Muscular dystrophy

A chronic disease of hereditary genesis, expressed by degeneration of the muscles that support the skeletal framework, is muscular dystrophy.

Medicine classifies nine types of this pathology, differing in the localization of the disorder, its characteristics, aggressiveness of progression, and the patient's age (how old was the patient when the first symptoms of the pathology began to appear).

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Causes of muscular dystrophy

Today, medicine cannot name all the mechanisms that trigger the process leading to muscular dystrophy. It can only be said for sure that all the causes of muscular dystrophy are based on mutations of the autosomal dominant genome, which is responsible in our body for the synthesis and regeneration of protein, which is involved in the formation of muscle tissue.

Depending on which chromosome in the human code has undergone a mutation, the pathology of which localization we will receive depends on the verification:

• Mutation of the sex X chromosome leads to the most common type of pathology - Duchenne muscular dystrophy. If a woman is a carrier of this chromosome - she often passes it on to her descendants. At the same time, she herself may not suffer from such disorders.
• Motonic muscular dystrophy occurs when a gene belonging to chromosome nineteen becomes defective.
• The following localization of muscular underdevelopment does not depend on the pathology of the sex chromosome: lower back - limbs, as well as shoulder - shoulder blade - face.

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Symptoms of Muscular Dystrophy

Symptoms of muscular dystrophy have a complex of basic, fundamental manifestations, but depending on the localization and characteristics of the pathology, there are also their own distinctive features. •

• Due to the lack of muscle mass in the legs, disturbances in a person's gait are observed.
• Muscle tone decreases.
• Skeletal muscles atrophy.
• The motor abilities that the patient had acquired before the disease began to progress are lost: the patient stops holding his head, walking, sitting, and loses other skills.
• Muscle pain is dulled, but sensitivity does not disappear.
• A decrease in overall vitality; the patient begins to tire very quickly.
• Muscle fibers begin to be replaced by connective tissue, which leads to an increase in the volume of the muscles themselves. This is especially noticeable in the calf section.
• Difficulties in learning appear.
• Falls are quite common.
• Difficulties arise when running and jumping.
• It becomes difficult for the patient to get up, both from a lying position and from a sitting position.
• The gait of such a patient becomes waddling.
• There is a decline in intelligence.

Duchenne muscular dystrophy

Currently, Duchenne muscular dystrophy is the most frequently manifested type of this disease. The defect, "due" to which the weakness of muscle tissue of this type develops, has been found and is a modified gene of the sex X chromosome. Often, a woman, without being ill herself, passes this defect on to her children. The first symptoms of the pathology in boys (for some reason, they are the ones who suffer most), who have received such a gene, are detected already at the age of two to five years.

The first signs of the disease begin to manifest themselves in the weakening of the tone of the lower limbs, as well as the pelvic area. With further progression of the disease, atrophy of the muscle group of the upper body is connected. Gradually, due to the degeneration of muscle fibers into connective ones, the calf areas of the patient's lower limbs increase in volume, and the size of the adipose tissue increases. The rate of development of this genetic disorder is quite high and by the age of 12 the child loses the ability to move at all. Often, such patients do not live to be twenty years old.

Weakening of the muscle tone of the lower extremities with the growth of the volumes of the calf area leads to the fact that the child begins to initially experience discomfort when walking and running, and subsequently loses this ability completely. Gradually rising upward and capturing an increasing number of muscle groups, at the terminal stage of Duchenne muscular dystrophy, the pathology begins to affect the complex of respiratory muscles, pharynx and face.

Pseudohypertrophy can progress not only in the calf area, it can also affect the buttocks, abdomen and tongue. With this pathology, damage to the heart muscles often occurs (changes occur according to the type of cardiomyopathy). The heart rhythm is disturbed, the tones become muffled, the heart itself increases in size. Cardiac muscular dystrophy is often the cause of death of the patient.

Characteristic symptoms include the fact that the patient suffers from mental retardation. This is explained by lesions that affect the cerebral hemispheres. As muscular dystrophy progresses, other associated diseases begin to appear. Such as, for example: diffuse osteoporosis, diseases associated with endocrine insufficiency, deformation of the chest, spine...

The main distinguishing feature of Duchenne-type pathology from other types is a high level of hyperfermentemia, which manifests itself already at the initial stage of pathology development.

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Progressive muscular dystrophy

The most common type of muscular-neurological disease is primary progressive muscular dystrophy, which is represented by a fairly extensive classification. The difference between one form and another depends on the location of the gene mutation, the rate of progression, the age characteristics of the patient (at what age the pathology began to manifest itself), whether pseudohypertrophy and other signs are present in the symptoms. Most of these myodystrophies (their symptoms), over almost a century of history, have been studied quite well, but the pathogenesis is still unknown, and, based on this, there are problems with high reliability of diagnostics. Without knowing the causes of pathological changes, it is very difficult to make a sufficiently rational classification of progressive muscular dystrophy.

In most cases, the division is carried out either by the form of inheritance or by clinical characteristics.

The primary form is damage to muscle tissue, in which the peripheral nerves remain active. The secondary form is when the damage begins from the nerve endings, initially not affecting the muscle layers of matter.

• Severe type of Duchenne pseudohypertrophy.
• A less common, less aggressive Becker type.
• Landouzy-Dejerine type. Affects the shoulder-scapula-face area.
• Erb-Roth type. Adolescent form of the disease.

These are the main types of muscular dystrophy that are diagnosed most often. Other varieties are less common and are atypical. For example, such as:

• Dystrophy of Landouzi Dejerine.
• Emery-Dreyfuss dystrophy.
• Limb-girdle muscular dystrophy.
• Oculopharyngeal muscular dystrophy.
• And also some others.

Becker muscular dystrophy

This pathology is relatively rare and, unlike the severe malignant form of Duchenne, is benign and progresses quite slowly. One of the characteristic signs may be that this form usually affects people of short stature. For a fairly long time, the disease does not make itself known and the person lives a normal life. The impetus for the development of the disease may be either a banal domestic injury or a concomitant disease.

Becker's muscular dystrophy is a milder form of the disease, both in terms of the severity of clinical symptoms and the completeness of molecular manifestations. Symptoms in the case of muscular dystrophy diagnosed according to Becker's form are weakly detected. A patient with such a pathology is capable of living a fairly normal life for several decades. With such weak symptoms, a poorly qualified doctor may well confuse Becker's dystrophy with limb-lumbar dystrophy. The first signs of this pathology usually begin to appear at the age of twelve. The teenager begins to feel pain in the lower limbs (in the shin area), especially during exercise. Urine analysis shows a high content of myoglobin, which is an indicator that muscle protein is being broken down in the body. Creatine kinase in the patient's body (an enzyme produced from ATP and creatine) increases. It is actively used by the body when physical stress increases.

Symptoms of Becker muscular dystrophy are quite similar to those of Duchenne pathology. However, manifestations of this form of the disease begin much later (by the age of 10-15), while the progression of the disease is not so aggressive. By the age of thirty, such a patient may still not lose his ability to work and walk quite normally. There are frequent cases when this pathology "runs in the family": a grandfather suffering from this disease passes the mutated gene to his grandson through his daughter.

This form of muscular dystrophy was described by doctors and scientists Becker and Kiener back in 1955, which is why it bears their name (it is known as Becker or Becker-Kiener muscular dystrophy).

The symptoms of the pathology, as in the case of Duchenne's disease, begin with deviations in the pelvic-girdle region, affecting the lower limbs. This is manifested in a change in gait, problems with climbing stairs appear, it becomes very difficult for such a patient to get up from a sitting position on low surfaces. The size of the calf muscles gradually increases. At the same time, changes in the area of the Achilles tendons, noticeable in Duchenne's pathology, are visualized insignificantly in this case. There is no decrease in a person's intellectual abilities, which is inevitable in malignant muscular dystrophy (according to Duchenne). Changes in the muscle tissue of the heart are not so significant, therefore, with the disease in question, cardiomyopathy is practically not observed, or it occurs in a mild form.

As with other forms of muscular dystrophy, clinical blood tests show increases in the levels of certain enzymes in the blood serum, although they are not as significant as in the case of Duchenne changes. Metabolic processes are also disrupted.

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Erb-Roth muscular dystrophy

This pathology is also called juvenile. Symptoms of this disease begin to appear between the ages of ten and twenty. A significant difference in the symptoms of this form of the disease is that the primary location of changes is the shoulder girdle, and then muscle atrophy begins to capture new areas of the patient's body: the upper limbs, then the area of the belt, pelvis and legs.

Cases of the disease occur in the proportion of 15 patients per one million population. The defective genome is transmitted hereditarily, in an autosomal recessive manner. Both women and men suffer from this disease with equal probability.

Erb-Roth muscular dystrophy significantly deforms the patient's chest (as if collapsing it back), the abdomen begins to protrude forward, the gait becomes uncertain, waddling. The first signs of the disease appear at approximately 14 - 16 years, but the range itself is much wider: there are cases of later development - after the third decade, or vice versa - at ten years (with early symptoms, the disease proceeds with more severe manifestations). The intensity and development of the course of the disease varies from case to case. But the average duration of the cycle from the moment the first symptoms appear to complete disability is from 15 to 20 years.

Most often, Erb's muscular dystrophy begins to manifest itself with changes in the pelvic-girdle region, as well as with edema and weakness in the legs. Then the spreading pathology gradually captures the rest of the muscle groups of the patient's body. Mostly, the lesion does not affect the facial muscles, the heart muscle remains untouched, the level of intelligence usually remains at the same level. The quantitative indicator of enzymes in the blood serum is slightly increased, but not to the same level as in previous cases.

Muscular dystrophy of the form under consideration is one of the most amorphous pathologies.

Primary muscular dystrophy

The disease in question is hereditary and sex-linked (X-chromosome genomic defect). The transmission route is recessive.

The clinical manifestation is quite early - before the baby is three years old. Even in infancy, you can notice a delay in the development of motor skills in the baby, later than healthy children, they begin to sit and walk. Already by the age of three, the baby has noticeable weakness in the muscles, he quickly gets tired, and does not tolerate even minor loads. Gradually, atrophy affects the pelvic girdle and proximal muscles of the lower extremities.

The classic symptomatology is pseudohypertrophy (muscle tissue is replaced by fat, increasing the size of this area). Most often, the calf region is subject to such damage, but there are cases of defects in the deltoid muscles. The so-called "gnome calves". Over time, it becomes difficult for the baby to run and jump, climb stairs. After some time, atrophy overtakes the shoulder girdle.

Neuromuscular dystrophy

Medicine counts a number of hereditary (genetic) diseases that affect muscle and nerve tissue. One of them is neuromuscular dystrophy, which is characterized by a violation of motor and static manifestations against the background of muscle atrophy. Neurons responsible for motor functions (anterior horn cells) are subject to damage, which leads to changes in a group of tissues of the spinal cord. Damage to neurons of the nucleus of the cells of the cranial nerve affects facial expressions, bulbar and ocular muscles. Also, the same type of cells are responsible for motor processes, when damaged, the nerve endings of the periphery and neuromuscular junctions suffer.

Basic signs of such pathology:

• Atrophy of muscular connective tissue.
• Muscle pain.
• Rapid fatigue of the patient.
• Decreased sensitivity of receptors.
• Or, on the contrary, increased sensitivity, up to pain syndromes.
• The appearance of sudden convulsions.
• Dizziness.
• Heart pathology.
• Deterioration of vision.
• Failure of the sweat system.

Landouzy Dejerine muscular dystrophy

Most often, the pathology of this form begins to manifest itself in adolescents aged 10-15 years, although in fact there are known cases when muscular dystrophy of Landuzi-dejerine began to develop in six-year-old children, or in a fifty-year-old person. The primary area of pathology, most often, is a group of muscles of the facial zone. Gradually, the halo of damage expands, the groups of the shoulder girdle, torso and further down begin to atrophy. When facial expressions are affected in the early period of the disease, the eyelids do not close tightly. The lips also remain slightly open, which leads to a speech defect. The course of the disease is slow - during this period, a person is completely able to work, only after 15-20 years, the muscles of the girdle and pelvis gradually begin to atrophy - this leads to motor passivity. And only by 40-60 years does the lesion completely affect the lower limbs.

That is, Landouzi-Dejerine muscular dystrophy can be called a favorable current manifestation of muscle damage.

Emery-Dreifuss muscular dystrophy

Like all the previous ones, Emery-Dreifuss muscular dystrophy is a hereditary disease. The main area of damage is atrophy of the shoulder-elbow and ankle muscles. This disease is characterized by a long period of development. In the vast majority of cases, the heart is affected: bradyarrhythmia, decreased blood flow, blockade, etc. Heart failure can cause fainting, and sometimes even death.

Early diagnosis of not only the disease itself, but also differentiation of its form will help save the life of more than one patient.

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Limb-girdle muscular dystrophy

Limb-girdle muscular dystrophy is a hereditary pathology, the inheritance paths of which are both autosomal recessive and autosomal dominant diseases. The basic area of damage is the area of the belt, torso and upper limbs. At the same time, the muscles of the facial muscles are not affected.

According to the research data, it was possible to establish at least two loci of the chromosome genome, the mutation of which creates an impetus for the development of limb-girdle muscular dystrophy. The progression of this lesion is quite slow, allowing the patient to fully enjoy life.

Oculopharyngeal muscular dystrophy

An autosomal dominant disease that manifests itself already at a fairly mature age is oculopharyngeal muscular dystrophy. As strange as it may sound, this pathology affects people belonging to certain ethnic groups.

Most often, symptoms begin to appear by the age of 25-30. Classic signs of this muscular dystrophy are atrophy of the facial muscles: ptosis of the eyelids, problems with swallowing function (dysphagia). The disease, gradually progressing, leads to immobility of the eyeball, while the internal muscles of the eye are not affected. At this stage, the changes can stop, but sometimes the rest of the facial muscles are also affected by the pathology. Quite rarely, but muscle groups of the shoulder girdle, neck, palate and pharynx are also involved in the destructive process. In this case, in addition to ophthalmoplegia and dysphagia, dysphonia (a problem with the speech apparatus) also progresses.

Muscular dystrophy in children

Childhood. Many remember it with a smile. Hide and seek, swings, bicycles... Yes, how many other different games children come up with. But there are little ones who cannot afford such luxury. Muscular dystrophy in children does not allow such an opportunity.

Almost all forms, with rare exceptions, can manifest themselves in children with their symptoms: both the malignant form of pathology according to Duchon (developing only in boys), and benign muscular dystrophy according to Becker and others. Pathology that develops rapidly and aggressively (form according to Duchon) is especially dangerous. Moreover, for a child, it is not so much the symptoms themselves (atrophy of almost all muscle groups) that are dangerous, but the secondary complications that lead to death by the age of twenty. Most often, a fatal outcome occurs due to a respiratory infection or heart failure. But these symptoms become more obvious only when the child begins to take his first steps.

• Developmental delay: such children start sitting and walking later.
• Slow intellectual development.
• The muscles of the spine are the first to be affected.
• It is difficult for such babies to run and climb stairs.
• Waddling gait.
• Spinal deformity.
• Walking on toes.
• The baby has difficulty supporting his weight and gets tired quickly.
• Due to fatty tissue, muscle size increases.
• The damage to the limbs is symmetrical.
• Pathological enlargement of the jaw and spaces between teeth.
• At about 13 years of age, the child stops walking completely.
• Pathology of the heart muscle.

In other forms of damage, the symptoms are quite similar, only the severity of the damage is much lower.

Diagnosis of muscular dystrophy

The diagnosis of muscular dystrophy is unambiguous:

• Collection of family history. The doctor needs to find out whether there were cases of this disease in the patient's family, what form of manifestation was observed, and the nature of its course.
• Electromyography. A method that allows determining the electrical activity of muscle tissue.
• Microscopic examination. Biopsy, allowing differentiation of the class of mutated changes.
• Genetic testing. Conducting molecular biological and immunological studies of a pregnant woman. These methods allow predicting the possibility of developing muscular dystrophy pathology in the future child.
• Consultation with a therapist, obstetrician-gynecologist, orthopedist.
• Blood test for enzyme levels. Without trauma, elevated levels of the enzyme creatine kinase indicate pathology.
• Urine analysis shows elevated levels of creatine, amino acids and decreased levels of creatinine.

The doctor can only say one thing: the later the symptoms of muscular dystrophy appear, the more gentle they are. Early manifestations lead to serious consequences: disability, and in some cases, death.

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Treatment of muscular dystrophy

Muscular dystrophy cannot be cured completely and irreversibly, but medicine tries to carry out measures as effectively as possible that would alleviate the symptoms of the disease as much as possible, while preventing the occurrence of complications.

Treatment of muscular dystrophy comes down to a comprehensive approach to the problem. In order to at least slightly stimulate muscle activity, the attending physician prescribes corticosteroids to the patient. For example, prednisone.

• Prednisone

If the disease is acute, the patient begins to take this medicine in three to four doses with a daily dosage of 0.02-0.08 g. When severe symptoms are relieved, the dose consumed is reduced to 0.005-0.010 g daily.

There are also restrictions on taking this drug. You should drink no more than 0.015 g at a time, the daily dosage is 0.1 g.

The duration of the course of treatment depends on the characteristics of the developing disease and the effectiveness of the clinical action of the drug. During the period of taking this drug, it is advisable for the patient to adhere to a diet rich in potassium salts and proteins. This diet will help to avoid or at least mitigate the side effects of prednisone consumption. For example, such as swelling, increased blood pressure, insomnia, convulsions, increased fatigue, and others.

This drug is strictly contraindicated for patients suffering from such diseases as: thrombophlebitis and thromboembolism, ulcerative manifestations of the stomach and duodenum, osteoporosis, hypertension, pregnancy and some others.

If the drug intake is extended over a long period of time, and the dosages consumed by the patient are impressive, it is recommended to take anabolic hormones in parallel (for example, methylandrostenediol).

• Methylandrostenediol

The tablet of medicine is placed under the tongue and kept there until completely dissolved.

For adults (prevention of protein metabolism disorders), the dosage is prescribed within 0.025–0.050 g per day. For children, the dosage is calculated from the proportions of 1.0–1.5 mg per 1 kg of the child's body weight, but the daily dosage should fall within the range of 0.010–0.025 g.

The duration of one course is three to four weeks, then a break of two to three weeks and you can start taking the next cycle.

The maximum daily dose is 0.10 g (for adults) and 0.050 g (for children). Single dose is 0.025 g.

It is not recommended to prescribe methylandrostenediol to patients with functional liver failure, individual intolerance to the components of the drug, prostate cancer, diabetes mellitus and some other diseases.

Patients with muscular dystrophy are also prescribed drugs that relieve muscle spasms: diphenin, carbamazepine.

• Diphenin

The medicine is available in tablet and capsule form. The medicine is taken three to four times a day, during or after meals. The daily dosage is 0.02-0.08 g (in acute cases of the disease), and subsequently the amount of the medicine taken is reduced to 0.005-0.010 g per day. If, on the contrary, the effectiveness of the medicine is low, the dose can be increased to 0.4 g.

The dosage for children is slightly different:

Children under five years of age are prescribed two doses of 0.025 g each.

For children aged five to eight years, the number of doses is increased to three to four per day at a dosage of 0.025 g.

For teenagers over eight years of age, the dose is divided into two parts, 0.1 g each.

The proposed drug is contraindicated for use by people suffering from hypersensitivity to the components of the drug, ulcerative diseases of the gastrointestinal tract, thrombosis, mental disorders, acute diseases of the heart and endocrine system, and some other diseases.

• Carbamazepine

The drug is used throughout the day, regardless of meals. The tablet is taken with a small amount of liquid. The starting dose of the drug is 100-200 mg and is taken once or twice a day. The dosage is gradually increased to achieve the desired effect, up to 400 mg. At the same time, the number of doses is also increased, bringing them to two or three per day. The maximum permissible daily dosage should not exceed 2000 mg.

The starting dose for five-year-old children is 20-60 mg daily. Then, every two days, the dosage is increased by the same 20-60 mg daily.

The starting daily dosage for children over five years of age begins with 100 mg. Then, each subsequent week, the dosage increases by 100 mg.

The total maintenance dose of the drug for babies is calculated based on the proportions: ten to twenty mg per kilogram of the child’s weight per day and is divided into two to three doses.

The use of the drug should be limited to patients suffering from epileptic seizures, acute forms of cardiovascular diseases, diabetes mellitus, hypersensitivity to tricyclic antidepressants, renal and hepatic insufficiency and other diseases.

After consultation with your doctor, it is possible to use so-called dietary supplements (biologically active additives).

• Creatine

This is a natural preparation that helps to increase muscle volume, activates them to adequately respond to loads. The dosage is prescribed by a doctor, individually for each individual case.

This dietary supplement is not recommended for patients suffering from asthma, diabetes. It is also not advisable to take creatine during pregnancy.

• Coenzyme Q10

Increases overall muscle endurance. The recommended daily dosage is three capsules, but can be adjusted by a doctor if necessary. The course of treatment is one month, then you need to take a break and the cycle can be resumed.

This drug is contraindicated for pregnant and lactating women, children under 12 years of age, in case of individual intolerance to any components of the drug, in case of ulcerative diseases of the gastrointestinal tract, hypertension, etc.

In muscular dystrophy, simple but quite effective exercises are practiced to stretch the muscles of the lower and upper extremities in order to prevent contracture (long-term, often irreversible tightening of muscle tissue fibers).

Physiotherapeutic treatment of muscular dystrophy involves therapeutic massages that increase muscle tone. Simple but effective breathing exercises are also practiced.

If the contracture or scoliosis is already quite pronounced, then after consultation with specialists in other, narrower fields (for example, an orthopedist, obstetrician-gynecologist, neurologist), the attending physician may decide on surgical intervention.

During pregnancy, a woman's hormonal background undergoes a restructuring, which can trigger the activation of the muscular dystrophy process. In such a case, in order to save the woman's life, she is recommended to terminate the pregnancy.

Treatment of Duchenne muscular dystrophy

A major breakthrough in the field of medicine was already the fact that scientists managed to specify the genome responsible for the onset of the progression of the disease, which is known to doctors as Duchenne muscular dystrophy. However, to date, it has not yet been possible to obtain a drug and determine a protocol of measures that would make the treatment of Duchenne muscular dystrophy effective. That is, today it is impossible to cure this disease.

There is only a possibility to reduce the aggressiveness of symptoms, at least slightly improve the quality and increase the life expectancy of the patient. These circumstances gave a powerful impetus to stimulating experimental research in this area.

Patients receive the necessary comprehensive treatment. But in addition to standard methods, they are often offered experimental methods that are only being developed. Through the efforts of doctors, the prognosis for improving the vital signs and life expectancy of such patients has been somewhat changed, but it is still not possible to completely defeat Duchenne muscular dystrophy.

Prevention of muscular dystrophy

At this stage of medical development, it is impossible to completely prevent muscular dystrophy. But it is possible to take some measures to recognize it at an early stage and start treatment or supportive therapy (depending on the form of the disease) faster.

Prevention of muscular dystrophy:

• Modern medicine can diagnose the pathological form of Duchenne even at the stage of intrauterine development. Therefore, pregnant women undergo laboratory tests to identify mutated genes, especially in cases where there have already been cases of muscular dystrophy in the family of the future person.
• The expectant mother should also visit the obstetrician-gynecologist regularly: once a month (at least) in the first trimester, once every two to three weeks in the second trimester, and once every seven to ten days in the last trimester. She must register with the gynecologist no later than the 12th week of pregnancy.
• An active lifestyle that includes exercises to stretch the muscles of the lower and upper extremities. These simple exercises will help to maintain the mobility and flexibility of the joints for longer.
• The use of special braces that help support atrophic muscle groups can slow down the development of contracture and maintain joint flexibility longer.
• Additional equipment (wheelchairs, walkers and canes) provide the patient with individual mobility.
• The respiratory muscles are often affected as well. The use of special breathing devices will allow the patient to receive oxygen in normal doses at night. Some patients require it around the clock.
• Infectious viruses can become a serious problem for a person with muscular dystrophy. Therefore, the patient must be protected from the possibility of infection as much as possible: a healthy epidemiological environment, regular flu vaccinations and other measures.
• Support from such a patient and his family members is also important: emotional, physical and financial.

Muscular Dystrophy Prognosis

The most unfavorable prognosis for muscular dystrophy is the Duchenne form (the most severe malignant form of the disease). The prognosis here is disappointing. Patients with this pathology rarely live to the age of twenty. Modern treatment can only prolong the life of such patients for a short time, but can significantly improve the quality of their existence.

In other cases, the prognosis of muscular dystrophy largely depends on the form of pathology and the factor that determines how early the disease was diagnosed. If the pathology is recognized at an early stage of development, and the disease can be classified as a mild form of manifestation, then there is a real opportunity to almost completely defeat the disease.

Modern medicine is not all-powerful. But there is no need to despair. The main thing is to be more attentive to your health and the health of your loved ones. If a diagnosis of muscular dystrophy is made, then it is necessary to do everything to pull your loved one out of this abyss. If the form of the pathology is such that complete recovery is impossible, you will have to do everything in your power to alleviate the symptoms of the disease, surround him with care and attention, try to fill the patient's life with positive emotions. The main thing is not to give up, under any circumstances.