Effect of Educational Booklet for Foot-related Exercises for Prevention and Treatment in People With Diabetic Neuropathy

University of Sao Paulo General Hospital50 enrolled

Overview

The main objective of this trial is to investigate the effect of an educational booklet foot-related exercise in diabetic neuropathy status, functional outcomes and gait biomechanics in people with diabetic neuropathy.

A randomized controlled trial will be performed with 48 patients with diabetic neuropathy. The participants will be randomly assigned into either a control group (recommended foot care by international consensus with no foot exercises) or an intervention group that will perform exercises at home, three times a week, through the booklet for 8-weeks. The subjects will be evaluated in 3 different times to access the effect of the intervention: baseline and 8weeks, for all outcomes; and 16 weeks, for follow-up reasons for all outcomes. The following outcomes will be assessed in all times: (1) diabetic neuropathy symptoms by Michigan Neuropathy Screening Instrument, (2) fuzzy score of the neuropathy severity, (3) tactile and vibration sensititivity (10-g monofilament and tuning fork), (4) foot-ankle kinematics and ankle kinetics during gait (infrared cameras and inverse dynamics, respectively), (5) foot isometric strength (by a pressure plate measurement), (6) functional balance reach test, (7) foot health and functionality by the Foot Health Status Questionnaire, (8) plantar pressure distribution during gait. The hypothesis of this study is that the intervention will increase the perception of the tactile and vibratory sensitivity of the foot, reduce the symptoms of diabetic neuropathy, increase the strength of the foot muscles, increase the functional balance score, decrease the severity of the diabetic neuropathy (fuzzy score), decrease the number of neuropathy symptoms, promote a more physiological foot rollover with a redistribution of plantar pressure during gait, as well as increase foot-ankle mobility after 08-weeks of intervention. There will be also beneficial biomechanical changes during gait, such as: (1) increase in the ankle extensor moment and ankle concentric power in the propulsion phase and (3) increase in the ankle flexor moment and ankle eccentric power in the load phase.

Study Type

INTERVENTIONAL

Allocation

RANDOMIZED

Purpose

TREATMENT

Masking

DOUBLE

Enrollment

Conditions

Diabetic Neuropathies

Interventions

Educational and home-based physical therapy by foot-related exercisesOTHER

The booklet is divided in 2: educational and exercise protocol. The aim of the first part is to guide the individual for a change in his/her health behavior, and comprises info about diabetic neuropathy, foot care, shoes, and benefits of exercising. The second part is the foot protocol, composed by 6 exercises. The maximum duration of a session is 20min and should be performed 3 times/week. The subject should warm-up the foot-ankle and then start exercising in the order suggested by the booklet, filling a table with the effort perceived (effort likert scale). The foot exercises progresses from one set with 30 repetitions in a sitting position, to exercising standing, then performing the exercise on one foot only. Other progression criterion is to increase the number of sets performed. The effort scale regulates the individual effort for his/her progression, which is also registered by the participant in the monthly table at the booklet.

Eligibility

Sex: ALLMin age: 18 YearsMax age: 65 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Diabetes mellitus type 1 or 2; * Moderate or severe neuropathy confirmed with the fuzzy software; * Ability to walk independently in the laboratory Exclusion Criteria: * Hallux amputation or total amputation of the foot; * History of surgical procedure in the knee, ankle or hip; * History of arthroplasty and / or lower limb orthosis or indication of lower limb arthroplasty throughout the intervention period; * Neurological and / or rheumatologic diseases diagnosed; * Inability to provide consistent information; * Perform physiotherapy intervention throughout the intervention period; * Receiving any physiotherapy intervention or offloading devices; * Major vascular complications; * Severe retinopathy; * Ulceration not healed for at least 6 months and / or active ulcer; * Score between 12-21 (Probable Depression) from the Hospital Anxiety and Depression Scale (HADS).

Locations (1)

Érica Queiroz da Silva

São Paulo, São Paulo, Brazil

Outcomes

Primary Outcomes

Change From Baseline Diabetic Neuropathy Symptoms at 8-weeks

Score of the Michigan Neuropathy Screening Instrument (MNSI). This questionnaire comprises 15 questions about symptoms and events related to leg and foot sensitivity and is administered by the participant himself. The answers are summed to get a total score. The sum of all items results in a score ranging from 0 to 13 (13 represents the worst rating of the neuropathy).

Time frame: 8-weeks

Change From Baseline of the Fuzzy Classification of the Diabetic Neuropathy Severity at 8-weeks

The fuzzy classification of the diabetic neuropathy severity will be given by the Fuzzy software score developed by the Laboratory of Biomechanics of Movement and Human Posture (LaBIMPH) available free of charge at: http://www.usp.br/labimph/fuzzy/. It is a decision support system for classification of the diabetic neuropathy. This decision is based on three domains: signs and symptoms extracted from the Michigan Neuropathy Screening Instrument; tactile sensitivity through the number of non-sensible areas using a 10-g monofilament; and vibration sensitivity by vibrating a tuning fork (128Hz) characterized as absent, present or diminished. The software produces a score from 0 to 10 and the higher the score, the more severe the diabetic neuropathy.

Time frame: 8-weeks

Change From Baseline Diabetic Neuropathy Symptoms at 16-weeks (Follow-up)

Time frame: 16-weeks (Follow-up)

Change From Baseline of the Fuzzy Classification of the Diabetic Neuropathy Severity at 16-weeks (Follow-up)

Data from ClinicalTrials.gov

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Secondary Outcomes

Change From Baseline of the Foot and Ankle Kinematics During Gait at 8-weeks

Sagital plane of ankle range of motion - initial of dorsiflexion until the end of plantaflexion (degrees) during stance phase of gait.

Time frame: 8-weeks

Change From Baseline of the Foot and Ankle Kinetics During Gait at 8-weeks

Peak joint moment of ankle plantarflexor moment at push off during stance phase of gait by inverse dynamic calculations

Time frame: 8-weeks

Change From Baseline Dynamic Plantar Pressure Distribution During Gait at 8-weeks

A pressure platform (emed®-q100, GmbH, Novel Munich, Germany) will be used to evaluate the pressure pattern during walking. The analysis of plantar pressure will be through the parameters: Heel peak pressure (kPa)

Time frame: 8-weeks

Change From Baseline Tactile Sensitivity at 8-weeks

Tactile sensorial deficits will be evaluated by monofilament with a tactile stimulus of a 10-g monofilament in 4 plantar areas (plantar face of the hallux, heads of 1st, 3rd and 5th metatarsals). The areas will be evaluated in random order and not allowing the participant to view the monofilament. The number of areas where the participant does not feel the pressure will be indicated. The greater the number of areas marked without sensing, the greater the impairment of tactile sensitivity.

Time frame: 8-weeks

Change From Baseline Vibration Sensitivity at 8-weeks

The vibration sensitivity will be assessed by vibrating a tuning fork (128Hz) in the dorsal region of the distal hallux phalanx. The participant should report the moment he/she does no longer feel the vibration of the tuning fork, and the evaluator must time the interval between which the participant reports that he/she ceases to feel the vibration and the moment the evaluator ceases to feel the vibration in the his/her hand. Values smaller than 10 seconds will be classified with present vibratory sensitivity; values greater than 10 seconds will be classified as decreased vibratory sensitivity. If the participant does not perceive the vibration imposed by the tuning fork, it will be classified as absent vibratory sensitivity.

Time frame: 8-weeks

Change From Baseline Foot Health and Functionality at 8-weeks

The Brazilian version of the Foot-Health Status Questionnaire (FHSQ-BR) will be used. The domain assessed was function that receives a score from 0 to 100, where 100 expresses the best function and 0 to worst.

Time frame: 8-weeks

Change From Baseline Foot Isometric Strength at 8-weeks

The muscle strength of the flexor muscles of the hallux and flexors of the toes will be evaluated using the emed®-q100 pressure platform (Novel, Germany) according to a test protocol already described elsewhere. The individual should stand, with the evaluated foot centered on the pressure platform, instructed to make as much force as possible with the hallux peak values of maximum force (% of bodyweight).

Time frame: 8-weeks

Change From Baseline Functional Balance at 8-weeks

It is a clinical test where the patient will be standing barefoot, perpendicular to the wall, with the shoulder flexed 90° and the elbow extended. A tape measure will be attached to the wall, parallel to the floor, positioned at the height of the patient's acromion. The volunteer will be instructed to lean forward as much as possible without losing balance or taking a step. The displacement of the wrist will be measured by the tape. The greater the distance in centimeter, the better the functional balance

Time frame: 8-weeks

Change From Baseline of the Foot and Ankle Kinematics During Gait at 16-weeks (Follow-up)

Sagital plane of ankle range of motion - initial of dorsiflexion until the end of plantaflexion (degrees) during stance phase of gait.

Time frame: 16-weeks (Follow-up)

Change From Baseline of the Foot and Ankle Kinetics During Gait at 16-weeks (Follow-up)

Peak joint moment of ankle plantarflexor moment at push off during stance phase of gait by inverse dynamic calculations

Time frame: 16-weeks (Follow-up)

Change From Baseline Dynamic Plantar Pressure Distribution During Gait at 16-weeks (Follow-up)

Time frame: 16-weeks (Follow-up)

Change From Baseline Tactile Sensitivity at 16-weeks (Follow-up)

Time frame: 16-weeks (Follow-up)

Change From Baseline Vibration Sensitivity at 16-weeks (Follow-up)

Time frame: 16-weeks (follow-up)

Change From Baseline Foot Health and Functionality at 16-weeks (Follow-up)

The Brazilian version of the Foot-Health Status Questionnaire (FHSQ-BR) will be used. The domain assessed was function and it receives a score from 0 to 100, where 100 expresses the best function and 0 to worst.