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ORTHOTIC MANAGEMENT OF
SPINA BIFIDA
By- Sanket Kumar Rout
MPO, 1st year student
INDIAN SPINAL INJURY CENTRE, NEW DELHI
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SPINA BIFIDA
Spina bifida is a congenital neural tube defect affectingfetal development of the central nervous system.
It is a birth defect affecting the spinal column and inmore severe cases, it involves the spinal cord.
It begins in the womb, when the tissues that fold to formthe neural tube do not stay closed completely. As aresult there is an opening in the vertebrae, whichsurround & protect the spinal cord.
This occurs just a few weeks (21 to 28 days)after conception.
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TYPES OF SPINA BIFIDA
There are three types of Spina bifida :
Spina bifida occulta
Meningocele Myelomeningocele
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SPINA BIFIDA OCCULTA
Occulta means hidden, and the defect is not visible It rarely linked with complications
It is probably the most common
type of spina bifida .
In this case, spinal cord does
not protrude through the skin.
A patch of hair, a dimple,
a birthmark may be present
on the skin over the lower spine.
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MENINGOCELE
This is an uncommon type of spina bifida
In this case the membrane that surrounds the spinal cord
may enlarge, creating a cyst,
if the spinal canal is bifid the cyst
may expand and come to the surface.
A fluid filled sac visible on the back,
which often covered by thin layer of skin.
In this type the nerves are notbadly damaged and are able to function
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MYELOMENINGOCELE
This is the most complex and severe
form of spina bifida
Usually involve with serious
neurological problems A section of the spinal cord
and the nerves that stem
from the cord are exposed
and visible on the outside of the body
If there is a cyst it encloses
a part of the cord and the nerves
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CAUSES OF SPINA BIFIDA
Both genetic factors (heredity) and environmentalfactors, such as nutrition and exposure to harmfulsubstances probably contribute to spina bifida.
Research suggests that spina bifida may be due to aninborn defect in folic acid metabolism rather than asimple deficiency in this nutrient
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COMPLICATIONS
Abnormalities at the lower spine are alwaysaccompanied by upper spine abnormalities, causingsubtle coordination problems
Spine, hip, foot & leg deformities are often due toimbalances in muscle strength & function resultingmostly from residual paralysis
Bladder & bowel problem
Obesity and urinary tract disorders
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COMPLICATIONS
Many children with myelomeningocele develops atethered spinal cord
Hydrocephalus is another common residual problem
Pathologic bone fracture Growth hormone deficiency resulting in short stature
Allergy to latex is very common in people with spinabifida
Psychological, social and sexual occurs more often.
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GOAL OF TREATMENT
There is no cure for spina bifida. The goal of treatmentfor spina bifida is to allow the individual to achieve thehighest possible level of function and independence.
Treatment should address any disability, physical,emotional, or educational, that interferes with thatpersons potential.
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Orthotic Management
New spina bifida patients initially are assessed atapproximately age of six to eight months to determinetheir motor function and predict their functional level laterin life to begin formulating a treatment plan.
Success of an orthotic management depends on severalclinical issues:
- level of neurological involvement
-degree of musculoskeletal deformity
- sensory impairment- existing muscle strength
-motivation and family support
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ORTHOTIC MANAGEMENT ACCORDING TOTHE LEVEL OF LESSION
Lesions at the sacral segment S3 level result infunctional disturbances of the foot muscles. Thus, inlaysand corrective shoes will have to compensate for activeformation of the foot arch.
For lesions at the sacral segment S2 level, the thigh andlower leg muscles will be so affected that lower legorthoses will be necessary. Faulty axial positions may be
corrected with spiral orthoses
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Lesions at the sacral segment S1 level may require thighpositioning to prevent secondary damage such asexternal tibia rotation and a valgus position in the knee.
Lesions at the lumbar segment L5 level require knee-ankle-foot orthoses
Lesions at the lumbar segment L4 level often require hip-ankle-foot orthoses (HKAFOs), provided with hipabduction joints to absorb pronounced internal rotation
forces.
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For lesions at the lumbar segment L3 level, the pelvismust be encased. A hip rotation joint with an arrestingeffect will exert a stabilizing effect since the hipextensors are no longer active. Limited rotation permits
walking to a certain degree. Lesions at the lumbar segment L2 level require an
adjustable hip rotation joint and an orthosis to encasethe pelvis and thorax.
For lesions at the lumbar segment L1 level, the
musculus quadratus lumborum is inactive. A reciprocalhip joint system of the LSU type produced by Fillauershould be employed.
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THERAPEUTIC CORRECTIVE SHOE
The therapeutic corrective shoe was developedspecifically for patients with inadequate foot arch andankle joint stability (see Figure 1 ). The shaft of the shoeextends approximately 5 cm above the ankle joint and
has reinforcement that extends medially to themetatarsophalangeal joint and laterally to the middle ofthe foot.
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Cast Resin Devices with Soft Footbeds
New production methods have been introduced fororthoses made of cast resin and thermoplastic materialsthat integrate articulated connections. These devicesembed the entire foot and stretch from the toes to well
above the ankle joint. A removable soft lining enhancescorrection.
The soft footbed cushions the limb and preventspressure points (without affecting the fit under long-term
stress). Difficult foot conditions, including those withopen pressure sores, have been treated with positiveresults.
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AFO
Usually the first type of orthosis a child with spina bifida
is fitted with is an ankle-foot orthosis (AFO) to preventplantarflexion contractures and other angulardeformities.
The AFO provides stability around the ankle and foot to
enable patients to stand. The most common type of AFO used in patients with
spina bifida is a solid AFO, followed by a floor-reactionAFO.
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A floor-reaction AFO would actually be the optimalorthosis to give adequate push-off or stabilization of theknee mechanism throughout stance phase
In addition to providing stability to the foot and anklecomplex, AFOs also act as protective devices
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PARAPODIUM
The parapodium is a modular system that providesupright stability across hip, knee and to ankle and footcomplex
Design principle and force application is same as in caseof standing frame but this has an additional capability toallow for sitting
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SMO/ Foot orthosis
For lesions at lower sacral level, surrounding muscles ofthe foot ankle complex may exhibit weakness
It improves weight bearing distribution, increased shockabsorption,joint motion control & proper joint alignment.
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KAFO
When AFO & assistive devices no longer can addressthe deformities related to the knee, then KAFOs areprescribe.d to improve function and increase comfort
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HKAFO
With HKAFOs, patients have enough muscular ability toadvance and extend their legs at the hip independently,so they inherently can do that, but they dont have the
ability to maintain an upright position due to the deficit of
innervation in their lower extremities,
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RGO
The Reciprocating Gait Orthosis orRGO is the most frequently used bracefor the ambulatory needs of aparalyzed child.For children who do not have themuscular ability to advance and extendtheir legs at the hip, which is the casewith many patients with spina bifida,RGOs provide a mechanism to shift
the weight and advance the legs withthe use of a walker, thereby achievinga reciprocating gait.
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Isocentric RGO
The ISOCENTRIC RGO is a walking brace for peoplewith little or no control of their lower extremities often dueto neuromuscular disorders or injuries. The device isideally suited for patients with spina bifida, traumatic
paraplegia, muscular dystrophy, and osteogenisisimperfecta.
The ISOCENTRIC RGO offers the followingadvantages:
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Efficient ambulation - compared to other RGOs theISOCENTRIC is more energy efficient. This savesexertion for people with muscle weakness. The hipmuscles that are used for walking are exercised and
conditioned as the person walks in the brace. Hands-free standing, balance and support -. The
brace not only stabilizes the hip, knee and ankle jointsbut it also balances (positions) the person so they can
stand without the use of crutches or walkers.
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Dynamic hip stretching - Many Spina Bifida andpeople with paraplegia are prone to hip flexioncontractures. This tendency is counteracted by the factthat the brace connects the two legs in such a way that
flexing of one leg causes extension of the opposite side.It is like getting therapy or stretching with every step aperson takes
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Management Beyond Childhood
As patients with spina bifida approach their teenageyears, those with higher level defects tend to use theirorthoses less frequently and eventually discard themaltogether.
By the time children stop using their orthoses often atthe age of 10 or 11 the RGO has basically done its
job. It has allowed them to ambulate and helped withbone and organ growth as well as weight management,
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TLSO
Another concern for children with spina bifida is thedevelopment of scoliosis or possible need for correctivespine surgery as they get older, hence,thoracolumbosacral orthoses (TLSOs) frequently are
incorporated into their orthotic treatment for externalsupport
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CONCLUSION
Finally, as Gingras noted, it should be remembered thatorthotic intervention and treatment is only one of thecogs in the wheel of care necessary in the treatment ofchildren with spina bifida.
Orthotists need to work very closely with other teammembers to assure the coordination of their collectiveefforts will lead to the successful fulfillment of the goalsthat are set forth for every individual child.
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REFERENCE
Prosthetics and Orthotics lower limb and spinal; Ron
Seymour,PT,PHD.
Orthotics and Prosthetics in Rehabilitation;MICHELLE
M.LUSARDI,Ph.D.,P.T.,CAROLINE C.NIELSEN, Ph.D
AAOS atlas of orthoses and assistivedevices;J.D.Hsu.J.W.Michael.J.R.Fisk,4.501-508
Articles from INTERNATIONAL FORUM--ProvidingOrthoses for Spina-Bifida Patients
Orthotic Management of Spina Bifida -Clinical orthoticsPosted on O&P Business News May 15, 2003
www.centerfororthoticsdesign.com/isocentric_rgo/index
.html
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