Hip strength: ankle proprioceptive threshold ratio predicts falls and injury in diabetic neuropathy

Maintained volitional activation of the muscle alters the cortical processing of proprioceptive afference from the ankle joint

Cortical proprioceptive processing of intermittent, passive movements can be assessed by extracting evoked and induced electroencephalographic (EEG) responses to somatosensory stimuli. Although the existent prior research on somatosensory stimulations, it remains unknown to what extent ongoing volitional muscle activation modulates the proprioceptive cortical processing of passive ankle-joint rotations. Twenty-five healthy volunteers (28.8 ± 7 yr, 14 males) underwent a total of 100 right ankle-joint passive rotations (4° dorsiflexions, 4 ± 0.25 s inter-stimulus interval, 30°/s peak angular velocity) evoked by a movement actuator during passive condition with relaxed ankle and active condition with a constant plantarflexion torque of 5 ± 2.5 Nm. Simultaneously, EEG, electromyographic (EMG) and kinematic signals were collected. Spatiotemporal features of evoked and induced EEG responses to the stimuli were extracted to estimate the modulation of the cortical proprioceptive processing between the active and passive conditions. Proprioceptive stimuli during the active condition elicited robustly ∼26 % larger evoked response and ∼38 % larger beta suppression amplitudes, but ∼42 % weaker beta rebound amplitude over the primary sensorimotor cortex than the passive condition, with no differences in terms of response latencies. These findings indicate that the active volitional motor task during naturalistic proprioceptive stimulation of the ankle joint enhances related cortical activation and reduces related cortical inhibition with respect to the passive condition. Possible factors explaining these results include mechanisms occurring at several levels of the proprioceptive processing from the peripheral muscle (i.e. mechanical, muscle spindle status, etc.) to the different central (i.e. spinal, sub-cortical and cortical) levels.

Ankle proprioception in children with cerebral palsy

PURPOSE

There is no established clinical standard to evaluate ankle proprioception in children with cerebral palsy (CP). This study compared ankle position sense of children with CP to age-matched children who are typically developing (TD).

METHODS

Children aged 6-17 years participated (15 CP, 58 TD). Using a custom-built device, the ankle was passively rotated to two positions for 25 trials. Using a psychophysical forced-choice paradigm, participants indicated which position was more plantarflexed. A psychometric function was fitted to the response data to determine the just noticeable difference (JND) threshold and the associated uncertainty (random error) for ankle position sense.

RESULTS

Median JND thresholds for the CP group were elevated (CP: 4.3°, TD: 3.0°). Three children with CP exceeded the 95th percentile of TD. No differences in random error were found.

CONCLUSION

This method assessed ankle proprioception relative to norm data and identified position sense impairments in children with CP. Using this method can provide data on proprioceptive status in CP, augmenting the assessment of motor impairment.

Clinical Considerations in Returning Pediatric and Young Adults With Cancer to Physical Activity

ABSTRACT

There is a gap in the literature on the best treatment of clinical sequelae within adolescent and young adult pediatric cancer populations. Children, adolescents, and young adults are at risk for a multitude of immediate and late effects of their disease and treatment that warrant a comprehensive, multidisciplinary team approach to optimize care. Sports medicine providers are well-equipped with their background to join the oncology rehabilitation team in diagnosing and managing cancer-related impairments to help these populations live a healthier and more active lifestyle. In this manuscript, four essential clinical components to consider when returning children, adolescents, and young adults with cancer history to physical activity are discussed: chemotherapy-induced peripheral neuropathy, cardiotoxicity, nutritional deficiencies, and deconditioning.

Comparison of the relationship between cognitive function and future falls in Chinese community-dwelling older adults with and without diabetes mellitus

OBJECTIVE

The aim of this study was to determine whether cognitive function is associated with future falls in older patients with diabetes mellitus (DM) compared with those without DM. Cognitive function was divided into several domains to further analyze.

METHODS

A total of 678 individuals met the inclusion criteria and comprised the final study population. The mean age was 74.35 ± 5.35 years, and 58.9% of the participants were female (n = 400). At the baseline, cognitive function was measured by the Mini Mental State Examination (MMSE), and DM diagnoses were determined by medical records. The self-reported any falls data were obtained via face-to-face questioning at the 1-year follow-up.

RESULTS

At baseline, 15.6% of participants (n = 106) were diagnosed with DM. According to whether they had any falls during 1-year follow-up, there was a significant difference between the two group in fasting plasma glucose (p = 0.012) and DM (p = 0.036) at baseline. Among the older adults with DM, those who had experienced any falls had poorer cognitive function (p = 0.014). After adjusting for various covariates, we found that MMSE (95% CI 0.790-0.991, p = 0.034), orientation to place (95% CI 0.307-0.911, p = 0.022) and registration (95% CI 0.162-0.768, p = 0.009) were significantly associated with falls in the follow-up.

CONCLUSION

Our study found that in patients with DM, cognitive function is related to future falls. Not only overall cognitive function, but also orientation to place and registration were all associated with future falls in older adults with DM. When completing the fall risk assessment of elderly patients with DM, clinicians should give more attention to the testing of cognitive function.

Tempo-controlled resistance training of the hip abductors and ankle dorsiflexors with light loads does not improve postural sway in older adults

The force steadiness capabilities of the hip abductors and ankle dorsiflexors can explain a significant amount of the variance in postural sway during four types of standing balance tests. Control over balance, as well as force steadiness, generally worsens with aging, although the latter can be improved with unique training interventions. The purpose of our study was to assess how tempo-controlled, light-load resistance training of the hip abductors and ankle dorsiflexors influences performance in clinical movement tests, postural sway, muscle strength, and force steadiness in older adults. Participants (n = 28, 70 ± 7 years, 8 men) completed nine training sessions for either the hip abductors or ankle dorsiflexors in the nondominant leg. Training involved lifting a load equal to 15% of the maximal force achieved during an isometric contraction. Linear mixed-effects models revealed no changes (p > 0.05) in Sit-To-Stand test, Timed Up-and-Go test, maximal voluntary contraction (MVC) torque, or postural sway from before to after either training intervention. Only the dorsiflexor group significantly improved nondominant leg dorsiflexion force steadiness, but this did not translate to any other tasks. However, absolute and relative measures of MVC torque and force steadiness of the hip abductors and ankle dorsiflexors in the dominant and nondominant legs could predict sway-area rate in each of the four standing balance conditions. The responsiveness of leg muscles to light-load steadiness training in older adults appears to depend on the type of exercises performed during the intervention.

The Impact of Diabetic Neuropathy on Activities of Daily Living, Postural Balance and Risk of Falls - A Systematic Review

OBJECTIVE

The objective of this review is to discuss a compilation of the currently available literature regarding the impact of diabetic neuropathy (DN) on activities of daily living (ADL), postural stability, and risk of falls.

METHODS

A systematic electronic search strategy was conducted on PubMed/MEDLINE database, Cochrane Library, and Embase in March 2020. This narrative review included clinical cross-sectional studies assessing ADL, postural balance, and falls in adults with DN. All studies underwent a quality assessment based on the Newcastle Ottawa scale developed to assess cross-sectional studies.

RESULTS

Forty-two studies were identified. A total of 37 studies evaluated postural stability in DN, 10 studies assessed fall accidents, and three studies assessed ADL in individuals with DN. Seven studies assessed both postural stability and fall accidents, and one study assessed postural stability and ADL. Each of the studied outcome variables was assessed separately. Based on a quality assessment, eight studies were excluded resulting in an evaluation of 34 studies.

CONCLUSIONS

Diabetic neuropathy has a negative impact on postural balance and gait kinematics combined with an increased fall risk. Because of the few number of studies available, we were unable to evaluate the impact of DN on ADL. Our findings are in concordance with previous reviews, supporting the evidence for DN as a critical measure negatively impacting postural stability and fall risk in individuals with diabetes. Further clinical investigative studies are needed.

SC, Crews RT. Diabetes and Reactive Balance: Quantifying Stepping Thresholds With a Simple Spring Scale to Measure Fall-Risk in Ambulatory Older Adults

BACKGROUND

Fall-risk assessments for patients with diabetes fail to consider reactive responses to balance loss. The purpose of this study was to assess the feasibility of using a simple clinical tool to evaluate the impact of diabetes and fall history on reactive balance in older adults.

METHODS

We recruited 72 older adults with and without diabetes. Postural perturbations were applied by a waist-mounted spring scale. Stepping thresholds (STs) in the anterior and posterior directions were defined as the lowest spring-loads that induced a step. Balance was assessed via the National Institutes of Health Toolbox Standing Balance Test, and lower extremity sensation was assessed using vibratory perception threshold and Semmes-Weinstein monofilaments. Fall history over the past year was self-reported. Cox regressions and analysis of variance were used to compare hazard rates for stepping and observed STs between groups.

RESULTS

Anterior STs were elicited in 42 subjects and posterior STs in 65 subjects. Hazard rates for posterior ST were significantly affected by diabetes, with greater hazards for fallers with diabetes versus control fallers and nonfallers, after accounting for balance and sensory loss. For those who stepped, ST was lower in the posterior direction for the diabetes group. Additionally, anterior but not posterior ST was lower in all fallers vs all nonfallers.

CONCLUSIONS

The waist-mounted spring scale is a clinically implementable device that can assess ST in older adults with diabetes. Using the device, we demonstrated that ST was affected by diabetes and could potentially serve as a fall-risk factor independent of balance or sensory loss.

Ankle Proprioception in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Ankle position sense may be reduced before the appearance of the clinical manifestation of diabetic peripheral neuropathy. This is known to impair gait and cause falls and foot ulcers. Early detection of impaired ankle proprioception is important because it allows physicians to prescribe an exercise program to patients to prevent foot complications.

METHODS

Forty-six patients diagnosed as having type 2 diabetes mellitus and 22 control patients were included in the study. Presence of neuropathy was assessed using the Michigan Neuropathy Screening Instrument (MNSI). Level of foot care awareness was determined using the Nottingham Assessment of Functional Footcare (NAFF). Joint position sense was measured using a dynamometer.

RESULTS

Mean absolute angular error (MAAE) values were significantly higher in the neuropathy group compared with the control group (P < .05). Right plantarflexion MAAE values were significantly lower in the group without neuropathy compared with the group with neuropathy (P < .05). No correlation was found between MAAE values (indicating joint position sense) and age, educational level, disease duration, glycemic control, NAFF score, and MNSI history and examination scores in the groups with and without neuropathy (P > .05). Educational level and disease duration were found to be correlated with NAFF scores.

CONCLUSIONS

Increased MNSI history scores and increased deficits in ankle proprioception demonstrate that diabetic foot complications associated with reduced joint position sense may be seen at an increased rate in symptomatic patients.

Chemotherapy-induced peripheral neuropathy increases nontraumatic fracture risk in breast cancer survivors

Chemotherapy is a common treatment for breast cancer (BrCa) and can cause chemotherapy‐induced peripheral neuropathy (CIPN). CIPN contributes to falls, and is thus a potential risk factor for nontraumatic fractures (NTFx); yet, the effect of CIPN on NTFx risk has not been examined for BrCa survivors. We therefore investigated the association between CIPN and NTFx in BrCa survivors. Data were extracted from Optum's Deidentified Clinformatics® Data Mart Database years 2010–2015 in this retrospective cohort study. Among women, three groups were derived based on BrCa and CIPN status: BrCa+/CIPN+ (primary group of interest), BrCa+/CIPN− (first comparison group), and BrCa−/CIPN− (second comparison group). After propensity score matching the comparison groups to BrCa+/CIPN+ at a ratio of 1:11 (BrCa:control) for demographics, osteoporosis, glucocorticoid medication, comorbidities, and cancer‐related variables for BrCa+/CIPN−, 1‐year incidence rate (IR) of NTFx was determined for each group. The incident rate ratio (IRR) determined if the IR for NTFx was different for BrCa+/CIPN+ compared to BrCa+/CIPN− and BrCa−/CIPN−. Cox proportional hazards regression models estimated the hazard ratios (HRs) after adjusting for covariates that were unable to be matched for. The crude IR (95% confidence interval [CI]) of NTFx was 4.54 (2.32–6.77) for BrCa+/CIPN+ (n = 359), 2.53 (2.03–3.04) for BrCa+/CIPN− (n = 3949), and 1.76 (1.35–2.18) for BrCa−/CIPN− (n = 3949). The crude IRR of NTFx was significantly elevated for BrCa+/CIPN+ as compared to BrCa+/CIPN− (IRR = 1.80; 95% CI, 1.06–3.05) and BrCa−/CIPN− (IRR = 2.58; 95% CI, 1.50–4.44). The elevated rate of NTFx for BrCa+/CIPN+ remained unchanged after adjusting for aromatase inhibitors compared to BrCa+/CIPN− (HR = 1.79; 95% CI, 1.06–3.04). Female BrCa survivors have an increased 1‐year IR of NTFx after the onset of CIPN, suggesting that CIPN is an additive burden on NTFx risk among BrCa survivors. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Extensor digitorum brevis bulk and associations with fibular motor nerve conduction amplitude

INTRODUCTION

Prior work demonstrates that fibular compound motor action potential (CMAP) amplitude <4.0 mV predicts impairment of ankle proprioceptive precision and increased fall risk. Extensor digitorum brevis (EDB) inspection may present a simple clinical surrogate for CMAP amplitude.

OBJECTIVE

(1) To estimate the inter-rater reliability of assessment of EDB bulk. (2) To determine whether inspection of EDB bulk is associated with fibular CMAP amplitude.

DESIGN

Prospective inter-raterreliability study.

SETTING

Academic center outpatient Physical Medicine & Rehabilitation electromyography (EMG) clinics.

PARTICIPANTS

Fifty-two adult participants (102 feet).

MAIN OUTCOME MEASURES

(1) Inter-rater reliability of assessment of EDB bulk. (2) Mean fibular CMAP amplitude. (3) A binary measure of fibular CMAP amplitude at/above or below a 4.0 mV threshold.

RESULTS

Inter-rater reliability of EDB bulk grading was moderate (kappa: 0.65 [95% confidence interval (CI) 0.48-0.82]). The mean CMAP value was 5.9 ± 2.2 mV when bulk was normal, 3.4 ± 2.1 mV when diminished, and 0.6 ± 0.9 mV when atrophied. A multivariable analysis demonstrated that EDB bulk, distal symmetric polyneuropathy (DSP), and lumbar radiculopathy were all associated with CMAP amplitude. The sensitivity and specificity of grading muscle bulk as normal versus abnormal in detecting CMAP amplitude above or below 4.0 mV were 0.86 (95% CI 0.78-0.94) and 0.71 (95% CI 0.54-0.88), respectively. An atrophied EDB was a highly specific indicator that CMAP amplitude was abnormal (<4.0 mV) in 100% of cases (8/8).

CONCLUSIONS

EDB bulk was associated with fibular CMAP amplitude. Atrophy was a highly specific indicator for CMAP amplitude below 4.0 mV. Evaluation of EDB bulk may represent a quick and easy clinical surrogate marker for CMAP amplitude and distal neuromuscular impairment.

Differences in postural sway among healthy adults are associated with the ability to perform steady contractions with leg muscles

Upright standing involves small displacements of the center of mass about the base of support. These displacements are often quantified by measuring various kinematic features of the center-of-pressure trajectory. The plantar flexors have often been identified as the key muscles for the control of these displacements; however, studies have suggested that the hip abductor and adductors may also be important. The purpose of our study was to determine the association between the force capabilities of selected leg muscles and sway-area rate across four balance conditions in young (25 ± 4 years; 12/19 women) and older adults (71 ± 5 years; 5/19 women). Due to the marked overlap in sway-area rate between the two age groups, the data were collapsed, and individuals were assigned to groups of low- and high-sway area rates based on a k-medoid cluster analysis. The number of participants assigned to each group varied across balance conditions and a subset of older adults was always included in the low-sway group for each balance condition. The most consistent explanatory variable for the variance in sway-area rate was force control of the hip abductors and ankle dorsiflexors as indicated by the magnitude of the normalized force fluctuations (force steadiness) during a submaximal isometric contraction. The explanatory power of the regression models varied across conditions, thereby identifying specific balance conditions that should be examined further in future studies of postural control.

Age-related changes in proprioception of the ankle complex across the lifespan

BACKGROUND

Ankle complex proprioceptive ability, needed in active human movement, may change from childhood to elderly adulthood; however, its development across all life stages has remained unexamined. The aim of the present study was to investigate the across-the-lifespan trend for proprioceptive ability of the ankle complex during active ankle inversion movement.

METHODS

The right ankles of 118 healthy right-handed participants in 6 groups were assessed: children (6-8 years old), adolescents (13-15 years old), young adults (18-25 years old), middle-aged adults (35-50 years old), old adults (60-74 years old), and very old adults (75-90 years old). While the participants were standing, their ankle complex proprioception was measured using the Active Movement Extent Discrimination Apparatus.

RESULTS

There was no significant interaction between the effects of age group and gender on ankle proprioceptive acuity (F (5, 106) = 0.593, p = 0.705, η² _p = 0.027). Simple main effects analysis showed that there was a significant main effect for age group (F (5, 106) = 22.521, p < 0.001, η ² _p = 0.515) but no significant main effect for gender (F (1,106) =  2.283, p = 0.134, η ² _p = 0.021) between the female (0.723 ± 0.092, mean ± SD) and the male (0.712 ± 0.083) participants. The age-group factor was associated with a significant linear downward trend in scores (F (1, 106) = 10.584, p = 0.002, η ² _p = 0.091) and a strong quadratic trend component (F (1,106) = 100.701, p < 0.001, η ² _p = 0.480), producing an asymmetric inverted-U function.

CONCLUSION

The test method of the Active Movement Extent Discrimination Apparatus is sensitive to age differences in ankle complex proprioception. For proprioception of the ankle complex, young adults had significantly better scores than children, adolescents, old adults, and very old adults. The middle-aged group had levels of ankle proprioceptive acuity similar to those of the young adults. The scores for males and females were not significantly different. Examination of the range of the scores in each age group highlights the possible level that ankle complex movement proprioceptive rehabilitation can reach, especially for those 75-90 years of age.

Selection-Related Aspects of Resistance Exercises for Elderly

AbstractResistance exercise has been widely recommended for elderly population, since this type of exercise induces important health benefits, especially to improve functional capacity and preserve muscle mass, thus reflecting on the quality of life of older individuals. Among the several components of the resistance exercises the selection of movements to be performed is one of the most important and must be carefully analyzed. Although there may be a wide range of options, the most important recommendations do not specifically indicate the movements that should be included and muscle groups that should be prioritized when prescribing resistance exercise for the elderly. Therefore, considering that there is a lack of information for the Physical Education professional about the topic, this study was developed to support the choices of the movements that will compose the resistance exercise program for the elderly. The study was carried out by compiling and analyzing assumptions and scientific evidences related to resistance exercises and needs of elderly individuals. In conclusion, the choice of movements should be based on the principles of kinesiology, the needs of the elderly, muscle action and exercise safety in order to obtain beneficial results for general health and attenuate possible risks.Keywords: Exercise. Aging. Physical Exertion.ResumoO exercício resistido vem sendo amplamente recomendado para população idosa, uma vez que esse tipo de exercício físico induz a importantes benefícios para saúde; sobretudo, no aprimoramento da capacidade funcional e na preservação da massa muscular, refletindo, desse modo, na qualidade de vida do indivíduo idoso. Dentre os diversos componentes dos exercícios resistidos, a seleção dos movimentos a serem executados é um dos mais importantes e deve ser cuidadosamente analisado. Embora possa existir vasta gama de opções, as principais recomendações não indicam especificamente os movimentos que devem ser incluídos e os grupos musculares que devem ser priorizados nos programas de exercícios resistidos. Portanto, considerando haver uma lacuna de informações sobre o tema, o estudo foi realizado com intuito de subsidiar a seleção dos movimentos que deverão compor os programas de exercícios resistidos para idosos. O estudo foi realizado mediante compilação e análise de pressupostos e evidências científicas referentes aos exercícios resistidos e as necessidades dos idosos. Concluiu-se que a seleção dos movimentos deve ser baseada nos princípios da cinesiologia, nas necessidades dos idosos, na ação muscular e na segurança de execução para se alcançar resultados benéficos para saúde em geral e atenuar possíveis riscos.Palavras-chave: Exercício. Envelhecimento. Esforço Físico.

The effects of total ankle arthroplasty on postural stability and loading symmetry in quiet stance

Ankle osteoarthritis is a debilitating condition affecting about 1% of the population with approximately 50,000 new instances annually. One treatment is total ankle arthroplasty (TAA), however, its effects on balance are not well understood. This study analyzed balance over a two-year period following TAA. 408 subjects (177 left, 231 right ankles) diagnosed with end-stage ankle osteoarthritis performed quiet standing trials while center of pressure (COP) data were collected. Data were compared across three time points (pre-op, 1-year, and 2-years post-op) and between surgical and non-surgical limbs using a linear mixed model with significance set at P = 0.05. COP excursions in the feet-together condition were not significantly different between limbs after 2 years in anteroposterior or mediolateral directions (P = 0.06, 0.08) after being significantly different between limbs in the anteroposterior (P = 0.014) and mediolateral direction (P < 0.001) pre-op. The vertical ground reaction force significantly decreased across time in the non-surgical limb, while reciprocally increasing in the surgical limb (P < 0.001). After 2 years, no significant difference in vertical ground reaction force between limbs existed (P = 0.20). Limb asymmetry indices decreased at each time point in both conditions (all P < 0.001) and were not significantly different from zero after 2 years in the feet-together condition (P = 0.290). In conclusion, surgical limb balance improved compared to pre-op, resulting in increased symmetry between limbs after 2 years. Vertical ground reaction forces on both limbs converge and limb asymmetry indices approach zero two years post-op. Differences in the COP excursion-loading symmetry relationship between limbs could be useful for identifying instability in other pathologies.

Geriatric rehabilitation

Rehabilitation of elderly persons is accompanied by unique challenges, as the physiologic changes with aging may be compounded by a multitude of psychologic, social, and genetic factors. In this chapter we present an overview of the impairments that develop with aging. We discuss factors to consider when evaluating a patient with functional complaints and opportunities for treatment. We provide an overview of common injuries encountered in the elderly, prognostication, and general strategies employed for rehabilitation. New treatment options and areas of ongoing research are also discussed.

Value-Added Electrodiagnostics: Targeting Interventions for Fall Risk Reduction

Walking confers numerous health benefits, particularly for middle-aged and older patients with diabetes and metabolic syndrome. Nevertheless, it brings a risk of injurious falls, especially among populations with diabetes and metabolic syndrome-related distal neuromuscular decline and frank neuropathy. Those who stand to benefit most from walking are at greatest risk. Development of practical clinical tools to more precisely quantify neuromuscular function and link it to mobility outcomes will help clinicians target interventions toward those at risk for falls. Electrodiagnosis, with inclusion of several newer techniques, serves as a promising tool for objective evaluation of distal neuromuscular function.

Patients with type 2 diabetes demonstrate proprioceptive deficit in the knee

AIM

To investigate proprioceptive discrepancies in the lower extremity in persons with type 2 diabetes mellitus (T2DM).

METHODS

In this cross-sectional study, a total of 46 older persons were divided into a T2DM group (n = 23) and a control group who did not have T2DM (n = 23). Participants were given a brief warm up with stretching exercises. Diabetic neuropathy scores were collected prior to proprioceptive testing. For proprioceptive testing, participants performed leg extensions to randomized target positions of 15°, 30°, 45, 60° degrees of elevation in the sagittal plane, each target was repeated a total of four times. Subjects were guided to target positions in the absence of visual feedback via auditory cues from a custom JPS application. When the participant entered the target position, they memorized the location of their limb in space and subsequently attempted to re-locate this position in space. Proprioceptive errors were measured from the target positioned, target remembered, target repositioned protocol.

RESULTS

Proprioceptive accuracy was lower in the diabetic group at all levels of target angle than the control group (P < 0.05). The diabetic group had 46% greater inaccuracy than the control group at all levels of target position. Diabetics also reported greater neuropathy scores than controls in the past 12 mo P < 0.01.

CONCLUSION

Deficits in lower limb localization and greater diabetic neuropathy scores were identified in this study. Our findings may be associated with deafferentation as peripheral neuropathy is a common complication with the disease. These findings may help to explain the declining balance function in the older persons with T2DM which is also commonly reported.

Clinical measures of balance in people with type two diabetes: A systematic literature review

Approximately 422 million people have diabetes mellitus worldwide, with the majority diagnosed with type 2 diabetes mellitus (T2DM). The complications of diabetes mellitus include diabetic peripheral neuropathy (DPN) and retinopathy, both of which can lead to balance impairments. Balance assessment is therefore an integral component of the clinical assessment of a person with T2DM. Although there are a variety of balance measures available, it is uncertain which measures are the most appropriate for this population. Therefore, the aim of this study was to conduct a systematic review on clinical balance measures used with people with T2DM and DPN. Databases searched included: CINAHL plus, MEDLINE, SPORTDiscus, Dentistry and Oral Sciences source, and SCOPUS. Key terms, inclusion and exclusion criteria were used to identify appropriate studies. Identified studies were critiqued using the Downs and Black appraisal tool. Eight studies were included, these studies incorporated a total of ten different clinical balance measures. The balance measures identified included the Dynamic Balance Test, balance walk, tandem and unipedal stance, Functional Reach Test, Clinical Test of Sensory Interaction and Balance, Berg Balance Scale, Tinetti Performance-Oriented Mobility Assessment, Activity-Specific Balance Confidence Scale, Timed Up and Go test, and the Dynamic Gait Index. Numerous clinical balance measures were used for people with T2DM. However, the identified balance measures did not assess all of the systems of balance, and most had not been validated in a T2DM population. Therefore, future research is needed to identify the validity of a balance measure that assesses these systems in people with T2DM.

Complex and Simple Clinical Reaction Times Are Associated with Gait, Balance, and Major Fall Injury in Older Subjects with Diabetic Peripheral Neuropathy

OBJECTIVE

The aim of this work was to identify relationships between complex and simple clinical measures of reaction time (RTclin) and indicators of balance in older subjects with and without diabetic peripheral neuropathy (DPN).

DESIGN

Prospective cohort design. Complex RTclin accuracy, simple RTclin latency, and their ratio were determined using a novel device in 42 subjects (mean ± SD age, 69.1 ± 8.3 yrs), 26 with DPN and 16 without. Dependent variables included unipedal stance time (UST), step width variability and range on an uneven surface, and major fall-related injury over 12 months.

RESULTS

In the DPN subjects, the ratio of complex RTclin accuracy to simple RTclin latency was strongly associated with longer UST (R/P = 0.653/0.004), and decreased step width variability and range (R/P = -0.696/0.001 and -0.782/<0.001, respectively) on an uneven surface. Additionally, the 2 DPN subjects sustaining major injuries had lower complex RTclin accuracy:simple RTclin latency than those without.

CONCLUSIONS

The ratio of complex RTclin accuracy:simple RTclin latency is a potent predictor of UST and frontal plane gait variability in response to perturbations and may predict major fall injury in older subjects with DPN. These short latency neurocognitive measures may compensate for lower limb neuromuscular impairments and provide a more comprehensive understanding of balance and fall risk.

Evaluation of hip abductor and adductor strength in the elderly: a reliability study

BACKGROUND

In elderly individuals an increased muscle strength contributes to the diminution of the falls risk and associated adverse events. An increasing interest in lateral control exists due to the fatal consequences of postero-lateral falls. Therefore a proper assessment of frontal plane hip muscle strength in elderly is important but remains challenging. Therefore we aimed to investigate the feasibility and repeatability of a hip abductor and adductor maximum voluntary isometric strength (MVIS) and rate of force generation (RFG) test in elderly. This represents an initial step in the development process of a new and clinically relevant test that could lead to more specific treatment protocols for this population.

METHODS

In this measurement focused study hip abduction (ABD) and adduction (ADD) MVIS and RFG were tested twice within one to three hours with a dynamometer fixed to a custom made frame in a geriatric population including fallers and non-fallers. Intraclass correlation coefficient (ICCagreement), standard error of measurement (SEM), and smallest detectable difference (SDD) were determined.

RESULTS

All recruited persons (N = 76; mean age (SD) 80.46 (7.05) years old) completed the tests. The average time needed to complete the strength tests was 10.58 min. (1.56) per muscle group. The reliability of the hip ABD and ADD was high with ICC'sagreement ranging from 0.83 to 0.97. The SDD varied between 18.1 and 81.8% depending on the muscle group and type of strength that was evaluated.

CONCLUSION

Hip abductor and adductor strength measures in older person are feasible and reliable. However, the significance of moderate changes in these measurements may be limited by the large SDD and SEM. Therefore, physical therapist should be careful when using this measure for assessing the progress of an individual person in a daily clinical use.

Gait Efficiency on an Uneven Surface Is Associated with Falls and Injury in Older Subjects with a Spectrum of Lower Limb Neuromuscular Function: A Prospective Study

OBJECTIVE

The objective of this study was to determine which gait measures on smooth and uneven surfaces predict falls and fall-related injuries in older subjects with diabetic peripheral neuropathy.

DESIGN

Twenty-seven subjects (12 women) with a spectrum of peripheral nerve function ranging from normal to moderately severe diabetic peripheral neuropathy walked on smooth and uneven surfaces, with gait parameters determined by optoelectronic kinematic techniques. Falls and injuries were then determined prospectively over the following year.

RESULTS

Seventeen subjects (62.9%) fell and 12 (44.4%) sustained a fall-related injury. As compared with nonfallers, the subject group reporting any fall, as well as the subject group reporting fall-related injury, demonstrated decreased speed, greater step width (SW), shorter step length (SL), and greater SW-to-SL ratio (SW:SL) on both surfaces. Uneven surface SW:SL was the strongest predictor of falls (pseudo-r = 0.65; P = 0.012) and remained so with inclusion of other relevant variables into the model. Post hoc analysis comparing injured with noninjured fallers showed no difference in any gait parameter.

CONCLUSION

SW:SL on an uneven surface is the strongest predictor of falls and injuries in older subjects with a spectrum of peripheral neurologic function. Given the relationship between SW:SL and efficiency, older neuropathic patients at increased fall risk appear to sacrifice efficiency for stability on uneven surfaces.

Accommodation of workers with chronic neurologic disorders

The ability to work is important to those with chronic neurologic disorders (CND) and to the aging workforce. Many signs and symptoms are similar in those with CND and normal aging, but may interfere with the ability to work if not appropriately accommodated. This requires the healthcare provider to recognize the specific features of the CND that interferes with work and how it can be accommodated. Review of the American with Disabilities Act and the subsequent amendment informs the healthcare provider as to what is covered under the law and how the disability can be accommodated. Overall employers want to retain qualified employees and therefore accommodating workers is beneficial to both the employee with CND and the employer.

Accuracy of Clinical Techniques for Evaluating Lower Limb Sensorimotor Functions Associated With Increased Fall Risk

BACKGROUND

In prior work, laboratory-based measures of hip motor function and ankle proprioceptive precision were critical to maintaining unipedal stance and fall/fall-related injury risk. However, the optimal clinical evaluation techniques for predicting these measures are unknown.

OBJECTIVE

To evaluate the diagnostic accuracy of common clinical maneuvers in predicting laboratory-based measures of frontal plane hip rate of torque development (Hip(RTD)) and ankle proprioceptive thresholds (AnkPRO) associated with increased fall risk.

DESIGN

Prospective, observational study.

SETTING

Biomechanical research laboratory.

PARTICIPANTS

A total of 41 older subjects (aged 69.1 ± 8.3 years), 25 with varying degrees of diabetic distal symmetric polyneuropathy and 16 without.

ASSESSMENTS

Clinical hip strength was evaluated by manual muscle testing (MMT) and lateral plank time, defined as the number of seconds that the laterally lying subject could lift the hips from the support surface. Foot/ankle evaluation included Achilles reflex and vibratory, proprioceptive, monofilament, and pinprick sensations at the great toe.

MAIN OUTCOME MEASURES

Hip(RTD), abduction and adduction, using a custom whole-body dynamometer. AnkPRO determined with subjects standing using a foot cradle system and a staircase series of 100 frontal plane rotational stimuli.

RESULTS

Pearson correlation coefficients (r) and receiver operator characteristic (ROC) curves revealed that LPT correlated more strongly with Hip(RTD) (r/P = 0.61/<.001 and 0.67/<.001, for abductor/adductor, respectively) than did hip abductor MMT (r/P = 0.31/.044). Subjects with greater vibratory and proprioceptive sensation, and intact Achilles reflexes, monofilament, and pin sensation had more precise AnkPRO. LPT of <12 seconds yielded a sensitivity/specificity of 91%/80% for identifying Hip(RTD) < 0.25 (body size in Newton-meters), and vibratory perception of <8 seconds yielded a sensitivity/specificity of 94%/80% for the identification of AnkPRO >1.0°.

CONCLUSIONS

LPT is a more effective measure of Hip(RTD) than MMT. Similarly, clinical vibratory sense and monofilament testing are effective measures of AnkPRO, whereas clinical proprioceptive sense is not.

Musculoskeletal, Neurologic, and Cardiopulmonary Aspects of Physical Rehabilitation in Patients with Chronic Graft-versus-Host Disease

Chronic graft-versus-host disease (cGVHD) has the potential to cause significant morbidity and mortality in people who undergo allogeneic hematopoietic stem cell transplantation. Management of complications due to cGVHD can be challenging because of multiorgan involvement and variable presentation of the disease. This paper outlines the diagnosis and management of musculoskeletal, neurologic, and cardiopulmonary manifestations of cGVHD that have the potential to cause profound functional impairment and that may significantly impact quality of life and lifespan. Expert evaluation by a physical medicine and rehabilitation physician and multidisciplinary team may be beneficial in the treatment of the disease sequelae, and examples of specific rehabilitation interventions are described.