Maximizing Ambulatory Potential

38th SBA National ConferenceSamuel R. Rosenfeld, M.D.CHOC Childrens Hospital

Rancho Los Amigos National Rehabilitation Center

University of California, Irvine 28 June 2011

Disclosure

Consultant, Zimmer Spine

I have no potential conflicts with this presentation

What problems are unique to the child with Spina Bifida?

What is the most significant physical impairment leading to the inability to maintain ambulatory status?

What is the most significant physical impairment leading to the inability to maintain independent sitting activities?

Define Neurologic Levels

ThoracicHigh LumbarLow LumbarSacral

Ambulators WheelchairStraight spineLevel pelvisExtended hips / knees

Straight spineLevel pelvis Mobile hipsKnee flexionShoeable feet

Criteria for ambulationPower

Antigravity muscles Hip extensor > G+Knee extensor > F+Tricep surae > F+

Criteria for ambulationRange of motionHip flexion contracture < 30 degreesKnee flexion contracture < 20 degreesBraceable hindfoot

Criteria for ambulationCrutchable upper extremities

Shoulder depressors > G+

Good gripFull elbow extension

Teres majorPectoralis majorLatissimus dorsi

Priority for ambulation

Energy efficiency

SafetySpeedAppearance

Significant physical impairments leading to the inability to maintain ambulatory status

Gluteus medius lurch, lateral trunk leanCrouched gaitKnee valgus (internal knee adductor moment)Knee flexion contractureTibial torsionAnkle calcaneal deformity

Etiologic factors resulting in crouched gait

Anatomic (structural)Neurologic (paralytic)Spinal cord pathology (fluctuating level,

spasticity)

Anatomical (structural)

Hip flexion contracture / lumbar kyphosisKnee flexion contractureShort fibulaAnkle calcaneal deformityRotational malalignment

Neurologic (paralytic)

Absence of hip abductionMaintenance of hip flexor and quadricep

strength with loss of hip extension and tricep surae power

Neuropathic joint, absence of proprioception

Spinal cord pathology

HydromyeliaSyringomyeliaDiastematomyeliaArnold-Chiari malformationSpinal cord tetheringLeptomyelolipoma Arachnoid cyst

Knee functional consequensesLack of plantar flexion strength

excess knee flexionIncreased pelvic transverse motion

increased transverse knee motion rotatory instability medial laxity

Orthotic managementRigid ankle to prevent dorsiflexionPrevent foot pronation, ankle eversionPosition ankle in mild plantarflexionGround (floor) reaction tibia

posteriorExtend to toes with metatarsal pad to prevent

toe clawing and protect insensate skinRear walker assistance

Knee flexion contracture

Consider surgical intervention > 20 degrees hamstring lengthening iliotibial band lengthening posterior knee capsulotomy guided growth with anterior hemi-epiphysiodesis

Gradual orthotic correction with adjustable locked articulated ground reaction ankle foot orthotic system

Anterior hemi-epiphysiodesis

Hip flexion contracture

Consider abandoning ambulatory programSurgical intervention > 30 degrees

tendon lengthening hip capsulotomy reduction unilateral hip dislocation augment muscle power

Proning programHKAFO, RGO, parapodium, standing frame

Significant physical impairment leading to inability to maintain independent sitting activities

Lumbar kyphosisPelvic obliquityHip contractures

Spinal orthotic management

Suspension TLSOWheelchair seating systems

Prevention of deformity and loss of functional skillsEarly aggressive managementOrthotic management coincidental with

initiation of ambulatory skillsProtect insensate skinRoutine thorough neurologic re-evaluationInterdisciplinary careSurgery only to facilitate orthotic

management