Effects of exercise training on bone mineral density in frail older women and men: a randomised controlled trial.
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Aged↗
Biomedical subjects
D R Sinacore
Publications and source records attributed to D R Sinacore.
Low-intensity exercise as a modifier of physical frailty in older adults.
OBJECTIVE: To examine the effects of a 3-month low-intensity exercise program on physical frailty. DESIGN: Randomized clinical trial. SETTING: Regional tertiary-care hospital and academic medical center with an outpatient rehabilitation fitness center. PARTICIPANTS: Eighty-four physically frail older adults (mean age, 83 +/- 4 yrs). INTERVENTION: Three-month low-intensity supervised exercise (n = 48) versus unsupervised home-based flexibility activities (n = 36). MAIN OUTCOME MEASURES: Physical performance test, measures of balance, strength, flexibility, coordination, speed of reaction, peripheral sensation. RESULTS: Significant improvement was made by the exercise group on our primary indicator of frailty, a physical performance test (PPT) (29 +/- 4 vs 31 +/- 4 out of a possible 36 points), as well as many of the risk factors previously identified as contributors to frailty; eg, reductions in flexibility, strength, gait speed, and poor balance. Although the home exercise control group showed increases in range of motion, the improvements in flexibility did not translate into improvements in physical performance capacity as assessed by the PPT. CONCLUSIONS: Our results suggest that physical frailty is modifiable with a program of modest activities that can be performed by virtually all older adults. They also indicate that exercise programs consisting primarily of flexibility activities are not likely to reverse or attenuate physical frailty. Although results suggest that frailty is modifiable, it is not likely to be eliminated with exercise, and efforts should be directed toward preventing the condition.
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Physical and performance measures for the identification of mild to moderate frailty.
BACKGROUND: The relative importance and association of factors contributing to physical frailty in elderly persons are unclear. METHODS: Physical measures of upper and lower extremity strength, range of motion, balance, coordination, sensation, and gait were evaluated in relation to scores obtained on a 36-point physical performance test (PPT) in 107 elderly subjects. RESULTS: Scores on the PPT were significantly associated with the measures of strength and balance, gait, several range of motion values, and sensation. Subjects were also grouped according to score on the PPT as not frail (32-36 points), mildly frail (25-31 points), or moderately frail (17-24 points). ANOVA followed by Bonferroni post hoc analyses were used to examine the relationships of physical measures to this index of frailty. Balance measures, an obstacle course, the Berg scale, the full tandem portion of the Romberg test, and fast gait speed were significantly different among the three groups. Multiple stepwise regression analyses indicated that the strongest combination of variables, explaining 73% of all the variance in the PPT, included obstacle course performance, hip abduction strength, the semitandem portion of the Romberg test, and coordination (pegboard). CONCLUSIONS: Results provide further insight into the relative importance of factors that contribute to frailty and factors that should be considered in treatment planning for the remediation of physical frailty in old adults.
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Effects of a tendo-Achilles lengthening procedure on muscle function and gait characteristics in a patient with diabetes mellitus.
STUDY DESIGN: Case report with repeated measures. OBJECTIVES: To describe the effects of a tendo-Achilles lengthening (TAL) and total contact casting (TCC) on wound healing, motion, plantar pressure, and function in a patient with diabetes mellitus, peripheral neuropathy, neuropathic ulcer, and limited dorsiflexion range of motion (DFROM). BACKGROUND: Limited DFROM has been associated with increased forefoot pressures and skin breakdown. A TAL was expected to increase DFROM and reduce forefoot pressures during walking, but the influence on muscle performance and function was unknown. METHODS AND MEASURES: The patient was a 42-year-old man with a 20-year history of type 1 diabetes (NIDDM) and a recurrent neuropathic plantar ulcer. Outcome measures were DFROM, isokinetic plantar flexor muscle peak torque, in-shoe and barefoot peak plantar pressure, physical performance test (PPT) score, and peak ankle and hip moments during walking obtained from an automated gait analysis. All tests were completed pre-TAL, 8 weeks post-TAL (after immobilization in a TCC), and 7 months post-TAL. RESULTS: The wound healed in 40 days. The TAL resulted in a sustained increase in DFROM (0 to 18 degrees). Plantar flexor peak torque was reduced by 21% 8 weeks after the TAL compared with the torque before surgery but recovered fully at 7 months. Seven months following TAL, in-shoe forefoot peak plantar pressure was reduced by 55%, barefoot pressure decreased by 14%, PPT score increased by 24%, peak ankle plantar flexor moment remained decreased by 30%, and the peak hip flexor moment increased by 41% during walking. CONCLUSION: For this patient, a TAL resulted in short-term deficits in peak plantar flexor torque, but a 7-month follow-up showed improvements in ankle DFROM, walking ability, and a decrease in forefoot in-shoe peak plantar pressure.
Achilles Tendon↗
Timing of peak plantar pressure during the stance phase of walking. A study of patients with diabetes mellitus and transmetatarsal amputation.
High plantar pressures contribute to skin breakdown in patients with diabetes mellitus and peripheral neuropathy. The primary purpose of this study was to determine the point during the stance phase of walking that corresponds with forefoot peak plantar pressures. Results indicate that peak plantar pressures occurred at 80% +/- 5% of the stance phase of gait in subjects with diabetes and transmetatarsal amputation, as well as in control subjects. Improved methods of footwear design or walking strategies proposed to patients should focus on the demands of the foot during the late stance phase of walking in order to increase available weightbearing area or to decrease forces, which will minimize plantar pressures and reduce trauma to the neuropathic foot.
Adult↗
Healing times of pedal ulcers in diabetic immunosuppressed patients after transplantation.
OBJECTIVE: To compare the healing time of neuropathic plantar ulcers treated by total-contact casting (TCC) in diabetic, immunosuppressed patients after organ transplantation with the healing time of plantar ulcers in control nonimmunosuppressed patients. DESIGN: A case-control design with the control group matched for age, race, sex, body dimensions (height, weight, and body mass index), presence of sensory neuropathy, foot deformity presence and location, and pedal ulcer area and depth. SETTING: An outpatient physical therapy clinic in a regional tertiary-care hospital and academic medical center. PARTICIPANTS: Nine patients with chronic diabetes mellitus and a previous organ transplantation who were currently receiving lifelong immunosuppressive drug therapy were treated for a neuropathic plantar ulcer by means of TCC. Fourteen group-matched control subjects with diabetes mellitus and a plantar ulcer but who had never had an organ transplantation and were not taking immunosuppressive agents were also studied. INTERVENTIONS: TCC with partial weight-bearing using an assistive device until ulcers healed. MAIN OUTCOME MEASURE: Healing time was defined as the number of days in the total-contact cast until the skin completely closed. RESULTS: All diabetic foot ulcers healed with casting. Immunosuppressed/transplanted patients healed in a mean time of 111 +/- 25 days; ulcers of control subjects healed in 47 +/- 18 days (p < .05). All patients returned to ambulation using prescribed therapeutic footwear. None of the patients required a lower extremity amputation throughout the follow-up period. CONCLUSIONS: TCC is a highly effective and rapid method of healing neuropathic pedal ulcers in diabetic immunosuppressed/transplantation patients, although it may take several weeks longer than it would for patients who were not immunocompromised.
Adult↗
Peak aerobic power is an important component of physical performance in older women.
BACKGROUND: The purpose of this study was to determine the relationship between peak aerobic power (VO2peak) and performance on a modified Physical Performance Test (modified PPT) in older women. METHODS: One hundred one women aged 75 years and older seeking enrollment in randomized, controlled trials of exercise and/or hormone replacement therapy were recruited from the community-at-large and from congregate living sites. Measures obtained included VO2peak, a modified PPT, and self-reports about performance of activities of daily living. RESULTS: Simple regression analysis demonstrated that VO2peak was associated with total PPT score (r =.53, p <.001), gait speed (r =.44, p <.001), time to arise from a chair five times (r =.43, p = <.001), and time to climb one flight of stairs (r =.36, p =.007). Multiple regression analysis revealed that the relationships between VO2peak and total modified PPT score, gait speed, chair rise time, and time to climb one flight of stairs were independent of age. CONCLUSIONS: Peak aerobic power is a significant independent predictor of performance on a standardized test of physical function in older women and is an important component of physical frailty in this population.
Activities of Daily Living↗
Resistance exercise training increases mixed muscle protein synthesis rate in frail women and men >/=76 yr old.
Muscle atrophy (sarcopenia) in the elderly is associated with a reduced rate of muscle protein synthesis. The purpose of this study was to determine if weight-lifting exercise increases the rate of muscle protein synthesis in physically frail 76- to 92-yr-old women and men. Eight women and 4 men with mild to moderate physical frailty were enrolled in a 3-mo physical therapy program that was followed by 3 mo of supervised weight-lifting exercise. Supervised weight-lifting exercise was performed 3 days/wk at 65-100% of initial 1-repetition maximum on five upper and three lower body exercises. Compared with before resistance training, the in vivo incorporation rate of [(13)C]leucine into vastus lateralis muscle protein was increased after resistance training in women and men (P < 0.01), although it was unchanged in five 82 +/- 2-yr-old control subjects studied two times in 3 mo. Maximum voluntary knee extensor muscle torque production increased in the supervised resistance exercise group. These findings suggest that muscle contractile protein synthetic pathways in physically frail 76- to 92-yr-old women and men respond and adapt to the increased contractile activity associated with progressive resistance exercise training.
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Recognition and management of acute neuropathic (Charcot) arthropathies of the foot and ankle.
STUDY DESIGN: Review of selected literature describing the outcomes related to the management of acute Charcot foot arthropathies in patients with diabetes mellitus. OBJECTIVE: To familiarize the rehabilitation specialist with the general principles of nonsurgical management for patients with acute neuropathic arthropathies of the foot and ankle. BACKGROUND: Neuropathic (Charcot) arthropathy of the foot or ankle is the most destructive and disabling chronic complication of all diabetic foot disease. METHODS AND MEASURES: We discuss the clinical presentation and the role that orthopaedic and sports physical therapists may have in identifying and preventing complications and the long-term disability associated with these arthropathies. We summarize the outcomes of 15 published reports from 1985-1999 located using the MEDLINE database from 1966-present. Studies were selected and included if the authors reported on (1) 2 or more patients with diabetes mellitus and acute Charcot arthropathies; (2) the short-term or long-term outcomes, including the length of follow-up; and (3) the pattern or location of the arthropathy. The short-term outcomes (percentage of patients healed, average time to healing) and long-term outcomes (percentage in whom treatment failed, amputation, disability) after treatment by immobilization alone or immobilization after surgery were reviewed and summarized. RESULTS: The prognosis for an individual with severe neuropathic skeletal foot deformities is poor. Eleven deaths (3.65%) in 301 patients were reported within the average follow-up period of 2.5 years after treatment for Charcot arthropathy. Partial or complete foot amputation occurred in 20 (6.6%) of 301, whereas 83 (28%) of 301 patients reviewed had mobility limitations or required ankle-foot orthoses or permanent bracing or assistive devices for ambulation at the time of follow-up. CONCLUSION: Rehabilitation specialists can improve the short-term outcomes and limit the long-term disabilities in patients with diabetes mellitus and peripheral neuropathy. Early recognition and prompt immobilization are the basic principles of nonsurgical management that influence therapeutic outcome.
Amputation, Surgical↗
Unilateral hip rotation range of motion asymmetry in patients with sacroiliac joint regional pain.
STUDY DESIGN: A cross-sectional study was used to determine whether limited range of motion in the hip was present in 100 patients--one group with unspecified low back pain and another group with signs suggesting sacroiliac joint dysfunction. OBJECTIVES: To determine whether a characteristic pattern of range of motion in the hip is related to low back pain in patients and to determine whether such a pattern is associated with and without signs of sacroiliac joint dysfunction. SUMMARY OF BACKGROUND DATA: The sacroiliac joint is often considered a potential site of low back pain. Problems with the sacroiliac joint, as well as with the low back, have often been related to reduced or asymmetric range of motion in the hip. The correlation between sacroiliac joint dysfunction and hip range of motion, however, has not been thoroughly evaluated with reliable tests in a population of patients with low back pain. METHODS: Passive hip internal and external rotation goniometric measurements were taken by a blinded examiner, while a separate examiner evaluated the patient for signs of sacroiliac joint dysfunction. Patients with sacroiliac joint dysfunction were further classified as having a left or a right posteriorly tilted innominate. RESULTS: The patients with low back pain but without evidence of sacroiliac joint dysfunction had significantly greater external hip rotation than internal rotation bilaterally, whereas those with evidence of sacroiliac joint dysfunction had significantly more external hip rotation than internal rotation unilaterally, specifically on the side of the posterior innominate. CONCLUSIONS: Clinicians should consider evaluating for unilateral asymmetry in range of motion in the hip in patients with low back pain. The presence of such asymmetry in patients with low back pain may help identify those with sacroiliac joint dysfunction.
Adolescent↗
Healing times of diabetic ulcers in the presence of fixed deformities of the foot using total contact casting.
In a diabetic foot, ulcers can lead directly to the loss of a limb, and they may be life threatening if the patient is not provided effective intervention directed at healing. This study reports on the healing times of diabetic neuropathic plantar ulcers in the presence of fixed deformities of the foot using the ambulatory method of total contact casting (TCC). In this study, 21 subjects with chronic diabetes mellitus, plantar ulcers, and fixed deformities of the foot were put in casts, and their progress was followed until the ulcers were completely healed. Results indicated that all of the ulcers healed. The average time to healing was 67 +/- 29 days. Ulcers located in the forefoot, midfoot, and rearfoot healed in an average of 35 +/- 12 days, 73 +/- 28 days, and 90 +/- 12 days, respectively. The location of the ulcer and the presence and location of a fixed deformity of the foot strongly correlated with and was predictive of healing time using TCC. The location of the ulcers and the location of the fixed deformities of the foot should always be considered by providers of rehabilitation who treat diabetic neuropathic foot ulcers using TCC.
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Total contact casting for diabetic neuropathic ulcers.
Despite its limited therapeutic use, several research reports indicate that TCC is currently the most rapid and effective technique for healing diabetic neuropathic ulcers. Skilled application and careful follow-up of the wound are necessary to avoid complications and minimize the risks for reulceration. As more clinicians adopt this form of therapy, the successful treatment of neuropathic ulcers using TCC should result in a lower incidence of infection, hospitalization and lost income in patients with chronic sensory neuropathies.
Casts, Surgical↗
Incidence of skin breakdown and higher amputation after transmetatarsal amputation: implications for rehabilitation.
The purpose of this study of patients with transmetatarsal amputation (TMA) is to describe multiple patient characteristics, including the incidence of subsequent skin breakdown and higher amputation, that may influence rehabilitation treatment and outcomes. Data were gathered on all patients having a TMA at this facility between April 1989 and September 1993. One hundred twenty TMAs were performed on 107 patients with a mean age of 62.4 +/- 13.8 years. There were 55 men and 52 women. Thirteen patients (12%) had a bilateral TMA. Twenty-nine patients (27%) developed skin breakdown. Of these, 48% occurred within the first 3 months after surgery. Thirty patients (28%) required a higher amputation. Of these, 60% occurred in the first month after TMA. In addition, this group of patients had a high incidence of diabetes mellitus (77%), hypertension (54%), electrocardiogram (EKG) abnormalities (60%), congestive heart failure (22%), and prior ipsilateral vascular surgery (51%). These results indicate that patients with TMA often present with a complicated medical condition and that they are at high risk of skin breakdown or higher amputation, especially in the first 3 months after surgery. The investigators conclude that patients with TMA may benefit from a rehabilitation program emphasizing protection of the residuum during their return to functional activities. Additional research is needed to determine optimal acute and long-term rehabilitation of patients with TMA.
Amputation, Surgical↗
High-voltage galvanic stimulation on wound healing in guinea pigs: longer-term effects.
The purpose of this investigation was to determine the effects of high-voltage stimulation (HVS) on wound tensile strength properties and wound closure (histology). Eighteen mature guinea pigs with full-thickness incisions were treated with HVS for 45 minutes daily for 2 weeks; 9 animals were studied after the 14 days of treatment and the remaining 9 were studied 2 weeks later. Five animals (10 wounds) served as controls at each time period. After 2 or 4 weeks, treated and untreated skin was harvested, tested to failure, and prepared for histological examination. Two-week-treated and control wounds had comparable values for peak force to failure, elongation, and energy absorbed to failure. Epithelialization was more advanced in treated animals at 14 days (p < .05). There was a trend (p = .068) toward stronger wounds in 4-week-treated animals (maximum load to failure), but not differences were observed between controls and treated groups for elongation or energy absorbed to failure. Dermal healing appeared to be more advanced in treated animals at 30 days. Although peak force to failure was almost 500g higher for treated guinea pigs after 2 weeks of treatment and more than 700g higher than controls after 4 weeks, mean data were highly variable, so the hypothesis that HVS augments wound strength could not be accepted. It is difficult, however, not to assign clinical significance to the findings.
Animals↗
The relationship of strength to function in the older adult.
Reduced lower extremity strength has been associated with reduction in gait speed, balance, stair-climbing ability, and getting up from a seated position. The relationship of lower extremity strength and the ability to accomplish selected functional activities was examined in 16 healthy but frail older adults ranging in age from 75 to 88 years (mean = 80.9 years). The following measures were obtained for each subject: preferred gait speed under laboratory and free walking conditions, 5 timed chair stand-ups, and time to complete an obstacle course. Strength measures of the hip extensors, hip abductors, knee extensors, planter flexors, and dorsiflexor muscle groups were obtained using a hand-held dynamometer. The relationship between the time to complete the functional activities and each of the strength variables was determined using Pearson product moment correlations. In addition, performance was examined in relation to various combinations of strength measures (e.g., hip and knee extension). Weak, nonsignificant hip, knee and ankle strength/functional activity relationships were found for all of the variables examined. When hip extension, knee extension, and ankle plantar flexion strength values were combined and normalized to body weight, a significant strength-to-functional activity relationship was found for 14" chair stand-ups (r = .636, p < .01). When values for quadriceps strength and gait speed for 35 adults ranging in age from 60-72 years were compared to those for 75-88 year olds, marked differences emerged. A more significant relationship between knee extension force and gait speed was observed for the younger adults (r = .528 vs r = .353).(ABSTRACT TRUNCATED AT 250 WORDS)
Activities of Daily Living↗
Hip and ankle walking strategies: effect on peak plantar pressures and implications for neuropathic ulceration.
Treatment of neuropathic plantar ulcers often is directed at reducing excessive, repeated peak plantar pressures (PPP). The purposes of this study were to determine whether instructing a subject to walk using a hip strategy would reduce forefoot PPP and change the kinematics of walking during a single session of testing. Thirteen subjects, 7 with peripheral neuropathy and a history of a recent plantar ulcer, and 6 controls participated. PPPs were measured with an in-shoe pressure monitoring system. Kinematics were measured with a computer-assisted motion analysis system. After data were collected as subjects walked using their normal walking pattern, subjects were instructed to walk using the hip strategy by decreasing their push-off, pulling their leg forward from their hips, decreasing step length, and maintaining their normal walking velocity. Compared with using the normal (ankle) strategy, using the hip strategy showed a significant 27% decrease in forefoot PPP and a 24% increase in heel PPP. Kinematic changes were decreased plantar flexion angular velocity, hip extension range-of motion (ROM), and step length, increased dorsiflexion ROM, and hip flexion ROM, but no change in walking velocity. These findings indicate that a change in walking pattern can result in lower forefoot PPP during a single session. Assuming patients can maintain the alterations in their walking pattern, these adaptations may help to heal plantar ulcers in some patients with peripheral neuropathy.
Adult↗
Quadriceps femoris muscle resistance to fatigue using an electrically elicited fatigue test following intense endurance exercise training.
BACKGROUND AND PURPOSE: Electrical stimulation has been used to assess skeletal muscle resistance to fatigue. The purpose of this study was to test the hypothesis that 12 weeks of intense endurance exercise training on a bicycle ergometer would reduce the percentage of decline in quadriceps femoris muscle torque during an electrically elicited fatigue test. SUBJECTS AND METHODS: Eleven nondisabled subjects performed 12 weeks of high-intensity endurance exercise training, and 6 subjects served as controls and did not exercise. Two electrically elicited fatigue tests, one with and one without prior voluntary fatiguing exercise, were administered to each subject before and after the 12-week training period. RESULTS: The percentage of decline in peak torque of the quadriceps femoris muscle over 50 electrically elicited muscle contractions did not change as a result of endurance exercise training, despite significant improvements in maximal oxygen consumption and quadriceps femoris muscle endurance. The recovery of maximal isometric torque immediately after exhausting voluntary exercise followed by electrical stimulation was significantly greater after 12 weeks of intense exercise training. CONCLUSION AND DISCUSSION: The percentage of decline in peak torque during an electrically elicited fatigue test does not detect improvements in quadriceps femoris muscle endurance induced by endurance exercise training. The percentage of initial torque recovered immediately after fatiguing exercise, however, is improved by endurance training. [Sinacore Dr, Jacobson RB, Delitto A. Quadriceps femoris muscle resistance to fatigue using an electrically elicited fatigue test following intense endurance exercise training.
Adult↗
Rehabilitation factors following transmetatarsal amputation.
Despite the occurrence of approximately 10,000 transmetatarsal amputations (TMAs) a year in the United States, there are few reports describing rehabilitation for this patient group. The purposes of this clinical perspective are (1) to identify common problems encountered during rehabilitation of patients with TMA, (2) to identify factors that may contribute to these problems, and (3) to propose methods to manage these problems. A review of the literature and biomechanical models of the residuum, footwear, and orthotic devices are provided to help accomplish these purposes. Common problems encountered during rehabilitation of patients with TMA are skin breakdown and instability during functional activities. Decreased foot length and peripheral neuropathies appear to contribute to these problems. Solutions focus on attempting to provide a substitute for the plantar-flexor lever arm and protection of the insensitive residual foot. Suggestions for additional research are presented.
Accidental Falls↗