Physical Medicine Interventions for Duchenne Muscular Dystrophy, the Including Avoiding Invasive Airway Tubes

8 walking.” However, we have found this to be too late. Besides requiring expensive and heavy long leg braces, the late approach necessitates extensive post-operative physical therapy and ambulation is often not recovered at all. It is also impossible to predict who will benefit at all from this late approach and post-operative therapy is long, expensive, and cumbersome so the use of this approach has fallen off over the years. D. Early Surgery Figure 2. A 7-year-old boy with Duchenne muscular dystrophy presents with knee and ankle contractures standing on his toes (A) and with increased lordosis, and a wide-based gait on the toes (B). After surgery, he maintains a normal stance (C), a heel-to-toe gait, decreased lordosis and knee and ankle contractures (D), and no longer falls. Lower limb musculotendinous releases along with tibialis posterior transfers have been performed as prophylactic and corrective measures for DMD, Becker, and other muscular dystrophies mainly in Italy, Germany, France, and by our clinic physicians. Early surgery when contractures begin to develop can eliminate the need for ongoing physical therapy and splinting and help preserve the strength of the weaker muscles by eliminating the over-pull of their antagonist (opposite) muscles. 3 It is most beneficial to prevent severe contractures and to transfer the tibialis posterior plantar flexor muscles into the second or third cuneiform bones on the dorsum (top) of the foot. Along with heel cord lengthening, this converts plantarflexors into dorsiflexors, balances up and down strength of the ankles, and normalizes ankle ROM to definitively prevent equinus feet deformities. By re- turning normal ROM of the ankles and balancing strength it prolongs brace-free walking for over a year (Figure 2). 1 Iliotibial band (lateral thigh soft tissue) contractures are measured by the angle the legs take from midposition when lying supine with the legs dangling. The early approach done at the outset of contractures includes tibialis posterior transfers,