David Cruz-Díaz

Osteosarcopenic obesity and fall prevention strategies

Sarcopenia, obesity, and osteoporosis are three interrelated entities which may share common pathophysiological factors. In the last decades, overall survival has drastically increased. Postmenopausal women, due to their estrogen depletion, are at higher risk of developing any of these three conditions or the three, which is termed osteosarcopenic obesity. One of the most common health problems among these patients is the elevated risk of falls and fractures. Falls and fall-related injuries are one of the major causes of mortality and morbidity in older adults, and have a significant impact on social, economical and health-related costs. Several extrinsic and intrinsic risk factors have been described that play a role in the etiology of falls. A therapeutic approach to osteosarcopenic obesity aimed at the prevention of falls must include several factors, and act on those risk elements which can be effectively modified. An adequate weight-loss diet and a good nutritional intake, with an appropriate amount of vitamin D and the right protein/carbohydrates ratio, may contribute to the prevention of falls. The recommendation of physical exercise, both traditional (resistance or aerobic training) and more recent varieties (Tai Chi, Pilates, body vibration), can improve balance and positively contribute to fall prevention, whether by itself or in combination with other therapeutic strategies. Finally, a pharmacological approach, especially one focused on hormone therapy, has shown to have a positive effect on postmenopausal womens balance, leading to a decreased risk of falls.

Effects of joint mobilization on chronic ankle instability: a randomized controlled trial.

Abstract Purpose: To evaluate the effects of joint mobilization, in which movement is applied to the ankles dorsiflexion range of motion, on dynamic postural control and on the self-reported instability of patients with chronic ankle instability (CAI). Methods: A double-blind, placebo-controlled, randomized trial with repeated measures and a follow-up period. Ninety patients with a history of recurrent ankle sprain, self-reported instability, and a limited dorsiflexion range of motion, were randomly assigned to either the intervention group (Joint Mobilizations, 3 weeks, two sessions per week) the placebo group (Sham Mobilizations, same duration as joint mobilization) or the control group, with a 6 months follow-up. Dorsiflexion Range of Motion (DFROM), Star Excursion Balance Test (SEBT) and CAI Tool (CAIT) were outcome measures. A separate 3 × 4 mixed model analysis of variance was performed to examine the effect of treatment conditions and time, and intention-to-treat (ITT) analysis was applied to evaluate the effect of the independent variable. Results: The application of joint mobilization resulted in better scores of DFROM, CAIT, and SEBTs in the intervention group when compared with the placebo or the control groups (p < 0.001). The effect sizes of group-by-time interaction, measured with eta-squared, oscillated between 0.954 for DFROM and 0.288 for SEBT posteromedial distance. In within-group analysis, the manipulation group showed an improvement at 6 months follow-up in CAIT [mean = 5.23, CI 95% (4.63–5.84)], DFROM [mean = 6.77, CI 95% (6.45–7.08)], anterior SEBT [mean = 7.35, CI 95% (6.59–8.12)], posteromedial SEBT [mean = 3.32, CI 95% (0.95–5.69)], and posterolateral SEBT [mean = 2.55, CI 95% (2.20–2.89)]. Conclusion: Joint mobilization techniques applied to subjects suffering from CAI were able to improve ankle DFROM, postural control, and self-reported instability. These results suggest that joint mobilization could be applied to patients with recurrent ankle sprain to help restore their functional stability. Implications for Rehabilitation Functional instability is a very common sequela in patients with CAI, resulting in reduced quality of living due to the limitations it imposes on daily life activities. The mobilization with movement technique presented by Mulligan, and based on the joint mobilization accompanied by active movement, appears as a valuable tool to be employed by physical therapists to restore ankle function after a recurrent ankle sprain history. ROM restriction, subjective feeling of instability and dynamic postural control are benefiting from the joint mobilization application.

Effects of a six-week Pilates intervention on balance and fear of falling in women aged over 65 with chronic low-back pain: A randomized controlled trial

OBJECTIVE The purpose of our study was to evaluate the effects of six weeks of Pilates regarding functional balance, fear of falling and pain in community living women older than 65 years old with chronic low-back pain. STUDY DESIGN A single blind controlled randomized trial of six weeks of Pilates in addition to physiotherapy treatment (n=50) vs. physiotherapy treatment alone (n=47) was conducted on 97 community living women (71.14 ± 3.30 years) with chronic low-back pain (CLBP). MAIN OUTCOME MEASURES Main outcome measures were fear of falling (FoF), assessed by the Falls Efficacy Scale-international; functional mobility and balance, measured with the Timed up and Go Test; and pain, evaluated using the numeric rating scale. RESULTS Only the Pilates group showed improvement in FoF (ES; d=.68) and functional mobility and balance (ES; d=1.12) after treatment, and also had better results in pain (ES; d=1.46) than the physiotherapy-only group. CONCLUSIONS Six weeks of Pilates exercises may be effective in fall prevention through the improvement of FoF, functional balance, and pain in Spanish women over 65 years old with CLBP.

The Spanish lower extremity functional scale: a reliable, valid and responsive questionnaire to assess musculoskeletal disorders in the lower extremity.

Abstract Purpose: The Lower Extremity Functional Scale (LEFS) is a widely used questionnaire to evaluate the functional impairment of a patient with a disorder of one or both lower extremities. It also can be used to monitor the patient over time and to evaluate the effectiveness of an intervention. Nevertheless there is no Spanish version of the LEFS, so the aim of this study was the translation and cross-cultural adaption of the Spanish version of the LEFS and to evaluate its psychometrics properties. Methods: The questionnaire was cross cultural adapted into Spanish. The psychometric properties tested in the Spanish version of the LEFS were: internal consistency, test–retest reliability, constructs validity, discriminative validity, responsiveness, concurrent validity and floor and ceiling effects in 132 participants seeking for treatment due to lower extremity dysfunction. Results: The Spanish version of the LEFS had high internal consistency (Cronbach’s α = 0.989), test–retest reliability (ICC = 0.998, 95% CI: 0.996–0.999) and presented a high correlation with the SF-36 (36-Item Short-Form Health Survey) especially with the physical function and pain subscales. The construct validity showed a single factor that account for 84.95% of the variance. The standard error of measurement of the Spanish version of the LEFS was 0.88 scale points (95% CI) and the minimal detectable change was 2.18 scale points (95% CI). The sample, collected from five Spanish physical therapy centers, was divided in groups (acute, sub-acute and chronic subjects). Within group changes showed a significant improvement on the LEFS score (p < 0.001) and effect sizes were large in all conditions. The LEFS allowed to distingue between acute and not acute conditions; for this criterion ROC curve was performed at baseline (area under the curve [AUC] = 0.95). There was no floor or ceiling effects. Conclusions: The Spanish version of the LEFS has been shown to be a valid and reliable tool to assess musculoskeletal dysfunction in the lower extremity that could be used with Spanish speaker population. Implications for Rehabilitation Cross-cultural adaptation of a self-reported questionnaire to evaluate musculoskeletal lower extremity disorders in the Spanish population. To provide Spanish clinicians and physiotherapists a useful tool to assess the lower extremity function. To provide Spanish researchers a valid tool for research on lower extremity function: patient’s improvement due to treatment, compare results obtained between populations, treatment.

Short- and long-term effects of a six-week clinical Pilates program in addition to physical therapy on postmenopausal women with chronic low back pain: a randomized controlled trial

Abstract Purpose: To determine the short- and long-term effectiveness of the application of Clinical Pilates in addition to physical therapy versus a physical therapy treatment alone in a population of postmenopausal women with chronic low back pain (CLBP). Methods: A single-blind randomized controlled trial with repeated measures and a follow-up period. One hundred and one patients were randomly allocated to a Pilates + physical therapy (PPT) group or to a physical therapy (PT) only group for six weeks. Pain and disability were measured by visual analog scale (VAS) and the Oswestry disability index respectively preintervention, after 6 weeks of treatment and after 1-year follow-up. Results: There were significant differences between groups in pain and disability after 6 weeks of treatment, with better results in the PPT group with an effect size of d = 3.14 and d = 2.33 for pain and disability. After 1-year follow-up, only PPT group showed better results compared with baseline with an effect size of d = 2.49 and d = 4.98 for pain and disability. Conclusion: The results suggest that using Clinical Pilates in addition to physical therapy provides improved results on pain management and functional status for postmenopausal woman with CLBP and that its benefits still linger after one year. Implications for Rehabilitation Chronic Low Back Pain could benefit from the Pilates practice in postmenopausal women. Improvement in pain and disability derived from CLBP seem to be maintained over time due to Pilates practice. Pilates constitutes a safe tool to be applied in older population with CLBP due to its ability to be adapted to every performance and physical level.

The Activities-specific Balance Confidence scale: reliability and validity in Spanish patients with vestibular disorders

Abstract Purpose: To examine the reliability and validity of the Spanish version of the Activities-specific Balance Confidence scale (ABC-S), and its ability to discriminate between patients with and without a history of falls among a Spanish population with vestibular disorders. Method: A total of 84 participants completed the ABC-S. Internal consistency, test–retest reliability and construct validity (exploratory factor analysis) were analysed. Concurrent validity was evaluated using the 12-item Short Form Health Survey (SF-12) and the Dizziness Handicap Inventory (DHI). To determine the accuracy of the ABC total score in discriminating patients with and without a history of falls, a receiver operating characteristic (ROC) curve analysis was performed. Results: The ABC-S showed excellent internal consistency (Cronbach’s α = 0.916) and substantial test–retest reliability (ICC = 0.86, 95% CI: 0.74–0.93), with standard error and minimal detectable change values of 8.64 and 16.94, respectively. Factor analyses suggested a three-factor structure (explained variance was 62.24%). The ABC total score significantly correlated with the physical component summary score of the SF-12 and with the DHI-P, DHI-E, DHI-F and DHI total scores (p < 0.001). The ABC-S was significantly able to discriminate between participants with and without a history of falls (p < 0.006). Conclusions: The ABC-S is a valid and reliable instrument, suitable to assess balance confidence in Spanish patients with vestibular disorders. Implications for Rehabilitation The Spanish version of the ABC scale is a valid and reliable measure of balance confidence in patients with vestibular disorders. In persons with vestibular disorders, the Spanish version of the ABC scale has shown the ability to discriminate between patients with and without a history of falls in the last year.

Association of bone mineral density with postural stability and the fear of falling in Spanish postmenopausal women

OBJECTIVE The purpose of our study was to investigate the relationship between bone mineral density (BMD) and postural stability and the fear of falling in a 50- to 65-year-old postmenopausal population. STUDY DESIGN A cross-sectional, observational study was conducted on 118 postmenopausal women. According to their BMD values, participants were divided into two groups: BMD>-2.0SD (n=95) and ≤-2.0SD (n=23). MAIN OUTCOME MEASURES Postural stability, assessed with a resistive multi-sensor platform, fear of falling (FoF) and the history of falls in the last 12 months were investigated. RESULTS Women with BMD≤-2.0SD reported a significantly increased FoF when compared to women with BMD>-2.0SD (P=0.024, η(2)=0.045, 1-β=0.624). In the postural stability analysis, the group with BMD≤-2.0SD showed, under the eyes-open condition, statistically significantly higher values for the velocity (VEO) (P=0.040, η(2)=0.037, 1-β=0.539) and the anteroposterior mean displacement of the center of pressure (YEO; P=0.017, η(2)=0.049, 1-β=0.669). No significant differences between groups were observed in the history of falls or in the rest of the stabilometric analyses. CONCLUSIONS In Spanish postmenopausal women under 65 years, a BMD≤-2.0SD is significantly associated with postural instability (elevated VEO and XEO) and an increased FoF, which are two highly influential factors in the risk of falling.

Sarcopenia and sarcopenic obesity in Spanish community-dwelling middle-aged and older women: Association with balance confidence, fear of falling and fall risk

OBJECTIVES To analyze the association of sarcopenia, obesity, and sarcopenic obesity (SO) with fear of falling (FoF) and balance confidence in a Spanish sample of middle-aged and older community-dwelling women. STUDY DESIGN AND OUTCOME MEASURES A total of 235 women (69.21±7.56 years) participated in this study. Body composition (bioelectrical impedance analysis), hand-grip strength, and physical performance (gait speed) were evaluated for the diagnosis of sarcopenia, obesity, and SO. Anxiety and depression were measured using the Hospital Anxiety and Depression Scale. The Activities-Specific Balance Confidence Scale (ABC) and the Falls Efficacy Scale-International (FES-I) were employed to assess FoF and balance confidence, respectively. Scores of >26 on the FES-I and <67% on the ABC were used to identify women at risk of falling. The independent associations of sarcopenia, obesity and SO with FoF, balance confidence, and fall risk were evaluated by multivariate linear and logistic regressions, adjusting for potential confounding variables. RESULTS 27.23% and 18.72% of women presented with sarcopenia and SO, respectively. Gait speed, body mass index (BMI), and fall history were independently associated with ABC score (adjusted-R2=0.152) and fall risk (ABC) (adjusted-R2=0.115). FES-I score was independently associated (adjusted-R2=0.193) with fall history, gait speed, BMI, and depression, which, together with obesity (BMI) and SO, remained independent factors for fall risk measured as FES-I score (adjusted-R2=0.243). CONCLUSION In community-dwelling middle-aged and older Spanish women, BMI, gait speed, and fall history were independently associated with FoF, balance confidence, and fall risk. Depression was related only to FoF, and, together with obesity (BMI) and SO, was an independent predictor of fall risk as assessed by the FES-I.

Development of the human shoulder joint during the embryonic and early fetal stages: anatomical considerations for clinical practice

Although several studies have been published regarding the morphology and anatomical variations of the human shoulder joint, most have dealt with adult individuals. Those looking into the development of the joint have been focused on specific structures or have observed specimens in advanced gestational stages. The goal of this paper is to perform a complete analysis of the embryonic and early fetal development of the elements in the shoulder joint, and to clarify some contradictory data in the literature. In our study, serial sections of 32 human embryos (Carnegie stages 16–23) and 26 fetuses (9–13 weeks) were analyzed. The chondrogenic anlagen of the humerus and the medial border of the scapula can be observed from as early as Carnegie stage 17, whereas that of the rest of the scapula appears at stage 18. The osteogenic process begins in week 10 for the humeral head and week 11 for the scapula. At stage 19 the interzone becomes apparent, which will form the glenohumeral joint. In the next stage the glenohumeral joint will begin delaminating and exhibiting a looser central band. Denser lateral bands will join the humeral head (caput humeri) and the margins of the articular surface of the scapula, thus forming the glenoid labrum, which can be fully appreciated by stage 22. In 24‐mm embryos (stage 21) we can observe, for the first time, the long head of the biceps tendon (which is already inserted in the glenoid labrum by week 9), and the intertubercular sulcus, whose depth is apparent since week 12. Regarding ligamentous structures, the coracohumeral ligament is observed at the end of Carnegie stage 23, whereas the primitive glenohumeral ligament already appeared in week 10. The results of this study provide a detailed description of the morphogenesis, origin and chronological order of appearance of the main intrinsic structures of the human shoulder joint during late embryonic and early fetal development. We expect these results to help explain several functional aspects of the shoulder joint, and to clarify some contradictory data in the literature regarding this complex anatomical and biomechanical structure, helping future researchers in their efforts.

Comparative effects of 12 weeks of equipment based and mat Pilates in patients with Chronic Low Back Pain on pain, function and transversus abdominis activation. A randomized controlled trial

BACKGROUND Pilates method has been recommended for patients with chronic low back pain (CLBP) and the activation of transversus abdominis has been deemed to play an important role in the improvement of these patients. Nevertheless, the evidence of the activation of TrA in Pilates practitioners remains unclear. OBJECTIVE To assess the effectiveness of 12 weeks of Pilates practice in disability, pain, kinesiophobia and transversus abdominis activation in patients with chronic nonspecific Low Back Pain. DESIGN A randomized controlled trial was carried out. METHODS A single-blind randomized controlled trial with repeated measures at 6 and 12 weeks was carried out. A total of ninety eight patients with low back pain were included and randomly allocated to a Pilates Mat group (PMG) equipment based with apparatus Pilates (PAG) or control group (CG). Roland Morris Disability Questionnaire (RMDQ), visual analog scale (VAS) Tampa Scale of Kinesiophobia (TSK), and transversus abdominis (TrA) activation assessed by real time ultrasound measurement (US) were assessed as outcome measures. RESULTS Improvement were observed in both intervention groups in all the included variables at 6 and 12 weeks (p<0.001). Faster enhancement was observed in the equipment based Pilates group (p=0.007). CONCLUSIONS Equipment based and mat Pilates modalities are both effective in the improvement of TaA activation in patients with CLBP with associate improvement on pain, function and kinesiophobia. Significant differences were observed after 12 weeks of intervention in PMG and PAG with faster improvement in PAG suggesting that, feedback provided by equipment could help in the interiorization of Pilates principles.