Limited joint mobility of the ankle in diabetic patients with cutaneous sensory deficit

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

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.

[Association between limited joint mobility syndrome and risk of accidental falls in diabetic patients]

INTRODUCTION

Limited joint mobility syndrome (LJMS) appears exclusively in both type 1 and type 2 diabetic patients. It is characterized by a limited range of digital motion, with involvement of small joints of the hands. It initially affects the proximal interphalangeal joints, followed by wrists, elbows, shoulders, knees, and axial skeleton. The diagnosis can be made by the simple "prayer sign" test. The objective was to study the prevalence of diabetic patients with LJMS, and to evaluate the association between LJMS and metabolic control, and the risk of accidental falls.

PATIENTS AND METHODS

A cross-sectional study was conducted in the San Fernando II Health Centre, Madrid (suburbs). The sample consisted of 184 patients with a diagnosis of diabetes of over 5 years from November to March, 2013. The prayer sign was used to define which patients had LJMS. Fall risk was determined using the Timed Up & Go test.

RESULTS

A total of 99 patients (53.8%) (95% CI 46.6 to 61) had a positive prayer sign. No statistically significant relationship was found with HbA1c, but there was an association with the Timed Up & Go test (P<.001) (95% CI 1.173 to 1.611). The patients with LJMS had a moderate risk of falls compared with those without LJMS, which was of low risk.

CONCLUSIONS

The prevalence of LJMS is high. This is the first study that shows a relationship between LJMS and the risk of falls in diabetic patients.

Mobilidade articular de idosos diabéticos e não diabéticos e influência da fisioterapia

INTRODUÇÃO: O diabetes tipo 2 (DM) é uma doença crônica que tem impacto socioeconômico importante nos dias atuais. Medidas de prevenção, detecção precoce e tratamento se mostram importantes para a diminuição da taxa de morbimortalidade dessa síndrome. OBJETIVOS: Verificar e comparar entre idosos, portadores ou não de diabetes mellitus, os que possuem maior limitação de mobilidade articular (LMA); analisar a relação da LMA com a idade, o tempo de DM, a presença de sinal da prece (SP), o risco neuropático (RN) e a influência dos exercícios utilizados na fisioterapia. MATERIAIS E MÉTODOS: Os indivíduos foram divididos em três grupos com n = 15 cada, sendo grupo C (controle), grupo DM, grupo DMF (DM em tratamento fisioterapêutico, por meio de alongamentos e exercícios leves). Foram avaliadas as goniometrias de tornozelos e punhos, SP e RN, bem como relacionou-se a média das amplitudes de movimento (ADMs) entre os grupos com a idade, o tempo de DM, o SP e o RN. RESULTADOS E CONCLUSÕES: A média das ADMs nos grupos foram C > DMF > DM, de forma significativa (p < 0,05), exceto flexão de punho direito. Observa-se a influência da fisioterapia (DMF > DM), significante no movimento de extensão de punho. Quanto maior a idade e o tempo de DM maior a tendência de LMA, porém, essas diferenças não foram significativas. No presente estudo, o RN e o SP não são os únicos determinantes da LMA. Conclui-se que o diabetes interfere significativamente na ADM e que houve influência benéfica da fisioterapia, por meio de alongamentos e exercícios leves.

Abnormal viscoelastic behaviour of passive ankle joint movement in diabetic patients: an early or a late complication?

AIMS/HYPOTHESIS

The goal of the present study was to compare the range of motion and both the viscous and elastic components of passive ankle joint movement in short- and long-term diabetic patients with that of a control population.

METHODS

Thirty-four diabetic patients and 16 control subjects entered into the study. Patients with a history of over 15 years of diabetes were considered as a long-term diabetic group. In order to quantify the passive ankle joint movement, a device was designed to measure the dorsi- and plantar-flexion angle and the net moment at the ankle. Elastic behaviour was examined as the separate slope of regression lines (stiffness) of plantar and dorsal components in the loading moment-angle curve. It was also examined as the slope of the regression line in the final 10% of each component. Hysteresis, a characteristic of viscoelastic materials that indicates loss of energy during unloading, was corrected for range of motion and used to examine viscous behaviour of the ankle joint.

RESULTS

Total and plantar ranges of motion were significantly lower in long-term diabetic patients than in short-term diabetic and control groups (p < 0.05). Plantar-flexion stiffness was significantly lower in short-term diabetic patients than in control subjects and long-term diabetic groups (p < 0.05). Corrected hysteresis was significantly higher in long-term diabetic than in short-term diabetic and control (p < 0.05) groups in the dorsal range of motion.

CONCLUSIONS/INTERPRETATION

This study shows that both decreased plantar and total ankle joint ranges of motion, and increased viscous component of passive ankle joint movement are among the late complications of diabetes.

The effect of ankle equinus upon the diabetic foot

The association between ankle equinus and common foot pathologies such as Achilles tendinitis, metatarsalgia, Morton's neuroma, hallux abductovalgus, and plantar fasciitis has been described. However, the association between ankle equinus and diabetic foot pathology has only been recognized recently. Over half of the non-traumatic amputations occurring in the United States are related to complications of diabetes. It is imperative that risk factors for lower extremity ulceration and amputation are identified and addressed. This article reviews the effect of ankle equinus deformity on the diabetic foot and the available treatment options. New data on the prevalence of equinus in a population of patients with diabetes are also presented.

Isolated gastrocnemius tightness

BACKGROUND

Contracture of the gastrocnemius-soleus complex has well-documented deleterious effects on lower-limb function in spastic or neurologically impaired individuals. There is scarce literature, however, on the existence of isolated gastrocnemius contracture or its impact in otherwise normal patients. We hypothesized that an inability to dorsiflex the ankle due to equinus contracture leads to increased pain in the forefoot and/or midfoot and therefore a population with such pain will have less maximum ankle dorsiflexion than controls. We further postulated that the difference would be present whether the knee was extended or flexed.

METHODS

This investigation was a prospective comparison of maximal ankle dorsiflexion, as a proxy for gastrocnemius tension, in response to a load applied to the undersurface of the foot in two healthy age, weight, and sex-matched groups. The patient group comprised thirty-four consecutive patients with a diagnosis of metatarsalgia or related midfoot and/or forefoot symptoms. The control group consisted of thirty-four individuals without foot or ankle symptoms. The participants were clinically examined for gastrocnemius and soleus contracture and were subsequently assessed for tightness with use of a specially designed electrogoniometer. Measurements were made both with the knee extended (the gastrocnemius under tension) and with the knee flexed (the gastrocnemius relaxed).

RESULTS

With the knee fully extended, the average maximal ankle dorsiflexion was 4.5 degrees in the patient group and 13.1 degrees in the control group (p < 0.001). With the knee flexed 90 degrees, the average was 17.9 degrees in the patient group and 22.3 degrees in the control population (p = 0.09). When gastrocnemius contracture was defined as dorsiflexion of < or = 5 degrees during knee extension, it was identified in 65% of the patients compared with 24% of the control population. However, when gastrocnemius contracture was defined as dorsiflexion of < or = 10 degrees, it was present in 88% and 44%, respectively. When gastrocnemius-soleus contracture was defined as dorsiflexion of < or = 10 degrees with the knee in 90 degrees of flexion, it was identified in 29% of the patient group and 15% of the control group.

CONCLUSIONS

On the average, patients with forefoot and/or midfoot symptoms had less maximum ankle dorsiflexion with the knee extended than did a control population without foot or ankle symptoms. When the knee was flexed 90 degrees to relax the gastrocnemius, this difference was no longer present.

CLINICAL RELEVANCE

These findings support the existence of isolated gastrocnemius contracture in the development of forefoot and/or midfoot pathology in otherwise healthy people. These data may have implications for preventative and therapeutic care of patients with chronic foot problems.

The effects of muscle activation on postural stability in diabetes mellitus patients with cutaneous sensory deficit in the foot

Activity of the lower leg muscles in response to an unexpected disturbance to upright standing was studied in diabetic patients and non-diabetic matched controls. The diabetic individuals were classified into two groups: diabetic patients with normal cutaneous sensitivity in the foot (n=27) and patients with cutaneous sensory deficit (n=23). All participants completed twenty trials standing on a force platform that rotated upward 8 deg at 50 deg/s. This movement produced short-latency and medium-latency responses in the gastrocnemius muscle and a single long-latency response in the anterior tibialis. All muscle activity was assessed using electromyography techniques. Results indicated that the average delay of the short-, medium- and long-latency responses produced by the diabetic groups was comparable to control group values. However, the within subject variability associated with activating the anterior tibialis was found to be statistically greater for the cutaneous deficit diabetic group. Additionally, fifty percent of the CD group failed to produce an observable stretch reflex response. The results suggest that the inability to generate a neuromuscular response with consistent temporal patterning is a contributing factor to greater postural sway observed in diabetic patients with cutaneous sensory deficit in the foot.