JOURNAL OF NEUROLOGY AND NEUROSURGERY

Introduction

Foot drop is a neurological condition in which the foot can’t be raised due to weakness of the muscles in the leg. It is a debilitating clinical condition characterized by the impairment of dorsiflexion of the foot or paralysis of the Anterior tibia, Extensor Hallucis Longus, and Extensor Digitorum Longus muscles [1,3]. Ankle dorsiflexion weakness causes symptoms like difficulty in lifting the foot towards the shin; this leads to a high-stepping gait and results in multiple falls and tripping. Individuals with foot drop walk with an odd step; they cautiously try to lift their feet as they walk, and in a few, there is clearly toe dragging or limping [2]. Foot drop is often a symptom of an underlying neurological, muscular, or skeletal dysfunction rather than a disease itself. It is a complex, multifaceted ailment, with almost 21% of cases presenting numerous medical disorders as its potential contributing factor [3]. These reasons may include muscular impairment, nerve injury, diabetes, stroke, multiple sclerosis (MS), Polio, and other neuromuscular disorders as spinal cord injury. It is linked to both disc herniation and spinal canal stenosis, two prevalent degenerative lumbar diseases. 62% of cases of Foot drop are due to compression or damage to the common peroneal nerve at the fibular head [4]. Commonly, with damage to the common peroneal nerve, there will be weakness of the tibialis anterior and other key dorsiflexors of the foot. These compressions can be caused by any trauma or injury to the lumbar spinal nerve root, fractures, or space-occupying lesions, leading to foot drop [5].

Foot drop diagnosis includes clinical examination, electromyography (EMG) [4], nerve conduction studies (NCS), and MRI to identify the underlying pathology. At present, treatment choices include surgical interventions in severe cases and functional electrical stimulation (FES) devices to manage the condition. Some alternative therapies have also given good results, including fixed ankle-foot orthoses (AFO) [3] if the weakness is more severe. Generally, 90% of patients undergo physical therapy, which reduces pain and is effective in restoring muscle strength, managing a good range of motion, and speeding up patients' clinical recovery [6,7]. Paakavayu or Panguvata in the Siddha system of medicine is used to describe weakness or paralysis of the limbs, including foot drop, a condition which is clinically characterized as severe weakening of ankles and toe dorsiflexion [8]. Traditional Siddha therapy offers symptomatic relief in foot drop by improving circulation, reducing muscle stiffness, increasing muscular strength, and supporting nerve function. Also, therapy works by aligning the spine, reducing pressure on the nerves, and restoring normal nerve signals to the affected foot [9]. While it does not directly treat the underlying neurological cause, it can help alleviate symptoms and improve mobility when used alongside rehabilitative supports.

Chkarasiddh spine expert therapy (CSET), incorporating Siddha techniques like deep-tissue pressures, varmam (energy) therapy [10], trigger point, and Thokkanam [11] (manipulation) therapy, has aided in the management of several musculoskeletal diseases with a good success rate [12]. Multiple database searches showed that several neurological disorders have been successfully treated with Siddha therapy, but very few case studies describe the management of foot drop secondary to common peroneal nerve injury. This intriguing fact adds to the interest and potential of this treatment. Though past successes where siddha has been used to correct physical dysfunctions in various disorders, the present case required implementation of a comprehensive and personalized treatment regimen rather than being used as a standalone treatment.

This case report aimed to assess the efficacy of a customized Siddha program, CSET, in a 36-year-old male with paraparesis along with left foot drop. Despite utilizing various treatment modalities as physiotherapy, kerala-massages and braces, the patient was unable to get a complete resolution of his condition. As a result, a customized CSET program was designed at Chakrasiddh with the goals of reducing tendonitis tightness, strengthening both extremities, preventing further muscle atrophy due to denervation, improving balance and gait, and improving daily living activities (ADL). Notably, after one month of application of CSET, the patient experienced a substantial improvement in foot mobility, strength, balance, gait, and pelvic floor function. The observed clinical response of this therapeutic approach underscores the need for further investigation into CSET as a possible adjunctive or primary intervention for foot drop cases with unclear etiology.

Case Presentation

A 36-year-old NRI male patient presented in our center, Chakrasiddh, with treatment-resistant foot drop, which was managed well in our clinic with the customized Siddha program “CSET”. His past medical history included a significant fall in his teens, resulting in severe lumbar pain and a foot fracture, initially managed well with conventional pharmacological treatment.

Initial Medical Consultations and Treatment

The patient was apparently right five years back until he contracted COVID-19 in 2020. Post his recovery, he started having lower back pain that was intermittent in nature. Sometimes, the pain was sharp and shooting type, which aggravated on movement and relieved on rest; since he was in Canada, he had to take over-the-counter pain killers to subdue discomfort and pain. Post covid, in India, he went to an orthopedic who suggested complete rest and NSAID’S for pain relief. To avoid taking medicines, he went for Kerala-massage therapy, which aggravated his agony, and he had to switch back to drug therapy. In April 2022, back in Canada, the patient did some intense labor work, after which he felt continuous lower back pain with no relief, even on rest and medications. He somehow managed pain for two years with medications, but there was a complaint of progressive weakness in both lower limbs. Aggravated symptoms made him unable to continue work in Canada, he came to India and visited his neurosurgeon, who went for an MRI (Magnetic Resonance Imaging) for a conclusive diagnosis. MRI was suggestive of spinal canal narrowing with thecal sac compression. On recommendation, he started wearing braces and opted for homeopathic drugs with physiotherapy sessions to strengthen his legs. In due course of time, the onset of foot drop progressed and was insidious in nature. Despite the pain and discomfort, he continued working on the floor in Canada until he noticed severe limping and an inability to bear weight on his left leg; his right leg also felt very weak. Over the next few months in India, he consulted multiple orthopedic, neurologists and underwent various MRIs and EMG studies, all yielding inconclusive results. Despite comprehensive neurological assessments and advanced imaging, no definitive underlying pathology could be established. The patient exhibited persistent functional impairment despite conventional medical interventions, rehabilitation programs, and alternative therapies. After six months of unsuccessful treatments, including traditional and alternative therapies, the patient was referred to our holistic centre “Chakrasiddh”, to seek some positive results.

Clinical Findings

On neurological examination, the range of motion (ROM) [15] of the affected extremity was measured before and after the CSET program (Table 1). For strength, the Manual Muscle Testing (MMT) [13] assessment was done before starting the therapy. According to the tone grading scale, the tone in the right lower limb was found to be +2 (Initiates some motion on gravity), but in the left lower extremity was found to be 1 (Evidence of slight contractibility but no joint motion). According to the American Spinal Injury Association (ASIA) [14] impairment scale, the grade was assessed as B (Incomplete functional impairment).

Table 1: ROM examination pre-therapy of both lower limbs (ROM-Range of motion; AROM-Active range of motion; PROM-Passive range of motion; N/A-Not assessable)

Diagnostic Investigations [2]

Blood counts, general biochemistry, protein, tumor markers, and levels of vitamin B12 and folic acid measured a month ago were either normal or negative; only the Vit D value was low (10 ng/mL). Thoracic spine x-ray depicted mild scoliosis; Lumbar spine X-ray showed degenerative disc at L4-L5, L5-S1, compressing the L4-L5 nerve roots; MRI Report mentioned disc dessication changes with diffuse disc buldge with moderate degree, focal type II posterior annular tear at L4-L5 and L5-S1; causing anterior thecal sac compression, abutting bilateral traversing nerve roots with bilateral inferior neural foramina and relative spinal canal narrowing. Impingement of the traversing right S1 nerve root by a central disc protrusion.

Therapeutic Interventions [16,17]

The patient was treated with CSET, which incorporates Siddha marma (energy) therapy along with Thokkanam therapy for thirty days, with a follow-up after 3 months.

Thokkanam (massages) Therapy: This therapy employs a natural, manual approach to pain management by utilizing targeted pressure techniques such as rhythmic tapping/punching, compressing/gripping, grasping/holding, and precise twisting at points for two minutes for good results. These bio-mechanical manipulations aid in spinal realignment, optimizing musculoskeletal balance, and overall strengthening of the spine and associated muscles.

Marma/Varmam (Energy) Therapy: Siddha varmam or Marma points related to foot movement are stimulated to enhance nerve regeneration. Gentle stretching and vibration-based muscle stimulation can help strengthen weakened foot muscles and activate endogenous healing mechanisms. Over time, this therapy improves the ability to lift the foot, reducing reliance on braces. In this patient, these points were intervened for twenty minutes with each marma point stimulated for only three minutes in each session, and two energy sessions were done by the chief healer. Key varmam points [10,18] for Foot drop, which were therapeutically stimulated, are mentioned in Table 2.

Table 2: Different Varmam Points for Manipulation and Their Location

Dietary Formulations [19]

While there is no specific diet to cure foot drop directly, maintaining a balanced, nutrient-rich diet can help in managing the condition by supporting nerve health, reducing inflammation, and aiding recovery. The patient was advised to incorporate anti-inflammatory food items like chia seeds, flax seeds, walnuts, curcumin, ginger, and berries. Vitamin B12 and B6 play a crucial role in nerve health, so foods like dairy products, bananas, potatoes, and chickpeas were added to the diet. To strengthen muscle function, magnesium-rich foods as spinach, kale, almonds, sunflower seeds, and pumpkin seeds are integrated into a daily diet. An antioxidant-rich diet including whole Grains, brown rice, quinoa, and oats also supports recovery of nerve damage.

Physiotherapy Intervention [20]

A customized physical therapy plan was made for the patient. The patient was given physiotherapy sessions for 4 weeks, along with therapy for nearly 20 minutes every day. The physical therapy regimen included Kegel's exercise, pelvic bridging, static back exercises, core strengthening, and breathing exercises, one set of 10 repetitions. For the first set of 10 repetitions of intrinsic exercise and Active Assisted Range of motion exercise was done. For gait, it was encouraged to walk in tandem, ascend stairs, move ahead and backward, step climb, and navigate obstacles.

Follow-up and Outcome

After implementing CSET therapy for 30 days, the patient reported substantive improvement in gait and muscle strength. Pre- and post-therapy scores of the Berg Balance Test [21], Dynamic Gait Index [22], Barthel Index [23], and Manual Muscle Testing [13] were recorded in Table 3. On evaluating the strength of pelvic floor muscles pre- and post-therapy, it was graded as 2 and 4 simultaneously, which showed a good transformation. Table 4 interprets ROM examination post-CSET.

Discussion