Osteoarthritis and Diabetes: Where Are We and Where Should We Go?

Diabetes mellitus (DM) and osteoarthritis (OA) are chronic noncommunicable diseases that affect millions of people worldwide. OA and DM are prevalent worldwide and associated with chronic pain and disability. Evidence suggests that DM and OA coexist within the same population. The coexistence of DM in patients with OA has been linked to the development and progression of the disease. Furthermore, DM is associated with a greater degree of osteoarthritic pain. Numerous risk factors are common to both DM and OA. Age, sex, race, and metabolic diseases (e.g., obesity, hypertension, and dyslipidemia) have been identified as risk factors. These risk factors (demographics and metabolic disorder) are associated with DM or OA. Other possible factors may include sleep disorders and depression. Medications for metabolic syndromes might be related to the incidence and progression of OA, with conflicting results. Given the growing body of evidence indicating a relationship between DM and OA, it is vital to analyze, interpret, and integrate these findings. Therefore, the purpose of this review was to evaluate the evidence on the prevalence, relationship, pain, and risk factors of both DM and OA. The research was limited to knee, hip, and hand OA.

Sedentary Behavior Counseling Intervention in Aging People With Type 2 Diabetes: A Feasibility Study.

This study examined the feasibility and effect of sedentary behavior (SB) counseling on total sitting time (TST) and glycemic control in people with type 2 diabetes (T2D). Community-dwelling sedentary adults with T2D (n = 10; 8 women; age 65.6 ± 7.31) completed SB counseling (motivational interviewing-informed education about SB) aided by an activity monitor with a vibrotactile feature (activPAL3TM). The monitor was worn for 7 days, on weeks 1 and 13 (without the vibrotactile feature) and during weeks 5 and 9 (with the vibrotactile feature). Intervention feasibility was determined by study retention rates and activity monitor tolerability, and differences between pre- and post-intervention average daily TST. Paired t-test were performed. The effect size (ES) was calculated using Cohen d. All participants attended all study sessions with only 20% reporting moderate issues tolerating the activity monitor. TST time decreased from 11.8 hours ± 1.76 at baseline to 10.29 hours ± 1.84 at 3 months' assessment (P < .05) with a large ES (Cohen d = .88). HbA1c was decreased by 0.51% (P < .05) at the end of the intervention. This study found that the intervention was feasible for sedentary adults with type 2 diabetes.

Lower extremity MRI following 10-week supervised exercise intervention in patients with diabetic peripheral neuropathy.

INTRODUCTION: The purpose of this study was to characterize using MRI the effects of a 10-week supervised exercise program on lower extremity skeletal muscle composition, nerve microarchitecture, and metabolic function in individuals with diabetic peripheral neuropathy (DPN). RESEARCH DESIGN AND METHODS: Twenty participants with DPN completed a longitudinal trial consisting of a 30-day control period, during which subjects made no change to their lifestyle, followed by a 10-week intervention program that included three supervised aerobic and resistance exercise sessions per week targeting the upper and lower extremities. The participants' midcalves were scanned with multinuclear MRI two times prior to intervention (baseline1 and baseline2) and once following intervention to measure relaxation times (T1, T1ρ, and T2), phosphocreatine recovery, fat fraction, and diffusion parameters. RESULTS: There were no changes between baseline1 and baseline2 MRI metrics (p>0.2). Significant changes (p<0.05) between baseline2 and postintervention MRI metrics were: gastrocnemius medialis (GM) T1 -2.3%±3.0% and soleus T2 -3.2%±3.1%. Trends toward significant changes (0.050.3) and tibial nerve fractional anisotropy (p>0.6) and apparent diffusion coefficient (p>0.4). CONCLUSIONS: The 10-week supervised exercise intervention program successfully reduced adiposity and altered resting tissue properties in the lower leg in DPN. Gastrocnemius mitochondrial oxidative capacity and tibial nerve microarchitecture changes were not observed, either due to lack of response to therapy or to lack of measurement sensitivity.

Using Cognitive Behavioral Therapy for Insomnia in People with Type 2 Diabetes, Pilot RCT Part I: Sleep and Concomitant Symptom.

OBJECTIVE/BACKGROUND: The primary aim of this study was to examine the effect of Cognitive Behavioral Therapy for Insomnia (CBT-I) on the severity of insomnia in people with Type 2 diabetes (T2D) compared to a health education (HE) control group. The secondary aim was to explore the effect of CBT-I on other sleep outcomes and concomitant symptoms. PARTICIPANTS: Twenty-eight participants with T2D were randomly assigned to CBT-I (n = 14) or HE (n = 14). METHODS: Validated assessments were used at baseline and post intervention to assess sleep outcomes and concomitant symptoms. In addition, actigraph and sleep diaries were used to measure sleep parameters. Independent sample t tests and Mann-Whitney U tests were utilized to measure between-group differences in the mean change scores. RESULTS: Participants in the CBT-I group showed higher improvements in the following mean change scores compared to the HE group: insomnia symptoms (d = 1.78; p < .001), sleep quality (d = 1.53; p =.001), sleep self-efficacy (d = 1.67; p < .001). Both actigraph and sleep diary showed improvements in sleep latency and sleep efficiency in the CBT-I group as compared to the HE group. In addition, participants in the CBT-I group showed greater improvement in the mean change scores of depression symptoms (d = 1.49; p = .002) and anxiety symptoms (d = 0.88; p = .04) compared to the HE group. CONCLUSION: This study identified a clinically meaningful effect of CBT-I on sleep outcomes and concomitant symptoms in people with T2D and insomnia symptoms. Further work is needed to investigate the long-term effects of CBT-I in people with T2D and insomnia symptoms.

Test-Retest Reliability of activPAL in Measuring Sedentary Behavior and Physical Activity in People With Type 2 Diabetes.

BACKGROUND: To investigate how changes in sedentary behavior relate to health outcomes, it is important to establish the test-retest reliability of activity monitors in measuring habitual sedentary behavior in people with type 2 diabetes (T2D) as a prerequisite for interpreting this information. Thus, the authors' objective was to examine the test-retest reliability of a common activity monitor (activPAL™) in measuring sedentary behavior and physical activity in people with T2D. METHODS: Sedentary-time, standing-time, stepping-time, step-count, and sit-to-stand transitions were obtained from two 7-day assessment periods separated by at least 1 week. Test-retest reliability was determined with the intraclass correlation coefficient (ICC) to compare sedentary and activity measures between the 2 time points. RESULTS: A total of 30 participants with self-reported T2D completed the study (age 65 [6] y, 63% women, body mass index 33.3 [5] kg/m2). High test-retest reliability was found for sedentary-time (ICC = .79; 95% confidence interval [CI], .61-.89) and standing-time (ICC = .74; 95% CI, .53-.87). Very high test-retest reliability was found for stepping-time (ICC = .90; 95% CI, .81-.95), step-count (ICC = .91; 95% CI, .83-.96), and sit-to-stand transitions (ICC = .90; 95% CI, .79-.95). CONCLUSION: The activPAL™ device showed high to very high test-retest reliability in measuring all tested activity categories in people with T2D.

The effects of cognitive behavioral therapy for insomnia in people with type 2 diabetes mellitus, pilot RCT part II: diabetes health outcomes.

BACKGROUND: Previous studies have shown the negative impact of sleep disturbances, specifically insomnia symptoms, on glucose metabolism for people with type 2 diabetes (T2D). People with insomnia symptoms are at risk of poor glycemic control and suboptimal diabetes self-care behavior (DSCB). Investigating the impact of a safe and effective intervention for individuals with T2D and insomnia symptoms on diabetes' health outcomes is needed. Therefore, the aim of this exploratory study is to examine the effects of Cognitive Behavioral Therapy for Insomnia (CBT-I) on glycemic control, DSCB, and fatigue. METHODS: Twenty-eight participants with T2D and insomnia symptoms, after passing an eligibility criteria at a medical research center, were randomly assigned to CBT-I (n = 14) or Health Education (HE; n = 14). The CBT-I and HE groups received 6 weekly one-hour sessions. This Randomized Controlled Trial (RCT) used a non-inferiority framework to test the effectiveness of CBT-I. Validated assessments were administered at baseline and post-intervention to assess glycemic control, DSCB, and fatigue. A Wilcoxon signed-rank test was utilized to compare within-group changes from baseline to post-intervention. A Mann-Whitney test was utilized to measure the between-group differences. Linear regression was used to assess the association between the blood glucose level and the number of days in the CBT-I group. RESULTS: The recruitment duration was from October 2018 to May 2019. A total of 13 participants completed the interventions in each group and are included in the final analysis. No adverse events, because of being a part of this RCT, were reported. CBT-I participants showed significantly greater improvement in glycemic control, DSCB, and fatigue. There was a significant association between the number of days in the CBT-I intervention with the blood glucose level before bedtime (B = -0.56, p = .009) and after awakening in the morning (B = -0.57, p = .007). CONCLUSIONS: This study demonstrated a clinically meaningful effect of CBT-I on glycemic control in people with T2D and insomnia symptoms. Also, CBT-I positively impacted daytime functioning, including DSCB and fatigue. Future research is needed to investigate the long-term effects of CBT-I on laboratory tests of glycemic control and to understand the underlying mechanisms of any improvements. TRIAL REGISTRATION: Clinical Trials Registry ( NCT03713996 ). Retrospectively registered on 22 October 2018.

The Association of Diabetes With Knee Pain Locations, Pain While Walking, and Walking Speed: Data From the Osteoarthritis Initiative.

OBJECTIVE: Osteoarthritis (OA) and diabetes mellitus (DM) often coexist and can result in negative outcomes. DM can affect pain and walking speed in people with knee OA; however, the impact of DM on OA is understudied. The purpose of this study was to investigate the association between diabetes and knee pain locations, pain severity while walking, and walking speed in people with knee OA. METHODS: A cross-sectional analysis was used. Data from 1790 individuals from the Osteoarthritis Initiative (mean [SD] age = 69 [8.7] years) with knee pain were included and grouped into knee OA and diabetes (n = 236) or knee OA only (n = 1554). Knee pain locations were categorized as no pain, localized pain, regional pain, or diffuse pain. Knee pain during a 20-m walk test was categorized as no pain, mild, moderate, or severe knee pain. Walking speed was measured using the 20-m walk test. Multinomial and linear regression analyses were performed. RESULTS: Diabetes was associated with regional knee pain (odds ratio [OR] = 1.77; 95% CI = 1.01-3.11). Diabetes was associated only with moderate (OR = 1.78; 95% CI = 1.02-3.10) or severe (OR = 2.52; 95% CI = 1.01-6.28) pain while walking. Diabetes was associated with decreased walking speed (B = -0.064; 95% CI = -0.09 to -0.03). CONCLUSIONS: Diabetes was associated with regional knee pain but not with localized or diffuse knee pain and was associated with moderate to severe knee pain while walking and slower walking speed in people with knee OA. IMPACT: Clinicians can use a knee pain map for examining knee pain locations for people with diabetes and knee OA. Knee pain during walking and walking speed should be screened for people with knee OA and diabetes because of the influence of diabetes on these parameters in this population. LAY SUMMARY: Diabetes might be associated with specific knee pain locations, pain during activities such as walking, and reduced walking speed in people with knee OA.

Sleep Efficiency and Total Sleep Time in Individuals with Type 2 Diabetes with and without Insomnia Symptoms.

There is increasing awareness of the high prevalence of insomnia symptoms in individuals with type 2 diabetes (T2D). Past studies have established the importance of measuring sleep parameters using measures of central tendency and variability. Additionally, subjective and objective methods involve different constructs due to the discrepancies between the two approaches. Therefore, this study is aimed at comparing the averages of sleep parameters in individuals with T2D with and without insomnia symptoms and comparing the variability of sleep parameters in these individuals. This study assessed the between-group differences in the averages and variability of sleep efficiency (SE) and total sleep time (TST) of 59 participants with T2D with and without insomnia symptoms. Actigraph measurements and sleep diaries were used to assess sleep parameter averages and variabilities calculated by the coefficient of variation across 7 nights. Mann-Whitney U tests were utilized to compare group differences in the outcomes. Validated instruments were used to assess the symptoms of depression, anxiety, and pain as covariates. Objective SE was found to be statistically lower on average (85.98 ± 4.29) and highly variable (5.88 ± 2.57) for patients with T2D and insomnia symptoms than in those with T2D only (90.23 ± 6.44 and 3.82 ± 2.05, respectively). The subjective average and variability of SE were also worse in patients with T2D and insomnia symptoms, with symptoms of depression, anxiety, and pain potentially playing a role in this difference. TST did not significantly differ between the groups on averages or in variability even after controlling for age and symptoms of depression, anxiety, and pain. Future studies are needed to investigate the underlying mechanisms of worse averages and variability of SE in individuals with T2D and insomnia symptoms. Additionally, prompting the associated risk factors of insomnia symptoms in individuals with T2D might be warranted.

The Association of Diabetes with Knee Pain Severity and Distribution in People with Knee Osteoarthritis using Data from the Osteoarthritis Initiative.

Limited research has examined the association between diabetes mellitus (DM) and knee pain in people with osteoarthritis (OA). Therefore, this study aimed at examining the association between DM and knee pain severity, and to explore the association between DM and knee pain distribution (unilateral or bilateral versus no pain) in subjects with knee OA. This is a cross-sectional analysis of the baseline visit of individuals who were enrolled in the Osteoarthritis Initiative. Data of participants with knee OA were used for this analysis (n = 1319), and grouped into subjects with both knee OA and DM (n = 148) or knee OA only without DM (n = 1171). Pain severity was measured using a numeric rating scale from 0 to 10 over the past 7 and 30 days for each knee, and the more symptomatic knee with higher pain severity was chosen for analysis. DM was significantly associated with increased knee pain severity over 7 days (B 0.68; 95% CI 0.25-1.11) and over 30 days (B 0.59; 95% CI 0.17-1.01) after adjustments for all covariates, including age, gender, BMI, race, depression symptoms, composite OA score, use of pain medications, and knee injections. Multinomial regression showed that participants with knee OA and DM had 2.45 (95% CI 1.07-5.61) to 2.55 (95% CI 1.12-5.79) times higher likelihood of having unilateral and bilateral knee pain than those without DM and without knee pain. This study found that DM was associated with higher pain severity and unilateral and bilateral knee pain distribution.

A comparison of diabetes self-care behavior in people with type 2 diabetes with and without insomnia symptoms.

AIMS: Individuals with type 2 diabetes (T2DM) are advised to undertake diabetes self-care behavior (DSCB) in order to avoid complications of T2DM. However, comorbidities, such as insomnia symptoms which are commonly reported in people with T2DM, may limit the ability to engage in DSCB. Insomnia and the common sequelae accompanying insomnia such as pain, depression, and anxiety may negatively influence the performance of DSCB. Therefore, this study aimed to compare the DSCB of people with T2DM with and without insomnia symptoms. METHODS: Sixty participants with T2DM were divided into two groups based on the presence of insomnia symptoms: T2DM-only group and T2DM+ insomnia group. Insomnia symptoms were identified using the Insomnia Severity Index (ISI). DSCB was assessed using the Diabetic Care Profile (DCP). A standardized composite score was established to account for all of the DCP domains. Chi-square and independent sample t tests were used to assess between-group differences in categorical and continuous variables, respectively. Stepwise linear regression analysis used the ISI score to predict standardized DCP composite score, while controlling for covariates. RESULTS: Significant between-group differences were found in age, symptoms of pain, depression, and anxiety. The total DCP composite score was significantly lower in the T2DM+ insomnia group compared to the T2DM-only group (- 0.30 ± 0.46 vs. 0.36 ± 0.48, respectively, p < 0.001) with large effect size (g = 1.40). Stepwise linear regression results showed that a 1-point increase in ISI score significantly predicted a .03-point decrease in standardized DCP composite score, after controlling for age, symptoms of pain, depression, and anxiety (ß = - 0.03, p = 0.04). CONCLUSIONS: The data suggest that people with T2DM and insomnia symptoms had worse scores on the majority of the DSCB domains and a worse DCP composite score compared to people with T2DM only. The data suggest a negative association between insomnia severity and DSCB among people with T2DM. Further research using a larger sample size and more rigorous research design is required to examine the causal relationship between insomnia symptoms and DSCB.

Type 2 Diabetes Affects Joint Pain Severity in People with Localized Osteoarthritis: A Retrospective Study.

OBJECTIVE: To examine the association between type 2 diabetes (T2D) and pain severity in people with localized osteoarthritis (OA) and to explore the association between glycemic control, measured by hemoglobin A1c (HbA1c) level, and pain severity in people with localized OA and T2D. DESIGN: Retrospective study. SETTING: A tertiary medical center. SUBJECTS: Data from 819 patients (mean age = 65.08±9.77 years, 54.3% women) were used. METHODS: Patients were grouped to localized OA only (N = 671) and localized OA+T2D (N = 148) based on diagnosis codes. An index date was set as the first diagnosis date of localized OA and linked to pain severity, measured by numeric rating scale from 0 to 10. HbA1c values were obtained for patients with T2D within six months of the index date. Multiple linear regression was used. RESULTS: After controlling for age, gender, body mass index (BMI); diagnoses of depression, hypertension, dyslipidemia; OA locations; and medication list (+/- 90 days of the index date), T2D was significantly associated with increased pain severity (B = 1.07, 95% confidence interval [CI] = 0.25 to 1.88, P = 0.014). For patients with T2D and localized OA with available data for HbA1c (N = 87), the results showed that an increased HbA1c value was significantly associated with higher pain severity (B = 0.36, 95% CI = 0.036 to 0.67, P = 0.029) after controlling for age, gender, BMI, medications, and OA locations. CONCLUSION: T2D was associated with higher pain severity in people with localized OA, and poor glycemic control was associated with higher pain severity in people with localized OA+T2D. Clinicians should emphasize that better HbA1c control might help with pain management in people with T2D and OA.

Effect of Cognitive Behavioral Therapy for Insomnia on Insomnia Symptoms for Individuals With Type 2 Diabetes: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: Insomnia symptoms are a common form of sleep difficulty among people with type 2 diabetes (T2D) affecting sleep quality and health outcomes. Several interventional approaches have been used to improve sleep outcomes in people with T2D. Nonpharmacological approaches, such as cognitive behavioral therapy for insomnia (CBT-I), show promising results regarding safety and sustainability of improvements, although CBT-I has not been examined in people with T2D. Promoting sleep for people with insomnia and T2D could improve insomnia severity and diabetes outcomes. OBJECTIVE: The objective of this study is to establish a protocol for a pilot randomized controlled trial (RCT) to examine the effect of 6 sessions of CBT-I on insomnia severity (primary outcome), sleep variability, and other health-related outcomes in individuals with T2D and insomnia symptoms. METHODS: This RCT will use random mixed block size randomization with stratification to assign 28 participants with T2D and insomnia symptoms to either a CBT-I group or a health education group. Outcomes including insomnia severity; sleep variability; diabetes self-care behavior (DSCB); glycemic control (A1c); glucose level; sleep quality; daytime sleepiness; and symptoms of depression, anxiety, and pain will be gathered before and after the 6-week intervention. Chi-square and independent t tests will be used to test for between-group differences at baseline. Independent t tests will be used to examine the effect of the CBT-I intervention on change score means for insomnia severity, sleep variability, DSCB, A1c, fatigue, sleep quality, daytime sleepiness, and severity of depression, anxiety, and pain. For all analyses, alpha level will be set at .05. RESULTS: This study recruitment began in February 2019 and was completed in September 2019. CONCLUSIONS: The intervention, including 6 sessions of CBT-I, will provide insight about its effect in improving insomnia symptoms, sleep variability, fatigue, and diabetes-related health outcomes in people with T2D and those with insomnia symptoms when compared with control. TRIAL REGISTRATION: ClinicalTrials.gov NCT03713996; https://clinicaltrials.gov/ct2/show/NCT03713996. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/14647.

The prevalence of type 2 diabetes and associated risk factors with generalized osteoarthritis: a retrospective study using ICD codes for clinical data repository system.

OBJECTIVE: Type 2 diabetes mellitus (T2DM) has been associated with osteoarthritis (OA). T2DM may be associated with generalized OA (GOA ≥ 3 joints) rather than localized OA (LOA < 3 joints). The purpose of this study was to examine the prevalence of T2DM in people with GOA compared with LOA and to investigate the association between demographic risk factors and chronic diseases (i.e., T2DM, hypertension, dyslipidemia, neuropathy, and body mass index (BMI)) with GOA compared with LOA. METHODS: A retrospective review of data was performed, and patients with diagnostic codes for OA were selected. Identified codes included primary GOA, primary LOA, T2DM, hypertension, dyslipidemia, neuropathy, depression, anxiety, and sleep disorders. Information about BMI and medication list was obtained. Chi-square and logistic regression were performed to examine the prevalence and risk factors, respectively. RESULTS: Data from 3855 patients (mean age = 66.43 ± 11.02, 60.9% women) included patients with GOA (n = 1265) and LOA (n = 2590). The prevalence of T2DM was significantly greater among patients with GOA (25.8%) compared with those with LOA (12.0%); however, the GOA group were older. Based on age groups, T2DM was prevalent in 17.8% of GOA compared with 7.2% in LOA for younger adults (aged 45-64 years) and was prevalent in 28.8% of GOA compared with 15.7% in LOA for older adults (aged 65 years or older). The odds ratio of GOA increased in people with chronic diseases compared with those without including T2DM (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.05-1.78, p = 0.02), hypertension (OR 1.99, CI 1.63-2.43, p < 0.001), and dyslipidemia (OR 3.46, CI 2.86-4.19, p < 0.001), adjusting for covariates. CONCLUSION: Higher prevalence of T2DM was found in people with GOA when compared with LOA across both age groups. T2DM, hypertension, and dyslipidemia were associated with GOA. Future research with longitudinal designs is needed to test the causality of this association.Key Points• The prevalence of type 2 diabetes in people with generalized osteoarthritis was almost double compared with localized osteoarthritis, although generalized osteoarthritis group were older.• Among people with osteoarthritis, the risk of generalized osteoarthritis is increased by 37% when people had type 2 diabetes, by 99% when people had hypertension, and by 246% when people had dyslipidemia.

A Subgroup of Chronic Low Back Pain Patients With Central Sensitization.

BACKGROUND: Our knowledge of central sensitization (CS) in chronic low back pain (CLBP) is limited. 2011 fibromyalgia criteria and severity scales (2011 FM survey) have been used to determine FM positive as a surrogate of CS. The major features of CS including widespread hyperalgesia and dysfunction of the descending inhibitory pathways can be identified by pressure pain threshold (PPT) and conditioned pain modulation (CPM) tests. The purpose of the study was to examine neurophysiological characteristics and psychosocial symptoms in a subgroup of FM-positive CLBP compared with FM-negative CLBP patients. METHODS: A total of 46 participants with CLBP and 22 pain-free controls completed outcome measures of the 2011 FM survey, PPT and CPM tests, and psychosocial questionnaires. Differences between FM-positive and FM-negative CLBP participants on these measures and correlations were analyzed. RESULTS: The 2011 FM survey identified 22 (48%) participants with CLBP as FM positive. FM-positive CLBP participants showed lower PPT values of the thumbnail (P=0.011) and lower back (P=0.003), lower CPM values of the thumbnail (P=0.002), and more severe pain catastrophizing, anxiety, and depression symptoms (P<0.05) than FM-negative CLBP participants. The 2011 FM scores were significantly correlated with the PPT and CPM values of the thumbnail and with psychosocial symptoms (P<0.001). DISCUSSION: Our findings suggest a subgroup of CLBP patients exhibiting with signs and symptoms of CS. Associations between subjective and objective CS measures indicate that the 2011 FM survey can be utilized to identify the presence of CS in CLBP in clinical practice.

Functional Reach, Depression Scores, and Number of Medications Are Associated With Number of Falls in People With Chronic Stroke.

BACKGROUND: Falls are a common adverse event among people with stroke. Previous studies investigating risk of falls after stroke have relied primarily on retrospective fall history ranging from 6-12 months recall, with inconsistent findings. OBJECTIVES: To identify factors and balance assessment tools that are associated with number of falls in individuals with chronic stroke. DESIGN: Secondary analysis of a randomized clinical trial. SETTING: Multisite academic and clinical institutions. PARTICIPANTS: Data from 181 participants with stroke (age 60.67 ± 11.77 years, post stroke 4.51 ± 4.78 years) were included. METHODS: Study participants completed baseline testing and were prospectively asked about falls. A multivariate negative binomial regression was used to identify baseline predictive factors predicting falls: age, endurance (6 minute walk test), number of medications, motor control (Fugl-Meyer lower extremity score), depression (Patient Health Questionnaire-9), physical activity (number of steps per week), and cognition (Mini Mental Status Exam score). A second negative binomial regression analysis was used to identify baseline balance assessment scores predicting falls: gait velocity (comfortable 10 Meter Walk), Berg Balance Scale (BBS), Timed Up and Go (TUG), and Functional Reach Test (FRT). Receiver operating characteristic (ROC) and area under the curve (AUC) were used to determine the cutoff scores for significant predictors of recurrent falls. MAIN OUTCOME MEASUREMENT: The number of falls during the 42-week follow-up period. RESULTS: Baseline measures that significantly predicted the number of falls included increased number of medications, higher depression scores, and decreased FRT. Cutoff scores for the number of medications were 8.5 with an AUC of 0.68. Depression scores differentiated recurrent fallers at a threshold of 2.5 scores with an AUC of 0.62. FRT differentiated recurrent fallers at a threshold of 18.15 cm with an AUC of 0.66. CONCLUSIONS: Number of medications, depression scores, and decreased FRT distance at baseline were associated with increased number of falls. Increased medications might indicate multiple comorbidities or polypharmacy effect; increased depression scores may indicate psychological status; and decreased functional reach distance could indicate dynamic balance impairments. LEVEL OF EVIDENCE: II.

Multitasking in older adults with type 2 diabetes: A cross-sectional analysis.

BACKGROUND AND PURPOSE: Deficits in the ability to multitask contribute to gait abnormalities and falls in many at-risk populations. However, it is unclear whether older adults with type 2 diabetes mellitus (DM) also demonstrate impairments in multitasking. The purpose of this study was to compare multitasking performance in cognitively intact older adults with and without DM and explore its relationship to measures of gait and functional ability. METHODS: We performed a cross-sectional analysis of 40 individuals aged 60 and older with type 2 DM and a matched group of 40 cognitively intact older adults without DM. Multitasking was examined via the ambulatory Walking and Remembering Test (WART) and seated Pursuit Rotor Test (PRT). Self-selected normal and fast walking speed and stride length variability were quantitatively measured, and self-reported functional ability was assessed via the Late Life Function and Disability Index (LLFDI). RESULTS: Participants with DM walked slower and took more steps off path when multitasking during the WART. No between-group differences in multitasking performance were observed on the PRT. Multitasking performance demonstrated little correlation with gait and functional ability in either group. DISCUSSION AND CONCLUSIONS: Older adults with DM appear to perform poorly on an ambulatory measure of multitasking. However, we analyzed a relatively small, homogenous sample of older adults with and without type 2 DM and factors such as peripheral neuropathy and the use of multiple comparisons complicate interpretation of the data. Future research should explore the interactions between multitasking and safety, fall risk, and function in this vulnerable population. Clinicians should recognize that an array of factors may contribute to gait and physical dysfunction in older adults with type 2 diabetes, and be prepared to assess and intervene appropriately.

The impact of diabetes on mobility, balance, and recovery after repositioning maneuvers in individuals with benign paroxysmal positional vertigo.

AIM: The prevalence of benign paroxysmal positional vertigo (BPPV) is higher in people with type 2 diabetes (DM). The impact of DM on mobility, balance, and management of BPPV is unknown. This prospective study compared symptom severity, mobility and balance before and after the canalith repositioning maneuver (CRM) in people with posterior canal BPPV canalithiasis, with and without DM. METHODS: Fifty participants, BPPV (n=34) and BPPV+DM (n=16) were examined for symptom severity (dizziness handicap inventory, DHI), mobility (functional gait assessment, FGA), and postural sway (using an accelerometer in five conditions) before and after the CRM. The number of maneuvers required for symptom resolution was recorded. RESULTS: At baseline, no differences in DHI or FGA scores were seen between groups, however, people with BPPV+DM had higher sway velocity in the medio-lateral direction in tandem stance (p<0.01). After treatment, both groups improved in DHI and FGA scores (p<0.01), with no differences between groups. Decrease in sway velocity in the mediolateral direction (p=0.003) were seen in tandem stance in persons with BPPV+DM. There were no differences between the groups in the number of CRMs provided. CONCLUSIONS: This pilot study showed no differences in symptom severity, mobility deficits or efficacy of CRM treatments in people with posterior canal BPPV canalithiasis with and without DM. Future studies examining the impact of the severity and duration of diabetes, as well as the influence of diabetic peripheral neuropathy on functional performance are essential.

Postural sway in individuals with type 2 diabetes and concurrent benign paroxysmal positional vertigo.

BACKGROUND AND PURPOSE: diabetes has been shown to affect the peripheral vestibular end organs and is associated with an increase in the frequency of benign paroxysmal positional vertigo (BPPV). People with diabetes have higher postural sway; however, the impact of symptomatic BPPV on postural sway in individuals with diabetes is unclear. The purpose of this cross-sectional study was to examine postural sway in people with type 2 diabetes who have symptomatic, untreated BPPV (BPPVDM). METHODS: fifty-two participants (mean age 56.9 ± 5.6 years) were enrolled: controls (n = 14), diabetes (n = 14), BPPV only (n = 13) and BPPVDM (n = 11). An inertial motion sensor was used to detect pelvic acceleration across five standing conditions with eyes open/closed on firm/foam surfaces. Range of acceleration (cm/s2), peak velocity (cm/s) and variability of sway [root mean square (RMS)] in the anterior-posterior (AP) and medial-lateral (ML) directions were used to compare postural sway between groups across conditions. RESULTS: participants with BPPVDM had higher ranges of acceleration in the AP (p = 0.02) and ML (p = 0.02) directions, as well as higher peak velocity (p < 0.001) and RMS values (p = 0.006) in the AP direction compared to the control and diabetes groups. Standing on foam with eyes closed and tandem stance were challenging conditions for people with BPPVDM. CONCLUSION: clinicians may consider using standing on foam with eyes closed and tandem standing with eyes open to assess postural control in people with BPPVDM to identify postural instability.

Effectiveness of Interventions for Promoting Objectively Measured Physical Activity of Adults With Type 2 Diabetes: A Systematic Review.

BACKGROUND: Many people with type 2 diabetes (T2D) are sedentary despite strong recommendations of regular physical activity (PA). Objective measures of PA provide accurate reflection of daily PA level. The purpose of this review was to analyze studies used pedometers or accelerometers to determine the outcome of interventions promoted daily PA in people with T2D. METHODS: An electronic literature search was conducted using the PubMed and CINAHL databases (2000-2016), with search terms: sedentary, diabetes, pedometer, physical activity, and accelerometer. Only peer-reviewed, randomized clinical trials (RCTs) that used objective measurement of daily PA level were included. All studies design, participant characteristics, intervention, and key findings were evaluated systematically and summarized. RESULTS: A total of 15 RCTs were identified investigated objectively measured daily PA in people with T2D. A significant increase in PA was found following exercise consultation, behavioral/cognitive consultation, continuous glucose monitoring counseling, and motivational phone calls promoting PA. However, this increase in daily PA level was evident only during the intervention period. CONCLUSIONS: Our systematic review of the literature indicated that a variety of interventions approaches were effective in increasing PA temporarily during the intervention period. Interventions that use objective methods in measuring PA and have long term improvement in overall PA are needed.

Aerobic exercise improves measures of vascular health in diabetic peripheral neuropathy.

AIMS: Aerobic exercise improves vascular endothelial function in people with Type 2 diabetes mellitus (T2DM). There is minimal information available regarding vascular health in people with T2DM and diabetic peripheral neuropathy (DPN). Thus, the primary aim of this secondary analysis was to determine whether a 16-week aerobic exercise intervention could improve vascular health in people with T2DM and DPN. A secondary aim was to explore the relationship between changes in flow-mediated dilation (FMD) and the number of years since diagnosis of DPN. METHODS: We examined whether a 16-week aerobic exercise intervention would improve vascular health in people with T2DM and DPN. We used Doppler ultrasound to assess brachial artery diameter and peak shear at baseline and post-exercise. Paired t-tests were used to determine whether the outcome measures improved from baseline to post-intervention. Pearson correlation assessed the relationship between DPN (years) and the percent change score (pre- to post-intervention) for FMD. RESULTS: Seventeen individuals were included in the data analysis. After the intervention, peak diameter increased (3.9 (0.5) to 4.0 (0.5) mm; p = 0.07). Time to peak shear occurred at 60.5 (24.6) seconds when compared to baseline at 68.2 (22.7) seconds; p = 0.17. We found that a longer duration (in years) of DPN demonstrated a fair, negative relationship (r = -0.41, p = 0.19) with the percent change in FMD. CONCLUSION: Aerobic exercise was beneficial for improving measures of vascular health but these were not statistically significant. The magnitude of change may be affected by the duration of DPN.