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Diabetes is one of the fastest-growing diseases worldwide, It has Devastating macrovascular complications (cardiovascular disease) and microvascular complications (such as diabetic kidney disease, diabetic retinopathy, and neuropathy) In Egypt, factors in patients that affect diabetic control include the patient's education and occupation and smoking status. Physical exercise is important for diabetes control. Metformin and investigation availability have a positive association with diabetes control.
Diabetes mellitus increases the risk and accelerates the course of peripheral artery disease, making patients more susceptible to ischemic events and infections and delaying tissue healing. The current understanding of pathogenic mechanisms is mainly based on the negative influence of diabetes mellitus on atherosclerotic disease and inflammation (Fadini et al., 2020).) An early diagnosis of peripheral arterial diseases PAD and correctly identifying patients with Chronic limb-threatening ischemia CLTI are crucial in patients with diabetes to improve outcomes.
Several treatment strategies can be subdivided into lifestyle modification, medical management, endovascular therapies, and surgical interventions for the treatment of PAD.
Exercise training improves walking ability, distances, physical function, and vitality. Physical activity by supervised exercise is recommended in first-line therapy for intermittent claudication by SVS, ESVS, and AHA (Treat-Jacobson et al., 219) More specifically, a supervised exercise program consists of walking a minimum of three times per week (30-60 min/session) for at least 12 weeks Therapeutic laser treatment, also known as low-level laser therapy (LLLT), offers numerous benefits. It is non-surgical, promotes tissue healing, and reduces edema, inflammation, and pain.
The participants will be submitted into two equal groups in numbers:
Group A (Study group) n=20 will receive a low-level laser (scanning laser) combined with an aerobic exercise program for 12 weeks (3 sessions/ week).
Group B (control group) n=20: Who will receive aerobic exercise for 12 weeks (3sessions/week) All patients with their prescribed medications (hypoglycemic, antiplatelet, anticoagulants, antihypertensive, vasodilators, analgesics)
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Study group A: Aerobic exercise+ low-level Laser therapy | Experimental | (Study group A): It will receive a low-level laser (scanning laser) on the course of the posterior tibial and anterior tibial artery combined with an aerobic exercise program for peripheral artery disorder for 12 weeks (3 sessions/ week). |
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| Control group B: Aerobic Exercise group B | Experimental | group B: They will receive aerobic exercise for 12 weeks. aerobic exercise program for peripheral arterial disorders and intermittent claudication. |
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| aerobic exercise + low-level laser therapy | Combination Product | low- level laser parameters: The wavelength: 808 +/- 5nm The power: output is 450 Mw Type of beam: red laser beam. Beam Divergent >,025 rad+/- ,005rad Nominal Distance of Sight hazard >8m The duration: is 20 min for each artery. Treatment period: 3 times/week for 3 months. |
| Measure | Description | Time Frame |
|---|---|---|
| body mass index | Body mass index (Kg/M^2): by dividing the weight by kilogram over Height by meter square. | 3 month |
| peak systolic velocities (PSV) | Duplex ultrasonography of the lower extremity arteries, from common femoral to pedal arteries is used to measure PSV
Severe arterial disease manifests as a PSV over 200 cm/s, monophasic waveform, and spectral broadening of the Doppler waveform. | 3 months |
| Ankle-Brachial Index (ABI) % | • Ankle-Brachial Index (ABI) is a ratio of the highest ankle systolic blood pressure obtained in the anterior tibial/ dorsalis pedis or posterior tibial artery to that of the highest brachial systolic pressure. An ABI < 0.9 was diagnostic of PAD and values were stratified according to severity as:
| 3 months |
| The visual analog scale (VAS) questionnaire for pain | The visual analog scale (VAS) is a validated, subjective measure for acute and chronic pain. Scores are recorded by making a handwritten mark on a 10-cm line that represents a continuum between "no pain" and "worst pain." Delgado etal., 2018).
| 3 months |
| The Edinburgh Claudication Questionnaire (ECQ) | The Edinburgh Claudication Questionnaire (ECQ) Definition of positive classification requires all of the following responses: \Yes" to (1), \No" to (2), \Yes" to (3), Grade 1 \No" to (4), and Grade 2 \Yes" to (4). If these criteria are met, a typical claudicant is one who indicates the pain is in the calf, regardless of whether the pain is also marked at other sites; a diagnosis of atypical claudication is made when the pain is marked in the thigh or buttock, in the absence of any calf pain. Subjects should not be diagnosed with claudication if the pain is indicated in the hamstrings, feet, shins, and joints, or radiates in the absence of any calf pain |
| Measure | Description | Time Frame |
|---|---|---|
| The initial claudication distance and The absolute claudication distance (meters) | The initial claudication distance (ICD), or pain-free walking distance; is the distance walked at the onset of claudication pain The absolute claudication distance (ACD), or maximal walking distance at which claudication pain becomes so severe that the patient is forced to stop (Jongert et al., 2003) | 3 months |
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Inclusion Criteria:
Exclusion Criteria:
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| Name | Affiliation | Role |
|---|---|---|
| Nesreen Gh EL NAHAS, doctor | head of physical therapy department for internal medicine, Cairo university. | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Cairo University | Cairo | Egypt | 12613 | Egypt |
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| ID | Term |
|---|---|
| D003924 | Diabetes Mellitus, Type 2 |
| D058729 | Peripheral Arterial Disease |
| ID | Term |
|---|---|
| D003920 | Diabetes Mellitus |
| D044882 | Glucose Metabolism Disorders |
| D008659 | Metabolic Diseases |
| D009750 | Nutritional and Metabolic Diseases |
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| ID | Term |
|---|---|
| D015444 | Exercise |
| D028022 | Low-Level Light Therapy |
| ID | Term |
|---|---|
| D009043 | Motor Activity |
| D009068 | Movement |
| D009142 | Musculoskeletal Physiological Phenomena |
| D055687 | Musculoskeletal and Neural Physiological Phenomena |
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the study is going to contain 2 experimental groups, the first one will receive combined therapy (aerobic exercise program for PAD + low-level laser therapy) the other group will receive aerobic exercise program for PAD only.
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| Aerobic exercise | Other | Aerobic exercise Frequency = 3sessions/week duration: 10 min warm up and 10 min cool down/ 30 min stance phase Intensity: moderate intensity initiating with 50% HR max to end 75% HR max |
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| 3 months |
| Maximum oxygen consumption Vo^2 max ((ml/kg/min)) | depend on Modified Bruce protocol with the treadmill. Modified Bruce protocol, the first stage at 1.7mph and 0% grade second stage at 1.7 mph 5% grade, and the third stage at 1.7 mph and 10% grade. The test score is the time taken on the test, in minutes. This can also be converted to an estimated VO2 max score using the calculator below and the following formulas, where the value "T" is the total time completed (expressed in minutes and fractions of a minute e.g. 9 minutes 25 seconds = 9.25 minutes). Men : VO2max (ml/kg/min) = 14.76 -(1.379 × T) + (0.451 × T²)-(0.012 × T³) Women: VO2max (ml/kg/min) = 4.38x T -3.9 (ACSM, 2023) | 3 months |
| D004700 | Endocrine System Diseases |
| D050197 | Atherosclerosis |
| D001161 | Arteriosclerosis |
| D001157 | Arterial Occlusive Diseases |
| D014652 | Vascular Diseases |
| D002318 | Cardiovascular Diseases |
| D016491 | Peripheral Vascular Diseases |
| D053685 | Laser Therapy |
| D013812 | Therapeutics |
| D010789 | Phototherapy |