Sanket Seminar 2

7/31/2019 Sanket Seminar 2

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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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Sanket Seminar 2