A randomized comparative study of two methods for controlling Tendo Achilles contracture in Duchenne muscular dystrophy

Yearly motor function changes in patients with Duchenne muscular dystrophy, including a COVID-19 behavioral restriction period

[Purpose] This study aimed to assess the motor function status of ambulatory patients with Duchenne muscular dystrophy in 2020, which included a 3-month period of behavioral restriction due to the coronavirus disease of 2019 (COVID-19) pandemic, in comparison to the previous 2 years. [Participants and Methods] A retrospective analysis was conducted on 12 patients (children with mean age: 9.58 ± 3.43 years in 2020). Parameters such as lower leg maximum circumference, 10-m running time, rising-from-the-floor time, ankle joint range-of-motion, 6-min walk distance, and North Star Ambulatory Assessment score were evaluated. [Results] Significant increases in the maximum right thigh circumference and prolonged 10-m running time were observed in 2020. Interestingly, an unexpected improvement in ankle dorsiflexion angle was noted in both ankles. No other statistically significant differences were observed among the assessed time points. [Conclusion] These findings highlight the critical importance of continuous exercise and rehabilitation for ambulatory children with Duchenne muscular dystrophy, emphasizing the potential of rehabilitation to mitigate and restore the transient motor function deterioration observed during periods of behavioral restrictions.

Impact of contractures on daily functioning in adolescents with spinal muscular atrophy: a qualitative study

PURPOSE

Exploring the impact of contractures in adolescents and young adults (AYA) with spinal muscular atrophy (SMA) on daily functioning and participation and the impact of received contracture management.

METHODS

We included 14, non-ambulant AYA with SMA types 2/3 (10 females and 4 males), aged 16-30 years. Interviews focused on two topics: perceived impact of contractures on daily functioning and of previous contracture management. We used inductive thematic analysis for interview analysis.

RESULTS

In general, participants experienced muscle weakness to be more of a hindrance than contractures; they had adapted to their contractures over time. Participants considered contracture treatment useful when goals were meaningful and realistic. Participants mentioned that their perspective on contracture management would change in light of a promise of improved motor function due to disease-modifying treatment.

CONCLUSION

Despite the relatively low impact of contractures in comparison to the loss of muscle strength, non-ambulant AYA with SMA should be informed on the potential impact of contractures and benefits and potential adverse effects of their management. This information can support the shared decision-making process. While respecting individual choices, allows for incorporating interventions into daily life and the promotion of daily functioning and participation when children with SMA are growing up.

Reference curves of motor function outcomes in young steroid-naïve males with Duchenne muscular dystrophy

AIM

To investigate functional motor performance in a large cohort of young steroid-naïve males with Duchenne muscular dystrophy (DMD) and typically developing males, and to develop specific reference curves for both groups. Also, to describe associations between anthropometric values and functional motor outcomes.

METHOD

Cross-sectional data of 196 steroid-naïve males with DMD aged 4 to 8 years and 497 typically developing males aged 2 years 6 months to 8 years were included. Both groups were evaluated with the time to rise from the floor test, 10-metre walk/run test, 6-minute walk test, and North Star Ambulatory Assessment. Reference curves with centiles 5%, 10%, 25%, 50%, 75%, 90%, and 95% were estimated using quantile regression.

RESULTS

Males with DMD scored significantly worse on all functional motor outcomes than age-matched typically developing males (p < 0.001): 89% to 95% of the males with DMD scored below the 5th centile of the typically developing males. No or weak correlations exist between anthropometric values and functional motor outcomes.

INTERPRETATION

The estimated reference curves can support consultation with families of young males with DMD and can support the evaluation of treatment for reaching motor skills and functional motor outcomes compared with typically developing males.

Little Evidence for Conservative Toe Walking Interventions in Autism Spectrum Disorders: a Systematic Review

This systematic review summarizes the evidence about toe walking (TW) interventions in persons with autism. Following the PRISMA guidelines, a systematic search of MEDLINE, CINAHL, PsycINFO, The Cochrane Library, Google Scholar, and Opengrey was performed. Nine articles (all case reports or case series) were included. Methodological quality was assessed using the Mayo Evidence-Based Practice Centre tool. The included studies considered 17 subjects (16 males; age range: 4–15 years). All studies reported a reduction of TW frequency, but the follow-up was lacking in seven studies. There is a lack of high-quality studies with a sufficiently large and well-characterized sample to assess the effectiveness of TW interventions in autistic persons. These findings strongly support the need for further research in this area.

Development of Contractures in DMD in Relation to MRI-Determined Muscle Quality and Ambulatory Function

BACKGROUND

Joint contractures are common in boys and men with Duchenne muscular dystrophy (DMD), and management of contractures is an important part of care. The optimal methods to prevent and treat contractures are controversial, and the natural history of contracture development is understudied in glucocorticoid treated individuals at joints beyond the ankle.

OBJECTIVE

To describe the development of contractures over time in a large cohort of individuals with DMD in relation to ambulatory ability, functional performance, and muscle quality measured using magnetic resonance imaging (MRI) and spectroscopy (MRS).

METHODS

In this longitudinal study, range of motion (ROM) was measured annually at the hip, knee, and ankle, and at the elbow, forearm, and wrist at a subset of visits. Ambulatory function (10 meter walk/run and 6 minute walk test) and MR-determined muscle quality (transverse relaxation time (T2) and fat fraction) were measured at each visit.

RESULTS

In 178 boys with DMD, contracture prevalence and severity increased with age. Among ambulatory participants, more severe contractures (defined as greater loss of ROM) were significantly associated with worse ambulatory function, and across all participants, more severe contractures significantly associated with higher MRI T2 or MRS FF (ρ: 0.40-0.61 in the lower extremity; 0.20-0.47 in the upper extremity). Agonist/antagonist differences in MRI T2 were not strong predictors of ROM.

CONCLUSIONS

Contracture severity increases with disease progression (increasing age and muscle involvement and decreasing functional ability), but is only moderately predicted by muscle fatty infiltration and MRI T2, suggesting that other changes in the muscle, tendon, or joint contribute meaningfully to contracture formation in DMD.

Knee Strength and Ankle Range of Motion Impacts on Timed Function Tests in Duchenne Muscular Dystrophy: In the Era of Glucocorticoids

BACKGROUND

Duchenne Muscular Dystrophy (DMD) is a neuromuscular disorder that presents in childhood and is characterized by slowly progressive proximal weakness and lower extremity contractures that limit ambulatory ability [1, 2]. Contractures develop in the ankles, knees, and hips due to muscle imbalances, fibrotic changes, loss of strength, and static positioning [2, 5]. Currently, standards of care guidelines emphasize the importance of maintaining good musculoskeletal alignment through stretching, bracing, and glucocorticoid (GC) therapy to preserve strength and function.

METHODS

This is a retrospective analysis of prospectively collected data through the CINRG Duchenne Natural history study (DNHS). The objectives of this analysis are to understand the progression of ankle contractures for individuals with DMD and to investigate the relationship between progressive lower limb contractures, knee strength, and Timed Function Tests.A collection of TFTs including supine to stand (STS), 10 meter walk test (10MWT), and timed stair climbing (4SC) have been used to monitor disease progression and are predictive of loss of ambulation in these patients [4]. Multiple factors contribute to loss of ambulation, including progressive loss of strength and contracture development that leads to changing biomechanical demands for ambulation. A better understanding of the changes in strength and range of motion (ROM) that contribute to loss of function is important in a more individualized rehabilitation management plan. In this longitudinal study, we measured strength using quantitative muscle testing (QMT) with the CINRG Quantitative Measurement System (CQMS)), ROM was measuresed with a goniometer and TFTs were measured using a standard stopwatch and methodology.

RESULTS

We enrolled 440 participants; mean baseline age was 8.9 (2.1, 28.0) years with 1321 observations used for analysis. GC use was stratified based on duration on drug with 18.7%at <  6 months or naïve; 4.3%<1 year; 58.0%1 <  10 years; and 19.3%between 10-25 years of GC use. Ankle ROM was better for those on GC compared to GC naive but did not significantly influence long-term progression rates. QMT, ROM, age and GCs contribute to speed of TFTs. Knee extension (KE) strength and Dorsiflexion (DF) ROM are significant predictors of speed for all TFTs (p <  0.001). Of the variables used in this analysis, KE strength is the primary predictor of walking speed, estimating that every pound increase in KE results in a 0.042 m/s improvement in 10MWT, and a smaller similar increase of 0.009 m/s with every degree of ankle DF ROM.

CONCLUSION

GC use provides an improvement in strength and ROM but does not affect rate of change. Knee strength has a greater influence on speed of TFTs than DF ROM, although both are statistically significant predictors of speed. Results show that retaining knee strength [1, 2], along with joint flexibility, may be important factors in the ability to perform walking, climbing and supine to stand activities.

Development of clinical practice guidelines for allied health and nursing assessment and management of Duchenne muscular dystrophy

PURPOSE

To provide evidence-based guidance specific to allied health and nursing practice for the assessment and management of individuals with Duchenne muscular dystrophy (DMD).

MATERIALS AND METHODS

Thirteen key focus areas were identified in consultation with health professionals and consumer advocacy groups. A series of systematic literature reviews were conducted to identify assessment and management strategies for each key focus area. A consensus process using modified Delphi methodology, including an Australia-New Zealand expert consensus meeting, was conducted. Recommendations underwent consultative review with key groups before being finalised and prepared for dissemination.

RESULTS

This clinical practice guideline (CPG) generated 19 evidence-based recommendations, 117 consensus-based recommendations and five research recommendations across the 13 focus areas to inform allied health assessment and management of individuals with DMD.

CONCLUSIONS

The resulting recommendations can be used in conjunction with existing medical CPGs to improve, standardise and advocate for allied health and rehabilitation care in DMD. The process used here may be useful for the development of CPGs in other rare diseases.Implications for rehabilitationImplementation-ready evidence-based statements to guide clinical care of individuals with DMD are provided with the potential to improve participation, function in the community and quality of life.A model for developing best practice statements for other rare neurological diseases is described.Allied health and nursing health professionals should focus research efforts to generate quality evidence to support rehabilitation practice.

Positive effect of the combination of multilevel contracture release and glucocorticoid treatment in Duchenne muscular dystrophy

PURPOSE

In the 1980s the first results of an early multilevel contracture release (MLCR) in patients suffering from progressive Duchenne muscular dystrophy (DMD) showed a positive effect on ambulation. Despite the demonstrated positive effects of prolongation of walking this treatment is not part of current guidelines. The aim of our study was to evaluate the effect of MLCR as well as its combination with glucocorticoid (GC) treatment on ambulation.

METHODS

Data of all boys (n = 86) with DMD treated in our outpatient department were analyzed regarding the treatment and loss of independent ambulation. In all, 23 were treated with GC only, ten were operated on, 21 received GC and underwent MLCR and 32 received neither of the two treatments.

RESULTS

The analysis of the loss of independent ambulation in our cohort showed a comparable extension of the ambulatory period between the GC-treated and MLCR-treated boys (p = 0.008 and p = 0.005, respectively). Furthermore, an additive effect of both therapies was found; patients with DMD who had both treatments were able to walk two years longer than those with only one of the two treatment options (p<0.001).

CONCLUSION

Standard GC treatment and early MLCR in lower limbs have an independent positive effect on prolongation of ambulation in patients with DMD. In our cohort, the combination of both therapies is significantly more effective than each therapy alone. We suggest both should be offered to all DMD patients eligible.Level of evidence: III.

Magnetic Resonance Imaging Studies in Duchenne Muscular Dystrophy: Linking Findings to the Physical Therapy Clinic

Duchenne muscular dystrophy (DMD) is a muscle degenerative disorder that manifests in early childhood and results in progressive muscle weakness. Physical therapists have long been an important component of the multidisciplinary team caring for people with DMD, providing expertise in areas of disease assessment, contracture management, assistive device prescription, and exercise prescription. Over the last decade, magnetic resonance imaging of muscles in people with DMD has led to an improved understanding of the muscle pathology underlying the clinical manifestations of DMD. Findings from magnetic resonance imaging (MRI) studies in DMD, paired with the clinical expertise of physical therapists, can help guide research that leads to improved physical therapist care for this unique patient population. The 2 main goals of this perspective article are to (1) summarize muscle pathology and disease progression findings from qualitative and quantitative muscle MRI studies in DMD and (2) link MRI findings of muscle pathology to the clinical manifestations observed by physical therapists with discussion of any potential implications of MRI findings on physical therapy management.

Adapted physical activity and therapeutic exercise in late-onset Pompe disease (LOPD): a two-step rehabilitative approach

Aerobic exercise, training to sustain motor ability, and respiratory rehabilitation may improve general functioning and quality of life (QoL) in neuromuscular disorders. Patients with late-onset Pompe disease (LOPD) typically show progressive muscle weakness, respiratory dysfunction and minor cardiac involvement. Characteristics and modalities of motor and respiratory rehabilitation in LOPD are not well defined and specific guidelines are lacking. Therefore, we evaluated the role of physical activity, therapeutic exercise, and pulmonary rehabilitation programs in order to promote an appropriate management of motor and respiratory dysfunctions and improve QoL in patients with LOPD. We propose two operational protocols: one for an adapted physical activity (APA) plan and the other for an individual rehabilitation plan, particularly focused on therapeutic exercise (TE) and respiratory rehabilitation.

Interventions for idiopathic toe walking

BACKGROUND

Idiopathic toe walking (ITW) is an exclusionary diagnosis given to healthy children who persist in walking on their toes after they should typically have achieved a heel-toe gait. The literature discusses conservative and surgical interventions using a variety of treatment modalities. Young children and children without a limitation in ankle dorsiflexion (the upwards movement of the foot towards the shin of the leg) are commonly treated with conservative interventions. Older children who continue toe walking and present with limitations in ankle dorsiflexion are sometimes treated with surgical procedures. This systematic review is needed to evaluate the evidence for any intervention for the treatment of ITW. The conclusions of this review may support decision making by clinicians caring for children with ITW. It may also assist families when deciding on treatment options for their children with ITW. Many of the treatments employed have financial implications for parents or healthcare services. This review also aims to highlight any deficits in the current research base.

OBJECTIVES

To assess the effects of conservative and surgical interventions in children with ITW, specifically effects on gait normalisation, ankle range of motion, pain, frequency of recurrence, and any adverse effects.

SEARCH METHODS

On 29 April 2019, we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL Plus, and PEDro. We searched the following registers of clinical trials for ongoing and recently completed trials: the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP, apps.who.int/trialsearch), and ClinicalTrials.gov (clinicaltrials.gov). We searched conference proceedings and other grey literature in the BIOSIS databases and System for Information on Grey Literature in Europe (OpenGrey, opengrey.eu). We searched guidelines via the Turning Research Into Practice database (TRIP, tripdatabase.com) and National Guideline Clearinghouse (guideline.gov). We did not apply language restrictions.

SELECTION CRITERIA

We considered randomised or quasi-randomised trials for inclusion in the review if they involved participants diagnosed with ITW gait in the absence of a medical condition known to cause toe walking, or associated with toe walking. As there is no universally accepted age group for ITW, this review includes ITW at any age, who have been toe walking for more than six months, who can or cannot walk with a heel-toe gait, and who may or may not have limited dorsiflexion of the ankle joint.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. The primary outcome was improvement in toe walking (defined as greater than 50% of time spent heel-toe walking). Secondary outcomes were active and passive range of motion of the ankle joint, pain, recurrence of ITW after treatment, and adverse events. We assessed the certainty of the evidence using the GRADE framework.

MAIN RESULTS

Four studies, comprising 104 participants, met the inclusion criteria. One study did not report data within the appropriate follow-up timeframe and data from two studies were insufficient for analysis. The single study from which we extracted data had 47 participants and was a randomised, controlled, parallel-group trial conducted in Sweden. It tested the hypothesis that combined treatment with serial casting and botulinum toxin type A (BTX) was more effective than serial casting alone in reducing ITW gait.This study found that more participants treated with BTX improved (defined as toe walking less than 50% of the time, as reported by parents) (risk ratio (RR) 1.21, 95% confidence interval (CI) 0.57 to 2.55; 1 trial, 46 participants; very low-certainty evidence). However, there was little or no difference between groups in passive ankle joint dorsiflexion range of movement on the right with the knee extended (mean difference (MD) -1.48º, 95% CI -4.13 to 1.16; 1 trial, 47 participants), on the right with the knee flexed (MD -0.04º, 95% CI -1.80 to 1.73; 1 trial, 46 participants), on the left with the knee flexed (MD 1.07, 95% CI -1.22 to 3.37), or on the left with the knee extended (MD 0.05, 95% CI -0.91 to 1.91). Nor was there a clear difference between the groups in recurrence of toe-walking gait (assessed via severity of toe walking (graded 1 (mild), 2 (moderate), or 3 (severe)) on gait analysis, analysed as continuous data: MD 0.34 points, 95% CI -0.09 to 0.78; 46 participants). In principle, MDs greater than zero (i.e.) positive values) would favour BTX and casting and negative values would favour casting alone. We have not reported effects as better or worse because all results were from evidence of very low certainty. We downgraded the certainty of evidence because of study limitations (outcome assessment was not blinded) and imprecision. Outcomes of pain and active range of motion were not reported in the included study.In terms of adverse events, calf pain was reported twice in the casting-only group and three times in the BTX group. There were three minor skin problems in each group and one reported case of pain directly after BTX injection. The report did not state if calf pain and skin irritation were from the same or different participants. The study authors reported that adverse events did not alter treatment adherence.

AUTHORS' CONCLUSIONS

The certainty of evidence from one study, which compared serial casting with serial casting with BTX for ITW in children, was too low for conclusions to be drawn. A further three studies reported outcomes relating to BTX, footwear, exercises, and different types of orthoses as interventions, however the outcome data were too limited to assess their effects.

Rehabilitation Management of the Patient With Duchenne Muscular Dystrophy

Steadily improving management of Duchenne muscular dystrophy (DMD) continues to lead to improved physical and functional status, allowing increasingly successful transitions to independence and self-actualization in adulthood. Rehabilitation principles remain key to overall management for individuals with DMD with increasing options for ever more successful management, reflecting a changing natural history based on the use of glucocorticoids, more consistent comprehensive care, and the emergence of disease-modifying treatments. Advances and expansion in assessment, cardiorespiratory management, preventive management of contracture and deformity, assistive technology, "smart" technology, and robotics with increased emphasis on function, participation, self-advocacy, and independence in decision-making should allow individuals with DMD to experience childhood and transition to adulthood with support that allows for increasing success in the achievement of individual goals and fulfillment across the life span.

Lower extremity joint contracture according to ambulatory status in children with Duchenne muscular dystrophy

Background

Lower extremity joint contractures have negative effects on gait in children with Duchenne muscular dystrophy (DMD). Thus, contracture prevention is essential for maintaining a patient’s functional ability and an acceptable quality of life. This study investigated hip flexion (HF), knee flexion (KF), and ankle joint plantar flexion (APF) contractures among male patients with DMD, based on the patients’ ambulatory status. Differences in major joint contractures, based on passive stretching exercise participation, were also investigated.

Methods

A total of 128 boys with DMD, followed at the DMD clinic of a tertiary care hospital, were included in this cross-sectional study. The passive ranges-of-motion of the hip, knee, and ankle joints were measured, in the sagittal plane, using a goniometer. The Vignos Scale was used to grade ambulatory function. Boys with DMD who performed stretching exercises for more than 5 min/session, > 3 sessions/week, were classified into the stretching group.

Results

The HF (23.5^o), KF (43.5^o), and APF (34.5^o) contracture angles in the non-ambulatory group were more severe than those in the ambulatory group. APF contractures (41 patients, 52.6%) were more frequently observed early, even within the ambulatory period, than were hip (8 patients, 10.3%), and knee joint (17 patients, 21.8%) contractures. Passive stretching exercises > 3 sessions/week were not associated with the degree of lower extremity joint contractures in the ambulatory or non-ambulatory group.

Conclusion

HF, KF, and APF contractures are more common and severe when there is deterioration of ambulatory function. Stretching exercises alone are unlikely to prevent lower extremity joint contractures.

The effect of wearing night splints for one year on the standing motor function of patients with Duchenne muscular dystrophy

[Purpose] To investigate the effect of night splints on the standing motor function and ankle dorsiflexion angles of patients with Duchenne muscular dystrophy (DMD). [Subjects and Methods] Nine boys (age <11 years) with DMD were divided into the sufficiently-wearing group and the insufficiently-wearing group, according to how often they wore their splint for one year. We evaluated the changes between the pre-implementation and the one-year-after assessments of both the sufficiently-wearing group and the insufficiently-wearing group for the ankle dorsiflexion angle, North Star Ambulatory Assessment, 10-m running time, and time to stand from the floor. [Results] Only the left dorsiflexion angle of the ankle showed significantly difference for the sufficiently-wearing group. For other indicators, there were tendency toward improvement and maintenance in the sufficiently-wearing group. [Conclusion] The standing motor function improved significantly in some patients in the sufficiently-wearing group, suggesting that wearing night splints may promote the improvement and/or maintain of standing motor function in patients with DMD.

Consensus on the diagnosis, treatment and follow-up of patients with Duchenne muscular dystrophy

INTRODUCTION

Duchenne muscular dystrophy (DMD) is the most common myopathy in children, with a worldwide prevalence of approximately 0.5 cases per 10,000 male births. It is characterised by a progressive muscular weakness manifesting in early childhood, with the subsequent appearance of musculoskeletal, respiratory, and cardiac complications, causing disability, dependence, and premature death. Currently, DMD is mainly managed with multidisciplinary symptomatic treatment, with favourable results in terms of the progression of the disease. It is therefore crucial to establish clear, up-to-date guidelines enabling early detection, appropriate treatment, and monitoring of possible complications.

DEVELOPMENT

We performed a literature search of the main biomedical databases for articles published in the last 10years in order to obtain an overview of the issues addressed by current guidelines and to identify relevant issues for which no consensus has yet been established. The degree of evidence and level of recommendation of the information obtained were classified and ordered according to the criteria of the American Academy of Neurology.

CONCLUSIONS

DMD management should be multidisciplinary and adapted to the patient's profile and the stage of clinical progression. In addition to corticotherapy, treatment targeting gastrointestinal, respiratory, cardiac, and orthopaedic problems, as well as physiotherapy, should be provided with a view to improving patients' quality of life. Genetic studies play a key role in the management of the disease, both in detecting cases and potential carriers and in characterising the mutation involved and developing new therapies.

Aquatic therapy for children with Duchenne muscular dystrophy: a pilot feasibility randomised controlled trial and mixed-methods process evaluation

BACKGROUND

Duchenne muscular dystrophy (DMD) is a rare disease that causes the progressive loss of motor abilities such as walking. Standard treatment includes physiotherapy. No trial has evaluated whether or not adding aquatic therapy (AT) to land-based therapy (LBT) exercises helps to keep muscles strong and children independent.

OBJECTIVES

To assess the feasibility of recruiting boys with DMD to a randomised trial evaluating AT (primary objective) and to collect data from them; to assess how, and how well, the intervention and trial procedures work.

DESIGN

Parallel-group, single-blind, randomised pilot trial with nested qualitative research.

SETTING

Six paediatric neuromuscular units.

PARTICIPANTS

Children with DMD aged 7-16 years, established on corticosteroids, with a North Star Ambulatory Assessment (NSAA) score of 8-34 and able to complete a 10-m walk without aids/assistance. Exclusions: > 20% variation between baseline screens 4 weeks apart and contraindications.

INTERVENTIONS

Participants were allocated on a 1 : 1 ratio to (1) optimised, manualised LBT (prescribed by specialist neuromuscular physiotherapists) or (2) the same plus manualised AT (30 minutes, twice weekly for 6 months: active assisted and/or passive stretching regime; simulated or real functional activities; submaximal exercise). Semistructured interviews with participants, parents (n = 8) and professionals (n = 8) were analysed using Framework analysis. An independent rater reviewed patient records to determine the extent to which treatment was optimised. A cost-impact analysis was performed. Quantitative and qualitative data were mixed using a triangulation exercise.

MAIN OUTCOME MEASURES

Feasibility of recruiting 40 participants in 6 months, participant and therapist views on the acceptability of the intervention and research protocols, clinical outcomes including NSAA, independent assessment of treatment optimisation and intervention costs.

RESULTS

Over 6 months, 348 children were screened - most lived too far from centres or were enrolled in other trials. Twelve (30% of target) were randomised to AT (n = 8) or control (n = 4). People in the AT (n = 8) and control (n = 2: attrition because of parental report) arms contributed outcome data. The mean change in NSAA score at 6 months was -5.5 [standard deviation (SD) 7.8] for LBT and -2.8 (SD 4.1) in the AT arm. One boy suffered pain and fatigue after AT, which resolved the same day. Physiotherapists and parents valued AT and believed that it should be delivered in community settings. The independent rater considered AT optimised for three out of eight children, with other children given programmes that were too extensive and insufficiently focused. The estimated NHS costs of 6-month service were between £1970 and £2734 per patient.

LIMITATIONS

The focus on delivery in hospitals limits generalisability.

CONCLUSIONS

Neither a full-scale frequentist randomised controlled trial (RCT) recruiting in the UK alone nor a twice-weekly open-ended AT course delivered at tertiary centres is feasible. Further intervention development research is needed to identify how community-based pools can be accessed, and how families can link with each other and community physiotherapists to access tailored AT programmes guided by highly specialised physiotherapists. Bayesian RCTs may be feasible; otherwise, time series designs are recommended.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN41002956.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 27. See the NIHR Journals Library website for further project information.

Use and tolerability of a side pole static ankle foot orthosis in children with neurological disorders

BACKGROUND

Transverse-plane foot deformities are a frequently encountered issue in children with neurological disorders. They are the source of many symptoms, such as pain and walking difficulties, making their prevention very important.

OBJECTIVES

We aim to describe the use and tolerability of a side pole static ankle foot orthosis used to prevent transverse-plane foot deformities in children with neurologic disorders.

STUDY DESIGN

Monocentric, retrospective, observational study.

METHODS

Medical data were collected from 103 children with transverse-plane foot deformities in one or both feet caused by a neurological impairment. All children were braced between 2001 and 2010.

RESULTS

Unilateral orthosis was prescribed for 32 children and bilateral orthosis for 71. Transverse-plane foot deformities were varus in 66% of the cases and an equinus was associated in 59.2% of the cases. Mean age for the first prescription was 8.6 years. For the 23 patients present at the 4-year visit, 84.8% still wore the orthosis daily, and 64.7% wore the orthosis more than 6 h per day. The rate of permanent discontinuation of wearing the orthosis was 14.7%.

CONCLUSION

The side pole static ankle foot orthosis is well tolerated with very few side effects, which promotes regular wearing and observance. Clinical relevance Side pole static ankle foot orthoses are well tolerated and can be safely used for children with foot abnormalities in the frontal plane that have a neurological pathology origin.

Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review

QUESTION

Is stretch effective for the treatment and prevention of contractures in people with neurological and non-neurological conditions?

DESIGN

A Cochrane Systematic Review with meta-analyses of randomised trials.

PARTICIPANTS

People with or at risk of contractures.

INTERVENTION

Trials were considered for inclusion if they compared stretch to no stretch, or stretch plus co-intervention to co-intervention only. The stretch could be administered in any way.

OUTCOME MEASURES

The outcome of interest was joint mobility. Two sets of meta-analyses were conducted with a random-effects model: one for people with neurological conditions and the other for people with non-neurological conditions. The quality of evidence supporting the results of the two sets of meta-analyses was assessed using GRADE.

RESULTS

Eighteen studies involving 549 participants examined the effectiveness of stretch in people with neurological conditions, and provided useable data. The pooled mean difference was 2 deg (95% CI 0 to 3) favouring stretch. This was equivalent to a relative change of 2% (95% CI 0 to 3). Eighteen studies involving 865 participants examined the effectiveness of stretch in people with non-neurological conditions, and provided useable data. The pooled standardised mean difference was 0.2 SD (95% CI 0 to 0.3) favouring stretch. This translated to an absolute mean increase of 1 deg (95% CI 0 to 2) and a relative change of 1% (95% CI 0 to 2). The GRADE level of evidence was high for both sets of meta-analyses.

CONCLUSION

Stretch does not have clinically important effects on joint mobility. [Harvey LA, Katalinic OM, Herbert RD, Moseley AM, Lannin NA, Schurr K (2017) Stretch for the treatment and prevention of contracture: an abridged republication of a Cochrane Systematic Review. Journal of Physiotherapy 63: 67-75].

Ankle-Foot Orthosis in Duchenne Muscular Dystrophy: A 4 year Experience in a Multidisciplinary Neuromuscular Disorders Clinic

OBJECTIVE

To assess Ankle-Foot-Orthosis (AFO) requirement and ambulation in Duchenne Muscular Dystrophy (DMD) patients seen over a period of 4 y at a multi-disciplinary Neuromuscular disorders clinic (NMD).

METHODS

A study was conducted in university quaternary research hospital with DMD patients confirmed by MLPA (multiplex ligation - dependent probe amplification) method and were evaluated between January 2012 and December 2015. Their ambulatory status, detailed neurological and functional status were recorded. Requirement of AFOs was determined and provided.

RESULTS

In total 126 DMD children reported to the NMD clinic. Mean age at presentation was 7.6 y (range 2 to12 y, SD 2.1). Mean duration of illness at first evaluation was 3.4 y (range 0.5 to 10 y, SD 2.0). AFO's were advised at a mean age of 8.5 y (range 7 to 12 y, SD 1.8). Fifty-nine patients were advised AFO as resting or walking splint. At last follow-up 113 patients were still ambulatory whereas 13 had become wheel chair bound. Out of 59 patients, 48 were still wearing AFOs and the remaining discontinued AFOs for various reasons.

CONCLUSIONS

Children with DMD require wearing of AFOs as resting or walking splint, mostly in first or early second decade of life. As there is some gap between onset of clinical signs and requirement of orthosis, follow-up preferably at a multidisciplinary clinic at regular intervals is desirable for timely intervention in the form of AFOs or other splints to prolong ambulatory status in these patients.

Stretch for the treatment and prevention of contractures

BACKGROUND

Contractures are a common complication of neurological and non-neurological conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective. This review is an update of the original 2010 version of this review.

OBJECTIVES

The aim of this review was to determine the effects of stretch on contractures in people with, or at risk of developing, contractures.The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions, spasticity and adverse events.

SEARCH METHODS

In November 2015 we searched CENTRAL, DARE, HTA; MEDLINE; Embase; CINAHL; SCI-EXPANDED; PEDro and trials registries.

SELECTION CRITERIA

We included randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias. The outcomes of interest were joint mobility, quality of life, pain, activity limitations, participation restrictions and adverse events. We evaluated outcomes in the short term (up to one week after the last stretch) and in the long term (more than one week). We expressed effects as mean differences (MD) or standardised mean differences (SMD) with 95% confidence intervals (CI). We conducted meta-analyses with a random-effects model. We assessed the quality of the body of evidence for the main outcomes using GRADE.

MAIN RESULTS

Forty-nine studies with 2135 participants met the inclusion criteria. No study performed stretch for more than seven months. Just over half the studies (51%) were at low risk of selection bias; all studies were at risk of detection bias for self reported outcomes such as pain and at risk of performance bias due to difficulty of blinding the intervention. However, most studies were at low risk of detection bias for objective outcomes including range of motion, and the majority of studies were free from attrition and selective reporting biases. The effect of these biases were unlikely to be important, given that there was little benefit with treatment. There was high-quality evidence that stretch did not have clinically important short-term effects on joint mobility in people with neurological conditions (MD 2°; 95% CI 0° to 3°; 26 studies with 699 participants) or non-neurological conditions (SMD 0.2, 95% CI 0 to 0.3, 19 studies with 925 participants).In people with neurological conditions, it was uncertain whether stretch had clinically important short-term effects on pain (SMD 0.2; 95% CI -0.1 to 0.5; 5 studies with 174 participants) or activity limitations (SMD 0.2; 95% CI -0.1 to 0.5; 8 studies with 247 participants). No trials examined the short-term effects of stretch on quality of life or participation restrictions in people with neurological conditions. Five studies involving 145 participants reported eight adverse events including skin breakdown, bruising, blisters and pain but it was not possible to statistically analyse these data.In people with non-neurological conditions, there was high-quality evidence that stretch did not have clinically important short-term effects on pain (SMD -0.2, 95% CI -0.4 to 0.1; 7 studies with 422 participants) and moderate-quality evidence that stretch did not have clinically important short-term effects on quality of life (SMD 0.3, 95% CI -0.1 to 0.7; 2 studies with 97 participants). The short-term effect of stretch on activity limitations (SMD 0.1; 95% CI -0.2 to 0.3; 5 studies with 356 participants) and participation restrictions were uncertain (SMD -0.2; 95% CI -0.6 to 0.1; 2 studies with 192 participants). Nine studies involving 635 participants reported 41 adverse events including numbness, pain, Raynauds' phenomenon, venous thrombosis, need for manipulation under anaesthesia, wound infections, haematoma, flexion deficits and swelling but it was not possible to statistically analyse these data.

AUTHORS' CONCLUSIONS

There was high-quality evidence that stretch did not have clinically important effects on joint mobility in people with or without neurological conditions if performed for less than seven months. Sensitivity analyses indicate results were robust in studies at risk of selection and detection biases in comparison to studies at low risk of bias. Sub-group analyses also suggest the effect of stretch is consistent in people with different types of neurological or non-neurological conditions. The effects of stretch performed for periods longer than seven months have not been investigated. There was moderate- and high-quality evidence that stretch did not have clinically important short-term effects on quality of life or pain in people with non-neurological conditions, respectively. The short-term effects of stretch on quality of life and pain in people with neurological conditions, and the short-term effects of stretch on activity limitations and participation restrictions for people with and without neurological conditions are uncertain.

Duchenne muscular dystrophy: the management of scoliosis

This study summaries the current management of scoliosis in patients with Duchenne Muscular Dystrophy. A literature review of Medline was performed and the collected articles critically appraised. This literature is discussed to give an overview of the current management of scoliosis within Duchenne Muscular Dystrophy. Importantly, improvements in respiratory care, the use of steroids and improving surgical techniques have allowed patients to maintain quality of life and improved life expectancy in this patient group.

Effectiveness of Stretch Interventions for Children With Neuromuscular Disabilities: Evidence-Based Recommendations

PURPOSE

To determine whether casting, orthoses, stretching, or supported standing programs are effective in improving or maintaining body functions and structures, activity, or participation in children with neuromuscular disabilities.

METHODS

A systematic review was conducted using 6 electronic databases to identify Level 1 and 2 studies investigating stretch interventions for children aged 0 to 19 years with neuromuscular disabilities. Interventions were coded using the International Classification of Function and rated with Grading of Recommendation Assessment, Development and Evaluation, the Oxford Levels of Evidence, and the Evidence Alert Traffic Light System.

RESULTS

Sixteen studies evaluated the effectiveness of stretch interventions. Low-grade evidence supports casting temporarily increasing ankle range of motion, orthoses improving gait parameters while they are worn, and supported standing programs improving bone mineral density.

CONCLUSION

There is limited evidence suggesting stretch interventions benefit body functions and structures. There is inconclusive evidence to support or refute stretching interventions for preventing contractures or impacting a child's activity or participation.

TRIAL REGISTRATION

Prospero CRD42014013807.

Supported Standing in Boys With Duchenne Muscular Dystrophy

PURPOSE

To evaluate the safety, tolerability, and efficacy of supported standing in a small sample of boys with Duchenne muscular dystrophy (DMD).

METHODS

Four 12- to 15-year-old boys with DMD engaged in a home-based supported standing program for 6 to 12 months. A single-subject design was employed to examine muscle length. Bone mineral density was assessed at 4-month intervals using dual-energy x-ray absorptiometry.

RESULTS

Upright, sustained supported standing was tolerated in 3 of the 4 boys. Mean weekly stand times ranged from 1.3 to 3.3 hours. Improved hip or knee flexor muscle length was seen in 3 of the 4 boys. No boys showed improved plantar flexor muscle length or increased lumbar bone mineral density.

CONCLUSIONS

Findings offer preliminary empirical evidence addressing the safety, tolerability, and efficacy of standing in boys with DMD. Additional research with an emphasis on better program adherence is indicated.

WITHDRAWN: Rehabilitation interventions for foot drop in neuromuscular disease

The Cochrane Neuromuscular Disease Group withdrew this review as of Issue 2, 2015 as the methodology was out of date and new trials have been published. The content partially overlaps with other reviews. The scope will be revised and this title will be replaced by a new protocol.

The editorial group responsible for this previously published document have withdrawn it from publication.

Is there any relationship between orthotic usage and functional activities in children with neuromuscular disorders?

BACKGROUND

Contractures of Achilles tendons and gastrocnemius muscle deteriorate the performance in daily living activities of patients with neuromuscular diseases. Ankle-foot orthoses help to prevent the progression of deformities and to obtain optimal position of the joints to support standing and walking.

OBJECTIVE

To investigate the relationship between orthotic usage and functional activities in pediatric patients with different neuromuscular diseases.

STUDY DESIGN

Retrospective study.

METHODS

A total of 127 subjects' physical assessment forms were analyzed. Functional level, type of orthoses, falling frequencies, ankle joint range of motion, and timed performance tests were examined in two consecutive dates with an interval of 3 months.

RESULTS

A total of 91 patients were using orthoses while 36 patients were not within assessment dates. A total of 64 of 91 (70.3%) patients were diagnosed with Duchenne muscular dystrophy. A total of 81 (89.0%) subjects were using plastic ankle-foot orthoses for positioning at nights and 10 (11%) were using different types of the orthoses (knee-ankle-foot orthoses, dynamic ankle-foot orthoses, and so on) for gait in the study group.

CONCLUSIONS

Night ankle-foot orthoses were not found to be effective directly on functional performance in children with neuromuscular diseases, although they protect ankle from contractures and may help to correct gait and balance.

CLINICAL RELEVANCE

This retrospective study shows that the positive effects of using an ankle-foot orthosis at night are not reflected in the functional performance of children with neuromuscular diseases. This may be due to the progressive deteriorating nature of the disease.

Physical therapy evaluation and management in neuromuscular diseases

Neuromuscular disorders (NMDs) are a group of myopathic or neuropathic diseases that directly or indirectly affect the functioning of muscle. Physical therapists (PTs) have extensive specialized training in musculoskeletal evaluation and assessment that gives them the tools to meet the significant needs of this population. This article reviews the role of PTs in treating the NMD population with a discussion of available evaluation techniques and interventions and with an effort to differentiate between treatments known to apply to this population and conventional practice of PTs. The status of currently available outcome measures used for research and their applicability to clinics are presented.

Preserving sarcomere number after tenotomy requires stretch and contraction

INTRODUCTION

Passive stretch therapy is utilized to improve the range of motion of chronically shortened muscles. However, human studies show conflicting results as whether passive stretch is clinically effective.

METHODS

The soleus muscles of adult rats were tenotomized to induce muscle shortening adaptation. Muscles included were non-treated normal, subjected to daily static stretch, or lengthened and isometrically contracted for 20 min/day. Muscle fiber structure was analyzed histochemically. Sarcomeres per millimeter length were counted to assess the effect of treatment.

RESULTS

Passive stretch significantly reduced central core lesion formation, but sarcomere loss was not prevented. The addition of isometric contraction during static stretch significantly (P < 0.001) reduced sarcomere loss.

CONCLUSIONS

Passive stretch alone does not prevent shortening adaptation. Contraction is required in combination with stretch to preserve the number of sarcomeres in series. The combination of stretch and contraction is necessary to maintain proper muscle fiber length.

Provision and financing of assistive technology devices in Germany: a bureaucratic odyssey? The case of amyotrophic lateral sclerosis and Duchenne muscular dystrophy

OBJECTIVE

The regulations for financing assistive technology devices (ATDs) are complex and fragmented and, thus, might influence adequate provision of these devices to people who need multiple ATDs. This study aims to explore and analyze patients' problems with the provision and financing of ATDs for the following two rare diseases: amyotrophic lateral sclerosis (ALS) and Duchenne muscular dystrophy (DMD).

METHODS

A survey was conducted by means of semi-standardized questionnaires addressing the issues of coverage decisions for ATDs and problems with provision of ATDs. Information was retrieved from ALS (n=19) and DMD (n=14) patients. Conducted interviews were transcribed verbatim and analyzed using qualitative content analysis.

RESULTS

Respondents experienced difficulties with the provision and financing of ATDs. They underlined problems such as long approval processes and a serious bureaucratic burden, which induced inadequate provision of ATDs. Experiences of ALS and DMD respondents frequently were similar, especially regarding financing decisions and the process of decision making by sickness funds.

CONCLUSION

The results suggest that difficulties in receiving and financing ATDs are common problems among ALS and DMD patients. There is a need for an interdisciplinary approach in the provision of ATDs and their financing, which should be coordinated by case managers.

Moving towards meaningful measurement: Rasch analysis of the North Star Ambulatory Assessment in Duchenne muscular dystrophy

AIM

Reliable measurement of disease progression and the effect of therapeutic interventions in Duchenne muscular dystrophy (DMD) require clinically meaningful and scientifically sound rating scales. Therefore, we need robust evidence to support such tools. The North Star Ambulatory Assessment (NSAA) is a promising, clinician-rated scale with potential uses spanning clinical practice and clinical trials. In this study, we used Rasch analysis to test its suitability in these roles as a measurement instrument.

METHOD

NSAA data from 191 ambulant boys (mean age at assessment 7 y 8 mo, SD 2 y 4 mo; range 3 y 6 mo-15 y 5 mo) with a confirmed diagnosis of DMD were examined for psychometric properties including clinical meaning, targeting, response categories, model fit, reliability, dependency, stability, and raw to interval-level measurement. All analyses were performed using the Rasch Unidimensional Measurement Model.

RESULTS

Overall, Rasch analysis supported the NSAA as being a reliable (high Person Separation Index of 0.91) and valid (good targeting, little misfit, no reversed thresholds) measure of ambulatory function in DMD. One item displayed misfit (lifts head, fit residual 6.9) and there was evidence for some local dependency (stand on right/left leg, climb and descend box step right/left leg, and hop on right/left leg, residual correlations >0.40), which we provide potential solutions for in future use of the NSAA. Importantly, our findings supported good clinical validity in that the hierarchy of items within the scale produced by the analyses was supported by clinical opinion, thus increasing the clinical interpretability of scale scores.

INTERPRETATION

In general, Rasch analysis supported the NSAA as a psychometrically robust scale for use in DMD clinical research and trials. This study also demonstrates how Rasch analysis is a useful instrument to detect and understand the key measurement issues of rating scales.

Effectiveness of stretch for the treatment and prevention of contractures in people with neurological conditions: a systematic review

BACKGROUND

Contractures are a disabling complication of neurological conditions that are commonly managed with stretch.

OBJECTIVE

The purpose of this systematic review was to determine the effectiveness of stretch for the treatment and prevention of contractures. The review is part of a more-detailed Cochrane review. Only the results of the studies including patients with neurological conditions are reported here.

DATA SOURCES

Electronic searches were conducted in June 2010 in the following computerized databases: Cochrane CENTRAL Register of Controlled Trials, Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment Database (HTA), MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, SCI-EXPANDED, and Physiotherapy Evidence Database (PEDro).

STUDY ELIGIBILITY CRITERIA

The review included randomized controlled trials and controlled clinical trials of stretch applied for the purposes of treating or preventing contractures in people with neurological conditions.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two reviewers independently selected studies, extracted data, and assessed risk of bias. The primary outcome measures were joint mobility (range of motion) and quality of life. Secondary outcome measures were pain, spasticity, activity limitation, and participation restriction. Meta-analyses were conducted using random-effects models.

RESULTS

Twenty-five studies met the inclusion criteria. These studies provide moderate-quality evidence that stretch has a small immediate effect on joint mobility (mean difference=3°, 95% confidence interval [CI]=0° to 5°) and high-quality evidence that stretch has little or no short-term or long-term effects on joint mobility (mean difference=1° and 0°, respectively, 95% CI=0° to 3° and -2° to 2°, respectively). There is little or no effect of stretch on pain, spasticity, and activity limitation.

LIMITATIONS

No studies were retrieved that investigated the effects of stretch for longer than 6 months.

CONCLUSION

Regular stretch does not produce clinically important changes in joint mobility, pain, spasticity, or activity limitation in people with neurological conditions.

Serial casting for the management of ankle contracture in Duchenne muscular dystrophy

PURPOSE

To evaluate the effect of serial casting in boys with Duchenne muscular dystrophy.

METHODS

Chart review of 9 patients with Duchenne muscular dystrophy, mean age 8.9 (±2.1) years.

RESULTS

Initial dorsiflexion -6.2° and -5.2° right and left, respectively. The mean improvement was 12° and 11.6° on the right and left (knee extended) and 7.7° and 8.7° on the right and left (knee flexed) or 2.7° and 3.9° per cast, respectively. Times to run 10 m, climb 4 steps, and get off the floor were unchanged. Correlations between range-of-motion change/cast and age were r = -0.86 right and r = -0.84 left. Three patients had delayed onset foot pain; one child had redness with symptom resolution in all cases.

CONCLUSIONS

Improvement in range of motion with the application of serial casting was found with no loss of function or speed despite the period of immobilization.

Stretch for the treatment and prevention of contractures

BACKGROUND

Contractures are a common complication of neurological and musculoskeletal conditions, and are characterised by a reduction in joint mobility. Stretch is widely used for the treatment and prevention of contractures. However, it is not clear whether stretch is effective.

OBJECTIVES

To determine the effects of stretch on contractures in people with, or at risk of, contractures.

SEARCH STRATEGY

Electronic searches were conducted on CENTRAL, DARE, HTA (The Cochrane Library); MEDLINE; CINAHL; EMBASE; SCI-EXPANDED; and PEDro (April 2009).

SELECTION CRITERIA

Randomised controlled trials and controlled clinical trials of stretch applied for the purpose of treating or preventing contractures were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed risk of bias. The primary outcomes of interest were joint mobility and quality of life. The secondary outcomes were pain, spasticity, activity limitation and participation restriction. Outcomes were evaluated immediately after intervention, in the short term (one to seven days) and in the long term (> one week). Effects were expressed as mean differences or standardised mean differences with 95% confidence intervals (CI). Meta-analyses were conducted with a random-effects model.

MAIN RESULTS

Thirty-five studies with 1391 participants met the inclusion criteria. No study performed stretch for more than seven months. In people with neurological conditions, there was moderate to high quality evidence to indicate that stretch does not have clinically important immediate (mean difference 3 degrees ; 95% CI 0 to 7), short-term (mean difference 1 degrees ; 95% CI 0 to 3) or long-term (mean difference 0 degrees ; 95% CI -2 to 2) effects on joint mobility. The results were similar for people with non-neurological conditions. For all conditions, there is little or no effect of stretch on pain, spasticity, activity limitation, participation restriction or quality of life.

AUTHORS' CONCLUSIONS

Stretch does not have clinically important effects on joint mobility in people with, or at risk of, contractures if performed for less than seven months. The effects of stretch performed for periods longer than seven months have not been investigated.

Interventions for increasing ankle range of motion in patients with neuromuscular disease

BACKGROUND

Reduced ankle dorsiflexion range of motion, or ankle equinus, is a common and disabling problem for patients with neuromuscular disease. Clinicians devote considerable time and resources implementing interventions to correct this problem although few of these interventions have been subject to rigorous empirical investigation.

OBJECTIVES

To assess the effect of interventions to reduce or resolve ankle equinus in people with neuromuscular disease.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Specialized Register (August 2009), Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2009), MEDLINE (1966 to August 2009), EMBASE (1980 to August 2009), CINAHL 1982 to August 2009), AMED (1985 to August 2009) and The Physiotherapy Evidence Database (PEDro) (1929 to August 2009). We searched the reference lists of identified articles and also contacted known experts in the field to identify additional or unpublished data.

SELECTION CRITERIA

Randomised controlled trials evaluating interventions for increasing ankle dorsiflexion range of motion in neuromuscular disease. Outcomes included ankle dorsiflexion range of motion, functional improvement, foot alignment, foot and ankle muscle strength, health-related quality of life, satisfaction with the intervention and adverse events.

DATA COLLECTION AND ANALYSIS

Two authors independently selected papers, assessed trial quality and extracted data.

MAIN RESULTS

Four studies involving 149 participants met inclusion criteria for this review. Two studies assessed the effect of night splinting in a total of 26 children and adults with Charcot-Marie-Tooth disease type 1A. There were no statistically or clinically significant differences between wearing a night splint and not wearing a night splint. One study assessed the efficacy of prednisone treatment in 103 boys with Duchenne muscular dystrophy. While a daily dose of prednisone at 0.75 mg/kg/day resulted in significant improvements in some strength and function parameters compared with placebo, there was no significant difference in ankle range of motion between groups. Increasing the prednisone dose to 1.5 mg/kg/day had no significant effect on ankle range of motion. One study evaluated early surgery in 20 young boys with Duchenne muscular dystrophy. Surgery resulted in increased ankle dorsiflexion range at 12 months but functional outcomes favoured the control group. By 24 months, many boys in the surgical group experienced a relapse of achilles tendon contractures.

AUTHORS' CONCLUSIONS

There is no evidence of significant benefit from any intervention for increasing ankle range of motion in Charcot-Marie-Tooth disease type 1A or Duchenne muscular dystrophy. Further research is required.

Diagnosis and management of Duchenne muscular dystrophy, part 2: implementation of multidisciplinary care

Optimum management of Duchenne muscular dystrophy (DMD) requires a multidisciplinary approach that focuses on anticipatory and preventive measures as well as active interventions to address the primary and secondary aspects of the disorder. Implementing comprehensive management strategies can favourably alter the natural history of the disease and improve function, quality of life, and longevity. Standardised care can also facilitate planning for multicentre trials and help with the identification of areas in which care can be improved. Here, we present a comprehensive set of DMD care recommendations for management of rehabilitation, orthopaedic, respiratory, cardiovascular, gastroenterology/nutrition, and pain issues, as well as general surgical and emergency-room precautions. Together with part 1 of this Review, which focuses on diagnosis, pharmacological treatment, and psychosocial care, these recommendations allow diagnosis and management to occur in a coordinated multidisciplinary fashion.

Rehabilitation interventions for foot drop in neuromuscular disease

BACKGROUND

"Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases.

OBJECTIVES

To conduct a systematic review of randomised trials for the treatment of foot drop resulting from neuromuscular disease.

SEARCH STRATEGY

In this update, we searched the Cochrane Neuromuscular Disease Group Trials Register (April 2009), MEDLINE (January 1966 to April 24 2009), EMBASE January 1980 to April 24 2009), CINAHL (January 1982 to May 6 2009), AMED (January 1985 to April 24 2009), the British Nursing Index (January 1985 to January 2008) and Royal College of Nursing Journal of Databases (January 1985 to January 2008).

SELECTION CRITERIA

Randomised and quasi-randomised trials of physical, orthotic and surgical treatments for foot drop resulting from lower motor neuron or muscle disease and related contractures were included. People with primary joint disease were excluded. Interventions included a 'wait and see' approach, physiotherapy, orthoses, surgery and pharmacological therapy. The primary outcome measure was quantified ability to walk whilst secondary outcome measures included range of movement, dorsiflexor torque and strength, measures of activity and participation, quality of life and adverse effects.

DATA COLLECTION AND ANALYSIS

Methodological quality was evaluated by two authors using the van Tulder criteria. Four studies with a total of n = 152 participants were included in the update to the original review. Heterogeneity of the studies precluded pooling the data.

MAIN RESULTS

Early surgery did not significantly affect walking speed in a trial including 20 children with Duchenne muscular dystrophy. Both groups deteriorated during the 12 months follow-up. After one year, the mean difference (MD) of the 28 feet walking time was 0.00 seconds (95% confidence interval (CI) -0.83 to 0.83) and the MD of the 150 feet walking time was -2.88 seconds, favouring the control group (95% CI -8.18 to 2.42). Night splinting of the ankle did not significantly affect muscle force or range of movement about the ankle in a trial of 26 participants with Charcot-Marie-Tooth disease. Improvements were observed in both the splinting and control groups. In a trial of 26 participants with Charcot-Marie-Tooth disease and 28 participants with myotonic dystrophy, 24 weeks of strength training significantly improved six-metre timed walk in the Charcot-Marie-Tooth group compared to the control group (MD 0.70 seconds, favouring strength training, 95% CI 0.23 to 1.17), but not in the myotonic dystrophy group (MD -0.20 seconds, favouring the control group, 95% CI -0.79 to 0.39). No significant differences were observed for the 50 metre timed walk in the Charcot-Marie-Tooth disease group (MD 1.90 seconds, favouring the training group, 95% CI -0.29 to 4.09) or the myotonic dystrophy group (MD -0.80 seconds, favouring the control group, 95% CI -5.29 to 3.69). In a trial of 65 participants with facioscapulohumeral muscular dystrophy, 26 weeks of strength training did not significantly affect ankle strength. After one year, the mean difference in maximum voluntary isometric contraction was -0.43 kg, favouring the control group (95%CI -2.49 to 1.63) and the mean difference in dynamic strength was 0.44 kg, favouring the training group (95%CI -0.89 to 1.77).

AUTHORS' CONCLUSIONS

Only one study, involving people with Charcot-Marie-Tooth disease, demonstrated a statistically significant positive effect of strength training. No effect of strength training was found in people with either myotonic dystrophy or facioscapulohumeral muscular dystrophy. Surgery had no significant effect in children with Duchenne muscular dystrophy and night splinting of the ankle had no significant effect in people with Charcot-Marie-Tooth disease. More evidence generated by methodologically sound trials is required.

Do people with acquired brain impairment benefit from additional therapy specifically directed at the hand? A randomized controlled trial

OBJECTIVE

To determine the benefits of additional therapy specifically directed at the hand in people with acquired brain impairment.

DESIGN

An assessor-blinded randomized controlled trial.

SETTING

Rehabilitation hospital.

PARTICIPANTS

A sample of 39 adults with hand impairment following stroke (90%) or traumatic brain injury (10%). The median (interquartile) time since injury was 1.6 months (0.5-3.5 months).

INTERVENTION

The experimental group (n = 20) received an additional one-hour session of task-specific motor training for the hand five times a week over a six-week period. The training was administered on a one-to-one basis. The control group (n = 19) received standard care which consisted of 10 minutes of hand therapy three times a week. Both groups continued to receive therapy directed at the shoulder and elbow.

OUTCOME MEASURES

Primary outcomes were the Action Research Arm and Summed Manual Muscle Tests measured at the beginning and end of the six-week period.

RESULTS

The mean (SD) Action Research Arm Test values for experimental participants improved from the beginning to the end of study from 10 points (15) to 21 points (23) and the equivalent values for the Summed Manual Muscle Test improved from 35% (33) to 49% (35). There were similar improvements in control participants. The mean between-group differences for the Action Research Arm and Summed Manual Muscle Tests were -6 points (95% confidence interval (CI), -20 to 8) and 3% (95% CI, -10 to 16), respectively.

CONCLUSION

Hand and overall arm function of all participants improved over the six-week period, however there was not a clear benefit from providing additional hand therapy.

Serial casting versus positioning for the treatment of elbow contractures in adults with traumatic brain injury: a randomized controlled trial

Objective: To compare the effects of serial casting with positioning for 1 hour per day for the treatment of elbow flexion contracture in adults with traumatic brain injury.

Design: Pragmatic randomized controlled trial with concealed allocation and assessor blinding.

Setting: Four brain injury rehabilitation units.

Subjects: Twenty-six adults with elbow flexion contracture after traumatic brain injury participating in multidisciplinary inpatient rehabilitation.

Interventions: Subjects were randomized to receive either serial casting or positioning for two weeks. In the subsequent four weeks subjects could be positioned for up to 1 hour/day.

Main measures: Torque-controlled passive elbow extension was measured at baseline, post-intervention (two weeks), post-intervention plus one day, and at follow-up (four weeks post-intervention).

Results: All 26 subjects completed the study. Post-intervention, serial casting reduced contracture by an average of 22 degrees (95% confidence interval (CI) 13 to 31; P <0.001) compared with the positioning group. One day later this effect had decreased to 11 degrees (95% CI 0 to 21 degrees; P= 0.052). The effect had almost completely disappeared at the four-week follow-up (mean 2 degrees, 95% CI -13 to 17; P= 0.782).

Conclusions: Serial casting induces transient increases in range of motion. These effects are not maintained.

Predictive factors for the development of scoliosis in Duchenne muscular dystrophy

OBJECTIVE

Scoliosis is a frequent complication (68-90%) of Duchenne muscular dystrophy (DMD). Prevention of limb deformities, rehabilitation in knee-ankle-foot-orthoses (KAFOs) and glucocorticoids prolong walking and standing, and might reduce scoliosis. We evaluated possible predictive factors for scoliosis development in a large DMD population.

METHODS

Case notes of 123 DMD boys, > or = 17 years, followed at our centre between 1992 and 2002 were reviewed. Univariate analysis was used to relate two outcome measures (age at onset of scoliosis and severity at 17 years) with (i) glucocorticoids treatment; (ii) ages at (a) loss of independent ambulation, (b) rehabilitation into KAFOs, (c) loss of standing, (iii) forced vital capacity (FVC) (%) between 11 and 12 years and (iv) lower limb contractures.

RESULTS

In total, 37/123 boys (30%) received intermittent prednisolone (0.75 mg/kg/day, 10 day/month) for a median 1-year (2 months-9 years), starting between 7.7 and 12.4 years (mean 9.5). About 96/123 (78%) were rehabilitated into KAFOs at 10.2+/-1.6 years. Age at loss of ambulation in KAFOs was 12.3+/-1.9 years and at loss of standing 12.8+/-2.1 years. About 95/123 (77%) boys developed scoliosis (Cobb angle >30 degrees ). Mean age+/-S.D. at scoliosis onset was 12.7+/-1.6 years. Forty-three boys (35%) had scoliosis surgery by 15+/-1.2 years. Later age at loss of ambulation (p<0.0001) and longer duration of prednisolone treatment (p=0.01) related to later scoliosis onset. Ages at loss of ambulation and standing were inversely related to scoliosis severity at 17 years (p<0.005). Hip asymmetry and %FVC at 11-12 years were directly related to scoliosis severity (p=0.02).

CONCLUSIONS

Our data indicate a significant association between prolonged ambulation and a reduced risk of scoliosis development. Glucocorticoid administration, in our series, appear to be associated with a later onset of scoliosis, but did not alter the severity at 17 years, probably reflecting the shorter overall glucocorticoid exposure in this population.

Rehabilitation interventions for foot drop in neuromuscular disease

BACKGROUND

"Foot drop" or "Floppy foot drop" is the term commonly used to describe weakness or contracture of the muscles around the ankle joint. It may arise from many neuromuscular diseases.

OBJECTIVES

To conduct a systematic review of randomised trials of treatment for footdrop resulting from neuromuscular disease.

SEARCH STRATEGY

We searched the Cochrane Neuromuscular Disease Group Trials Register (July 2005), MEDLINE (January 1966 to July 2005), EMBASE (January 1980 to July 2005), AMED (January 1985 to July 2005) and CINAHL databases (January 1982 to July 2005).

SELECTION CRITERIA

Randomised and quasi-randomised trials of physical, orthotic and surgical treatments for footdrop resulting from lower motor neuron or muscle disease and related contractures were included. People with primary joint disease were excluded. Interventions included a 'wait and see' approach, physiotherapy, orthotics, surgery and pharmacological therapy. The primary outcome measure was ability to walk whilst secondary outcome measures included dorsiflexor torque and strength, measures of 'activity' and 'participation' and adverse effects.

DATA COLLECTION AND ANALYSIS

Methodological quality was evaluated by two authors using the van Tulder criteria. Three studies with altogether 139 participants were included in the review. Heterogeneity of the studies precluded pooling the data.

MAIN RESULTS

Early surgery did not significantly affect walking speed in a trial including 20 children with Duchenne muscular dystrophy. After one year, the mean difference (MD) of the 28 feet walking time was 0.00 seconds (95% confidence interval (CI) -0.83 to 0.83) and the MD of the 150 feet walking time was -2.88 seconds, (95% CI -8.18 to 2.42). In a trial with altogether 26 participants with Charcot-Marie-Tooth disease (hereditary motor and sensory neuropathy), long-term strength training significantly increased walking speed on a 6 metre timed walk (MD -0.70 seconds, 95% CI -1.17 to -0.23) but not on a 50 metre timed walk (MD -1.9 seconds, 95% CI -4.09 to 0.29). In a trial of a 24-week strength training programme in 28 participants with myotonic dystrophy, there was no significant change in walking speed on either a 6 or 50 metre walk.

AUTHORS' CONCLUSIONS

Using the primary outcome of ability to walk, only one study demonstrated a positive effect and that was an exercise programme for people with Charcot-Marie-Tooth disease. Surgery was not significantly effective in children with Duchenne Muscular Dystrophy. More evidence generated by methodologically sound trials is required.

Night splinting does not increase ankle range of motion in people with Charcot-Marie-Tooth disease: a randomised, cross-over trial

QUESTION

What is the effect of wearing splints at night to stretch the plantarflexors on dorsiflexion range of motion (ROM) in people with Charcot-Marie-Tooth disease?

DESIGN

Randomised, assessor-blinded, cross-over trial.

PARTICIPANTS

14 people (1 dropout) aged 7 to 30 years with Charcot-Marie-Tooth disease Type 1A and with < or = 15 degrees dorsiflexion range of motion (ROM).

INTERVENTION

A splint holding the ankle in maximum dorsiflexion was worn nightly on one leg for 6 weeks followed by the opposite leg for the subsequent 6 weeks.

OUTCOME MEASURES

The primary outcome was dorsiflexion ROM; secondary outcomes were eversion ROM, and dorsiflexion, eversion, and inversion strength, measured before and after splinting, and three months later.

RESULTS

There was no significant difference between the experimental and the control intervention in terms of ROM or strength. Wearing the splint at night increased dorsiflexion ROM by 1 degree (95% CI -3 to 4; p = 0.72) and eversion ROM by 1 degree (95% CI -1 to 3; p = 0.28) compared to not wearing the splint. Wearing the splint increased dorsiflexion strength by 41 N (95% CI -53 to 135; p = 0.38), reduced eversion strength by 6 N (95% CI -112 to 101; p = 0.92) and reduced inversion strength by 8 N (95% CI -110 to 95; p = 0.88) compared to not wearing the splint.

CONCLUSION

Wearing night splints does not increase ankle ROM or strength in people with Charcot-Marie-Tooth disease Type 1A.

Physical therapy management of Pompe disease

Pompe disease (Glycogen storage disease type II, GSDII, or acid maltase deficiency) is an autosomal recessive disorder characterized by deficiency of acid alpha-glucosidase resulting in intra-lysosomal accumulation of glycogen and leading to progressive muscle dysfunction. The natural history of infantile-onset Pompe disease is characterized by hypertrophic cardiomyopathy and profound generalized weakness presenting in the first few months of life, with rapid progression and death usually occurring by one year of age. Late-onset Pompe disease is characterized by onset of symptoms after one year of age, less severe or absence of cardiac involvement and slower progression, with symptoms primarily related to progressive dysfunction of skeletal muscles and respiratory muscle involvement. Recent clinical trials of enzyme replacement therapy have begun to allow greater opportunity for potential improvement in motor status, function, and survival than ever before, with hopes of moving toward maximizing physical function for individuals with Pompe disease. Children are living longer with some achieving independent sitting, creeping, and walking-milestones typically never achieved in the untreated natural history of the disorder. With increased survival, clinical management based on an understanding of the pathology and pathokinesiology of motor function gains importance. This article reviews current knowledge regarding the motor system in Pompe disease and provides an overview of physical therapy management of Pompe disease, including management strategies for individuals on enzyme replacement therapy.

Passive stretching does not enhance outcomes in patients with plantarflexion contracture after cast immobilization for ankle fracture: a randomized controlled trial

OBJECTIVE

To compare the efficacy of short- and long-duration passive stretches with a control treatment for the management of plantarflexion contracture after cast immobilization for ankle fracture.

DESIGN

Assessor-blinded, randomized controlled trial.

SETTING

Hospital physical therapy outpatient departments.

PARTICIPANTS

Adults with plantarflexion contracture (N=150) after cast immobilization for ankle fracture. All subjects were weight bearing or partial weight bearing.

INTERVENTIONS

Exercise only, exercise plus short-duration passive stretch, and exercise plus long-duration passive stretch. All subjects had a 4-week course of exercises. In addition, subjects in the short-duration stretch plus exercise group completed 6 minutes of stretching per day, and subjects in the long-duration stretch plus exercise group completed 30 minutes of stretching per day.

MAIN OUTCOME MEASURES

Lower Extremity Functional Scale and passive dorsiflexion range of motion with the knee bent and straight at baseline, and at 4 weeks and 3 months postintervention.

RESULTS

One hundred thirty-nine (93%) subjects completed the 4-week assessment and 134 (89%) subjects completed the 3-month assessment. There were no statistically significant or clinically important between-group differences for the primary outcomes.

CONCLUSIONS

The addition of passive stretching confers no benefit over exercise alone for the treatment of plantarflexion contracture after cast immobilization for ankle fracture.