Maintaining Remission Induced Frailty by Offloading Bijan Najafi, PhD. Baylor College of Medicine Houston, Texas, USA

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1 Maintaining Remission Induced Frailty by Offloading Bijan Najafi, PhD Professor of Surgery Director of Clinical Research, Division of Vascular Surgery and Endovascular Therapy Director of Interdisciplinary Consortium on Advanced Motion Performance (icamp) Michael E. DeBakey Department of Surgery Baylor College of Medicine Houston, Texas, USA 1

2 Disclosure Research funding from PulseFlow, OHI, AVEX, LifeNet, and EO2 Joint STTR/SBIR NIH funding with Biosensics and Eden. Consultant for Biosensics LLC, Results Group, and PM Society, and Hamad Medical Co. 20+ issued Patents, pending patents, and provisional patents Other funding including NIH, NSF, DoD, and Qatar National Research Foundation (QNRF) 2

3 More than 25% of the U.S. population aged 65 years has diabetes Over 30 million adults 2015 Over 12 million (40%) older adults 2015 Over $ 300 billion 2017 Kirkman et al (2012), Diabetes Care American Diabetes Association

4 Age-Related Changes in Skin Aging Epidermis thickness Fat layer Density of sweat glands Loss of elastin and collagen fibers Thickening the remained collagen fiber DFU risk Reduction in resilience to shear stress Increased hardness (leading to increase in pressure) Dryness and loss of elastic recoil corns and callus (hyperkeratosis) Hyperkeratosis pain & abnormal distribution of plantar pressure Wrobel & Najafi (2010), J. of Diabetes Sci. & Tech; Menz (2015), Gerontology

5 Age-Related Changes in Plantar Soft Tissues Deeper pad Aging DFU risk Better protection underlying blood vessels and nerves Better attenuation of shear forces Better attenuation of pressure and collision impact Thickness Stiffness Dissipate more energy when compressed Slower recovery after the load is removed Heel pad elasticity Thickness of the plantar fascia (with decreased echogenicity) 9 14mm Higher peak pressure in particular under the lateral metatarsal heads Poor gait and balance higher stance phase pressure time integral Foot Pain reducing mobility joint rigidity high plantar pressure Up to 46% compression during walking mm Wrobel & Najafi (2010), J. of Diabetes Sci. & Tech; Menz (2015), Gerontology

6 Age-Related Changes in Joint Range of Motion Aging Reduction in the water content of the cartilage Increased stiffness Reduced range of motion Reduction in ankle dorsiflextion plantarflextion (~32%) Reduction in subtalar joint inversion eversion RoM (12 30%) DFU risk Poor adaptation to uneven terrain Impaired balance & gait Impaired functional reach Increased risk of falls Joint pain High pressure Joint deformity Wrobel & Najafi (2010), J. of Diabetes Sci. & Tech; Menz (2015), Gerontology 6

7 Age-Related Changes in Foot Strength Aging Reduced muscle mass (size and number of fibers) Type II fibers atrophy (Slower twitch motor units) DFU risk Decrease in strength (20 40%) Decrease in ankle plantarflexor strength Difficulties in rising onto the toes Toe plantar flexor weakness grasping function & weight bearing activities Impaired balance and functional ability Joint deformity (hallux valgus, lesser toes) Wrobel & Najafi (2010), J. of Diabetes Sci. & Tech; Menz (2015), Gerontology

8 Prolonged immobilization of foot could accelerate age-related changes in lower extremities Frail Patients Foot Ulcer Wound healing Prolonged Immobilization with offloading Recurrence Slow Muscle Recovery Lee et al (2017), DFCON Meeting 8

9 Ulcer Recurrence and Remission Ulcer recurrence is approximately 40% within the first year! ~40% 19 studies Armstrong et al (2017), The New England Journal of Medicine

10 Frailty induced by offloading and risk of ulcer remission! Vicious cycle toward limb amputation Low Risk ~40% Limb Health High Risk for Amputation Footwear Choice Initial ulcer Street Shoe Medical Intervention Over use Reulceration Reulceration TCC Diabetic Shoe TCC Shorter Irritation or overexertion D. Shoe Readmission Readmission TCC Shorter D. Shoe Longer Longer Roser et al (2017), JDST Armstrong et al (2017), NEJM

11 Lower extremity muscle loss affects propulsion performance Lower Extremity Speed Alteration in Propulsion Performance Earlier heel off 58% Poor power generated during propulsion 45% Slower Gait 31% Propulsion Speed (deg/s) Lee et al (2017), DFCon N=161, age % frail or pre frail Rahemi, Nguyen, et al (2018), Sensors Nguyen et al (2018), DFCon

12 Offloading induced frailty may lead to reduce propulsive gait and lead to increase plantar pressure while reducing gait speed Alteration in Propulsive Function Plantar Pressure 109% Area of contact is shrinking while the weight has not be completely transferred to the contralateral side! Lee et al (2017), DFCON Meeting Non Frail Frail

13 There is evidence that foot and ankle exercise could address some of the Age- Related Biomechanics factors including: Foot strength Lower extremity range of motion Balance Gait Falls Schwenk,, Najafi (2013), JAPMA

14 Gamification - Exergaming Game-based exercise provides personalizes foot and ankle exercise & increases patient engagement Game based exercise (Exergame) sensor on the dorsum of each foot body & mind exercise Zhou et al. (2018), DFCon 14

15 Other solutions New offloading with mechanical or electrical plantar stimulation New insoles with mechanical stimulation Exoskeleton enabled footwear Plantar Electrical Stimulation Rahemi et al (2017), DFCon Zahiri et al (2018), DFCon Roser et al (2017), JDST Najafi et al (2017), JDST

16 Summary Aging impacts biomechanics of lower extremities Skin Soft tissue Joint range of motion Arch collapse and foot deformity Poor gait & poor balance Offloading and prolonged immobilization of foot could accelerate aging related alteration in biomechanics of lower extremities High rate of recurrence of ulcers There is an urgent need to tailor diabetic foot management in older adults Lower extremities exercise during and post wound healing Compromised offloading Footwear tailored for older adults

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18 Age-Related Changes in Foot Posture and Dynamic Foot Function N=619 Foot arch shock attenuation Generate power for propulsion Aging Gradual lowering of the arch Greater medial displacement of the CoP (more pronation) Reduced midfoot and metatarsal mobility Less plantarflexed calcaneus at toes off Poor propulsive gait pattern (pull off rather than push off) Redmond et al (2008), J Foot Ankle Res DFU risk Less gait efficiency & high pressure Foot deformities (overlapping toes, hammer toes, hallux valgus, heel &arch pain) Wrobel & Najafi (2010), J. of Diabetes Sci. & Tech; Menz (2015), Gerontology Young Old