What are the orthopaedic management recommendations for patients with poliomyelitis (polio)?

Orthopedic Management of Poliomyelitis

Orthopedic management of poliomyelitis should focus on addressing contractures, muscle weakness, and functional limitations through a combination of surgical intervention, physical therapy, and appropriate orthotic devices to improve mobility and quality of life.

Clinical Presentation and Pathophysiology

• Poliomyelitis affects the anterior horn cells of the spinal cord, causing lower motor neuron damage that leads to muscle weakness, atrophy, and eventual contractures 1
• Most poliovirus infections are asymptomatic, but paralytic polio occurs in approximately 0.1-1% of all infections 1
• Paralytic manifestations typically include asymmetric spinal paralysis that is more severe proximally than distally, with absent or diminished deep tendon reflexes 1
• Post-polio syndrome affects 25-40% of polio survivors 30-40 years after initial infection, characterized by new muscle weakness, pain, and fatigue 1, 2

Contracture Management

• Hip and knee flexion contractures are common sequelae of poliomyelitis and require thorough understanding of the anatomy of the fascia lata and iliotibial band for proper treatment 3
• Treatment approach should be based on severity of contractures:
  • Mild contractures: manipulation and plaster casting 4
  • Moderate contractures: partial soft-tissue release of hamstrings and fascia lata followed by gradual stretching through manipulation and plaster 4
  • Severe contractures: skeletal traction through Steinmann pins inserted into the tibia and calcaneus 4
• Maintenance of correction requires plaster immobilization, physical therapy, and appropriate orthotic devices to prevent recurrence 4
• Severity of knee contractures often correlates with hip flexion-abduction contractures and ankle equinus deformity, requiring simultaneous correction 4

Muscle Strengthening

• High-resistance, short-duration muscle strengthening exercises should be considered for moderately weak muscles in post-polio patients 5
• A structured weight training program (three times weekly, five sets of ten repetitions) has shown significant improvements in muscle strength (32-61% increase) after one year 5
• Exercise programs must be carefully designed due to potential detrimental effects related to excessive use and dysfunction of motor neurons 6

Fall Prevention and Functional Improvement

• Polio survivors fall up to four times more often than age-matched healthy peers due to impaired balance, slow gait, and dysfunctional lower-limb kinematics 6
• Interventions should address:
  • Balance training to improve postural control 6
  • Cognitive behavioral therapy to address psychological aspects 6
  • Appropriate orthotic prescription to enhance stability and function 6

Post-Polio Syndrome Management

• Post-polio syndrome primarily manifests as increased muscle weakness, muscle atrophy, joint pain, and unexplained fatigue 2
• The main impact of disability is in mobility-related activities, with greater dependence in instrumental activities of daily living (cooking, transportation, cleaning, shopping) 2
• An interdisciplinary approach addressing both impairment and disability aspects is essential for effective treatment and intervention 2

Practical Considerations

• Dependence in personal activities of daily living is relatively rare, but difficulties with instrumental activities are common, especially in those with post-polio syndrome 2
• Mental health support may be needed as patients cope with new health problems and increasing disabilities 2
• Orthopedic interventions should be part of a comprehensive rehabilitation approach that includes physical therapy, occupational therapy, and psychological support 2, 6