meningomyelocele - physical and rehabilitation medicine - rehabilitation
meningomeloocele - medicina física e reabilitação - reabilitação
Myelomeningocele (MMC) is a form of spinal disraphism resulting from a defective closure
of the posterior portion of the neural tube, during the fourth week of gestation[1]. In Brazil, the incidence is 2.28:1,000 births[1]. An MMC frequently results in neuromusculoskeletal complications, including tetra-
or paraparesis, neurogenic bowel and bladder, hydrocephalus and cognitive issues[1],[2],[3]. Many infants do not ambulate during infancy[4],[5],[6] and have difficulty acquiring self-care skills[2],[5]. Musculoskeletal immobility reflects on neuromuscular and cardiovascular systems
and contributes to social and cognitive delays[2],[5].
Bartoneck and Saraste[6] studied 53 children with MMC (3-11 years) to determine whether they achieved the
expected level of ambulation. Thirty-one reached the expected ambulation based on
their motor paresis. However, 22 performed worse than expected, due to balance disturbances
and spasticity. Therefore, children with similar muscle paresis may exhibit different
ambulatory function[6].
After this study, the same center followed 43 children prospectively, from six months
to six years. Walking function was achieved at the one-year follow up in two children;
at the two-year follow up in 14; at the four-year follow up in 28; and at the six-year
follow up in 30 children. At the six-year follow-up, all children used orthoses, and
nine had not achieved the level expected, based on muscle function[7]. Although non-ambulating children had greater neurological and orthopedic symptoms,
parents (including those of ambulating and non-ambulating children) reported a similar
quality of life[8].
Trunk control is essential for the acquisition of a sitting position, which allows
bimanual skills development[9]. The standing position is adopted passively, with orthotic devices, when the child
does not have the strength to stand on his/her own[5],[9]. Conventional physical therapy (CPT) is usually performed with the aim of keeping
the lower extremities aligned and to compensate for motor deficits in children with
MMC[9].
Prior studies have shown that lower limb weakness is related to worse ambulatory function[10]; however, strength training usually emphasizes the upper limbs and trunk. Although
advances in multidisciplinary treatment of children with MMC have led to improvement
in functional outcome, early clinical therapeutic interventions that might help infants
acquire stronger or better functional control of their lower limbs have been neglected.
Ultrasound examinations of fetuses with MMC indicated the presence of hip and knee
flexion and extension movements[11]. The presence of motor evoked potentials on the lower limbs suggests that there
is excitable neural tissue below the level of malformation, including in the case
of complete lower limb plegia[12]. The preservation of motor neurons can be explained by the fact that MMC results
from the exposure of the dorsal part of the neural tube. Thus, the cells from the
ventral horn of the spinal cord would be less affected, allowing lower limb motor
activity.
Upper and lower limb synchrony patterns have also been described as lasting longer
than isolated movements. Although this leg activity would be expected to increase
in the weeks after birth, it usually decreases[12]. Taken together, these data indicate the presence of some neural activity in plegic
muscles and the possibility of the preservation of sensory-motor spinal cord structures.
Considering that sensory and motor structures may be partially intact in babies with
MMC, even when there is no function, it is possible that physical therapy could help
not only in maintaining, but also in optimizing the sensory-motor function. Infants
with MMC responded to the treadmill practice by stepping (but less so than infants
with typical development) and showed increased motor activity, although they demonstrated
a different developmental trajectory[13]. In this case, reflex stimulation, based on the Proprioceptive Neuromuscular Facilitation
technique (PNF), could also be useful to improve motor function.
The PNF principles postulated that movement patterns, performed with facilitatory
procedures (such as sensory information), would result in enhanced voluntary responses.
The PNF technique was developed to strengthen muscles in the mass movement patterns
in which they function. Patterns are spiral and diagonal and closely resemble functional
movements in daily life. Manual contact facilitates underlying muscles and applies
resistance to activate muscle spindles. When it is not possible to apply resistance,
passive or assisted movements are recommended[14]. According to Voss, Ionta and Myers[14], sensory stimulation provides the best possible motor response. Labyrinthine reflexes
can be used to increase muscle tone and recruitment.
Sá, Santos and Xavier[15] described a three-month program with 30-minute sessions, twice a week for children
with cerebral palsy. One group was treated with PNF and another group with the Bobath
technique. Children treated with PNF had greater sensory-motor improvement.
Britto, Correa and Vincent[16] investigated the effect of PNF on muscle tone, low back pain, functional performance
and gait speed in adults with myelopathy. They included two PNF techniques (rhythmic
initiation and a combination of isotonics)[14]to facilitate rolling, sit-to-stand, walking and stair climbing. Patterns were rolling
supine to lateral, transition from sitting to standing, standing on one leg, weight
shifting forward and backward, walking forwards, backwards and sideways, going up
and down stairs[14]. The PNF improved muscle tone, low back pain, functional performance and gait speed[16].
No studies have tested the effects of physical therapy with reflex stimulation (RPT),
based on PNF, in children with MMC and only two mention this approach in children
with cerebral palsy[15],[17]. Children with MMC might benefit from RPT, considering the evidence presented above[11],[12],[13]. We hypothesized that RPT might provide experience and input relevant to, and usable
by, the neuromotor systems of infants with incomplete spinal lesions.
Our goals were to 1) investigate whether infants with MMC would improve their functional
activity (measured by the Gross Motor Function Measure) and/or functional independence
(measured by the Pediatric Evaluation of Disability Inventory) after ten sessions
of physical therapy; 2) compare the outcomes of CPT and RPT and 3) examine the relationship
between functional independence and motor function.
METHODS
Twenty children diagnosed with MMC participated in this experimental study. They were
separated into categories according to their MMC level. The Hoffer classification
system[18] was used to define lesion levels as thoracic (no sensation below the hips and no
strength in hip muscles); upper lumbar (some sensation below the hips, some strength
in hip adductors/flexors, or in knee extensors); lower lumbar (strength in knee flexors,
ankle dorsiflexors, or hip abductors); and sacral (strength in ankle plantiflexors,
or in hip extensors).
The children were randomly enrolled into an experimental (RPT) or control group (CPT).
This study was approved by the Ethics Committee of Faculdade de Medicina da Universidade
de São Paulo (number 285/10, 09/29/2010). Parents gave written consent to the children
to participate. Eight children did not complete the study, due to social difficulties
(difficulties in taking public transportation) or clinical complications (infection).
All infants had hydrocephalus, with a ventriculoperitoneal shunt and urinary and fecal
incontinence. The mean age was 18.2 ± 15.6 months in the RPT group and 18.3 ± 12.4
months in the CPT group.
Motor function was assessed by the Gross Motor Function Measure[19]. Although the use of the Gross Motor Function Measure in children with spinal dysraphism
has not been validated, it is the most-used scale in the literature. It has been used
to measure the motor function of children with cerebral palsy, Down syndrome and spinal
cord diseases[20],[21]. The Gross Motor Function Measure consists of 88 items grouped in five dimensions:
lying and rolling; sitting; crawling and kneeling; standing; walking, running and
jumping. Items are scored on a four-point ordinal scale. Scores for each dimension
are expressed as a percentage of the maximum score. A total score is obtained by adding
the percentage of each dimension and dividing by five. Partial scores can also be
calculated by adding the percent scores of two or more dimensions and dividing by
the number of dimensions used[19]. In children who are unable to cooperate, scoring is based on the examiner’s observation.
The examiner can assist the child in assuming the initial testing position and observe
movement patterns and the ability to overcome gravity.
The Pediatric Evaluation of Disability Inventory measures functional status in children
between six months and seven-and-a-half years in three domains: self-care, mobility,
and social function. It consists of an interview with the parents about the functional
independence of the child. Numerous studies have examined the sensitivity of tests
to identify changes during the recovery from brain or spinal injury[5],[22],[23]. In this study, we used the scaled scores of the Pediatric Evaluation of Disability
Inventory.
Intervention
Children were randomly selected for the two treatment alternatives. We treated six
children with RPT and six with CPT. Interventions consisted of ten 45-minute weekly
sessions, performed by the same physical therapists. A blind examiner assessed all
children before and after treatment.
The CPT interventions centered on optimizing mobility and maximizing independence.
Sessions consisted of muscle strengthening, enhancing postural control and correcting
positioning with orthotic devices. Muscle strengthening consisted of 10 to 30 repetitions
of isotonic contractions of shoulder flexors, extensors, abductors, internal and external
rotators, elbow flexors and extensors, with the child in a sitting position on the
mat or chair. Trunk flexors and extensors were solicited with the child in a supine
or prone position[23],[24]. Children who could not cooperate due to their age or cognitive impairment were
assisted by the therapist (active-assisted mobility).
Postural control was trained by postural maintenance for as long as possible, (e.g. sitting, crawling, kneeling, standing), and postural changes (e.g. rolling, transition from supine to sitting, from prone to crawling, from sitting
to crawling, from crawling to kneeling). Three to ten repetitions of each transition
were performed in each session. Therapists helped children perform the transitions
when necessary. Children unable to sit without support were not positioned kneeling.
The correct positioning aimed to optimize motor function, and deformities were prevented
with orthotic devices.
The RPT aimed to help the initiation of postural changes as well as the maintenance
of different postures. Myotatic reflexes were obtained by muscle stretching before
and during the contraction of the muscle belly or by tendon percussion. Skin receptors
were stimulated by manual contact on the cutaneous region related to the specific
muscle or motion desired, joint approximation or traction, and diagonal and rotational
movement patterns[14]. Passive and assisted phases of rhythmic initiation stimulated rolling, sitting
and crawling[14],[16]. Manual assistance was performed on a minimum of two muscles or muscle regions,
with a minimum of five repetitions, in every session.
Righting reactions were used in the RPT[14]. Vestibular stimulation facilitated extensor muscles, and was performed by inclining
the child to the side, starting from the upright sitting position. Three to five lateral
inclinations were performed on each side. Children were positioned in prone on a ball
and stimulated to resist the gravity force and, if possible, manual resistance of
the therapist on the upper or lower trunk, to radiate muscle recruitment to the lower
limbs. Movements were passive and assisted whenever possible[14],1516,[17]. Five to ten trunk extensions were performed. Attention was paid to the appropriate
body position to facilitate the child’s movement[14].
Parents of children in both groups were taught home exercises programs, based on the
training during therapy sessions. They were encouraged to practice the exercises for
15 to 20 minutes daily.
Statistical analysis
Non-parametrical tests were used due to the small number of children in each group
and to non-normally distributed data. Mann-Whitney tests investigated possible differences
in the improvement in the Gross Motor Function Measure and the Pediatric Evaluation
of Disability Inventory between the groups (CPT and RPT). Wilcoxon tests compared
the performance of each group before after the treatment. Spearman’s correlation tests
investigated possible relationships between the Gross Motor Function Measure and Pediatric
Evaluation of Disability Inventory scores. The significance level was 0.05.
RESULTS
As most patients in both groups scored zero on initial and final assessments for standing
and walking, running, and jumping on the Gross Motor Function Measure, the score ABC
[(sum of domains A, B and C)/3] was used. [Table 1] shows the children’s characteristics and scores.
Table 1
Gender, age, neurological level of myelomeningocele and respective scores (in percentage)
on Gross Motor Function Measure of each child treated with RPT or CPT obtained on
assessments 1 (before treatment) and 2 (after treatment).
Group/ subject
|
Gender
|
Age (months)
|
Neurologial level
|
Assessment 1
|
Assessment 2
|
|
|
A
|
B
|
C
|
D
|
E
|
ABC
|
Total
|
A
|
B
|
C
|
D
|
E
|
ABC
|
Total
|
RPT
|
C.
|
m
|
22
|
High lumbar
|
73.0
|
42.0
|
12.0
|
0.0
|
0.0
|
42.0
|
25.0
|
89.0
|
70.0
|
20.0
|
5.0
|
0.0
|
59.0
|
27.0
|
J.
|
m
|
48
|
High lumbar
|
70.6
|
35.0
|
7.1
|
0.0
|
0.0
|
37.0
|
22.0
|
88.2
|
53.3
|
7.1
|
0.0
|
0.0
|
49.0
|
29.0
|
N.
|
f
|
7
|
Low lumbar
|
51.0
|
28.3
|
0.0
|
0.0
|
0.0
|
26.0
|
15.0
|
72.5
|
38.3
|
0.0
|
0.0
|
0.0
|
36.0
|
22.0
|
K.
|
m
|
7
|
Low lumbar
|
64.7
|
16.7
|
0.0
|
0.0
|
0.0
|
27.0
|
16.0
|
96.1
|
71.7
|
0.0
|
0.0
|
0.0
|
55.0
|
33.0
|
L.
|
f
|
10
|
Sacral
|
72.5
|
40.0
|
0.0
|
0.0
|
0.0
|
37.0
|
22.0
|
90.2
|
53.3
|
2.4
|
2.6
|
0.0
|
48.0
|
29.0
|
J.
|
f
|
20
|
Sacral
|
100.0
|
88.5
|
57.1
|
5.1
|
0.0
|
82.0
|
50.0
|
100.0
|
91.7
|
62.0
|
10.3
|
5.6
|
84.0
|
54.0
|
Median
|
71.6
|
37.5
|
3.6
|
0.0
|
0.0
|
37.0
|
22.0
|
89.6
|
61.7
|
4.8
|
1.3
|
0.0
|
52.0
|
29.0
|
CPT
|
A.
|
m
|
3
|
High lumbar
|
19.6
|
15.0
|
0.0
|
0.0
|
0.0
|
11.0
|
7.0
|
49.0
|
23.3
|
0.0
|
0.0
|
0.0
|
24.0
|
14.0
|
G.
|
m
|
37
|
High lumbar
|
88.2
|
75.0
|
21.4
|
0.0
|
0.0
|
61.0
|
36.0
|
88.2
|
85.0
|
21.4
|
0.0
|
0.0
|
65.0
|
39.0
|
I.
|
f
|
6
|
Low lumbar
|
29.4
|
18.3
|
0.0
|
0.0
|
0.0
|
16.0
|
9.0
|
70.6
|
31.7
|
0.0
|
0.0
|
0.0
|
34.0
|
20.0
|
L;
|
m
|
20
|
Low lumbar
|
100.0
|
81.7
|
0.0
|
0.0
|
0.0
|
60.0
|
36.0
|
100.0
|
86.7
|
62.0
|
5.1
|
1.3
|
82.0
|
51.0
|
N.
|
f
|
21
|
Sacral
|
95.0
|
52.3
|
10.0
|
0.0
|
0.0
|
52.0
|
31.0
|
100.0
|
75.0
|
10.0
|
10.0
|
0.0
|
61.0
|
39.0
|
M.
|
f
|
24
|
Sacral
|
98.0
|
77.9
|
38.1
|
0.0
|
0.0
|
71.0
|
42.0
|
100.0
|
86.7
|
54.8
|
10.3
|
1.4
|
80.0
|
50.0
|
Median
|
91.6
|
63.7
|
5.0
|
0.0
|
0.0
|
56.0
|
33.5
|
94.1
|
80.0
|
15.7
|
2.6
|
0.0
|
63.0
|
39.0
|
RPT: reflex physical therapy group; CPT: conventional physical therapy group; f: female;
m: male; ABC Score: mean score (in percentage) of domains A, B and C of the gross
motor function measure; total score: mean score (in percentage) of all domains of
the gross motor function measure.
In the CPT group, domain A of the Gross Motor Function Measure improved from 91.6
to 94.1 (2.5%) and domain B from 63.7 to 80.0 (16.3%). In the RPT group, domain A
improved from 71.6 to 89.6 (18.0%) and domain B improved from 37.5 to 61.7 (24.2%).
Individual findings of the scaled scores on the Pediatric Evaluation of Disability
Inventory before and after treatment are shown in [Table 2]. Wilcoxon tests compared the performances before and after treatment for each group.
Both groups showed significant improvement on all items, except on social function
([Table 3]).
Table 2
Gender, age, neurological level of myelomeningocele and respective scaled scores on
functional skills of the Pediatric Evaluation of Disability Inventory (PEDI) of each
child treated with RPT or CPT obtained on assessments 1 (before treatment) and 2 (after
treatment).
Group/ subject
|
Gender
|
Age (months)
|
Neurologial level
|
Assessment 1
|
Assessment 2
|
|
|
SC
|
MO
|
SF
|
SC
|
MO
|
SF
|
RPT
|
C.
|
m
|
22
|
High lumbar
|
34.1
|
11.4
|
31.6
|
44.4
|
15.2
|
42.5
|
J.
|
m
|
48
|
High lumbar
|
37.8
|
30.6
|
14.7
|
39.6
|
32.0
|
34.0
|
N.
|
f
|
7
|
Low lumbar
|
29.4
|
6.1
|
35.1
|
34.1
|
11.4
|
35.1
|
K.
|
m
|
7
|
Low lumbar
|
28.0
|
11.4
|
31.6
|
42.0
|
18.2
|
42.5
|
L.
|
f
|
10
|
Sacral
|
34.1
|
11.4
|
21.6
|
44.4
|
15.2
|
45.0
|
J.
|
f
|
20
|
Sacral
|
39.6
|
32.0
|
39.6
|
45.2
|
35.9
|
46.2
|
Median
|
34.1
|
11.4
|
31.6
|
43.2
|
16.7
|
42.5
|
CPT
|
A.
|
m
|
3
|
High lumbar
|
11.8
|
0.0
|
14.7
|
26.2
|
6.1
|
14.7
|
G.
|
m
|
37
|
High lumbar
|
41.2
|
32.0
|
47.9
|
48.9
|
33.4
|
56.0
|
I.
|
f
|
6
|
Low lumbar
|
21.4
|
6.1
|
27.2
|
26.2
|
11.4
|
30.0
|
L;
|
m
|
20
|
Low lumbar
|
39.6
|
34.7
|
41.8
|
45.2
|
40.3
|
41.8
|
N.
|
f
|
21
|
Sacral
|
39.6
|
32.0
|
41.8
|
45.2
|
33.4
|
41.8
|
M.
|
f
|
24
|
Sacral
|
50.3
|
33.4
|
47.9
|
56.2
|
47.0
|
53.7
|
Median
|
39.6
|
32.0
|
41.8
|
45.2
|
33.4
|
41.8
|
RPT: reflex physical therapy group; CPT: conventional physical therapy group; f: female;
m: male; SC: self-care; MO: mobility; SF: social function.
Table 3
Results of the Wilcoxon tests. The score on assessment 2 (after treatment) was compared
to assessment 1 (before treatment).
Variable
|
GMFM_T
|
GMFM_ABC
|
PEDI_SC
|
PEDI_MO
|
PEDI_SF
|
RPT
|
p-value
|
0.04
|
0.04
|
0.04
|
0.04
|
0.06
|
CPT
|
p-value
|
0.04
|
0.04
|
0.04
|
0.04
|
0.10
|
RPT: reflex physical therapy; CPT: conventional physical therapy; GMFM_T: total score
on GMFM; GMFM_ ABC: score on domains A, B and C of GMFM [(domain A+ domain B+ domain
C) /3]; PEDI: pediatric evaluation of disability inventory; PEDI_SC: self-care section
of PEDI; PEDI_MO: mobility section of PEDI; PEDI_SF: social function section of PEDI.
The Mann-Whitney U test showed no significant difference between the groups on the
Gross Motor Function Measure (total score: U = 9.0, p = 0.54; score ABC: U = 11.0,
p = 0.84). The Mann-Whitney U test also showed no significant difference on the Pediatric
Evaluation of Disability Inventory (self-care: U = 9.5, p = 0.55; mobility: U = 8.0,
p = 0.42; social function: U = 5.0, p = 0.15).
A possible relation between the two scales (Gross Motor Function Measure and Pediatric
Evaluation of Disability Inventory) was investigated with Spearman’s non-parametric
tests. Since there were no differences between the groups, all twelve of the patients
were analyzed together. There were strong correlations between the Gross Motor Function
Measure and Pediatric Evaluation of Disability Inventory scores ([Table 4]).
Table 4
Results of the non-parametrical Spearman’s correlations tests. There were strong correlations
between parts A and B and average ABC of Gross Motor Function Measure (GMFM) and the
sections of total scores of Pediatric Evaluation of Disability Inventory (PEDI).
Variable
|
Assessment 1 (before treatment)
|
Assessment 2 (after treatment)
|
|
|
GMFM_A
|
GMFM_B
|
GMFM_ABC
|
GMFM_A
|
GMFM_B
|
GMFM_ABC
|
PEDI_SC
|
0.87
|
0.87
|
0.86
|
0.86
|
0.90
|
0.92
|
PEDI_MO
|
0.96
|
0.92
|
0.94
|
0.91
|
0.94
|
0.94
|
PEDI_SF
|
0.84
|
0.84
|
0.82
|
0.77
|
0.84
|
0.87
|
PEDI_TOTAL
|
0.88
|
0.88
|
0.86
|
0.86
|
0.90
|
0.93
|
GMFM_A: score on domain A of GMFM; GMFM_B: score on domain B of GMFM; GMFM_ABC: score
on domains A, B and C of GMFM [(domain A + domain B + domain C)/3]; PEDI_SC: self-care
section of PEDI; PEDI_MO: mobility section of PEDI; PEDI_SF: social function section
of PEDI; PEDI_TOTAL: total score of functional skills parts of PEDI.
DISCUSSION
Two treatment protocols for children with MMC were compared: CPT and RPT. In both
groups, postural control improved, mainly in prone, supine and sitting. The CPT group
probably improved this control with adaptations (joint stabilization with orthoses[23],[24], range of motion maintenance[23]) and compensations (stimulation of movements and weight bearing with lower limbs[23]). Training was primarily directed to strengthen and optimize the preserved sensorimotor
functions[24] and took advantage of cognitive abilities, stimulating the child to cooperate during
the exercises whenever possible.
The RPT aimed to facilitate the conduction of stimuli from the extremities to the
cortex by the remaining afferent pathways. In the RPT group, there was possibly an
increase of peripheral sensory information. This increase in sensory information arriving
at the cortex is important to improve sensory-motor integration and the quality of
motor responses.[25] Conversely, improvement in muscular recruitment could explain gains in postural
changes after CPT. Reflex physical therapy can be performed without the cooperation
of the patient and may be a good alternative in patients 0–2 years, or for patients
with cognitive impairment.
No significant differences were found between CPT and RPT. It is possible that CPT
optimized motor strategies of the trunk and upper limbs to compensate for the loss
of lower limb control. Conversely, RPT could favor better lower limb control. Both
protocols may have resulted in higher activation of the remaining spinal interneurons,
or of cortical neuronal networks. It is interesting to note that, although we analyzed
a relatively short period of treatment (10 weeks), we detected significant improvement
in both groups.
According to Muir and Steeves26 and Raineteau and Schwab[27], the improvement of functional recovery after spinal injuries depends on reorganization
of undamaged neural pathways. This could enhance the limited ability of neurons to
restore damaged connections between the spinal cord and brain[26],[27]. Spinal cord circuits are capable of significant reorganization induced by both
activity-dependent and injury-induced plasticity. Regenerating spinal tract fibers
needs functional training to make the appropriate connections, and training effects
are enhanced by regenerating fibers[25]. This would result, for instance, in a better impulsion for rolling, or in a better
fixation of the lower limbs during the transition from lying to sitting. In fact,
as shown in [Table 1], these skills of the Gross Motor Function Measure improved 2.5% in the CPT on domain
A, which assesses lying and rolling, and 16.3% on domain B, which assesses sitting.
In the RPT, these skills improved 18.0% on domain A and 24.2% on domain B.
Plasticity after spinal cord injury can be initiated by specific patterns of sensory
feedback, leading to a reorganization of spinal and cortical networks26. Many rehabilitation approaches focus on the exploitation of spinal cord plasticity
below the level of lesion, for example, by locomotor training. Protocols with spinal
injury patients showed that training can improve the functional locomotor abilities.
This plasticity becomes even more evident in the ability of spinalized animals to
regain a certain degree of motor function[25]. Additionally, Pantall et al.[28] verified that increased sensory feedback improved the step pattern of children with
MMC who walked on a motorized treadmill.
Recently, Heathcock et al.[29] proposed treadmill training for toddlers with spinal cord injury before the onset
of walking. They reported the intervention and stepping behaviors, on a treadmill
and on the ground, of a toddler after the surgical removal of a rare spinal tumor
resulting in spinal cord injury. The toddler presented with an inability to step on
the left, rare stepping on the right, and an apparent lack of sensation in the lower
extremities. Step training on a treadmill and on the ground occurred once a week from
15 to 35 months of age. Independent symmetrical stepping emerged both on and off the
treadmill over 20 months. Walking speed increased, and milestones important to ground
walking developed. Independent steps developed during the intervention with little
sensory and motor development of the lower extremities during the first year of life[29].
Very few studies discuss the dosing of physical therapy for MMC treatment. Karmel-Ross
et al.[30] reported the positive effect of electrical stimulation applied to the quadriceps
femoris in conjunction with walking and standing activities for 30 minutes sessions,
six times per week for eight weeks[30]. The present study reached positive results in 45 minutes per week for 10 weeks.
Also in our study, both groups’ parents were taught an individualized program of home
exercises and encouraged to practice them for 15 to 20 minutes daily.
The present study shows strong correlations between the Gross Motor Function Measure
and the Pediatric Evaluation of Disability Inventory scores for both groups. We believe
that the improvement in motor function resulted in a higher functional independence.
Danielsson et al.[5] found reduced muscle strength and occurrence of spasticity around the hip and knee
affected ambulation, functional mobility and self-care (measured by the Pediatric
Evaluation of Disability Inventory). They also concluded that patients with reduced
functional mobility and self-care experienced a lower physical quality of living.
The Gross Motor Function Measure scores may indirectly reflect muscle strength and
spasticity. As a limitation of the present study, we must mention that we did not
measure the amount of tactile or proprioceptive stimulation of the lower limbs reaching
the cortex. However, previous studies have reported that part of these pathways is
intact in many patients[11],[12]. Besides, both protocols offered vestibular stimuli and all kinds of sensory stimuli
in the upper limbs, which could have helped sensory-motor integration in the spine
and cortex.
Another limitation is that the scales used in the present study do not allow the differentiation
of automatic and voluntary control, nor the differentiation of upper limb, lower limb,
or trunk movements. We believe that the global automatic and voluntary controls have
improved, because the performance on tasks that involve weight bearing, such as rolling
and crawling showed improvement.
We must also mention that the groups had a small number of patients with heterogeneous
clinical features due to the low prevalence of MMC. Furthermore, a control group (with
no intervention) was not compared, because we believe it would be unethical to follow
a group with no therapy. We must also consider age perspective in a child’s development
over ten weeks, which may have influenced our results.
In conclusion, two different physical therapy protocols resulted in motor and functional
improvement in children with MMC. The gains in motor ability were associated with
a better functional status. Further studies are necessary to improve physical therapy
techniques for children with MMC as well as to verify the benefits of physical therapy
based on the PNF concept in the treatment of children with neurological dysfunctions.