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ABSTRACT Background Implementation of interprofessional clinical guidelines for the prevention of neuropathic diabetic foot ulceration has demonstrated positive effects regarding ulceration and amputation rates. Current foot care recommendations are primarily based on research regarding the prevention of ulcer recurrence and focused on reducing the magnitude of plantar stress (pressure overload). Yet, foot ulceration remains to be a prevalent and debilitating consequence of Diabetes Mellitus. There is limited evidence targeting the prevention of first-time ulceration, and there is a need to consider additional factors of plantar stress to supplement current guidelines. Objectives The first purpose of this article is to discuss the biomechanical theory underpinning diabetic foot ulcerations and illustrate how plantar tissue underloading may precede overloading and breakdown. The second purpose of this commentary is to discuss how advances in biomechanical foot modeling can inform clinical practice in the prevention of first-time ulceration. Discussion Research demonstrates that progressive weight-bearing activity programs to address the frequency of plantar stress and avoid underloading do not increase ulceration risk. Multi-segment foot modeling studies indicate that dynamic foot function of the midfoot and forefoot is compromised in people with diabetes. Emerging research demonstrates that implementation of foot-specific exercises may positively influence dynamic foot function and improve plantar stress in people with diabetes. Conclusion Continued work is needed to determine how to best design and integrate activity recommendations and foot-specific exercise programs into the current interprofessional paradigm for the prevention of first-time ulceration in people with Diabetes Mellitus.

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ABSTRACT Objective: To empirically test the relationships proposed by the International Classification of Functioning, Disability and Health (ICF) among its domains. Method: The cross-sectional study was completed with 226 adult patients with different health conditions who attended a Brazilian rehabilitation unit. The ICF components were measured with the following instruments: World Health Organization Disability Assessment Instrument II, Functional Independence Measure, Participation Scale, Craig Hospital Inventory of Environmental Factors, and a protocol designed to gather information on body structure and function and personal factors. Results: Structural equation modeling showed good model adjustment, GFI=0.863; AGFI=0.795; RMSEA=0.028 (90% CI=0.014-0.043). Significant relationships were found between activity and both body structure and function (standard coefficient=0.32; p<0.0001) and participation components (standard coefficient=–0.70; p<0.0001). Environmental and personal factors had a significant effect on the three functioning components (standard coefficient =0.39; p<0.0001; standard coefficient =-0.35; p<0.001, respectively). In contrast, body structure and function had no significant effect on participation (standard coefficient=–0.10; p=0.111) and health conditions had no significant effect on any of the functioning components, i.e., body structure and function, activity, and participation (standard coefficient=–0.12; p=0.128). Conclusion: Some of the ICF’s proposed relationships across domains were confirmed, while others were not found to be significant. Our results reinforce the contextual dependency of the functioning and disability processes, in addition to putting into perspective the impact of health conditions.

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ABSTRACT Background Muscle strength is usually measured in individuals with stroke with Portable dynamometers (gold standard). However, no studies have investigated the reliability, the standard error of measurement (SEM) and the minimal detectable difference (MDD95%) of the dynamometry for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke. Objective 1) To investigate the intra and inter-rater reliability, the SEM and the MDD95% of the portable dynamometers for the measurement of grip, pinch and trunk strength in subjects with subacute stroke, and 2) to verify whether the use of different number of trials (first trial and the average of the first two and three trials) affected the results. Method 32 subjects with subacute stroke (time since stroke onset: 3.6 months, SD=0.66 months) were evaluated. Hand grip, 3 pinch grips (i.e. pulp-to-pulp/palmar/lateral) and 4 trunk muscles (i.e. flexors, extensors, lateral flexors and rotators) strength were bilaterally assessed (except trunk flexors/extensors) with portable dynamometry by two independent examiners over two sessions (1-2 weeks apart). One-way ANOVAs and intraclass correlation coefficients (ICC2,k) were used for analysis (α=0.05). SEM and MDD95% were also calculated. Results For all muscular groups and sources of outcome values, including one trial, after familiarization, similar results were found (0.01≤F≤0.08; 0.92≤p≤0.99) with significant and adequate values of intra-rater (0.64≤ICC≤0.99; 0.23≤95%CI≤0.99) and inter-rater (0.66≤ICC≤0.99; 0.25≤95%CI≤0.99) reliability. SEM and MDD95% were considered low (0.39≤EPM≤2.21 Kg; 0.96≤MMD95%≤6.12 Kg) for all outcome scores. Conclusion Only one trial, following familiarization, demonstrated adequate intra-rater and inter-rater reliability of the portable dynamometers for the measurement of hand grip, pinch grip and trunk strength in subjects with subacute stroke.

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ABSTRACT Background Few studies have explored the effects of stretching techniques on diaphragm and spine kinematics. Objective To determine whether the application of diaphragm stretching resulted in changes in posterior chain muscle kinematics and ribcage and abdominal excursion in healthy subjects. Method Eighty healthy adults were included in this randomized clinical trial. Participants were randomized into two groups: the experimental group, which received a diaphragmatic stretching technique, or the placebo group, which received a sham-ultrasound procedure. The duration of the technique, the position of participants, and the therapist who applied the technique were the same for both treatments. Participant assessment (cervical range of movement, lumbar flexibility, flexibility of the posterior chain, and rib cage and abdominal excursion) was performed at baseline and immediately after the intervention by a blinded assessor. Results The mean between-group difference [95% CI] for the ribcage excursion after technique at xiphoid level was 2.48 [0.97 to 3.99], which shows significant differences in this outcome. The remaining between-group analysis showed significant differences in cervical extension, right and left flexion, flexibility of the posterior chain, and ribcage excursion at xiphoid level (p<0.05) in favor of the experimental group. Conclusion Diaphragm stretching generates a significant improvement in cervical extension, right and left cervical flexion, flexibility of the posterior chain, and ribcage excursion at xiphoid level compared to a placebo technique in healthy adults.

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ABSTRACT Background Cultural and social factors play an important role in the development and persistence of Low Back Pain (LBP). Nevertheless, there are few studies investigating differences in LBP features between countries. Objective To determine differences in pain perception between individuals with LBP living in Brazil and Spain. Method Thirty Spanish individuals and 30 age- and sex-comparable Brazilian individuals with LBP were recruited from the Public Health Services of both countries. The Numerical Pain Rating Scale and the pain rating index (PRI), the number of words chosen (NWC), and the present pain index (PPI) extracted from the McGill Pain Questionnaire were used to assess pain. The Oswestry Disability Index, the Short Form-36, Beck Depression Inventory-II, and Pittsburgh Sleep Quality Index were also applied. Differences between countries and the correlation between demographic and clinical variables in each country were assessed with parametric and the nonparametric tests. Results A significant Country by Gender interaction was found for the PRI total score (P=0.038), but not for intensity of pain, disability, PPI, or NWC, in which Spanish women exhibited greater pain ratio than Spanish men (P=0.014), and no gender differences were identified in Brazilians. The Spanish group showed a consistent pattern of correlations for clinical data. Within Brazilian patients, fewer correlations were found and all of the coefficients were lower than those in the Spanish group. Conclusion The pain perception in patients with LBP is different depending on the country. Within Spanish patients, LBP is considered a more global entity affecting multidimensional contexts.

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ABSTRACT Background Dry needling (DN) and percutaneous electrical nerve stimulation (PENS) are widely used techniques in the treatment of myofascial pain. Objective To investigate the immediate and short-term effects of the combination of DN and PENS compared to DN alone on the upper trapezius muscle. Method This is a 72-hour follow-up single-blinded randomized controlled trial. Sixty-two volunteer patients with chronic myofascial neck pain with active Myofascial Trigger Points (MTrPs) in the upper trapezius muscle were recruited. Randomization was performed, and 31 patients received DN treatment (DN group) and 31 received DN and PENS (DN+PENS group). The primary outcomes were neck disability index (NDI) and visual analog scale for pain for both post-needling soreness (PNS) and neck pain intensity (NPI). Pressure pain threshold (PPT) and cervical range of motion (CROM) were the secondary outcomes. Results We detected between-group differences in NPI and PNS in favor of the DN+PENS group immediately after treatment. No between-group differences in NDI were observed. Conclusion PENS application after dry needling treatment is more effective than dry needling alone for decreasing soreness in the short term and improving neck pain intensity immediately in patients with myofascial chronic neck pain.

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ABSTRACT Background Sarcopenic obesity is associated with disability in older people, especially in women. Resistance exercises are recommended for this population, but their efficacy is not clear. Objective To evaluate the effects of a progressive resistance exercise program with high-speed component on the physical function of older women with sarcopenic obesity. Method Twenty-eight women 65 to 80 years old, with a body mass index ≥30kg/m2 and handgrip strength ≤21kg were randomly allocated to two groups. The experimental group underwent a 10-week resistance exercise program designed to improve strength, power, and endurance of lower-limb muscles, with open chain and closed chain exercises. The control group had their health status monitored through telephone calls. The primary outcomes were lower limb muscle performance measured by knee extensor strength, power and fatigue by isokinetic dynamometry, and mobility measured by the Short Physical Performance Battery and by gait velocity. The secondary outcome was health-related quality of life assessed by the SF-36 Questionnaire. Results The average rate of adherence was 85%, with few mild adverse effects. There were no significant between-group differences for any of the outcomes. Conclusion In this study, a progressive resistance exercise program with high-speed component was not effective for improving the physical function of older women with sarcopenic obesity.

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ABSTRACT Background Airflow limitation frequently leads to the interruption of activities of daily living (ADL) in patients with Chronic Obstructive Pulmonary Disease (COPD). These patients commonly show absence of ventilatory reserve, reduced inspiratory reserve volume, and dynamic hyperinflation (DH). Objective To investigate ventilatory response and DH induced by three ADL-based protocols in COPD patients and compare them to healthy subjects. Method Cross-sectional study. COPD group: 23 patients (65±6 years, FEV1 37.2±15.4%pred); control group: 14 healthy subjects (64±4 years) matched for age, sex, and body mass index. Both groups performed all three tests: Glittre-ADL test; an activity test that involved moving objects on a shelf (TSHELF); and a modified shelf protocol isolating activity with upper limbs (TSHELF-M). Ventilatory response and inspiratory capacity were evaluated. Results Baseline ventilatory variables were similar between groups (p>0.05). The ventilatory demand increased and the inspiratory capacity decreased significantly at the end of the tests in the COPD group. Ventilatory demand and DH were higher (p<0.05) in the TSHELF than in the TSHELF–M in the COPD group (p<0.05). There were no differences in DH between the three tests in the control group (p>0.05) and ventilatory demand increased at the end of the tests (p<0.05) but to a lower extent than the COPD group. Conclusion The TSHELF induces similar ventilatory responses to the Glittre-ADL test in COPD patients with higher ventilatory demand and DH. In contrast, the ventilatory response was attenuated in the TSHELF-M, suggesting that squatting and bending down during the Glittre-ADL test could trigger significant ventilatory overload.

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Abstract Background Health-related control and self-efficacy beliefs can be assessed in the general population using Multidimensional Health Locus of Control-A subscales (MHLC-A) and the General Self-Efficacy Scale (GSES), respectively. Objective To test construct validity, internal consistency, reliability (test-retest) and ceiling and floor effects of Portuguese-Brazil versions of MHLC-A and GSES. Method Civil servants (N=2901) enrolled in a large Brazilian cohort were included. A new version of the GSES was produced (GSES-Brazil). Procedures for cross-cultural adaptation and testing of psychometric properties followed well-accepted international guidelines. Results Confirmatory factor analyses yielded the following indices: MHLC-A (tridimensional model): χ2[df]=223.45[132], p-value <0.01; CFI=0.87; TLI=0.85; RMSEA=0.07 (0.07-0.08); WRMR=3.00. GSES-Brazil (unidimensional model): χ2[df]=788.60[35], p-value <0.01; CFI=0.95; TLI=0.94; RMSEA=0.09 (0.08-0.09); WRMR=2.50. Cronbach’s alpha coefficients and Intraclass Correlation Coefficients (ICC2,1) ranged from 0.57 (0.54-0.59) and 0.57 (0.47-0.65) for MHLC-A internality to 0.80 (0.79-0.81) and 0.71 (0.66-0.77) for GSES-Brazil, respectively. There was no evidence of ceiling and floor effects. Convergent validity analyses provided further support for construct validity of both scales. Conclusion These findings support the use of the newly developed version of GSES-Brazil for the assessment of general self-efficacy of adult Brazilians. Internal consistency was lower than ideal for MHLC-A, indicating these subscales may need further refinements to provide a more psychometrically sound measure of control beliefs.

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ABSTRACT Background A joint symbolic analysis (JSA) is applied to assess the strength of the cardiovascular coupling from spontaneous beat-to-beat variability of the heart period (HP) and the systolic arterial pressure (SAP) during an experimental protocol inducing a gradual baroreflex unloading evoked by postural change (i.e. graded head-up tilt). Method: The adopted JSA can quantify the degree of association between the HP and SAP variabilities as a function of the time scale of the HP and SAP patterns. Traditional linear tools assessing the HP-SAP coupling strength, such as squared correlation coefficient, squared coherence function, and percentage of baroreflex sequences, were computed as well for comparison. Results: We found that: i) JSA indicated that the strength of the cardiovascular coupling at slow temporal scales gradually increased with the magnitude of the orthostatic challenge, while that at fast temporal scales gradually decreased; ii) the squared correlation coefficient and percentage of baroreflex sequences did not detect this behavior; iii) even though squared coherence function could measure the magnitude of the HP-SAP coupling as a function of the time scale, it was less powerful than JSA owing to the larger dispersion of the frequency domain indexes. Conclusion: Due to its peculiar features and high statistical power, JSA deserves applications to pathological groups in which the link between HP and SAP variabilities is lost or decreased due to the overall depression or impairment of the cardiovascular control.

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ABSTRACT Objective: To determine the responsiveness of the domain climbing up and going down stairs of the Functional Evaluation Scale for Duchenne Muscular Dystrophy (FES-DMD-D3) in a one-year follow-up study. Method: The study included 26 patients with DMD. Effect Size (ES) and Standardized Response Mean (SRM) described the scale’s responsiveness. Results: For climbing up stairs, ES showed that responsiveness was low in the three-month assessments (0.26; 0.35; 0.13; 0.17), low to moderate in the six-month assessments (0.58; 0.48; 0.33), moderate in the nine-month assessments (0.70; 0.68), and high in the 12-month assessment (0.88). SRM showed that responsiveness was low in the three-month assessments (0.29; 0.38; 0.18; and 0.19), low to moderate in the six-month assessments (0.59; 0.51; 0.36), moderate in the nine-month assessments (0.74 and 0.70), and high in the 12-month assessment (0.89). For going down stairs, ES showed that responsiveness was low in the three- and six-month assessments (0.16; 0.25; 0.09; 0.08 and 0.48; 0.35; 0.18, respectively), low to moderate in the nine-month assessments (0.59; 0.44), and moderate in the 12-month assessment (0.71). SRM showed that responsiveness was low in the three- and six-month assessments (0.25; 0.35; 0.12; 0.09 and 0.47; 0.38; 0.21, respectively), low to moderate in the nine-month assessment (0.62; 0.49), and moderate in the 12-month assessment (0.74). Conclusion: Climbing up stairs should be assessed at intervals of nine months or longer, when responsiveness is moderate to high. Going down stairs should be assessed annually because moderate responsiveness was observed in this period.

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ABSTRACT Background These trials are the first randomised controlled trials of telephone-based weight management and healthy lifestyle interventions for low back pain and knee osteoarthritis. This article describes the protocol and statistical analysis plan. Method These trials are parallel randomised controlled trials that investigate and compare the effect of a telephone-based weight management and healthy lifestyle intervention for improving pain intensity in overweight or obese patients with low back pain or knee osteoarthritis. The analysis plan was finalised prior to initiation of analyses. All data collected as part of the trial were reviewed, without stratification by group, and classified by baseline characteristics, process of care and trial outcomes. Trial outcomes were classified as primary and secondary outcomes. Appropriate descriptive statistics and statistical testing of between-group differences, where relevant, have been planned and described. Conclusions A protocol for standard analyses was developed for the results of two randomised controlled trials. This protocol describes the data, and the pre-determined statistical tests of relevant outcome measures. The plan demonstrates transparent and verifiable use of the data collected. This a priori protocol will be followed to ensure rigorous standards of data analysis are strictly adhered to.