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van Netten JJ, Sacco ICN, Lavery L, Monteiro-Soares M, Paton J, Rasmussen A, Raspovic A, Bus SA. 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. Diabetes Metab Res Rev 2024; 40:e3649. [PMID: 37132203 DOI: 10.1002/dmrr.3649] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 04/17/2023] [Indexed: 05/04/2023]
Abstract
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.
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Affiliation(s)
- Jaap J van Netten
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lawrence Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matilde Monteiro-Soares
- Portuguese Red Cross School of Health-Lisbon, Lisbon, Portugal
- MEDCIDS-Departamento de Medicina da Comunidade Informação e Decisão em Saúde, Faculty of Medicine of the University of Porto, Porto, Portugal
- RISE@ CINTESIS, Faculty of Medicine Oporto University, Porto, Portugal
| | - Joanne Paton
- School of Health Professions, University of Plymouth, Plymouth, UK
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Sicco A Bus
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Program Rehabilitation, Amsterdam, The Netherlands
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Lepesis V, Marsden J, Rickard A, Latour JM, Paton J. 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. Diabetes Metab Res Rev 2023; 39:e3692. [PMID: 37431167 DOI: 10.1002/dmrr.3692] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/05/2023] [Accepted: 06/17/2023] [Indexed: 07/12/2023]
Abstract
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.
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Affiliation(s)
- Vasileios Lepesis
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Jonathan Marsden
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Alec Rickard
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Jos M Latour
- School of Nursing and Midwifery, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Joanne Paton
- School of Health Professions, Faculty of Health, University of Plymouth, Plymouth, UK
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Okemuo AJ, Gallagher D, Dairo YM. Effects of rebound exercises on balance and mobility of people with neurological disorders: A systematic review. PLoS One 2023; 18:e0292312. [PMID: 37797042 PMCID: PMC10553300 DOI: 10.1371/journal.pone.0292312] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/05/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Therapeutic rebound exercise is gaining popularity among the general population, but its effectiveness in individuals with neurological impairments remains uncertain. To shed light on this, a systematic review was conducted between November 2021 and March 2023 to study the impact of rebound exercise on balance and mobility in this group. METHODS Six databases were searched. Studies were included if written in English, peer-reviewed, had original research data and assessed the effect of rebound exercise in adults with neurological disorders. The outcomes measured were balance and mobility. Two reviewers independently appraised study quality using the Critical Appraisal Skills Program for Randomized Controlled Trials. Finally, a meta-summary of the included studies was completed, and a meta-analysis was performed using RevMan software version 5.3 to determine the effectiveness of the intervention. RESULTS Five studies were included comprising 130 participants aged 31.32±7.67 to 58±12 years, 72% male and 28% female. Participants were in-patients with stroke (49%), multiple sclerosis (24%), Parkinson's disease (15%) and spinal cord injury (12%). The included papers had moderate to high methodological quality. The timed up-and-go test revealed that the rebound group participants could walk 6.08 seconds quicker over three to eight weeks. Pooled results show that rebound exercise significantly improves mobility (-0.53[-0.94, -0.11], p = 0.01), but no significant improvement was observed in balance. CONCLUSION Rebound exercise has shown the potential to improve mobility in people with neurological disorders. However, the findings should be in the context that the included studies are few and participants were in in-patient settings. PROSPERO registration: CRD42021298030.
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Affiliation(s)
- Adaora Justina Okemuo
- School of Health and Social Care Professions, Buckinghamshire New University, High Wycombe, United Kingdom
- Department of Medical Rehabilitation, University of Nigeria, Enugu Campus, Nsukka, Nigeria
| | - Dearbhla Gallagher
- School of Human and Social Sciences, Buckinghamshire New University, High Wycombe, United Kingdom
| | - Yetunde Marion Dairo
- School of Health and Social Care Professions, Buckinghamshire New University, High Wycombe, United Kingdom
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Monteiro RL, Ferreira JSSP, Silva ÉQ, Cruvinel-Júnior RH, Veríssimo JL, Bus SA, Sacco ICN. Effects of foot-ankle exercises on foot-ankle kinematics, plantar pressure, and gait kinetics in people with diabetic neuropathy: Secondary outcomes from a randomized controlled trial. Braz J Phys Ther 2023; 27:100517. [PMID: 37348358 DOI: 10.1016/j.bjpt.2023.100517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 12/22/2022] [Accepted: 06/01/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND Follow-up report of secondary outcomes of a randomized, single-blinded, parallel controlled trial that investigated the benefits of a foot-ankle therapeutic exercise program on foot-ankle kinematics, plantar pressure, and lower limb kinetics during gait in individuals with diabetic neuropathy (DPN). METHODS Sixty-six participants with DPN were randomly allocated into a control group (CG; n = 31), which received usual care, and an intervention group (IG; n = 35), which received usual care plus a 12-week group-based foot-ankle exercise program. Outcomes were assessed at baseline and 12 weeks by an assessor blinded to group allocation. RESULTS The generalized linear mixed model and intention-to-treat analysis revealed a greater hip extensor moment at push-off and greater hallux contact area in the IG than CG after 12 weeks. A within-group analysis revealed a larger arch height during stance and higher peak pressure and pressure-time integral at the central forefoot region in the IG after 12 weeks compared to baseline. There were no other significant group difference or changes over time in foot-ankle kinematics or in any other joint moment related to overall lower limb biomechanics. CONCLUSION The increases in hip moment at push-off and hallux surface contact area suggest an improvement in the propulsion phase with greater participation of the toes in foot rollover after 12 weeks of a group-based foot-ankle exercises program for people with DPN. Individual face-to-face, longer-term, and more intensive interventions may be needed to positively influence foot-ankle biomechanics and pressure parameters in other plantar areas.
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Affiliation(s)
- Renan L Monteiro
- Physical Therapy, Speech and Occupational Therapy Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Department of Health and Biological Science, Universidade Federal do Amapá, Macapá, AP, Brazil
| | - Jane S S P Ferreira
- Physical Therapy, Speech and Occupational Therapy Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Érica Q Silva
- Physical Therapy, Speech and Occupational Therapy Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ronaldo H Cruvinel-Júnior
- Physical Therapy, Speech and Occupational Therapy Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jady L Veríssimo
- Physical Therapy, Speech and Occupational Therapy Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation medicine, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Sacco ICN, Trombini-Souza F, Suda EY. Impact of biomechanics on therapeutic interventions and rehabilitation for major chronic musculoskeletal conditions: A 50-year perspective. J Biomech 2023; 154:111604. [PMID: 37159980 DOI: 10.1016/j.jbiomech.2023.111604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023]
Abstract
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.
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Affiliation(s)
- Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil.
| | - Francis Trombini-Souza
- Department of Physical Therapy, University of Pernambuco, Petrolina, Pernambuco, Brazil; Master's and Doctoral Programs in Rehabilitation and Functional Performance, University of Pernambuco, Petrolina, Pernambuco, Brazil
| | - Eneida Yuri Suda
- Postgraduate Program in Physiotherapy, Universidade Ibirapuera, São Paulo, Brazil
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Gracia-Sánchez A, López-Pineda A, Lázaro-Martínez JL, Pérez A, Pomares-Gómez FJ, Fernández-Seguín LM, Gil-Guillén VF, Chicharro-Luna E. Consensus-based recommendations on physical activity and exercise in patients with diabetes at risk of foot ulcerations: a Delphi study. Braz J Phys Ther 2023; 27:100500. [PMID: 37079949 DOI: 10.1016/j.bjpt.2023.100500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 03/08/2023] [Accepted: 03/24/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND Patients with diabetes mellitus are exposed to important complications. Currently little evidence exist on the guidelines that these patients, at some risk of foot ulceration, should follow for physical exercise. OBJECTIVES To reach a consensus among multidisciplinary and international experts on physical activity/exercise recommendations for patients with diabetes, according to foot ulcer risk. METHODS Using a three-round Delphi method, a panel composed of 28 multidisciplinary experts in the management of diabetic foot assessed 109 recommendations on physical activity/exercise for patients with diabetes mellitus, according to their risk of foot ulcer. Consensus was assumed when 80% of responses matched the same category (agreement/disagreement). RESULTS Twenty-nine experts participated in the first and second rounds of consultation, and twenty-eight did so in the third, reaching final agreement on 86 of the 109 recommendations considered (78.9%). The study, thus, generated a consensus set of recommendations concerning different aspects of diabetic footcare before, during, and after exercise (e.g. when to examine the foot, how to assess it, what type of sock and insole to use, what types of exercise to perform, and when it is advisable to return to activity after an ulceration). CONCLUSION This Delphi study generated recommendations based on the consensus of international experts on physical activity and exercise by patient with diabetes at risk of ulceration. Recommendations considered the state of the foot and the patient's history and status before physical activity and included information on intensity, duration, frequency, and progressions of physical activity/exercise, and the use of custom-made plantar orthoses, shoe prescription, and the convenience of returning to physical activity after an ulceration.
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Affiliation(s)
- Alba Gracia-Sánchez
- Nursing Service, Department of Health and Behavioral Sciences, Faculty of Medicine, University Miguel Hernández de Elche, San Juan de Alicante, Spain
| | - Adriana López-Pineda
- Clinical Medicine Department, University Miguel Hernández de Elche, San Juan de Alicante, Spain; Atenea Research Group, Foundation for the Promotion of Health and Biomedical Research, San Juan de Alicante, Spain; Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Alicante, Spain.
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit,Universidad Complutense de Madrid. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Antonio Pérez
- Endocrinology and Nutrition Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Medicine Department, Universitat Autònoma de Barcelona, CIBER de Diabetes y Enfermedades metabólicas (CIBERDEM), Barcelona, Spain
| | | | | | - Vicente F Gil-Guillén
- Clinical Medicine Department, University Miguel Hernández de Elche, San Juan de Alicante, Spain; Network for Research on Chronicity, Primary Care, and Health Promotion (RICAPPS), Alicante, Spain; Research Unit, University General Hospital of Elda, Elda, Spain
| | - Esther Chicharro-Luna
- Nursing Service, Department of Health and Behavioral Sciences, Faculty of Medicine, University Miguel Hernández de Elche, San Juan de Alicante, Spain
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Bhardwaj H, Khute S, Sahu R, Jangde RK. Advanced Drug Delivery System for Management of Chronic Diabetes Wound Healing. Curr Drug Targets 2023; 24:1239-1259. [PMID: 37957907 DOI: 10.2174/0113894501260002231101080505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/28/2023] [Accepted: 09/07/2023] [Indexed: 11/15/2023]
Abstract
The diabetic wound is excessively vulnerable to infection because the diabetic wound suggests delayed and incomplete healing techniques. Presently, wounds and ulcers related to diabetes have additionally increased the medical burden. A diabetic wound can impair mobility, lead to amputations, or even death. In recent times, advanced drug delivery systems have emerged as promising approaches for enhancing the efficacy of wound healing treatments in diabetic patients. This review aims to provide an overview of the current advancements in drug delivery systems in managing chronic diabetic wound healing. This review begins by discussing the pathophysiological features of diabetic wounds, including impaired angiogenesis, elevated reactive oxygen species, and compromised immune response. These factors contribute to delayed wound healing and increased susceptibility to infection. The importance of early intervention and effective wound management strategies is emphasized. Various types of advanced drug delivery systems are then explored, including nanoparticles, hydrogels, transferosomes, liposomes, niosomes, dendrimers, and nanosuspension with incorporated bioactive agents and biological macromolecules are also utilized for chronic diabetes wound management. These systems offer advantages such as sustained release of therapeutic agents, improved targeting and penetration, and enhanced wound closure. Additionally, the review highlights the potential of novel approaches such as antibiotics, minerals, vitamins, growth factors gene therapy, and stem cell-based therapy in diabetic wound healing. The outcome of advanced drug delivery systems holds immense potential in managing chronic diabetic wound healing. They offer innovative approaches for delivering therapeutic agents, improving wound closure, and addressing the specific pathophysiological characteristics of diabetic wounds.
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Affiliation(s)
- Harish Bhardwaj
- Department of Pharmacy, University Institute of Pharmacy, Pt. Ravishankar Shukla University Raipur, C.G, India
| | - Sulekha Khute
- Department of Pharmacy, University Institute of Pharmacy, Pt. Ravishankar Shukla University Raipur, C.G, India
| | - Ram Sahu
- Department of Pharmaceutical Sciences, Assam University (A Central University), Silchar, Assam, India
- Department of Pharmaceutical Sciences, Hemvati Nandan Bahuguna Garhwal University (A Central University), Chauras Campus, Tehri Garhwal-249161, Uttarakhand, India
| | - Rajendra Kumar Jangde
- Department of Pharmacy, University Institute of Pharmacy, Pt. Ravishankar Shukla University Raipur, C.G, India
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Cruvinel-Júnior RH, Ferreira JSSP, Veríssimo JL, Monteiro RL, Suda EY, Silva ÉQ, Sacco ICN. Could an Internet-Based Foot-Ankle Therapeutic Exercise Program Modify Clinical Outcomes and Gait Biomechanics in People with Diabetic Neuropathy? A Clinical Proof-of-Concept Study. SENSORS (BASEL, SWITZERLAND) 2022; 22:9582. [PMID: 36559949 PMCID: PMC9781221 DOI: 10.3390/s22249582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 06/17/2023]
Abstract
Previous studies have shown the efficacy of foot-ankle exercises in people with diabetic peripheral neuropathy (DPN), but the quality of evidence is still low. This proof-of-concept study pursues preliminary evidence for potential clinical and gait biomechanical benefits from an internet-based foot-ankle therapeutic exercise program for people with DPN. We randomized 30 individuals with DPN (IWGDF risk category 1 or 2) into either the control group (CG) receiving the usual care or the intervention group (IG) receiving the usual care plus an internet-based foot-ankle exercise program, fully guided by the Sistema de Orientação ao Pé Diabético (SOPeD; translation: Diabetic Foot Guidance System) three times per week for 12 weeks. We assessed face-to-face clinical and biomechanical outcomes at baseline, 12 weeks, and 24 weeks (follow up). Participants had good adherence to the proposed intervention and it led to only mild adverse events. The IG showed improvements in the ankle and first metatarsophalangeal joint motion after 12 and 24 weeks, changed forefoot load absorption during foot rollover during gait after 24 weeks, reduced foot pain after 12 weeks, and improved foot function after 24 weeks. A 12-week internet-based foot-ankle exercise program using the SOPeD software (version 1.0) has the potential to reduce foot pain, improve foot function, and modify some important foot-ankle kinematic outcomes in people with DPN.
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Affiliation(s)
- Ronaldo H. Cruvinel-Júnior
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
| | - Jane S. S. P. Ferreira
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
| | - Jady L. Veríssimo
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
| | - Renan L. Monteiro
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
- . Department of Biological and Health Science, Federal University of Amapá, Rod. Juscelino Kubitschek, km 02—Jardim Marco Zero, Macapá 68903-419, AP, Brazil
| | - Eneida Y. Suda
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
- Postgraduate Program in Physical Therapy, Ibirapuera University, Av. Interlagos, 1329—Chácara Flora, São Paulo 04661-100, SP, Brazil
| | - Érica Q. Silva
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
| | - Isabel C. N. Sacco
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51—Butantã, São Paulo 05360-160, SP, Brazil
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Kaminski MR, Golledge J, Lasschuit JWJ, Schott KH, Charles J, Cheney J, Raspovic A. Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease. J Foot Ankle Res 2022; 15:53. [PMID: 35791023 PMCID: PMC9258081 DOI: 10.1186/s13047-022-00534-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/16/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Michelle R Kaminski
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia. .,Department of Podiatry, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia.,The Department of Vascular and Endovascular Surgery, The Townsville University Hospital, Townsville, Queensland, Australia
| | - Joel W J Lasschuit
- Department of Endocrinology and Diabetes, St Vincent's Hospital, Sydney, New South Wales, Australia.,Healthy Ageing, Garvan Institute of Medical Research, Sydney, New South Wales, Australia.,Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Karl-Heinz Schott
- Southern Cross University School of Health and Human Sciences / Pedorthics, Gold Coast, Queensland, Australia
| | - James Charles
- First Peoples Health Unit, Health Group, Griffith University, Gold Coast, Queensland, Australia
| | - Jane Cheney
- Diabetes Victoria, Melbourne, Victoria, Australia
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
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10
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Foot-ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial. Sci Rep 2022; 12:7561. [PMID: 35534614 PMCID: PMC9082985 DOI: 10.1038/s41598-022-11745-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 04/29/2022] [Indexed: 11/08/2022] Open
Abstract
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).
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11
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Streckmann F, Balke M, Cavaletti G, Toscanelli A, Bloch W, Décard BF, Lehmann HC, Faude O. Exercise and Neuropathy: Systematic Review with Meta-Analysis. Sports Med 2021; 52:1043-1065. [PMID: 34964950 DOI: 10.1007/s40279-021-01596-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Fiona Streckmann
- Department of Sport, Exercise and Health, University of Basel, Grosse Allee 6, 4052, Basel, Switzerland. .,Department of Oncology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland. .,Institute for Cardiovascular Research and Sports Medicine, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany.
| | - Maryam Balke
- Department of Early Neurological and Interdisciplinary Rehabilitation, St. Marien-Hospital, Kunibertskloster 11-13, 50668, Cologne, Germany.,Department of Rehabilitation Sciences, University of Witten/Herdecke, Holthauser Talstraße 2, 58256, Ennepetal, Germany
| | - Guido Cavaletti
- Experimental Neurology Unit, School of Medicine and Surgery and Milan Center for Neuroscience, University of Milano-Bicocca, via Cadore 48, 20900, Monza, Italy
| | - Alexandra Toscanelli
- Department of Sport, Exercise and Health, University of Basel, Grosse Allee 6, 4052, Basel, Switzerland
| | - Wilhelm Bloch
- Institute for Cardiovascular Research and Sports Medicine, German Sport University Cologne, Am Sportpark Müngersdorf 6, 50933, Cologne, Germany
| | - Bernhard F Décard
- Department of Medicine, Neurologic Clinic and Policlinic, University Hospital Basel and University of Basel, 4031, Basel, Switzerland.,Department of Biomedicine, Neurologic Clinic and Policlinic, University Hospital Basel and University of Basel, 4031, Basel, Switzerland.,Department of Clinical Research, Neurologic Clinic and Policlinic, University Hospital Basel and University of Basel, 4031, Basel, Switzerland
| | - Helmar C Lehmann
- Department of Neurology, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Oliver Faude
- Department of Sport, Exercise and Health, University of Basel, Grosse Allee 6, 4052, Basel, Switzerland
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12
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Detection of Motion on a Trampoline with a Smartwatch. SENSORS 2021; 21:s21248413. [PMID: 34960504 PMCID: PMC8704400 DOI: 10.3390/s21248413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/15/2021] [Accepted: 12/15/2021] [Indexed: 11/17/2022]
Abstract
In this study, we develop a method for detecting the motions performed on a trampoline using an accelerometer mounted on a smartwatch. This method will lead to a system that can be used to promote trampoline exercise using a home trampoline by detecting motions on the trampoline using a smartwatch. We proposed a method based on the convolutional neural network to detect the motions on a trampoline. As a result of the performance evaluation by leave-one-subject-out cross-validation on eight subjects, our method achieves 78.8% estimation accuracy, which is the best estimation accuracy compared to the baseline methods. We also evaluate the inference time and the battery consumption when the model is actually running on a smartwatch. Our method is effective for on-device prediction.
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13
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The Role of New Technological Opportunities and the Need to Evaluate the Activities Performed in the Prevention of Diabetic Foot with Exercise Therapy. MEDICINES 2021; 8:medicines8120076. [PMID: 34940288 PMCID: PMC8706849 DOI: 10.3390/medicines8120076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/22/2021] [Accepted: 11/28/2021] [Indexed: 01/22/2023]
Abstract
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.
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The Application of Exercise Training for Diabetic Peripheral Neuropathy. J Clin Med 2021; 10:jcm10215042. [PMID: 34768562 PMCID: PMC8584831 DOI: 10.3390/jcm10215042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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15
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Davis IS, Hollander K, Lieberman DE, Ridge ST, Sacco ICN, Wearing SC. Stepping Back to Minimal Footwear: Applications Across the Lifespan. Exerc Sport Sci Rev 2021; 49:228-243. [PMID: 34091498 DOI: 10.1249/jes.0000000000000263] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Minimal footwear has existed for tens of thousands of years and was originally designed to protect the sole of the foot. Over the past 50 yr, most footwear has become increasingly more cushioned and supportive. Here, we review evidence that minimal shoes are a better match to our feet, which may result in a lower risk of musculoskeletal injury.
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Affiliation(s)
- Irene S Davis
- Spaulding National Running Center, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA
| | | | - Daniel E Lieberman
- Department of Human Evolutionary Biology, Harvard University, Cambridge MA
| | - Sarah T Ridge
- Department of Exercise Sciences, Brigham Young University, Salt Lake City, Utah
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy, School of Medicine, University of São Paulo, São Paulo, Brazil
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16
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Kale MB, Bajaj K, Umare M, Wankhede NL, Taksande BG, Umekar MJ, Upaganlawar A. Exercise and Nutraceuticals: Eminent approach for Diabetic Neuropathy. Curr Mol Pharmacol 2021; 15:108-128. [PMID: 34191703 DOI: 10.2174/1874467214666210629123010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 02/28/2021] [Accepted: 03/05/2021] [Indexed: 11/22/2022]
Abstract
Diabetic neuropathy is an incapacitating chronic pathological condition that encompasses a large group of diseases and manifestations of nerve damage. It affects approximately 50% of patients with diabetes mellitus. Autonomic, sensory, and motor neurons are affected. Disabilities are severe, along with poor recovery and diverse pathophysiology. Physical exercise and herbal-based therapies have the potential to decrease the disabilities associated with diabetic neuropathy. Aerobic exercises like walking, weight lifting, the use of nutraceuticals and herbal extracts are found to be effective. Literature from the public domain was studied emphasizing various beneficial effects of different exercises, use of herbal and nutraceuticals for their therapeutic action in diabetic neuropathy. Routine exercises and administration of herbal and nutraceuticals, either the extract of plant material containing the active phytoconstituent or isolated phytoconstituent at safe concentration, have been shown to have promising positive action in the treatment of diabetic neuropathy. Exercise has shown promising effects on vascular and neuronal health and has proven to be well effective in the treatment as well as prevention of diabetic neuropathy by various novel mechanisms, including herbal and nutraceuticals therapy is also beneficial for the condition. They primarily show the anti-oxidant effect, secretagogue, anti-inflammatory, analgesic, and neuroprotective action. Severe adverse events are rare with these therapies. The current review investigates the benefits of exercise and nutraceutical therapies in the treatment of diabetic neuropathy.
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Affiliation(s)
- Mayur Bhimrao Kale
- Shrimati Kishoritai Bhoyar College of Pharmacy, New Kamptee, Nagpur 441002, Maharashtra, India
| | - Komal Bajaj
- Shrimati Kishoritai Bhoyar College of Pharmacy, New Kamptee, Nagpur 441002, Maharashtra, India
| | - Mohit Umare
- Shrimati Kishoritai Bhoyar College of Pharmacy, New Kamptee, Nagpur 441002, Maharashtra, India
| | - Nitu L Wankhede
- Shrimati Kishoritai Bhoyar College of Pharmacy, New Kamptee, Nagpur 441002, Maharashtra, India
| | | | - Milind Janrao Umekar
- Shrimati Kishoritai Bhoyar College of Pharmacy, New Kamptee, Nagpur 441002, Maharashtra, India
| | - Aman Upaganlawar
- SNJB's Shriman Sureshdada Jain College of Pharmacy, Neminagar, Chandwad-42310, Nasik, Maharashtra, India
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17
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Silva ÉQ, Santos DP, Beteli RI, Monteiro RL, Ferreira JSSP, Cruvinel-Junior RH, Donini A, Verissímo JL, Suda EY, Sacco ICN. Feasibility of a home-based foot-ankle exercise programme for musculoskeletal dysfunctions in people with diabetes: randomised controlled FOotCAre (FOCA) Trial II. Sci Rep 2021; 11:12404. [PMID: 34117342 PMCID: PMC8196027 DOI: 10.1038/s41598-021-91901-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 06/02/2021] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Érica Q Silva
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Danilo P Santos
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Raquel I Beteli
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Renan L Monteiro
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil.,Department of Physical Therapy, Universidade Federal do Amapá, Amapá, Brazil
| | - Jane S S P Ferreira
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Ronaldo H Cruvinel-Junior
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Asha Donini
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Jady L Verissímo
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil
| | - Eneida Y Suda
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil.,Department of Physical Therapy, Universidade Ibirapuera, São Paulo, SP, Brazil
| | - Isabel C N Sacco
- Department of Physical Therapy, Speech, and Occupational Therapy, Faculdade de Medicina, Universidade de São Paulo, Rua Cipotânea, 51, Cidade Universitária, São Paulo, SP, 05360-160, Brazil.
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18
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Cruvinel Júnior RH, Ferreira JSSP, Beteli RI, Silva ÉQ, Veríssimo JL, Monteiro RL, Suda EY, Sacco ICN. Foot-ankle functional outcomes of using the Diabetic Foot Guidance System (SOPeD) for people with diabetic neuropathy: a feasibility study for the single-blind randomized controlled FOotCAre (FOCA) trial I. Pilot Feasibility Stud 2021; 7:87. [PMID: 33766146 PMCID: PMC7995736 DOI: 10.1186/s40814-021-00826-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 01/18/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Diabetic neuropathy dramatically affects musculoskeletal structure and function of the lower limbs by impairing their muscle strength and mobility. Specific muscle strengthening through physiotherapy strategies appears to be promising; however, adherence to physiotherapy treatment is low in people with chronic diseases. Thus, an internet-based foot-ankle exercise program was created as a potential telerehabilitation alternative for people with diabetes to improve their self-monitoring and self-care management. This study assessed the feasibility, safety, acceptability, and changes in foot health and neuropathy symptoms in people with diabetes after 12 weeks of the intervention program with the Sistema de Orientação ao Pé diabético - Diabetic Foot Guidance System (SOPeD). METHODS Fourteen individuals were recruited and randomized to either the usual care (control group) or usual care plus an internet-based foot-ankle exercise program through SOPeD (intervention group) three times per week for 12 weeks. For feasibility, we assessed contact and recruitment rates per week; program adherence, determined as completing over 70% of the 36 sessions; and participant satisfaction and safety assessed through a questionnaire and scored on a 5-point Likert scale. We assessed changes in neuropathy symptoms and foot health and functionality from baseline to 12 weeks estimating differences or median of differences and 95% confidence intervals in the intervention group. RESULTS In 24 weeks, of the 822 patients in the database, 192 were contacted, 65 were assessed for eligibility, and 20 were considered eligible. The recruitment rate was 0.83 participants per week. Fourteen out of the 20 eligible participants agreed to participate, resulting in recruitment success of 70%. Adherence to the program was 66.7%, and there was no dropout. Participants' median level of satisfaction was 5.0 (IQR: 4.5-5.0) and perceived safety was 5.0 (IQR: 5.0-5.0). CONCLUSION The internet-based foot-ankle exercise program using SOPeD is feasible, satisfactory, and safe. Although this study had moderate adherence and a zero-dropout rate, recruitment needs to be improved in the larger trial. TRIAL REGISTRATION ClinicalTrials.gov, NCT04011267 . Registered on 8 July 2019.
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Affiliation(s)
- Ronaldo H Cruvinel Júnior
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - Jane S S P Ferreira
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - Raquel I Beteli
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - Érica Q Silva
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - Jady L Veríssimo
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - Renan L Monteiro
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
- Department of Physical Therapy, Federal University of Amapá, Amapá, Brazil
| | - Eneida Y Suda
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
- Department of Physical Therapy, Ibirapuera University, São Paulo, SP, Brazil
| | - Isabel C N Sacco
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil.
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19
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Tran MM, Haley MN. Does exercise improve healing of diabetic foot ulcers? A systematic review. J Foot Ankle Res 2021; 14:19. [PMID: 33743791 PMCID: PMC7980337 DOI: 10.1186/s13047-021-00456-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/11/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND For patients with diabetic foot ulcers, offloading is one crucial aspect of treatment and aims to redistribute pressure away from the ulcer site. In addition to offloading strategies, patients are often advised to reduce their activity levels. Consequently, patients may avoid exercise altogether. However, it has been suggested that exercise induces an increase in vasodilation and tissue blood flow, which may potentially facilitate ulcer healing. The aim of this systematic review was to determine whether exercise improves healing of diabetic foot ulcers. REVIEW We conducted a systematic search of MEDLINE, CINAHL and EMBASE between July 6, 2009 and July 6, 2019 using the key terms and subject headings diabetes, diabetic foot, physical activity, exercise, resistance training and wound healing. Randomised controlled trials were included in this review. Three randomised controlled trials (139 participants) were included in this systematic review. All studies incorporated a form of non-weight bearing exercise as the intervention over a 12-week period. One study conducted the intervention in a supervised setting, while two studies conducted the intervention in an unsupervised setting. Two studies found greater improvement in percentage wound size reduction in the intervention group compared with the control group, with one of these studies achieving statistically significant findings (p < 0.05). The results of the third study demonstrated statistically significant findings for total wound size reduction (p < 0.05), however results were analysed within each treatment group and not between groups. CONCLUSION This systematic review found there is insufficient evidence to conclusively support non-weight bearing exercise as an intervention to improve healing of diabetic foot ulcers. Regardless, the results demonstrate some degree of wound size reduction and there were no negative consequences of the intervention for the participants. Given the potential benefits of exercise on patient health and wellbeing, non-weight bearing exercise should be encouraged as part of the management plan for treatment of diabetic foot ulcers. Further research is required to better understand the relationship between exercise and healing of diabetic foot ulcers.
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Affiliation(s)
- Morica M Tran
- Department of Podiatry, Eastern Health, Melbourne, Victoria, 3128, Australia.
| | - Melanie N Haley
- Department of Aged and Complex Medicine, Eastern Health, Melbourne, Victoria, 3128, Australia
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20
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Aagaard TV, Moeini S, Skou ST, Madsen UR, Brorson S. Benefits and Harms of Exercise Therapy for Patients With Diabetic Foot Ulcers: A Systematic Review. INT J LOW EXTR WOUND 2020; 21:219-233. [PMID: 32924691 DOI: 10.1177/1534734620954066] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Thomas Vedste Aagaard
- Department of Physiotherapy and Occupational Therapy, Holbaek Hospital, Holbaek, Denmark.,Department of Orthopaedic Surgery, Holbaek Hospital, Holbaek, Denmark.,Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
| | - Sahar Moeini
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark
| | - Søren T Skou
- Department of Physiotherapy and Occupational Therapy, Naestved-Slagelse-Ringsted Hospitals, Slagelse, Denmark.,Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Ulla Riis Madsen
- Department of Orthopaedic Surgery, Holbaek Hospital, Holbaek, Denmark.,The Danish Knowledge Centre for Rehabilitation and Palliative Care. University of Southern Denmark, Odense, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Zealand University Hospital, Koege, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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21
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Monteiro RL, Ferreira JS, Silva ÉQ, Donini A, Cruvinel-Júnior RH, Verissímo JL, Bus SA, Sacco IC. 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. SENSORS 2020; 20:s20185129. [PMID: 32916792 PMCID: PMC7570556 DOI: 10.3390/s20185129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/19/2020] [Accepted: 09/04/2020] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Renan L. Monteiro
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
- Department of Physical Therapy, Federal University of Amapá, Rod. Juscelino Kubitschek, km 02 - Jardim Marco Zero, Macapá, AP 68903-419, Brazil
| | - Jane S.S.P. Ferreira
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
| | - Érica Q. Silva
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
| | - Asha Donini
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
| | - Ronaldo H. Cruvinel-Júnior
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
| | - Jady L. Verissímo
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
| | - Sicco A. Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands;
| | - Isabel C.N. Sacco
- Departamento de Fisioterapia, Fonoaudiologia e Terapia Ocupacional da Faculdade de Medicina da Universidade de São Paulo, Rua Cipotânea, 51 - Butantã, São Paulo, SP 05360-000, Brazil; (R.L.M.); (J.S.S.P.F.); (É.Q.S.); (A.D.); (R.H.C.-J.); (J.L.V.)
- Correspondence: ; Tel.: +55-11-3091-8426; Fax: +55-11-3091-7462
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van Netten JJ, Raspovic A, Lavery LA, Monteiro-Soares M, Rasmussen A, Sacco ICN, Bus SA. Prevention of foot ulcers in the at-risk patient with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3270. [PMID: 31957213 DOI: 10.1002/dmrr.3270] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo, The Netherlands
| | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde & CINTESIS - Center for Health Technology and Services Research, Faculdade de Medicina, Universidade do Porto, Porto, Portugal
| | | | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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Bus SA, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Sacco ICN, van Netten JJ. Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3269. [PMID: 32176451 DOI: 10.1002/dmrr.3269] [Citation(s) in RCA: 154] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde and CINTESIS-Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
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van Netten JJ, Sacco ICN, Lavery LA, Monteiro-Soares M, Rasmussen A, Raspovic A, Bus SA. Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3271. [PMID: 31957306 DOI: 10.1002/dmrr.3271] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/01/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Jaap J van Netten
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Diabetic Foot Clinic, Department of Surgery, Ziekenhuisgroep Twente, Almelo and Hengelo, The Netherlands
| | - Isabel C N Sacco
- Physical Therapy, Speech, and Occupational Therapy Department, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matilde Monteiro-Soares
- MEDCIDES: Departamento de Medicina da Comunidade Informação e Decisão em Saúde & CINTESIS-Center for Health Technology and Services Research, Faculdade de Medicina da Universidade do Porto, Oporto, Portugal
| | | | - Anita Raspovic
- Discipline of Podiatry, School of Allied Health, La Trobe University, Melbourne, VIC, Australia
| | - Sicco A Bus
- Amsterdam UMC, University of Amsterdam, Department of Rehabilitation, Amsterdam Movement Sciences, Meibergdreef 9, Amsterdam, The Netherlands
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Silva EQ, Suda EY, Santos DP, Veríssimo JL, Ferreira JSSP, Cruvinel Júnior RH, Monteiro RL, Sartor CD, Sacco ICN. 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. Trials 2020; 21:180. [PMID: 32054510 PMCID: PMC7020575 DOI: 10.1186/s13063-020-4115-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 01/28/2020] [Indexed: 12/25/2022] Open
Abstract
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.
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Affiliation(s)
- E Q Silva
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - E Y Suda
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - D P Santos
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - J L Veríssimo
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - J S S P Ferreira
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - R H Cruvinel Júnior
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil
| | - R L Monteiro
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil.,Department of Physical Therapy, Federal University of Amapá, Macapá, Amapá, Brazil
| | - C D Sartor
- Department of Physical Therapy, Ibirapuera University, São Paulo, São Paulo, Brazil
| | - I C N Sacco
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo, 05360-160, Brazil.
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Ferreira JSSP, Cruvinel Junior RH, Silva EQ, Veríssimo JL, Monteiro RL, Pereira DS, Suda EY, Sartor CD, Sacco ICN. Study protocol for a randomized controlled trial on the effect of the Diabetic Foot Guidance System (SOPeD) for the prevention and treatment of foot musculoskeletal dysfunctions in people with diabetic neuropathy: the FOotCAre (FOCA) trial I. Trials 2020; 21:73. [PMID: 31931855 PMCID: PMC6958734 DOI: 10.1186/s13063-019-4017-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2019] [Accepted: 12/19/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND This study is part of a series of two clinical trials. Taking into account the various musculoskeletal alterations of the foot and ankle in people with diabetic peripheral neuropathy (DPN) and the need for self-care to avoid more serious dysfunctions and complications, a self-manageable exercise protocol that focuses on strengthening the foot muscles is presented as a potentially effective preventive method for foot and gait complications. The aim of this trial is to investigate the effect of a customized rehabilitation technology, the Diabetic Foot Guidance System (SOPeD), on DPN status, functional outcomes and gait biomechanics in people with DPN. METHODS/DESIGN Footcare (FOCA) trial I is a randomized, controlled and parallel two-arm trial with blind assessment. A total of 62 patients with DPN will be allocated into either a control group (recommended foot care by international consensus with no foot exercises) or an intervention group (who will perform exercises through SOPeD at home three times a week for 12 weeks). The exercise program will be customized throughout its course by a perceived effort scale reported by the participant after completion of each exercise. The participants will be assessed at three different times (baseline, completion at 12 weeks, and follow-up at 24 weeks) for all outcomes. The primary outcomes will be DPN symptoms and severity classification. The secondary outcomes will be foot-ankle kinematics and kinetic and plantar pressure distribution during gait, tactile and vibration sensitivities, foot health and functionality, foot strength, and functional balance. DISCUSSION As there is no evidence about the efficacy of rehabilitation technology in reducing DPN symptoms and severity or improving biomechanical, clinical, and functional outcomes for people with DPN, this research can contribute substantially to clarifying the therapeutic merits of software interventions. We hope that the use of our application for people with DPN complications will reduce or attenuate the deficits caused by DPN. This rehabilitation technology is freely available, and we intend to introduce it into the public health system in Brazil after demonstrating its effectiveness. TRIAL REGISTRATION ClinicalTrials.gov, NCT04011267. Registered on 8 July 2019.
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Affiliation(s)
- J. S. S. P. Ferreira
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
| | - R. H. Cruvinel Junior
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
| | - E. Q. Silva
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
| | - J. L. Veríssimo
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
| | - R. L. Monteiro
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
- Department of Physical Therapy, Federal University of Amapá, Amapá, Brazil
| | - D. S. Pereira
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
| | - E. Y. Suda
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
| | - C. D. Sartor
- Department of Physical Therapy, Ibirapuera University, São Paulo, SP Brazil
| | - I. C. N. Sacco
- Department of Physical Therapy, Speech, and Occupational Therapy, School of Medicine, University of São Paulo, Rua Cipotânea, 51 - Cidade Universitária, São Paulo, São Paulo 05360-160 Brazil
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Ferreira JSSP, Sacco ICN, Siqueira AA, Almeida MHM, Sartor CD. Rehabilitation technology for self-care: Customised foot and ankle exercise software for people with diabetes. PLoS One 2019; 14:e0218560. [PMID: 31220155 PMCID: PMC6586406 DOI: 10.1371/journal.pone.0218560] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/04/2019] [Indexed: 12/19/2022] Open
Abstract
AIMS To develop and validate the content of a free web-based software (desktop and mobile applications) for the self-management of and customised foot-ankle exercises for people with diabetes and diabetic neuropathy. METHODS The development of the programme was based on gamification principles and addressed three main areas: foot care recommendations; self-assessment of feet according to the main complications of diabetic neuropathy; and customised foot-ankle exercises to strengthen muscles, increase the range of motion and improve functionality. The content was validated using the Delphi methodology and a quantitative approach in two rounds with diabetes specialists (n = 9) and users with diabetes (n = 20). A 70% approval rate was considered sufficient in the second round for final validation purposes. The data analysis was conducted using descriptive statistics, absolute and relative frequencies and the content-validity index (CVI). RESULTS Among specialists, the CVI was 0.812 after the first round, and final approval was 100% after the second round. Among users, the CVI was 0.902 in the first round, and the final approval was 97%. CONCLUSION This free access web software was developed based on the high agreement rating between specialists and users and has the potential to prevent complications arising from diabetic polyneuropathy. It allows for self-monitoring and promotes personalised exercises, following a preventive model that can be applied in primary and secondary care services as a complementary treatment for chronic complications. However, further steps to validate the software in a larger population are recommended.
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Affiliation(s)
- Jane S. S. P. Ferreira
- Departamento Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Isabel C. N. Sacco
- Departamento Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | | | - Maria H. M. Almeida
- Departamento Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Cristina D. Sartor
- Departamento Fisioterapia, Fonoaudiologia e Terapia Ocupacional, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Universidade Ibirapuera, São Paulo, São Paulo, Brazil
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RIDGE SARAHT, OLSEN MARKT, BRUENING DUSTINA, JURGENSMEIER KEVIN, GRIFFIN DAVID, DAVIS IRENES, JOHNSON AWAYNE. Walking in Minimalist Shoes Is Effective for Strengthening Foot Muscles. Med Sci Sports Exerc 2019; 51:104-113. [DOI: 10.1249/mss.0000000000001751] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Telfer S, Bigham JJ. The influence of population characteristics and measurement system on barefoot plantar pressures: A systematic review and meta-regression analysis. Gait Posture 2019; 67:269-276. [PMID: 30391749 DOI: 10.1016/j.gaitpost.2018.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The measurement of plantar pressure distributions during gait can provide insights into the effects of musculoskeletal disease on foot function. A range of hardware, software, and protocols are available for the collection of this type of data, with sometimes disparate and conflicting results reported between individual studies. In this systematic review and meta-regression analysis of dynamic regional peak pressures, we aimed to test if 1) the system used to obtain the pressure measurements and 2) the characteristics of the study populations had a significant effect on the results. METHODS A systematic review of the literature was undertaken to identify articles reporting regional peak plantar pressures during barefoot walking. A mixed-effects modeling approach was used to analyze the extracted data. Initially, the effect of the system used to collect the data was tested. Following this, the effect of participant characteristics on the results were analyzed, using moderators of cohort type (defined as the primary health characteristic of the participants), age, sex, and BMI. RESULTS 115 participant groups were included in the analysis. Sufficient cohorts were available to test those that consisted of healthy individuals, and those with diabetes and diabetic neuropathy. Significant differences were found between results reported by studies using different pressure measurement systems in 8 of the 16 regions analyzed. The analysis of participant characteristics revealed a number of significant relationships between regional peak pressures and participant characteristics, including: BMI and midfoot plantar pressures; elevated forefoot pressures as a result of diabetic neuropathy; and sex-differences in regional loading patterns. CONCLUSIONS At the level of the literature, we confirmed significant effects of disease status, age, BMI, and sex on regional peak plantar pressures. Researchers and clinicians should be aware that measurements of peak plantar pressure variables obtained from different collection equipment are not directly comparable.
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Affiliation(s)
- S Telfer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, United States.
| | - J J Bigham
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, United States
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Saber HJ, Daoud AS. Knowledge and practice about the foot care and the prevalence of the neuropathy among a sample of type 2 diabetic patients in Erbil, Iraq. J Family Med Prim Care 2018; 7:967-974. [PMID: 30598942 PMCID: PMC6259530 DOI: 10.4103/jfmpc.jfmpc_163_18] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
CONTEXT Patients with diabetes need to receive medical care from collaborative, integrated teams with expertise in diabetes. They must also assume an active role in their care. One aspect of health education for diabetic patients is foot care, therefore identifying patients foot care knowledge and practice is central in diabetes management. AIMS To know level of foot care, to assess peripheral neuropathy and association between them. SETTINGS AND DESIGN Cross sectional study in Rizgary Teaching Hospital and Layla Qasim diabetic center in Erbil, Iraq. SUBJECTS AND METHODS A sample of 250 patients aged ≥ 18 years with type 2 diabetes were interviewed to complete a questionnaire about foot care. Then a Michigan Neuropathy Screening Instrument was used as screening tool to detect neuropathy. STATISTICAL ANALYSIS USED Statistical Package for Social Sciences version 25 used with a statistical significance level of < 0.05. The results presented as rates, frequencies, percentages in tables and analyzed using Chi-square test. RESULTS The mean age of the sample was 53.75 ± 12.08 years. The mean knowledge and practice scores were 6.1 ± SD 2.6 and 5.8 ± SD 2.1, respectively. The majority of participants were of poor knowledge score and moderate practice score (38% and 40%, respectively). The percentage of neuropathy was 31.20%. The neuropathy was highest among those who had low knowledge score (P < 0.05). CONCLUSIONS The mean knowledge and practice scores were moderate, knowledge had significant influence on practice. Peripheral neuropathy was significantly higher among those with low knowledge score.
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Affiliation(s)
- Hemin Jawad Saber
- Department of Family Medicine, Kurdistan Board for Medical Specialties, Erbil, Iraq
| | - Ali Shakir Daoud
- Department of Community Medicine, College of Medicine, Hawler Medical University, Erbil, Iraq
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Francia P, Anichini R, Seghieri G, De Bellis A, Gulisano M. History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature. Curr Diabetes Rev 2018; 14:411-426. [PMID: 28814244 PMCID: PMC6343166 DOI: 10.2174/1573399813666170816142731] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 07/06/2017] [Accepted: 07/12/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot. OBJECTIVES The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers. METHODOLOGY An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications. RESULTS Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed. CONCLUSION Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.
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Affiliation(s)
- Piergiorgio Francia
- Address correspondence to this author at the Department of Experimental and Clinical, Medicine, University of Florence, Largo Brambilla, 3 - 50134 Florence, Italy; Tel/Fax: +39 0552758050;, E-mail:
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Vileikyte L, Crews RT, Reeves ND. Psychological and Biomechanical Aspects of Patient Adaptation to Diabetic Neuropathy and Foot Ulceration. Curr Diab Rep 2017; 17:109. [PMID: 28942488 DOI: 10.1007/s11892-017-0945-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review was to elucidate how psychological and biomechanical factors interrelate in shaping patients' experience with diabetic symmetric polyneuropathy (DSPN) and its sequela-diabetic foot ulceration (DFU). RECENT FINDINGS Recent findings emphasize the importance not only of neuropathic pain but also of other DSPN symptoms, such as unsteadiness. We highlight the negative spiral between unsteadiness, falls, and psychological distress. Moreover, unsteadiness is a key determinant of non-adherence to offloading resulting in the delayed DFU healing. While depression is an established predictor of incident DFU, findings linking depression and DFU healing remain inconclusive. Examination of physical activity in DFU development and healing represents the most recent application of research to this field. Research evidence indicates that DSPN markedly impairs physical and emotional functioning and suggests that there is an unmet need for the development of multifaceted interventions that address both psychological distress and biomechanical challenges experienced by patients with this debilitating complication of diabetes.
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Affiliation(s)
- Loretta Vileikyte
- Department of Medicine, University of Manchester, Manchester, M13 9WL, UK.
| | - Ryan T Crews
- William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, 60064, USA
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, M1 5GD, UK
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