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Introduction :
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.
It 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.
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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.
Other Assessments
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
Normal Development
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.
How to Use the Developmental
Charts
Although the
child with spina bifida does not progress in the same way as other
children, the stages of normal development are still used as the basis
for assessment and treatment.
The above
mentioned development chart shows the order in which some abilities
develop and the age at which most children learn them.
The chart will
identify what he can do, what he cannot do, and what he needs to be
taught to do. Record this on the assessment form.
Encouraging Normal
Development
An infant with
spina bifida and hydrocephalus will usually have a delay in the
development. This may be present from birth. It is due to several
reasons which can include the following:
-
long periods of time in
hospital after birth
-
parents' concerns about
having an infant with spina bifida and not knowing how to handle
-
the infant's heavy head due
to hydrocephalus making it hard to gain head control
-
the infant's difficulty in
learning to move due to muscle paralysis, contractures or
deformities
This delay in development can be lessened by carrying out a programme
of treatment. The programme should be aimed at encouraging normal
development from the first few months of life. It should also aim at
making the child as independent as possible in the community as it
grows and develops. The programme should be carried out by the family
at home. The family will need to be taught special exercises and
activities by the rehab professionals to help their infant's
development.
Some examples
of exercises and activities will be mentioned in Part II. These
exercises will include methods of carrying, positioning and playing.
They will help to stimulate the child's development.
(To be continued in the next
issue)
Source of
information:
International Federation for Hydrocephalus and Spina Bifida (ifHSB)
WHO/RHB/96.5
Spina Bifida Association of America (SBAA)
Association for Spina Bifida and Hydrocephalus (ASBAH)
For more
information look into: www.sbaa.org
/ www.asbh.org
This
information was compiled and reviewed by: C. Ambalavanan, MD, DMR
(UK), Specialist in Physical Medicine and Rehabilitation, JCRPO, P.O.
Box 27240, Riyadh 11417, Kingdom of Saudi Arabia.
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