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Spina Bifida – management towards
optimal standing and walkingÅsa Bartonek1,2 PT PhD
Marie Eriksson1,3 CPO PhD
Lanie Gutierrez-Farewik1,4 PhD
Eva Pontén1,2 MD PhD
1Dept. of Women’s and Children’s Health, Karolinska Institutet2Dept. of Musculoskeletal Disorders, Karolinska University Hospital3TeamOlmed4KTH Royal Institute of Technology
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References
Bartonek A, Saraste H, Knutson LM. Comparison of different systems to classify the neurological level of lesion in patients with
myelomeningocele. Developmental medicine and child neurology. 1999 Dec;41(12):796-805.
Bartonek A, Saraste H. Factors influencing ambulation in myelomeningocele: a cross-sectional study. Developmental medicine
and child neurology. 2001 Apr;43(4):253-60.
Gutierrez EM, Bartonek A, Haglund-Akerlind Y, Saraste H. Centre of mass motion during gait in persons with myelomeningocele.
Gait & posture. 2003 Oct;18(2):37-46.
Gutierrez EM, Bartonek A, Haglund-Akerlind Y, Saraste H. Characteristic gait kinematics in persons with lumbosacral
myelomeningocele. Gait Posture. 2003 Dec;18(3):170-7.
Gutierrez EM, Bartonek A, Haglund-Akerlind Y, Saraste H. Kinetics of compensatory gait in persons with myelomeningocele. Gait
Posture 2005 Jan;21(1):12-23.
Bartonek A, Gutierrez EM, Haglund-Akerlind Y, Saraste H. The influence of spasticity in the lower limb muscles on gait pattern in
children with sacral to mid-lumbar myelomeningocele: a gait analysis study. Gait & Posture. 2005;22:10-25.
Bartonek A, Eriksson M, Gutierrez-Farewik EM. Effects of carbon fibre spring orthoses on gait in ambulatory children with motor
disorders and plantarflexor weakness. Dev Med Child Neurol. 2007 Aug;49:615-20.
Danielsson A, Bartonek Å, Levey E, McHale K, Sponseller P, Saraste H. Associations between orthopaedic findings, ambulation
and health-related quality of life in children with myelomeningocele. J Child Orthop. 2008,2:45-54.
Bartonek Å. Motor Development Toward Ambulation in Preschool Children with Myelomeningocele—A Prospective Study.
Pediatric Physical Therapy. 2010;22:52-60.
Bartonek A, Saraste H, Danielsson A. Health-related quality of life and ambulation in children with myelomeningocele in a
Swedish population. Acta paediatrica. 2012 Sep;101(9):953-6.
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326 oktober 2016
Muscle
Function
Class
MFC I-V
I: Sacral II: Low Lumbar III: Mid-lumbar IV: High
Lumbar
V: High
Lumbar/
Thoracic
‘Low’ lesion ’High’ lesion
Muscle Strength
grade 1-5,
1= no trace of
contraction,
5=normal
strength
Weakness of
intrinsic foot
muscles
Plantarflexion:
4-5
Plantar flexion 3,
fair or less
Knee flexion 3,
Hip extension
and/or hip
abduction 2- 3
Hip flexion 4-5
Knee extension 4-
5 good-to-normal
Knee flexion 3,
fair or less
Trace of hip
extension, hip
abduction
No knee
extension
No hip adduction
Hip flexion 2,
poor or less
Pelvic elevation
2-3, fair or poor
No muscle
activity in the
lower limbs
No pelvic
elevation
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Realistic prognosis of ambulation
Level of motor paresis
Analysis of additional ambulation-related factors
• Contractures
• Spasticity
• Balance problems
• Generalized muscle hypotonia
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Orthotics vocabulary
Categories of orthoses reference to the anatomical segments
and joints they encompass
FO foot orthosis
AFO ankle-foot orthosis
KAFO knee-ankle-foot orthosis
HKAFO hip-knee-ankle-foot orthosis
THKAFO trunk-hip-knee-ankle-foot orthosis
(ISO 8449-3 : 1989)
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Orthosis types
Polycentric
Locked
Reciprocal
Solid Freely-
articulating
3-D
Overlapping
AFO KAFO HKAFO
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MFC I
Weakness of intrinsic foot muscles and flexor hallucis longus
Expected ambulation:
Community ambulation. Ability to keep up with peers when walking
outdoors
Orthoses: Insoles, FO
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Höger
Vänster
Gait analysis
Left File 21 (Przemekstiffknee2.c3d) Right File 21 (Przemekstiffknee2.c3d)
Trunk Sway20
-20
Up
Down
deg
Pelvic Obliquity20
-20
Up
Down
deg
Hip Ab-Adduction20
-15
Add
Abd
deg
Trunk Tilt20
-20
Post
Ant
deg
Pelvic Tilt35
-5
Ant
Post
deg
Hip Flexion-Extension60
-15
Flex
Ext
deg
Knee Flexion-Extension90
-15
Flex
Ext
deg
Dorsi-Plantarflexion40
-40
Dors
Plan
deg
Trunk Rotation20
-20
Int
Ext
deg
Pelvic Rotation30
-30
Int
Ext
deg
Hip Rotation40
-30
Ext
Int
deg
Foot Progression40
-40
Int
Ext
deg
SagittalFrontal Transvers
e
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Trunk Sway30
-30
Up
Down
Pelvic Obl.20
-20
Up
Down
Hip Ab-Add.25
-25
Add
Abd
Knee Valg-Var30
-30
Var
Val
Trunk Tilt20
-20
Post
Ant
Pelvic Tilt35
0
Ant
Post
Hip Flex/Ext.60
-10
Flex
Ext
Knee Flex/Ext.85
-10
Flex
Ext
Dorsi-Plantarflex.30
-20
Dors
Plan
Trunk Rot.20
-20
Int
Ext
Pelvic Rot.30
-30
Int
Ext
Hip Rotation30
-30
Int
Ext
Foot Progression40
-40
Int
Ext
MFC I
TD
MFC I
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Main problem: Plantarflexion weakness
Expected ambulation
Community ambulation with need of orthoses.
No walking aid.
Wheelchair use only for long distances outdoors
Orthoses: Initially free-articulated KAFO, thereafter AFO
Freely-articulating KAFO AFO (solid/overlap) AFO (polycentric)
MFC II
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Ex. MFC II with AFOs, 11.7 years
Trunk Sway30
-30
Up
Down
Pelvic Obl.20
-20
Up
Down
Hip Ab-Add.25
-25
Add
Abd
Knee Valg-Var30
-30
Var
Val
Trunk Tilt20
-20
Post
Ant
Pelvic Tilt35
0
Ant
Post
Hip Flex/Ext.60
-10
Flex
Ext
Knee Flex/Ext.85
-10
Flex
Ext
Dorsi-Plantarflex.30
-20
Dors
Plan
Trunk Rot.20
-20
Int
Ext
Pelvic Rot.30
-30
Int
Ext
Hip Rotation30
-30
Int
Ext
Foot Progression40
-40
Int
Ext
TD
MFC II
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MFC III
No below-knee muscle strength
Weakness of hip extensors, hip abductors
Expected ambulation:
Household ambulation with orthoses, sometimes walking aids
Wheelchair use only outdoors, and for long distances indoors
Orthoses: HKAFO, KAFO, AFO with condylar support
HKAFO 3D hip joint Freely-articulating KAFO AFO with condylar support
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Ex. MFC III with KAFOs, 7.8 yearsHips contained
Trunk Sway30
-30
Up
Down
Pelvic Obl.20
-20
Up
Down
Hip Ab-Add.25
-25
Add
Abd
Knee Valg-Var30
-30
Var
Val
Trunk Tilt20
-20
Post
Ant
Pelvic Tilt35
0
Ant
Post
Hip Flex/Ext.60
-10
Flex
Ext
Knee Flex/Ext.85
-10
Flex
Ext
Dorsi-Plantarflex.30
-20
Dors
Plan
Trunk Rot.20
-20
Int
Ext
Pelvic Rot.30
-30
Int
Ext
Hip Rotation30
-30
Int
Ext
Foot Progression40
-40
Int
Ext
TD
MFC III
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Compensatory gait
TD MFC III MFC III
With stable hips
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MFC III
Midlumbar
Keep the hips reduced!
Modern hip surgery, without tendon transfers, combined
with well-aligned orthoses
For children with potential walking capacity
Contained hips
Higher quality of lifeDanielsson et al 2008
No walking aids
hands are free to be used for other things!
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Effect of Spasticity: Standing
22
23
262524
27
2829
32
333130
Group 3a Group 3b Group 3c
32
6
4 5
1
7
10
8 9
Group 1bGroup 1a
13
11
15
12
16
18
14
17
21
19
20
Group 2a Group 2b Group 2c
MFC INo spast Ankle Ankle + knee/hip
MFC IINo spast Ankle Ankle + knee+/hip
MFC IIINo spast Ankle Ankle + knee/hip
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MFC IV
Knee extensor weakness
Remaining pelvic elevation
Expected ambulation: Household ambulation with orthoses and
walking aids. Wheelchair use both in- and outdoors
Orthoses: HKAFO, locked knee joint
HKAFO (3-D hip joint) Reciprocating gait orthosis (RGO)
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MFC V
No muscle activity in the lower limbs
No pelvic elevation
Expected ambulation: Non-functional ambulation
• Ambulation during therapy, in school, and for limited time at home• Wheelchair is used for mobility
Orthoses: THKAFO
Standing device Swivel walker Para walker
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Physiotherapy
• Orthosis timing
• Standing
• Walking
• Orthosis acceptance
• Orientation in space
• Avoiding muscle inbalance
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Standing and Walking
Side steps for pelvic elevation
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Orthosis acceptance and
Orientation in space
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Avoiding muscle inbalance
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Summary
Characteristic similarities in muscle function
classes
Heterogeneity within and between groups
Optimal gait achieved by body alignment
Contained hips
Prevention of deformities
Stable orthoses in frontal and transverse planes