The Riyadh Medical Rehabilitation Centre (RMRC) was the first Artificial Limb Fitting Centre to be established in the Kingdom of Saudi Arabia for providing both prosthetic and orthotic treatment as well as a variety of mobility aids to patients with varying degrees of physical disability.2
For a number of years, RMRC was the only place to which all physically handicapped patients from all over the Kingdom were referred for prosthetic or orthotic management. Therefore, the data reported in this paper will also reveal, to a certain extent, the number of poliomyelitis cases in the Kingdom. The Saudi Arabian Ministry of Health (S.A.M.O.H.) alone, not including other governmental medical services and the private sector, runs six fully equipped Rehabilitation Centres/Orthopaedic Workshops in different regions in the Kingdom (Statistical Review [MOH], 1987). The Ministry also includes an Orthotics/Prosthetics Unit in each of six hospitals that are presently under construction. Introduction
Poliomyelitis is endemic in Saudi Arabia, as in many developing countries of the Middle Fast and other surrounding regions (Review of Literature on poliomyelitis, 1988). Epidemics have not been encountered in the Kingdom, as in most developing countries, since family ties are strong enough to lead to an effective herd immunity. Such epidemics elsewhere have been reported by many workers.
Bernier reviewed more than 100 different surveys carried out throughout the developing world since 1974 in order to estimate the prevalence of lameness due to poliomyelitis.3 The rates reported ranged from less than 1 to as high as 25 per 1,000.
Sabin and Silva determined the prevalence of poliomyelitis in Brazil to be 2.3-5.4/1,000.16 Reports from India were varied with a prevalence ranging from 0.7 to 10/1,000.4,14,16 In Taiwan, 1,031 cases of poliomyelitis were reported from May to October, 1982.5,9
Although 90% of polio cases were not reported,12 the rate of polio lameness in Ghana was found to be 5-8/1,000 and the annual incidence of the disease was approximately 28 per 100,000 in the general population.11,12 A prevalence rate of 7/1,000 was also reported among school-age children in Niger18 and Gambia. 10 Cross and Webber reported a rate of prevalence of 3/1,000 in Tanzania.6
In the Kingdom of Saudi Arabia, the incidence of acute cases of poliomyelitis has decreased considerably since 1976.7 The Saudi Arabian Ministry of Health annual report for 1982 shows 100 new polio cases were reported that year alone. Despite the fact that no comprehensive survey has been carried out in Saudi Arabia yet, it is estimated that the prevalence rate is about 1-2/1,000 and the annual incidence of the disease is approximately 1-2/100,000 in the general population.
In most cases of residual paralysis due to poliomyelitis that are referred to the Centre for orthotic treatment, diagnosis, surgery, and prescription were made before patients were referred to the Centre by hospitals and clinics in different parts of the Kingdom. In 1985, the concept of a medical rehabilitation team was adopted and a Medical Committee, consisting of an orthopaedic surgeon, an orthotist/prosthetist, a physical therapist, and a bioengineer, was formed. Since then, the Medical Committee has held a clinic once a week to examine cases presenting complications. The cases with severe deformities which require surgical intervention before orthotic treatment are referred to either Riyadh Central Hospital or King Khalid University Hospital for Surgery.
From 1977 to 1987, 13,913 new cases were referred to Riyadh Medical Rehabilitation Centre for prosthetic or orthotic management. Of these, 5,045 (36.3%) were of post- polio infantile paralysis, of which 27% had contracted the polio virus at the age range 0-1, 32% at the age range 1-2, and 18% at the age range 2-3 (Table 1) .
A decrease and then an increase in the attendance of polio patients were noted (Table 2 and Figure 2 ). This may be due to increased awareness of facilities available for treatment. As reported by the Ministry of Health, the incidence of poliomyelitis has been reduced to almost negligible numbers by its successful immunization program. In comparison with different conditions presented at the Centre, poliomyelitis is decreasing while other cases, such as congenital deformities, amputations, fractures, etc. are increasing (Table 3 and Figure 3 ).
The involvement of males was found to be greater than females by the ratio of 1.4:1. Most of the patients (37.4%) were in the age group 10-20. Patients in the age group 0-1 represent only 1% of the total number of patients, confirming what has been already mentioned with regards to the Ministry of Health Immunization Programme and its effectiveness (Table 4 and Figure 4 ).
It was observed that lower limbs were more often affected (88%) than upper limbs (Table 5) . This compares well with the findings of many workers who reported lower limb involvement to be ranging from 85% to 90%. 1,13,14,17
The majority of cases presented at the Centre required either special orthopaedic shoes (39%), knee-ankle-foot orthoses (25%) or ankle-foot orthoses (12%) (Table 6) .
A retrospective study of 5,045 cases of post-polio infantile paralysis was carried out at Riyadh Medical Rehabilitation Centre, Kingdom of Saudi Arabia. The high polio incidence of 36.3% seen at the Centre does not represent the true incidence of poliomyelitis in Riyadh or the Kingdom, since it only represents the percentage of polio cases out of various disabilities referred to the Centre. The number of polio cases has been decreasing. The greatest number of cases reported was found in the 10-20 years age range (37.4%), and males were more common than females, constituting approximately 60% of cases. This study reveals a greater number of attendances during the later stages of poliomyelitis. Involvement of the lower extremities was greater than that of the upper extremities. Nearly 80% of the cases involved one lower extremity.
Although the Saudi Ministry of Health has already embarked on an adequate inoculation campaign against poliomyelitis, the importance of such a comprehensive immunization program cannot be overemphasized. Also, early detection and treatment of polio cases will certainly decrease its incidence. Further, the development of Orthotic Centres in the Kingdom to supply orthoses of the highest standards will no doubt be of great benefit to polio patients.