Exercise Training for Diabetic Neuropathy

Exercise Training for Diabetic Neuropathy Field of Research Preventive and Rehabilitation Topic of Research Efficacy of exercise training along with foot Orthotic intervention in modifying the natural course of diabetic peripheral neuropathy. Brief Introduction and Literature Review Diabetic Plantat Ulcers Diabetic myelitis is a group of chronic metabolic diseases caused by insufficient production of Insulin, results in abnormal metabolism of carbohydrates, fats and proteins. Diabetic mellitus can be classified into Type I or Insulin dependent Diabetic mellitus; occurs due to autoimmune destruction of insulin secreting cell in the pancreas. The Type II Diabetic mellitus or Non insulin Dependent Diabetic mellitus, which is characterized by increase insulin resistant and relative lack of insulin(Kumar et al 2005). It was estimated 381 billion people suffering globally from Diabetics in 2013, among which 90% cases are Type II. The South Asian countries are having the highest number of diabetic patients in the world, with highest numbers in India and China(IDF). The peripheral nerve damage often involved in diabetic patient, affecting 60% of patients with Type I and Type II diabetes. In many instances, most of the patient had already some mild to severe form of peripheral neuropathies at the time of diagnosis (Boulton AJ et al 1998). The symptom in includes numbness, tingling or burning sensation, extreme sensitivity to touch, and insensitive to hot and pain in hands and feet. Diabetic Neuropathic feet- Biomechancial fault. For normal gait, everyone requires the integrated function of sensory and motor functions. The sensory input to adapt and modify the motor output to optimize ideal gait pattern. In addition, there should be a fully functional bone and joints with adequate muscle strength, are also vital(Aminian K at al., 2002). Futhermore, the muscle weakness, anesthesia and loss of proprioception alters the foot biomechanics, often leads to changes in mobility, gait and balance. In this way, peripheral neuropathy directly contributes to joint subluxation and lack of accommodation to ground reaction force. These changes put the patient vulnerable for foot deformities and foot injuries. Foot injuries are being considered as dangerous to diabetics because peripheral neuropathy and superimposed impaired circulation makes wound healing delayed and complicated, increase the risk of repeated infection. These might ultimately lead to amputation of the affected limb. The structural changes occur within the ligament, capsule and tendons of foot joints. The collagens of ligament, capsule and tendon disorganized, lose its elasticity and tensile strength, and become more stiff (Grant WP 1996). The resultant foot joint immobility, leads to abnormal biomechanics, thus further results in either joint subluxation or the risk of injury. Therefore, it is imperative to identify the biomechanical faults are an important component in the overall care of diabetic foot. The biomechanical examination includes neutral calcaneal stance position(NCSP), relaxed calcaneal stance position(RCSP), Rang of Ankle joint dorsiflexion, position and mobility of the first ray, Forefoot to rearfoot relationship, range of motion at first MTPJ, Foot Pasture Index, Functional Hallux test (FHT), Limb length examination and plantar pressure examination. A direct correlation between ulceration and areas of high pressure has been established (Veves A 1992). A fundamental part of the physical examine involves inspection of the plantar aspect of the foot for any discrete or diffuse calluses that may indicate focal areas of high pressure or areas of increased shear forces. The sensory testing with Semmes -Weinstein Monofilaments (SWFs) should be assessed to identify the people at high risk of ulcer. It was found that 5.07 Semmes -Weinstein Monofilaments more sensitive in detecting patient with risks of plantar ulcers(Pham H et al 2000). Foot Orthotics intervention for biomechnical fault The functional and accomodative foot orthosis has been a well accepted method of treatment for patient with neurologically impaired foot for a few decades(C. S. Nicolopoulos, B. W. Scott, P. V. Giannoudis 2000; .H Cross et al,1996; Hastings MK 2006). These foot orthotic intervention decreases peak plantar pressure by evenly distributing the body weight into the ground. Foot orthosis is a biomechanical device that controls the degree of pronation and supination of the foot while walking and running. By addressing the foot biomechanical fault in patients with foot orthosis, not only prevent the plantar ulcers and it also improve their adherence to physical exercise, which can prevent or modify the peripheral neuropathy of a diabetic patient. Exercise and Peripheral Neuropathy Based on published evidence, can benefit from regular participation in mild to moderate aerobic, resistance, and balance activities in presenting the onset or modify the natural history diabetic peripheral neuropathy(Colberg SR 2014; Balducci S 2006). StefanoBalducci, et al found that a significant difference in nerve conduction parameters in Sural and peroneal nerves between experimental and control groups(StefanoBalducci, 2006) Outcome Measure Nerve Conduction Study (NCS) Compound Muscle Action Potentials(CMAP), Compound Sensory Action Potentials(CSNP), and distal latencies of Peroneal and Sural nerve of both lower limbs will be measured as per the standardized procedure((DeLisa, 1994; Misra Kalita, 2006; Nasseri et al., 1998). Vibration Perception Thershold (VPT) Sense of vibration of the plantar side of big toe will be assessed using Vibrometer. There are many published evidence to suggest that vibration perception threshold measure can be effectively and accurately identify risks of diabetic neuropathy(Garrow AP et al, 2006; Catherine L 2010) Quantitative Warmth Cold sensation Assessment Michigan Diabetic Neuropathy Score Objective of the Study To assess biomechanical deviation of foot in preventing foot related problem in diabetic feet. To develop clinical long term exercise regime in preventing diabetic induced peripheral neuropathy To ascertain Orthotic intervention for biomechanical deviation of foot in enhancing patient adherence to exercise programs. To develop a clinical exercise tool to enhance functional outcome of diabetic induced peripheral neuropathy of the feet. To identify the effectiveness of clinical exercise tool to achieve treatment goals To study the reliability and validity of clinical exercise tool in the clinical setting. Methodology of the Study Phase I A systematic review and biomechanical analysis (Deformity, muscle patterns, and plantar pressure) are needed to understand biomechanial and functional aspect of neuropathic feet of a diabetic patient in comparison with healthy subjects. This analysis is crucial in developing an understanding of possible foot orthotic intervention to prevent undue pressure of anesthetic feet during weight being phase of gait. Phase II The effective exercise intervention protocol is needed to achieve desirable treatment goals. Therefore, in this phase, will focus development of the exercise protocol aimed to modify or prevent diabetic neuropathy. Besides, each patient with biomechanical deviation treated with appropriate functional and or accommodative foot Orthosis. Nerve conduction studies: Amplitude, distal latency, velocity and Vibration Perception threshold (VPT) and Semmen’s- Weinstein monofilaments touch, pressure sensation of both lower limbs will be recorded for all patients as a baseline. Phase III To test the validity and reliability of exercise protocol and foot orthosis in preventing or modifying diabetic neuropathy Nerve Conduction studies, VPT and Semmen’s- Weinstein monofilaments touch, pressure sensation Contribution This study, perhaps, may lead to improve or modify the natural course of diabetic neuropathy in patients at the risk or diagnosed peripheral neuropathy in diabetics. Orthotics intervention by means of accommodative / functional foot orthosis for the biomechanically abnormal foot helps the patient in preventing planar ulcers and aggravation of deformity. Besides, the foot orthotic intervention also might enhance the adherence to mild to moderate aerobic, resistance and balance activities. The finding from this study may provide better understanding of long term exercise protocol along with foot functional othosis in preventing or modifying diabetic neuropathy. Timeline/ Plan of Study Brief Bibliography Boulton AJ, Malik RA. Diabetic neuropathy.Med Clin North Am. Jul 1998;82(4):909-29 Aminian K, Najafi B, Bula C, Leyvraz P, Robert P. Spatio-temporal parameters of gait measured by an ambulatory system using miniature gyroscopes. J Biomech. 2002;35:689-99. Shaw JE, van Schie CH, Carrington AL, Abbott CA, Boulton AJ. An analysis of dynamic forces transmitted through the foot in diabetic neuropathy. Diabetes Care. 1998;21(11):1955-9. Yavuzer G, Yetkin I, Toruner FB, Koca N, Bolukbasi N. Gait deviations of patients with diabetes mellitus: looking beyond peripheral neuropathy. Eura Medicophys. 2006;42(2):127-33. Mueller MJ, Minor SD, Sahrmann SA, Schaaf JA, Strube MJ. 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