Sheila A. Dugan

Hemiplegic gait : Relationships between walking speed and other temporal parameters

It has been asserted that speed alone is an effective indicator of the degree of gait abnormality. To determine the validity of this assertion, relationships between velocity and 18 other temporal gait parameters were determined in 25 patients with a first hemispheric stroke resulting in hemiplegia or hemiparesis of at least one month duration. Gait characteristics were recorded using footswitchs connected to a portable computerized monitoring device. Velocity was found to be significantly correlated with cadence, mean cycle duration, mean cycle length, hemiplegic limb stance phase duration, nonhemiplegic limb stance phase duration and percent, nonhemiplegic limb swing phase percent, double support phase duration and percent, hemiplegic limb swing/stance phase ratio, nonhemiplegic limb swing/stance phase ratio, and swing phase symmetry ratio but not with the hemiplegic limb stance phase percent, hemiplegic limb swing phase duration and percent, nonhemiplegic limb swing phase duration, stance phase symmetry ratio, and overall asymmetry ratio. Velocity is related to most, but not all, of the other temporal measures of hemiplegic gait. A comprehensive gait evaluation should also include characterization of the degree of asymmetry and descriptions of individual phase durations and proportions (particularly hemiplegic stance and swing percentages).

Testosterone and Visceral Fat in Midlife Women: The Study of Women's Health Across the Nation (SWAN) Fat Patterning Study

Visceral fat (VF) increases with the menopause and is an independent predictor of the metabolic syndrome, diabetes, and cardiovascular disease (CVD) in women. Little is known about how hormonal changes during the menopausal transition are related to the increase in VF. We aimed to determine the relationship between bioavailable testosterone and VF in middle‐aged women at various stages of the menopausal transition and whether this relationship is independent of age and other CVD risk factors. The Study of Womens Health Across the Nation (SWAN) is a longitudinal, community‐based study. This report uses baseline data from a population‐based longitudinal ancillary study at the Chicago site to examine the cross‐sectional relationship between testosterone and computed tomography (CT)–assessed VF in women at different stages of the menopausal transition. Included are 359 women (47.2% black), aged 42–60 years, who were randomly selected from a complete community census in which a 72% participation rate was achieved. In multivariate models, bioavailable testosterone was associated with VF independent of age, race, percent total body fat, and other cardiovascular risk factors. Bioavailable testosterone was a stronger predictor than estradiol and was interchangeable in its strength of association with sex hormone–binding globulin (SHBG). As bioavailable testosterone was associated with VF even after adjusting for insulin resistance, this suggests that it plays an important role in regional fat distribution. Our findings may have direct implications in explaining the effect of menopause‐related testosterone predominance on VF accumulation and subsequent cardiovascular risk.

Incidence of postpartum lumbosacral spine and lower extremity nerve injuries.

OBJECTIVE Neurological injury associated with present day labor and delivery is thought to be unusual. The purpose of this study was to estimate the incidence, severity, and duration of postpartum lumbosacral spine and lower extremity nerve injury and identify factors related to nerve injury. METHODS All women who delivered a live born infant from July 1997 through June 1998 were asked about symptoms of lumbosacral spine and lower extremity nerve injury the day after delivery. Women with symptoms were examined by a physiatrist to confirm injury, and their cases were then followed by telephone until the symptoms resolved. Maternal variables (including prospective documentation of time spent pushing in various positions) and fetal variables that might be associated with risk of nerve injury were compared between women with injury and those without. RESULTS Six thousand fifty-seven women delivered live born infants; 6048 were interviewed and 56 had a confirmed new nerve injury, an incidence of 0.92%. Factors found by logistic regression analysis to be associated with nerve injury were nulliparity and prolonged second stage of labor. Women with nerve injury spent more time pushing in the semi-Fowler–lithotomy position than women without injury. The median duration of symptoms was 2 months. CONCLUSION The estimated incidence of postpartum nerve injury was greater than reported from previous studies and is associated with nulliparity and prolonged second stage of labor.

Musculoskeletal aspects of pregnancy

Sex-specific care of musculoskeletal impairments is an increasingly important topic in womens health. This is clinically relevant and of paramount importance as it pertains to diagnosis and treatment of musculoskeletal and peripheral neurologic disorders of pregnancy and the puerperium. It is estimated that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms. This review provides information on common pregnancy-related musculoskeletal conditions, including a discussion of anatomy and physiology, diagnosis, prognosis, and treatment of these disorders.

Musculoskeletal pain and menopausal status.

ObjectivesThe authors examined whether self-reported menopausal status is associated with musculoskeletal pain in a multiethnic population of community-dwelling middle-aged women after considering sociodemographics, medical factors, smoking, depression, and body mass index using a cross-sectional study design. MethodsParticipants were 2218 women from the Study of Womens Health Across the Nation assessed at the time of their third annual follow-up exam. Two dependent variables were derived from a factor analysis of survey questions about pain. These 2 outcomes were Aches and Pains, derived from 5 of 6 pain symptom questions and Consultation for Low Back Pain, derived from 1 question. ResultsPrevalence of aches and pains was high, with 1 in 6 women reporting daily symptoms. Compared with premenopausal women, those who were early perimenopausal (P=0.002), late perimenopausal (P=0.002), or postmenopausal (P<0.0001) reported significantly more aches and pains in age-adjusted analysis. With complete risk factor adjustment, postmenopausal women still reported significantly greater pain symptoms (P=0.03) than did premenopausal women. Menopausal status was marginally related to consulting a healthcare provider for back pain. DiscussionThis study demonstrates an association between pain and self-reported menopausal status, with postmenopausal women experiencing greater pain symptoms than premenopausal women.

Depressive Symptoms and Increased Visceral Fat in Middle-Aged Women

Objective: To examine whether depressive symptoms are differentially associated with visceral adipose tissue (VAT), which is more metabolically active and confers greater cardiovascular risk than subcutaneous fat (SAT). Prior research has shown an association between depression and central adiposity. Mechanisms underlying the association between depression and increased cardiovascular risk remain poorly understood. Central adiposity is one potential pathway. Methods: We investigated the cross-sectional association between depressive symptoms, assessed by the Center for Epidemiological Studies Depression Scale (CES-D), and VAT and SAT, assessed by computed tomography, in a sample of 409 middle-aged women (44.7% African-Americans, 55.3% Whites; mean age = 50.4 years) participating in the Chicago site of the Study of Womens Health Across the Nation (SWAN). Results: With adjustments for age, race, total percent fat, and sex hormone binding globulin (SHBG), each 1-point higher score on the CES-D was associated with 1.03-cm2 greater VAT (p < .001). Women with a CES-D score of ≥16, indicative of clinically relevant depressive symptomatology, had 24.5% more VAT than women with lower CES-D scores (p < .001). Further adjustment for Framingham Risk Score and physical activity did not alter the findings, and associations did not vary by race. Associations were strongest in obese and overweight women. Depressive symptoms were unrelated to SAT. Conclusions: Increased visceral fat may be one pathway by which depression contributes to excess risk for cardiovascular disease and diabetes. Further research is needed to examine whether depressive symptoms influence accumulation of VAT over time. BMI = body mass index; CES-D = Center for Epidemiological Studies Depression Scale; CT = computed tomography; CVD = cardiovascular disease; DXA = dual energy x-ray absorptiometry; FRS = Framingham Risk Score; Health ABC = Dynamics of Health, Aging and Body Composition; HDL-C = high-density lipoprotein cholesterol; HPA = hypothalamic-pituitary-adrenal; KPAS = Kaiser Physical Activity Survey; SAT = subcutaneous adipose tissue; SHBG = sex hormone binding globulin; SWAN = Study of Womens Health Across the Nation; VAT = visceral adipose tissue.

Review of Anatomy, Evaluation, and Treatment of Musculoskeletal Pelvic Floor Pain in Women

The purpose of this review is 2‐fold. The first is to provide a review for physiatrists already providing care for women with musculoskeletal pelvic floor pain and a resource for physiatrists who are interested in expanding their practice to include this patient population. The second is to describe how musculoskeletal dysfunctions involving the pelvic floor can be approached by the physiatrist using the same principles used to evaluate and treat others dysfunctions in the musculoskeletal system. This discussion clarifies that evaluation and treatment of pelvic floor pain of musculoskeletal origin is within the scope of practice for physiatrists. The authors review the anatomy of the pelvic floor, including the bony pelvis and joints, muscle and fascia, and the peripheral and autonomic nervous systems. Pertinent history and physical examination findings are described. The review concludes with a discussion of differential diagnosis and treatment of musculoskeletal pelvic floor pain in women. Improved recognition of pelvic floor dysfunction by healthcare providers will reduce impairment and disability for women with pelvic floor pain. A physiatrist is in the unique position to treat the musculoskeletal causes of this condition because it requires an expert grasp of anatomy, function, and the linked relationship between the spine and pelvis. Further research regarding musculoskeletal causes and treatment of pelvic floor pain will help validate these concepts and improve awareness and care for women limited by this condition.

Exercise for preventing childhood obesity.

Childhood obesity is a key public health issue in the United States and around the globe in developed and developing countries. Obese children are at increased risk of acute medical illnesses and chronic diseases-in particular, osteoarthritis, diabetes mellitus, and cardiovascular disease, which can lead to poor quality of life; increased personal and financial burden to individuals, families, and society; and shortened lifespan. Physical inactivity and sedentary lifestyle are associated with being overweight in children and adults. Thus it is imperative to consider exercise and physical activity as a means to prevent and combat the childhood obesity epidemic. Familiarity with definitions of weight status in children and health outcomes like metabolic syndrome is crucial in understanding the literature on childhood obesity. Exercise and physical activity play a role in weight from the prenatal through adolescent time frame. A childs family and community impact access to adequate physical activity, and further study of these upstream issues is warranted. Recommended levels of physical activity for childhood obesity prevention are being developed.

Physical Activity and Health During the Menopausal Transition

The benefits of regular physical activity are well established, but evidence for a protective effect against the adverse health consequences accompanying the menopausal transition is limited. This article reviews that evidence, concluding that more physical activity is generally associated with fewer somatic and mood symptoms. Physical activity seems to minimize weight gain and changes in body composition and fat distribution experienced at midlife and might attenuate the rapid bone density loss that occurs. Given these benefits, clinicians treating perimenopausal women should encourage their patients to follow guidelines for physical activity (≥150 minutes a week of moderate-intensity activity).

Physical Activity and Reduced Intra-abdominal Fat in Midlife African-American and White Women

The purpose of our study was to determine whether self‐reported physical activity (PA), including recreational, household, and exercise activities, is associated with intra‐abdominal fat (IAF) in community‐dwelling white and black midlife women. We performed a cross‐sectional study of 369 women from the Chicago site of the Study of Womens Health Across the Nation (SWAN) ancillary study, the SWAN Fat Patterning Study. PA level was the independent variable, and IAF, assessed by computerized tomography (CT) scan, was the dependent variable. Measures were obtained at SWAN Fat Patterning Baseline visit between August 2002 and December 2005. Linear regression models explored the association between PA and IAF. The first model included IAF as the outcome and total score PA as the main predictor, adjusting for total percent fat mass, age, and ethnicity. The second model included education, parity, sex hormone–binding globulin (SHBG) level, and depressive symptoms, measured by Center for Epidemiological Studies‐Depression (CES‐D) scale. Each 1‐point higher total PA score was associated with a 4.0 cm2 lower amount of IAF (P = 0.004), independent of total percent fat mass, age, ethnicity, SHBG level, educational level, CES‐D, and parity. Associations did not differ between white and black women. This study demonstrates a significant negative association between PA and IAF independent of multiple covariates in midlife women. Our findings suggest that motivating white and black women to increase PA during midlife may lessen IAF, which may have a positive impact on subsequent development of diabetes and cardiovascular disease.