Duchenne muscular dystrophy (DMD) is a devastating muscle disease with pre mature loss of ambulation1. The disease is caused by deficiency of the sarco lemmal protein dystrophin and results in weakness affecting the proximal portions of the limbs, usually starting during the third and fourth years of life, in association with progressive loss of functional abilities1. The unique medical treatment available is steroid therapy, which appears to prolong walking capacity by at least two years2,3. Strength loss, such as in hip extension and ankle dorsiflexion, is considered the primary predictor of loss of ambu lation in DMD4, leading to progressively reduced walking capacity5,6. During the period of loss of ambulation, the children develop many compensatory movements to compensate for the weakness of limbgirdle muscles in the legs, such as the gluteus and quadriceps. The Gowers signal is the most famous compensatory movement, in which a patient,to rise from a sitting to a standing position, has to use his hands and arms to “walk” up his own body from a squatting position to compensate the reduced hip and thigh muscle strength. However, with the pro gression of the disease, compensatory movements are unable to avoid the loss of ambulation. Even in the first stage of the disease it is possible to quantify very early modifications in loco motion7. Doglio et al., using a Gait Analysis Laboratory, showed important functional changes in patients with DMD in the first stage of the disease7. These changes include alterations in spatial and temporal parameters (increases of cadence, and decreases of step length), increase in the range of anteriorposterior pelvic tilt and in pelvic rotation, in the pelvic obliquity and in the plantarflexion of the ankle in swing. Differences in power generation and absorption at the hip joint and at the ankle joint were also detected, together with reduction in the flexor moment of the knee in midstance and in the dorsiflexor moment of the ankle in terminal stance with a consequent reduction in the peaktopeak excursion. Thus, besides medical treatment, the physical therapy in multidisciplinary care is impe rative for alleviating muscle atrophy, skeletal deformities, and motor function deteriora tion8. Physical therapy might improve the function of those muscles that are more affected in the lower limbs, especially in the period of loss of ambulation. In this way, qualitative analysis of compensatory movements during functional tasks in the critical periods of loss of ambulation may allow for recognition of important changes in synergies to help pro fessionals provide more specific assistance and guidance to patients. Moreover, the use of steroids might prolong walking capacity while also modifying the compensation pattern. Consequently, analysis of the compensatory movements can also help during the follow up of steroid treatment response. The paper presented in this volume by Martini et al. aimed to show the main compensa tory movements in children with DMD immediately before walking loss.9 The authors des cribed and quantified compensatory movements while sitting down/rising from the floor, and while climbing up/down steps. The most frequently observed compensatory move ments were upper limbs support on the lower limbs/floor/handrail during all tasks and lumbar hyperlordosis, trunk support on handrail, equines foot, increased base of support, nonalternated descent, and pauses while climbing up/down steps. They also showed that sitting down/rising from the floor seems to be lost before climbing up/down steps in ambu latory children with DMD. Departamento de Neurologia, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
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