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PART 1 WORKING WITH THE CHILD AND FAMILY: Information on different DisabilitiesB. Recognizing, Helping with, and Preventing Common Disabilities 059 CHAPTER 7PolioInfantile ParalysisHOW TO RECOGNIZE PARALYSIS CAUSED BY POLIO
060 BASIC QUESTIONS AND ANSWERS ABOUT POLIO How common is it? In many countries, polio - or 'poliomyelitis'- is still the most common cause of physical disability in children. In some areas, at least one of every 100 children may have some paralysis from polio. Where vaccination programs are effective, polio has been greatly reduced.What causes it? A virus (infection). The infection attacks parts of the spinal cord, where it damages only the nerves that control movement. In areas with poor hygiene and lack of latrines, the polio infection spreads when the stool (shit) of a sick child reaches the mouth of a healthy child. Where sanitation is better, polio spreads mostly through coughing and sneezing.  Do all children who become infected with the polio virus become paralyzed? No, only a small percentage become paralyzed. Most only get what looks like a bad cold, with fever. However, if a child with a 'cold' caused by the polio virus is given an injection of any medication, the irritation caused by the injection can bring on paralysis. (See warning on Page 19.) Is the paralysis contagious? No, not after 2 weeks from when a child first gets sick with polio. In fact, most polio is spread through the stool of non-paralyzed children who have 'only a cold' caused by the polio virus. At what age do children get polio? In areas with poor sanitation, polio most often attacks babies from 8 to 24 months old, but occasionally children up to age 4 or 5. As sanitation improves, polio tends to strike older children and even young adults. Who does it most often affect? Boys, a little more than girls. Unvaccinated children much more often than vaccinated children. (See Page 74). Young children who are given injections unnecessarily are paralyzed by polio more often those who are not. How does the paralysis begin? It begins after signs of a cold and fever, sometimes with diarrhea or vomiting. After a few days the neck becomes stiff and painful and parts of the body become limp. Parents may notice the weakness right away, or only after the child recovers from the acute illness. Once a child is paralyzed, what changes or improvements can be expected? Often the paralysis will gradually go away, partly or completely. Any paralysis left after 7 months is usually permanent. The paralysis will not get worse. However, certain secondary problems may develop-especially if precautions are not taken to prevent them. What are the child's chances of leading a happy, productive life? Usually very good-provided the child is encouraged to do things for himself, to get the most out of school, and to learn useful skills within his physical limitations (see Page 497). Can persons with polio marry and have normal children? Yes. Polio is not inherited (familial) and does not affect ability to have children. SECONDARY PROBLEMS TO LOOK FOR WITH POLIOBy secondary problems, we mean further disabilities or complications that can appear after, and because of, the original disability.
A contracture is a shortening of muscles and tendons (cords) so that the full range of limb movement is prevented. Unless preventive steps are taken, joint contractures will form in many paralyzed children. Once formed, often they must be corrected before braces can be fitted and walking is possible. Correction of advanced contractures, whether through exercises, casts, or surgery (or a combination), is costly, takes time and causes discomfort. Therefore early prevention of contractures is very important. A full discussion of contractures, their causes, prevention, and treatment is in the next chapter (Chapter 8). Methods and aids for correcting contractures are described in Chapter 59.
OTHER COMMON DEFORMITIES Weight bearing (supporting the body's weight) on weak joints can cause deformities, Including:
SPINAL CURVE
062 WHAT OTHER DISABILITIES CAN BE CONFUSED WITH POLIO?
WHAT CAN BE DONE?DURING THE ORIGINAL ILLNESS, when the child first becomes paralyzed:
Note: To reduce pain, you may need to put cushions under the knees, but try to keep the knees as straight as you can. FOLLOWING THE ORIGINAL ILLNESS:
064 REHABILITATION OF THE CHILD WITH PARALYSIS All children paralyzed by polio can be helped by certain basic rehabilitation measures-such as exercise to keep a full range of motion in the affected limbs. However, each child will have a different combination and severity of paralyzed muscles, and therefore will have his own special needs. For some children, normal exercise and play may be all that are needed. Others may require special exercises and playthings. Still others may need braces or other aids to help them move about better, do things more easily, or keep their bodies in healthier, more useful positions. Those who are severely paralyzed may be helped most by a wheelboard (trolley) or wheelchair.
  Unfortunately, 'in most areas where polio is still common, village rehabilitation programs do not exist or are just beginning. Many children (and adults) who have been paralyzed for a long time already have severe deformities or joint contractures. Often these must be corrected before a child can use braces or begin to walk. Because contractures are such a common problem, not only with polio but with many other disabilities, we discuss them separately in the next chapter. Before evaluating a child with polio, we strongly suggest you read Chapter 8 on contractures.
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 1. exercises to keep full range of motion, starting within days after paralysis appears and continuing throughout rehabilitation  2. supported sitting in positions that help prevent contractures  3. active exercises with limbs supported, to gain strength and maintain full motion 4. exercise in water - walking, floating, and swimming, with the weight of the limbs supported by the water  5. wheelboard or wheelchair with supports to prevent or correct early contractures.  Note: These also provide good arm exercise in preparation for walking with crutches.  6. braces to prevent contractures and prepare for walking  7. parallel bars for beginning to balance and walk  8. walking machine or 'walker'  9. crutches modified as walker for balance and extra support  10. under arm crutches  11 . forearm crutches and perhaps in time . . .  12. a cane or no arm supports at all Note: These pictures are only an example - but most of the steps are necessary for many children. Children who begin rehabilitation late may also have contractures or deformities requiring corrective steps not shown here. 066 EVALUATING A CHILD'S NEEDS FOR AIDS AND PROCEDURESStep 1: Start by learning what you can through talking with the child and family (see Child's History, Page 37 to 38). As you do this, watch the child move about. Observe carefully which parts of the body seem strong, and which seem weak. Look for any differences between one side of the body and the other-such as differences in the length or thickness of the legs. Are there any obvious deformities, or joints that do not seem to straighten all the way? If the child walks, what is unusual about the way she does it? Does she dip forward or to one side? Does she help support one leg with her hand? Is one hip lower than the other? Or one shoulder? Does she have a humpback, a swayback, or a sideways curve of the back? These early observations will help you know what parts of the body you most need to check for strength and range of motion. Often, by watching a child you can begin to get an idea about what kind of aids or assistance may help. For example:
067
Step. 2: This is the physical examination. It should usually include: 1.Range-of-motion testing, especially where you think there might be contractures. (See "Physical Examination," Page 27 to 29, and "Contractures," Page 79 and 80.) 2. Muscle testing, especially of muscles that you think may be weak. Also test muscles that need to be strong to make up for weak ones (such as arm and shoulder strength for crutch use). (See Page 27 and Page 30 to 33.) 3. Check for deformities: contractures; dislocations (hip, knee, foot, shoulder, elbow); difference in leg length; tilt of hips; and curve or abnormal shape of the back. (See Page 34.) 068 Step 3: After the physical exam, again observe how the child moves or walks. Try to relate her particular way of moving and walking with your physical findings (such as weakness of certain muscles, contractures, and leg length). (For an example, see Page 70.) Step 4: Based on your observations and tests, try to figure out what kind of exercises, aids, or assistance might help the child most. Consider the advantages of different possibilities: benefit, cost, comfort, appearance, availability of materials, and whether the child is likely to use the aid you make. Ask the child and parents for their opinions and suggestions. Step 5: Before making a final brace or aid to fit the child, if possible test to see how well it may work by using a temporary aid or old brace from another child. For example,
Step 6: After the child, her parents, and you have decided what kind of brace or aid might work best, take the necessary measurements and make the brace or aid. When making it, once again it is wise to put it together temporarily so that you can make adjustments before you rivet, glue, or nail it into its final form. (See Page 540.)  Step 7: Have the child try the brace or aid for a few days to get used to it and to see how well it works. Ask the child and parents if it seems to help. Does it hurt? Are there any problems? How could it be improved? Is there something that might work better? Make what adjustments are necessary. But remember that no brace or aid is likely to meet the needs of a child perfectly. Do the best you can. 069 Here is a story of how workers in a small village rehabilitation program figured out what kind of aids a child needed. How many of the steps we have just discussed did they follow? Was each step important? A STORY: A BRACE FOR SAUL  One day a mother from a neighboring village arrived at the village center with her 6 year old son, Saul. Mari and Chelo, 2 of the village rehabilitation workers, welcomed them warmly. Learning that Saul had polio as a baby, they asked him to walk, and then to run, while they watched carefully. Saul limped a lot and one leg looked thinner and shorter. With each step it bent back at the knee. "He walks quite well, really," said Mari. "But he has to 'lock' his knee back in order to put weight on it. That knee is going to keep stretching back and some day it will give out." "A long-leg brace would protect his knee," suggested Chelo. "Oh, please, no!" said Saul's mother. "A year ago we took Saul to the city and the doctors had a big metal brace made for him. It cost so much we are still in debt! Saul hated it! He would always take it off and hide it. We tried and tried to get him to use it, but he wouldn't."  "That's not surprising," said Mari. "Often a child who can walk without a brace will refuse to use one-even if he walks better with it. We could make him a long-leg brace out of plastic. It would be much lighter. What do you say, Saul?" Saul began to cry. "Don't worry, Saul. Maybe we can do something simpler," said Mari. "But first let's examine you, okay?" Saul nodded. On muscle testing Saul, they found he could not straighten his knee at all. But he had fair strength for bending his knee back  and his hip forward,  and good strength for bending his hip back.  "With the hip and thigh strength he has, he should almost be able to stand on that leg without the knee bending back," said Mari. "Saul, let's see you try it like this. Pretend you're a stork!" For a moment Saul could do it. "Good!" said Mari. "Every day stand like that and see how high you can count without letting your knee go back. Every day try to beat your old record! Okay?"  "Okay," said Saul. Sounds like fun!" "The stork exercises may help," said Chelo. "But I still think he needs a brace. At least at first." We must weigh the advantages against the disadvantages," said Mari. "A long-leg brace would keep his knee straight. But it could weaken the muscles he needs to strengthen. Since the brace would keep his leg from bending back, he wouldn't have to use his muscles to do it.  "On the other hand, we might try a short-leg brace that holds his foot at almost a right angle. Then, to step flat he will have to keep his knee nearly straight. It could help him strengthen his behind-the-thigh muscles." "Let's try it!" Everyone agreed, except Saul.  Chelo brought someone's old, lower-leg plastic brace and showed it to Saul. "See how it will fit right around your leg. It isn't heavy at all. Lift it! And no metal joints to get in the way! What do you say? Do you want to try it?" "I guess so," said Saul. When the brace was made, they tested it. Saul said he liked it. At first, when he tried hard, he could walk without bending his knee back. But after a few days, his mother complained that often he would walk, or even stand, with his knee bent way back as before, and his toes in the air, like this.   "I have an idea," said Chelo. "Why don't we let the heel stick out behind the shoe. That way, when he steps, his weight will come well forward of the back of his heel. This should help bring his foot down and his knee forward." They tried it, and most of the time (especially when he was reminded) Saul walked without letting his knee bend back much."   At home Saul's mother encouraged him to do his stork exercises. As his muscles grew stronger, he began to walk without bending his knee far back-even in active play!  071 WILL MY CHILD EVER BE ABLE TO WALK? " This is often one of the first questions asked by the parents of a disabled child. It is an important question. However, we must help parents realize that other things in life can be more important than walking (see Page 93). If the child whose legs are severely paralyzed by polio is to walk, generally she will need at least 2 things: 1. fairly strong shoulders and arms for crutch use 2. fairly straight legs (hips, knees, and feet). (it is important to correct contractures so that the legs are straight or nearly straight before trying to adapt braces for walking.) To evaluate a child's possibility for walking, always test arm and shoulder strength:  Have her try to lift her body weight off the ground with her arms, like this. If she can easily lift up and down several times, she has a GOOD chance of being able to walk using crutches. If her arms and shoulders are so weak she cannot begin to lift herself, her chances for crutch - walking are POOR.  If her shoulder and arm strength is FAIR, and the child can almost lift herself, daily exercise lifting her weight like this may increase strength enough to make crutch use possible. Having the child lift herself while holding bar like this will also help strengthen her hands and wrists for crutch use.  Pushing herself in a wheelchair or wheelboard (trolley) is a practical way to strengthen shoulders, arms, and hands.  If the child cannot lift herself because of weak elbows, put simple splints on her arms to see if she can lift herself with these.  If she can lift herself with the elbow splints, maybe she can use crutches that give elbow support.  If she is fat, she should lose weight. This will make walking on weak limbs much easier. Now check how straight the legs will go. (See range-of-motion testing, Page 27.)  If the hips, knees, and feet can be placed in fairly straight positions, chances for walking soon with braces are good (if arm strength is good).  But if the child has much contracture of the hips, knees, or feet, these will need to be straightened before she will be able to walk. For correction of contractures, see Chapters 8 and 59.  Sometimes, if contractures are severe in one leg only, the child can learn to walk on the other leg only, with crutches. But it is best with both legs, whenever possible. 072 After checking arm strength and leg straightness, the next thing to check is the strength in the ankles, knees, and hips. This will help you decide if the child needs braces, and what kind. A child with a foot that hangs down (foot drop), or flops to one side may be helped by a below-knee brace of plastic or metal.
For foot drop, you can make a brace that lifts the foot with a spring or rubber band. (See Page 545.)  The kind of brace you choose will depend on various factors, including cost, available skills and materials, and what seems to work best for the particular child. Advantages and disadvantages of different kinds of braces, and how to make them, are discussed in Chapter 58. A child with a weak knee may need a long-leg brace of plastic or metal.
Note: Not all children with no strength to straighten the knee need long-leg braces:A child with strong butt muscles may be able to walk without a brace.
073 A child with very weak hip muscles may find his leg flops or twists about too much with a long-leg brace.    He may need a brace with a hip band to help stabilize the leg at the hip.
A child with weak body and back muscles, who cannot hold up her body well, may need long-leg braces attached to a body brace or body jacket.   Note: Often a child at first may need a hip band or body jacket to help stabilize her for walking. A few weeks or months later she may no longer need it. Removing it may help the child gain more strength and control. It is important to re-evaluate the child's needs for bracing periodically.
A child whose backbone is becoming seriously curved may benefit from a body brace (or in severe cases, she may need surgery).   If necessary, the body brace can be attached to long-leg braces as shown above. More information on spinal curve can be found in Chapter 20. For information on how to make body braces and jackets, see Chapter 58. 074 PREVENTION OF POLIO
It is estimated that in poor countries at least one-third of vaccines are spoiled by the time they reach the children. Therefore, even in children who have been vaccinated, additional precautions are needed: 
075 PREVENTION of secondary problemsWe have already discussed some ways to prevent new problems or complications in a child with paralysis. In summary, important measures include:
For more details, see "Contractures," Chapter 8.
076 A BOY WITH POLIO BECOMES AN OUTSTANDING HEALTH AND REHABILITATION WORKER Marcelo Acevedo was disabled by polio. He and his family lived in a village 2 days from the closest road. Village health workers from Project Piaxtla helped Marcelo get surgery for his knee contractures. After surgery he got braces and went to school. Then they trained him as a village health worker, and he returned to serve his village.    When PROJIMO was formed, Marcelo joined as a village rehabilitation worker. He studied brace-making as an apprentice in 2 brace shops in Mexico City.
Marcelo is now one of the leaders in PROJIMO, and has gained the respect of the whole village. He has recently married a village woman. Go back to the CONTENTS Disabled Village Children A guide for community health workers, rehabilitation workers, and families by David Werner Published by The Hesperian Foundation P.O. Box 11577 Berkeley, CA 94712-2577 Copyright © 1987 by the Hesperian Foundation 2nd edition, 5th printing February 1999 |
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'Knee jerks' and other tendon reflexes in the affected limb are reduced or absent. (In cerebral palsy, 'knee jerks' often jump more than normal. See 
