Spina Bifida is a neurological disorder whose main attribute is a failure of the spine to close properly before birth. As the fetus develops in the first month of pregnancy, the brain and spinal cord form from a small piece of tissue called the neural tube. For one in approximately every one thousand babies, this neural tube does not close properly after the spinal cord has developed, resulting in a portion of the spinal cord being exposed at birth. It is not known what exactly causes this malformation, but it has been hypothesized that there may be a genetic link. Another explanation is that Spina Bifida may be caused by this genetic link in combination with a deficiency of folic acid in the mother during pregnancy. Folic acid is a B vitamin that is important for fetal development in the first three months of pregnancy, thus an insufficient amount could lead the spinal cord not forming properly. The brain and spinal cord are some of the first organs to develop in the fetus, and thus a lack of folic acid could interrupt their development (Watson 4-8).
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In the most severe cases of Spina Bifida, classified as forms of Spina Bifida Cystica, a sac is exposed on the child’s back that contains fluid, nerves, protective nerve coverings, and sometimes a portion of the spinal cord (“Resources for Working with Youth with Special Needs”). This sac is surgically removed within the first few days after birth, while trying to save and replace in the body as many of the viable nerves as possible.
The extent of the damage to the spinal cord depends on how far down the spine the opening occurs. This in turn determines the level of paralysis or disability of the individual. The spinal cord and nerves are not always exposed in a sac outside of the body, but can also be just slightly damaged in a form of the condition known as “hidden” Spina Bifida. Whether or not there is a sac present outside of the body, the deformity of the spinal cord can occur in varying degrees, resulting in three main types of Spina Bifida (National Institutes of Health; Watson, 6).
The most common type of Spina Bifida, which results in the most severe disabilities, is called Myelomeningocele Spina Bifida. The characterizing exposed sac protrudes out of an opening in the baby’s back, and contains a portion of the spinal cord. Because many of the nerves contained in this sac are damaged, this form of Spina Bifida can cause severe disabilities including weakness, loss of feeling in or paralysis of the feet, legs and sometimes waist (“Center for Disease Control and Prevention”).
Meningocele Spina Bifida is less severe than Myelomeningocele, but has similar effects on the individual. The neural sac is still exposed and exists outside of the body, however it does not contain any part of the spinal cord itself, and thus causes less nerve damage. Individuals with this form of Spina Bifida may have some loss of feeling, weakness or paralysis in the feet and lower legs (“Center for Disease Control and Prevention”).
The mildest form is called Spina Bifida Occulta. It is often referred to as “hidden” Spina Bifida, because it is not apparent at birth and usually does not affect the individual at all. The spinal cord is not damaged in this form of the disease, but there is a small opening between vertebrae in the spine. Because it is so subtle, Spina Bifida Occulta is usually not diagnosed unless the individual has an X-ray or test done for another condition, and it generally is not severe enough to even require treatment (Watson, 6).
Many individuals with Spina Bifida also have a condition known as Hydrocephalus, or “water on the brain”, which is essentially a build-up of cerebro-spinal fluid around the brain. A widening of the spinal canal called hydromyelia, which creates a cavity where fluid can build up, can cause hydrocephalus. It is a common co-occurrence with Spina Bifida because the deformity of the spinal cord can prevent the fluid from draining as it normally would (Watson, 7). This condition is usually treated with a shunt placed in the individual’s skull, which helps to properly drain the excess fluid. In many cases, the hydrocephalus itself is caused by another common co-occurring condition with Spina Bifida, called Chiari II Malformation. This is a malformation of the skull that results in the bottom portion of the skull being smaller than normal. When this happens, part of the cerebellum and brain stem are pushed downward into the neck, blocking the flow of cerebrospinal fluid and causing hydrocephalus (“National Institutes of Neurological Disorders and Stroke”). Since the cerebellum is the portion of the brain that controls balance, this can affect the individual’s vestibular sense.
Many of the problems associated with the two more severe forms of Spina Bifida can be improved with equine assisted activities. Due to the fact that all forms of Spina Bifida affect the spinal cord and nerves of the individual, the most common problems associated with the disease relate to motor coordination as a result of lack of feeling, weakness or paralysis in the lower limbs. Sometimes, difficulties with bilateral integration can also occur depending on the specific individual’s disability. Often, individuals with Spina Bifida have increased muscle tone and some spasticity in their legs. Usually they are able to walk with the use of equipment such as leg braces, body braces, crutches and walkers, but have abnormal gaits and have difficulty standing without movement (Bartonek, et. al). They can also have difficulty with trunk control and holding them selves in a sitting position if the nerve damage affected their ability to feel and control their hips and waist. Due to the lack of feeling in some parts of the body, some individuals with Spina Bifida may have problems with sensory integration to some extent. This would be present mainly in terms of the vestibular and proprioceptive senses. Some additional problems such as tendonitis and skin breakdown can co-occur with Spina Bifida, mainly due to the loss of feeling in the lower extremities. In some cases, mental along with physical function is affected and the individual may have some degree of mental retardation, but this is often not the case.
Equine Assisted Activities
Individuals with Spina Bifida could participate in and benefit from two main Equine Assisted Activities: Hippotherapy and Therapeutic Riding. Because Spina Bifida primarily causes physical problems, hippotherapy would probably be the best option, as it is a true therapy that would provide more medical benefits than a therapeutic riding lesson alone could provide. However, hippotherapy could be used in conjunction with therapeutic riding. Hippotherapy and Therapeutic riding would provide very different benefits, however, they both have the potential to improve an individual’s physical motor skills along with their mental and social skills if those areas were affected. Hippotherapy would most likely be the best option for an individual with Spina Bifida, as the condition’s primary manifestations affect the physical abilities of the individual, requiring more assistance from a physical therapist to improve motor function.
Hippotherapy would most likely be the main equine assisted activity for riders with Spina Bifida. It would provide the required physical therapy to improve muscle tone and motor function, more so than therapeutic riding alone. The activities and exercises in hippotherapy target neuromuscular function, movement disorders and sensory integration disorders, which are all areas that can be affected in a person with Spina Bifida. Overall, as with other equine assisted activities, the horse would provide perfect three-dimensional motion and warmth, allowing the rider to relax their muscles and let the horse move their legs and hips. This movement would be key, as many individuals with Spina Bifida focus on learning how to walk so they are not confined to a wheelchair. Though many will not be able to walk without crutches or braces, the movement of the horse can teach them both mentally and physically what the patterns of walking look and feel like so that someday they may be able to implement the motions off the horse.
Since the purposes of hippotherapy revolve around goals related to physical and sensory abilities, the rider would be focused on improving in some of the following areas. Most importantly, the stretches and balancing exercises in hippotherapy could help improve muscle tone and movement, allowing the rider to work on further developing their balance, posture and mobility. Some examples of these exercises could include the rider standing in the stirrups, with assistance if needed, trying to maintain balance, or the rider laying on their back on the horse, using their leg muscles to hold themselves up on the horse’s neck. Ultimately, all of the skills and improvements gained from hippotherapy sessions could lead to a final goal of improved gross motor skills such as walking, sitting and standing which are the simple daily tasks that most Spina Bifida patients struggle with throughout their lives.
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Therapeutic Riding could benefit riders with Spina Bifida, but would most likely be in addition to hippotherapy. Therapeutic riding could provide the added benefit of social interaction and learning riding skills on top of the more intense physical therapy gained from hippotherapy. Therapeutic riding could provide a setting in which the rider could refine the stretches and activities learned in hippotherapy and apply them on a more simplistic level while riding in a therapeutic lesson. Whether in Hippotherapy or Therapeutic Riding, the same fundamental benefits of simply being on the horse would exist. The three-dimensional motion and patterns of the horse’s gait would encourage walking, and in this setting would be more relaxed than in an intense physical therapy-type lesson.
Though hippotherapy would provide most of the necessary therapy components to a rider with Spina Bifida, therapeutic riding does have several aspects that are not present in hippotherapy that could greatly benefit the riders. They would be required to use their bodies a little bit differently in a riding lesson-that is, rather than the horse simply being a prop that moves underneath them while the lay down or stretch, they would have to integrate their movements with those of the horse. The riders would need to use their legs to signal the horse to walk on, and they would need to maintain balance and posture throughout the lesson, requiring them to use their leg, hip, and trunk muscles. In certain activities, such as trotting and two-pointing, they would be required to use their leg muscles even more to keep balanced and remain steady on the horse. This may be very challenging for some individuals, depending on their level of weakness or paralysis in the legs.
On top of these benefits, therapeutic riding would provide a setting in which individuals could interact with other riders and their volunteers in a fun and relaxed setting. Hippotherapy, as it is a true therapy, would most likely be very challenging and tiring, and therapeutic riding could provide a setting in which riders could enjoy the company of other people and horses in a less intense session.
Contraindications for Spina Bifida and Equine Assisted Activities
Though a rider with Spina Bifida can benefit greatly from equine assisted activities, there are several contraindications that should be considered before beginning with either hippotherapy or therapeutic riding. Many of the common contraindications of riding horses are present in individuals with Spina Bifida. However, some can be present but mild enough so as not to limit the rider. Either way, it is important to consider all of the possible contraindications and risks before he rider begins either a hippotherapy or therapeutic riding session.
One of the most important things to consider when looking into contraindication for a rider with Spina Bifida is the ability to maintain a sitting position on the horse. If a rider is unable to maintain this position without causing kyphosis or lordosis (inward curving or bowing of the spine), then the Spina Bifida itself could be considered a contraindication (“Medline Plus”). In most cases, it is only a precaution if a correctly fitted, deep-seated saddle (most likely a western saddle) is available.
Another prevalent contraindications for riders with Spina Bifida is hydrocephalus, a common co-occurrence of Spina Bifida. Generally it is a contraindication due to the fact that it is treated with the placement of a shunt. If a properly fitting helmet cannot be placed on the rider without putting pressure on the shunt, it may only be a precaution (“North Okanagan Therapeutic Riding Association”).
Another common contraindication associated with Spina Bifida is the possibility of developing a condition known as Tethered Cord Syndrome-when the base of the spinal cord is held down and unable to move freely in the spinal column. This condition normally occurs as a result of scar tissue forming from the original surgery to remove the myelomeningocele or meningocele. This scar tissue is what ties the spinal cord down. In some cases, the motion of the horse can increase the chances of this condition forming, or aggravate it if the condition has already begin to develop, making it an important contraindication to consider. Tethered cord syndrome can worsen the already existent problems associated with Spina Bifida. It can cause worsening of gait associated with increased pain and spasticity in the legs, and rapid development of scoliosis (Spina Bifida Association).
Spina Bifida is a common neurological disorder that can cause lack of feeling, weakness and paralysis of the lower extremities. In some cases, other conditions such as hydrocephalus, Chiari II malformation, Tethered Cord Syndrome, tendonitis and mental retardation can co-occur with Spina Bifida, ultimately resulting in struggles with physical and sometimes mental function. The problems associated with Spina Bifida and its co-occurrences primarily affect motor function and the tactile, proprioceptive and vestibular senses. For this reason, equine assisted activities such as Hippotherapy and Therapeutic riding can have a very positive impact on riders with Spina Bifida. One or both of these activities can be implemented in the individual’s routine to improve their motor function, specifically in terms of their abilities to use the muscles in their feet, legs, hips and trunk. Gross motor skills such as standing and walking are the main challenges that individuals with Spina Bifida face, and the natural movements of the horse, along with therapy exercises and activities can be very effective in improving these skills in order for individuals to achieve more independence and in turn, better quality of life.
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