Case Report #1, Draft #4, 1/17/2022

Physical Therapy Treatment for Sensory and Motor Symptoms of Peripheral Neuropathy
Acquired After ICU Hospitalization Following COVID-19 Illness

Author: Brenda Casanova

Research Advisor: Caroline S. Gwaltney, PT, DPT, CWS

Doctoral Program in Physical Therapy

Central Michigan University
Mount Pleasant, Michigan

January 17, 2022

Submitted to the Faculty of the

Doctoral Program in Physical Therapy at

Central Michigan University

In partial fulfillment of the requirements of the

Doctorate of Physical Therapy

Accepted by the Faculty Research Advisor

Caroline S. Gwaltney, PT, DPT, CWS

Date of Approval: _________

 ABSTRACT

Background and Purpose

Over 3 million people infected with COVID-19 were hospitalized in the United States between

January 2020 and December 2021. Prolonged hospitalization and prone positioning improve the

survival rates of COVID-19 illness; however, survivors have demonstrated functional and

physical deficits impacting their quality of life. These deficits include impairments in muscle

strength, sensation, pulmonary function, balance, and walking ability affecting independence and

performance of activities of daily living (ADL) and instrumental activities of daily living

(IADL). Furthermore, peripheral neurological complications have been reported after prolonged

hospitalization and prolonged prone positioning. Current research has addressed the long-term

effects and deficits caused by COVID-19. However, limited research focuses on the treatment

and rehabilitation of those with peripheral neuropathy after COVID-19 hospitalization. The

purpose of this case report was to summarize physical therapy interventions for functional

deficits secondary to prolonged hospitalization and immobility secondary to COVID-19 illness

and peripheral neuropathy secondary to prolonged hospitalization and prone positioning during

mechanical ventilation treatment for COVID-19.

Case Description

A 36-year-old male was referred to outpatient physical therapy for critical illness neuropathy for

15 weeks following COVID-19 illness. The patient required mechanical ventilation for 20 days

in the intensive care unit (ICU), leading to functional deficits due to prolonged immobility. The

patient presented with impaired sensation and motor function consistent with common fibular

nerve damage causing drop foot. He had no active right ankle dorsiflexion, eversion, and

bilateral great toe extension. His impairments led to limitations of balance and gait. He scored a
38 on the BBS and 10 on the DGI, indicating a severe risk of falling. The patient ambulated with

a front-wheeled walker and AFO on the right lower extremity. Physical therapy interventions

consisted of dry needling with electrical stimulation, desensitization, balance, gait, and strength

training.

Outcomes

The patient demonstrated minor improvements in his sensory and motor deficits related to his

peripheral nerve symptoms. However, he also demonstrated notable improvements in his

dynamic standing and walking balance, as noted by scores of 53 on the BBS and 20 on the DGI.

The patient demonstrated improvements in gait as he demonstrated a coordinated ambulation

pattern with minor gait disturbances without the use of an assistive device.

Discussion

The functional improvements made by the patient are similar to improvements made in

individuals with peripheral neuropathy with balance and gait deficits. The patient performed

functional and task-specific balance activities as well as strengthening exercises. Although he

demonstrated remarkable improvements in his balance and gait mechanics, he demonstrated

minor improvements in sensory and motor function due to peripheral nerve injury. It was

uncertain whether the patient presented with peripheral neuropathy due to critical illness

neuropathy or compression injury due to prolonged position. Still, he continued to present with

right foot drop and sensory loss. Peripheral nerve regeneration is a slow process, and it can be

years before full or partial function is regained. Further research should be conducted to

investigate the cause of peripheral nerve injury in patients similar to the one studied in this case

report as a better understanding of the etiology could lead to more effective physical therapy

interventions.
Background and Purpose

The novel Coronavirus disease of 2019 (COVID-19), caused by severe acute respiratory

syndrome-coronavirus 2 (SARS-CoV-2), has rapidly spread and infected more than 47 million

people in the United States at the time of writing this.1,2 This disease can cause mild to severe

impairments; adults older than 65 and people with underlying medical conditions are at increased

risk for severe illness.3 Over 3 million people infected with COVID-19 were hospitalized in the

United States between January 2020 and December 2021.2

Upper respiratory symptoms, including shortness of breath, sore throat, cough, and fever

or chills are the most common symptoms of COVID-19. Respiratory issues can quickly progress

to acute respiratory distress syndrome (ARDS) and acute respiratory failure.4 Severe ARDS

cases have increased worldwide, increasing the use of mechanical ventilation.5 Optimal

positioning for mechanical ventilation consists of prone positioning, which has been considered

one of the few interventions for ARDS to reduce mortality rates.5

Although prolonged hospitalization and prone positioning are necessary to improve the

survival rates of COVID-19 illness, survivors have demonstrated functional and physical deficits

impacting their quality of life.6,7 These deficits include impairments in muscle strength,

sensation, pulmonary function, balance, and walking ability affecting independence and

performance of activities of daily living (ADL) and instrumental activities of daily living

(IADL).6,7 Patients admitted to inpatient rehabilitation after hospitalization demonstrated

improvements in mobility by discharge; however, a significant number of patients still exhibited

significant deficits, especially with functional strength, balance, and gait.6 Given the magnitude

of physical impairments and persistent functional deficits after COVID-19 illness, many

survivors could benefit from ongoing treatment and physical therapy interventions.6,7

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 Following COVID-19 illness hospitalization, recent research7,8 has recommended that

early physical therapy interventions should focus on compensatory strategies to address

problems with performing ADLs and functional tasks. Smith et al7 emphasized utilizing relevant

and task-specific exercises to improve the performance of movement and motor learning. Once

function has been addressed, treatment should integrate activities that focus on strengthening,

endurance training, circuit and high-intensity interval training, balance training, and

interventions to increase range of motion.7,9,10 Dosing and progression of exercises to achieve

overload should depend on the patient’s physiological response to the intervention, according to

Smith et al.7

While the respiratory system is primarily impacted during COVID-19 illness, peripheral

neurological complications have been reported.11,12,13,14,15 Immune-mediated neuropathies

following COVID-19 illness such as Guillian-Barre syndrome and chronic inflammatory

demyelinating polyneuropathy were reported by Fernandaz et al12 and Tsiyggoulis et al.15

Prolonged hospitalization can also lead to peripheral nerve pathology due to intensive care unit

acquired weakness (ICUAW).16 Intensive care unit acquired weakness is a neuromuscular

disorder causing general weakness and failure to wean from a ventilator.16

There are three different subtypes of ICUAW: critical illness neuropathy (CIP), critical

illness myopathy (CIM), and critical illness neuromyopathy (CINM), which is a combination of

CIP and CIM.13,16 Critical illness myopathy is characterized by proximal weakness, sensory

preservation, and atrophy depending on the duration of illness.16 The combination of CIM and

CIP is characterized by proximal weakness, distal sensory loss, and variable atrophy.16

Many patients with COVID-19 illness required intensive care unit treatment and

ventilatory support, increasing the risk of CIM and CIP.11 A recent case series assessed the

2
presence of either CIP or CIM in patients with COVID-19 in the ICU and found a predominance

of CIP diagnoses.11,14,17 Furthermore, a recent prospective study reported 14 COVID-19 patients

out of 111 were diagnosed with ICUAW.17

Interestingly, a recent case series by Hokkoku et al13 described three COVID-19 patients

with ICUAW complicated by nerve compression neuropathy. Nerve compression neuropathy has

been reported secondary to long-standing prone positioning.12,13,18,19,20,21,22,23 The common fibular

nerve is the most frequent nerve compressed in the lower extremities and typically at the level of

the fibular head due to suboptimal knee position during prolonged prone positioning.12,21

Complete or partial footdrop with associated numbness or tingling may be present with fibular

compression neuropathy.21

A recent case series reported neurophysiological data of 7 patients with nerve

compression injuries following COVID-19 illness.18 One of the 7 patients presented with

axonotmesis of the right peroneal nerve at the popliteal fossa/fibular head after being treated with

mechanical ventilation for 37 days. The other COVID-19 survivors presented with upper

extremity nerve compression injuries.18 Additionally, a case serious of 5 patients presented with

unilateral ankle dorsiflexion weakness after ICU prone ventilation during the COVID-19

pandemic.19 The EMG studies conducted in this case series support the possibility that the

etiology was unilateral compressive neuropathy of the common fibular nerve.19

Treatment options for peripheral nerve injury include conservative measures such as pain

medications and physical therapy, steroid injections, and surgery in more severe cases.12 Physical

therapy rehabilitation has been found to be beneficial to improve deficits related to peripheral

neuropathy including impairments in balance, strength, and sensation.24,25,26

3
 Current research has determined exercise to be safe and effective for patients with

peripheral neuropathy.24,25,26 Balance training appeared to be the most effective to improve both

sensory and motor symptoms in peripheral neuropathy according to a systemic review by

Streckmann et al.26 Dynamic and task-specific balance exercises improved parameters of balance

control.26 Granacher et al (Granacher)25 and Bruhn et al (Bruhn)24 concluded that strength training

prevented muscle loss and improved coordination and neural control contributing to improved

stability and gait. Additionally, intra-muscular electrical stimulation through dry needling

(IMES) may be beneficial to improve muscle strength and contraction of de-innervated muscles27

and improve pain, balance, and sensation deficits in patients with idiopathic peripheral

neuropathy.28

Although, current research has addressed the long-term effects and deficits caused by

coronavirus disease, there was limited research focused on the treatment and rehabilitation of

those deficits. The purpose of this case report was to outline physical therapy interventions for

functional deficits secondary to prolonged hospitalization and immobility secondary to COVID-

19 illness and peripheral neuropathy secondary to prolonged hospitalization and prone

positioning during mechanical ventilation treatment for COVID-19.

Prior to preparing this report, assent was obtained from the patient and consent was

obtained from the patient. All information contained in this case report meets the Health

Insurance Portability Accountability Act (HIPAA) requirements of the clinical agency for

disclosure of protected health information. This case report was completed under the direction of

the Department of Physical Therapy and with oversight of the College of Graduate Studies at

Central Michigan University.

Case Description

4
Patient History and Systems Review

A 36-year-old male was referred to an outpatient physical therapy clinic with a diagnosis

of critical illness neuropathy following the onset of COVID-19 approximately 3 months ago.

Shortly after testing positive for COVID-19, the patient experienced shortness of breath and

measured his own oxygen saturation (SpO2) level to be at 51%. The patient’s spouse

immediately drove him to the emergency department. By the time he was admitted to the

hospital, his SpO2 level dropped to 39%.

The patient was transferred from the emergency department to a larger hospital system’s

intensive care unit (ICU) due to his extremely low SpO2 levels. At the time, the patient was still

experiencing shortness of breath but with no other notable COVID-19 symptoms. The patient

was given supplemental oxygen via a nasal cannula for the next couple of days. He was also

progressed to a bipap machine to improve his SpO2 levels shortly after. Unfortunately, his

oxygen levels were not improving, and the attending physician recommended the patient be put

on a ventilator.

On the sixth after being admitted to the ICU, the patient was put on a ventilator for a total

of 20 days. He was taken off the ventilator after 18 days, however, later that day he wasn’t doing

as well as expected and needed to be back on the ventilator for a day and a half. A day after the

removal of the endotracheal tube, the patient noticed numbness in his right lower extremity and

the inability to move his right ankle and left great toe while in acute care. He spent 5 additional

days in acute care working on bed mobility, transfers, and ambulation before being discharged to

inpatient rehab.

In inpatient rehab, he received 3 hours of therapy each day, consisting of both physical

and occupational therapy. After 8 days of treatment in inpatient rehab, he was able to ambulate

5
1200 feet with a four wheeled walker and demonstrated independence with transfers, stairs, and

activities of daily living (ADLs). The patient was discharged home with a referral to outpatient

physical therapy to continue making improvements with balance, endurance, and functional

strength. The inpatient rehabilitation discharge note reported the patient was unable to produce

active ankle dorsiflexion. The note indicated the patient was able to discharge home with

assistance as needed and was at low risk of falling with his four wheeled walker per Timed Up

and Go (TUG). He was also noted to have impaired balance, endurance/activity tolerance, and

strength of the right lower extremity.

The patient reported no prior history of health or mobility issues prior to his diagnosis of

COVID-19. The patient lived with his wife and dog in a 1-story home with 4 stairs to enter. Prior

to being hospitalized, the patient was fostering two elementary-aged relatives; after admission to

the hospital, the children went to live with another relative. Before testing positive for COVID-

19, the patient was independent with all ADLs and ambulated without an assistive device. The

patient had a physical job in construction and played snare drums for church services on the

weekend.

After hospitalization, the patient required a four-wheeled walker to ambulate community

distances and a cane for household distances. He was unable to walk his dog or drive due to his

right lower extremity weakness, impaired balance, and reduced endurance. He ascended and

descended steps with a step-to pattern, leading up with the left and down with the right due to his

inability to dorsiflex his right ankle. The patient required modifications to complete ADLs, as he

donned and doffed his pants and socks in a seated position instead of standing. The patient was

unable to return to his job in construction or stand to play the drums at church.

6
 The patient experienced excruciating, burning pain of the right posterior lower leg and

dorsum of the right foot especially with showering, wearing socks, and rubbing against materials

such as sheets and blankets. The patient took Gabapentin and Tylenol as needed to manage nerve

pain symptoms in the right lower extremity.

The patient stated his goals were to gain function back in the right foot and continue to

make progress his balance and gait deficits. He also wants to be cleared to drive and have enough

standing endurance and stability to don/doff clothing and play the drums. Additionally, he

wanted to ambulate at least a half mile without his walker to walk his dog.

Clinical Impression #1

Given the patient’s history and referral diagnosis of critical illness neuropathy, it was

expected that he would present to physical therapy with bilateral lower extremity weakness and

atrophy. Limited active range of motion of the foot/ankle complex was also anticipated,

considering the patient’s subjective history and inpatient rehabilitation discharge note. Lower

extremity manual muscle testing and range of motion measurements would be helpful to

understand the severity of the patient’s weakness and mobility deficits.

Additionally, altered bilateral sensation and diminished reflexes of the lower extremities

would also be expected with the diagnosis of critical illness neuropathy. Deep tendon reflexes

and light touch sensation testing would help determine the extent of peripheral nerve damage.

Pain throughout his lower extremities was also anticipated given his subjective history. To get a

better understanding of the patient’s pain, the numeric pain rating scale (NPRS) would be useful

to assess his current, best, and worst pain levels.

Because the patient maintained a prone position for prolonged periods of time,

compression injury to the common fibular peripheral nerve was also considered. Due to

7
suboptimal positioning of the knee in the prone position, the common fibular nerve is the most

common nerve compressed in the lower extremity.12 Weakness and atrophy of the muscles

throughout the lateral and anterior compartment of the leg innervated by the common fibular

nerve was possible.

With prolonged bed rest, impaired cardiovascular function and endurance was anticipated

as well as altered balance and stability due the patient’s subjective history of drop foot and

altered sensation. Balance and gait deficits put the patient at an increase fall risk. To determine

fall risk, balance and gait outcome measures including the Berg Balance Scale (BBS) and

Dynamic Gait Index (DGI) would help gain insight on the patient’s stability and function.

Abnormal gait mechanics such as a toe drag or compensatory excessive knee and/or hip flexion

to clear the right foot during the swing phase of gait was expected. Observational gait assessment

utilizing Rancho Los Amigos gait phases and terminology would be necessary to determine gait

dysfunction. Endurance and fatigue would be assessed via observation of heavy or shallow

breathing, sweating, face coloration, and required rest breaks during the BBA and DGI

assessment.

The patient’s cognition may have also been affected given the long duration of

mechanical ventilation. Prolonged ventilation, according to Rengel et al29 is a risk factor for

developing long-term cognitive and functional impairments. Cognition would be assessed based

on the observation of the alertness and orientation levels.

Examination

Observation. The initial examination was performed by a licensed physical therapist prior to the

author’s arrival at the outpatient clinic. The patient was alert and oriented to person, place, time,

and situation. He ambulated with a step-through gait pattern with a four wheeled walker and

8
AFO on the right lower extremity. The patient also ambulated at a slow and controlled gait

speed. He relied on bilateral upper extremity support to ambulate, stand, and transfer from sit to

stand.

Pain. Pain was assessed utilizing the NPRS as outlined by McCaffery.30 The patient was asked to

rate the intensity of his current, best, and worst pain levels over the past 24 hours on a scale for 0

indicating no pain to 10 indicating worst pain imaginable.30 Psychometric properties were based

on non-specific patient population. Excellent interrater reliability between two raters scoring the

0–10-point NPRS was reported by Herr et al.31 Excellent correlation was determined between

NPRS and Visual Analogue Scale (r=0.86) and excellent correlation between NRPS and verbal

descriptor scale (r=0.88).31

The patient noted his current right foot pain to be 3/10 on the 0–10-point NPRS. At best,

his pain was a 3/10 while the pain at his worst was 10/10 in the right foot.

Range of motion. General observational range of motion (ROM) of the lower extremities was

screened based on the procedures determined by Kendall.32 Passive range of motion (PROM)

was within normal limits throughout the patient’s bilateral lower extremities. Lower extremity

active range of motion (AROM) was also within normal limits, except for right ankle

dorsiflexion and bilateral great toe extension as he no active contraction of these muscles.

Strength testing. Manual Muscle Testing (MMT) of the lower extremities was used to measure

motion and strength based on the techniques and test positions defined by Kendall.32 Strength

grades were given to each muscle based on the 5-point scale with 0 demonstrating no voluntary

muscle contraction and 5 demonstrating maximum muscle strength.32

Since there was limited research regarding lower extremity MMT of individuals with

critical illness neuropathy after COVID-19, reliability of MMT for people with inflammatory

9
myopathy (IM) was used. The impairments in people with IM were similar to the impairments

experienced by the patient.33 Baschung et al33 noted the interrater reliability of MMT scores were

excellent (ICC>0.9) for testing strength throughout the body, including ankle extension, hip

abduction, hip extension, and knee extension. Further, MMT scores and dynamometer test scores

have been significantly correlated in patients with neuromuscular or cardiopulmonary conditions

(p<0.001), suggesting that the two methods measure the same level of strength according to

Bohannon.34

The patient presented with notable weakness throughout his bilateral lower extremities.

Right ankle dorsiflexion, right ankle eversion, and bilateral great toe extension were measured to

be 0/5. Although the patient demonstrated full passive ROM of the right foot/ankle complex, he

was unable to achieve muscle contraction in the gravity eliminated position for the right ankle

dorsiflexors, evertors, and great toe extensors. The patient also demonstrated significant

weakness of the right ankle plantar flexors (3/5). He was able to obtain full right plantarflexion

ROM against gravity but was unable to hold the test position against resistance. See Table 1 for a

full list of the patient’s bilateral lower extremity MMT measurements.

Sensory Testing. Dermatome light touch sensation was assessed utilizing the distribution points

of the lower extremities according to American Spinal Injury Association (ASIA) impairment

scale (AIS).35 Although the AIS was developed to test sensation for people with spinal cord

injuries, dermatome distributions points were utilized to determine the patient’s light touch

sensation because of the standardization of the lower extremity key sensory points.

Dermatome sensation testing was used in conjunction with peripheral nerve distribution

light touch sensation testing to differentiate spinal nerve root injury from a peripheral nerve

injury. Light touch sensation of the peripheral nerve distribution was performed according to

10
Reese.36 Sensation was assessed using a cotton ball in supine with the areas of the tested skin

exposed and vision obscured.36

Due to limited research utilizing AIS light touch sensation testing with peripheral nerve

injury and neuropathy, reliability and validity measures were based on individuals with spinal

cord injuries (SCI). Curt and Diez37 analyzed construct validity of the sensory component of the

AIS to somatosensory evoked potentials (SSEP). The AIS scores and SSEP scores were

significantly related to the outcome of ambulation (P < .05), but the sensory component of the

AIS was less sensitive compared to the SSEP.37 AIS light touch sensation testing for chronic SPI

showed excellent interrater reliability (ICC>=0.75) and excellent intra-rater reliability

(ICC=0.99) according to Marino et al.38

Diminished sensation was documented in the L3, L4, and L5 dermatomes of the right

lower extremity. The dermatomes of L1, L2, S1, and S2 were intact. On the left lower extremity,

the patient demonstrated diminished sensation at L5 and S1. Absent sensation of the common

fibular nerve, deep fibular nerve, and superficial fibular nerve was discovered on the right lower

extremity. Decreased/altered sensation of the deep branch of the common fibular nerve was also

noted.

To further determine the extent of the patient’s lower extremity peripheral nerve damage,

the muscle stretch reflex at the Achilles and patellar tendons were assessed utilizing the

guidelines described by Reese.36 The grades range from 0 meaning no response to 4+ signifying

hyperreflexia with 2+ indicating normal response. According to Reese36, Grades 0 and 4+

indicate pathology while grades 1+ and 3+ are generally normal unless asymmetric or paired

with other abnormal findings. Absent or hyporeflexia generally indicate a lower motor neuron

lesion while hyperactive reflexes indicate upper motor neuron disease.

11
 There was limited research validating reliability and validity of the muscle stretch reflex

of the lower extremities especially with individuals with peripheral nerve damage. Deep tendon

reflex reliability was determined based on multiple neurological diagnosis (n=80).39 Litvan et al39

reported that intra-rater reliability (kappa values of .77 to .91) was more accurate than inter-rater

reliability (kappa values of .50-.64) and reliability of lower extremity DTRs was higher than that

of upper extremity DTRs. Validity of DTRs was determined based on the patella reflex response

in asymptomatic individuals. Dafkin et al40 found that subject assessments of the deep tendon

reflexes correlated strongly with electromyographic measurements.

On the right, the patient showed an absent Achilles tendon reflex, as muscle contraction

was not palpable or visible. At the patellar tendon, a minimal response consisting of slight

muscle contraction was observed on the right. The left Achilles tendon reflex was diminished

and patellar tendon reflex was intact.

Balance. The Berg Balance Scale (BBS) was utilized to assess the patient’s static and dynamic

balance as described by Berg.41 The BBS includes 14 sitting and standing functional tasks.

Scoring for each item ranges from 0, indicating lowest level of function, to 4, the highest level of

function.41 The maximum score of the BBS is 56.41 According to Berg et al41, a score less than 45

indicates individuals may be at greater risk of falling. A score of less than 40 on the BBS is

associated with an almost 100% fall risk.42 Due to limited research of assessing balance utilizing

the BBS with patients after COVID-19 infection, reliability and validity data were used based on

chronic obstructive pulmonary disease because of the effect on the pulmonary and cardiovascular

system. Jacome et al43 found interrater reliability to be excellent (ICC=0.94) and intra-rater

reliability adequate (ICC=0.52) for people with COPD. Construct validity had a moderate

correlation (r=0.75) with the Activities-Specific Balance Confidence Scale to assess fall risk for

12
those with COPD. The minimal detectable change (MDC) was 5.9 and a score less than 52.2

indicates a risk for falls.43

The patient performed the BBS with his shoes and AFO off because he described losing

balance most often at home without the use of his AFO. He a scored a 38 on the BBS, indicating

he was at a greater risk of falling. The patient had the most difficulty with turning 360 degrees,

tandem standing, standing on one foot, and reaching forward.

Gait. Observational gait was assessed utilizing Rancho Los Amigos gait phases and terminology

to determine gait dysfunction described by O’Sullivan.44 Minor gait dysfunction was observed

when the patient ambulated with his walker and AFO including a reduced gait speed. For this

reason, gait was assessed without the patient’s prosthesis or assistive device. He ambulated with

excessive right knee and hip flexion to clear his right foot during the swing phase of gait. At

initial contact, there was an absent heal strike as he demonstrated initial forefoot contact instead.

The patient also presented with a reduced gait speed and rigidity in the trunk during ambulation

with occasional loss of balance in the frontal plane.

The Dynamic Gait Index (DGI) was utilized to examine the patient’s balance during gait.

The DGI is used to analyze an individual’s ability to modify and maintain balance while walking

during challenging tasks.45 This was developed as a clinical tool to assess gait, balance, and fall

risk.45 The DGI is typically performed over a distance of 20 feet, and it can be performed with or

without an assistive device. Scores are based on a 4-point scale with “0” meaning severe

impairment and “3” meaning no gait dysfunction.45 The highest score possible is 24 points and

tasks include steady-state walking, walking with changing speeds, walking with head turns both

horizontally and vertically, walking while stepping over and around obstacles, pivoting while

walking, and stair climbing.45

13
 According to Vereeck et al,46 normative data on the DGI for an individual in their thirties

is between 23-24. Again, there is limited research regarding validity and reliability of utilizing

the DGI to assess gait and balance of individuals post COVID-19. However, the patient

presented with foot drop, which is a common walking challenge caused by stroke; according to

the American Stroke Association,47 about twenty percent of stroke survivors have drop foot.

Therefore, reliability and validity measures of the DGI for the post-stroke population were

thought to be relevant for this patient. Jonsdottir & Catteneo48 found the DGI to have excellent

test-retest reliability (ICC>0.94), excellent interrater reliability (ICC=0.96), and moderate

concurrent validity with the ABC (r=0.68) testing individuals’ post-stroke. MDC calculated by

Jonsdottir & Catteneo48 was 2.6 points on the DGI.

The patient scored a 10 out of 25 on the DGI without using his assistive device revealing

he was at increased risk for falling. He demonstrated moderate impairments during gait with

vertical and horizontal head turns, pivot turns, stepping over and around obstacles as he had a

difficult time maintaining speed and smooth gait path. He also demonstrated a loss of balance

during these challenges, causing at least one reactive step to regain stability. While he performed

the pivot turn, he made a slow wide turn to maintain steadiness during this task. The patient had

the ability to alternate steps on the stairs but required bilateral handrail support to perform the

task.

Endurance. During the balance and gait assessments, the patient reported fatigue in his lower

extremities and required 30 seconds or less of standing rest breaks between the standing and gait

functional tasks on the BBS and DGI. After about 5 minutes of performing standing and gait

activities, shallow breathing, sweating, and flushed skin were observed. A seated 2-minute rest

break was required between assessing the BBS and DGI.

14
Clinical Impression #2

The patient presented with extreme weakness throughout the right lower leg as he did

not demonstrate palpable muscle contraction with right ankle dorsiflexion, eversion, and bilateral

great toe extension. The patient also demonstrated absent light touch sensation throughout the

distribution of the right common fibular nerve, right superficial fibular nerve and bilateral deep

fibular nerves. Absent Achille’s tendon and diminished patellar tendon reflexes were observed

on the right lower extremity, while an intact patellar and diminished Achilles’s tendon reflex

were observed on the left lower extremity.

The patient’s strength and sensory impairments affected his ability to maintain balance

and stability during dynamic standing tasks and gait. Based on the BBS and DGI outcome

measures, the patient presented with significant static and dynamic balance deficits and was

considered at a high risk of falling especially without the use of assistive.

The patient had good rehabilitation potential as he did not have previous health

conditions or comorbidities to slow progression of therapy. The patient was also motivated to

return to his normal function which included returning to work and taking care of his kids.

However, the patient remained immobilized for 4 weeks in the hospital, and recovery of his

affected nerves could take years to restore function negatively impacting his rehabilitation

potential. Because the patient was experiencing neuromuscular complications after

hospitalization following the novel COVID-19 illness, the patient was a good candidate for this

case report.

Skilled physical therapy was recommended to address the patient’s deficits through dry

needling with electrical stimulation to improve muscle contraction and strength, desensitization

15
therapy to improve allodynia, balance training to reduce the risk of falling and improve gait, and

strength training of the lower extremities to improve overall function.

The patient and physical therapist collaborated on the goals relevant to the patient’s

deficits and needs. The goals focused on the patient’s impaired standing and gait balance by

demonstration of improved scores on the BBS and DGI. The patient’s goals also addressed right

lower extremity strength deficits and nerve pain. Functional goals that involved ambulation

distance and completion of hobbies were also addressed. See Table 2 for a detailed list of

therapeutic goals.

Intervention

The patient attended outpatient physical therapy 2 times per week for 9 weeks, then 1

time per week for an additional 6 weeks, for a total of 24 treatment sessions. Each session lasted

about 50-60 minutes. Treatment consisted of dry needling with electrical stimulation, therapeutic

exercise; neuromuscular re-education including balance training, proprioceptive, and

coordination training, and desensitization training; therapeutic activity; gait training; and stair

training.

Dry needling. There was limited research for the use of dry needling with electrical

stimulation to improve voluntary muscle activation for patients with peripheral nerve injury

following COVID-19. However, a case report by Nasr et al28 suggested that intramuscular

electrical stimulation and neurodynamic exercises to the treatment of idiopathic neuropathy may

be beneficial to improve pain, balance, and sensation deficits.

Furthermore, intra -muscular electrical stimulation via dry needling as also been used to

stimulate muscle contraction to improve muscle strength in a patient with shoulder subluxation

due to chronic hemiplegia.27 Hultman et al49 reported that only 1/10th of the voltage was needed

16
to activate muscle with IMES versus traditional surface stimulation, suggesting that IMES may

be better tolerated than external stimulation

The patient received intramuscular dry needling paired with electrical stimulation of the

right tibialis anterior and fibularis longus/brevis and bilateral extensor halluces longus/brevis to

stimulate muscle activation and contraction for 24 visits. Dry needling was performed at the

beginning of each treatment session lasting between 5-10 minutes. The needles were placed in

the muscle belly and stimulation intensity was determined at a level sufficient to elicit muscle

contraction at frequency of 2hz.

Desensitization training. Since there is limited research on performing desensitization

training techniques for lower extremity dysesthesia, conclusions and intervention protocols were

interpreted from research based on hand dysesthesia. A systematic review by Quintal50 et al

investigated the evidence on interventions for the treatment of hand dysesthesia in patients after a

peripheral nerve injury. The articles reviewed suggested that tactile stimulation programs may

play a role in decreasing hand dysesthesia, however there was inconclusive evidence and

inconsistent application of tactile stimulation programs. Quintal et al50 found that tactile

stimulation was generally applied between 1 to 12 times per day for <1 to 10 minutes and

application should be increased based on the patient's response (tolerable symptoms or no

increase in pain).

Due to the discrepancies with application of tactile stimulation protocols, the treatment

intervention used in this case report was based on a home desensitization program developed by

the University of Michigan.51 This protocol suggested gradual progression from stimuli that

produce the least painful stimuli response to the most painful response. Once the affected area

begins to adapt to the initial stimulus, another stimulus may be incorporated. Textures were first

17
applied to the patient’s left limb in the same area of pain as the affected limb. The protocol

suggested that materials should be self-applied to the skin using light stroking, firm stroking,

tapping, and circular motions according to what the patient tolerates with eyes open, looking at

what is being applied and where it is applied to the skin. However, the student physical therapist

applied the stimulus initially in the same matter to allow the patient to experience the

desensitization protocol steps. The patient was instructed to say the name of the item applied to

the body and where it was applied out loud while concentrating on how it felt. The same process

was then repeated on the right lower extremity. If the patient experienced similar sensations

between the lower extremities without pain, a more abrasive material was introduced. If the

patient experienced an altered or painful sensation, the same procedure and material was used

again at the next session.

The materials first introduced to the patient were soft objects such as a pillowcase and

microfiber cloth. The soft materials, applied in a circular motion, were used for the first three

weeks of treatment before more abrasive materials were used such as a dry or damp scratchy

washcloth. Finger tapping and vibration was introduced to the skin after a month of consistently

performing desensitization training. This treatment technique was utilized at each treatment

session after dry needling was performed for about 5 minutes for 8 weeks before being

discontinued to home only. The patient was instructed to complete at least 1-8 minutes of

desensitization to the affected area 4-8x each day with varying the stimulus used each day at

home.

Balance and gait training. A systematic review by Streckmann et al26 summarized that

balance training can improve sensory and motor symptoms in peripheral neuropathy. The

systematic review concluded dynamic and task-specific balance exercises improved parameters

18
of balance control such as decreased sway paths, improved unilateral stance, fewer trunk

repositioning errors, faster reaction time, better performance-based mobility, improved static and

dynamic balance, and reduced concern regarding falling for individuals with peripheral

neuropathy. Balance exercises also led to improved gait parameters, such as gait speed and

walking distance. The systematic review concluded sensorimotor training and whole-body

vibration can potentially play a crucial role neural adaptation in individuals with chemotherapy

induced peripheral neuropathy, which shares symptoms similar to critical illness neuropathy.26

The patient performed balance-related exercises at each treatment session for 20-30

minutes with minimal rest breaks between the different balance tasks. The balance exercises

were dynamic and task-specific. The patient performed varying balance exercises based on his

BBS and DGI outcomes and subjective history. Standing balance exercises with dynamic upper

and lower extremity movements on even surfaces were initially performed by the patient,

including reaching to targets in the sagittal and frontal planes with his upper and lower

extremities.

When the patient was able to maintain balance without upper extremity support on level

surfaces while performing extremity movements, the balance exercises were progressed. This

progression included performing dynamic balance activities on uneven surfaces such as blue

foam and DynaDiscs (DynaDisc, Exertools). To further challenge the patient’s dynamic balance,

multi-plane upper and lower extremity movements were introduced to the patient. Reaching

targets and hurdles were placed at varying distances outside of the patient’s base of support.

Multidirectional stepping and alternating step-taps on uneven surfaces were also performed by

the patient.

19
 When the patient demonstrated reduced episodes of loss of balance and when he only

required stand-by assistance with reaching and stepping exercises, balance activities were further

progressed to include squatting, lunging, and step-ups with multi-directional reaching on varying

surfaces including foam, half foam roll, and the full-body vibration plate. A Power Plate (Power

Plate Pro 5, Power Plate Inc.) was used to illicit full-body vibration at a frequency of 30Hz for 30

seconds while the patient performed various balance tasks mentioned above, as suggested by

Streckman.26

Hip, knee, and ankle strategies were also challenged during this phase of treatment by

allowing the patient to lean beyond his limits of stability and to allow for self-correction of

balance. When the patient was able to confidently walk without an assistive device, ambulatory

balance activities were introduced to the patient which included forward and sidestepping over

hurdles, walking with head turns, and walking at different speeds.

Strength Training. According to an article review by Tofthagen et al,52 strength exercises

that specifically target weak lower extremity muscles are safe and effective for individuals with

peripheral neuropathy. Tofthagen et al52 concluded exercise programs conducted by physical

therapists that focused on improving lower extremity strength and balance are safe and reduce

fall risk. A randomized control trial (RCT) conducted by Allet et al53 reported significant

improvements in balance and strength, increased walking speed, and decreased fear of falling

after patients participated in a strength, balance, and functional training program for 60 minutes,

twice a week for 12 weeks. The effects of the strength, balance, and functional training were

maintained for 6 months after the discontinuation of treatment according to Allet et al.53

Strength training was performed in conjunction with balance training to achieve

improvements in functional strength and peripheral neuropathy-related symptoms. Strength

20
training consisted of 15-30 minutes of the treatment session, and exercises were functional,

closed-chained, and challenged the patient’s stability. Strength exercises were performed in a

circuit for 30-45 seconds with a standing 10-20 second rest break between exercises. Circuits

were repeated 2-3 times depending on the assessment of form and fatigue the patient was

experiencing.

Initially the patient performed sit-to-stands at standard chair height and body weight mini

squats and lunges. These activities were progressed when the patient demonstrated good control

over the movement, i.e., no loss of balance or use of upper extremity support. Full body-weight

squats and lunges were introduced next as well as a modified single leg sit to stands (left lower

extremity on stool) between weeks 2-4.

Between weeks 4-6, the patient was introduced to resisted forward/backward walking and

side stepping using a cable machine (Keiser Infinity Series, Keiser Inc.). The level of resistance

was based on the patient’s ability to maintain stability and form with enough resistance to

achieve noted muscle fatigue.

Once the patient was able to maintain form and stability throughout the entirety of the

repeated exercises, reaching in multiple directions with light weight was added to the sit to

stands, squats and lunges at weeks 6-8 of physical therapy. Also, during weeks 6-8, the patient

began performing bilateral forward and lateral step-ups on a 16-inch step and controlled step

down and crossover step-ups on a 6-inch step. Once the patient demonstrated adequate

coordination of movement and without use of upper extremity support, the patient performed

body weight single leg step ups in multiple directions throughout weeks 9-11.

21
 Between weeks 11-13, the patient was able to tolerate power exercises which included

squats with weighted throughs, jumping with upper extremity support, step-ups on 16inch step

with maximal push off, and resisted forward and lateral hops on cable machine.

Outcomes

The patient demonstrated overall improvements after 15 weeks of physical therapy

rehabilitation. The patient’s most notable achievements were improved balance, ambulation, and

functional strength.

Strength

The patient showed improvements in hip and knee strength on the right lower extremity.

See Table 1 for all strength measures. The most notable improvements consisted of the right

ankle evertors and left great toe extensors, which improved from no palpable contraction during

the exam to palpable contraction (1/5) at the completion of therapy.

Sensation

The patient demonstrated improvements in light touch sensation on his lower extremities.

At the examination, he had absent sensation throughout the distribution of the right common

fibular nerve, right superficial fibular nerve, and bilateral deep fibular nerves. After 15 weeks of

intervention, sensation throughout the right common fibular nerve and bilateral deep fibular

nerves were present but diminished. There were no changes in the patient’s sensation of the right

superficial fibular nerve and Achille’s tendon and patellar tendon DTRs at the conclusion of

treatment.

Pain

The patient noted improved nerve pain symptoms throughout the dorsum of his right foot.

He reported did not experience any pain with hot or cold sensations or pain from rubbing against

22
his sheets or putting on socks. He still experienced occasional allodynia over the posterior lateral

aspect of his right lower leg. He noticed similar symptoms present on the dorsum of his left foot,

which were not present initially. The patient noted his pain at best with medication was 0-1/10

and pain at worst was 5-6/10. Without medication, he reported an increase in intensity of his

symptoms to be a 7-8/10, which was an improvement since the initial eval.

Balance

The patient demonstrated improvements on the BBS; his score improved from 38 to 53.

The improvement was clinically significant, according to Jacome et al.43 The patient’s score on

the BBS was just above the cut-off score considered at risk for falling for individuals with

COPD.43 The patient demonstrated improvements with turning 360 degrees, reaching forward,

picking an object up off the floor, and alternating step taps. However, the patient continued to

have difficulty maintaining stability during tandem stance and standing on one foot.

Functionally, the patient was able to transfer without upper extremity support, squat, or lunge to

pick objects off the ground.

Gait

The patient demonstrated notable improvements on the DGI as his score improved by 10

points, which exceeded the MDC reported by Jonsdottir and Catteneo .48Although the patient

showed improvements in his ability to maintain balance and stability while ambulating during

challenging tasks, he did not achieve the normative value of 23-24 for his age range46; he scored

a 20 on the DGI after 15 weeks of treatment. He demonstrated only slight impairment with each

of the different challenges on the DGI; he was able to complete all the tasks but at a slightly

slower speed to allow for extra time to adjust to maintain balance and smooth gait path.

23
Functionally, the patient described improvements in standing and walking muscular endurance.

He also met his goal of walking a half mile and standing for over an hour to play the drums.

Endurance

When reassessing the BBS and DGI at discharge, the patient did not show signs of

shallow breathing, flushed skin, or sweating. He did not require seated or standing rest breaks

between the standing balance tasks or during the gait assessment, indicating an improvement in

his functional endurance.

Discussion

The purpose of this case report was to outline physical therapy interventions for

functional deficits and peripheral neuropathy symptoms related to prolonged hospitalization and

immobility secondary to COVID-19 illness for a 36-year-old male. Physical therapy

interventions consisted of dry needling with electrical stimulation, desensitization training,

balance training, gait training, and strength training.

The patient started therapy with no active muscle contraction of the right ankle

dorsiflexors and evertors and bilateral great toe extensors. By discharge the patient demonstrated

trace contraction of the right ankle evertors and left great toe extensors in the gravity eliminated

position. No improvements were observed of the right ankle dorsiflexors and great toe extensors.

Similar to the findings of Chea et al,54 no improvements of muscular activation were observed.

Chea et al54 summarized percutaneous intramuscular motor electrical stimulation was no more

effective than percutaneous sensory electrical stimulation in facilitating the motor recovery and

had no effect on the functional use of the paretic upper limb or volitionally generated EMG

activity.

24
 Although a case study Chea et al27 observed improvements in muscle activation of the

rotator cuff muscles and pain of a hemiparetic upper extremity of a stroke survivor, the

pathology and affected part of body was not consistent with the patient of this case study. There

was no current research investigating the use of this technique with treatment of motor symptoms

related to critical illness neuropathy or compression nerve injury. However, a case report by

Nasr28 et al suggested that intramuscular electrical stimulation and neurodynamic exercises to the

treatment of idiopathic neuropathy may be beneficial to improve pain, balance, and sensation

deficits which is consistent with this patient.

Although the evidence was inconclusive for utilizing desensitization training to decrease

dysesthesia50, the current patient noted improved nerve pain symptoms throughout his right lower

leg. Stimulus from running water, socks, or sheets no longer provoked burning pain in the

posterior lateral right lower leg or dorsum of the foot. The patient was not initially experiencing

dysesthesia on the dorsum of his left foot as he had absent sensation at the time of the evaluation.

Sensation was possibly returning on the dorsum of his left foot as he progressed from absent

sensation to altered sensation. After 9 weeks of physical therapy, desensitization training was

discontinued to perform at home only and consistency of desensitization treatment was not

maintained.

While the patient experienced minor improvements in sensory and motor deficits related

to his peripheral neuropathy, nerve repair and restoration of sensory and motor symptoms

depends on the extent and type of damage to the nerve.55 There are three classifications of nerve

injuries: neurapraxia, axonotmesis, and neurotmesis.55 Neuropraxia is the first-degree injury that

commonly results in sensory loss and the recovery may take a few days up to 12 weeks.55

Axonotmesis is the second-degree injury leading to axonal loss recovery for this type of nerve

25
injury can be result in full or partial recovery regenerating at slow rate of a 1mm/day.55 It may

take weeks to years to see improvements in sensory and motor symptoms. Neurotmesis is the

third-degree and the most severe nerve injury with no expected recovery.55 Complete recovery of

the patient’s motor and sensory symptoms may depend on the severity of the nerve injury. To

assess both motor and sensory function of the effected nerves, a nerve conduction study may be

beneficial.

At the initial evaluation, the patient presented with impaired balance, A systematic

review by Streckmman et al26 concluded that patients with peripheral neuropathy responded the

best to balance training that was functional and task-specific to improve motor and sensory

symptoms. According to current research, strength training prevented muscle loss and improved

coordination and neural control contributing to improved stability and gait. Further, an article

review by Tofthagen et al52 concluded that exercises focused on improving lower extremity

strength and balance are safe and reduce fall risk. The patient made improvements consistent

with the current research after receiving similar interventions described by Streckmman et al26

and Tofthagen et al.52 Not only did the patient demonstrate improvements on the BBS and DGI,

but he also improved his sensory and motor deficits related to peripheral neuropathy. By

discharge, the patient demonstrated notable lower extremity strength improvements except for

the muscles effected by the right common fibular nerve and left deep fibular nerve. He presented

with improved gait mechanics as he ambulated with equal step and stride lengths at normal gate

speed. Further, he ambulated without an assistive device but required an AFO on the right to

prevent footdrop.

There were various limitations in this case report. The psychometric properties of the

tests and measures used in this case report were not based on individuals following COVID-19

26
illness and complications. There was no literature supporting the interventions addressing

functional deficits and peripheral nerve symptoms following prolonged hospitalization secondary

to COVID-19. However, there was evidence to support balancer, gait, and strength training to

improve symptoms related to peripheral neuropathy. The etiology of the nerve injury was unlike

the comparable diagnoses and in consequent different outcomes were expected. The case report

design is another limitation due to the inability to generalize the outcomes observed to the

greater population. No cause-and-effect relationships can be determined from a case report.

Further research should be conducted to investigate the cause of peripheral nerve injury

in patients similar to the one studied in this case report. A cohort study could be completed using

EMG data to identify the common etiology of peripheral nerve injuries in people after prolonged

hospitalization due to COVID-19. A better understanding of the etiology could lead to more

effective interventions. Patients that have required prolonged hospitalization and prolonged

prone positioning following COVID-19 illness seem to be at an increased risk for peripheral

nerve injury. Identifying potential causes or risk factors would be beneficial for then hospital

staff to reduce the prevalence of these injuries if the neuropathy is due to immobilization.

Additionally, further research to determine effectiveness of physical therapy interventions with

peripheral nerve injuries and/or critical illness neuropathies to determine effectiveness following

COVID-19. Further research would be useful to assess the most beneficial outcome measures for

people after COVID-19 illness in all settings by determining reliability and validity in this

population.

27
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32
Table 1.
Lower Extremity Manual Muscle Testing (Kendall).

Movement Initial Eval: Initial Eval: Discharge: Discharge:

Right Strength Left Strength Right Strength Left Strength
Hip Flexion 4 4 5 5
Hip Abduction 4 4 5 5
Knee Flexion 4 4+ 5 5
Knee Extension 4 4+ 5 5
Ankle Dorsiflexion 0 4+ 0 4+
Ankle Plantar Flexion 3 4+ 3+ 4+
Ankle Eversion 0 4+ 1 4+
Great toe extension 0 0 0 1
0=no movement, no contractions felt in the muscle, 3=moves through full range of motion in the
antigravity position, holds test position with no added pressure, 4=moves through full range of
motion and holds test position against moderate pressure, 4+=moves through full range of
motion and holds test position against moderate to strong pressure, 5=moves through full range
of motion and holds test position against strong pressure
Table 2.
Long-term Goals. To be completed by discharge.

Goals Met Progressing Not Met

The patient will be able to independently don/doff X
clothes while standing.
The patient will be able to ambulate half of a mile X
without an assistive device.
The patient will be able to stand for an hour without a X
seated rest break to allow him to be able to play the
drums at church.
The patient will note no more than 2/10 nerve pain to X
improve quality of life.
The patient will demonstrate a 5/5 MMT for B hip X
abductor strength.
The patient will demonstrate a 5/5 MMT for B hip X
flexor strength.
The patient will demonstrate a 5/5 MMT for B knee X
extensor strength.
The patient will score a 52 on the BBS to reduce his risk X
of falling.
The patient will score a 23 on the DGI to achieve the X
normative value for his age range.
MMT=manual muscle testing