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Najafi B, Grewal GS, Bharara M, Menzies R, Talal TK, Armstrong DG. Can't Stand the Pressure: The Association Between Unprotected Standing, Walking, and Wound Healing in People With Diabetes. J Diabetes Sci Technol 2017; 11:657-667. [PMID: 27510440 PMCID: PMC5588814 DOI: 10.1177/1932296816662959] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The objective was to report patterns of physical activity and their relationship to wound healing success in patients with diabetic foot ulcers protected with removable or irremovable offloading devices. METHODS Forty-nine people with diabetic foot ulcers were randomized to wear either a removable cast walker (RCW) or an irremovable instant total contact cast (iTCC). Primary outcome measures included change in wound size, physical activities including position (ie, sitting, standing, lying) and locomotion (speed, steps, etc). Outcomes parameters were assessed on weekly basis until wound healing or until 12 weeks. RESULTS A higher proportion of patients healed at 12 weeks in the iTCC group ( P = .038). Significant differences in activity were observed between groups starting at week 4. RCW patients became more active than the iTCC group (75% higher duration of standing, 100% longer duration of walking, and 126% longer unbroken walking bout, P < .05). Overall, there was an inverse association between rate of weekly wound healing and number of steps taken per day ( r < -.33, P < .05) for both groups. RCW patients had a significant inverse correlation between duration of daily standing and weekly rate of healing ( r = -.67, P < .05). Standing duration was the only significant predictor of healing at 12 weeks. CONCLUSION The results from this study suggest significant differences in activity patterns between removable and irremovable offloading devices. These patterns appear to start diverging at week 4, which may indicate a decline in adherence to offloading. Results suggest that while walking may delay wound healing, unprotected standing might be an even more unrealized and sinister culprit.
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Affiliation(s)
- Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Southern Arizona Limb Salvage Alliance (SALSA), College of Medicine, University of Arizona, Tucson, AZ, USA
- Bijan Najafi, PhD, Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza, MS:BCM390, Houston, TX 77030, USA. ;
| | - Gurtej S. Grewal
- Southern Arizona Limb Salvage Alliance (SALSA), College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Manish Bharara
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP), Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Robert Menzies
- Diabetic Foot and Wound Clinic, Department of Medicine, Hamad Medical Co, Doha, Qatar
| | - Talal K. Talal
- Diabetic Foot and Wound Clinic, Department of Medicine, Hamad Medical Co, Doha, Qatar
| | - David G. Armstrong
- Southern Arizona Limb Salvage Alliance (SALSA), College of Medicine, University of Arizona, Tucson, AZ, USA
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Ghomian B, Naemi R. The influence of rocker outsole design on the ground reaction force alignment during walking. FOOTWEAR SCIENCE 2017. [DOI: 10.1080/19424280.2017.1314365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Banafshe Ghomian
- Department of Orthotics and Prosthetics, Iran University of Medical Sciences, Tehran, Iran
| | - Roozbeh Naemi
- Staffordshire University, Staffordshire, United Kingdom
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53
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Almurdhi MM, Brown SJ, Bowling FL, Boulton AJM, Jeziorska M, Malik RA, Reeves ND. Altered walking strategy and increased unsteadiness in participants with impaired glucose tolerance and Type 2 diabetes relates to small-fibre neuropathy but not vitamin D deficiency. Diabet Med 2017; 34:839-845. [PMID: 28103405 DOI: 10.1111/dme.13316] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 12/17/2022]
Abstract
AIMS To investigate alterations in walking strategy and dynamic sway (unsteadiness) in people with impaired glucose tolerance and people with Type 2 diabetes in relation to severity of neuropathy and vitamin D levels. METHODS A total of 20 people with Type 2 diabetes, 20 people with impaired glucose tolerance and 20 people without either Type 2 diabetes or impaired glucose tolerance (control group) underwent gait analysis using a motion analysis system and force platforms, and detailed assessment of neuropathy and serum 25 hydroxy-vitamin D levels. RESULTS Ankle strength (P = 0.01) and power (P = 0.003) during walking and walking speed (P = 0.008) were preserved in participants with impaired glucose tolerance but significantly lower in participants with Type 2 diabetes compared with control participants; however, step width (P = 0.005) and dynamic medio-lateral sway (P = 0.007) were significantly higher and posterior maximal movement (P = 0.000) was lower in participants with impaired glucose tolerance, but preserved in those with Type 2 diabetes compared with the control group. Dynamic medio-lateral sway correlated with corneal nerve fibre length (P = 0.001) and corneal nerve branch density (P = 0.001), but not with vibration perception threshold (P = 0.19). Serum 25 hydroxy-vitamin D levels did not differ significantly among the groups (P = 0.10) and did not correlate with any walking variables or measures of dynamic sway. CONCLUSIONS Early abnormalities in walking strategy and dynamic sway were evident in participants with impaired glucose tolerance, whilst there was a reduction in ankle strength, power and walking speed in participants with Type 2 diabetes. Unsteadiness correlated with small-, but not large-fibre neuropathy and there was no relationship between vitamin D levels and walking variables.
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Affiliation(s)
- M M Almurdhi
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - S J Brown
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - A J M Boulton
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - M Jeziorska
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - R A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, University of Manchester and Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Weill-Cornell Medicine-Qatar, Doha, Qatar
| | - N D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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54
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Reddy PN, Cooper G, Weightman A, Hodson-Tole E, Reeves ND. Walking cadence affects rate of plantar foot temperature change but not final temperature in younger and older adults. Gait Posture 2017; 52:272-279. [PMID: 28012341 DOI: 10.1016/j.gaitpost.2016.12.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/30/2016] [Accepted: 12/05/2016] [Indexed: 02/02/2023]
Abstract
This study examined the relationship between (1) foot temperature in healthy individuals and walking cadence, (2) temperature change at different locations of the foot, and (3) temperature change and its relationship with vertical pressures exerted on the foot. Eighteen healthy adult volunteers (10 between 30 and 40 years - Age: 33.4±2.4years; 8 above 40 years - Age: 54.1±7.7years) were recruited. A custom-made insole with temperature sensors was placed directly onto the plantar surface of the foot and held in position using a sock. The foot was placed on a pressure sensor and the whole system placed in a canvas shoe. Participants visited the lab on three separate occasions when foot temperature and pressure data were recorded during walking on a treadmill at one of three cadences (80, 100, 120steps/min). The plantar foot temperature increased during walking in both age groups 30-40 years: 4.62±2.00°C, >40years: 5.49±2.30°C, with the rise inversely proportional to initial foot temperature (30-40 years: R2=-0.669, >40years: R2=-0.816). Foot temperature changes were not different between the two age groups or the different foot locations and did not depend on vertical pressures. Walking cadence affected the rate of change of plantar foot temperature but not the final measured value and no association between temperature change and vertical pressure was found. These results provide baseline values for comparing foot temperature changes in pathological conditions which could inform understanding of pathophysiology and support development of evidence based healthcare guidelines for managing conditions such as diabetic foot ulceration (DFU).
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Affiliation(s)
- Prabhav Nadipi Reddy
- School of Engineering, Manchester Metropolitan University, Manchester, M15GD, United Kingdom.
| | - Glen Cooper
- School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, M13 9PL, United Kingdom
| | - Andrew Weightman
- School of Mechanical, Aerospace and Civil Engineering, The University of Manchester, Manchester, M13 9PL, United Kingdom
| | - Emma Hodson-Tole
- School of Healthcare Science, Manchester Metropolitan University, Manchester, M15GD, United Kingdom
| | - Neil D Reeves
- School of Healthcare Science, Manchester Metropolitan University, Manchester, M15GD, United Kingdom
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55
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Bagherzadeh Cham M, Mohseni-Bandpei MA, Bahramizadeh M, Kalbasi S, Biglarian A. The clinical and biomechanical effects of subthreshold random noise on the plantar surface of the foot in diabetic patients and elder people: A systematic review. Prosthet Orthot Int 2016; 40:658-667. [PMID: 26951143 DOI: 10.1177/0309364616631351] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 10/22/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Central nervous system receives information from foot mechanoreceptors in order to control balance and perform movement tasks. Subthreshold random noise seems to improve sensitivity of the cutaneous mechanoreceptor. OBJECTIVES The purpose of this study was to systematically review published evidence conducted to evaluate the clinical and biomechanical effects of subthreshold random noise on the plantar surface of the foot in diabetic patients and elder people. STUDY DESIGN Systematic review. METHODS A literature search was performed in PubMed, Scopus, ScienceDirect, Web of Knowledge, CINAHL, and EMBASE databases based on population, intervention, comparison, outcomes, and study method. Quality of studies was assessed using the methodological quality assessment tool, using Physiotherapy Evidence Database scale. RESULTS In all, 11 studies were selected for final evaluation based on inclusion criteria. Five studies evaluated the effects of subthreshold random noise in diabetic patients and six in elder people. In seven studies, biomechanical (balance and gait parameters) effects and in four studies clinical (pressure and vibration sensations) effects of subthreshold random noise were investigated. All reviewed studies were scored fair (2) to good (9) quality in terms of methodological quality assessment using Physiotherapy Evidence Database scale. CONCLUSION The results indicated that subthreshold random noise improves balance and sensation in diabetic patients and elder people. Also gait variables can be improved in elder people with subthreshold random noise. However, further well-designed studies are needed. CLINICAL RELEVANCE The previous studies reported that subthreshold random noise may improve gait, balance, and sensation, but more studies are needed to evaluate the long-term effect of subthreshold random noise in shoe or insole for daily living tasks in diabetic patients and elder people.
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Affiliation(s)
- Masumeh Bagherzadeh Cham
- Department of Orthotics & Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mohammad Ali Mohseni-Bandpei
- Iranian Research Center on Aging, Department of Physiotherapy, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran .,University Institute of Physical Therapy, Faculty of Allied Health Sciences, University of Lahore, Lahore, Pakistan
| | - Mahmood Bahramizadeh
- Department of Orthotics & Prosthetics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Saeed Kalbasi
- Endocrine Research Center, Research Institute for Endocrine Science, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Akbar Biglarian
- Department of Biostatistics, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Paton J, Hatton AL, Rome K, Kent B. Effects of foot and ankle devices on balance, gait and falls in adults with sensory perception loss: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2016; 14:127-162. [PMID: 28009675 PMCID: PMC5437711 DOI: 10.11124/jbisrir-2016-003229] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Foot and ankle devices are being developed as a method of preventing people with sensory perception loss sustaining a fall. Such devices are believed to work by reducing the likelihood of a fall by improving the balance and gait of the user. OBJECTIVES The objective of the review was to evaluate the effectiveness of foot and ankle devices for the prevention of falls and the improvement of balance and gait in adults with sensory perception loss. INCLUSION CRITERIA TYPES OF PARTICIPANTS Participants were community-dwelling adults with bilateral pathological sensory perception loss. TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST The current review evaluated any foot or ankle device, including but not restricted to, all types of footwear (therapeutic and retail), insoles (customized and prefabricated) and ankle-foot orthoses (AFOs). TYPES OF STUDIES In the absence of randomized controlled trials (RCT), the review considered experimental and epidemiological study designs, except case series, individual case reports and descriptive cross-sectional studies. OUTCOMES The primary outcome was number of falls. Secondary outcome measures were clinical or laboratory measures of balance or gait. SEARCH STRATEGY A search for published and unpublished literature from inception to March 2015 written in the English language was conducted across a number of major electronic databases. A three-step search strategy was developed using MeSH terminology and keywords to ensure all that relevant materials are captured. METHODOLOGICAL QUALITY Methodological quality of included studies was assessed by two reviewers, who appraised each study independently, using standardized Joanna Briggs Institute (JBI) critical appraisal tools. DATA EXTRACTION Quantitative data were extracted from the studies that were identified as meeting the criteria for methodological quality using the standardized JBI data extraction tools. DATA SYNTHESIS Due to the heterogeneity of populations, interventions and outcome measures, meta-analyses were not possible and results are presented in narrative form. RESULTS Nine trials (from 10 papers) involving 238 participants, (14 with multiple sclerosis and 16 with idiopathic peripheral neuropathy, 150 with diabetic neuropathy) and 58 controls were included in the review. No study reported falls as an outcome measure. The results of the included studies found that in people with sensory perception loss, postural sway improved with vibrating insoles and AFO, altering the softness and texture of the top cover had no effect on postural sway, wearing footwear over long distances or AFOs improved step-to-step consistency, and no foot and ankle device was reported to have a negative effect on the balance or gait of people with sensory perception loss. The methodological quality of the included studies was poor. No study used a randomized controlled trial (RCT) methodology. No study incorporated a follow-up period or tested the intervention within the context of the intended clinical environment. CONCLUSION There is limited evidence to suggest that footwear and insole devices can artificially alter postural stability and may reduce the step-to-step variability in adults with sensory perception loss. Varying the material properties of an insole does not notably affect static balance or gait.
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Affiliation(s)
- Joanne Paton
- School of Health Professions, Plymouth University, Plymouth, Devon, United Kingdom
| | - Anna L. Hatton
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Keith Rome
- Health and Rehabilitation Research Institute, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland 1010, New Zealand
| | - Bridie Kent
- The University of Plymouth Centre for Innovations in Health and Social Care: a Joanna Briggs Institute Centre of Excellence
- School of Nursing and Midwifery, Plymouth University, Plymouth, Devon, United Kingdom
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Mantovani AM, Savian NU, Palma MR, Faria CRSD, Fregonesi CEPT. Vasculopathy associated with peripheral neuropathy in gait parameters of diabetic people. MOTRIZ: REVISTA DE EDUCACAO FISICA 2016. [DOI: 10.1590/s1980-6574201600040002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Fernando ME, Crowther RG, Lazzarini PA, Sangla KS, Wearing S, Buttner P, Golledge J. Plantar pressures are higher in cases with diabetic foot ulcers compared to controls despite a longer stance phase duration. BMC Endocr Disord 2016; 16:51. [PMID: 27629263 PMCID: PMC5024422 DOI: 10.1186/s12902-016-0131-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Current international guidelines advocate achieving at least a 30 % reduction in maximum plantar pressure to reduce the risk of foot ulcers in people with diabetes. However, whether plantar pressures differ in cases with foot ulcers to controls without ulcers is not clear. The aim of this study was to assess if plantar pressures were higher in patients with active plantar diabetic foot ulcers (cases) compared to patients with diabetes without a foot ulcer history (diabetes controls) and people without diabetes or a foot ulcer history (healthy controls). METHODS Twenty-one cases with diabetic foot ulcers, 69 diabetes controls and 56 healthy controls were recruited for this case-control study. Plantar pressures at ten sites on both feet and stance phase duration were measured using a pre-established protocol. Primary outcomes were mean peak plantar pressure, pressure-time integral and stance phase duration. Non-parametric analyses were used with Holm's correction to correct for multiple testing. Binary logistic regression models were used to adjust outcomes for age, sex and body mass index. Median differences with 95 % confidence intervals and Cohen's d values (standardised mean difference) were reported for all significant outcomes. RESULTS The majority of ulcers were located on the plantar surface of the hallux and toes. When adjusted for age, sex and body mass index, the mean peak plantar pressure and pressure-time integral of toes and the mid-foot were significantly higher in cases compared to diabetes and healthy controls (p < 0.05). The stance phase duration was also significantly higher in cases compared to both control groups (p < 0.05). The main limitations of the study were the small number of cases studied and the inability to adjust analyses for multiple factors. CONCLUSIONS This study shows that plantar pressures are higher in cases with active diabetic foot ulcers despite having a longer stance phase duration which would be expected to lower plantar pressure. Whether plantar pressure changes can predict ulcer healing should be the focus of future research. These results highlight the importance of offloading feet during active ulceration in addition to before ulceration.
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Affiliation(s)
- Malindu E. Fernando
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Qld 4814 Australia
- Podiatry Service, Townsville Community Health Service , Townsville, QLD Australia
- Movement Analysis Laboratory, Sport and Exercise Science, James Cook University, Townsville, Australia
| | - Robert G. Crowther
- Sport and Exercise, School of Health and Wellbeing, University of Southern Queensland, Ipswich, QLD Australia
| | - Peter A. Lazzarini
- Allied Health Research Collaborative, Metro North Hospital & Health Service, Queensland Health, Brisbane, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Kunwarjit S. Sangla
- Department of Diabetes and Endocrinology, The Townsville Hospital, Townsville, QLD Australia
| | - Scott Wearing
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD Australia
| | - Petra Buttner
- Centre for Chronic Disease Prevention, James Cook University, Cairns, QLD Australia
- Tropical Health Solutions Pty Ltd., Townsville, QLD Australia
| | - Jonathan Golledge
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Qld 4814 Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD Australia
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Brown S, Boulton A, Bowling F, Reeves N. Benefits, Challenges, and Potential Utility of a Gait Database for Diabetes Patients. J Diabetes Sci Technol 2016; 10:1065-72. [PMID: 27022098 PMCID: PMC5032949 DOI: 10.1177/1932296816640290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gait analysis is a useful tool in understanding movement impairments, which impact on patient well-being. The use of gait analysis in patients with diabetes has led to improvements in health care including the treatment and prevention of ulceration and development of targeted exercise interventions. The current convention when analyzing gait is to address specific complications of diabetes, controlling for potential influencing conditions within a study sample to understand the effects of the few specific complications chosen for analysis. Databases allow for the storage of data in a structured format, allowing easy access to large quantities of data in a consistent, comparable manner. A database of gait analyses of patients with diabetes has the potential to include far greater sample sizes for statistical analyses, allowing multiple influencing factors to be assessed simultaneously, and relationships identified between multiple influencing factors. However, a database of this type would encounter ethical and methodological challenges in its implementation, which are discussed. This article introduces some of the potential benefits, challenges, and utility of a gait database for diabetes patients. We highlight that, whereas the creation of a database within this clinical population would be a complex process both ethically and practically, huge potential benefits could be gained, overcoming some of the limitations faced by traditional isolated gait analysis studies.
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Affiliation(s)
- Steven Brown
- Manchester Metropolitan University, Faculty of Science and Engineering, School of Healthcare Science, Manchester, UK
| | - Andrew Boulton
- Manchester Royal Infirmary, Division of Medicine, University of Manchester, UK
| | - Frank Bowling
- Manchester Royal Infirmary, Division of Medicine, University of Manchester, UK
| | - Neil Reeves
- Manchester Metropolitan University, Faculty of Science and Engineering, School of Healthcare Science, Manchester, UK
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Deschamps K, Matricali GA, Desmet D, Roosen P, Keijsers N, Nobels F, Bruyninckx H, Staes F. Efficacy measures associated to a plantar pressure based classification system in diabetic foot medicine. Gait Posture 2016; 49:168-175. [PMID: 27427834 DOI: 10.1016/j.gaitpost.2016.07.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 06/27/2016] [Accepted: 07/07/2016] [Indexed: 02/02/2023]
Abstract
AIMS The concept of 'classification' has, similar to many other diseases, been found to be fundamental in the field of diabetic medicine. In the current study, we aimed at determining efficacy measures of a recently published plantar pressure based classification system. METHODS Technical efficacy of the classification system was investigated by applying a high resolution, pixel-level analysis on the normalized plantar pressure pedobarographic fields of the original experimental dataset consisting of 97 patients with diabetes and 33 persons without diabetes. Clinical efficacy was assessed by considering the occurence of foot ulcers at the plantar aspect of the forefoot in this dataset. Classification efficacy was assessed by determining the classification recognition rate as well as its sensitivity and specificity using cross-validation subsets of the experimental dataset together with a novel cohort of 12 patients with diabetes. RESULTS Pixel-level comparison of the four groups associated to the classification system highlighted distinct regional differences. Retrospective analysis showed the occurence of eleven foot ulcers in the experimental dataset since their gait analysis. Eight out of the eleven ulcers developed in a region of the foot which had the highest forces. Overall classification recognition rate exceeded 90% for all cross-validation subsets. Sensitivity and specificity of the four groups associated to the classification system exceeded respectively the 0.7 and 0.8 level in all cross-validation subsets. CONCLUSIONS The results of the current study support the use of the novel plantar pressure based classification system in diabetic foot medicine. It may particularly serve in communication, diagnosis and clinical decision making.
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Affiliation(s)
- Kevin Deschamps
- KU Leuven, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Group, Belgium, KU Leuven, Laboratory for Clinical Motion Analysis, University Hospital Pellenberg, Belgium, Parnasse-ISEI, Department of Podiatry, Avenue E. Mounier, 84 - 1200 Bruxelles, Weligerveld 1, 3212 Pellenberg, Belgium.
| | - Giovanni Arnoldo Matricali
- KU Leuven, Department of Development & Regeneration, Belgium, KU Leuven, Multidisciplinary Diabetic Foot Clinic, University Hospitals Leuven, Belgium, Weligerveld 1, 3212 Pellenberg, Belgium.
| | - Dirk Desmet
- KU Leuven, Department of Mechanical Engineering, Belgium, Celestijnenlaan 300B bus 2420, Room 01.053, B-3001 Leuven (Heverlee), Belgium.
| | - Philip Roosen
- Department of Rehabilitation Sciences and Physiotherapy, Research Group: Musculoskeletal Rehabilitation, University Ghent, Belgium, Campus Heymans (UZ Gent), Blok B3, De Pintelaan 185, 9000 Gent.
| | - Noel Keijsers
- Sint Maartenskliniek Nijmegen, Research Department, PO box 9011, 6500 GM Nijmegen, The Netherlands.
| | - Frank Nobels
- Department of Internal Medicine- Endocrinology, Multidisciplinary Diabetic Foot Clinic, Onze-Lieve-Vrouw Ziekenhuis Aalst, Belgium, Moorselbaan 164, 9300 Aalst, Belgium.
| | - Herman Bruyninckx
- KU Leuven, Department of Mechanical Engineering, Belgium., Celestijnenlaan 300B bus 2420, room 01.053, B-3001 Leuven (Heverlee), Belgium.
| | - Filip Staes
- KU Leuven, Department of Rehabilitation Sciences-Musculoskeletal Rehabilitation Research Group, Belgium., Tervuursevest 101, B-3001 Leuven (Heverlee), Belgium.
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Kucera T, Shaikh HH, Sponer P. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. J Diabetes Res 2016; 2016:3207043. [PMID: 27656656 PMCID: PMC5021483 DOI: 10.1155/2016/3207043] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 08/02/2016] [Indexed: 12/23/2022] Open
Abstract
Charcot neuropathic osteoarthropathy of the foot is a relatively common complication of diabetic neuropathy. Incorrect diagnosis and improper treatment often result in the extremity having to be amputated. This paper summarises the current view on the etiology, diagnostics, and treatment of diabetic Charcot neuropathic osteoarthropathy, with particular focus on preserving the extremity through surgical intervention from our own experiences.
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Affiliation(s)
- Tomas Kucera
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
| | - Haroun Hassan Shaikh
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Pavel Sponer
- Department of Orthopaedic Surgery, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
- Faculty of Medicine in Hradec Kralove, Charles University in Prague, Prague, Czech Republic
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Gait parameters of people with diabetes-related neuropathic plantar foot ulcers. Clin Biomech (Bristol, Avon) 2016; 37:98-107. [PMID: 27389946 DOI: 10.1016/j.clinbiomech.2016.06.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 06/20/2016] [Accepted: 06/27/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Foot ulceration associated with diabetic peripheral neuropathy is a global concern. Biomechanical investigation allows the identification of gait abnormalities that may adversely affect ulcer healing. The objective of this case-control study was to compare the gait parameters of cases with diabetes-related foot ulcers to controls. METHODS Three-dimensional movement analyses were performed on 21 people with diabetes-related neuropathic plantar foot ulcers (cases), 69 people with diabetes without a foot ulcer history (diabetes controls) and 56 healthy controls. Outcome data were reported as mean differences, 95% confidence intervals and Cohen's d effect sizes. Binary logistic regressions were used to adjust for age, sex and body mass index. FINDINGS People with foot ulcers had a smaller plantar flexion (Cohen's d=-0.6 vs. diabetes controls and d=-0.8 vs. healthy controls), knee flexion (d=-0.6 vs. diabetes controls and d=-1.0 vs. healthy controls) and pelvic obliquity (d=-0.9 vs. diabetes controls and d=-0.7 vs. healthy controls) (all P<0.05). They also had a significantly greater range of anterior-posterior ground reaction force (d=1.0 vs. diabetes controls and d=1.7 vs. healthy controls) and total vertical ground reaction force (d=0.9 vs. diabetes controls and d=1.1 vs. healthy controls) and significantly slower walking speed and smaller step length compared to controls (all P<0.05). INTERPRETATION People with plantar foot ulcers have considerably different gait parameters to controls. Whether the observed gait parameters contributed to the ulcer development or are a response to the ulcer is currently unclear and needs further investigation.
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Brown SJ, Handsaker JC, Maganaris CN, Bowling FL, Boulton AJM, Reeves ND. Altered joint moment strategy during stair walking in diabetes patients with and without peripheral neuropathy. Gait Posture 2016; 46:188-93. [PMID: 27131200 DOI: 10.1016/j.gaitpost.2016.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/16/2016] [Accepted: 03/10/2016] [Indexed: 02/02/2023]
Abstract
AIM To investigate lower limb biomechanical strategy during stair walking in patients with diabetes and patients with diabetic peripheral neuropathy, a population known to exhibit lower limb muscular weakness. METHODS The peak lower limb joint moments of twenty-two patients with diabetic peripheral neuropathy and thirty-nine patients with diabetes and no neuropathy were compared during ascent and descent of a staircase to thirty-two healthy controls. Fifty-nine of the ninety-four participants also performed assessment of their maximum isokinetic ankle and knee joint moment (muscle strength) to assess the level of peak joint moments during the stair task relative to their maximal joint moment-generating capabilities (operating strengths). RESULTS Both patient groups ascended and descended stairs slower than controls (p<0.05). Peak joint moments in patients with diabetic peripheral neuropathy were lower (p<0.05) at the ankle and knee during stair ascent, and knee only during stair descent compared to controls. Ankle and knee muscle strength values were lower (p<0.05) in patients with diabetic peripheral neuropathy compared to controls, and lower at knee only in patients without neuropathy. Operating strengths were higher (p<0.05) at the ankle and knee in patients with neuropathy during stair descent compared to the controls, but not during stair ascent. CONCLUSION Patients with diabetic peripheral neuropathy walk slower to alter gait strategy during stair walking and account for lower-limb muscular weakness, but still exhibit heightened operating strengths during stair descent, which may impact upon fatigue and the ability to recover a safe stance following postural instability.
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Affiliation(s)
- Steven J Brown
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom.
| | - Joseph C Handsaker
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
| | | | - Frank L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, United Kingdom
| | - Andrew J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, United Kingdom
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
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Handsaker JC, Brown SJ, Bowling FL, Marple-Horvat DE, Boulton AJM, Reeves ND. People with diabetic peripheral neuropathy display a decreased stepping accuracy during walking: potential implications for risk of tripping. Diabet Med 2016; 33:644-9. [PMID: 26172114 DOI: 10.1111/dme.12851] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2015] [Indexed: 10/23/2022]
Abstract
AIM To examine the stepping accuracy of people with diabetes and diabetic peripheral neuropathy. METHODS Fourteen patients with diabetic peripheral neuropathy (DPN), 12 patients with diabetes but no neuropathy (D) and 10 healthy non-diabetic control participants (C). Accuracy of stepping was measured whilst the participants walked along a walkway consisting of 18 stepping targets. Preliminary data on visual gaze characteristics were also captured in a subset of participants (diabetic peripheral neuropathy group: n = 4; diabetes-alone group: n = 4; and control group: n = 4) during the same task. RESULTS Patients in the diabetic peripheral neuropathy group, and patients in the diabetes-alone group were significantly less accurate at stepping on targets than were control subjects (P < 0.05). Preliminary visual gaze analysis identified that patients diabetic peripheral neuropathy were slower to look between targets, resulting in less time being spent looking at a target before foot-target contact. CONCLUSIONS Impaired motor control is theorized to be a major factor underlying the changes in stepping accuracy, and potentially altered visual gaze behaviour may also play a role. Reduced stepping accuracy may indicate a decreased ability to control the placement of the lower limbs, leading to patients with neuropathy potentially being less able to avoid observed obstacles during walking.
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Affiliation(s)
- J C Handsaker
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - S J Brown
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - D E Marple-Horvat
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - A J M Boulton
- Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - N D Reeves
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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Arsanjani Shirazi A, Nasiri M, Yazdanpanah L. Dermatological and musculoskeletal assessment of diabetic foot: A narrative review. Diabetes Metab Syndr 2016; 10:S158-S164. [PMID: 27016885 DOI: 10.1016/j.dsx.2016.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/05/2016] [Indexed: 01/11/2023]
Abstract
AIMS Diabetic Foot Syndrome (DFS) is the most costly and devastating complication of diabetes mellitus (DM), which early effective assessment can reduce the severity of complications including ulceration and amputations. This study aimed to review dermatological and musculoskeletal assessment of diabetic foot. MATERIALS AND METHODS In this review article, we searched for articles published between March 1, 1980 and July 28, 2015 in PubMed, Science Direct, Embase, Web of Science, and Scopus, for both English and non-English language articles with the following keywords: "Diabetic foot syndrome", "Ulceration", "Amputation", "Foot assessment", "Skin disorders" and "Musculoskeletal deformities". RESULTS In dermatological dimension, most studies focused on elucidated changes in skin temperature, color, hardiness and turgor as well as common skin disorders such as Diabetic Dermopathy (DD), Necrobiosis Lipoidica Diabeticorum (NLD) and Diabetic Bullae (DB), which are common in diabetic patients and have high potential for leading to limb-threatening problems such as ulceration and infection. In musculoskeletal dimension, most studies focused on range of motion and muscle strength, gait patterns and as well as foot deformities especially Charcot osteoarthropathy (COA), which is the most destructive musculoskeletal complication of diabetes. CONCLUSION DFS as a common condition in DM patients lead to ulceration and lower limb amputation frequently unless a prompt and comprehensive assessment was taken. So that dermatological and musculoskeletal assessments are usually neglected in primary health care, these assessments should be done frequently to reduce the high risk of serious complications.
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Affiliation(s)
- Azam Arsanjani Shirazi
- Department of Midwifery, Nursing and Midwifery School, Dezful Islamic Azad University, Khouzastan, Iran.
| | - Morteza Nasiri
- Department of Operating Room, Paramedical School, Qom University of Medical Sciences, Qom, Iran.
| | - Leila Yazdanpanah
- Health Research Institute, Diabetes Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Drenth H, Zuidema S, Bunt S, Bautmans I, van der Schans C, Hobbelen H. The Contribution of Advanced Glycation End product (AGE) accumulation to the decline in motor function. Eur Rev Aging Phys Act 2016; 13:3. [PMID: 26949420 PMCID: PMC4779236 DOI: 10.1186/s11556-016-0163-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 03/01/2016] [Indexed: 12/23/2022] Open
Abstract
Diminishing motor function is commonly observed in the elderly population and is associated with a wide range of adverse health consequences. Advanced Glycation End products (AGE's) may contribute to age-related decline in the function of cells and tissues in normal ageing. Although the negative effect of AGE's on the biomechanical properties of musculoskeletal tissues and the central nervous system have been previously described, the evidence regarding the effect on motor function is fragmented, and a systematic review on this topic is lacking. Therefore, a systematic review was conducted from a total of eight studies describing AGE's related to physical functioning, physical performance, and musculoskeletal outcome which reveals a positive association between high AGE's levels and declined walking abilities, inferior ADL, decreased muscle properties (strength, power and mass) and increased physical frailty. Elevated AGE's levels might be an indication to initiate (early) treatment such as dietary advice, muscle strengthening exercises, and functional training to maintain physical functions. Further longitudinal observational and controlled trial studies are necessary to investigate a causal relationship, and to what extent, high AGE's levels are a contributing risk factor and potential biomarker for a decline in motor function as a component of the ageing process.
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Affiliation(s)
- Hans Drenth
- />Research Group Healthy Ageing, Allied Healthcare and Nursing, Hanze University of Applied Sciences, PO Box 3109, 9701 DC Groningen, The Netherlands
- />Zuid Oost Zorg, Organisation for Elderly Care. Burg, Wuiteweg 140, 9203 KP Drachten, The Netherlands
| | - Sytse Zuidema
- />Department of General Practice, University of Groningen, University Medical Center Groningen, PO Box 196 9700 AD, Groningen, HPC FA21 The Netherlands
| | - Steven Bunt
- />Research Group Healthy Ageing, Allied Healthcare and Nursing, Hanze University of Applied Sciences, PO Box 3109, 9701 DC Groningen, The Netherlands
| | - Ivan Bautmans
- />Frailty in Ageing Research Group and Gerontology Department, Free University of Brussels, Laarbeeklaan 103, B-1090 Brussels, Belgium
| | - Cees van der Schans
- />Research Group Healthy Ageing, Allied Healthcare and Nursing, Hanze University of Applied Sciences, PO Box 3109, 9701 DC Groningen, The Netherlands
| | - Hans Hobbelen
- />Research Group Healthy Ageing, Allied Healthcare and Nursing, Hanze University of Applied Sciences, PO Box 3109, 9701 DC Groningen, The Netherlands
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GUIOTTO ANNAMARIA, SCARTON ALESSANDRA, SAWACHA ZIMI, GUARNERI GABRIELLA, AVOGARO ANGELO, COBELLI CLAUDIO. GAIT ANALYSIS DRIVEN 2D FINITE ELEMENT MODEL OF THE NEUROPATHIC HINDFOOT. J MECH MED BIOL 2016. [DOI: 10.1142/s0219519416500123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The diabetic foot is one of the most serious complications of diabetes mellitus and it can lead to foot ulcerations and amputations. Finite element analysis quantifies the loads developed in the different anatomical structures and describes how these affect foot tissue during foot–floor interaction. This approach for the diabetic subjects’ foot could provide valuable information in the process of plantar orthosis fabrication and fit. The purpose of this study was to develop two finite element models of the hindfoot, of healthy and diabetic neuropathic subjects. These models accounts for in vivo kinematics, kinetics, plantar pressure (PP) data and magnetic resonance images. These were acquired during gait analysis on 10 diabetic neuropathics and 10 healthy subjects. Validity of the models has been assessed through comparison between the peak PPs of simulated and experimental data: root mean square error (RMSE) in percentage of the experimental peak value was evaluated. Two different finite elements analysis were performed: subject-specific simulations in terms of both geometry and gait analysis, and by adopting the complete gait analysis dataset as boundary conditions. Model predicted plantar pressures were in good agreement with those experimentally measured. Best agreement was obtained in the subject-specific case (RMSE of 13%).
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Affiliation(s)
- ANNAMARIA GUIOTTO
- Department of Information Engineering, University of Padova, Via Gradenigo 6b, 35131 Padova, Italy
| | - ALESSANDRA SCARTON
- Department of Information Engineering, University of Padova, Via Gradenigo 6b, 35131 Padova, Italy
| | - ZIMI SAWACHA
- Department of Information Engineering, University of Padova, Via Gradenigo 6b, 35131 Padova, Italy
| | - GABRIELLA GUARNERI
- Department of Clinical Medicine and Metabolic Disease, University Polyclinic of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - ANGELO AVOGARO
- Department of Clinical Medicine and Metabolic Disease, University Polyclinic of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - CLAUDIO COBELLI
- Department of Information Engineering, University of Padova, Via Gradenigo 6b, 35131 Padova, Italy
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Almurdhi MM, Reeves ND, Bowling FL, Boulton AJM, Jeziorska M, Malik RA. Reduced Lower-Limb Muscle Strength and Volume in Patients With Type 2 Diabetes in Relation to Neuropathy, Intramuscular Fat, and Vitamin D Levels. Diabetes Care 2016; 39:441-7. [PMID: 26740641 PMCID: PMC5317239 DOI: 10.2337/dc15-0995] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 11/24/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Muscle weakness and atrophy of the lower limbs may develop in patients with diabetes, increasing their risk of falls. The underlying basis of these abnormalities has not been fully explained. The aim of this study was to objectively quantify muscle strength and size in patients with type 2 diabetes mellitus (T2DM) in relation to the severity of neuropathy, intramuscular noncontractile tissue (IMNCT), and vitamin D deficiency. RESEARCH DESIGN AND METHODS Twenty patients with T2DM and 20 healthy control subjects were matched by age, sex, and BMI. Strength and size of knee extensor, flexor, and ankle plantar and dorsiflexor muscles were assessed in relation to the severity of diabetic sensorimotor polyneuropathy (DSPN), amount of IMNCT, and serum 25-hydroxyvitamin D (25OHD) levels. RESULTS Compared with control subjects, patients with T2DM had significantly reduced knee extensor strength (P = 0.003) and reduced muscle volume of both knee extensors (P = 0.045) and flexors (P = 0.019). Ankle plantar flexor strength was also significantly reduced (P = 0.001) but without a reduction in ankle plantar flexor (P = 0.23) and dorsiflexor (P = 0.45) muscle volumes. IMNCT was significantly increased in the ankle plantar (P = 0.006) and dorsiflexors (P = 0.005). Patients with DSPN had significantly less knee extensor strength than those without (P = 0.02) but showed no difference in knee extensor volume (P = 0.38) and ankle plantar flexor strength (P = 0.21) or volume (P = 0.96). In patients with <25 nmol/L versus >25 nmol/L 25OHD, no significant differences were found for knee extensor strength and volume (P = 0.32 vs. 0.18) and ankle plantar flexors (P = 0.58 vs. 0.12). CONCLUSIONS Patients with T2DM have a significant reduction in proximal and distal leg muscle strength and a proximal but not distal reduction in muscle volume possibly due to greater intramuscular fat accumulation in distal muscles. Proximal but not distal muscle strength is related to the severity of peripheral neuropathy but not IMNCT or 25OHD level.
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Affiliation(s)
- Monirah M Almurdhi
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, U.K
| | - Frank L Bowling
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Andrew J M Boulton
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Maria Jeziorska
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Rayaz A Malik
- Centre for Endocrinology and Diabetes, Institute of Human Development, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K. Weill Cornell Medical College, Doha, Qatar
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69
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Maksimovic A, Hanewinckel R, Verlinden VJA, Ligthart S, Hofman A, Franco OH, van Doorn PA, Tiemeier H, Dehghan A, Ikram MA. Gait characteristics in older adults with diabetes and impaired fasting glucose: The Rotterdam Study. J Diabetes Complications 2016; 30:61-6. [PMID: 26585369 DOI: 10.1016/j.jdiacomp.2015.10.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/12/2015] [Accepted: 10/13/2015] [Indexed: 11/20/2022]
Abstract
AIMS To investigate the association of diabetes mellitus and impaired fasting glucose with gait in the general middle-aged and elderly population. METHODS We performed a cross-sectional study on 3019 participants from the population-based Rotterdam Study (aged >45years, 54% women). The presence of diabetes mellitus and impaired fasting glucose was evaluated by measuring serum glucose levels and by documenting anti-diabetic treatment. Participants underwent gait analysis using an electronic walkway. Thirty gait variables were summarized into five independent gait domains for normal walking (Rhythm, Variability, Phases, Pace and Base of Support), one for turning (Turning) and one for walking heel to toe (Tandem), which were averaged into Global Gait. Linear regression analyses were performed to determine the association of diabetes, impaired fasting glucose and continuous glucose levels within the normal range with gait. RESULTS Diabetes mellitus was associated with worse Global Gait (Z-score difference -0.19, 95% confidence interval (CI) -0.30; -0.07), worse Pace (-0.20, 95% CI -0.30; -0.10) and worse Tandem (-0.21, 95% CI -0.33; -0.09), after adjusting for age, sex, height and weight. The association with Tandem remained significant after additional adjustment for cardiovascular risk factors. Impaired fasting glucose and continuous glucose levels within the normal range were not associated with any of the gait domains. CONCLUSION In our population-based study diabetes mellitus was associated with worse Global Gait, which was mostly reflected in Pace and Tandem. These associations were partly driven by other cardiovascular risk factors, emphasizing the importance of optimal control of cardiovascular risk factor profiles in patients with diabetes.
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Affiliation(s)
- Ana Maksimovic
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Rens Hanewinckel
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | | | - Symen Ligthart
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Albert Hofman
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Oscar H Franco
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Pieter A van Doorn
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Henning Tiemeier
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Psychiatry, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Abbas Dehghan
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - M Arfan Ikram
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
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70
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Petrova NL, Edmonds ME. Acute Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2016; 32 Suppl 1:281-6. [PMID: 26451965 DOI: 10.1002/dmrr.2734] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 07/06/2015] [Accepted: 10/06/2015] [Indexed: 01/29/2023]
Abstract
Charcot neuro-osteoarthropathy (CN) is one of the most challenging foot complications in diabetes. Common predisposing and precipitating factors include neuropathy and increased mechanical forces, fracture and bone resorption, trauma and inflammation. In the last 15 years, considerable progress has been made in the early recognition of the acute Charcot foot when the X ray is still negative (stage 0 or incipient Charcot foot). Recent advances in imaging modalities have enabled the detection of initial signs of inflammation and underlying bone damage before overt bone and joint destruction has occurred. Casting therapy remains the mainstay of medical therapy of acute CN. If timely instituted, offloading can arrest disease activity and prevent foot deformity. In cases with severe deformity, modern surgical techniques can correct the unstable deformity for improved functional outcome and limb survival. Emerging new studies into the cellular mechanisms of severe bone destruction have furthered our understanding of the mechanisms of pathological bone and joint destruction in CN. It is hoped that these studies may provide a scientific basis for new interventions with biological agents.
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MESH Headings
- Arthropathy, Neurogenic/complications
- Arthropathy, Neurogenic/diagnosis
- Arthropathy, Neurogenic/physiopathology
- Arthropathy, Neurogenic/therapy
- Bone Density Conservation Agents/adverse effects
- Bone Density Conservation Agents/therapeutic use
- Combined Modality Therapy/adverse effects
- Combined Modality Therapy/trends
- Congresses as Topic
- Diabetic Foot/complications
- Diabetic Foot/diagnosis
- Diabetic Foot/physiopathology
- Diabetic Foot/therapy
- Diabetic Neuropathies/complications
- Diabetic Neuropathies/diagnosis
- Diabetic Neuropathies/physiopathology
- Diabetic Neuropathies/therapy
- Early Diagnosis
- Evidence-Based Medicine
- Fractures, Bone/complications
- Fractures, Bone/epidemiology
- Fractures, Bone/etiology
- Fractures, Bone/therapy
- Humans
- Limb Salvage/adverse effects
- Limb Salvage/trends
- Postoperative Complications/prevention & control
- Precision Medicine
- Protective Devices/trends
- Plastic Surgery Procedures/adverse effects
- Plastic Surgery Procedures/trends
- Risk Factors
- Severity of Illness Index
- Therapies, Investigational/adverse effects
- Therapies, Investigational/trends
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Affiliation(s)
- N L Petrova
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
| | - M E Edmonds
- Diabetic Foot Clinic, King's College Hospital NHS Foundation Trust, London, UK
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71
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Miller JD, Najafi B, Armstrong DG. Current Standards and Advances in Diabetic Ulcer Prevention and Elderly Fall Prevention Using Wearable Technology. CURRENT GERIATRICS REPORTS 2015. [DOI: 10.1007/s13670-015-0136-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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72
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Yang C, Xiao H, Wang C, Mai L, Liu D, Qi Y, Ren M, Yan L. Variation of plantar pressure in Chinese diabetes mellitus. Wound Repair Regen 2015; 23:932-8. [PMID: 26084591 DOI: 10.1111/wrr.12331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 05/17/2015] [Accepted: 05/26/2015] [Indexed: 11/29/2022]
Abstract
To investigate dynamic changes in plantar pressure in Chinese diabetes mellitus patients and to provide a basis for further preventing diabetic foot. This is a cross-sectional investigation including 649 Chinese diabetes mellitus patients (diabetes group) and 808 "normal" Chinese persons (nondiabetes group) with normal blood glucose levels. All the subjects provided a complete medical history and underwent a physical examination and a 75-g oral glucose tolerance test. All subjects walked barefoot with their usual gait, and their dynamic plantar forces were measured using the one-step method with a plantar pressure measurement instrument; 5 measurements were performed for each foot. No significant differences were found in age, height, body weight, or body mass index between the two groups. The fasting blood glucose levels, plantar contact time, maximum force, pressure-time integrals and force-time integrals in the diabetes group were significantly higher than those in the nondiabetes group (p < 0.05). However, the maximum pressure was significantly higher in the nondiabetes group than in the diabetes group (p < 0.05). No difference was found in the contact areas between the two groups (p > 0.05). The maximum plantar force distributions were essentially the same, with the highest force found for the medial heel, followed by the medial forefoot and the first toe. The peak plantar pressure was located at the medial forefoot for the nondiabetes group and at the hallucis for the diabetes group. In the diabetes group, the momentum in each plantar region was higher than that in the nondiabetes group; this difference was especially apparent in the heel, the lateral forefoot and the hallucis. The dynamic plantar pressures in diabetic patients differ from those in nondiabetic people with increased maximum force and pressure, a different distribution pattern and significantly increased momentum, which may lead to the formation of foot ulcers.
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Affiliation(s)
- Chuan Yang
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huisheng Xiao
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chuan Wang
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - LiFang Mai
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dan Liu
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yiqing Qi
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Meng Ren
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
| | - Li Yan
- The Institute of Endocrinology and Metabolism, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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73
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Grewal GS, Sayeed R, Schwenk M, Bharara M, Menzies R, Talal TK, Armstrong DG, Najafi B. Balance rehabilitation: promoting the role of virtual reality in patients with diabetic peripheral neuropathy. J Am Podiatr Med Assoc 2015; 103:498-507. [PMID: 24297986 DOI: 10.7547/1030498] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Individuals with diabetic peripheral neuropathy frequently experience concomitant impaired proprioception and postural instability. Conventional exercise training has been demonstrated to be effective in improving balance but does not incorporate visual feedback targeting joint perception, which is an integral mechanism that helps compensate for impaired proprioception in diabetic peripheral neuropathy. METHODS This prospective cohort study recruited 29 participants (mean ± SD: age, 57 ± 10 years; body mass index [calculated as weight in kilograms divided by height in meters squared], 26.9 ± 3.1). Participants satisfying the inclusion criteria performed predefined ankle exercises through reaching tasks, with visual feedback from the ankle joint projected on a screen. Ankle motion in the mediolateral and anteroposterior directions was captured using wearable sensors attached to the participant's shank. Improvements in postural stability were quantified by measuring center of mass sway area and the reciprocal compensatory index before and after training using validated body-worn sensor technology. RESULTS Findings revealed a significant reduction in center of mass sway after training (mean, 22%; P = .02). A higher postural stability deficit (high body sway) at baseline was associated with higher training gains in postural balance (reduction in center of mass sway) (r = -0.52, P < .05). In addition, significant improvement was observed in postural coordination between the ankle and hip joints (mean, 10.4%; P = .04). CONCLUSIONS The present research implemented a novel balance rehabilitation strategy based on virtual reality technology. The method included wearable sensors and an interactive user interface for real-time visual feedback based on ankle joint motion, similar to a video gaming environment, for compensating impaired joint proprioception. These findings support that visual feedback generated from the ankle joint coupled with motor learning may be effective in improving postural stability in patients with diabetic peripheral neuropathy.
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Affiliation(s)
- Gurtej S Grewal
- Interdisciplinary Consortium on Advanced Motion Performance, University of Arizona, College of Medicine, Tucson, AZ
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Błażkiewicz M, Sundar L, Healy A, Ramachandran A, Chockalingam N, Naemi R. Assessment of lower leg muscle force distribution during isometric ankle dorsi and plantar flexion in patients with diabetes: a preliminary study. J Diabetes Complications 2015; 29:282-7. [PMID: 25454742 DOI: 10.1016/j.jdiacomp.2014.10.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 10/06/2014] [Accepted: 10/15/2014] [Indexed: 12/25/2022]
Abstract
AIM The aim of this study was to evaluate the differences in ankle muscle strength using hand-held dynamometry and to assess difference in the isometric muscle force distribution between the people with diabetes and control participants. METHODS The maximal muscle strength of ankle plantarflexion, dorsiflexion, eversion, inversion, lesser toes flexors and extensors, hallux flexors, and extensors was assessed in 20 people with diabetes and 20 healthy participants using hand-held dynamometry. The maximal isometric ankle plantarflexion and dorsiflexion were imported to OpenSim software to calculate 12 individual muscle (8 plantarflexors and 4 dorsiflexors) forces acting on ankle joint. RESULTS A significant reduction in ankle strength for all measured actions and a significant decrease in muscle force for each of the 12 muscles during dorsi and plantar flexion were observed. Furthermore, the ratios of agonist to antagonist muscle force for 6 of the muscles were significantly different between the control group and the group with diabetes. CONCLUSIONS It is likely that the muscles for which the agonist/antagonist muscle force ratio was significantly different for the healthy people and the people with diabetes could be more affected by diabetes.
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Affiliation(s)
- Michalina Błażkiewicz
- Department of Physiotherapy, Józef Piłsudski University of Physical Education, Warsaw, Poland; CSHER, Faculty of Health Sciences, Staffordshire University, Stoke on Trent, ST4 2DF, UK.
| | - Lakshmi Sundar
- CSHER, Faculty of Health Sciences, Staffordshire University, Stoke on Trent, ST4 2DF, UK; AR Hospitals, India Diabetic Research Foundation, Egmore, Chennai, India
| | - Aoife Healy
- CSHER, Faculty of Health Sciences, Staffordshire University, Stoke on Trent, ST4 2DF, UK
| | | | | | - Roozbeh Naemi
- CSHER, Faculty of Health Sciences, Staffordshire University, Stoke on Trent, ST4 2DF, UK
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75
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An immediate effect of custom-made ankle foot orthoses on postural stability in older adults. Clin Biomech (Bristol, Avon) 2014; 29:1081-8. [PMID: 25467809 DOI: 10.1016/j.clinbiomech.2014.10.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 10/14/2014] [Accepted: 10/15/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Foot and ankle problems are highly prevalent fall risks in the elderly. Ankle foot orthoses designed to stabilize the foot and ankles have been studied within specific patient groups, but their efficacy with a less restrictive elderly population is unknown. This study investigated if custom-made ankle foot orthoses improve postural stability in older adults. METHODS Thirty ambulatory older adults averaged 73 (standard deviation=6.5) years completed Romberg's balance (eyes-open/eyes-closed), functional reach, and Timed Up and Go tests while wearing validated kinematic sensors. Each test was completed in standardized shoes with and without bilateral orthoses. Additionally, barefoot trials were conducted for the Romberg's and functional reach tests. FINDINGS Compared to the barefoot and 'shoes alone' conditions, the orthoses reduced center of mass sway on average by 49.0% (P=0.087) and 40.7% (P=0.005) during eyes-open balance trials. The reduction was amplified during the eyes-closed trials with average reductions of 65.9% (P=0.000) and 47.8% (P=0.004), compared to barefoot and 'shoes alone' conditions. The orthoses did not limit functional reach distance nor timed-up and go completion times. However, the medial-lateral postural coordination while reaching was improved significantly with orthoses compared to barefoot (14.3%; P=0.030) and 'shoes alone' (13.5%; P=0.039) conditions. INTERPRETATION Ankle foot orthoses reduced postural sway and improved lower extremity coordination in the elderly participants without limiting their ability to perform a standard activity of daily living. Additional studies are required to determine if these benefits are retained and subsequently translate into fewer falls.
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76
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Boivin GP, Elenes EY, Schultze AK, Chodavarapu H, Hunter SA, Elased KM. Biomechanical properties and histology of db/db diabetic mouse Achilles tendon. Muscles Ligaments Tendons J 2014. [PMID: 25489543 DOI: 10.11138/mltj/2014.4.3.280] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Foot ulcers are a severe complication of diabetic patients resulting from nerve and tendon pathologic alterations. In diabetic patients the tendons are thicker, shorter and have increased stiffness. We examined C57BL/KsJ (BKS.Cg-Dock7(m) +/+ Lepr (db) /J) (db/db) mice tendons to determine whether they are an animal model for human diabetic tendon changes. We hypothesized that the Achilles tendons of db/db diabetic mice would be thicker, stiffer, fail at lower loads and stresses, and have degenerative changes compared to control mice. Biomechanical and histologic analyses of the Achilles tendons of 16 week old db/db and control male mice were performed. There was a significant increase in tendon diameter and significant decreases in maximum load, tensile stress, stiffness and elastic modulus in tendons from diabetic mice compared to controls. Mild degenerative and neutrophil infiltration was observed near the tendon insertions on the calcaneous in 25% of db/db mice. In summary, hyper-glycemia and obesity lead to severe changes in db/db mice will be a useful model to examine mechanisms for tendon alterations.
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Affiliation(s)
| | | | | | - Harshita Chodavarapu
- Department of Pharmacology and Toxicology, Wright State University, Dayton, OH USA
| | | | - Khalid M Elased
- Department of Pharmacology and Toxicology, Wright State University, Dayton, OH USA
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77
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Brown SJ, Handsaker JC, Bowling FL, Maganaris CN, Boulton AJ, Reeves ND. Do patients with diabetic neuropathy use a higher proportion of their maximum strength when walking? J Biomech 2014; 47:3639-44. [DOI: 10.1016/j.jbiomech.2014.10.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Revised: 09/30/2014] [Accepted: 10/05/2014] [Indexed: 12/19/2022]
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78
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Wrobel JS, Ammanath P, Le T, Luring C, Wensman J, Grewal GS, Najafi B, Pop-Busui R. A novel shear reduction insole effect on the thermal response to walking stress, balance, and gait. J Diabetes Sci Technol 2014; 8:1151-6. [PMID: 25107709 PMCID: PMC4455476 DOI: 10.1177/1932296814546528] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Shear stresses have been implicated in the formation of diabetes-related foot ulcers. The aim of this study was to evaluate the effect of a novel shear-reducing insole on the thermal response to walking, balance, and gait. Twenty-seven diabetes peripheral neuropathy patients were enrolled and asked to take 200 steps in both intervention and standard insoles. Thermal foot images of the feet were taken at baseline (1) following a 5-minute temperature acclimatization and (2) after walking. Testing order was randomized, and a 5-minute washout period was used between testing each insole condition. Sudomotor function was also assessed. Gait and balance were measured under single and dual task conditions using a validated body worn sensor system. The mean age was 65.1 years, height was 67.3 inches, weight was 218 pounds, and body mass index was 33.9, 48% were female, and 82% had type 2 diabetes. After walking in both insole conditions, foot temperatures increased significantly in standard insoles. The intervention insole significantly reduced forefoot and midfoot temperature increases (64.1%, P = .008; 48%, P = .046) compared to standard insoles. There were significant negative correlations with sudomotor function and baseline temperatures (r = .53-.57). The intervention demonstrated 10.4% less gait initiation double support time compared to standard insoles (P = .05). There were no differences in static balance measures. We found significantly lower forefoot and midfoot temperature increases following walking with shear-reducing insoles compared to standard insoles. We also found improvements in gait. These findings merit future study for the prevention of foot ulcer.
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Affiliation(s)
- James S Wrobel
- Metabolism, Endocrinology and Diabetes (MEND), University of Michigan, Ann Arbor, MI, USA
| | - Peethambaran Ammanath
- Michigan Orthotics and Prosthetics Center, University of Michigan, Ann Arbor, MI, USA
| | - Tima Le
- Metabolism, Endocrinology and Diabetes (MEND), University of Michigan, Ann Arbor, MI, USA
| | - Christopher Luring
- Michigan Orthotics and Prosthetics Center, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey Wensman
- Michigan Orthotics and Prosthetics Center, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Rodica Pop-Busui
- Metabolism, Endocrinology and Diabetes (MEND), University of Michigan, Ann Arbor, MI, USA
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79
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Morrison S, Colberg SR, Parson HK, Vinik AI. Exercise improves gait, reaction time and postural stability in older adults with type 2 diabetes and neuropathy. J Diabetes Complications 2014; 28:715-22. [PMID: 24929798 DOI: 10.1016/j.jdiacomp.2014.04.007] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 04/10/2014] [Accepted: 04/10/2014] [Indexed: 11/19/2022]
Abstract
AIMS For older adults with type 2 diabetes (T2DM), declines in balance and walking ability are risk factors for falls, and peripheral neuropathy magnifies this risk. Exercise training may improve balance, gait and reduce the risk of falling. This study investigated the effects of 12weeks of aerobic exercise training on walking, balance, reaction time and falls risk metrics in older T2DM individuals with/without peripheral neuropathy. METHODS Adults with T2DM, 21 without (DM; age 58.7±1.7years) and 16 with neuropathy (DM-PN; age 58.9±1.9years), engaged in either moderate or intense supervised exercise training thrice-weekly for 12weeks. Pre/post-training assessments included falls risk (using the physiological profile assessment), standing balance, walking ability and hand/foot simple reaction time. RESULTS Pre-training, the DM-PN group had higher falls risk, slower (hand) reaction times (232 vs. 219ms), walked at a slower speed (108 vs. 113cm/s) with shorter strides compared to the DM group. Following training, improvements in hand/foot reaction times and faster walking speed were seen for both groups. CONCLUSIONS While falls risk was not significantly reduced, the observed changes in gait, reaction time and balance metrics suggest that aerobic exercise of varying intensities is beneficial for improving dynamic postural control in older T2DM adults with/without neuropathy.
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Affiliation(s)
- Steven Morrison
- School of Physical Therapy and Athletic Training, Old Dominion University, Norfolk, VA.
| | - Sheri R Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA
| | - Henri K Parson
- Strelitz Diabetes Center, Eastern Virginia Medical School, Norfolk, VA
| | - Aaron I Vinik
- Strelitz Diabetes Center, Eastern Virginia Medical School, Norfolk, VA
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80
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Boivin GP, Elenes EY, Schultze AK, Chodavarapu H, Hunter SA, Elased KM. Biomechanical properties and histology of db/db diabetic mouse Achilles tendon. Muscles Ligaments Tendons J 2014; 4:280-4. [PMID: 25489543 PMCID: PMC4241416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Foot ulcers are a severe complication of diabetic patients resulting from nerve and tendon pathologic alterations. In diabetic patients the tendons are thicker, shorter and have increased stiffness. We examined C57BL/KsJ (BKS.Cg-Dock7(m) +/+ Lepr (db) /J) (db/db) mice tendons to determine whether they are an animal model for human diabetic tendon changes. We hypothesized that the Achilles tendons of db/db diabetic mice would be thicker, stiffer, fail at lower loads and stresses, and have degenerative changes compared to control mice. Biomechanical and histologic analyses of the Achilles tendons of 16 week old db/db and control male mice were performed. There was a significant increase in tendon diameter and significant decreases in maximum load, tensile stress, stiffness and elastic modulus in tendons from diabetic mice compared to controls. Mild degenerative and neutrophil infiltration was observed near the tendon insertions on the calcaneous in 25% of db/db mice. In summary, hyper-glycemia and obesity lead to severe changes in db/db mice will be a useful model to examine mechanisms for tendon alterations.
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Affiliation(s)
| | | | | | - Harshita Chodavarapu
- Department of Pharmacology and Toxicology, Wright State University, Dayton, OH USA
| | | | - Khalid M. Elased
- Department of Pharmacology and Toxicology, Wright State University, Dayton, OH USA
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81
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Honeine JL, Schieppati M, Gagey O, Do MC. By counteracting gravity, triceps surae sets both kinematics and kinetics of gait. Physiol Rep 2014; 2:e00229. [PMID: 24744898 PMCID: PMC3966244 DOI: 10.1002/phy2.229] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Accepted: 01/09/2014] [Indexed: 12/20/2022] Open
Abstract
In the single-stance phase of gait, gravity acting on the center of mass (CoM) causes a disequilibrium torque, which generates propulsive force. Triceps surae activity resists gravity by restraining forward tibial rotation thereby tuning CoM momentum. We hypothesized that time and amplitude modulation of triceps surae activity determines the kinematics (step length and cadence) and kinetics of gait. Nineteen young subjects participated in two experiments. In the gait initiation (GI) protocol, subjects deliberately initiated walking at different velocities for the same step length. In the balance-recovery (BR) protocol, subjects executed steps of different length after being unexpectedly released from an inclined posture. Ground reaction force was recorded by a large force platform and electromyography of soleus, gastrocnemius medialis and lateralis, and tibialis anterior muscles was collected by wireless surface electrodes. In both protocols, the duration of triceps activity was highly correlated with single-stance duration (GI, R (2) = 0.68; BR, R (2) = 0.91). In turn, step length was highly correlated with single-stance duration (BR, R (2) = 0.70). Control of CoM momentum was obtained by decelerating the CoM fall via modulation of amplitude of triceps activity. By modulation of triceps activity, the central nervous system (CNS) varied the position of CoM with respect to the center of pressure (CoP). The CoM-CoP gap in the sagittal plane was determinant for setting the disequilibrium torque and thus walking velocity. Thus, by controlling the gap, CNS-modified walking velocity (GI, R (2) = 0.86; BR, R (2) = 0.92). This study is the first to highlight that by merely counteracting gravity, triceps activity sets the kinematics and kinetics of gait. It also provides evidence that the surge in triceps activity during fast walking is due to the increased requirement of braking the fall of CoM in late stance in order to perform a smoother step-to-step transition.
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Affiliation(s)
- Jean-Louis Honeine
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France
| | - Marco Schieppati
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France ; Centro Studi Attività Motorie laboratory, Salvatore Maugeri Foundation (IRCCS) and Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, I-27100, Italy
| | - Oliver Gagey
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France ; Department of Orthopaedics, Faculty of Medicine, University Paris-Sud, Le Kremlin-Bicêtre, F-94276, France
| | - Manh-Cuong Do
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France
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82
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Honeine JL, Schieppati M, Gagey O, Do MC. By counteracting gravity, triceps surae sets both kinematics and kinetics of gait. Physiol Rep 2014. [PMID: 24744898 DOI: 10.1002/phy2.229phy2229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
In the single-stance phase of gait, gravity acting on the center of mass (CoM) causes a disequilibrium torque, which generates propulsive force. Triceps surae activity resists gravity by restraining forward tibial rotation thereby tuning CoM momentum. We hypothesized that time and amplitude modulation of triceps surae activity determines the kinematics (step length and cadence) and kinetics of gait. Nineteen young subjects participated in two experiments. In the gait initiation (GI) protocol, subjects deliberately initiated walking at different velocities for the same step length. In the balance-recovery (BR) protocol, subjects executed steps of different length after being unexpectedly released from an inclined posture. Ground reaction force was recorded by a large force platform and electromyography of soleus, gastrocnemius medialis and lateralis, and tibialis anterior muscles was collected by wireless surface electrodes. In both protocols, the duration of triceps activity was highly correlated with single-stance duration (GI, R (2) = 0.68; BR, R (2) = 0.91). In turn, step length was highly correlated with single-stance duration (BR, R (2) = 0.70). Control of CoM momentum was obtained by decelerating the CoM fall via modulation of amplitude of triceps activity. By modulation of triceps activity, the central nervous system (CNS) varied the position of CoM with respect to the center of pressure (CoP). The CoM-CoP gap in the sagittal plane was determinant for setting the disequilibrium torque and thus walking velocity. Thus, by controlling the gap, CNS-modified walking velocity (GI, R (2) = 0.86; BR, R (2) = 0.92). This study is the first to highlight that by merely counteracting gravity, triceps activity sets the kinematics and kinetics of gait. It also provides evidence that the surge in triceps activity during fast walking is due to the increased requirement of braking the fall of CoM in late stance in order to perform a smoother step-to-step transition.
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Affiliation(s)
- Jean-Louis Honeine
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France
| | - Marco Schieppati
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France ; Centro Studi Attività Motorie laboratory, Salvatore Maugeri Foundation (IRCCS) and Department of Public Health, Experimental and Forensic Medicine, University of Pavia, Pavia, I-27100, Italy
| | - Oliver Gagey
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France ; Department of Orthopaedics, Faculty of Medicine, University Paris-Sud, Le Kremlin-Bicêtre, F-94276, France
| | - Manh-Cuong Do
- Complexité, Innovation et Activité Motrices et Sportive laboratory, Sport-Science Faculty, University Paris-Sud, Orsay, F-91405, France
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83
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Najafi B, Khan T, Fleischer A, Wrobel J. The impact of footwear and walking distance on gait stability in diabetic patients with peripheral neuropathy. J Am Podiatr Med Assoc 2014; 103:165-73. [PMID: 23697719 DOI: 10.7547/1030165] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We explored gait differences in patients with diabetes and peripheral neuropathy (DPN) and aged-matched controls over short and long walking distances. The potential benefit of footwear for improving gait in patients with DPN was also explored. METHODS Twelve patients with DPN and eight controls walked at their habitual speed over short (7 m) and long (20 m) distances under two conditions: barefoot and regular shoes. A validated system of body-worn sensors was used to extract spatiotemporal gait parameters. Neuropathy severity was quantified using vibratory perception threshold measured at the great toe. RESULTS Gait deterioration in the DPN group was observed during all of the walking trials. However, the difference between patients with DPN and participants in the control group achieved statistical significance only during long walking distance trials. Shod and barefoot double support times were longer in the DPN group during long walking distances (>20%, P = .03). Gait unsteadiness, defined as coefficient of variation of gait velocity, was also significantly higher in the DPN group when barefoot walking over long distances (83%, P = .008). Furthermore, there was a high correlation between neuropathy severity and gait unsteadiness best demonstrated during the barefoot walking/long walking distance condition (r = 0.77, P < .001). The addition of footwear improved gait steadiness in the DPN group by 46% (P = .02). All differences were independent of age, sex, and body mass index (P > .05). CONCLUSIONS This study suggests that gait alteration in patients with DPN is most pronounced while walking barefoot over longer distances and that footwear may improve gait steadiness in patients with DPN.
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Affiliation(s)
- Bijan Najafi
- Southern Arizona Limb Salvage Alliance, Interdisciplinary Consortium for Advanced Motion Performance, University of Arizona College of Medicine, Tucson, AZ 85724, USA.
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84
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Fan Y, Fan Y, Li Z, Newman T, Lv C, Zhou Y. Screening method based on walking plantar impulse for detecting musculoskeletal senescence and injury. PLoS One 2013; 8:e83839. [PMID: 24386288 PMCID: PMC3875488 DOI: 10.1371/journal.pone.0083839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 11/18/2013] [Indexed: 11/18/2022] Open
Abstract
No consensus has been reached on how musculoskeletal system injuries or aging can be explained by a walking plantar impulse. We standardize the plantar impulse by defining a principal axis of plantar impulse. Based upon this standardized plantar impulse, two indexes are presented: plantar pressure record time series and plantar-impulse distribution along the principal axis of plantar impulse. These indexes are applied to analyze the plantar impulse collected by plantar pressure plates from three sources: Achilles tendon ruptures; elderly people (ages 62-71); and young people (ages 19-23). Our findings reveal that plantar impulse distribution curves for Achilles tendon ruptures change irregularly with subjects' walking speed changes. When comparing distribution curves of the young, we see a significant difference in the elderly subjects' phalanges plantar pressure record time series. This verifies our hypothesis that a plantar impulse can function as a means to assess and evaluate musculoskeletal system injuries and aging.
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Affiliation(s)
- Yifang Fan
- Center for Scientific Research, Guangzhou Institute of Physical Education, Guangzhou, P.R. China
| | - Yubo Fan
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, P.R. China
| | - Zhiyu Li
- College of Foreign Studies, Jinan University, Guangzhou, P.R. China
| | - Tony Newman
- College of Foreign Studies, Jinan University, Guangzhou, P.R. China
| | - Changsheng Lv
- Center for Scientific Research, Guangzhou Institute of Physical Education, Guangzhou, P.R. China
| | - Yi Zhou
- Center for Scientific Research, Guangzhou Institute of Physical Education, Guangzhou, P.R. China
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85
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Deschamps K, Matricali GA, Roosen P, Desloovere K, Bruyninckx H, Spaepen P, Nobels F, Tits J, Flour M, Staes F. Classification of forefoot plantar pressure distribution in persons with diabetes: a novel perspective for the mechanical management of diabetic foot? PLoS One 2013; 8:e79924. [PMID: 24278219 PMCID: PMC3838415 DOI: 10.1371/journal.pone.0079924] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Accepted: 09/29/2013] [Indexed: 12/20/2022] Open
Abstract
Background The aim of this study was to identify groups of subjects with similar patterns of forefoot loading and verify if specific groups of patients with diabetes could be isolated from non-diabetics. Methodology/Principal Findings Ninety-seven patients with diabetes and 33 control participants between 45 and 70 years were prospectively recruited in two Belgian Diabetic Foot Clinics. Barefoot plantar pressure measurements were recorded and subsequently analysed using a semi-automatic total mapping technique. Kmeans cluster analysis was applied on relative regional impulses of six forefoot segments in order to pursue a classification for the control group separately, the diabetic group separately and both groups together. Cluster analysis led to identification of three distinct groups when considering only the control group. For the diabetic group, and the computation considering both groups together, four distinct groups were isolated. Compared to the cluster analysis of the control group an additional forefoot loading pattern was identified. This group comprised diabetic feet only. The relevance of the reported clusters was supported by ANOVA statistics indicating significant differences between different regions of interest and different clusters. Conclusion/s Significance There seems to emerge a new era in diabetic foot medicine which embraces the classification of diabetic patients according to their biomechanical profile. Classification of the plantar pressure distribution has the potential to provide a means to determine mechanical interventions for the prevention and/or treatment of the diabetic foot.
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Affiliation(s)
- Kevin Deschamps
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- Laboratory for Clinical Motion Analysis, University Hospitals Leuven, Pellenberg, Belgium
- Multidisciplinary Diabetic Foot Clinic, University Hospitals Leuven, Leuven, Belgium
- * E-mail:
| | - Giovanni Arnoldo Matricali
- Multidisciplinary Diabetic Foot Clinic, University Hospitals Leuven, Leuven, Belgium
- Department of Development & Regeneration, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Philip Roosen
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Kaat Desloovere
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
- Laboratory for Clinical Motion Analysis, University Hospitals Leuven, Pellenberg, Belgium
| | - Herman Bruyninckx
- Department of Mechanical Engineering, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Pieter Spaepen
- Department of Mechanical Engineering, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Frank Nobels
- Department of Internal Medicine- Endocrinology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Jos Tits
- Department of Internal Medicine- Endocrinology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Mieke Flour
- Multidisciplinary Diabetic Foot Clinic, University Hospitals Leuven, Leuven, Belgium
- Department of Dermatology, University Hospitals Leuven, Leuven, Belgium
| | - Filip Staes
- Department of Rehabilitation Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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86
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Fernando M, Crowther R, Lazzarini P, Sangla K, Cunningham M, Buttner P, Golledge J. Biomechanical characteristics of peripheral diabetic neuropathy: A systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure. Clin Biomech (Bristol, Avon) 2013; 28:831-45. [PMID: 24035444 DOI: 10.1016/j.clinbiomech.2013.08.004] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/08/2013] [Accepted: 08/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diabetic peripheral neuropathy is an important cause of foot ulceration and limb loss. This systematic review and meta-analysis investigated the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and dynamic plantar pressures. METHODS Electronic databases were searched systematically for articles reporting the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and plantar pressures. Searches were restricted to articles published between January 2000 and April 2012. Outcome measures assessed included spatiotemporal parameters, lower limb kinematics, kinetics, muscle activation and plantar pressure. Meta-analyses were carried out on all outcome measures reported by ≥3 studies. FINDINGS Sixteen studies were included consisting of 382 neuropathy participants, 216 diabetes controls without neuropathy and 207 healthy controls. Meta-analysis was performed on 11 gait variables. A high level of heterogeneity was noted between studies. Meta-analysis results suggested a longer stance time and moderately higher plantar pressures in diabetic peripheral neuropathy patients at the rearfoot, midfoot and forefoot compared to controls. Systematic review of studies suggested potential differences in the biomechanical characteristics (kinematics, kinetics, EMG) of diabetic neuropathy patients. However these findings were inconsistent and limited by small sample sizes. INTERPRETATION Current evidence suggests that patients with diabetic peripheral neuropathy have elevated plantar pressures and occupy a longer duration of time in the stance-phase during gait. Firm conclusions are hampered by the heterogeneity and small sample sizes of available studies.
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Affiliation(s)
- Malindu Fernando
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; Movement Analysis Laboratory, Institute of Sports and Exercise Science, James Cook University, Townsville, Australia.
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Robinson CC, Balbinot LF, Silva MF, Achaval M, Zaro MA. Plantar pressure distribution patterns of individuals with prediabetes in comparison with healthy individuals and individuals with diabetes. J Diabetes Sci Technol 2013; 7:1113-21. [PMID: 24124936 PMCID: PMC3876353 DOI: 10.1177/193229681300700503] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Since elevated mechanical stress along with loss of plantar protective sensation are considered relevant factors in skin breakdown resulting in diabetic foot ulcerations, the assessment of plantar pressure is important for the prevention of diabetic foot complications. Prediabetes subjects are at risk of chronic hyperglycemia complications, among them neuropathy, but information about plantar loading in this population is not available. We aimed to compare baropodometric parameters of individuals with prediabetes versus healthy persons and persons with diabetes mellitus (DM). METHODS Baropodometric data from 73 subjects (15 with prediabetes (pre-DM), 28 with type 2 DM, 30 healthy) aged between 29 and 69 years of both genders were registered through a pressure platform with self-selected gait speed and first-step protocol. Peak plantar pressure, stance time, percentage of contact time, percentage of contact area and pressure-time integral were assessed in five plantar foot regions: heel, midfoot, metatarsals, hallux, and toes 2 to 5. Groups were compared by one-way analysis of variance with Scheffé post hoc (α = 0.05). RESULTS Age, body mass index, gender, and arch height index did not differ between groups. Pre-DM and DM subjects presented increased peak pressure and pressure-time integral in metatarsals (p = .010; p > .001), as well as increased percentage of contact time in midfoot (p = .006) and metatarsals (p = .004) regions when compared with healthy subjects. Stance time was significantly higher (p = .017) in DM subjects. CONCLUSIONS Pre-DM subjects seem to exhibit an altered plantar pressure distribution pattern similar to that often found in DM subjects.
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Grewal GS, Bharara M, Menzies R, Talal TK, Armstrong D, Najafi B. Diabetic peripheral neuropathy and gait: does footwear modify this association? J Diabetes Sci Technol 2013; 7:1138-46. [PMID: 24124939 PMCID: PMC3876356 DOI: 10.1177/193229681300700506] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Gait-related fall risk is the leading cause of mortality among patients with diabetes, especially those older than 65 years. Deterioration in balance and loss of protective sensation in lower extremities contribute significantly to fall risk in patients with diabetic peripheral neuropathy (DPN). This study aimed to explore the impact of neuropathy and foot ulcer on gait. METHODS We recruited 39 participants (age, 56.9 ± 8.2 years; body mass index, 29.6.3 ± 4.7 kg/m2), including 15 DPN patients without foot ulcers, 16 DPN patients with foot ulcers, and 8 healthy aged-matched controls. Patients with active foot ulcers wore an offloading device during gait examination, including removable cast walker. RESULTS Results suggest that neuropathy alters gait mainly by increasing gait initiation, gait variability (coefficient of variation of gait velocity), and double support (DS) time, while reducing knee range of motion and center of mass sway (p < .05). Interestingly, the presence of foot ulcer does not impact gait velocity (p > .1) but enhances some of the gait parameters such as gait variability and DS time. CONCLUSIONS This study demonstrates that neuropathy deteriorates gait, but the presence of foot ulcers does not alter gait parameters further than neuropathy. In addition, patients with foot ulcers demonstrated a better gait compared with DPN patients without ulcers. We speculate that offloading footwear may be enhancing the somatosensory feedback from sensate skin, thereby positively affecting gait parameters. A study with a larger sample is required to explore the effect of prescribed footwear in the DPN population in order to validate the findings of this research study.
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Affiliation(s)
- Gurtej S. Grewal
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Manish Bharara
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert Menzies
- Wound and Diabetic Foot Center, Department of Medicine, Hamad Medical Co., Doha, Qatar
| | - Talal K. Talal
- Wound and Diabetic Foot Center, Department of Medicine, Hamad Medical Co., Doha, Qatar
| | - David Armstrong
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
| | - Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance (iCAMP)/Southern Arizona Limb Salvage Alliance (SALSA), Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona
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Najafi B, Armstrong DG, Mohler J. Novel wearable technology for assessing spontaneous daily physical activity and risk of falling in older adults with diabetes. J Diabetes Sci Technol 2013; 7:1147-60. [PMID: 24124940 PMCID: PMC3876357 DOI: 10.1177/193229681300700507] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND As baby boomers age and their expected life span increases, there is an unprecedented need to better manage the health care of elders with diabetes who are at increased risk of falling due to diabetes complications, frailty, or other conditions. New clinical and research tools are needed to measure functioning accurately and to identify early indicators of risk of falling, thus translating into more effective and earlier intervention. METHODS The objective of this pilot study was to validate a significant change in hardware and algorithm to track activity patterns using a single triaxial accelerometer through validation of timed up and go and standard measures of balance and gait. We recruited a convenience sample of eight older adults with diabetes and peripheral neuropathy (age, 77 ± 7 years old) who were asked to wear the sensor for imposed daytime activity performed in our gait laboratory. Subjects were stratified into risk of falling categories based on Tinetti scores. We examined the accuracy of the suggested technology for discrimination of high- versus low-risk groups. RESULTS The system was accurate in identifying the number of steps taken and walking duration (random error <5%). The proposed algorithm allowed accurate identification and stratification of those at highest risk of falling, suggesting that subjects with high risk of falling required a substantially longer duration for rising from a chair when compared with those with low risk of falling (p < .05). CONCLUSIONS Our new single triaxial accelerometer algorithm successfully tracked postural transition, allowing accurate identification of those at high risk of falling, and could be useful for intermittent or even continuous monitoring of older adults with diabetes. Other potential applications could include activity monitoring of the diabetes population with lower extremity disease and of patients undergoing surgical procedures or as an objective measure during rehabilitation.
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Affiliation(s)
- Bijan Najafi
- Interdisciplinary Consortium on Advanced Motion Performance, College of Medicine, University of Arizona, P.O. Box 245072, 1501 N. Campbell Ave., Room 4402, Tucson, AZ 85724-5072.
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Gait characteristics of people with diabetes-related peripheral neuropathy, with and without a history of ulceration. Gait Posture 2013; 38:723-8. [PMID: 23583607 DOI: 10.1016/j.gaitpost.2013.03.009] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 02/19/2013] [Accepted: 03/09/2013] [Indexed: 02/02/2023]
Abstract
Biomechanical alterations in diabetes are believed to contribute to plantar neuropathic ulceration. This exploratory study documents clinical measures of flexibility and strength, alongside three-dimensional biomechanical gait data of the lower limb, in 10 patients with a history of neuropathic ulceration (DNU; n=10). Comparative data is presented from age and gender matched groups with; diabetes peripheral neuropathy and no ulcer history (DWN; n=10), diabetes and no peripheral neuropathy (DNN; n=10) and a non-diabetes reference group (NOND; n=10). Biomechanical data were collected at a comfortable walking speed with a Vicon motion analysis system. Clinical measures showed a non-significant trend toward decreased static range of motion at the ankle and first metatarsophalangeal joints, with worsening neuropathy status. Of the diabetes groups, knee and ankle strength was significantly lower in those with an ulcer history (p=0.01-0.03), with the exception of knee extension. In the DNU group, walking speed was on average 0.17 ms slower compared to NOND (p=0.04). The DNU group demonstrated a lower range of motion than NOND at the: hips (frontal plane, by 25%: p=0.03); hips and knees (transverse plane, 31%: p=0.01 and 32%: p<0.01); ankles (sagittal plane, 22%: p<0.01) and first metatarsophalangeal joints (sagittal plane, 32%: p=0.01), with less foot rotation (24%: p=0.04). Kinetic alterations in DNU included lower: ankle maximum power (21%: p=0.03) and vertical ground reaction force 2nd peak (6%: p<0.01). The study findings identified gait alterations in people with clinically severe peripheral neuropathy and related plantar foot ulcer history. Further research is needed to explore potential casual pathways.
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Afferent control of walking: are there distinct deficits associated to loss of fibres of different diameter? Clin Neurophysiol 2013; 125:327-35. [PMID: 23948160 DOI: 10.1016/j.clinph.2013.07.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 07/10/2013] [Accepted: 07/22/2013] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To compare the gait pattern in patients affected by different types of neuropathy. METHODS We recruited healthy subjects (HS, n=38), patients with Charcot-Marie-Tooth disease type 1A (CMT1A) (n=10) and patients with diabetic neuropathy (DNP) (n=12). Neuropathy impairment score and neuropathy score were assessed. Body sway during quiet stance, and spatio-temporal gait parameters were recorded. RESULTS Most patients had reduced or absent tendon-tap reflexes. Strength of foot dorsiflexor muscles (p<0.05) and conduction velocity (CV) of leg nerves (p<0.0001) were more impaired in CMT1A than DNP, whereas joint-position sense was more affected (p<0.05) in DNP. Body sway while standing was larger in DNP compared to CMT1A and HS (p<0.01 and p<0.0001 respectively). During gait, the distribution of foot sole contact pressure was abnormal in CMT1A (p<0.05) but not in DNP. Velocity and step length were decreased, and foot yaw angle at foot flat increased, in DNP with respect to CMT1A and HS (both variables, p<0.001). Gait velocity and step length were decreased (p<0.005) also in CMT1A, but to a smaller extent than in DNP, so that the difference between patient groups was significant (p<0.0005). Duration of the double support was protracted in DNP compared to CMT1A and HS (p<0.0005). For DNP only, velocity of gait and duration of single support were correlated (p<0.05) both to sway path and lower limb muscle strength. CONCLUSIONS Changes in both body sway and stance phase of gait were larger in DNP than CMT1A, indicating more impaired static and dynamic control of balance when neuropathy affects the small in addition to the large afferent fibres. Diminished somatosensory input from the smaller fibres rather than muscle weakness or foot deformity plays a critical role in the modulation of the support phase of gait. SIGNIFICANCE The analysis of balance and gait in patients with neuropathy can offer a tool for understanding the nature and functional impact of the neuropathy and should be included in their functional evaluation.
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Deschamps K, Matricali GA, Roosen P, Nobels F, Tits J, Desloovere K, Bruyninckx H, Flour M, Deleu PA, Verhoeven W, Staes F. Comparison of foot segmental mobility and coupling during gait between patients with diabetes mellitus with and without neuropathy and adults without diabetes. Clin Biomech (Bristol, Avon) 2013; 28:813-9. [PMID: 23829980 DOI: 10.1016/j.clinbiomech.2013.06.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2013] [Revised: 06/15/2013] [Accepted: 06/17/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Reduction in foot mobility has been identified as a key factor of altered foot biomechanics in individuals with diabetes mellitus. This study aimed at comparing in vivo segmental foot kinematics and coupling in patients with diabetes with and without neuropathy to control adults. METHODS Foot mobility of 13 diabetic patients with neuropathy, 13 diabetic patients without neuropathy and 13 non-diabetic persons was measured using an integrated measurement set-up including a plantar pressure platform and 3D motion analysis system. In this age-, sex- and walking speed matched comparative study; differences in range of motion quantified with the Rizzoli multisegment foot model throughout different phases of the gait cycle were analysed using one-way repeated measures analysis of variance (ANOVA). Coupling was assessed with cross-correlation techniques. FINDINGS Both cohorts with diabetes showed significantly lower motion values as compared to the control group. Transverse and sagittal plane motion was predominantly affected with often lower range of motion values found in the group with neuropathy compared to the diabetes group without neuropathy. Most significant changes were observed during propulsion (both diabetic groups) and swing phase (predominantly diabetic neuropathic group). A trend of lower cross-correlations between segments was observed in the cohorts with diabetes. INTERPRETATION Our findings suggest an alteration in segmental kinematics and coupling during walking in diabetic patients with and without neuropathy. Future studies should integrate other biomechanical measurements as it is believed to provide additional insight into neural and mechanical deficits associated to the foot in diabetes.
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Affiliation(s)
- K Deschamps
- KU Leuven, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Group, Weligerveld 1, 3212 Pellenberg, Belgium; KU Leuven, Laboratory for Clinical Motion Analysis, University Hospital Pellenberg, Weligerveld 1, 3212 Pellenberg, Belgium; KU Leuven, Multidisciplinary Diabetic Foot Clinic, University Hospitals Leuven, Weligerveld 1, 3212 Pellenberg, Belgium; Institut D'Enseignement Supérieur Parnasse Deux-Alice, Division of Podiatry, Bruxelles, Weligerveld 1, 3212 Pellenberg, Belgium.
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Formosa C, Gatt A, Chockalingam N. The importance of clinical biomechanical assessment of foot deformity and joint mobility in people living with type-2 diabetes within a primary care setting. Prim Care Diabetes 2013; 7:45-50. [PMID: 23332418 DOI: 10.1016/j.pcd.2012.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Revised: 12/02/2012] [Accepted: 12/21/2012] [Indexed: 11/17/2022]
Abstract
AIMS The aim of the study was to assess foot morphology and document foot deformities and joint mobility in a cohort of subjects living with type-2 diabetes mellitus in Malta in a Primary Care setting. METHODS A retrospective observational study was conducted on 243 subjects who participated in a local pilot diabetes foot screening project. Assessments included hammer/claw toes, hallux valgus, hallux limitus, prominent metatarsal heads, bony prominences, Charcot deformity, plantar callus, foot type and ankle and hallux mobility. The clinical assessments used during this screening program were based on validated and previously published tools. RESULTS Upon clinical examination 38% of the sample was found to have developed some form of corns or callosities in their feet. Hallux valgus deformity was present in 49.4% of the sample, whilst 39% of the sample had hammer toes. Prominent metatarsal heads (24%), other bony prominences (44%) and limited joint mobility were also reported. Furthermore, 56% of the sample presented with unsuitable footwear and upon clinical biomechanical examination a further 28% of the sample required prescription orthosis. CONCLUSIONS/INTERPRETATION A significant proportion of participants living with type-2 diabetes presented with foot deformities which are known to be predictive of foot ulceration in this high risk population. This research conducted in a primary care setting highlights the importance of increased vigilance coupled with strengthening of existing screening structures and introducing clinical guidelines with regards to biomechanical assessment of the feet in a primary care setting in order to reduce the incidence of diabetes foot complications.
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A growing troubling triad: diabetes, aging, and falls. J Aging Res 2013; 2013:342650. [PMID: 23476773 PMCID: PMC3586503 DOI: 10.1155/2013/342650] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 01/11/2013] [Indexed: 11/17/2022] Open
Abstract
There is a significant and troubling link between diabetes (DM) and falls in the elderly. Individuals with DM are prone to fall for reasons such as decreased sensorimotor function, musculoskeletal/neuromuscular deficits, foot and body pain, pharmacological complications, and specialty (offloading) footwear devices. Additionally, there is some concern that DM patients are prone to have more severe problems with falls than non-DM individuals. Fractures, poorer rehabilitation, and increased number of falls are all concerns. Fortunately, efforts to mitigate falls by DM patients show promise. A number of studies have shown that balance, strength, and gait training may be utilized to successfully reduce fall risk in this population. Furthermore, new technologies such as virtual reality proprioceptive training may be able to provide this reduced risk within a safe training environment.
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Kelly C, Fleischer A, Yalla S, Grewal GS, Albright R, Berns D, Crews R, Najafi B. Fear of falling is prevalent in older adults with diabetes mellitus but is unrelated to level of neuropathy. J Am Podiatr Med Assoc 2013; 103:480-8. [PMID: 24297984 PMCID: PMC4732269 DOI: 10.7547/1030480] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with diabetic peripheral neuropathy (DPN) demonstrate gait alterations compared with their nonneuropathic counterparts, which may place them at increased risk for falling. However, it is uncertain whether patients with DPN also have a greater fear of falling. METHODS A voluntary group of older adults with diabetes was asked to complete a validated fear of falling questionnaire (Falls Efficacy Scale International [FES-I]) and instructed to walk 20 m in their habitual shoes at their habitual speed. Spatiotemporal parameters of gait (eg, stride velocity and gait speed variability) were collected using a validated body-worn sensor technology. Balance during walking was also assessed using sacral motion in the mediolateral and anteroposterior directions. The level of DPN was quantified using vibration perception threshold from the great toe. RESULTS Thirty-four diabetic patients (mean ± SD: age, 67.6 ± 9.2 years; body mass index, 30.9 ± 5.7; hemoglobin A1c, 7.9% ± 2.3%) with varying levels of neuropathy (mean ± SD vibration perception threshold, 34.6 ± 22.9 V) were recruited. Most participants (28 of 34, 82%) demonstrated moderate to high concern about falling based on their FES-I score. Age (r = 0.6), hemoglobin A1c level (r = 0.39), number of steps required to reach steady-state walking (ie, gait initiation) (r = 0.4), and duration of double support (r = 0.44) were each positively correlated with neuropathy severity (P < .05). Participants with a greater fear of falling also walked with slower stride velocities and shorter stride lengths (r = -0.3 for both, P < .05). However, no correlation was observed between level of DPN and the participant's actual concern about falling. CONCLUSIONS Fear of falling is prevalent in older adults with diabetes mellitus but is unrelated to level of neuropathy.
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Affiliation(s)
- Carolyn Kelly
- Advocate Illinois Masonic Medical Center, Chicago, IL
| | - Adam Fleischer
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Sai Yalla
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Gurtej S. Grewal
- Southern Arizona Limb Salvage Alliance, Department of Surgery and Interdisciplinary Consortium on Advanced Motion Performance, Arizona Center on Aging, University of Arizona College of Medicine, Tucson, AZ
| | - Rachel Albright
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Dana Berns
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Ryan Crews
- Center for Lower Extremity Ambulatory Research, Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, North Chicago, IL
| | - Bijan Najafi
- Southern Arizona Limb Salvage Alliance, Department of Surgery and Interdisciplinary Consortium on Advanced Motion Performance, Arizona Center on Aging, University of Arizona College of Medicine, Tucson, AZ
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Shen J, Liu F, Zeng H, Wang J, Zhao JG, Zhao J, Lu FD, Jia WP. Vibrating perception threshold and body mass index are associated with abnormal foot plantar pressure in type 2 diabetes outpatients. Diabetes Technol Ther 2012; 14:1053-9. [PMID: 22934798 PMCID: PMC3482851 DOI: 10.1089/dia.2012.0146] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS This study investigated the influencing factors of foot plantar pressure and attempted to find practical indicators to predict abnormal foot pressure in patients with type 2 diabetes mellitus (T2DM). SUBJECTS AND METHODS Vibration perception threshold (VPT) and foot plantar pressure in 1,126 T2DM outpatients were examined. Patients were assigned to Group A (n=599), Group B (n=312), and Group C (n=215) according to VPT values and to Group I (n=555), Group II (n=436), and Group III (n=135) based on body mass index (BMI). The clinical characteristics and pressure-time integral (PTI) were compared among the three groups, and the associated factors of the total PTI in the entire foot (T-PTI) were analyzed. RESULTS PTI of Group C in heel medial and heel lateral was significantly higher than that of Group A (all P<0.01). PTI of Group B in the right fifth metatarsal and heel medial was significantly higher than that of Group A (all P<0.05). T-PTI of Group C was significantly higher than those of Groups A and B, and that of Group B was higher than that of Group A (all P<0.01). PTI of Groups II and III in the second, third, and fourth metatarsal, midfoot, heel medial, and heel lateral was significantly higher than that of Group I (all P<0.05). T-PTI of Groups II and III was significantly higher than that of Group I (all P<0.01). Pearson correlation analysis showed that T-PTI was positively associated with age, VPT, waist circumference, waist-to-hip ratio, and BMI (P<0.05). In multiple stepwise regression analysis, VPT (P=0.004) and BMI (P=0.000) were independent risk factors of T-PTI, and each 1 unit increase in BMI increased the T-PTI by 5.962 kPa•s. Receiver operator characteristic curve analysis further revealed that the optimal cutpoint of VPT and BMI to predict the abnormal PTI was 21 V (odds ratio=2.33, 95% confidence interval 1.67-3.25) and 24.9 kg/m(2) (odds ratio=2.12, 95% confidence interval 1.55-2.90), respectively. CONCLUSIONS Having a VPT higher than 21 V and a BMI above 24.9 kg/m(2) increases the risk of excessive foot plantar pressure in Chinese T2DM.
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Affiliation(s)
- Jing Shen
- Department of Endocrinology & Metabolism, Shanghai Jiaotong University-Affiliated Sixth People's Hospital, Shanghai Clinical Medical Center of Diabetes, Shanghai Institute for Diabetes, Shanghai Key Laboratory of Diabetes, Shanghai, China
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Plantar Temperature Response to Walking in Diabetes with and without Acute Charcot: The Charcot Activity Response Test. J Aging Res 2012; 2012:140968. [PMID: 22900177 PMCID: PMC3413979 DOI: 10.1155/2012/140968] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 06/25/2012] [Indexed: 12/29/2022] Open
Abstract
Objective. Asymmetric plantar temperature differences secondary to inflammation is a hallmark for the diagnosis and treatment response of Charcot foot syndrome. However, little attention has been given to temperature response to activity. We examined dynamic changes in plantar temperature (PT) as a function of graduated walking activity to quantify thermal responses during the first 200 steps.
Methods. Fifteen individuals with Acute Charcot neuroarthropathy (CN) and 17 non-CN participants with type 2 diabetes and peripheral neuropathy were recruited. All participants walked for two predefined paths of 50 and 150 steps. A thermal image was acquired at baseline after acclimatization and immediately after each walking trial. The PT response as a function of number of steps was examined using a validated wearable sensor technology. The hot spot temperature was identified by the 95th percentile of measured temperature at each anatomical region (hind/mid/forefoot). Results. During initial activity, the PT was reduced in all participants, but the temperature drop for the nonaffected foot was 1.9 times greater than the affected side in CN group (P = 0.04). Interestingly, the PT in CN was sharply increased after 50 steps for both feet, while no difference was observed in non-CN between 50 and 200 steps. Conclusions. The variability in thermal response to the graduated walking activity between Charcot and non-Charcot feet warrants future investigation to provide further insight into the correlation between thermal response and ulcer/Charcot development. This stress test may be helpful to differentiate CN and its response to treatment earlier in its course.
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Kim JY, Hwang S, Lee Y. Selective plantar fascia release for nonhealing diabetic plantar ulcerations. J Bone Joint Surg Am 2012; 94:1297-302. [PMID: 22810400 DOI: 10.2106/jbjs.k.00198] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Achilles tendon lengthening can decrease plantar pressures, leading to resolution of forefoot ulceration in patients with diabetes mellitus. However, this procedure has been reported to have a complication rate of 10% to 30% and can require a long period of postoperative immobilization. We have developed a new technique, selective plantar fascia release, as an alternative to Achilles tendon lengthening for managing these forefoot ulcers. METHODS We evaluated sixty patients with diabetes for a mean of 23.5 months after selective plantar fascia release for the treatment of nonhealing diabetic neuropathic ulcers in the forefoot. Preoperative and postoperative dorsiflexion range of motion of the affected metatarsophalangeal joint and wound-healing data were used to evaluate the effectiveness of the procedure and to determine the relationship between plantar fascia release and ulcer healing. Complications were recorded. RESULTS Thirty-six (56%) of the ulcers healed within six weeks, including twenty-nine (60%) of the plantar toe ulcers and seven (44%) of the metatarsophalangeal joint ulcers. The mean range of motion of the affected metatarsophalangeal joint increased from 15.3° ± 7.8° to 30.6° ± 14.1° postoperatively (p < 0.05). All patients in whom the preoperative dorsiflexion of the affected metatarsophalangeal joint was between 5° and 30° and in whom the range of motion of that joint increased by ≥13° after the procedure experienced healing of the ulcer. No ulcer recurrence in the original location was identified during follow-up. No patients experienced any complications associated with the selective plantar fascia release. CONCLUSIONS Our results suggest that selective plantar fascia release can lead to healing of neuropathic plantar forefoot ulcers in diabetic patients. Ulcers in patients in whom the preoperative dorsiflexion angle of the affected metatarsophalangeal joint is between 5° and 30° and in whom the increase in range of motion is ≥13° postoperatively have the greatest chance of being cured. LEVEL OF EVIDENCE Therapeutic level IV. See Instructions for Authors for a complete description of the levels of evidence.
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Affiliation(s)
- J Young Kim
- Foot and Ankle Center, Department of Orthopedic Surgery, Heymin General Hospital, 627-3, Jayang dong, Gwangjingu, Seoul, South Korea.
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Najafi B, Bharara M, Talal TK, Armstrong DG. Advances in balance assessment and balance training for diabetes. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/dmt.12.38] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Grewal G, Sayeed R, Yeschek S, Menzies RA, Talal TK, Lavery LA, Armstrong DG, Najafi B. Virtualizing the assessment: a novel pragmatic paradigm to evaluate lower extremity joint perception in diabetes. Gerontology 2012; 58:463-71. [PMID: 22572476 DOI: 10.1159/000338095] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Accepted: 03/16/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Individuals with diabetes have a higher risk of falls and fall-related injuries. People with diabetes often develop peripheral neuropathy (DPN) as well as nerve damage throughout the body. In particular, reduced lower extremity proprioception due to DPN may cause a misjudgment of foot position and thus increase the risk of fall. OBJECTIVE An innovative virtual obstacle-crossing paradigm using wearable sensors was developed in an attempt to assess lower extremity position perception damage due to DPN. METHODS 67 participants (age 55.4 ± 8.9, BMI 28.1 ± 5.8) including diabetics with and without DPN as well as aged-matched healthy controls were recruited. Severity of neuropathy was quantified using a vibratory perception threshold (VPT) test. The ability of perception of lower extremity was quantified by measuring obstacle-crossing success rate (OCSR), toe-obstacle clearance (TOC), and reaction time (T(R)) while crossing a series of virtual obstacles with heights at 10% and 20% of the subject's leg length. RESULTS No significant difference was found between groups for age and BMI. The data revealed that DPN subjects had a significantly lower OCSR compared to diabetics with no neuropathy and controls at an obstacle size of 10% of leg length (p < 0.05). DPN subjects also demonstrated longer T(R) compared to other groups and for both obstacle sizes. In addition, TOC was reduced in neuropathy groups. Interestingly, a significant correlation between T(R) and VPT (r = 0.5, p < 10(-3)) was observed indicating a delay in reaction with increasing neuropathy severity. The delay becomes more pronounced by increasing the size of the obstacle. Using a regression model suggests that the change in T(R) between obstacle sizes of 10% and 20% of leg length is the most sensitive predictor for neuropathy severity with an odds ratio of 2.70 (p = 0.02). CONCLUSION The findings demonstrate proof of a concept of virtual-reality application as a promising method for objective assessment of neuropathy severity, however a further study is warranted to establish a stronger relationship between the measured parameters and neuropathy.
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Affiliation(s)
- Gurtej Grewal
- Center for Lower Extremity Ambulatory Research, Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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