Mobilisations of joint restrictions in Diabetes

Mr Vasileios Lepesis

MSc, PGCert Manual Therapy, FHEA

HCPC Reg. Physiotherapist & Podiatrist

Diabetes

• Why joint restrictions?

• Why joint mobilisations?

• What are the musculoskeletal complications of Diabetes?

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)

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

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)

Diagnosis of LJMS – table top

(Abourazzak et al., 2014)

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 1st MTPJ ROM (Zimny et al., 2004; Giacomozzi et al., 2005); 1st MTPJ dorsiflexion (Turner et al., 2007; Wrobel et al., 2003)

LJMS and changes in gait and foot rollover

• Ankle stiffness (equinus) affects the 2nd rocker in preserving forward momentum

• 1st MTPJ stiffness affects the 3rd rocker in preserving forward momentum and passive toe off

(Sacco et al., 2009)

LJMS in the foot and ankle and evidence of increased ulceration risk

Ankle and 1st 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)

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 (2nd to glycosylation)• Joint stiffness/capsular restriction (2nd to glycosylation)• Muscle weakness (ankle, knee)/atrophy (distal and mid leg)/activation delay (tib ant, gastrocs)

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)?

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”

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”

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”

Evidence on manual therapy…

Foot and Ankle Mobilisation in Diabetic Peripheral Neuropathy: randomised controlled trial

IRAS Project ID: 228115 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

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 Pressures4. Improves Balanceand to determine the relationship between these outcome measures

Practical session

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

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

Joint mobilisationManual 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)

Video of ankle joint moving

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)

Treatment: Grades of movement

I Small-amplitude movement, short of resistance

II Large-amplitude movement, short of resistance

I II Large amplitude movement, into resistance

IV Small-amplitude movement, into resistance(Maitland, 2005 & Petty, 2004)

Pain

Stiffness

Grades of movement

I

II

III

IV

Beginning of ROM End of ROM (resistance)

I

II

III

IV

Beginning of ROM End of current ROM (resistance)

End of normal ROM

Grades of movement

Indications & contraindications

Contraindications Non-mechanical pain/Signs of serious pathology/medical history

Cancer

Osteoporosis

Active RA

Red Flags

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

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

Concave-convex rule

Exelby (1996)

Concave – convex rule

• To increase ankle joint DF – therapist needs to apply a AP (anterior to posterior direction) glide of talus on ankle mortise

Concave – convex rule

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

References

• ABATE, M., SCHIAVONE, C., PELOTTI, P. & SALINI, V. 2011. Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus. Arch Gerontol Geriatr, 53, 135-40.

• AVERY, N. C. & BAILEY, A. J. 2005. Enzymic and non-enzymic cross-linking mechanisms in relation to turnover of collagen: relevance to aging and exercise. Scand J Med Sci Sports, 15, 231-40.

• DELBRIDGE, L., PERRY, P., MARR, S., ARNOLD, N., YUE, D. K., TURTLE, J. R. & REEVE, T. S. 1988. Limited joint mobility in the diabetic foot: relationship to neuropathic ulceration. Diabet Med, 5, 333-7.

• FERNANDO, D. J., MASSON, E. A., VEVES, A. & BOULTON, A. J. 1991. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care, 14, 8-11.

• GERRITS, E. G., LANDMAN, G. W., NIJENHUIS-ROSIEN, L. & BILO, H. J. 2015. Limited joint mobility syndrome in diabetes mellitus: Aminireview. World J Diabetes, 6, 1108-12.

• UPRETI, V., VASDEV, V., DHULL, P. & PATNAIK, S. K. 2013. Prayer sign in diabetes mellitus. Indian Journal of Endocrinology and Metabolism,17, 769-770.

• ABOURAZZAK, F. E., AKASBI, N., HOUSSAINI, G. S., BAZOUTI, S., BENSBAA, S., HACHIMI, H., AJDI, F. & HARZY, T. 2014. Articular and abarticular manifestations in type 2 diabetes mellitus. Eur J Rheumatol, 1, 132-134.

References cont.

• TURNER, D. E., HELLIWELL, P. S., BURTON, A. K. & WOODBURN, J. 2007. The relationship between passive range of motion and range of motion during gait and plantar pressure measurements. Diabetic Medicine, 24, 1240-1246.

• MALUF, K. S. & MUELLER, M. J. 2003. Novel Award 2002. 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, 567-75.

• GIACOMOZZI, C., CASELLI, A., MACELLARI, V., GIURATO, L., LARDIERI, L. & UCCIOLI, L. 2002. Walking strategy in diabetic patients with peripheral neuropathy. Diabetes Care, 25.

• ZIMNY, S., SCHATZ, H. & PFOHL, M. 2004. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care, 27, 942-6.

• SACCO, I., HAMAMOTO, A., GOMES, A. A., ONODERA, A., HIRATA, R. & HENNIG, E. 2009. Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy. Clin. Biomech., 24, 687-692.

References cont.

• SARTOR, C. D., HASUE, R. H., CACCIARI, L. P., BUTUGAN, M. K., WATARI, R., PÁSSARO, A. C., GIACOMOZZI, C. & SACCO, I. C. 2014. 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, 1-13.

• FRANCIA, P., ANICHINI, R., DE BELLIS, A., SEGHIERI, G., LAZZERI, R., PATERNOSTRO, F. & GULISANO, M. 2015. 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, 21-32.

• HOCH, M. C., ANDREATTA, R. D., MULLINEAUX, D. R., ENGLISH, R. A., MEDINA MCKEON, J. M., MATTACOLA, C. G. & MCKEON, P. O. 2012. Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. J OrthopRes, 30, 1798-804.

• KALTENBORN, F. 2011. Manual Mobilisation of the Joints: The Extremeties, Oslo, Orhtopaedic Physical Therapy.