Definition.
It is one of the congenital anomalies in which there is developmental defect in the spinal column
due to failure of fusion of the vertebral arches leading to protrusion of the spinal cord or its membranes .
Brief pathology.
During the intrauterine life, the neural plate is formed at the eighteenth day of the gestation, this neural plate divide into neural tube and neural arch. The neural tube forms the central nervous system (brain and spinal cord). The neural arch forms the peripheral nervous system. This defect appear within first few weeks of gestation, as the neural plate has cranial part which close at the day of 26 of gestational life ,if this closure not occur this will lead to encephalomyopathy which lead to death. The caudal part close at the day of 28 of the gestation, spina bifida result from failure of closure of this part.but wether the cuase is genetic or environmental is unknown.
Types of Spina bifida
1- Spina bifida oculta: there is defect only in the neural arch without neural tissue involvement, there is skin changes and hairy patches.
2-Spina bifida cystica:it include two types:
a)Meningocele: the vertebral arch un fused , there is herniation of the meninges , part of the cord or nerve roots may present in sac but conduct impulse normally.
b)Myelomeningocele: sac contain neural elements that protrude through the spinal defect. The overlying skin is thin andleaks of spinal fluid. There may be secondary infection,neurological and orthopedic problems and hydrocephalus
clinical picture : it will differ according to the affected level . the most common affected is lumbosacral region. it may include:
1- Fflaccide paralysis.
2- Muscle weakness and wasting.
3- Decreased or absent tendon reflexes.
4- Decreased or absent extroceptive and propioceptive sensation.
5-Rectal and bladder incontinance.
6-Hydrocephalus.
7-Sever vasomotor changes.
pt examination.
1) By sight:we can see on the back of the patient one or more of the following:
a)Tuft of hair.
b)Subcutaneous lipoma.
c)Localized sac.
d)Increased head size.
e)Deformity of the lower limb .
2)By palpation:a)bony defect
b)Subcutaneous lipoma.
c) Loss of sensation.
d)Muscle bulk.
3)Measurement and tests:
1-Tape measurement:a) round measurement for head circumferance and muscle contour.
b)Long measurement for lower limb.
2-Range of motion: child with age less than 3 years can not obey to command so we use test for tightness as indicator for limited range of motion.
3-Muscle test: we can do functional muscle test with the following grades:
a-Functional : child can performs the task completely.
b-Sub functional: it start from inability to do task completely to the ability to do flicker contraction in the muscle.
c-Non functional: inability to perform the task.
Exercise for the upper limb:children with spina bifida need to compensate motor control of their legs and trunk. they use their arms as assistance for daily living activities:a- transferring from seat to bed and toilet.
b-Helping children without trunk stability to sit.
c- Standing up from the floor or from wheel chair.So, exercises to strengthen the arms are important part of the treatment as press up with pillows under the knees and feets.
poor sitting balance:many children with spina bifida have poor sitting balance and there is many factors lead to this problem as 1-Weak trunk muscles.
2- Paralyzed lower limb.
3- Lack of sensation.
We can deal with this problem through:
1-Strengthening exercises for back extensors and balance exercise as sitting astride the legs of the therapist or stride aroll.
2- Special seats or wheel chairs are molded to provide adequate support for the trunk .
Pt modalities can be used in the management of the symptoms that result from spina bifida
1- In patient with partial paralysis an extensive program of physical application should be applied aiming to improve muscle power and to increase physical abilities of the patient.Pt modalities can be used in the management of the symptoms that result from spina bifida
2- Electric appliances may be used to relieve pain, induce relaxation or to improve function.
3- Passive movement and passive stretch should be used to prevent and correct contracture and deformities .
4- Active exercise to prevent muscle imbalance and to keep the gained range during passive manibulation.
5-Hydrotherapy is very effective when skin is intact.
6-Gait training by using braces.
Orthoses:
Many patients who have lower lumber lesion and in whom there is power 5 of the quadriceps and 4 of the medial hamstring have the potential to walk with ankle / foot orthoses with or without external aids. the factors affecting ambulatory status are related expenditure and control of obesity. two orthoses have been introduced reciprocating gait pattern and to enable standing.these are reciprocating gait orthoses and hip guidance orthoses . apre-requisite fitting such an orthoses is that there is no more than 20 degree flexion in the hip, the knee and the foot can be rendered in plantigrade position.
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