Spina Bifida

Athenas R., Cynthia W., Osiris R.

Myelomeningocele(MMC): is the most serious and most common type of spina bifida. A sac of fluid comes
through an opening in the baby’s back. Part of the spinal cord and nerves are in this sac and are damaged.
This causes moderate to severe disabilities, such as problems affecting how the person goes to the bathroom, loss
of feeling in the person’s legs or feet, and not being able to move the legs.

Meningocele: a sac of fluid comes through an opening in the baby’s back. But, the spinal cord is not in this sac.
There is usually little or no nerve damage. This type of spina bifida can cause minor disabilities

Spina Bifida Occulta: “hidden” spina bifida, mildest type of spina bifida. there is a small gap in the spine, but no
opening or sac on the back. The spinal cord and the nerves usually are normal. Many times, spina bifida occulta is
not discovered until late childhood or adulthood. This type of spina bifida usually does not cause any disabilities.
Diagnosis-Spina Bifida- means “split spine”
● Spina Bifida is the result of a defective closing of the neural tube
of a developing embryo in the uterus. It mainly affects the lower
parts of the spinal cord usually before the 28th day of gestation
inside the uterus.
● Etiology- unknown cause; 60%-70% have a genetic component
● diagnosed-high resolution u/s
● Special tests-blood test for alpha- fetoprotein 
● Age/time of onset- 28 days prenatally to life.

Screenings taken during pregnancy: AFP alpha-fetoprotein,

Ultrasound, and Amniocentesis

After a baby is born: Sometimes there is a hairy patch of skin or a

dimple on the baby’s back that is first seen after the baby is born. A
doctor can use an image scan, such as an, X-ray, MRI, or CT, to get a
clearer view of the baby’s spine and the bones in the back.

● Sometimes spina bifida is not diagnosed until after the baby is

born, because the mother did not receive prenatal care or an
ultrasound did not show clear pictures of the affected part of the
spine.
Spina Bifida of a
developing fetus
 Spinal level of
Thoracic Trunk weakness. Positional deformities of hips,

lesions
T7-T9 upper abdominals
T9-T12 lower abdominals
T12 has weak quadratus lumborum
knees, and ankles. Secondary to
frog-leg posture

High Unopposed hip flexors, and some adductors Hip flexion, adduction
lumbar Hip dislocation, lumbar lordosis,
(L1-L2) knee flexion, and plantar flexion

Mid lumbar Strong hip flexors, adductors. Weak hip rotators, anti Hip dislocation, subluxation, genu
(L3) gravity knee extension recurvatum

Low Strong quadriceps, medial knee flexors against Equinovarus, calcaneovarus or

lumbar gravity, ankle dorsiflexion and inversion calcaneocavus foot
(L4)

Low Weak hip extension, abduction. Good knee flexion Equinovarus, calcaneovalgus, or
Lumbar against gravity, weak PF with eversion calcaneocavus foot
(L5)

Sacral (S1) Good hip abductors, weak PF -

Sacral (S2- Good hip extensors, and PF -

S3)
 Impairments
● Neurological: Motor and sensory impairments such as abnormal sensation or paralysis, seizures
(shunt malformation)

● Musculoskeletal: Muscle paralysis results in an impairment of voluntary movement of the trunk and
LE
Children with the classic lower motor neuron presentation of flaccid paralysis have no LE motion, and
the legs are drawn into frog-like position by gravity.

● Gastrointestinal: some loss of bowel control (neurogenic bowel) constipation, and incontinence.

● Cardiac: congenital heart disease (lower chance)

● Pulmonary: Chiari malformation- The brainstem, or lowest part of the brain above the spinal cord, is
elongated and positioned lower than usual. This can cause problems with breathing and swallowing.
 Activity Limitations
Functional limitations: main problems difficulty or an inability to stand, walk, and involuntarily bladder control and
bowel functions (incontinence).
Treatment strategies: Core strengthening→ bridges, superman, LE strengthening→sit<>stand, pull<>stand
Gait training → with AD, Pelvic floor strengthening →kegels (ball squeeze)

SHUNT PRECAUTIONS : -avoid any activity which involves twisting at the waist, as this can dislodge the shunt. -Keep all
products with magnets at least 2 inches away from the valve implant site (your head) pressure
setting of some VP shunts may accidentally change. -Don’t use magnetic therapy pads and pillows
Parental Education

● You can show the child’s parents how to place the infant prone
on their laps and gently rock to soothe and stimulate head
lifting
● Holding the infant high on the shoulder, with support under the
arms, fosters head control and is easiest position for an infant
with MMC to maintain a stable head.
● The infant’s head should be supported when the infant is
picked up and put down.
● As a PTA do not hesitate to correct errors in hand placement
● When the shunt is inserted you should always follow any
positioning precautions according to the physician’s orders
Medical Treatments
Child’s primary care physician and orthopedic should also be in contact with the PT.

Orthotist- custom made orthotics

Neurologist/Neurosurgeon- More for cases such as hydrocephalus. Only the neurosurgeon operates.

Urologist- Can help treat urinary and bladder issues.

Treating bladder problems: Many people with spina bifida have problems controlling their bladder

Gastroenterologist- Treats diseases of the digestive system including constipation.

➔ Antibiotics
➔ Urinary Catheterization: needed to drain pee from the bladder several times a day to help prevent infection
➔ By the age of 3 or 4 most children begin to work on gaining urinary continence by using intermittent catheterization
➔ By age 6 the child should be independent in self-intermittent catheterization

Pelvic floor PT

Treating bowel problems: particularly constipation

➔ Laxatives
➔ Medications- Valproate, and carbamazepine- also treat epilepsy
Prognosis
● In general the long-term prognosis for children with Spina Bifida will likely require ongoing care and management,
the majority can expect to lead long and fulfilling lives.
➔ Advances in medical treatments, such as fetal surgery have ensured almost all children born with spina bifida
survive.

SLP Outcome: Some children with spina bifida may have difficulty forming words and speaking clearly.

➔ Speech Pathologists increase a child’s oral motor skills and communication acumen by using exercises that train
the brain to pronounce, understand, and interpret individual words, sounds, numbers, and gestures.

OT Outcome:

➔ OT’s goal is to teach children important practical skills, such as bathing, dressing, and using the bathroom. They also
help children learn to put on and take off braces or orthotics and care for these devices
 The purpose of a shunt in the population

VentriculoPeritoneal shunt provides primary drainage of

cerebrospinal fluid from the ventricles to an extracranial compartment,
usually either the heart or the abdominal or peritoneal cavity.

● Extra tubing is left in the extracranial site to uncoil as the child grows.
● Unidirectional valve designed to open at a predetermined
intraventricular pressure and to close when the pressure falls below
that level prevents backflow of fluid.
● You are able to palpate the shunt tubing
● Movement is usually not restricted unless MD specifies.

Hydrocephalus can occur in children with MMC. It is treated

neurosurgical with the placement of a Ventriculoperitoneal shunt which
drained excess CSF into the peritoneal cavity.
Signs of shunt malformation

● If the child becomes very ill

➔ persistent vomiting
➔ extreme sleepiness
➔ severe headache
➔ Seizures (either the onset of new seizures or an increase in the
frequency of existing seizures)
● You may see only one or two warning signs at a time.
➔ You will not see all of the signs at one time.

*Call your child’s doctor if you notice one or more of these signs in your
child*
Latex Sensitivity in Spina Bifida Population
● 50% of children with MMC (myelomeningocele spina bifida)
are allergic to latex.
● Cause: Infant is exposed repeatedly to latex products through
multiple surgeries, diagnostic tests and examinations.
➔ Exposure to latex can potentially produce a life-threatening
allergic reaction as the child gets older.
● All contact with latex products should be avoided
from the beginning, including catheters, surgical gloves,
and Theraband.
➔ Any surgery should be performed in a latex free environment
● Toys to avoid: rubber balls, balloons (any toy containing
latex)
Positions to avoid

● Upside down
● Frog leg position (prone or supine)
● W sitting
● Ring sitting
● Heel sitting
● Cross-legged sitting
Precautions with Spina Bifida
● Cover the infant’s feet, temperature regulation is impaired.

● Motor paralysis and sensory loss are BELOW the level of lesion;
test dermatomes

● Well fitted shoes [to avoid pressure sores]

● Skin inspection & pressure relief

● Protect skin from heat (Hot bath water, hot car seats, and metal seat belt
clasps, since they may cause burns.)

● Gentle ROM to prevent contractures 2-3 X’s daily

 Pediatric Outcome Tests and Measures

● Functional Independence Measure (FIM)

● Modified TUG (3+ years old)
● 6 minute push test (6MPT)
● MMT
Spina Bifida Interventions
General physical therapy goals during the first stage of care include the following:

● Prevent secondary complications (ie: contractures, deformities, skin

breakdown)
● Promote age-appropriate sensorimotor development
● Prepare the child for ambulation
● Educate the family about appropriate strategies to manage the child’s
condition

1. Weight Shifting in Standing: Weight shifting the child while in standing

can promote head and trunk righting reactions. Preparing the child for
later weight shifting during ambulation
2. Ball Exercises: Prone positioning on a ball with the child’s weight shifted
forward for head lifting. OR Reaching with both arms over a ball
3. Prone Carrying: Prone carrying with extra support for jaw or forehead
 EVIDENCE BASED RESEARCH

●Open fetal repair of the spinal lesion has been shown to improve hindbrain herniation, ventriculoperitoneal shunting, independent mobility and
bladder outcomes for the child and, despite an increased risk of prematurity, does not seem to increase the risk of neurodevelopmental impairment.

The long‐term outcomes of the MOMS trial have not

yet been reported; therefore, cohorts operated prior to
the MOMS trial are, at present, the only source of
these data. Five‐year follow‐up studies of 30 fetal
surgery cases performed prior to the MOMS trial
have reported a shunt rate of 47–55%. Average or
high‐average IQ scores were found in 90% of
patients; this was significantly lower in those who
had required a ventriculoperitoneal shunt compared
with those who had not.37 Functional and self‐care
scores were lower than for age‐matched population
norms,38 but behavioural problems were no higher in
fetal surgery patients than healthy controls.39
References
Latex allergy. Spina Bifida Association of Northeastern New York. (n.d.). Retrieved November 29, 2021, from
http://sbaneny.org/secondary-conditions/latex-allergy/.

http://sbaneny.org/secondary-conditions/latex-allergy/

Martin, S. "T., & Kessler, M. (2021). chapter 7. In Neurologic Interventions for Physical Therapy (4th ed., pp. 189–215).,
Elsevier Saunders.

Palisano, R. J., Orlin, M. N., & Schreiber, J. (2017). Chapter 23 In Campbell's physical therapy for children (5th ed., pp. 543–578).
book, Saunders.

https://nyulangone.org/conditions/spina-bifida-in-children/treatments/rehabilitation-for-spina-bifida-in-children

Sacco A, Ushakov F, Thompson D, et al. Fetal surgery for open spina bifida. Obstet Gynaecol. 2019;21(4):271-282. doi:10.1111/tog.12603