Is conservative treatment with physical therapy and home exercise programs medically indicated for this patient with impaired mobility and strength?

Medical Necessity of Continued Physical Therapy for This Patient

Continued physical therapy with a structured home exercise program is medically indicated for this patient, as the functional decline demonstrated by decreased HFMSE scores (from 17 to 11) and emerging left-sided weakness represent clinically significant deterioration that requires immediate therapeutic intervention to prevent further loss of mobility and independence. 1, 2

Evidence Supporting Medical Necessity

Documented Functional Decline Requiring Intervention

The patient demonstrates clear regression in key functional measures that mandate continued therapy:

• HFMSE score dropped from 17 to 11 – a 35% decline indicating significant loss of seated functional capacity 1
• RHS score of 12 with inability to reach eye level with good trunk control on the left side 1
• RULM asymmetry (right 28, left 21) with new left-sided weakness at shoulder level, despite right side improvements 1
• Progressive contractures limiting floor sitting and standing frame use 1

Physical therapy is strongly recommended for patients with progressive neuromuscular conditions to maintain functional abilities and prevent secondary complications. 1, 2

Specific Therapeutic Interventions Are Evidence-Based

The provider's prescribed interventions align with established guidelines for neuromuscular rehabilitation:

Passive stretching and positioning exercises are recommended to preserve joint mobility and prevent contracture progression, particularly for hamstring tightness and knee flexion contractures 2, 1

Trunk stabilization exercises address the documented kyphotic posture and posterior pelvic tilt that limit independent sitting 1, 2

Home-based exercise programs with supervision have demonstrated effectiveness in maintaining muscle strength and functional capacity when patients cannot access facility-based therapy 1, 3

Critical Clinical Indicators Supporting Continuation

Prevention of Rapid Functional Deterioration

Without intervention, the documented decline trajectory will accelerate, leading to:

• Complete loss of independent sitting ability due to progressive hip and knee contractures 1
• Further asymmetric weakness compromising upper extremity function for activities of daily living 1
• Increased risk of scoliosis development with declining trunk control 1
• Loss of standing frame tolerance, eliminating weight-bearing opportunities 1

Glucocorticoid therapy alone does not address musculoskeletal complications – physical therapy is essential as an adjunct treatment to manage contractures and maintain functional mobility 1

Addressing Modifiable Barriers to Function

The assessment identifies specific, treatable impairments:

Hamstring and hip flexor tightness preventing floor sitting can be addressed through daily passive stretching protocols (3 sets of 8-10 repetitions at submaximal range) 1, 2

Left shoulder weakness requires targeted strengthening within functional activities to prevent further asymmetry 2, 1

Posterior pelvic tilt and kyphotic posture respond to positioning education and trunk exercises performed during routine activities (watching TV, car rides) 1, 2

Recommended Therapeutic Approach

Structured Home Exercise Protocol

Implement a supervised home program with the following components 2, 1:

• Passive stretching: Daily hamstring, hip flexor, and knee extension stretches held 30-60 seconds, 3-5 repetitions per position 2, 1
• Positioning exercises: Anterior pelvic tilt training in supported sitting, performed 3 times daily during sedentary activities 1, 2
• Trunk stabilization: Seated reaching activities within tolerance, progressing from right (stronger) to left side 2, 1
• Active range of motion: Upper extremity elevation exercises focusing on left shoulder, 10-15 repetitions, 2-3 times daily 2

Monitoring and Progression Strategy

Monthly reassessment using standardized measures (RULM, HFMSE) is conditionally recommended to track response to intervention and adjust treatment intensity 1

Physical therapy visits every 4 months for technique review, program modification, and caregiver training are recommended for neuromuscular conditions 1

Common Pitfalls to Avoid

Discontinuing therapy based on motivation concerns alone is inappropriate when objective functional decline is documented – the 6-point HFMSE drop represents real loss of capacity requiring intervention 1

Waiting until contractures become fixed deformities significantly limits treatment options and functional recovery potential 1, 2

Focusing solely on pharmacological management without addressing musculoskeletal complications leads to preventable disability in neuromuscular conditions 1

Quality of Life and Morbidity Considerations

Maintaining seated independence and upper extremity function directly impacts 1:

• Ability to perform self-care activities
• Participation in educational and social activities
• Prevention of pressure injuries from immobility
• Caregiver burden and family quality of life

The evidence demonstrates that structured physical therapy programs improve functional outcomes and slow decline in patients with progressive neuromuscular conditions, even when complete reversal of symptoms is not achievable 1, 2