Plantar fascia thickness, a measure of tissue glycation, predicts the development of complications in adolescents with type 1 diabetes

Protein glycation in diabetes mellitus

Diabetes mellitus is the ninth leading cause of mortality worldwide. It is a complex disease that manifests as chronic hyperglycemia. Glucose exposure causes biochemical changes at the proteome level as reflected in accumulation of glycated proteins. A prominent example is hemoglobin A1c (HbA1c), a glycated protein widely accepted as a diabetic indicator. Another emerging biomarker is glycated albumin which has demonstrated utility in situations where HbA1c cannot be used. Other proteins undergo glycation as well thus impacting cellular function, transport and immune response. Accordingly, these glycated counterparts may serve as predictors for diabetic complications and thus warrant further inquiry. Fortunately, modern proteomics has provided unique analytic capability to enable improved and more comprehensive exploration of glycating agents and glycated proteins. This review broadly covers topics from epidemiology of diabetes to modern analytical tools such as mass spectrometry to facilitate a better understanding of diabetes pathophysiology. This serves as an attempt to connect clinically relevant questions with findings of recent proteomic studies to suggest future avenues of diabetes research.

Presurgical Perspective and Postsurgical Evaluation of the Plantar Fascia

The plantar fascia is an important structure in the foot that acts as a major stabilizer of the longitudinal arch, along with the midfoot ligaments and intrinsic and extrinsic muscles. It is composed predominantly of longitudinally oriented collagen fibers that vary in thickness and are organized into bundles closely associated with the interstitial tissues of the foot. This composition enables the plantar fascia to withstand the weight-bearing forces concentrated on the foot while standing, jumping, walking, or running. This article discusses the normal anatomy and the various pathologies that affect the plantar fascia with an emphasis on presurgical and postoperative appearances on magnetic resonance and ultrasonography imaging.

A systematic review of the prevalence, risk factors and screening tools for autonomic and diabetic peripheral neuropathy in children, adolescents and young adults with type 1 diabetes

AIMS

We aimed to estimate the prevalence of Diabetic peripheral neuropathy (DPN) and Cardiac autonomic neuropathy (CAN) in youth with type 1 diabetes; identify key risk factors; identify the most useful tests for the diagnostic evaluation of DPN and CAN; identify key treatment options for DPN and CAN.

METHODS

A systematic search was performed including studies published in the last 15 years. PICO framework was used in the selection process and evidence was assessed using the GRADE system.

RESULTS

A total of 758 studies were identified and a final number of 49 studies were included in this systematic review. According to moderate-high level quality studies, the prevalence of probable DPN, ranged between 13.5 and 62%; subclinical DPN between 22 and 88%; confirmed DPN between 2.6 and 11%. The Michigan Neuropathy Screening Instrument was the tool with higher sensitivity and specificity for detecting DPN, which needs to be confirmed by nerve conduction velocity. The prevalence of CAN was 4-39%. Specific treatment options for DPN or CAN in patients younger than 25 years are not available. Key risk factors for DPN and CAN are hyperglycemia/HbA1c, age, diabetes duration, the presence of other microvascular complications, waist/height ratio, lipid profile and blood pressure. For CAN, additional risk factors were cigarette smoking, BMI and total daily insulin.

CONCLUSIONS

Prevalence of neuropathy in youth with type 1 diabetes varies depending on different screening methods and characteristics of the study populations. However, the assessed studies confirmed a relatively high prevalence of subclinical neuropathy, reiterating the importance of early identification of risk factors to prevent this complication.

Irregularity in Plantar Fascia, Muscle Edema and Tendon Thickness in Patients with High-Risk for Diabetic Foot

AIM

To investigate the alterations in the plantar fascia (PF), intrinsic muscles, and tendons in the feet of patients at high risk for developing diabetic foot.

METHODS

The healthy feet of 22 patients with type 2 diabetes, who had developed diabetic foot ulcers on a single foot without any pathology on the contralateral extremity, and those of 22 healthy volunteers were evaluated by magnetic resonance imaging. The volume of the Achilles tendon (AT), the surface area of the PF, the thickness of AT, flexor hallucis longus, flexor digitorum longus, tibialis posterior, and peroneus longus tendons, irregularity in the PF, and edema of intrinsic foot muscles were examined.

RESULTS

Nineteen patients (86%) had irregularity in the PF, whereas none of the healthy controls had any (p<0.001). Intrinsic muscle edema was more common in the group with diabetes (p=0.006). The volume of AT and the surface area of PF were decreased in patients with peripheral arterial disease (PAD) (p<0.05). Patients with diabetes mellitus but without PAD had a larger surface area of PF than that of controls (p<0.05). There were no differences in the volume of AT, the surface area of the PF, and other tendon thickness between the groups.

CONCLUSION

Irregularity in the PF and muscle edema may indicate a high risk for the diabetic foot. The presence of PAD may lead to regression in the structure of AT and PF.

Large fibre, small fibre and autonomic neuropathy in adolescents with type 1 diabetes: A systematic review

AIMS

To estimate the prevalence of neuropathy in adolescents with type 1 diabetes.

METHODS

Systematic collection of published studies exploring the prevalence of large fibre neuropathy (LFN), small fibre neuropathy (SFN), and autonomic neuropathy in adolescents with type 1 diabetes. Following prospective registration (Prospero CRD42020206093), PubMed, EMBASE, and Cochrane Library were searched for studies from 2000 to 2020. PICO framework was used in the selection process (Population: adolescents aged 10-19 years with type 1 diabetes; Intervention: diagnostic methods for neuropathy; Comparison: reference data; Outcome: data on prevalence or comparison). Data were extracted concerning study quality based on available data and established methods for determining and diagnosing various neuropathy types.

RESULTS

From 2,017 initial citations, 27 studies (7589 participants) fulfilled eligibility criteria. The study population (47% males) had a diabetes duration between 4.0 and 10.6 years, and HbA1c level between 7.3 and 10.8%, 56-95 mmol/mol. The prevalence of LFN, based on nerve conduction studies, was 10-57%. Based on other tests for neuropathy, the prevalence of LFN and SFN was 12-62%, and that of cardiac autonomic neuropathy was 12-75%.

CONCLUSION

The described prevalence of neuropathy in adolescents with type 1 diabetes varied, which can be methodological due to different screening methods and classifications of neuropathy.

Reliability in ultrasound measurements of plantar aponeurosis thickness

PURPOSE

Given the increasing research interest in ultrasound plantar aponeurosis (PA) thickness measurements, this study aimed to analyze the inter and intra-rater reliability of independent sonograms and to identify the error related to the image analysis procedure.

METHODS

Twenty-one healthy men participated in this study. Imaging of PA consisted of two independent sonograms per subject. Two raters (R1 and R2) evaluated each sonogram twice using standardized steps. Precision of the image analysis procedure was analyzed using the Bland and Altman plot and Intraclass Correlation Coefficient (ICC). Agreement estimates and ICC were used to assess absolute and relative inter and intra-rater reliability.

RESULTS

Reliability of PA thickness was found to depend strongly on the number of images acquired per subject. Intra-rater agreement for single measurements were 0.696 (R1) and 0.495 (R2), whereas average measurements yielded values of 0.821 (R1) and 0.662 (R2), respectively. Precision within a sonogram varied from ICC values of 0.873 to 0.960 (intra-rater) and 0.670 to 0.822 (inter-rater).

CONCLUSION

Most part of the error in PA thickness measurements seems to be related to the sonogram acquisition process and not to the visual inspection of the image. To minimize error, average values of a minimum of two images per subject should be used. The moderate agreement between raters found in this study ratifies the need of all measurements being made by the same rater or group of raters. If a single rater evaluates all subjects, performing multiple measurements over one image does not seem to affect ICC as much as acquiring multiple images.

Effects of Long-Term Physical Activity and Diet on Skin Glycation and Achilles Tendon Structure

Advanced glycation end-products (AGEs) accumulate with aging and have been associated with tissue modifications and metabolic disease. Regular exercise has several health benefits, and the purpose of this study was to investigate the effect of regular long-term exercise and diet on skin autofluorescence (SAF) as a measure of glycation and on Achilles tendon structure. In connection with the 2017 European Masters Athletics Championships Stadia, high-level male athletes (n = 194) that had regularly trained for more than 10 years were recruited, in addition to untrained controls (n = 34). SAF was non-invasively determined using an AGE Reader. Achilles tendon thickness and vascular Doppler activity were measured by ultrasonography, and diet was assessed by a questionnaire. There was no significant difference in SAF between the athletes and controls. However, greater duration of exercise was independently associated with lower SAF. Diet also had an effect, with a more "Western" diet in youth being associated with increased SAF. Furthermore, our data demonstrated that greater Achilles tendon thickness was associated with aging and training. Together, our data indicate that long-term exercise may yield a modest reduction in glycation and substantially increase Achilles tendon size, which may protect against injury.

Ultrasonographic assessment of patellar tendon thickness at 16 clinically relevant measurement sites - A study of intra- and interrater reliability

OBJECTIVES

To determine intra- and interrater reliability of ultrasonographic imaging (USI) measurements of patellar tendon (PT) thickness using 16 measurement sites covering the entire tendon.

DESIGN

Reliability study.

SETTING

Physiotherapy outpatient clinic.

PARTICIPANTS

Twenty healthy and physically active volunteers (9 women). Mean age: 24 years (SD ± 2.73). Mean body mass: 75.8 kg (SD ± 11.8).

MAIN OUTCOME MEASURES

Intraclass correlation coefficient (ICC) and 95% limits of agreement (LOA) in cm and in percentage relative to the mean PT thickness.

RESULTS

Intrarater reliability ranged from 0.59 to 0.87 and 0.59 to 0.93 for examiners I and II, respectively. Interrater reliability ranged from 0.37 to 0.89. Measurement precision for examiner I ranged from 0.05 to 0.09 cm (17.5%-26.7%) while ranging from 0.04 to 0.13 cm (13.3%-38.7%) for examiner II. Interrater measurement precision ranged from 0.07 to 0.15 cm (19.1%-42.5%).

CONCLUSION

In an attempt to replicate daily clinical USI practice, this was the first study extensively assessing reliability throughout the full range of the patellar tendon - revealing a considerable variation in intra- and interrater reliability as well as measurement precision throughout the 16 individual PT sites. In a clinical context, the low interrater reliability and precision found at the proximal tendon insertion site may have implications for USI of the symptomatic PT, as this is the site mainly associated with underlying pathologic changes. Further reliability studies are needed to clarify the region-specific reliability of the full length PT.

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

BACKGROUND

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

OBJECTIVES

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

METHODOLOGY

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

RESULTS

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

CONCLUSION

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

Injected corticosteroids for treating plantar heel pain in adults

BACKGROUND

Plantar heel pain, commonly resulting from plantar fasciitis, often results in significant morbidity. Treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), orthoses, physical therapy, physical agents (e.g. extracorporeal shock wave therapy (ESWT), laser) and invasive procedures including steroid injections.

OBJECTIVES

To assess the effects (benefits and harms) of injected corticosteroids for treating plantar heel pain in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (the Cochrane Library), MEDLINE, Embase, CINAHL, clinical trials registries and conference proceedings. Latest search: 27 March 2017.

SELECTION CRITERIA

Randomised and quasi-randomised trials of corticosteroid injections in the treatment of plantar heel pain in adults were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

At least two review authors independently selected studies, assessed risk of bias and extracted data. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcome measures. We used a fixed-effect model unless heterogeneity was significant, when a random-effects model was considered. We assessed the overall quality of evidence for individual outcomes using the GRADE approach.

MAIN RESULTS

We included a total of 39 studies (36 randomised controlled trials (RCTs) and 3 quasi-RCTs) that involved a total of 2492 adults. Most studies were small (median = 59 participants). Participants' mean ages ranged from 34 years to 59 years. When reported, most participants had heel pain for several months. The trials were usually conducted in outpatient specialty clinics of tertiary care hospitals in 17 countries. Steroid injection was given with a local anaesthetic agent in 34 trials. Follow-up was from one month to over two years. With one exception, trials were assessed at high risk of bias in one or more domains, mostly relating to lack of blinding, including lack of confirmation of allocation concealment. With two exceptions, we rated the available evidence as very low quality, implying in each case that we are 'very uncertain about the estimate'.The 39 trials covered 18 comparisons, with six of the seven trials with three or four groups providing evidence towards two comparisons.Eight trials (724 participants) compared steroid injection versus placebo or no treatment. Steroid injection may lead to lower heel pain visual analogue scores (VAS) (0 to 100; higher scores = worse pain) in the short-term (< 1 month) (MD -6.38, 95% CI -11.13 to -1.64; 350 participants; 5 studies; I² = 65%; low quality evidence). Based on a minimal clinically significant difference (MCID) of 8 for average heel pain, the 95% CI includes a marginal clinical benefit. This potential benefit was diminished when data were restricted to three placebo-controlled trials. Steroid injection made no difference to average heel pain in the medium-term (1 to 6 months follow-up) (MD -3.47, 95% CI -8.43 to 1.48; 382 participants; 6 studies; I² = 40%; low quality evidence). There was very low quality evidence for no effect on function in the medium-term and for an absence of serious adverse events (219 participants, 4 studies). No studies reported on other adverse events, such as post-injection pain, and on return to previous activity. There was very low quality evidence for fewer treatment failures (defined variously as persistent heel pain at 8 weeks, steroid injection at 12 weeks, and unrelieved pain at 6 months) after steroid injection.The available evidence for other comparisons was rated as very low quality. We are therefore very uncertain of the estimates for the relative effects on people with heel pain of steroids compared with other interventions in:1. Tibial nerve block with anaesthetic (2 trials); orthoses (4 trials); oral NSAIDs (2 trials); and intensive physiotherapy (1 trial).2. Physical modalities: ESWT (5 trials); laser (2 trials); and radiation therapy (1 trial).3. Other invasive procedures: locally injectable NSAID (1 trial); platelet-rich plasma injections (5 trials); autologous blood injections (2 trials); botulinum toxin injections (2 trials); cryopreserved human amniotic membrane injection (1 trial); localised peppering with a needle (1 trial); dry needling (1 trial); and mini scalpel needle release (1 trial).We are also uncertain about the estimates from trials testing different techniques of local steroid injection: ultrasonography-guided versus palpation-guided (5 trials); and scintigraphy-guided versus palpation-guided (1 trial).An exploratory analysis involving pooling data from 21 trials reporting on adverse events revealed two ruptures of plantar fascia (reported in 1 trial) and three injection site infections (reported in 2 trials) in 699 participants allocated to steroid injection study arms. Five trials reported a total of 27 participants with less serious short-term adverse events in the 699 participants allocated steroid injection study arms. Reported treatments were analgesia, ice or both. Given the high risk of selective reporting for these outcomes and imprecision, this evidence was rated at very low quality.

AUTHORS' CONCLUSIONS

We found low quality evidence that local steroid injections compared with placebo or no treatment may slightly reduce heel pain up to one month but not subsequently. The available evidence for other outcomes of this comparison was very low quality. Where available, the evidence from comparisons of steroid injections with other interventions used to treat heel pain and of different methods of guiding the injection was also very low quality. Although serious adverse events relating to steroid injection were rare, these were under-reported and a higher risk cannot be ruled out.Further research should focus on establishing the effects (benefits and harms) of injected steroids compared with placebo in typical clinical settings, subsequent to a course of unsuccessful conservative therapy. Ideally, this should be preceded by research, including patient involvement, aimed to obtain consensus on the priority questions for treating plantar heel pain.

Higher skin autofluorescence in young people with Type 1 diabetes and microvascular complications

AIM

To test the hypothesis that non-invasive skin autofluorescence, a measure of advanced glycation end products, would provide a surrogate measure of long-term glycaemia and be associated with early markers of microvascular complications in adolescents with Type 1 diabetes.

METHODS

Forearm skin autofluorescence (arbitrary units) was measured in a cross-sectional study of 135 adolescents with Type 1 diabetes [mean ± sd age 15.6 ± 2.1 years, diabetes duration 8.7 ± 3.5 years, HbA_1c 72 ± 16 mmol/mol (8.7 ± 1.5%)]. Retinopathy, assessed using seven-field stereoscopic fundal photography, was defined as ≥1 microaneurysm or haemorrhage. Cardiac autonomic function was measured by standard deviation of consecutive RR intervals on a 10-min continuous electrocardiogram recording, as a measure of heart rate variability.

RESULTS

Skin autofluorescence was significantly associated with age (R² = 0.15; P < 0.001). Age- and gender-adjusted skin autofluorescence was associated with concurrent HbA_1c (R² = 0.32; P < 0.001) and HbA_1c over the previous 2.5-10 years (R² = 0.34-0.43; P < 0.002). Age- and gender-adjusted mean skin autofluorescence was higher in adolescents with retinopathy vs those without retinopathy [mean 1.38 (95% CI 1.29, 1.48) vs 1.22 (95% CI 1.17, 1.26) arbitrary units; P = 0.002]. In multivariable analysis, retinopathy was significantly associated with skin autofluorescence, adjusted for duration (R² = 0.19; P = 0.03). Cardiac autonomic dysfunction was also independently associated with skin autofluorescence (R² = 0.11; P = 0.006).

CONCLUSIONS

Higher skin autofluorescence is associated with retinopathy and cardiac autonomic dysfunction in adolescents with Type 1 diabetes. The relationship between skin autofluorescence and previous glycaemia may provide insight into metabolic memory. Longitudinal studies will determine the utility of skin autofluorescence as a non-invasive screening tool to predict future microvascular complications.

Plantar fascia enthesopathy is highly prevalent in diabetic patients without peripheral neuropathy and correlates with retinopathy and impaired kidney function

BACKGROUND

Aim of this study was to evaluate the prevalence of plantar fascia (PF) enthesopathy in Type 2 diabetes mellitus (T2DM) patients without distal peripheral neuropathy (DPN).

METHODS

We recruited 50 T2DM patients without DPN and 50 healthy controls. DPN was excluded using the Michigan Neuropathy Screening Instrument (MNSI). All patients underwent a bilateral sonographicevaluation of the enthesealportion of the PF.

RESULTS

PF thickness was significantly higher in T2DM patients (p<0.0001). T2DM patients presented a higher prevalence of entheseal thickening (p = 0.002), enthesophyte (p = 0.02) and cortical irregularity (p = 0.02). The overall sum of abnormalities was higher in T2DM patients (p<0.0001), as was the percentage of bilateral involvement (p = 0.005). In a logistic regression analysis, retinopathy predicted entheseal thickening (OR 3.5, p = 0.05) and enthesophytes (OR 5.13, p = 0.001); reduced eGFR predicted enthesophytes (OR 2.93, p = 0.04); body mass index (BMI) predicted cortical irregularity (OR 0.87, p = 0.05); mean glucose predicted enthesophyte (OR 1.01, p = 0.03); LDL cholesterol predicted cortical irregularity (OR 0.98, p = 0.02).

CONCLUSIONS

Our data suggest that T2DM is associated with PF enthesopathyindependently of DPN.

Imaging of plantar fascia disorders: findings on plain radiography, ultrasound and magnetic resonance imaging

Plantar fascia (PF) disorders commonly cause heel pain and disability in the general population. Imaging is often required to confirm diagnosis. This review article aims to provide simple and systematic guidelines for imaging assessment of PF disease, focussing on key findings detectable on plain radiography, ultrasound and magnetic resonance imaging (MRI). Sonographic characteristics of plantar fasciitis include PF thickening, loss of fibrillar structure, perifascial collections, calcifications and hyperaemia on Doppler imaging. Thickening and signal changes in the PF as well as oedema of adjacent soft tissues and bone marrow can be assessed on MRI. Radiographic findings of plantar fasciitis include PF thickening, cortical irregularities and abnormalities in the fat pad located deep below the PF. Plantar fibromatosis appears as well-demarcated, nodular thickenings that are iso-hypoechoic on ultrasound and show low-signal intensity on MRI. PF tears present with partial or complete fibre interruption on both ultrasound and MRI. Imaging description of further PF disorders, including xanthoma, diabetic fascial disease, foreign-body reactions and plantar infections, is detailed in the main text. Ultrasound and MRI should be considered as first- and second-line modalities for assessment of PF disorders, respectively. Indirect findings of PF disease can be ruled out on plain radiography.

Teaching Points

• PF disorders commonly cause heel pain and disability in the general population.

• Imaging is often required to confirm diagnosis or reveal concomitant injuries.

• Ultrasound and MRI respectively represent the first- and second-line modalities for diagnosis.

• Indirect findings of PF disease can be ruled out on plain radiography.

Musculoskeletal manifestations of diabetes mellitus

The prevalence of Type 1 and Type 2 diabetes are increasing significantly worldwide. Whilst vascular complications of diabetes are well recognized, and account for principle mortality and morbidity from the condition, musculoskeletal manifestations of diabetes are common and whilst not life threatening, are an important cause of morbidity, pain and disability. Joints affected by diabetes include peripheral joints and the axial skeleton. Charcot neuroarthropathy is an important cause of deformity and amputation associated with peripheral neuropathy. A number of fibrosing conditions of the hands and shoulder are recognized, including carpal tunnel syndrome, adhesive capsulitis, tenosynovitis and limited joint mobility. People with diabetes are more prone to gout and osteoporosis. Management of these conditions requires early recognition and close liaison between diabetes and rheumatology specialists.

Achilles tendons in people with type 2 diabetes show mildly compromised structure: an ultrasound tissue characterisation study

BACKGROUND

Musculotendinous overuse injuries are prevalent in people with type 2 diabetes. Non-enzymatic glycosylation of collagen resulting in tendon stiffening may play a role. In this case-control study we determined whether patients with diabetes had poorer ultrasonographic structure in their Achilles tendons compared to age-matched controls.

METHODS

People with type 1 diabetes or type 2 diabetes, and age-matched controls, had computerised ultrasound tissue characterisation of both Achilles tendons. In contiguous ultrasonographic images of the tendon, echopatterns were quantified and categorised into four echo-types. Tendon abnormality was quantified as sum of echo-types III+IV. Furthermore, skin autofluorescence (AF) of the forearm (AF-value) was gathered.

RESULTS

Twenty four type 2 diabetes patients, 24 controls, 24 type 1 diabetes patients and 20 controls were included. AF-value was higher in type 1 diabetes (1.55±0.17) than in their controls (1.39±0.18, p<0.001) and in type 2 diabetes (2.28±0.38) compared to their controls (1.84±0.32, p<0.001) Achilles tendons of type 2 diabetes patients contained more echo-types III+IV (14.1±7.9%) than matched controls (8.0±5.4%, p<0.001). There was a trend towards a difference in echo-types III+IV between type 1 diabetes patients (9.5±5.3%) and their controls (6.5±3.7%, p=0.055). In a stepwise linear regression analysis, body mass index (BMI) was moderately associated with tendon abnormality in patients with diabetes and controls (β=0.393, p<0.001).

CONCLUSIONS

Type 2, and possibly type 1, diabetes patients showed poorer ultrasonographic Achilles tendon structure that may be a risk factor for tendinopathy. Although markers for accumulation of advanced glycation end products were elevated in both diabetes populations, only BMI was associated with these abnormalities.

TRIAL REGISTRATION NUMBER

NTR2209.

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

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

Poorer glycaemic control is associated with increased skin thickness at injection sites in children with type 1 diabetes

We aimed to assess the association between skin thickness and glycaemic control in children with type 1 diabetes. Forty-five children (51% males) aged 10.5 ± 2.1 years were studied. Thickness of skin layers were determined by ultrasonography, with participants having ultrasound scans of three anatomical regions (abdomen, thigh, and buttocks). Poorer glycaemic control (increasing HbA1c values) was associated with greater thickness of the dermis (p = 0.015), with an estimated thickening of 87 μm with every 1% increase in HbA1c. Our data suggest that dermal changes associated with poorer glycaemic control in adults are also observed in childhood.

Skin autofluorescence reflects integration of past long-term glycemic control in patients with type 1 diabetes

OBJECTIVE

The aim was to investigate the relationships between skin autofluorescence (AF) and the impact of past glycemic control and microvascular complications in Japanese patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Two hundred forty-one patients and 110 controls were enrolled. Advanced glycation end product accumulation was measured with AF reader. Three monthly HbA1c levels during the past 20 years were determined from medical records, and the HbA1c area under the curve (AUC) was calculated. We performed multivariate regression analyses to examine the associations between the severity of diabetes complications and various variables.

RESULTS

Skin AF values increased with increasing the severity of retinopathy (P < 10(-11), linear regression analysis) and nephropathy (P < 10(-5) for chronic kidney disease stage; P < 10(-5) for albuminuria-based stage). HbA1c AUC values over the past 15 years were significantly correlated with skin AF values (past 5 years: R = 0.35, P < 0.0001; past 10 years: R = 0.36, P < 0.0001; past 15 years: R = 0.55, P < 0.0001; past 20 years: R = 0.22, P = 0.13). HbA1c AUC values over the past 3, 5, 10, and 15 years were significantly associated with the severity of both nephropathy and retinopathy. Multivariate analyses in which HbA1c AUC value was removed from the independent variables indicated that only skin AF was independently associated with nephropathy, whereas age at registration, age at onset of diabetes, and skin AF were independently associated with retinopathy.

CONCLUSIONS

Skin AF reflects past long-term glycemic control and may serve as a surrogate marker for the development of microvascular complications in place of HbA1c AUC value.

[Update on diabetic macroangiopathy]

Current findings from the literature on the multifactorial genesis of macroangiopathy of diabetes mellitus (DM) were compiled using the PubMed database. The primary aim was to find an explanation for the morphological, immunohistochemical and molecular characteristics of this form of atherosclerosis. The roles of advanced glycation end products (AGE), defective signal transduction and imbalance of matrix metalloproteinases in the increased progression of atherosclerosis in coronary and cerebral arteries as well as peripheral vascular disease are discussed. The restricted formation of collateral arteries (arteriogenesis) in diabetic patients with postischemic lesions is also a focus of attention. The increased level of prothrombotic factors and the role of diabetic neuropathy in DM are also taken into account. Therapeutic influences of AGE-RAGE (receptor of AGE) interactions on the vascular wall and the effects of endothelial progenitor cells in the repair of diabetic vascular lesions are additionally highlighted.

Plantar fascia thickness is longitudinally associated with retinopathy and renal dysfunction: a prospective study from adolescence to adulthood

AIM

The aim was to study the longitudinal relationship between plantar fascia thickness (PFT) as a measure of tissue glycation and microvascular (MV) complications in young persons with type 1 diabetes (T1DM).

METHODS

We conducted a prospective longitudinal cohort study of 152 (69 male) adolescents with T1DM who underwent repeated MV complications assessments and ultrasound measurements of PFT from baseline (1997-2002) until 2008. Retinopathy was assessed by 7-field stereoscopic fundal photography and nephropathy by albumin excretion rate (AER) from three timed overnight urine specimens. Longitudinal analysis was performed using generalized estimating equations (GEE).

RESULTS

Median (interquartile range) age at baseline was 15.1 (13.4-16.8) years, and median follow-up was 8.3 (7.0-9.5) years, with 4 (3-6) visits per patient. Glycemic control improved from baseline to final visit [glycated hemoglobin (HbA1c) 8.5% to 8.0%, respectively; p = .004]. Prevalence of retinopathy increased from 20% to 51% (p < .001) and early elevation of AER (>7.5 μg/min) increased from 26% to 29% (p = .2). A greater increase in PFT (mm/year) was associated with retinopathy at the final assessment (ΔPFT 1st vs. 2nd-4th quartiles, χ(2) = 9.87, p = .02). In multivariate GEE, greater PFT was longitudinally associated with retinopathy [odds ratio (OR) 4.6, 95% confidence interval (CI) 2.0-10.3] and early renal dysfunction (OR 3.2, CI 1.3-8.0) after adjusting for gender, blood pressure standard deviation scores, HbA1c, and total cholesterol.

CONCLUSIONS

In young people with T1DM, PFT was longitudinally associated with retinopathy and early renal dysfunction, highlighting the importance of early glycemic control and supporting the role of metabolic memory in MV complications. Measurement of PFT by ultrasound offers a noninvasive estimate of glycemic burden and tissue glycation.

Intra- and interobserver reliability of quantitative ultrasound measurement of the plantar fascia

PURPOSE

To determine intra- and interobserver reliability and measurement precision of sonographic assessment of plantar fascia thickness when using one, the mean of two, or the mean of three measurements.

METHODS

Two experienced observers scanned 20 healthy subjects twice with 60 minutes between test and retest. A GE LOGIQe ultrasound scanner was used in the study. The built-in software in the scanner was used to measure the thickness of the plantar fascia (PF). Reliability was calculated using intraclass correlation coefficient (ICC) and limits of agreement (LOA).

RESULTS

Intraobserver reliability (ICC) using one measurement was 0.50 for one observer and 0.52 for the other, and using the mean of three measurements intraobserver reliability increased up to 0.77 and 0.67, respectively. Interobserver reliability (ICC) when using one measurement was 0.62 and increased to 0.82 when using the average of three measurements. LOA showed that when using the average of three measurements, LOA decreased to 0.6 mm, corresponding to 17.5% of the mean thickness of the PF.

CONCLUSIONS

The results showed that reliability increases when using the mean of three measurements compared with one. Limits of agreement based on intratester reliability shows that changes in thickness that are larger than 0.6 mm can be considered actual changes in thickness and not a result of measurement error.

Plantar enthesopathy: thickening of the enthesis is correlated with energy dissipation of the plantar fat pad during walking

BACKGROUND

The enthesis of the plantar fascia is thought to play an important role in stress dissipation. However, the potential link between entheseal thickening characteristic of enthesopathy and the stress-dissipating properties of the intervening plantar fat pad have not been investigated.

PURPOSE

This study was conducted to identify whether plantar fat pad mechanics explain variance in the thickness of the fascial enthesis in individuals with and without plantar enthesopathy.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The study population consisted of 9 patients with unilateral plantar enthesopathy and 9 asymptomatic, individually matched controls. The thickness of the enthesis of the symptomatic, asymptomatic, and a matched control limb was acquired using high-resolution ultrasound. The compressive strain of the plantar fat pad during walking was estimated from dynamic lateral radiographs acquired with a multifunction fluoroscopy unit. Peak compressive stress was simultaneously acquired via a pressure platform. Principal viscoelastic parameters were estimated from subsequent stress-strain curves.

RESULTS

The symptomatic fascial enthesis (6.7 ± 2.0 mm) was significantly thicker than the asymptomatic enthesis (4.2 ± 0.4 mm), which in turn was thicker than the enthesis (3.3 ± 0.4 mm) of control limbs (P < .05). There was no significant difference in the mean thickness, peak stress, peak strain, or secant modulus of the plantar fat pad between limbs. However, the energy dissipated by the fat pad during loading and unloading was significantly lower in the symptomatic limb (0.55 ± 0.17) when compared with asymptomatic (0.69 ± 0.13) and control (0.70 ± 0.09) limbs (P < .05). The sonographic thickness of the enthesis was correlated with the energy dissipation ratio of the plantar fat pad (r = .72, P < .05), but only in the symptomatic limb.

CONCLUSION

The energy-dissipating properties of the plantar fat pad are associated with the sonograpic appearance of the enthesis in symptomatic limbs, providing a previously unidentified link between the mechanical behavior of the plantar fat pad and enthesopathy.

A constitutive model for the mechanical characterization of the plantar fascia

A constitutive model is proposed to describe the mechanical behavior of the plantar fascia. The mechanical characterization of the plantar fascia regards the role in the foot biomechanics and it is involved in many alterations of its functional behavior, both of mechanical and nonmechanical origin. The structural conformation of the plantar fascia in its middle part is characterized by the presence of collagen fibers reinforcing the tissue along a preferential orientation, which is that supporting the major loading. According to this anatomical evidence, the tissue is described by developing an isotropic fiber-reinforced constitutive model and since the elastic response of the fascia is here considered, the constitutive model is based on the theory of hyperelasticity. The model is consistent with a kinematical description of large strains mechanical behavior, which is typical of soft tissues. A fitting procedure of the constitutive model is implemented making use of experimental curves taken from the literature and referring to specimens of human plantar fascia. A satisfactory fitting of the tensile behavior of the plantar fascia has been performed, showing that the model correctly interprets the mechanical behavior of the tissue in the light of comparison to experimental data at disposal. A critical analysis of the model with respect to the problem of the identification of the constitutive parameters is proposed as the basis for planning a future experimental investigation of mechanical behavior of the plantar fascia.

The fascia of the limbs and back--a review

Although fasciae have long interested clinicians in a multitude of different clinical and paramedical disciplines, there have been few attempts to unite the ensuing diverse literature into a single review. The current article gives an anatomical perspective that extends from the gross to the molecular level. For expediency, it deals only with fascia in the limbs and back. Particular focus is directed towards deep fascia and thus consideration is given to structures such as the fascia lata, thoracolumbar fascia, plantar and palmar fascia, along with regional specializations of deep fascia such as retinacula and fibrous pulleys. However, equal emphasis is placed on general aspects of fascial structure and function, including its innervation and cellular composition. Among the many functions of fascia considered in detail are its ectoskeletal role (as a soft tissue skeleton for muscle attachments), its importance for creating osteofascial compartments for muscles, encouraging venous return in the lower limb, dissipating stress concentration at entheses and acting as a protective sheet for underlying structures. Emphasis is placed on recognizing the continuity of fascia between regions and appreciating its key role in coordinating muscular activity and acting as a body-wide proprioceptive organ. Such considerations far outweigh the significance of viewing fascia in a regional context alone.

Albuminuria in children

PURPOSE OF REVIEW

Albuminuria is a marker of present and future cardiovascular and renal morbidity, and mortality, in adults. Because the roots of these diseases extend back into childhood, assessment of albuminuria has become relevant to child and adolescent clinical care.

RECENT FINDINGS

Normal levels of albumin excretion in children are well below the cut-off for microalbuminuria. In healthy children, albuminuria relates to fasting insulin, but not blood pressure, BMI, lipid levels, fasting glucose, or insulin resistance. In obese children, albuminuria relates to multiple measures of insulin resistance. In children with type 1 diabetes, hemoglobin A1c seems to be the most consistent clinical predictor of microalbuminuria although multiple mechanisms seem to be involved, including genetic polymorphisms. Children with type 2 diabetes and hypertension already exhibit microalbuminuria.

SUMMARY

When considering the population as a whole, children make ideal subjects in which to study the natural history of albuminuria given their relative lack of multiple morbidities commonly seen in adults. The unfortunate rise in 'adult' diseases in the pediatric age group makes this especially relevant. There is a need for longitudinal studies examining predictors of elevated urinary albumin levels as well as potential treatment strategies.

Association between p.Leu54Met polymorphism at the paraoxonase-1 gene and plantar fascia thickness in young subjects with type 1 diabetes

OBJECTIVE

In type 1 diabetes, plantar fascia, a collagen-rich tissue, is susceptible to glycation and oxidation. Paraoxonase-1 (PON1) is an HDL-bound antioxidant enzyme. PON1 polymorphisms have been associated with susceptibility to macro- and microvascular complications. We investigated the relationship between plantar fascia thickness (PFT) and PON1 gene variants, p.Leu54Met, p.Gln192Arg, and c.-107C>T, in type 1 diabetes.

RESEARCH DESIGN AND METHODS

This was a cross-sectional study of 331 adolescents with type 1 diabetes (162 male and 169 female). PFT was assessed by ultrasound, PON1 was assessed by genotyping with PCR and restriction fragment-length polymorphism, and serum PON1 activity was assessed by rates of hydrolysis of paraoxon and phenylacetate.

RESULTS

Median (interquartile range) age was 15.4 (13.5-17.3) years, and diabetes duration was 7.6 (4.9-10.6) years. The distribution of p.Leu54Met genotypes was LL 135 (40.8%), ML 149 (45%), and MM 47 (14.2%). PFT was abnormal (>1.7 mm) in 159 adolescents (48%). In multivariate analysis, predictors of abnormal PFT were ML/LL versus MM p.Leu54Met polymorphism (odds ratio 3.84 [95% CI 1.49-9.82], P = 0.005); BMI (percentile) (1.02 [1.01-1.03], P = 0.007); systolic blood pressure (percentile) (1.01 [1.00-1.02], P = 0.03); and male sex (3.29 [1.98-5.46], P < 0.001).

CONCLUSIONS

Thickening of the plantar aponeurosis occurs predominantly in overweight and male adolescents with type 1 diabetes. The MM genotype at PON1 p.Leu54Met is associated with a reduced risk of abnormal PFT.