Search

Background: The patellofemoral joint is an important source of pain in knee osteoarthritis. Most biomechanical research in knee osteoarthritis has focused on the tibiofemoral joint during level walking. It is unknown what happens during stair negotiation in patients with patellofemoral joint osteoarthritis, a task commonly increasing pain. Conservative therapy for patellofemoral joint osteoarthritis includes the use of a sleeve knee brace. We aimed to examine the effect of a sleeve knee brace on knee biomechanics during stair negotiation in patellofemoral joint osteoarthritis patients. Methods: 30 patellofemoral joint osteoarthritis patients (40–70 years) ascended and descended an instrumented staircase with force plates under two conditions – wearing a Lycra flexible knee support (Bioskin Patellar Tracking Q Brace) and no brace (control condition). Knee joint kinematics (VICON) and kinetics were recorded. Findings: During stair ascent, at the knee, the brace significantly reduced the maximal flexion angle (2.70, P = 0.002), maximal adduction angle (2.00, P = 0.044), total sagittal range of motion (2.00, P = 0.008), total frontal range of motion (1.70, P = 0.023) and sagittal peak extension moment (0.05 Nm/kg, P = 0.043) compared to control. During stair descent, at the knee, the brace significantly reduced the maximal flexion angle (1.80, P = 0.039) and total sagittal range of motion (1.50, P = 0.045) compared to control. Interpretation: The small changes in knee joint biomechanics during stair negotiation observed in our study need to be investigated further to help explain mechanisms behind the potential benefits of a sleeve knee brace for painful patellofemoral joint osteoarthritis.

The negative effects of SARS-CoV-2 infection on the musculoskeletal system include symptoms of fatigue and sarcopenia. The aim of this study is to assess the impact of COVID-19 on foot muscle strength and evaluate the reproducibility of peak ankle torque measurements in time by using a custom-made electronic dynamometer. In this observational cohort study, we compare two groups of four participants, one exposed to COVID-19 throughout measurements and one unexposed. Peak ankle torque was measured using a portable custom-made electronic dynamometer. Ankle plantar flexor and dorsiflexor muscle strength was captured for both feet at different ankle angles prior and post COVID-19. Average peak torque demonstrated no significant statistical differences between initial and final moment for both groups (p = 0.945). An increase of 4.8%, p = 0.746 was obtained in the group with COVID-19 and a decrease of 1.3%, p = 0.953 was obtained in the group without COVID-19. Multivariate analysis demonstrated no significant differences between the two groups (p = 0.797). There was a very good test–retest reproducibility between the measurements in initial and final moments (ICC = 0.78, p < 0.001). In conclusion, peak torque variability is similar in both COVID-19 and non-COVID-19 groups and the custom-made electronic dynamometer is a reproducible method for repetitive ankle peak torque measurements.

Background and Objectives: Barefoot peak plantar pressures (PPPs) are elevated in diabetes patients with neuropathic foot ulcer (DFU) history; however, there is limited reported evidence for a causative link between high barefoot PPP and DFU risk. We aimed to determine, using a simple mat-based methodology, the site-specific, barefoot PPP critical threshold that will identify a plantar site with a previous DFU. Materials and Methods: In a cross-sectional study, barefoot, site-specific PPPs were measured with normal gait for patients with DFU history (n = 21) and healthy controls (n = 12), using a validated carbon footprint system. For each participant, PPP was recorded at twelve distinct plantar sites (1st–5th toes, 1st–5th metatarsal heads (MTHs), midfoot and heel), per right and left foot, resulting in the analysis of n = 504 distinct plantar sites in the diabetes group, and n = 288 sites in the control group. Receiver operator characteristic curve analysis determined the optimal critical threshold for sites with DFU history. Results: Median PPPs for the groups were: diabetes sites with DFU history (n = 32) = 5.0 (3.25–7.5) kg/cm2, diabetes sites without DFU history (n = 472) = 3.25 (2.0–5.0) kg/cm2, control sites (n = 288) = 2.0 (2.0–3.25) kg/cm2; (p < 0.0001). Diabetes sites with elevated PPP (>6 kg/cm2) were six times more likely to have had DFU than diabetes sites with PPP ≤ 6 kg/cm2 (OR = 6.4 (2.8–14.6, 95% CI), p < 0.0001). PPP > 4.1 kg/cm2 was determined as the optimal critical threshold for identifying DFU at a specific plantar site, with sensitivity/specificity = 100%/79% at midfoot; 80%/65% at 5th metatarsal head; 73%/62% at combined midfoot/metatarsal head areas. Conclusions: We have demonstrated, for the first time, a strong, site-specific relationship between elevated barefoot PPP and previous DFU. We have determined a critical, highly-sensitive, barefoot PPP threshold value of >4.1 kg/cm2, which may be easily used to identify sites of previous DFU oc

Inactivity negatively influences general health, and sedentary behaviour is known to impact the musculoskeletal system. The aim of the study was to assess the impact of time spent in active and sedentary behaviour on foot muscle strength. In this observational study, we compared the acute effects of one day of prolonged sitting and one day of low-to-moderate level of activity on ankle torque in one group of eight healthy participants. Peak ankle torque was measured using a portable custom-made electronic dynamometer. Three consecutive maximal voluntary isometric contractions for bilateral plantar flexor and dorsiflexor muscles were captured at different moments in time. The average peak torque significant statistically decreased at 6 h (p = 0.019) in both static and active behaviours, with a higher average peak torque in the active behaviour (p < 0.001). Age, gender, body mass index and average steps did not have any significant influence on the average value of maximal voluntary isometric contraction. The more time participants maintained either static or active behaviour, the less force was observed during ankle torque testation. The static behaviour represented by the sitting position was associated with a higher reduction in the average peak ankle torque during a maximal voluntary isometric contraction when compared to the active behaviour.

Diabetic peripheral neuropathy (DPN) is a common condition that is associated with neuromuscular dysfunction and peripheral sensory impairment. These deficits predispose patients to sensory and motor system limitations, foot ulcers and a high risk of falls. Exercise training has been proposed as an effective tool to alleviate neural deficits and improve whole-body function. Here we review the effects of DPN on neuromuscular function, the mechanisms underlying this impairment, and the neural and muscular adaptations to exercise training. Muscle dysfunction is an early hallmark of DPN. Deficits in muscle strength, power, mass and a greater fatigability are particularly severe in the lower extremity muscles. Non-enzymatic glycation of motor proteins, impaired excitation–contraction coupling and loss of motor units have been indicated as the main factors underlying muscular dysfunction. Among the exercise-based solutions, aerobic training improves neural structure and function and ameliorates neuropathic signs and symptoms. Resistance training induces marked improvement of muscle performance and may alleviate neuropathic pain. A combination of aerobic and resistance training (i.e., combined training) restores small sensory nerve damage, reduces symptoms, and improves muscle function. The evidence so far suggests that exercise training is highly beneficial and should be included in the standard care for DPN patients.

Purpose: Muscular dystrophy (MD) is an umbrella term for muscle wasting conditions, for which longitudinal changes in function and body composition are well established in children with Duchenne (DMD), however, changes in adults with DMD and Beckers (BMD), respectively, remain poorly reported. This study aims to assess 12-month changes in lower-limb strength, muscle size, body composition and physical activity in adults with Muscular Dystrophy (MD). Methods: Adult males with Duchenne MD (DMD; N = 15) and Beckers MD (BMD; N = 12) were assessed at baseline and 12-months for body composition (Body fat and lean body mass (LBM)), Isometric maximal voluntary contraction (Knee-Extension (KEMVC) and Plantar-Flexion (PFMVC)) and physical activity (tri-axial accelerometry). Results: 12-Month change in strength was found as −19% (PFMVC) and −14% (KEMVC) in DMD. 12-Month change in strength in BMD, although non-significant, was explained by physical activity (R =0.532–0.585). Changes in LBM (DMD) and body fat (BMD) were both masked by non-significant changes in body mass. Discussion: 12-Month changes in adults with DMD appear consistent with paediatric populations. Physical activity appears important for muscle function maintenance. Specific monitoring of body composition, and potential co-morbidities, within adults with MD is highlighted.Implications for rehabilitation Quantitative muscle strength assessment shows progressive muscle weakness in adults with Duchenne Muscular Dystrophy is comparable to paediatric reports (−14 to −19%). Physical activity should be encouraged in adults with Beckers Muscular Dystrophy, anything appears better than nothing. Body composition, rather than body mass, should be monitored closely to identify any increase in body fat. 2

Portable, custom-made electronic dynamometry for the foot and ankle is a promising assessment method that enables foot and ankle muscle function to be established in healthy participants and those affected by chronic conditions. Diabetic peripheral neuropathy (DPN) can alter foot and ankle muscle function. This study assessed ankle toque in participants with diabetic peripheral neuropathy and healthy participants, with the aim of developing an algorithm for optimizing the precision of data processing and interpretation of the results and to define a reference frame for ankle torque measurement in both healthy participants and those affected by DPN. This paper discloses the software chain and the signal processing methods used for voltage—torque conversion, filtering, offset detection and the muscle effort type identification, which further allowed for a primary statistical report. The full description of the signal processing methods will make our research reproducible. The applied algorithm for signal processing is proposed as a reference frame for ankle torque assessment when using a custom-made electronic dynamometer. While evaluating multiple measurements, our algorithm permits for a more detailed parametrization of the ankle torque results in healthy participants and those affected by DPN.

Background and Objectives: Smart wearable devices are effective in diabetic foot ulcer (DFU) prevention. However, factors determining their acceptance are poorly understood. This systematic review aims to examine the literature on patient and provider perspectives of smart wearable devices in DFU prevention. Materials and Methods: PubMed, Scopus, and Web of Science were systematically searched up to October 2021. The selected articles were assessed for methodological quality using the quality assessment tool for studies with diverse designs. Results: A total of five articles were identified and described. The methodological quality of the studies ranged from low to moderate. Two studies employed a quantitative study design and focused on the patient perspective, whereas three studies included a mixed, quantitative/qualitative design and explored patient or provider (podiatrist) perspectives. Four studies focused on an insole system and one included a smart sock device. The quantitative studies demonstrated that devices were comfortable, well designed and useful in preventing DFU. One mixed design study reported that patients did not intend to adopt an insole device in its current design because of malfunctions, a lack of comfort. and alert intrusiveness, despite the general perception that the device was a useful tool for foot risk monitoring. Two mixed design studies found that performance expectancy was a predictor of a podiatrist's behavioural intention to recommend an insole device in clinical practice. Disappointing participant experiences negatively impacted the podiatrists' intention to adopt a smart device. The need for additional refinements of the device was indicated by patients and providers before its use in this population. Conclusions: The current evidence about patient and provider perspectives on smart wearable technology is limited by scarce methodological quality and conflicting results. It is, thus, not possible to draw definitive conclusions reg

Custom-made dynamometry was shown to objectively analyze human muscle strength around the ankle joint with accuracy, easy portability and low costs. This paper describes the full method of calibration and measurement setup and the measurement procedure when capturing ankle torque for establishing reliability of a portable custom-built electronic dynamometer. After considering the load cell offset voltage, the pivotal position was determined, and calibration with loads followed. Linear regression was used for calculating the proportionality constant between torque and measured voltage. Digital means were used for data collection and processing. Four healthy consenting participants were enrolled in the study. Three consecutive maximum voluntary isometric contractions of five seconds each were registered for both feet during plantar flexion/dorsiflexion, and ankle torque was then calculated for three ankle inclinations. A calibration procedure resulted, comprising determination of the pivotal axis and pedal constant. Using the obtained data, a measurement procedure was proposed. Obtained contraction time graphs led to easier filtering of the results. When calculating the interclass correlation, the portable apparatus demonstrated to be reliable when measuring ankle torque. When a custom-made dynamometer was used for capturing ankle torque, accuracy of the method was assured by a rigorous calibration and measurement protocol elaboration.

Diabetic peripheral neuropathy (DPN) is associated with peripheral sensory and motor nerve damage that affects up to half of diabetes patients and is an independent risk factor for falls. Clinical implications of DPN-related falls include injury, psychological distress and physical activity curtailment. This review describes how the sensory and motor deficits associated with DPN underpin biomechanical alterations to the pattern of walking (gait), which contribute to balance impairments underpinning falls. Changes to gait with diabetes occur even before the onset of measurable DPN, but changes become much more marked with DPN. Gait impairments with diabetes and DPN include alterations to walking speed, step length, step width and joint ranges of motion. These alterations also impact the rotational forces around joints known as joint moments, which are reduced as part of a natural strategy to lower the muscular demands of gait to compensate for lower strength capacities due to diabetes and DPN. Muscle weakness and atrophy are most striking in patients with DPN, but also present in non-neuropathic diabetes patients, affecting not only distal muscles of the foot and ankle, but also proximal thigh muscles. Insensate feet with DPN cause a delayed neuromuscular response immediately following foot–ground contact during gait and this is a major factor contributing to increased falls risk. Pronounced balance impairments measured in the gait laboratory are only seen in DPN patients and not non-neuropathic diabetes patients. Self-perception of unsteadiness matches gait laboratory measures and can distinguish between patients with and without DPN. Diabetic foot ulcers and their associated risk factors including insensate feet with DPN and offloading devices further increase falls risk. Falls prevention strategies based on sensory and motor mechanisms should target those most at risk of falls with DPN, with further research needed to optimise interventions.

Diabetic foot ulcers (DFUs) are a life-changing complication of diabetes that can lead to amputation. There is increasing evidence that long-term management with wearables can reduce incidence and recurrence of this condition. Temperature asymmetry measurements can alert to DFU development, but measurements of dynamic information, such as rate of temperature change, are under investigated. We present a new wearable device for temperature monitoring at the foot that is personalised to account for anatomical variations at the foot. We validate this device on 13 participants with diabetes (no neuropathy) (group name D) and 12 control participants (group name C), during sitting and standing. We extract dynamic temperature parameters from four sites on each foot to compare the rate of temperature change. During sitting the time constant of temperature rise after shoe donning was significantly (p < 0.05) faster at the hallux (p = 0.032, 370.4 s (C), 279.1 s (D)) and 5th metatarsal head (p = 0.011, 481.9 s (C), 356.6 s (D)) in participants with diabetes compared to controls. No significant differences at the other sites or during standing were identified. These results suggest that temperature rise time is faster at parts of the foot in those who have developed diabetes. Elevated temperatures are known to be a risk factor of DFUs and measurement of time constants may provide information on their development. This work suggests that temperature rise time measured at the plantar surface may be an indicative biomarker for differences in soft tissue biomechanics and vascularisation during diabetes onset and progression.

© 2020, International Osteoporosis Foundation and National Osteoporosis Foundation. Summary: We describe the physical function in adults with osteogenesis imperfecta (OI) and explored clinical and non-clinical factors related to its impairment. Our data showed that physical dysfunction is a common feature of adults with OI, varying by OI severity, and mediated by the presence and quality of pain and fatigue symptoms. Introduction: There is a paucity of data describing physical function in adults with osteogenesis imperfecta (OI). We investigated the effects of OI and its severity on physical function and explored the relationship between physical function and number of fractures and symptomatology. Methods: Adults with OI of different types were recruited from the RUDY study, an ongoing UK-based prospective cohort study. Participants completed demographic and clinical questions and questionnaires. These assessed physical function (SF-36), mobility (EQ-5D-5L and NEADL), fatigue (FACIT-F), and pain (SF-MQ-2). Scores were compared using parametric or non-parametric statistical analyses, whereas correlations between outcomes were examined using univariate and multivariate regression analysis. Results: Seventy-eight adults with OI aged 43.5 ± 14.5 years were enrolled (type I, 32; type III, 11; type IV, 10; unknown type, 26). Physical function (PCS, SF-36) was significantly lower in all participants than normative values (p < 0.001) and in type III than type I (p = 0.008). Mobility was significantly different across the types (EQ-5D-EL, p = 0.007; NEADL, p < 0.001), with type III having more severe problems, followed by types IV, unknown, and I. Physical function was associated with OI type (r = 0.26; p = 0.021), presence and quality of pain (r = − 0.57; p < 0.0001), and fatigue (r = − 0.51; p < 0.0001). Multivariate analysis revealed that physical function correlated independently with age, OI type, fatigue, and non-neuropathic pain. Conclusions: Individuals with OI disp

There has been a substantial amount of research involving computer methods and technology for the detection and recognition of diabetic foot ulcers (DFUs), but there is a lack of systematic comparisons of state-of-the-art deep learning object detection frameworks applied to this problem. DFUC2020 provided participants with a comprehensive dataset consisting of 2,000 images for training and 2,000 images for testing. This paper summarizes the results of DFUC2020 by comparing the deep learning-based algorithms proposed by the winning teams: Faster R-CNN, three variants of Faster R-CNN and an ensemble method; YOLOv3; YOLOv5; EfficientDet; and a new Cascade Attention Network. For each deep learning method, we provide a detailed description of model architecture, parameter settings for training and additional stages including pre-processing, data augmentation and post-processing. We provide a comprehensive evaluation for each method. All the methods required a data augmentation stage to increase the number of images available for training and a post-processing stage to remove false positives. The best performance was obtained from Deformable Convolution, a variant of Faster R-CNN, with a mean average precision (mAP) of 0.6940 and an F1-Score of 0.7434. Finally, we demonstrate that the ensemble method based on different deep learning methods can enhance the F1-Score but not the mAP.

AIM:Self-rated health, a measure of self-reported general health, is a robust predictor of morbidity and mortality in various populations, including persons with diabetes. This study examines correlates of self-rated health in adults with diabetic peripheral neuropathy (DPN). METHODS:Participants recruited from the UK and USA (n = 295; mean (± sd) age: 61.5 ± 10.7 years; 69% male; 71% type 2 diabetes) rated their health at baseline and 18 months. DPN severity was assessed using the neuropathy disability score and the vibration perception threshold. Validated self-report measures assessed neuroticism, DPN-symptoms of pain, unsteadiness and reduced sensation in feet, DPN-related limitations in daily activities, DPN-specific emotional distress and symptoms of depression. RESULTS:In the fully adjusted baseline model, younger age, presence of cardiovascular disease and higher depression symptom scores showed likely clinically meaningful independent associations with worse health ratings. Being at the UK study site and presence of nephropathy indicated potentially meaningful independent associations with lower baseline health ratings. These predictors were largely consistent in their association with health ratings at 18 months. CONCLUSION:Results identify independent correlates of health ratings among adults with DPN. Future research should investigate the clinical implications of associations and examine changes in these variables over time and potential effects on changes in health perceptions. If these associations reflect causal pathways, our results may guide interventions to target issues that are likely to have an impact on subjectively experienced health as an important patient-reported outcome in DPN care.

Background: Previous work has highlighted the highly functional post-rehabilitation level of military individuals who sustained traumatic amputation. Understanding how these individuals walk with their prosthesis could be key to setting a precedent for what is realistically possible in the rehabilitation of individuals with amputations. Objective: The aim of this paper is to answer how "normal" should the gait of an individual with an amputation(s) be and can we aspire to mimic able-bodied gait with the most advanced prosthetics in highly functioning individuals? Methods: This was a cross-sectional study comparing the gait of severely injured and highly functional UK trans-tibial (n=10), trans-femoral (n=10) and bilateral trans-femoral (n=10) military amputees after completion of their rehabilitation programme to that of able-bodied controls (n=10). Joint kinematics and kinetics of the pelvis, hip, knee and ankle were measured with 3-D gait analysis during 5min of walking on level ground at a self-selected speed. Peak angle, moment or range of motion of intact and prosthetic limbs were compared to control values. Results: Joint kinematics of unilateral trans-tibial amputees was similar to that of controls. Individuals with a trans-femoral amputation walked with a more anterior tilted pelvis (P=0.006), with reduced range of pelvic obliquity (P=0.0023) and ankle plantarflexion (P<0.001) than controls. Across all amputee groups, hip joint moments and power were greater and knee and ankle joint moments were less than for controls. Conclusions: This is the first study to provide a comprehensive description of gait patterns of unilateral trans-tibial, trans-femoral and bilateral trans-femoral amputees as compared with healthy able-bodied individuals. The groups differed in joint kinematics and kinetics, but these can be expected in part because of limitations in prosthesis and socket designs. The results from this study could be considered benchmark data for healthcare pr

© 2020 We are proposing optimal training conditions that can lead to an increase in the number of serial sarcomeres (SSN) and muscle fascicle length (FL) in spastic muscles. Therapeutic interventions for increasing FL in clinical populations with neurological origin, in whom relative shortness of muscle fascicles contributed to the presentation of symptoms such as spasticity, contracture, and limited functional abilities, do not generally meet these conditions, and therefore, result in less than satisfactory outcomes. Based on a review of literature, we argue that protocols of exercise interventions that led to sarcomerogenesis, and increases in SSN and FL in healthy animal and human models satisfied three criteria: 1) all involved eccentric exercise at appropriately high velocity; 2) resulted in positive strain of muscle fascicles; and 3) momentary deactivation in the stretched muscle. Accordingly, to increase FL in spastic muscles, new exercise protocols in which the three presumed criteria are satisfied, must be developed, and long-term muscle architectural and functional adaptations to such trainings must be examined.

© 2020 The Author(s) Background: Increased postural balance challenge is associated with more fluctuations in centre of pressure movement, indicating increased interference from the postural control system. The role of intrinsic foot muscles in balance control is relatively understudied and whether such control system interference occurs at the level of these muscles is unknown. Research Question: Do fewer fluctuations in intrinsic foot muscle excitation occur in response to increased postural balance challenge? Methods: Surface EMGs were recorded using a grid of 13 × 5 channels from the plantar surface of the foot of 17 participants, who completed three balance tasks: bipedal stance; single leg stance and bipedal tip-toe. Centre of pressure (CoP) movement was calculated from simultaneously recorded force plate signals. Fluctuations in CoP and EMGs for each task were quantified using a sample entropy based metric, Entropy Halflife (EnHL). Longer EnHL indicates fewer signal fluctuations. Results: The shortest EMG EnHL, 9.27 ± 3.34 ms (median ± interquartile range), occurred during bipedal stance and the longest during bipedal tip-toe 15.46 ± 11.16 ms, with 18.80 ± 8.00 ms recorded for single leg stance. Differences were statistically significant between bipedal stance and both bipedal tip-toe (p < 0.001) and single leg stance (p < 0.001). CoP EnHL for both anterior-posterior and medial-lateral movements also differed significantly between tasks (p < 0.001, both cases). However, anterior-posterior CoP EnHL was longest for bipedal stance 259.84±230.22 ms and shortest for bipedal tip-toe 146.25±73.35 ms. Medial-lateral CoP EnHL was also longest during bipedal stance 215.73±187.58 ms, but shortest for single leg stance 113.48±83.01 ms. Significance: Fewer fluctuations in intrinsic foot muscle excitation occur in response to increased postural balance challenge. Fluctuations in CoP movement during balance must be predominantly driven by excitation of muscles extrinsic to

© 2020 The Authors. Journal of Anatomy published by John Wiley & Sons Ltd on behalf of Anatomical Society Femoral neck anteversion (FNA) is the angle between the femoral neck and femoral shaft, indicating the degree of torsion of the femur. Differences in FNA affect the biomechanics of the hip, through alterations in factors such as moment arm lengths and joint loading. Altered gait associated with differences in FNA may also contribute to the development of a wide range of skeletal disorders including osteoarthritis. FNA varies by up to 30° within apparently healthy adults. FNA increases substantially during gestation and thereafter decreases steadily until maturity. There is some evidence of a further decrease at a much lower rate during adulthood into old age, but the mechanisms behind it have never been studied. Development of FNA appears to be strongly influenced by mechanical forces experienced during everyday movements. This is evidenced by large differences in FNA in groups where movement is impaired, such as children born breech or individuals with neuromuscular conditions such as cerebral palsy. Several methods can be used to assess FNA, which may yield different values by up to 20° in the same participant. While MRI and CT are used clinically, limitations such as their cost, scanning time and exposure to ionising radiation limit their applicability in longitudinal and population studies, particularly in children. More broadly, applicable measures such as ultrasound and functional tests exist, but they are limited by poor reliability and validity. These issues highlight the need for a valid and reliable universally accepted method. Treatment for clinically problematic FNA is usually de-rotational osteotomy; passive, non-operative methods do not have any effect. Despite observational evidence for the effects of physical activity on FNA development, the efficacy of targeted physical activity remains unexplored. The aim of this review is to describe the biome

© 2020 The Authors The purpose of this study was to estimate the potential for impaired driving performance in current drivers with diabetic peripheral neuropathy compared to healthy controls. We analysed, using a driving simulator, three important aspects of driving - use of the accelerator pedal, steering wheel and eye-steering coordination - to test for any differences, and then to integrate these findings to identify a unique pattern of changes in people driving with diabetic peripheral neuropathy. Patients with diabetic peripheral neuropathy displayed differences in use of the accelerator pedal compared to healthy control drivers (p < 0.05) which could be a direct consequence of their sensorimotor impairment due to diabetic peripheral neuropathy. Drivers with DPN used the more extreme high and low positions of the pedal to a greater extent than the Control group who exhibited a more graded use of the accelerator pedal over the mid-range. Eye-steering coordination was also different in drivers with diabetic peripheral neuropathy (p < 0.05) and, as it improved during the second drive, becoming closer to healthy drivers’ values, the occasional loss of control experienced during driving reduced. These insights demonstrate that diabetic peripheral neuropathy affects multiple aspects of driving performance suggesting the need for an integrated approach to evaluate the potential for driving safely in this population.

© 2020 John Wiley & Sons Ltd The prevalent and long neglected diabetic foot ulcer (DFU) and its related complications rank among the most debilitating and costly sequelae of diabetes. Management of the DFU is multifaceted and requires constant monitoring from patients, caregivers, and healthcare providers. The alarmingly high rates of recurrence of ulcerations in the diabetic foot requires a change in our approach to care and to the vernacular in the medical literature. Our efforts should be directed not only on healing of open wounds, but also on maximizing ulcer-free days for the patient in diabetic foot remission. The increasing development and use of technology within every aspect of our lives represents an opportunity for creative solutions to prevent or better manage this devastating condition. In particular, recent advances in wearable and mobile health technologies appear to show promise in measuring and modulating dangerous foot pressure and inflammation to extend remission and improve the quality of life for these most complex patients. This review article discusses how harnessing wearables and digital technologies may improve the management and optimize prevention of DFUs by identifying high-risk patients for triage and timely intervention, personalizing prescription of offloading, and improving adherence to protective footwear. While still in their infancy, we envisage a future network of skin-worn, jewellery-worn, and implantable sensors that, if allowed to effectively communicate with one another and the patient, could dramatically impact measuring, personalizing, and managing how we and the patients we serve move through our collective world.

© 2020 The Authors Recognition and analysis of Diabetic Foot Ulcers (DFU) using computerized methods is an emerging research area with the evolution of image-based machine learning algorithms. Existing research using visual computerized methods mainly focuses on recognition, detection, and segmentation of the visual appearance of the DFU as well as tissue classification. According to DFU medical classification systems, the presence of infection (bacteria in the wound) and ischaemia (inadequate blood supply) has important clinical implications for DFU assessment, which are used to predict the risk of amputation. In this work, we propose a new dataset and computer vision techniques to identify the presence of infection and ischaemia in DFU. This is the first time a DFU dataset with ground truth labels of ischaemia and infection cases is introduced for research purposes. For the handcrafted machine learning approach, we propose a new feature descriptor, namely the Superpixel Colour Descriptor. Then we use the Ensemble Convolutional Neural Network (CNN) model for more effective recognition of ischaemia and infection. We propose to use a natural data-augmentation method, which identifies the region of interest on foot images and focuses on finding the salient features existing in this area. Finally, we evaluate the performance of our proposed techniques on binary classification, i.e. ischaemia versus non-ischaemia and infection versus non-infection. Overall, our method performed better in the classification of ischaemia than infection. We found that our proposed Ensemble CNN deep learning algorithms performed better for both classification tasks as compared to handcrafted machine learning algorithms, with 90% accuracy in ischaemia classification and 73% in infection classification.

AIM:To investigate whether the sensory-motor impairment attributable to diabetic peripheral neuropathy would affect control of the accelerator pedal during a driving simulator task. METHODS:A total of 32 active drivers, 11 with diabetic peripheral neuropathy (mean ± sd age 67±5.0 years), 10 with diabetes but no neuropathy (diabetes group; mean ± sd age 62±10 years), and 11 healthy individuals without diabetes (healthy group; mean ± sd age 60±11 years), undertook a test on a dynamometer to assess ankle plantar flexor muscle strength and ankle joint proprioception function of the right leg, in addition to a driving simulator task. The following variables were measured: maximal ankle plantar flexor muscle strength; speed of strength generation (Nm/s); and ankle joint proprioception (ankle repositioning error, degrees). In the driving simulator task, driving speed (mph), accelerator pedal signal (degrees) and the duration of specific 'loss-of-control events' (s) were measured during two drives (Drive 1, Drive 2). RESULTS:Participants with diabetic peripheral neuropathy had a lower speed of strength generation (P<0.001), lower maximal ankle plantar flexor muscle strength (P<0.001) and impaired ankle proprioception (P=0.034) compared to healthy participants. The diabetic peripheral neuropathy group drove more slowly compared with the healthy group (Drive 1 P=0.048; Drive 2 P=0.042) and showed marked differences in the use of the accelerator pedal compared to both the diabetes group (P=0.010) and the healthy group (P=0.002). Participants with diabetic peripheral neuropathy had the longest duration of loss-of-control events, but after one drive, this was greatly reduced (P=0.023). CONCLUSIONS:Muscle function, ankle proprioception and accelerator pedal control are all affected in people with diabetic peripheral neuropathy, adversely influencing driving performance, but potential for improvement with targeted practice remains possible. This article is protected by copyright.

© 2019 Elsevier Ltd Human movement control requires attention to accurately tune motor commands in response to environmental changes. Dual task paradigms are used to test the role of attention on motor performance. Usually the tasks used have little resemblance with every day experience. Here we ask: Does a common cognitive task, such as a mobile phone conversation, compromise motor performance on stairs? Eight young participants negotiated an instrumented seven-step staircase. Stair negotiation while talking on a mobile phone was compared to normal stair negotiation. Stepping parameters, jerk cost (measure of smoothness of locomotion) and step clearance were measured. When talking on a mobile phone, participants’ overall body velocity (mean(sd): Ascent 0.534(0.026) vs 0.511(0.024) m/s, Descent 0.642(0.026) vs 0.511(0.024) m/s, No phone/Phone respectively) and cadence decreased significantly (Ascent 75.8(5.8) vs 65.6(4.4) steps/min, Descent 117.4(4.2) vs 108.6(6.0) steps/min, No Phone/Phone respectively). Pelvis and feet jerk cost also changed significantly, mostly decreasing with phone use. Foot clearance did not show significant changes between No Phone and Phone conditions. These pilot results show that, even for young, healthy and cognitively intact individuals, talking on a mobile phone whilst negotiating a staircase induces measurable changes in motor performance. Participants moved slowly but more smoothly, reducing the motor control cost, possibly at the expense of movement accuracy. The reduction in motor performance is likely to be due to the difficulty in integrating the two sub-tasks. These results suggest that even young, healthy individuals show stair gait impairment when simultaneously negotiating stairs and performing another cognitive task, such as talking on the phone.

© 2019 by the authors. The purpose of this short review is to discuss the effects of eccentric exercise in modifying the properties of tendon tissue in healthy individuals. The tendon provides a mechanical link between muscle and bone, allowing force transmission to the skeleton, and thus, its properties have significant functional implications. Chronic resistance training has long been shown to increase the stiffness and Young’s modulus of the tendon and even tendon cross-sectional area. However, as the tendon responds to the amount and/or frequency of strain, it has been previously suggested that eccentric training may result in greater adaptations due to the potential for greater training loads. Thus, this review discusses the effects of eccentric training upon healthy tendon tissue and compares these to other training modalities. Furthermore, it has been reported that the tendon may undergo adverse age-related changes. Thus, this review also discusses the potential application of eccentric resistance training as a preferential modality for counteracting these age-related changes. We conclude that while there may be no difference between contraction types for overall tendon adaptation, the lower demands of eccentric contractions may make it more appealing for the elderly population.

© 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Background: Prevention of diabetic foot ulcer recurrence in high risk patients, using current standard of care methods, remains a challenge. We hypothesised that an innovative intelligent insole system would be effective in reducing diabetic foot ulcer recurrence in such patients. Methods: In this prospective, randomised, proof-of-concept study, patients with diabetes, and with peripheral neuropathy and a recent history of plantar foot ulceration were recruited from two multidisciplinary outpatient diabetic foot clinics in the UK, and were randomly assigned to either intervention or control. All patients received an insole system, which measured plantar pressure continuously during daily life. The intervention group received audiovisual alerts via a smartwatch linked to the insole system and offloading instructions when aberrant pressures were detected; the control group did not receive any alerts. The primary outcome was plantar foot ulcer occurrence within 18 months. This trial is registered with ISRCTN, ISRCTN05585501, and is closed to accrual and complete. Findings: Between March 18, 2014, and Dec 20, 2016, 90 patients were recruited and consented to the study, and 58 completed the study. At follow-up, ten ulcers from 8638 person-days were recorded in the control group and four ulcers from 11 835 person-days in the intervention group: a 71% reduction in ulcer incidence in the intervention group compared with the control group (incidence rate ratio 0·29, 95% CI, 0·09–0·93; p=0·037). The number of patients who ulcerated was similar between groups (six of 26 [control group] vs four of 32 [intervention group]; p=0·29); however, individual plantar sites ulcerated more often in the control group (ten of 416) than in the intervention group (four of 512; p=0·047). In an exploratory analysis of good compliers (n=40), ulcer incidence was reduced by 86% in the interv

© 2019 The Author(s). Background: Muscle weakness is a defining characteristic of Muscular Dystrophy (MD); however, yet while speculated, objective measures of muscle weakness has not been reported in relation to quality of life in adults with MD. Objectives: 1) compare the self-reported QoL of adults with Duchenne MD (DMD), Beckers MD (BMD), Limb-Girdle MD (LGMD) and Fascioscapulohumeral MD (FSHD, and a non-MD (CTRL) group; 2) present and compare between groups measures of Impairment (Muscle Strength and Activities of Daily Living) and Perception (Fatigue, Pain and Self-Efficacy); and 3) identify associations between QoL domains and measures of Impairment and Perception (See above). Methods: Seventy-Five males, including MD classifications DMD, BMD, LGMD, FSHD and CTRL, completed measures for QoL, Knee-Extension Maximal Voluntary Contraction (KEMVC), Fatigue, Pain, Self-Efficacy and Activities of Daily Living (ADL). Results: QoL was lower across many domains in MD than CTRL. FSHD scored lower than DMD for mental wellbeing domains. KEMVC associated with Physical-Function domain for BMD. Pain, Self-Efficacy and ADLs associated with QoL domains, with Fatigue the most consistently associated. Conclusion: The present study identified differences between MD classifications within self-perceptions of mental-health. Muscle weakness is a defining feature of MD; however, it doesn't define QoL in adults with MD. A greater understanding of mental wellbeing, independence, and management of fatigue and pain, are required to improve QoL for adults with MD.

Copyright © 2019 Gavin, Reeves, Jones, Roys, Buckley, Baltzopoulos and Maganaris. Introduction: Stair descent is a physically demanding activity of daily life and common risk for falls. Age-related deteriorations in ankle joint capacities make stair descent particularly challenging for older adults in built environments, where larger rise steps are encountered. Exercise training may allow older adults to safely cope with the high biomechanical demands of stair descent. However, little is known about the demands of increased rise stairs for older adults, nor the impact of exercise. Aim: We investigated whether the effects of lower-limb resistance training would alter joint kinetics and movement strategies for older adults when descending standard rise, and increased rise stairs. Methods: Fifteen older adults descended a four-step stair adjusted to standard rise (170 mm), and increased rise (255 mm) on separate visits. Between these two visits, randomly allocated participants underwent 16 weeks of either: resistance exercise training (n = 8) or habitual activity (n = 7). Kinetic data were measured from stepmounted force plates, and kinematic data from motion-capture cameras. Training involved twice-weekly sessions of lower-limb resistance exercises (three sets of ∼8 repetitions at ∼80% three-repetition maximum), and static plantarflexor stretching (three, 45 s holds per leg). Results: Standard stairs - Peak ankle joint moments increased (p < 0.002) and knee joint moments decreased (p < 0.01) during descent after exercise training. Peak centre of pressure-centre of mass (CoP-CoM) separations increased in posterior (p = 0.005) and mediolateral directions (p = 0.04) after exercise training. Exercise training did not affect CoM descent velocity or acceleration. Increased rise stairs - Required greater ankle, knee, and hip moments (p < 0.001), peak downward CoM velocity and acceleration (p = 0.0001), and anterior-posterior CoP-CoM separation (p = 0.0001), but lower medial

© 2019 Background: Maintaining body centre of mass (CoM) lowering velocity within manageable/safe limits during stair descent can be problematic for older individuals due to reduced ranges of motion at the involved joints (ankle and knee) and a reduced ability to generate adequate joint moments at the extremes in joint ranges of motion. These problems are likely to magnify in circumstances where the distance of lowering increases, or when misjudging the height of lowering. Research question: How does a 50% increase in standard stair riser-height affect control of CoM velocity and acceleration of older people during stair descent? Methods: Fifteen older (75 ± 3 years) and seventeen young (25 ± 4 years) healthy adults descended a 4-step staircase, at two riser-heights: 170 mm, 255 mm. Changes in peak vertical CoM acceleration and velocity, and lower-limb joint kinetics (moments, work) during landing and lowering phases of stair descent were assessed using a mixed-design repeated measures analysis of variance. Results: Peak CoM accelerations and velocities during landing and lowering were lower in older compared to young adults and increased in both groups at 255 mm riser-height. Duration of lowering also increased, particularly for older adults. Peak ankle moments during landing and lowering, which were lower in older compared to young adults, increased when descending from 255 mm riser-height, whilst the peak knee moment reduced. Both groups produced increased landing-limb negative (eccentric) ankle joint work when descending from 255 mm, but increases were greater for older adults (87.8%) compared to young (76.1%). Significance: Descending stairs became more challenging in both age groups as riser-height increased. Older adults adopted a strategy of reducing CoM velocity to lessen the eccentric landing demands. In both groups, but more so older adults, there was a greater reliance on using leading-limb eccentric plantarflexion at 255 mm riser-height compared to 170

AIM:To investigate whether the sensory-motor impairment attributable to diabetic peripheral neuropathy would affect control of the accelerator pedal during a driving simulator task. METHODS:A total of 32 active drivers, 11 with diabetic peripheral neuropathy (mean ± sd age 67±5.0 years), 10 with diabetes but no neuropathy (diabetes group; mean ± sd age 62±10 years), and 11 healthy individuals without diabetes (healthy group; mean ± sd age 60±11 years), undertook a test on a dynamometer to assess ankle plantar flexor muscle strength and ankle joint proprioception function of the right leg, in addition to a driving simulator task. The following variables were measured: maximal ankle plantar flexor muscle strength; speed of strength generation (Nm/s); and ankle joint proprioception (ankle repositioning error, degrees). In the driving simulator task, driving speed (mph), accelerator pedal signal (degrees) and the duration of specific 'loss-of-control events' (s) were measured during two drives (Drive 1, Drive 2). RESULTS:Participants with diabetic peripheral neuropathy had a lower speed of strength generation (P<0.001), lower maximal ankle plantar flexor muscle strength (P<0.001) and impaired ankle proprioception (P=0.034) compared to healthy participants. The diabetic peripheral neuropathy group drove more slowly compared with the healthy group (Drive 1 P=0.048; Drive 2 P=0.042) and showed marked differences in the use of the accelerator pedal compared to both the diabetes group (P=0.010) and the healthy group (P=0.002). Participants with diabetic peripheral neuropathy had the longest duration of loss-of-control events, but after one drive, this was greatly reduced (P=0.023). CONCLUSIONS:Muscle function, ankle proprioception and accelerator pedal control are all affected in people with diabetic peripheral neuropathy, adversely influencing driving performance, but potential for improvement with targeted practice remains possible. This article is protected by copyright.

© 2019, The Author(s). This study used a micromechanical finite element muscle model to investigate the effects of the redistribution of spatial activation patterns in young and old muscle. The geometry consisted of a bundle of 19 active muscle fibers encased in endomysium sheets, surrounded by passive tissue to model a fascicle. Force was induced by activating combinations of the 19 active muscle fibers. The spacial clustering of muscle fibers modeled in this study showed unbalanced strains suggesting tissue damage at higher strain levels may occur during higher levels of activation and/or during dynamic conditions. These patterns of motor unit remodeling are one of the consequences of motor unit loss and reinnervation associated with aging. The results did not reveal evident quantitative changes in force transmission between old and young adults, but the patterns of stress and strain distribution were affected, suggesting an uneven distribution of the forces may occur within the fascicle that could provide a mechanism for muscle injury in older muscle.

© 2018 The Author(s) People with diabetes display biomechanical gait alterations compared to controls and have a higher metabolic cost of walking (CoW), but it remains unknown whether differences in the vertical displacement of the body centre of mass (CoM) may play a role in this higher CoW. The aim of this study was to investigate vertical CoM displacement (and step length as a potential underpinning factor) as an explanatory factor in the previously observed increased CoW with diabetes. Thirty-one non-diabetic controls (Ctrl); 22 diabetic patients without peripheral neuropathy (DM) and 14 patients with moderate/severe Diabetic Peripheral Neuropathy (DPN), underwent gait analysis using a motion analysis system and force plates while walking at a range of matched speeds between 0.6 and 1.6 m/s. Vertical displacement of the CoM was measured over the gait cycle, and was not different in either diabetes patients with or without diabetic peripheral neuropathy compared to controls across the range of matched walking speeds examined (at 1 m/s: Ctrl: 5.59 (SD: 1.6), DM: 5.41 (1.63), DPN: 4.91 (1.66) cm; p > 0.05). The DPN group displayed significantly shorter steps (at 1 m/s: Ctrl: 69, DM: 67, DPN: 64 cm; p > 0.05) and higher cadence (at 1 m/s: Ctrl: 117 (SD1.12), DM: 119 (1.08), DPN: 122 (1.25) steps per minute; p > 0.05) across all walking speeds compared to controls. The vertical CoM displacement is therefore unlikely to be a factor in itself that contributes towards the higher CoW observed recently in people with diabetic neuropathy. The higher CoW in patients with diabetes may not be explained by the CoM displacement, but rather may be more related to shorter step lengths, increased cadence and the associated increased internal work and higher muscle forces developed by walking with more flexed joints.

Background and Purpose— A quarter of individuals who experience a stroke are under the age of 65 years (defined as young adults), and up to 44% will be unable to return to work poststroke, predominantly because of walking difficulties. No research study has comprehensively analyzed walking performance in young adult’s poststroke. The primary aim of this study is to investigate how a stroke in young adults affects walking performance (eg, walking speed and metabolic cost) compared with healthy age-matched controls. The secondary aim is to determine the predictive ability of walking performance parameters for return to employment poststroke. Methods— Forty-six individuals (18–40 years: n=6, 41–54 years: n=21, 55–65 years: n=19) who have had a stroke and 15 healthy age-matched able-bodied controls were recruited from 6 hospital sites in Wales, United Kingdom. Type, location, cause of stroke, and demographic factors (eg, employment status) were recorded. Temporal and spatial walking parameters were measured using 3-dimensional gait analysis. Metabolic energy expenditure and metabolic cost of walking were captured during 3 minutes of walking at self-selected speed from measurements of oxygen consumption. Results— Stroke participants walked slower (P<0.004) and less efficiently (P<0.002) than the controls. Only 23% of stroke participants returned to employment poststroke. Walking speed was the strongest predictor (sensitivity, 0.90; specificity, 0.82) for return to work (P=0.004) with a threshold of 0.93 m/s identified: individuals able to walk faster than 0.93 m/s were significantly more likely to return to work poststroke than those who walked slower than this threshold. Conclusions— This study is the first to capture walking performance parameters of young adults who have had a stroke and identifies slower and less efficient walking. Walking speed emerged as the strongest predictor for return to employment. It is recommended that walking speed be used as a simple but s

High plantar pressure as a result of diabetic peripheral neuropathy is often reported as a major risk factor for ulceration. However, previous studies are confined to laboratories with equipment limited by cables, reducing the validity of measurements to daily life. The participant concerned in this case report was wearing an innovative plantar pressure feedback system as part of a wider study. The system allows for continuous plantar pressure monitoring and provides feedback throughout all activities of daily living. The participant concerned was a 59-year-old male with type 2 diabetes who presented with severe peripheral neuropathy. In addition, the right ankle had previously undergone fusion. Between monthly study appointments, the participant unknowingly had a screw embedded in his right shoe, while pressure was being recorded. Although no significant differences in pressure were present for the right foot with the embedded screw, the contralateral foot showed significantly higher pressure when the screw was embedded, compared with pre and post time periods. The increase in pressure on the contralateral foot is expected to result from the protrusion of the screw in the right shoe, causing a perturbation to balance and a shift in the center of pressure toward the contralateral side. This compensatory effect is likely to have been magnified by the limited mobility of the fused right ankle. These findings highlight the importance of checking both feet for ulcer risk, in the event of receiving high-pressure feedback. This innovative technology may improve our understanding of diabetic plantar foot ulcer development.

© 2018 Elsevier Ltd. Descending stairs requires elevated joint moment-generating capability in the lower limbs, making it a challenging daily activity, particularly for older individuals. The aim of the study was to investigate the influence of three different strategies for descending standard and increased height stairs: step-over-step (SoS), step-by-step (SbS) and side-step (SS) on lower limb kinetics in older people. Eleven participants (mean ± SD age: 74.8 ± 3.1 years, height: 1.63 ± 0.07 m, mass: 67.7 ± 9.5 kg) descended a four-step custom built instrumented staircase at a self-selected speed, adopting each of the three strategies, at two configurations: a step-rise height of 170 mm (standard; STD) and a step-rise height of 255 mm (increased; INC). 3D motion capture, synchronised with embedded force plates enabled the calculation of joint kinetics of lead and trail limbs. Data were analysed using a Linear Mixed Model with gait speed selected as a covariate during weight acceptance (WA) and controlled lowering (CL) phases. A large increase in hip extensor moment in both WA and CL in the lead limb was evident during both SoS and SbS at INC step height compared to STD (P <.015 for all), with no such increase in hip flexor moment evident in SS strategy (P =.519). Lead limb knee extensor moment decreased and plantarflexor moment increased in INC SoS compared to STD SoS during CL (P <.001 for both). In the trail limb, increased hip extensor and plantarflexor moments were seen in INC SS compared to STD SS (P <.001 for both). The alternate strategies result in the overall task demand being split between the lead limb (weight acceptance) and trail limb (controlled lowering). Differential demand distribution patterns exist between strategies that imply targeted interventions and/or advice could be provided to older individuals in order to promote safe descent of stairs, particularly for those with specific muscle weaknesses or at high risk of falls.

Intrinsic foot muscles (IFM) are a crucial component within the human foot. Investigating their functioning can help understand healthy and pathological behaviour of foot and ankle, fundamental for everyday activities. Recording muscle activation from IFM has been attempted with invasive techniques, mainly investigating single muscles. Here we present a novel methodology, to investigate the feasibility of recording physiological surface EMG (sEMG) non-invasively and quantify patterns of activation across the whole plantar region of the foot. sEMG were recorded with a 13 × 5 array from the sole of the foot (n = 25) during two-foot stance, two-foot tiptoe and anterior/posterior sways. Physiological features of sEMG were analysed. During anterior/posterior epochs within the sway task, sEMG patterns were analysed in terms of signal amplitude (intensity) and structure (Sample Entropy) distribution, by evaluating the centre of gravity (CoG) of each topographical map. Results suggest signals are physiological and not affected by loading. Both amplitude and sample entropy CoG coordinates were grouped in one region and overlapped, suggesting that the region with highest amplitude corresponds with the most predictable signal. Therefore, both spatial and temporal features of IFM activation may be recorded non-invasively, providing opportunity for more detailed investigation of IFM function in healthy and patient populations.

PURPOSE: The biarticular rectus femoris (RF), operating on the ascending limb of the force-length curve, produces more force at longer lengths. However, experimental studies consistently report higher knee extension torque when supine (longer RF length) compared to seated (shorter RF length). Incomplete activation in the supine position has been proposed as the reason for this discrepancy, but differences in antagonistic co-activation could also be responsible due to altered hamstrings length. We examined the role of agonist and antagonist muscles in explaining the isometric knee extension torque variation with changes in hip joint angle. METHOD: Maximum voluntary isometric knee extension torque (joint MVC) was recorded in seated and supine positions from nine healthy males (30.2 ± 7.7 years). Antagonistic torque was estimated using EMG and added to the respective joint MVC (corrected MVC). Submaximal tetanic stimulation quadriceps torque was also recorded. RESULT: Joint MVC was not different between supine (245 ± 71.8 Nm) and seated (241 ± 69.8 Nm) positions and neither was corrected MVC (257 ± 77.7 and 267 ± 87.0 Nm, respectively). Antagonistic torque was higher when seated (26 ± 20.4 Nm) than when supine (12 ± 7.4 Nm). Tetanic torque was higher when supine (111 ± 31.9 Nm) than when seated (99 ± 27.5 Nm). CONCLUSION: Antagonistic co-activation differences between hip positions do not account for the reduced MVC in the supine position. Rather, reduced voluntary knee extensor muscle activation in that position is the major reason for the lower MVC torque when RF is lengthened (hip extended). These findings can assist standardising muscle function assessment and improving musculoskeletal modelling applications.

The anterior cruciate ligament (ACL) plays a key role in the stability of the knee joint restricting the rotation and anterior tibial translation. However, there is a lack of knowledge of the in vivo ACL mechanical behaviour during high impact manoeuvres. The motion of 12 young participants with healthy knees was captured while they performed the following activities: walking, running, cross-over cutting, sidestep cutting, jumping and jumping with one leg. The in vivo ACL length and strain were estimated using experimental kinematic data and three degree of freedom (DOF) knee model. The in vivo ACL tensile forces were determined with a well-established force/strain relationship obtained through ACL tensile tests. Statistical regression models between ACL length with respect to angles for each activity have been performed in order to better understand the ACL failure mechanisms. The maximum ACL tensile force was observed during jumping vertically at maximum effort with two legs (1.076±0.113 N/BW). Surprisingly, the peak tensile ACL force for all subjects during crossover cutting (0.715±0.2647 N/BW) was lower than during walking (0.774±0.064 N/BW). Regression coefficients for crossover cutting indicated that excessive knee rotation and abduction angles contribute more significantly to the ACL elongation than in activities such as walking or running. These findings suggested that the ACL is subjected to multidirectional loading; further studies will be performed to investigate torsion, tensile and shear force on the ligament.

© 2017, Springer Science+Business Media, LLC. Purpose of Review: The purpose of this review was to elucidate how psychological and biomechanical factors interrelate in shaping patients’ experience with diabetic symmetric polyneuropathy (DSPN) and its sequela-diabetic foot ulceration (DFU). Recent Findings: Recent findings emphasize the importance not only of neuropathic pain but also of other DSPN symptoms, such as unsteadiness. We highlight the negative spiral between unsteadiness, falls, and psychological distress. Moreover, unsteadiness is a key determinant of non-adherence to offloading resulting in the delayed DFU healing. While depression is an established predictor of incident DFU, findings linking depression and DFU healing remain inconclusive. Examination of physical activity in DFU development and healing represents the most recent application of research to this field. Summary: Research evidence indicates that DSPN markedly impairs physical and emotional functioning and suggests that there is an unmet need for the development of multifaceted interventions that address both psychological distress and biomechanical challenges experienced by patients with this debilitating complication of diabetes.

Skeletal muscle contracts either by shortening or lengthening (concentrically or eccentrically, respectively); however, the two contractions substantially differ from one another in terms of mechanisms of force generation, maximum force production and energy cost. It is generally known that eccentric actions generate greater force than isometric and concentric contractions and at a lower metabolic cost. Hence, by virtue of the greater mechanical loading involved in active lengthening, eccentric resistance training (ECC RT) is assumed to produce greater hypertrophy than concentric resistance training (CON RT). Nonetheless, prevalence of either ECC RT or CON RT in inducing gains in muscle mass is still an open issue, with some studies reporting greater hypertrophy with eccentric, some with concentric and some with similar hypertrophy within both training modes. Recent observations suggest that such hypertrophic responses to lengthening vs. shortening contractions are achieved by different adaptations in muscle architecture. Whilst the changes in muscle protein synthesis in response to acute and chronic concentric and eccentric exercise bouts seem very similar, the molecular mechanisms regulating the myogenic adaptations to the two distinct loading stimuli are still incompletely understood. Thus, the present review aims to, (a) critically discuss the literature on the contribution of eccentric vs. concentric loading to muscular hypertrophy and structural remodeling, and, (b) clarify the molecular mechanisms that may regulate such adaptations. We conclude that, when matched for either maximum load or work, similar increase in muscle size is found between ECC and CON RT. However, such hypertrophic changes appear to be achieved through distinct structural adaptations, which may be regulated by different myogenic and molecular responses observed between lengthening and shortening contractions.

© 2017 Maganaris, Chatzistergos, Reeves and Narici. By virtue of their anatomical location between muscles and bones, tendons make it possible to transform contractile force to joint rotation and locomotion. However, tendons do not behave as rigid links, but exhibit viscoelastic tensile properties, thereby affecting the length and contractile force in the in-series muscle, but also storing and releasing elastic stain energy as some tendons are stretched and recoiled in a cyclic manner during locomotion. In the late 90s, advancements were made in the application of ultrasound scanning that allowed quantifying the tensile deformability and mechanical properties of human tendons in vivo. Since then, the main principles of the ultrasound-based method have been applied by numerous research groups throughout the world and showed that tendons increase their tensile stiffness in response to exercise training and chronic mechanical loading, in general, by increasing their size and improving their intrinsic material. It is often assumed that these changes occur homogenously, in the entire body of the tendon, but recent findings indicate that the adaptations may in fact take place in some but not all tendon regions. The present review focuses on these regional adaptability features and highlights two paradigms where they are particularly evident: (a) Chronic mechanical loading in healthy tendons, and (b) tendinopathy. In the former loading paradigm, local tendon adaptations indicate that certain regions may "see," and therefore adapt to, increased levels of stress. In the latter paradigm, local pathological features indicate that certain tendon regions may be "stress-shielded" and degenerate over time. Eccentric exercise protocols have successfully been used in the management of tendinopathy, without much sound understanding of the mechanisms underpinning their effectiveness. For insertional tendinopathy, in particular, it is possible that the effectiveness of a loading/rehabi