The Efficacy of Orthoses Wear in a Patient with Sacral Level Myelomeningocele: A Case Report and Evidence Based Analysis

Intro: The purpose of this case report was to evaluate the effectiveness during gait of Supra-Malleolar Orthoses (SMO) on a child with sacral level myelomeningocele who lacks normal strength in her lower extremities. A secondary purpose of this case report was to thoroughly review the current available literature regarding commonly used orthoses in children with sacral level myelomeningocele in order to adequately make further recommendations for a new pair of orthoses. Methods: Subject was a 6 year old female with a diagnosis of S1 myelomeningocele, which was present at birth Evaluation and examination was performed by one examiner which was a Physical Therapy student. A clinical instructor observed all sessions with the patient and student. The patient’s lower extremity Range of Motion, muscle strength and sensation were all tested. The patient was also administered the BOT II both while wearing her Supra-Malleolar Orthoses and tennis shoes and in just tennis shoes. A gait analysis was performed at the University of New Mexico Gait Lab using a Vicon Gait Analysis system. The patient was analyzed with in the barefoot condition, as well as with her SMOs and tennis shoes. Sagittal Parameters of the knee and ankle as well as Spatial and Temporal Parameters were measured during the gait analysis. A literature search was conducted using the following databases: Academic Search Complete, PubMed, and Web of Knowledge. A total of 8 articles were reviewed, analyzed and compared to the clinical question presented in the case. Findings: The SMOs were not found to greatly increase the student’s score of the BOT II Examination. During the gait analysis the patient showed an increase in knee extension and dorsiflexion during the stance phase when the SMOs were worn. However, the values were still not enough to provide the patient with normal or near normal ranges. Benefits of the SMOs found during the gait analysis included: more symmetrical values during double limb support, step length, and cadence, increased stride length, increased walking speed. The literature search revealed that many children with sacral level myelomeningocele wear an Ankle-Foot Orthoses (AFO) opposed to any other type of orthotic. The literature also provided a sound argument that an AFO is much more beneficial to a child of this population when compared to the barefoot condition. Various types of AFOs were compared in the literature including: Carbon Fiber Spring AFO, Hinged AFO, Ground Reaction AFO and Solid AFO. The literature lacked in quality RCTs a systematic reviews. Conclusions: The SMOs are not providing the patient with the maximal amount of benefit she needs. A different orthotic such as an AFO would be of much more benefit to this patient and provide her with the support and alignment which she so desperately needs to prevent further impairments and complications. Further higher quality research is needed in the topic of bracing children with sacral level myelomeningocele