Case Study – Radiation-induced Peripheral Neuropathy

July 4, 2017 | By | Reply READ MORE...

Mr. Ramesh C, 72 year old male came to PhysioRehab with the following complaints:

  • Inability to walk independently (without use of assistive device or splints) for the last 1.5 years.
  • Difficulty in balancing on uneven surfaces or changing directions while walking (even with splints).
  • Difficulty in lifting both feet up (left more than right).
  • Decreased sensation in both feet, heaviness in sole of feet.
  • Occasional complains of pain in left foot and toes.

HISTORY:

  • Mr. Ramesh was diagnosed with colon cancer 2 years ago, for which colostomy was done.
  • This was followed by 5 weeks of chemotherapy and 5 weeks of radiation therapy.
  • He had almost recovered completely and become almost fully independent in his activities of daily living.
  • About 2-3 months later, he slowly started observing altered sensations in both feet, difficulty in wearing footwear, and gradual weakness in his ankle muscles leading to a foot drop.

INVESTIGATION:

  • Nerve conduction tests revealed sensory motor neuropathy of bilateral tibial and common peroneal nerves induced by radiation therapy.
  • Mr. Ramesh was advised to wear ankle foot orthosis and started physiotherapy elsewhere for almost 10 months in the form of electrical muscle stimulation and few exercises.
  • When he came to PhysioRehab, the patient’s clinical picture was as follows.

EXAMINATION:

  • Moderately built gentleman with a good upper body posture.
  • Stands with a slight forward lean from hip, wide base of support and with hyperextension of both knees (right more than left).
  • Foot drop present on both sides (right more than left).
  • Severe tightness of right gastro soleus muscles, moderate tightness of left gastro soleus, both glutei, both adductors and piriformis muscles.

Muscle strengths –

  • Toe extensors – nil; Toe flexors – very weak on right, almost nil on left.
  • Tibialis anterior – weak on right (in available range), very weak on left; Gastro soleus – good on both sides.
  • Strong knee musculature.
  • Gluteal muscles- fair on both sides.

Reflexes –

  • All normal except diminished ankle jerk on both sides.

Sensations –

  • Light touch, pain, deep pressure –diminished b/l over entire foot (right 30% more than left).

Joint proprioception –

  • Fair on right, Poor on left.

Balance –

  • Static balance- fair
  • Dynamic balance- poor
  • Activities like 1 leg standing, tandem stance, standing with feet together not possible to do.

PATIENT’S GOALS:

  • Mr. Ramesh has been a very active person and an avid gym goer since the past 40 years. He still continues to do weight training of upper body and hip and knee musculature.
  • His goal was to be able to walk outdoors and do all other activities of daily living without using dynamic ankle foot orthosis.

PLAN OF TREATMENT:

  • Improving muscle length of both calves along with simultaneous strengthening of ankle dorsiflexors.
  • Improving sensations of both feet by sensory stimulation techniques.
  • Improve strength in proximal musculature of both lower limbs.
  • Functional training for improving balance and proprioception.

TREATMENT:

  • As the calf muscle length was very less, we first started with manual/ static stretching of both calf muscles with a little more focus on the right calf.
  • We then began strengthening of the gluteal muscles in the form of bridging and leg raises lying on one side to build up some proximal stability in standing.
  • We then introduced different neuro-muscular facilitatory techniques to improve sensation as well as strength of ankle dorsiflexors and toe extensors. These were in the form of tapping, stroking, brushing, quick stretch to ankle muscles.
  • Use of different textures like cotton, sponge and sand paper was done while using these techniques.

  • Electrical muscle stimulation for ankle dorsiflexors was also given for the first few sessions.
  • All this was followed by the same facilitatory techniques in sitting position.

Balance and proprioception training was started as follows –

  • Standing weight shifts with splints to without splints.
  • Keeping one foot on stepper up and down- forward and sideways.
  • Standing with one foot on stepper- static, progressed to dynamic by giving reach outs with and without splints.
  • Standing on foam- static, progressed to dynamic by giving reach outs with and without splints.

Functional training –

  • Standing on wedge- static, progressed to dynamic by giving reach outs.
  • Walking on wedge with support – 1 to 2 steps.
  • Walking around cones – with and without splints.
  • Turning 360 degrees.
  • Walking sideways and walking backwards.


Gait training –

  • On ground with constant verbal cues to clear toes off the floor.
  • Treadmill training with splints and sports shoes to help rhythmical stepping was also done.

After 6 weeks of therapy, the pain in left foot had completely subsided. Calf muscle lengths were significantly better. There was no foot drop on Right side and only mild weakness in left foot was present. Sensations in both feet were 30% better.

Mr. Ramesh still continues coming for Physiotherapy sessions with PhysioRehab. As of today, he is able to walk without splints indoors with confidence. He can stand on one leg for 10 seconds and is much more confident in transfers and his activities of daily living.

Here is what he has to say:

“Both my legs and feet were weakened and damaged due to radiation therapy.  I was suffering from foot drop in both feet and I was unable to walk.  Since last two years I was using Splints for both legs and manage to walk.  I was looking for a good Physiotherapist in the vicinity of my residence in Goregaon. 
Mr. Shah from our Society suggested I visit your Physio Rehab Centre at Malad.  In my first visit Ms. Shinee & Ms. Purti Oak asked me the entire history and gave me hope that they will try their level best and give physiotheraphy so that I may walk without splints or any support. Ms. Purti Oak started giving me treatment and I found that she does the treatment sincerely and dedicatedly. She tries to go to the root cause. She first started the treatment to improve my muscle strength, my reflex action and lengthening of leg muscles.
Ms. Purti Oak and Ms. Yashada Karmarkar both attended to me. I found both of them dedicated to my treatment.
I found myself confident that my buttocks, hips and calf muscles are getting stronger.  I find the treatment very satisfactory and entire staff is also very co-operative.
Yours sincerely,
Mr. Ramesh Chafekar”

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Category: Case Studies

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