Gladys L.Y. Cheing

Microvascular dysfunction in diabetic foot disease and ulceration

Diabetic foot disease and ulceration is a major complication that may lead to the amputation of the lower limbs. Microangiopathy may play a significant role in the pathogenesis of tissue breakdown in the diabetic foot. However, the precise mechanisms of this process remain unclear and poorly understood. Microvasculature in the skin is comprised of nutritive capillaries and thermoregulatory arteriovenous shunt flow. It is regulated through the complex interaction of neurogenic and neurovascular control. The interplay among endothelial dysfunction, impaired nerve axon reflex activities, and microvascular regulation in the diabetic patient results in the poor healing of wounds. Skin microvasculature undergoes both morphologic changes as well as functional deficits when parts of the body come under stress or injury. Two important theories that have been put forward to explain the abnormalities that have been observed are the haemodynamic hypothesis and capillary steal syndrome. With advances in medical technology, microvasculature can now be measured quantitatively. This article reviews the development of microvascular dysfunction in the diabetic foot and discusses how it may relate to the pathogenesis of diabetic foot problems and ulceration. Common methods for measuring skin microcirculation are also discussed. Copyright

Motivational Enhancement Therapy in Addition to Physical Therapy Improves Motivational Factors and Treatment Outcomes in People With Low Back Pain: A Randomized Controlled Trial

OBJECTIVES To examine whether the addition of motivational enhancement treatment (MET) to conventional physical therapy (PT) produces better outcomes than PT alone in people with chronic low back pain (LBP). DESIGN A double-blinded, prospective, randomized, controlled trial. SETTING PT outpatient department. PARTICIPANTS Participants (N=76) with chronic LBP were randomly assigned to receive 10 sessions of either MET plus PT or PT alone. INTERVENTION MET included motivational interviewing strategies and motivation-enhancing factors. The PT program consisted of interferential therapy and back exercises. MAIN OUTCOME MEASURES Motivational-enhancing factors, pain intensity, physical functions, and exercise compliance. RESULTS The MET-plus-PT group produced significantly greater improvements than the PT group in 3 motivation-enhancing factors; proxy efficacy (P<.001), working alliance (P<.001), and treatment expectancy (P=.011). Furthermore, they performed significantly better in lifting capacity (P=.015), 36-Item Short Form Health Survey General Health subscale (P=.015), and exercise compliance (P=.002) than the PT group. A trend of a greater decrease in visual analog scale and Roland-Morris Disability Questionnaire scores also was found in the MET-plus-PT group than the PT group. CONCLUSION The addition of MET to PT treatment can effectively enhance motivation and exercise compliance and show better improvement in physical function in patients with chronic LBP compared with PT alone.

Optimal stimulation duration of tens in the management of osteoarthritic knee pain.

OBJECTIVE This study examined the optimal stimulation duration of transcutaneous electrical nerve stimulation (TENS) for relieving osteoarthritic knee pain and the duration (as measured by half-life) of post-stimulation analgesia. SUBJECTS Thirty-eight patients received either: (i) 20 minutes (TENS20); (ii) 40 minutes (TENS40); (iii) 60 minutes (TENS60) of TENS; or (iv) 60 minutes of placebo TENS (TENS(PL)) 5 days a week for 2 weeks. METHODS A visual analogue scale recorded the magnitude and pain relief period for up to 10 hours after stimulation. RESULTS By Day10, a significantly greater cumulative reduction in the visual analogue scale scores was found in the TENS40 (83.40%) and TENS60 (68.37%) groups than in the TENS20 (54.59%) and TENS(PL) (6.14%) groups (p < 0.000), such a group difference was maintained in the 2-week follow-up session (p < 0.000). In terms of the duration of post-stimulation analgesia period, the duration for the TENS40 (256 minutes) and TENS60 (258 minutes) groups was more prolonged than in the other 2 groups (TENS20 = 168 minutes, TENS(PL) = 35 minutes) by Day10 (p < 0.000). However, the TENS40 group produced the longest pain relief period by the follow-up session. CONCLUSION 40 minutes is the optimal treatment duration of TENS, in terms of both the magnitude (VAS scores) of pain reduction and the duration of post-stimulation analgesia for knee osetoarthritis.

A randomized clinical trial of TENS and exercise for patients with chronic neck pain

Objective: To investigate the effect of transcutaneous electrical nerve stimulation (TENS) on acupuncture points and neck exercise in chronic neck pain patients. Design: A randomized clinical trial. Setting: Hospital-based practice. Subjects: Two hundred and eighteen patients with chronic neck pain. Interventions: Subjects were randomized into three groups, receiving either (1) TENS over the acupuncture points plus infrared irradiation (TENS group); (2) exercise training plus infrared irradiation (exercise group); or (3) infrared irradiation alone (control); twice a week for six weeks. Outcome measures: The values of verbal numeric pain scale, Northwick Park Neck Pain Questionnaire, and isometric neck muscle strength were assessed before, at the end of the six-week treatment, and at the six-month follow-up. Results: Results demonstrated that after the six-week treatment, significant improvement in the verbal numerical pain scale was found only in the TENS group (0.60±2.54, p=0.027) and the exercise group (1.57±2.67, p<0.001). Though significant reduction in Northwick Park Neck Pain Questionnaire score was found in all three groups, post-hoc tests showed that both the TENS and the exercise group produced better improvement (0.38±0.60% and 0.39±0.62% respectively) than the control group (0.23±0.63%). Significant improvement (p = <0.001 to 0.03) in neck muscle strength was observed in all three groups, however, the improvement in the control group was not clinically significant and it could not be maintained at the six-month follow-up. Conclusions: After the six-week treatment, patients in the TENS and exercise group had a better and clinically relevant improvement in disability, isometric neck muscle strength, and pain. All the improvements in the intervention groups were maintained at the six-month follow-up.

OPTIMAL STIMULATION FREQUENCY OF TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION ON PEOPLE WITH KNEE OSTEOARTHRITIS

OBJECTIVE This is a double blind study that examined the optimal stimulation frequency of transcutaneous electrical nerve stimulation in reducing pain due to knee osteoarthritis. SUBJECTS Thirty-four subjects were randomly allocated into 4 groups receiving transcutaneous electrical nerve stimulation at either: (i) 2 Hz; (ii) 100 Hz; (iii) an alternating frequency of 2 Hz and 100 Hz (2/100 Hz); or (iv) a placebo transcutaneous electrical nerve stimulation. METHODS Treatment was administered 5 days a week for 2 weeks. The outcome measures included: (i) a visual analogue scale; (ii) a timed up-and-go test; and (iii) a range of knee motion. RESULTS The 3 active transcutaneous electrical nerve stimulation groups (2 Hz, 100 Hz, 2/100 Hz), but not the placebo group, significantly reduced osteoarthritic knee pain across treatment sessions. However, no significant between-group difference was found. Similarly, the 3 active transcutaneous electrical nerve stimulation groups, but not the placebo group, produced significant reductions in the amount of time required to perform the timed up-and-go test, and an increase in the maximum passive knee range of motion. CONCLUSION Our findings suggested that 2 weeks of repeated applications of transcutaneous electrical nerve stimulation at 2 Hz, 100 Hz or 2/100 Hz produced similar treatment effects for people suffering from osteoarthritic knee.

Does four weeks of TENS and/or isometric exercise produce cumulative reduction of osteoarthritic knee pain?

Objective: To evaluate the cumulative effect of repeated transcutaneous electrical nerve stimulation (TENS) on chronic osteoarthritic (OA) knee pain over a four-week treatment period, comparing it to that of placebo stimulation and exercise training given alone or in combination with TENS. Design: Sixty-two patients, aged 50–75, were stratified according to age, gender and body mass ratio before being randomly assigned to four groups. Interventions: Patients received either (1) 60 minutes of TENS, (2) 60 minutes of placebo stimulation, (3) isometric exercise training, or (4) TENS and exercise (TENS & Ex) five days a week for four weeks. Main outcome measures: Visual analogue scale (VAS) was used to measure knee pain intensity before and after each treatment session over a four-week period, and at the four-week follow-up session. Results: Repeated measures ANOVA showed a significant cumulative reduction in the VAS scores across the four treatment sessions (session 1, 10, 20 and the follow-up) in the TENS group (45.9% by session 20, p < 0.001) and the placebo group (43.3% by session 20, p = 0.034). However, linear regression of the daily recordings of the VAS indicated that the slope in the TENS group (slope = -2.415, r = 0.943) was similar to the exercise group (slope = -2.625, r = 0.935), which were steeper than the other two groups. Note that the reduction of OA knee pain was maintained in the TENS group and the TENS & Ex group at the four-week follow-up session, but not in the other two groups. Conclusions: The four treatment protocols did not show significant between-group difference over the study period. It was interesting to note that isometric exercise training of the quadriceps alone also reduced knee pain towards the end of the treatment period.

Predicting employment outcomes of rehabilitation clients with orthopedic disabilities: A CHAID analysis

Purpose. To examine demographic and service factors affecting employment outcomes of people with orthopedic disabilities in public vocational rehabilitation programs in the United States. Method. The sample included 74,861 persons (55% men and 45% women) with disabilities involving the limbs or spinal column who were closed either as rehabilitated or not rehabilitated by their state-run vocational rehabilitation agencies in the fiscal year 2001. Mean age of participants was 41.4 years (SD = 11.2). The dependent variable is employment outcomes. The predictor variables include a set of personal history variables and rehabilitation service variables. Results. The chi-squared automatic interaction detector (CHAID) analysis indicated that job placement services significantly enhanced competitive employment outcomes but were significantly underutilized (only 25% of the clients received this service). Physical restoration and assistive technology services along with support services such as counseling also contributed to positive employment outcomes. Importantly, clients who received general assistance, supplementary security income, and/or social security disability insurance benefits had a significant lower competitive employment rates (45%) than clients without such work disincentives (60%). Conclusion. The data mining approach (i.e., CHAID analysis) provided detailed information and insight about interactions among demographic variables, service patterns, and competitive employment rates through the segmentation of the sample into mutually exclusive homogeneous subgroups.

Effects of deep and superficial heating in the management of frozen shoulder

OBJECTIVES To determine whether the addition of deep or superficial heating to stretching produces better clinical outcomes than stretching alone in the management of frozen shoulder. DESIGN A single-blinded, randomized controlled study. SUBJECTS Thirty subjects suffering from the stiffness phase of frozen shoulder. METHODS Subjects were randomly allocated to receive: (i) deep heating plus stretching; (ii) superficial heating plus stretching; or (iii) stretching alone. Both heating groups received the respective treatments 3 times per week for 4 weeks. All groups received a standard set of shoulder stretching exercises. The American Shoulder and Elbow Surgeons assessment form was recorded at the baseline, sessions 6 and 12, and at the 4-week follow-up session. RESULTS A significant improvement was seen in all groups in all outcome measures except for that of shoulder flexion range. The improvement in the shoulder score index and in the range of motion was significantly better in the deep heating group than in the superficial heating group. CONCLUSION The addition of deep heating to stretching exercises produced a greater improvement in pain relief, and resulted in better performance in the activities of daily living and in range of motion than did superficial heating.

The effect of aging on the biomechanical properties of plantar soft tissues

BACKGROUND Foot problems are common in elderly people and stiffened plantar soft tissues may lead to ulceration in people with Diabetes Mellitus. It is unclear how the biomechanical properties of plantar soft tissues change with advancing age. Therefore, this study examined the age-related differences in the biomechanical properties of plantar soft tissues. METHODS Sixty healthy volunteers without foot problems, aged from 41 to 83 years, were examined using tissue ultrasound palpation system. The thickness and stiffness of the plantar soft tissues under the big toe, first metatarsal head, third metatarsal head, fifth metatarsal head, and heel were measured. The load-deformation curve of the plantar soft tissues was plotted. The correlation between age and biomechanical properties was examined and comparisons were made between four age groups. FINDINGS The mean stiffness of the plantar soft tissues at big toe, first metatarsal head, third metatarsal head, fifth metatarsal head, and the heel significantly increased with age (P<0.001). The plantar soft tissues at the heel were the thickest (P<0.001), with the plantar soft tissue tending to be increasingly thicker with age, although there was no statistical significance. Strong positive correlations between age and stiffness of the plantar soft tissues were found at the big toe (r=0.608), first metatarsal head (r=0.549), third metatarsal head (r=0.657), fifth metatarsal head (r=0.633), and heel (r=0.584) (all P<0.001). INTERPRETATION The loss of compliance in the plantar soft tissues may be one of the factors responsible for the higher incidence of foot problems in elderly individuals.

EFFECTIVENESS OF ELECTROACUPUNCTURE AND INTERFERENTIAL ELECTROTHERAPY IN THE MANAGEMENT OF FROZEN SHOULDER

OBJECTIVE To examine whether the addition of either electroacupuncture or interferential electrotherapy to shoulder exercises would be more effective in the management of frozen shoulder. DESIGN A double-blinded, randomized, controlled trial. METHODS A total of 70 subjects were randomly allocated to receive either: (i) electroacupuncture plus exercise; (ii) interferential electrotherapy plus exercise; or (iii) no treatment (the control group). Subjects in groups (i) and (ii) received 10 sessions of the respective treatment, while the control group received no treatment for 4 weeks. Each subjects score on the Constant Murley Assessment and visual analogue scale were recorded at baseline, post-treatment session and subsequent follow-up sessions. RESULTS In both the electroacupuncture and interferential electrotherapy groups, the Constant Murley Assessment score increased and the visual analogue scale score decreased significantly (both p < 0.001). No significant change was found in any outcome of the control group, and no significant difference was found between the 2 intervention groups (all p > 0.05). The observed improvement was well maintained in both intervention groups at least until the 6-month follow-up session. CONCLUSION Either electroacupuncture or interferential electrotherapy in combination with shoulder exercises is effective in treating frozen shoulder patients. However, no significant difference was found between these types of treatment.