Motor learning of a gait pattern to reduce forefoot plantar pressures in individuals with diabetic peripheral neuropathy.

OBJECTIVE: To examine the role of visual feedback in the reduction of plantar pressures through teaching a "new" gait pattern to diabetic peripheral neuropathy subjects. Immediate, next day, and 1-week retention were studied to determine if motor pattern changes could occur. DESIGN: Randomized controlled trial. SETTING: VA Urban Healthcare System. PARTICIPANTS: Twenty-nine community-dwelling older adults with diabetic peripheral neuropathy volunteered. INTERVENTIONS: Subjects were randomized into feedback and no-feedback groups. All subjects received instruction and 2 days of practice and returned for a 1-week retention test. Instruction to pull the leg forward from the hip to initiate swing rather than push off the ground with the foot while walking was given to all subjects. The feedback group received visual feedback regarding peak plantar pressures after each practice trial. The no-feedback group received no feedback. MAIN OUTCOME MEASURES: Peak plantar pressures in the forefoot region for immediate retention (retention 1), next day retention (retention 2), and long-term retention (1-week retention). RESULTS: Peak plantar pressures were significantly (P < .01) reduced from baseline to retention 2 testing at the first metatarsal area in the feedback group. The feedback group walked significantly (P < .01) slower at retention 1 and 1-week testing compared with baseline. CONCLUSIONS: Individuals with diabetic peripheral neuropathy were unable to use a "new" strategy gait pattern to reduce peak plantar pressures long term (1 week). The use of visual feedback following the trial did not assist in the learning of a new walking pattern.

Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction.

PURPOSE: Breathing pattern retraining is frequently used for exertional dyspnea relief in adults with moderate to severe chronic obstructive pulmonary disease. However, there is contradictory evidence to support its use. The study objective was to compare 2 programs of prolonging expiratory time (pursed-lips breathing and expiratory muscle training) on dyspnea and functional performance. METHODS: A randomized, controlled design was used for the pilot study. Subjects recruited from the outpatient pulmonary clinic of a university-affiliated Veteran Affairs healthcare center were randomized to: 1) pursed-lips breathing, 2) expiratory muscle training, or 3) control. Changes over time in dyspnea [modified Borg after 6-minute walk distance (6MWD) and Shortness of Breath Questionnaire] and functional performance (Human Activity Profile and physical function scale of Short Form 36-item Health Survey) were assessed with a multilevel modeling procedure. Weekly laboratory visits for training were accompanied by structured verbal, written, and audiovisual instruction. RESULTS: Forty subjects with chronic obstructive pulmonary disease [age = 65 +/- 9 (mean +/- standard deviation) years, forced expiratory volume 1 second/forced vital capacity % = 46 +/- 10, forced expiratory volume 1 second % predicted = 39 +/- 13, body mass index = 26 +/- 6 kg/m, inspiratory muscle strength = 69 +/- 22 cm H2O, and expiratory muscle strength (PEmax) = 102 +/- 29 cm H2O] were enrolled. No significant Group x Time difference was present for PEmax (P = .93). Significant reductions for the modified Borg scale after 6MWD (P = .05) and physical function (P = .02) from baseline to 12 weeks were only present for pursed-lips breathing. CONCLUSION: Pursed-lips breathing provided sustained improvement in exertional dyspnea and physical function.

Chest pain among combat veterans: a conceptual framework.

This article describes the decision-making processes regarding seeking treatment for the symptom of chest pain in a population of combat veterans with post-traumatic stress disorder and panic disorder. Qualitative methods and standardized tools were used to explore the prehospital experiences of combat veterans who met diagnostic criteria for post-traumatic stress disorder, panic disorder, and admission to a coronary care unit for the symptom of chest pain. Semistructured audiotaped interviews were conducted. Obtaining medical treatment for the chest pain was dependent on internal and external motivating forces outweighing internal and external restraining forces in the decision-making process. The experience of military training influenced responses because of the expectation of self-reliance. A conceptual model emerged from the data that described the influences and restraints in seeking medical treatment.