ROLE OF MODALITY IN MUSCULAR DYSTROPHY
The main goal of physiotherapy in patients with Muscular dystrophy is to maintain the available function in their limbs and attain maximum possible improvement in the associated disabilities. This would help the patient attain a socially functional status so that he/she can function in the surroundings, of their own accord, bringing about a sense of independence in the patients.
The therapeutic practices involved and their importance in the life of an Muscular dystrophy patient are as follows:
ELECTROTHERAPY: A patient with Muscular dystrophy often complains of musculoskeletal pains at various sites. Electrotherapeutic modalities like paraffin wax bath over the fractured limb, TENS, IFT, Ultrasonic therapy for tender points and Contrast Bath can be done to relieve such pains. Passive movement: Passive movements are a technique that involves movement of limbs by the physiotherapist, in all ranges, in a manner so as to maintain joint and muscle integrity. Long term immobilization in patients due to the weakness of the muscles can render the muscle fibrotic and the joint may become stiff. To avoid the development of these comorbidities one needs to maintain the integrity of structures by passive movements.
ACTIVE ASSISTED MOVEMENTS: The Muscular dystrophy patient has limited muscle power. Therefore, with maximum effort, they can attain only a limited range by active contraction of their muscle. To maintain this power, the maximum amount of activity up to the fatigue threshold should be encouraged in these patients. While the patient maintains muscle force, the physiotherapist should assist the completion of this movement in the normal biomechanical pattern. This will maintain the joint proprioception i.e. the sense of joint position in space.
STRETCHING MANOEUVRES: Often again due to immobility and poor power of muscles, the muscles shorten in length. The joints adapt a gravity-assisted position and internal muscular forces cannot work against the external gravitational force. As a result of this joint contractures develop. To open up these joints and retain the normal muscle length, stretching is done on the joints. A sustained long duration stretch with crepe bandages or taping can be given initially and this can be toned down a bit in later stages to short-duration stretches with greater repetitions given manually.
JOINT MOBILIZATION: Due to the imbalance of muscular forces, the joints often get displaced from their normal anatomical position. To guide them back so that proper weight bearing can be done on the joints without causing any harm to the associated structures, the physiotherapist passively mobilizes the bones of each joint to bring them in place.
BALANCE AND GAIT TRAINING: Muscular imbalances are so profound in Muscular dystrophy that sitting and standing balance are greatly affected in the patients. So with gradual progression from kneeling to quadruped to high sitting to standing position, balance training should be given. As the balance improves the patient will be able to function better by himself/herself. With gradual degradation of power in lower extremities, the locomotion or gait is affected. So gait training involving proper training in parallel bars progressing from supported to unsupported walking should be done under the supervision of the physiotherapist.
HYDROTHERAPY: Hydrotherapy or aquatic exercises are an innate part of physiotherapy rehabilitation protocol for Muscular dystrophy. Activities are performed in water at a warmer temperature than the body. This helps in the following manner: The buoyancy of water protects and braces the weak joints. In the water, a person can feel very little of his/her own weight so this makes activities of partial weight-bearing possible. Adding floatation devices can assist the movements while adding high-pressure water jet can help in performing mild resistance training in better muscle groups. Warmer water helps in maintaining good thermo-stasis in the body and keeps the active muscle warm and hence at ease. Cardiac Pacing and Breathing Exercises: As the muscles of the heart and respiratory system weaken, greater chest and cardiac congestion are seen in the patients with Muscular dystrophy. To avoid the deleterious effects of an insufficient cardiopulmonary system, one needs to keep in mind a few points.
CHEST PHYSIOTHERAPY:The clear airway should be maintained by passive chest manipulations given by the physiotherapist. The patient should be taught huffing and coughing to aid him in spitting out the chest secretions. Deep breathing exercises should be taught to condition the general cardiorespiratory performance and endurance. Each therapy session lasts for as much as 45 to 60 minutes.
COUNSELING: Besides the therapy sessions, it is the duty of the physiotherapist to counsel the patient about what his/her condition is and how he/she may expect to change in the course of the disease. The parents/guardians/caretaker should be enlightened about the progressive and degrading condition of the disease and the fatality of the condition if applicable. They should be explained the necessity of the physiotherapy regime that needs to be followed back at home as well after one or two sessions under the physiotherapist’s supervision.
GENETIC COUNSELLING: A prime part of counseling involves Genetic Counselling. As Muscular dystrophy is an inheritable disorder, patients with Muscular dystrophy who are in their youth or adulthood should be explained the risks involved in having their biological progeny. This can increase the risk of developing a similar problem in the child as well. Only by chance can the presence of this condition skip a few generations but the innate problem of the affected gene remains. Thus if not now, the condition can easily present in one or the other following generations. To avoid this, even if one generation is of adopted children, the risk of affections in the future progenies is greatly reduced. The physiotherapist’s duty also includes the prescription of orthoses and wheelchairs in conjunction with other rehabilitation professionals.