The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the ...prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at‐risk patient about appropriate foot self‐care and treat any pre‐ulcerative sign on the foot. Instruct moderate‐to‐high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non‐surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high‐risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days, and to reduce the patient and health care burden of diabetic foot disease.
Background:
Running-related injuries (RRIs) are a pervasive menace that can interrupt or end the participation of recreational runners in this healthy physical activity. To date, no satisfactory ...treatment has been developed to prevent RRIs.
Purpose:
To investigate the efficacy of a novel foot core strengthening protocol based on a ground-up approach to reduce the incidence of RRIs in recreational long-distance runners over the course of a 1-year follow-up.
Study Design:
Randomized controlled trial; Level of evidence, 1.
Methods:
The participants, 118 runners, were assessed at baseline and randomly allocated to either an intervention group (n = 57) or a control group (n = 61). The intervention group received an 8-week training course focused on the foot-ankle muscles, followed by remotely supervised training thereafter. Assessments consisted of 3 separate biomechanical evaluations of foot strength and foot posture and a weekly report on each participant’s running distance, pace, and injury incidence over 12 months.
Results:
The control group participants were 2.42 times (95% CI, 1.98-3.62) more likely to experience an RRI within the 12-month study period than participants in the intervention group (P = .035). Time to injury was significantly correlated with Foot Posture Index (P = .031; r = 0.41) and foot strength gain (P = .044; r = 0.45) scores. This foot exercise program showed evidence of effective RRI risk reduction in recreational runners at 4 to 8 months of training.
Conclusion:
Recreational runners randomized to the new foot core strengthening protocol had a 2.42-fold lower rate of RRIs compared with the control group. Further studies are recommended to better understand the underlying biomechanical mechanisms of injury, types of injuries, and subgroups of runners who might benefit maximally.
Registration:
NCT02306148 (ClinicalTrials.gov identifier).
The pivotal role of biomechanics in the past 50 years in consolidating the basic knowledge that underpins prevention and rehabilitation measures has made this area a great spotlight for health ...practitioners. In clinical practice, biomechanics analysis of spatiotemporal, kinematic, kinetic, and electromyographic data in various chronic conditions serves to directly enhance deeper understanding of locomotion and the consequences of musculoskeletal dysfunctions in terms of motion and motor control. It also serves to propose straightforward and tailored interventions. The importance of this approach is supported by myriad biomechanical outcomes in clinical trials and by the development of new interventions clearly grounded on biomechanical principles. Over the past five decades, therapeutic interventions have been transformed from fundamentally passive in essence, such as orthoses and footwear, to emphasizing active prevention, including exercise approaches, such as bottom-up and top-down strengthening programs for runners and people with osteoarthritis. These approaches may be far more effective inreducing pain, dysfunction, and, ideally, incidence if they are based on the biomechanical status of the affected person. In this review, we demonstrate evidence of the impact of biomechanics and motion analysis as a foundation for physical therapy/rehabilitation and preventive strategies for three chronic conditions of high worldwide prevalence: diabetes and peripheral neuropathy, knee osteoarthritis, and running-related injuries. We conclude with a summary of recommendations for future studies needed to address current research gaps.
To develop and validate the content of a free web-based software (desktop and mobile applications) for the self-management of and customised foot-ankle exercises for people with diabetes and diabetic ...neuropathy.
The development of the programme was based on gamification principles and addressed three main areas: foot care recommendations; self-assessment of feet according to the main complications of diabetic neuropathy; and customised foot-ankle exercises to strengthen muscles, increase the range of motion and improve functionality. The content was validated using the Delphi methodology and a quantitative approach in two rounds with diabetes specialists (n = 9) and users with diabetes (n = 20). A 70% approval rate was considered sufficient in the second round for final validation purposes. The data analysis was conducted using descriptive statistics, absolute and relative frequencies and the content-validity index (CVI).
Among specialists, the CVI was 0.812 after the first round, and final approval was 100% after the second round. Among users, the CVI was 0.902 in the first round, and the final approval was 97%.
This free access web software was developed based on the high agreement rating between specialists and users and has the potential to prevent complications arising from diabetic polyneuropathy. It allows for self-monitoring and promotes personalised exercises, following a preventive model that can be applied in primary and secondary care services as a complementary treatment for chronic complications. However, further steps to validate the software in a larger population are recommended.
The medial-longitudinal arch (MLA) is perhaps the most important feature characterizing foot morphology. While current skin-markers based models of the MLA angle used in stereophotogrammetry allow to ...estimate foot arch shape and deformation, these do not always appear consistent with foot anatomy and with standard clinical definitions. The aim of this study was to propose novel skin-markers based measures of MLA angle and investigate their reliability during common motor tasks.
Markers on the calcaneus, navicular tuberosity, first metatarsal head and base, and on the two malleoli were exploited to test eight definitions of MLA angle consistent with foot anatomy, both as angles between two 3-dimensional vectors and as corresponding projections on the sagittal plane of the foot. The inter-trial, inter-session and inter-examiner reliability of each definition was assessed in multiple walking and running trials of two volunteers, tested by four examiners in three sessions.
Inter-trial variability in walking was in the range 0.7–1.2 deg, the inter-session 2.8–7.5 deg, and the inter-examiner in the range 3.7–9.3 deg across all MLA definitions. The Rizzoli Foot Model definition showed the lowest inter-session and inter-examiner variability. MLA measures presented similar variability in walking and running.
This study provides preliminary information on the reliability of MLA measurements based on skin-markers. According to the present study, angles between 3-dimensional vectors and minimal marker sets should be preferred over sagittal-plane projections. Further studies should be sought to investigate which definition is more accurate with respect to the real MLA deformation in different loading conditions.
During rowing, foot positioning on the foot stretcher is critical to optimise muscle force transmission and boat propulsion. Following the beneficial effects of textured insoles on gait and balance, ...this study aims at investigating whether passive stimulation of foot mechanoreceptors induced by these insoles may contribute to improving foot loading pattern and symmetry during indoor rowing.
Eleven elite rowers were assessed during controlled training on a standard rowing machine while wearing control, low-density or high-density textured insoles. Plantar pressure and knee and trunk kinematics were measured; performance data were recorded from the machine. Insole effect on kinematic parameters, peak and average values of foot force, contact area and position of centre of pressure was assessed with ANOVA and Bonferroni correction for pair-wise comparisons.
A main effect was observed for force and contact area, with the high-density insoles providing greatest values (P<0.035). No interaction was observed between side and insole (P>0.190), even though symmetry was higher with high-density insoles. Kinematics (P = 0.800) and rowing performance were not affected by insole type; a consistent though not statistically significant increase in mean travelled distance was observed for denser insoles (P>0.21).
The high-density textured insoles affected foot loading distribution during indoor rowing. Rowers applied greater foot force and over a greater foot stretcher area with the high-density than the low-density and control insoles. These findings and the methodology applied may be relevant for the understanding and monitoring of rowing performance.
This study sought to determine whether a foot-ankle therapeutic exercise program can improve daily physical activity (i.e. number of steps) and fast and self-selected gait speed in people with ...diabetic peripheral neuropathy (DPN). In this single-blind randomized controlled trial and intention-to-treat analysis, 78 volunteers with DPN were allocated into a control group, which received usual care, and an intervention group (IG), which received usual care plus a 12-week foot-ankle exercise program. The adherence at 12 weeks rate in the IG was 92.3% (36 participants) and the dropout was 5.1% in the control group (2 participants). The number of steps and self-selected gait speed did not change significantly in either group (p > 0.05), although a 1,365-step difference between groups were observed at 1-year followup. The 12-week foot-ankle therapeutic exercises improved significantly fast-gait speed (primary outcome) (p = 0.020), ankle range of motion (p = 0.048), and vibration perception (secondary outcomes) (p = 0.030), compared with usual-care at 12 weeks. At 24 weeks, the IG showed better quality of life than controls (p = 0.048). At 1-year, fast-gait speed and vibration perception remained higher in the IG versus controls. Overall, the program may be a complementary treatment strategy for improving musculoskeletal and functional deficits related to DPN.Trial registration ClinicalTrials.gov NCT02790931 (06/06/2016).
Pelvic floor muscle (PFM) force and coordination are related to urinary incontinence severity and to sexual satisfaction. Health professionals frequently combine classic PFM exercises with hip ...adduction/abduction contraction to treat these disorders, but the real benefits of this practice are still unknown. Based on a theoretical anatomy approach whereby the levator ani muscle is inserted into the obturator internus myofascia and in which force generated by hip movements should increase the contraction quality of PFMs, our aim was to investigate the effects of isometric hip adduction and abduction on PFM force generation. Twenty healthy, nulliparous women were evaluated using two strain-gauge dynamometers (one cylinder-like inside the vaginal cavity, and the other measuring hip adduction/abduction forces around both thighs) while performing three different tasks: (a) isolated PFM contraction; (b) PFM contraction combined with hip adduction (30% and 50% maximum hip force); and (c) PFM contraction combined with hip abduction (30% and 50% maximum hip force). Data were sampled at 100Hz and subtracted from the offset if existent. We calculated a gradient between the isolated PFM contraction and each hip condition (Δ Adduction and Δ Abduction) for all variables: Maximum force (N), instant of maximum-force occurrence (s), mean force in an 8-second window (N), and PFM force loss (N.s). We compared both conditions gradients in 30% and 50% by paired t-tests. All variables did not differ between hip conditions both in 30% and 50% of maximum hip force (p>.05). PFM contraction combined with isometric hip abduction did not increase vaginal force in healthy and nulliparous women compared to PFM contraction combined with isometric hip adduction. Therefore, so far, the use of hip adduction or abduction in PFM training and treatments are not justified for improving PFM strength and endurance.
Abstract
Background
This exploratory study aimed to investigate the extent to which mechanical properties of the plantar skin and superficial soft tissue (hardness, stiffness, and thickness) and ...vibration perception thresholds (VPTs) predict plantar pressure loading during gait in people with diabetes compared to healthy controls.
Methods
Mechanical properties, VPTs, and plantar loadings during gait at the heel and first metatarsal head (MTH) of 20 subjects with diabetes, 13 with DPN, and 33 healthy controls were acquired. Multiple regression analyses were used to predict plantar pressure peaks and pressure-time integrals at both locations based on the mechanical properties of the skin and superficial soft tissues and VPTs.
Results
In the diabetes group at the MTH, skin hardness associated with 30-Hz (R
2
= 0.343) and 200-Hz (R
2
= 0.314) VPTs predicted peak pressure at the forefoot. In the controls at the heel, peak pressure was predicted by the skin thickness, hardness, and stiffness associated with 30-Hz (R
2
= 0.269, 0.268, and 0.267, respectively) and 200-Hz (R
2
= 0.214, 0.247, and 0.265, respectively) VPTs.
Conclusion
The forefoot loading of people with diabetes can be predicted by the hardness of the skin when combined with loss of vibration perception at low (30-Hz) and high (200-Hz) frequencies. Further data from larger sample sizes are needed to confirm the current findings.
The practice of running has consistently increased worldwide, and with it, related lower limb injuries. The type of running surface has been associated with running injury etiology, in addition other ...factors, such as the relationship between the amount and intensity of training. There is still controversy in the literature regarding the biomechanical effects of different types of running surfaces on foot-floor interaction. The aim of this study was to investigate the influence of running on asphalt, concrete, natural grass, and rubber on in-shoe pressure patterns in adult recreational runners. Forty-seven adult recreational runners ran twice for 40 m on all four different surfaces at 12 ± 5% km · h
−1
. Peak pressure, pressure-time integral, and contact time were recorded by Pedar X insoles. Asphalt and concrete were similar for all plantar variables and pressure zones. Running on grass produced peak pressures 9.3% to 16.6% lower (P < 0.001) than the other surfaces in the rearfoot and 4.7% to 12.3% (P < 0.05) lower in the forefoot. The contact time on rubber was greater than on concrete for the rearfoot and midfoot. The behaviour of rubber was similar to that obtained for the rigid surfaces - concrete and asphalt - possibly because of its time of usage (five years). Running on natural grass attenuates in-shoe plantar pressures in recreational runners. If a runner controls the amount and intensity of practice, running on grass may reduce the total stress on the musculoskeletal system compared with the total musculoskeletal stress when running on more rigid surfaces, such as asphalt and concrete.
PDF
