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Bakgrund: En amputation innebär ett avlägsnade av en kroppsdel. De flesta amputationer utförs i de nedre extremiteterna. I Sverige sker årligen ungefär 2250 amputationer i de nedre extremiteterna. Orsaken till amputation kan vara kärlsjukdomar, diabetes samt trauma. Sjuksköterskan har i sin profession en betydande roll i mötet med patienten. Syfte: Syftet var att beskriva patienters upplevelser efter amputation av nedre extremitet. Metod: En litteraturöversikt genomfördes utifrån Fribergs metodbeskrivning. Tio kvalitativa originalartiklar inhämtades via databaserna PubMed och Cinahl Complete. Primära sökord som användes var amputation, nedre extremitet och livsförändrade händelser med begränsningar såsom engelska och peer reviewed. Resultat: Fyra teman identifierades: Upplevelsen av psykiska och fysiska förändringar, Att uppleva rollförändring och förlust av självständighet, Förändrad kroppsuppfattning och känslan av sårbarhet samt Vägen tillbaka efter amputation. Resultatet visade att patienterna upplevde en förlust av självständighet vilket gav upphov till en känsla av att vara en börda för sin familj. Den fysiska förmågan försämrades vilket bidrog till att de inte kunde ta sig utanför hemmet. Detta resulterade i att de kände sig ensamma och isolerade. Slutsats: Patienter upplevde känslomässig chock och rädsla inför framtiden. Att inte kunna prestera till fullo, bidrog till en känsla av förlust av identitet och självständighet. Vikten av stöd från familj, vänner och vårdpersonal har en central betydelse för återhämtning efter amputation. Amputation innebär att patienten genomgår en övergång till en ny fas i livet, en transition. / Background: An amputation implies a removal of a body part. Most amputations transact at the lower extremities. In Sweden approximately 2250 lower extremity amputations are made a year. The causes of amputation may be vascular diseases, diabetes or trauma. The profession of a nurse has a major role in the relation to the patient. Aim: The aim was to investigate patients’ experiences after an amputation of lower extremity. Method: To approach the aim a literature review was performed by the method of Friberg. Ten qualitative original articles were collected by the databases PubMed and Cinahl Complete. Primary keywords were amputation, lower extremity and life change events. Limitations were English and peer reviewed. Results: Four themes were identified: Experience of psychological and physical changes, To experience changes of identity and loss of independents, Changes of self-perceptions and the feeling of being vulnerable and How to recover after an amputation. The result showed that the patients’ experienced a loss of independence which resulted in a feeling of being a burden. The physical ability was impaired and contributed to a feeling of being isolated and lonely. Conclusion: The patients’ experienced emotional shock and a fear for the future. Not being able to perform to the fullest produced a loss of identity and independence. Support from family, friends and healthcare professionals has a central value for the recovery. To be amputated results in a transitioning and a new phase in life.

Bakgrund: En underbensamputation innebär en stor livsförändring för patienten. En förlorad kroppsdel är inte bara en förlust av de funktionella förmågorna, de psykologiska förändringar som en amputation innebär ger upphov till en förlust av ett sätt att leva och en förlorad kontroll. Sjuksköterskans roll inom omvårdnaden efter en amputation är en central del för att främja rehabiliteringen, där kunskap för det psykiska måendet och lyhördhet inför den nya livssituationen är av stor vikt. Syftet: Syftet med litteraturstudien är att belysa forskning om patienters upplevelse av det dagliga livet efter en underbensamputation. Metod: Litteraturstudie baserad på tolv studier med kvalitativ studiedesign. Lämpliga studier valdes ut och kvalitetsgranskning genomfördes enligt SBU:s kvalitetsgranskningsmall (SBU 2014). Därefter genomfördes analys utifrån Popenoe m.fl. (2021) där resultatet kategoriserades. Resultat: Tre huvudkategorier identifierades i resultatet, upplevelse av förändring i det dagliga livet, en förändrad kroppsuppfattning och att främja välbefinnandet. Under respektive huvudkategori urskildes subkategorier, dessa innefattade upplevda hinder i vardagen, upplevelse av smärta och fantomsmärta, förändring i relationer, förlust av självständighet, känsla av maktlöshet, upplevelsen av den nya spegelbilden, det sociala nätverket som stöd, vägen till självständighet och anpassningen till den nya livssituationen. Konklusion: Förlusten av en kroppsdel är permanent och innebär en stor förändring hos patienterna i det dagliga livet. Oavsett bakomliggande orsak till amputationen gav detta upphov till olika hinder i vardagen, en förlust av självständighet och en förändrad spegelbild. För att främja återhämtning och rehabilitering var förberedelse, tydlig information och delaktighet av stor vikt samtidigt som en personcentrerad vård såg till hela patientens behov. / Background: Lower limb amputation represents a major life change for the patient. The loss of a limb is a loss of functional abilities where psychological changes lead to a loss of way of life and control. The nurses can help promote rehabilitation, where knowledge of the patient’s well-being and sensitivity to the new life situation are important. Purpose: The purpose of this literature review is to highlight research on patients’ experience of daily life after a lower limb amputation. Method: Qualitative literature review based on twelve studies with a qualitative study design. Suitable studies were selected, a quality review was conducted according to SBU's quality review template (SBU 2014). Analysis was then carried out according to Popenoe et al. (2021), where the results were categorized. Results: Three main categories were identified, experience of change in daily life, changed body image and promoting well- being. Under each main category, subcategories were distinguished, perceived barriers in daily life, experience of pain and phantom pain, change in relationships, loss of independence, feeling powerless, experiencing a new mirror image, the social network as support, the path to independence and adaptation to the new life situation. Conclusion: The loss of a limb is permanent and represents a major change in patients’ lives. Regardless of the case of the amputation, it resulted in various barriers to daily life, loss of independence and an altered reflection. To promote recovery and rehabilitation, preparation, clear information, and participation were essential while person-centred care addressed the needs of the whole patient.

Charles University Faculty of Pharmacy in Hradec Králové Department of Pharmacology and Toxicology Student: Jan Juhász Supervisor: Prof. MUDr. Radomír Hrdina, CSc. Title of diploma thesis: Treatment of lower extremity peripheral artery disease The lower extremities ischemia is a disease caused most often by atherosclerosis during which the lumen in lower limb arteries becomes narrow. Its prevalence is increasing, especially in the developed countries. The disease can be asymptomatic and symptomatic. The symptoms are very unpleasant and decrease patient's quality of life. Advanced stages of the disease may be life threatening. Therefore, it is vital to timely and correctly diagnose the illness. During the therapy, it is possible to use pharmacological as well as non-pharmacological procedures, and, preferably, a combination of the two types of treatment. The pharmacotherapy can be divided into several parts. The prevention of atherosclerotic complications makes use of preventive measures and antiplatelet therapy to reduce the cardiovascular risk. The symptoms therapy focuses on improving patients' quality of life by prescribing the vasoactive medications cilostazol, naftidrofuryl or pentoxifylin. The critical limb ischemia therapy uses prostaglandin analogues alprostadil, iloprost, limaprost or...

O objetivo deste estudo foi investigar os padrões de distribuição de energia e as propriedades espectrais dos principais músculos de membro inferior de diabéticos neuropatas durante a marcha, utilizando a análise de wavelet. Foram coletados dados de EMG de superfície (bipolar) dos músculos tibial anterior, vasto lateral e gastrocnêmio medial no ciclo da marcha em 21 pacientes diabéticos diagnosticados com neuropatia periférica, e 21 indivíduos não- diabéticos. A energia do sinal e freqüência foram comparados entre os grupos no ciclo da marcha e em cada faixa de freqüência (7-542Hz), utilizando testes t. A Análise de Componentes Principais foi utilizada para avaliar as diferenças entre os padrões eletromiográficos de diabéticos e não-diabéticos. Os indivíduos diabéticos exibiram menores energias nas menores frequências para todos os músculos, e energias mais altas nas maiores frequências nos músculos extensores do membro inferior. Os pacientes também apresentaram menor energia de gastrocnêmio medial e uma maior energia de vasto lateral comparado aos não diabéticos, e este último achado sugere uma estratégia para compensar o déficit dos extensores de tornozelo para impulsionar o corpo na marcha. Os resultados mostram, de maneira geral, uma mudança na estratégia neuromuscular dos pacientes diabéticos, sugerindo que os principais músculos extensores do membro inferior adaptam a sua resposta a fim de produzir a energia necessária para realizar essa tarefa, a do andar / The aim of this study was to investigate lower limb muscle\'s energy patterns and spectral properties of diabetic neuropathic individuals during gait cycle using wavelet approach. Bipolar surface EMG of tibialis anterior, vastus lateralis and gastrocnemius medialis were acquired in the whole gait cycle in 21 diabetic patients already diagnosed with peripheral neuropathy, and 21 non-diabetic individuals. The signal´s energy and frequency were compared between groups in the whole gait cycle and in each frequency band (7-542Hz) using t tests. Principal component analysis was used to assess differences between diabetic and non-diabetic EMG patterns. The diabetic individuals displayed lower energies in lower frequency bands for all muscles and higher energies in higher frequency bands in the extensors\' muscles. They also showed lower energy of gastrocnemius and a higher energy of vastus, and this last finding suggests a strategy to compensate the ankle extensor deficit to propel the body forward. The overall results suggest a change in the neuromuscular strategy of diabetic patients, suggesting that the main extensor muscles of the lower limb adapt their response to produce the energy necessary to accomplish the walking task

INTRODUÇÃO: A escala MESS foi um instrumento desenvolvido para auxiliar o cirurgião na decisão entre amputar e preservar o membro inferior gravemente lesado. Neste estudo acompanhamos um grupo de pacientes com fratura exposta dos ossos da perna com MESS >= sete, preditivo para amputação, durante seu tratamento até a sua reabilitação completa. OBJETIVO: O objetivo do estudo foi determinar a relação de sucesso/insucesso funcional nos pacientes com escore MESS >= sete com o membro reconstruído no longo prazo (mínimo de dez anos de seguimento). MÉTODOS: Foram incluídos no estudo, os pacientes com fratura exposta Gustilo IIIB e IIIC dos ossos da perna com critérios de membros inferiores gravemente lesados modificados de Gregory e Bonanni e escore MESS >= sete. Os pacientes foram incluídos no período de 2003-2006. Os pacientes foram avaliados através da Medida de Independência Funcional e escala de incapacidade pela dor. RESULTADOS: Dos 26 pacientes selecionados, foram realizadas amputações em cinco e preservação do membro acometido, após intervenções, em 21 pacientes. Nove pacientes foram reavaliados após mais de 10 anos de seguimento. Destes, sete apresentavam o membro preservado e apenas um teve a reconstrução considerada como falha. Dos pacientes preservados, o paciente com fratura exposta Gustilo IIIC teve a reconstrução considerada falha. As duas amputações também foram consideradas funcionais. CONCLUSÃO: A escala MESS não é um bom instrumento para indicar amputação / INTRODUCTION: The MESS score was designed as a tool to assist the surgeon in deciding between amputate or preserve the severely injured lower limb. In this study we followed patients with severe open fractures of the leg with MESS >= seven, predictive for amputation during their treatment until their complete rehabilitation. OBJETIVE: The aim of the study was to determine the relative success / failure in patients with functional MESS score >= seven with the reconstructed member. METHODS: We included in the study, patients with open fractures Gustilo IIIB and IIIC of the leg with criteria for seriously injured lower limb modified by Gregory and Bonanni and MESS score >= seven. All patients were included from 2003 to 2006. Patients were evaluated through the Functional Independence Measure and Pain Disability Index. RESULTS: From selected 26 patients, five had below knee amputation and 21 after reconstructive procedures got limb salvage. Nine patients were evaluated after 10 years follow-up. Seven of them have the reconstructed limb, only one of these was considered as functional failure. Of the patients with lower limb reconstruction only Gustilo IIIC open fracture has a non-functional member. The two patients with amputation also have functional results. CONCLUSION: MESS is not a proper instrument to indicate amputation

A Trombomodulina é um marcador endotelial da doença aterosclerótica, e seu uso como preditor da doença arterial obstrutiva periférica (DAOP) deve ser comprovada. Avaliou-se 41 pacientes com claudicação intermitente e 40 com isquemia crítica. A Trombomodulina plasmática (TMp) foi quantificada em todos os pacientes, através de método imunoenzimático (ELISA). As hipóteses de normalidade e de homogeneidade de variância foram provadas, respectivamente, pelos testes de Shapiro-Wilk e de Levene. A comparação da TMp entre ambos os grupos foi realizada empregando-se o teste t de Student. A utilização de pacientes com Claudicação Intermitente e com Isquemia Crítica é interessante como modelo de estudo e deve ser empregado para avaliar diferentes marcadores de prognóstico da DAOP. Não foi observada diferença estatisticamente significante nos níveis de TMp nos grupos, não permitindo utilizar-se a TMp para avaliar o prognóstico da doença arterial obstrutiva periférica (DAOP) / Thrombomodulin (TM) is an endothelial marker of arterosclerotic disease and its use as a predictor of Peripheral Arterial Disease (PAD) must be proven. Forty-one patients having intermittent claudication and forty having critical ischemia were evaluated. Plasmatic Thrombomodulin (TMp) was quantified in all patients using the immunoenzymatic method (ELISA). The hypotheses of normality and variance homogeneity were proven, respectively, using the Wilk-Shapiro and Levene Tests. The comparison of the TMp between both groups was carried out using the Student-T Test. The utilization of patients with Intermittent Claudication and Critical Ischemia is interesting as a study model and should be used to evaluate different prognostic markers of PAD. No statistically significant difference was observed in the TMp levels between the groups, thus not permitting the use of TMp to evaluate the prognostics of Peripheral Arterial Disease (PAD)

INTRODUÇÃO: A implantação de stent auto-expansível de nitinol para o tratamento das lesões oclusivas femoro-poplíteas tem sido associado com maus resultados a longo prazo. O everolimus administrado via oral para inibir reestenoses do stent foi investigado recentemente em animais com bons resultados, porém sua segurança e eficácia não têm sido estudada em seres humanos. O propósito deste estudo piloto foi avaliar o impacto da terapia antiproliferativa com everolimus administrado via oral por 28 dias na diminuição de reestenose após implante de stent auto-expansível de nitinol para tratamento de lesões oclusivas da artéria femoral superficial. MÉTODOS E RESULTADOS: Trinta e quatro pacientes foram recrutados para este estudo randomizado, prospectivo. O grupo que recebeu everolimus via oral foi constituído por 15 pacientes e o grupo que não recebeu medicação composto por 19 pacientes. As características basais e do procedimento foram similares entre os dois grupos. Todos os pacientes tinham isquemia crônica do membro inferior e oclusão da artéria femoral superficial (média da lesão de 83,14 mm no grupo sem medicação e 105 mm no grupo everolimus). O objetivo primário do estudo foi a redução da porcentagem média do diâmetro da reestenose intra-stent após seis meses da angioplastia avaliada por angiografia quantitativa. A porcentagem média do diâmetro das reestenoses foi 46,9% no grupo tratado com everolimus e 44,5% no grupo que não recebeu a medicação (p=0,81). Não foram observados efeitos colaterais graves nos grupos. No acompanhamento clínico aos 24 meses não houve diferenças significativas entre os grupos em relação a eventos clínicos. A patência primária, primária assistida e secundária em 24 meses, foi 42%, 74% e 79% no grupo sem medicação e 27%, 73% e 73% no grupo tratado com everolimus. CONCLUSÃO: O everolimus via oral por 28 dias em doses altas é seguro e bem tolerado, com baixo índice de efeitos colaterais, porém não é eficaz na redução da porcentagem média do diâmetro da reestenose intra-stent em pacientes com implante de stents auto-expansíveis de nitinol nas lesões oclusivas complexas da artéria femoral superficial. / INTRODUCTION: The implantation of a self-expanding of nitinol stent in the treatment of femoropopliteal occlusive lesions has been associated with a poor outcome in a long term setting. Everolimus administered orally to inhibit restenosis of the stent was investigated recently in animals with good results, but its safety and efficacy has not been studied in humans. The purpose of this pilot study was to evaluate the impact of antiproliferative therapy with everolimus administered orally for 28 days in the reduction of restenosis after implantation of self-expandable nitinol stent for treatment of occlusive lesions of the superficial femoral artery. METHODS AND RESULTS: Thirty-four patients were recruited for this randomized, prospective study. The group that received oral Everolimus was consisted of 15 patients and the group that received no medication was 19 patients. The baseline characteristics and procedure were similar in both groups. All the patients had chronic lower limb ischemia and occlusion of the superficial femoral artery (mean of the lesion of 83.14 mm in the group without medication and 105 mm in the everolimus group). The primary objective of the study was to evaluate the reduction of the average percentage of the diameter of in-stent restenosis six months after angioplasty assessed by quantitative angiography. The in-stent mean percent diameter stenosis was 46.9% in the group treated with everolimus and 44.5% in the group that received no medication (p = 0.81). There were no serious side effects seen in either group in the clinical follow up at 24 months. There was no significant difference between groups in relation to clinical events. The primary patency, assisted primary and secondary in 24 months was 42%, 74% and 79% in the group without medication and 27%, 73% and 73% in the group treated with Everolimus. CONCLUSION: Everolimus administered orally for 28 consecutive days to stent implantation in high doses proves to be safe and well tolerated, with low rate of side effects, but it is not effective in reducing the average percentage of diameter of in-stent restenosis in patients with implantation of self-expandable nitinol stent in complex occlusive lesions of the superficial femoral artery.

I found that 2.6ml of 0.5% levobupivacaine had similar clinical characteristics as the same volume of 0.5% bupivacaine in spinal anaesthesia. Both were effective for spinal anaesthesia in urological surgery, when a sensory block up to at least T10 dermatome was required. In comparing the use of levobupivacaine alone and levobupivacaine with fentanyl, there were no significant differences in haemodynamic changes and quality of sensory and motor block, when 2.6ml of levobupivacaine alone or 2.3ml of levobupivacaine with fentanyl 15mcg (0.3ml) were used in spinal anaesthesia. Both were effective for spinal anaesthesia in urological surgery. In comparing the use of ropivacaine 10mg and bupivacaine 10mg, both with fentanyl 15mcg in spinal anaesthesia for urological surgery, all the patients achieved adequate level of sensory block up to T10 dermatome or higher. The two drugs were similar in the onset time of motor block, the characteristics of sensory block and haemodynamic changes; however, the duration of motor block was shorter with ropivacaine. I concluded that both studied solutions, ropivacaine-fentanyl and bupivacaine-fentanyl, were effective for spinal anaesthesia in urological surgery and the duration of motor block was shorter with the ropivacaine-fentanyl solution. The dose-response relationship of ropivacaine in spinal anaesthesia for lower limb surgery requiring a sensory block up to at least the T12 dermatome was defined. Anaesthesia was successful in 0, 0, 42, 83 and 100% when ropivacaine at doses of 2, 4, 7, 10 and 14mg respectively were given. The derived values for ED50 and ED95 were 7.6mg and 11.4mg respectively. The cephalic level of sensory block and the degree of motor block increased with larger doses of ropivacaine. Finally, the median effective dose (ED50) of bupivacaine, levobupivacaine and ropivacaine in spinal anaesthesia for lower limb surgery were defined as 5.50mg (95% CI: 4.90--6.10mg), 5.68mg (95% CI: 4.92--6.44mg), and 8.41mg (95% CI: 7.15--9.67mg) respectively. The relative potency ratios were 0.97 (95% CI: 0.81--1.17) for levobupivacaine/bupivacaine, 0.65 (95% CI: 0.54--0.80) for ropivacaine/bupivacaine and 0.68 (95% CI: 0.55--0.84) for ropivacainellevobupivacaine. / In this series of studies, I have shown that levobupivacaine and ropivacaine are effective local anaesthetic agents for spinal anaesthesia in lower limb and urological surgery. This proved my hypothesis. Both are suitable alternatives to bupivacaine for spinal anaesthesia. Furthermore, these studies showed that ropivacaine is less potent than levobupivacaine and bupivacaine and the potency is similar between levobupivacaine and bupivacaine at median effective dose. / Levobupivacaine and ropivacaine are two relatively new local anaesthetics which were developed in view of their potential for less cardiotoxicity in comparison with bupivacaine, the most common local anaesthetic used in spinal anaesthesia for many years. Both are produced in pure S(-) enantiomer form in contrast to bupivacaine which is a racemic mixture. They have been shown to be effective in peripheral nerve blocks, and epidural analgesia and anaesthesia; nevertheless, experience of their use in spinal anaesthesia is limited. The objective of this thesis was to evaluate their use in spinal anaesthesia for surgery in non-obstetric patients. My hypothesis was that levobupivacaine and ropivacaine are effective local anaesthetic agents for spinal anaesthesia in lower limb and urological surgery. In order to test this hypothesis, I conducted five clinical studies on 269 patients who had urological surgery or lower limb surgery under spinal or combined spinal-epidural anaesthesia. First, I investigated the efficacy and clinical characteristics of levobupivacaine and the mixture of levobupivacaine with fentanyl in spinal anaesthesia. Next, I compared the use of ropivacaine-fentanyl with bupivacaine-fentanyl in spinal anaesthesia. Finally, I defined the dose-response relationship of ropivacaine in spinal anaesthesia using traditional dose-response methodology and defined the relative potency among levobupivacaine, ropivacaine and bupivacaine by comparing the defined ED50 in spinal anaesthesia using up-down sequential allocation method. / Lee, Ying Yin. / Source: Dissertation Abstracts International, Volume: 73-06, Section: B, page: . / Thesis (M.D.)--Chinese University of Hong Kong, 2011. / Includes bibliographical references (leaves 133-150). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Electronic reproduction. [Ann Arbor, MI] : ProQuest Information and Learning, [201-] System requirements: Adobe Acrobat Reader. Available via World Wide Web.

Estimativa das forças musculares de diabéticos pode apoiar a compreensão das estratégias mecânicas e musculares que esses pacientes adotam para preservar a habilidade de realizar a marcha e garantir sua independência à medida que lidam com seus déficits neurais e musculares devido a diabetes e à neuropatia. O objetivo do presente estudo foi estimar a distribuição da força muscular do membro inferior durante a marcha em pacientes diabéticos com e sem neuropatia diabética, bem como compará-los com indivíduos saudáveis. Dados de força de reação do solo (100 Hz) e cinemática tridimensional do tornozelo, joelho e quadril (100 Hz) de 10 diabéticos neuropatas (GDN), 10 diabéticos não neuropatas (GD) e 10 indivíduos saudáveis (GC) foram utilizados como variáveis de entrada para o modelo musculoesquelético computacional gait 2392 (23 graus de liberdade e 92 atuadores musculoesqueléticos) no software OpenSim. O modelo genérico padrão foi dimensionado para se adequar à antropometria de cada indivíduo coletado, antes da execução das simulações. O modelo musculoesquelético dos indivíduos diabéticos neuropatas apresentou força isométrica máxima reduzida em 30% para os extensores do tornozelo e 20% para os dorsiflexores do tornozelo, buscando aproximar o modelo da redução de força muscular distal consequente à neuropatia diabética exibida por pacientes. As séries temporais da força dos músculos dos membros inferiores foram calculadas usando o procedimento de otimização estática. As forças musculares máximas foram calculadas durante intervalos do ciclo de marcha em que a ação dos músculos é fundamental para execução da tarefa. Os picos de força foram comparados entre os grupos de indivíduos utilizando MANOVA para os grupos musculares flexores e extensores das articulações do quadril, joelho e tornozelo, seguidas de ANOVA e pós-hoc de Newman-Keuls (p < 0,05). GDN apresentou maior pico de força dos músculos flexores de joelho (bíceps femoral cabeça curta/ p < 0,001, semitendinoso/ p < 0,001 e semimenbranoso/ p < 0,001) na fase de propulsão, em relação à GD e GC. GDN também apresentou menor pico de força dos músculos gastrocnêmio medial e sóleo, bem como maior pico de força para gastrocnêmio lateral comparado a GD e GC, nesta mesma fase. GD exibiu menor pico de força dos músculos extensores de quadril (semitendinoso e semimembranoso) ao final da fase de balanço e músculos abdutores do quadril durante a fase de apoio, bem como maior pico de força para os músculos extensores de joelho (vasto medial e lateral/ p = 0,004) no início da fase de apoio, comparado a GDN e GC. Os pacientes diabéticos com e sem neuropatia adotam distintas estratégias de distribuição de força muscular, apesar da piora progressiva em seu estado de saúde. Ambos os grupos diabéticos demonstraram alterações na produção de força dos músculos extensores de tornozelo, com redução do pico de força do sóleo (GD) e gastrocnêmio medial (GDN), entretanto, apenas o GDN aumentou o pico de força dos isquiotibiais (flexores de joelho) na fase de propulsão. GD apresentou redução expressiva da produção de força do glúteo médio, o que pode sugerir prejuízo para a estabilização látero-lateral da pelve. Pode-se considerar incluir programas de treinamento de resistência de músculos proximais relacionados à articulação do joelho em uma rotina de reabilitação para pacientes diabéticos. Outras inclusões potenciais em protocolos de reabilitação são o treino de marcha e a prática de exercícios funcionais com foco na ativação dos músculos isquiotibiais / Muscle force estimation could support a better understanding of the mechanical and muscular strategies that diabetic patients adopt to preserve walking ability and to guarantee their independence as they deal with their neural and muscular impairments due to diabetes and neuropathy. Our aim was to estimate and compare the lower limb\'s muscle force distribution during gait in diabetic patients with and without diabetic neuropathy. Data from ground reaction force (AMTI OR61000 force plate at 100Hz) and three-dimensional kinematics of ankle, knee and hip (eight-camera Optitrack® at 100 Hz) of 10 neuropathic (DNG), 10 diabetic non-neuropathic (DG) and 10 healthy individuals (CG) were used as input variables for the musculoskeletal model gait 2392 (23 degrees of freedom and 92 musculoskeletal actuators) in the OpenSim software. The standard generic model was scaled to fit the anthropometry of each individual collected, prior to the execution of the simulations. The musculoskeletal model of neuropathic individuals presented maximum isometric force reduced in 30% for ankle extensors and 20% for ankle dorsiflexors to mimic the atrophy of ankle muscles due to diabetic neuropathy. The force time series of lower limb muscles were calculated using the static optimization procedure. The peak muscle forces were calculated during selected time bands of the gait cycle. The peak force was compared between groups using MANOVA for the flexor and extensor muscle groups of hip, knee and ankle joints followed by ANOVA and post-hoc of Newman-Keuls (p < 0.05). DNG showed higher knee flexors peak force (biceps femoris short head / p < 0,001, semitendinous / p < 0,001 and semimenbranous / p < 0,001) during push-off, compared to DG and CG. DNG also presented lower peak force for gastrocnemius medialis and soleus, as well as higher peak force for gastrocnemius lateralis compared to DG and CG in the same gait phase. DG exhibited lower peak force for the hip extensor muscles (semitendinous and semimembranous) in the final swing and hip abductor muscles during stance, as well as higher peak force for the knee extensor muscles (vastus medialis and lateralis / p=0,004) in the early stance compared to DNG and CG. Diabetic patients with and without neuropathy appear to adopt different muscle force distribution strategies in spite of the progressive worsening in their health condition. While reducing ankle extensor forces, DG increased knee extensor muscle forces at early stance and reduced the hamstrings force at the end of swing phase, whereas DNG increased the hamstrings muscle forces at push-off. A resistance training program for the proximal muscles related to the knee joint could be considered in a rehabilitation routine for diabetic patients. Other potential inclusions in rehabilitation protocols consist of gait retraining and practicing functional exercises focusing on the activation of the hamstring muscles