CDC Looks At Exercise Limitations Among People With Diabetes And Arthritis

Brian McCurdy, Senior Editor

Getting patients with diabetes to exercise may be an uphill battle due to disease concerns. The combination of arthritis with diabetes can be an additional barrier to activity, according to a large survey conducted by the Centers for Disease Control and Prevention (CDC).
The CDC utilized 2005 and 2007 data from the Behavioral Risk Factor Surveillance System (BRFSS), which surveyed hundreds of thousands of people across the United States and its territories. The BRFSS survey indicated that the prevalence of arthritis in adults diagnosed with diabetes was 52 percent. Furthermore, researchers say the prevalence of physical inactivity was 28.9 percent among adults with diabetes and arthritis in comparison to 21 percent in adults with diabetes alone. The BRFSS survey notes that association was independent of age, sex or body mass index (BMI).
The study emphasizes that inactive people with diabetes who become more active benefit from improved physical function and glucose tolerance. However, researchers say such patients also face the same common barriers to being more physically active as most adults face.These barriers include a lack of time, competing responsibilities, lack of motivation and difficulty finding an enjoyable activity.
For people with arthritis, there are additional disease-specific barriers, according to the study. These barriers include patient concerns about potentially aggravating arthritis pain or causing further joint damage, as well as apprehension about which types and amounts of activity are safe for their joints.

Exploring Fitness Options For Patients With Diabetes And Arthritis
Researchers suggest that healthcare providers recommend exercise programs that are specific to arthritis or evidencebased self-management and exercise programs. Cherri Choate, DPM, advocates water exercises, which are non-weightbearing and decrease the pull of gravity for the patient. As she notes, more gyms and senior centers have water exercise programs like aqua aerobics and aqua cross-training.
For patients with diabetes and arthritis, Babak Baravarian, DPM, says lowimpact exercises would be safe. He notes that such exercises reduce both the chance for diabetes-related injury and the risk of arthritic pain. Dr. Baravarian also cites the efficacy of a recumbent bike, saying patients can raise their heart rate safely while putting little weight on the foot, knees and lower back.
Dr. Choate also recommends a recumbent bike or flat walking combined with light weights. In addition, she strongly suggests Pilates, which strengthens, stretches and tones patients so the body is better conditioned to handle weightbearing cardio activities.
“With a lack of activity, patients often will feel a level of depression for many reasons,” says Dr. Baravarian.“These reasons include a feeling of being handicapped, a feeling of remorse for their medical ailments and a feeling of less self-worth.”
Research has shown that the release of endorphins into the body increases psychological well being after exercise, according to Dr. Baravarian, an Assistant Clinical Professor at UCLA School of Medicine
“The depression related to chronic disease is overwhelming and often under-recognized,” says Dr. Choate, an Adjunct Assistant Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. “The benefit of exercise is that it actually helps relieve some of the depression that many of these patients experience.”


What Is The Best Approach To Patellofemoral Pain Syndrome?
by Brian McCurdy, Senior Editor

What is the best treatment for patellofemoral pain syndrome (PFPS)? An abstract presented at the recent American College of Sports Medicine conference examined the impact of orthoses and physical therapy for this condition.
For the abstract, researchers assessed 179 people with patellofemoral pain syndrome and randomized them into four treatment groups: flat-shoe (placebo) inserts, orthoses, physical therapy or orthoses plus physical therapy. Follow-up visits occurred at six, 12 and 52 weeks.
At six weeks, patients showed significantly greater improvements with the combination of foot orthoses and physical therapy, and physical therapy alone in comparison to placebo inserts, according to the abstract. Findings were similar at 12 weeks. Furthermore, the study notes that patients who had the least amount of pain were in the group that had orthoses and physical therapy, although combining the two treatments only affected the condition minimally in the short term. The researchers noted that the pain “leveled out” in all groups at 52 weeks.

Keys To Diagnosing And Treating PFPS
Once one has diagnosed PFPS, David Levine, DPM, CPed, says appropriate treatment depends on several variables, including the patient’s size and weight, activity level, activities, footwear and orthotics.
In general,Dr. Levine advocates modifying activities that lead to the exacerbation of symptoms. For athletes who need to keep fit, even while they are injured, he says one should consider cross-training with an activity that does not cause pain. Successful tactics include stretching, consistent ice application and strengthening exercises, according to Dr. Levine, who is in private practice in Frederick, Md.
In addition, he says it is helpful to conduct a biomechanical exam that includes a gait analysis in order to identify the biomechanical factors that may be contributing to the problem. The abstract was problematic in this regard according to Dr. Levine, who says there was a lack of detail about any biomechanical factors the authors observed.
For patients with PFPS, Dr. Levine says treatment should be conservative and comprehensive. Dr. Levine says the treatment plan should include orthotics and emphasizes a “heightened attention to footwear.” Dr. Levine adds that the abstract authors did not discuss the type of orthosis they used or its fabrication.
To treat PFPS, Doug Richie Jr., DPM, uses a combination of physical rehabilitation and orthotic therapy.
“This study reaffirms our experience that foot orthoses can be a significant adjunct to physical therapy in the treatment of patellofemoral pain syndrome,” says Dr. Richie, an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College.
As Dr. Richie notes, most clinicians would never advocate foot orthoses alone as the primary treatment for PFPS. On the other hand, many therapists and orthopedic surgeons advocate physical therapy alone as the primary treatment and overlook the role of abnormal foot function in the pathomechanics of the disorder, according to Dr. Richie.

Study Addresses Ulcer Recurrence After TMA And TAL
by Brian McCurdy, Senior Editor
A recent study in the Journal of Foot and Ankle Surgery (JFAS) examines how to prevent ulcer recurrence in patients who have undergone a tendo-Achilles lengthening (TAL) after a transmetatarsal amputation (TMA).
Researchers reviewed patient charts for 28 patients with ulcers who had been treated over a 12-year period. Patients had undergone TAL for neuropathic ulcers following transmetatarsal amputation.The study notes patients healed in an average of 9.4 weeks after the TAL procedure.
Out of the 28 patients, authors found that 10 had recurrent ulcers while six developed new ulcers in a different location, five in the heel and one in the sub-fifth metatarsal stump. What explains the rate of recurrence?
The JFAS study cites previous research indicating that percutaneous TALs affect peak plantar pressure and range of motion. The JFAS authors recommend addressing intrinsic and extrinsic factors to prevent ulcer recurrence. They suggest that surgeons performTAL for neuropathic ulcers as an adjunctive procedure in concert with correction of the deformity, appropriate shoegear and patient education.The study authors also advocate careful post-op monitoring in clinics where patients commonly undergo TAL for ulcer treatment.

Pertinent Tips On Ulcer Prevention And Proper Patient Selection
How can one effectively prevent ulcer recurrence after TAL and an amputation? Study author Javier La Fontaine, DPM, says the most effective prevention method is applying a posterior splint immediately after surgery. Doing so will prevent equinus and accordingly prevent ulcer recurrence, explains Dr. La Fontaine, an Assistant Professor at the University of Texas Health Science Center Department of Orthopedics.
In certain patients, he says one may need to include an ankle-foot orthotic in an extra depth shoe.
As for screening methods, Dr. La Fontaine suggests ruling out osseous equinus, bone hypertrophy and appropriate metatarsal parabola.
“I found that in very short TMAs, the TAL as a single procedure is not effective because the lateral part of the foot becomes the only weightbearing surface,” points out Dr. La Fontaine.
Dr. La Fontaine says future studies should focus on the amount of dorsiflexion required to prevent ulcer recurrence. He says researchers should assess other factors, such as activity level or postop shoes, to see if they contribute to ulcer recurrence. Dr. La Fontaine also says future studies should explore whether physicians can accomplish the same results with gastroc recession as those surgeons obtain with the combination of amputation and TAL.

Study Examines Insole Properties For Patients With Diabetes
by Brian McCurdy, Senior Editor

When it comes to choosing insoles for patients with diabetes, special considerations may be appropriate due to the extent of the disease. A recent study in the Journal of the American Podiatric Medical Association (JAPMA) examines common insole materials and evaluates their efficacy.
Researchers studied 30 cellular polymeric materials that are commonly utilized in insole fabrication. The study authors discovered that certain EVA and polyethylene foams with low hardness are the most beneficial materials when it comes to adaptation or accommodation.The authors point out that these materials “conform to the foot in the insole and homogenize the plantar pressures.”
Polyurethane foams are best for cushioning due to their low resilience, according to the study. The study authors also note that latex foams may be an alternative to polyurethane.
When it comes to properties like hardness, compression set and compression fatigue, study authors say one can know the general performance of a combination of materials by knowing the performance of the component materials. This in turn should provide with more objective criteria to select materials, according to the study authors.
What are the most important characteristics to examine when choosing insoles for patients with diabetes? Patrick Nunan, DPM, suggests asking if the insole can mold to the patient’s foot and if the patient feels comfortable. He says the insole also should fit the entire plantar aspect of the foot and not just the shape of the shoe. Dr. Nunan says a combination of Plastazote and EVA best fits those characteristics.
Dr. Nunan suggests a few changes that insole manufacturers might make to serve patients better. He reiterates that the insoles should be wider to cover the whole foot and the shoes would need to be wider as well.The profession also needs insoles that are available in different densities, according to Dr. Nunan, a Fellow of the American College of Foot and Ankle Surgeons.
“One size does not fit all,” he says. “There is a difference between a 120- pound diabetic and a 400-pound diabetic as far as force on the foot.”


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