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Comunicación escrita: III Congreso Internacional sobre Movimiento y Dolor. La Salle.

 

Efectos del ejercicio terapéutico en personas con dolor por neuropatía diabética: revisión sistemática.

Palabras clave: exercise, peripheral neuropathy, diabetes, pain.

 

Antecedentes: la cifra de personas con diabetes a nivel mundial alcanzó los 366 millones en el año 2011 y se calcula que en el 2030 la cantidad de afectados habrá crecido un 9`9% hasta superar los 552 millones.

Un mal control glucémico, el tiempo de duración de la diabetes y la hiperlipidemia provocan que la mitad de estas personas sufra neuropatía diabética (NPD), relacionada con una apoptosis neuronal e inhibición de la regeneración nerviosa que afectan a la sensibilidad táctil y vibratoria, a la propiocepción en miembros inferiores y a la cinestesia.  A su vez, parece probable que la saturación de oxígeno intravascular a nivel epineural o el flujo sanguíneo insuficiente provoquen una hipoxia capaz de convertir en dolorosa la presencia de neuropatía. Otros hallazgos implican al sistema nervioso central en la hiperexcitabilidad y ampliación de la sensación dolorosa.  La distribución del dolor se da con más frecuencia en los miembros inferiores y de manera especialmente intensa en los pies, se pronuncia durante la noche y en momentos de fatiga y estrés, lo que afecta a la calidad de vida del paciente y aumenta sus niveles de ansiedad y depresión . Además del propio tratamiento para el control glucémico, el abordaje del dolor neuropático se lleva a cabo con fármacos destinados a reducir la sintomatología dolorosa, lo que sigue siendo un reto de resultados controvertidos. Los expertos defienden que es preciso investigar sobre otras líneas de tratamiento no farmacológicas para crear una segunda línea de tratamiento, y la realización de ejercicio físico se erige como una opción prometedora por los resultados obtenidos en diabéticos con o sin neuropatía, entre otras razones porque promueve la mejora del aporte sanguíneo y las factores tróficos en los nervios periféricos. Durante años, la perspectiva de realizar ejercicios de carga en personas con NPD fue desestimada por el riesgo de fomentar la aparición de úlceras plantares a causa del déficit sensorial en esta zona, sin embargo, varios estudios desmintieron esta creencia y cabe destacar de entre ellos un ensayo clínico aleatorizado llevado a cabo en el 2008 en el que se demostró que el ejercicio en carga no aumentaba el riesgo de ulceración plantar. Desde entonces, las guías de ejercicio físico para población con NPD hablan de la conveniencia de realizar ejercicio de intensidad moderada en carga, pero siguen siendo escasas las investigaciones sobre esta práctica en presencia de dolor. Además del deterioro anímico que sufre esta población, es preciso tener en cuenta que también su funcionalidad se ve afectada por la presencia de dolor: las características de su marcha son muy variables y ofrecen poca estabilidad, de modo que un tercio de esta población requiere ayudas técnicas para desplazarse. Los efectos del ejercicio en animales con diabetes y dolor neuropático muestran buenos resultados.

Objetivos: revisar los resultados de estudios experimentales en los que se investigue el efecto del ejercicio terapéutico en personas con diabetes y dolor neuropático.

Metodología: búsqueda de publicaciones científicas sobre la materia en las bases de datos Medline, Cochrane y PEDro introduciendo palabras clave coincidentes con los descriptores. Los criterios de inclusión son: 1.que se realicen en humanos, 2.que tengan un diseño experimental, 3.que incluyan el dolor como síntoma a evaluar, 4) que las herramientas para medir el dolor estén validadas.

Resultados: se han obtenido 67 artículos, de los cuales se  han seleccionado 3 que cumplen los criterios de inclusión. Las eliminaciones se han llevado a cabo a través de la lectura del resumen. La mayor parte de los resultados hace mención a la NPD pero no ponen el foco de atención en el dolor y otros carecen de diseño experimental. De los seleccionados, dos proponen una intervención con ejercicio aeróbico y trabajo de resistencia controlados y supervisados y en ambos se observa mejoría en el padecimiento de dolor, ya que en uno disminuye la intensidad  y en el otro la interferencia del dolor en actividades como caminar o dormir. En ninguno de ellos existe grupo control y el tamaño muestral es pequeño. En estas mismas condiciones, otro estudio utilizó el ejercicio de fuerza isométrico en miembros inferiores en personas con diabetes tipo II y dolor neuropático, pero no se encontró mejoría significativa y la realización de los ejercicios resultó dolorosa durante su ejecución y al finalizar esta.

Conclusiones: existe poca evidencia sobre los efectos del ejercicio terapéutico en el dolor neuropático de personas con diabetes. En el futuro, es preciso que se desarrollen ensayos clínicos aleatorizados con un tamaño muestral amplio y nuevos programas de ejercicio terapéutico. También sería conveniente evaluar los resultados a medio y largo plazo e interpretarlos estratificando a la población por edad, tipo de diabetes y tiempo de duración de la misma.

 

 

Title: The effects of therapeutic exercise in persons with painful diabetic neuropathy: a systematic review.

Key words: exercise, peripheral neuropathy, diabetes, pain.

Background: the global prevalence of diabetes mellitus in 2011 was 366 million, and this figure is expected to increase to 552 million by 2030 . A poor glycemic control, hyperlipidemia and duration of diabetes are associated with diabetic peripheral neuropathy (DPN), a frequent complication of diabetes that affects up to 50% diabetic patients in United States, by promoting neuronal apoptosis and inhibiting nerve regeneration, which leads to significant deficits in tactile sensitivity, vibration sense, lower-limb propioception and kinesthesia. Hemodynamic factors have been suggested to be distinct between the non-painful versus painful phenotypes, epineurial intravascular oxygen saturation and blood flow were shown to be higher in people with painful diabetic peripheral neuropathy (P-DPN). Recent studies have also implicated involvements of central pain processing mechanisms, showing that diabetic patients could become hyper-excitable and amplify the painful sensation. Pain tends to be bilateral and it predominantly involves lower limbs, specifically the foot, it is often worse during the night, as well as under stress and fatigue. All this is associated with significant reductions in overall quality of life of the patients and increase their levels of anxiety and depression. The current standard care for treatment of P-DPN focuses on pharmacological treatments aiming to relieve painful symptoms but, perhaps the myriad of novel drugs that have been introduced, finding appropriate pharmacological therapies remains a strenuous effort that is currently inadequate. A group of Toronto Expert Panel of Diabetic Neuropathy stated a need for well-designed studies investigating non-pharmacological approaches, and exercise appears as a promising option in diabetic patients with or without neuropathy because of, among other reasons, its potential effect in blood supply to peripheral nerves. Previously, weight-bearing exercises have been contraindicated among people with DPN, likely due to a greater perceive risk of foot injury that may be unnoticed by patients, however, several studies, specially a randomized controlled trial in 2008, showed that weight-bearing exercise didn`t increase the risk of foot ulceration. It has led to a recent change in exercise guidelines for people with DPN to allow moderate-intensity of weight-bearing exercise, but the lack of evidence remains still unclear the effects of exercise in patients with P-DPN. These patients suffer mood disorders and functional impairment influenced by neuropathy and by pain, and their biomechanics during walking have great variability and poor balance control, so one-third of them require a walking assist device. The effects of exercise on P-DPN patients are largely limited to animal studies that report promising results, but little is known about its consequences in humans.

Objectives: to review the results of experimental studies about the effect of therapeutic exercise in persons with P-DNP.

Methods: using the key words previously shown, three major scientific databases were searched: Medline, Cochrane and PEDro. The following criteria were subsequently applied: 1. the subjects must be humans, 2. an experimental design is required, 3. Pain must be a main symptom to treat, 4. tools to measure pain must be validated. 

Results: the initial keywords search yielded 67 articles. Two authors reviewed all abstracts and after applying criteria 3 articles remained. That is, the vast majority of articles reported results in DPN but excluding pain, or did not use an experimental design. One of the articles did not measure pain with a validated instrument, so it was finally excluded. Two of the selected articles used a supervised aerobic and resistance training program and showed good results in pain: one of them reduces pain intensity and the other reduces pain interference in several activities as sleeping or walking, but neither of them have control group and the sample size is too little. With the same kind of design, the third article applies isometric exercise in lower-limbs of type II diabetic patients. Making the exercise was painful during and after the practice and the authors did not find significant improvements in perceived pain.

Conclusions:  there`s poor evidence about the effects of therapeutic exercise in people with P-DNP. Future randomized controlled trials with a bigger sample size and new exercise proposals are needed. We suggest the necessity of taking into account the long term effects of exercise and the convenience of stratifying the sample by age, type of diabetes and time of diabetes evolution criteria. 

 

 

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