Here we have February’s Journal Club article that we discussed at the hospital’s monthly Journal Club.
Honestly, I felt like this article had a bit of a “duh” factor, but the basics here must NOT be common knowledge, otherwise why would anyone bother writing a scholarly article on it? Apparently it has been the norm to blanketly recommend not performing weight bearing exercise for people who are diagnosed with diabetic peripheral neuropathy. The concern being that their insensate feet are too vulnerable to injury, so the risks outweigh the gains.
WRONG! So says the article….
First of all, let’s start with the diabetes itself. Most everyone knows that Type II diabetes (and perhaps Type III diabetes) is a lifestyle disease– too much glucose in and not enough glucose expended out over years and years and eventually, your pancrease gets worn out and quits. So what sense does it make to further restrict the output methods, make the diabetes worse and therefore possibly the neuropathy as well? It doesn’t.
Now to the physiology and physics that the article mentions. The integumentary system (skin), like any other bodily system, adapts to the stressors placed upon it. That’s how we grow and survive in this world of ours. But our bodies are also a little lazy. If we don’t stress them in the right manner, then they say, “Hey, why not take a load off? All this extra work apparently isn’t necessary anymore,” and become deacclimated to the stress it used to be able to handle just fine. So, in the case of the skin, if we decided to forgo weight bearing exercise because it’s “too dangerous,” we are in fact sliding our skin back in the opposite direction, as it becomes deacclimated to any weight bearing stress what-so-ever. Then you get skin tears on feet during a transfer or ulcers just from wearing shoes. But all in all, people with diabetic neuropathy should be doing the exact same FITT principle exercise prescriptions as the rest of the homo sapien population. (Apparently I need to do a post on the FITT principle, because everything that’s coming up on the first Google page doesn’t cover it well.) I also found it interesting that exercise seems to have a protective effect on the nerves of diabetic people and that a little exercise can even reduce the neuropathic symptoms! How about that?
Of course there are a few people with diabetic neuropathy that also have other comorbidities that should NOT be doing weight bearing exercise without proper considerations. And we therapists need to screen these people out and make appropriate recommendations.
There are 6 areas we need to look at in these folk:
- Skin, including
- History of skin breakdown or amputations– likely to have more in future
- Current calluses, blisters or redness= areas of friction at risk for breakdown. Refer to podiatrist.
- Dry skin with hair loss– doesn’t move as well as moisturized skin, may indicate circulation trouble.
- Temperature and color– warm, red skin could indicate infection whereas cold, pale may indicate poor circulation.
- Overgrown or thickened nails– can cause self-injury in exercise. Refer to podiatrist.
- Nervous system, including
- Light touch– intact (>80% accuracy) over areas at high risk for breakdown (“metatarsal heads, heel, pad of great toe and any plantar bony prominence”) to 10g Semmes-Weinstein monofilament
- Achilles tendon reflex intact
- Onset and dampening of vibration with 128-Hz tuning fork
- Musculoskeletal system
- ROM of effected areas
- Muscular strength of effected areas
- Location of any areas of bony prominences
- Should recommend appropriate foot wear, which in general “should maximize force distribution and minimize rubbing and should fit the length of the foot, and the toe box must be the width and depth necessary to accommodate any forefoot deformities. Shoes with laces can prevent slipping without being overly tight, and enclosed footwear offers greater protection from foreign objects…. A well-made insole is one with materials that will not be easily compressed, that helps to disperse forces, and that reduces areas of high stress.” NOT those ridiculous memory foam shoes! I would love to give whoever invented memory foam a piece of my mind.
- Remind them that they need to be checking their feet for injury, redness DAILY. And if they can’t get to their feet to see all angles, get them a mirror!
- Vascular system
- Be able to palpate dorsalsis pedis and tibialis posterior arteries
- have capillary refill of <4.5 sec at nail bed
- Endocrine system assessment– should be able to verbalize their glucose management plan (what meds they take, how much, and when) and what they would do in case of a hyper- or hypo- glycemic incident. This is for their own safety. Knowing the A1C is also important.
- Cardiovascular system– if you have serious concerns about this, refer to cardiologist, request stress test or EKG to clear for exercise, just like any other person.
If ANY of these areas give you pause for concern, better to have their PCP and/or podiatrist clear them than to send them to the physician later with a horrible ulcer saying, “Oops?”
As far as finding the perfect “window” of stress– not too little that they lose adaptation and not too much in that they are injured– go slow and conservative and make sure again that they can and are checking those feet DAILY!
Exercise is medicine for everyone.
Just a heads up: with CSM being this week, I’m not sure what my post schedule will look like or if I will even have time to post this week honestly. There are days I will be at the convention/before and after shenanigans for 12-15 hours! (And that’s just the scheduled stuff!) I may make a few quickies with interesting things.
That being said, I would also love to meet as many of you fine PT folk that are attending CSM as I can! Feel free to message me through the “Contact” button at the top for e-mail or on my Twitter or Facebook pages so we can find each other. I’m also on the hunt for a few people to do guest posts around the blog here. So come with your post ideas to share! Tell us about your research or facility or product or whatever neuro passion you have!