Poliomyelitis and PPRP: Comprehensive Clinical Guide

PART 1: STAGES OF POLIOMYELITIS

STAGE 1: ACUTE STAGE

• Malaise, anorexia, low-grade fever
• Sore throat, headache, vomiting
• Constipation, upper respiratory tract symptoms
• May resolve here completely (abortive polio)

• Recurrence of fever after an afebrile interval ("dromedary" or biphasic fever)
• Severe headache, nuchal rigidity, back pain
• Hyperesthesia or paresthesia in the extremities
• Meningism: positive Kernig's and Brudzinski's signs
• Marked flushing of skin, apprehension, muscle pain (tender even to gentle palpation)
• Superficial reflexes disappear first; deep tendon reflexes (DTRs) disappear when the muscle group is paralyzed
• Limitation of straight-leg raise
• Asymmetric flaccid paralysis develops - lower limbs twice as commonly affected as upper limbs

• Complete bed rest
• Analgesics for pain
• Anatomic positioning of limbs to prevent contractures
• Gentle passive range-of-motion exercises performed several times daily
• Respiratory monitoring - diaphragmatic dysfunction can be life-threatening if upper cervical cord involved

STAGE 2: CONVALESCENT (RECOVERY) STAGE

• Muscle power improves spontaneously - most dramatically in the first 4 months, then gradually
• A muscle with >80% return of strength at 3 months recovers spontaneously
• A muscle with <30% normal strength at 3 months is considered permanently paralyzed
• Weakness is clinically detectable only when >60% of nerve cells supplying the muscle have been destroyed
• Asymmetric weakness pattern is maintained throughout recovery

• Muscle strength assessed monthly for 6 months, then every 3 months
• Physical therapy emphasizing muscle activity in normal patterns and development of maximal capability of individual muscles
• Mild-to-moderate contractures: vigorous passive stretching and wedging casts
• Contractures persisting >6 months: surgical release of tight fascia, aponeuroses, and tendon lengthening
• Orthoses for joint support until no further recovery is anticipated

STAGE 3: CHRONIC/RESIDUAL STAGE (PPRP)

• Fixed muscle imbalance leads to progressive joint deformity
• Young growing children are more prone to bony deformity than adults due to skeletal growth potential
• Dynamic joint instability - if uncorrected - eventually results in fixed bony deformity not controllable with orthoses

• Quadriceps femoris (most common)
• Gluteus maximus and medius
• Anterior tibial (tibialis anterior)
• Medial hamstrings
• Hip flexors

PART 2: CLINICAL FEATURES OF PPRP (POST-POLIO RESIDUAL PARALYSIS) - DETAILED

1. Motor Features

• Flaccid paralysis: Lower motor neuron (LMN) pattern - loss of voluntary movement in affected muscles
• Asymmetric weakness: Characteristically asymmetric, often unilateral or affecting one limb more than another
• Muscle wasting (atrophy): Progressive wasting of denervated muscle groups, resulting in thin, wasted limbs
• Hypotonia: Reduced muscle tone in paralyzed segments
• Absent or reduced deep tendon reflexes (DTRs) in affected segments
• No sensory loss: Polio exclusively targets motor neurons; sensation remains intact (important distinguishing feature)
• Normal bladder and bowel function: Autonomic functions are preserved

2. Bony and Structural Features

• Limb length discrepancy: The affected limb is shorter and thinner due to disuse during growth
• Osteoporosis of the affected limb: Reduced bone density from disuse
• Joint deformities: Genu recurvatum, equinus foot, hip dislocation (see table above)
• Scoliosis: If paravertebral muscles involved
• Pelvic obliquity: From asymmetric lower limb weakness and limb length difference

3. Gait Abnormalities (Pathological Gait Patterns)

4. Functional and ADL Limitations

• Difficulty rising from floor, climbing stairs, squatting
• Falls risk due to knee instability (genu recurvatum) and foot drop
• Inability to run
• Difficulty with dressing (lower body), bathing, transfers
• Reduced walking speed and endurance
• In severe cases: wheelchair dependence

5. Secondary Complications

• Joint pain from abnormal mechanics
• Overuse injuries to unaffected limb from compensatory loading
• Psychological impact: poor self-esteem, social isolation in school-age children
• Scoliosis if unilateral limb weakness persists during growth

PART 3: INVESTIGATIONS FOR PPRP

A. Clinical Assessment Tools

1. Manual Muscle Testing (MMT) - MRC Scale (0-5)
   • Grade 0: No contraction
   • Grade 1: Visible/palpable flicker, no movement
   • Grade 2: Movement possible with gravity eliminated
   • Grade 3: Movement against gravity only
   • Grade 4: Movement against gravity + some resistance
   • Grade 5: Normal strength
   • Critical for: mapping paralyzed vs. functioning muscles; planning tendon transfers; monitoring progress
2. Gait Analysis (Observational or Instrumented)
   • Walking pattern, stance/swing ratio
   • Compensatory mechanisms
   • Footprint analysis for base width and step length
3. Joint Range of Motion (ROM) assessment with goniometer
   • Identify contractures, fixed deformities
4. Limb Length Measurement
   • True leg length: ASIS to medial malleolus
   • Apparent leg length: umbilicus to medial malleolus

B. Electrophysiological Studies

1. Electromyography (EMG)
   • Shows features of chronic denervation and reinnervation:
     • Positive sharp waves and fibrillation potentials (acute denervation)
     • Large amplitude, long duration, polyphasic motor unit potentials (chronic reinnervation)
     • Reduced interference pattern
     • Normal sensory nerve action potentials (distinguishes from peripheral neuropathy)
   • Useful to confirm polio vs. differential diagnoses (Guillain-Barre, ALS, CMT)
2. Nerve Conduction Studies (NCS)
   • Motor conduction velocity: reduced amplitude, normal or slightly reduced velocity
   • Sensory conduction: normal (sensory fibers intact)

C. Imaging

1. X-ray of affected limb and pelvis (AP and lateral)
   • Limb length discrepancy
   • Osteoporosis, thin cortices
   • Bony deformities: genu recurvatum, pelvic obliquity, scoliosis
   • Hip subluxation/dislocation
   • Foot deformities
2. Spine X-ray (full-length standing)
   • Scoliosis, pelvic tilt
3. Ultrasound of muscles
   • Muscle thickness and echo intensity changes
   • Fatty infiltration vs. viable muscle
4. MRI Spine (if diagnosis uncertain)
   • Identifies cord lesions, rules out compressive myelopathy

D. Functional and Laboratory Assessment

1. Functional Independence Measure (FIM) or Barthel Index
   • Quantifies ADL independence
2. Pediatric Balance Scale / Berg Balance Scale
   • Assesses fall risk
3. 6-Minute Walk Test (6MWT)
   • Baseline functional walking capacity
4. Pulmonary Function Tests
   • If respiratory muscles involved
5. Laboratory tests (to exclude differential diagnoses)
   • CBC, ESR, CRP: exclude inflammatory myopathy
   • Serum CK: usually normal in PPRP (helps exclude muscular dystrophy)
   • Viral serology if acute phase (stool culture for poliovirus, CSF analysis)

PART 4: HOME-BASED PHYSIOTHERAPY PROTOCOL

Important principle: Avoid overwork/fatigue. The "use it or lose it" principle does NOT apply to polio-affected muscles. Overexertion causes overwork weakness - a genuine worsening of residual muscle function. All exercises should be non-fatiguing, performed within the comfortable range, with adequate rest between sessions.

PHASE 1: FOUNDATION (Weeks 1-4)

Daily Morning Routine (20-30 min)

• Hip flexor stretch: Child lies supine at edge of bed; unaffected leg brought to chest, left leg hangs down in controlled extension - hold 30 seconds, 5 repetitions
• Hamstring stretch: Supine, left leg raised with knee straight (with parent's assistance) - hold 20-30 seconds, 5 repetitions
• Calf/Achilles stretch: Supine, foot held at neutral (90°) or slight dorsiflexion against plantarflexion resistance - hold 30 seconds, 5 repetitions
• Hip abductor stretch: Side-lying, passive hip adduction stretch for abductor contracture if present

• Ankle circles (assisted by parent): 10 circles each direction
• Knee flexion and extension (gravity eliminated, side-lying): 10 repetitions if grade ≥2
• Hip flexion in supine (active-assisted): 10 repetitions

• Avoid prolonged sitting with knee bent (promotes hamstring contracture)
• Use a footboard or firm pillow to keep ankle at 90° during sleep (anti-equinus positioning)
• Sleep with AFO if prescribed

PHASE 2: STRENGTHENING AND ACTIVATION (Weeks 4-12)

Exercise Program (5 days per week, rest on weekends)

• Side-lying hip abduction (for gluteus medius if grade 2): 3 sets of 8 repetitions
• Supine knee extension against gravity eliminated (quadriceps activation): 3 sets of 10 repetitions
• Ankle dorsiflexion in sitting with foot in water (for tibialis anterior): 3 x 10 reps

• Supine straight-leg raise (quadriceps, hip flexors): 3 x 10 reps; progress to ankle weight (250g) once 3 x 15 achieved with ease
• Standing hip abduction holding support (hand on wall): 3 x 8 reps
• Seated toe raises / calf raises (plantarflexors if strong): 3 x 10 reps

• Mini squats (bilateral, holding chair/rail): 3 x 10 - using strong limb to assist, encouraging left limb participation
• Step-ups on a low step (5-10 cm): 2 x 8 repetitions with rail support
• Bridging (supine, both feet on floor, lift pelvis): 3 x 10 - engages gluteus maximus and hamstrings

• Pool exercises are ideal for PPRP - buoyancy reduces gravity load
• Walking in waist-deep water, kicking exercises, float-assisted leg raises
• 20-30 minutes, 3x per week

PHASE 3: GAIT TRAINING (Weeks 6 onwards, ongoing)

Pre-gait Training (In parallel from Week 1)

1. Standing balance exercises:
   • Stand holding chair - weight shift side to side: 3 x 1 minute
   • Single-leg standing on right limb (unaffected): 3 x 20 seconds
   • Tandem standing (feet in line): progress to tandem walking
2. Weight-bearing on affected limb:
   • Standing at parallel bars/against wall, encourage left limb weight-bearing
   • Partial weight-bearing with crutches progressing to full weight-bearing

Orthotic Use in Gait (liaise with orthotist)

• Ankle Foot Orthosis (AFO): For foot drop/equinus; improves swing phase foot clearance and stance stability
• Knee-Ankle-Foot Orthosis (KAFO)/caliper: For combined knee + ankle weakness; enables ambulation
• Hip stabilizing orthosis: If significant pelvic instability

Gait Pattern Training (with orthosis in place)

• Start in parallel bars, progress to crutches (axillary or forearm crutches)
• Progress gait aid: parallel bars → crutches → walking frame → single crutch → cane → unaided (goal depends on available muscle strength)
• Heel-toe walking practice (if ankle strength allows)
• Practice on different surfaces: flat, carpet, slight incline, outdoor pavement
• Stair climbing: unaffected limb leads going up; affected limb leads going down ("good up, bad down")
• Practice getting up from floor (safety training for falls)

Energy conservation strategies:

• Rest periods between activity bouts
• Use of wheelchair for long distances to preserve muscle resources for short-distance walking

PHASE 4: ADL TRAINING (Ongoing from Week 4)

PHASE 5: HOME EXERCISE MAINTENANCE (Month 3 onwards)

• Increased pain after exercise (lasting >1 hour)
• New weakness in previously functioning muscles
• New deformity developing (increased foot drop, knee bending)
• Falls increasing in frequency

MONITORING AND PROGRESSION CRITERIA

MULTIDISCIPLINARY TEAM INVOLVEMENT

• Orthopaedic surgeon: Tendon transfers (when strength is grade ≥4 in donor muscle), contracture release, deformity correction
• Orthotist: AFO/KAFO fabrication and fitting; serial casting if needed
• Occupational therapist: Home and school adaptations, ADL training, assistive devices
• Paediatrician: Nutritional support, vaccination status review (IPV)
• Psychologist/counselor: School reintegration, self-esteem, peer interaction

• Campbell's Operative Orthopaedics 15th Ed, 2026 - Table 36.1 Stages of Poliomyelitis; pp. 1616-1618
• PM&R KnowledgeNow - Poliomyelitis/Post-Polio Syndrome
• RACGP Rehabilitation for Postpolio Sequelae
• Post-Polio Ireland: Physiotherapy and PPS