Weight-bearing Activity Research Articles

Kinematic Performance of Medial Pivot Total Knee Arthroplasty

BackgroundTotal knee arthroplasty (TKA) implants have continued to evolve to accommodate new understandings of knee mechanics. The medial-pivot implant is a newer design, which is intended to limit anterior-posterior translation in the medial compartment while allowing lateral compartment translation. However, evidence for a generalized medial-pivot characteristic across all activities is limited. The purpose of the study was to quantify and compare in vivo knee joint kinematics using high-speed stereo radiography during activities of daily living in patients who have undergone a TKA with a cruciate sacrificing medial-pivot implant to age-matched and sex-matched native controls. MethodsFifteen participants (7 patients, 4 women, mean age 70 years and 8 nonsymptomatic controls, 4 women, mean age 64 years) performed 6 functional tasks in high-speed stereo radiography: deep-knee lunge, chair rise, step down, gait, gait with 90° turn, and seated knee extension. Translational differences between groups (surgical versus control) were assessed for the medial and lateral condyle, while pivot location was normalized to subject-specific tibial plateau geometry. ResultsThe surgical cohort displayed a more constrained medial condyle that provided greater stability of the medial compartment and did not result in the paradoxical anterior translation at mid-flexion angles during weight-bearing activities, but was associated with less condylar translation than native knees. Additionally, the transverse tibial pivot location occurs most commonly in the middle third of the tibial plateau and secondarily on the medial third. ConclusionsSome variability in pivot location occurs between activities and is more in nonsymptomatic, native knee controls.

Intensified acute in-hospital physiotherapy for patients after hip fracture surgery: a pragmatic, randomized, controlled feasibility trial

Purpose Intensified acute in-hospital physiotherapy (IP) after hip fracture (HF) may enhance patient’s ability to regain basic mobility at discharge. The primary objective was to assess the feasibility of IP. Secondary to estimate the effect of IP on regained basic mobility at discharge. Materials and methods In a pragmatic, randomized, unblinded feasibility trial, 60 patients (mean age 79 years, 41 women) with HF and an independent pre-fracture basic mobility level were randomized (2:1) to IP with two daily sessions on weekdays focusing on functional training and weight-bearing activities (n = 40) versus usual care (UC) physiotherapy once daily (n = 20). Feasibility outcomes included physiotherapy completion rates, reasons for non-successful completion, and adverse events. The primary effect outcome was recovery of basic mobility (Cumulated Ambulation Score (CAS)). Results Eighty-two percent of the sessions in the IP group were successfully- or partially completed versus 94% of the sessions in the UC group. No adverse events occurred. The main reason for not completing physiotherapy was fatigue. At discharge (median 7 days), 50% in the IP group had regained their pre-fracture basic mobility level (CAS = 6) versus 16% in the UC group; odds ratio = 5.33, 95%CI [1.3;21.5]. Conclusions IP seems feasible for patients after HF surgery, and it may enhance recovery. Fatigue was the primary obstacle to completing IP.

Persistent altered knee loading in patients with meniscectomy: A systematic review and meta-analysis

ObjectivesTo determine the changes in knee flexion moment (KFM) and knee adduction moment (KAM) during weight-bearing activities following meniscectomy. DesignMeta-Analysis. SettingLaboratory. Participants332 meniscectomy patients and 137 healthy controls (from 13 qualified studies) Main outcome measuresCohen's d effect sizes (ESs) were calculated to compare KAM and KFM values of the surgical legs to the non-surgical and to healthy control legs. ResultsWhen compared to healthy controls, meniscectomy patients' surgical legs demonstrated a significantly greater KAM (ES = 0.310; P = 0.002) but no significant difference in KFM (ES = −0.182; P = 0.051). When compared to the patients' non-surgical legs, however, the surgical legs showed no difference in KAM (ES = −0.024; P = 0.716) but a significantly lower KFM (ES = −0.422; P < 0.001). High heterogeneity among study ESs was observed in patients’ between-limb comparison for KAM (Q-value = 20.08, P = 0.005; I2 = 65.1%) and KFM (Q-value = 43.96, P < 0.001; I2 = 79.5%). However, no significant differences in study ESs (all P > 0.102) of KFM and KAM were identified when comparing studies with various times post-surgery, weight-bearing tasks, walking speeds, or patient demographics. ConclusionElevated KAM and reduced/asymmetrical KFM observed in meniscectomy patients may contribute to the increased risk of knee OA. Rehabilitation should focus on movement education to restore between-limb KFM symmetry and reduce KAM bilaterally post-meniscectomy.

Efficacy of Transverse Friction Massage versus Dry Cupping on Flexor Digitorum Brevis and Gastrocsoleus in Patients with Planter fasciitis

Purpose: Plantar fasciitis is a musculo-skeletal ailment prevalent in people of diverse ages and levels of physical activity. This condition causes pain in the medial side of heel, which is exacerbated by weight-bearing activities as well as in rest or non-weight bearing. The objective of the study was to compare the effects on transverse friction massage and dry cupping on pain, disability and activity limitations in patients with planter fasciitis.&#x0D; Methodology: It was a quasi-experimental study with sample size of 32 and convenient sampling was used to recruit patients in study. Inclusion criteria of study were females and males of age 21 to 35 years, chronic pain in foot for more than 4 months and had positive windlass test. Study duration was 6 months. Out of 32 patients 16 were enrolled in group-A (baseline therapy and Transverse Friction Massage) and remaining 16 were enrolled in group-B (baseline therapy and Dry Cupping). Intensity of pain was assessed by NPRS before and after the treatment of 4 week and functional limitations was measure by Foot Function Index (FFI). Data was analyzed by software SPSS 24.0.&#x0D; Findings: Out of 32 participants 37.5% were men and 62.5% were women. Results demonstrated that median of NPRS in group A before treatment was 6.50 and after treatment it was 3.00. Median of NPRS in group B before treatment was 6.00 and after treatment it was 2.50. Pre-treatment mean of FFI in group A was 64.18±7.40 which reduced to 21.12±9.26 after the treatment of 4 weeks. Pre-treatment mean of FFI in group b was 63.18±7.70 and after treatment it was 23.12±8.24. A statistical significant difference was found in pre and post treatments of both groups p≤0.05). Between group analysis of A and B showed no statistical significant difference (p&gt;0.05). Transverse friction massage and dry cupping showed equal effects in reducing disability, activity limitations and pain in the patients of planter fasciitis.&#x0D; Recommendations: Transverse Friction Massage and Dry Cupping demonstrate equivalent therapeutic benefits for plantar fasciitis patients. Clinicians are advised to consider both interventions, factoring in patient comfort and logistical constraints. It's imperative for policymakers to integrate these findings into clinical guidelines, while also promoting further research to elucidate the specific therapeutic mechanisms involved.

Marijuana-Provoked Hypoprolactinemia and Impaired Bone Mineral Density: Case Report and Review of Literature

Introduction: The incidence of concurrent hypoprolactinemia and impaired bone mineral density (IBMD) induced by marijuana abuse has not been observed among the general population. To the very best of our knowledge, none of these two rare conditions have previously been documented among Nigerians, within the existing literature. Case Report: Herein, is a rare case of concurrent hypoprolactinemia and IBMD triggered by marijuana abuse, in a 21-year-old undergraduate Nigerian male, who is a regular/heavy marijuana smoker of thirteen months duration. He had presented in our medical facility with complaints of recurrent excruciating lower back pain of three weeks duration which intensified with walking and while undertaking weight-bearing activities. He attested to having and seeking medical attention for, excessive sweating, and insomnia symptoms before the onset of current presenting symptoms. Results of investigations showed positive urine test for marijuana, hypoprolactinemia, distortions of biomarkers of bone metabolism, and radiologic features consistent with IBMD, Having found no other discernible cause of the low back/hip pain and hyoprolactinemia, he was diagnosed clinically with hypoprolactinemia and IBMD secondary to marijuana abuse. This warranted hospital admission where he obtained standardized specialist medical care and was subsequently discharged in good clinical condition with an uneventful follow-up period. Conclusion: This case highlights the dangers of metabolic aberrations due to marijuana abuse and the need to always maintain a high index of suspicion when confronted with it to avoid unnecessary medical protocols.

In vivo segmental vertebral kinematics in patients with degenerative lumbar scoliosis.

This study aimed to find a standard of the vertebra kinematics during functional weight-bearing activities in degenerative lumbar scoliosis (DLS) patients. Fifty-four patients were involved into this study with forty-two in DLS group and twelve in the control group. The three-dimensional (3D) vertebral models from L1 to S1 of each participant were reconstructed by computed tomography (CT). Dual-orthogonal fluoroscopic imaging, along with FluoMotion and Rhinoceros software, was used to record segmental vertebral kinematics during functional weight-bearing activities. The primary and coupled motions of each vertebra were analyzed in patients with DLS. During flexion-extension of the trunk, anteroposterior (AP) translation and craniocaudal (CC) translation at L5-S1 were higher than those at L2-3 (9.3 ± 5.1mm vs. 6.4 ± 3.5mm; P < 0.05). The coupled mediolateral (ML) translation at L5-S1 in patients with DLS was approximately three times greater than that in the control group. During left-right bending of the trunk, the coupled ML rotation at L5-S1 was higher in patients with DLS than that in the control group (17.7 ± 10.3° vs. 8.4 ± 4.4°; P < 0.05). The AP and CC translations at L5-S1 were higher than those at L1-2, L2-3, and L3-4. During left-right torsion of the trunk, the AP translation at L5-S1 was higher as compared to other levels. The greatest coupled translation was observed at L5-S1 in patients with DLS. Coupled AP and ML translations at L5-S1 were higher than those in healthy participants. These data improved the understanding of DLS motion characteristics.

Comparing the Utility of Custom Foot Orthoses vs Prescription-grade Prefabricated Foot Orthoses

Category: Hindfoot; Ankle Introduction/Purpose: Both prefabricated and custom-made foot orthoses have long been effective treatment foot and ankle conditions and deformities. Foot orthoses function by replacing the insole of a shoe to redistribute forces during weightbearing activities and can be a cost-effective and noninvasive treatment modality. Custom foot orthoses are created using a 3D scan or weightbearing impression of the patient’s foot and are intended to accommodate a patient’s foot anatomy, whereas prefabricated (off the shelf) orthoses are often prescribed unaltered or minimally modified. Custom orthoses have a much higher cost and are variably covered by insurance. The aim of this study is to compare the effectiveness of custom versus prefabricated foot orthoses for foot and ankle conditions using validated patient-reported outcome scales. Methods: Consecutive patients prescribed custom or prefabricated orthoses at a single institution were retrospectively reviewed. Following IRB approval, a follow-up research survey was distributed to patients to collect patient-reported outcomes. Collected outcome measures included the Foot and Ankle Single Assessment Numeric Evaluation (FA SANE), PROMIS Mobility, PROMIS Pain Interference (PI), and PROMIS Physical Function (PF). All patients with a baseline and minimum three-month follow-up score were included in the final sample. Statistical analysis was conducted using the ANOVA statistical test. In all cases, a p-value of less than 0.05 was considered significant. Results: A total of 238 patient records were included. 152 patients received a custom orthosis, while 86 patients received a prefabricated orthosis. Both groups reported significant improvement from baseline to follow-up in the FA SANE, PROMIS PI and PROMIS PF (p &lt; 0.001). However, assessing PROMIS Mobility, we did not observe a significant difference in improvement from baseline to follow-up in either group. Comparing outcomes between groups, patients receiving custom orthoses reported significantly greater PF at follow-up compared to the prefabricated group (p &lt; 0.05). However, at follow-up there was no significant difference between the custom and prefabricated groups in PI, Mobility, or FA SANE. Mean satisfaction scores were significantly higher for patients with custom orthotics compared to prefabricated orthotics (8.1 vs. 7.5, p &lt; 0.01). Conclusion: Both custom and prefabricated foot orthoses result in improvement in pain and physical function over time. Although the results found in this study lacked definitive evidence in favor of the custom orthoses over prefabricated orthoses, overall patient-reported outcomes were higher for patients receiving custom orthoses. Further research, including longer term follow up, differentiation based on specific clinical diagnoses and deformities, and subsequent need for surgery may ultimately lead to definitive guidelines for custom versus prefabricated orthoses.

The reliability and validity of the Norwegian version of the Victorian Institute of Sports Assessment for gluteal tendinopathy questionnaire (VISA-G-Norwegian) for patients with greater trochanteric pain syndrome

BackgroundGreater Trochanteric Pain Syndrome (GTPS) is a common chronic musculoskeletal condition that may affect physical function, quality of life and sleep. The Victorian Institute of Sport Assessment-Gluteal questionnaire (VISA-G) has been developed as a Patient-Reported Outcome Measurement (PROM) to address pain, everyday activities, physical activities, and difficulty with weight bearing activities. The aim of the study was to test the reliability, validity and floor and ceiling effects of the Norwegian version of the VISA-G (VISA-G-Norwegian) in a population with GTPS in a specialist health care setting.MethodsThis psychometric evaluation of the VISA-G-Norwegian questionnaire were conducted with a prospective observational design. The VISA-G was translated into Norwegian following recommended guidelines. A subgroup repeated the VISA-G-Norwegian a week after the initial submission. For the reliability, the Intraclass Correlation Coefficient (ICC2.1), Standard Error of the Measurement (SEM) and the Smallest Detectable Change (SDC95%) were calculated. Internal consistency was measured using a Cronbach´s alpha. Floor and ceiling effects were evaluated, and construct validity was assessed with three a priori hypotheses.Results78 participants were included in the study of which 47 stable participants undertook the test-retest reliability arm of the study. The ICC2.1 for the total score was 0.85 (95% CI 0.68, 0.92), SEM was 6.6 points and SDC95% 18.4 points. Cronbach`s alpha was 0.77 (95% CI 0.69, 0.84). No floor or ceiling effects were found in the total score, but ceiling effect was found in three of the eight items. For construct validity, one of the three hypotheses were confirmed. VISA-G-Norwegian correlated to the modified Harris Hip Score (mHHS), Oswestry Disability Questionnaire (ODI) and Numeric Pain Rating Scale (NPRS), 0.64, -0.75 and − 0.63 respectively.ConclusionThe VISA-G-Norwegian has acceptable reliability and validity, despite ceiling effect of individual items. The large SDC95% should be considered when measuring change in similar cohorts with GTPS. For a potential future version, it would be recommended to consider response options for questions with ceiling effect and the comprehensibility of question eight.Trial registrationRegistered at ClinicalTrials.gov the 28/02/2020 (NCT04289922).

Comparison of clinical efficacy between closed reduction combined with semi-circular external fixator and minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of middle and distal tibia fractures

To compare the clinical efficacy between closed reduction combined with semi-circular external fixator and minimally invasive percutaneous plate osteosynthesis (MIPPO) in the treatment of middle anddistal tibia fractures. The clinical data of sixty patients with middle and distal tibia fractures admitted between January 2019 and November 2022, were retrospectively analyzed. These patients were categorized into external fixation group (n=30) and internal fixation group (n=30). There were 18 males and 12 females in the external fixation group, with an average age of (49.29±2.35) years old. Among them, 14 patients presented with fractures on the left side, and 16 patients presented with fractures on the right side. Closed reduction, arched wire, and semi-circular external fixator were used for treatment. There were 20 males and 10 females in the internal fixation group, with an average age of (48.96±1.87) years old. Among them, 15 patients presented with fractures on the left side, and 15 patients presented with fractures on the right side. MIPPO technique was used for the treatment. Perioperative parameters, including time injury to surgery, surgical duration, incision length, intraoperative bleeding, time to active activity, and incision healing level, were compared between the two groups. Clinical outcomes were also assessed, including Johner-Wruhs scores, time to minimum pain-adapted full weight-bearing, visual analog scale (VAS), SF-36 scale, and complications. The external fixation group exhibited a significantly shorter incision length (1.36±0.86) cm and lower intraoperative bleeding (10.83±5.73) ml compared to the internal fixation group (12.74±3.12) cm and (86.47±8.90) ml, respectively(P<0.05). The postoperative active activity time (1.50±0.54) days and minimum pain-adapted full weight-bearing activity time(108.87±3.43) days in the external fixation group were slightly delayed than the internal fixation group(1.15±0.98) days and (105.27±3.68) days, respectively(P<0.05). Over a mean postoperative follow-up duration of (6.23±1.89) months, both groups showed improved VAS and SF-36 scale scores. There were no statistically significant differences in VAS and SF-36 scale scores 1, 3, 6 months post-operatively between the two groups(P>0.05). The intraoperative surgical time in the external fixation group (35.42±9.31) minutes was shorter than that in the internal fixation group(74.22±7.81) minutes (P<0.05). There was no intraoperative vascular or nerve injury, nor postoperative skin necrosis in the external fixation group. However, skin necrosis was observed in 6 patientsin the internal fixation group, representing a statistically significant difference (P<0.05). Both external fixation and plate internal fixation are effective methods for the treatment of middle and distal tibia fractures. External fixation exhibits the advantage of less surgical trauma and a lower incidence of complications.

Phase change material-enhanced shoe sole for foot thermal regulation to prevent hyperthermia

Along with the aesthetics and comfort of the shoes, the thermal characteristics of the shoes are one of the most important factors that should be considered in their design. In weight-bearing activities of daily living, the foot plantar temperature can increase considerably which can be uncomfortable and lead to injuries. Most literature has focused on the mechanical behavior of the shoe sole to accommodate cushioning. In this study, a shoe sole design that can accommodate appropriate thermal properties to prevent excessive foot temperature rise during activities of daily living was investigated.As it is challenging to find a material that has both suitable thermal and mechanical properties, in this study, a Phase Change Material (PCM) -enhanced shoe sole was innovated and proposed. In this design, a structured porous layer is embedded inside the shoe sole, in which the pore space is filled with PCM. Different low-temperature PCMs were proposed and simulated. Among them, paraffin wax (RT35) and PEG 900 showed outstanding performance. It was shown that using these PCM-enhanced shoe soles can keep foot soles cool, after 30 min of slow walking. These sole designs were also effective in keeping the foot sole cool during intensive activities like jogging or running.

A Study to Assess the Postural Habits and its Association with Socio-Personal variables among students studying in selected schools of Ernakulam District, Kerala

Posture is the position in which we hold our bodies while standing, sitting, or lying down. A good posture is important because it helps us stand, walk, sit, and lie in positions that place the least strain on supporting muscles and ligaments during movement and weight-bearing activities. This study was aimed to assess the postural habits and to find its association with socio-personal variables among students studying in selected schools of Ernakulam district, Kerala. A quantitative descriptive analytical design was undertaken for the study. Data was collected from school children by using structured questionnaire. The content validity of the tool was established by experts and the samples consisted of 250 school children who satisfied the inclusion criteria and were selected by using convenience sampling technique. The objectives of the study were to assess the postural habits among school children by a structured questionnaire, to find the association between postural habits and socio-personal variables among school children and to find the correlation between postural habits with height and weight. The selected data was tabulated and analysed by using descriptive and inferential statistics. The findings showed that 9.2% had good postural habits, 66% had fair postural habits and 24.8% had bad postural habits. The results also showed that about 23 students from rural area had good postural habits whereas none of the students from urban area had good postural habits. Almost 152 students from rural area maintained average postural habits and 13 students from urban area had the same. About 47 students from rural area and 15 from urban area had bad postural habits. It concludes that there is a significant association between postural habits and place of residence.

Recommendations for physiotherapy and physical activity for children with Legg-Calvé-Perthes disease: a survey of pediatric orthopedic surgeons and physiotherapists in Sweden.

Physiotherapy, restrictions of physical activity, and weightbearing are part of the treatment of children with Legg-Calvé-Perthes disease (LCPD). Prescription practices are widely discussed and vary between pediatric orthopedic surgeons (POSs) and physiotherapists (PTs). The purpose of this study was to identify recommendations for treatment methods in clinical practice to find some consensus and elaborate guidelines. A web-based questionnaire including 3 cases of LCPD (initial, fragmentation, and reossification stages) was answered by 25 POSs and 19 PTs. They were asked to describe their preferred recommendations for physiotherapy, including stretching, strengthening, weightbearing, and physical activities in relation to, e.g., range of motion (ROM) pain, sex, and disease stage. ROM was considered to be important when recommending physiotherapy; PTs also recognized pain and disease stage. Sex was reported as a factor with low importance. Stretching exercises were recommended for all disease stages. Recommendations for strengthening exercises varied for the initial and fragmentation stages. None of the participants recommended total non-weightbearing. Most restricted trampolining, running, ball sports, and gymnastics in the first 2 stages of the disease and allowed swimming, short walks, cycling, and horse riding without restrictions for all stages. We found high agreement on recommending stretching exercises for all disease stages, but controversies regarding recommendations for strengthening exercises in the initial and fragmentation stages. No non-weightbearing treatment for the affected hip was recommended by any participants at any stage of the disease. There was no clear consensus regarding the appropriate timeline for resuming full activities.

Suboptimal Use of DOACs Post-Discharge for Geriatric Hip Fractures with Isolated Calf Deep Vein Thrombosis: Do Clinician Prescribing Preferences and Patient Compliance Alters Clinical Outcomes?

This study aimed to examine the impacts of DOACs compliance and prescribing preferences on clinical outcomes in elderly hip fracture patients with isolated calf deep vein thrombosis (ICDVT). We conducted a retrospective cohort study that evaluated 702 patients who underwent surgical treatment combined with ICDVT in an academic university hospital between January 2016 and October 2021. DOACs compliance was investigated through telephone and outpatient follow-up, and ICDVT clinical outcomes were collected 30 and 90 days post-discharge, respectively. Variables of interest were collected through the electronic medical record system, and data were analyzed after adjusting for predictors of non-completely dissolved (CD) of ICDVT. The DOACs compliance survey revealed that 375 (53.42%) patients were fully adherent, 270 (38.46%) were fairly adherent, and 57 (8.12%) were poorly adherent. Approximately 62% of patients had ICDVT dissipation within 30 days after discharge, reaching 94% within 90 days. DOACs QD/BID regimen is often based on economic status, activity capacity, discharge destination and post-operative weight-bearing activities (p<0.05).The mechanism of injury, ASA classification, surgical technique and timing of ICDVT formation were significantly correlated with DOACs 14/28 days regimen (p<0.05).Multivariate analysis revealed that rural patients [OR 1.518 (95% CI, 1.117-2.236)], pre-operative ICDVT[OR 2.816 (95% CI, 1.862-4.259)] and thrombus length [OR 1.157 (95% CI, 1.263-1.821)] were ICDVT risk factors for non-CD. Furthermore, DOACs fair compliance [OR 0.087 (95% CI, 0.042-0.178)], DOACs full compliance [OR 0.283 (95% CI, 0.139-0.579)], and hospitalization duration [OR 0.793 (95% CI, 0.694-0.907)] were ICDVT protective factors for CD. Better compliance with DOACs benefits early ICDVT dissipation, but final clinical outcomes have to be validated with longer follow-up periods. When managing elderly patients with hip fractures, indications for anticoagulation should be considered and individualized protocols should be used.

Crural and Plantar Fasciae Changes in Chronic Charcot Diabetic Foot: A Cross-Sectional Ultrasound Imaging Study-An Evidence of Fascial Continuity.

Crural fascia (CF) and plantar fascia (PF) are biomechanically crucial in the gait and in the proprioception, particularly in the propulsion phase of the foot during the gait cycle and in the dissipation of forces during weight-bearing activities. Recent studies have revealed an association between increases in PF thickness and diabetes. The purpose of this study was to measure and compare by ultrasound (US) imaging the thickness of the CF and PF at different regions/levels in chronic Charcot diabetic foot patients (group 1) and in healthy volunteers (group 2). A cross-sectional study was performed using US imaging to measure the CF with Pirri et al.'s protocol and PF with a new protocol in a sample of 31 subjects (15 patients and 16 healthy participants). The findings for CF and PF revealed statistically significant differences in the poster region of CF (Post 1: group 1 vs. group 2: p = 0.03; Post 2: group 1 vs. group 2: p = 0.03) and in PF at two different levels (PF level 1: group 1 vs. group 2: p < 0.0001; PF level 2: group 1 vs. group 2: p < 0.0001). These findings suggest that chronic Charcot diabetic foot patients have CF and PF thicker compared to healthy volunteers. The US examination suggests that fascial thicknesses behavior in these patients points out altered fascial remodeling due to diabetes pathology and biomechanical changes.

Reambulation following hindlimb unloading attenuates disuse-induced changes in murine fracture healing.

Patients with bone and muscle loss from prolonged disuse have higher risk of falls and subsequent fragility fractures. In addition, fracture patients with continued disuse and/or delayed physical rehabilitation have worse clinical outcomes compared to individuals with immediate weight-bearing activity following diaphyseal fracture. However, the effects of prior disuse followed by physical reambulation on fracture healing cellular processes and adjacent bone and skeletal muscle recovery post-injury remains poorly defined. To bridge this knowledge gap and inform future treatment and rehabilitation strategies for fractures, a preclinical model of fracture healing with a history of prior unloading with and without reambulation was employed. First, skeletally mature male and female C57BL/6J mice (18 weeks) underwent hindlimb unloading by tail suspension (HLU) for 3 weeks to induce significant bone and muscle loss modeling enhanced bone fragility. Next, mice had their right femur fractured by open surgical dissection (stabilized with 24-gauge pin). The, mice were randomly assigned to continued HLU or allowed normal weight-bearing reambulation (HLU + R). Mice given normal cage activity throughout the experiment served as healthy age-matched controls. All mice were sacrificed 4-days (DPF4) or 14-days (DPF14) following fracture to assess healing and uninjured hindlimb musculoskeletal properties (6-10 mice per treatment/biological sex). We found that continued disuse following fracture lead to severely diminished uninjured hindlimb skeletal muscle mass (gastrocnemius and soleus) and femoral bone volume adjacent to the fracture site compared to healthy age-matched controls across mouse sexes. Furthermore, HLU led to significantly decreased periosteal expansion (DPF4) and osteochondral tissue formation by DPF14, and trends in increased osteoclastogenesis (DPF14) and decreased woven bone vascular area (DPF14). In contrast, immediate reambulation for 2 weeks after fracture, even following a period of prolonged disuse, was able to increase hindlimb skeletal tissue mass and increase osteochondral tissue formation, albeit not to healthy control levels, in both mouse sexes. Furthermore, reambulation attenuated osteoclast formation seen in woven bone tissue undergoing disuse. Our results suggest that weight-bearing skeletal loading in both sexes immediately following fracture may improve callus healing and prevent further fall risk by stimulating skeletal muscle anabolism and decreasing callus resorption compared to minimal or delayed rehabilitation regimens.

Greater myofibrillar protein synthesis following weight-bearing activity in obese old compared with non-obese old and young individuals

The mechanisms through which obesity impacts age-related muscle mass regulation are unclear. In the present study, rates of integrated myofibrillar protein synthesis (iMyoPS) were measured over 48-h prior-to and following a 45-min treadmill walk in 10 older-obese (O-OB, body fat[%]: 33 ± 3%), 10 older-non-obese (O-NO, 20 ± 3%), and 15 younger-non-obese (Y-NO, 13 ± 5%) individuals. Surface electromyography was used to determine thigh muscle “activation”. Quadriceps cross-sectional area (CSA), volume, and intramuscular thigh fat fraction (ITFF) were measured by magnetic resonance imaging. Quadriceps maximal voluntary contraction (MVC) was measured by dynamometry. Quadriceps CSA and volume were greater (muscle volume, Y-NO: 1182 ± 232 cm3; O-NO: 869 ± 155 cm3; O-OB: 881 ± 212 cm3, P < 0.01) and ITFF significantly lower (m. vastus lateralis, Y-NO: 3.0 ± 1.0%; O-NO: 4.0 ± 0.9%; O-OB: 9.1 ± 2.6%, P ≤ 0.03) in Y-NO compared with O-NO and O-OB, with no difference between O-NO and O-OB in quadriceps CSA and volume. ITFF was significantly higher in O-OB compared with O-NO. Relative MVC was lower in O-OB compared with Y-NO and O-NO (Y-NO: 5.5 ± 1.6 n·m/kg−1; O-NO: 3.9 ± 1.0 n·m/kg−1; O-OB: 2.9 ± 1.1 n·m/kg−1, P < 0.0001). Thigh muscle “activation” during the treadmill walk was greater in O-OB compared with Y-NO and O-NO (Y-NO: 30.5 ± 13.5%; O-NO: 35.8 ± 19.7%; O-OB: 68.3 ± 32.3%, P < 0.01). Habitual iMyoPS did not differ between groups, whereas iMyoPS was significantly elevated over 48-h post-walk in O-OB (+ 38.6 ± 1.2%·day−1, P < 0.01) but not Y-NO or O-NO (+ 11.4 ± 1.1%·day−1 and + 17.1 ± 1.1%·day−1, respectively, both P > 0.271). Equivalent muscle mass in O-OB may be explained by the muscle anabolic response to weight-bearing activity, whereas the age-related decline in indices of muscle quality appears to be exacerbated in O-OB and warrants further exploration.

Adherence to limiting weight-bearing activity in patients with diabetic foot ulcers: A qualitative study.

Patients with diabetic foot ulcers are advised to limit weight-bearing activity for ulcers to heal. Patients often disregard this advice although the reasons are not yet fully understood. This study explored (1) patients' experiences of receiving the advice and (2) factors influencing adherence to the advice. Semi-structured interviews were conducted with 14 patients with diabetic foot ulcers. Interviews were transcribed and analysed using inductive thematic analysis. Advice regarding limiting weight-bearing activity was described by patients as directive, generic and conflicting with other priorities. Rapport, empathy and rationale supported receptivity to the advice. Barriers and facilitators to limiting weight-bearing activity included demands of daily living, enjoyment of exercise, sick/disabled identity and burden, depression, neuropathy/pain, health benefits, fear of negative consequences, positive feedback, practical support, weather and active/passive role in recovery. It is important that healthcare professionals pay attention to how limiting weight-bearing activity advice is communicated. We propose a more person-centred approach in which advice is tailored to individuals' specific needs with discussion around patient priorities and constraints.

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2023 update).

This is the 2023 International Working Group on the Diabetic Foot guideline on the prevention of foot ulcers in persons with diabetes, which updates the 2019 guideline. This guideline is targeted at clinicians and other healthcare professionals. We followed the Grading of Recommendations, Assessment, Development and Evaluations methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature including, where appropriate, meta-analyses, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where (sufficient) evidence was not available, and a weighing of the desirable and undesirable effects of an intervention, as well as patient preferences, costs, equity, feasibility and applicability. We recommend screening a person with diabetes at very low risk of foot ulceration annually for the loss of protective sensation and peripheral artery disease, and screening persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate persons at-risk about appropriate foot self-care, educate not to walk without suitable foot protection, and treat any pre-ulcerative lesion on the foot. Educate moderate-to-high risk people with diabetes to wear properly fitting, accommodative, therapeutic footwear, and consider coaching them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking, to help prevent plantar foot ulcer recurrence. Consider advising people at low-to-moderate risk to undertake a, preferably supervised, foot-ankle exercise programme to reduce ulcer risk factors, and consider communicating that a total increase in weight-bearing activity of 1000 steps/day is likely safe with regards to risk of ulceration. In people with non-rigid hammertoe with pre-ulcerative lesion, consider flexor tendon tenotomy. We suggest not to use a nerve decompression procedure to help prevent foot ulcers. Provide integrated foot care for moderate-to-high-risk people with diabetes to help prevent (recurrence of) ulceration. These recommendations should help healthcare professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days and reduce the patient and healthcare burden of diabetes-related foot disease.

Effectiveness of offloading interventions for people with diabetes-related foot ulcers: A systematic review and meta-analysis.

Offloading treatment is crucial to heal diabetes-related foot ulcers (DFU). This systematic review aimed to assess the effectiveness of offloading interventions for people with DFU. We searched PubMed, EMBASE, Cochrane databases, and trials registries for all studies relating to offloading interventions in people with DFU to address 14 clinical question comparisons. Outcomes included ulcers healed, plantar pressure, weight-bearing activity, adherence, new lesions, falls, infections, amputations, quality of life, costs, cost-effectiveness, balance, and sustained healing. Included controlled studies were independently assessed for risk of bias and had key data extracted. Meta-analyses were performed when outcome data from studies could be pooled. Evidence statements were developed using the GRADE approach when outcome data existed. From 19,923 studies screened, 194 eligible studies were identified (47 controlled, 147 non-controlled), 35 meta-analyses performed, and 128 evidence statements developed. We found non-removable offloading devices likely increase ulcers healed compared to removable offloading devices (risk ratio [RR] 1.24, 95% CI 1.09-1.41; N=14, n=1083), and may increase adherence, cost-effectiveness and decrease infections, but may increase new lesions. Removable knee-high offloading devices may make little difference to ulcers healed compared to removable ankle-high offloading devices (RR 1.00, 0.86-1.16; N=6, n=439), but may decrease plantar pressure and adherence. Any offloading device may increase ulcers healed (RR 1.39, 0.89-2.18; N=5, n=235) and cost-effectiveness compared to therapeutic footwear and may decrease plantar pressure and infections. Digital flexor tenotomies with offloading devices likely increase ulcers healed (RR 2.43, 1.05-5.59; N=1, n=16) and sustained healing compared to devices alone, and may decrease plantar pressure and infections, but may increase new transfer lesions. Achilles tendon lengthening with offloading devices likely increase ulcers healed (RR 1.10, 0.97-1.27; N=1, n=64) and sustained healing compared to devices alone, but likely increase new heel ulcers. Non-removable offloading devices are likely superior to all other offloading interventions to heal most plantar DFU. Digital flexor tenotomies and Achilles tendon lengthening in combination with offloading devices are likely superior for some specific plantar DFU locations. Otherwise, any offloading device is probably superior to therapeutic footwear and other non-surgical offloading interventions to heal most plantar DFU. However, all these interventions have low-to-moderate certainty of evidence supporting their outcomes and more high-quality trials are needed to improve our certainty for the effectiveness of most offloading interventions.

Patellofemoral Joint Loading Progression Across 35 Weightbearing Rehabilitation Exercises and Activities of Daily Living

Background: Exercises that provide progressive therapeutic loading are a central component of patellofemoral pain rehabilitation, but quantitative evidence on patellofemoral joint loading is scarce for a majority of common weightbearing rehabilitation exercises. Purpose: To define a loading index to quantify, compare, rank, and categorize overall loading levels in the patellofemoral joint across 35 types of weightbearing rehabilitation exercises and activities of daily living. Study Design: Descriptive laboratory study. Methods: Model-estimated knee flexion angles and extension moments based on motion capture and ground-reaction force data were used to quantify patellofemoral joint loading in 20 healthy participants who performed each exercise. A loading index was computed via a weighted sum of loading peak and cumulative loading impulse for each exercise. The 35 rehabilitation exercises and daily living activities were then ranked and categorized into low, moderate, and high “loading tiers” according to the loading index. Results: Overall patellofemoral loading levels varied substantially across the exercises and activities, with loading peak ranging from 0.6 times body weight during walking to 8.2 times body weight during single-leg decline squat. Most rehabilitation exercises generated a moderate level of patellofemoral joint loading. Few weightbearing exercises provided low-level loading that resembled walking or high-level loading with both high magnitude and duration. Exercises with high knee flexion tended to generate higher patellofemoral joint loading compared with high-intensity exercises. Conclusion: This study quantified patellofemoral joint loading across a large collection of weightbearing exercises in the same cohort. Clinical Relevance: The visualized loading index ranks and modifiable worksheet may assist clinicians in planning patient-specific exercise programs for patellofemoral pain rehabilitation.