Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Exercise interventions for diabetic foot complications

Discussion in 'Diabetic Foot & Wound Management' started by NewsBot, May 10, 2014.

  1. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1

    Members do not see these Ads. Sign Up.
    Diabetic Foot and Exercise Therapy: Step by Step The Role of Rigid Posture and Biomechanics Treatment.
    Francia P, Gulisano M, Anichini R, Seghieri G.
    Curr Diabetes Rev. 2014 May 7.
     
    • Like Like x 1
    • Dumb Dumb x 1
    • List
  2. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Exercise improves gait, reaction time and postural stability in older adults with type 2 diabetes and neuropathy.
    Morrison S, Colberg SR, Parson HK, Vinik AI.
    J Diabetes Complications. 2014 Apr 18.
     
  3. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Should patients with active foot ulcers be non-weight bearing or take exercise to improve cardiovascular fitness?
    Ketan Dhatariya, Martin Fox
    Diabetic Foot Canada, 2015, Vol 3, No 1, pages 12–17 (full text)
     
  4. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Diabetic foot prevention: the role of exercise therapy in the treatment of limited joint mobility, muscle weakness and reduced gait speed.
    Francia P, Anichini R, De Bellis A, Seghieri G, Lazzeri R, Paternostro F, Gulisano M.
    Ital J Anat Embryol. 2015;120(1):21-32.
     
  5. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    This clinical trial was just registered:
    Effects of a Exercise Program on Health Outcomes in People With Diabetic Foot Ulcers
     
  6. Admin2

    Admin2 Administrator Staff Member

  7. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The Effect of Foot Exercises on Wound Healing in Type 2 Diabetic Patients With a Foot Ulcer.
    Eraydin Ş, Avşar G.
    J Wound Ostomy Continence Nurs. 2017 Dec 19. doi: 10.1097/WON.0000000000000405. [Epub ahead of print]
     
  8. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Physical activity and exercise on diabetic foot related outcomes: a systematic review
    Monica Matos et al
    Diabetes Research and Clinical Practice 23 February 2018
     
  9. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The Effect of Foot Exercises on Wound Healing in Type 2 Diabetic Patients With a Foot Ulcer: A Randomized Control Study.
    Eraydin Ş, Avşar G.
    J Wound Ostomy Continence Nurs. 2018 Mar/Apr;45(2):123-130.
     
  10. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effect of Exercise on Risk Factors of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.
    Liao F et al
    Am J Phys Med Rehabil. 2018 Jul 16
     
  11. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Effect of Exercise on Risk Factors of Diabetic Foot Ulcers: A Systematic Review and Meta-analysis.
    Liao F et al
    Am J Phys Med Rehabil. 2018 Jul 16
     
  12. scotfoot

    scotfoot Well-Known Member

    With regard to post #9 above does anyone know what specific exercises were used ? Did they use exercises which targeted the intrinsics ?

    I have tried contacting the authors for this information , since it costs $39 to view the article in the publishing journal ( which seems excessive ) ,but did not get any reply .

    How gratifying would it be , as a podiatrist , to supervise a foot exercise program in patient with diabetic foot ulceration , and see accelerated healing of the ulcer , over the course of a number of appointments .

    Here is the conclusion from the abstract .

    CONCLUSION:
    The ulcer areas decreased significantly in the study intervention group compared to the control group during the 3 follow-up measurements. An important finding in this study was the DFU area decreased more in those who exercised more. Findings suggests foot exercises should be included in the treatment plan when managing patients with diabetic foot ulcers.





    J Wound Ostomy Continence Nurs. 2018 Mar/Apr;45(2):123-130. doi: 10.1097/WON.0000000000000405.
    The Effect of Foot Exercises on Wound Healing in Type 2 Diabetic Patients With a Foot Ulcer: A Randomized Control Study.

    Eraydin Ş1, Avşar G.
     
  13. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    This is what they did:
    Diabetic Foot Exercises: Instructions to patients with DFU were provided that included the following information: (1) avoid exercises that require weight bearing, 23 ; (2) complete the exercise program in a sitting position at fi rst and in a standing position after the wound heals 24 ; (3) exercises include range-of-motion movements of plantar fl exion, dorsifl exion, inversion, eversion, circumduction, and plantar and dorsal fl exion of toes; (4) exercise series should include, at minimum, 5 to 10 exercises with 10 to 15 repeats 23.24 ; (5) exercise 1 hour after taking insulin and before refreshments; (6) blood glucose level should be 100 to 125 mg/dL before the exercise; (7) defer exercises if the blood glucose level is more than 300 mg/dL and the blood pressure is more than 180 mm Hg before the exercise; and (8) discontinue the exercise if the patient feels nausea, dizziness, or drowsiness during the exercise. 23 Participants completed 18 exercises with 10 repeats.
     
  14. DaVinci

    DaVinci Well-Known Member

    What about aerobic type exercises to generically help the diabetes?
     
  15. scotfoot

    scotfoot Well-Known Member

    Many thanks for the information .

    Some years ago I came across a paper which looked at the effects of range of motion exercises around the ankle joint on blood flow into and out of the foot . I cannot now find the paper in question but if memory serves the exercises did not increase blood flow into the foot .
    In the Eraydin Ş1, Avşar G paper , perhaps toe exercises are key to increasing blood flow into the foot and bringing about more rapid healing of ulcers .
    Intriguingly , the authors found that more exercise of the type they prescribed results in faster healing . What might the limits be on this effect ?

    My understanding is that aerobic exercises help with diabetes at a systemic level but it would appear that site specific exercise may have benefits over and above the whole body approach and so it might be a good idea to use both .
     
  16. scotfoot

    scotfoot Well-Known Member

    So I still can't track down that paper on range of motion exercises , but I did just find something equally as interesting . I do not have access to the Eraydin /Asvar paper and so do not know if they cited the paper listed below , but it is clearly relevant to their work .

    The paper from 2010 looks at non weight bearing ankle exercises and the healing rates of diabetic foot ulcers . The author found no statistical differences between exercise and non exercise groups .

    This is in marked contrast to the more resent study of Eraydin /Asvar which clearly showed improved healing rates in the exercise group .

    So why the difference ? Well , compliance may have been better with Eraydin /Asvar .

    But what else did Erayin /Asvar have that Flahr didn't ? Answer; Toe flexion exercises .

    So is that really all it takes to accelerate diabetic foot ulcer healing ? Usual care coupled with something as easy as flexing the toes backwards and forwards under appropriate supervision ?



    Ostomy Wound Manage. 2010 Oct;56(10):40-50.
    The effect of nonweight-bearing exercise and protocol adherence on diabetic foot ulcer healing: a pilot study.

    Flahr D1.
    Author information

    Abstract


    Innovative approaches to the prevention and treatment of foot wounds in persons with diabetes mellitus are needed and preliminary research suggests that exercise therapy may increase joint mobility and blood flow. A 12-week, prospective, quasi-experimental pilot study was conducted to evaluate the potential influence of nonweight-bearing ankle exercises, and adherence to same, on the size of neuropathic, diabetic foot wounds in community-dwelling older adults. Nineteen patients were recruited. Of those, 10 (88.9% men) were randomized to ankle exercise treatments and nine (50% men) continued their previous care regimen. Patients randomized to the exercise program were younger and had smaller wounds than those in the control group (average age 62.2 ± 8.54 versus 74.25 ± 16.25 years and measurement 0.94 cm2 ± 1.89 versus 2.53 cm2 ± 3.647, respectively). Thirty percent (30%) of the patients in theexercise and 33.3% in the control group healed. The percent wound reduction between groups was not significantly different (Mann Whitney U test, P = .696). Adherence to the recommended exercise program was variable but 70% performed some exercises. The results of this pilot study provide important lessons for future studies, including the need to enroll more patients and provide more exercise guidance. Considering the increasing prevalence of diabetes mellitus and resultant complications, as well as the potential benefits of this non-invasive treatment regimen, larger studies are warranted.
    acess to the
     
  17. scotfoot

    scotfoot Well-Known Member

    I completely missed this . It's a study which shows that the intrinsic foot muscles can be redeveloped in the diabetic foot by toe flexion exercises . The paper , and a link to an article about the paper are listed at the end of the post.

    The article from which the following quotes are taken was written by an Australian podiatrist called Matt Dilnot .

    Quotes

    " There is now a growing body of research which demonstrates we can indeed reverse muscle atrophy in the forefoot, improve mobility of toes and when we do so we can reduce plantar pressures which crush the tissues under the foot (Allet et al., 2010; Sartor et al., 2014; Kanchanasamut and Pensri, 2017).
    An excellent example of such research was published by Höhne et al in Cologne, Germany (Höhne et al., 2012). "

    And ( about the Hohne 2012 paper)

    "All patients improved strength, with the average increase being a staggering 55% increase in just 8 weeks. The intervention took only 10 minutes roughly 3 times per week and could be performed at home with little difficulty. In addition, there were no instructions to utilise their strength in everyday activities. So the strength gains can only be attributed to intervention of a total of 30 minutes per subject per week. Furthermore, the MRI results showed an average increase of 5% muscle bulk in just those 8 weeks. "

    The implications of the above are enormous . Huge .

    In my humble opinion it would be of great help if this paper were openly available .


    Links To Matt Dilnot article https://www.mytoepro.com.au/blog

    And
    Journal of Biomechanics | Proceedings of ESB2012 - 18th Congress ...


    https://www.sciencedirect.com/journal/journal-of-biomechanics/vol/45/.../S1?page...

    4 Jul 2012 - INCREASED STRENGTH OF INTRINSIC FOOT MUSCLES IN DIABETES AND PERIPHERAL NEUROPATHY. Page S201. Angela Höhne ...
     
  18. scotfoot

    scotfoot Well-Known Member

    Looking at the posts above it seems likely to me that the primary mechanism by which foot muscle atrophy occurs in diabetes is not due to motor nerve neuropathy , but rather metabolic problems within the muscle itself .

    Recent research has shown that diabetes affects the contractile proteins within the muscle and that this may be caused by an inflammatory process which can be reduced by exercising the specific muscle in question .

    Hohne's paper ( 2012) demonstrated that TARGETED , FOOT SPECIFIC , isometric exercise can actually promote muscle growth , as well as strengthening , in a foot with diabetic neuropathy and intrinsic muscle atrophy .

    If these results can be achieved with isometric exercise , then how much better would the results be with concentric exercise . For example the theraband exercises used by Karen Mickle in other types of trial ?

    Worth saying again TARGETED , FOOT SPECIFIC .
     
    Last edited: Oct 13, 2018
  19. scotfoot

    scotfoot Well-Known Member

    Dr Hohne and her group used a toe dynamometer ( under supervision ) to strengthen the intrinsic foot muscles .

    So targeted , foot specific exercise becomes TARGETED , TOE FLEXOR SPECIFIC exercise under supervision .
     
  20. scotfoot

    scotfoot Well-Known Member

    So the isometric exercises used by Hohne and her colleagues can rebuild muscle within the foot . So what ?

    In people with diabetes , atrophy of the intrinsic foot muscles often occurs before any signs of neuropathy are present . The mechanism by which this muscle wasting is caused is increasingly believed to be due to autoimmune related inflammatory reactions which are ameliorated by specific exercise of the muscles involved . It not much of a stretch to hypothesis that this same muscle specific exercise might also reduce autoimmune related inflammatory reactions in motor nerve fibers within the muscle concerned slowing or even halting motor nerve damage .

    Thus it may be possible , if diabetes related atrophy of the intrinsic foot muscles is caught at an early stage ,to greatly influence for the better , the pathological progress of this aspect of the disease , since it may be that targeted toe flexor exercise of a concentric type , done under supervision , may restore lost muscle to near former levels and prevent rapid decline of the neuro , muscular and vascular systems in the foot .

    It is also worth pointing out that the plantar venous plexus , an integral part of the circulatory system in the lower leg and foot , is dependent on the presence of the intrinsic musculature for its effective functioning . If the intrinsics are severely atrophied then the output from the PVP becomes much reduced and sporadic (seen in paraplegic feet ) .

    So it's possible that in the future targeted toe flexor exercise , done under supervision , coupled with supervised mobility exercises , may become a vital part of the treatment of feet affected by diabetes .

    Any thoughts ?
     
  21. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    This clinical trial was just registered:
    Patients With Diabetic Neuropathy Who Receive Physiotherapy Treatment Will Have a Decrease in Diabetic Foot Ulcers
     
  22. scotfoot

    scotfoot Well-Known Member

    With regard to the above I see that Isabel Sacco is mentioned , which augurs well for methodology . Not so good that Karen Mickle and her theraband exercises are not mentioned .

    It's none of my business of course but , in light of Mickle's present area of research , if the researchers involved in this study were to give Dr Mickle a phone , perhaps they might glean a fresh gem or two of knowledge .

    Perhaps they already have !
     
    Last edited: Nov 1, 2018
  23. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Structured exercise program on Foot Biomechanics & Insulin Resistance among people living with type 2 diabetes with and without peripheral neuropathy
    Kumar, Sampath A and Hazari, Animesh and Maiya, Arun G and Shastry, BA and Shivashankara, KN and Vaishali, K
    Diabetes Mellitus, 22 (6). pp. 1-9. ISSN 2072-0351
     
  24. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    A REVIEW OF BENEFICIAL LOW-INTENSITY EXERCISES IN DIABETIC PERIPHERAL NEUROPATHY PATIENTS
    Carley E Johnson, Jody K Takemoto
    JOURNAL OF PHARMACY & PHARMACEUTICAL SCIENCES OPEN JOURNAL SYSTEMS
     
  25. scotfoot

    scotfoot Well-Known Member

    The paper mention in post #23 is seems very interesting - Structured exercise program on Foot Biomechanics & Insulin Resistance among people living with type 2 diabetes with and without peripheral neuropathy

    Conclusion: The present study shows that the structured exercise protocol is very effective in improving the biomechanics of foot in people with type 2 diabetes with and without neuropathy. It could help to correct the structure and function of the foot and eventually could reduce the risk of foot complications like diabetic foot ulcers.

    Does anyone know what the exercises were in the " structured exercise protocol " ?

    Also related , but on a more general theme , could anyone enlighten me as to the amount of time spent teaching lower limb physiotherapy techniques to podiatry students in the UK ?

    Looking forwards , these techniques seem set to become more important particularly in relation to foot related complications of diseases such as diabetes .
     
  26. Matt Dilnot

    Matt Dilnot Member

    Thanks for the reference to my blog post Gerrard.

    Just a couple of points, the plantar intrinsic muscles work in both an isometric and concentric manner but it is important to recognise that this occurs in propulsion when the MTPJs are in an extended position (dorsiflexed) therefore targeting these muscles requires for the strengthening to occur in positions that replicate this position.

    Luke Kelly discusses it here:

    Kelly LA, Lichtwark G, Cresswell AG (2015) Active regulation of longitudinal arch compression and recoil during walking and running. J R Soc Interface 12:20141076.

    Therefore, ideally strengthening of these muscles to be most targeted should occur with the MTPJs in an extended position whilst they are loaded with functional loads (Theraband is not as effective because of the lower loads). This has been the Achilles heel (pardon the pun) of a lot of foot strengthening research because they are using lower loads with the toes not replicating the position in which we wish for them to be most powerful.

    Feel free to contact me for the "structured exercise protocol" that was referred to in that other diabetes paper also. Happy to discuss things in more detail via email.

    We have a research program using the ToePro in diabetes beginning in the USA soon which is very exciting.

    My email is: equus@equusmedical.com

    Kind regards,

    Matt Dilnot, Podiatrist
     
  27. Plantar intrinsic muscles aid in propulsion only according to the latest research.

    Might be time to reconsider strengthening them for diabetic patients. Especially those with neuropathy and toe grip for balance
     
  28. scotfoot

    scotfoot Well-Known Member

    The evidence seems to suggest that the intrinsic musculature can be restored in a foot with diabetes related atrophy , but it is really only the Hohne conference paper (cheers Matt ) that supports this notion .

    That is what makes Mickles work so important .

    If Mickle and her colleagues can show that progressive resistance exercise can significantly restore the intrisic musculature in the diabetic foot then a major podiatry led health care intervention is on the cards .

    Mickles work seems to be taking quite a bit of time to reach publication but I suspect that if the initial results were positive , steps might have been taken to increase numbers and hence the power of the study . A study that puts things beyond doubt would more easily attract the funds for a major trial .
     
  29. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Exercise and Chronic Wound Healing.
    Bolton L
    Wounds. 2019 Feb;31(2):65-67.
     
  30. Matt Dilnot

    Matt Dilnot Member

    The study we are conducting in the US is doing exactly that. Even though it is only a pilot study we will be able to see how much we can improve plantar intrinsic strength in people with diabetes over a 3 month program.

    The studies I have conducted in my own practice have shown up to a tripling of grip strength and significant improvement in balance and MTPJ flexibility. The limitations are in the patients who are too far gone with AGE's, neuropathy and wasting. There is a sweet spot for intervention. The beauty now is that I can measure strength as part of their regular diabetes assessment, assess biomechanics very quickly - ankle ROM, MTPJ ROM, toe position, etc and provide an effective intervention if and when necessary. More than anything it gives me something pro-active to do with the patient rather than waiting for neuropathy and vascular changes to kick in. A much more pleasant intervention with no side-effects other than a small time commitment of the patient.

    Cheers,

    Matt
     
  31. scotfoot

    scotfoot Well-Known Member

    Matt
    That's a very interesting post indeed and I look forward to reading the results of your pilot study in the USA .
    Did your patients report any pain reduction ?

    Gerry
     
  32. Matt Dilnot

    Matt Dilnot Member

    Do you mean neuropathic pain?

    Patient's with diabetes with pain (for whatever reason) that can be improved with strengthening do have reduced pain levels - but that is a rather vague and non-scientific statement - just like non-diabetics would.

    Maybe clarify what you mean exactly.

    Cheers,

    Matt
     
  33. scotfoot

    scotfoot Well-Known Member

    Yes , neuropathic pain .

    Gerry
     
  34. Matt Dilnot

    Matt Dilnot Member

    I actually don't have any patients at the moment with neuropathic pain so I can't provide any feedback on that at the moment. Obviously there are papers which have suggested that exercise therapy appears to be helpful in lessening neuropathic pain but I am yet to see it first hand.

    Matt
     
  35. scotfoot

    scotfoot Well-Known Member

    Matt ,

    In your pilot do you have any plans to look at plantar venous plexus function pre and post intervention ?

    Gerry
     
  36. Matt Dilnot

    Matt Dilnot Member

    No, not at this stage. The main priority is if we can improve foot strength in people with diabetes. Maybe something to look at later.

    Matt
     
  37. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The Effect of Range of Motion Practice on Vascularity of Feet in Patients with Diabetes Mellitus in Kudus, Central Java
    Sukarmin Sukarmin • A. Nor Syafik
    Conference paper 4th International Conference on Public Health 2018 • August 2018 Indonesia
     
  38. Matt Dilnot

    Matt Dilnot Member

    I guess it was a student project.

    ABI has to be one of the least sensitive tests for vascular improvement. This seems like it would be a good student paper to review to understand the potential flaws in research. The full text does not have any more detail about the intervention.
     
  39. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    The effect of exercise therapy combined with psychological therapy on physical activity and quality of life in patients with painful diabetic neuropathy: a systematic review
    Charlotte C.M. van Laake-Geelen et al
    Published Online: 2019-05-21 | DOI: https://doi.org/10.1515/sjpain-2019-0001
     
  40. NewsBot

    NewsBot The Admin that posts the news.

    Articles:
    1
    Rehabilitation technology for self-care: Customised foot and ankle exercise software for people with diabetes.
    Ferreira JSSP et al
    PLoS One. 2019 Jun 20;14(6):e0218560
     
Loading...

Share This Page