PEDIATRIC

PHYSIOTHERAPY
MAMOONA ANWAR
SHS.510.Lec.19
 Today’s Topic
• Spina Bifida
 What is spina bifida?
• “Split Spine” caused by incomplete closure of the neural tube, usually in
the lumbar or sacral region
 Types of spina bifida
• Several classifications that vary in severity depending on location and
extent of opening
• 1-Spina bifida occulta
• 2-Spina bifida cystica
•  meningocele
• myelomenigocele
 1-Spina bifida occulta
• The bony vertebra is open, but the spine is within the spinal canal

• The skin may have a lipoma (small benign fatty tumor), some
discoloration (birthmark), or a small tuft of hair overlying the spinal
defect

• There may be tethering of the spinal cord

 Spina bifida occulta – tethered spinal
cord
• Often occurs later in life

• Caused by limitations of movement of the spinal cord within the spinal

column

• Patients often have low back pain, weakness in the legs, and/or
incontinence depending on the site of tethering
 2-Spina bifida cystica – meningocele
• The bony vertebra is open, part of the meninges is protruding out of the
spinal canal

• Since the spinal cord is not protruding, there is often normal function

• Some cases of tethering have been reported

Spina bifida cystica – myelomeningocele
• The bony vertebra is open, part of the meninges and part or
all of the spinal cord is protruding out of the spinal canal

• Since the spinal cord is protruding, it is often not fully

developed

• Involved nerve roots are often not developed resulting in

weakness, pain, and/or paralysis
 Clinical pictures of spina bifida
• a-Primary clinical pictures
• b-Secondary clinical pictures
 a-Primary clinical pictures
• 1-Abnormal nerve conduction, resulting in:
• Somatosensory losses
• Motor paralysis, including loss of bowel and bladder control (all are
below level of lesion)
•  Changes in muscle tone
• 2-Hydrocephalus
 Motor level
Lesion Level Spinal-related disability

Above L3 Complete paraplegia and dermatomal para-

anesthesia, Bladder incontinence, Nonambulatory

Same as for above L3 except preservation of hip

L4 and below
flexors, hip adductors, knee extensors; Ambulatory
with aids,
Motor level

Lesion Level Spinal-related disability

S1 and below Same as for L4 and below except preservation of feet

dorsiflexors, and partial preservation of hip
extensors and knee flexors; Ambulatory with
minimal aids
S3 and below
Normal lower extremity motor function; Saddle
anesthesia; Variable bladder-rectal incontinence
 Sensory Levels
• T4
• T10
• L1
• L2
• L3
• Musculoskeletal deformities (scoliosis)

• Joint and extremity deformities (joint contractures, club foot, hip

subluxations, diminished growth of non-weight bearing limbs)

• Abnormal or damaged nerve tissue which can lead to loss of

extroceptive and prorioceptive sensation
MANAGEMENT
 SURGICAL MANAGEMENT
• Surgery
• In some cases the spinal cord is exposed to the environment or tethered
• Surgery is performed in order to cover the spinal cord with muscle and
skin or to untether the spinal cord
 Physiotherapy
• General functional expectations have been developed for patients in each
lesion-level group to help direct physical therapy goals within an
appropriate developmental context from infancy through adulthood.

• The therapy programs should be designed to parallel the normal

achievement of gross motor milestones.
 Physiotherapy
• In managing the cases of newborns, the physical therapist establishes a baseline of
muscle function.

• As the child develops, the physical therapist monitors joint alignment, muscle
imbalances, contractures, posture, and signs of progressive neurologic dysfunction.

• The physical therapist also provides caregivers with instruction in handling and
positioning techniques and recommends orthotic positioning devices to prevent soft
tissue contractures.
 Physiotherapy
• Provide the infant with sitting opportunities to facilitate the development
of head and trunk control.
• Near the end of the first year of life, provide the child with an effective
means of independent mobility in conjunction with therapeutic exercises
that promote trunk control and balance.
• For patients who are not likely to become ambulatory, place emphasis on
developing proficiency in wheelchair skills
 Physiotherapy
• For patients who are predicted to ambulate, pregait training should begin
with use of a parapodium.

• Exercise or household-distance ambulation may be pursued with use of

traditional long leg braces (eg, hip-knee-ankle-foot orthosis, knee-ankle-
foot orthosis) or the reciprocating gait orthosis [RGO]).
 MANAGEMENT OF
MUSCULOSKELETAL
DEFORMITIES
 MANAGEMENT OF
MUSCULOSKELETAL DEFORMITIES
PROM
• Passive range of- motion (PROM) exercise is applied to all joints below
the level of paralysis.
POSITIONING
• The infant should not lie constantly in one position, but should be moved
and turned frequently.
 MANAGEMENT OF
MUSCULOSKELETAL DEFORMITIES
SPLINTS
• Splints must be used with great precaution, removed frequently to check
for skin irritation, and adjusted or discontinued if such a problem occurs.

PARENT’S PARTICIPATION
• This practice must be taught to parents
 MANAGEMENT OF
MUSCULOSKELETAL DEFORMITIES
STRENGTHENING AND MUSCLE TRANSFER
• Strengthening exercises are sometimes beneficial for partially innervated
muscles or after surgical muscle transfer for improving strength or
function.
 MANAGEMENT OF
MUSCULOSKELETAL DEFORMITIES
STRENGTHENING AND MUSCLE TRANSFER
• Depending on the functional level of the lesion, strengthening is important
for increasing cardiopulmonary endurance, ambulation training, and upper
extremity strength for manual wheelchair use and assistive devices.

• The caregivers should be encouraged to facilitate functional independent

mobility.
BOTTOM SCOOTING
BABY ARMY CRAWL
SUMMARY