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Reviews and Letters
Praise for The Concord Review
From The New York Times: 'A Vital Touchstone For High Schools'
From The Wall Street Journal: 'History Lesson'
From Education Week: 'History Journal Gives High School Students a Showcase'
From The Boston Globe: 'Giving young scholars a voice--Teenagers analyze history in The Concord Review'
Letters to The Concord Review
The Concord Review - Varsity Academics

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I very much like and support what you are doing with The Concord Review. It's original, important, and greatly needed, now more than ever, with the problem of historic illiteracy growing steadily worse among the high school generation nearly everywhere in the country.
--David McCullough, Historian

The Concord Review provides a splendid forum for the best student work in history..It deserves the support of everyone in the country who cares about improving the study of history in the schools.
--Diane Ravitch, Senior Scholar, New York University

The Concord Review enjoys an excellent reputation among the I.B. and A.P. teachers with whom I have taught. The Concord Review is a must for those teachers striving for excellence in the classroom.
--Doug Harvey, History Teacher, Hong Kong International School

The Concord Review becomes better all the time..You are to be congratulated on creating a very useful publication.
--Stephen R. Graubard, Editor, DÆDALUS

We have set our standards too low in all fields for far too long. It is a pleasure to see The Concord Review as an example of what we should be striving for.
--Richard Askey, Professor of Mathematics, University of Wisconsin

The New York Times
Wednesday, March 3, 2004
METROPOLITAN DESK
On Education: A Vital Touchstone For High Schools
Michael Winerip
SUDBURY, Mass. -- IN 1987, Will Fitzhugh started The Concord Review, a scholarly publication that printed the best high school history research papers in America. His intent was simple: to recognize students who produced high-quality research, to show teachers and students what could be done, and to thereby raise the standard for high school writing.
On one level, he succeeded brilliantly. In 17 [21] years, he has published 627 [824] student papers in 57 issues [75] of the quarterly, tackling some of history's most challenging questions. In a 6,235-word paper, Rachel Hines of Montgomery High in Rockville, Md., asked: Did Chaim Rumkowski, the Jewish leader of Poland's Lodz ghetto, do more good or harm by cooperating with the Nazis? Aaron Einbond of Hunter High in New York City explored to what extent John Maynard Keynes's economic ideas were truly revolutionary, and to what extent they were borrowed from others.
Jessica Leight of Cambridge Rindge and Latin in Massachusetts wanted to know why Anne Hutchinson suffered so much more at the hands of the Puritans than her brother-in-law, the Rev. John Wheelwright, when both attacked the leadership. Jennifer Shingleton of Phillips Academy in Andover, Mass., questioned whether Abigail Adams really was a feminist, or was being taken out of 18th-century context by contemporary feminist historians.
Britta Waller of Roosevelt High in Kent, Ohio, wrote about the Ferris wheel. 'Fascinating,' Mr. Fitzhugh says. 'The guy who invented it died brokenhearted. I tell people, the topic doesn't matter, it's the quality that matters, so a kid learns the joy of scholarship. If you learn what it means to go in depth, you also realize when you're being superficial.'
Some of America's best-known historians -- Arthur Schlesinger Jr., David McCullough, Shelby Foote -- have praised the Review. And the published students -- who often include their Review papers with their college applications -- have prospered. Seventy- four went on to Harvard, 57 to Yale, 30 to Princeton.
And yet for much of the time, Mr. Fitzhugh has felt like a boatman on the Lewis and Clark expedition, paddling upstream on the Missouri and making little headway. He fears the high school research paper is on the verge of extinction, shoved aside as students prepare for the five-paragraph essays now demanded on state tests, the SAT II and soon, the SAT. 'I'm convinced the majority of high school students graduate without reading a nonfiction book cover to cover,' he says. Mr. Fitzhugh is offended that the National Endowment for the Humanities sponsors a $5,000 history essay contest with a 1,200-word limit. 'I have kids writing brilliant 5,000-word papers, and they're not eligible,' he says. He is saddened by a letter from the chairman of the history department at Boston Latin, that city's premier high school. 'Over the past 10 years, history teachers have largely stopped assigning the traditional term papers,' Walter Lambert, the chairman, wrote.
While much of the education establishment crows about how standardized testing and the SAT writing sample are raising standards, Mr. Fitzhugh is not alone in seeing a dumbing down. Ken Fox, a college counselor at Ladue Horton Watkins High in St. Louis says that in test preparation courses, his students learn to write a generic five-paragraph essay that can be modified when they take the SAT. 'They're trained to write to formula,' he says.
He has urged students to submit papers to the Review, and Robert Levin did -- on the emancipation proclamation that John Fremont, a Union Army commander, issued in Missouri in 1861, two years before Lincoln's took effect. 'The big thing,' says Robert, who wrote the paper on his own time, 'is I've been living here my whole life, interested in the Civil War, and never knew there was this whole huge deal of an emancipation proclamation in Missouri.'
'I loved breaking free from the writing formula they teach us,' he says. 'I think that hampers your writing.'
Mr. Fitzhugh has been called elitist, but Bruce Gans, a professor in the Chicago community college system who teaches a course on writing research papers, says students need to begin in high school. Mr. Gans says English 101 -- which requires an eight-page paper with eight sources -- is taught at Chicago's seven community colleges and has the highest class dropout rate in the system. 'Kids are terrified of that paper,' Mr. Gans says. 'Will Fitzhugh is fighting by himself on this. I don't know how he does it.'
BARELY. After graduating from Harvard in 1962, Mr. Fitzhugh held several jobs, including teaching high school history nearby for 10 years. That was when he came to believe that if you asked more of students, they would respond. He started the Review with his 'last $100,000,' a family inheritance, plus the cashed-in value of his teaching pension. 'I'm stupid,' he says, 'I thought people would subscribe.' After 17 [21] years, he has 1,100 [1,300] subscribers and requires a $40 fee when a paper is submitted.
Twice he has stopped publishing when he ran out of money. Most foundations -- 145 at last count -- have turned him down. His savior has been John Abele, co-founder of Boston Scientific, a medical equipment company that has provided $185,000 a year, enabling Mr. Fitzhugh to move the Review out of his house and to hire an assistant. They have started a National History Club in hopes of broadening its constituency.
Each year, Mr. Fitzhugh offers four $3,000 awards, the Emerson prizes, for the best Review pieces. His dream is that the Emersons will do for high school history what the Intel research awards have done for science. But he never knows if he will be financed from year to year. 'John Abele has been wonderful,' he says, 'but he had a stroke a few years ago. Thank God he recovered, but if something happens to him, we're history, so to speak.'
Mr. Fitzhugh lives with his wife, Sophia, a retired teacher, in the same house they bought for $43,000 in 1971. His Review salary is $36,000 [$8,600 in 2007] -- compared with $38,000 he made his last year teaching, 1988. 'I'll be 68 in August,' he says. 'I'd like to retire after the 70th issue. What I need is to bring someone in before I fall over, but I don't have the money. The problem is, it's not a very prestigious job.'

The Wall Street Journal
Review & Outlook
Friday, May 26, 2000
'History Lesson'
Bill McGurn, Chief Editorial Writer
Want to read another story about the dumbing down of American students? How far SAT scores have dropped or standards fallen?
If so, look elsewhere.
We wish instead to draw your attention to one of those little starbursts of intelligence sparkling over our dreary educational landscape: The Concord Review. The first and only academic journal dedicated to the work of high school students, The Concord Review has published essays on everything from the sinking of the Lusitania to the Pullman Strike of 1894 and the Harlem Renaissance. Appropriately enough, it is published out of the same town where, more than two centuries back, embattled farmers fired the shot heard 'round the world.
The Review is the child of Will Fitzhugh, a Harvard alumnus who started publishing it out of his own home in 1987 while a high school teacher himself. The next year he quit his job and dedicated himself to the journal full-time. Not least of the spurs behind his decision was having witnessed two of his fellow Concord teachers propose an after- school program to help a select group of students prepare a serious history essay-only to be shot down by the administration on the grounds of 'elitism.'
Like most such academic adventures, the Review isn't going to challenge People magazine any time soon; it still has only about 850 subscribers, and among the high schools that don't subscribe are a number whose students have been published in the Review itself. But it is attracting attention. The Concord Review has received endorsements from a cross-section of prominent historians such as David McCullough, Eugene Genovese, Diane Ravitch, and Arthur Schlesinger, Jr., who says 'there should be a copy in every high school.' Another fan is James Basker, a Barnard and Columbia professor who also serves as president of the Gilder Lehrman Institute of American History.
'Students rise to the expectations you have of them,' states Mr. Basker. 'All you have to do is show them they are capable of writing serious historical essays, and off they go.' To emphasize the point, his institute will on June 10 inaugurate three annual Gilder Lehrman Essay Prizes in American History drawn from Concord Review essayists. This year's first prize, for $5,000, goes to Hannah S. Field for her contribution about library efforts to suppress Frank Baum's 'Wizard of Oz.'
All this acclaim notwithstanding, Mr. Fitzhugh believes today's culture retains a pronounced bias against academic achievement and excellence. He cites the example of a Concord Review essayist from Connecticut who subsequently went on to Dartmouth and will be studying medicine this fall at Harvard. When Mr. Fitzhugh paid a visit to her high school, he found that though everyone knew she was all-state in soccer, no one knew that an essay of hers had appeared in the Review, beating out hundreds of the finest student essays from not only the U.S. but other parts of the English-speaking world. It's one of the things that tells him that the need for such a journal remains strong.
'Varsity athletics and athletes are celebrated everywhere,' Mr. Fitzhugh says. 'We've decided to celebrate varsity academics.'

Education Week
Wednesday, June 16, 1999
'History Journal Gives High School Students a Showcase'
Kathleen Kennedy Manzo
At age 18, Jonah Knobler has accomplished what usually takes a young historian years: the publication of his work in an acclaimed academic journal.
This spring, his analysis of the effects of U.S. immigration policy on Jews prior to World War II appears in The Concord Review, alongside essays on child labor and longtime U.S. senator and former presidential candidate Barry Goldwater.
Now in its 12th year of gathering outstanding essays from around the country [and so far from 24 other countries], the quarterly journal has become an important outlet for recognizing student work in a field of study that, for high school students, is often overlooked.
'There is no shortage of math contests and science contests,' said Mr. Knobler, who graduated last week as valedictorian at Sycamore High School in Cincinnati and will begin his freshman year at Harvard in the fall. 'But there is virtually no recognition, short of publishing a book, if your talent lies in the humanities.'
'A National Concern'
That's what led Will Fitzhugh to [found the journal in 1987, and] quit his job as a history teacher in 1988 to begin publishing the Review out of his home in Sudbury, Massachusetts.
Concerned that schools were becoming anti-intellectual and holding students to low standards, he thought the venture could fuel a national--even international--interest in student research and writing in history.
'As a teacher, it is not uncommon to have your consciousness end at the classroom wall. But [on a sabbatical] I came to realize that there was a national concern about students' ignorance of history and their inability to write,' he said.
During his 10 years of teaching at Concord-Carlisle High School, the 62-year-old educator said in a recent interview, he always had a handful of students who did more than he asked, and whose papers reflected serious research.
Those students 'just had higher standards, and I was always impressed by that,' Mr. Fitzhugh said. 'I figured there have got to be some wonderful essays just sitting out there. I wanted to recognize and encourage kids who are already working hard, and to challenge the kids who are not.'
Within a year of his sending out brochures to 25,000 high schools here and abroad, a steady flow of submissions began.
Expanded Mission
This year, Mr. Fitzhugh is expanding on his premise by organizing the National Writing Board to rate student papers in history and English. The Board will follow what Mr. Fitzhugh describes as an international standard [based on the experience of The Concord Review] that he is devising along the lines of the Advanced Placement exams and the evaluations used by the International Baccalaureate program.
Once trained, a group of veteran teachers will review papers twice a year and issue ratings on a scale of 1 to 6. Strong scores could be used to bolster many students' college applications, Mr. Fitzhugh believes.
'Colleges have expressed a great deal of concern over the writing and attendant reading capabilities of their freshmen,' Mr. Fitzhugh wrote in announcing the Board earlier this month. The National Writing Board will help them better gauge the work of their applicants, he added, and will 'also encourage more interest on the part of high school instructors of history and literature in the amount and quality of the academic writing they require of their students.'
Over the years, The Concord Review has acquired a following among some prominent scholars.
The historian Arthur Schlesinger, Jr., the education historian Diane Ravitch, and Chancellor John R. Silber of Boston University have praised the Review for highlighting student achievement.
The journal is 'a wonderful opportunity for high school students to publish and to take their history seriously,' said Dr. Ravitch, who is on the publication's Board of Directors. '[It] gives the highly proficient history student a chance of showing off his or her best work.'
In the beginning, Mr. Fitzhugh believed the journal could be self-supporting. Surely, he thought, thousands of students and teachers would jump at the chance to read the best student essays from around the world.
But the Review has struggled since its inception, with too few subscribers to pay for its printing. Mr. Fitzhugh said he has put more than $100,000 into the non-profit publication, and even cashed in his retirement account.
This year, the journal reports a little more than 800 subscribers from 42 states and more than 20 countries. Subscriptions cost $35 a year.
Mr. Fitzhugh has found some private support: John E. Abele, founder and chairman of Boston Scientific Corporation, which designs and manufactures medical equipment, has paid for three years' printing costs. But Mr. Fitzhugh said he has been turned down for grants from 130 foundations, the National Endowment for the Humanities, and the U.S. Department of Education--more proof, he believes, that academic achievement does not get the credit it deserves.
But his resolve has not diminished. 'One of my hypotheses from the start was that I could find the essays, and that turned out to be true,' he said. 'The other was that I could get teachers to support it, and that turned out to be false. There are schools where kids have been published that haven't subscribed.'
'We do a great deal to acknowledge and celebrate high school athletic achievement,' Mr. Fitzhugh said, 'but when it comes to academic achievement, we'd rather not talk about it.'
Incentive for Hard Work
Alison Mara Friedman agrees. As a student at Sidwell Friends School, a private school in Washington, she wrote two essays she thought were pretty good.
'With most people, when they get a paper back, it ends up in the bottom of their locker, or their parents see it and that's it,' said Ms. Friedman, who just completed her freshman year at Brown University in Providence, R.I.
One of her high school papers was a history of Chinese poetry, which was published in the Review in fall 1997, and another looked at the history of the Chinatown in the nation's capital. For this work she was awarded one of four Emerson Prizes this year, the Review's top honor, with a check for $3,000.
'The Concord Review is a place for the papers to go,' Ms. Friedman said. 'You just want it to go somewhere else after you put so much work into it.'
William Fitzsimmons, the dean of admissions and financial aid at Harvard, said the Review helps inspire students to undertake the often lengthy and grueling task of scholarly research and writing.
'We live in the age of the sound bite and the short attention span. If you have to explain something in more than five to 10 seconds, it's lost,' said Mr. Fitzsimmons, who has agreed to serve on the Writing Board's Advisory Council which Mr. Fitzhugh is organizing. 'Most serious work requires many of the same skills that have to be employed in good writing and good research.'
The Review, he added, 'provides an additional piece of evidence from an outside body that [an applicant] has gone above and beyond what is required.'
Meanwhile Mr. Fitzhugh remains optimistic that the journal he launched will survive. He even has hopes for what he has already named The Walden Review, a sister publication that would publish literature essays. 'There is a need to encourage these kids, and I think there is an endless opportunity to provide the right message.'
The Review is on the World Wide Web at www.tcr.org.
Note: This version contains corrections and emendations by Will Fitzhugh. Such corrections and emendations are enclosed in brackets.

The Boston Sunday Globe
Learning Section
June 13, 1999
'Giving young scholars a voice--Teenagers analyze history in The Concord Review'
Nina McCain, Globe correspondent
William Fitzhugh would like to do for academic achievement what Olga Korbut did for gymnastics. 'Kids rise to a challenge,' Fitzhugh says. 'When Olga Korbut got on a balance beam at the 1972 Olympics, 10,000 little girls all over the country got on balance beams..If you provide a way, motivation is released. My goal is to provide a way to tap that motivation and reward it.'
Fitzhugh is talking about superior performance in history, not gymnastics. Instead of a balance beam, he uses The Concord Review, a quarterly journal he founded that publishes the essays of high school history students from throughout the United States and around the world.
But he says the dynamics are the same. You recognize and reward young people for writing cogent, well- researched essays, on everything from Barry Goldwater's presidential campaign in 1964 to the impact of Sylvia Beach's Paris bookstore on 20th-century literature. Then you say to other students, 'You can do that too.'
'We want both to recognize good work and to inspire other kids to try,' Fitzhugh says. 'We also want to encourage teachers. It's hard to maintain high standards.'
Fitzhugh, a former Concord-Carlisle High School history teacher, founded the Review in 1987. Since then, he has published 418 essays from students in 37 states and 24 foreign countries. He says it is the only quarterly journal in the world devoted to the work of high school students.
'I feel the ability to write good essays is widely distributed,' Fitzhugh says. 'Many times kids are not being asked to try.'
The Review has won praise from such influential people as Doris Kearns Goodwin, education-reform advocate Theodore Sizer, and the late Albert Shanker, president of the American Federation of Teachers. College admissions officials, such as William Fitzsimmons of Harvard University, think highly of it.
What the Review does not have is money. Fitzhugh has put all of his time and energy into the journal, which is published out of his home in Sudbury. Despite applications to 130 foundations, none of the big money donors has signed on.
The Review relies on revenue from about 850 subscribers at $35 a head and on contributions of about $120,000 from two small foundations and two individuals. Most of the money comes from John E. Abele, founder and chairman of a medical instruments company and chairman of the Review's board.
To put the Review on a more secure financial footing, Abele hired a consultant to do a business plan. Using an idea of Fitzhugh's for an external assessment of students' academic work that would be useful for college admissions officers, they came up with a proposal for the National Writing Board.
The plan calls for 'senior history and literature instructors' to read student papers in history and literature and grade them 'against an international standard of performance' on a scale of 1 to 6. The scores would be sent to the colleges to which the student is applying.
The fee for each paper would be $60 and the proceeds would go to support both the Board and the Review.
Abele has pledged a challenge grant of $50,000 to be matched two-for-one up to $100,000.
Fitzhugh says the proposal has been welcomed by college admissions officers, and Fitzsimmons, dean of admissions and financial aid at Harvard, serves on the advisory council.
If all goes well, history-paper evaluations will begin in June next year and literature will be added the following year.
Meanwhile, young people continue to send in essays to the Review. Fitzhugh gets from 500 to 600 a year and publishes about 8 percent of the total. About half come from private schools and half from public schools.
One, about Barry Goldwater's presidential campaign, was written by Gilman Barndollar of Portsmouth, N.H., who is a junior at Phillips Academy in Andover.
Barndollar, who describes himself as 'kind of conservative,' said he saw Goldwater as the 'founder of the conservative movement in America' and wanted to find out why he lost so overwhelmingly to Lyndon Johnson.
'When I began, I saw it as a result of negative advertising,' Barndollar says. 'But as I did the research, I saw that basically all the factors were stacked against him..The campaign was basically doomed from the start.'
Barndollar says he wrote the paper for an Advanced Placement history class in his sophomore year and submitted it for a school prize. His history teacher, James M. Rogers, suggested that he send it to the Review. When he learned that it would be published, Barndollar says he was 'happy for the recognition.'
Another Review article, on the effects of school desegregation in Kent County, MD., was written by Ann Collier, who grew up in the county and is a senior at the Groton School.
Collier began the article by acknowledging that she had attended an all-white private school, had no black friends, and 'Not once, in all those years, did I think about race.' But she thought about it a great deal as she did a prodigious amount of research for the article, poring through back copies of the local newspaper and interviewing black and white community leaders, teachers and students.
Her history teacher, John Lyons, says Collier is an 'exceptionally talented young woman' who 'did a terrific job of exploiting the primary sources.' She will be attending the University of North Carolina next fall where she will be a Moorehead Scholar with all of her educational expenses paid.
Lyons, who has been teaching history for 16 years, is a big fan of The Concord Review.
'I walk in with a copy in mid-winter when we begin to write the big research paper,' he says. 'I say, 'This is what is possible.' It's a source of inspiration. It sets a standard.'

Letters to The Concord Review

Letters from:
Chiara R. Nappi
Theoretical Physicist, Institute for Advanced Study, Princeton University
William R. Fitzsimmons
Dean of Admissions and Financial Aid, Harvard College
Eugene D. Genovese
President, The Historical Society
John Silber
Chancellor, Boston University
Arthur Schlesinger, Jr.
Historian
Jonathan P. Reider
Senior Associate Director of Undergraduate Admissions, Stanford University
The Giraffe Project
'Moving people to stick their necks out for the common good'
Broeck N. Oder
Chair, Department of History, Santa Catalina School
Rachel Davidson
Princeton Class of 1993
Loretta Heuer
Director, Heueristics
John Wardle
Head of History, Northern Secondary School
Scott R. Reisinger
Head of History, Greens Farms Academy
Jesse Esch
University of Alberta Class of 2001
Ginger Gentile
East Hampton High School Class of 1998
HS Author Inspiration (samples from letters)

Letter from Chiara R. Nappi
Theoretical Physicist, Institute for Advanced Study, Princeton University
INSTITUTE FOR ADVANCED STUDY
EINSTEIN DRIVE
PRINCETON, NEW JERSEY 08540
Telephone: (609) 734-8000 FAX: (609) 924-8399
SCHOOL OF NATURAL SCIENCES
22 June 2000
Will Fitzhugh, President
The National Writing Board
730 Boston Post Road, Suite 24
Sudbury, Massachusetts 01776
Dear Mr. Fitzhugh:
I recently came across The Concord Review, and I would like to express to you my appreciation for your leadership role and your continuous dedication to this endeavor. Not only am I impressed with the high quality of the history articles that appear on the Review, but I am also impressed with the very idea of a publication which provides a forum for the academic work of high school students in history. As a physicist, I am accustomed to the many initiatives, such as math competitions and physics olympiads, instituted to recognize and promote interest and talent in the sciences among high school students. However, I have always felt that there are no equivalent mechanisms to encourage and nurture students in the humanities, and to recognize their accomplishments. The Concord Review strikes me as a simple yet brilliant idea to help fill that gap, and as a very effective way to promote high standards and excellence in the humanities.
Sincerely,
Chiara R. Nappi
Theoretical Physicist

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Letter from William R. Fitzsimmons
Dean of Admissions and Financial Aid, Harvard College
Harvard College
OFFICE OF ADMISSIONS AND FINANCIAL AID
BYERLY HALL
8 GARDEN STREET
CAMBRIDGE, MASSACHUSETTS 02138
January 6, 1999
Mr. Will Fitzhugh Editor & Publisher
The Concord Review
Post Office Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh,
Thank you for sending along Jonathan Hopkins' essay. I will be certain to include it with his application materials for review by the Committee, and I know they will find it most helpful.
I appreciate your taking the time and trouble to send this along. All of us here in the Admissions Office are big fans of The Concord Review!
Sincerely,
[signed]
William R. Fitzsimmons
Dean of Admissions and Financial Aid

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Letter from Eugene D. Genovese
President, The Historical Society
THE HISTORICAL SOCIETY
Eugene D. Genovese, President
1487 Sheridan Walk
Atlanta, GA 30324
14 July 1998
Will Fitzhugh Editor & Publisher
The Concord Review
Post Office Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh:
May I take this opportunity to congratulate you on your splendid journal, The Concord Review. That you are performing a valuable service to American education goes without saying. What I find most remarkable is that the journal is intrinsically worth reading as interesting historical writing and not merely as a celebration of young talent. The articles would delight any professor of history if submitted to an advanced undergraduate class, and the best are of graduate student quality. With each issue I feel better about the future of American education and of our profession.
I wonder if The Concord Review would care to explore an attachment to The Historical Society. As you know, we are making a serious effort to recruit secondary school teachers and to promote the teaching of history in secondary schools, public and private. Since some people, most notably Diane Ravitch and yourself, are connected with both organizations, may I suggest we hold informal discussions with a view toward seeing how we might help each other.
With good wishes,
Sincerely yours,
[signed]
Eugene D. Genovese

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Letter from John Silber
Chancellor, Boston University
Chairman, State Board of Education, Massachusetts
May 16, 1997
Mr. Will Fitzhugh
Editor and Publisher
The Concord Review, P.O. Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh,
I have read your fine address of April 7, given at the Kennedy Library. This is the first time I was fully aware of the seriousness of your financial problems
The objection to elitism applies only if we are talking about an aristocratic or an oligarchic elite. Those who excel in academic and intellectual matters, Jefferson's natural aristoi, are not the sort of elite to be looked down upon or rejected. We are a society that makes heroes of the elites in entertainment and athletics. Why should we scorn academic elites?
The Concord Review will fill a need for years, if not generations, to come. I hope it can be an enduring presence. I wish we could insist on copies of the Review being in every high school, and I wish every high school principal at high school assemblies would urge that every student read The Concord Review. Students can be motivated by observing the work of their peers; sometimes they are only intimidated by the work of their elders.
With best wishes, Sincerely,
John Silber, Boston University

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Comment from Arthur Schlesinger, Jr.
Historian
May 24, 1997
455 East 51st Street, New York, NY 10022
Dear Mr. Fitzhugh,
If you know of any foundations that might be interested in helping The Concord Review, I would be more than happy to write a letter of support. I heartily agree with John Silber that there should be a copy in every high school.
Sincerely yours,
Arthur Schlesinger, Jr.

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Letter from Jonathan P. Reider
Senior Associate Director of Undergraduate Admissions, Stanford University
STANFORD UNIVERSITY
Undergraduate Admissions
Old Union
Stanford, California 94305-3005
August 30, 1999
Mr. Will Fitzhugh
Editor
The Concord Review
P.O. Box 661

Research Analysis Papermr. Becker's Classrooms

Concord, MA 01742
Dear Mr. Fitzhugh,
I want to tell you how pleased I am with the quality of the several issues of The Concord Review which you have recently sent to us. In the selective college admission process, admission officers rarely have the opportunity to read anything of intellectual depth written by high school students. We usually only have the short essays they write specifically for our applications. We read many testimonials to the quality of students' writing from teachers, but we can rarely judge for ourselves.
The quality of the writing and thinking found in The Concord Review is extremely high, equal in many cases to the best work done at the top colleges. I was pleased to read one essay from a student who has recently been admitted to Stanford. The quality of her work confirmed that we had made a good decision.
When a student applies to Stanford in the future, I would like to know if they have been published in your journal, or even if their essay has been considered seriously for publication. In a few special cases, (e.g., selective summer academic programs, certain science research awards) simple participation or membership by a student is a definite plus in the admission process. Henceforth, I will regard The Concord Review in the same light.
Sincerely,
Jonathan P. Reider, Ph.D.
Senior Associate Director
Undergraduate Admission

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A Giraffe's been sighted in Concord!
The Giraffe Project, a national nonprofit organization, has named Will Fitzhugh
a Giraffe for sticking his neck out for the common good.
We invite you to tell his story.
High school history teacher Will Fitzhugh took a long, hard look at his life after two friends died when they were barely fifty years old. What did he really want to do with his own life?
He'd been bothered for years by his observation that students' academic achievements went largely ignored, while athletic successes were grandly celebrated. He'd always wanted to bring that kind of appreciation to star scholars.
So he quit teaching and used every cent he had to start The Concord Review, a quarterly journal of history research papers--all written by high school students. Since 1987 he's worked alone out of his house to honor good students. He says he's countering the usual message they get: 'If you do good academic work we won't tell anybody so they won't hate you. They won't find you in the hallway.. students are under a tremendous amount of pressure to at least pretend not to care about academics.'
The Concord Review has the high quality look of adult academic journals like Dædalus. Concord essays are eclectic, well researched and finely crafted, and average 5,000 words. The subjects are as varied as King Arthur, kamikaze pilots, women's suffrage, the Industrial Revolution, and ferris wheels; the young authors are from the US, Norway, Kenya, Indonesia--anywhere good scholars may be.
Teachers use the Review to show students what's possible when they go the extra mile. Students who are published in the Review add the honor to their college applications and their resumes. Other kids reference Review articles for their own papers, and in the process learn to respect the effort it takes to produce such first rate work. 'I'm not patting kids on the head,' Fitzhugh says. 'I'm using their work to feed back into the system evidence to other students of what they are capable of if they work hard.'
But The Concord Review is on the endangered list. Maintaining it has cost Fitzhugh more than $100,000--so far. He's gotten a few foundation grants, but far more rejections, many of them giving a disturbing reason for saying no: The Concord Review, they've said, is 'elitist' for accepting only the best.
Fitzhugh publishes top notch work, regardless of where it comes from. He doesn't care about a young author's race, gender, family background or income; he's concerned only with the quality of the work. Publishing second-rate work in order to be politically correct would be, he feels, akin to awarding varsity letters to every kid who wants to play, even the ones with two left feet.
Will Fitzhugh is dedicated to keeping The Concord Review going as the honor it has always been. There are new generations of scholars to be found and encouraged.

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The Concord Review : 'informative, accessible, and instructive'
Santa Catalina School
Mark Thomas Drive
Monterey, California 93940
408-655-9300 FAX 408-649-3056
July 12, 1995
Will Fitzhugh
Editor & Publisher
The Concord Review
Post Office Box 661
Concord, MA 01742
Dear Will,
It was great to talk to you the other day, and I'm happy to send along this letter describing both 'logistical' and pedagogical dimensions of how I have used The Concord Review in class since employing the first class sets in the 1988-89 academic year. You know from the fact that we have expanded our class subscription 'coverage' from all U.S. History classes to all U.S. History and World History since 1500 classes that we have been very happy with the Review. In fact, I am happy to say that, due to an expanding school enrollment, our class set for 1995-96 will number about 150 subscriptions.
In terms of 'logistics,' the system we have employed here has been simple and consistent with how we deal with texts in all disciplines. Our students purchase their texts, so as students move through our bookstore before school opens, they mark the texts they need on a list, and the above-noted classes simply have The Concord Review listed as a text. At the end of the process, the girls turn in their lists to the bookstore manager, who double-checks their 'pile' of books for correctness and then retains the list (with student name and grade) for billing purposes. The girls are informed that they will receive their Reviews in class from their instructor. Once school starts, I submit a 'finalized' list to the bookstore as a 'fail- safe' double-check, verifying the students enrolled in U.S. History (college prep and AP) and World History since 1500. The parents are then billed for the Review just as for any other text. The Reviews come to me quarterly, and are distributed to the students when appropriate. The 'logistics,' then are very simple and have worked most efficiently for us in this regard.
Pedagogically, I (or other appropriate instructor) view each issue with an eye toward an article or articles which are appropriate for any part of the material under current or imminent study. Because of the wide range of subjects and chronological eras covered in each issue, it is pretty easy to discern immediately one or more articles which will be applicable and useful. I do not feel compelled to put the Review in student hands the day the issues arrive, but rather plan ahead. For example, I might be covering mid-19th century reform in US History when new issues arrive, but will hold off until we are doing the Civil War to distribute the Reviews and assign an article on some phase of the Civil War. The girls are told to treat each issue of the Review as an extension of their texts, meaning that they must hold on to each issue, for additional articles may be assigned from a given issue later in the year. Again, given the wide range of topics and eras covered in the typical issue, it is not unusual for me to be able (again, as an example) to assign an article from one issue on the Civil War in December, then go back to the same issue in April for an article on some portion of mid-20th century history. Students have been great about this, and are thus prepared throughout the year.
As to the articles themselves, I have found several uses for them. An obvious advantage of the articles in the Review is that they are scholarly and informative, and, as my students have noted, a refreshing break from the text (this is a comment I frequently hear). Secondly, the articles, in addition to being scholarly, are readable, and the 'right size,' and thus readily accessible to high school students. Even 'popular' history such as found in American Heritage, American History Illustrated, or similar sources can be 'too much' for high schoolers, as the articles can be too long or presume too much a priori knowledge. The articles in The Concord Review are substantial and appropriately challenging, yet 'intellectually digestible' for all students, not just the gifted few in an AP section, for example.
In addition to providing excellent reading, allowing for deeper exploration and discussion of some aspect of history, the Review provides an excellent methodological model. All students in History at Santa Catalina must write research papers based on both primary and secondary sources, with the length and quality expectations of the papers escalating appropriately from freshman to senior year. Sometimes, as you well know from your own teaching experience, explaining 'arcane' items like where to put footnotes, etc. to students can be like trying to explain what 'pink' looks like to a person who has never been able to see. The Review puts in students' hands excellent history, not only in terms of content, but in terms of methodology as well: footnotes, bibliography, placement, and all the other details. I have found it helpful not only to have students read an article for its content, but then to dissect it methodologically, asking my students (as appropriate to their level) to identify primary as opposed to secondary sources, to suggest what other sources might have been helpful, which sources might have the most credibility, and so on. We can thus effectively and efficiently combine quality reading with critical thinking/analysis and a methodology 'practicum.' The fact that teenagers are always highly interested in what other teenagers are doing is helpful, for the articles hold something of a natural attraction to the students. In addition, they are always impressed that students like themselves can and do produce such high-quality work. Many teens are used to hearing how poorly their age group is doing academically, but the Review is refreshing proof that such is not universally the case!
I could go on anecdotally for quite a while, but I think that would result in an excessively long epistle! Suffice it to say that my students (yes, even those who don't 'like History') find the Review informative, accessible, and instructive, not only in terms of material they are learning, but also in terms of critical thinking and mastery of historical methodology. In a time when those of us who teach History frequently find ourselves hard-pressed for classroom time in meeting our goals, the Review is truly 'triply rewarding' for students and instructors. I cannot imagine a junior high or high school history course which could not benefit immediately and tangibly from having its students utilize the Review.
All Best Wishes,
(signed)
Broeck N. Oder, Chair
Department of History
Santa Catalina School

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Letter from Rachel Davidson
Princeton Class of 1993
Author of an essay on Women's Suffrage (Winter 1988)
October 27, 1995
William Fitzhugh
Editor and Publisher
The Concord Review
P.O. Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh,
As you know, while I was at Princeton I discovered and eventually majored in civil engineering. I am now in my third year of a Ph.D. program at Stanford University, where my current focus is earthquake engineering and risk assessment. Clearly, the subject matter I covered in my essay for The Concord Review ('The Split in the 19th Century Women's Suffrage Movement') is quite different from the issues I study now. Still, it becomes increasingly clear to me that the ability to write clearly and convincingly is important in any field, even engineering.
Being published in The Concord Review was a wonderful confidence-building experience for me. I am sure that the many other authors you have supported share my appreciation for the opportunity to see our work in print at such an early age. I hope that you are able to continue offering this opportunity to many more students in the future. I wish you the best of luck.
Sincerely,
(signed)
Rachel Davidson
Stanford University

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The Concord Review: 'excellence and elegance'
Heueristics
Loretta Heuer, Director
(508) 429-1436
164 Norfolk Street
Holliston, MA 01746
June 12, 1995
Mr. William Fitzhugh
The Concord Review
Post Office Box 661
Concord, MA 01742
Dear Mr. Fitzhugh,
As a satisfied charter subscriber I wanted to explain why I'll not be sending in my renewal this year.
This fall, my son Tad, who was homeschooled for most of his secondary coursework, will be entering a new phase of his education, heading off to Brown. When you first began publishing Tad was only twelve, but he loved history and politics. At that age, he didn't read the Review. Instead, I'd read the papers that interested me, mention them briefly, and then shelve each issue in his room. Gradually, there developed this scholarly-looking row of journals on his shelf. Then one day, at a time when he was interested in the sinking of the Titanic, I mentioned that there was a paper on the subject in a past issue. From that point on the Review became a living resource, not just for its eclectic content, but for the excellence of the authors' varied writing styles.
Although Tad never submitted a paper to the Review, it certainly had an impact on his historical thought and expression. Last year at Harvard Summer School he did well in the foreign policy and history of science courses he elected to take. His op-ed article on term limits was published by The Middlesex News, and a letter confronting the stereotype of homeschoolers was printed in U.S News and World Report. As an aide to Representatives Barbara Gardner and Mark Roosevelt he wrote press releases and letters to constituents. He is a far better writer for having read your contributors' work.
Before he heads off to college and I become busy with other things, I wanted to let you know the impact your project had on one of your readers. Thank you for taking a risk, following your dream, and creating something of excellence and elegance that has affected both a young person and his mentor.
With warmest regards,
(signed)
Loretta Heuer

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Compliment on the 'consistently high standards' of The Concord Review
John Wardle
Head of History
Northern Secondary School
851 Mount Pleasant Road
Toronto, Ontario M4P 2L5
12 September 1996
Please find enclosed four essays for your consideration. All of these girls were students in my Modern Western Civilization class here at Northern.
I would also like to compliment you on the consistently high standards of The Concord Review. Our collection of them has proven to be a terrific educational tool for my senior students. For a few, it gives them ideas for topics of their own. For many more, it provides outstanding background material for their own research. For all of them, it is the benchmark against which they can measure their own writing and historical skills. Since we began setting aside class time for reading them, student essay writing has improved considerably.
From a teacher's point of view, it is tremendously rewarding to see students get engrossed in topics of their own choosing, enthusiastically pursue them and then produce strong, correct papers. The discussions before, during and especially after this creative process are always memorable. Almost without exception, the students feel that, by the end, they have gained a solid understanding and mastery of a particular aspect of history. By producing first-rate work, they also know they are ready for, and able to handle, post-secondary education.
When I returned their essays this year, for example, the question they posed each other was not 'What was your mark?' but rather 'Can I read your paper?' They spent the entire 76 minute period sharing essays, exchanging thoughts and genuinely learning from each other. I merely watched and listened. Professionally, it was a wonderful experience. As the catalyst, The Concord Review deserves a great deal of the credit for this kind of academic success.

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Letter from Scott R. Reisinger
Head of History, Greens Farms Academy
Greens Farms, Connecticut
July 21, 1997
Mr. Will Fitzhugh
The Concord Review
P.O. Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh,
For nine years now, The Concord Review has offered my students not only examples of the finest historical writing completed by high schoolers across this country and around the world, but it has also supplied a standard of achievement toward which to work. It has given them an opportunity to gain public recognition for the work they have completed. This recognition has been invaluable in building their confidence and in letting them see that their work is taken seriously enough to warrant its exposure to a wider audience than merely their high school teacher.
Many of us still hold that there is an inextricable connection between the teaching of clear, analytical thinking and good, solid, expository writing. Here The Concord Review serves as a model. The essays you publish -- the product of research and subtle writing -- illustrate the power of reason, and the compelling nature of fine writing.
After a number of years of using The Concord Review to help motivate students to the highest standards, our history department has decided to join a select group of schools that have ordered subscriptions for their students. So impressed have we been with the quality of the essays, we believe that all of our juniors should have the opportunity to read the volumes on their own. They will become an integral part of the teaching of writing in our program.
I know that you and your journal have received many plaudits and endorsements from professional historians, educators and professional organizations throughout the country. None has been more important to me, however, than a comment from one student of mine upon whom you've made such an impact by publishing her work. In reflecting upon what The Concord Review meant to her, she told me how much the publication of her paper made her feel like she was a genuine historian, writing real history. I was impressed by the extent to which she had already lived up to the late Carl Becker's dream of making 'every man his own historian.'
Indeed, your vision and leadership have provided opportunities for students of history to aspire to one of the highest goals for any historian: finding a proper audience for their work. You've performed a vital service. With best wishes,
Cordially,
Scott R. Reisinger, Assistant Head of School
Greens Farms Academy, Greens Farms, Connecticut

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Letter from Jesse Esch, Edmonton, Alberta
University of Alberta Class of 2001
Author of an essay on Operation Jubilee (Summer 1997)
August 20, 1997
William Fitzhugh
Editor and Publisher
The Concord Review
P.O. Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh,
I am writing to thank you for publishing my International Baccalaureate essay ('An Assessment of the Handling of Operation Jubilee') in this summer's issue of The Concord Review. I was very excited when I first heard that this essay was being considered for publication, and I can happily say that all my expectations have been met and surpassed. I am very pleased with the final result, and am very proud to be in the company of the other fine authors (and historians!) published by the Review.
Although I am now studying mathematics at the University of Alberta, I am still grateful for my experiences with The Concord Review, and with the study of history in general. The opportunity you offer young historians is essential because it provides a goal for them to strive for; moreover, achieving this goal gives them greater confidence in their ability to contribute something to our understanding of the past (and perhaps of our future). Further, I think it is important that people such as yourself continue to support the study of history, which is sometimes looked down upon as not being very 'useful.' I firmly believe that an understanding of the past, by providing a framework into which knowledge may be placed, enhances the study of any subject, no matter how far removed it may seem to be from history.
Finally, I would be remiss if I did not thank you, on behalf of all students who have been called upon to attempt the seemingly insurmountable task of writing an in-depth history paper, for providing us with plentiful examples of good writing and good history. Your publication has helped us to see a way through the jungle.
Again, many thanks. I wish you all the best!
Sincerely,
(signed)
Jesse Esch
Edmonton, Alberta, Canada

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Letter from Ginger Gentile
East Hampton High School Class of 1998
Author of an essay on the Women's Christian Temperance Union (Fall 1997)
September 7, 1997
William Fitzhugh
Editor and Publisher
The Concord Review
P.O. Box 661
Concord, Massachusetts 01742
Dear Mr. Fitzhugh,
I want to thank you for publishing my essay in the fall edition of The Concord Review. Before beginning the seven-month odyssey of researching and writing on my topic, the Women's Christian Temperance Union, I considered myself a lover of history but a possessor of second-rate writing skills. Part of the reason for my lack of confidence is that I attend a school where students are given few opportunities to develop their talents in this field (it is assumed students will learn how to write in college). With publication in your journal as my goal, and with the help of my teacher, Mr. Timothy Rood, I began the process of learning how to use the English language to prove my thesis. The results were not only vastly improved skills but also, due to the nature of my topic, the questioning of my own feminist beliefs.
The back copies you sent me were a great help. I want to thank the other students who have been published in The Concord Review, the quality of their articles was what I aspired to. In the future I will use their techniques, such as using more original sources, to enhance my writing.
As a public school student, I want to urge other students in similar situations to consider independently studying a historical topic and experiencing the thrill of becoming an author. For myself, being published has opened doors not only in the academic world, but in my own mind as well.
Sincerely,
(signed)
Ginger Gentile
East Hampton, New York

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Samples from Authors' letters

Albert Shanker was one of a tiny handful of unusual individuals (20 years ago) who understood right away that The Concord Review was not meant to benefit only, or even mainly, those whose work was published, but rather was “equally important” for those students who could be inspired, by reading the diligent work of their peers in this journal, to make more of an effort with their own academic work in high school…
Albert Shanker (1993): “Publication in The Concord Review is a kind of prize—a recognition of excellence and a validation of intellectual achievement—that could be for young historians what the Westinghouse [Intel] Science Competition is for young scientists. Equally important, the published essays can let youngsters see what other students their own age are capable of and what they themselves can aspire to.”
HS Author Inspiration (samples from letters)
Kaitlin Marie Bergan: “When I first came across The Concord Review, I was extremely impressed by the quality of writing and the breadth of historical topics covered by the essays in it. While most of the writing I have completed for my high school history classes has been formulaic and limited to specified topics, The Concord Review motivated me to undertake independent research in the development of the American Economy. The chance to delve further into a historical topic was an incredible experience for me and the honor of being published is by far the greatest I have ever received. This coming autumn, I will be starting at Oxford University, where I will be concentrating in Modern History.”
Jesse Esch: “Finally, I would be remiss if I did not thank you, on behalf of all students who have been called upon to attempt the seemingly insurmountable task of writing an in-depth history paper, for providing us with plentiful examples of good writing and good history.”
Candace Choi: “I attend a public high school with teachers who rarely, if ever, assign any paper that exceeds two thousand words, much less a research paper. Therefore, I am writing my paper as independent research…I thank you for this great opportunity you are providing for high-schoolers all around the globe. It is indeed rare to have a publication that showcases works of secondary students.”
Emma Curran Donnelly Hulse: “As I began to research the Ladies’ Land League, I looked to The Concord Review for guidance on how to approach my task. At first, I did check out every relevant book from the library, running up some impressive fines in the process, but I learned to skim bibliographies and academic databases to find more interesting texts. I read about women’s history, agrarian activism and Irish nationalism, considering the ideas of feminist and radical historians alongside contemporary accounts…Writing about the Ladies’ Land League, I finally understood and appreciated the beautiful complexity of history…In short, I would like to thank you not only for publishing my essay, but for motivating me to develop a deeper understanding of history. I hope that The Concord Review will continue to fascinate, challenge, and inspire young historians for years to come.”
Shounan Ho: “Although history has always been my favorite subject, I had never written a paper with this extensive research before. After reading the high quality of essays in The Concord Review, I was very inspired to try to write one myself. I though it was a significant opportunity to challenge and expand my academic horizons. Thus during the summer before my Senior year, I began doing the research for my own paper…”
Samuel Brudner: “No one from my school had ever been published in The Concord Review, and I’ll admit I was unfamiliar with it at first. A little research, however, alerted me to its outstanding quality, and I revisited my paper with my teacher’s suggestions and a sense of the journal’s high standards in mind. After several months of further research and revisions, I completed something I though would be worth submitting. The process of revision was as transformative for me as it was for my paper, not only better informing me about an important controversy, but also leading me to think very deeply about certain ideas at play in the world. Studying a subject as closely as The Concord Review requires was a valuable experience for me, as I am sure it has been for many students. I cannot thank you enough for motivating me to achieve, and for recognizing the hard work I put into my paper. I am honored to see my paper among the fine examples of terrific historical research published in your journal.”
Daniel Winik: “As many others have no doubt told you, your publication of The Concord Review is a noble enterprise with tremendous value for young historians..it not only recognizes such work but also encourages it. Your publication of my paper has inspired several of my classmates to consider submitting theirs. I can only hope that with your jubilee [50th] issue, you will begin to receive the accolades you deserve. Once more, I thank you for honoring me and for recognizing the work of young historians everywhere.”
Colin Rhys Hill: “Also, for your information, most of the ‘get into college’ publications I read referred to The Concord Review as the ‘Intel Science Competition’ of the humanities and the only serious way to get academic work noticed.”
Antoine Cadot-Wood: “The paper I wrote three years ago for The Concord Review was an undertaking beyond what I had attempted up to that point, and I have continued to write papers on history frequently every since. The [Emerson] prize will be put to good use, as I embark this week on a six-month trip to China. I will be attending a program to continue to improve my Mandarin, with the goal of being able to use it for research as my college career continues. Thank you for providing me with such a great opportunity during my last year of high school, and I hope that The Concord Review continues to publish for many years more.”
Jessica Leight: “At CRLHS, a much-beloved history teacher suggested to me that I consider writing for The Concord Review, a publication that I had previously heard of, but knew little about. He proposed, and I agreed, that it would be an opportunity for me to pursue more independent work, something that I longed for, and hone my writing and research skills in a project of considerably broader scope than anything I had undertaken up to that point…I likewise hope that the range of academic opportunities and challenges I discovered beyond my school, that contributed to make my experience in secondary school so rewarding and paved the way for a happy and successful career as an undergraduate [at Yale] and (I hope) as a graduate student [Rhodes Scholar], will still be available for them [her children]. Among those opportunities, of course, is The Concord Review. Twenty or twenty-five years from now, I will be looking for it.

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Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the Muscular Dystrophies article more useful, or one of our other health articles.

Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

The muscular dystrophies (MDs) are a group of inherited disorders characterised by progressive muscle wasting and weakness. Becker's muscular dystrophy (BMD) is similar to the more common muscular dystrophy - Duchenne muscular dystrophy (DMD) - but the clinical course is milder. As with DMD, there is muscle wasting and weakness which is mainly proximal. Generally, walking difficulties begin after the age of 16.^[1]

Trending Articles

Female carriers of BMD may be affected, either by some degree of muscle weakness and/or by cardiomyopathy.

Epidemiology

The incidence is about 1 in 17,000 live births (about one fifth of DMD incidence).^[2] BMD is caused by abnormalities of the dystrophin gene, which is responsible for the muscle protein dystrophin. In BMD, abnormal but only partly functional dystrophin is produced (cf DMD, where dystrophin is lacking).

• It is inherited in an X-linked recessive pattern. There are various gene defects which give rise to BMD, affecting different parts of the dystrophin gene. The clinical severity of BMD varies and this is probably due to:
  • Variation in the individual genetic defects and hence in the dystrophins thus produced.
  • Factors other than the dystrophin gene, which determine the severity of BMD in an individual. In one reported family, two brothers with an identical gene defect had very different clinical manifestations of BMD.^[1]
• BMD can occur as a new mutation. Therefore, not all mothers of BMD patients will be carriers of the gene. BMD can also occur through mosaicism (where only some cell lines are affected).

Presentation^[2]

Symptoms

Symptoms usually begin in childhood. The average age at diagnosis is 11 years but there is a wide age range. The clinical severity varies.

Early symptoms

• Delayed walking (sometimes).
• Muscle cramps on exercise.
• Most BMD children are not 'athletic' and may struggle with school sports.

Later symptoms

• Muscle weakness:
  • Affects the proximal muscles of the limbs mainly.
  • May begin in teenage years or 20s, causing difficulty in climbing stairs, fast walking and lifting heavy objects.
• BMD patients can walk independently until the age of 16 or later (cf DMD, where patients cannot walk beyond the age of 12). Walking ability is lost (usually at the age of 40-60) but sometimes earlier, around the age of 20-30.

Signs

• Wasting of the proximal muscles; hypertrophy of others, particularly the calf muscles.

Other presentations

• Myoglobinuria.
• Anaesthetic complications - a dangerous, malignant hyperthermia-like reaction with some anaesthetic agents.
• Cardiomyopathy may be the first presentation, if muscle weakness is subclinical.
• There is a higher incidence of learning difficulties, behavioural problems and autistic spectrum disorders, compared with the general population.

Assessment

Investigations

Initial investigations

• Serum creatine kinase (CK) - shows moderate-severe increase in BMD (5-50 x normal levels).^[2]
• Raised CK levels in this scenario merit specialist referral for further investigation.

Further investigations

• Genetic analysis
• Muscle biopsy - for dystrophin staining
• Genetic tests and counselling for the family
• Monitoring for cardiomyopathy (see 'Cardiac complications', below).

Differential diagnosis

• Other muscular dystrophies: differentiation is by the clinical features such as age of onset and pattern of muscle weakness, by muscle biopsy features and by DNA analysis.
• Other myopathies - eg, thyrotoxicosis, Cushing's syndrome.
• Neurological causes of muscle weakness: spinal cord lesions, spinal muscular atrophy, motor neurone disease, multiple sclerosis. These conditions may have additional features such as sensory loss, upper motor neurone signs or muscle fasciculation.

Management

Treatment is supportive and includes:

• Exercise programmes and physiotherapy. Recent evidence suggests that exercise training is beneficial.^[3]
• Muscle cramps may be helped by night splints, massage or compression treatment using air-filled boots.
• Optimise nutrition:
  • Vitamin D and calcium for bone health.
  • Avoid obesity.
• After walking ability is lost - wheelchairs and other aids.
• Psychological support and employment advice.
• Monitoring/treatment of complications.

Complications and their management

Musculoskeletal complications

• Weakness can lead to joint contractures and scoliosis, which may require orthotic or orthopaedic treatment.
• Complications of immobility - eg, constipation and osteoporosis.

Cardiac complications^[4]

The severity of cardiomyopathy and congestive heart failure may not parallel the severity of skeletal muscle disease. Atrial and ventricular arrhythmias may be life-threatening. The degree of hypoventilation and pulmonary dysfunction also affects cardiac function in muscular dystrophy.^[5]

• Dilated cardiomyopathy:
  • Occurs in most BMD patients.^{[2, 6]}It is the main factor influencing survival.
  • May be the presenting feature, if muscle weakness is mild. The severity of cardiac involvement does not correlate with the severity of skeletal muscle weakness.^[7]
  • Asymptomatic (subclinical) cardiomyopathy is common.^[8]
  • Symptoms may be nonspecific - eg, fatigue, poor sleep, weight loss, vomiting.
• Arrhythmias.

Monitoring and treatment

• Regular cardiac monitoring from diagnosis/from age 10 years, including:
  • Clinical evaluation.
  • Electrocardiogram (ECG) and echocardiogram - these may be difficult to interpret due to scoliosis.
  • Other possible tests - cardiac MRI, multigated acquisition study (MUGA) and tissue Doppler echocardiography may be more helpful than standard echocardiography.^[9]
• Treatment is with standard regimens - eg, angiotensin-converting enzyme (ACE) inhibitors, beta-blockers and diuretics for cardiac failure.
• Consider anticoagulation, as thromboembolism risk is increased.
• Nutrition and respiratory function should be optimised.
• Some patients require cardiac transplantation.^[6]

Anaesthetic complications^[4]

• Life-threatening rhabdomyolysis (malignant hyperthermia-type reaction) to some anaesthetic agents.
• Hyperkalaemia in response to succinylcholine.
• Higher risk of complications due to cardiac disease.
• Careful assessment and monitoring are required with any anaesthetic procedure or surgery.

Other complications

• Respiratory muscle weakness:
  • Depending on the clinical severity of muscle weakness, this is a possible complication. Management would be similar to that for DMD respiratory complications. See the separate Duchenne Muscular Dystrophy article.
• Pain in the lower back, spine and legs.^[10]

Prognosis

Research Analysis Paper Mr. Becker's Classroom Login

• Life expectancy is often reduced but there is a wide variation in severity and the prognosis can be excellent.
• Cardiomyopathy is the cause of death in about half of BMD patients.^[11]

Research Analysis Papermr. Becker's Classroom

Female carriers of Becker's muscular dystrophy

Cardiomyopathy risk

• Female carriers of the BMD gene may have an increased risk of cardiomyopathy.
• The extent of the risk is debatable; evidence is conflicting regarding rates of cardiomyopathy in carriers and regarding whether life expectancy is affected.^[12]
• An international workshop in 2002 recommended regular cardiac screening for BMD carriers.^[4]This recommendation has, however, been questioned.^[12]

Manifesting carriers^[2]

Most carriers are asymptomatic but a small percentage (2-5%) may have skeletal muscle symptoms; they are known as manifesting carriers of BMD:

• The reason why the gene manifests in some women but not in others may be through the mechanism of 'X-inactivation', where the normal X chromosome is inactive and the X chromosome carrying the BMD mutation is the active one.
• As with BMD boys, there may be no family history of the disease.
• Some cases of BMD manifesting carriers were previously diagnosed as having another type of muscular dystrophy but, with new techniques such as dystrophin staining, have been identified as having BMD.

Clinical features

• There is wide individual variation in the severity of symptoms - from mild muscle weakness, aches or calf muscle enlargement, to a disease as severe as that in boys.
• Onset of symptoms can be in adulthood.
• There is usually some gradual progression of symptoms with time.
• Cardiac involvement can occur.

Diagnosis

• Muscle biopsy looking at dystrophin is usually helpful.
• Genetic tests, including X-inactivation patterns.

Management, follow-up and prognosis
This varies depending on individual severity of symptoms.

Research Analysis Paper Mr. Becker's Classroom Lesson

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1. Muscular Dystrophy, Becker Type, BMD; Online Mendelian Inheritance in Man (OMIM)

2. Manzur AY, Muntoni F; Diagnosis and new treatments in muscular dystrophies. J Neurol Neurosurg Psychiatry. 2009 Jul80(7):706-14.

3. Sveen ML, Jeppesen TD, Hauerslev S, et al; Endurance training improves fitness and strength in patients with Becker muscular dystrophy. Brain. 2008 Nov131(Pt 11):2824-31. Epub 2008 Sep 6.

4. No authors listed; Cardiovascular health supervision for individuals affected by Duchenne or Becker muscular dystrophy. Pediatrics. 2005 Dec116(6):1569-73.

5. Romfh A, McNally EM; Cardiac assessment in duchenne and becker muscular dystrophies. Curr Heart Fail Rep. 2010 Dec7(4):212-8. doi: 10.1007/s11897-010-0028-2.

6. Connuck DM, Sleeper LA, Colan SD, et al; Characteristics and outcomes of cardiomyopathy in children with Duchenne or Becker muscular dystrophy: a comparative study from the Pediatric Cardiomyopathy Registry. Am Heart J. 2008 Jun155(6):998-1005. Epub 2008 Mar 19.

7. Finsterer J, Stollberger C; Cardiac involvement in Becker muscular dystrophy. Can J Cardiol. 2008 Oct24(10):786-92.

8. Sultan A, Fayaz M; Prevalence of cardiomyopathy in Duchenne and Becker's muscular dystrophy. J Ayub Med Coll Abbottabad. 2008 Apr-Jun20(2):7-13.

9. Meune C, Pascal O, Becane HM, et al; Reliable detection of early myocardial dysfunction by tissue Doppler echocardiography in Becker muscular dystrophy. Heart. 2004 Aug90(8):947-8.

10. Zebracki K, Drotar D; Pain and activity limitations in children with Duchenne or Becker muscular dystrophy. Dev Med Child Neurol. 2008 Jul50(7):546-52.

11. Finsterer J, Stollberger C; The heart in human dystrophinopathies. Cardiology. 200399(1):1-19. The order 1886 sequel.

12. Holloway SM, Wilcox DE, Wilcox A, et al; Life expectancy and death from cardiomyopathy amongst carriers of Duchenne and Becker muscular dystrophy in Scotland. Heart. 2007 Oct 11

Research Analysis Paper Mr. Becker's Classroom Assessment

Research Analysis Papermr. Becker's Classroom Assessment

My symptoms are below:-Mid 2006- Felt right leg week when I am exercising. Felt right hand weak and fine tremor.-Did all possible tests and MRI,EMG, everything normal in 2008.-2006-2017 - I let it go..

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