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Role of Physiotherapy in helping children with Duchenne’s muscular dystrophy

May 17, 2022

Duchenne muscular dystrophy (DMD) is a genetic disorder characterized by progressive muscle degeneration and weakness due to the alterations of a protein called dystrophin that helps keep muscle cells intact.It can begin as early as age 2 or 3.

Weakness related to Duchenne muscular dystrophy (DMD)affects the limb muscles close to the trunk before the ones far from it; the legs are affected before the arms. 

Lack of dystrophin causes muscle damage and progressive weakness, beginning in early childhood.

DMD carriers are females who have a normal dystrophin gene on one X chromosome and an abnormal dystrophin gene on the other X chromosome.

Some muscular dystrophies are not identified until a child is 3 to 6 years of age. Often, parents must wait 1 to 2 years to obtain an accurate diagnosis even after symptoms of weakness are present. Seeking treatment as early as possible and looking out for care by experts in movement disorders can make a difference in helping children with muscular dystrophy reach their full potential.


Must Read: Importance of exercise during pregnancy

Symptoms

-Muscle weakness and muscle wasting

-Difficulty jumping, running, and walking ,Enlargement of the calves called as pseudohypertrophy, or "false enlargement," 

-Waddling gait

-Lumbar lordosis (inward curve of the spine) 

-Progressive weakness and scoliosis result in impaired pulmonary function, which can eventually cause acute respiratory failure 

-Short stature

-Muscle cramps

-Clumsy and fall often 

-Often late walkers

-Trouble climbing stairs

-Delayed speech and language

-Delayed motor development

-Head lag (difficulty controlling the head or neck)

-Difficulty learning and in emotional interaction

-Contractures (shortening or hardening of muscles, tendons, or tissues) that affect the joints, curvature of the spine

-Cardiac problems

-Turning on to the stomach before getting up from the floor 

-When arising from the floor, child may use hand support to push themselves to an upright position ( Gower’s sign)

-By school age, child may walk on their toes or the balls of their feet

-To try to keep their balance, they may stick out their bellies and pull back their shoulders.  

-They may also have difficulty raising their arms

-Problems that indicate poor respiratory function like headaches, mental dullness, difficulty concentrating or staying awake, and nightmares.

-Weakened respiratory muscles make coughing difficult, leading to increased risk of serious respiratory infection. A simple cold can quickly progress to pneumonia. 

Physiotherapy Management

Physiotherapy is essential to the management of Duchenne’s muscular dystrophy. It is important to monitor the physical symptoms of the condition and physiotherapy can help keep the child active for as long as possible. Physiotherapists will work with the parents and provide them with information and treatment that will be helpful for the child. 

Contractures are addressed through a stretching routine, which can also be taught to the parents.

Physiotherapists also advise the parents on any orthoses, such as AFOs. They also help families choose what mobility aids and equipment the child might need. 

In the early stages of the condition, the physiotherapist will be involved in helping keep the child active. During later stages of the condition, the physiotherapist will help more with respiratory issues as well. 

Physiotherapists monitor the child’s posture in sitting, lying and standing.They can inform the parents of ways to help the child sit, stand and lie in optimal positions using pillows or splints. A sleep system and night splints may be recommended for nighttime to help maintain the child’s posture over a long period of time. 

 Physiotherapists help slow the regression of range of motion, muscle strength, daily function, work to improve gait pattern and posture/alignment. Physiotherapy can also address the pain that the patient may be experiencing. As the patient's walking and standing abilities decline the physiotherapist may choose to implement a standing program. 

They maintain or improve cardiorespiratory and muscle strength, adapt activities or the child’s home or school environments to promote movement and mobility skills, and increase daily activities, which encourage participation in the community. 

Passive and active stretching

 Performing gentle "passive" stretches for your child, gently moving their legs and arms, and teaching you and your child how to perform active stretches in order to increase joint flexibility (range of motion) and prevent or delay the development of contractures.

It helps in:

  • Temporary improvement in blood flow to the muscle 
  • Decreases discomfort 
  • Temporary increase in tolerance to stretch 
  • Temporary decrease in muscle stiffness 
  • Continued movement through the joint’s full available range of motion 

Exercises to maintain strength

 Physiotherapists will teach the parents and child exercises to maintain muscle and trunk strength and to use good posture and body mechanics throughout the lifespan. The therapist will include  games and fun tasks that promote strength. As the child grows, the therapist will incorporate new games and activities to reduce the risk of obesity and increase heart health. 

Exercises for breathing

The therapist will start a program to maintain good respiratory strength, or may work with respiratory therapists or speech therapists to design such a program.

Improvement of developmental skills

The physical therapist will help the child in learning crawling, getting up to stand, walking, and jumping.  Individualized plan of care is made that is appropriate based on your child's developmental level and motor needs.

Overall health

The therapist will help the child in community involvement that will promote the child’s good health. 

Physiotherapy may be provided in the home or at another location, such as a community center, school, or a physiotherapy outpatient clinic. 

During post op rehabilitation. They also work on early mobilization post op to help with recovery and maximize the child's independence.They also rehabilitate the child after injury or fracture. 

The child should have a thorough physiotherapy evaluation (strength, function and range of motion of the hips, knees, ankles, shoulders, elbows and wrists) at least every 4-6 months. 

Bracing

If your child is expected to have corrective orthopedic surgery for scoliosis or contractures, the therapist can assist in evaluating the need for equipment, orthopedic appliances used for support, or bracing that might be needed to foster a quick recovery.

Bracing helps to keep the joints in alignment and maintain flexibility and function of the joint by providing a long (maintained) stretch. Braces can be used on the lower limbs (ankle-foot orthosis (AFO) and knee-ankle-foot orthosis (KAFO), the wrists, and the hands. 

Wearing braces at night (“night splints” or “moon boots”) enables the joints of the ankle and feet to be stretched for several hours. 

Serial Casting

Serial casting refers to a process of applying a series of rigid casts (typically plaster) over an individual’s joint. The casts are used to slowly (with frequent cast changes over several weeks) increase range of motion at a specific joint.

Using wheelchair inserts and support

Bolsters, rolls, or pillows can be used to position or support a body part in a good alignment. It is important to be sure they are in a good position to help maintain their range of motion and comfort. 

Ideal seated positions include:

  • Both feet flat on the floor or footrest (or box step for younger boys), with hips and knees at a 90-degree position and back and pelvis aligned with hips 
  • Avoid long periods of time with legs in a frog position (splayed out). Knees should be in line with feet & hips. 
  • During growth, changing the dimensions of the chair helps maintain the best upright posture without having to lean.

Safety

 Make sure areas are free from clutter, be careful on slippery surfaces or fall hazards, to prevent falls.  While using a mobility device, always wear the seatbelt.

Must Read: Exercising while Expecting


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