Barefoot pressure distribution of diabetic patients and non-diabetic volunteer subjects after sensorimotor training with an unstable shoe construction.

BACKGROUND: Forty-three percent of all diabetic foot ulcers occur under the medial forefoot due to a medial deviation of elevated pressures and premature forefoot ground contact in neuropathic diabetic patients. A 6-week sensorimotor training period with an unstable shoe construction reduces in-shoe peak pressures and contact times under the medial aspect of the forefoot. METHODS: The study was designed as a Randomised Control Trial with two diabetic groups (one served as intervention group and one as control group) and one non-diabetic intervention group. Measurements for barefoot pressure distribution and contact times were taken by means of an Emed® pressure measurement platform (Novel GmbH, Munich) before and after 6 weeks. During this time the diabetic and the non-diabetic intervention groups were required to wear an unstable shoe construction (Masai Barefoot Technology, MBT®) for at least four hours per day. FINDINGS: Results for the non-diabetic intervention group showed significantly later contact times for the medial portion of the forefoot, resulting in shorter contact times. Peak pressure was also reduced under the medial aspect of the foot while it was increased under the lateral aspect of the foot. Changes for the diabetic intervention group followed the same pattern while the values of the diabetic control group shifted away from the reference values. INTERPRETATION: A 6-week sensorimotor training period with an unstable shoe construction can change barefoot peak pressures and contact times in non-diabetic subjects and in diabetic patients in the most endangered area, i.e. the medial forefoot.

Accuracy and repeatability of a semi-quantitative barefoot pressure measurement method for clinical use: The Derks Calculation Method.

BACKGROUND: This study was designed to assess the accuracy and repeatability of the Derks Calculation Method in the normal foot during walking. METHODS: Measurements were taken from 25 healthy subjects (age 32.0 ± 12.4), 23 females and 2 males, on five separate occasions at seven days, three weeks, three months, and nine months apart by means of a mid-gait method. Values were calculated for internal rotation (IR) and external rotation of the heel (ER), heel valgus/varus (HV), heel length (HL), heel width (HW), width of the midfoot (WM) and the forefoot (WF), and the length of the foot (LF). RESULTS: For all five separate occasions and in 87.5% of the parameters investigated, the coefficient of repeatability (CR, expressed as a percentage of the mean) was less than 5%. One parameter showed a high CR - heel valgus/varus (HV) was extremely high (>800%). The maximum 95% Confidence Interval (CI) for the five different occasions was no higher than 0.2 cm for IR, ER and HV with a standard error (SE) of 0.01 and >0.01 respectively. The maximum 95% CI for WF was 0.4 cm (SE 0.1), and for HW, WM and LF the maximum 95% CI was 0.7 cm (SE 0.1 or 0.2). HL showed the highest 95% CI (0.9 cm) with an SE of 0.2. CONCLUSION: The Derks Calculation Method was found to be accurate and repeatable if HV was excluded, which renders this method a viable clinical tool in settings where sophisticated computerised systems are still unavailable.

Normal pressure values and repeatability of the Emed® ST2 system.

OBJECTIVES: This study was designed to assess the repeatability of the Emed® ST2 system and identify the range of pressure values observed in the normal foot. METHODS: Measurements were taken from twenty-three healthy subjects, 14 females and 9 males, on two occasions 7 days apart. Begin of contact (BC), end of contact (EC), contact time (CT), peak pressure (PP), instant of peak pressure (IPP), contact area (CA) and pressure-time integral (PTI) were recorded. RESULTS: The coefficient of repeatability (CR) was less than 16.0% for all 63 parameters considered. In 87.3% of the parameters investigated (55 of 63) the CR (expressed as a percentage of the mean) was less than 10%. The highest areas of PP were found under the great toe and second metatarsal heads, with mean (S.D.) equal to 435 kPa (202) and 407 kPa (146), respectively, followed by the third metatarsal head 345 kPa (96) and the hindfoot 332 kPa (93). The CT (% ROP (range of pressure)) was in the range 74-85% under the metatarsal heads, and 71% under the great toe. CA was highest under the heel at 33.8 cm(2). CONCLUSION: Emed® ST2 system was found to be repeatable. The presented range of parameters compared very well to the results presented in the literature for the Emed® ST4 system.

Effects of back extensor strength training versus balance training on postural control.

PURPOSE: Aim of this study was to investigate effects of 1) regular back extensor strength training as opposed to balance training, and 2) the influence of the sequence of both training types on postural control, force, and muscle efficiency. METHODS: Twenty-six young, healthy subjects were investigated at baseline, 1 month and 2 months later. At each examination, subjects completed a posturographic, balance skill, and isometric maximum voluntary (MVC) back extension testing, including surface electromyographic (SEMG) recordings. After baseline evaluation, subjects were assigned to either daily strength training or balance training. After 1 month, the type of training was exchanged between groups. RESULTS: After 1 month, back extensor strengthening led to decreased postural stability on hard surface, whereas there were no change after balance skill training. Analysis of the low- and high-frequency components of the sway signal revealed that strength training increased control efforts as indicated by an increased high-frequency component in order to maintain postural stability and unchanged low-frequency component. Balance skill training, however, increased postural stability as indicated by a decreased low-frequency component. The control effort remained unchanged. After completing either sequence of training, all postural parameters remained unchanged in both groups. Muscular efficiency as measured by SEMG root mean square during a standardized motor skill task revealed improved muscle economy regardless of the type of training. Back extension torque improved in both groups. CONCLUSION: To avoid reduction of postural stability in rehabilitation processes, we recommend to include antagonist muscles in a comprehensive strength training regime or balance skill training.

Load-dependence of fatigue related changes in tremor around 10 Hz.

OBJECTIVES: The aim of the study was to investigate the effects of different loads on tremor around 10 Hz during fatiguing contractions. METHODS: Eighteen healthy volunteers performed sustained isometric knee extensions at 30%, 50% and 70% maximum voluntary contraction (MVC). During the fatiguing contractions, mechanical recordings were made with a high-resolution force sensor. Tremor-power was calculated for the 6-20 Hz frequency window as a function of time normalized to endurance time. RESULTS: Initial tremor power was different between the high and low load tasks. Changes of tremor with contraction time differed between the three tasks, in that tremor of the 30% MVC contraction showed the least decrease throughout the sustained contraction, whilst that of the 50% and 70% MVC showed progressively higher decreases. At failure, all 3 contractions merged to the same tremor level. CONCLUSION: Load-dependent, fatigue-related 6-20 Hz tremor changes during sustained submaximum voluntary contractions seem mainly the consequence of recruitment of new units and fatigue-related properties of the high threshold motor units of muscles.

The role of the biarticular agonist and cocontracting antagonist pair in isometric muscle fatigue.

Isometric knee extensions until exhaustion at 30%, 50%, and 70% of maximum voluntary contraction were performed by 18 healthy subjects. During muscle fatigue, surface electromyographic activity was recorded from the knee-extensors vastus lateralis, vastus medialis, and rectus femoris, and the coactive antagonistic biceps femoris. The electromyographic parameter median frequency (MF) served as a measure of fatigue. Coefficients of regression of the MF fatigue changes were analyzed statistically. MF fatigue occurred within the coactive biceps femoris and was significantly more pronounced than in the quadriceps. When the MF fatigue shifts of the coactive biceps femoris were compared with each of the three investigated parts of the quadriceps separately, MF fatigue shifts were similar in shape for the biarticular coactive biceps femoris and the biarticular rectus femoris, but differed significantly between the biceps femoris and the two monoarticular muscles, vastus medialis and vastus lateralis. As both the biarticular agonist and coactive antagonist muscles fatigued at a higher rate than the two monoarticular muscles, it seems likely that this biarticular agonist/antagonist pair determines the time to the limit of endurance.

[Evaluation of long-term results and donor site defects following transposition of connective tissue flaps]. / Evaluierung der Langzeitergebnisse und Hebedefekte nach Transposition des subpektoralen Gleitgewebslappens.

Nine patients suffering from chronic pain after surgery for thoracic outlet syndrome or after radiation therapy underwent neurolysis of the brachial plexus. To avoid a recurrence of scar formation, a pedicled subpectoral transposition flap of connective tissue, utilizing the pectoral branch of the A. thoraco-acromialis, was wrapped around the neurolyzed structures. Long-term follow-up results are presented.

Subpectoral gliding tissue flap.

By cadaver dissection, the anatomy of the connective tissue between the pectoralis major and the pectoralis minor muscle was studied. The possibility of creating a pedicled flap of gliding tissue based on the pectoral branch of the thoracoacromial artery was confirmed. The clinical relevance of this tissue was defined in nine patients. To avoid recurrent fibrosis after neurolysis of the structures of the brachial plexus in patients with recurrent pain syndromes, the envelopment of the neurolyzed nerves by a subpectoral gliding tissue flap was carried out and was successful in eight cases. After the transposition of the subpectoral gliding tissue flap, the remaining pectoralis major muscle showed only a small partial atrophy in the clavicular segment without any functional impairment; this was confirmed by physical examination and by electromyogram.

[Functional follow-up of combined musculocutaneous tensor fasciae latae and rectus femoris flap repair. Supplementary information on the Handchir. Mikrochir. Plast. Chir. 21 (1989) 315-317 contribution]. / Funktionelle Nachuntersuchung nach kombinierter muskulokutaner Tensor fasciae latae- und Rectus femoris-Lappenplastik. Ergänzung zur Arbeit Handchir. Mikrochir. Plast. Chir. 21 (1989) 315-317.

As a supplement to our publication in the Journal Handchirurgie, Mikrochirurgie, Plastische Chirurgie 21 (1989) 315-317, we would like to report a five-year follow up of a patient with recurrent sigmoid carcinoma, infiltrating all layers of the abdominal wall. Treatment was by radical tumor excision and reconstruction with a combined tensor fasciae latae and rectus femoris flap. Abdominal wall, hip, and knee functions were evaluated by gait-analysis (Motion Analysis Corporation AMTI) and dynamometry (Cybex 6000). The dynamometry of knee motion showed a slight deficit of the operated side regarding the parameters of strength-endurance as well as work-recovery. All other parameters (peak-torque) were equal for both sides corresponding to the activities of daily living of the patient. Gait-analysis showed a reduced rotation of the pelvis as well as a functional deficit of extension of the knee during stance and swing phase. We can document a good functional result in all motions without major impairment of every-day activities.

Gait after knee arthroplasty for femoral tumor. Foot pressure patterns recorded in 20 patients.

We evaluated pressure distribution patterns under the feet during gait in 20 patients after resection of malignant bone tumor and endoprosthetic replacement of the distal femur. In all cases, a modular cementless, hinged prosthesis had been used. The examination was performed after 4 (1-6) years. Shortened contact phase, decreased peak pressure, and reduced force-time integral during gait analysis were observed on the operated side. Peak pressure in the heel and the toe regions was decreased and the load (force-time integral) in the metatarsal heads and the big toe regions was reduced. There was a positive correlation between load under the foot and knee extension strength, measured isokinetically.

[Physical therapy of idiopathic spinal disorders]. / Physikalische Therapie idiopathischer Wirbelsäulenstörungen.

In Physical Medicine and Rehabilitation structural and functional disorders in the genesis of back pain are of great importance. From an epidemiological point of view this has great consequences. Active and passive forms of physical therapy are available. Assuming that the intradiscal pressure has an influence on the origin of back pain, the aim of physiotherapy has to be that any movement of the vertebral column has to be controlled with a minimum of muscular contraction. Passive forms of physical therapy like heat and cold, electrotherapy or mechanotherapy have a reflective reaction beside a physical effect. Sometimes a combination of active and passive forms are of benefit. Every treatment concept has to pay regard to the actuality of pain, the load of every day life and the physical and social situation of the patient. Last but not least one has to learn to cope with the pain.

Knee function after operation for malignancy of the distal femur. Quadriceps muscle mass and knee extension strength in 21 patients with hinged endoprostheses.

We evaluated quadriceps muscle mass and knee extension strength in 21 patients after resection and endoprosthetic replacement of the distal femur for malignant bone tumor. In all cases, a modular cementless, hinged prosthesis had been used. The mean follow-up period was 4 (2-9) years. Muscle mass was measured ultrasonographically, and strength isokinetically with a Cybex 6000 dynamometer. All the data for the operated side are given as percentage of the non-operated side. The average quadriceps mass was 48 (27-70) percent. The average peak torque was 31 (14-48) and 36 (18-55) percent at the speed of 30 degrees/s and 90 degrees/s, respectively. The reduction in extension strength became greater with increasing flexion. There was a moderate correlation between muscle mass and muscle strength. Most of the patients who had kept more than 40 percent of the quadriceps mass had more than 30 percent peak torque. Patients with excellent function (Enneking 1987) had more quadriceps muscle mass and higher strength than those that were merely good with the borderline at about 40 percent muscle mass.

[Effects of flexed position of the wrist joint after flexor tendon sutures on the median nerve]. / Auswirkung der Beugestellung des Handgelenkes nach Beugesehnennähten auf den Nervus medianus.

Twelve patients with dynamically treated ruptures of finger flexor tendons the median nerve was electroneurologically examined at an average of 16 months after operation. The parameters were abnormal in about one third to three quarters of the patients. In accordance with literature the reason for this is seen in pronounced flexion position of the wrist during treatment according to Kleinert.

[Evaluation of shoulder function after removal of the latissimus dorsi muscle for surgical flap]. / Beurteilung der Schulterfunktion nach M. latissimus dorsi-Entnahme zur Lappenplastik.

The latissimus dorsi muscle is frequently used in reconstructive surgery. The present study was undertaken to determine the post-operative function of the shoulder girdle with respect to dominance in 26 patients following latissimus dorsi flap transplantation mainly for soft tissue coverage in the lower leg. The patients were interviewed and examined, with special attention being paid to shoulder mobility, dexterity and muscular strength. On interview, a considerable majority felt that very good results had been achieved. Raising the latissimus dorsi flap did however influence shoulder retroversion, particularly when surgery was performed on the non-dominant side. The influence of dominance was further noted as regards inward rotation of the shoulder and the ability to lead the hand backward over the shoulder. Dexterity was determined by a modified tapping test in the sagittal plane. Other than a minor correlation with age, post-operative function depended on whether the latissimus dorsi flap had been raised from the dominant or non-dominant shoulder. No effect of operation or dominance was observed in terms of isometric muscular strength, measured with an electronic device (Hottinger-Baldwin-Messtechnik). We believe that the function of the latissimus dorsi muscle can be compensated for by synergistic muscles. Yet, in rehabilitation, particular attention must be paid to the function of the non-dominant shoulder since it is used less in daily activity.

[Rehabilitation following reconstruction of the anterior cruciate ligament. The effect of a 6-week training program]. / Rehabilitation nach Rekonstruktion des vorderen Kreuzbands. Der Einfluss eines Sechs-Wochen-Trainingsprogramms.

Operations on the anterior cruciate ligament (ACL) represents a great challenge to the therapeutic team. Apart from early mobilisation, increasing attention must be paid to long-term after-care. Nineteen patients receiving reconstruction of the ACL underwent 6 weeks of training an average of 7.6 months after the procedure. At the start and end of the program, a dynamometric test (Dynamatik), and a function test, modified by Noyes, comprising a one-leg standing jump and hopping on one leg for six meters, were performed. Dynamometry revealed a clearly greater improvement in knee extension in the operated leg as compared with the non-operated leg, while the function tests revealed an improvement only in the operated leg. Correlation studies revealed no relationship between knee extension and function tests. For this reason, in addition to muscular strength, both training programs and after-care should take account also of the functional components of human locomotion, and should be carried out for a number of years.

[Electrotherapy of pain relief using the Tenzcare stimulator. A clinico-experimental study]. / Elektrotherapie zur Schmerzbekämpfung unter Verwendung des Tenzcare-Stimulators. Eine klinisch-experimentelle Studie.

Electrotherapy was introduced into the aftercare programme for patients with serial rib fractures in the acute stage, shoulder injuries or fractures of the radius. Electrical stimulation was carried out with the Tenzcare Nr. 6240 apparatus. The results were significantly better in each of the three groups than in the respective control group. Patients after thorax trauma complained less of pain in the acute phase: there was less pulmonary secretion on X-ray and, on average, their blood gas values returned to normal three days earlier. None of them required assisted respiration. Patients with shoulder injuries or fractures of the radius complained less frequently of pain during physio-therapy after removal of their plaster casts. They attained their optimum range of movement on average ten and eight days earlier, respectively than the controls.

[The effect of standardized acupuncture programs in the after-care of accident patients]. / Die Wirkung von standardisierten Akupunkturprogrammen in der Nachbehandlung von Unfallpatienten.

153 patients suffering from pain, edematous conditions, and impaired movement following traumas sustained in accidents were treated or after-treated with acupuncture. Acupuncture was applied in adherence to a standardized program according to the individual types of injury. The stimulus was applied by means of steel needles inserted into body as well as ear acupuncture points. In all 9 groups, improvement of the painful condition was significant to highly significant as it was regarding improvement of the movement impairment, the latter not having been emphasized in the other 3 groups. Remaining complaints of long standing following accident traumas could also be positively influenced. Acupuncture proved itself to be an effective form of therapy for after-treatment of accident patients, presenting a valuable supplement to the field of rehabilitation, especially when combined with other physical therapeutic measures.

[Testing the effect of acupuncture in accident patients using skin temperature measurements]. / Prüfung zur Wirkung der Akupunktur bei Unfallpatienten mittels Hauttemperaturmessung.

Skin temperature was studied on a group of 54 patients suffering from accident traumas and 20 healthy probands during and after treatment. In all patients there was a very significant rise in skin temperature in the area of the lesion which persisted beyond the treatment period, and in some cases even increased. This effect was also observed to a lesser extent on the contralateral, untreated extremity. No change in skin temperature was observed in the healthy probands who were treated in the same manner. This leads to the conclusion that needle stimuli in the area of lesions have not only a local, hyperemic effect, but also demonstrate superregional actions; this is, however, dependent on the integrity of the organism.