Poliomyelitis

Original Editor -Chrysolite Jyothi Kommu

Top Contributors - Chrysolite Jyothi Kommu, Nikhil Benhur Abburi, Momina Khalid and Simisola Ajeyalemi  

Introduction

Poliomyelitis is a virus infection of nerve cells in the anterior gray matter or cranial nerve nuclei in the brain stem leading in many cases to temporary or permanent paralysis of muscles that they activate.

Cause

It is caused by infection with virus of three types have been identified as;

Type-1-Brunhilde,

Type-2-Lanchi,

Type-3-Leon.

Mode of transmission:

The spread is mainly by fecal contamination route in poor hygine countries and by droplet infecion where sanitation is good.

poliovirus is an Enterovirus that colonises the GIT.

Pathology

The disease occurs in three stages:

1.Alimntary Stage:

After gaining access to the body through the nasopharynx on the GIT,the virus muliplies in the epithelial cells of the intestinal mucosa.

2.Viremic Stage:

The virus spreads through the blood stream and after a sort of conflict between the virus and the antibodies,in case the virus turns victorious then it leads to the third stage.

3.Neural Stage:

The virus finds its way to the anterior horn cells of the spinal cord and nerve cells in the brain stem.

According to the virulence of the infection the cells may escape serious harm or they may be damaged or killed.If cells are killed then the paralysis is permanent.

Clinical features:

Th course of the disease is divided into four stages;

1.Prodromal Stage or Pre-Paralytic Stage:

It is nonspecific.

It may last from a few hours to a few days and 1 to 3 days is the usual duration.

Many patients never progress beyond this stage and are only diagonised with laboratory findings of the poliovirus in the throats or the stools.

The importance of his stage is that exercise,injections or operations may precipitate severe paralysis in the limbs exercise or traumatized.

Signs and Symptoms:

-Headache. -Backache.

-Sore throat. -Joint pains.

-Malaise. -Pyrexia of variable duration and severity.

-Slight Cough. -Mild neck stiffness.

-Diarrhea or constipation. -Irritability.

Treatment:

The only practical measures which can be taken in suspects in economically poor countries is to stop the playing of games and other such manual work if possible.

Performance of tosillectomies and other non-emergency surgery should be discouraged.

The nasopharyngeal secretions and feces or highly effective at this stage of illness and children suspected infections should be isolated if possible particularly from other children and babies.An additional booster dose may be given to both affected and unaffected children for added protection.

2.Acute Stage:

This is the early stage of paralysis.

Signs and Symptoms

-Fever

-Diarrhea,nausea,vomiting.

-Irritability.

-Limb and joint pains-Due to painful surrounding muscles.

-Muscle tenderness is the most important sign seen in this stage.

to test this press the calf muscles when child is quiet.If he cries,he has tenderness.

Duration:

3 to 6 weeks from the onset of Poliomyelitis.

Treatment:

1.Rest:The child should not be over handled.All the physical activity should be discouraged at this stage.

2.Isolation:This is necessary to protect the other children frrom contacting the infection because stools,urine and droplets arehighly contaminated and contagious.

3.Booster dose

4.Nutrition:Diet rich in Protein.

5.Correct handling technique:

Parents should be taught correct handling technique to prevent further damage other neural structures.

1.The child should not be lifted by one hand.

2.While carrying the child,they should be held in front and preferably with the Hip in extension without any abduction.

6.Splinting and correct positioning: Splinting can be given so that lower limb can be immobilized to prevent further damage to the muscles.

7.Sister Kenny's Bath:This is a form of moist heat.The towel is dipped in hot water and wringed.Then it is placed on the limbs and lumbar spine of the patient.This helps to resolve inflammation to some extent.

Massage is contraindicated as it may cause more damage.

8.MMT:To know the extent of weekness or paralysis.

9.Gentle passive movement:Given 2 to 3 times a day to keep the muscl and joint flexible as well as to improve circulation to the limbs.

3.Convalescent Stage: This is a stage of true or actual paralysis.

Duration :3 months.

Signs and Symptoms: Vary in both duration and severity.The effects may lead to paralysis which may take any of the following forms:

1.Spinal.

2.Bulbar.

. 3.Spinobulbar/Bulbospinal.

4.Postencephalitic type of paralysis.

1.Spinal Type:

Here the anterior horn cells are affected with resulting paralysis of lower moor neuron type with assymtrical flaccid paralysis and normal sensation.

The lower limb muscles are more often involved than upper limb muscles.

Due to gross motor imbalance as a result of such paralysis contractures are liable to occur.Contractures evevntually lead to deformity particularly seen in lower limbs where flexors of Hip,knee and ankle are often paralyzed than the extensors.

Flexion contractures of hip,knee and equinus deformity of the ankle are common.

2.Bulbar Type:

The most important sign of Bulbar paralysis is- the inability to swallow due o pharyngeal paralysis.

-The patient chokes on both solid and liquid food,

-Cannot swallow on his own.

-Cannot cough properly- due to paralysis of larynx,

-Has difficulty in speaking- due to paralysis of palate.

-The patient requires urgent ventilatory support for respiration and Ryle's tube for feeding to save his life as both respiratory and swallowing muscles are affected.

-The early signs of respiratory involvement includes breathing,feeling of suffocation,slight cyanosis,use of sternomastoids,alae nasae and other accessory muscles of respiration.

3.Spinobulbar:

This type has a combinaion of both spinal and bublbar type.

Patients with predominant spinal and less bulbar presntation-Spinobulbar type.

Patients with more bulbar signs and less spinal signs-Bulbospinal type.

4.Postencephalic:

This is rare.

Mental disturbance,coma,paralysis of facial muscles,symptoms similar to meningitis like headache,vomiting,neck stiffness may occur

Treatment:

1.Continuous Splintage;Above knee splint or L splint-to prevent knee flexion,

Below knee splint-Equinus deformity.

Abdominal Corset-weakness of abdominal muscles.

2.Muscle Charting: It is important to assess all the muscle groups as soon as the tenderness in the muscles will allow(3 to 4 weeks after the onset of paralysis)

3.Positioning:Patients relatives should not carry the child in indian position as it increases IT band contractures.[1]

Allow child to sleep in prone to avoid flexion conractures.

Paralyzed arms are best supported on pillows with slight abduction.

Child should not be pulled up holding his hands as it may lead to shoulder subluxation.

Shoulder rolls in the form of towel rolled and kept under axilla helps to prevent shoulder subluxation.

4.Changing the position:Turning the patient every 2 to 4 hours and night prevents bed sores and keeps the skin dry.

5.Stretching of contractures:Stretching should be gentle and consistent.Principal contractures are IT band and ankle equines.

-For tendo Achilles,if the muscle is weak with grade 0 or 1,excessive stretching should be avoided,as there is more anterior gliding of tibia which could lead to calcaneal deformity.

-In gluteus medius weakness,full stretching of IT band should be avoided as it will further weaken the muscle and will lead to exaggerated Trendelenburg lurch.

6.Stimulation and facilitation technique:IG stimulation can be given if patient can tolerate to maintain muscle property.

4.Stage of Recovery

This stage extends for almost 2 years.Thus muscle in the polio patient can be strengthened to their maximum capacity upto 2years after this it wont be possible to activate any paralyzed muscle.Before 2years time if any muscle is seen regaining the power,it must be exercised quite skillfully to achieve maximum rehabilitation output.

Various strengthening techniques include:

1.Sensory integraion.

2.Resisted exercises with springs and pulleys.

3.Hydrotherapy and suspension therapy.

4.Play therapy.

5.Mat Exercises.

Stage of Residual Paralysis

Paralysis or weakness after 2 years is permanent.The extent of residual paralysis ranges between mild significant local weakness to gross paralysis of trunk and limb musculature leading to severe disability and functional dependency.

Treatment:

Patient may be given combination of stretching,strengthening and calliprization.

Tailor-made calipers can prevent the deformity from aggravating.

Tendon transfers may be done in case there is availability of good donor muscle without compromising balance on that side.

Arthrodesis [2] is preferred especially around the ankle in case of severe instability making weight bearing difficult.

Common Problmes Encountered by Polio Patients

Muscle weakness

Bony Changes:Most common changes are-Shortening,Ostoporesis,Deformities.

References

Physiotherapy in Neuro-conditions,Glady Samuel Raj