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Thomas KF, Boyer ER, Krach LE. Variability in lower extremity motor function in spina bifida only partially associated with spinal motor level. J Pediatr Rehabil Med 2022; 15:559-569. [PMID: 36502349 DOI: 10.3233/prm-220047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE Previous studies have found motor function to correlate with spinal motor level and, accordingly, individuals with spina bifida are frequently categorized clinically in this manner. The aim of the current study was to describe how lower extremity functions including strength, selective motor control, and mirror movements vary by motor level in children and young adults with spina bifida. METHODS A single center, retrospective, cross-sectional, descriptive study using data collected in the National Spina Bifida Patient Registry and by a gait laboratory was performed. RESULTS Seventy-seven individuals with spina bifida were included with the majority having myelomeningocele (59 lumbar, 18 sacral motor level). Lower extremity strength and selective motor control varied to a certain extent with motor level. However, 90% of individuals showed strength or weakness in at least one muscle group that was unexpected based on their motor level. Mirror movements did not clearly vary with motor level. CONCLUSION Lower extremity strength, selective motor control, and mirror movements in individuals with spina bifida were not entirely predicted by motor level. This highlights the possible need for an improved spina bifida classification system that describes not only spinal motor level but more clearly defines a particular individual's functional motor abilities.
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Affiliation(s)
- Katherine Fisher Thomas
- Department of Pediatric Rehabilitation Medicine, Gillette Children's, Saint Paul, MN, USA.,Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN, USA
| | - Elizabeth Rose Boyer
- Center for Gait and Motion Analysis, Gillette Children's, Saint Paul, MN, USA.,Department of Orthopedic Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Linda Elsie Krach
- Department of Pediatric Rehabilitation Medicine, Gillette Children's, Saint Paul, MN, USA.,Department of Physical Medicine and Rehabilitation, University of Minnesota, Minneapolis, MN, USA
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Abstract
BACKGROUND CONTEXT Patients with spina bifida (SB) are at risk for pathological fractures and low bone mineral density (BMD). PURPOSE AND METHODS This article reviews the literature and provides a comprehensive overview of how the characteristics of SB and its associated comorbidities intersect with bone fragility to identify possible pathophysiological mechanisms of fractures and low BMD. RESULTS Bone fragility occurs early in the life of patients with SB as a result of a disturbance that determines changes in bone shape, quantity, and quality, as poor mineralization reduces bone stiffness. Bone fragility in SB occurs due to local and systemic factors and may be considered a state of impaired bone quality of multifactorial aetiology, with complex interacting influences of neurological, metabolic, and endocrinological origins and the presence of smaller bones. Bone fragility should be evaluated globally according to skeletal age and Tanner staging. The phases of the evolution of Charcot joints seem to intercept the evolution of epiphyseal fractures. Charcot arthropathy in SB may be initiated by the occurrence of repetitive trauma and fractures in epiphyseal and subepiphyseal regions, where there is a deficit of bone mineralization and greater bone mass deficits. CONCLUSION Bone fragility in MMC potentially has a multifactorial neuro-endocrinological-metabolic-renal dimension, with smaller bones, lower bone mass, and mineralization deficits affecting bone strength.
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Dennis M, Salman MS, Jewell D, Hetherington R, Spiegler BJ, MacGregor DL, Drake JM, Humphreys RP, Gentili F. Upper limb motor function in young adults with spina bifida and hydrocephalus. Childs Nerv Syst 2009; 25:1447-53. [PMID: 19672605 PMCID: PMC3075008 DOI: 10.1007/s00381-009-0948-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective of the study was to measure upper limb motor function in young adults with spina bifida meningomyelocele (SBM) and typically developing age peers. METHOD Participants were 26 young adults with SBM, with a Verbal or Performance IQ score of at least 70 on the Wechsler scales, and 27 age- and gender-matched controls. Four upper limb motor function tasks were performed under four different visual and cognitive challenge conditions. Motor independence was assessed by questionnaire. RESULTS Fewer SBM than control participants obtained perfect posture and rebound scores. The SBM group performed less accurately and was more disrupted by cognitive challenge than controls on limb dysmetria tasks. The SBM group was slower than controls on the diadochokinesis task. Adaptive motor independence was related to one upper limb motor task, arm posture, and upper rather than lower spinal lesions were associated with less motor independence. CONCLUSIONS Young adults with SBM have significant limitations in upper limb function and are more disrupted by some challenges while performing upper limb motor tasks. Within the group of young adults with SBM, upper spinal lesions compromise motor independence more than lower spinal lesions.
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Affiliation(s)
- M. Dennis
- Program in Neurosciences & Mental Health, The Hospital for Sick Children, Toronto, ON, Canada,Department of Psychology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada,Department of Surgery, University of Toronto, Toronto, ON, Canada,Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - M. S. Salman
- Section of Pediatric Neurology, Children’s Hospital, University of Manitoba, Winnipeg, MB, Canada
| | - D. Jewell
- Program in Neurosciences & Mental Health, The Hospital for Sick Children, Toronto, ON, Canada
| | - R. Hetherington
- AboutKidsHealth, The Hospital for Sick Children, Toronto, ON, Canada,Department of Psychology, University of Toronto, Toronto, ON, Canada
| | - B. J. Spiegler
- Department of Psychology, The Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - D. L. MacGregor
- Department of Neurology, The Hospital for Sick Children, Toronto, ON, Canada,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - J. M. Drake
- Department of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - R. P. Humphreys
- Department of Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada,Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - F. Gentili
- Department of Neurosurgery, The Toronto Hospital Western Division, Toronto, ON, Canada
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Chang CK, Wong TT, Huang BS, Chan RC, Yang TF. Spinal dysraphism: a cross-sectional and retrospective multidisciplinary clinic-based study. J Chin Med Assoc 2008; 71:502-8. [PMID: 18955184 DOI: 10.1016/s1726-4901(08)70158-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Spinal dysraphism is a common birth defect that causes different kinds of secondary impairments, including joint deformities, reduced mobility, and bowel/bladder dysfunction. Due to the diversity in terminology, cultural/ethnic differences, and medical policies, prior study results cannot be generalized to all populations. Therefore, we performed this study to define the characteristics of patients in Taiwan with spinal dysraphism. METHODS Patients diagnosed with a myelomeningocele or lipomyelomeningocele were identified from the database of our spinal dysraphism multidisciplinary clinic. A cross-sectional study was conducted by telephone interview and retrospective chart review. Clinical characteristics, such as neurologic level, orthopedic deformities, assistive device use, and level of ambulation, were collected. Spearman's correlation (r) tests were performed between ambulation or neurologic level and other variables. RESULTS Seventy-eight subjects were included in the current study. Subjects with myelomeningoceles had more severe neurologic involvement, poorer ambulation outcome, and higher rates of orthopedic deformities, assistive device use, lower hand function, and bowel/bladder dysfunction. The correlation test revealed that the level of ambulation was negatively influenced by a higher neurologic level, a history of shunt placement, and various orthopedic deformities. Neurologic level also had widespread influence on history of shunt placement, orthopedic deformities, assistive device use, the need for additional assistive devices, aggressiveness of assistive devices, and bowel/bladder dysfunction. CONCLUSION For patients with spinal dysraphism, the neurologic level is the most important prognostic factor for many other clinical characteristics, including ambulation status.
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Affiliation(s)
- Chih-Kang Chang
- Rehabilitation Center, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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Landry SH, Taylor HB, Guttentag C, Smith KE. Chapter 2 Responsive Parenting. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/s0074-7750(08)00002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
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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. [PMID: 15996587 DOI: 10.1016/j.gaitpost.2004.06.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2004] [Accepted: 06/16/2004] [Indexed: 02/02/2023]
Abstract
Gait analysis and recording of standing position were performed in 38 ambulatory children with myelomeningocele. Thirty-four were independent ambulators and four required a walking aid. All subjects were assigned one of four muscle function groups based on muscle strength. They were also divided into subgroups based on the distinction between flaccid and spastic paresis in the lower limb joints. A comparison was made between the gait pattern of the children with spasticity and that of the children with flaccid paresis in each muscle function group. Spasticity in only the ankle joint muscles influenced the subject's gait and standing position compared to the subgroups with a flaccid paresis. Even larger deviations in gait and standing position were observed when spasticity occurred in muscles at the knee and hip joints. When setting ambulatory goals the presence of additional neurological symptoms such as spasticity and inadequate balance should be taken into consideration.
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Affiliation(s)
- Asa Bartonek
- MotorikLab Q2:07 ALB, Astrid Lindgrens Children's Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden.
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Abstract
Spastic paresis follows chronic disruption of the central execution of volitional command. Motor function in patients with spastic paresis is subjected over time to three fundamental insults, of which the last two are avoidable: (1) the neural insult itself, which causes paresis, i.e., reduced voluntary motor unit recruitment; (2) the relative immobilization of the paretic body part, commonly imposed by the current care environment, which causes adaptive shortening of the muscles left in a shortened position and joint contracture; and (3) the chronic disuse of the paretic body part, which is typically self-imposed in most patients. Chronic disuse causes plastic rearrangements in the higher centers that further reduce the ability to voluntarily recruit motor units, i.e., that aggravate baseline paresis. Part I of this review focuses on the pathophysiology of the first two factors causing motor impairment in spastic paresis: the vicious cycle of paresis-disuse-paresis and the contracture in soft tissues.
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Affiliation(s)
- Jean-Michel Gracies
- Department of Neurology, Mount Sinai Medical Center, One Gustave L Levy Place, Annenberg 2/Box 1052, New York, New York 10029-6574, USA.
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Brinker MR, Rosenfeld SR, Feiwell E, Granger SP, Mitchell DC, Rice JC. Myelomeningocele at the sacral level. Long-term outcomes in adults. J Bone Joint Surg Am 1994; 76:1293-300. [PMID: 8077258 DOI: 10.2106/00004623-199409000-00003] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We reviewed the long-term outcome of thirty-six patients who had a myelomeningocele at the sacral level and whose average age was twenty-nine years (range, nineteen to fifty-one years). The patients were followed at our institution for an average of ten years (range, one to thirty-three years); however, the medical records from birth on were available for all of the patients. Instead of the expected outcome that function had been maintained in this group of patients, we found a decline in the ability to walk of eleven of the thirty-five patients who had been community ambulators initially. At the time of the most recent follow-up examination, five had become household ambulators, two were non-functional ambulators, and four were non-ambulators. The one patient who initially had been a household ambulator was a non-ambulator at the time of the most recent follow-up examination. A decrease in plantar flexion was found in fourteen patients and a decrease in plantar sensation, in fifteen. Breakdown of the skin and soft-tissue infections on the plantar surface of the metatarsal heads and of the heel were seen in twenty-seven and twenty-three patients, respectively, and were related to the absence of plantar sensation. Fifteen patients had osteomyelitis involving the lower extremity. Eleven patients had had a total of fourteen amputations: five involved one toe or more, four involved one ray or more, two were Syme amputations, and three were below-the-knee amputations. By the most recent follow-up examination, thirty-three patients had had a total of 371 orthopaedic procedures. The procedures included tendinous procedures; osteotomies; soft-tissue releases, transfers, and débridements; amputations; and arthrodeses of the lower extremities or spine.
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Affiliation(s)
- M R Brinker
- Spina Bifida Clinic, Rancho Los Amigos Medical Center, Downey, California 90242
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McDonald CM, Jaffe KM, Mosca VS, Shurtleff DB. Ambulatory outcome of children with myelomeningocele: effect of lower-extremity muscle strength. Dev Med Child Neurol 1991; 33:482-90. [PMID: 1864474 DOI: 10.1111/j.1469-8749.1991.tb14913.x] [Citation(s) in RCA: 71] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The relationship between patterns of strength and mobility was studied in 291 children with myelomeningocele, graded as community ambulators, partial (household) ambulators and nonambulators. Iliopsoas strength was found to be the best predictor of ambulation, with the quadriceps, anterior tibialis and glutei also contributing significantly. Grade 0 to 3 iliopsoas strength was always associated with partial or complete reliance on a wheelchair. No patient with grade 4 to 5 iliopsoas and quadriceps function relied completely on wheelchairs and the majority were community ambulators. Grade 4 to 5 gluteal and anterior tibialis function was associated with community ambulation, without aids or braces. Deterioration in mobility was most common in those with strong iliopsoas/quadriceps and grade 0 to 3 gluteus medius, and was not age-related.
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Affiliation(s)
- C M McDonald
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle
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Rosenstein BD, Greene WB, Herrington RT, Blum AS. Bone density in myelomeningocele: the effects of ambulatory status and other factors. Dev Med Child Neurol 1987; 29:486-94. [PMID: 3678627 DOI: 10.1111/j.1469-8749.1987.tb02508.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Measurements were made of distal radius, mid-radius, tibia and metatarsal bone-density of 80 patients with myelomeningocele (17 thoracic, six L1/L2, 13 L3, 30 L4, 14 L5/sacral). For the upper extremity the bone density primarily was low in the thoracic patients, but in the tibia and metatarsal it showed a more linear correlation with neurological levels. The effect of age was highly significant at all sites; after controlling for this, the neurological level was a significant determinant of bone density at all sites, and this effect was greater in older children. Patients with impaired ambulation had decreased bone-density in the distal radius, tibia and metatarsal, but not in the mid-radius. Race had no significant effect on density after accounting for differences in neurological level. Weight for height and multiple fractures did not correlate with bone density. Although ambulatory status (weight-bearing stresses) and neurological status (muscle stresses) are both important factors in bone density, this study suggests that the latter is a more important determinant.
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Affiliation(s)
- B D Rosenstein
- University of North Carolina School of Medicine, Chapel Hill 27514
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