Duchenne Muscular Dystrophy (DMD)

Medical Management

Thanks to advances in many areas of medicine, such as cardiology and pulmonology, people with Duchenne muscular dystrophy in the 21st century are living longer than in previous decades, often well into adulthood.

The use of available treatments can help maintain comfort and function and prolong life. Talk with an MDA clinic physician for more information.

Anesthesia

People with DMD may have unexpected adverse reactions to certain types of anesthesia. It's important that the surgical team know about the patient's DMD so that complications can be avoided or quickly treated.

Braces, standing frames and wheelchairs

Braces, also called orthoses, support the ankle and foot, or may extend up over the knee. Ankle-foot orthoses (AFOs) are sometimes prescribed for night wear to keep the foot from pointing downward and keep the Achilles tendon stretched while the child is sleeping.

Standing for a few hours each day, even with minimal weight bearing, promotes better circulation, healthier bones and a straight spine. A standing walker or standing frame can assist people with DMD to stand. Some wheelchairs will raise the user into a standing position.

Sooner or later, a wheelchair is needed in DMD, typically by about age 12. Unless there's an injury, such as a broken leg, wheelchair use usually is gradual. Many at first use wheelchairs for long distances, such as at school or the mall, and continue to walk at home.

Although the child and parents may dread the wheelchair as a symbol of disability, most find that when they start to use one, they are actually more mobile, energetic and independent than when trying to walk.

Other mobility and positioning aids can help parents and caregivers. Among the simplest aid is a transfer board for helping the person move in and out of the wheelchair. Mechanical lifts, shower chairs and electronic beds also can be useful.

MDA's national equipment program may be able to help families obtain some needed equipment.

Also see:

• Putting Your Best Foot Forward
• Stand Up and Go with Mobile Standers and Standing Wheelchairs

Cardiac care

The American Academy of Pediatrics recommends that people with DMD have a complete cardiac evaluation by a specialist beginning in early childhood and again at least every other year until age 10. After that, the evaluations should be done every year or at the onset of symptoms of heart weakness, such as fluid retention or shortness of breath.

Female carriers of DMD are at higher-than-average risk of developing cardiomyopathy. The academy suggests that carriers should undergo a complete cardiac evaluation in late adolescence or early adulthood, or sooner if symptoms occur, and that they should be evaluated every five years starting at age 25 to 30.

There’s some preliminary evidence that treatment with angiotensin converting enzyme (ACE) inhibitors and beta blockers can slow the course of cardiac muscle deterioration in DMD if the medications are started as soon as abnormalities on an echocardiogram (ultrasound imaging of the heart) appear but before symptoms occur.

Also see:

• Doctors Talk Heart to Heart (pediatric cardiologists and other experts at an MDA-sponsored meeting exchanged information and planned studies regarding the heart in DMD and BMD)
• Revising Cardiac Care in Muscular Dystrophies

Contractures

The impact of DMD can be minimized significantly by keeping the body as flexible, upright and mobile as possible. There are several ways to do this.

As muscle deteriorates, a person with muscular dystrophy often develops fixations of the joints, known ascontractures. If not treated, these will become severe, causing discomfort and restricting mobility and flexibility. Contractures can affect the knees, hips, feet, elbows, wrists and fingers.

However, there are many ways to minimize and postpone contractures. Range-of-motion exercises, performed on a regular schedule, help delay contractures by keeping tendons from shortening prematurely. It’s important that a physical therapist show you how to do range-of-motion exercises correctly.

Braces on the lower legs also can help keep the limbs stretched and flexible, delaying the onset of contractures.

When contractures have advanced, surgery may be performed to relieve them. A tendon release procedure, also called heel cord surgery, is often done to treat ankle and other contractures while the child is still walking. Usually the boy will need to wear lower leg braces after this.

Diet

No special dietary restrictions or additions are known to help in DMD. Most doctors recommend a diet similar to that for any growing boy but with a few modifications.

A combination of immobility and weak abdominal muscles can lead to severe constipation, so the diet should be high in fluid and fiber, with fresh fruits and vegetables dominant.

For boys who use power wheelchairs, take prednisone or who aren’t very active, excessive weight gain can become a problem. For these boys, caloric intake should probably be somewhat restricted to keep weight down. Obesity puts greater stress on already weakened skeletal muscles and the heart. Doctors have found that a low-calorie diet doesn’t have any harmful effect on the muscles.

Those on prednisone and those with heart problems may need a sodium-restricted diet.

Also see:

• Nutritional Considerations While on Corticosteroids (includes meal planning guides and suggested food options)

Exercise

Exercise can help build skeletal muscle, keep the cardiovascular system healthy, and contribute to feeling better. But in muscular dystrophy, too much exercise could damage muscle. Consult with your doctor about how much exercise is best. A person with DMD can exercise moderately but shouldn’t go to the point of exhaustion.

Many experts recommend swimming and water exercises (aquatic therapy) as a good way to keep muscles as toned as possible without causing undue stress on them. The buoyancy of the water helps protect against certain kinds of muscle strain and injury.

Before undertaking any exercise program, make sure to have a cardiac evaluation.

Learning disabilities

Children with DMD who are suspected of having a learning disability can be evaluated by a developmental or pediatric neuropsychologist through the school system’s special education department or at a medical center with a referral from the MDA clinic.

If a learning disability is diagnosed, educational and psychological interventions can begin right away. The specialist may prescribe exercises and techniques, and the school also can provide special help with learning.

Also see:

• When Neuromuscular Disease Affects the Brain
• The Brain in Duchenne Muscular Dystrophy: Are learning disabilities part of the picture?
• A Teacher's Guide to Neuromuscular Disease

Medications

Medications that lessen the workload on the heart are sometimes prescribed for DMD (See cardiac care, above).

Medications belonging to a group known ascorticosteroids have been found to be effective in slowing the course of DMD. The corticosteroids prednisone and deflazacort are beneficial in the treatment of DMD.

The FDA on Feb. 9, 2017, approved deflazacort (brand name Emflaza) to treat DMD. For more, see FDA Approves Emflaza for Treatment of Duchenne Muscular Dystrophy.

Several high-quality studies of these medications in DMD showed a significant increase in strength, timed muscle function (such as the time it took to climb stairs) and pulmonary function.

Chronic use of corticosteroids is part of the standard of care for DMD, but such treatment can lead to side effects and rapid withdrawal of corticosteroids can result in life-threatening complications. The PJ Nicholoff Protocol guides withdrawal from corticosteroids following longterm treatment.

Physical and occupational therapy

A physical therapy program is usually part of the treatment for DMD. Your MDA clinic physician will refer you to a physical therapist for a thorough evaluation and recommendations. The primary goals of physical therapy are to allow greater motion in the joints and to prevent contractures and scoliosis.

While physical therapy emphasizes mobility and, where possible, strengthening of large muscle groups, occupational therapy focuses on specific activities and functions. Occupational therapy can help with tasks for work, recreation or daily living, such as dressing or using a computer.

Respiratory care

As the muscles that assist in breathing get weaker, the bronchial system must be kept free of secretions, either by using a cough assist device or by manual assisted coughing with the help of a caregiver. A respiratory therapist or pulmonologist can be consulted for the needed information. At some point, assisted ventilation may be needed to help provide sufficient air flow into and out of the lungs.

The first step in using assisted ventilation is usually a noninvasive device, meaning one that doesn’t require any surgical procedures. The person receives air under pressure through a mask, nosepiece or mouthpiece. Noninvasive ventilation usually is required only part time, often only during sleep.

If round-the-clock ventilatory support becomes necessary, it’s possible to use noninvasive ventilation full time, under the care of a doctor knowledgeable in this practice. Some young men choose to switch to an invasive system, which means that a surgical opening called a tracheostomy is performed, allowing air to be delivered directly into the trachea (windpipe).

For more, see:

• Getting a Tracheostomy: My Story (a physician with mitochondrial myopathy describes undergoing and taking care of her tracheostomy)
• The Great Trach Escape: Is it for You? (portable but powerful equipment, skilled guidance make noninvasive ventilation an option for many)

Spinal curvatures

In young men with DMD, the spine can be gradually pulled into a curved shape. The spine may curve from side to side (scoliosis) or forward in a “hunchback” shape (kyphosis).

Scoliosis usually appears after a boy has started using a wheelchair full time. The “swayback” curvature that's sometimes seen in those who are still walking is called lordosis.

Severe scoliosis can interfere with sitting, sleeping and even breathing, so measures should be taken to try to prevent it.

Exercises to keep the back as straight as possible and advice about sitting and sleeping positions can be obtained from a physical therapist.

Spine-straightening surgery involves inserting metal rods with hooks into the spine.

Surgery for youngsters with DMD is usually performed in adolescence.

Standards of care

Updates to the 2010 Centers for Disease Control (CDC) Care Considerations for Duchenne muscular dystrophy were published in 2018.

• Diagnosis and management of Duchenne muscular dystrophy, part 1: diagnosis, and neuromuscular,
  rehabilitation, endocrine, and gastrointestinal and nutritional management; and
• Diagnosis and management of Duchenne muscular dystrophy, part 2: respiratory, cardiac,
  bone health, and orthopaedic management.
• Diagnosis and management of Duchenne muscular dystrophy, part 3: primary care,
  emergency management, psychosocial care, and transitions of care across the lifespan.

Updates to the 2005 American Academy of Neurology (AAN) guideline on corticosteroid treatment of DMD were issued in 2016.

General recommendations for medical care in DMD were issued in 2010 by the DMD Care Considerations Working Group, under the auspices of the U.S. Centers for Disease Control and Prevention. These include:

• DMD: diagnosis, and pharmacological and psychosocial management; and
• DMD: implementation of multidisciplinary care.

A family friendly version of the guidelines is available courtesy of TREAT-NMD. MDA contributed to the development of the comprehensive guide.

Guidelines for care of people with DMD receiving anesthesia or sedation were released by the American College of Chest Physicians in 2007.

Recommendations for cardiovascular health supervision in BMD and DMD carriers were issued in 2005 by the American Academy of Pediatrics.

Guidelines for respiratory care in DMD were released by the American Thoracic Society in 2004.