Toe walking (walking on "tip toes" or the ball of the foot) is due to tightening of the Achilles tendon at the back of the ankle. This tightening (equine deformity) prevents the heel striking the ground properly. Particularly in the wheelchair stage, other muscles around the ankle also become tight. If measures are not taken to minimize this tightening, the front of the foot may not only point down but the whole foot may start to turn under so that the outer side of the foot rests on the foot plate of the wheelchair (equino-varus deformity). As mentioned previously, the use of physiotherapy and plastic splints can help slow down the development of these conditions. If toe walking proves to be a problem or if in the wheelchair phase the deformity causes problems or is cosmetically unacceptable, an operation can be performed to correct the malalignment. This operation is called elongation of the tendon-Achilles (ETA). Under some circumstances a tendon may be transferred from the back to the front of the ankle at the time that the ETA is being performed, to help pull the front of the foot up. This is called a tibialis posterior transfer operation. The feet need to be in a plaster cast for about 3 weeks after an ETA, but for longer after the transfer operation. Hence the procedure is usually reserved for patients who cannot walk.

Attempts to stop increasing curvature by various body jackets and bracing devices have not been successful. It is now felt that once this problem has developed the only reliable way to prevent deterioration is to operate to straighten the spine and fuse the bones together by bone grafts. The spine is kept straight with various rods and wires attached to the bones while waiting for them to fuse solidly together. The rods do not need to be removed. It is usually performed at 13 or 14 years of age. Although the operation is a major one, most boys have tolerated it well and have benefited physically and psychologically from having it done.

Tightening of muscles and fibrous tissue at the front of the hips and around the knees occurs as mobility decreases. This tightening increases in severity once the wheelchair stage is reached. Similar tightening develops in the arms at a later stage than in the legs. Operations are not needed in the arms or hands but sometimes they are required at the hips. Occasionally operations other than those mentioned above are necessary. It should be remembered that not all boys with Duchenne muscular dystrophy require all, Sometimes even any, of these operations.

The life span of people with Duchenne muscular dystrophy is determined largely by the strength of the chest muscles needed for breathing and coughing. In recent years, advances in the ability to provide mechanical assistance for breathing have meant that options for relieving some of the symptoms of breathing failure in the late stages of the disease have increased. The options range from using a mask over the nose at night to full mechanical ventilation during the day via a tracheostomy tube (a tube in the windpipe). Whether any of these techniques are used depends very much on the personal views of the affected person and his family. A detailed discussion of the pros and cons and the problems involved in assisted ventilation is beyond the scope of this booklet.

If there are symptoms and signs of a heart failure these can usually be relieved by drugs that are commonly used to treat older people with heart failure from other causes. Tablets to decrease body fluid (diuretics) and to stimulate heart muscle (usually dioxin) are used. Occasionally other drugs are used to treat abnormalities in heart rhythm.

If most of the weight of the body is put onto one buttock for long periods while sitting in a wheelchair there may be discomfort in that area or even sciatica (pain down the back of the leg) if there is pressure on the sciatic nerve.

If constipation does become a problem regular enemas or bowel washouts may be required. If a boy attends a school for the physically disabled it is usually possible to arrange for these treatments to be given at school. Usually, an oral medication is also started. When the bowel is emptied the enemas can be stopped and control maintained with the oral medication.

It has been the experience of many parents that "water beds" significantly assist the comfort levels of children affected by MD. In many instances the number of night turns has been reduced for 6-8 times per night down to 1 - 2 per night. It should be noted that "bladder" type waterbeds have been found to be generally not suitable. The preferred type being thy "waveless" baffled bladder, offering the highest degree of comfort and stability during (un) dressing.

Dietitians are able to advise on the level of food intake required and on the appropriate balance of the various components of the diet. Good dietary advice plays an important role for the older person with Duchenne muscular dystrophy but the basis for good care lies in the appropriate attitude of parents to diet in the early stages of the disease.

Fathers too can have difficulty accepting that they have a disabled son who will not be able to do things that they would like them to do.

• A DMD patient should be in touched with following specialists and follow their medical suggestions to minimize the effects of disease, like General Physicians, Chest Specialist, Cardiologist, Orthopedist, Nutritionist, Neurologist, Physiotherapist, Occupational Therapists, Psychologist and other professional specialist.
• Use of AFO & KAFO for convenience on standing and walking.
• The contractured parts of joints in legs, knees and heaps should be surgically operated to make expandable and comfortable.
• Wearing of Night Splint shoes made of plastic while sleeping a long time in night to prevent the leg contractures and banding.
• Use of wheelchair when there is real problems on standing & walking.
• Surgical operation of the spinal curvature (deformation) to re-position it if is bent. The children can breathe better and often need less assisted respiration afterwards.
• Use of belt on heap as per the suggestions of Doctors.
• Use of Tracheostomy Ventilation (breathing through an opening in the widepipe) for breathing disorders.
• Regular and proper physical exercises only with the suggestions of professional experts and physiotherapists are most common and effective aid to delay muscle deterioration and joint contracture for several years.
• Regular tests of chest, heart echo, pathological test of urine and stool on six monthly average schedule to know about the accurate position of the patient.
• Use of steroids (deflazacort & prednisone) on strict recommendations of concerned Doctors to activate & strengthen the muscle to some extent.
• Consumption of secondary food items likes a high protein, Calcium, Vitamin-D, low fat, low sugar and low salt etc on the recommendation of nutrition specialist.
• A DMD suffering child should be treated like a normal child (not as disabled/handicapped) and should be provided with proper education according to his will. It helps to boost up him morally and feels himself normal as others. Computer program always comes first as a possible profession and help to further activities forever, and other like drawing, painting, music, writing etc.