The Effects of a Three-week Exercises Program in Patients with Diabetic Polyneuropathy: Randomized Controlled Trial

Brief name: Exercise program Patients in the intervention group received alpha-lipoic acid intravenously at a dose of 600 mg dissolved in 250 ml of 0.9% sodium chloride solution, administered over 60 minutes once a day for 15 consecutive therapy days, excluding weekends. Additionally, they participated in a 50–60-minute daily exercise program for 15 consecutive therapy days, excluding weekends. The intervention comprised a specific one-on-one kinesiotherapy program consisting of four exercise blocks, each targeting different objectives: (a) increasing foot and ankle range of motion, (b) strengthening foot and ankle muscles, (c) performing functional (balance) exercises and (d) training walking skills and foot rollover. Each session was composed of some of the exercises from the four exercise blocks. Gradual and progressive difficulty is offered to the patient, respecting any limitation due to pain and/or decrease in performance during execution. In addition, in each session, the exercises were performed following an order that starts with the passive exercises, progresses to active, and finishes with walking and functional skills. The exercises were individually adjusted to each patient, guided and supervised by a physiotherapist. The intensity and speed of performing the exercises are adjusted to prevent pain and discomfort during execution. Each exercise was performed for a specified number of repetitions as described below. After the 15 days program patients were advised to continue with the learned exercises during the next 6 months and no other advice or restrictions were provided. Attendance at exercises and all notes are kept in a diary for each patient individually. During follow-up sessions, a questionnaire was filled out regarding how often exercises were performed at home (yes, no, how many times per week). Range of motion improvement exercises: - Passive stretching of the flexors and extensors of the toes and hallux was performed from a long sitting position, with knees extended and ankles in a neutral position. Flexion and extension of the toes and hallux are performed separately. Each stretching exercise is repeated 5 times, with each repetition held for 30 seconds. - The self-stretching of the triceps surae was performed standing, with the contralateral limb positioned ahead, knee bent, and the ipsilateral limb positioned behind, with the foot facing forward. Each exercise position was repeated 5 times, with each repetition held for 30 seconds. Approximate duration: 15-20 minutes. Strengthening foot and ankle muscles exercises: Muscle strengthening exercises for the toes' flexor muscles were performed from a supine lying position using manual resistance. Additionally, exercises for the intrinsic muscles of the foot involved sitting with the foot flat on the floor, gripping an object with the toes. To strengthen the toes' extensor muscles, exercises were done from a supine lying position with manual resistance and from a sitting position with the foot flat, focusing on toe extension without allowing dorsiflexion. Exercises for the flexors, extensors, invertors, and evertors of the foot and ankle were performed from a supine lying position using manual resistance. Standing on heels and toes was also included, performed for 1 set of 30 repetitions, except for standing on heels and toes which was done for 1 set of 20 repetitions. Approximate duration:15 minutes. Functional (Balance) Training: - Standing on one leg with or without upper limb support, based on patient tolerance, performed 5 times for 30 seconds on each side. - Standing on a rubber disc filled with air with support from both legs, performed 5 times for 30 seconds. - Standing on heels and toes, performed 5 times for 30 seconds. Balance training started with eyes open and progressed to eyes closed. Approximate duration: 7 minutes. Gait training: - Walking over the heels, toes, lateral border, and medial border of feet at preferred speed. - Walking in tandem. - Walking with softening of heel and forefoot contact during normal walking. - Walking while actively grabbing the floor with toes. - Walking with normal foot rollover: heel strike, midfoot contact, lateral forefoot, medial forefoot, and hallux contact. Execution: All walking tasks performed in a straight line at preferred speed for 60 meters each. Approximate Duration: 10-15 minutes.