Ambulation/Mobility
As stated, the job of a child is to explore the environment. The ability to ambulate and gait abnormalities
| Gross Motor Skills Acquisition | ||||
| LEVEL OF LESI | ON AND SKILL T12 AND ABOVE | L1/L2 | L3/L4 | L5/SACRAL |
| Rolling over | Delayed, but can be achieved by compensatory means at around 18 months | Delayed, but can be achieved by compensatory methods | Delayed | Minimal delay |
| Sitting | Delayed, but can sit with propping and equipment | Delayed but can achieve sitting, may have some balance issues | Delayed but able to sit | Minimal delay |
| Floor mobility | Rolling, combat crawling, bottom scooting | Rolling, combat crawling and bottom scooting | Modified crawling | Crawling |
| Ambulation | With adapted equipment, orthotics, poor probability of ambulation HKAFO, KAFO, RGO, dynamic and static standers | With adapted equipment and orthotics, household ambulation KAFO, RGO, dynamic standers | With orthotics, household and community ambulation KAFO, floor-reaction AFO, AFO, walkers, and crutches | Community ambulation AFO, UCB |
| Source: HKAFO, hip knee ankle foot orthosis. | ||||
have a direct relationship to the neurologic level of the spina bifida.
Mobility can be achieved through various means, including self-propulsion, adapted equipment, and orthotics. Introduction of equipment should follow developmental sequences. Children are pulling to stand at around 1 year and walking by 18 months. Introduction of dynamic standers can be done early in thoracic and high lumbar levels. These include mobile prone stander, Parapodium, and swivel walkers. If the latter is used, you may also need to incorporate a reverse walker. The advantage of using this type of equipment is not only mobility, but also passive stretch of the joints in the lower extremities and a different orientation to the environment.Orthotics are used in all levels of spina bifida. The child with a thoracic and high level requires much more sophisticated bracing than the lower lumbar levels. Hip knee ankle foot orthosis (HKAFO) and knee ankle foot orthosis (KAFO) stabilize the joints in the lower extremities to allow upright positioning. HKAFO is used when hip instability interferes with knee alignment. With the HKAFO, a child must use a walker and move the brace forward by either leaning or lifting to achieve ambulation. It is a difficult skill to use and is why many children abandon this as they grow. Use of reciprocal gait systems includes a cross-linked hip orthosis, a reciprocal gait orthosis (RGO), or a free hinged gait orthosis such as a hip-guided orthosis (HGO). The isocentric RGO system uses a cabling system. The brace provides structural stability during the stance phase on one side while the opposite side advances. Simply putting hip flexion on one side causes hip extension on the opposite through the cabling system.
Hip-guided orthosis or the Orlau ParaWalker is also an RGO-type system. It does not employ the use of cables, but uses joint stabilization and a rocker foot plate. There are some advantages to using a walking system in young children, as Mazur's study showed fewer fractures and pressure ulcers when comparing those who strictly use a wheelchair to those using a walking system (120). Implementation of these types of braces is best employed when children are around 3 years of age.
Mid-lumbar lesions have knee extension muscles that have a great impact on ambulation. It is imperative that hip flexion and knee flexion contractures be addressed, as these affect upright position. Options include KAFOs and, in some cases, floor-reaction AFOs to assist with knee extension. The majority of these children can hope to have household ambulation with limited community ambulation. All children with spina bifida can be expected to have a delay in ambulation even at the lower sacral levels. In children with the lower sacral levels, parents can expect ambulation by age 2 years. Typical gait patterns include a Trendelenburg associated with weak hip abduction and steppage gait associated with weak dorsiflexors. Bracing includes AFOs and floor-reaction AFO. Floor reaction is used to assist knee extension and prevent the crouching patterns seen in stance phase. The foot must have some flexibility to accommodate this brace. Community ambulation is possible in these individuals.
Bracing studies have shown that the use of ankle foot orthosis (AFO) in children with L4-sacral-level lesions had improved energy expenditure. Walking speed and stride length increased, while energy costs decreased, using braces compared to not using braces. This is surmised to be related to stability that the braces provide (121). If crutches will be used, most children cannot learn the skill until at least 2 to 3 years of age. Walkers can be used at earlier ages, and dynamic standers can be used when children should be upright.
Ambulation is always one of the first questions parents will ask a health care provider: Will my child be able to walk? To address this question, one needs to look at the whole child and all the factors involved. Swank found that sitting balance and neurologic level were good predictors of ambulation potential (122). A study by Williams et al tracked 173 children with spina bifida (123). Thoracic level was found in 35 children, and only 7 walked at 4.5 years.
The study followed 10 children with L1/L2 lesion—and 5/10 walked by 5 years. They followed 15 children with L3, and 9/15 walked at 5 years. There were 45 children in the L4/ L5 group, and 38/45 walked at almost 4 years. The 68 children with sacral level were able to achieve ambulation by 2 years. Walking was delayed in all groups, and the higher levels abandoned walking earlier than was previously documented. With development, those with a sacral level do not lose ambulation skills (123). Success in maintaining ambulation has been associated with muscle function of the hip abductors and ankle dorsiflexors (124).This may be a paradigm shift toward earlier acceptance of wheelchair mobility as a viable option. The demands of walking increase as the person grows taller and requires more energy. Spine deformity has been well documented to have an impact on ambulation. Scoliosis surgery can change ambulation patterns.
Wheelchair mobility should be introduced to all children who will potentially use this as a primary or secondary option. We introduce it at a fairly young age and have found children as young as 1 year can efficiently push a wheelchair. This allows them independence to explore the world around them. Wheelchairs should be appropriately configured to meet the needs of the child. A child is not a small adult and should not be placed in a wheelchair they can grow into. Seating will be adjusted based on neurologic level, posture, and balance. Proper cushions, the seat back, seat, and foot rests should be positioned to prevent pressure areas from developing.