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Toledo TG, Freire LAM, dos Reis LM, Terra AMSV, Santos ATS. Effect of Foot Reflexology on Muscle Electrical Activity, Pressure, Plantar Distribution, and Body Sway in Patients with Type 2 Diabetes Mellitus: A Pilot Randomized Controlled Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:14547. [PMID: 36361426 PMCID: PMC9655389 DOI: 10.3390/ijerph192114547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To verify the effect of foot reflexology on the electrical muscle activity of the lateral and medial gastrocnemius muscle, and to examine the distribution, plantar pressure, and body sway in patients with type 2 diabetes mellitus. METHODS This pilot randomized controlled trial enrolled 17 volunteers who were clinically diagnosed with diabetes mellitus. The sample was assigned to one of two groups: the control group (CG, n = 7), who received information on foot care and health, and the intervention group (IG, n = 10), who received the application of foot reflexology on specific areas of the feet, for 10 consecutive days. There was blinding of the evaluator and the therapist. Surface electromyography (EMG) was used to assess the electrical activity of the medial and lateral gastrocnemius muscles in maximum voluntary isometric contraction (MVIC) and isotonic contraction (IC); baropodometry and stabilometry were used to analyze unloading, plantar weight distribution, and body sway. RESULTS There was a statistically significant difference for the variables of maximum peak electrical activity of the left medial gastrocnemius (p = 0.03; effect size = 0.87 and power = 0.81) and left lateral gastrocnemius muscles (p = 0.04, effect size = 0.70 and power = 0.66) respectively, in the intragroup IC, and median frequency of the left medial gastrocnemius muscle in the intragroup MVIC (p = 0.03; effect size = 0.64 and power = 0.59), and in the variables intergroups of the total area on the right side (p = 0.04; effect size = 1.03 and power = 0.50) and forefoot area on the left side (p = 0.02; effect size = 0.51 and power = 0.16). CONCLUSIONS We conclude that foot reflexology influenced some variables of the intergroup plantar distribution and intragroup EMG in the sample studied. There is a need for a placebo group, a larger sample and a follow-up to strengthen the findings of these experiments.
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Affiliation(s)
- Thais Gebin Toledo
- Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
- Post-Graduation in Rehabilitation Sciencies, Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
| | - Larissa Alves Moreira Freire
- Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
| | - Luciana Maria dos Reis
- Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
- Post-Graduation in Rehabilitation Sciencies, Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
| | - Andréia Maria Silva Vilela Terra
- Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
- Post-Graduation in Rehabilitation Sciencies, Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
| | - Adriana Teresa Silva Santos
- Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
- Post-Graduation in Rehabilitation Sciencies, Human Performance Research Laboratory, Institute of Motor Sciences, Federal University of Alfenas, Santa Clara Campus, Alfenas 37133-840, MG, Brazil
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Rasmussen NH, Vestergaard P. Diabetes and osteoporosis - Treating two entities: A challenge or cause for concern? Best Pract Res Clin Rheumatol 2022; 36:101779. [PMID: 36154803 DOI: 10.1016/j.berh.2022.101779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
People with T1D and T2D have an increased risk of fractures than the general population, posing several significant pathophysiologic, diagnostic, and therapeutic challenges. The pathophysiology is still not fully elucidated, but it is considered a combination of increased skeletal fragility and falls. Diagnostics issues exist, as regular and even newer scan methods underestimate the true incidence of osteoporosis and thus the fracture risk. Therefore, co-managing diabetes and osteoporosis by using top-line strategies is essential to preserve bone health and minimize the risk of falls. The therapeutic focus should start with lifestyle implementation and physical exercise interventions to reduce diabetic complications, strengthen bones, and improve postural control strategies. In addition, osteoporosis should be treated according to current guidelines by including bisphosphonates and antidiabetic drugs that support bone health. Finally, potentially modifiable risk factors for falls should be managed.
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Affiliation(s)
| | - Peter Vestergaard
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Denmark
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EMG analysis across different tasks improves prevention screenings in diabetes: a cluster analysis approach. Med Biol Eng Comput 2022; 60:1659-1673. [PMID: 35428958 PMCID: PMC9079040 DOI: 10.1007/s11517-022-02559-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/27/2022] [Indexed: 11/01/2022]
Abstract
Abstract
The aim of this work was twofold: on one side to determine the most suitable parameters of surface electromyography (sEMG) to classify diabetic subjects with and without neuropathy and discriminate them from healthy controls and second to assess the role of the task acquired in the classification process. For this purpose 30 subjects were examined (10 controls, 10 diabetics with and 10 without neuropathy) whilst walking and stair ascending and descending. The electrical activity of six muscles was recorded bilaterally through a 16-channel sEMG system synchronised with a stereophotogrammetric system: Rectus Femoris, Gluteus Medius, Tibialis Anterior, Peroneus Longus, Gastrocnemius Lateralis and Extensor Digitorum. Spatiotemporal parameters of gait and stair climbing and the following sEMG parameters were extracted: signal envelope, activity duration, timing of activation and deactivation. A hierarchical clustering algorithm was applied to the whole set of parameters with different distances and linkage methods. Results showed that only by applying the Ward agglomerative hierarchical clustering (Hamming distance) to the all set of parameters extracted from both tasks, 5 well-separated clusters were obtained: cluster 3 included only DS subjects, cluster 2 and 4 only controls and cluster 1 and 5 only DNS subjects. This method could be used for planning rehabilitation treatments.
Graphical abstract
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Khan KS, Andersen H. The Impact of Diabetic Neuropathy on Activities of Daily Living, Postural Balance and Risk of Falls - A Systematic Review. J Diabetes Sci Technol 2022; 16:289-294. [PMID: 33719603 PMCID: PMC8861804 DOI: 10.1177/1932296821997921] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of this review is to discuss a compilation of the currently available literature regarding the impact of diabetic neuropathy (DN) on activities of daily living (ADL), postural stability, and risk of falls. METHODS A systematic electronic search strategy was conducted on PubMed/MEDLINE database, Cochrane Library, and Embase in March 2020. This narrative review included clinical cross-sectional studies assessing ADL, postural balance, and falls in adults with DN. All studies underwent a quality assessment based on the Newcastle Ottawa scale developed to assess cross-sectional studies. RESULTS Forty-two studies were identified. A total of 37 studies evaluated postural stability in DN, 10 studies assessed fall accidents, and three studies assessed ADL in individuals with DN. Seven studies assessed both postural stability and fall accidents, and one study assessed postural stability and ADL. Each of the studied outcome variables was assessed separately. Based on a quality assessment, eight studies were excluded resulting in an evaluation of 34 studies. CONCLUSIONS Diabetic neuropathy has a negative impact on postural balance and gait kinematics combined with an increased fall risk. Because of the few number of studies available, we were unable to evaluate the impact of DN on ADL. Our findings are in concordance with previous reviews, supporting the evidence for DN as a critical measure negatively impacting postural stability and fall risk in individuals with diabetes. Further clinical investigative studies are needed.
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Orlando G, Balducci S, Boulton AJM, Degens H, Reeves ND. Neuromuscular dysfunction and exercise training in people with diabetic peripheral neuropathy: A narrative review. Diabetes Res Clin Pract 2022; 183:109183. [PMID: 34929255 DOI: 10.1016/j.diabres.2021.109183] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/29/2021] [Accepted: 12/13/2021] [Indexed: 11/21/2022]
Abstract
Diabetic peripheral neuropathy (DPN) is a common condition that is associated with neuromuscular dysfunction and peripheral sensory impairment. These deficits predispose patients to sensory and motor system limitations, foot ulcers and a high risk of falls. Exercise training has been proposed as an effective tool to alleviate neural deficits and improve whole-body function. Here we review the effects of DPN on neuromuscular function, the mechanisms underlying this impairment, and the neural and muscular adaptations to exercise training. Muscle dysfunction is an early hallmark of DPN. Deficits in muscle strength, power, mass and a greater fatigability are particularly severe in the lower extremity muscles. Non-enzymatic glycation of motor proteins, impaired excitation-contraction coupling and loss of motor units have been indicated as the main factors underlying muscular dysfunction. Among the exercise-based solutions, aerobic training improves neural structure and function and ameliorates neuropathic signs and symptoms. Resistance training induces marked improvement of muscle performance and may alleviate neuropathic pain. A combination of aerobic and resistance training (i.e., combined training) restores small sensory nerve damage, reduces symptoms, and improves muscle function. The evidence so far suggests that exercise training is highly beneficial and should be included in the standard care for DPN patients.
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Affiliation(s)
- Giorgio Orlando
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK.
| | | | - Andrew J M Boulton
- Department of Medicine, Manchester Royal Infirmary, Manchester, UK; Diabetes Research Institute, University of Miami, Miami, FL, USA
| | - Hans Degens
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK; Lithuanian Sport University, Kaunas, Lithuania
| | - Neil D Reeves
- Research Centre for Musculoskeletal Science & Sports Medicine, Department of Life Sciences, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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Rosenblatt NJ, Young J, Andersen R, Wu. SC, Crews RT. Diabetes and Reactive Balance: Quantifying Stepping Thresholds With a Simple Spring Scale to Measure Fall-Risk in Ambulatory Older Adults. J Diabetes Sci Technol 2021; 15:1352-1360. [PMID: 33354995 PMCID: PMC8655272 DOI: 10.1177/1932296820979970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fall-risk assessments for patients with diabetes fail to consider reactive responses to balance loss. The purpose of this study was to assess the feasibility of using a simple clinical tool to evaluate the impact of diabetes and fall history on reactive balance in older adults. METHODS We recruited 72 older adults with and without diabetes. Postural perturbations were applied by a waist-mounted spring scale. Stepping thresholds (STs) in the anterior and posterior directions were defined as the lowest spring-loads that induced a step. Balance was assessed via the National Institutes of Health Toolbox Standing Balance Test, and lower extremity sensation was assessed using vibratory perception threshold and Semmes-Weinstein monofilaments. Fall history over the past year was self-reported. Cox regressions and analysis of variance were used to compare hazard rates for stepping and observed STs between groups. RESULTS Anterior STs were elicited in 42 subjects and posterior STs in 65 subjects. Hazard rates for posterior ST were significantly affected by diabetes, with greater hazards for fallers with diabetes versus control fallers and nonfallers, after accounting for balance and sensory loss. For those who stepped, ST was lower in the posterior direction for the diabetes group. Additionally, anterior but not posterior ST was lower in all fallers vs all nonfallers. CONCLUSIONS The waist-mounted spring scale is a clinically implementable device that can assess ST in older adults with diabetes. Using the device, we demonstrated that ST was affected by diabetes and could potentially serve as a fall-risk factor independent of balance or sensory loss.
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Affiliation(s)
- Noah J. Rosenblatt
- Dr William M. Scholl College of
Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
- Noah Rosenblatt, Dr. William M. Scholl
College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research
(CLEAR) at Rosalind Franklin University of Medicine and Science, 3333 Green Bay
Road, North Chicago, IL 60064, USA.
| | - Jennifer Young
- Dr William M. Scholl College of
Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Ryley Andersen
- Dr William M. Scholl College of
Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Stephanie C. Wu.
- Dr William M. Scholl College of
Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Ryan T. Crews
- Dr William M. Scholl College of
Podiatric Medicine’s Center for Lower Extremity Ambulatory Research (CLEAR) at
Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
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The Application of Exercise Training for Diabetic Peripheral Neuropathy. J Clin Med 2021; 10:jcm10215042. [PMID: 34768562 PMCID: PMC8584831 DOI: 10.3390/jcm10215042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/13/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022] Open
Abstract
Diabetic peripheral neuropathy (DPN) is the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after the exclusion of other causes. It is associated with pain, paresthesia, sensory loss, muscle atrophy with fat infiltration, and muscular dysfunction typically starting distally in the feet and progressing proximally. Muscle deterioration within the leg and foot can lead to muscle dysfunction, reduced mobility, and increases the risk of disability, ulceration, and amputation. Exercise training is an established method for increasing the different components of physical fitness, including enhancing body composition and improving neuromuscular strength. A number of experimental studies have utilized exercise training to treat various impairments associated with DPN, such as nerve conduction velocity, pain tolerance, and balance. However, the broad spectrum of exercise training modalities implemented and differences in target outcome measurements have made it difficult to understand the efficacy of exercise training interventions or provide appropriate exercise prescription recommendations. Therefore, the aims of this review were to (1) briefly describe the pathophysiology of DPN and (2) discuss the effects of exercise training interventions on sensorimotor, metabolic, and physical functions in people with DPN.
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Khan KS, Pop-Busui R, Devantier L, Kristensen AG, Tankisi H, Dalgas U, Overgaard K, Andersen H. Falls in individuals with type 2 diabetes; a cross-sectional study on the impact of motor dysfunction, postural instability and diabetic polyneuropathy. Diabet Med 2021; 38:e14470. [PMID: 33259675 DOI: 10.1111/dme.14470] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 01/19/2023]
Abstract
AIM To estimate the incidence of falls in individuals with type 2 diabetes compared to healthy controls and to describe the characteristics of fallers with type 2 diabetes in relation to motor dysfunction, postural instability and diabetic polyneuropathy (DPN). METHODS This is a cross-sectional study of individuals with type 2 diabetes with DPN (n = 54), without DPN (n = 38) and healthy controls (n = 39). Falls were recorded within the preceding year. DPN was defined by clinical scores and nerve conduction studies. Motor function was assessed by a 6-min walk test (6 MWT), five-time sit-to-stand test (FTSST) and isokinetic dynamometry at the non-dominant ankle and knee. An instability index (ST) was measured using static posturography. Univariate and bivariate descriptive statistics were used for group comparisons. RESULTS Compared with healthy controls, individuals with diabetes had a higher incidence of falls 36%, (n = 33) versus 15%, (n = 6), p = 0.02. There were no differences in falls when comparing individuals with and without DPN. Fallers had an impaired 6 MWT versus non-fallers (450 ± 153 m vs. 523 ± 97 m respectively), a slower FTSST (11.9 ± 4.2 s vs. 10.3 ± 2.9 s respectively) and a higher ST (53 ± 29 vs. 41 ± 17 respectively), p < 0.02 for all. CONCLUSION Individuals with type 2 diabetes reported a higher number of falls within the preceding year compared to healthy controls, irrespective of the presence of DPN. The main factors associated with falls were increased postural instability, lower walking capacity and slower sit-to-stand movements. The 6 MWT, FTSST and posturography should be considered in future screening programs in identification of individuals at risk for falls.
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Affiliation(s)
- Karolina S Khan
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Louise Devantier
- Department of Oto-Rhino-Laryngology, Regional Hospital West Jutland, Denmark
| | - Alexander G Kristensen
- Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Aarhus University, Aarhus, Denmark
| | - Hatice Tankisi
- Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Clinical Neurophysiology, Aarhus University, Aarhus, Denmark
| | - Ulrik Dalgas
- Sport Biological Research, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Kristian Overgaard
- Sport Biological Research, Department of Public Health, Aarhus University, Aarhus, Denmark
| | - Henning Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
- Faculty of Health, Aarhus University, Aarhus, Denmark
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Reeves ND, Orlando G, Brown SJ. Sensory-Motor Mechanisms Increasing Falls Risk in Diabetic Peripheral Neuropathy. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57050457. [PMID: 34066681 PMCID: PMC8150714 DOI: 10.3390/medicina57050457] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/16/2021] [Accepted: 04/30/2021] [Indexed: 12/25/2022]
Abstract
Diabetic peripheral neuropathy (DPN) is associated with peripheral sensory and motor nerve damage that affects up to half of diabetes patients and is an independent risk factor for falls. Clinical implications of DPN-related falls include injury, psychological distress and physical activity curtailment. This review describes how the sensory and motor deficits associated with DPN underpin biomechanical alterations to the pattern of walking (gait), which contribute to balance impairments underpinning falls. Changes to gait with diabetes occur even before the onset of measurable DPN, but changes become much more marked with DPN. Gait impairments with diabetes and DPN include alterations to walking speed, step length, step width and joint ranges of motion. These alterations also impact the rotational forces around joints known as joint moments, which are reduced as part of a natural strategy to lower the muscular demands of gait to compensate for lower strength capacities due to diabetes and DPN. Muscle weakness and atrophy are most striking in patients with DPN, but also present in non-neuropathic diabetes patients, affecting not only distal muscles of the foot and ankle, but also proximal thigh muscles. Insensate feet with DPN cause a delayed neuromuscular response immediately following foot–ground contact during gait and this is a major factor contributing to increased falls risk. Pronounced balance impairments measured in the gait laboratory are only seen in DPN patients and not non-neuropathic diabetes patients. Self-perception of unsteadiness matches gait laboratory measures and can distinguish between patients with and without DPN. Diabetic foot ulcers and their associated risk factors including insensate feet with DPN and offloading devices further increase falls risk. Falls prevention strategies based on sensory and motor mechanisms should target those most at risk of falls with DPN, with further research needed to optimise interventions.
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Perazzolo M, Reeves ND, Bowling FL, Boulton AJM, Raffi M, Marple‐Horvat DE. Altered accelerator pedal control in a driving simulator in people with diabetic peripheral neuropathy. Diabet Med 2020; 37:335-342. [PMID: 30924960 PMCID: PMC7004113 DOI: 10.1111/dme.13957] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2019] [Indexed: 11/29/2022]
Abstract
AIM To investigate whether the sensory-motor impairment attributable to diabetic peripheral neuropathy would affect control of the accelerator pedal during a driving simulator task. METHODS A total of 32 active drivers, 11 with diabetic peripheral neuropathy (mean ± sd age 67±5.0 years), 10 with diabetes but no neuropathy (diabetes group; mean ± sd age 62±10 years), and 11 healthy individuals without diabetes (healthy group; mean ± sd age 60±11 years), undertook a test on a dynamometer to assess ankle plantar flexor muscle strength and ankle joint proprioception function of the right leg, in addition to a driving simulator task. The following variables were measured: maximal ankle plantar flexor muscle strength; speed of strength generation (Nm/s); and ankle joint proprioception (ankle repositioning error, degrees). In the driving simulator task, driving speed (mph), accelerator pedal signal (degrees) and the duration of specific 'loss-of-control events' (s) were measured during two drives (Drive 1, Drive 2). RESULTS Participants with diabetic peripheral neuropathy had a lower speed of strength generation (P<0.001), lower maximal ankle plantar flexor muscle strength (P<0.001) and impaired ankle proprioception (P=0.034) compared to healthy participants. The diabetic peripheral neuropathy group drove more slowly compared with the healthy group (Drive 1 P=0.048; Drive 2 P=0.042) and showed marked differences in the use of the accelerator pedal compared to both the diabetes group (P=0.010) and the healthy group (P=0.002). Participants with diabetic peripheral neuropathy had the longest duration of loss-of-control events, but after one drive, this was greatly reduced (P=0.023). CONCLUSIONS Muscle function, ankle proprioception and accelerator pedal control are all affected in people with diabetic peripheral neuropathy, adversely influencing driving performance, but potential for improvement with targeted practice remains possible.
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Affiliation(s)
- M. Perazzolo
- Research Centre for Musculoskeletal Science and Sports MedicineSchool of Healthcare ScienceFaculty of Science and EngineeringManchester Metropolitan UniversityManchesterUK
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - N. D. Reeves
- Research Centre for Musculoskeletal Science and Sports MedicineSchool of Healthcare ScienceFaculty of Science and EngineeringManchester Metropolitan UniversityManchesterUK
| | - F. L. Bowling
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
| | - A. J. M. Boulton
- Faculty of Biology, Medicine and HealthUniversity of ManchesterManchesterUK
- Diabetes Research InstituteUniversity of MiamiMiamiFLUSA
| | - M. Raffi
- Department of Biomedical and Neuromotor SciencesUniversity of BolognaBolognaItaly
| | - D. E. Marple‐Horvat
- Research Centre for Musculoskeletal Science and Sports MedicineSchool of Healthcare ScienceFaculty of Science and EngineeringManchester Metropolitan UniversityManchesterUK
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Fernando ME, Crowther RG, Lazzarini PA, Sangla KS, Wearing S, Buttner P, Golledge J. Gait in People With Nonhealing Diabetes-Related Plantar Ulcers. Phys Ther 2019; 99:1602-1615. [PMID: 31411324 DOI: 10.1093/ptj/pzz119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/26/2019] [Accepted: 04/20/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND Abnormalities in gait have been associated with high plantar pressures and diabetes-related plantar foot ulcers. Whether these are a transient response to the ulcer or are representative of long-term lower limb biomechanical abnormalities is currently unknown. OBJECTIVE The aim of this study was to examine whether 12 gait parameters identified as being associated with nonhealing diabetes-related plantar foot ulcers at baseline remained associated during a 6-month follow-up period. DESIGN This was a longitudinal observational case-control study. METHODS Gait assessments were performed at entry and twice during follow-up over a 6-month period in 12 participants with nonhealing diabetes-related plantar foot ulcers (case participants) and 62 people with diabetes and no history of foot ulcers (control participants) using a standardized protocol. Linear mixed-effects random-intercept models were used to identify gait parameters that consistently differed between case participants and control participants at all assessments after adjustment for age, sex, body mass index, presence of peripheral neuropathy, and follow-up time. Standardized mean differences (SMD) were used to measure effect sizes. RESULTS Five of the 12 gait parameters were significantly different between case participants and control participants at all 3 time points. Case participants had a more abducted foot progression angle (SMD = 0.37), a higher pelvic obliquity at toe-off (SMD = -0.46), a greater minimum pelvic obliquity (SMD = -0.52), a lower walking speed (SMD = -0.46), and a smaller step length (SMD = -0.46) than control participants. LIMITATIONS The limitations included a small sample size, the observational nature of the study, and the inability to evaluate the impact of gait on wound healing. CONCLUSIONS This study identified abnormal gait parameters consistently associated with nonhealing diabetes-related plantar foot ulcers. Further research is needed to test the clinical importance of these gait characteristics.
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Affiliation(s)
- Malindu E Fernando
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Australian Institute of Tropical Health Medicine, Townsville, Queensland, Australia; School of Clinical Sciences, Queensland University of Technology, Queensland, Australia; and Movement Analysis Laboratory, Sports and Exercise Science, James Cook University, Townsville, Australia
| | - Robert G Crowther
- School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia, and Movement Analysis Laboratory, Sports and Exercise Science, James Cook University
| | - Peter A Lazzarini
- School of Clinical Sciences, Queensland University of Technology and Allied Health Research Collaborative, Metro North Hospital & Health Service, Queensland Health, Australia
| | - Kunwarjit S Sangla
- Department of Diabetes and Endocrinology, Townsville Hospital, Queensland, Australia
| | - Scott Wearing
- School of Clinical Sciences, Queensland University of Technology and Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia; and Conservative and Rehabilitative Orthopaedics, Faculty for Sport and Health, Technische Universität München, Germany
| | - Petra Buttner
- Centre for Chronic Disease Prevention, James Cook University, Cairns, Australia
| | - Jonathan Golledge
- Ulcer and Wound Healing Consortium (UHEAL), Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, Australian Institute of Tropical Health Medicine, James Cook University, 1 James Cook Drive, Douglas, QLD 4814, Australia; and Department of Vascular and Endovascular Surgery, The Townsville Hospital
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12
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Boulton AJM. The 2017 Banting Memorial Lecture The diabetic lower limb - a forty year journey: from clinical observation to clinical science. Diabet Med 2019; 36:1539-1549. [PMID: 30659650 DOI: 10.1111/dme.13901] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2019] [Indexed: 11/29/2022]
Abstract
A series of clinical research projects conducted over the past 40 years, all of which were informed by clinical observation or discussions with people with diabetes and staff colleagues are described in this review. A study of necrobiosis lipoidica diabeticorum confirmed that this rare skin complication occurs predominantly in young women with Type 1 diabetes and other microvascular complications. Biopsies of necrobiotic lesions showed destruction of superficial nerve fibres by inflammatory tissue, which likely causes the sensory loss in lesions that is pathognomonic of the condition. The development of corneal confocal microscopy as a new non-invasive surrogate marker of peripheral neuropathy in diabetes is described next and several small studies of the use of this new technique in clinical research are reported. The influence of blood glucose instability on the genesis of neuropathic pain is then explained, with results suggesting that the stability of glycaemic control may be more important than the level of control achieved. Lastly, in neuropathy, studies of gustatory sweating are discussed, including the observation that sweating in the head and neck region is more common in people with end-stage diabetic nephropathy than in those with neuropathy. The disappearance of gustatory sweating after renal transplantation suggests a metabolic cause and for those with troublesome sweating, use of the anticholinergic, anti-muscarinic, topical cream glycopyrrolate is confirmed in a randomized control trial. In the area of diabetic foot research, distended dorsal foot veins were observed to be a clinical sign of sympathetic autonomic neuropathy: raised venous Po2 and Doppler abnormalities of blood flow are highly suggestive of arteriovenous shunting. A series of studies of the abnormalities of pressures and loads under the neuropathic diabetic foot are described: high dynamic plantar pressures are highly predictive of subsequent ulceration in the neuropathic foot. Lastly, a number of recent studies on unsteadiness and gait abnormalities when climbing and descending stairs are described. It is hoped that the art of clinical observation survives in the highly technological 21st century.
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Affiliation(s)
- Andrew J M Boulton
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, University of Manchester, Manchester, UK
- Manchester Royal Infirmary, Manchester, UK
- Diabetes Research Institute, University of Miami, Miami, FL, USA
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13
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Zilliox LA, Russell JW. Physical activity and dietary interventions in diabetic neuropathy: a systematic review. Clin Auton Res 2019; 29:443-455. [PMID: 31076938 PMCID: PMC6697618 DOI: 10.1007/s10286-019-00607-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/09/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Diabetic neuropathy is a common and disabling disorder, and there are currently no proven effective disease-modifying treatments. Physical activity and dietary interventions in patients with diabetes and diabetic neuropathy have multiple beneficial effects and are generally low risk, which makes lifestyle interventions an attractive treatment option. We reviewed the literature on the effects of physical activity and dietary interventions on length-dependent peripheral neuropathy and cardiac autonomic neuropathy in diabetes. METHODS The electronic database PubMed was systematically searched for original human and mouse model studies examining the effect of either dietary or physical activity interventions in subjects with diabetes, prediabetes, or metabolic syndrome. RESULTS Twenty studies are included in this review. Fourteen studies were human studies and six were in mice. Studies were generally small with few controlled trials, and there are no widely agreed upon outcome measures. CONCLUSIONS Recent research indicates that dietary interventions are effective in modifying diabetic neuropathy in animal models, and there are promising data that they may also ameliorate diabetic neuropathy in humans. It has been known for some time that lifestyle interventions can prevent the development of diabetic neuropathy in type 2 diabetes mellitus subjects. However, there is emerging evidence that lifestyle interventions are effective in individuals with established diabetic neuropathy. In addition to the observed clinical value of lifestyle interventions, there is emerging evidence of effects on biochemical pathways that improve muscle function and affect other organ systems, including the peripheral nerve. However, data from randomized controlled trials are needed.
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Affiliation(s)
- Lindsay A Zilliox
- Department of Neurology, School of Medicine, University of Maryland, 3S-129, 110 South Paca Street, Baltimore, MD, 21201-1595, USA
- Maryland VA Healthcare System, Baltimore, MD, USA
| | - James W Russell
- Department of Neurology, School of Medicine, University of Maryland, 3S-129, 110 South Paca Street, Baltimore, MD, 21201-1595, USA.
- Maryland VA Healthcare System, Baltimore, MD, USA.
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14
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Edwards N, Dulai J, Rahman A. A Scoping Review of Epidemiological, Ergonomic, and Longitudinal Cohort Studies Examining the Links between Stair and Bathroom Falls and the Built Environment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16091598. [PMID: 31067692 PMCID: PMC6540131 DOI: 10.3390/ijerph16091598] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 11/16/2022]
Abstract
Stair and bathroom falls contribute to injuries among older adults. This review examined which features of stairs and bathrooms have been assessed in epidemiological, ergonomic, and national aging studies on falls or their risk factors. Epidemiological and ergonomic studies were eligible if published from 2006-2017, written in English, included older persons, and reported built environment measures. The data extracted included the following: study population and design, outcome measures, and stair and bathroom features. National aging studies were eligible if English questionnaires were available, and if data were collected within the last 10 years. Sample characteristics; data collection methods; and data about falls, the environment, and assistive device use were extracted. There were 114 eligible articles assessed-38 epidemiologic and 76 ergonomic. Among epidemiological studies, 2 assessed stair falls only, 4 assessed bathroom falls only, and 32 assessed falls in both locations. Among ergonomic studies, 67 simulated stairs and 9 simulated bathrooms. Specific environmental features were described in 14 (36.8%) epidemiological studies and 73 (96%) ergonomic studies. Thirteen national aging studies were identified-four had stair data and six had bathroom data. Most epidemiologic and national aging studies did not include specific measures of stairs or bathrooms; the built environment descriptions in ergonomic studies were more detailed. More consistent and detailed environmental measures in epidemiologic and national aging studies would better inform fall prevention approaches targeting the built environment.
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Affiliation(s)
- Nancy Edwards
- School of Nursing, University of Ottawa, Ottawa, ON K1S 5L5, Canada.
| | - Joshun Dulai
- School of Nursing, University of Ottawa, Ottawa, ON K1S 5L5, Canada.
| | - Alvi Rahman
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, QC H3A 0G4, Canada.
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15
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Dias LS, Nienov OH, Goelzer Neto CF, Schmid H. Unsteady walking as a symptom in type 2 diabetes mellitus: independent association with depression and sedentary lifestyle and no association with diabetic neuropathy. ACTA ACUST UNITED AC 2018; 51:e6605. [PMID: 29590256 PMCID: PMC5886546 DOI: 10.1590/1414-431x20186605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 01/04/2018] [Indexed: 11/22/2022]
Abstract
The purpose of this study was to look at the determinants of the unsteady walking (UW) symptom in patients with type 2 diabetes mellitus (T2DM) by defining if UW and/or the Diabetic Neuropathy Symptoms Score (DNSS) are associated with positive scores in Beck's Depression Inventory (BDI) and with a positive Michigan Neuropathy Screening Instrument score (MNSI). We evaluated 203 T2DM patients without visible gait disturbances. They were divided into UW (+) and UW (−) or DNSS (+) and DNSS (−) according to symptoms. We found a prevalence of 48.3% for UW (+) and of 63% for DNSS (+) in our sample. In univariate analysis, the presence of UW was significantly associated with waist circumference (P=0.024), number of comorbidities (P=0.012), not practicing physical exercise (P=0.011), positive BDI score (P=0.003), presence of neuropathic symptoms by the MNSI questionnaire (P<0.001), and positive diabetic neuropathy screening by MNSI (P=0.021). In multivariate analysis, UW (used as a dependent variable) was independently associated with a positive BDI score (P<0.001; 95%CI=1.01-1.03), T2DM duration (P=0.023; 95%CI=1.00–1.03), number of co-morbidities (P=0.032; 95%CI=1.01–1.37), and a sedentary lifestyle (P=0.025; 95%CI=1.06–2.5). The UW symptom and a positive DNSS are more closely related to a positive score for depression than to presence of neuropathy in T2DM.
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Affiliation(s)
- L S Dias
- Programa de Pós-Graduação em Ciências da Saúde, Ginecologia e Obstetrícia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.,Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - O H Nienov
- Programa de Pós-Graduação em Ciências da Saúde, Ginecologia e Obstetrícia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | - C F Goelzer Neto
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil
| | - H Schmid
- Programa de Pós-Graduação em Ciências da Saúde, Ginecologia e Obstetrícia, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil.,Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS, Brasil.,Serviço de Endocrinologia, Hospital Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brasil.,Departamento de Medicina Interna, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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Crews RT, Schneider KL, Yalla SV, Reeves ND, Vileikyte L. Physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers: a critical review. Diabetes Metab Res Rev 2016; 32:791-804. [PMID: 27155091 PMCID: PMC5466070 DOI: 10.1002/dmrr.2817] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 03/24/2016] [Accepted: 04/21/2016] [Indexed: 02/06/2023]
Abstract
Obesity and a sedentary lifestyle are common challenges among individuals at risk of diabetic foot ulcers. While substantial research exists on physical activity interventions in adults with diabetes, those at greatest risk for foot ulceration were often excluded or not well represented. Both at-risk patients and their clinicians may be hesitant to increase physical activity because of their perception of diabetic foot ulcer risks. Physical activity is not contraindicated for those at risk of diabetic foot ulcer, yet patients at risk present with unique barriers to initiating increases in physical activity. This review focuses upon the physiological and psychological challenges of increasing physical activity and exercise in patients at risk of diabetic foot ulcers. Offloading, diabetic peripheral neuropathy, depression, pain, self-efficacy and social support, diabetic foot ulcer risk-specific beliefs and emotions, and research to date on exercise interventions in this population are all discussed. Additionally, recommendations for implementing and researching physical activity interventions for individuals at risk for diabetic foot ulcer are provided. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Ryan T Crews
- Center for Lower Extremity Ambulatory Research (CLEAR) at Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA.
| | - Kristin L Schneider
- Department of Psychology, College of Health Professions, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Sai V Yalla
- Center for Lower Extremity Ambulatory Research (CLEAR) at Dr. William M. Scholl College of Podiatric Medicine, Rosalind Franklin University of Medicine and Science, North Chicago, IL, USA
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, UK
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17
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Altered EMG patterns in diabetic neuropathic and not neuropathic patients during step ascending and descending. J Electromyogr Kinesiol 2016; 31:32-39. [PMID: 27632533 DOI: 10.1016/j.jelekin.2016.08.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 07/18/2016] [Accepted: 08/17/2016] [Indexed: 11/22/2022] Open
Abstract
Diabetic peripheral neuropathy (DPN) causes motor control alterations during daily life activities. Tripping during walking or stair climbing is the predominant cause of falls in the elderly subjects with DPN and without (NoDPN). Surface Electromyography (sEMG) has been shown to be a valid tool for detecting alterations of motor functions in subjects with DPN. This study aims at investigating the presence of functional alterations in diabetic subjects during stair climbing and at exploring the relationship between altered muscle activation and temporal parameter. Lower limb muscle activities, temporal parameters and speed were evaluated in 50 subjects (10 controls, 20 with DPN, 20 without DPN), while climbing up and down a stair, using sEMG, three-dimentional motion capture and force plates. Magnitude and timing of sEMG linear envelopes peaks were extracted. Level walking was used as reference condition for the comparison with step negotiation. sEMG, speed and temporal parameters revealed significant differences among all groups of patients. Results showed an association between earlier activation of lower limb muscles and reduced speed in subjects with DPN. Speed and temporal parameters significantly correlated with sEMG (p<0.05). The findings of this study are encouraging and could be used to improve rehabilitation programs aiming at reducing falls risk in diabetic subjects.
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18
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Jacobs JV. A review of stairway falls and stair negotiation: Lessons learned and future needs to reduce injury. Gait Posture 2016; 49:159-167. [PMID: 27427833 DOI: 10.1016/j.gaitpost.2016.06.030] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 05/27/2016] [Accepted: 06/23/2016] [Indexed: 02/02/2023]
Abstract
Stairways are a common location for falls, and they result in a disproportionate risk of death or severe injury. Stairway falls are a significant problem across the lifespan and are often coincident with risky behaviors during stair use. The mechanics of successful stair negotiation for healthy young and older adults have been well described. These studies imply that current stair design does not offer an optimal universal design to meet the needs of older adults or people with health conditions. In addition, impaired stair negotiation associates with more than impaired strength, including functional impairments of cognitive load, sensory function and central motor coordination. Identification of behavioral strategies or stairway environments that assist or hinder recovery from a loss of balance on stairs remains incomplete. Therefore, future studies should investigate the mechanisms of balance recovery on stairs as well as the effectiveness of environmental interventions to mitigate stairway falls and injuries. Potential areas for evaluation may include modifying stair dimensions, surfaces, handrails, visual cues, and removing distractors of attention. Studies should also evaluate combinatorial interventions on person-related factors, such as behavioral interventions to decrease risky behaviors during stair use as well as interventions on cognitive, sensory, and motor functions relevant to stair use. Moreover, future studies should take advantage of new technologies to record stair use outside the laboratory in order to identify people or locations at risk for stairway falls. Such studies would inform the potential for broad-spectrum programs that decrease the risk of stairway falls and injuries.
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Affiliation(s)
- Jesse V Jacobs
- Center for Physical Ergonomics, Liberty Mutual Research Institute for Safety, 71 Frankland Rd., Hopkinton, MA, 01748, USA.
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19
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Brown S, Boulton A, Bowling F, Reeves N. Benefits, Challenges, and Potential Utility of a Gait Database for Diabetes Patients. J Diabetes Sci Technol 2016; 10:1065-72. [PMID: 27022098 PMCID: PMC5032949 DOI: 10.1177/1932296816640290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Gait analysis is a useful tool in understanding movement impairments, which impact on patient well-being. The use of gait analysis in patients with diabetes has led to improvements in health care including the treatment and prevention of ulceration and development of targeted exercise interventions. The current convention when analyzing gait is to address specific complications of diabetes, controlling for potential influencing conditions within a study sample to understand the effects of the few specific complications chosen for analysis. Databases allow for the storage of data in a structured format, allowing easy access to large quantities of data in a consistent, comparable manner. A database of gait analyses of patients with diabetes has the potential to include far greater sample sizes for statistical analyses, allowing multiple influencing factors to be assessed simultaneously, and relationships identified between multiple influencing factors. However, a database of this type would encounter ethical and methodological challenges in its implementation, which are discussed. This article introduces some of the potential benefits, challenges, and utility of a gait database for diabetes patients. We highlight that, whereas the creation of a database within this clinical population would be a complex process both ethically and practically, huge potential benefits could be gained, overcoming some of the limitations faced by traditional isolated gait analysis studies.
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Affiliation(s)
- Steven Brown
- Manchester Metropolitan University, Faculty of Science and Engineering, School of Healthcare Science, Manchester, UK
| | - Andrew Boulton
- Manchester Royal Infirmary, Division of Medicine, University of Manchester, UK
| | - Frank Bowling
- Manchester Royal Infirmary, Division of Medicine, University of Manchester, UK
| | - Neil Reeves
- Manchester Metropolitan University, Faculty of Science and Engineering, School of Healthcare Science, Manchester, UK
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20
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Brown SJ, Handsaker JC, Maganaris CN, Bowling FL, Boulton AJM, Reeves ND. Altered joint moment strategy during stair walking in diabetes patients with and without peripheral neuropathy. Gait Posture 2016; 46:188-93. [PMID: 27131200 DOI: 10.1016/j.gaitpost.2016.03.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 01/16/2016] [Accepted: 03/10/2016] [Indexed: 02/02/2023]
Abstract
AIM To investigate lower limb biomechanical strategy during stair walking in patients with diabetes and patients with diabetic peripheral neuropathy, a population known to exhibit lower limb muscular weakness. METHODS The peak lower limb joint moments of twenty-two patients with diabetic peripheral neuropathy and thirty-nine patients with diabetes and no neuropathy were compared during ascent and descent of a staircase to thirty-two healthy controls. Fifty-nine of the ninety-four participants also performed assessment of their maximum isokinetic ankle and knee joint moment (muscle strength) to assess the level of peak joint moments during the stair task relative to their maximal joint moment-generating capabilities (operating strengths). RESULTS Both patient groups ascended and descended stairs slower than controls (p<0.05). Peak joint moments in patients with diabetic peripheral neuropathy were lower (p<0.05) at the ankle and knee during stair ascent, and knee only during stair descent compared to controls. Ankle and knee muscle strength values were lower (p<0.05) in patients with diabetic peripheral neuropathy compared to controls, and lower at knee only in patients without neuropathy. Operating strengths were higher (p<0.05) at the ankle and knee in patients with neuropathy during stair descent compared to the controls, but not during stair ascent. CONCLUSION Patients with diabetic peripheral neuropathy walk slower to alter gait strategy during stair walking and account for lower-limb muscular weakness, but still exhibit heightened operating strengths during stair descent, which may impact upon fatigue and the ability to recover a safe stance following postural instability.
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Affiliation(s)
- Steven J Brown
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom.
| | - Joseph C Handsaker
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
| | | | - Frank L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, United Kingdom
| | - Andrew J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, United Kingdom
| | - Neil D Reeves
- School of Healthcare Science, Faculty of Science and Engineering, Manchester Metropolitan University, Manchester, United Kingdom
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Handsaker JC, Brown SJ, Bowling FL, Maganaris CN, Boulton AJM, Reeves ND. Resistance exercise training increases lower limb speed of strength generation during stair ascent and descent in people with diabetic peripheral neuropathy. Diabet Med 2016; 33:97-104. [PMID: 26108438 DOI: 10.1111/dme.12841] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2015] [Indexed: 12/18/2022]
Abstract
AIM To examine the effects of a 16-week resistance exercise training intervention on the speed of ankle and knee strength generation during stair ascent and descent, in people with neuropathy. METHODS A total of 43 people: nine with diabetic peripheral neuropathy, 13 with diabetes but no neuropathy and 21 healthy control subjects ascended and descended a custom-built staircase. The speed at which ankle and knee strength were generated, and muscle activation patterns of the ankle and knee extensor muscles were analysed before and after a 16-week intervention period. RESULTS Ankle and knee strength generation during both stair ascent and descent were significantly higher after the intervention than before the intervention in the people with diabetes who undertook the resistance exercise intervention (P < 0.05). Although muscle activations were altered by the intervention, there were no observable patterns that underpinned the observed changes. CONCLUSIONS The increased speed of ankle and knee strength generation observed after the intervention would be expected to improve stability during the crucial weight acceptance phase of stair ascent and descent, and ultimately contribute towards reducing the risk of falling. Improvements in muscle strength as a result of the resistance exercise training intervention are likely to be the most influential factor for increasing the speed of strength generation. It is recommended that these exercises could be incorporated into a multi-faceted exercise programme to improve safety in people with diabetes and neuropathy.
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Affiliation(s)
- J C Handsaker
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - S J Brown
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
| | - F L Bowling
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - C N Maganaris
- School of Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - A J M Boulton
- Faculty of Medical & Human Sciences, University of Manchester, Manchester, UK
| | - N D Reeves
- School of Healthcare Science, Manchester Metropolitan University, Manchester, UK
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Abstract
Length-dependent neuropathy is the most common and costly complication of diabetes and frequently causes injury primarily to small-diameter cutaneous nociceptive fibers. Not only persistent hyperglycemia but also metabolic, endocrine, and inflammatory effects of obesity and dyslipidemia appear to play an important role in the development of diabetic neuropathy. Rational therapies aimed at direct control of glucose or its increased entry into the polyol pathway, oxidative or nitrosative stress, advanced glycation end product formation or signaling, microvascular ischemia, or adipocyte-derived toxicity have each failed in human trials of diabetic neuropathy. Aerobic exercise produces salutary effects in many of these pathogenic pathways simultaneously and, in both animal models and human trials, has been shown to improve symptoms of neuropathy and promote re-growth of cutaneous small-diameter fibers. Behavioral reduction in periods of seated, awake inactivity produces multimodal metabolic benefits similar to exercise, and the two strategies when combined may offer sustained benefit to peripheral nerve function.
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Affiliation(s)
| | - A Gordon Smith
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Robin L Marcus
- Department of Physical Therapy, University of Utah, Salt Lake City, UT, USA
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