Acute Flaccid

Paralysis
Rehabilitation
Prof. Nongmaithem Romi Singh
Department of Physical Medicine and Rehabilitation
Regional Institute of Medical Sciences, Imphal

Introduction
Acute flaccid paralysis is defined as
weakness in one or more limbs, or the
respiratory or bulbar muscles, resulting
from damaged lower motor neurones
The term"flaccid"indicates the presence
of LMN paralysis

LOWER MOTOR NEURON

LOWER MOTOR NEURON

LESION
Classically there is
Weakness
Reduced tone (flaccid weakness)
Reduced or absent reflexes
Remembered that acute spinal shock
(e.g. caused by trauma) can initially
cause flaccid paralysis before
spasticity develops
4

CONDITIONS CAUSING AFP

SITE

CONDITIONS

Anterior horn cells

Poliomyelitis
Transverse myelitis
Other enteroviruses

Peripheral nerves

Guillian Barre Syndrome

Toxins(diphtheria,Porphyria)

Neuromuscular junction

Myasthenia gravis
Botulinum
Tick toxin

Muscle

Myopathy
Metabolic( periodic paralysis)
5

Polio vs GBS vs Transverse

myelitis
Age

Fever

Paralysis

CSF

Paralytic
Polio

Below 3
years

Just before
onset of
paralysis

Asymmetric
al
Descending
Proximal
muscle
involve first

Normal
protein
WBC 20300

GBS

Above 2
years

Occurs 2-3
weeks
before onset
of paralysis

Symmetrica Increased
l
protein
Ascending
WBC <10
Distal small
muscles
involve first

Transverse
Myelitis

4 and above Rare

Symmetrica Increased
l
protein
Ascending
Increased
WBC
6

Complications
Weakness
Fatigue, muscle and
joint pain
Tightness/ contracture
Deformity
Wasting/ atrophy
ADL- eating, grooming,
bathing, toileting,
dressing
Transfer & Ambulation
7

Deformity:
Spine
: scoliosis
Hip
: flex/ abd, ext rotation,
subluxation hip
Knee
: flex deformity of knee
genu recurvatum of
knee, Valgus
Ankle
: equinus, varus, valgus,
pes planus
Limb length: shortening
Upper limb :adduction & subluxation
8

MANAGEMENT
Clinical work up
Treatment

10

TREATMENT
Specific treatment
Symptomatic and supportive
Rehabilitation

11

Symptomatic and
supportive
Bed rest
Pain management
Positioning of the limbs
Good nutrition

12

 Bed rest
Essential during acute phase
Physical activity and trauma
increase the risk of paralytic polio
Position change every 2-3 hourly

13

 Pain
management
Analgesics
Physical
therapy
- Moist Heat
Therapy
- Paraffin Wax
Bath

14

Positioning of the limbs

To prevent
Contracture
pressure ulcer
compression of
nerve
To start as soon as
possible

15

 Supine
Hip slightly flex
Knee 5 degree flexion
Foot 90 degree support
against footboard/ firm
pillow

16

Side lying:

Positioning on either side

Hip and knee flexion of top

leg
Pillow in between leg
Lower arm externally rotated
Top arm support with pillow

17

Prone:
Hip & knee - extension
Arm abducted, elbow extended ,
forearm supinated
Wrist extended
Shoulder roll under each shoulder

18

REHABILITATION

Exercises
Physical Therapy
Orthoses
Gait Aids
Surgery
Lifestyle modification

19

 Exercise
Range of
motion(ROM):
ROM of affected limb
To prevent contracture
To maintain joint and
soft tissue mobility
Depending on degree of
pain and weakness
Types: passive ROM
active ROM
active assisted
ROM

20

Stretching:
To increase ROM
To increase extensibility of soft tissue
To prevent contracture associated with
weakness
Manually, mechanically, splint, casts
Moving in the direction opposite to
restriction
Slow prolonged stretch 5 secs to 5 mins
Avoid stretching beyond the point of skin
blanching
21

Strengthening:
Assess strength of muscle before
starting
To avoid overwork weakness(if <3/5
grade)
AIM: To facilitate performance of ADL and
and ambulation with assistive
device
Types: Isometric
Isotonic (progressive resistive
22

Isometric
Muscle contraction with
no limb motion
To prevent or minimize
muscle atrophy
To improve muscle
strength
5 secs contraction, 5
secs hold for 3 times
daily

23

Isotonic
Muscle contraction
with limb motion
Late stage of
rehabilitation
Muscle power 3/5
Active resistive
exercise

24

Electrical stimulation
Faradic type- innervated muscle
Galvanic type- denervated
muscle
impulse duration of 100 msec
Uses: Assist in muscle
contraction
Prevent muscle atrophy
Effects of ES:
Increased metabolism
Removal of waste products
Increase blood supply to muscle
25

Knee Ankle Foot

Orthosis(KAFO)
External device attached
to lower limb
To provide stability of
weak limb
To aid in ambulation and
correct deformity

26

Ankle Foot Orthosis (AFO)

Plastic moulded AFO
Used for foot drop
Keep the ankle at 90
degrees and prevent
the foot from
dropping towards the
ground
easier for the
patient to walk
Dorsiflexion
Resisting AFO

27

 Floor Reaction
AFO
Maintain the
affected joints in
proper alignment
Accentuate knee
extension at
midstance
Compensate for
weak calf
muscles

28

29

Shoe Modification
Applied heel only or whole
length of outsole
Applied internally
To compensate fixed
equinus deformity
leg length shortening
more than
inch(1.25cm)
30

Gait Aid

TYPES:
Straight cane- 1 point of support
mild to
moderate
weakness
Quad cane- 4 points of support
moderate
weakness
31

Axillary crutch
-single base of support
-usually use in pairs
- mild to moderate weakness
Forearm crutch
-single base of support
-moderate to sever weakness
Walker - 4 points base of support

32

Surgery

Tendon transfer: insertion of healthy

functioning muscle to a new site,
so that the muscle has a different
action
Indication:
Deformity resulting from muscle
imbalance
Interfere with ambulation or
function of upper extremities
To restore or improve active control
33

Operation:
Tibialis anterior muscle
weakness
Loss of DF and inversion
Equinus, cavus, planovalgus
deformity
Transfer of peroneus longus to
base of 2nd metatarsal
Tibialis posterior weakness
Hindfoot and forefoot eversion
Transfer of flexor hallucis longus
34

Wrist extensor and finger

weakness
Transfer of pronator teres to
extensor carpi radialis brevis
Flexor carpi ulnaris toextensor
digitorum and extensor pollicis
longus
Palmaris longus to abductor pollicis
longus
35

Limb lengthening:
Indication- shortening >
4cm
Management:
Tendoachilles(TA)
lengthening in
contracture
Ilizarov technique
Correct angulation as well
as lengthening
Distraction at rate of
2mm /day
Maximum gain of 5mm in

36

Lifestyle modification:
Maintain weight
Regular rest during day to avoid
fatigue
Moderate physical activity

37

38

39

 correct balance of rest and exercise

is essential
Avoid overuse as much exercise
causes increased weakness and
fatigue in damaged muscles
Graded exercise is beneficial probably be broken up by periods of
rest
Non-swimming exercise in warm
water
40