refrences kessler tecklin darcy. a all round description of assesment in physiotherapeutic methods and management techniques. participationn increasing measures and limitation reduction stratergies

1. SPINA BIFIDA

2. NORMAL EMBRYONIC
NEURAL TUBE CLOSURE

4. TYPES

5. Spina bifida Occulta-
⮚Due to non-fusion of the and the vertebral
arches.
⮚Most common site is lumbosacral junction.
⮚No clinical sympotms.
Spina bifida Cystica-
⮚ failue of closure of the vertebral arches and the
neural tube both.
⮚Common at the thoracolumbar and lumbosacral
regions.

6. Other less common types
Sacral Agensis Lipoceole/
Tetherd
Cord
Diastometmyliea Anencephaly

7. Causes of spina bifida
• The most common cause is genetic predeposition
along with environmental causes.
• The most common environmental cause is folate
deficiency.
• Presence of other comorbities like intake of tertogens
(oc pills, anticonvulsants), diabetes , smoking,
alcoholism, obesity and maternal fever.

8. CLINICAL FEATURES:
1. Impaired sensation below the level of lesion.
2. Flaccid paralysis .
3. Muscle weakness.
4. Decreased or absent tendon reflexes.
5. Decreased or absent propioceptive sensation.
6. Rectal and bladder incontinence.
7. Hydrocephalous .
SECONDARY CLINICAL FEATURES:
1. Pressure ulcerations –Absent sensation and poor nutrition.
2. Osteoporosis with probability of fractures.
3. Soft tissue contractures and deformities.
4. Obesity due to limited mobility and decreased energy
expenditure.

9. OTHER MANIFESTATIONS
1)MUSCULOSKELETAL IMPAIRMENTS:
⮚ Hip flexion,knee extension and ankle dorsiflexion
contractures.
⮚ Increased thoracic kyphosis and lumbar lordosis,scoliosis due
to vertebral abnormalities.
⮚ Congenital equinovarus and rocker bottom deformity,hip
dislocation.
2)NEUROLOGICAL IMPAIRMENT:
• Hydrocephalus:80% associated with MMC .
• Chiari malformation:Herniation of hindbrain into cervical
spinal canal with compressive damage of cranial nerves.

10. • Respiratory stridor ,difficulty in swallowing and abnormal gag
reflex.
⮚ Hydromyelia -80% associated with MMC due to dilation of
central canal of spinal cord.
• Tethered cord syndrome-Pathological fixation of spinal cord
due to adhesions formed at the site of original back lesion.
3)COGNITIVE IMPAIRMENT AND LEARNING ISSUES:
⮚ Intellectual and perceptive deficits due to damage to white
matter caused by ventricular enlargement.
4)LATEX ALLERGY:
⮚ Repeated exposure leads to development of Ig E Antibody.

11. DIAGNOSIS
1. ALPHA FETOPROTEIN –AFP levels are high in fetal blood
and amniotic fluid from 6th to 14th week of gestation.
1. ULTRASOUND- Spina bifida in developing fetus is detected.
Shape of the frontal bone of the foetal skull lose convex
shape and appears flattened called as lemon sign before 24
weeks of gestation.

12. ASSESSMENT
1. Proper history taking:
• Pre natal ,natal and post natal history.
• Developmental history .
• Latex allergy if present or not and presence of VP shunt.
2. On observation :
• Skin changes
• Posture and deformity
3. Higher mental functions:
Cognition- modified mini mental scale.

13. Neurological:
• Tone and reflexes
• Sensory
Check for dermatome and myotome to assess neurological
level .
5. Musculoskeletal :
• Range of motion
• Manual muscle testing
6. Gait
7. Functional assessment
8. Head circumference
9. IQ of the patient.

15. ICF

16. STRUCUTRES AND REALTED
FUNCTION
AFFECTED AND CLINICAL REASON
Nervous System 1) HMF might be intact or affected depending on the
severity of hydrocephalus
2) Spinal cord- Ascending and desending tracts are not
formed at level of lesion
3) Spinal nerves not mature
4) Lower limb ANS
Neuromusculoskeletal As the AHC and the supplying tracts are not mature the
motor function is affected
Lower limb deformity
Skin and Related Structures Trophic changes- sensory loss and ANS dysfunction
Cardiovascular and Respiratory
Systems
Cough and sneezing reflexes
Odema of the lower limb
Genitourinary and Reproductive
Systems
Spastic or flacid bladder and bowel reduced libido
The Eye, Ear and Related
Structures
Hydrocephalus might have visual impairements
Voice and Speech Hypoglossal nerve involvement associated with AC
malformation
Metabolism related Obesity

17. ACTIVITY AND PARTICIPATIONS LIMITATIONS
Mobility
Changing and maintaining body position
Carrying, moving and handling objects
Walking and moving
Moving around using transportation
Self-care
Looking after one’s health
Washing oneself
Caring for body parts
Toileting/Dressing
Eating /Drinking
CONTEXTUAL FACTORS
Environmental
Personal

18. MANAGEMENT
I. Infancy – 1.5- 2 Yrs
II. Pre School- School age
III. School - Adulthood

20. I. INFANCY
Goals
• Parental education
• Facilitation of developmental milestones
• Preventions of contractures
• Prerequisites for ambulation

21. Parental education
• Handling of child and Being part of the
treatment

22. • Symptoms of Shunt malfunctioning

23. Sensory issues-
• play by tickling to identify clear line of
sensory loss
• put stockings
• Clean the home regularly
Latex allergy
Bowl and bladder management
• Using diapers and food favouring healthy
bowel and guiding parents to talk about it to
doctors for pharmacological management.
Support groups

24. • High thoracic High lumbar level - hip dislocations, spinal
deformities
• Low lumbar(L4-5)- spinal deformities, introsion of tibia,
ctev, pes cavus, pes planus
• Sacral level- pes cavus planus claw toe, ctev
Contractures

25. Preventions of contractures
• ROM excs. for lower limb.
• Positioning- prone lying.
• Hip abduction splint.
– Checking 15mins wear and check for redness that doesnt
go by 20mins.
• If Sitting not achieved by 6-9 months then sitting
device to be given.

26. • If hip dislocation or contractures present –
– mx- conservatively slow stretching of the tight structures.
or Shoelifts give to compensate
– Sx- corrected in patients ONLY with potential of
ambulating without assistive device.
Because - post of complications.

27. Facilitation of developmental
milestones
0-6 months-Head control, rolling
Prerequisites
Neck muscle strength
Orientation of head in space
head right reactions and equilibrium reactions

29. FACILITATION OF ROLLING

30. 6-9 months sitting control
Start from- Propped up sitting to independence
Sitting control- righting and equilibrium and
protective reactions

31. FACILITATION OF SITTING
IMPROVING TRUNK
CONTROL

32. Mat activites
• The supine to sit
• prone to sit
• Supine to side lying
Sit to quadriped
• Quadriped to kneeling
• crawling

33. • 9-11 months – intermittent standing using parapodium or
standing frame
• standing 30 min 5 times in a day
• To mimic pull to stand
• 1yr on wards- 60 mins 3 times 5 days
What to do when child is standing-
• Trunk control- righting equilibrium reactions.
• UL fine motor activity
When to stop using stander-
• Good neck and trunk control
• Good Upper limb strength

34. Prerequisites for ambulation
• Upper limb strengthening- crutch muscles
• Trunk strengthening.
• Equilibrium reaction and protective reactions- of trunk and
head.
• Cognitive training
• Social training

37. II. School age - adolescence
Goals
• Mobility
• Independence
• Continuation of previous goals

38. Mobility
• Major part of gait training , as child better
understands commands.
• Orthosis selection
• Assistive device selection depending on the
level and cognative skill of the child.
• Gait training

39. Standing frame
THORACIC LEVEL

40. THORACIC LEVEL AND HIGH LUMBAR
1) Standing frame:
• Used when sufficient head control present.
• By 1 year of age, children with motor level L3 and above
is given.
• It is a tubular frame that supports trunk, hips, knees and
hands are free for playing with toys.
• Allows the child with upright position in terms of muscle
strength, maintains blood pressure and proper pressure on
skin surfaces.
• Most often prescribed to allow children with significant
mobility impairment to participate in activities typically
done in standing position in school and home settings.
• Routine use of standing frames appears to limit severity
of knee and hip flexion contracture, as well as decrease
level of assistance.

41. PARAPODIUM
• Similar to standing frame except childs hip and knee can be
unlocked and it prevents orthopedic deformities.
• Pivoting gait can be learned with the parapodium and swing to
and swing through gait pattern can be attempted.

42. SWIVEL WALKER

43. • The ankles are stabilized in a neutral position against the
footplate,Knees in extension by a padded anterior
bar,Hips in extension by a broad pelvic band, Trunk
supported by a broad chest strap.
• Each footplate is spring loaded and is able to swivel
forward independently.
• With crutches,the child may be able to learn swing to and
swing through gait pattern.
• For high lumbar and thoracic lesion and it has no locks at
hip and knee so sitting is not possible.
• ORLAU –Orthotic research and locomotion assessment is
used mostly.
SWIVEL WALKER

44. RECIPROCAL GAIT ORTHOSIS(RGO)
• Consists of cable system,thoracic strap,pelvic band and
thoracic uprights.
• Orthosis of choice for progressing child who begin ambulating
with parapodium.
• Employs cable system to cause hip extension reciprocally on
the stance limb when hip flexion is initiated on swing side.
• This gait pattern requires no active motor function of lower
extremity ,but if active hip flexion is present.
• It maintains ankle at 90⁰ with extension at hip and knee.
ISOCENTRIC RGO
• Eliminates posterior cable system and slight weight shift
enables the bar to work and causes hip flexion on the swing
side and extension at stance limb with less energy
expenditure.

46. HIP KNEE ANKLE FOOT ORTHOSIS
(HKAFO)
• HKAFO holds both lower extremities in a stable extended
position for upright standing.
• Persons wearing this orthosis use either a hop-to gait with
walkers or swing through gait with a pair of crutches for
ambulation.
• Metal and leather and HKAFO with its pelvic band
orthotic hip knee ankle joints and locks,Proximal and
distal thigh bands, stabilization pads,Proximal and distal
calf bands.
• Active strength of hip flexors can attempt to walk with
one or both the joints unlocked.
• In absence of innervated gluteals,when both joints are
unlocked,jackknife pattern used with hyperextension at
lumbar spine.

47. PROGRESSION
Crutch training: 4 point => 2 point => 3point

48. LOW LUMBAR
Knee ankle foot orthosis (KAFO)
• used for L3-L4 Level.
• Made up of pair of uprights as a frame, leather cuffs that
cover posterior thigh and calf, single axis locking
orthotic knee joint and single axis dorsiflexion assistance
orthotic ankle joint with plantarflexion stop.
• Works on 3 point pressure system to keep knee extended.

49. Twister cables
1. Used to avoid progression of the tibial and femoral intorsion and
maintain lower limb alignment for gait training
2. Until the child gains skeletal maturity for derotation surgeries.
Mostly by 6-8 years

50. SACRAL
• AFO- Calf band and 2 Metal uprights.
– solid AFO- To hold the ankle and foot in as close to
biomechanically neutral position
– Posterior leaf AFO-It supports the weight of the foot
during swing phase as a means of enhancing swing limb
clearance
– articulated AFOs can also be used with a combination of
an SMO in patients having good A-P ankle control but
lack medio-lateral control and unstable foot.

51. SUPRAMALLEOLAR ORTHOSIS
• Extends proximally to malleoli and it contains well molded
medial and lateral walls that wraps over the dorsum of foot .
• It allows active Dorsiflexion and plantarflexion and Its medial
and lateral extensions attempt to improve control of subtalar
valgus or varus stress.

52. UCBL orthosis.
• University of california biomechanics laboratory and for sacral
involvement.
• For subtalar joint instability.
• UCBL controls flexible calcaneal deformities (rear foot varus/valgus)
and transverse plane deformities of the mid tarsal joints (forefoot
abduction/ adduction)
• It realigns the calcaneus improving the angle of pull of the achilles
tendon and provides more stable foundation for articular surface of
talus, navicular and cuboid
• Used for dynamic control of coronal plane deformities at the subtalar
joint

54. PROGRESSION

55. INDEPENDENCE
• Donning and doffing orthosis
• Being part of the excercise program.
• In transfers
• Selfcare and self inspection
• Bladder care
• Exploring the home and community
• Prevocational training- depending on the
cognitive level

57. ADULTHOOD
Goals
• Re evaluation of mobility
• Increased independence
• Recreation

58. Re evaluation of mobility
MOTOR LEVEL ASSISTIVE DEVICE Community Mobility
Thoracic May use THKAFO or HKAFO for
supported standing when young
W/C but practice prone lying
and use of standing frame
L1–L2 May use KAFO, RGO with walker or
crutches for short distances in house
when young
W/C
L3 May use KAFO with walker or crutches
for short distances in house and
community
W/C
L4 Uses AFO and crutches in community Community,W/C for long
distances
L5 May or may not use AFO, FO in
community, crutches for long distances
Community, W/C for sports
Sacral May or may not use FO in community Community

59. Increased independence
• Transfer
• Bladder and bowel management.
• Community ambulation
• Getting into job providing - vocational training
and job opportunities.

60. RECREATION
• Merging the child into community physical
activity for maintaince of fitness andhealthy
lifestyle.

61. REFRENCES
• DARCY
• TECKLIN
• KESSLER

62. By, ragini and susan