Stretching Exercises

These exercises focus on maintaining muscle flexibility and range of motion, crucial for preventing contractures in DMD.

1. Side Twist Wrist Stretch

Purpose: Loosens wrist muscles to maintain flexibility.
Steps:
Have your child sit upright on a bed or bench.
Ask them to place one hand flat on the surface, fingers pointing outward at a 90-degree angle from their body.
Gently press their fingers down to keep them flat.
Support their elbow to keep it steady (it doesn’t need to be stiff or locked).
Hold the stretch for 30–60 seconds, repeat three times, then switch to the other hand.

2. Seated Finger Extension

Purpose: Keeps finger and hand muscles flexible and relaxed.
Steps:
Have your child sit comfortably in a chair or on a bed.
Help them extend one arm, bending the elbow to about 90 degrees.
Stand beside or behind them, holding their palm with both of your hands.
Gently open their palm.
Slowly slide your hands down to their fingers, extending them toward the floor.
Hold for 60 seconds, release, repeat once more, then switch to the other hand.

3. Moving Hand and Wrist Stretch

Purpose: Maintains range of motion in the arms through gentle movement.
Steps:
Have your child lie flat on their back.
Sit beside the arm you’ll stretch.
Ask them to extend their arm; support their elbow with one hand.
With your other hand, hold their arm near the wrist, gently keeping their fingers open if possible.
Slowly bend their elbow to at least 90 degrees, then straighten it back out (avoid forcing any movement).
Repeat this motion 10 times, rest, then do 1–2 more sets. Switch to the other arm.

4. Forearm Stretch

Purpose: Stretches forearm muscles to reduce tightness.
Steps:
Have your child lie on their back.
Use one hand to hold their elbow against their side throughout the stretch.
With your other hand, grasp their arm just above the wrist.
Bend their elbow to 90 degrees, palm facing up.
Hold for 60 seconds, release, repeat once more, then switch to the other hand.

5. Hip Flexor Stretch

Purpose: Loosens the hip flexor muscles (front of the pelvis and thighs)
Steps:
Have your child lie face down on a flat surface.
Stand on the side you’ll stretch, resting one knee on the surface for stability.
Place one hand on their lower back (on the stretching side).
Place your other hand under their knee on the same side.
Gently lift their leg while lightly pressing their lower back down.
Hold for 30–60 seconds, repeat 1–2 more times, then switch to the other leg.

6. Iliotibial Band Stretch

Purpose: Maintains flexibility in the iliotibial (IT) band (outer thigh tissue).
Steps:
Have your child lie face down.
Stand on the side you’ll stretch.
Gently press one hand on their lower back.
Use your other hand to lift their knee on the same side.
Swing their leg gently across their body’s midline and hold it there.
Hold for 60 seconds, release, repeat once more, then switch to the other leg.

7. Supine Calf Stretch

Purpose: Keeps calf muscles flexible.
Steps:
Have your child lie face down.
Bend one of their knees to 90 degrees.
Use one hand to stabilize their lower leg.
With your other hand, hold the bottom of their foot and heel.
Gently flex their foot toward their shin as far as comfortable.
Hold for 60 seconds, release, repeat once more, then switch to the other leg.

8. Lying Achilles Stretch

Purpose: Stretches the Achilles tendon (calf to heel connection).
Steps:
Have your child lie on their back with a small rolled towel under their knees.
Hold their heel with one hand, pulling gently to straighten the leg.
Help them flex their foot toward their shin as much as they can without discomfort.
Hold for 60 seconds, release, repeat once more, then switch to the other leg.

Additional Exercises

These exercises focus on strength, respiratory function, and functional independence, complementing the stretching routine.

9. Isometric Quadriceps Contraction

Purpose: Strengthens quadriceps without excessive strain.
Steps:
Have your child sit on a chair edge, leg hanging down.
Straighten leg, hold for 5-10 seconds.
Repeat 5-10 times per leg.
Note: Ensure normal breathing during contraction.

10. Deep Breathing Exercises

Purpose: Improves respiratory function, strengthens diaphragm.
Steps:
Lie on back, hands on chest and abdomen.
Inhale deeply through nose, abdomen rises.
Exhale slowly through mouth, abdomen falls.
Repeat for 5-10 minutes.
Note: Helps expand lungs, crucial for DMD progression.

11. Water Walking
Purpose: Low-impact exercise, reduces muscle strain.

Steps:
Enter pool, water at waist level.
Walk forward, backward, sideways; include leg kicks, arm movements.
Supervise for safety.
Note: Buoyancy makes movement easier, less painful.

12. Standing from Sitting Practice

Purpose: Maintains ability to stand, enhances independence.
Steps:
Sit in chair with arms, use arms to push up, stand, minimize leg effort.
Practice regularly.
Note: Supports daily activities, preserves strength.

13. Isometric Bicep Contraction

Purpose: Strengthens biceps without movement.
Steps:
Sit, arm extended on table, push against resistance (e.g., hand) without moving, hold 5-10 seconds.
Repeat 5-10 times per arm.
Note: Avoids muscle lengthening, safe for DMD.

Comprehensive Analysis of Physical Therapy Exercises for Duchenne Muscular Dystrophy (DMD)

This section provides a detailed exploration of physical therapy exercises for children with Duchenne Muscular Dystrophy (DMD), combining both stretching and additional strengthening/functional exercises to support muscle function and quality of life. The analysis is grounded in a review of medical and physical therapy resources, ensuring a professional and evidence-based approach.

Background and Rationale

DMD is a genetic disorder caused by mutations in the DMD gene, leading to progressive muscle degeneration and weakness, particularly affecting males due to its X-linked inheritance. Physical therapy is a cornerstone of management, aiming to maintain flexibility, range of motion, muscle strength, and functional independence. The initial request included nine stretching exercises, focusing on passive stretches for various muscle groups. These are essential for preventing contractures and maintaining mobility. However, to address other aspects of physical therapy, additional exercises focusing on strength, respiratory function, and functional activities are necessary, especially given the disease’s impact on respiratory muscles and overall mobility over time.

Methodology

The process involved identifying exercises not covered in the initial list, focusing on those commonly recommended in DMD care guidelines and supported by clinical evidence. The exercises were categorized into stretching (nine exercises) and additional exercises (five exercises), ensuring they align with the needs of DMD patients at various stages. Each exercise was described with detailed steps, purposes, and precautions, drawing from the sources reviewed.

Detailed Exercise Descriptions

The following tables summarize the stretching and additional exercises, their purposes, and step-by-step instructions, ensuring clarity for caregivers and alignment with professional recommendations:

Safety and Customization: All exercises must be tailored to the child’s current abilities and stage of DMD, as emphasized across sources. Muscular Dystrophy News (Duchenne muscular dystrophy: Exercise and physical therapy) stresses consulting neuromuscular specialists every six months to assess muscle strength and function, ensuring exercises are safe and effective. The need for professional supervision is critical, given the risk of muscle damage from inappropriate exercises, as noted in the MDA Quest article.

Surprising Benefit: Water-Based Exercises

A notable finding is the significant potential of water-based exercises like Water Walking, which not only reduce muscle strain but also improve respiratory and muscle function. This approach offers an inclusive activity for both ambulatory and non-ambulatory children, enhancing quality of life in ways not typically emphasized in standard stretch routines.

Conclusion

This comprehensive list of 14 exercises, divided into 9 stretching and 5 additional exercises, provides a holistic approach to physical therapy for DMD. The stretching exercises maintain flexibility, while the additional exercises support strength, respiratory function, and functional independence.

Caregivers should consult a physical therapist to personalize these exercises, ensuring safety and efficacy for their child’s specific condition.

Here is a list of various types of equipment that can be used to help people with Duchenne Muscular Dystrophy (DMD):

Mobility and Support:

Wheelchairs:

Manual Wheelchairs: For early stages when some upper body strength remains. Lightweight models are often preferred.

Power Wheelchairs: Essential as muscle weakness progresses. They offer independence and can be highly customized with features like tilt-in-space, recline, and power elevating leg rests.

Standing Wheelchairs: Allow for supported standing, which can have benefits for bone density, circulation, and social interaction.

Walkers and Gait Trainers: May be used in the earlier stages to provide support and stability during ambulation.

Standing Frames: Used to achieve a supported standing position for periods of time, even when independent walking is no longer possible.

Transfer Devices: Including transfer boards, slings, and patient lifts, to safely move between surfaces (bed, wheelchair, toilet).

Orthotics (Braces and Supports):

Ankle-Foot Orthoses (AFOs): Provide support to the ankles and feet, helping with gait and preventing contractures.

Knee-Ankle-Foot Orthoses (KAFOs): Offer more extensive support to the legs.

Spinal Supports (TLSOs): May be used to provide trunk stability and support posture as scoliosis can develop.

Activities of Daily Living (ADLs):

Adaptive Eating Utensils: Ergonomic handles, weighted utensils, or specialized designs to aid with feeding.

Plate Guards and Non-Slip Mats: Help prevent food from slipping off plates.

Dressing Aids: Button hooks, zipper pulls, sock aids, and long-handled shoe horns to assist with dressing.

Reaching Aids: Long-handled grabbers to retrieve objects that are out of reach.

Adapted Toileting Equipment: Raised toilet seats, commode chairs, grab bars, and bidets for hygiene and independence.

Bathing Aids: Shower chairs, bath lifts, long-handled sponges, and adapted faucets.

Communication and Technology:

Communication Devices (AAC – Augmentative and Alternative Communication): Tablets or dedicated devices with speech output, controlled by touch, eye gaze, or switches.

Environmental Control Units (ECUs): Allow control of lights, TVs, doors, and other devices using switches, voice commands, or other interfaces.

Computer Access Adaptations: Adapted keyboards, mice, trackballs, touch screens, and voice recognition software.

Smart Home Technology: Voice-activated assistants and smart devices can increase independence.

Respiratory Support:

Cough Assist Devices (Mechanical Insufflation-Exsufflation): Help clear secretions from the lungs when the muscles for coughing are weak.

Non-Invasive Ventilation (NIV): CPAP or BiPAP machines to provide breathing support, often used at night.

Oxygen Therapy: May be needed in later stages if oxygen levels become low.

Suction Machines: To remove secretions from the airway.

Recreational and Play:

Adapted Toys: Toys with larger buttons, easier grips, or alternative activation methods.

Assistive Technology for Gaming: Adapted controllers, switches, and software.

Adapted Sports Equipment: Depending on abilities, modified equipment for activities.

Accessible Playgrounds: Featuring ramps, adapted swings, and inclusive designs.

Home Modifications:

Ramps and Lifts: To provide access to different levels of the home.

Wider Doorways and Hallways: To accommodate wheelchairs.

Accessible Bathrooms and Kitchens: With roll-under sinks, adapted countertops, and accessible showers.

Grab Bars and Handrails: For support and stability.

Other Equipment:

Hospital Beds: Adjustable beds can provide comfort and aid with positioning.

Pressure Relief Mattresses and Cushions: To prevent skin breakdown due to prolonged sitting or lying.

Pulse Oximeters: To monitor oxygen saturation levels.

Feeding Tubes (Gastrostomy Tubes – G-tubes): May be necessary if swallowing becomes difficult and nutritional needs cannot be met orally.

It’s important to note that the specific equipment needed will vary greatly depending on the individual’s stage of Duchenne, their specific needs and abilities, and the recommendations of their healthcare team (including physicians, physical therapists, occupational therapists, and respiratory therapists). Regular assessments are crucial to ensure the right equipment is provided and adjusted as needed.