Dr. DeHeer's Article Review: Range of Motion and Plantar Pressure Evaluation for the Effects of Self-Care Foot Exercises on Diabetic Patients with and Without Neuropathy

Article: Range of Motion and Plantar Pressure Evaluation for the Effects of Self-Care Foot Exercises on Diabetic Patients With and Without Neuropathy

Cerrahoglu, L., Kosan, U., Sirin, T. C., & Ulusoy, A. (2016). Range of Motion and Plantar Pressure Evaluation for the Effects of Self-Care Foot Exercises on Diabetic Patients with and Without Neuropathy. Journal of the American Podiatric Medical Association, 106(3), 189-200.

Abstract Link: http://www.japmaonline.org/doi/abs/10.7547/14-095


Key Points:

  1. Diabetic peripheral neuropathy (DPN) is present in 50% of diabetics with diabetes for > 10 years – loss of protective sensation (sensory) and structural changes (motor and autonomic)
  2. DPN, ischemia, infection and diabetic foot ulceration (DFU) are most important causes of foot amputations
  3. DFUs are most expensive and critical complications of diabetes worldwide
  4. 84% of non-traumatic amputations in DM patients are preceded by a DFUs
  5. Total cost of diabetic foot care for DM with DPN estimated $11 billion annually
  6. Prevention is essential
  7. Hyperglycemia results in glycosylation of Achilles tendon fibers resulting in cross-linking of the fibers and shortening resulting in increased forefoot pressures and risk of ulceration
  8. Study objectives -
    1. Primary objective – is there a difference in plantar pressures in patients with DPN and without DPN
    2. Secondary objective – evaluate the effect of a home stretching and strengthening program on ankle range of motion (AROM) and 1st MPJ ROM
  9. Study consisted of 80 type II DM patients – 40 with Neuropathy Disability Scores (NDSs) < 6 (non neuropathic) and 40 with scores > 6 (neuropathic)
    1. Both groups randomized into exercise group (N=20) and control group (N=20)
    2. NDSs of all of the patients were calculated – based on vibration perception, pinprick sensation, temperature perception, and Achilles reflexes
  10. ROM measured with a goniometer average of 3 measurements – STJ was placed in neutral position but midtarsal joint was not supinated
    1. Only AROM DF for L side showed statistically significant difference between the DPN and non-DPN groups on initial exam
  11. Pedobarography for plantar pressure assessment done on all 80 patients
    1. No significant difference between static and dynamic pedobarographic evaluation between DPN and non-DPN
  12. 76 patients completed the study (38 DPN and 38 non-DPN) – 19 each for exercise and control subgroups within each group (DPN & non-DPN)
    1. Sex, age, duration of DM, BMI were not statistically significant
    2. No significant difference in presence of callus between groups
  13. Evaluation after 4 weeks -
    1. Home exercise sub groups (both DPN & non-DPN) – significant increase in AROM and 1st MPJ ROM compared to initial exam, static pedobarographic pressure measurements significant reductions in right foot forefoot pressures, and significant decreases were seen in dynamic pedobarographic values of peak plantar pressure at the left forefoot medial, right forefoot lateral, left midfoot, and right hindfoot
    2. No significant positive or negative correlation was found between the neuropathy and nonneuropathy group
  14. Conclusion – “A home exercise program could be an effective preventive method for improving ROM for foot joints and plantar pressure distribution in diabetic patients independent of the presence of neuropathy. “


DeHeer’s Opinion: I have long felt prophylactic Gastrocsoleal stretching should be the fourth leg of preventative care in diabetic patients to go along with diabetic foot exams, nail and callus debridement, and diabetic shoes and orthoses. It is clear from other studies by that diabetics are more prone to equinus, which in turn results in increased forefoot pressures and risk for ulceration. The use of posterior muscle group lengthening (TAL or gastroc recession) for non-healing forefoot ulcerations is indicative of the importance of equinus in diabetic patients. It is always preferable to prevent pathology than treat pathology. The role of preventative stretching should be included in the care of any diabetic patient with ankle joint dorsiflexion less than 5° with the knee extended.

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