Gait kinematics and kinetics are affected more by peripheral arterial disease than by age

Diagnosis of disease affecting gait with a body acceleration-based model using reflected marker data for training and a wearable accelerometer for implementation

This paper demonstrates the value of a framework for processing data on body acceleration as a uniquely valuable tool for diagnosing diseases that affect gait early. As a case study, we used this model to identify individuals with peripheral artery disease (PAD) and distinguish them from those without PAD. The framework uses acceleration data extracted from anatomical reflective markers placed in different body locations to train the diagnostic models and a wearable accelerometer carried at the waist for validation. Reflective marker data have been used for decades in studies evaluating and monitoring human gait. They are widely available for many body parts but are obtained in specialized laboratories. On the other hand, wearable accelerometers enable diagnostics outside lab conditions. Models trained by raw marker data at the sacrum achieve an accuracy of 92% in distinguishing PAD patients from non-PAD controls. This accuracy drops to 28% when data from a wearable accelerometer at the waist validate the model. This model was enhanced by using features extracted from the acceleration rather than the raw acceleration, with the marker model accuracy only dropping from 86 to 60% when validated by the wearable accelerometer data.

Association of AST/ALT (De Ritis) ratio with sarcopenia in a Chinese population of community-dwelling elderly

Background

The aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio, also known as De Ritis ratio, has been reportedly associated with malnutrition which plays a crucial role in sarcopenia. The aim of this study was to examine the relationship between AST/ALT ratio and sarcopenia in the Chinese community-dwelling elderly.

Methods

A cross-sectional study with 2751 participants (1343 men and 1408 women) aged ≥60 years was performed. Appendicular skeletal muscle mass index (ASMI), grip strength, and gait speed were measured to diagnose sarcopenia according to the latest Asian Working Group for Sarcopenia (AWGS) consensus. The association of AST/ALT ratio with sarcopenia was examined using logistic regression analysis.

Results

The prevalence of sarcopenia in the present study was 4.4%. AST/ALT ratio was higher in the sarcopenia group than in the non-sarcopenia group (1.30 ± 0.33 vs. 1.16 ± 0.62, P = 0.010). AST/ALT ratio was negatively correlated with the components of sarcopenia, including ASMI, grip strength, and gait speed. Logistic regression analysis indicated that high AST/ALT ratio (>1.20) was associated with increased risk of sarcopenia even after adjustment for potential confounders (adjusted OR = 2.33, 95%CI = 1.48-3.68, P < 0.001). Stratification analyses indicated that the association of high AST/ALT ratio with high risk of sarcopenia was more significant in males and the elderly with ≥70 years.

Conclusions

Our findings demonstrate that high AST/ALT ratio is associated with increased risk of sarcopenia in a Chinese population of community-dwelling elderly.

A biomechanical perspective on walking in patients with peripheral artery disease

The most common symptom of peripheral artery disease (PAD) is intermittent claudication, which consists of debilitating leg pain during walking. In clinical settings, the presence of PAD is often noninvasively evaluated using the ankle-brachial index and imaging of the arterial supply. Furthermore, various questionnaires and functional tests are commonly used to measure the severity and negative effect of PAD on quality of life. However, these evaluations only provide information on vascular insufficiency and severity of the disease, but not regarding the complex mechanisms underlying walking impairments in patients with PAD. Biomechanical analyses using motion capture and ground reaction force measurements can provide insight into the underlying mechanisms to walking impairments in PAD. This review analyzes the application of biomechanics tools to identify gait impairments and their clinical implications on rehabilitation of patients with PAD. A total of 18 published journal articles focused on gait biomechanics in patients with PAD were studied. This narriative review shows that the gait of patients with PAD is impaired from the first steps that a patient takes and deteriorates further after the onset of claudication leg pain. These results point toward impaired muscle function across the ankle, knee, and hip joints during walking. Gait analysis helps understand the mechanisms operating in PAD and could also facilitate earlier diagnosis, better treatment, and slower progression of PAD.

Lower-extremity muscle wasting in patients with peripheral arterial disease: quantitative measurement and evaluation with CT

OBJECTIVES

Lower-extremity peripheral arterial disease (PAD) results in limb ischemia and is strongly associated with sarcopenia. This study aimed to retrospectively evaluate the association between the quantity of muscle mass in the lower extremities and the severity of vascular stenosis in PAD patients.

METHODS

Between January 2018 and August 2021, 128 patients with PAD and 53 individuals without PAD, diagnosed by computed tomography, were enrolled. The severity of stenosis of lower-extremity arteries was measured using a grading system. The muscle and fat mass areas were calculated in the abdomen at the L3 or L4 level, mid-thigh, and lower leg. Multivariable logistic regression was conducted to clarify the risk associated with low muscle mass. The difference in muscle mass between PAD and non-PAD patients was evaluated by using propensity score matching.

RESULTS

A strong positive correlation between the abdomen muscle area and leg muscle area was observed. The muscle area and muscle index of the leg were lower in PAD patients. These changes occurred earlier than in the abdomen muscle area. The group with more severe artery stenosis had more muscle wasting in the lower extremities. Greater age, female, lower BMI, and PAD were associated with low muscle mass. After propensity score matching, the leg muscle area was still lower in PAD patients.

CONCLUSIONS

There is a direct association between PAD and regional muscle wasting. This occurs earlier regionally in the lower extremities than in central muscles. Early diagnosis of PAD might prevent progressive muscle loss, improving disease outcome and quality of life.

KEY POINTS

• Peripheral arterial disease is strongly associated with sarcopenia. • Muscle wasting in the lower extremities is earlier and more prominent than that in the abdomen. • More severe arterial stenoses are associated with higher muscle wasting in the lower extremities.

Machine Learning-Based Peripheral Artery Disease Identification Using Laboratory-Based Gait Data

Peripheral artery disease (PAD) manifests from atherosclerosis, which limits blood flow to the legs and causes changes in muscle structure and function, and in gait performance. PAD is underdiagnosed, which delays treatment and worsens clinical outcomes. To overcome this challenge, the purpose of this study is to develop machine learning (ML) models that distinguish individuals with and without PAD. This is the first step to using ML to identify those with PAD risk early. We built ML models based on previously acquired overground walking biomechanics data from patients with PAD and healthy controls. Gait signatures were characterized using ankle, knee, and hip joint angles, torques, and powers, as well as ground reaction forces (GRF). ML was able to classify those with and without PAD using Neural Networks or Random Forest algorithms with 89% accuracy (0.64 Matthew's Correlation Coefficient) using all laboratory-based gait variables. Moreover, models using only GRF variables provided up to 87% accuracy (0.64 Matthew's Correlation Coefficient). These results indicate that ML models can classify those with and without PAD using gait signatures with acceptable performance. Results also show that an ML gait signature model that uses GRF features delivers the most informative data for PAD classification.

Peripheral artery disease affects the function of the legs of claudicating patients in a diffuse manner irrespective of the segment of the arterial tree primarily involved

Different levels of arterial occlusive disease (aortoiliac, femoropopliteal, multi-level disease) can produce claudication symptoms in different leg muscle groups (buttocks, thighs, calves) in patients with peripheral artery disease (PAD). We tested the hypothesis that different locations of occlusive disease uniquely affect the muscles of PAD legs and produce distinctive patterns in the way claudicating patients walk. Ninety-seven PAD patients and 35 healthy controls were recruited. PAD patients were categorized to aortoiliac, femoropopliteal and multi-level disease groups using computerized tomographic angiography. Subjects performed walking trials both pain-free and during claudication pain and joint kinematics, kinetics, and spatiotemporal parameters were calculated to evaluate the net contribution of the calf, thigh and buttock muscles. PAD patients with occlusive disease affecting different segments of the arterial tree (aortoiliac, femoropopliteal, multi-level disease) presented with symptoms affecting different muscle groups of the lower extremity (calves, thighs and buttocks alone or in combination). However, no significant biomechanical differences were found between PAD groups during the pain-free conditions with minimal differences between PAD groups in the claudicating state. All statistical differences in the pain-free condition occurred between healthy controls and one or more PAD groups. A discriminant analysis function was able to adequately predict if a subject was a control with over 70% accuracy, but the function was unable to differentiate between PAD groups. In-depth gait analyses of claudicating PAD patients indicate that different locations of arterial disease produce claudication symptoms that affect different muscle groups across the lower extremity but impact the function of the leg muscles in a diffuse manner generating similar walking impairments.

Characteristics of Plantar Pressure Distribution in Diabetes with or without Diabetic Peripheral Neuropathy and Peripheral Arterial Disease

Background. Excessive plantar pressure leads to increased risk of diabetic foot ulcers. Diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) have been considered to be associated with alterations in gait and plantar pressure in diabetic patients. However, few studies have differentiated the effects with each of them. Objective. To investigate the plantar pressure distribution in diabetic patients, with DPN and PAD as independent or combined factors. Methods. 112 subjects were recruited: 24 diabetic patients with both DPN and PAD (DPN-PAD group), 12 diabetic patients with DPN without PAD (DPN group), 10 diabetic patients with PAD without DPN (PAD group), 23 diabetic patients without DPN or PAD, and 43 nondiabetic healthy controls (HC group). The in-shoe plantar pressure during natural walking was measured. Differences in peak pressure, contact area, proportion of high pressure area (%HP), and anterior/posterior position of centre of pressure (COP) were analysed. Results. Compared with HC group, in DPN-PAD group and DPN group, the peak pressures in all three forefoot regions increased significantly; in PAD group, the peak pressure in lateral forefoot increased significantly. The contact area of midfoot in the DPN-PAD group decreased significantly. PAD group had larger HP% of lateral forefoot, DPN group had larger HP% of inner forefoot, and DPN-PAD group had larger HP% of total plantar area. There was a significant tendency of the anterior displacement of COP in the DPN-PAD group and DPN group. No significant differences were observed between the D group and HC group. Conclusion. DPN or PAD could affect the plantar pressure distribution in diabetic patients independently or synergistically, resulting in increased forefoot pressure and the area at risk of ulcers. DPN has a more pronounced effect on peak pressure than PAD. The synergistic effect of them could significantly reduce the plantar contact area of midfoot.

Impaired microcirculatory function, mitochondrial respiration, and oxygen utilization in skeletal muscle of claudicating patients with peripheral artery disease

Peripheral artery disease (PAD) is an atherosclerotic disease that impairs blood flow and muscle function in the lower limbs. A skeletal muscle myopathy characterized by mitochondrial dysfunction and oxidative damage is present in PAD; however, the underlying mechanisms are not well established. We investigated the impact of chronic ischemia on skeletal muscle microcirculatory function and its association with leg skeletal muscle mitochondrial function and oxygen delivery and utilization capacity in PAD. Gastrocnemius samples and arterioles were harvested from patients with PAD (n = 10) and age-matched controls (Con, n = 11). Endothelium-dependent and independent vasodilation was assessed in response to flow (30 μL·min-1), acetylcholine, and sodium nitroprusside (SNP). Skeletal muscle mitochondrial respiration was quantified by high-resolution respirometry, microvascular oxygen delivery, and utilization capacity (tissue oxygenation index, TOI) were assessed by near-infrared spectroscopy. Vasodilation was attenuated in PAD (P < 0.05) in response to acetylcholine (Con: 71.1 ± 11.1%, PAD: 45.7 ± 18.1%) and flow (Con: 46.6 ± 20.1%, PAD: 29.3 ± 10.5%) but not SNP (P = 0.30). Complex I + II state 3 respiration (P < 0.01) and TOI recovery rate were impaired in PAD (P < 0.05). Both flow and acetylcholine-mediated vasodilation were positively associated with complex I + II state 3 respiration (r = 0.5 and r = 0.5, respectively, P < 0.05). Flow-mediated vasodilation and complex I + II state 3 respiration were positively associated with TOI recovery rate (r = 0.8 and r = 0.7, respectively, P < 0.05). These findings suggest that chronic ischemia attenuates skeletal muscle arteriole endothelial function, which may be a key mediator for mitochondrial and microcirculatory dysfunction in the PAD leg skeletal muscle. Targeting microvascular dysfunction may be an effective strategy to prevent and/or reverse disease progression in PAD.NEW & NOTEWORTHY Ex vivo skeletal muscle arteriole endothelial function is impaired in claudicating patients with PAD, and this is associated with attenuated skeletal muscle mitochondrial respiration. In vivo skeletal muscle oxygen delivery and utilization capacity is compromised in PAD, and this may be due to microcirculatory and mitochondrial dysfunction. These results suggest that targeting skeletal muscle arteriole function may lead to improvements in skeletal muscle mitochondrial respiration and oxygen delivery and utilization capacity in claudicating patients with PAD.

Perfusion, Stance and Plantar Pressure Asymmetries on the Human Foot in the Absence of Disease—A Pilot Study

Physiological perfusion asymmetries in the lower limb are known, although poorly understood, as are asymmetries reported in plantar pressure and stance. This preliminary study aims to explore potential relationships between perfusion and pressure variables in humans. A convenience sample of eight healthy individuals (25.25 ± 5.37 years old) of both sexes, was selected. Chosen variables were perfusion, plantar pressure, and stance. Perfusion was measured in both feet by laser Doppler flowmetry (LDF) and polarized light spectroscopy (PSp), and plantar pressure and stance obtained by a pressure plate. These were measured in baseline (Phase I) in a repeated squatting (Phase II), and in recovery (Phase III). A 95% confidence interval was adopted. Intraindividual significant perfusion asymmetries between both feet were detected by LDF in Phase I. These disappeared in Phase II and returned in Phase III. PSp did not detect any asymmetries. Plantar pressure was also asymmetric and differently distributed along both feet with no statistical significance except in the hindfoot. Significant correlations were found between BMI and mean Plantar Pressure in Phase I and Phase III, and an inverse correlation between LDF perfusion and Plantar Pressure in Phase I. These results seem to suggest an interesting direction for exploration and study of these asymmetries in the absence of disease.

Location of ischemia and ischemic pain intensity affect spatiotemporal parameters and leg muscles activity during walking in patients with intermittent claudication

The ways in which locations of ischemia and ischemic pain affect spatiotemporal gait parameters and leg electromyographic activity during walking have never been investigated in patients with peripheral arterial disease presenting intermittent claudication. Two groups were classified according to unilateral location of ischemia (distal, n = 10, or proximo-distal, n = 12). Patients described pain and three gait phases-initial pain-free, onset of pain and maximum pain-were analyzed. Patients with proximo-distal ischemia walked less (230 ± 111 m vs 384 ± 220 m), with increased step length, step time (+ 5.4% and + 5.8%) and reduced cadence (- 8.2%), than patients with distal ischemia. In both, the peaks of vertical ground reaction force were reduced in maximum pain (Peak1-distal: - 11.4%, Peak1-proximo-distal: - 10.3%; Peak2-distal: - 11.8%, Peak2-proximo-distal: - 9.0%). In the proximo-distal group, tibialis anterior activation peak and time were lower than in the distal group (- 4.5% and - 19.7%). During the maximum pain phase, this peak decreased only in the proximo-distal group (- 13.0%), and gastrocnemius medialis activation peak and time decreased in both groups (- 2.5% in distal and - 4.5% in proximo-distal). Thus, proximo-distal ischemia leads to more adverse consequences in gait than distal ischemia only. Increasing ischemic pain until maximum, but not onset of pain, induced gait adaptations.

Habitual endurance running does not mitigate age-related differences in gait kinetics

Older adults often walk with smaller ankle joint kinetics and larger hip joint kinetics compared to young adults. These age-related differences have been attributed, in part, to weaker plantarflexor muscles. While it is thought that regular physical activity helps to maintain muscle strength and mobility in older adults, physical activity levels on average decline with age. Therefore, understanding the effect of physical activity level on gait kinetics is an important objective for the management of mobility impairment in older adults. The purpose of this study was determine the effect of habitual endurance running on lower-extremity joint kinetics. 12 male older long-term runners (67 ± 5 yrs., 1.79 ± 0.07 m, 77.3 ± 13.7 kg) and 12 male older non-runners (70 ± 3 yrs., 1.78 ± 0.06 m, 79.68 ± 10.6 kg), performed overground walking trials at 1.3 m/s while kinematic and kinetic data were collected. Participants also performed maximal voluntary contractions at the hip, knee, and ankle joints on an isokinetic dynamometer. Older runners displayed similar ankle plantarflexor strength, similar hip extensor strength, and greater knee extensor strength compared to older non-runners, and walked with similar ankle joint kinetics (p > 0.05), and larger hip joint kinetics compared to older non-runners (p < 0.05). Thus, physical activity, in the form of running at least 20 miles/wk. and training for at least one race per year, did not mitigate the characteristic age-related differences in gait kinetics. Our findings may indicate that age-related differences in lower-extremity gait kinetics are a normal consequence of natural aging.

Effects of Physical Rehabilitation on Spatiotemporal Gait Parameters and Ground Reaction Forces of Patients with Intermittent Claudication

Chronic ischemia of the lower extremities often presents as intermittent claudication characterized by lower limb pain which subsides after a short break. This study aimed to provide an assessment of the spatiotemporal parameters of gait and ground reaction forces in patients with PAD participating in three forms of supervised physical training. A total of 80 subjects completed a three-month supervised physical rehabilitation program with three sessions per week. The subjects were assigned to one of three programs: group 1—standard walking training on a treadmill (TT); group 2—Nordic walking (NW) training; group 3—strength and endurance training comprised of NW with isokinetic resistance training (NW + ISO). Gait biomechanics tests (kinematic and kinetic parameters of gait) and a six-minute walk test were carried out before and after three months of physical training. Nordic walking training led to the greatest improvements in the gait pattern of patients with PAD and a significant increase in the absolute claudication distance and total gait distance. Combined training (NW + ISO) by strengthening the muscles of the lower extremities increased the amplitude of the general center of gravity oscillation to the greatest extent. Treadmill training had little effect on the gait pattern. Nordic walking training should be included in the rehabilitation of patients with PAD as a form of gait training, which can be conducted under supervised or unsupervised conditions.

Sarcopenia and peripheral arterial disease: a systematic review

BACKGROUND

Patients with lower extremity peripheral arterial disease (PAD) and sarcopenia are a population at risk requiring specific and targeted care. The aim of this review is to gather all relevant studies associating sarcopenia and PAD and to identify the underlying pathophysiological mechanisms as well as potential therapeutic strategies to improve skeletal muscle function.

METHODS

A systematic review was carried out following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Data extraction allowed the evaluation of 140 publications; 87 met the inclusion criteria; of which 79 were included in the final review, reporting sufficient data for epidemiological and diagnostic criteria, mechanical analysis, and therapeutic approaches. Epidemiological analysis and diagnostic criteria were based on 18 studies following 2362 PAD patients [31.39% (SD 7.61) women], aged 72.42 (SD 2.84); sarcopenia was present in 34.63% (SD 12.86) of the patients. Mechanical and pathway analysis were based on five animal studies and 29 clinical reports, showing significantly altered muscle strength and function in 1352 PAD patients [26.49% (SD 17.32) women], aged 67.67 (SD 5.14) years; impaired muscle histology in 192 PAD patients (9.2% (SD 11.22) women), aged 64.3 (SD 0.99) years; +58.63% (SD 25.48) of oxidative stress in 69 PAD patients [16.96% (SD 8.10) women], aged 63.17 (SD 1.43) years; mitochondriopathy in 153 PAD patients [29.39% (SD 28.27) women], aged 63.50 (SD 1.83) years; +15.58% (SD 7.41) of inflammation in 900 PAD patients [40.77% (SD 3.71) women], aged 74.88 (SD 2.76) years; and altered signalling pathways in 51 PAD patients [34.45% (SD 32.23) women], aged 72.25 (SD 5.25) years. Therapeutic approaches analysis was based on seven animal studies and 21 clinical reports. In total, 884 patients followed an exercise therapy, and 18 received an angiogenesis treatment; 30.84% (SD 17.74) were women. Mean ages of patients studied were 66.85 (SD 3.96).

CONCLUSIONS

Sarcopenia and lower extremity PAD have musculoskeletal consequences that directly impair patients' quality of life and prognosis. Although PAD is primarily a vascular disease, all etiological factors of sarcopenia identified so far are present in PAD. Indeed, both sarcopenia and PAD are accompanied by oxidative stress, skeletal muscle mitochondrial impairments, inflammation, inhibition of specific pathways regulating muscle synthesis or protection (i.e. IGF-1, RISK, and SAFE), and activation of molecules associated with muscle degradation. To date, besides revascularization, the best therapeutic strategy includes exercise, but approaches targeting the underlying mechanisms still deserve further studies.

Changes in Gait Variables in Patients with Intermittent Claudication

Objective

Intermittent claudication (IC) is a pathological symptom with a particular effect on human gait patterns. Therefore, analyzing these patterns can facilitate rehabilitation or treatment through comparison of the values of kinematic and kinetic variables of patients with the normal values of healthy people. Therefore, the aim of this study was to find differences in the values of gait variables between patients with IC and healthy people.

Methods

The study included 98 patients diagnosed with peripheral arterial disease with IC. The patients traveled a distance of 6 m at a voluntary gait velocity. Ground reaction forces while the foot contacted the ground and kinematic variables of lower limb movements were recorded. The values of normal gait variables were computed based on the results obtained in a group of 30 healthy people.

Results

Patients used a gait velocity below the norm for healthy people. The velocity during the lower limb swing and the step and stride length in patients with IC were below the norm. Differences were also found in the ranges of motion between patients with IC and healthy people for the pelvic obliquity, pelvic rotation, hip flexion-extension, hip abduction-adduction, hip internal-external rotation, knee flexion-extension, ankle dorsi-plantar flexion, and foot progression angles.

Conclusions

The presented kinematic and kinetic characteristics measured by gait variables suggest differences between patients with IC and healthy people. Considering kinematic and kinetic gait variables during the rehabilitation process would facilitate the development of a more economic gait technique (with increased stride length and range of motion in the lower limb joints) to obtain the desired rehabilitation effects. Patients with IC should receive rehabilitation oriented towards improving mobility and increasing muscle strength in selected lower limb joints to increase gait velocity and stride length.

Hip flexor muscle dysfunction during walking at self-selected and fast speed in patients with aortoiliac peripheral arterial disease

OBJECTIVE

Intermittent claudication aggravates physical function and is associated with an increased risk of death in patients with peripheral arterial disease (PAD). Previous studies on kinetic parameters (joint moment and power) of lower limbs in these patients have largely focused on the decline in the ankle plantar flexor moment and power at self-selected (SS) walking speed, which may not be an optimal condition to induce claudication pain. In the present study, we investigated the abnormalities in joint kinetic parameters in patients with PAD at both SS and at fast walking speeds.

METHODS

We recruited 16 patients with aortoiliac PAD (4 unilateral and 12 bilateral) and 10 healthy controls. The participants were instructed to walk at SS and fast speeds along a 7-meter walkway embedded with a force plate. Spatiotemporal parameters and joint kinetic parameters of the lower limbs during the stance phase were recorded using a three-dimensional motion analysis device.

RESULTS

Compared with the controls, patients with PAD showed a significant reduction in their walking speed, step length, stride length, and cadence. Further, a reduction in peak hip flexor moment at fast walking speed and in peak hip flexor generation power was observed in both modes of walking. However, no significant between-group differences were observed for the peak ankle plantar flexor moment or power at either walking speed. Multiple regression analysis showed peak hip flexor generation power was a strong contributor to reduction at both SS and fast walking speeds in patients with PAD.

CONCLUSIONS

Patients with aortoiliac PAD walk slowly and show reduced kinetic parameters of the hip joint at both SS and fast walking speeds. Our results suggest that hip flexor muscles may be a useful target for exercise training in patients with aortoiliac PAD.