REHABILITATION

The role of the rehabilitation specialist with neural tube defects is specifically to understand the com­plex nature of this group of disorders and apply sound principles in defining a plan.

Musculoskeletal

Conservative management of potential or existing musculoskeletal deformities begins in the newborn and should continue as part of daily care thereafter. Passive range-of-motion exercise (PROM) is applied to all joints below the level of paralysis, with special emphasis on joints with evident muscle imbalance. The infant should not lie constantly in one position, but should be moved and turned frequently. This prac­tice must be taught to parents, not only to mitigate contractures, including those related to gravity, but also to avoid breakdown of the anesthetic skin. For the same reason, splints must be used with great precau­tion, removed frequently to check for skin irritation, and adjusted or discontinued if such problem occurs. PROM and splints are advisable after surgical correc­tion of deformities to maintain joint mobility gained by the procedure. Strengthening exercises are some­times beneficial for partially innervated muscles or after surgical muscle transfer for improving strength or function. They are also part of ambulation training with upper extremity assistive devices.

Examination of motor function in the neonate is based primarily on observation of spontaneous move­ments, presence or absence of deep tendon and infant­like reflexes, habitual postures, passive joint motion, and tone. For example, consistently maintained hip flexion, particularly when passive extension is incom­plete, is a sign of hip extensor weakness.

Development

Development is the natural and predictable sequence that an individual progresses through to attain skills in mul­tiple domains. Children with physical disabilities may not be able to accomplish these tasks, given their physi­cal and cognitive limitations. The impairment will affect activities and participation. Motor acquisition can be predicted based on the level of the lesion, which affects normal balance, coordination, and postural control.

First Six Months of Life

Most children do follow normal development, attaining head control, fine motor skills, and language. This can be disrupted in light of hydrocephalus, medical complica­tions, and severe cognitive involvement (see Table 9.2).

Six to Twelve Months of Age

This is a critical time for gross motor development, where most typically developing children are sitting, crawling, and walking. Predictably, children with spina bifida can be expected to have delays in this domain. The residual motor function will allow the medical team to discuss realistic expectations for family mem­bers. Early mobility mirroring normal development should be incorporated into the rehabilitation plan. Lack of environmental experiences can lead to sensory/ motor deprivation and affect developmental potential. Children are amazing at learning substitution patterns to compensate for these neurologic losses.

Head control is a crucial milestone and prereq­uisite for emerging skills. Most children achieve this skill irrespective of level of lesion.

Floor mobility is a way for a child to move from place to place. It is needed for environmental explo­ration, and different neurologic levels have different methods. Children with high-level lesions tend to roll, and in sitting, lean forward over the legs and combat­crawl. Crawling is really not a viable option unless the child has hip flexor strength and knee extension.