EISHNA SHARMA

ROLL NO. 3
B.Ph.T-final prof.
 •Poliomyelitis commonly
called as polio is an endemic
and epidemic infectious viral
disease caused by polio
virus.
•Poliomyelitis is derived
from Greek word
•Polio meaning “grey”
•Myelon means “spinal cord”
•itis denotes inflammation
 oThis is a viral
infection of the
anterior horn cell of
the spinal cord or
nerve cells of the brain
stem, resulting in
temporary and
permanent paralysis.

oThere is flaccid
paralysis without a
sensory loss.
When the polio vaccine was not
introduced, poliomyelitis was
found in all countries. But with
the invention and use of polio
vaccine there is total eradication
of disease from many developed
countries.
In India ,in 2003-225 cases
reported
2018-33 cases
National immunization
programme is carried out by govt.
of India to eradicate polio.
Under this, all the children under
the age of 5 years are
administrated with oral polio
vaccine(OPV),free of cost.
VIROLOGY: The polio virus is
a spherical virus of 25-27 microns
in diameter.
In a cold environment, it can live
in water for 4 months and in feces
for 6 months.
Poliovirus has three serotypes:
TYPE I- BRUNHILDE
TYPE II-LANSING
TYPE III-LEON
PERIOD OF COMMUNICABILITY: 7-10 days before and after
onset of symptoms.
AGE OF ONSET: It is a disease of infancy and childhood .
common in children less than 5 years of age
SEX AFFECTED MOST : MALE : FEMALE ratio = 3 : 1
ENVIRONMENTAL FACTORS: likely to occur during rainy
season.
Sources: contaminated water, food and flies
Overcrowding and poor sanitation.
RISK FACTORS: -immune deficiency
Malnutrition
Tonsillectomy
Physical activity immediately following the onset of paralysis.
Skeletal muscle injury due to i.m. injection or in child on
cortisone therapy.
INCUBATION PERIOD:- 7-14 DAYS
 FECAL-ORAL ROUTE: DROPLET INFECTION:
(main route) (Usually occurs in the
Infection may spread acute phase of disease)
directly through Virus is present in the
contaminated fingers throat.
where the hygiene is poor Close personal contact
or indirectly through with infected person may
contaminated water, food, facilitate droplet spread.
flies etc…
 ACUTE PHASE CONVALESCENT OR CHRONIC OR
(0-2 or 3 weeks) RECOVERY PHASE RESIDUAL PHASE
Child is restless and (3 weeks -12months) (12-18 months)
irritable due to pain and follows the acute phase no hope of recovery.
muscle tenderness where the damage to the Damage to ant. Horn
together with spasm, neurons is less resulting cells of spinal cord or
joints are also involved. either in spontaneous brain stem leading to
General malaise, recovery (upto 5 weeks) of paralysis ranging from
headache and bowel upset the affected muscle or minimal degree to
may be present with low cause various degree of complete paralysis.
grade fever and sore paralysis. Bones and joints are
throat. The rate of recovery slows affected due to long term
Involvement of brain is down, and hardly of contractures.
little or absent. continues beyond 6-12 Paralysis may lead to
months. imbalance and deformities
 INAPPARENT OR SUBCLINICAL INFECTION
Seen in 95% cases of polio infection
Recovery is fast and there is no such presenting symptoms.
Recognition is only by virus isolation.
ABORTIVE POLIO OR MINOR ILLNESS
Seen in 4-8% of polio infection
Causes self -limiting illness and recovers fast.
Minor symptoms include: - sore throat
-malaise
-headache
-GIT upset(diarrhea)
-low grade fever
-muscle pain and tenderness
 NON-PARALYTIC POLIO
Occurs in 2-3% cases of polio.
The damaged neurons undergo
regeneration and the recovery occurs.
The symptoms include:
-stiffness and pain in neck and back.
-high grade fever
-malaise
-nausea
-vomiting
-muscle weakness
-upper respiratory tract infection
-joint pain
-diarrhea or constipation
-excessive tiredness and fatigue
 PARALYTIC POLIOMYELITIS
Seen in less than 1% cases.
The signs and symptoms vary acc. To the duration and severity of
damage. It includes:
-asymmetrical flaccid paralysis is the prominent sign at this phase of
the disease.
-onset is associated with fever.
-meningeal irritation i.e. stiffness of neck and back muscles
-Tripod sign is the peculiar feature of polio i.e. the child finds difficulty
in sitting and sits by supporting hands at the back and by partially
flexing the hips and knees.
-descending type of paralysis.
-deep tendon reflexes are lost but sensation is intact.
-In severe cases, there is involvement of cranial nerves leading to bulbar
and bulbospinal form of paralysis. In this type of paralysis, there is facial
asymmetry, difficulty in swallowing, resp. insufficiency.
-leads to the weakness of muscles innervated --difficulty in breathing, speaking and
by the dead neurons. swallowing
-muscle atrophy occurs. -facial weakness
-muscle becomes weak, floppy and poorly -abnormal resp. rate, depth and rhythm
controllable and finally paralyzed.
-fever and muscle pain.
-deep tendon reflexes-absent or diminished
-sensation is intact.
-asymmetrical paralysis
 19% CASES

Also called as respiratory polio

Virus affects upper part of cervical spinal cord(c3 through

c5), and paralysis of diaphragm occurs.

Patient is on ventilator support.

It can lead to paralysis of the arms and legs and may also
effect swallowing and heart function.

Facial weakness
 IN THE EARLY STAGE
The child is febrile, with rigidity of the neck and tender
muscles; there is diffuse muscle paralysis.
Involvement of affected muscle is asymmetrical.
It occurs commonly in lower limbs because the anterior
Horn cells of the lumbar enlargement of the spinal cord are
affected often.
Muscles affected are: quadriceps, although in some cases it
is partially paralyzed
Tibialis anterior: complete paralysis
Opponens pollicis
If motor neurons of medulla are affected, it results in
bulbospinal polio which is life-threatening polio. It involves
cardiovascular and respiratory centers and may be fatal .
Paralysis may result in wasting, weakness and deformities of limb.
The deformities result from imbalance between muscle of
opposite groups at a joint, or due to action of gravity on the
paralyzed limb.
Various deformities are:-
1. Hip is in flexion, abduction and external rotation

this is due to weakness of the extensors, adductors and internal

rotators of the hip.
EXAMINATION: THOMAS TEST-normal hip is flexed, there is
flexion of the affected hip in adduction position rather than in
abduction.
Normal hip is flexed, there is flexion of the affected
hip in adduction position rather than in abduction.
 1.Valgus deformity is due to
paralysis of semitendinosus and
semimembranosus.
2. Genu recurvatum is due to
lateral rotation of tibia on femur
and the lateral subluxation of
knee.
EXAMINATION: FLEXION
DEFORMITY:
By extending hip fully
For valgus deformity: measure the
q angle. Q angle is formed by ASIS,
centre of patella and tibial tuberosity.
It is reduced in this deformity.
Normal angle in men=14 degrees
Women_17 degrees
 1.VIRAL ISOLATION: poliovirus may be recovered from the
stool or pharynx of a person.
Isolation of virus from CSF is diagnostic
2.SEROLOGY
3.CEREBROSPINAL FLUID(CSF): contains increase no. of
wbc’s (10-200 cells/mm3 ) primarily lymphocytes, and a mildly
elevated protein from 40-50mg/100ml
PROGNOSIS
 -Out of total cases
--50% do not develop paralysis
--40% develop varying degree of paralysis
--10% die of respiratory muscle paralysis.
-Max. spontaneous recovery: 3rd, 4th and 5th
week after onset.
-Recovery becomes slow from 6-10th
months and by 12th months total possible
recovery is attained.
 CEREBRAL PALSY of floppy type
Overactive knee jerk and abnormal reflexes,
developmental delay and some muscle
tenseness(spasticity).

MUSCULAR DYSTROPHY: paralysis begin slowly

HIP PROBLEMS can cause limping and muscle may
become thin and weak.
 CLUBBED FOOT is present from birth
ERB’S PALSY or partial paralysis in one arm and hand ,
comes from birth injury to shoulders.
LEPROSY : foot and hand paralysis begin gradually in
older child . there are skin patches and loss of sensation .
SPINA BIFIDA is present from birth, there is reduced
sensation in feet and often a lump on the back and
bilaterally symmetrical paralysis of muscles.
INJURIES TO THE SPINAL CORD or nerves going into arm
or legs.
TUBERCULOSIS OF THE SPINE typical hump on spine is
present.
GUILLAIN-BARRE SYNDROME: begins without warning in
the legs and may spread within a few days to paralyze the
whole body.
 “PREVENTION IS BETTER THAN CURE”
PREVENTIVE TREATMENT: immunization is the sole
effective means of preventing poliomyelitis.
•Complete rest and relaxation to body as well as
nervous system in non-paralytic polio.
•Analgesics- paracetamol , acetaminophen for
pain relief.
•Splints are used to prevent contractures in case
of paralysis
•Calipers are used to improve gait.
•If the condition is very serious and the deformity
is not corrected by splintage, then surgery is to be
done.
 •TENDON TRANSPLANTATION: Tendon is transferred
from one site to another site in order to redistribute the
available muscle power or to equalize an unbalanced
paralysis.
•RELEASE OF CONTRACTURE: the soft tissue is released in
order to correct the deformity by soft tissue contracture
Such as:-Soutter’s release ( hip)
-Ober-yount’s procedure (iliotibal band)
-steindler’s release(for cavus foot)
-Tendo-achillis
•ARTHRODESIS: The articular cartilage along with the
underlying bone is resected and then fusion of the joint is
done.
•TRIPLE ARTHRODESIS is the bony stabilization for
paralytic foot. It is performed after 13 years of age. In
this the subtalar, talonavicular and calcaneocuboid
joints are fused.

•RESECTION: It includes bone resection within the joints

and wedge resection of bone outside the joint without
excising articular cartilage.
 •TENDON LENGTHENING: It is done by either
•Z-PLASTY
•FRACTIONAL LENGTHENING

•OSTEOTOMY: Bone is cut down and realigned in order to

correct the normal alignment of the body.
 LOCAL EXAMINATION:
It includes:
-Examination of any local deformity present
-Any contracture formation
-Presence of any wound
-Dislocation of particular joint
-Position of shoulder, ASIS, knee, foot and spine
-PALPATION:
•Examination of ant tenderness present
•Check local temperature
•Any swelling if present.
 MOTOR EXAMINATION:
MANUAL MUSCLE TESTING (MMT)
It is the way of testing the muscle strength and is graded into
0-5 grades:

Testing of an individual muscles of upper and lower limb

should be done on both the sides.
 RANGE OF MOTION(ROM)
This can be tested with the help of goniometer. It helps in
evaluating the amount of deformity present by measuring the
angles created by human joints.
Angles of both affected and non affected sides should be
measured.
NORMAL RANGE OF VARIOUS JOINTS:
UPPER EXTREMITY
SHOULDER:
FLEXION=0-180 DEGREES
EXTENSION=0-60DEGREES
ABDUCTION=0-180DEGREES
ADDUCTION=180-0DEGREES
INTERNAL ROTATION=0-90DEGREES
EXTERNAL ROTATION=0-90DEGREES
ELBOW AND FOREARM
FLEXION=0-150DEGREES
EXTENSION=150-0DEGREES
PRONATION=0-80DEGREES
SUPINATION=0-80DEGREES
 WRIST
FLEXION=0-60DEGREES
EXTENSION=0-60DEGREES
RADIAL DEVIATION=0-20DEGREES
ULNAR DEVIATION=0-20DEGREES
LOWER EXTREMITY
HIP
FLEXION-0-120 DEGREES
EXTENSION=0-45DEGREES
ABDUCTION=0-45DEGREES
ADDUCTION=0-20DEGREES
INTERNAL ROTATION=0-35DEGREES
EXTERNAL ROTATION=0-45DEGREES
 KNEE
FLEXION=0-120DEGREES
EXTENSION=120-0DEGREES
ANKLE AND FOOT
DORSIFLEXION=0-20DEGREES
PLANTARFLEXION=0-45DEGREES
INVERSION=0-20DEGREES
EVERSION=0-25DEGREES
EXAMINATION OF SUPERFICIAL REFLEXES
•Abdominal reflex
•Cremasteric reflex
•Anal reflex
•Plantar reflex
EXAMINATION OF DEEP TENDON REFLEXES
 SENSORY EXAMINATION
a) Temperature sensation
b) Touch sensation
c) Pressure sensation
d) Vibration sensation
POSTURAL EXAMINATION
The patient is examined in three views:
Anterior
Posterior
Lateral
GAIT EXAMINATION
Polio shows a typical pattern of gait:
1. Excessive knee extension and inadequate knee flexion
2. Excessive hip flexion during swing phase of the gait cycle.
3. Excessive plantarflexion.
 ACUTE PHASE(FIRST 3-5 WEEKS)
Early stage of disease where the paralysis had not been
developed.
Main emphasis is to get relieved from the minor symptoms
seen in the phase of disease i.e. headache, back pain,
muscular spasm, fever etc, and most important prevent
contracture formation and deformities.
This phase can be managed by:
- Full bed rest:-to provide relaxation to muscle.
-Forceful exercises are avoided as it may make the muscle
tense and tired and so recovery become slow.
-Good food:-it helps in fast recovery of the child as this will
provide strength to the patient.
 -Supportive medication:- to get relief
from headache, fever and pain.
-Positioning:- It should be comfortable
so as to avoid contractures . At first,
muscles will be painful, and the child will
not want to straighten his joints. Slowly
and gently try to straighten his arms and
legs so that the child lies in a good
position as possible. Good positioning
plays a major role in preventing
contracture formation which may lead to
various forms of deformities.
-Support:- this is done by providing firm
mattress supported by a board with back
support at the lumbar region and full
support to the paralyzed limb.
 •Hydrocollator packs:-
• Painful spastic muscles are relaxed
with the help of hydrocollator packs or
warm wet towels placed over the tender
muscles.
• This can be repeated in every 2-4 hours
in severe pain and spasm.
•Heating the tissue by this method is
both easy and comfortable.
• Such type of heating provides
superficial heating of the tissues.
•Heating increases the blood circulation
of the area and loosens the adhesion
formations, thus helps in getting relief
from spasm and provide relaxation to
the muscles.
 EXERCISES:
•To prevent contractures and deformities.

•RELAXED PASSIVE MOVEMENTS: These movements are

performed accurately and smoothly by the physiotherapist to
the existing free range and within the limits of pain.

•These movements are repeated twice a day.

•Joints are also put to full ROM in order to prevent

contracture formation.

•With the progression passive movements are stopped and

the patient is encouraged to do FREE ACTIVE EXERCISES.
PRINCIPLES

•RELAXATION

•FIXATION

•SUPPORT

•TRACTION

•RANGE

•SPEED AND
DURATION
 •To improve circulation.

•To increase rate and depth of respiration.

•To mobilize stiff joints.

•To improve ROM.

•To strengthen weak muscles.

•To improve co-ordination and balance.

•To correct deformities.

•To improve posture.

•To improve gait.

Aerobic exercises such as swimming, cycling and
active games helps in the quick recovery as the
patient enjoy doing various exercises. These
activities are important throughout the child’s
rehabilitation.
•Intramuscular injections, inoculation or any surgical
procedures should be avoided as these induce cell
vulnerability.
•REGULAR EXAMINATION OF MUSCLE POWER should
be done in order to avoid weakness of the muscle which
may further lead to paralysis.
•Bulbar or respiratory paralysis is life-threatening. In
this condition, physiotherapist uses POSTURAL
DRAINAGE to clean the airway and breathing
exercises to improve the vital capacity of lungs. It helps
to remove all secretions from the lungs and facilitate
airway clearance.
•Postural drainage therapy includes-
•PERCUSSION
•VIBRATION(only during expiration)
•SHAKING
 Breathing exercises and ventilatory training helps in the
management of acute and chronic disorders.
In bulbar paralysis, the respiratory muscles become weak
and finally paralyzes. Breathing exercises help in increase
the strength and endurance of these muscle and improves
ventilation.
Various forms of breathing exercises-
•DIAPHRAGMATIC BREATHING
•SEGMENTAL BREATHING
•GLOSSOPHARYNGEAL BREATHING
•PURSED-LIP BREATHING
•RESPIRATORY RESISTANCE TRAINING
GLOSSOPHARYNGEAL
BREATHING helps to
increase depth of
inspiration and vital
capacity of lungs.
 Pursed lip breathing is
suggestive to COPD patients
with the problem of dyspnea.
It decreases the respiratory
rate; increases tidal volume and
improved exercises intolerance.
•In the case of Dyspnea,
controlled breathing helps in
preventing the episode of
breathlessness which can be
done by pacing activities and
by becoming aware of what
activities or situation causes
dyspnea.
•Paralysis of some muscles have developed but certain fibres are
spared so, spontaneous recovery is possible.
•This phase is divided into 2 stages:
•EARLY STAGE(4-18WEEKS)
•AIM: to prevent the deformity and if occurred should be
corrected.
•To restore the strength of the spared muscles.
•POSITIONING: to avoid hip flexion contractures, patient should
sleep in prone.
•Paralyzed limbs should be well supported on pillows.
•Shoulder rolls are kept under the axilla helps to prevent
shoulder subluxation as it offers an upward pressure.
•To prevent contractures.
•To avoid shortening of limb and thus prevent the mal-alignment.
 •SUPPORT: Adequate support is important to provide
support to the patient.
1. SUPINE POSITION: one pillow under head to
prevent rolling of head and provide support
posteriorly. A small pillow under knees relieving
tension of hamstrings and ilio-femoral ligament
and give support to lumbar spine. One pillow under
elbow with arm slightly abducted at the shoulder
and elbow slightly flexed.
2. HALF -LYING: thighs fully supported and feet rest on
floor. One pillow under the head.
3.PRONE LYING: Head turned to one side. One pillow
under hip, lower abdomen to prevent hollowing of
the back and one pillow under lower leg.

4.SIDE-LYING: Body turned on one side. 1st pillow

under head. 2nd pillow under upper arm and 3rd
pillow between two legs.
 FARADIC STIMULATION:

•FREQUENCY: 50-100Hz

•It will stimulate the sensory and

motor nerves and also induces
muscle contraction.

•This current is useful in this

phase as it stimulate the
recovery of the affected muscle
and restore the function of
spared muscles.
 EXERCISES
1. PASSIVE MOVEMENTS followed by
ACTIVE ASSISTED MOVEMENTS
2. ACTIVE MOVEMENTS {maintain
muscle tone, inc. muscle power}
3. SPLINTAGE:
Above knee splint or even L splint-to
prevent knee flexion and equines
deformity.
Below knee splint- for equines
deformity.
Provided by various forms of calipers as
well.
It gives support, gradual traction to the
part, thus helps in correcting the
deformity.
 JOINT MOBILIZATION
It prevents the formation of contracture and muscle
spasms by making the joint mobile.

GRADE I and GRADE II- for pain

GRADE III and GRADE IV- to inc. ROM
 STRETCHING:
To prevent contracture and relieve already formed
contracture.
At the area of contracture,
1.Stretch the area
2.Sustain in the position
3.Release
(at least 2 times a day initially then progression to
once a day)
If tendo Achilles is weak with grade either 0 or 1 then
while stretching it out, excessive stretch should be
avoided, as there is more ant. Gliding of tibia which
could lead to calcaneal deformity. Therefore it should
be stretched only to neutral position.
IT band contractures needs full stretching normally but
in cases where there is gluteus medius weakness, full
stretching of IT band will further weaken the gluteus
medius due to excessive stretch and will lead to or
exaggerated Trendelenburg lurch.
GYM BALL EXERCISES:
Training for balance and co-ordination.
 GAIT TRAINING
•Parallel bars and mirror
gives feedback to patient.
•CRUTCHES reduce
weight bearing, gives
support where balance is
impaired and strength is
inadequate.
•WALKERS OR FRAMES
•CANE OR STICK
•WHEELCHAIR provides
support and prevent or
correct early
contractures.
HYDROTHERAPY
 -It helps in maintaining balance.
-Inc. the strength and endurance of the muscles affective
at this phase.
-It comes in the form of whirlpool(small size, local
immersion of body part and has adjustable temp.) and
Hubbard tank(large size, 8x6x4 ft. and has 26-36 degrees
temp.)
HOT PACK
-Relaxes the muscle
GRADUAL TRACTION
Peripheral and spinal joints
LUMBAR TRACTION- 25-50% of body weight
CERVICAL TRACTION-7-9% of body weight
 PNF or PROPRIOCEPTIVE NEUROMUSCULAR
FACILITATION

To evoke motor response and hence improves neuromuscular

control and function.
Develops muscle strength and endurance.
Facilitate stability, mobility, neuromuscular control and co -
ordinated movements.
 Reduces muscle spasm.
When ice is applied to the skin, it causes stimulation
to the skin which has an effect on the ant. Horn cells,
changing its state of inhibition in which a transient
reduction in tone is achieved. Once spasm is reduced,
it is very important that more long- term treatment is
given in order to sustain this condition.

SOFT TISSUE MASSAGE

It releases contracture formation and relaxes muscle.
-This is the phase of recovery which needs
adequate program of graded resistance to
the concerned muscles.
RESISTED EXERCISES: (1) Manual
resistance : resistance is applied by the
therapist in the direction opposite to the
movement.
(2)Mechanical resistance: resistance
applied by mechanical means like springs
, weights , dumbles etc…
-tricycling is best resistive exercises for
small children.
-Aerobic program: swimming, brisk
walking etc..
 -Hydrotherapy in this phase is quite effective as
exercise under water provide resistance to the action
done by the patient and thus inc. strength and
endurance of the muscle.
 Paralysis or weakness persisting after a year or 2 is
permanent.
-There is no neural recovery and the patient suffers from
varying degree of paralysis depending on the amount of
nerve damage.
TREATMENT:
-positioning of the body and limb should be proper.
-move the limb regularly
-encourage the child to do normal daily activities.
-proper and adequate support is provided by orthosis
to prevent fatigue and overstretching of the paralysed
muscles and joints.
 Cont….
-Splinting the paralysed muscles is
also necessary to avoid the effect of
imbalance and gravity on the
muscles.
-- patient should be given the
combination of stretching,
strengthening and calliperization.
 Polio patients are provided with orthosis to give
support and stability to joints.
Orthosis ia an external appliance worn to restrict or
assist the motion or transfer the load of the body to the
appliance.
Calipers are available which are mainly used by polio
patients. Calipers are used for:
-providing support and stability to paralysed limb
-give relief from pain.
-provide weight relief.
-correct the deformity of the limb.
 TYPES OF CALIPERS
It includes:
1.Foot Orthosis
2.Ankle foot orthosis(AFO)
-rigid AFO
-hinged AFO
-Posterior leaf spring AFO
-Patellar tibia bearing{PTB}-AFO
-floor reaction AFO
-conventional AFO
3. Knee ankle foot orthosis(KAFO)
-weight relieving KAFO
-Non-wt. relieving KAFO