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Master's Dissertation
DOI
10.11606/D.5.2007.tde-21082007-105944
Document
Author
Full name
Paula Marie Hanai Akashi
E-mail
Institute/School/College
Knowledge Area
Date of Defense
Published
São Paulo, 2007
Supervisor
Committee
Sacco, Isabel de Camargo Neves (President)
Barela, José Angelo
Luccia, Nelson de
Title in Portuguese
Influência da neuropatia periférica e da ulceração plantar nas variáveis cinéticas e eletromiográficas durante a marcha de diabéticos
Keywords in Portuguese
Biomecânica
Diabetes Mellitus
Eletromiografia
Marcha
Neuropatias diabéticas
Úlcera do pé
Abstract in Portuguese
O objetivo deste trabalho foi investigar a influência da neuropatia diabética e da presença da ulceração plantar na história clínica de diabéticos neuropatas, como conseqüência desta doença, na sensibilidade somatossensorial plantar e nas variáveis cinéticas e eletromiográficas do membro inferior durante a marcha descalça em grupos de diabéticos neuropatas com e sem história de ulceração plantar. Os grupos estudados foram formados por 45 voluntários adultos, não idosos, de ambos os sexos, divididos em três grupos: GD - grupo de diabéticos neuropatas sem úlceras plantares (n=19), GDU - grupo de diabéticos neuropatas em cuja história clínica houve pelo menos ocorrência de uma ulceração plantar nos últimos dois anos (n= 10) e GC - grupo controle (n= 16) constituído de sujeitos assintomáticos, não diabéticos, da mesma faixa etária que os grupos GD e GDU. Os resultados da avaliação sensorial mostraram uma piora progressiva do déficit sensorial com a piora da neuropatia. Os indivíduos do GDU apresentaram maior déficit de sensibilidade plantar que os do GD. O GDU também apresentou maior tempo de apoio em comparação com o grupo não ulcerado (GC=693,1 ± 65,98; GD=681,5 ± 51,2; GDU=758,5 ± 105,1, em milisegundos) indicando que estes sujeitos apresentam um maior tempo de exposição do pé às pressões exercidas com o contato com o solo durante a marcha. Houve uma redução gradativa dos valores de segundo pico da FRS vertical do GC para o GD e deste para o GDU, que foi significativa destes últimos em relação ao GC (GC=1,09 ± 0,06; GD = 1,05 ± 0,08; GDU = 1,02 ± 0,06). Dentre as alterações eletromiográficas apresentadas pelos diabéticos ulcerados, destacam-se: o atraso do pico de ativação dos músculos vasto lateral, logo após o contato do calcanhar (GC=10,82 ± 3,33; GD=11,97 ± 2,31; GDU=14,83 ± 3,53,% do tempo de apoio) e o atraso do gastrocnêmio lateral na fase de propulsão (GC=63,53 ± 3,65; GD=62,84± 5,06; GDU=68,00± 4,78, % do tempo de apoio). Essas alterações biomecânicas sugerem que os diabéticos neuropatas ulcerados apresentam uma ineficiência do sistema musculoesquelético tanto na fase de absorção do choque no momento do contato do calcanhar quanto na fase de propulsão. Embora sem diferenças significantes, observou-se também maior atividade do tibial anterior entre os sujeitos do GD, sugerindo a presença de um mecanismo compensatório para diminuir a sobrecarga do antepé na fase de aplainamento. As alterações encontradas, associadas aos outros sinais da neuropatia, como o déficit de sensibilidade plantar, podem ser fatores predisponentes para a formação ou recorrência de úlceras plantares.
Title in English
Influence of diabetic neuropathy and history of plantar ulceration on kinectic and electromiographic variables during gait
Keywords in English
Biomechanics
Diabetes Mellitus
Diabetic neuropathies
Electromography
Foot ulcer
Gait
Abstract in English
The aim of this work was to investigate the influence of diabetic neuropathy and the clinical history of plantar ulceration in the somatossensorial plantar sensitivity and in kinectic and electromyographic lower limb variables during gait of diabetic neuropathic subjects with (UDG) and without (DG) history of plantar ulceration. The casuistics was composed by 45 gender and age matched adult subjects, who were divided into three groups: DG - diabetic neuropathic group (n=19), UDG - diabetic neuropathic group composed by diabetic neuropathic subjects who presented at least one foot ulceration in the past two years (n=10), and a control group (CG) composed by non-diabetics asymptomatic adults. The results of somatossensorial tests showed a gradual loss of plantar sensitivity with the neuropathy progression. Subjects from UDG had worse plantar sensitivity than the DG. UDG also showed higher total contact time than DG (CG=693,1 ± 65,98; DG=681,5 ± 51,2; UDG=758,5 ± 105,1, in miliseconds). These numbers indicate that UDG subjects have a longer exposition time of the plantar surface to the pressures made by the contact with the ground durint gait. There was a gradual reduction of the vertical GRF second peak, from CG to DG, and from this last group to the UDG (CG=1,09 ± 0,06; DG = 1,05 ± 0,08; UDG = 1,02 ± 0,06). The main electromiographic changes found in UDG were: a delayed peak of activation of vastus lateralis muscle, right after the heel contact (CG=10,82 ± 3,33; DG=11,97 ± 2,31; UDG=14,83 ± 3,53,% of contact time), and a delayed peak of activation of gastrocnemius lateralis muscle (CG=63,53 ± 3,65; DG=62,84± 5,06; UDG=68,00± 4,78,% of contact time). These biomechanical changes suggest that diabetic neuropathic subjects with history of foot ulceration have a muscleskeleton system inefficacy during the shock absorption phase and during the propulsion phase of the gait. Although there were no significant differences in tibialis anterior muscle activity, DG subjects showed higher TA EMG activity, which suggests a compensatory mechanism to diminish overload on the forefoot during flat foot phase. The biomechanical changes found, associated with other sign and symptoms of neuropathy, like the loss of sensitivity, could be considerate predisposable factors for plantar ulcers formation or its recurrence.
 
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Publishing Date
2007-08-22
 
WARNING: The material described below relates to works resulting from this thesis or dissertation. The contents of these works are the author's responsibility.
  • AKASHI, P.M.H., et al. The effect of the diabetic neuropathy and previous foot ulceration in the EMG and ground reaction forces during gait [doi:10.1016/j.clinbiomech.2007.11.015]. Clinical Biomechanics (Bristol) [online], 2008, vol. 23, p. 584-592.
  • BACARIN, T.A., AKASHI, P.M.H., and SACCO, I. C. N. Duration of disease, neuropathy symptoms and plantar sensitivity in diabetic patients with and without previous plantar ulceration. Wounds.. A Compendium of Clinical Research and Practice [online], 2008, vol. 20, p. 37-45. Available from: http://www.woundsresearch.com/article/8290#.
  • SACCO, I. C. N., et al. Sensibilidade plantar e distribuição de pressão plantar na marcha de diabéticos no Dia Nacional do Diabético. Diabetes Clinica (Atibaia), 2006, vol. 10, p. 413-420.
  • SACCO, I. C. N., AKASHI, P.M.H., and HENNIG, E.M. A comparison of lower limb EMG and ground reaction forces between barefoot and shod gait in participants with diabetic neuropathic and healthy controls [doi:10.1186/1471-2474-11-24]. BMC Musculoskeletal Disorders [online], 2010, vol. 11, p. 2-9.
  • SACCO, I. C. N., AKASHI, P.M.H., and HENNIG, E.M. Reply to: The vertical component of the ground reaction force does not reflect horizontal braking or acceleration per se [doi:10.1016/j.clinbiomech.2009.05.014]. Clinical Biomechanics (Bristol) [online], 2009, vol. 24, p. 595-595.
  • AKASHI, P.M.H., et al. Coactivation of distal muscles in neuropathic diabetic patients during gait. In V World Congress of Biomechanics, Alemanha, 2006. Journal of Biomechanics.New York, 2006. Abstract. Available from: http://www.elsevier.com/locate/jbiomech.
  • SACCO, I. C. N., BACARIN, T.A., and AKASHI, P.M.H. Diabetic neuropathy and orthopedic foot alteration: which is the most influencing factor In peak plantar pressure?. In V World Congress of Biomechanics, Alemanha, 2006. Journal of Biomechanics.EUA, 2006. Abstract. Available from: http://www.elsevier.com/locate/jbiomech.
  • WATARI, R., AKASHI, P.M.H., e SACCO, I. C. N. Análise eletromiográfica da marcha sem o uso de calçados em diabéticos neuropatas. In XIV Simpósio Internacional de Iniciação Científica da Universidade de São Paulo - SIICUSP., Ribeirão Preto, 2006. Anais.São Paulo : USP, 2006. Resumo.
  • AKASHI, P.M.H., and SACCO, I. C. N. Diabetic neuropathy progression effects in ground reaction forces and in lower limb emg during barefoot gait. In Congress of the International Society of Electrophysiology and Kinesiology, Niagara, 2008. Proceedings. : ISEK, 2008. Abstract.
  • AKASHI, P.M.H., and SACCO, I. C. N. Influence of diabetic neuropathy and history of plantar ulceration on kinetic and electromiographic variables during gait. In Masters Degree Dissertations, 2008. Clinics, supplement., 2008. Abstract.
  • AKASHI, P.M.H., and SACCO, I. C. N. The history of foot ulceration does not changes lower leg EMG activity during shod gait in diabetic neuropathy. In VI Congresso Internacional de Controle Motor, Santos, 2007. Motor Control., 2007. Abstract.
  • AKASHI, P.M.H., and SACCO, I. C. N. The influence of diabetic neuropathy and the use of habitual shoes in lower limb emg and in vertical forces during gait. In XVII Congress of the International Society of Electrophysiology and Kinesiology, Niagara, 2008. Proceedings., 2008. Abstract.
  • AKASHI, P.M.H., WATARI, R., e SACCO, I. C. N. A história de ulceração plantar altera as forças de reação do solo durante o andar descalço de diabéticos neuropatas. In XII Congresso Brasileiro de Biomecânica, São Pedro, 2007. Anais. : SBB, 2007.
  • ONODERA, A.N., et al. Cinemática e EMG de membros inferiores de diabéticos neuropatas durantes o subir escadas. In XIII Congresso Brasileiro de Biomecânica, São Paulo, 2009. Anais do XIII Congresso Brasileiro de Biomecânica.São Paulo : SBB, 2009. Resumo.
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