasion probably occurs via the pharynx.
⬢ This stage lasts only 24 to 48 hours and is usually so trivial as
to be recognized.
⬢ A 'minor illness' results with fever, malaise, sore throat and
gastro-intestinal upset.
⬢ The only feasible treatment is prophylaxis by preventive
inoculation and precautionary isolation.

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Pre-paralytic / Acute Stage
⬢ Up to 3 – 5 days duration
⬢ The virus has by now penetrated the CNS and is multiplying.
⬢ There may be a sudden onset of' major illness’, with fever, headache,
vomiting, stiffness of neck and back, and pain in the trunk and limbs.
⬢ As the symptoms increase in severity, neck stiffness appears, and
meningitis may be suspected.
⬢ The patient lies curled up with the joints flexed
⬢ The muscles are painful and tender and passive stretching provokes
painful spasms.

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Paralytic Stage
⬢ 3 to 6 weeks from the onset of poliomyelitis
⬢ Soon after the major illness, paralysis appears and is quickly maximal in
extent.
⬢ There is spasm and tenderness of muscles.
⬢ A tendency to develop rapid fibrous contractures in the tendons, muscle
sheath and fascia.
⬢ May give rise to difficulty with breathing and swallowing and can be fatal
due to respiratory paralysis
⬢ Pain and pyrexia subside after 7–10 days and the patient enters the
convalescent stage.

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Convalescent/ Recovery Stage
⬢ This stage extends for almost 2 years.
⬢ The virus is dead but has destroyed a variable number of nerve
cells.
⬢ The patient is no longer ill in himself, and paralysis to some
extent recovers.
⬢ Recovery of function is assisted by physical treatment and by
training, while intermittent splintage is often required.

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Stage of Residual Paralysis
⬢ The period beyond 2 years after the onset of the disease.
⬢ There is permanent residual paralysis with deformity, flailness and trophic
changes.
⬢ The degree of paralysis depends on;
⬡ The extent of neuronal damage occurred in earlier stages.
⬡ The recovery of injured cells.
⬡ Resolving of inflammation clear the temporary interruption of the nerve
cell conduction due to swelling.
⬡ Re-routing of some of the neuronal pathways through axon sprouting.

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Post Polio Syndrome
⬢ Newly occurring late manifestations of poliomyelitis that develop in patients 30-40
years after the occurrence of the acute illness.
⬢ This weakness is not a result of the earlier disease but believed to be by overuse of
the muscles that were originally affected
⬢ Studies have shown that;
⬡ a muscle must lose from 30% to 40% of its strength for weakness to be
detected using manual muscle testing.
⬡ activities of daily living such as gait require more muscle strength and stamina
than previously appreciated.
⬢ So, putting the previously weak muscles to work harder to regain strength and
demands of ADL is proved to be detrimental and to lead to chronic overuse of
muscles and further functional decline.

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Examination of the Patient
⬢ Major characteristic features of poliomyelitis:
⬡ Predominantly lower extremities are involved.
⬡ Asymmetric nature of paralysis.
⬡ Paresis of Deltoid and Quadriceps and complete paralysis
of tibialis anterior is common.
⬡ Reflexes are reduced but sensorium remains undisturbed.

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⬢ General observation of posture to detect the areas of
involvement.
⬢ Inability to move one limb indicates the involvement of that
limb.
⬢ Look for the degree of consciousness, choking, squint,
spontaneous nystagmus, facial paralysis, disinclination to move
or change position, feeble cry or cough, diminished respiratory
excursion and accumulation of secretions should be carefully
examined to detect a brain lesion.

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⬢ Spinal rigidity: Neck and the whole spine should be examined
for rigidity.
Kernig's sign: resistance or pain
while extending flexed knee with
hip 900 flexion.
Brudzinski's sign: when bringing
patient’s chin to chest passively
causes flexion of the hips.

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⬢ Strength of intercostals, diaphragm and abdominals should be assessed.
⬢ Intercostal and diaphragmatic weakness will be indicated by insufficiency of
inspiration
⬢ weakness of abdominals will produce deficient expiration.
⬢ Asynchronous expansion may occur with functional diaphragmatic
impairment, pain or paralysis of the intercostals.
⬢ Feeble cry or feeble coughing will indicate deficient abdominals.
⬢ Deviation of the umbilicus upwards, downwards or to one side indicates
segmental weakness of the abdominals.
⬢ The ability to ventilate should be measured by spirometry

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⬢ The extremities are examined for gross weakness of the limb
and degree of paralysis in the individual muscle groups.
⬢ The tendon reflexes disappearance confirms an LMN lesion.
⬢ Sensations are not affected in poliomyelitis.
⬢ The degrees of contractures and deformities should be
accurately assessed and recorded at each stage to control
them with early care.

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Treatment
Acute phase
⬢ The patient must be kept isolated and barrier-nursed due to
infection.
⬢ Precautions to be taken during the early stages of polio
⬡ Avoid unnecessary activities.
⬡ Avoid injections, surgical operations, etc.
⬡ Avoid unnecessary transfers, etc.
⬡ Avoid improper positions.

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Treatment
Acute phase
⬢ Relief of pain.
⬢ Supportive medication for the relief of pain and relaxation.
⬢ Relaxation, local tenderness and pain due to spasm of the offending muscle
groups can be effectively managed with moist heat or Sister Kenny’s bath.
⬢ Excessive heating should be strictly avoided.
⬢ Whenever muscular pain or spasm permits, relaxed passive
movements to be initiated at least once in a day.
⬢ The patient's position changed frequently but gently for
prevent bedsores and gravity assisted the drainage of mucus.
https://www.physio-pedia.com/File:HSC-973.39.1.jpg

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Treatment
Acute phase
⬢ Prevention of contractures is a major goal during early convalescence as
the contracture and deformities begin to appear at this stage.
⬢ It is preferable to put the limb in proper position for prevention of
deformities rather than applying rigid splints.
⬢ Parents should be guided on the methods of proper positioning of the limb.
⬢ Common sites of early contractures
⬡ Hip – flexion abduction
⬡ Knee – flexion
⬡ Ankle and foot – plantar flexion (equinus), varus or valgus
⬡ Shoulder – abduction
⬡ Elbow – flexion

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Treatment
Acute phase
⬢ Bulbar paralysis
⬢ Pharyngeal paralysis: inability to swallow/chokes on even liquid food or
saliva which can cause death if not prevented. There is difficulty in coughing
or speaking.
⬢ Respiratory paralysis: breathlessness, suffocation, cyanosis and use of alae
nasi.
⬢ Tracheostomy or intermittent positive pressure respiration (IPPR) or a
respirator may be necessary.
⬢ The most important role of the physiotherapist is to use postural drainage
and improve vital capacity.

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Treatment
Early convalescence phase
⬢ Simple exercises for important muscle groups in the beginning.
⬢ Methods to prevent contractures should be taught to the mother and the
child.
⬢ The value of regular physiotherapy follow-up should be explained to the
parents.
⬢ Only one or two exercises are taught in one session.
⬢ Exercises in warm water pool are effective.
⬢ Assisted exercises like tricycling (tie ankles and feet to the peddle if needed)
⬢ Prevent early weight bearing to prevent deformities.
⬢ Necessary appliances should be given as soon as the child start to weight
bear.

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Treatment
Early convalescence phase
⬢ Home treatment
⬢ Continue same as in hospital
⬢ Parents should be warned against early weight bearing on
weak muscles which might lead to deformities like subluxation
of the hip, genu recurvatum/valgum/varum and valgus foot.
⬢ Parents should be instructed to bring the child regularly for
physiotherapy to the department for better recovery.

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Incorrect position Correct position Foot supports
Feet unsupported
(incorrect)
Feet supported
(correct)

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Treatment
Late convalescence phase
⬢ This is a phase of recovery or hypertrophy of the residual
muscle fibres
⬢ This requires the assistance of graded resistance exercise to
the concerned muscles.
⬢ Resistance can be given in sync with daily activities like playing.
⬢ Example: Resistance can be applied to a great advantage while
moving the tricycle with own efforts to improve strength and
coordination.

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Treatment
Late convalescence phase
⬢ PT with the help of P&O can also fabricate braces to offer
resistance in gait movements
⬢ Aerobic program like swimming, fast walking and sports can be
initiated and made competitive whenever feasible.
⬢ Limb length discrepancy should be checked as this is
commonly seen in children with unilateral lower limb
involvement.
⬢ It needs to be assessed and properly compensated at regular
intervals.

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Treatment
Residual phase
⬢ Functional assessment
1. Ability to turn
2. Ability to sit up
3. Assistance to sit
4. Ability to sit up without assistance – posture and balance.
5. Ability to stand - support required, independence, balance and
posture of head, spine, hips (Trendelenburg), knees and feet.
6. Walking – unaided, aided – what aids gait and speed.
7. Braces – details.
8. Managing curbs, stairs – independent, with aid (type of aid); ability to
do floor sitting, squatting, cross-leg sitting.

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Treatment
Residual phase
⬢ Emphasis should be on further strengthening the functional needs of the
patient as neurological recovery are practically nil .
⬢ These movements should be made stronger by graduated resistance.
⬢ Prevent posture, positions and activities that put compressive or stretching
forces on the involved muscles and the joints supported by them.
⬢ Provide aids or supports to facilitate functional as well as physical work
requirements.
⬢ Correct use of braces, canes, crutches, wheelchairs or any orthosis is to be
assured.
⬢ Frequent consultation and advice on the prevention of contractures and
deformities

⬢ Foot and ankle
⬡ Claw toes
⬡ Claw foot
⬡ Talipes equinus
⬡ Talipes equinovalgus
⬡ Flail foot
⬡ Pes cavus
⬡ Dorsal bunion
⬡ Talipes equinovarus
⬡ Talipes calcaneovalgus
⬢ Knee
⬡ Flexion contracture of the knee
⬡ Quadriceps paralysis
⬡ Genu recurvatum
⬡ Flail knee
⬢ Hip
⬡ Flexion abduction contractures of the hip
⬡ Paralysis of gluteus medius, maximus
⬡ Paralytic dislocation of hip
⬢ Iliotibial Band Contractures
1. Lumbar scoliosis
2. Pelvic obliquity
3. Hip flexed and abducted
4. External rotation of femur
5. Flexion and valgus of knee
6. Posterior and lateral subluxaion of tibia
7. External rotation of tibia
8. Foot in equinus
9. Shortening
⬢ Spine
⬡ Kyphosis
⬡ Scoliosis
⬡ Kyphoscoliosis
⬢ Upper limbs
⬡ Paralysis of shoulder, elbow, forearm and
hand muscles
28
Common orthopaedic deformities in poliomyelitis

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Surgical methods
⬢ Soft tissue release for soft tissue contractures
⬢ Tendon transfers when dynamic muscle imbalance produces
deformity requiring brace protection.
⬢ Arthrodesis to stabilize a flail joint.
⬢ Osteotomies to correct deformities like genu valgum, varum,
flexion, etc.
⬢ Ilizarov technique for leg length equalization can be done by
lengthening of the shortened femur or tibia.

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Postsurgical Physiotherapy
⬢ After maximum protection phase graded strengthening, stretching and
weight bearing can be started depending on child’s age, general condition
etc.
⬢ Take adequate hygienic measures to avoid wound site infection.
⬢ Control inflammation by Ice
⬢ Proper positioning and general mobility to avoid bed sores, contractures etc
⬢ After hip contracture release: Prone lying
⬢ After iliotibial and hamstring release: Knee extension
⬢ TA Z-plasty: Dorsiflexion in neutral position

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⬢ After release of soft tissue contractures, the following measures are
suggested:
⬡ Measures to prevent recurrence by appropriate joint positioning and
graded exercise of the antagonistic muscles to strengthen them and
increase their endurance.
⬡ Measures to mobilize the joints by active and passive ROM exercises.
⬡ Retraining measures in gait, weight-bearing joint movements, etc.
⬡ Measures of home treatment program include proper positioning,
exercises, weight-bearing, etc.

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⬢ After tendon transfers reeducation of the transferred tendon
for its newly acquired role is very vital.
⬢ The following measures are suggested:
⬡ Gentle passive stretching exercises after 6 weeks when pain
free.
⬡ Gradual active and active assisted movements.
⬡ The electrical stimulation greatly helps.
⬡ Dynamic orthotics may help in some cases.

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⬢ After arthrodesis
⬡ Strengthening exercises to the adjacent joints are given.
⬡ Patient is trained in non-weight bearing crutch walking.
⬡ Mobilization regime after arthrodesis is planned.
⬡ Single leg balance, walking aids, weight transfers, etc. are
some of the recommended measures.

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⬢ After limb lengthening procedures
⬡ Active ROM exercises to unaffected joints.
⬡ Isometric exercises to quadriceps and glutei after removal
of the fixator.
⬡ Training in gait, balance, weight bearing and weight
transfers are given.

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Post Polio Syndrome (PPS)
⬢ Post-polio syndrome (PPS) is a disorder of the nerves and muscles that
appear decades — an average of 30 to 40 years — after the initial polio
illness.
⬢ In general, symptoms of PPS may include:
⬡ Progressive weakness, tiredness (fatigue)
⬡ Pain in the muscles and joints
⬡ Muscle wasting
⬡ Trouble swallowing
⬡ Breathing problems
⬡ Sleep disorders
⬡ Sensitivity to cold temperatures

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Post Polio Syndrome (PPS)
Physiotherapy
⬢ Only supportive therapies can help manage the condition.
⬢ The goal of treatment is to reduce the impact of the condition on patient’s daily life.
You may
⬢ use assistive devices such as lightweight braces, canes, walkers, scooters, and
wheelchairs to save energy and muscle strength.
⬢ Advice to get plenty of rest.
⬢ improve muscle strength with specially designed non-fatiguing low-intensity muscle-
strengthening exercise programs.
⬢ Hydrotherapy, swimming, non-fatiguing recreational activities may improve well-
being.
⬢ Cold/hot therapy to ease pain
⬢ Physical therapy to keep as much mobility as possible

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References
1. INDIA: A push to vaccinate every child, everywhere, ended polio in India [Internet]. who.int. World Health
Organization; 2021 [cited 2021 Jun 10]. Available from: https://tinyurl.com/wns6hvbv
2. Poliomyelitis [Internet]. Physiopedia. 2018 [cited 2021 Jun 10]. Available from: https://www.physio-
pedia.com/Poliomyelitis
3. Ranade AS. Poliomyelitis: Background, Pathophysiology, Etiology [Internet]. Medscape.com. Medscape;
2020 [cited 2021 Jun 10]. Available from: https://emedicine.medscape.com/article/1259213-overview
4. Joshi J, Kotwal P. Chapter 28. Poliomyelitis. In: Essentials of Orthopaedics and Applied Physiotherapy. 3rd ed.
New Delhi: RELX India Pvt. Ltd.; 2017.
5. Ebnezar J. Essentials of Orthopaedics for Physiotherapists. In: 2nd ed. Bengaluru: Jaypee Brothers Medical
Publishers; 2011. p. 465–70.
6. Sud A, Varshney MK. Chapter 27, Poliomyelitis. In: Essential Orthopedics: Principles & Practice (2 Volumes).
New Delhi: Jaypee Brothers Medical Publisher (P) Ltd; 2016. p. 651–74.
7. Apley AG. Paralytic poliomyelitis. Postgrad Med J. 1955;31(352):60-66. doi:10.1136/pgmj.31.352.60
8. Post-Polio Syndrome | Cedars-Sinai [Internet]. Cedars-sinai.org. 2021 [cited 2021 Jun 11]. Available from:
https://www.cedars-sinai.org/health-library/diseases-and-conditions/p/post-polio-syndrome.html

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