Deficits in lower extremity muscle and gait performance among renal transplant candidates

Measurement properties of performance-based measures to assess physical function in chronic kidney disease: recommendations from a COSMIN systematic review

Background

There is wide heterogeneity in physical function tests available for clinical and research use, hindering our ability to synthesize evidence. The aim of this review was to identify and evaluate physical function measures that could be recommended for standardized use in chronic kidney disease (CKD).

Methods

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, CINAHL, Scopus and Web of Science were searched from inception to March 2022, identifying studies that evaluated a clinimetric property (validity, reliability, measurement error and/or responsiveness) of an objectively measured performance-based physical function outcomes using the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology and Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) based recommendations. Studies with individuals of all ages and of any stage of CKD were included.

Results

In total, 50 studies with 21 315 participants were included. Clinimetric properties were reported for 22 different physical function tests. The short physical performance battery (SPPB), Timed-up-and-go (TUG) test and Sit-to-stand tests (STS-5 and STS-60) had favorable properties to support their use in CKD and should be integrated into routine use. However, the majority of studies were conducted in the hemodialysis population, and very few provided information regarding validity or reliability.

Conclusion

The SPPB demonstrated the highest quality of evidence for reliability, measurement error and construct validity amongst transplant, CKD and dialysis patients. This review is an important step towards standardizing a core outcome set of tools to measure physical function in research and clinical settings for the CKD population.

Feature selection, construction and test of model for estimating lower extremity strength of older adults using foot motion measured by an in-shoe motion sensor

Lower extremity strength (LES) is essential to support activities in daily living. To extend healthy life expectancy of elderly people, early detection of LES weakness is important. In this study, we challenge to develop a method for LES assessment in daily living via an in-shoe motion sensor (IMS). To construct the estimation model, we collected data from 62 subjects. We used the outcome of the five-times-sit-to-stand test to represent the performance of LES as the target variable. Predictors were constructed from the subjects' foot motions measured by the IMS during straight path walking. We used the leave-one-subject-out least absolute shrinkage and selection operator algorithm to select features and construct respective models for the males and females. As a result, the models achieved fair and a good intra-class correlation coefficient agreement between the true and estimation values, with mean absolute errors of 2.14 and 1.21 s (variation of 23.6 and 16.0%), respectively. To validate the models, we separately collected data from 45 subjects. The models successfully predicted 100% and 90% of the male and female subjects' data, respectively, which suggests the robustness of the constructed estimation models. The results suggested that LES can be identified more effectively in daily living by wearing an IMS, and the use of an IMS has the potential for future frailty and fall risk assessment applications.

Optimal procedure and characteristics in using five times sit to stand test among older adults: A systematic review

BACKGROUND

Falls are a major concern for people of all ages, especially older adults with declining physical functions and deteriorating muscle strength. The Five Times Sit to Stand Test is used for the assessment of lower limb strength along with balance and postural control. Therefore, the systematic review at hand aimed to determine the optimal procedure and characteristics among older adults.

METHODS

The following databases served as the primary sources through which the target studies were searched for and obtained for review. They included Google Scholar, Pedro, BIOMED Central, Cochrane Library, MEDLINE, PUBMED and Science DIRECT. With the aim of fulfilling the eligibility criteria, 16 full-text studies were included and the quality assessment was performed. using the Thomas Tool.

RESULTS

The total number of the subjects who participated in the included studies was 15,130 and the ages of the aforementioned participants ranged from 60 to 80 years. In 15 of the studies, a stopwatch was used as the scoring method where the mean chair height of 42 cm was reported. Two studies reported that no significant influence of the arm position (P = .096) on the time allocated for test completion was identified. However, posterior foot placement (P < .001) led to shorter times of completion. Individuals who are unable to complete the test are more susceptible to activities of daily living related disabilities (P < .01) when compared to fall risk (P = .09).

CONCLUSION

The Five Times Sit-to-Stand Test is a safe test, providing added value to apply risk for falls in people at moderate risk and in healthy populations using standardized chair heights and stopwatches.

Association Between Protocols of the Sit-to-Stand Test and Lower Limb Muscle Force Output in Patients on Hemodialysis and Subjects Without Chronic Kidney Disease

OBJECTIVE

To evaluate the association of three protocols of the sit-to-stand (STS) test with muscle force output of knee extension (KE) and knee flexion (KF) in patients on hemodialysis and subjects without chronic kidney disease.

METHODS

This cross-sectional study included a hemodialysis group [n = 60, 59.5 (16.8) years, 55% female] and a control group [n = 60, 43.0 (11.8) years, 50% female]. The assessments were performed in 2 days, and the participants were submitted to three protocols of STS test (5-repetition STS, 10-repetition STS and 30-s STS) or muscle force output of the KE and KF evaluation by handheld dynamometer based on randomization.

RESULTS

The hemodialysis group presented reduced muscle force output of the KE and KF, a longer time to perform the 5 STS and 10 STS tests, and a lower number of repetitions in the 30-s STS test. The three STS tests were associated with muscle force output of the KE in the hemodialysis group, in which the 10-repetition STS test showed the best association (R² = 0.47; adjusted R² = 0.42). However, the only association between the STS test and muscle force output of the KE in the control group was found in the 10-repetition STS test (R² = 0.20; adjusted R² = 0.13).

CONCLUSIONS

The three protocols of STS tests were associated with muscle force output of the KE in patients on hemodialysis. However, the 10-repetition STS test was the best protocol to estimate the quadriceps muscle torque in these patients.

Determination of five times-sit-to-stand test performance in patients with multiple sclerosis: validity and reliability

PURPOSE/AIM

Although Five Times-Sit-To-Stand test (FTSST) performance is known to be a valid and reliable method in people with chronic stroke, Parkinson's disease, and balance disorder, it has not been widely studied in patients with Multiple sclerosis (MS). The main aim of this study was to evaluate validity and reliability of the FTSST in patients with MS.

METHODS

The first outcome measure of the study was the FTSST, which was conducted by two different researchers. Secondary outcome measures were Biodex Stability System (BSS), 10-meter walk test, time up go test (TUG), EDSS scoring, Fatigue Severity Scale (FSS), Barthel Index, Quadriceps Muscle strength test, Functional Reach test. Intraclass correlation coefficient (ICC) was used for the validity and reliability of the FTSST, which was made by two different researchers, and Pearson Correlation Analysis was used to determine its relationship with other measurements.

RESULTS

Interrater and test-retest reliability for the FTSST were excellent (Intraclass correlation coefficients of 0.98 and 0.99, respectively). A statistically significant correlation was found between all secondary outcome measures and FTSST (p < 0.05).

CONCLUSION

FTSST is considered to be a valid, reliable, easy, and rapid method for evaluating lower extremity muscle strength and balance in patients with MS.

Gait disorders in CKD patients: muscle wasting or cognitive impairment? A cross-sectional pilot study to investigate gait signatures in Stage 1-5 CKD patients

Background

Instrumental gait analysis in nephrology is widely neglected, although patients with chronic kidney disease (CKD) show brain changes due to cerebrovascular disease and metabolic disorders that can potentially influence gait quality. Our study assesses the association between CKD stages and gait parameters, to understand the prevalent status of brain related gait parameters (i.e. variability) and of performance related parameters (i.e. gait speed, stride length). We hypothesize that gait changes are detectable already in early stages of CKD.

Methods

Forty-five participants distributed in 5 CKD severity groups underwent an instrumental gait analysis via a triaxial accelerometer affixed to the lower trunk under single- and dual-task conditions. In addition to spatio-temporal parameters, variability and dual-task cost of gait were extracted. A battery of clinical assessments was conducted with the aim of helping to better explain the findings of the gait analysis. A correlation analysis was made to investigate a linear relation between gait parameters and CKD severity.

Results

Statistically significant correlations (Pearson correlation coefficient) with CKD severity were found for gait speed (p < 0.01, r = -0.55, 95% CI [-0.73;-0.30]), stride length ( p < 0.01, r = -0.40, 95% CI [-0.62;-0.12]), step length (p < 0.01, r = -0.41, 95% CI [-0.63;-0.13], coefficient of variance (CV) of step length (p = 0.01, r = 0.36, 95% CI [0.08;0.59]), gait regularity (p < 0.01, r = -0.38, 95% CI [-0.61;-0.10]), dual-task cost of gait speed (p < 0.01, r = 0.40, 95% CI [0.13;0.62]) and dual-task cost of stride time (p = 0.03, r = 0.32, 95% CI [0.03;0.57]). Adjustment for age and gender confirmed all results except for gait regularity. With increasing severity of renal failure, Handgrip strength, Time for the Expanded Timed Get Up and Go test, executive functions, haemoglobin, and haematocrit, worsen.

Conclusions

The correlation of CKD severity with spatio-temporal parameters (performance indices mainly relatable to peripheral functionality) and with variability of gait (related to central factors) supported by the results of the clinical assessments, suggests that gait disturbance in CKD patients is not only due to metabolic factors that lead to muscle wasting, but also to brain changes that affect motor control. This suggests that the treatment of renal disease should include cognitive aspects in addition to metabolic and functional factors.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-022-02697-8.

Five-Repetition Sit-to-Stand Test Performance in Healthy Individuals: Reference Values and Predictors From 2 Prospective Cohorts

Objective

The 5-repetition-sit-to-stand (5R-STS) test is an objective test of functional impairment- commonly used in various diseases, including lumbar degenerative disc diseases. It is used to measure the severity of disease and to monitor recovery. We aimed to evaluate reference values for the test, as well as factors predicting 5R-STS performance in healthy adults.

Methods

Healthy adults (> 18 years of age) were recruited, and their 5R-STS time was measured. Their age, sex, weight, height, body mass index (BMI), smoking status, education level, work situation and EuroQOL-5D Healthy & Anxiety category were recorded. Linear regression analysis was employed to identify predictors of 5R-STS performance.

Results

We included 172 individuals with mean age of 39.4±14.1 years and mean BMI of 24.0 ±4.0 kg/m². Females constituted 57%. Average 5R-STS time was 6.21 ±1.92 seconds, with an upper limit of normal of 12.39 seconds. In a multivariable model, age (regression coefficient [RC], 0.07; 95% confidence interval [CI], 0.05/0.09; p<0.001), male sex (RC, -0.87; 95% CI, -1.50 to -0.23; p=0.008), BMI (RC, 0.40; 95% CI, 0.10–0.71; p=0.010), height (RC, 0.13; 95% CI, 0.04–0.22; p=0.006), and houseworker status (RC, -1.62; 95% CI, -2.93 to -0.32; p=0.016) were significantly associated with 5R-STS time. Anxiety and depression did not influence performance significantly (RC, 0.82; 95% CI, -0.14 to 1.77; p=0.097).

Conclusion

The presented reference values can be applied as normative data for 5R-STS in healthy adults, and are necessary to judge what constitutes abnormal performance. We identified several significant factors associated with 5R-STS performance that may be used to calculate individualized expected test times.

GENDER DIFFERENCE OF KNEE JOINT TORQUE DURING MAXIMAL VOLUNTARY CONTRACTION IN THE ELDERLY

Reduced muscle strength is an important fall risk factor. The fall occurs more in elderly women than in elderly men. The aim of this study is to investigate muscle strength and the ability to generate rapid torque for knee joint in elderly men and women. Twenty healthy elderly participants (10 men and 10 women) performed maximal voluntary knee extension and flexion during concentric, isometric and eccentric conditions. The peak torque and rate of torque development (RTD) was normalized by each subject’s body mass. Independent [Formula: see text]-tests were employed in the comparison of elderly women with elderly men. Elderly women exhibited weaker isometric flexion and eccentric extension strength compared to elderly men ([Formula: see text]). Although there was no significant gender difference in isometric extension peak torque, RTD of elderly women was slower than it of elderly men ([Formula: see text]). In contrast, no significant gender differences were observed in concentric contraction condition ([Formula: see text]). These results indicate that the deteriorated RTD as well as muscle strength per body mass may be associated with a higher frequency of falls in elderly women than in elderly men. This study suggests that training of specific-contraction type should be considered for fall prevention in elderly women.

Gait characteristics of CKD patients: a systematic review

BACKGROUND

People with Chronic Kidney Disease (CKD) often present with prevalent gait impairment and high fall rates, particularly in advanced CKD stages. Gait impairment and its consequences is associated with increased hospital admission, institutionalization, and greater need for health care. The objective of this systematic review was to evaluate the quality of studies investigating CKD patients' gait characteristics at different CKD stages, to highlight areas of agreement and contradiction between studies reporting aspects of gait in CKD, and to discuss and emphasize gait parameters associated with fall risk.

METHODS

We performed a literature search of trials in CINAHL (EBSCO), Cochrane Library, EMBASE, Medline (EBSCO), PEDro, PubMed, and Scopus databases from their inception to June 30th 2018 using a two-stage process for the identification of studies. We retrieved English-, German-, Italian-, Spanish-, Portuguese and Dutch-language articles for review. Methodological quality of randomized and non-randomized studies was assessed with an adapted version of the Downs and Black checklist.

RESULTS

Thirty-one studies (22 cross-sectional with 3901 participants) and 9 longitudinal intervention studies (1 randomized control trial, 5 controlled clinical trials and 3 one-group pre-post-test; with 659 participants) were considered. The studies revealed a primary emphasis on gait speed measures within clinical tests, and a neglect of spatiotemporal gait variables. Most of the studies showed that CKD progression is associated with slowing of walking speed. No studies analysed the relation between gait parameters and fall risk.

CONCLUSIONS

There was a paucity of studies investigating aspects of gait quality in patients with CKD. In the majority of studies, only gait speed is analysed as a performance indicator. The relation between gait parameters and fall risk in CKD is not investigated. We formulate several recommendations to fill the current research gap, encourage the use of standardized gait analysis protocols that include assessment of spatiotemporal parameters in clinical care of patients with CKD, aimed at prevention of mobility decline and falls risk.

Considerations and Practical Options for Measuring Muscle Strength: A Narrative Review

Muscle strength impairments are related to mobility limitations and other untoward outcomes. This narrative review, therefore, describes considerations relative to the definition and measurement of muscle strength. Thereafter, practical options for measuring muscle strength are described and their clinimetric properties are delineated. Information provided herein may help students, clinicians, and researchers select the strength tests best suited to their research needs and limitations.

Associations between nutrition risk status, body composition and physical performance among community-dwelling older adults

OBJECTIVE

To investigate the associations between nutrition risk status, body composition and physical performance among community-dwelling older New Zealanders.

METHODS

This cross-sectional study enrolled 257 community-dwelling older adults (median age 79 years). Assessments included the Mini Nutritional Assessment-Short Form (MNA®-SF) for nutrition risk; the Eating Assessment Tool-10 for dysphagia risk; bioimpedance analysis for body composition (free fat mass (FFM) and percentage body fat) and gait speed for physical performance. A multiple logistics regression analysis was conducted, to determine factors associated with lower odds [OR (95% CI)] for nutrition risk.

RESULTS

Every yearly increase in age was associated with higher odds 1.09 (1.01-1.17) for nutrition risk. Additionally, nutrition risk was less likely to occur among participants of age <85 years 0.30 (0.11-0.79), with no dysphagia 0.29 (0.09-0.97) and those with a healthy gait speed 0.29 (0.09-0.97). Lower odds for nutrition risk were also found with increasing values of FFM index 0.51 (0.34-0.77), and percentage body fat 0.81 (0.72-0.90). Gait speed was positively correlated with FFM index (r=0.19 p<0.022), percentage body fat (r=0.23, p=0.006) and BMI (r=0.29, p<0.001).

CONCLUSION

Among these participants, associations between nutrition risk, body composition and physical performance were found. Implications for public health: Routine screening of nutrition risk and/or physical performance among vulnerable older adults is key towards identifying those in need of assessment and dietary intervention. Alongside strategies to encourage physical activity, this may help to slow losses of FFM and protect physical performance.

The relationship of sit-to-stand tests with 6-minute walk test in healthy young adults

The aim of this study was to evaluate the timed sit-to-stand (STS) test performances of healthy young adults and to investigate the relationship of timed STS tests with 6-minute walk test (6MWT). A cross-sectional study was performed. A total of 40 healthy volunteers (mean age: 21.7 ± 1.2 years) were evaluated with 10, 30, and 60 seconds STS tests and 6MWT. Fatigue and shortness of breath were rated using Borg category-ratio scale (CR10) before and after each test. Weekly energy expenditures of volunteers were calculated using International Physical Activity Questionnaire. 30 and 60 seconds STS tests were moderately (r = 0.611 and r = 0.647, respectively) (P < .001) and 10 seconds STS test was weakly (r = 0.344) (P = .028) correlated with 6MWT. Among correlations of each STS test with 6MWT, none of them was statistically stronger to one another (P > .05). Borg fatigue scores after 10, 30, and 60 seconds STS tests were weakly correlated with fatigue score after 6MWT (r = 0.321, r = 0.378, and r = 0.405, respectively) (P < .05). Weekly energy expenditure (MET-min/week) was moderately correlated with 10, 30, and 60 seconds STS tests and 6MWT (r = 0.533, r = 0.598, r = 0.598, and r = 0.547, respectively) (P < .001). Considering the statistically significant relationship between timed STS tests and 6MWT, any of the timed STS tests may be used for a quick and alternative measurement of physical performance and functional capacity in healthy young adults.

Proposing Development and Utility of a Mobility Composite Measure in Patients with a Neurologic Disorder

Background

Outcome measures typically assess single domains making holistic assessment difficult. Our purpose was to develop a mobility composite measure (MCM) based on four commonly used outcome measures and compare this composite score to the individual measures in patients with neurologic disorders.

Methods

We retrospectively reviewed 148 medical records for inclusion of primary neurologic diagnosis and scoring for 5 times sit-to-stand test (5TSST), 10-meter walk test (10MWT), 2-minute walk test (2MWT), and activities-specific balance confidence (ABC) scale.

Results

After establishing that a single concept was being assessed with interitem correlations, raw scores were converted to percentage of normal and combined into the MCM for analysis from admission to discharge. Scores on each measure significantly improved after intervention (5TSST, p < .001; 10MWT, p < .001; 2MWT, p < .001; ABC, p = .02). Mean MCM (n = 93) admission scores were 67.55 ± 31.88% and discharge scores were 74.81 ± 34.39% (p = .002). On average, patients improved 7.26% on the MCM exceeding the threshold of expected error (MDC₉₅ = 3.59%).

Conclusions

MCM detected change in patient outcomes statistically and clinically and appears to capture a holistic picture of functional status. We recommend a prospective study to further investigate a "composite measure" incorporating measures from several functional domains.

Integrating culturally informed approaches into the physiotherapy assessment and treatment of chronic pain: protocol for a pilot randomised controlled trial

INTRODUCTION

There is strong evidence that biopsychosocial approaches are efficacious in the management of chronic pain. However, implementation of these approaches in clinical practice is known not to account for the beliefs and values of culturally and linguistically diverse (CALD) patients. This limitation in translation of research contributes to the disparities in outcomes for CALD patients with chronic pain adding to the socioeconomic burden of this prevalent condition. Cultural adaptation of chronic pain assessment and management is urgently required. Thus, the aim of this pilot randomised controlled trial (RCT) is to determine the feasibility, participant acceptance with and clinical effectiveness of a culturally adapted physiotherapy assessment and treatment approach when contrasted with 'usual evidence based physiotherapy care' for three CALD communities.

METHODS AND ANALYSIS

Using a participant-blinded and assessor-blinded randomised controlled pilot design, patients with chronic pain who self-identify as Assyrian, Mandaean or Vietnamese will be randomised to either 'culturally adapted physiotherapy assessment and treatment' or 'evidence informed usual physiotherapy care'. We will recruit 16 participants from each ethnocultural community that will give a total of 24 participants in each treatment arm. Both groups will receive physiotherapy treatment for up to 10 sessions over 3 months. Outcomes including feasibility data, acceptance with the culturally adapted intervention, functional and pain-related measures will be collected at baseline and 3 months by a blinded assessor. Analysis will be descriptive for feasibility outcomes, while measures for clinical effectiveness will be explored using independent samples t-tests and repeated measures analysis of variance. This analysis will inform sample size estimates while also allowing for identification of revisions in the protocol or intervention prior to a larger scale RCT.

ETHICS AND DISSEMINATION

This trial has full ethical approval (HREC/16/LPOOL/194). The results from this pilot RCT will be presented at scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12616000857404.

Comparison of Gait Speed and Peripheral Nerve Function Between Chronic Kidney Disease Patients With and Without Diabetes

OBJECTIVE

To compare overall physical function, including gait speed and peripheral nerve function, between diabetic chronic kidney disease (CKD) patients and nondiabetic CKD patients and to investigate the association between gait speed and peripheral nerve function in CKD patients.

METHODS

Sixty adult CKD patients (35 with and 25 without diabetes), who received maintenance hemodialysis (HD), were included in this study. Demographic data, past medical history, current medical condition and functional data-usual gait speed, vibration perception threshold for the index finger (VPT-F) and the great toe (VPT-T), activity of daily living (ADL) difficulty, and peripheral neuropathy (PN) along with the degree of its severity-were collected and compared between the two groups. Correlations between the severity of PN and the impairment of other functions were identified.

RESULTS

Diabetic CKD patients showed significantly slower gait speed (p=0.029), impaired sensory function (VPT-F, p=0.011; VPT-T, p=0.023), and more frequent and severe PN (number of PN, p<0.001; severity of PN, p<0.001) as compared to those without diabetes. Usual gait speed had a significant negative correlation with the severity of PN (rho=-0.249, p=0.013). By contrast, VPT-F (rho=0.286, p=0.014) and VPT-T (rho=0.332, p=0.035) were positively correlated with the severity of PN. ADL difficulty was comparatively more frequent in the patients with more severe PN (p=0.031).

CONCLUSION

In CKD patients with maintenance HD, their gait speed, sensory functions, and peripheral nerve functions were all significantly impaired when they have diabetes, and the severity of PN was negatively correlated with their gait speed, sensory function, and ADL function. Adverse effects of diabetes impacted physical performance of CKD patients. The physical disability of those patients might be attributable to PN and its severity.

Assessment of sit-to-stand movement in nonspecific low back pain: a comparison study for psychometric properties of field-based and laboratory-based methods

One of the most difficult tasks associated with the management of nonspecific low back pain (LBP) is its clinical assessment. Objective functional methods have been developed for assessment. However, few studies have used daily activities such as sit-to-stand (STS). The aim was to compare the psychometric properties of two commonly used STS assessment methods. A test-retest reliability study design was used. Participants with nonspecific LBP performed the 30-s chair stand test (30CST) and the STS test in Balance Master, which measures weight transfer, rising index and centre of gravity sway velocity. The same tests were reperformed after 48-72 h. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), minimal detectable change and coefficient of variation were calculated to compare the reliability. The correlations between the tests, the Oswestry Disability Index and pain intensity were examined for validation. The 30CST had very high intrarater reliability (ICC=0.94). The variables of STS test in Balance Master had moderate intrarater reliability (ICC=0.62-0.69). There were significant correlations between the 30CST, Oswestry Disability Index and pain intensity at activity (P<0.01). The rising index was the only one variable that was significantly correlated with pain intensity at activity (P<0.05). The 30CST as the field-based method to measure STS movement was better than the laboratory-based method in terms of their psychometric properties. Moreover, the 30CST was associated with disability and pain related to LBP. The 30CST is a simple, cheap, less time consuming and psychometrically appropriate method to use in individuals with nonspecific LBP.

Impact of loaded sit-to-stand exercises at different speeds on the physiological cost of walking in children with spastic diplegia: A single-blind randomized clinical trial

PURPOSE

In the present study, we aimed to determine whether similarly loaded sit-to-stand exercises at different speeds improve the physiological cost of walking in children with spastic diplegia.

METHODS

This design was a single-blind randomized clinical trial. Sixteen children with cerebral palsy (CP), aged 12-18 years, with a diagnosis of spastic diplegia, were randomly allocated to a slow loaded sit-to-stand exercise group (n=8) and a self-paced loaded sit-to-stand exercise group (n=8). Loaded sit-to-stand exercise was conducted at home for 15min, 4 sets per day, 3-4days per week, for 6 weeks. The patients were evaluated immediately before the intervention and after the training. Lower limb muscle strength using a hand-held dynamometer, selective voluntary motor control using SCALE, 6-min walk distance (6MWD), and Physiological Cost Index (PCI) were measured.

RESULTS

The 6MWD showed a significant difference before and after intervention. PCI showed a significant difference between the two groups and the two time points. 6MWD and the PCI improved after intervention in the slow sit-to-stand exercise group.

CONCLUSIONS

Compared to loaded sit-to-stand exercise at a regular speed, slow low-loaded sit-to-stand exercise improved the 6MWD and PCI in children with CP, suggesting that this decrease in speed during exercise improves the physiological cost of walking in these children.

Relationship between performances of 10-time-repeated sit-to-stand and maximal walking tests in non-disabled older women

Aim

Sit-to-stand (STS) test is extensively used to assess the functionality of the lower body in elderly people. This study aimed to examine how the score of STS can be associated with that of maximal walking (MW) tests through a cross-sectional as well as longitudinal analysis for non-disabled older women.

Method

Times taken for a 10-time-repeated STS (STS time) and 5-m MW (MW time) were determined before (pre) and after (post) a 3-month body mass-based exercise program in 154 non-disabled women aged 60 to 79 years. In addition to the time scores, STS and MW power indexes (STS-PI and MW-PI, respectively) were calculated using the following equations: STS-PI = (body height − 0.4) × body mass × 10/STS time and MW-PI = body mass × 5/MW time.

Results

At pre- and post-intervention, STS-PI was significantly correlated to MW-PI, with higher correlation coefficients (r = 0.545–0.567, P < 0.0001) than those between the two time scores (r = 0.271–0.309, P < 0.001). The intervention significantly improved STS-time (13.6 ± 3.2 s at pre to 9.4 ± 1.8 s at post, P < 0.0001), MW time (2.4 ± 0.3 s to 2.2 ± 0.3 s, P < 0.0001), STS-PI (46.5 ± 12.5 to 65.7 ± 12.7, P < 0.0001), and MW-PI (112.1 ± 20.2 to 124.2 ± 24.4, P < 0.0001). There were significant correlations between the changes of STS and MW times (r = 0.281, P < 0.001) and between those of STS-PI and MW-PI (r = 0.366, P < 0.0001).

Conclusion

In elderly women, the performance of sit-to-stand task and its training-induced gain are associated with those of the maximal walking task. In addition, the current results indicated that translation of the performance scores of the sit-to-stand and maximal walking tasks to power indexes may be a useful approach for examining the association between the two tasks.

Relationship between vitamin D and lung function, physical performance and balance on patients with stage I-III chronic obstructive pulmonary disease

Summary Objectives: vitamin D is important for muscle function and it affects different aspects of muscle metabolism. This study aim to determine whether serum 25(OH) D levels are related to lung functions, physical performance and balance in patients with chronic obstructive pulmonary disease (COPD). Methods: in 90 patients with COPD and 57 healthy controls lung function tests, physical performance tests (time up and go, gait velocity test, sit-to-stand test, isometric strength, isokinetic strength), static (functional reach test) and dynamic (time up and go) balance tests and the association of 25(OH)D levels with lung functions, physical performance and balance were evaluated. Results: the COPD patients had significantly more deficit in physical function and balance parameters, and in dynamic balance test (p<0.005). Isokinetic knee muscle strength (flexor and extensor) in COPD patients was significantly lower than in the controls (p<0.05); FEV1 (p=0.008), FVC (p=0.02), FEV1/FVC (p=0.04), TLC (p=0.01) were lower in COPD patients with vitamin D deficiency [25(OH) D less than 15ng/mL] than in COPD patients without vitamin D deficiency. Hand grip test (p=0.000) and isokinetic knee muscle strength (flexor and extensor) (p<0.05) were also lower in COPD patients with vitamin D deficiency. Vitamin D deficiency was more pronounced in patients with stage III COPD (p<0.05). Conclusion: patients with COPD had worst physical functioning, poor balance and less muscle strength. Severe disturbed lung and peripheral muscle functions are more pronounced in COPD patients with vitamin D deficiency.

Impact of physical therapy on functional capacity and life quality of patients with chronic kidney disease

Introduction Studies have demonstrated beneficial effects of exercise in patients with chronic kidney disease, however, based on current scientific literature, more research is needed to increase evidence level of potential effects of physical activity for this population. Objective To evaluate effects of physical therapy based on the supervised exercise practice on functional capacity and life quality of patients with chronic kidney disease. Material and methods This quasi-experimental study, with repeated measures design, was conducted in the ambulatory of physical therapy, in a public hospital, located in a city of the state of Pará (north region of Brazil). Functional capacity and life quality were assessed at baseline and after six weeks of aerobic and resistance training performed three times per week on alternate days with hemodialysis. Results Eight patients (3M / 5F) with a mean age of 60.38 years (SD = 14.75) were evaluated. There was significant increase of 24% in distance walked in six minute walk test (p = 0.007), and of 47% in number of repetitions during sit-to-stand test (p = 0.002); there was also significant improvement in emotional role (p = 0.043) of life quality assessed with SF36 questionnaire. Conclusion There was a positive impact of only six weeks of rehabilitation with physical exercise on functional capacity and emotional role of life quality of patients with chronic kidney disease.

High intensity training improves health and physical function in middle aged adults

High intensity training (HIT) is effective at improving health; however, it is unknown whether HIT also improves physical function. This study aimed to determine whether HIT improves metabolic health and physical function in untrained middle aged individuals. Fourteen (three male and eleven female) untrained individuals were recruited (control group n = 6: age 42 ± 8 y, weight 64 ± 10 kg, BMI 24 ± 2 kg·m⁻² or HIT group n = 8: age 43 ± 8 y, weight 80 ± 8 kg, BMI 29 ± 5 kg·m⁻²). Training was performed twice weekly, consisting of 10 × 6-second sprints with a one minute recovery between each sprint. Metabolic health (oral glucose tolerance test), aerobic capacity (incremental time to exhaustion on a cycle ergometer) and physical function (get up and go test, sit to stand test and loaded 50 m walk) were determined before and after training. Following eight weeks of HIT there was a significant improvement in aerobic capacity (8% increase in VO₂ peak; p < 0.001), physical function (11%–27% respectively; p < 0.05) and a reduction in blood glucose area under the curve (6% reduction; p < 0.05). This study demonstrates for the first time the potential of HIT as a training intervention to improve skeletal muscle function and glucose clearance as we age.

Exercise limitation following transplantation

Organ transplantation is one of the medical miracles or the 20th century. It has the capacity to substantially improve exercise performance and quality of life in patients who are severely limited with chronic organ failure. We focus on the most commonly performed solid-organ transplants and describe peak exercise performance following recovery from transplantation. Across all of the common transplants, evaluated significant reduction in VO2peak is seen (typically renal and liver 65%-80% with heart and/or lung 50%-60% of predicted). Those with the lowest VO2peak pretransplant have the lowest VO2peak posttransplant. Overall very few patients have a VO2peak in the normal range. Investigation of the cause of the reduction of VO2peak has identified many factors pre- and posttransplant that may contribute. These include organ-specific factors in the otherwise well-functioning allograft (e.g., chronotropic incompetence in heart transplantation) as well as allograft dysfunction itself (e.g., chronic lung allograft dysfunction). However, looking across all transplants, a pattern emerges. A low muscle mass with qualitative change in large exercising skeletal muscle groups is seen pretransplant. Many factor posttransplant aggravate these changes or prevent them recovering, especially calcineurin antagonist drugs which are key immunosuppressing agents. This results in the reduction of VO2peak despite restoration of near normal function of the initially failing organ system. As such organ transplantation has provided an experiment of nature that has focused our attention on an important confounder of chronic organ failure-skeletal muscle dysfunction.

The five times sit to stand test in senior athletes

BACKGROUND AND PURPOSE

The Five Times Sit to Stand Test (FTSST) has been established as a valid and reliable functional measure for older adults. Norms have been clearly defined for community-dwelling older adults and can be useful in the identification of mobility decline and prediction of future disability. However, because of the high rates of inactivity in the population of community-dwelling older adults, it seems inappropriate to compare high-functioning older adults, for example, senior athletes, to these norms. With trends showing increased senior athlete participation, new norms may be necessary to appropriately evaluate this population of older adults. The purpose of this study was to (1) compare results of the FTSST in senior athletes older than 60 years to norms for community-dwelling adults of the same age (2) determine the effects of age, gender, and sport intensity on FTSST performance in senior athletes, and (3) establish norms appropriate for this population of interest.

METHODS

The FTSST was performed on 276 (104 men, 172 women) senior athletes age 50 to 91 years (mean age = 64.9, SD = 15) reporting an average of 4 hours of cardiovascular training and 1 hour of strength training each week. All were actively engaged in national or state senior game competitions.

RESULTS

All participants were able to complete the test. One hundred ninety-four participants between 60 and 89 years of age showed significantly faster times than currently reported norms. Performance was negatively associated with age, but did not differ significantly between genders. Participants in more physically demanding sports did show the best FTSST times, although athletes engaged in more leisure sports still outperformed norms for community-dwelling seniors.

CONCLUSION

Senior athletes show significantly greater FTSST speed than norms derived from community-dwelling older adults. New normative guidelines are presented to assist the screening of these athletes on this functional performance measure.

Five-repetition sit-to-stand test: usefulness for older patients in a home-care setting

The usefulness of the five-repetition sit-to-stand (FRSTS) test was assessed with older patients in a home-care setting. Records of 45 patients (> or = 65 years old) were examined for information on FRSTS test performance. 5 patients were excluded. 23 patients were unable to complete the test. For the 17 able to complete the FRSTS test, the time required was statistically significantly greater than age-stratified norms. For patients treated in a home-care setting, inability to complete the FRSTS test clearly underscores the test's limitations and the need for alternatives.

Test-retest reliability and minimal detectable change scores for sit-to-stand-to-sit tests, the six-minute walk test, the one-leg heel-rise test, and handgrip strength in people undergoing hemodialysis

BACKGROUND

Determining the relative and absolute reliability of outcomes of physical performance tests for people undergoing hemodialysis is necessary to discriminate between the true effects of exercise interventions and the inherent variability of this cohort.

OBJECTIVE

The aims of this study were to assess the relative reliability of sit-to-stand-to-sit tests (the STS-10, which measures the time [in seconds] required to complete 10 full stands from a sitting position, and the STS-60, which measures the number of repetitions achieved in 60 seconds), the Six-Minute Walk Test (6MWT), the one-leg heel-rise test, and the handgrip strength test and to calculate minimal detectable change (MDC) scores in people undergoing hemodialysis.

DESIGN

This study was a prospective, nonexperimental investigation.

METHODS

Thirty-nine people undergoing hemodialysis at 2 clinics in Spain were contacted. Study participants performed the STS-10 (n=37), the STS-60 (n=37), and the 6MWT (n=36). At one of the settings, the participants also performed the one-leg heel-rise test (n=21) and the handgrip strength test (n=12) on both the right and the left sides. Participants attended 2 testing sessions 1 to 2 weeks apart.

RESULTS

High intraclass correlation coefficients (≥.88) were found for all tests, suggesting good relative reliability. The MDC scores at 90% confidence intervals were as follows: 8.4 seconds for the STS-10, 4 repetitions for the STS-60, 66.3 m for the 6MWT, 3.4 kg for handgrip strength (force-generating capacity), 3.7 repetitions for the one-leg heel-rise test with the right leg, and 5.2 repetitions for the one-leg heel-rise test with the left leg. Limitations A limited sample of patients was used in this study.

CONCLUSIONS

The STS-16, STS-60, 6MWT, one-leg heel rise test, and handgrip strength test are reliable outcome measures. The MDC scores at 90% confidence intervals for these tests will help to determine whether a change is due to error or to an intervention.

The Five-Times-Sit-to-Stand test, a marker of global cognitive functioning among community-dwelling older women

OBJECTIVE

To determine whether there was an association between the Five-Times-Sit-to-Stand test (FTSS) and the global cognitive function assessed with Short-Portable-Mental-State-Questionnaire (SPMSQ) among the EPIDOS cohort.

DESIGN

Cross-sectional study corresponding to the baseline assessment of the EPIDOS study.

SETTING

Five French cities including Amiens, Lyon, Montpellier, Paris and Toulouse.

PARTICIPANTS

7421 community-dwelling older women (mean age 80.41 ± 0.04 years).

MEASUREMENTS

Time to achieve FTSS, and SPMSQ score. Age, body mass index, high number of comorbidities, cardiovascular risk factors, depression, regular physical activity, joint pain, quadriceps strength, visual acuity, use of psychoactive drugs, serum albumin, vitamin D deficiency (i.e., serum concentration < 10 ng/mL), and the influence of seasons and study centers were used as covariables. Subjects were divided into 2 groups according to SPMSQ score (either impaired < 8/10 or normal ≥ 8/10).

RESULTS

Compared to their counterparts, the women with cognitive impairment (n=1190, mean 81.51 ± 0.45 years) took more time in performing FTSS (17.8± 0.9 seconds versus 16.1 ± 0.3 seconds, P < 0.001). There was a significant negative association of SPMSQ score with FTSS (Unadjusted β=-0.02(95%CI -0.03;-0.01), P< 0.001; Fully Adjusted β=-0.03(95%CI -0.05;-0.01), P=0.003; Stepwise Backward Adjusted β=-0.02(95%CI -0.04;-0.01), P=0.005), as well as with advance in age (β=-0.04, P=0.006) and vitamin D deficiency (β=-0.34, P=0.011). The FTSS limit value in predicting moderate cognitive impairment was set at 15 seconds by a sensitivity analysis (negative predictive value=86%).

CONCLUSION

We found a negative association of FTSS with global cognitive performance. Achieving FTSS in less than 15 seconds made unlikely the existence of a moderate cognitive impairment. FTSS could be used as a tool in primary care medicine to exclude moderate cognitive decline.

Sit-to-stand test: Performance and determinants across the age-span

Although the validity of the sit-to-stand (STS) test as a measure of lower limb strength has been questioned, it is widely used as such among older adults. The purposes of this study were: 1) to describe five-repetition STS test (FRSTST) performance (time) by adolescents and adults and 2) to determine the relationship of isometric knee extension strength (force and torque), age, gender, weight, and stature with that performance. Participants were 111 female and 70 male (14-85 years) community-dwelling enrollees in the NIH Toolbox Assessment of Neurological and Behavioral Function. The FRSTST was conducted using a standard armless chair. Knee extension force was measured using a belt-stabilized hand-held dynamometer; knee extension torque was measured using a Biodex dynamometer. The mean times for the FRSTST ranged from 6.0 sec (20-29 years) to 10.8 sec (80-85 years). For both the entire sample and a sub-sample of participants 50-85 years, knee extension strength (r = -0.388 to -0.634), age (r = 0.561 and 0.466), and gender (r = 0.182 and 0.276) were correlated significantly with FRSTST times. In all multiple regression models, knee extension strength provided the best explanation of FRSTST performance, but age contributed as well. Bodyweight and stature were less consistent in explaining FRSTST performance. Gender did not add to the explanation of FRSTST performance. Our findings suggest, therefore, that FRSTST time reflects lower limb strength, but that performance should be interpreted in light of age and other factors.

Balance ability, not muscle strength and exercise endurance, determines the performance of hemiparetic subjects on the timed-sit-to-stand test

OBJECTIVE

To examine the contribution of balance ability, muscle strength, and exercise endurance to performance in the timed-sit-to-stand test among chronic hemiparetic subjects.

DESIGN

A cross-sectional study with 68 community-dwelling stroke survivors.

RESULTS

By using Pearson correlation coefficient, the five-times-sit-to-stand (FTSTS) test scores showed the highest negative correlation with Berg Balance Scale scores (r = -0.837, P < 0.001), and it showed significant moderate correlation with muscle strength index (r = -0.577, P < 0.001) and distance covered in a 6-min walk test (r = -0.598, P < 0.001). After controlling for demographic factors, significant partial correlation was identified between FTSTS scores and Berg Balance Scale scores only (r = -0.630, P < 0.001). Linear regression model, after accounting for demographics and subjective balance confidence, showed that FTSTS scores were independently associated with Berg Balance Scale scores (beta = -0.630, P < 0.001), whereas muscle strength index and distance covered in the 6-min walk test were not significant predictors of FTSTS scores. The whole model could explain 71% of the variance in FTSTS scores.

CONCLUSIONS

This is the first study documenting the importance of balance ability, not muscle strength and exercise endurance, as an important determinant of performance on the FTSTS test by community-dwelling stroke patients. These findings suggest that the FTSTS test may be a more appropriate proxy indicator of balance performance in chronic community-dwelling stroke subjects.

Determinants of exercise capacity in CKD patients treated with hemodialysis

There are many ways to measure physical functioning. Oxygen uptake at peak exercise is considered to be the most objective or 'gold-standard' measure and is determined by the integrated functioning of multiple physiological systems. Renal failure can affect the functioning of several of these systems which results in low levels of peak oxygen uptake. This review examines the determinants of oxygen uptake as defined by the Fick Equation, and presents data from studies that have reported these physiological measures. It becomes clear that there are many factors that may limit peak oxygen uptake in these patients and any one mechanism may be difficult to identify.

Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders

This meta-analysis was conducted to generate normative values for the 5-repetition sit-to-stand (STS) test suitable for application to individuals at least 60 years of age. A thorough review of the literature yielded 13 papers (14 studies) relevant to this purpose. After the exclusion of potentially unrepresentative data, meta-analysis of these 13 papers indicated that judgments about normal performance should be based on age. Analysis demonstrated that individuals with times for 5 repetitions of this test exceeding the following can be considered to have worse than average performance: 11.4 sec (60 to 69 years), 12.6 sec. (70 to 79 years), and 14.8 sec. (80 to 89 years).

Comparison of the Sit-to-Stand Test with 6 min walk test in patients with chronic obstructive pulmonary disease

OBJECTIVE

To discuss the utility of Sit-to-Stand Test (STST) compared to the 6min walking test (6MWT) for the evaluation of functional status in patients with chronic obstructive pulmonary disease (COPD).

MATERIAL-METHOD

SUBJECTS

Fifty-three patients with stable COPD (mean forced expiratory volume in 1s (FEV(1)) 46+/-9% predicted, mean age 71+/-12 year) and 15 healthy individuals (mean FEV(1) 101+/-13% predicted and mean age 63+/-8) were included.

INTERVENTIONS

Functional performance was evaluated by STST and 6MWT. During the tests, severity of dyspnea (by Modified Borg Scale), heart rate, pulsed oxygen saturation (SpO(2), by Modified Borg Scale) (by pulse oxymeter), blood pressure were measured. The pulmonary function (by spirometry), quadriceps femoris muscle strength (by manual muscle test) and quality of life (by Nottingham Health Profile Survey) were evaluated.

RESULTS

The STST and 6MWT results were lower in COPD group than the healthy group (P<0.05). During the 6MWT the rise in the heart rate, systolic blood pressure and the decrease in SpO(2) were statistically significant according to STST in COPD groups (P<0.05). The STST and 6MWT were strongly correlated with each other in both groups (P<0.05). Similarly, they were correlated with age, quality of life, peripheral muscle strength and dyspnea severity in COPD groups (P<0.05).

CONCLUSION

Similar to 6MWT, STST is also able to determine the functional state correctly. Additionally, it produces less hemodynamical stress compared to the 6MWT. In conclusion, STST can be used as an alternative of the 6MWT in patients with COPD.

Body weight-supported treadmill training in chronic incomplete spinal cord injury: a pilot study evaluating functional health status and quality of life

STUDY DESIGN

A controlled single-case design: A1 (baseline: 6 weeks), B (intervention: 12 weeks of treadmill training (TT), maximally five times a week/30 min a day), A2 (wash-out: 6 weeks), follow-up measurement: 6 months.

OBJECTIVE

To investigate the effects of TT on functional health status (FHS) and quality of life (QoL) in subjects with a chronic incomplete spinal cord injury (ISCI).

SETTING

Rehabilitation Department, University Medical Centre Utrecht, The Netherlands.

METHODS

Three male subjects with a stable (>48 months postinjury) ISCI, American Spinal Injury Association (ASIA) class C (n=2) and D (n=1). Performance-based walking, subject's perception concerning quality of life (SEIQoL) and activities of daily living Canadian Occupational Performance Measure (COPM).

RESULTS

The results of the three subjects were variable. Changes in QoL were relatively small and diverse. After 6 months' follow-up, QoL was unchanged in subjects 1 and 2, and improved in subject 3. In subject 2, performance of activities of daily living (ADL) was significantly improved, consistent with his perception of improvement (P<0.05), and this improvement was sustained throughout the follow-up period. Walking ability improved in subject 3 (P<0.05) but performance of other activities remained stable. Performance of ADL decreased slightly in subject 1 whereas his walking speed and Get up and Go performance improved (P<0.05).

CONCLUSIONS

This study demonstrates positive effects of TT on FHS. A randomised clinical trial should be executed before definite conclusions about the effect of TT on FHS and QoL can be drawn.

SPONSORSHIP

KF Hein Foundation and Rehabilitation Centre De Hoogstraat Scientific Foundation.

Physical functioning in end-stage renal disease patients: Update 2005

Physical functioning in patients with end-stage renal disease treated with dialysis is low, whether measured using objective laboratory measures, physical performance testing, or self-reported measures. Peak oxygen uptake (VO2peak), self-reported functioning measures, and physical activity levels are independent predictors of mortality in these patients. Cardiovascular exercise training studies result in improvements in VO2peak, physical performance tests, and self-reported functioning. Resistance exercise training improves muscle strength. Exercise training may have positive benefits on other factors that are important clinical issues in dialysis patients, including cardiovascular risk profile, oxidative stress, and inflammation. Endothelial function, a surrogate marker of atherosclerosis, has been shown to improve with exercise training in dialysis patients. Although there have been numerous recent studies on benefits of exercise, few dialysis clinics or nephrologists provide encouragement or programs as a part of their routine care of their patients. There are many national guidelines that include exercise or increasing physical activity as a part of the treatment of many conditions that are relevant in dialysis patients, including hypertension, hyperlipidemia, and high cardiovascular disease risk. The nephrology community continues to state concern for outcomes; however, a simple, low-tech intervention that has many benefits to their patients (i.e., encouragement, recommendations, and opportunity for increasing physical activity) has not been adopted as part of the standard care. Adoption of routine counseling and encouragement for physical activity has the potential to improve outcomes, improve physical functioning, and optimize quality of life and overall health of dialysis patients.

Effects of an exercise program on muscle performance in patients undergoing allogeneic bone marrow transplantation

Allogeneic bone marrow transplantation (BMT) has been successfully used for the treatment of several hematological malignancies; however, it is associated with transplant-related toxicities such as functional impairment and muscle weakness. In order to analyze how an exercise program may influence muscle strength in patients undergoing BMT, we carried out a prospective study assessing patients from the pre-BMT phase to 16 weeks post-BMT. In all, 18 patients underwent three trials: (1) pre-BMT, (2) after marrow engraftment, and (3) 6 weeks after trial 2. After trial 2, the patients were randomized in a control group (CG) or treatment group (TG), which received a 6-week exercise program with active exercise, muscle stretching and treadmill walking. The results obtained in trial 1 showed similar values for CG and TG, as both groups had muscle strength lower than normal patterns based on data concerning age, sex and weight. In trial 2, CG and TG showed similarly decreased values. In trial 3, TG showed values higher than CG for all muscle groups tested. These results suggest that the exercise program was efficient in promoting an increase of muscle strength after allogeneic BMT.

Preoperative predictors of locomotor ability two months after total knee arthroplasty for severe osteoarthritis

OBJECTIVE

To identify preoperative predictors of locomotor ability 2 months after total knee arthroplasty (TKA).

METHODS

Sixty-five participants scheduled for a first TKA were recruited. The dependent variable was the distance covered during the 6-minute gait test 2 months after TKA. The independent variables, measured before surgery, were grouped into 3 categories: 1). personal; 2). organic system, and 3). capability variables. Multiple regression analyses were conducted to determine the best predictors of the dependent variable. Modified cross-validation of the model combining predictors from the three categories was obtained with 10 random samples derived from the original cohort by resampling with replacement.

RESULTS

Predictors were identified in the 3 categories: 1). gender, number of comorbidities, body mass index, 2). knee pain, flexion and strength, lower limb mechanical power, and 3). preoperative 6-minute gait distance. When these variables were modeled together only the preoperative 6-minute gait distance and knee pain and flexion remained significant (adjusted R(2) = 0.66).

CONCLUSION

Using variables easily measured before surgery, it is possible to predict with good accuracy locomotor ability 2 months after TKA.

Arthrodesis as an early alternative to nonoperative management of charcot arthropathy of the diabetic foot

BACKGROUND

This study was performed to evaluate the use of arthrodesis of the tarsal-metatarsal area for the treatment of Eichenholtz stage-I Charcot arthropathy in patients with diabetes. Currently, the standard treatment of stage-I Charcot arthropathy is the application of a non-weight-bearing total-contact cast. Although this treatment can be effective for allowing a patient to walk without undergoing an operation, a nonunion or malunion may still result. The subsequent deformities may lead to complications, including ulceration of the foot and the need for operative intervention. Recently, a group of patients who had had early operative intervention for a variety of reasons provided us with the opportunity to objectively evaluate the effects of such treatment. This analysis provided valuable information about whether this treatment is a reasonable alternative to current nonoperative approaches.

METHODS

Between January 1991 and December 1996, fourteen patients had an operation because of Eichenholtz stage-I diabetic neuropathy. The classification of the disease as Eichenholtz stage I (the developmental stage) was based on radiographic evidence of varying degrees of articular-surface and subchondral-bone resorption and fragmentation as well as joint subluxation or dislocation without evidence of coalescence or callus formation. The operative procedure consisted of extensive debridement, open reduction, and internal fixation of the tarsal-metatarsal region with autologous bone graft. Postoperative treatment consisted of immobilization of the limb in a non-weight-bearing cast for a minimum of six weeks. All of the patients returned for a final follow-up visit at a mean of forty-one months (range, 25.3 to 77.3 months) postoperatively, at which time clinical and radiographic evaluations as well as gait analysis (with measurement of plantar pressures) were performed. The gait-analysis data was compared with similar data from a group of fourteen patients with diabetic neuropathy who had had a below-the-knee amputation and with that from a group of fourteen patients with diabetic neuropathy who had no history of plantar ulceration.

RESULTS

All of the arthrodesis procedures were successful. Clinically, none of the patients had immediate or long-term complications postoperatively. No patient reported ulceration after the operation. The mean time to assisted weight-bearing was 10 +/- 3.3 weeks (range, six to fifteen weeks), the mean time to unassisted weight-bearing was 15 +/- 8.8 weeks (range, eight to thirty-four weeks), and the mean time to return to the use of regular shoes was 27 +/- 14.4 weeks (range, twelve to sixty weeks). All of the patients regained the level of walking ability that they had had prior to the arthropathy. The calculated confidence intervals revealed no differences between the arthrodesis group and either of the two comparison groups with regard to the time-distance gait parameters of velocity, cadence, and stride length or with regard to the minimum, maximum, and total range of motion of each of the joints. In contrast to able-bodied subjects, all three groups showed a reduction in sagittal-plane ankle motion that was primarily related to loss of plantar flexion. The first metatarsal, great toe, and heel showed the highest peak plantar pressures, with little difference among the groups.

CONCLUSIONS

To our knowledge, the present study is the first to demonstrate the potential for early operative treatment to restore anatomical alignment and improve function of diabetic patients with stage-I Charcot arthropathy.

Quadriceps muscle strength and dynamic stability in elderly persons

Several measures of dynamic stability during two functional activities correlated to quadriceps femoris muscle strength. A total of 34 disabled elders (aged 60-88) living in the Boston area consented to maximum isometric quadriceps muscle strength testing, chair rise and gait analysis. During chair rise, quadriceps strength significantly correlated with maximum upper body vertical linear momentum, r=0.53, P<0.005, anterior posterior linear momentum, r=0. 38, P<0.05, and the time to complete the chair rise, r=-0.48, P<0.05, n=29. Stride length and gait velocity correlated (r=0.56, P<0.001 and r=0.51, P<0.002, n=34) with quadriceps muscle strength. The maximum range of whole body anteroposterior (A/P) linear momentum during gait also correlated with quadriceps strength (r=0.47, P=0. 004, n=31). Dynamic stability during chair rise and gait, at preferred speed, correlates directly with quadriceps femoris muscle strength in functionally limited elderly individuals. In our sample, elders performed one of three movement strategies to arise from a chair, and quadriceps strength did not statistically differ between the chair rise strategy groups. However, persons with the greatest quadriceps strength values were more stable regardless of which chair rise strategy they performed. Our data indicate that clinicians should not suggest that patients use compensatory momentum inducing locomotor strategies unless the patient has sufficient strength to control these induced forces.

Intertester reliability of hand-held dynamometry: a concise summary of published research

Literature describing the use of hand-held dynamometry was examined to determine whether conclusions could be drawn regarding intertester reliability. 18 studies reporting intertester reliability coefficients were found and summarized. These suggest that high intertester reliability can be obtained, but that it is in jeopardy if tester strength is low relative to the forces being measured.