Relationships within and between lower and upper extremity dysfunction in people with diabetes.

INTRODUCTION: Diabetes mellitus (DM) is associated with systemic musculoskeletal system impairments suggesting concurrent development of lower and upper extremity musculoskeletal problems. This study aims to examine relationships between lower and upper extremity function in people with DM. METHODS: Sixty people with type 2 DM and peripheral neuropathy [mean (standard deviation); 67(6) years old, DM duration 14(10) yrs] completed the following measures: 1) Self-reports of function: Foot and Ankle Ability Measure (FAAM; higher = better function) and Shoulder Pain and Disability Index (SPADI; lower = better function), 2) Range of motion (goniometry): ankle dorsiflexion and shoulder flexion, and 3) Strength: unilateral heel rise power (UHR, 3D kinetics) and hand grip dynamometry. Pearson correlations examined associations between lower and upper extremity measures, p < .05. RESULTS: Forty of 60 (67%) reported pain/disability in both the foot/ankle and shoulder and 95% of study participants had some limitation in foot or shoulder function. Significant between extremity correlations: FAAM and SPADI (r = -0.39), ankle dorsiflexion and shoulder flexion range of motion (r = 0.35), and UHR and hand grip strength (r = 0.40). Significant within extremity correlations: FAAM and UHR (r = .47) and SPADI with shoulder flexion (r = -0.44). CONCLUSION: Upper and lower extremity inter- and intra-relationships indicate systemic musculoskeletal impairments in people with DM. Healthcare practitioners should consider the potential for concurrent and disabling musculoskeletal problems in people with DM.

Three dimensional kinematics of visually classified lower extremity movement patterns during a single leg squat among people with chronic hip joint pain.

OBJECTIVE: Describe the proportional occurrence of visually determined, lower extremity movement patterns (dynamic knee valgus [DKVal], neutral [NEU], dynamic knee varus [DKVar]) during a single leg squat (SLSquat) among patients with chronic hip joint pain (CHJP). Compare 3D hip and pelvic kinematics among the categories and determine whether within-session movement pattern changes are possible among those who demonstrate DKVal or DKVar. Design: Cross-sectional. Setting: Movement science laboratory. Participants: 36 patients with CHJP (18 to 40 years). Main Outcome Measures: Visually based classification of lower extremity movement and 3D kinematic angles of hip and pelvis during SLSquat, performed under usual (self-selected) and modified (therapist instruction) conditions. Results: Based on visual appraisal, 14 patients demonstrated DKVal, 22 demonstrated NEU and none demonstrated DKVar. Those with DKVal demonstrated greater hip adduction (23.5 + 5.7º vs. 16.0 + 5.7º, p < 0.001) and internal rotation (7.4 + 7.1º vs. 1.6 + 7.0º, p = 0.023) than those with NEU. Compared to the usual condition, the DKVal group demonstrated significant decrease in hip adduction (23.5 + 5.7° vs. 20.9 + 5.8°, p = 0.001) and internal rotation (7.4 + 7.1° vs. 5.3 + 7.8°, p = .050) in the modified condition. Conclusions: Patients with CHJP demonstrated 2 movement patterns, DKVal and NEU. Compared to NEU, those with DKVal demonstrated greater hip adduction and internal rotation motion and were able to make small modifications to their movement pattern with therapist instruction.

Static and Dynamic Predictors of Foot Progression Angle in Individuals with and without Diabetes Mellitus and Peripheral Neuropathy.

INTRODUCTION: Foot progression angle (FPA) is a predictor of elevated regional plantar stresses and loads, which are indicators of dermal injury risk in individuals with diabetes mellitus and peripheral neuropathy (DMPN). FPA accounts for 15-45% of the variance in plantar stresses and loads in adults with DMPN. However, the biomechanical factors underlying an "out-toeing" gait pattern in this clinical population have not been examined. The primary purpose of this study was to identify static and dynamic predictors of foot progression angle magnitude in adults with and without DMPN. METHODS: Thirty-three adults with and 12 adults without diabetes mellitus participated. Hip rotation, ankle dorsiflexion, and resting calcaneal stance position were measured using a standard goniometer. Kinematic and kinetic data were collected during walking. RESULTS AND DISCUSSION: Static predictor variables did not significantly predict foot progression angle magnitude using multiple regression analysis. Of the dynamic predictor variables, thigh and shank lateral rotation accounted for 37% of foot progression angle variance (p<.01). CONCLUSIONS: Our results show that dynamic measures of external rotation of proximal segments (thigh, shank) during gait are strong predictors of foot progression angle. Static measures of limited joint mobility and joint position do not predict foot progression angle. These findings suggest that targeting the thigh and shank rotation using verbal or tactile cueing may be a potential strategy when trying to alter walking movement patterns towards decreasing external (lateral) FPA to minimize risk of elevated regional plantar stresses in adults with DMPN at risk for ulceration.

A pilot study of regional perfusion and oxygenation in calf muscles of individuals with diabetes with a noninvasive measure.

OBJECTIVE: To assess alterations in the regional perfusion and oxygenation of the calf muscles in individuals with diabetes. METHODS: Age-matched individuals with (n = 5) and without diabetes (n = 6) were investigated. Skeletal muscle perfusion, oxygen extraction fraction, and oxygen consumption rate were measured by newly developed noncontrast magnetic resonance imaging (MRI) techniques. The subjects lay supine on the MRI table with their foot firmly strapped to a custom-built isometric exercise device. The measurements were performed at rest and during an isometric plantar flexion muscle contraction. RESULTS: Individuals without diabetes had up to a 10-fold increase in muscle perfusion, 25% elevation in muscle oxygen extraction fraction, and a 12-fold increase in oxygen consumption rate in the calf during the plantar flexion isometric contraction. In patients with diabetes, the increases in these parameters were only up to sixfold, 2%, and sixfold, respectively. Exercise oxygen consumption rate was inversely associated with blood HbA1c levels (r(2) = .91). CONCLUSIONS: This is the first study to quantify regional skeletal muscle oxygenation in patients with diabetes using noncontrast MRI and warrants additional study. Attenuation of perfusion and oxygenation during exercise may have implications for understanding diabetic complications in the lower extremities.