physiotherapy management of poliomyelitis

1. PHYSIOTHERAPY
MANAGEMENT OF
POLIOMYELITIS
SAYALI GUJJEWAR
MPT II

2. QUESTIONS
o Enumerate the guidelines for the physiotherapeutic management of
poliomyelitis. (20 M)
o Discuss the role of physiotherapy in the management of Polio. (8 M)

3. ROLE OF PHYSIOTHERAPY IN THE
TREATMENT OF POLIOMYELITIS
o Active and Passive Movements of Joints:
Joints should not be forced in the first two or three weeks of illness while the muscles are
still in spasm and very tender. Within the limits of pain, however, much can be achieved in
keeping hips, ankles and other joints mobile and moving through a full range each day.
Where possible this should be done by active movements, but as many of the joints are
paralysed this may have to be done by passive movements instead.
o Posture Splinting and Support:
It is more important to prevent deformities than to treat them, and also much easier. The
correct posture of the patient in bed will often achieve much. This is frequently difficult to
maintain, and detachable supports, particularly in the form of above-knee calipers, will not
only support knees and ankles and prevent deformities, but by their weight and the fact
that they keep the knee straight, will help to prevent or correct any hip flexion deformities
as well. Spinal supports for the convalescent patient with a flail spine will help support a
back. It can not prevent a deformity, however, unless it is of the Milwaukee type from chin

4. o Post-operative Treatment:
Post-operative treatment in poliomyelitis should be directed particularly to the active and
passive movement of joints, and to getting the patient up and walking. Breathing
exercises may also be necessary postoperatively for those patients with respiratory
insufficiency.
o Simple Muscle Charting:
Physiotherapists should be able to carry out muscle charting accurately, as this will assist
the doctor in the assessment of the patient's disability.
o Teaching of Relatives and Friends of Patients:
Relatives or friends of patients can carry out many simple procedures, and should be
taught passive stretching of muscles and contracted joints, supervision of muscle re-
education, correct fitting of calipers, and assisting the patient to walk.
o Teaching Patients to Walk:
Patients who have never walked, or those who have been crawling for a long time, or who
walk badly, must he taught to walk in calipers and crutches.
o Teaching of Orthpaedic Assistants:
Ancillary staff need to be taught the simpler and more important aspects of
physiotherapy. These include simple active and passive exercises, fitting of calipers and
supports, getting patients walking and very simple muscle charting.
REFERENCE: Poliomyelitis A Guide fo r Developing Countries — including Appliances and Rehabilitation for the Disabled R. L. Huckstep

5. GUIDELINES FOR THE
PHYSIOTHERAPEUTIC
MANAGEMENT OF POLIOMYELITIS
o Be aware that exercise programs for polio patients require closer monitoring than
the normal population because there is a risk of muscle weakness and fatigue due to
excessive exercise.
o Every exercise program must be specifically tailored to the individual’s functional
status and needs.
o Exercise should not overly fatigue the patient because this may lead to an increase
in chronic fatigue levels and muscle weakness, thereby decreasing the patient’s
functional level.
o Strengthening Exercise:
Manual muscle testing must be performed before and during the exercise program to
closely monitor changes in muscle strength.
General recommendations for strengthening exercise are: low resistance, high

6. o Cardiovascular Exercise:
Excessive cardiovascular exercise has been shown to increase levels of chronic
fatigue.
However some amount of exercise is necessary for improving cardiovascular
fitness.
Therefore the correct level of exercise must be determined in order to gain
maximal cardiovascular fitness without worsening levels of chronic fatigue.
The major principles are: to exercise at a moderate (rather than maximal)
intensity, have short sessions with frequent rests and have adequate recovery
time between session days.
REFERENCE: Exercise Guidelines for People with Polio: A Guide for Physiotherapists. A Polio Services Victoria Production
Published October 2005

7. PHYSIOTHERAPY MANAGEMENT OF
POLIOMYELITIS
 MOBILISATION OF PATIENTS
o Methods of gradually mobilising the convalescent patients are illustrated in Figs.
2l(a) and (b).
o This progresses from supports in bed, to support in a chair through to exercises in
bed or a couch and then to sitting and walking.
o Mobilisation in a swimming pool, if available, is also helpful. The water in the
swimming pools should be warm and properly maintained.
o The progressive mobilisation of the paralysed patient out of bed is shown in Fig.
21(b), and this varies from a wheel-chair in the severely paralysed to a walking
machine, parallel bars and crutches and calipers in the less severely disabled.
o Some patients with weak quadriceps are capable of walking without calipers by
forcing back their knee or by supporting their knee with a hand (Fig. 21(c)). This may
be satisfactory in the patient with strong hip extensors and a moderate plantar

9.  ORTHOSIS
 Calipers
All children with weak limbs and with the possibilities of deformity should be
encouraged to wear calipers until they have at least completed their growth period,
even if they can walk without support. It is important that the caliper fits properly.
Above-Knee Caliper
1. This should extend no higher than l" below the groin on the inner side.
2. Straps should be adjusted fairly tightly and the same other criteria apply as with
fitting a below-knee caliper.
3. The knee piece must be adjusted to give the knee adequate support anteriorly, and
except in the case of genu recurvatum, the posterior knee strap should be slightly
loose.
4. A valgus knee is common and it is essential that the metal of the caliper does not
rub on the inside of the knee in these patients, especially when weight-bearing.
INDICATIONS OF ABOVE KNEE CALIPER
1. Where the quadriceps has power less than 3 (i.e., the leg cannot be held up against
gravity).
2. To prevent a possible contracture developing in a growing child, due to imbalance of
muscles.

10. o Below-Knee Caliper
1. This should allow full flexion of the knee, and the strap at the top of the caliper should be
fairly tight.
2. The sockets in clog or shoe should fit firmly and not allow too much free movement, and
there must always be a supporting ankle strap.
3. In the case of a foot which tends to go into equinus, a backstop must also be used.
INDICATION OF BELOW KNEE CALIPER
1. When the quadriceps has a power greater than 3 and yet the foot is flail and dropping or
tending to go into valgus or varus, and therefore needs support.
INDICATIONS OF ABOVE OR BELOW-KNEE CALIPER WITH BACKSTOP
1. When the tendo Achillis is tight, with a resulting tendency for an equinus deformity of the
ankle to develop.
CONTRA-INDICATIONS TO A CALIPER
1. In a patient with an uncorrected deformity unless it is of slight degree, and the caliper
designed to correct it. However, where operation must be delayed or is refused, a caliper
should be ordered, even though it would otherwise be contraindicated.
2. Where there is severe weakness of both legs and at the same time appreciable weakness of

11.  Crutches
1. Crutches should be correct both in length and in the position of the hand grip.
2. Their length should be l" less than the distance of the anterior axillary fold to the
sole of the foot.
3. The hand grip is approximately one third down the crutch from the top but may
be less.
4. In the case of weakness of the trunk or arms the top of the crutch should be well
padded to avoid pressure in the axilla and a radial nerve palsy.
INDICATIONS FOR CRUTCHES
o Bilateral calipers or a caliper on one leg associated with weakness of the opposite
leg or spine.
o Also in some patients with weakness of the hip on the side with a severely affected
lower leg.
 Plastic Knee Splint
1. A plastic knee splint is sometimes indicated in patients who have knee extensors
with power less than three and a fairly stable and serviceable foot and ankle
which does not require the support of a caliper.
2. The place of a plastic knee splint, however, is very limited as it takes longer to

13.  PREVENTION OF CONTRACTURES
 Splints
1. Splints, except for back slabs for a drop foot, are now seldom used.
2. Reliance is placed much more on daily stretching plus correct support of
paralysed limbs in bed.
 Stretching of Muscles and Joints (Fig. 22(b))
1. Joints must be stretched in the direction opposite to that of the contracture.
2. This must be carried out at least once a day by the physiotherapist and at
least three times a day by relatives.
 Flexion Contracture of the Hip (Fig. 22(b))
1. Pressure backwards should be in the upper third of the thigh, excessive
leverage should cause a fracture.
2. The opposite hip must be fully flexed to eliminate lumbar lordosis, and the
leg should be brought down in slight adduction to stretch the abductors
which are usually tight as well.
3. Lying the patient on his face in bed, with a pillow under the lower thigh is
useful, provided the patient will tolerate the position. The hips can also he
extended while the patient is in this position.

15.  Flexion Contracture of Knee (Fig. 22(b))
1. It is essential that the knee is manipulated as shown and that pressure is exerted near the
joint.
2. If this is not done fractures of the tibia or femur, slipping of the epiphyses and backward
subluxation of the tibia on the femur are liable to occur.
 Preventing a Recurrence of Contracture
1. Apart from stretching imbalanced muscles, the only way of preventing a recurrence of a
contracture is to hold a joint in an overcorrected position so that the deforming muscles
are acting at a mechanical disadvantage.
2. This is most easily achieved by fitting calipers as soon as the tender muscles will allow, (in
small children within a few days or even immediately) and leaving the calipers on for most
of the day and night in the acute and subacute stages.
 Calipers for Deformed Knees
1. This caliper for a slight flexion deformity of the knee is merely an ordinary caliper with a
loose posterior strap and a tight knee piece which may need to be padded. This type of
support, which helps correct the knee as a patient walks, can only be used to correct a
deformity of 30 degrees or less due to the difficulty of fitting.
2. A caliper for genu recurvatum has the opposite effect with a tight broad posterior strap and
the knee piece needs to be fairly loose anteriorly. In this type of support only slight tension
on the posterior strap is required as the deformity is easily correctable when the patient
ceases to stand.

16.  Manipulation of Ankle and Foot Deformities (Fig. 22(d))
1. The most important deformity to correct is equinus. The correct method is
demonstrated with the ankle firmly supported as the foot is dorsi-flexed.
2. In the case of varus of the foot or adduction of the forefoot it is important
to be firm yet gentle and to avoid too rapid or forceful a manipulation. Much
more is achieved by firm pressure for at least five minutes in the opposite
direction to the deformity, and this will usually need to he repeated and
followed by surgical correction to prevent recurrence.
 BRACING FOR SPINE DEFORMITIES

17. MANAGEMENT OF POST POLIO
RESIDUAL PARALYSIS
 TRUNK ROTATION EXERCISES FOR SCOLIOSIS
 Subjects performed exercises for 60 minutes with adequate interval of rest and
twice daily for five months.
 Flexion rotation exercise (Group A): This exercise is performed in straight supine
lying position. The subjects are asked to hold both hands together during flexion
rotation of trunk and head towards right side. The hands reach to the right knee for
right scoliosis subjects.
 Extension rotation exercise (Group B): This exercise is performed in straight prone
lying position. The subjects are asked to hold both hands in the back during
extension rotation of trunk and head to the left side. Do lumbar extension until chest
raised from the table and rotate the trunk, head and shoulder to the left side. The
right elbow stretch towards the left hip for right scoliosis subjects.
 Combined flexion rotation and extension rotation exercise (Group C): Subjects
asked to perform both flexion rotation and extension rotation exercise for a total of
60 minutes.REFERENCE: Jibi Paul. Effect of trunk rotation exercise on scoliosis in post- polio residual paralysis. Int J Physiother Res 2013;05:261-

19.  POLYPROPYLENE BRACES
 Patients are comfortable as the brace is light weight.
 Patient compliance is much better than the conventional orthotics because of
light weight, cosmetic appearance and ability to use normal foot wear.
REFERENCE: Polypropylene Orthotics in Rehabilitation of Post Polio Residual Paralysis. P. Srikanth et al. Proceedings RC IEEE-
EMBS & 14th BMESI - 1995

20.  COMPARISON OF DROP-LOCK KNEE-ANKLE-FOOT ORTHOSES AND PNEUMATIC
CONTROL KNEE-ANKLE-FOOT ORTHOSES
 Persons with quadriceps muscles weakness are often prescribed a KAFO that
locks the knee in full extension during both stance-and-swing (S-N-S) phases
of gait. Locking the knee results in abnormal gait pattern characterized by hip
hiking and leg circumduction during swing.
 Pneumatic cylinder is incorporated in free KAFO, i.e., light in weight as well as
small in size, that permits free knee motion during swing while resisting knee
flexion during stance, thereby supporting the limb during weight bearing.
 The subjects’ stride parameter was measured using 10-m paper walk test,
energy expenditure was measured by subtracting resting heart rate from
walking heart rate divided by speed using pulseoximeter and stopwatch and
user’s satisfaction was measured using orthotic prosthetic user’s survey
questionnaire.
 In this study, walking with pneumatic control KAFO significantly increased the
step length and significantly increased the stride length as compared to walking
with standard drop-lock KAFO.
REFERENCE: Pattnaik PP, Kumar R, Kumari P. Stride, energy expenditure, and user’s satisfaction in person with postpolio residual paralysis:
A comparative study between pneumatic control and drop-lock knee joint using knee-ankle-foot orthosis. Int J Health Allied Sci
2018;7:75-9.

22. POST POLIO SYNDROME
Post Polio Syndrome is a condition that affects polio survivors years
after recovery from an initial acute attack of the poliomyelitis virus.
CRITERIA FOR PPS
 Confirmed history of polio.
 Partial or complete neurological and functional recovery.
 Period of at least 15 years with neurological and functional stability.
 Development of new neurogenic weakness with no other medical
diagnosis to explain these health problems.

23. STRENGTH TRAINING
 The subject carried out maximum voluntary contractions (MVCs) of the thumb for 3–
5 s at a 45-degree angle across the palm. Three or more MVCs were carried out until
the subject could produce two highest MVCs that were within 10% of each other. The
average tension from these two trials was used for analysis.
Each subject underwent a supervised progressive resistance training regime three
times per week for 12 weeks.
 At each training session, the subject performed three sets of eight 3–5 s voluntary
contractions.
 A 5-min rest was given between sets to allow recovery from fatigue.
 To safeguard against the possible risk of overuse, the initial training load was set at
50% MVC.
 This was increased by 10% each week only if the subject was able to consistently
meet or exceed the target load.
 No further increase was made once the 70% MVC level had been reached.
REFERENCE: Chan KM, Amirjani N, Sumrain M, Clarke A, Strohschein FJ. Randomized controlled trial of strength training in post-polio patients. Muscle &
Nerve 2003; 27: 332–338.

24. MUSCLE TRAINING
 Before each training session, a standardized warm-up program was used with five
minutes on a bicycle ergometer at a load of 30W.
 The training program was performed on the Cybex II isokinetic dynamometer with
12 sets of eight isokinetic contractions, each at 180”/sec angular speed interposed
with 12 sets of isolated four-second isometric contractions (table2).
 Subjects were encouraged to perform maximal exercise.
 The total time for isokinetic work was 48 seconds: 16 seconds/group of sets =
16sec x 3 = 48seconds.
 Time consumed for contractions during each session was 96 seconds.
 All 12 subjects performed the training program in six weeks with three sessions
per week.
REFERENCE: Einarsson G. Muscle conditioning in late poliomyelitis. Archives of Physical Medicine & Rehabilitation 1991; 72: 11–14.

26. ENDURANCE TRAINING
EVALUATION:
Measurements of muscle strength (isokinetic/isometric Kin-Corn dynamometer),
muscle fatigue (isokinetic dynamometer), and graded exercise test (GXT) (bicycle
ergonometer) were taken 3 months before training, just before the training started,
and at the end of the training period. Preexercise and postexercise muscle biopsies
were also obtained.
TRAINING PROTOCOL:
 The exercise sessions were performed twice a week for 22 weeks.
 A total of 40 sessions were given.
 A physiotherapist led each class and monitored the subjects.
 Music was used to pace and encourage the exercise.

27.  Each session lasted 60 minutes and consisted of 5 minutes of
general warm-up followed by low-resistance, high-repetition
exercise for all major muscle groups in both upper and lower
extremities as well as the trunk.
 More time was spent on exercises specific for the quadriceps.
 After 1 month of training, 5 minutes of exercise on a bicycle was
included at approximately 60% to 80% of maximal heart rate as
determined by the GXT.
 Heart rate was monitored regularly during training and the
resistance on the bike was increased to maintain 60% to 80% of
maximal heart rate.
The amount of time on the bike remained at 5 minutes at each
session.
A 5-minute cool-down period followed at the end of each session.
REFERENCE: Ernstoff B, Wetterqvist H, Kvist H, Grimby G. Endurance training effect on individuals with postpoliomyelitis. Archives of
Physical Medicine & Rehabilitation 1996; 77:843–848.

28. EXERCISE AND LIFESTYLE
MODIFICATION
 After the initial evaluation, subjects were randomly assigned to 1 of the 3 treatment
groups.
Group 1
 Subjects were placed on a home exercise program that focused on strengthening
and stretching the hip-extensor and knee-extensor muscle groups with active range-
of-motion exercises.
 For example, one of the exercises was a straight leg raise; subjects would lie on
their back in bed, keeping 1 leg bent, with the foot flat on the bed and the other leg
straight out with the knee extended as much as possible. Subjects were instructed to
tighten the muscles on the top of the thigh, lift the heel of the straight leg about 4 to
6 in, hold for 3 seconds, and then slowly lower the foot back to the bed.
 All the exercises were of similar intensity and were performed with subjects either
standing while holding a sturdy chair or table for support, sitting, or lying on a bed.
Gravity and the weight of the limb were the only sources of resistance.
 The specific exercises varied according to the physical ability of each subject, and

29.  Subjects were assigned 3 to 5 exercises and were instructed to exercise up
to 30 minutes a day.
 They were taught to use the Borg Scale to monitor their exertion level. The
target level on the scale was between fairly light and somewhat hard (12–14
on the 6–20 scale).
GROUP 2
 Subjects were instructed in lifestyle modification techniques designed to
avoid shoulder overuse(eg, carry even loads, sit to work when possible, plan
tasks to decrease frequency of moving from sit to stand, take frequent rest
periods, use assistive devices like raised toilet seats).
GROUP 3
 Subjects received both treatment interventions.
REFERENCE: Klein MG, Whyte J, Esquenazi A, Keenan MA, Costello R. A comparison of the effects of exercise and lifestyle modification on the resolution of
overuse symptoms of the shoulder in polio survivors: a preliminary study. Archives of Physical Medicine & Rehabilitation 2002; 83: 708–713.

30. DYNAMIC WATER EXERCISE
 The training period lasted for 8 months.
 Training sessions were held twice weekly in warm water (133°C).
 The 40-minute training program was led by a physiotherapist and was
accompanied by music.
 It was designed to train general physical fitness including resistance and
endurance activities, balance, stretching, and relaxation (table 1).
 The participants were told to pace the exercises at the intensity level
where muscle fatigue was not present during or after the training session,
including the night after.
REFERENCE: Willen C, Sunnerhagen KS, Grimby G. Dynamic water exercise in individuals with late poliomyelitis. Archives of Physical
Medicine & Rehabilitation 2001; 82: 66–72.

32. INSPIRATORY MUSCLE TRAINING
 IMT was performed at home with the Threshold loading device.
 A nose clip was used during the training.
 The training intensity was initially chosen to approximately 30% of
Pimax (Maximal inspiratory pressure) and was not to be perceived as
more than ‘‘15’’ (hard) at the RPE scale at the end of the training.
 The patients performed the training for 20 minutes (1 minute of
training and 1 minute of rest, repeated 10 times) once every day for a
period of 10 weeks.
 At the last minute of training, the patients graded their perceived
inspiration exertion using the RPE scale.
REFERENCE: Klefbeck B, Lagerstrand L, Mattsson E. Inspiratory muscle training in patients with prior polio who use parttime
assisted ventilation. Archives of Physical Medicine & Rehabilitation 2000; 81: 1065–1071.

33. THRESHOLD LOADING DEVICE
 This device produces reliable inspiratory pressure loads
independent of airflow.

34. AEROBIC TRAINING
 The patients exercised at 70% of maximal heart rate in a 16-week aerobic exercise
program and it was found to be beneficial. (1)
 The subjects trained three times a week for 20 minutes per session in a 16-week
upper extremity aerobic exercise program. Exercise intensity was prescribed at 70%
to 75% of heart rate reserve plus resting heart rate and this exercise program
achieved an increase in aerobic capacity. (2)
 The subjects participated in a 6-week exercise training program for 30 to 40
minutes, three times a week. The program consisted of treadmill walking at 55% to
70% of age-predicted maximum heart rates. Movement economy, which is related to
the energy cost of walking, was significantly improved; and walking duration was
significantly increased at the end of training. (3)
REFERENCE: 1. Jones DR, Speier J, Canine K, Owen R, Stull A. Cardiorespiratory responses to aerobic training by patients with postpoliomyelitis sequelae.
JAMA 1989; 261: 3255–3258.
2. Kriz JL, Jones DR, Speier JL, Canine JK, Owen RR, Serfass RC. Cardiorespiratory responses to upper extremity aerobic training by postpolio subjects.
Archives of Physical Medicine and Rehabilitation 1992; 73: 49–54.
3. Dean E, Ross J. Effect of modified aerobic training on movement energetics in polio survivors. Orthopedics 1991; 14: 1243–1246.

35. OTHER TECHNIQUES
 Speech therapy
 Laryngeal muscle training
 Treatment in warm climate
REFERENCE: EFNS guideline on diagnosis and management of post-polio syndrome. Report of an EFNS task force. European Journal of Neurology
2006, 13: 795–801