Mobilisations of joint restrictions in Diabetes. Mr Vasileios Lepesis MSc, PGCert Manual Therapy, FHEA HCPC Reg. Physiotherapist & Podiatrist

Transcription

1 Mobilisations of joint restrictions in Diabetes Mr Vasileios Lepesis MSc, PGCert Manual Therapy, FHEA HCPC Reg. Physiotherapist & Podiatrist

2 Diabetes Why joint restrictions? Why joint mobilisations? What are the musculoskeletal complications of Diabetes?

3 Diabetes and Glycosylation The non-enzymatic reaction of proteins (collagen) with glucose (Collagen includes: skin, cartilage, tendons, bones and joint capsule) Increased amount and duration of glucose in the blood allows more glycosylation to occur and an increase in cross-linking within collagen fibres (Abate et al., 2011). Thereby increasing mechanical strength and stiffness and reducing its optimal elasticity ( Avery and Bailey, 2005)

4 Limited Joint Mobility Syndrome (LJMS) One of the most common MSK complications in diabetes which is underexposed and underdiagnosed (Gerrits et al., 2015) Originally known as cheiroarthropathy ; painless stiffness of hands and fingers, fixed flexion contractures Ultimately, results in impairment of joint mobility

5 Diagnosis of LJMS prayer sign Clinically, it is detected by performing the prayer sign ; by asking the patient to put his or her hands together in a praying position with the fingers fanned and to press together the palmar surfaces of the interphalangeal joints and the palms (Upreti et al., 2013)

6 Diagnosis of LJMS table top (Abourazzak et al., 2014)

7 LJMS in the foot and ankle (joints) Reductions in total ankle ROM (Zimny et al., 2004); end-range ankle dorsiflexion (Wrobel et al., 2003) Reductions in STJ mobility ((Delbridge et al., 1988) Reductions in total 1 st MTPJ ROM (Zimny et al., 2004; Giacomozzi et al., 2005); 1 st MTPJ dorsiflexion (Turner et al., 2007; Wrobel et al., 2003)

8 LJMS and changes in gait and foot rollover Ankle stiffness (equinus) affects the 2 nd rocker in preserving forward momentum 1 st MTPJ stiffness affects the 3 rd rocker in preserving forward momentum and passive toe off (Sacco et al., 2009)

9 LJMS in the foot and ankle and evidence of increased ulceration risk Ankle and 1 st MTPJ reductions in DF with neuropathy can lead to increases in forefoot peak plantar pressure and ultimately risk of foot ulceration (Delbridge et al., 1988; Fernando et al., 1991; Zimny et al., 2004)

10 Management Traditionally focus on reducing tissue stress and off-loading Callus debridement Custom-made insoles/orthotics/padding Custom-made footwear These are not addressing the biomechanical deficits: Muscle stiffness/tendon thickening (2 nd to glycosylation) Joint stiffness/capsular restriction (2 nd to glycosylation) Muscle weakness (ankle, knee)/atrophy (distal and mid leg)/activation delay (tib ant, gastrocs)

11 Questions Does a shift needs to take place from mainly passive therapies (orthotics, footwear etc.) to active and preventative interventions (exercise therapy, manual therapy)? Do we need to place more emphasis in the prevention of the long-term complications of neuropathy rather than focusing when already present (foot deformities, ulcerations, amputations)?

12 Emerging evidence on exercise therapy Sartor et al., 2014 This change toward a more physiological pattern, together with foot and ankle function improvement, entails a better foot-to-floor interaction

13 Recent evidence Francia et al., 2015 exercise therapy significantly improves joint mobility, muscular performance and walking speed in diabetic patients--thus limiting one of the pathogenic factors of diabetic foot and potentially preventing disability

14 Recent evidence Sacco and Sartor, 2016 if foot and ankle exercises are performed following the early diagnosis of diabetes, they can enable the patient to maintain sufficient residual function to interact with the environment

15 Evidence on manual therapy Foot and Ankle Mobilisation in Diabetic Peripheral Neuropathy: randomised controlled trial IRAS Project ID: REC Number: 17/SW/0170 Investigators: Mr Vasileios Lepesis, Prof Jon Marsden, Dr Joanne Paton, Prof Jos Latour Sponsor: University of Plymouth Funder: Charitable Trust of Chartered Society of Physiotherapy

16 Foot and Ankle Mobilisation in Diabetic Peripheral Neuropathy Effects of a 6-week Foot and Ankle Joint Mobilisations combined with a home programme of ankle stretches on: 1. Increasing Ankle Dorsiflexion and Total Range of Motion 2. Increasing Hallux Dorsiflexion 3. Reduces Forefoot Peak Plantar Pressures 4. Improves Balance and to determine the relationship between these outcome measures

17 Practical session Manual therapy - Indications and Contraindications - Mechanisms - Concave-convex rule - Maitland concept and grading - Hands on: Ankle, Hallux, (Subtalar Joint)

18 Worth considering again Diabetic podiatry specialist needs to integrate MSK assessment to appreciate lower limb mechanics and generation of forces Integration of passive therapies (orthotics, footwear) with active therapies (exercise prescription and rehabilitation) Clinically assess for LJMS and monitor/treat biomechanical deficits due to muscle weakness and joint stiffness Not suitable for every patient with diabetes

19 Joint mobilisation Manual therapy is a common form of treatment employed, in order to help increase range of motion of a specific joint region by restoring the arthrokinematic accessory gliding and rolling movement that is associated with normal joint movement. (Joint mobilisation is also used to relieve pain)

20 Video of ankle joint moving

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22 Rationale for mobilisations - To increase ROM into ankle and 1st MTPJ dorsiflexion - Increase the posterior capsular endpoint and provide stimulation or articular mechanoreceptors from oscilations that span the length of the available accessory motion (Hoch et al., 2012) - Improve the mechanical sensitivity of the joint and the soft tissue adoptation to the load (Hengeveld and Banks, 2013) - Joint mobilisation aims to increase physiologic and accessory motion by increasing the extensibility of the noncontractile capsular and ligamentous tissues and improve the trasmission of afferent information by stimulation joint mechanoreceptors (Kaltenborn, 2011)

23 Treatment: Grades of movement I II I II IV Small-amplitude movement, short of resistance Large-amplitude movement, short of resistance Large amplitude movement, into resistance Small-amplitude movement, into resistance (Maitland, 2005 & Petty, 2004) Pain Stiffness

24 Grades of movement I II III IV Beginning of ROM End of ROM (resistance)

25 Grades of movement I II III IV Beginning of ROM End of current ROM (resistance) End of normal ROM

26 Indications & contraindications Contraindications Non-mechanical pain/signs of serious pathology/medical history Cancer Osteoporosis Active RA Red Flags

27 Joint mobilisation treatment dose Factors & variables: Patient position Movement Direction of force applied Magnitude of force applied Amplitude of oscillation Speed Rhythm Time Symptom response

28 Concave-convex rule Ankle joint Convex dome of the talus moving on concave ankle mortise glides in opposite direction Big toe joint - Concave head of MTPJ moving on convex proximal IPJ glides in same direction Exelby (1996)

29 Concave convex rule To increase ankle joint DF therapist needs to apply a AP (anterior to posterior direction) glide of talus on ankle mortise

30 Concave convex rule To increase 1 st MTPJ DF therapist needs to apply a PA (posterior to anterior glide) of the proximal phalanx on 1 st metatarsal head

31 References ABATE, M., SCHIAVONE, C., PELOTTI, P. & SALINI, V Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus. Arch Gerontol Geriatr, 53, AVERY, N. C. & BAILEY, A. J Enzymic and non-enzymic cross-linking mechanisms in relation to turnover of collagen: relevance to aging and exercise. Scand J Med Sci Sports, 15, DELBRIDGE, L., PERRY, P., MARR, S., ARNOLD, N., YUE, D. K., TURTLE, J. R. & REEVE, T. S Limited joint mobility in the diabetic foot: relationship to neuropathic ulceration. Diabet Med, 5, FERNANDO, D. J., MASSON, E. A., VEVES, A. & BOULTON, A. J Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care, 14, GERRITS, E. G., LANDMAN, G. W., NIJENHUIS-ROSIEN, L. & BILO, H. J Limited joint mobility syndrome in diabetes mellitus: A minireview. World J Diabetes, 6, UPRETI, V., VASDEV, V., DHULL, P. & PATNAIK, S. K Prayer sign in diabetes mellitus. Indian Journal of Endocrinology and Metabolism, 17, ABOURAZZAK, F. E., AKASBI, N., HOUSSAINI, G. S., BAZOUTI, S., BENSBAA, S., HACHIMI, H., AJDI, F. & HARZY, T Articular and abarticular manifestations in type 2 diabetes mellitus. Eur J Rheumatol, 1,

32 References cont. TURNER, D. E., HELLIWELL, P. S., BURTON, A. K. & WOODBURN, J The relationship between passive range of motion and range of motion during gait and plantar pressure measurements. Diabetic Medicine, 24, MALUF, K. S. & MUELLER, M. J Novel Award Comparison of physical activity and cumulative plantar tissue stress among subjects with and without diabetes mellitus and a history of recurrent plantar ulcers. Clin Biomech (Bristol, Avon), 18, GIACOMOZZI, C., CASELLI, A., MACELLARI, V., GIURATO, L., LARDIERI, L. & UCCIOLI, L Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care, 25. ZIMNY, S., SCHATZ, H. & PFOHL, M The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care, 27, SACCO, I., HAMAMOTO, A., GOMES, A. A., ONODERA, A., HIRATA, R. & HENNIG, E Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy. Clin. Biomech., 24,

33 References cont. SARTOR, C. D., HASUE, R. H., CACCIARI, L. P., BUTUGAN, M. K., WATARI, R., PÁSSARO, A. C., GIACOMOZZI, C. & SACCO, I. C Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial. BMC Musculoskeletal Disorders, 15, FRANCIA, P., ANICHINI, R., DE BELLIS, A., SEGHIERI, G., LAZZERI, R., PATERNOSTRO, F. & GULISANO, M Diabetic foot prevention: the role of exercise therapy in the treatment of limited joint mobility, muscle weakness and reduced gait speed. Ital J Anat Embryol, 120, HOCH, M. C., ANDREATTA, R. D., MULLINEAUX, D. R., ENGLISH, R. A., MEDINA MCKEON, J. M., MATTACOLA, C. G. & MCKEON, P. O Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. J Orthop Res, 30, KALTENBORN, F Manual Mobilisation of the Joints: The Extremeties, Oslo, Orhtopaedic Physical Therapy.