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By Alice Lou Plastridge, Head Physiotherapist, Georgia Warm Springs Foundation.

BECAUSE of the muscular weakness which follows an attack of poliomyelitis, there are very typical limps or gaits which appear when any attempt is made to walk.

In order that these limps and distorted positions shall not become conspicuous and shall not persist as "habit limps" even after the muscles gain the needed strength, there are a number of suggestions which should be followed. If used from the very beginning they will help materially.

First, in making the walking inconspicuous, (by moving quietly and steadily without needless body, leg or arm motions which would attract attention to the disability).

Second, in helping a handicapped person to walk as rapidly as possible with safety both to himself and his weakened muscles.

Because muscles can be affected so differently, each case is a law unto itself. It is difficult to lay down set rules to cover all conditions. Therefore, each person's individual problem must be carefully studied. The type of walking permitted may, in some cases be unique.

It has been said that a person having an arm and hand good enough to handle a crutch can somehow be taught to walk, even though the rest of the body is badly weakened. However difficult, this is usually true.

The trunk muscles are tremendously important in walking. If they are strong they are capable of indirectly moving the legs about, compensating, in a measure, for weak hip and leg muscles. If the trunk muscles are paralyzed, particularly the abdominals, walking is quite difficult, even with strong leg muscles.

Hip muscles are next in importance for walking. The buttocks, the muscles covering the back of the hips, are absolutely necessary for standing upright without support (i. e., without holding on to something) although with one good buttock, balance can be maintained.

These muscles, plus the hip abductors, which lie across the outside of the hips, are essential to keep the body from swaying backward and from side to side.

The hip flexors, the muscles which lie over the front of the hips, are more necessary for stair climbing than for ordinary walking. However, the lack of them makes a very awkward gait, using a forward lurch of the body to help drag the leg forward.

Weak knees and ankles should be braced in order to prevent deformities and to give proper support for weakened joints, allowing a perfectly upright, steady position.

It is rather rare to find only one group of muscles affected. Usually there are several rather confusing and seemingly conflicting actions which are exceedingly difficult to distinguish correctly. However, this study of gaits is one of the best guides we have to determine the particular type of exercise which will be most beneficial for the individual.

For the severe or moderately severe cases the best results are obtained if the patient is not allowed to stand or walk for at least eight months, and probably a year or longer after onset.

At the end of this period, carefully supervised standing and balancing exercise can be attempted. Three minutes, once a day, is enough at first. Parallel bars of the proper height and width are very useful for this and for the first walking practice.

These walking steps can be taken forward, backward and sideways, always being sure to keep the feet pointing directly forward, with the hips square to the front without twisting. At first, not even five steps should be taken in any one of these directions, for the simplest type of weight bearing is very fatiguing.

Crutch walking can be taught next. The simplest method is the "four count" method, (Fig. 1) where the left crutch is placed forward first (a); on count two, the right foot (b) ; on count three, the right crutch (c) ; and on count four, the left foot is brought forward, (d). This method allows the weight to be thrown on one arm with the opposite leg for balance, so that the other crutch can be placed forward, the weight thrown on it and then the other leg drawn through. Arm or shoulder disability may interfere with smoothness of crutch technique.

In cases where there is one very strong and one very weak hip, it is sometimes advisable to use both crutches and the weak hip at the same time (Fig. 2) in order to protect the weak hip by taking more weight on the arms.

When the body balance is very good it is sometimes possible to walk quite rapidly by moving one crutch and the opposite foot simultaneously, making a "two count" gait (Fig. 3, a and b).

If trunk and arm muscles and the body balance are all very good it may be possible to use canes in any one of the above mentioned ways (Fig. 4, a). If only one cane is needed, it is better to use it in the hand opposite the weak leg. (Fig. 4, b).

In some conditions, it is advisable to teach a person using two crutches and two leg braces to swing both legs through together using a tripod position to maintain balance. (Fig. 5.) This is only advisable for long distance walking or speed. It is then usually necessary only when, with a good trunk development, the legs are perfectly flail.