The pattern of muscle involvement in poliomyelitis of the upper limb

International Orthopaedics (SICOT) (1986) 10: l l-15 International

Orthopaedics © Springer-Verlag 1986

The pattern of muscle involvement in poliomyelitis of the upper limb*

K. K u m a r and N. K. K a p a h t i a

Department of Orthopaedics, M. G. Institute of Medical Sciences, Sevagram 442102, District Wardha, India

Summary . The pattern of muscle paralysis and paresis in the upper limb has been studied in 31 children with poliomyelitis. The incidence o f involvement o f the upper limb alone is the same as o f the upper and lower limbs together, and o f the spine and upper limb. The left arm was more commonly affected than the right. The muscle most frequently paralysed was the deltoid. When complete paralysis o f the whole deltoid occurred and was associated with paralysis of the rotator cuff muscles, the shoulder often subluxed downwards. The next most commonly affected muscles were the elbow flexors and extensors. In the hand the opponens pollicis was most often involved. As far as the spinal segments are concerned, C5 involvement was usually associated with paralysis and C7 with paresis.

R/~sum& Les auteurs ont ~tudib chez 31 enfants po- liomy~litiques la topographie au membre supbrieur des muscles paralysds ou par~si~s. La frbquence de l'atteinte isolbe du membre supbrieur est la m~me que celle de l'association membre supbrieur et membre infbrieur et que celle de l'association rachis et membres. Le bras gauche est plus souvent atteint que le droit. Le muscle le plus frbquemment para- lys~ est le deltoide. Lorsqu'il existe une paralysie compldte de la totalit~ du deltoi'de, associ~e d une paralysie des muscles rotateurs, l'bpaule se subluxe souvent vers le bas. Les muscles qui sont ensuite le plus frbquemment atteints sont les flbchisseurs et les extenseurs du coude. A la main c'est l'opposant qui est le plus souvent en cause. Dans la mesure olJ la topographie est radiculaire, l'atteinte de C5 s'ac- compagne g~nbralement de paralysies et celle de C7 de parbsies.

* This study is a part of National Project on Poliomyelitis sponsored by the Indian Council of Medical Research, New Delhi, India.

Address offprint requests to: Kush Kumar

Key words: Poliomyelitis, Muscle paralysis, Upper limb

Most research on pol iomyel i t i s was u n d e r t a k e n in Western countr ies abou t 20 years ago, but since then the disease has a lmos t d i s a p p e a r e d f rom that pa r t o f the world. There is, therefore , at the present t ime, a great need to s tudy the disease in deve lop ing countr ies like Ind ia because the p rob- lems of m a n a g e m e n t and rehabi l i ta t ion are different, and there is a t r end towards increased mor - bidi ty [1, 2].

The s tudy o f the d is t r ibut ion o f musc le pa ra ly - sis in po l iomyel i t i s is one aspec t to be cons idered . The pa t te rn o f para lys is in the lower l imb has been discussed in detail by several au thors [5, 7, 9], but no deta i led descr ip t ion o f the pa t t e rn o f u p p e r l imb para lys is could be found in the Engl ish l i terature. The present p a p e r is devo ted to this aspect o f the disease.

This s tudy is a par t o f a N a t i o n a l Project on Pol iomyel i t i s s p o n s o r e d by the I n d i a n Counc i l o f Medica l Research , N e w Delhi , which is enti t led: ' Paed ia t r i c Disabi l i ty , P reven t ion and Rehabi l i ta - t ion - A pi lo t s tudy on Pol iomyel i t i s . '

Material and methods

Thirty-one children suffering from poliomyelitis of the upper Iimb were studied, out of a total of 217 cases of post-polio- myelitic residual paralysis seen between February 1982 and May 1983. Uncooperative children, children with severe sec~ ondary deformity and those in whom assessment of the pattern of paralysis was not certain were not included in this study.

There were 13 males (42%) and 18 females (58%) with ages from 2 to 15 years. Twenty-nine children (94%) had unilateral upper limb involvement, whereas 2 children (6%) had both upper limbs affected~ making a total of 33 paralysed upper limbs.

The study was carried out in an area of Central India with a population of 500,000, out of which 400,000 was rural and

12

Table 1. Details of muscle charting

K. Kumar and N. K. Kapahtia: Pattern of muscle involvement in upper limb poliomyelitis

Muscles 0 1 2 3 4 Total

A) Trapezius 1 6 4 6 11 28 B) Deltoid 8 17 3 4 - 32 C) Elbow flexors 1 7 8 8 0 24 D) Elbow extensors 1 4 7 8 3 23 E) Wrist dorsiflexors - - 2 7 7 16 F) Wrist palmarflexors - 1 2 7 7 17 G) Long finger flexors - - 2 4 9 15 H) Long finger extensors - - 3 6 5 14 I) Opponens of thumb 5 2 2 4 3 16

Table 2. Ratio of muscle paralysis and paresis

Muscles Paralysis Paresis Ratio grade 0-1 grade 2-3

A) Trapezius 7 21 0.33 B) Deltoid 24 8 3.00 C) Elbow flexors 8 16 0.50 D) Elbow extensors 5 18 0.27 E) Wrist dorsiflexors - 16 - F) Wrist palmarflexors 1 16 0.06 G) Long finger flexors - 15 - H) Long finger extensors - 14 - I) Opponens of thumb 7 9 0.77

plus ( + + ) has been taken as the grade higher. For example, grade 3 + was taken as grade 3, but grade + + was taken as grade 4. Nowhere were the grades minus ( - ) or grade minus- minus ( - - ) used.

Muscle grading in children

Precise grading of power was difficult in children below 3 years of age. In such instances, the history given by the parents of inability to perform a particular movement, the wasted ap- pearance of the affected muscle, the attitude of the l imb and the residual deformity following paralysis helped in detecting the paralysed muscle. Further grading was achieved by show- ing some attractive object and asking the child to touch it. As the child made the attempt the object was moved farther away and the power of the muscle was assessed. Objectively, the l imb was passively lifted in the direction of the muscle action to be tested and gently dropped. I f the limb fell like a dead weight or without any effort by the child to resist the fall it was graded as 0 to grade 2. Otherwise, if it fell with some control, it was graded as 3 or above. This method was particularly useful in testing the deltoid muscle, the limb being abducted while the child was sitting and then lying on his side. Lastly, muscles were gently stimulated by direct tapping and the resultant con- traction was noted in determining the lower grades.

No electrical testing was employed to determine muscle power. To make the analysis of the final results more uniform, grade 0 and grade 1 were taken as indicating paralysis and grades 2 - 4 were taken as muscle paresis (Tables 1 and 2, Fig. 1).

52 133 0.39 Results

100,000 was urban. The ratio of rural to urban distribution of children was 19 (61%): 12 (39%).

Grading of muscle power

The Medical Research Council (UK) Scale of 0 - 5 grades was used. In each limb 18 muscles or groups of muscles were tested. Huckstep [3] has suggested the use of one plus ( + ) or two plus ( + + ) for differentiating between the intermediate pow- ers between two grades. However, in the present study, grade one plus ( + ) has been taken as the same grade, but grade two

3 5

30

25

g 20 ac~

E

I

Muscle

~Para[ysed muscte

n Peresed muscle

o=~ 7 = 8_

Fig. 1. The pattern of muscle involvement in poliomyelitis

Of 217 children affected with poliomyelitis, only 31 had upper limb involvement, an incidence of about 14%. Isolated paralysis of the upper limb was seen in 11 children (6%), whereas in the re- maining 20 children, the upper limb was involved in association with the lower limb, spine or trunk (intercostal and abdominal) muscles in 94% (Table 3).

Involvement of the left upper limb was seen more frequently (21) than the right (8). Bilateral limb involvement was seen in 2 cases. Thus, a total of 33 paralytic upper limbs were available for study in 31 children.

The commonest age at which the disease first affected the children was between 1 and 3 years

Table 3. Distribution of combinat ion of paralysis

No. %

1. Isolated upper limb involvement 11 35.5

2. Upper limb + spine l0 32.3

3. Upper limp + lower limb 9 29.0

4. Quadriplegia 1 3.2 (upper l imb + spine + lower limb)

31 100.0


Table 4. Paralysis of muscles acting on various joints

1. Shoulder only 1 (3%) 2. Shoulder + Elbow 15 (54.5%) 3. Shoulder + Wrist and 8 (24%)

Hand (partially flail limb)

4. Elbow + Wrist 1 (3%) and Hand

5. Shoulder + Elbow + 8 (24%) Wrist and Hand (totally flail limb)

1. Shoulder 32 (97%) 2. Elbow 24 (73%) 3. Wrist 17 (51.5%) and Hand

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Table 5.

Segment Paralysis Paresis Ratio

C4 7 21 0.33 C5 32 24 1.33 C6 13 66 0.19 C 7 5 79 0.06 C8 - 29 - TI 7 9 0.77

Total 64 228 0.28

and muscle wasting was the most constant feature in all cases.

Usually the proximal part of the limb was more severely paralysed than the distal part (centripetal type). The deltoid muscle was the most commonly affected, and in all the 32 limbs with deltoid involvement there was paralysis of the la- teral acromial fibres (multipennate), which were either involved alone or in association with ante-

80

70

60

50

x~ 40 E

30

20

10

0

I

Ca C5 C6 C7

Spinet segment

>omtysed {egment

C8 "i1

Fig. 2. The segmental distribution of muscle paresis and paralysis in poliomyelitis

13

rior pectoral (unipennate) or posterior spinous (unipennate) parts. In no case were unipennate fibres involved alone leaving the multipennate fibres intact. Whenever deltoid paralysis was associated with paralysis of the rotator cuff muscles the shoulder had a tendency to sublux downwards.

The elbow flexors and extensors were the next most commonly affected muscles, but they were more often partially than totally paralysed. The wrist dorsiflexors were next and were always partially paralysed. Wrist drop due to complete paralysis of wrist dorsiflexors was not encountered. Among the intrinsic muscles of the hand, the opponens of the thumb was the most likely muscle to be involved, either in isolation or in combination with total paralysis of all the intrinsics of the hand, as seen in flail limbs. In no case were the lumbricals and interossei involved leaving the opponens intact.

When the combination of muscles involved is considered, the shoulder and elbow joint motors were most commonly involved, followed by a flail limb. The other combinations were rare (Table 4). It was also found that involvement of the C 5 spinal segment was most commonly associated with paralysis of the muscles, whereas involvement of the C 7 spinal segment commonly led to partial paralysis only (Table 5, Fig. 2).

D i s c u s s i o n

The poliomyelitis virus primarily affects the ante- rior horn cells of the spinal cord and the motor nuclei of the cranial nerves, leading to a pure lower motor neurone type of paralysis without any sensory loss. Motor involvement at the onset is massive and bizzare, but gradually a pattern of paralysis emerges as recovery sets in. Much work has been done on the pattern of lower limb paralysis, but very little on the upper limb.

The incidence of upper limb involvement i n poliomyelitis in the present study was about 14% which is higher than the about 9% reported by Sancheti et al. [8]. However, the two studies are not strictly comparable as the total number of cases was greater in the Sancheti study. However, if the cases in both studies are put together, the overall incidence of upper limb involvement is about 10%.

The ratio of upper limb only involvement to upper limb + lower limb involvement to upper limb + spine involvement is about 1/3:1/3:1/3 (Table 3). The commonest age of onset of disease

14

was from 1 to 3 years, which was in accordance with other studies from India [4, 8]. This indicates that there is very little change in the host-environ- ment relationship. The World Health Organisa- tion has warned that if the infant mortality rate in developing countries falls below 75 live births, then the incidence of polio would increase [11]. However, as standards of living and sanitation in developing countries improve, older children will become affected more often [6]. Thus, epidemiological surveillance is very important in developing countries [8].

Though no significant difference was seen in the pattern of paralysis between the sexes, the left upper limb was more frequently involved than the right, with a left to right ratio of 2.6 : I. Preponder- ant involvement of the left upper limb has also been reported by others. No suitable explanation is available in the literature, but it can be postulat- ed that, like the left lower limb, the left upper limb also hangs down when the child is carried in the traditional way on the mother's waist (Fig. 3). Thus, the left upper and lower limbs suffer more trauma due to dangling and subsequently get the disease. Furthermore, injections are more often given on the left side and this may also be another responsible factor.

Fig. 3. The mode of carrying children in India. The mother carries the child on her right side (master side) so that the child's left arm and leg hang downwards


The tendency for a particular muscle to be paralysed, partially or completely, depends on the relative length of its spinal nuclear columns. The shorter the nuclei the more severe is the paralysis and vice versa. This indicates that the deltoid muscle has separate nuclei for the multipennate and unipennate fibres. The representation of multipennate fibre is smaller so that multipennate fibres are always paralysed in association with unipennate fibres, but the reverse is not true. The sites of representation in the spinal cord of the deltoid and rotator cuff muscles appear to be fair- ly near to each other, as total deltoid paralysis (paralysis of uni- and multipennate fibres) was in- variably associated with paralysis of the rotator cuff muscles, a point not discussed in the literature. It was also seen that this combination of paralysis was associated with inferior subluxation of the shoulder joint.

Sharrard [10] reported that the deltoid, triceps and pectoralis major muscles have the highest incidence of involvement, whereas the long flexors of the hand had the lowest. The present study indicates that the deltoid, biceps and triceps muscles are commonly involved. The proximal muscles of the limb around the shoulder girdle, which are responsible for vigorous activity of the limb, are more prone to t rauma as they bear the weight of the hanging limb, and hence are more often paralysed. The elbow extensors normally act with gravity during routine use and thus are more likely to be partially than totally para lysed .

Sharrard [10] reported that the C 5 and C 6 cervi- cal segments are the most commonly affected, whereas in our study the C 5 segment was most commonly associated with paralysis and C 7 with paresis of the muscles. However, in the present study also, the long flexors of the fingers and wrist were the least commonly affected, suggest- ing that they have a long column of representation in the spinal cord.

It is interesting to speculate that representation in the spinal cord does not appear to be in accordance with that in the motor cortex of the brain. The thumb has a large area in the motor cortex compared to the rest o f the hand, but opponens pollicis is much more often paralysed compared to the other intrinsic muscles of the hand, which suggests that it has a small representation in the spinal motor column.

In contrast to lower limb involvement (centri- fugal type), the upper limb involvement is pre- dominantly centripetal. Therefore, when manag- ing upper limb paralysis, the aim must be to

K. Kumar and N. K. Kapahtia: Pattern of muscle involvement in upper limb poliomyelitis 15

achieve proximal stability with distal mobility. There is no point in stabilising a flail shoulder when the hand is paralysed.

It is difficult to explain the differences between our own and other studies described above. Is it due to affection by different viral strains, al- tered behaviour of the virus in different geogra- phical locations or is there some other responsible factor which governs the extent of the paralysis?

References

1 Chandankar VP, Dave KH (1979) Pattern of prevalence of poliomyelitis in Greater Bombay. J Indian Med Assoc 73 : 25

2 Haffkine Institute (1977) Annual report of the year 1974-1975, Bombay, India, p 44

3 Huckstep RL (1975) Poliomyelitis - a guide for developing countries. Churchill Livingston, New York

4 Indian Council of Medical Research. Technical report bulletin. ICMR New Delhi, India, 1975

5 Kumar K, Kapahtia NK (1984) Pattern of muscle involvement in lower limb in poliomyelitis. Paper presented at 44th Annual Conference of Association of Surgeons of In- dia held at KG Med College, Lucknow from 27th-30th December, 1984

6 Park JE (1972) Text book of Preventive and Social Medi- cine, 3rd Edn. Banarsidas Bhanot, Jabalpur, MP India, p 448

7 Punatar B, Patel DA (1977) Pattern of residual paralysis in poliomyelitis. Indian J Orthopaed 2:174

8 Sancheti KH, Sahasrabuddhe BG, Hingre RK, Electric- wala JJ (1983) Clinico-environmental profile of residual paralytic poliomyelitis - an epidemiological case study. Published by the Sancheti Institute of Orthopaedic Educa- tion Research, Pune 411005, India

9 Sharrard WJW (1955) Distribution of permanent paralysis of lower limbs in poliomyelitis - a clinical and pathologi- cal study. J Bone Joint Surg 37 B: 540

10 Sharrard WJW (1979) Paediatric orthopaedics and frac- tures. 2nd Blackwell Scientific publications, Oxford Lon- don, p 889

l 1 Ho W (1955) Poliomyelitis. Monograph Ser 26

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The pattern of muscle involvement in poliomyelitis of the upper limb