Case Report
A Case Report for diabetis
https://doi.org/10.21203/rs.3.rs-1741822/v2
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Background
Limitation of tibio-tarsal joint mobility in diabetic patients can occur within a few years of diagnosis, even in young patients.
Case presentation
A patient with type 2 diabetes.
Conclusions
The results suggest that the role of manual treatment combined with an exercise programme could increase tarsal dorsiflexion and consequently decrease plantar pressures.
Physical Therapy
Mobilization
diabetes
The diabetic foot is a condition characterised by anatomo-functional alterations caused by peripheral occlusive arteriopathy and/or diabetic neuropathy that may favour the development of ulcerations.
The diabetic foot is a major and growing health problem that often leads to foot ulceration, lower limb amputation and increased mortality rates. The main aetiological factors of diabetic ulcers are neuropathy, vasculopathy and infection. However, there are many factors such as limited joint mobility, muscle weakness, gait abnormalities and foot deformities that together are responsible for the more or less early development of increased pressure at the foot level, leading to a serious ulcerative risk both in the short and long term(1).
Diabetic patients have been found to have muscle weakness, balance deficits and reduced mobility in the ankle, sub-astragalic and first metatarsophalangeal joints that interfere with normal foot rocker during gait, leading to abnormalities in walking. These factors may also alter the normal distribution of plantar pressures and thus lead to an increased risk of foot ulceration. Specifically, limitation of tibio-tarsal joint mobility in diabetic patients has an insidious onset, followed by progressive asymptomatic deterioration. This limitation may occur a few years after diagnosis, even in young patients. At the same time, it is known that there is a significant correlation between the range of motion of the foot and ankle joints. It is believed that this joint movement deficit is due to stiffness in muscles, tendons, joint capsules, ligaments and skin(2–6). There are also important relationships between polyneuropathy and muscle weakness, as both result in reduced strength and muscle atrophy in the lower limbs. The association between type 2 diabetes and loss of strength and quality of movement in the lower limbs has recently been demonstrated, resulting in early disability and worsening the patient's quality of life(7–12). With this in mind, the aim of this study is to observe whether orthopaedic manual therapy and specific exercise for subjects with diabetes mellitus can lead to an increase in joint mobility with a subsequent reduction in plantar pressures.
The 65-year-old male subject suffers from diabetes mellitus type II diagnosed about 5 years ago, and lives in the city of Bologna. He has a bilateral dorsal flexion deficit that makes his walking less efficient and certainly more physically demanding. The subject has a family history of diabetes, and his therapy consists of taking oral hypoglycaemic drugs; he underwent successful total coxofemoral joint arthroplasty surgery in January 2018.
Limited joint mobility and reduced tissue elasticity are very common in diabetic patients, even in the absence of complications. These characteristics may explain the difficulties diabetic patients have in performing physical activities with the subsequent development of additional functional impairments. In the presence of reduced dorsal tibio-tarsal flexion, the foot is unable to properly deliver shock absorption on contact with the ground and may lose the ability to maintain normal plantar pressure (18–20). This effect can facilitate trauma in the plantar surface and eventually lead to foot ulceration. In this context, therapeutic exercise has always been considered an important component of prevention and therapy; in contrast, the effect of orthopaedic manual therapy has never been explored. There is evidence to support that regular physical activity can play a role in the primary and secondary prevention of several chronic diseases, including diabetes(21).
In line with these observations, our results show that a period of 8 weeks of manual therapy and therapeutic exercise, adapted to the condition of the subject, are able to improve the mobility of the ankle joint. Already after the first session, an improvement in plantar pressures was observed with a decrease in both peaks from 413.6 Kpa to 99 Kpa in both feet; but more importantly, the results of the average plantar pressures also improved significantly from 129.8 Kpa to 54.5 Kpa for both feet with a decrease in plantar pressures at the forefoot from 43.7 % to 33.2 %. Tissue elasticity was assessed with the Lunge Test(22–24), which measures the stiffness of the gastrocnemius-soleus complex by measuring the dorsal flexion of the tibio-tarsus under load, increased from 8 cm to 9.5 cm, albeit with data that are not yet optimal to make the test good (the normal range is > 10 cm). Gait performance with inertial motion sensors did not change significantly, perhaps also due to the short time of the study. It is evident that the decline in the musculoskeletal form of diabetic patients, which often results in disability, may be reversible. The improvement we saw in our study in the patient(s)' performance after orthopaedic manual therapy combined with exercise can improve their ability to meet the demands of daily life and allow them to maintain functional independence. Our study also demonstrates the effectiveness and feasibility of an exercise programme for diabetic patients associated with manual therapy, suggesting that such programmes should be suggested as routine therapy in this type of patient.
1. Standard Italiani 2.0 AMD-SID standard italiani per la cura del diabete mellito 2014 – Il Diabete Online [Internet]. [cited 2022 May 8]. Available from: https://www.ildiabeteonline.it/standard-italiani-2-0-amd-sid-standard-italiani-per-la-cura-del-diabete-mellito-2014/
2. Marrón-Gómez D, Rodríguez-Fernández ÁL, Martín-Urrialde JA. The effect of two mobilization techniques on dorsiflexion in people with chronic ankle instability. Phys Ther Sport. 2015 Feb;16(1):10–5.
3. Collins N, Teys P, Vicenzino B. The initial effects of a Mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. Man Ther. 2004 May;9(2):77–82.
4. Hidalgo B, Hall T, Berwart M, Biernaux E, Detrembleur C. The immediate effects of two manual therapy techniques on ankle musculoarticular stiffness and dorsiflexion range of motion in people with chronic ankle rigidity: A randomized clinical trial. J Back Musculoskelet Rehabil. 2018;31(3):515–24.
5. Mason-Mackay AR, Whatman C, Reid D. The effect of reduced ankle dorsiflexion on lower extremity mechanics during landing: A systematic review. J Sci Med Sport. 2017 May;20(5):451–8.
6. Zordão CC, Mendonça Junior ES, Valério PM, Perez CS, Ferro AP, Guirro EC de O. Immediate Effect of Manual Therapy on Tibiotarsal Joint Mobility and Static Balance in Individuals With Diabetes. J Chiropr Med. 2021 Sep;20(3):128–37.
7. Apelqvist J, Bakker K, van Houtum WH, Schaper NC, International Working Group on the Diabetic Foot (IWGDF) Editorial Board. Practical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007) Prepared by the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev. 2008 Jun;24 Suppl 1:S181-187.
8. Boulton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive Foot Examination and Risk Assessment. Diabetes Care. 2008 Aug;31(8):1679–85.
9. Fernando DJ, Masson EA, Veves A, Boulton AJ. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care. 1991 Jan;14(1):8–11.
10. Mueller MJ, Diamond JE, Delitto A, Sinacore DR. Insensitivity, Limited Joint Mobility, and Plantar Ulcers in Patients with Diabetes Mellitus. Physical Therapy. 1989 Jun 1;69(6):453–9.
11. Zimny S, Schatz H, Pfohl M. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care. 2004 Apr;27(4):942–6.
12. Sacco ICN, Hamamoto AN, Gomes AA, Onodera AN, Hirata RP, Hennig EM. Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy. Clin Biomech (Bristol, Avon). 2009 Oct;24(8):687–92.
13. Yumpu.com. valutazione delle distribuzioni delle pressioni plantari in soggetti con ... [Internet]. yumpu.com. [cited 2022 May 8]. Available from: https://www.yumpu.com/it/document/view/14922720/valutazione-delle-distribuzioni-delle-pressioni-plantari-in-soggetti-con-
14. Wiva - inertial system for performance analysis [Internet]. [cited 2022 May 8]. Available from: http://www.e-wiva.com/
15. Bennell KL, Talbot RC, Wajswelner H, Techovanich W, Kelly DH, Hall AJ. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Aust J Physiother. 1998;44(3):175–80.
16. Gabbe BJ, Finch CF, Wajswelner H, Bennell KL. Predictors of lower extremity injuries at the community level of Australian football. Clin J Sport Med. 2004 Mar;14(2):56–63.
17. Pope R, Herbert R, Kirwan J. Effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in Army recruits. Aust J Physiother. 1998;44(3):165–72.
18. Sawacha Z, Gabriella G, Cristoferi G, Guiotto A, Avogaro A, Cobelli C. Diabetic gait and posture abnormalities: a biomechanical investigation through three dimensional gait analysis. Clin Biomech (Bristol, Avon). 2009 Nov;24(9):722–8.
19. Rao S, Saltzman CL, Yack HJ. Relationships between segmental foot mobility and plantar loading in individuals with and without diabetes and neuropathy. Gait Posture. 2010 Feb;31(2):251–5.
20. Giacomozzi C, Caselli A, Macellari V, Giurato L, Lardieri L, Uccioli L. Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care. 2002 Aug;25(8):1451–7.
21. Francia P, Anichini R, Seghieri G, De Bellis A, Gulisano M. History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature. Curr Diabetes Rev. 2018 Oct;14(5):411–26.
22. Cejudo A, Sainz de Baranda P, Ayala F, Santonja F. A simplified version of the weight-bearing ankle lunge test: description and test-retest reliability. Man Ther. 2014 Aug;19(4):355–9.
23. Powden CJ, Hoch JM, Hoch MC. Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review. Man Ther. 2015 Aug;20(4):524–32.
24. Williams CM, Caserta AJ, Haines TP. The TiltMeter app is a novel and accurate measurement tool for the weight bearing lunge test. J Sci Med Sport. 2013 Sep;16(5):392–5.
25. Searle A, Spink MJ, Ho A, Chuter VH. Association between ankle equinus and plantar pressures in people with diabetes. A systematic review and meta-analysis. Clin Biomech (Bristol, Avon). 2017 Mar;43:8–14.
26. Lepesis V, Marsden J, Paton J, Rickard A, Latour JM. Experiences of foot and ankle mobilisations combined with home stretches in people with diabetes: a qualitative study embedded in a proof-of-concept randomised controlled trial. J Foot Ankle Res. 2022 Jan 29;15(1):7.
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