AMPUTEES
DEFINITION
Amputation is the intentional surgical removal of a limb or body part. It is performed to remove diseased tissue or relieve pain or due to Trauma.
PURPOSE
Arms, legs, hands, feet, fingers, and toes can be amputated. Most amputations involve small body parts such as a finger, rather than an entire limb. Amputation is performed for the following reasons:
· to remove tissue that no longer has an adequate blood supply
· to remove malignant tumors
· because of severe trauma to the body part
The blood supply to an extremity can be cut off because of injury to the blood vessel, hardening of the arteries, arterial embolism, impaired circulation as a complication of diabetes mellitus, repeated severe infection that leads to gangrene, severe frostbite, Raynaud's disease, or Buerger's disease.
CAUSES:
· Trauma
· Circulatory disorders
· Neoplasm
· Deformities
· Infection
· Athletic performance
· Legal punishment
Traumatic amputation
Traumatic amputation is the partial or total avulsion of a part of a body during a serious accident, like traffic, labor, or combat.Traumatic amputation of a human limb, either partial or total, creates the immediate danger of death from blood loss
Circulatory disorders
· Diabetic foot infection or gangrene (the most frequent reason for infection-related amputations)
· Sepsis with peripheral necrosis
Neoplasm
Transfemoral amputation due to liposarcoma
· Cancerous bone or soft tissue tumors (e.g. osteosarcoma, osteochondroma, fibrosarcoma, epithelioid sarcoma, Ewing's sarcoma, synovial sarcoma, sacrococcygealteratoma, liposarcoma)
· Melanoma
Deformities
Deformities of digits and/or limbs (e.g., proximal femoral focal deficiency)
· Extra digits and/or limbs (e.g., polydactyly)
Infection
· Bone infection (osteomyelitis)
· diabetes
· frostbite
Athletic performance
· Sometimes professional athletes may choose to have a non-essential digit amputated to relieve chronic pain and impaired performance. Australian Rules footballer Daniel Chick elected to have his left ring finger amputated as chronic pain and injury was limiting his performance. Rugby union player Jone Tawake also had a finger removed. National Football League safety Ronnie Lott had the tip of his little finger removed after it was damaged in the 1985 NFL season.
Legal punishment
· Amputation is used as a legal punishment in a number of countries, among them Iran, Yemen, Saudi Arabia, Sudan, and Islamic regions of Nigeria.
TYPES OF AMPUTATION
The following three sections discuss the two main categories of amputation and the areas of the body that are most commonly affected:
Traumatic amputation
Of course, in the broadest sense of the term, all amputations are traumatic. However, the category ‘traumatic amputation’ refers to the way in which the amputation has occurred i.e. it is a sudden, violent and unexpected event that causes the loss of a person’s limbs.
There are innumerable ways in which an amputation can occur; ranging from high-risk situations where people are knowingly in positions of considerable danger, through to unfortunate and randomly occurring ‘freak-accidents’.
Causes
· Amputations in traffic accidents (cars, motorcycles, bicycles, trains, etc.)
· Amputations in labor accidents (equipments, instruments, cylinders, chain saws, press machines, meat machines, wood machines, etc.)
· Amputations in agricultural accidents, with machines and mower equipments.
· Amputations from electric shock hazard
· Amputations from guns, weapons, and explosives, dynamite, bombs, fireworks, etc.
· Amputations from violent rupture of ship rope or industry wire rope.
· Amputations from ring traction (ring amputation, de-gloving injuries)
· Amputations from building doors and car doors.
· Amputations from other rare accidents.
A traumatic amputation is an incredibly dangerous and often life-threatening situation, particularly through the loss of blood, but due to the advances in medical science during the last century, the prospects of survival have increased considerably. Treatment is usually quick to arrive at the scene of an accident, and efficient transferral to hospitals is possible by both road and air.
In traumatic amputations where a limb cannot be re-attached, the injured person—or amputee—will most likely undergo surgery to shape the bone in the remaining limb, to clean the wound (also known as debridement), and to close it. This may involve skin grafts, and could require more than one surgical procedure.
Surgical amputation
Surgical amputations have been a vital practice in medicine for thousands of years. They were once the main duty performed by surgeons, although the frequency of this has since diminished as medicine has advanced.
The most common reason for amputation in the UK is through complications with the blood vessels. In particular, this is when the blood’s supply to the limb has been lost and causes an extremely debilitating symptom called ‘necrosis’, which is when cells within living tissue die prematurely.
A surgical amputation can be necessary after a person has suffered from a traumatic injury, and they can be carried out as part of the immediate emergency treatment to save the person’s life or because their bones, tissuestissues—or both—have been so badly damaged that they cannot later be reconstructed. However, surgical amputation is usually considered to be a last resort, and if it is believed that a limb can be saved, surgeons will first try to do so.
For example, it could be that an injury sustained was only strong enough to remove a limb partially and therefore in the first instance it would be surgically reattached. In some complete traumatic amputation cases, surgeons can even attempt to reattach a previously severed but preserved limb via a method called ‘replantation surgery’. Such treatments are often very successful but, unfortunately, that may not always be the case.
It could be possible that a matter of weeks or months after the initial injury, it may become clear that a limb has lost its full and useful function, or that the person is now enduring insufferable pain. Following which, a decision could be made to amputate.
Some surgical amputations are even carried out many years after the initial injury. As an example, a person may have initially undergone major joint reconstruction. As their condition deteriorates over time a joint replacement may become necessary, but due to their injuries, the limb has been weakened and therefore unable to withstand further surgery, making surgical amputation the only option.
Once surgical amputation is underway, the medical team will aim to save as much of the injured limb as possible so that they can maximise the degree of function, which could include the future use of prosthetics.
AREAS OF AMPUTATION
An amputation can happen to any of the body’s limbs and extremities, be it the upper or lower half of the body. How the specific amputation is categorised is defined by the part of the body that is removed.
Read on for the different categories of amputation, and please note that the terms here apply to both traumatic and surgical amputations.
Upper-limb amputation – refers to the arms, hands or fingers and can be categorised as follows:
Lower-limb amputation – refers to amputations of the legs, feet or toes and can take the form of the following:
Pelvic or transpelvic amputation (also known as hemipelvectomy) - this is a rare form of lower-extremity amputation, involving the removal of up to half of the pelvis and the entire leg on that side. Hemipelvectomies can be further broken down into two sub-categories
1. Internal – this is where a part of the pelvis is removed but the leg is saved.
2. External – this is where the leg cannot be saved when part of the pelvis is removed.
· Hip disarticulation – amputations of the entire leg through the hip joint capsule.
· Transfemoral amputation (above the knee) – an amputation that occurs between the hip and the knee (through the thighbone), where the person retains full use of the hip joint.
· Knee disarticulation – these are amputations through the knee joint itself.
· Transtibial amputation (below the knee) – this is an amputation that occurs between the knee and the foot, preserving use of the knee. They are statistically the most common form of amputation in the U.K.
· Ankle disarticulation – these are amputations through the ankle joint itself, removing the foot but otherwise preserving the leg.
· Partial foot amputation – amputations where part of the foot is removed.
· Digit amputation – these are amputations of one or more toes. It can be the removal of the entire toe, or a partial amputation such as the ‘tip’.
Any amputation is a devastating and life-changing experience.
Its effects are far-reaching and varied, with no two cases of amputation being exactly the same. However, there are some overriding features that are common to most forms of amputation, whilst others are more injury-specific.
To assess the total effects of amputation on a person, a number of factors must be taken into account:
· The type of amputation
· The condition of the remaining limb
· Whether a prosthetic limb can be used
· The person’s age
· Their pre-injury health
· Other injuries sustained at the same time as the amputation
· Their domestic situation
· The emotional and psychological effect on the person
This section provides an overview of the more common effects of amputation.
The immediate physical effects of an amputation may seem obvious. For example, the loss of a leg will prevent a person from being able to walk without some form of assistance. However, such is the dramatic change to a person’s body, there are several further physical effects that can impact the life of an amputee:
Mobility and dexterity
The main effect of a lower-limb amputation is a reduction of that person’s mobility, meaning that they will not be able to walk as they did pre-injury or surgery. In the majority of cases, after sufficient care and rehabilitation, the injured person will be able to make use of a prosthetic limb.
Meanwhile, the loss of an upper-limb will also affect mobility (most likely affecting a person’s balance). This can make the injured person prone to falls or collisions with objects and people. Whilst they will not usually require a wheelchair, their mobility and agility may be adversely affected, especially in the early stages after the injury.
After someone has undergone an amputation, it is likely that the basic pursuits of daily living will become much more difficult, or perhaps even impossible. Previously straightforward tasks such as food preparation or housework may become a tremendous challenge, and the amputee may be limited in the activities they can perform unaided. Many of these are tasks that we often take for granted, such as getting dressed, washing, or carrying shopping.
Upper-limb amputees who have lost their dominant hand or arm are very likely to have difficulty completing tasks that require manual dexterity, and to compensate for this will need to learn how to use their previously non-dominant limb. For example, one particularly taxing transfer of skill would be learning how to write with their weaker hand.
Stump and phantom limb pain
An amputee may suffer from either stump pain or phantom limb pain, or perhaps even both. Stump pain is felt in the remaining part of the injured limb, and the source of this pain is found in the damaged groups of nerves at the site of amputation.
Meanwhile, phantom limb pain is a very widespread condition that affects up to 80% of all amputees. It refers to the sensation of pain that an injured person feels in their ‘missing’ limb. The word ‘phantom’ does not in any way mean that the pain does not exist; it is all too real to the person suffering from it, but the source of the pain is actually within the person’s brain.
The extent of phantom limb pain differs from case to case. Some people may experience temporary and brief shock-like stabs of discomfort or burning sensations, whilst others report more chronic and unbearable levels of excruciating pain. This phenomenon occurs more commonly in women, and then even more so in those who have lost an upper-limb as opposed to a lower-limb.
Infection
Problems can develop for amputees if the skin on their stump breaks down causing wounds to open. Such occurrences can give rise to infections, and may prevent them from being able to make full use of a prosthetic limb. There may be a problem with blood supply and circulation, culminating in blood clots; or it could be that an excess of moisture has built up at the stump and infected the wounds.
Unfortunately, such infections very often result in further surgical processes to remove more of the extremity, or perhaps even the rest of the remaining limb.
Muscle contractures
A muscle contracture happens when there is an imbalance of the muscles in a limb. Lower-limb amputees are at very high risk of muscle contractures due to the sudden and drastic alteration of their anatomy and central nervous system, as well as the weight-bearing stresses placed on the lower extremities.
Specifically, contractures are a shortening and tightening of the various remaining muscle groups in a limb, and are usually the result of the amputee remaining in one fixed position for an extended period of time, such as when they are bed-ridden at home or in the hospital.
It is important that these contractures are addressed through stretching exercises, so that potentially devastating complications are prevented from developing in the future. For example, if left untreated an amputee may lose the capability to fit a prosthetic limb, which in turn will mean that their mobility is further diminished.
Deep vein thrombosis
Deep vein thrombosis (also referred to as deep venous thrombosis or DVT) is a deep blood-clotting condition that usually affects the lower-limbs of the body. People who have suffered from an amputation of their lower extremities are at a high risk of experiencing this condition, particularly if they have undergone surgical amputation where their limb has been immobilised and tied.
If untreated, a potentially fatal secondary effect called a pulmonary embolism may develop, which is where part of the blood clot breaks away from the leg and travels to the person’s lungs.
Fatigue
The additional effort required by amputees to perform many of the routine activities of daily life can result in increased levels of tiredness and fatigue. For example, this might be from the increased exertion required by a lower-limb amputee to walk with a prosthetic limb, or simply from the fact that many ordinary activities can take longer to complete than previously.
In some cases, the side effects of a person’s pain medication might make them feel more tired or cause them to sleep for longer. In addition, the psychological effects of the injury and accident may disturb a person’s sleep and exacerbate their fatigue.
The psychological and emotional effects of losing a limb can be extremely significant, not only on the injured person but also on those close to them such as their family, friends and colleagues.
Traumatic effects
If a person has experienced a traumatic amputation, memories of the incident could cause them to suffer from post-traumatic stress disorder (PTSD) or other similar psychological conditions. Symptoms can include flashbacks; nightmares; depression; insomnia; avoidance; anger outbursts, and various other challenging behaviours.
It is also more likely that a person who has suffered from a traumatic amputation will feel the emotional and psychological impact of their situation more heavily than someone who has undergone a planned surgical amputation because they have not had the time to prepare for the loss of a limb.
Adapting to amputation
Whilst some psychological symptoms are the result of the initial traumatic injury suffered, other symptoms can develop gradually as the amputee lives with their disability. It can be mentally challenging for a person to adapt to the loss of sensation in their missing limb, or alternatively, it could be just as psychologically demanding for a person to suffer from chronic aches and pains.
As a result, depression is a very common consequence, both in the early stages of the injury and also as time progresses. The injured person may well suffer from a feeling of loss in relation to their removed limb, which some amputees have reported as similar to a feeling of bereavement after the death of a loved one.
It may seem like a downward spiral, but with both professional help and the care of the people that surround them, the hope is that the amputee will be able to navigate successfully through the five-stage cycle of grief; from the initial phase of denial and isolation; past anger, bargaining and depression; ultimately arriving at the final stage of acceptance.
Body image
After an amputation, people can be prone to suffering from body image issues, and in particular, they can be self-conscious about the appearance of their injured limb. Such body image issues are the result of an amputee’s internal perception of their own outer appearance and their greater self; and as a person’s body image usually includes four limbs, it can be a very difficult situation to adapt to.
It is not uncommon for an injured person to consciously - or subconsciously - hide their affected limb from sight so as not to draw attention to it, or because of fear about the way other people may react. These body image issues tend not to affect very young children who have undergone amputations, but it becomes more pronounced from adolescence onwards.
Social impact
An amputation can affect a person’s ability to take part in the same social activities, leisure pursuits or hobbies that they would have otherwise enjoyed.
This may be due to practical reasons, such as not being able to participate in physical activities in the same manner as they could prior to their amputation. In addition they may be inhibited by the levels of high levels of pain they experience, or the side-effects of their medication.
Social withdrawal can often result, leaving the injured person feeling isolated. Their personal relationships can be heavily affected, as some amputees completely avoid contact with their friends and peers, or even exhibit outbursts of anger at those loved ones they are still in contact with; most likely those who are helping them and providing care.
Whilst still in hospital, the amputee will be under the primary care of a consultant, with further care to be provided by such specialists as physiotherapists; occupational therapists; and so forth.
Once the patient leaves hospital, they may be transferred to a designated rehabilitation facility where they will receive all multi-disciplinary rehabilitation; or they may be discharged from the hospital directly to their home in order to undertake rehab as an outpatient, which may involve attending various specialist centres.
Recovery levels differ from person to person; some people may adapt to their new circumstances quickly, whilst others may not be so adept. How people react depends on an almost innumerable amount of factors, but the rehabilitation team’s aim is to help the amputee achieve their best possible level of recovery.
For continuity purposes, the patient will work with the same individual team members on a long-term basis. Although that may not always be guaranteed, it can be expected that the amputee will receive ongoing rehabilitation under the care of specialists in the following roles:
Consultant and nurses
It is important to note that the consultant is a doctor and not the amputee’s surgeon. The consultants is an expert in the field of amputation rehabilitation, prosthetics and limb-care, and is responsible for making final medical decisions in the patient’s best interests along with providing acute pain management.
Nurses are available in the hospital round the clock and attend to the immediate needs of amputees. This can range from helping patients with their self-care and mobility, through to wound care and providing advice.
Physiotherapy
The physiotherapist has one of the most crucial and vital roles in the rehabilitation process.
An amputation means that people have to learn how to use their bodies in a completely different manner. It is a monumental challenge, but physiotherapy helps people to adapt to their new situation through repetitive strength-building exercises.
It is hugely important that the amputee keeps using their remaining limbs through exercise, because it does not take very long for unused or less-active muscle groups to begin to waste away via a process known as muscle atrophy.
The physiotherapist draws up a therapeutic exercise plan to assist with:
· Strength building
· Stump positioning – helps to improve handling and healing of the remaining limb
· Fitness building – particularly if inactive for some time
· Gait training – helping the patient to continue to use an even amount of muscles on either side of the body
· Relieving pressure on wounds – particularly the parts of the body that are susceptible to pressure sores if bed-bound for extended period of time
· Prosthetic limb usage
· Body transferrals – for example, from the bed to a wheelchair
· Wheelchair usage
As the patient’s strength, balance and coordination improves over time, the physiotherapist gradually readjusts and refines these methods to customise the rehabilitation process towards the amputee’s specific needs.
For example, if it is known that the patient will later make use of a prosthetic, the process may be tailored to account for any post-surgery swelling via methods such as stump massage and ongoing oedema management as preparation for the limb fitting.
Occupational therapy
An occupational therapist assists the patient by helping them with their self-care needs and day-to-day activities.
Occupational therapy helps the patient to put into practice the advantages gained through physiotherapy. For example, the strength-building exercises that they may have benefitted from can be applied to many activities, such as the following:
· Housework
· Personal care (such as washing, bathing and grooming)
· Toilet usage
· Daily tasks such as preparing food and drinks
There are many more activities that the occupational therapist can help with, and in circumstances where the amputee cannot complete a task, they may assess whether further assistive equipment is necessary, or whether there should be adaptations to the amputee’s property that may help; for example, through installing raised toilet seats or a shower chair.
In addition, should the amputee later adopt the use of a prosthetic limb, the occupational therapist will help them learn how to use the appendage in day-to-day situations.
The goal is to increase the amputee’s independence, particularly important when it comes to matters involving the bathroom or dressing. However, equally important is maximising the patient’s safety, and they must be able to complete any tasks without putting themselves in unnecessary danger.
Over time, the amputee’s skills should develop and they will be able to complete the majority these tasks to a level of efficiently not unlike their pre-injury lifestyle, although only as much as their condition will permit.
Prosthetist
A prosthetist is somebody who cares for amputees by designing and providing the best-suited artificial limb that will help them to function in their lives in the best way possible.
The prosthetist models the amputee’s stump (or region of the body that the assistive appendage will be fitted to) by creating a mould, either via an actual physical cast, or more commonly in recent years through 3D digital imaging.
The thoughts and opinion of the amputee are highly valuable to the prosthetist, as they will discuss every single aspect in order to create a limb that is equal parts functional, safe, and visually appealing.
Furthermore, technology progresses at an almost impossibly rapid rate, so the prosthetist will be abreast will all the latest developments to be able to identify those that are most suited to the patient, also providing recommendations and advice going forward.
Various prosthetic limbs have been developed that apply to certain situations and terrains. For example, there are the high performance and lightweight prosthetic feet sometimes referred to as ‘blades’ much like those seen worn by runners at the Paralympics, whilst others are more sturdy and anatomically correct in their visual representation of feet.
Once selected, the prosthetist can demonstrate to the patient the correct way of using their new limb, and also the right way to look after it. Going forward, adjustments and adaptations can be made in order to refine the limb’s suitability to amputee.
Social worker
A social worker is a facilitator for the amputee, who provides advice and support. Rather like a case manager, they help make arrangements to bring the amputee’s requirements into fruition.
Such examples include arranging private home care visits; assessing as to whether ‘meals on wheels’ may be required and if so implementing it; transportation requirements; recommending and helping to obtain benefits; and so forth.
Clinical psychologist
It is quite understandable that people who have undergone an amputation will feel a strong emotional and psychological impact on their lives. Not only that, but it can also heavily affect their family and friends.
For that reason, it is often recommended that people in such situations attend counselling sessions in confidence to help them cope with any feelings of depression, sadness and despair. Talking about the situation can help people face up to their future and cope with their emotionally debilitating issues.
ASSISTIVE DEVICES
An assistive device is any medical device that improves the treatment of a patient OR improves their condition of life. These can be used to help a patient live (i.e. insulin pump) or just simply allow a patient to live a more normal life (i.e. prosthetic limb).
Prosthetic Limbs
A person would need a prosthetic limb if they have an injury so severe that it requires amputation. Prosthetic limbs (or artificial limbs) have been around since 300 B.C.E. The following are the types of prosthetic limbs.
— 1) Transtibial Prosthesis: It replaces a leg amputated below the knee. Since the knee is retained, these amputees can regain normal leg movement faster than a transfemoral amputation.
— 2) Transfemoral Prosthesis: This involves the replacement of a leg amputated above the knee. Since the knee is removed, the patient has major difficulty moving (use 80% more energy than a normal two legged walker!). Lots of occupational therapy is required.
— 3) Transradial Prosthesis: Replaces an arm amputated below the elbow. Two types: cable operated and myoelectric.
— 4) Transhumeral Prosthesis: Replaces an arm, amputated above the elbow. Since the elbow is gone, it is hard for these amputees to regain normal movement of the arm. Again, cable and myoelectric types.
Other Assistive Devices
There are so many other assistive devices out there that it is too much to catalog. Some of the more common ones include: hearing aids, insulin pumps, wheelchairs, crutches, braillers, etc…
Artificial Organs
Artificial organs fall into the grey area of assistive devices. They assist in giving a patient life, but the patient cannot live without them in many cases, which is unlike most other assistive devices. The medical definition for an artificial organ is a man-made device integrated into a patient to replace a natural organ. Some of the current artificial organs being used today include:
— 1) Artificial Heart: The 1st artificial heart to be surgically implanted (Jarvik 7) into a human patient was in 1982. That patient lived for 112 days after.
— 2) Brain Pacemaker: These are inserted into the brain to send electrical signals used to stop things like depression, epilepsy and the tremors associated with Parkinson’s.
— 3) Cochlear implants: Implanted into the inner ear to improve hearing.
Amputation is a dramatic, life-altering event that typically results from either disease or trauma. The number of amputations appears to be on the rise despite advances in vascular surgery and diabetes management, and mortality following lower limb amputation is high.
Evidence among United States veterans with lower extremity amputation have shown that inpatient rehabilitation services provided immediately following the surgical amputation improves patient outcomes such as home discharge, survival, physical functioning, and receipt of a prescription for a prosthetic limb. Whiles these findings cannot be expected to completely generalize to non-veterans in the United States or people, who experience limb loss in other nations, we believe the prognostic factors discovered and the general findings related to expectations associated with various types of care provide important insights. Research beyond this population will be essential.
POLIO
DEFINITION
Poliomyelitis, also called polio or infantile paralysis, is a highly infectious viral disease that may attack the central nervous system and is characterized by symptoms that range from a mild nonparalytic infection to total paralysis in a matter of hours.
DESCRIPTION
The reason it is called poliomyelitis is because the prefix polio means 'grey' in ancient Greek, myelo refers to the spinal cord, and itis refers to the inflammation of something. Therefore, when we combine all of these terms together we get the inflammation of the spinal cord's grey matter, or poliomyelitis.
Poliomyelitis or infantile paralysis is a viral infection that affects the nerves of the spinal cord, located inside the spinal bones (vertebrae) at the back of the body. This infection can cause permanent paralysis of muscles. Poliomyelitis mostly affects children up to 15 years of age, but can affect adults too. After the acute phase, the disease is not communicable to others. Since poliomyelitis does not affect the brain, the intellectual ability of children with poliomyelitis remains intact.
Recovery after poliomyelitis takes place in three stages.
1. Acute phase: (i.e. the first half-year) is a time when there can be a lot of pain, so children are often left to lie quietly. This frequently results in contractures.The incidence of contractures can be markedly reduced with gentle exercises and proper positioning.
2. Convalescent phase: (i.e. the next 2−3 years) is a time when there may be some gradual recovery of muscle strength. Exercises to prevent contractures are continued, and an effort is made to gradually get the child active.
3. Chronic phase: After 2−3 years, recovery of muscle strength stops. At this point, plans need to be made to get the child up and walking if possible, using crutches and/or orthoses. During this phase, surgery is often needed to allow the child to fit comfortably into the orthosis, or to move muscles into a different position to reduce deformity due to uneven muscle pull. In Tajikistan, by 2015, all children who contracted poliomyelitis during the 2010 epidemic will now be in the chronic phase of rehabilitation, which lasts for the rest of the child’s life.
It’s estimated that 95 to 99 percent of people who contract poliovirus are asymptomatic. This is known as subclinical polio. Even without symptoms, people infected with poliovirus can still spread the virus and cause infection in others.
Signs and symptoms of non-paralytic polio can last from one to 10 days. These signs and symptoms can be flu-like and can include:
Non-paralytic polio is also known as abortive polio.
About 1 percent of polio cases can develop into paralytic polio. Paralytic polio leads to paralysis in the spinal cord (spinal polio), brainstem (bulbar polio), or both (bulbospinal polio).
Initial symptoms are similar to non-paralytic polio. But after a week, more severe symptoms will appear. These symptoms include:
It’s rare for full paralysis to develop. Less than 1 percent of all polio cases will result in permanent paralysis. In 5–10 percent of the polio paralysis cases, the virus will attack the muscles that help you breathe and cause death.
It’s possible for polio to return even after you’ve recovered. This can occur after 15 to 40 years. Common symptoms of post-polio syndrome (PPS) are:
Talk to your doctor if you’ve had polio and are starting to see these symptoms. It’s estimated that 25 to 50 percent of people who survived polio will get PPS. PPS can’t be caught by others having this disorder. Treatment involves management strategies to improve your quality of life and reduce pain or fatigue.
CASE CLASSIFICATION
· Under investigation: A case that has been notified, but information is not yet available to classify it as probable or confirmed.
· Probable: A clinically compatible illness with an epidemiological link.
· Confirmed: A clinically compatible illness that is laboratory confirmed.
· Not a case: A case that has been investigated and subsequently found not to meet the case definition, including cases under the age of 15 years who have been deemed to have a non-polio paralytic illness by the National Certification Committee for the Eradication of Polio.
Cases can be further classified as follows.
· Vaccine-associated paralytic poliomyelitis: VAPP is a rare event where neurological damage is caused by a virus ingested from the oral polio vaccine (OPV). A mutation of the vaccine virus known as a reversion causes previously attenuated poliovirus to revert to a more neurovirulent form. The paralysis that results is identical to that caused by wild poliovirus.
· Wild virus-associated poliomyelitis: Any case not meeting the criteria for being vaccine associated. Such cases will be imported since New Zealand was declared free of poliomyelitis by WHO in 2000.
· Imported: A case occurring in a person who has travelled or resided in a polioendemic area within 30 days of disease onset or who is epidemiologically linked to a person who has done so. Surveillance should be intensified at both local and national levels to detect any additional cases without delay.
· Vaccine derived poliomyelitis infection (VDPV): Vaccine-derived poliovirus is the live, attenuated strain of the poliovirus contained in the OPV that has changed and reverted to a form that can cause paralysis in humans and has the capacity for sustained circulation. Vaccine-derived polioviruses differ from the parental (original) Sabin strains found in the vaccine by 1 percent to 15 percent of VP1 nucleotides. This is a measurement of genetic change that scientists use to monitor the circulation of viruses.
WHAT CAN WE DO FOR CHILDREN WITH CHRONIC POLIOMYELITIS PARALYSIS?
Exercises to reduce contractures
Range-of-motion exercises: Each joint in the body can move a specific amount. We call this the “range of motion” of the joint. Through passive and active range-of-motion exercises, we try to maintain the normal amount of movement in all joints in order to prevent contractures. However, range-of-motion exercises should be conducted properly, carefully, and always respecting each child’s limitations. For example, we should respect the limits of each joint movement and never go beyond the normal amount. Range-of-motion exercises should be done slowly and gently. The person performing the exercises should remember that it is easy to use too much force and injure the child. Typical range-of-motion exercises needed for children who have had poliomyelitis are: hip extension, knee extension, ankle dorsiflexion, wrist extension and thumb abduction and opposition. Other joints may also need exercises, and the child’s doctor will suggest these as necessary. Range-of-motion exercise 2 Rehabilitation plan Doctors and therapists need to decide what each child will be capable of doing within the limits of his/her muscle weakness. This is recorded in a rehabilitation plan. Part of the planning is to decide what sort of assistive devices the child needs.
Positioning
Ensuring that the child sits with his/her feet flat on the floor in a childsized chair (proper positioning) can help to prevent the development of foot contractures. Making certain that the person does not always lie or sit in one position can help to prevent tightness and contractures.
Crutches and walkers
Crutches and walkers are used by children to support themselves during standing and walking. Walkers are very helpful for children with poor balance and weak muscles. Crutches can be very helpful for children with stronger muscles. Both can help people with poliomyelitis gain balance, confidence and, ultimately, the ability to walk on their own. There are two types of crutches available in Tajikistan. Axillary crutches (where the child’s weight is supported under the armpits) are usually prescribed for children who have weak muscles in their arms, legs or trunk. Forearm crutches are usually prescribed for children who have stronger muscles in their arms and legs.
Initially, try different combinations of assistive devices and observe which is the safest and most comfortable option for each child. As the child gets stronger and more confident, you should re-evaluate and assess whether a different device is needed. For example: a child who started by using a walker may become stronger and more confident after some time. This child may then be ready to change to crutches and walk with less support.
Wheelchair
For a few children with poliomyelitis, wheelchairs can be an important component of their rehabilitation. Wheelchairs are usually prescribed for children who are unable to walk even with assistive devices. Wheelchairs should also be considered for those children who have difficulty walking long distances. In addition, a child who can walk a fair distance but tires very quickly may need a wheelchair at school or during other community activities.
Strengthening exercises
The rehabilitation plan should establish a specific programme of strengthening exercises that will help the child to be as independent as possible. When a child is doing these exercises, you should bear in mind the need to avoid fatigue and exhaustion. Exercises should be planned to:
• keep the child active
• prevent muscle weakness
• increase or maintain muscle strength
• prevent deformities.
Exercises for strengthening the arms and improving balance are highly recommended. Strengthening exercises need to be scaled up as the child’s strength increases. For example, a child may start with 5−10 repetitions of the exercises two or three times a day. As the child gets stronger, he/she may work up to 20−30 repetitions. Once the muscle is strong enough for the child to use it properly while moving, then moving alone should maintain the child’s strength.
Surgery
Doctors will need to decide whether surgery will help. An operation may help the child fit more easily and comfortably into an orthosis. Or surgery may be needed to correct or prevent deformities that are continuing in spite of exercises. Sometimes moving the muscle tendons in order to change their action will help a child to be more independent.
SPINAL CORD INJURIES
DEFINITION
A spinal cord injury — damage to any part of the spinal cord or nerves at the end of the spinal canal — often causes permanent changes in strength, sensation and other body functions below the site of the injury.
Medical providers divide the spinal cord into four distinct regions. Knowing the region in which the injury is located is often the key to understanding diagnosis and treatment. The four spinal cord regions are:
CHARACTERSTICS
Spinal cord injuries occur for many different reasons. Depending upon the severity of the injury, patient’s symptoms may be mild, moderate, or severe enough to cause death. Spinal cord injuries should be treated as quickly as possible to avoid further damage. Some patients may experience temporary symptoms while others will be left with lifelong symptoms.
Causes for spinal cord injuries are characterized as ‘traumatic’ or ‘non-traumatic.’ Traumatic injuries are caused by an abrupt traumatic hit to the spine which results in damage to one or more of the vertebrae, or a severing of the spinal cord. Non-traumatic injuries are the result of slow internal damage to the spinal cord region.
Traumatic spinal cord injuries occur due to:
Non-traumatic spinal cord injuries occur due to:
TYPES OF SPINAL CORD INJURIES
All spinal cord injuries are divided into two broad categories: incomplete and complete.
Incomplete spinal cord injuries are increasingly common, thanks in part to better treatment and increased knowledge about how to respond—and how not to respond—to a suspected spinal cord injury. These injuries now account for more than 60% of spinal cord injuries, which means we're making real progress toward better treatment and better outcomes.
Some of the most common types of incomplete or partial spinal cord injuries include:
Knowing the location of your injury and whether or not the injury is complete can help you begin researching your prognosis and asking your doctor intelligent questions. Doctors assign different labels to spinal cord injuries depending upon the nature of those injuries. The most common types of spinal cord injuries include:
Injuries below the lumbar spinal cord do not typically produce symptoms of paralysis or loss of sensation. They can, however, produce nerve pain, reduce function in some areas of the body, and necessitate several surgeries to regain function. Injuries to the sacral spinal cord, for instance, can interfere with bowel and bladder function, cause sexual problems, and produce weakness in the hips or legs. In vary rare cases, sacral spinal cord injury survivors suffer temporary or partial paralysis.
Asia Impairment Scale
Neurological Category: This is assessed by the American Spinal Injury Association (ASIA) impairment scale.
|
A |
COMPLETE |
No motor or sensory function is preserved in the sacral segments S4 to S5 |
|
B |
INCOMPLETE |
Sensory but not motor function is preserved below the neurological level and includes the sacral segments S4 to S5 |
|
C |
INCOMPLETE |
Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3 |
|
D |
INCOMPLETE |
Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more |
|
E |
INCOMPLETE |
Motor and sensory function is normal |
Examples of recreation therapy intervention programs for adolescents with SCI
|
Physical competence |
Psychological competence |
Social competence |
|
• Strength training • Aerobic conditioning • Coordination and balance • Specific leisure-activity skills training • Wheelchair mobility skills • Wheelchair sports preparation and participation |
• Cognitive-behavioral therapy • Self-awareness • Leisure education • Educational information sessions • Pain management • Relaxation and stress management • Communication skills • Value clarification |
• Social skills training • Assertiveness • Communication • Team-building activities • Peer support and peer mentoring program (maintaining contact with previous SCI patients) • Community reentry program |
MANAGEMENT
A multidisciplinary team approach offers the best chance of a successful outcome following SCI. Medical therapy and rehabilitation are initiated the moment the patient is admitted to hospital. Both go on hand-in-hand. About 50% of the patients have associated injuries to the head, chest, abdomen or appendicular skeleton. Loss of sensations below the level of injury necessitates a very thorough evaluation, clinical and radiological, to rule out hidden injuries. Not all spinal column injuries are associated with injury to the spinal cord. Immobilization of the spine at the site of accident and during transfer has proven to reduce the incidence of neurological complications.
Acute care begins with attention to fundamentals of trauma care, i.e., cardiopulmonary resuscitation.
a. Airway maintenance with cervical spine control.
b. Breathing.
c. Circulation.
d. Disability.
e. Exposure.
This sequence of assessment must always be adhered to without any exception. If a spinal cord injury is suspected, immediate orthopaedic or neurosurgical consultation must be sought. Indicators of possible spinal cord injury are:
1. Slow heart rate < 60 beats per minute.
2. Hypotension.
3. Abdominal breathing.
4. Inability to move limbs with loss of sensations.
In an unconscious victim, spinal cord injury must always be suspected and appropriate immobilization of spine maintained till it is ruled out by a specialist.
LIST OF COMPLICATIONS
|
EARLY |
LATE |
|
1. Spinal shock 2. Pressure sores 3. Deep vein thrombosis (DVT) 4. Autonomic Dysfunction (AD) a) Autonomic Dysreflexia b) Orthostatic hypotension c) Impaired thermoregulation d) Bladder and bowel disturbances e) Altered genital function 5. Pulmonary disturbances |
Spasticity Pain Contractures Osteoporosis Heterotopic Ossification +early |
PHYSICAL THERAPY
1. Range of motion (ROM) exercises of all four limbs is begun soon after evaluation. This helps prevent contractures and DVT. It should be done daily. Initially the physiotherapist provides therapy but later a family member has to take over under the guidance of the therapist. Contractures are a potential cause of pain and interfere in rehabilitation.
2. Light weight exercises of normally innervated muscles are begun in addition, to prevent disuse atrophy.
3. Chest physiotherapy is an important aspect of early rehabilitation. Incentive spirometry, deep breathing techniques, assisted cough and respiratory treatment are practiced.
4. When the patient can be mobilized out of bed tilt table exercises begun. This helps reduce orthostatic hypotension. Tilting begins from 15 degrees and gradually increased to reach at least 80 degrees.
5. Sitting balance exercises.
6. Wheelchair mobilization techniques.
7. Transfer training from all types of surfaces: bed, wheelchair, floor. 8. Techniques of weight transfer to avoid pressure sores.
FUTURE
Evidence from recent research holds promise. The long standing belief that spinal cord cannot regenerate has been proven wrong. Regeneration of spinal cord has been successful in animals in the laboratory.
· Stem Cell Therapy
Embryonic cells transplanted to the injured cord have led to motor improvement in rats. Olfactory ensheating glial (OEG) cells are specialized cells that grow throughout life. OEG cells transplanted to the injured spinal cord have consistently shown regeneration of motor tracts in adult rats.
· Vaccination
Vaccination of animals by spinal cord proteins is believed to stimulate antibodies against growth inhibitors. Almost half of the inoculated mice regenerated about 75% of spinal cord cells.
· Immunotherapy
Injury leads to repair. Immunologic modulated demyelination followed by Schwann cell transplantation has shown promising recovery in rats.
· Growth Factors
All cells require factors to grow. So do neurons. The first such factor discovered was NGF by Levi-Montalcini (Nobel Prize in Medicine). Numerous factors have since been isolated that facilitate neural regeneration of adult rat spinal cord cells.
· Gene Therapy
Cells have been genetically modified to secrete neurotrophic growth factors. Such cells transplanted to the injury site have shown promising neural tissue regeneration.
SPINA BIFIDA
Spina bifida literally means ‘split spine’
A fault in the development of the spinal cord and surrounding bones (vertebrae) leaves a gap or split in the spine. The spinal cord has not formed properly, and may also be damaged. To help understand what it is, it is useful to explain the composition of the nervous system.
The Central Nervous System
The central nervous system consists of the brain and the spinal cord. All activities are controlled by the brain which receives information from touching, seeing, feeling, tasting and hearing – responding to this information by initiating the appropriate movements of different parts of the body. Messages from the brain are carried to different parts of the body by the spinal cord which runs down the centre of the spinal column. This communication system
for the body is very important and needs protection.
The Spine
The spine is made up of 33 bones or vertebrae. The vertebrae have two main functions. One is to provide anchorage for muscles so that we can move as the brain dictates to those muscles. The other is to provide protection to the spinal cord.
The Neural Tube
The central nervous system and spine develops between the 14th and 23rd day after conception. Spina bifida occurs when the neural tube fails to close correctly. The vertebrae also fail to close in complete rings around the affected portion of the spinal cord. This leaves a gap posteriorly (at the back), involving one or more vertebrae. The fault may occur in one or more of the vertebrae but it is most common around waist-level.
TYPES OF SPINA BIFIDA
The three main types of spina bifida always present at birth are:
Spina Bifida Cystica (cyst-like)
The visible signs are a sac or cyst, rather like a large blister on the back, covered by a thin layer of skin. There are two forms:
1) Myelomeningocele (meningomyelocele)
Myelomeningocele is the most serious and more common of the two forms of cystic spina bifida. Here the cyst not only contains tissue and cerebro-spinal fluid but also nerves and part of the spinal cord. The spinal cord is damaged or not properly developed. As a result, there is always some paralysis and loss of sensation below the damaged region.
The amount of disability depends very much on where the spina bifida is, and the amount of affected nerve tissue involved. Bladder and bowel problems occur in most people with myelomeningocele, as the nerves come from the bottom of the spinal cord, so are always below the lesion. It is also necessary to have intact nerve pathways to the brain for complete control and sensation.
The outer part of the vertebrae is split. The spinal cord and meninges are damaged and pushed out through the opening. Hydrocephalus is usually associated with this form.
2) Meningocele
In this form, the sac contains meninges (tissues which cover the brain and spinal cord) and cerebro-spinal fluid, which bathes the central nervous system. Development of the spinal cord may be affected, but impairment is usually less severe than myelomeningocele. Meningocele is the least common form of spina bifida.
The outer part of the vertebrae is split. The spinal cord is normal. The meninges are damaged and pushed out through the opening.
3)Spina Bifida Occulta (hidden form)
This is a mild form of spina bifida which is very common. Estimates vary but between 5% and 10% of people may have spina bifida occulta. It must be emphasised that, for the vast majority of those affected, having spina bifida occulta is of no consequence whatsoever. Often people only become aware that they have spina bifida occulta after having a back x-ray for an unrelated problem.
The outer part of the vertebrae is not completely joined. The spinal cord and its covering (the meninges) are undamaged Encephalocele.
· Encephalocele
This is a sac which is formed when the bones of the skull fail to develop. It may contain only cerebro-spinal fluid or part of the brain may also be present in the sac, resulting in brain damage.
· Anencephaly
This is where the brain does not develop properly or is absent, and the baby is either still born or dies shortly after birth.
· Hydrocephalus Most babies born with myelomeningocele also have hydrocephalus (from the Greek hydro, meaning water, and cephalie meaning brain). This is an accumulation of cerebro-spinal fluid which arises from an imbalance in the production and drainage of that fluid.
TREATMENT
· In the past, babies born with spina bifida died shortly after birth. Today, early surgery is usually
· recommended and is often performed within the first forty-eight hours of birth. Surgery increases
· the survival rate and many spina bifida patients live well into adulthood; however, children with
· spina bifida typically require several operations during their childhood to correct defects, particularly
· in the hips, feet and spine.
POSSIBLE PROBLEMS
· Hydrocephalus (large head)
· Paralysis of lower limbs
· Sensory loss of paralysed limbs
· Deformity of spine, knees, ankle and feet
· Stool and urine incontinence (lack of control of urine and stool).
MANAGEMENT
· Assessment - to be conducted by trained medical and rehabilitation professionals
· Physical abilities, mobility, sensory loss and bowel and bladder control.
· Careful handing to ensure that the child does not get injury or hurt as child may not feel pain
· due to sensory loss in paralysed limbs.
· Correct positioning on chair or wheelchair.
MUSCULAR DYSTROPHY
¡ Muscular Dystrophy (MD) is a group of inherited diseases in which the voluntary muscles progressively weaken overtime.
¡ Heart and other organs can also be affected.
¡ 9 major types:
§ Duchenne, Myotonic, Becker, Limb-girdle, Facioscapulohumeral, Congenital, Oculopharyngeal, Distal, and Emery-Dreifuss
§ Can occur at any age
§ Most common in young males.
§ Type is based on what age the individual is when muscular dystrophy appears
§ Also depends on how severe the disease is, which muscles it affects, rate of progression, and the way it appears.
§ Some types of muscular dystrophy only affect males.
§ Some individuals with this disease experience mild symptoms, while others suffer from severe muscle weakness, dying at an early age.
CAUSES
§ Defects in certain genes
§ The type of MD is determined by which gene is defective
§ In 1986, researchers discovered the gene that, when defective causes Duchenne MD.
§ In 1987, the muscle protein associated with this gene was given the name dystrophin
§ When the gene fails to produce dystrophin, Duchenne MD occurs
§ Duchenne muscular dystrophy is the most common and fatal childhood type.
Duchenne Muscular Dystrophy
§ 1 in 5000 males
§ Begins with proximal muscle weakness around age 4
§ Progresses to distal muscles, making walking more difficult
§ Around age 10, most children are in wheelchairs
§ Some experience cognitive problems
§ Most types of MD are a form of inherited disease called X-linked disorders or genetic diseases that mothers can pass on to their child, even though the mothers are not affected by the disease.
§ Some forms of MD are not inherited but occur because of a gene abnormality or mutation.
SYMPTOMS
§ All forms: muscle weakness
§ Myotonic: muscle spasms or stiffening after use, hand weakness, foot drop
§ Duchenne and Becker: clumsiness, frequent falling, difficulty getting up, waddling gait, curvature of the spine.
§ Drooling, eyelid drooping
MD DIAGNOSIS
§ Muscle biopsy
§ DNA testing
§ Blood enzyme tests
§ Electromyography or nerve conduction tests
o Electrodes are used to test the muscle and/or nerves
TREATMENT
§ No cure
§ Medications and therapy can relieve symptoms and slow progression of the disease
§ However, scientists are researching ways to insert a working dystrophin gene into muscles of boys with Duchenne and Becker MD
§ Also, researchers are exploring potential muscle-building drugs to help reverse progression
§ Dietary supplements, creatine, and glutamine are other potential treatments being studied
§ Braces, wheelchairs, and canes can improve mobility
§ Surgery on the spine or legs also may be an option to improve function.
§ Exercise!
§ People suffering from MD should be as active as possible.
§ Physical inactivity may make the disease worse