Basic Physiotherapy of Spina Bifida J. E. HEWSON The aim of physiotherapy for the spina bifida child is to help him become as independent as possible. On occasions this will mean the child spending some time in a wheelchair, but standing and walking whenever possible. Useful independence in our Unit necessitates being able to walk 25 metres and sitting into and rising from a chair. Since many children will require long-term physiotherapy, for both social and economic reasons the parents are taught the required techniques to carry out at home, with regular advice and encouragement from the physiotherapist. The physiotherapist must therefore be prepared to be readily available to the parents, at the end of a telephone line, attending the doctor's clinics, in the department and by visiting the child's home. She may see the child more frequently than other members of the team and therefore becomes an important channel of communication, often having to interpret the doctor's language to a confused parent. We first see the child before the back is closed, when the muscle power of the lower limbs is assessed and charted. This assessment needs experience with both normal and abnormal movements and uses techniques of stretch reflexes and positioning to elicit neonatal reflex activity. Muscle groups only are tested and classified according to the MRC Scale (1943). Skin sensation is also assessed. The chart is taken into consideration when deciding whether to close the back, and further charts at one month and then at six-monthly intervals are done mainly for the benefit of the orthopaedic surgeons. Full-range passive movements of all the joints of the lower limbs, which can be either prophylactic or therapeutic, are the basis of physiotherapy. If some muscle groups are contracted, gentle but firm stretching is necessary to achieve full range. Certain muscle groups require particular attention, for example the hip flexors and adductors, as contractures of these muscles may be associated with muscle imbalance and dislocation of the hips. Contractures of the hamstrings and tensor fasciae latae cause difficulty with sitting and with use of calipers. As well as regular stretching, the child with weak lower-limbs requires encouragement to reach his developmental milestones, and this is best done in play. Simple exercises are taught to improve trunk balance and strengthen the arms and trunk. The extensor muscle groups of the arms are the most important to strengthen, since they are the force behind walking, wheelchair propulsion and the ability to transfer from chair to bed to bath and vice versa. At about two years of age the child's walking potential is assessed. The factors influencing this are intelligence, stage of maturation and deformities. With early selection of infants for operation, the majority of children now surviving have good walking potential. When necessary, the child is supplied with calipers. which are often extensive but are gradually reduced to long-leg calipers or even below-knee irons. The caliper hip-joints d o not lock and allow a full range of flexion, 10" of extension, 15" of abduction and 53 of adduction. Jack-knifing at the hip joints is prevented by posterior straps, which are removed when the Senior Physiotherapist, Spina Bifida Unit, Queen Mary's Hospital for Children, Carshalton, Surrey.

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child can control this movement by trunk and hip extension. The child is taught to walk between parallel bars, using an alternate leg gait: if he wishes to move his right leg forward he pushes on his right arm, thereby transferring the weight off the right leg; the movement of the caliper hip-joint then allows the right leg to swing forward. He then repeats the movements with his left arm and leg. Canadian/Carshalton Sticks are introduced early in the training of walking. It is hoped that the child will be walking independently and able to sit and stand by the time school-age is reached. Pressure sores are a complication with which the physiotherapist often deals. The important factor is to remove the source of pressure: caliper bands may need to be raised or lowered, or boots cut out to relieve pressure on a heel sore. The sores are usually treated with icepacks and saline baths, a simple but effective treatment which is able to be carried out at home. It is important to realise that in all of this treatment the parents do most of the hard work, and in my experience do it very well indeed. Acknowledgenzent: I wish to thank Mr. Geoffrey Walker, FRCS, and my physiotherapy colleagues at Queen Mary’s Hospital for their help and encouragement in preparing this paper.

SUMMARY

Physiotherapy for children with spina bifida uses very basic techniques which include prophylactic and therapeutic ‘stretching’, training to walk, supervision of calipers, and instruction to the parents. Success or failure of treatment very largely depends on the ability of the physiotherapist to teach and encourage the parents to help the child become as independent as possible in all aspects of daily living. ZUSAMMENFASSUNG

Basisphys~otherapiebei Kindern mit Spina bijida Die Physiotherapie bei Kindern mit Spina bifida bedient sich sehr grundlegender Techniken, die prophylaktisches und therapeutisches ‘Dehnen’, Lauftrainig und Zirkelgebrauch und Elterninstruktion beinhalten. Der Erfolg oder Mioerfolg der Behandlung hangt weitgehend von den Fahigkeiten des Physiotherapeuten ab, die Eltern zu instruieren und zu ermutigen, ihrem Kind zu helfen, in allen taglichen Lebensbereichen so unabhangig wie moglich zu werden. RESU MEN

Fisioterapia bhsica para niiios con espina b$da La fisioterapia para niiios con espina bifida utiliza ticnicas muy bisicas que incluyen el ‘estiramiento’ profilactico y terapiutico, el entrenamiento de la marcha y de la utilizacion de muletas y la instrucci6n de 10s padres. El exit0 o el fall0 del tratamiento depende mucho de la habilidad del fisioterapeuta a enseiiar y a animar a 10s padres a ayudar al niiio a llegar a ser lo mas independiente posible en todos 10s aspectos de la vida diaria. REFERENCE M. R. C. Scale (1943) Aids to the Investigation of Peripheral Nerve Injuries. London: H.M.S.0

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