Neuropathy: mobility and quality of life

The Effect of Resistance Exercises Using an Elastic Band on Balance and Fear of Falling in Older Adults With Diabetic Peripheral Neuropathy: A 16-week Randomized Controlled Trial

OBJECTIVE

The current study aimed to investigate the effect of resistance training using an elastic band on balance and fear of falling in older adults with diabetic peripheral neuropathy.

DESIGN

The study was a clinical controlled trial with a repeated measure design.

SETTING

Iranian Diabetes Foundation of Mashhad.

PARTICIPANTS

The participants were 51 older adults with diabetic peripheral neuropathy and balance impairment (N=51).

INTERVENTIONS

Participants were randomly assigned to 2 groups; 1 group received balance training using an elastic band and the other group just received balance training.

MAIN OUTCOME MEASURES

The main outcomes were balance and fear of falling that were measured using Berg Balance Scale and a short version of the Fall Efficiency Scale-International, respectively.

RESULTS

The results showed that balance resistance training with and without using an elastic band significantly enhances balance and reduces fear of falling in diabetic older adults suffering from balance issues. However, balance resistance training using an elastic band had a significantly better effect on the balance and fear of falling in the participants. The best results were obtained after week 12 (48 sessions of balance training).

CONCLUSION

Balance rehabilitation programs may include an elastic band in balance resistance training for 12 weeks (3-4 sessions a week) for enhancing balance in diabetic older adults suffering from balance impairment.

The Impact of Hoffmann Reflex on Standing Postural Control Complexity in the Elderly with Impaired Plantar Sensation

In people with peripheral neuropathy (PN), impaired plantar sensation can cause adaptive changes in the central nervous system (CNS), resulting in changes in the standing postural control, which is reflected in the variability of standing output signals. Standard deviation (SD) and entropy are reliable indicators of system variability, especially since entropy is highly sensitive to diseased populations. The relation between SD and entropy, CNS and center of pressure (COP) variability is unclear for people with severe PN. The purpose of this study was to explore the adaptability of the CNS to the severe of PN and its effect on the degree and complexity of COP variability. Here, people with PN were divided into less affected (LA) and more affected (MA) groups based on plantar pressure sensitivity. We studied Hoffmann reflex (H-reflex) and standing balance performance with the control group (n = 8), LA group (n = 10), and MA group (n = 9), recording a 30 s COP time series (30,000 samples) of double-leg standing with eyes open. We observed that the more affected group had less COP complexity than people without PN. There is a significant negative correlation between the SD and sample entropy in people without PN, less affected and more affected. The COP complexity in people without PN was inversely correlated with H-reflex. We concluded that: (1) The complexity of COP variability in patients with severe plantar sensory impairment is changed, which will not affect the degree of COP variability; (2) The independence of the COP entropy in the AP and ML directions decreased, and the interdependence increased in people with PN; (3) Although the CNS of people with PN has a greater contribution to standing balance, its modulation of standing postural control is decreased.

Footwear and insole design parameters to prevent occurrence and recurrence of neuropathic plantar forefoot ulcers in patients with diabetes: a series of N-of-1 trial study protocol

BACKGROUND

Foot complications occur in conjunction with poorly controlled diabetes. Plantar forefoot ulceration contributes to partial amputation in unstable diabetics, and the risk increases with concomitant neuropathy. Reducing peak plantar forefoot pressure reduces ulcer occurrence and recurrence. Footwear and insoles are used to offload the neuropathic foot, but the success of offloading is dependent on patient adherence. This study aims to determine which design and modification features of footwear and insoles improve forefoot plantar pressure offloading and adherence in people with diabetes and neuropathy.

METHODS

This study, involving a series of N-of-1 trials, included 21 participants who had a history of neuropathic plantar forefoot ulcers. Participants were recruited from two public hospitals and one private podiatry clinic in Sydney, New South Wales, Australia. This trial is non-randomised and unblinded. Participants will be recruited from three sites, including two high-risk foot services and a private podiatry clinic in Sydney, Australia. Mobilemat™ and F-Scan® plantar pressure mapping systems by TekScan® (Boston, USA) will be used to measure barefoot and in-shoe plantar pressures. Participants' self-reports will be used to quantify the wearing period over a certain period of between 2 and 4 weeks during the trial. Participant preference toward footwear, insole design and quality-of-life-related information will be collected and analysed. The descriptive and inferential statistical analyses will be performed using IBM SPSS Statistics (version 27). And the software NVivo (version 12) will be utilised for the qualitative data analysis.

DISCUSSION

This is the first trial assessing footwear and insole interventions in people with diabetes by using a series of N-of-1 trials. Reporting self-declared wearing periods and participants' preferences on footwear style and aesthetics are the important approaches for this trial. Patient-centric device designs are the key to therapeutic outcomes, and this study is designed with that strategy in mind.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12620000699965p. Registered on June 23, 2020.

Cross-Sectional Area of the Tibial Nerve in Diabetic Peripheral Neuropathy Patients: A Systematic Review and Meta-Analysis of Ultrasonography Studies

Background: There is a link between diabetic peripheral neuropathy (DPN) progression and the increase in the cross-sectional area (CSA) of the tibial nerve at the ankle. Nevertheless, no prior meta-analysis has been conducted to evaluate its usefulness for the diagnosis of DPN. Methods: We searched Google Scholar, Scopus, and PubMed for potential studies. Studies had to report tibial nerve CSA at the ankle and diabetes status (DM, DPN, or healthy) to be included. A random-effect meta-analysis was applied to calculate pooled tibial nerve CSA and mean differences across the groups. Subgroup and correlational analyses were conducted to study the potential covariates. Results: The analysis of 3295 subjects revealed that tibial nerve CSA was 13.39 mm2 (CI: 10.94−15.85) in DM patients and 15.12 mm2 (CI: 11.76−18.48) in DPN patients. The CSA was 1.93 mm2 (CI: 0.92−2.95, I2 = 98.69%, p < 0.01) larger than DPN-free diabetic patients. The diagnostic criteria of DPN and age were also identified as potential moderators of tibial nerve CSA. Conclusions: Although tibial nerve CSA at the ankle was significantly larger in the DPN patients, its clinical usefulness is limited by the overlap between groups and the inconsistency in the criteria used to diagnose DPN.

Development of a prototype toe sensor for detection of diabetic peripheral small fiber neuropathy

Diabetic peripheral neuropathy (DPN) affects a large proportion of people with diabetes, and early detection is essential to prevent further progression. Widespread clinical testing relies on simplicity and cost-effectiveness of examination. Early signs of DPN may be detected by assessing the sudomotor nerves, and sudomotor activity can be measured by bioimpedance. We present a prototype toe probe for DPN detection including sensors for measuring skin AC conductance, skin temperature and humidity. The prototype was tested on five participants with DPN and five healthy age-matched controls in a pilot study. Sudomotor sensor responses to a simple deep breathing test were very weak or absent in the DPN group, with all controls having larger responses than the DPN group. Evaporation was lower for the DPN group, and skin temperature was higher on average. For the same foot, the results for sudomotor responses were in agreement with sensory neurography amplitudes from the sural nerve whereas the monofilament test gave normal results for two of the DPN participants. If sufficient detection accuracy is confirmed in larger studies, the method may provide a simple and cost-effective tool to support clinical examination. Clinical Relevance- We present the early realization and testing of a simple device to support early detection of diabetic peripheral neuropathy.

Foot-ankle therapeutic exercise program can improve gait speed in people with diabetic neuropathy: a randomized controlled trial

This study sought to determine whether a foot–ankle therapeutic exercise program can improve daily physical activity (i.e. number of steps) and fast and self-selected gait speed in people with diabetic peripheral neuropathy (DPN). In this single-blind randomized controlled trial and intention-to-treat analysis, 78 volunteers with DPN were allocated into a control group, which received usual care, and an intervention group (IG), which received usual care plus a 12-week foot–ankle exercise program. The adherence at 12 weeks rate in the IG was 92.3% (36 participants) and the dropout was 5.1% in the control group (2 participants). The number of steps and self-selected gait speed did not change significantly in either group (p > 0.05), although a 1,365-step difference between groups were observed at 1-year followup. The 12-week foot–ankle therapeutic exercises improved significantly fast-gait speed (primary outcome) (p = 0.020), ankle range of motion (p = 0.048), and vibration perception (secondary outcomes) (p = 0.030), compared with usual-care at 12 weeks. At 24 weeks, the IG showed better quality of life than controls (p = 0.048). At 1-year, fast-gait speed and vibration perception remained higher in the IG versus controls. Overall, the program may be a complementary treatment strategy for improving musculoskeletal and functional deficits related to DPN.

Trial registration ClinicalTrials.gov NCT02790931 (06/06/2016).

Physical impairments, sensory disturbance, and functional ability in a cancer patient with and without chemotherapy-induced peripheral neuropathy symptoms

OBJECTIVE

The present study examined the objective and patient-reported measures of physical impairments, sensory disturbance, and functional ability between cancer patients with and without chemotherapy-induced peripheral neuropathy (CIPN) symptoms.

METHODS

Forty-one cancer survivors exposed to neurotoxic chemotherapies were conveniently recruited and completed a single cross-sectional assessment of patient-reported outcomes (VAS for pain intensity and ABC scale) and objective assessments (SWM test, TUG test, 5xSTS test, Romberg test with eyes open and eyes closed, 6MWT, and FAB scale).

RESULTS

Cancer patients who had undergone chemotherapy with CIPN symptoms did significantly worse in the SWM test, TUG test, 5xSTS test, Romberg test with eyes closed, 6MWT, FAB scale, and ABC scale (p < 0.05) when compared with cancer survivors without CIPN symptoms.

CONCLUSION

Cancer survivors with CIPN symptoms have lower physical performance, sensory perception, and functional ability, which may increase the risk of falling and disability. These findings further emphasize the need for effective rehabilitation and interventions to treat CIPN symptoms and related physical impairment and functional deficits.

Chemotherapy-Induced Neuropathy and Diabetes: A Scoping Review

Although cancer and diabetes are common diseases, the relationship between diabetes, neuropathy and the risk of developing peripheral sensory neuropathy while or after receiving chemotherapy is uncertain. In this review, we highlight the effects of chemotherapy on the onset or progression of neuropathy in diabetic patients. We searched the literature in Medline and Scopus, covering all entries until 31 January 2021. The inclusion and exclusion criteria were: (1) original article (2) full text published in English or Spanish; (3) neuropathy was specifically assessed (4) the authors separately analyzed the outcomes in diabetic patients. A total of 259 papers were retrieved. Finally, eight articles fulfilled the criteria, and four more articles were retrieved from the references of the selected articles. The analysis of the studies covered the information about neuropathy recorded in 768 cancer patients with diabetes and 5247 control cases (non-diabetic patients). The drugs investigated are chemotherapy drugs with high potential to induce neuropathy, such as platinum derivatives and taxanes, which are currently the mainstay of treatment of various cancers. The predisposing effect of co-morbid diabetes on chemotherapy-induced peripheral neuropathy depends on the type of symptoms and drug used, but manifest at any drug regimen dosage, although greater neuropathic signs are also observed at higher dosages in diabetic patients. The deleterious effects of chemotherapy on diabetic patients seem to last longer, since peripheral neuropathy persisted in a higher proportion of diabetic patients than non-diabetic patients for up to two years after treatment. Future studies investigating the risk of developing peripheral neuropathy in cancer patients with comorbid diabetes need to consider the duration of diabetes, cancer-induced neuropathic effects per se (prior chemotherapy administration), and the effects of previous cancer management strategies such as radiotherapy and surgery.

Disease related changes in vocal parameters of patients with type 2 diabetes mellitus

BACKGROUND

As the duration of diabetes progresses, various disease related complications might occur in patients. The main goal of this paper is to compare acoustic and aerodynamic measures of patients with type 2 diabetes mellitus (T2DM) with a control group of healthy subjects.

METHODS

A total of 91 subjects, 51 individuals with type 2 diabetes mellitus (DM group) and 40 healthy volunteers (HV group) were participated in the study. Maximum phonation time (MPT) was captured for assessing phonatory mechanics. Acoustic voice parameters, including mean fundamental frequency (mean fo), jitter local (Jlocal), jitter absolute (Jabs), shimmer local (Slocal), shimmer decibel (SdB), and harmonics to noise ratio (HNR) were detected using the Praat software program.

RESULTS

Only for Jabs, statically significant difference was found between the groups. There were no statically significant differences between any voice parameters of HV versus those with the duration of diabetes ≥10 years and the HbA1c level ≥7%. However, statically significant differences for MPT and Slocal were found between patients with neuropathy versus HV. In addition, a comparison between patients with voice complaint versus HV showed significant differences for Slocal and SdB.

CONCLUSIONS

The findings of the present study do not provide strong evidence about the possible effect of DM on the human voice. However, diabetic neuropathy is considered to be a factor affecting the voice parameters in the target population. The physicians should pay attention to the acoustic and aerodynamic voice parameters in patients with diabetes, particularly in those with neuropathy or voice complaints.

Validation of a new hand function outcome measure in individuals with Charcot-Marie-Tooth disease

The symptomatology of Charcot-Marie-Tooth (CMT) disease mainly involves the feet and the hands. To date, there is no consensus on how to evaluate hand function in CMT. The aim of this study is to correlate the data of the engineered glove Hand Test System (HTS) with specific tests and the CMT examination score (CMTES). We analyzed 45 patients with the diagnosis of CMT using HTS, which measures the hand dexterity by specific sequences performed at maximum velocity. We completed the evaluation with the CMTES, tripod pinch and hand grip strength tested by a dynamometer, thumb opposition test (TOT), and Sollerman Hand function test (SHFT), and we conducted a test-retest with 20 normal subjects. Finger tapping (FT) and index-medium-ring-little (IMRL) sequence showed a significant correlation with CMTES (FT: dominant hand (DH): P = .036; non-dominant hand (NDH): P = .033; IMRL: DH: P = .009; NDH: P = .046). TOT correlated with CMTES significantly in both hands (P < .0001). tripod pinch showed a statistically significant correlation with CMTES (DH: P = .002; NDH: P = .005). Correlation between the hand grip and CMTES was significant only in DH (DH: P = .002). SHFT had a significant correlation with the CMTES (DH: P = .002). Test-retest showed a good reliability. HTS parameters correlate with CMTES confirming that this tool is sensitive to the hand deficits. In conclusion, we can state that HTS is a good, simple to use, and objective instrument to evaluate the hand function of CMT patients, but more studies on responsiveness and sensitivity are needed.

FUNCTIONAL ANALYSIS OF GAIT WITH INSOLE USE IN DIABETIC FEMALE RATS: A CROSS-SECTIONAL STUDY

ABSTRACT Introduction: Diabetes mellitus is a chronic disease that is characterized by causing damage to the peripheral nervous system, generating sensory and motor changes. Objective: This study aims at analyzing the impact of the use of different orthotic insoles on the gait of diabetic female rats. Methods: Twenty-six female Wistar rats were randomly divided into the Control and Diabetic groups. The mechanical sensitivity test was performed manually on the surface of the animals' hind paws using the von Frey test. The functional evaluation was carried out on an adapted platform where the animals were stimulated to walk in order to capture images of the ventral region for measurements of the right and left hind paws. After the images were collected they were processed using Kinovea software version 0.8.27 to assess: stride distance, time, speed and acceleration. Results: There was a reduction in the weight of the animals in the Diabetic Group (p = 0.0018), associated with hyperglycemia (p = <0.0001), and a decrease in mechanical sensitivity as compared to the Control Group (p = 0.0372). Gait analysis showed a reduction in stride speed (p = 0.0482) and acceleration (p = 0.0149), with the silicone orthosis in the Diabetic Group. Conclusions: The silicone orthosis demonstrated a reduction in stride speed and acceleration, without compromising the other variables in the diabetic rats. The other insoles showed no functional difference between groups. Even though the animals showed a change in sensitivity at the end of 28 days of DM induction, this time does not appear to have been able to develop extensive changes in the rats' gait function. Level of evidence II; Therapeutic studies - Investigating the Results of Treatment.

Peripheral Nerve Impairment and Recurrent Falls Among Women: Results From the Study of Women's Health Across the Nation

BACKGROUND

Falls and related injuries are important public health concerns yet underappreciated in early aging. This study examined the association of peripheral nerve impairment (PNI) with fall outcomes in early old aged women (60-72 years).

METHODS

Women (n = 1,725; mean age 65.1 ± 2.7 years) from the longitudinal cohort Study of Women's Health Across the Nation completed a PNI questionnaire on presence, frequency, and severity of symptoms, and 10- and 1.4-g monofilament testing in 2016-2017. PNI was defined as four or more self-reported symptoms or monofilament insensitivity. Recurrent falls (two or more) and recurrent fall injuries (two or more falls with one or more injuries) in the previous 12 months were assessed via questionnaire. Poisson regression was used to generate risk ratios (RRs) and corresponding 95% confidence intervals (CIs) for the fall outcomes, adjusting for covariates.

RESULTS

Approximately 12.3% of participants reported two ore more falls, 7.6% reported recurrent falls with injury, and 15.8% reported four or more PNI symptoms. Women with recurrent falls were more likely to report four or more PNI symptoms compared to women without recurrent falls (32.1% vs 13.5%; p < .001). One quarter (25.6%) of participants had four or more PNI symptoms or monofilament insensitivity; after adjusting for covariates, women with either symptoms or insensitivity were more likely to report recurrent falls compared to women with neither (RR = 1.64; 95% CI: 1.24, 2.17).

CONCLUSIONS

These findings suggest that PNI may identify those at high risk for falls, particularly among women during early late life. Neuropathy screening instruments such as symptom questionnaires or monofilament testing are easy to implement and may have utility for fall risk assessment.

Footwear and insole design features that reduce neuropathic plantar forefoot ulcer risk in people with diabetes: a systematic literature review

BACKGROUND

In people with diabetes, offloading high-risk foot regions by optimising footwear, or insoles, may prevent ulceration. This systematic review aimed to summarise and evaluate the evidence for footwear and insole features that reduce pathological plantar pressures and the occurrence of diabetic neuropathy ulceration at the plantar forefoot in people with diabetic neuropathy.

METHODS

Six electronic databases (Medline, Cinahl, Amed, Proquest, Scopus, Academic Search Premier) were searched in July 2019. The search period was from 1987 to July 2019. Articles, in English, using footwear or insoles as interventions in patients with diabetic neuropathy were reviewed. Any study design was eligible for inclusion except systematic literature reviews and case reports. Search terms were diabetic foot, physiopathology, foot deformities, neuropath*, footwear, orthoses, shoe, footwear prescription, insole, sock*, ulcer prevention, offloading, foot ulcer, plantar pressure.

RESULTS

Twenty-five studies were reviewed. The included articles used repeated measure (n = 12), case-control (n = 3), prospective cohort (n = 2), randomised crossover (n = 1), and randomised controlled trial (RCT) (n = 7) designs. This involved a total of 2063 participants. Eleven studies investigated footwear, and 14 studies investigated insoles as an intervention. Six studies investigated ulcer recurrence; no study investigated the first occurrence of ulceration. The most commonly examined outcome measures were peak plantar pressure, pressure-time integral and total contact area. Methodological quality varied. Strong evidence existed for rocker soles to reduce peak plantar pressure. Moderate evidence existed for custom insoles to offload forefoot plantar pressure. There was weak evidence that insole contact area influenced plantar pressure.

CONCLUSION

Rocker soles, custom-made insoles with metatarsal additions and a high degree of contact between the insole and foot reduce plantar pressures in a manner that may reduce ulcer occurrence. Most studies rely on reduction in plantar pressure measures as an outcome, rather than the occurrence of ulceration. There is limited evidence to inform footwear and insole interventions and prescription in this population. Further high-quality studies in this field are required.

The association between perceived discrimination in midlife and peripheral neuropathy in a population-based cohort of women: the Study of Women's Health Across the Nation

PURPOSE

Peripheral neuropathy (PN) is a highly prevalent condition with serious sequelae. Many studies of the condition have been restricted to populations with diabetes, limiting evidence of potential contributing risk factors including salient psychosocial risk factors such as discrimination.

METHODS

The longitudinal Study of Women's Health Across the Nation was used to assess the relationship between perceived discrimination and prevalent PN in 1718 ethnically diverse midlife women. We used multivariable logistic regression to determine the association between perceived discrimination (Detroit Area Study Everyday Discrimination Scale) and PN (symptom questionnaire and monofilament testing) and conducted an assessment of the mediating effects of body mass index (BMI).

RESULTS

The prevalence of PN was 26.1% in the total sample and 40.9% among women with diabetes. Women who reported perceived discrimination had 29% higher odds of PN compared with women who did not report perceived discrimination (95% confidence interval, 1.01-1.66). Approximately 30% of the total effect of discrimination on PN was mediated indirectly by BMI.

CONCLUSIONS

More research is needed to determine the contributing factors to nondiabetic PN. Our findings reaffirm the impact of financial strain, BMI, and diabetes as significant correlates of PN and highlight discrimination as an important risk factor.

Effect of deep tissue laser therapy treatment on peripheral neuropathic pain in older adults with type 2 diabetes: a pilot randomized clinical trial

Background

This study assessed the safety and efficacy of deep tissue laser therapy on the management of pain, functionality, systemic inflammation, and overall quality of life of older adults with painful diabetic peripheral neuropathy.

Methods

The effects of deep tissue laser therapy (DTLT) were assessed in a randomized, double-masked, sham-controlled, interventional trial. Forty participants were randomized (1:1) to receive either DTLT or sham laser therapy (SLT). In addition to the standard-of-care treatment, participants received either DTLT or SLT twice weekly for 4 weeks and then once weekly for 8 weeks (a 12-week intervention period). The two treatments were identical, except that laser emission was disabled during SLT. Assessments for pain, functionality, serum levels of inflammatory biomarkers, and quality of life (QOL) were performed at baseline and after the 12-week intervention period. The results from the two treatments were compared using ANOVA in a pre-test-post-test design.

Results

All participants randomized to the DTLT group and 85% (17 of 20) of participants randomized to the SLT group completed the trial. No significant differences in baseline characteristics between the groups were observed. After the 12-week intervention period, pain levels significantly decreased in both groups and were significantly lower in the DTLT group than in the SLT group. The Timed Up and Go test times (assessing functionality) were significantly improved in both groups and were 16% shorter in the DTLT group than in the SLT group. Serum levels of IL-6 decreased significantly in both groups. Additionally, serum levels of MCP-1 decreased significantly in the DTLT group but not in the SLT group. Patients’ quality of life improved significantly in the DTLT group but not in the SLT group.

Conclusions

Deep tissue laser therapy significantly reduced pain and improved the quality of life of older patients with painful diabetic peripheral neuropathy.

Trial registration

Clinical Trial Registry-India CTRI/2017/06/008739. [Registered on: 02/06/2017]. The trial was registered retrospectively.

An Optimization Method Tracking EMG, Ground Reactions Forces, and Marker Trajectories for Musculo-Tendon Forces Estimation in Equinus Gait

In the context of neuro-orthopedic pathologies affecting walking and thus patients' quality of life, understanding the mechanisms of gait deviations and identifying the causal motor impairments is of primary importance. Beside other approaches, neuromusculoskeletal simulations may be used to provide insight into this matter. To the best of our knowledge, no computational framework exists in the literature that allows for predictive simulations featuring muscle co-contractions, and the introduction of various types of perturbations during both healthy and pathological gait types. The aim of this preliminary study was to adapt a recently proposed EMG-marker tracking optimization process to a lower limb musculoskeletal model during equinus gait, a multiphase problem with contact forces. The resulting optimization method tracking EMG, ground reactions forces, and marker trajectories allowed an accurate reproduction of joint kinematics (average error of 5.4 ± 3.3 mm for pelvis translations, and 1.9 ± 1.3° for pelvis rotation and joint angles) and ensured good temporal agreement in muscle activity (the concordance between estimated and measured excitations was 76.8 ± 5.3 %) in a relatively fast process (3.88 ± 1.04 h). We have also highlighted that the tracking of ground reaction forces was possible and accurate (average error of 17.3 ± 5.5 N), even without the use of a complex foot-ground contact model.

It's never too late - balance and endurance training improves functional performance, quality of life, and alleviates neuropathic symptoms in cancer survivors suffering from chemotherapy-induced peripheral neuropathy: results of a randomized controlled trial

Background

Chemotherapy-induced peripheral neuropathy (CIPN) can affect functional performance and quality of life considerably. Since balance training has proven to enhance physical function, it might be a promising strategy to manage CIPN-induced functional impairments.

Methods

Fifty cancer survivors with persisting CIPN after finishing their treatment were randomly allocated to an intervention (IG) or active control group (CG). The IG did endurance plus balance training, the CG only endurance training (twice weekly over 12 weeks). Pre- and post-assessments included functional performance, cardiorespiratory fitness, vibration sense, and self-reported CIPN symptoms (EORTC QLQ-CIPN20).

Results

Intention-to-treat analyses (n = 41) did not reveal a significant group difference (CG minus IG) for sway path in semi-tandem stance after intervention (primary endpoint), adjusted for baseline. However, our per-protocol analysis of 37 patients with training compliance ≥70% revealed: the IG reduced their sway path during semi-tandem stance (− 76 mm, 95% CI -141 – -17; CG: -6 mm, 95% CI -52 – 50), improved the duration standing on one leg on instable surface (11 s, 95% CI 8–17; CG: 0 s, 95%CI 0–5) and reported decreased motor symptoms (−8points, 95% CI -18 – 0; CG: -2points 95% CI -6 – 2). Both groups reported reduced overall- (IG: -10points, 95% CI -17 – -4; CG: -6points, 95% CI -11 – -1) and sensory symptoms (IG: -7points, 95% CI -15 – 0; CG: -7points, 95% CI -15 – 0), while only the CG exhibited objectively better vibration sense (knuckle: 0.8points, 95% CI 0.3–1.3; IG: 0.0points, 95% CI -1.1 – 0.9; patella: 1.0points, 95% CI 0.4–1.6: IG: -0.8points, 95% CI -0.2 – 0.0). Furthermore, maximum power output during cardiopulmonary exercise test increased in both groups (IG and CG: 0.1 W/kg, 95% CI 0.0–0.2), but only the CG improved their jump height (2 cm, 95% CI 0.5–3.5; IG: 1 cm, 95% CI -0.4 – 3.2).

Conclusion

We suppose that endurance training induced a reduction in sensory symptoms in both groups, while balance training additionally improved patients’ functional status. This additional functional effect might reflect the IG’s superiority in the CIPN20 motor score. Both exercises provide a clear and relevant benefit for patients with CIPN.

Trial registration

German Clinical Trials Register (DRKS) number: DRKS00005419, prospectively registered on November 19, 2013.

Continuous Movement Monitoring of Daily Living Activities for Prevention of Diabetic Foot Ulcer: A Review of Literature

Lower extremity ulcers represent the most ominous, feared, and costly complications of diabetes mellitus. The aim of this review is to highlight the role of daily life physical activities (PAs) and continuous movement monitoring (CMM) in the prevention of foot ulcers. Peripheral neuropathy and peripheral vascular disease are the main causes of foot ulceration and contribute, in turn, to the development of additional risk factors such as foot deformities and/or joint and muscular alterations. Moreover, a deficit of balance, posture abnormalities, followed by gait alterations, increases the risk of ulceration. PA can play a key role in the management of patients with diabetes and in the prevention of ulcers; however, even if it has been reported that some of these risk factors significantly improve after a few weeks of exercise therapy (ET), the real preventive role of ET has not yet been demonstrated. These uncertain results can occur due to some limitations in the management of the same relationship between PA and diabetic foot prevention. Technological advances during the last years enable timely management of overall daily PA. The use of these modern technologies and devices allows CMM assessment and description of daily PA even in the long term. The data collected from these devices can be used to properly manage patients' PA and thus contribute to the prevention of foot ulcers.

An altered spatiotemporal gait adjustment during a virtual obstacle crossing task in patients with diabetic peripheral neuropathy

This study investigates spatiotemporal gait adjustments that occur while stepping over virtual obstacles during treadmill walking in people with/without diabetic peripheral neuropathy (DPN). Eleven adults with Type 2 diabetes mellitus, ten DPN, and 11 age-matched healthy adults (HTY) participated in this study. They stepped over forthcoming virtual obstacles during treadmill walking. Outcomes such as success rate, spatiotemporal gait characteristics during obstacle crossing, and correlations between these variables were evaluated. The results partially supported our hypotheses that when comparing with HTY and DM, people with DPN adopted a crossing strategy which decreased obstacle crossing success rate and maximal toe elevation, and increased stride time and stance time during virtual obstacle crossing. This might be due to the compromised somatosensory functions of their lower extremity which may increase the risk of falling. This study also found an inter-leg relationship which may be applied to future stepping or obstacle crossing training that incorporates both legs as a means for improving outcomes of the trailing leg during daily obstacle negotiation.

Protocol for evaluating the effects of a foot-ankle therapeutic exercise program on daily activity, foot-ankle functionality, and biomechanics in people with diabetic polyneuropathy: a randomized controlled trial

BACKGROUND

Diabetic polyneuropathy (DPN) negatively affects foot and ankle function (strength and flexibility), which itself affects the daily physical activity and quality of life of patients. A physical therapy protocol aiming to strengthen the intrinsic and extrinsic foot muscles and increase flexibility may be a promising approach to improve lower-extremity function, prevent further complications, and improve autonomy for daily living activities in these patients. Thus, the inclusion of a specific foot-related exercises focused on the main musculoskeletal impairments may have additional effects to the conventional interventions in the diabetic foot.

METHODS/DESIGN

A prospective, parallel-group, outcome-assessor blinded, randomized controlled trial (RCT) will be conducted in 77 patients with DPN who will be randomly allocated to usual care (control arm) or usual care with supervised foot-ankle exercises aiming to increase strengh and flexibility twice a week for 12 weeks and remotely supervised foot-ankle exercises for a year through a web software. Patients will be evaluated 5 times in a 1 year period regarding daily physical activity level, self-selected and fast gait speeds (primary outcomes), foot ulcer incidence, ulcer risk classification, neuropathy testing, passive ankle range of motion, quality of life, foot health and functionality, foot muscle strength, plantar pressure, and foot-ankle kinematics and kinetics during gait.

DISCUSSION

This study aims to assess the effect of a foot-ankle strength and flexibility program on a wide range of musculoskeletal, activity-related, biomechanical, and clinical outcomes in DPN patients. We intend to demonstrate evidence that the year-long training program is effective in increasing gait speed and daily physical activity level and in improving quality of life; foot strength, functionality, and mobility; and biomechanics while walking. The results will be published as soon as they are available.

TRIAL REGISTRATION

This study has been registered at ClinicalTrials.gov as NCT02790931 (June 6, 2016) under the name "Effects of foot muscle strengthening in daily activity in diabetic neuropathic patients".

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.

Using Plantar Electrical Stimulation to Improve Postural Balance and Plantar Sensation Among Patients With Diabetic Peripheral Neuropathy: A Randomized Double Blinded Study

OBJECTIVE

People with diabetic peripheral neuropathy (DPN) often exhibit deteriorations in motor-performance mainly due to lack of plantar-sensation. The study explored effectiveness of plantar electrical-stimulation therapy to enhance motor-performance among people with DPN.

DESIGN AND METHODS

Using a double-blinded model, 28 volunteers with DPN (age: 57.8 ± 10.2 years) were recruited and randomized to either intervention (IG: n = 17) or control (CG: n = 11) group. Both groups received identical plantar-stimulation devices for six weeks of daily use at home; however, only the IG devices were set to deliver stimulation. Balance (ankle, hip, and center of mass [COM] sway) and gait (stride velocity [SV], stride time [ST], stride length [SL], and cadence) were measured using validated wearable sensors. Outcomes were assessed at baseline and at six-week. Clinical assessment including vascular as measured by ankle-brachial-index (ABI) and plantar-sensation as quantified by vibratory plantar threshold (VPT) were also measured at baseline and six weeks.

RESULTS

No difference were observed between groups for baseline characteristics ( P > .050). Posttherapy, ankle and COM sway with eyes open were significantly improved ( P < .05, Cohen's effect size d = 0.67-0.76) in the IG with no noticeable changes in CG. All gait parameters were significantly improved in the IG with highest effect size observed for cadence ( d = 1.35, P = .000). Results revealed improvement in VPT ( P = .004, d = 1.15) with significant correlation with stride velocity improvement ( r = .56, P = .037). ABI was improved in the IG in particulate among those with ABI>1.20 ( P = .041, d = 0.99) Conclusion: This study suggests that daily home use of plantar electrical-stimulation may be a practical means to enhance motor-performance and plantar-sensation in people with DPN.

Polyneuropathy relates to impairment in daily activities, worse gait, and fall-related injuries

OBJECTIVE

To extensively investigate the association of chronic polyneuropathy with basic and instrumental activities of daily living (BADL and IADL), falls, and gait.

METHODS

A total of 1,445 participants of the population-based Rotterdam Study (mean age 71 years, 54% women) underwent a polyneuropathy screening involving a symptom questionnaire, neurologic examination, and nerve conduction studies. Screening yielded 4 groups: no, possible, probable, and definite polyneuropathy. Participants were interviewed about BADL (Stanford Health Assessment questionnaire), IADL (Instrumental Activities of Daily Living scale), and frequency of falling in the previous year. In a random subset of 977 participants, gait was assessed with an electronic walkway. Associations of polyneuropathy with BADL and IADL were analyzed continuously with linear regression and dichotomously with logistic regression. History of falling was evaluated with logistic regression, and gait changes were evaluated with linear regression.

RESULTS

Participants with definite polyneuropathy had more difficulty in performing BADL and IADL than participants without polyneuropathy. Polyneuropathy related to worse scores of all BADL components (especially walking) and 3 IADL components (housekeeping, traveling, and shopping). Participants with definite polyneuropathy were more likely to fall, and these falls more often resulted in injury. Participants with polyneuropathy had worse gait parameters on the walkway, including lower walking speed and cadence, and more errors in tandem walking.

CONCLUSIONS

Chronic polyneuropathy strongly associates with impairment in the ability to perform daily activities and relates to worse gait and an increased history of falling.

Sensory Functions, Balance, and Mobility in Older Adults With Type 2 Diabetes Without Overt Diabetic Peripheral Neuropathy: A Brief Report

This study examined possible subtle degradation in sensory functions, balance, and mobility in older adults with type 2 diabetes (T2D) prior to overt development of diabetic peripheral neuropathy (DPN). Twenty-five healthy controls (HC group, age = 74.6 ± 5.4) and 35 T2D elderly without DPN (T2D group, age = 70.6 ± 4.7) were recruited. Sensory assessment included vibrotactile sensitivity, bilateral caloric weakness, and visual contrast sensitivity. Self-report measures comprised of Activity-Specific Balance Confidence (ABC), Human Activity Profile–adjusted activity scores (HAP-AAS), falls, and mobility disability. Performance measures included modified Timed-Up and Go (mTUG), Clinical Test of Sensory Integration for Balance (mCTSIB), and Frailty and Injuries (FICSIT-4) balance test. T2D group demonstrated significantly worse bilateral caloric weakness, marginally higher threshold of vibrotactile sensitivity and lower visual contrast sensitivity, and as well as signifcantly lower HAP-AAS. A significantly higher proportion of the T2D group failed mCTSIB Condition 4 than in the HC group. Subtle changes in multiple sensory systems of older adults with T2D may reduce redundancy available for balance control while performing challenging activities much before DPN development.

Balance impairments and neuromuscular changes in breast cancer patients with chemotherapy-induced peripheral neuropathy

OBJECTIVE

Chemotherapy-induced peripheral neuropathy (CIPN) is a common side effect of cancer treatment. Resulting sensory and motor dysfunctions often lead to functional impairments like gait or balance disorders. As the underlying neuromuscular mechanisms are not fully understood, we compared balance performance of CIPN patients with healthy controls (CON) to specify differences responsible for postural instability.

METHODS

20 breast cancer patients with CIPN (PAT) and 16 matched CONs were monitored regarding centre of pressure displacement (COP) and electromyographic activity of M. soleus, gastrocnemius, tibialis anterior, rectus femoris and biceps femoris. We calculated antagonistic co-contraction indices (CCI) and elicited soleus H-reflexes to evaluate changes in the elicitability and sensitivity of spinal reflex circuitry.

RESULTS

PAT's COP displacement was greater than CON's (p=.013) and correlated significantly with the level of CCIs and self-reported CIPN symptoms. PAT revealed prolonged H-wave latency (p=.021), decreased H-reflex elicitability (p=.001), and increased H-reflex sensitivity from bi- to monopedal stance (p=.004).

CONCLUSIONS

We summarise that CIPN causes balance impairments and leads to changes in elicitability and sensitivity of spinal reflex circuitry associated with postural instability. We assume that increased simultaneous antagonistic muscle activation may be used as a safety strategy for joint stiffness to compensate for neuromuscular degradation.

SIGNIFICANCE

Sensorimotor training has the potential to influence neuromuscular mechanisms in order to improve balance performance. Therefore, this training modality should be evaluated as a possible treatment strategy for CIPN.

Fear of falling is common in patients with type 2 diabetes and is associated with increased risk of falls

AIMS

fear of falling is an important falls-related symptom that has received little attention in studies of falls risk in older adults with type 2 diabetes.

METHODS

matched pairs of participants with diabetes or with normoglycaemia (n = 186 per group) recruited from a community-based survey underwent an assessment of fear of falling and associated falls risk factors. Multivariate methods examined associations between fear of falling and risk factors for history of recent falls.

RESULTS

compared with the normoglycaemic participants, those with diabetes had worse mobility (slow timed Up and Go test times: 16.2 versus 4.9%, P < 0.01), more fear of falling (24.2 versus 15.1%, P < 0.05) and more activity restriction from fear of falling (indoors: 14.0 versus 4.8%, P = 0.006), but there was no increase in reported recent falls. In the combined sample, a history of recent falls was negatively associated with fear-related limitation of outdoor activities (odds ratio (95% confidence interval): 0.30 (0.15-0.58), P < 0.001) and positively associated with age (1.65 (1.20-2.28) per 10-year increase, P = 0.002) and use of antidepressants (2.14 (1.02-4.50, P = 0.044). The frequency of falls in those with recurrent falls was negatively associated with measures of balance.

CONCLUSIONS

type 2 diabetes is associated with increased fear of falling and fear-associated activity restriction, and this modifies the risk of falls even in the face of increased falls risk factors including worse mobility. Future studies of falls in diabetes need to consider that fear of falling is an important modifier of the relationship between risk factors and falls.

Effects of thai foot massage on balance performance in diabetic patients with peripheral neuropathy: a randomized parallel-controlled trial

BACKGROUND Peripheral neuropathy is the most common complications of diabetic patients and leads to loss of plantar cutaneous sensation, movement perception, and body balance. Thai foot massage is an alternative therapy to improve balance. Therefore, the purpose of this study was to investigate the effects of Thai foot massage on balance performance in diabetic patients with peripheral neuropathy. MATERIAL AND METHODS Sixty patients with type-2 diabetes were recruited and randomly assigned into either the Thai foot massage or control groups. The Thai foot massage group received a modified Thai traditional foot massage for 30 min, 3 days per week for 2 weeks. We measured timed up and go (TUG), one leg stance: OLS), the range of motion (ROM) of the foot, and foot sensation (SWMT) before treatment, after the first single session, and after the 2-week treatment. RESULTS After the single treatment session, only the Thai foot massage group showed a significant improvement in TUG. After the 2-week treatment, both Thai foot massage and control groups showed a significant improvement of TUG and OLS (P<0.05); however, when comparing between 2 groups, the Thai foot massage group showed better improvement in TUG than the control group (p<0.05). The Thai foot massage group also showed significant improvements in ROM and SWMT after the 2-week treatment. CONCLUSIONS The results of this study suggest that Thai foot massage is a viable alternative treatment for balance performance, ROM of the foot, and the foot sensation in diabetic patients with peripheral neuropathy.

Balance rehabilitation: promoting the role of virtual reality in patients with diabetic peripheral neuropathy

BACKGROUND

Individuals with diabetic peripheral neuropathy frequently experience concomitant impaired proprioception and postural instability. Conventional exercise training has been demonstrated to be effective in improving balance but does not incorporate visual feedback targeting joint perception, which is an integral mechanism that helps compensate for impaired proprioception in diabetic peripheral neuropathy.

METHODS

This prospective cohort study recruited 29 participants (mean ± SD: age, 57 ± 10 years; body mass index [calculated as weight in kilograms divided by height in meters squared], 26.9 ± 3.1). Participants satisfying the inclusion criteria performed predefined ankle exercises through reaching tasks, with visual feedback from the ankle joint projected on a screen. Ankle motion in the mediolateral and anteroposterior directions was captured using wearable sensors attached to the participant's shank. Improvements in postural stability were quantified by measuring center of mass sway area and the reciprocal compensatory index before and after training using validated body-worn sensor technology.

RESULTS

Findings revealed a significant reduction in center of mass sway after training (mean, 22%; P = .02). A higher postural stability deficit (high body sway) at baseline was associated with higher training gains in postural balance (reduction in center of mass sway) (r = -0.52, P < .05). In addition, significant improvement was observed in postural coordination between the ankle and hip joints (mean, 10.4%; P = .04).

CONCLUSIONS

The present research implemented a novel balance rehabilitation strategy based on virtual reality technology. The method included wearable sensors and an interactive user interface for real-time visual feedback based on ankle joint motion, similar to a video gaming environment, for compensating impaired joint proprioception. These findings support that visual feedback generated from the ankle joint coupled with motor learning may be effective in improving postural stability in patients with diabetic peripheral neuropathy.

Assessment of lower leg muscle force distribution during isometric ankle dorsi and plantar flexion in patients with diabetes: a preliminary study

AIM

The aim of this study was to evaluate the differences in ankle muscle strength using hand-held dynamometry and to assess difference in the isometric muscle force distribution between the people with diabetes and control participants.

METHODS

The maximal muscle strength of ankle plantarflexion, dorsiflexion, eversion, inversion, lesser toes flexors and extensors, hallux flexors, and extensors was assessed in 20 people with diabetes and 20 healthy participants using hand-held dynamometry. The maximal isometric ankle plantarflexion and dorsiflexion were imported to OpenSim software to calculate 12 individual muscle (8 plantarflexors and 4 dorsiflexors) forces acting on ankle joint.

RESULTS

A significant reduction in ankle strength for all measured actions and a significant decrease in muscle force for each of the 12 muscles during dorsi and plantar flexion were observed. Furthermore, the ratios of agonist to antagonist muscle force for 6 of the muscles were significantly different between the control group and the group with diabetes.

CONCLUSIONS

It is likely that the muscles for which the agonist/antagonist muscle force ratio was significantly different for the healthy people and the people with diabetes could be more affected by diabetes.

Motor neuropathy

In distal symmetric sensorimotor polyneuropathy (DSPN) in diabetes, involvement of the motor system is rarely seen. Using dynamometry, substantial weakness at the ankle and knee has been found in type 1 and type 2 diabetic patients. The muscle weakness is found only in diabetic patients with DSPN, and is closely related to signs and severity of DSPN. In long-term follow-up studies, neuropathic patients have accelerated loss of muscle strength. Studies using MRI have shown that muscle weakness is paralleled by muscular atrophy within the feet and lower legs and in follow-up studies this atrophy is accelerated compared to healthy controls and non-neuropathic patients. In large-scale studies of diabetic subjects, lower muscle quality has been found, which indicates that even with preserved muscle strength diabetes per se causes lower strength per unit striated muscle. Muscle weakness causes slower movements of the feet and legs, unstable gait, and more frequent falls. Furthermore, weakness is also an independent risk factor for the development of foot ulcers. Training may improve strength, postural stability, and walking performance; however, this still needs to be studied including patients with various degrees of DSPN.

Retrogression of Nervous Fibers According to the Age of Patients with Diabetes Mellitus (DM)

[Purpose] This study was performed to discover the possible onset time of diabetic neuropathy by age of diabetic patients, and to provide the knowledge necessary for preventing or managing diabetic neuropathy. [Subjects] The subjects of this study were outpatients who visited D Hospital Department of Neurology with complaints of significant neuropathic symptoms including dullness, numbness and paraesthesia. [Methods] Stimulations of 5 Hz, 250 Hz and 2,000 Hz were generated with a Neurometer CPT (Neurotron Inc., Baltimore, MD, USA) and delivered selectively to C fibers, A-delta fibers and A-beta fibers. The intensity of the stimulations of 5 Hz, 250 Hz and 2,000 Hz was incrementally increased as much as 0.01 mA. [Result] The results of this experiment show that the period of retrogression of nervous fibers was different significantly according to the age of patients with diabetes mellitus. Especially, in the case of individuals in their 50's, Aβ, Aδ, and C fibers in both the right and left lower limbs significantly changed within a period of 2 months. In the case of individuals in their 60's, Aβ and C fibers of the right lower limb meaningfully changed 2 months after the onset of the disease, and Aβ, Aδ, and C fibers of the left lower limb also significantly changed within a period of 2 months. [Conclusion] We discovered that patients suffering from DM especially in their 50's or 60's should be thoroughly followed for their condition, right from the onset of DM, in order to prevent the retrogression of nervous fibers.

Diabetic peripheral neuropathy and gait: does footwear modify this association?

BACKGROUND

Gait-related fall risk is the leading cause of mortality among patients with diabetes, especially those older than 65 years. Deterioration in balance and loss of protective sensation in lower extremities contribute significantly to fall risk in patients with diabetic peripheral neuropathy (DPN). This study aimed to explore the impact of neuropathy and foot ulcer on gait.

METHODS

We recruited 39 participants (age, 56.9 ± 8.2 years; body mass index, 29.6.3 ± 4.7 kg/m2), including 15 DPN patients without foot ulcers, 16 DPN patients with foot ulcers, and 8 healthy aged-matched controls. Patients with active foot ulcers wore an offloading device during gait examination, including removable cast walker.

RESULTS

Results suggest that neuropathy alters gait mainly by increasing gait initiation, gait variability (coefficient of variation of gait velocity), and double support (DS) time, while reducing knee range of motion and center of mass sway (p < .05). Interestingly, the presence of foot ulcer does not impact gait velocity (p > .1) but enhances some of the gait parameters such as gait variability and DS time.

CONCLUSIONS

This study demonstrates that neuropathy deteriorates gait, but the presence of foot ulcers does not alter gait parameters further than neuropathy. In addition, patients with foot ulcers demonstrated a better gait compared with DPN patients without ulcers. We speculate that offloading footwear may be enhancing the somatosensory feedback from sensate skin, thereby positively affecting gait parameters. A study with a larger sample is required to explore the effect of prescribed footwear in the DPN population in order to validate the findings of this research study.

Alterations in circulating angiogenic and anti-angiogenic factors in type 2 diabetic patients with neuropathy

Diabetic peripheral neuropathy (DPN) is one of the most common diabetic chronic complications. There is an increased attention directed towards the role of angiogenic factors including vascular endothelial growth factor (VEGF) and anti-angiogenic factors including soluble endoglin (sEng) as contributors to diabetic microvascular complications including neuropathy. The purposes of this study were to determine the role of these angiogenesis regulators in the prognosis of DPN. The study group included 60 patients with type 2 diabetes mellitus (T2DM) and 20 clinically healthy individuals. The patients were divided into two groups. Group I included 20 T2DM patients without peripheral neuropathy, and Group II consisted of 40 T2DM patients with DPN. In all groups, plasma VEGF, sEng and endothelin-1 (ET-1), nitric oxide and ET-1 mRNA were estimated. Plasma levels of VEGF, sEng, ET-1 and nitric oxide were significantly elevated in diabetic patients (Groups I and II) compared with healthy control subjects, with a higher increase in their levels in patients with DPN compared with diabetic patients without peripheral neuropathy. Measurement of plasma levels of angiogenesis-related biomarkers in high-risk diabetic patients might identify who later develop DPN, thus providing opportunities for early detection and targets for novel treatments.

Prevalence and correlates of disability in a late middle-aged population of women

OBJECTIVE

This study estimates the prevalence of disability among late middle-aged women and identifies important correlates of disability among this population.

METHOD

Disability was assessed among 376 participants of the Michigan Study of Women's Health Across the Nation cohort at the 2011 follow-up using the World Health Organization Disability Assessment Schedule. Demographic and health measures were related to disability status using logistic regression models (none or mild vs. moderate, severe, or extreme disability).

RESULTS

Nearly 25% of women reported moderate to extreme global disability. African American race/ethnicity, economic strain, peripheral neuropathy, and depressive symptomatology were associated with global disability. Obesity, knee osteoarthritis, and hypertension were only associated with disability for the mobility domain (getting around).

DISCUSSION

The prevalence of disability is relatively high among this population of late middle-aged women. Efforts to prevent or forestall disability should be extended to include middle-aged populations as they may be most amenable to intervention.

Risk of fall for people with diabetes

PURPOSE

To examine the risk of fall for people with diabetes compared with healthy control subjects. Correlation between tactile sensation and postural control was examined for subjects with diabetes.

METHODS

Subjects with type 2 diabetes were classified into two groups: (i) diabetes without neuropathy (n = 23) and (ii) diabetic peripheral neuropathy (DPN) (n = 9). Age-matched healthy control subjects (n = 32) were recruited. Tactile sensation, equilibrium scores (ES), strategy scores and sensory analysis scores from the Sensory Organization Test (SOT) were compared among the groups.

RESULTS

Subjects with diabetes without neuropathy demonstrated impaired postural control upon the disruption of somatosensory inputs. Subjects with DPN lost balance upon being deprived of visual inputs. A decrease in tactile sensation was associated with a decrease in the ESs in all subjects with diabetes (r = -0.35 to -0.77; p < 0.05), and they tend to use more hip strategy for postural control upon being deprived of visual inputs.

CONCLUSIONS

Different postural control strategies are adopted by various subgroups of subjects with diabetes. Subjects with DPN demonstrated a significant shift from ankle to hip strategies for balance tests when vision was deprived. Implications for Rehabilitation The severity of diabetic peripheral neuropathy (DPN) is associated with the risk of fall. Different compensatory strategies in balance control have been adopted by different subgroups of people with diabetes. In order to minimize the risk of fall, specific balance training program should be offered to different subgroups of people with diabetes. The balance training should emphasize on optimizing the competence of their existing compensatory postural control strategies.

Performance-based physical functioning and peripheral neuropathy in a population-based cohort of women at midlife

Peripheral neuropathy is underappreciated as a potential cause of functional limitations. In the present article, we assessed the cross-sectional association between peripheral neuropathy and physical functioning and how the longitudinal association between age and functioning differed by neuropathy status. Physical functioning was measured in 1996-2008 using timed performances on stair-climb, walking, sit-to-stand, and balance tests at the Michigan site of the Study of Women's Health Across the Nation, a population-based cohort study of women at midlife (n = 396). Peripheral neuropathy was measured in 2008 and defined as having an abnormal monofilament test result or 4 or more symptoms. We used linear mixed models to determine whether trajectories of physical functioning differed by prevalent neuropathy status. Overall, 27.8% of the women had neuropathy. Stair-climb time differed by neuropathy status (P = 0.04), and for every 1-year increase in age, women with neuropathy had a 1.82% (95% confidence interval: 1.42, 2.21) increase compared with a 0.95% (95% confidence interval: 0.71, 1.20) increase for women without neuropathy. Sit-to-stand time differed by neuropathy status (P = 0.01), but the rate of change did not differ. No differences between neuropathy groups were observed for the walk test. For some performance-based tasks, poor functioning was maintained or exacerbated for women who had prevalent neuropathy. Peripheral neuropathy may play a role in physical functioning limitations and future disability.

Comparison of different screening tests for diagnosis of diabetic peripheral neuropathy in Primary Health Care setting

BACKGROUND

DPN is an important complication and contributes to the morbidity of diabetes mellitus. Evidence indicates early detection of DPN results in fewer foot ulcers and amputations.

OBJECTIVE

The purpose of this study was to compare different screening tests in the detection of DPN in primary care setting.

METHODOLOGY

It is a cross-sectional study in a random sample (N = 242) of type 2 diabetes mellitus participants at primary care setting. Different screening tests for detecting DPN such as Michigan Neuropathy Screening Instrument (MNSI), Semmes-Weinstein Monofilament (SWM), vibration sensation and ankle reflex were performed for each patient and compare between them.

RESULTS

45% of the participant had DPN based on MNSI, The detection rate using the 128-Hz tuning fork and 10-g SWM was nearly same (32.6 & 31.4%) respectively and significantly higher than ankle reflexes (23.1%). Although, the prevalence of DPN determined by the combined two tests (38.79%) was higher than that through the single test.

CONCLUSION

this study showed different results of DPN screening tests, even in the same group of patients. However there was a significant correlation between them. 128-Hz tuning fork and 10-g SWM monofilament would appear to be an appropriate, cheap and easy to use tool for identifying patients at risk of having neuropathy in primary care setting.

Muscle strength and ankle mobility for the gait parameters in diabetic neuropathies

AIMS

To evaluate the spatio-temporal variables of gait and the isometric muscle strength component of the ankle in patients with peripheral diabetic neuropathy. Also, verify the relationship between these variables and gait parameters.

METHODS

This study involved 25 diabetic peripheral neuropathy (DPN) participants (62.4±8.36 years) and 27 age-matched healthy control individuals (64.48±6.21 years). The assessment of the spatio-temporal parameters of gait was performed using an electronic baropodometry treadmill. Prior to the collection data, each participant was instructed to walk on the treadmill in her/his habitual self-selected speed.

RESULTS

Diabetic neuropathy group showed impairment of gait, with a smaller stride and length speed of the cycle, and increased duration of support time. Restricted dorsiflexion mobility and increased plantarflexion mobility were found, with a decrease in muscle strength of the dorsiflexors and plantiflexors. There was a significant relationship between plantiflexor muscle strength and the length and speed of the gait cycle. Also the muscle strengths of the plantiflexors and dorsiflexors, and the range of motion of dorsiflexion were predictors of gait performance.

CONCLUSIONS

The ankle, muscle strength and ankle mobility variables could explain changes in gait speed and range of motion in patients with DPN, allowing for the application of preventive strategies.

Serial anthropometry predicts peripheral nerve dysfunction in a community cohort

BACKGROUND

Obesity is a risk factor for glucose intolerance, but the independent role of obesity in the development of peripheral neuropathy is unclear. This study assessed the impact of body size trajectories on prevalent nerve dysfunction in community-dwelling women with and without glucose intolerance.

METHODS

Annual (1996-2008) anthropometric measures of weight, height, waist circumference and body mass index [BMI, weight (kg)/height (m(2) )] were assessed in the Study of Women's Health Across the Nation - Michigan site. Glucose intolerance was defined annually on the basis of current use of diabetes medications, self-reported diabetes diagnosis and, when available, fasting glucose. Peripheral nerve dysfunction in 2008 was defined as abnormal monofilament testing or ≥4 symptoms or signs. Linear mixed models were used to determine trajectories of anthropometry by subsequently identified nerve dysfunction status.

RESULTS

Mean BMI was 32.4 kg/m(2) at baseline, and 27.8% of the women had nerve dysfunction in 2008. BMI, weight and waist circumference increased over time. Women who would have nerve dysfunction were significantly larger than women without dysfunction, independent of glucose intolerance. At mean baseline age of 46, BMI, weight and waist circumference differed significantly (p-value < 0.01) by subsequent nerve dysfunction status, independent of glucose intolerance and hypertension. These body size differences were maintained but not exacerbated over time.

CONCLUSIONS

Peripheral nerve dysfunction is prevalent among community-dwelling women. Twelve years before the nerve assessment, anthropometry differed between women who would and would not have nerve dysfunction, differences that were maintained over time. Obesity deserves attention as an important and potentially modifiable risk factor for peripheral nerve dysfunction.

Progressive axonal dysfunction precedes development of neuropathy in type 2 diabetes

To evaluate the development of diabetic neuropathy, the current study examined changes in peripheral axonal function. Nerve excitability techniques were undertaken in 108 type 2 diabetic patients with nerve conduction studies (NCS), HbA(1c) levels, and total neuropathy score (TNS). Patients were categorized into two cohorts: patients with diabetes without neuropathy (DWN group [n = 56]) and patients with diabetes with neuropathy (DN group [n = 52]) and further into severity grade 0 (TNS 0-1 [n = 35]), grade 1 (TNS 2-8 [n = 42]), and grade 2/3 (TNS 9-24 [n = 31]). Results revealed that the DWN group had a significantly increased threshold, prolonged latency, and changes in excitability parameters compared with age-matched control subjects. Patients with neuropathy demonstrated significant alteration in recovery cycle parameters and depolarizing threshold electrotonus. Within the DWN cohort, there were significant correlations between HbA(1c) level and latency and subexcitability, whereas the estimated glomerular filtration rate correlated with superexcitability in patients with neuropathy. Furthermore, excitability parameters became progressively more abnormal with increasing clinical severity. These results suggest a spectrum of excitability abnormalities in patients with diabetes and that early axonal dysfunction may be detected prior to the development of neuropathy. As progressive changes in excitability parameters correlated to neuropathy severity, excitability testing may provide a biomarker of the early development and severity of diabetic neuropathy, providing insights into the pathophysiological mechanisms producing axonal dysfunction.

Virtualizing the assessment: a novel pragmatic paradigm to evaluate lower extremity joint perception in diabetes

BACKGROUND

Individuals with diabetes have a higher risk of falls and fall-related injuries. People with diabetes often develop peripheral neuropathy (DPN) as well as nerve damage throughout the body. In particular, reduced lower extremity proprioception due to DPN may cause a misjudgment of foot position and thus increase the risk of fall.

OBJECTIVE

An innovative virtual obstacle-crossing paradigm using wearable sensors was developed in an attempt to assess lower extremity position perception damage due to DPN.

METHODS

67 participants (age 55.4 ± 8.9, BMI 28.1 ± 5.8) including diabetics with and without DPN as well as aged-matched healthy controls were recruited. Severity of neuropathy was quantified using a vibratory perception threshold (VPT) test. The ability of perception of lower extremity was quantified by measuring obstacle-crossing success rate (OCSR), toe-obstacle clearance (TOC), and reaction time (T(R)) while crossing a series of virtual obstacles with heights at 10% and 20% of the subject's leg length.

RESULTS

No significant difference was found between groups for age and BMI. The data revealed that DPN subjects had a significantly lower OCSR compared to diabetics with no neuropathy and controls at an obstacle size of 10% of leg length (p < 0.05). DPN subjects also demonstrated longer T(R) compared to other groups and for both obstacle sizes. In addition, TOC was reduced in neuropathy groups. Interestingly, a significant correlation between T(R) and VPT (r = 0.5, p < 10(-3)) was observed indicating a delay in reaction with increasing neuropathy severity. The delay becomes more pronounced by increasing the size of the obstacle. Using a regression model suggests that the change in T(R) between obstacle sizes of 10% and 20% of leg length is the most sensitive predictor for neuropathy severity with an odds ratio of 2.70 (p = 0.02).

CONCLUSION

The findings demonstrate proof of a concept of virtual-reality application as a promising method for objective assessment of neuropathy severity, however a further study is warranted to establish a stronger relationship between the measured parameters and neuropathy.

Postural strategies in diabetes patients with peripheral neuropathy determined using cross-correlation functions

BACKGROUND

Although postural control strategies have been largely explored in diabetes patients with peripheral neuropathy, the literature on their postural control strategies related to peripheral neuropathy level and task complexity is still limited. The aim of this study is then to investigate how balance task difficulty influences postural strategies in diabetes patients with peripheral neuropathy.

SUBJECTS AND METHODS

Postural strategies and instability were evaluated in 25 diabetes patients during four standing tasks. The root mean square value of the anterior-posterior angular velocity, measured at the trunk and the ankle, was investigated and analyzed using cross-correlation functions (CCFs). Correlations between balance and clinical variables were analyzed.

RESULTS

A significant decrease in CCFs between trunk and ankles was observed under dynamic balance conditions. Correlations were observed between postural strategies and balance instability with the level of peripheral neuropathy and with hip and ankle strength.

CONCLUSION

Postural strategies are influenced by more demanding standing tasks and correlated with the level of peripheral neuropathy and strength of muscles in diabetes patients.

Lower extremity muscle strength is reduced in people with type 2 diabetes, with and without polyneuropathy, and is associated with impaired mobility and reduced quality of life

AIM

The purpose of the present study was to distinguish the effects of both diabetes mellitus type 2 (DM2) and diabetic polyneuropathy (DPN) on mobility, muscle strength and health related quality of life (HR-QoL).

METHODS

DPN patients (n=98), DM2 patients without DPN (DC) (n=39) and healthy subjects (HC) (n=19) performed isometric and isokinetic lower limb muscle strength tests. Mobility was determined by a timed up and go test (TUGT), a 6 min walk test and the physical activity scale for the elderly questionnaire. HR-QoL was determined by the SF36 questionnaire.

RESULTS

DPN patients had moderate polyneuropathy. In both DPN and DC patients leg muscle strength was reduced by 30-50% compared to HC. Muscle strength was correlated with mobility tests, and reduced muscle strength as well as impaired mobility were associated with a loss of HR-Qol (all p<0.05). We did not observe major differences in muscle strength, mobility (except for the TUGT, p<0.01) and HR-QoL between diabetic patients with and without DPN.

CONCLUSION

DM2 patients, with and without DPN, have decreased maximal muscle strength in the lower limbs and impaired mobility. These abnormalities are associated with a loss of HR-QoL. The additional effect of moderate DPN was small in our patients.

New Treatment Approaches for Older Adults with Multiple Myeloma

The incidence of multiple myeloma (MM) increases with age, and with the aging of the population, the number of adults with MM is expected to double in the next 20 years. Novel agents, including the immunomodulatory agents thalidomide and lenalidomide, and the proteosome inhibitor bortezomib have dramatically changed the treatment of multiple myeloma in the past decade. The purpose of this review was to examine the recent clinical therapeutic trials in older adults with MM. A number of trials have evaluated the addition of novel agents to the traditional backbone of melphalan and prednisone. The combination of thalidomide with melphalan and prednisone has been evaluated in 7 randomized trials. The combination improves response rates and, in meta-analyses, survival, but at the expense of increased toxicity. Other combination regimens which include lenalidomide or bortezomib likewise are associated with higher response rates, but at the expense of greater toxicity. High dose dexamethasone is excessively toxic in older adults and should be avoided. The roles for high-dose therapy with autologous stem cell transplant or intermediate-dose melphalan with autologous stem cell transplant in older adults with MM in the era of modern therapy remain to be defined. In summary, there are a number of new therapeutic options for older adults with MM, allowing an individualized treatment strategy based on the patient's comorbidities and goals of care.

Peripheral vascular disease and peripheral neuropathy in individuals with cardiometabolic clustering and obesity: National Health and Nutrition Examination Survey 2001-2004

OBJECTIVE

Two lower-extremity diseases (LEDs), including peripheral neuropathy and peripheral vascular disease (PVD), are leading causes of disability in the U.S. Although LEDs can be complications of diabetes, their prevelances and risk factors apart from diabetes are poorly described. This study describes the prevalence of LEDs and examines the association of obesity and cardiometabolic clustering in a population-based sample.

RESEARCH DESIGN AND METHODS

Adults aged≥40 years (n=2,514) were evaluated in the 2001-2004 National Health and Nutrition Examination Survey for clustering of two or more cardiometabolic characteristics, including elevated triglycerides or plasma glucose, low HDL cholesterol levels, increased waist circumference, or hypertension. Clustering was combined with BMI (dichotomized at ≥30 kg/m2) to generate three groups: obese (with or without clustering); nonobese with clustering; and nonobese without clustering. Multivariate logistic regression procedures incorporated the complex survey sampling design.

RESULTS

Overall, 9.0% of individuals had peripheral neuropathy alone, 8.5% had PVD alone, and 2.4% had both LEDs. The obese group was more likely to have peripheral neuropathy (odds ratio 2.20 [95% CI 1.43-3.39]), PVD (3.10 [1.84-5.22]), and both LEDs (6.91 [2.64-18.06]) compared with nonobese subjects without clustering. Within the nonobese group, clustering increased the odds of peripheral neuropathy (1.50 [1.00-2.25]) and PVD (2.48 [1.38-4.44]) compared with no clustering.

CONCLUSIONS

Obesity and clustering markedly increased the likelihood of LEDs in this sample and identified a group for whom preventive activities may reduce the risk of future disability.