Diabetic Polyneuropathy

Case Study:Diabetic Polyneuropathy

Background: 

Polyneuropathies are conditions that damage multiple peripheral nerves. Most polyneuropathies are associated with decreased sensation and strength, particularly in the distal extremities.  Diabetes is a common chronic condition associated with polyneuropathy.  Chronically high blood sugar can damage nerves in the hands, feet, arms and legs.  Clients with diabetes, in general, do not heal as well as others if their skin becomes irritated or injured, and clients with polyneuropathy are more likely to sustain injuries in their feet and legs.  Even minor injuries can lead to serious complications including amputations (Cameron & Monroe, 2011).

Case Study:

You are the PTA in a rehabilitation hospital working with outpatients with variety of neurological problems. You have access to a gym that is well-equipped with treadmills, stationary and recumbent bicycles, an arm ergometer, a Nu Step, free weights and pulley machines, therapy balls and Bosu balls, parallel bars, training stairs and ramps.

You are working with DiaBetic, a 70-year-old retired sociology professor who has had diabetes for 16 years.  Her date of birth is Jan. 1, 1945. Seven years ago she first started noticing numbness and tingling in her feet.  Four years ago, she also started noticing pain.  She has had 2 falls within the past 6 months.

Mrs. Betic’s physician has diagnosed her with diabetic polyneuropathy.  In addition to medical treatment to help her improve her blood sugar control, he referred Mrs. Betic to physiotherapy to address her pain, weakness, balance problems and fall risk.

Mrs. Betic lives with her 80-year-old husband, who is in the early stages of Alzheimer’s disease.  Mrs. Betic does not like to leave him alone at home, because last month she came home to find he had left the an empty pot on a hot stove and it had started to burn.  She has a daughter who is able to stay with him for short periods of time on the weekends, and her seventeen year-old granddaughter can stay with him after school for a couple of hours. However, despite this support, Mrs. Betic is experiencing caregiver stress.  She is having trouble dealing with her husband’s personality changes and is anxious about their future together.

Mrs. Betic and her husband live in an old Victorian home that has multiple stories.  Some of the stairs have railings, but some do not.  The mortgage has been paid off and they have a reasonable pension and retirement savings, but they still have to be careful in their spending habits.

Significant findings from physiotherapy assessment:

Impairments:

1. Musculoskeletal: Muscle strength graded as 4/5 for the tibialis anterior, toe extensors, and gastrocnemius and soleus.  Muscle strength 5/5 in the other muscle groups of the lower extremities. ROM was normal.
2. Neuromuscular: Pain severity at rest was 5/10 in her feet and increased to 6/10 with walking.  Pin prick sensation was absent from the middle lower leg to her feet in a sock-like pattern.

Activity Limitations:

56. Functional outcome measures: Berg Balance Score 41/56.  Timed up and go test score:  15 seconds.  Six-minute walk test:  350m, with no rests required.
57. Ambulation: Betic walks independently indoors with a slightly wide base of support.   However, she has difficulty negotiating obstacles safely.  She requires close supervision to walk up a ramp and to ascend and descend 2 flights of stairs with no railing.

Participation Restrictions:

1. Betic used to belong to a bird watching club, but has stopped participating both because she is afraid of falling outdoors, and also because the group would meet during the day, when it is hard to find someone to stay home with her husband.

Physiotherapy Intervention:

1. Working with the client to developformal short term and long term treatment goals.
2. Education regarding prognosis and diagnosis.
3. Gait aid prescription: rollator walker for use outside the home.
4. Education regarding management of diabetes and the prevention of further disability, including skin ulcerations.
5. TENS with a pulse duration of 60µs, a frequency of 150 pulses per second (Hz) and an intensity that will produce a comfortable tingling sensation to be used at home as needed.
6. Strengthening, balance and cardiovascular exercises to be performed 3 times per week.The treadmill is used most often for cardiovascular training in the rehabilitation center.
7. Gait training indoors without a gait aid. Training in negotiating obstacles such as ramps and stairs.  Gait training with a rollator walker outdoors.
8. Home exercises to improve strength and balance.
9. Education in ways to improve safety at home.
10. Formal referral to other members of the health care team as appropriate.

Questions:Total Marks:  65 (15% of TecCar Final Mark)

1. Choose one of the functional outcome measures used in the client’s assessment (the Berg Balance Score, the Timed Up and Go or the six-minute walk test). Look up information on your chosen outcome measure.  How do Mrs. Betic’s scores compare to normative data?  What do these results suggest about Mrs. Betic’s current level of function?Include a reference.  (3 marks)
2. What aspects of the physiotherapy intervention listed in the case study are beyond the scope of practice of a PTA and should be carried out by the physiotherapist?(3 marks)
3. What aspects of the physiotherapy intervention could be assigned to you?(5 marks)
4. What symptom is being treated with TENS? What type of TENS is being used?  How long is the effect expected to last? What kind of electrode placement would you recommend?(5 marks)
5. What are three recommendations you would give this client to improve her safety at home?

(3 marks)

6. Describe one balance exercise that would be appropriate for Mrs. Betic to practice with you, and one balance exercise you feel would be safe for her to practice at home.(4 marks)
7. Describe two strengthening exercises you would give Mrs. Betic including the muscle groups you are working and parameters. Provide a rationale for each exercise you chose.(6 marks)
8. Describe two safety precautions you would put in place when Mrs. Betic is working with you in the rehab center. (2 marks)
9. Why do you think the physiotherapist decided to include cardiovascular (aerobic) exercise with this client? Use the FITT principle to describe an appropriate cardiovascular exercise prescription for this client.(5 marks)
10. Betic has decided she would like to buy a piece of cardiovascular equipment to use at home. What would you recommend?  Why?  Research affordable options for your client, and indicate the price of the equipment and a website or other contact information Mrs. Betic could use to purchase the equipment.(4 marks)
11. Aside from the physiotherapist, the PTA and the physician, identify two other members of the health care team who could help Mrs. Betic, and describe what you feel their roles would be. (4 marks)
12. Identify one community resource (outside of the health care system) that you feel could help Mrs. Betic improve her physical and/or psychosocial well-being. Provide a rationale for your answer and relevant contact information (i.e. website, phone number address).  (3 marks)
13. Charting:

Today when Mrs. Betic arrives she tells you that the pain in her feet is 4/10.  She reports that she has been practicing the exercises you taught her every day at home.  Her HR at rest is 80, strong and regular, and on the treadmill at peak intensity is 100, strong and regular.  Her HR returns to 82 bpm with a 5 minute rest.  You retest the Timed up and Go and her score is 14 seconds.  You notice that her gait pattern has improved with a narrower base of support.  Mrs. Betic walks for 10 minutes on the treadmill at 2.5 mph.  After her session on the treadmill, you practice stairs with her and notice she still requires close supervision to ascend and descend 2 flights with no railing.  You have no concerns and your plan is to continue with treatment as assigned by the physiotherapist.

Document this session using SOAP format.  (10 marks)

14. Betic tells you she never uses her rollator walker outside because it makes her feel old, and she feels she really doesn’t need it anyway. She says “That’s just between you and me.  Don’t tell the physiotherapist.  I don’t want her to worry.”  What would you do in this situation?  Describe what you would say to Mrs. Betic.  (3 marks)
15. Several weeks have passed and Mrs. Betic is making good progress towards her treatment goals. Unfortunately, her husband had heart attack which affects both his physical and cognitive function.  Beticcan not longer come to the rehabilitation center for treatment.  The physiotherapist arranges for home care to continue treatment with her.  Describe two potential advantages and two potential disadvantages of this change in treatment setting.  (4 marks)
16. Include a reference list using APA format. (1 mark)