A Combination Effect of Sensory Motor Training and Proprioceptive Neuromuscular Facilitation in A Case of Peripheral Polyneuropathy Manifested by Foot Drop in Type II Diabetes Mellitus – A Case Study

Peripheral neuropathy is one of the common complications in patients with diabetes Mellitus (DM) which leads to disrupting the peripheral nervous system resulting in reduce sensory inputs and motor outputs. Patients with foot drop (FD) will have weakness in dorsiflexor muscles of ankle and toe and sensory loss due to disruption of small myelinated and unmyelinated nerve fibers. Sensory motor training (SMT) will facilitate sensory inputs, correcting muscle imbalance, and ensuring correct program at the level of central nervous system whereas Proprioceptive Neuromuscular facilitation techniques (PNF) not only helps facilitating the weaker group of muscles also improve strength . Hence the purpose of the study to combine the effect on use of SMT along with PNF in a case of peripheral polyneuropathy manifested by foot drop in patient with type II DM. The case report study of 72 year old male patient diagnosed with diabetic polyneuropathy manifested by foot drop in type II diabetes mellitus on medication. Intervention of patient received Sensory motor training and Proprioceptive Neuromuscular


Introduction
Diabetes mellitus (DM) is a metabolic disease depicted by hyperglycemia that results from deficiencies in insulin secretion, insulin action on target tissue, or both. The long-standing of chronic hyperglycemia may result in damage and failure of various organs, namely the kidneys, heart, eyes, blood vessels, and nerves [1,2,3] .According to the WHO, the diabetic population of developing countries around Asia wereestimated about 60% by 2025.Currently, around the globe the second highest number of cases of type 2 DM were in India.Some of the important complications include coronary artery disease, nephropathy, retinopathy, microalbuminuria, and neuropathy. [1,2] One of the most common complications of DM were diabetic peripheral neuropathy (DPN) and is seen in 50% of all patients with diabetes. The main characteristic feature of diabetic neuropathy is the continuing destruction of the nerves which results in reduced sensory inputs and motor outputs. Most of the polyneuropathies result in lengthrelated, distal greater than proximal i.e. foot, sensory loss, weakness and hyporeflexia. This classic description is appropriate for the common distal symmetric polyneuropathy (DSP), but a variety of other patterns are also encountered. Patients with DSP usually report sensory disturbances involving the feet as the presenting symptom. These disturbances may be "negative" in nature, involving loss of sensations described as numbness or deadness and "positive" like dysesthetic sensory symptoms are common as well. These are often described as tingling or "pins and needles", and can range from mild to very severe. Clinically important weakness usually only develops late in progression of the neuropathy, though signs of motor involvement such as weakness in dorsiflexor muscles of ankle and toe and wasting of intrinsic foot muscles are present much earlier and may lead to foot drop which interferes with the initial foot contact at the beginning of the stance phase and hinders ankle dorsiflexion during the swing phase of gait. Consequently, foot drop contributes to disruption in weight acceptance and weight transfer; reduces walking speed, efficiency and stability of gait and increases the risk of falling [3,[4][5] .The individuals having all these symptoms will affect activities of daily living and consequently reduce the quality of life.Previous studies on foot drop which were performed aimed at individually improving range of motion, strength, gait and balance in lower limbs but not on overall augmentation in the performance of the lower limbs in individuals with foot drop. Various interventions have been used to improve the function of the patients with foot drop in the form of stretching, strength training (ST), endurance training (ET), resistance training, functional electrical stimulation (FES), transcutaneous electrical nerve stimulation (TENS), orthosis, balance training, Swiss ball exercises, etc., have been used [6,7] . Sensory motor training (SMT) is a global approach and emphasizes the sensorimotor system function as one unit, and works on enhancing sensory inputs and proper recruitment patterns of various muscles in maintaining joint stability, range of motion, strength, motor learning and sensory loss by regulating movement through Central Nervous System. Proprioceptive Neuromuscular Facilitation (PNF) techniques such as , Slow reversal technique helps to strengthen and build up endurance of weaker muscles or of two antagonistic patterns and to develop co-ordination whereas Rhythmic initiation helps to improve the ability to initiate movement [8,9] .It"s says that sensory and motor functions of Lower Limb (LL) has an important role for a person"s ability to explore and interact with the surroundings in many daily activities. It is also described that lack of sensory and proprioceptive information from lower extremities in distal sensorimotor polyneuropathy patients has resulted in postural instability [10,11] . The activity limitations may in turn lead to restriction in social roles and perceived participation. Despite these problems, little attention is paid to the sensory impairment in diabetic polyneuropathy rehabilitation of the LL [12] . Hence there is a need of study to combine the effect on use of Sensory Motor training and PNF in foot drop patients in type II DM. And consequently there is a great need to develop more efficient rehabilitation interventions for the LL in persons with sensorimotor impairments after diabetic polyneuropathy.

PROPRIOCEPTIVE NEUROMUSCULAR FACILITA-TION
 Rhythmic initiation  Slow reversal 1 st week 10 reps 2 nd week 2 sets of 10 reps 3 rd and 4 th week 3 sets of 10 reps

DISCUSSION
The current case study report on the combine effects of Sensory Motor training and PNF in foot drop patients in type II DM manifested by peripheral polyneuropathy with 4 weeks of intervention with pre and post outcomes i.e. Stanmore Assessment Questionnaire and Diabetic Neuropathy Examination, have shown improved after intervention. The changes within one section of the sensorimotor system are reflected by adaptations made elsewhere in the system thus, the sensori motor system works as one unit [13,14] . The new coordinated movement pattern is programmed in the sub-cortical region becoming more "automatic" and requiring less conscious thought processing, thus becoming much quicker. This explains the possible mechanism of improvement on sensory motor training. At this point, ""feedforward"" mechanisms become important. Feed-forward mechanisms are important in preparing the body for movement by contracting stabilizing muscles prior to initiating the movement which occurs unconsciously. The joints are protected for dynamic functional stability throughout the body due to this automatic level of processing. SMT is to increase proprioceptive input in order to stimulate subcortical pathways and facilitate automatic coordinated movement pattern [6,9,17,18] . Whereas PNF techniques increases the stimulation of mechanoreceptors present in muscle spindle, golgi tendon organs and joint capsule responsible for enhancing proprioception inputs from foot and ankle. Use of PNF techniques suggests a stronger sensory excitation at cortical level leading to increased number and improved threshold of motor neurons which result in improved strength, balance and range of motion, enhances proprioception firing, sensory-motor function, and muscle stabilization [9,[16][17][18][19][20] . On top of that, the manual 26 67 14 8

PRE POST
contact and the tailor-made resistance offered by the therapist also played their role by inducing tactile feedback and making the treatment more subject-specific. In this study we assessed the patient on Stanmore Assessment Questionnaire which showed improvement in degree of active dorsiflexion of ankle and ability to wear normal shoes, whereas Diabetic Neuropathy Examination (DNE) showed improvement in muscle strength of quadriceps femoris, tibialis anterior and improved sensitivity to touch and pin prick.

CONCLUSION
In present case study, from the results of this study, it can be concluded that combination of Sensory Motor Training and Proprioceptive Neuromuscular Facilitation techniques have shown improvement effectively on improving ankle range of motion and strength, sensory discrimination have reduce functional dependence and improve quality of life.