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BMC Musculoskeletal Disorders
Published in: BMC Musculoskeletal Disorders 1/2014

Open Access 01-12-2014 | Research article

Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial

Authors: Cristina D Sartor, Renata H Hasue, Lícia P Cacciari, Marco K Butugan, Ricky Watari, Anice C Pássaro, Claudia Giacomozzi, Isabel CN Sacco

Published in: BMC Musculoskeletal Disorders | Issue 1/2014

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Abstract

Background

Foot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy.
AIM: To investigate the effects of strengthening, stretching, and functional training on foot rollover process during gait.

Methods

A two-arm parallel-group randomized controlled trial with a blinded assessor was designed. Fifty-five patients diagnosed with diabetic polyneuropathy, 45 to 65 years-old were recruited. Exercises for foot-ankle and gait training were administered twice a week, for 12 weeks, to 26 patients assigned to the intervention group, while 29 patients assigned to control group received recommended standard medical care: pharmacological treatment for diabetes and foot care instructions. Both groups were assessed after 12 weeks, and the intervention group at follow-up (24 weeks). Primary outcomes involved foot rollover changes during gait, including peak pressure (PP). Secondary outcomes involved time-to-peak pressure (TPP) and pressure–time integral (PTI) in six foot-areas, mean center of pressure (COP) velocity, ankle kinematics and kinetics in the sagittal plane, intrinsic and extrinsic muscle function, and functional tests of foot and ankle.

Results

Even though the intervention group primary outcome (PP) showed a not statistically significant change under the six foot areas, intention-to-treat comparisons yielded softening of heel strike (delayed heel TPP, p=.03), better eccentric control of forefoot contact (decrease in ankle extensor moment, p<.01; increase in function of ankle dorsiflexion, p<.05), earlier lateral forefoot contact with respect to medial forefoot (TPP anticipation, p<.01), and increased participation of hallux (increased PP and PTI, p=.03) and toes (increase in PTI, medium effect size). A slower COP mean velocity (p=.05), and an increase in overall foot and ankle function (p<.05) were also observed. In most cases, the values returned to baseline after the follow-up (p<.05).

Conclusions

Intervention discreetly changed foot rollover towards a more physiological process, supported by improved plantar pressure distribution and better functional condition of the foot ankle complex. Continuous monitoring of the foot status and patient education are necessary, and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy.

Trial registration

ClinicalTrials.gov Identifier:NCT01207284, registered in 20th September 2010.
Appendix
Available only for authorised users
Literature
1.
Veves A, Murray HJ, Young MJ, Boulton AJ: The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia. 1992, 35 (7): 660-663. 10.1007/BF00400259.CrossRefPubMed
2.
Allet L, Armand S, Golay A, Monnin D, de Bie RA, de Bruin ED: Gait characteristics of diabetic patients: a systematic review. Diabetes Metab Res Rev. 2008, 24 (3): 173-191. 10.1002/dmrr.809.CrossRefPubMed
3.
Rao S, Saltzman CL, Yack HJ: Relationships between segmental foot mobility and plantar loading in individuals with and without diabetes and neuropathy. Gait Posture. 2010, 31 (2): 251-255. 10.1016/j.gaitpost.2009.10.016.CrossRefPubMed
4.
Frykberg RG, Lavery LA, Pham H, Harvey C, Harkless L, Veves A: Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care. 1998, 21 (10): 1714-1719. 10.2337/diacare.21.10.1714.CrossRefPubMed
5.
Mueller MJ, Diamond JE, Delitto A, Sinacore DR: Insensitivity, limited joint mobility, and plantar ulcers in patients with diabetes mellitus. Phys Ther. 1989, 69 (6): 453-459. discussion 459–462PubMed
6.
Stess RM, Jensen SR, Mirmiran R: The role of dynamic plantar pressures in diabetic foot ulcers. Diabetes Care. 1997, 20 (5): 855-858. 10.2337/diacare.20.5.855.CrossRefPubMed
7.
Giacomozzi C, Caselli A, Macellari V, Giurato L, Lardieri L, Uccioli L: Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care. 2002, 25 (8): 1451-1457. 10.2337/diacare.25.8.1451.CrossRefPubMed
8.
Rao S, Saltzman C, Yack HJ: Segmental foot mobility in individuals with and without diabetes and neuropathy. Clin Biomech (Bristol, Avon). 2007, 22 (4): 464-471. 10.1016/j.clinbiomech.2006.11.013.CrossRef
9.
Sacco IC, Hamamoto AN, Gomes AA, Onodera AN, Hirata RP, Hennig EM: Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy. Clin Biomech (Bristol, Avon). 2009, 24 (8): 687-692. 10.1016/j.clinbiomech.2009.05.003.CrossRef
10.
Saltzman CL, Nawoczenski DA: Complexities of foot architecture as a base of support. J Orthop Sports Phys Ther. 1995, 21 (6): 354-360. 10.2519/jospt.1995.21.6.354.CrossRefPubMed
11.
McPoil TG, Knecht HG: Biomechanics of the foot in walking: a function approach. J Orthop Sports Phys Ther. 1985, 7 (2): 69-72. 10.2519/jospt.1985.7.2.69.CrossRefPubMed
12.
Kjaer M: Role of extracellular matrix in adaptation of tendon and skeletal muscle to mechanical loading. Physiol Rev. 2004, 84 (2): 649-698. 10.1152/physrev.00031.2003.CrossRefPubMed
13.
Goldin A, Beckman JA, Schmidt AM, Creager MA: Advanced glycation end products: sparking the development of diabetic vascular injury. Circulation. 2006, 114 (6): 597-605. 10.1161/CIRCULATIONAHA.106.621854.CrossRefPubMed
14.
Fiolkowski P, Brunt D, Bishop M, Woo R, Horodyski M: Intrinsic pedal musculature support of the medial longitudinal arch: an electromyography study. J Foot Ankle Surg. 2003, 42 (6): 327-333. 10.1053/j.jfas.2003.10.003.CrossRefPubMed
15.
Headlee DL, Leonard JL, Hart JM, Ingersoll CD, Hertel J: Fatigue of the plantar intrinsic foot muscles increases navicular drop. J Electromyogr Kinesiol. 2008, 18 (3): 420-425. 10.1016/j.jelekin.2006.11.004.CrossRefPubMed
16.
van Schie CH: A review of the biomechanics of the diabetic foot. Int J Low Extrem Wounds. 2005, 4 (3): 160-170. 10.1177/1534734605280587.CrossRefPubMed
17.
Abboud RJ, Rowley DI, Newton RW: Lower limb muscle dysfunction may contribute to foot ulceration in diabetic patients. Clin Biomech (Bristol, Avon). 2000, 15 (1): 37-45. 10.1016/S0268-0033(99)00038-8.CrossRef
18.
Sacco IC, Amadio AC: Influence of the diabetic neuropathy on the behavior of electromyographic and sensorial responses in treadmill gait. Clin Biomech (Bristol, Avon). 2003, 18 (5): 426-434. 10.1016/S0268-0033(03)00043-3.CrossRef
19.
Greenman RL, Khaodhiar L, Lima C, Dinh T, Giurini JM, Veves A: Foot small muscle atrophy is present before the detection of clinical neuropathy. Diabetes Care. 2005, 28 (6): 1425-1430. 10.2337/diacare.28.6.1425.CrossRefPubMedPubMedCentral
20.
Andreassen CS, Jakobsen J, Andersen H: Muscle weakness: a progressive late complication in diabetic distal symmetric polyneuropathy. Diabetes. 2006, 55 (3): 806-812. 10.2337/diabetes.55.03.06.db05-1237.CrossRefPubMed
21.
Bus SA, Valk GD, van Deursen RW, Armstrong DG, Caravaggi C, Hlavácek P, Bakker K, Cavanagh PR: The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev. 2008, 24 (Suppl 1): S162-180.CrossRefPubMed
22.
Cavanagh PR, Bus SA: Off-loading the diabetic foot for ulcer prevention and healing. Plast Reconstr Surg. 2011, 127 (Suppl 1): 248S-256S.CrossRefPubMed
23.
Waaijman R, Keukenkamp R, De Haart M, Polomski WP, Nollet F, Bus SA: Adherence to Wearing Prescription Custom-Made Footwear in Patients With Diabetes at High Risk for Plantar Foot Ulceration. Diabetes Care. 2013, 36 (6): 1613-8. 10.2337/dc12-1330.CrossRefPubMedPubMedCentral
24.
Pataky Z, de León Rodriguez D, Allet L, Golay A, Assal M, Assal JP, Hauert CA: Biofeedback for foot offloading in diabetic patients with peripheral neuropathy. Diabet Med. 2010, 27 (1): 61-64. 10.1111/j.1464-5491.2009.02875.x.CrossRefPubMed
25.
Richardson JK, Sandman D, Vela S: A focused exercise regimen improves clinical measures of balance in patients with peripheral neuropathy. Arch Phys Med Rehabil. 2001, 82 (2): 205-209. 10.1053/apmr.2001.19742.CrossRefPubMed
26.
Goldsmith JR, Lidtke RH, Shott S: The effects of range-of-motion therapy on the plantar pressures of patients with diabetes mellitus. J Am Podiatr Med Assoc. 2002, 92 (9): 483-490. 10.7547/87507315-92-9-483.CrossRefPubMed
27.
York RM, Perell-Gerson KL, Barr M, Durham J, Roper JM: Motor learning of a gait pattern to reduce forefoot plantar pressures in individuals with diabetic peripheral neuropathy. PM R. 2009, 1 (5): 434-441. 10.1016/j.pmrj.2009.03.001.CrossRefPubMed
28.
Sartor CD, Watari R, Passaro AC, Picon AP, Hasue RH, Sacco ICN: Effects of a combined strengthening, stretching and functional training program versus usual-care on gait biomechanics and foot function for diabetic neuropathy: a randomized controlled trial. BMC Musculoskelet Disord. 2012, 13: 36-10.1186/1471-2474-13-36.CrossRefPubMedPubMedCentral
29.
Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A: Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000, 23 (5): 606-611. 10.2337/diacare.23.5.606.CrossRefPubMed
30.
Tesfaye S, Boulton AJ, Dyck PJ, Freeman R, Horowitz M, Kempler P, Lauria G, Malik RA, Spallone V, Vinik A, Bernardi L, Valensi P, Toronto Diabetic Neuropathy Expert Group: Diabetic neuropathies: update on definitions, diagnostic criteria, estimation of severity, and treatments. Diabetes Care. 2010, 33 (10): 2285-2293. 10.2337/dc10-1303.CrossRefPubMedPubMedCentral
31.
Fernando M, Crowther R, Lazzarini P, Sangla K, Cunningham M, Buttner P, Golledge J: Biomechanical characteristics of peripheral diabetic neuropathy: A systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure. Clin Biomech (Bristol, Avon). 2013, 28 (8): 831-45. 10.1016/j.clinbiomech.2013.08.004.CrossRef
32.
33.
34.
Bakker K, Apelqvist J, Schaper NC, Board IWGoDFE: Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev. 2012, 28 (1): 225-231.CrossRefPubMed
35.
Powell LE, Myers AM: The Activities-specific Balance Confidence (ABC) Scale. J Gerontol A Biol Sci Med Sci. 1995, 50A (1): M28-34. 10.1093/gerona/50A.1.M28.CrossRefPubMed
36.
Winter D: The Biomechanics and Motor Control of Human Gait: Normal, Elderly and Pathological. 1991, Waterloo, CA: University of Waterloo Press
37.
Campbell K: Data acquisition and Analysis. ASME International Computers in Engineering Conference and Exhibition. 1987, New York, NY
38.
Trombini-Souza F, Kimura A, Ribeiro AP, Butugan M, Akashi P, Pássaro AC, Arnone AC, Sacco IC: Inexpensive footwear decreases joint loading in elderly women with knee osteoarthritis. Gait Posture. 2011, 34 (1): 126-130. 10.1016/j.gaitpost.2011.03.026.CrossRefPubMed
39.
Dempster WT, Gaughran GRL, Dempster WT, Gaughran GRL: Property of body segments based on size and weigth. Am J Anat. 1967, 120 (1): 33-54. 10.1002/aja.1001200104.CrossRef
40.
Kendall F, McCreary E, Provance P, Rodgers M, Romani W: Testing and Function with Posture and Pain. 2005, New York, USA: Lippinicott Williams & Wilkins
41.
van Schie CH, Vermigli C, Carrington AL, Boulton A: Muscle weakness and foot deformities in diabetes: relationship to neuropathy and foot ulceration in caucasian diabetic men. Diabetes Care. 2004, 27 (7): 1668-1673. 10.2337/diacare.27.7.1668.CrossRefPubMed
42.
Bacarin TA, Sacco IC, Hennig EM: Plantar pressure distribution patterns during gait in diabetic neuropathy patients with a history of foot ulcers. Clinics (Sao Paulo). 2009, 64 (2): 113-120.CrossRefPubMedCentral
43.
Haukoos JS, Newgard CD: Advanced statistics: missing data in clinical research–part 1: an introduction and conceptual framework. Acad Emerg Med. 2007, 14 (7): 662-668.PubMed
44.
Twisk J, de Vente W: Attrition in longitudinal studies. How to deal with missing data. J Clin Epidemiol. 2002, 55 (4): 329-337. 10.1016/S0895-4356(01)00476-0.CrossRefPubMed
45.
Armstrong DG, Peters EJ, Athanasiou KA, Lavery LA: Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration?. J Foot Ankle Surg. 1998, 37 (4): 303-307. 10.1016/S1067-2516(98)80066-5.CrossRefPubMed
Metadata
Title
Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial
Authors
Cristina D Sartor
Renata H Hasue
Lícia P Cacciari
Marco K Butugan
Ricky Watari
Anice C Pássaro
Claudia Giacomozzi
Isabel CN Sacco
Publication date
01-12-2014
Publisher
BioMed Central
Published in
BMC Musculoskeletal Disorders / Issue 1/2014
Electronic ISSN: 1471-2474
DOI
https://doi.org/10.1186/1471-2474-15-137

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