Improving Balance in Patients With Peripheral Neuropathy: An Outpatient
Physical Therapy Program Using Therapeutic Exercises
Chris Grant
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Introduction
Diabetes, namely type 2, is on the rise in America. In healthy individuals when blood
sugar rises, the pancreas secretes insulin to aid in the uptake of blood sugar into cells,
which provides an energy source to the cell. Those with uncontrolled type 2 diabetes
have constantly high blood sugar levels. The insulin secreted from the pancreas cannot
keep up with high blood sugar levels. The cells over time become resistant to insulin and
blood sugar remains elevated. Elevated blood sugar slowly begins to damage the nerves
and sensation to damaged areas is lost or diminished. Diabetic Peripheral Neuropathy
(DPN) is a common problem amongst those with diabetes.
Those with DPN have a typical gait characterized by slow speed, decreased stride length,
decreased cadence and a higher step-to-step variability [3]. This puts patients at an
increased risk for falls. In addition to a characteristic gait DPN causes numbness and
tingling in the feet, which prevents or impairs somatosensory feedback, which aids in
maintaining balance. Impaired sensation decreases balance, which eventually leads to
falls. Falls or slips in elderly are one of the most common causes of injuries or death [2]
Falls and injuries often begin a vicious circle because of their potentially detrimental
influence on physical activity [3]. The role of physical therapy is to help these patients
compensate for a loss of their somatosensory sensory system. Many times clinics will
give patients non-customized balance programs in an effort to improve balance. There is
relatively little research on improving balance in individuals with DPN. Many of the
studies are using circuit-training programs, which cannot be adapted to all patients
because of variations in their balance problems as well as functional requirements [3]. It
has been found that it is more beneficial to give patients a customized program in order to
see the best results [1].
Through customized patient programs, which use strength training, visual and vestibular
activities balance can be improved. An improvement in balance translates to fewer
injuries, continued movement, and quality of life. The purpose of this case report is to
describe the physical therapy plan of care for a patient who has peripheral neuropathy and
how his balance was improved through these methods.
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Case Description
Patient
The patient is a 62 year-old male with a history of bilateral lower extremity peripheral
neuropathy and right foot drop. He stated that 6 weeks ago he was immobilized for 3
days and was unable to get up from the floor when he was using meth. He stated that he
was hospitalized and was given a forward wheeled walker with push down rear brakes
and a few exercises to do at home. The patient continued to complain of bilateral lower
extremity weakness and difficulty with balance. The patient also stated that previous to
the use of his forward wheeled walker he fell frequently, especially when not using his
AFO on his right lower extremity.
Examination
The following examination was performed by the physical therapist 6 weeks after the
patient’s fall and subsequent hospitalization.
Posture
Sitting Balance
Standing Balance
Range of motion
Strength
Gait
Activity Tolerance
Sensation
Pain
Integumentary Status
Cognition
Mobility skill/transfers
Forward flexed slightly, shoulders rounded,
head forward.
WNL
Requires use of 4WW for stabilization and
balance.
B LE all WNL
B Hip extension 3-/5,
B hip ABD 3+/5
R ankle DF – trace
R ankle EV 2/5
R ankle INV 2/5
R ankle PF 3-/5
Pt currently ambulating with 4 WW
Pt is deconditioned and requires frequent
rest breaks.
Decreased to light touch L lateral thigh and
B LE distal to mid calf. Loss of
proprioceptive sensation to monofilament
testing B plantar surface
Pt has no c/o pain
Skin is clean and intact
Patient alert and oriented to person, place,
time, and event
Sit to stand with use of B UE for assistance,
CGA needed for balance with sit to stand and
pivot transfers. BERG 10/56
Interventions
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After examining the patient, the patient and physical therapist discussed therapy
and patient goals. The following long-term goals were set and agreed upon by both
the therapist and patient.
Short-Term Goals:
1. Pt able to maintain feet together stance x 20 seconds independently.
2. Pt to demonstrate proper upright posture when walking with 4WW
Long –Term Goals:
1. Pt to demonstrate a 5/5 strength for B hip extension, ABD, gluteus medius
2. Pt to score > 21 on Berg Balance Test.
Long and short-term goals to be accomplished in 6-8 weeks
Plan
Patient is to follow up 1 time per week for 3 weeks with PTA for more aggressive
balance training, bilateral lower extremity strengthening with emphasis on
education in use of his quad cane and improving safety with ambulation and
transfers. The patient was in agreement with the plan of care. Pt will be discharged
from PT is compliance does not improve with PT intervention.
Balance Training
Balance training was initially performed with use of four-wheeled walker. The
patient practiced standing with a narrow base of support in a corner for 3 minutes.
A quad cane and a gait belt were used as the patient progressed. The patient was
able to ambulate through an obstacle course with varying changes in surface and
height. It was difficult to progress the patients activities due to his lack of
participation in his home exercise program. The patient upon initial evaluation
scored a 10/56 on the BERG balance scale that put him at a high risk for falls. The
patient needed assistance with all activities, which involved standing unsupported
and transferring. These were areas that were to be focused on in his treatment
sessions in addition to strength training
Strength Training
Visit 1: Hip and
quad strength
Prone R/L hip
extension
Side lying hip ABD
Visit 2: Review of
HEP
A/P weight shifts
Visit 3: Cardio and
Strength
Nu Step
Visit 4: Reevaluation
BERG
Sit to stand
Quadruped PNF
5 time sit to
stand
Sit to partial stand
with use of 4 WW
R/L hip extension
and ABD
Quadruped bird dog
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Stretching to
improve ROM in
ankle via
gastroc/soleus
stretch. Quad and
hamstring stretch to
improve ROM in
bilateral knees
Stretching to
improve ROM in
ankle via
gastroc/soleus
stretch. Quad and
hamstring stretch to
improve ROM in
bilateral knees
Stretching to
improve ROM in
ankle via
gastroc/soleus
stretch. Quad and
hamstring stretch to
improve ROM in
bilateral knees
Patient Education
The patient was educated on gait safety, proper use of his quad cane, and stair
safety. The patient was given a print out of a series of exercises he was to perform at
home. The patient was instructed in proper technique of the exercises to be
performed at home. The patient understood the exercises and had no questions. The
patient was educated on the importance of exercises and safety around the home
and in the community. He was instructed to continue to use his quad cane until
instructed otherwise.
Outcomes
The following table outlines the patient’s status as of the most recent re-evaluation.
The patient has been scheduled for 4 more visits with a PTA. The patient will then
be re-evaluated by the physical therapist for possible transition to a home exercise
program as the patient becomes more compliant with his exercises at home. No
formal muscle testing or range of motion testing was done. A 5 time sit to stand and
BERG balance test were used to measure the patient’s progress.
Posture
Sitting Balance
Standing Balance
Range of motion
Strength
Gait
Activity Tolerance
Sensation
Pain
Improved trunk and shoulder posture.
WNL
Requires use of quad cane for stabilization
and balance. BERG score 28/50
B LE all WNL
Not Tested
Pt currently using SPC at home. Tested using
a quad can. Improved trunk and shoulder
posture. Slight R LE ER in swing stance
5 time sit to stand in 9 sec
Decreased to light touch L lateral thigh and
B LE distal to mid calf. Loss of
proprioceptive sensation to monofilament
testing B plantar surface
Pt has no c/o pain
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Integumentary Status
Cognition
Mobility skill/transfers
Skin is clean and intact
Patient alert and oriented to person, place,
time, and event
BERG 28/50, 5 time sit to stand in 9 sec
Discussion
The goals of physical therapy for patients with peripheral neuropathy are to
improve balance, strength, and most of all to prevent falls. This is done through
1. Choosing a treatment program that is individualized to the patient.
2. Performing regular strength training
3. Challenging balance and teaching the patient safety strategies.
There are few studies that discuss the best treatment for those with peripheral
neuropathy. Customizing the program to the individuals needs is a key element in
improving balance. This patient exhibited difficulty originally in all aspects the
BERG test which required transfers or standing unsupported. Strength training and
transfers were incorporated into the patients program to address the specific needs
he had. It has been a point of controversy if those with DPN should be involved in
exercise because it puts them at a higher risk for foot ulceration.
In a study performed by Kruse et al the program was found to be safe and well
tolerated [4]. It is important to customize programs and to include both strength
and balance training to help patients to obtain their highest level of safety possible.
Mobility and strength deficits found at the knee and ankle joints have been shown to
place patients at a high risk for falls as well [3]. A stretching and strengthening
program was given to improve range of motion and strength in the patient’s ankle in
an effort to improve balance. Although the patient was only seen for a limited
number of visits he was still able to increase his BERG score by 18 points. Had this
patient been seen for additional visits I would have continued working on the
patient’s hip, core, and ankle strength. These areas have been found to improve
balance the most. This was accomplished through the methods discussed in this
case study.
Conclusion
It is possible to improve balance in those patients who have peripheral neuropathy.
There is little research on which is the best treatment plan however. What is know
is that balance can be improved through strength training, customized balance
programs, and that these programs can help reduce the risk of falls.
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References
1. Kadabi N, Kumar S. Effects of customized proprioceptive training and balance
exercises among diabetic patients. Indian Journal of Physiotherapy &
Occupational Therapy. 2012;6:77-80.
2. Akbari M, Jafari H, Moshashaee A, Forugh B. Do Diabetic neuropathy patients
benefit from balance training. Journal of Rehabilitation Research and
Development. 2012;49:333-338.
3. Allet L, Armand S, de Bie A, Golay, et al. The gait and balance of patients with
diabetes can be improved: a randomized control trial. Diabetologia.2010;53:458466.
4. Tofthagen C, Visovsky C, Berry D. Strength and Balance Training for Adults
With Peripheral Neuropathy and High Risk of Fall: Evidence and Implications for
Future Research. Oncology Nursing Forum. 2012;39:416-424.
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