Biomechanical characteristics of peripheral diabetic neuropathy : a systematic review and meta-analysis of findings from the gait cycle, muscle activity and dynamic barefoot plantar pressure

Background: Diabetic peripheral neuropathy is an important cause of foot ulceration and limb loss. This systematic review and meta-analysis investigated the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and dynamic plantar pressures. Methods: Electronic databases were searched systematically for articles reporting the effect of diabetic peripheral neuropathy on gait, dynamic electromyography and plantar pressures. Searches were restricted to articles published between January 2000 and April 2012. Outcome measures assessed included spatiotemporal parameters, lower limb kinematics, kinetics, muscle activation and plantar pressure. Meta-analyses were carried out on all outcome measures reported by ≥3 studies. Findings: Sixteen studies were included consisting of 382 neuropathy participants, 216 diabetes controls without neuropathy and 207 healthy controls. Meta-analysis was performed on 11 gait variables. A high level of heterogeneity was noted between studies. Meta-analysis results suggested a longer stance time and moderately higher plantar pressures in diabetic peripheral neuropathy patients at the rearfoot, midfoot and forefoot compared to controls. Systematic review of studies suggested potential differences in the biomechanical characteristics (kinematics, kinetics, EMG) of diabetic neuropathy patients. However these findings were inconsistent and limited by small sample sizes.; Interpretation: Current evidence suggests that patients with diabetic peripheral neuropathy have elevated plantar pressures and occupy a longer duration of time in the stance-phase during gait. Firm conclusions are hampered by the heterogeneity and small sample sizes of available studies. Interpretation: Current evidence suggests that patients with diabetic peripheral neuropathy have elevated plantar pressures and occupy a longer duration of time in the stance-phase during gait. Firm conclusions are hampered by the heterogeneity and small sample sizes of available studies.

Force-deformation properties of the human heel pad during barefoot walking

Introduction: The plantar heel pad is a specialized fibroadipose tissue that attenuates and, in part, dissipates the impact energy associated with heel strike. Although near maximal deformation of the heel pad has been shown during running, in vivo measurement of the deformation and structural properties of the heel pad during walking remains largely unexplored. This study employed a fluoroscope, synchronized with a pressure platform, to obtain force–deformation data for the heel pad during walking. Methods: Dynamic lateral foot radiographs were acquired from 6 male and 10 female adults (age, 45 ± 10 yrs; height, 1.66 ± 0.10 m; and weight, 80.7 ± 10.8 kg), while walking barefoot at preferred speeds. The inferior aspect of the calcaneus was digitized and the sagittal thickness and deformation of the heel pad relative to the support surface calculated. Simultaneous measurement of the peak force beneath the heel was used to estimate the principal structural properties of the heel pad. Results: Transient loading profiles associated with walking induced rapidly changing deformation rates in the heel pad and resulted in irregular load–deformation curves. The initial stiffness (32 ± 11 N.mm-1) of the heel pad was an order of magnitude lower than its final stiffness (212 ± 125 N.mm-1) and on average, only 1.0 J of energy was dissipated by the heel pad with each step during walking. Peak deformation (10.3 mm) approached that predicted for the limit of pain tolerance (10.7 mm). Conclusion: These findings suggest the heel pad operates close to its pain threshold even at speeds encountered during barefoot walking and provides insight as to why barefoot runners may adopt ‘forefoot’ strike patterns that minimize heel loading.

Achilles tendon loading patterns during barefoot walking and slow running on a treadmill: An ultrasonic propagation study

Measurement of tendon loading patterns during gait is important for understanding the pathogenesis of tendon "overuse" injury. Given that the speed of propagation of ultrasound in tendon is proportional to the applied load, this study used a noninvasive ultrasonic transmission technique to measure axial ultrasonic velocity in the right Achilles tendon of 27 healthy adults (11 females and 16 males; age, 26 ± 9 years; height, 1.73 ± 0.07 m; weight, 70.6 ± 21.2 kg), walking at self-selected speed (1.1 ± 0.1 m/s), and running at fixed slow speed (2 m/s) on a treadmill. Synchronous measures of ankle kinematics, spatiotemporal gait parameters, and vertical ground reaction forces were simultaneously measured. Slow running was associated with significantly higher cadence, shorter step length, but greater range of ankle movement, higher magnitude and rate of vertical ground reaction force, and higher ultrasonic velocity in the tendon than walking (P < 0.05). Ultrasonic velocity in the Achilles tendon was highly reproducible during walking and slow running (mean within-subject coefficient of variation < 2%). Ultrasonic maxima (P1, P2) and minima (M1, M2) were significantly higher and occurred earlier in the gait cycle (P1, M1, and M2) during running than walking (P < 0.05). Slow running was associated with higher and earlier peaks in loading of the Achilles tendon than walking.

The barefoot book of monsters!

Inspirado en cuentos populares, desde las montañas de Nepal a las llanuras de América del Norte. Es una lectura esencial para cualquier niño que quiere la emoción de conocer algunas de las criaturas más fantásticas y monstruosas del folklore de todo el mundo.

The Barefoot book of pirates.

Siete cuentos de todo el mundo conforman esta colección de narraciones de piratas. Algunas de las historias de esta antología se basan en aventuras de piratas reales, algunos feroces y temibles como el capitán alemán de la historia Kobold y los piratas. Relata tradiciones de diversas culturas, desde Japón a Marruecos a Persia, si bien predominan los de Europa. Especialmente compilados para primeros lectores, han sido escogidos a fin de combinar una rica variedad de argumentos con vocabulario variado.

The barefoot book of princesses.

Culturas de todo el mundo están representadas en estas siete historias. Sólo dos de los siete cuentos son conocidos: La princesa y el guisante, La Bella Durmiente.

Barefoot in the Head

A co-edited book (Article Press, UCE, 2011), and book chapter written in response to the event: 'Barefoot in the Head', co-curated with Alun Rowlands and Mark Beasley at Bruce High Quality Foundation University, 225 West Broadway, as part of Performa 09 New York, 12 November 2009 Also including authored chapter: Russell, J. ‘A largely intolerable combination of two mainly unconnected texts: 1. Description of the Barefoot in the Head event, at BHQU, NY, 12/11/09; 2. Fictioning and the End.’ pp 68-85.

A largely intolerable combination of two mainly unconnected texts: 1. Description of the Barefoot in the Head event, at BHQU, NY, 12/11/09; 2. Fictioning and the End

An evaluation of the 'Barefoot in the Head' performance event, I co-curated with Alun Rowlands and Mark Beasley, at Bruce High Quality Foundation University, New York, as part of Performa 09 New York, 12 November 2009 - an examination of my own performance and the other performances occurring simultaneously at the event.

Effects of conifer sawdust, hardwood sawdust, and peat on soil properties and a barefoot conifer seedling development

Organic amendments are commonly used to improve tree nursery soil conditions for increased seedling growth. However, few studies compare organic amendments effects on soil conditions, and fewer compare subsequent effects on seedling growth. The effects of three organic amendments on soil properties and seedling growth were investigated at the USDA Forest Service J.W. Toumey Nursery in Watersmeet, MI. Pine sawdust (red pine, Pinus resinosa), hardwood sawdust (maple, Acer spp. and aspen, Populus spp.), and peat were individually incorporated into a loamy sand nursery soil in August, 2006, and soil properties were sampled periodically for the next 14 months. Jack (Pinus banksiana), red, and white pine (Pinus strobus) were sown into test plots in June, 2007 and sampled for growth responses at the end of the growing season. It is hypothesized; pine sawdust and peat can be used as a satisfactory soil amendment to improve soil conditions and produce high quality seedlings, when compared to hardwood sawdust in bareroot nursery soils. This study has the potential to reduce nursery costs while broadening soil amendment options. The addition of peat and pine sawdust increased soil organic matter above control soil conditions after 14 months. However, hardwood sawdust-amended soils did not differ from control soils after same time period. High N concentrations in peat increased total soil N over the other treatments. Similarly, the addition of peat increased soil matric potential and available water over all other treatments. Seedlings grew tallest with the largest stem diameter, and had the largest biomass in both control soil and soil amended with peat, compared to either sawdust treatment. Seedlings grown in peat-amended soils had higher N concentrations than those grown in soils treated with pine sawdust, though neither was different from seedlings grown in control or hardwood sawdust-amended soils. Overall, peat is a well suited organic soil amendment for the enhancement of soil properties, but no amendments were able to increase one-year seedling growth over control soils.

What do people think about running barefoot/with minimalist footwear? A thematic analysis

Objectives

Barefoot running describes when individuals run without footwear. Minimalist running utilizes shoes aimed to mimic being barefoot. Although these forms of running have become increasingly popular, we still know little about how recreational runners perceive them.
Design

In-depth interviews with eight recreational runners were used to gather information about their running experiences with a focus on barefoot and minimalist running.
Methods

Interviews were analysed using a latent level thematic analysis to identify and interpret themes within the data.
Results

Although participants considered barefoot running to be ‘natural’, they also considered it to be extreme. Minimalist running did not produce such aversive reactions. ‘Support’ reassured against concerns and was seen as central in protecting vulnerable body parts and reducing impact forces, but lacked a common or clear definition. A preference for practical over academic knowledge was found. Anecdotal information was generally trusted, as were running stores with gait assessment, but not health professionals.
Conclusion

People often have inconsistent ideas about barefoot and minimalist running, which are often formed by potentially biased sources, which may lead people to make poor decisions about barefoot and minimalist running. It is important to provide high-quality information to enable better decisions to be made about barefoot and minimalist running.

Statement of contribution

What is already known on this subject?
There is no known work on the psychology behind barefoot and minimalist running. We believe our study is the first qualitative study to have investigated views of this increasingly popular form of running.
What does this study add?
The results suggest that although barefoot running is considered ‘natural’, it is also considered ‘extreme’. Minimalist running, however, did not receive such aversive reactions.
‘Support’ was a common concern among runners. Although ‘support’ reassured against concerns and was seen as central in protecting vulnerable body parts and reducing impact forces, it lacked a common or clear definition.
A preference for practical over academic knowledge was found. Anecdotal information was generally trusted, as were running stores with gait assessment, but not health professionals.

The neuro-muscular and musculo-skeletal characterization of children with joint hypermobility

In children, joint hypermobility (typified by structural instability of joints) manifests clinically as neuro-muscular and musculo-skeletal conditions and conditions associated with development and organization of control of posture and gait (Finkelstein, 1916; Jahss, 1919; Sobel, 1926; Larsson, Mudholkar, Baum and Srivastava, 1995; Murray and Woo, 2001; Hakim and Grahame, 2003; Adib, Davies, Grahame, Woo and Murray, 2005:). The process of control of the relative proportions of joint mobility and stability, whilst maintaining equilibrium in standing posture and gait, is dependent upon the complex interrelationship between skeletal, muscular and neurological function (Massion, 1998; Gurfinkel, Ivanenko, Levik and Babakova, 1995; Shumway-Cook and Woollacott, 1995). The efficiency of this relies upon the integrity of neuro-muscular and musculo-skeletal components (ligaments, muscles, nerves), and the Central Nervous System’s capacity to interpret, process and integrate sensory information from visual, vestibular and proprioceptive sources (Crotts, Thompson, Nahom, Ryan and Newton, 1996; Riemann, Guskiewicz and Shields, 1999; Schmitz and Arnold, 1998) and development and incorporation of this into a representational scheme (postural reference frame) of body orientation with respect to internal and external environments (Gurfinkel et al., 1995; Roll and Roll, 1988). Sensory information from the base of support (feet) makes significant contribution to the development of reference frameworks (Kavounoudias, Roll and Roll, 1998). Problems with the structure and/ or function of any one, or combination of these components or systems, may result in partial loss of equilibrium and, therefore ineffectiveness or significant reduction in the capacity to interact with the environment, which may result in disability and/ or injury (Crotts et al., 1996; Rozzi, Lephart, Sterner and Kuligowski, 1999b). Whilst literature focusing upon clinical associations between joint hypermobility and conditions requiring therapeutic intervention has been abundant (Crego and Ford, 1952; Powell and Cantab, 1983; Dockery, in Jay, 1999; Grahame, 1971; Childs, 1986; Barton, Bird, Lindsay, Newton and Wright, 1995a; Rozzi, et al., 1999b; Kerr, Macmillan, Uttley and Luqmani, 2000; Grahame, 2001), there has been a deficit in controlled studies in which the neuro-muscular and musculo-skeletal characteristics of children with joint hypermobility have been quantified and considered within the context of organization of postural control in standing balance and gait. This was the aim of this project, undertaken as three studies. The major study (Study One) compared the fundamental neuro-muscular and musculo-skeletal characteristics of 15 children with joint hypermobility, and 15 age (8 and 9 years), gender, height and weight matched non-hypermobile controls. Significant differences were identified between previously undiagnosed hypermobile (n=15) and non-hypermobile children (n=15) in passive joint ranges of motion of the lower limbs and lumbar spine, muscle tone of the lower leg and foot, barefoot CoP displacement and in parameters of barefoot gait. Clinically relevant differences were also noted in barefoot single leg balance time. There were no differences between groups in isometric muscle strength in ankle dorsiflexion, knee flexion or extension. The second comparative study investigated foot morphology in non-weight bearing and weight bearing load conditions of the same children with and without joint hypermobility using three dimensional images (plaster casts) of their feet. The preliminary phase of this study evaluated the casting technique against direct measures of foot length, forefoot width, RCSP and forefoot to rearfoot angle. Results indicated accurate representation of elementary foot morphology within the plaster images. The comparative study examined the between and within group differences in measures of foot length and width, and in measures above the support surface (heel inclination angle, forefoot to rearfoot angle, normalized arch height, height of the widest point of the heel) in the two load conditions. Results of measures from plaster images identified that hypermobile children have different barefoot weight bearing foot morphology above the support surface than non-hypermobile children, despite no differences in measures of foot length or width. Based upon the differences in components of control of posture and gait in the hypermobile group, identified in Study One and Study Two, the final study (Study Three), using the same subjects, tested the immediate effect of specifically designed custom-made foot orthoses upon balance and gait of hypermobile children. The design of the orthoses was evaluated against the direct measures and the measures from plaster images of the feet. This ascertained the differences in morphology of the modified casts used to mould the orthoses and the original image of the foot. The orthoses were fitted into standardized running shoes. The effect of the shoe alone was tested upon the non-hypermobile children as the non-therapeutic equivalent condition. Immediate improvement in balance was noted in single leg stance and CoP displacement in the hypermobile group together with significant immediate improvement in the percentage of gait phases and in the percentage of the gait cycle at which maximum plantar flexion of the ankle occurred in gait. The neuro-muscular and musculo-skeletal characteristics of children with joint hypermobility are different from those of non-hypermobile children. The Beighton, Solomon and Soskolne (1973) screening criteria successfully classified joint hypermobility in children. As a result of this study joint hypermobility has been identified as a variable which must be controlled in studies of foot morphology and function in children. The outcomes of this study provide a basis upon which to further explore the association between joint hypermobility and neuro-muscular and musculo-skeletal conditions, and, have relevance for the physical education of children with joint hypermobility, for footwear and orthotic design processes, and, in particular, for clinical identification and treatment of children with joint hypermobility.

Body size and walking cadence affect lower extremity joint power in children's gait

Obese children move less and with greater difficulty than normal-weight counterparts but expend comparable energy. Increased metabolic costs have been attributed to poor biomechanics but few studies have investigated the influence of obesity on mechanical demands of gait. This study sought to assess three-dimensional lower extremity joint powers in two walking cadences in 28 obese and normal-weight children. 3D-motion analysis was conducted for five trials of barefoot walking at self-selected and 30% greater than self-selected cadences. Mechanical power was calculated at the hip, knee, and ankle in sagittal, frontal and transverse planes. Significant group differences were seen for all power phases in the sagittal plane, hip and knee power at weight acceptance and hip power at propulsion in the frontal plane, and knee power during mid-stance in the transverse plane. After adjusting for body weight, group differences existed in hip and knee power phases at weight acceptance in sagittal and frontal planes, respectively. Differences in cadence existed for all hip joint powers in the sagittal plane and frontal plane hip power at propulsion. Frontal plane knee power at weight acceptance and sagittal plane knee power at propulsion were significantly different between cadences. Larger joint powers in obese children contribute to difficulty performing locomotor tasks, potentially decreasing motivation to exercise.

The role of vision in obese and normal-weight children's gait control

Previous research has suggested that perceptual-motor difficulties may account for obese children's lower motor competence; however, specific evidence is currently lacking. Therefore, this study examined the effect of altered visual conditions on spatiotemporal and kinematic gait parameters in obese versus normal-weight children. Thirty-two obese and normal-weight children (11.2 ± 1.5 years) walked barefoot on an instrumented walkway at constant self-selected speed during LIGHT and DARK conditions. Three-dimensional motion analysis was performed to calculate spatiotemporal parameters, as well as sagittal trunk segment and lower extremity joint angles at heel-strike and toe-off. Self-selected speed did not significantly differ between groups. In the DARK condition, all participants walked at a significantly slower speed, decreased stride length, and increased stride width. Without normal vision, obese children had a more pronounced increase in relative double support time compared to the normal-weight group, resulting in a significantly greater percentage of the gait cycle spent in stance. Walking in the DARK, both groups showed greater forward tilt of the trunk and restricted hip movement. All participants had increased knee flexion at heel-strike, as well as decreased knee extension and ankle plantarflexion at toe-off in the DARK condition. The removal of normal vision affected obese children's temporal gait pattern to a larger extent than that of normal-weight peers. Results suggest an increased dependency on vision in obese children to control locomotion. Next to the mechanical problem of moving excess mass, a different coupling between perception and action appears to be governing obese children's motor coordination and control.