unstable ankle

[lobuotor]

Hello everyone.
Please i need help with a patient of mine.She's a 4yrs old girl,who had spinal bifida at birth.a surgery was done to correct it at 5 months of age.
She's now 4yrs old.she can stand without a back slab while holding on to a walking frame.The problem i have now is that her ankle are very unstable or wobbly.she has no muscle control at the ankles.
her treatment plan includes:
1. Electrical stimulation of the dorsiflexors, evertors & invertors
2. Propriceptive neuromuscular facilitation.
3. strengthening execises of the entire lower limbs
4. Balance training
5. Splinting

Please i need suggestion as to what else i can do to facilitate movement at the ankles & also encourage ambulation.

Thanks for all your anticipated responses.

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[CenteredHealth]

It sounds as though you are on the right track. I am however, curious as to what level the spina bifida was located. I am guessing L5S1 as it is a common area but also because of the ankle issues. Neurologically, the L5S1 nerve roots control, to a great extent, the ankle and foot. As I stated above, it sounds that you have given her a good functional program including strengthening, PNF, E-Stim, and weight-bearing activities. In conjunction to this I would begin to look at her on a structural level especially through the LS junction (L5S1), assessing biomechanics, dural mobility, myofascial imbalances, etc. Addressing dysfunctions on this level will facilitate healing through the nervous system and allow for improved neurological control to the lower extremities.

[sharileedahl]

I do not see this type of client so I won't comment much on treatment...I'll leave that to the folks that have some experience with this clientele
But...as a side question...
Is there any concern with this type of patient having a tethered cord due to either the spina bifida and / or previous surgery in the area. In which case would you be concerned about treatment directed at neural mobility (as mentioned by "CenteredHealth")? I understand we would be looking at each individual's signs / symptoms however this is just a general question based on what you (and other therapists) have seen.
Thanks.

[CenteredHealth]

I do not see this type of client so I won't comment much on treatment...I'll leave that to the folks that have some experience with this clientele
But...as a side question...
Is there any concern with this type of patient having a tethered cord due to either the spina bifida and / or previous surgery in the area. In which case would you be concerned about treatment directed at neural mobility (as mentioned by "CenteredHealth")? I understand we would be looking at each individual's signs / symptoms however this is just a general question based on what you (and other therapists) have seen.
Thanks.

Thanks for the comment, as it is a definite concern. I have experience working with spina bifida in both the pediatric and adult populations, which is why I was interested in this topic and offered my thoughts. Any treatments directed at improving mobility through the nervous system will only improve the overall outcomes. I must state, however, that when I speak of neural mobility I am not referring to nerve glides or dural slump stretching, or any other direct/aggressive treatment. I am referring to much more indirect therapies which are gentle and subtle; something along the lines of CranioSacral Therapy.

[lobuotor]

Thank you very much for your response.i'm very curious about this neural mobility appoach you made mention of.the spinal bifida was at the L5S1 level,and the operation left some scar tissues along that area.please is neural mobility the same thing as mobilising the scar tissues at the L5S1 level.please can u share more light on thie neural mobility approch.Last week,i started making use of a tricycle to encourage ambulation.she doesn't pedal the tricycle,but rather the either is for her to use her feet to propel herself forward while seated on the tricycle.
Thank you once again.