Effects of a foot-ankle muscle strengthening program on pain and function in individuals with knee osteoarthritis: a randomized controlled trial.

BACKGROUND: Foot-ankle exercises could improve pain and function of individuals with KOA and need to be tested. OBJECTIVE: To investigate whether an 8-week foot-ankle muscle strengthening program is effective for individuals with KOA to reduce pain and improve function. METHODS: In this randomized controlled trial, individuals diagnosed with clinical and radiographic KOA were randomized into the intervention (supervised foot-ankle strengthening exercise program three times a week for 8 weeks) or control (usual care and recommendations of the healthcare team) group. Effectiveness was assessed by changes in clinical and functional outcomes between baseline and 8 weeks with pain as the primary outcome. ANCOVA tests using the intervention group as a reference and sex, body mass index, and baseline values as covariates assessed between-group differences. RESULTS: The intervention group showed lower pain scores (-4.4 units; 95%CI = -7.5, -1.1), better function (-7.1 units; 95%CI = -12.7, -1.4), higher total functional score (-11.9 units; 95%CI = -20.7, -3.1), with confidence intervals indicating a potential for the differences to be clinically meaningful, and better scores for the 30-s chair stand test (2.7 repetitions; 95%CI = 1.1, 4.1), with a confidence interval indicating a moderate clinically meaningful difference, compared to the controls. CONCLUSION: The 8-week foot-ankle exercise program showed positive, and potentially clinically meaningful, effects on knee pain and physical function among individuals with KOA, when compared to usual care. TRIAL REGISTRATION: NCT04154059. https://clinicaltrials.gov/ct2/show/NCT04154059.

Effects of Foot-Core Training on Foot-Ankle Kinematics and Running Kinetics in Runners: Secondary Outcomes From a Randomized Controlled Trial.

This study investigated the effectiveness of an 8-week foot-core exercise training program on foot-ankle kinematics during running and also on running kinetics (impact loads), with particular interest in biomechanical outcomes considered risk factors for running-related injuries in recreational runners. A single-blind, randomized, controlled trial was conducted with 87 recreational runners randomly allocated to either the control (CG) or intervention (IG) group and assessed at baseline and after 8 weeks. The IG underwent foot-core training 3 times/week, while the CG followed a placebo lower-limb stretching protocol. The participants ran on a force-instrumented treadmill at a self-selected speed while foot-segment motion was captured simultaneously with kinetic measurements. After the intervention, there were statistically significant changed in foot biomechanics, such as: IG participants strike the ground with a more inverted calcaneus and a less dorsiflexed midfoot than those in the CG; at midstance, ran with a less plantarflexed and more adducted forefoot and a more abducted hallux; and at push-off, ran with a less dorsiflexed midfoot and a less adducted and more dorsiflexed hallux. The IG runners also had significantly decreased medial longitudinal arch excursion (p = 0.024) and increased rearfoot inversion (p = 0.037). The 8-week foot-core exercise program had no effect on impact (p = 0.129) and breaking forces (p = 0.934) or on vertical loading rate (p = 0.537), but it was positively effective in changing foot-ankle kinematic patterns."

Predictive Effect of Well-Known Risk Factors and Foot-Core Training in Lower Limb Running-Related Injuries in Recreational Runners: A Secondary Analysis of a Randomized Controlled Trial.

BACKGROUND: Running carries the risk of several types of running-related injuries (RRIs), especially in the lower limbs. The variety of risk factors and the lack of strong evidence for several of these injury risks hinder the ability to draw assertive conclusions about them, hampering the implementation of effective preventive strategies. Because the etiology of RRIs seems to be multifactorial, the presence of RRI risk factors might influence the outcome of therapeutic strategies in different ways. Thus, further investigations on how risk and protective factors influence the incidence and prevention of RRIs should be conducted. PURPOSE: To investigate the predictive effect of well-known risk factors and 1 protective factor-foot-core training-on the incidence of lower limb RRIs in recreational runners. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: Middle- and long-distance recreational runners (N = 118) were assessed at baseline and randomly allocated to either an intervention group (n = 57) or a control group (n = 61). The intervention group underwent an 8-week (3 times/wk) foot-core training program. Participants were followed for a year after baseline assessment for the occurrence of RRIs. Logistic regression with backward elimination of variables was used to develop a model for prediction of RRI in recreational runners. Candidate predictor variables included age, sex, body mass index, years of running practice, number of races, training volume, training frequency, previous RRI, and the foot-core exercise training. RESULTS: The final logistic regression model included 3 variables. As previously shown, the foot-core exercise program is a protective factor for RRIs (odds ratio, 0.40; 95% CI, 0.15-0.98). In addition, older age (odds ratio, 1.07; 95% CI, 1.00-1.14) and higher training volume (odds ratio, 1.02; 95% CI, 1.00-1.03) were risk factors for RRIs. CONCLUSION: The foot-core training was identified as a protective effect against lower limb RRI, which can be negatively influenced by older age and higher weekly training volume. The predictive model showed that RRIs should be considered a multivariate entity owing to the interaction among several factors. REGISTRATION: NCT02306148 (ClinicalTrials.gov identifier).

Subgroups of Foot-Ankle Movement Patterns Can Influence the Responsiveness to a Foot-Core Exercise Program: A Hierarchical Cluster Analysis.

The purpose of this study is to identify homogenous subgroups of foot-ankle (FA) kinematic patterns among recreational runners and further investigate whether differences in baseline movement patterns can influence the mechanical responses to a foot-core exercise intervention program. This is a secondary analysis of data from 85 participants of a randomized controlled trial (clinicaltrials.gov - NCT02306148) investigating the effects of an exercise-based therapeutic approach focused on FA complex. A validated skin marker-based multi-segment foot model was used to acquire kinematic data during the stance phase of treadmill running. Kinematic features were extracted from the time-series data using a principal component analysis, and the reduced data served as input for a hierarchical cluster analysis to identify subgroups of FA movement patterns. FA angle time series were compared between identified clusters and the mechanical effects of the foot-core exercise intervention was assessed for each subgroup. Two clusters of FA running patterns were identified, with cluster 1 (n = 36) presenting a pattern of forefoot abduction, while cluster 2 (n = 49) displayed deviations in the proximal segments, with a rearfoot adduction and midfoot abduction throughout the stance phase of running. Data from 29 runners who completed the intervention protocol were analyzed after 8-weeks of foot-core exercises, resulting in changes mainly in cluster 1 (n = 16) in the transverse plane, in which we observed a reduction in the forefoot abduction, an increase in the rearfoot adduction and an approximation of their pattern to the runners in cluster 2 (n = 13). The findings of this study may help guide individual-centered treatment strategies, taking into account their initial mechanical patterns.

Effects of a foot-ankle strengthening programme on clinical aspects and gait biomechanics in people with knee osteoarthritis: protocol for a randomised controlled trial.

INTRODUCTION: Studies have indicated that hip and knee muscle strengthening are effective in reducing pain, improving self-reported function and increasing lower limb strength, without, however, decreasing knee joint overload during gait in patients with knee osteoarthritis (KOA). Recent research has shown that strengthening the foot-ankle muscles improved function in diabetic patients and reduced patellofemoral pain. The aim of this paper is to investigate whether an 8-week therapeutic foot-ankle exercise programme improves pain, functionality, foot strength, foot kinematics and knee joint overload during gait, and decreases medication intake in individuals with KOA. METHODS AND ANALYSIS: This two-arm, prospectively registered, randomised controlled trial with blinded assessors will involve 88 patients with medial tibiofemoral osteoarthritis. Subjects will be randomly allocated to a control group that will receive no specific foot intervention and will follow treatment recommended by the medical team; or an intervention group that will undergo an 8-week physiotherapist-supervised strengthening programme for extrinsic and intrinsic foot muscles, three times a week. The primary outcome will be the pain domain of the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC). The secondary outcomes include WOMAC stiffness and function domains, total WOMAC score, physical function, foot muscle isometric strength, foot kinematics and knee kinetics during gait, and medication intake. Data will be analysed on intention-to-treat principles and a per protocol basis. ETHICS AND DISSEMINATION: Investigators and sponsors will communicate trial results to participants and healthcare professionals through scientific databases and social media. In addition, findings will be reported in peer-review publications, and at national and international conference presentations. Ethics approval: Ethics Committee of the Universidade Federal de São Carlos, São Carlos, SP, Brazil (N° 3.488.466). TRIAL REGISTRATION NUMBER: NCT04154059.

Recognition of Foot-Ankle Movement Patterns in Long-Distance Runners With Different Experience Levels Using Support Vector Machines.

Running practice could generate musculoskeletal adaptations that modify the body mechanics and generate different biomechanical patterns for individuals with distinct levels of experience. Therefore, the aim of this study was to investigate whether foot-ankle kinetic and kinematic patterns can be used to discriminate different levels of experience in running practice of recreational runners using a machine learning approach. Seventy-eight long-distance runners (40.7 ± 7.0 years) were classified into less experienced (n = 24), moderately experienced (n = 23), or experienced (n = 31) runners using a fuzzy classification system, based on training frequency, volume, competitions and practice time. Three-dimensional kinematics of the foot-ankle and ground reaction forces (GRF) were acquired while the subjects ran on an instrumented treadmill at a self-selected speed (9.5-10.5 km/h). The foot-ankle kinematic and kinetic time series underwent a principal component analysis for data reduction, and combined with the discrete GRF variables to serve as inputs in a support vector machine (SVM), to determine if the groups could be distinguished between them in a one-vs.-all approach. The SVM models successfully classified all experience groups with significant crossvalidated accuracy rates and strong to very strong Matthew's correlation coefficients, based on features from the input data. Overall, foot mechanics was different according to running experience level. The main distinguishing kinematic factors for the less experienced group were a greater dorsiflexion of the first metatarsophalangeal joint and a larger plantarflexion angles between the calcaneus and metatarsals, whereas the experienced runners displayed the opposite pattern for the same joints. As for the moderately experienced runners, although they were successfully classified, they did not present a visually identifiable running pattern, and seem to be an intermediate group between the less and more experienced runners. The results of this study have the potential to assist the development of training programs targeting improvement in performance and rehabilitation protocols for preventing injuries.

Automated Accelerometer-Based Gait Event Detection During Multiple Running Conditions.

The identification of the initial contact (IC) and toe off (TO) events are crucial components of running gait analyses. To evaluate running gait in real-world settings, robust gait event detection algorithms that are based on signals from wearable sensors are needed. In this study, algorithms for identifying gait events were developed for accelerometers that were placed on the foot and low back and validated against a gold standard force plate gait event detection method. These algorithms were automated to enable the processing of large quantities of data by accommodating variability in running patterns. An evaluation of the accuracy of the algorithms was done by comparing the magnitude and variability of the difference between the back and foot methods in different running conditions, including different speeds, foot strike patterns, and outdoor running surfaces. The results show the magnitude and variability of the back-foot difference was consistent across running conditions, suggesting that the gait event detection algorithms can be used in a variety of settings. As wearable technology allows for running gait analyses to move outside of the laboratory, the use of automated accelerometer-based gait event detection methods may be helpful in the real-time evaluation of running patterns in real world conditions.

Use of baseline pelvic acceleration during running for classifying response to muscle strengthening treatment in patellofemoral pain: A preliminary study.

BACKGROUND: Objectively identifying patients at baseline who may not respond well to a generic muscle strengthening intervention could improve clinical practice by optimizing treatment strategies. The purpose of this study was to determine whether pelvic acceleration measures during running, and clinical and demographic variables could classify patellofemoral pain patients according to their response to a 6-week hip/core and knee exercise-based rehabilitation protocol. METHODS: Forty-one individuals with patellofemoral pain participated in a 6-week exercise intervention program and were sub-grouped into treatment Responders (n = 28) and Non-responders (n = 13) based on self-reported pain and function measures. Baseline pelvic acceleration measures were reduced using a principal component analysis and combined with patient reported outcome measures and demographic variables in a support vector machine to retrospectively classify patient treatment response. FINDINGS: The final classification model had 85.4% classification accuracy, which was significantly better than treatment success rate, with excellent detection rates for Responders (recall: 96.4%), but 23.1% of misclassifications among Non-responders (precision: 90.0%). Thus, it resulted in an F1-score of 0.93 and a Matthews correlation coefficient of 0.69. INTERPRETATION: Overall, the classifier successfully separated patellofemoral pain patients into exercise-based treatment Responders and Non-responders based on a combination of three components of the pelvic accelerations. While this model requires independent validation, it has the potential for further development and to be applied in clinical practice and improve treatment strategies for patellofemoral pain.

Runners with patellofemoral pain demonstrate sub-groups of pelvic acceleration profiles using hierarchical cluster analysis: an exploratory cross-sectional study.

BACKGROUND: Previous studies have suggested that distinct and homogenous sub-groups of gait patterns exist among runners with patellofemoral pain (PFP), based on gait analysis. However, acquisition of 3D kinematic data using optical systems is time consuming and prone to marker placement errors. In contrast, axial segment acceleration data can represent an overall running pattern, being easy to acquire and not influenced by marker placement error. Therefore, the purpose of this study was to determine if pelvic acceleration patterns during running could be used to classify PFP patients into homogeneous sub-groups. A secondary purpose was to analyze lower limb kinematic data to investigate the practical implications of clustering these subjects based on 3D pelvic acceleration data. METHODS: A hierarchical cluster analysis was used to determine sub-groups of similar running profiles among 110 PFP subjects, separately for males (n = 44) and females (n = 66), using pelvic acceleration data (reduced with principal component analysis) during treadmill running acquired with optical motion capture system. In a secondary analysis, peak joint angles were compared between clusters (α = 0.05) to provide clinical context and deeper understanding of variables that separated clusters. RESULTS: The results reveal two distinct running gait sub-groups (C1 and C2) for female subjects and no sub-groups were identified for males. Two pelvic acceleration components were different between clusters (PC1 and PC5; p < 0.001). While females in C1 presented similar acceleration patterns to males, C2 presented greater vertical and anterior peak accelerations. All females presented higher and delayed mediolateral acceleration peaks than males. Males presented greater ankle eversion (p < 0.001), lower knee abduction (p = 0.007) and hip adduction (p = 0.002) than all females, and lower hip internal rotation than C1 (p = 0.007). CONCLUSIONS: Two distinct and homogeneous kinematic PFP sub-groups were identified for female subjects, but not for males. The results suggest that differences in running gait patterns between clusters occur mainly due to sex-related factors, but there are subtle differences among female subjects. This study shows the potential use of pelvic acceleration patterns, which can be acquired with accessible wearable technology (i.e. accelerometers).

Determination of patellofemoral pain sub-groups and development of a method for predicting treatment outcome using running gait kinematics.

BACKGROUND: Not all patients with patellofemoral pain exhibit successful outcomes following exercise therapy. Thus, the ability to identify patellofemoral pain subgroups related to treatment response is important for the development of optimal therapeutic strategies to improve rehabilitation outcomes. The purpose of this study was to use baseline running gait kinematic and clinical outcome variables to classify patellofemoral pain patients on treatment response retrospectively. METHODS: Forty-one individuals with patellofemoral pain that underwent a 6-week exercise intervention program were sub-grouped as treatment Responders (n=28) and Non-responders (n=13) based on self-reported measures of pain and function. Baseline three-dimensional running kinematics, and self-reported measures underwent a linear discriminant analysis of the principal components of the variables to retrospectively classify participants based on treatment response. The significance of the discriminant function was verified with a Wilk's lambda test (α=0.05). FINDINGS: The model selected 2 gait principal components and had a 78.1% classification accuracy. Overall, Non-responders exhibited greater ankle dorsiflexion, knee abduction and hip flexion during the swing phase and greater ankle inversion during the stance phase, compared to Responders. INTERPRETATION: This is the first study to investigate an objective method to use baseline kinematic and self-report outcome variables to classify on patellofemoral pain treatment outcome. This study represents a significant first step towards a method to help clinicians make evidence-informed decisions regarding optimal treatment strategies for patients with patellofemoral pain.

Validation of a Torso-Mounted Accelerometer for Measures of Vertical Oscillation and Ground Contact Time During Treadmill Running.

The purpose of this study was to validate measures of vertical oscillation (VO) and ground contact time (GCT) derived from a commercially-available, torso-mounted accelerometer compared with single marker kinematics and kinetic ground reaction force (GRF) data. Twenty-two semi-elite runners ran on an instrumented treadmill while GRF data (1000 Hz) and three-dimensional kinematics (200 Hz) were collected for 60 s across 5 different running speeds ranging from 2.7 to 3.9 m/s. Measurement agreement was assessed by Bland-Altman plots with 95% limits of agreement and by concordance correlation coefficient (CCC). The accelerometer had excellent CCC agreement (> 0.97) with marker kinematics, but only moderate agreement, and overestimated measures between 16.27 mm to 17.56 mm compared with GRF VO measures. The GCT measures from the accelerometer had very good CCC agreement with GRF data, with less than 6 ms of mean bias at higher speeds. These results indicate a torso-mounted accelerometer provides valid and accurate measures of torso-segment VO, but both a marker placed on the torso and the accelerometer yield systematic overestimations of center of mass VO. Measures of GCT from the accelerometer are valid when compared with GRF data, particularly at faster running speeds.

Alterations in the lower limb joint moments precede the peripheral neuropathy diagnosis in diabetes patients.

BACKGROUND: Changes in gait patterns in individuals with diabetes and neuropathy are still inconclusive. Our aim was to identify differences in the net intralimb moments distribution and lower limb kinematics during gait in different stage of diabetes. SUBJECTS AND METHODS: This was an observational cross-sectional study that assessed 38 adults: a control group (n=12), a group with diabetes (n=12), and a group with diabetic neuropathy (n=14). The flexor and extensor joint moment peaks and kinematics of ankle, knee, and hip angles were compared among groups (by analysis of variance). RESULTS: At initial contact, both diabetes groups present more hip flexion and smaller hip extensor moment. During late midstance, hip extension decreases, and flexion moment increases in both diabetes groups. For the same diabetes groups, during push off, the hip is more flexed, and the hip extensor moment decreases. Only for the diabetes group without neuropathy is the knee markedly more flexed, and the extensor moment is higher than in the other groups. At push off, the ankle is less extended in both diabetes groups, but the ankle extensor moment is significantly smaller only in neuropathic subjects. CONCLUSIONS: The biomechanical modifications on the gait appeared to be a continuous process that was already revealed in patients without neuropathy. The use of the hip joint as a mechanism of forward progression of the body, instead of using the ankle, was more evident and consistent for the patients with diabetic neuropathy. The knee seems to have a major role in those with diabetes without neuropathy who presented higher extensor moments to support the body during early stance.

Abnormalities of plantar pressure distribution in early, intermediate, and late stages of diabetic neuropathy.

Inconsistent findings with regard to plantar pressure while walking in the diabetic population may be due to the heterogeneity of the studied groups resulting from the classification/grouping criteria adopted. The clinical diagnosis and classification of diabetes have inherent uncertainties that compromise the definition of its onset and the differentiation of its severity stages. A fuzzy system could improve the precision of the diagnosis and classification of diabetic neuropathy because it takes those uncertainties into account and combines different assessment methods. Here, we investigated how plantar pressure abnormalities evolve throughout different severity stages of diabetic polyneuropathy (absent, n=38; mild, n=20; moderate, n=47; severe, n=24). Pressure distribution was analysed over five areas while patients walked barefoot. Patients with mild neuropathy displayed an increase in pressure-time integral at the forefoot and a lower peak pressure at the heel. The peak and pressure-time integral under the forefoot and heel were aggravated in later stages of the disease (moderate and severe) compared with early stages of the disease (absent and mild). In the severe group, lower pressures at the lateral forefoot and hallux were observed, which could be related to symptoms that develop with the aggravation of neuropathy: atrophy of the intrinsic foot muscles, reduction of distal muscle activity, and joint stiffness. Although there were clear alterations over the forefoot and in a number of plantar areas with higher pressures within each severity stage, they did not follow the aggravation evolution of neuropathy classified by the fuzzy model. Based on these results, therapeutic interventions should begin in the early stages of this disease to prevent further consequences of the disease.

Multichannel EMG-based estimation of fiber conduction velocity during isometric contraction of patients with different stages of diabetic neuropathy.

This study compares muscle fiber conduction velocities estimated using surface electromyography during isometric maximal voluntary contraction in different stages of diabetic neuropathy. Eighty-five adults were studied: 16 non-diabetic individuals and 69 diabetic patients classified into four neuropathy stages, defined by a fuzzy expert system: absent (n=26), mild (n=21), moderate (n=11) and severe (n=11). Average muscle fiber conduction velocities of gastrocnemius medialis, tibialis anterior, vastus lateralis and biceps femoris were assessed using linear array electrodes, and were compared by ANOVA. Conduction velocities were significantly decreased in the moderate neuropathy group for the vastus lateralis compared to other groups (from 18% to 21% decrease), and were also decreased in all diabetic groups for the tibialis anterior (from 15% to 20% from control group). Not only the distal anatomical localization of the muscle affects the conduction velocity, but also the proportion of muscle fiber type, where the tibialis anterior with greater type I fiber proportion is affected earlier while the vastus lateralis with greater type II fiber proportion is affected in later stages of the disease. Generally, the muscles of the lower limb have different responsiveness to the effects of diabetes mellitus and show a reduction in the conduction velocity as neuropathy progresses.

Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: results of a randomized controlled trial.

BACKGROUND: Foot musculoskeletal deficits are seldom addressed by preventive medicine despite their high prevalence in patients with diabetic polyneuropathy. AIM: To investigate the effects of strengthening, stretching, and functional training on foot rollover process during gait. METHODS: A two-arm parallel-group randomized controlled trial with a blinded assessor was designed. Fifty-five patients diagnosed with diabetic polyneuropathy, 45 to 65 years-old were recruited. Exercises for foot-ankle and gait training were administered twice a week, for 12 weeks, to 26 patients assigned to the intervention group, while 29 patients assigned to control group received recommended standard medical care: pharmacological treatment for diabetes and foot care instructions. Both groups were assessed after 12 weeks, and the intervention group at follow-up (24 weeks). Primary outcomes involved foot rollover changes during gait, including peak pressure (PP). Secondary outcomes involved time-to-peak pressure (TPP) and pressure-time integral (PTI) in six foot-areas, mean center of pressure (COP) velocity, ankle kinematics and kinetics in the sagittal plane, intrinsic and extrinsic muscle function, and functional tests of foot and ankle. RESULTS: Even though the intervention group primary outcome (PP) showed a not statistically significant change under the six foot areas, intention-to-treat comparisons yielded softening of heel strike (delayed heel TPP, p=.03), better eccentric control of forefoot contact (decrease in ankle extensor moment, p<.01; increase in function of ankle dorsiflexion, p<.05), earlier lateral forefoot contact with respect to medial forefoot (TPP anticipation, p<.01), and increased participation of hallux (increased PP and PTI, p=.03) and toes (increase in PTI, medium effect size). A slower COP mean velocity (p=.05), and an increase in overall foot and ankle function (p<.05) were also observed. In most cases, the values returned to baseline after the follow-up (p<.05). CONCLUSIONS: Intervention discreetly changed foot rollover towards a more physiological process, supported by improved plantar pressure distribution and better functional condition of the foot ankle complex. Continuous monitoring of the foot status and patient education are necessary, and can contribute to preserving the integrity of foot muscles and joints impaired by polyneuropathy. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01207284, registered in 20th September 2010.

Effect of diabetic neuropathy severity classified by a fuzzy model in muscle dynamics during gait.

BACKGROUND: Electromyography (EMG) alterations during gait, supposedly caused by diabetic sensorimotor polyneuropathy, are subtle and still inconsistent, due to difficulties in defining homogeneous experimental groups with a clear definition of disease stages. Since evaluating these patients involve many uncertainties, the use of a fuzzy model could enable a better discrimination among different stages of diabetic polyneuropathy and lead to a clarification of when changes in muscle activation start occurring. The aim of this study was to investigate EMG patterns during gait in diabetic individuals with different stages of DSP severity, classified by a fuzzy system. METHODS: 147 subjects were divided into a control group (n = 30) and four diabetic groups: absent (n = 43), mild (n = 30), moderate (n = 16), and severe (n = 28) neuropathy, classified by a fuzzy model. The EMG activity of the vastus lateralis, tibialis anterior, and gastrocnemius medialis were measured during gait. Temporal and relative magnitude variables were compared among groups using ANOVA tests. RESULTS: Muscle activity changes are present even before an established neural involvement, with delay in vastus lateralis peak and lower tibialis anterior relative magnitude. These alterations suggest an impaired ankle shock absorption mechanism, with compensation at the knee. This condition seems to be more pronounced in higher degrees of neuropathy, as there is an increased vastus lateralis activity in the mild and severe neuropathy groups. Tibialis anterior onset at terminal stance was anticipated in all diabetic groups; at higher degrees of neuropathy, the gastrocnemius medialis exhibited activity reduction and peak delay. CONCLUSION: EMG alterations in the vastus lateralis and tibialis anterior occur even in the absence of diabetic neuropathy and in mild neuropathic subjects, seemingly causing changes in the shock absorption mechanisms at the heel strike. These changes increase with the onset of neural impairments, and the gastrocnemius medialis starts presenting altered activity in the later stages of the disease (moderate and severe neuropathy). The degree of severity of diabetic neuropathy must be taken into account when analyzing diabetic patients' biomechanical patterns of locomotion; we recommend the use of a fuzzy model for classification of disease stages.

Effects of a combined strengthening, stretching and functional training program versus usual-care on gait biomechanics and foot function for diabetic neuropathy: a randomized controlled trial.

BACKGROUND: Polyneuropathy is a complication of diabetes mellitus that has been very challenging for clinicians. It results in high public health costs and has a huge impact on patients' quality of life. Preventive interventions are still the most important approach to avoid plantar ulceration and amputation, which is the most devastating endpoint of the disease. Some therapeutic interventions improve gait quality, confidence, and quality of life; however, there is no evidence yet of an effective physical therapy treatment for recovering musculoskeletal function and foot rollover during gait that could potentially redistribute plantar pressure and reduce the risk of ulcer formation. METHODS/DESIGN: A randomised, controlled trial, with blind assessment, was designed to study the effect of a physiotherapy intervention on foot rollover during gait, range of motion, muscle strength and function of the foot and ankle, and balance confidence. The main outcome is plantar pressure during foot rollover, and the secondary outcomes are kinetic and kinematic parameters of gait, neuropathy signs and symptoms, foot and ankle range of motion and function, muscle strength, and balance confidence. The intervention is carried out for 12 weeks, twice a week, for 40-60 min each session. The follow-up period is 24 weeks from the baseline condition. DISCUSSION: Herein, we present a more comprehensive and specific physiotherapy approach for foot and ankle function, by choosing simple tasks, focusing on recovering range of motion, strength, and functionality of the joints most impaired by diabetic polyneuropathy. In addition, this intervention aims to transfer these peripheral gains to the functional and more complex task of foot rollover during gait, in order to reduce risk of ulceration. If it shows any benefit, this protocol can be used in clinical practice and can be indicated as complementary treatment for this disease. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01207284.

Classification of the severity of diabetic neuropathy: a new approach taking uncertainties into account using fuzzy logic.

OBJECTIVE: This study proposes a new approach that considers uncertainty in predicting and quantifying the presence and severity of diabetic peripheral neuropathy. METHODS: A rule-based fuzzy expert system was designed by four experts in diabetic neuropathy. The model variables were used to classify neuropathy in diabetic patients, defining it as mild, moderate, or severe. System performance was evaluated by means of the Kappa agreement measure, comparing the results of the model with those generated by the experts in an assessment of 50 patients. Accuracy was evaluated by an ROC curve analysis obtained based on 50 other cases; the results of those clinical assessments were considered to be the gold standard. RESULTS: According to the Kappa analysis, the model was in moderate agreement with expert opinions. The ROC analysis (evaluation of accuracy) determined an area under the curve equal to 0.91, demonstrating very good consistency in classifying patients with diabetic neuropathy. CONCLUSION: The model efficiently classified diabetic patients with different degrees of neuropathy severity. In addition, the model provides a way to quantify diabetic neuropathy severity and allows a more accurate patient condition assessment.

Classification of the severity of diabetic neuropathy: a new approach taking uncertainties into account using fuzzy logic

OBJECTIVE: This study proposes a new approach that considers uncertainty in predicting and quantifying the presence and severity of diabetic peripheral neuropathy. METHODS: A rule-based fuzzy expert system was designed by four experts in diabetic neuropathy. The model variables were used to classify neuropathy in diabetic patients, defining it as mild, moderate, or severe. System performance was evaluated by means of the Kappa agreement measure, comparing the results of the model with those generated by the experts in an assessment of 50 patients. Accuracy was evaluated by an ROC curve analysis obtained based on 50 other cases; the results of those clinical assessments were considered to be the gold standard. RESULTS: According to the Kappa analysis, the model was in moderate agreement with expert opinions. The ROC analysis (evaluation of accuracy) determined an area under the curve equal to 0.91, demonstrating very good consistency in classifying patients with diabetic neuropathy. CONCLUSION: The model efficiently classified diabetic patients with different degrees of neuropathy severity. In addition, the model provides a way to quantify diabetic neuropathy severity and allows a more accurate patient condition assessment.

Effects of a multidisciplinary cognitive rehabilitation program for patients with mild Alzheimer's disease.

OBJECTIVE: To evaluate the effects of a multidisciplinary rehabilitation program on cognition, quality of life, and neuropsychiatry symptoms in patients with mild Alzheimer's disease. METHOD: The present study was a single-blind, controlled study that was conducted at a university-based day-hospital memory facility. The study included 25 Alzheimer's patients and their caregivers and involved a 12-week stimulation and psychoeducational program. The comparison group consisted of 16 Alzheimer's patients in waiting lists for future intervention. INTERVENTION: Group sessions were provided by a multiprofessional team and included memory training, computer-assisted cognitive stimulation, expressive activities (painting, verbal expression, writing), physiotherapy, and physical training. Treatment was administered twice a week during 6.5-h gatherings. MEASUREMENTS: The assessment battery comprised the following tests: Mini-Mental State Examination, Short Cognitive Test, Quality of Life in Alzheimer's disease, Neuropsychiatric Inventory, and Geriatric Depression Scale. Test scores were evaluated at baseline and the end of the study by raters who were blinded to the group assignments. RESULTS: Measurements of global cognitive function and performance on attention tasks indicated that patients in the experimental group remained stable, whereas controls displayed mild but significant worsening. The intervention was associated with reduced depression symptoms for patients and caregivers and decreased neuropsychiatric symptoms in Alzheimer's subjects. The treatment was also beneficial for the patients' quality of life. CONCLUSION: This multimodal rehabilitation program was associated with cognitive stability and significant improvements in the quality of life for Alzheimer's patients. We also observed a significant decrease in depressive symptoms and caregiver burden. These results support the notion that structured nonpharmacological interventions can yield adjunct and clinically relevant benefits in dementia treatment.