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Balak BK, Anaforoglu B. Examination time-distance characteristics of gait and pelvic kinematics in individuals with Diabetic polyneuropathy: a case-control study. Neurol Res 2024:1-6. [PMID: 38916096 DOI: 10.1080/01616412.2024.2367938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 06/09/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Diabetic Peripheral Neuropathy (DPN) disrupts body and movement biomechanics, increases mechanical stress during walking, and predisposes individuals to injuries owing to the repetitive effects of these stresses. AIMS This study aimed to assess and compare the impact of neuropathy on gait and pelvic kinematics in individuals with DPN. METHODS This case-control study included two groups: 23 individuals diagnosed with DPN aged between 35-70 and 23 healthy individuals aged-35-70. The BTS-G, a wireless motion sensor, was used to assess the time-distance characteristics of walking in all participants. The system analyzed data pertaining to walking speed, cadence, percentages of stance and swing phases, durations of walking cycles, double-step lengths, pelvic tilt, obliquity, and rotation symmetries. RESULTS There were no statistically significant differences between the groups in cadence, left and right stance phase percentages, or left and right swing phase percentages (p > 0.05). However, significant differences were observed between the groups in terms of speed, left and right walking cycle durations, and left and right double-step lengths (p < 0.05). Additionally, no statistically significant difference was found between the groups in pelvic tilt symmetry and left and right pelvic tilt range of motion values (p > 0.05). Nevertheless, significant differences were identified between the groups in pelvic obliquity symmetry, pelvic rotation symmetry, left and right pelvic obliquity range of motion, and left and right pelvic rotation range of motion values (p < 0.05). CONCLUSIONS The findings of this study suggest that individuals with DPN exhibit decreased walking speed, prolonged gait cycle duration, increased double step length, and reduced pelvic obliquity and rotation range of motion.
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Affiliation(s)
- Büşra Kalkan Balak
- Department of Physiotherapy and Rehabilitation, Yuksek Ihtisas University Faculty of Health Sciences, Ankara, Türkiye
| | - Bahar Anaforoglu
- Department of Physiotherapy and Rehabilitation, Ankara Yildirim Beyazit University Faculty of Health Sciences, Ankara, Türkiye
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Hoveizavi R, Gao F, Ramirez VJ, Shuman BR, Joiner JC, Fisher SJ. Compromised neuromuscular function of walking in people with diabetes: a narrative review. Diabetes Res Clin Pract 2023:110802. [PMID: 37356728 DOI: 10.1016/j.diabres.2023.110802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 04/18/2023] [Accepted: 06/22/2023] [Indexed: 06/27/2023]
Abstract
AIM This review summarizes recent studies that have investigated the neuromuscular dysfunction of walking in people with diabetes and its relationship to ulcer formation. METHODS A comprehensive electronic search in the database (Scopus, Web of Science, PsycINFO, ProQuest, and PubMed) was performed for articles pertaining to diabetes and gait biomechanics. RESULTS The Achilles tendon is thicker and stiffer in those with diabetes. People with diabetes demonstrate changes in walking kinematics and kinetics, including slower self-selected gait speed, shorter stride length, longer stance phase duration, and decreased ankle, knee, and metatarsophalangeal (MTP) joint range of motion. EMG is altered during walking and may reflect diabetes-induced changes in muscle synergies. Synergies are notable because they provide a more holistic pattern of muscle activations and can help develop better tools for characterizing disease progression. CONCLUSION Diabetes compromises neuromuscular coordination and function. The mechanisms contributing to ulcer formation are incompletely understood. Diabetes-related gait impairments may be a significant independent risk factor for the development of foot ulcers.
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Affiliation(s)
- Roya Hoveizavi
- Department of Kinesiology and Health promotions, University of Kentucky, Lexington, KY, USA.
| | - Fan Gao
- Department of Kinesiology and Health promotions, University of Kentucky, Lexington, KY, USA.
| | - Vanessa J Ramirez
- US Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Benjamin R Shuman
- RR&D Center for Limb Loss and MoBility (CLiMB), Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Joshua C Joiner
- College of Medicine, University of Kentucky, Lexington, KY, USA.
| | - Simon J Fisher
- Division of Endocrinology, Diabetes and Metabolism, Dept. of Internal Medicine, University of Kentucky, Lexington, KY, USA.
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Jones SL, van Emmerik REA. Impaired foot vibration sensitivity is related to altered plantar pressures during walking in people with multiple sclerosis. Mult Scler Relat Disord 2023; 75:104767. [PMID: 37216882 DOI: 10.1016/j.msard.2023.104767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 04/05/2023] [Accepted: 05/15/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Balance and mobility impairment are two of the most common and debilitating symptoms among people with multiple sclerosis (MS). Somatosensory symptoms, including reduced plantar cutaneous sensation, have been identified in this cohort. Given the importance of the somatosensory system in gait, it is likely that impaired plantar sensation may play a role in the walking adaptations commonly observed in people with MS, including decreased stride length and increased stride width and dual support time, often described as a cautious gait strategy. Understanding the contributions of plantar sensation to these alterations may provide targets for interventions that seek to improve sensory feedback and normalize gait patterns. This cross-sectional study determined whether individuals with MS who demonstrate reduced sensitivity of the plantar surfaces also demonstrate altered plantar pressure distributions during walking compared to a control cohort. METHODS Twenty individuals with MS and twenty age- and sex-matched control participants walked barefoot at preferred and three matched speeds. Participants walked across a walkway with an embedded pressure plate used to quantify pressures within ten plantar zones. In addition, vibration perception thresholds were assessed at four sites on the plantar surface. RESULTS Individuals with MS demonstrated increased peak total plantar pressures compared to control participants, that increased with walking speed. For the MS group, plantar pressures were higher on the less sensitive foot, although pressures on both feet exceeded those of the control cohort. Positive correlations between vibration perception threshold and peak total pressure were evident, although generally stronger in the MS cohort. CONCLUSION A relationship between plantar vibration sensitivity and pressure could indicate that individuals with MS seek to increase plantar sensory feedback during walking. However, because proprioception may also be impaired, increased plantar pressure could result from inaccurate foot placement. Interventions targeting improved somatosensation may have the potential to normalize gait patterns and should be investigated.
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Affiliation(s)
- Stephanie L Jones
- Department of Kinesiology, 110 Totman Building, School of Public Health and Health Sciences, University of Massachusetts Amherst, 30 Eastman Lane, Amherst, MA 01003-9258, USA; Department of Exercise and Sport Studies, 410 Scott Gym, Smith College, 102 Lower College Lane, Northampton, MA 01063, USA.
| | - Richard E A van Emmerik
- Department of Kinesiology, 110 Totman Building, School of Public Health and Health Sciences, University of Massachusetts Amherst, 30 Eastman Lane, Amherst, MA 01003-9258, USA
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Maeshige N, Moriguchi M, Fujii M, Kanazawa H, Yoshikawa Y, Kitamura K, Okuno F, Yamaguchi A, Uemura M, Hosomi M, Hara K, Terashi H, Fujino H. Acute Effects of Combination Therapy by Triceps Surae Stretching and Electrical Stimulation to the Tibialis Anterior on Medial Forefoot Plantar Pressure During Gait in Patients With Diabetes Mellitus. INT J LOW EXTR WOUND 2023:15347346221148456. [PMID: 36594523 DOI: 10.1177/15347346221148456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
High plantar flexor moment and limited ankle mobility are known to cause high plantar pressure under the forefoot. Stretching is an effective physical therapy for the limited ankle range of motion (ROM), and electrical stimulation is used to regulate the activity of antagonistic muscle via the action of reciprocal inhibition. Additionally, stretching paired with electrical stimulation has been reported to improve the limited ROM significantly. This study aims to investigate the influences of stretching on triceps surae (STR), electrical stimulation to tibialis anterior (ES), and the combination (ES+STR) on the ROM, kinematic parameters, and plantar pressure distribution during gait in patients with diabetes mellitus. Planter pressure and other parameters were measured before and after the intervention of ES, STR, ES+STR, or the rest sitting on the bed (CON) for 10 min. Pressure time integral under the medial forefoot decreased in the ES+STR compared to CON (P< .05). Interestingly, ES+STR increased passive and dynamic ROM on ankle dorsiflexion during gait and increased the lateral center of pressure excursion (P < .05). Furthermore, these changes were followed by decreased contact duration under the medial forefoot (P < .05). The combined therapy improves ankle mobility during gait and reduces the contact duration and the plantar pressure under the medial forefoot in patients with diabetes mellitus.
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Affiliation(s)
- Noriaki Maeshige
- Department of Rehabilitation Science, 12885Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Maiki Moriguchi
- Department of Rehabilitation Science, 12885Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Miki Fujii
- Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine, Tokyo, Japan
- Division of Regenerative Therapy, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Hoshinori Kanazawa
- Graduate School of Information Science and Technology, 13143The University of Tokyo, Tokyo, Japan
| | - Yoshiyuki Yoshikawa
- Department of Rehabilitation, Faculty of Health Sciences, 12968Naragakuen University, Nara, Japan
| | | | - Fumiya Okuno
- Department of Rehabilitation, Eikokai Ono Hospital, Ono, Japan
| | - Atomu Yamaguchi
- Department of Rehabilitation Science, 12885Kobe University Graduate School of Health Sciences, Kobe, Japan
| | - Mikiko Uemura
- Department of Rehabilitation Science, 12885Kobe University Graduate School of Health Sciences, Kobe, Japan
| | | | - Kenta Hara
- 36719Kita-Harima Medical Center, Ono, Japan
| | - Hiroto Terashi
- Department of Plastic Surgery, 12885Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hidemi Fujino
- Department of Rehabilitation Science, 12885Kobe University Graduate School of Health Sciences, Kobe, Japan
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Khalaf K, Mohan DM, Hindi MA, Khandoker AH, Jelinek HF. Plantar pressure alterations associated with increased BMI in young adults. Gait Posture 2022; 98:255-260. [PMID: 36201927 DOI: 10.1016/j.gaitpost.2022.09.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 08/30/2022] [Accepted: 09/14/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Despite evidence suggesting that excess weight is linked to gait alterations and foot disorders, its effect on peak plantar pressure (PPP) variability and complexity during walking remains poorly understood. RESEARCH QUESTION This study aimed to examine the influence of overweight (BMI ≥ 25) on the dynamic PPP distribution during gait using traditional and nonlinear dynamic measures in young college students. METHODS Fifty-two overweight (BMI >25, average 29.3 ± 4.02) and sixty-four control college students (BMI<25, 21.7 ± 1.76) aged 18-25 years, walked across a Tekscan gait assessment system at their preferred speed. A t-test or a Mann Whitney U test was used for analysis, subject to data normality. Kinematic, kinetic, spatiotemporal, and GaitEn (sample entropy of 2D spatial PPP maps) for window lengths (m=2) at various filtering levels (r) were used to explore the impact of BMI on PPP alterations. RESULTS AND SIGNIFICANCE The overweight group exhibited significantly higher mean PPP. The PPP under the forefoot region was also significantly higher for the overweight group as compared to the heel. The mean GaitEn values of overweight and control groups were found significantly different at r = (0.7-0.8) x STD, where GaitEn of the control group was relatively higher, which indicates better gait performance as compared to the overweight group in alignment with previous studies. A significant correlation of GaitEn with STD of PPP was revealed for the overweight group only, suggesting that overweight could significantly change the regularity or the complexity of the PPP series. Although no spatiotemporal parameters (stride length, step length, step width) were significantly affected by the increased BMI, GaitEn dynamic measure, along with spatiotemporal (decrease in gait velocity and cadence with increased BMI), and kinetic measures (increased maximum forces and plantar pressure with increased BMI), were significantly affected by overweight, indicating the feasibility of assessing the impact of increased BMI using pressure platforms in clinical settings.
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Affiliation(s)
- Kinda Khalaf
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates; Health Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates.
| | - Dhanya Menoth Mohan
- Health Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Maha Al Hindi
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Ahsan Habib Khandoker
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates; Health Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
| | - Herbert F Jelinek
- Department of Biomedical Engineering, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates; Health Engineering Innovation Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates; Biotechnology Center, Khalifa University of Science and Technology, Abu Dhabi, United Arab Emirates
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Thielen M, Waible D, Krautwurst BK, Wolf SI, Dreher T. Effects of artificially induced bilateral internal rotation gait on gait kinematics and kinetics. Gait Posture 2022; 95:204-209. [PMID: 35533614 DOI: 10.1016/j.gaitpost.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 04/20/2022] [Accepted: 05/02/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Bilateral internal rotation gait is a common gait abnormality in children with bilateral cerebral palsy, but still not fully understood. RESEARCH QUESTION The aim of this clinical study was to analyze the effects of artificially induced bilateral internal rotation gait on kinematics and kinetics. Our hypothesis was, that the internal rotation gait defined as increased dynamic internal hip rotation itself causes significant alterations in gait kinematics and kinetics. METHODS 30 typically developing children with a mean age of 12 (SD 3) years (range 8 - 16) performed three-dimensional gait analysis in two different conditions: with unaffected gait and with artificially induced bilateral internal rotation gait with two rotation bandages worn in order to internally rotate the hips. Kinematic and kinetic changes between these two conditions were calculated and compared using a mixed linear model with "gait condition" as fixed effect and both "limb" and "patient" as random effects. RESULTS The rotation bandages induced a significant increase in internal hip rotation and foot progression angle towards internal without affecting pelvic rotation. The peak hip internal rotator moment during loading response and the peak hip external rotator moment during the first half of stance phase increased significantly and the peak hip internal rotator moment during the second half of stance phase decreased significantly. Anterior pelvic tilt, hip flexion, knee flexion and ankle dorsiflexion increased significantly. The first peak of the frontal hip moment decreased, and the second increased significantly. The second peak of the frontal knee moment decreased significantly, while the first didn't change significantly. SIGNIFICANCE The data suggest, that the bilaterally increased dynamic internal hip rotation itself has a relevant impact on frontal hip moments. The increased anterior pelvic tilt, hip and knee flexion may be either induced by the pull of the rotation bandage or a secondary gait deviation.
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Affiliation(s)
- Mirjam Thielen
- University Hospital Heidelberg, Clinic for Orthopedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany; BG Klinik Ludwigshafen, Department of Hand, Plastic and Reconstructive Surgery, Burn Center, Plastic and Hand Surgery, Ludwig-Guttmann-Str. 13, 67071 Ludwigshafen am Rhein, Germany.
| | - Dorothea Waible
- University Hospital Heidelberg, Clinic for Orthopedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany.
| | - Britta K Krautwurst
- University Hospital Heidelberg, Clinic for Orthopedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany; University Children's Hospital Zurich, Department of Pediatric Orthopedics, Steinwiesstr. 75, 8032 Zürich, Switzerland.
| | - Sebastian I Wolf
- University Hospital Heidelberg, Clinic for Orthopedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany.
| | - Thomas Dreher
- University Hospital Heidelberg, Clinic for Orthopedic and Trauma Surgery, Schlierbacher Landstr. 200a, 69115 Heidelberg, Germany; University Children's Hospital Zurich, Department of Pediatric Orthopedics, Steinwiesstr. 75, 8032 Zürich, Switzerland.
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Sadler SG, Lanting SM, Searle AT, Spink MJ, Chuter VH. Does a weight bearing equinus affect plantar pressure differently in older people with and without diabetes? A case control study. Clin Biomech (Bristol, Avon) 2021; 84:105324. [PMID: 33756401 DOI: 10.1016/j.clinbiomech.2021.105324] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND A weight bearing ankle equinus has adverse effects on forefoot plantar pressure variables in older adults with diabetes, but it is unclear if this is also the case in older adults without diabetes. METHODS 40 older adults with diabetes (88% type 2, mean diabetes duration 17.6 ± 14.8 years) and 40 older adults without diabetes, matched for age (±3 years), sex and BMI (±2 BMI units) were included (63% female, mean age 72 ± 4 years, BMI 30 ± 4 kg/m2). Primary outcomes were prevalence of a weight bearing equinus and evaluation of barefoot forefoot plantar pressures in older adults with and without diabetes. FINDINGS A weight bearing equinus was present in 37.5% and 27.5% of the diabetes and non-diabetes group respectively with no significant difference between groups (p = 0.470). People with diabetes and equinus displayed higher peak pressure (808 versus 540 kPa, p = 0.065) and significantly higher pressure-time integral (86 versus 68 kPa/s, p = 0.030) than people with diabetes and no equinus group. The non-diabetes equinus group had significantly higher peak pressure (665 versus 567 kPa, p = 0.035) than those with no diabetes and no equinus, but no difference in pressure-time integral. INTERPRETATION A high prevalence of a weight bearing equinus was detected in older adults with and without diabetes, with associated increases in plantar pressures. As an equinus has been associated with many foot pathologies this study's findings suggest that clinicians should check for the presence of a weight bearing ankle equinus in all older adults.
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Affiliation(s)
- Sean G Sadler
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Australia.
| | - Sean M Lanting
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Australia
| | - Angela T Searle
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Australia
| | - Martin J Spink
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Australia
| | - Vivienne H Chuter
- Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Australia; Priority Research Centre for Physical activity and Nutrition, University of Newcastle, Australia
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Thielen M, Wolf SI, Klotz MCM, Geisbüsch A, Putz C, Krautwurst B, Dreher T. Supracondylar femoral rotation osteotomy affects frontal hip kinetics in children with bilateral cerebral palsy. Dev Med Child Neurol 2019; 61:322-328. [PMID: 30255540 DOI: 10.1111/dmcn.14035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2018] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the influence of supracondylar femoral derotation osteotomy (FDO) on hip abduction muscle force and frontal hip moments in children with bilateral cerebral palsy. METHOD For this retrospective cohort study 79 children (36 females, 43 males; mean age at surgery 11y [SD 3y]; range 4-17y) with bilateral cerebral palsy and preoperatively and 1-year postoperatively documented frontal hip moments who received supracondylar FDO in 134 limbs were included. The control group consisted of eight children (two females, six males; mean age 11y [SD 4y]; range 5-17y) who received single-event multi-level surgery without FDO. RESULTS Hip joint impulse (p<0.001) and the first peak of frontal hip moments (p=0.003) increased, whereas the second peak decreased (p<0.001) from preoperatively to postoperatively. Hip abductor strength improved (p=0.001) from preoperatively to postoperatively. INTERPRETATION Despite the compensatory mechanism, frontal hip moments are decreased preoperatively. Supracondylar FDO results in increased frontal hip moments. Changes in anteversion directly influence hip kinetics, although no direct change of the proximal bony geometry is performed. WHAT THIS PAPER ADDS Internal rotation gait cannot fully restore the frontal hip moment. Supracondylar femoral derotation osteotomy (FDO) influences frontal hip kinetics in children with bilateral cerebral palsy. Supracondylar FDO changes the curve progression of frontal hip moments. Supracondylar FDO restores the hip abductor moment arm. Supracondylar FDO leads to an increase in hip abductor muscle force.
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Affiliation(s)
- Mirjam Thielen
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Sebastian I Wolf
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Matthias C M Klotz
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Andreas Geisbüsch
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Cornelia Putz
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Britta Krautwurst
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Dreher
- Clinic for Orthopedic and Trauma Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Deforth M, Zwicky L, Horn T, Hintermann B. The effect of foot type on the Achilles tendon moment arm and biomechanics. Foot (Edinb) 2019; 38:91-94. [PMID: 30849670 DOI: 10.1016/j.foot.2018.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 08/30/2018] [Accepted: 10/08/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim was to calculate the Achilles tendon moment arm in different degrees of plantarflexion for pes planus, pes cavus and normal arched feet. METHODS 99 patients (99 radiographs; 40 males, 59 females; mean age 49 years, SD 15) with a healthy ankle joint and a preoperative weightbearing lateral radiograph of the foot were included. Three groups (pes planus, pes cavus and normal-arched feet) with equal sample sizes (n=33) were formed. On radiographs, the angle formed between a horizontal line and the line connecting the insertion of the Achilles tendon with the center of rotation of the ankle, was measured. The interrater reliabilities (ICC) of the angle alpha were compared on radiographs and on MRIs. Using the angle alpha, the Achilles tendon moment arm was calculated in different plantarflexion positions. RESULTS The ICC of alpha was higher on radiographs (0.84, [0.73-0.91]) than on MRIs (0.61, [0.27-0.81]). The average alpha was statistically significantly different (normal arched foot 31 degrees (°), pes planus 24°, pes cavus 36°, p=0.021), resulting in a significant shorter Achilles tendon moment arm for pes cavus than for pes planus (p<0.0001) and normal arched feet (p=0.006) in neutral position. CONCLUSION The data suggests that it is feasible to use radiographs to measure the Achilles tendon moment arm. The maximum Achilles tendon moment arm is reached at different angles of ankle flexion for pes cavus, pes planus and normal-arched feet. This has to be taken into consideration when planning surgeries.
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Affiliation(s)
- Manja Deforth
- Clinic for Orthopaedic and Trauma Surgery, Kantonsspital Baselland, Switzerland
| | - Lukas Zwicky
- Clinic for Orthopaedic and Trauma Surgery, Kantonsspital Baselland, Switzerland
| | - Tamara Horn
- Clinic for Orthopaedic and Trauma Surgery, Kantonsspital Baselland, Switzerland
| | - Beat Hintermann
- Clinic for Orthopaedic and Trauma Surgery, Kantonsspital Baselland, Switzerland.
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Hazari A, Maiya AG, Shivashankara K. Foot Kinetic and Kinematic Profile in Type 2 Diabetes Mellitus with Peripheral Neuropathy A Hospital-Based Study from South India. J Am Podiatr Med Assoc 2019; 109:36-49. [PMID: 29389217 DOI: 10.7547/17-059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND A kinetic change in the foot such as altered plantar pressure is the most common etiological risk factor for foot ulcers in people with diabetes mellitus. Kinematic alterations in joint angle and spatiotemporal parameters of gait have also been frequently observed in participants with diabetic peripheral neuropathy (DPN). Diabetic peripheral neuropathy leads to various microvascular and macrovascular complications of the foot in type 2 diabetes mellitus. There is a gap in the literature for biomechanical evaluation and assessment of type 2 diabetes mellitus with DPN in the Indian population. We sought to assess and determine the biomechanical changes, including kinetics and kinematics, of the foot in DPN. METHODS This cross-sectional study was conducted at a diabetic foot clinic in India. Using the purposive sampling method, 120 participants with type 2 diabetes mellitus and DPN were recruited. Participants with active ulceration or amputation were excluded. RESULTS The mean ± SD age, height, weight, body mass index, and diabetes duration were 57 ± 14 years, 164 ± 11 cm, 61 ± 18 kg, 24 ± 3 kg/m2, and 12 ± 7 years, respectively. There were significant changes in the overall biomechanical profile and clinical manifestations of DPN. The regression analysis showed statistical significance for dynamic maximum plantar pressure at the forefoot with age, weight, height, diabetes duration, body mass index, knee and ankle joint angle at toe-off, pinprick sensation, and ankle reflex ( R = 0.71, R2 = 0.55, F12,108 = 521.9 kPa; P = .002). CONCLUSIONS People with type 2 diabetes mellitus and DPN have significant changes in their foot kinetic and kinematic parameters. Therefore, they could be at higher risk for foot ulceration, with underlying neuropathy and biomechanically associated problems.
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Affiliation(s)
- Animesh Hazari
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
| | - Arun G. Maiya
- Department of Physiotherapy, School of Allied Health Sciences, Manipal University, Manipal, Karnataka, India
| | - K.N. Shivashankara
- Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
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11
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Telfer S, Bigham JJ. The influence of population characteristics and measurement system on barefoot plantar pressures: A systematic review and meta-regression analysis. Gait Posture 2019; 67:269-276. [PMID: 30391749 DOI: 10.1016/j.gaitpost.2018.10.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/17/2018] [Accepted: 10/25/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND The measurement of plantar pressure distributions during gait can provide insights into the effects of musculoskeletal disease on foot function. A range of hardware, software, and protocols are available for the collection of this type of data, with sometimes disparate and conflicting results reported between individual studies. In this systematic review and meta-regression analysis of dynamic regional peak pressures, we aimed to test if 1) the system used to obtain the pressure measurements and 2) the characteristics of the study populations had a significant effect on the results. METHODS A systematic review of the literature was undertaken to identify articles reporting regional peak plantar pressures during barefoot walking. A mixed-effects modeling approach was used to analyze the extracted data. Initially, the effect of the system used to collect the data was tested. Following this, the effect of participant characteristics on the results were analyzed, using moderators of cohort type (defined as the primary health characteristic of the participants), age, sex, and BMI. RESULTS 115 participant groups were included in the analysis. Sufficient cohorts were available to test those that consisted of healthy individuals, and those with diabetes and diabetic neuropathy. Significant differences were found between results reported by studies using different pressure measurement systems in 8 of the 16 regions analyzed. The analysis of participant characteristics revealed a number of significant relationships between regional peak pressures and participant characteristics, including: BMI and midfoot plantar pressures; elevated forefoot pressures as a result of diabetic neuropathy; and sex-differences in regional loading patterns. CONCLUSIONS At the level of the literature, we confirmed significant effects of disease status, age, BMI, and sex on regional peak plantar pressures. Researchers and clinicians should be aware that measurements of peak plantar pressure variables obtained from different collection equipment are not directly comparable.
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Affiliation(s)
- S Telfer
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, United States.
| | - J J Bigham
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, United States
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Henderson AD, Johnson AW, Ridge ST, Egbert JS, Curtis KP, Berry LJ, Bruening DA. Diabetic Gait Is Not Just Slow Gait: Gait Compensations in Diabetic Neuropathy. J Diabetes Res 2019; 2019:4512501. [PMID: 31815148 PMCID: PMC6878800 DOI: 10.1155/2019/4512501] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/05/2019] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Neuropathic complications from diabetes mellitus affect multiple nerve types and may manifest in gait. However, gait compensations are still poorly understood, as narrow analyses and lack of speed controls have contributed to conflicting or equivocal results. PURPOSE To evaluate gait mechanics and energetics in diabetic peripheral polyneuropathy. METHODS Instrumented gait analysis was performed on 14 participants with diabetic peripheral polyneuropathy and 14 matched controls, walking at 1.0 m/s. A full-body model with a multisegment foot was used to calculate inverse dynamics and analyze sagittal plane metrics and time series waveforms across stance phase. RESULTS Alterations included increased hip and knee flexion in early stance followed by a prolonged hip extension moment in midstance. Late stance ankle dorsiflexion and power absorption were increased, and final push-off was delayed and truncated. CONCLUSION A neuropathic diabetic gait shares important similarities to a mild crouch gait with weakness/dysfunction in the foot and ankle. This study highlights two main compensation mechanisms that have been overlooked in previous literature. First, increased triceps surae stretch in terminal stance may be used to increase proprioception and/or energy storage, while a prolonged hip extension moment in midstance compensates for a limited push-off. These result in an overall workload shift from distal to proximal joints. Clinical assessment, monitoring, and treatment of neuropathy may benefit by focusing on these specific functional alterations.
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Affiliation(s)
| | - A. Wayne Johnson
- Exercise Sciences Department, Brigham Young University, Provo, UT, USA
| | - Sarah T. Ridge
- Exercise Sciences Department, Brigham Young University, Provo, UT, USA
| | | | - Kevin P. Curtis
- Exercise Sciences Department, Brigham Young University, Provo, UT, USA
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Nakajima H, Yamamoto S, Katsuhira J. Effects of diabetic peripheral neuropathy on gait in vascular trans-tibial amputees. Clin Biomech (Bristol, Avon) 2018; 56:84-89. [PMID: 29864596 DOI: 10.1016/j.clinbiomech.2018.05.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 04/14/2018] [Accepted: 05/08/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with diabetes often develop diabetic peripheral neuropathy, which is a distal symmetric polyneuropathy, so foot function on the non-amputated side is expected to affect gait in vascular trans-tibial amputees. However, there is little information on the kinematics and kinetics of gait or the effects of diabetic peripheral neuropathy in vascular trans-tibial amputees. This study aimed to clarify these effects, including the biomechanics of the ankle on the non-amputated side. METHODS Participants were 10 vascular trans-tibial amputees with diabetic peripheral neuropathy (group V) and 8 traumatic trans-tibial amputees (group T). Each subject's gait was analyzed at a self-selected speed using a three-dimensional motion analyzer and force plates. FINDINGS Ankle plantarflexion angle, heel elevation angle, and peak and impulse of anterior ground reaction force were smaller on the non-amputated side during pre-swing in group V than in group T. Center of gravity during pre-swing on the non-amputated side was lower in group V than in group T. Hip extension torque during loading response on the prosthetic side was greater in group V than in group T. INTERPRETATION These findings suggest that the biomechanical function of the ankle on the non-amputated side during pre-swing is poorer in vascular trans-tibial amputees with DPN than in traumatic trans-tibial amputees; the height of the center of gravity could not be maintained during this phase in vascular trans-tibial amputees with diabetic peripheral neuropathy. The hip joint on the prosthetic side compensated for this diminished function at the ankle during loading response.
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Affiliation(s)
- Hiroshi Nakajima
- Tokyo Medical University Ibaraki Medical Center, 3-20-1 Chuo, Ami, Ibaraki 300-0395, Japan.
| | - Sumiko Yamamoto
- International University of Health and Welfare, 1-3-3 Minami-Aoyama, Minato-ku, Tokyo 107-0062, Japan
| | - Junji Katsuhira
- Niigata University of Health and Welfare, 1398, Simami-cho, Niigata 950-3198, Japan
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Alam U, Riley DR, Jugdey RS, Azmi S, Rajbhandari S, D'Août K, Malik RA. Diabetic Neuropathy and Gait: A Review. Diabetes Ther 2017; 8:1253-1264. [PMID: 28864841 PMCID: PMC5688977 DOI: 10.1007/s13300-017-0295-y] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Indexed: 01/08/2023] Open
Abstract
Diabetic peripheral neuropathy (DPN) is a major sequela of diabetes mellitus and may have a detrimental effect on the gait of people with this complication. DPN causes a disruption in the body's sensorimotor system and is believed to affect up to 50% of patients with diabetes mellitus, dependent on the duration of diabetes. It has a major effect on morbidity and mortality. The peripheral nervous system controls the complex series of events in gait through somatic and autonomic functions, careful balancing of eccentric and concentric muscle contractions and a reliance on the sensory information received from the plantar surface. In this literature review focussing on kinetics, kinematics and posture during gait in DPN patients, we have identified an intimate link between DPN and abnormalities in gait and demonstrated an increased risk in falls for older patients with diabetes. As such, we have identified a need for further research on the role of gait abnormalities in the development of diabetic foot ulceration and subsequent amputations.
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Affiliation(s)
- Uazman Alam
- Diabetes and Endocrinology Research, Department of Eye and Vision Sciences, Institute of Ageing and Chronic Disease, University of Liverpool and Aintree University Hospital NHS Foundation Trust, Liverpool, UK.
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, UK.
| | | | | | - Shazli Azmi
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, UK
| | | | - Kristiaan D'Août
- Evolutionary Morphology and Biomechanics Group, Department of Musculoskeletal Biology, Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Rayaz A Malik
- Division of Diabetes, Endocrinology and Gastroenterology, Institute of Human Development, University of Manchester and the Manchester Royal Infirmary, Central Manchester Hospital Foundation Trust, Manchester, UK
- Weill Cornell Medicine-Qatar, Doha, Qatar
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The Effect of Diabetic Peripheral Neuropathy on Ground Reaction Forces during Straight Walking in Stroke Survivors. Rehabil Res Pract 2017; 2017:5280146. [PMID: 28491477 PMCID: PMC5401715 DOI: 10.1155/2017/5280146] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/23/2017] [Accepted: 03/26/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose. The aim of this present study was to investigate the ground reaction forces (GRFs) alterations in stroke survivors with diabetic peripheral neuropathy (DPN). Methods. Ten stroke survivors with DPN, 10 stroke survivors without DPN, and 10 healthy controls with matched body weight between groups participated in this case-control cross-sectional study. Three-dimensional GRFs (anterior-posterior, medial-lateral, and vertical) were collected at a comfortable walking speed using the Nexus Vicon motion analysis system and force plate. The Kruskal–Wallis test was used to analyze GRFs parameters. Results. We found significant alterations of medial-lateral forces of the nonparetic side and vertical forces of the paretic side in stroke survivors with DPN compared to stroke survivors without DPN and healthy controls. In addition, there were smaller braking and lower propulsion peak in anterior-posterior forces, smaller magnitude of medial-lateral forces, and lower first and second peak of vertical forces in stroke survivors with DPN compared to stroke survivors without DPN and healthy controls. Conclusion. The study findings identified that GRFs were affected in stroke survivors with DPN on both the paretic and the nonparetic sides. Further investigations are warranted to explore the impact of DPN on the kinematics and muscle activity related to the gait performance in stroke survivors with DPN.
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Hazari A, Maiya AG, Shivashankara KN, Agouris I, Monteiro A, Jadhav R, Kumar S, Shashi Kumar CG, Mayya SS. Kinetics and kinematics of diabetic foot in type 2 diabetes mellitus with and without peripheral neuropathy: a systematic review and meta-analysis. SPRINGERPLUS 2016; 5:1819. [PMID: 27812455 PMCID: PMC5071310 DOI: 10.1186/s40064-016-3405-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 09/28/2016] [Indexed: 12/12/2022]
Abstract
Background
Diabetes mellitus patients are at increased risk of developing diabetic foot with peripheral neuropathy, vascular and musculoskeletal complications. Therefore they are prone to develop frequent and often foot problems with a relative high risk of infection, gangrene and amputation. In addition, altered plantar pressure distribution is an important etiopathogenic risk factor for the development of foot ulcers. Thus the review on study of foot kinematic and kinetic in type 2 diabetes mellitus to understand the biomechanical changes is important. Methodology
Scientific articles were obtained using electronic databases including Science Direct, CINAHL, Springer Link, Medline, Web of Science, and Pubmed. The selection was completed after reading the full texts. Studies using experimental design with focus on biomechanics of diabetic foot were selected. Results The meta-analysis report on gait velocity (neuropathy = 128 and non-diabetes = 131) showed that there was a significantly lower gait velocity in neuropathy participants compared to non-diabetes age matched participants at a high effect level (−0.09, 95 % CI −0.13 to 0.05; p < 0.0001). Regarding knee joint flexion range there was a significant difference between neuropathy and non-diabetes group (4.75, 95 % CI, −7.53 to 1.97, p = 0.0008). Conclusions The systematic review with meta-analysis reported significant difference in kinematic and kinetic variables among diabetic with neuropathy, diabetic without neuropathy and non-diabetes individuals. The review also found that the sample size in some studies were not statistically significant to perform the meta-analysis and report a strong conclusion. Therefore a study with higher sample size should be done.
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Affiliation(s)
| | | | | | - Ioannis Agouris
- Sports and clinical Biomechanics, Robert Gordon University, Scotland, UK
| | - Ashma Monteiro
- Department of Statistics, Manipal University, Manipal, India
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Fernando ME, Crowther RG, Lazzarini PA, Sangla KS, Wearing S, Buttner P, Golledge J. Plantar pressures are higher in cases with diabetic foot ulcers compared to controls despite a longer stance phase duration. BMC Endocr Disord 2016; 16:51. [PMID: 27629263 PMCID: PMC5024422 DOI: 10.1186/s12902-016-0131-9] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 09/06/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Current international guidelines advocate achieving at least a 30 % reduction in maximum plantar pressure to reduce the risk of foot ulcers in people with diabetes. However, whether plantar pressures differ in cases with foot ulcers to controls without ulcers is not clear. The aim of this study was to assess if plantar pressures were higher in patients with active plantar diabetic foot ulcers (cases) compared to patients with diabetes without a foot ulcer history (diabetes controls) and people without diabetes or a foot ulcer history (healthy controls). METHODS Twenty-one cases with diabetic foot ulcers, 69 diabetes controls and 56 healthy controls were recruited for this case-control study. Plantar pressures at ten sites on both feet and stance phase duration were measured using a pre-established protocol. Primary outcomes were mean peak plantar pressure, pressure-time integral and stance phase duration. Non-parametric analyses were used with Holm's correction to correct for multiple testing. Binary logistic regression models were used to adjust outcomes for age, sex and body mass index. Median differences with 95 % confidence intervals and Cohen's d values (standardised mean difference) were reported for all significant outcomes. RESULTS The majority of ulcers were located on the plantar surface of the hallux and toes. When adjusted for age, sex and body mass index, the mean peak plantar pressure and pressure-time integral of toes and the mid-foot were significantly higher in cases compared to diabetes and healthy controls (p < 0.05). The stance phase duration was also significantly higher in cases compared to both control groups (p < 0.05). The main limitations of the study were the small number of cases studied and the inability to adjust analyses for multiple factors. CONCLUSIONS This study shows that plantar pressures are higher in cases with active diabetic foot ulcers despite having a longer stance phase duration which would be expected to lower plantar pressure. Whether plantar pressure changes can predict ulcer healing should be the focus of future research. These results highlight the importance of offloading feet during active ulceration in addition to before ulceration.
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Affiliation(s)
- Malindu E. Fernando
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Qld 4814 Australia
- Podiatry Service, Townsville Community Health Service , Townsville, QLD Australia
- Movement Analysis Laboratory, Sport and Exercise Science, James Cook University, Townsville, Australia
| | - Robert G. Crowther
- Sport and Exercise, School of Health and Wellbeing, University of Southern Queensland, Ipswich, QLD Australia
| | - Peter A. Lazzarini
- Allied Health Research Collaborative, Metro North Hospital & Health Service, Queensland Health, Brisbane, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
| | - Kunwarjit S. Sangla
- Department of Diabetes and Endocrinology, The Townsville Hospital, Townsville, QLD Australia
| | - Scott Wearing
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD Australia
| | - Petra Buttner
- Centre for Chronic Disease Prevention, James Cook University, Cairns, QLD Australia
- Tropical Health Solutions Pty Ltd., Townsville, QLD Australia
| | - Jonathan Golledge
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Qld 4814 Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD Australia
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Fernando ME, Crowther RG, Cunningham M, Lazzarini PA, Sangla KS, Golledge J. Lower limb biomechanical characteristics of patients with neuropathic diabetic foot ulcers: the diabetes foot ulcer study protocol. BMC Endocr Disord 2015; 15:59. [PMID: 26499881 PMCID: PMC4619003 DOI: 10.1186/s12902-015-0057-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 10/15/2015] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Foot ulceration is the main precursor to lower limb amputation in patients with type 2 diabetes worldwide. Biomechanical factors have been implicated in the development of foot ulceration; however the association of these factors to ulcer healing remains less clear. It may be hypothesised that abnormalities in temporal spatial parameters (stride to stride measurements), kinematics (joint movements), kinetics (forces on the lower limb) and plantar pressures (pressure placed on the foot during walking) contribute to foot ulcer healing. The primary aim of this study is to establish the biomechanical characteristics (temporal spatial parameters, kinematics, kinetics and plantar pressures) of patients with plantar neuropathic foot ulcers compared to controls without a history of foot ulcers. The secondary aim is to assess the same biomechanical characteristics in patients with foot ulcers and controls over-time to assess whether these characteristics remain the same or change throughout ulcer healing. METHODS/DESIGN The design is a case-control study nested in a six-month longitudinal study. Cases will be participants with active plantar neuropathic foot ulcers (DFU group). Controls will consist of patients with type 2 diabetes (DMC group) and healthy participants (HC group) with no history of foot ulceration. Standardised gait and plantar pressure protocols will be used to collect biomechanical data at baseline, three and six months. Descriptive variables and primary and secondary outcome variables will be compared between the three groups at baseline and follow-up. DISCUSSION It is anticipated that the findings from this longitudinal study will provide important information regarding the biomechanical characteristic of type 2 diabetes patients with neuropathic foot ulcers. We hypothesise that people with foot ulcers will demonstrate a significantly compromised gait pattern (reduced temporal spatial parameters, kinematics and kinetics) at base line and then throughout the follow-up period compared to controls. The study may provide evidence for the design of gait-retraining, neuro-muscular conditioning and other approaches to off-load the limbs of those with foot ulcers in order to reduce the mechanical loading on the foot during gait and promote ulcer healing.
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Affiliation(s)
- Malindu Eranga Fernando
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia.
- Movement analysis Laboratory, Discipline of Sports and Exercise Science, James Cook University, Townsville, Australia.
- Podiatry Service, Kirwan Community Health Campus, Townsville, QLD, Australia.
| | - Robert George Crowther
- Movement analysis Laboratory, Discipline of Sports and Exercise Science, James Cook University, Townsville, Australia.
- Sport and Exercise, School of Health and Wellbeing, University of Southern Queensland, Brisbane, Australia.
| | - Margaret Cunningham
- Department of Health Sciences, University of Stirling, Stirling, Scotland, UK.
| | - Peter Anthony Lazzarini
- Allied Health Research Collaborative, Metro North Hospital & Health Service, Queensland Health, Brisbane, Australia.
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Australia.
| | | | - Jonathan Golledge
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, 4811, Australia.
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, Australia.
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Niklasch M, Wolf SI, Klotz MC, Geisbüsch A, Brunner R, Döderlein L, Dreher T. Factors associated with recurrence after femoral derotation osteotomy in cerebral palsy. Gait Posture 2015; 42:460-5. [PMID: 26276696 DOI: 10.1016/j.gaitpost.2015.07.059] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 07/15/2015] [Accepted: 07/25/2015] [Indexed: 02/02/2023]
Abstract
Femoral derotation osteotomy (FDO) as gold standard treatment for internal rotation gait in cerebral palsy (CP) leads to satisfying short-term results, whereas rates of recurrence up to 33% are reported in long-term outcome studies. The purpose of this study was therefore to identify factors contributing to recurrence of internal rotation gait in patients with CP who were treated with FDO in childhood. 70 patients (age: 10 (± 3.3) years at surgery) with bilateral CP and internal rotation gait were examined pre-, one year and at least five years (mean 8 ± 2 years) postoperatively after distal or proximal FDO, using standardized clinical examination and 3D gait-analysis. 27 patients had a good hip rotation one year postoperatively (between 5° external and 15° internal for both limbs) and were considered for the analysis of factors contributing to recurrence of internal rotation gait. Regarding all included patients both mean hip rotation and foot progression angle improved significantly (p < 0.001) from pre- to postoperative. A significant deterioration in hip rotation (more involved side) (p < 0.001) from one year postoperatively to the long-term follow-up can be observed. Younger age, reduced hip joint impulse, increased plantar flexion and internal foot progression angle postoperatively could be identified as factors for recurrence. FDO on average leads to a satisfactory correction of internal rotation gait. In order to improve the long-term outcome after FDO the time of multilevel surgery should be indicated as late as possible and the different factors leading to potential recurrence should be considered.
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Affiliation(s)
- M Niklasch
- Paediatric Orthopaedics and Foot Surgery, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - S I Wolf
- Paediatric Orthopaedics and Foot Surgery, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - M C Klotz
- Paediatric Orthopaedics and Foot Surgery, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - A Geisbüsch
- Paediatric Orthopaedics and Foot Surgery, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - R Brunner
- Paediatric Orthopaedic Department, University Children's Hospital Basle (UKBB), Basle, Switzerland
| | - L Döderlein
- Orthopaedic Hospital for Children, Behandlungszentrum Aschau, Aschau, Germany
| | - T Dreher
- Paediatric Orthopaedics and Foot Surgery, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany.
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Sacco ICN, Picon AP, Macedo DO, Butugan MK, Watari R, Sartor CD. Alterations in the lower limb joint moments precede the peripheral neuropathy diagnosis in diabetes patients. Diabetes Technol Ther 2015; 17:405-12. [PMID: 25664904 DOI: 10.1089/dia.2014.0284] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Changes in gait patterns in individuals with diabetes and neuropathy are still inconclusive. Our aim was to identify differences in the net intralimb moments distribution and lower limb kinematics during gait in different stage of diabetes. SUBJECTS AND METHODS This was an observational cross-sectional study that assessed 38 adults: a control group (n=12), a group with diabetes (n=12), and a group with diabetic neuropathy (n=14). The flexor and extensor joint moment peaks and kinematics of ankle, knee, and hip angles were compared among groups (by analysis of variance). RESULTS At initial contact, both diabetes groups present more hip flexion and smaller hip extensor moment. During late midstance, hip extension decreases, and flexion moment increases in both diabetes groups. For the same diabetes groups, during push off, the hip is more flexed, and the hip extensor moment decreases. Only for the diabetes group without neuropathy is the knee markedly more flexed, and the extensor moment is higher than in the other groups. At push off, the ankle is less extended in both diabetes groups, but the ankle extensor moment is significantly smaller only in neuropathic subjects. CONCLUSIONS The biomechanical modifications on the gait appeared to be a continuous process that was already revealed in patients without neuropathy. The use of the hip joint as a mechanism of forward progression of the body, instead of using the ankle, was more evident and consistent for the patients with diabetic neuropathy. The knee seems to have a major role in those with diabetes without neuropathy who presented higher extensor moments to support the body during early stance.
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Affiliation(s)
- Isabel C N Sacco
- Physical Therapy, Speech and Occupational Therapy Department, School of Medicine, University of São Paulo , São Paulo, Brazil
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Fawzy OA, Arafa AI, El Wakeel MA, Abdul Kareem SH. Plantar pressure as a risk assessment tool for diabetic foot ulceration in egyptian patients with diabetes. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2014; 7:31-9. [PMID: 25520564 PMCID: PMC4257475 DOI: 10.4137/cmed.s17088] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 10/15/2014] [Accepted: 10/17/2014] [Indexed: 01/12/2023]
Abstract
BACKGROUND Diabetic foot ulceration is a preventable long-term complication of diabetes. In the present study, peak plantar pressures (PPP) and other characteristics were assessed in a group of 100 Egyptian patients with diabetes with or without neuropathy and foot ulcers. The aim was to study the relationship between plantar pressure (PP) and neuropathy with or without ulceration and trying to clarify the utility of pedobarography as an ulceration risk assessment tool in patients with diabetes. SUBJECTS AND METHODS A total of 100 patients having diabetes were selected. All patients had a comprehensive foot evaluation, including assessment for neuropathy using modified neuropathy disability score (MNDS), for peripheral vascular disease using ankle brachial index, and for dynamic foot pressures using the MAT system (Tekscan). The studied patients were grouped into: (1) diabetic control group (DC), which included 37 patients who had diabetes without neuropathy or ulceration and MNDS ≤2; (2) diabetic neuropathy group (DN), which included 33 patients who had diabetes with neuropathy and MNDS >2, without current or a history of ulceration; and (3) diabetic ulcer group (DU), which included 30 patients who had diabetes and current ulceration, seven of those patients also gave a history of ulceration. RESULTS PP parameters were significantly different between the studied groups, namely, forefoot peak plantar pressure (FFPPP), rearfoot peak plantar pressure (RFPPP), forefoot/rearfoot ratio (F/R), forefoot peak pressure gradient (FFPPG) rearfoot peak pressure gradient (RFPPG), and forefoot peak pressure gradient/rearfoot peak pressure gradient (FFPPG/RFPPG) (P < 0.05). FFPPP and F/R were significantly higher in the DU group compared to the DN and DC groups (P < 0.05), with no significant difference between DN and DC. FFPPG was significantly higher in the DU and DN groups compared to the DC group (P < 0.05). RFPPP and FFPPG/RFPPG were significantly higher in the DU and DN groups compared to the DC group (P < 0.05) with no significant difference between the DN and DU groups (P > 0.05). FFPPP, F/R ratio, FFPPG, and FFPPG/RFPPG correlated significantly with the severity of neuropathy according to MNDS (P < 0.05). These same variables as well as MNDS were also significantly higher in patients with foot deformity compared to those without deformity (P < 0.05). Using the receiver operating characteristic analysis, the optimal cut-point of PPP for ulceration risk, as determined by a balance of sensitivity, specificity, and accuracy was 335 kPa and was found at the forefoot. Multivariate logistical regression analysis for ulceration risk was statistically significant for duration of diabetes (odds ratio [OR] = 0.8), smoking (OR = 9.7), foot deformity (OR = 8.7), MNDS (OR = 1.5), 2-h postprandial plasma glucose (2 h-PPG) (OR = 0.9), glycated hemoglobin (HbA1c) (OR = 2.1), FFPPP (OR = 1.0), and FFPPG (OR = 1.0). CONCLUSION In conclusion, persons with diabetes having neuropathy and/or ulcers have elevated PPP. Risk of ulceration was highly associated with duration of diabetes, smoking, severity of neuropathy, glycemic control, and high PP variables especially the FFPPP, F/R, and FFPPG. We suggest a cut-point of 355 kPa for FFPPP to denote high risk for ulceration that would be more valid when used in conjunction with other contributory risk factors, namely, duration of diabetes, smoking, glycemic load, foot deformity, and severity of neuropathy.
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Affiliation(s)
- Olfat A Fawzy
- Department of Endocrinology & Metabolism, AL Azhar Faculty of Medicine for Girls, Cairo, Egypt
| | - Asmaa I Arafa
- Department of Endocrinology & Metabolism, AL Azhar Faculty of Medicine for Girls, Cairo, Egypt
| | - Mervat A El Wakeel
- Department of Endocrinology & Metabolism, AL Azhar Faculty of Medicine for Girls, Cairo, Egypt
| | - Shaimaa H Abdul Kareem
- Department of Endocrinology & Metabolism, AL Azhar Faculty of Medicine for Girls, Cairo, Egypt
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Francia P, Gulisano M, Anichini R, Seghieri G. Diabetic foot and exercise therapy: step by step the role of rigid posture and biomechanics treatment. Curr Diabetes Rev 2014; 10:86-99. [PMID: 24807636 PMCID: PMC5750747 DOI: 10.2174/1573399810666140507112536] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/02/2014] [Accepted: 05/05/2014] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
| | | | | | - Giuseppe Seghieri
- Department of Experimental and Clinical Medicine, University of Florence, Largo Brambilla, 3 - 50134 Florence, Italy.
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Melai T, Schaper NC, Ijzerman TH, de Lange TL, Willems PJ, Lima Passos V, Lieverse AG, Meijer K, Savelberg HH. Lower leg muscle strengthening does not redistribute plantar load in diabetic polyneuropathy: a randomised controlled trial. J Foot Ankle Res 2013; 6:41. [PMID: 24138784 PMCID: PMC4015645 DOI: 10.1186/1757-1146-6-41] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 09/19/2013] [Indexed: 11/30/2022] Open
Abstract
Background Higher plantar pressures play an important role in the development of plantar foot ulceration in diabetic polyneuropathy and earlier studies suggest that higher pressures under the forefoot may be related to a decrease in lower leg muscle strength. Therefore, in this randomised controlled trial we evaluated whether lower-extremity strength training can reduce plantar pressures in diabetic polyneuropathy. Methods This study was embedded in an unblinded randomised controlled trial. Participants had diabetes and polyneuropathy and were randomly assigned to the intervention group (n = 48) receiving strength training during 24 weeks, or the control group (n = 46) receiving no intervention. Plantar pressures were measured in both groups at 0, 12, 24 and 52 weeks. A random intercept model was applied to evaluate the effects of the intervention on peak pressures and pressure–time-integrals, displacement of center-of-pressure and the forefoot to rearfoot pressure–time-integral-ratio. Results Plantar pressure patterns were not affected by the strength training. In both the intervention and control groups the peak pressure and the pressure–time-integral under the forefoot increased by 55.7 kPa (95% CI: 14.7, 96.8) and 2.0 kPa.s (95% CI: 0.9, 3.2) over 52 weeks, respectively. Both groups experienced a high number of drop-outs, mainly due to deterioration of health status and lower-extremity disabilities. Conclusions Plantar pressures under the forefoot increase progressively over time in people with diabetic polyneuropathy, but in this study were not affected by strength training. Future intervention studies should take this increase of plantar pressure into account and alternative interventions should be developed to reduce the progressive lower extremity problems in these patients. Trial registration This study was embedded in a clinical trial with trial number NCT00759265.
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Affiliation(s)
- Tom Melai
- Department of Human Movement Sciences, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre, Maastricht, The Netherlands.
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Fernando M, Crowther R, Lazzarini P, Sangla K, Cunningham M, Buttner P, Golledge J. Biomechanical characteristics of peripheral diabetic neuropathy: A systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure. Clin Biomech (Bristol, Avon) 2013; 28:831-45. [PMID: 24035444 DOI: 10.1016/j.clinbiomech.2013.08.004] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2013] [Revised: 08/08/2013] [Accepted: 08/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diabetic peripheral neuropathy is an important cause of foot ulceration and limb loss. This systematic review and meta-analysis investigated the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and dynamic plantar pressures. METHODS Electronic databases were searched systematically for articles reporting the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and plantar pressures. Searches were restricted to articles published between January 2000 and April 2012. Outcome measures assessed included spatiotemporal parameters, lower limb kinematics, kinetics, muscle activation and plantar pressure. Meta-analyses were carried out on all outcome measures reported by ≥3 studies. FINDINGS Sixteen studies were included consisting of 382 neuropathy participants, 216 diabetes controls without neuropathy and 207 healthy controls. Meta-analysis was performed on 11 gait variables. A high level of heterogeneity was noted between studies. Meta-analysis results suggested a longer stance time and moderately higher plantar pressures in diabetic peripheral neuropathy patients at the rearfoot, midfoot and forefoot compared to controls. Systematic review of studies suggested potential differences in the biomechanical characteristics (kinematics, kinetics, EMG) of diabetic neuropathy patients. However these findings were inconsistent and limited by small sample sizes. INTERPRETATION Current evidence suggests that patients with diabetic peripheral neuropathy have elevated plantar pressures and occupy a longer duration of time in the stance-phase during gait. Firm conclusions are hampered by the heterogeneity and small sample sizes of available studies.
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Affiliation(s)
- Malindu Fernando
- Vascular Biology Unit, Queensland Research Centre for Peripheral Vascular Disease, School of Medicine and Dentistry, James Cook University, Townsville, Australia; Movement Analysis Laboratory, Institute of Sports and Exercise Science, James Cook University, Townsville, Australia.
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25
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Strength training affects lower extremity gait kinematics, not kinetics, in people with diabetic polyneuropathy. J Appl Biomech 2013; 30:221-30. [PMID: 24042012 DOI: 10.1123/jab.2013-0186] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Increased forefoot loading in diabetic polyneuropathy plays an important role in the development of plantar foot ulcers and can originate from alterations in muscle strength, joint moments and gait pattern. The current study evaluated whether strength training can improve lower extremity joint moments and spatiotemporal gait characteristics in patients with diabetic polyneuropathy. An intervention group receiving strength training during 24 weeks and a control group receiving no intervention. Measurements were performed in both groups at t=0, t=12, t=24 and t=52 weeks at an individually preferred and standardized imposed gait velocity. The strength training did not affect the maximal amplitude of hip, knee and ankle joint moments, but did result in an increase in stance phase duration, stride time and stride length of approximately 5%, during the imposed gait velocity. In addition, both groups increased their preferred gait velocity over one year. Future longitudinal studies should further explore the possible effects of strength training on spatiotemporal gait characteristics. The current study provides valuable information on changes in gait velocities and the progressive lower extremity problems in patients with polyneuropathy.
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Melai T, Schaper NC, Ijzerman TH, de Lange TLH, Willems PJB, Meijer K, Lieverse AG, Savelberg HHCM. Increased forefoot loading is associated with an increased plantar flexion moment. Hum Mov Sci 2013; 32:785-93. [PMID: 23958476 DOI: 10.1016/j.humov.2013.05.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2012] [Revised: 02/21/2013] [Accepted: 05/01/2013] [Indexed: 10/26/2022]
Abstract
The aim of this study was to identify the cascade of effects leading from alterations in force generation around the ankle joint to increased plantar pressures under the forefoot. Gait analysis including plantar pressure measurement was performed at an individually preferred and a standardized, imposed gait velocity in diabetic subjects with polyneuropathy (n=94), without polyneuropathy (n=39) and healthy elderly (n=19). The plantar flexion moment at 40% of the stance phase was negatively correlated with the displacement rate of center of pressure (r=-.749, p<.001 at the imposed, and r=-.693, p<.001 at the preferred gait velocity). Displacement rate of center of pressure was strongly correlated with forefoot loading (r=-.837, p<.001 at the imposed, and r=-.731, p<.001 at the preferred gait velocity). People with a relatively high plantar flexion moment at 40% of the stance phase, have a faster forward transfer of center of pressure and consequently higher loading of the forefoot. This indicates that interventions aimed at increasing the control of the roll-off of the foot may contribute to a better plantar pressure distribution.
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Affiliation(s)
- Tom Melai
- Department of Health Innovation & Technology, Institute of Allied Health Professions, Fontys University of Applied Sciences, Eindhoven, The Netherlands; Department of Human Movement Sciences, NUTRIM School for Nutrition, Toxicology and Metabolism, Maastricht University Medical Centre+, Maastricht, The Netherlands
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27
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Reduced plantar cutaneous sensation modifies gait dynamics, lower-limb kinematics and muscle activity during walking. Eur J Appl Physiol 2012; 112:3829-38. [PMID: 22391682 DOI: 10.1007/s00421-012-2364-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 02/20/2012] [Indexed: 10/28/2022]
Abstract
Peripheral neuropathy is the most common long-term complication in diabetes and is involved in changes in diabetic gait and posture. The regression of nerve function leads to various deficits in the sensory and motor systems, impairing afferent and efferent pathways in the lower extremities. This study aimed to examine how reduced plantar-afferent feedback impacts the gait pattern. Cutaneous sensation in the soles of both feet was experimentally reduced by means of intradermal injections of an anaesthetic solution, without affecting foot proprioception or muscles. Ten subjects performed level walking at a controlled velocity before and after plantar anaesthesia. Muscle activity of five leg-muscles, co-contraction ratios for the knee and ankle joint, ground reaction forces (GRF), spatiotemporal characteristics, joint angles and moments of the hip, knee and ankle were analysed. The intervention significantly lowered plantar sensation, reducing it to the level of sensory neuropathy. Spatiotemporal gait characteristics remained unchanged. The ankle joint was more dorsiflexed which coincided with increased tibialis anterior and decreased gastrocnemius medialis muscle activity during foot flat to mid-stance. In addition, the knee joint was more flexed accompanied by increased biceps femoris activity and higher internal knee-extension moment. With regard to gait dynamics, a delay of the first peak of the vertical GRF was observed. Increased soleus and tibialis anterior muscle activity were found during the end of stance. Short-term loss of plantar sensation affects lower-limb kinematics and gait dynamics, particularly during the first half of stance, and contributes to modified muscle-activation patterns during locomotion.
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28
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El Boghdady NA, Badr GA. Evaluation of oxidative stress markers and vascular risk factors in patients with diabetic peripheral neuropathy. Cell Biochem Funct 2012; 30:328-34. [DOI: 10.1002/cbf.2808] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 01/13/2012] [Accepted: 01/18/2012] [Indexed: 12/22/2022]
Affiliation(s)
| | - Gamal Ali Badr
- Faculty of Medicine, Department of Internal Medicine; Al Azhar University; Cairo; Egypt
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Abstract
Neuropathy is a frequent complication in diabetes and most commonly seen as distal symmetrical sensorimotor polyneuropathy (PN). Involvement of the motor system is infrequently seen at the clinical examination. However, with the application of quantitative techniques, that is, isokinetic dynamometry, type 1 and type 2 diabetic patients have been detected to have weakness at the ankle and the knee. Muscle weakness is found only in diabetic patients with PN, while non-neuropathic patients even with long-term diabetes have normal strength. The weakness is closely related to signs and severity of PN. With the use of magnetic resonance imaging, muscle weakness is found to be paralleled by muscular atrophy, which is observed in the feet and at the lower leg. Following diabetic patients for 8-10 years, we have observed accelerated loss of muscle strength in patients with symptomatic PN; similarly, accelerated loss of muscle mass is observed in the feet and lower legs. In large-scale studies of diabetic and non-diabetic subjects, lower muscle quality in diabetic patients is also found. Thus, in addition to PN, diabetes per se leads to lower strength per unit striated muscle. Muscle weakness is related to the slowing of movements, unstable gait, and more frequent falls. Furthermore, motor dysfunction leads to an increased risk of developing a foot ulcer due to due to alterations of the biomechanics of the feet caused by muscle atrophy. This may lead to an increased skin pressure that may lead to foot ulceration and ultimately amputation. Muscle and balance training may improve strength, postural stability, and walking performance; however, this needs to be studied in more detail.
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Affiliation(s)
- Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus C, Denmark.
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30
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Allet L, IJzerman H, Meijer K, Willems P, Savelberg H. The influence of stride-length on plantar foot-pressures and joint moments. Gait Posture 2011; 34:300-6. [PMID: 21700463 DOI: 10.1016/j.gaitpost.2011.05.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 05/18/2011] [Accepted: 05/22/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE Joint moments have been acknowledged as key factors in understanding gait abnormalities. Gait velocity is further known to affect joint moments and foot pressures. Keeping gait velocity constant is thus a strategy to cancel out the influence of different preferred gait speed between groups. But even if gait velocity is controlled, individuals can choose different stride length-stride frequency combinations to cope with an imposed gait velocity. SCOPE To understand the influence of stride frequency-stride length on joint moments and plantar pressures. METHODS Twenty healthy young adults had to cross an 8m walkway with a walking speed of 1.3ms(-1). The wooden walkway was equipped with a force and a pressure platform. While walking speed was kept constant each participant walked with five different imposed stride lengths (SL): preferred (SL0); with a decrease of 10% (SL-10); with a decrease of 20% (SL-20); with an increase of 10% (SL+10) and with an increase of 20% (SF+20). RESULTS Ankle and knee joint moments significantly decreased with a decrease in SL. A significant (p<.05) lower peak pressure was achieved with a decreased SL under the heel, toes and midfoot. DISCUSSION/CONCLUSION The results showed that a change in stride lengths alters both, joint moments and foot pressures with clinically interesting indications. Redistribution of joint moments in the elderly for example might rather result from decreased SL than from age.
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Affiliation(s)
- Lara Allet
- Department of Human Movement Sciences, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands.
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31
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Hirata RP, Arendt-Nielsen L, Graven-Nielsen T. Experimental calf muscle pain attenuates the postural stability during quiet stance and perturbation. Clin Biomech (Bristol, Avon) 2010; 25:931-7. [PMID: 20692746 DOI: 10.1016/j.clinbiomech.2010.06.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 04/23/2010] [Accepted: 06/02/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate how acute pain changes the postural control and stability during quiet standing and after unexpected perturbations. METHODS Nine subjects stood as quiet as possible on a movable force platform that recorded the centre of pressure position and provided unexpected floor perturbations, before, during and after experimental calf muscle pain. Bilateral surface electromyography from the tibialis anterior and medial gastrocnemius muscles was recorded. The foot pressure distributions were measured using pressure insoles. Intramuscular injections of hypertonic saline were administrated (right leg) to induce acute pain in the tibialis anterior and/or medial gastrocnemius muscles, and an isotonic injection was used as control. FINDINGS Simultaneous pain in tibialis anterior and medial gastrocnemius altered the postural control. During quiet standing: higher medial-lateral centre of pressure speed and increased total sway displacement (P<0.05), weight moved to the non-painful side, (P<0.05) and plantar centre of pressure of the left foot was shifted towards the heel's direction (P<0.05). During forward perturbation: higher mean displacement in the medial-lateral direction (P<0.05). After the perturbation: larger sway area (P<0.05). Pain only in the medial gastrocnemius muscle increased medial-lateral centre of pressure speed (P<0.05) during the quiet standing. Pain only in the tibialis anterior muscle increased peak pressure on the contralateral foot (P<0.05). INTERPRETATION These findings suggest that large acute painful areas on the calf muscles impair the postural control and potentially increase the risk factors for falls. Further strategies aiming to reduce pain in patients may lead to improvement in balance.
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Affiliation(s)
- Rogério Pessoto Hirata
- Center for Sensory-Motor Interaction, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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32
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Allet L, Armand S, Aminian K, Pataky Z, Golay A, de Bie RA, de Bruin ED. An exercise intervention to improve diabetic patients' gait in a real-life environment. Gait Posture 2010; 32:185-90. [PMID: 20471273 DOI: 10.1016/j.gaitpost.2010.04.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Revised: 03/19/2010] [Accepted: 04/15/2010] [Indexed: 02/02/2023]
Abstract
AIMS Gait characteristics and balance are altered in diabetic individuals. Little is known about possible treatment strategies. This study evaluated the effect of a specific training program on diabetic patients' gait. METHODS A randomized controlled trial (N=71) with an intervention (IG) (N=35), and control group (CG) (N=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-oriented strengthening. Controls received no treatment. RESULTS After intervention the IG increased their habitual walking speed by 0.149ms(-1) (0.54kmh(-1)) on tarred terrain and by 0.169ms(-1) (0.61kmh(-1)) on the cobblestones. This significant treatment effect (p<0.001) decreased slightly at the six-month follow-up, but remained significant (p<0.001). In a similar manner, significant improvement was observed for cadence, gait cycle time and stance time on both terrains. All outcomes except stance time on the tarred terrain remained significant at the six-month follow-up. No significant effect was observed for stride length and the coefficient of variation of gait cycle time (on either surface) at the corrected significance level of p<0.004. CG patients' parameters all remained unchanged or progressively deteriorated compared to baseline values. DISCUSSION Cadence contributed 80%, whereas stride length only contributed 20% to the change of gait velocity. This may be due to the treatment or to diabetic patients' potential to regulate their cadence and stride length. CONCLUSION A specific training program can improve diabetic patients' gait in a real life environment. A challenging environment highlights treatment effects on patients' gait better than an evenly tarred surface.
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Affiliation(s)
- L Allet
- Care Services Directorate, Unit of Physiotherapy Research and Quality Assurance, Geneva University Hospital and University of Geneva, 1211 Geneva, Switzerland.
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Savelberg HHCM, Ilgin D, Angin S, Willems PJB, Schaper NC, Meijer K. Prolonged activity of knee extensors and dorsal flexors is associated with adaptations in gait in diabetes and diabetic polyneuropathy. Clin Biomech (Bristol, Avon) 2010; 25:468-75. [PMID: 20207058 DOI: 10.1016/j.clinbiomech.2010.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 02/05/2010] [Accepted: 02/09/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND People with diabetes or diabetic polyneuropathy often experience limitations in mobility and gait. These limitations are believed to be related to disturbed muscle function and sensory information. In previous studies on diabetic gait, results were confounded by a lower, preferred walking speed in people with diabetes or diabetic polyneuropathy. This study aimed to identify gait-velocity independent effects of diabetes and diabetic polyneuropathy on lower extremity kinematics and muscle activation patterns. METHODS Eight people with diabetic polyneuropathy, 10 diabetic controls without polyneuropathy and ten healthy, age-matched controls walked at their preferred velocity and a standard velocity of 1.4 ms(-1). Muscle activation patterns of gluteus maximus, biceps femoris, rectus femoris, vastus medialis, gastrocnemius medialis, soleus, and tibialis anterior, and spatiotemporal and joint angles characteristics were analysed. FINDINGS Independent of walking speed, muscle activation differed between groups. In diabetic polyneuropathy participants activation of ankle-joint dorsal flexors was prolonged by 5-10% of the stride cycle. Activity of monoarticular knee-joint extensors lasted about 10% longer in both diabetic groups compared to healthy elderly. Initiation of muscle activity did not differ between groups. If gait velocity was controlled, spatiotemporal characteristics were similar between groups. INTERPRETATION The study showed that independent of the preferred lower gait velocity, people with diabetes or diabetic polyneuropathy adjust the timing of muscle activity. Contrarily, the concurrent changes in spatiotemporal characteristics occurred to be the result of changed velocity only. The delayed cessation of muscle activity suggested a reduced rate of force development underlying the adjusted timing of muscle activation.
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Affiliation(s)
- Hans H C M Savelberg
- Department of Human Movement Sciences, Nutrition and Toxicology Research Institute Maastricht, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands.
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Kamboj SS, Vasishta RK, Sandhir R. N-acetylcysteine inhibits hyperglycemia-induced oxidative stress and apoptosis markers in diabetic neuropathy. J Neurochem 2009; 112:77-91. [PMID: 19840221 DOI: 10.1111/j.1471-4159.2009.06435.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Several studies have indicated the involvement of oxidative stress in the development of diabetic neuropathy. In the present study, we have targeted oxidative stress mediated nerve damage in diabetic neuropathy using N-acetyl-l-cysteine (NAC), a potent antioxidant. After 8 weeks, streptozotocin-induced diabetic rats developed neuropathy which was evident from decreased tail-flick latency (thermal hyperalgesia). This was accompanied by decreased motor coordination as assessed by performance on rota-rod treadmill. Na(+) K(+) ATPase, a biochemical marker of development of diabetic neuropathy, was significantly inhibited in sciatic nerve of diabetic animals. NAC treatment at a daily dose between 1.4 and 1.5 g/kg body weight to diabetic animals for 7 weeks in drinking water ameliorated hyperalgesia, improved motor coordination and reversed reduction in Na(+) K(+) ATPase activity. There was an increase in lipid peroxidation in sciatic nerve of diabetic animals along with decrease in phospholipid levels, while NAC treatment attenuated lipid peroxidation and restored phospholipids to control levels. This was associated with decrease in glutathione and protein thiols. The activities of antioxidant enzymes; superoxide dismutase, catalase, glutathione reductase, glutathione peroxidase and glutathione-S-transferase were reduced in sciatic nerve of diabetic animals. Cytochrome c release and active caspase 3 were markedly increased in nerve from diabetic animals suggesting activation of apoptotic pathway. NAC treatment significantly ameliorated decrease in antioxidant defense and prevented cytochrome c release and caspase 3 activation. Electron microscopy revealed demyelination, Wallerian degeneration and onion-bulb formation in sciatic nerve of diabetic rats. NAC on the other hand was able to reverse structural deficits observed in sciatic nerve of diabetic rats. Our results clearly demonstrate protective effect of NAC is mediated through attenuation of oxidative stress and apoptosis, and suggest therapeutic potential of NAC in attenuation of diabetic neuropathy.
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Affiliation(s)
- Sukhdev Singh Kamboj
- Department of Biochemistry, Basic Medical Science Block, Panjab University, Chandigarh, India
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