187J Contemp Med Sci | Vol. 6, No. 4, July-August 2020: 187–190 Case Report ISSN 2413-0516 Introduction Diabetes mellitus (DM) is a metabolic disorder characterized by chronic hyperglycemia which is due to alteration in insulin production and its action.1 DM affects multiple systems in our body leading to complications such as retinopathy, nephropa- thy, neuropathy, cardiovascular diseases, and other complica- tions such as infections and cognitive impairment.2 Diabetic foot ulcer (DFU) is one of the major complications following diabetes in an individual that leads to substantial morbidity. Prevalence of DFU in UK is around 7% and USA is 8% and lifetime risk is 15%. In India, around 15% of patients with dia- betes are affected by DFU during their lifespan. Out of this proportion, 50% is infected that requires hospitalization and 20% need amputation in India. DFU alone contributes 80% of non-traumatic amputation and have huge burden in terms of expenses and morbidity.3,4 There are several factors which contribute in the devel- opment of diabetic ulcer; however, neuropathy and ischemia due to peripheral vascular diseases are the major contribut- ing factors. In diabetic patient, production of nerve cell myoi- nositol that regulates normal neural conduction is hampered. This affects all the components of neural functions including motor, sensory and autonomic functions. Deformities such as claw-toe and high arched foot are the result of motor nerve involvement in diabetic patients that results in uneven distri- bution of force in foot, and thus formation of callus and skin breakdown. Dryness of skin and peripheral edema is a result of autonomic dysfunction in diabetic that leads to development of fissured skin. Decreased perception of pain and sensation leads to inability to detect any injury in subjects with diabetes due to which wound goes unnoticed for several duration until it gets worsened. Endothelial dysfunction associated with dia- betes results in atherosclerosis which contributes in decreased blood supply.5-7 Wound healing is a complex process that follows a well-designed pattern of various biological and molecular events. Certain intrinsic factors and extrinsic factors such as neuropathy, vasculopathy, immunity, wound infection, wound cell abnormalities contributes in delayed wound heal- ing in diabetic population. Early detection and intervention is needed in order to enhance healing process in DFU which can also predict the long-term progression.8, 9 Identification of associated risk factors and its management can prevent DFU.10 Several guidelines have been published that provides informa- tion regarding management of diabetic foot ulcer which can be broadly divided into surgical and conservative management. Surgical management includes debridement and amputation. Conservative management includes prescription of protective footwear, pharmacological management of infection and res- toration of perfusion, wound care through regular inspection and debridement, controlling of optimal glucose level, and educating patients regarding self care and management.11-13 Adjunctive therapies such as negative pressure wound ther- apy, hyperbaric oxygen therapy, and electrotherapy along with other physical agents such as ultrasound therapy, ultraviolet ray therapy, low laser therapy have been used to enhance heal- ing of wound.14,15 Matrix rhythm therapy is a therapeutic method developed and improved by Dr. Ulrich Randall that is based on a fact Effect of matrix rhythm therapy in diabetic foot ulcer healing: A case report Varun Naik1, Chandra Bahadur Khatri2*, Ganesh BR1 1Department of Cardiovascular and Pulmonary Physiotherapy, KAHER’s Institute of Physiotherapy, Belagavi, Karnataka, India 2 KAHER institute of Physiotherapy, Nehrunagar, Belagavi, Karnataka, India Corresponding author: Chandra Bahadur Khatri (E-mail: cbkbharat@gmail.com) Abstract Introduction: Diabetic foot ulcer is one of the major complications following diabetes. In India, 15% of diabetic patient develop DFU once in their lifetime. Neuropathy associated with diabetes is a major factor in development of foot ulcer in such patients. Infection, peripheral arterial diseases, altered functions of white blood cells, stem cells and regenerating tissues, and co-morbidities lead to delayed wound healing. Matrix rhythm therapy is a recent advancement in the field of Physiotherapy. It provides external oscillation that activates normal rhythm of cell that is between 8 and 12 Hz which improves cellular function within cell and extracellular matrix, enhancing tissue healing. A 70-year-old female presented with infected diabetic foot ulcer on her right foot in out-patient department of KLE hospital. She had non- healing ulcer since one and half months and undergone conservative treatment of wound care along with strategies of diabetic foot care. Clinical findings: Subject complained of pain with score of 2 at rest and 6 while walking which was recorded on the basis of Visual Analogue Scale. Wound appeared ischemic and non-healing. On wound assessment, size of wound was 12 mm in diameter and 6 mm depth. It was identified as Type D grade I on the basis of classification of wound provided by University of Texas Health Science center. Intervention: Matrix rhythm therapy was applied on posterior aspect of leg region extending around wound area once a week for 5 weeks with treatment duration of 1 h. Result: Pain of the subject after 5 weeks of intervention was 0 at rest and 2 while walking on the basis of VAS. Size of wound decreased with dimension of 6 mm in diameter and 2 mm depth and categorized as Type A grade 1. Conclusion: Matrix rhythm therapy could be considered as adjunct in wound healing of diabetic foot ulcer. Key words: Diabetic foot ulcer, matrix rhythm therapy 188 Case Report Effect of matrix rhythm therapy in diabetic foot ulcer healing: A case report Varun Naik J Contemp Med Sci | Vol. 6, No. 4, July-August 2020: 187–190 that all cells of biological system follow a rhythmic pattern of vibrations when they are living. This conclusion was drawn from a research conducted at Erlangen University in Germany. Matrix rhythm therapy delivers the vibrations ranging from 8 to 12 Hz that mimics normal oscillation that brings changes in cellular level thereby enhancing the function at cellular level (within cell and extracellular matrix).16 Patient information A 70-year-old female presented with open wound on the plan- tar aspect of her right foot which was evident since one-and- half months. She complained pain at the site of wound which is aggravated on walking or weight bearing on same side. She gave the history of trauma due to uneven foot placement on a pebble. She noticed a wound on foot after a week of injury and applied local wound ointment for a month. Wound was increasing in size along with pain during weight bearing. She consulted physician and was referred to physiotherapy depart- ment for further management. Subject gave the history of diabetes and hypertension since 20 years and 30 years, respectively, and under medica- tion. She takes 16 units and 10 units of insulin in the morning and night for the management of diabetes and diuretics and ace inhibitors for hypertension management. She had under- gone coronary artery bypass graft 16 years back. Clinical findings Pain assessment: Visual analogue scale was used to assess pain. It was 2/10 at rest and 6/10 while walking. Wound examination: Size of wound was 12 mm diame- ter with 6 mm of depth which was located lateral aspect of posterior one-third on plantar surface of right foot. Wound appeared dry with calcified vascular tissues. Granulation tis- sues were minimal in appearance. Wound bed was filled with pus suggestive of infection. Diagnostic assessment: Physical examination was carried out along with an X-ray. X-ray findings were normal to the age of the subject. Wound was classified on the basis of diabetic wound clas- sification system provided by The University of Texas Health Science Center. Wound was identified as Type D grade I. Pain was assessed on the basis of visual analogue scale which was recorded as 20 mm on rest and 70 mm on weight-bearing activities. Therapeutic intervention Matrix rhythm therapy was performed on the affected limb. It was applied starting from posterior aspect of knee joint extending around the wound. Treatment was given for 5 ses- sions lasting up to 1 h in each session. Frequency of treatment was 1 session per week. Follow-up and outcomes Outcome measures were recorded in terms of size of the wound, grading of wound and VAS for pain. Subject has fol- lowed up till 1 month after cessation of treatment. Figure 1 shows appearance of wound before and after intervention of Matrix Rhythm Therapy. First follow-up: • VAS: 2 at rest and 6 on walking • Shape of wound: It changed to rectangular shape from circular • Size of wound: length=10 mm, breadth: 6 mm and depth: 5 mm • Grading: Type C, Grade I • Appearance: Ischemic, with partial vasularization of sur- rounding tissues Second follow-up: • VAS: 0 at rest and 5 on walking • Shape of wound: rectangular • Size: length=8 mm, breadth= 8 mm, depth: 5 mm • Grading: Type C, grade I Third follow-up: • VAS: 0 at rest and 3 while walking • Shape of wound: oval • Size: greatest length=8 mm, greatest breadth=5 mm, depth=4 mm • Grading: Type B, grade I Fourth follow up: • VAS: 0 at rest and 2 while walking • Shape of wound: irregular • Size: Greatest length: 6 mm, greatest breadth=4 mm, depth=2 mm • Grading: Type A, grade I No any adverse effects or intolerance was observed or experienced by subject throughout the treatment sessions and follow-ups. At the end of session, wound changed from non-healing ulcer to healing ulcer with vascularization of sur- rounding tissues. Discussion Our study aimed to determine the effects of matrix rhythm therapy on diabetic foot ulcer. Application of matrix rhythm therapy for five sessions, one session a week showed acceler- ated wound-healing process in non-healing diabetic foot ulcer along with decreased pain intensity. This study is novel of its kind which is applied for wound healing, and till now no pub- lished literature is available. DFU is of the major complications that lead in disability and decreased quality of life in diabetic population. Multiple approaches have been applied for the prevention and manage- ment of DFU but effective approach that enhances healing of ulcer is not established. Several physical modalities such as low level laser, ultraviolet radiation, electrical stimulation have been used in management of wound but most of the studies lack quality of evidence and physiological basis for wound healing.15 Most of the studies related to the physiotherapy approaches in wound healing have used multiple therapeutic methods which lead overlapping of physiological effects and results cannot be specified to a particular method.17, 18 In our study, we have used only matrix rhythm therapy and its effect on wound can be specified. 189 Case Report Effect of matrix rhythm therapy in diabetic foot ulcer healing: A case reportVarun Naik J Contemp Med Sci | Vol. 6, No. 4, July-August 2020: 187–190 Use of vibrations as interventions for therapeutic benefit has history since 19th century. Vibrations has been used for management of neurological conditions, increasing power and flexibility in athletes, maintenance of bone density in astro- nauts, and recently it has been used to enhance wound-healing process. A study was done in regarding the effect of vibration in healing process in diabetic mice. It has been found that vibrations produces stimulus that helps in release of growth factors, stem cell proliferation, and cell differentiation when applied to bone. In wound, it increases angiogenesis, forma- tion of granulation tissues, and promotes the accumulation of macrophages, fastens the wound closure, and re-epitheli- alization. They also found that there is decrease in number of neutrophils cells in wound that decreases the inflamma- tory conditions within wound. Similarly, there was decrease in blood glucose levels and increase in microcirculation after application of vibrations.20,21 In these, studies the frequency of vibrations applied was 35–45 Hz compared to physiological oscillations/vibrations in our study. Though one of study on effects of vibrations in blood flow in healthy inactive subjects showed that vibration is responsible for increase in blood sup- ply, there are very limited studies related to role of vibrations in wound healing in diabetic subjects.22 In our study, wound healing in DFU is accelerated that can be possibly due to cellular effect of vibrations produced by the application of matrix rhythm therapy. Matrix rhythm therapy produces oscillations of 8–12 Hz in cells that mim- ics the normal rhythmic oscillations when cells are alive. In diseased condition, normal rhythmic oscillations are affected thereby impairing functions within cells and its surrounding environment, i.e., extracellular matrix. Following applica- tion of this therapeutic approach normal oscillations can be restored leading to normal function of cell and its environ- ment.19 Similarly, application of matrix rhythm therapy leads to increased circulation which was observed in a study done in athletes. In their study, they compared the effects on cir- culation by using conventional massage with matrix rhythm therapy. They concluded that, matrix rhythm therapy leads to 190 Case Report Effect of matrix rhythm therapy in diabetic foot ulcer healing: A case report Varun Naik J Contemp Med Sci | Vol. 6, No. 4, July-August 2020: 187–190 This work is licensed under a Creative Commons Attribution-NonCommercial 3.0 Unported License which allows users to read, copy, distribute and make derivative works for non-commercial purposes from the material, as long as the author of the original work is cited properly. https://doi.org/10.22317/jcms.v6i4.774 increase in circulation through compression effect and soft tis- sue mobilization along with contraction of muscles produced by stimulation of tonic vibration reflex.23 There are certain limitations of the study despite being first of its kind to intervene matrix rhythm therapy. More emphasis would have been given in detailed objective exam- ination of diabetic foot ulcer and intervention frequency was less which could have been increased. In future, more number of patients can be involved as to develop a case series and can be compared with other physical modalities. In conclusion, matrix rhythm therapy may be used as an adjunctive therapy for wound healing in diabetic foot ulcer. It could be beneficial in not only enhancing healing of wound but also overall improvement on functions of cell and its envi- ronment thereby creating optimal atmosphere. Informed consent: Was duly obtained from subject regarding recoding and publication of data Source of Funding: Nil Conflict of Interest: Nil References 1. World Health Organization. Definition, diagnosis and classification of diabetes mellitus and its complications: Report of a WHO consultation. Part 1, Diagnosis and classification of diabetes mellitus. Geneva: World health organization; 1999. 2. Nathan DM. Long-term complications of diabetes mellitus. New Engl J Med. 1993 Jun 10;328(23):1676-85. 3. Jeffcoate WJ, Harding KG. Diabetic foot ulcers. 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