Polio, Polio Surgery and Post-Polio Syndrome
John Dugaw MD, PP, PHF, Treasurer Rotary E-Club SW USA
These two photographs show deformities that are typical of what occurs to paralyzed limbs after
acute paralytic poliomyelitis. Problems like these occur in the arms and legs of victims depriving
them of use of their hands, feet, ability to walk, keeping them dependent on their family and
community. In an area hit with a recent polio epidemic beggars who are “crawlers like the boy with
the legs in the second photo are all too common. A recent club program brought out that many of
our members are unaware of all the long term sequelae of paralytic poliomyelitis. President Ginny
asked for a program on this as we have seen some children like this in Guatemala. I will try to take
you all briefly through this difficult area.
The boy in the top photo cannot straighten out his legs and is waiting for a “polio” surgery, the legs
of the boy in the bottom do not move out of the position they are in. The boy on the top had a
surgery and is probably walking with braces and crutches. Hopefully the boy on the bottom has
received the help he needs by now. As I remember the beginning of Rotary Polio Plus Campaign in
1985, the major reason to tackle poliomyelitis was that when it killed children it was emotionally
devastating for the families; but when the children survived crippled, unable to work or provide for
themselves, families, many of whom were already destitute, were financially ruined by having a
non-productive extra child or adult needing care. A polio epidemic in a poor rural community would
affect the life in that community for many years. These communities could almost never reverse the
downward trend that this disease had given them. A dead child is a loss for the moment, a crippled
child is a terrible burden for all around them. In our society today we struggle financially to provide
nursing home care for the elderly, it is a huge burden in a rich society. Polio is a terrible disease
from both a medical and social view point and a disaster in a poor society. In 1986 Rotary stepped
up to eradicate polio and also to help survivors move on to lead productive lives. This mean
vaccination along with medical, surgical, social services for the survivors. If the boy in the top photo
can walk in braces he can care for himself for most needs, possibly work. The boy at the bottom
probably cannot adequate use a toilet hygienically let alone work. These devastating deformities
are amenable to surgical treatment by specialized orthopedic polio surgeons. The Rotary
Foundation has a strong program to provide this sort of care, especially in India.
Rotary International has been supporting the Polio Ward at St. Stephens Hospital in New Delhi
India. Please look at this link and watch the associated video to see what is being done there and
experience the gratitude of the patients who were “crawlers” before their surgeries.
http://www.voanews.com/content/indian-surgeon-helping-polio-patients-take-firststeps/1766219.html
The surgery is complicated to perform, involves taking muscles that are functioning and diverting
them to do the opposite action from what they were doing. A tendon that pulls the foot down is cut
and pulled through between bones of the forefoot and sutured to a tendon in the foot that previous
had pulled the foot up. A downer becomes an upper and the patient has more mobility, but does
need a lot of therapy to make it work, but it does. I was fortunate when a medical student to work
with a hand surgeon who was a really polio specialist as those cases made up a large part of his
training in the late 1940’s. What he could do to help these people was amazing, and the upper
became a downer and the remaining uppers still upped. Knee and ankle joints that have twisted
into positions that seem impossible with casting, surgical release of over tight ligaments can be put
into functional positions so the patient can use them again. These people go from crawling
beggars to functional adults. The same types of surgery are also done in other recently polio
afflicted countries. The surgeries that can be done are five types.
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Contracture release surgery
Muscle transplantation
Joint stabilization
Limb lengthening
Foot contracture surgery
This man has had a leg lengthening surgery
and a foot contracture surgery.
The frame work is Ilizarov surgical frames.
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This patient had a 180 degree rotational of his
lower leg and foot and a foot contracture.
This is an example of a down tendon converted to an up tendon
In 1996 this was the status of polio surgery from: Mary Ann Keenan, MD, Albert Einstein
Healthcare Network, Philadelphia, Pennsylvania
“The procedures for polio now are the same as then, but fewer are done. The goals for surgery are
very much the same – rebalance the muscle forces. Even a weak muscle, totally unopposed
across a joint with nothing to balance it on the other side, needs to be in balance. Surgery aims to
correct limb deformities, improve function, and to stabilize the spine or limb.
Previously the goal was to eliminate braces. But now the goal is to improve bracing options. Older
individuals have less muscle power and polio-affected muscles have been working extra hard.”
From the crawlers to the toe walkers polio leaves wretched deformities, debility and functional loss.
This video is an advertisement for a private polio surgeon Dr. Bhola, showing actual patients and
how they improved from surgery. It is in Hindi with subtitles. I thought it really demonstrated that
almost 30 years of Polio Plus is truly worth the work if we can prevent problems such as those
shown in this video. Residuals of polio will be with us for a while longer. Rotary will be there
helping. Here is a You Tube video of his work and people helped.
https://www.youtube.com/watch?v=zyKdG_1-4-s
If one survives the initial infection and paralysis from polio and does well there is another problem
which started to be identified in the late 1970’s. This will affect a lot of the people who have
undergone polio surgery but with the surgery they will have had 30 or so years of reduced disability
and improved function. There is no solution except eradication of the disease but post-polio
syndrome is a different sort of problem. These patients have had polio 30-40 years prior and have
recovered function well and suddenly they develop slowly progressive weakness in the muscles
that were involved with the previous polio infection. It occurs in 25-28% of patients with previous
poliomyelitis. Those more frequently affected are persons who had poliomyelitis at a younger age
and very severe disease at that time; those with incomplete recovery and residual disability and
those who have had greater physical activity in the intervening years—such as elite runners and
other types of athletes. It was first described in the medical journals in 1984. It seems to be that the
poliomyelitis virus kills a lot of the nerve cells in the spinal cord and as healing occurs the
remaining nerve cells take on the work of those cells which died. This allows the patient to heal and
regain function. But apparently these “overextended” motor neurons just finally run out of gas and
prematurely degenerate. They are unable to maintain the connections with the muscle cells. The
process is very slow as there is a loss of over 50% of the overworked nerve cells before weakness
can be detected. This syndrome can look like other diseases such as ALS (Lou Gehrig’s disease),
multiple sclerosis, spinal stenosis and multiple other conditions. It is a clinical diagnosis made
mostly by what it is not than by what it is. Once the “is not” category is eliminated and a history of
polio is found the diagnosis can be presumptively made. There is no “golden standard” blood
analysis or other testing for a “certain” diagnosis. There is no evidence of treatment that is proven
effective but general muscular rehabilitation measures are used with generally an improvement in
fatigue, functional ability and quality of life measures. Some become very debilitated and go from
full activity to electric wheel chairs. The process is very slow with 1% loss of muscle strength per
year.
Rotary International has taken on the eradication of Poliomyelitis and the rehabilitation treatment of
its many victims. We are close to eradication, however, after the last case of polio we will have to
be absolutely vigilant in continuing vaccination as usually only two cases in a hundred of active
poliomyelitis are paralytic. So for the obvious case there are 49 others without symptoms or
residuals, which is why we are monitoring the sewage out flow in cities looking for the virus and
checking water supplies in endemic countries at this time. We will need to keep up that surveillance
and we will need to change to an inactivated Salk injectable vaccine to prevent the possibility of
transmitting paralysis from the currently used oral live polio vaccine. This much more expensive but
what we have been doing in the USA for almost 20 years. We are very close to eradication but we
will not see the end of the mayhem wrought by poliomyelitis on its victims for a long time. But there
will be an end.