Diagnosis of spina bifida and symptoms of bilateral foot pain: a case report

Gibson, Allison
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Angelo State University. Department of Physical Therapy.

Spina bifida is a rare neural tube defect in which malformation of the posterior arch of vertebra leaves the spinal column open. Signs and symptoms of spina bifida include but are not limited to back and lower extremity pain, bowel and bladder dysfunction, and lower extremity weakness and deformity. My goal of the case report is to provide a unique report of a patient who had significant clinical improvement and developed a new belief in the positive impact of physical therapy. The patient is a 34-year-old logistic analyst who presented to physical therapy with a chief complaint of bilateral foot pain causing limited standing and walking tolerance. The onset of pain was insidious approximately 3 years ago. The patient was diagnosed with spina bifida occulta and tethered cord syndrome and had corrective surgery about 1 year ago. Previous treatment for their condition included bilateral tarsal tunnel decompression surgery 1 year ago. Primary interventions include pain neuroscience education, gastrocnemius stretching, and strengthening. The patient present had improvement in ankle dorsiflexion and a slight improvement in plantar flexion range of motion. The patient had improvement in plantar flexion strength with no increase in pain with inversion during manual muscle testing. The patient’s pain scale improved during the time of the progress note and in their reporting of the worst pain in the past 2 weeks. The patient also improved on their LEFS and the single leg balance test. An important finding from the case report is the positive effect of pain neuroscience education on a patient with chronic pain. A primary lesson to take away is to look at the biological, psychological, and social aspects of a person to provide the best care to the patient.