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

10 Without surgery “foot drop” is ubiquitous in DMD. Ankle foot orthoses (AFOs) can be used to stabilize the ankle but they prevent walking unless tibialis posteriors are transferred and then they are not needed. Since it is difficult to stand from a chair with an AFO that holds the ankle in a fixed position (as it limits knee bending), dynamic components to promote ankle dorsiflexion can be used. Dynamic splints provide force to assist movable body parts. Static AFO’s are used for individuals with flaccid ankles, whereas spring-loaded braces assist ankle dorsiflexion without restricting plantarflexion. Patients often refuse to use “resting” splints during sleep. They hamper bed mobility and sleep and do not prevent contracture progression. Fabrication of full-length lower limb splints would also need to be repeated about every 6 months. Casting can provide sustained stretching of joints at maximum tolerated angles. Casts can be re-applied every few days to progressively stretch the joint. This is known as serial casting. Without continuous casting, however, contractures progress. Standers and standing motorized wheelchairs can give support to the trunk, hips, knees, and ankles to both stretch the contractures and provide weight bearing to impede osteoporosis. G. Extremity Exercise Muscle groups with greater than anti-gravity strength can be strengthened by resistance exercise training. However, even with strengthening, subsequent muscle weakening, with or without continued exercise, may be even greater than without exercise. Muscles with less than anti-gravity strength cannot be strengthened with exercise. 8 Nevertheless, there is no harm exercising, and DMD patients with still good strength have been demonstrated to increase strength by as much as 70%. 9 However, no children should be forced to exercise by overzealous parents. Vignos advised 2 to 3 hours per day of standing, walking, or swimming as long as one feels rested after a night’s sleep. This is still appropriate today. Keep active with enjoyable activities while avoiding muscle strain. H. Respiratory Muscle Exercises Inspiratory muscle resistive exercises can improve inspiratory muscle endurance but not vital capacity (VC). The increased endurance permits breathing at 30% to 90% of maximum voluntary ventilation (breathing), or against higher pressures, for longer periods of time. However, this only occurs if VC is greater than 30% of normal when beginning the exercises. 10 There is no evidence that inspiratory exercise can delay need for NVS or decrease the risk of acute respiratory failure (ARF). 11 This is because the episodes of ARF are primarily due to expiratory (cou- gh), rather than inspiratory muscle dysfunction. 12