Letter to the Editor in response to the article 'Association between diabetic peripheral neuropathy and lower limb muscle strength in patients with type 2 diabetes mellitus: A systematic review and meta-analysis'.

ABSTRACTPurposeLower limb muscle strength is often reduced in patients with type 2 diabetes and is associated with a lower quality of life and poorer walking ability. Diabetic peripheral neuropathy (DPN) may contribute to muscle weakness, though evidence is inconsistent. No meta‐analysis has specifically examined the effect of DPN on lower limb muscle strength. This study aimed to review the literature and assess whether lower limb muscle strength is reduced in individuals with DPN compared to those without DPN.MethodsMEDLINE, Embase, and CENTRAL were searched for cohort and case‐control studies on the association between DPN and lower limb muscle strength in individuals with type 2 diabetes. We pooled mean differences and standard deviations using random effects models. We evaluated the risk of bias in the included studies using the Quality in Prognosis Studies tool and determined the certainty of the evidence using the Grading of Recommendations Assessmet, Development and Evaluation (GRADE) approach.ResultsOverall, 25 studies for qualitative synthesis and 23 (2,798 participants) for meta‐analysis were selected. The methodological quality demonstrated a moderate risk of bias in 72% of the included studies. There was low‐certainty evidence of an association between DPN and lower extremity muscle strength (standardized mean difference ‐0.46, 95% CI −0.65 to −0.27).ConclusionsPatients with type 2 diabetes and DPN may have lower muscle strength than those without DPN. Moreover, they should be informed of the risk of muscle weakness. Further research is needed to identify factors contributing to lower extremity weakness in DPN and determine which muscle groups are most susceptible.

Background and Aims In patients on hemodialysis, muscle weakness is highly prevalent and may lead to frailty, limitation of mobility and functional impairment. Moreover, low muscle strength was associated with an increase in mortality risk in these patients. Despite the fact that some studies showed that resistance training improves muscle strength in patients on hemodialysis, the effects of virtual reality (VR) exercise should be confirmed. Therefore, the aim of this study was to evaluate the effects of an intradialytic non-immersive VR exercise program, performed at different times during the hemodialysis session, on lower limb muscle strength in patients on hemodialysis. Method A randomized clinical trial was conducted with patients aged ≥18 years who were undergoing hemodialysis treatment for at least 3 months. Patients were randomized into 2 protocols of exercise at different times during the hemodialysis session (first 2 hours and last two hours) for 3 months. The intradialytic exercise program in both groups consisted of a non-immersive VR game (Treasure Hunting) in which the patients try to catch treasures and avoid bombs by moving their lower limbs (hip flexion, abduction and adduction, and knee flexion and extension), with a progressive duration of 6 to 36 minutes. The difficulty level of the game was graduated according to the characteristics of each patient. The muscle strength of the hip flexion (HF), hip abduction (HA) and ankle extension (AE) was evaluated using a portable handheld dynamometer during hemodialysis session. Patients were advised to perform a 5 s maximum isometric contraction, and the peak values were recorded for 3 repetitions in both lower limbs. The mean muscle strength of 3 trials was recorded. Data were expressed as the median (interquartile range). The Mann‒Whitney U test was used for between-group comparisons. The Friedman test was conducted to evaluate the differences in medians among the muscle strength data at baseline, after 1, 2 and 3 months of exercise program. Results This study included 11 patients in the exercise within the first 2 hours group [50 (55-75) years, 55% male] and 11 patients in the exercise within the last 2 hours group [64 (58-72) years, 64% male]. Table 1 shows that muscle strength of the HA and AE increased significantly in the exercise within the first 2 hours group. Muscle strength of HF, HA and AE improved significantly in the exercise within the last 2 hours group. There were no significant differences between two groups. Conclusion This study suggests that an intradialytic non-immersive VR exercise program can improve lower limb muscle strength in patients on hemodialysis.

Objective:To systematically review the published studies that compare lower limb muscle strength in patients with low back pain to matched healthy controls.Methods:We searched Medline, SciELO, Cumulative Index to Nursing and Allied Health (CINAHL), and Scopus up until December 2017. Studies comparing lower limb muscle strength in people diagnosed with low back pain to healthy control participants were included in the systematic review.Results:14 studies, which included 951 healthy controls and 919 patients with low back pain, fulfilled the inclusion criteria. Meta-analysis revealed a lower muscle strength of hip abductor/extensors and knee extensors in patients with low back pain in comparison to healthy controls. The average strength of hip abductors (Five studies, SMD=0.7 95% CI: 0.49 to 0.9) and hip extensors (Two studies, SMD=0.93, 95% CI: 0.62 to 1.23) was significantly lower in patients with low back pain compared to that of healthy controls. Knee extensor muscle strength was significantly lower in patients with low back pain compared to healthy controls (Three studies, WMD=0.31 Nm/kg, 95% CI: 0.1 to 0.5). The meta-analysis indicated a no significant difference in knee flexor muscle strength in patients with low back pain compared to healthy controls.Conclusions:Lower limb muscle is impaired in patients with low back pain.

To determine the effects of resistance training (RT) on symptoms, function, and lower limb muscle strength in patients with knee osteoarthritis (KOA), and to determine the optimal dose-response relationships. We searched the PubMed, MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and ClinicalTrials.gov databases from inception to January 23, 2022. Randomized controlled trials that examined the effects of RT in KOA patients (mean age ≥50 years) were included. We applied Hedges' g of the random-effects model to calculate the between-subject standardized mean difference (SMDbs). A random-effects metaregression was calculated to explain the influence of key training variables on the effectiveness of RT. We used the Grading of Recommendations Assessments, Development and Evaluation (GRADE) method to appraise the certainty of evidence. A total of 46 studies with 4289 participants were included. The analysis revealed moderate effects of RT on symptoms and function (SMDbs =-0.52; 95% CI: -0.64 to -0.40), and lower limb muscle strength (SMDbs = 0.53; 95% CI: 0.42 to 0.64) in the intervention group compared with the control group. The results of the metaregression revealed that only the variable "training period" (P< .001) had significant effects on symptoms, function, and lower limb muscle strength, and the 4 to 8 weeks of training subgroup showed greater effects than other subgroups (SMDbs =-0.70, -0.91 to -0.48; SMDbs = 0.76, 0.56 to 0.96). Compared with inactive treatments, RT is strongly recommended to improve symptoms, function, and muscle strength in individuals with KOA. Dose-response relationship analysis showed that 4 to 8 weeks of RT had more benefits.

Associations Between Measures of Physical Activity and Muscle Size and Strength: A Systematic Review

IntroductionEnd stage liver disease (ESLD) negatively impacts muscle homeostasis with observed reductions in muscle mass (sarcopenia) and strength. The current recommended measures of muscle mass in ESLD are 3rd lumbar...

The effect of peripheral neuropathy on lower limb muscle strength in diabetic individuals

Purpose Reviewing systematically the randomized controlled trials (RCTs) that evaluated aerobic exercisealone vs. usual care in exercise tolerance, functional capacity, and quality of life (QoL) in patients withpre-dialysis. Methods Searches in the MEDLINE, Cochrane CENTRAL, EMBASE, PEDro, and LILACS databases untilFebruary 2021 included RCTs that evaluated the effects of aerobic exercise on peak VO2, functional capacity,lower limb muscle strength, and QoL. The random effect meta-analysis model was used andreported as mean difference (MD) and 95% confidence interval (CI), risk of bias through RoB2.0 and thequality of evidence by GRADE. Results 10 RCTs, with 365 patients. Aerobic exercise increased 2.07 ml/kg/min (95% CI = 1.16 to 2.98; I2= 24%, QoE moderate) at peak VO2; 77.78m (95% CI= 33.27 to 122.30; I2= 44.5%, QoE moderate) in the 6MWT and 7.65 repetitions (95% CI= 5.73 to 9.58; I2= 0 %; QoE moderate) in STS-30 versus usual care. In QoL, studies reported improvements in the questionnaire scores. Eu. 2 = 24%, QoE moderado) no pico de VO2; 77,78 m (IC95% = 33,27-122,30; Eu. 2 = 44,5%, QoE moderado) nas repetições 6MWT e 7,65 (IC95% = 5,73-9,58; Eu. 2 = 0%; QoE moderado) em STS-30" Conclusion Aerobic exercise increases VO2 peak, functional capacity and lower limb muscle strength in patients with pre-dialysis. Effects on QoL appear to be beneficial. IMPLICATIONS FOR REHABILITATION Aerobic exercise should be encouraged in the rehabilitation of patients at any stage of chronic kidney disease. Aerobic exercise promotes improved exercise tolerance, functional capacity, and muscle strength of the lower limbs. There is some evidence to show it is beneficial to improve the quality of life.

Objective: The high incidence and prevalence of falls among older people with type 2 diabetes mellitus (ODM) have been documented. The risk factors of falls among ODM were identified as poor diabetic control, diabetic peripheral neuropathy (DPN) and balance impairment. This study aimed to investigate the contribution of DPN to history of falls. The differences of balance performance and lower limb muscle strength among ODM with and without DPN were also explored. Methods: This cross-sectional study interviewed 112 ODM for their falls occurrences within the previous 6 months. DPN was determined by the score of the Michigan Neuropathy Screening Instrument. Balance performance tests included Clinical Test of Sensory Interaction and Balance (mCTSIB), Functional Reach Test (FRT) and Timed Up and Go Test (TUG). Leg muscle strength was also measured. The logistic regression analysis was performed. Results: The history of falls was reported 30.6% of ODM with DPN and 10.4% of ODM without DPN. Presenting of DPN influenced falls with odds ratio of 3.46 among ODM. Differences were found of mCTSIB in the condition of eyes closed on firm and foam surfaces, FRT, and TUG between those with and without DPN. Knee extensor strength differed between those with and without DPN. Conclusion: DPN was more prominent among fallers. Balance performance and leg strength were lower in ones with DPN. Falls prevention programs including balance training and therapeutic exercise to improve balance performance and muscle strength should be emphasized among ODM, especially before the onset of DPN.

To observe the effect of early acupoint electrical stimulation on the decline of lower limbs muscle strength in patients with intensive care unit-acquired weakness (ICU-AW) caused by septic shock. A total of 58 patients with ICU-AW caused by septic shock were randomly divided into an observation group (28 cases, 1 case dropped off ) and a control group (30 cases, 2 cases dropped off ). Patients in both groups received routine basic treatment. In the observation group, acupoint electric stimulation therapy was added at Huantiao (GB 30), Futu (ST 32), Zusanli (ST 36), Xuanzhong (GB 39) and Taichong (LR 3). Unilateral point with electrodes were applied, the SDZ-Ⅱ electronic instrument (discontinuous wave, frequency in 2 Hz, strength in 5 mA) was connected and changed to the other side after 30 min of unilateral treatment.The treatment was given 2 times daily, continued for 7 d or until the medical research council (MRC) score being 54 points or more. The changes of lower limb muscle strength MRC score, modified Rankin scale (MRS) score, bilateral quadriceps thickness and gastrocnemius pinnate angle of both groups were observed before treatment and on discharge. The time of admission to ICU, time of hospitalization, mortality during hospitalization, and mortality 28 d after discharge were compared between the two groups. The MRS scores of the two groups were followed up 28 d after discharge. The MRC scores of lower limb muscle strength in the two groups on discharge were higher than those before treatment (P<0.05), and the MRS scores on discharge and 28 d after discharge in the two groups were lower than those before treatment (P<0.05). The MRC scores of lower limb muscle strength on discharge in the observation group were higher than thoes in the control group (P<0.05), and the MRS scores on discharge and 28 d after discharge in the observation group were lower than those in the control group (P<0.05). On discharge, bilateral quadriceps thickness and gastrocnemius pinnate angle in the two groups were increased compared with those before treatment (P<0.05), and thoese in the observation group was higher than the control group (P<0.05). There was no significant difference between the two groups in the time of admission to ICU, time of hospitalization, mortality during hospitalization, and mortality 28 d after discharge (P>0.05). Early acupoint electrical stimulation can improve the lower extremity muscle decline in patients with ICU-AW caused by septic shock.

ObjectiveTo compare balance performance and lower limb muscle strength between older adults with type 2 diabetes mellitus (DM), with and without sensory impairments and non-DM groups. Influence of a number of sensory impairments, and muscle strength on balance performance were explored.MethodsNinety-two older adults with and without type 2 DM, were examined relative to visual function with the Snellen chart, Melbourne Edge test, and Howard-Dolman test, vestibular function with the modified Romberg test, proprioception of the big toe, and diabetic peripheral neuropathy with the Michigan Neuropathy Screening Instrument. Balance performances were evaluated with the Romberg test, Functional Reach Test (FRT), and Timed Up and Go test (TUG). Strength of knee and ankle muscles was measured.ResultsFRT of type 2 DM groups with at least two sensory impairments, was lower than the non-DM group (p<0.05). TUG of all DM groups, was worse than the non-DM group (p<0.01). Lower limb muscle strength of type 2 DM groups with two and three sensory impairments, was weaker than non-DM group (p<0.05). Regression analysis showed that type 2 DM with three sensory impairments, ankle dorsiflexors strength, and age were influential predictors of TUG.ConclusionThere were significant differences, of muscle strength and balance performance among groups. Poorer balance and reduced lower limb strength were marked in older adults with type 2 DM, even ones without sensory impairment. Muscle weakness seemed to progress, from the distal part of lower limbs. A greater number of sensory impairments, weaker dorsiflexors, and advanced age influenced balance performance.

Background and Aims This study evaluated dynamic balance, quadriceps, and hamstring strength in individuals with Covid 19 compared with healthy control ones. Methods A total of 30 people were divided into two groups, including healthy people (n=15) and people with Covid-19. Dynamic balance was measured using the star excursion balance test. A dynamometer performed lower limb muscle strength measurements. An independent t-test was used to compare the two groups statistically. The significance level was considered 0.05. Results Quadriceps and hamstring muscle strength were similar in both groups (P&gt;0.05). The results showed that the values of dynamic balance in the lateral (P=0.001), medial (P=0.001), and posterior medial (P=0.001) directions were significantly lower in the group with Covid-19 than that in the healthy group. Conclusion In general, the balance of people with Covid-19 was significantly lower than the healthy group. Decreased balance due to this disease can increase the risk of injury. There was no significant difference in lower limb muscle strength in patients with Covid-19 compared with healthy individuals. Perhaps more research is needed in the future to prove this better.

BackgroundOsteoarthritis (OA) is a common health issue worldwide in the aging population who are also commonly deficient in vitamin D. Our previous study suggested that higher serum 25-(OH)D levels were associated with reduced knee cartilage loss, implying that vitamin D supplementation may prevent the progression of knee OA. The aim of the VItamin D Effects on OA (VIDEO) study is to compare, over a 2- year period, the effects of vitamin D supplementation versus placebo on knee structural changes, knee pain, and lower limb muscle strength in patients with symptomatic knee OA.Methods/designRandomised, placebo-controlled, and double-blind clinical trial aiming to recruit 400 subjects (200 from Tasmania and 200 from Victoria) with both symptomatic knee OA and vitamin D deficiency (serum [25-(OH)D] level of >12.5 nmol/liter and <60 nmol/liter). Participants will be randomly allocated to vitamin D supplementation (50,000 IU compounded vitamin D3 capsule monthly) or identical inert placebo group for 2 years. The primary endpoint is loss of knee cartilage volume measured by magnetic resonance imaging (MRI) and Western Ontario and McMaster Universities Index of OA (WOMAC) knee pain score. The secondary endpoints will be other knee structural changes, and lower limb muscle strength. Several other outcome measures including core muscle images and central blood pressure will be recorded. Linear and logistic regression will be used to compare changes between groups using univariable and multivariable modeling analyses. Both intention to treat and per protocol analyses will be utilized.DiscussionThe trial is designed to test if vitamin D supplementation will reduce loss of knee cartilage volume, prevent the progression of other knee structural abnormalities, reduce knee pain and strengthen lower limb muscle strength, thus modify disease progression in knee OA.Trial registrationClinicalTrials.gov identifier: NCT01176344; Australian New Zealand Clinical Trials Registry: ACTRN12610000495022

The physical capabilities underlying timed “Up and Go” test are time-dependent in community-dwelling older women

Case Scenario: Residual Curarization in Diabetic Polyneuropathy