Case Study and Medical History Analysis of a Patient from an Integrative
Manual Therapy TM Perspective 
Author: Kris Albrecht MA PT
Abstract: This case study focuses on a 12 year old girl diagnosed with Charcot Marie Tooth Syndrome and peripheral neuropathy of both hands and feet. Upon evaluation, the patient presented with complaints of pain and weakness in the extremities, recurrent ankle sprains, foot deformities, and a difficulty walking with decreased endurance. The patient’s mother reported a very involved past medical history including a traumatic birth. The patient was treated with Integrative Manual Therapy for several sessions. After the treatment was completed, the patient presented with significant increases in range of motion in her spine and ankles as well as improved gait and mobility.
Key Words: Descended Sacrum, Tethered Cord, Charcot Marie Tooth, Peripheral Neuropathy
Introduction
This patient is a 12 year old female diagnosed with Charcot-Marie-Tooth Syndrome and peripheral neuropathy of the hands and feet. The patient reported the following symptoms: pain and weakness in the extremities, ankles and feet most severe; recurrent ankle sprains; foot deformities; difficulty walking with decreased endurance.
Past Medical History
The girl’s past medical history included a vaginal delivery at 38 weeks in car en route to the hospital with a birth weight of 4 pounds, 4 ounces. At 2 months, she had a bilateral inguinal hernia repair with "post-operative difficulty and a reaction to anesthesia" (1). At 2.5 months, the patient began using the formula, Enfamil. When the girl was 4 months of age, she had a 100.2 fever with a rash on her face and chest for 3 days, followed by a rash on her tongue for 3 days. At 4.5 months, her formula was changed from Enfamil to Prosorbee which caused her to be very congested, gassy, wheezing, spitting up, with a respiratory rate greater then 40 breaths per minute. When the patient was 5.5 months old, she became very sick and was diagnosed with asthma. At 7 months, she became anemic. The patient’s early childhood past medical history included recurrent sinus, ear, and respiratory infections. At 8 years old, the patient had an ophthalmology consult for Duane’s Syndrome (weakness of the lateral rectus muscle of the eye). When she was 9 years old, she had an onset of idiopathic precocious puberty (1) along with a palate spreader (pre-orthodontia). At 9.5 years old, the patient experienced recurrent ankle sprains followed by weakness, numbness, and tingling in her lower and then upper extremities. When the girl was 10 years old, she had testing for Charcot Marie Tooth which came back negative. ("Charcot Marie Tooth variance, possibly consistent with spinal muscle atrophy type" (1)). Currently, the girl presents with swollen gums, difficulty concentrating, and a diagnosis of Attention Deficit Disorder. Current Medical Recommendations include bilateral strong bracing, surgical tendon transfer of the tibialis posterior muscle, and possible surgery for a tethered cord.
Medications
At time of evaluation, the patient was not on any medications. During the past 5 years, she has been on Nasalcort, Proventil, Robitussin, Intal, and multiple antibiotics.
Social History
During intake, the mother stated that her daughter was very shy, spoke little, and was insecure.
Physical Examination
Posture: Patient presented with the following postural deviations upon physical examination: forward head and neck posture, protracted shoulder girdles bilaterally, decreased thoracic kyphosis, distended abdomen, bilateral downslips of ilia, bilateral descended sacrum, foot position: bilateral hindfoot equinus with internal rotation of tali and pronation of midfeet.
Range of Motion: Patient presented with a severe restriction in spinal motion with minimal segmental motion. She had minus 10 degrees of bilateral ankle dorsiflexion.
Muscle Tone: She had increased muscle tone at bilateral hip adductor muscles, gluteal muscles, quadriceps, and gastrocnemii.
Gait: During gait analysis, patient presented with an absence of heel strike bilaterally with initial contact on forefoot or flat foot; negative loading on tibia secondary to lack of heel strike; excessive hip flexion to advance trunk; an absence of center of gravity shifting over the foot; incomplete one-legged support during stance phase; and no early or late push-off.
Integrative Diagnostics
Myofascial Mapping: Positive mapping of brainstem, intraoral, spinal cord, sacrum, ischia, sacral plexi, filum terminale, knees, ankles, and feet.
1st Visit:
Treatment: Advanced Strain/Counterstrain for the Spinal artery, Circle of Willis, and Middle Sacral artery (3). Muscle Energy and ‘Beyond’ Technique for bilateral downslips and descended sacrum (4). Neural Tissue Tension Technique bilateral S3 and S4 (5).
Results: After treatment with Integrative Manual Therapy was completed, patient presented with significant increases in forward bending in Thoracic and Lumbar areas to 40 degrees. Myofascial Mapping was negative at bilateral ischial tuberosities (2). During the patient’s second visit, her mother reported, "She’s a different girl- much more talkative and outgoing."
2nd Visit:
Initial Testing: Positive Myofascial Mapping intraoral and sinuses, sacrum, and both legs. Patient presented with noticeable swelling in her gums.
Treatment: Orthotic casting to restore heel loading and provide medial support during ambulation.
3rd Visit:
Initial Testing: A major change in the girl’s affect was noted; the patient was talkative and friendly. The mother reported that the girl was playing tennis and "flying down the stairs." Her braces have been removed secondary to gum inflammation.
Treatment: Foot and ankle mobilizations; Compression Syndromes for bilateral shins, calves, ankles, and feet with treatment of Disruption of Membranes and Immune Deficiency Motility as found (6); Jones’ Strain and Counterstrain to ankles and feet (7); orthotics checked to insure proper fit and biomechanics.
Homework: Neurofascial Process (8).
Results: After treatment, the patient presented with an increase in dorsiflexion by 5 degrees to minus 5 degrees bilaterally; increase in eversion by 5 degrees to minus 1 degree on the left and 5 degrees on the right. During gait analysis post treatment, the patient had bilateral heel loading at heel strike; weight transmitted through tibiae; center of gravity moved over base of support resulting in smoother, more efficient gait pattern.
Follow-up
Patient’s treatment plan includes cranial/intraoral follow-up work. Her mother does not plan to have her braces reapplied.
Discussion
It is interesting to note the interplay of biomechanics and neurology in this case as demonstrated by the increases in mobility and function with restoration of articular balance through the spine and extremities. Also removing the adverse mechanical tension (9) via correction of the bilateral downslips and descended sacrum allow normalization of the sacral nerve root irritation and the paresthesias in the feet. Equally interesting, however, is to note the progression of the patient’s history, especially within the framework of Integrative Manual Therapy. On evaluation, the patient presented with a descended sacrum. This typically occurs as a result of an inferiorly-directed force to the frontal or parietal areas, causing the sacrum to lock downward within the ilia.4 This may have occurred in utero, during the patient’s very sudden birth in the car on the way to the hospital, or at some point thereafter. The inferior traction on the dura however, would feed into a facilitation of the central nervous system, (9) while the inferior positioning of the sacrum would increase pressure in the pelvic cavity and irritate the sacral nerve roots (4). This may have been a factor in the development of the bilateral inguinal hernias, which were repaired at 2 months old. The patient was weaned to formula shortly thereafter (Enfamil) and developed a fever and rash on the face, chest, and tongue. This may have indicated a developing sensitivity to the formula, or possibly a dairy allergy. She was then changed to a soy-based formula, with an escalation of respiratory and digestive complaints. While this may have been done to remove dairy as a potential allergen, the child may have been sensitive to soy as well. Within another month the (5) and a half month old was very sick, and diagnosed with asthma. It may have been that a compromised system, continually exposed to an allergen/irritant, then manifested the genetic predisposition to asthma.
At 7 months old, the patient was found to be anemic. This, as well as her rapid respiratory rate (>40 breaths per minute), may have been secondary to irritation of the primary respiratory center in the brainstem. When the sacrum is displaced inferiorly, there is often displacement of other structures as well, including the brainstem (10). The improper intake of oxygen may interfere with the oxygenation of the hemoglobin and result in anemia. The patient experienced several sinus, ear and respiratory infections during childhood. Central to the philosophy of Integrative Manual Therapy is the idea that the body will reflexogenically protect a compromised area at least as long as is necessary for healing to occur (6). Further, it will especially protect the brain and heart to keep them free from infection (11). With recurrent infections in the sinuses, ears and airway these protective mechanisms would necessarily be elicited. The onset of "idiopathic precocious puberty" at 9 years old may also indicate dysfunction or imbalance in the pituitary area. If the body was reflexogenically trying to contain infection in the sinuses and airway passages, the introduction of a mechanical force in the form of the palate spreader prior to orthodontia could be directly counter to this. This forced widening of a protected area would transmit the tension distally, potentially increasing the tension on the sacral nerve roots already facilitated by the descended sacrum. This may explain why the extremity paresthesias and muscle weakness, as well as the ankle sprains, began after the application of braces. It could also explain the presence of the tethered spinal cord via tension and fibrosis of the filum terminale. And, it would explain why the patient was so much more functional after biomechanical correction of the tension and removal of the braces.
Follow-up would necessarily involve clean-up and focus on the mouth area, as indicated in the treatment plan. This case clearly illustrates the use of Integrative Manual Therapy principles and techniques to normalize orthopedic and neurologic imbalance. Looking at the structure and history of the patient from the viewpoint that the system is doing the absolute best it can to maintain its function and allow its compromised areas to heal, allows us to design a treatment plan that supports the body’s efforts. This is truly client-centered therapy.
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