FOot CAre and Exercises ImplementatioN for People With Diabetes in Primary Care (FOCAIN)

Implementing a Contextually Appropriate Intervention Strategy in Primary Care for the Foot-ankle of People With Diabetes to Improve Clinical and Functional Status and Quality of Life

The main objective of this type 2 hybrid implementation effectiveness trial is to implement a contextually appropriate preventive intervention for 8 weeks face to face group foot and ankle exercises for people with diabetic foot in the primary care of the city of Limeira/SP, through the training of physical therapists from the Family Health Care Center and Primary Care (NASF) team. The study will monitor the implementation itself and the clinical outcomes: clinical and functional status and quality of life.

The study is a type 2 hybrid implementation effectiveness trial, whose objective is to simultaneously test the clinical intervention and the implementation strategy. The study will take place in 4 phases, the first being pre-implementation, whose objective is to gather information about local characteristics, barriers and facilitators, and constitute the implementation team. During the second phase, the implementation team will be responsible for structuring the actions for the implementation of the intervention, adapting it to the context defined in phase 1, developing strategies for the training of NASF physiotherapists, in addition to the capacitation of the physiotherapists on the proposed clinical intervention. In phase 3, we will implement the intervention either using a software or a booklet for people with diabetes and we will monitor the participants' diabetes-related, functional and quality of life outcomes after the 8 weeks of intervention. Reach, adoption and implementation will be evaluated using the RE-AIM tool. In phase 4 - _maintenance - _the municipality will be responsible for maintaining, expanding and improving the changes achieved, promoting the sharing of experience with other public and private institutions, facilitating the diffusion of similar programs. Specifically in the phase 3, a randomized controlled trial will be performed with 356 patients with diabetic neuropathy. The participants will be randomly assigned into either a control group (recommended foot care by international consensus with no foot exercises) or an intervention group that will perform face to face exercises, supervised by physiotherapists for 8-weeks. The subjects will be evaluated in 2 different times to access the effect of the intervention: baseline and 8 weeks, for all outcomes. The following outcomes will be assessed in all times: (1) diabetic neuropathy symptoms by Michigan Neuropathy Screening Instrument, (2) fuzzy score of the neuropathy severity, (3) tactile and vibration sensitivity (10-g monofilament and tuning fork), (4) range of motion of the ankle and first metatarsophalangeal joint, (5) finger strength (by a pressure plate measurement), (6) ulcers and pre-ulcerative lesions and (7) quality of life (EQ-5D). The hypothesis of this study is that the intervention will increase the perception of the tactile and vibratory sensitivity of the foot, reduce the symptoms of diabetic neuropathy, increase the strength of the foot muscles, decrease the severity of the diabetic neuropathy (fuzzy score), decrease the number of neuropathy symptoms, as well increase range of motion and quality of life.

exercise therapy, diabetic foot, preventive care, foot-related exercises, musculoskeletal functions, primary health care

Participants in the control group will not receive any specific intervention in addition to the treatment recommended by the health professionals team (doctors, nurses, podiatrists), which includes pharmacological treatment, and self-care recommendations and foot care by international consensus.

Face to face foot-related exercises, supervised by physiotherapist and based in the specific software (Sistema de Orientação do Pé diabético, SOPED) and or booklet. The maximum duration of a session is 40 min and should be be performed 1-2 times/week. The subject should warm-up the foot-ankle and then start exercising in the order suggested by the physiotherapist. The foot exercises progresses from one set with 30 repetitions in a sitting position, to exercising standing, then performing the exercise on one foot only. Other progression criterion is to increase the number of sets performed. The effort scale regulates the individual effort for his/her progression.

Score of the Michigan Neuropathy Screening Instrument (MNSI). This questionnaire comprises 15 questions about symptoms and events related to leg and foot sensitivity and is administered by the participant himself. The answers are summed to get a total score. The sum of all items results in a score ranging from 0 to 13 (13 represents the worst rating of the neuropathy)

The fuzzy classification of the diabetic neuropathy severity will be given by the Fuzzy software score developed by the Laboratory of Biomechanics of Movement and Human Posture available free of charge at: http:// www.usp.br/labimph/fuzzy/. It is a decision support system for classification of the diabetic neuropathy. This decision is based on three domains: signs and symptoms extracted from the Michigan Neuropathy Screening Instrument; tactile sensitivity through the number of non-sensible areas using a 10-g monofilament; and vibration sensitivity by vibrating a tuning fork (128Hz) characterized as absent, present or diminished. The software produces a score from 0 to 10 and the higher the score, the more severe the diabetic neuropathy.

Toes strength will be measured by a pressure plate with the subjects pressing down the plataform with toes standing.

Hallux strength will be measured by the paper grip test using a card where the examiner places it under the participant's hallux, asking the participant to hold it firmly with the hallux. The examiner pulls the card with increasing force while the participant resists

Participants will answer the EQ-5D questionnaire, which is a generic instrument for measuring health-related quality of life that allows generating an index representing the value of an individual's health status.

According to the RE-AIM tool, percentage of coverage and representativeness of people with diabetes participating in the intervention. It will be calculated at the individual level by dividing the population reached by the intervention by the total population of people with diabetes eligible for the intervention. Furthermore, the representativeness of this population will be observed based on sociodemographic data and compared to the non-participating group.

According to the RE-AIM tool, percentage of coverage and representativeness of locations that we will implement (18 clusters) and key actors participating in phase 1 and in the professional training in phase 2. Representativeness of the participating units and professionals will also be considered in the analysis

According to the RE-AIM tool, fidelity to the initially proposed intervention will be evaluated qualitatively and quantitatively, as well as the adaptations - if carried out, through feedback during the course of implementation and in the final evaluation

The presence of ulcers or pre-ulcerative lesions will be monitored through photos without identifying the participant. In cases of doubt, there will be a case discussion with a stoma therapist nurse, specialized in wounds on the feet of people with diabetes

Inclusion Criteria: Diabetes mellitus type 1 or 2; Be able to read e provide consistent information; Ability to walk independently for at least 10 meters; Availability to participate in the intervention at the established group time. Exclusion Criteria: Neurological and / or rheumatologic diseases diagnosed; Perform physiotherapy intervention throughout the intervention period; Receiving any physiotherapy intervention or offloading devices; Active foot ulcer; Major vascular complications.