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

Abstract

BackgroundFoot 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.MethodsA 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.ResultsEven 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).ConclusionsIntervention 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 registrationClinicalTrials.gov Identifier: NCT01207284, registered in 20th September 2010.

Exercícios físicos em portadores de neuropatia diabética: revisão sistemática e metanálise de ensaios clínicos randomizados

“…ABC Scale -combined (resistance/balance) exercise vs. control by the ABC Scale, there was no significant change in the groups for the study of Richardson et al 8 , but a significant improvement was shown in the intervention group for isolated activities, such as up and down stairs, activities such as standing up to pick up an object, staying on tiptoe, among others. In the analysis of the study of Sartor et al 9 , we can observe that there was significant improvement in the balance between the intervention and control groups after 12 weeks of intervention. The results suggest that after an intervention with combined exercises proposed for patients with DN, foot positioning was altered slightly, with improvement in the distribution of the dynamic pressure, in ankle extension and a better functional condition of the ankle and foot muscles.…”

“…The evidence available from the meta-analysis of these two RCTs (71 individuals), which compared exercise combined (resistance/balance) versus control, maintains that the combined exercise significantly improved the balance of individuals with DN 8,9 .…”

“…Adjustments due to moderate-intensity aerobic exercise can lead to restoration of peripheral nerve functions by the activation of endothelial derived nitric oxide 9 .…”

“…We analyzed five studies, two RCTs that compared combined exercises versus control evaluated the balance by ABC scale 8,9 , two RCTs that compared combined exercises versus control that evaluated the balance by Berg Balance Scale and evaluated the muscle strength of LL 10,11 , and one RCTs that compared aerobic exercise versus control evaluated the postprandial and fasting glycemic indexes 12 .…”

“…Both evaluated the combined exercise (resistance/balance) versus (vs.) control 8,9 (n=71) (Figure 2).…”