Poliomyelitis: Extensive Paralysis

EXTENSIVE PARALYSIS

Man Crawling The severely paralysed child in a developing country usually dies long before maturity (Fig. 28(a)). Initial respiratory paralysis, or respiratory infection during the first few months after paralysis, is often lethal in the early stages of the disease. In addition, many children tend to be neglected in favour of the able-bodied, especially in countries where food is in short supply and families are large. Relatively few children, therefore, ever reach hospital or see a doctor, and even fewer survive to adult life. Some survive because of the care of relatives and a strong will to live on the part of the patient. In some poor communities the severely disabled are taken care of as well as the able-bodied, but they are the exception rather than the rule.

The correct decision regarding management of these patients is a difficult one for the doctor responsible for treatment. The doctor knows that, if the patient is sent away as hopeless and untreatable, there will be little chance of the child surviving, or ever returning for more definitive treatment. On the other hand, prolonged treatment of one severely paralysed patient may mean neglecting twenty or thirty children with easily correctable deformities, and some of these latter patients will also die if left untreated. The compromise is often to perform the simplest procedure initially which will keep the patient alive and which will allow mobility to be achieved if possible. Extensive operations, prolonged physiotherapy and expensive apparatus should be left for the future, and should not even be considered except in very special cases. Simple apparatus can be made very easily in developing countries, or locally adapted from the practical designs available.

The Extensively Paralysed Patient

PRINCIPLES OF TREATMENT (Fig. 28(b))

Some type of independent mobility, however slow and however bizarre, is often a great advance over no mobility at all. On the other hand, this does not mean that months, or even years, should be spent in straightening legs, fitting calipers or giving extensive physiotherapy to enable the patient to take two or three slow steps on a level floor. It is far better that he should be able to crawl fast or swing his body between his arms or use a wheelchair well.

The exception to this is a child who should be got walking if at all possible. It is often surprising how well a child will progress while he or she is upright. Four categories of patients will now be considered under extensive paralysis.

Mobilisation of the quadraplegic patient

a. Moderately severe paralysis

Some patients will be found who are able to walk with supports despite some weakness in all four limbs. These patients are usually the ones with adequate power in at least part of one leg plus the trunk. Encouragement of this type of patient is essential and mobility should be the aim, particularly in children.

b. Type 1 — Severe disability

This is the type of patient who, with treatment, might be able to walk. An important aspect of treatment after careful assessment, is the character and the determination of the patient and the likely co-operation of relatives and friends. Such a patient should have a trial with supports and crutches in order that a practical assessment can be carried out before any major surgery is embarked upon, except for simpler subcutaneous corrections of contractures. However, major surgery is not indicated unless there is a considerable likelihood that the patient will be benefited by such procedures. Major operations, especially those involving bone division, should not be considered, the possible exception being in the case of a child.

c. Type II — Severe disability

The second category of patient is the one who will obviously need a considerable amount of effort to enable the patient just to progress, whether this is by operation or physiotherapy, or both. This is the patient who should be given a wheelchair, if possible, and if the patient is crawling, supports for the arms and feet or knees. Prolonged, painful operations which may leave stiff and sometimes painful joints, are not indicated except in very special cases. The end result may be a patient who can neither crawl nor walk, and who has exchanged a painless disability for a painful one and is worse off than before.

d. Type III — Severe disability

Finally, the third category of patient is the one in which the paralysis of the limb and trunk is so extensive that there is no possibility of getting the patient walking. This is the type of patient for whom a wheelchair is indicated without delay. Rehabilitation for such a patient is important, and every effort should be made to find the patient a job and also to teach the patient to feed, dress and work. In this latter connection, a support for an unstable spine to let the patient sit up properly in a wheelchair, or operations on the upper limb to improve function may be indicated.

APPLIANCES FOR THE SEVERELY DISABLED

Wheelchairs, elbow crutches, walking frames, and modifications to bed, chair and wheelchair are discussed for all these severely disabled patients. In addition a design for a wheelchair and an overhead beam for the very severely disabled patient is described.

Other type of support for the severely disabled

Many patients in developing countries, even if they are lucky enough to be given a wheelchair, will need supports for the arms and legs in order that they should be able to progress outside of a wheelchair. Supports for the hands and the knees are illustrated and although these may look crude, they are in fact, comfortable and practical for a patient, particularly one living outside of major cities.

Each patient should be assessed on his or her merits and it is sometimes better to give a severely paralysed patient hand holds so that he can swing his legs between his arms rather than try to get him to crawl with very severe contractures.

Finally, there is a whole series of patients who will only just be able to progress, often in a bizarre type of manner. It is seldom that such patients cannot be helped to some extent by supports on arms or legs or both, and these patients should be considered individually and made an appropriate support, as illustrated.