ORTHOTIC MANAGEMENT OF SPINA BIFIDA

By- Sanket Kumar Rout MPO, 1st year student INDIAN SPINAL INJURY CENTRE, NEW DELHI

SPINA BIFIDA
Spina bifida is a congenital neural tube defect affecting fetal development of the central nervous system. It is a birth defect affecting the spinal column and in more severe cases, it involves the spinal cord. It begins in the womb, when the tissues that fold to form the neural tube do not stay closed completely. As a result there is an opening in the vertebrae, which surround & protect the spinal cord. This occurs just a few weeks (21 to 28 days) after conception.

TYPES OF SPINA BIFIDA

There are three types of Spina bifida : Spina bifida occulta Meningocele Myelomeningocele

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.

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 not badly damaged and are able to function

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

CAUSES OF SPINA BIFIDA

Both genetic factors (heredity) and environmental factors, such as nutrition and exposure to harmful substances probably contribute to spina bifida. Research suggests that spina bifida may be due to an inborn defect in folic acid metabolism rather than a simple deficiency in this nutrient

COMPLICATIONS
Abnormalities at the lower spine are always accompanied by upper spine abnormalities, causing subtle coordination problems Spine, hip, foot & leg deformities are often due to imbalances in muscle strength & function resulting mostly from residual paralysis Bladder & bowel problem Obesity and urinary tract disorders

COMPLICATIONS
Many children with myelomeningocele develops a tethered 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 spina bifida Psychological, social and sexual occurs more often.

GOAL OF TREATMENT
There is no cure for spina bifida. The goal of treatment for spina bifida is to allow the individual to achieve the highest possible level of function and independence. Treatment should address any disability, physical, emotional, or educational, that interferes with that persons potential.

Orthotic Management
New spina bifida patients initially are assessed at approximately age of six to eight months to determine their motor function and predict their functional level later in life to begin formulating a treatment plan. Success of an orthotic management depends on several clinical issues: - level of neurological involvement -degree of musculoskeletal deformity - sensory impairment - existing muscle strength -motivation and family support

ORTHOTIC MANAGEMENT ACCORDING TO THE LEVEL OF LESSION

Lesions at the sacral segment S3 level result in functional disturbances of the foot muscles. Thus, inlays and corrective shoes will have to compensate for active formation of the foot arch.

For lesions at the sacral segment S2 level, the thigh and lower leg muscles will be so affected that lower leg orthoses will be necessary. Faulty axial positions may be corrected with spiral orthoses

 Lesions at the sacral segment S1 level may require thigh positioning to prevent secondary damage such as external tibia rotation and a valgus position in the knee. Lesions at the lumbar segment L5 level require kneeankle-foot orthoses Lesions at the lumbar segment L4 level often require hipankle-foot orthoses (HKAFOs), provided with hip abduction joints to absorb pronounced internal rotation forces.

 For lesions at the lumbar segment L3 level, the pelvis must be encased. A hip rotation joint with an arresting effect will exert a stabilizing effect since the hip extensors 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 encase the pelvis and thorax. For lesions at the lumbar segment L1 level, the musculus quadratus lumborum is inactive. A reciprocal hip joint system of the LSU type produced by Fillauer should be employed.

THERAPEUTIC CORRECTIVE SHOE

The therapeutic corrective shoe was developed specifically for patients with inadequate foot arch and ankle joint stability (see Figure 1 ). The shaft of the shoe extends approximately 5 cm above the ankle joint and has reinforcement that extends medially to the metatarsophalangeal joint and laterally to the middle of the foot.

Cast Resin Devices with Soft Footbeds

New production methods have been introduced for orthoses made of cast resin and thermoplastic materials that integrate articulated connections. These devices embed the entire foot and stretch from the toes to well above the ankle joint. A removable soft lining enhances correction. The soft footbed cushions the limb and prevents pressure points (without affecting the fit under long-term stress). Difficult foot conditions, including those with open pressure sores, have been treated with positive results.

AFO
Usually the first type of orthosis a child with spina bifida is fitted with is an ankle-foot orthosis (AFO) to prevent plantarflexion contractures and other angular deformities. 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-reaction AFO.

 A floor-reaction AFO would actually be the optimal orthosis to give adequate push-off or stabilization of the knee mechanism throughout stance phase In addition to providing stability to the foot and ankle complex, AFOs also act as protective devices

Standing frame
When children with spina bifida are approximately one year old, they are then fit with a standing frame. One of the biggest factors in the early intervention in standing is that these children dont have to use their upper extremities to support themselves so they can do some hands-free playing and other normal developmental activities.

PARAPODIUM
The parapodium is a modular system that provides upright stability across hip, knee and to ankle and foot complex Design principle and force application is same as in case of standing frame but this has an additional capability to allow for sitting

Swivel walker
Ambulation is possible with the addition of the swivel walker. It can be attached distally and underneatf the supporting base of the parapodium This device is indicated for younger children who has initiated upright posture,patients with upper limb weakness and patient with limited mobility who require free upper limb for function.

SMO/ Foot orthosis

For lesions at lower sacral level, surrounding muscles of the foot ankle complex may exhibit weakness It improves weight bearing distribution, increased shock absorption,joint motion control & proper joint alignment.

KAFO
When AFO & assistive devices no longer can address the deformities related to the knee, then KAFOs are prescribe.d to improve function and increase comfort

HKAFO
With HKAFOs, patients have enough muscular ability to advance 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,

RGO
The Reciprocating Gait Orthosis or RGO is the most frequently used brace for the ambulatory needs of a paralyzed child. For children who do not have the muscular ability to advance and extend their legs at the hip, which is the case with many patients with spina bifida, RGOs provide a mechanism to shift the weight and advance the legs with the use of a walker, thereby achieving a reciprocating gait.

Isocentric RGO
The ISOCENTRIC RGO is a walking brace for people with little or no control of their lower extremities often due to neuromuscular disorders or injuries. The device is ideally suited for patients with spina bifida, traumatic paraplegia, muscular dystrophy, and osteogenisis imperfecta. The ISOCENTRIC RGO offers the following advantages:

 Efficient ambulation - compared to other RGOs the ISOCENTRIC is more energy efficient. This saves exertion for people with muscle weakness. The hip muscles 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 joints but it also balances (positions) the person so they can stand without the use of crutches or walkers.

 Dynamic hip stretching - Many Spina Bifida and people with paraplegia are prone to hip flexion contractures. This tendency is counteracted by the fact that 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 a person takes

Management Beyond Childhood

As patients with spina bifida approach their teenage years, those with higher level defects tend to use their orthoses less frequently and eventually discard them altogether. By the time children stop using their orthoses often at the age of 10 or 11 the RGO has basically done its job. It has allowed them to ambulate and helped with bone and organ growth as well as weight management,

TLSO
Another concern for children with spina bifida is the development of scoliosis or possible need for corrective spine surgery as they get older, hence, thoracolumbosacral orthoses (TLSOs) frequently are incorporated into their orthotic treatment for external support

CONCLUSION
Finally, as Gingras noted, it should be remembered that orthotic intervention and treatment is only one of the cogs in the wheel of care necessary in the treatment of children with spina bifida. Orthotists need to work very closely with other team members to assure the coordination of their collective efforts will lead to the successful fulfillment of the goals that are set forth for every individual child.

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 assistive devices;J.D.Hsu.J.W.Michael.J.R.Fisk,4.501-508 Articles from INTERNATIONAL FORUM--Providing Orthoses for Spina-Bifida Patients Orthotic Management of Spina Bifida -Clinical orthotics Posted on O&P Business News May 15, 2003 www.centerfororthoticsdesign.com/isocentric_rgo/index .html