Physical Therapists as Primary Care Providers for Chronic Neuromuscular Disease:

A Case Report
Nancy Mulligan PT DPT, Barbara Tschoepe, PT PhD, Marcia Smith, PT PhD
School of Physical Therapy, Regis University, Denver, CO

INTRODUCTION EXAMINATION INTERVENTION DISCUSSION

Charcot-Marie-Tooth Disease (CMT) is known for its
slowly progressive symmetrical weakness that
begins distally creating concurrent functional
losses. While CMT’s progression is
documented, few studies have reported long
term effects of PT interventions.
Purpose:
1. Describe a PT plan of care for an individual with
CMT 1A that emphasized motor learning and
motor control while incorporating surface
electromyography (sEMG), manual therapy,
strengthening, and aerobic conditioning.
2. Illustrate the PT’s role as primary care provider for a
person with a chronic neuromuscular disability
over a 5 year period.
CASE DESCRIPTION
A 52 yo woman recently diagnosed
with CMT 1A
Initial goals:
•Decrease fatigue
•Complete job responsibilities
•Walk independently from car to office (3000ft)
•Improve balance to reduce fall frequency (4 falls
reported over previous year)
PT in a primary care model periodically addressed:
•Patient goals
•Body structure and function impairments
•Activity limitations
•Participation restrictions
Systems review – moderate cardiovascular risk
•Posture and gait analysis – significant asymmetries
•MMT, ROM, muscle length testing – proximal trunk and
distal muscle weakness/length deficits
•Surface electromyography (sEMG) analysis of muscle
activation patterns – poor muscle onset and offset timing,
inappropriate sequencing and low amplitudes throughout
the gait cycle
•Balance – no ankle strategies, inappropriate hip and
stepping strategies, poor anticipatory responses and poor
stability
•Functional Outcome Measures – PPT-7, sit to stand x 5,
gait speed, Patient Specific Functional Scale
DIAGNOSIS
Balance and gait dysfunction, motor recruitment and
strength deficits associated with CMT
PROGNOSIS
Progressive disorder with guarded ability to improve
function
• Retraining of trunk, hip and LE recruitment patterns as
they related to posture, balance and gait
• Gait re-education with sEMG and MBT® heel rocker shoe
with cane  standard shoes without cane and retro TM
• Balance training: proactive, reactive and stability
• HEP for enhanced core control  circuit training at
health club
• Aerobic conditioning with recumbent bike and TM
• Manual therapy for periodic episodes of neck, hip and
knee pain
• Neurologist, orthopedist, psychologist and sport podiatrist
referral
OUTCOMES
sEMG analysis of muscle activation patterns – Unopposed
firing of tibialis anterior 2° to no gastroc-soleus activity
progressed to an alternating pattern.
Patient Specific Functional
Goals
Activity
Walk 3000ft to office
10 K Walk without
walking sticks
Recreational Skier
PT care plans typically address acute episodic events with
short term interventions that demonstrate limited
functional gains, challenging evidence for the long-term
efficacy of PT. This case report illustrates the impact of a
comprehensive 5 year PT-guided program that
strategically prioritized problems during an extended
follow-up period and resulted in significant gains across
multiple functional outcomes.
CLINICAL RELEVANCE
•PT serving as a primary care provider can mange the
patients care and refer to physicians and other health
care providers as needed to address the long term
functional goals of patients with neuromuscular
conditions
Goal Achieved •The authors encourage colleagues to combine evidence
Safe community
ambulation
from both neuromuscular and musculoskeletal literature
2 hours and 18 minutes to optimize outcomes for patients with CMT
Green and Blue
diamond ability