MOBILITY AIDS FOR CHILDREN WITH HIGH-LEVEL MYELOMENI NGOCELE: PARAPODIUM VERSUS WHEELCHAIR

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Myelomeningocele (MM) is a serious, complex birth-defect characterized by impaired mobility. Options available for improving the mobility of children with MM include wheelchairs (Butler et al. 1983, Shurtleff 1986, Trefler 1987) and devices that provide both support and mobility. This second category includes braces that support the legs individually, allowing reciprocal movement, such as the hip-knee-foot orthosis (HKAFO)(Cane 1969, Menelaus 1980, Asher and Olson 1983), and the reciprocating gait orthosis (Yngve et al. 1984, McCall and Schmidt 1986); or braces that support both legs as a unit and allow mobility by means of swing-through or swivelling, such as the parapodium (Gram et al. 1981, Rose et al. 1983, Lough and Nielsen 1986). The choice of a mobility device may have other implications for the care of the child. For example if children are oriented to an upright posture, greater emphasis may be placed on the correction and prevention of lower-extremity contractures by surgical intervention, bracing and physical therapy. For children in wheelchairs, less emphasis may be placed on the control of contractures and more on learning activities of daily living, such as independent dressing and toileting. The following are common arguments in favour of the two approaches: (1) Children using the parapodium will have less reflw and hydronephrosis than

children using the wheelchair, because the upright posture will promote better drainage of the urinary tract. (2) Children using the wheelchair will have more skin breakdown than children using the parapodium because of longer periods sitting. (3) Children using the wheelchair will have worse hip-flexion contractures than those using the parapodium because they spend more time with their hips flexed (Shurtleff et al. 1986). (4) Children using the parapodium will be more likely to have dislocated hips than those using the wheelchair because children who are upright have a greater load on their hips. ( 5 ) Children using the parapodium will have fewer pathological fractures than those who use the wheelchair because standing helps bone growth and mineralization (Anscheutz et al. 1984, Mazur et al. 1989). (6) Children using the parapodium will be less obese than those using the wheelchair because they expend more energy to cover the same distance (Evans and Tew 1981, Agre et al. 1987). (7) Children using the parapodium will have more stool and urinary incontinence than children using the wheelchair: parents and children report that fecal and urinary accidents increase when children with M M are upright and active. (8) Children using wheelchairs will engage

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in more sports and extracurricular activities than those using the parapodium because wheelchairs allow children more functional independence and greater speed, and because programs that emphasize the wheelchair promote greater involvement in these activities. (9) Children using wheelchairs will provide more independent care of themselves than those using the parapodium because programs that emphasize the wheelchair also emphasize activities of daily living, as opposed to range-ormotion exercises. (10) Children in programs that rely on the wheelchair will need less orthopedic surgery, since maintaining alignment of the hips, knees, ankles and feet is less important than it is for those in the upright posit ion. In spite of these claims, the ideal program for helping young children with MM achieve independence through mobility is uncertain and controversial, with very little scientific evidence that one type of mobility device has advantages over another. The purpose of this study was to evaluate the effects of the parapodium and the wheelchair 'on the functional status of children with MM.

Material and method

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Patient population The Easter Seal Center for Strong Children of the University of Rochester, Rochester, New York, provides care to over 98 per cent of the children with MM in an ll-county region of New York State. This program has advocated early, exclusive use of the parapodium for children for the past 20 years. Children with MM were identified who had a thoracic or high-lumbar lesion and who had been born between January 1970 and June 1984, had used the Rochester parapodium, a standing brace with joints in the region of the hips and knees (Gram et al. 1981), and had survived past the age of three years. All but three families who were offered the parapodium accepted during this period. Children who had additional disorders, such as a major medical problem (e.g. cardiac disease or chromosome anomaly), or who had an IQ of < 65-usually a result of ventriculitis-

were excluded from the study, even if they had used the parapodium. Of the original 45 children meeting these criteria, 40 were available for follow-up (two died after three years of age and three had moved out of the region). Thirty-nine of these 40 families agreed to participate in the study and were matched with children from the Birth Defects Clinic of the University of Washington, which treats children from five states in the northwest United States. This program offers a similar team approach to the care of children with MM to that offered by the Rochester program. However, children in Seattle are introduced to the wheelchair as the only initial means of mobility, with no attempt at standing. Matching was done for the following criteria: diagnosis, gender, age within 12 months, IQ within 15 points, and functional motor level of lesion (Sharrard 1964) within one vertebra. 29 children from Seattle were successfully matched with 29 children from the Rochester program; there were no matched cases available for 10 of the children from Rochester.

Data collection Data were collected using the International Myelodysplasia Study Group Protocols (IMSG) (Shurtleff 1986, Mazur et al. 1989). These examinations and interviews, which have written guidelines, have been standardized and pretested, and were performed during regular visits. Data not routinely collected by the IMSG protocols were obtained from special examinations, including standardized developmental tests (such as the StanfordBinet and WISC-R), a parental interview, which had been pretested on a sample from Rochester, and review of medical records (outpatient and inpatient, from all hospitals that had treated the children). Data were collected over an 18-month period. In order to standardize data collection, the pediatrician, physical therapist and occupational therapist from Rochester had collaborative discussions with their counterparts in Seattle and observed children being tested in Seattle with the IMSG protocols. The physical therapists from both programs also performed simultaneous examinations on a group of

TABLE I Comparison of selected study variables Variable

Mean age (SD) N female (070) N white (070) N children in household (SD) Mean education level of parents (SD) Mean IQ (SD) Motor level* (SD) Sensory level* (SD) N shunted (070)

Rochester (N= 39)

(N= 29)

Seattle

10.3 (4.0) 23 (59) 35 (90) 2.8 (1.4) 13.2 (1.8) 81 (14) 3.9 (2.6) 2.6 (1.7) 33 (84)

1 1 . 1 (4.3) 17 (59) 28 (96) 3-1 (2-1) ,13-3 (1-6) 89 (15) 4.1 (2.6) 2.8 (2.4) 24 (83)

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NS NS NS NS NS NS NS

*Corresponds approximately to LI level.

patients in Seattle, with an inter-observer agreement of 97 per cent.

Data management and analysis Data obtained from the IMSG protocols and other examinations and questionnaires were entered on R-Base (Microrim, Redmond, Washington), then exported to the Statistical Package for the Social Sciences (SPSS 1986) for statistical analyses. These included determination of arithmetic means and standard deviations, twotailed paired t tests, two-tailed grouped t tests, x2 analysis, step-wise linear multiple regression and Pearson correlation coefficients. The occurrence of statistically significant differences between the two groups using paired 1 tests for the 29 pairs was identical to that found using grouped data (39 children in Rochester and 29 in Seattle). p values from t tests reported in this paper will be those from the grouped t tests.

Results Sample characteristics A comparison of selected variables is shown in Table I. There were no significant differences between the children from Rochester and Seattle for those variables. None of the children from Rochester had deterioration of muscle strength; two children from Seattle had deterioration, one of whom had had surgery for a tethered spinal-cord. The usual place of dwelling was categorized as mobile home, apartment or permanent residence: the respective numbers of children from Rochester were 5, 10

and 85 per cent; and 28, 14 and 57 per cent for Seattle. Thus children from Seattle were more likely to dwell in mobile homes or apartments than their counterparts in Rochester (x2=7.91, p=O-O2). Families were asked about their children's participation in early intervention programs. All the children from Rochester and Seattle had some form of pre-kindergarten intervention that included either physical or occupational therapy. At the time of the study, 50 per cent of the children from Seattle were receiving regular physical therapy, compared with 79 per cent of the children from Rochester @=0.01); 34 per cent of the children in Seattle were receiving occupational therapy, compared with 26 per cent from Rochester @= 0.63); most of the children were receiving their therapy services in the public schools-94 per cent in Seattle and 77 per cent in Rochester (p= 0.06). A subset of 22 questions, administered as part of the parental interview, was taken from the Home Observation for Measurement of the Environment (HOME) scale (Caldwell and Bradley 1978, Bradley and Caldwell 1980), an instrument which assesses environmental stimulation. The mean score for this subset of questions was 8.0 for Rochester and 8.2 for Seattle @=0.55).

Use of mobility device Children in Rochester began using the parapodium at a mean age of two years, averaging four hours a day, and continued using it for an average of five years. No child used a wheelchair while

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using the parapodium. At the time of the study, 59 per cent of the children from Rochester had discontinued using the parapodium and were using HKAFOs and/or wheelchairs. Children in Seattle began using the wheelchair at a mean age of three years, averaging eight hours per day, and continued using it for an average of seven years. At the time of the study, all but one of the children from Seattle were using wheelchairs.

Renal health and skin breakdown Hydronephrosis, determined by renal ultrasound or intravenous pyleography, occurred in 25 per cent of the children from Rochester and 24 per cent of those from Seattle. Vesico-ureteral reflux, graded according to the international classification system (Levitt 1981), was determined from voiding cysto-urethrography. 34 per cent of the children from Rochester and 32 per cent of those from Seattle had reflux on either side; 25 and 21 per cent, respectively, had reflux greater than grade 1 on the worse side. None of these differences was statistically significant. Children from Rochester had had an average of 5.9 episodes of skin breakdown since birth, compared with 5.3 episodes for the children from Seattle. No significant differences were found in the severity (Shea 1975) of the skin lesions. However, the Rochester children were more likely to develop skin breakdown of the foot and distal lower extremity (54 per cent for Rochester vs. 36 per cent for Seattle), whereas children from Seattle were more likely to develop skin breakdown of the sacrum, ischium and perineum (24 per cent for Rochester vs. 35 per cent for Seattle) (x2=7.5,p 25" was examined. However, 62 per cent of the children from Rochester had dislocation of either hip on clinical and radiological examination compared with 38 per cent of those from Seattle @= 0.05). The mean maximum extension of both knees (where 0" is complete extension) was 8" for children from Rochester and 17.2" for children from Seattle (p=O*Ol). 42 per cent of the children from Rochester had a flexion contracture of 2 1 5 " for either knee, compared with 69 per cent of the children from Seattle (x2= 4.82, p < 0.05). The mean number of fractures sustained since birth was 1.1 for children from Rochester and 1.2 for children from Seattle, with 46 per cent of the entire sample having had at least one fracture since birth. The distribution of fractures was the same for both groups; 59 per cent of tlje fractures in children from Rochester were of the femur and 40 per cent of the tibia and/or fibula, compared with 61 per cent and 38 per cent, respectively, for Seattle. None of these differences was statistically significant.

Obesity and extracurricular activities Skinfold thicknesses of the triceps and subscapular areas were assessed using a 60mm manual skinfold caliper, and a centile for age was derived (Cronk and Roche 1982). Arm-span, which has been shown to be a valid measurement of growth velocity in children with MM (Rosenblum et al. 1983, Belt-Niedbala et al. 1986), was assessed using a metal rule. The mean skinfold centile-by-age was 62 for children in Rochester and 59 for those in Seattle; weight centile-by-age (Hamill et al. 1979) was 41 for children from Rochester and 31 for those from Seattle. Neither of these differences was statistically significant. The mean weight centile-by-arm-span for children in Rochester was 53, versus 32 for those from Seattle (p =0-04). Approximately

TABLE I1 Comparison of selected measures of independence Variable

Independence score*

Cleaning and adjusting braces Dressing Transferring to chair Transferring to toilet Ability to attend to own Bowel function Bladder function Total N ADLs Percentage of expected ADLs

p

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Seattle

2-9 2.2 1.5 3.1

2.3 1.8 1-2 2.6

NS NS NS NS

3.2 3.8 19.5 87.3

3.1 3.1 21-1 83.6

NS NS NS NS

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*The higher the number, the greater the independence.

26 per cent of the children from Rochester had a weight centile-by-arm-span of > 95, compared with 4 for Seattle (x2=5.15, p=0*02). No significant differences were found in the percentage of children from Rochester or Seattle who participated in sports (41 vs. 48) or in other extracurricular activities, such as scouts or clubs (23 vs. 20). However, the mean number of hours spent watching television in a twoday period was 4.8 for children from Rochester and 3.4 for those from Seattle 0,= 0.03). The correlation betwen time spent watching the television and weight centile-by-arm-span was 0.20 0,= 0.06). The correlations between time spent watching television and weight centile-byage and skinfold centile were 0.34 and 0.41, respectively (p=O.Ol for both correlations). Using step-wise multiple linear regression equations with the three measures of obesity as dependent variables, and time spent watching television, level of lesion, gender and socio-economic status as independent variables, the only variable correlated highly enough (at p 3 hrs Transporting device

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2-86 3-33 3- 14 2-80 2.72 2.58 2-31 2.26 2.82

2.17 1.58

NS 0.01

2.04

0.002

1.80 1.77 2.00 1.72 1.70 2.78

0.003 0.005 0.05 0.04

NS NS

*Scored 1 to 5: 1 =extremely easy and 5 = extremely difficult.

from Seattle had an average of slightly more hzspital admissions over their lifetime, the difference was not statistically significant. Children from Seattle were more likely to visit the Emergency Department while children from Rochester were more likely to make unscheduled visits to their primary-care physicians for acute problems. Thirty-five per cent of all orthopedic procedures were performed on the foot or ankle, 45 per cent on the hip or proximal femur and 14 per cent on the back. The distribution of these procedures was virtually identical for both groups.

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Evaluation of mobility aids Families were asked about the difficulties their children had encountered with their mobility aids. Neither group had had

difficulty on wood or linoleum floors; however, 66 per cent of those who used the parapodium said they had difficulty on carpets or shag-pile rugs, compared with 6 per cent of those using the wheelchair @=0.01). A greater proportion of families whose children used the parapodium reported having difficulty on outdoor surfaces, including level turf (31 per cent vs. 10 per cent), rough or irregular surfaces such as sand, gravel or rocky surfaces (92 per cent vs. 62 per cent), ramps and curbs (58 per cent vs. 3 1 per cent), and snow and ice (100 per cent vs. 62 per cent) (pCO.05 for all comparisons). The only area in which the parapodium was an advantage was stairs, which were impossible for those in a wheelchair. Table IV summarizes the results of

questions regarding the ease of performance of various activities for the two devices. Most activities such as toileting for bowel movements, dressing and undressing, and getting into and out of the device were easier for those in the wheelchair than for those in the parapodium. Girls using the parapodium had much greater difficulty catheterizing themselves for urine than did girls using the wheelchair. Families were asked an open-ended question about their views of their children's mobility devices. The answers were coded into 26 categories and scored. 59 per cent of comments on the parapodium and 76 per cent of the comments on the wheelchair were classified as positive (xz = 10.78, p = 0.001). The most frequent positive comment about the parapodium was that it allowed an upright position; the most frequent negative comment was that it was cumbersome to use. The most frequent positive comment about the wheelchair was to do with its speed; the most frequent ,negative comment was its lack of adapt'ability to different environments.

Discussion Methodology The ideal method of examining the impact of mobility devices is a randomized trial; however, such a trial is unlikely to be performed for a number of reasons. Families and community therapists are aware of the care being received by other children in the community; they would request the mobility aid that they believe is most effective, which would lead to a diffusion of treatments, The optimal use of each device requires a team of specialists, including therapists, orthotists and physicians, who are dedicated to and trained in the use of that particular device. Since most health-care teams have been trained to introduce only one type of mobility device, and believe that their method is the best, a randomized trial would require retraining of professionals. Despite this training, children might receive inadequate supportive services because of inexperienced or uncommitted professionals. Although this study was not a randomized trial, the comparison of two

centers with very different approaches to the habilitation of children is an appropriate method for examining the differences between complicated interdisciplinary processes. The greatest problem with the non-randomized design chosen for this study is that other factors in the communities, such as climate or early intervention programs, may have had major effects on the outcomes selected. Another problem with clinical studies such as this one is that the treatments were not provided in a completely standardized fashion. For example although the Rochester parapodium is usually introduced at about the second birthday, it may be introduced at 18 or 30 months. In addition, the use of mobility devices is often interrupted by admittance to hospital or illness. Therefore the generalizability of the findings of this study should be interpreted with consideration to the limitations of a non-randomized design. Findings Considerable controversy surrounds the use of mobility devices for children with MM, with advocates for each type of intervention believing that their method is superior. In this study, children using the parapodium or wheelchair as their initial mobility aid showed no differences in the occurrence of reflw, hydronephrosis or reported urinary-tract infections. The over-all occurrence and severity of skin breakdown was the same for both groups; differences in distribution were consistent with the areas of pressure experienced by the children in their respective devices. Hip-flexion contractures were no more common among those in a wheelchair. Dislocations of the hips were more common among children who used the parapodium, which is compatible with the load on the hip joint caused by upright weight-bearing. Knee-flexion contractures were more common among children using the wheelchair-which would be expected, since children in the parapodium are held with their knees in full extension. The occurrence of fractures in this sample (46 per cent over 10 years) is comparable to the fracture rate of 3 per cent per year reported by Anschuetz et al.

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(1984), and was not affected by the type of initial bracing. Many fractures occur in children with MM after postoperative immobilization (Drummond et a/. 1981); early upright posture does not appear to be protective. This finding differs from that of Mazur et al. (1989), who noted that fractures were less common among children who initially used the HKAFO than among those who used the wheelchair. Contrary to expectations, children from Rochester were more obese than those from Seattle. No differences were found between the groups in extracurricular activities; however, the children from Rochester spent more time watching television-a factor correlated with obesity-than did those from Seattle. Obesity was not correlated with level of lesion, gender or socio-economic status. A number of factors could explain the difference between the two groups. The program in Seattle has a nutritionist, whereas that in Rochester does not, so children in Seattle may be eating less fattening diets as a result of counseling. Children in Rochester may spend more free time inside the house and be less active because of the difference in weather between the two cities. The differences may also be related to statistical variation. No difference was found in urinary continence. However, children in wheelchairs had fewer fecal accidents than children using the parapodium. This is probably related to mechanical compression of the anus during sitting in a wheelchair and the increased abdominal pressure of those standing in a brace. (The occurrence of constipation was not assessed because of the difficulty in quantifying it.) No differences in extracurricular activities or independent skills were found between the two groups in this sample. The use of health services was similar for the two groups, including the distribution of orthopedic procedures. Children in Rochester were more likely to see their primary-care physician for acute visits, while those in Seattle were more likely to visit an emergency ward. This finding is consistent with previous studies of child health performed in Rochester (Haggerty et al. 1975, McInerny et al. 1978, Roghmann et al. 1984), which has an

extensive network of primary physicians and community health-centers. Based on the comments of the families in this study, the wheelchair is clearly faster and more convenient for many routine activities. Although a greater number of positive comments were made about the wheelchair, comments on the parapodium were more emotionally intense; for example, one mother stated: ‘the day that I saw her upright was the most wonderful day of my life’. Children’s upright posture in a parapodium, allowing them to be at the same eye-level as their peers, is viewed as a great advantage by many families. However, the effects of this upright posture on social interactions has not been formally evaluated.

Conclusion There appear to be no significant differences in medical complications, use of health-care services or activities of daily living related to the use of the parapodium or wheelchair as the initial mobility aid in children with MM. However, differences in the patterns of complications did occur: children who used the parapodium were more likely to have skin breakdown of their lower extremities, while those in the wheelchair had breakdown of their ischial, sacral and perineal regions; also, children using the parapodium were more likely to have dislocated hips, whereas those using the wheelchair were more likely to have kneeflexion contractures. The over-all effects of these complications on functioning, however, appeared to be identical, although whether functioning will be affected during adulthood remains to be studied. Early use of the parapodium does not protect against the occurrence of fractures or obesity; other measures to prevent these complications are necessary. Despite the parapodium’s disadvantages as a mobility device, the upright position it allows is considered extremely important by many families. In addition, there may be advantages in upper-extremity functioning (Bloss et al. 1991), cognitive development (Kermoian and Campos 1988) or psycho-social factors that were not examined in this paper. Based on the results of this and other

studies (Mazur et al. 1989), a combined approach that allows children with MM to be upright at times and also to Use wheeled mobility would appear to be ~h~ of any program, however, depends on the skill and- dedication of the entire team caring for these children. Accepted for publication 14th April 1992 Acknowledgements The authors thank Kristin Ainsworth and Luise Byrne for their assistance. This project was

supported by grant No. 10826 from the Robert Wood Johnson Foundation.

Authors’ Appointmenfs *Gregory S. Liptak, M.D., M.P.H., Associate Professor of Pediatrics, University of Rochester School of Medicine, 601 Elmwood Avenue, Rochester. NY 14642-0777. David B. Shurtleff, M.D., Professor of Pediatrics, University of Washington School of Medicine. Jill W. Bloss. R.P.T.. Senior Physical Therapist: Elizabeth Baltus-Hebert, M.S.; O.T.R., Senior Occupational Therapist; Phyllis Manitta, O.T.R., Occupational Therapist; University of Rochester School of Medicine. ‘Correspondence to first author.

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SUMMARY The optimal method for providing mobility for children with myelomeningocele remains controversial. 39 children using a parapodium were compared with 29 children in wheelchairs. There were no significant differences between the two groups for medical complications, use of health-care services or activities of daily living, although there were differences in the patterns of complications. Children using the parapodium were more likely to develop lesions of the lower extremities, to have dislocated hips, to be more obese and to watch more television; children using wheelchairs were more likely to develop lesions of the gluteal region, to have knee-flexion contractures and to have fewer fecal accidents. The parapodium was judged by families to be less effective as a mobility aid; however, the upright posture it allows was considered extremely advantageous. A combined approach allowing upright posture and wheeled mobility would appear to be optimal. RESUME Aides au deplacement dans les spina bifida de localisation haute: deambulateur contre fauteuil

roulant La mkthode optimale pour apporter la mobilitk aux spina bifida est discutie. 39 enfants utilisant un diambulateur ont i t e compares a 29 enfants en fauteuil roulant. 11 n’y avait pas de differences significatives entre les deux groupes pour les complications medicales, I’utilisation de services de soins ou I’activiti journalikre, bien qu’il ait eu des diffirences dans I’allure des complications. Les

enfants utilisant le deambulateur avaient plus de chance de developper des lesions des extremitks

infirieures, itaient plus obkses et regardaient davantage la television; les enfants en fauteuil roulant developpaient plus facilement des lesions fessiltres, des contractures des genoux et avaient moins d’accidents d’incontinence fecale. Le diambulateur etait jug6 par les familles comme une aide de mobilite moins efficace; cependant la position irigie que permet le diambulateur est considCree comme tres avantageuse. Une approche combinee associant la position erigee et la mobilitk du fauteuil semble optimale. ZUSAMMENFASSUNG Mobilitatshilfen fur Kinder mit hochsitzender Myelomeningocele: Parapodium contra Rollstuhl Es besteht keine Einigkeit uber die optimale Methode, Kindern mit Myelomeningocele Mobilitat zu verschaffen. 39 Kinder, die ein Parapodium benutzten, wurden mit 29 Kindern im Rollstuhl verglichen. Es fanden sich keine signifikanten Unterschiede zwischen den beiden Gruppen im Hinblick auf medizinische Komplikationen, Beanspruchung medizinischer Dienstleistungen oder Aktivitaten im taglichen Leben, es gab jedoch Unterschiede bei der Art der Komplikationen. Kinder, die ein Parapodium benutzten, entwickelten haufiger Liisionen der unteren Extremitaten, hatten eher dislozierte Huften, waren adiposer und sahen mehr fern: Kinder im Rollstuhl entwickelten haufiger Lasionen in der Glutealregion, Beugekontrakturen der Kniegelenke und hatten seltener Stulprobleme. Nach dem Urteil der Familien war ein Parapodium als Mobilitatschilfe weniger geeignet, die dadurch gegebene aufrechte Haltung jedoch wurde als sehr vorteilhaft angesehen. Eine Kombination von aufrechter Haltung und rollender Mobilitat wurde optimal sein. RESUMEN Ayudas para la movilidad para niitos con un mielomeningocele de nivel alto: parapodio frente a silla de ruedas El metodo 6ptimo para proporcionar movilidad a niflos con mielomeningocele continua siendo objeto de discusih. Se compararon 39 niflos que usaban parapodium con 29 que usaban silla de ruedas. No habia diferencias significativas entre ambos grupos por lo que hace a complicaciones medicas, el us0 de cuidados sanitarios o 10s actividades de la vida &aria, pero habia diferencias en el patr6n de las complicaciones. Los niflos que usaban el parapodium tenian m b tendencia a sufrir lesiones en las extremidades inferiores, a tener Iuxaci6n de cadera, a ser m b obesos y a mirar m b la television. Los niflos con silla de ruedas tenian mhs tendencia a lesiones de la regi6n glutea, a

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contracturas en flexion d e las rodillas y a tener menos accidentes fecales. Los familiares juzgaban el parapodium como menos eficiente como ayuda a la mobilidad; sin embargo la postura erecta que proporciona era considerada como altamente ventajosa. Un planteamiento combinado que permita la postura erguida y la mobilidad rodada parece que seria lo optimo.

References Agre, J . C., Findley, T. W., McNally, M. C., Habeck. R.. Leon. A. S.. Stradel. L.. Birkebak. R., Schmalz, R. (1987) ‘Physical activity capacity in children with myelomeningocele.’ Archives of Physical Medicine and Rehabilitation, 68, 372-377.

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Anschuetz, R. H., Freehafer, A. A., Shaffer, J. W., Dixon. M. S. (1984) ‘Severe fracture comolications in myelodysplasia.’ Journal of Pediairic Orthopaedics, 4, 22-24.. Asher. M., Olson, T. (1983) ‘Factors affecting the ambulatory status of patients with spina bifida cystica.’ Journal of Bone and Joint Surgery, 65A, 350-356.

Belt-Niedbala, B. J., Ekvall, S., Cook, C. M., Oppenheimer. S., Wessel, J. (1986) ‘Linear growth measurement: a comparison of single armlengths and arm-span.’ Developmental Medicine and Child Neurology, 28, 3 19-324. Bloss, J. W., Liptak, G. S., Shurtleff, D. B., BaltusHebert, E., Manitta, P. (1991) ‘Upper extremity functioning in children with meningomyelocele: parapodium versus wheelchair.’ (In press.) Bradley, R. H., Caldwell, B. M. (1980) ‘The relation of home environment, cognitive competence, and 1Q among males and females.’ Child Development, 51, 1140-1148. Butler, C., Okamoto, G. A., McKay, T. M. (1983) ‘Powere! mobility for very young disabled children. Developmental Medicine and Child Neurology, 25,472474, Caldwell, B. M., Bradley, R. H. (1978) Home Observation for Measurement of the Environment. Little Rock, AR: University of Arkansas. Cane, F. R. (1969) ‘Walking training of the young child with myelomeningocele.’ Physiotherapy, 55, 322-327.

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Mobility aids for children with high-level myelomeningocele: parapodium versus wheelchair.

The optimal method for providing mobility for children with myelomeningocele remains controversial. 39 children using a parapodium were compared with ...
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