CASE REPORT PROPOSAL

Title of Case Report:

Is Otago exercise program effective for reducing fall risk in patient with Diabetic peripheral neuropathy?

Type of Case Report: Case report focusing on intervention

Background and Purpose Statement:

Peripheral neuropathy is one of the most common complications in patients with Diabetes. (Deshpande, Harris-Hayes, & Schootman, 2008) Neuropathy can lead to impaired sensations and motor functions which can adversely affect gait, balance and postural control. Due to the presence of these impairments, people with Diabetic peripheral neuropathy (DPN) are at increased risk for falls. Falls in elderly may lead to the cascade of complications including high mortality, injuries, reduced quality of life, depression and sedentary behaviors. Falls have a huge economic impact on health care. Direct medical costs for related injuries result in $6 to $8 billion per year in the United States. (Carroll, Slattum, & Cox, 2005)

Otago exercise program (OEP) is a series of exercises emphasizing strength and balance training along with an independent walking plan. OEP can be administered at lower costs (Carande-Kulis, Stevens, Florence, Beattie, & Arias, 2015) and less utilization of the number of Physical Therapy visits available to the patient per year. This program has been studied on community-dwelling elderly patients with stroke to improve fall efficacy. (Park, & Chang, 2016) The purpose of this report is to identify the effects of OEP on balance and functional mobility in diabetic peripheral neuropathy.

Case Description:

The patient was a 65-year-old male who was referred to outpatient physical therapy for DPN. Patient reported being diagnosed with DM for 3 years. He had 3 falls in the past year and was noticing increasing difficulties with routine activities due to weakness and fear of falls. Patient’s goals from Physical Therapy was to be able to get stronger and walk safely. Patient participated in OEP for 8 weeks.

Data Collection:

Physical therapy evaluation included the following domains:

●       History – Chief complaints, Pain levels, Pre-morbid medical history, Surgical history, Review of medication list

●       BMI

●       Vitals assessment

●       Observation – skin condition, gait, and posture analysis

●       Gross ROM of bilateral lower extremities and lumbar spine

●       Gross manual muscle testing of bilateral lower extremities

●       Sensory examination

●       Functional outcome measures (as per table- 1)

Table 1:

Timed Up and GO Test was used to assess functional mobility and determine fall risk. According to Jernigan, Pohl, Mahnken and Kluding, 2012 TUG test demonstrated the highest accuracy at 88.9% of fall risk assessment in people with DPN. TUG is a sensitive and specific measure to identify community dwelling older adults who are at increased for fall risk. (Shumway-Cook, Baldwin, Polissar & Gruber, 1997)

30 sec Sit to Stand Test was utilized to assess functional strength of lower extremities. This test has good test re-test reliability and excellent criterion related validity. (Jones, Rikli & Beam, 1999) Normative data from a study performed by Rikli and Jones, 1999 indicates a cut of score of 17 for men between age of 60-64 years.

Berg Balance Scale was used to assess static and dynamic balance. BBS is designed to measure balance and determine fall risk in older adults (Berg, Wood-Dauphinee, Williams & Maki, 1992; Shumway-Cook, Baldwin, Polissar & Gruber, 1997). It has good sensitivity and specificity for predicting fall risk in community dwelling elderly population with a cutoff score of 45/56. (Berg et al., 1992; Shumway-Cook et al., 1997).

These tests were administered pre and post interventions to assess changes in functional outcomes.

Intervention:

OEP emphasizing series of progressive strength and balance training was implemented for 8 weeks. Patient participated in outpatient physical therapy for once a week for first 4 weeks followed by once in two weeks, total 8 visits. Including Physical Therapy sessions, patient was advised to exercise 3 times a week for 30-45 minutes. Patient was advised for walking twice a week, progressively building up to 30 minutes per day. He was also recommended staying active with his routine activities. Supervised program was implemented at outpatient physical therapy to assure patient’s safety, progression of program and proper form of exercises to avoid muscle substitution. Selected intervention was utilized to reduce fall risk and improve patient’s safety while reducing costs occurring to patient.

References

• Berg, K. O., Wood-Dauphinee, S. L., Williams, J. I., & Maki, B. (1992). Measuring balance in the elderly: validation of an instrument. Canadian Journal of Public Health, 83 (S) 7-11.
• Carande-Kulis, V., Stevens, J. A., Florence, C. S., Beattie, B. L., & Arias, I. (2015). A cost– benefit analysis of three older adult fall prevention interventions. Journal of Safety Research,52, 65-70.
• Carroll, N. V., Slattum, P. W., & Cox, F. M. (2005). The Cost of Falls Among the Community-Dwelling Elderly. Journal of Managed Care Pharmacy, 11(4), 307-316.
• C. Jessie Jones, Roberta E. Rikli & William C. Beam (1999). A 30-s Chair-Stand Test as a Measure of Lower Body Strength in Community-Residing Older Adults. Research Quarterly for Exercise and Sport, 70:2, 113-119.
• Deshpande, A. D., Harris-Hayes, M., & Schootman, M. (2008). Epidemiology of diabetes and diabetes-related complications. Physical Therapy, 88(11), 1254-1264.
• Jernigan, S. D., Pohl, P. S., Mahnken, J. D., & Kluding, P. M. (2012). Diagnostic Accuracy of Fall Risk Assessment Tools in People With Diabetic Peripheral Neuropathy. Physical Therapy, 92(11), 1461-1470.
• Park, Y., & Chang, M. (2016). Effects of the Otago exercise program on fall efficacy, activities of daily living and quality of life in elderly stroke patients. Journal of Physical Therapy Science,28(1), 190-193.
• Rikli, R. E., & Jones, C. J. (1999). Functional Fitness Normative Scores for Community-Residing Older Adults, Ages 60-94. Journal of Aging and Physical Activity, 7(2), 162-181.
• Shumway-Cook, A., Baldwin, M., Polissar, N. L., & Gruber, W. (1997). Predicting the probability for falls in community-dwelling older adults. Physical Therapy, 77(8), 812-819.
• Shumway-Cook, A., Brauer, S., & Woollacott, M. (2000). Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Physical therapy, 80(9), 896-903.