Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists.

Knee and hip osteoarthritis are common disabling conditions globally. Although numerous international clinical practice guidelines exist to guide physiotherapy management, not all recommendations issued from these guidelines can be translated to other contexts without considering the cultural acceptability and clinical implementability of targeted countries. Because the ADAPTE framework provides a robust methodology to adapt guidelines to the local context, this study used its methodology to adapt high-quality guideline recommendations to promote optimal physiotherapy care for knee and hip osteoarthritis in Hong Kong. The ADAPTE framework was used and modified to complete the adaptation process. International clinical practice guidelines were identified from eight guideline clearinghouses and six electronic databases. Two independent reviewers critically appraised the eligible guidelines using the AGREE II tool. We extracted and tabulated recommendations from high-quality guidelines. A voting-based consensus among interdisciplinary experts was conducted to decide on suitable recommendations for the Hong Kong context and whether there was a need to modify them. Pertinent recommendations were then translated into the traditional Chinese language. Our team members suggested modifying four tools and adding one to explore the patient's feedback on the recommendations, to the ADAPTE framework. The adaptation was performed on three high-quality guidelines. We adapted 28 and 20 recommendations for treating knee and hip osteoarthritis, respectively. We recommend a multimodal treatment for managing knee and hip osteoarthritis. Land- and aquatic-based exercises, patient education, and self-management were strongly recommended for patients with knee osteoarthritis. Land- and aquatic-based exercises were strongly recommended for patients with hip osteoarthritis. This is the first adaptation study in Hong Kong. It provides guidance to local physiotherapists on managing patients with knee and hip osteoarthritis. Future studies should test the effectiveness of implementing this adapted guideline to improve local physiotherapy care in Hong Kong.

Effect of chest wall mobilization on respiratory muscle function in patients with severe chronic obstructive pulmonary disease (COPD): A randomized controlled trial.

BACKGROUND: Clinical trials have demonstrated positive correlation between pulmonary function and chest wall expansion in COPD. Decrease in chest wall expansion in patients with COPD compromises rib cage mobility and functional length of respiratory muscles that ultimately jeopardize the efficacy and function of respiratory system. METHOD: Thirty male adults (mean age: 74.97 ± 6.29) suffered with severe COPD were randomly allocated to either experimental group (chest wall mobilizations) or control group. Both groups received standardized education and walking exercise (twice/week) for 6 weeks. Patients in experimental group received additional chest wall mobilizations that include stretching and joints mobilization. Pulmonary function, respiratory muscle strength, thoracic excursion, cervical and thoracic range of movement were evaluated at baseline, post-program and at 3-month follow-up. RESULTS: There were significantly greater improvements in respiratory muscle strength, thoracic excursion and thoracic range of movement (p < 0.01) except thoracic flexion. Lower thoracic excursion is strongly associated with increase in maximum inspiratory pressure (ß = 13.64, p < 0.001) and maximum expiratory pressure (ß = 16.23, p < 0.001). Thoracic range of movement especially extension (p < 0.001) and bilateral rotation (p < 0.01) exhibit a strong relationship with increase in lower thoracic excursion (adjusted R2 = 0.876) as shown in multiple regression analysis. CONCLUSION: Additional chest wall mobilization in the rehabilitation of patients with COPD is likely to enhance thoracic extension and rotation which increase lower thoracic excursion. This significant improvement in chest expansion capacity allows respiratory muscles to work at an optimal functional length which result in greater respiratory muscle strength in patients with severe COPD.

Excessive use of electronic devices among children and adolescents is associated with musculoskeletal symptoms, visual symptoms, psychosocial health, and quality of life: a cross-sectional study.

Objective: Electronic devices have become an indispensable part of our daily lives. The frequency and duration of device use in children and adolescents have increased drastically over the years and the study of its negative musculoskeletal, visual and psychosocial health impacts is necessary. Materials and methods: This cross-sectional study aimed to evaluate the associations between electronic device use and the prevalence and severity of musculoskeletal symptoms, visual symptoms, psychosocial health, and quality of life in children and adolescents studying at primary and secondary schools. Data were collected through confidential online and paper-and-pencil questionnaires. Primary 4-5 and Secondary 1-4 students were recruited from 3 schools in Hong Kong. Demographics, frequency and duration of electronic device use, frequencies of musculoskeletal symptoms, visual symptoms, psychosocial health, and quality of life outcomes were measured. Results: 1,058 children and adolescents aged 9-17 years participated. Sixty-one percent and 78% of all students spent more than 2 h per day using electronic devices during school days and weekend/holidays, respectively. Extended electronic device use was associated with increased prevalence and severity of musculoskeletal symptoms (ρ's = 0.28-0.33, P's < 0.001), visual symptoms (ρ's = 0.33-0.35, P's < 0.001), and poorer device use-related psychosocial health (ρ's = 0.38-0.47, P's < 0.001). Secondary school students reported greater device use and severity of symptoms than primary school students. Conclusion: Excessive electronic device use was associated with increased prevalence and severity of physical and psychosocial symptoms, and such use is more prevalent in adolescents when compared to the children. The findings have important health implications for children and adolescents, suggesting that early intervention is needed to reduce the risk of developing device use-related disorders.

Severity of slouched posture during smartphone use is associated with the musculoskeletal discomfort, daily usage, and school year among adolescents.

Real-time measurement of the craniovertebral, thoracic kyphosis, and lumbar lordosis angles during natural and smartphone usage postures in sitting were analysed in a cohort of 560 adolescents using independent t-tests and Spearman's correlations between their reported musculoskeletal symptoms, daily device use and school year. Students with musculoskeletal symptoms (mean difference: 4.1-9.4°, p < .001) and in secondary schools (mean difference: 13.6-29.4°, p < .001) had a greater forward-head posture quantified by craniovertebral angle in both postures. Loss of lumbar lordosis was found in students spending ≥2 h/day on electronic devices (mean difference: 3.2°, p = .029) and those with musculoskeletal symptoms (mean difference: 5.4°, p = .001). Secondary school students exhibited a greater thoracic kyphosis when using smartphones (mean difference: 3.3°, p = .003). Findings suggest the urgent need for early and proactive intervention targeted to minimise the risk of developing musculoskeletal disorders related to intense device use for young adolescents.Practitioner Summary: Adolescents: (1) in higher school year had increased forward-head posture (FHP) and thoracic kyphosis; (2) with musculoskeletal symptoms had increased FHP and loss of lumbar lordosis, and; (3) with extended device use had a loss of lumbar lordosis. Early intervention targeting young adolescents promoting optimal posture and habit of device use is warranted.

Effectiveness of pelvic floor muscle training alone or combined with either a novel biofeedback device or conventional biofeedback for improving stress urinary incontinence: A randomized controlled pilot trial.

PURPOSE: To (i) compare the acceptance of a newly developed, novel biofeedback device (PelviSense) with that of conventional biofeedback (CB) using an intravaginal probe for the treatment of stress urinary incontinence (SUI) in women, (ii) examine the feasibility and safety of using the PelviSense device as a pelvic floor muscle (PFM) training (PFMT) adjunct, and (iii) compare the PFMT adherence and effectiveness of CB, the PelviSense device, with PFMT alone for women with SUI. METHODS: An assessor-blinded, three-arm, randomized controlled pilot trial was conducted among 51 women with SUI. Women were randomly allocated to one of three study groups (PelviSense-assisted PFMT, CB-assisted PFMT, or PFMT alone [control]). Outcome measures included the International Consultation on Incontinence Questionnaire-Short Form, the 1-h pad test, and the Modified Oxford Scale. RESULTS: Participants in the PelviSense-assisted PFMT group expressed good device acceptance. PFMT adherence was greater in the PelviSense-assisted PFMT group than in the unassisted or CB-assisted PFMT groups. Between-groups analysis revealed significant effects on improved SUI symptoms, urine loss severity, and PFM strength for the PelviSense-assisted PFMT group compared with the CB-assisted and PFMT alone groups. CONCLUSIONS: The pilot trial results demonstrated moderate to high PFMT adherence in the PelviSense-assisted PFMT group and supported the safety of using the PelviSense device. The preliminary results of the pilot trial showed that PelviSense-assisted PFMT was more effective for reducing SUI symptoms among women than unassisted or CB-assisted PFMT. TRIAL REGISTRATION: This trial was registered in http://ClinicalTrials.gov (reference number: NCT04638348) before the recruitment of the first participant.

Age-Related Modifications of Muscle Synergies and Their Temporal Activations for Overground Walking.

Healthy ageing modifies neuromuscular control of human overground walking. Previous studies found that ageing changes gait biomechanics, but whether there is concurrent ageing-related modulation of neuromuscular control remains unclear. We analyzed gait kinematics and electromyographic signals (EMGs; 14 lower-limb and trunk muscles) collected at three speeds during overground walking in 11 healthy young adults (mean age of 23.4 years) and 11 healthy elderlies (67.2 years). Neuromuscular control was characterized by extracting muscle synergies from EMGs and the synergies of both groups were k -means-clustered. The synergies of the two groups were grossly similar, but we observed numerous cluster- and muscle-specific differences between the age groups. At the population level, some hip-motion-related synergy clusters were more frequently identified in elderlies while others, more frequent in young adults. Such differences in synergy prevalence between the age groups are consistent with the finding that elderlies had a larger hip flexion range. For the synergies shared between both groups, the elderlies had higher inter-subject variability of the temporal activations than young adults. To further explore what synergy characteristics may be related to this inter-subject variability, we found that the inter-subject variance of temporal activations correlated negatively with the sparseness of the synergies in elderlies but not young adults during slow walking. Overall, our results suggest that as humans age, not only are the muscle synergies for walking fine-tuned in structure, but their temporal activation patterns are also more heterogeneous across individuals, possibly reflecting individual differences in prior sensorimotor experience or ageing-related changes in limb neuro-musculoskeletal properties.

The HDAC2/SP1/miR-205 feedback loop contributes to tubular epithelial cell extracellular matrix production in diabetic kidney disease.

Extracellular matrix (ECM) accumulation is considered an important pathological feature of diabetic kidney disease (DKD). Histone deacetylase (HDAC) inhibitors protect against kidney injury. However, the potential mechanisms of HDACs in DKD are still largely unknown. Here, we describe a novel feedback loop composed of HDAC2 and miR-205 that regulates ECM production in tubular epithelial cells in individuals with DKD. We found that HDAC2 mRNA expression in peripheral blood was markedly higher in patients with DKD than in patients with diabetes. Nuclear HDAC2 protein expression was increased in TGFß1-stimulated tubular epithelial cells and db/db mice. We also found that miR-205 was regulated by HDAC2 and down-regulated in TGFß1-treated HK2 cells and db/db mice. In addition, HDAC2 reduced histone H3K9 acetylation in the miR-205 promoter region to inhibit its promoter activity and subsequently suppressed miR-205 expression through an SP1-mediated pathway. Furthermore, miR-205 directly targeted HDAC2 and inhibited HDAC2 expression. Intriguingly, miR-205 also regulated its own transcription by inhibiting HDAC2 and increasing histone H3K9 acetylation in its promoter, forming a feedback regulatory loop. Additionally, the miR-205 agonist attenuated ECM production in HK2 cells and renal interstitial fibrosis in db/db mice. In conclusion, the HDAC2/SP1/miR-205 feedback loop may be crucial for the pathogenesis of DKD.

Gray Matter Abnormalities in Type 1 and Type 2 Diabetes: A Dual Disorder ALE Quantification.

Aims/hypothesis: Diabetes mellitus (DM) is associated with comorbid brain disorders. Neuroimaging studies in DM revealed neuronal degeneration in several cortical and subcortical brain regions. Previous studies indicate more pronounced brain alterations in type 2 diabetes mellitus (T2DM) than in type 1 diabetes mellitus (T1DM). However, a comparison of both types of DM in a single analysis has not been done so far. The aim of this meta-analysis was to conduct an unbiased objective investigation of neuroanatomical differences in DM by combining voxel-based morphometry (VBM) studies of T1DM and T2DM using dual disorder anatomical likelihood estimation (ALE) quantification. Methods: PubMed, Web of Science and Medline were systematically searched for publications until June 15, 2020. VBM studies comparing gray matter volume (GMV) differences between DM patients and controls at the whole-brain level were included. Study coordinates were entered into the ALE meta-analysis to investigate the extent to which T1DM, T2DM, or both conditions contribute to gray matter volume differences compared to controls. Results: Twenty studies (comprising of 1,175 patients matched with 1,013 controls) were included, with seven studies on GMV alterations in T1DM and 13 studies on GMV alterations in T2DM. ALE analysis revealed seven clusters of significantly lower GMV in T1DM and T2DM patients relative to controls across studies. Both DM subtypes showed GMV reductions in the left caudate, right superior temporal lobe, and left cuneus. Conversely, GMV reductions associated exclusively with T2DM (>99% contribution) were found in the left cingulate, right posterior lobe, right caudate and left occipital lobe. Meta-regression revealed no significant influence of study size, disease duration, and HbA1c values. Conclusions/interpretation: Our findings suggest a more pronounced gray matter atrophy in T2DM compared to T1DM. The increased risk of microvascular or macrovascular complications, as well as the disease-specific pathology of T2DM may contribute to observed GMV reductions. Systematic Review Registration: [PROSPERO], identifier [CRD42020142525].

Differences in skin blood flow oscillations between the plantar and dorsal foot in people with diabetes mellitus and peripheral neuropathy.

BACKGROUND: Understanding the differences in skin blood flow (SBF) on the plantar and dorsal foot in people with diabetes mellitus (DM) may help to assess the influence of diabetes and neuropathy on microvascular dysfunction and risks of diabetic foot ulcers in this population. However, there is no study comparing SBF oscillations between the plantar and dorsal foot in people with DM and peripheral neuropathy (PN). OBJECTIVE: The objective of this study was to compare SBF oscillations between the plantar and dorsal foot in people with DM and PN and investigate the underlying mechanisms responsible for the differences. METHODS: 18 people with Type 2 DM and PN and 8 healthy controls were recruited. Laser Doppler flowmetry (LDF) was used to measure SBF on the plantar and dorsal foot for 10 min when the subject was in the supine position. Wavelet analysis was used to quantify the relative amplitude of the characteristic frequency components of SBF oscillations. Sample entropy analysis was used to quantify the regularity degree of SBF oscillations. RESULTS: People with DM and PN had a higher SBF on the plantar foot compared to the dorsal foot. The relative wavelet amplitudes of metabolic and myogenic frequency components on the plantar foot were respectively higher and lower compared to the dorsal foot. Sample entropy analysis showed that SBF on the plantar foot had a higher degree of regularity compared to the dorsal foot. CONCLUSIONS: In people with DM and PN, higher SBF on the plantar foot is attributed to the metabolic and myogenic controls, and SBF on the plantar foot exhibits a higher degree of regularity compared to the dorsal foot. People with DM and PN also had higher plantar and dorsal SBF compared to the healthy controls. This study provides evidence to document differences in SBF of the plantar and dorsal foot in people with DM and PN.

Correction: Effects of pulsed electromagnetic field (PEMF) on the tensile biomechanical properties of diabetic wounds at different phases of healing.

[This corrects the article DOI: 10.1371/journal.pone.0191074.].

Effects of pulsed electromagnetic field (PEMF) on the tensile biomechanical properties of diabetic wounds at different phases of healing.

The present study investigated the effects of pulsed electromagnetic field (PEMF) on the tensile biomechanical properties of diabetic wounds at different phases of healing. Two intensities of PEMF were adopted for comparison. We randomly assigned 111 10-week-old male streptozotocin-induced diabetic Sprague-Dawley rats to two PEMF groups and a sham control group. Six-millimetre biopsy punched full thickness wounds were made on the lateral side of their hindlimbs. The PEMF groups received active PEMF delivered at 25 Hz with intensity of either 2 mT or 10 mT daily, while the sham group was handled in a similar way except they were not exposed to PEMF. Wound tissues were harvested for tensile testing on post-wounding days 3, 5, 7, 10, 14 and 21. Maximum load, maximum stress, energy absorption capacity, Young's modulus and thickness of wound tissue were measured. On post-wounding day 5, the PEMF group that received 10-mT intensity had significantly increased energy absorption capacity and showed an apparent increase in the maximum load. However, the 10-mT PEMF group demonstrated a decrease in Young's modulus on day 14. The 10-mT PEMF groups showed a significant increase in the overall thickness of wound tissue whereas the 2-mT group showed a significant decrease in the overall maximum stress of the wounds tissue. The present findings demonstrated that the PEMF delivered at 10 mT can improve energy absorption capacity of diabetic wounds in the early healing phase. However, PEMF (both 2-mT and 10-mT) seemed to impair the material properties (maximum stress and Young's modulus) in the remodelling phase. PEMF may be a useful treatment for promoting the recovery of structural properties (maximum load and energy absorption capacity), but it might not be applied at the remodelling phase to avoid impairing the recovery of material properties.

Application of Multiscale Entropy in Assessing Plantar Skin Blood Flow Dynamics in Diabetics with Peripheral Neuropathy.

Diabetic foot ulcer (DFU) is a common complication of diabetes mellitus, while tissue ischemia caused by impaired vasodilatory response to plantar pressure is thought to be a major factor of the development of DFUs, which has been assessed using various measures of skin blood flow (SBF) in the time or frequency domain. These measures, however, are incapable of characterizing nonlinear dynamics of SBF, which is an indicator of pathologic alterations of microcirculation in the diabetic foot. This study recruited 18 type 2 diabetics with peripheral neuropathy and eight healthy controls. SBF at the first metatarsal head in response to locally applied pressure and heating was measured using laser Doppler flowmetry. A multiscale entropy algorithm was utilized to quantify the regularity degree of the SBF responses. The results showed that during reactive hyperemia and thermally induced biphasic response, the regularity degree of SBF in diabetics underwent only small changes compared to baseline and significantly differed from that in controls at multiple scales (p < 0.05). On the other hand, the transition of regularity degree of SBF in diabetics distinctively differed from that in controls (p < 0.05). These findings indicated that multiscale entropy could provide a more comprehensive assessment of impaired microvascular reactivity in the diabetic foot compared to other entropy measures based on only a single scale, which strengthens the use of plantar SBF dynamics to assess the risk for DFU.

Robot-Assisted Training for People With Spinal Cord Injury: A Meta-Analysis.

OBJECTIVE: To investigate the effects of robot-assisted training on the recovery of people with spinal cord injury (SCI). DATA SOURCES: Randomized controlled trials (RCTs) or quasi-RCTs involving people with SCI that compared robot-assisted upper limbs or lower limbs training with a control of other treatment approach or no treatment. We included studies involving people with complete or incomplete SCIs. STUDY SELECTION: We searched MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials (Cochrane Library), and Embase to August 2016. Bibliographies of relevant articles on the effect of body-weight-supported treadmill training on subjects with SCI were screened to avoid missing relevant articles from the search of databases. DATA EXTRACTION: All kinds of objective assessments concerning physical ability, mobility, and/or functional ability were included. Assessments could be clinical tests (ie, 6-minute walk test, FIM) or laboratory tests (ie, gait analysis). Subjective outcome measures were excluded from this review. DATA SYNTHESIS: Eleven RCT studies involving 443 subjects were included in the study. Meta-analysis was performed on the included studies. Walking independence (3.73; 95% confidence interval [CI], -4.92 to -2.53; P<.00001; I2=38%) and endurance (53.32m; 95% CI, -73.15 to -33.48; P<.00001; I2=0%) were found to have better improvement in robot-assisted training groups. Lower limb robot-assisted training was also found to be as effective as other types of body-weight-supported training. There is a lack of upper limb robot-assisted training studies; therefore, performing a meta-analysis was not possible. CONCLUSIONS: Robot-assisted training is an adjunct therapy for physical and functional recovery for patients with SCI. Future high-quality studies are warranted to investigate the effects of robot-assisted training on functional and cardiopulmonary recovery of patients with SCI.

In vivo and ex vivo approaches to studying the biomechanical properties of healing wounds in rat skin.

An evaluation of wound mechanics is crucial in reflecting the wound healing status. The present study examined the biomechanical properties of healing rat skin wounds in vivo and ex vivo. Thirty male Sprague-Dawley rats, each with a 6 mm full-thickness circular punch biopsied wound at both posterior hind limbs were used. The mechanical stiffness at both the central and margins of the wound was measured repeatedly in five rats over the same wound sites to monitor the longitudinal changes over time of before wounding, and on days 0, 3, 7, 10, 14, and 21 after wounding in vivo by using an optical coherence tomography-based air-jet indentation system. Five rats were euthanized at each time point, and the biomechanical properties of the wound tissues were assessed ex vivo using a tensiometer. At the central wound bed region, the stiffness measured by the air-jet system increased significantly from day 0 (17.2%), peaked at day 7 (208.3%), and then decreased progressively until day 21 (40.2%) as compared with baseline prewounding status. The biomechanical parameters of the skin wound samples measured by the tensiometer showed a marked reduction upon wounding, then increased with time (all p < 0.05). On day 21, the ultimate tensile strength of the skin wound tissue approached 50% of the normal skin; while the stiffness of tissue recovered at a faster rate, reaching 97% of its prewounded state. Our results suggested that it took less time for healing wound tissues to recover their stiffness than their maximal strength in rat skin. The stiffness of wound tissues measured by air-jet could be an indicator for monitoring wound healing and contraction.

Risk of fall for people with diabetes.

PURPOSE: To examine the risk of fall for people with diabetes compared with healthy control subjects. Correlation between tactile sensation and postural control was examined for subjects with diabetes. METHODS: Subjects with type 2 diabetes were classified into two groups: (i) diabetes without neuropathy (n = 23) and (ii) diabetic peripheral neuropathy (DPN) (n = 9). Age-matched healthy control subjects (n = 32) were recruited. Tactile sensation, equilibrium scores (ES), strategy scores and sensory analysis scores from the Sensory Organization Test (SOT) were compared among the groups. RESULTS: Subjects with diabetes without neuropathy demonstrated impaired postural control upon the disruption of somatosensory inputs. Subjects with DPN lost balance upon being deprived of visual inputs. A decrease in tactile sensation was associated with a decrease in the ESs in all subjects with diabetes (r = -0.35 to -0.77; p < 0.05), and they tend to use more hip strategy for postural control upon being deprived of visual inputs. CONCLUSIONS: Different postural control strategies are adopted by various subgroups of subjects with diabetes. Subjects with DPN demonstrated a significant shift from ankle to hip strategies for balance tests when vision was deprived. Implications for Rehabilitation The severity of diabetic peripheral neuropathy (DPN) is associated with the risk of fall. Different compensatory strategies in balance control have been adopted by different subgroups of people with diabetes. In order to minimize the risk of fall, specific balance training program should be offered to different subgroups of people with diabetes. The balance training should emphasize on optimizing the competence of their existing compensatory postural control strategies.

Electrophysical therapy for managing diabetic foot ulcers: a systematic review.

To systematically assess published reports on the efficacy of electrophysical therapy in the treatment of diabetic foot ulcers, including electrical stimulation, low-level laser therapy, therapeutic ultrasound and electromagnetic therapy. Databases searched included MEDLINE, CINAHL, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) from 1966 to 2011. Studies reviewed included only randomised controlled trials (RCTs) on treatment with electrophysical modalities compared with sham, conventional treatment or other electrophysical modalities. Information extracted were objective measures of healing and data useful for the calculation of effect size. Eight RCTs were eventually included in the critical appraisal, with a combined total of 325 participants. Five studies were conducted on electrical stimulation, two on phototherapy and one on ultrasound. All studies reported that the experimental group was significantly more favourable than the control or sham group. The pooled estimate of the number of healed ulcers of the three studies on electrical stimulation compared to the control or sham electrical stimulation showed statistical significance [mean difference of 2·8 (95% CI = 1·5-5·5, P = 0·002] in favour of electrical stimulation. The results indicated potential benefit of using electrophysical therapy for managing diabetic foot ulcers. However, due to the small number of trials ever conducted, the possibility of any harmful effects cannot be ruled out, and high-quality trials with larger sample sizes are warranted.

Do the biomechanical properties of the ankle-foot complex influence postural control for people with Type 2 diabetes?

BACKGROUND: The ankle-foot complex plays an important role in the mechanics of postural control. The objectives of this study were to compare the biomechanical properties of the ankle-foot complex of people with diabetes who had or did not have peripheral neuropathy with those healthy individuals; and to examine its correlation with postural control. METHODS: A total of 64 individuals participated in this study: 9 people with diabetic peripheral neuropathy, 23 diabetes without neuropathy, and 32 healthy controls. A hand-held ultrasound indentation system was used to assess the soft tissue biomechanical properties of the ankle-foot complex. The Sensory Organization test was performed using The Smart EquiTest system to assess postural control. FINDINGS: The soft tissue of the Achilles tendon was significantly thickened in all individuals with diabetes (P<0.001), and was associated with the vestibular ratio (r=0.40; P<0.05). The Young's modulus of the plantar soft tissue was significantly increased in the diabetic neuropathy group (all P<0.05). Also, the Young's modulus of the plantar soft tissue at the first metatarsal head was positively correlated with the somatosensory ratio (r=0.46; P<0.05) and visual ratio (r=0.39; P<0.05). INTERPRETATION: Diabetic patients with or without neuropathy had a thicker Achilles tendon and stiffer plantar soft tissue than the healthy control. Changes in the biomechanical properties of the ankle-foot complex were correlated with the use of vestibular, somatosensory or visual inputs to maintain balance in individuals with diabetes.

The association between skin blood flow and edema on epidermal thickness in the diabetic foot.

BACKGROUND: Skin blood flow plays an important role in maintaining the health of the skin. The development of interstitial edema may impede oxygen diffusion to the skin. The aim of this study was to evaluate the association of skin blood flow and edema and epidermal thickness in the feet of people with and without diabetic neuropathy compared with a healthy control group. SUBJECTS AND METHODS: Eighty-seven subjects (19 people with diabetic neuropathy and foot ulceration, 35 people with diabetes but without neuropathy, and 33 healthy controls without diabetes) participated in the study. High-frequency ultrasonography was used to measure the epidermal thickness and edema in papillary skin at the big toe as reflected by the thickness of the subepidermal low echogenic band (SLEB). The capillary nutritive blood flow was measured by the use of video capillaroscopy, and skin blood flux was monitored by laser Doppler flowmetry. RESULTS: There was a 7.2% increase in epidermal thickness in those with diabetes but without neuropathy and a 16.5% decrease in people with diabetic neuropathy and foot ulceration compared with the healthy controls (all P<0.05). The SLEB thickness increased in all subjects with diabetes to a greater degree in those with neuropathy and ulceration than in those without (64.7% vs. 11.8%, P<0.001). Skin blood flux was shown to be higher in the diabetes groups than in the controls (all P<0.05), but no significant differences were found in the resting nutritive capillary blood flow (P>0.05). A significant negative correlation (P=0.002, r=-0.366) was demonstrated between the SLEB and epidermal thickness at the pulp of the big toe, whereas no significant correlation was demonstrated between skin blood flow and epidermal thickness (all P>0.05). CONCLUSIONS: An increase in subepidermal edema was demonstrated in people with diabetic neuropathy and ulceration, which may partly contribute to reduced epidermal thickness at the pulp of the big toe. This may subsequently lead to the breaking down of skin in the diabetic foot.

Immediate effects of monochromatic infrared energy on microcirculation in healthy subjects.

OBJECTIVE: The purpose of this study was to evaluate the influence of monochromatic infrared energy (MIRE) on the microcirculation of the skin surface of the feet in healthy subjects. BACKGROUND DATA: Near-infrared energy was shown to increase microcirculation in an animal study. In humans, only one case study demonstrated that MIRE increases microcirculation in the skin of the lower limbs. METHODS: Thirty healthy volunteers were recruited and randomly allocated into three groups to receive either: (1) active MIRE; (2) sham MIRE (placebo group); or (3) warm packs (control group) on the feet. The MIRE device comprised an array of 60 x 890 nm LEDs attached to flexible pads (3×7.5 cm). Each diode spot size was 0.2 cm(2), and each LED power was 12 mW with a power density of 60 mW/cm(2). The arrays were placed in direct contact with the skin for 30 min delivering a total fluence of 108 J/cm(2) over an area of 22.5 cm(2). Capillary blood cell velocity (CBV) and superficial skin blood flow (flux) were recorded before and after intervention. RESULTS: Significant differences among the three groups were recorded in both CBV and flux (both p<0.05). Post-hoc comparisons indicated that a significantly greater increase in both CBV and flux occurred in the active MIRE group than in the placebo group and control group (all p<0.05). CONCLUSIONS: A 30-min MIRE produced a significantly greater increase in the CBV and flux of the feet in the active MIRE group than in the placebo and control groups.

A randomized controlled trial of auricular transcutaneous electrical nerve stimulation for managing posthysterectomy pain.

Background. A patient- and assessor-blinded randomized controlled trial was conducted to examine the effectiveness of auricular transcutaneous electrical nerve stimulation (TENS) in relieving posthysterectomy pain. Method. Forty-eight women who had undergone a total abdominal hysterectomy were randomly assigned into three groups (n = 16 each) to receive either (i) auricular TENS to therapeutic points (the true TENS group), (ii) auricular TENS to inappropriate points (the sham TENS group), or (iii) 20 minutes of bed rest with no stimulation (the control group). The intervention was delivered about 24 hours after the operation. A visual analogue scale was used to assess pain while resting (VAS-rest) and upon huffing (VAS-huff) and coughing (VAS-cough), and the peak expiratory flow rate (PEFR) was assessed before and at 0, 15, and 30 minutes after the intervention. Result. As compared to the baseline, only the true TENS group reported a significant reduction in VAS-rest (P = .001), VAS-huff (P = .004), and VAS-cough (P = .001), while no significant reduction in any of the VAS scores was seen in the sham TENS group (all P > .05). In contrast, a small rising trend was observed in the VAS-rest and VAS-huff scores of the control group, while the VAS-cough score remained largely unchanged during the period of the study. A between-group comparison revealed that all three VAS scores of the true TENS group were significantly lower than those of the control group at 15 and 30 minutes after the intervention (all P < .02). No significant between-group difference was observed in PEFR at any point in time. Conclusion. A single session of auricular TENS applied at specific therapeutic points significantly reduced resting (VAS-rest) and movement-evoked pain (VAS-huff, VAS-cough), and the effects lasted for at least 30 minutes after the stimulation. The analgesic effects of auricular TENS appeared to be point specific and could not be attributed to the placebo effect alone. However, auricular TENS did not produce any significant improvement in the performance of PEFR.