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

Background: Polyneuropathy is a complication of diabetes mellitus that has been very challenging for clinicians. It results in high public health costs and has a huge impact on patients' quality of life. Preventive interventions are still the most important approach to avoid plantar ulceration and amputation, which is the most devastating endpoint of the disease. Some therapeutic interventions improve gait quality, confidence, and quality of life; however, there is no evidence yet of an effective physical therapy treatment for recovering musculoskeletal function and foot rollover during gait that could potentially redistribute plantar pressure and reduce the risk of ulcer formation. Methods/Design: A randomised, controlled trial, with blind assessment, was designed to study the effect of a physiotherapy intervention on foot rollover during gait, range of motion, muscle strength and function of the foot and ankle, and balance confidence. The main outcome is plantar pressure during foot rollover, and the secondary outcomes are kinetic and kinematic parameters of gait, neuropathy signs and symptoms, foot and ankle range of motion and function, muscle strength, and balance confidence. The intervention is carried out for 12 weeks, twice a week, for 40-60 min each session. The follow-up period is 24 weeks from the baseline condition. Discussion: Herein, we present a more comprehensive and specific physiotherapy approach for foot and ankle function, by choosing simple tasks, focusing on recovering range of motion, strength, and functionality of the joints most impaired by diabetic polyneuropathy. In addition, this intervention aims to transfer these peripheral gains to the functional and more complex task of foot rollover during gait, in order to reduce risk of ulceration. If it shows any benefit, this protocol can be used in clinical practice and can be indicated as complementary treatment for this disease.National Council for Scientific and Technological Development (CNPq) [MCT/CNPq 10/2010, 503240/2010-9, MCT/CNPq 70/2009, 556374/2010-0]State Sao Paulo Research Foundation (FAPESP) [2011/19304-4

Efeitos da intervenção fisioterapêutica nas respostas sensoriais e funcionais de diabéticos neuropatas

The purpose of this study was to elaborate and apply a physical therapy treatment for diabetic neuropathic patients, comparing their sensorial, motor and functional responses before and after treatment to those of a healthy control group. Ten healthy subjects (CG) and 10 neuropathic diabetes patients (DG) clinically diagnosed were studied. Motor, functionaland sensorial evaluations were performed pre and post-intervention in both groups. Treatment was individually applied in 45-minute sessions twice a week, during 5 weeks. Therapy program consisted in stretching exercises for hamstrings, triceps surae and tibialis anterior muscles, actively-resisted exercises for intrinsic and extrinsic foot and ankle muscles, practice of daily activities and feet self-care orientations. Data were statistically analysed. When comparing DG post treatment data to DG-pre and CG, thermal sensitivity showed improvement in heel, hallux, lateral and medial forefoot; DG ankle dorsiflexion and eversion ROM reached values similar to those of CG's; DG showed significant improvement in ankle extension and inversion; and DG-post reached the same muscular functions observed in CG in intrinsic feet muscles, tibialis anterior and triceps surae. The physical therapy treatment showed effective in reducing distal numbness, tingling and pricking and it was also effective in preventing muscle function and mobility limitations in diabetic neuropathic patients.O objetivo foi elaborar e aplicar um tratamento fisioterapêutico para diabéticos neuropatas e comparar suas respostas sensoriais, motoras e funcionais, pré e pós-intervenção, com um grupo de sujeitos não-diabéticos assintomáticos. Participaram do estudo 10 sujeitos controle (GC) e 10 diabéticos neuropatas (GD) diagnosticados clinicamente. Realizou-se uma avaliação motora, funcional e sensorial nos dois grupos pré e pós-intervenção. O tratamento foi aplicado individualmente duas vezes por semana, por 45 minutos, durante 5 semanas. Foram feitos alongamentos de cadeia posterior e tibial anterior; exercícios ativos resistidos para musculatura intrínseca do pé e tornozelo; treino de atividades de vida diária e fornecidas orientações de autocuidado com os pés. Os dados foram analisados estatisticamente. Comparando-se os dados do GD pós-tratamento com os do GC, verificou-se melhora na sensibilidade térmica nas regiões de calcanhar, hálux, antepé lateral e medial; a amplitude ativa de dorsiflexão e eversão do tornozelo igualou-se à do GC; houve melhora significativa da extensão e inversão do pé; e o GD alcançou funções musculares (musculatura intrínseca do pé,tríceps sural e tibial anterior) semelhantes às do GC. Em diabéticos neuropatas, o tratamento fisioterapêutico proposto mostrou-se eficaz na atenuação dos sintomas dormência, formigamento e queimação, além de contribuir para a mobilidade e prevenção de limitações de função muscular

Functional independence of one- to four-year-old children with myelomeningocele

Myelomeningocele is caused by neural tube closure defects and represents the second cause of locomotion disability in children. Functional independence depends on level of spine injury and assessment is important to determine proper therapeutic approaches. We aimed to describe functional Independence and level of injury in 15 children, aged one to four years and with complete spinal cord injury caused by myelomeningocele. This is an observational transversal study developed in the Ibirapuera University and Santa Cecília University. The Pediatric Evaluation of Disability Inventory (PEDI) was used to ask parents about the functional independence of children in daily life activities. The International Standards for Neurological Classification of Spinal Cord Injury of the American Spinal Injury Association was used to determine the motor and sensory levels. Nine girls and six boys were assessed (27.0 ±11.8 months of age). Three children showed thoracic level, nine showed high lumbar level, two were classified as low lumbar, and one as sacral level. PEDI scores varied from 15 to 60% on the self-care area, from 10 to 15% on mobility, and from 19 to 58% on social function. High variability was observed on the functional independence of children with myelomeningocele, detected by self-care and social function areas of PEDI. Mobility was the most affected domain.El mielomeningocele es causado por defecto en el cierre del tubo neural. La enfermedad representa la segunda causa de deficiencia crónica en el aparato locomotor en niños. La independencia funcional depende del nivel de la lesión medular y su evaluación es importante para determinar enfoques terapéuticos adecuados. El objetivo fue describir la independencia funcional y el nivel de lesión de 15 niños de seis meses a cuatro años con lesión medular completa causada por mielomeningocele. Se realizó un estudio observacional del tipo transversal en las Universidades Ibirapuera y Santa Cecilia. Se aplicó el Inventario de Evaluación Pediátrica de Discapacidad (Pediatric Evaluation of Disability Inventory, PEDI) con los padres para evaluar la independencia funcional en las actividades de vida diaria de los niños. La escala de Estándares Internacionales para la Clasificación Neurológica de la Lesión Medular de la Asociación Americana de la Lesión Medular (International Standards for Neurological Classification of Spinal Cord Injury of the American Spinal Injury Association) fue utilizada para determinar el nivel motor y sensitivo de la lesión. Se evaluaron seis niños y nueve niñas (27,0 ± 11,8 meses de edad). Tres niños presentaron lesión torácica, nueve presentaron lesión lumbar alta, dos presentaron lesión lumbar baja y una presentó lesión en el sacro. Las puntuaciones en la PEDI variaron del 15 al 60% en el dominio autocuidado, del 10 al 15% en el ámbito de la movilidad y del 19 al 58% en el ámbito de la función social. Hubo gran variabilidad en el desempeño funcional de los niños con mielomeningocele, detectada por los campos autocuidado y función social de la PEDI. Los niños presentaron gran daño en el dominio de la movilidad.A mielomeningocele é causada por defeito no fechamento do tubo neural. A doença representa a segunda causa de deficiência crônica no aparelho locomotor em crianças. A independência funcional depende do nível da lesão medular e sua avaliação é importante para a determinação de abordagens terapêuticas adequadas. O objetivo foi descrever a independência funcional e o nível de lesão de 15 crianças de seis meses a quatro anos com lesão medular completa causada por mielomeningocele. Foi realizado um estudo observacional do tipo transversal nas Universidades Ibirapuera e Santa Cecília. O Inventário de Avaliação Pediátrica de Incapacidade (Pediatric Evaluation of Disability Inventory - PEDI) foi aplicado com os pais, para avaliação da independência funcional nas atividades de vida diária das crianças. A escala de Padrões Internacionais para Classificação Neurológica de Lesão da Medula Espinhal da Associação Americana de Lesão Medular (International Standards for Neurological Classification of Spinal Cord Injury of the American Spinal Injury Association) foi utilizada para determinar o nível motor e sensitivo da lesão. Foram avaliados seis meninos e nove meninas (27,0±11,8 meses de idade). Três crianças apresentaram lesão torácica, nove apresentaram lesão lombar alta, duas apresentaram lesão lombar baixa e uma apresentou lesão sacral. As pontuações na PEDI variaram de 15 a 60% no domínio autocuidado, de 10 a 15% no domínio mobilidade e de 19 a 58% no domínio função social. Houve grande variabilidade no desempenho funcional de crianças com mielomeningocele, detectada pelos domínios autocuidado e função social da PEDI. As crianças apresentaram grande prejuízo no domínio mobilidade

Influence of a Physical Therapy intervention for foot and ankle on gait biomechanics of patients with diabetic polineuropathiy: a randomized controlled trial

Este estudo mostra como o rolamento do pé de pacientes com polineuropatia diabética pode ser melhorado com exercícios para pés e tornozelos, visando a recuperação muscular e articular comprometidos pela doença. Um ensaio clínico randomizado, paralelo, com um braço de crossover, e avaliador cego, foi conduzido. Cinquenta e cinco pacientes com polineuropatia diabética foram randomizados e alocados para o grupo controle (n=29) e grupo intervenção (n=26). A intervenção foi aplicada por 12 semanas, 2 vezes por semana, por 40 a 60 minutos cada sessão. As variáveis primárias foram definidas como as que descrevem o rolamento do pé: pressão plantar em seis regiões plantares de interesse. As variáveis secundárias foram a cinética e cinemática de tornozelo no plano sagital, e as medidas clínicas da função de pés e tornozelo (teste de função muscular manual, testes funcionais), de sinais e sintomas da polineuropatia diabética, exame físico dos pés e teste de confiança e equilíbrio em atividades da marcha. Os efeitos de tempo (baseline e 12 semanas), de grupo (controle e intervenção) e de interação foram calculados por meio de ANOVAs casewise 2 fatores, e para as comparações intragrupo do grupo intervenção (baseline, 12 semanas e 24 semanas) foram usadas ANOVAs para medidas repetidas. As variáveis não paramétricas foram comparadas entre grupos por meio de testes de Mann-Whitney e entre os tempos de intervenção por meio do teste de Wilcoxon. Adotou-se um ? de 5% para diferenças estatísticas e o coeficiente d de Cohen para descrição do tamanho do efeito da intervenção. Após 12 semanas de exercícios, observou-se mudanças positivas no rolamento do pé. Houve uma suavização do contato do calcanhar no apoio inicial, refletido pelo aumento do tempo do pico de pressão e da integral do pico de pressão. O médio-pé aumentou sua participação no rolamento observado pela diminuição da velocidade média do deslocamento do centro de pressão e aumento da integral do pico de pressão. O antepé lateral passou a realizar o apoio no solo antecipadamente em relação ao antepé medial, que previamente à intervenção aconteciam concomitantemente, e esse resultado foi evidenciado pela antecipação do tempo do pico de pressão em antepé lateral após a intervenção. A ação de hálux e dedos também aumentou (aumento de integral do pico de pressão e picos de pressão), em uma patologia marcada pela diminuição do contato do hálux e desenvolvimento de dedos em garra, que diminui o contato dos dedos com o solo. O grupo controle apresentou algumas pioras com relação à função muscular e parâmetros cinéticos e cinemáticos de tornozelo, enquanto que o grupo intervenção mostrou melhora na função de muitos grupos musculares, em testes funcionais e no pico de momento extensor na fase de aplainamento do pé. Apesar do protocolo de intervenção ter sido construído de modo a permitir que o paciente incorpore os exercícios na sua rotina diária, a aderência a este tipo de intervenção deve ser estudada, já que grande parte das variáveis retornaram ao baseline após o período de follow up. Ações preventivas são fundamentais para diminuir as complicações devastadoras da neuropatia diabéticaThis study shows how the foot rollover process during gait of patients with diabetic polyneuropathy can be improved with exercises for foot and ankle, aiming at the recovery of the muscles and joints affected by the disease. A clinical trial randomized, parallel, one arm of crossover, with blind assessment was conducted. Fifty-five patients with diabetic polineuropathy were randomly allocated to the control group (n = 29) and intervention group (n = 26). The intervention was applied for 12 weeks, twice a week, for 40 to 60 minutes per session. The primary variables were defined as those that describe the foot rollover: plantar pressure in 6 plantar areas of interest. The secondary variables were kinetic and kinematics of the ankle in the sagittal plane were calculated, and the clinical measures of foot and ankle function (manual muscle function testing, functional testing), signs and symptoms of diabetic polyneuropathy, physical examination of the feet and balance and confidence test in gait activities. The time effects (baseline and 12 weeks), group effects (control and intervention groups) and interaction effects were calculated using casewise two factos ANOVAs, and for intragroup comparisons of intervention group (baseline, 12 weeks and 24 weeks) it was used ANOVAs for repeated measures. The nonparametric variables were compared between groups using Mann-Whitney tests and between periods of assessment using Wilcoxon test. We adopted an ? of 5% for statistical differences and the Cohen\'s d coefficient for description of the effect size. After 12 weeks ofexercises, there were positive changes in the foot rollover process. There was a softening of heel contact in initial contact, reflected by the increase in time to peak pressure and the pressure time integral. The midfoot increased its participation observed by the decrease in speed of displacement of the center of pressure and increased pressure time integral. The lateral forefoot contact was earlier relative to the medial forefoot, that occurred at the same time before intervention, observed by the early time to peak pressure of lateral forefoot after the intervention. The participation of the hallux and toes also increased (increase of pressure time integral and peak pressure), in a pathology that is marked by decreased contact of the hallux and development of claw toes, which reduces contact of the toes with the ground. CG showed some worsening in relation to muscle function and kinematic and kinetic parameters of the ankle, while the IG showed improvement in the function of many muscles groups, functional tests and peak extensor moment during the forefoot contact. The intervention protocol was constructed to allow the patient to incorporate exercise into their daily routine, but adherence to treatment should be studied and motivational strategies need to be applied, since most of the variables returned to baseline after the follow up period (12 weeks after the intervention). Preventive actions are critical to reducing the devastating complications of diabetic neuropath

Time-varying patterns reveal foot loading changes after footankle exercises for diabetic polineuropathy

International audienceThe increased risk of plantar ulceration in patients with diabetic polyneuropathy (DPN) is often associated with an heterogeneous plantarpressure distribution characterized by overloading the anterior regions, unloading the toes and hallux, and a reduced role of lateral forefootand toes. he most studied loading variables in this population are mean and standard deviation of peak pressure and pressure-time integral,that reduces the complex and interdependent foot segments dynamics to a simple average value of many steps, that is also representedby only one sensor. Therefore, they are not optimal variables for describing time changes during the whole process of foot-floor interaction.Our aim is to propose a method for identifying plantar areas that most discriminate the overall changes through time in the plantar pressuredistribution during gait, after an exercise intervention protocol for DPN patient

An 'importance' map of signs and symptoms to classify diabetic polyneuropathy: An exploratory data analysis

International audienceAims/Hypothesis: Early diagnosis of diabetic polyneuropathy (DPN) is critical for a good prognosis. We aimed to identify different groups of patients, based on the various common clinical signs and symptoms of DPN, that represent a progressive worsening of the disease before the onset of plantar ulceration or amputation. We also sought to identify the most important DPN-related variables that can discriminate between groups, thus representing the most informative variables for early detection. Methods: In 193 diabetic patients, we assessed 16 DPN-related signs, symptoms, and foot characteristics, based on the literature and the International Consensus on the Diabetic Foot. We used multiple correspondence analysis and the Kohonen algorithm to group the variables into micro and macro-classes and to identify clusters of patients that represent different DPN conditions. Results: Four distinct groups were observed. One group showed no indication of DPN. The remaining groups were characterized by a progressive loss of the vibration perception, without a worsening of symptoms or tactile perception. The 2 intermediate groups presented different aspects of DPN: one showed mostly DPN symptoms and the other showed the incipient vibration impairment, callus and crack formation, and foot arch alteration. The fourth group showed more severe foot and DPN conditions, including ulceration and amputation, absence of vibration and tactile perception (irrespective of how many compromised foot areas), and worse foot deformities and callus and crack formation. Conclusion: Vibration perception was more informative than tactile sensitivity in discriminating early DPN onset because its impairment was evident in more groups. Symptoms and callus and cracks did not discriminate the severity status and should be interpreted in association with other clinical variables. Reconsideration of the current screening techniques is needed to clinically determine the early onset of neuropathy using tactile perception

Representation of the distances in the Kohonen map.

<p>The gaps coincide with the fontiers of the macro-classes (colored).</p

Hierarchical classification.

<p>The y axis indicates the macro-classes that are represented in Figs <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0129763#pone.0129763.g002" target="_blank">2</a> and <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0129763#pone.0129763.g003" target="_blank">3</a>.</p

Sample demographic and anthropometric data.

<p>Sample demographic and anthropometric data.</p

The MCA representation.

<p>The projection on the first 2 axes (29%) and 2 (17%) represents only 46% of the explained inertia from <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0129763#pone.0129763.t002" target="_blank">Table 2</a>. The ‘+’ input is for the rows (i.e. patients) and the ‘o’ input is for the columns (i.e. symptoms).</p