Intralimb Coordination Patterns in Absent, Mild, and Severe Stages of Diabetic Neuropathy: Looking Beyond Kinematic Analysis of Gait Cycle

NONAN GaitPrint: An IMU gait database of healthy young adults

An ongoing thrust of research focused on human gait pertains to identifying individuals based on gait patterns. However, no existing gait database supports modeling efforts to assess gait patterns unique to individuals. Hence, we introduce the Nonlinear Analysis Core (NONAN) GaitPrint database containing whole body kinematics and foot placement during self-paced overground walking on a 200-meter looping indoor track. Noraxon Ultium MotionTM inertial measurement unit (IMU) sensors sampled the motion of 35 healthy young adults (19-35 years old; 18 men and 17 women; mean ± 1 s.d. age: 24.6 ± 2.7 years; height: 1.73 ± 0.78 m; body mass: 72.44 ± 15.04 kg) over 18 4-min trials across two days. Continuous variables include acceleration, velocity, position, and the acceleration, velocity, position, orientation, and rotational velocity of each corresponding body segment, and the angle of each respective joint. The discrete variables include an exhaustive set of gait parameters derived from the spatiotemporal dynamics of foot placement. We technically validate our data using continuous relative phase, Lyapunov exponent, and Hurst exponent-nonlinear metrics quantifying different aspects of healthy human gait.

Method for Assessing the Motor Coordination of Runners Based on the Analysis of Multichannel EMGs

In this paper, we propose a method to evaluate the motor coordination of runners based on the analysis of amplitude and spatiotemporal dynamics of multichannel electromyography. A new diagnostic index for the coordination of runners was proposed, including the amplitude of electromyography, the spatiotemporal stability coefficient, and the symmetry coefficient of muscle force. The motor coordination of 13 professional runners was studied. Detailed anthropometric information was recorded about the professional runners. It has been found that professional athletes are characterized by the stability of movement repetition (more than 83%) and the high degree of symmetry of muscle efforts of the left and right legs (more than 81%) regardless of the changes in load during running at a speed of 8-12 km/hr. Scientific and technological means can support the scientific training of athletes. The end of the Winter Olympic Games has shown us the powerful power of a series of intelligent scientific equipment, including electro-magnetic gun, in sports training. We also look forward to the continuous innovation of these advanced technologies, which will contribute to the intelligent development of sports scientific research.

Effect of Partial Foot Amputation Level on Gait Independence in Patients With Chronic Lower Extremity Wounds: A Retrospective Analysis of a Japanese Multicenter Database

Partial foot amputation (PFA) is generally planned to minimize the amputation level; nonetheless, the effect of PFA levels on gait independence in amputees remains unclear. This study aimed to investigate the impact of PFA levels of the forefoot on gait independence in patients with chronic lower extremity (LE) wounds. This multicenter retrospective cohort study included 232 hospitalized Japanese patients treated and rehabilitated for chronic LE wounds. A multivariate analysis based on PFA levels was conducted for gait independence at discharge, with age and comorbidities as independent variables. Patients with Lisfranc amputation had significantly less independent gait than patients with more distal amputation and those without amputation (<22% vs >40%; P = .027; Fisher's exact test). Logistic regression analysis revealed that Lisfranc amputation (odds ratio [OR]: 0.257, P = .047), age (OR: 0.559, P = .043), and chronic limb-threatening ischemia (OR: 0.450, P = .010) were independent factors associated with gait independence. Additionally, the regression model confirmed discrimination performance using the C index (0.691, P < .001) with receiver operating characteristic analysis. In patients with chronic LE wounds undergoing PFA, Lisfranc amputation was negatively associated with gait independence.

Changes in Coordination and Its Variability with an Increase in Functional Performance of the Lower Extremities

Clinical gait analysis has a long-standing tradition in biomechanics. However, the use of kinematic data or segment coordination has not been reported based on wearable sensors in "real-life" environments. In this work, the skeletal kinematics of 21 healthy and 24 neurogeriatric participants was collected in a magnetically disturbed environment with inertial measurement units (IMUs) using an accelerometer-based functional calibration method. The system consists of seven IMUs attached to the lower back, the thighs, the shanks, and the feet to acquire and process the raw sensor data. The Short Physical Performance Battery (SPPB) test was performed to relate joint kinematics and segment coordination to the overall SPPB score. Participants were then divided into three subgroups based on low (0-6), moderate (7-9), or high (10-12) SPPB scores. The main finding of this study is that most IMU-based parameters significantly correlated with the SPPB score and the parameters significantly differed between the SPPB subgroups. Lower limb range of motion and joint segment coordination correlated positively with the SPPB score, and the segment coordination variability correlated negatively. The results suggest that segment coordination impairments become more pronounced with a decreasing SPPB score, indicating that participants with low overall SPPB scores produce a peculiar inconsistent walking pattern to counteract lower extremity impairment in strength, balance, and mobility. Our findings confirm the usefulness of SPPB through objectively measured parameters, which may be relevant for the design of future studies and clinical routines.

A vicious cycle: employment challenges associated with diabetes foot ulcers in an economically marginalized Southwest US sample

Aim

To describe patients' reported employment challenges associated with diabetic foot ulcers (DFUs).

Methods

Fifteen patients from under-resourced communities in Southern Arizona, with a history of DFUs and/or amputations, were recruited from a tertiary referral center from June 2020 to February 2021. Participants consented to an audio-recorded semi-structured phone interview. Interviews were transcribed and thematically analyzed using the Dedoose data analysis platform.

Results

Participants shared a common theme around the cyclic challenges of DFU prevention/management and employment. Those employed in manual labor-intensive jobs or jobs requiring them to be on their feet for long durations of time believed working conditions contributed to the development of their DFUs. Patients reported work incapacity due to declines in mobility and the need to offload for DFU management. Many expressed frustration and emotional distress related to these challenges noting that DFUs resulted in lower remuneration as medical expenses increased. Consequently, loss of income and/or medical insurance often hindered participants' ability to manage DFUs and subsequent complications.

Conclusion

These data illuminate the vicious cycle of DFU and employment challenges that must be addressed through patient-centered prevention strategies. Healthcare providers should consider a person's contextual factors such as employment type to tailor treatment approaches. Employers should establish inclusive policies that support patients with DFUs returning to work through flexible working hours and adapted work tasks as needed. Policymakers can also mitigate employment challenges by implementing social programs that provide resources for employees who are unable to return to work in their former capacity.

An Analysis of Lower Limb Coordination Variability in Unilateral Tasks in Healthy Adults: A Possible Prognostic Tool

Interlimb coordination variability analysis can shed light into the dynamics of higher order coordination and motor control. However, it is not clear how the interlimb coordination of people with no known injuries change in similar activities with increasing difficulty. This study aimed to ascertain if the interlimb coordination variability range and patterns of healthy participants change in different unilateral functional tasks with increasing complexity and whether leg dominance affects the interlimb coordination variability. In this cross-sectional study fourteen younger participants with no known injuries completed three repeated unilateral sit-to-stands (UniSTS), step-ups (SUs), and continuous-hops (Hops). Using four inertial sensors mounted on the lower legs and thighs, angular rotation of thighs and shanks were recorded. Using Hilbert transform, the phase angle of each segment and then the continuous relative phase (CRP) of the two segments were measured. The CRP is indicative of the interlimb coordination. Finally, the linear and the nonlinear shank-thigh coordination variability of each participant in each task was calculated. The results show that the linear shank-thigh coordination variability was significantly smaller in the SUs compared to both UniSTS and Hops in both legs. There were no significant differences found between the latter two tests in their linear coordination variability. However, Hops were found to have significantly larger nonlinear shank-thigh coordination variability compared to the SUs and the UniSTS. This can be due to larger vertical and horizontal forces required for the task and can reveal inadequate motor control during the movement. The combination of nonlinear and linear interlimb coordination variability can provide more insight into human movement as they measure different aspects of coordination variability. It was also seen that leg dominance does not affect the lower limb coordination variability in participants with no known injuries. The results should be tested in participants recovering from lower limb injuries.

Measuring Kinematic Response to Perturbed Locomotion in Young Adults

Daily life activities often require humans to perform locomotion in challenging scenarios. In this context, this study aimed at investigating the effects induced by anterior-posterior (AP) and medio-lateral (ML) perturbations on walking. Through this aim, the experimental protocol involved 12 participants who performed three tasks on a treadmill consisting of one unperturbed and two perturbed walking tests. Inertial measurement units were used to gather lower limb kinematics. Parameters related to joint angles, as the range of motion (ROM) and its variability (CoV), as well as the inter-joint coordination in terms of continuous relative phase (CRP) were computed. The AP perturbation seemed to be more challenging causing differences with respect to normal walking in both the variability of the ROM and the CRP amplitude and variability. As ML, only the ankle showed different behavior in terms of joint angle and CRP variability. In both tasks, a shortening of the stance was found. The findings should be considered when implementing perturbed rehabilitative protocols for falling reduction.

PORTRAIT AND HILBERT TRANSFORM METHODS FOR EVALUATING CONTINUOUS RELATIVE PHASE BETWEEN LOWER-LIMB JOINTS IN THE ELDERLY DURING WALKING

In order to calculate the continuous relative phase (CRP) between joints, the portrait method based on the joint angle and angular velocity and the Hilbert transform method based on the analytical signal have been widely used. However, there are few comparisons of these methods. Therefore, the aim of this study is to quantitatively compare these methods by calculating the CRP in the lower-limb joints of the elderly during level free walking. Eighteen elderly female adults ([Formula: see text] year-old, [Formula: see text][Formula: see text]cm, [Formula: see text][Formula: see text]kg) wearing a Helen Hayes full-body marker set walked 10[Formula: see text]m on level ground at a self-selected velocity. The angles of the hip, knee, and ankle were measured. To calculate the CRP using the portrait method, the angular velocities were measured. Then, the phases between the angle and the angular velocity were calculated. To calculate the CRP using the Hilbert transform method, analytical signals were acquired. Then, the phases between the real and imaginary parts were calculated. A CRP was calculated as the difference between the phase in the proximal joint and the phase in the distal joint. To evaluate the similarity in the shape between the portrait and Hilbert transform methods, the cross-correlation was calculated. Bland–Altman plot analyses were performed to assess the agreement between these methods. For the root mean squares (RMSs) and standard deviations (SDs), a paired [Formula: see text]-test and the Pearson correlation between methods were evaluated. There were similarities in the in-phase or out-of-phase features and in the RMS and SD between the methods. Additionally, a higher cross-correlation and agreement between them were found. These results indicated the similarity between the portrait and Hilbert transform methods for the calculation of the CRP. Therefore, either method can be used to evaluate joint coordination.

The Association of Diabetes With Knee Pain Locations, Pain While Walking, and Walking Speed: Data From the Osteoarthritis Initiative

OBJECTIVE

Osteoarthritis (OA) and diabetes mellitus (DM) often coexist and can result in negative outcomes. DM can affect pain and walking speed in people with knee OA; however, the impact of DM on OA is understudied. The purpose of this study was to investigate the association between diabetes and knee pain locations, pain severity while walking, and walking speed in people with knee OA.

METHODS

A cross-sectional analysis was used. Data from 1790 individuals from the Osteoarthritis Initiative (mean [SD] age = 69 [8.7] years) with knee pain were included and grouped into knee OA and diabetes (n = 236) or knee OA only (n = 1554). Knee pain locations were categorized as no pain, localized pain, regional pain, or diffuse pain. Knee pain during a 20-m walk test was categorized as no pain, mild, moderate, or severe knee pain. Walking speed was measured using the 20-m walk test. Multinomial and linear regression analyses were performed.

RESULTS

Diabetes was associated with regional knee pain (odds ratio [OR] = 1.77; 95% CI = 1.01-3.11). Diabetes was associated only with moderate (OR = 1.78; 95% CI = 1.02-3.10) or severe (OR = 2.52; 95% CI = 1.01-6.28) pain while walking. Diabetes was associated with decreased walking speed (B = -0.064; 95% CI = -0.09 to -0.03).

CONCLUSIONS

Diabetes was associated with regional knee pain but not with localized or diffuse knee pain and was associated with moderate to severe knee pain while walking and slower walking speed in people with knee OA.

IMPACT

Clinicians can use a knee pain map for examining knee pain locations for people with diabetes and knee OA. Knee pain during walking and walking speed should be screened for people with knee OA and diabetes because of the influence of diabetes on these parameters in this population.

LAY SUMMARY

Diabetes might be associated with specific knee pain locations, pain during activities such as walking, and reduced walking speed in people with knee OA.

Clustering classification of diabetic walking abnormalities: a new approach taking into account intralimb coordination patterns

BACKGROUND

It is well recognized that diabetes and peripheral neuropathy have a detrimental effect on gait. However, there are large variations in the results of studies addressing this aspect due to the heterogeneity of diabetic population in relation to presence and severity of diabetes complications. The aim of this study is to adopt an unsupervised classification technique to better elucidate the gait changes throughout the entire spectrum of diabetes and neuropathy.

METHODS

Sixty subjects were assessed and classified into four groups using a fuzzy logic model: 13 controls (55 ± 7years), 18 diabetics subjects without neuropathy (59 ± 6 years, 11 ± 7 diabetes years), 7 with mild neuropathy (56 ± 4years, 19 ± 7 diabetes years), and 22 with moderate to severe neuropathy (57 ± 5 years, 14 ± 8 diabetes years). Data were gathered by six infrared cameras at 100 Hz regarding lower limb joint kinematics (angles and angular velocities) and the relative phase for the hip-ankle, hip-knee, and knee-ankle were calculated. The K-means clustering algorithm was adopted to classify subjects considering the whole kinematics time series. A one-way ANOVA test was used to compare both clinical and kinematics parameters across clusters.

RESULTS

Only the classification based on the intralimb coordination variables succeeded in defining 5 well separated clusters with the following clinical characteristics: controls were grouped mainly in Cluster 2, diabetics in Cluster 4, and neuropathic subjects in Cluster 5 (which included various degrees of severity). Hip-ankle coordination in Clusters 4 and 5 were significantly different (p < 0.05) with respect to Cluster 2, mainly in the stance phase. During the swing phase, differences were observed in the ankle-knee coordination (p < 0.05) across clusters.

CONCLUSION

Classification based on intralimb coordination patterns succeeded in efficiently categorize gait alterations in diabetic subjects. It can be speculated that variables extracted from sagittal plane kinematics might be adopted as a support to clinical decision making in diabetes.

Inter-joint coordination during obstacle crossing in people with diabetic neuropathy

Sensori-motor deficit due to diabetic peripheral neuropathy (DPN) alters the quality of obstacle-crossing which may increase the risk of falling. The aim of this study was to compare inter-joint coordination (IJC) during obstacle-crossing between people with DPN and healthy controls. Fifteen DPN and 15 healthy people crossed over obstacles with heights of 10% and 20% of the subject's leg length. The mean absolute relative phase (MARP) and deviation phase (DP) of both leading and trailing limbs were used to calculate the phase dynamic and variability of IJC. Furthermore, correlation between Berg Balance Scale (BBS), Fall Efficacy Scale (FES-I), Timed Up and Go (TUG) and MARP, DP were assessed in DPN group. There was no significant interaction between group and obstacle height on measured variables. However, Group had significant main effect on DP of hip-knee in leading limb (p < 0.05). Additionally, the main effects of the obstacle's height were significant on MARP of hip-knee of trailing limb (p < 0.01) and knee-ankle in leading limb (p < 0.05). FES-I was significantly correlated to hip-knee and knee-ankle MARPs of leading limb for crossing over 20% and knee-ankle MARP for crossing over 10% height obstacle (r = 0.68, 0.69, 0.59, respectively, p < 0.05). This score was also significantly correlated with hip-knee DP of both trailing and leading limbs when crossing 10% obstacle (r = 0.59, 0.57, respectively, p < 0.05). In conclusion, IJC during obstacle-crossing was less variable and more out-of-phase, as a result of DPN and obstacle height, respectively. Moreover, when crossing over lower obstacles, fear of falling is related to IJC dynamics and variability of more proximal segment, especially in the leading limb.

Peripheral nerve disease

Polyneuropathies are common neurologic disorders affecting the peripheral nerves. There are a number of causes of damage to these structures, such as genetic and metabolic factors, autoimmune disorders, infection, drug or environmental toxicity, and malignancy. Motor and sensory impairments are commonly encountered in these conditions, leading to altered balance and gait with increased risk of falling. Diabetic neuropathy is the most common cause of peripheral nerve disease and extensive investigation of balance and walking function revealed greater postural instability and delayed activation of distal muscles during walking. Although classically thought to be due to sensory impairment, it is now recognized that a motor contribution to balance and gait impairment cannot be ruled out in diabetic neuropathy. Inflammatory and inherited neuropathies have had less investigation. Variations in static and dynamic balance and depend on the sensory afferents affected and the degree of motor impairment. Motor impairment is a major contributor to alterations in gait pattern. Exercise is an effective rehabilitation approach that can improve muscle strength and postural responses. The gains can carry over into improved functional balance and walking. Orthotic interventions are also promising in supporting joints where there is significant muscle weakness, but newer devices are being developed that provide sensory feedback, e.g., vibration, which may be effective where sensory impairment is a key contributor to postural instability.

Cross-cultural adaptation and measurement properties of the Brazilian Version of the Michigan Neuropathy Screening Instrument

BACKGROUND

The Michigan Neuropathy Screening Instrument is an easy-to-use questionnaire aimed at screening and detecting diabetic polyneuropathy.

OBJECTIVE

To translate and cross-culturally adapt the MNSI to Brazilian Portuguese and evaluate its measurement properties.

METHODS

Two bilingual translators translated from English into Brazilian Portuguese and made a synthetic version. The synthetic version was back translated into English. A committee of specialists and the translator checked the cultural adaptations and developed a pre-final questionnaire in Brazilian Portuguese (prefinal version). In pretesting, the prefinal version was applied to a sample of 34 subjects in which each subject was interviewed to determine whether they understood each item. For the later assessment of measurement properties, 84 subjects were assessed.

RESULTS

A final Brazilian Portuguese version of the instrument was produced after obtaining 80% agreement (SEM<0.01%) among diabetic patients and specialists. We obtained excellent intra-rater reliability (ICC_3,1=0.90), inter-rater reliability (ICC_2,1=0.90) and within-subject reliability ICC_3,1=0.80, excellent internal consistency (Cronbach's alpha>0.92), reasonable construct validity for the association between the MNSI and Neuropathy Symptom Score (r=0.46, p<0.05) and excellent association between the MNSI and Neuropathy Disability Score (r=0.79, p<0.05). We did not detect floor and ceiling effects (<9.5% of patients with maximum scores).

CONCLUSIONS

The Brazilian Portuguese version of the MNSI is suitable for application in the Brazilian diabetic population and is a reliable tool for the screening and detection of DPN. The MNSI can be used both in clinical practice and also for research purposes.

Effects of knee sleeves on coordination of lower-limb segments in healthy adults during level walking and one-leg hopping

The evaluation of multisegment coordination is important in gaining a better understanding of the gait and physical activities in humans. Therefore, this study aims to verify whether the use of knee sleeves affects the coordination of lower-limb segments during level walking and one-leg hopping. Eleven healthy male adults participated in this study. They were asked to walk 10 m on a level ground and perform one-leg hops with and without a knee sleeve. The segment angles and the response velocities of the thigh, shank, and foot were measured and calculated by using a motion analysis system. The phases between the segment angle and the velocity were then calculated. Moreover, the continuous relative phase (CRP) was calculated as the phase of the distal segment subtracted from the phase of the proximal segment and denoted as CRPTS (thigh–shank), CRPSF (shank–foot), and CRPTF (thigh–foot). The root mean square (RMS) values were used to evaluate the in-phase or out-of-phase states, while the standard deviation (SD) values were utilized to evaluate the variability in the stance and swing phases during level walking and in the preflight, flight, and landing phases during one-leg hopping. The walking velocity and the flight time improved when the knee sleeve was worn (p < 0.05). The segment angles of the thigh and shank also changed when the knee sleeve was worn during level walking and one-leg hopping. The RMS values of CRPTS and CRPSF in the stance phase and the RMS values of CRPSF in the preflight and landing phases changed (p < 0.05 in all cases). Moreover, the SD values of CRPTS in the landing phase and the SD values of CRPSF in the preflight and landing phases increased (p < 0.05 in all cases). These results indicated that wearing a knee sleeve caused changes in segment kinematics and coordination.

Later stages of diabetic neuropathy affect the complexity of the neuromuscular system at the knee during low-level isometric contractions

INTRODUCTION

This study evaluates the complexity of force and surface electromyography (sEMG) during knee extension and flexion at low-level isometric contractions in individuals with different degrees of diabetic peripheral neuropathy (DPN).

METHODS

Ten control and 38 diabetic participants performed isometric contractions at 10%, 20%, and 30% of maximal voluntary contraction. Knee force and multichannel sEMG from vastus lateralis (VL) and biceps femoris were acquired. The SD of force and sample entropy (SaEn) of both force and sEMG were computed.

RESULTS

Participants with moderate DPN demonstrated high force-SD and low force-SaEn. Severely affected participants showed low SaEn in VL at all force levels.

DISCUSSION

DPN affects the complexity of the neuromuscular system at the knee for the extension task during low-level isometric contractions, with participants in the later stages of the disease (moderate and severe) demonstrating most of the changes. Muscle Nerve 57: 112-121, 2018.