Background and Purpose:
Diabetic peripheral neuropathy (DPN) is a complication affecting up to 50% of persons with diabetes, and resulting in up to a 20-fold increase in fall risk relative to an age-matched healthy control. DPN typically results in predictable changes in gait patterns, which increase risk for plantar foot ulceration. Few studies report the efficacy of interventions for persons with severe DPN and/or with multi-comorbidity. The purpose of this case study is to illustrate the effectiveness of physical therapy (PT) to improve gait and balance in a person with DPN and multi-comorbidity.
Case Description:
This case study examines a 62yo with DPN, a chief complaint of balance disorder, and multiple cardiovascular, integumentary, and orthopedic comorbidities. Restrictions from his physicians and podiatrist included: no walking more than 1 mile per day, no carrying more than 20lbs, and no intrinsic foot muscle strengthening or forefoot mobilizations. He presented with impaired static and dynamic balance, reduced gait speed relative to age matched norms, reduced functional strength, and reduced lower extremity range of motion. Interventions addressed balance (firm and compliant surface training, dynamic gait tasks), range of motion (mobilizations to the talocrural joint and stretching), and strength (nonweightbearing strengthening for hip and ankle musculature plus functional strengthening with limited external resistance.) The patient was prescribed a right ankle foot orthosis to address foot slap during gait, chosen in collaboration with a certified orthotist. Outcomes included: 5 Time Sit to Stand (5TSTS), ankle dorsiflexion range of motion (ROM), Berg Balance Scale (BBS), 10 Meter Walk Test (10mwt), and Functional Gait Assessment (FGA).
Outcomes:
The patient participated in 25 sessions over 9 months. Treatments resulted in improvements in 5TSTS (18.1 seconds to 8.3 seconds), ROM (right: -12 to -5, left -9 to 7), 10mwt (0.99m/s to 1.15m/s), BBS (49/56 to 54/56), and FGA (19/30 to 28/30).
Discussion:
This case study demonstrates a PT plan of care which resulted in improvements in gait and balance, despite constraints on intervention selection and intensity. Intensity was modulated by allowing errors during balance training, optimizing attentional focus during balance practice, and selecting nonweightbearing exercises which required high effort. The plan of care emphasized education regarding how each intervention related to a specific activity limitation or participation restriction the patient had previously identified. An AFO was provided based on clinical presentation in the absence of evidence based guidelines. Further research is needed to confirm the validity of using carbon fiber, minimalistic AFOs to reduce foot slap during gait, as well as the efficacy of PT for patients with DPN and multi-comorbidity.
References:
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Monteiro RL, Ferreira JSSP, Silva ÉQ, et al. Foot-ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial [published correction appears in Sci Rep. 2022 Jul 11;12(1):11768. doi: 10.1038/s41598-022-16172-9]. Sci Rep. 2022;12(1):7561. Published 2022 May 9. doi:10.1038/s41598-022-11745-0
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