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Feet First: Promoting Physical Activity Among People With Diabetes Mellitus and Insensate Feet

The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. Identifier: NCT00286598
Recruitment Status : Completed
First Posted : February 3, 2006
Last Update Posted : October 5, 2016
Robert Wood Johnson Foundation
Information provided by (Responsible Party):
University of Missouri-Columbia

Brief Summary:

The role of weight-bearing physical activity in the development of diabetic foot ulcers remains poorly understood. Regular participation in moderately intense physical activity (e.g. brisk walking ) reduces 8-year cardiovascular mortality in those with diabetes mellitus by over 30%. The American Diabetes Association (ADA) recommends at least 30 minutes of daily moderate intensity activity for people with diabetes. However, the ADA recommends that people with diabetes and insensate feet, which affects up to 40% of those with diabetes, should limit their walking because of concerns that walking could increase the risk of foot ulcers and amputation. Firm evidence is lacking to support these concerns; in fact, while a research fellow I conducted an observational study that showed daily weight-bearing activity may reduce the risk of foot ulceration among people with diabetic foot problems. A controlled clinical trial is needed to study these issues further.

The present study is a randomized controlled trial in 100 older adults with diabetes and insensate feet, 50 of whom will participate in an individually-tailored behavior-change intervention called "Feet First", and 50 of whom will be controls. The intervention is based on the extensively-tested CHAMPS model used by the Robert Wood Johnson Foundation's Active for Life Program. Feet First extends the target population beyond older adults generally to people with insensate feet due to diabetic peripheral neuropathy.

The specific aims of the study are:

  • To determine whether Feet First intervention subjects achieve a greater increase in weight-bearing activity than control subjects, and
  • To obtain preliminary evidence on intervention subjects' foot outcomes (foot function, foot-related self-care, and risk of foot ulcers), compared to control subjects.

Condition or disease Intervention/treatment Phase
Diabetes Mellitus Peripheral Neuropathies Behavioral: Feet First Phase 1

Detailed Description:

Physical activity is a vital component of self-management for patients with diabetes mellitus, yet there are special problems in patients whose disease is complicated by insensate feet (i.e. loss of protective sensation caused by diabetic distal symmetric sensory peripheral neuropathy). Foot ulcers develop in 15% of the 17 million people in the United States with diabetes mellitus, and contribute to 84% of foot or toe amputations. Foot ulcer risk is very high among those with insensate feet. Although the roles of neuropathy, plantar foot pressure, and footwear in foot ulcers have been extensively studied, the independent role of physical activity has not. The overall goal of this study is to determine whether a "lifestyle" physical activity intervention, based on the Second Community Healthy Activities Model Program for Seniors (CHAMPS II), which we call FEET FIRST, can be used to safely increase moderate-intensity physical activity (achieving at least 40% of maximal oxygen consumption, as in walking briskly) among people with diabetes and insensate feet. "Lifestyle" physical activity interventions help participants to accumulate at least 30 minutes of self-selected activities in short bouts during the day. CHAMPS II effectively and safely increased physical activity in sedentary older adults with multiple chronic illnesses.

Substantial research has also found that people with diabetic peripheral neuropathy are also at increased risk of falls. Diabetic peripheral neuropathy also leads to postural instability, i.e. impairment in measures of functional dynamic balance. Moreover, this instability worsens with age. People with diabetic peripheral neuropathy in particular tend to have ankle instability due to decreased proprioception, making them less able to rapidly recover balance during sudden ankle dorsiflexion, inversion or eversion when walking on uneven surfaces.

There is ample evidence that promotion of an active lifestyle and specific exercises targeting endurance, strength and balance improves reduces functional decline in the elderly, and that home-based exercise programs effectively decrease fall risk in the elderly as well. One small, non-randomized trial found preliminary evidence that a 3-week intervention that focused on ankle strength improved balance measures in those with diabetic peripheral neuropathy. However, no randomized studies have investigated the effect of a physical activity intervention on fall risk in community-dwelling people with diabetic peripheral neuropathy, who may also be at increased risk of cutaneous injuries (i.e. foot lesions) during weight-bearing activity. Before we unequivocally recommend to people with diabetic peripheral neuropathy that they engage in exercise, we need to determine that this will be safe for their feet, and not increase fall risk.

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Study Type : Interventional  (Clinical Trial)
Actual Enrollment : 79 participants
Allocation: Randomized
Intervention Model: Single Group Assignment
Masking: Single (Outcomes Assessor)
Primary Purpose: Treatment
Official Title: Feet First: Increasing Activity Without Increasing the Risk of Foot Ulcers in People With Diabetes and Insensate Feet
Study Start Date : January 2005
Actual Primary Completion Date : June 2007
Actual Study Completion Date : June 2008

Resource links provided by the National Library of Medicine

Arm Intervention/treatment
Experimental: Feet First
Phase 1: (enrollment to 3 months) 8 sessions with a physical therapist learning leg strengthening and balance exercises, and initiating a walking program Phase 2: Motivational enhancement calls from a nurse every 2 weeks.
Behavioral: Feet First
Phase 1: (enrollment to 3 months) 8 sessions with a physical therapist learning leg strengthening and balance exercises, and initiating a walking program Phase 2: Motivational enhancement calls from a nurse every 2 weeks.

No Intervention: Control
Usual care

Primary Outcome Measures :
  1. Change in weight-bearing physical activity (steps/day) [ Time Frame: Baseline, 3, 6 and 12 months post-enrollment ]

Secondary Outcome Measures :
  1. Partial or greater depth foot ulcer (Wagner Gr. 1 or deeper) [ Time Frame: continuously post-enrollment for 12 months ]
  2. Falls [ Time Frame: continuously post-enrollment for 12 months ]
  3. Self-reported foot disability [ Time Frame: baseline, 6 and 12 months post enrollment ]
  4. Foot-related self-care [ Time Frame: baseline, 6 and 12 months post enrollment ]

Information from the National Library of Medicine

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Ages Eligible for Study:   50 Years and older   (Adult, Older Adult)
Sexes Eligible for Study:   All
Accepts Healthy Volunteers:   No

Inclusion Criteria:

  • Diagnosed type 1 or 2 diabetes mellitus
  • Age 50 years or older
  • Absent 5.07 Semmes Weinstein monofilament sensation to > 1 point on both feet
  • Residence within 50 miles of Columbia, MO
  • Functioning telephone service
  • Not currently participating in 20 or more minutes of moderately intense activity more than twice a week

Exclusion Criteria:

  • Hospitalization in the last year for any of the following reasons:
  • Proliferative diabetic retinopathy
  • Accelerated hypertension (systolic BP >200 or diastolic BP > 120)
  • Myocardial infarction or unstable angina
  • New hemodynamically significant arrhythmia
  • Acute congestive heart failure
  • Failure to attend 3 of the last 5 scheduled clinic visits
  • Foot deformities requiring a custom shoe
  • "Timed Up and Go" test 3 > 15 seconds Subjects unable to ambulate without assistance
  • Severe cardiac autonomic neuropathy
  • Lower extremity amputation > one digit
  • Heart, kidney or other transplant
  • Currently unhealed foot ulcer (or healed for less than 1 month

Information from the National Library of Medicine

To learn more about this study, you or your doctor may contact the study research staff using the contact information provided by the sponsor.

Please refer to this study by its identifier (NCT number): NCT00286598

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United States, Missouri
University of Missouri
Columbia, Missouri, United States, 65212
Sponsors and Collaborators
University of Missouri-Columbia
Robert Wood Johnson Foundation
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Principal Investigator: Joseph W LeMaster, MD, MPH University of Missouri-Columbia
Publications automatically indexed to this study by Identifier (NCT Number):
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Responsible Party: University of Missouri-Columbia Identifier: NCT00286598    
Other Study ID Numbers: UMHS IRB 1040047
First Posted: February 3, 2006    Key Record Dates
Last Update Posted: October 5, 2016
Last Verified: October 2016
Individual Participant Data (IPD) Sharing Statement:
Plan to Share IPD: No
Keywords provided by University of Missouri-Columbia:
foot ulcer
diabetes mellitus
motor activity
randomized controlled trial
Additional relevant MeSH terms:
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Peripheral Nervous System Diseases
Diabetes Mellitus
Glucose Metabolism Disorders
Metabolic Diseases
Endocrine System Diseases
Neuromuscular Diseases
Nervous System Diseases