Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial

Brazilian Society of Angiology and Vascular Surgery 2023 guidelines on the diabetic foot

The diabetic foot interacts with anatomical, vascular, and neurological factors that challenge clinical practice. This study aimed to compile the primary scientific evidence based on a review of the main guidelines, in addition to articles published on the Embase, Lilacs, and PubMed platforms. The European Society of Cardiology system was used to develop recommendation classes and levels of evidence. The themes were divided into six chapters (Chapter 1 - Prevention of foot ulcers in people with diabetes; Chapter 2 - Pressure relief from foot ulcers in people with diabetes; Chapter 3 -Classifications of diabetic foot ulcers; Chapter 4 - Foot and peripheral artery disease; Chapter 5 - Infection and the diabetic foot; Chapter 6 - Charcot's neuroarthropathy). This version of the Diabetic Foot Guidelines presents essential recommendations for the prevention, diagnosis, treatment, and follow-up of patients with diabetic foot, offering an objective guide for medical practice.

Clinical and biomechanical effectiveness of foot-ankle exercise programs and weight-bearing activity in people with diabetes and neuropathy: A systematic review and meta-analysis

BACKGROUND

Most interventions to prevent foot ulcers in people with diabetes do not seek to reverse the foot abnormalities that led to the ulcer. Foot-ankle exercise programs target these clinical and biomechanical factors, such as protective sensation and mechanical stress. Multiple RCTs exist investigating the effectiveness of such programs, but these have never been summarised in a systematic review and meta-analysis.

METHODS

We searched the available scientific literature in PubMed, EMBASE, CINAHL, Cochrane databases and trial registries for original research studies on foot-ankle exercise programs for people with diabetes at risk of foot ulceration. Both controlled and non-controlled studies were eligible for selection. Two independent reviewers assessed the risk of bias of controlled studies and extracted data. Meta-analysis (using Mantel-Haenszel's statistical method and random effect models) was performed when >2 RCTs were available that met our criteria. Evidence statements, including the certainty of evidence, were formulated according to GRADE.

RESULTS

We included a total of 29 studies, of which 16 were RCTs. A foot-ankle exercise programme of 8-12 weeks duration for people at risk of foot ulceration results in: (a) no increase or decrease risk of foot ulceration or pre-ulcerative lesion (Risk Ratio (RR): 0.56 (95% CI: 0.20-1.57)); (b) no increase or decrease risk of adverse events (RR: 1.04 (95% CI: 0.65-1.67)); (c) not increase or decrease barefoot peak plantar pressure during walking (Mean Difference (MD): -6.28 kPa (95% CI: -69.90-57.34)); (d) no increase or decrease health-related quality of life (no meta-analysis possible). Likely results in increases in ankle joint and first metatarsalphalangeal joint range of motion (MD: 1.49° (95% CI: -0.28-3.26)) may result in improvements in neuropathy signs and symptoms (MD: -1.42 (95% CI: -2.95-0.12)), may result in a small increase in daily steps in some people (MD: 131 steps (95% CI: -492-754)), and may not increase or decrease foot and ankle muscle strength and function (no meta-analysis was possible).

CONCLUSIONS

In people at risk of foot ulceration, a foot-ankle exercise programme of 8-12 weeks duration may not prevent or cause diabetes-related foot ulceration. However, such a programme likely improves the ankle joint and first metatarsalphalangeal joint range of motion and neuropathy signs and symptoms. Further research is needed to strengthen the evidence base, and should also focus on the effects of specific components of foot-ankle exercise programs.

Effects of foot and ankle mobilisations combined with home stretches in people with diabetic peripheral neuropathy: a proof-of-concept RCT

INTRODUCTION

People with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st metatarsophalangeal (MTP) joint mobilisations and home-based stretches in people with DPN improve joint range of motion (ROM) and reduce forefoot PPPs.

DESIGN AND METHODS

Sixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n = 31) and home-based stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test, static 1st MTP joint dorsiflexion ROM, dynamic plantar pressure and balance.

RESULTS

At T1 and T2 there was no difference between both groups in ankle dorsiflexion in stance phase, plantar pressure and balance. Compared to the control group, the intervention group showed a statistically significant increase in static ankle dorsiflexion range (Left 1.52 cm and 2.9cms, Right 1.62 cm and 2.7 cm) at 6 (T1) and 18 weeks (T2) respectively p < 0.01). Between group differences were also seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux dorsiflexion ROM (4.9°, p < 0.01) at T2 follow up. Further, functional reach showed a significant increase in the intervention group (T1 = 3.13 cm p < 0.05 and T2 = 3.9 cm p < 0.01). Intervention adherence was high (80%).

CONCLUSIONS

Combining ankle and 1st MTP joint mobilisations with home-based stretches in a 6-week programme in people with DPN is effective in increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk.

TRIAL REGISTRATION

https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03195855 .

Systematic review and meta-analysis of the effects of foot and ankle physical therapy, including mobilisations and exercises, in people with diabetic peripheral neuropathy on range of motion, peak plantar pressures and balance

To evaluate the effects of foot and ankle physical therapy on ankle and first metatarsophalangeal joint range of motion (ROM), peak plantar pressures (PPPs) and balance in people with diabetes. MEDLINE, EBSCO, Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database of Systematic Reviews, PROSPERO, EThOS, Web of Science and Google Scholar were searched in April 2022. Randomised Controlled Trials (RCT), quasi-experimental, pre-post experimental design and prospective cohort studies were included. Participants were people with diabetes, neuropathy and joint stiffness. Interventions included physical therapy such as mobilisations, ROM exercises and stretches. Outcome measures focused on ROM, PPPs and balance. Methodological quality was assessed with Critical Appraisal Skills Programme RCT and Risk-of-Bias 2 tool. Meta-analyses used random-effects models and data was analysed using the inverse variance method. In total, 9 studies were included. Across all studies, participant characteristics were similar; however, type and exercise dosage varied greatly. Meta-analysis was performed with four studies. Meta-analysis showed significant effects of combined exercise interventions in increasing total ankle ROM (3 studies: MD, 1.76; 95% CI, 0.78-2.74; p = 0; I2  = 0%); and reducing PPPs in the forefoot area (3 studies; MD, -23.34; 95% CI, -59.80 to 13.13; p = 0.21, I2  = 51%). Combined exercise interventions can increase ROM in the ankle and reduce PPPs in the forefoot. Standardisation of exercise programmes with or without the addition of mobilisations in the foot and ankle joints needs further research.

Impact of biomechanics on therapeutic interventions and rehabilitation for major chronic musculoskeletal conditions: A 50-year perspective

The pivotal role of biomechanics in the past 50 years in consolidating the basic knowledge that underpins prevention and rehabilitation measures has made this area a great spotlight for health practitioners. In clinical practice, biomechanics analysis of spatiotemporal, kinematic, kinetic, and electromyographic data in various chronic conditions serves to directly enhance deeper understanding of locomotion and the consequences of musculoskeletal dysfunctions in terms of motion and motor control. It also serves to propose straightforward and tailored interventions. The importance of this approach is supported by myriad biomechanical outcomes in clinical trials and by the development of new interventions clearly grounded on biomechanical principles. Over the past five decades, therapeutic interventions have been transformed from fundamentally passive in essence, such as orthoses and footwear, to emphasizing active prevention, including exercise approaches, such as bottom-up and top-down strengthening programs for runners and people with osteoarthritis. These approaches may be far more effective inreducing pain, dysfunction, and, ideally, incidence if they are based on the biomechanical status of the affected person. In this review, we demonstrate evidence of the impact of biomechanics and motion analysis as a foundation for physical therapy/rehabilitation and preventive strategies for three chronic conditions of high worldwide prevalence: diabetes and peripheral neuropathy, knee osteoarthritis, and running-related injuries. We conclude with a summary of recommendations for future studies needed to address current research gaps.

The Effects of a 12-Week-Long Sand Exercise Training Program on Neuromechanical and Functional Parameters in Type II Diabetic Patients with Neuropathy

Studies have proven the effectiveness of different weight-bearing exercise interventions for diabetic patients with neuropathy; however, several adverse effects were reported using solid surfaces. Thus, in the present study, we investigated the effects of a novel sand exercise training intervention on biomechanical and functional parameters in seven diabetic patients (age = 62.7 ± 9.7 years) with neuropathy. Patients underwent a 12-week sand exercise training program, using strengthening, stretching, balance, and gait exercises. They were tested for ankle plantar- and dorsiflexion peak torque, active range of motion (ROM), timed up and go (TUG), and bilateral static balance. EMG activity of tibialis anterior (TA), gastrocnemius medialis (GM), and lateralis (GL) muscles were measured during unilateral isometric contraction in plantar- and dorsiflexion. In the intervention period, plantarflexion peak torque improved significantly (p = 0.033), while dorsiflexion torque remained unchanged. Plantar- and dorsiflexion ROM increased (p = 0.032) and (p = 0.021), respectively. EMG activity of GM (p = 0.005) and GL (p = 0.002) measured during dorsiflexion and postural sway in the balance test, as well as time to complete the TUG test, decreased significantly (p = 0.021) and (p = 0.002), respectively. No adverse effect was reported during the intervention period. We concluded that sand exercise training can be a safe and effective method to improve plantarflexion strength, ankle flexibility, and balance, which is reflected in better gait function in patients with diabetic peripheral neuropathy (DPN).

Exercise in adults admitted to hospital with diabetes-related foot ulcers: a pilot study of feasibility and safety

Background

Diabetes-related foot ulcers result in significant mortality, morbidity and economic costs. Pressure offloading is important for ulcer healing, but patients with diabetes-related foot ulcers are presented with a dilemma, because whilst they are often advised to minimise standing and walking, there are also clear guidelines which encourage regular, sustained exercise for patients with diabetes. To overcome these apparently conflicting recommendations, we explored the feasibility, acceptability and safety of a tailored exercise program for adults admitted to hospital with diabetes-related foot ulcers.

Methods

Patients with diabetes-related foot ulcers were recruited from an inpatient hospital setting. Baseline demographics and ulcer characteristics were collected, and participants undertook a supervised exercise training session comprising aerobic and resistance exercises followed by prescription of a home exercise programme. Exercises were tailored to ulcer location, which complied with podiatric recommendations for pressure offloading. Feasibility and safety were assessed via recruitment rate, retention rate, adherence to inpatient and outpatient follow up, adherence to home exercise completion, and recording of adverse events.

Results

Twenty participants were recruited to the study. The retention rate (95%), adherence to inpatient and outpatient follow up (75%) and adherence to home exercise (50.0%) were all acceptable. No adverse events occurred.

Conclusions

Targeted exercise appears safe to be undertaken by patients with diabetes-related foot ulcers during and after an acute hospital admission. Recruitment in this cohort may prove challenging, but adherence, retention and satisfaction with participation in exercise were high.

Trial registration

The trial is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12622001370796).

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-023-00616-0.

Weight-bearing physical activity in people with diabetes-related foot disease: A systematic review

INTRODUCTION

Weight-bearing physical activity is important for people with diabetes-related foot disease but may also contribute to ulceration or delayed ulcer healing. No overview of weight-bearing activity of people at different stages of foot disease is available. We aimed to summarise quantitatively measured daily activity levels in people with diabetes-related foot disease.

METHODS

We systematically searched peer-reviewed literature for studies reporting objectively measured weight-bearing activity in people with diabetes-related foot disease. We calculated daily step counts' means (over studies) and weighted means (over participants). International Working Group on the Diabetic Foot (IWGDF) risk strata, different climates, and activity indoors versus outdoors were compared.

RESULTS

From 1247 publications, 27 were included. Mean steps/day in people with IWGDF risk 1/2: 6125 (12 studies; 345 participants; weighted mean: 5384). In IWGDF risk 3: 6167 (8 studies; 291 participants; weighted mean: 6239). In those with a foot ulcer: 4248 (6 studies; 186 participants; weighted mean: 4484). People living in temperate oceanic climates are more active compared to those in hotter or more humid climates (mean steps/day for no ulcer: 7712 vs. 5224 [18 studies]; for ulcer: 6819 vs. 2945 [6 studies]). People are more active indoors than outdoors (mean 4047 vs. 2514 [3 studies]).

CONCLUSION

Levels of weight-bearing physical activity are similar between people with diabetes at various risk levels for foot ulceration but lower for those with a foot ulcer. Weight-bearing activity differs depending on the climatological environment and is higher indoors than outdoors. These findings provide reference for intervention studies or for clinicians aiming to provide mobility advice in this population.

Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

BACKGROUND

There are no current Australian guidelines on the prevention of diabetes-related foot ulceration (DFU). A national expert panel aimed to systematically identify and adapt suitable international guidelines to the Australian context to create new Australian evidence-based guidelines on prevention of first-ever and/or recurrent DFU. These guidelines will include for the first-time considerations for rural and remote, and Aboriginal and Torres Strait Islander peoples.

METHODS

The National Health and Medical Research Council procedures were followed to adapt suitable international guidelines on DFU prevention to the Australian health context. This included a search of public databases after which the International Working Group on the Diabetic Foot (IWGDF) prevention guideline was deemed the most appropriate for adaptation. The 16 IWGDF prevention recommendations were assessed using the ADAPTE and GRADE systems to decide if they should be adopted, adapted or excluded for the new Australian guideline. The quality of evidence and strength of recommendation ratings were re-evaluated with reference to the Australian context. This guideline underwent public consultation, further revision, and approval by national peak bodies.

RESULTS

Of the 16 original IWGDF prevention recommendations, nine were adopted, six were adapted and one was excluded. It is recommended that all people at increased risk of DFU are assessed at intervals corresponding to the IWGDF risk ratings. For those at increased risk, structured education about appropriate foot protection, inspection, footwear, weight-bearing activities, and foot self-care is recommended. Prescription of orthotic interventions and/or medical grade footwear, providing integrated foot care, and self-monitoring of foot skin temperatures (contingent on validated, user-friendly and affordable systems becoming available in Australia) may also assist in preventing DFU. If the above recommended non-surgical treatment fails, the use of various surgical interventions for the prevention of DFU can be considered.

CONCLUSIONS

This new Australian evidence-based guideline on prevention of DFU, endorsed by 10 national peak bodies, provides specific recommendations for relevant health professionals and consumers in the Australian context to prevent DFU. Following these recommendations should achieve better DFU prevention outcomes in Australia.

Foot-ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial

This study sought to determine whether a foot–ankle therapeutic exercise program can improve daily physical activity (i.e. number of steps) and fast and self-selected gait speed in people with diabetic peripheral neuropathy (DPN). In this single-blind randomized controlled trial and intention-to-treat analysis, 78 volunteers with DPN were allocated into a control group, which received usual care, and an intervention group (IG), which received usual care plus a 12-week foot–ankle exercise program. The adherence at 12 weeks rate in the IG was 92.3% (36 participants) and the dropout was 5.1% in the control group (2 participants). The number of steps and self-selected gait speed did not change significantly in either group (p > 0.05), although a 1,365-step difference between groups were observed at 1-year followup. The 12-week foot–ankle therapeutic exercises improved significantly fast-gait speed (primary outcome) (p = 0.020), ankle range of motion (p = 0.048), and vibration perception (secondary outcomes) (p = 0.030), compared with usual-care at 12 weeks. At 24 weeks, the IG showed better quality of life than controls (p = 0.048). At 1-year, fast-gait speed and vibration perception remained higher in the IG versus controls. Overall, the program may be a complementary treatment strategy for improving musculoskeletal and functional deficits related to DPN.

Trial registration ClinicalTrials.gov NCT02790931 (06/06/2016).

Relationship Between Plantar Tissue Hardness and Plantar Pressure Distributions in People With Diabetic Peripheral Neuropathy

Objective: People with diabetic peripheral neuropathy (DPN) are usually accompanied with increased plantar pressure. Such high plantar loading during daily activities may cause changes in the biomechanical properties of plantar soft tissue, whose viability is critical to the development of foot ulcers. This study aimed to investigate the relationship between plantar tissue hardness and plantar pressure in people with and without DPN, and preliminarily explore the influence of plantar loading patterns on the plantar pressure and tissue hardness.

Methods: The study was conducted on 14 people with DPN and 14 diabetic people without DPN. The Shore durometer and MatScan System were used to measure the plantar tissue hardness and plantar pressure, respectively. The plantar loading level was evaluated by the duration of daily weight-bearing activity and was used to group diabetic participants with and without DPN into two subgroups (lower loading group and higher loading group).

Results: The plantar tissue hardness was significantly correlated with static peak plantar pressure (PPP, p < 0.05) and dynamic pressure-time integral (PTI, p < 0.05) in the forefoot region in people with DPN. Results of variance analysis showed a significant interaction effect between peripheral neuropathy and plantar loading on tissue hardness (p < 0.05), but not plantar pressure. For people with DPN, significant differences in tissue hardness between the higher loading group and lower loading group were observed in the forefoot, midfoot and hindfoot regions. In the higher loading group, people with DPN had significantly greater tissue hardness than that in people without DPN in the toes, forefoot, midfoot and hindfoot regions (p < 0.05).

Conclusions: There is a significant correlation between tissue hardness and PPP, and between tissue hardness and PTI in people with DPN. Plantar loading associated with daily activities plays a significant role on the plantar tissue hardness in people with DPN. The findings of this study contribute to further understand the relationship between increased plantar tissue hardness and high plantar pressure in people with diabetic peripheral neuropathy.

Effects of progressive resistance training in individuals with type 2 diabetic polyneuropathy: a randomised assessor-blinded controlled trial

AIMS/HYPOTHESIS

The aim of this study was to evaluate the effects of progressive resistance training (PRT) on muscle strength, intraepidermal nerve fibre density (IENFD) and motor function in individuals with type 2 diabetic polyneuropathy (DPN) and to compare potential adaptations to those of individuals with type 2 diabetes without DPN and healthy controls.

METHODS

This was an assessor-blinded trial conducted at the Neurology department, Aarhus University Hospital. Adults with type 2 diabetes, with and without DPN and healthy control participants were randomised to either supervised PRT or non-PRT for 12 weeks. Allocation was concealed by a central office unrelated to the study. The co-primary outcomes were muscle strength in terms of the peak torque of the knee and ankle extensors and flexors, and IENFD. Secondary outcome measures included the 6 min walk test (6MWT), five-time sit-to-stand test (FTSST) and postural stability index obtained by static posturography.

RESULTS

A total of 109 individuals were enrolled in three groups (type 2 diabetes with DPN [n = 42], type 2 diabetes without DPN [n = 32] and healthy control [n = 35]). PRT resulted in muscle strength gains of the knee extensors and flexors in all three groups using comparative analysis (DPN group, PRT 10.3 ± 9.6 Nm vs non-PRT -0.4 ± 8.2 Nm; non-DPN group, PRT 7.5 ± 5.8 Nm vs non-PRT 0.6 ± 8.8 Nm; healthy control group, PRT 6.3 ± 9.0 Nm vs non-PRT -0.4 ± 8.4 Nm; p<0.05, respectively). Following PRT the DPN group improved the 6MWT (PRT 34.6 ± 40.9 m vs non-PRT 2.7 ± 19.6 m; p=0.001) and the FTSST (PRT -1.5 ± 2.2 s vs non-PRT 1.5 ± 4.6 s; p=0.02). There was no change in IENFD following PRT in any of the groups.

CONCLUSIONS/INTERPRETATION

PRT improved muscle strength of the knee extensors and flexors and motor function in individuals with type 2 diabetic polyneuropathy at levels comparable with those seen in individuals with diabetes without DPN and healthy control individuals, while no effects were observed in IENFD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03252132 FUNDING: Research reported in this paper is part of the International Diabetic Neuropathy Consortium (IDNC) research programme, supported by a Novo Nordisk Foundation Challenge Program grant (grant no. NNF14OC0011633) and Aarhus University.

Prevention of Peripheral Distal Polyneuropathy in Patients with Diabetes: A Systematic Review

Background: Diabetic peripheral neuropathy (DPN) is the most frequent chronic complication and is that which generates the highest disability and mortality in diabetes mellitus (DM). As it is currently the only microvascular complication of DM without a specific treatment, prevention is essential. The aim of this study was to determine the most effective preventive strategy to avoid or delay the appearance and/or development of DPN in patients with DM. Methods: A systematic search was carried out in the main health science databases (PubMed, Scopus, CINAHL, PEDro and The Cochrane Library) from 1 January 2010 to 31 August 2020. The study selection was conducted by two independent reviewers and data extraction was performed by the author. The eligibility criteria included randomized clinical trials (RCTs) and cohort studies from RCTs. Results: Eleven studies were selected that included 23,595 participants with DM. The interventions evaluated were intensive or standard glycemic control, the use of drugs to achieve glycemic control, and the promotion of a healthy lifestyle and exercise. Intensive glucose control achieved a significant reduction in the development of DPN in TIDM patients, and lifestyle modifications and exercise achieved it moderately in TIIDM patients. Conclusions: The main preventive strategy for DPN is intensive glycemic control with a target HbA1c < 6% in patients with TIDM and standard control of 7.0−7.9 in patients with TIIDM, incorporating lifestyle modifications.

Effect of lower body positive pressure aerobic training on fall risk in patients with diabetic polyneuropathy: randomized controlled trial

BACKGROUND

Retarded task-oriented gait, balance performance and increased fall risk are among the most debilitating problems in patients with diabetic polyneuropathy (DPN). The lower body positive pressure (LBPP) training was recently introduced in the field of rehabilitation, but evaluating the effects of the LBPP on gait, balance and fall risk in patients with DPN has not been thoroughly investigated.

AIM

The aim of this study was to evaluate the effect of LBPP treadmill training program on task-oriented gait, balance performance and fall risk in patients with DPN.

DESIGN

Single-blinded, randomized-controlled trial.

SETTING

Rehabilitative outpatient unit.

POPULATION

Sixty-two patients with DPN were randomly assigned into 5-groups; group-A (100% weight-bearing; N.=12), group-B (75% weight-bearing; N.=13), group-C (50% weight-bearing; N.=13), group-D (25% weight-bearing; N.=12) and group-E (control group; N.=12).

METHODS

The intervention groups (A, B, C, D) received moderate intensity aerobic exercise training (AET) program (30-45 minutes, 50-70% heart rate reserve) on the AlterG (AlterG, Inc., Fremont, CA, USA) treadmill for 12-weeks. Task-oriented gait, balance performance and the fall risk were evaluated at baseline (evaluation-1), after 12-weeks (evaluation-2) and 12-weeks poststudy cessation (evaluation-3; follow-up) for all groups using the Tinetti balance assessment tool.

RESULTS

At evaluation-2, there were significant "within-groups" increases in the balance, gait and fall risk scores. There were significant "between-groups" differences in the same evaluated variables, with the highest increases were in group-B (P<0.05). At evaluation-3, there was a decline in the mean values of the evaluated variables, but still significant increases in the mean values of balance, gait and fall risk compared to the baseline mean values. There were significant "between-groups" differences in all variables, with the highest increases were in group-B (P<0.05).

CONCLUSIONS

Moderate intensity LBPP treadmill training program can effectively improve task-oriented gait, balance performance, and fall risk scores in patients with DPN. The 25% off-loading weight percentage during the LBPP treadmill training program yielded the most favorable short and long-term improvements compared to the other weight off-loading percentages in patients with DPN.

CLINICAL REHABILITATION IMPACT

The LBPP aerobic training program is an effective rehabilitation procedure in patients with DPN especially when utilizing the 25% off-loading weight percentage during the LBPP treadmill training program.

Exercise as Treatment for Neuropathy in the Setting of Diabetes and Prediabetic Metabolic Syndrome: A Review of Animal Models and Human Trials

BACKGROUND

Peripheral neuropathy is among the most common complications of diabetes, but a phenotypically identical distal sensory predominant, painful axonopathy afflicts patients with prediabetic metabolic syndrome, exemplifying a spectrum of risk and continuity of pathogenesis. No pharmacological treatment convincingly improves neuropathy in the setting of metabolic syndrome, but evolving data suggest that exercise may be a promising alternative.

OBJECTIVE

The aim of the study was to review in depth the current literature regarding exercise treatment of metabolic syndrome neuropathy in humans and animal models, highlight the diverse mechanisms by which exercise exerts beneficial effects, and examine adherence limitations, safety aspects, modes and dose of exercise.

RESULTS

Rodent models that recapitulate the organismal milieu of prediabetic metabolic syndrome and the phenotype of its neuropathy provide a strong platform to dissect exercise effects on neuropathy pathogenesis. In these models, exercise reverses hyperglycemia and consequent oxidative and nitrosative stress, improves microvascular vasoreactivity, enhances axonal transport, ameliorates the lipotoxicity and inflammatory effects of hyperlipidemia and obesity, supports neuronal survival and regeneration following injury, and enhances mitochondrial bioenergetics at the distal axon. Prospective human studies are limited in scale but suggest exercise to improve cutaneous nerve regenerative capacity, neuropathic pain, and task-specific functional performance measures of gait and balance. Like other heath behavioral interventions, the benefits of exercise are limited by patient adherence.

CONCLUSION

Exercise is an integrative therapy that potently reduces cellular inflammatory state and improves distal axonal oxidative metabolism to ameliorate features of neuropathy in metabolic syndrome. The intensity of exercise need not improve cardinal features of metabolic syndrome, including weight, glucose control, to exert beneficial effects.

Exercise and Neuropathy: Systematic Review with Meta-Analysis

INTRODUCTION

Peripheral neuropathies are a prevalent, heterogeneous group of diseases of the peripheral nervous system. Symptoms are often debilitating, difficult to treat, and usually become chronic. Not only do they diminish patients' quality of life, but they can also affect medical therapy and lead to complications. To date, for most conditions there are no evidence-based causal treatment options available. Research has increased considerably since the last review in 2014 regarding the therapeutic potential of exercise interventions for patients with polyneuropathy.

OBJECTIVE

Our objective in this systematic review with meta-analysis was to analyze exercise interventions for neuropathic patients in order to update a systematic review from 2014 and to evaluate the potential benefits of exercise on neuropathies of different origin that can then be translated into practice.

METHODS

Two independent reviewers performed a systematic review with meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Inclusion criteria according to the PICOS approach were: neuropathic patients, exercise interventions only, an inactive or non-exercising control group, and solely randomized controlled trials with the following outcome parameters: neuropathic symptoms, balance parameters, functional mobility, gait, health-related quality of life, and HbA1c (glycated hemoglobin).

RESULTS

A total of 41 randomized, controlled trials met all inclusion criteria, 20 of which could be included in the quantitative analysis. Study quality varied from moderate to high. Current data further support the hypothesis that exercise is beneficial for neuropathic patients. This is best documented for patients with diabetic peripheral neuropathy (DPN) (27 studies) as well as for chemotherapy-induced peripheral neuropathy (CIPN) (nine studies), while there are only few studies (five) on all other causes of neuropathy. We found standardized mean differences in favor of the exercise group of 0.27-2.00 for static balance, Berg Balance Scale, Timed-up-and-go-test, nerve conduction velocity of peroneal and sural nerve as well as for HbA1c in patients with DPN, and standardized mean differences of 0.43-0.75 for static balance, quality of life, and neuropathy-induced symptoms in patients with CIPN.

CONCLUSION

For DPN, evidence-based recommendations can now be made, suggesting a combination of endurance and sensorimotor training to be most beneficial. For patients with CIPN, sensorimotor training remains the most crucial component. For all other neuropathies, more high-quality research is needed to derive evidence-based recommendations. Overall, it seems that sensorimotor training has great potential to target most neuropathies and combined with endurance training is therefore currently the best treatment option for neuropathies. REGISTRATION NUMBER: (PROSPERO 2019 CRD42019124583)/16.04.2019.

Effect of Exercise Volume on Plantar Microcirculation and Tissue Hardness in People With Type 2 Diabetes

Objective: Exercise has been reported to be beneficial for people with type 2 diabetes (T2DM), but exercise, especially weight-bearing exercise, may increase the risk of diabetic foot ulcers (DFUs). This study aimed to explore the associations between different volumes of weight-bearing physical activities and plantar microcirculation and tissue hardness in people with T2DM.

Methods: 130 elderly people with T2DM were enrolled for this cross-sectional study. They were classified into the high exercise volume group and the low exercise volume group based on their weekly energy expenditure (metabolic equivalents per week) in the past year. Weekly energy expenditure was calculated using the International Physical Activity Questionnaire and the Compendium of Physical Activities. The plantar oxygen saturation (SO₂) and soft tissue hardness of each participant’s right foot were measured.

Results: A total of 80 participants completed the trial. The average exercise energy expenditure of the high exercise volume group and the low exercise volume group were significantly different (p < 0.05). The results showed that the SO₂ of the high exercise volume group (67.25 ± 6.12%) was significantly higher than the low exercise volume group (63.75 ± 8.02%, p < 0.05). The plantar tissue hardness of the high exercise volume group was lower than the low exercise volume group in the big toe, midfoot and hindfoot regions (p < 0.05).

Conclusion: This study demonstrates that higher volumes of exercise are associated with better plantar microcirculation and lower plantar tissue hardness in people with T2DM. The findings of this study indicate that weight-bearing exercise may not increase risk of developing diabetic foot ulcers.

The Application of Exercise Training for Diabetic Peripheral Neuropathy

Diabetic peripheral neuropathy (DPN) is the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes. It is associated with pain, paresthesia, sensory loss, muscle atrophy with fat infiltration, and muscular dysfunction typically starting distally in the feet and progressing proximally. Muscle deterioration within the leg and foot can lead to muscle dysfunction, reduced mobility, and increases the risk of disability, ulceration, and amputation. Exercise training is an established method for increasing the different components of physical fitness, including enhancing body composition and improving neuromuscular strength. A number of experimental studies have utilized exercise training to treat various impairments associated with DPN, such as nerve conduction velocity, pain tolerance, and balance. However, the broad spectrum of exercise training modalities implemented and differences in target outcome measurements have made it difficult to understand the efficacy of exercise training interventions or provide appropriate exercise prescription recommendations. Therefore, the aims of this review were to (1) briefly describe the pathophysiology of DPN and (2) discuss the effects of exercise training interventions on sensorimotor, metabolic, and physical functions in people with DPN.

Dosing Activity and Return to Preulcer Function in Diabetes-Related Foot Ulcer Remission

Diabetes-related foot ulcers are a leading cause of global morbidity, mortality, and health-care costs. People with a history of foot ulcers have a diminished quality of life attributed to limited walking and mobility. One of the largest concerns is ulceration recurrence. Approximately 40% of patients with ulcerations will have a recurrent ulcer in the year after healing, and most occur in the first 3 months after wound healing. Hence, this period after ulceration is called "remission" due to this risk of reulceration. Promoting and fostering mobility is an integral part of everyday life and is important for maintaining good physical health and health-related quality of life for all people living with diabetes. In this short perspective, we provide recommendations on how to safely increase walking activity and facilitate appropriate off-loading and monitoring in people with a recently healed foot ulcer, foot reconstruction, or partial foot amputation. Interventions include monitored activity training, dosed out in steadily increasing increments and coupled with daily skin temperature monitoring, which can identify dangerous "hotspots" prone to recurrence. By understanding areas at risk, patients are empowered to maximize ulcer-free days and to enable an improved quality of life. This perspective outlines a unified strategy to treat patients in the remission period after ulceration and aims to provide clinicians with appropriate patient recommendations based on best available evidence and expert opinion to educate their patients to ensure a safe transition to footwear and return to activity.

Resistance training improves nerve conduction and arterial stiffness in older adults with diabetic distal symmetrical polyneuropathy: A randomized controlled trial

Diabetes is the main cause of peripheral neuropathy where older patients are at increased risk of diabetic distal symmetrical polyneuropathy (DSPN) due to age-related nerve degeneration and vascular changes. The aim of the study was to investigate the effect of resistance training on nerve conduction, measures of neuropathy and arterial stiffness in older patients with DSPN. In a randomized controlled trial, thirty-four older adults with type-2 diabetes and peripheral neuropathy were enrolled and randomly assigned to experimental and control groups. The experimental group carried out circuit resistance training (1-3 rounds, 11 exercises, 10-15 reps, 50%-60% of 1RM, 3 times per week) for 12 weeks. Measurements were performed at baseline and 48 h after the intervention. Measures of DSPN including Michigan neuropathy screening instrument (MNSI), Michigan diabetic neuropathy score (MDNS), motor nerve action potential amplitude (APA), sensory and motor nerve conduction velocity (NCV) improved following intervention (p < 0.001, p = 0.001, p = 0.034, p = 0.001, and p = 0.001, respectively). Sensory APA did not change after the intervention (p = 0.139). Cardio-ankle vascular index (CAVI) and ankle-brachial index (ABI) improved in the experimental group compared with the control group (p = 0.014 and p = 0.033, respectively). In addition, HbA1C decreased following the 12-week resistance training program (p = 0.002). Older adults with DSPN respond positively to resistance training by improved neuropathy symptoms, nerve conduction, arterial stiffness and glucose regulation. Resistance training offers a positive intervention that can abate the progression of DSPN in older adults.

Feasibility of a home-based foot-ankle exercise programme for musculoskeletal dysfunctions in people with diabetes: randomised controlled FOotCAre (FOCA) Trial II

This study sought to assess the feasibility of design, adherence, satisfaction, safety and changes in outcomes followed by a home-based foot–ankle exercise guided by a booklet in individuals with diabetic peripheral neuropathy (DPN). 20 participants were allocated usual care [control group (CG)] or usual care plus home-based foot–ankle exercises [intervention group (IG)] for 8 weeks. For feasibility, we assessed contact, preliminary screening and recruitment rates, adherence, and using a 5-point Likert scale to satisfaction and safety of the booklet. In the IG, we assessed preliminary changes in DPN symptoms, DPN severity (classified by a fuzzy model) and foot–ankle range of motion between baseline and Week 8. In the first 20 weeks, 1310 individuals were screened for eligibility by phone contact. Contact rate was 89% (contacted participants/20w), preliminary screening success 28% (participants underwent screening/20w), and recruitment rate 1.0 participants/week (eligible participants/20w). The recruitment rate was less than the ideal rate of 5 participants/week. The adherence to the exercises programme was 77%, and the dropout was 11% and 9% for the IG and CG, respectively. In the IG, participants’ median level of satisfaction was 4 (IQR: 4–5) and perceived safety was 3 (IQR: 3–5). IG significantly decreased the DPN severity (p = 0.020), increased hallux relative to forefoot (first metatarsal) range of motion (ROM) (p < 0.001) and decreased maximum forefoot relative to hindfoot (midfoot motion) dorsiflexion during gait (p = 0.029). The home-based programme was feasible, satisfactory, safe and showed preliminary positive changes in DPN severity and foot motion during gait.

Trial Registration ClinicalTrials.gov, NCT04008745. Registered 02/07/2019. https://clinicaltrials.gov/ct2/show/NCT04008745.

Interventions for promoting physical activity in people with neuromuscular disease

BACKGROUND

The World Health Organization (WHO) recommends that people of all ages take regular and adequate physical activity. If unable to meet the recommendations due to health conditions, international guidance advises being as physically active as possible. Evidence from community interventions of physical activity indicate that people living with medical conditions are sometimes excluded from participation in studies. In this review, we considered the effects of activity-promoting interventions on physical activity and well-being in studies, as well as any adverse events experienced by participants living with inherited or acquired neuromuscular diseases (NMDs).  OBJECTIVES: To assess the effects of interventions designed to promote physical activity in people with NMD compared with no intervention or alternative interventions.

SEARCH METHODS

On 30 April 2020, we searched Cochrane Neuromuscular Specialised Register, CENTRAL, Embase, MEDLINE, and ClinicalTrials.Gov. WHO ICTRP was not accessible at the time.

SELECTION CRITERIA

We considered randomised or quasi-randomised trials, including cross-over trials, of interventions designed to promote physical activity in people with NMD compared to no intervention or alternative interventions. We specifically included studies that reported physical activity as an outcome measure. Our main focus was studies in which promoting physical activity was a stated aim but we also included studies in which physical activity was assessed as a secondary or exploratory outcome.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane procedures.

MAIN RESULTS

The review included 13 studies (795 randomised participants from 12 studies; number of participants unclear in one study) of different interventions to promote physical activity. Most studies randomised a minority of invited participants. No study involved children or adolescents and nine studies reported minimal entry criteria for walking. Participants had one of nine inherited or acquired NMDs. Types of intervention included structured physical activity support, exercise support (as a specific form of physical activity), and behaviour change support that included physical activity or exercise. Only one included study clearly reported that the aim of intervention was to increase physical activity. Other studies reported or planned to analyse the effects of intervention on physical activity as a secondary or exploratory outcome measure. Six studies did not report results for physical activity outcomes, or the data were not usable. We judged 10 of the 13 included studies at high or unclear risk of bias from incomplete physical activity outcome reporting. We did not perform a meta-analysis for any comparison because of differences in interventions and in usual care. We also found considerable variation in how studies reported physical activity as an outcome measure. The studies that reported physical activity measurement did not always clearly report intention-to-treat (ITT) analysis or whether final assessments occurred during or after intervention. Based on prespecified measures, we included three comparisons in our summary of findings. A physical activity programme (weight-bearing) compared to no physical activity programme One study involved adults with diabetic peripheral neuropathy (DPN) and reported weekly duration of walking during and at the end of a one-year intervention using a StepWatch ankle accelerometer. Based on the point estimate and low-certainty evidence, intervention may have led to an important increase in physical activity per week; however, the 95% confidence interval (CI) included the possibility of no difference or an effect in either direction at three months (mean difference (MD) 34 minutes per week, 95% CI -92.19 to 160.19; 69 participants), six months (MD 68 minutes per week, 95% CI -55.35 to 191.35; 74 participants), and 12 months (MD 49 minutes per week, 95% CI -75.73 to 173.73; 70 participants). Study-reported effect estimates for foot lesions and full-thickness ulcers also included the possibility of no difference, a higher, or lower risk with intervention. A sensor-based, interactive exercise programme compared to no sensor-based, interactive exercise programme One study involved adults with DPN and reported duration of walking over 48 hours at the end of four weeks' intervention using a t-shirt embedded PAMSys sensor. It was not possible to draw conclusions about the effectiveness of the intervention from the very low-certainty evidence (MD -0.64 hours per 48 hours, 95% CI -2.42 to 1.13; 25 participants). We were also unable to draw conclusions about impact on the Physical Component Score (PCS) for quality of life (MD 0.24 points, 95% CI -5.98 to 6.46; 35 participants; very low-certainty evidence), although intervention may have made little or no difference to the Mental Component Score (MCS) for quality of life (MD 5.10 points, 95% CI -0.58 to 10.78; 35 participants; low-certainty evidence). A functional exercise programme compared to a stretching exercise programme One study involved adults with spinal and bulbar muscular atrophy and reported a daily physical activity count at the end of 12 weeks' intervention using an Actical accelerometer. It was not possible to draw conclusions about the effectiveness of either intervention (requiring compliance) due to low-certainty evidence and unconfirmed measurement units (MD -8701, 95% CI -38,293.30 to 20,891.30; 43 participants). Functional exercise may have made little or no difference to quality of life compared to stretching (PCS: MD -1.10 points, 95% CI -5.22 to 3.02; MCS: MD -1.10 points, 95% CI -6.79 to 4.59; 49 participants; low-certainty evidence). Although studies reported adverse events incompletely, we found no evidence of supported activity increasing the risk of serious adverse events.

AUTHORS' CONCLUSIONS

We found a lack of evidence relating to children, adolescents, and non-ambulant people of any age. Many people living with NMD did not meet randomised controlled trial eligibility criteria. There was variation in the components of supported activity intervention and usual care, such as physical therapy provision. We identified variation among studies in how physical activity was monitored, analysed, and reported. We remain uncertain of the effectiveness of promotional intervention for physical activity and its impact on quality of life and adverse events. More information is needed on the ITT population, as well as more complete reporting of outcomes. While there may be no single objective measure of physical activity, the study of qualitative and dichotomous change in self-reported overall physical activity might offer a pragmatic approach to capturing important change at an individual and population level.

Effect of tap dance on plantar pressure, postural stability and lower body function in older patients at risk of diabetic foot: a randomized controlled trial

INTRODUCTION

To examine the effects of tap dance (TD) on dynamic plantar pressure, static postural stability, ankle range of motion (ROM), and lower extremity functional strength in patients at risk of diabetic foot (DF).

RESEARCH DESIGN AND METHODS

A randomised, single-blinded, two-arm prospective study of 40 patients at risk of DF was conducted. The intervention group (n=20) received 16 weeks of TD training (60 min/session×3 sessions/week). The control group attended four educational workshops (1 hour/session×1 session/month). Plantar pressure, represented by the primary outcomes of peak pressure (PP) and pressure-time integral (PTI) over 10 areas on each foot, was measured using the Footscan platform system. Secondary outcomes comprised static postural stability, ankle ROM and lower extremity functional strength.

RESULTS

Reductions in intervention group PP (right foot: mean differences=4.50~27.1, decrease%=25.6~72.0; left foot: mean differences=-5.90~6.33, decrease%=-22.6~53.2) and PTI at 10 areas of each foot (right foot: mean differences=1.00~12.5, decrease%=10.4~63.6; left foot: mean differences=0.590~25.3, decrease%=21.9~72.6) were observed. Substantial PP and PTI differences were noted at the second through fourth metatarsals, medial heel and lateral heel in the right foot. Substantial PP and PTI differences were detected at metatarsals 1 and 2 and metatarsal 2 in the left foot, respectively. Moderate training effects were found in plantar flexion ROM of both feet, lower extremity functional strength, and length of center-of-pressure trajectory with eyes closed and open (r=0.321-0.376, p<0.05).

CONCLUSIONS

A 16-week TD training program can significantly improve ankle ROM, lower extremity functional strength, and static postural stability. To attain greater improvements in plantar pressure, a longer training period is necessary.

TRIAL REGISTRATION NUMBER

ChiCTR1800014714.

Efficacy of exercise on balance, fear of falling, and risk of falls in patients with diabetic peripheral neuropathy: a systematic review and meta-analysis

Diabetic peripheral neuropathy (DPN) is the most common complication of diabetes mellitus. Our objective was to evaluate the efficacy of exercise interventions in DPN patients from randomized controlled trials. The primary outcomes were the risk of falls, fear of falling, balance and quality of life. Two reviewers independently selected studies from Embase, Medline, LILACS, CENTRAL, and PEDro. They assessed the risk of bias and extracted data from the trials. The relative risk (RR) and the differences between means (MD) were calculated with a 95% confidence interval (CI) and used as the effect size. We used a random-effects model to pool results across studies, and the Grading of Recommendations Assessment, Development, and Evaluation system to evaluate the certainty of evidence. Eight trials were included. No clear effect was observed in the risk of falls (RR: 0.93, 95% CI: 0.41 to 2.09, 79 participants, 1 trial, low-certainty evidence). Regarding fear of falling, using the Falls Efficacy Scale, a small difference in favor of the intervention was observed (MD: -2.42, 95%, CI: -4.7 to -0.15, 3 trials, 185 participants, low-certainty evidence). The meta-analysis of balance using the unipedal stance test showed a small difference in favor of the intervention. One study evaluated quality of life, and in the mental score there was a MD in favor of the intervention. In DPN patients, a combination of gait, balance, and functional training improved balance, the fear of falling, quality of life in the mental score, but not the risk of falls.

The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: A systematic review

Purpose

Diabetic peripheral neuropathy (DPN) leads to decreased sole sensation and balance disorder, all of which increase the risk of falls and socioeconomic costs. Since the physiotherapists do not use the same manner to lessen the complications of this problem. Therefore, this review study was directed to appraise physiotherapy intervention efficiencies in diminishing DPN's symptoms and complications.

Method

A database search of Pubmed, Elsevier, Google Scholar, and Embase was performed to determine DPN's published documents. Finally, studies of DPN and treatments available in this field, particularly physiotherapy that included electrotherapy, exercise therapy, and other therapies, were identified.

Result

According to a database search on August 1, 2019, from 1989 to 2019, in the last 30 years, about 968 articles were found, 345 of which were free full text available, and finally, 19 articles were approved. These articles examined the effects of physiotherapy interventions, including exercise therapy, electrotherapy, and other treatment techniques on DPN patients.

Conclusions

The results showed that most diabetic peripheral neuropathy patients suffer from muscle weakness, pain, loss of balance, and lower limb dysfunction. As a result, their daily activity and Life satisfaction are gradually impaired. Exercise therapy, electrotherapy, and other physiotherapy methods have been used to reduce the mentioned cases. Among these interventions, exercise therapy has been the most effective. Although there was little evidence of aerobic exercise in these patients, further studies should be done on other therapies' effects.

Midfoot and ankle motion during heel rise and gait are related in people with diabetes and peripheral neuropathy

BACKGROUND

Midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy (DMPN) is associated with midfoot deformity and increased plantar pressures during gait. If midfoot and ankle motion during heel rise and push-off of gait have similar mechanics, heel rise performance could be a clinically feasible way to identify abnormal midfoot and ankle function during gait.

RESEARCH QUESTION

Is midfoot and ankle joint motion during a heel rise associated with midfoot and ankle motion at push-off during gait in people with DMPN?

METHODS

Sixty adults with DMPN completed double-limb heel rise, single-limb heel rise, and walking. A modified Oxford multi-segment foot model (forefoot, hindfoot, shank) was used to analyze midfoot (forefoot on hindfoot) and ankle (hindfoot on shank) sagittal angle during heel rise and gait. Pearson correlation was used to test the relationship between heel rise and gait kinematic variables (n = 60). Additionally, we classified 60 participants into two subgroups based on midfoot and ankle position at peak heel rise: midfoot and ankle dorsiflexed (dorsiflexed; n = 23) and midfoot and ankle plantarflexed (plantarflexed; n = 20). Movement trajectories of midfoot and ankle motion during single-limb heel rise and gait of the subgroups were examined.

RESULTS

Peak double-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.49 and r = 0.40, respectively). Peak single-limb heel rise and gait midfoot and ankle angles were significantly correlated (r = 0.63 and r = 0.54, respectively). The dorsiflexed subgroup, identified by heel rise performance showed greater midfoot and ankle dorsiflexion during gait compared to the plantarflexed subgroup (mean difference between subgroups: midfoot 3°, ankle 3°).

SIGNIFICANCE

People with DMPN who fail to plantarflex the midfoot and ankle during heel rise have difficulty plantarflexing the midfoot and ankle during gait. Utilizing a heel rise task may help identify midfoot and ankle dysfunction associated with gait in people with DMPN.

Relationship Between Long-Term Objectively Measured Physical Activity and Glycemic Control in Type 2 Diabetes Mellitus Patients: A Prospective Cohort Study

INTRODUCTION

Increasing physical activity (PA) improves glycemic control in patients with type 2 diabetes mellitus (T2DM). However, whether long-term objectively measured PA is related to glycemic control remains unclear. The aim of this study was to investigate the relationship between long-term objectively measured PA and glycemic control in T2DM patients.

RESEARCH DESIGN AND METHODS

This prospective cohort study recruited T2DM patients admitted to a hospital-based diabetes management and education program. The primary outcome was glycemic control by hemoglobin A1c at 6 months after discharge. We defined poor glycemic control according to the Japanese Clinical Practice Guidelines. The PA was objectively measured using a three-axis accelerometer during 6 months' period after discharge. The representative value of PA was the average daily steps during the measurement period and was divided into quartiles. To determine the relationship between the daily steps and poor glycemic control, we performed a multivariate logistic regression analysis.

RESULTS

Ninety-four participants were enrolled in the study. Their median age was 59 years, and 38 (40.0%) of them showed poor glycemic control. Multivariate logistic regression analysis showed that the first (Q1, ≤ 6106 steps/day) and second quartiles (Q2, 6107-8258 steps/day) had significantly elevated risks of poor glycemic control compared to Q4 (≥ 10,542 steps/day), with odds ratios of 8.55 [95% confidence intervals (CI) =1.43-51.23] and 15.62 (95% CI 2.63-92.87), respectively.

CONCLUSION

We found that lesser PA was significantly associated with poor glycemic control in T2DM patients. This finding may be beneficial for clinicians while providing long-term advice to diabetic patients.

The Role of Foot-Loading Factors and Their Associations with Ulcer Development and Ulcer Healing in People with Diabetes: A Systematic Review

We aimed to comprehensively and systematically review studies associating key foot-loading factors (i.e., plantar pressure, weight-bearing activity, adherence or a combination thereof) with ulcer development and ulcer healing in people with diabetes. A systematic literature search was performed in PubMed and EMBASE. We included studies if barefoot or in-shoe plantar pressure, weight-bearing activity or footwear or device adherence was measured and associated with either ulcer development or ulcer healing in people with diabetes. Out of 1954 records, 36 studies were included and qualitatively analyzed. We found low to moderate quality evidence that lower barefoot plantar pressure and higher footwear and device adherence associate with lower risk of ulcer development and shorter healing times. For the other foot-loading factors, we found low quality evidence with limited or contradictory results. For combined measures of foot-loading factors, we found low quality evidence suggesting that lower cumulative plantar tissue stress is associated with lower risk of ulcer development and higher ulcer healing incidence. We conclude that evidence for barefoot plantar pressure and adherence in association with ulcer outcome is present, but is limited for the other foot-loading factors. More comprehensive investigation in particularly the combination of foot-loading factors may improve the evidence and targeting preventative treatment.

Relation of exercise and pain in patients with idiopathic distal axonal polyneuropathies

Although exercise is associated with better outcomes in patients with some peripheral neuropathies, data in idiopathic peripheral neuropathies is lacking. This study was completed to do a comprehensive data analysis about the benefits of regular exercise in a well-characterized cohort of patients with idiopathic distal, symmetrical, axonal polyneuropathy enrolled in the Peripheral Neuropathy Research Registry (PNRR) at Johns Hopkins University School of Medicine. From the patient-reported exercise habits, metabolic equivalents (METs) were calculated and the patient information was grouped into four categories. The PNRR data set, including patient reported pain, numbness, and weakness, was analyzed using the METs categories to evaluate for the benefits of exercise. We controlled for the components of metabolic syndrome including Hemoglobin A1c (HbA1c), systolic and diastolic blood pressure (BP), high density lipids (HDL) and triglyceride level, and body mass index (BMI) as defined by the Adult Treatment Panel III Guidelines. Lower METs were associated with neuropathic pain, but not with other peripheral neuropathy symptoms. Patients with IPN who exercised were less likely to have painful neuropathy independent of the average METs per week (P < .01). No significant differences were seen for patient reported numbness, weakness, or balance issues. The data suggests that patients with idiopathic neuropathy benefit from exercises even if performed on a low intensity level or less frequently, and patients are less likely to have severe pain symptoms when exercising on a regular basis.

Benefits and Harms of Exercise Therapy for Patients With Diabetic Foot Ulcers: A Systematic Review

AIM

Exercise therapy is a core element in the treatment of diabetes, but the benefits and harms for patients with a diabetic foot ulcer (DFU) are unknown. We therefore aimed to systematically review the benefits on health-related quality of life (HRQoL) and harms of exercise therapy for patients with DFU.

METHODS

We searched 6 major databases. We performed citation and reference searches of included studies and contacted authors of ongoing trials. We included randomized controlled trials (RCTs) to assess potential benefits on HRQoL and harms of exercise therapy. Observational studies were included to identify potential harms of exercise therapy.

RESULTS

We included 10 published publications of 9 trials and results from 2 unpublished trials including a total of 281 individuals with DFUs receiving various forms of exercise therapy. Due to lack of HRQoL measurements and high heterogeneity, it was not possible to perform meta-analyses. Results on HRQoL was present in one unpublished study. Harms reported ranged from musculoskeletal problems, increased wound size, to amputation; however, no safe conclusions could be drawn from the available data due to high heterogeneity and risk of bias in the trials.

CONCLUSIONS/INTERPRETATION

Protective strategies are often preferred over therapeutic exercise that might have unforeseen consequences for patients over time. Based on the current literature, no evidence-based recommendations can be provided on the benefits and harms of exercise therapy for patients with DFUs. Well-conducted RCTs are needed to guide rehabilitation including detailed description of adverse events and an exercise program in a semisupervised or fully supervised setting.

Feasibility and Preliminary Efficacy of a Foot-Ankle Exercise Program Aiming to Improve Foot-Ankle Functionality and Gait Biomechanics in People with Diabetic Neuropathy: A Randomized Controlled Trial

Foot-ankle strengthening and mobility exercises are part of international guideline recommendations for people at risk of diabetic foot disease. We examined the feasibility and preliminary efficacy of a 12-week foot-ankle exercise program on clinical, functional and biomechanical outcomes in people with diabetic neuropathy (DPN). We randomly allocated 30 people with DPN to usual care (control) or usual care plus a supervised exercise program (intervention). For feasibility, we assessed recruitment rate and participant adherence and satisfaction. For program efficacy, we assessed baseline to 12-week changes in daily physical activity level, gait speed, tactile sensitivity, ankle range of motion, DPN symptoms, quality of life, foot health and functionality, foot strength and plantar pressure during gait, using paired t-tests (p < 0.05). In 52 weeks, we recruited 45 eligible participants (0.90/week). Program adherence was 80% and participants’ satisfaction had a mean (SD) of 4.57 (0.70) out of 5. The intervention group significantly improved on toes strength, contact time during gait and DPN symptoms, and peak forefoot pressures increased over time; controls showed significantly increased heel peak pressures and force. The exercise program was feasible, based on a moderate recruitment rate and an adherent and satisfied population, and the intervention showed several positive preliminary effects over time compared to usual care.

Relationships within and between lower and upper extremity dysfunction in people with diabetes

INTRODUCTION

Diabetes mellitus (DM) is associated with systemic musculoskeletal system impairments suggesting concurrent development of lower and upper extremity musculoskeletal problems. This study aims to examine relationships between lower and upper extremity function in people with DM.

METHODS

Sixty people with type 2 DM and peripheral neuropathy [mean (standard deviation); 67(6) years old, DM duration 14(10) yrs] completed the following measures: 1) Self-reports of function: Foot and Ankle Ability Measure (FAAM; higher = better function) and Shoulder Pain and Disability Index (SPADI; lower = better function), 2) Range of motion (goniometry): ankle dorsiflexion and shoulder flexion, and 3) Strength: unilateral heel rise power (UHR, 3D kinetics) and hand grip dynamometry. Pearson correlations examined associations between lower and upper extremity measures, p < .05.

RESULTS

Forty of 60 (67%) reported pain/disability in both the foot/ankle and shoulder and 95% of study participants had some limitation in foot or shoulder function. Significant between extremity correlations: FAAM and SPADI (r = -0.39), ankle dorsiflexion and shoulder flexion range of motion (r = 0.35), and UHR and hand grip strength (r = 0.40). Significant within extremity correlations: FAAM and UHR (r = .47) and SPADI with shoulder flexion (r = -0.44).

CONCLUSION

Upper and lower extremity inter- and intra-relationships indicate systemic musculoskeletal impairments in people with DM. Healthcare practitioners should consider the potential for concurrent and disabling musculoskeletal problems in people with DM.

Classification of functionality of people with diabetic peripheral neuropathy based on international classification of functioning, disability and health Core set (ICF-CS) of diabetes mellitus

PURPOSE

The aim of this study was the application of International Classification of Functioning, Disability and Health Core Set (ICF- CS) of Diabetes Mellitus (DM) to investigate body function impairment (BF) & body structure (BS), activity limitation & participation restriction in people with diabetes mellitus with and without peripheral neuropathy.

METHOD

A total of 120 subjects with diabetes were interviewed using four categories of the ICF-CS of DM through ICF documentation form including body functions, body structures, activities and participation, and environmental factors.

RESULTS

Subjects with diabetic peripheral neuropathy (DPN) experienced more physical dysfunctions and impairments when compared with subjects having diabetes without peripheral neuropathy when assessed with ICF-CS of DM. DPN patients experienced significant problem in 19 categories in BF, 3 categories in BS, 10 categories in activity and participation and 4 categories in environmental factors when compared with diabetes patients without peripheral neuropathy on chi square analysis. Findings of regression analysis suggest that people with DPN have more chances of impairments in BF and BS, activities and participation, and environmental factors.

CONCLUSION

The difference observed between subjects having diabetes with and without peripheral neuropathy on the scores of ICF-CS domains suggest that, people with DPN faces more problems in health and function. These people should be targeted with more intensive care for improving the health standards.

Skeletal Muscle Regeneration in Advanced Diabetic Peripheral Neuropathy

BACKGROUND

Decreased lean muscle mass in the lower extremity in diabetic peripheral neuropathy (DPN) is thought to contribute to altered joint loading, immobility, and disability. However, the mechanism behind this loss is unknown and could derive from a reduction in size of myofibers (atrophy), destruction of myofibers (degeneration), or both. Degenerative changes require participation of muscle stem (satellite) cells to regenerate lost myofibers and restore lean mass. Determining the degenerative state and residual regenerative capacity of DPN muscle will inform the utility of regeneration-targeted therapeutic strategies.

METHODS

Biopsies were acquired from 2 muscles in 12 individuals with and without diabetic neuropathy undergoing below-knee amputation surgery. Biopsies were subdivided for histological analysis, transcriptional profiling, and satellite cell isolation and culture.

RESULTS

Histological analysis revealed evidence of ongoing degeneration and regeneration in DPN muscles. Transcriptional profiling supports these findings, indicating significant upregulation of regeneration-related pathways. However, regeneration appeared to be limited in samples exhibiting the most severe structural pathology as only extremely small, immature regenerated myofibers were found. Immunostaining for satellite cells revealed a significant decrease in their relative frequency only in the subset with severe pathology. Similarly, a reduction in fusion in cultured satellite cells in this group suggests impairment in regenerative capacity in severe DPN pathology.

CONCLUSION

DPN muscle exhibited features of degeneration with attempted regeneration. In the most severely pathological muscle samples, regeneration appeared to be stymied and our data suggest that this may be partly due to intrinsic dysfunction of the satellite cell pool in addition to extrinsic structural pathology (eg, nerve damage).

CLINICAL RELEVANCE

Restoration of DPN muscle function for improved mobility and physical activity is a goal of surgical and rehabilitation clinicians. Identifying myofiber degeneration and compromised regeneration as contributors to dysfunction suggests that adjuvant cell-based therapies may improve clinical outcomes.

Microvascular Control Mechanism of the Plantar Foot in Response to Different Walking Speeds and Durations: Implication for the Prevention of Foot Ulcers

Physical activity has been recommended by the American Diabetes Association (ADA) as a preventive intervention of diabetes complications. However, there is no study investigating how microvascular control mechanism respond to different walking intensities in people with and without diabetes. The purpose of this study was to assess microvascular control mechanism of the plantar foot in response to various walking speeds and durations in 12 healthy people using spectral analysis of skin blood flow (SBF) oscillations. A 3×2 factorial design, including 3 speeds (3, 6, and 9 km/h) and 2 durations (10 and 20 minutes), was used in this study. Plantar SBF was measured using laser Doppler flowmetry over the first metatarsal head. Borg Rating of Perceived Exertion (RPE) scale and heart rate maximum were used to assess the walking intensity. Wavelet analysis was used to quantify regulations of metabolic (0.0095-0.02 Hz), neurogenic (0.02-0.05 Hz), myogenic (0.05-0.15 Hz), respiratory (0.15-0.4 Hz), and cardiac (0.4-2 Hz) controls. For 10-minute walking, walking at 9 km/h significantly increased the ratio of wavelet amplitudes of metabolic, neurogenic, myogenic, respiratory, and cardiac mechanisms compared with 3 km/h (P < .05). For 20-minute walking, walking at 6 km/h significantly increased the ratio of wavelet amplitudes of metabolic, myogenic, respiratory, and cardiac compared with 3 km/h (P < .05). RPE showed a significant interaction between the speed and duration factors (P < .01). This is the first study demonstrating that different walking speeds and durations caused different plantar microvascular regulations.

Multi-System Factors Associated with Metatarsophalangeal Joint Deformity in Individuals with Type 2 Diabetes

The underlying factors contributing to metatarsophalangeal joint deformity, a known precursor to skin breakdown in individuals with diabetes mellitus (DM), is likely to involve multiple body systems. The purpose of this cross-sectional study was to identify multi-system factors associated with metatarsophalangeal joint deformity in individuals with type 2 DM and peripheral neuropathy (n = 60). Metatarsophalangeal joint deformity was quantified with a computed tomography (CT) scan. System biomarkers included the musculoskeletal system (foot intrinsic muscle deterioration, tarsal/metatarsal bone mineral density, ankle dorsiflexion, metatarsophalangeal extension movement during a sit to stand task); the vascular system (ankle-brachial index); and the endocrine/immune systems (high sensitivity C-reactive protein, skin intrinsic fluorescence, and hemoglobin A1C). Muscle deterioration (r = 0.27), bone density (r = -0.35), metatarsophalangeal extension movement (r = 0.50), maximum dorsiflexion (r = -0.31), and ankle-brachial index (r = 0.33) were related to metatarsophalangeal joint deformity (p < 0.05). Bone mineral density and metatarsophalangeal extension movement were retained in a regression model relating to deformity (R2 = 0.34). All musculoskeletal system biomarkers and the ankle-brachial index demonstrated weak to moderate relationships to metatarsophalangeal joint deformity. Bone mineral density of the tarsal/metatarsal bones and extending the toes during a sit to stand task were the two strongest factors associated with metatarsophalangeal joint deformity. Evaluation and management of foot bone mineral density and toe extension movement pattern could reduce metatarsophalangeal joint deformity and the risk of skin breakdown and subsequent amputation.

Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review

Prevention of foot ulcers in patients with diabetes is important to help reduce the substantial burden on both patient and health resources. A comprehensive analysis of reported interventions is needed to better inform healthcare professionals about effective prevention. The aim of this systematic review is to investigate the effectiveness of interventions to help prevent both first and recurrent foot ulcers in persons with diabetes who are at risk for this complication. We searched the available medical scientific literature in PubMed, EMBASE, CINAHL, and the Cochrane databases for original research studies on preventative interventions. We screened trial registries for additional studies not found in our search and unpublished trials. Two independent reviewers assessed data from controlled studies for methodological quality, and extracted and presented this in evidence and risk of bias tables. From the 13,490 records screened, 35 controlled studies and 46 non-controlled studies were included. Few controlled studies, which were of generally low to moderate quality, were identified on the prevention of a first foot ulcer. For the prevention of recurrent plantar foot ulcers, there is benefit for the use of daily foot skin temperature measurements, and for therapeutic footwear with demonstrated plantar pressure relief, provided it is consistently worn by the patient. For prevention of ulcer recurrence, there is some evidence for providing integrated foot care, and no evidence for a single session of education.Surgical interventions have been shown effective in selected patients, but the evidence base is small. Foot-related exercises do not appear to prevent a first foot ulcer. A small increase in the level of weight-bearing daily activities does not seem to increase the risk for foot ulceration. The evidence base to support the use of specific self-management and footwear interventions for the prevention of recurrent plantar foot ulcers is quite strong. The evidence is weak for the use of other, sometimes widely applied, interventions, and is practically non-existent for the prevention of a first foot ulcer and non-plantar foot ulcer.

The future for diabetic foot ulcer prevention: A paradigm shift from stratified healthcare towards personalized medicine

Prevention of diabetic foot ulcers is important to reduce the burden of diabetic foot disease. However, we found that ulcer prevention is underexposed in research and clinical practice. Barriers to explain this are seen in patient's goal-setting; in the lack of interdisciplinary teams for ulcer prevention; in sample sizes and funding for research; in industrial engagement; and in limited understanding of ulcer development. Rather than separately solving these barriers, we propose a paradigm shift from stratified healthcare towards personalized medicine for diabetic foot disease. Personalized medicine aims to deliver the right treatment to the right patient at the right time, based on individual diagnostics. Different treatment strategies should be available for different patients, delivered in an integrated, objective, quantitative and evidence-based approach. More than on the classical risk factors of peripheral neuropathy and peripheral artery disease, individual diagnostics should focus on modifiable risk factors for ulceration. This includes structured biomechanical and behavioral profiling, while new research with (big) data science may identify additional risk factors, such as geographical or temporal patterns in ulceration. Industry involvement can drive the development of wearable instruments and assessment tools, to facilitate large-scale individual diagnostics. For a paradigm shift towards personalized medicine in prevention, large-scale collaborations between stakeholders are needed. As each ulcer episode not prevented costs about €10,000 in medical costs alone, such investments can be cost-effective. We hope to see more discussions around this paradigm shift, and increasing investments of energy and money in diabetic foot ulcer prevention in research and clinical practice.

Mobility advice to help prevent re-ulceration in diabetes

Clinicians and patients face a dilemma in understanding how best to resume walking after a healed diabetic neuropathic ulcer. The objectives of this brief review are to: provide context for the patient's health and mobility status; propose 5 suggestions to safely and effectively progress mobility following a healed foot ulcer; and to consider topics for future research to improve care in this area. Rates of ulcer recurrence and mortality are high, and activity is low following a diabetic foot wound. Medical and rehabilitation approaches have emphasized protection of the insensitive, fragile foot with the hope to prevent subsequent harm to the foot and person. In particular, the 1-2 months following wound unloading and "healing" have the greatest risk for ulcer recurrence. While early protection should be emphasized, a growing body of evidence suggests that over-protection of the foot and limited walking can be harmful, presumably because of the negative effects of prolonged immobility and stress protection. Multiple recent studies report the ability of exercise and walking to have a positive effect on various diabetic foot outcomes without additional harm. Much less is known about how an ulcerated foot can resume walking after the wound is healed. This review integrates available guidelines, evidence, and precautions to suggest advice on how best to resume and progress walking in this population at high risk for ulcer recurrence.

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at-risk patient about appropriate foot self-care and treat any pre-ulcerative sign on the foot. Instruct moderate-to-high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non-surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high-risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days, and to reduce the patient and health care burden of diabetic foot disease.

Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review

BACKGROUND

Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown.

METHODS

The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self-management; pre-ulcer treatment; orthotic interventions; and foot- and mobility-related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre-ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables.

RESULTS

We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self-care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom-made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot- and mobility-related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting.

CONCLUSIONS

Structured education for patients and health care professionals, callus removal, custom-made therapeutic footwear, and foot- and mobility-related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.

Effect of an educational booklet for prevention and treatment of foot musculoskeletal dysfunctions in people with diabetic neuropathy: the FOotCAre (FOCA) trial II, a study protocol of a randomized controlled trial

Background

This study is a part of a series of two clinical trials. We consider diabetic polyneuropathy (DPN), a common chronic and progressive complication of diabetes mellitus that has several impacts on individuals’ foot health and quality of life. Based on the current trends of self-monitoring and self-care, providing a tool with foot-related exercises and educational care may help patients to avoid or reduce the musculoskeletal complications resulting from DPN, improving autonomous performance in daily living tasks. The aim of this trial is to evaluate the effects of an educational booklet for foot care and foot muscle strengthening on DPN symptoms and severity, clinical outcomes, and gait biomechanics in patients with DPN.

Methods/design

The FOotCAre (FOCA) trial II study has been designed as a single-blind, two-parallel-arm randomized controlled trial. It will include 48 patients with DPN who will be randomly allocated to a control (recommended foot care by international consensus with no foot exercises) group or an intervention (foot-related exercises using an educational booklet three times/week at home for 8 weeks) group. Participants from both groups will be assessed at baseline, after 8 weeks, and at 16 weeks for follow-up. The primary outcomes are the DPN symptoms and severity, and the secondary outcomes are foot–ankle kinematics, gait kinetics, plantar pressure distribution during gait, tactile and vibratory sensitivities, foot strength, functional balance, and foot health and functionality.

Discussion

The booklet is a management tool that allows users to be autonomous in their treatment by choosing how and where to perform the exercises. This allows the patients to perform the exercises regularly as a continuous habit for foot care and health, which is an important element in the management of the diabetic foot. As the booklet focuses on specific foot–ankle exercises, we expect that it will improve the clinical aspects of DPN and produce beneficial biomechanical changes during gait, becoming a powerful self-management tool that can be easily implemented to improve the performance of daily living tasks.

Trial registration

ClinicalTrials.gov, NCT04008745. Registered on 2 July 2019.

Effectiveness of Exercise Therapy on Gait Function in Diabetic Peripheral Neuropathy Patients: A Systematic Review of Randomized Controlled Trials

The purpose of this study was to review the current evidence on the effectiveness of exercise therapy on gait function in patients with diabetic peripheral neuropathy. A comprehensive search of literature published between October 2010 and May 2020 was conducted using the following electronic databases; PubMed, AMED, CINAHL, ScienceDirect, Cochrane Library, PEDro and Google Scholar. Randomized control trials conducted to determine the effectiveness of exercise therapy on gait function in patients with diabetic neuropathy were included in this review. Non-English language published papers were excluded. This review was done in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Data extraction and risk of bias assessment of the studies were carried out independently by two authors. The methodological quality of the studies was evaluated using the PEDro scale and GRADE approach. The overall methodological quality of studies rated from moderate to high. Meta-analysis was not carried out due to the heterogeneity of included trials. The primary outcome measures of gait functions were the six-minute walk test, 10-meter walk test and Tinetti scale. Nine randomized controlled trials with 370 participants were analyzed. Out of them, eight studies proved its effectiveness on gait function on individuals with diabetic peripheral neuropathy. The finding of this study suggested that multi-component exercise therapy consisted of strength, ROM exercise, balance, flexibility and stretching exercises, circuit exercise training, and gait training found to enhance gait function for individuals suffering with diabetic peripheral neuropathy compared to control groups.

The Role of Physical Therapists in Fighting the Type 2 Diabetes Epidemic

BACKGROUND

In 2014, the total prevalence of diabetes was estimated to be 422 million people worldwide. Due to the aging population and continued increase in obesity rates, the prevalence is expected to rise to 592 million by 2035. Diabetes can lead to several complications, including cardiovascular disease, stroke, peripheral arterial disease, nephropathy, neuropathy, retinopathy, lower extremity amputation, and musculoskeletal impairments.

CLINICAL QUESTION

Up to 80% of patients referred for outpatient physical therapy have diabetes or are at risk for diabetes, providing an opportunity for physical therapists to intervene. Therefore, we asked, "What is the role of physical therapists in fighting the diabetes epidemic?"

KEY RESULTS

Physical therapists commonly prescribe physical activity for the treatment of diabetes and other chronic diseases, such as cardiovascular disease and osteoarthritis. Physical therapists may also screen for risk factors for diabetes and diabetes-related complications and modify traditional musculoskeletal exercise prescription accordingly. Physical therapists must advocate for regular physical activity as a key component of the treatment of chronic diseases in all patient interactions.

CLINICAL APPLICATION

This commentary (1) describes the diabetes epidemic and the health impact of diabetes and diabetes-related complications, (2) highlights the physical therapist's role as front-line provider, and (3) provides recommendations for physical therapists in screening for diabetes risk factors and diabetes-related complications and considerations for patient management. We focus on type 2 diabetes. J Orthop Sports Phys Ther 2020;50(1):5-16. Epub 28 Nov 2019. doi:10.2519/jospt.2020.9154.

Short-term strength and balance training does not improve quality of life but improves functional status in individuals with diabetic peripheral neuropathy: a randomised controlled trial

AIMS/HYPOTHESIS

The aim of this study was to test the effectiveness of a structured strength and balance training intervention in improving health-related quality of life (HRQoL) and functional status in individuals with diabetic peripheral neuropathy (DPN).

METHODS

The study was a single-blind parallel-group randomised controlled trial comparing 2 months of once-weekly home-based strength and balance training against standard medical therapy. Participants were patients with physician-diagnosed type 2 diabetes and neuropathy recruited from five public sector institutions in Singapore between July 2014 and October 2017. Participants were block-randomised to intervention or control arms. Outcomes were assessed at baseline, 2 months and 6 months by a trained assessor blinded to group assignment. Primary outcomes were change in physical component summary (PCS) score of SF-36v2 (a 36-item generic HRQoL instrument that has been validated for use in Singapore) and EQ-5D-5L index score (derived from a five-item generic HRQoL instrument [EQ-5D-5L]) over 6 months. Secondary outcomes were change in functional status (timed up-and-go [TUG], five times sit-to-stand [FTSTS], functional reach, static balance, ankle muscle strength and knee range of motion) and balance confidence over 6 months. Mean differences in scores between groups were compared using mixed models.

RESULTS

Of the 143 participants randomised (intervention, n = 70; control, n = 73), 67 participants were included in each arm for the final intention-to-treat analysis. The two groups were similar, except in terms of sex. There were no significant differences between groups on the primary outcomes of PCS score (mean difference [MD] 1.56 [95% CI -1.75, 4.87]; p = 0.355) and EQ-5D-5L index score (MD 0.02 [95% CI -0.01, 0.06]; p = 0.175). There were significant improvements in TUG test performance (MD -1.14 [95% CI -2.18, -0.1] s; p = 0.032), FTSTS test performance (MD -1.31 [95% CI -2.12, -0.51] s; p = 0.001), ankle muscle strength (MD 4.18 [95% CI 0.4, 7.92] N; p = 0.031), knee range of motion (MD 6.82 [95% CI 2.87, 10.78]°; p = 0.001) and balance confidence score (MD 6.17 [95% CI 1.89, 10.44]; p = 0.005). No adverse events due to study participation or study intervention were reported.

CONCLUSIONS/INTERPRETATION

Short-term structured strength and balance training did not influence HRQoL but produced sustained improvements in functional status and balance confidence at 6 months. More intensive interventions may be needed to influence HRQoL in these individuals. However, this intervention may be a useful treatment option for individuals with DPN to reduce the risk of falls and injuries.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02115932 FUNDING: This work was supported by the National Medical Research Council, Singapore.

Feasibility of a Low-Intensity, Technology-Based Intervention for Increasing Physical Activity in Adults at Risk for a Diabetic Foot Ulcer: A Mixed-Methods Study

BACKGROUND

Among adults with diabetes, 19-34% will develop a diabetic foot ulcer (DFU), which increases amputation risk and health care costs, and worsens quality of life. Regular physical activity, when increased gradually, may help prevent DFUs. In this mixed-methods study, we examined the feasibility of a low-intensity, technology-based behavioral intervention to increase activity in adults at risk for DFUs.

METHOD

Participants at risk for a DFU (n = 12; 66% female; mean age = 59.9 years) received four in-person exercise and behavioral counseling sessions over 2-3 weeks, supplemented with use of an activity monitor (to track steps) and text messages (to reinforce behavioral strategies) for an added 8 weeks. Pre- and postintervention assessments of accelerometer measured activity, daily mobility, and glycemic control (A1C) were completed. Treatment acceptability was assessed by questionnaire and via key informant interview.

RESULTS

The program appears feasible since all but one participant attended all four sessions, all used the activity monitor and all responded to text messages. Treatment acceptability (scale: 1 = very dissatisfied, 5 = extremely satisfied) was high; average item ratings were 4.79 (SD = 0.24). Participants increased their steps by an average of 881.89 steps/day (d = 0.66). A1C decreased on average by 0.33% (d = 0.23). Daily mobility did not change. Interview results suggest that participants perceived benefits from the intervention. Participant recommended improvements included providing more physical activity information, addressing pain, and intervention delivery in a podiatry clinic.

CONCLUSION

Individuals at risk for a DFU might benefit from a minimally intensive, technology-based intervention to increase their physical activity. Future research comparing the intervention to usual care is warranted.

Physical activity and dietary interventions in diabetic neuropathy: a systematic review

PURPOSE

Diabetic neuropathy is a common and disabling disorder, and there are currently no proven effective disease-modifying treatments. Physical activity and dietary interventions in patients with diabetes and diabetic neuropathy have multiple beneficial effects and are generally low risk, which makes lifestyle interventions an attractive treatment option. We reviewed the literature on the effects of physical activity and dietary interventions on length-dependent peripheral neuropathy and cardiac autonomic neuropathy in diabetes.

METHODS

The electronic database PubMed was systematically searched for original human and mouse model studies examining the effect of either dietary or physical activity interventions in subjects with diabetes, prediabetes, or metabolic syndrome.

RESULTS

Twenty studies are included in this review. Fourteen studies were human studies and six were in mice. Studies were generally small with few controlled trials, and there are no widely agreed upon outcome measures.

CONCLUSIONS

Recent research indicates that dietary interventions are effective in modifying diabetic neuropathy in animal models, and there are promising data that they may also ameliorate diabetic neuropathy in humans. It has been known for some time that lifestyle interventions can prevent the development of diabetic neuropathy in type 2 diabetes mellitus subjects. However, there is emerging evidence that lifestyle interventions are effective in individuals with established diabetic neuropathy. In addition to the observed clinical value of lifestyle interventions, there is emerging evidence of effects on biochemical pathways that improve muscle function and affect other organ systems, including the peripheral nerve. However, data from randomized controlled trials are needed.

Exercise Intensities as Factors of Metabolic Outcomes in Type 2 Diabetes: A Systematic Review

Exercise is effective to prevent and treat type 2 diabetes, although currently underutilized. This review analyzes the metabolic response to exercise performance at various intensities in individuals with type 2 diabetes. These findings provide insight into the development of safe and efficacious exercise prescriptions and education. We conducted a systemic review of the literature to examine the association of various exercise protocols with metabolic outcomes in type 2 diabetes. Between 1984 and 2018, 29 studies were categorized per exercise mode and intensity levels according to the American College of Sports Medicine standards. The most consistent improvement was found in HbA1c following moderate- to high-intensity exercise—post-exercise fasting glucose improved to a lesser extent. Low-intensity exercise improved HOMA-IR (homeostasis model assessment for insulin resistance) levels. Glucose and HbA1c improved most following interval compared with continuous exercise, irrespective of intensity. A comparison of high-intensity exercise with moderate-intensity exercise demonstrated few differences in HbA1c, fasting glucose, fasting insulin, and HOMA-IR. Irrespective of exercise intensity, HbA1c improvements were observed, suggesting a delayed progression to diabetes-related complications. Initial low-intensity exercise, with increased quantities when feasible, will contribute to metabolic improvements. The variability in methodology and measurement contributed to inconsistent outcomes; additional research with larger samples sizes is warranted.

Mobility in survivors with chemotherapy-induced peripheral neuropathy and utility of the 6-min walk test

BACKGROUND

Chemotherapy-induced peripheral neuropathy (CIPN) is a significant and often lasting side effect of cancer treatment, with increasing CIPN severity associated with increasing deficits in balance, gait, and mobility. The 6-min walk test (6MWT) is a widely validated and utilized measure of general physical functioning and mobility, although its utility in a CIPN context is unclear. This study aimed to determine the utility of the 6MWT as an assessment of mobility deficits in a CIPN cohort and utilize the 6MWT to compare mobility data from CIPN patients to those of healthy and clinical populations.

METHODS

Cancer survivors exposed to neurotoxic chemotherapies (N = 100; mean 17 ± 13 months post-treatment; mean age 59 ± 13 years) completed a single cross-sectional assessment of patient-reported and objective CIPN, mobility (6MWT), and disability.

RESULTS

CIPN symptoms were reported in the majority of the cohort (87%). Increasing age, patient-reported and objective CIPN symptoms, and disability were associated with decreasing 6MWT distance (.48 ≤ R ≤ .63; p < .001) in bivariate models. Multiple regression models of 6MWT distance included age, sex, and patient-reported or objective CIPN severity as significant independent correlates (.62 ≤ R ≤ .64; p < .03). 6MWT distances in patients with CIPN symptom severity above the cohort mean were consistent with mean values reported in diabetic neuropathy and clinical populations.

CONCLUSIONS

Increased CIPN symptoms are associated with increased mobility deficits. The 6MWT demonstrates promising utility as a mobility assessment in a CIPN cohort.

IMPLICATIONS FOR CANCER SURVIVORS

The impact of the progression of CIPN on mobility deficits in survivors emphasizes the need for effective interventions to treat and prevent CIPN.