DMD Multidisciplinary Care: Building and Coordinating the Clinical Team

Welcome back to another Neurology Live Peers & Perspectives Exchange series. In this episode titled "DMD Multidisciplinary Care: Building and Coordinating the Clinical Team," moderator John Brandsema, MD, Children's Hospital of Philadelphia, Philadelphia, PA, and panelist Aravindhan Veerapandiyan, MD, Arkansas Children's Hospital, Springdale, AR, discuss multidisciplinary care and transition of care in Duchenne muscular dystrophy.

Drs. Brandsema and Veerapandiyan open by examining the composition and coordination of multidisciplinary DMD care teams. Dr. Veerapandiyan describes his center's core team, which includes neuromuscular neurology, cardiology, pulmonology, physical therapy, rehabilitation medicine, and endocrinology, with additional access as needed to gastroenterology, psychiatry, psychology, palliative care, and social work. He notes that not all specialists are seen on the same clinic day — involvement is guided by individual patient needs and disease stage.

Dr. Brandsema raises the practical tension between comprehensive care and clinical logistics. Packing every specialist into a single visit is neither realistic nor patient-centered; a child who has been through multiple exams will not perform reliably on functional outcome measures later in the day. Specialist involvement should be sequenced thoughtfully — for example, a young boy may benefit from an introductory meeting with a cardiologist early in the disease course without requiring that specialist at every visit, while pulmonary involvement becomes more central as the disease progresses. He also identifies a persistent gap at his own center: the absence of an embedded psychologist or neuropsychologist who can spend meaningful time with families to address behavioral and neuropsychiatric needs — something a social worker, however skilled, cannot fully substitute for.

Dr. Veerapandiyan outlines three coordination practices that have proven effective: dedicated nurse care coordinators who serve as the primary contact for families and triage questions to the appropriate specialist; monthly team meetings to review upcoming patients and anticipated needs; and having all providers share physical space on clinic days to enable real-time communication and eliminate redundancy. Dr. Brandsema adds that involving primary care providers in team communications, and leveraging the growing advanced practice provider community, has meaningfully expanded care capacity and consistency.

In the next episode, "DMD Case Study: Treatment Decisions and Managing Multisystem Complications," the panel walks through a representative patient case to illustrate how treatment strategies and care priorities evolve across the DMD disease course.