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University of Sharjah
College of Health Science
Physiotherapy Department

Instructor: Dr. Fatma Hegazy

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Poliomyelitis
It is an acute (sudden onset) viral infection that invades the motor
neurons of the CNS especially of those of the spinal cord (anterior horn
cells) of the (lower motor neuron). There will be motor deficits but no
sensory loss because posterior horn cells are not attacked.

Causes: common Polio virus:

Type 1: Brunhild
Type 2: Lancing
Type 3: Leon

N.B: these viruses are transmitted by ingestion of food and water (i.e.
via digestive system).

Vaccination:
There are 2 types of vaccination used for poliomyelitis:

Salk: (TYPE I)
 The vaccine contains killed virus to stimulate the immune system
for strange body.
 Causes fast response by the body.
 Its effect does not extend for a long time.
 Given intravenously.

Sabin: (TYPE II)

 Contains virus that is weakened but not dead completely.
 When given to the child it will not cause poliomyelitis because it is
not strong enough.
 Slower response by the body.
 Its effect extends for a long time.
 Given by oral drops.

N.B: Vaccination for poliomyelitis should contain either killed or

weakened types of all viruses.

Vaccination Times:
Vaccination is given each 2 month/4 month/6 month/1.5 year.
Pre-school dose (at about 4 years).
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Pathology of poliomyelitis:

 The virus attacks only the anterior horn cells and not posterior
horn cells.
 If the body has antibodies for the virus (mainly from vaccine), the
body’s immune system will be ready to overcome any attack by the
virus.
 If the body has no antibodies that work against the polio virus, the
anterior horn cells will be attacked by it.
 Poliomyelitis is a patchy disease meaning that it does not have a
classic shape. It can affect any number or level of AHC or cranial
motor nuclei. Also, it may affect one muscle or it may affect group
of muscles.
 Commonly lower limbs will be affected more that upper limbs.
 If limbs are bilaterally affected there will be asymmetrical effect.

The child will go into stages of the diseases:

1- Acute stage
2- Convalescent stage (Stage of recovery).
3- Chronic stage. (Stage of residual disability).

Acute stage:
 The acute stage is flu-like attack accompanied by joint pain, fever,
malaise, muscle pain & cramps.
 It takes a maximum of (2-4 weeks).

Convalescent stage (stage of recovery):

It starts after acute stage until (18 months – 2 years).

What are the causes of recovery in this stage?

I. Neuroplasticity: Meaning that the CNS HAS THE ABILITY TO

COMPENSATE ANY LESION THAT OCCURS IN IT by the
following theories:
1. There are some nervous cells in the body with unknown
function that may take function of damaged nervous cells.
2. There is cells of known function can take extra function of
these damaged cells.
3. Axonal sprouting theory:
Normally, nerve impulses are transmitted from nerve cell 1 to
2 to 3. If nerve 2 is damaged, cell 3 will be orphan (because
cell 2 is damaged). So, according to neuroplasticity (axonal
sprouting theory), cell 3 will release certain chemicals that
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stimulate arborization of dendrites of cell 1 and will facilitate
transmission of nerve impulses to cell 3.

1 2 3

Damaged cell Orphan cell

II. Relief of inflammation and edema:

Destruction of the nerve cells causes inflammation that result in
edema of the neighboring cells. This edema compresses the
neighboring cells and doesn't damage them but leads to
physiological block in which the neighboring cells will not be able
to perform their function due to edema. So when inflammation
resolves, the edema will decrease and the neighboring cells will be
able to perform their functions.
For example, you can observe some movement occurring in recovery
stage.

Chronic stage:
Stage of residual disability. (after 2 years)

Features of poliomyelitis:

o Muscles (lower motor neuron lesion flaccid paralysis):

o Weakness
o Hypotonia
o Hyporeflexia
o After sometimes disused atrophy
The most common muscles affected in poliomyelitis are
quadriceps and tibialis anterior.

o Bones:
o Rate of bone growth decrease. Bone lengthening is
stimulated mainly by muscle pull. The limb in poliomyelitis
patient is relatively short.

o Decrease in the bone thickness. Bone thickening is

stimulated mainly by weight bearing.

o Joints:
Muscle imbalance leads to contractures causing further deformities.
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o Skin:
There will be skin changes due to paralysis that cause stasis of blood
circulation especially in cold weather and gravity effect.

o Respiration:
Respiration is affected in 2 ways:
1- Primary effect: when intercostal muscles are paralyzed at spinal
level.
2- Secondary effect: If during poliomyelitis the child walks with hand
to knee gait or any abnormal gait pattern this will lead to scoliosis or
kyphosis, which adversely affect respiratory functions.

o Bulbar:
o Anterior horn cells in spinal cord are equivalent to motor
nuclei of cranial nerves of the brainstem.
o In poliomyelitis, the polio virus may invade the motor nuclei
of 9-10-11-12th cranial nerves that are located in medulla
oblongata.
o Speech & swallowing may be affected in bulbar palsy (rare).

Physiotherapy examination
History taking
Personal history

 Present history: onset, course, duration.

 Chief complain: usually taken from the mother.

 Past history: any disease that the child have but not related to
polio. Also date of vaccination is taken from the mother because
if the vaccine is expired it will not be effective or the child may
have taken it and vomited it.

 Development history: indicate what the child is able to do and

what he/she is not able to do according to his/her chronological
age.
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Physical examination

Subjective Observation:
 Observation of the child as whole (general over view).
 Observe respiratory rate.
 Observe: deformities, shortening, leg and arm length
discrepancy
 Wasting and atrophy (texture)
 Skin condition (color of skin).
 Observe if there is any wound or scar (Observe weather the scar
is regular or irregular).
 If the scar is regular indicate that surgery performed due to
tendon release. If irregular it indicates old wound.

Objective:

1- Muscle tone assessment:

In polio the child has hypotonia which can be observed by passive
movement while the child is completely relaxed as possible.
o Hypotonia may be mild, moderate, or severe.
o Remember that ashworth scale is only used for measuring
spasticity and not general muscle tone.

2- ROM assessment: we use goniometer if child is above 3 years.

 With goniometry assesses both AROM & PROM
Why we need to assess both AROM & PROM?
 If PROM is greater than AROM this indicates muscle
weakness.
But if AROM and PROM are equal but less than normal its
indication depends on the end feel:
o Rebound end feel: indicate soft tissue contracture.
o Hard end feel: indicate joint block.

3- Assess soft tissue tightness: for UL & LL

Assess tightness of LL muscles:
 Hamstring muscles
 Rectus femoris : Thomas test
 Iliotibial band: Ober & Thomas test
 Calf ( gastrocnemius & solius)
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Assess tightness of upper limb muscles:
 For example: biceps brachi

N.B If the child cries or express pain during the test, it indicates that
he/she has tightness

There are 3 degrees of tightness:

 Mild tightness
 Moderate tightness
 Severe tightness

Tightness commonly occurs in

 biceps
 iliopsoas
 hamstring
 calf muscles

4- Hip dislocation tests as a routine presence of hypotonic or

ligamentous laxity. Three tests are commonly used:
For Infants:
 Ortolani Test: abduct both hip joints.
o Positive sign: Limited abduction of affected hip joint.
 Barlaw Test: hold greater and lesser trochanter, slide for joint
play.
o Positive sign: can palpate or hear a click / joint play can
be excessive.
Any age:
 Piston’s (telescoping test): flex the hip & knee joints to 90o then
distract.
o Positive sign: can palpate or hear click.

5- Muscle test in pediatrics:

If the child is older than 3 years, we can do normal muscle
test like adult..
But if the child is under 3 years old, do the following:
 Observe the child spontaneous movement
 Put the child in uncomfortable position (like prone-lying,
prone-falling).
 Repeated passive movement
 Use developmental reflexes (according to child age). Can
use tactile stimulation.
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 Motivate using toys, games…etc.

6- Limb Length Measurements:

 Measure the limb length to determine if there is any
discrepancy. Measurement can be whole or segmental.
 Limb girth measurement to determine any atrophy.
N.B. commonly, the UL & LL are asymmetric in polio.

7- Assessment of posture:
Child with polio can have scoliosis, or kyphosis or kypho-
scoliosis.
These deformities occur due to:
1- Muscle imbalance.
2. Hand to knee gait (the child locks the knee by pushing it by
his hand due to weakness of quadriceps muscles).
3- LLD (LEG LENGTH DISCPRANCY).

8- Assessment of respiration:
 Chest Expansion test by tape measurement
 Can use respirometer

9- Gait assessment: kinematics and kinetic

10- Cranial nerves assessment
11- Deep tendon reflexes
12- Sensory assessment

What are the common deformities seen in

poliomyelitis?

These are common deformities that occur for a child with

poliomyelitis:

 LLD
 Kypho-scoliosis
 Genu-recurvarum: is hyperextension of the knee due to
hypotonia and ligament laxity .
 Genu varus
 Genu valgus
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 Drop foot
 Equines deformity: mostly due to tightness of calf muscles.
 Talipes equino varus (club foot): deformity in the hind foot
 Coax vara
 Coax valgus
 Elbow flexion deformity
 Claw hand
 Drop wrist

What causes these deformities in poliomyelitis?

 Muscle weakness & muscle imbalance
 Muscle contracture
 Ligament laxity
 Leg length discrepancy: that leads to faulty posture and spinal
deformity
 Incorrect posture
 Weight bearing on the weak joints
 Effects of gravity.

Deformity grading:
 Corrected actively (Grade 1)
 Corrected passively (Grade 2)
 Cannot be corrected actively or passively / fixed or structural
deformity (Grade 3)

Physiotherapy treatment of poliomyelitis:

Aims of each stage:

Acute Stage Recovery Stage Chronic Stage
- Rest - Walk with normal pattern - Allow substitution pattern
- Good positioning: to - Increase muscle strength - Prevent and correct deformities
prevent contracture - Increase respiratory vital - Improve sleep capacity
- Respiratory care capacity - Use assistive devices (brace,
- Circulatory exercises - Stretch tight muscles and crutch, ex…)
Regain muscle flexibility
- Don’t allow substitution
pattern
- Prevent deformities
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Treatment

Heat: to improve circulation

Facilitation for motor development: if there is any delay due to
paralysis. (muscle weakness)
Facilitation of active movement:
(Active graduated exercise): active, active assistive, active free.

Electrotherapy: like Faradic stimulation

TVR (tendon vibration reflex): which is specialized vibrator has high

frequency is higher than 100 HZ/seconds. It is applied on the
musculotendinous junction & causes continuous contraction.

Tactile Stimulation:
 Brief icing as facilitator but prolonged icing as inhibitor for
muscle tone.
 Joint compression (approximation): jerky, irregular, fast.
 Tapping, squeezing, brushing, tactile stimulation techniques.

Vestibular stimulation (like use ball, balance board to stimulate

balance and modulation for muscle tone).

Quick stretch used as facilitatory technique but prolongs starch as

inhibitory technique

Hydrotherapy

Biofeedback: like use of mirror and EMG (age more than 6 years old).

PNF technique: for child older than 3 years.

Stretching for tightened muscle

Splinting / orthosis: in polio splint mostly used at night but brace used
during walking.

Respiratory exercise
Postural correction
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Gait training: will be progressed from a closed to open environment
depending on the extend of problems present.
 Close:
Parallel bars and stepper. Will be initiated with free walking, then
obstacles of same height, then obstacles of different heights.
 Open:
Outside parallel bars. Use walkers, crutches, cane, free movement.

Muscle re-education: re-educate the new transferred muscle for the

new action. Using:
 Faradic stimulation.
 TVR 80-120 Hz.
 Repeated passive movements.

Post-polio syndrome
 The signs of polio will appear again after many years.
 The pathology itself is not clear but there are many theories
defining it.
 Not all patients with polio are exposed to post polio syndrome.
 Late sign and symptoms of polio occur many years after the
initial illness.

Clinical picture of Post-polio syndrome:

 Muscle weakness
 Easily fatigue
 Pain
 Sleep apnea
 Bulbar symptoms (it can be fatal)
 Respiratory problem (it can be fatal): because immunity in
adults is less compared to childhood.

N.B. Post -polio syndrome occurs from 30 to 40years, or more

after initial contact

Precipitating factor:
 Overuse (exhausting)
 Repeated minor trauma
 Weight gain
 Prolonged rest

Precautions during exercise patient with post-polio:

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 Give rest in between exercises.
 No resistance given with high repetitions.
 No exercise to fatigue point.
 No increase in intensity of exercise.