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Michelle Stobart

Acupuncture Case Study: Drop Foot

Foot drop is a condition wherein the patient cannot properly dorsiflex the foot when walking. This often results in the dragging of toes leading to increased risk of tripping. The weakening or sometimes paralysis of the muscles and nerve sensations that control the motor function of the foot results in lifting the knee higher as if marching rather than walking, slapping of the foot onto the ground with each step, dragging the foot when walking, as well as loss of sensation on the top of the foot and in the toes. (Cleveland Clinic, 2023)


Electro acupuncture (e-stim) in combination with manual therapy is a great way to help patients presenting with foot drop regain censorial awareness as well as motor coordination again. There are multiple causes that could create a foot drop issue. In this case study, lumbar radiculopathy was the root.


Patient History

Patient is a 71 year old male with a history of lap band surgery in 2006, two knee surgeries from 2003 to present, and lumbar disc issues from L2-L5. He reports always having some sort of low back pain for years. In 2020, he began to feel numbness in his left leg and his foot function began to decrease. He was told he had a “collapsed L5 impinging upon the nerves” that was leading to the loss of sensory and motor function in his foot. In 2020, he had major surgery on his lower back that resulted in two (2) ten-inch rods and ten (10) screws fusing his lumbar spine with the goal of creating a balanced space between the vertebrae for proper nerve conduction. He began coming to acupuncture in September 2023 as the surgery didn't bring recovery to the nerve issues or left foot drop, though it did decrease, but not eliminate, the pain in his back.


The Initial Visit


To assess the patient's function and sensation, I conducted movement and sensory tests comparing the left and right sides' function, sensation, and range of motion. These evaluations identified dysfunctions affecting communication from spinal nerves to dermatomes and muscles, including:


  • asking patient to dorsiflex and plantar flex the foot while seated and standing stationary

  • watching the patient's gait and noting motor dysfunction in foot, knee, hip and back

  • palpation of the leg musculature with and without dorsiflexion and plantar flexion movements

  • dermatomal nerve sensory testing as it relates to L2-S1 dermatomes

  • palpation of lumbar spine and gluteals with patient in prone position on treatment table

  • palpation of surgical scar and hardware from 2020 surgery


I formulated the following treatment approach to help restore the patient to health:


  • treat muscles of dorsiflexion on left lower leg with electrical stimulation to re-awaken sensation and decrease muscle atrophy

  • treat muscles of lower back to decrease pain and nerve impingement from inflammation

  • treat muscles of gluteals to restore function and aid in gate improvements

  • treat systemic inflammation and stagnation creating additional burden on the system


The Treatment Protocol

Armed with information from the assessment, the diagnosis of Liver Blood and Kidney Deficiency with Qi and Blood stagnation on the Bladder, Stomach and Gallbladder meridians was my diagnosis. My approach to treatment was to:


  • move qi and blood to clear out the stagnation around the lower back and create more free flow to the extremities. I did this through using the pair of LI4 and LR 3, SP10, plus a hand protocol for back pain that includes: Ling Gu 22.05, Da Bai 22.04, Wan Shun Er, Wan Shun Yi (SI3), Luozhen M-UE-24.

  • tonify qi and invigorate blood to bring vitality back to his muscles and tendons. I used ST 36, SP10, GB34, KD3 to address overall qi and blood, activate command point of the muscles and tendons as well as bring extra strength and vitality to lower back and qi through the source point on kidney meridian.

  • stimulate motor and sensory nerve sensation to the left lower leg. I used the foot motor sensory scalp acupuncture points as well as local points of ST 36, GB34, ST 37, ST 40, ST43, GB41 including e-stim on these points (more on this later).

  • Restore function to gluteals that aren't firing and relax tight and tense low back muscles. I used BL17, BL21-BL26 (surgical scar site), M-BW-35 Huatuojiaji points in the BL21-26 region, BL30, BL54, GB 30, BL40 primarily to achieve these objectives.


The patient followed a twice-weekly treatment from September 2023 to January 2024, occasionally meeting once a week due to holidays and scheduling conflicts. The points used varied, adapting to the patient's improvements and needs.


Each session began with patient movement and sensory assessment, followed by scalp acupuncture with manual stimulation while the patient dorsiflexed and plantar flexed the foot with and without resistance to activate brain and nerve pathways. Scalp needles remained in place as the patient moved to a treatment table. In the first month, treatments focused on the lower limb with e-stim and lower back hand protocol while the patient was face-up. The second month involved side-lying treatment on the right side for the lower back and continued e-stim on the left lower leg. In the third month, weekly treatments alternated between supine focus on the lower limb and prone focus on the lower back, both with e-stim. Treatments adapted to address the most pressing issues, and as function and sensation improved, kinesiology foot tape was added post-treatment for support.


Progress was marked by patients reports of pain reduction, restored function and sensation and increase of confidence walking. He has been able to play 18 holes of golf regularly without back pain and with restored confidence walking on hills. Though he wakes with stiffness and some pain, it easily works out as he begins the first few hours of moving around each day. I also made measurements of the patients dorsiflexion of the foot which went from zero degrees of movement from the floor to 10 degrees of movement with visible contraction of tibialis anterior with dorsiflexion. We still have some work to do here, but that is a 40-50% restoration, with normal range of dorsiflexion being between 10 and 20 degrees of movement. (Brockett, 2016)


Use of Electro acupuncture

Electro acupuncture was a huge tool in getting the patient the results he wasn't able to achieve with surgical intervention. I used two types of stim devices: a portable e-stim device with leads for direct needle attachment and the handheld Pointer Plus Stimulator were used. Additionally, I had my patient purchase a Pointer Excel II for at home use for stimulating the lower leg and foot as well as scar remodel work on the lower back surgical site. Body and scalp acupuncture were done with DBC Spring 10 and single needles ranging from .25mm x .30 mm-.50 mm. The perfusion electro acupuncture treatments on the lumbar spine were done with MAC pipe handle needles .25mm x .75mm.


For patient visits, I used continuous low frequency current to stimulate and awaken atrophied muscles and nerves, applying it for 15-20 minutes per session on the lower limb. Occasionally, I added a low/medium frequency combination for the lower back, also for 15-20 minutes. Medium frequency is gentler and used for pain management. I placed the red lead on proximal and medial points and the black lead on distal and lateral points, adjusting based on observations each session. Examples of my lower limb protocols included:


Treatment 1: ST36 red lead to GB 41 black lead

(supine) ST37 red lead to LR 3 black lead

2hz continuous at 4mA (milliamps)


Treatment 2: ST36 red lead to ST 41 black lead

(supine) ST37 red lead to LR 3 black lead

ST40 red lead to ST 43 black lead

2hz continuous at 4mA


Treatment 3: ST36 red lead to ST37 black lead

(supine) SP10 red lead to LR 3 black lead

ST40 red lead to GB34 black lead

2hz continuous at 4mA


For the lower back treatments, I used these treatment protocols:


Treatment 1: BL23 red lead to BL40 black lead (right side)

(side lying) BL 23 red lead to GB 34 black lead (left side)

2 hz continues at 4mA


Treatment 2: BL17 red lead to BL26 black lead

(prone) BL53 red lead to BL 40 black lead

5/25 dense disperse at 2.25 mA


Treatment 3: Exstore lower perfusion treatment

(prone) JJ from L2 to L5

25hz continuous at 2mA


The treatment current intensity varied based on patient tolerance. We started the lower leg at 4 mA, decreasing to 2 mA as sensation and function improved. Initially, the patient couldn't feel the pulses, so I capped it at 4 mA to avoid overstimulation or injury. Lower limb protocols required higher mA than low back protocols. While others might use higher intensities, I prefer lower settings, especially when the patient lacks sensation and can't give feedback. This approach was validated by the patient's functional and sensory improvements and my assessments.


Conclusion

While this is just a single case study, it is my belief that without the use of electro acupuncture in this foot drop case, we wouldn't have obtained the results and improvements seen with this patient. Additionally, I believe it was equally important for the patient to have the hand held device to do daily stimulation on both the lower leg atrophy and the lower back scar tissue to improve tissue relaxation and nerve sense restoration. It is also important to be committed to a treatment plan but flexible within that commitment. The beauty of our work as acupuncturists is that we are not bound by the same thing every time. We can adapt as our patient improves and go back to the drawing board if improvements aren't progressing as we think they should be.


There is much research available on more standardized protocols for neuropathy conditions due to varying causes. In my initial work up for this patient, I relied on that research to help clarify and define some starting points for my treatments. However, it is my belief that published research is a starting point and no substitution for your own observations, inquiry and palpation with your patient. I encourage you to get in there, get curious and get to the root of your patient's problem. This medicine allows us the privilege of curiosity and adaptation. I recommend you take full advantage of that privilege.




About the author

Michelle Stobart is a Licensed Acupuncturist, Certified Yoga Therapist and Thai Massage Practitioner in Athens, Ohio. She incorporates her years of practice as a yoga therapist and massage practitioner into her acupuncture treatments to provide a whole person approach to treatment of musculoskeletal disorders. She specializes in pain management, women's health and emotional disorders. More information about her can be found at www.inhaleyoga.org.


Device Recommendations

ITO-ES 130 – 3 channel professional electrotherapy device

Pointer Plus Stimulator


References

Brockett, Claire L. and Chapman, Graham J. Biomechanics of the ankle. Orthop Trauma. 2016 Jun;30(3):232–238. doi: 10.1016/j.mporth.2016.04.015


Cleveland Clinic. Foot drop. Health Library. 2023. https://my.clevelandclinic.org/health/symptoms/17814-foot-drop


Deadman, P., et al. (2007) A manual of acupuncture. Sung In Printing America, Inc., Daly City.



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