Tissue adaptation to physical stress: a proposed "Physical Stress Theory" to guide physical therapist practice, education, and research

Incidence and Risk Factors of Diabetic Foot Syndrome in Patients Early After Pancreas or Kidney/Pancreas Transplantation and its Association with Preventive Measures

Diabetic foot (DF) can develop in diabetic patients after organ transplantation (Tx) due to several factors including peripheral arterial disease (PAD), diabetic neuropathy and inappropriate DF prevention. Aim: To assess the occurrence of DF and associated risk factors in transplant patients. Methods: Fifty-seven diabetic patients were enrolled as part of this prospective study. All patients underwent organ Tx (01/2013-12/2015) and were followed up for minimum of 12 months up to a maximum of 50 months. Over the study period we evaluated DF incidence and identified a number of factors likely to influence DF development, including organ function, presence of late complications, PAD, history of DF, levels of physical activity before and after Tx, patient education and standards of DF prevention. Results: Active DF developed in 31.6% (18/57) of patients after organ Tx within 11 months on average (10.7 ± 8 months). The following factors significantly correlated with DF development: diabetes control (p = .0065), PAD (p<0.0001), transcutaneous oxygen pressure (TcPO2;p = .01), history of DF (p = .0031), deformities (p = .0021) and increased leisure-time physical activity (LTPA) before Tx (p = .037). However, based on logistic stepwise regression analysis, the only factors significantly associated with DF during the post-transplant period were: PAD, deformities and increased LTPA. Education was provided to patients periodically (2.6 ± 2.5 times) during the observation period. Although 94.7% of patients regularly inspected their feet (4.5 ± 2.9 times/week), only 26.3% of transplant patients used appropriate footwear. Conclusions: Incidence of DF was relatively high, affecting almost 1/3 of pancreas and kidney/pancreas recipients. The predominant risk factors were: presence of PAD, foot deformities and higher LTPA before Tx. Therefore, we recommend a programme involving more detailed vascular and physical examinations and more intensive education focusing on physical activity and DF prevention in at-risk patients before transplantation.

Application of the Staged Approach for Rehabilitation Classification System and Associated Improvements in Patient-Reported Outcomes Following Rehabilitation for Shoulder Pain

OBJECTIVE

The Staged Approach for Rehabilitation Classification for the Shoulder (STAR-Shoulder) has been proposed as a model to guide management and improve outcomes for patients with shoulder pain; however, the effect of its utilization on patient outcomes has not been established. Therefore, the primary purpose of this study was to determine whether patient outcomes were improved if care was matched to the STAR-Shoulder system compared with unmatched care.

METHODS

Collected and reviewed demographic, examination, and intervention data for all patients receiving physical therapist treatment for shoulder pain during a 1-year period within a single health care system. Outcome variables included the numeric pain rating scale, the Quick Disabilities of the Arm, Shoulder and Hand Questionnaire (QuickDASH), and the number of visits. Clinical records from patients receiving care at the discretion of the therapist were systematically audited to determine whether care provided was considered matched or unmatched.

RESULTS

A total of 692 patient records were examined. The interrater reliability of classifying care as matched or unmatched was substantial (κ = 0.6; 95% CI = 0.4 to 0.9), with 82% agreement. Changes in patient outcome scores were significantly better for those patients whose care matched the STAR-Shoulder system for pain changes (mean difference = -1.2; 95% CI = 0.8 to 1.6; effect size [d] = 0.5) and QuickDASH score (mean difference = 12.7; 95% CI = 9.9 to 15.5; d = 0.7). No difference was noted for number of visits.

CONCLUSION

The STAR-Shoulder system appears to be a meaningful way to classify patients and guide intervention to improve patient outcomes.

IMPACT

Application of the STAR-Shoulder system to help align physical therapist interventions more closely with tissue irritability and physical impairments appears to improve patient outcomes. These findings support this model as a promising approach to advance evidence-based practice for shoulder pain.

Barefoot walking is beneficial for individuals with persistent plantar heel pain: A single-blind randomized controlled trial

BACKGROUND

A lack of data exist about the effectiveness of active treatments for persistent plantar heel pain (PPHP).

OBJECTIVES

To compare short-term functional and clinical effects of a 4-week barefoot or shod treadmill walking program for people with PPHP.

METHODS

A single-blinded clinical trial randomized 52 participants with PPHP into either a barefoot walking group (BWG), or a shod walking group (SWG). All participants received therapeutic ultrasound. Outcomes were measured at baseline (t0), following 4 weeks of treatment (t1), and at 1-month follow-up (t2). The SF-36 functional questionnaire score was the main outcome. Secondary outcomes were self-reported and clinically-assessed pain provocation levels, pressure pain thresholds and pain tolerance. Treadmill walking time and speed were measured at t0 and t1; people also recorded the time spent walking each day in a diary.

RESULTS

The BWG exhibited significant improvements in all SF-36 items (except "emotional well-being") (P < 0.05), whereas the SWG exhibited improvements only in "pain" and "health change" items (P = 0.0001; effect size 0.13-0.94). Greater improvements were observed in the BWG than the SWG for "physical function" (P = 0.019) and "role limitations due to physical health" items (P = 0.035). Both groups demonstrated significant improvements in pain, with greater improvements in the BWG (P = 0.0001; effect size 0.89). Only the BWG showed significant improvements in pain pressure thresholds (P < 0.05; effect size 0.70) and pain tolerance (P < 0.001; effect size 0.67). Both groups significantly increased their speed and time spent walking on the treadmill (BWG Δ=19.7 min and Δ=1.7 km/h; SWG Δ=16.7 min and Δ=1.1 km/h) and time outdoors (SWG ∆=38.2 min/week; BWG mean ∆=48.5 min/week) (P < 0.001). All clinical tests of pain were significantly less positive in the BWG at all time points (P < 0.05).

CONCLUSIONS

Both walking programs benefited people with PPHP by alleviating pain and improving function and quality of life. Greater improvements were observed in the BWG than the SWG overall.

Diabetes foot complications and standardized mortality rate in type 2 diabetes

AIM

To quantify the impact of foot complications on mortality outcomes in people with type 2 diabetes (T2D), and how routinely measured factors might modulate that risk.

MATERIALS AND METHODS

Data for individuals with T2D for 2010-2020, from the Salford Integrated Care Record (Salford, UK), were extracted for laboratory and clinical data, and deaths. Annual expected deaths were taken from Office of National Statistics mortality data. An index of multiple deprivation (IMD) adjusted the standardized mortality ratio (SMR_IMD). Life years lost per death (LYLD) was estimated from the difference between expected and actual deaths.

RESULTS

A total of 11 806 T2D patients were included, with 5583 new diagnoses and 3921 deaths during 2010-2020. The number of expected deaths was 2135; after IMD adjustment, there were 2595 expected deaths. Therefore, excess deaths numbered 1326 (SMR_IMD 1.51). No foot complications were evident in n = 9857. This group had an SMR_IMD of 1.13 and 2.74 LYLD. In total, 2979 patients had any foot complication recorded. In this group, the SMD_IMR was 2.29; of these, 2555 (75%) had only one foot complication. Patients with a foot complication showed little difference in percentage HbA1c more than 58 mmol/mol. In multivariate analysis, for those with a foot complication and an albumin-to-creatinine ratio of more than 3 mg/mmol, the odds ratio (OR) for death was 1.93, and for an estimated glomerular filtration rate of less than 60 mL/min/1.73m2 , the OR for death was 1.92.

CONCLUSIONS

Patients with T2D but without a foot complication have an SMR_IMD that is only slightly higher than that of the general population. Those diagnosed with a foot complication have a mortality risk that is double that of those without T2D.

Comparison of Joint Mobilization and Movement Pattern Training for Patients With Hip-Related Groin Pain: A Pilot Randomized Clinical Trial

OBJECTIVE

The objective of this study was to assess the feasibility of completing a randomized clinical trial (RCT) and examine the preliminary effects of 2 interventions for hip-related groin pain (HRGP).

METHODS

In this pilot RCT, patients with HRGP, who were 18 to 40 years old, were randomized (1:1 ratio) to a joint mobilization (JtMob) group or a movement pattern training (MoveTrain) group. Both treatments included 10 supervised sessions and a home exercise program. The goal of JtMob was to reduce pain and improve mobility through peripherally and centrally mediated pain mechanisms. The key element was physical therapist-provided JtMob. The goal of MoveTrain was to reduce hip joint stresses by optimizing the biomechanics of patient-specific tasks. The key element was task-specific instruction to correct abnormal movement patterns displayed during tasks. Primary outcomes were related to future trial feasibility. The primary effectiveness outcome was the Hip Disability and Osteoarthritis Outcome Score. Examiners were blinded to group; patients and treatment providers were not. Data collected at baseline and immediately after treatment were analyzed with analysis of covariance using a generalized linear model in which change was the dependent variable and baseline was the covariate. The study was modified due to the coronavirus disease 2019 (COVID-19) pandemic.

RESULTS

The COVID-19 pandemic affected participation; 127 patients were screened, 33 were randomized (18 to the JtMob group and 15 to the MoveTrain group), and 29 (88%) provided posttreatment data. Treatment session adherence was 85%, and home exercise program component adherence ranged from 71 to 86%. Both groups demonstrated significant mean within-group improvements of ≥5 points on Hip Disability and Osteoarthritis Outcome Score scales. There were no between-group differences in effectiveness outcomes.

CONCLUSIONS

A large RCT to assess the effects of JtMob and MoveTrain for patients with HRGP may be feasible. Preliminary findings suggested that JtMob or MoveTrain may result in improvements in patient-reported pain and activity limitations.

IMPACT

The COVID-19 pandemic interfered with participation, but a randomized controlled trial may be feasible. Modification may be needed if the trial is completed during future pandemics.

Physical therapy in diabetic foot ulcer: Research progress and clinical application

Diabetes foot ulcer (DFU) is one of the most intractable complications of diabetes and is related to a number of risk factors. DFU therapy is difficult and involves long-term interdisciplinary collaboration, causing patients physical and emotional pain and increasing medical costs. With a rising number of diabetes patients, it is vital to figure out the causes and treatment techniques of DFU in a precise and complete manner, which will assist alleviate patients' suffering and decrease excessive medical expenditure. Here, we summarised the characteristics and progress of the physical therapy methods for the DFU, emphasised the important role of appropriate exercise and nutritional supplementation in the treatment of DFU, and discussed the application prospects of non-traditional physical therapy such as electrical stimulation (ES), and photobiomodulation therapy (PBMT) in the treatment of DFU based on clinical experimental records in ClinicalTrials.gov.

Ultrasonographic Evaluation of Thickness and Stiffness of Achilles Tendon and Plantar Fascia in Type 2 Diabetics Patients: A Cross-sectional Observation Study

Background

Diabetes mellitus (DM) can contribute to the development of foot ulcers, a known complication of DM with a high financial and social burden. Achilles tendon (AT) and plantar fascia (PF) are well known to play an important role in foot biomechanics. The present study focuses on the alteration in thickness and stiffness of the AT and PF in Type 2 DM patients compared with the normal controls.

Methods

A cross-sectional observational study was conducted with 55 DM patients and 55 healthy volunteers as controls. The thickness of the AT and PF were measured using B-mode ultrasound and stiffness was measured using shear wave elastography. Both the thickness and stiffness in the patient group and controls were compared. The values were also compared with the clinical and demographic profiles of the patients.

Results

DM patients had considerably thicker AT and PF than controls (P < 0.05); mean values of AT thickness for DM patients and controls were 5.66 ± 0.54 mm and 4.61 ± 0.39 mm, respectively, and for PF were 2.53 ± 0.51 mm and 1.97 ± 0.19 mm, respectively. Furthermore, the stiffness of AT and PF was significantly (P < 0.05) lower in DM patients compared to controls, suggestive of softening of AT and PF in Type 2 DM patients. Mean values of shear wave velocity for DM patients and controls in AT were 5.53 ± 0.54 m/s and 7.25 ± 0.61 m/s, respectively, and for PF, 4.53 ± 0.89 m/s and 6.28 ± 0.88 m/s, respectively.

Conclusion

We conclude that there is softening and thickening of the AT and PF in Type 2 DM patients, which can impair foot biomechanics.

How controlled motion alters the biophysical properties of musculoskeletal tissue architecture

INTRODUCTION

Movement is fundamental to the normal behaviour of the hand, not only for day-to-day activity, but also for fundamental processes like development, tissue homeostasis and repair. Controlled motion is a concept that hand therapists apply to their patients daily for functional gains, yet the scientific understanding of how this works is poorly understood.

PURPOSE OF THE ARTICLE

To review the biology of the tissues in the hand that respond to movement and provide a basic science understanding of how it can be manipulated to facilitate better functionThe review outlines the concept of controlled motion and actions across the scales of tissue architecture, highlighting the the role of movement forces in tissue development, homeostasis and repair. The biophysical behaviour of mechanosensitve tissues of the hand such as skin, tendon, bone and cartilage are discussed.

CONCLUSION

Controlled motion during early healing is a form of controlled stress and can be harnessed to generate appropriate reparative tissues. Understanding the temporal and spatial biology of tissue repair allows therapists to tailor therapies that allow optimal recovery based around progressive biophysical stimuli by movement.

Rehabilitation for people wearing offloading devices for diabetes-related foot ulcers: a systematic review and meta-analyses

BACKGROUND

Offloading devices improve healing of diabetes-related foot ulcers (DFUs) but they can limit mobilisation. Rehabilitation during or after removal of these devices may promote physical activity in a population at risk of poor health outcomes for which inactivity is a reversible risk factor.

METHODS

This systematic review examined the effectiveness of rehabilitation interventions to promote physical activity during and/or after wearing an offloading device to treat diabetes-related foot ulcers. Searches using MESH terms and free-text combinations: 'foot ulcer', 'diabetic foot', 'casts, surgical', 'orthotic devices' were applied to MEDLINE, Embase, The Cochrane Library and clinical trial registers for randomised and observational studies published to September 2022. Methodological quality assessment of included studies was undertaken using the Cochrane Risk of Bias (RoB 2.0) and Risk of Bias In Non-randomised studies of Interventions (ROBINS-I) tools.

RESULTS

Of 3332 records identified, eight studies (441 participants), four clinical trials and four cohort studies, were included. None delivered or tested a structured rehabilitation programme, but all reported physical activity outcomes during or after device use. People wearing non-removable total contact casts were less active than those wearing devices (SMD -0.45; 95% CI - 0.87 to - 0.04; p = 0.03; I² 56%; 4 trials). Diabetes-related foot ulcers in people wearing total contact casts were more likely to heal compared to removable devices at 12 weeks (OR 2.69; 95% CI 0.97 to 7.45; p = 0.06; I² = 64%; 4 trials) and 20 weeks (OR 2.35; 95% CI 0.95 to 5.82; p = 0.07; I² = 65%; 4 trials).

CONCLUSIONS

Despite physical activity being low throughout off-loading treatment, no studies have specifically tested rehabilitation. There is a need to investigate the clinical and cost-effectiveness of rehabilitation programmes in this population. High quality trials are needed to provide robust evidence to support to rehabilitation after DFU treatment.

Injury rates in the National Football League during the 2020 COVID-19 season

OBJECTIVES

The National Football League (NFL) altered the 2020 season due to the COVID-19 pandemic, which resulted in canceled preseason games and a dynamic regular season schedule to accommodate for canceled games. The purpose of this study was to evaluate if the disrupted training and preseason schedule lead to increased injury rates as seen in other professional sports. We hypothesized that the overall injury rate would be higher in the 2020 season compared to the 2018-2019 seasons and that this increase will affect all body regions equally.

METHODS

Publicly released NFL weekly injury reports were queried to identify players listed as out or placed on the injured reserve for at least one game in the 2018-2020 seasons. Injuries were categorized into upper extremity, lower extremity, spine/core, head, illness, not injury related and undisclosed injuries. Incidents per 1000 athlete exposures were calculated for the prior two seasons (2018-2019) and for the 2020 season separately. Percentage of injuries occurring in each position was calculated separately for the pre-COVID-19 (2018 and 2019) and post-COVID-19 (2020) cohorts. Incidence rate ratios (IRR) and confidence intervals were used to compare injury rates in 2018-2019 versus 2020. The z-test for proportions was used to determine significant differences between injury incidences.

RESULTS

The overall incidence rate per 1000 athlete exposures in 2020 was not significantly different compared to pre-COVID-19 seasons (21.6 versus 23.1, IRR 0.94, 95% CI: 0.9-1.0 p > 0.999). The proportion of injuries by position did not change before and after COVID-19 either (p > 0.999). Out listings due to illness were significantly increased during the 2020 season (0.8 versus 0.3, IRR 2.8, 95% CI: 1.4-5.2, p = 0.004).

CONCLUSION

The incidence of NFL injuries did not significantly change in 2020. The distribution of injuries did not change with respect to position.

The Effects of Increasing Trunk Flexion During Stair Ascent on the Rate and Magnitude of Achilles Tendon Force in Asymptomatic Females

Research indicates that increasing trunk flexion may optimize patellofemoral joint loading. However, this postural change could cause an excessive Achilles tendon force (ATF) and injury risk during movement. This study aimed to examine the effects of increasing trunk flexion during stair ascent on ATF, ankle biomechanics, and vertical ground reaction force in females. Twenty asymptomatic females (age: 23.4 [2.5] y; height: 1.6 [0.8] m; mass: 63.0 [12.2] kg) ascended stairs using their self-selected and flexed trunk postures. Compared with the self-selected trunk condition, decreases were observed for peak ATF (mean differences [MD] = 0.14 N/kg; 95% confidence interval [CI], 0.06 to 0.23; Cohen d = -1.2; P = .003), average rate of ATF development (MD = 0.25 N/kg/s; 95% CI, 0.07 to 0.43; Cohen d = -0.9; P = .010), ankle plantar flexion moment (MD = 0.08 N·m/kg; 95% CI, 0.03 to 0.13; Cohen d = -1.1; P = .005), and vertical ground reaction force (MD = 38.6 N/kg; 95% CI, 20.3 to 56.90; Cohen d = -1.8; P < .001). Increasing trunk flexion did not increase ATF. Instead, this postural change was associated with a decreased ATF rate and magnitude and may benefit individuals with painful Achilles tendinopathy.

Puncture Capsulotomy Technique for Hip Arthroscopy: Midterm Functional Outcomes

Background

The most common surgical approaches in hip arthroscopy are interportal and T-capsulotomy. However, these methods may introduce capsular instability. Puncture capsulotomy preserves capsuloligamentous integrity by avoiding iatrogenic transection of the iliofemoral capsular ligament.

Purpose

To present minimum 2-year functional outcomes for patients who underwent arthroscopic treatment for acetabular labral tears and concomitant femoroacetabular impingement using the puncture capsulotomy technique.

Study Design

Case series; Level of evidence, 4.

Methods

The authors conducted a retrospective review of prospectively collected data on patients who underwent arthroscopic acetabular labral tear treatment between December 2013 and May 2019. Included were patients aged ≥18 years who underwent hip arthroscopy by a single surgeon and completed a minimum of 2 years of patient-reported outcome measure (PROM) surveys. Intraoperatively, patients underwent hip arthroscopy via puncture capsulotomy to treat labral tears and any concomitant femoroacetabular impingement. Clinical outcome data consisted of PROMs.

Results

A total of 163 hips were included; the mean patient follow-up was 30.4 months (range, 24-60 months; 95% CI, 28.5-32.3 months). Patients had a mean age of 37.9 years (range, 36.1-39.6 years), with a mean body mass index of 25.9 (range, 25.2-26.5). There were significant improvements in mean [95% CI] baseline to final follow-up scores for the 33-Item International Hip Outcome Tool (iHOT-33) (39.6 [36.8-42.4] vs 76.1 [72.7-79.6]), Hip Outcome Score-Activities of Daily Living (70.0 [67.0-73.0] vs 89.3 [87.3-91.3]), modified Harris Hip Score (60.1 [57.9-62.4] vs 84.9 [82.5-87.2]), and Hip Outcome Score-Sports Specific Subscale (41.8 [37.9-45.6] vs 75.7 [71.7-79.7]) (P < .001 for all). Additionally, the mean [95% CI] visual analog scale pain scores were noted to significantly improve throughout the duration of the postoperative period (from 6.3 [5.9-6.7] to 2.2 [1.8-2.6]; P < .001). There were no incidences of infection, avascular necrosis of the femoral head, dislocation/instability, or femoral neck fracture. At the 2-year follow-up, 81.0%, 62.0%, and 58.9% of hips achieved previously published clinically meaningful iHOT-33 thresholds for minimally clinically important difference, Patient Acceptable Symptom Score, and substantial clinical benefit, respectively.

Conclusion

Puncture capsulotomy demonstrated significantly improved functional and clinically meaningful outcomes at a minimum 2-year follow-up, along with a minimal complication rate.

Effects of Walking Speeds and Durations on Peak Plantar Pressures

BACKGROUND

Walking at various speeds and durations may result in different peak plantar pressure (PPP). However, there is no study comparing the effect of walking speeds and durations on PPP. The purpose of this study was to explore whether different walking speeds and durations significantly change PPP and establish a normal response in healthy people.

METHODS

An in-shoe plantar pressure system was used to measure PPP under the first toe, first metatarsal, second metatarsal, and heel regions in 12 healthy, young people. All participants performed six walking trials at three speeds (3, 6, and 9 km/h) and for two durations (10 and 20 min). The 3 × 2 two-way analysis of variance was used to examine the main effects of speeds and durations and their interaction.

RESULTS

The results showed that walking speeds significantly affected PPP and that walking duration did not. No interaction between the walking speed and duration was observed. Peak plantar pressure values under the first toe and the first metatarsal head were significantly higher (P < .05) at 9 km/h (509.1 ± 314.2 kPa and 591.4 ± 302.4 kPa, respectively) than at 3 km/h (275.4 ± 168.7 kPa and 369.4 ± 205.4 kPa, respectively) after 10-min walking.

CONCLUSIONS

People at risk for foot ulcers may use slow and brisk walking for exercise to reduce PPP, thus reducing risk for foot ulcers. Our study demonstrated that slow running at 9 km/h significantly increases PPP.

The Safety and Effectiveness of Early, Progressive Weight Bearing and Implant Choice after Traumatic Lower Extremity Fracture: A Systematic Review

The goal of this systematic review was to examine existing evidence on the effectiveness of early, progressive weight bearing on patients after traumatic lower extremity fractures and relate these findings to device/implant choice. A search of the literature in PubMed/Medline, Embase, Web of Science, and the Cochrane Library was performed through January 2022. Randomized controlled trials and non-randomized, prospective longitudinal investigations of early, progressive weight bearing in skeletally mature adults after traumatic lower extremity fracture were included in the search, with 21 publications included in the final analysis. A summary of the loading progressions used in each study, along with the primary and additional outcomes, is provided. The progression of weight bearing was variable, dependent on fracture location and hardware fixation; however, overall outcomes were good with few complications. Most studies scored "high" on the bias tools and were predominately performed without physical therapist investigators. Few studies have investigated early, progressive weight bearing in patients after traumatic lower extremity fractures. The available clinical evidence provides variable progression guidelines. Relatively few complications and improved patient function were observed in this review. More research is needed from a rehabilitation perspective to obtain graded progression recommendations, informed by basic science concepts and tissue loading principles.

The association between foot posture, single leg balance and running biomechanics of the foot

OBJECTIVES

A mal-aligned foot posture (high-arched and flat feet) and poor single leg balance ability have been separately associated with foot injuries during running. Therefore, clinicians assess these routinely. However, the extent to which foot posture and single-leg balance ability affect actual foot biomechanics during running is not known. This study aims to investigate the association of foot posture, single-leg balance ability, and foot biomechanics during running.

METHOD

This is a cross sectional study of sixty-nine participants who had their foot postures and single-leg balance ability assessed. The Foot Posture Index and Balance Error Scoring System were used. Their foot kinetics was measured as they ran on an instrumented treadmill and foot kinematics was processed using a 3D motion capture system. Multiple-regression was used to analyse the variance of foot biomechanics explained by foot posture and single-leg balance ability.

RESULTS

Foot posture and single-leg balance ability were found to account significantly for the variance in rearfoot eversion (24%) and forefoot dorsiflexion (7%). Two regression equations were derived, where rearfoot eversion and forefoot dorsiflexion during running may be predicted.

CONCLUSION

Foot posture and single-leg balance ability can predict rearfoot eversion and forefoot dorsiflexion only during running. Based on the regression equations, individuals with the same foot posture but different single-leg balance ability may exhibit different foot kinematics. However, the angular differences are small. The equations may be useful for clinicians working in places where running gait analysis equipment are not readily accessible. Further studies with larger sample sizes are required to validate these equations. In addition, further studies are necessary to investigate the effect of these two variables under different running conditions e.g. with footwear and with orthoses.

Variations in the Thickness of the Plantar Fascia After Training Based in Training Race. A Pilot Study

Plantar fascia (PF) is a connective tissue made up of mostly type 1 collagen that is subjected to constant loads. This study evaluated the effect of continuous running on tissue stress in the PF by measuring changes in the thickness of the PF using ultrasound scans. It was a cross-sectional study involving 24 runners from the University of Valencia, recruited as volunteers between December 2018 and February 2019. A variety of data was recorded: (age, body mass index, type of footwear, number of workouts per week, KM run per week, sports injuries in the last year, pre and postrace ultrasound PF measurements). There were significant differences in the 3 postrace measurements of the left foot (<0.001). PF thicknesses were measured before and after running, with a minimal average difference of 0.4 mm in the medial and central fascicles, and 0.3 mm in the lateral fascicle. We observed PF thicknesses above 4mm in asymptomatic patients with no signs of vascularisation, proving that increased PF thickness is not the only criterion for diagnosis of plantar fasciitis.

A literature review of the studies concerning selected plant-derived adaptogens and their general function in body with a focus on animal studies

BACKGROUND

Adaptogens are generally referred to the substances, mostly found in plants, which non-specifically increase resilience and chances of survival by activation of signaling pathways in affected cells.

PURPOSE

This literature review was conducted to summarize the investigation, until March 2021, on selected adaptogenic plants and plant-derived substances.

STUDY DESIGN

Electronic databases were searched (up to March 2021) for in vitro and animal studies, as well as clinical trials. Moreover, all modes of action connected with the adaptogenic effects of plants and phytochemicals were collected.

METHODS

The search of relevant studies was performed within electronic databases including Scopus, Science Direct, PubMed, and Cochrane library. The most important keywords were adaptogen, plant, phytochemical, and plant-derived.

RESULTS

The most investigated medicinal herbs for their adaptogenic activity are Eleutherococcus senticosus, Panax ginseng, Withania somnifera, Schisandra chinensis, and Rhodiola spp., salidroside, ginsenosides, andrographolide, methyl jasmonate, cucurbitacin R, dichotosin, and dichotosininare are phytochemicals that have shown a considerable adaptogenic activity. Phytochemicals that have been demonstrated adaptogenic properties mainly belong to flavonoids, terpenoids, and phenylpropanoid glycosides.

CONCLUSION

It is concluded that the main modes of action of the selected adaptogenic plants are stress modulatory, antioxidant, anti-fatigue, and physical endurance enhancement. Other properties were nootropic, immunomodulatory, cardiovascular, and radioprotective activities.

Effects of walking speeds and durations on the plantar pressure gradient and pressure gradient angle

BACKGROUND

Walking exercise has been demonstrated to improve health in people with diabetes. However, it is largely unknown the influences of various walking intensities such as walking speeds and durations on dynamic plantar pressure distributions in non-diabetics and diabetics. Traditional methods ignoring time-series changes of plantar pressure patterns may not fully capture the effect of walking intensities on plantar tissues. The purpose of this study was to investigate the effect of various walking intensities on the dynamic plantar pressure distributions. In this study, we introduced the peak pressure gradient (PPG) and its dynamic patterns defined as the pressure gradient angle (PGA) to quantify dynamic changes of plantar pressure distributions during walking at various intensities.

METHODS

Twelve healthy participants (5 males and 7 females) were recruited in this study. The demographic data were: age, 27.1 ± 5.8 years; height, 1.7 ± 0.1 m; and weight, 63.5 ± 13.5 kg (mean ± standard deviation). An insole plantar pressure measurement system was used to measure plantar pressures during walking at three walking speeds (slow walking 1.8 mph, brisk walking 3.6 mph, and slow running 5.4 mph) for two durations (10 and 20 min). The gradient at a location is defined as the unique vector field in the two-dimensional Cartesian coordinate system with a Euclidean metric. PGA was calculated by quantifying the directional variation of the instantaneous peak gradient vector during stance phase of walking. PPG and PGA were calculated in the plantar regions of the first toe, first metatarsal head, second metatarsal head, and heel at higher risk for foot ulcers. Two-way ANOVA with Fisher's post-hoc analysis was used to examine the speed and duration factors on PPG and PGA.

RESULTS

The results showed that the walking speeds significantly affect PPG (P < 0.05) and PGA (P < 0.05), and the walking durations does not. No interaction between the walking duration and speed was observed. PPG in the first toe region after 5.4 mph for either 10 or 20 min was significantly higher than 1.8 mph. Meanwhile, after 3.6 mph for 20 min, PPG in the heel region was significantly higher than 1.8 mph. Results also indicate that PGA in the forefoot region after 3.6 mph for 20 min was significantly narrower than 1.8 mph.

CONCLUSIONS

Our findings indicate that people may walk at a slow speed at 1.8 mph for reducing PPG and preventing PGA concentrated over a small area compared to brisk walking at 3.6 mph and slow running at 5.4 mph.

What do we actually know about a common cause of plantar heel pain? A scoping review of heel fat pad syndrome

Background

The heel fat pad is an important structure of the foot as it functions as a cushion to absorb shock and distribute plantar force during ambulation. Clinical practice guidelines or decision support platforms emphasize that heel fat pad syndrome (HFPS) is a distinct pathology contributing to plantar heel pain. We aimed to identify and synthesize the prevalence, etiology and diagnostic criteria, and conservative management of HFPS.

Methods

A comprehensive search was conducted in May 2021 and updated in April 2022, using MEDLINE, Scopus, Cinahl, EMBASE, Cochrane Library, SPORTDiscus, and PEDro and ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform (ICTRP) for pertinent registrations. We included all study types and designs describing the prevalence; etiology and diagnostic criteria; and non-pharmacological, non-surgical interventions for HFPS.

Results

We found a small body of original research for HFPS (n = 7). Many excluded full-text articles were expert-opinion articles or studies of heel fat pad in participants with plantar fasciitis/fasciopathy or unspecified heel pain. HFPS may be the second leading cause of plantar heel pain, based on two studies. A number of differentiating pain characteristics and behaviors may aid in diagnosing HFPS vs. plantar fasciopathy. Thinning heel fat pad confirmed by ultrasonography may provide imaging corroboration. Randomized controlled trials assessing the efficacy of viscoelastic heel cups or arch taping for managing HFPS do not exist.

Conclusions

The research literature for HFPS is sparse and sometimes lacking scientific rigor. We have identified a substantial knowledge gap for this condition, frequent inattention to distinguishing HFPS from plantar fasciopathy when describing plantar heel pain, and an absence of robust clinical trials to support the commonly recommended conservative management of HFPS.

Effects of the advanced mandibular spring on mandibular retrognathia treatment: a three-dimensional finite element study

Background

The Advanced Mandibular Spring (AMS) was newly developed as a dentofacial orthopedic appliance in conjunctive use of clear aligners to treat Class II malocclusion with mandibular retrognathia in adolescents. This study aimed to launch a biomechanical assessment and evaluate whether the stress patterns generated by AMS promote mandibular growth.

Methods

A three-dimensional finite element model was constructed using images of CBCT and spiral CT. The model consisted of craniomaxillofacial bones, articular discs, retrodiscal elastic stratum, masticatory muscle, teeth, periodontal ligament, aligner and AMS. Mechanical effects were analyzed in three types of models: mandibular postural position, mandibular advancement with AMS, and mandibular advancement with only muscular force.

Results

The stress generated by AMS was distributed to all teeth and periodontal ligament, pushing mandibular teeth forward and maxillary teeth backward. In the temporomandibular joint area, the pressure in the superior and posterior aspects of the condyle was reduced, which conformed to the stress pattern promoting condylar and mandibular growth. Stress distribution became even in the anterior aspect of the condyle and the articular disc. Significant tensile stress was generated in the posterior aspect of the glenoid fossa, which conformed to the stress pattern stimulating the remodeling of the fossa.

Conclusions

AMS created a favorable biomechanical environment for treating mandibular retrognathia in adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02308-w.

Pain Science in Practice (Part 3): Peripheral Sensitization

In most cases, tissue injuries lead to inflammation and sensitization. From a neuroscience perspective, this is why one usually hurts when one is injured. Peripheral sensitization is an essential principle in pain science, and it is associated with hyperalgesia, inflammation, and clinical pain conditions, including acute injuries and rheumatological diseases. This editorial explains peripheral sensitization, neurogenic inflammation, and the axon reflex, as well as the role of second messengers and peptidergic C-fibers. J Orthop Sports Phys Ther 2022;52(6):303-306. doi:10.2519/jospt.2022.11202.

Relationship Between Plantar Tissue Hardness and Plantar Pressure Distributions in People With Diabetic Peripheral Neuropathy

Objective: People with diabetic peripheral neuropathy (DPN) are usually accompanied with increased plantar pressure. Such high plantar loading during daily activities may cause changes in the biomechanical properties of plantar soft tissue, whose viability is critical to the development of foot ulcers. This study aimed to investigate the relationship between plantar tissue hardness and plantar pressure in people with and without DPN, and preliminarily explore the influence of plantar loading patterns on the plantar pressure and tissue hardness.

Methods: The study was conducted on 14 people with DPN and 14 diabetic people without DPN. The Shore durometer and MatScan System were used to measure the plantar tissue hardness and plantar pressure, respectively. The plantar loading level was evaluated by the duration of daily weight-bearing activity and was used to group diabetic participants with and without DPN into two subgroups (lower loading group and higher loading group).

Results: The plantar tissue hardness was significantly correlated with static peak plantar pressure (PPP, p < 0.05) and dynamic pressure-time integral (PTI, p < 0.05) in the forefoot region in people with DPN. Results of variance analysis showed a significant interaction effect between peripheral neuropathy and plantar loading on tissue hardness (p < 0.05), but not plantar pressure. For people with DPN, significant differences in tissue hardness between the higher loading group and lower loading group were observed in the forefoot, midfoot and hindfoot regions. In the higher loading group, people with DPN had significantly greater tissue hardness than that in people without DPN in the toes, forefoot, midfoot and hindfoot regions (p < 0.05).

Conclusions: There is a significant correlation between tissue hardness and PPP, and between tissue hardness and PTI in people with DPN. Plantar loading associated with daily activities plays a significant role on the plantar tissue hardness in people with DPN. The findings of this study contribute to further understand the relationship between increased plantar tissue hardness and high plantar pressure in people with diabetic peripheral neuropathy.

Detection of Physical Strain and Fatigue in Industrial Environments Using Visual and Non-Visual Low-Cost Sensors

The detection and prevention of workers’ body straining postures and other stressing conditions within the work environment, supports establishing occupational safety and promoting well being and sustainability at work. Developed methods towards this aim typically rely on combining highly ergonomic workplaces and expensive monitoring mechanisms including wearable devices. In this work, we demonstrate how the input from low-cost sensors, specifically, passive camera sensors installed in a real manufacturing workplace, and smartwatches used by the workers can provide useful feedback on the workers’ conditions and can yield key indicators for the prevention of work-related musculo-skeletal disorders (WMSD) and physical fatigue. To this end, we study the ability to assess the risk for physical strain of workers online during work activities based on the classification of ergonomically sub-optimal working postures using visual information, the correlation and fusion of these estimations with synchronous worker heart rate data, as well as the prediction of near-future heart rate using deep learning-based techniques. Moreover, a new multi-modal dataset of video and heart rate data captured in a real manufacturing workplace during car door assembly activities is introduced. The experimental results show the efficiency of the proposed approach that exceeds 70% of classification rate based on the F1 score measure using a set of over 300 annotated video clips of real line workers during work activities. In addition a time lagging correlation between the estimated ergonomic risks for physical strain and high heart rate was assessed using a larger dataset of synchronous visual and heart rate data sequences. The statistical analysis revealed that imposing increased strain to body parts will results in an increase to the heart rate after 100–120 s. This finding is used to improve the short term forecasting of worker’s cardiovascular activity for the next 10 to 30 s by fusing the heart rate data with the estimated ergonomic risks for physical strain and ultimately to train better predictive models for worker fatigue.

Tissue Oxygenation Measurements to Aid Scalpel Debridement Removal in Patients With Diabetes

BACKGROUND

Callus formation in the diabetic foot increases the risk of ulcer onset. It is standard procedure to remove these dead tissue layers to reduce rising pressures. In a surgical procedure known as scalpel debridement, or chiropody the callus tissue is removed up to the epidermal layer. Factors may influence the outcome of this surgical process such as clinician inexperience. In an effort to standardize the debridement process, tissue oxygenation (TO) measurements are obtained before and after to study the effect of debridement on callus tissue.

METHODS

Fifteen debridement cases were analyzed using near infrared (NIR) imaging to study changes in TO. The NIR-based device used in this study estimates effective changes in TO in terms of oxy-, deoxy-, total hemoglobin, and oxygen saturation. Weber contrasts between callus tissue and the surrounding normal tissue were compared following debridement for all TO parameters. In a secondary analysis, callus tissue was segmented into quadrants and a percent of significance (in terms of total TO change) was calculated using a t-test.

RESULTS

Results show majority of cases displayed greater than 80% as the significant change in TO following debridement, except in cases with the presence of blood clot (a common precursor for ulceration). In cases where incomplete debridement was suspected, a significant change in TO was still observed.

CONCLUSIONS

With extensive systematic studies in the future, NIR imaging technique to measure changes in TO may be implemented as a low-cost hand-held imaging device useful for objectively assessing the effectiveness of the scalpel debridement process.

A Systematic Review and Meta-Analysis of Exercise Interventions and Use of Exercise Principles to Reduce Fear of Falling in Community-Dwelling Older Adults

OBJECTIVE

Fear of falling (FOF) contributes to activity restriction and institutionalization among older adults, and exercise interventions are linked to reduction in FOF. Adhering to exercise principles and adapting optimal exercise parameters are fundamental to optimizing the effectiveness of exercise interventions. The purpose of this review was to describe FOF exercise interventions in community-dwelling older adults, evaluate the extent to which these interventions followed the exercise principles and reported exercise parameters, and quantify the effect of these interventions on reducing FOF.

METHODS

Randomized controlled trials (RCTs) of FOF exercise interventions in older adults (≥65 years) were identified from 4 databases. The methodological quality of RCTs was assessed using the Physiotherapy Evidence Database scale. A random-effect model was used in the meta-analysis.

RESULTS

Seventy-five RCTs were included in this review. With regard to reporting exercise principles, specificity was reported in 92% of trials, progression in 72%, reversibility in 32%, overload in 31%, diminished return in 21%, and initial value in 8%. For exercise parameters, 97% of RCTs reported exercise type; 89%, frequency; and 85%, time. Only 25% reported the intensity. The pooled effect of exercise interventions on FOF among all included studies was a standard mean difference of -0.34 (95% CI = -0.44 to -0.23).

CONCLUSION

This study showed a significant small to moderate effect size of exercise interventions in reducing FOF among community-dwelling older adults. Most exercise principles and intensity of exercises were not adequately reported in included trials.

IMPACT

These inadequate reports could undermine efforts to examine the optimal dosage for exercise prescription. More attention must be given to designing and reporting components of therapeutic exercise programs to facilitate evidence-based practice.

The Association between Symmetrical or Asymmetrical High-Arched Feet and Muscle Fatigue in Young Women

The foot arches are responsible for proper foot loading, optimal force distribution, and transmission throughout the soft tissues. Since the foot arch is an elastic structure, able to adapt to forces transmitted by the foot, it was reported that low arch is related to excessive foot pronation, while high arched foot is more rigid and inflexible. Therefore, it is also probable, that foot arch alterations may change the force transmission via myofascial chains. The objective of this study was to evaluate the effect of symmetrical and asymmetrical excessive feet arching on muscle fatigue in the distal body parts such as the lower limbs, trunk, and head. Seventy-seven women (25.15 ± 5.97 years old, 62 ± 10 kg, 167 ± 4 cm) were assigned to three groups according to the foot arch index (Group 1—both feet with normal arch, Group 2—one foot with normal arch and the other high-arched, Group 3—both feet with high-arch). The bioelectrical activity of the right and left hamstrings muscles, erector spine, masseter, and temporalis muscle was recorded by sEMG during the isometric contraction lasting for 60 s. The stable intensity of the muscle isometric contraction was kept for all the time during the measurement. Mean frequency difference (%), slope (Hz), and intercept (Hz) values were calculated for muscle fatigue evaluation. No differences were observed in fatigue variables for all evaluated muscles between the right and left side in women with symmetrical foot arches, but in the group with asymmetric foot arches, the higher muscle fatigue on the normal-arched side compared to the high-arched side was noted. Significantly greater values of the semitendinosus—semimembranosus muscle frequency difference was observed on the normal-arched side compared to the high-arched side (p = 0.04; ES = 0.52; −29.5 ± 9.1% vs. −24.9 ± 8.4%). In the group with asymmetric foot arches, a significantly higher value of lumbar erector spinae muscle frequency slope (p = 0.01; ES = 1.32; −0.20 ± 0.04 Hz vs. −0.14 ± 0.05 Hz) and frequency difference (p = 0.04; ES = 0.92; −7.8 ± 3.1% vs. −4.8 ± 3.4%) were observed on the high-arched foot side compared to the side with normal foot arching. The thoracic erector spine muscle frequency slope was significantly larger in women with asymmetrical arches than in those with both feet high-arched (right side: p = 0.01; ES = 1.25; −0.20 ± 0.08 Hz vs. −0.10 ± 0.08 Hz); (left side: p = 0.005; ES = 1,17; −0.19 ± 0.04 Hz vs. −0.13 ± 0.06 Hz) and compared to those with normal feet arches (right side: p = 0.02; ES = 0.58; −0.20 ± 0.08 Hz vs. −0.15 ± 0.09 Hz); (left side: p = 0.005; ES = 0.87; −0.19 ± 0.04 Hz vs. −0.14 ± 0.07 Hz). In the group with asymmetric foot arches, the frequency difference was significantly higher compared to those with both feet high-arched (right side: p = 0.01; ES = 0.87; −15.4 ± 6.8% vs. 10.4 ± 4.3%); (left side: p = 0.01; ES = 0.96; 16.1 ± 6.5% vs. 11.1 ± 3.4%). In the group with asymmetric foot arches, a significantly higher value of the masseter muscle frequency difference was observed on the high-arched side compared to the normal-arched side (p = 0.01; ES = 0.95; 6.91 ± 4.1% vs. 3.62 ± 2.8%). A little increase in the longitudinal arch of the foot, even though such is often not considered as pathological, may cause visible changes in muscle function, demonstrated as elevated signs of muscles fatigue. This study suggests that the consequences of foot high-arching may be present in distal body parts. Any alterations of the foot arch should be considered as a potential foot defect, and due to preventing muscle overloading, some corrective exercises or/and corrective insoles for shoes should be used. It can potentially reduce both foot overload and distant structures overload, which may diminish musculoskeletal system pain and dysfunctions.

Effects of a 12-Week Interventional Exercise Programme on Muscle Strength, Mobility and Fitness in Patients With Diabetic Foot in Remission: Results From BIONEDIAN Randomised Controlled Trial

OBJECTIVES

Diabetic foot syndrome (DFS) is a serious late diabetic complication characterised by limited joint mobility and other biomechanical and muscle abnormalities.

AIM

To evaluate the effect of an interventional exercise programme on anthropometric parameters, muscle strength, mobility and fitness in patients with diabetic foot in remission.

DATA SOURCES AND STUDY SELECTION

Thirty-eight patients with type 2 diabetes and DFS without active lesions (mean age 65 ± 6.9 years, BMI 32 ± 4.7 kg.m^-2, waist-hip ratio (WHR)1.02 ± 0.06) were enrolled in our randomised controlled trial. All subjects were randomised into two groups: an intervention group (I; n=19) and a control group (C; n=19). The 12-week exercise intervention focused on ankle and small-joint mobility in the foot, strengthening and stretching of the lower extremity muscles, and improvements in fitness. Changes (Δ=final minus initial results) in physical activity were assessed using the International Physical Activity Questionnaire (IPAQ), with joint mobility detected by goniometry, muscle strength by dynamometry, and fitness using the Senior Fitness Test (SFT).

DATA EXTRACTION

Due to reulceration, 15.8% of patients from group I (3/19) and 15.8% of patients from group C were excluded. Based on the IPAQ, group I was more active when it came to heavy (p=0.03) and moderate physical activity (p=0.06) after intervention compared to group C. Group I improved significantly in larger-joint flexibility (p=0.012) compared to controls. In group I, dynamometric parameters increased significantly in both lower limbs (left leg; p=0.013, right leg; p=0.043) compared to group C. We observed a positive trend in the improvement of fitness in group I compared to group C. We also confirmed positive correlations between heavy physical activity and selected parameters of flexibility (r=0.47; p=0.007), SFT (r=0.453; p=0.011) and dynamometry (r=0.58; p<0.0025). Anthropometric parameters, such as BMI and WHR, were not significantly influenced by the intervention programme.

CONCLUSION

Our 12-week interventional exercise programme proved relatively safe, resulting in improved body flexibility and increased muscle strength in DF patients in remission.

Exercise Dosage in Reducing the Risk of Dementia Development: Mode, Duration, and Intensity-A Narrative Review

Senile dementia, also known as dementia, is the mental deterioration which is associated with aging. It is characterized by a decrease in cognitive abilities, inability to concentrate, and especially the loss of higher cerebral cortex function, including memory, judgment, abstract thinking, and other loss of personality, even behavior changes. As a matter of fact, dementia is the deterioration of mental and intellectual functions caused by brain diseases in adults when they are mature, which affects the comprehensive performance of life and work ability. Most dementia cases are caused by Alzheimer’s disease (AD) and multiple infarct dementia (vascular dementia, multi-infarct dementia). Alzheimer’s disease is characterized by atrophy, shedding, and degenerative alterations in brain cells, and its occurrence is linked to age. The fraction of the population with dementia is smaller before the age of 65, and it increases after the age of 65. Since women live longer than men, the proportion of women with Alzheimer’s disease is higher. Multiple infarct dementia is caused by a cerebral infarction, which disrupts blood supply in multiple locations and impairs cerebral cortex function. Researchers worldwide are investigating ways to prevent Alzheimer’s disease; however, currently, there are no definitive answers for Alzheimer’s prevention. Even so, research has shown that we can take steps to reduce the risk of developing it. Prospective studies have found that even light to moderate physical activity can lower the risk of dementia and Alzheimer’s disease. Exercise has been proposed as a potential lifestyle intervention to help reduce the occurrence of dementia and Alzheimer’s disease. Various workout modes will be introduced based on various physical conditions. In general, frequent exercise for 6–8 weeks lessens the risk of dementia development.

Effect of Exercise Volume on Plantar Microcirculation and Tissue Hardness in People With Type 2 Diabetes

Objective: Exercise has been reported to be beneficial for people with type 2 diabetes (T2DM), but exercise, especially weight-bearing exercise, may increase the risk of diabetic foot ulcers (DFUs). This study aimed to explore the associations between different volumes of weight-bearing physical activities and plantar microcirculation and tissue hardness in people with T2DM.

Methods: 130 elderly people with T2DM were enrolled for this cross-sectional study. They were classified into the high exercise volume group and the low exercise volume group based on their weekly energy expenditure (metabolic equivalents per week) in the past year. Weekly energy expenditure was calculated using the International Physical Activity Questionnaire and the Compendium of Physical Activities. The plantar oxygen saturation (SO₂) and soft tissue hardness of each participant’s right foot were measured.

Results: A total of 80 participants completed the trial. The average exercise energy expenditure of the high exercise volume group and the low exercise volume group were significantly different (p < 0.05). The results showed that the SO₂ of the high exercise volume group (67.25 ± 6.12%) was significantly higher than the low exercise volume group (63.75 ± 8.02%, p < 0.05). The plantar tissue hardness of the high exercise volume group was lower than the low exercise volume group in the big toe, midfoot and hindfoot regions (p < 0.05).

Conclusion: This study demonstrates that higher volumes of exercise are associated with better plantar microcirculation and lower plantar tissue hardness in people with T2DM. The findings of this study indicate that weight-bearing exercise may not increase risk of developing diabetic foot ulcers.

Effects of and Response to Mechanical Loading on the Knee

Mechanical loading to the knee joint results in a differential response based on the local capacity of the tissues (ligament, tendon, meniscus, cartilage, and bone) and how those tissues subsequently adapt to that load at the molecular and cellular level. Participation in cutting, pivoting, and jumping sports predisposes the knee to the risk of injury. In this narrative review, we describe different mechanisms of loading that can result in excessive loads to the knee, leading to ligamentous, musculotendinous, meniscal, and chondral injuries or maladaptations. Following injury (or surgery) to structures around the knee, the primary goal of rehabilitation is to maximize the patient's response to exercise at the current level of function, while minimizing the risk of re-injury to the healing tissue. Clinicians should have a clear understanding of the specific injured tissue(s), and rehabilitation should be driven by knowledge of tissue-healing constraints, knee complex and lower extremity biomechanics, neuromuscular physiology, task-specific activities involving weight-bearing and non-weight-bearing conditions, and training principles. We provide a practical application for prescribing loading progressions of exercises, functional activities, and mobility tasks based on their mechanical load profile to knee-specific structures during the rehabilitation process. Various loading interventions can be used by clinicians to produce physical stress to address body function, physical impairments, activity limitations, and participation restrictions. By modifying the mechanical load elements, clinicians can alter the tissue adaptations, facilitate motor learning, and resolve corresponding physical impairments. Providing different loads that create variable tensile, compressive, and shear deformation on the tissue through mechanotransduction and specificity can promote the appropriate stress adaptations to increase tissue capacity and injury tolerance. Tools for monitoring rehabilitation training loads to the knee are proposed to assess the reactivity of the knee joint to mechanical loading to monitor excessive mechanical loads and facilitate optimal rehabilitation.

Musculoskeletal pain in Parkinson's disease: a narrative review

The prevalence of musculoskeletal (MSK) pain in people with Parkinson's disease (PD) is higher than that of age-matched controls. In this review, we outline what is known about MSK pain in PD, focusing on the neck, shoulder, knee, hip and low back. We also compare what is known about MSK pain in PD to what is known in older adults without PD. Finally, we outline areas of for future research related to MSK pain in people with PD.

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a leading cause of the global disease burden. Most DFUs are caused, and prolonged, by high plantar tissue stress under the insensate foot of a person with peripheral neuropathy. Multiple different offloading treatments have been used to try to reduce high plantar tissue stress and heal DFUs, including bedrest, casting, offloading devices, footwear, and surgical procedures. The best offloading treatments are those that balance the benefits of maximizing reductions in high plantar tissue stress, whilst reducing the risks of poor satisfaction, high costs and potential adverse events outcomes. This review aimed to summarize the best available evidence on the effects of offloading treatments to heal people with DFUs, plus review their use in clinical practice, the common barriers and solutions to using these treatments, and discuss promising emerging solutions that may improve offloading treatments in future. Findings demonstrate that knee-high offloading devices, non-removable or removable knee-high devices worn for all weight-bearing activities, are the gold standard offloading treatments to heal most patients with DFU, as they are much more effective, and typically safer, quicker, and cheaper to use compared with other offloading treatments. The effectiveness of offloading treatments also seems to increase when increased offloading mechanical features are incorporated within treatments, including customized insoles, rocker-bottom soles, controlled ankle motion, and higher cast walls. However, in clinical practice these gold standard knee-high offloading devices have low rates of prescription by clinicians and low rates of acceptance or adherence by patients. The common barriers resulting in this low use seem to surround historical misperceptions that are mostly dispelled by contemporary evidence. Further, research is now urgently required to close the implementation gap between the high-quality of supporting evidence and the low use of knee-high devices in clinical practice to reduce the high global disease burden of DFU in future.

Mechanobiology and Adaptive Plasticity Theory as a Potential Confounding Factor in Predicting Musculoskeletal Foot Function

There are many theoretical models that attempt to accurately and consistently link kinematic and kinetic information to musculoskeletal pain and deformity of the foot. Biomechanical theory of the foot lacks a consensual model: clinicians are enticed to draw from numerous paradigms, each having different levels of supportive evidence and contrasting methods of evaluation, in order to engage in clinical deduction and treatment planning. Contriving to find a link between form and function lies at the heart of most of these competing theories and the physical nature of the discipline has prompted an engineering approach. Physics is of great importance in biology and helps us to model the forces that the foot has to deal with in order for it to work effectively. However, the tissues of the body have complex processes that are in place to protect them and they are variable between individuals. Research is uncovering why these differences exist and how these processes are governed. The emerging explanations for adaptability of foot structure and musculoskeletal homeostasis offer new insights into how clinical variation in outcomes and treatment effects might arise. These biological processes underlie how variation in the performance and use of common traits, even within apparently similar subgroups, make anatomical distinction less meaningful and are likely to undermine the justification of a "foot type." Furthermore, mechanobiology introduces a probabilistic element to morphology based on genetic and epigenetic factors.

Sedentary behaviour is an independent predictor of diabetic foot ulcer development: An 8-year prospective study

AIMS

To prospectively explore the association between sedentary time (SED-time) and the development of diabetic foot ulcer (DFU) in people with diabetic peripheral neuropathy (DPN).

METHODS

175 DPN individuals who attended the annual evaluation for the SAMBA Study (2012-2019) were included. Main outcome measure was the first diagnosis of DFU. SED-time was measured by the PAS 2.1 questionnaire. Nerve function was evaluated by nerve conduction studies. Vascular function was assessed by Ankle-brachial index (ABI) and pedal pulses. Foot deformity and skin dryness were examined by visual inspection.

RESULTS

62 participants (35.5%) developed a DFU during the study. SED-time was significantly higher in people who developed DFUs (12.8 ± 3.0 vs 9.4 ± 3.1 h/day). Logistic regression showed that among several nervous (motor amplitude, OR 0.33, 95% CI, 0.18-0.60; sensory amplitude, 0.85, 0.77-0.94) and vascular parameters (ABI, 0.23, 0.1-0.61; pedal pulses, 2.81, 0.12-0.63) and foot characteristics (deformity, 2.63, 1.30-5.32; skin dryness, 2.04, 0.95-4.37), SED-time was one of the strongest variables contributing to the development of DFUs (2.95, 1.45-6.44).

CONCLUSIONS

SED-time is an independent predictor of the risk of DFU in people with DPN. The monitoring of SED-time with strategies aimed at reducing it should be included in the standard care of diabetic patients.

The neurodynamic treatment induces biological changes in sensory and motor neurons in vitro

Nerves are subjected to tensile forces in various paradigms such as injury and regeneration, joint movement, and rehabilitation treatments, as in the case of neurodynamic treatment (NDT). The NDT induces selective uniaxial repeated tension on the nerve and was described to be an effective treatment to reduce pain in patients. Nevertheless, the biological mechanisms activated by the NDT promoting the healing processes of the nerve are yet still unknown. Moreover, a dose-response analysis to define a standard protocol of treatment is unavailable. In this study, we aimed to define in vitro whether NDT protocols could induce selective biological effects on sensory and motor neurons, also investigating the possible involved molecular mechanisms taking a role behind this change. The obtained results demonstrate that NDT induced significant dose-dependent changes promoting cell differentiation, neurite outgrowth, and neuron survival, especially in nociceptive neurons. Notably, NDT significantly upregulated PIEZO1 gene expression. A gene that is coding for an ion channel that is expressed both in murine and human sensory neurons and is related to mechanical stimuli transduction and pain suppression. Other genes involved in mechanical allodynia related to neuroinflammation were not modified by NDT. The results of the present study contribute to increase the knowledge behind the biological mechanisms activated in response to NDT and to understand its efficacy in improving nerve regenerational physiological processes and pain reduction.

An Investigation of Regional Plantar Soft Tissue Hardness and Its Potential Correlation with Plantar Pressure Distribution in Healthy Adults

Background

The plantar soft tissue plays a critical role in absorbing shocks and attenuating excessive stresses during walking. Plantar soft tissue property and plantar pressure are critical information for footwear design and clinical assessment. The aim of this study was to investigate the relationship between plantar soft tissue hardness and plantar pressure during walking.

Methods

59 healthy volunteers (27 males and 32 females, aged 20 to 82) participated in this study. The plantar surface was divided into five regions: lateral rearfoot, medial rearfoot, lateral midfoot, lateral forefoot, and medial forefoot, and the plantar tissue hardness was tested using Shore durometer in each region. Average dynamic pressures in each region were analyzed for the five regions corresponding to the hardness tests. The relationship between hardness and average dynamic pressure was analyzed in each region.

Results

The average hardness of the plantar soft tissue in the above five regions is as follows: lateral rearfoot (34.49 ± 6.77), medial rearfoot (34.47 ± 6.64), lateral midfoot (27.95 ± 6.13), lateral forefoot (29.72 ± 5.47), and medial forefoot (28.58 ± 4.41). Differences of hardness were observed between age groups, and hardness of plantar soft tissues in forefoot regions increased with age (P < 0.05). A negative relationship was found between plantar soft tissue hardness and pressure reduction at lateral rearfoot, medial rearfoot, and lateral midfoot (P < 0.05).

Conclusion

The hardness of plantar soft tissues changes with age in healthy individuals, and there is a trend of increasing hardness of the plantar soft tissue with age. The plantar soft tissue hardness increases with plantar pressure.

Gait retraining for runners with patellofemoral pain: A protocol for systematic review and meta-analysis

INTRODUCTION

Patellofemoral pain (PFP) is highly prevalent in runners. Physical therapies were proved to be effective in the treatment of PFP. Gait retraining is an important method of physical therapy, but its effectiveness and safety for PFP remained controversial. Previous review suggests gait retraining in the treatment of PFP warrants consideration. However, recent publications of randomized controlled studies and case series studies indicated the positive effect of gait retraining in clinical and functional outcomes, which re-raise the focus of gait retraining. This paper will systematically review the available evidence, assessing the safety and effectiveness for the use of gait retraining for runners with PEP.

METHOD AND ANALYSIS

A systematic review of relevant studies in Pubmed, Embase, SCOPUS, and Cochrane Library were synthesized. Inclusion criteria are studies evaluating clinical outcomes (i.e., changes to pain and/or function) following running retraining interventions in symptomatic running populations; Studies with less than 10 participants in total or in the running retraining intervention group were excluded. The primary outcomes measured will be pain score, Lower extremity functional scale and training related injuries or complications. Review Manager (Revman Version 5.3) software will be used for data synthesis, sensitivity analysis, meta regression, subgroup analysis and risk of bias assessment. A funnel plot will be developed to evaluate reporting bias and Begg and Egger tests will be used to assess funnel plot symmetries. We will use the Grading of Recommendations Assessment, Development and Evaluation system to assess the quality of evidence.

ETHICS AND DISSEMINATION

Our aim is to publish this systematic review in a peer-reviewed journal. Our findings will provide information about the safety of gait retraining and their effect on reliving pain and improving function of lower limb on runners with PEP. This review will not require ethical approval as there are no issues about participant privacy.

Should weight-bearing activity be reduced during healing of plantar diabetic foot ulcers, even when using appropriate offloading devices?

Physical activity is an essential part of general health and diabetes management. However, recommending weight-bearing physical activity for people with plantar diabetic foot ulcers is controversial, even when gold standard offloading devices are used, as it is commonly thought to delay healing. We aimed to narratively review relevant studies investigating the relationship between plantar diabetic foot ulcer healing and weight-bearing activity, plantar pressure and device adherence. We defined relevant studies as those from two systematic reviews, along with those identified since using a similar updated Pubmed search strategy. We identified six studies. One study found that more daily steps were associated with worse ulcer healing, three found no significant association between steps and ulcer healing, and in two others the association was unclear. Thus, there is weak evidence for an inverse relationship between weight-bearing physical activity and plantar ulcer healing while utilizing offloading devices. We propose a Diabetic foot Offloading and Activity framework to guide future research to find the optimal balance between the positive and negative effects of weight-bearing activity in the context of foot ulcers. We hope such future studies will shed more conclusive light on the impact of weight-bearing activity on healing of plantar diabetic foot ulcers.

Mixed-Methods Approach to Understanding Determinants of Practice Change in Skilled Nursing Facility Rehabilitation: Adapting to and Sustaining Value With Postacute Reform

BACKGROUND AND PURPOSE

Postacute care reform is driving physical and occupational therapists in skilled nursing facilities (SNFs) to change how they deliver care to produce better outcomes in less time. However, gaps exist in understanding determinants of practice change, which limits translation of evidence into practice. This study explored what determinants impacted change in care delivery at 2 SNFs that implemented a high-intensity resistance training intervention.

METHODS

We used a mixed-methods, sequential explanatory design to explain quantitative findings using qualitative methods with a multiple-case study approach. Quantitative data were collected on therapists' attitudes toward evidence-based practice and aspects of intervention implementation. We conducted focus groups with therapists (N = 15) at 2 SNFs, classified as either high- (SNF-H) or low-performing (SNF-L) based on implementation fidelity and sustainability.

RESULTS AND DISCUSSION

Determinants of SNF rehabilitation practice change included the organizational system, team dynamics, patient and therapist self-efficacy, perceptions of intervention effectiveness, and ability to overcome preconceived notions. A patient-centered system, positive team dynamics, and ability to overcome preconceived notions fostered practice change at SNF-H. While self-efficacy and perception of effectiveness positively impacted change in practice at both SNFs, these determinants were not enough to overcome challenges at SNF-L. To adapt to changes and sustain rehabilitation value, further research must identify the combination of determinants that promote application of evidence-based practice.

CONCLUSIONS

This study is the first step in understanding what drives change in SNF rehabilitation practice. As SNF rehabilitation continues to face changes in health care delivery and reimbursement, therapists will need to adapt, by changing practice patterns and adopting evidence-based approaches, to demonstrate value in postacute care.

Geriatric Activation Program Pellenberg, a novel physiotherapy program for hospitalized patients on a geriatric rehabilitation ward

BACKGROUND AND PURPOSE

Regaining functional independence and independent living is challenging in hospitalized geriatric patients. Different from community dwelling and institutionalized older people, geriatric patients on rehabilitation wards generally receive more frequent and structured physiotherapy with the primary aim to discharge them to their home or place of residence. There is a paucity of evidence concerning the structure and components of physiotherapy programs to improve functional performance in this particular group. In this paper, we describe how we developed the Geriatric Activation Program Pellenberg (GAPP) based on patients' needs and available literature.

METHODS

We searched the literature on physiotherapy interventions focusing on the core components for improvement of functional performance: strength, balance, function, (gait)speed, coordination, and endurance training. Based on physiotherapist staffing and physiotherapy time allocated to each patient, we organized the practical, daily delivery of the program.

RESULTS

GAPP is a 5-day program, repeated weekly, delivered by physiotherapists and physiotherapy students. Each day, one or a combination of two to three different core components of functional performance is trained intensively in 45-min sessions. A set of standard exercises is constantly adjusted to each patients' capacity. On day 5, there is a mix of these core elements in a group session (e.g., chair-dance, table tennis, karate) and the Berg Balance Scale is completed to evaluate progress.

CONCLUSION

GAPP is a multicomponent physiotherapy program for hospitalized patients on a geriatric rehabilitation ward, aimed at improving functional performance.

Heel Rise and Non-Weight-Bearing Ankle Plantar Flexion Tasks to Assess Foot and Ankle Function in People With Diabetes Mellitus and Peripheral Neuropathy

OBJECTIVE

The objective of this study was to examine the effects of diabetes mellitus and peripheral neuropathy (DMPN), limited joint mobility, and weight-bearing on foot and ankle sagittal movements and characterize the foot and ankle position during heel rise.

METHODS

Sixty people with DMPN and 22 controls participated. Primary outcomes were foot (forefoot on hindfoot) and ankle (hindfoot on shank) plantar-flexion/dorsiflexion angle during 3 tasks: unilateral heel rise, bilateral heel rise, and non-weight-bearing ankle plantar flexion. A repeated-measures analysis of variance and Fisher exact test were used.

RESULTS

Main effects of task and group were significant, but not the interaction in both foot and ankle plantar flexion. Foot and ankle plantar flexion were less in people with DMPN compared with controls in all tasks. Both DMPN and control groups had significantly less foot and ankle plantar flexion with greater weight-bearing; however, the linear trend across tasks was similar between groups. The DMPN group had a greater percentage of individuals in foot and/or ankle dorsiflexion at peak unilateral heel rise compared with controls, but the foot and ankle position was similar at peak bilateral heel rise between DMPN and control groups.

CONCLUSION

Foot and ankle plantar flexion is less in people with DMPN. Less plantar flexion in non-weight-bearing suggests that people with DMPN have limited joint mobility. However, peak unilateral and bilateral heel rise is less than the available plantar flexion range of motion measured in non-weight-bearing, indicating that limited joint mobility does not limit heel rise performance. A higher frequency of people with DMPN are in foot and ankle dorsiflexion at peak unilateral heel rise compared with controls, but the position improved with lower weight-bearing.

IMPACT

Proper resistance should be considered with physical therapist interventions utilizing heel rise because foot and ankle plantar flexion position could be improved by reducing the amount of weight-bearing.

Injury Rates in Major League Baseball During the 2020 COVID-19 Season

Background:

The 2020 Major League Baseball (MLB) season was drastically altered because of the COVID-19 pandemic. The changes included an extended layoff between March and July as well as a shortened preseason.

Purpose/Hypothesis:

To determine the incidence and epidemiology of MLB injuries in the abbreviated 2020 season compared with prior seasons. We hypothesized that there was an increase in the overall injury rate in the 2020 season compared with the 2018-2019 seasons and that it equally affected all body regions.

Study Design:

Descriptive epidemiology study.

Methods:

The MLB transactions database was queried to find players who had been placed on the injury list between 2018 and 2020. Injuries were categorized into upper extremity, lower extremity, spine/core, and other injuries. Incidence per 1000 athlete-exposures was calculated for the prior 2 seasons (2018-2019) and for the 2020 season separately. Incidence for each category was also calculated separately for pitchers and fielders. Incidence rate ratios (IRRs) and confidence intervals were used to compare injury rates in 2018-2019 versus 2020. The z test for proportions was used to determine significant differences between injury incidences.

Results:

In 2020, the overall incidence rate per 1000 athlete-exposures was almost twice the rate compared with the 2 seasons before COVID-19 (8.66 vs 5.13; IRR, 1.69 [95% CI, 1.53-1.87]; P < .001). Injury incidence increased similarly in 2020 for both pitchers (IRR, 1.68 [95% CI, 1.47-1.91]; P < .001) and fielders (IRR, 1.68 [95% CI, 1.45-1.96]; P < .001). Increases in injury incidence were seen in the upper extremity, spine/core, and other injury categories; however, the incidence of the lower extremity did not change significantly.

Conclusion:

There was a significant increase in injury incidence for both pitchers and fielders in 2020. Injury rates increased in anatomic zones of the upper extremity and spine/core but were not significantly changed in the lower extremity. The overall increase in injury rate suggests that irregular or insufficient sport-specific preparation prior to the start of the season placed athletes at a greater risk of injury when play resumed.

Anterior cruciate ligament injury: towards a gendered environmental approach

BACKGROUND

The anterior cruciate ligament (ACL) injury rate for girls/women has not changed in over 20 years, and they remain 3-6 times more likely to experience injury compared with boys/men. To date, ACL injury prevention and management has been approached from a sex-based biological point of view which has furthered our understanding of injury risk factors, mechanisms, and prevention and rehabilitation programmes. However, the traditional sex-based approach does not take into account the growing recognition of how sex and gender (a social construct) are 'entangled' and influence each other.

OBJECTIVE

This paper discusses the curious absence of gender as an influencer in the dialogue surrounding ACL injuries. We propose adding gender as a pervasive developmental environment as a new theoretical overlay to an established injury model to illustrate how gender can operate as an extrinsic determinant from the presport, training and competition environments through to ACL injury and the treatment environment.

APPROACH

We draw on social epidemiological theories of the embodiment of gender and health to provide plausible examples of how gender may influence ACL injury, and demonstrate the opportunity for new, interdisciplinary research in the field.

CONCLUSION

Over 20 years of research has failed to decrease the ACL injury rate disparity between girls/women and boys/men. Embedding gender in the study of ACL injury will heighten awareness of possible influences outside the traditional biological elements, challenge us to think about the inextricable 'entanglement' of sex and gender, and inform more effective approaches to ACL injury prevention and treatment.

Reliability and Concurrent Validity of Shoulder Tissue Irritability Classification

OBJECTIVE

Rating tissue irritability has been recommended to aid decision making in several recent clinical practice guidelines. An explicit method for rating tissue irritability was proposed as part of the Staged Algorithm for Rehabilitation Classification: Shoulder Disorders (STAR-Shoulder), but the reliability and validity of this classification are unknown. The purpose of this study was to examine the reliability and concurrent validity of shoulder tissue irritability ratings as part of a system designed to guide appropriate treatment strategy and intensity.

METHODS

A clinical measurement, prospective repeated-measures cross-sectional design was used. The 101 consecutive participants with primary complaints of shoulder pain were assessed by pairs of blinded raters (24 raters in total) and rated for tissue irritability. Patients completed 3 patient-reported outcome (PRO) measures reflecting both pain and disability, and these scores were compared with ratings of tissue irritability. Paired ratings of irritability were analyzed for reliability with prevalence-adjusted, bias-adjusted Kappa for ordinal scales. Analysis of variance was used to compare PRO measures across different levels of irritability. Receiver operating characteristic curve analysis was utilized to derive cut-off scores for 3 PRO instruments.

RESULTS

Interrater reliability was 0.69 (95% CI = 0.59-0.78), with 67% agreement. All PRO measures were significantly different among 3 levels of tissue irritability.

CONCLUSION

There appears to be acceptable reliability and a strong relationship between PRO measures and therapist-rated tissue irritability, supporting the use of the STAR-Shoulder irritability rating system.

IMPACT

Several clinical practice guidelines have recommended that clinicians rate tissue irritability as part of their examination. This study provides important new information supporting the reliability and validity of the STAR-Shoulder tissue irritability rating system.