Page Two P H Y S I O T H E R A P Y January, 1951 P O L I O M Y E L I T I S By A. E. WILKINSON, M.B., Ch.B., F.R.C.S.(Ed.), F.R.F.P.S. T H I S paper is written from an unusual viewpoint, viz: that of the patient, and deals with the symptoms and treatm ent o f the acute stage o f polio­ m yelitis w here physiotherapy is all important. The disease begins like influenza, with malaise, headache, fever and pain in the muscles, especially in the lumbar region. These sym ptom s may regress tem porarily for tw o days or so, at the onset, and then becom e m ore severe, or m ay be progressive from the start. Pyrexia varies from 100 to 104 deg. and m ay last one week. Hyperaesthesia to light touch precedes paralysis and renders the pressure of the bed clothes uncomfortable or painful. A t this stage the reflexes are generally increased. Flushing, mottling, coldness of the extrem i­ ties and other vasom otor disturbances m ay occur. Restlessness m ay be marked during the first week, the patient having a continual desire to alter his position. This is the m ore distressing as he requires help in order to m ove. Anorexia, vom iting and diarrhoea occur in m any cases. Flaccid paralysis or paresis com es on the second to fourth day, and may increase in extent and severity for tw o or three days. In health, the ability to m ove with ease and strength is taken for granted. In polio, the loss o f power is sudden and often occurs over­ night. The patient suddenly finds himself seriously incapacitated or altogether helpless. It can be appre­ ciated that this is an acutely alarming ■ experience. Furthermore, recovery does not begin immediately. It is delayed for one or tw o w eeks and commences very slowly. During this period of maximum disability it is only too easy for the patient to feel very de­ pressed. Paralysis or paresis m ay affect the members o f a group of muscles in varying degrees, or m ay in­ volve a single muscle or a w hole limb. Paralysis is com m onest in the low er limbs, occurring in 80 to 90 per cent of cases; the arms being involved in 30— 50 per cent o f patients (W iles1). Involvem ent of the intercostal muscles and diaphragm m ay lead to res­ piratory failure. Because the nuclei of the phrenic nerves and the nerves to the shoulder girdle lie close together in the spinal cord, diaphragmatic paralysis and deltoid weakness are often associated (Heym ann2). Stiffness of the neck and back are com m on symptoms. Meningeal sym ptom s and involvem ent of the cranial nerves m ay occur. Constipation often occurs and de- faecation is both difficult and tiring for a patient with weak abdominal muscles. Retention of urine may occur and last for som e days. Muscle tenderness occurs after the paralysis has started. This is a deep tenderness and m ay persist for many months, causing pain w henever the affected links are lifted unless held at the joints only. Muscle spasm is com m on in the early stages, and varies from a state of continual spasm in a muscle group to transi­ tory spasm initiated by m ovem ent. Muscle atrophy begins during the third week. The pressure of the cerebro-spinal fluid is slightly raised. The cell-count varies between 50— 250 cells per cubic millimetre. Polym orphonuclear leucocytes predominate in the early stages, being replaced by lym phocytes later. The chloride and sugar content are normal, but protein is increased. Depending on the incidence, severity and duration of the symptoms, the disease m ay be divided into types, such as: meningeal, bulbar, spinal and abortive types. TREATMENT. The first essential is to reassure the patient ,and give him as encouraging an outlook as possible. This should be continued throughout the illness so as to maintain the patient’s co-operation and active interest in his exercises and treatment. The strength o f all the muscles should be tested on admission and re­ corded at m onthly intervals. The patient should be nursed on a fracture board and a cradle provided to support the bed-clothes. For the first week t h e 1 patient is allowed to lie in any position he finds com ­ fortable. After that the lim bs should be kept in a neutral position by means of pillows or small sand­ bags. Plaster splints are useful. The patient is kept on his back. Knees and hips should be slightly flexed. The feet should be at right angles to the iegs and neither inverted or everted. The arms are abducted about 70 deg.; the wrists slightly dorsiflexed and the elbows at right angles. Hot packs and dry heat in the form of electric cradles relieve pain and keep the ' muscles in good condition. Respiratory failure is treated by the physician. Raising the head of the bed helps in mild cases. Luminal is given for restlessness, Etamon for muscle spasm and liquid paraffin and enemas for constipation. After the tem perature has settled, massage and exercises are begun. All affected muscles are first 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. ) J a n u a r y J ^ S I ! P H Y S I O T H E R A P Y Page Three ssaged and are then exercised. Massage should be light effleurage and petrissage and should be done ently so as not to en ter-th e zone of deep tenderness and cause spasm. E x e r c is e s a r e g r a d e d a c c o r d i n g to t h e s t r e n g t h of the muscles and m ay require slings and weights to assist in overcom ing gravity. Care should be taken not to cause excessive fatigue. Trick m ovem ents must be g u a rd e d against. These are perform ed unwittingly by the patient w ho tends to concentrate on a gross result e.g. moving a limb, instead of contracting cer­ tain muscles and will result in strengthening strong muscles at the expense of weak muscles if allowed to p e r s i s t . Doing t h e m ovem ents w i t h the sound limb first, helps to eliminate trick movements. In the de Lorme method, the muscles are contracted first | against half the m axim um weight, then three-quarters the maximum weight and finally against the full weight. This is valuable as it allows the muscles to “ warm up” and so contract against a greater m a x i m u m than would otherwise be possible. It also necessitates accurate records of muscle strength. It is m ost en­ couraging to refer back to these records. Treatment in the Hubbard tank should begin early. It is very encouraging for the patient to see the extent PERSONAL DURBAN. Miss W. Blackie, Joint Secretary of the Natal Branch, sailed on the Stirling Castle for England on Friday, 1st December. She is going to manage the Ladies’ Inter-Varsity H ockey Team. Mrs. P. Sanderson (nee B ody) gave birth to a daughter on 26th October. ^NORTHERN CAPE BRANCH. Miss Doreen Tredrea, a foundation m em ber o f the Society, has recently returned from a visit to England and the Continent. W e are pleased to hear that Miss Tredrea’s health has benefitted as a result of the trip. ^SOUTHERN TRANSVAAL. Miss Margaret Greenlees Barbour, of Johannesburg General Hospital, is engaged to Dr. David Allison Dodds, B.D.S. The engagem ent was announced at the Graduation Ceremony on 6th December, when they both received their degrees. Miss Ada van Niekerk, of Johannesburg General Hospital, is engaged to Dr. W illem Kelfkens. The wedding will take place in April in Som erset East. Congratulations to Miss Lois Dyer, of Coronation Hospital, who is leading one of the first W om en’s Inter-Provincial Cricket XI. to which he can m ove in water, hence exercise in the tank has an excellent effect on morale. It results in a feeling of well-being and increases both appetite and sleep. The temperature of the water should be 95— 100 deg. F. and must be measured with a bath thermometer. Electrical stimulation may be required for very weak muscles. Occupational therapy is a useful ad­ ju n ct to physiotherapy. Special care m ust be given to the back muscles and sitting erect must not be allowed till these are strong. The crutch chair is a useful device to facilitate walking. The day when the patient first walks is a great triumph to both patient and physiotherapist. In conclusion, I wish to record m y very best thanks to the dictors and physiotherapists w ho helped me through the acute stage of polio. REFERENCES: 1. W iles, P. (1949) Essentials of Orthopaedica. Lon­ don. J. v. A . Churchill Limited. 2. Heymann, S. (1950) S. Af. Med. J. 24, 20. 3. Mercer, W . (1947) Orthopaedic Surgery, Edward Arnold & Co. Miss Baines, o f the W itwatersrand University staff, sailed for England in December, to take up her former post on the staff at G uy’s Hospital. W e offer our sym pathy to Miss S. Oosthuizen on the occasion of the death o f her brother, Mr. Albert S. Oosthuizen, on December 16th. BRANCH NEWS NATAL. Recently when the posts of Physiotherapist w ere re­ designated into the Lower Professional group o f the Public Service, the Commission decided to reduce the leave from 39 days to 31 days per annum. The Com­ mission, however, reconsidered this w hen it was pointed out by the Secretary of the King Edward Hospital that Physiotherapists com e into direct con ­ tact with sick people. A small Jumble , sale was held at the King Edward Hospital on Saturday, 2nd December, by the Branch. The fine sum of £31 5s. was the result of a small effort. NORTHERN CAPE. W hile the General Secretary for the S.A.S.P., Miss S. Oosthuizen, was visiting Kimberley for the Confer­ ence of the National Council for the Care of Cripples, a meeting of Physiotherapists resident in this city was held, at which it was decided to form the Northern Cape Branch of the S.A.S.P. 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. )