Transcript Poliomyelitis

POLIOMYELITIES
Copyright 2005 Lippincott Williams & Wilkins
POLIOMYELITIES
Definition: Acute viral infection of motor nuclei of
CNS mainly
motor nuclei of anterior horn cell of spinal cord and motor nuclei of
the cranial nerve leading to lower motor neuron lesion (LMNL) of
flaccid paralysis with normal sensation.
Poliomyelitis, often called polio or infantile paralysis, is an acute
viral infectious disease spread from person to person, primarily via
the fecal-oral route.The term derives from the Greek poliós (πολιός),
meaning "grey", myelós (µυελός), referring to the "spinal cord", and
the suffix -itis, which denotes inflammation.
Types of Polio virus:
1- Brunhilde
2-Lansing
3- Lean
infection of one virus give immunity to this type only
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Types of Vaccination:
1- Sabine:
Attenuated live polio virus Anticipated intramuscular
Dose------- 2,4,6 month poster dose 18 month
preschool age 4 years
Advantage : Complete immunity with in 3 days
2- Salk:
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Killed virus attenuated oral or not supported by intestinal tract
Advantages: effective, safe
Dose: 2,4,6 month, 4 years
Disadvantages: need repeated injection, delay in immunity takes 3 weeks
to response & incomplete immunity
Stages:
1- Acute Stage;
The first 2 Weeks
• Viral infection (vomiting, headache at the end of acute stage then
paralysis appear in respiratory muscle and extremity)
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2- Recovery Stage; From 2 weeks to 2 Years
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Called stage of functional recovery because:
• 1- Subside to edema
• 2- Improved neural plasticity
• 3- Hypertrophy of non affected muscle
Character paralysis:
• 1- LMNL
2- Flaccid
• 3- massive (affected more than one group)
• 4- Asymmetrical lesion
• 5- Patchy distribution
After 2 years recovery cannot occur because:
• 1- New formation of new motor end plate
• 2- Orientation of the axon is parallel to muscle
Chronic Stage: After 3 years
a- Muscle skletal deformity : Muscle weakness------contracture……Deformity
b- Respiratory affection:
 Affection in respiratory center in medulla lead to irregular breathing
 Affection in Spinal cord or nerves of respiration ------- respiratory muscles
become weak
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Approximately 90% of polio infections cause no symptoms at
all, affected individuals can exhibit a range of symptoms if
the virus enters the blood stream.
1% of cases the virus enters the central nervous system, and
destroying motor neurons, leading to muscle weakness and
acute flaccid paralysis. Different types of paralysis may
occur, depending on the nerves involved.
Spinal polio is the most common form, characterized by
asymmetric paralysis that most often involves the legs.
Bulbar polio leads to weakness of muscles innervated by
cranial nerves. Bulbospinal polio is a combination of bulbar
and spinal paralysis
Copyright 2005 Lippincott Williams & Wilkins
Classification of poliomyelitis:
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The term poliomyelitis is used to identify the disease caused by any of
the three serotypes of poliovirus. Two basic patterns of polio infection
are described:
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Minor illness which does not involve the central nervous system
(CNS), sometimes called abortive poliomyelitis.
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Major illness involving the CNS, which may be paralytic or nonparalytic
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In most people with a normal immune system, a poliovirus infection is
asymptomatic. Rarely the infection produces minor symptoms; these
may include upper respiratory tract infection (sore throat and fever),
gastrointestinal disturbances (nausea, vomiting, abdominal pain,
constipation or, rarely, diarrhea), and influenza-like illness.
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The virus enters the central nervous system in about 3% of infections. Most patients with
CNS involvement develop non-paralytic aseptic meningitis, with symptoms of headache,
neck, back, abdominal and extremity pain, fever, vomiting and irritability.
Approximately 1 in 1000 cases progress to paralytic disease, in which the muscles become
weak, floppy and poorly controlled, and finally completely paralyzed; this condition is known
as acute flaccid paralysis Depending on the site of paralysis, paralytic poliomyelitis is
classified as spinal, bulbar, or bulbospinal
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Transmission
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Poliomyelitis is highly contagious via the oral-oral (oropharyngeal source) and fecal-oral
(intestinal source) routes . It is seasonal in temperate climates, with peak transmission
occurring in summer and autumn.
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Risk Factors of polio include:
immune deficiency, malnutrition, tonsillectomy, physical activity immediately following the
onset of paralysis, skeletal muscle injury due to injection of vaccines or therapeutic
agents, and pregnancy.
Although the virus can cross the placenta during pregnancy, the fetus does not appear to
be affected by either maternal infection or polio vaccination.[Maternal antibodies also
cross the placenta, providing passive immunity that protects the infant from polio infection
during the first few months of life.
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Physical Therapy Evaluation:
1- History:
Personal History
Past History
Present History
History of vaccination
2- Informal evaluation;
A- Look to the child while entering the treatment room (if mother carrying him or not,
walk alone, gait and type of brace
B- On the plinth, general conditions of the child(anemic , healthy)
C- Observe the chest from the anterior view(rate, pattern of breathing: shallow, irregular
D- Positions of the limb and leg length discrepancy
E- Skin condition(ulcer due to brace , scar due to tendon release
F-Spontaneous motility
G- Deformities:#
Acute Stage : Muscle imbalance , prolonged bed rest, inadequate P.T,
Shortening, Contracture Weight bearing on weak joints
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Chronic Stage: Deformities like:
Lower Limb : Hip---- Flexion, abduction, external rotation
Knee: Flexion deformity, genu valgus, genu varum, Genu
Recurvatum due to Ms imbalance between quadriceps and hamstring Ms
Ankle: equines deformity(plantar flexion), calcenous deformity(dorsiflexion)
Varus deformity(inversion), valgus deformity(eversion)
Talipus equino varus, Talipus equino valgus
Talipus calcenus varus, Talipus calcenus valgus
Quick Test :
Crock lying position to detect leg discrepancy:
If end of femur is forward --------- shortening of tibia
If end of femur upward------------ shortening of femur
Postural Fixation ; raise limb upward let it drop
Sudden drop limb ---------- hypotonia
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3- Formal Evaluation;
Muscle Tone
Flexibility test
Muscle Test
ROM
Measurement
Postural assessment
Gait Analysis
A- Muscle tone:
By Observation: Supine----- Flaccid paralysis of limb due to hypotonia---------Frog like
position(Abd, Ext Rotation hip, Plantar flex ankle).
Passive Movement Don’t forget to support distal part
Postural fixation raise limb then sudden drop : polio ----sudden Drop
B- Flexibility Test: To test tightness of tendoachilis :
Supine lying with hip and knee flexion
Grasp : Thumb on sole of foot , Index on shaft of tibia, 4 fingers cubing on the heel
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From flexion knee make dorsiflexion ankle---------tightness of soleus
From extension knee make dorsiflexion ankle- Tightness in Gastrocniemus
Muscle Test:
Above 3 Years------------------ MMs Test
Below 3 years----------------Functional Ms test
Zero---------- No Contraction
Sub functional-----------Not complete ROM
Functional ------------------- complete ROM
Methods:
a- Unfavorable position: Prone lying will facilitate neck trunk extension and by this
way you can test neck and back Ms
Half prone for testing hip and knee flexors
b- Reflexes according to age :
Positive supporting to test extensor of lower limb and plantar flexors
C- Toys put toy in direction that can facilitate movement
d- spontaneous motility: uncontrolled movements
e- Tactile stimulation( Scratching, Squeezing, tapping)
Hip:Tactile Stimulation of hip flexors
(iliopsoas): supine lying
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Grasp: Thumb on the sole of the foot, Index on shaft of tibia - 4 fingers cubing heel of the
foot
Scratch: on inguinal ligament by followed passive movement until you feel that child can
perform it actively
Gluteus Maximus: Half Prone lying with untested limb between my leg, Tested limb kept
in flexion to isolate hamstring
Scratch on Gluteus Maximus followed by passive hip extension,
or painful stimulus on ant aspect of thigh above just knee
Hip Adductors: Supine lying: Grasp One hand cubing heel of the foot other hand Scratch
medial aspect of thigh followed by passive hip adduction by the hand which cup heel
or painful stimulus on the greater trochanter
Knee: Tactile Stimulation: Knee flexors
Position : prone lying Knee slight flexion(10-15) to isolate gastrocnemius
Scratch by the hand which support pelvis on the back of the knee
Other hand which cup heel make passive knee flexion
Painful Stimuli on the ant aspect of distal part of tibia
To isolate biceps femoris put tested knee slight flexion with Ext Rotation
To isolate Semitendinosus put tested knee slight flexion with Med Rotation
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Knee extensors (Quadriceps):
Position : Supine lying tested limb in hip and Knee slight flexion Grasp :
thumb above knee , index on lateral aspect of thigh, middle two fingers below
knee from back for supporting, little finger to initate movement
Scratch by the hand which support pelvis on the Pelly of the muscle
Other hand which cup heel make passive knee flexion
Painful Stimuli on the post aspect of calcaneus
Ankle: Tibilais anterior
Tibilais posterior
Pronei(longus, brevis, tertus) in these 3 muscles must put knee in
slight flexion(10-15) :
1-To isolate gastrocnemius
2- to prevent damage of collateral ligaments of knee
3- To prevent compression of post aspect of knee
Tactile stimulation to Tibilais anterior:
Position: supine lying with flexion knee , Thumb flex toes to isolate flexor hallicus, and
digitorium , Index on ant aspect and medial of foot to maintain full inversion and plantar
flexion, Middle finger palpat tendon of tibialis anterior, Ring and little finger on heel to
perform passive dorsi flexion, Painful stimulus : On the sole of the foot
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• Tibialis Posterior: Mainly inversion & assist in
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planter flexion
Grasp: one hand catch lower end of tibia and other hand hold foot from
ankle
Scratch: on medial malleoli by little finger
Peroneus longus---------eversion +plantar flexion Tendon Below Lat
Malleoli
Peroneus brevis--------eversion +mid position of ankle Tendon Below Lat
Malleoli
Peroneus Tartius -------eversion +dorsi flexion Tendon above Lat
Malleoli Painful stimulus on the medial aspect of foot
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