Orthopaedic management of high-level spina bifida. Early walking compared with early use of a wheelchair.

To determine whether it is worth while to encourage patients who have high-level spina bifida to walk at an early age, we compared the cases of thirty-six patients who had participated in a walking program with those of thirty-six patients for whom a wheelchair had been prescribed early in life. The patients in the two groups were matched for age, sex, level of the lesion, and intelligence. Only twelve of the patients who had been able to walk at an early age were still able to do so effectively at the time of this study, when their ages ranged from twelve to twenty years, but still these patients fared somewhat better than the other patients did. The patients who walked early had fewer fractures and pressure sores, were more independent, and were better able to transfer than were the patients who had used a wheelchair from early in life. However, during childhood and early adolescence, the patients who had always used a wheelchair had spent fewer days in the hospital than did those who had participated in the walking program. There were no major differences between the two groups with regard to skills of daily living, function of the hands, and frequency and severity of obesity.

Orthopaedic management of the lower extremities in spina bifida.

Myelodysplasia is a multisystem disease that requires a multidisciplinary approach. The orthopaedist is often the first to identify a changing neurologic picture or deformity and must work closely with neurosurgical colleagues to identify correctable neurologic lesions. The role of the orthopaedist begins at the birth of the child with spina bifida. At this time, the level of neurologic involvement can be determined. Education of the parents can then begin by outlining the expected ambulatory potential of the child, and predicting deformities or complications that might be anticipated depending on the level of neurologic involvement. The orthopaedist must also emphasize the extreme importance of neurosurgical care in preventing deterioration of neurologic function, so that goals for ambulation and musculoskeletal function can be achieved. As the child gets older, motor milestones paralleling those of a normal child should be sought with use of a corner chair or sitting device, followed by the use of a standing frame if needed. If appropriate, the child will then progress to full-control braces, with weaning as determined by neurologic level of involvement . Long-term mobility may be achieved by bracing or by the use of a wheelchair. A realistic approach must be taken in goal-setting, so that a child is not pressured to achieve unrealistic goals yet is enabled to achieve full functional capacity.

A report of children with spinal dysraphism managed conservatively.

This investigation is a retrospective study of 12 patients with spinal dysraphism. There were 5 males and 7 females in the cohort. Their ages ranged from 4 to 13 years at the time of their last assessment. Initial presentation included one or more of the following--a blemish on the back in the midline (lump, hairy patch, sinus and/or angioma), abnormal neurological signs and symptoms in one or both legs, and in one case dribbling of urine. Investigations performed included plain X-rays of the spine, CT scans alone or in combination with a myelogram and MR scans. Findings included thickened filum terminale, low lying cord, lipoma, syringomyelia, diastematomyelia, spina bifida occulta and sacral agenesis. The children were followed up for between 2 and 10 years. During the period of observation, none developed new symptoms or signs, and there was no progression of existing neurological deficits. This preliminary report suggests that there is no justification for prophylactic surgery in this group of patients.

Integrating the physically handicapped child.

This paper will serve several purposes: (1) to provide information on the incidence of physically handicapped children (exclusive of the blind and deaf) who are likely to be integrated into schools for normal non-physically impaired children, (2) to describe briefly the major handicapping conditions and their educational implications, (3) to comment on why integration has come about and why it promises to enrich the lives of normal children, (4) to suggest how physicians, physical therapists, and occupational therapists might help to make schools programs successful, (5) to comment briefly on financial implications of this program and to suggest ways in which the complexity of the medical management might be simplified, (6) to provide factual knowledge about the handicapped child and his potential to teachers who are already on the firing line to "improve" the academic achievement of the alleged normal child.

[Physical education for spina bifida children in special schools for the physically handicapped (primary school)]. / Leibesübungen mit Spina bifida-Kindern an der Sonderschule für Körperbehinderte (Grundschule).

With a rate of 0.5-1/1,000 of the total number of births in West Germany, spina bifida is next to cerebral paresis one of the most frequent congenital defects. Altogether, fifty places in special schools are needed per one million of inhabitants for spina bifida children. The loss of physical unctions is comparable to that in the case of paraplegia. The variety of medical and psychological problems makes the cooperation of highly different branches of study indispensible in a rehabilitation team (neurosurgeon, neuropediatrician, urologist, orthopaedist, pediatrician, educator, social worker, physical therapist). Each team member must be informed about the complete rehabilitation plan. These children's shortage of environmental experience is mainly due to their backwardness as regards motoric development, which cannot be recovered by means of individual physical therapy alone. On the other hand, additional, specifically selected and organised physical education makes possible the necessary mobility and social experiences. By giving the children exercises suitable for their ages it is hoped to achieve a late maturation and stabilization of the personality. In choosing the exercises it is first of all necessary to go back to the so-called fundamental activities like climbing, hanging by one's hands, sliding, pushing oneself up off the ground, swinging or throwing and catching, before going on to wheel-chair sports. Wheel-chair sport promises a varied selection for group exercises (games) and for everyday use. Using the wheel-chair as sports equipment, it is possible for persons with other types of locomotive handicaps to be integrated into the group. For physical education in special schools the pupils whould be arranged into groups according to their ability in order to keep the groups as homogenous and the children's chances as equal as possible. The most important teaching criteria are in this case: the creation of a happy atmosphere, a high degree of clarity, the fulfilment of individual inclinations, the encouragement of independence, the development of community life and the fulfilment of everyday tasks. In swimming, the spina bifida child differs from the normal child in his greater initial fear and in the existence of contractions, a scoliosis, hyperlordosis or -kyphosis due to the resultant instability of the water. Because of this, specifically oriented swim- and work-aids must be used. The didactic procedure is then the same as in the case of normal children. After the child's familiarity with and safety in the water is assured, one can proceed to individual swimming techniques and in a few cases to sport swimming. Bacteriological examination of the water did not yield any results which could cause objection on the grounds of hygiene.

Assessment of orthoses by means of speed and heart rate.

Energy expenditure is an important parameter in the assessment of gait and orthotic treatment of heavily handicapped patients, since any orthosis which increases the effort required is likely to be discarded with consequently disturbing implications. Heart rate has been shown to be a reliable monitor of energy expenditure and is convenient because ECG can be telemetered by a miniature radio transmitter. Using a transmitter causes minimal interference with the patient, but care must be employed to obtain ECG signals free of artefact from subjects who are exercising. Means of reducing artefact are discussed, as are ways in which heart rate monitoring by radio telemetry is being used in the routine assessment of orthotic treatment of paediatric patients and the development of new orthotic devices.

The production of spinal jackets for children with spina bifida.

This paper discusses the problems of spinal deformity and instability in spina bifida. A technique for suitable bracing is described and the available materials investigated.

Conductive education at the Petö Institute, Budapest.

Conductive education, which was developed at the Petö Institute in Budapest, has been publicised incorrectly as a method of treatment for children with cerebral palsy. From the results of information given and our own observations during a week's visit to the institute we conclude that a minority of carefully selected children with cerebral palsy and spina bifida, who have a relatively good prognosis, are educated at the institute; the education is carried out with appropriate medical, surgical, and orthotic intervention; and the children probably function better as a result of the intensive programme than do similar children in Britain in areas where therapy is scarce. They seem to achieve, however, what we would expect similar children in Britain to do when facilities are adequate. Though our findings do not therefore justify using public funds to refer children to the institute, some (self selected) families benefit from a visit, particularly from the positive attitudes of the staff. The role of the conductor and the integration of programmes into a classroom setting have much to recommend them, and conductive education, if successfully transferred to Britain, might be beneficial to a wider range of children than in Hungary.

Educational mainstreaming of physically handicapped children.

The therapeutic and educational needs of 31 children who, after attending a private pre-school for the physically handicapped, were mainstrained in public schools are described in this paper. Their adjustment was followed for one to three years. Information was gathered through questionnaires and interviews with parents, children, and classroom teachers on how successful and to what extent the children had been mainstreamed, as well as what physical, academic, and social problems were encountered. Patterns and trends of relative educational abilities and disabilities of children with spina bifida and cerebral palsy are discussed in view of the literature and the problems encountered by this population. Questions that teachers frequently asked of health professionals who are experienced in dealing with the effects of handicapping conditions as well as a procedure for providing this information are also discussed. Successful mainstreaming depends on cooperative work and mutual advocacy among health professionals, parents, and educational personnel.

The use of self-modeling to improve the swimming performance of spina bifida children.

The use of edited videotape replay (which showed only "positive" behaviors) to improve the water skills of three spina bifida children, aged 5 to 10 years was examined. A multiple baseline across subjects design was used, and behavioral changes were observed to occur in close association with intervention. One child was given successive reapplications of videotaped self-modeling with continuing improvements. It appears that a useful practical technique has been developed.

Effects of a remedial program on visual-motor perception in spina bifida children.

Most studies dealing with spina bifida children concentrate on medical or physical factors, largely ignoring any psychosocial and educational consequences. The present study assessed the effect of a remedial program on visual-motor perception in spina bifida children. Thirty-six spina bifida boys and girls (mean age 82.87 months) with a myelomeningocele and an associated hydrocephalus were assigned randomly to either a control, attention-placebo, or experimental group. Following the administration of the Frostig Program for the Development of Visual Perception, the experimental group significantly improved on a global index of visual perception and the five subtests of Frostig's Development Test of Visual Perception; at a maintenance test two months later, all treatment gains (except on the visual spatial perception subtest) were still evident. These results are discussed in terms of the provision of remedial education for spina bifida children, and a possible cognitive mechanism mediating the behavioral change in the experimental group.

Moulded supportive seating for the disabled.

In severe cases of physical disability intimate supportive seating may be required to provide maximum comfort, a good position for functional activities, improved respiration, relief of localized pressure, control of spasm, protection, or improved management. A service for providing such seating has been developed at Chailey Heritage. The seat is vacuum-formed from thermoplastic materials, having a soft non-absorbent foam for the linear and a hard semi-rigid outer shell. A mould is obtained by casting the patient using the vacuum consolidation technique and by recording the resulting impression using plaster-of-Paris. Nearly 200 seats have been made using the technique with a high rate of success.

Effects of physical exercise on peripheral vision and learning in children with spina bifida manifesta.

The purpose of this research was to investigate the effects of active exercise of the arms on various physiological, perceptual, and cognitive parameters of children with spina bifida manifesta who were aged 9 to 12 yr. Following a 5-min. rest interval, subjects were either not exercised (control days) for a 6-min. period or were exercised (experimental days) for a 6-min. period. Cardiac measures, respiratory function, peripheral vision, and figural learning trials were recorded after exercise. Wilcoxon matched-pairs signed rank tests were computed on the means of the exercise and no-exercise conditions for each measure. Six minutes of active exercise resulted in significant increases in peripheral vision, respiratory and cardiac measures and significant decreases in figural learning trials for these children. A floor effect was noted for the figural learning test. It was concluded that exercise increased blood flow through the lungs allowing for greater oxygen diffusion in the brain and other facilitatory effects resulting in more effective cerebral activity. Curriculum revisions for such children seem to indicate the importance of activity in facilitating subsequent learning.