Introduction

Diabetes mellitus (DM) affects as many as 537 million adults aged between 20 and 79 years worldwide, and in Poland DM prevalence is estimated at about 8% of the adult population. As a result of this epidemiology, diabetic foot (DF), which affects approximately 15–30% of patients with DM, is a significant clinical and social issue. Diabetic foot is defined as the infection, ulceration and/or destruction of the tissues of the foot associated with neuropathy and/or peripheral artery disease (PAD) of a lower extremity in a person with DM. The main problem for patients with DF is chronic non-healing foot ulcers which do not heal in a reasonable period of time, despite optimal medical and surgical patient management [1–4], offloading [5–13], and the use of conventional and advanced treatments in accordance with the TIMERS framework. TIMERS stands for the following: T – tissue management and debridement: this involves approaches that are surgical, sharp, autolytic, mechanical (such as hydrosurgery, i.e. using a hydro-knife), enzymatic, surfactant, or biological, such as maggot debridement therapy (MDT), called also larval debridement therapy; I – inflammation and infection control: this involves, for instance, dressings that are silver- or antimicrobial-based (using, for example, iodine, polyvinyl alcohol, carbon, or Manuka honey), nanoparticles, systemic antibiotics, or biofilm management; M – moisture balance: this includes applying advanced wound dressings that use a technology lipido-colloid nano-oligosaccharide factor or ointments, absorbent compress dressings, or employing negative pressure wound therapy (NPWT); E – epithelial edge advancement: this includes debridement, excision of sclerosed margins, and wound fillers (e.g. collagen); R – repair and regeneration: using, for example, topical zinc oxidate, oxygen, ozone, carbon dioxide, collagen, NPWT, MDT, and dermal replacement [14]; and S – social and patient characteristics: such as the patient’s level of education, motivation, family support, and adherence to and understanding of the care plan [15].

It has been reported that during a one-year follow-up, DF ulcers healed in only 46% of patients and later recurred in 10% of this group [16]. Non-healing ulcers in patients with DF are associated with substantial morbidities, requiring frequent healthcare provider visits, daily wound care, antimicrobial therapy, surgical procedures, and a high healthcare cost which surpasses that of conditions such as cancer or depression [17]. Diabetic foot infections remain the most frequent diabetes-related complications requiring hospitalization and the most common precipitating events leading to lower extremity amputation, which, in turn, triples the risk for subsequent, contralateral leg amputation, has an unfavorable effect on the progress of rehabilitation, and compromises functional improvement and quality of life [16–18]. The number of complications linked with DF lead to a shortening of patient life expectancy, with mortality amounting to 25–30% per 10 years for patients with uncomplicated neuropathic foot, 70% per 5 years for patients with Charcot foot, and 25% per year among patients with DF and chronic limb-threatening ischemia (CLTI) [2–4, 11, 19–22].

Diabetic foot is a heterogeneous clinical condition that requires both general, DM-specific (e.g. diet, exercise, pharmacology, and bariatric and general surgery) and DF type-specific (i.e. foot-related) management. Diabetic foot is divided into neuropathic-ischemic and neuropathic types. Neuropathic-ischemic DF is associated with diabetic neuropathy and PAD, which leads to imbalance between the blood supply to the foot and the foot tissue demand for oxygen and nutritional factors. This imbalance can also be exacerbated, by, for example, the course of infection or processes related to wound healing. The clinical manifestations of this form of DF consist of foot deformity, necrosis, and unhealing ulcers and signs of CLTI [2–4]. Whereas, the clinical manifestations of neuropathic DF are dominated by signs of motor, sensual, and autonomic nerve dysfunction. Diabetic neuropathy leads to foot deformity and loss of protective sensation, which is defined as the inability to sense light pressure such as that applied with a 10-gram Semmes-Weinstein monofilament [16]. The most severe complications of diabetic neuropathy are diabetic ulcers, Charcot arthropathy, and lower limb amputation.

Charcot osteoarthropathy (Charcot foot) is a non-infectious inflammatory destruction of bone and joint(s). In the acute phase, it is associated with signs of foot inflammation, hyperemia and bone marrow edema detected on virtual non-calcium images calculated from dual-energy computed tomography [22, 23]. Charcot foot is associated with serious and life-threatening complications and increased risk of phantom limb pain following both below-the-knee and above-the-knee leg amputation [16, 22, 24, 25].

The aim of this paper is to present the current data concerning the role of the physiotherapist as an independent medical professional in primary and secondary DF prevention and the care of patients with DF in order to reduce all-cause and cardiovascular mortality and major adverse cardiovascular events (MACE) occurrence, increase the likelihood of limb preservation, support ulcer healing, and prevent muscle and joint contractures. The paper also considers the role of the physiotherapist in managing patients undergoing leg amputation during the pre- and postoperative periods, including preparing the patient for a prosthesis.

The role of the physiotherapist in management of a patient with diabetic foot

Physiotherapy, together with blood glucose and cardiovascular risk control, plays an important role in the multidisciplinary management of patients with DM and DF. The role of the physiotherapist in DF patient management focuses on diagnosis, interventions, and the monitoring of outcomes. Physiotherapy diagnosis should be based on the medical history obtained, physical examination, and analysis of imaging and laboratory tests. The physiotherapist should, at the very least, obtain information concerning a history of DM, its treatment, measures to control blood glucose and other cardiovascular risk factors, comorbidities, including chronic kidney disease, any history of MACE, nicotine, alcohol, and/or opioids addiction, and the level of social and family support. In terms of physical examination, the following are important: analysis of vital signs, effort capacity, balance, muscle strength, mass, endurance, and performance, nutritional and cognitive status (such as through a Comprehensive Geriatric Assessment), as well as an evaluation of the passive and active range of joint motion (e.g. ankle, knee, hip, arm, and elbow). In addition, there should be an assessment of the strength of the skeletal muscles (e.g. dorsiflexors, plantar flexors, invertors, evertors, rotators, flexors, and extensors)
using selected manual, functional, or mechanical scales (e.g. dynamometer, Lovett scale, Seddon scale, Medical Research Council Scale for Muscle Strength, also known as the Oxford Scale, or Motor Strength Scale), and/or an assessment of skeletal muscle quantity and quality by ultrasound examination [26]. The same functional tests should be used in the monitoring of physiotherapeutic procedure outcomes.

Interventions that can be proposed by the physiotherapist in the management of patients with DM and DF are:

• improvement of general effort capacity, mobility, balance, performance, daily functioning, and quality of life (health-related quality of life – HRQoL) in order to reduce the complications of prolonged immobilization, lower the risk of MACE, prevent sarcopenia development and/or progression (i.e. increasing skeletal muscle strength, mass, endurance, and performance), and prevent DF development according to DF risk stratification and type (neuropathic-
ischemic or neuropathic), and preparation of the patient for eventual limb amputation via improving balance and strengthening the skeletal muscles in the shoulder and pelvic girdle,

• concentrating on focal, foot-related problems and supporting wound healing through personalized, patient-tailored DF therapy, such as limb offloading according to tissue destruction severity, ulcer size and location, foot deformity, coexistent foot and leg ischemia, and individual risk of leg amputation determined by, for example, using the Wound, ischemia, and foot infection (WIfI) or Diabetic Foot Risk Assessment (DIAFORA) score system [1–4, 16, 19–21, 27].

Physical activity as a tool for cardiovascular risk reduction and diabetes mellitus control

As stated above, the physiotherapist can take part in the multidisciplinary care of patients with DM and DF, both through planning general (whole-body) physical activity as well as foot-oriented therapy, in regard to primary and secondary DF prevention, the treatment of patients in the active phase of DF, and/or after minor or major leg amputation. With regard to whole-body physical activity, the current European Society of Cardiology guidelines recommend that adults of all ages get at least 150–300 min of moderate intensity or 75–150 min of vigorous intensity physical aerobic activity a week, as well as performing resistance exercise involving balance and strength training at moderate or greater intensity at least 3 days per week, and, at least 2 days per week, conducting resistance exercises for strengthening all major muscle groups [2–4]. These types of aerobic and resistance training reduce all-cause mortality, the risk of MACE and major adverse limb events (MALE), as well as being an important part of anti-diabetic treatment and improving sensitivity to insulin, blood glucose control, and HRQoL, and preventing diabetes-related foot ulcer development and leg amputation [1–3, 28]. Physical activity, especially in the form of walking training, is also an effective part of intermittent claudication management, improving hemodynamic arterial indices, HRQoL, and walking ability in type 2 DM with PAD [3, 29]. Buerger-Allen exercise can be effective in patients with ischemic DF and CLTI [30]. As a result of the high risk of leg amputation, amounting to more than 25% per year among this group, as well as the high prevalence and risk of sarcopenia development or progression, all patients with DF and CLTI should be prepared for eventual limb amputation. Patients can be prepared through exercises that improve body balance and strengthen skeletal muscle, and increase muscle mass and performance, especially in regard to the shoulder and pelvic girdle. Such exercises play a role in limb-sparing because the extent of leg amputation depends not only on improvement of blood supply, but also on the likelihood of reconstruction and rehabilitation, which is strongly related to skeletal muscle mass in, for example, stump shaping. As every DM patient should be regarded as someone with a high risk of MACE, both aerobic and resistance exercises ought to be supervised by the physiotherapist.

It should be taken into account that diabetic neuropathy is not only a cause of DF but is also associated with other sensation, motor, and autonomic dysfunctions, which should be diagnosed by a physiotherapist. Therefore, tests of cardiac autonomic reflexes and the evaluation of sensory and motor diabetic neuropathy severity should be performed for every DF patient. Sensory neuropathy changes skin sensation and evokes hyperalgesia, paresthesia, and abnormal deep sensation, which increase the risk of falls and lead to balance disturbances (posterior cord ataxia) [1, 19–21]. Diabetic motor neuropathy leads to limb weakness and muscle atrophy, and autonomic neuropathy is linked to increased cardiovascular event risk [31] and leg injury during training, as well as decreases in exercise capacity and training pulse.

Diabetic foot prophylaxis

The physiotherapist plays an important role in the management of foot-related problems in patients with DM through DF severity stratification and recommendations for offloading devices and training programs to improve physical fitness, foot muscle strength, and joint mobility. However, it should be underlined that the only efficient method for causative DF prevention is control of blood glucose concentration and a focus on other cardiovascular risk factors, such as smoking, dyslipidemia, excess of body mass, and hypertension, especially in regard to prevention of neuropathic-
ischemic DF [1]. In order to achieve the therapeutic goals, the patient should adhere to the clinical practice guidelines for foot self-care practice, such as:

• self-care maintenance (e.g. education on prevention, on control of risk factors, on daily foot care, and on appropriate footwear and socks),

• self-care monitoring (e.g. foot inspection and the detection of signs of infection and other diabetes-
related foot disease complications),

• self-care management (e.g. responses to signs and symptoms, foot wound care, and following-up with health professionals and health services) [1, 19–21, 32].

Artificial intelligence is further increasingly playing a role in these aspects of DF prevention and therapy [33].

Regular foot examination should also be performed by health professionals regardless of whether symptoms have appeared. Every patient with a diagnosis of type 1 DM should have a foot examination 5 years after the diagnosis, and each patient with type 2 DM should have such an examination at the time of diagnosis and at least once a year after that. However, in patients stratified as high risk for foot wound or ulcer development, foot examination ought to be done every 1–3 months, regardless of DM type [1].

The suggested risk factors for DF development that can be diagnosed by both patients and healthcare professionals are:

• demographic and socioeconomic (higher age, male sex, being divorced),

• medical (obesity, the need for treatment with insulin, history of minor or major foot or leg amputation, risk of cardiovascular event, presence of multi-site atherosclerosis, walking abnormalities),

• lifestyle risk (being a smoker, low level of physical activity) [1, 19–21].

Such fundamental DF risks can be refined depending on:

• DM duration and control;

• presence, number, and severity of DF risk factors (e.g. past foot ulcer, history of amputation, foot deformity, or chronic kidney disease);

• data obtained during physical examination (e.g. foot inspection and assessment of physical fitness and mobility [34]; checking for the presence of sensory neuropathy using a 10 g Semmes-Weinstein monofilament [35] and checking for decrease in vibration sensation; assessment of balance control and motion at lower-limb joints and deterioration in foot function using, for example, a functional reach test, step test, timed up and go (TUG) test, or timed static stance test; evaluation of signs of PAD and the presence of an arterial pulse on the posterior tibial artery and perfusion, extent, depth, infection and sensation (PEDIS) for dorsalis artery; assessment of foot hygiene, post-ulcer scars and calluses, foot deformity, foot drop, weakness of tendon reflexes, skeletal muscle atrophy, and reduction in joint movement) [36];

• the results of general and foot-oriented functional physiotherapeutic tests;

• measurements using special diagnostic techniques, such as:

– thermography in order to identify early infections [37],

– pedobarography, a podoscan device, or a podometric or tensometric platform for the biomechanic analysis of plantar pressure distribution [7, 38],

– in-shoe pressure measurements [39],

– doppler ultrasound with evaluation of blood flow parameters, including pedal acceleration time measurement; ankle-brachial index (ABI), toe brachial index, arterial pressure on the toe or ankle, transcutaneous oxygen pressure (TcPO₂) for the purpose of eventual foot ischemia examination [1, 3],

– ultrasound evaluations of foot, ankle, and calf skeletal muscles to check for the presence of muscle atrophy, eventually suggested by reduced foot muscle thickness and muscle cross-sectional area [26, 40];

• the interpretation of laboratory tests (e.g. those for urine analysis, assessment of urine albumin-to-creatinine ratio, HbA_1c, blood glucose, blood creatine concentration, estimated glomerular filtration rate, blood morphology with white blood cell count, and C-reactive protein and lipid profile) [1–4, 19–21].

The holistic diagnosis of DM patients as presented above, including a detailed evaluation of cardiovascular system status [3] and foot inspection, is necessary before physiotherapy planning because even walking training to improve general fitness and blood circulation in the legs can only be recommended for DM patients without an ulcer on the pedal surface of the foot and for those who have properly fitted shoes. Only after fulfilment of the safety criteria can rehabilitation and personalized training programs be recommended for patients with DF. In patients with less advanced PAD, walking training and climbing the stairs can be recommended and, in patients with CLTI, the physiotherapist can recommend Buerger-Allen exercises that rely on elevating and lowering the legs with some foot movement (dorsal and pedal flexion) to provoke alternating lower limb ischemia and hyperemia and improve blood circulation and collateral development in the lower limbs [1–4, 30]. It is proven that physical activity and exercises to improve joint movement and muscle strength may also decrease the risk of DF development.

In DM patients with dominant sensory and motor diabetic neuropathy, several specially designed devices
may be useful in the prevention of DF development through improvement in standing balance, walking ability, and ankle-foot muscle activity. The footwear devices suggested include: simple shoe insoles to decrease the plantar pressure gradient and increase the plantar gradient angle [41, 42]; highly personalized insoles obtained from 3D printing technology [43]; self-adjusting insoles dedicated to lowering pressure in a specific part of the foot, such as in the heel [44]; vibrating shoe insoles that stimulate foot sensory receptors and improve motor impairments [45]; vibrating foot orthoses for improving tactile sensation [46]; and pressure-relieving footwear and insoles with replaceable top covers [47]. It has been proven that custom-made offloading devices are more effective than standard devices for preventing DF ulceration; however, their cost-effectiveness compared to standard insoles and offloading devices needs to be studied further [1, 19–21, 48]. Moreover, in DM patients with diabetic neuropathy, the following techniques have been found to be effective in the prevention of diabetic wound development:

• proprioceptive, aerobic, and resistance training on platforms, use of virtual reality devices, and Tai Chi [49],

• exercises strengthening the intrinsic foot muscles,

• ankle mobilization combined with home stretches, as limited joint mobility is a proven risk factor in DF ulceration when present in the subtalar and first metatarsophalangeal joints [50–53],

• daily whole-body aerobic, strengthening, balance, and flexibility exercises, which are crucial to mobilize patients [54].

Such health-promoting and foot-oriented exercise programs as those listed above can improve the signs and symptoms of diabetic polyneuropathy, enhance gait, restore mobility in the foot and ankle joints, redistribute pressure while walking, and increase foot strength and function, and can, ultimately, help mitigate the risk factors for DF ulceration and complications associated with prolonged immobilization [53]. An example of foot-oriented exercise program may consist of 10–20 repetitions of some or all of the following: heel cord stretch (wall push), heel cord stretch with bent knee, Achilles stretch, standing heel raise, golf ball roll, towel stretch, calf raise (two-legged or one-legged), ankle range-of-motion exercises, marble pickup, towel curl, ankle dorsiflexion/plantar flexion, single leg balance, ankle rotation, sitting plantar fascia stretch, toe spread, writing the alphabet with the feet, ankle out strengthening exercises using a resistance band, basic balance, big toe stretch, toe splay, and sand walking. However, a recent meta-analysis by van Netten et al. [55] showed that a foot-ankle exercise program of 8–12 weeks’ duration may not prevent diabetes-related foot ulceration, decrease barefoot peak plantar pressure during walking, improve HRQoL, or increase foot and ankle muscle strength and function; however, such a program may improve the ankle joint and first metatarsal-phalangeal joint range of motion and neuropathy signs and symptoms [52].

Treatment for diabetic foot

As stated in the introduction, there are a number of interventions that play a role in the treatment of DF. The main approaches are: blood glucose control; nutritional support, including immune nutrition; wound management in accordance with the TIMERS framework; intravenous therapy with antibiotics in patients with a systemic response to foot infection; revascularization in the case of neuropathic-ischemic DF; and spinal cord stimulation, which is recognized as a safe and effective treatment for pain reduction in neuropathic/nociceptive pain conditions in neuropathic DF [56]. Treatment of DF should be performed in a diabetic foot multidisciplinary unit (DFMU), an approach that is associated with a reduced risk of limb amputation [1, 16, 19–21]. In this type of a multidisciplinary DF treatment team, the physiotherapist plays an important role, which, as in every case, relies on diagnosis and the introduction and monitoring of interventions and their outcomes. The physiotherapist should educate patients on foot offloading and explain the rehabilitation program to protect patients from the complications of immobilization. Moreover, in every DM patient with DF undergoing surgical treatment (e.g. advanced wound debridement, limb revascularization, and/or leg amputation), the physiotherapist should work with dieticians and psychologists in formulating prehabilitation procedures and models of enhanced recovery after surgery [57].

Diagnosis in every patient with DF and an active wound or ulcer should, among other factors, consist of the patient’s scores in standard classifications, such as the WIfI system or PEDIS, site, ischemia, neuropathy, bacterial infection and depth, Infectious Diseases Society of America, International Working Group on the Diabetic Foot, or Wagner scale, or in regard to another locally accepted scale, for instance the diabetic foot questionnaire [1, 19–21, 58]. Scoring in these scales helps to inform decisions about the type and length of therapeutic interventions such as treatment with antibiotics, revascularization, surgical ulcer debridement, assess qualification for physiotherapy, as well as providing an estimation of the risk of minor and major foot or limb amputation.

As stated above, physiotherapy for DF patients should be planned after a detailed patient examination, including an interview, physical examination, imaging, and laboratory tests. In addition to a general examination, the strength, endurance, and performance of the skeletal muscles of the whole body and the affected limb, and an appropriate functional test, should be performed. The effectiveness of every intervention ought to be monitored using the same functional tests and, when an intervention outcome is disappointing, appropriate modification of the kind of physiotherapy should be introduced. In the majority of patients with active DF, basic kinesiotherapy consists of exercises for the following: strengthening the skeletal muscles of the shoulder and pelvic girdle to improve balance and the ability to move with crutches; strengthening the muscles of the affected lower limb (e.g. ankle toe movements, static quadriceps, static hamstrings, dynamic quads, initiation of partial weight bearing); strengthening the unaffected lower limb and bilateral upper limb (e.g. heel slides with a 1 kg weight cuff, dynamic quads, bicep curls with a 1 kg weight cuff, improving upper limb mobility with flexion/extension, and abduction/adduction with a 1 kg weight cuff); improving ambulation with a walker for non-weight bearing of the affected leg and pivot transfers while walking; bed mobility exercises (e.g. transitioning from supine to side-lying and from side-lying to sitting); breathing exercises, such as pursed lip breathing and thoracic expansion exercises with upper limb mobility with a 5-second hold; education in mobilizing; aerobic and resistance exercises (for general fitness and sarcopenia prevention); balance and anti-contraction exercises; sensory integration therapy [54]; and anti-thrombotic exercises (e.g. mobilization of foot, ankle, and calf pumps) with the use of muscle pump activator devices [59].

In the treatment of active DF, the physiotherapist may also apply physical energy-based therapies, which are evidenced as being efficient in stimulating foot ulcer healing, as follows: extracorporeal shockwave therapy [60]; photobiomodulation (light therapy); combined ultrasound and electrostimulation [11]; and low-level laser therapy and electrical stimulation [61, 62]. The physiotherapist may also apply NPWT; and gas-based therapy, including ozone, carbon dioxide, and hyperbaric oxygen therapy [1, 14, 16, 19–21]. Physical therapy supports wound healing through microcirculation stimulation, cell activation, and infection control. However, updated recommendations derived from systematic reviews and best practice statements show a lack of evidence that physical treatment methods are effective for wound healing, so each physiotherapist should balance the benefits and harms of using physical methods [16].

Charcot osteoarthropathy

As stated above, the most advanced form of neuropathic DF is Charcot osteoarthropathy. The prevalence of Charcot foot among patients with DM is estimated at 0.56–0.79%, with an incidence rate of 6.4–9.5 per 10,000 with DM. The significant risk factors for the development of Charcot foot within 12 months are the presence of peripheral neuropathy, repeated minor trauma, foot ulceration, infection or surgery of the affected limb, long DM duration, presence of retinopathy, micro- and macroalbuminuria, elevated HbA_1c levels, and PAD coexistence. In addition, women with type 1 DM and men with type 2 DM have a higher risk of developing Charcot foot compared to their counterparts of the opposite sex [63]. Charcot foot should be suspected in every DM patient with neuropathy and unilateral foot reddening, edema, and warming (the skin temperature difference between the feet may amount to as much as 2–6ºC). The following should be taken into consideration in the differential diagnosis of Charcot foot: deep vein thrombosis of the lower extremities, foot phlegmon, trauma, and gout. Vitamin B₁₂ deficiency should also be considered as a potential factor in diabetic neuropathy progression in patients treated with metformin.

In patients in an active phase of Charcot foot, in addition to glucose control, the basis of physiotherapy is keeping the affected foot as still as possible and avoiding putting any weight on it. This can be achieved by round-the-clock lower extremity knee-high offloading until an inactive phase has been achieved [5–13]. The offloading devices used in DF treatment are divided into removable and non-removable [1, 5–13, 19–21], depending on ulcer location. Removable offloads are recommended for patients with non-plantar ulcers, infected plantar ulcers in the forefoot, or heel ulcers. Offloading therapy can have the form of a knee-high brace, orthoses, or offloading shoes. Non-removable offloading devices, usually a type of plaster cast from below the knee or a protective boot (total contact softcasts and total contact casts are forms of non-removable walkers) are only recommended for offloading in patients with forefoot and metatarsal ulcers but without signs of infection [5]. Unfortunately, many DM patients exhibit a limited tolerance for these devices, which contributes to their underuse [19–21, 64]. In such clinical conditions and as additional offloads, as well as walking limitation, items that patients can use at home include temporary shoes for offloading the forefoot or heel, therapeutic insoles, crutches, a wheelchair, and knee-high foot and shin orthoses (walking boots). In patients with active Charcot foot, Buerger-Allen exercises are recognized as a part of the offloading intervention and are shown to help in wound healing [30]. The offloading effectiveness of custom-made footwear for people with DM should be assessed using multidimensional plantar pressure measurements and maximum peak plantar pressure [5, 7, 10, 13, 41, 44]. The effectiveness of the offloads listed above can also be monitored remotely using sensor technologies that measure pressure, cumulative plantar tissue stress, and weight-bearing activity, exemplified through applications such as smart insoles and the SmartBoot, and other digital health technologies that show promise in improving offloading and changing patient behavior [65, 66].

Resolution of an inflammatory state during Charcot foot treatment may be very slow, and some patients might even require 6–12 months of offloading. Therefore, care should be taken in a return to normal foot loading. The high risk of ulcer and Charcot foot recurrence ought also to be taken into account. Management of the inactive phase of Charcot foot should be controlled using, for example, thermography and a comparison of the skin temperature on the surfaces of both feet, reduction in bone marrow edema in magnetic resonance imaging, and evaluation of foot bone consolidation using X-ray. During the inactive phase of Charcot foot, the patient’s management relies on education in regard to foot hygiene, use of specialist insoles and/or orthopedic interventions (e.g. arthrodesis), and correcting foot deformity that occurred during the acute phase. Moreover, the physiotherapist should manage these patients after orthopedic surgery and following lower limb revascularization in regard to diagnosis of lower limb ischemia recurrence and need of repeated intervention, thorough regular assessment of occurrence of resting pain and/or necrosis, and decrease of ABI value < 0.4, or TcPO₂ < 25–30 mm Hg [3, 67].

Secondary prevention

Secondary DF prevention relies on:

• prophylaxis for the foot wound and ulcer recurrence after healing,

• prevention of foot ulcer infection, osteitis, and gangrene,

• lowering the risk of leg amputation or limiting its extent,

• correcting of foot deformity that occurred during the active phase of DF and Charcot foot.

It has been revealed that the risk of foot ulcer recurrence amounts to 40% per year, and this increases to 60% within 3 years. The main risk factors of DF recurrence are PAD, foot deformity, past ulcer on the plantar foot surface, diabetic neuropathy and retinopathy, diabetic kidney disease, and male gender [67]. Secondary DF prevention ought to be performed within a multidisciplinary team, and the basis of this type of prophylaxis is regular control of blood glucose concentration and other cardiovascular and neuropathy risk factors, as well as regular foot inspections and the monitoring of foot skin condition. The physiotherapeutic methods recommended for secondary DF prevention are largely the same as those enumerated in the subsection on primary DF prevention, and based mainly on the patient’s self-care, some form of general fitness exercise, exercising the lower limbs, prevention of skin dryness and damage (using emollients and moisturizing cream), and the use of fitted lace-up, natural leather edema shoes and seamless socks. Patients with diabetic neuropathy should avoid heating their feet.

Physiotherapy in patients after lower limb amputation

After an incidence of DF or Charcot foot and following foot or leg amputation, measures for preventing re-amputation of the affected limb and prophylaxis for contralateral limb injury and amputation should be introduced for the patient [68]. Patients also require rigorous control of blood glucose and HbA_1c levels and cardiovascular risk due to high all-cause mortality after leg amputation in DM patients, which amounts to 5–17%, 13–40%, and 39–80%, after 1 month, 1 year, and 3–5 years, respectively [1, 18–21]. The risk of limb re-amputation in patients with DF is 31.5% within 2 years [69].

The physiotherapist can improve patients’ prognoses and functional status through the introduction of physical training, perioperative patient care, stump shaping, education in the use of crutches and wheelchairs, as well as help with adapting to a prosthetic limb. The role of aerobic and resistance training in the reduction of MACE risk was presented earlier. In patients with planned limb amputation, the physiotherapist should introduce prehabilitation rules, as well as general improvement, isometric, synergistic, and resistance exercises. Following limb amputation, the physiotherapist should instruct the patient in the following: anti-thrombotic breathing exercises, thoracic expansion and effective cough exercises, or forced inspiration and resistance exhalation using various respiratory trainers (e.g. POWERBreathe, RespiPro, or breathing into a bottle containing water, or a glove, connected to the patient by a plastic tube); general improvement and relaxation exercises; patient positioning and posture correction; mobilization, balance and anti-contraction exercises; obstacle avoidance; walking with a brace or stick; walking on surfaces of different hardnesses; lifting objects; sitting down and getting up from a chair; independent use of the toilet and ability to transfer between seats while using a wheelchair; prosthesis hygiene; and skin and deep sensory integration therapy [54]. The effectiveness of such rehabilitation should be monitored using a functional test, for example a TUG test, 10-meter walk test, or 2-minute walk test [70]. Moreover, after limb amputation, the patient should be prepared by the physiotherapist for a limb prosthesis, using measures such as massages and stump forming and hardening.

Conclusions

Physiotherapy is useful in both the primary and secondary prevention of DF, during wound healing in the DF acute phase, including Charcot foot, and after minor or major limb amputation. A physiotherapist working in a DFMU or taking part in other multidisciplinary teams is able to:

• diagnose the type and severity of a patient’s dysfunctionality,

• recommend a physiotherapeutic intervention (e.g. aerobic, resistance, balance, flexibility, breathing, and anti-thrombotic training models, joint mobilization, skeletal muscle strengthening, a choice of physical therapy, use of offloading techniques, and sensory protection), and educate the patient in self-management,

• monitor the patient’s adherence to an intervention and its outcome.

Through such activities, the physiotherapist is not only able to manage foot-related DM complications, but also prevent MACE and MALE occurrence, foot ulcer recurrence, and the need for re-amputation, as well as protect DF patients from the consequences of prolonged immobilization, such as loss of physical fitness, falls, and balance disturbances. The physiotherapist should prioritize the use of innovative physiotherapeutic techniques, tailored to individual patient needs, and integrate advanced technologies such as telemedicine and wearable devices for continuous monitoring. The physiotherapist should also consider the psychological aspects of DF management to improve patient adherence and outcomes, as well as patients’ HRQoL and health status, reduce the risk of limb amputation, and prolong life expectancy.

Disclosures

1. Institutional review board statement: Not applicable.

2. Assistance with the article: None.

3. Financial support and sponsorship: None.

4. Conflicts of interest: None.

References