008 Layout SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 27 BACKGROUND Diabetes and its complications are significant causes of morbidity and mor- tality in the world. The South African national burden of disease study, 2000, ranks the top 20 diseases contributing to the greatest disease burden (Bradshaw et al, 2000). Diabetes mellitus is twelfth in the rank of diseases responsible for premature death and sixteenth as a cause of disability adjusted life years (Bradshaw et al, 2000). Among the most common of the long-term compli- cations of diabetes, are those affecting the peripheral nervous system. Diffuse symmetrical sensory motor neuropathy occurs in Insulin Dependent, Non-Insulin Dependent and in the secondary forms of diabetes (Boulton et al, 2004). Reported prevalence ranges between 10 – 90% of an unselected diabetic popu - lation and diabetic neuropathy increases with worsening hyperglycaemia. Symmetrical sensory loss in the distal lower extremities is the most common manifestation of diffuse sensory motor neuropathy. Nerve loss affects small unmyelinated and myelinated fibres first, causing a reduction in pain and temperature sensation (Boulton et al, 2004). Distal symmetrical polyneuropathy is one of the most important predictors of ulcers and amputation due to atrophy and weakness of the small foot muscles which change the biomechanical proper- ties of the feet, resulting in increased foot pressures during weight bearing (American Diabetes Association, 2001a). Older persons with peripheral neuro - pathy are at an increased risk for falls due to postural instability when com- pared to older persons with healthy peripheral nerves (Richardson et al, 2001). The same authors identified that the causes of postural instability in older persons with peripheral neuropathy are distal sensory and motor impairments. The strength of the ankle and knee extensors and flexors, and the move- ments of the ankle have been found to be moderately impaired in long- term Insulin Dependent and Non-Insulin Dependent Diabetes Mellitus patients (Boulton et al, 2004). All these changes lead to an abnormal walking pattern in neuropathic patients. They demonstrate a shift from physiological ankle control The effects of isometric exercises and stretching on postural stability in Non–Insulin Dependent Diabetes Mellitus patients with diffuse symmetrical sensory motor neuropathy R e s e a r c h A r t i c l e A BST R A CT: The purpose of this study was to explore the effects of isometric exercis- es and stretching on postural stability in Non – Insulin Dependent Diabetes Mellitus (NIDDM) patients with diffuse symmetrical sensory motor neuropathy. Patients were assigned to an experimental group and a matched control group. The experimental group received isometric exer- cises and stretching three times weekly for 12 weeks in addition to routine medication and dietary advice. A t the end of this period, this group was compared with the control group, which received routine medication and dietary advice only. Measurements of muscle strength of quadriceps, ham- strings, ankle plantar and dorsiflexors, and Romberg’s test for postural sta- bility were carried out before and after the 12 weeks intervention. The study showed that isometric exercises and stretching for the lower extremities improved postural stability (p = 0.00) and strength of the quadriceps (p = 0.001) hamstrings (p = 0.001) dorsiflexors (p = 0.001) plantarflexors (p = 0.001) in NIDDM patients with diffuse symmetrical sensory motor neuropathy. This exercise regimen also had a lowering effect on blood glucose level (p = 0.00). In conclusion it seems that the simple exercise intervention described in this study may be of benefit to these patients if incorporated into their management programmes. KEY W ORDS: DIA BETIC PERIPHERA L NEUROPATHY ; ISOMETRIC EX ERCISE; STRETCHING; POSTURA L STA BILITY Nenkova S, MSc (Physiotherapy)1; Stewart A, PhD2; Potterton J, PhD2; Becker P, PhD3 1 Department of Physiotherapy, Middelburg Hospital, Private Bag X1812, Middelburg, 1050, South Africa. 2 Department of Physiotherapy, School of Therapeutic Sciences, Faculty of Health Sciences University of the Witwatersrand, Johannesburg, South Africa. 3 Medical Research Council, Pretoria. Correspondence to: Prof A Stewart Physiotherapy Department School of Therapeutic Sciences Faculty of Health Science University of the Witwatersrand 7 York Rd, Parktown Johannesburg 2193 28 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 to hip postural control (Giacomini et al, 1996). Diabetic patients with sensory motor neuropathy use hip postural con- trol due to the loss of proprioceptive inputs from the ankle joints. Although the metabolic effects of exercise on diabetes have been inves - tigated thoroughly (American Diabetes Association 2001c), there is very little documented about the effect of exercise on postural stability in patients with diabetic neuropathy. It is not known whether isometric exercises and stretch- ing will improve balance and postural stability in patients with distal symme - trical sensory motor neuropathy. METHOD Study design This was a prospective, experimental study with an experimental and a matching control group that fitted the inclusion criteria listed below. The control group was matched for the stage of neuropathy and as far as possible for gender and age. Subjects A convenience sample meeting the inclusion criteria listed below was drawn from the Middelburg General Hospital chronic diseases clinic, Mpumalanga Province and “St. Joseph” Old Age Home (Middelburg) South Africa. Ethical clearance was obtained from the Committee for Research on Human Subjects (Medical) of the University of the Witwatersrand, Johan - nesburg. All subjects gave consent to participate in the study. Inclusion criteria: - Subjects between 40 – 70 years old - Female and male - Non – Insulin Dependent Diabetes Mellitus - Diffuse symmetrical sensory motor neuropathy - Ability to walk without assistance or a walking aid - Strength of knee and ankle muscles grade 3 (antigravity) or greater by manual muscle testing Exclusion criteria: - Uncontrolled diabetes mellitus (fluctuating blood glucose levels: less than 5.5 mmol/l and more than 14 mmol/l (99 and 252 mg/dl) - Retinopathy - Coronary artery disease and a his- tory of angina or angina – equiva- lent symptoms - Uncontrolled hypertension (systolic > 160 mmHg and diastolic > 90 mmHg) - Autonomic neuropathy - A history of central nervous system dysfunction i.e. hemiparesis, myelo- pathy, cerebellar ataxia - Musculoskeletal deformity: ampu- tation, scoliosis, and inability to actively move ankle and knee joints in all directions - Lower extremity arthritis or pain that limited standing - A history or evidence on physical examination of vestibular dysfunc- tion - Foot ulcer at the time of examination Sample size A sample size of 20 per group gave a power of 80% using a change in Romberg’s test of 7 (±7 secs) and allowing for a 15% drop out from the exercise intervention. Procedure A medical officer performed the initial clinical examination. The recommen - dations of the San Antonio conference were used to diagnose diffuse symmetri- cal sensory motor neuropathy (American Diabetes Association, 2001b). The cli - nical examination included: general medical and neurological history of the patient and neurological examination (ability to perceive the touch of a 10-gram monofilament on the plantar surface of the hallux and centrally at the heel; ability to sense a 128 Hz tuning fork on the great toe; pinprick sensation at the great toe; ability to identify the joint position of the toe; Achilles reflex; strength of knee and ankle flexors and extensors; and cardiac autonomic neu- ropathy tests). The results of the exami- nation were used to determine the stage of diabetic neuropathy in the system proposed by Dyck et al, (1991): 0– No Neuropathy: No symptoms and fewer than two abnormalities on testing (including autonomic function test). 1– Asymptomatic Neuropathy: No symptoms but two or more abnor- malities on testing. 2– Symptomatic Neuropathy: Minor symptoms with two or more abnor- malities. 3— Disabling Neuropathy: Severe symptoms with two or more abnor- malities. The subjects in the experimental group received 45 minutes of isometric exer- cises and stretching, 3 times a week for 12 weeks, in addition to their oral hypoglycaemic medication and dietary recommendations. The exercises were done in a class in non-weight bearing positions i.e. lying, long sitting and cross sitting. The exercise programme was as follows: The exercises started with a 10 minute “warm up” session consisting of stretching for the muscles of the toes, ankles and knees. Each stretch was held for 20 seconds and repeated twice on each side. Subjects were instructed not to hold their breath during stretching and to do the stretching slowly so as to avoid pain. Isometric exercises were then done for the muscles of the lower extremities, namely the quadriceps, hamstrings, plantarflexors and dorsiflexors. The iso- metric ‘hold” was held for five seconds and this was followed by 10 seconds of relaxation. Each exercise was repeated six times. Subjects were instructed not to hold their breath and to do the isometric exercises rhythmically. This part of the exercise programme lasted for 25 minutes. The exercise sessions were concluded with “cooling down” using stretching exercises for the knee and hip muscles. The stretch was held for 20 seconds and repeated twice on each side. Subjects in the control group received their routine oral hypoglycaemic medi - cation and their dietary recommenda- tions. Control subjects came to the hospital for all testing at the beginning SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 29 and at the end of the study i.e. after 12 weeks. Romberg’s test for postural stability and the muscle strength of the qua - driceps, hamstrings, dorsiflexors and pantarflexors were measured at the beginning and the end of the study by the first author. The muscle strength was established using a hand held dynamo - meter and the best of three measures was recorded. Blood glucose levels, blood pressure and heart rate were measured before and 3 minutes after each treat- ment session by an attendant nursing sister. The intrarater reliability of the first author conducting Romberg’s test as well as the muscle strength tests was established on a group of five patients and repeated five days later on the same subjects prior to the commencement of the study. Statistical analysis This study was conducted as a two arm, controlled, parallel, intervention study comparing subjects undergoing an exer- cise intervention to control subjects who did not receive an exercise intervention. The primary outcome variables were postural stability measured in seconds by Romberg’s test and muscle strength in kilograms of force measured using a dynamometer. The secondary outcome variables were blood glucose levels in mmol/l; blood pressure in mm/Hg; and heart rate in beats/min. Non-parametric data were analysed by using Fisher’s exact test and para- metric data were analysed by using the two-sample t-test for comparisons between groups. An analysis of covari- ance (ANCOVA) was done to compare the experimental and control groups with respect to changes from baseline. Testing was done at the 0.05 level of significance using Stata V7 statistical software. RESULTS Twenty subjects from the experimental group and twenty subjects from the control group completed the study. Six subjects from the intervention group missed one exercise session there fore attending 35 sessions, and six subjects missed two exercise sessions therefore attending 34 exercise sessions. Reasons for missing sessions ranged from having head colds to transport difficulties. The rest of the group i.e. eight subjects attended 36 exercise sessions (3 times a week for 12 weeks). Exercise related injuries were not reported. Hypogly - caemic incidents were not observed dur- ing or after the exercise intervention. There was no significant difference in age, gender, race and stage of neuropathy between the experimental and control groups (Table 1). The major indicator for recruitment of patients in this study was the stage of diabetic diffuse symmetrical sensory motor neu- ropathy because the subject of the study was one of its manifestations namely, postural instability. The duration of NIDDM and duration of diabetic neu- ropathy do not always correlate with the stage of neuropathy (American Diabetes Association, 2001b). So the significant differences at baseline for the duration of NIDDM and duration of neuropathy do not affect the study outcomes. Table 2 shows the changes in Romberg’s test and muscle strength before and after 12 weeks. Romberg’s test improved significantly in the exer- cise group relative to the control group (p=0.001). The strength of the quadri- ceps, hamstrings, dorsiflexors and plan- tarflexors were substantially improved in the exercise group relative to the control group (p=0.001). The blood glucose level decreased on average by 3.7 mmol/l in the exercise group, and increased by 0.9 mmol/l in the control group during the interven- tion (p = 0.00). There was a significant reduction in resting systolic blood pressure in the exercise group and there were no changes in resting systolic blood pressure in the control group (p = 0.003). The changes in resting diastolic blood pressure were not signifi- cantly different between groups (0.13). There was not a significant difference in the change in resting heart rate (p = 0.89) during the intervention between groups. DISCUSSION The main finding of this study is that a special regimen of isometric exercises and stretching for the lower extremities Subject Experimental Control group p - Values characteristics group (n=20) (n=20) Age (years) 59.6 (± 9.4) 58.9( ± 6.2) NS (41-70) (48-69) Gender: female 14 12 NS male 6 8 Race: black| 12 10 NS Indian 0 2 white 8 8 Stage of Neuropathy: 2nd 19 19 NS 3rd 1 1 Duration of NIDDM (years) 11.5 ± 6.7 (5-20) 7.8 ± 4.6 (2-16) 0.04* Duration of Neuropathy (years) 6.3 ± 4.4 (2-15 3.8 ± 2.5 (1-10) 0.04* Note: Values presented as mean ± SD; the ranges are given in brackets. n = number of subjects in the group NS = Not Significant * = Significant Table 1: Demographic characteristics of subjects. 30 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 Dependent Before After Change form p-Value variable baseline to post intervention Romberg’s test (sec) EG (n = 20) 10.7 ± 7.1 18.25 ± 9.0 + 7.55 0.001* CG (n = 20) 13.05 ± 6.3 11.45 ± 5.1 - 1.6 Quadriceps (kg/force) right (EG, n=20) 9.6 ± 1.6 10.58 ± 1.8 + 0.98 0.001* right (CG, n=20) 11.0 ± 2.3 10.96 ± 2.3 - 0.04 left (EG, n=20) 8.8 ± 1.9 10.0 ± 2.0 + 1.2 0.001* left (CG, n=20) 9.84 ± 2.1 9.82 ±2.1 - 0.02 Hamstrings (kg/force) right (EG, n=20) 7.5 ± 1.9 8.5 ± 1.8 + 1.0 0.001* right (CG, n=20) 8.3 ± 2.2 8.31 ± 2.2 + 0.01 left (EG, n=20) 6.9 ± 2.0 8.02 ± 2.0 + 1.12 0.001* left (CG, n=20) 7.55 ± 2.3 7.56 ± 2.3 + 0.01 Dorsiflexors (kg/force) right (EG, n=20) 4.9 ± 1.0 5.7 ± 1.0 + 0.8 0.001* right (CG, n=20) 6.11 ± 1.5 6.1 ± 1.5 - 0.01 left (EG, n=20) 4.4 ± 1.0 5.2 ± 1.0 + 0.8 0.001* left (CG, n=20) 5.7 ± 1.5 5.7 ± 1.5 0.0 Plantarflexors (kg/force) right (EG, n=20) 6.2 ± 0.9 7.0 ± 0.8 + 0.8 0.001* right (CG, n=20) 7.1 ± 1.7 7.0 ± 1.7 - 0.1 left (EG, n=20) 5.8 ± 0.9 6.6 ± 0.8 + 0.8 0.001* left (CG, n=20) 6.5 ± 1.7 6.48 ± 1.7 - 0.02 left (EG, n=20) 37.6 ± 5.4 38.4 ± 5.5 + 0.8 0.001* left (CG, n=20) 37.5 ± 4.0 37.5 ± 4.0 0.0 Note: Values presented as mean ± SD; p – values of the change (ANCOVA); EG = Experimental Group; CG = Control Group; n = number of subjects in the group; * = Significant. Table 2: Romberg’s test and muscle strength data pre and post intervention. Dependent Before After Change form p-Value variable baseline to post intervention Blood glucose level (mmol/l) EG (n=20) 9.9 ± 1.1 6.2 ± 0.7 - 3.7 0.00* CG (n=20) 8.6 ± 1.9 9.5 ± 1.5 + 0.9 Blood pressure (mmHg) systolic (EG, n=20) 141.0 ± 15.2 130.0 ± 7.9 - 11.0 0.003* systolic (CG, n=20) 139.5 ± 12.8 139.5 ± 12.3 0.0 diastolic (EG, n=20) 79.5 ± 8.3 77.0 ± 5.7 - 2.5 0.13 (NS) diastolic (CG, n=20) 82.5 ± 7.9 83.0 ± 6.6 + 0.5 Heart rate (beats/min) EG (n=20) 74.4 ± 5.1 74.3 ± 4,2 - 0.1 CG (n=20) 76.3 ± 4.6 76.3 ± 4.6 0.0 0.89 (NS) Note: Values presented as mean ± SD; p – values of the changes (ANCOVA); EG = Experimental Group; CG = Control Group; n = number of subjects in the group; NS = Non Significant; * = Significant. Table 3: Blood glucose level, blood pressure and heart rate data pre and post intervention. SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 31 can improve postural stability as mea- sured by Romberg’s test in patients with diabetic peripheral neuropathy. This agrees with the findings by Richardson at al, (2001). The reason why their patients showed an improvement in three commonly used measures of balance (functional reach, tandem stance, unipedal stance) was, as they suggested, most probably because the subjects improved their available ankle strength, which provides torque to the ankle. They concluded that an isolated improvement in the strength of the ankle musculature would likely be sufficient to lead to the improvements noted in their study. This appears to have been a reasonable conclusion because as the results for this study show, there was both an improvement in muscle strength and postural stability in these subjects. An improvement in ankle muscle strength, might also improve ankle propriceptive thresholds hence postural stability in diabetics with peripheral neu- ropathy (Richardson et al, 2001). This study shows that muscle strengthening together with increased proprioceptive thresholds may be equally important for postural stability. An improvement in proprioceptive input may be achieved by other techniques in addition to mus- cle strengthening. In this study stretch- ing was used as well in order to increase the ankle proprioceptive threshold. As mentioned by Fremerey et al, (2001), extensive stretching may stimulate vari- ous mechanoreceptors which can boost the proprioceptive awareness and hence postural stability. Isometric exercises and a stretching programme applied to the lower limbs increased the available strength of quadriceps, hamstrings, dorsiflexors and plantarflexors. Considering the length of this study design (12 – week interven- tion) the strengthening that occurred in the experimental group may have been related to a synchronisation of motor units and muscle hypertrophy as well. The improved synchronisation of motor units may be related to neural changes and appears early in muscle strength gains (Richardson et al 2001; White et al, 2004). There was a significant decrease in blood glucose levels during the isomet- ric exercises and stretching programme. At the end of the study patients in the experimental group had blood glucose levels close to normal. This observation agrees with the findings by Castaneda et al, (2002). The blood glucose lowering effect of isometric exercises and stretch- ing supports the American Diabetes Association, (2001c) recommendations that long-term exercise programmes are important for the treatment and preven- tion of NIDDM. Other than a reduction in systolic blood pressure in the experimental group at the end of the intervention there were no changes in blood pressure and heart rate. CONCLUSION The isometric exercises and stretching programme for the lower extremities improved postural stability and motor function in patients with diabetic symmetrical sensory motor neuropathy. This exercise regimen had a lowering effect on blood glucose level as well. REFERENCES American Diabetes Association 2001a Preven - tive foot care in people with diabetes Diabetes Care 24: S56 – 57. American Diabetes Association 2001b Screening for diabetes Diabetes Care 24: S21 – 24. American Diabetes Association 2001c Diabetes mellitus and exercise. Diabetes Care 24: S51 –55. Boulton AJM Malik RA Arezzo JC Sosenko JM 2004 Diabetic somatic neuropathies (Technical Review) Diabetes Care 27: 1458-1486 Bradshaw D, Groenewald P, Laubscher R, Nannan N, Nojilana B, Norman R 2000. Initial estimates from South African national burden of disease study, Medical Research Council Policy Brief 1, March 2003. http://www. mrc. ac. za /bod/bod. Htm Castaneda C, Layne J, Munoz – Orians L, Gordon P, Walsmith J, Foldvari M 2002 A randomised controlled trial of resistance exercise training to improve glycaemic control in older adults with type 2 diabetes. Diabetes Care 25: 2335 – 2341. Dyck PJ, Kratz KM, Lehman KA, Karnes JL, Melton LJ, O’Brien PC 1991 The Rochester Diabetic Neuropathy Study: design, criteria for types of neuropathy, Selection bias, and reproducibility of neuropathic tests. Neurology; 41: 799 – 807. Fremery R, Lobenhoffer P, Skutek M, Gerich T, Bosch U. 2001 Proprioception in anterior cruciate ligament reconstruction. Endoscopic versus open two-tunnel technique. International Journal of Sports Medicine; 22: 144 – 148. Giacomini PG, Bruno E, Monticone G, Girolamo S, Magrini A, Parisi L 1996 Postural rearrangement in IDDM patients with periph- eral neuropathy. Diabetes Care 19: 372 – 374. Richardson JK, Sandman D, Vela S. 2001 Focused exercise regimen improves clinical measures of balance in patients with peripheral neuropathy. Archives of Physical Medicine and Rehabilitation 82: 205 – 209. White Cm Pritchard J Turner-Stokes L 2004 Exercise for people with peripheral neuropathy Cochrane Database of Systematic reviews issue 4:CD003904.DOI: 10.1002/14651858. CD003904.pub2 32 SA JOURNAL OF PHYSIOTHERAPY 2009 VOL 65 NO 2 1. INTRODUCTION A characteristic of any profession is that it occupies a social standing relative to other professions (Turner, 2001). The professional relationship between physio- therapists and chiropractors is important as both physiotherapists and chiroprac- tors are members of a multidisciplinary team and contribute to the holistic care of patients. Understanding the perceptions and attitudes of undergraduate students, (who are a key target because they are future practitioners), would help the pro- fession create more effective marketing strategies, knowing the misconceptions that need to be corrected (Prati and Liu, 2006). This study was undertaken to determine the perceptions, attitudes and knowledge that Physiotherapy and chiropractic students have of each others’ professional practice. 1.1 Physiotherapy Education and Practice Physiotherapy is concerned with ‘assess- ing, treating and preventing movement disorders, restoring normal function or minimising dysfunction and pain in adults and children with physical impairment, to enable them to achieve the highest possible level of indepen- dence; preventing recurring injuries and disability in the workplace, at home, or during recreational activities and promoting community health for all age groups (South African Society of Physio therapy, 2008). Physiotherapists use ‘skilled evaluation, skilled hands on therapy such as mobilisation, manipu lation, massage and acupres- sure; indi vi dually designed exercise The perceptions, attitudes and knowledge of physiotherapy and chiropractic students regarding each others’ professional practice R e s e a r c h A r t i c l e A BST R A CT: Introduction: The roles of physiotherapists and chiropractors demon- strate some overlap. Both are members of a multidisciplinary team and contribute to the holistic care of patients. Good understanding of each others’ professional practice may lead to good working relationships with effective referrals, inter - disciplinary and multidisciplinary management of patients. Purpose: To investigate the perceptions, attitudes and knowledge of undergraduate physiotherapy and chiropractic students about each others’ professional roles in clinical practice. M ethodology: Data was obtained using a questionnaire with closed and open-ended questions. First and final-year physiotherapy (n = 72) and chiropractic students (n = 49) participated. R esults: First and final year physiotherapy students scored 58% and 62% respectively in the “test” on chiropractic; chiropractic students scored 52% and 68% respectively in the test on physiotherapy. Seventy percent of the chiro - practic and 14% of the physiotherapy students had visited the practice of other profession. Sixty seven percent of the chiropractic and 38% of the physiotherapy students found it was effective. Forty seven percent chiropractic and 80% physiotherapy students considered physiotherapy and chiropractic to be in direct competition. Sixty six percent of the chiropractic students and 49% of the physiotherapy students expressed the intention of working together with the other profession. Discussion: The reason for the possible feelings of competitiveness could be because in South A frica there is vast overlap of practice in both professions; Physiotherapists and chiropractors are seen to use modalities that are similar. This may be viewed as an indication of the importance in defining the roles, scope and characteristics of both physio- therapy and chiropractic. Conclusion: The knowledge of the physiotherapy and chiropractic students is equal, however, chiropractic students have more positive perceptions and attitudes towards physiotherapy than physiotherapy students have of chiropractic. KEY W ORDS: PHY SIOTHERA PY, CHIROPRA CTIC, HEA LTH KNOW LEDGE, ATTITUDES, PROFESSIONA L PRA CTICE. Naidoo N1; Bühler L2 1 Lecturer,Discipline of Physiotherapy. 2 Discipline of Physiotherapy. Correspondence to: Nirmala Naidoo Discipline of Physiotherapy School of Physiotherapy, Sports Science and Optometry Faculty of Health Science University of KwaZulu-Natal Private Bag X54001 Durban 4000 South Africa Tel: +27 31 2607817 Fax: +27 31 2608106 Email: naidooni@ukzn.ac.za