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

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 cause, since fatigue is harmful.

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 regions of the body such as:

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 footwear and the absence of pain in the region.

*Muscular Dystrophies*

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

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

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

clarify the effects of disease and feeding on the percentage gain and fat mass.

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.

. Thus, it was observed that,

of age and showed a body mass index (BMI) of 21 ± 8 kg/m2

**80**

Knees—usually only needed after loss of gait to prevent flexion by retraction of the hamstrings, allowing prolongation of the verticalization and adoption of a more comfortable sleeping position, manual stretching posture and posture with weights in a sitting position, with the basin in retroversion and the lower limbs aligned.

Ankle—in small children it is possible to do the manual stretching in the ventral decubitus, with the knee in 90° bending. In greater angles the instrumental stance is necessary and in passive mobilization. The use of the ventral decubitus should be recommended whenever possible for sleeping, watching television, reading, etc.

Spine—changes occur after loss of gait. The use of orthoses, which can be the shaped vest, is of controversial interest. During the reducible phase, the manual positions of flank opening in the concavity and the passive traction are used.

Shoulders—tardily after loss of gait, make manual stretches of upper trapezius.

Elbows—also after loss of gait. The aim is not to totally avoid bending but to stagnate the angle at which there is the best lever arm for the weakened flexor muscles. Already the supination deficit must be combated, with mobilization and manual postures.

It is also not a goal to completely combat the retraction of the flexors and extensors of the wrist, since from a certain point the tenodesis grasp (passive hand grasp and release induced by wrist extension or flexion) may be the only one possible.

Hydrotherapy is also important in terms of respiratory function, as it depends on the efficacy of respiratory muscles, as well as the degree of bronchial obstruction, once is known the hydrostatic pressure factor on the rib cage. Because of the initial deficit of forced expiration and cough efficacy, maintenance of bronchial clearance is particularly important from early stages. Subsequently, the ability to inhale deeply is lost.

This is particularly important if we note that in the lung development process, the number of pulmonary alveoli stabilizes at about 8 years of age and then increases in size to adult size. If deep inspirations are not performed, which are important for this increase, the alveolar growth is not so great, being a factor of aggravation of the restrictive disease and of the thoracic deformity.

Hydrotherapy should be done regularly as it improves the technique of bronchial clearance and acceleration of the expiratory flow, causing an active (possible while walking) or passive expiration, which causes the secretions to be released up to the coughing zone. Previously, the secretions must be humidified with air or with flutuators. Percussions are often traumatic and vibrations alone are not productive.

The amplitude maintenance techniques are initially activated and then performed using ventilatory assist devices. When vital capacity equals tidal volume, measures may be taken to establish permanent ventilation.

Until a few years ago, physical treatment of DMD was aimed at preserving and stimulating mobility and motility (as far as possible) through "corrective gymnastics, swimming, prophylaxis of contractures, combating inactivity and unnecessary bed rest" [5] which consisted of nondrug treatment. However, physical therapy is much more than "corrective gymnastics", "swimming" and "combating inactivity". Physical therapy traces treatment with goal-based conduits.

The goal of physical therapy is to enable the child to gain control over his or her possible movements, balance and general coordination, delay weakness of the pelvic girdle and scapular muscles, correct postural alignment (standing, sitting, lying down or during movements), balancing muscle work, avoid fatigue, develop the contractile force of respiratory muscles and control breathing through the correct use of the diaphragm and prevent early muscle shortening.

To achieve these goals, a playful treatment is proposed to indulge playfulness of these patients, as they are still children and become bored easily. Physiotherapeutic procedures should be adapted to the age range of the child and are mainly aimed at

**83**

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

delaying clinical evolution and preventing secondary complications (contractures and deformities). In some cases, corrective surgeries and orthotics assist in the

The specific respiratory exercises include motivation, such as "flower smelling" and "blow the candle", provided that in dorsal decubitus at 45° of inclination, neither the inspiratory reserve volume nor the expiratory reserve volume (VRE), without using the accessory muscles, nor do resistance to expiration. Taking this into account, it's important to highlight that the effects of inspiratory resistance training on respiratory muscle function were investigated. The authors [11] evaluated 11 patients with DMD and facioscapulohumeral muscular dystrophy, after respiratory training, which consisted of 2 sessions of 15 min per day at home for 6 weeks; there was a significant increase in respiratory muscle endurance, positively correlated with vital capacity (r = 0.84, p < 0.05) and maximal inspiratory pressure (r = 0.76, p < 0.05). According to the authors, the improvement of respiratory muscle function may delay the installation of respiratory complications in these patients. In another study on respiratory muscle training with patients with DMD and spinal muscular atrophy, it was found that gains in expiratory muscle strength were rapidly lost with the end of treatment. However, the perception of respiratory effort remained for a longer period, which could be associated with a reduction of respiratory symptoms. In a 6-month study of specific inspiratory muscle training in DMD patients in the advanced stages, the authors realized that, even after 6 months of termination of the training protocol, the respiratory benefits remained for a long

The activities in the therapeutic balls favor the alignment and flexibility of the spine, stimulate the mechanoreceptors and articular proprioceptors and improve

The use of hydrotherapy, using methods adapted from Halliwick and Bad Ragaz, is a complementary feature to ground kinesiotherapy, in order to improve muscle strength, respiratory capacity and joint amplitudes and avoid muscular shortening. The causes of orthopedic contractures in neurological patients are immobilization, muscle weakness and spasticity. The literature describes techniques of treatment of contractures passive stretching, continuous passive mobilization, splinting, electrical stimulation, botulinum toxin injections and tenotomies. There is no consensus on the best way to use the techniques of treatment of contractures, whether combined or isolated in series. Stretching of the sural triceps, ilium-psoas and tibialis-ischemia should be stimulated in the early stages. Short, ankle-foot orthosis (AFO) or long knee-ankle-foot orthosis (KOFO) should be worn at night to prevent muscle shortening. For postural alignment, instruct the child not to stay too long in the same position and give the child the highest body awareness possible. Parents should be instructed and trained to continue home treatment and to encourage their children to engage in age-oriented recreational activities that provide balance, strength and coarse motor coordination. One study [16] followed 204 children with DMD for a period of 8.9 years on average at a research center in the United States. It was able to monitor the effects of physical therapy and orthopedic treatment on lower limb contractures (LLC) and the duration of walking ability. MMI contractures were better controlled when patients performed a combination

tone and muscle strength, coordination and balance.

Free active and isometric exercises are proposed. Playing a wooden doll, because the movements are monoarticular, requires the contraction of a muscle or a reduced group of muscles; on quadruped or weight-bearing position, as it strengthens the scapular and pelvic girdle. During the execution of these exercises, one must seek to evaluate the range of motion (ROM) and muscle strength, request isometric contractions during movements and make use of weight segments as resistance for

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

treatment.

period of time.

the muscle group exercised.

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

delaying clinical evolution and preventing secondary complications (contractures and deformities). In some cases, corrective surgeries and orthotics assist in the treatment.

Free active and isometric exercises are proposed. Playing a wooden doll, because the movements are monoarticular, requires the contraction of a muscle or a reduced group of muscles; on quadruped or weight-bearing position, as it strengthens the scapular and pelvic girdle. During the execution of these exercises, one must seek to evaluate the range of motion (ROM) and muscle strength, request isometric contractions during movements and make use of weight segments as resistance for the muscle group exercised.

The specific respiratory exercises include motivation, such as "flower smelling" and "blow the candle", provided that in dorsal decubitus at 45° of inclination, neither the inspiratory reserve volume nor the expiratory reserve volume (VRE), without using the accessory muscles, nor do resistance to expiration. Taking this into account, it's important to highlight that the effects of inspiratory resistance training on respiratory muscle function were investigated. The authors [11] evaluated 11 patients with DMD and facioscapulohumeral muscular dystrophy, after respiratory training, which consisted of 2 sessions of 15 min per day at home for 6 weeks; there was a significant increase in respiratory muscle endurance, positively correlated with vital capacity (r = 0.84, p < 0.05) and maximal inspiratory pressure (r = 0.76, p < 0.05). According to the authors, the improvement of respiratory muscle function may delay the installation of respiratory complications in these patients. In another study on respiratory muscle training with patients with DMD and spinal muscular atrophy, it was found that gains in expiratory muscle strength were rapidly lost with the end of treatment. However, the perception of respiratory effort remained for a longer period, which could be associated with a reduction of respiratory symptoms. In a 6-month study of specific inspiratory muscle training in DMD patients in the advanced stages, the authors realized that, even after 6 months of termination of the training protocol, the respiratory benefits remained for a long period of time.

The activities in the therapeutic balls favor the alignment and flexibility of the spine, stimulate the mechanoreceptors and articular proprioceptors and improve tone and muscle strength, coordination and balance.

The use of hydrotherapy, using methods adapted from Halliwick and Bad Ragaz, is a complementary feature to ground kinesiotherapy, in order to improve muscle strength, respiratory capacity and joint amplitudes and avoid muscular shortening.

The causes of orthopedic contractures in neurological patients are immobilization, muscle weakness and spasticity. The literature describes techniques of treatment of contractures passive stretching, continuous passive mobilization, splinting, electrical stimulation, botulinum toxin injections and tenotomies. There is no consensus on the best way to use the techniques of treatment of contractures, whether combined or isolated in series. Stretching of the sural triceps, ilium-psoas and tibialis-ischemia should be stimulated in the early stages. Short, ankle-foot orthosis (AFO) or long knee-ankle-foot orthosis (KOFO) should be worn at night to prevent muscle shortening. For postural alignment, instruct the child not to stay too long in the same position and give the child the highest body awareness possible. Parents should be instructed and trained to continue home treatment and to encourage their children to engage in age-oriented recreational activities that provide balance, strength and coarse motor coordination. One study [16] followed 204 children with DMD for a period of 8.9 years on average at a research center in the United States. It was able to monitor the effects of physical therapy and orthopedic treatment on lower limb contractures (LLC) and the duration of walking ability. MMI contractures were better controlled when patients performed a combination

*Muscular Dystrophies*

manual postures.

inhale deeply is lost.

Knees—usually only needed after loss of gait to prevent flexion by retraction of the hamstrings, allowing prolongation of the verticalization and adoption of a more comfortable sleeping position, manual stretching posture and posture with weights in a sitting position, with the basin in retroversion and the lower limbs aligned.

Ankle—in small children it is possible to do the manual stretching in the ventral decubitus, with the knee in 90° bending. In greater angles the instrumental stance is necessary and in passive mobilization. The use of the ventral decubitus should be recommended whenever possible for sleeping, watching television, reading, etc. Spine—changes occur after loss of gait. The use of orthoses, which can be the shaped vest, is of controversial interest. During the reducible phase, the manual positions of flank opening in the concavity and the passive traction are used.

Shoulders—tardily after loss of gait, make manual stretches of upper trapezius. Elbows—also after loss of gait. The aim is not to totally avoid bending but to stagnate the angle at which there is the best lever arm for the weakened flexor muscles. Already the supination deficit must be combated, with mobilization and

It is also not a goal to completely combat the retraction of the flexors and extensors of the wrist, since from a certain point the tenodesis grasp (passive hand grasp and release induced by wrist extension or flexion) may be the only one possible. Hydrotherapy is also important in terms of respiratory function, as it depends on the efficacy of respiratory muscles, as well as the degree of bronchial obstruction, once is known the hydrostatic pressure factor on the rib cage. Because of the initial deficit of forced expiration and cough efficacy, maintenance of bronchial clearance is particularly important from early stages. Subsequently, the ability to

This is particularly important if we note that in the lung development process, the number of pulmonary alveoli stabilizes at about 8 years of age and then increases in size to adult size. If deep inspirations are not performed, which are important for this increase, the alveolar growth is not so great, being a factor of

Hydrotherapy should be done regularly as it improves the technique of bronchial clearance and acceleration of the expiratory flow, causing an active (possible while walking) or passive expiration, which causes the secretions to be released up to the coughing zone. Previously, the secretions must be humidified with air or with flutuators. Percussions are often traumatic and vibrations alone are not productive. The amplitude maintenance techniques are initially activated and then performed using ventilatory assist devices. When vital capacity equals tidal volume,

Until a few years ago, physical treatment of DMD was aimed at preserving and stimulating mobility and motility (as far as possible) through "corrective gymnastics, swimming, prophylaxis of contractures, combating inactivity and unnecessary bed rest" [5] which consisted of nondrug treatment. However, physical therapy is much more than "corrective gymnastics", "swimming" and "combating inactivity".

The goal of physical therapy is to enable the child to gain control over his or her possible movements, balance and general coordination, delay weakness of the pelvic girdle and scapular muscles, correct postural alignment (standing, sitting, lying down or during movements), balancing muscle work, avoid fatigue, develop the contractile force of respiratory muscles and control breathing through the correct

To achieve these goals, a playful treatment is proposed to indulge playfulness of these patients, as they are still children and become bored easily. Physiotherapeutic procedures should be adapted to the age range of the child and are mainly aimed at

aggravation of the restrictive disease and of the thoracic deformity.

measures may be taken to establish permanent ventilation.

Physical therapy traces treatment with goal-based conduits.

use of the diaphragm and prevent early muscle shortening.

**82**


#### **Table 1.**

*General exercises guidelines for patients with DMD [18].*

of daily passive stretches, stood and walked for some periods of the day, had a tenotomy of the calcaneus tendon, transferred posterior tibial tendon and applied KAFO-type orthoses. After 2 years of the use of bracing, the calcaneus contractures were identical in those patients who performed and who did not perform surgeries. Near the fourth-year post-bracing, however, patients who did not undergo surgery had more severe contractures. Five to 7 years after the operation and the use of bracing, the management of contractures was still good, especially in those patients who performed posterior tibial tendon transfer.

Knee contractions were controlled 5 to 7 years after the placement of bracing, with or without surgery. Patients who used bracing were able to walk for an average of 13.6 years, and even after they lost the ability to walk with bracing, the use of orthoses allowed these patients to remain in orthostasis for an additional 2 years. Another study [17] also reinforces the prolongation of gait and orthostasis with the aid of KAFO-type orthoses, but there is no clarification as to whether it is possible to prolong gait functionally.

These procedures are just suggestions. It is up to the technician to choose the most suitable resources available to his/her patients. It is important to note that fatigue and myalgia on the day after the physical therapy session indicate that there was an excess in the number of exercises and their repetitions and that the intensity should be decreased and have more time to rest. Therefore, the main objective to be achieved is to improve the quality of life and the functionality of these children. The quality of life of an adult can be improved by increasing their independence. For the child, the improvement of their quality of life implies the action of playing, however, in a functional way.

In the late stages of the life of the DMD patient, the goal is to comfort the patient: treat pain and dyspnoea, provide palliative care, meet the psychosocial and spiritual needs of the patient and family and respect the patient's and family's choices in what examination and treatment (**Table 1**).
