Effect of tool-use observation on metric body representation and peripersonal space.

In everyday life, we constantly act and interact with objects and with others' people through our body. To properly perform actions, the representations of the dimension of body-parts (metric body representation, BR) and of the space surrounding the body (peripersonal space, PPS) need to be constantly updated. Previous evidence has shown that BR and PPS representation are highly flexible, being modulated by sensorimotor experiences, such as the active use of tools to reach objects in the far space. In this study, we investigate whether the observation of another person using a tool to interact with objects located in the far space is sufficient to influence the plasticity of BR and PPS representation in a similar way to active tool-use. With this aim, two groups of young healthy participants were asked to perform 20 min trainings based on the active use of a tool to retrieve far cubes (active tool-use) and on the first-person observation of an experimenter doing the same tool-use training (observational tool-use). Behavioural tasks adapted from literature were used to evaluate the effects of the active and observational tool-use on BR (body-landmarks localization task-group 1), and PPS (audio-tactile interaction task - group 2). Results show that after active tool-use, participants perceived the length of their arm as longer than at baseline, while no significant differences appear after observation. Similarly, significant modifications in PPS representation, with comparable multisensory facilitation on tactile responses due to near and far sounds, were seen only after active tool-use, while this did not occur after observation. Together these results suggest that a mere observational training could not be sufficient to significantly modulate BR or PPS. The dissociation found in the active and observational tool-use points out differences between action execution and action observation, by suggesting a fundamental role of the motor planning, the motor intention, and the related sensorimotor feedback in driving BR and PPS plasticity.

Wii Fit™ exercise therapy for the rehabilitation of ankle sprains: Its effect compared with physical therapy or no functional exercises at all.

Lateral ankle sprains represent the most common sports-related injuries. The Nintendo Wii Fit™ could be useful in the treatment of ankle sprains. The aim of this study was to compare the effectiveness of exercise training using the Wii Fit™ in ankle sprain patients: (a) with physical therapy; and (b) a control group not receiving any treatment. Ninety lateral ankle sprain patients were randomized to a Wii Fit™, physical therapy, or control group. We assessed the following outcome measures before, and 6 weeks after starting the allocated treatment: Foot and Ankle Ability Measure, pain during rest and walking, delay before return to sport, patient satisfaction, and effectiveness of the allocated treatment. Six weeks after the baseline measures, foot and ankle ability scores had improved in all groups, and pain had decreased during walking (P < 0.050). No between-group differences were detected between Wii Fit™ treatment, and both other groups (P > 0.050). In conclusion, the Wii Fit™ could be used as an exercise therapy to treat ankle sprain patients. However, Wii Fit™ was not more effective than only physical therapy, or no exercise therapy at all. Patients who did not receive treatment showed similar results as people who got any kind of exercise therapy.

Biofeedback can reduce foot pressure to a safe level and without causing new at-risk zones in patients with diabetes and peripheral neuropathy.

BACKGROUND: Plantar pressure reduction is mandatory for diabetic foot ulcer healing. Our aim was to evaluate the impact of a new walking strategy learned by biofeedback on plantar pressure distribution under both feet in patients with diabetic peripheral neuropathy. METHODS: Terminally augmented biofeedback has been used for foot off-loading training in 21 patients with diabetic peripheral sensory neuropathy. The biofeedback technique was based on a subjective estimation of performance and objective visual feedback following walking sequences. The patient was considered to have learned a new walking strategy as soon as the peak plantar pressure (PPP) under the previously defined at-risk zone was within a range of 40-80% of baseline PPP in 70% of the totality of steps and during three consecutive walking sequences. The PPP was measured by a portable in-shoe foot pressure measurement system (PEDAR(®)) at baseline (T0), directly after learning (T1) and at 10-day retention test (T2). RESULTS: The PPP under at-risk zones decreased significantly at T1 (165 ± 9 kPa, p < 0.0001) and T2 (167 ± 11, p = 0.001), as compared with T0 (242 ± 12 kPa) without any increase of the PPP elsewhere. At the contralateral foot (not concerned by off-loading), the PPP was slightly higher under the lateral midfoot at T1 (68 ± 8 kPa, p = 0.01) and T2 (65 ± 8 kPa, p = 0.01), as compared with T0 (58 ± 6 kPa). CONCLUSIONS: The foot off-loading by biofeedback leads to a safe and regular plantar pressure distribution without inducing any new 'at-risk' area under both feet.

[Treatment of tendinopathies: role for autologous platelet-rich plasma injections]. / Traitement des tendinopathies chroniques: intérêt des injections de plasma riche en plaquettes (PRP).

Chronic degenerative tendinopathies are frequent and difficult to treat. Tendon healing is under influence of many growth factors that can be obtained from patient's blood (platelet-rich plasma). Basic research is quite optimistic but evidence-based studies examining the treatment of human tendinopathies are lacking. Nevertheless, such treatments are increasingly used in clinical practice and expectations of those injections are high. However, the use of autologous blood injections for the management of chronic human tendinopathies can currently not be recommended.

Interest of dual-task-related gait changes in idiopathic normal pressure hydrocephalus.

BACKGROUND: Gait disorders in patients with idiopathic normal pressure hydrocephalus (iNPH) share similar characteristics found in pathologies presenting with higher-level gait disorders that have been specifically associated with gait changes during walking while simultaneously performing an attention-demanding task (i.e. dual tasking). The current study assessed the effect of cerebrospinal fluid (CSF) tapping on quantitative gait modification during single and dual tasking in patients with a suspicion of iNPH. METHODS: Of 53 patients suspected of iNPH, 18 have been included in this study. Gait analysis during single- and dual-task condition (walking and backward counting) before and after tapping of 40 ml CSF has been performed. RESULTS: Gait speed (P < 0.01) and stride length (P < 0.05) were significantly improved during dual-task conditions after CSF tapping compared to the gait performance before spinal tapping, without such improvement for gait parameters during single-tasking. CONCLUSION: Dual-tasking condition better reveals gait improvement after CSF tapping than single-tasking in patients suspected of iNPH.

An exercise intervention to improve diabetic patients' gait in a real-life environment.

AIMS: Gait characteristics and balance are altered in diabetic individuals. Little is known about possible treatment strategies. This study evaluated the effect of a specific training program on diabetic patients' gait. METHODS: A randomized controlled trial (N=71) with an intervention (IG) (N=35), and control group (CG) (N=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-oriented strengthening. Controls received no treatment. RESULTS: After intervention the IG increased their habitual walking speed by 0.149ms(-1) (0.54kmh(-1)) on tarred terrain and by 0.169ms(-1) (0.61kmh(-1)) on the cobblestones. This significant treatment effect (p<0.001) decreased slightly at the six-month follow-up, but remained significant (p<0.001). In a similar manner, significant improvement was observed for cadence, gait cycle time and stance time on both terrains. All outcomes except stance time on the tarred terrain remained significant at the six-month follow-up. No significant effect was observed for stride length and the coefficient of variation of gait cycle time (on either surface) at the corrected significance level of p<0.004. CG patients' parameters all remained unchanged or progressively deteriorated compared to baseline values. DISCUSSION: Cadence contributed 80%, whereas stride length only contributed 20% to the change of gait velocity. This may be due to the treatment or to diabetic patients' potential to regulate their cadence and stride length. CONCLUSION: A specific training program can improve diabetic patients' gait in a real life environment. A challenging environment highlights treatment effects on patients' gait better than an evenly tarred surface.

Biofeedback for foot offloading in diabetic patients with peripheral neuropathy.

AIMS: The reduction of high plantar pressure in diabetic patients with peripheral neuropathy is mandatory for prevention of foot ulcers and amputations. We used a new biofeedback-based method to reduce the plantar pressure at an at-risk area of foot in diabetic patients with peripheral neuropathy. METHODS: Thirteen diabetic patients (age 60.8 +/- 12.3 years, body mass index 29.0 +/- 5.0 kg/m(2)) with peripheral neuropathy of the lower limbs were studied. Patients with memory impairment were excluded. The portable in-shoe foot pressure measurement system (PEDAR) was used for foot offloading training by biofeedback. The learning procedure consisted in sequences of walking (10 steps), each followed by a subjective estimation of performance and objective feedback. The goal was to achieve three consecutive walking cycles of 10 steps, with a minimum of seven steps inside the range of 40-80% of the baseline peak plantar pressure. The peak plantar pressure was assessed during the learning period and at retention tests. RESULTS: A significant difference in peak plantar pressure was recorded between the beginning and the end of the learning period (when the target for plantar pressure was achieved) (262 +/- 70 vs. 191 +/- 53 kPa; P = 0.002). The statistically significant difference between the beginning of learning and all retention tests persisted, even at the 10-day follow-up. CONCLUSIONS: Terminal augmented feedback training may positively affect motor learning in diabetic patients with peripheral neuropathy and could possibly lead to suitable foot offloading. Additional research is needed to confirm the maintenance of offloading in the long term.

The gait and balance of patients with diabetes can be improved: a randomised controlled trial.

AIMS/HYPOTHESIS: Gait characteristics and balance are altered in diabetic patients. Little is known about possible treatment strategies. This study evaluates the effect of a specific training programme on gait and balance of diabetic patients. METHODS: This was a randomised controlled trial (n=71) with an intervention (n=35) and control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up. RESULTS: The trial is closed to recruitment and follow-up. After training, the intervention group increased habitual walking speed by 0.149 m/s (p<0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength. Two patients developed pain in their Achilles tendon: the progression for two related exercises was slowed down. CONCLUSIONS/INTERPRETATION: Specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients. Further studies are needed to explore the influence of these improvements on the number of reported falls, patients' physical activity levels and quality of life. TRIAL REGISTRATION: ClinicalTrials.gov NCT00637546 FUNDING: This work was supported by the Swiss National Foundation (SNF): PBSKP-123446/1/

Clinical factors associated with gait alterations in diabetic patients.

AIM: To identify clinical factors associated with gait alterations in patients with Type 2 diabetes. METHODS: A sample of 76 diabetic patients underwent clinical examination and an outdoor gait assessment on tarred and cobblestoned terrains. We calculated respective differences in gait speed (performance measure) and gait variability (fall risk index) on changing terrains. Associations with clinical factors were investigated using correlation coefficients and linear regression analysis. RESULTS: The mean walking speed on the tarred pathway was 4.5 +/- 0.6 km/h and 3.9 +/- 0.8 km/h on the cobblestone pathway (P < 0.001). The CVGCT increased from 2.6 +/- 0.9% on the tarred pathway to 5.1 +/- 2.8% on the cobblestone pathway (P < 0.001). Regression analysis showed that 36% of the decrease in gait speed was explained proportionally by the mean of maximal isometric lower limb strength (22.2%; P < or = 0.01), fear of falls (7.4%; P < or = 0.01) and participants' perceived vibration threshold (6.4%; P < or = 0.01). Moreover, mean maximal isometric strength explained 11.8% (P < or = 0.01) of the increase of the coefficient of variation of the gait cycle time when participants changed from tarred terrain to cobblestones. CONCLUSION: This study indicated that both physiological (strength and proprioception) and cognitive-behavioural factors (fear of falls) should be considered when treating diabetic patients with gait alterations. Therapists should apply these findings when developing specific fall prevention and treatment programmes.

Investigation of standing balance in diabetic patients with and without peripheral neuropathy using accelerometers.

BACKGROUND: Peripheral neuropathy is recognised to be the most symptomatic complication of diabetes and is also linked to postural instability. This study investigates balance instability in diabetic patients with and without peripheral neuropathy. METHODS: Quiet standing balance was investigated using an accelerometric-based method in 24 diabetic patients (12 with and 12 without peripheral neuropathy) and compared with 12 control subjects. Accelerations were measured at lumbar and ankle levels using three accelerometers. Two standing conditions of 30s were evaluated (i.e., eyes opened, eyes closed). The range and root mean square values were calculated on the anterior posterior component of lumbar and ankle accelerations and for the medial lateral component of lumbar accelerations. Differences between parameters were compared between groups using ANOVA and post hoc comparisons. FINDINGS: The diabetic patients with peripheral neuropathy show higher-range and root mean square values compared with those of control subjects and diabetic patients without peripheral neuropathy. Significant differences between groups have been detected for anterior posterior range of lumbar acceleration, which was significantly higher for diabetic patients with peripheral neuropathy, compared with those of others groups. Significant higher values for diabetic patients with peripheral neuropathy were also detected for anterior posterior range and root mean square of ankle accelerations compared with control subjects. Visual deprivation shows an increase in accelerometric parameters for each group. INTERPRETATION: This study is the first to investigate the balance instability of diabetic patients using accelerometers. Results confirm that diabetic patients with peripheral neuropathy have greater postural instability with higher acceleration values than those of control group and diabetic patients without peripheral neuropathy.

Reliability of diabetic patients' gait parameters in a challenging environment.

UNLABELLED: Activities of daily life require us to move about in challenging environments and to walk on varied surfaces. Irregular terrain has been shown to influence gait parameters, especially in a population at risk for falling. A precise portable measurement system would permit objective gait analysis under such conditions. The aims of this study are to (a) investigate the reliability of gait parameters measured with the Physilog in diabetic patients walking on different surfaces (tar, grass, and stones); (b) identify the measurement error (precision); (c) identify the minimal clinical detectable change. METHODS: 16 patients with Type 2 diabetes were measured twice within 8 days. After clinical examination patients walked, equipped with a Physilog, on the three aforementioned surfaces. RESULTS: ICC for each surface was excellent for within-visit analyses (>0.938). Inter-visit ICC's (0.753) were excellent except for the knee range parameter (>0.503). The coefficient of variation (CV) was lower than 5% for most of the parameters. Bland and Altman Plots, SEM and SDC showed precise values, distributed around zero for all surfaces. DISCUSSION: Good reliability of Physilog measurements on different surfaces suggests that Physilog could facilitate the study of diabetic patients' gait in conditions close to real-life situations. Gait parameters during complex locomotor activities (e.g. stair-climbing, curbs, slopes) have not yet been extensively investigated. CONCLUSION: Good reliability, small measurement error and values of minimal clinical detectable change recommend the utilization of Physilog for the evaluation of gait parameters in diabetic patients.

Gait characteristics of diabetic patients: a systematic review.

Patients with diabetes are at higher risk of experiencing fall-related injuries when walking than healthy controls. The underlying mechanism responsible for this is not yet clear. Thus we intend to summarize diabetic patients' gait characteristics and emphasize those which could be the possible underlying mechanisms for increased fall risk. This systematic review aims, in particular, to: (1) evaluate the quality of existing studies which investigate the gait characteristics of diabetic patients, (2) highlight areas of agreement and contradiction in study results, (3) discuss and emphasize parameters associated with fall risk, and (4) propose new orientations and further domains for research needed for their fall risk prevention. We conducted an electronic search of Pedro, PubMed, Ovid and Cochrane. Two authors independently assessed all abstracts. Quality of the selected articles was scored, and the study results summarized and discussed. We considered 236 abstracts of which 28 entered our full text review. Agreement on data quality between two reviewers was high (kappa: 0.90). Authors investigating gait parameters in a diabetic population evaluated in particular parameters either associated with fall risk (speed, step length or step-time variability) or with ulcers (pressure). There is agreement that diabetic patients walk slower, with greater step variability, and present higher plantar pressure than healthy controls. We concluded that diabetic patients present gait abnormalities, some of which can lead to heightened fall risk. To understand its' underlying mechanisms, and to promote efficient prevention, further studies should analyse gait under 'real-life' conditions.