Management of lower limbs
Management of lower limbs paraparesis or paraplegia can be described under following headings:

Initial Assessment: This is done with the help of physiotherapist:

• Presence or absence of the movement in the legs: Muscle charting is a useful way of recording these movements. While recording these movements, look at the movement of each joint to see if it is presence or not. The strength of the movement at joint should also be graded and charted. It is important that the movement in each leg is recorded separately as there is often a difference in the strength of each leg.
  
  
• Presence or absence of feeling in the legs: It is difficult to assess the loss of feeling in the leg of an infant with Spina Bifida. The best way to do this is to use light pinch or prick with a pin over the toes, feet and legs. The infant's reaction e.g. pulling away, crying or no reaction should be recorded.
  
  
• Assessment of contractures and deformities: When an infant with Spina Bifida is born, some joints or muscles in the legs may be contracted or deformed. A contracture is a shortened muscle, which prevents the full range of movement being carried out at a joint. The joint may become stiff. A deformity is an abnormal position of a joint. The joint may or may not move at all. At the first, assessment of an infant with spina bifida all limbs should be checked. This is done by moving all joints in the arms and legs through a full range of movement.

It is important to move each joint in the lower limbs through full range of movement every day even if contracture and deformities are not present. This will prevent the joints from developing contractures.

Other assessments:
There are some further areas that should be looked at:

• How awake and alert the infant is
  
  
• How the infant likes being moved around
  
  
• How much the infant cries
  
  
• Parents response to the infants
  
  
• Family concerns about the infants

Treatment of contractures and deformities

• Stretching: If a full movement of joint is not possible. The child needs daily stretching exercises.
  
  
• Positioning: Positioning of the infant or child can assist in correction and prevention of contracture and deformities. The child should not remain in one position for long period of time.

Management of orthopedic problem:
The deformities and contractures, which are not managed by the regular stretching exercise and physiotherapy, are treated surgically. The commonest foot deformity we have encountered is congenital talipes equinus varus. The CTEV is corrected by the manipulation under anesthesia, cast application and the surgical correction. Contractures are treated by tendon release surgeries and tendon transplants. Eversion, inversion and calcaneous foot deformities are the other common deformities, which we see in our patients. An orthopedic surgeon in our spina bifida team corrects these deformities.