Limited joint mobility (LJM) in elderly subjects with type II diabetes mellitus

The impact of diabetes status on pain and physical function following total joint arthroplasty for hip and knee osteoarthritis: variation by sex and body mass index

Few studies have examined diabetes impact on total joint arthroplasty (TJA) outcomes, with variable findings. We investigated the association between diabetes and post-TJA physical function and pain, examining whether diabetes impact differs by sex and BMI. Patient sample completed questionnaires within 3 months prior to hip or knee TJA for osteoarthritis (OA) and 1-year post-surgery. Surgical 'non-response' was defined as < 30% improvement in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and physical function at 1-year. Two adjusted logistic regression models were estimated: (1) excluding, (2) including an interaction between diabetes, sex and BMI. The sample (626 hip, 754 knee) was 54.9% female, had mean BMI of 30.1, 13.0% reported diabetes. In adjusted models excluding an interaction, diabetes was not associated with non-response. However, a significant 3-way interaction (physical function: p = 0.003; pain: p = 0.006) between diabetes, sex, and BMI was found and was associated with non-response: non-response probability increased with increasing BMI in men with diabetes, but decreased with increasing BMI in women in diabetes. Findings suggest uncertainty in diabetes impact may be due to differential impacts by sex and BMI. A simple consideration of diabetes as present vs. absent may not be sufficient, with implications for the large TJA population.

The impact of diabetes on physical and mental health status and patient satisfaction after total hip and knee arthroplasty

OBJECTIVE

To assess the impact of diabetes on physical and mental health status, as well as patient satisfaction, one-year following knee and hip total joint arthroplasty (TJA) for osteoarthritis (OA).

METHODS

Participants were 626 hip and 754 knee TJA patients. Pre-surgery data were collected on socio-demographics and health status. The 12-item Short Form Health Survey (SF-12) was collected pre- and one year post-surgery, and physical (PCS) and mental component (MCS) summary scores computed. One-year patient satisfaction was also recorded. Four regression models tested the effect of diabetes on: 1) PCS change score; 2) MCS change score; 3) achieving minimal clinically important improvement (MCII) on PCS; and 4) patient satisfaction ('Somewhat or Very Satisfied' vs. 'Somewhat or Very Dissatisfied'). An interaction between surgical joint and diabetes was tested in each model.

RESULTS

Self-reported diabetes prevalence was 13.0% (95% CI: 11.2%-14.7%) and was more common in knee 16.1% (95% CI: 13.4%-18.7%) than hip 9.3% (95% CI: 7.0%-11.5%) patients. In adjusted analyses, change scores were 2.3 units less on the PCS for those with diabetes compared to those without (p = 0.005). Patients with diabetes were about half as likely to achieve MCII as patients without diabetes (p = 0.004). Diabetes was not significantly associated with satisfaction or changes in MCS scores. Diabetes effects did not differ by surgical joint.

CONCLUSIONS

Findings support that diabetes has a negative impact on improvements in physical health after TJA. Considering the growing prevalence of OA and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing TJA.

Effects of foot and ankle mobilisations combined with home stretches in people with diabetic peripheral neuropathy: a proof-of-concept RCT

INTRODUCTION

People with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st metatarsophalangeal (MTP) joint mobilisations and home-based stretches in people with DPN improve joint range of motion (ROM) and reduce forefoot PPPs.

DESIGN AND METHODS

Sixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n = 31) and home-based stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test, static 1st MTP joint dorsiflexion ROM, dynamic plantar pressure and balance.

RESULTS

At T1 and T2 there was no difference between both groups in ankle dorsiflexion in stance phase, plantar pressure and balance. Compared to the control group, the intervention group showed a statistically significant increase in static ankle dorsiflexion range (Left 1.52 cm and 2.9cms, Right 1.62 cm and 2.7 cm) at 6 (T1) and 18 weeks (T2) respectively p < 0.01). Between group differences were also seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux dorsiflexion ROM (4.9°, p < 0.01) at T2 follow up. Further, functional reach showed a significant increase in the intervention group (T1 = 3.13 cm p < 0.05 and T2 = 3.9 cm p < 0.01). Intervention adherence was high (80%).

CONCLUSIONS

Combining ankle and 1st MTP joint mobilisations with home-based stretches in a 6-week programme in people with DPN is effective in increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk.

TRIAL REGISTRATION

https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03195855 .

Intelligent plantar pressure offloading for the prevention of diabetic foot ulcers and amputations

The high prevalence of lower extremity ulceration and amputation in people with diabetes is strongly linked to difficulties in achieving and maintaining a reduction of high plantar pressures (PPs) which remains an important risk factor. The effectiveness of current offloading footwear is opposed in part by poor patient adherence to these interventions which have an impact on everyday living activities of patients. Moreover, the offloading devices currently available utilize primarily passive techniques, whereas PP distribution is a dynamically changing process with frequent shifts of high PP areas under different areas of the foot. Thus, there is a need for pressure offloading footwear capable of regularly and autonomously adapting to PPs of people with diabetes. The aim of this article is to summarize the concepts of intelligent pressure offloading footwear under development which will regulate PPs in people with diabetes to prevent and treat diabetic foot ulcers. Our team is creating this intelligent footwear with an auto-contouring insole which will continuously read PPs and adapt its shape in the forefoot and heel regions to redistribute high PP areas. The PP-redistribution process is to be performed consistently while the footwear is being worn. To improve adherence, the footwear is designed to resemble a conventional shoe worn by patients in everyday life. Preliminary pressure offloading and user perceptions assessments in people without and with diabetes, respectively, exhibit encouraging results for the future directions of the footwear. Overall, this intelligent footwear is designed to prevent and treat diabetic foot ulcers while enhancing patient usability for the ultimate prevention of lower limb amputations.

Effect of diabetes mellitus on physical activity in patients with knee osteoarthritis: A cross-sectional study

PURPOSE

Knee osteoarthritis (OA) may be comorbid with diabetes mellitus (DM), and physical activity is a recommended lifestyle strategy for both diseases. The present study investigated the physical activity differences by intensity between knee OA patients with or without DM, and evaluated if physical activity was associated with the presence of DM in knee OA patients.

METHODS

A total of 183 patients (mean age 74.9 ± 6.4 years) with moderate-to-severe knee OA underwent evaluation of knee function (i.e., knee flexion/extension range-of-motion, knee-extension muscle strength, and knee pain), the timed up-and-go (TUG) test, and physical activity measurement using an accelerometer. Physical activity by intensity was compared between knee OA patients with and without DM. The association between physical activity, including knee function and the TUG test time, and DM was assessed.

RESULTS

The 2 groups (with or without DM) did not differ significantly in knee OA severity or age. Compared to knee OA patients without DM, knee OA patients with DM had a significantly lower average daily step count (p < 0.001), and significantly shorter times spent performing light-intensity physical activity (LPA; p < 0.001) and moderate-to-vigorous-intensity physical activity (MVPA; p = 0.006). After adjusting for age, sex, and body mass index, we found that a lower average daily step count and shorter LPA time significantly correlated with DM (β = -0.200, p = 0.006; β = -0.216, p = 0.004, respectively) and a longer TUG test time (β = -0.196, p = 0.014; β = -0.208, p = 0.011, respectively). A shorter MVPA time significantly correlated with lower contralateral knee-extension muscle strength (β = 0.187, p = 0.032).

CONCLUSION

Knee OA patients with DM had significantly lower physical activity levels than those without DM. Furthermore, the presence of DM correlated with a lower step count and a shorter LPA time in knee OA patients.

Type 2 diabetes mellitus, physical activity, and neuromusculoskeletal complications

Objectives

The objectives of the study were to investigate the neuromusculoskeletal complications of Type 2 diabetes mellitus (T2DM) and their associated factors, including the level of physical activity (PA) and clinicodemographic characteristics.

Materials and Methods

In this cross-sectional analysis, we included 370 participants diagnosed with T2DM for no <1 year who satisfied the inclusion and exclusion criteria. Demographic and clinical characteristics were noted and a thorough clinical examination was performed on all the participants. International PA Questionnaire-Short Form was used to evaluate the level of PA of the participants. The continuous data is presented as mean ± SD and the categorical data is presented as the number of participants (n) and percentage (%). A logistic regression model was used to investigate the predictors for the prevalence of the complications.

Results

The mean duration of T2DM was 7.32 ± 5.53 years and the mean hemoglobin A1C (HbA1c) level (%) was 8.16±1.67. A majority of the participants were having uncontrolled diabetes with an HbA1c level ≥7.5% (n = 190; 51.35%). The level of PA was low in a substantial proportion of the participants (n = 276; 74.59%). A total of 162 (43.78%) participants were diagnosed with neuromusculoskeletal complications. Low back pain was the most common complication and degenerative disk disease was the most common diagnosis overall. Longer duration of diabetes, poor glycemic control, and low PA were associated with the prevalence of neuromusculoskeletal complications (P < 0.05).

Conclusion

Neuromusculoskeletal complications of T2DM are common and can result in significant disability in this population. Low PA is very common among T2DM patients and an important contributor to the development of complications. Health-care providers should consider PA an integral component of the management protocol for T2DM patients.

The complex relationship between physical activity and diabetes: an overview

Diabetes mellitus (DM) is a widespread condition, representing a challenging disease to manage. Exercise is being increasingly recommended as part of the therapeutic regimen for DM but the management of different forms of physical activity is difficult for individuals with diabetes, trainers, and physicians. Regular exercise can improve health and well-being, helping individuals to achieve their target lipid profile, body composition, cardio-respiratory fitness, and glycemic goals. People with diabetes tend to be as inactive as the general population, with a large percentage of individuals not achieving the minimum amount of recommended physical activity levels. Indeed, several barriers to exercise exist for persons with diabetes, including sports eligibility, multi-modality management of diabetic athletes, and inadequate knowledge about adequate type and intensity of exercise. The aim of the present review is to provide the current understanding of mechanisms, recommendations, and beneficial effects of different modalities of exercise for the treatment of DM.

Causes of Shoulder Dysfunction in Diabetic Patients: A Review of Literature

Objective: Understanding the underlying mechanisms behind shoulder dysfunctions in patients with diabetes mellitus. Study Design: Systematic qualitative literature review. Participants: Patients with shoulder dysfunctions and diagnosed with impaired glucose tolerance or diabetes mellitus. Intervention: Published scientific literature containing evidence about the mechanisms of shoulder dysfunctions in the diabetic population. Articles were selected based on criteria containing diabetic population, shoulder dysfunction, methodological quality ≥ 6/9 and >20 subjects. Main Outcome measures: range of motion; questionnaires (QoL, UCLA-m, SPADI, DASH); blood glucose, blood HbA1C; calculated capsular stiffness (Kcap); calcification shoulder joint; shoulder dysfunction in patients with glucose metabolism disorders and diabetes mellitus. Results: We found 17 published articles with level 2 and 3 evidence. Multiple factors such as age, duration of diabetes mellitus (DM), glycated hemoglobin (HbA1c), advanced glycation end products (AGE), vascular endothelial growth factor (VEGF), interleukin-1ß (IL-1ß) were shown to be associated with tendon changes and increased capsular stiffness (Kcap) conceivably leading to limited range of motion (ROM) or frozen shoulder. Decreased ROM and frozen shoulder have a significantly higher prevalence in DM than in non-DM. Conclusions: Based on the current literature we confirm a high prevalence of shoulder dysfunctions in patients with diabetes mellitus. The cause of the shoulder complications is unknown, and more research is mandatory to shed more light on the complex interplay between the multifactorial causes of shoulder dysfunction in diabetes mellitus.

The influence of subtalar axis orientation on the foot posture of older adults in a closed kinetic chain

Objectives: This study compared the influence of subtalar axis position on foot behavior in a closed kinetic chain in older and younger adults. Methods: The sample included 50 older adults and a control group of 50 younger adults. The variables were initially analyzed for both feet together, and were later analyzed separately, comparing each foot (right and left) between groups. Range of motion was assessed by validated goniometric procedures: the position of subtalar axis was evaluated by the palpation technique, while the Foot Posture Index was used to assess behavior in a closed kinetic chain. Student’s t-test / Mann-Whitney test compared the main variables according to sample distribution, while Student’s t-test / Wilcoxon test was used for paired samples. A standardized Haberman residuals test was also used to determine the connection between the position of subtalar joint axis and the Foot Posture Index. Results: Data from the right and left feet were similar for all variables. The older group had reduced mobility in the ankle and first metatarsophalangeal joint (5.42º [SD (Standard Deviation), 4.49] and 76.12º [SD, 19.24], respectively) with statistically significant values, (p < 0.001). The difference in subtalar axis position was not significant (p = 0.788), with more internal deviations in both groups. There was a significant difference in Foot Posture Index (p = 0.006, by applying the chi-square test), with the normal position more prevalent in the older group and the prone position more prevalent in the younger group. Conclusions: Regarding internal deviations in the subtalar joint axis, the older group had a higher frequency of feet in the normal position, while the younger group had a higher frequency of feet in the prone position which, in this case, agrees with the rotational balance theory. For the normal axis position, a higher frequency of normal position was found in both groups. Regarding external deviations of the subtalar joint axis, neither group followed the pattern expected in rotational balance theory. The most consistent connection in the older group was between external axis position and supine foot position, whereas in the younger group it was between normal axis position and normal foot position.

Prognostic factors of shoulder manipulation under ultrasound-guided cervical nerve root block for frozen shoulder for patient with diabetes mellitus: A retrospective cohort study

Introduction

Shoulder manipulation under ultrasound-guided cervical nerve root block (MUC) gives good clinical results in patients with frozen shoulder 1 week after the procedure. However, some patients are refractory to MUC. The present study was performed to investigate the prognostic factors of MUC for frozen shoulder.

Methods

We evaluated 73 frozen shoulders (70 patients) to investigate the prognostic factors of MUC. The patients' mean age was 56.6 years, and 60% were female. The mean duration of symptoms before MUC was 8.6 months. We assessed pain using a numeric rating scale (NRS), range of motion (ROM), and the American Shoulder and Elbow Surgeons (ASES) score before and 1 year after MUC. We compared patients with an ASES score of <80 (defined as a poor clinical result) with those with an ASES score of ≥80 (good clinical result). To identify the risk factors for a poor clinical result, multiple logistic regression analysis was performed using the following variables: age, sex, duration of symptoms before MUC, diabetes mellitus (DM), initial NRS score, and initial ROM.

Results

The initial NRS score and the prevalence of DM were significantly greater in the poor clinical results group. Multiple logistic regression analysis revealed that DM was the only independent risk factor for a poor clinical result after MUC (odds ratio, 51; 95% confidence interval, 10.9–237; p = .01).

Conclusions

DM is a negative prognostic factor of MUC for frozen shoulder, and patients with DM should be informed of this before they undergo treatment for frozen shoulder.

•

We investigated the prognostic factor of manipulation under cervical nerve block.

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DM is a negative prognostic factor for frozen shoulder.

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Patients with DM should be informed of this before they undergo manipulation.

Explaining Variability in the Prevalence of Achilles Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the prevalence of, and factors associated with, Achilles tendon abnormalities observed on imaging in asymptomatic individuals.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science were searched from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of Achilles tendon abnormalities, observed with any imaging modality, in an asymptomatic population. We excluded studies if participant mean age was younger than 12 years or if participants had current/previous lower-limb tendon injuries/symptoms or other systemic conditions.

DATA SYNTHESIS

Random-effects proportion meta-analysis was used to estimate prevalence. We used meta-regression for continuous variables (mean age and body mass index [BMI], sample size, proportion of female participants) and stratified categorical variables (imaging modality and participation in physical activity) to explain between-study heterogeneity.

RESULTS

We included 91 studies (10 156 limbs, 5841 participants). The prevalence of Achilles tendon abnormalities on imaging ranged from 0% to 80% per participant. Between-study heterogeneity was high (I²>90%, P<.001), precluding data pooling. Between-study heterogeneity was partly explained by participant mean BMI (slope, 2.8% per 1-unit increase in BMI; 95% confidence interval: 0.57%, 5.03%; P = .015) and participation in physical activity per limb, and mean age of 40 years old or older (P = .022) per participant.

CONCLUSION

There was substantial variability in the prevalence of Achilles tendon abnormalities on imaging in asymptomatic individuals. Higher prevalence of abnormalities was associated with older age (40 years old or older), higher BMI, and participation in physical activity. A large proportion of heterogeneity remains unaccounted for, likely due to variations in abnormality definitions and study design. J Orthop Sports Phys Ther 2021;51(5):232-252. Epub 28 Mar 2021. doi:10.2519/jospt.2021.9970.

Physical Activity and Investigation With Magnetic Resonance Imaging Partly Explain Variability in the Prevalence of Patellar Tendon Abnormalities: A Systematic Review With Meta-analysis of Imaging Studies in Asymptomatic Individuals

OBJECTIVE

To estimate the pooled prevalence of, and factors associated with, the presence of patellar tendon abnormalities observed on imaging in people without symptoms.

DESIGN

Systematic review with stratified meta-analysis and meta-regression.

LITERATURE SEARCH

We searched Embase, Scopus, MEDLINE, CINAHL, SPORTDiscus, and Web of Science from 1980 to August 2020.

STUDY SELECTION CRITERIA

We included studies that reported the prevalence of asymptomatic patellar tendon abnormalities on imaging. We excluded studies of participants with current tendon pain, a history of tendon pain, or other systemic conditions.

DATA SYNTHESIS

Stratification and meta-regression of studies based on study-level descriptive statistics (mean age, body mass index, proportion of female participants, physical activity participation, imaging modality) were performed using a random-effects model to account for between-study heterogeneity. Risk of bias was assessed using the modified Newcastle-Ottawa scale.

RESULTS

Meta-analysis of 64 studies (7125 limbs from 4616 participants) found significant between-study heterogeneity (I²≥90%, P<.01), which precluded a summary prevalence estimate. Heterogeneity was partially explained by studies that included participants who were physically active and studies that assessed tendon abnormalities using magnetic resonance imaging compared to ultrasound (P<.05). Mean age, body mass index, proportion of female participants, and sample size did not explain the remaining heterogeneity.

CONCLUSION

There was substantial variability in the reported prevalence of asymptomatic patellar tendon abnormalities. A clear and valid method is needed to assess and report the presence of patellar tendon abnormalities to increase research capacity and establish the clinical value of imaging the patellar tendon. J Orthop Sports Phys Ther 2021;51(5):216-231. Epub 28 Mar 2021. doi:10.2519/jospt.2021.10054.

Heel Rise and Non-Weight-Bearing Ankle Plantar Flexion Tasks to Assess Foot and Ankle Function in People With Diabetes Mellitus and Peripheral Neuropathy

OBJECTIVE

The objective of this study was to examine the effects of diabetes mellitus and peripheral neuropathy (DMPN), limited joint mobility, and weight-bearing on foot and ankle sagittal movements and characterize the foot and ankle position during heel rise.

METHODS

Sixty people with DMPN and 22 controls participated. Primary outcomes were foot (forefoot on hindfoot) and ankle (hindfoot on shank) plantar-flexion/dorsiflexion angle during 3 tasks: unilateral heel rise, bilateral heel rise, and non-weight-bearing ankle plantar flexion. A repeated-measures analysis of variance and Fisher exact test were used.

RESULTS

Main effects of task and group were significant, but not the interaction in both foot and ankle plantar flexion. Foot and ankle plantar flexion were less in people with DMPN compared with controls in all tasks. Both DMPN and control groups had significantly less foot and ankle plantar flexion with greater weight-bearing; however, the linear trend across tasks was similar between groups. The DMPN group had a greater percentage of individuals in foot and/or ankle dorsiflexion at peak unilateral heel rise compared with controls, but the foot and ankle position was similar at peak bilateral heel rise between DMPN and control groups.

CONCLUSION

Foot and ankle plantar flexion is less in people with DMPN. Less plantar flexion in non-weight-bearing suggests that people with DMPN have limited joint mobility. However, peak unilateral and bilateral heel rise is less than the available plantar flexion range of motion measured in non-weight-bearing, indicating that limited joint mobility does not limit heel rise performance. A higher frequency of people with DMPN are in foot and ankle dorsiflexion at peak unilateral heel rise compared with controls, but the position improved with lower weight-bearing.

IMPACT

Proper resistance should be considered with physical therapist interventions utilizing heel rise because foot and ankle plantar flexion position could be improved by reducing the amount of weight-bearing.

Prevalence of Upper Extremity Musculoskeletal Disorders in Patients with Type 2 Diabetes in General Practice

Background: One of the lesser recognized complications of diabetes mellitus are musculoskeletal (MSK) complications of the upper and lower extremity. No prevalence studies have been conducted in general practice. Thus, the aim of this study was to investigate the prevalence of upper extremity MSK disorders in patients with type 2 diabetes (T2DM) in the Netherlands. Methods: We conducted a cross-sectional study with two different approaches, namely a representative Dutch primary care medical database study and a questionnaire study among patients with T2DM. Results: In the database study, 2669 patients with T2DM and 2669 non-diabetes patients were included. MSK disorders were observed in 16.3% of patients with T2DM compared to 11.2% of non-diabetes patients (p < 0.001, OR 1.53, 95% CI 1.31, 1.80). In the questionnaire study, 200 patients with T2DM were included who reported a lifetime prevalence of painful upper extremity body sites for at least four weeks of 67.3%. Conclusion: We found that upper extremity MSK disorders have a high prevalence in Dutch patients with T2DM presenting in general practice. The prevalence ranges from 16% based on GP registered disorders and complaints to 67% based on self-reported diagnosis and pain. Early detection and treatment of these disorders may play a role in preventing the development of chronic MSK disorders.

The Structural Effects of Diabetes on Soft Tissues: A Systematic Review

Hyperglycemia, which is associated with diabetes, increases the production of advanced glycation end products. Advanced glycation end products lead to the structural degradation of soft tissues. The structural degradation of diabetic soft tissues has been investigated in humans, rodents, and canines. Therefore, the objective of this review is to unify the various contributions to diabetes research through the mechanical properties and geometric characteristics of soft tissues. A systematic review was performed and identified the effects of diabetes on mechanical and geometric properties of soft tissues via experimental testing or in vivo - driven finite element analysis. The literature concludes that diabetes contributes to major structural changes in soft tissues but does not cause the same structural changes in all soft tissues (e.g., diabetic tendons are weaker and diabetic plantar tissues are tougher). Diabetes stiffens and toughens soft tissues, thus altering viscoelastic behavior (e.g., poor strain and stress response). However, diabetes management routines can prevent or minimize the effects of diabetes on the mechanical and geometric properties of soft tissues. Unification of the structural effects of diabetes on soft tissues will contribute to the pathophysiology of diabetes.

ASSESSING THE POTENTIAL INFLUENCE OF DIFFERENT WALKING STRATEGIES ON PLANTAR PRESSURE DISTRIBUTION TRIGGERED BY A PORTABLE BIOFEEDBACK-BASED GAIT TRAINING DEVICE

Plantar pressure refers to the interfacial contact pressure between the foot and the supporting surface during daily locomotor activities. Information derived from plantar pressure measures is essential in gait and posture research for diagnosing patho-mechanics associated with the musculoskeletal diseases. In particular, it is compulsory to reduce the abnormally high plantar pressure in people with diabetes for the prevention and treatment of foot ulcerations in this population. In this study, a portable biofeedback-based gait training device is developed to advocate able-bodied subjects to adopt different movement patterns in walking to manipulate the plantar pressure distribution under the foot. Through the simultaneous detection of the plantar pressure pattern and the kinematics of the lower extremity joints, it was revealed that the unloading effects for the plantar site in particular to the lateral forefoot subareas were more abundant through biofeedback-assisted gait alterations than the self-awareness control for gait adjustment. In addition, the corresponding relationship between joint coordination and pressure redistribution pattern was obtained, which could potentially be used in gait retraining interventions to correct abnormal plantar pressure patterns in people with diabetes.

Relationships within and between lower and upper extremity dysfunction in people with diabetes

INTRODUCTION

Diabetes mellitus (DM) is associated with systemic musculoskeletal system impairments suggesting concurrent development of lower and upper extremity musculoskeletal problems. This study aims to examine relationships between lower and upper extremity function in people with DM.

METHODS

Sixty people with type 2 DM and peripheral neuropathy [mean (standard deviation); 67(6) years old, DM duration 14(10) yrs] completed the following measures: 1) Self-reports of function: Foot and Ankle Ability Measure (FAAM; higher = better function) and Shoulder Pain and Disability Index (SPADI; lower = better function), 2) Range of motion (goniometry): ankle dorsiflexion and shoulder flexion, and 3) Strength: unilateral heel rise power (UHR, 3D kinetics) and hand grip dynamometry. Pearson correlations examined associations between lower and upper extremity measures, p < .05.

RESULTS

Forty of 60 (67%) reported pain/disability in both the foot/ankle and shoulder and 95% of study participants had some limitation in foot or shoulder function. Significant between extremity correlations: FAAM and SPADI (r = -0.39), ankle dorsiflexion and shoulder flexion range of motion (r = 0.35), and UHR and hand grip strength (r = 0.40). Significant within extremity correlations: FAAM and UHR (r = .47) and SPADI with shoulder flexion (r = -0.44).

CONCLUSION

Upper and lower extremity inter- and intra-relationships indicate systemic musculoskeletal impairments in people with DM. Healthcare practitioners should consider the potential for concurrent and disabling musculoskeletal problems in people with DM.

Influence of type 1 diabetes on the postural control of women in the third gestational trimester

BACKGROUND

Diabetes can cause biomechanical alterations that may be responsible for additional changes to those existing in a regular gestational period. The way a maternal body responds when affected by diabetes has not been clearly understood. This study aimed to describe the influence of type 1 diabetes on pregnant women's postural control.

METHODS

Forty pregnant women in their third gestational trimester were allocated in two equal groups - the control group and the type 1 diabetic group. The variables related to postural control and balance were assessed using photogrammetry (head protrusion; cervical lordosis; thoracic kyphosis; lumbar lordosis; pelvic anteversion, knee flexion, tibiotarsal and foot inclination angles were measured), and baropodometry (anteroposterior and mediolateral distance trajectory of the center of pressure, amplitude and average speed of displacement of the center of pressure).

FINDINGS

The results of the type 1 diabetic group showed, in the postural analysis, lower head protrusion and pelvic anteversion angles, while there was higher cervical lordosis, thoracic kyphosis, and lumbar lordosis angles. In the baropodometry, the anteroposterior distance and the amplitude of the center of pressure displacement with eyes open and closed were higher.

INTERPRETATION

The findings suggest that type 1 diabetes mellitus in the third trimester of pregnancy is associated with postural changes, a decrease in the active ankle range of motion and increase in the anteroposterior oscillation of the center of pressure, with negative repercussions for postural control.

Not a Painless Condition: Rheumatological and Musculoskeletal Symptoms in Type 2 Diabetes, and the Implications for Exercise Participation

OBJECTIVES

People with type 2 diabetes (T2D) are more likely to develop a range of rheumatological and musculoskeletal symptoms (RMS), and experience both chronic and widespread pain, compared with the general population. However, these symptoms are not commonly acknowledged by researchers, which hampers our understanding of the impact on this population. Since exercise is a key lifestyle management strategy for T2D and participation levels are typically low, understanding the potential impact of RMS on exercise participation is critical. The aim of this review is to summarise the literature regarding the prevalence and pathophysiology of RMS in T2D, the evidence for the benefits and risks associated with exercise on RMS, and the currently available tools for the reporting of RMS in both research studies and community settings.

METHODS

A narrative review.

RESULTS

There are numerous exercise trials in T2D, but few have sufficiently reported pain-related adverse events and even fewer have investigated the effects of exercise on RMS and chronic pain.

DISCUSSION

Recommendations for future research are provided.

Peroneal Tendon Lengthening as an Adjunct Procedure to Aid in the Reduction of the Lateral Malleolus in Diabetic Ankle Fractures: 2 Case Reports

It is well-documented that individuals with longstanding diabetes mellitus are at risk for specific metabolic abnormalities; this includes but is not limited to increased glycation of collagenous soft-tissue structures. It is also apparent that such changes can manifest as thickening and increased stiffness of tendinous structures. What remains unknown are the biomechanical ramifications of these changes and how they should affect the surgical management of lower extremity injuries. Previous research suggests that the Achilles tendon demonstrates increased stiffness in the presence of diabetes. It is therefore reasonable to presume that increased collagen glycation and the resultant tendon stiffness can also lead to decreased extensibility and shortening of the peroneus longus and brevis tendons. The significance of this leads us to the conclusion that glycation of the peroneal tendons can create a deforming force in displaced lateral malleolar fractures because of the adjacent position of the peroneal tendons relative to the lateral malleolus. Complications stemming from this can lead to increased difficulty in reducing fibular fractures and subsequent shortening of the fibula. For the purpose of this article, we present 2 cases, 1 using open reduction with internal fixation and the other with external fixation. We will demonstrate that, in both reduction methods, lengthening of the peroneal tendons can be a useful adjunct procedure to aid in restoration of fibular length in diabetic ankle fractures.

Range of motion of the ankle joint in male Japanese patients undergoing hemodialysis: influence of diabetes and hemodialysis

[Purpose] The purpose of this study was to analyze ankle range of motion in patients undergoing hemodialysis and those with diabetes. [Participants and Methods] Eight male kidney disease patients without diabetes undergoing hemodialysis and 10 male kidney disease patients with diabetes undergoing hemodialysis were enrolled in this study. For comparison, 27 patients with diabetes not undergoing hemodialysis and 10 healthy participants were included. All participants were divided into 4 groups: patients without diabetes undergoing hemodialysis, patients with diabetes undergoing hemodialysis, patients with diabetes not undergoing hemodialysis, and control group. The measured parameter was the passive range of motion of the ankle joint. [Results] Patients with diabetes not undergoing hemodialysis demonstrated the greatest joint restriction, followed by patients with diabetes undergoing hemodialysis. The main effect of diabetes was observed in ankle range of motion, rather than hemodialysis. There was a significant difference between both the diabetes undergoing hemodialysis and the diabetes not undergoing hemodialysis groups and the other groups. [Conclusion] Limited joint mobility of the ankle in patients undergoing hemodialysis may be affected by diabetes rather than hemodialysis.

Relationship between range of motion of foot joints and amount of physical activity in middle-aged male diabetic patients

[Purpose] This study aimed to verify the relationship between foot range of motion and the amount of physical activity in diabetic patients. [Participants and Methods] There were twenty-eight male patients with diabetes (age ranged from 50 to 69 years old) and 10 healthy, non-diabetic male individuals within the same age range in the diabetes group and control group, respectively. The passive ranges of motion of the following joints were measured in the right foot of each participant: the ankle joint, the first metatarsophalangeal joint, and the subtalar joint. The amount of daily physical activity was estimated using the short Japanese version of the International Physical Activity Questionnaire. [Results] The mean range of motion of the ankle joints in the diabetic and control groups was 55.4 ± 8.4° and 69.1 ± 9.2°, respectively, whereas the mean range of motion of the first metatarsophalangeal joints in the diabetic and control groups was 82.9 ± 9.6° and 96.3 ± 8.9°, respectively. The diabetic group showed a significantly higher restriction in joint range of motion than did the control group. The amount of physical activity was a contributing factor toward the ankle range of motion according to multiple regression analysis. [Conclusion] We determined that the range of motion in the ankle joints of diabetic patients was affected by their level of physical activity.

Awareness of limited joint mobility in type 2 diabetes in general practice in the Netherlands: an online questionnaire survey

BACKGROUND

Next to the well-known micro- and macrovascular complications, type 2 diabetes mellitus (T2DM) is associated with musculoskeletal disorders of the upper extremities referred to as limited joint mobility (LJM), e.g. carpal tunnel syndrome (CTS) and adhesive capsulitis. Unrecognized and untreated LJM can lead to poor quality of life and non-compliance to diabetes treatment which aggravates LJM. Despite its reported higher prevalence in international prevalence studies, examination of the upper extremities is still no part of the regular diabetes mellitus (DM) check-ups. The primary aim of this study was therefore to evaluate the awareness of Dutch GPs and nurse practitioners concerning LJM. Secondary aims were to evaluate the current management of a patient with LJM, and to assess opinions regarding the question of who should screen for LJM if this is done in the near future.

METHODS

An online survey was conducted among 390 general practitioners (GPs) and 245 nurse practitioners (NPs) of three diabetes care groups in The Netherlands to assess their awareness of the association between DM and LJM.

RESULTS

Most GPs are not aware that LJM is a DM complication, with an unawareness for specific upper extremity disorders ranging from 59 to 73%. Of the NPs, 76% is not aware either. Only 41% of GPs would advise the most optimal treatment for diabetes patient with CTS. Finally, only 25% of the GPs believe that screening for LJM should be performed during the regular diabetes check-up compared to 63% of the NPs.

CONCLUSION

The majority of GPs and NPs are not aware of LJM as a T2DM complication. In contrast to NPs, most GPs do not believe that screening for LJM should be performed during the regular diabetes check-up.

Synergistic activity of platelet rich plasma and high volume image guided injection for patellar tendinopathy

PURPOSE

Platelet rich plasma and high volume image guided injections of saline have been used in the treatment of patellar tendinopathy with positive results. As the different mechanisms of action do not interfere each other, it can be hypothesized that they can be used in combination. Aim of this study was twofold: first, to evaluate the efficacy of these two treatments in the management of patellar tendinopathy; second, to verify whether the combination of these therapies could provide further advantages.

METHODS

Fifty-four patients suffering from patellar tendinopathy were enrolled. After clinical (VAS and VISA-P) and sonographic evaluation, two ultrasound guided injections (2 weeks apart) of platelet rich plasma, high-volume image-guided injections of saline, or both in association were performed. The VAS and VISA-P scores obtained from the three treatments groups (18 patients in each group) were compared across the different follow-up times (3 and 6 months).

RESULTS

In the short term both treatments showed comparable efficacy, whereas in the medium term the positive effects of high-volume image-guided injections gradually diminished and platelet rich plasma showed greater efficacy. Better results (reduced pain, improved function and increased number of subjects who exhibited optimal recovery [> 20 points in VISA-P score]) were observed when both procedures were associated.

CONCLUSIONS

The contemporaneous administration of platelet rich plasma and high volume image guided injections of saline treatments, which influence tendon repair by means of different mechanisms, grants a greater improvement for patellar tendinopathy. This finding has clinical relevance, given that this condition has a substantial impact on sports and work performance.

LEVEL OF EVIDENCE

III.

Effect of a Shoulder Movement Intervention on Joint Mobility, Pain, and Disability in People With Diabetes: A Randomized Controlled Trial

BACKGROUND

People with diabetes are at high risk for shoulder pain, limited joint mobility, and adhesive capsulitis.

OBJECTIVE

The objective of this study was to evaluate the effects of a shoulder movement intervention (ShoMo) compared to a wellness intervention on the primary outcomes of active shoulder flexion and reported Shoulder Pain and Disability Index (SPADI) measured after intervention and 9 months later.

DESIGN

The design was a prospective, randomized, controlled clinical trial.

SETTING

The setting was a research center at an academic medical center.

PARTICIPANTS

Fifty-two participants with type 2 diabetes and shoulder pain or limited motion were randomized to a group receiving ShoMo (N = 27; mean age = 59.3; SD = 7.0) or a group receiving wellness activities (N = 25; mean age = 57.9; SD = 7.7).

INTERVENTION

The ShoMo group received instruction in a progressive, active shoulder movement program. The wellness group received instruction in diabetes management.

MEASUREMENTS

Measurements were made at baseline, after 3 months of intervention, and at 6, 9, and 12 months after baseline.

RESULTS

After intervention, the ShoMo group had a 7.2-degree increase in active shoulder flexion compared with the wellness group (95% CI = 0.9-13.5°), but there was no difference at subsequent follow-ups. The ShoMo group showed a 12.7-point improvement in the SPADI score compared to the wellness group after intervention (95% CI = 1.1-24.3), which remained better than the wellness group 9 months later.

LIMITATIONS

The number of participants and duration of follow-up were inadequate to determine if intervention can help to prevent future severe shoulder problems.

CONCLUSIONS

A progressive shoulder movement program can have meaningful effects on active motion and symptoms in people with type 2 diabetes and mild-to-moderate shoulder symptoms, with symptom improvement lasting at least 9 months.

Duration of Type 2 Diabetes is a Predictor of Elevated Plantar Foot Pressure

AIMS

Elevated plantar pressure is considered a significant risk factor for ulceration in diabetes mellitus. The aim of this study was to determine whether duration of diabetes could affect plantar pressure in patients with no known significant comorbidity or foot pathology.

METHODS

Participants with type 2 diabetes, but without known confounding factors that could alter peak pressure, were matched for age, weight, and gender and categorized into 3 groups of diabetes duration: group 1 (1-5 yr), group 2 (6-10 yr), and group 3 (11-15 yr). Plantar pressures were recorded utilizing a two-step protocol at a self-selected speed.

RESULTS

One-way analysis of variance (ANOVA) revealed significant differences in mean peak plantar pressures between the three groups under the 2^nd - 4^th metatarsophalangeal joint (MPJ) region of interest (ROI) (p = 0.012 and p = 0.022, respectively) and left heel (p = 0.049). Also, a significant difference in mean pressure-time integral under the left 2^nd - 4^th MPJ ROI (p = 0.021) and right heel (p = 0.048) was observed. Regression analysis confirmed that mean peak plantar pressures in the first group (but not in the second group) were significantly lower than in the third group (p = 0.005).

CONCLUSIONS

As the duration of diabetes increased, peak plantar pressure increased significantly under the 2^nd - 4^th MPJ ROIs. These findings suggest that clinicians should make more use of pressure mapping technology as part of their clinical management plan in patients with diabetes >10 yr, even if they have no complications or deformities, to preserve functional limbs in this high-risk population.

History, Prevalence and Assessment of Limited Joint Mobility, from Stiff Hand Syndrome to Diabetic Foot Ulcer Prevention: A Narrative Review of the Literature

BACKGROUND

Limited Joint Mobility (LJM) is a dreaded complication of Diabetes Mellitus (DM). During the last half century, LJM has been studied in patients of different age because it has been considered useful for the monitoring of a patient's condition and for the prevention of vascular disease and diabetic foot.

OBJECTIVES

The main aims of this review are to describe the relationship between DM and joint mobility as well as its prevalence and assessment. We have also investigated the role of LJM in the development of diabetic foot ulcers.

METHODOLOGY

An in-depth literature search was conducted to identify studies that examined the prevalence and characteristics of LJM in patients with DM of different types, age, durations and chronic complications.

RESULTS

Many factors (therapy improvements, population characteristics and different evaluation methods) concur to hinder an exact assessment of the prevalence of LJM. However, it has been confirmed that LJM is widespread among patients with DM and may affect more than two-thirds of them in addition to being a major risk factor for foot ulcer. Its role in the monitoring of a patient's condition is also important for the definition of risk thresholds such as in patients with diabetic foot. The efficacy of exercise therapy for the treatment of LJM, also in patients at risk of foot ulcer, has not been discussed.

CONCLUSION

Difficulties encountered in the definition of the prevalence of LJM may hinder its study and the establishment of preventive interventions. However, LJM plays a key role in the monitoring of patients, especially those at risk for ulcer.

Limited Joint Mobility Progression in Type 1 Diabetes: A 15-Year Follow-Up Study

OBJECTIVE

To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility.

METHODS

Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1_c), urinary albumin excretion (UAE), and ophthalmoscopy.

RESULTS

Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001).

CONCLUSIONS

In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

Muscle force distribution of the lower limbs during walking in diabetic individuals with and without polyneuropathy

BACKGROUND

Muscle force estimation could advance the comprehension of the neuromuscular strategies that diabetic patients adopt to preserve walking ability, which guarantees their independence as they deal with their neural and muscular impairments due to diabetes and neuropathy. In this study, the lower limb's muscle force distribution during gait was estimated and compared in diabetic patients with and without polyneuropathy.

METHODS

Thirty individuals were evaluated in a cross-sectional study, equally divided among controls (CG) and diabetic patients with (DNG) and without (DG) polyneuropathy. The acquired ground reaction forces and kinematic data were used as input variables for a scaled musculoskeletal model in the OpenSim software. The maximum isometric force of the ankle extensors and flexors was reduced in the model of DNG by 30% and 20%, respectively. The muscle force was calculated using static optimization, and peak forces were compared among groups (flexors and extensors of hip, knee, and ankle; ankle evertors; and hip abductors) using MANOVAs, followed by univariate ANOVAs and Newman-Keuls post-hoc tests (p < 0.05).

RESULTS

From the middle to late stance phase, DG showed a lower soleus muscle peak force compared to the CG (p=0.024) and the DNG showed lower forces in the gastrocnemius medialis compared to the DG (p=0.037). At the terminal swing phase, the semitendinosus and semimembranosus peak forces showed lower values in the DG compared to the CG and DNG. At the late stance, the DNG showed a higher peak force in the biceps short head, semimembranosus, and semitendinosus compared to the CG and DG.

CONCLUSION

Peak forces of ankle (flexors, extensors, and evertors), knee (flexors and extensors), and hip abductors distinguished DNG from DG, and both of those from CG. Both diabetic groups showed alterations in the force production of the ankle extensors with reductions in the forces of soleus (DG) and gastrocnemius medialis (DNG) seen in both diabetic groups, but only DNG showed an increase in the hamstrings (knee flexor) at push-off. A therapeutic approach focused on preserving the functionality of the knee muscles is a promising strategy, even if the ankle dorsiflexors and plantarflexors are included in the resistance training.

Altered leverage around the ankle in people with diabetes: A natural strategy to modify the muscular contribution during walking?

Diabetes patients display gait alterations compared to controls including a higher metabolic cost of walking. This study aimed to investigate whether differences in external moment arm (ExtMA) and effective mechanical advantage (EMA) at the ankle in diabetes patients could partly explain the increased cost of walking compared to controls. Thirty one non-diabetic controls (Ctrl); 22 diabetes patients without peripheral neuropathy (DM) and 14 patients with moderate/severe diabetic peripheral neuropathy (DPN) underwent gait analysis using a motion analysis system and force plates. The internal Achilles tendon moment arm length was determined using magnetic resonance imaging during weight-bearing and ExtMA was calculated using gait analysis. A greater value (P<0.01) for the EMA at the ankle was found in the DPN (0.488) and DM (0.46) groups compared to Ctrl (0.448). The increased EMA was mainly caused by a smaller ExtMA in the DPN (9.63cm; P<0.01) and DM (10.31cm) groups compared to Ctrl (10.42cm) These findings indicate that the ankle plantarflexor muscles would need to generate lower forces to overcome the external resistance during walking compared to controls. Our findings do not explain the previously observedhigher metabolic cost of walking in the DM and DPN groups, but uncover a new mechanism through which patients with diabetes and particularly those with DPN reduce the joint moment at the ankle during walking: by applying the ground reaction force more proximally on the foot, or at an angle directed more towards the ankle, thereby increasing the EMA and reducing the ankle joint moment.

Relationship of shoulder activity and skin intrinsic fluorescence with low level shoulder pain and disability in people with type 2 diabetes

AIM

People with type 2 diabetes (T2DM) have a high incidence of musculoskeletal disorders thought to be influenced by high non-enzymatic advanced glycated end-products (AGEs). The goals of this study were to determine differences in shoulder activity level and AGEs in people with T2DM compared to matched controls, and to determine factors associated with shoulder pain and disability.

METHODS

Eighty-one participants, T2DM (n=52) and controls (n=29), were examined for magnitude and duration of shoulder activity (measured using accelerometers), skin intrinsic florescence (SIF) as a surrogate measure of AGE level, and the Shoulder Pain and Disability Index (SPADI) as a self-report of shoulder pain and disability.

RESULTS

Compared with controls, T2DM participants had 23% less shoulder activity (p=0.01), greater SIF level (3.6±1.7 vs 2.7±0.6AU, p=0.01), less shoulder strength (p<0.05), and the duration of their shoulder activity was moderately associated (r=0.40; p<0.01) with reported shoulder pain and disability. Shoulder pain and disability were not related to SIF level.

CONCLUSIONS

Persons with T2DM have higher SIF levels and shoulder symptoms and disability indices than controls. Research is needed to determine if a shoulder mobility intervention to increase strength and mobility can help decrease shoulder pain and disability.

Factors affecting the range of motion of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis who walk daily

[Purpose] Increased plantar pressure during walking is a risk factor for foot ulcers because of reduced range of motion at the ankle and first metatarsophalangeal joints. However, the range of motion in patients undergoing hemodialysis has not yet been determined. A cross-sectional study was performed to investigate the factors affecting the range of motion of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis who walk daily. [Subjects and Methods] Seventy feet of 35 patients receiving hemodialysis therapy were examined. Measurements included the passive range of motion of plantar flexion and dorsiflexion of the ankle joint, and flexion and extension of the first metatarsophalangeal joint. [Results] Hemodialysis duration was not associated with ankle and first metatarsophalangeal joint range of motion in patients undergoing hemodialysis. Diabetes duration was significantly associated with limited ankle joint mobility. Finally, blood hemoglobin levels, body mass index, and age were associated with first metatarsophalangeal joint range of motion. [Conclusion] The present study identified age, diabetes, and decreased physical activity, but not hemodialysis duration, to be risk factors for limited joint mobility of the ankle and first metatarsophalangeal joints in patients undergoing hemodialysis.

Gout-related inpatient utilization: a study of predictors of outcomes and time trends

Background

To assess inpatient healthcare burden of gout in the USA after an Emergency Department (ED) visit and the predictors of gout-related hospitalizations.

Method

We used the 2009, 2010 and 2012 US National ED Sample (NEDS) data to examine the time trends in inpatient visits with gout as the primary diagnosis. We used the 2012 NEDS data to assess multivariable-adjusted predictors of length of hospital stay, discharge to home (versus other) and total charges for gout-related inpatient visits.

Results

Of the 205,152 ED visits for gout as the primary diagnosis in 2012, 7.7 % resulted in hospitalization. In 2009, 2010 and 2012, 63 %, 63 % and 64.5 % of hospitalized patients were discharged home; respective durations of hospital stay were 4.15, 4.00 and 3.86 days. Older age 50 to <65 years (ref <50), renal failure, heart failure, osteoarthritis and diabetes were associated with a longer hospital stay and self-pay/uninsured status, hospital location in the Midwest or Western USA with a shorter hospital stay for gout. Similar factors were associated with total charges for gout-related admissions. Older age (65 to <80 and ≥80, relative to <50 years), diabetes, self-pay/no charge insurance status, metropolitan area residence, and a longer length of hospital stay were associated with lower odds of discharge to home; and self-pay/no charge (uninsured) status was associated with higher odds of discharge to home, compared to Medicare coverage.

Conclusions

Using a national sample, we noted declining duration of hospital stay and identified factors associated with the length of hospital stay, discharge to home and charges for gout hospitalization following an ED visit. Future studies should examine whether better management of comorbidities in patients with gout can further reduce utilization and cost of gout-related hospitalizations.

How Obesity Affects Tendons?

Several epidemiological and clinical observations have definitely demonstrated that obesity has harmful effects on tendons. The pathogenesis of tendon damage is multi-factorial. In addition to overload, attributable to the increased body weight, which significantly affects load-bearing tendons, systemic factors play a relevant role. Several bioactive peptides (chemerin, leptin, adiponectin and others) are released by adipocytes, and influence tendon structure by means of negative activities on mesenchymal cells. The ensuing systemic state of chronic, sub-clinic, low-grade inflammation can damage tendon structure. Metabolic disorders (diabetes, impaired glucose tolerance, and dislipidemia), frequently associated with visceral adiposity, are concurrent pathogenetic factors. Indeed, high glucose levels increase the formation of Advanced Glycation End-products, which in turn form stable covalent cross-links within collagen fibers, modifying their structure and functionality.Sport activities, so useful for preventing important cardiovascular complications, may be detrimental for tendons if they are submitted to intense acute or chronic overload. Therefore, two caution rules are mandatory: first, to engage in personalized soft training program, and secondly to follow regular check-up for tendon pathology.

Relationship Between Skin Intrinsic Fluorescence--an Indicator of Advanced Glycation End Products-and Upper Extremity Impairments in Individuals With Diabetes Mellitus

BACKGROUND

Accumulation of advanced glycation end products (AGEs) is thought to contribute to limited joint mobility in people with diabetes mellitus (DM), but the relationships among AGEs, shoulder structural changes, movement, and disability are not understood.

OBJECTIVE

The purpose of this study was to determine the differences and relationships among skin intrinsic fluorescence (SIF), a proxy measure of AGEs, biceps and supraspinatus tendon thickness, upper extremity movement, and disability in groups with and without DM.

DESIGN

This was a cross-sectional, case-control study.

METHODS

Fifty-two individuals participated: 26 with type 2 DM and 26 controls matched for sex, age, and body mass index. The main outcome measures were: SIF; biceps and supraspinatus tendon thickness; 3-dimensional peak shoulder motion; and Disability of the Arm, Shoulder and Hand (DASH) questionnaire scores.

RESULTS

Mean SIF measurements were 19% higher in the DM group compared with the control group (P<.05). Biceps tendons (mean and 95% confidence interval [CI]) (4.7 mm [4.4, 5.0] versus 3.2 mm [2.9, 3.5]) and supraspinatus tendons (6.4 mm [5.9, 6.8] versus 4.9 mm [4.4, 5.3]) were thicker and peak humerothoracic elevation (139° [135°, 146°] versus 150° [146°, 155°]) and glenohumeral external rotation (35° [26°, 46°] versus 51° [41°, 58°]) were reduced in the DM group compared with the control group (P<.05). In the DM group, SIF was correlated to biceps tendon thickness, DASH score, and shoulder motion (r=.44-.51, P<.05). The SIF score and shoulder strength explained 64% of the DASH scores (P<.01).

LIMITATIONS

Because this was a cross-sectional study design, a cause-effect relationship could not be established.

CONCLUSIONS

Accumulation of AGEs in the connective tissues of individuals with DM appears to be associated with increased tendon thickness and decreased shoulder joint mobility and upper extremity function. Physical therapists should be aware of these possible metabolic effects on structure, movement, and disability when treating people with diabetes.

The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer

AIMS

Evaluation of how ankle joint mobility (AJM) can be useful in the identification of patients with diabetes at risk of foot ulcer (FU).

METHODS

Plantar and dorsal flexion of foot were evaluated using an inclinometer in 87 patients (54 type 2 and 33 type 1), and 35 healthy sex- and age-matched control subjects. Patients with diabetes were followed up for diagnosis of FU over the next 8 years and subsequently, patients were subdivided into: those without a history of FU (18 type 1 and 33 type 2), those who had a history of FU detected before baseline evaluation (14 type 2) and those who had history of first ulceration detected by the 8th year of the evaluation period (7 type 2).

RESULTS

Aging and diabetes caused a significant reduction in mobility of each of the movements investigated (p<0.001), whereas after adjusting for the confounding effect of age, diabetes specifically reduced plantar flexion (p<0.0001). AJM was significantly lower in those with history of previous FU compared to all the other groups (p<0.001). The first ulceration was detected in the same foot presenting lower AJM in 17 of the 22 subjects with diabetes with history of ulcer (77.27%).

CONCLUSIONS

Diabetes and aging reduce AJM although diabetes seems to reduce plantar flexion to a more specific extent. Reduced AJM is mostly associated with a previous history of FU. The evaluation of AJM is a valid and reliable ulcer risk scale that indicates which foot is at higher ulcer risk.

Shoulder limited joint mobility in people with diabetes mellitus

BACKGROUND

Limited joint mobility at the shoulder is an understudied problem in people with diabetes mellitus. The purpose of this study was to determine the differences in shoulder kinematics between a group with diabetes and those without diabetes.

METHODS

Fifty-two participants were recruited, 26 with diabetes and 26 non-diabetes controls (matched for age, BMI and sex). Three-dimensional position of the trunk, scapula and humerus were collected using electromagnetic tracking sensors during scapular plane elevation and rotation movements.

FINDINGS

Glenohumeral external rotation was reduced by 11.1°-16.3° (P<0.05) throughout the humerothoracic elevation range of motion, from neutral to peak elevation, in individuals with diabetes as compared to controls. Peak humerothoracic elevation was decreased by 10-14°, and peak external rotation with the arm abducted was decreased 22° in the diabetes group compared to controls (P<0.05). Scapulothoracic and glenohumeral internal rotation motions were not different between the two groups.

INTERPRETATION

Shoulder limited joint mobility, in particular decreased external rotation, was seen in individuals with diabetes as compared to control participants. Future research should investigate causes of diabetic limited joint mobility and strategies to improve shoulder mobility and prevent additional detrimental changes in movement and function.

An innovative ultrasound foot scanner system for measuring the change in biomechanical properties of plantar tissue from sitting to standing

The present study investigated the reliability of an innovative ultrasound foot scanner system in assessing the thickness and stiffness of plantar soft tissue and the comparison of stiffness and thickness in sitting and standing. Fifteen young healthy individuals were examined. The target sites on the foot sole for investigation included the heel pad, the fifth metatarsal head, the second metatarsal head, the first metatarsal head, and the pulp of the hallux. The test (day 1) and retest (day 2) were performed 1 week apart at the exact time with humidity and temperature of the assessment room under control. The thickness and stiffness of the plantar soft tissue obtained in sitting and standing positions on day 1 were used for comparison. The results showed significant test-retest reliability [intraclass correlation coefficient(3,2)>0.90, P<0.001] at all five sites in both sitting and standing positions. When changing from sitting to standing, the plantar soft tissue became significantly thinner (with decrease ranging from 10 to 14% at various sites) and stiffer (with increase ranging from 123 to 164% at various sites, all P<0.05). The present innovative system is a reliable device for the measurement of the thickness and stiffness of plantar soft tissue in either the sitting or the standing position. The change in positions from sitting to standing resulted in a significant thinning and stiffening of plantar soft tissues. This system could be a potential clinical device to monitor the biomechanical properties of plantar tissue in the elderly or in patients with diseases such as diabetes to estimate the risk of developing foot ulcer or other foot complications.

Biomechanical properties and histology of db/db diabetic mouse Achilles tendon

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.

Upper extremity impairments, pain and disability in patients with diabetes mellitus

OBJECTIVES

To determine the severity of, and relationships between, upper extremity impairments, pain and disability in patients with diabetes mellitus, and to compare upper extremity impairments in patients with diabetes with non-diabetic controls.

DESIGN

Case-control, cross-sectional design.

SETTING

University-based, outpatient diabetes centre and physical therapy research clinic.

PARTICIPANTS

Two hundred and thirty-six patients with diabetes attending an outpatient diabetes clinic completed the Shoulder Pain and Disability Index (SPADI) questionnaire. A detailed shoulder and hand examination was conducted on a subgroup of 29 volunteers with type 2 diabetes, and 27 controls matched for age, sex and body mass index.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

SPADI score, passive shoulder range of motion (ROM) and strength, grip strength, hand sensation, dexterity and limited joint mobility of the hand.

RESULTS

Sixty-three percent (149/236) of patients with diabetes reported shoulder pain and/or disability [median SPADI score 10.0 (interquartile range 0.0 to 39.6)]. Compared with the control group, the subgroup of patients with diabetes had substantial reductions in shoulder ROM, shoulder muscle strength, grip and key pinch strength (P<0.05). Patients with diabetes had a greater prevalence of decreased sensation (26/27 vs 14/27) and limited joint mobility of the hand (17/27 vs 4/27) compared with the control group. Total SPADI score was negatively correlated (P<0.05) with shoulder ROM (r=-0.42 to -0.74) and strength measures (r=-0.44 to -0.63) in patients with diabetes.

CONCLUSIONS

Upper extremity impairments in this sample of patients with diabetes were common, severe and related to complaints of pain and disability. Additional research is needed to understand the unique reasons for upper extremity problems in patients with diabetes, and to identify preventative treatments.

Decrease in Talocrural Joint Mobility is Related to Alteration of the Arterial Blood Flow Velocity in the Lower Limb in Diabetic Women

[Purpose] The purpose of this study was to correlate the talocrural range of motion (ROM) and blood flow velocity in the lower limb arteries of diabetic women. [Subjects and Methods] Thirty women were divided into a control group (G1), consisting of 15 sedentary right-handed subjects (41.27 ± 7.24 years old) who had no history of blood system disorder, and a diabetes group (G2), consisting of 15 sedentary right-handed subjects (57.87 ± 6.20 years old) who had type 2 diabetes mellitus. Talocrural ROM was measured by using goniometry for dorsiflexion and plantar flexion movements. In addition, blood flow velocity of the dorsalis pedis, posterior tibial, and popliteal arteries was also assessed. [Results] No significant differences were found between the groups by comparing talocrural ROM and arterial blood velocity. However, a significant association was found in G2 only between the following variables: plantar flexion and blood flow velocity of the dorsalis pedis artery (rs = 0.57), plantar flexion and blood flow velocity of the popliteal artery (rs = 0.50), and dorsiflexion and blood flow velocity of the posterior tibial artery (rs = 0.57). [Conclusion] The decrease in talocrural ROM is related to a decrease in the arterial blood flow velocity in diabetic women.

Metabolomic profiling reveals severe skeletal muscle group-specific perturbations of metabolism in aged FBN rats

Mammalian skeletal muscles exhibit age-related adaptive and pathological remodeling. Several muscles in particular undergo progressive atrophy and degeneration beyond median lifespan. To better understand myocellular responses to aging, we used semi-quantitative global metabolomic profiling to characterize trends in metabolic changes between 15-month-old adult and 32-month-old aged Fischer 344 × Brown Norway (FBN) male rats. The FBN rat gastrocnemius muscle exhibits age-dependent atrophy, whereas the soleus muscle, up until 32 months, exhibits markedly fewer signs of atrophy. Both gastrocnemius and soleus muscles were analyzed, as well as plasma and urine. Compared to adult gastrocnemius, aged gastrocnemius showed evidence of reduced glycolytic metabolism, including accumulation of glycolytic, glycogenolytic, and pentose phosphate pathway intermediates. Pyruvate was elevated with age, yet levels of citrate and nicotinamide adenine dinucleotide were reduced, consistent with mitochondrial abnormalities. Indicative of muscle atrophy, 3-methylhistidine and free amino acids were elevated in aged gastrocnemius. The monounsaturated fatty acids oleate, cis-vaccenate, and palmitoleate also increased in aged gastrocnemius, suggesting altered lipid metabolism. Compared to gastrocnemius, aged soleus exhibited far fewer changes in carbohydrate metabolism, but did show reductions in several glycolytic intermediates, fumarate, malate, and flavin adenine dinucleotide. Plasma biochemicals showing the largest age-related increases included glycocholate, heme, 1,5-anhydroglucitol, 1-palmitoleoyl-glycerophosphocholine, palmitoleate, and creatine. These changes suggest reduced insulin sensitivity in aged FBN rats. Altogether, these data highlight skeletal muscle group-specific perturbations of glucose and lipid metabolism consistent with mitochondrial dysfunction in aged FBN rats.

Diabetic foot and exercise therapy: step by step the role of rigid posture and biomechanics treatment

Lower extremity ulcers represent a serious and costly complication of diabetes mellitus. Many factors contribute to the development of diabetic foot. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute in turn to the growth of additional risk factors such as limited joint mobility, muscular alterations and foot deformities. Moreover, a deficit of balance, posture and biomechanics can be present, in particular in patients at high risk for ulceration. The result of this process may be the development of a vicious cycle which leads to abnormal distribution of the foot's plantar pressures in static and dynamic postural conditions. This review shows that some of these risk factors significantly improve after a few weeks of exercise therapy (ET) intervention. Accordingly it has been suggested that ET can be an important weapon in the prevention of foot ulcer. The aim of ET can relate to one or more alterations typically found in diabetic patients, although greater attention should be paid to the evaluation and possible correction of body balance, rigid posture and biomechanics. Some of the most important limitations of ET are difficult access to therapy, patient compliance and the transitoriness of the results if the training stops. Many proposals have been made to overcome such limitations. In particular, it is important that specialized centers offer the opportunity to participate in ET and during the treatment the team should work to change the patient's lifestyle by improving the execution of appropriate daily physical activity.

The effects of high-fat diet, branched-chainamino acids and exercise on female C57BL/6 mouse Achilles tendon biomechanical properties

Objectives

The goals of this study were: 1) to determine if high-fat diet (HFD) feeding in female mice would negatively impact biomechanical and histologic consequences on the Achilles tendon and quadriceps muscle; and 2) to investigate whether exercise and branched-chain amino acid (BCAA) supplementation would affect these parameters or attenuate any negative consequences resulting from HFD consumption.

Methods

We examined the effects of 16 weeks of 60% HFD feeding, voluntary exercise (free choice wheel running) and BCAA administration in female C57BL/6 mice. The Achilles tendons and quadriceps muscles were removed at the end of the experiment and assessed histologically and biomechanically.

Results

HFD feeding significantly decreased the Achilles tendon modulus without histological alterations. BCAA administration significantly decreased the stiffness of Achilles tendons in the exercised normal diet mice. Exercise partially ameliorated both the weight gain and glucose levels in the HFD-fed mice, led to a significant decrease in the maximum load of the Achilles tendon, and an increase in the average fibril diameter of the quadriceps femoris muscle. There were significant correlations between body weight and several biomechanical properties, demonstrating the importance of controlling obesity for maintaining healthy tendon properties.

Conclusions

In summary, this study showed a significant impact of obesity and body weight on tendon biomechanical properties with limited effects of exercise and BCAAs.

Cite this article: Bone Joint Res 2013;2:186–92.

Body mass index and musculoskeletal pain: is there a connection?

Background

Back pain is one of the most common complaints that patients report to physicians and two-thirds of the population has an elevated body mass index (BMI), indicating they are either overweight or obese. It was once assumed that extra body weight would stress the low back and lead to pain, however, researchers have reported inconsistencies association between body weight and back pain. In contrast, more recent studies do indicate that an elevated BMI is associated with back pain and other musculoskeletal pain syndromes due to the presence of a chronic systemic inflammatory state, suggesting that the relationship between BMI and musculoskeletal pains be considered in more detail.

Objective

To describe how an elevated BMI can be associated with chronic systemic inflammation and pain expression. To outline measurable risk factors for chronic inflammation that can be used in clinical practice and discuss basic treatment considerations.

Discussion

Adiposopathy, or “sick fat” syndrome, is a term that refers to an elevated BMI that is associated with a chronic systemic inflammatory state most commonly referred to as the metabolic syndrome. The best available evidence suggests that the presence of adiposopathy determines if an elevated BMI will contribute to musculoskeletal pain expression. It is not uncommon for physicians to fail to identify the presence of adiposopathy/metabolic syndrome.

Conclusion

Patients with an elevated BMI should be further examined to identify inflammatory factors associated with adiposopathy, such as the metabolic syndrome, which may be promoting back pain and other musculoskeletal pain syndromes.