Page Eight P H Y S I O T H E R A P Y April, 1954. K EN N Y CONCEPT of TREATM ENT of P O L IO M Y E L IT IS By BARBARA J. BROW NLEE, B .Sc. (Rand).* *Kenny Therapist in charge o f the Out-patient Department, POLIO M Y ELITIS is an acute, infectious disease caused by a filtrable virus which attacks the anterior hern and . internuncial cells and causes disorganization o f the neuromuscular system. Kenny believed the disease to be systemic. This has not been proved, although the known facts tend to establish her theory. The types o f poliom yelitis are bulbar, spinal, bulbar- spinal, encephalitic, abortive and nonparalytic. The K enny method is directed towards the treatment o f muscles in which are found “shortening, inco-ordination and mental alienation.” and is o f m ost benefit in the acute and early convalescent stages o f the disease. The disease is considered acute until the temperature has dropped and remained normal" for 48 hours. The convalescent stage continues until maximum recovery is reached— 1 to 2 years after onset—and poliomyelitis is chronic when a stationary level is maintained. The othod ox concept states that the pathology is in the anterior horn cells with resulting flaccidity o f the affected muscles. The normal, strong muscles pull against the weak muscles, causing a muscle imbalance which can result in deformities if untreated. The K enny concept P) of the disease states that the clinical m anifestations are: M uscle spasm (shortening). M ental alienation (pseudoparalysis). Inco-ordination o f muscle action. Paralysis and weakness (denervation). M uscle Spasm D efin ition : A hypertonicity of muscle marked by an involuntary and persistent contraction. Because o f this loss o f extensibility the muscle is unable to relax, and deformities occur if it is allowed to go untreated. It is the earliest symptom of poliomyelitis, and. is always present, even if there is no paralysis or weakness. The muscles are hyperirritable, tender and painful. Shortening is found in paralyzed muscles, as well as in normal ones. According to D o c to r PohK2), local changes apparently take place in the muscle tissue. The hypertonicity o f poliom yelitis does not always subside spontaneously.. In meningitis, for exam ple, the hypertonicity subsides as the disease regresses in the spinal cord. D octor Pohl reasons, therefore, that nerve origin alone cannot suffice as an explanation for the shortening in poliomyelitis. Other authorities have thought that the shortening is neurogenic or vascular in origin. There is evidence o f shortening in skin, subcutaneous tissue and fascia. The skin is often tender, and becomes adherent, thick or tight, if left untreated. The skin folds are diminished, and there may be interference o f normal muscle movement where there is no evidence o f muscle paralysis. The pain o f skin tightening is sharp, whereas that o f muscle is dull. When the erectons pilorum is in ­ volved, there is an appearance of cutis anserina. Evidence suggests that the m ost pain is caused by the condition o f the skin fascia, or subcutaneous tissue(3). M ental Alienation or Pseudoparalysis M uscles opposed to those in spasm appear, to be paralysed, flacid and toneless, but are not painful, seeming to indicate that these muscles are not directly affected. It is observed that when the shortened muscles are relaxed by treatment, there is function in the seemingly paralyzed Sister K enny H ospital for Poliom yelitis, El M onte, California. muscles. I f left untreated, permanent paralysis and atrophy may occur. The cause o f alienation is not fully understood. There are thought to be possible reflex m echanism s as an explanation. 1. Reflex pain inhibition. The patient protects the painful muscle by reflexly inhibiting the action o f any adjacent muscles, e.g., if the gastrocnem ius is tight and painful, the anterior'tibialis will make no effort to contract, as that m ovem ent would put the gastrocnem ius on stretch and cause further pain. 2. Stretch paralysis. Persistent stretching o f a muscle opposed to one in spasm may cause a stretch paralysis, e.g., i f the gastrocnem ius is tight, persistent elongation o f the anterior tibialis may cause that m uscle to becom e paralysed eventually. 3. Reciprocal innervation. This depends on the hypothesis that spasm is the result o f a continuou s discharge o f im pulses from the anterior horn cells. The theory o f reciprocal inhibition states that when any m uscle group is activated reflexly o r voluntarily there is norm ally a sim ultaneous inhibition o f the antagonist muscle group0). Tnco-ordination Poliom yelitis causes disorganization o f the neuro­ muscular system, with consequent misdirection o f nerve impulses resulting in the sm ooth, rhythmic muscle c o n ­ traction becoming inco-ordinated and ineffective, e.g.: (a) A muscle attempts to pull from reversed origin insertion. (b) O pposing muscles attempt to w ork together; the pectoralis major contracts when abduction is attempted. (c) Unrelated muscle m ovem ents; the hamstrings contract to attempt plantar flexion. Inco-ordination should not be confused with substi­ tution, which is a voluntary condition. Denervation There is paralysis caused by injury or destruction o f anterior horn cells. The condition m ay be temporary, with som e recovery as the inflam m atory process subsides. Where there is permanent destruction there is irreversible . paralysis. , TREA TM EN T The K enny treatment for poliom yelitis is m ost effective in the acute or early convalescent stages o f the diseases. After m axim um relaxation and co-ordination o f function have been obtained, the patient is referred to the rehabili­ tation service, i f further treatment is necessary. In the early stages o f the disease the patient is hyper­ irritable, and touching or stretching lead to increased dis­ com fort. The patient is made as com fortable as possible with the support o f pillow s and sandbags. M oist hot packs are ordered as soon as the diagnosis is made. The packs are m ade o f material o f at least 75% w ool, which holds the heat but does not adhere to the skin. They are boiled, wrung dry and wrapped, at a temperature o f 140 degrees Fahrenheit, around the part, which must be dry to prevent burning. The joints are left “free” to preserve the sensation o f m ovem ent when the therapist takes the limb through a range o f joint m ovement. Packs m ay also be draped over the limbs, or concentrated to an especially tight part, e.g., the chest, where breathing may be inhibited due to muscle tightness. G entle m anipulations o f a stretching nature are then performed to release adherent fascia and relieve shorten- R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) April, 1954. P H Y S I Q T H E R A P Y Page Nine ing. It must be stressed that these manipulations should never cause any increase o f pain or shortening. A s so o n as the tenderness subsides sufficiently to allow it, muscle reeducation is begun. The K enny system o f muscle re-education consists of: (1) Tendon stim ulation. (2) R estoration o f awareness. (3) R estoration o f co-ordinated function. Tendon Stimulation. A n attempt is made to stimulate the proprioceptive reflex arc. W hile the afferent pathway remains intact, there m ay be a physiological block o f the efferent pathway leading to alienation or pseudoparalysis. The patient is relaxed, and makes no attempt to help the therapist. The proprioceptive afferent pathway is stimulated by taking the joint through a small range o f vibratory movement. I f the efferent jpathway is intact, the tendon will be seen to contract. Restoration o f Awareness. The patient is m ade aware o f the co-ordinated, sm ooth conttraction o f a muscle. His attention is directed towards the tendinous insertion o f the muscle while the therapist takes the joint through passive movements. The afferent nerves are stimulated and consciousness established at the cerebral level. Restoration o f Co-ordination o f Function. The patient attempts to help the therapist perform the m ovement, using only the muscles indicated. The weight o f the limb is taken by the therapist, and the patient attempts to contract the muscle from the tendinous insertion indicated. N o active m ovement is carried out if not co-ordinated, e . g - opposing muscles must not be allowed to contract sim ul­ taneously. Treatment is carried out on a wooden table. The com plete attention o f both patient and therapist is required. A s soon as is possible and without causing- pain, an attem pt is m ade to stand the patient. W hile in bed a foot­ board is placed at the foot o f the bed with space between a hard mattress and the foot-board for the heels. The patient keeps his feet against the board to preserve his sense o f standing. H e attempts to push dow n against the foot­ board to sim ulate standing. G ait training is begun when the patient has recovered sufficiently. > SU M M A R Y K enny treatment o f poliom yelitis is m ost effective in the acute and subacute stages o f the disease. Non-paralytic poliom yelitis should be treated to prevent deform ities occurring from “ spasm ” o f muscles. The clinical m anifestations o f the K enny C oncept are: M uscle “spasm ” ' Inco-ordination A lienation D enervation W hile the orthodox conception i s : Paralysis with flaccidity; M uscle imbalance causing deformities. BIBLIOGRAPHY (‘ ) P o h l , J o h n F . : K enny C oncept o f Infa n tile P aralysis and its T reatm ent (in collaboration with Sister Elizabeth Kenny), M inneapolis & Saint Paul, M innesota, 1949. (2) P o h l , J o h n F . : P eripheral D iseases o f P oliom yelitis, J . B one a n d J o in t Surg., 29 : 4, Oct. 1947. (3) K e n n y , S i s t e r E l i z a b e t h : P hysical M edicine" the Science o j D erm o-N euro-Afuscular Therapy as applied to In fa n tile Paralysis, M inneapolis, M innesota (pub­ lished by the author), 1946. 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