An exercise program for people with severe peripheral neuropathy and diabetic foot ulcers – a case series on feasibility and safety

The Effect of Resistance Exercises Using an Elastic Band on Balance and Fear of Falling in Older Adults With Diabetic Peripheral Neuropathy: A 16-week Randomized Controlled Trial

OBJECTIVE

The current study aimed to investigate the effect of resistance training using an elastic band on balance and fear of falling in older adults with diabetic peripheral neuropathy.

DESIGN

The study was a clinical controlled trial with a repeated measure design.

SETTING

Iranian Diabetes Foundation of Mashhad.

PARTICIPANTS

The participants were 51 older adults with diabetic peripheral neuropathy and balance impairment (N=51).

INTERVENTIONS

Participants were randomly assigned to 2 groups; 1 group received balance training using an elastic band and the other group just received balance training.

MAIN OUTCOME MEASURES

The main outcomes were balance and fear of falling that were measured using Berg Balance Scale and a short version of the Fall Efficiency Scale-International, respectively.

RESULTS

The results showed that balance resistance training with and without using an elastic band significantly enhances balance and reduces fear of falling in diabetic older adults suffering from balance issues. However, balance resistance training using an elastic band had a significantly better effect on the balance and fear of falling in the participants. The best results were obtained after week 12 (48 sessions of balance training).

CONCLUSION

Balance rehabilitation programs may include an elastic band in balance resistance training for 12 weeks (3-4 sessions a week) for enhancing balance in diabetic older adults suffering from balance impairment.

Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis

BACKGROUND

Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU.

METHODS

We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed.

RESULTS

From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N = 14, n = 1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N = 6, n = 439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N = 5, n = 235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N = 1, n = 16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N = 1, n = 64) and sustained healing compared to devices alone, but likely increase new heel ulcers.

CONCLUSIONS

Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

Physiotherapeutic Interventions in Diabetic Foot Ulcer Management: A Case Report

Diabetic foot ulcers (DFUs) represent prominent complications arising from diabetes mellitus, characterized by the development of severe and persistent wounds involving the loss of epidermal and/or dermal layers, with the potential to extend into subcutaneous and underlying tissue structures. In the presented case, a 62-year-old male patient presented with complaints of pain and the emergence of blisters on the right foot, marked by an insidious onset and gradual progression in size, ultimately leading to ulcer formation subsequent to blister rupture. The patient had a medical history spanning 25 years of diabetes mellitus, accompanied by diminished range of motion and muscle strength in the affected foot. The primary goals in the management of DFU encompass addressing muscular weakness, skin manifestations, and any associated underlying health comorbidities. Central to this management approach lies the incorporation of physical therapy and rehabilitation modalities. The rehabilitation regimen designed for the patient was tailored to include targeted resistance exercises, infrared radiation therapy, and sensory integration therapy. Outcome measures, including the Numeric Pain Rating Scale (NPRS), World Health Organization Quality of Life questionnaire (WHO-QOL), and Diabetic Foot Self-Care Questionnaire (DFSQ-UMA), demonstrated substantial improvements, reflecting enhanced activities of daily living. This case underscores the pivotal role of incorporating physiotherapy into a comprehensive multidisciplinary approach for optimizing the management of DFUs. Such integration aims to improve patient outcomes and overall quality of life.

Effect of strength training on functional outcomes and strength in patients with polyneuropathy: A scoping review

Introduction: Polyneuropathy (PNP) is a chronic progressive disease that over time can lead to damage of sensory, motor and/or autonomic peripheral nerves. Symptoms vary from predominantly sensory to severe sensorimotor affection both proximally and distally. This can result in considerable functional impairments that affect activities of daily living. In other neurological patients, strength training has shown to improve strength and functional outcomes. Since medical treatment only exists for very few percentages of the underlying causes it is obvious to consider if strength training could be a potential treatment for functional impairments. To date little is known on the effect of strength training in patients with PNP.

Aim: The aim of this scoping review was to summarize research on strength training and outcomes on physical function in patients with PNP.

Methods: We systematically searched five data bases; Pubmed, Embase, Cinahl, Cochrane library and Web of science. Studies on strength training (load ≥70% of 1RM) in patients with PNP were included. The search was carried out in November 2022.

Results: 362 articles were screened by title and abstract, 101 articles were full text screened. Eight studies were included. Patients with Charcot-Marie-Tooth (CMT), chronic inflammatory polyneuropathy (CIDP) and diabetic polyneuropathy (DPN) were represented in the studies (five RCTs, two case-series, and one cross-over trial). The methodological quality ranged from fair-poor in seven studies, one study reached good quality. Results from the studies indicated that strength training in CMT, CIDP and DPN may improve strength. However, various outcomes were used to evaluate strength training, so direct comparisons were difficult.

Discussion: In this scoping review we summarized research on strength training and outcomes evaluated in interventions in patients with PNP. Eight studies were included, they indicated that strength training may be beneficial for patients with PNP. However, due to low methodological strength of most studies a recommendation for patients with PNP cannot be made. Thus, the low number of studies with relatively low quality, where various functional outcomes were used, underscores the importance of future studies to evaluate the effect of strength training on relevant functional outcomes and strength in patients with PNP.

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.

Physiotherapeutic interventions in the treatment of patients with diabetic foot ulcers: a systematic literature review

BACKGROUND

Diabetic foot ulcers are chronic wounds that are difficult to heal, with a high rate of recurrent hospitalizations. Due to its multifactorial complexity, treatment must be considered as multidisciplinary, with adjuvant therapy required to aid the healing process.

OBJECTIVES

To identify physiotherapeutic interventions for the treatment of diabetic foot ulcers through a systematic literature review.

DATA SOURCES

PubMed, Cochrane Library, SciELO and Web of Science were searched in April 2020.

STUDY SELECTION OR ELIGIBILITY CRITERIA

The inclusion criteria for this review were: randomised controlled trial published in the last 5 years; written in Portuguese, English or Spanish; subjects aged> 18 years with a diagnosis of diabetic foot ulcers; and physiotherapeutic intervention in combination with multidisciplinary wound management. The methodological quality was assessed using the PEDro scale.

RESULTS

Eight studies were included. Physiotherapists can treat diabetic foot ulcers using therapeutic exercises, electrotherapy, manual therapy and assistive technologies. All physiotherapeutic interventions were adjuvant to standard treatment for wounds provided by other health professionals. The main outcomes were wound size and healing time, with highly favourable results obtained for the experimental groups compared with the control groups.

CONCLUSIONS

Therapeutic exercise, electrotherapy, manual therapy and assistive technologies are physiotherapeutic modalities that, when combined with standard treatment, have been shown to be beneficial in the healing of diabetic foot ulcers.

Measurement Properties of the Patient-Specific Functional Scale and Its Current Uses: An Updated Systematic Review of 57 Studies Using COSMIN Guidelines

OBJECTIVE

To systematically review measurement properties, including acceptability, feasibility, and interpretability, and current uses of the Patient-Specific Functional Scale (PSFS).

DESIGN

Systematic review of a patient-reported outcome measure using the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) guidelines.

LITERATURE SEARCH

We searched 11 databases from January 2010 to July 2020 for articles on measurement properties or use of PSFS.

STUDY SELECTION CRITERIA

Published primary articles without language restrictions.

DATA SYNTHESIS

Two independent reviewers screened all records, extracted data, and performed risk of bias assessments using COSMIN guidelines. We qualitatively synthesized findings for each measurement property in musculoskeletal and nonmusculoskeletal conditions, and 2 reviewers independently performed Grading of Recommendations Assessment, Development and Evaluation assessments. This study was preregistered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/42UZT).

RESULTS

Of the 985 articles screened, we included 57 articles on measurement properties and 255 articles on the use of PSFS. The PSFS had sufficient test-retest reliability in musculoskeletal (22 studies, 845 participants, low-to-moderate certainty) and nonmusculoskeletal conditions (6 studies, 197 participants, very low certainty), insufficient construct validity as a measure of physical function (21 studies, 2 945 participants, low-to-moderate certainty), and sufficient responsiveness (32 studies, 13 770 participants, moderate-to-high certainty). The standard error of measurement ranged from 0.35 to 1.5. The PSFS was used in 87 unique health conditions, some without prior evidence of validity.

CONCLUSION

The PSFS is an easy-to-use, reliable, and responsive scale in numerous musculoskeletal conditions, but the construct validity of PSFS remains uncertain. Further study of the measurement properties of the PSFS in nonmusculoskeletal conditions is necessary before clinical use. J Orthop Sports Phys Ther 2022;52(5):262-275. Epub: 05 Feb 2022. doi:10.2519/jospt.2022.10727.

Quality of Life and Self-care Activities in Diabetic Ulcer Patients, Grade 3: Gender Differences

Introduction: Diabetic foot ulcer (DFU) is a common complication of diabetes mellitus associated with increased morbidity and mortality and diminished quality of life (QoL). This study aimed to explore the effect of gender differences on QoL and adherence to self-care activities.

Methods: In this cross-sectional study, we enrolled 135 male and 135 female patients with DFU. Data was collected using the Short Form Health Survey (SF-36) and a questionnaire that measured self-care activities (Diet, Exercise, Blood Examination, and Foot Check). Data analysis was performed using SPSS version 20.

Results: In terms of QoL, male participants had moderate to high levels in the categories of energy/fatigue, emotional well-being, social functioning, and bodily pain, whereas they had low levels in physical functioning, physical role, and emotional role. Female patients had moderate QoL in the categories of energy/fatigue and social functioning, whereas they had low QoL in physical functioning, physical role, emotional role, emotional well-being, and bodily pain. Finally, regarding general health, male participants had moderate QoL and females had moderate to low QoL. Both males and females had low adherence to exercise and high in blood-examinations. For both genders, adherence to exercise had a statistically significant association with all sub-categories of QoL apart from those of role (physical and emotional).

Conclusion: It is essential for health care professionals to provide gender-specific approaches in treatment of ulceration.

The Role of New Technological Opportunities and the Need to Evaluate the Activities Performed in the Prevention of Diabetic Foot with Exercise Therapy

The diabetic foot (DF) is one of the most feared conditions among chronic complications of diabetes, which affects a growing number of patients. Although exercise therapy (ET) has always been considered a pillar in the treatment of patients at risk of DF it is not usually used. Several causes can contribute to hindering both the organization of ET protocols for Diabetes Units and the participation in ET programs for patients at different levels of risk of foot ulceration. The risk of favoring the occurrence of ulcers and the absence of clear evidence on the role played by ET in the prevention of ulcers could be considered among the most important causes leading to the low application of ET. The increased availability of new technologies and in particular of systems and devices equipped with sensors can enable the remote monitoring and management of physical activity performed by patients. Consequently, they can become an opportunity for introducing the systematic use of ET for the treatment of patients at risk. Considering the complexity of the clinical conditions that patients at risk or with diabetic foot ulcer can show, the evaluation of how patients perform the ET proposed can consequently be very important. All this can contribute to improving the treatment of patients and avoiding possible adverse effects. The aim of this brief review was to describe that the use of new technologies and the assessment of the execution of the ET proposed allows an important step forward in the management of patients at risk.

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices. We propose a Diabetic foot Offloading and Activity framework to guide future research to find the optimal balance between the positive and negative effects of weight-bearing activity in the context of foot ulcers. We hope such future studies will shed more conclusive light on the impact of weight-bearing activity on healing of plantar diabetic foot ulcers.

The effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients

Objectives

This study aimed to analyze the effect of audiovisual and group support foot exercises on the Ankle Brachial Pressure Index and foot sensation.

Methods

This study used a quasi-experimental design. The sample number of this study was 156 using a purposive sampling technique. The research group was divided into three groups. The variables measured in this study were ABPI, foot sensation, and foot exercise experience. The statistical analysis was conducted by a paired-sample t-test, an independent-sample t-test, and a two-way Manova.

Results

The results showed that each group had a difference in how ABPI and foot sensation were influenced (p = 0.000). Additionally, audiovisual and group support foot exercises have been shown to influence ABPI (p = 0.000) and foot sensation (p) = 0.000).

Conclusions

Audiovisual and group support foot exercises significantly influenced the Ankle Brachial Pressure Index value and foot sensation in diabetic mellitus patients. This intervention is encouraged for diabetic mellitus patients who would like to see the benefits of exercise and group support.

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.