Discussion

Foot drop is characterized by difficulty or inability to move the ankle and toes upward (dorsiflex). The dropping of the forefoot is most commonly caused by a central or peripheral neurological disorder. Less commonly is foot drop a result of musculoskeletal disorders or side effects from pharmaceutical medication.1 Foot drop causes asymmetry in the gait, affecting the swing phase, the step length, and the stance time between steps; resulting in a slower and unstable gait. Furthermore, foot drop consequently leads to increased falls and injuries,2 and limits the ability to perform daily activities. Thus, negatively affecting quality of life.3 Current treatment methods include orthotics/braces4, physical therapy5, nerve stimulation6, medication for muscular spasticity and surgery7.

Background

Acupuncture for the Treatment of Foot Drop: A Case Report Lung-Sheng Hsiao, MD (China)

Judith Miller, MAOM Nathan Yeargin, DC, MAOM

A 75 year-old male presented with left foot drop to the SCU Health System, Whittier, CA starting in July of 2013. The onset of the foot drop occurred four weeks prior and was concurrent with a deep/sharp pain in the low back that radiated down the leg and into the foot. The patient needed a cane to assist him in walking. The low back pain was significantly decreased after chiropractic treatment, but the foot drop still remained unchanged. The patient has a history of episodic chronic low back pain spanning over twenty years due to disc rupture. Previous x-rays show lumbar and sacral degeneration.

CasePresenta3on

Diagnosis

In his initial visit the patient had numbness on his left leg and dorsal area of his foot, subjectively characterized as “heaviness”. Average pain was reported as a 2 out of 10 on the Visual Analogue Pain Scale (VAS) and occurred 25-50% of time. Pain occurred in the low back and traveled into the leg. There was no other significant past medical history or family history reported. Positive physical exam findings included no muscular contraction (grade 0/5) of his left ankle and big toe (dorsiflexion). Also his left C5/C6 and left L4 dermatome showed hypoesthesia (grade 1). His tongue was purple with a wide body, hammer tip, and white coating. The pulse was thin and slippery. His Traditional Chinese Medicine diagnoses were determined as wei syndrome with damp accumulation.

At the end of six treatments, the patient reported he no longer had any pain in his low back or leg, and the range of motion of the ankle improved from 0o to 47o/50o; dorsiflexion strength increased from grade 0 to grade 4-/5; Big Toe dorsiflexion strength increased from grade 0 to grade 4/5. Additionally, the patient did not have to use a cane to assist with walking and reported feeling more confident when walking because he no longer was tripping over the foot or having to lift the hip/thigh up to move the left foot forward. Additionally, it was observed that the patient still had some mild muscular weakness causing the toe off phase and swing phase to still be delayed.

Overall, the patient responded positively to treatment and made significant improvements in muscular contraction and range of motion. However, it is important to note that the patient was simultaneously seeking occasional chiropractic care to manage his low back pain and was given ankle joint taping. He was also advised to do at home exercises to increase muscular function, strength, and mobility. It is unknown how this may have affected the outcome. The patient discontinued regular treatment after the sixth visit and it would have been interesting to record if there was increased improvement after the use of electro-acupuncture. During our literature search, we found little information on the specific study of acupuncture for dfoot drop. However, acupuncture has been reported to have immediate effects on reducing or alleviating pain8, strength performance, restoring neuromuscular function9 and improving quality of life10. More importantly, the contemporary use of scalp acupuncture has found to be effective in treating the numerous chronic and acute central nervous system disorders. Scalp acupuncture follows the western mapping of the cerebral cortex and the regions chosen for acupuncture should correspond to the brain’s neruo-anatomy11. Thereby, demonstrating that acupuncture may be useful in the management and treatment of foot drop.

Conclusion

References1.  LiuK,ZhuW,ShiJ,etal.FootDropCausedbyLumbarDegenera?veDisease:ClinicalFeatures,Prognos?cFactorsofSurgicalOutcome

andClinicalStage.PLoSONE.2013;8(11).2.  SuatE,FatmaU,NilgÜnB.Theeffectsofdynamicankle-footorthosesonfunc?onalambula?onac?vi?es,weightbearingandspa?o-

temporalcharacteris?csofhemipare?cgait.DisabilRehabil.2011;33(25/26):2605-2611.3.  GrahamJ.Footdrop:explainingthecauses,characteris?csandtreatment.BrJNeurosciNurs.2010;6(4):168-1725p.4.  SteinRB,EveraertDG,ThompsonAK,etal.Long-termtherapeu?candortho?ceffectsofafootdrops?mulatoronwalking

performanceinprogressiveandnonprogressiveneurologicaldisorders.NeurorehabilNeuralRepair.2010;24(2):152-167.5.  TaylorP,Barre`C,MannG,WarehamW,SwainI.AFeasibilityStudytoInves?gatetheEffectofFunc?onalElectricalS?mula?onand

PhysiotherapyExerciseontheQualityofGaitofPeopleWithMul?pleSclerosis.Neuromodula:on.2014;17(1):75-84.6.  WilkenfeldAJL.Reviewofelectricals?mula?on,botulinumtoxin,andtheircombina?onforspas?cdropfoot.JRehabilResDev.

2013;50(3):315-32612p.7.  WardAB.Managingspas?cfootdropaderstroke.EurJNeurol.2014;21(8):1053-1054.8.  TheEfficacyofAcupuncturefortheTreatmentofScia?ca:ASystema?cReviewandMeta-Analysis.Evid-BasedComplementAlternMed

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crossovertrial.EurJApplPhysiol.2010;110(2):353-358.10.  FriskJ,KällströmA-C,WallN,FredriksonM,HammarM.Acupunctureimproveshealth-relatedquality-of-life(HRQoL)andsleepin

womenwithbreastcancerandhotflushes.SupportCareCancerOffJMul:natlAssocSupportCareCancer.2012;20(4):715-724.11. HaoJJ,HaoLL.ReviewofClinicalApplica?onsofScalpAcupunctureforParalysis:AnExcerptFromChineseScalpAcupuncture.GlobAdv

HealthMed.2012;1(1):102-121.

Treatment

A total of six acupuncture treatments, once per week for 30 minutes were provided. Scalp acupuncture was administered on the right side of the patient’s head. The scalp areas used included the lower limb region of the Motor Line and the Sensory Line, and the Leg Motor and Sensory Line. Mild manual manipulation was performed, then the patient was asked to walk short distances (approximately 10 feet) with the needles retained. The clinician would watch for visible changes in the gait and also ask the patient to report if it became easier to lift his foot for the heel strike. Acupuncture points on the body included: ST 36, SP 9, GB 34, ST 40 on the left side of the body during the first five courses of treatment. Left ST 41, SP 6, GB34, and ST40 were also stimulated using electro-acupuncture on the sixth treatment.

Results

The current case may provide insight to a promising alternative approach to managing acute cases of foot drop with acupuncture. More rigorous clinical trials are needed to determine both traditional and scalp acupuncture’s role in treating drop foot and understand its specific mechanisms of action, especially if acupuncture can treat more serious and chronic cases of foot drop.

SummaryofPa3entResults•  Lowbackandlegpainresolved•  Dorsiflexionrangeofmo?onincreasedatotalof

47°•  Dorsiflexionofankleandbigtoemusclestrength

increasedfromagrade0toagrade4-/5

SummaryofTreatmentProtocol

•  Sixconsecu?veweeklytreatments

•  ScalpacupunctureontheMotorLine,SensoryLineandtheLegMotorandSensoryLine

•  AcupunctureatledST36,SP9,GB34,ST40

•  Electro-acupunctureusedonsixthtreatmentatSP6toGB41&ST40toGB34