Effect of foot-ankle flexibility and resistance exercise in the secondary prevention of plantar foot diabetic ulcer

Effect of photobiomodulation as preventive treatment of diabetic foot ulcer: randomised, controlled, double-blind, clinical trial protocol

INTRODUCTION

The prevention of diabetic foot ulcer (DFU) involves the classification of risk, systemic care, regular examinations, foot care, therapeutic education and adjunct treatments. Photobiomodulation (PBM) has been successfully administered for the healing of DFU and its preventive effects have drawn the interest of researchers.

METHODS AND ANALYSIS

The purpose of the study is to assess the effect of PBM for the prevention of DFU through a randomised, controlled, double-blind, clinical trial. Individuals from 18 to 75 years of age of both sexes with type 2 diabetes mellitus (DM) at moderate to high risk of developing DFU will be randomly allocated to two groups of 32 participants each. The PBM group will wear a boot with 1344 light-emitting diodes (LEDs)-504 with a wavelength of 660 nm located on the sides of the boot (28.5 mW, 10 J per LED), 504 with a wavelength of 850 nm also on the sides of the boot (23 mW, 8 J per LED), 168 with a wavelength of 660 nm on the base of the boot (28.5 mW, 10 J per LED) and 168 with a wavelength of 850 nm also on the base of the boot (23 mW, 8 J per LED). The boot will be worn once a day for 6 min over 60 days and the participants will also receive therapeutic education. The control group will wear a non-therapeutic LED boot (sham) under the same conditions and will also receive therapeutic education. Assessments will be performed at the beginning of the study, after 30 days (clinical examination) and after 60 days (clinical examination, assessment of peripheral neuropathy (PN) and peripheral artery disease (PAD), blood and urine examinations and quality of life).

ETHICS AND DISSEMINATION

This protocol received approval from the Human Research Ethics Committee of Nove de Julho University and the Mandaqui Hospital Complex (certificate number: 66098522.0.3001.5511; final approval date: 22 June 2023). The findings will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06353568, ClinicalTrials.gov.

Effect of Early Postoperative Physical Therapy and Educational Program on Wound Recurrence in Diabetic Foot Ulcers: A Randomized Controlled Trial

Objective: This study aimed to examine the impact of early postoperative physical therapy combined with an educational program on wound recurrence and quality of life in patients with foot ulcers. Methods: Forty-eight postoperative patients with diabetic foot ulcers were randomly assigned to either an intervention group, which received both physical therapy and an educational program (n = 25), or a control group, which received physical therapy only (n = 23). Each intervention was initiated on the day after surgery in both groups. The intervention group participated in physical therapy sessions, followed by a 15 min disease education program conducted five times per week. The primary endpoint was the rate of wound recurrence six months after hospital discharge. Secondary endpoints included ankle dorsiflexion range of motion, knee extension strength, gait functional independence measure scores, problem areas in diabetes scores, and EuroQol-5 dimensions-5 levels scores. Results: The intervention group demonstrated a significantly lower rate of wound recurrence within six months after discharge (10.5%) compared with the control group (27.7%). Conclusions: The combined use of early postoperative physical therapy and educational programs was an effective intervention strategy, contributing to reduced wound recurrence rates in patients with diabetic foot ulcers.

Effect of three-week exercise program on muscle strength and joint mobility in patients with diabetic polyneuropathy: Randomized controlled trial

BACKGROUND

Limited joint mobility is the proven risk factor for diabetic foot ulceration when present in the subtalar and first metatarsophalangeal joints. Evidence shows that a foot-related exercise program, combined with a health-promoting program, can improve the signs and symptoms of diabetic polyneuropathy, enhance gait, restore mobility in the foot and ankle joints, redistribute pressure while walking, and increase foot strength and function. As a result, these exercise programs can help mitigate the risk factors for diabetic foot ulceration.

AIM

To determine the effect of supervised stretching, strengthening, functional and walking exercises on joint mobility and muscle strength in patients with diabetic polyneuropathy.

METHODS

This was a randomized controlled trial conducted in a tertiary hospital. The study included 82 participants allocated into the intervention group (alpha-lipoic acid and exercise on 15 consecutive therapeutic days, n = 42) and control group (alpha lipoic acid only, n = 40). Muscle strength included dorsal and plantar flexors dynamometry and strength score, while range of motion included ankle, subtalar and first metatarsophalangeal joint goniometry.

RESULTS

Change of motion range was significantly higher in the intervention group compared to the control group regarding ankle joint on day 15 (9.9 ± 7.2 vs 0.1 ± 3.3; P = 0.006) and month 6 (2.8 ± 7.3 vs -0.9 ± 4.1; P < 0.001), subtalar joint on day 15 (7.5 ± 5.1 vs -0.25 ± 2.25; P < 0.001) and month 6 (3.9 ± 6.4 vs -0.13 ± 3.49; P < 0.001). Change in dorsal flexors was significantly higher in the intervention group compared to the control group on day 15 (2.62 ± 1.69 vs 0.10 ± 1.35; P < 0.001) and month 6 (0.66 ± 2.38 vs -0.75 ± 1.94; P = 0.004) as well as plantar flexors on day 15 (3.3 ± 1.6 vs 0.3 ± 1.5; P < 0.001) and month 6 (1.8 ± 2.2 vs -0.9 ± 2.1; P < 0.001). Muscle strength score change was significantly lower in the intervention group compared to the control group on day 15 (-1.45 ± 1.42 vs -0.03 ± 0.16; P < 0.001) and month 6 (-1.17 ± 1.53 vs 0.20 ± 0.56; P < 0.001).

CONCLUSION

Exercise in combination with alpha-lipoic acid can improve joint mobility, as well as strength of the foot and lower leg muscles in patients with diabetic polyneuropathy.

Effectiveness of a web-based foot-ankle exercise program for treating ulcer risk factors in diabetic neuropathy in a randomized controlled trial

The need for strategies to prevent complications from diabetic neuropathy (DPN) is well recognized. However, foot-ankle exercise programs show weak to moderate evidence, and barriers to their implementation persist, including broad and facilitated access to exercise programs, which guarantee for equity. In this paper, we report for the first time the effectiveness of a web-based foot-ankle exercise program aiming to improve DPN-related outcomes, gait biomechanics and functional outcomes. Sixty-two participants with DPN were randomly allocated into the control group (CG; n = 31), which received the usual care, or the intervention group (IG; n = 31), which received the usual care plus a 12-week foot-ankle exercise program using a web-based software (the SOPeD software). The primary outcomes, DPN symptoms and severity, were assessed using the Brazilian version of the Michigan Neuropathy Screening Instrument and the Decision Support System for Classification of Diabetic Polyneuropathy, respectively. Secondary outcomes included tactile sensitivity (monofilaments) and vibration perception (tuning fork), functional outcomes, such as foot pain and function (Foot Health Status Questionnaire), foot muscle strength and plantar pressure during gait (emed plate), and foot-ankle kinematics and kinetics during gait. Outcomes were assessed at baseline, 12 and 24 weeks by an assessor blinded to group allocation. DPN symptoms and severity remained unchanged after the web-based foot-ankle program. However, IG showed improvements compared to CG, with greater functional reach at 12 weeks, better foot function, reduced foot pain and greater plantarflexion degree during push-off at 24 weeks. Regarding plantar loading during gait, the forefoot pressure reduced in the IG at 12 weeks compared to baseline, but at 24 weeks, forefoot load increased in the IG compared to CG. The 12-week web-based foot-ankle exercise program was feasible, acceptable, demonstrating safety with minimal adverse events, such as delayed onset muscle soreness and foot muscle cramping. While DPN-related outcomes were unaffected by the 12-week SOPeD program, modest improvements in foot pain and function, functional reach, and changes in plantar pressure and plantarflexion degree during gait were noted, mostly at 24 weeks.Trial registration: ClinicalTrials.gov, NCT04011267. Registered on 8 July 2019.

Prevention of foot ulcers recurrence in patients with diabetes: a systematic review and meta-analysis of randomized controlled trials for the development of the italian guidelines for the treatment of diabetic foot syndrome

AIM

To compare the effectiveness of preventive interventions in reducing reccurrent diabetic foot ulcers. Meta-analysis (MA) was conducted to address clinical questions on this topic of the Italian guidelines on diabetic foot.

METHODS

This MA includes randomized controlled trials evaluating the effectiveness of various preventive interventions, namely: treatment of pre-ulcerative foot lesions, structured educational programs, psychological interventions and the use of therapeutic footwear to relieve plantar pressure in people with diabetes mellitus and a history of previous ulcers.

RESULTS

A total of 731 studies were identified and 14 were considered eligible for the analysis. We found that treatments of pre-ulcerative foot lesions did not provide any statistically significant effects (MH-OR: 0.84 [0.31, 2.33], p = 0.74, I2 = 38%). Conversely, structured educational programs were associated with a trend toward reduction of ulcer recurrence risk (MH-OR: 0.13 [0.01, 1.64], p = 0.10, I2 = 88%). No randomized controlled studies assessing the efficacy of psychological interventions have been retrieved. The use of therapeutic footwears can effectively reduce the risk of reulceration in diabetic patients with an history of previous DFU, in particular prefabricated rigid-soled therapeutic footwears showed a significant reduction of the risk of ulcer recurrence in comparison with semirigid soles (MH-OR: 0.17 [0.05, 0.57], p = 0.004).

CONCLUSIONS

The study provides low-certainty evidence that, among preventive strategies in patients with previous DFU, rigid-sole therapeutic footwear and structured education programs are capable of reducing the risk of foot re-ulceration.

Affordable web-based foot-ankle exercise program proves effective for diabetic foot care in a randomized controlled trial with economic evaluation

The aim of this study was to shed light on a crucial issue through a comprehensive evaluation of the cost-effectiveness and cost-utility of a cutting-edge web-based foot-ankle therapeutic exercise program (SOPeD) designed for treating modifiable risk factors for ulcer prevention in individuals with diabetes-related peripheral neuropathy (DPN). In this randomized controlled trial, 62 participants diagnosed with DPN were assigned to the SOPeD software or received usual care for diabetic foot. Primary outcomes were DPN symptoms and severity, foot pain and function, and quality-adjusted life years (QALYs). Between-group comparisons provided 95% confidence intervals. The study also calculated incremental cost-effectiveness and cost-utility ratios (ICERs), analyzed direct costs from a healthcare perspective, and performed a sensitivity analysis to assess uncertainty. The web-based intervention effectively reduced foot pain, improved foot function and showed favorable cost-effectiveness, with ICERs ranging from (USD) $5.37-$148.71 per improvement in different outcomes. There is a high likelihood of cost-effectiveness for improving DPN symptoms and severity, foot pain, and function, even when the minimum willingness-to-pay threshold was set at $1000.00 USD. However, the intervention did not prove to be cost-effective in terms of QALYs. This study reveals SOPeD's effectiveness in reducing foot pain, improving foot function, and demonstrating cost-effectiveness in enhancing functional and clinical outcomes. SOPeD stands as a potential game-changer for modifiable risk factors for ulcers, with our findings indicating a feasible and balanced integration into public health systems. Further studies and considerations are vital for informed decisions to stakeholders and the successful implementation of this preventive program on a larger scale.Trial Registration: ClinicalTrials.gov, NCT04011267. Registered on 8 July 2019.

Effect of exercise training on glycemic control in diabetic peripheral neuropathy: A GRADE assessed systematic review and meta-analysis of randomized-controlled trials

AIMS

We conducted a systematic review and meta-analysis to investigate the effect of exercise training on HbA1c, and on fasting and postprandial plasma glucose concentrations in patients with diabetic peripheral neuropathy (DPN).

METHODS

Two independent researchers performed a systematic search in the electronic databases of PubMed, Web of Science and Scopus. Studies investigating the effect of exercise training on patients diagnosed with DPN using a randomized-controlled design were included in the meta-analysis.

RESULTS

Of 1254 retrieved studies, 68 studies were identified to undergo full-text review; out of these a total of 13 randomized trials met the inclusion criteria. Eleven studies assessed HbA1c, 8 fasting plasma-glucose concentration, and 3 postprandial plasma-glucose concentration. Overall, exercise training significantly decreased HbA1c [-0.54% (95% CI -0.78 to -0.31%)], fasting plasma glucose [-32.6 mg/dl [-1.8 mmol/L] (-44.2 to -20.9 mg/dl [-2.4 to -1.1 mmol/L])] and postprandial plasma glucose [-67.5 mg/dl [-3.7 mmol/L] (-129.5 to -5.4 mg/dl [-7.1 to -0.3 mmol/L])]. Studies with aerobic training intervention yielded the largest significant mean reduction in HbA1c (-0.75%) and fasting plasma glucose concertation (34.0 mg/dl).

CONCLUSIONS

aerobic training is the most effective modality to reduces HbA1c, fasting and postprandial plasma glucose concentration in patients with DPN. From a metabolic perspective, the magnitude precision range of the reduction in HbA1c is of clinical importance for patients with DPN. This area of research warrants further attention to investigate the impact of various exercise modalities on glycemic control. Registration number CRD42023413687.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-management practices for preventing complications of type II diabetes mellitus in low and middle-income countries: A scoping review

Introduction

The projected increase in the prevalence of diabetes mellitus globally is expected to hit the low and middle income countries the hardest. The majority of the day to day disease management activities needed to achieve glycaemic control and improve the quality of life among patients with diabetes mellitus falls on the patient and/or their families. Determining the self-management practices by patients with diabetes mellitus can help develop interventions that can enhance these practices and help prevent complications.

Objective

The current study aimed to explore the self-management practices of patients with type II diabetes mellitus in low and middle-income countries to prevent complications.

Design

A scoping review was conducted using the Joanna Briggs Institute approach to conducting scoping reviews. The context of the review was low and middle income countries with the core concept being self-management practices for prevention of complications.

Methods

Articles in Scopus databases and on the EBSCOHost platform were searched, as were their reference lists. If abstracts met inclusion criteria, full articles were downloaded and data extracted. The review included original research studies, published in the English language. The research studies included in the review were conducted between the year 2000 to 2022 among patients diagnosed with type II diabetes mellitus.

Results

This search yielded 823 articles; after deduplication, twelve studies were included in the final list. Four categories of self-management practices for preventing complications of type II diabetes mellitus were identified. The categories are i) acquisition of diabetes-related knowledge, ii) essential skills to manage diabetes mellitus, iii) lifestyle modification, and iv) availability of psychological support and follow-up.

Conclusions

Most diabetes care is dependent on patients' self-management levels. The studies reviewed in this article show that patients are capable of adequate self-management when practices are tailored to their needs.

Registration

The scoping review protocol was registered in the Fig Share platform on 17th January 2022 under the digital object identifier https://doi.org/10.38140/ufs.17206751.

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

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

Results of Neuropathy Screening Test for Lower Limb Amputees With Diabetes Mellitus and Their Prosthetic Rehabilitation: A Cross-Sectional Study

Introduction To prevent foot ulcers and subsequent amputation on the non-amputated side, we conducted tests for diabetic neuropathy. The results were then used in prosthetic rehabilitation for lower limb amputees with diabetes mellitus. Materials and methods This cross-sectional retrospective study included patients admitted to our convalescent rehabilitation ward for prosthetic rehabilitation between April 2019 and December 2022 following lower limb amputation due to diabetes. We investigated the positive rate of the modified Ipswich Touch Test (mIpTT) in lower limb amputees with diabetes, and physical and orthotic therapy and prosthetic rehabilitation based on medical records. Results Twenty-seven transtibial amputees and nine transfemoral amputees had diabetes. The mIpTT results were positive in 22 (81%) transtibial and eight (89%) transfemoral amputees. There were no apparent differences in positivity rates by amputation level, gender, or age. Based on these results, personalized physical therapy and insoles were prescribed for the non-amputee foot in parallel with prosthetic rehabilitation. Conclusions Lower limb amputees with diabetes have diabetic neuropathy more frequently than diabetic patients without amputation. As a result, they may also be at a higher risk of developing foot ulcers and subsequent amputation due to neuropathy. Therefore, rehabilitation to prevent amputation on the non-amputated side of lower limb amputees with diabetes had better encompassing foot exercises and orthotic therapy on the non-amputated side during the prosthetic rehabilitation period.