J O U R N A L O F T H E S O U T H A F R I C A N L O G O P E D C SOCIETY 

POLIOMYELITIS 
RUTH MILLBURN. CLARK, Ph.D.* 

and 
RUTH A. LUND, M.A.* 

INTRODUCTION: 
The  medical profession  agrees  that  poliomyelitis is caused by a 

filterable  virus whose only known host is man. How this virus spreads 
how it enters  the body, and what happens to it, are still not completely 
decade ^ g r e a t  s t r i d e s  h a v e b e e n m a d e i n this'area  i n tjie lOJt 

There  are three  distinct  types of  polio, Spinal polio, Bulbar polio 
and Spino-bulbar polio. It  is the cranial nerve type of  bulbar polio which 
is of  most concern  to the speech therapist  V 

IMPLICATIONS FOR THE SPEECH 
THERAPIST. 

SPEECH INVOLVEMENTS IN BULBAR POLIO. 
in the upper cranial nerves the third, iiith, 

r.xih, seventh a n d eighth nerves suffer involve-
:.-.cnt. Most frequent involvement falls on the 
:<?nlh nerve: In the Minnesota epidemic of 
i.-lu, 9 0 % of the patients with b u l b a r t y c e 
..".owed symptoms indicating the tenth nerve 
wc:s affected. 

In the cranial group, symptoms vary from 
'•-'.lent to patient, affecting most of the pro-
v e s of speech. Most frequent conditions 

nasal.quality, hoarseness, l a r y n g e a l stridor, 
.".lateral or bilateral w e a k n e s s of the tongue' 
«:=uctor paralysis of the vocal folds, accumu-
»:on οι saliva in the oropharynx, difficulty in 
"''jiiov/mg, paresis of the velum, occasion-

—y cpnonia, a n d reflex s o a s m of the laryn-
•c-i musculature. (4). 

O F ' SPECIFIC NERVE INVOLVE-
MENT : 

. following is a breakdown of the results 
- j - . e involvement of these cranial nerves..Also 
: : r c . s d l s t h e order cf frequency of o c c u r e n c e 

to a study of 107 b u l b a r c a s e s ad-
: ' ' \ o % t n e U n i v e r s i t y of Minnesota Hospital 

^ V a g u s — 10th N e r v e : 95 c a s e s . Motor 
c a r r i e d from this nerve to the larynx, 

--•(I"' T T v e l u m · ^ ^ Posterior root of the 
•'"^o Unilateral paralysis c a u s e s w e a k n e s s 

s o f t P a ^ t e , pharynx a n d - larynx. 
~ ^ r f e . 3 m t h e v ° i c e , such a s hoarseness, 
" ° r progressive w e a k n e s s or difficulty 

OTe d u e t o involvements of the 
: ' V - k ^ ® ' T h e s e a r e o f t e n Θ α Γ ΐ ^ symptoms 

bulbar type polio a n d should b e inter- " 

preted a s danger signals pointing to obstruc-
tion of the airways. 

Complete bilateral paralysis of the V a g u s 
nerve is almost always fatal. There is com-
plete paralysis of the pharynx, rendering both 
vocal cords motionless in a halfway position 
between^abduction and adduction. The glottis 
cannot close, the patient can neither speak nor 
breathe. This, of course, l e a d s to suffocation, 
unless a tracheotomy is performed. 

(2) Facial—7th Nerve : 71 cases. Supplies 
motor fibers to the lips a n d face. Paralysis 
may involve the whole or lower part of the 
face and accordingly, affect different facial 
muscles e n g a g e d in speech. The patient can-
not whistle or blow out his cheeks. The lack 
of control of lips and cheeks also prevents him. 
from correctly producing the sounds, p, b t " 
d, ch, j, g and possibly others. The vowels 
will also b e involved. 

(3) A c c e s s o r y — I I t h N e r v e : 40 cases. A 
few motor fibers from the 11th n e r v e " b r a r c h 
;o tne muscles of the pharynx, velum, and 
posterior root of the tongue. S o m e of ihe motor 
aoers^ go to the muscles which a r e used in 
forced inhalation. 

(4) H y p o g l o s s a l — 1 2 t h N e r v e : 15 cases. 
Carries motor fibers to some of the extrinsic 
muscles a n d to the intrinsic muscles of "the 
tongue. Also to certain muscles used in forced 
exnaiation. Unilateral paralysis c a u s e s a de-
viation of the tongue to the paralyzed side, 
causing slight impairment in mastication and 
possibly faulty articulation. Bilateral paralysis 

Dr. Cicmc is associate Professor of Speech and 
Director of tne Chiicren's Speech Clinic, University of 
Denver, Coicraao, United States of America She was 
visiting lecturer in Lcgopedics, University of the Wit-

_watsrsrcnd,. Johannesburg, 1950-1951. 
*Miss Lund, M.A., University of Denver. 

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J O U R N A L O F THE SOUTH A F R I C A N L O G O P E D I C SOCIETY MA 

results in the inability to protrude the tongue 
at all—affecting " t h " a n d promoting sloppy-
articulation. 

(5) Trigeminal—5th N e r v e : 10 c a s e s . Car-
ries motor fibers to the muscles of the man-
dible. Paralysis m a y c a u s e disturbances in 
chewing a n d mastication. A unilateral par-/ 
alysis of these muscles is rarely seen in polio. 
(5, 4, 7). 

(6) The Glossopharyngeal—9ih Nerve : Is 
sometimes involved. It carries a few motor 
fibers to the pharynx, velum, a n d to the pos-
terior root of the tongue. Paralysis generally 
occurs, concomitantly with the tenth nerve 
involvement; it contributes to difficulties in 
swallowing. (2). 

B e c a u s e the speech mechanism is so highly· 
developed and complicated, ii must b e given 
special consideration in the general re-educa-
tion program that follows an attack of bul-
bar polio. Frequently, it - will b e found that 
difficulties in swallowing, regurgitation of 
food, a n d pooling of saliva h a v e c e a s e d but 
speech has not readjusted itself to its former 
normal function. It h a s a l s o been observed 
that while there m a y b e almost complete 
paralysis of the soft p a l a t e and a s s o c i a t e d 
inability to move the p a l a t e in speaking, the 
reflex activities of swallowing, laughing, etc., 
frequently may b e impaired only partially or 
not at all. (7). 

It is regrettable, but none the less true, that 
s p e e c h deficiencies resulting from this form of 
polio h a v e received much less attention from 
the medical personnel than a n y other p h a s e s 
of this disease. 

PREMISES FOR SPEECH THERAPY : 

Nelson (4) in considering therapy for dys-
functions in speech resulting from bulbar polio, 
states some general concepts for s p e e c h 
therapy in this situation. They a r e as follows : 

1. The musculature of the speech mechan-
ism, in which is included the muscles which 
expand a n d contract the rib c a g e , the larynx, 
pharynx, velum, j a w , tongue a n d lips, is m a d e 
up of the cross-striated or red muscles, having 
the s a m e composition a s a n y of the skeletal 
muscles and hence under the control of the 
Central Nervous System. However, a number 
of differences which distinguish the speech 
muscles from other skeletal muscles must b e 
noted.. The a x o n a l endings a r e more complex 
in the speech musculature, especially in the 
muscles of the larynx, than in most of the other 
b i g muscles. The speech organs, for the most 
Part, a r e unpaired mid-line structures. S o m e 

of the impulses going to the muscles control 
ling the speech functions a r e under control c 
the cortex ; in other impulses, partial contrc 
is exercised ; and in some instances there i 
little or no volitional control, a s in gaggin 
or in the sneezing reflex. The task of stimulc; 
ing inert musculature over which there is lit;: 
voluntary control is indeed more difficult the: 
in those muscles which a r e under the contrc 
of the cortex. 

2. The cerebral cortex is so little affected fc-
the virus of polio that it may b e a c c e p t e d the 
the patient can rapidly begin to relearn pc: 
terns of motor activity which formerly wer· 
smoothly a n d automatically regulated by ; 
brain stem without severe lesions. These nev 
patterns of motor activity which a r e so import 
ant to recovery.of speech function a r e governs·: 
b y the cerebral cortex. 

3. Lesions in the brain stem must reach c 
certain threshold of severity, varying with th; 
margin of safety of e a c h center, before dy= 
function of speech can b e observed. Recover;· 
of function results from two p r o c e s s e s : firs: 
the regeneration of neurons not d a m a g e : 
sufficiently to b e destroyed ; second, the re-
routing of nerve impulses from interrupte: 
primary pathways. The first process is usually 
complete in the first month after the virus in-
vades, but the second process is a long tern 
relearning activity. 

4. Where there is muscle atrophy, causec 
b y denervation, a compensatory muscle aciicr 
may b e had from muscle fibers v/ith intact in-
nervation. Such compensatory muscle actic-
likewise is a slow relearning process. 

5. Nerve cells m a y b e injured to an exten' 
incompatible v/ith recovery. Such injury will 
account for much of the early paralysis. Eu: 
b e c a u s e of the margin of safety of nerve cell; 
in the cranial nuclei controlling motor activity 
in speech, irreversible d a m a g e resulting ir. 
complete paralysis is not frequent. 

6. The impact of polio on the human syste."' 
is violent physically and psychologically 
Speech is a b a s i c human process, and an in-
terruption of its function is fraught with iru; 
tration. S p e e c h therapy must treat the whclr 
person consistent with other administer·?: 
therapies, and consider ail of the psycholo-
gical trauma left in the wa k e of the disease· 

7. Audio-stimulcrtion can well b e utilize·-
b y the speech therapist. Where lesions in in-
brain stem must b e b y p a s s e d to restore func-
tion, nev/ cerebral a n d motor configuration; 
must b e set up. Audio-stimulation is part 
this process. 

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J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D C SOCIETY 

ο The d a y to d a y improvement· is slight 
..-A is usually not discernible to the patient or 

Those closely a s s o c i a t e d with him. It is im-
'-riant to the patient to know that he is im-

-"oving· Therefore, the therapist should use 
'..••• -'ever m e a n s he c a n to h a v e the patient 
"· ; e r v e his improvement. P e r h a p s the most 

• radical method is to retain samples of speech 
* _:::ined at intervals on a wire or tape re-

ader. 
9. Except for very young children, speech 

•'.crapy in b u l b a r polio will consist of helping 
:..c patient to r e l e a s e skills which h a v e b e e n 
.:.·,!. Since most of the patients will h a v e ex-
: «.-rienced normal communication before their 
..Inesses, they will appreciate the g o a l s for 
which the therapist strives. Motivation should 
!.o excellent. 

10. Many of the techniques used by the 
pnysical therapist c a n b e a d a p t e d to improve 
,;',e speech of bulbar polio patients. For ex-
ample, the pattern of large muscle movement 
~~n be broken down and a n a l y z e d in terms of 

component parts. Intensive work on iso-
ir.'.ed parts of a larger action is often produc-
:.ν·3 and very frequently n e c e s s a r y . In this 
.••-̂ pect, Nelson quotes from Westlake (6) who 

•..'j.r>  made some suggestions concerning cere-
;:rcl palsied s p e e c h which might well b e ap-
plied to the speech of a victim of polio. West-
:ake points out "that a detailed scrutiny of 
muscle activity frequently reveals remedial 
• ieiects which interfere with the speaking a c t . " 
iio then goes on to say that the s p e e c h act can 
••ο fractioned into these abilities : 

"a. Ability to sustain an even exhalation for 
10 seconds. 

b. Ability to sustain an even tone for 10 
seconds, j 

c. Ability to open a n d close the lips 10 
times in 10 seconds. 

d. Ability to open and close the lips 10 
times in 10 seconds, while the mandible 
is stabilized b y keeping the upper and 
lower teeth together. 

e. Ability to raise tip of tongue to the r u g a e 
10 times in 10 seconds,·while the man-
bible is stabilized b y setting a rubber 
block, about a quarter of an inch thick, 
between the teeth. 
Ability to move the tongue tip from one 
corner of mouth to other 10 times in 10 
seconds. 

9- Ability to extend the corners of the lips 
from the round position 5 times in 10 
seconds .when the mandible is stabilized 
by keeping the teeth together. 

h. G o o d peristoltic activity of the tongue 
—ability to propel foods from the front 
of the mouth to the b a c k of the mouth 
a n d swallowing them." 

These rates a r e arbitrary, a n d a r e used only 
for reference of measurements a n d there are, 
of course, m a n y other possibilities in which 
the speech functions c a n b e divided. Westlake 
s a y s this approach h a s four a d v a n t a g e s : 

" a . It describes the over-all motor a d e q u a c y . 

b. It isolates foci of particular difficulty. 

c. It encourages a systematic therapy since 
it constitutes a map of an important as-
pect of the speech training." 

11. Perhaps the most frequent disability of 
s p e e c h resulting from bulbar polio is hyper-
nasality. The therapist should b e a w a r e of 
the more recent experimental evidence which 
indicates that the naso-pharynx port need not 
b e closed for nasality-free speech. 

According to McDonald a n d Koepp-Baker, 
(3). "There is a critical point at which a critical 
b a l a n c e is established between oral and n a s a l 
resonance. If this critical point is not reached, 
nasality will occur." To these authors, the 
determination of the path of the air stream, the 
action a n d position of the tongue is of much 
greater significance in cleft p a l a t e speech than 
the action of the palate. Although these men 
question the efficacy .of blowing exercises 
for cleft p a l a t e speech, Nelson (4), Zausmer 
(7), a n d Baker and Sokoloff (1) all a g r e e that 
blowing should provide help for the palatal 
and p h a r y n g e a l weakness growing out of bul-
b a r polio. Blowing provides exercise against 
resistance, which kind of exercise has b e e n 
effective in restoring tonus a n d strength to 
other muscles of the body. This does not pre-
clude giving attention to direction of the air 
stream a n d position of the tongue in both cleft 
p a l a t e e n d bulbar polio c a s e s showing signs 
of hypernasality. 

SPECIFIC THERAPY IN POST-BULBAR POLIO 
S P E E C H : 

S i n c e the characteristic syndrome of post-
b u l b a r polio speech resembles that of cleft 
palate,' the therapy generally attempted is 
closely allied to the techniques utilized with 
cleft palate. 

To strengthen velar action a n d make soft 
p a l a t e more pliable a n d movable, many types 
of blowing exercises a r e found helpful. ( 1 , 7 ) 
Candles, pin-wheels, soft balloons, harmoni-
cas, whistles, feathers, ping-pong, bails h a v e 
all b e e n found useful gadgets. 

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J O U R N A L OF T H E S O U T H A F R I C A N L O G O P E D I C SOCIETY MAY 

Other techniques found to b e helpful in 
stimulating velar activity a r e panting a n d 
yawning exercises a n d m a s s a g e of the p a l a t e 
b y a sterile s w a b or finger. The latter therapy 
tends to e n c o u r a g e a g a g reflex which elevates 
the p a l a t e . In c a s e s where there a r e residual 
t r a c e s which show activity in the velum, elec-
trical stimulation of the p a l a t e to increase the 
movement of this structure m a y b e attempted. 
(This type of therapy should b e under ihe 
direction and surveillance or a physician who 
is a specialist in physical medicine.) (1). 

Ear training is of great importance since all 
authorities agree- that a major problem with 
most patients is their inability to tell the dif-
ference b e t w e e n n a s a l a n d non-nasal sound. 
(7). 

SUMMARY. 
The pathological effects of this d i s e a s e that 

result in speech disorders a r e generally in the 
Bulbar-Cranial type group with many a n d 
varied types of disorder according to the 
amount, type a n d extent of involvements of the 
nerves. Nasality seems to b e the most com-
mon speech problem. Due to the paucity of 
material, the s p e e c h correctionist must take 
from other sources a n d work on this disorder 
much a s she would for nasality for Cleft 
P a l a t e speech. 

It is important to remember that the "im-
pact of polio on the human system is violent 
physically a n d psychologically. S p e e c h beinc 
a b a s i c human process, an interruption of 
function is fraught with frustration." There-
fore, we must h a v e a gestalt approach and 
treat the whole person consistently with the 
other administered iherapies. (4). 

A fundamental principle to k e e p in mind is 
that the organism r e a c t s a s a whole a n d thai 
anything that affects a part of the organism 
will have an effect on the whole organism. 

BIBLIOGRAPHY. 
1. Baker, E. E„ Jr., &  Sokoloff, M.A. "Therapy ίο; 

Speech Deficiencies resulting from Acute Bulbar 
•Poliomyelitis Infection." Jomal of Speech and Hear-
ing Disorders. Vol. 14:4, 1951. 

2. Campbell, Winona G. "Diagnosis of Poliomye-
litis." Arizona Medical Journal. Vol. 8:25-36, 1951. 

3. McDonald, Τ. E., & Koepp-Baker, H.G. "Cleft Palate 
Speech—An Integration of Research and Clinical 
Observation.' Journal of Speech and Hearing Dis-
orders. Vol. 16:9, 1951. 

4. Nelson, Roy C. "Bulbar Poliomyelitis : Its Sequelcs 
in the Speech Processes with Some Suggestions fcr 
Theraoy." Western Speech. Vol. 16:4 October 
1952. 

5. Neuberger, Κ. T. et al. "Bulbar Poliomyelitis." 
Papers and Discussions Presented at the Firs! 
International Poliomyelitis Conference Lipperi-
cott Co. 1943. 

6. Westlake, Harold. "Muscle Training for Cerebral 
Palsied Speech Cases.' Journal oi Speech and 
Hecring Disorders. Vol. 16:103-108. June, 1951. 

7. Zausrner, Elizabeth. "Speech Defects Resulting 
From Bulbar Policmvelitis." Physical Therapy Re-
view. Vol. 31:7. July] 1951. 

ERRATUM. 

The Editor wishes to draw attention to the 
error that a p p e a r e d in the article "The Treat-
ment of Habitual D y s p h o r i a , " Journal of the 
South African Logopedic Society, September, 
1954, Volume 2, Number I. The sentence or. 
p a g e 13 in the first p a r a g r a p h under the.head-
ing POSTURAL EXERCISES should r e a d : 

" . . . A mirror allowing him to s e e heac 
and shoulders is essential," and not "A 
mirror allowing him to s e e h e a d cn^ 
should is e s s e n t i a l . " 

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B O O K S E L L E R S 

23, JOUBEHT STREET. JOHANNESBURG 
Telephone 23-3511 

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