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Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/burns

Potential efficacy of sensorimotor exercise program

on pain, proprioception, mobility, and quality of life
in diabetic patients with foot burns: A 12-week
randomized control study

Walid Kamal Abdelbasset a,b, *, Shereen H. Elsayed c,d, Gopal Nambi a,

Sayed A. Tantawy e , Dalia M. Kamel f , Marwa M. Eid g,h ,
Samah A. Moawd a,d , Saud F. Alsubaie a
a
Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam bin Abdulaziz
University, Al-Kharj, Saudi Arabia
b
Department of Physical Therapy, Kasr Al-Aini Hospital, Cairo University, Giza, Egypt
c
Department of Rehabilitation Sciences, Faculty of Health and Rehabilitation Sciences, Princess Nourah bint
Abdulrahman University, Riyadh, Saudi Arabia
d
Department of Physical Therapy for Cardiovascular/Respiratory Disorders and Geriatrics, Faculty of Physical
Therapy, Cairo University, Giza, Egypt
e
Department of Physiotherapy, Center of Radiation Oncology & Nuclear Medicine, Cairo University, Giza, Egypt
f
Department of Physical Therapy for Women's Health, Faculty of Physical Therapy, Cairo University, Giza, Egypt
g
Department of Physical Therapy, College of Applied Medical Sciences, Taif University, Taif, Saudi Arabia
h
Department of Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Giza, Egypt

article info abstract

Article history: Background: Both diabetes mellitus (DM) and burn injuries lead to physical and psychological
Accepted 5 August 2020 impairments. Foot burns are still a challenging health condition because of its important
Available online xxx sensory role. No previous studies have assessed the physical therapy intervention on
diabetic patients with foot burns. Therefore, this study aimed to assess the potential efficacy
of sensorimotor exercise on pain, proprioception, mobility, balance, and quality of life in
Keywords:
diabetic patients with foot burns.
Diabetes
Methods: Between July 2019 and February 2020, thirty-three diabetic patients with foot burns,
Foot burns
aged 32 to 46yrs, were enrolled in this randomized control study, and randomized
Sensorimotor exercise
consecutively into two groups, study group (n=16) and control group (n=17). The study group
Pain
underwent a sensorimotor exercise program thrice a week for 12 consecutive weeks,
Proprioception
however the control group did not undergo the exercise intervention. Both groups were
instructed to conduct home exercises. Visual analogue scale (VAS), proprioceptive
responses, time-up and go (TUG) values, and short form-36 (SF-36) have been assessed
prior and subsequent to the study intervention.
Results: No significant differences were observed between groups regarding baseline data
(p>0.05). Subsequent to 12wk intervention, the study group showed significant improve-
ments in outcome measures (proprioceptive responses, p<0.05, VAS, p<0.001, TUG, p=0.003,

* Corresponding author at: Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam bin
Abdulaziz University, Al-Kharj, Saudi Arabia.
E-mail address: walidkamal.wr@gmail.com (W.K. Abdelbasset).
https://doi.org/10.1016/j.burns.2020.08.002
0305-4179/© 2020 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002
JBUR 6225 No. of Pages 7

2 burns xxx (2020) xxx xxx

and SF-36, p< 0.001) and the control group exhibited significant changes in VAS and SF-36
(p=0.004, p=0.043 respectively) however, no significant changes were found in propriocep-
tive responses and TUG values (p>0.05). Between groups, the post-intervention comparison
demonstrated statistical differences with tending toward the study group (proprioceptive
responses, p<0.05, VAS, p< 0.001, TUG, p=0.013, and SF-36, p=0.046).
Conclusions: Sensorimotor exercise training may improve, pain, proprioceptive responses,
mobility, balance, and quality of life in diabetic patients with foot burns. Physiotherapists
and rehabilitation providers should include the sensorimotor exercise in their protocols in
the treatment of diabetic patients with foot burns.
© 2020 Elsevier Ltd and ISBI. All rights reserved.

around a joint, we must recognize the importance of the

1. Introduction central nervous system (CNS) in motion regulation to achieve
desirable patterns for preserving joint stability [17,18]. It has
Egypt is one of the 21 international locations and regions of the been reported that sensorimotor exercise training is charac-
International Diabetes Federation (IDF) in the Middle East and terized by regeneration of neuromuscular structures [19], the
North Africa (MENA) locale. In the world, 463 million persons reduced occurrence of injuries [20,21], and by functional
have diabetes mellitus (DM), and 55 million are in the Middle adaptations of the neuromuscular system [22,23], leading to
East and North Africa (MENA) region; by 2045 this is projected proprioception improvement [23], balance control and coordi-
to be 108 million people. DM is a fast-growing health problem, nation [24] and improving mobility.
affecting 15.2% of the Egyptian adults (8,850,400 millions) Although previous studies confirmed the beneficial effects
among 58,091,500 total adults [1]. of exercise on diabetics and burn patients separately [17,25
DM leads to delay of wound healing, vascular damage, 27] or in combination [28], our current study is the first to
immune dysfunction, metabolic disturbances, high risk of assess the potential efficacy of sensorimotor exercise on pain,
infection and vascular injury [2]. Therefore, burned patients proprioception, mobility, balance, and quality of life in diabetic
with uncontrolled diabetes are at risk for detrimental results patients with foot burns theorizing that this type of exercise
[3]. Healthy people with burns additionally develop stress- may improve pain, proprioception, mobility, balance, quality
induced hyperglycemia because of endocrinal complications of life in those patients.
from their injury [4]. In the meantime, people with pre-existing
DM are at a higher risk for burns and wound healing
complications [5]. 2. Materials and methods
DM has a less understood complication on the vestibular
system, which is responsible for balance in static and dynamic 2.1. Study design
conditions. DM affects the structures and functions of
vestibular system in animals and clinical studies [6 8]. This study was a single-blind randomized control clinical
Therefore, physiotherapists have to consider the effect of study. It was conducted at the physiotherapy outpatient clinic
DM on vestibular system due to the risk of falls during of the tertiary Kasr-Al-Aini hospital between July 2019 and
assessment, planning and treatment. Physiotherapy can February 2020. It was approved by the local Institutional
improve diabetic control, physical function, gait and balance Ethical Committee of the Physical Therapy Department at
by exercises either aerobic, resistive or a combination of them Cairo University Hospitals in accordance with ethical stand-
in diabetic patients [9 12]. ards and guidelines of Helsinki Declaration, and each patient
Foot burns are a critical health problem that could lead to was instructed to sign a written informed consent before
physical and psychological disabilities [13]. Although the foot starting the study.
has a small surface area (approximately 3.5% of the total body
surface area), it has an important and specialized role in 2.2. Participants
function that could lead to a serious morbidity. Because of the
location, burns to the feet may prolong bedrest, delay return to Thirty-four diabetic patients with foot burns, aged 32 46yrs,
work, and burn-related complications could give rise to were recruited from the Department of Surgery and Burns, and
emotional and financial effects [14,15]. randomized consecutively into two equal groups (n=17), study
Usually, foot burns occur in patients with DM and disability group (SG) and control group (CG). Patients were included in
in different ages such as elderly, adults, and children [13,15]. the study according to the following criteria; (1) diagnosed with
Soft tissue loss subsequent to foot burns is considered a difficult type 2 diabetes mellitus (T2DM), (2) more than 6-month post
problem as a result of poor vascularization of lower limbs, foot burns, (3) total body surface area (TBSA)30%, (4) flames
reasonably tensed skin tissues, and restricted local flutters [16]. or scalds burn, (5) partial to full-thickness burn, (6) skin graft or
Sensorimotor exercise training is an unusual form of none, (7) visual analogue scale (VAS)8. However, the
proprioceptive and stability exercises that is used for the exclusion criteria were cognitive or mentality dysfunctions,
chronic musculoskeletal pain. It depends on the concept that psychiatric conditions, fractures, pregnancy, cancer, severe
instead of emphasizing the isolated muscle group strength vascular complications, inability to walk.

Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002
JBUR 6225 No. of Pages 7

burns xxx (2020) xxx xxx 3

2.3. Randomization and blindness stimuli [30,31]. All patients were informed about the test
procedures before undergoing the test. Each patient was
After assessing the patients for eligibility, they were random- instructed for a maximal tilting from standing position in left,
ized using sealed envelopes to two groups, equal in number right, forward, and backward directions. The maximal tilt
(n=17). The study group (SG) underwent the sensorimotor angle was measured as a center of pressure. The patient was
exercise program plus home exercise program, and the control then instructed to shift the center of pressure to the colored
group (CG) underwent the home exercise program only mark presented on the monitor with pointer assistance and to
without conducting the sensorimotor exercise program. keep this mark in mind, and after that reaching the mark on
Before starting the study, a simple randomization was the monitor without pointer assistance. The changes in the
performed by a blinded physiotherapist using opaque sealed maximal tilt angle between the baseline and adaptable stimuli
envelopes contained a specific code for each group. were assessed in all directions.

2.4. Intervention 2.7. Pain severity assessment

The two study groups were recommended and encouraged Pain severity was assessed using the visual analogue scale
frequently to conduct the home exercise program regularly (VAS). It is a widely used, validated and reliable 10-cm
through the twelve weeks of the study in the form of stretching instrument [32]. Each patient was asked to draw a perpendic-
and walking exercise at least twice weekly. Each patient was ular line on the VAS at the point that signifies the pain severity.
informed about the benefits of adherence to home exercise The score of VAS ranged 0 10, 0 suggests no pain and 10
program and encouraged to conduct it. One of the family suggest severe pain [33].
members confirmed patient adherence to the recommended
home exercise program. 2.8. Mobility and balance assessment
The study group underwent a sensorimotor exercise
program plus home exercise program. The sensorimotor Mobility and balance were assessed using Time Up and Go
exercise program was performed three times per week for (TUG) test. The reliable TUG test was validated to assess the
twelve consecutive weeks in the outpatient physiotherapy function of lower limbs in burned patients [34]. Each patient
clinic under the professional supervision of physiotherapists. was asked to stand from the chair, to walk 3 meters, and come
Each training has been started with 10min warming-up of back to the chair. The time spent was recorded in sec and the
moderate-intensity aerobic exercise (50 60% of maximal differences between pre- and post-intervention were
heart rate) using a treadmill or cycle ergometer. The assessed.
sensorimotor exercise has consisted of core and balance
exercises and wall slides on unstable surfaces using soft 2.9. Quality of life assessment
Thera-Band stability trainers (TheraBand1 , Richmond, Texas,
USA), and different patterns of gait training including side to Quality of life (QOL) was assessed using the short form-36
side, forward, and backward walking exercises. The session questionnaire (SF-36). This 36-item self-reported question-
was ended with 5 10min cooling-down of deep breathing and naire comprises 8 domains including general health, mental
mild-stretching exercises. The exercise session was adapted, health, role emotion, role physical, body pain, social function,
delayed, or discontinued in accordance with the standards of physical function, and vitality. SF-36 consists mainly of
medical care in diabetes reported by the American Diabetes physical and mental components [35]. It is a valid and reliable
Association [29]. The level of exercise increased gradually instrument used in the assessment of burned survivors [36].
every six sessions if endured. Total score ranges from 0 to 100, 0 indicates the poor quality of
The control group was recommended to regularly undergo life and 100 indicates the best quality of life.
the home exercise program only without conducting the
sensorimotor exercise program through the twelve weeks of 2.10. Sample size computation
the study.
Sample sized computation was based on VAS changes utilizing
2.5. Outcome measures G*Power for window (Version 3.1.9.2, Dusseldorf, Germany)
aiming to identify a mean difference of 2 and a standard
The main measure of the study was a proprioceptive deviation of 1.6 depending on preliminary study findings.
assessment, while secondary measures were pain severity, Using a two-sided t-test and a-error of 0.05, 14 patients per
mobility, balance, and quality of life. All measures were each group were required to achieve 90% power. A total sample
assessed pre- and post-intervention by blinded physiothera- of 34 patients was included in the study considering the
pists who were not included in the study interventions. maximal dropout rate is 20%.

2.6. Proprioception assessment 2.11. Statistical analysis

Proprioceptive response was assessed using Pedalo-balance Demographic and baseline data were examined for normality
equipment (Pedalo1 Sensamove. Balance Test with Sensor, using the Shapiro Wilk test. Descriptive analysis was con-
Sport-Thieme AG, Gallen, Switzerland). It is a reliable device, ducted to assess the differences between and within groups.
used to assess the differences between baseline and adaptable Continuous data were analyzed using Students’ t-test

Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002
JBUR 6225 No. of Pages 7

4 burns xxx (2020) xxx xxx

Fig. 1 – The CONSORT flow diagram of the study.

(independent between groups and dependent within each statistically significant differences in favor of SG (p<0.001). For
group), however categorical data were analyzed using Mann TUG, there were significant changes in the SG (p=0.003)
Whitney U test and Chi-square test. SPSS for windows (V.25, however no significant change was found in the CG (p=0.429),
IBM Corp., Armonk, NY, USA) was used for all statistical and between groups comparison showed a significant differ-
analysis and the level of significance was set at p-value<0.05. ence in favor SG (p=0.013). For the quality of life, the total score
of SF-36 showed significant changes in the SG and CG groups
(p<0.001, p=0.043 respectively). SF-36 showed a greater
3. Results

Forty-one patients were assessed for eligibility for the study.

Thirty-four of them were eligible and included in the study Table 1 – Baseline characteristics of the study.
procedures. One patient discontinued the SG treatment and SG CG p-Value
has been excluded from the data analyses. The CONSORT flow (n=16) (n=17)
diagram of the study is displayed in Fig. 1. Patient baseline
Age, yr 38.6 7.1 39.2 6.7 0.804
characteristics are displayed in Table 1. No significant differ- Sex, M/F 10/6 9/8 0.578
ences were observed between groups regarding baselines such BMI, kg/m2 25.7 3.5 26.1 3.8 0.755
as age, sex, BMI, duration post-burn, duration of hospital stay, HbA1c, % 7.4 1.6 7.2 1.8 0.738
TBSA, etiology, depth of burns (p>0.05). Duration post burns, m 8.7 1.7 8.3 1.5 0.478
The mean differences in the baseline outcome measures Duration of hospital stay, days 42.3 7.2 41.5 6.6 0.741
Affected side, uni/bilateral 9/7 11/6 0.619
showed no significant differences between SG and CG groups
TBSA, % 24.3 3.8 23.9 4.2 0.776
as displayed in Table 2 (p>0.05). The maximal tilt angle Burn depth, n (%)
between the baseline and adaptable stimuli showed signifi- Partial thickness 11 (68.75) 13 (76.47) 0.618
cant reduction in the SG in all directions (forward, p=0.024, Full thickness 5 (31.25) 4 (23.53)
backward, p=0.006, right, p=0.002, left, p=0.001) however no Skin graft, n (%)
significant changes were found in the CG (forward, p=0.503, Yes 10 (62.5) 12 (70.6) 0.622
No 6 (37.5) 5(29.4)
backward, p=0.562, right, p=0.491, left, p=0.464). Between
Etiology of burn, n (%)
groups, the post-intervention comparison has demonstrated
Scald 11 (68.75) 11 (64.7) 0.805
statistical significant differences (forward, p=0.047, backward, Flame 5 (31.25) 6 (35.3)
p=0.016, right, p=0.008, left, p=0.009) as demonstrated in
Significant at p-value< 0.05. Data showed as means SD and
Table 2.
frequency (percentages), SG: study group, CG: control group, BMI:
Regarding pain severity, VAS has significantly improved in body mass index, HbA1c: glycated hemoglobin, TBSA: total body
the SG and CG groups (p<0.001, p=0.004 respectively). Between surface area.
groups, the post-intervention comparison has demonstrated

Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002
JBUR 6225 No. of Pages 7

burns xxx (2020) xxx xxx 5

Table 2 – Mean pre- and post-intervention changes between and within groups.
Measures SG CG p-Value
(n=16) (n=17)
Proprioception, MTA
Forward, degrees
Pre- 7.68  3.64 7.72 3.68 0.975
Post- 5.32  1.7 6.96 2.8 0.047*
p-value 0.024* 0.503
Backward, degrees
Pre- 9.85  4.32 9.96 4.52 0.943
Post- 6.17  2.51 9.11 3.92 0.016*
p-value 0.006* 0.562
Right, degrees
Pre- 8.75  3.83 8.82 3.79 0.958
Post- 5.02  2.13 7.94 3.56 0.008*
p-value 0.002* 0.491
Left, degrees
Pre- 8.61  3.68 8.78 3.75 0.896
Post- 4.93  2.06 7.84 3.63 0.009*
p-value 0.001* 0.464
VAS
Pre- 6.5 1.4 6.6 1.2 0.827
Post- 3.2 0.8 5.4 1.1 <0.001*
p-value <0.001* 0.004*
TUG, s
Pre- 10.5  1.4 10.7 1.6 0.706
Post- 9.2 1.1 10.3 1.3 0.013*
p-value 0.003* 0.429
SF-36, total score
Pre- 44.8  9.5 48.3 10.7 0.329
Post- 63.5  8.3 56.3 11.4 0.046*
p-value <0.001* 0.043
*
Significant at p-value <0.05. Data showed as means  SD, SG: study group, CG: control group, MTA: maximal tilt angle, VAS: Visual analogue scale,
TUG: time up & go, SF-36: short form-36.

improvement in the SG than CG (p=0.046) as demonstrated in more susceptible to severe complications of burn injury that
Table 2. oblige specific modalities of the rehabilitation program [39].
Foot burns are still a challenging heath condition because of
the important sensory role of the feet [40]. It constitutes an
4. Discussion imperative sensory component in the physiological control of
body posture. As an explicit and overwhelmingly unique
The current study assessed the effects of sensorimotor mediator between humans’ body and the ground, feet allow
exercise on diabetic patients with foot burns theorizing that the body to feel and react with indoor and outdoor environ-
this type of exercise may improve pain, proprioception, ments [41]. Sensation inputs supplied by cutaneous and
mobility, balance, quality of life in those patients. The study muscular receptors in the feet provide the capability of upright
contributes to the literature by showing that 12 wk sensori- standing, and posture sway is required to reveal body position
motor exercise may improve VAS, proprioception, TUG, and and movement in the space. The sensitivity of foot skin declines
SF-36. in aging and other neural dysfunctions such as diabetes-related
Treatment of diabetic patients with foot burns has to focus neuropathy [41]. This impairment of foot sensitivity conse-
on eliminating subsequent deformities, reducing post-burn quently affects body posture and body balance, and increases
pain, improving proprioception and balance, restoring mobili- the risk of falling among diabetic patients with foot burns.
ty, and improving the quality of life, whether surgical or non- Our study showed that sensorimotor exercise plays an
surgical interventions were performed. important role in interventional physiotherapy and rehabili-
Burns are generally related to numerous serious physical tation modalities for diabetic patients with foot burns.
and psychological complications in healthy subjects that lead Through undergoing a 12wk sensorimotor exercise program,
to an increase in morbidity and mortality rates [37]. DM is also there were improvements in pain, proprioception, mobility,
associated with serious health problems such as axons and and quality of life. Therefore, diabetic patients with foot burns
neuronal deficit through inflammatory influences which who undertake this type of exercise may have less pain and
could lead to peripheral neuropathy [38]. DM has been better proprioception, mobility, balance, and quality of life.
identified as an important risk factor that affects burn injury Moreover, sensorimotor exercise may improve static and
because of sensory and vision impairments such as diabetic dynamic balance [42], and thereby declines the risk of falls
neuropathy and retinopathy. As a result, diabetic patients are among those patients.

Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002
JBUR 6225 No. of Pages 7

6 burns xxx (2020) xxx xxx

In conformity with our findings, previous studies have

concluded that exercise training reduces musculoskeletal pain Conflicts of interest
in diabetic patients [43]. Exercise training has analgesic
influences through enhancing the release of endogenous No competing interests to disclose.
opioids [44]. An earlier study supported the analgesic
responses to exercise training in healthy individuals, and
reported that both high and moderate intensity exercises have Acknowledgements
potential analgesic effects in healthy individuals [45].
For proprioception, 12-week of sensorimotor exercise shows This research was funded by the Deanship of Scientific
that the errors of position imitation have reduced in forward, Research at Princess Nourah bint Abdulrahman University
backward, right and left directions. Additionally, it was reported through the Fast-track Research Funding Program. The
that 8-week of balance training has improved the proprioceptive authors would like to thank all patients for their participation
responses in diabetic neuropathy patients [46]. Since the decline in the study.
of proprioception leads to posture instability in diabetic patients,
improvement in proprioception responses may enhance posture
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Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002
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Please cite this article in press as: W.K. Abdelbasset, et al., Potential efficacy of sensorimotor exercise program on pain,
proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study, Burns (2020),
https://doi.org/10.1016/j.burns.2020.08.002