Barefoot Training & Diabetic Peripheral Neuropathy

According to the World Health Organization (WHO) over 347 million people around the world are diagnosed with diabetes mellitus.  As the incidence of this disease continues to rise the importance of health and fitness professionals to play an active role in the prevention and management of diabetes has never been greater.

As a Podiatrist one area of diabetes which I encounter on a daily basis is diabetic peripheral neuropathy (DPN).   Although DPN is often associated with those patients who have had diabetes for greater than 10 years, this is not always the case.   More frequently we are seeing the loss of plantar foot sensation as the initial symptom in pre-diabetic patients.

As a diabetic patient begins to lose the sensation to the plantar foot their is a direct impact on balance stability and fall risk.   Studies have shown that diabetics with DPN have a 15x greater fall risk when compared to those without DPN.  15x!

With fall risk being a major concern for all public health and insurance companies it is time to start re-thinking the way we approach the patient, client or even athlete with diabetes.

What is diabetic peripheral neuropathy? 

Diabetes is a condition associated with poor glucose control and frequent hyperglycemic episodes.   During periods of hyperglycemia the excess blood sugar is highly reactive with free proteins in our blood stream.    These free proteins react with glucose through a process called glycation and results in the formation of advanced glycation end products (AGEs).  

It is these AGEs that are damaging to connective tissue and the nerves throughout the body.   As a special type of free radical the AGEs cause adhesions in fascia, stiffening of blood vessels and a loss of elasticity in tendons – all resulting in impaired flexibility, a loss of micro-circulation and damage to the peripheral nerves.

Classically presenting as a stocking glove pattern, diabetics with DPN with complain about tingling, burning, paresthesias in the tips of the toes and even all the way up to the tibial tuberosity.   With symptoms more pronounced at night or during periods of elevated glucose, most diabetics see DPN as an accepted progression of their diabetes.

However there is actually much that can be done to prevent, manage and even reverse the deleterious effects of DPN.

Barefoot Science & DPN

As the diabetic begins to lose sensation in their feet most Podiatrist adopt the recommendation of “never take off your shoes”.   Although this is a general good recommendation to protect the diabetic from stepping on something sharp that they may not feel, there is still a benefit to the controlled stimulation and strengthening of the foot.

What’s important to note is that most DPN is sensory – and not motor – which means that although the diabetic may lose sensation in the bottom of the foot they are still able to engage the muscles of the foot!    Here comes the perfect application of short foot in these clients to stimulate the proximal co-activation patterns of the hip and core – as well as the deep front fascial line!

Because our nervous system is plastic what we challenge the body will begin to grow, strengthen and adapt.   Through the controlled stimulation of the plantar nerves with vibration training, textures, balance etc. benefits can still be seen in the diabetic with DPN.

Nerve Protective Supplements

While integrating barefoot training with your diabetic client I would also consider and highly recommend the following nerve protective supplements.   These supplements are responsible for blocking the interaction between free proteins and glucose forming AGEs – as well as in the stimulation of nerve growth factor.

Vitamin #1 – L-Methyl Folate

This is not your mother’s folic acid!

L-methyl folate is the activated form of folate (folic acid) which has been shown to increase nerve growth factor. When taken over a period of 6 months studies have shown an increase in epidermal nerve fiber density (or in other words more peripheral nerves!).   Link to study 

Dosage: 1000 ug X 3 times day

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Vitamin #2 – Acetyl-L-Carnitine

ALC is another powerful nerve protective supplement.

ALC has been shown to decrease painful nerve symptoms, as well as increase vibratory sensation. Remember that we maintain balance and absorb impact forces based on our ability to detect vibration so this is extremely beneficial as age!

Dosage: 500mg x 2 times day

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Vitamin #3 – R-Lipoic Acid

This is probably my favorite supplement! (Yes I do get that excited over a vitamin)

Touted as one of the most powerful anti-oxidants, ALA has been shown to improve micro-circulation to peripheral nerves while decreasing oxidative stress.   A key point about ALA is that it must be taken in the R-LA form. “R” form is one that is biologically active (vs. “S” form).

Dosage: 600mg x 1 time day

Final Recommendations

As you begin to integrate barefoot training with your diabetic client there may be some initial opposition as diabetics are so used to hearing “never take off your shoes” however if you do it in a safe, controlled, clean environment such as a gym studio floor and do a foot check before and after – your diabetic client will begin to build trust in this approach.

Complete loss of plantar foot sensation is still not an contraindication to the barefoot training as balancing exercises and foot strengthening will transfer to better proximal stability.   Teaching your diabetic client to correct their shifts in COG from their thoracolumbar fascia is a huge step in the reduction of falls.

Stay tuned for our next article where we will explore fascia, flexibility and the diabetic client!

Stay barefoot strong!

Dr E