Ask The Expert

Wish you had some 1-on-1 time with an expert CMT Neurologist? Now you do!

Join our “Ask the Expert” weekly with Dr. Florian Thomas and Dr. Jafar Kafaie. Knowledge is Power!

Dr. Florian Thomas

Dr. Thomas is a clinician and researcher, board-certified in neurology and neural repair and rehabilitation.

CMT has been a big part of Dr. Thomas’ professional career for over 25 years. After medical and graduate school, Dr. Thomas completed training in Neurology at Case Western Reserve University in and in Peripheral Nerve Disorders at Columbia University. He earned a Ph.D. in Molecular Biology at McGill University, and joined St. Louis University in 1995. For 20 years he has engaged in basic research & clinical research of acquired and hereditary neuropathies and multiple sclerosis. He has worked with both the CMTA and the Hereditary Neuropathy Foundation and established neuropathy Centers of Excellence in Missouri and New Jersey where in 2016 he became chair of Neurology in Hackensack.

Dr. Thomas is dedicated to providing patient-centered comprehensive care that addresses each person’s physical and emotional needs. He supports patients and caregivers affected by chronic conditions to self-advocate, engage in their own care, and maintain a positive attitude.

Dr. Jafar Kafaie

Dr. Kafaie is an Associate Professor in the Department of Neurology.  He treats patients with neuromuscular diseases including motor neuron disease, muscle diseases, neuromuscular junction disorders and different forms of peripheral neuropathies. He has appointments with both SSM- Saint Louis University Hospital and Cardinal Glennon Children Hospital and takes care of patient both in pediatric and adult clinics. He does electrodiagnostic tests (nerve conduction study and electromyography) on both sites. He is the director of HNF- Designated CMT center of Excellence in Saint Louis University. He is side director for multiple clinical trials including a large international study on CMT1A. Dr. Kafaie is also director of the adult neurology residency program and is extensively involved in the teaching of residents. 

Dr. Kafaie was born and raised in Tabriz, Iran.  He attended Tehran Medical University and obtained his Ph.D. from McGill University before doing his residency followed by a fellowship in neuromuscular medicine at Washington University in Saint Louis, MO.

Dr. Kafaie is a member of the American Association of Neurology and the American Association of Neuromuscular and Electrodiagnostic Medicine.

If you would like to ask a question, we invite you to do so by filling out the form below. We will be sending Dr. Thomas and Dr. Kafaie your questions and posting their responses as they come in. Please understand if they are unable to get to your question due to time or topic constraints. Thanks in advance for your participation!

What should I be getting myself checked for with a doctor?

As a child doctors would measure and document my strength and offer me options that could facilitate my life. But, now that I’m not a child anymore, I don’t know what I should be doing or getting checked for in regards to CMT.

Dr. Florian Thomas: I have a couple of suggestions. Two independent conditions can both damage the same organ, e.g. nerves. That can happen at any point in a person’s life. I take care of several CMT patients who 10 years after their first visit developed diabetes, which further damaged their nerves. So that is an issue that your doctors need to check for periodically. As we get older more of us become B12 deficient. That is another issue that I check my patients for regularly. As patients with CMT get older they may need bone densitometry tests and, if abnormal, may need to be treated for bone loss. Patients may not need ankle braces when they are younger, but need them as they get older. Patients may have no problems with finger/hand function when they are younger, but may require adapted (“gloved”) tools later, such as pens, kitchen utensils, tooth brushes, hair brushes, etc.

So in summary, regular evaluations by a neuromuscular physician and rehab therapists make sense to me, with the frequency being individualized. Some patients worry about how CMT affects their lives in the personal, social, and professional world with issues such as: having children, performing at work, others thinking that the patient is drunk when the patients walks abnormally; they may also worry about their appearance when they have very skinny legs. Patients may be reluctant to use canes or ankle braces because they don’t want to “look” or “feel” sick, but not doing so may increase their fall risk. So talking to a counselor is often helpful.

What are the best ways to live with CMT (CMT2)?

At what point is it considered a disability?

Dr. Florian Thomas: I advise my patients with CMT to take care of one’s body, avoid gaining weight, minimize the risk of additional neuropathies besides CMT (such as caused by diabetes or too much alcohol), exercise to keep one’s heart and blood vessels healthy and take care to avoid falls by using ankle braces (if necessary), get monitored for bone loss (so that if one falls, one does not break a bone), follow up with your team of doctors and rehab therapists, and lead a happy healthy life in general.

Is there a physical therapy/workout routine DVD or equipment for CMT?

My thinking is unaffected muscles should not be allowed to atrophy from disuse because others are affected. Yet one wants to avoid overuse of affected muscles.

Dr. Florian Thomas: I agree. Overall, exercise is good for patients with CMT, assuming you are otherwise healthy. It is good for the brain and may protect against diabetes. Even if the foot and hand muscles are weak and may not respond to exercise, keeping the muscles closer to the hips and shoulders strong may help with endurance. There is no evidence to recommend one form of exercise over another. Swimming may be preferable for people who feel unsteady. Whether too much exercise of already weak muscles can damage them, is controversial. I suggest you first see a physical therapist and have that person advise you as to a good exercise routine.

Is it common to have stomach issues when you have HNPP?

Could this have anything to do with my nerves in that area?

Dr. Florian Thomas: While I have taken care of many patients with HNPP, it is possible that many others go undiagnosed and we may not yet fully the breadth of symptoms that can be associated with this condition. There are no large studies that have documented stomach, bladder or heart rhythm issues in HNPP. But there are individual case reports which however cannot prove that HNPP is the cause of such issues as opposed to a change association. Whenever a person has a diagnosis, it is easy for both the patient & their doctors to assume that other symptoms result from that one condition; that assumption may be true or false. It is important to not jump to conclusions until other causes of symptoms have been fully evaluated. You may want to seek a referral to a gastroenterologist who is an expert in the lower intestinal tract.

What would happen if two people with CMT were to have a child?

What if they had CMT type 1A and CMT type 2?

Dr. Florian Thomas: The medical-genetic term for the scenario you describe is “compound heterozygote”. “Heterozygote” means that a person has one copy of a mutated gene (as opposed to homozygote when a person has two such copies) and “compound” refers to two independent issues in one person. There are a couple of such instances reported in the literature in general. I myself have published 3 such instances when patients had an hereditary muscle disease and a hereditary nerve disease. What would happen in the situation you describe is not easily predictable, because:

(1) When one person with an autosomal dominant condition (meaning one bad gene copy will cause disease) and another person with a different autosomal condition have children, each prospective parent has a 50% chance of passing on the mutation. So on average (!!!) 25% of children will inherit the “good” copies of each gene, 25% will inherit the “bad” copies of each gene, and 50% will inherit one bad copy from one parent and one good copy from the other parent. 

(2) It depends in part on any interaction between the proteins resulting from the CMT1A mutation and the CMT2 mutation. That is a very complex issue which also depends on the very specific mutation.

 

Can alcohol make CMT symptoms worse either directly or indirectly by the alcohol causing B12 deficiency?

Dr. Florian Thomas: People who consume a lot of alcohol such that a significant portion of their daily calories come from alcohol, often are lacking in regular nutrition and thus can become vitamin deficient, and many vitamin deficiencies can damage nerves.

Is CMT linked to brain fog?

Dr. Florian Thomas: Given that CMT in the overwhelming majority of patients is limited to peripheral nerves, there is little biological basis for “brain fog”. However in addition to intrinsic brain conditions, symptoms such as mental fatigue can result from sleep deprivation and depression which could occur for a number of reasons in people with CMT. Thyroid disorders and vitamin B12 deficiencies can cause “brain fog” and those can be identified with simple blood tests. Furthermore, “brain fog” is common in people who take many medications that affect the brain, e.g. for neuropathic pain, anxiety, depression, insomnia, high blood pressure, and many others.

What is necessary to definitively diagnose a type of CMT today?

Is genetic testing reliable and sufficient?

Dr. Florian Thomas: Assuming that a patient’s history, examination, and family history all point towards CMT, an electrodiagnostic study (often called EMG) can confirm that diagnosis and help tell apart normal conduction speed CMT2 from slow conduction speed CMT1. Half of all CMT patients (those with CMT1A) share the same genetic anomaly, that is a doubling up of a region on chromosome 17 which contains the PMP22 gene. So by testing just for mutations in that gene, one will identify the subtype in many people. A couple of other genes are implicated in another ~25% of patients. The rest has mutations in another 80 genes. And testing for most of those can be done
and is in part covered by many medical insurances.

Do you have any suggestions for pain management?

Dr. Florian Thomas: Patients with CMT can have both musculoskeletal pain (originating in joints, tendons) and neuropathic pain (often described as tingling or burning). So the first step is to for a physician to analyze the pain for causes. Chronic pain is best addressed by a psycho-socio-bio-logical paradigm, because chronic pain can lead to sleep problems, sadness, social withdrawal and fear of more pain resulting in a vicious cycle because if a person is unhappy, the tolerance for pain is lowered. Counseling psychologists can help people with chronic pain have a better quality of life despite pain.

Is it possible that HNPP affects fertility?

Knowing I could pass the condition on to a child was definitely the hardest part of my diagnosis.

Dr. Florian Thomas: Geneticists can advise as to childbearing. I had a patient who was quite affected with CMT and did not want to pass it on. She underwent prenatal testing and found out that her baby was not going to be affected. When a person struggles the consequences of an illness such as CMT, often a psychological counselor can help a person cope better and live life to the fullest despite the condition.

Many of us with CMT1A experience ongoing issues with gastrointestinal (GI) motility...

Is this an area that has been researched with, for example, patient surveys of a sizable population?

Dr. Florian Thomas: There is not a whole lot of evidence for CMT1A affecting GI motility, but studies are limited. If you consider how CMT affects the longest nerves earlier than shorter nerves, that makes sense. People have problems in their feet and ankles much earlier than in their thighs. They may drop things from their hands long before their shoulders are weak. Many nerves to the gut are relatively short. Of course there are many tests that specialized gastroenterologists use to find the causes of constipation and gastroparesis so if I were you, I would ask my neurologist for a referral to the GI department of a major university medical center where you are more likely to find such experts.

Can CMT symptoms be caused by B12 deficiency instead of the person actually having CMT?

Dr. Florian Thomas: B12 deficiency cannot cause CMT. But B12 deficiency can cause an acquired neuropathy.

Does CMT cause hypermobility, loose ligaments, and swan-neck deformity in hands/fingers?

Is Ehlers-Danlos syndrome a possibility?

Dr. Florian Thomas: CMT does not cause loose ligaments, but the finger deformities that can result in CMT from muscle weakness can superficially resemble the swan-neck deformity seen in Ehlers-Danlos. Given how rare Ehlers-Danlos is, it may not be easy to find a physician with a lot of experience. The condition may fall into the domain of dermatologists and orthopedic surgeons. I would start with one of these specialists, probably in a major medical center.

Has there been, or plan to be, any serious research into medical marijuana on the effects of CMT?

Dr. Florian Thomas: There is a dearth of studies on medical benefits of marijuana in any form. This has several reasons. For one it is essentially impossible to have a double blinded, placebo controlled study, since people will feel the effects of marijuana. One can study some of the 200-300 components of marijuana that lack mind-altering properties in controlled studies, but an individual component obviously does not reflect all that is in marijuana. In other conditions marijuana seems to help pain and spasms, but of course other medications can help with that. And marijuana can make people fatigued and compromise reaction times. Typically marijuana does not improve skin sensation or muscle strength.

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