Muscular dystrophy is a group of genetic diseases that causes progressive muscle weakness and loss of muscle mass due to defects in proteins needed for healthy muscle. The most common and severe type is Duchenne Muscular Dystrophy (DMD), which affects boys in early childhood and is often fatal in the 20s due to heart and respiratory failure. Treatment focuses on managing symptoms, maintaining function and quality of life through physical and occupational therapy, bracing, wheelchairs, and respiratory support as needed.
Spina Bifida: Physiotherapy in the management of meningomyeloceleAyobami Ayodele
Spina bifida is a treatable spinal cord malformation that occurs in varying degrees of severity. Meningomyelocele is associated with abnormal development of the cranial neural tube, which results in several characteristic CNS anomalies. About 90% of babies born with Spina Bifida now live to be adults, about 80% have normal intelligence and about 75% play sports and do other fun activities. Most do well in school, and many play in sports.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Spina Bifida: Physiotherapy in the management of meningomyeloceleAyobami Ayodele
Spina bifida is a treatable spinal cord malformation that occurs in varying degrees of severity. Meningomyelocele is associated with abnormal development of the cranial neural tube, which results in several characteristic CNS anomalies. About 90% of babies born with Spina Bifida now live to be adults, about 80% have normal intelligence and about 75% play sports and do other fun activities. Most do well in school, and many play in sports.
This is the presentation which was delivered to third year Bachelor of Physiotherapy students at Kathmandu University School of Medical Sciences (KUSMS), Dhulikhel, Nepal. Different schools of thoughts in manual therapy are the part of curriculum for the undergraduate students at KUSMS.
Vojta technique is neuromuscular approach deals with all the conditions of CNS and Musculoskeletal system.
Contents :
Introduction
Definition
What is REFLEX LOCOMOTION
Indication
Stimulating Points
Reflex locomotion
Reflex Rolling phase 1
Reflex Rolling phase 2
Reflex creeping
Effects of Vojta technique
Muscle energy technique, a manual therapy technique with a long term history and 8 variations which can be used in various condition to treat muscle as well as joints. This slide show consists of detailed history, variations/types and summary of MET in detail.
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
Brunnstrom Approach
Brunnstrom's Approach (SIGNE BRUNNSTROM)
Objectives: ➢ Discuss the concepts and principles underlying Brunnstrom’s approach ➢ Brunnstrom recovery stages ➢ Treatment principles & techniques
★ Brunnstrom’s approach was developed by the physical therapist from Sweden in the early 1950’s
★ Brunnstrom used motor control theory and observations of the patients'
★ Procedure: In a “trial & error” fashion ★ Later modified: in light of neurophysiological knowledge
Introduction: Reflex Theory Movement is controlled by stimulus-response. Reflexes are the basis for movement: reflexes are combined into actions that create behavior. Hierarchical Theory Characterized by a top-down structure, in which higher centers are always in charge of lower centers.
● When the CNS is injured, as, in a cerebrovascular accident, an individual goes through an “evolution in reverse”. Movement becomes primitive, reflexive, and automatic.
● Changes in tone and the presence of reflexes are considered a normal process of recovery.
● Movement recovery tends to be stereotypic.
● Patients exhibit only a few stereotypic movement patterns: Basic Limb Synergies.
● Based on observations of recovery following a stroke, this approach makes use of associated reactions, tonic reflexes, and the development of basic limb synergies to facilitate movements.
● The use of such a procedure is temporary.
Basic Limb Synergies:
● Normal synergistic movements are purposeful movements with maximum precision and minimum waste of energy.
● Basic limb synergy (BLS) does not permit the different combinations of muscles.
● BLS is considered primitive, automatic, and reflexive due to loss of inhibitory control from higher centers.
● Mass movement patterns in response to a stimulus or voluntary effort both Gross flexor movement (Flexor Synergy) Gross extensor movement (Extensor Synergy) Combination of the strongest component of the synergies (Mixed Synergy)
● Appear during the early spastic period of recovery
Upper Limb Flexor Synergy: Scapula: Retraction / Elevation Shoulder: Abduction and External rotation Elbow: Flexion Forearm: Supination Wrist and Finger: Flexion Lower Limb Extensor Synergy: Pelvis: posterior tilt Hip: Extension, Adduction & Internal rotation Knee: Extension Ankle: Plantarflexion Toes: Flexion Upper Limb Extensor Synergy: Scapula: Protraction / Depression Shoulder: Adduction and Internal rotation Elbow: Extension Forearm: Pronation Wrist: Extension Finger: Flexion Lower Limb Flexor Synergy: Pelvis: anterior tilt Hip: Flexion, Abduction & External rotation Knee: Flexion Ankle: Dorsiflexion Toes: Extension
Upper Limb Mixed Synergy: Scapula retraction Shoulder add.+IR Elbow flexion Forearm pronation Wrist & fingers flexion Lower Limb Mixed Synergy: Pelvis post tilt hip add.+IR Knee extension Ankle & toes plantarflexion
Rubrospinal tract Vestibulospinal tract
Associated Reactions
Primitive Reflexes
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
Vojta technique is neuromuscular approach deals with all the conditions of CNS and Musculoskeletal system.
Contents :
Introduction
Definition
What is REFLEX LOCOMOTION
Indication
Stimulating Points
Reflex locomotion
Reflex Rolling phase 1
Reflex Rolling phase 2
Reflex creeping
Effects of Vojta technique
Muscle energy technique, a manual therapy technique with a long term history and 8 variations which can be used in various condition to treat muscle as well as joints. This slide show consists of detailed history, variations/types and summary of MET in detail.
This presentation is detail about Volta therapy which is commonly used in paediatric neurological conditions and also for adults. this presentation explains what are the various techniques, methods of application of Volta therapy, indications, contraindications, etc.
Brunnstrom Approach
Brunnstrom's Approach (SIGNE BRUNNSTROM)
Objectives: ➢ Discuss the concepts and principles underlying Brunnstrom’s approach ➢ Brunnstrom recovery stages ➢ Treatment principles & techniques
★ Brunnstrom’s approach was developed by the physical therapist from Sweden in the early 1950’s
★ Brunnstrom used motor control theory and observations of the patients'
★ Procedure: In a “trial & error” fashion ★ Later modified: in light of neurophysiological knowledge
Introduction: Reflex Theory Movement is controlled by stimulus-response. Reflexes are the basis for movement: reflexes are combined into actions that create behavior. Hierarchical Theory Characterized by a top-down structure, in which higher centers are always in charge of lower centers.
● When the CNS is injured, as, in a cerebrovascular accident, an individual goes through an “evolution in reverse”. Movement becomes primitive, reflexive, and automatic.
● Changes in tone and the presence of reflexes are considered a normal process of recovery.
● Movement recovery tends to be stereotypic.
● Patients exhibit only a few stereotypic movement patterns: Basic Limb Synergies.
● Based on observations of recovery following a stroke, this approach makes use of associated reactions, tonic reflexes, and the development of basic limb synergies to facilitate movements.
● The use of such a procedure is temporary.
Basic Limb Synergies:
● Normal synergistic movements are purposeful movements with maximum precision and minimum waste of energy.
● Basic limb synergy (BLS) does not permit the different combinations of muscles.
● BLS is considered primitive, automatic, and reflexive due to loss of inhibitory control from higher centers.
● Mass movement patterns in response to a stimulus or voluntary effort both Gross flexor movement (Flexor Synergy) Gross extensor movement (Extensor Synergy) Combination of the strongest component of the synergies (Mixed Synergy)
● Appear during the early spastic period of recovery
Upper Limb Flexor Synergy: Scapula: Retraction / Elevation Shoulder: Abduction and External rotation Elbow: Flexion Forearm: Supination Wrist and Finger: Flexion Lower Limb Extensor Synergy: Pelvis: posterior tilt Hip: Extension, Adduction & Internal rotation Knee: Extension Ankle: Plantarflexion Toes: Flexion Upper Limb Extensor Synergy: Scapula: Protraction / Depression Shoulder: Adduction and Internal rotation Elbow: Extension Forearm: Pronation Wrist: Extension Finger: Flexion Lower Limb Flexor Synergy: Pelvis: anterior tilt Hip: Flexion, Abduction & External rotation Knee: Flexion Ankle: Dorsiflexion Toes: Extension
Upper Limb Mixed Synergy: Scapula retraction Shoulder add.+IR Elbow flexion Forearm pronation Wrist & fingers flexion Lower Limb Mixed Synergy: Pelvis post tilt hip add.+IR Knee extension Ankle & toes plantarflexion
Rubrospinal tract Vestibulospinal tract
Associated Reactions
Primitive Reflexes
Brian Mulligan described novel concept of the simultaneous application of therapist applied accessory mobilizations and patient generated active movements
Medical Technology Tackles New Health Care Demand - Research Report - March 2...pchutichetpong
M Capital Group (“MCG”) predicts that with, against, despite, and even without the global pandemic, the medical technology (MedTech) industry shows signs of continuous healthy growth, driven by smaller, faster, and cheaper devices, growing demand for home-based applications, technological innovation, strategic acquisitions, investments, and SPAC listings. MCG predicts that this should reflects itself in annual growth of over 6%, well beyond 2028.
According to Chris Mouchabhani, Managing Partner at M Capital Group, “Despite all economic scenarios that one may consider, beyond overall economic shocks, medical technology should remain one of the most promising and robust sectors over the short to medium term and well beyond 2028.”
There is a movement towards home-based care for the elderly, next generation scanning and MRI devices, wearable technology, artificial intelligence incorporation, and online connectivity. Experts also see a focus on predictive, preventive, personalized, participatory, and precision medicine, with rising levels of integration of home care and technological innovation.
The average cost of treatment has been rising across the board, creating additional financial burdens to governments, healthcare providers and insurance companies. According to MCG, cost-per-inpatient-stay in the United States alone rose on average annually by over 13% between 2014 to 2021, leading MedTech to focus research efforts on optimized medical equipment at lower price points, whilst emphasizing portability and ease of use. Namely, 46% of the 1,008 medical technology companies in the 2021 MedTech Innovator (“MTI”) database are focusing on prevention, wellness, detection, or diagnosis, signaling a clear push for preventive care to also tackle costs.
In addition, there has also been a lasting impact on consumer and medical demand for home care, supported by the pandemic. Lockdowns, closure of care facilities, and healthcare systems subjected to capacity pressure, accelerated demand away from traditional inpatient care. Now, outpatient care solutions are driving industry production, with nearly 70% of recent diagnostics start-up companies producing products in areas such as ambulatory clinics, at-home care, and self-administered diagnostics.
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
Deep Leg Vein Thrombosis (DVT): Meaning, Causes, Symptoms, Treatment, and Mor...The Lifesciences Magazine
Deep Leg Vein Thrombosis occurs when a blood clot forms in one or more of the deep veins in the legs. These clots can impede blood flow, leading to severe complications.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
2. Introduction
• Muscular dystrophy is a group of diseases that cause
progressive weakness and loss of muscle mass.
• In muscular dystrophy, abnormal genes (mutations)
interfere with the production of proteins needed to
form healthy muscle.
• Symptoms of the most common variety begin in
childhood, mostly in boys. Other types don't surface
until adulthood.
• There's no cure for muscular dystrophy. But
medications and therapy can help manage symptoms
and slow the course of the disease
3. • MD is a progressive condition, which means it
gets worse over time. It often begins by
affecting a particular group of muscles, before
affecting the muscles more widely.
• Some types of MD eventually affect the heart
or the muscles used for breathing, at which
point the condition becomes life-threatening.
4. prevalance
• The estimated prevalence of Duchenne and Becker muscular dystrophy
(DBMD) was 1 in every 7,250 males aged 5 – 24 years.
• The prevalence of Duchenne muscular dystrophy (DMD) was three times
higher than the prevalence of Becker muscular dystrophy (BMD).
• Among males with DMD who did not have a family history of muscular
dystrophy:
– There was an average of 2½ years between when a parent or caregiver
noticed the first signs and symptoms of DMD, and when a diagnosis of
DMD was made based on a muscle biopsy or a DNA test.
– The average age at diagnosis for DMD was 5 years.
5. types
• Duchenne MD – one of the most common and severe forms, it usually affects
boys in early childhood; people with the condition will usually only live into
their 20s or 30s
• myotonic dystrophy – a type of MD that can develop at any age; life
expectancy isn't always affected, but people with a severe form of myotonic
dystrophy may have shortened lives
• Facio scapulo humeral MD – a type of MD that can develop in childhood or
adulthood; it progresses slowly and isn't usually life-threatening
• Becker MD – closely related to Duchenne MD, but it develops later in
childhood and is less severe; life expectancy isn't usually affected as much
• limb-girdle MD – a group of conditions that usually develop in late childhood
or early adulthood; some variants can progress quickly and be life-
threatening, whereas others develop slowly
• Oculo pharyngeal MD – a type of MD that doesn't usually develop until a
person is between 50 and 60 years old, and doesn't tend to affect life
expectancy
• Emery-Dreifuss MD – a type of MD that develops in childhood or early
adulthood; most people with this condition will live until at least middle age
6.
7.
8. Duchenne Muscular Dystrophy (DMD)
• Duchenne Muscular Dystrophy (DMD) is an X-linked
inherited disorder with a worldwide incidence of 1 in 3,500-
6,000 males.The genetic defect is a deletion, duplication, or a
point mutation on the XP-21 region. This defect leads to an
absence or decrease of dystrophin, a cytoskeletal protein
resulting in progressive weakness. (Emery AEH, 1991)
• The natural progression of children with DMD is well
documented and characterized. Boys who are untreated lose
the ability to walk by age 10-12 and 80% develop a scoliosis
after loss of ambulation and standing, with death historically
occurring in the late teens, due to respiratory (70%) or cardiac
(30%) complications.(Emery AEH,1993)
9. Early Signs and Symptoms Early signs and symptoms as reported
by families and care providers include
• Delayed walking
• Delayed speech
• Delayed motor development
• Neck flexor weakness when pulled to sit
• Inability to hop and jump
• Difficulty getting up from floor (Gower’s maneuver)
• Difficulty running
• Difficulty with stairs
• Frequent falls
• Toe walking
• Characteristic gait: anterior pelvic tilt, lumbar lordosis, posterior and lateral
lean during stance, “hip waddling” gait from hip abductor and extensor
weakness, compensatory movement patterns (such as excessive arm swing for
momentum), and foot/ankle pronation and eversion.
– DMD should be considered in any male child with unknown etiology
of:
– • Low muscle tone/hypotonia
– • Developmental delay
10.
11.
12.
13.
14. Tests and Measures
• Health-Related Quality of Life:
– Pediatric Quality of Life Inventory (Peds QL) and Neuromuscular
Module (PedsQL 3.0 NMM)
• Participation:
– Enderle-Severson Transition Rating Scale-3
– Pediatric Evaluation Disability Inventory
– School Function Assessment
– Functional Independence Measure (FIM or the FIM for Children
(WeeFIM)
• Self Determination:
– American Institute for Research (AIR) Self-Determination
Scales
– Arc Self-Determination Scale
15. • Function:
– Egen Klassifikation (EK) Scale
– Jebsen Hand Function Test
– Modified Vignos Lower-Extremity Scale
– Motor Function Measure
– North Star Ambulatory Assessment (NSAA)
– Timed tests
– Gait, Stair, Gower, and Chair Assessment (GSGS)
• Impairments:
– Muscle strength (manual muscle testing [MMT]protocol, Medical
Research Council [MRC] Scale)
– Range of motion and measures of muscle extensibility (goniometer)
– Scoliosis screening and postural assessment
• If your state, clinic, or school district requires standardized assessments,
assessments to consider include:
– Battelle Developmental Inventory 2
– Peabody Developmental Motor Scales (PDMS2)
– Bruininks-Oseretsky Test of Motor Proficiency (BOT-2)
16. Intervention recommendation
• Care recommendations state that comprehensive care should be
anticipatory and preventive, based on an understanding of the well-defined
natural history.
• Multidisciplinary care is critical, with early referral to specialists including
physical therapists, occupational therapists, speech therapists, nutritionists,
psychologists, social workers, orthopedists, pulmonologists, cardiologists,
and gastroenterologists.
• Testing is recommended prior to starting school to allow early
identification and intervention for educational needs.
• The role of physical therapist will vary based on the setting and the stage at
which the child is seen. It may include evaluation, consultation,
coordination, education, and/or direct treatment.
• Promote self-advocacy.
• Participation
• Function
17. • The family may require the home to be modified. This takes time and
financial consideration. Become knowledgeable about simple architectural
Americans with Disabilities’ (ADA) requirements.
• Functional and recreational activities such as bike riding and swimming are
recommended, with caution against excessively strenuous exercise. Exercise
should remain submaximal and avoid resistive and eccentric exercise.
• KAFOs (knee-ankle-foot orthoses) or long leg braces may be recommended
to prolong ambulation.
• Power-positioning components on motorized wheelchairs .
• Seating systems in wheelchairs may include a solid seat and back, rigid
lateral trunk supports, hip guides, and swing-away adductors to provide
appropriate support; pressure relief cushion to maintain skin integrity; and
swing-away leg rests to facilitate transfers. Additional options based on the
needs of the child may include elevating leg rests, head rests, and a variety of
different options for upper-extremity support.
18. • Standers and power ‘stand and drive’ wheelchairs.
• Prevention of contracture and deformity :
• Daily active/active-assisted and/or passive:
– stretching of plantar flexors (with knees flexed and extended), hip flexors,
iliotibial bands, hamstrings, and posterior tibialis.
– stretching of long wrist and finger flexors, and neck extensors in older
individuals as well as any structures or soft tissues identified as “at risk’” in
physical therapy evaluation.
• Custom-molded ankle-foot orthoses (AFOs) for stretching and to sleep in at night if
tolerated
• Serial casts recommended in some situations
• Wrist/hand splints/stretching gloves may be recommended in older individuals for
prevention of contracture in long wrist and finger flexors and extensors.
• Anticipatory, preventive care (with respect to prevention of contracture and
deformity). Waiting until it is obvious that muscle or joint tightness is developing, or
that positioning or alignment, puts the individual at risk for deformity.
• In some instances, respiratory management. Respiratory management may occur in
conjunction with respiratory therapy and pulmonary medicine, and should include
consideration of assisted coughing (mechanically assisted coughing by caregiver as
well as “Cough Assist” machines) and non-invasive ventilation, with BiPAP or a
ventilator when needed.
19. refrences
• APTA Guidelines
• Measure for Children (WeeFIM) conceptual basis and pilot use in
children with develop-mental disabilities. Clin Pediatr.
1994;33:421-430.
• Wolman JM, Campeau PL, DuBois PA, Mithaug DE, Stolarski
VS. AIR Self-Determination Scale and User Guide. Washington,
DC: American Institutes for Research; 1994.
http://www.sdtac.uncc.edu/air.pdf. Accessed May 31, 2012.
• Wehmeyer ML, Kelchner K. Arc Self-Determination Scale.
Washington,
• DC: The ARC of the United States; 1995.
http://www.ou.edu/content/dam/Education/documents/miscellaneo
us/the-arc-self-determination-scale.pdf. Accessed May 31, 2012.
• Steffensen BF, Hyde SA, Atterman J, Mattssson E. Reliability of
the EK scale, a functional test for non-ambulatory persons with
Duchenne dystrophy. Advances in Physiother. 2002;4(1):37-47.
• Academy of Pediatric Physical Therapy Fact Sheet/Resource
20. • Steffensen BF, Hyde S, Lyager S, Mattsson E. Validity of the EK scale, a functional assessment of non-ambulatory
individuals with Duchenne muscular dystrophy or spinal muscle atrophy. Physiother Res Int. 2001;6:3:119-34.
• Hiller LB, Wade CK. Upper extremity functional assessment scales in children with Duchenne muscular dystrophy: a
comparison. Arch Phys Med Rehabil. 1992;73:6:527-534.
• Wagner MB, Vignos PJ, Carlozzi C, Hull AL. Assessment of hand function in Duchenne muscular dystrophy. Arch Phys
Med Rehabil. 1993;74(8):801-804.
• Barr AE, Diamond BE, Wade CK, et al. Reliability of testing measures in Duch-enne or Becker muscular dystrophy.
Arch Phys Med Rehabil. 1991;72:315-319.
• Bérard C, Payan C, Hodgkinson I, Fermanian J. The MFM Collaborative Study Group. A motor function measure for
neuromuscular diseases: construction and validation study. Neuromuscul Disord. 2005; 15(7):463-470.
• Mazzone ES, Messina S, Vasco G, et al. Reliability of the North Star Ambulatory Assessment in a multicentric setting.
Neuromuscul Disord. 2009;19:458-461.
• McDonald CM, Henricson EK, Han JJ, et al. The 6-minute walk test as a new outcome measure in Duchenne muscular
dystrophy. Muscle Nerve. 2010;41(4):500-510.
• Florence JM, Pandya S, King WM, et al. Intrarater reliability of manual muscle test (Medical Research Council scale)
grades in Duchenne muscular dystrophy. Phys Ther. 1992;72(2):115-22
• Brooke MH, Griggs RC, Mendell JR, Fenichel GM, Shumate JB, Pellegrino RJ. Clinical trail in Duchenne dystrophy,
part 1: The design of the protocol. Muscle Nerve. 1981;4;186-197.
• Florence JM, Pandya S, King WM, et al. Clinical trials in Duchenne dystro-phy: standardization and reliability of
evaluation procedures. Phys Ther. 1984;64:41-45.
• Pandya S, Florence JM, King WM, Robinson JD, Oxman M, Province MA. Reliability of goniometric measurements in
patients with Duchenne muscular dystrophy. Phys Ther. 1984;64(1): 41-45.
• Newborg J. Battelle Developmental Inventory: Second Edition. Itasca, IL: Riverside Publishing; 2005.
• Folio MR, Fewell RR. Peabody Developmental Motor Scales. 2nd ed. Austin, Tex: Pro-Ed Inc; 2000.
• Bushby K, Finkel R, Birnkrant DJ, et al. Diagnosis and management of Duchenne muscular dystrophy, part 1:
diagnosis, and pharmacological and psychosocial management. Lancet Neurol. 2010;9(1):77-93.
• Bruininks RH, Bruininks BD. Bruininks-Oseretsky Test of Motor Proficiency: 2nd Edition Manual. Minneapolis, MN:
NCS Pearson; 2005.