Combined exercise and visual gaze training improves stepping accuracy in people with diabetic peripheral neuropathy.

INTRODUCTION: Patients with diabetes and diabetic peripheral neuropathy (DPN) place their feet with less accuracy whilst walking, which may contribute to the increased falls-risk. This study examines the effects of a multi-faceted intervention on stepping accuracy, in patients with diabetes and DPN. METHODS: Forty participants began the study, of which 29 completed both the pre and post-intervention tests, 8 patients with DPN, 11 patients with diabetes but no neuropathy (D) and 10 healthy controls (C). Accuracy of stepping was measured pre- and post-intervention as participants walked along an irregularly arranged stepping walkway. Participants attended a one-hour session, once a week, for sixteen weeks, involving high-load resistance exercise and visual-motor training. RESULTS: Patients who took part in the intervention improved stepping accuracy (DPN: +45%; D: +36%) (p < 0.05). The diabetic non-intervention (D-NI) group did not display any significant differences in stepping accuracy pre- to post- the intervention period (-7%). DISCUSSION: The improved stepping accuracy observed in patients with diabetes and DPN as a result of this novel intervention, may contribute towards reducing falls-risk. This multi-faceted intervention presents promise for improving the general mobility and safety of patients during walking and could be considered for inclusion as part of clinical treatment programmes.

Is There an Optimal Speed for Economical Running?

The influence of running speed and sex on running economy is unclear and may have been confounded by measurements of oxygen cost that do not account for known differences in substrate metabolism, across a limited range of speeds, and differences in performance standard. Therefore, this study assessed the energy cost of running over a wide range of speeds in high-level and recreational runners to investigate the effect of speed (in absolute and relative terms) and sex (men vs women of equivalent performance standard) on running economy. To determine the energy cost (kcal · kg-1 · km-1) of submaximal running, speed at lactate turn point (sLTP), and maximal rate of oxygen uptake, 92 healthy runners (high-level men, n = 14; high-level women, n = 10; recreational men, n = 35; recreational women, n = 33) completed a discontinuous incremental treadmill test. There were no sex-specific differences in the energy cost of running for the recreational or high-level runners when compared at absolute or relative running speeds (P > .05). The absolute and relative speed-energy cost relationships for the high-level runners demonstrated a curvilinear U shape with a nadir reflecting the most economical speed at 13 km/h or 70% sLTP. The high-level runners were more economical than the recreational runners at all absolute and relative running speeds (P < .05). These findings demonstrate that there is an optimal speed for economical running, there is no sex-specific difference, and high-level endurance runners exhibit better running economy than recreational endurance runners.

Running Technique is an Important Component of Running Economy and Performance.

Despite an intuitive relationship between technique and both running economy (RE) and performance, and the diverse techniques used by runners to achieve forward locomotion, the objective importance of overall technique and the key components therein remain to be elucidated. PURPOSE: This study aimed to determine the relationship between individual and combined kinematic measures of technique with both RE and performance. METHODS: Ninety-seven endurance runners (47 females) of diverse competitive standards performed a discontinuous protocol of incremental treadmill running (4-min stages, 1-km·h increments). Measurements included three-dimensional full-body kinematics, respiratory gases to determine energy cost, and velocity of lactate turn point. Five categories of kinematic measures (vertical oscillation, braking, posture, stride parameters, and lower limb angles) and locomotory energy cost (LEc) were averaged across 10-12 km·h (the highest common velocity < velocity of lactate turn point). Performance was measured as season's best (SB) time converted to a sex-specific z-score. RESULTS: Numerous kinematic variables were correlated with RE and performance (LEc, 19 variables; SB time, 11 variables). Regression analysis found three variables (pelvis vertical oscillation during ground contact normalized to height, minimum knee joint angle during ground contact, and minimum horizontal pelvis velocity) explained 39% of LEc variability. In addition, four variables (minimum horizontal pelvis velocity, shank touchdown angle, duty factor, and trunk forward lean) combined to explain 31% of the variability in performance (SB time). CONCLUSIONS: This study provides novel and robust evidence that technique explains a substantial proportion of the variance in RE and performance. We recommend that runners and coaches are attentive to specific aspects of stride parameters and lower limb angles in part to optimize pelvis movement, and ultimately enhance performance.

Altered joint moment strategy during stair walking in diabetes patients with and without peripheral neuropathy.

AIM: To investigate lower limb biomechanical strategy during stair walking in patients with diabetes and patients with diabetic peripheral neuropathy, a population known to exhibit lower limb muscular weakness. METHODS: The peak lower limb joint moments of twenty-two patients with diabetic peripheral neuropathy and thirty-nine patients with diabetes and no neuropathy were compared during ascent and descent of a staircase to thirty-two healthy controls. Fifty-nine of the ninety-four participants also performed assessment of their maximum isokinetic ankle and knee joint moment (muscle strength) to assess the level of peak joint moments during the stair task relative to their maximal joint moment-generating capabilities (operating strengths). RESULTS: Both patient groups ascended and descended stairs slower than controls (p<0.05). Peak joint moments in patients with diabetic peripheral neuropathy were lower (p<0.05) at the ankle and knee during stair ascent, and knee only during stair descent compared to controls. Ankle and knee muscle strength values were lower (p<0.05) in patients with diabetic peripheral neuropathy compared to controls, and lower at knee only in patients without neuropathy. Operating strengths were higher (p<0.05) at the ankle and knee in patients with neuropathy during stair descent compared to the controls, but not during stair ascent. CONCLUSION: Patients with diabetic peripheral neuropathy walk slower to alter gait strategy during stair walking and account for lower-limb muscular weakness, but still exhibit heightened operating strengths during stair descent, which may impact upon fatigue and the ability to recover a safe stance following postural instability.

Diabetic peripheral neuropathy compromises balance during daily activities.

OBJECTIVE: Patients with diabetes with peripheral neuropathy have a well-recognized increased risk of falls that may result in hospitalization. Therefore this study aimed to assess balance during the dynamic daily activities of walking on level ground and stair negotiation, where falls are most likely to occur. RESEARCH DESIGN AND METHODS: Gait analysis during level walking and stair negotiation was performed in 22 patients with diabetic neuropathy (DPN), 39 patients with diabetes without neuropathy (D), and 28 nondiabetic control subjects (C) using a motion analysis system and embedded force plates in a staircase and level walkway. Balance was assessed by measuring the separation between the body center of mass and center of pressure during level walking, stair ascent, and stair descent. RESULTS: DPN patients demonstrated greater (P < 0.05) maximum and range of separations of their center of mass from their center of pressure in the medial-lateral plane during stair descent, stair ascent, and level walking compared with the C group, as well as increased (P < 0.05) mean separation during level walking and stair ascent. The same group also demonstrated greater (P < 0.05) maximum anterior separations (toward the staircase) during stair ascent. No differences were observed in D patients. CONCLUSIONS: Greater separations of the center of mass from the center of pressure present a greater challenge to balance. Therefore, the higher medial-lateral separations found in patients with DPN will require greater muscular demands to control upright posture. This may contribute to explaining why patients with DPN are more likely to fall, with the higher separations placing them at a higher risk of experiencing a sideways fall than nondiabetic control subjects.

Contributory factors to unsteadiness during walking up and down stairs in patients with diabetic peripheral neuropathy.

OBJECTIVE: Although patients with diabetic peripheral neuropathy (DPN) are more likely to fall than age-matched controls, the underlying causative factors are not yet fully understood. This study examines the effects of diabetes and neuropathy on strength generation and muscle activation patterns during walking up and down stairs, with implications for fall risk. RESEARCH DESIGN AND METHODS: Sixty-three participants (21 patients with DPN, 21 diabetic controls, and 21 healthy controls) were examined while walking up and down a custom-built staircase. The speed of strength generation at the ankle and knee and muscle activation patterns of the ankle and knee extensor muscles were analyzed. RESULTS: Patients with neuropathy displayed significantly slower ankle and knee strength generation than healthy controls during stair ascent and descent (P < 0.05). During ascent, the ankle and knee extensor muscles were activated significantly later by patients with neuropathy and took longer to reach peak activation (P < 0.05). During descent, neuropathic patients activated the ankle extensors significantly earlier, and the ankle and knee extensors took significantly longer to reach peak activation (P < 0.05). CONCLUSIONS: Patients with DPN are slower at generating strength at the ankle and knee than control participants during walking up and down stairs. These changes, which are likely caused by altered activations of the extensor muscles, increase the likelihood of instability and may be important contributory factors for the increased risk of falling. Resistance exercise training may be a potential clinical intervention for improving these aspects and thereby potentially reducing fall risk.

Do patients with diabetic neuropathy use a higher proportion of their maximum strength when walking?

Diabetic patients have an altered gait strategy during walking and are known to be at high risk of falling, especially when diabetic peripheral neuropathy is present. This study investigated alterations to lower limb joint torques during walking and related these torques to maximum strength in an attempt to elucidate why diabetic patients are more likely to fall. 20 diabetic patients with moderate/severe peripheral neuropathy (DPN), 33 diabetic patients without peripheral neuropathy (DM), and 27 non-diabetic controls (Ctrl) underwent gait analysis using a motion analysis system and force plates to measure kinetic parameters. Lower limb peak joint torques and joint work done (energy expenditure) were calculated during walking. The ratio of peak joint torques and individual maximum joint strengths (measured on a dynamometer) was then calculated for 59 of the 80 participants to yield the 'operating strength' for those participants. During walking DM and DPN patients showed significantly reduced peak torques at the ankle and knee. Maximum joint strengths at the knee were significantly less in both DM and DPN groups than Ctrls, and for the DPN group at the ankle. Operating strengths were significantly higher at the ankle in the DPN group compared to the Ctrls. These findings show that diabetic patients walk with reduced lower limb joint torques; however due to a decrement in their maximum ability at the ankle and knee, their operating strengths are higher. This allows less reserve strength if responding to a perturbation in balance, potentially increasing their risk of falling.