PHYSIOTHERAPY BASICS

For PPMD Israel

April 2011

WHY IS A PHYSICAL THERAPIST NEEDED?

A PT is best qualified to monitor all aspects of the musculoskeletal system including

Muscle strength

Functional abilities & gross motor skills

Range of movement in joints

Respiratory function

Monitor the spine to prevent scoliosis

By careful regular assessment the PT will know when treatment and interventions are needed preferably before secondary problems arise

EARLY YEARS ( FROM DIAGNOSIS )

Encourage some active exercise ( normal

recreational activities are good )

Start a hydrotherapy or swimming program

Begin the stretch program

Introduce night splints as needed

Begin early respiratory activities with

whistles bubbles and blowing toys

PT ASSESSMENTS

What are they

How often

Who

Why

WHAT ASSESSMENTS

Muscle strength--- Manual Muscle Tests & Myometry

Range of movement in joints

Assessment of posture & gait

Timed tests 6 minute walk

Motor Function scales

Respiratory function tests

Activity of daily living assessment

WHAT IS ‘SUITABLE ’EXERCISE?

Hardest exercise should be done in water

Normal age appropriate activities which do not

cause too much fatigue

Or in a non weight bearing way such as on

bicycles

MORE ABOUT SUITABLE EXERCISE

Low load = gravity eliminated

Concentric=muscle fibers are shortening as they fire

Non weight bearing =bicycles &swimming

All conducted within fatigue levels

ACTIVE EXERCISE IN POOL

PREVENTING OR MINIMIZING CONTRACTURES

Stretches

* active self stretches

* passive self stretches

* manual stretches

Splints to be worn at night

Standing, Easy stand, standing frames,

prone lying

WHY DO WE STRETCH?

Prevents the scar tissue from ‘firming' in a shortened position

Maintain the length in those muscles which tighten

Maintains symmetry Prolongs ability to

walk Improves comfort Keep feet on foot

plates & wear shoes Ease of dressing Comfort especially

comfort in bed

STRETCHES IN THE EARLY YEARS

Lower limb

* Tendo Achilles ( ankle )

* Hamstrings ( back of thigh )

* Hip flexors ( front of hip )

* Iliotibial band ( side of thigh )

Upper limb

Will need checking only, until much

later but always check the fingers

ORTHOTICS (NIGHT SPLINTS)

WHY WEAR THEM

To keep ankle at maximum comfortable range

while he sleeps

Prevents the weight of bed clothes pushing

feet into a plantar flexed ( pointing down )

position.

Most effective way of preventing contractures

is to do stretches and wear night splints

( Hyde et al 2000 )

Walking is becoming more difficult

Falls are more frequent

Needs to provide help to travel long

distances_ consider equipment options

Begin teaching respiratory measures –

familiarize with Ambu bag and cough Assist

IN MIDDLE YEARS

ASSESSMENT OF POSTURE AND GAIT

PT ‘s regular assessment

of gait & posture will

identify changes which

may modify his treatment

Eg this boy’s asymmetrical

stance will lead to

contractures in the leg

which he uses to prop

DON’T LET HIM WALK LONG

DISTANCES- PROVIDE TRANSPORT

ASSESSMENT OF SITTING POSTURE &

INTERVENTION

Most boys who have had the benefits

steroids are remaining strong in the spinal

muscles

However If strength is declining

It is important to monitor closely

Consider seating options and provide good

supports before they are needed

IF WHEN SITTING HE IS BEGINNING TO LOSE THE

NORMAL SPINAL CURVES

THERE IS AN INCREASING RISK OF SCOLIOSIS

DEVELOPMENT

LATER YEARS

When no longer weight bearing- focus on restoring independent mobility with best posture modified motorised chair

Provide back up manual chair and recommend other aids and equipment

Continue stretches –concentrating on upper limb to maintain use of hands

Continue hydrotherapy as appropriate

Respiratory therapy Cough assist and Ambu bag training

WHAT SORT OF

POSTURAL

MODIFICATIONS AND

SEATING

NO SUPPORT FOR DECLINING STRENGTH

IN STANDARD SEATING

Weight of gravity

through erect

spine causes it to

collapse

No support for

normal spinal

curves

SUPPORTIVE SEATING FOR DMD

Backrest to spine of scapular

Contoured back rest

Lateral supports

Lumbar roll to help restore the normal lumbar curve

5-10 degree recline on back rest

Provide head rest

Supportive seat or pressure relieving cushion

CONTINUE STRETCHES AND INCLUDE UPPER

LIMB

Elbow flexors

Forearm pronators ( enables boy to turn palms up)

long finger flexors

Mobilise the shoulder

WATER THERAPY IS STILL WONDERFUL

AMBU BAG

Manual hyper inflation of lungs is often used to

Assist effective cough

Help bring up retained secretions

Help keep boys free of infection and out of hospital

COUGH ASSIST MACHINE

Most effective

way of bringing up

Retained secretions

It has been one of

the biggest boons to

the Duchenne

population

WHAT TO EXPECT OF YOUR PT

Assessments—strength, Range of movement ,timed tests .posture, gait, equipment needs, respiration & functional abilities

Exercise-- what type & how much is too much

Those stretches –why ? What sort ? How often

Help with equipment- seating-scooter splints wheel chairs, standers, respiratory equipment

Respiratory issues if no respiratory therapist

Use your PT to liaise with schools

PTs can advocate on your behalf in many problem areas

THANK YOU

HELENPOSSELT@OZEMAIL.COM.AU