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Background: Diabetes-related peripheral neuropathy (DPN) and limited joint mobility of the foot and ankle are implicated in the development of increased plantar pressures and diabetes-related foot ulcers. The extent of this relationship has not been conclusively established. We aimed to determine the relationship between ankle joint and first metatarsophalangeal joint dorsiflexion range of motion and DPN using a cross-sectional observational study design., Methods: Primary outcomes were DPN status, ankle joint range of motion (extended and flexed knee lunge tests), and nonweightbearing first metatarsophalangeal joint range of motion. Correlations were performed using Pearson r, and hierarchical regression analyses were undertaken to determine the independent contribution of DPN to the variance in dorsiflexion range of motion of ankle and first metatarsophalangeal joints using standardized β regression coefficients, controlling for age, sex, body mass index, diabetes duration, and hemoglobin A1c level., Results: One hundred one community-dwelling participants (mean ± SD age, 65.0 ± 11.2 years; 55 men; 97% type 2 diabetes; mean ± SD diabetes duration, 8.7 ± 7.8 years; 23% with DPN) were recruited. Diabetes-related peripheral neuropathy demonstrated significant correlations with reduced range of motion at the ankle joint (knee extended: r = -0.53; P < .001 and knee flexed: r = -0.50; P < .001) and the first metatarsophalangeal joint (r = -0.37; P < .001). Also, DPN made significant, unique contributions to the regression models for range of motion at the ankle joint (knee extended: r2 change = 0.121; β = -0.48; P < .001 and knee flexed: r2 change = 0.109; β = -0.45; P < .001) and first metatarsophalangeal joint (r2 change = 0.037; β = -0.26; P = .048)., Conclusions: These findings suggest that DPN contributes to reduced ankle and first metatarsophalangeal joint range of motion. Due to the established link between reduced ankle and first metatarsophalangeal joint range of motion and risk of diabetes-related foot ulcer, we recommend that clinicians assess dorsiflexion range of motion at these joints as part of routine foot assessment in people with diabetes, especially those with DPN. Globally, approximately 436 million adults aged 20 to 79 years are living with diabetes.1 Diabetes is the leading cause of lower-limb amputation and is associated with a lifetime incidence of diabetes-related foot ulcer (DFU) of up to 34%.2 Diabetes-related peripheral neuropathy (DPN) affects approximately 30% to 50% of people with diabetes3 and is one of the most significant risk factors for the development of DFU and amputation.4 Diabetes-related peripheral neuropathy occurs as a result of neural ischemia and perineural edema causing neural demyelination, affecting nerve conductivity.5 In the presence of DPN, intrinsic foot muscle wasting can lead to the development of foot deformities such as digital clawing, which, when coupled with structural and functional changes to the skin, make it less resistant to shear forces and further increase plantar pressure and risk of DFU.6,7.

Background: Lower limb peripheral artery disease (PAD) is associated with poor outcomes including ulceration, gangrene, amputations, and mortality. Clinicians therefore routinely perform point-of-care tests in high-risk populations to identify PAD and subsequently implement cardiovascular management and appropriate interventions. Pulse oximetry has been suggested as a useful adjunct test for identifying PAD., Objective: The aim of this systematic review was to determine the sensitivity and specificity of pulse oximetry in the lower limb for identifying PAD., Methods: MEDLINE, EMBASE, and CINAHL were searched up until January 10, 2023, to identify studies of sensitivity and specificity of pulse oximetry that used criterion standard diagnostic imaging as a reference standard. Two authors screened articles for inclusion and appraised quality of included studies using the Quality Appraisal for Diagnostic Accuracy Studies, version 2., Results: A total of 6371 records were screened, and 4 were included. The included studies had a total of 471 participants, with an age range of 41 to 80.6 years. All studies were cross-sectional and conducted in hospital settings. Sensitivity values for pulse oximetry compared with diagnostic imaging in identifying PAD ranged from 44% to 76%, and specificity values ranged from 85% to 96%. There was no consensus regarding measurement techniques and diagnostic thresholds for pulse oximetry, which precluded meta-analysis., Conclusions: There is currently inadequate evidence to support the use of pulse oximetry for identifying PAD. Current evidence suggests that pulse oximetry has low levels of sensitivity and is therefore likely to miss PAD when it is present., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population., Research Design and Methods: This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation., Results: A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m 2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03)., Conclusions: In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal., (© 2022 The Authors. Diabetic Medicine published by John Wiley & Sons Ltd on behalf of Diabetes UK.)

Background: To systematically evaluate the literature investigating the relationship between cutaneous microvascular reactivity in the foot of adults with diabetes-related Charcot neuroarthropathy compared to a non-Charcot adult control group., Methods: A systematic search was conducted to June 2021 using the biomedical databases EBSCO Megafile Ultimate, Cochrane Library and EMBASE. Original research conducting comparative investigation of cutaneous microvascular reactivity in the foot of adults with diabetes and any pattern of acute or chronic Charcot neuroarthropathy and any non-Charcot adult control groups were included. A modified Critical Appraisal Skills Programme tool was used for quality appraisal. Cutaneous microvascular reactivity in diabetes-related Charcot neuroarthropathy data were synthesised and meta-analysis conducted where possible., Results: The search strategy identified 1,684 articles, with seven eligible for inclusion. Included studies used various methodologies and equipment to assess cutaneous microvascular reactivity in 553 participants (162 with Charcot neuroarthropathy). Cutaneous microvascular reactivity in Charcot neuroarthropathy groups was impaired compared to uncomplicated diabetes groups. Meta-analysis investigating the difference in response to thermal hyperaemia demonstrated a significant difference in cutaneous microvascular reactivity between Charcot neuroarthropathy and peripheral neuropathy with a large, pooled effect size (SMD 1.46 95% CI: 0.89-2.02) and low heterogeneity (I 2  = 4%, T 2  = 0.01) indicating that the cutaneous microvascular response is more impaired in peripheral neuropathy than in Charcot neuroarthropathy., Conclusions: Charcot neuroarthropathy is associated with greater cutaneous microvascular reactivity in the periphery relative to diabetes cohorts with diabetes-related peripheral neuropathy alone. It is unknown if this occurs prior to, or as a result of, Charcot neuroarthropathy., (© 2022. The Author(s).)

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration., (© 2021 The Wound Healing Society.)

Background: High plantar pressures are associated with increased foot ulcer risk in people with diabetes. Identification of high plantar pressures in people with diabetes is clinically challenging due to time and cost constraints of plantar pressure testing. Factors affecting foot biomechanics, including reduced joint range of motion and foot deformity, are implicated in the development of high plantar pressures and may provide a method to clinically identify those at risk of pressure related complications. The aim of this study was to investigate the contribution of joint range of motion and foot deformity measures on plantar pressures in a community dwelling group with diabetes., Methods: Barefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, weight bearing ankle dorsiflexion, hallux range of motion, lesser toe deformities and hallux abductus (HAV) scale were assessed in 136 adults with diabetes (52.2% male; mean age 68.4 years). Multivariate multiple linear regression was used to assess the effect of the four biomechanical factors plus neuropathy and body mass index on plantar pressure variables. Non-parametric bootstrapping was employed to determine the difference in plantar pressure variables for participants with two or more foot biomechanical pathologies compared to those with less than two pathologies., Results: Almost one third (32%) of the cohort had two or more foot biomechanical pathologies. Participants with two or more foot biomechanical pathologies displayed significant increases in all barefoot plantar pressure regions (except forefoot), compared to those with less than two pathologies. No significant changes were found for the in-shoe plantar pressure variables. The regression model explains between 9.9% (95%CI: 8.4 to 11.4%) and 29.6% (95% CI: 28.2 to 31%), and between 2.5% (1.0 to 4.0%) and 43.8% (95% CI: 42.5-44.9%), of the variance in the barefoot and in-shoe plantar pressure variables respectively., Conclusions: Participants presenting with two or more factors affecting foot biomechanics displayed higher peak pressures and pressure time integrals in all foot regions compared to those with less than two factors. The tests used in this study could help clinicians detect elevated plantar pressures in people with diabetes and present an opportunity for early preventative interventions., (© 2021. The Author(s).)

Backgrounds and Aims: Obesity and diabetes independently contribute to cutaneous microvascular dysfunction via pathological processes that are not fully understood. We sought to determine if obesity severity is associated with cutaneous microvascular dysfunction and measures of peripheral arterial disease in adults with type 2 diabetes in cross-sectional observational study design., Methods and Results: Primary outcomes were post-occlusive reactive hyperaemia as determined by laser-Doppler fluxmetry (peak flux post-occlusion, time to peak flux post-occlusion, peak as a percentage of baseline, and area under the curve [AuC] index post-occlusion to pre-occlusion). Secondary outcomes were ankle- and toe-brachial indices (ABI and TBI) and systolic toe pressure. Thirty-six participants (20 men, 16 women) with mean age 55 ± 8 years, BMI of 36 ± 5 kg/m 2 and duration of diabetes 8 ± 6 years underwent measurements. After adjusting for age and duration of diabetes, SAT and total percentage body fat were able to explain 29% (p = 0.001) and 20% (p = 0.01) of variance of AuC index models, as well as 29% (p = 0.02) and 18% (p = 0.02) of peak as a percentage of baseline models, respectively. Though TBI demonstrated moderate, significant correlations with SAT (r:0.37, p = 0.04) and total percentage body fat (r:0.39, p = 0.03), these were not upheld by regression analyses. Neither ABI nor systolic toe pressure significantly correlated with any measure of adiposity or obesity., Conclusion: These findings demonstrate impairment in cutaneous microvascular function related to adiposity and obesity severity in adults with type 2 diabetes, suggesting that obesity may pathologically effect cutaneous microvascular function in the absence of overt macrovascular disease, warranting further investigation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: A weight bearing ankle equinus has adverse effects on forefoot plantar pressure variables in older adults with diabetes, but it is unclear if this is also the case in older adults without diabetes., Methods: 40 older adults with diabetes (88% type 2, mean diabetes duration 17.6 ± 14.8 years) and 40 older adults without diabetes, matched for age (±3 years), sex and BMI (±2 BMI units) were included (63% female, mean age 72 ± 4 years, BMI 30 ± 4 kg/m 2 ). Primary outcomes were prevalence of a weight bearing equinus and evaluation of barefoot forefoot plantar pressures in older adults with and without diabetes., Findings: A weight bearing equinus was present in 37.5% and 27.5% of the diabetes and non-diabetes group respectively with no significant difference between groups (p = 0.470). People with diabetes and equinus displayed higher peak pressure (808 versus 540 kPa, p = 0.065) and significantly higher pressure-time integral (86 versus 68 kPa/s, p = 0.030) than people with diabetes and no equinus group. The non-diabetes equinus group had significantly higher peak pressure (665 versus 567 kPa, p = 0.035) than those with no diabetes and no equinus, but no difference in pressure-time integral., Interpretation: A high prevalence of a weight bearing equinus was detected in older adults with and without diabetes, with associated increases in plantar pressures. As an equinus has been associated with many foot pathologies this study's findings suggest that clinicians should check for the presence of a weight bearing ankle equinus in all older adults., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Aim: To systematically evaluate research investigating the accuracy of the ankle-brachial index (ABI) for diagnosing peripheral artery disease (PAD) in people with diabetes, as the accuracy is thought to be reduced in this cohort., Methods: A database search of EBSCO Megafile Premier, Embase and The Cochrane Library was conducted to 28 February 2019. Prospective and retrospective investigations of the diagnostic accuracy of the ABI for PAD in people with diabetes using an imaging reference standard were eligible. Sensitivity and specify of the ABI and bivariate meta-analysis against reference tests, or a standard summary receiver operating curve analysis (SROC) was performed., Results: Thirty-three studies met the inclusion criteria. ABI was compared with angiography in 12 studies and with colour duplex ultrasound (CDUS) in 21 studies. A SROC analysis of studies using angiography as the reference standard found a diagnostic odds ratio (DOR) of 9.06 [95% confidence interval (CI) 3.61 to 22.69], and area under the curve (AUC) of 0.76 (95% CI 0.66 to 0.86). Bivariate analysis of studies using CDUS demonstrated mean sensitivity of 0.60 (95% CI 0.48 to 0.71; P = 0.097) and mean specificity of 0.87 (95% CI 0.78 to 0.92; P < 0.001) with a DOR of 9.76 (95% CI 5.24 to 18.20; P < 0.0001) and AUC 0.72., Conclusions: These results suggest the ABI has a high specificity but lower sensitivity in detecting imaging diagnosed PAD in people with diabetes. The low probability of the testing being able to rule diagnosis in or out suggest that the ABI has limited effectiveness for early detection of PAD in this cohort., (© 2020 Diabetes UK.)

Background: Low-volume high-intensity interval training (HIIT) may be a time-efficient strategy that leads to similar or superior improvements in cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) risk factors when compared with moderate-intensity continuous training (MICT). Our study investigated the effect of low-volume HIIT or MICT versus sham placebo-control (PLA) on central arterial stiffness, hemodynamic responses, and CVD risk factors in adults with obesity and type 2 diabetes (T2D)., Methods: Eligible participants were previously inactive adults with obesity and T2D. Individuals were randomly allocated to: i) HIIT (1 × 4 min cycling at 90% peak oxygen consumption [V̇O 2peak ]); ii) MICT (45 min of cycling at 60% VO 2peak ); or PLA. Training groups exercised thrice weekly for 12 weeks. Central arterial stiffness, hemodynamics and CVD risk factors were assessed at baseline and post-intervention. Analysis of covariance (ANCOVA) was used to examine changes following HIIT, MICT and PLA., Results: Thirty-five participants (age: 55.1 ± 1.4 years, BMI: 36.1 ± 0.8 kg/m 2 ) completed the study. A significant intervention effect was found for changes in pulse wave velocity (PWV) (p = .03), which reduced with HIIT (-0.3 ± 0.9 m/s) and MICT (-0.1 ± 1.1 m/s) but increased with PLA (0.8 ± 1.6 m/s). There was a significant intervention effect for changes in V̇O 2peak (p < .01), glycosylated hemoglobin (p = .03), systolic blood pressure (p < .01), and waist circumference (p = .03), which all improved following MICT or HIIT but not PLA; there was no difference between MICT and HIIT., Conclusions: Twelve minutes of low-volume HIIT per week leads to improvements in central arterial stiffness and cardiovascular health in inactive individuals with obesity and T2D., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: The aim of this study was to examine the effect of a novel low-volume high-intensity interval training (HIIT), moderate-intensity continuous training (MICT), or placebo (PLA) intervention on liver fat, glycemia, and cardiorespiratory fitness using a randomized placebo-controlled design., Research Design and Methods: Thirty-five inactive adults (age 54.6 ± 1.4 years, 54% male; BMI 35.9 ± 0.9 kg/m 2 ) with obesity and type 2 diabetes were randomized to 12 weeks of supervised MICT ( n = 12) at 60% VO 2peak for 45 min, 3 days/week; HIIT ( n = 12) at 90% VO 2peak for 4 min, 3 days/week; or PLA ( n = 11). Liver fat percentage was quantified through proton MRS., Results: Liver fat reduced in MICT (-0.9 ± 0.7%) and HIIT (-1.7 ± 1.1%) but increased in PLA (1.2 ± 0.5%) ( P = 0.046). HbA 1c improved in MICT (-0.3 ± 0.3%) and HIIT (-0.3 ± 0.3%) but not in PLA (0.5 ± 0.2%) ( P = 0.014). Cardiorespiratory fitness improved in MICT (2.3 ± 1.2 mL/kg/min) and HIIT (1.1 ± 0.5 mL/kg/min) but not in PLA (-1.5 ± 0.9 mL/kg/min) ( P = 0.006)., Conclusions: MICT or a low-volume HIIT approach involving 12 min of weekly high-intensity aerobic exercise may improve liver fat, glycemia, and cardiorespiratory fitness in people with type 2 diabetes in the absence of weight loss. Further studies are required to elucidate the relationship between exercise-induced reductions in liver fat and improvements in glycemia., (© 2020 by the American Diabetes Association.)

Arterial investigations are an essential part of lower extremity wound assessment. The results of these investigations assist the wound clinician to determine the etiology of the wound, predict healing capacity, and inform further management. There are a number of noninvasive testing methods available to practitioners, all with varying levels of reliability and accuracy. Clinical wound assessment guidelines give varied recommendations when it comes to lower limb vascular assessment in the presence of a wound. This leaves clinicians with little guidance on how to choose the most appropriate test, and uncertainty remains about which tests provide the most accurate information in different patient-specific contexts. Conditions such as advanced age, diabetes, and renal disease are known to affect the accuracy of some commonly used lower limb arterial assessment methods, and alternate testing methods should be considered in these cases. This seminal review discusses the reliability and accuracy of lower limb vascular assessment methods used to guide lower limb arterial assessment in the presence of wounds.

Objectives: We aimed to investigate which prevention strategies for low back pain (LBP) are most effective., Design: We completed a Bayesian network meta-analysis to summarise the comparative effectiveness of LBP prevention strategies. The primary outcomes were an episode of LBP and LBP-associated work absenteeism represented as ORs with associated 95% credibility intervals (CrIs). We ranked all prevention strategies with surface under the cumulative ranking curve (SUCRA) analysis., Data Sources: PubMed, EMBASE and CENTRAL databases were searched along with manual searches of retrieved articles. We only included randomised controlled trials (RCTs) that reported an episode of LBP and/or LBP-associated work absenteeism evaluating LBP prevention strategies were included., Eligibility Criteria for Selecting Studies: Data were independently extracted by two investigators, and RCT quality was assessed using the Cochrane Risk of Bias tool., Results and Summary: Forty RCTs were included. Exercise combined with education (OR: 0.59, CrI: 0.41 to 0.82) and exercise alone (OR: 0.59, CrI: 0.36 to 0.92) both prevented LBP episodes; exercise combined with education and education alone both had large areas under the curve (SUCRA: 81.3 and 79.4, respectively). Additionally, exercise (OR: 0.04, CrI: 0.00 to 0.34) prevented LBP-associated work absenteeism, with exercise and the combination of exercise and education ranking highest (SUCRA: 99.0 and 60.2, respectively)., Conclusions: Exercise alone and exercise combined with education can prevent episodes of LBP and LBP-related absenteeism., Trial Registration Number: PROSPERO 42017056884., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The ankle-brachial index (ABI) is widely used for determining the presence and severity of peripheral arterial disease (PAD), and current guidelines suggest it should be used to monitor possible progression in affected individuals. It is therefore important that the technique demonstrates adequate reliability for repeated measurements. Existing studies suggest that the ABI is reliable in the general population however, there is a lack of evidence for the reliability of the ABI in people with diabetes. The aim of this study was to investigate the intra-tester reliability of the ABI in people with and without diabetes., Methods: Eighty-five participants (40 with and 45 without diabetes) underwent ankle and brachial systolic blood pressure measurements by a single clinician during two testing sessions. Intraclass correlation coefficients (ICC), their 95% limits of agreement, standard error of measurement and minimal detectable change were determined., Results: Intra-tester reliability of the ABI was found to be good (ICC: 0.80), however sub-group analysis of participants with and without diabetes found that ABI was slightly less reliable in people with diabetes (ICC: 0.78) than in those without (ICC: 0.82). The relatively large limits of agreement (- 0.16 to 0.16), standard error of measurement (0.03 overall, 0.04 for the diabetes group), and minimal detectable change (0.08 overall, 0.11 for the diabetes group) suggest that a large change in ABI is required for it to demonstrate a true change rather than the result of measurement variability. The minimal detectable change for the ABI was 0.08 overall, and 0.11 for the diabetes group., Conclusions: The ABI demonstrated good reliability in all groups analysed. However, the wide limits of agreement and considerable standard error of measurement obtained support the use of multiple methods of vascular assessment for ongoing monitoring of lower limb vascular status.

Background: Testing of protective sensation and vibration perception are two of the most commonly used non-invasive methods of screening for diabetes-related peripheral neuropathy (DPN). However, there is limited research investigating the reliability of these tests in people with diabetes. The aim of this study was to determine the inter- and intra-rater reliability of methods used to test vibration perception and protective sensation in a community-based population of adults with type 2 diabetes., Methods: Three podiatrists with varying clinical experience tested four- and 10-site, 10 g monofilament and vibration perception threshold (VPT). In a separate cohort, the reliability of a graduated tuning fork as well as two methods of conventional tuning fork (on/off method and dampening method) was undertaken by a new graduate podiatrist and podiatrist with one-year's clinical experience. The intra- (Cohen's К) and inter-rater (Cohen's or Fleiss' К) reliability of each test was determined., Results: Fifty participants (66% male, 100% type 2, 32% with DPN) underwent monofilament and neurothesiometer testing with 44 returning for the retest. Twenty-four participants (63% male, 100% type 2, 4% with DPN) underwent tuning fork testing and returned for retest. All tests demonstrated acceptable inter-rater reliability ranging from moderate (10-site monofilament, К: 0.54, CI: 0.38-0.70, p  = 0.02) to substantial (graduated tuning fork, К: 0.68, CI: 0.41-0.95, p  < 0.01). The 10-site monofilament (К: 0.44-0.77) outperformed the 4-site test (К: 0.34-0.67) and the dampened tuning fork method (К: 0.41-0.49) showed lower intra-rater reliability compared to both conventional (К: 0.52-0.57) and graduated methods (К: 0.50-0.57)., Conclusion: We support the current recommendations of using more than one test to screen and monitor progression of DPN. Four- and 10-site 10 g monofilament testing have similarly acceptable levels of reliability and the neurothesiometer is the most reliable method of assessing vibration perception function. Use of a graduated tuning fork was slightly more reliable than other methods of tuning fork application however all had substantial reliability. Years of clinical experience only marginally affected test reliability overall and due to subjective nature of the tests we suggest that testing should be performed regularly and repetitively., Competing Interests: Competing interestsNone of the authors have any conflicts of interests to declare., (© The Author(s). 2020.)

Objectives: Rheumatoid arthritis (RA) is associated with higher risk of atherosclerotic vascular disease, including peripheral arterial disease (PAD). The aim of this study was to measure lower limb vascular characteristics (indicative of PAD), using non-invasive chairside testing methods, in people with RA compared to matched controls, and to determine the association between vascular characteristics and gait velocity as a measure of functional capacity in people with RA., Methods: This was a cross-sectional pilot study which measured lower limb vascular characteristics (bilateral continuous wave Doppler, toe brachial index [TBI] and ankle brachial index [ABI]) and gait velocity (6-m walk test) in people with RA and controls. Differences in vascular characteristics between groups were determined using linear regression models, and associations between vascular characteristics and gait were determined using logistic regression models., Results: Seventy-two participants were included: 34 participants with RA mean disease duration 26.2 (SD 12.1) and 38 age- and sex-matched controls. The control group contained 30 females (79%), and the RA group had 28 females (82%). There were no significant differences between the RA and control groups for lower limb vascular characteristics. People with RA walked significantly slower compared to controls (1.10 m/s vs 0.91 m/s, P < .001). People with RA who had abnormal TBI, or abnormal qualitative Doppler walked significantly slower compared to those with normal TBI (0.86 m/s vs 0.95 m/s, P = .043 and 0.81 m/s, vs 0.93 m/s, P = .028). There was no significant association between ABI and gait velocity., Conclusion: This study did not identify different lower limb vascular characteristics in people with RA compared to matched controls. However, in people with RA, abnormal Doppler and TBI results are associated with slower walking velocity., (© 2019 Asia Pacific League of Associations for Rheumatology and John Wiley & Sons Australia, Ltd.)

Background: Limited ankle dorsiflexion, or equinus, is associated with elevated plantar pressures, which have been implicated in the development and non-healing of foot ulcer. A stretching intervention may increase ankle dorsiflexion and reduce plantar pressures in people with diabetes., Methods: Two arm parallel randomised controlled trial from September 2016 to October 2017. Adults with diabetes and ankle equinus (≤5° dorsiflexion) were randomly allocated to receive an 8 week static calf stretching intervention or continue with their normal activities. Primary outcome measures were change in weight bearing and non-weight bearing ankle dorsiflexion and forefoot peak plantar pressure. Secondary outcome measures were forefoot pressure time integrals and adherence to the stretching intervention., Findings: 68 adults (mean (standard deviation) age and diabetes duration 67.4 (10.9) years and 14.0 (10.8) years, 64.7% male) were randomised to stretch (n = 34) or usual activity (n = 34). At follow up, no significant differences were seen between groups (adjusted mean difference) for non-weight (+1.3°, 95% CI:-0.3 to 2.9, p = 0.101) and weight bearing ankle dorsiflexion (+0.5°, 95% CI:-2.6 to 3.6, p = 0.743) or forefoot in-shoe (+1.5 kPa, 95% CI:-10.0 to 12.9, p = 0.803) or barefoot peak pressures (-19.1 kPa, 95% CI:-96.4 to 58.1, p = 0.628). Seven of the intervention group and two of the control group were lost to follow up., Interpretation: Our data failed to show a statistically significant or clinically meaningful effect of static calf muscle stretching on ankle range of motion, or plantar pressures, in people with diabetes and ankle equinus., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Podiatric vascular assessment practices in the United Kingdom (UK) are currently unknown. This study aimed to describe the current practices for performing lower limb vascular assessments by podiatrists in the UK, and, to investigate the effect of practitioner characteristics, including education level and practice setting, on the choice of tests used for these assessments., Methods: A cross-sectional observational online survey of registered podiatrists in the UK was conducted using SurveyMonkey® between 1st of July and 5th of October 2018. Item content related to: practitioner characteristics, vascular testing methods, barriers to completing vascular assessment, interpretation of vascular assessment techniques, education provision and ongoing management and referral pathways. Descriptive statistics were performed, and multinomial logistic regression analyses were used to determine whether practitioner characteristics could predict the choice of vascular tests used., Results: Five hundred and eighty five participants accessed the online survey. After drop-outs and exclusions, 307 participants were included in the analyses. Comprehensive vascular assessments had most commonly been performed once (15.8%) or twice (10.4%) in the past week. The most common indicators for performing vascular assessment were symptoms of suspected claudication (89.3%), suspected rest pain (86.0%) and history of diabetes (85.3%). The most common barrier to performing vascular assessment was time constraints (52.4%). Doppler examination (72.3%) was the most frequently reported assessment type, with ankle-brachial index (31.9%) and toe brachial index (5.9%) less frequently performed. There were variable interpretations of vascular test results. The most common topic for education was smoking cessation (69.5%). Most participants (72.2%) were confident in determining ongoing management, with the majority referring to the patient's general practitioner (67.6%). Practitioner characteristics did not predict the types of vascular tests performed., Conclusion: The majority of vascular assessments currently performed by podiatrists in the UK are inconsistent with UK or international vascular guidelines and recommendations. Despite this, most podiatrists felt confident in diagnosing, referring and managing patients with peripheral arterial disease (PAD), however many felt they needed more education to feel confident to assist patients with PAD to manage their cardiovascular risk factors., Competing Interests: Competing interestsNone of the authors have any conflicts of interests to declare.

Aims: To describe the physical activity levels of an Australian community-based adult population with diabetes, and investigate the interaction between diabetes complications and physical activity., Methods: Anthropometric, demographic, biochemical and self-reported physical activity measures (IPAQ) were performed. Associations and multiple regression analyses were undertaken between physical activity, known risk factors for diabetes complications, and history of cardiovascular disease (CVD), neuropathy and foot ulceration obtained from medical records., Results: 240 participants were recruited (96% type 2 diabetes; age 68.7 ± 10.5 y; 58% men; diabetes duration 14.3 ± 11.4 y). Sixty seven percent of participants reported undertaking moderate or vigorous intensity exercise to recommended levels, and 29% reported no moderate-vigorous exercise. In addition to being associated with known demographic and biochemical risk factors and other complications, diabetes complications were also associated with different physical activity behaviours. Individuals with a history of CVD were more likely to participate in moderate-vigorous exercise and meet exercise guidelines, individuals with neuropathy undertook less walking and moderate intensity exercise, and those with a history of foot ulceration sat more and participated less in vigorous exercise., Conclusions: In Australian adults, the presence of diabetes complications may influence physical activity participation, and associate with characteristic physical activity approaches., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: An association between equinus and plantar pressure may be important for people with diabetes, as elevated plantar pressure has been linked with foot ulcer development. To determine the prevalence of equinus in community dwelling people with diabetes and to examine any association between presence of equinus and forefoot plantar pressures., Methods: Barefoot (Tekscan HR Mat™) and in-shoe (Novel Pedar-X®) plantar pressure variables, non-weight bearing ankle range of motion and neuropathy status were assessed in 136 adults with diabetes (52.2% male; 47.8% with neuropathy; mean (standard deviation) age and diabetes duration: 68.4 (11.5) and 14.6 (11.1) years respectively)., Findings: Equinus, when measured as ≤5° dorsiflexion, was present in 66.9% of the cohort. There was a significant correlation between an equinus and barefoot (r = 0.247, p = 0.004) and in-shoe forefoot pressure time integrals (r = 0.214, p = 0.012) and in-shoe forefoot alternate pressure time integrals (r = 0.246, p = 0.004). Significantly more males (p < 0.01) and people with neuropathy (p = 0.02) or higher glycated haemoglobin levels (p < 0.01) presented with an equinus., Interpretation: Community dwelling adults with diabetes have a high rate of ankle equinus which is associated with increased forefoot pressure time integrals and a two-fold increased risk of high in-shoe peak pressures. Clinical assessment of an ankle equinus may be a useful screening tool to identify adults at increased risk of diabetic foot complications., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Whilst post exercise ankle-brachial indices (ABI) are commonly used to help identify peripheral arterial disease (PAD), the role of post exercise toe pressures (TP) or toe-brachial indices (TBI) is unclear . The aim of this study was to determine, in a population without clinical signs of PAD, the effect that 30 s of weight-bearing heel raises has on TP and TBI values. Additionally, the ability of resting TP and TBI values to predict change in post-exercise values using the heel raise method was investigated., Methods: Participants over the age of 18 with a resting TBI of ≥0.60 and ABI between 0.90 and 1.40, without diabetes, history of cardiovascular disease and not currently smoking were included. Following ten minutes of supine rest, right TP and bilateral brachial pressures were performed in a randomized order using automated devices. Participants then performed 30 s of weight-bearing heel raises, immediately after which supine vascular measures were repeated. Data were assessed for normality using the Shapiro-Wilk test. For change in TP and TBI values the Wilcoxon Signed-Rank Test was performed. For correlations between resting and change in post exercise values, the Spearman Rank Order Correlations were performed, and where significant correlation identified, a linear regression undertaken., Results: Forty-eight participants were included. A statistically significant decrease was seen in the median TP from resting 103.00 mmHg (IQR: 89.00 to 124.75) to post exercise 98.50 mmHg (IQR: 82.00 to 119.50), z = - 2.03, p  = 0.04. This difference of 4.50 mmHg represents a 4.37% change and is considered a small effect size ( r  = 0.21). The median TBI also demonstrated a statistically significant decrease from resting 0.79 (IQR: 0.68 to 0.94) to post exercise 0.72 (IQR: 0.60 to 0.87), z = - 2.86, p  = < 0.01. This difference of 0.07 represents an 8.86% change and is considered a small effect size ( r  = 0.29). Linear regression demonstrated that resting TBI predicted 22.4% of the variance in post exercise TBI, p  = < 0.01, coefficients beta - 0.49., Conclusions: Thirty seconds of weight-bearing heel raises resulted in a similar decrease in TBI values seen in longer periods of exercise. TP values also showed a decrease post exercise; however this was contrary to previous studies., Competing Interests: This research was completed under the ethical approval of the University of Newcastle ethics committee approval number H-2016-0340.Not applicable.The author declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Accurate measurement of ankle joint dorsiflexion is clinically important as a restriction has been linked to many foot and ankle pathologies, as well as increased ulcer risk and delayed ulcer healing in people with diabetes. Use of the reliable weight bearing (WB) Lunge test is limited as normal and restricted ranges for WB ankle joint dorsiflexion are not identified. Additionally the extent of WB dorsiflexion restriction that results in clinically adverse outcomes is unclear. Therefore the aim of this investigation is to validate a proposed weight bearing equinus value (dorsiflexion < 30°) in unimpaired cohorts, and secondly to investigate any clinical effects this degree of ankle dorsiflexion restriction has on forefoot plantar pressure variables in older adults with diabetes., Methods: Ankle dorsiflexion was measured using a Lunge test with the knee extended in young adults without diabetes (YA) and older adults with diabetes (DA). In-shoe and barefoot plantar pressure was recorded for the DA group. Spearman's correlation was calculated to determine any association between the presence of ankle equinus and plantar pressure variables in the DA group. DA group differences in people with and without an equinus were examined., Results: A weight bearing equinus of < 30°, assessed in a lunge using an inclinometer placed on the anterior tibia, falls within the restricted range in young unimpaired cohorts. In the DA group this degree of ankle restriction had a fair and significant association with elevated barefoot forefoot peak pressure ( r  = 0.274, p  = 0.005) and pressure-time integrals ( r  = 0.321, p  = .001). The DA equinus group had significantly higher barefoot peak pressure (mean kPa (SD): 787.1 (246.7) vs 652.0 (304.5), p  = 0.025) and pressure-time integrals (mean kPa (SD): 97.8 (41.6) vs 80.4 (30.5), p  = 0.017) than the DA non equinus group., Conclusions: We support a preliminary weight bearing ankle equinus value of < 30°. This value represents a restricted range in young adults and is correlated with increased forefoot plantar pressure variables in older adults with diabetes. Mean population weight bearing ankle dorsiflexion data presented here for older adults with diabetes, will allow use of the more functional Lunge test with knee extended in research and clinical practice., Competing Interests: Ethics approval was granted by the University of Newcastle Human Research Ethics Committee (H-2015-0354) and written informed consent was obtained from all participants prior to their participation.Not applicableThe authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Background: Continuous-wave Doppler is frequently used for detecting peripheral arterial disease in patients with diabetes; however, there is limited evidence investigating diagnostic accuracy. This study aimed to determine sensitivity and specificity of continuous-wave Doppler for detecting peripheral arterial disease in populations with, and without, diabetes and to investigate the influence of disease severity on sensitivity of continuous-wave Doppler for detecting peripheral arterial disease., Results: Data from 396 participants were included. Using colour Duplex ultrasound as reference standard (N=66), printed continuous-wave Doppler waveform analysis sensitivity was 81.75% (95% confidence interval: 76.75 to 85.88) and specificity 89.34% (95% confidence interval: 82.62 to 93.67). Printed continuous-wave Doppler waveform analysis sensitivity for peripheral arterial disease was comparable to sensitivity calculated using angiography as the reference standard (81.67%; 95% confidence interval: 69.56 to 90.48). Sensitivity and specificity were unaffected by diabetes diagnosis (n = 176), sensitivity 82.76% (95% confidence interval: 74.86 to 88.55), and specificity 88.33% (95% confidence interval: 77.82 to 94.23)., Conclusion: Continuous-wave Doppler is a fair assessment tool for peripheral arterial disease in a community-based sample with suspected peripheral arterial disease. Diagnostic accuracy of continuous-wave Doppler for peripheral arterial disease is unaffected by the presence of diabetes.

Background: Accurate measurement of ankle dorsiflexion is important in both research and clinical practice as restricted motion has been associated with many foot pathologies and increased risk of ulcer in people with diabetes. This study aimed to determine the level of association between non-weight bearing versus weight bearing ankle dorsiflexion in adults with and without diabetes, and to evaluate the reliability of the measurement tools., Methods: One hundred and thirty-six adults with diabetes and 30 adults without diabetes underwent ankle dorsiflexion measurement non-weight bearing, using a modified Lidcombe template, and weight bearing, using a Lunge test. Pearson product-moment correlation coefficients, intraclass correlation coefficients (ICCs) with 95% confidence intervals, standard error of measurement and minimal detectable change were determined., Results: There was a moderate correlation (r = 0.62-0.67) between weight and non-weight bearing tests in the non-diabetes group, and a negligible correlation in the diabetes group(r = 0.004-0.007). Intratester reliability was excellent in both groups for the modified Lidcombe template (ICC = 0.89-0.94) and a Lunge test (ICC = 0.83-0.89). Intertester reliability was also excellent in both groups for the Lidcombe template (ICC = 0.91) and a Lunge test (ICC = 0.88-0.93)., Conclusions: We found the modified Lidcombe template and a Lunge test to be reliable tests to measure non-weight bearing and weight bearing ankle dorsiflexion in adults with and without diabetes. While both methods are reliable, further definition of weight bearing ankle dorsiflexion normative ranges may be more relevant for clinical practice.

The postexercise ankle-brachial index (ABI) is recommended in patients with normal resting ABI when peripheral artery disease (PAD) is suspected. The aims of this study were to determine the comparative diagnostic accuracy of the resting and postexercise ABI for detecting PAD, and, the effect of the presence of diabetes on these. Three methods of interpretation currently in use were also investigated: a reduction in postexercise ABI by >20% compared to resting ABI, an ABI value of ≤0.90 postexercise, or a reduction in systolic ankle pressure of >30 mmHg postexercise. This retrospective study used colour duplex ultrasound (CDU) as the reference standard. In 278 limbs (whole group), the resting ABI had an overall area under the curve (AUC) of 0.71, with the postexercise ABI yielding a similar diagnostic accuracy of AUC 0.72. In the non-diabetes group ( n=171), the resting ABI had an overall AUC of 0.74 and the postexercise ABI had a similar AUC of 0.76. In the diabetes group ( n=107), overall accuracy was reduced compared to the non-diabetes group, with the resting ABI having an overall AUC of 0.65 and the postexercise ABI yielding a similar accuracy with an AUC of 0.64. The overall diagnostic accuracy of the postexercise ABI for diagnosing PAD was not greatly improved compared to resting ABI. Given the lower overall diagnostic accuracy in the diabetes group, both the resting and the postexercise ABI results in diabetes populations should be interpreted with caution. There is a risk of undiagnosed disease if relying on these results alone to determine lower limb vascular status.

Background: The resting systolic toe pressure (TP) is a measure of small arterial function in the periphery. TP is used in addition to the ankle-brachial index when screening for peripheral arterial disease (PAD) of the lower limb in those with diabetes, particularly in the presence of lower limb medial arterial calcification. It may be used as an adjunct assessment of lower limb vascular function and as a predictor of wound healing. The aim of this study was to determine the diagnostic accuracy of TP for detecting PAD in people with and without diabetes., Methods: This was a retrospective case-control study. Two researchers extracted information from consecutive patient records, including TP measurements, colour Duplex ultrasound results, demographic information, and medical history. Measures of diagnostic accuracy were determined by receiver operating curve (ROC) analysis, and calculation of sensitivity, specificity, and positive and negative likelihood ratios., Results: Three hundred and nintey-four participants with suspected PAD were included. In the diabetes group ( n  = 176), ROC analysis of TP for detecting PAD was 0.78 (95%CI: 0.69 to 0.84). In the control group ( n  = 218), the ROC of TP was 0.73 (95%CI: 0.70 to 0.80). TP had highest sensitivity when anatomical distribution of disease was both proximal and distal (diabetes group: 79.49%, the control group: 82.61%). TP yielded highest sensitivity in mild disease (50-75% stenosis) in diabetes group, (81.82%) and moderate disease (>75% stenosis) in control group (80.77%)., Conclusions: Our findings indicate that TPs are useful to assist in diagnosing PAD in clinical practice, however, results should be interpreted with caution due to the small probability of PAD being present with a negative test., Competing Interests: This research was completed under the ethical approval of the University of Newcastle ethics committee approval number H2010–1230.Not applicable.The authors declare that they have no competing interests.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Aims: Diabetes-related microvascular disease has been implicated in the development of foot ulceration and amputation. Assessment of microvascular function may be effective in identifying those at risk of diabetic foot complications. We investigated the relationship between active or previous foot complication and post-occlusive reactive hyperaemia (PORH) measured by laser-Doppler fluxmetry (LDF) in people with type 2 diabetes., Methods: PORH measures were obtained from the hallux apex in 105 people with type 2 diabetes. Associations were investigated between active or previous foot complication and PORH measures: time to peak (TtPeak) and peak as a percentage of baseline (P%BL). Multinomial logistic regression was used to determine the association of PORH with the likelihood of active foot ulcer or previous foot complication., Results: For each second increase in TtPeak, the likelihood of a participant having a history of foot complication is increased by 2% (OR=1.019, p=0.01). This association was not reflected in people with an active foot ulcer (OR=1.003, p=0.832). P%BL was not found to be significantly different between those with a current or previous foot complication and those without (p=0.404)., Conclusions: This investigation in a cohort with type 2 diabetes has demonstrated that longer TtPeak is associated with history of diabetic foot complications., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Ectopic adipose tissue surrounding the intra-abdominal organs (visceral fat) and located in the liver, heart, pancreas and muscle, is linked to cardio-metabolic complications commonly experienced in type 2 diabetes. A systematic review and meta-analysis was performed to determine the effect of exercise on ectopic fat in adults with type 2 diabetes. Relevant databases were searched to February 2016. Included were randomised controlled studies, which implemented≥4 weeks of aerobic and/or resistance exercise and quantified ectopic fat via magnetic resonance imaging, computed tomography, proton magnetic resonance spectroscopy or muscle biopsy before and after intervention. Risk of bias and study quality was assessed using Egger's funnel plot test and modified Downs and Black checklist, respectively. Of the 10,750 studies retrieved, 24 were included involving 1383 participants. No studies were found assessing the interaction between exercise and cardiac or pancreas fat. One study assessed the effect of exercise on intramyocellular triglyceride concentration. There was a significant pooled effect size for the meta-analysis comparing exercise vs. control on visceral adiposity (ES=-0.21, 95% CI: -0.37 to -0.05; P=0.010) and a near-significant pooled effect size for liver steatosis reduction with exercise (ES=-0.28, 95% CI: -0.57 to 0.01; P=0.054). Aerobic exercise (ES=-0.23, 95% CI: -0.44 to -0.03; P=0.025) but not resistance training exercise (ES=-0.13, 95% CI: -0.37 to 0.12; P=0.307) was effective for reducing visceral fat in overweight/obese adults with type 2 diabetes. These data suggest that exercise effectively reduces visceral and perhaps liver adipose tissue and that aerobic exercise should be a key feature of exercise programs aimed at reducing visceral fat in obesity-related type 2 diabetes. Further studies are required to assess the relative efficacy of exercise modality on liver fat reduction and the effect of exercise on pancreas, heart, and intramyocellular fat in type 2 diabetes and to clarify the effect of exercise on ectopic fat independent of weight loss., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Aim: Regular aerobic exercise reduces visceral adipose tissue (VAT) and liver fat, however, not all individuals are able to adopt and adhere to such programs. Progressive resistance training (PRT) may be an alternative therapy, but there is limited available evidence. We examined the efficacy of PRT as per current exercise guidelines, compared with sham exercise placebo on liver fat and VAT., Methods: Twenty-nine inactive and overweight/obese (body mass index ≥25 kg/m 2 ) adults (age 29-59) were randomized to receive 8 weeks of PRT (n = 15, 10 exercises per session, 8-12 repetitions, 2-3 sets per exercise at 80-85% of one-repetition maximum, 3 days per week) or a sham exercise placebo control (CON) (n = 14). Change in liver fat, VAT, and abdominal s.c. adipose tissue (SAT) were assessed by magnetic resonance spectroscopy and imaging)., Results: There were no significant group by time interactions for change in liver fat in PRT versus CON groups (-0.07 ± 0.31% vs. 0.55 ± 0.77%, respectively, P = 0.19), VAT (-175 ± 85 cm 3 vs. 10 ± 64 cm 3 , respectively, P = 0.11), or abdominal SAT (-436 ± 245 cm 3 vs. 127.29 ± 182 cm 3 , respectively, P = 0.10) despite a significant increase in muscle volume (55 ± 78 cm 3 vs. -0.04 ± 8 cm 3 , respectively, P = 0.03)., Conclusion: Traditional PRT is not effective for reducing liver fat in overweight/obese adults compared with placebo control. Although PRT has known metabolic benefits, an adequate volume of aerobic exercise should be promoted if liver fat is the therapeutic target., (© 2016 The Japan Society of Hepatology.)

Background: Low back pain (LBP) is an increasingly common condition worldwide with significant costs associated with its management. Identification of musculoskeletal risk factors that can be treated clinically before the development of LBP could reduce costs and improve the quality of life of individuals. Therefore the aim was to systematically review prospective cohort studies investigating lower back and / or lower limb musculoskeletal risk factors in the development of LBP., Methods: MEDLINE, EMBASE, AMED, CINAHL, SPORTDiscus, and the Cochrane Library were searched from inception to February 2016. No age, gender or occupational restrictions of participants were applied. Articles had to be published in English and have a 12 month follow-up period. Musculoskeletal risk factors were defined as any osseous, ligamentous, or muscular structure that was quantifiably measured at baseline. Studies were excluded if participants were pregnant, diagnosed with cancer, or had previous low back surgery. Two authors independently reviewed and selected relevant articles. Methodological quality was evaluated independently by two reviewers using a generic tool for observational studies., Results: Twelve articles which evaluated musculoskeletal risk factors for the development of low back pain in 5459 participants were included. Individual meta-analyses were conducted based on risk factors common between studies. Meta-analysis revealed that reduced lateral flexion range of motion (OR = 0.41, 95% CI 0.24-0.73, p = 0.002), limited lumbar lordosis (OR = 0.73, 95% CI 0.55-0.98, p = 0.034), and restricted hamstring range of motion (OR = 0.96, 95% CI 0.94-0.98, p = 0.001) were significantly associated with the development of low back pain. Meta-analyses on lumbar extension range of motion, quadriceps flexibility, fingertip to floor distance, lumbar flexion range of motion, back muscle strength, back muscle endurance, abdominal strength, erector spinae cross sectional area, and quadratus lumborum cross sectional area showed non-significant results., Conclusion: In summary, we found that a restriction in lateral flexion and hamstring range of motion as well as limited lumbar lordosis were associated with an increased risk of developing LBP. Future research should aim to measure additional lower limb musculoskeletal risk factors, have follow up periods of 6-12 months, adopt a standardised definition of LBP, and only include participants who have no history of LBP.

Aims: It is unclear how well non-invasive lower-limb vascular assessments can identify those at risk of foot complications in people with diabetes. We aimed to investigate the relationship between a history of foot complication (ulceration or amputation) and non-invasive vascular assessments in people with diabetes., Methods: Bilateral ankle-brachial index (ABI), toe brachial index (TBI) and continuous wave Doppler (CWD) were performed in 127 adults with diabetes (97% type 2; age 66.08±11.4years; 55% men; diabetes duration 8.8±7.6years; 28% on insulin therapy; 31% with foot complication history. Correlations were performed between known risk factors for, and documented history of, foot complication. Regression analysis was used to determine the effect of TBI on the likelihood of a prior foot complication., Results: By logistic regression, the likelihood of foot complication history was highest in those with TBI <0.6 (OR=7.74, p=0.001); then longer diabetes duration (OR=1.06, p=0.05). HbA1c did not independently predict history of foot complications (OR=1.10, p=0.356)., Conclusions: Likelihood of previous foot complication in this population was ~8 times higher when TBI was <0.6. Such clinical risk profiling was not shown by other non-invasive measures. Prioritizing TBI as a measure of lower-limb vascular disease may be useful to prospectively identify those at risk of diabetic foot complications., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objectives: This study aimed to review the efficacy of exercise training for improving cutaneous microvascular reactivity in response to local stimulus in human adults., Design: Systematic review with meta-analysis., Methods: A systematic search of Medline, Cinahl, AMED, Web of Science, Scopus, and Embase was conducted up to June 2015. Included studies were controlled trials assessing the effect of an exercise training intervention on cutaneous microvascular reactivity as instigated by local stimulus such as local heating, iontophoresis and post-occlusive reactive hyperaemia. Studies where the control was only measured at baseline or which included participants with vasospastic disorders were excluded. Two authors independently reviewed and selected relevant controlled trials and extracted data. Quality was assessed using the Downs and Black checklist., Results: Seven trials were included, with six showing a benefit of exercise training but only two reaching statistical significance with effect size ranging from -0.14 to 1.03. The meta-analysis revealed that aerobic exercise had a moderate statistically significant effect on improving cutaneous microvascular reactivity (effect size (ES)=0.43, 95% CI: 0.08-0.78, p=0.015)., Conclusions: Individual studies employing an exercise training intervention have tended to have small sample sizes and hence lacked sufficient power to detect clinically meaningful benefits to cutaneous microvascular reactivity. Pooled analysis revealed a clear benefit of exercise training on improving cutaneous microvascular reactivity in older and previously inactive adult cohorts. Exercise training may provide a cost-effective option for improving cutaneous microvascular reactivity in adults and may be of benefit to those with cardiovascular disease and metabolic disorders such as diabetes., (Copyright © 2016 Sports Medicine Australia. Published by Elsevier Ltd. All rights reserved.)

The aim of the study was to investigate the relationship between the toe brachial index (TBI) and foot ulceration and amputation in older people. Two hundred and sixty-one participants meeting guidelines for lower limb vascular assessment had their toe and brachial blood pressure measured, medical records audited and signs and symptoms of peripheral arterial disease (PAD) recorded. Pearson's correlation and linear regression analyses were performed to determine the strength of relationships between variables. Significant correlations were found between the TBI and painful symptoms (r = -0·35, P < 0·05) and foot complications (r = -0·31, P < 0·05). After adjusting for traditional risk factors for foot complications, participants with a TBI <0·70 were 19 times more likely to have a history of foot wounds or amputation (odds ratio = 19·20, 95% confidence interval (CI): 2·36-155·96, P < 0·001) than those with higher TBI values (>0·70). This preliminary study supports a TBI threshold of 0·70 for PAD diagnosis and indicates that lower values are associated with painful symptoms, history of ulceration and amputation. Future longitudinal investigation of the predictive capacity is now warranted., (© 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Background: Podiatrists routinely perform non-invasive lower limb vascular assessment, however frequently cite time as a major barrier in performing regular assessment. The aim of this study was to develop an evidence-based vascular assessment method to guide podiatrists' decision-making processes to aid in timely vascular assessment in at risk populations., Method: The sample underwent brachial pressure measurement, ankle pressures, toe pressure and Doppler waveform with colour duplex ultrasound (CFDU) used as the reference standard. Both the targeted screening method and the American Heart Association (AHA) guideline for vascular screening were then applied to the data set and sensitivity and specificity of each method was calculated., Results: One hundred nineteen participants were included. Sensitivity of the targeted screening method (62%, 95% CI 47.17-75.35) was higher than the AHA method (49%, 95% CI 34.75-63.40), however, specificity of the AHA method (94%, 95% CI 85.62-98.37) was higher than the targeted screening method (85%, 95% CI 74.26-92.60). Diagnostic accuracy was similar with the AHA method yielding 74% diagnostic accuracy and the targeted screening method 73%., Conclusion: The targeted screening method and the broad international guideline demonstrated similar accuracy, however clinicians may save time using the targeted screening method. This study highlights the difficulties in obtaining accuracy in lower limb vascular assessment in general.

Background: Foot pain is a common problem affecting up to 1 in 5 adults and is known to adversely affect activities of daily living and health related quality of life. Orthopaedic footwear interventions are used as a conservative treatment for foot pain, although adherence is known to be low, in part due to the perception of poor comfort and unattractiveness of the footwear. The objective of this trial was to assess the efficacy of flip-flop style footwear (Foot Bio-Tec©) with a moulded foot-bed in reducing foot pain compared to participant's usual footwear., Methods: Two-arm parallel randomised controlled trial using computer generated random allocation schedule at an Australian university podiatry clinic. 108 volunteers with disabling foot pain were enrolled after responding to an advertisement and eligibility screening. Participants were randomly allocated to receive footwear education and moulded flip-flop footwear to wear as much as they were comfortable with for the next 12 weeks (n = 54) or footwear education and instructions to wear their normal footwear for the next 12 weeks (n = 54). Primary outcome was the pain domain of the Foot Health Status Questionnaire (FHSQ). Secondary outcomes were the foot function and general foot health domains of the FHSQ, a visual analogue scale (VAS) for foot pain and perceived comfort of the intervention footwear., Results: Compared to the control group, the moulded flip-flop group showed a significant improvement in the primary outcome measure of the FHSQ pain domain (adjusted mean difference 8.36 points, 95 % CI 5.58 to 13.27, p < 0.01). Statistical and clinically significant differences were observed for the secondary measure of foot pain assessed by a VAS and the FSHQ domains of foot function and general foot health. None of the participants reported any pain or discomfort from the intervention footwear and six (footwear group = 4) were lost to follow up., Conclusions: Our results demonstrate that flip-flop footwear with a moulded foot-bed can have a significant effect on foot pain, function and foot health and might be a valuable adjunct therapy for people with foot pain., Trial Registration: ACTRN12614000933651 . Retrospectively registered: 01/09/2014.

The toe-brachial index (TBI) is used as an adjunct to the ankle-brachial index (ABI) for non-invasive lower limb vascular screening. With increasing evidence suggesting limitations of the ABI for diagnosis of vascular complications, particularly in specific populations including diabetes cohorts, the TBI is being used more widely. The aim of this review was to determine the sensitivity and specificity of the TBI for detecting peripheral artery disease (PAD) in populations at risk of this disease. A database search was conducted to identify current work relating to the sensitivity and specificity of toe-brachial indices up to July 2015. Only studies using valid diagnostic imaging as a reference standard were included. The QUADAS-2 tool was used to critically appraise included articles. Seven studies met the inclusion criteria. Sensitivity of the TBI for PAD was reported in all seven studies and ranged from 45% to 100%; specificity was reported by five studies only and ranged from 16% to 100%. In conclusion, this review suggests that the TBI has variable diagnostic accuracy for the presence of PAD in specific populations at risk of developing the disease. There was a notable lack of large-scale diagnostic accuracy studies determining the diagnostic accuracy of the TBI in detecting PAD in different at-risk cohorts. However, standardised normal values need to be established for the TBI to conclusively determine the diagnostic accuracy of this test., (© The Author(s) 2016.)

Aims: Neuropathies are common complications of diabetes and are proposed to influence peripheral bone, principally via an altered vascular supply. This study aimed to determine the relationship between subtypes of neuropathy and vascular reactivity on foot bone density in people with diabetes., Methods: A case-control observational design was utilised with two groups: those with diabetic peripheral large fibre neuropathy (n=23) and a control group with diabetes but without neuropathy (n=23). Bone density in 12 foot bones was determined with computed tomography scanning. Additionally, post-occlusive reactive hyperemia, presence of small fibre neuropathy and heart rate variability were determined. T-tests and hierarchical regression were used to examine the relationships among the variables., Results: No difference in foot bone density was found between those with and those without large fibre neuropathy. Furthermore, no association between heart rate variability or reactive hyperemia and bone density was found. Small fibre neuropathy was associated with increased cuboid trabecular bone density (p=0.006) with its presence predictive of 14% of the variance., Conclusions: This study found no clear association between presence of diabetic neuropathies and foot bone density. Furthermore, vascular reactivity appears to have no impact on bone density., (Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.)

Objective: This study examined whether the presence of peripheral sensory neuropathy or cardiac autonomic deficits is associated with postocclusive reactive hyperemia (reflective of microvascular function) in the diabetic foot., Research Design and Methods: 99 participants with type 2 diabetes were recruited into this cross-sectional study. The presence of peripheral sensory neuropathy was determined with standard clinical tests and cardiac autonomic function was assessed with heart rate variation testing. Postocclusive reactive hyperemia was measured with laser Doppler in the hallux. Multiple hierarchical regression was performed to examine relationships between neuropathy and the peak perfusion following occlusion and the time to reach this peak., Results: Peripheral sensory neuropathy predicted 22% of the variance in time to peak following occlusion (p<0.05), being associated with a slower time to peak but was not associated with the magnitude of the peak. Heart rate variation was not associated with the postocclusive reactive hyperemia response., Conclusions: This study found an association between the presence of peripheral sensory neuropathy in people with diabetes and altered microvascular reactivity in the lower limb.

Background & Aims: Non-invasive lower limb vascular assessment in people at risk of peripheral arterial disease (PAD) including those with diabetes is crucial. There is evidence that standard assessment techniques such as the ankle-brachial index (ABI) may be less effective in people with diabetes. However there is limited evidence for other frequently used tests including continuous wave Doppler (CWD), and the toe-brachial index (TBI). The aim of this study was to determine the sensitivity and specificity of, ABI, CWD and TBI in a population with, and without diabetes., Methods: Participants with and without diabetes who met current guidelines for vascular screening were recruited, and CWD waveforms, an ABI and a TBI were obtained from the right lower limb. Diagnostic accuracy was determined using colour duplex ultrasound (CFDU). Receiver operating characteristic curves were calculated., Results: 117 participants were recruited, seventy-two with diabetes and forty-five without diabetes. CWD had the highest sensitivity in people with diabetes (74%) and without (84%). CWD also had the highest specificity in people with diabetes (74%) and without (84%) compared to both TBI and ABI. In participants with diabetes, the ABI was a poor test, area under the curve: 0.58 (p=0.27)., Conclusions: CWD waveform is more likely to detect significant PAD compared to ABI and TBI in people with and without diabetes., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Deterioration of the structure and function of the vascular system is the underlying feature in cardiovascular disease (CVD), which is the highest cause of mortality in type 2 diabetes (T2D). Studies assessing the effect of exercise on vascular function and stiffness have used different measurement techniques and small cohorts, making it difficult to conclude on the overall efficacy of exercise on these outcomes. The aim of this study was to assess the effect of exercise on vascular function and stiffness in T2D. Electronic database searches were performed in AMED, MEDLINE, MEDLINE Daily Update, PREMEDLINE, SPORTDiscus, CINAHL, EMBASE and Web of Science. The effect size (ES), and 95% confidence intervals (CIs) of eligible studies were calculated. Pooled estimates of the effect of aerobic exercise (AEx) on vascular function and stiffness, using ES, were obtained. Results show that AEx led to a near-significant reduction in PWV (ES = -0.472; 95% CI: -0.949 to 0.005; P = 0.052), a significant reduction in EID (ES = 0.416, 95% CI: 0.062 to 0.769; P= 0.021), and a non-significant benefit in FMD measures. There were limited studies using resistance training or in combination with aerobic exercise, to assess a pooled effect on vascular function or stiffness. These data suggest that aerobic exercise training should be used as a primary treatment strategy for improving vascular smooth muscle function as measured by EID in individuals with T2D. There is currently insufficient evidence concerning the efficacy of regular exercise for improving vascular function and stiffness as measured by FMD and PWV.

Background: Podiatrists play a central role in conducting non-invasive vascular assessment in the lower extremity. This involves screening for signs and symptoms of peripheral arterial disease (PAD) and ongoing monitoring of the condition. Podiatric vascular assessment practices in Australia and New Zealand are currently unclear. Determining the clinical habits of Podiatrists is essential in identifying if there is a need for further education or support in performing accurate vascular assessments., Methods: A web-based, secure, anonymous questionnaire was conducted of registered Podiatrists in Australia and New Zealand between 1 April and 31 July 2013. The questions examined clinician's regular practices in vascular assessment, clinical indicators to perform and barriers in completing vascular assessment. Nominal logistic regression was performed to further examine years of experience and practice setting on clinical indicators to perform vascular assessment and types of assessment performed., Results: Four hundred forty-seven podiatrists participated in the survey. Clinical indicators for vascular assessment, along with barriers and available equipment were examined and the results varied depending on the podiatrists' geographical location, practice setting, and experience. Palpation of pedal pulses was the most frequently reported assessment (97 %) along with Doppler assessment (74 %). Pressure measurement was the least frequently reported vascular assessment method, with only 34 % undertaking ankle-brachial indices and 19 % completing toe-brachial indices. Public podiatrists reported more varied and complete vascular assessment compared to those in private practice. Lack of time was identified as the most frequently reported barrier (66 %) in performing vascular assessment, followed by lack of equipment (28 %). In New Zealand podiatrists, lack of equipment was much more of an issue than in Australian podiatrists., Conclusion: Large variations exist in vascular assessment methods amongst Australian and New Zealand podiatrists. Some assessments being undertaken are potentially inadequate for accurate screening for PAD. There is a need for continuing education in vascular assessment to address the deficiencies in technique reported by some Podiatrists. A podiatry-relevant summary of broad international guidelines for PAD screening may be of use to improve utilisation and accuracy of screening methods to improve patient management.

Objectives: The toe-brachial index (TBI) is an alternative to the ankle-brachial index (ABI) in screening for peripheral arterial disease (PAD); however, there is limited evidence comparing their diagnostic accuracy. This study compared the diagnostic accuracy of the ABI and TBI in a population at risk of PAD., Methods: The sensitivity and specificity of the ABI and TBI were determined by color duplex sonography. Receiver operating characteristic (ROC) analysis was performed., Results: A total of 119 participants were recruited (75 male and 44 female). The sensitivity for PAD was highest for the TBI (71%; ABI, 45%), and the specificity was highest for the ABI (93%; TBI, 78%). Receiver operating characteristic analysis indicated that the TBI (ROC area, 0.77; P = .0001) had greater clinical efficacy for diagnosis of PAD than the ABI (ROC area, 0.65; P = .005)., Conclusions: In specific populations, the TBI may have greater clinical efficacy than the ABI for diagnosis of PAD., (© 2015 by the American Institute of Ultrasound in Medicine.)

Objectives: Evaluation of peripheral blood supply is fundamental to risk categorization and subsequent ongoing monitoring of patients with lower extremity peripheral arterial disease. Toe systolic blood pressure (TSBP) and the toe brachial index (TBI) are both valid and reliable vascular screening techniques that are commonly used in clinical practice. However, the effect of pretest rest duration on the magnitude of these measurements is unclear., Methods: Eighty individuals meeting current guidelines for lower extremity peripheral arterial disease screening volunteered to participate. The Systoe and MicroLife automated devices were used to measure toe and brachial systolic blood pressures, respectively, following 5, 10 and 15 min of rest in a horizontal supine position. A ratio of TSBP to brachial pressure was used to calculate the TBI and change in TBI at each time interval was investigated., Results: A significant increase in TSBP [3.66 mmHg; 95% confidence interval (CI): 1.44-5.89; P≤0.001] and the TBI (0.03; 95% CI: 0.01-0.05; P≤0.001) occurred between 5 and 10 min. Between 10 and 15 min, there was a nonsignificant decrease in TSBP (-0.73 mmHg; 95% CI: -1.48 to 2.93; P=1.000) and the TBI (0.00; 95% CI: -0.02 to 0.02; P=1.000)., Conclusion: Ten minutes of pretest rest is recommended for measurement of TSBP and for both pressure measurements used in the calculation of a TBI to ensure that stable pressures are measured.

Background: Hand held Doppler examination is a frequently used non-invasive vascular assessment utilised by podiatrists. Despite this, the reliability of hand-held Doppler has not been thoroughly investigated. Given the importance of Doppler in completing a vascular assessment of the lower limb, it is essential to determine the reliability of the interpretation of this testing method in practicing podiatrists., Methods: This was a multi-centre inter and intra-rater reliability study. Four podiatrists (the raters) participated in this study, two public and two private practitioners. Three aspects of Doppler use were examined; (i) use of Doppler (i.e., technique and interpretation), (ii) interpretation of Doppler audio sounds, and (iii) interpretation of visual Doppler waveforms (i.e., tracings). Participants meeting current guidelines for vascular screening attended two testing sessions, 1 week apart at either the private practice (n = 32), or the public practice (n = 31). To assess use of Doppler, the raters evaluated the Doppler waveforms that they collected, rating them as mono-phasic or multi-phasic. To assess Doppler audio sounds and visual Doppler waveforms, raters were required to evaluate 30 audio recordings of Doppler sounds and 30 waveform tracings, respectively, that were previously recorded and chosen at random by the researchers. Cohen's kappa (κ) statistics were used to calculate inter and intra-rater reliability using SPSS version 19., Results: Use of Doppler demonstrated the lowest reliability for both pairs of clinicians (inter-rater reliability κ 0.20 to 0.24 and intra-rater reliability κ 0.27 to 0.42). The public podiatrists showed higher reliability in audio interpretation (inter-tester reliability κ 0.61, intra-tester reliability κ 1.00) compared to the private podiatrists (inter-tester reliability κ 0.31, intra-tester reliability κ 0.53). Evaluation of Doppler waveform tracings demonstrated highest reliability, with inter-rater reliability ranging from κ 0.77 to 0.90 and intra-rater reliability from κ 0.81 to 1.00., Conclusions: There is a need for ongoing education for podiatrists using Doppler in clinical practice, as the reliability for the clinical use of the Doppler was low. This indicates that technique could be an issue. There is also a need to further evaluate if hand-held Doppler equipment, using the examinations that we evaluated, is suitable for use in the contexts examined in this study.

Background & Aims: Aerobic exercise reduces liver fat and visceral adipose tissue (VAT). However, there is limited data from randomized trials to inform exercise programming recommendations. This study examined the efficacy of commonly prescribed exercise doses for reducing liver fat and VAT using a randomized placebo-controlled design., Methods: Inactive and overweight/obese adults received 8 weeks of either; i) low to moderate intensity, high volume aerobic exercise (LO:HI, 50% VO 2peak, 60 min, 4d/week); ii) high intensity, low volume aerobic exercise (HI:LO, 70% VO 2peak, 45 min, 3d/week); iii) low to moderate intensity, low volume aerobic exercise (LO:LO, 50% VO 2peak, 45 min, 3d/week); or iv) placebo (PLA). Liver fat (spectroscopy) and VAT (magnetic resonance imaging) were measured before and after intervention., Results: Forty-seven of the 48 (n = 12 in each group) participants completed the trial. There were no serious adverse events. There was a significant change in group × time interaction in liver fat, which reduced in HI:LO by 2.38 ± 0.73%, in LO:HI by 2.62 ± 1.00%, and in LO:LO by 0.84 ± 0.47% but not in PLA (increase of 1.10 ± 0.62%) (p = 0.04). There was a significant reduction in VAT in HI:LO (-258.38 ± 87.78 cm(3)), in LO:HI (-386.80 ± 119.5 cm(3)), and in LO:LO (-212.96 ± 105.54 cm(3)), but not in PLA (92.64 ± 83.46 cm(3)) (p = 0.03). There were no significant differences between the dose or intensity of the exercise regimen and reductions in liver fat or VAT (p > 0.05)., Conclusion: The study found no difference in efficacy of liver fat reduction by either aerobic exercise dose or intensity. All of the aerobic exercise regimens employed reduced liver fat and VAT by a small amount without clinically significant weight loss., (Copyright © 2015 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Objectives: Toe pressures are used to evaluate lower extremity healing capacity and screen for peripheral arterial disease (PAD). Although toe pressures are commonly used clinically both as an independent measure and in the calculation of the toe-brachial index, the effect of pre-measurement rest duration on the magnitude and reliability of toe pressures is unknown. This study investigated the effect of pre-measurement rest duration on toe pressures., Methods: Seventy community-based participants meeting guidelines for PAD screening were recruited. Systolic toe pressures either at the left or right hallux were manually measured using photoplethysmography following 5, 10 and 15 min of rest in a supine horizontal position. Testing was repeated 7-10 days later., Results: A significant drop in toe pressure (3.86 mmHg) occurred between 5 and 10 min (p = 0.001). No significant change occurred between 10 and 15 min. Reliability after 5 min was excellent (intra-class correlation coefficient, ICC = 0.80, 95% CI 0.68-0.89), increasing slightly at 10 and 15 min (ICC = 0.86, 95% CI 0.77-0.92 and ICC = 0.82, 95% CI 0.69-0.89)., Conclusions: Toe pressures stabilize after 10 min of rest in a supine horizontal position. Longer periods of pre-measurement rest did not improve reliability significantly.

Background: Poor core stability is linked to a range of musculoskeletal pathologies and core-strengthening programmes are widely used as treatment. Treatment outcomes, however, are highly variable, which may be related to the method of delivery of core strengthening programmes. We investigated the effect of identical 8 week core strengthening programmes delivered as either supervised or home-based on measures of core stability., Methods: Participants with poor core stability were randomised into three groups: supervised (n=26), home-based (n=26) or control (n=26). Primary outcomes were the Sahrmann test and the Star Excursion Balance Test (SEBT) for dynamic core stability and three endurance tests (side-bridge, flexor and Sorensen) for static core stability. The exercise programme was devised and supervised by an exercise physiologist., Results: Analysis of covariance on the change from baseline over the 8 weeks showed that the supervised group performed significantly better on all core stability measures than both the home-based and control group. The home-based group produced significant improvements compared to the control group in all static core stability tests, but not in most of the dynamic core stability tests (Sahrmann test and two out of three directions of the SEBT)., Conclusions: Our results support the use of a supervised core-strengthening programme over a home-based programme to maximise improvements in core stability, especially in its dynamic aspects. Based on our findings in healthy individuals with low core stability, further research is recommended on potential therapeutic benefits of supervised core-strengthening programmes for pathologies associated with low core stability., Trial Registration Number: ACTRN12613000233729., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)