Foot and Ankle Mobilisation in Diabetic Peripheral Neuropathy

NewsBot · Jun 22, 2017

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This clinical trial has just been registered:
Foot and Ankle Mobilisation in Diabetic Peripheral Neuropathy

Diabetes can affect the blood supply to the nerves in the legs. When this occurs a peripheral neuropathy can occur when the nerves carrying sensory information are affected. People with diabetic peripheral neuropathy have a high risk of foot ulceration and amputation which affects function and associated with high NHS and social care costs. People with diabetes can also have reduced movement at joints caused by increased stiffness in connective tissue. Reductions in ankle and big toe movement leads to increases in the pressure over the sole on the front part of the foot (the forefoot) when walking; this is a risk factor for ulceration.

The study will to assess whether ankle and big toe joint mobilisations and home program of stretches in people with diabetic peripheral neuropathy improves joint range of motion and reduces forefoot peak pressures.

Fifty eight people with diabetic peripheral neuropathy and a moderate risk of plantar ulceration will be recruited from a local podiatry clinic. They will be randomly assigned to an intervention (29 people) or control group (29 people). We will control for between-group differences in age using a minimization process. The intervention will consist of a 6 week program of ankle and big toe joint mobilisation by a physiotherapist and home stretches. The control group will consist of usual care including podiatry interventions.

Outcome measures will be taken at baseline, post intervention and at 3 month follow up by an assessor who does not know the group allocation. Primary outcome will be ankle range while walking with secondary outcomes including big toe joint range, forefoot pressure while walking and balance.

Changes over time between the groups will be compared statistically and the relationship between ankle range of motion and peak plantar pressure will be analysed using linear regression.
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Admin2 · Jun 22, 2017

Related Thread:
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NewsBot · May 5, 2020

Another clinical trial registered:

Effect of Manual Therapy on Tibiotarsal Joint Mobility in Diabetic Individuals

The study aimed to evaluate the acute effect of manual therapy on ankle joint mobility in diabetic patients. Forty volunteers, with a mean age of 59.35±7.85, with type 2 DM and neurological symptoms of Diabetic Distal Polyneuropathy according to a Diabetic Polyneuropathy Diagnostic Scale (EDPNDD) protocol with the amplitude were performed. Were divided into two groups: Sham group (GS), and intervention group (GI), which underwent manual manipulation intervention and seven-day follow-up. Joint range of motion analysis was performed using digital goniometry and static discharge of weights assessed by computerized baropodometry with open and closed eyes, and the Shapiro-Wilk normality test evaluated data distribution and relative, Tukey post hoc set ANOVA tests were used for non-normal variables. The Kruskal- Wallis test followed by Dunn's post-hoc test. SAS statistical software was used and the significance level of 5%. Results: The results showed an increased joint range of motion, plantar flexion, and dorsiflexion, between the moments and moments after manipulation and follow-up. It was still possible to make a significant difference between GI when it was with GS at poster and follow-up. No intragroup analysis was performed by GS, for analysis over time. Regarding intragroup comparisons over time (pre, post-intervention, and follow-up), a significant difference was made for Front and back displacement amplitude (PAD) with open eyes of the GI, with an increase after intervention and reduction without follow up. Conclusion: Based on the results obtained, the work performed with manual therapy increased the ankle joint amplitude in diabetic individuals.
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NewsBot · Feb 8, 2022

Experiences of foot and ankle mobilisations combined with home stretches in people with diabetes: a qualitative study embedded in a proof-of-concept randomised controlled trial
Vasileios Lepesis, Jonathan Marsden, Joanne Paton, Alec Rickard & Jos M. Latour
Journal of Foot and Ankle Research volume 15, Article number: 7 (2022)

Background
The benefits of exercise and staying active are widely reported in the literature, however adherence and engagement with exercise amongst people with long-term illness and diabetes is poor. Physiotherapy aims to promote independence and physical activity using a range of strategies, including manual therapy and education/advice on exercises. However, low adherence impacts negatively on treatment outcomes. In this study, the practicality of physiotherapy interventions in patients who participate in a proof-of-concept (PoC) randomised controlled trial (RCT) will be considered.

Aim
To explore the experiences of people with diabetes who received an intervention package of foot and ankle mobilisations combined with home stretches for a 6-week period.

Design
An embedded qualitative study in a proof-of-concept RCT using semi-structured interviews and thematic analysis.

Participants
Purposive sample of 16 participants (mean age 73 years) with a diagnosis of diabetes (mean duration 13.4 years) were recruited.

Results
Analysis revealed seven themes informing the adherence and non-adherence to the exercise intervention. Themes describing the positive experiences were: 1) support from others to do the exercises; 2) psychological factors to motivate exercise adherence; 2) physical factors contributing to exercise adherence; 4) acceptability of home exercises during and beyond the study. Other themes described barriers: 5) social factors that contributed to exercise disengagement; 6) emotional limitations that influence exercise avoidance; 7) physical circumstances that made exercise participation burdensome. Themes highlighted positive influences by physiotherapists, the motivation of doing exercises while participating in a study, improving the perceived range of motion in their foot and ankle and reducing discomfort in these joints whilst being more active with daily activities.

Conclusion
Our findings highlighted that the intervention of foot and ankle mobilisations combined with home stretches is feasible for study participants. Psycho-social support, self-efficacy, and physiotherapy support are motivational to adhere to the study intervention and might contribute to the success of a full-scale RCT.
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NewsBot · Jun 23, 2022

Manual therapy in diabetic patients with tibio-tarsal
dorsiflexion deficit and forefoot overload.
Functional assessment of plantar pressures and
gait after manual treatment. A Case Report
Roberto Tedeschi
Research Square

Background
Limitation of tibio-tarsal joint mobility in diabetic patients can occur within a few years of diagnosis, even
in young patients. This joint movement deficit is believed to be due to stiffness in muscles, tendons, joint
capsules, ligaments and skin. With this in mind, the aim of this study is to design an experimental
protocol of orthopaedic manual therapy and therapeutic exercise in the future for subjects with diabetes,
reduced joint mobility and subsequent insufficient dorsal flexion of the tibio-ankle, and to test the reduced
avampodalic pressure that correlates with an increased ulcerative risk.
Case presentation
A patient with type 2 diabetes, inertial motion sensors, Baropodometric platform, Lounge test, MWM.
Already after the first session an improvement in plantar pressures was observed with a decrease both in
the peaks from 413.6 Kpa to 99 Kpa in both feet and in the average plantar pressures from 129.8 Kpa to
54.5 Kpa for both feet with a decrease in plantar pressures at the forefoot from 43.7–33.2%. Tissue
elasticity was assessed with the Lunge Test, and increased from 8 cm to 9.5 cm.
Conclusions
The results suggest that the role of manual treatment combined with an exercise programme could
increase tarsal dorsiflexion and consequently decrease plantar pressures.
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NewsBot · Aug 7, 2023

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
Vasileios Lepesis et al
Diabetes Metab Res Rev. 2023 Jul 10

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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NewsBot · Aug 15, 2023

Effects of foot and ankle mobilisations combined with home
stretches in people with diabetic peripheral neuropathy: a proof-ofconcept RCT.
VASILEIOS LEPESIS et al
Source

Introduction
People with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak
plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st
metatarsophalangeal (MTP) joint mobilisations and home stretches in people with DPN improve joint range of motion (ROM) and reduce
forefoot PPPs.
Design and methods
Sixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n
= 31) and home stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a
blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test,
static 1st MTP joint, dynamic plantar pressure and balance.
Results
No significant differences in dynamic ankle dorsiflexion were found between both groups. A statistically significant difference was
observed in ankle dorsiflexion range in both feet across time between groups (Left 1.52cm and 2.9cms, Right 1.62cm and 2.7cm) at 6
(T1) and 18 weeks (T2) respectively p < 0.01). Between both groups, a significant increase in functional reach was observed (T1 = 3.13cm
p < 0.05 and T2 = 3.9cm p < 0.01). Between group differences were seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux
dorsiflexion (4.9°, p < 0.01) at T2 follow up. No significant between group differences were found for peak plantar pressure or postural
sway. Intervention adherence was high (80%).
Conclusions
Combining ankle and 1st MTP joint mobilisations with home stretches in a 6-week programme in people with DPN is effective in
increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior
stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk
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NewsBot · Dec 12, 2023

Effects of foot and ankle mobilisations combined with home stretches in people with diabetic peripheral neuropathy: a proof-of-concept RCT
Vasileios Lepesis, Joanne Paton, Alec Rickard, Jos M. Latour & Jonathan Marsden
Journal of Foot and Ankle Research volume 16, Article number: 88 (2023)

Introduction
People with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st metatarsophalangeal (MTP) joint mobilisations and home-based stretches in people with DPN improve joint range of motion (ROM) and reduce forefoot PPPs.

Design and methods
Sixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n = 31) and home-based stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test, static 1st MTP joint dorsiflexion ROM, dynamic plantar pressure and balance.

Results
At T1 and T2 there was no difference between both groups in ankle dorsiflexion in stance phase, plantar pressure and balance. Compared to the control group, the intervention group showed a statistically significant increase in static ankle dorsiflexion range (Left 1.52 cm and 2.9cms, Right 1.62 cm and 2.7 cm) at 6 (T1) and 18 weeks (T2) respectively p < 0.01). Between group differences were also seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux dorsiflexion ROM (4.9°, p < 0.01) at T2 follow up. Further, functional reach showed a significant increase in the intervention group (T1 = 3.13 cm p < 0.05 and T2 = 3.9 cm p < 0.01). Intervention adherence was high (80%).

Conclusions
Combining ankle and 1st MTP joint mobilisations with home-based stretches in a 6-week programme in people with DPN is effective in increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk.
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