POLIOMYELITIS (poliomyelitis; grech, polios gray + myelitis; synonym Heine — Medina a disease) — the acute viral disease of the person which is characterized by defeat of gray matter of a spinal cord and a brain trunk with development of sluggish paresis and paralyzes.
- 1 History
- 2 Statistics and geographical distribution
- 3 An etiology
- 4 The epidemiology
- 5 The pathogeny
- 6 The pathological anatomy
- 7 Immunity
- 8 The clinical current
- 9 Complications
- 10 The diagnosis
- 11 The differential diagnosis
- 12 Treatment
- 13 Rehabilitation
- 14 The forecast
- 15 Prevention
P. — a disease very ancient. So, in Ancient Egypt mummies with the bone deformations typical for P. (4 century BC) are found. The evidence of distribution of P. in Ancient Egypt is the wall image of the priest which is also found in one of temples of Memphis with the atrophied and deformed leg — a characteristic effect of paralytic P. (2 century BC). Hippocrates (4 century BC) describes the outbreak of the paralytic diseases corresponding on a wedge, a picture P. (an atrophy of the paralyzed extremities).
Descriptions of outbreaks of paralytic children's diseases meet also in the Middle Ages. By the end 18 — to the beginning of 19 century data on P. as a peculiar children's disease collect. It is mute. the orthopedist Heine (J. Heine, 1840, 1860) described P. as an independent disease and offered methods of treatment at different stages of its development. Pathoanatomical researches in the next years revealed the leading value in P.'s pathogeny of defeat of neyrotsy-t of front horns of a spinal cord. The Swedish doctor Medin (O. of Medin, 1890) came to a conclusion about inf. to the nature of a disease. In domestic literature of P. as an independent form inf. diseases it was for the first time described by A. Ya. Kozhevnikov (1883).
Small flashes of P. were observed in 80th and 90th 19 century in Sweden and Norway, and in 1905 in these countries there were large epidemics (apprx. 1200 diseases in Sweden and St. 900 — in Norway). In the next years P.'s epidemics in other European countries, the USA and Canada flashed. During World War I reduction of incidence of P. was noted, however in post-war years of a disease and P.'s flash were noted in all parts of the world.
The problem P. acquired special relevance after World War II. Incidence sharply increased in many European countries, the USA, Canada, Australia. It caused intensive development of vaccines. The first serious success in this direction was creation by Solk (J. E. Salk, 1953) the inactivated vaccine against P., use a cut promoted decrease in incidence in a number of the countries. The live vaccine from attenuirovanny virus strains of P. selected in the mid-fifties by Seybi-nom (A. V. of Sabin) was much more effective.
Wide-ranging and multilateral scientific research and the subsequent tests of this vaccine prepared in the USSR in 1958 — 1960 by M. P. Chumakov with sotr. and A. A. Smorodintsev with sotr., showed its safety, an areaktogennost and high performance. Mass use of a vaccine led to falloff and even elimination of incidence of P. in a number of large geographical regions.
Statistics and geographical distribution
the Most wide spread occurance of P. was noted in the late forties — the beginning of the 50th of 20 century, especially in the countries of Europe and North America. In 1946 — 1955 P.'s incidence in England and Wales on 100 000 population made: in 1947 — 18,1, in 1949 — 13,7, in 1950 — 17,7, in 1953 — 10,3 and in 1955 — 14,2. In Austria P.'s incidence in 1947 reached level 50,7 on 100 000 population, in Switzerland in 1954 — 33,0, in Sweden in 1953 — 71,0, and in Denmark in 1952 — 131,0 (epidemic, unprecedented in quantity of cases and weight of diseases, in Copenhagen). In the USA in the same decade P.'s incidence annually made from 10 827 cases in 1947 to 57 879 — in 1952 (i.e. reached an indicator 37,2 on 100 000 population). In the USSR in 1940 1243 cases of P. (0,64 on 100 000 population), in 1950 — 2590 (1,43), in 1955 — 17 364 (8,85), and in 1958 — 22 054 are registered (10,66).
Introduction to broad practice of specific prevention of P. led to falloff of incidence of P. in Europe, the USA and Canada in 1956 — 1960. In the USSR by 1965 incidence decreased to 300 cases, and in 1975 — to 133 cases (0,05 on 100 000 population). Essential decrease in incidence in 1961 — 1970 is registered also in some countries of Asia (Israel, Singapore, Japan), Central and South America (Costa Rica, Cuba, Puerto Rico, Uruguay), in Australia and New Zealand. At the same time in many developing countries of Asia, Africa and America where inoculations against P. are not carried out, incidence or remains at the considerable level, or increases.
Mortality from P. in the late forties — the beginning of the 50th, during its first flashes in the European countries, made 10 — 12 on 100 000 population, and in 1950 — 1960 in many countries even in days of especially high incidence did not exceed 2 — 4 on 400 000 population. After 1960 this indicator in many countries still decreased in connection with reduction of incidence
of P. Letalnost at P. in days of the first epidemics in the countries of Europe and America fluctuated from 10 to 20%, raising in interepidemic years to 25 — 30% that, apparently, reflects incomplete diagnosis of easy forms during this period. So, in 1950 — 1959 in the USA, Australia and Sweden the lethality at P. against the background of high incidence was rather homogeneous (4 — 10%). In Japan these years decrease in a lethality (from 24% in 1950 to 6% in 1960) is observed that it is possible to charge to improvement of diagnosis of lungs and the erased forms P.
During the early period of studying of P. it was described as a typical children's disease of the first 2 — 3 years of life; according to G. Oppengeym (1896) at the age of 4 years P.'s cases were observed very seldom. Such nature of age incidence of P. remained in many countries of Europe without considerable changes before World War II. However, in the 30th in a number of the European countries and in the USA it was noted that increase in number of diseases of P. is followed also by its «povzrosleniye». More noticeable this tendetion became in post-war years. So, average age of sick P. in England and Wales in 1912 — 1919 made 3,9 years, and in 1944 — 1950 — 8,5 years among boys and 9,2 years among girls. Similar shifts in age distribution of diseases of P. were revealed in the majority of the developed countries of the world (the country of Europe and North America, Australia) while in developing countries of P. remains a disease of early children's age. In the USSR increase of cases of P. among school students of advanced age and young adult population was observed in the late forties and in the 50th in the republics of the Baltics. At the heart of P.'s «povzrosleniye», according to J. Melnik, J. R. Paul, etc., lies improvement a dignity. - a gigabyte. living conditions, observed in many countries and leading to reduction of contacts between children. At the same time a considerable part of the population does not catch a virus P. in childhood, and the meeting with it at more advanced age leads to clinically expressed disease more often, than to an asymptomatic infection.
The disease meets at men a little more often, than at women.
the Activator P. — the virus which is usually called by a virus P. or a poliomyelitis virus. There are three types of a poliomyelitis virus (type I, type II and type III) which are types of the sort Enterovirus in the Picornaviridae family. All three types of a virus have a wide spread occurance and are found in various countries and parts of the world.
The main part of diseases (and epidemics) P. usually is caused by a virus of I type, II viruses and III have smaller epidemic value. The majority of epidemics of P. and seasonal rises in incidence are connected, however, with two or three types of viruses though one type is prevailing always.
For the first time the virus etiology of P. is established in 1909. K. Landshtey-ner and Popper (E. Popper) which reproduced a paralytic disease at monkeys, having infected them intraperitoneally with a suspension of cells of gray matter of a spinal cord of the child who died from poliomyelitis. In 1910 S. Fleksner and J. Lewis successfully had an infection from a monkey to a monkey, having created, thus, a method of maintenance of laboratory virus strains. They showed a possibility of long preservation of a virus in the pieces of brain fabric placed in glycerin. For many years monkeys remained the only model for virusol. researches at P. V 1939 the susceptibility to a virus P. of cotton rats (Sigmo-don hispidus hispidus) and a possibility of adaptation of its certain strains (only type II) to an organism of white mice was shown. The important role in studying of a virus P. was played by use of culture of fabric. Not only the possibility of reproduction of a virus P. in the absence of nervous cells in culture, but also its destroying action on cells of culture of fabric — so-called cytopathic effect was established.
On morfol, to the characteristic, the sizes and other signs the virus P. is the typical representative intestinal viruses (see). In cytoplasm of cells where the virus breeds, the kristallopodobny structures consisting of densely laid virus particles (fig. 1) can form.
The virus P. is completely inactivated within 30 min. at t ° 50 °, and also at various modes of pasteurization; boiling and autoclaving almost immediately lead to an inactivation of a virus. At the room temperature viability of a virus P. remains within several days, at t ° 4 — 6 ° — within several weeks or months, and in the frozen look (at t ° — 20 ° below) — for many years. Drying leads to a bystry inactivation of a virus. Absence as a part of particles of a virus P. of structural lipids causes its resistance to effect of ether and other solvents of fats. Usual desinfectants are ineffective concerning a virus P. Ultraviolet radiation, free residual chlorine (0,3 — 0,5 mg/l) and formaldehyde have the inactivating effect on a virus (0,3% solution above).
the Source of an infection at P. is the person (the patient or a virus carrier). The virus is allocated to the environment with separated from a nasopharynx and with excrements. Allocation of a virus begins on 2 — the 4th day after infection. With separated from a nasopharynx a virus it is allocated during 1 — 2 week, and with excrements — 4 — 7 weeks. Cases of long allocation of a virus with excrements — to 4 months and more are described.
Transfer of a virus happens as a fecal and oral way, and, perhaps, airborne. Major importance in epidemich. process at P. has the fecal and oral mechanism of transmission of infection that is caused by duration of allocation of a virus with excrements from the infected organism and high concentration of a virus, edge can reach several million particles in 1 g of excrements. Hit of a virus P. in a human body rather seldom leads to development of a typical disease — one case of a disease is the share of 100 — 1000 cases of an asymptomatic carriage of virus. Therefore such virus carriers play the main role in distribution of the Item.
Massive allocation of a virus with excrements to the environment defines a possibility of its distribution through water, foodstuff, hands, flies. In drain waters of large settlements the virus P. is found quite often during the whole year. Usual methods of processing of drain waters not always lead to death of a virus. Cases of allocation of a virus P. from mains water are known. It is supposed that the flies adjoining to excrements of the person can become mechanical carriers of a virus P. The infectiousness remaining to 2 — 3 weeks is revealed by a virus of nek-ry species of the synanthropic flies caught in
P. K centers to the factors promoting spread of a virus P. density of the population, overpopulation of dwellings, lack of plumbing and sanitary, disturbance a dignity belong. - a gigabyte. governed, first of all in child care facilities.
Most often P.'s diseases are registered in aestivo-autumnal months (August — October in the countries sowing. hemispheres and January — April in the countries yuzh. hemispheres). So, for 1950 — 1958 in the USSR in the I quarter of year 9% of annual number of diseases of P., in the II quarter — 16%, in the III quarter — 50%, in the IV quarter — 25% were registered on average. In the countries of a tropical belt P. is registered more evenly within a year, however seasonal rises in incidence are observed.
the Preferential place of implementation of a virus P. in an organism is went. - kish. path. Reproduction of a virus happens in limfoepitelialny formations of a throat and intestines where it is defined in high concentration in 2 — 4 days after infection. The following stage — virusemia (see) — corresponds to the beginning of the preparalytic period of a disease when the virus can be allocated from blood of patients. With the help immunofluorescence (see) the virus is found also in leukocytes which, perhaps, play a role in the course of its dissimination in many bodies and fabrics. The virus breeds in limf, nodes, a spleen, liver, lungs, sometimes in kidneys and a cardiac muscle. The stage of a virusemia comes to an end by the end of preparalytic — the beginning of the paralytic period. The mechanism of penetration of a virus into a nervous system through a blood-brain barrier is studied insufficiently. Believe that the virus P. passes through an endothelium of small vessels, vascular textures, an ependyma of ventricles; some other way penetrations are peripheral nerves. High speed of advance of a virus on nerves (2,4 mm an hour) demonstrates passive distribution of virions on perineural spaces or through an axoplasm. However it is impossible to exclude a possibility of reproduction of a virus in neurolemmocytes (schwannian cells) and fibroblasts of endothelial and perineural covers.
After penetration of a virus into c. the N of page occurs its distribution on marrow which is followed by damage of motive cells up to their death. For 1 — 2 days the titre of a virus in marrow accrues, and then begins to decrease quickly, and the virus completely disappears. Clinically emergence of paresis and paralyzes (see. Paralyses, paresis ) and dynamics of their development match the period of the maximum reproduction of a virus and its subsequent disappearance. Spread of a virus in a nervous system happens on dendrites of the struck cells and, perhaps, through intercellular spaces. Interaction of a virus and a cell includes several phases: adsorption of a virus on a cell, its penetration into a cell, biosynthesis of virus components, formation of virus particles, a necrosis of cells. However various extent of defeat of motor-neurons is possible, including it can be reversible. Synthesis of virus particles happens in cytoplasm of a cell and is followed by suppression of synthesis of DNA, RNA and proteins of a host cell. The first morfol, expression of the changes occurring in a neurocyte is disturbance of structure of tigroid — a basphilic component ergastoplaz-we (tigroliz). Profound destructive changes in a cell lead to a rupture of its outside cover and an exit of a mature virus in intercellular space.
Genetic researches established correlation between paralytic P. and presence of a haplotype of HL-A3 and HL-A7. Thus, weight of disease is defined not only by properties of the activator, but also a condition of a macroorganism, including its genetic features. The pathogeny a wedge, manifestations of the residual period is connected with the death of motive neurocytes of a spinal cord and a brain trunk leading to denervation of muscles, disturbance of their trophicity, switching off from autokinesias. Long inaction of muscles, reduction of their blood supply, stay of extremities in the wrong situation are the cornerstone of reorganization of anatomical structure of muscles, bones, joints. The affected muscles decrease in sizes, are replaced with fatty and connecting tissue, sinews are shortened. Joint cartilages become thinner, their color changes, it is tarnished, the bone tissue atrophies. Gradually muscular and joint contractures form. Due to the selective damage of one muscles and safety of others changes their normal fiziol, relationship that serves as the reason patol, provisions of a trunk and extremities, their deformations. Influence of an exercise stress, napr, long vertical position of a body, walking, aggravates the available pathology of muscles, bones and joints and involves compensatory changes in not affected muscles. In development of contractures and deformations also the trophic frustration leading to a growth inhibition of extremities, their shortening play a role. Uneven recovery of function of muscles can be the reason of deformation of bones.
The pathological anatomy
At a macroscopic research of the central nervous system attracts attention a plethora of vessels of substance and the surface of a spinal cord; the plethora is especially expressed in gray matter, a cut on cross sections has the bulked-up appearance.
The most expressed morfol, changes at P. find in back and a myelencephalon, in the bridge of a brain, an average and a diencephalon, in precent-ralnykh crinkles of bark of a great brain. Defeat and death of neurocytes are preceded by a number of changes which can be considered as changes of the preparalytic period of the Item. They are studied at morfol, a research of a nervous system of the people who died in early terms of a disease and in experiments on animals. Carry a plethora of vessels, hypostasis of an endothelium of capillaries and vessels of a spinal cord, an arachnoid membrane, its kruglokletochny infiltration to the earliest changes (tsvetn. fig. 1), a chromatolysis in neurocytes (tsvetn. fig. 2), hypertrophy and proliferation of glial macrophages (see). In neurons, cells of a neuroglia — astrocytes, oligodendroglyocites, in an endothelium of vessels and macrophages find a virus in the form of kristallopodobny and massive accumulations of mature virions with a virus matrix. Virus inclusions usually are located in perinuclear and peripheral sites of a neuroplasm of these cells. After implementation of a virus the dystrophic, and then combined with them necrotic processes with full disintegration of all ultrastructures, including and a nuclear membrane, and also the processes connected with a reproduction of a virus develop in neurocytes. In the first days after emergence of paralyzes the plethora of vessels and moderately expressed hypostasis of substance back and a brain, small expansion of cerebral cavities, a hyperemia of vessels back and a myelencephalon, the bridge of a brain, especially in the field of a tire, hypostasis of walls and an endothelium of vessels come to light, staz (see), hemorrhages, perivascular kruglokletochny infiltrates, sharply expressed hypertrophy and a hyperplasia (diffusion and focal) gliotsit, loss, i.e. disappearance, neurocytes, especially in front horns of a spinal cord (tsvetn. fig. 3 and 4), and also kruglokletochny infiltration of an arachnoid membrane of a spinal cord. In the same terms infiltration of gray matter of a spinal cord by polymorphonuclear leukocytes, and also their accumulation in sites of a full and incomplete necrosis is observed (tsvetn. fig. 5) of gray matter, in to-rykh glial macrophages, hypertrophied astrocytes find, granular spheres (see) (tsvetn. fig. 6). Especially many glial macrophages meet in places of loss of neurocytes. In the remained neurocytes the chromatolysis is observed (see. Nervous cell ), sharp reduction of contents in a neuroplasm of RNA, neyronofagiya (see) and psevdoneyronofagiya (tsvetn. fig. 7). Near such neurocytes glial macrophages can be found. Many neurocytes take a form of cells shadows, about them accumulation of the gliotsit which are taking part in process of a neyronofagiya is quite often observed (tsvetn. fig. 8). In kernels of neurocytes the single and located groups oxyphilic and basphilic inclusions by the sizes 0,8 — 2,4 microns sometimes meet. Death of neurocytes is followed by disintegration of synapses, vallerovsky regeneration of nerve fibrils of ventral roots of spinal nerves, and also spinal and cranial nerves (see. Valera regeneration ). Inflammatory changes with perivascular kruglokletochny infiltrates, a neyronofagiya and psevdoneyronofagiya find also in spinal nodes and sensitive nodes of cranial nerves. At death of a large number of neurocytes of kernels of cranial nerves and a reticular formation of a brain trunk disturbances of the central regulation of breath and blood circulation develop. The structure of the majority of the remained neurocytes most often is recovered within the first month after the acute period of a disease. Perivascular kruglokletochny infiltrates, in structure to-rykh are found lymphocytes and plasmocytes, accumulations of astrocytes and glial macrophages — glial small knots (tsvetn, the tab., Art. 176, fig. 9) in nek-ry cases can be found at morfol, a research of c. N of page through Z,5—4 of month. The died on the spot neurocytes develops isomorphic and anizomorfny gliosis (see), in the field of the centers of a necrosis — gliomezodermalny hems. At the dead from P. note a hyperplasia single and group limf, follicles of a mucous membrane of a small bowel, limf, nodes, a spleen (sometimes with a moderate splenomegaly), dystrophic changes of a myocardium, liver, kidneys; in some cases find pneumonia, atelectases of lungs.
For a virologic research on opening take tissue of a head and spinal cord, blood, cerebrospinal liquid, contents of intestines.
as a result of infection with a virus P. in an organism develops humoral and local fabric immunity (see). In blood serum find neutralized, complement-linked and precipitant antibodies (see). Neutralized antibodies appear soon after infection, is frequent prior to the beginning of a disease, and remain throughout all life. Fixators arise in the first 3 weeks of a disease and disappear within several next years. Precipitant antibodies are defined already on 1 — 2nd week of a disease, then their caption sharply decreases, and in 3 — 4 months they disappear. Maternal antibodies are transferred to the child and the first 3 — 6 months of life remain. Passively entered antibodies remain in blood of only 3 — 5 weeks.
Antibodies at P. have type-specific character, but infection with a virus of one type can lead to emergence in low credits a heterolog of ichny antibodies, usually quickly disappearing.
The role of the antibodies circulating in blood comes down hl. obr. to neutralization of a virus in the period of a virusemia and to the prevention, thus, penetrations of a virus into a nervous system.
The immunogenesis at P. includes both humoral, and cellular factors of immunity. At the same time it is not possible to establish direct dependence between antiserum capacities in blood and reproduction of a virus P. in a nervous sistvkhma where antibodies either are absent, or have the low credits which are not determined by usual methods. Nevertheless in 1 — 2 day after penetration of a virus into a nervous system the quantity it begins to decrease quickly, and soon the virus disappears. At the monkeys infected intratserebralno and who do not have antibodies in blood, a virus in c. the N of page is found in the same terms, as in monkeys with high antiserum capacities. The given facts gave the grounds to consider that, except humoral immunity, the local fabric resistance which is not depending on concentration of antibodies in blood develops. The mechanism of the specified phenomenon is studied insufficiently.
Existence in intestines of the virus neutralizing antibodies relating to IgA is considered one of factors of intestinal resistance. Also the hypothesis of production of the inhibitor capable to slow down reproduction of a virus, in particular in nervous tissue expresses.
Immunity at P. has resistant character. However, considering that it is type-specific, perhaps recurrent disease of P. at infection with a virus of other type.
At specific prevention of P. the live vaccine prepared from three types of a virus P. creates rather durable immunity to infection (see below the section Prevention).
The clinical current
the Incubation interval lasts from 2 to 35 days, 10 — 12 days are more often.
Klien, P.'s classification is based on modern idea of a pathogeny of a disease, according to the Crimea inf. process at P. has stage development: reproduction of a virus in limfoepitelialny formations of a throat and intestines, a virusemia, penetration of a virus into a nervous system. On each of stages process can stop. Depending on it develops: inapparantny P. (carriage of virus); The item without defeat of a nervous system (abortal, or visceral); The Item with defeat of a nervous system (not paralytic, or Meningeal, and paralytic).
On degree of manifestation a wedge, symptoms P.'s current can be easy, medium-weight and heavy.
Inapparantny poliomyelitis represents a carriage of virus, to-rogo reproduction of a virus in limfoepitelialny formations of a throat and intestines without wedge is the cornerstone, of displays of a disease. Inapparantny P.'s cases meet considerably more often clinically expressed forms.
Abortal poliomyelitis is characterized by development of a virusemia and clinically shown by the fever moderated by intoxication, weakness, a small headache, sometimes the moderate catarral phenomena, a hyperemia of a pharynx, dysfunction of intestines. Clinical signs of defeat of a nervous system and inflammatory changes of cerebrospinal liquid are absent. The current of this form P. favorable, recovery comes in 3 — 7 days.
Not paralytic (Meningeal) poliomyelitis. Conducting a wedge, a syndrome is serous meningitis (see). The disease begins sharply (high temperature, a headache, repeated vomiting). Approximately at 1/3 patients the temperature curve has two-wave character, and the first wave reminds an abortal form of a disease, and then, after 1 — 3 days of absence of fever, there is the second feverish wave about a wedge, signs of defeat of a meninx. Degree of manifestation of a meningeal syndrome usually moderate, sometimes easy. At a part of patients Meningeal signs are absent, despite inflammatory changes in cerebrospinal liquid. Spontaneous extremity and spin pains, a hyperesthesia of skin, positive symptoms of a tension of roots of spinal nerves and nervous trunks — Neri's signs, Lasega and others are characteristic (see. Radiculitis ), sometimes pain at a palpation on the course of nervous trunks.
Cerebrospinal liquid transparent, colourless, follows under supertension. The quantity of cells is increased (from 30 to 150 in 1 mkl), is rare to more high level. The pleocytosis has lymphocytic character. Protein content normal or is slightly increased. The amount of sugar is increased or is normal. Normalization of temperature and improvement of the general state occur at the beginning of the 2nd week of a disease, normalization of composition of cerebrospinal liquid — on the 3rd week.
Paralytic poliomyelitis depending on localization of defeats in a nervous system is divided into the following forms: spinal, bulbar, pontinny and mixed (pontosshshalny and bulbospinalny). On a wedge, to a current paralytic P. is divided into four periods: preparalytic, paralytic, recovery and residual.
Preparalytic period. At all forms of paralytic P. the preparalytic period has identical a wedge, a current. The disease begins sharply with temperature increase to high figures, an indisposition, weakness, anorexia. At a half of patients the moderate catarral phenomena from upper respiratory tracts are noted and dysfunction of intestines. In 1 — 2 day signs of defeat of a nervous system join.
At a part of patients temperature has two-wave character, and then nevrol. symptoms appear on the second wave after the short period (1 — 2 day) of absence of fever. The meningoradikulyarny syndrome is observed: a headache, vomiting (2 — 3 times a day), extremity and spin pains, a hyperesthesia, muscle tension of a nape and back, positive Kernig's signs (see. Kerniga symptom ), Brudzinsky (see. Meningitis ), symptoms of a tension of nervous trunks and roots of spinal nerves. In separate groups of muscles twitchings are observed. The motive concern of patients is noted. The preparalytic period lasts from 1 to 6 days. In nek-ry cases paralyzes develop in the first day of a disease («morning paralysis») without the accurate preparalytic phenomena.
Paralytic period. The clinic of the paralytic period is defined by localization of defeats in a nervous system.
The spinal form P. develops at defeat of motive neurocytes of front horns of a spinal cord. Paralyzes arise on 1 — the 6th day of a disease, usually by the end of the feverish period or during the first hours after decrease in temperature. Typically rapid development of paralyzes within a short period of time — from several hours to 1 — 2 days, but is no more than 3 days. Paralyzes have all signs characteristic of defeat of peripheral motor-neuron: a low muscle tone, decrease, and in some cases lack of reflexes (see. Areflexia ), in the subsequent an atrophy of muscles. Preferential proximal departments of extremities suffer, is more often than legs (fig. 2). There are no losses of sensitivity. Pyramidal signs and dysfunctions of pelvic bodies are absent. Asymmetric chaotic distribution of paresis and paralyzes is characteristic that reflects a different damage rate of motive neurocytes even in one segment of a spinal cord. Depending on quantity of the struck segments the spinal form P. can be limited (monoparesis) or extended (fig. 3). The heaviest are spinal forms with damage of intercostal muscles and diaphragms. In these cases patients have signs of respiratory insufficiency: cyanosis, short wind, restriction of mobility of a thorax, retraction at a breath of intercostal spaces and epigastric area, inclusion in the act of breath of auxiliary muscles. The voice becomes silent, the tussive push weakens or disappears.
The bulbar form P. proceeds hard, with disturbance of the vital functions.
The disease begins sharply, after very short preparalytic period or without it. A condition of the patient from the very beginning of a disease heavy (high temperature, vomiting, the general intoxication).
The main the wedge, symptoms are defined by localization of defeat in a brain trunk. Defeat of a joint kernel leads IX and X parcherepnomozgovy nerves (nuci, ambiguus) to disturbances of swallowing (pharyngeal paralysis) and phonations (laryngeal paralysis). Sharply secretion of slime amplifies, edges accumulates in upper respiratory tracts and obturirut them (a wet form). Sharper aggravation of symptoms of patients occurs at defeat of the respiratory and vasomotor centers located also in a brain trunk. It is followed by disturbance of a normal respiratory rhythm with the advent of pauses and emergence patol, rhythms, development of vasculomotor spots, cyanosis, tachycardia or bradycardia, increases in the beginning, and then falling of the ABP. Perhaps also defeat of motive kernels III, VI and VII couples of cranial nerves. It leads to oculomotor disturbances and asymmetry of the person at the expense of paresis of face muscles. The rapid current of a disease at a bulbar paralytic form P. often leads to a bystry lethal outcome. If it does not come, then in the next 2 — 3 days there is a stabilization of process, and then, on 2 — 3rd week of a disease, the condition of the patient improves due to the begun recovery.
The Pontinny form P. develops at the isolated defeat of a kernel of a facial nerve (the VII steam) which is in area of the brain bridge. From here and name «pontinny form». Wedge, current of this form less heavy. Full or partial loss of mimic movements on one half of the face comes to light. The palpebral fissure is not closed (lagophthalmia), the corner of a mouth hangs down. Any pain, sensitive frustration, disturbances of a slezootdeleniye does not happen.
The Pontospinalny form P. is characterized by a combination of paresis of a facial nerve to damage of muscles of a trunk and extremities.
The Bulbospinalny form P. is shown by a combination of bulbar symptoms to paresis and paralyzes of muscles of a trunk and extremities.
In the paralytic period of P. at most of patients (90%) in cerebrospinal liquid inflammatory changes are noted. The normal structure it often remains at the pontinny and easily proceeding spinal form with the limited nature of paresis.
In preparalytic and at the beginning of the paralytic period (to 10 — the 12th day of a disease) in cerebrospinal liquid the pleocytosis of lymphocytic character, usually to 100 cells in 1 mkl is observed, rarely it is more. Impurity of neutrophils, sometimes even their dominance (to 60 — 70%), can be in the first 3 — 5 days of a disease. The amount of protein normal or is a little increased. Further, by the end of the 2nd week of a disease, or there occurs normalization of composition of cerebrospinal liquid, or against the background of the decreasing cytosis protein content increases to 1,5 — 2%.
The paralytic period of all listed forms P. lasts from several days to 2 weeks. The first signs of recovery of motive functions testify to the beginning of the recovery period.
The recovery period at a spinal form begins on 2 — 3rd week of a disease with recovery of function of slightly affected muscles and occurs slowly and unevenly. As a rule, function of hard affected muscles completely is not recovered or in general paralyzes do not find a tendency to involution.
Irregularity and mosaicity of damage of muscles is especially expressed in the recovery period. It leads to various deformations of a bone skeleton and development of contractures. By the end of the first month of a disease atrophies which progress further begin to develop. Process of recovery goes especially actively within the first 3 — 6 months of reconvalescence, then it is slowed down, but about a year more usually proceeds. Slight paresis within 2 — 4 months can come to an end with a complete recovery, there is only a small hypotrophy of muscles. If after 1 — 1V2 years there are paresis and paralyzes which are not finding a tendency to further recovery, they are considered as the residual phenomena.
At a bulbar form P. during the recovery period there is a complete recovery of the act of swallowing, phonation, breath. Oculomotor disturbances and paresis of a facial nerve with weakness of mimic muscles can remain for the rest of life.
The isolated defeat of a kernel of a facial nerve (a pontinny form P.) can also have resistant character though at most of patients since 2 — process of recovery which comes to an end with complete or partial recovery of mimic movements begins 3rd week.
The residual period is characterized by the sluggish paralyzes and paresis having resistant character, expressed by trophic frustration, muscular and joint contractures (see), secondary deformations of a trunk and extremities. These phenomena of hl are observed. obr. at severe spinal forms of a disease.
Trophic disturbances are most expressed in the paralyzed extremities and are shown by an atrophy of muscles, decrease in temperature of skin, dryness or the increased perspiration of skin, cyanosis, a peeling. Nek-ry patients can have an imperceptible atrophy of muscles because of excess adjournment in them of fat and growth of connecting fabric.
Contractures and deformations form standing more often. Defeat of extensive groups of muscles of a hip and shin can lead to flexion contractures of coxofemoral and talocrural joints. These deformations often develop at the same time or emergence of one — leads development another. More bystry recovery of function of front and back tibial muscles and a tricipital muscle of a shin at paralysis of their antagonists — fibular muscles promotes development clubfoot (see). On the contrary, recovery of function of fibular muscles at paralysis of tibial leads to formation of ploskovalgusny deformation of foot. At paralysis of a gastrocnemius muscle and recovery of function of razgibately foot calcaneal foot is observed. Various deformations feet (see) can be combined depending on a combination of functions of the affected and kept muscles.
At paralysis of muscles of a hip changes in a knee joint — the so-called stirred-up joint can be observed (see. the Dangling joint ), characterized by excess overextension (recurvation). In hard cases of recurvation knee joint (see) there can be an incomplete dislocation of a shin of a kzada. At stretching of the copular device of a hip joint and safety of adductors of a hip the incomplete dislocation or dislocation of a femur forms (see. Hip joint ).
In cases of widespread damage of muscles of a trunk the rachiocampsis develops back — kyphosis (see) which is more often observed in chest department. A curvature of lumbar department of a backbone forward — lordosis (see) — develops at paralysis of belly muscles and relative safety of muscles of a back, and also at paralysis of gluteuses. At uneven damage of long muscles of a back there is a side rachiocampsis — scoliosis (see). The rotational deformations of a backbone which are observed at scolioses are the reason of formation of a so-called costal hump, at the same time protrusion is formed on side of the affected muscles. Scoliosis of a backbone can be combined with a kyphosis or be followed by its compensatory side curvature in other department. A rachiocampsis and deformations of a thorax involves dysfunctions of lungs, heart and other bodies.
In a belt of upper extremities the deltoid muscle most often is surprised. Under the influence of weight of the hanging-down hand the joint bag of a shoulder joint stretches that can lead to dislocation of a shoulder (see. Shoulder joint ). Reduction of a big pectoral muscle and muscles of a shovel causes development of the bringing contractures of a shoulder joint, high standing of a shovel and turn of its knaruzha. At paralysis of a tricipital muscle of a shoulder and the kept function of a biceps flexion contractures develop seldom since the hand droops under the influence of sole weight. Forearm at the same time pronirovano. Paralysis of back group of muscles of a forearm leads to a passive otvisaniye of a brush with assignment it in the elbow or beam party. Depending on defeat of these or those groups of muscles of a forearm the brush can take a form of a sharp-clawed paw, the hanging-down brush, a monkey brush (see. Elbow nerve , Beam nerve , Median nerve ).
Various compensatory poses and the movements, to the Crimea the patient for ensuring stability and movement of the affected extremities resorts and the available deformations can aggravate influence of body weight and cause secondary. At the same time the affected muscles stretch even more that in turn leads to strengthening of deformations. Thus, deformations, contractures in the residual period of P. have resistant character and without holding necessary medical and correctional actions are inclined to progressing.
Complications are observed by hl. obr. in the paralytic period. Pneumonia, an atelectasis of a lung, intersticial myocarditis concern to them. At a bulbar form sometimes there is an acute gastrectasia, stomach ulcers, gastric bleedings.
P.'s Diagnosis is made on the basis of the given clinical picture and laboratory researches.
From a wedge, P. given the greatest value for diagnosis have an acute feverish onset of the illness, a meningoradikulyarny syndrome with inflammatory changes in cerebrospinal liquid, development within the first week of a disease of sluggish paresis or paresis of motive cranial nerves without disturbances of sensitivity and frustration of pelvic bodies. The wedge, data are compared with results of virologic and serological researches. An additional role at diagnosis of a spinal form P. is played by an elektromiografichesky research (see. Electromyography ), establishing localization of process in front horns of a spinal cord. At a global electromyography of the affected muscles the neyronalny type of denervation of motive neurocytes comes to light.
In hard affected muscles at an elektromiografichesky research (fig. 4) it is not possible to catch biopotentials. This phenomenon carries the name «bioelectric silence». At safety of a certain amount of motor-neurons the electromyogram is characterized by an urezheniye of a rhythm due to synchronization that is characteristic of all diseases with localization of process in front horns of a spinal cord. In easily affected muscles autokinesia gives an interferential curve on the electromyogram, however at synergy change of a tone in them it is possible to catch emergence of the rare oscillations testimonial of defeat of front horns of a spinal cord.
Virusol. the research comes down to establishment of a virus etiology of a disease and definition like a virus P. For this purpose use various methods of allocation and typing of a virus (see. Virologic researches ) or the methods allowing to reveal antibodies to a virus P. and to define their caption (see. Serological researches ). The excrements (collected in a bottle or on a rectal tampon), washouts from a nasopharynx, cerebrospinal liquid and blood are investigated. Materials for a research take in perhaps earlier terms of a disease. If the research is not conducted at once, tests store at t ° — 20 °. Blood to department of serum is not frozen, do not add preservatives to serum; it is possible to store it at t ° 4 °. From excrements prepare 10 — 20% of suspension which clarify centrifuging. Add antibiotics for suppression of a bacterial flora to suspension of excrements.
Allocation of a virus P. is carried out on primary or intertwined cellular cultures (cells of kidneys of an embryo or amnion of the person, kidneys of monkeys, cells of HeLa, etc.). The studied material is placed in 3 — 4 test tubes with culture, put in the thermostat at t ° 36 ° and daily mikroskopirut. A sign of reproduction of a virus P. is the cytopathic effect (fig. 5) developing within 2 — 7 days. At its absence on 6 — the 8th day can be spent a «blind» passage, i.e. to transfer cultural liquid to a series of test tubes with fresh culture that in some cases reveals the virus P. which is present at the studied material in the minimum concentration. The degeneration of the most part of cells in culture indicates high concentration of a virus in cultural liquid, sufficient for carrying out typing. The type of a virus is defined in a neutralization test by mixes of immune type-specific serums for what mixes of a virus with serums bring in culture of cells (points lack of a degeneration of cells to neutralization of a virus). Typing is carried out also by method of the color test based on discoloration of the indicator of phenol red in culture medium where add a suspension of cells and mix of a virus with type-specific serums (in the presence of viable cells reaction of the environment moves in the acid party, at destruction of cells a virus it remains neutral or slightly alkaline). At release of mix of viruses P. of different types or mix of a virus P. with other intestinal viruses their division is carried out by means of a method of receiving separate colonies of a virus.
Serological investigate pair tests of the blood serum taken in the first days of a disease and later 2 — 3 weeks. Apply a neutralization test of a virus to detection of antibodies and definition of their caption. The standard dose of a virus is usually mixed with each of double consecutive cultivations of blood serum (from 1:2 to 1: 10 24 ). The result is considered on cytopathic effect in culture of fabric a method of plaque-forming cells or by method of color test. Identification of antibodies and definition of their caption to a virus P. carry out also by means of reaction of binding complement (see). As antigen serves the cultural liquid raw or heated-up, with the high content of a virus.
Positive diagnostic value has allocation of a virus P. (especially from cerebrospinal liquid, and on section — from substance of a head and spinal cord) and emergence or considerable (not less than quadruple) increase of an antiserum capacity in pair tests of blood serum.
In the conditions of broad use of a live vaccine for P.'s prevention at laboratory inspection of persons with a disease, suspicious on P., the allocation of a vaccinal virus accompanied with identification of antibodies in blood serum is possible. In this case it is necessary to establish an origin of the allocated virus, using methods of intra-standard differentiation of virus strains.
The differential diagnosis
Not paralytic (Meningeal) P. should be differentiated with serous meningitis of other etiology — enteroviral, parotitis, tubercular (see. Meningitis ). Enteroviral meningitis often is followed by manifestations, atypical for P. — a polymorphic menocelis, mialgiya, herpetic rashes on a mucous membrane of a pharynx, an oral cavity, skin of hands and legs. Parotitis meningitis differs in higher figures of a pleocytosis (more than 300 — 500 cells in 1 mkl cerebrospinal liquid), increase in a diastase in urine and blood. Tubercular meningitis is characterized by a current, the long fever, incremental on weight, early joining psychotic disturbances and basal symptoms. In cerebrospinal liquid the level of sugar decreases.
Spinal form paralytic II. differentiate with kostnosustavny pathology, a myelitis, a polyradiculoneuritis. Bone and joint pathology is characterized sparing, but not the paretic nature of gait, morbidity at the passive movements in joints, by safety of a muscle tone and tendon jerks, absence patol, change in cerebrospinal liquid, inflammatory changes in blood. Myelitis (see) is followed by conduction disturbances of sensitivity, disturbances from bodies of a basin, trophic disorders of skin with formation of decubituses, often symmetric nature of paresis, pyramidal signs. The beginning of a polyradiculoneuritis (see. Polyneuritis ) often fever-free, a rise period of paresis longer, the course of a disease sometimes wavy or recurrent, distribution of paresis symmetric, preferential distal type, disorder of sensitivity goes on polyneuritic and radicular type, in cerebrospinal liquid the increased amount of protein at a normal cytosis. Poliomiyelitopodobny diseases (see) have often fever-free beginning, the limited nature of paresis; composition of cerebrospinal liquid normal; the complete recovery of function of the affected muscles comes within the first 2 months of a disease. Sometimes these diseases are followed by changes in cerebrospinal liquid and deep paresis. In similar cases it is possible to resolve an issue of an etiology of process only by means of virologic and serological researches.
The bulbar form should be differentiated with a bulbar syndrome which can arise at a polyradiculoneuritis and involvement in process of roots and trunks of cranial nerves. Unlike P. defeat usually has bilateral symmetric character — a diplegia of a facial nerve, bilateral defeat of third cranial nerves. Differential diagnosis of a bulbar form P. with trunk encephalitis is complicated (see. Encephalitis ). At the last all-brain symptoms, disturbances of consciousness, pyramidal signs, spasms are more expressed, very rare at P.
Pontinnaya the form is differentiated with neuritis facial nerve (see). Neuritis develops at children more often 7 years are more senior. Paresis of mimic face muscles at neuritis is followed by morbidity of trigeminal points at a palpation, spontaneous pains in a half of the face, disturbances of superficial sensitivity on a face, dacryagogue on the struck party, decrease in flavoring sensitivity on sweet and salty on front two thirds of language from defeat.
In the recovery and residual period of P. it is necessary to differentiate with a number of the diseases proceeding with flaccid paralyzes and secondary bone deformations. Hereditary forms of spinal amiotrofiya, such as disease of Verdniga — Goffmanna and Kugelberg's disease — Velandera (see. Amyotrophy ), as well as P., are characterized by defeat of motive neurocytes of a spinal cord. However they have a number of differences: gradual increase of motive frustration, preferential defeat of proximal groups of muscles at long safety distal, quite often family nature of a disease. At a poliomiyelitichesky form of a tick-borne encephalitis Meningeal symptoms can precede development of sluggish paralyzes (see. viral tick-borne Encephalitises ). Paralyzes are localized by hl. obr. in muscles of a neck and a shoulder girdle. In differential diagnosis of these diseases epidemiological data (spring and summer seasonality), virologic and serological researches matter. Patrimonial traumatic peripheral paresis and paralyzes have local character and are observed from the first days of life of the child. At miyelopoliradikulonevrita (see) and focal myelites along with peripheral paresis signs of damage of other parts of the nervous system, napr, sensitive frustration, patol, pyramidal symptoms, dysfunctions of pelvic bodies are noted.
P.'s manifestations in the residual period should be differentiated with an arthrogryposis — an inborn disease of a musculoskeletal system, for to-rogo multiple contractures of joints owing to a sharp underdevelopment of muscles are characteristic (see. Arthrogryposis ).
At P.'s differentiation with inflammatory damages of bones and joints, rheumatism (see), arthritis (see), osteomyelitis (see), etc., leading to sharp restriction of movements in extremities — to so-called pseudoparalyses, serological, X-ray, elektromiografichesky inspections are important.
At emergence the wedge, simptomovg suspicious on P., is necessary a high bed rest that has special value in the preparalytic period as for reduction of degree of the paralyzes developing further, and for their prevention.
In the preparalytic period (the first days of a disease) carry out only symptomatic therapy (appoint ascorbic to - that, analgetics, the febrifugal, hyposensibilizing means). Use of gamma-globulin does not warn and does not stop development of paralyzes.
In the paralytic period the correct position of a body and the paralyzed extremities is of great importance. The early orthopedic mode is the most important measure of prevention of contractures and stretchings of paretichny muscles. For reduction of pains appoint soothing and calmatives, hot wrappings and other thermal procedures (sollyuks, paraffin, ozokerite, etc.). It is necessary to avoid injections, exercise and mental stresses.
A specific place is held by treatment of patients with disorders of breath and disturbance of the act of swallowing. During the weakening of a tussive push and accumulation of slime in upper respiratory tracts it is necessary to suck away it a suction machine. If suction of slime through a nose does not give effect, it is necessary to make tracheostomy (see) and to continue removal of slime through a tracheostoma. The indication for use of an artificial respiration is decrease in vital capacity of lungs to 25%, the maintenance of CO 2 in expired air more than 4,5%, hypercapnia and anoxemia. Disturbance of the act of swallowing demands introduction of a gastric tube.
In the recovery period (on 3 — 4th week of a disease) begin treatment with mediators and stimulators. Use antikholinesterazny drugs — prozerin, Galantaminum (Nivalinum) which promote transfer of nervous impulse in synapses. Treatment by mediators (repeated courses within 20 — 30 bucketed days in 2 — 3 months) it is carried out it is long. Appoint also the Dibazolum possessing vasodilating, spasmolytic action and exerting the stimulating impact on a nervous system. Purpose of vitamins of group B, especially the B12 vitamin promoting recovery of synthesis nucleinic to - t in the struck motive neurocytes is shown. Anabolic steroids — methandrostenolone, Nerobolum, retabolil are used. Within the first year of a disease treatment is recommended to spend by two-three short courses (20 — 25 days) bucketed not less than 40 days.
In the residual period the main attention is paid to fight against contractures and a motive training against the maximum use of the remained muscles. It is reached by orthopedic means in combination with to lay down. physical culture, massage, fizio-and balneoterapiya, and also repeated courses of drug treatment. Appoint the antikholinesterazny drugs improving neuromuscular conductivity (Galantaminum, Kalyminum, an ambenonium chloride, prozerin, etc.); the means influencing preferential processes of fabric exchange (Cerebrolysinum, cocarboxylase, ATP, vitamins of group B, nicotinic to - that, etc.). For improvement of function of muscles use drugs, phosphorated, calcium, potassium, and also lipocerebrinum, methionine, vitamin E, etc. Include also biogenic stimulators in courses of treatment (pyrogenal, proper-is lovely, an aloe, FIBS, etc.).
The physical therapy at P. is directed to recovery remained, but functionally oppressed sites of c. N of page, on stimulation of compensatory opportunities of an organism during the recovery and residual periods. At the choice of a physical factor and technique of influence proceed from the period of a disease, localization of process and a wedge, manifestations. The physical therapy is most often applied at paralytic P. (spinal, pontinny and ponto-spinal forms); the physical therapy at bulbar symptoms with disturbance of a respiratory rhythm and cordial activity is contraindicated.
In the paralytic period after normalization of temperature, usually with 7 — the 12th day of a disease, on a zone of the struck segments of a spinal cord apply electric field of UVCh (see. UVCh-therapy ), magnetic field of high or ultrahigh frequency in slaboteplovy dosages by a cross technique of influence of small duration (10 — 12 min.), daily or every other day (see. Inductothermy ). Besides, the area of paretichny muscles is irradiated with a lamp sollyuks, carry out local electrolight bathtubs (see. Phototherapy ). At purpose of thermal procedures it is necessary to consider a condition of cardiovascular system of the patient and to watch his health during the procedure. Procedures should be performed, whenever possible, at a bed of the patient. The principles of treatment of a pontinny form P. same, as at treatment of defeats of a facial nerve of other etiology (see. Facial nerve ).
In the recovery period for treatment use a direct current in the form of local (cross or longitudinal) galvanization (see) and an electrophoresis of medicinal substances — calcium, iodine, novocaine, a prozerin, Nivalinum, etc. (see. Electrophoresis, medicinal ) for the purpose of reduction of pain, rendering resorptional action and improvement of excitability and conductivity of the neuromuscular device. Except these procedures, it is possible to continue use of those which are begun in the paralytic period (a high-frequency or ultrahigh-frequency inductothermy), influencing not only a zone of the struck segments of a spinal cord, but also the paralyzed muscles. The specified procedures are carried out by the sparing techniques and combined with electrostimulation of the paralyzed muscles (see. Electrostimulation ).
In recovery (in 1,5 — 3 months) and residual the periods, except hardware physical therapy, apply the water thermotherapy directed to improvement of a trophicity, conductivity and excitability of the neuromuscular device, to stimulation of processes of recovery and compensation of the lost functions. For these purposes appoint the general and local mineral and medicinal bathtubs (see) — salt and coniferous, chloride sodium, radonic, sulphidic, sagy, etc., 12 — 15 on a course. Mud cure (see), paraffin therapy (see) and ozoceritotherapy (see) are carried out in the form of applications on a segmented zone and the paralyzed extremities. For fight against paralyzes, contractures and deformations of a trunk and extremities use underwater shower massage (see), swimming (see) and a kinesitherapy in pools (see. Physiotherapy exercises as method ). All specified procedures are combined with electrostimulation by segmented and local techniques.
Before orthopedic operations widely use a thermotherapy (gryazeparafinoozokeritoleche-ny, hot wrappings of an extremity), an electrophoresis of medicinal substances, ultrasound, massage, to lay down. physical culture.
Treatment of patients shall be systematic, especially in the first 3 years after the postponed disease.
Within the first year it is necessary to conduct 4 courses of physical therapy, on the 2nd year — 3 courses, and on the 3rd — not less than two courses.
Ortopedo-hirurgichesky treatment is carried out in the paralytic, recovery and residual periods of P., it can be conservative and operational.
Treat means and methods of conservative treatment: plaster beds, splints, bandages and other means for treatment by situation; procedures in the swimming pool for development of joints gymnastics; massage; the equipment for development of movements in joints; corsets, tires, special footwear and other products for prosthetics; extension and passive stretching of kontragirovanny muscles; pharmaceuticals of fortifying character and stimulating the neuromuscular device.
Operational treatment includes the recovery, stabilizing, corrective and cosmetic, and also combined operations.
In the paralytic period as it is stated above, prevention of contractures and an atrophy of muscles is reached by the correct laying of the patient on a hard bed with preservation of functionally advantageous position of a trunk and extremities.
In the recovery period carry out all types of conservative therapy promoting recovery processes, the prevention and correction of deformations of joints, stimulation of muscles, development of the correct act of walking. For not skeletal traction the cuff or a splint holding the lower extremity in functionally advantageous position are recommended; development of contractures of a knee joint is made with use distraktsionno-compression devices (see) — Volkov's devices — Oganesyan, Dyagelev, etc.
In the residual period along with the conservative treatment described above quite often there is a need for an operative measure. Indications to operation depend on age of the patient (them carry out not earlier than in 5 years after an onset of the illness and at children 7 years are not younger), conditions of the remained muscles, a type of deformations, compensatory adaptations. Myotomies and fasciotomies should not be applied since they cause additional damage to the paralyzed muscles.
Recovery operations include different types of a tendinous myoplasty (change, a transposition, tonic mio-71 an eraser, a miotransmissiya, lengthening and shortening of sinews and muscles). These operations take the central place in ortopedo-hirurgiche-skom treatment as they provide recovery of a form and function of an extremity.
The greatest attention is deserved by tendinous and muscular changes. They provide change of a point of an attachment of a myogaster, her sinews, their movement to the new place, intradermal fixing. The muscle gets new function. Changes of muscles depending on technology of operation are subdivided on peripheral, central, full, separate and partial. It is possible to replace both synergists, and antagonists.
For treatment of horse and calcaneal foot resort to operations on bones of foot and to changes of muscles (see. Foot ). At pes varus replace a front tibial muscle to the outer edge of foot, and at pes valgus — a long fibular muscle on an inner edge of foot. Paralysis of four muscles of a hip leads to serious stati-to-dynamic frustration. For their normalization it is possible to recommend change of sinews of a part of a sgibately shin for a front surface of a tibial bone.
At paralysis of gluteuses replace a napryagatel of a wide fascia to the place of the muscle straightening a trunk. After operation apply a circular plaster bandage 6 weeks. In the next few days begin special gymnastics in a plaster bandage for elaboration of new function of the replaced muscles. Before operation appoint a course of the stimulating fizio-and medicamentous therapy.
The stabilizing operations apply to creation of stability of joints at total paralyzes of muscles. A number of operations is for this purpose developed: arthrorisis (see), tenodesis (see), fasciodesis (see) and other operations with use of synthetics, napr, lavsan. The best stabilizing effect gives full bone short circuit of a joint (see. Artificial ankylosis ).
Apply to stabilization of a backbone front or back spondylodesis (see). On upper extremities usually carry out an artificial ankylosis of a shoulder joint. Grays's operation is applied to short circuit of a collision and calcaneal joint among other types of an artificial ankylosis: two bone transplants from a tibial bone implement in a collision and calcaneal joint. After operation for several months apply a plaster bandage or the compression device.
Corrective operations carry out for correction of deformations and shortenings of extremities. Use different types osteotomies (see), including and extending using distraktsionno-compression devices. At side curvatures of a knee joint along with an osteotomy it is necessary to strengthen copular kapsulyarny the device.
Cosmetic operations carry out for the prevention and correction of deformations of extremities. Side curvatures warn by method of an epifizodez — temporary short circuit of regions of growth metal brackets. Apply also modeling osteotomy of a shin across Ilizarov at paralysis of her muscles (fig. 6). Shortening of bones is corrected by means of an osteotomy and remote and calibration devices.
The combined operations provide a combination of the listed interventions. An example of such operation is passive and active static stabilization according to Ginzburg — creation of the immovability of all joints (pan-artificial ankylosis) of foot and change of a muscle straightening a trunk and the broadest muscle of a back on the proximal end of a hip with use instead of sinews of wide and long mylar films.
Correctly carried out ortopedo-surgical treatment in combination with social and labor rehabilitation allows the patients who transferred P. to get not only sedentary professions (the accountant, the seamstress, etc.), but to perform physical activity (the turner, the electrician, the driver, etc.).
Physiotherapy exercises. Physical exercises, increasing number of impulses to motive neurocytes of a head and spinal cord, exert positive impact on the centers of braking in nervous elements arising at the Item. The medical fizkultu'ra at P. is directed to stimulation and recovery of the paralyzed muscles, strengthening of muscles with the weakened function, the prevention and elimination of contractures, education at patients of skill of movement, and at irreversible motive disturbances — to development in sick skills of compensatory character.
Lech. the physical culture and massage are shown to patients with motive disturbances of various depth and localization (at decrease in force of muscles, existence of contractures, trophic disturbances). They will be out more actively in the recovery and residual period. Treatment continues is long and gives the best effect in the recovery period. In the residual period in connection with existence of permanent changes in joints and muscles carry out preferential passive movements in joints, mechanotherapy (see) and correction by situation. Besides, the technique of treatment in this period is defined by the nature of surgery.
Physical exercises and massage are contraindicated to patients in paralytic the period and in the early recovery period at the general serious condition of the patient and temperature increase.
Use the following means to lay down. physical culture: to lay down. gymnastics, physical exercises in water, training and a training in walking, a training of household skills, work therapy (fig. 7) and treatment by situation (fig. 8). Physical exercises carry out at individual classes with the patient by the techniques developed by S. I. Uarova-Jacobson (1935), A. F. Kaptelin (1958, 1961, 1969), Kabat (N. of Rabat, 1953), Jlepya (D. Leroy, 1956). Their features consist in selective impact on the paralyzed muscles, in a strict dosage of an exercise stress according to depth of damage of muscles, creation of optimal conditions for blood circulation and food of muscles, the maximum activation of patients in the period of a bed rest; repeated use for day of passive exercises in joints in the presence of contractures, development of skills of walking, the prevention of vicious installations in joints and irrational compensatory adaptations.
For a possibility of performance by the patient of certain physical exercises use various ways of simplification of movements with support of an extremity a soft strap (fig. 9, a), with a support on a slippery surface from plastic (fig. 9,6), with an equilibration of weight of an extremity a load (fig. 9, c), etc.
Preliminary thermal influences (a paraffinotherapy, hot wrappings) improve a functional condition of muscles, promote elimination of secondary changes in joints and increase functional effect of physical exercises.
The training action of exercises amplifies use of electrostimulation of muscles.
Lech. the physical culture is closely combined with use of massage which is carried out according to localization of damage of muscles and with the intensity depending on depth of their defeat (intensity of massage the smallest at falloff of function of muscles).
Sanatorium treatment in local sanatoria is shown in the early recovery period, but not earlier than in 1 — 2 month from the beginning of a disease, in balneogryazevy resorts (Anapa, Jalal-Abad, Dzhermuk, Druskininkai, Yevpatoria, Odessa, the lakes Bitter and Karachi, Pyatigorsk, etc.); in the recovery and residual periods not earlier than in 4 — 5 months and not later than in 8 — 10 years, and also after the orthopedic actions in the presence of signs of the continuing recovery of functions at a possibility of independent movement and self-service of the patient.
Philosophy of rehabilitation therapy at P. are its complexity, the early beginning, and also constant holding medical and correctional actions. Rehabilitation therapy of P. is carried out taking into account character, localization, distribution of motive frustration, age of the patient and his psychological features. Long overseeing by patients, their treatment and rehabilitation are carried out by succession various to lay down. institutions (nevrol. department-tsy — ortopedo-hi-rurgichesky a hospital — children's policlinic — profile sanatorium).
Not paralytic (Meningeal) P. proceeds favorably and without effects. At paralytic P. the forecast depends on depth of paresis and paralyzes. The complete recovery of motive functions occurs at 20 — 40% of patients. Residual paresis and paralyzes in those groups of muscles where the movements completely are absent are most probable, and Elektromiograficheski is marked out «bioelectric silence». The forecast is most serious at spinal, bulbar and bulbospinal-ache forms with disturbances of breath.
the Main measure of prevention of P. is immunization. Two types of vaccines — inactivated (Solk's vaccine) and the living, made of attenuirovanny strains Seybina are applied. The inactivated vaccine represents a suspension of particles of the virus P. which is grown up in culture of fabric and inactivated by formalin. In inoculative practice usually use the trivalent vaccine containing all three antigenic types of a virus. Vaccination includes three intramuscular or subcutaneous injections at an interval of 6 weeks with the subsequent single revaccination in 6 months (the scheme accepted in the USA) or two injections at an interval of 2 — 4 weeks with 2 revaccinations — in a year and in 4 — 5 years (the scheme accepted in Sweden). Begin inoculations to children of the first year of life on reaching them six-months age.
In the USSR since 1959 apply only a live poliomyelitic vaccine.
It is made in the form of the trivalent drug (can be applied and monovalent vaccines) representing mix of three types of a virus P. (attenuirovanny strains of Seybin) who is grown up in culture of fabric. The standard drug used in the USSR contains in one dose 5 X 105 particles of a virus of I, 2 X 105 type of particles of an II and 3 X 105 virus of particles of an III virus. The vaccine is issued in the form of liquid drug or candies dragees and is entered through a mouth. Inoculations are carried out to the USSR in a planned order according to the calendar of inoculations accepted in 1980. Vaccination is performed within the first year of life of the child on reaching it three-months age and consists of three inoculations at an interval of 1,5 months. At the age of 1 — 2 and 2 — 3 years carry out the revaccinations consisting of two inoculations at an interval of 1,52 months. Additional revaccinations (one inoculation) are provided in age of 7 — 8 and 15 — 16 years.
Contraindications to use of a live poliomyelitic vaccine are acute feverish or heavy hron, diseases (e.g., severe forms of dystrophy, rickets, tuberculosis, cardiovascular diseases in a stage of a decompensation).
Inoculations a live poliomyelitic vaccine (vaccination) lead to formation of immunity to P. (to a virus of all three types) at 85 — 95% vaccinated. Revaccinations are directed to correction of accidental defects of vaccination and to long maintenance of rather high level of immunity.
Sick P. surely hospitalize and isolate (see. Isolation of infectious patients ). Indoors, where there is a patient, carry out daily wet cleaning, allocations of the patient and the linen contaminated by them disinfect, boil ware, wash objects of a nosotrophy and a toy with soap, destroy flies. Final disinfection provides disinfecting of allocations of the patient, ware, linen, chamber disinfection of outerwear, bedding and processing of the room with solution of chloroamine (see. Disinfection ).
At emergence of flash of P. bystry vaccination of the susceptible contingents in the center promotes restriction of flash and its bystry fading.
Bibliography: Vashchenko M. A. Infectious neuritis of a facial nerve at children, Kiev, 1974; In and l h at r O. M. and Kaptelin A. F. Fizioterapiya and remedial gymnastics for children in the recovery period of poliomyelitis, M., 1958; Ginzburg Yu. B. Treatment is total the paralyzed lower extremity at patients with effects of poliomyelitis, Yerevan, 1976, bibliogr.; To Debra R., etc. Poliomyelitis, the lane with English, M., 1957; Drozdov S. G. Poliomyelitis and its prevention worldwide, M., 1967; Kaptelin A. F. Recovery treatment (physiotherapy exercises, massage and work therapy) at injuries and deformations of a musculoskeletal system, page 289, M., 1969; Konovalov N. V. The main questions on-liomielita, Zhurn, a neuropath, and psikhiat., t. 51, No. 3, page 3, 1951; Kostenko T. N. and With about to l and to about in and S. P. Treatment of effects of poliomyelitis, the Index of domestic literature of 1958 — ■ 1967, Kharkiv, 1974; Krasnov A. F. New methods of creation of a physiological or optimum tension of muscles at change of sinews, Ortop. and travmat., t. 22, No. 2, page 59, 1961; it, About operational treatment of side curvatures in a knee joint, Vestn, hir., t. 91, No. I, page 52, 1963; Laboratory diagnosis of viral and rickettsial diseases, under the editorship of E. Lennet and N. Schmidt, the lane with English, page 68, 421, M., 1974; Treatment of acute poliomyelitis, under the editorship of U. Spencer, the lane with English, M., 1959; Magrupov A. I., Kasymkhodzhayev E. S. and Alimov V. A. Pathological anatomy of poliomyelitis, Tashkent, 1963, bibliogr.; Melnik J. L. Merits and demerits of the killed and live poliomyelitic vaccines, Bulletin WHO, t. 56, No. 1, page 19, 1978; The Multivolume guide to pathological anatomy, under the editorship of A. I. Strukov, t. 9, page 107, M., 1964; Orthopedic treatment of effects of poliomyelitis, under the editorship of M. V. Volkov, M., 1979; Acute epidemic poliomyelitis, under the editorship of N. V. Konovalov, M., 1956; The Guide to infectious diseases at children, under the editorship of S. D. Nosov, M., 1980; The Guide to physical therapy and physioprevention of children's diseases, under the editorship of A. N. Obrosov and T. V. Karachevtseva, page 326, M., 1976; Tsuker M. B. Clinical neuropathology of children's age, M., 1978; Chumakov M. P., Pris m and I. M. and Zatsepin T. S. Poe-liomielit N, Children's spinal paralysis, M., 1953; Epidemic poliomyelitis, under the editorship of N. V. Konovalov, M., 1957, bibliogr.; Baker A. Century of a. Corn-well S. Poliomyelitis, Arch. Path., v. 61, p. 185, 1956; Handbuch der Neuro-logie, hrsg. v. O. Bumke u. O. Foerster, Bd 13, S. 89, B., 1936; Human viruses in water, wastewater and soil, Wld Hlth Org. techn. Rep. Ser. N 639, Geneva, 1979; Leroy D. La reeduation poliomyelti-que, Rev. med. Suisse rom., t. 76, p. 924, 1S56; M a d e 1 e at Page R. Guide to the collection and transport of virological specimens, Geneva, 1977; M e 1 n i with k J. L. a. o. Picornaviridae, Intervirology, v. 4, p. 303, 1974; Nathanson N. Cole G. Immunosuppression and experimental virus infection of the nervous system, Advanc. Virus Res., v. 16, p. 397, 1970; Paccaud M. F. World trends in poliomyelitis morbidity and mortality, 1951 — 1975, Wld Hlth Stat. Quart., v. 32, p. 198, 1979; Peers J. H. The pathology of convalescent poliomyelitis in man, Amer. J. Path., v. 19, p. 673, 1943; S a-b i n A. B. Poliomyelitis vaccination, Evaluation and direction in continuing application, Amer. J. clin. Path., v. 70, p. 136,1978; Wyatt H. V. Poliomyelitis in the fetus and the newborn, Clin. Pediat., v. 18, p. 33, 1979.
L. O. Badalyan, E. V. Leshchinskaya; M. I. Antropova (fiziobalneoterapiya), S.G. Drozdov (etiol., epid., laboratory diagnosis, profit.), A. F. Kaptelin (physiotherapy exercises), A. F. Krasnov (ortopedo-surgical treatment), V. A. Morgunov (stalemate. An.).