Joseph W. LeMaster

Comprehensive Foot Examination and Risk Assessment A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists

It is now 10 years since the last technical review on preventative foot care was published (1), which was followed by an American Diabetes Association (ADA) position statement on preventive foot care in diabetes (2). Many studies have been published proposing a range of tests that might usefully identify patients at risk of foot ulceration, creating confusion among practitioners as to which screening tests should be adopted in clinical practice. A task force was therefore assembled by the ADA to address and concisely summarize recent literature in this area and then recommend what should be included in the comprehensive foot exam for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists. The lifetime risk of a person with diabetes developing a foot ulcer may be as high as 25%, whereas the annual incidence of foot ulcers is ∼2% (3–7). Up to 50% of older patients with type 2 diabetes have one or more risk factors for foot ulceration (3,6). A number of component causes, most importantly peripheral neuropathy, interact to complete the causal pathway to foot ulceration (1,3–5). A list of the principal contributory factors that might result in foot ulcer development is provided in Table 1. View this table: Table 1— Risk factors for foot ulcers The most common triad of causes that interact and ultimately result in ulceration has been identified as neuropathy, deformity, and trauma (5). As identification of those patients at risk of foot problems is the first step in preventing such complications, this report will focus on key components of the …

Effect of Weight-Bearing Activity on Foot Ulcer Incidence in People With Diabetic Peripheral Neuropathy: Feet First Randomized Controlled Trial

Background: Weight-bearing exercise has been contraindicated among people with diabetic peripheral neuropathy (DM+PN). However, recent cohort studies have suggested that daily weight-bearing activity is associated with lower risk for foot ulceration. Objective: The objective of this study was to determine the effect of a lower-extremity exercise and walking intervention program on weight-bearing activity and foot ulcer incidence in people with DM+PN. Design: This was an observer-blinded, 12-month randomized controlled trial. Setting: The settings were physical therapy offices in part 1 of the intervention and the community in part 2 of the intervention. Participants: The participants were 79 individuals with DM+PN who were randomly assigned either to a control group (n=38) or an intervention group (n=41) group. Intervention: Intervention components included leg strengthening and balance exercises; a graduated, self-monitored walking program (part 1); and motivational telephone calls every 2 weeks (part 2). Both groups received diabetic foot care education, regular foot care, and 8 sessions with a physical therapist. Measurements: Total and exercise bout–related daily steps at baseline and at 3, 6, and 12 months were measured by accelerometers. Foot lesions/ulcers were photographed and classified by an independent panel of dermatologists. Use of adequate footwear was monitored. Results: At 6 months, bout-related daily steps increased 14% from baseline in the intervention group and decreased 6% from baseline in the control group. Although the groups did not differ statistically in the change in total daily steps, at 12 months steps had decreased by 13% in the control group. Foot ulcer rates did not differ significantly between groups. Conclusion: Promoting weight-bearing activity did not lead to significant increases in foot ulcers. Weight-bearing activity can be considered following adequate assessment and counseling of patients with DM+PN.

Metabolic effects of interventions to increase exercise in adults with type 2 diabetes

Aims/hypothesisThe aim of this meta-analysis was to integrate the results of primary research testing the effect of diabetes self-management interventions that included recommendations to increase exercise on metabolic outcomes among adults with type 2 diabetes.Materials and methodsExtensive literature searching strategies were used to identify published and unpublished intervention studies that measured glycated haemoglobin outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses.ResultsData were synthesised across 10,455 subjects from 103 research reports. The overall mean weighted effect size for two-group comparisons was 0.29 (higher mean for treatment than control). This effect size is consistent with a difference in HbA1c means of 0.45% (e.g. 7.38% for treatment subjects vs 7.83% for control subjects). For single-group studies, the overall mean weighted effect size was 0.32–0.34. Control group subjects experienced no improvement in metabolic control during participation in the studies. Interventions that targeted multiple health behaviours resulted in smaller effect size estimates (0.22) than interventions that focused only on exercise behaviours (0.45). Funded studies reported greater improvements in metabolic controls. Studies with a greater proportion of female subjects reported lower effect sizes. Baseline HbA1c and BMI were unrelated to metabolic outcomes.Conclusions/interpretationThese findings suggest that self-management interventions that include exercise recommendations improve metabolic control, despite considerable heterogeneity in the magnitude of the intervention effect. Interventions that emphasise exercise may be especially effective in improving metabolic control. Primary research testing interventions in randomised trials to confirm causal relationships would be constructive.

Motivation and diabetes self-management

Objective: To examine the relationship between autonomous motivation and diabetes self-care activities among individuals with diabetes. Methods: Seventy-seven individuals recruited from outpatient clinic registries (64% female, 77% Caucasian, mean age 63 years) completed measures of diabetes-related self-care (Summary of Diabetes Self-care Activities), motivation (Treatment Self-regulation Questionnaire), health literacy (Rapid Estimate of Adult Literacy in Medicine, Newest Vital Sign), health (SF-36v2), social support (Social Support Survey) and self-efficacy (Perceived Competence Scale). Results: Autonomous motivation was the only variable significantly associated with maintaining diet (p<0.0001) and blood glucose testing (p<0.04) in regression analyses. No significant associations were identified for exercise. The variable of age approached significance (p = 0.06), with older individuals being less likely to have exercised in the past week. Discussion: Individuals in this study had difficulty in maintaining self-care demands, especially exercise. Meeting recommended levels of self-care activity was challenging, even for patients with adequate levels of health literacy. Individuals with higher levels of autonomous motivation reported higher frequencies for maintaining diet and testing blood glucose, however, which supports the utility of Self-Determination Theory in promoting diabetes self-care.

Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial.

OBJECTIVE To determine the effects of weight-bearing (WB) versus nonweight-bearing (NWB) exercise for persons with diabetes mellitus (DM) and peripheral neuropathy (PN). DESIGN Randomized controlled trial with evaluations at baseline and after intervention. SETTING University-based physical therapy research clinic. PARTICIPANTS Participants with DM and PN (N=29) (mean age ± SD, 64.5±12.5y; mean body mass index [kg/m(2)] ± SD, 35.5±7.3) were randomly assigned to WB (n=15) and NWB (n=14) exercise groups. All participants (100%) completed the intervention and follow-up evaluations. INTERVENTIONS Group-specific progressive balance, flexibility, strengthening, and aerobic exercise conducted sitting or lying (NWB) or standing and walking (WB) occurred 3 times a week for 12 weeks. MAIN OUTCOME MEASURES Measures included the 6-minute walk distance (6MWD) and daily step counts. Secondary outcome measures represented domains across the International Classification of Functioning, Disability and Health. RESULTS The WB group showed greater gains than the NWB group over time on the 6MWD and average daily step count (P<.05). The mean and 95% confidence intervals (CIs) between-group difference over time was 29m (95% CI, 6-51) for the 6MWD and 1178 (95% CI, 150-2205) steps for the average daily step count. The NWB group showed greater improvements than the WB group over time in hemoglobin A1c values (P<.05). CONCLUSIONS The results of this study indicate the ability of this population with chronic disease to increase 6MWD and daily step count with a WB exercise program compared with an NWB exercise program.

Comprehensive foot examination and risk assessment

Ten years have elapsed since the last American Diabetes Association (ADA) technical review on preventive foot care was published (1), which was followed by an ADA position statement on preventive foot care in diabetes (2). Numerous published studies have proposed a range of tests that might usefully identify patients at risk for foot ulceration, creating confusion among practitioners about which screening tests should be adopted in clinical practice. Therefore, a task force was assembled by the ADA to review and provide a concise summary of the recent literature in this area and then recommend what factors should be included in the comprehensive foot examination for adult patients with diabetes. The committee was cochaired by the immediate past and current chairs of the ADA Foot Care Interest Group (A.J.M.B. and D.G.A.), with other panel members representing primary care, orthopedic and vascular surgery, physical therapy, podiatric medicine and surgery, and the American Association of Clinical Endocrinologists.

Bike, Walk, and Wheel: A Way of Life in Columbia, Missouri, Revisited

BACKGROUND In 2003, Columbia MO was the recipient of a Robert Wood Johnson Foundation (RWJF) Active Living by Design (ALbD) grant to foster active living in the community through behavioral (social marketing, education) and environmental change (improved street design standards, sidewalks around schools, activity-friendly infrastructure) strategies. PURPOSE To examine the extent to which the ALbD intervention was associated with increased active living in children and adults community-wide. METHODS Seasonal pedestrian and bicyclist counts were performed quarterly in January, April, July, and October at four intersections in downtown Columbia from 2007 to 2009. RESULTS Pedestrian counts increased significantly during July 2009 and October 2009 compared to 2007 and 2008, whereas cyclist counts increased significantly during only July 2009 compared to 2007 and 2008. CONCLUSIONS The ALbD intervention in Columbia was associated with modest increases in active living in the community, and continued evaluation of these behavior patterns is warranted. The combination of multiple strategies (social marketing, local programming, and infrastructure changes) may be a critical factor in improving active living in communities.

Updating public health teaching methods in the era of social media.

Julie M. Kapp, MPH, PHDab Joseph W. LeMaster, MD, MPHa M. Boden Lyon, MEdc Beilei Zhang, MSd Michael C. Hosokawa, EdD* Web 2.01 describes the interactive, collective intelligence of todays Internet experience. Web-based information technologies, such as social media, enhance public health practice through the accelerated dissemination of health promo tion and disease detection information. Social media sites such as YouTube

Safety of Aerobic Exercise in People With Diabetic Peripheral Neuropathy: Single-Group Clinical Trial

Background Exercise is recommended for people with diabetes, but little is known about exercise in people with diabetic peripheral neuropathy (DPN). Objective The primary purpose of this preliminary study was to examine adverse events (AEs) during moderate-intensity, supervised aerobic exercise in people with DPN. The secondary purpose was to examine changes in fatigue, aerobic fitness, and other outcomes after intervention. Design This was a single-group preliminary study. Setting The setting was an academic medical center. Participants Participants were 18 people who were sedentary and had type 2 diabetes and peripheral neuropathy (mean age=58.1 years, SD=5). Intervention The intervention was a supervised 16-week aerobic exercise program (3 times per week at 50% to >70% oxygen uptake reserve). Measurements Adverse events were categorized as related or unrelated to the study, anticipated or unanticipated, and serious or not serious. Outcomes included fatigue (Multidimensional Fatigue Inventory), cardiovascular fitness (peak oxygen uptake), body composition (dual-energy x-ray absorptiometry), sleep quality, plasma metabolic markers, and peripheral vascular function. Results During the study, 57 nonserious AEs occurred. Improvements were found in general fatigue (mean change=−3.5; 95% confidence interval [95% CI]=−1.3, −5.3), physical fatigue (mean change=−3.1; 95% CI=−1.2, −5.0), peak oxygen uptake (mean change=1.1 mL·kg−1·min−1; 95% CI=0.2, 1.9), total body fat (mean change=−1%; 95% CI=−0.3, −1.7), fat mass (mean change=−1,780 g; 95% CI=−616.2, −2,938.7), and peripheral blood flow (mean change=2.27%; 95% CI=0.6, 4.0). Limitations This was a small-scale, uncontrolled study. A future randomized controlled trial is needed to fully assess the effects of exercise on the outcomes. Conclusions This study provides new support for supervised aerobic exercise in people with DPN. However, it is important for physical therapists to carefully prescribe initial exercise intensity and provide close monitoring and education to address the anticipated AEs as people who are sedentary and have DPN begin an exercise program.

A Walking School Bus program: impact on physical activity in elementary school children in Columbia, Missouri

BACKGROUND The Robert Wood Johnson Foundation (RWJF) provided Columbia MO with an Active Living by Design (ALbD) grant in 2003 to promote active living in the community. A separate project was funded in 2006 through RWJFs Active Living Research program. PURPOSE To evaluate whether participation in a Walking School Bus (WSB) program increased or decreased active living in elementary school children residing in Columbia, in association with ALbD funding. METHODS Objective measures of physical activity obtained using accelerometers were collected over 7 days in children participating in a WSB program and children in a nonparticipating comparison group. Differences in the percentage of time spent in moderate- to vigorous-intensity exercise (%MVPA) were compared between groups. RESULTS Children in WSB programs showed no differences in %MVPA compared to children not participating in the WSB; however, when comparing the relationship of %MVPA and age, the slope of the regression line was steeper for those children not participating in the WSB. CONCLUSIONS The ALbD intervention in Columbia did not result in measurable changes in physical activity in children participating in the Walking School Bus program, but there was a negative association between age and physical activity, and the slope of that regression line was affected by participation in the program.