Chapter 39: Orthoses for myelomeningocele

Question 1

What is myelomeningocele?

Answer 1

A neural tube defect and a major birth defect.
It is characterized by a variation of motor impairments, ranging from minimal muscle wakness to complete paralysis.
Spasticity may be present.
Musculoskeletal deformity and sensory deficits are common.

Question 2

What can prevent myelomeningocele?

Answer 2

Folic acid

Question 3

What is another name for myelomeningocele?

Answer 3

Spina bifada.

Question 4

Lesions at the motor levels designated as thoracic/high lumbar reveal a significant compromise of muscle strength where?

Answer 4

Lower limbs and some weakness of the upper limbs.

Question 5

Thoracic/hih lumbar level lesions tend to develop what?

Answer 5

Scoliosis
Hip dislocations
Contractures of the hip and knee

Question 6

What type of patients with myelomeningocele might benefit from a standing frame?

Answer 6

Patient with thoracic/high lumbar lesion, good head control, good sitting balance and age 12-24 months.

Question 7

What is the advantage of the parapodium compared to the standing frame?

Answer 7

It allows for sitting and ambulation is possible with a swivel walker.

Question 8

What does the RGO require in order to use?

Answer 8

Active hip flexion to facilitate extension of the contralateral limb.
Upper limb strength
hip and knee flexion contractures less than 30 degrees.
No obesity
No significant spinal deformities.

Question 9

Patients with lower lumbar lesions typically exhibit what?

Answer 9

Functional level consistent with active hip flexors, hip adductors, knee extensors, and knee flexors.
Motor deficits are hip extensors, hip abductors, and ankle plantarflexors and dorsiflexors.

Question 10

What are the common gait deviation seen in a lower lumbar lesion of myelomeningocele?

Answer 10

Posterior trunk lean through swing and stance
Excessive pelvic rotation and obliquity
Exaggerated stance phase hip abduction (lateral trunk lean)
Increased hip and knee flexion
Increased stance phase dorsiflexion.

Question 11

Posterior trunk lean and increased anterior pelvic tilt are commonly due to what?

Answer 11

hip extensors weakness.

It is necessary for the child’s stability

Question 12

Weak hip extensors leads to what?

Answer 12

hip flexion contracture
Increased hip flexion in terminal stance
Diminished step length during gait.

Question 13

Lateral trunk lean is usually caused by what?

Answer 13

Weak abductors.

Question 14

What is usually also present with lateral trunk lean?

Answer 14

Valgus stress at the knee in the stance phase limb.
hyperpronation (internal hip rotation, increased knee flexion, ankle dorsiflexion, hindfoot valgus) and medial tibial torsion.

Question 15

Why does excessive pelvic roation occur?

Answer 15

Hip flexion contracture

Crouch gait pattern.

Question 16

Patients with high sacral level lesions will have what?

Answer 16

Increased strength around the hip complex.
Hip flexors/extensors, abductors/adductors, and knee extensors/flexors are active
However hip extensors and abductors are still weak and might show some of the gait deviations seen in low lumbar level lesions.
They is always absent plantaflexors, but sometimes absent dorsiflexors.

Question 17

Patients with low sacral level lesions will exhibit what?

Answer 17

Muscle weakness around the foot and ankle complex.

Muscle strength is variable

Question 18

What AFO are often used for patients with myelomeningocele

Answer 18

Solid AFo

FRAFO

Question 19

What does a solid AFo do?

Answer 19

It stops forward tibial translation in stance phase to limit crouch pattern.
Trim lines are anterior to malleoli
Reinforcment around the ankle
Use of polypro plastic.
It should be at neutral in a shoe not 90 degrees without a shoe.

Question 20

What does the FRAFO do?

Answer 20

The anterior section facilitates more effective knee extension moment than a solid AFO.

Question 21

KAFO can be used for who?

Answer 21

patients with a lumbar level lesion who have knee instability.

Question 22

Anterior lean may be a sign of what?

Answer 22

Quad weakness.

Question 23

What orthoses can be used for lower sacral level lesions?

Answer 23

FO
UCBL
SMOs.

Question 24

SMOs are good for who?

Answer 24

Patient with weakness and developing deformities due to the weakness at the subtalar joint alignment.

Question 25

When muscle fatige is less of an issue than foot alignment and kinematic issues, what orthosis should be used?

Answer 25

FO

Question 26

The neuromuscular (paralytic) scoliosis curve is usually what?

Answer 26

Long and C-shaped with decompensation and , in the nonambulatory population, is evidenced by marked pelvic obliquity and problems with seating balance.

Question 27

What is secondary to Neuromuscular scoliosis curves?

Answer 27

intraabdominal crowding which may affects gastrointestinal function as well as elevate the position of the diaphragm, hindering pulmonary function.

Question 28

What are the goals for orthotic managment for scoliosis in myelogmeningocele?

Answer 28

Delay fusion until sufficient skeletal maturity

Prevent progression of curves between 20 and 40.

Question 29

What might be a contraindication for scoliotic correction with an orthosis?

Answer 29

obesity because of skin breakdown possibilities.

Question 30

What do the scoliosis orthotics look like?

Answer 30

Polyethylene
TLSO
Anterior opening and circumferential design.
Instead of 3 point pressure system, lateral bending bending toward the convexity of the curve to put the iliotibial band on stretch.