Commentary on "Progression of Ankle Plantarflexion Contractures and Functional Decline in Duchenne Muscular Dystrophy: Implications for Physical Therapy Management".

Abstract

“How might I apply this information?” This information can be best applied by establishing early and ongoing intervention programs to minimize development of plantar flexor contractures in individuals with Duchenne muscular dystrophy (DMD) and being aware of trends and correlations suggesting the need for additional interventions. Trends reported showed progressive decline in ankle dorsiflexion passive range of motion (PROM) with age, progressive functional decline after 7 years of age as measured by North Star Ambulatory Assessment (NSAA), and correlation between functional decline and decline in ankle dorsiflexion PROM. Understanding and acting on the relationship between contracture and functional losses are critical in providing preventive, anticipatory care in DMD as shown across all ages in this study. Decreases in ankle dorsiflexion PROM emerged before the age of 7 years despite increasing function, supporting the importance of initiating early preventive intervention to minimize contracture development rather than waiting for functional losses, especially in those younger than 7 years. Older individuals who were walking had less extreme ranges of plantar flexor contracture than those 7 to 15 years of age despite lower NSAA functional scores, highlighting the functional importance of minimizing plantar flexor contractures over time, with adequate dorsiflexion range a potential requirement for walking with increased age and weakness. Challenges in preventing plantar flexor contractures, evidenced by variability in the data, support the need for comprehensive individualized approaches described, including home stretching, regular direct skilled physical therapy, orthotic intervention, serial casting, optimal positioning, supported standing, and assessment of PROM and muscle extensibility with sufficient frequency to identify needs for additional interventions. “What I might be mindful of when applying this information?” Individual correlations between ankle dorsiflexion PROM, functional scores, walking status, genetic mutations, steroid use, and therapeutic intervention in participants were not reported, details that might provide insight into individual interactions between factors in the successful prevention of plantar flexor contractures and optimizing function. Laura E. Case, PT, DPT, MS, PCS Doctor of Physical Therapy Division Duke University School of Medicine Durham, North Carolina Julie Coats, PT, DPT Department of Physical Therapy and Occupational Therapy Duke University Medical Center Durham, North Carolina