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Medical
Considerations for Therapeutic Riding
Reprinted from Strides
Magazine, July 1997 (Vol. 3, No. 3)
By Liz Baker, PT,
Medical Committee Chairman
Spina bifida is a
descriptive diagnosis that also goes by the names myelomeningocele, spina
bifida cystica, and myelodysplasia. It is diagnosed at birth by the presence of
an external sac on the child's back along the spine. This sac contains the
spinal cord and the meninges, the protective layers of tissue that enclose the
spinal cord. Surgery is usually performed within days after birth to close the
causative defect in the vertebrae so that the myelomeningocele (and the spinal
cord) is no longer exposed, and less likely to be
injured.
The result of the
myelomeningocele and the surgery is essentially a spinal cord injury. There is
some amount of paralysis and sensory loss below the level of the sac. There is
also usually some degree of hydrocephalus, an increase of fluid in the brain.
The hydrocephalus is treated with a shunt, which is a tube surgically implanted
from the brain to the abdomen to help regulate the amount of fluid. As with all
spinal cord injuries, the exact impairment is unique to each individual person.
However, spina bifida is usually also accompanied by other malformations of the
brain and spinal cord. These include Chiari II malformation, hydromyelia and
tethered cord. These associated conditions may become symptomatic, particularly
during the child's growth.
Spina bifida is usually
both an indication and a precaution to horseback riding. It is an indication
because some of the physical and developmental problems associated with it are
very likely to improve through therapeutic riding. For example, a child or
adult with spina bifida may have decreased independent sitting balance; a
well-planned therapeutic riding program can fine-tune the sitting balance so
that off-the-horse functional daily living activities, such as sitting or
walking, also improve. However, spina bifida is a precaution to riding because
that same impaired sitting balance makes a fall more likely. Additionally, the
rider is likely to have decreased sensation in the legs and seat area, making
pressure sores and skin irritation a possibility. Thus, if the word
"precaution" implies the need for further investigation prior to
riding, taking a rider with spina bifida means the operating center will need
to obtain an updated medical history and further evaluate that rider in order
to plan a safe and effective program.
The rider with spina
bifida should provide the center with information such as the spinal cord level
of the defect, any associated known medical problems, and the presence of a
shunt, scoliosis, hydromyelia, Chiari II malformation, and tethered cord. The
center should obtain a therapist's report which reviews the rider's range of
motion, functional abilities such as walking, transfers, ability to and manner
of propelling the w/c, sitting and standing balance, arm and hand control, as
well as sensation and history of skin breakdown in the affected areas. There is
usually normal cognition. Preferably, the center's therapist should evaluate
the rider and plan the program with the therapeutic riding instructor.
It may be very
appropriate for the child with spina bifida to ride with a physical or
occupational therapist in a treatment situation such as hippotherapy, or in a
class with the therapist providing hands-on therapeutic input. Children with
spina bifida often have aspects of delayed development -- for example impaired
processing of sensations such as their position in space -- simply due to the
fact that they are physically disabled. The child may have impaired movement
and body position sense simply because he did not move as much as a normal
child and was physically touched and moved less by parents and caretakers.
Therefore, the riding program may need to be more focused initially on the
developmental level and less on learning riding skills.
When a child with spina
bifida rides, the center and the instructor should be familiar with the
symptoms of tethered cord, Chiari II and hydromyelia. Tethered cord occurs when
the surgically repaired myelomeningocele becomes bound down or anchored due to
the formation of scar tissue after surgery. Normally, as the rider's spine
moves in response to the horse's movement, and as the child grows, the spinal
cord moves freely in the spinal canal. It is encased but not restricted by the
vertebrae of the spine. When tethered cord occurs, the rider's spinal cord is
anchored in the area of the repaired myelomeningocele and cannot move freely in
the spinal canal. Certain symptoms can be observed when tethered cord is
present, and the center staff should take note of them, as follows:
ˇ
worsening
gait
ˇ
rapidly
increasing scoliosis
ˇ
increasing
incontinence
ˇ
back
or leg pain
ˇ
spasticity
(newly appeared or worsening)
If these symptoms
appear the center should report them to the child's parent or caretaker and the
physician. The riding program may be the most consistent source of therapy the
child has, so the center's role in noting and reporting the symptoms of
tethered cord is important. It is most likely to observe such symptoms in a
growing child, and particularly one who is more functional, with a lower level
spinal defect and the ability to walk.
Also associated with
spina bifida is Chiari II malformation. It is a congenital, structural set of
abnormalities of the lower brain that result in compression of the brain stem
and obstruction of the natural flow of cerebrospinal fluid (the fluid that
encases and protects the brain and spinal cord). Although most children with
spina bifida appear to have this brain abnormality, it only causes symptoms in
20-30%. However, the symptoms can be very problematic because the brain stem
coordinates very basic activities, such as breathing.
Again, the riding
program may be the most consistent form of therapy the child receives, so the
center may note the development of the following symptoms:
ˇ
Respiratory
distress (noisy congestion or difficulty breathing, retraction of the chest
during the inhale instead of expansion)
ˇ
Apnea
(breathing stops)
ˇ
Stridor
-- a harsh croupy noise while breathing, or cyanosis, a bluish tint to the
fingernails and mouth due to lack of oxygen
ˇ
Increased
difficulty swallowing, increased drooling, gagging or vomiting
ˇ
New
backward spastic arching of the head, neck or entire body
ˇ
Increased
weakness/spasticity of the arms
ˇ
Persistent
severe headaches, radiating from the base of the skull and neck
Lastly, the person with
spina bifida may also have hydromyelia, an abnormally increased amount of
cerebrospinal fluid in the spinal cord. It causes increased muscle weakness and
pressure on the spinal nerves. This allows the development of a scoliosis.
Hydromyelia is relieved by repair of the shunt, the implantation of a shunt in
the spinal cord, or surgical drainage of the fluid. The center should watch for
and report symptoms including:
ˇ
Progressive
loss of muscle strength
ˇ
Rapidly
increasing scoliosis
The above conditions
associated with spina bifida should not be taken lightly. As operating centers increase
in number and clientele, it is likely that a center will encounter a child with
such symptoms. As centers serve more socially and economically disadvantaged
people, particularly children, it is possible that the center's instructors and
therapists may be the first to notice persistent symptoms. The instructor and
therapist should ask whether the child with spina bifida has been assessed for
the presence of symptomatic tethered cord, Chiari II and hydromyelia. If the
parent or caretaker appears unaware that such conditions can exist, the center
may even need to familiarize them with the symptoms and encourage them to ask
the child's neurologist and physician about the conditions. Thus, the
precautionary aspect of spina bifida is that, while the condition is
technically non-progressive in nature, there are associated problems that can
be very progressive and even life-threatening.
In the past, riders
with spina bifida have been considered to be the least problematic, most
capable and most likely to benefit from horseback riding. Although the center's
instructors and therapists need to closely monitor the rider for the problems
discussed above, therapeutic riding continues to be in most instances a very
healthy, beneficial and therapeutic activity for all people with spina bifida.
Many such people can progress to high levels of independence in their riding
skills and go on to competition. Therapeutic riding can be an excellent
lifelong way for the person with spina bifida to maintain or improve functional
life skills, fitness and strength, while providing a rewarding experience for
the rider and the entire therapeutic riding team.