2. INTRODUCTION
• Poliomyelitis, is an acute infectious disease caused by the
poliovirus. The types of virus responsible for causing
poliomyelitis are: Type I- Brunhilde, Type II- Lansing, Type II-
Leon.
• The infection may manifest as an episode of diarrhoea or may
affect the anterior horn cells of the spinal cord and lead to
extensive paralysis of the muscles.
• In extreme forms, the paralysis may involve respiratory muscles,
and may lead to death.
3. AETIOPATHOLOGY
• The poliovirus enters the body either through the faeco-oral
route or by inhalation of droplets.
• Paralysis may be precipitated after strenuous physical activity,
by an intramuscular injection or in a child on cortisone
therapy.
• A tonsillectomy, adenoidectomy or tooth extraction
predisposes to paralysis during polio epidemics.
• The infection occurs commonly in summer.
4. PATHOGENESIS
• The virus multiplies in the intestine. From here it
travels to enter the blood circulation.
• If the defense mechanism of the body is poor, the
virus reaches the nervous system (anterior horn cells)
via the blood or peripheral nerves.
• The neurons undergo varying degree of damage –
some may permanently die, others may be
temporarily damaged, others may undergo only
functional impairment due to tissue oedema.
5. PATHOGENESIS
• The neurons, which are permanently damaged,
lead to permanent paralysis; while the others may
regenerate, so that partial recovery of the
paralysis may occur.
• It is this residual paralysis (called post-polio
residual paralysis – PPRP) which is responsible
for the host of problems associated with a
paralytic limb (deformities, weakness etc.).
6. CLINICAL FEATURES
• The patient is a child around the age of 9 months. The
mother gives a history that the child developed mild
pyrexia associated with diarrhoea, followed by
inability to move a part or whole of the limb.
• The lower limbs are affected most commonly.
Paralysis is of varying severity and asymmetrical in
distribution.
• In extreme cases, the respiratory muscles may also be
paralyzed.
7. CLINICAL FEATURES
• In the early stages, the child is seen by a paediatrician
and then referred to an orthopaedic surgeon.
• By this time the paralysis may already be on its way
to recovery.
• Recovery of power, if it occurs, may continue for a
period of 2 years. Most of the recovery occurs within
the first 6 months.
• Any residual weakness persisting after 2 years is
permanent, and will not recover.
8. General Pattern of Paralysis and Expected Recovery
Following Acute Episode
Vigorous concentrated physiotherapy from week 3 or as soon as tenderness
subsides up to 6 months is crucial. Maximum advantage can be derived at this
stage.
9. EXAMINATION
• In the early stage, the child is febrile, often with rigidity of
the neck and tender muscles.
• This may be associated with diffuse muscle paralysis. The
following are some of the typical features of a paralysis
resulting from polio:
It is asymmetric i.e., the involvement of the affected
muscles is haphazard.
It occurs commonly in the lower limbs because the anterior
horn cells of the lumbar enlargement of the spinal cord are
affected most often.
The muscle affected most commonly is the quadriceps,
although in most cases it is only partially paralyzed.
10. EXAMINATION
The muscle which most often undergoes complete
paralysis is the tibialis anterior.
The muscle in the hand affected most commonly is the
opponens pollicis.
The motor paralysis is not associated with any sensory
loss.
Bulbar or bulbo-spinal polio: This is a rare but life
threatening polio (the motor neurons of the medulla are
affected). This results in involvement of respiratory and
cardiovascular centres, and may cause death.
11. EXAMINATION
• In late stage (PPRP), the paralysis may result in
wasting, weakness, and deformities of the limbs.
• The deformities result from imbalance between
muscles of opposite groups at a joint, or due to
the action of the gravity on the paralyzed limb.
• The common deformity at the hip is flexion-
abduction-external rotation.
12. EXAMINATION
• At the knee, flexion deformity is common.
• At the foot, equino-varus deformity is the commonest;
others being equino-valgus, calcaneo-valgus and
calcaneocavus.
• In the upper limbs, polio affects shoulder and elbow
muscles.
• Muscles of the hand are usually spared.
• With time, the deformities become permanent due to
contracture of the soft tissues and mal-development of the
bones in the deformed position.
14. PROGNOSIS
• Of the total number of cases infected with the poliovirus, 50
per cent do not develop paralysis at all (non-paralytic
polio).
• 40 per cent develop paralysis of a varying degree (mild,
moderate or severe).
• 10 per cent patients die because of respiratory muscle
paralysis.
• Of the patients with paralytic polio, 33 per cent recover
fully, 33 per cent continue to have moderate paralysis, while
another 33 per cent remain with severe paralysis.
15. PROGNOSIS OF RECOVERY IN RELATION TO THE
INITIAL ASSESSMENT OF MUSCLE POWER
• All the muscle groups of the affected limb should be divided into
two groups:
• Group I – muscles that are partially paralyzed (MMT grade = 1 to
3)
• Group II – muscles that are totally paralyzed (MMT grade = 0)
17. MEDICAL TREATMENT
• Polio can be prevented by immunization.
• It is important to immunize patients even after an attack
of acute poliomyelitis. This is because there are three
strains of the virus, and the patient could still get
paralytic polio by another strain.
• The treatment principles are:
(i) To provide supportive treatment during the stage of
paralysis or recovery
(ii) To prevent the development of deformities during this
period
(iii) To use, in a more efficient way, whatever muscles are
functioning.
18. TREATMENT
Stage of onset: It is generally not possible to diagnose polio at
this stage. In an endemic area, if a child is suspected of having
polio, intramuscular injections and excessive physical activity
should be avoided.
Stage of maximum paralysis: In this stage, the child needs
mainly supportive treatment.
• A close watch is kept for signs suggestive of bulbar polio.
These are signs of paralysis of the vagus nerve, causing
weakness of the soft palate, pharynx and the vocal cords –
hence problem in deglutition, and speech. A respirator may be
necessary to save life if the respiratory muscles are paralyzed.
• Paralytic limbs may have to be supported by splints to prevent
the development of contractures.
• All the joints should be moved through the full range of
motion several times a day.
• Muscle pain may be eased by applying hot packs.
19. Stage of recovery: The principles of treatment
during this stage are as follows:
• Prevention of deformity by proper splintage, and
joint mobilizing exercises.
• Correction of the deformity that may have already
occurred.
• Retraining of muscles that are recovering by
exercises. Progress evaluated by repeated
examination of the motor power of the paralyzed
limb.
• Encourage walking with the help of appliances,
wherever possible.
20. TREATMENT
Stage of residual paralysis: It consists of the following:
• Detailed evaluation of the patient: Most patients with residual polio
(PPRP) walk with a limp, with or without calipers. An assessment is
made whether functional status of the patient can be improved.
• For this, an evaluation of the deformities and muscle weakness is
made.
• Prevention or correction of deformities: The main emphasis is on
prevention of deformity.
• Splinting the paralyzed part in such a way that the effect of muscle
imbalance and gravity is negated.
• An operation may be required to prevent the deformity. For example,
in a foot with severe muscle imbalance between opposite group of
muscles, a tendon transfer operation is done. A ‘balanced’ foot
produces less possibility of deformity
21. TREATMENT
• Tendon transfers: It is not done before 5 years of age, as the child has to be
manageable enough to be taught proper exercises. More commonly
performed tendon transfers are as follows:
• Transfer of extensor hallucis longus (EHL) from the distal phalanx of great
toe to the neck of the first metatarsal. This is done to correct first metatarsal
drop in case of tibialis anterior muscle weakness.
• Transfer of peroneus longus and brevis muscles to the dorsum of the foot.
The transfer is required in a foot with dorsiflexor weakness. Evertors can
be spared for more useful function of dorsiflexion of the foot.
• Hamstring (knee flexors) transfer to the quadriceps muscle to support a
weak knee extensor.
22. Principles of tendon transfers
Donor tendon
• Should be expandable
• Minimum power 4/5
• Amplitude of excursion to match that of the recipient muscle
• Preferably a synergistic muscle
Recipient site
• Range of movements of the joints on which the transferred muscle is expected to work
should be good
• No scarring at the bed of the transferred tendon
Technical considerations
• Transferred tendon should take a straight route
• It should be placed in subcutaneous space
• Fixation must be under adequate tension
Patient considerations
• Age – minimum 5 years*
• The disease should be non-progressive
* Minimum age when a child can be trained in using the transferred muscle.
23. TREATMENT
• Stabilization of flail joints: Joints with severe muscle
paralysis that the body loses control over them are called
flail joints.
• Stabilization of these joints is necessary for walking. This
can be achieved by operative or non-operative methods.
Non-operative methods consist of calipers, shoes etc.
• Operative methods consist of fusion of the joints (e.g., triple
arthrodesis for stabilization of the foot).
• Leg length equalization: In cases where a leg is short by
more than 4 cm, a leg lengthening procedure may be
required.
28. Lower limb: Release of soft tissue contractures
• Hip: The flexion contracture at the hip is corrected by Soutter’s operation in
which the tight structures along the anterior iliac crest are released and the
deformity is corrected. The abduction contracture is corrected by release of
abductors, fascia lata and the iliotibial band. Postoperatively, the patient is given
a POP hip spica, in the corrected position, for about 4–6 weeks. The joints are
then mobilized but the correction is maintained in a caliper.
• Knee: Mild flexion contractures are generally due to tight iliotibial band that is
divided. Moderate degrees of flexion contracture can be treated by lengthening of
the hamstrings. Severe flexion contractures require lengthening of hamstrings and
posterior capsulotomy of the knee (Wilson’s operation). Postoperatively, an
above-knee plaster cast for 4–6 weeks followed by mobilization is the usual
regime. The correction is maintained in a caliper.
29. • Ankle: The commonest deformity is equinus, which results from contracture of
the tendoachilles. Lengthening of the tendoachilles by Z-plasty is undertaken.
An above-knee plaster cast for 3–6 weeks is given after operation. A below-
knee caliper is usually worn for 3–6 months to prevent recurrence.
• Foot: Contracture of the plantar fascia produces a cavus deformity of the foot.
The tight plantar fascia is stripped from its attachment to the calcaneus
(Steindler’s operation). In the postoperative period, a below-knee plaster is
given for 2–4 weeks, after which a night splint is used for 2–4 months.
Lower limb: Release of soft tissue
contractures
31. PHYSIOTHERAPY FOLLOWING SURGERY
• The basic approach of physiotherapy varies according to the type of the
surgical procedure:
1. After release of the soft tissue contractures, measures should be taken to
avoid recurrence of contracture.
2. Following tendon transplants, the emphasis should be on re-education of
the transplanted muscle to its new role.
3. Following the joint arthrodesis, the emphasis should be on educating the
functional use of the limb in which the joint is arthrodesed.
32. RELEASE OF THE SOFT TISSUE CONTRACTURES
• 1. Positioning: Proper Positioning of the operated limb and of the body will not
facilitate recurrence of the contracture.
• Long periods of prone lying are important to prevent recurrence of hip flexion
contracture following Soutter’s release.
• Maintaining optimal extension at the knee after release of the iliotibial band and the
hamstrings are important.
• Maintaining neutral dorsiflexion is mandatory in the release of tendoachilles.
• The shell of POP or suitable orthoses is necessary to retain till the position of
correction is maintained with active efforts by the patient.
• 2. Mobilization: Graded mobilizing procedures are used to regain early full ROM at
the joint related to the soft tissue release.
• Relaxed passive movements following soothing heat is also ideal.
33. • 3. Muscle strengthening and endurance exercises: Exercises should be given to improve
strength and endurance of the muscle groups antagonistic to the ones that were
released surgically, to maintain the corrected position of the joint concerned.
Therefore, gluteus maximus in the release of hip flexion contracture and quadriceps in
the release of knee flexion contracture needs attention.
• Agonistic control as well as overall strengthening of the other muscle groups of the limb
should not be neglected.
• Surgical scar should be mobilized by friction massage or ultrasound to avoid it getting
adherent.
• 4. Re-education: Re-education of the proper use of the joint, weight bearing and gait is
done to avoid recurrence of soft tissue contractures.
• 5. Home treatment program: Simple regular regime of correct positioning and exercises
need to be continued at home.
RELEASE OF THE SOFT TISSUE CONTRACTURES
34. TENDON TRANSFERS
• In Preoperative management and training, four factors need special
consideration:
• 1. Due to imbalanced muscular action, the concerned joint is most likely to
get stiff in the direction of the weaker muscle, e.g., limitation of inversion in
dorsiflexion when anterior tibial group is paralysed and peronei are strong.
The transplant can never be effective unless full ROM is achieved at the
concerned joint in the direction of the proposed action of the transplant.
• 2. The muscle to be transplanted is bound to get weak after the
transposition and therefore it should be stronger before surgery.
• Therefore, concentrated sessions of preoperative training of strengthening
and isometric holding of the muscle to be transplanted is a must.
35. • 3. There is a tendency for the transplanted muscle to continue its previous
action even after transposition. This is avoided by adequate training of the
patient on the contralateral limb, e.g., correct groove of dorsiflexion with
inversion is repeatedly practiced on the contralateral limb before
undertaking peroneal transplant for the paralysed anterior tibial group.
• 4. Specific strengthening procedures are given to the associated muscle
groups of the movement for which the transplant is planned.
• These muscle groups are instrumental in assisting the performance of the
transplanted muscle. For example, extensor digitorum and hallucis longus
are strengthened when the peroneal transplant to the dorsum of the foot is
planned to assist dorsiflexion.
TENDON TRANSFERS
37. • Postoperatively: Re-education of the transplanted muscle is important.
• Begin with guided passive full-range movement in the exact groove of the expected arc of
movement.
• Gradually progress to assisted movement by encouraging the patient to actively contract
the transplanted muscle.
• Electrical stimulation synchronized with the patient’s effort is extremely useful in re-
education. Biofeedback also provides an excellent means of re-education.
• The sessions of muscle re-education and strengthening should be continued and
progressed till strong and controlled movements by the transplanted muscle are
achieved.
• Guided functional training hastens the recovery.
• Dynamic orthosis may sometimes become necessary to provide assistance and to avoid
unwanted movements.
TENDON TRANSFERS
38. ARTHRODESIS
• This is a joint stabilizing procedure where immobilization is usually done for a long
period.
Preoperative training
• The patient is taught the procedures of functionally using the limb effectively, e.g., non–
weight-bearing crutch walking.
• Exercises are given to strengthen the movements of the joints adjacent to the joint to be
arthrodesed.
• Mobilization of the shoulder girdle and pelvic girdle are given when the arthrodesis is
planned for shoulder and hip, respectively. It helps in the functional use of the limb
following stabilization.
During immobilization:
• Vigorous exercises are given to the joints free from immobilization.
• Gait training is started as soon as the pain recedes.
39. Mobilization:
• As the initial weight bearing is painful, weight transfers to the limb; single leg balance and
ambulation are done in a graduated manner.
• Adequate walking aid may be necessary initially, but it should be waned gradually.
• Functional use of the operated joint is emphasized by teaching compensatory mechanisms
by using adjacent joints.
• The exercise program is then made vigorous, emphasizing endurance training.
CORRECTION OF THE LIMB LENGTH DISPARITY
• The period of immobilization is long and therefore strengthening and endurance exercises
are emphasized to all the free joints.
• Proper positioning of the limb is ensured in the external fixator.
• Isometrics to the glutei and quadriceps are given on removal of the external fixator or POP.
• Gradual training in weight bearing, weight transfers, balance and gait is initiated and
progressed to normal use.
ARTHRODESIS
40. Thanks
Dr. Sanjib Kumar Das, MPT(Musculoskeletal)
Fellow PhD (Ergonomics & Human Factors)
Contact No. +918879485847 / 8169951520
Email: sanjib_bpt@yahoo.co.in / skdas@amity.edu
Google Scholar:https://scholar.google.com/citations?user=rdOq9r8AAAAJ&hl=en&oi=ao
Linkedin: https://www.linkedin.com/in/dr-sanjib-kumar-das-75950936/
