Strength And Balance Training on Diabetic Peripheral Neuropathy
Condition: Diabetic Peripheral Neuropathy
MeSH terms: Peripheral Nervous System Diseases; Diabetic Neuropathies
Study type: Interventional

Summary: 
      A Randomized Control Trial was conducted on 20 participants, equally allocated in strength
      plus balance and aerobic group from February-2020 until December-2020.Participants were
      selected according to inclusion and exclusion criteria on purposive sampling technique and
      randomization was done by sealed envelope method. Inclusion criteria was both gender, 40
      years to 80 years, Patients with type 2 diabetes ,diabetic peripheral neuropathy and Toronto
      neuropathy score 6 or greater. Participants were assessed after taking consent before and
      after 12 sessions through Toronto clinically neuropathy system, SF-36 and berg balance scale.
      Data was analyzed using SPSS v.22.
    

Detailed description: 
      Diabetic peripheral neuropathy (DPN) adds to decrease functional performance in people with
      diabetes. People having DPN found to have decrease proprioception, decrease muscle strength
      specifically in dorsiflexion and planter-flexors of foot and decrease ankle mobility. An
      important result of DPN on skeletal muscle is speeded motor axon loss. The injuries to motor
      units have been found in intrinsic foot and hands muscles as well as dorsiflexion of lower
      limb. Declined muscle strength with DPN has been told in a number of muscles, counting
      plantar flexor and dorsi-flexors of ankle, flexor and extensor of knee. As predicted, the
      peripheral ankle muscles have more decline in strength as compared thigh muscle. M.Davies
      stated in his study that DPN has a negative effect on the quality of life of an individual.In
      "Painful diabetic peripheral neuropathy", the emotional and physical of quality of life are
      markedly changed, and associated anxiety, sleep disturbance and depression are found in 43%
      of the affected population. Occupation status in 35 to 43% of patients were affected, within
      job patients, as a result of pain, admit an usual of 5.5 missed workdays/month (30). Besides
      compromised life quality, patients with DPN also have greater fall risk due to imbalance
      problem and this risk is probable high in older age, associated depression and severity of
      DPN. Consequently, falls and broken bones are common among patients affected, occurring in
      around 25% of adults greater than 65 years with diabetes compared with 18% same population
      with no diabetes. The most common complication linked with DPN is frequent foot infections,
      ulcers and amputations, and Charcot's-joints. It was calculated that 15% of diabetic patients
      will progress to at least one foot ulcer, and one latest study witnessed a yearly occurrence
      of approximately 2%. It has been stated that 60%-70% of foot ulcers caused by diabetes are
      neuropathic in nature .Worldwide incidence of foot ulcer is 6.3%, and the occurrence in
      Africa, North America, Europe, Oceania and Asia was 7.2%, 13.0%, and 5.1%, 3.0% and 5.5%
      respectively. A literature also described the occurrence of diabetic foot in Pakistan around
      7.6%, with more prevalent in men than women. Other difficulties of DPN contains imbalance,
      greater fall risk, psychosocial problems, mobility restriction, and sever case can lead to
      amputation thus restricting patient socially and has severely negative effect on patients
      life.There is very little data available on the effects of DPN on mortality.Elder individuals
      have a greater frequency of neuropathy than younger people, and are 17 times more likely to
      fall. It is crucially important to improve strength and in patients having large nerve fiber
      involvement. Elder can take benefit from intense strength training by improving coordination,
      increasing muscle strength and balance, and thus dropping fall and fracture risk. Resistance
      exercise is suggested for patients having diabetes type 2 and controlling mass of skeletal
      muscle (sarcopenia) with high resistance (1 RM) 2 to 4 days/week. Both side ankle ROM
      exercise, functional balance exercises like sit to stand, gait training for reduction planter
      load , Proprioceptive training exercise such as, stepping with alternate feet, balance board
      training (prevention of fall) .Several studies were also carried on effects of aerobic
      exercises and reported quit good effects. A literature review was done in the year 2019.
      Study concluded that among different physical therapy approaches, Aerobic exercise is best
      for reducing diabetic risk factors including diabetic neuropathy. In the year 2017,
      S.Billinger conducted a trail on aerobic exercises. Objectives of the study were to find the
      effects of aerobic exercises on vascular health. Duration of the study was 16 weeks and study
      reported that there is slight improvement in the vascular health of diabetic patients.
      Further 2 trails were conducted by S.Dixit in the year 2013 and 2014. Main objective of the
      study was to evaluate the effects of aerobic exercise on quality of life and progression of
      diabetic neuropathy respectively. Study stated the positive effects of aerobic training that
      I could improve the quality of life and slow down the progression of DPN.Another study was
      done by A.Waje in the year 2020. Study was based on the comparison of balance training
      exercise with PNF and its effects on balance. Study reported positive effects of both
      exercises but also report great effects when both treatments were given combined.
      K.Venkataraman et al conducted a study on short term effects of strength and balance training
      on functional status and quality of life in patients with diabetic neuropathy. Study claimed
      that strength and balance training can improve functional status, but failed to report its
      effects on quality of life and severity of diabetic neuropathy.Different studies were done on
      effects of PNF on balance and functional status in DPN. A study was done by K.Singh in the
      year 2016 on the effects of Proprioceptive Neuromuscular Facilitation (PNF) therapy in
      improving sensorimotor functions. Study claimed that PNF approach can improve the
      sensorimotor functions of diabetic neuropathic patients .Regarding Proprioceptive treatment,
      a study was done in the year 2012 by A.El-Wishy. Study was carried out in Egypt on 28
      individuals. Purpose of the research was to know and equate the effects of proprioceptive
      exercises and conventional exercises on balance. Study reported that combination of
      proprioceptive and conventional exercises were more effective than isolated conventional
      physical therapy.
    

Intervention name(s): Strength and balance training; Aerobics training
Intervention type(s): Other; Other
Intervention description(s): Passive ROM to possible level of knee (flexion and extension), ankle (dorsiflexion and plantar flexion), forefoot (inversion and eversion) and toe (flexion and extension, adduction and abduction) joints.Resisted flexion and extension of knee, dorsiflexion and planter flexion of ankle, inversion and eversion of foot, flexion/extension, and abduction/adduction of toe with help of thera-band.The exercise prescription for strength training was made at approximately 50% of the estimated 1-RM. Exercise progression was achieved by instructing participants to increase the weight lifted in a specific exercise when they could perform 2 sets of 10-12 repetitions without maximal exertion on 2 consecutive training days. On basis of Borg Rating of Perceived Exertion of 10 to 13.Tandem leg stance for first 2 weeks and then it was progressed to Single leg stance toe and heel stance.For dynamic balance:backward walk Tandem walk and sideways walk.; After the baseline assessment, the participant in the Group B received Aerobic exercise with routine medical care.
All patients were followed for 3 days a week for 8 weeks treatment. Control Group received aerobic training. Control group received stretching exercise for 10 minutes and then treadmill walk for 10 minutes and then stationary bicycle for 10 minutes, and steppers for 10 minutes and 5 minute cool down .
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: Resistance Training; Diabetic Neuropathies; Quality of Life; Diabetes Mellitus, Type 2