Poliomyelitis

Introduction

• Poliomyelitis often called Polio or infantile paralysis is an

acute, viral, infectious disease spread from person to person,
primarily via the fecal-oral route.
• It is an acute viral infectious disease caused by enterovirus.
• The word ‘myletis’ means an inflammation in the spinal cord,
which often targets insulating material covering nerve cell
fibers (myelin). Greek word:-
“polios”-grey
“Myelos” –spinal cord
• Poliomyelitis, literally meaning “grey spinal cord inflammation
• It is a viral infection
• Poliomyelitis is a disease of the anterior horn motor neurons
of the spinal cord and brain stem caused by poliovirus.
• The types of virus responsible for causing poliomyelitis are:
Type I- Brunhilde, Type II- Lansing, Type III- 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.
 Transmission

• Transmission Person-to-person spread of poliovirus via the

fecal-oral route is the most important route of transmission,
although the oral-oral route may account for some cases.
 Risk factors
• Infants and elderly
• Living with an infected person
• Compromised immune
system
• Lack of immunization
against polio
• Extreme stress or
strenuous activity
• Travel to an area that has ben experienced a polio
outbreak.
• The virus multiplies in the
intestine. From here it travels
to enter the blood circulation.
Pathogene
• If the defense mechanism of
the body is poor, the virus sis
reaches the nervous system
(anterior horn cells) via the
blood or peripheral nerves.
• The neurons undergo varying
degree of damage – some
may die, others may be
temporarily damaged, others
may undergo only functional
impairment due to tissue
oedema.
Pathogenesis
 PATHOGENESIS cont…
• 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.).
 Clinical features / Types
• Infection may occur in two forms:-
[Link]/ asymptomatic(90-95%)
 Accounts for approximately 95% of cases
 Virus stays in intestinal tract and does not attack the
nerves
 Virus is shed in the stool so infected individual is still
able to infect others
2. Apparent/ symptomatic (5-10%)
 Abortive polio
 Non-paralytic aseptic meningitis
 Paralytic poliomyelitis
 Polio encephalitis
• Abortive polio
 4-8% infections
 Does not lead to paralysis
 Minor illness Symptoms :-  Low grade fever  Sore
throat  Vomiting  Abdominal pain  Loss of appetite 
Malaise  Recovery:- complete, most recover in <1 week ,
no paralysis.
• Non-paralytic aseptic meningitis
 Occurs in 1-2% of polio infections
Symptoms :-  Headache  Nausea  Vomiting  Pain and
stiffness of neck, back and legs.  Complete recovery after
2-10 days of symptoms.
 Signs

• Tripod sign
• Head drop sign
• Method:- hand placed under
patient’s shoulder and trunk is
raised.
• Observation:- head lags behind
limply
 Paralytic poliomyelitis

• 2 phases-
• Minor- same as abortive polio
• Major- muscle pain, spasm and return of fever
• Followed by rapid onset flaccid paralysis, complete
within 72hrs.
• It is of three types:-
[Link] paralytic poliomyelitis
2. Bulbar poliomyelitis
3. Bulbo-spinal poliomyelitis
1. Spinal paralytic poliomyelitis
• It results from a lower motor neuron lesion of the anterior horn
cells of the spinal cord and affects the muscles of the legs, arms
and/or trunk.
• Most common 80% of cases
• Severe cases- quadriplegia, paralysis of trunk, abdominal and
thoracic muscles.
• Muscles- floppy
• Reflexes- diminished, Deep tendon reflex lost before onset of
paralysis
• Sensation- normal
• Residual paralysis- after 60 days.
2. Bulbar poliomyelitis
• Results from a cranial nerve lesion, resulting in respiratory
insufficiency and difficulty in swallowing, eating or speaking.
• Accounts for 2% of paralytic polio
• Life threatening & Virus attacks motor neurons in brainstem
• Affects cranial nerve function - Cranial nerve lesion- vagus
• Facial asymmetry present
• Dyspnea(difficult or laboured breathing.)  Dysphagia
(difficulty or discomfort in swallowing)  Child refuses to feed
 Secretions accumulate in pharynx- aspiration 
Involvement of  Respiratory centre- shallow, irregular
respiration
3. Bulbo-spinal poliomyelitis
• Accounts for 20% of paralytic cases.
• Combination of spinal paralytic and bulbar polio.
• Affects extremities and cranial nerves.
• Leads to severe respiratory involvement.
 Stages

1. Acute Stage:-
• Generally last for 7 to 10 days.
• Many includes fever , pharyngitis, headache, anorexia,
nausea, and vomiting.
• These patients develop a higher fever & sever
headache with stiffness of the neck and back.
• Paralysis of the respiratory muscles or from cardiac
arrest if the neurons in the medulla oblongata are
destroyed.
2. Convalescent Stage:-
• From 2 days after the temperature return to normal
and continues for 2 years.
• Muscle power improves.
• Physical therapy is recommended for full recovery.
3. Chronic Stage :-
• 24 months after the active illness:
• The goals of treatment include correcting any
significant muscle imbalance and preventing or
correcting soft tissue or bony deformities.
• Static joint instability can be controlled by Orthoses.
• Dynamic joint instability result in a fixed deformity
that cannot be controlled by Orthoses.
 Residual Paralysis
• As the acute phase of illness (0-4 weeks) subsides, the
recovery begins in paralyzed muscles.
• The extent of recovery is variable ranging from mild to
severe residual paresis at 60 days, depending upon the
extent of damage
• Maximum neurological recovery takes place in the first 6
months of the illness; slow recovery continues up to two
years.
• After two years, no more recovery is expected and the child
is said to have post polio residual paralysis, which persists
throughout life.
 Diagnosis

• The diagnosis is based on the history and the characteristic

clinical manifestations
• Stool examination is recommended in every case of acute
flaccid paralysis (AFP).
• Virus can be detected from onset to 8 or more weeks after
paralysis;
• Examination of the cerebrospinal fluid (cell count, gram
stain, protein and glucose) is useful in eliminating other
conditions that cause AFP.
 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.
 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.
 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.
 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.
 Treatment

• Treatment should be early and appropriate to the stage

and degree of paralysis.
• proper positioning of the affected limb and passive range
of movement at the joints.
• Analgesics can also be given to relieve pain and fever.
• All the joints of affected limb/limbs should be moved
through their passive range of movements, 2-3
times/day for 10 times at each joint, to prevent joint
stiffness.
 Treatment
• Vaccines- There are 2 types of vaccines oral polio
vaccine ( OPV ) and inactivated polio vaccine ( IPV ).
• Eradication of Polio –
• Attaining High Routine Immunization - Immunize every
child aged <1 year with at least three doses of oral
poliovirus virus (OPV).
• National Immunization Days (NIDs) - OPV doses are
administered to every child <5-year-old.
Intensification of the PPI program is accom plished by
the addition of extra immunization rounds, adding a
house-to-house "search and vaccinate"
 Treatment
• Guidelines by AMERICAN PHYSICAL THERAPY ASSOCIATION –
General Strengthening Exercise Guidelines
• Exercise should not cause muscle soreness or pain
• Exercise should not lead to fatigue that prevents
participation in other activities that day or the days following
• Strengthening exercises should only be attempted with
muscles that move through their full range of motion
• Minimal to moderate intensity exercise is generally
recommended
• Progression of exercise is slow especially in those muscles
that have not been exercised for a period of time or have
chronic weakness from the initial polio virus
• Aerobic Exercise
• Aerobic exercise is recommended for most individuals with
Post Polio Syndrome except when there are complaints of
overwhelming fatigue. It is important to find the best type of
activity to safely achieve a cardiovascular benefit.
• Duration:
 Aerobic activity is recommended 3-4 times per week
building up to a total of 30 minutes each session.
• Mode of exercise:
 Walking over ground or on a treadmill may be
recommended for individuals who do not have symptoms of
leg weakness or pain.
 An upper body ergometer (UBE) or arm bike may be
recommended when the arms are strong but there are
symptoms of leg weakness.
 A stationary bike may be recommended when arm
weakness is the primary problem, or balance problems
limit safe walking
•  Intensity:
 Light to moderate intensity
• Aquatic exercises – Water exercises in a warm pool
can improve pain, endurance and reports of
wellbeing.
• Water exercises are used for strengthening, flexibility
and aerobic exercise.
• People with PPS must use caution in the pool to
avoid overuse and fatigue. Water can make the limbs
and trunk feel weightless but it can also
• Stretching
• Flexibility is important for improving muscle length
and joint range of motion for daily activities such as
reaching and walking.
• Stretching exercises can help to:
 Manage pain
 Improve flexibility
 Reduce risk of osteoporosis
 Reduce risk of falls
 Treatment

• TREATMENT  Stage of onset: It is generally not possible to diagnose

polio at this stage.
•  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.
 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.
• 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
• 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
• 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.
• Hamstring (knee flexors) transfer to the quadriceps
muscle to support a weak knee extensor.
• 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.
 POST –OP : PT management
[Link] release of the soft tissue contractures,
measures should be taken to avoid recurrence of
contracture.
[Link] tendon transplants, the emphasis should
be on re-education of the transplanted muscle to its
new role.
[Link] the joint arthrodesis, the emphasis should
be on educating the functional use of the limb in
which the joint is arthrodesed.
• 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.
• 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.
Three levels of prevention
• Prevention interventions can be at one of three levels.
• Primary prevention – Primary prevention is directed at avoidance
and uses interventions that prevent health conditions from occurring.
These interventions are mainly aimed at people (e.g. changing health
behaviours, immunization, nutrition) and the environments in which
they live (safe water supplies, sanitation, good living and working
conditions). Primary prevention is equally important for people with
and without disabilities and is the main focus of this element.
• Secondary prevention is the early detection and early treatment
of health conditions, with the aim of curing or lessening their
impacts. Examples of early detection include mammograms to
detect breast cancer and eye examinations to detect cataracts;
Secondary prevention strategies for people both with and without
disabilities are discussed in the Medical care element below.
• Tertiary prevention aims to limit or reverse the impact of already
existing health conditions and impairments; it includes
rehabilitation services and interventions that aim to prevent
activity limitations and to promote independence, participation and
inclusion. Tertiary prevention strategies are discussed in the
elements on Rehabilitation and Assistive devices.
 Polio Eradication Efforts in India

• India committed to resolution passed by World Health Assembly

for global polio eradication in 1988.
• National Immunization Day (NID) commonly known as Pulse
Polio Immunization programme was launched in India in 1995,
and is conducted twice in early part of each year.
• Additionally multiple rounds (at least two) of sub national
immunization day (SNID) have been conducted over the years in
high risk states/areas. In these campaigns, children in the age
group of 0-5 years are administered polio drops.