Limited joint mobility in the hands and feet of adolescents with Type 1 diabetes mellitus

The external validity of a novel contract-relax stretching technique on knee flexor range of motion

Introduction

Compromised joint range of motion (ROM) can negatively affect the capacity to perform activities of daily living in clinical populations. Recently, similar improvements in dorsiflexion ROM were reported following dynamometry‐based contract‐relax (CR) stretching and modified CR stretching technique (stretch‐return‐contract [SRC]) where the contraction phase was performed “off stretch.” As neither the impact of SRC on other muscle groups nor the ecological validity of SRC performed in an applied environment has been tested, the acute effects of both techniques in dynamometry‐ (CR_dyna and SRC_dyna) and field‐based (CR_field and SRC_field) environments were compared with the hamstring muscle group.

Methods

Seventeen participants performed each of the four stretching conditions on separate days in a randomized order. Before and after the stretches, knee extension ROM and passive knee flexor moment were recorded on an isokinetic dynamometer.

Results

Significant (P < .01) increases in knee extension ROM (4.6‐5.2°) and elastic potential energy storage (12.0%‐23.6%) and decreases in the slope of the passive moment‐angle relation (8.9%‐12.2%) occurred in all conditions. Significant increases in peak passive joint moment were observed after field‐ (14.3%‐14.8%) but not dynamometry‐based (4.6%‐6.6%) stretches. No difference (P > .05) in any measure was found between conditions.

Conclusions

These data confirm the acute efficacy of the SRC technique in the hamstring muscle group and demonstrate its ecological validity in an applied environment in healthy participants. As the field‐based SRC technique was performed without partner assistance, when compared with classical PNF it represents an equally effective and practical stretching paradigm to support athletic and clinical exercise prescription.

Glycemic Control Maintained over Time and Joint Stiffness in Young Type 1 Patients: What Is the Mathematical Relationship?

BACKGROUND

It is widely known that diabetes can induce stiffness and adversely affect joint mobility even in young patients with type 1 diabetes mellitus (T1D). The aim of this study was to identify a mathematical model of diabetes mellitus long-term effects on young T1D patients.

METHODS

Ankle joint mobility (AJM) was evaluated using an inclinometer in 48 patients and 146 healthy, sex- BMI-, and age-matched controls. Assuming time invariance and linear superposition of the effects of hyperglycemia, the influence of T1D on AJM was formalized as an impulse response putting into relationship past supernormal HbA1c concentrations with the ankle total range of motion. The proposed model was identified by means of a nonlinear evolutionary optimization algorithm.

RESULTS

AJM was significantly reduced in young T1D patients (P < .001). AJM in both plantar and dorsiflexion was significantly lower in subjects with diabetes than in controls (P < .001). The identified impulse response indicates that impaired metabolic control requires 3 months to bring out its maximum effect on the reduction of AJM, while the following long-lasting decay phase with the expected AJM recovery times, normally depends on the slow turnover of collagen. HbA1c concentration levels above 7.2% are sufficient to produce a reduction of ankle ROM.

CONCLUSIONS

In young patients with T1D the lack of glycemic control over time affects AJM. HbA1c levels can serve as a relevant prognostic factor for assessing the progression of LJM in subjects with diabetes.

Hamstring Stiffness Returns More Rapidly After Static Stretching Than Range of Motion, Stretch Tolerance, and Isometric Peak Torque

Context: Hamstring injuries are common, and lack of hamstring flexibility may predispose to injury. Static stretching not only increases range of motion (ROM) but also results in reduced muscle strength after stretching. The effects of stretching on the hamstring muscles and the duration of these effects remain unclear. Objective: To determine the effects of static stretching on the hamstrings and the duration of these effects. Design: Randomized crossover study. Setting: University laboratory. Participants: A total of 24 healthy volunteers. Interventions: The torque-angle relationship (ROM, passive torque [PT] at the onset of pain, and passive stiffness) and isometric muscle force using an isokinetic dynamometer were measured. After a 60-minute rest, the ROM of the dynamometer was set at the maximum tolerable intensity; this position was maintained for 300 seconds, while static PT was measured continuously. The torque-angle relationship and isometric muscle force after rest periods of 10, 20, and 30 minutes were remeasured. Main Outcome Measures: Change in static PT during stretching and changes in ROM, PT at the onset of pain, passive stiffness, and isometric muscle force before stretching were compared with 10, 20, and 30 minutes after stretching. Results: Static PT decreased significantly during stretching. Passive stiffness decreased significantly 10 and 20 minutes after stretching, but there was no significant prestretching versus poststretching difference after 30 minutes. PT at the onset of pain and ROM increased significantly after stretching at all rest intervals, while isometric muscle force decreased significantly after all rest intervals. Conclusions: The effect of static stretching on passive stiffness of the hamstrings was not maintained as long as the changes in ROM, stretch tolerance, and isometric muscle force. Therefore, frequent stretching is necessary to improve the viscoelasticity of the muscle-tendon unit. Muscle force decreased for 30 minutes after stretching; this should be considered prior to activities requiring maximal muscle strength.

Type 1 diabetes, sport practiced, and ankle joint mobility in young patients: What is the relationship?

BACKGROUND/OBJECTIVE

It is known that patients with diabetes can develop limited joint mobility (LJM) and that this can depend on the metabolic control maintained and the duration of the disease. The aims of this study were to verify the presence of ankle joint mobility (AJM) deficits in both plantar and dorsiflexion in young type 1 diabetic patients (T1D) considering also the possible role of sport practiced as a further factor, able to modify AJM.

METHODS

AJM was evaluated by an inclinometer in 82 T1D patients (M/F: 48/34), mean age 12.9 ± 2.6 years, body mass index (BMI) 19.7 ± 3.6 kg/m² , duration of diabetes 5.6 ± 3.3 years, mean HbA1c 7.5 ± 1.0% and in 226 healthy controls (M/F: 146/80), age-, gender-, and BMI-matched practicing different sports (soccer, volleyball, basketball, and dance).

RESULTS

The patients' ankle range of motion was significantly lower than that in controls (132.7 ± 22.3° vs 126.1 ± 17.9°; P < .017). In particular, ankle plantar flexion was significantly lower in the patients group (31.6° ± 7.9° vs 28.5° ± 6.6°; P < .002). Soccer players showed lower AJM in both groups: patients (120.1 ± 15.9° vs 127.3 ± 18.1) and controls (119.4 ± 21.1° vs 142.0 ± 18.1; P < .0001) than subjects practicing other sports or who were sedentary. In both groups, patients and controls, age, sex, duration of disease, hemoglobin 1Ac, and BMI have not been shown to be correlated to the mobility assessed.

CONCLUSIONS

The results of this study, in addition to confirming the negative effect of diabetes on AJM of young T1D patients, suggest that during these evaluations the sport-related effect should be considered because it can induce significant changes of AJM.

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.

Limited Joint Mobility Progression in Type 1 Diabetes: A 15-Year Follow-Up Study

OBJECTIVE

To assess the evolution of joint mobility over a period of 15 years in type 1 diabetic patients and healthy controls and to determine whether microalbuminuria is associated with a different evolution of joint mobility.

METHODS

Joint mobility of hand and wrist was determined in 63 patients with type 1 diabetes and 63 healthy subjects. Fifteen years later, 37 (58.7%) diabetic patients and 16 (25.4%) healthy subjects were studied again. Joint mobility was assessed with the Prayer sign and by measuring the angle of maximal flexion of the fifth and third metacarpophalangeal (MCP) joints and wrist. Patients with diabetes were visited 2-4 times every year with regular assessment of glycated hemoglobin (HbA1_c), urinary albumin excretion (UAE), and ophthalmoscopy.

RESULTS

Fifteen years after the initial exam, diabetic patients showed reduced flexion of the fifth MCP joint (82.6 ± 5.8 versus 76.0 ± 6.4 degrees, p < 0.001) and wrist (75.9 ± 8.1 versus 73.2 ± 7.4 degrees, p = 0.015) compared to baseline examination. Joint mobility did not change significantly in healthy subjects. Patients with microalbuminuria showed greater reduction in hand joint mobility than diabetic patients with normal UAE or than healthy subjects (p < 0.001).

CONCLUSIONS

In type 1 diabetic patients, the severity of LJM progresses with time, and the progression is enhanced in patients with microalbuminuria.

Acute effects of contract-relax (CR) stretch versus a modified CR technique

PURPOSE

Contract-relax (CR) stretching increases range of motion (ROM) substantively, however its use in athletic environments is limited as the contractions performed in a highly stretched position require partner assistance, are often painful, and may induce muscle damage. Therefore, the acute effects of performing the contractions 'off stretch' in the anatomical position [stretch-return-contract (SRC)] were compared with traditional CR stretching in 14 healthy human volunteers.

METHODS

Passive ankle joint moment and dorsiflexion ROM were recorded on an isokinetic dynamometer with electromyographic monitoring of the triceps surae, whilst simultaneous real-time motion analysis and ultrasound imaging recorded gastrocnemius medialis muscle and Achilles tendon elongation. The subjects then performed CR or SRC stretches (4 × 10-s stretches and 5-s contractions) randomly on separate days before reassessment.

RESULTS

Significant increases in dorsiflexion ROM (4.1°-4.0°; P < 0.01) and peak passive moment (10.9-15.1%; P < 0.05) and decreases in the slope of the passive moment curve (19.1-13.3%; P < 0.05), muscle stiffness (21.7-21.3%; P < 0.01) and tendon stiffness (20.4-15.7%; P < 0.01) were observed in CR and SRC, respectively. No between-condition differences were found in any measure (P > 0.05).

CONCLUSIONS

Similar mechanical and neurological changes were observed between conditions, indicating that identical mechanisms underpin the ROM improvements. These data have important practical implications for the use of this stretching mode in athletic environments as performing the contractions 'off stretch' eliminates the pain response, reduces the risk of inducing muscle damage, and removes the need for partner assistance. Thus, it represents an equally effective, simpler, and yet potentially safer, stretching paradigm.

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.

Spectrum of cutaneous manifestations of type 1 diabetes mellitus in 500 South Asian patients

BACKGROUND

Data on cutaneous manifestations of type 1 diabetes mellitus (DM) is scarce.

OBJECTIVES

To study the spectrum of dermatoses in patients with type 1 DM and the effects of disease duration and long-term glucose control on these cutaneous manifestations.

SUBJECTS AND METHODS

After prior consent, clinical examination and relevant investigations were done in 500 subjects with type 1 DM enrolled between July 2011 and June 2012. Statistical tests were performed using SPSS 16. The presence of various dermatoses was correlated with the duration of diabetes.

RESULTS

Of five hundred subjects, 339 (67·8%) had one or more dermatoses. The mean age of the patients was 16·9 ± 6·9 years (range 1-25 years) and mean total duration of diabetes was 4·43 ± 4·4 years. Cutaneous adverse effects related to insulin injections (CAII), comprising lipohypertrophy (41%), post-inflammatory hyperpigmentation (3%), lipoatrophy (0·6%) and acanthosis nigricans (0·4%), were the most common findings, followed by limited joint mobility (LJM) (16·8%), xerosis (15·8%) and scleroderma-like skin changes (10%). Patients having long-duration DM (> 4·4 years) were significantly more likely to have lipohypertrophy (P = 0·000), LJM (P = 0·000), scleroderma-like skin changes (P = 0·000), diabetic dermopathy (P = 0·000), acanthosis nigricans (P = 0·005) and skin tags (P = 0·002). Lipohypertrophy, LJM and scleroderma-like skin changes also showed significant correlation with blood glucose level.

CONCLUSIONS

Our study suggests that cutaneous changes are common in young Asian patients with type 1 DM. Information, education and counselling of patients and care givers, and awareness among physicians is essential for the prevention and early management of these dermatoses.

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

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

Neuromuscular factors influencing the maximum stretch limit of the human plantar flexors

Maximum joint range of motion is an important parameter influencing functional performance and musculoskeletal injury risk. Nonetheless, a complete description of the muscle architectural and tendon changes that occur during stretch and the factors influencing maximum range of motion is lacking. We measured muscle-tendon elongation and fascicle lengthening and rotation sonographically during maximal plantar flexor stretches in 21 healthy men. Electromyogram (EMG) recordings were obtained synchronously with ultrasound and joint moment data, and H-reflex measurements were made with the ankle at neutral (0°) and dorsiflexed (50% maximal passive joint moment) positions; the maximum H amplitude (normalized to maximum M-wave amplitude; M(max)) and H-amplitude elicited at a stimulation intensity that evoked 10% M(max) were obtained. Maximal stretch was accomplished through significant muscle (14.9%; 30 mm) and tendon lengthening (8.4%; 22 mm). There were similar relative changes in fascicle length and angle, but planimetric modeling indicated that the contribution of fascicle rotation to muscle lengthening was small (<4 mm). Subjects with a greater range of motion showed less resistance to stretch and a greater passive joint moment at stretch termination than less flexible subjects (i.e., greater stretch tolerance). Also, greater fascicle rotation accompanied muscle elongation (9.7 vs. 5.9%) and there was a greater tendon length at stretch termination in more flexible subjects. Finally, a moderate correlation between the angle of EMG onset and maximum range of motion was obtained (r = 0.60, P < 0.05), despite there being no difference in H-reflex magnitudes between the groups. Thus clear differences in the neuromuscular responses to stretch were observed between "flexible" and "inflexible" subjects.

Fatores preditivos da marcha em pacientes diabéticos neuropático e não neuropáticos

OBJETIVO: Analisar a amplitude de movimento do tornozelo e as forças de reação vertical do solo envolvidas na marcha de pacientes portadores de diabetes com e sem neuropatia periférica. CASUÍSTICA E MÉTODO: 36 indivíduos divididos em três grupos: Controle - GC: 10 indivíduos sem diabetes, Diabetes - GD: 10 indivíduos portadores de diabetes sem neuropatia periférica e Neuropatia - GDN: 16 indivíduos portadores de diabetes e neuropatia diabética periférica. Foi realizada análise da marcha - AMTI® OR6/6, e da amplitude de movimento articular tíbio-társica - Sistema Vicom 640® - de todos os participantes. RESULTADOS: O primeiro e segundo pico de força vertical de reação do solo são maiores no grupo Neuropatia e a amplitude de movimento articular do tornozelo é menor nos grupos Diabetes e Neuropatia. CONCLUSÃO: A amplitude de movimento da articulação tíbio-társica está diminuida nos diabetéticos, independente da presença ou ausência de neuropatia periférica, e os diabéticos com neuropatia periférica, apresentaram aumento no primeiro e no segundo pico da força de reação vertical do solo durante a marcha.

Foot problems and effectiveness of foot care education in children and adolescents with diabetes mellitus

OBJECTIVES

To assess foot care in paediatric and adolescent patients with diabetes mellitus and to evaluate the effectiveness of foot care education given to participants.

RESEARCH DESIGN AND METHODS

An 8-month prospective study of foot care in children and adolescents with type 1 and type 2 diabetes mellitus who attended diabetes clinics at the Royal Children's Hospital, Melbourne, where foot examination was performed at baseline and at follow-up. Patients and parents were given oral and written advice regarding foot care.

RESULTS

Five hundred and fifty-seven patients were examined at baseline, and 312 patients were reviewed at follow-up 3-6 months later. The majority of foot problems found at first assessment were potentially modifiable disorders of skin and nails (68.8%). The remainder (31.2%) were structural musculoskeletal disorders requiring referral to a podiatrist/orthotist. A total of 532 foot problems were recorded at baseline in a cohort of 557 patients and 161 foot problems at follow-up of 312 patients. Significant reduction of modifiable foot problems was seen at follow-up, particularly in those with longer duration of diabetes and in those whose body mass index was higher.

CONCLUSIONS

This study highlights the importance of foot examination and foot care advice for children and adolescents with diabetes. Larger prospective studies are required to establish prevalence and to optimize preventive interventions.

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

OBJECTIVE

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

RESEARCH DESIGN AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

Direct measurement of collagen glycation requires skin biopsy, which is invasive. We hypothesized that measurement of plantar fascia thickness (PFT) by ultrasound is an alternative index of tissue glycation and a marker of microvascular disease.

RESEARCH DESIGN AND METHODS

This was a prospective longitudinal study of microvascular complications in 344 adolescents with type 1 diabetes, whose PFT was assessed by ultrasound at baseline. Retinopathy was assessed by seven-field fundal photography, albumin excretion rate (AER) measured from three consecutive timed overnight urine specimens, autonomic neuropathy by pupillometry and cardiovascular tests, and peripheral neuropathy by vibration and thermal thresholds. Longitudinal analysis was performed using generalized estimating equations with baseline PFT, duration, and A1C as explanatory variables.

RESULTS

At first assessment, median (interquartile range) age was 15.1 (13.5-17.2) years and diabetes duration was 8.5 (6.0-11.5) years. Median follow up was 3.2 (2.1-4.5) years with a median of 4 (2-13) complications assessments per patient. In multivariate analysis, baseline PFT (abnormal in 132 subjects, 38%) predicted subsequent development of retinopathy (odds ratio 2.4 [95% CI 1.1-5.0]), elevated AER (2.24 [1.05-5.11]), peripheral neuropathy (2.3 [1.2-4.41]), and autonomic neuropathy (4.94 [2.46-9.91]). Limited joint mobility was present in only 4%.

CONCLUSIONS

PFT is a significant predictor of the subsequent development of complications in type 1 diabetes, suggesting that glycation and oxidation of collagen in soft tissues may be independent risk factors for microvascular complications.

Foot abnormalities in Canadian Aboriginal adolescents with Type 2 diabetes

AIMS

To determine the profile of foot abnormalities in Canadian Aboriginal adolescents with Type 2 diabetes and the risk factors associated with these abnormalities.

METHODS

Aboriginal adolescents with Type 2 diabetes underwent an interview, medical record review and foot examination in a tertiary care, paediatric hospital diabetes clinic and two geographically remote outreach clinics. The notes of 110 subjects were reviewed [mean age 15 +/- 3 years; mean duration of diabetes, 30 +/- 20 months; 71 (66%) female and 39 (34%) male] and 77 (70%) of the subjects were examined.

RESULTS

Foot abnormalities were identified by either interview or notes review, and included poor toenail condition in 85 (77%), paronychia in 29 (26%), ingrowing toenails in 16 (15%) and neuropathic symptoms in 13 (12%) subjects. Foot abnormalities were identified by examination in many subjects, including poor toenail condition in 38 (49%), calluses in 34 (44%) and paronychia in 13 (17%) subjects. Eighteen (24%) of 75 subjects did not have running water in the home. Factors that significantly increased the presence of foot abnormalities included: foot care provided by a person other than self; absence of running water in the home; decreased frequency of bathing; and decreased frequency of nail clipping. A greater percentage of subjects living on a reservation or rural community had specialized consultations for retinal examination, footwear, or both than of those living in an urban or unknown residence.

CONCLUSIONS

A high prevalence of foot abnormalities was noted in Aboriginal adolescents with Type 2 diabetes. These findings highlight the associated comorbidities in this population, emphasizing the need for early detection and intervention.

Segmental foot mobility in individuals with and without diabetes and neuropathy

BACKGROUND

Impairment in intrinsic foot mobility has been identified as an important potential contributor to altered foot function in individuals with diabetes mellitus and neuropathy, however the role of limited foot mobility in gait remains poorly understood. The purpose of our study was to examine segmental foot mobility during gait in subjects with and without diabetes and neuropathy.

METHODS

Segmental foot mobility during gait was examined using a multi-segment kinematic foot model in subjects with diabetes (n=15) and non-diabetic control subjects (n=15).

FINDINGS

Subjects with diabetes showed reduced frontal as well as sagittal plane excursion of the calcaneus relative to the tibia. Decreased excursion of the first metatarsal relative to the calcaneus in the frontal as well as transverse plane was noted in subjects with diabetes.

INTERPRETATION

Our findings agree with traditional understanding of foot mechanics and shed new light on patterns and magnitude of motion during gait. Calcaneal pronation, noted in early stance in both groups, was reduced in subjects with diabetes and may have important consequences on joints proximal as well as distal to it. Subjects with diabetes showed reduced foot 'splay' in early stance, indicated by first metatarsal and forefoot eversion. At terminal stance, decreases in calcaneal plantarflexion, first metatarsal and forefoot supination were noted in subjects with diabetes, suggesting that less supination is required in subjects with diabetes to create a rigid lever. In subjects with diabetes, a greater proportion of midfoot stability may be derived from modified/stiffer soft tissue such as the plantar fascia.

Diabetes mellitus en niños y adolescentes: complicaciones crónicas y enfermedades asociadas

Diabetes is one of the most common chronic diseases. Type 1, or autoimmune, diabetes accounts for more than 95 % of cases in children and adolescents. Chronic hyperglycemia per se is responsible for the development of several microvascular (retinopathy, nephropathy, neuropathy) and macrovascular complications (ischemic heart disease, cerebrovascular disease, and peripheral vascular disease). Other autoimmune diseases are also more frequent in type 1 diabetic patients. The present review aims to provide an update on some recent advances in this field to aid early detection of these complications and prevent or delay their progression through improved metabolic control.

Contemporary Australian outcomes in childhood and adolescent type 1 diabetes: 10 years post the Diabetes Control and Complications Trial

The reporting of the results of the Diabetes Control and Complications Trial in 1993 has led to a major reappraisal of management practices and outcomes in type 1 diabetes in children and adolescents. A considerable body of outcome data has been generated from Australia in this post-Diabetes Control and Complications Trial era relating to incidence, metabolic control, growth, hypoglycaemia, microvascular and macrovascular complications, cognition, behaviour and quality of life. These data are important in planning future management strategies and resource allocation and as a basis for future research.

Complications of diabetes mellitus in childhood

Complications of diabetes include retinopathy, nephropathy, neuropathy, macrovascular disease, and associated autoimmune diseases. Clinical manifestations of complications uncommonly present in childhood and adolescence. Screening during the early years can identify subclinical disease and it offers an opportunity for early intervention. The Diabetes and Complications Control Trial has provided evidence for the long-term benefits of good glycemic control in preventing and delaying the onset of microvascular complications. Complications begin to manifest during adolescence, during which time all efforts should be made to educate and support young persons in achieving optimal diabetes control.

Early subclinical limited axial and large joint flexibility in type 1 diabetes mellitus adolescents

OBJECTIVE

The objective of this study was to compare the axial and large joint mobility in adolescents with and without type 1 diabetes mellitus (DM1).

PATIENT AND METHODS

To check this relationship, 72 DM1 adolescents aged 9-20 years were admitted into the trial and compared with 46 healthy control subjects aged 10-18 years. The youths were compared with regard to anthropometrics (age, proportion female/male, weight, height, and BMI) data. The years from DM1 diagnosis and HbA(1c) (index) were 4.9 +/- 3.6 years and 1.40 +/- 0.39%, respectively. The values of the tests of flexibility of the movements of cervical joint, the abduction of scapular, wrist and back-lumbar joints and abduction of lame-femoral were obtained through the Fleximeter.

RESULTS

The DM1 patients and controls did not differ regarding age (DM1 median 16, range 9-20 years vs. controls 16, range 10-18 years) and BMI (DM1 mean+/-S.D. 21.49 +/- 3.69 kg/m(2) vs. controls 20.76 +/- 2.81 kg/m(2)). The scapular, back-lumbar, and lame-femoral flexibility were, respectively, significantly lower (P < .001) in DM1 adolescents (175 +/- 8 degrees , 107 +/- 4 degrees , 66 +/- 10 degrees) compared with controls (189 +/- 13, 116 +/- 14, 76 +/- 12), but the cervical joint mobility was the same in both groups (DM1: 98 +/- l2 degrees vs. control: 101 +/- 13 degrees).

CONCLUSION

Thus, the results of our study show a subclinical limited axial and large joint mobility in DM1 adolescents. Future prospective studies are needed to ascertain whether the joint limitations found in these DM1 adolescents will persist into adulthood and play a role in the development of other diabetic complications.

Dorsal mobility and first ray stiffness in patients with diabetes mellitus

BACKGROUND

Limited joint mobility in diabetic patients has been identified as a risk factor in the development of plantar ulcers. We examined dorsal mobility and passive first ray stiffness in patients with diabetes and investigated the relationship between first ray mobility and ankle joint dorsiflexion.

METHODS

Forty individuals were studied: 20 with diabetes (mean estimated duration of 16 +/- 10 years) and 20 matched controls. Dorsal first ray mobility was measured using a mechanical device. Force-vs-dorsal mobility displacement values were collected at 10 N increments to a load limit of 55 N. Ankle joint dorsiflexion motion was measured with a goniometer. The "prayer sign," a clinical indicator of limited joint mobility, was evaluated in each patient. Subjects were separated into the two groups for data analysis.

RESULTS

Patients in the diabetic group had more stiffness and less dorsal first ray mobility than the control group (p <.05). In particular, patients with a positive prayer sign had significant first ray stiffness (p <.05). Patients with diabetes also had less ankle dorsiflexion (p <.05).

CONCLUSION

Patients with diabetes have more stiffness and less first ray mobility and less ankle dorsiflexion than those without diabetes. The presence of a positive prayer sign correlates with stiffness and loss of first ray mobility. Soft-tissue stiffness may contribute to the development of foot ulcers in diabetic patients with neuropathy.

Mechanical Loading and Off-Loading of the Plantar Surface of the Diabetic Foot

During weight-bearing activities, the feet are exposed to large forces, particularly when the activity is dynamic, such as walking. The pressure under the plantar surface during walking varies per foot area because of a number of factors related to the normal rollover during the stance phase of gait. Diabetes mellitus often results in loss of protective sensation and in structural changes that make the feet more susceptible to injury. Increased plantar pressure is an important factor in the development and maintenance of diabetic foot ulceration. Increased plantar pressures and associated ulcers need to be treated by off-loading of the plantar surface. Useful off-loading mechanisms include reduction of walking speed, alteration of foot rollover during gait, and transfer of load from affected areas to other areas of the foot or the lower leg. These plantar off-loading mechanisms could result in an optimization of treatment, but clinical effectiveness must be demonstrated.

Ultrasonography of plantar soft tissues thickness in young people with diabetes

AIMS

The aims of this study were to examine soft tissue changes in the skin and plantar aponeurosis of young people with Type 1 diabetes mellitus (T1DM) and to evaluate any relationship between any soft tissue changes, arch length, limited joint mobility (LJM) and plantar pressure.

METHODS

The thickness of the skin on the plantar surface of the foot and plantar aponeurosis were examined using ultrasound in 216 young people with diabetes and 57 controls. Foot length, arch length, joint mobility, peak pressure and pressure time integrals were evaluated.

RESULTS

Skin was not significantly thicker in the diabetic subjects. The plantar aponeurosis was significantly thicker in the diabetic subjects and was associated with foot size, male gender and subtalar joint (ST) LJM (P < 0.01). Males were nearly three times more likely to have thickened plantar aponeurosis.

CONCLUSION

Soft tissue thickening in young people with T1DM affects the deeper structures on the plantar surface of the foot rather than the skin. Thickening of the plantar aponeurosis was associated with LJM at the ST joint and male gender, but was not associated with plantar pressure or arch height changes. Plantar aponeurosis thickening does not appear to alter foot mechanics in young people with T1DM.

The effect of ankle equinus upon the diabetic foot

The association between ankle equinus and common foot pathologies such as Achilles tendinitis, metatarsalgia, Morton's neuroma, hallux abductovalgus, and plantar fasciitis has been described. However, the association between ankle equinus and diabetic foot pathology has only been recognized recently. Over half of the non-traumatic amputations occurring in the United States are related to complications of diabetes. It is imperative that risk factors for lower extremity ulceration and amputation are identified and addressed. This article reviews the effect of ankle equinus deformity on the diabetic foot and the available treatment options. New data on the prevalence of equinus in a population of patients with diabetes are also presented.

Limited joint mobility in type 1 diabetic patients: associations with microangiopathy and subclinical macroangiopathy are different in men and women

OBJECTIVE

To study the relationship of limited joint mobility (LJM) in type 1 diabetic patients with microvascular complications, hypertension, and early atherosclerosis and to determine whether sex has an influence on possible associations.

RESEARCH DESIGN AND METHODS

A total of 335 consecutive unselected patients (191 women and 144 men), aged 14-40 years, were studied for LJM, retinopathy, nephropathy (stages III and IV), and hypertension. Standard laboratory tests were performed; the intima-media thickness (IMT) of the carotid arteries, which reflects the extent of early atherosclerosis, was measured by high-resolution ultrasound, and plaques were identified.

RESULTS

The frequency of LJM was 33.7% (29.8% in women and 38.9% in men). Subjects with LJM had a longer diabetes duration (P < 0.001) than those without (women 16.7 +/- 9.1 vs. 10.3 +/- 6.0 years; men 15.0 +/- 9.0 vs. 9.4 +/- 6.3 years). Age, HbA1c, lipids, and systolic/diastolic blood pressure were not different between men and women with or without LJM. Men with LJM had a higher albumin excretion rate (37.1 vs. 13.1 microg/min, P < 0.05) than those without LJM and showed a higher risk of proteinuria (odds ratio 1.8, 95% CI 1.2-2.7; P < 0.05), retinopathy (2.4, 1.7-3.5; P < 0.001), and hypertension (1.7, 1.2-2.6; P < 0.05). The occurrence of these complications was not different between women with and without LJM, but only women with LJM had a greater IMT (0.59 +/- 0.13 vs. 0.55 +/- 0.10 mm, P < 0.05) and a higher risk of plaques (odds ratio 2.1, 95% CI 1.3-3.4; P < 0.05) than women without LJM. In a multiple logistic regression analysis, adjusted for age and diabetes duration, male sex independently predicted the presence of LJM. Moreover, LJM proved to be an independent predictor of retinopathy in men only.

CONCLUSIONS

LJM is an indicator of microvascular disease in men, and LJM is associated with early macrovascular disease in women.