PHYSICAL THERAPY IN SPINA BIFIDA
Saudi Journal of Disability and Rehabilitation
Volume 8; No 3; July-September 2002
PHYSICAL THERAPY IN SPINA BIFIDA
Part I: Assessment
This section includes useful information on a specific disabling medical disorder. However this is not a substitute for medical diagnosis
When an infant with spina bifida is born it is necessary to see a doctor immediately. This usually requires an operation to repair the spina bifida and the patient may be required to stay in the hospital for some time. When the infant returns from the hospital, it will be very important to assess carefully and design a treatment plan. This plan will assist you in developing special exercises which will help promote the infant's development. It may be done in consultation with the rehabilitation professionals (Physiatrist, Physical therapist & Occupational therapist).
Assessment of the Infant
Assessment of an infant with spina bifida must cover several areas. These include: movements (muscle function), deformities and sensation.
Presence or absence of movements in the legs
At the first assessment, movements in the infant's legs should be looked at. The presence or absence of leg movements should be observed and recorded on an assessment form. A muscle chart is a useful way of recording these movements. Rather than looking at each individual muscle in the leg,
look at the movement at each joint to see if it is present or not. The following diagrams show what the joint movements are called. The diagrams show the movement being guided by the hands. When you are observing active movements do not place your hands on the infant just watch to see what the infant can do on his own. The strength of the movement at the joints should also be graded and recorded. Consult a rehab professional if you are unsure of how to use the following muscle strength gradings: 0-no contraction, 1-contraction, no movement, 2-movement without gravity, 3-movement against gravity, no resistance, 4-movement against gravity, with resistance, 5-normal strength. It is difficult to record accurately the strength of an infant's movements
t should be done when the baby is awake as you need to see what movements it can do on it's own. Talking to the infant and holding toys or brightly coloured objects in front of it may stimulate movement. It may also help to look at the movements in the infant's legs when it is crying as they may move more at this time. It is important that the movement in each leg is recorded separately as there is often a difference in the strength of each leg.
Assessment of contractures and deformities
When an infant with spina bifida is born, some joints or muscles in the legs may be contracted or deformed. This happens because some muscles are stronger than others. It can also happen when joints do not move and stay in one position for long periods of time. A contracture is a shortened muscle which prevents the full range of movement being carried out at a joint. The joint may become stiff.
A deformity is an abnormal position of a joint. The joint may not move at all.
At the first assessment of an infant with spina bifida, all limbs should be checked, including the upper limbs. This is done by moving all joints in the arms and legs through a full range of movement. Any joints which are tight or contracted should be recorded on an assessment form.
Presence or Absence of Feeling in the Legs
It is difficult to assess the loss of feeling in the legs of an infant with spina bifida. You may be able to see where she feels by looking at her face and breathing to see if she reacts to touch.
The best way to do this is to use a light pinch or prick with a pin over the toes, feet and legs. The infants reaction eg: pulling away, crying or no reaction sould be recorded on an assessment form. Colour in the areas on the form where you think the infant does not feel.
There are some further areas that should be looked at when the infant with spina bifida is first assessed. These include:
" how awake and alert the infant is
" how the infant likes being moved around
" how much the infant cries
" parents response to the infant
" family concerns about the infant
These areas are important to assess when the infant is first seen as these indicators may show if he has some brain damage present because of hydrocephalus. This information can also help when you are developing your plans for treatment.
Assessment of the Child
As the child grows and develops it is very improtant to assess him regularly. Movement skills, contractures and deformities can change over time due to unequal muscle strength. The child should also be progressing through the developmental stages of movement, such as sitting, standing and walking.
A regular reassessment (at least every three months) will indicate if the child's treatment programme is appropriate and effective.
It is necessary to record:
" child's developmental progress
" changes in movement and feeling of lower limbs
" development of deformities or contractures
" changes in the shape of the child's spine
" problems that might arise as a result of hydrocephalus
" problems with urine and stools
" family concerns about the child
An understanding of normal child development helps you to identify children who are not developing as expected, to plan treatment and to check the progress. Developmental stages are reached in a particular order. The control of the body develops progressively from the head to the feet. Large movements develop before smaller more skilled movements.
The various stages in development, like sitting and standing, are reached at roughly the same age in all children. We decide how well a child is developing by comparing him with other children of the same age. When progress is slower than expected it is called developmental delay.
Children with spina bifida and hydrocephalus will have a developmental delay. They take longer to learn to move because of muscle paralysis, presence of contractures and deformities, and a lack of feeling in their legs. Spina bifida is just one of a number of conditions which cause delay.