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.

Examination of the Lumbar Movement Pattern during a Clinical Test and a Functional Activity Test in People with and without Low Back Pain.

BACKGROUND: It is assumed that the lumbar movement pattern observed during a clinical test is representative of the movement pattern used during a functional activity. Very little is known about how the lumbar movement pattern during a clinical test is associated with the lumbar movement pattern during a functional activity and how the lumbar movement pattern is associated with functional limitation. OBJECTIVE: The purpose was to examine the lumbar movement pattern during a clinical test and a functional activity test in people with and people without low back pain (LBP), and the relationship of lumbar motion to LBP-related functional limitation. DESIGN: Observational study. PARTICIPANTS: 16 back-healthy adults and 32 people with chronic LBP. METHODS: Participants performed a standardized clinical test of forward bending and a functional activity test of picking up an object. MAIN OUTCOME MEASUREMENTS: Maximal lumbar excursion and lumbar excursion at 0% to 50% and 50% to 100% of movement time were examined. RESULTS: Significant associations were present between the two movement tests for both back-healthy people and people with LBP (r = 0.47-0.73). In people with LBP the amount of lumbar motion in the 0% to 50% of movement time interval for both tests was significantly associated with functional limitation (r = 0.43-0.62). CONCLUSION: Lumbar movement patterns were similar between the two tests, and lumbar motion early in the movement of a functional test was related to self-report of functional limitation. LEVEL OF EVIDENCE: III.

Diffusion Tensor Imaging of the Calf Muscles in Subjects With and Without Diabetes Mellitus.

BACKGROUND: Diffusion tensor imaging (DTI) has been used to characterize calf skeletal muscle architecture. PURPOSE: To assess the diffusional properties of the calf muscles of subjects with and without diabetes, at rest and during isometric plantarflexion exercise. STUDY TYPE: Prospective. SUBJECTS: Twenty-six subjects in two groups: 13 healthy and 13 subjects with type 2 diabetes (DM); each group consisted of seven females and six males. FIELD STRENGTH/SEQUENCE: 3T/2D single-shot spin echo planar imaging. ASSESSMENT: Fractional anisotropy (FA), mean diffusivity (MD), diffusion eigenvalues, and fiber tracking indices were obtained from the medial gastrocnemius (MG), lateral gastrocnemius (LG), and soleus (SOL) muscles of the calf at rest and during isometric plantarflexion exercise. STATISTICAL TESTS: We used a combination of nonparametric (Wilcoxon) and parametric (t-test) statistical assessments. RESULTS: The medial gastrocnemius muscle had more indices with significant differences between the two groups (six indices with P < 0.05) than did the lateral gastrocnemius (three indices with P < 0.05) and soleus muscles (only one index with P < 0.05). While the healthy group showed elevated MD values from rest to exercise (MG = 5.83%, LG = 13.45%, and SOL = 11.68%), the diabetic MD showed higher increases (MG = 19.74%, LG = 29.31%, and SOL = 20.84%) that were different between groups (MG: P = 0.009, LG: P = 0.037, and SOL: P = 0.049). DATA CONCLUSION: Our results indicate considerable diffusional changes between healthy subjects and subjects with diabetes at rest and during isometric plantarflexion exercise in the calf muscles. The medial gastrocnemius muscle displayed the most diffusion sensitivity to diabetes-related microstructural changes. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;49:1285-1295.

Intravenous contrast-free standardized exercise perfusion imaging in diabetic feet with ulcers.

BACKGROUND: Impaired foot perfusion is a primary contributor to foot ulcer formation. There is no existing device nor method that can be used to measure local foot perfusion during standardized foot muscle exercise in an MRI environment. PURPOSE: To develop a new MRI-compatible foot dynamometer and MRI methods to characterize local perfusion in diabetic feet with ulcers. STUDY TYPE: Prospective. POPULATION/SUBJECTS: Seven participants without diabetes and 10 participants with diabetic foot ulcers. FIELD STRENGTH/SEQUENCE: 3.0T, arterial spin labeling (ASL). ASSESSMENTS: Using a new MRI-compatible foot dynamometer, all participants underwent MRI ASL perfusion assessment at rest and during a standardized toe-flexion exercise. The participants without diabetes were scanned twice to assess the reproducibility of perfusion measurements. The absolute perfusion and perfusion reserve values were compared between two groups and between regions near ulcers (peri-ulcer) and away from ulcers (away-ulcer). STATISTICAL TESTS: Bland-Altman methods for the calculation of coefficient of repeatability (CR) and two-sided and unpaired Student's t-test to compare multiple differences. RESULTS: The perfusion reserves measured had the best reproducibility (CR in medial region: 1.6, lateral region: 0.9). The foot perfusion reserve was significantly lower in the participants with diabetes compared with the participants without diabetes (1.34 ± 0.32, 95% confidence interval [CI]: 1.1, 1.58 vs. 1.76 ± 0.31, 95% CI: 1.53, 1.98, P = 0.02). Both peri-ulcer exercise perfusion (8.7 ± 3.9 ml/min/100g) and perfusion reserve (1.07 ± 0.39, 95% CI: 0.78, 1.35) were significantly lower than away-ulcer exercise perfusion (12.7 ± 3.8 ml/min/100g, P = 0.02) and perfusion reserve (1.39 ± 0.37, 95% CI: 1.11, 1.66, P = 0.03), respectively. DATA CONCLUSION: This study demonstrates intravenous contrast-free methods for local perfusion in feet with ulcers by standardized exercise-based MRI. Ischemia regions around foot ulcers can be quantitatively distinguished from normal perfused muscle regions. LEVEL OF EVIDENCE: 2 Technical Efficacy: Stage 2 J. Magn. Reson. Imaging 2019;50:474-480.

Effect of a Shoulder Movement Intervention on Joint Mobility, Pain, and Disability in People With Diabetes: A Randomized Controlled Trial.

Background: People with diabetes are at high risk for shoulder pain, limited joint mobility, and adhesive capsulitis. Objective: The objective of this study was to evaluate the effects of a shoulder movement intervention (ShoMo) compared to a wellness intervention on the primary outcomes of active shoulder flexion and reported Shoulder Pain and Disability Index (SPADI) measured after intervention and 9 months later. Design: The design was a prospective, randomized, controlled clinical trial. Setting: The setting was a research center at an academic medical center. Participants: Fifty-two participants with type 2 diabetes and shoulder pain or limited motion were randomized to a group receiving ShoMo (N = 27; mean age = 59.3; SD = 7.0) or a group receiving wellness activities (N = 25; mean age = 57.9; SD = 7.7). Intervention: The ShoMo group received instruction in a progressive, active shoulder movement program. The wellness group received instruction in diabetes management. Measurements: Measurements were made at baseline, after 3 months of intervention, and at 6, 9, and 12 months after baseline. Results: After intervention, the ShoMo group had a 7.2-degree increase in active shoulder flexion compared with the wellness group (95% CI = 0.9-13.5°), but there was no difference at subsequent follow-ups. The ShoMo group showed a 12.7-point improvement in the SPADI score compared to the wellness group after intervention (95% CI = 1.1-24.3), which remained better than the wellness group 9 months later. Limitations: The number of participants and duration of follow-up were inadequate to determine if intervention can help to prevent future severe shoulder problems. Conclusions: A progressive shoulder movement program can have meaningful effects on active motion and symptoms in people with type 2 diabetes and mild-to-moderate shoulder symptoms, with symptom improvement lasting at least 9 months.

Relationship of shoulder activity and skin intrinsic fluorescence with low level shoulder pain and disability in people with type 2 diabetes.

AIM: People with type 2 diabetes (T2DM) have a high incidence of musculoskeletal disorders thought to be influenced by high non-enzymatic advanced glycated end-products (AGEs). The goals of this study were to determine differences in shoulder activity level and AGEs in people with T2DM compared to matched controls, and to determine factors associated with shoulder pain and disability. METHODS: Eighty-one participants, T2DM (n=52) and controls (n=29), were examined for magnitude and duration of shoulder activity (measured using accelerometers), skin intrinsic florescence (SIF) as a surrogate measure of AGE level, and the Shoulder Pain and Disability Index (SPADI) as a self-report of shoulder pain and disability. RESULTS: Compared with controls, T2DM participants had 23% less shoulder activity (p=0.01), greater SIF level (3.6±1.7 vs 2.7±0.6AU, p=0.01), less shoulder strength (p<0.05), and the duration of their shoulder activity was moderately associated (r=0.40; p<0.01) with reported shoulder pain and disability. Shoulder pain and disability were not related to SIF level. CONCLUSIONS: Persons with T2DM have higher SIF levels and shoulder symptoms and disability indices than controls. Research is needed to determine if a shoulder mobility intervention to increase strength and mobility can help decrease shoulder pain and disability.

Asymmetry of lumbopelvic movement patterns during active hip abduction is a risk factor for low back pain development during standing.

An induced-pain paradigm has been used in back-healthy people to understand risk factors for developing low back pain (LBP) during prolonged standing. We examined asymmetry of lumbopelvic movement timing during a clinical test of active hip abduction in back-healthy people who developed LBP symptoms during standing (Pain Developers; PDs) compared to back-healthy people who did not develop LBP symptoms during standing (Non Pain Developers, NPDs). Participants completed the hip abduction test while movement was recorded with a motion capture system. Difference in time between start of hip and lumbopelvic movement was calculated (startdiff). PDs moved the lumbopelvic region earlier during left hip abduction than right hip abduction. There was no difference between sides in NPDs. In PDs, the amount of asymmetry was related to average symptom intensity during standing. Asymmetric lumbopelvic movement patterns may be a risk factor for LBP development during prolonged standing.

Psychological Factors Are Related to Pain Intensity in Back-Healthy People Who Develop Clinically Relevant Pain During Prolonged Standing: A Preliminary Study.

BACKGROUND: An induced-pain paradigm has been used to examine risk factors for the development of low back pain (LBP) during prolonged standing in back-healthy people (standing paradigm). Previous studies that used induced-pain methods suggest that pain intensity may be related to psychologic factors. It is not currently known, however, whether pain intensity reported during the standing paradigm is related to psychologic factors. OBJECTIVE: To examine the relationship between LBP symptom intensity and psychological factors (fear of pain and pain catastrophizing) in back-healthy people who develop LBP during prolonged standing. We hypothesized that symptom intensity during standing would be positively related to initial levels of fear of pain and pain catastrophizing in people who developed LBP during standing. DESIGN: Cross-sectional. SETTING: Movement science research center at an academic medical center. PARTICIPANTS: Fifty seven back-healthy participants. METHODS: Participants completed the Fear of Pain Questionnaire-III (FPQ-III) and Pain Catastrophizing Scale (PCS) before a 2-hour standing protocol. Participants rated LBP intensity on a 100-mm visual analogue scale (VAS) throughout standing and were classified as pain developers (PDs) or nonpain developers (NPDs). Relationships between LBP intensity and psychological measures were examined in PDs that did and did not have a ≥20 mm maximum VAS score. MAIN OUTCOME MEASUREMENTS: FPQ-III and PCS total scores, maximum and average VAS scores during standing. RESULTS: There were 24 (42%) PDs. Five PDs reported a maximum VAS score ≥20 mm. For PDs with a maximum VAS score <20 mm, correlations between average VAS scores and each psychological measure were small and nonsignificant (FPQ-III: r = 0.16, P = .50; PCS: r = 0.27, P = .26). For PDs with a maximum VAS score ≥20 mm, correlation between average VAS scores and FPQ-III was large and significant (r = 0.91, P = .03), and large for PCS but nonsignificant (r = 0.87, P = .06). CONCLUSION: These preliminary data suggest that if pain exceeds a clinically meaningful threshold (20 mm) during standing, pain intensity is related to psychological factors. Understanding factors that modulate acute pain response can inform early intervention strategies. LEVEL OF EVIDENCE: II.

Association between rotation-related impairments and activity type in people with and without low back pain.

OBJECTIVE: To determine whether people with low back pain (LBP) who regularly participated in a rotation-related activity displayed more rotation-related impairments than people without LBP who did and did not participate in the activity. DESIGN: Secondary analysis of data from a case-control study. SETTING: Musculoskeletal analysis laboratory at an academic medical center. PARTICIPANTS: A convenience sample of participants with LBP (n=55) who participated in a rotation-related sport, back-healthy controls (n=26) who participated in a rotation-related sport, and back-healthy controls (n=42) who did not participate in a rotation-related sport. Participants were matched based on age, sex, and activity level. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The total number of rotation-related impairments and asymmetrical rotation-related impairments identified during a standardized clinical examination. RESULTS: Compared with the back-healthy controls who do not play a rotation-related sport group, both the LBP and back-healthy controls who play a rotation-related sport groups displayed significantly more (1) rotation-related impairments (LBP, P<.001; back-healthy controls who play a rotation-related sport, P=.015), (2) asymmetrical rotation-related impairments (LBP, P=.006; back-healthy controls who play a rotation-related sport, P=.020), and (3) rotation-related impairments with trunk movement tests (LBP, P=.002; back-healthy controls who play a rotation-related sport, P<.001). The LBP group had significantly more rotation-related impairments with extremity movement tests than both of the back-healthy groups (back-healthy controls who play a rotation-related sport, P=.011; back-healthy controls who do not play a rotation-related sport, P<.001). CONCLUSIONS: The LBP and back-healthy controls who play a rotation-related sport groups demonstrated a similar number of total rotation-related impairments and asymmetrical rotation-related impairments, and these numbers were greater than those of the back-healthy controls who do not play a rotation-related sport group. Compared with people without LBP, people with LBP displayed more rotation-related impairments when moving an extremity. These findings suggest that impairments associated with extremity movements may be associated with having an LBP condition.

Is lumbar lordosis related to low back pain development during prolonged standing?

BACKGROUND: An induced-pain paradigm has been used in back-healthy people to understand risk factors for developing low back pain during prolonged standing. OBJECTIVES: The purposes of this study were to (1) compare baseline lumbar lordosis in back-healthy participants who do (Pain Developers) and do not (Non-Pain Developers) develop low back pain during 2 h of standing, and (2) examine the relationship between lumbar lordosis and low back pain intensity. DESIGN: Cross-sectional. METHOD: First, participants stood while positions of markers placed superficial to the lumbar vertebrae were recorded using a motion capture system. Following collection of marker positions, participants stood for 2 h while performing light work tasks. At baseline and every 15 min during standing, participants rated their low back pain intensity on a visual analog scale. Lumbar lordosis was calculated using marker positions collected prior to the 2 h standing period. Lumbar lordosis was compared between pain developers and non-pain developers. In pain developers, the relationship between lumbar lordosis and maximum pain was examined. RESULTS/FINDINGS: There were 24 (42%) pain developers and 33 (58%) non-pain developers. Lumbar lordosis was significantly larger in pain developers compared to non-pain developers (Mean difference = 4.4°; 95% Confidence Interval = 0.9° to 7.8°, Cohen's d = 0.7). The correlation coefficient between lumbar lordosis and maximum pain was 0.46 (P = 0.02). CONCLUSION: The results suggest that standing in more lumbar lordosis may be a risk factor for low back pain development during prolonged periods of standing. Identifying risk factors for low back pain development can inform preventative and early intervention strategies.

Validity of a Paradigm for Low Back Pain Symptom Development During Prolonged Standing.

OBJECTIVES: Examine the validity of an induced pain paradigm in which people stand while performing simulated light work tasks (standing paradigm). MATERIALS AND METHODS: Initially, people with low back pain (LBP) reported the quality and location of their typical symptoms on a body pain diagram. Then, people with LBP and back-healthy people stood for 2 hours and reported the intensity, quality, and location of symptoms at baseline and every 15 minutes. Quality and location of typical symptoms of people with LBP were compared with their symptoms during standing. Back-healthy people were separated into pain developers (PDs) and nonpain developers. Symptom quality and location were compared between people with LBP and PDs. RESULTS: There were no differences in the quality and location of typical symptoms and symptoms during standing in people with LBP (P>0.05). Three symptom descriptors were used by >30% of people with LBP to describe typical symptoms. Only 2 people with LBP used these descriptors to describe typical symptoms but not during standing. There were no differences in the quality and location of symptoms reported in standing between people with LBP and PDs (P>0.05). Four symptom descriptors were used by >30% of participants with LBP during standing. There were no symptoms reported by PDs that were not reported by people with LBP. DISCUSSION: This study provides evidence that symptoms experienced during the standing paradigm are similar to symptoms experienced by people with LBP and, thus, provides support for the validity of the paradigm.

The effects of postseason break on knee biomechanics and lower extremity EMG in a stop-jump task: implications for ACL injury.

The effects of training on biomechanical risk factors for anterior cruciate ligament (ACL) injuries have been investigated, but the effects of detraining have received little attention. The purpose of this study was to evaluate the effects of a one-month postseason break on knee biomechanics and lower extremity electromyography (EMG) during a stop-jump task. A postseason break is the phase between two seasons when no regular training routines are performed. Twelve NCAA female volleyball players participated in two stop-jump tests before and after the postseason break. Knee kinematics, kinetics, quadriceps EMG, and hamstring EMG were assessed. After one month of postseason break, the players demonstrated significantly decreased jump height, decreased initial knee flexion angle, decreased knee flexion angle at peak anterior tibial resultant force, decreased prelanding vastus lateralis EMG, and decreased prelanding biceps femoris EMG as compared with prebreak. No significant differences were observed for frontal plane biomechanics and quadriceps and hamstring landing EMG between prebreak and postbreak. Although it is still unknown whether internal ACL loading changes after a postseason break, the more extended knee movement pattern may present an increased risk factor for ACL injuries.

The effects of postseason break on stabilometric performance in female volleyball players.

Ankle sprain is a common injury in volleyball. Poor stabilometric performance (SP) is associated with high risks of sustaining ankle sprain. Balance training can improve SP and reduce ankle sprain, but no research has studied the effects of detraining on SP in highly trained athletes. The purpose of this study was to determine the effects of one-month postseason break on SP in female volleyball players. Eleven NCAA female volleyball players participated in two eye-closed single-leg stance tests before and after a one-month postseason break. Stance time, center of pressure (COP) area, COP standard deviation, and COP mean velocity were assessed during the tests. During the postseason break, subjects conducted self-selected exercise and the average training duration was 87% lower compared to the competition season. Subjects demonstrated significant increases in anterioposterior (A/P) COP standard deviation (1.6 +/- 0.4 vs. 1.8 +/- 0.4 cm, p = 0.05), mediolateral (M/L) COP velocity (6.5 +/- 1.5 vs. 7.1 +/- 1.3 cm/s, p = 0.05), and overall COP velocity (10.1 +/- 2.0 vs. 11.6 +/- 1.9 cm/s, p = 0.02) after postseason break. SP decreased in highly trained female volleyball players after one-month postseason break. The decrease in SP indicated a possible increased risk for ankle sprain injury.