Walking a day in a pachyonychia congenita patient's shoes: Impact on plantar pain and activity levels measured with wristband activity trackers.

Background Plantar keratoderma is a common finding in pachyonychia congenita, significantly impairing ambulation and quality of life. Due to the variation of pain reporting in pachyonychia congenita clinical studies, it is difficult to evaluate the efficacy of treatment outcomes for painful plantar keratodermas. Objectives To objectively analyse associations between plantar pain and activity levels in pachyonychia congenita patients using a wristband tracker. Methods Pachyonychia congenita patients and matched normal controls wore wristband activity trackers and completed a daily digital survey to record their highest and total pain scores (0-10 scale) each day for 28 consecutive days during four different seasons. Results Twenty four participants (12 pachyonychia congenita patients and 12 matched normal controls) completed the study. Pachyonychia congenita patients walked 1801.30 fewer steps/day (95% CI, -3666.4, 64.1) than normal controls (P = 0.072) and had greater average total [5.26; SD, 2.10] and highest (6.92; SD, 2.35) daily pain than normal controls [0.11 (SD, 0.47), 0.30 (SD, 0.22), respectively] (P < 0.001, both). On average, for each one unit increase in daily highest pain level, pachyonychia congenita activity decreased 71.54 steps/day (SE, 38.90, P = 0.066). Limitation The study had a small number of participants, limiting statistical power. Only pachyonychia congenita patients, ages 18 years or older, with keratin 6a, keratin 16, and keratin 17 mutations were included, limiting generalizability. Conclusion Pachyonychia congenita patients were less active with significantly higher pain than normal controls. There was an inverse correlation between pain and activity. Our findings suggest that wristband tracker technology may be used to evaluate treatment efficacy in future trials on severe plantar pain; therapeutic interventions that decrease plantar pain should correlate with significant increases in activity using wristband trackers.

Gait analysis of leprosy patients with foot drop using principal component analysis.

BACKGROUND: Peripheral nerve injury caused by leprosy can lead to foot drop, resulting in an altered gait pattern that has not been previously described using 3D gait analysis. METHODS: Gait kinematics and dynamics were analyzed in 12 patients with unilateral foot drop caused by leprosy and in 15 healthy controls. Biomechanical data from patients' affected and unaffected limbs were compared with controls using inferential statistics and a standard distance, based on principal components analysis (PCA). FINDINGS: Patients walked slower than controls (0.8 ± 0.2 vs. 1.1 ± 0.2 m/s, p = 0.003), with a reduced stance and increased swing percentage. The affected limb increased (p < 0.05) plantar flexion at the initial contact (-16.8o ± 8.3), terminal stance (-29.1o ± 11.5), and swing (-12.4o ± 6.2) in the affected limb compared to unaffected (-6.6o ± 10.3; -14.6o ± 11.6; 2.4o ± 7.6) and controls (-5.4o ± 2.5; -18.8o ± 5.8; -1.4o ± 3.9). Increased pelvic tilt and knee adduction/abduction range, with lower hip adduction, were observed. The second peak of ground reaction force (98.6 ± 5.2 %BW), ankle torque (0.99 ± 0.33 Nm/kg), and net ankle work in stance (-0.03 ± 5.4 J/Kg) decreased in the affected limb compared to controls (104.1 ± 5.5 %BW; 1.24 ± 0.4 Nm/kg; -4.58 ± 5.19 J/kg; p < 0.05). There were decreasing multivariate standard distances in the affected limb compared with the unaffected and controls. PCA loading factors highlighted the major differences between groups. INTERPRETATION: Leprosy patients with foot drop presented altered gait patterns in affected and unaffected limbs. There were remarkable differences in ankle kinematics and dynamics. Rehabilitation devices, such as ankle foot orthosis or tendon transfer surgeries to increase ankle dorsiflexion, could benefit these patients and reduce deviations from normal gait.

Prognostic comparison of the FRIEND and Wasserman/Hansen peak VO2 equations applied to a submaximal walking test in outpatients with cardiovascular disease.

AIMS: The aim of this study was to determine the ability to predict all-cause mortality using established per cent-predicted (%PRED) equations for peak oxygen consumption (VO2peak) estimated by a submaximal walk test in outpatients with cardiovascular disease. METHODS: Male patients (N = 1491) aged 62 ± 10 years at baseline underwent a moderate and perceptually regulated (11-13 on the 6-20 Borg scale) 1-km treadmill-walking test to estimate VO2peak. %PRED was derived from the Fitness Registry and the Importance of Exercise: A National Data Base (FRIEND) and the Wasserman/Hansen equations. RESULTS: There were 215 deaths during a median 9.4-year follow-up. The FRIEND prediction equation provided better prognostic information with receiver operating curve analysis showing significantly different areas under the curve (0.72 and 0.69 for the FRIEND and the Wasserman/Hansen equations respectively, p = 0.001). Overall mortality rate was higher across decreasing tertiles of %PRED using FRIEND, with 26%, 11% and 5% for the least fit, intermediate and high fit tertiles, respectively (p for trend < 0.0001). Compared with the least fit tertile, the adjusted hazard ratios for the second and third tertiles were 0.54 (95% confidence interval 0.34-0.87, p = 0.01) and 0.45 (95% confidence interval 0.25-0.81, p = 0.008), respectively. Each 1% increase in %PRED conferred a 3% improvement in survival (p = 0.0004). CONCLUSION: Low %PRED VO2peak in cardiac outpatients determined by the FRIEND equation was associated with a high mortality rate independent of traditional cardiovascular risk factors and clinical history. The FRIEND equation may provide a suitable normal standard when applied to clinically stable outpatients with cardiovascular disease.

Commentary: Suggesting Shinrin-yoku (forest bathing) for treating addiction.

Shinrin-yoku ('') (i.e., forest bathing), a Japanese wellbeing practice, aims to harmonise a person with a forest by bathing in the forest mindfully using our five senses (Miyazaki, 2018). Practitioners can choose whatever they like to focus on in the forest: different colours of leaves, the sounds of streams, or the warmth of sunshine beaming between leaves. Since the birth of this practice in 1982, shinrin-yoku has been widely used in the Japanese clinical fields (Hansen, Jones, & Tocchini, 2017). Recently, this healing practice has received attention from healthcare practitioners and researchers worldwide (Wen, Yan, Pan, Gu, & Liu, 2019). In this commentary, we will discuss limitations of the current shinrin-yoku research, and how future research can be conducted to appraise the effects of shinrin-yoku on addiction.

Relationship of preoperative neurologic score with intervals to regaining micturition and ambulation following surgical treatment of thoracolumbar disk herniation in dogs.

OBJECTIVE To estimate the times required for dogs to regain micturition and ambulation following surgical treatment for thoracolumbar Hansen type I intervertebral disk extrusion (IVDE) and determine whether these variables were associated with preoperative modified Frankel score (MFS). DESIGN Retrospective case series with nested cohort study. ANIMALS 54 dogs weighing < 20 kg (44 lb) that were surgically treated for Hansen type I IVDE at a referral hospital between January and December 2015. PROCEDURES Medical records and CT and MRI data were reviewed. Information was collected regarding dog signalment, type and duration of clinical signs, preoperative MFS, degree of spinal cord compression, type of medical and surgical treatment provided, and intervals from surgery to regaining micturition and ambulation (outcomes). Collected data were evaluated for correlations with outcomes. RESULTS Mean ± SD interval from surgery to regaining micturition was 4.1 ± 4.4 days, and mean interval from surgery to regaining ambulation was 13.8 ± 25.1 days. These intervals differed significantly. Significant negative correlations with MFS were identified for interval to regaining micturition (r = -0.63) and interval to regaining ambulation (r = -0.64). No other correlations with outcome were identified. CONCLUSIONS AND CLINICAL RELEVANCE The amount of time required for dogs to regain micturition and ambulation following surgery for thoracolumbar IVDE was correlated with preoperative severity of clinical signs, as reflected by preoperative MFSs. This information should be useful for pre- and postoperative decision-making and setting of expectations for owners of and clinicians treating affected dogs.

Determining the best percent-predicted equation for estimated VO2 peak by a 1-km moderate perceptually-regulated treadmill walk to predict mortality in outpatients with cardiovascular disease.

OBJECTIVES: To determine the prognostic ability of established percent-predicted equations of peak oxygen consumption (%PRED) estimated by a moderate submaximal walking test in a large cohort of outpatients with cardiovascular disease (CVD). DESIGN: Population-based prospective study. METHODS: A total of 1442 male patients aged 25-85 years at baseline, underwent a moderate perceptually-regulated (11-13 on the 6-20 Borg scale) treadmill walk (1k-TWT) for peak oxygen consumption estimation (VO2 peak). %PRED was derived from ACSM, Ades et al, Morris et al, and the Wasserman/Hansen equations, and their prognostic performance was assessed. Overall mortality was the end point. Participants were divided into quartiles of %PRED, and mortality risk was estimated using a Cox regression model. RESULTS: During a median 8.2year follow-up, 167 all-cause deaths occurred. The Wasserman/Hansen equation provided the highest prognostic value. Mortality rate was lower across increasing quartiles of %PRED. Compared to the first quartile, after adjustment for confounders, the mortality risk decreased for the second, third, and fourth quartiles, with HRs of 0.75 (95% CI 0.44-1.29, p=0.29), 0.67 (95% CI 0.38-1.18, p=0.17), and 0.37 (95% CI 0.10-0.78, p=0.009), respectively (p for trend <0.0001). Each 1% increase in %PRED conferred a 4% improvement in survival. CONCLUSIONS: The percent-predicted VO2 peak determined by Wasserman/Hansen equations applied to the 1k-TWT is inversely and significantly related to survival in cardiac outpatients. The 1k-TWT is a simple and useful tool for stratifying mortality risk in patients participating in secondary prevention programs.

Plantar pressure and daily cumulative stress in persons affected by leprosy with current, previous and no previous foot ulceration.

Not only plantar pressure but also weight-bearing activity affects accumulated mechanical stress to the foot and may be related to foot ulceration. To date, activity has not been accounted for in leprosy. The purpose was to compare barefoot pressure, in-shoe pressure and daily cumulative stress between persons affected by leprosy with and without previous or current foot ulceration. Nine persons with current plantar ulceration were compared to 15 with previous and 15 without previous ulceration. Barefoot peak pressure (EMED-X), in-shoe peak pressure (Pedar-X) and daily cumulative stress (in-shoe forefoot pressure time integral×mean daily strides (Stepwatch™ Activity Monitor)) were measured. Barefoot peak pressure was increased in persons with current and previous compared to no previous foot ulceration (mean±SD=888±222 and 763±335 vs 465±262kPa, p<0.05). In-shoe peak pressure was only increased in persons with current compared to without previous ulceration (mean±SD=412±145 vs 269±70kPa, p<0.05). Daily cumulative stress was not different between groups, although persons with current and previous foot ulceration were less active. Although barefoot peak pressure was increased in people with current and previous plantar ulceration, it did not discriminate between these groups. While in-shoe peak pressure was increased in persons with current ulceration, they were less active, resulting in no difference in daily cumulative stress. Increased in-shoe peak pressure suggests insufficient pressure reducing footwear in persons with current ulceration, highlighting the importance of pressure reducing qualities of footwear.

Foot impairments and limitations in walking activities in people affected by leprosy.

OBJECTIVE: To explore the relationships between perceived limitations in walking-related daily activities, walking ability (capacity), and the amount of daily walking (performance) in persons affected by leprosy and to identify their determinants. DESIGN: A cross-sectional study. SUBJECTS: Thirty-nine persons affected by leprosy. METHODS: Perceived limitations were assessed with the World Health Organization Disability Schedule II, domain "getting around". Walking capacity was assessed as covered distance in 6 min. Walking performance was recorded as mean strides/day with the Stepwatch(TM) 3 Activity Monitor. Potential determinants were sensory function, foot deformities, joint mobility, ankle muscle strength and co-morbidity. RESULTS: Perceived limitations in walking-related activities were significantly correlated with walking capacity (r = -0.47; p < 0.01) but not with walking performance, although walking capacity significantly correlated with walking performance (r = 0.38; p < 0.05). Various foot impairments independently contributed to reduced walking capacity and, to a lower degree, to perceived limitations in activities and performance. CONCLUSION: People affected by leprosy perceive limitations in walking-related activities that are determined by a reduced walking ability and the severity of foot impairments. Since perceived limitations in walking-related activities were not related to walking performance, perceived limitations are apparently weighted against the individual's needs.

Early active motion versus immobilization after tendon transfer for foot drop deformity: a randomized clinical trial.

BACKGROUND: Immobilization after tendon transfers has been the conventional postoperative management. Several recent studies suggest early mobilization does not increase tendon pullout. QUESTIONS/PURPOSES: To confirm those studies we determined whether when compared with immobilization early active mobilization after a tendon transfer for foot-drop correction would (1) have a similar low rate of tendon insertion pullout, (2) reduce rehabilitation time, and (3) result in similar functional outcomes (active ankle dorsiflexion, plantar flexion, ROM, walking ability, Stanmore score, and resolution of functional problems. METHODS: We randomized 24 patients with surgically corrected foot-drop deformities to postoperative treatment with early mobilization with active motion at 5 days (n = 13) or 4 weeks of immobilization with active motion at 29 days (n = 11). In both groups, the tibialis posterior tendon was transferred to the extensor hallucis longus and extensors digitorum communis for foot-drop correction. Rehabilitation time was defined as the time from surgery until discharge from rehabilitation with independent walking. The minimum followup was 16 months (mean, 19 months; range, 16-38 months) in both groups. RESULTS: We observed no case of tendon pullout in either group. Rehabilitation time in the mobilized group was reduced by an average of 15 days. The various functional outcomes were similar in the two groups. CONCLUSION: In patients with Hansen's disease, an early active mobilization protocol for foot-drop correction has no added risk of tendon pullout and provides similar functional outcomes compared with immobilization. Early mobilization had the advantage of earlier restoration of independent walking. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

The treatment of unstable ankle fractures in patients over eighty years of age.

BACKGROUND: The current study examined the outcomes of operative treatment of unstable ankle fractures in patients at least 80 years old at the time of injury. METHODS: Of 2,682 patients who presented for treatment of ankle fractures, 17 patients met the study criteria. These patients had open reduction and internal fixation after sustaining 15 closed and two open unstable ankle fractures. There were 11 type B fractures and six type C fractures by the Danis-Weber classification, and 12 supination-external rotation and five pronation-external rotation fractures by the Laugen-Hansen classification systems. RESULTS: When noncompliant patients who developed complications were removed from analysis, the fixation failure and deep infection rates were 0% each. CONCLUSIONS: These results highlight the importance of patient compliance and non-weightbearing status in the treatment of ankle fractures in patients over 80 years.

Mechanics of tarsal disintegration and plantar ulcers in leprosy by stress analysis in three dimensional foot models.

This paper describes three dimensional two arch models of feet of a normal subject and two leprosy subjects, one in the early stage and the other in the advanced stage of tarsal disintegration, used for analysis of skeletal and plantar soft tissue stresses by finite element technique using NISA software package. The model considered the foot geometry (obtained from X-rays), foot bone, cartilages, ligaments, important muscle forces and sole soft tissue. The stress analysis is carried out for the foot models simulating quasi-static walking phases of heel-strike, mid-stance and push-off. The analysis of the normal foot model shows that highest stresses occur at push-off over the dorsal central part of lateral and medial metatarsals and dorsal junction of calcaneus and cuboid and neck of talus. The skeletal stresses, in early state leprosy with muscle paralysis and in the advanced stage of tarsal distintegration (TD), are higher than those for the normal foot model, by 24% to 65% and 30% to 400%, respectively. The vertical stresses in the soft tissue at the foot-ground interface match well with experimentally measured foot pressures and for the normal and leprosy subjects they are the highest in the push-off phase. In the leprosy subject with advanced TD, the highest soft tissue stresses and shear stresses (about three times the normal value) occur in push-off phase in the scar tissue region. The difference in shear stresses between the sole and the adjacent soft tissue layer in the scar tissue for the same subject is about three times the normal value. It is concluded that the high bone stresses in leprosy may be responsible for tarsal distintegration when the bone mechanical strength decreases due to osteoporosis and the combined effect of high value of footsole vertical stresses, shear stresses and the relative shear stresses between two adjacent soft tissue layers may be responsible for plantar ulcers in the neuropathic leprosy feet.

Three-dimensional foot modeling and analysis of stresses in normal and early stage Hansen's disease with muscle paralysis.

The models of the foot available in the literature are either two- or three-dimensional (3-D), representing a part of the foot without considering different segments of bones, cartilages, ligaments, and important muscles. Hence, there is a need to develop a 3-D model with sufficient details. In this paper, a 3-D, two-arch model of the foot is developed, taking foot geometry from the X-rays of nondisabled controls and a Hansen's disease (HD) subject, and taking into consideration bones, cartilages, ligaments, important muscle forces, and foot sole soft tissue. The stress analysis is carried out by finite element (FE) technique using NISA software for the foot models, simulating quasi-static walking phases of heel-strike, midstance, and push-off. The analysis shows that the highest stresses occur during push-off phase in the dorsal central part of the lateral and medial metatarsals, the dorsal junction of the calcaneus, and the cuboid and plantar central part of the lateral metatarsals in the foot. The stresses in push-off phase in critical tarsal bone regions, for the early stage of HD with muscle paralysis, increase by 25-50% as compared with the control foot model. The model calculated stress results at the plantar surfaces are of the same order of magnitude as the measured foot pressures (0.2-0.5 MPa). The high stress concentration areas in the foot bones indicated above are of great importance, since it is found from clinical reports that in some subjects with pathogenic decrease in the mechanical strength of the bone from HD, these areas of bone are disintegrated. Therefore, this investigation could possibly provide an insight into the factors contributing to disintegration of tarsal bones in HD.

New on-line parameters for analysis of dynamic foot pressures in neuropathic feet of Hansen's disease subjects.

Pressures on the foot during walking are affected by the weight of the person and the walking velocity. It is also found that both the magnitude and duration of the dynamic foot pressures are important in ulcer formation in the neuropathic feet of persons with Hansen's disease (HD). Therefore, new parameters, Normalized Peak Pressure (NPP) and Pressure Contact Ratio (PCR), are calculated from dynamic foot pressure data in 10 defined areas of the feet of 52 nonimpaired controls and 108 persons with HD with different pathologies, using a long barograph that could accommodate at least two foot prints in one walking cycle. Statistical study of these new parameters, for various classes of HD subjects, shows significantly different mean values in the foot areas and hence could aid the clinician in better diagnosis and therapy planning. The second part of the article deals with on-line calculations and gray scale display of these parameter transforms for all the points on the plantar surfaces of both feet in a way that could help the clinician in quick analysis and better management and care of neuropathic feet.

Analysis of stresses in two-dimensional models of normal and neuropathic feet.

A two-dimensional model of the normal foot skeleton, which includes cartilages and ligaments, is used in this analysis of stresses during three quasi-static walking phases: heel-strike, mid-stance and push-off. It is found that in all the walking phases the maximum values of principal stresses occur in the dorsal anterior region of the talus, whereas the highest stress occurs in the push-off phase. The model is used for the simulation of muscle paralysis and its effect on the distribution of principal stresses. Subsequently, the model is used to analyse stresses in the deformed feet of three leprosy patients with complete paralysis of certain muscles. The results demonstrate that both the shape of the foot and the type of muscle paralysis contribute to the development of high stresses in different regions of the foot. These high stresses in regions with reduced mechanical strength could be one of the important factors in the process of tarsal disintegration in leprosy.

New image-processing system for analysis, display and measurement of static and dynamic foot pressures.

A new image-processing system, using a video digitiser with an IBM-compatible PC/AT, is developed for acquisition and processing of low-contrast, low-intensity barographic images of both feet for assessment of pressure distribution during standing and walking. Data displays, in the form of centres of pressures, isopressures contours, perspective views of pressures, grey scale image and walking pressure patterns, combined image of walking pressures, paths of centres of pressures and pressure variations with time, are developed. These have provided very useful and early information regarding the internal structural changes in the bones of the foot and sites at risk of ulcer development in leprosy subjects and enable suitable corrective orthopaedic procedures to be adopted.