**2. Exercise for Duchenne muscular dystrophy**

Hydrotherapy is a classic form of treatment, used with large varieties of functions [6]. The physical properties of heated water promote a facilitating movement and relief of pain, as well as allowing group work and making therapy pleasant, especially for children, who are often unable to perform certain activities in another environment, if not the aquatic. In this study, the effects of immersion in warm water in children with Duchenne muscular dystrophy were measured using HR, O2 saturation, maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and oral temperature (OT) measurements. A total of 20 children with Duchenne muscular dystrophy, male, aged 8 to 15 years, participated in this study.

Regarding the heart rate, a mean decrease of 7.3 bpm was observed between the initial immersion period and the pre-immersion period; between the final immersion period and the beginning of the immersion, there was an average increase of 7 bpm and observed a mean decrease of 0.3 bpm between the pre-immersion and final immersion periods. The oral temperature showed an increase of 0.1° C, during the initial immersion period; in relation to the pre-immersion period, this increase is probably associated with the immersion in warm water added to the physical activity, a decrease of 0.1°C between the final immersion period and the initial immersion period.

The O2 saturation showed a decrease in the values obtained after immersion, where there was a decrease of 2.7 between the initial immersion period and the pre-immersion; a 0.9% increase occurred between the initial and final immersion periods and one increase of 1.8% between the values of the final and pre-immersion periods, which were also considered measures of normal physiological adjustments to physical activities.

At the maximum inspiratory pressure, there was a mean decrease of 8 cm of water between the initial period of immersion and the pre-immersion; this change was considered clinically significant; between the periods of immersion, an average increase of 3.8 cm of water was observed of maximal inspiratory pressure.

At the maximum expiratory pressure in relation to the values obtained between the pre-immersion and initial immersion periods, we obtained an increase of 7.4 cm of water, and subsequently between the immersion and thin periods, there was a drop of 6.8 cm of water. This study showed that hydrotherapy is a therapeutic resource that does not represent an overload for children with Duchenne muscular dystrophy. Another study [7] was aimed to verify the benefits of hydrotherapy in improving gait and balance in patients with mild spastic diplegic type of muscular dystrophy, using a proposed protocol. The objective of this study was to analyze the changes in movements in the lower limbs during gait through a treatment protocol using aquatic rehabilitation, to help the child to achieve better gait independence, for which a case study was used, selecting a male child with gait changes.

The protocol was based on relaxation for 5 minutes: muscle stretching of ankle flexors, ankle dorsiflexors, hip adductors, hip and trunk flexors; passive ankle, plantar and dorsiflexion and circular movements; pelvic girdle dissociation; muscle

**79**

in subjects with DMD.

*Physical Exercise as a Tool to Delay the Development Process of Duchenne Muscular Dystrophy*

strengthening of hip and knee extensors and abductors and bicycle and gait training associated with balance training using a 1-pound ankle support and water turbulence. The patient was submitted to the protocol twice a week, lasting 50 minutes

In the initial evaluation, it was observed that the patient, in his functional activities, acquired all the positions without aid except the standing position and the gait. In the evaluation of the gait after the treatment compared to the initial evaluation, it was verified that there were no changes in gait phases. However, when analyzing the patient in the sagittal plane, it is emphasized that the patient used the support of one hand; there was a moment when he wandered without support, evidencing an improvement in the balance. In this study it can be concluded that the application of the proposed protocol in the hydrotherapeutic rehabilitation of the gait was considered efficient due to the good results obtained and proven in the reevaluation as an

Other authors [8] evaluated individuals with muscle tone disorders, posture and voluntary movement. These disorders are characterized by the lack of control over the movements, by adaptive modifications of the muscular length, resulting in some cases in bone deformities. Neuromotor involvement of this disease may involve distinct parts of the body, resulting in specific topographical classifications (quadriplegia, hemiplegia and diplegia). A child with DMD with diagnosis of hemiplegia, male, 8 months of age, participated in this study. In the therapy performed, a swimming pool with water between 30 and 32°C degrees was used, twice a week with a duration of 30 minutes in the period of August to December of 2004, totaling 40 sessions. The hydrotherapy sessions consisted of joint mobilizations, stretches, active exercises, Halliwick concept and Bad Ragaz ring method and neuro-evolutionary

Bobath treatment adapted in the water with a duration of 30 minutes.

After the hydrotherapy treatment, the child achieved in the area of personal care the following acquisitions: variability of food textures and use of spoon in food, holding an object against gravity and gains in personal hygiene by acquiring partial brushing of teeth and hair and participation in bathing and dressing. It was noted in the area of mobility the condition of sitting in vehicles and moving within it. He was also able to perform transfers from posture to sitting and transfer from the ground to the bed and vice versa, independence in locomotion in internal and external environments, gain of the distance walked. In the social function area, the child acquired comprehension of word meanings and increased vocabulary, comprising complex sentences, aptly naming objects, concomitantly making use of appropriate gestures and problem solving, resulting in greater interaction with children of his or her age. The analysis of this study can be concluded that the application of hydrotherapy in hemiplegic patients provided a sensorimotor improvement in existing functional skills, as well as in the acquisition of others. Thus, the child

According with this line of investigation, another author [9] sought to correlate

fat mass and muscle strength, maximum respiratory pressures and respiratory function in individuals with DMD. We selected 68 subjects with DMD. Muscle strength was assessed through manual tests, maximal respiratory pressures through a vacuum gauge and the Vignos test collected by observation. The fat mass was evaluated by bioimpedance, and BMI was also evaluated. Descriptive statistical analysis and regression model construction were performed. A descriptive analysis of the data was performed, and the subjects were divided by quartiles of age. There was a significant correlation between the dependent values, fat percentage and age. Based on this study, it was concluded that there is a correlation between the percentage of fat and muscle strength, respiratory pressures and respiratory function

*DOI: http://dx.doi.org/10.5772/intechopen.84453*

each session, totaling seven sessions.

increase in balance and gait control.

was better adapted to its development.

#### *Physical Exercise as a Tool to Delay the Development Process of Duchenne Muscular Dystrophy DOI: http://dx.doi.org/10.5772/intechopen.84453*

strengthening of hip and knee extensors and abductors and bicycle and gait training associated with balance training using a 1-pound ankle support and water turbulence. The patient was submitted to the protocol twice a week, lasting 50 minutes each session, totaling seven sessions.

In the initial evaluation, it was observed that the patient, in his functional activities, acquired all the positions without aid except the standing position and the gait. In the evaluation of the gait after the treatment compared to the initial evaluation, it was verified that there were no changes in gait phases. However, when analyzing the patient in the sagittal plane, it is emphasized that the patient used the support of one hand; there was a moment when he wandered without support, evidencing an improvement in the balance. In this study it can be concluded that the application of the proposed protocol in the hydrotherapeutic rehabilitation of the gait was considered efficient due to the good results obtained and proven in the reevaluation as an increase in balance and gait control.

Other authors [8] evaluated individuals with muscle tone disorders, posture and voluntary movement. These disorders are characterized by the lack of control over the movements, by adaptive modifications of the muscular length, resulting in some cases in bone deformities. Neuromotor involvement of this disease may involve distinct parts of the body, resulting in specific topographical classifications (quadriplegia, hemiplegia and diplegia). A child with DMD with diagnosis of hemiplegia, male, 8 months of age, participated in this study. In the therapy performed, a swimming pool with water between 30 and 32°C degrees was used, twice a week with a duration of 30 minutes in the period of August to December of 2004, totaling 40 sessions.

The hydrotherapy sessions consisted of joint mobilizations, stretches, active exercises, Halliwick concept and Bad Ragaz ring method and neuro-evolutionary Bobath treatment adapted in the water with a duration of 30 minutes.

After the hydrotherapy treatment, the child achieved in the area of personal care the following acquisitions: variability of food textures and use of spoon in food, holding an object against gravity and gains in personal hygiene by acquiring partial brushing of teeth and hair and participation in bathing and dressing. It was noted in the area of mobility the condition of sitting in vehicles and moving within it. He was also able to perform transfers from posture to sitting and transfer from the ground to the bed and vice versa, independence in locomotion in internal and external environments, gain of the distance walked. In the social function area, the child acquired comprehension of word meanings and increased vocabulary, comprising complex sentences, aptly naming objects, concomitantly making use of appropriate gestures and problem solving, resulting in greater interaction with children of his or her age. The analysis of this study can be concluded that the application of hydrotherapy in hemiplegic patients provided a sensorimotor improvement in existing functional skills, as well as in the acquisition of others. Thus, the child was better adapted to its development.

According with this line of investigation, another author [9] sought to correlate fat mass and muscle strength, maximum respiratory pressures and respiratory function in individuals with DMD. We selected 68 subjects with DMD. Muscle strength was assessed through manual tests, maximal respiratory pressures through a vacuum gauge and the Vignos test collected by observation. The fat mass was evaluated by bioimpedance, and BMI was also evaluated. Descriptive statistical analysis and regression model construction were performed. A descriptive analysis of the data was performed, and the subjects were divided by quartiles of age. There was a significant correlation between the dependent values, fat percentage and age. Based on this study, it was concluded that there is a correlation between the percentage of fat and muscle strength, respiratory pressures and respiratory function in subjects with DMD.

*Muscular Dystrophies*

immersion period.

to physical activities.

found in the heat of the water.

**2. Exercise for Duchenne muscular dystrophy**

of activities of greater degree of difficulty, providing patients with psychological benefits. If compared to techniques performed on the ground, hydrotherapy due to the physical principles of water facilitates and improves balance, coordination and posture and gives the patient the feeling of safety. For the child the feeling of safety is found in the arms of the parents and in the contact with the body. This was experienced in the sensation of water environment, before birth, and is now again

Hydrotherapy is a classic form of treatment, used with large varieties of functions [6]. The physical properties of heated water promote a facilitating movement and relief of pain, as well as allowing group work and making therapy pleasant, especially for children, who are often unable to perform certain activities in another environment, if not the aquatic. In this study, the effects of immersion in warm water in children with Duchenne muscular dystrophy were measured using HR, O2 saturation, maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP) and oral temperature (OT) measurements. A total of 20 children with Duchenne muscular dystrophy, male, aged 8 to 15 years, participated in this study. Regarding the heart rate, a mean decrease of 7.3 bpm was observed between the initial immersion period and the pre-immersion period; between the final immersion period and the beginning of the immersion, there was an average increase of 7 bpm and observed a mean decrease of 0.3 bpm between the pre-immersion and final immersion periods. The oral temperature showed an increase of 0.1° C, during the initial immersion period; in relation to the pre-immersion period, this increase is probably associated with the immersion in warm water added to the physical activity, a decrease of 0.1°C between the final immersion period and the initial

The O2 saturation showed a decrease in the values obtained after immersion, where there was a decrease of 2.7 between the initial immersion period and the pre-immersion; a 0.9% increase occurred between the initial and final immersion periods and one increase of 1.8% between the values of the final and pre-immersion periods, which were also considered measures of normal physiological adjustments

At the maximum inspiratory pressure, there was a mean decrease of 8 cm of water between the initial period of immersion and the pre-immersion; this change was considered clinically significant; between the periods of immersion, an average

At the maximum expiratory pressure in relation to the values obtained between the pre-immersion and initial immersion periods, we obtained an increase of 7.4 cm of water, and subsequently between the immersion and thin periods, there was a drop of 6.8 cm of water. This study showed that hydrotherapy is a therapeutic resource that does not represent an overload for children with Duchenne muscular dystrophy. Another study [7] was aimed to verify the benefits of hydrotherapy in improving gait and balance in patients with mild spastic diplegic type of muscular dystrophy, using a proposed protocol. The objective of this study was to analyze the changes in movements in the lower limbs during gait through a treatment protocol using aquatic rehabilitation, to help the child to achieve better gait independence,

increase of 3.8 cm of water was observed of maximal inspiratory pressure.

for which a case study was used, selecting a male child with gait changes.

The protocol was based on relaxation for 5 minutes: muscle stretching of ankle flexors, ankle dorsiflexors, hip adductors, hip and trunk flexors; passive ankle, plantar and dorsiflexion and circular movements; pelvic girdle dissociation; muscle

**78**

Another research [10] studied the correlation between fat mass and age in Duchenne muscular dystrophy. Were selected 68 individuals with ages between 5 and 20 years, with molecular diagnosis of DMD. All were submitted to weight and height measurements and to the body composition analysis test with the use of bioimpedance, in the morning, all on the same day. The results were analyzed by grouping the individuals into quartiles of age and showed a body mass index (BMI) of 21 ± 8 kg/m2 . Thus, it was observed that, with the age and degree of sedentarism imposed by the disease, there was an accumulation of body fat and loss of lean mass. They understand that, in fact, more studies are needed related to the nutritional characteristics of these individuals, in order to better clarify the effects of disease and feeding on the percentage gain and fat mass.

An investigation [11] was conducted to evaluate respiratory muscle strength and peak flow in patients with Duchenne muscular dystrophy undergoing noninvasive ventilation and hydrotherapy. Six volunteers of male gender, aged between 13 and 19, were divided into two groups: control (treated with hydrotherapy) and experimental (treated with hydrotherapy associated with NIV), which were evaluated before and after the 10th and 20th sessions. The results showed a significant difference (p < 0.05) when we compared MEP between the control and experimental groups after the 10th (p = 0.025) and the 20th (p = 0.005) sessions. The study demonstrated that NIV was able to influence an increase in life expectancy, according to the patients' own reports, and that hydrotherapy was a favorable therapy in the improvement of the expiratory musculature in patients with DMD. For this purpose, physical activities were carried out once a week in a pool, with a duration of 30 minutes. The main objective was to maintain and stimulate the patient's respiratory function, which was exercised without the use of a life-saving vest or other type of fluid. The pool height was 110 cm in the shallow part and 115 cm in the deepest part. The water was kept warm at 34°C. The activities were carried out with a group of three children besides the teacher. For warm-up exercises, for 10 minutes, involving movements of the body segments, the following activities were carried out to collect rings at the bottom of the pool, to pass under and over flutuators organized in sequence, to enter and exit the flutuators, to blow balls and fish of floating material and to sink balls. For each of these activities, it was requested to perform inspiration out of the water and exhale with the whole body inside the water. In this way the water exerted pressure against the rib cage, and the inspiration occurred against the resistance. At the end, in the period of 3 to 4 minutes, relaxation was carried out with the student floating in the pool. Six measurements were performed, once a month. The first occurred on July 8, 2001, and the last on December 5, 2001. The values were obtained for respiratory rate per minute and vital capacity. No changes were observed in the value of vital capacity between the first and last evaluations, remaining in 800 cm3. Regarding respiratory rate, a decrease from 29 to 26 cycles per minute was observed. It was observed that there was an increase in the thoracic perimeter in normal inspiration and deep inspiration over the 6 months. There was an increase of 1.5 cm in the thoracic perimeter in the normal inspiration and the values obtained in the thoracic perimeter evaluations. According to the author [12] who studies the muscular attrition associated to DMD starts at the beginning of the second childhood and respiratory muscle weakness leads to a series of events that culminate in respiratory complications that worsen considerably at around 10 to 19 years of age. The respiratory complications presented by DMD patients are due, in part, to muscle weakness and thoracic cavity changes caused by scoliosis that affects the patient with disease progression [13].

In another study [14] authors sought to determine the effects of pool physical exercises on the pulmonary function of the person with Duchenne muscular dystrophy. Physiotherapeutic treatment has proven to be important not only in-patient rehabilitation but also in the prevention of imperative changes in this pathology and in teaching to the family, because better results are expected if the parents cooperate.

**81**

ergometer.

skills.

*Physical Exercise as a Tool to Delay the Development Process of Duchenne Muscular Dystrophy*

Examinations of neurodevelopmental status, locomotor system, functional capacity and respiratory system are therefore important. Only then can the main problems be identified, to collect the necessary information and then structure the treatment objectives, which vary according to each specific case. Thus, several protocols have been introduced in order to document the evolution of neuromuscular diseases. Timed functional tests and specific rating scales were designed to document decreased functional capacity. Developed in 1963, the "Vignos Scale for the Classification of Duchenne Muscular Dystrophy Cases" was elaborated [15] which determines the functional degrees of limbs. Repeated studies were developed to determine the reliability of the functional tests, including the Vignos scale, which demonstrated a high degree of reliability. Manual muscle testing (MMT) and its quantitative muscle testing (QMT) were also applied in order to determine its

usefulness and reliability to document the evolution of functional decay.

Quantitative muscle testing (QMT) includes determination of isometric strength

Tests that examine respiratory function, including forced vital capacity (FVC) and forced expiratory volume (FEV) per second, determined with the help of the vitalograph, provide information about the strength of the respiratory muscles. It may be equally interesting to determine the endurance capacity of the respiratory muscles. For professional evaluation of the examination plan to be used, the child's age, ability to follow instructions, availability of equipment, place of examination (clinic, residence, school), available time and (for research purposes or to serve as a

Currently, some specialized sites have a specific record of evaluation of these neuromuscular pathologies, the "MRC grading muscle strength". This sheet assesses the strength of different muscle groups of the upper and lower limbs and head and trunk but also refers to joint limitations caused by contractures as well as motor

Although these assessments are quite comprehensive and complex, they should be repeated regularly for a correct planning of the treatment, according to the current needs of the individual in question. These needs vary according to the stage of

**3. Hydrotherapy on Duchenne muscular dystrophy cases: a summary** 

Hydrotherapy with temperatures above 30°C will have a beneficial effect on circulation and will improve the elasticity of connective tissue. Particular attention should be paid to the excessive weariness of the child, which very hot water can

Muscle strengthening techniques are not indicated, as it is reported that they worsen muscle degradation. It is extremely important to prevent contractures and deformities. In this way the exercises should be performed in the most affected

Tibiotarsus and feet—the use of instrumental positions with wedges and in vertical or inclined plane, thus using body weight. When the child is seated, the feet should be supported in a neutral position of the tibiotarsus and without abduction of the hips. The purpose of this care is to prolong verticalization, the use of foot-

and is the most direct method to examine the contractile activity of a particular muscle group. It has the advantage of muscle length, joint angle and speed of being kept constant. This test requires the application of special equipment such as an

*DOI: http://dx.doi.org/10.5772/intechopen.84453*

basis for treatment) need to previously assessed.

the patient, and their treatment must be adapted.

**proposal for intervention**

cause, since fatigue is harmful.

regions of the body such as:

wear and the absence of pain in the region.

#### *Physical Exercise as a Tool to Delay the Development Process of Duchenne Muscular Dystrophy DOI: http://dx.doi.org/10.5772/intechopen.84453*

Examinations of neurodevelopmental status, locomotor system, functional capacity and respiratory system are therefore important. Only then can the main problems be identified, to collect the necessary information and then structure the treatment objectives, which vary according to each specific case. Thus, several protocols have been introduced in order to document the evolution of neuromuscular diseases. Timed functional tests and specific rating scales were designed to document decreased functional capacity. Developed in 1963, the "Vignos Scale for the Classification of Duchenne Muscular Dystrophy Cases" was elaborated [15] which determines the functional degrees of limbs. Repeated studies were developed to determine the reliability of the functional tests, including the Vignos scale, which demonstrated a high degree of reliability. Manual muscle testing (MMT) and its quantitative muscle testing (QMT) were also applied in order to determine its usefulness and reliability to document the evolution of functional decay.

Quantitative muscle testing (QMT) includes determination of isometric strength and is the most direct method to examine the contractile activity of a particular muscle group. It has the advantage of muscle length, joint angle and speed of being kept constant. This test requires the application of special equipment such as an ergometer.

Tests that examine respiratory function, including forced vital capacity (FVC) and forced expiratory volume (FEV) per second, determined with the help of the vitalograph, provide information about the strength of the respiratory muscles. It may be equally interesting to determine the endurance capacity of the respiratory muscles. For professional evaluation of the examination plan to be used, the child's age, ability to follow instructions, availability of equipment, place of examination (clinic, residence, school), available time and (for research purposes or to serve as a basis for treatment) need to previously assessed.

Currently, some specialized sites have a specific record of evaluation of these neuromuscular pathologies, the "MRC grading muscle strength". This sheet assesses the strength of different muscle groups of the upper and lower limbs and head and trunk but also refers to joint limitations caused by contractures as well as motor skills.

Although these assessments are quite comprehensive and complex, they should be repeated regularly for a correct planning of the treatment, according to the current needs of the individual in question. These needs vary according to the stage of the patient, and their treatment must be adapted.
