Groovin’ With Jonah Berger: Camp Footprint and So Much More……….

In addition to providing services to adults with CMT, the CMTA provides services to children and teens who are also aware of the struggles that they face every day. Jonah Berger and his team have helped the CMTA transform youth into leaders and fulfill their dreams at Camp Footprint for nearly twenty years. His book The Strangest Of Places was published in 2021, and it is a collection of stories that will leave you laughing, crying, and inspired.

As part of episode 18 of the CMTA’s official podcast, CMT 4 Me, Chris and Liz O. discuss Jonah Berger’s experience with CMT and his role with the CMTA, as well as who Jonah is and what he is passionate about.

Jonah: My role at the CMTA, my official title is the National Youth Programs Manager. So, to boil that down into human talk, I run the youth program and I am responsible for working side by side with the team and with the leadership of the youth to come up with programming and offerings for the youth, connecting the youth throughout the year, and then the big shiny diamond at the top of the mountain Camp Footprint every year.

Chris: Jonah, how did you stumble upon the CMTA? Did you hear about us in a support group?

Jonah: I remember the very day I went to a Patient/Family Conference in Washington, D.C. My mom had signed us up to go and I went with her and I met Jeana Sweeney that very day.  That was my first kind of true introduction to someone official with the CMTA. I met Jeana when I first arrived at 9:00 AM. She was the first one I met. By the end of the day, I had also met Elizabeth, who also blew my mind. There are probably thousands of people out there who could easily agree with me. Jeana’s enthusiasm and passion for the mission was infectious. By the end of that day, I had met many people through the organization that just impressed me with their grounded nature in what they were up to, and the fact that they weren’t afraid to have fun and laugh while they were doing it. I caught that day one, and I would say that from then on it was just trying to volunteer or help in any way that I could, and the rest kind of took over organically.

Chris: What type of CMT do you have and some indications of your existing symptoms, and whether those have progressed over the years or where you were 10 years ago? Tell us a little bit about that history?

Jonah: I have CMT 1X, as does my mother, as did my grandmother, as do two of my aunts, and three total out of nine cousins on that side of the family. I have two kids now. I have a three-year-old daughter who does have it. I have a three-month-old son who does not. We know this because with CMT 1X for men, such as myself, every daughter I have, I’ll have given my X chromosome, therefore she will have it. Every son I have, I’ll have given my Y and he will not have it. So we didn’t know what we were having both times, but when they showed themselves to us, we knew right away if they would or would not have CMT.

 I would say that my overall effect is pretty balanced. I’m quite an active person. I bike a ton. I’ve done a lot of hiking and crazy things physically in my day. I would say that I have been noticing in the last few years, especially in the last year to two years, that I’m having more trouble with balance than I did before. And as Dr. Shy explains it to me, that is not necessarily at my age.It is the progression of CMT as much as it is CMT working with an ever-aging body. So at the same level, you kind of plateau at a certain point in my case, but as I get older, that same level will appear to be more severe because I’m getting older. 

Elizabeth: I was reading your book,The Strangest of Places. Is that the whole title? 

Jonah: The Strangest Of Places, which is a Grateful Dead quote.

 “Once in a while, you get shown the light in the strangest of places if you look at it right” -The Grateful Dead

Elizabeth: I’m just reading that and devouring it. I’ve learned a couple of things about Jonah, Chris. He was traumatized at a young age by a very mean teacher who brought vegetables in every morning and cut them up, so he never eats healthy. I mean, never even celery. It’s fun reading his stories and he loves nature and he’s out camping. But Jonah, you never mentioned CMT in this book. I’m halfway through. All I know is your father’s chasing after you. You jump in your room, lock the door, and he’s grabbing your foot. I mean, there’s no mention of hobbling over. So I was wondering when you were younger, did you have any symptoms? When did they start? 

Jonah: When I was that age, no, I was pretty quick, or else he would’ve caught me. No question about it. You did not raise your voice to my mother when you were in our house, which is a good rule now in retrospect, but my biggest concern being the pickiest eater on the planet was what was gonna be for dinner every night. I would call out to my mom, “Mom! What’s for dinner tonight?” She had her canned answer. You’ll find out when you get to the table. Which is for me, you’ll find out in an hour if you’ll eat or not.  

I wasn’t having that. So one night, I had it. I don’t know how old I was. I was probably eight or nine. I said,”Mom, what’s for dinner?” She said,”You’ll find out when you get to the table.” Don’t ask me what came over me. But out of my nine-year-old mouth, I said, “Mom, what the F is for dinner?” And all I heard was my father coming up the steps… My father’s giant feet. I ran and I managed to make it to my room and close the door and push my bed against the door. That’s before my dad got to me.  

I didn’t really start showing symptoms per se until I was closer to 13. I would say that’s when I really could tell that my feet were getting a little weaker, that I was having a little bit of trouble doing things that should be completely normal for a 13-year-old. And then, by the time I was 15, you can tell in pictures of the way I walked in videos that I was stumbling more for sure. 

Chris: Jonah, were you engaged in sports when you were in school? 

Jonah: I was. I played soccer for a few seasons as a kid.  I was the manager of the girls’ volleyball team in high school. They were seven times state champs and they were tall and lovely. So it was a great situation for me. I had found a way to become part of a sports team without having any athletic ability.

Elizabeth:  It sounds like you were never really shy. You mentioned a lot of crushes in your book and like the sun rose and set in her eyes, you know, like things like that. It doesn’t sound like you were a shy kid, even though you were traumatized about going to school when you were younger.

Jonah:  I was not a shy kid by nature. I was a very outgoing spirit by nature. I think what happened in kindergarten (which we laugh about a lot) was a teacher who just lost her cool on me as a kindergarten kid and it did traumatize me for several years. I became shy as a result of that, but I think through a lot of love for my parents and through summer camp. Quite honestly, that’s what brought me back out of my shell and kind of into my natural way. 

Chris: Jonah, if you don’t mind, what happened? What was that experience in brief? 

Jonah: Mrs. Preston, who we call the Pickle Witch in my family. There is a chapter, by the way, about CMT. You’ll get to it in the second half of the book. I had the best kindergarten teacher in history. Ms. Gillespie. She was so great that they promoted her in the middle of the year to a high-level position in the county. First mistake. You never take a teacher out of the classroom at that age unless you have to. They replaced Ms. Gillespie with Mrs. Preston, who decided she was going to earn the favor of these kindergarten-age kids by instituting a vegetable tasting day every Wednesday.

I was already a picky eater. So she would bring in a vegetable, cut it up, and we’d all have to come up, take a bite, and say what we thought of it. I was having nothing to do with vegetable tasting day, and it all came to a head on pickle day. She brought in a pickle. Cut it up, we came up to try it. She said, “Jonah, will you come up and try it?”

I said, “No, no way.” She said, “Jonah, come up and try it.” I said, “No.” And then, evidently, I don’t remember her screaming, but the room mother told my mom, she just lost her cool and started screaming at me. I went under a table and grabbed the table legs. Mrs. Sullivan, the room mom, went to the office, called my mom, and said, “You better get down here.” They peeled me off my mom kicking and screaming every day for the rest of kindergarten, first, second, and part of third grade. 

Chris: Wow. So that went on for quite a while.

Jonah: It was a very traumatic pickle incident. 

Elizabeth: How did these experiences of early life help you? Because you’ve always been interested in helping kids with differences with different abilities. Did that have anything to do with the future of helping kids be themselves or find themselves? 

Jonah: I would say CMT was major. My dad is like the king of all times with a teacher, camp director, and childcare. He was just the maestro.  I think I was always kind of inclined towards working with kids, but my disability helped me to steer that passion into working with kids with disabilities. I think what happened to me as a kindergartner made me extra attentive to the kids who are on the fringes. So on the first day of camp, I am always laser-focused on where the homesick kids are. Let me give them extra love because I know exactly what’s going on in their gut at the time. 

Chris: I want our listeners to learn more about Camp Footprint and what you have done, and it’s just such an incredible event. So why don’t you tell our listeners a little bit about Camp Footprint and what that’s all about in your role and your attitude towards it and what you get out of it, et cetera. 

Jonah: Well, in 2016, the organization decided it was time to get a camp together just for kids with CMT because the avenue had always been a Muscular Dystrophy Association camp, which is a beautiful avenue. I’m a huge fan of the MDA’s Camp Program. But MDA is an umbrella term that encapsulates 50 different disabilities and diagnoses. I think that CMT, being as prevalent as it is and specific as it is with its symptomatology, needed its own program and they happened to have someone on their advisory board, myself at the time, who was a camp director. His whole career with CMT and was used to working with kids with CMT, so thank goodness it was a no-brainer because it is the greatest joy I’ve ever experienced professionally in my entire life. I’ve been directing eight different camp programs now, including Footprint. And I’ve never seen anything like it.

Jeana Sweeney and Jonah

I’m biased because I help to plan and run it, but there’s something bigger than any one of us that goes on when we get kids together who are used to being the one in their friends’ group, some of them, the only one in their family to have a physical disability, the one that is looked at as abnormal and all of a sudden you put them into a situation where a hundred other kids or 99 other kids and three-quarters of the staff and the director has CMT and not only are they understood, but they are understood about one of their most personal challenges without them having to say one word and they know it. And as a result, everyone relaxes. And I don’t put a lot of value on normalcy, as you can probably tell. They are allowed and gifted the ability to feel normal, some of them for the first time in most of their lives. And it is so cool to watch what happens to a kid when they’re not trying so hard to cover something up, when they can just relax. And that’s the bottom line behind the success of Footprint.

Elizabeth: Bring us through a day in the life. 

Jonah: This was the first year of Footprint 2016. On the first full day when the kids were there, the first morning I got up, I grabbed my braces with my right hand, and my shoes with my left hand, and I came out and I sat down on the couch in the common area of the boys’ cabin, and I started doing my morning routine of five minutes of getting my legs strapped on. At one point, I turn my head to the right and two little boys are sitting next to me on the couch putting their leg braces on. And it was the first time in my 43-year-old life at the time that I had company, and I had company that got it, and it was really a pretty incredible moment. We have breakfast, we do chair dancing every morning after breakfast, which is our way of exercising without having to have balance be a part of it.

So everyone sits in chairs. Bridget, our unbelievable Director of Greatness, is leading it. She’s a dance instructor and so many other things, but brought chair dancing to the kids and it is one of everyone’s favorite parts of the day. We just rock out and get our hearts pumping and no one has to worry about tripping or falling. I love it.  After dancing, we go to activities in the morning. We have activities in the morning and afternoon. They are traditional camp activities. We do boating and swimming archery! Wall climbing, zip-lining, and fishing. It’s just so fun. And it’s a camp that is designed for disabilities. So everything is adaptive. Their attitude and our attitude is, if you want to do it, we will figure it out. We will find a way to get you to do anything under the sun. 

Chris: I think that’s so cool. All the activities you offer and I can only imagine, you must have some of the attendees very hesitant to try some of these new things, right? They’ve never done them and maybe in their mind they’re thinking, I don’t think I can do this. So it’s gotta be such a cool feeling to see them participate.

Jonah:  When we are there we ask, “What do you want to do?” We’re never saying, “you can’t, you shouldn’t, you need to do this activity instead of that activity.” We’re saying, “What do you want to do?” If a kid wants to get up to the top of the climbing wall, we’re gonna get that kid to the top of the climbing wall. If it takes three people climbing around them and helping them, they’re gonna get up there. I think that’s different from what they experience in typical days of their lives. 

Jeana Sweeney, Jonah and Laurel Richardson

We do lunch. We have rest time after lunch where no one rests, but we all hang out and talk. I think honestly, my favorite activity at Camp Footprint is sitting around and talking to the kids, and the other counselors. It’s as important a part of our day as any other part of our day because the whole goal here is connection.  Tapping into the understanding, you get from these other people. So we don’t want you just running around the whole time doing activities. We want you balanced between running around doing activities and sitting there and just talking or listening as other people say. Things that sound like they’ve come directly from your own experience. 

We swim in the afternoon, which is so much fun. Then we do dinner, and then we do an evening activity every night. The evening activities are always a blast. We have a dance, we have a talent show. Usually, at one point or another, we do a campfire the first night of camp where I do a drumming circle with everyone and we sing and it’s just wonderful.

It’s funny as a camp director and as someone who’s done triathlons and climbed mountains and done all these big things, I tend to get an inflated sense of ego from time to time. My wife will tell you. But then you hang out with these kids who are facing some unbelievable challenges in the most graceful of ways, and I’m reminded of humility every year at camp, I am reminded of the absolute vital value and importance.

Connection to others, not just of your own tribe, but of each other. I think the biggest gift that CMT gives us and that Camp Footprint gives the kids is the reminder that we need each other. We can’t really function, especially happily unless we’re together. We were designed to be in a community, and that’s why camp is my favorite place in the world and that is why almost every kid and counselor who comes to Camp Footprint goes home thinking the same exact thing. It’s a yearly reminder for me to keep on going even though I appear to be pretty confident with my disability.

My disability causes me a lot of internal struggle and I am aware that people are looking at me all the time and I am self-conscious as a result of my disability. Whether I show it on the outside or not, I am. Camp is a reminder that you’re great the way you are. 

Elizabeth: There are times I have an internal struggle. Do you bring your struggles to camp and talk about it?

Jonah: Yeah, I am completely honest with the kids and counselors.

Anyone at Camp Footprint will tell you. They know me inside and out. There’s no holding back. At that point, the kids, for the most part, are so mature. They just get it because they deal with struggles. They don’t have the luxury of ignorance. They have to be engaged. And as a result, we get some pretty amazing kids.

Jeana, for example, while she’s amazing, is an example of adults being children locked in adult bodies. So not all adults are mature. That’s why Jeana and I get along so well, but everyone’s on the same level. At Camp Footprint,there’s no separation between admin and counselors and campers. CMT cuts through all of it and we all function on the exact same plane, and I think, as a result, it’s just easier to develop a connection that way. 

Chris: Jonah, do you have an experience at Camp Footprint that you can remember where you feel like you really influenced one of the campers, or maybe they were struggling with something?

Jonah: There are two that come to mind. There’s a chapter in my book, Elizabeth, it’s called The Golden Pine Cone, which is kind of my wife and I’s love story basically. Let’s just say it has to do with the Golden Pine Cone, but one year earlier, at camp, we got back from Lake Day, we got back and there’s some downtime where we’re all sitting on blankets on the field and I happened to sit down with a group of about 10 kids. I don’t know why, but somehow the Golden Pinecone story came up. So I told the whole story and now it’s a tradition. Every year on Wednesday afternoon, I find a new group of kids.

I sat down and told them the Golden Pine Cone story. 

So far it’s been going over well. That’s an example of sharing my 50-year-old wisdom with these kids any chance I get in any creative way that I can model for them. That no matter what your circumstances, you don’t stop. You keep on going. 

The one story that sticks out in my mind is there was a camper who was pretty shy and didn’t want to be in front of others but made it clear that she loved to sing. But she was terrified of singing in front of other people. That year, on Wednesday night at the Night Swim, I think it actually was Jeana who encouraged this kid to come to the edge of the pool and got everyone to be quiet.  I was in the pool at the time playing ball with the kids and everyone was quiet. Everyone came over to that side of the pool and this kid sang her song. Wow. An entire song for the camp, and her voice was shaking like nothing you’ve ever heard. She was scared to death, but she was doing it. And the applause that erupted when she was done with her song was the most magical thing I’ve ever seen. I’ll never forget it. Hannah Roberts and I looked at each other and we had tears in our eyes. Unbelievable moment because that’s it, it’s an illustration of what Footprint’s all about. It’s like whatever it is, that’s your mountain to climb. If you climb it during camp, you’re gonna have a lot of people cheering you on. That was kind of a shiny example of that. And you could see this kid just growing. Infinitely in that one moment, and I see that about a hundred times a day. It’s pretty cool. 

Elizabeth: I can’t thank you enough for doing what you do. I was skeptical at first of camp when the idea came up, and I told you that many times and throughout the years the feedback has been phenomenal. 

So tell me, we have Camp Footprint, but we have other youth programs, so I get confused about Youth Council and Compass and what are we doing at the CMT with all these programs.

Jonah: So my kind of focus in the first few years was to establish infrastructure within the youth program. That was the first big step to that was the youth council. The youth council and a lot of the ideas for the youth program came from one of the youth council members who is about to age out of it in three weeks. But Erin Black came to me one day and she said,”The youth at the CMTA don’t have enough of a voice. We don’t have a seat at the table.” And I said that’s something that ought to be fixed and is fixable. Because I knew that the adults at the CMTA were heart filled. Like you just have to push and so we did. 

The youth councils are a group of kids who show themselves to be organized, passionate, and dynamic. Natural leaders.We gather them, we use them as a kind of a youth board of directors to bounce ideas off of. We develop fundraisers, develop programming. A lot of my ideas throughout the year, I’ll bounce off of them because they are the ones representing the very kids who are going to be benefiting hopefully from those ideas. I get a lot of my ideas from the youth council and then I go run with them as things I institute into the youth program. So it’s an invaluable group of kids. We meet once a month. They’re on committees. They have a fundraising committee, a special projects committee, and a social media committee. They do unbelievable work and it’s all voluntary.  Navigating the world of CMT or life with CMT with other young adults. 

Elizabeth: I just wanted you to say a word or two about Compass. What are the age groups for that? 

Jonah:  Compass is our newest program for 19 to 29 or 30 years old. The youth program is primarily for 10 to 18-year-olds. I believe the CMTA should be supporting someone from birth to death and everything in between. We do a ton of that already, but there are some holes in our system just because it hasn’t been done yet. So we’re filling those in.

I have a lot of ideas. They have to be futuristic but for the whole infant, toddler, and young kids. phases. We connect parents as an organization, but there’s just even more that I would love to develop around that. Once a kid is 10, they can come to Camp Footprint. They’re involved in programming for the youth program. When they turn eighteen or nineteen, that’s when they start evolving into being young adults and applying for colleges and needing to keep accommodations in mind and dating and sexuality and all of these things. We decided that was the next step in the process. So we created Compass. 

It is a monthly meeting online to start with that covers a different topic each month. They’ve done a month on symptoms and what you use to help you. They’ve got a list of unbelievable topics, including accommodations at college, dating, and sexuality. Who better to talk to than other young adults in your position? And young adults especially are a group that was overlooked because I think the branch system that we have developed over many years, tends to run in older adults. So younger adults don’t often flock to that model. It’s not their jam. We wanted to create a jam that was just for them. My huge belief is that I can help to plan it, but I don’t run it. I’ve got Julia Beron who was on your show. Katerina Ballsmith and they are two young adults with CMT who are running this program with my support and help. I want young adults to show up and be served by young adults. The youth movement’s slogan is Youth Empowering Youth. Not a 50-year-old empowering youth. It’s empowering youth. 

Chris: So, Jonah, if someone in our audience with CMT, a youth, et cetera, how would they go about learning more about these opportunities to participate in these programs? Would they reach out to you directly? Do they go to the website? What’s the information you can share with the community? 

Jonah: They can do one or the other. So my information, I’m hoping you’ll spread it far and wide, is Jonah@cmtausa.org. People can contact me any time of day. The best way to get all the information under the sun in one place is our website, which is CMTAUSA.ORG 

Chris: What would you like to leave our listeners with or what advice would you love to give our listeners as we close?

Jonah:  I’ve got a small one and a big one. The small one is, and again, it’s biased because I work for the CMTA and I’m paid by the CMTA, but I also see frontline what the CMTA does and accomplishes, and I’ve never been a part of an organization that does it better. I just never have. And so, the small one you can do is keep supporting and that could be financial.  It can also be participating in things. It can also be a connection or volunteering, as there are so many ways to support this organization.I’m here to tell you all from the front lines. This organization is worth every minute of your energy and effort and every penny you donate. It’s beautiful because not every organization I’ve worked for I could say that about, but I can about the CMTA. 

I guess the bigger one I would say comes directly from my exposure to the youth of the CMTA and my work. Don’t ever believe that the world is a bad place. Yes, the world is going through a lot of issues and we have a world of work to do in our culture and on the way we prioritize and treat each other. But the same thing from the front lines. If you are lucky enough to do the work that I do, you see this side of humanity, this beauty, this strength, man, that same thing as I said about parenting and marriage. We have a lot of challenges on our plate as a community, as a larger world community, but it’s worth the effort. You gotta keep doing the work because the golden moments are still very much alive and there’s nothing but hope in the future as long as you’re willing to stay focused. 

Guest Blogger: Kenneth B Raymond Tackles the Question – How Do You Explain CMT?

Eleven years ago, late CMTUS founder, Gretchen Glick and I talked about starting the first ever CMT Awareness Week. The 2 organizations (CMTA and CMTUS) worked collaboratively to get the word out about CMT. At the CMTA, I had posters created, wrote email blasts, and asked our branch leaders to spread awareness through groups across the country.

This first CMT awareness week was so successful, that the following year, we dedicated an entire month to CMT awareness, and somehow, Gretchen got American radio host, Shadoe Stevens, to do a PSA about CMT. Listen to this 29-second clip from 2012:

Eleven years later, it is still hard to explain CMT. I read Kenny Raymond’s latest blog post where he addressed this issue, and he brilliantly defines some of the challenges of explaining what CMT is. Thanks, Kenny B. Raymond for putting your thoughts on paper for reflection. How do you explain CMT? Before you answer, read Kenny’s article and then, come up with your elevator speech and share it in the comments. I’d love to hear your ideas!

Kenny Raymond at Cycle 4 CMT, VT

We All Know the Drill

Exploring the Burgeoning Question: “What is CMT?”

by Kenneth Raymond

“Why are you wearing shin guards? You play soccer?”

“What’s wrong with your hands?”

“What’s wrong with your legs?”

Etc., Etc., Etc.

We all know the drill. The answer to the seemingly never-ending questions involves those three lovely letters, C-M-T. And then, the proverbial follow-up, whether it’s a random person in public or even a healthcare provider, requires us to dig deep in hopes of giving them a straight-to-the-point answer that’ll leave them knowing just enough about our disease to remember the name should they hear it again, all the while hoping we give them enough information to know it’s not a tooth disease and that it has nothing to do with sharks.

What is CMT?

“What is CMT?” I’m always trying to improve on how I answer this question. I can easily rattle off some quick factoids, such as CMT is a heterogeneous group of inheritable peripheral polyneuropathies whose name comes from the three doctors who first described it in 1886: Drs. Charcot, Marie, and Tooth; and this name, CMT, has since become an umbrella term that refers to many different inheritable sensory and/or motor neuropathies. Quick and to the point, right? This doesn’t say much about what the disease is though.

Medically, CMT is a genetically caused neuromuscular disease—neuro because peripheral nerve, muscular because the disease in the peripheral nerves causes symptoms in muscles. Genetically caused because each subtype is caused by a mutation in any one of many different genes.

Medically, CMT is an inheritable multisystem neuromuscular peripheral polyneuropathy. Inheritable because each of the genetic mutations that cause CMT are inheritable. Peripheral because CMT is a disease of the peripheral nerves. Polyneuropathy because CMT affects more than one peripheral nerve at a time (poly), as opposed to only one peripheral nerve (mononeuropathy). Neuropathy because peripheral nerve disease. Then, multisystem because CMT can affect hearing, vision, breathing, genitourinary, and much more, in addition to feet/legs/hands.

Statistically, CMT is the most commonly inherited neuromuscular disease nobody has ever heard of. This one is a weird dichotomy unto itself. CMT is a rare disease by every statistical and modeling measure. At the same time, when it comes to inheritable neuromuscular diseases, in totality, CMT is the most commonly inherited. In this context, common and rare can peacefully coexist even if it seems like they shouldn’t.

These above are just a select few examples of how CMT can be described. All of these descriptions are fine and dandy, but not only are these difficult to remember, firing off any of them to Jane Q. Public tends to render confusion about a disease they’ve never heard of. Is there a viable solution—a grand unifying answer, so to speak?

The Elevator Speech

I’m often asked to give my “45-second elevator speech” on what CMT is. My response typically hits several talking points and is usually along the lines of “CMT stands for Charcot-Marie-Tooth disease and is a rare inheritable neuromuscular peripheral neuropathy named after the three doctors who first described it more than 130 years ago. Although rare by definition, affecting only 1 in every 2,500 people, and totaling about 3 million people worldwide, CMT is the most commonly inherited peripheral nervous system disease. CMT causes the peripheral nerves to stop working correctly; and this leads to muscle weakness and atrophy, joint changes, difficulty with walking, and hand issues. Some who have CMT have breathing issues, hearing impairment, vision problems, bladder issues, and GI issues. The disease progressively worsens over one’s lifetime, there is currently no treatment, the disease can’t be cured, and it affects everybody very differently from one another.” Sometimes, people will ask follow-up questions. Other times, we part ways with only a, “whoa,” and maybe they’ll recognize the name the next time they hear it.

My “elevator speech” has been a go-to for many years, having evolved only slightly since my initial CMT diagnosis. It’s very easy for me to throw it out there anytime I’m asked. Does it say enough about what CMT is as a whole that it could be adopted by anybody who needs a quick go-to description? Until a week ago, I thought it did and I thought it could. What changed?

Bicyclists as a Catalyst

Kate Lair and Kenny Raymond

For the first time, I attended the Charcot-Marie-Tooth Association’s Cycle 4 CMT fundraising event held annually the last weekend of August in Charlotte, Vermont. This event is huge and people from all over the place, not just locals, attend and/or participate. I met and spoke with many CMTers. Some CMTers were cycling participants riding a treacherous 40-mile course through the western Vermont mountains even though there were shorter less-challenging routes. Some CMTers were there to participate in non-cycling activities. Some were event volunteers. Some were parents who do not have CMT, but their child does (or children do). Some were members of the CMTA leadership and social media teams.

Some of the CMTers at Cycle 4 CMT used wheelchairs, canes, walkers, etc. Some CMTers wore leg braces. Some CMTers had breathing issues. Some CMTers had severely twisted and deformed feet. Some CMTers had hearing loss. Some CMTers had speech impairment. Some CMTers had <fill in the blank>. I’m confident there were many hidden symptoms that went unmentioned and unnoticed. Without a doubt, it was the most diverse single-source representation of what CMT is that I have experienced in-person. As I spoke with CMTers and as I looked around, it became apparent that my go-to elevator speech is grossly inadequate and under-represents what CMT is.

It’s well established that CMT can and does affect everybody differently, and even within the same family. CMT can cause many things. Not everybody who has CMT will experience all symptoms of CMT. The mix of symptoms, the severity of individual symptoms, the rate of disease progression, and the overall disease severity can be quite different for every CMTer. What one CMTer experiences cannot be used to gauge or to predict what the disease will be for the next CMTer, regardless of subtype. It’s one thing for me to read it, and another for me to witness these concepts firsthand.

Is There a Solution for the Question?

What is CMT? The answer to that question, as it turns out, is quite different for every CMTer. My CMT is different than somebody else’s CMT. CMT, for me, looks quite different than does CMT for another. CMT, for me, is twisted, contorted, crooked feet that have led to tendons tearing requiring corrective reconstruction surgery of my right foot (and upcoming surgery for my left foot). CMT, for me, is weakened hands that easily cramp, a knee that used to dislocate before corrective surgery, bilateral hearing loss, unrelenting fatigue, chronic whole-body pain, progressively weakening upper leg muscles, spine changes (kyphoscoliosis), premature degenerative joint changes, speech/vocal difficulties, and for me, CMT is breathing issues. For another CMTer, CMT is wheelchair dependency, is an inability to hold and use a pen or pencil, is 24/7 mechanical ventilation via tracheostomy, and is total deafness. Yet, for another, CMT is none of these things, or a is a combination of these.

What is CMT? True to CMT, there isn’t a one-size-fits-all answer. The answer to the proverbial question is unique to the CMTer who is asked. The answer is even unique to the healthcare provider and to the scientific investigator. There are wrong answers to the question, such as a suggestion that CMT is an autoimmune disease. While CMT might share symptoms with some autoimmune diseases, such as Multiple Sclerosis (MS) and Chronic Inflammatory Demyelinating Polyneuropathy (CIDP) for example, CMT is decidedly not an autoimmune disease. Nonetheless, the answer to the burgeoning question is dependent on what CMT looks like for the one who’s giving the answer.

If you were to line up ten random CMTers—somebody who has CMT or somebody whose loved one has CMT, and ask each, “what is CMT?” each of the ten answers are likely going to be very different from one another. The differences are not born of inaccuracy or of a misunderstanding of their disease. The differences instead come from how differently CMT looks for each individual and from how each person individually experiences CMT.

What is CMT? For me, CMT is a cruel and often debilitating neuromuscular disease that looks very different from person-to-person. For me, what was once an easy answer to a complex question, or what was a complex answer to an easy question, has become exponentially more difficult to answer. As a CMTer, it’s easy to answer the question by simply describing what CMT looks like for me. As an advocate, however, I’ve learned my “45-second elevator speech,” while it gives a lot of information, is a disservice to the CMT community as a whole. The solution? I resolve to do better. I have to do better. I will do better.

About the Author

Kenneth Raymond was first diagnosed clinically with CMT1 in late 2002, at the age of 29. He was genetically confirmed to have CMT1A a year later. Kenneth has since devoted his life to studying, researching, and learning all things CMT, with an emphasis on the genetics of CMT as they relate to everyday CMTers. As a member of the Charcot-Marie-Tooth Association’s Advisory Board, Kenneth serves as a CMT genetics expert, a CMT-related respiratory impairment expert, and as a CMT advocate who is committed to raising CMT awareness through fact-based information rooted in the latest understandings of CMT. Kenneth has just published,

Charcot-Marie-Tooth Disease Gene and Subtype Discovery: The Complete Bibliography – Fall 2022 Release: A Desk Reference for the Everyday CMTer, the Practicing Clinician, and the CMT Researcher Paperback which is available on Amazon. Kenny also has an excellent website and blog to check out: expertsincmt.com

Kenneth Raymond is an administrator of several Facebook groups. He helps people with their CMT questions, especially those related to breathing and genetics. The CMTA is fortunate to have such a well-versed, well-educated Advisory Board member willing to work tirelessly for the CMTA community!

Dr. Glenn Pfeffer Answers All Your Questions About CMT foot surgery

dR pFEFFER WITH BONSAI
Dr. Glenn Pfeffer: Orthopedic Surgeon at Cedars-Sinai

The CMTA hosted a very informative talk on Zoom in September, 2020 to the CMT community featuring well-known orthopedic surgeon, Dr. Glenn Pfeffer. I’ve transcribed this talk for you! Enjoy!

Elizabeth Ouellette: Welcome Dr. Glenn Pfeffer.  Dr. Pfeffer is the Director of the Foot and Ankle Surgical Program at Cedars-Sinai in Los Angeles.

I can’t tell you how much I appreciate and admire Dr. Pfeffer. He spends all his time with people with CMT. He wants to better their lives. He wants to see people walk.  He has devoted so much time and energy to the CMT community. I am just so honored to have him here as a doctor, my son’s surgeon, as a friend and as a colleague. So welcome, Dr. Pfeffer, and thank you for coming on. 

Dr. Pfeffer: Well, thanks for having me, and I’m surprised so many people came on a Saturday! 

Elizabeth: First, I’d like to get to know Dr. Pfeffer a little bit more. And when I was doing some research on him, I saw that he did magic.  I’m like, what surgeon does magic? 

Dr. Pfeffer: Actually, magic is important to me. I did this through high school, college and medical school. I actually performed in nightclubs.  I spent the summer in Nantucket at the Rose and Crown as their magician.  And whatever it is that attracted me and still attracts me to magic, is the exact same feeling I get two weeks after surgery when a CMT patient is sitting in the office.  Your foot’s going to be a little bloody.  You’re going to have some sutures to take out, and we open up the cast, and you’ll see some pictures of this, and I hold their foot and I say, “Take a look here, your foot.”  And it’s a new foot. It’s a foot they haven’t seen, perhaps ever, and the look on their face is identical to the look on people’s faces when you do a magic trick for them.

So whatever that is that attracts me is why I continue with magic. Magic is very simple you know. You can do things like this where you can take something and have it disappear. You can make it a little more complicated, which I do in the office for kids.  You just take the same little piece of foam or whatever, and you just put it into this hand and you can just show people that it’s empty.  So that’s sleight of hand, which of course is great for the magician. I still do this at orthopedic parties.  But not to belabor it, if I were going to do this I wanted this to have the same absolutely startling response that people have with CMT when they see their new foot. 

Elizabeth: Your father was a surgeon?

Dr. Pfeffer: He was a general surgeon.

Elizabeth: Oh and so is that what inspired you to be a surgeon?

Dr. Pfeffer: Yes, absolutely –  I don’t think I’d ever have even gone into medicine if not from my dad’s influence.  You know like all of us, I’m a mix of my dad’s DNA and my mom’s and they were very different people.  But dad really inspired me with his surgery, and he was hard-working and I think it was my destiny.  I probably have very little free choice in life.  He didn’t make me but in terms of who I was, it was sort of my destiny, like the Jedi.

Elizabeth: You horseback ride or you did in the past.  You scuba dive, you dance, you create bonsai, and I read somewhere you made a correlation between bonsai trees and surgery.  Could you tell us a little bit more about that? 

Dr. Pfeffer: I’ve always been interested in bonsai which are, you know, plants; they’re trees, and you keep them miniature by trimming their leaves, by trimming their roots, and you keep them in small pots.  Everyone knows what they are, and what you do to shape them is you wire the branches and you hold them down so they look like a tree.  And I realized only a year ago that what I’m doing with bonsai is identical to what I’m doing with CMT feet. I was sitting there in surgery and we were wiring a foot down and putting screw into it, and somebody who knew about bonsai said, “You know, Glenn, that’s exactly what you’re doing with bonsai.”  And it was startling to me. You would think it would be obvious but it wasn’t.

As you may know I’ve got my own foot problem.

Elizabeth: I was just about to ask you; when you told me you had foot issues, I’m like, “He gets it.He knows what it is like to have a foot problem, and I think that’s a bonus for your patients.”

Dr. Pfeffer: Well I was just going to say, though, that’s how I got into horseback riding.  Because I’m athletic by nature, but I couldn’t run.  You know, I didn’t know what I had. It’s very poignant for me, the CMT world, because patient after patient, everyone who’s listening knows this, everyone, unless you had a mother or father who had CMT, you grew up not quite knowing what was wrong with you, right? And I didn’t either.  I didn’t know I had a problem with my foot for 40 years. It sounds dumb, right?  But if someone’s out there with CMT and no one told them they had CMT for 40 years, and they just thought they walked funny and they couldn’t keep up, and they were a little unbalanced, nobody would know. So I took up horseback riding because I could do what I wanted to do. I could fly through the air and jump, and I’m sure all the people listening have modified their lives in way so that they can function with their CMT.

Elizabeth: I think you can really relate to people with CMT and understand foot issues and the inability to do certain things. 

Dr. Pfeffer: Well there’s no question, you know I don’t like to talk about it too much because you don’t want to get a little corny on a Zoom chat with all these people, but yes, I 100 percent relate to what people are going through. I’m not in a wheelchair.  I don’t have problems breathing. My hands are strong.  But for the isolation that somebody feels, the difference that somebody feels growing up with CMT, that is exactly what I felt for sure, and I don’t know that you can teach somebody that.  I’m not sure you can really learn it, but it’s just in my soul.  I’m not as bad off as most of the people with CMT at all but that’s why I get it, you know, that’s why I think it’s probably why I was attracted to all this. 

Elizabeth: So why don’t we start your presentation, I think you are a fascinating person, and I know you’re an expert surgeon and the best of the best.  And you’re also a great presenter, so I’m sure people want to hear what you do every single day.

Dr. Pfeffer: I want to just show you my world of CMT, and I have a certain kind of person that comes to me, right?  Somebody who was unfortunately paralyzed in a wheelchair would not be getting to my office, so I do understand that I’m seeing a segment of the CMT population.  But this is my world and what I go through every single day. At this point I’m confident that we at Cedars are operating on more CMT patients than anywhere else in the United States and we have a plethora of experience with it. 

We’re lucky enough to have a large CMT program at Cedars with some of the most famous CMT neurologists on the face of the planet, such as Rich Lewis and Bob Baloh, and with amazing geneticists. If you have an issue, you can come to see the program. You’ll see a lot of people. Instagram is as alien to me as, you know, speaking Russian or French and yet it’s been a tremendous success for me and the people who follow it. I mean, my gosh, I didn’t even understand that at one point I had two people following it. Now we have close to 1400 people across the world, and I communicate with them all. It’s sad when someone from Ethiopia says “How can I come and have surgery?”, and of course the chance of them having surgery is almost zero for financial and travel reasons.

I encourage you to follow me on Instagram: #CharcotMarieToothSurgery

The foot has 20 muscles.

The foot’s complicated, right?  It’s got a lot of muscles in it.  There are 20 muscles in the foot, more than there is in the entire leg. 

The tibialis anterior lifts the foot.

The tibialis anterior muscle is the strongest dorsiflexor (muscle lifting foot up toward the shin) and helps to lift the foot from the ground. The Tibialis Anterior Muscle also facilitates flexion of the foot upwards and extension of the toes. The Tibialis Anterior Muscle originates from the outer surface of the tibia and inserts into the first metatarsal bone in the foot which is located behind the big toe. 

Extensor digitorum longus muscle - Wikipedia
Toe extensors

Above are the toe extensors. These are what lift up your toes, and interestingly with CMT, if the tibialis anterior that lifts your ankle gets weak, these toe extensors will start working harder, which is why so many of you will have a toe deformity. As the Tibialis Anterior muscle gradually weakens and the foot drops down, a contracture of the Achilles will occur because the tendon is no longer being stretched out during gait. The worse the contracture, the harder it is for the weakened Tibialis Anterior to lift (dorsiflex) the ankle. 

Achilles Tendinitis For Runners
The Achilles tendon tightens with CMT
Peroneus brevis - Wikipedia
Peroneus Brevis

Above is an image of the Peroneus Brevis, one of the key muscles that weakens in CMT.  Why it happens exactly is still unknown, but this muscle, when it weakens, destabilizes the ankle and the foot starts to turn in, because this muscle is weak.  And the other reason the foot starts to turn in so commonly is because this muscle in the right foot, looking from behind, stays strong.

So one weak muscle, and one strong muscle causes the foot to start to deform.

So let’s talk about that what causes the CMT deformity. I’m talking about this common cavovarus  (very high-arch) foot.  This is what happens every millisecond in our body. Muscles are pulling back and forth but keeping us balanced, right? With CMT, because of the paralysis that’s uneven, involving some muscles but no other muscles, they become weak.  There is CMT. Some muscles are powerfully strong, and others are weak and that causes a deformity.  It’s called a cavovarus, and you can really see it on this right foot. 

cavovarus foot

If you took your hand, put it in your pocket and left it there for a year. Not only will you not be able to move it, you’ll probably never be able to open it up again because all of the soft tissue contracts. And that’s what you don’t want to have happen.  If there’s one message I can give you, don’t let that happen. 

The minority of patients I think benefit from surgery with CMT: Most patients do not need surgery.

The person below is wearing ground reaction force braces. This type of brace, made from carbon fiber or plastic actually bends and stores energy.

So when you have no function in the leg and the Achilles tendon isn’t working, these braces are just terrific.  This person could walk a hundred miles if they had to because their foot’s flat on the ground and they’re doing great. Now, here are all the types of braces there are. Some are off the shelf.  Some are custom made. Which is better than the other?  I don’t know.

 I absolutely think chocolate ice cream is the best. Does anyone disagree?  Some people like strawberry or maybe vanilla, and the problem with the braces is you can’t try them all on unless you go to a spectacular brace shop, which I’m lucky enough to work with at our Center of
Excellence.  Would anybody say that a size six dress of a certain brand is perfect for you?  Of course not. You’d want to at least get it in the mail, try it on and send it back.  That’s what you have to be able to do with braces. Unfortunately, we can’t try all these braces and some of them cost thousands of dollars, so try to go to a brace shop that has a wide selection to let you try some of them off the shelf.

Now that is not the right brace for a for this crooked foot.  Some of you have it. I see this situation every day of the week.  Would anyone put a foot like this into a brace?  It’s like putting a square peg into a round hole.  This is from Friday.

This brace does not work for a crooked foot.

 I was a little delayed today getting my talk all set because this gal just came in. She lives on a ranch.  That’s the shape of her foot. That’s the shape of her brace.  Shame on everyone taking care of her.  Shame on her brace maker. She has pain walking on the side of her foot in a brace that looks like it’s something to a caged up an animal.  That foot should never be allowed to walk the face of the Earth.  That can be made flat, and even if this woman can’t get out of her brace, she can get into a brace with her foot balanced and her body weight plumb lined with no pressure walking on the side of the foot.

I can’t see you all, but how many of you have had or have a callus on the side of your foot?  Right. That’s what happens. So these people should all have surgery, that’s how I feel. Now some people don’t want to wear a brace. 

This is Katie’s Story

“Hi, my name is Katie. I live in Florida and I have CMT. Katie didn’t want to wear a brace. It was in sixth grade when I first started getting made fun of for the way that I walked and noticed that running and keeping up with my friends was becoming more difficult for me, and my parents started taking me to some doctors to try to find out what I could do to help me with my CMT.  With each doctor that I met with, I felt like they didn’t understand my specific case of CMT.  And they gave me some options, like braces and orthotics, and some of them would help me temporarily but nothing ever really helped me. So when I was in high school, I started falling almost regularly, and I missed out on my homecoming and my prom and just gave up on trying to find shoes that fit and started to become really discouraged.”

So Katie was a young woman, and she didn’t want to wear braces. She could have actually been in a brace.  So she came from Florida. She said, “I don’t want to wear braces the rest of my life.”  So I said okay and she had some muscles that were working.  We operated on one foot, and she was incredibly brave and so we operated on the other. Katie could hardly walk without a brace without holding onto a wall.

Many of you know that kind of person.  So the CMT type foot deformity is a tricky surgery. That’s the problem, right?  People have had a lot of issues with it.  There’s so many components to CMT surgery.  The surgeries will take at least three to four and a half hours. There’s no way to get through it quickly.  Basically, the failure of CMT surgery is when we don’t do enough.

So this is what we put on the operative board at Cedars-Sinai.  We put all the procedures someone’s going to have. “Hi, we’re going to fuse a part of your toe joint,” you’d say to a patient, “Okay, let’s schedule you for surgery.  Hi, we’re going to do a tendon transfer on you. Okay let’s schedule you for surgery.” But the tendon transfers are some of the most complicated and extensive surgeries that there is in all of orthopedics except for some spine surgery or hip surgeries with dislocations and acetabular malformations.

Many surgeries in one – CMT foot surgery

Now how do we know what to do? Well, the problem is there is no good consensus on what to do. At least there hasn’t been, but we’ve done a lot of studies on this at Cedars and much thanks to the CMTA for their help.

This was a study we did. It was published in 2018. It was sponsored by the Charcot- Marie-Tooth Association (CMTA) and this was really incredible for us because we won a prize for this operation telling us how to correct the heel varus.  And we won a prize for this as one of three research studies of the year most likely to change orthopedics. I just happened to have it here.

We took a print of one of my patient’s foot – Sarah. And we printed out 18 “Sarah’s”, 18 of these and then we studied them with different operations in the lab, but very exactly, and we showed which was actually the best operations for correcting heel deformities in CMT patients with her type of problem.  Since then we’ve done other research more on heal osteotomies.  We’ve looked at extensor transfers  The most difficult, competitive organization in the world and the most academic is the orthopedic research society.  And Max, who’s going to be joining us, he’s the second author, won a prize here just this past spring for a young investigator’s prize. I mean this is like winning a Nobel Prize in orthopedics and I was actually stunned by it.  But part of the reason is because the whole area of CMT surgery is so poorly investigated, it’s not that hard to do some landmark work if you do the research. 

Now there’s a big hole on how you should do CMT surgery and how it ends up in people and how do people do it. We’re just starting now.  Some of you I’ve operated on. I always say I’m a pretty accessible guy and I don’t hear about too many people doing poorly. I know the ones I’ve had to re-operate on.  I just spoke to a woman this morning where a young girl in New York is not having the motor strength that she needs. So I think I have a sense of it, but we’re going to study it and hopefully publish that by the end of the year. 

So this was a remarkable thing – years in the planning. There were seven past presidents of the American Orthopedic Foot National Society and some of the most famous foot and ankle surgeons on the face of the planet, and with the sponsor of the CMTA sponsorship and Elizabeth’s fire in her belly. we brought these people together.  And it almost killed me, literally, but we finally published a paper on our results, which just came out, and this is a consensus. We didn’t get everyone to agree, but I think just to sum it up here, this is accessible. You can get it through the CMTA and other places and if you’re going to have surgery locally in your area if you can’t come to Los Angeles for some reason, give this to your surgeon and say, listen I’m sure you know all about this but would you mind taking a look at this paper. And if they haven’t seen it they’ll be grateful to have it.  https://www.cmtausa.org/news/breakthrough-guide-to-orthopedic-surgery-for-cmt/

Chicago Think Tank

Consensus Paper – Can be found on CMTA website: https://www.cmtausa.org/news/breakthrough-guide-to-orthopedic-surgery-for-cmt/

  The goal of surgery is to give you a flat foot, and to balance your foot.  My goal is to keep you out of a brace if I can, and I usually can if I’m willing to operate on you.  It doesn’t always work that way, and if we can’t get you out of a brace, at least we’ll get you into a smaller brace.  Much better to wear just a small piece of plastic than some of these bigger, bulky braces.  So what do we do? We transfer tendons, which is moving muscle.  We move strong muscles that are deforming the foot to weaker muscles which are letting the foot become deformed.  We cut through the bone. Here you can see a bone. This is a right heel we’re looking at.

 We take a wedge out of the bone. We twist the heel around.  Here you can see it. So this is the heel from behind on the right side. You can see what we do. We take a wedge out and then we just simply shift the heel.

Okay, now who can you trust to do surgery?  I hear there’s a lot of talk about me in chat rooms and stuff. I said, is there anything I ask my patients they don’t like.  One person said, well you kept them waiting a lot, and another person apparently said, well, I just didn’t like him, but I guess he’s a good surgeon.  But look out there. I don’t hear anybody saying about me, anyway, oh he sold me a bill of goods. He said I’d be good but I’m not. I just do not hear it.  And if you do, tell Elizabeth and she’ll tell me because I want to hear about the failures I’ve had.  I know the failures. I know why they’ve occurred but most of them have just been in the hands of God.  Find someone who does at least one CMT surgery a month.

Find someone you trust


That’s a fair number of CMT surgeries to do. Most very experienced, busy surgeons will be doing three CMT surgeries, maybe two a year. But if you can find people around the country. that’s a good thing. 

When should you do your surgery?  Do it as soon as you know that you or your child can’t live with their foot the rest of your life.  The sooner the better. Dr. K, my partner, because I don’t operate on people really under the age of nine, he just operated on a four-year-old yesterday from Utah, both feet. All these people are the perfect age for me to be doing surgery.  You know, 10, 11, 15, 16, but you can do it anytime. It just gets harder because things get stiffer the older you are. So every day, because of Instagram, I chat with people.  Some people are from Eastern Europe. Some people are from United States, and I have met most of them.  I guarantee you I will make you better. I don’t know how much better.  I’m not 100% sure I’ll keep you out of a brace, but I tell people you’re about a C-. I’ll at least get him to a B +. All right. So all I need is one strong muscle.

All I need is that muscle to move.  That’s it.  I just need any muscle. Is there risk? Of course. 

CMT Foot

The biggest reason surgery fails are that not enough was done. To do 18 surgeries at one time is a lot.  T

 

Sarah was one of the most amazing. You may have seen her. She was 16.  She couldn’t walk. We operated on one foot.  All she said she wanted to do was walk down the high school aisle without having to hold on to her father.  I called her years later.  I said, “How are you doing? What’s going on with you?”  And she said, Dr. Pfeffer, you don’t understand.” She said, “I just walked 10 kilometers around London with my boyfriend in cute shoes.”  So that’s a magic trick all right.  This gal, she said, “I don’t want to wear braces. I’ve had surgery.  I’m going to be the first woman President of the United States.  I’m going off to college.”

There she is.  I mean, I can’t do that.  Could she? She texted me a while ago. She goes, “After five or six hours of walking around campus, I need a little co-op brace. You know, ones that go into your laces because I get tired at the end of the day and sometimes need a little bit of help.” That’s better than I ever thought. 

Q & A

I’m wondering how you deal with toes.  Yeah it’s a great question.   Very succinctly, toes  are among the most difficult, actually, of  surgery to do  and the the longer people wait, the worse off they are. I can  still  fix the rest of the foot, but the toes  become more and more problematic  and  there’s no easy answer for that.  Sometimes as simple as just  transferring the tendons. Sometimes we just cut the  flexor tendons but I don’t like to do  that in someone who has a motor disease.  And what I’ve been doing lately with  severe problems is we actually have been  fusing these joints. It’s okay because  the joints are useless. It’s not doing  anything for anyone except getting in  the way.  So we fuse the joints and leave the  tendons alone  and and we can have some beautiful  results with that. The problem is  it’s a lot of surgery. That, in and of  itself, that operation could take an hour,  hour and a half. To add that onto a four  hour operation …  someone like the boy I’m operating on on  Monday who has all that  may have to come back, he may for the  toe operation.

I had foot surgery, now my knee and hips  are not aligned with my feet and I am having gait problems as well as some knee and hip issues. I’m wondering  if that is because she waited too long and  the CMT foot made her walk differently  or do you do gait analysis beforehand?  Have you heard of these problems?    Someone has foot surgery. They get  deconditioned and the hip muscles which  are vulnerable to begin with, and the  knee muscles  get weaker, right? So they just get  deconditioned. I know of one person in my  career from Santa Barbara,  and she had foot surgery. She was, you  know, recovering  and then she had that problem. You know,  and all of a sudden her hips started to  have a problem.  It’s really really rare if the foot’s  have been bad … feet have been balanced  properly. My first thought is that the  surgery didn’t work on the feet and that  they’re imbalanced.  The key is to remain conditioned, even if confined to a bed. Get some five pound  weights on your ankle and lift up the leg.

Do you ever do both feet  at the same time? 

Never. You could do double surgery, like in a four-year-old like yesterday where Dr. K  did that.  Where you can just carry them around  easily, but no,  an adult is going to be completely  impaired because they can’t put any  weight on their foot for six weeks.  Yeah. They would have to be tiny.  Carry them around to the toilet. Carry  them to the chair.  What weight would that be? I don’t  even know. You know, 50 pounds  if dad’s strong.

Is there a particular age you recommend surgery?

There’s not a specific age, but how do you  know  to bring your child to trust you with  his feet or her feet?  When do you do it? Well, it’s absolutely  the  most important question anybody can ask,  and I don’t have an answer. To operate on the crooked foot at any  age,  operate certainly on the young  adolescent at 12 or 13,  as soon as you know that person’s not  going to live with that foot ideally for  the rest of their life.  If you look at your child, your friend,  and you say  I don’t want them to have that foot the  rest of their life, that’s the time to  have surgery. 

Since CMT is a progressive disease  do you do surgery and then 20 years  later you have to do it again  because the foot deforms or what is your  experience with that? 

There’s no literature on that whatsoever.  The study that we  started in 2017  will be coming to fruition soon. I said   I told you, anyone I’ve operated out  there  please answer us when we write to you,  and we’ll follow these patients along  forever, and the only way  anyone will have an answer for that is  in 2037 when those patients are still  around.  Most … many of them … many of them were  young and we’re going to find out how  they’re doing  but I can tell you this. If anyone’s  considering surgery  and they’re not doing well, don’t delay  because someone says, tells you, you’re  just going to be paralyzed in 10 years  anyway.  That’s not my experience. I’ve been  operating for 30 years  in California and no one has ever come  back to me and said  the operation hasn’t worked because I’ve  gotten weaker,  ever. And I’m around, you know, so I’ve  never had that. So I don’t  think these things progress. and I    personally think that when you do this  on a young person …  this is really critical … what do you  think happens? And we’re doing a study on  this.

Is it true you should not operate on children  until their bones are finished  developing? Is that sort of an  old school philosophy?

No, it’s an old  school philosophy. Just  throw it out the window.

How can you find a foot and ankle surgeon,  one who really knows what they’re doing on  the CMT foot, 

  I want people to come here if they  can.  I’m  amazed but I admire that  COVID is not stopping anyone. Tomorrow  there’s a girl from Texas  and she’s driven up. There’s a boy next  week from New York, and he’s flying in,  you know.  So it doesn’t seem to stop anybody much  for the CMT and they think it’s a  good time, right, because schools are  virtual. So all of a sudden  someone’s saying, well, this is not worth  it to be freshman in college for seventy  thousand dollars a year. I’m gonna get my  feet taken care of.  People come, I want them to stay.  A lot of surgeons wouldn’t want that,  but I want the person to stay here for  two weeks.

Now it’s a big  city and a lot of people have relatives  and I would say what I tell everyone. You  can get a hotel  out of town for $59 somewhere  a week and you can get a hotel in town  for $5,900  a night, and I’ve had both types of  patients.  Normally the former than the latter  but you stay and then the sutures will  come out in two weeks and then you go  home.  Insurance will … we’ve never been denied  insurance because most …   if you’re in North Dakota …  in your town the insurance knows that  there’s nobody who’s going to  want to do this, and if they do want to  do it, the patient will say doctor how  many have you done?  Have uoi done hundreds of patients, the way  they have at Cedars? It’s too difficult  a surgery to take on you know  so the the surgeons don’t want it. Even  the HMOs will allow people that …  one of those people I showed you is  from an HMO, which is very restrictive  healthcare, right,  in Hawaii but the HMO doctor  doesn’t want to do it.  Medicaid and the medical patients aren’t  allowed to come  but almost all insurances will allow  this.

I’m an employee. I don’t get a penny  from doing the surgery,  just not a penny. I’m an employee of  Cedars and Cedars is part of almost  all plans.  And the last thing I would just say is  if somebody doesn’t allow you to come at  first,  they will because all you have to do is  say this is where I want to go.  Are you willing to take the  responsibility,  doctor, insurance plan, but I’m not going  to do well.  And the answer for that 99% of the time  would be,  why don’t you go to Los Angeles? Now there  are  certainly people who do what I do in the  United States, but they’re large areas  where they’re not.  Okay, that’s a really helpful answer.  Great to know.  I just said the cash price is just  insurmountable. I just …  it’s tens and tens of thousands of  dollars. So you really need to  to go through insurance and get that. 

So in that regard  we’ve never had anyone turned down. Sal  Rosette, my surgery scheduler …  I was working late night in the office,  he was leaving late and I asked Sal  about this.  And he said to me is exactly what he said. I don’t know if it’s true or not.  He said, Doc, he goes, we have no one ever  turned down by  insurance for you. Each doctor has  something called an NPI number that  designates them.  He said he’s at the insurance company  I’m talking to them on the phone  and they say well what’s his NPI number  and it’s CMT  and the insurance just  immediately says, oh yeah, you can go  there.  I don’t know if … I don’t know if he’s  just reading into that  or not. I said, so they’re tracking us  with CMT and my doctor number? He goes. ” they must.”  Blue Cross, he said … I don’t know if it’s  true … but according to him he said Blue  Cross knows about you  and CMT. Anyway that’s a long answer.  That’s okay, very helpful. Back  to the age a little bit, and I know you  spoke to the crooked foot  being, you know, of surgical  possibility at any age. 

What are your thoughts on ankle fusion?

There was a consortium  in Europe which you know about. Dr.  Shy was there and others  looking at this, the  surgical issue,  and we met and I was amazed that one of  the surgeons there does a lot of CMT  surgery said  we do fusions in everyone. We do tendon  transfers and fusions. 

So I was born with a  fusion  You can do okay with the fusion of the  joints that are usually involved with  CMT,  but you’re not perfect. And I had …  if my foot moved perfectly, I would not  have dislocated my ankle when I fell in  the pool recently.  You  don’t want to do a fusion in a young  person.  If you have to, it’s not the end of the  world.  Let me tell you, if anyone’s telling you  who has CMT  that you need an ankle a fusion, you need  another opinion  from out of town.

But never  fuse an ankle in a CMT patient  as a general rule. Why? Because you’ll do  much better with those braces.  When you fuse the ankle, you take all the  spring out of the ankle  and you negate the ability of using  those wonderful braces, those ground  reaction force braces that are made now,  and those braces are anything from over  the counter or  basically online to  ten twelve thousand dollars a pair, so  there’s a lot of options.  But you have options unless you get your  ankle fused. 

Who should do my surgery?

  There are orthopedic foot and ankle  specialists. That’s who you want to see.  An orthopedic  MD foot and ankle specialist … M-D,  someone who went to medical school.  You know,  that’s the first thing. Not a podiatrist. If there’s a podiatrist  out there who’s done 100 CMT surgeries,  then fine,  I have no problem with that. You know,  podiatrists are not medical doctors.  There’s some natural competition  between orthopedic surgeons and  podiatrists.

I’ve operated on always over 40 000  people with CMT. Wow. In this one you need somebody with gray  hair. I am  so much better at this than I was 15  years ago.  Go see somebody. Contact me if you want.  Set up a telemedicine visit,  and I’ll tell you whether I agree with  your opinion or not.

And I know everybody,  and I’ll secretly tell you if I think it’s a  good person to go with.

The Consensus Paper – Take that paper, put it in your pocket  bring it to your surgeon …  learn it. CMT patients are pretty smart  people.  And learn what’s in that paper. Ask a few  questions and see what the answers are.  What we wrote in that consensus patient  paper will change  and it’s not the final answer, but it’s a  very good start to knowing who the right  surgeon is for you, right?

Elizabeth: I can’t thank you for being so  passionate about our cause,  and you’re very approachable, and even  in  the world of orthopedic surgeons. And  it’s you guys are very very busy,  and very task oriented, but you care. You  have heart.  You have soul. You follow up with your  patients.  I mean, the quality of care that you give  is amazing. So not only are you a very  competent surgeon, but also you’re  somebody that’s approachable and you can  talk to and you’re interesting.  And so A+. Thank you so much.  Thank you so much for this wonderful  presentation and caring about our community. 

September is CMT Awareness Month: New Quiz for 2020!

How much do you know about CMT? Take the quiz to find out and let us know how you did! Answers at the end. Good luck! For more information on CMT, CMTA or CMTA STAR research, please visit: http://www.cmtausa.org

*Denotes explanation at the bottom of page.

1) CMT is a genetically heterogeneous disorder. What does heterogeneous mean?

a. Like the process of breaking down fat molecules in milk, CMT can be broken down into smaller particles through a high-pressure procedure.

b. Mutations in different genes can produce the same clinical symptoms.

c. A term used to explain the genius-level IQ of most people with CMT.

d. Belonging to the same family,

2) When researchers study the natural history of CMT, what exactly are they doing?

a. They are trying to figure out which components of CMT are artificial.

b. It’s all old news.

c. They are studying the progression of CMT over time.

d. They are trying to determine the origins of CMT and when it all began.

3) People with CMT often use AFOs. What does AFO stand for?

a. Ankle Foot Orthosis

b. About-Face-Onward

c. Air Force One

d. Area Financing Officer

*4) What is HNPP?

a. HNPP stands for Hereditary Neuropathy with Liability to Pressure Palsies

b. HNPP is a sub-type of CMT.

c. HNPP is most often caused by a deletion of the PMP22 gene.

d. All of the above.

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5) What is Foot Drop?

a. An abrupt 1-foot fall or slope

b. Inability to lift the foot at the ankle due to weakness or paralysis of the anterior (front) muscles of the lower leg.

c. A secret play in football when the quarterback drops the ball 1 foot from the goal line.

d. The name of a used shoe company.

6) To date, how many genes have been found to cause CMT?

a. 10

b. Over 100

c. 212

d. We cannot count that high.

7) If a child inherits CMT from a parent, will it be the same type of CMT?

a. Yes. The type of CMT does not change between generations.

b. No. CMT is variable and changes sub-types from one generation to the next.

c. Children do not inherit CMT from parents.

d. I do not know, but the child will love Country Music Television!

*8) Is CMT like Muscular Dystrophy (MD) or Multiple Sclerosis (MS)?

a. Yes, because CMT is under the Muscular Dystrophy umbrella. 

b. No. They are completely different and separate diseases.

c. No one really knows.

d. Yes, because MD, MS and CMT are just different acronyms for the same disease.

9) Anyone in the world can be born with CMT because everyone is susceptible to random or de novo gene mutations.

a. Only people in the US are susceptible to new, random mutations.

b. This statement is false.

c. I have no idea if this is true or false.

d. True

*10) If two people who have an autosomal dominant (“Autosomal” means that the gene in question is located on one of the numbered, or non-sex, chromosomes. “Dominant” means that a single copy of the disease-associated mutation is enough to cause the disease) form of CMT (like CMT 1A) have children, what is the chance that their children will inherit CMT?

a. 0%

b. 25%

c. 75%

d. 100%

*11) What is Dominant Intermediate Charcot-Marie-Tooth Disease (DI-CMT)

a. A rare, dominantly inherited type of CMT

b. Just an expression used to liken the inheritance of CMT to a roll of the dice.

c. Does not exist. Just a made up name to throw you off the right answer.

d. A type of CMT that affects people with Type A personalities.

12) Your CMT genetic test comes back negative. What does this mean?

a. No one really knows.

b. You still may have CMT. There isn’t any one lab testing for all known mutations in any one test. Moreover, not all genetic mutations underlying CMT have been found or can be detected with a DNA test.

c. A negative result rules out CMT since all sub-types of CMT are easily recognizable.

d. Retake the test 5-6 more times to be sure of the results.

13) What does the CMTA’s research initiative, STAR, stand for?

a. Strategy to Accelerate Research

b. Strategy to Advance Rats

c. Situation, Task, Action Result

d. Sewage Telecommunication Access By Robot

14) Although there is no medicinal cure for CMT,  we can treat the symptoms of CMT with:

a. Exercise, physical and occupational therapy, healthy diet

b. Braces and other orthopedic devices

c. Surgery can help prevent or reverse foot and joint deformities

d. All the above

15) Since the launch of STAR in 2008, how much money has the CMTA spent on treatment-driven CMT research?

a. 1 million

b. 5 Million

c. 10 Million

d. 16 Million

Answers

  1. b
  2. c
  3. a
  4. d
  5. b
    • The ankle dorsiflexors, the muscles that lift up the foot and ankle, are frequently involved in foot drop. When the Tibialis Anterior muscle weakens, the foot begins to drop down. This is usually a gradual process, occurring over months or years.
  6. b
  7. a
  8. b
    • Charcot-Marie-Tooth (CMT), Multiple Sclerosis (MS) and Muscular Dystrophy (MD) are three completely separate and distinct diseases. Remember that our neuromuscular system really starts at the brain, which is the master computer, and sends signals to the motor (muscles) via the spinal cord (an intermediate connecting cable), which hooks up to the peripheral nerves (the connecting lines between brain and muscle).
    • Muscular Dystrophy is a disease of the muscle itself, which causes weakness of varying degrees. There are many forms of MD. Sometimes the heart is involved because it is a muscle too. The lungs can also be affected because the breathing muscles are weak (similar to CMT, although in CMT it is because the phrenic nerves are affected, which in turn weakens the diaphragm, the main breathing muscle).
    • CMT is primarily a disease of the peripheral nerves (the connecting lines between brain and muscle). CMT causes weakness and impaired sensory perception because the signal can’t get to and from the brain to muscle and skin, among other things. The muscles shrink because they aren’t getting the proper signals, but the muscles themselves are not directly diseased per se.
    • Multiple Sclerosis is a disease of the brain and spinal cord. It can affect both movement and sensory perception and sometimes thinking processes.
  9. d
    • There is a 75% chance that they will have a child that is affected.  Broken down, there is a 50% chance that the child will get the duplication from one or the other parent, a 25% chance they will get it from both parents (i.e. for CMT1A they will then have 4 copies of the PMP22 gene), and a 25% chance they will not inherit CMT and have the normal copy number of PMP22.  We have seen a few cases of kids that have inherited 4 copies of the PMP22 gene and they seem to be more significantly affected than their parents, but we have not looked at this longitudinally because it is rare. (Answered by Shawna Feely, CGC)
  10. c
  11. a
    • CMT-DI takes its name from the nerve conduction velocity (NCV), which is considered intermediate. The nerve biopsies from patients with DI-CMT have shown both axonal degeneration as well as demyelination. Dominant mutations in the genes DNM2MPZ, and YARS are associated with DI-CMT types B, D, and C, respectively.

12. b

13. a

14. d

15. d

CMT Awareness Month Quiz! New Questions – 2019

1) Charcot-Marie-Tooth Disease (CMT) is also known as:

a. Inflammatory Nerve and Muscle Syndrome

b. Hereditary Motor and Sensory Neuropathy

c. Funky Foot Disorder

d. Chronic Tendinopathy with fatigue

2) How many different inheritance patterns does CMT have?

a. 1

b. 2

c. 3

d. Too many to count.

3) Can CMT skip generations?

a.Yes

b. No

4) Can CMT appear in a child if the parents’ DNA is normal?

a.Yes

b. No

5). Is CMT a type of Muscular Dystrophy?

a. Yes

b. No

6). What type of pain might you experience with CMT?

a. Neuropathic or nerve pain

b. Muscle pain

c. Joint pain

d. All of the above.

7). CMT is a heterogeneous disease. What does heterogeneous mean?

a. CMT is an inherited disease.

b. CMT is usually related to having a very high IQ.

c. CMT is caused by many different gene mutations.

d. CMT affects both men and women equally.

8). Can a person have 2 types of CMT?

a. Yes

b. No

9). Is HNPP a type of CMT?

a. Yes

b. No

10).  CMT has no cure. But, non-medicinal treatments include:

a. Physical and Occupational therapies

b. AFOs or leg braces

c. Orthopedic surgery

d. All of the above

ANSWERS

#1 – b

Hereditary Motor and Sensory Neuropathy (HMSN) Hereditary means that the disease tends to run in families and causes problems with the sensory and motor nerves, the nerves that run from the arms and legs to the spinal cord and brain.

#2 – c : 3 

The 3 types of inheritance are Autosomal Dominant, Autosomal Recessive and X-Linked. Autosomal Dominant – the faulty gene is located on one of the numbered, or non-sex, chromosomes.  Humans typically have 46 chromosomes or 23 pairs of chromosomes.  The first 22 chromosomal pairs are called autosomes. Autosomal dominant conditions affect men and women equally, and both men and women have a 50% chance in each pregnancy of passing on the condition.

If a child inherits the mutation, that child will have CMT and will have a 50% chance of passing it on again.  If the child does not inherit the change, that child will not have CMT, will not have symptoms, and will not be able to pass on the change that is in the family in the future. 

Autosomal Recessive – 2 copies of the mutation are needed to cause the disease, meaning neither copy of the gene is working properly.  In almost all cases, the changes in the gene were inherited from the parents. Each parent has one copy of the gene with a change, but because that person has one copy of the gene without a change, that person does not have symptoms of CMT and is called a “carrier.” Only people with autosomal recessive forms of CMT in the family can be considered carriers. Both males and females are affected equally with autosomal recessive conditions, and there is an equal chance of passing it on to a child, no matter the sex. If two people are carriers of an autosomal recessive form of CMT, there is a 1 in 4, or 25%, chance of both passing down the copies of the genes that do not work to a child in each pregnancy. It is only the child that inherits two copies of the gene that have mutations that will have CMT. For a person who has a recessive type of CMT, that person will pass on one of the copies of the gene with the mutation to all of that person’s children. However, only if that person’s partner is also a carrier of a mutation in this gene will it be possible to have a child that is affected with the condition. If the partner is not a carrier, it is not possible to have children affected with a recessive form of CMT, but all children will be carriers.

X-Linked – the last pair of chromosomes is called sex chromosomes. the Y and the X.  For a person with an X-linked form of CMT, the inheritance is different depending on the sex of the person affected. X-linked forms of CMT (such as CMT1X) are caused by a mutation in a gene carried on the X chromosome. Recall that females have two X chromosome and males have an X and a Y chromosome. If a female has a mutation in an X chromosome gene, she will have a 50% chance of passing on that mutation to each of her children, no matter the sex of the child. However, if a male has a mutation in an X chromosome gene, the sex of the child does make a difference. As males pass on their X chromosome to their daughters and their Y chromosome to their sons, all of the daughters of a male with an X-linked mutation will inherit the condition, and none of the sons will. Source: https://www.rarediseasesnetwork.org/cms/inc/Charcot-Marie-Tooth/What-is-CMT

#3. No. 

CMT does not skip generations.

#4. Yes.

Sometimes the parents’ DNA is normal and the CMT variation happens when the child’s DNA is forming. This is called a new or spontaneous mutation.

#5. No No, CMT is not a type of muscular dystrophy.

CMT is primarily a disease of the peripheral nerves. CMT causes weakness and impaired sensory perception because the signal can’t get to and from the brain to muscle and skin, among other things. The muscles atrophy because they aren’t getting the proper signals, but the muscles themselves are not directly diseased, per se. Muscular dystrophy is a group of diseases of the muscle itself, which causes weakness of varying degrees (there are many forms of MD).

Sometimes the heart is involved because it is a muscle too. The lungs can also be affected because the breathing muscles are weak (similar to CMT, although in CMT it is because the phrenic nerves are affected, which in turn weakens the diaphragm, our main breathing muscle). So, in summary, CMT is a genetic neuropathy which is of course a neuromuscular disorder (The euro part of the word comes from nerve). When they were expanding  the MDA early one, they included 41 of the neuromuscular diseases, including Muscular Dystrophy, CMT, Spinal Muscular Atrophy, Myasthenia Gravis and so on. The thing to remember is that when nerves stop sending the correct signals, muscles atrophy and you wind up with similar problems to those experienced by someone with a “muscle disease” like MD.

# 6. D – All the above. 

#7. C

Over 100 different genes have been identified as causing CMT  (and counting).

#8. Yes. 

The statistic is that about 1.5 percent of people will have two types of CMT. Not all variants are disease-causing. In many cases, the results of the genetic tests are often very difficult to decipher and seeing a trained CMT expert who also performs a physical exam is key for an accurate diagnosis.Please see a licensed genetic counselor (www.nsgc.org) to better understand your genetic testing results.

#9. Yes

Yes, HNPP is a form of CMT. There are three different types of CMT associated with PMP22.  People with a duplication of PMP22 have CMT1A, people with a deletion of PMP22 have HNPP, and people with a missense mutation (single letter mutation changing an amino acid) in the PMP22 gene have CMT1E.  All are hereditary forms of peripheral neuropathy, and as CMT is the umbrella name for all forms of hereditary peripheral neuropathy, that would include HNPP. (Written by genetic counselor, Shawna Feely)

#10. D. 

CMT has no cure and treatments are supportive. Foot orthotics and braces (ankle-foot-orthotics, AFOs) are commonly prescribed  to help with foot deformity and foot drop. Surgery to correct foot alignment or to lengthen or transfer tendons is often performed. Physical and occupational therapies are instrumental in providing long lasting quality of life. There is no cure for CMT nor any drug or vitamin known at this time to make CMT better.

Questions? WWW.CMTAUSA.ORG