Role of ankle mobility in foot rollover during gait in individuals with diabetic neuropathy

The effects of the use of customized silicone digital orthoses on pre-ulcerative lesions and plantar pressure during walking in people with diabetic neuropathy: A study protocol for a randomized controlled trial

Background

People with diabetes and diabetic peripheral neuropathy (DPN) often develop calluses due to toe misalignment and increased plantar pressure. Untreated, these issues can progress into ulcers, making early intervention crucial. This trial protocol aims to evaluate the efficacy and safety of customized silicone digital orthoses in preventing ulcers, pre-ulcerative lesions, and peak pressure during gait in people with DPN.

Methods

In this superiority randomized controlled parallel trial with single-blind assessment, 60 participants will be allocated to the control group (CG) or the intervention group (IG). The CG will receive specialized nurse-administered foot care, including callus removal, nail care guidance, and self-care education. The IG will receive the same care plus a customized silicone orthosis for toe realignment for 6 months. Assessments will occur at baseline and 3 and 6 months for the primary outcomes (pre-ulcerative lesions and ulcer incidence) and secondary outcomes (pressure distribution, foot function and health, quality of life, safety, and comfort). Two-way ANOVAs (p < .05) will assess group, time, and group by time effects following an intention-to-treat approach.

Conclusion

Although recommended for foot ulcer prevention, custom silicone orthosis adoption remains limited due to the low certainty of evidence. This trial seeks to provide more consistent evidence for the use of toe orthoses in preventing callus and ulcer formation for individuals with DPN.

Trial registry

ClinicalTrials.gov (NCT05683106) "Effects of Customized Silicone Digital Orthoses in People with Diabetic Neuropathy" (registered on December 20, 2022).

Effects of foot and ankle mobilisations combined with home stretches in people with diabetic peripheral neuropathy: a proof-of-concept RCT

INTRODUCTION

People with diabetic peripheral neuropathy (DPN) and limited joint mobility syndrome (LJMS) can experience increased forefoot peak plantar pressures (PPPs), a known risk factor for ulceration. The aim of this study was to investigate whether ankle and 1st metatarsophalangeal (MTP) joint mobilisations and home-based stretches in people with DPN improve joint range of motion (ROM) and reduce forefoot PPPs.

DESIGN AND METHODS

Sixty-one people with DPN (IWGDF risk 2), were randomly assigned to a 6-week programme of ankle and 1st MTP joint mobilisations (n = 31) and home-based stretches or standard care only (n = 30). At baseline (T0); 6-week post intervention (T1) and at 3 months follow-up (T2), a blinded assessor recorded dynamic ankle dorsiflexion range using 3D (Codamotion) motion analysis and the weight bearing lunge test, static 1st MTP joint dorsiflexion ROM, dynamic plantar pressure and balance.

RESULTS

At T1 and T2 there was no difference between both groups in ankle dorsiflexion in stance phase, plantar pressure and balance. Compared to the control group, the intervention group showed a statistically significant increase in static ankle dorsiflexion range (Left 1.52 cm and 2.9cms, Right 1.62 cm and 2.7 cm) at 6 (T1) and 18 weeks (T2) respectively p < 0.01). Between group differences were also seen in left hallux dorsiflexion (2.75°, p < 0.05) at T1 and in right hallux dorsiflexion ROM (4.9°, p < 0.01) at T2 follow up. Further, functional reach showed a significant increase in the intervention group (T1 = 3.13 cm p < 0.05 and T2 = 3.9 cm p < 0.01). Intervention adherence was high (80%).

CONCLUSIONS

Combining ankle and 1st MTP joint mobilisations with home-based stretches in a 6-week programme in people with DPN is effective in increasing static measures of range. This intervention may be useful for improving ankle, hallux joint mobility and anteroposterior stability limits in people with diabetes and neuropathy but not for reducing PPP or foot ulcer risk.

TRIAL REGISTRATION

https://classic.

CLINICALTRIALS

gov/ct2/show/NCT03195855 .

Potential predictive effect of mechanical properties of the plantar skin and superficial soft tissue, and vibration perception on plantar loading during gait in individuals with diabetes

BACKGROUND

This exploratory study aimed to investigate the extent to which mechanical properties of the plantar skin and superficial soft tissue (hardness, stiffness, and thickness) and vibration perception thresholds (VPTs) predict plantar pressure loading during gait in people with diabetes compared to healthy controls.

METHODS

Mechanical properties, VPTs, and plantar loadings during gait at the heel and first metatarsal head (MTH) of 20 subjects with diabetes, 13 with DPN, and 33 healthy controls were acquired. Multiple regression analyses were used to predict plantar pressure peaks and pressure-time integrals at both locations based on the mechanical properties of the skin and superficial soft tissues and VPTs.

RESULTS

In the diabetes group at the MTH, skin hardness associated with 30-Hz (R2 = 0.343) and 200-Hz (R2 = 0.314) VPTs predicted peak pressure at the forefoot. In the controls at the heel, peak pressure was predicted by the skin thickness, hardness, and stiffness associated with 30-Hz (R2 = 0.269, 0.268, and 0.267, respectively) and 200-Hz (R2 = 0.214, 0.247, and 0.265, respectively) VPTs.

CONCLUSION

The forefoot loading of people with diabetes can be predicted by the hardness of the skin when combined with loss of vibration perception at low (30-Hz) and high (200-Hz) frequencies. Further data from larger sample sizes are needed to confirm the current findings.

Evaluation of in-shoe plantar pressure and shear during walking for diabetic foot ulcer prevention

OBJECTIVE

To investigate reliability and changes of in-shoe plantar pressure and shear during walking at three cadences with two insole designs. This was a precursor to the investigation of plantar loading in people with diabetes for potential foot ulcer prevention.

METHOD

A sensorised insole system, capable of measuring plantar pressure and shear at the heel, fifth metatarsal head (5MH), first metatarsal head (1MH) and hallux, was tested with ten healthy participants during level walking. Reliability was evaluated, using intra-class correlation coefficient (ICC), while varying the cadences and insole types. Percentage changes in pressure and shear relative to values obtained at self-selected cadence with a flat insole design were investigated.

RESULTS

Mean±standard deviation of maximum pressure, medial-lateral and anterior-posterior shear of up to 380±24kPa, 46±2kPa and -71±4kPa, respectively, were measured. The ICC in ranges of 0.762-0.973, 0.758-0.987 and 0.800-0.980 were obtained for pressure, anterior-posterior and medial-lateral shear, respectively. Opposite anterior-posterior shear directions between 5MH and 1MH (stretching), and between 1MH and hallux (pinching) were observed for some participants. Increasing cadence increased pressure and anterior-posterior shear (by up to +77%) but reduced medial-lateral shear at the heel and hallux (by up to -34%). Slower cadence increased anterior-posterior shear (+114%) but decreased medial-lateral shear (-46%) at the hallux. The use of a flexible contoured insole resulted in pressure reduction at the heel and 5MH but an increase in anterior-posterior shear at the heel (+69%) and hallux (+75%).

CONCLUSION

The insole system demonstrated good reliability and is comparable to reported pressure-only systems. Pressure measurements were sensitive to changes in cadence and insole designs in ways that were consistent with the literature. However, our plantar shear showed localised shear changes with cadences and insoles for the first time, as well as stretching and pinching effects on plantar tissue. This opens new possibilities to investigate plantar tissue viability, loading characteristics and orthotic designs aimed towards foot ulcer prevention.

Immediate Effects of Weight-Bearing Calf Stretching on Ankle Dorsiflexion Range of Motion and Plantar Pressure During Gait in Patients with Diabetes Mellitus

High plantar pressure is a risk factor for diabetic foot ulcers, and it is known that restriction of ankle dorsiflexion range of motion (ROM) causes high plantar pressure. Stretching is a non-invasive and general means to improve ROM; however, the effect of stretching on the ROM and plantar pressure has not been clarified in patients with diabetes mellitus. We aimed to study the effects of intermittent weight-bearing stretching on ankle dorsiflexion ROM and plantar pressure during gait in patients with diabetes mellitus. Seven patients with diabetes mellitus participated, and their triceps surae was stretched using weight-bearing stretching with a stretch board. Five minutes of stretching was performed 4 times with a rest interval of 30 s. Ankle dorsiflexion ROM was measured with the knee flexed and extended. Peak pressure and pressure-time integral during gait were measured and calculated for the rearfoot, midfoot, forefoot, and total plantar surface before and after stretching. Ankle dorsiflexion ROM with the knee extended or bent increased significantly after stretching (P < .05). Peak pressure and the pressure-time integral decreased significantly, especially in the forefoot (P < .01), and these also decreased significantly in the total plantar surface (P < .05). The duration of foot-flat decreased after stretching (P < .05). Weight-bearing stretching improved ankle dorsiflexion ROM and reduced plantar pressure during gait. These results suggest that weight-bearing calf stretching may be an effective means to prevent and treat diabetic foot ulcers.

Compromised neuromuscular function of walking in people with diabetes: a narrative review

AIM

This review summarizes recent studies that have investigated the neuromuscular dysfunction of walking in people with diabetes and its relationship to ulcer formation.

METHODS

A comprehensive electronic search in the database (Scopus, Web of Science, PsycINFO, ProQuest, and PubMed) was performed for articles pertaining to diabetes and gait biomechanics.

RESULTS

The Achilles tendon is thicker and stiffer in those with diabetes. People with diabetes demonstrate changes in walking kinematics and kinetics, including slower self-selected gait speed, shorter stride length, longer stance phase duration, and decreased ankle, knee, and metatarsophalangeal (MTP) joint range of motion. EMG is altered during walking and may reflect diabetes-induced changes in muscle synergies. Synergies are notable because they provide a more holistic pattern of muscle activations and can help develop better tools for characterizing disease progression.

CONCLUSION

Diabetes compromises neuromuscular coordination and function. The mechanisms contributing to ulcer formation are incompletely understood. Diabetes-related gait impairments may be a significant independent risk factor for the development of foot ulcers.

Effects of foot-ankle exercises on foot-ankle kinematics, plantar pressure, and gait kinetics in people with diabetic neuropathy: Secondary outcomes from a randomized controlled trial

BACKGROUND

Follow-up report of secondary outcomes of a randomized, single-blinded, parallel controlled trial that investigated the benefits of a foot-ankle therapeutic exercise program on foot-ankle kinematics, plantar pressure, and lower limb kinetics during gait in individuals with diabetic neuropathy (DPN).

METHODS

Sixty-six participants with DPN were randomly allocated into a control group (CG; n = 31), which received usual care, and an intervention group (IG; n = 35), which received usual care plus a 12-week group-based foot-ankle exercise program. Outcomes were assessed at baseline and 12 weeks by an assessor blinded to group allocation.

RESULTS

The generalized linear mixed model and intention-to-treat analysis revealed a greater hip extensor moment at push-off and greater hallux contact area in the IG than CG after 12 weeks. A within-group analysis revealed a larger arch height during stance and higher peak pressure and pressure-time integral at the central forefoot region in the IG after 12 weeks compared to baseline. There were no other significant group difference or changes over time in foot-ankle kinematics or in any other joint moment related to overall lower limb biomechanics.

CONCLUSION

The increases in hip moment at push-off and hallux surface contact area suggest an improvement in the propulsion phase with greater participation of the toes in foot rollover after 12 weeks of a group-based foot-ankle exercises program for people with DPN. Individual face-to-face, longer-term, and more intensive interventions may be needed to positively influence foot-ankle biomechanics and pressure parameters in other plantar areas.

Impact of biomechanics on therapeutic interventions and rehabilitation for major chronic musculoskeletal conditions: A 50-year perspective

The pivotal role of biomechanics in the past 50 years in consolidating the basic knowledge that underpins prevention and rehabilitation measures has made this area a great spotlight for health practitioners. In clinical practice, biomechanics analysis of spatiotemporal, kinematic, kinetic, and electromyographic data in various chronic conditions serves to directly enhance deeper understanding of locomotion and the consequences of musculoskeletal dysfunctions in terms of motion and motor control. It also serves to propose straightforward and tailored interventions. The importance of this approach is supported by myriad biomechanical outcomes in clinical trials and by the development of new interventions clearly grounded on biomechanical principles. Over the past five decades, therapeutic interventions have been transformed from fundamentally passive in essence, such as orthoses and footwear, to emphasizing active prevention, including exercise approaches, such as bottom-up and top-down strengthening programs for runners and people with osteoarthritis. These approaches may be far more effective inreducing pain, dysfunction, and, ideally, incidence if they are based on the biomechanical status of the affected person. In this review, we demonstrate evidence of the impact of biomechanics and motion analysis as a foundation for physical therapy/rehabilitation and preventive strategies for three chronic conditions of high worldwide prevalence: diabetes and peripheral neuropathy, knee osteoarthritis, and running-related injuries. We conclude with a summary of recommendations for future studies needed to address current research gaps.

The pressure time integral: An underused, clinically significant parameter as a determinant of neuropathic ulceration in diabetes

BACKGROUND

The purpose of this study was to evaluate plantar pressure dynamics in the occurrence of active diabetic neuropathic ulceration (DNU) and any changes in loadings occurring in individuals with a history of diabetic neuropathic ulceration (DHNU). Since current gold standard offloading strategies are not producing desirable healing outcomes and optimum ulcer prevention, this study aimed to better understand the effect of diabetic peripheral neuropathy (DPN) and ulceration on mean peak plantar pressure (MPPP) and pressure-time integral (PTI) changes.

RESEARCH QUESTION

Is there a redistribution of plantar pressure during gait in the presence of active and history of diabetic neuropathic ulceration?

METHODS

A prospective, cross-sectional study was conducted, in which, eighty adult participants were divided into four groups, namely, the DM, DPN, DNU and DHNU groups. Participants were instructed to walk barefoot over a Tekscan HR Mat™ at self-selected speed. MPPP and PTI data were analysed under five forefoot anatomical landmarks and compared between individuals with and without active neuropathic ulceration.

RESULTS

Minimal MPPP significant changes were observed between ulcerated and non-ulcerated groups, however, PTI values were significantly increased in the ulcerated groups under all plantar ulceration regions. No significant plantar pressure differences were observed between the DNU and DHNU groups. Logistic regression tests demonstrated that as PTIs under the hallux increase, the likelihood of an individual living with DPN developing ulceration increases.

SIGNIFICANCE

A significant increase in PTI values in the presence of ulceration highlights the importance of evaluating the duration of loads under forefoot regions during gait rather than just focusing on the magnitude of pressures during ulcer management and prevention. Moreover, results show that PTI values remain high in the presence of a history of neuropathic ulceration, possibly demonstrating the value of PTI as a clinical tool over MPPP in the assessment of the high-risk diabetic foot.

Pathological gait in partial foot amputation versus peripheral neuropathy

Partial foot amputation (PFA) is a common surgical loss of part of either the forefoot or mid-foot. It is usually the sequel to a cascade of physiological foot dysfunction such as peripheral neuropathy (PN). The gait compensation mechanisms associated with these foot disorders aren't well understood yet.

PURPOSE

The aim of the study was to evaluate pathological gait compensation mechanisms in PFA due to PN versus PN alone through a comprehensive gait analysis.

METHODS

Plantar pressure, GRF, load distribution, footprint length and area, foot progression angle, step length, percentage of double limb support, and stance time were measured on 53 participants assigned into two well-matched groups: (A) 25 subjects with healed unilateral PFA and (B) 28 subjects with PN without ulcer. The gait analysis was conducted at a self-preferred walking speed using the FREEMED baropodometric platform and FREESTEP software.

RESULTS

The PFA group showed a significant decrease in load over the remaining toes and metatarsal heads compared to the PN group (p = .001 and p = .003, respectively). Conversely, the PFA group showed a significant increase in load over the mid-foot and peak plantar pressure during mid-stance (p = .007 and p = .016, respectively). All other measured variables showed no significant difference between the two groups (p > .05).

CONCLUSION

Individuals with PFA and PN or PN alone tend to shift their body loads posteriorly and redistribute their loads to compensate for the insufficient support from the forefoot. The PFA group was worse than the PN group. Furthermore, the PFA may not be the primary cause of the altered gait but rather the underlying systemic disease. The PFA surgery only worsens the compensatory mechanism.

Acute Effects of Combination Therapy by Triceps Surae Stretching and Electrical Stimulation to the Tibialis Anterior on Medial Forefoot Plantar Pressure During Gait in Patients With Diabetes Mellitus

High plantar flexor moment and limited ankle mobility are known to cause high plantar pressure under the forefoot. Stretching is an effective physical therapy for the limited ankle range of motion (ROM), and electrical stimulation is used to regulate the activity of antagonistic muscle via the action of reciprocal inhibition. Additionally, stretching paired with electrical stimulation has been reported to improve the limited ROM significantly. This study aims to investigate the influences of stretching on triceps surae (STR), electrical stimulation to tibialis anterior (ES), and the combination (ES+STR) on the ROM, kinematic parameters, and plantar pressure distribution during gait in patients with diabetes mellitus. Planter pressure and other parameters were measured before and after the intervention of ES, STR, ES+STR, or the rest sitting on the bed (CON) for 10 min. Pressure time integral under the medial forefoot decreased in the ES+STR compared to CON (P< .05). Interestingly, ES+STR increased passive and dynamic ROM on ankle dorsiflexion during gait and increased the lateral center of pressure excursion (P < .05). Furthermore, these changes were followed by decreased contact duration under the medial forefoot (P < .05). The combined therapy improves ankle mobility during gait and reduces the contact duration and the plantar pressure under the medial forefoot in patients with diabetes mellitus.

Influence of Contoured Insoles with Different Materials on Kinematics and Kinetics Changes in Diabetic Elderly during Gait

BACKGROUND

Alterations in the lower limb kinematics and kinetics of diabetic patients have been reported in previous studies. Inappropriate choices of orthopedic insole materials, however, fail to prevent diabetic foot ulcers and modify abnormal gait. The aim of this study was to quantitatively compare the effects of contoured insoles with different materials on the kinematics of and kinetics changes in the diabetic elderly during gait.

METHODS

There were 21 diabetic patients who participated in this study. Three-dimensional (3D) experimental contoured insoles constructed of soft (i.e., Nora Lunalastik EVA and PORON^® Medical 4708) and rigid (i.e., Nora Lunalight A fresh and Pe-Lite) materials with Langer Biomechanics longitudinal PPT^® arch pads were adopted. An eight-camera motion capture system (VICON), two force plates, and an insole measurement system-Pedar^® with 99 sensors-were utilized to obtain the kinematics and kinetics data. The plug-in lower body gait model landmarks were used for dynamic data acquisition during gait. The corresponding data from five gait cycles were selected and calculated.

RESULTS

The range of motions (ROMs) of the ankle joint (p = 0.001) and knee joint (p = 0.044) were significantly influenced when the contoured insoles were worn in comparison to the barefoot condition. The joint moments of the lower limbs with maximum ankle plantarflexion during the loading response and maximum knee and hip flexions were significantly influenced by the use of contoured insoles with different materials in the diabetic elderly. The peak plantar pressure (PPP) of the forefoot (p < 0.001), midfoot (p = 0.009), and rearfoot (p < 0.001) was significantly offloaded by the contoured insoles during the stance phase, whilst the PPP of the rearfoot (p < 0.001) was significantly offloaded during the swing phase.

CONCLUSIONS

The contoured insoles, especially those constructed with soft materials, significantly offloaded the PPP during gait-hence accommodating certain abnormal gait patterns more effectively compared to going barefoot.

Experiences of foot and ankle mobilisations combined with home stretches in people with diabetes: a qualitative study embedded in a proof-of-concept randomised controlled trial

Background

The benefits of exercise and staying active are widely reported in the literature, however adherence and engagement with exercise amongst people with long-term illness and diabetes is poor. Physiotherapy aims to promote independence and physical activity using a range of strategies, including manual therapy and education/advice on exercises. However, low adherence impacts negatively on treatment outcomes. In this study, the practicality of physiotherapy interventions in patients who participate in a proof-of-concept (PoC) randomised controlled trial (RCT) will be considered.

Aim

To explore the experiences of people with diabetes who received an intervention package of foot and ankle mobilisations combined with home stretches for a 6-week period.

Design

An embedded qualitative study in a proof-of-concept RCT using semi-structured interviews and thematic analysis.

Participants

Purposive sample of 16 participants (mean age 73 years) with a diagnosis of diabetes (mean duration 13.4 years) were recruited.

Results

Analysis revealed seven themes informing the adherence and non-adherence to the exercise intervention. Themes describing the positive experiences were: 1) support from others to do the exercises; 2) psychological factors to motivate exercise adherence; 2) physical factors contributing to exercise adherence; 4) acceptability of home exercises during and beyond the study. Other themes described barriers: 5) social factors that contributed to exercise disengagement; 6) emotional limitations that influence exercise avoidance; 7) physical circumstances that made exercise participation burdensome. Themes highlighted positive influences by physiotherapists, the motivation of doing exercises while participating in a study, improving the perceived range of motion in their foot and ankle and reducing discomfort in these joints whilst being more active with daily activities.

Conclusion

Our findings highlighted that the intervention of foot and ankle mobilisations combined with home stretches is feasible for study participants. Psycho-social support, self-efficacy, and physiotherapy support are motivational to adhere to the study intervention and might contribute to the success of a full-scale RCT.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00512-z.

Effect of sensorimotor training on spatiotemporal parameters of gait among middle and older age adults with diabetic peripheral neuropathy

PURPOSE

The study aimed to evaluate the effect of sensorimotor training on spatiotemporal parameters of gait among middle-aged and older adults with diabetic peripheral neuropathy (DPN).

METHODS

A randomised controlled study with four parallel arms (two intervention groups and two control groups) was conducted. Thirty-seven DPN patients were selected on the basis of inclusion and exclusion criteria. Of these, 16 middle-aged and 21 older adults were randomly allocated to the intervention and control groups. Participants in the intervention group were administered eight weeks (three days/week) of sensorimotor training along with diabetes and foot care education whereas participants in the control group received only diabetes and foot care education. Outcome measures involved spatiotemporal parameters of gait at self-paced and maximal-paced, measured before and after eight weeks.

RESULTS

Age difference was found to be significant in velocity (p ≤ 0.013) and stride length (p ≤ 0.017) at self-paced and maximal-paced walking. After the intervention, velocity was found to be a significant group effect and time × group interaction at self-paced (p = 0.003) and maximal-paced (p = 0.003) walking. Stride length (p = 0.006) was found to be a significant group effect and time × group interaction at self-paced only. Cadence (p = 0.041) and gait cycle (p = 0.05) were found to be significant time × group interaction only at maximal-paced walking. Stance (p ≤ 0.047) and double limb support (p ≤ 0.02) were found to be significant group effect and time × group interaction at self-paced and maximal-paced walking.

CONCLUSION

Sensorimotor training improves spatiotemporal parameters of gait after eight weeks in similar fashion in middle-aged and older age DPN patients, regardless of age.

Using Manchester Scale classification of Hallux Valgus as a valuable tool in determining appropriate risk categorization during initial diabetic foot screening in primary health care settings

Limitations have been identified in the current state of primary care practises with regards to identifying and correctly categorizing foot deformity and its associated risk of developing foot ulcers in patients with diabetes. This study aims to bridge these gaps through the implementation of additional categorization tools to be made available for primary care professionals. This study thus analysed the relationship between foot pressure distribution and amount in patients with diabetes with Hallux Valgus foot deformity, and its different stages, in order to better understand the clinical applications of the Manchester Scale. Statistically significant data in pressure distribution (P < 0.05) was found in all three severity groups identified by the Manchester Scale (Mild, Moderate and Severe) when compared to a No deformity group. However, only the Severe Hallux Valgus group crossed the threshold over 500 kPa in the area of first metatarsal bone. Further research should aim to analyse pressure distribution and amount in patients with both diabetes and diabetic neuropathy of all stages of Hallux Valgus.

Sensory-Motor Mechanisms Increasing Falls Risk in Diabetic Peripheral Neuropathy

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.

Ankle and foot mechanics in individuals with chronic ankle instability during shod walking and barefoot walking: A cross-sectional study

PURPOSE

This study evaluated the angular kinematic and moment of the ankle and foot during shod walking and barefoot walking in individuals with unilateral chronic ankle instability (CAI).

METHODS

Recreational soccer players with unilateral CAI were recruited for this cross sectional study conducted between January and August 2019. A total of 40 participants were screened for eligibility but only 31 met the inclusion criteria based on the methods of Delahunt et al and Gribble et al. Except for 3 participants not attending the evaluation session, 28 participants were finally included. A three dimensional motion analysis system made up of ProReflex motion capture unit and an AMTIb Kistler force plate, embedded in the middle of nine meter walkway, were used to assess the ankle and foot angles and moment during shod walking and barefoot walking conditions. A Statistical Package for Social Sciences (version 20.0) was used to analyze data.

RESULTS

During shod walking, the ankle joint plantar-flexion range of motion (ROM) at 10% of the gait cycle (GC) and dorsiflexion ROM at 30% of the GC were significantly higher than those during barefoot walking for both feet (p = 0.001, 0.001, 0.027, and 0.036 respectively). The inversion ROM during shod walking was significantly higher than that during barefoot walking for both feet at 10% and 30% of the GC (p = 0.001. 0.001, 0.001, and 0.042 respectively). At 10% of the GC, the eversion moment was significantly higher between barefoot and shod walking for both feet (both p = 0.001). At 30% of the GC, there was no significant difference between shod and barefoot walking plantar-flexion moment of both feet (p = 0.975 and 0.763 respectively), and the eversion moment of both feet (p = 0.116 and 0.101 respectively).

CONCLUSION

At the early stance, shod walking increases the ankle plantar-flexion and foot inversion ROM, and decreases the eversion moment for both feet in subjects with unilateral CAI. Therefore, the foot wearing condition should be considered during evaluation of ankle and foot kinematics and kinetics.

Cutaneous and muscular afferents from the foot and sensory fusion processing: Physiology and pathology in neuropathies

The foot-sole cutaneous receptors (section 2), their function in stance control (sway minimisation, exploratory role) (2.1), and the modulation of their effects by gait pattern and intended behaviour (2.2) are reviewed. Experimental manipulations (anaesthesia, temperature) (2.3 and 2.4) have shown that information from foot sole has widespread influence on balance. Foot-sole stimulation (2.5) appears to be a promising approach for rehabilitation. Proprioceptive information (3) has a pre-eminent role in balance and gait. Reflex responses to balance perturbations are produced by both leg and foot muscle stretch (3.1) and show complex interactions with skin input at both spinal and supra-spinal levels (3.2), where sensory feedback is modulated by posture, locomotion and vision. Other muscles, notably of neck and trunk, contribute to kinaesthesia and sense of orientation in space (3.3). The effects of age-related decline of afferent input are variable under different foot-contact and visual conditions (3.4). Muscle force diminishes with age and sarcopenia, affecting intrinsic foot muscles relaying relevant feedback (3.5). In neuropathy (4), reduction in cutaneous sensation accompanies the diminished density of viable receptors (4.1). Loss of foot-sole input goes along with large-fibre dysfunction in intrinsic foot muscles. Diabetic patients have an elevated risk of falling, and vision and vestibular compensation strategies may be inadequate (4.2). From Charcot-Marie-Tooth 1A disease (4.3) we have become aware of the role of spindle group II fibres and of the anatomical feet conditions in balance control. Lastly (5) we touch on the effects of nerve stimulation onto cortical and spinal excitability, which may participate in plasticity processes, and on exercise interventions to reduce the impact of neuropathy.

Feasibility and Preliminary Efficacy of a Foot-Ankle Exercise Program Aiming to Improve Foot-Ankle Functionality and Gait Biomechanics in People with Diabetic Neuropathy: A Randomized Controlled Trial

Foot-ankle strengthening and mobility exercises are part of international guideline recommendations for people at risk of diabetic foot disease. We examined the feasibility and preliminary efficacy of a 12-week foot-ankle exercise program on clinical, functional and biomechanical outcomes in people with diabetic neuropathy (DPN). We randomly allocated 30 people with DPN to usual care (control) or usual care plus a supervised exercise program (intervention). For feasibility, we assessed recruitment rate and participant adherence and satisfaction. For program efficacy, we assessed baseline to 12-week changes in daily physical activity level, gait speed, tactile sensitivity, ankle range of motion, DPN symptoms, quality of life, foot health and functionality, foot strength and plantar pressure during gait, using paired t-tests (p < 0.05). In 52 weeks, we recruited 45 eligible participants (0.90/week). Program adherence was 80% and participants’ satisfaction had a mean (SD) of 4.57 (0.70) out of 5. The intervention group significantly improved on toes strength, contact time during gait and DPN symptoms, and peak forefoot pressures increased over time; controls showed significantly increased heel peak pressures and force. The exercise program was feasible, based on a moderate recruitment rate and an adherent and satisfied population, and the intervention showed several positive preliminary effects over time compared to usual care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The role of foot pressure measurement in the prediction and prevention of diabetic foot ulceration-A comprehensive review

The predominant risk factor of diabetic foot ulcers (DFU), peripheral neuropathy, results in loss of protective sensation and is associated with abnormally high plantar pressures. DFU prevention strategies strive to reduce these high plantar pressures. Nevertheless, several constraints should be acknowledged regarding the research supporting the link between plantar pressure and DFUs, which may explain the low prediction ability reported in prospective studies. The majority of studies assess vertical, rather than shear, barefoot plantar pressure in laboratory-based environments, rather than during daily activity. Few studies investigated previous DFU location-specific pressure. Previous studies focus predominantly on walking, although studies monitoring activity suggest that more time is spent on other weight-bearing activities, where a lower "peak" plantar pressure might be applied over a longer duration. Although further research is needed, this may indicate that an expression of cumulative pressure applied over time could be a more relevant parameter than peak pressure. Studies indicated that providing pressure feedback might reduce plantar pressures, with an emerging potential use of smart technology, however, further research is required. Further pressure analyses, across all weight-bearing activities, referring to location-specific pressures are required to improve our understanding of pressures resulting in DFUs and improve effectiveness of interventions.

Influence of Diabetic Distal Symmetric Polyneuropathy on the Performance of the Musculoskeletal System of Lower Leg and Foot

Introduction:

Complications on the lower extremities are a major cause of morbidity, disability, emotional and physical suffering in people with diabetes. Diabetic neuropathy (DN) is the most frequent complication of both types of diabetes. Lack of performance of the musculoskeletal system of lower leg and foot can results in high focal plantar pressures with increased ulceration risk in patients with neuropathy.

Aim:

To determine the impact of the severity of distal symmetric polyneuropathy (DSPN) on the foot and ankle muscle strength and the range of motion (ROM) at ankle joint (AJ), subtalar joint (SJ) and first metatarsophalangeal joint (I MTP).

Methods:

A cross-sectional study was conducted among 100 diabetic patients. The level of DSPN was assessed using the Neuropathy Disability Score. Function of ten foot and ankle muscles has been evaluated by manual muscle testing. Muscle strength was scored by semiquantitative grading system used in the Michigan Diabetic Neuropathy Score. ROM at the AJ, SJ and I MTP was measured with goniometer.

Results:

The average patients age was 61.91±10.74 and diabetes duration 12.25±8.60 years. DSPN was present in 45% of patients. The average strength of foot and ankle muscles expressed by muscle score was 11.56±5.08. The average ROM at AJ was 47.85°, at SJ 35.10° and at I MTP 72.70°. Correlations between the severity of the DSPN and muscle function, ROM at AJ, SJ and I MTP were statistically significant. ROM at SJ and I MTP declines significantly with progression of neuropathy but not significant at AJ.

Conclusion:

The severity of DSPN is significantly associated with foot and ankle muscle weakness and ROM at the SJ and the I MTP, but not significantly with the ROM at the AJ.

Foot Kinetic and Kinematic Profile in Type 2 Diabetes Mellitus with Peripheral Neuropathy A Hospital-Based Study from South India

BACKGROUND

A kinetic change in the foot such as altered plantar pressure is the most common etiological risk factor for foot ulcers in people with diabetes mellitus. Kinematic alterations in joint angle and spatiotemporal parameters of gait have also been frequently observed in participants with diabetic peripheral neuropathy (DPN). Diabetic peripheral neuropathy leads to various microvascular and macrovascular complications of the foot in type 2 diabetes mellitus. There is a gap in the literature for biomechanical evaluation and assessment of type 2 diabetes mellitus with DPN in the Indian population. We sought to assess and determine the biomechanical changes, including kinetics and kinematics, of the foot in DPN.

METHODS

This cross-sectional study was conducted at a diabetic foot clinic in India. Using the purposive sampling method, 120 participants with type 2 diabetes mellitus and DPN were recruited. Participants with active ulceration or amputation were excluded.

RESULTS

The mean ± SD age, height, weight, body mass index, and diabetes duration were 57 ± 14 years, 164 ± 11 cm, 61 ± 18 kg, 24 ± 3 kg/m², and 12 ± 7 years, respectively. There were significant changes in the overall biomechanical profile and clinical manifestations of DPN. The regression analysis showed statistical significance for dynamic maximum plantar pressure at the forefoot with age, weight, height, diabetes duration, body mass index, knee and ankle joint angle at toe-off, pinprick sensation, and ankle reflex ( R = 0.71, R² = 0.55, F_12,108 = 521.9 kPa; P = .002).

CONCLUSIONS

People with type 2 diabetes mellitus and DPN have significant changes in their foot kinetic and kinematic parameters. Therefore, they could be at higher risk for foot ulceration, with underlying neuropathy and biomechanically associated problems.

Foot function and strength of patients with diabetes grouped by ulcer risk classification (IWGDF)

BACKGROUND

The stratification system from the International Working Group on the Diabetic Foot (IWGDF) was used to classify the participants as to the ulcer risk. However, it is not yet known what the classification groups' individual deficits are regarding sensitivity, function, and musculoskeletal properties and mechanics. This makes it difficult to design proper ulcer prevention strategies for patients. Thus, this study aimed to investigate the foot function, foot strength and health of people with diabetes mellitus (DM)-with or without DPN-while considering the different ulcer risk classifications determined by the IWGDF.

METHODS

The subject pool comprised 72 people with DM, with and without DPN. The patients were divided into three groups: Group 0 (G0), which comprised diabetic patients without DPN; Group 1 (G1), which comprised patients with DPN; and Group 2 (G2), which comprised patients with DPN who had foot deformities. The health and foot function of the subjects' feet were assessed using a foot health status questionnaire (FHSQ-BR) that investigated four domains: foot pain, foot function, footwear, and general foot health. The patients' foot strength was evaluated using the maximum force under each subject's hallux and toes on a pressure platform (emed q-100, Novel, Munich, Germany).

RESULTS

Moderate differences were found between G0 and G1 and G2 for the foot pain, foot function, general foot health, and footwear. There was also a small but significant difference between G0 and G2 in regards to hallux strength.

CONCLUSION

Foot health, foot function and strength levels of people with DM and DPN classified by the ulcer risk are different and this must be taken into account when evaluating and developing treatment strategies for these patients.

Diabetic Gait Is Not Just Slow Gait: Gait Compensations in Diabetic Neuropathy

BACKGROUND

Neuropathic complications from diabetes mellitus affect multiple nerve types and may manifest in gait. However, gait compensations are still poorly understood, as narrow analyses and lack of speed controls have contributed to conflicting or equivocal results.

PURPOSE

To evaluate gait mechanics and energetics in diabetic peripheral polyneuropathy.

METHODS

Instrumented gait analysis was performed on 14 participants with diabetic peripheral polyneuropathy and 14 matched controls, walking at 1.0 m/s. A full-body model with a multisegment foot was used to calculate inverse dynamics and analyze sagittal plane metrics and time series waveforms across stance phase.

RESULTS

Alterations included increased hip and knee flexion in early stance followed by a prolonged hip extension moment in midstance. Late stance ankle dorsiflexion and power absorption were increased, and final push-off was delayed and truncated.

CONCLUSION

A neuropathic diabetic gait shares important similarities to a mild crouch gait with weakness/dysfunction in the foot and ankle. This study highlights two main compensation mechanisms that have been overlooked in previous literature. First, increased triceps surae stretch in terminal stance may be used to increase proprioception and/or energy storage, while a prolonged hip extension moment in midstance compensates for a limited push-off. These result in an overall workload shift from distal to proximal joints. Clinical assessment, monitoring, and treatment of neuropathy may benefit by focusing on these specific functional alterations.

Prevalence of ankle equinus and correlation with foot plantar pressures in people with diabetes

BACKGROUND

An association between equinus and plantar pressure may be important for people with diabetes, as elevated plantar pressure has been linked with foot ulcer development. To determine the prevalence of equinus in community dwelling people with diabetes and to examine any association between presence of equinus and forefoot plantar pressures.

METHODS

Barefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, non-weight bearing ankle range of motion and neuropathy status were assessed in 136 adults with diabetes (52.2% male; 47.8% with neuropathy; mean (standard deviation) age and diabetes duration: 68.4 (11.5) and 14.6 (11.1) years respectively).

FINDINGS

Equinus, when measured as ≤5° dorsiflexion, was present in 66.9% of the cohort. There was a significant correlation between an equinus and barefoot (r = 0.247, p = 0.004) and in-shoe forefoot pressure time integrals (r = 0.214, p = 0.012) and in-shoe forefoot alternate pressure time integrals (r = 0.246, p = 0.004). Significantly more males (p < 0.01) and people with neuropathy (p = 0.02) or higher glycated haemoglobin levels (p < 0.01) presented with an equinus.

INTERPRETATION

Community dwelling adults with diabetes have a high rate of ankle equinus which is associated with increased forefoot pressure time integrals and a two-fold increased risk of high in-shoe peak pressures. Clinical assessment of an ankle equinus may be a useful screening tool to identify adults at increased risk of diabetic foot complications.

Validation of a weight bearing ankle equinus value in older adults with diabetes

Background

Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes.

Methods

Ankle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In-shoe and barefoot plantar pressure was recorded for the DA group. Spearman’s correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined.

Results

A weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure (r = 0.274, p = 0.005) and pressure-time integrals (r = 0.321, p = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p = 0.025) and pressure-time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p = 0.017) than the DA non equinus group.

Conclusions

We support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice.

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".

The Evaluation of Foot Rockers on the Kinematic Parameters of Individuals With Diabetes

BACKGROUND

A variety of shoe modifications have been used to reduce the forces applied on the plantar surface of the foot in those with diabetes. Toe and heel rockers are 2 of the most common types used. The aim of this study is to evaluate the effect of these shoe modifications on the kinematics of both normal and diabetic individuals.

METHOD

Two groups of healthy and diabetic individuals were recruited for this study. The Qualysis motion analysis system was used to record the motions of participants while walking with shoes with toe and a combination of toe and heel rockers (combined). The effects of the type of rockers used and the effect of groups were determined using MANOVA.

RESULTS

Results of the study demonstrated no discernible difference between the spatiotemporal and range of motion of the ankle, knee, and hip joints while walking with a toe and combined rockers. There was also no difference between healthy and diabetic individuals in relation to these parameters (P value >.05).

CONCLUSION

Results of this study demonstrated no difference between the spatiotemporal and range of motion of lower-limb joints in healthy and diabetic individuals when walking with toe and combined rockers. Because the use of these rockers did not influence the kinematics of the joints while walking, it is recommended that they be used for this group of individuals if they influence the forces applied on the foot.

LEVELS OF EVIDENCE

Level IV.

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.

Diabetic Neuropathy and Gait: A Review

Diabetic peripheral neuropathy (DPN) is a major sequela of diabetes mellitus and may have a detrimental effect on the gait of people with this complication. DPN causes a disruption in the body's sensorimotor system and is believed to affect up to 50% of patients with diabetes mellitus, dependent on the duration of diabetes. It has a major effect on morbidity and mortality. The peripheral nervous system controls the complex series of events in gait through somatic and autonomic functions, careful balancing of eccentric and concentric muscle contractions and a reliance on the sensory information received from the plantar surface. In this literature review focussing on kinetics, kinematics and posture during gait in DPN patients, we have identified an intimate link between DPN and abnormalities in gait and demonstrated an increased risk in falls for older patients with diabetes. As such, we have identified a need for further research on the role of gait abnormalities in the development of diabetic foot ulceration and subsequent amputations.

Predictive simulation of diabetic gait: Individual contribution of ankle stiffness and muscle weakening

Diabetic neuropathic individuals present massive muscle strength reduction at the ankle plantar- and dorsiflexors and increased joint stiffness. Our aim is to investigate the adaptation strategies to these musculoskeletal alterations during walking by means of predictive simulations. We used a seven segment planar musculoskeletal model actuated by eight Hill-type muscles in each leg. The effect of all passive tissue in muscles and other joint structures was modeled by net passive joint moment curves. The predictive simulations were generated by solving an optimal control problem that minimized a cost function, including effort and tracking terms, using direct collocation and a commercial optimal control package. We simulate four conditions to represent the weakening of the distal muscles triceps sural (TS) and tibialis anterior (TA), and five conditions to represent the effect of increasing nonlinear ankle stiffness in flexion. The weakening of the distal muscles leads to a delayed action of the TS and a progressive decrease of the gastrocnemius peak force in the push-off phase. This distal deficit is compensated by a larger hip flexion moment resulting from an increase in the iliopsoas muscle force in this phase, known as the hip strategy. The adaptation mechanisms observed in response to an increase in ankle stiffness include the hip strategy and the exploitation of the passive joint structures as springs, which store energy during midstance and release it during push-off, reducing TS force and power in this phase and leading to a consistent decrease in the overall muscle force levels.

Impact of Generalized Joint Laxity on Plantar Loading Patterns in Young Females

BACKGROUND

Generalized joint laxity is often associated with gait deviations. The aim of this study was to investigate the static and dynamic loading pattern of the foot with increasing joint mobility and to discuss the potential impact of this condition on the plantar loading patterns.

METHODS

Seventy female participants between ages of 18 and 30 were included in this cross-sectional survey. The Beighton-Horan Joint Mobility Index scores were assessed and participants divided into 3 categories: no hypermobility (NH) group, scores 0 to 2; moderate hypermobility (MH) group, scores 3 to 4; distinct hypermobility (DH) group, scores 5 to 9. Pedobarographic analysis was performed both in static and walking conditions. Dynamic foot loading examined in 10 anatomic zones. Contact areas of forefoot, midfoot, and rearfoot were recorded.

RESULTS

In the dynamic pedobarographic analysis, individuals with distinct joint hypermobility displayed higher peak pressure and maximum force values under the hallux, compared with other groups ( P < .05). The maximum force value of the second metatarsal was higher in the DH group than in the MH group ( P < .05).

CONCLUSION

Our study results suggest that plantar loading pattern differs with increasing degrees of the hypermobility score.

CLINICAL RELEVANCE

Differences in plantar loading parameters in people with severe joint mobility scores may be useful in interpreting the foot pathologies of these individuals.

Effectiveness of Total Contact Orthosis for Plantar Pressure Redistribution in Neuropathic Diabetic Patients During Different Walking Activities

BACKGROUND

Using a total contact orthosis (TCO) is an effective method to offload in diabetic patients with foot neuropathy. However, the redistribution of peak plantar pressure is mostly observed during level walking, which may differ from other walking activities. The aim of this study was to investigate the plantar pressure from 4 regions of the foot during different walking activities (level walking, ramp ascending, ramp descending, stair ascending, and stair descending) in neuropathic diabetic patients with and without a TCO.

METHODS

Sixteen neuropathic diabetic patients aged 40 to 60 years with calluses and hallux valgus were included in this study and were provided with TCOs made up of multifoam, Plastazote, and microcellular rubber. The plantar pressure and contact area with the TCO and without the TCO were recorded using the Pedar X system during different walking activities.

RESULTS

A significant reduction of plantar pressure during different walking activities at the toes and forefoot regions was observed while walking with the TCO compared with walking without the TCO (control condition). Plantar pressure increased at the midfoot region when walking with the TCO, and no significant difference was observed at the hindfoot region between the control and TCO conditions. Furthermore, maximum contact area was observed during level walking with the TCO compared with other walking activities.

CONCLUSION

The TCO significantly reduced and redistributed the peak plantar pressure from the sites where the ulceration rate is higher at the toes and forefoot compared with the other regions of the foot.

LEVEL OF EVIDENCE

Therapeutic level II, lesser quality randomized controlled trial.

Association between ankle equinus and plantar pressures in people with diabetes. A systematic review and meta-analysis

BACKGROUND

Diabetes is one of the most common chronic diseases in the world and is associated with a life-time risk of foot ulcer of 12-25%. Diabetes related restriction in ankle joint range of dorsiflexion is proposed to contribute to elevated plantar pressures implicated in the development of foot ulcers.

METHODS

A systematic search of EBSCO Megafile Premier (containing MEDLINE, CINAHL, SPORTSdiscus and Academic Search Complete) and The Cochrane Library was conducted to 23rd November 2016. Two authors independently reviewed and selected relevant studies. Meta-analysis of study data were conducted where possible.

FINDINGS

Fifteen studies met the inclusion criteria. Three studies were eligible to be included in the meta-analysis which found that equinus has a significant, but small, effect on increased plantar pressures (ES=0.26, CI 95% 0.11 to 0.41, p=0.001). Of the remaining studies, eight found evidence of an association between limited ankle dorsiflexion and increased plantar pressures while four studies found no relationship.

INTERPRETATION

Limited ankle joint dorsiflexion may be an important factor in elevating plantar pressures, independent of neuropathy. Limited ankle dorsiflexion and increased plantar pressures were found in all the studies where the sample population had a history of neuropathic foot ulceration. In contrast, the same association was not found in those studies where the population had neuropathy and no history of foot ulcer. Routine screening for limited ankle dorsiflexion range of motion in the diabetic population would allow for early provision of conservative treatment options to reduce plantar pressures and lessen ulcer risk.

The prevention of diabetic foot ulceration: how biomechanical research informs clinical practice

Background

Implementation of interprofessional clinical guidelines for the prevention of neuropathic diabetic foot ulceration has demonstrated positive effects regarding ulceration and amputation rates. Current foot care recommendations are primarily based on research regarding the prevention of ulcer recurrence and focused on reducing the magnitude of plantar stress (pressure overload). Yet, foot ulceration remains to be a prevalent and debilitating consequence of Diabetes Mellitus. There is limited evidence targeting the prevention of first-time ulceration, and there is a need to consider additional factors of plantar stress to supplement current guidelines.

Objectives

The first purpose of this article is to discuss the biomechanical theory underpinning diabetic foot ulcerations and illustrate how plantar tissue underloading may precede overloading and breakdown. The second purpose of this commentary is to discuss how advances in biomechanical foot modeling can inform clinical practice in the prevention of first-time ulceration.

Discussion

Research demonstrates that progressive weight-bearing activity programs to address the frequency of plantar stress and avoid underloading do not increase ulceration risk. Multi-segment foot modeling studies indicate that dynamic foot function of the midfoot and forefoot is compromised in people with diabetes. Emerging research demonstrates that implementation of foot-specific exercises may positively influence dynamic foot function and improve plantar stress in people with diabetes.

Conclusion

Continued work is needed to determine how to best design and integrate activity recommendations and foot-specific exercise programs into the current interprofessional paradigm for the prevention of first-time ulceration in people with Diabetes Mellitus.

Kinetics and kinematics of diabetic foot in type 2 diabetes mellitus with and without peripheral neuropathy: a systematic review and meta-analysis

Background

Diabetes mellitus patients are at increased risk of developing diabetic foot with peripheral neuropathy, vascular and musculoskeletal complications. Therefore they are prone to develop frequent and often foot problems with a relative high risk of infection, gangrene and amputation. In addition, altered plantar pressure distribution is an important etiopathogenic risk factor for the development of foot ulcers. Thus the review on study of foot kinematic and kinetic in type 2 diabetes mellitus to understand the biomechanical changes is important.

Methodology

Scientific articles were obtained using electronic databases including Science Direct, CINAHL, Springer Link, Medline, Web of Science, and Pubmed. The selection was completed after reading the full texts. Studies using experimental design with focus on biomechanics of diabetic foot were selected.

Results

The meta-analysis report on gait velocity (neuropathy = 128 and non-diabetes = 131) showed that there was a significantly lower gait velocity in neuropathy participants compared to non-diabetes age matched participants at a high effect level (−0.09, 95 % CI −0.13 to 0.05; p < 0.0001). Regarding knee joint flexion range there was a significant difference between neuropathy and non-diabetes group (4.75, 95 % CI, −7.53 to 1.97, p = 0.0008).

Conclusions

The systematic review with meta-analysis reported significant difference in kinematic and kinetic variables among diabetic with neuropathy, diabetic without neuropathy and non-diabetes individuals. The review also found that the sample size in some studies were not statistically significant to perform the meta-analysis and report a strong conclusion. Therefore a study with higher sample size should be done.

Gait parameters of people with diabetes-related neuropathic plantar foot ulcers

BACKGROUND

Foot ulceration associated with diabetic peripheral neuropathy is a global concern. Biomechanical investigation allows the identification of gait abnormalities that may adversely affect ulcer healing. The objective of this case-control study was to compare the gait parameters of cases with diabetes-related foot ulcers to controls.

METHODS

Three-dimensional movement analyses were performed on 21 people with diabetes-related neuropathic plantar foot ulcers (cases), 69 people with diabetes without a foot ulcer history (diabetes controls) and 56 healthy controls. Outcome data were reported as mean differences, 95% confidence intervals and Cohen's d effect sizes. Binary logistic regressions were used to adjust for age, sex and body mass index.

FINDINGS

People with foot ulcers had a smaller plantar flexion (Cohen's d=-0.6 vs. diabetes controls and d=-0.8 vs. healthy controls), knee flexion (d=-0.6 vs. diabetes controls and d=-1.0 vs. healthy controls) and pelvic obliquity (d=-0.9 vs. diabetes controls and d=-0.7 vs. healthy controls) (all P<0.05). They also had a significantly greater range of anterior-posterior ground reaction force (d=1.0 vs. diabetes controls and d=1.7 vs. healthy controls) and total vertical ground reaction force (d=0.9 vs. diabetes controls and d=1.1 vs. healthy controls) and significantly slower walking speed and smaller step length compared to controls (all P<0.05).

INTERPRETATION

People with plantar foot ulcers have considerably different gait parameters to controls. Whether the observed gait parameters contributed to the ulcer development or are a response to the ulcer is currently unclear and needs further investigation.

The Effects of a 4-Layer Compression Bandaging System on Skin Perfusion Pressure in Healthy Adults

OBJECTIVE

Current practice precludes compression in patients with wounds and reduced arterial flow; however, this treatment may reduce edema and vascular resistance, thus improving distal circulation. The objective of this study was to determine the effects of compression on skin perfusion pressure (SPP), edema, and ankle range of motion.

DESIGN

This was a quasi-experimental time series.

SETTING

The study was conducted at The Center for Skin Integrity in Cheektowaga, New York.

PARTICIPANTS

The study participants were 20 healthy adults, 10 in a younger age bracket (22.10 [SD, 2.77] years, 23.14 [SD, 5.03] kg/m) and 10 in an older age bracket (55.90 [SD, 4.48] years, 28.84 [SD, 4.83] kg/m).

INTERVENTIONS

Sixty minutes of Profore Multi-layer Compression was performed.

MAIN OUTCOME MEASURES

Precompression and postcompression measurements: SPP, Ankle Brachial Index, calf circumference (15 cm proximal to lateral malleolus), and static and dynamic ankle dorsiflexion range of motion (DF ROM) compared between young and older adults.

MAIN RESULTS

There was a significant main effect for time for SPP (P = .049) and static (P = .02) and dynamic (P = .03) DF ROM. Skin perfusion pressure significantly increased at 40, 50, and 60 minutes of compression compared with precompression. Static and dynamic DF ROM significantly increased from precompression to postcompression. Although not statistically significant, calf circumference decreased by 6 cm in the older-adult group postcompression.

CONCLUSION

A 4-layer compression dressing system improved SPP; this may be secondary to the decongestion of a proximal confined space. The 4-layer compression dressing also improves DF ROM postcompression and may reduce lower-extremity edema. Seeing these results in healthy participants suggests the need for future research in a patient population to determine if compression can be used to offload arterial structures and thus promote wound healing in patients.

The influence of monocular vision on the plantar pressure distribution

BACKGROUND

Although the influence of monocular vision to upper limb biomechanics has been well documented, data about lower extremity biomechanics are limited. The objective of the present study was to demonstrate pedobarographic differences between both feet of the individuals with monocular vision in static and dynamic conditions.

METHODS

Pedobarographic analysis of twenty-four participants with monocular vision was performed. Relative static pressure load (%) and dynamic peak plantar pressure (N/cm(2)), force (N) distributions and contact area percentages (%) were recorded under both low vision and normal vision side foot.

FINDINGS

The results showed that relative static pressure loads did not differ between low vision and normal vision foot. Under midfoot of low vision side, a significant increment was found in peak plantar pressures (2.42 (SD 1.09) N/cm(2)) and forces (136.77 (SD 64.96) N) compared to normal vision side foot (1.87 (SD 0.96) N/cm(2); 106.94 (SD 65.03) N). No difference in contact area percentages was detected.

INTERPRETATION

These results indicate that there are differences in plantar pressure measurements between feet of individuals with monocular vision. These pedobarographic differences reported here appear to support the assumption that individuals with monocular vision have adaptive gait strategies such as, decreased walking speed, limited ankle motion and postural compensations.

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

AIM

Diabetes Mellitus progressively leads to impairments in stability and joint motion and might affect coordination patterns, mainly due to neuropathy. This study aims to describe changes in intralimb joint coordination in healthy individuals and patients with absent, mild and, severe stages of neuropathy.

METHODS

Forty-seven diabetic patients were classified into three groups of neuropathic severity by a fuzzy model: 18 without neuropathy (DIAB), 7 with mild neuropathy (MILD), and 22 with moderate to severe neuropathy (SVRE). Thirteen healthy subjects were included as controls (CTRL). Continuous relative phase (CRP) was calculated at each instant of the gait cycle for each pair of lower limb joints. Analysis of Variance compared each frame of the CRP time series and its standard deviation among groups (α = 5%).

RESULTS

For the ankle-hip CRP, the SVRE group presented increased variability at the propulsion phase and a distinct pattern at the propulsion and initial swing phases compared to the DIAB and CTRL groups. For the ankle-knee CRP, the 3 diabetic groups presented more anti-phase ratios than the CTRL group at the midstance, propulsion, and terminal swing phases, with decreased variability at the early stance phase. For the knee-hip CRP, the MILD group showed more in-phase ratio at the early stance and terminal swing phases and lower variability compared to all other groups. All diabetic groups were more in-phase at early the midstance phase (with lower variability) than the control group.

CONCLUSION

The low variability and coordination differences of the MILD group showed that gait coordination might be altered not only when frank evidence of neuropathy is present, but also when neuropathy is still incipient. The ankle-knee CRP at the initial swing phase showed distinct patterns for groups from all degrees of neuropathic severity and CTRLs. The ankle-hip CRP pattern distinguished the SVRE patients from other diabetic groups, particularly in the transitional phase from stance to swing.

From treatment to preventive actions: improving function in patients with diabetic polyneuropathy

Diabetic polyneuropathy is an insidious and long-term complication of this disease. Synergistic treatments and preventive actions are crucial because there are no clear boundaries for determining when health professionals should intervene or what intervention would best avoid the consequences of neuropathy. Until now, most therapies to any diabetic individual were applied only after the patient's limb was ulcerated or amputated. The loss of muscle and joint functions is recognized as the main cause of plantar overloading. However, if foot and ankle exercises are performed following the early diagnosis of diabetes, they can enable the patient to maintain sufficient residual function to interact with the environment. This article summarizes the current knowledge about the musculoskeletal deficits and biomechanical alterations caused by neuropathy. It also describes the potential benefits of foot and ankle exercises for any diabetic patient that is not undergoing the plantar ulcer healing process. We concentrate on the prevention of the long-term deficits of neuropathy. We also discuss the main strategies and protocols of therapeutic exercises for joints and muscles with deficits, which are applicable to all diabetic patients with mild to moderate neuropathy. We describe further efforts in exploiting the applicability of assistive technologies to improve the adherence to an exercise program. Following the contemporary trends towards self-monitoring and self-care, we developed a software to monitor and promote personalized exercises with the aim of improving autonomous performance in daily living tasks. Initiatives to prevent the complications of functional diabetes are highly recommended before it is too late for the patient and there is no longer an opportunity to reverse the tragic consequences of neuropathy progression.

Footwear and Foam Surface Alter Gait Initiation of Typical Subjects

Gait initiation is the task commonly used to investigate the anticipatory postural adjustments necessary to begin a new gait cycle from the standing position. In this study, we analyzed whether and how foot-floor interface characteristics influence the gait initiation process. For this purpose, 25 undergraduate students were evaluated while performing a gait initiation task in three experimental conditions: barefoot on a hard surface (barefoot condition), barefoot on a soft surface (foam condition), and shod on a hard surface (shod condition). Two force plates were used to acquire ground reaction forces and moments for each foot separately. A statistical parametric mapping (SPM) analysis was performed in COP time series. We compared the anterior-posterior (AP) and medial-lateral (ML) resultant center of pressure (COP) paths and average velocities, the force peaks under the right and left foot, and the COP integral x force impulse for three different phases: the anticipatory postural adjustment (APA) phase (Phase 1), the swing-foot unloading phase (Phase 2), and the support-foot unloading phase (Phase 3). In Phase 1, significantly smaller ML COP paths and velocities were found for the shod condition compared to the barefoot and foam conditions. Significantly smaller ML COP paths were also found in Phase 2 for the shod condition compared to the barefoot and foam conditions. In Phase 3, increased AP COP velocities were found for the shod condition compared to the barefoot and foam conditions. SPM analysis revealed significant differences for vector COP time series in the shod condition compared to the barefoot and foam conditions. The foam condition limited the impulse-generating capacity of COP shift and produced smaller ML force peaks, resulting in limitations to body-weight transfer from the swing to the support foot. The results suggest that footwear and a soft surface affect COP and impose certain features of gait initiation, especially in the ML direction of Phase 1.

Relationship between elevated plantar pressure of toes and forefoot and gait features in diabetic patients

This cross-sectional observational study is to reveal what kind of gait feature is relevant to elevated segment and its plantar pressure for prevention of diabetic foot ulcers. In 57 diabetic patients, the relationship between elevated plantar pressure and gait features was analyzed. To conduct this investigation, a simultaneous measurement system of plantar pressure and gait features was constructed. Plantar pressure distribution was measured by F-scan with customized footwear, and gait features were mainly measured using wireless motion sensors attached to the sacrum and feet. Several gait features of small rolling during the mid-stance phase were relevant to the elevated plantar pressure.

Alterations in the lower limb joint moments precede the peripheral neuropathy diagnosis in diabetes patients

BACKGROUND

Changes in gait patterns in individuals with diabetes and neuropathy are still inconclusive. Our aim was to identify differences in the net intralimb moments distribution and lower limb kinematics during gait in different stage of diabetes.

SUBJECTS AND METHODS

This was an observational cross-sectional study that assessed 38 adults: a control group (n=12), a group with diabetes (n=12), and a group with diabetic neuropathy (n=14). The flexor and extensor joint moment peaks and kinematics of ankle, knee, and hip angles were compared among groups (by analysis of variance).

RESULTS

At initial contact, both diabetes groups present more hip flexion and smaller hip extensor moment. During late midstance, hip extension decreases, and flexion moment increases in both diabetes groups. For the same diabetes groups, during push off, the hip is more flexed, and the hip extensor moment decreases. Only for the diabetes group without neuropathy is the knee markedly more flexed, and the extensor moment is higher than in the other groups. At push off, the ankle is less extended in both diabetes groups, but the ankle extensor moment is significantly smaller only in neuropathic subjects.

CONCLUSIONS

The biomechanical modifications on the gait appeared to be a continuous process that was already revealed in patients without neuropathy. The use of the hip joint as a mechanism of forward progression of the body, instead of using the ankle, was more evident and consistent for the patients with diabetic neuropathy. The knee seems to have a major role in those with diabetes without neuropathy who presented higher extensor moments to support the body during early stance.

The role of joint mobility in evaluating and monitoring the risk of diabetic foot ulcer

AIMS

Evaluation of how ankle joint mobility (AJM) can be useful in the identification of patients with diabetes at risk of foot ulcer (FU).

METHODS

Plantar and dorsal flexion of foot were evaluated using an inclinometer in 87 patients (54 type 2 and 33 type 1), and 35 healthy sex- and age-matched control subjects. Patients with diabetes were followed up for diagnosis of FU over the next 8 years and subsequently, patients were subdivided into: those without a history of FU (18 type 1 and 33 type 2), those who had a history of FU detected before baseline evaluation (14 type 2) and those who had history of first ulceration detected by the 8th year of the evaluation period (7 type 2).

RESULTS

Aging and diabetes caused a significant reduction in mobility of each of the movements investigated (p<0.001), whereas after adjusting for the confounding effect of age, diabetes specifically reduced plantar flexion (p<0.0001). AJM was significantly lower in those with history of previous FU compared to all the other groups (p<0.001). The first ulceration was detected in the same foot presenting lower AJM in 17 of the 22 subjects with diabetes with history of ulcer (77.27%).

CONCLUSIONS

Diabetes and aging reduce AJM although diabetes seems to reduce plantar flexion to a more specific extent. Reduced AJM is mostly associated with a previous history of FU. The evaluation of AJM is a valid and reliable ulcer risk scale that indicates which foot is at higher ulcer risk.

Plantar pressure distribution in patients with ankylosing spondylitis

BACKGROUND

Ankylosing spondylitis is one of the most common inflammatory rheumatic diseases and is associated with alterations in posture. The aim of this study was to investigate the pedobarographic changes among ankylosing spondylitis patients, in an attempt to understand whether the alterations in the posture affect the plantar pressure distribution.

METHODS

The study population consisted of 38 patients with ankylosing spondylitis and 33 healthy volunteers. The static and dynamic pedobarographic measurements were performed to determine the plantar pressure distribution. Moreover, the Bath Ankylosing Spondylitis Disease Activity Index, Bath Ankylosing Spondylitis Functional Index, Ankylosing Spondylitis Quality of Life Questionnaire and Bath Ankylosing Spondylitis Metrology Index were used to assess the clinical state of the patients.

RESULTS

The static pedobarographic measurements did not reveal any intergroup difference. There were differences between the groups in the results of dynamic peak pressure measurements under the metatarsal areas and under the midfoot region. The percentage of the midfoot in the dynamic plantar contact area was higher in ankylosing spondylitis patients in comparison to the controls. No clinically significant correlation was found between the clinical scores and static pedobarographic measurements. The plantar pressures under the metatarsal heads, medial and lateral heel regions declined with increasing disease activity according to the Bath Ankylosing Spondylitis Disease Activity Index scores. The lower peak pressures on the forefoot and rearfoot, were associated with the higher Bath Ankylosing Spondylitis Metrology Index scores of the patients.

INTERPRETATION

The alterations in the posture may have effects on the plantar pressures in patients with ankylosing spondylitis, especially during dynamic activities.

Self-care associated with home exercises in patients with type 2 diabetes mellitus

The objective of this study was to verify self-care guidelines together with lower limb home exercises alter ankle and foot plantar pressure and alignment in patient with Type 2 Diabetes Mellitus (DM) measuring health and sociodemographic factors. The health factors analyzed were sensitivity and circulation aspects, risk rating, and neuropathy symptom score, ankle and foot alignment (photogrammetry), plantar pressures, and postural stability (baropodometry) before and after administering these guidelines and home exercises in 97 patients type 2 DM during 10 months. The self-care guidelines and exercises changed the forefoot alignment (Right Foot – Initial vs Final, p = 0.04; Left Foot, P<0.01), the center of the force displacement in the mediolateral (Right Foot - Initial versus Final, p = 0.02; Left Foot, P<0.01), and the anterior-posterior (Right foot - Initial versus Final, p = 0.01) direction, and body balance (Initial versus Final, p = 0.02). There was no change in the remaining assessed parameters. Self-care associated with the guidelines for home exercises for the lower limbs in patients with type 2 DM are effective in maintaining and improving the alignment of the feet, mediolateral stability and prevention of complications.

Trial Registration

The Brazilian Clinical Trials Registry RBR-8854CD

Abnormalities of plantar pressure distribution in early, intermediate, and late stages of diabetic neuropathy

Inconsistent findings with regard to plantar pressure while walking in the diabetic population may be due to the heterogeneity of the studied groups resulting from the classification/grouping criteria adopted. The clinical diagnosis and classification of diabetes have inherent uncertainties that compromise the definition of its onset and the differentiation of its severity stages. A fuzzy system could improve the precision of the diagnosis and classification of diabetic neuropathy because it takes those uncertainties into account and combines different assessment methods. Here, we investigated how plantar pressure abnormalities evolve throughout different severity stages of diabetic polyneuropathy (absent, n=38; mild, n=20; moderate, n=47; severe, n=24). Pressure distribution was analysed over five areas while patients walked barefoot. Patients with mild neuropathy displayed an increase in pressure-time integral at the forefoot and a lower peak pressure at the heel. The peak and pressure-time integral under the forefoot and heel were aggravated in later stages of the disease (moderate and severe) compared with early stages of the disease (absent and mild). In the severe group, lower pressures at the lateral forefoot and hallux were observed, which could be related to symptoms that develop with the aggravation of neuropathy: atrophy of the intrinsic foot muscles, reduction of distal muscle activity, and joint stiffness. Although there were clear alterations over the forefoot and in a number of plantar areas with higher pressures within each severity stage, they did not follow the aggravation evolution of neuropathy classified by the fuzzy model. Based on these results, therapeutic interventions should begin in the early stages of this disease to prevent further consequences of the disease.