Archive \ Volume.11 2020 Issue 1

 

Evaluating the depression status following backward walking exercise in diabetic neuropathy patients

 

Walid Kamal Abdelbasset1,2,*, Gopal Nambi1, Samah Alsaid Moawd1,3, Saud Mashi Alrawaili1, Tamer Emam Elnegamy1, Ahmed Abdelmomen Elshehawy3,4, Amira Hamed Eltrawy5,6

 

 

1 Department of Physical Therapy and Health Rehabilitation, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia.2 Department of Physical Therapy, Kasr Al-Aini Hospital, Cairo University, Giza, Egypt. 3 Department of Physical Therapy for Cardiovascular/Respiratory Disorder and Geriatrics, Faculty of Physical Therapy, Cairo University, Giza, Egypt.4 Department of Physical Therapy, Faculty of Applied Medical Sciences, Tabuk University, Tabuk, Saudi Arabia.5 Department of Anatomy, Faculty of Medicine, Alexandria University, Alexandria, Egypt.6 Department of Anatomy, Faculty of Medicine, Tabuk University, Tabuk, Saudi Arabia.

 

Abstract

 

The incidence rate of psychological depression is commonly grown among patients with diabetic neuropathy (DN). This pilot retrospective study aims to assess the effects of backward walking exercise (BWE) on depression condition in patients experiencing DN. This pilot retrospective study included 27 patients who clinically suffered from moderate depression related to DN between August 2017 and December 2018, and their mean age was 43.5±6.4 years. They were equipped for a program of backward walking exercise for six weeks, quartile weekly, and lasting for 50-60 minutes. The depression level was evaluated before and after backward walking exercise program utilizing Hamilton depression rating scale (HRS). The results showed that six-week backward walking exercise results in a significant reduction in HRS in DN patients (p˂0.001). The percentage of changes of HRS was 32.9% at the end of the exercise program. These findings provided that the backward walking exercise has a beneficial influence on depression status among diabetic patients, especially who experiencing DN.

 

Keywords: Diabetes, Neuropathy, Depression, Backward walking exercise, Proprioception

 

INTRODUCTION

 

The frequency rate of depression condition was grown among diabetic individuals with approximately two-fold risks of non-diabetic peers [1]. Previous studies have confirmed that diabetes mellitus (DM) increases the prevalence of depression for about 24% [2]. The incidence of depression condition is commonly increased in chronic diseases and extremely elevated in diabetic disease which affects behavioral lifestyle [3]. Vascular complications are numerous in DM such as neuropathy, nephropathy, and retinopathy [4] due to microcirculation impairment [5].

Strong association was detected between diabetic neuropathy (DN) and depression manifestations related to symptomatic DN such as diabetic foot, leg pain, and body instability [6]. It was stated in a study that the depressive condition stands for a considerable co-morbidity of DN-related pain [7] according to the severity level of pain [8]. Although depression conditions may be related to other common co-morbidities which are associated with DM [8, 9], it is not constantly considered when examining the association between DN and depression disorder.

Backward walking exercise (BWE) is an important modality of proprioception exercise programs which is preferred than forward walking in plantar pressure distribution and enhancing coordinative and balance abilities. BWE may also improve neural performance, decrease pattern of foot contact and stride length which consequently diminishes contact-impact force [10]. Moreover, it was previously documented that BWE has some benefits such as reducing the ground reaction force, lengthening of hamstring muscle related to limited knee joint mobility, and enhancing proprioceptive equilibrium during daily activities [11]. Therefore, BWE may provide lower limb stability, balance, strength, and decrease DN symptoms. Consequently, we have proposed this study to assess the effects of backward walking exercise on depression condition in patients experiencing DN with hypothesis that six-week BWE may improve depression status among DN patients and improve their quality of life.

MATERIALS AND METHODS

Study design

This study was a pilot retrospective study. It was performed on 27 DN patients experiencing moderate depression in the outpatient physiotherapy clinic, Cairo University Hospitals between August 2017 and December 2018. This pilot study was approved by the institutional review board according to Helsinki Declaration 1975.

Subjects

Twenty-seven patients have been diagnosed with diabetic neuropathy and moderate depression following clinical and laboratory assessments, their age range was 37-50 years. They were referred by psychiatric and diabetic physicians to outpatient physiotherapy clinic. Patients were excluded from the study if they had mild or severe depressive disorder, uncontrolled hyperglycemia, antidepressant medications, and any restrictions affecting physical exercise. Each patient was informed about the details of the study procedures and instructed to sign a written consent form.

Materials

The depression level has been assessed using valid Hamilton depression scale (HDS) pre- and post-six weeks of BWE program. HDS is a 17-item valid and reliable scale. Each item is scored 0-4. Total score is classified into normal (˂10), mild (10-13), moderate (14-17), and severe (˃17) [12, 13].

Procedures

Assessment

Demographic data and clinical characteristics have been collected from patients' files and have been entered into Microsoft Excel 2010 and analyzed using SPSS version 25. HDS was assessed before starting the BWE program and reassessed after six weeks after finishing the study intervention.

BWE program

The study participants were recruited to BWE program which detailed as; 50-meter corridor, two-side landing strip zones with a length of 10-meter and width of 5-meters between the 2 zones which were spotted utilizing a colored sticky tape. The patient was instructed to walk barefoot normally in a backward direction for 50-60 minutes, quartile weekly, for six weeks duration.

Statistical analysis

Data were collected and analyzed consuming SPSS version 23 (IBM Corp., Armonk, NY, USA). Paired t-test was executed to evaluate the pre- and post-intervention changes in the HDS. Data were detailed as mean ± standard deviation. The significance level was considered at p-value<0.05.

RESULTS

Of referred 32 patients, 27 patients have regularly attended the study program and five have attended 50 % of the interventional sessions of BWE program. Table 1 shows demographic and clinical characteristics of the 27-patient (18 males and 9 females) with mean age of 43.5±6.4 years. All participants were non-smokers. 6 patients were insulin-dependent DM and 21 were non-insulin dependent DM. Their mean body mass index (BMI) was 28.7±4.2 Kg/m2. Mean glycated hemoglobin (HbA1c) was 7.3±1.8% and mean HRS was 15.5±1.3 reflecting that the study participants were suffering from moderate depression.

Table 1. The baseline and clinical characteristics of the study participants

Variables

(n=27)

Age

43.5±6.4

Gender (M/F)

18/9

BMI (Kg/m2)

28.7±4.2

Duration of diabetes (years)

9.7±4.5

Insulin dependent DM n(%)

6(22)

Non-insulin dependent DM n(%)

21(78)

HbA1c (%)

7.3±1.8

HRS

15.5±1.3

BMI: body mass index; DM: diabetes mellitus; HbA1c: glycated haemoglobin; HRS: Hamilton depression rating scale.

As explained in Table 2 and described in Figure 1, using of paired t-test showed a significant reduction of HRS from 15.5±1.3 pre-intervention to 10.4±0.9 post-intervention with (p˂0.001). Comparison between baseline HRS and post-six weeks intervention showed that the percentage of changes was 32.9%.

Table 2: The changes in mean values of HRS between pre- and post-six weeks intervention

HRS

(n=27)

Pre-

15.5±1.3

Post-

10.4±0.9

P-value

˂0.001

% of changes

-32.9%

Significant at p-value<0.05; HRS: Hamilton depression rating scale.

Figure 1: Pre-Post changes of HRS

 

DISCUSSION

This retrospective study aims to assess the effects of backward walking exercise on depression condition in patients experiencing DN with hypothesis that six-week BWE may improve depression status and quality of life among DN patients. The findings confirmed our hypothesis and showed a significant reduction of HRS from 15.5±1.3 pre-intervention to 10.4±0.9 post-intervention with (p˂0.001). The comparison between baseline HRS and post-six weeks intervention showed reduction around 32.9% of the HRS score.

Different physiological mechanisms could clarify that backward walking exercise enhances balance, stability, and proprioceptors of the distal extremities. Similar to our findings, a prior study has approved that proprioceptive exercise combined with traditional physical therapy program improve balance and proprioceptive sensation [14]. Sensory dysfunctions of the feet may lead to balance disturbance and posture instability. The enhancement of proprioceptive sensation may improve posture stability and body balance which improves somatosensory integrations [15,16] and consequently improves psychological status and reduces depression condition.

Many studies have approved that exercise training may improve psychological conditions [17-19], quality of life [20,21], aerobic capacity, and liver functions, and reduce blood glucose levels in diabetic patients [22-24].

BWE should be involved in rehabilitation program as a simple, low-cost, and safe modality in enhancing balance and quality of life through preventing falls risks during daily activities in DN patients.     

This work has strengths for clinical practitioners joining the physiotherapy team. Firstly, it is very critical to be aware that disturbed psychological status can affect our interventional program. Secondly, it is satisfying for rehabilitation team to understand that proprioceptive training can positively affect psychological domains. Finally, the backward walking exercise may reduce depression severity among DN patients. On the other hand, our retrospective study has some limitations. Our study has a small sample size and lacked for control group which affect the generalization of the study findings.

CONCLUSIONS

Based on the study findings, the backward walking exercise has a beneficial effect on depression condition among diabetic patients, especially among experiencing diabetic neuropathy. Future studies may assess the effect of backward walking exercise on other health problems such as muscle fatigability, pain, and anxiety.

ACKNOWLEDGEMENT

This publication was supported by the Deanship of Scientific Research at Prince Sattam bin Abdulaziz University.

Funding

No funds to declare.

Competing interests

The authors declare that no competing interests to disclose.

REFERENCES

  1. Roy T and Lloyd CE. Epidemiology of depression and diabetes: a systematic review. J Affect Disord 2012; 142(Suppl.):S8–S2
  2. Nouwen A, Winkley K, Twisk J, Lloyd CE, Peyrot M, Ismail K, Pouwer F. Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis.  Diabetologia 2010; 53(12):2480-6.
  3. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry 2003; 54: 216–226.
  4. Vileikyte L, Peyrot M, Gonzalez JS, Rubin RR, Garrow AP, Stickings D, Waterman C, Ulbrecht JS, Cavanagh PR, Boulton AJ. Predictors of depressive symptoms in persons with diabetic peripheral neuropathy: a longitudinal study. Diabetologia 2009; 52:1265–1273.
  5. De Groot M, Anderson R, Freedland KE, Clouse RE, Lustman PJ. Association of depression and diabetes complications: a metaanalysis. Psychosom Med 2001; 63: 619–630.
  6. Vileikyte L, Leventhal H, Gonzalez JS, Peyrot M, Rubin RR, Ulbrecht JS, Garrow A, Waterman C, Cavanagh PR, Boulton AJ. Diabetic peripheral neuropathy and depressive symptoms: The association revisited. Diabetes Care 2005; 28(10):2378-83.
  7. Jain R, Jain S, Raison CL, Maletic V. Painful diabetic neuropathy is more than pain alone: examining the role of anxiety and depression as mediators and complicators. Curr Diab Rep 2011; 11: 275–284.
  8. Gore M, Brandenburg NA, Dukes E, Hoffman DL, Tai KS, Stacey B. Pain severity in diabetic peripheral neuropathy is associated with patient functioning, symptom levels of anxiety and depression, and sleep. J Pain Symptom Manage 2005; 30: 374–385.
  9. Spallone V, Greco C. Painful and painless diabetic neuropathy: one disease or two? Curr Diab Rep 2013; 13: 533–54
  10. Arata AW. Described between kinetic and kinematic evaluation of high speed backward running. Available from: http://www.dtic.mil/dtic/tr/fulltext/u2/ a366361.pdf.
  11. Bates BT. Conducted study between retro walking for rehabilitation and fitness. Available from: http://www.darkwing.uoregon.edu/btbates/backward /backward1.htm.
  12. Hamilton M. Development of a rating scale; for primary depressive illness. Br J Soc Clin Psychol 1967; 6(4):278-96.
  13. De Carvalho Alves LP, de Almeida Fleck MP, Boni A, da Rocha NS. The major depressive disorder hierarchy: rasch analysis of 6 items of the Hamilton depression scale covering the continuum of depressive syndrome. PLoS One 2017; 12(1):e0170000.
  14. Dixit S, Maiya A, Shastry BA, Guddattu. Analysis of postural control during quiet standing in a population with diabetic peripheral neuropathy undergoing moderate intensity aerobic exercise training: a single blind, randomized controlled trial. Am J Phys Med Rehabil 2016; 95(7):516-24.
  15. Peterka RJ, Murchison CF, Parrington L, Fino PC, King LA. Implementation of a Central Sensorimotor Integration Test for Characterization of Human Balance Control during Stance. Front Neurol 2018; 9: 1045.
  16. Phil P. Sensory motor training a global approach for balance training. J Body Work Move Ther 2006; 10: 77-84.
  17. Abdelbasset WK, Alqahtani BA. A randomized controlled trial on the impact of moderate-intensity continuous aerobic exercise on the depression status of middle-aged patients with congestive heart failure. Medicine (Baltimore) 2019; 98(17):e15344.
  18. Abdelbasset WK, Alqahtani BA, Alrawaili SM, Ahmed AS, Elnegamy TE, Ibrahim AA, Soliman GS. Similar effects of low to moderate-intensity exercise program vs moderate-intensity continuous exercise program on depressive disorder in heart failure patients: A 12-week randomized controlled trial. Medicine (Baltimore) 2019; 98(32):e16820.
  19. Abdelbasset WK, Alqahtani BA, Elshehawy AA, Tantawy SA, Elnegamy TE, Kamel DM. Examining the impacts of 12 weeks of low to moderate-intensity aerobic exercise on depression status in patients with systolic congestive heart failure - A randomized controlled study. Clinics (Sao Paulo) 2019; 74: e1017.
  20. Abdelbasset WK, Alsubaie SF, Tantawy SA, Abo Elyazed TI, Elshehawy AA. A cross-sectional study on the correlation between physical activity levels and health-related quality of life in community-dwelling middle-aged and older adults. Medicine (Baltimore) 2019; 98(11):e14895.
  21. Abdelbasset WK, Nambi G. Relationship between physical activity and health-related quality of life in elderly people: a cross-sectional study. Sanamed 2017; 12: 87–92.
  22. Abdelbasset WK, Alsubaie SF, Tantawy SA, Abo Elyazed TI, Kamel DM. Evaluating pulmonary function, aerobic capacity, and pediatric quality of life following a 10-week aerobic exercise training in school-aged asthmatics: a randomized controlled trial. Patient Prefer Adherence 2018; 12: 1015-1023.
  23. Abdelbasset WK, Tantawy SA, Kamel DM, Alqahtani BA, Soliman GS. A randomized controlled trial on the effectiveness of 8-week high-intensity interval exercise on intrahepatic triglycerides, visceral lipids, and health-related quality of life in diabetic obese patients with nonalcoholic fatty liver disease. Medicine (Baltimore) 2019; 98(12):e14918.
  24. Abdelbasset WK, Tantawy SA, Kamel DM, Alqahtani, BA, Elnegamy TE, Soliman GS, Ibrahim AA. Effects of high-intensity interval and moderate intensity continuous aerobic exercise on diabetic obese patients with nonalcoholic fatty liver disease. Medicine (Baltimore) 2020; 99(10):e19471.