Investigation of standing balance in diabetic patients with and without peripheral neuropathy using accelerometers

Effect of Moving Tactile Stimuli to Mimic Altered Weight Distribution During Gait on Quiet Stance Body Sway

Our purpose in the present study was to examine whether moving tactile stimuli to the sole to mimic moving weight distribution over the feet during gait would influence body sway in quiet stance. Fifteen healthy males maintained the quiet stance, and we delivered moving tactile stimuli to mimic the change in their weight distribution during gait. Moving tactile stimuli did not change the length of the center of pressure (COP) displacement and COP position. Vision decreased the length of the COP, but it did not interact with moving tactile stimuli for the COP length and position. The COP position rhythmically moved in the medial-lateral axis along with the cycle of moving tactile stimuli. The COP was at the lateral peak position at the period at which moving tactile stimuli mimicked the weight distribution in the transition between the swing and stance phases of the gait cycle. This finding may indicate that the body is positioned at the lateral peak position in quiet stance when people perceive the sensation of weight distribution over the feet at the most unstable phase of the gait cycle. We suggest that moving tactile stimuli to the sole may induce medial-lateral body sway before gait initiation for patients with Parkinson's disease to improve their freezing of gait initiation.

Diabetic older women without peripheral neuropathy amplify body sway but are capable of improving postural stability during a saccadic gaze task

BACKGROUND

Diabetic older people tend to present deteriorated performance in balance and locomotion activities, even those without peripheral neuropathy. There is evidence that saccadic eye movements are used to reduce body sway in young and older healthy adults, but it has not been shown that diabetic older people preserve this visuomotor adaptation capacity.

RESEARCH QUESTION

Are diabetic older women without peripheral neuropathy capable of improving postural stability during a saccadic gaze task?

METHODS

Seventeen type 2 diabetic older women (68.2 ± 10.7 years old) and seventeen healthy women, age-matched controls (66.0 ± 8.4 years old) voluntarily participated in the study. All participants were instructed to stand upright, barefoot, as stable as possible, for 30 s. Participants maintained their feet parallel to each other, at standard and narrow bases of support, while either fixating on a stationary target (fixation condition) or performing horizontal saccadic eye movements to follow a target (eccentricity of 11° of visual angle), which continuously disappeared and reappeared immediately on the opposite side (saccade 0.5 Hz and saccade 1.1 Hz conditions).

RESULTS

Results indicated that the diabetic group clearly had deteriorated postural control, as shown by increased values of mean sway amplitude and mean sway velocity. However, diabetic and control groups were similarly capable of using saccadic eye movements to improve their postural stability, reducing their sway velocity compared to a gaze fixation condition.

SIGNIFICANCE

Diabetes per se (without peripheral neuropathy) amplifies postural sway of older women as compared to their healthy age-matched controls. However, diabetic older women without peripheral neuropathy are capable of improving postural stability during a saccadic gaze task.

Wearable sensors-based postural analysis and fall risk assessment among patients with diabetic foot neuropathy

AIMS

To investigate the cross-sectional association between deep and superficial diabetic neuropathy, postural impairment assessed by wearable inertial sensors, and the risk of fall among patients with diabetic foot.

METHODS

Diabetic patients attending a University Podiatric Clinic were evaluated for the presence of deep and superficial peripheral neuropathy in sensory tests. Postural impairment was assessed using a wearable inertial sensor, and the evaluation of balance/gait and risk of fall was determined by the Tinetti Scale and Downton Index, respectively. Glycemic control was measured by glycated haemoglobin concentration and fasting glycaemia. The postural parameters measured were the anteroposterior and medio-lateral sway of the center of mass (CoM) and the sway area (area traveled by the CoM per second). The results were analyzed through a logistic regression model to assess those posture variables mostly significantly associated with neuropathy and risk of fall scales.

RESULTS

A total of 85 patients were evaluated. Spearman's rank correlation coefficients showed a strong and significant relationship (p < 0.05) between deep diabetic neuropathy assessed by Semmes-Weinstein monofilament, diapason and biothensiometer and postural alterations, whereas no significant correlations between superficial (painful sensitivity) neuropathy and the postural parameters. The sway path of the displacement along the anterior-posterior axis recorded during tests performed with eyes open and feet close together were significantly (p < 0.05) correlated with a poor glycemic (glycated haemoglobin concentration) control and each other with all diabetic neuropathy tests, fall risk scales, muscular weakness, ankle joint limitation and history of ulcers.

CONCLUSIONS

The results support the existence of a strong association between alterations of the deep somato-sensitive pathway (although depending on the tool used to measure peripheral neuropathy), glycemic control and balance impairments assessed using a wearable sensors. Wearable-based postural analysis might be part of the clinical assessment that enables the detection of balance impairments and the risk of fall in diabetic patients with diabetic peripheral neuropathy.

Effect of Laterally Moving Tactile Stimuli to Sole on Anticipatory Postural Adjustment of Gait Initiation in Healthy Males

This present study examined the effect of the laterally moving tactile stimuli (LMTS) to the sole on the anticipatory postural adjustment (APA) of the gait initiation. Thirteen healthy males participated in this study. A sound cue was provided at the beginning of each trial. The participants took three steps forward from a quiet stance at their preferred time after the start cue. The LMTS were delivered to the sole after the start cue. The loci of the tactile stimuli moved from the left- to the right-most side of the sole and then moved from the right- to the left-most side of that in a stimuli cycle. The duration of one stimuli cycle was 960 ms, and this cycle was repeated 16 times in a trial. The APA did not onset at the specific direction or phase of the LMTS, indicating that they did not use any specific phase of the stimuli as a trigger for initiating the gait. The LMTS decreased the amplitude and increased the duration of the APA. Simultaneously, the LMTS increased the time between the APA onset and toe-off of the initial support leg, indicating that they moved slowly when initiating gait during the LMTS. Those findings are explained by the view that the suppression of the APA induced via the LMTS to the sole is caused by the slowing down of the gait initiation due to masking the tactile sensation of the sole.

Accelerometry applications and methods to assess standing balance in older adults and mobility-limited patient populations: a narrative review

Accelerometers provide an opportunity to expand standing balance assessments outside of the laboratory. The purpose of this narrative review is to show that accelerometers are accurate, objective, and accessible tools for balance assessment. Accelerometry has been validated against current gold standard technology, such as optical motion capture systems and force plates. Many studies have been conducted to show how accelerometers can be useful for clinical examinations. Recent studies have begun to apply classification algorithms to accelerometry balance measures to discriminate populations at risk for falls. In addition to healthy older adults, accelerometry can monitor balance in patient populations such as Parkinson's disease, multiple sclerosis, and traumatic brain injury. The lack of software packages or easy-to-use applications have hindered the shift into the clinical space. Lack of consensus on outcome metrics has also slowed the clinical adoption of accelerometer-based balance assessments. Future studies should focus on metrics that are most helpful to evaluate balance in specific populations and protocols that are clinically efficacious.

Combined effect of gender differences and fatiguing task on postural balance, functional mobility and fall risk in adults with multiple sclerosis: A preliminary study

AIM

To investigate the gender difference effect on postural balance, functional mobility, and fall risk after performing a fatiguing task in adults with multiple sclerosis (MS).

METHODS

Eleven women (30.91 ± 8.19 years) and seven men (30.29 ± 7.99 years) with relapsing-remitting MS performed a fatiguing task: three sets of the Five-repetition Sit-To-Stand Test (5-STST) were performed before and after the six-minute WalkTest (6MWT). Bipedal postural balance in eyes open and eyes closed conditions were assessed prefatigue (T0) and postfatigue (T3) using a force platform. Unipedal balance, functional mobility (Timed Up and Go Test), fall risk (Four Square Step Test) and fatigue [Visual Analogue Scale of Fatigue (VASF)] were assessed at T0 and T3. Heart rate (HR) and Rating of Perceived Exertion (RPE) were recorded before (only for HR), during and after the fatiguing task.

RESULTS

Compared to women, men showed an impairment of posturographic parameters [mean center of pressure (CoP) velocity (CoPVm) in both conditions (p < 0.05); CoP sway area (CoPAr) in both conditions (p < 0.01)], unipedal balance on the dominant leg (p <0.001), mobility (p<0.001) and an increased fall risk (p < 0.05). No gender differences were observed in 6MWT, 5-STST, HR, RPE, and VASF.

CONCLUSION

This preliminary study showed that fatiguing task negatively affected postural control, mobility and fall risk only in men. These gender differences were inconclusive but could be taken into account in postural balance rehabilitation programs for MS persons.

Simultaneous measurement of centre of pressure and centre of mass in assessing postural sway in healthcare workers with non-specific back pain: protocol for a cross-sectional study

INTRODUCTION

Low back pain (LBP) is widely prevalent in healthcare workers. It is associated with impaired postural and core stability. So far, centre of pressure (CoP) measures have been commonly recorded through the use of a force plate in order to assess postural stability. However, this approach provides limited information about the centre of mass (CoM) movement in the lumbar region in individuals with LBP. Recent developments in sensor technology enable measurement of the trunk motion which could provide additional information on postural sway. However, the question remains as to whether CoM measures would be more sensitive in discriminating individuals with mild and moderate back pain than traditional CoP analyses. This study aims to investigate the sensitivity of CoP and CoM measures under varied stable, metastable and unstable testing conditions in healthcare workers, and their relationship with the level of subjective reported back pain.

METHODS AND ANALYSIS

This is a cross-sectional controlled laboratory study. A group of 90 healthcare professionals will be recruited from rehabilitation centres within local areas. Participants will complete the Oswestry Disability Questionnaire. The primary outcome will be the rate of their back pain on the 0-10 Low Back Pain Scale (1-3 mild pain and 4-6 moderate pain). Secondary outcomes will include variables of postural and core stability testing during bipedal and one-legged stance on a force plate, a foam mat placed on the force plate, and a spring-supported platform with either eyes open or eyes closed. Both CoP using the posturography system based on a force plate and CoM using the inertial sensor system placed on the trunk will be simultaneously measured.

ETHICS AND DISSEMINATION

Projects were approved by the ethics committee of the Faculty of Physical Education and Sport, Comenius University in Bratislava (Nos. 4/2017, 1/2020). Findings will be published in peer-reviewed journals and presented at conferences.

Effect of a HIIT protocol on the lower limb muscle power, ankle dorsiflexion and dynamic balance in a sedentary type 1 diabetes mellitus population: a pilot study

Background

Type 1 diabetes mellitus (T1DM) is commonly associated with premature loss of muscle function, ankle dorsiflexion and dynamic balance. Those impairments, usually, lead to physical functionality deterioration. High-intensity interval training is an efficient and safety methodology since it prevents hypoglycemia and not requires much time, which are the main barriers for this population to practice exercise and increase physical conditioning. We hypothesized that a 6-week HIIT program performed on a cycle ergometer would increase lower limb muscle power, ankle dorsiflexion range of motion and dynamic balance without hypoglycemic situations.

Methods

A total of 19 diagnosed T1DM subjects were randomly assigned to HIIT group (n = 11; 6-week HIIT protocol) or Control group (n = 8; no treatment). Lower limb strength was evaluated through velocity execution in squat with three different overloads. Weight bearing lunge test (WBLT) was performed to test ankle dorsiflexion range of motion and Y-Balance test (YBT) was the test conducted to analyze dynamic balance performance.

Results

Velocity in squat improved a 11.3%, 9.4% and 10.1% (p < 0.05) with the 50%, 60% and 70% of their own body mass overload respectively, WBLT performance increased a 10.43% in the right limb and 15.45% in the left limb. YBT showed improvements in all directions (right limb-left limb): Anterior (4.3–6.1%), Posteromedial (1.8–5.2%) and Posterolateral (3.4–4.5%) in HIIT group (p < 0.05), unlike control group that did not experience any significant change in any of the variables (p > 0.05).

Conclusion

A 6-week HIIT program is safe and effective to improve execution velocity in squat movement, a fundamental skill in daily living activities, as well as ankle dorsiflexion range of motion and dynamic balance to reduce foot ulcers, risk falls and functional impairments. HIIT seems an efficient and safety training methodology not only for overcome T1DM barriers for exercising but also for improving functional capacities in T1DM people.

Standing Balance Performance and Knee Extensors' Strength in Diabetic Patients with Neuropathy

Diabetes peripheral neuropathy (DPN) leads to balance impairment among diabetes mellitus (DM). The aims of this study were to (1) distinguish between DM patients who have/do not have DPN and to (2) compare quadriceps' strength and balance performance of DM, DPN, and healthy groups. Fifteen healthy females and 33 females with type 2 diabetic patients participated. The electrodiagnostic method was used to classify diabetic patients into DM and DPN. A dynamometer was used to measure quadriceps' strength. Single-leg standing on a force plate was also used to quantify participants' balance. Smaller conduction velocity and amplitude and greater distal latency of all nerves were observed in the DPN compared with the DM in particular for sensory nerve. In DPN, conduction velocity was asymmetrical. The quadriceps' strength of both legs in DPN and the right leg in DM was smaller than in the control group. The root mean square of the center of pressure was similar between DM and DPN. But it was larger in DPN than in the control group. DPN is associated with asymmetrical conduction velocity, smaller quadriceps' strength, and weaker balance performance that is suggestive of higher risk of falling. Balance training is recommended for the DPN group during their rehabilitation to reduce their falling risk.

Reliability of accelerometric assessment of balance in children aged 6-12 years

BACKGROUND

Development and evaluation of an accelerometers technique for collecting data for asses balance had reported difficulty due to equilibrium reactions and continuous bursts. The aim of this study is to determine the reliability and internal consistency of accelerometric measurements, related to static equilibrium and gait in children aged 6 to 12 years.

METHODS

This descriptive and cross-sectional study involved 70 healthy children (50% girls) with a mean age of 9 years old. At the height of the 4th lumbar vertebra and directly on the skin, an accelerometer was placed on each participant. All of them had to complete four trials three times: balancing on one leg with eyes closed and eyes open, dynamic balancing on one leg on a foam mat, and normal gait.

RESULTS

Results show that tests performed in older children had higher internal consistency than those performed in younger children (vertical axis r = 0.82, sagittal axis r = 0.77, and perpendicular axis r = 0.74). Tests performed in children aged 8 years or older presented a strong correlation between trials (r > 0.71). The three static equilibrium tests obtained reliability values between 0.76 y 0.84. On the contrary, gait test obtained inferior and poorer results (0.6 < r < 0.71).

CONCLUSIONS

This method of assessment obtained positive results as an instrument for the quantitative assessment of balance in school-aged children. Values obtained for the three one-leg balance and static tests,were more strongly correlated than the normal gait test for all axes.

Are Accelerometer-based Functional Outcome Assessments Feasible and Valid After Treatment for Lower Extremity Sarcomas?

BACKGROUND

Aspects of physical functioning, including balance and gait, are affected after surgery for lower limb musculoskeletal tumors. These are not routinely measured but likely are related to how well patients function after resection or amputation for a bone or soft tissue sarcoma. Small, inexpensive portable accelerometers are available that might be clinically useful to assess balance and gait in these patients, but they have not been well studied.

QUESTIONS/PURPOSES

In patients treated for lower extremity musculoskeletal tumors, we asked: (1) Are accelerometer-based body-worn monitor assessments of balance, gait, and timed up-and-go tests (TUG) feasible and acceptable? (2) Do these accelerometer-based body-worn monitor assessments produce clinically useful data (face validity), distinguish between patients and controls (discriminant validity), reflect findings obtained using existing clinical measures (convergent validity) and standard manual techniques in clinic (concurrent validity)?

METHODS

This was a prospective cross-sectional study. Out of 97 patients approached, 34 adult patients treated for tumors in the femur/thigh (19), pelvis/hip (3), tibia/leg (9), or ankle/foot (3) were included in this study. Twenty-seven had limb-sparing surgery and seven underwent amputation. Patients performed standard activities while wearing a body-worn monitor on the lower back, including standing, walking, and TUG tests. Summary measures of balance (area [ellipsis], magnitude [root mean square {RMS}], jerkiness [jerk], frequency of postural sway below which 95% of power of acceleration power spectrum is observed [f95 of postural sway]), gait [temporal outcomes, step length and velocity], and TUG time were derived. Body-worn monitor assessments were evaluated for feasibility by investigating data loss and patient-reported acceptability and comfort. In addition, outcomes in patients were compared with datasets of healthy participants collected in parallel studies using identical methods as in this study to assess discriminant validity. Body-worn monitor assessments were also investigated for their relationships with routine clinical scales (the Musculoskeletal Tumour Society Scoring system [MSTS], the Toronto Extremity Salvage Score [TESS], and the Quality of life-Cancer survivors [QoL-CS)] to assess convergent validity and their agreement with standard manual techniques (video and stopwatch) to assess concurrent validity.

RESULTS

Although this was a small patient group, there were initial indications that body-worn monitor assessments were well-tolerated, feasible to perform, acceptable to patients who responded (95% [19 of 20] of patients found the body-worn monitor acceptable and comfortable and 85% [17 of 20] found it user-friendly), and produced clinically useful data comparable with the evidence. Balance and gait measures distinguished patients and controls (discriminant validity), for instance balance outcome (ellipsis) in patients (0.0475 m/s [95% confidence interval 0.0251 to 0.0810]) was affected compared with controls (0.0007 m/s [95% CI 0.0003 to 0.0502]; p = 0.001). Similarly gait outcome (step time) was affected in patients (0.483 seconds [95% CI 0.451 to 0.512]) compared with controls (0.541 seconds [95% CI 0.496 to 0.573]; p < 0.001). Moreover, body-worn monitor assessments showed relationships with existing clinical scales (convergent validity), for instance ellipsis with MSTS (r = -0.393; p = 0.024). Similarly, manual techniques showed excellent agreement with body-worn monitor assessments (concurrent validity), for instance stopwatch time 22.28 +/- 6.93 seconds with iTUG time 21.18 +/- 6.23 seconds (intraclass correlation coefficient agreement = 0.933; p < 0.001). P < 0.05 was considered statistically significant.

CONCLUSIONS

Although we had a small, heterogeneous patient population, this pilot study suggests that body-worn monitors might be useful clinically to quantify physical functioning in patients treated for lower extremity tumors. Balance and gait relate to disability and quality of life. These measurements could provide clinicians with useful novel information on balance and gait, which in turn could guide rehabilitation strategies.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Percentiles and Reference Values for the Accelerometric Assessment of Static Balance in Women Aged 50-80 Years

The identification of factors that alter postural stability is fundamental in the design of interventions to maintain independence and mobility. This is especially important for women because of their longer life expectancy and higher incidence of falls compared to men. The objective of this study was to construct the percentile box charts and determine the values of reference for the accelerometric assessment of the static balance in women. For this, an observational and cross-sectional study with a sample composed of 496 women (68.8 ± 10.4 years old) was conducted. The measurement of accelerations used a triaxial accelerometer during three tests: two tests on the ground in monopodal support and a test on a mat with monopodal support for 30 s each. In all of the variables, an increase in the magnitude of the accelerations was detected as the age advanced. The box charts of the percentiles of the tests show the amplitude of the interquartile ranges, which increased as the age advanced. The values obtained can be used to assess changes in static balance due to aging, trauma and orthopaedic and neurodegenerative alterations that may alter postural stability and increase the risk of falling.

The insole materials influence the plantar pressure distributions in diabetic foot with neuropathy during different walking activities

BACKGROUND

Abnormal peak plantar pressure in neuropathic diabetic foot during walking activities is well managed through the use of appropriate design and material selection for the fabrication of custom made insoles (CMI). The redistribution of plantar pressure is possible by selecting an appropriate material for the fabrication of CMI. The walking activities may alter the plantar pressure distribution; which may differ while using CMI with different materials.

OBJECTIVE

The objective of the study was to evaluate the effectiveness of CMI's materials on plantar pressure distribution during different walking activities, in diabetic feet with neuropathy.

METHODS

The study was conducted on sixteen diabetic neuropathic subjects. The subjects were provided with two types of CMI; CMI-A (Plastazote® and microcellular rubber) and CMI-B (Multifoam, Plastazote® and microcellular rubber). Maximum peak plantar pressure and plantar pressure distribution were determined by Pedar-X® sensor insole during level walking, ramp walking and stair walking.

RESULTS

The CMI-B lessened the maximum peak plantar pressure from the forefoot throughout the walking activities compared to CMI-A. The contact area was observed as lower using CMI-A compared to CMI-B, while performing walking activities.

CONCLUSION

CMI-B, with multifoam as an additional top layer, provided more effective peak plantar pressure reduction at forefoot and it had better plantar pressure distribution compared to CMI-A during level walking and ramp ascending in diabetic foot with neuropathy.

Development of New Soft Wearable Balance Exercise Device Using Pneumatic Gel Muscles

Decreased ability to control posture is correlated with the risk of falls among older individuals. In particular, reactive postural control ability response to even small perturbations is important for fall prevention of older individuals. The current study sought to design a new wearable assistive device for improving balance function by generating small perturbations using pneumatic gel muscle (PGM). Furthermore, we investigated the effects of using the proposed device for balance training. The proposed wearable balance exercise device utilized PGMs possessing various features, such as a lightweight design and the ability to generate small perturbations with a small power source. We investigated the effects of the device on reactive postural control exercises. Seven healthy participants participated in this study. Three-dimensional acceleration data (Ax, Ay, and Az) were measured from participants during a single leg stance in each session. The peak Ax value generated by perturbations and responses significantly differed from baseline peak acceleration. The peak Ay value caused by perturbations was significantly decreased compared with baseline peak acceleration. In addition, the root mean square Ax value of the post-test significantly decreased compared with the pre-test value. Our results revealed that the proposed wearable balance exercise device was able to create small perturbations for assessing reactive postural balance control. Furthermore, the device was able to improve users’ stability.

Cognitive impairment and postural control deficit in adults with Type 2 diabetes

BACKGROUND

Diseases induced by metabolic disorders, eg, Type 2 diabetes, has recently been linked to both sensory and motor deficit in the absence of a formal clinical diagnosis of peripheral neuropathy. Studies have demonstrated mild cognitive impairment in diabetic patients, which also plays a role in one's loss of ability to successfully perform basic motor activities. This project focused on evaluating cognitive function while maintaining balance. We hypothesized that simultaneous cognitive and motor deficit would occur among adults with Type 2 diabetes versus healthy age- and sex-matched control during a balance task.

METHODS

A sample of 10 Type 2 diabetes patients and 10 age-matched and sex-matched controls underwent a series of sensory, motor, cognitive, and cognitive-motor evaluations. Blood pressure and A_1c levels were assessed.

RESULTS

Significantly lower cognitive function scores, particularly in the domain of working memory, were exhibited in the diabetic group than controls. Balance in the diabetic group was overall poorer in both single- and dual-tasks than controls. When diabetic patients were asked to verbally recall different words while maintaining their balance, their accuracy rate was significantly lower than controls. Some health state measures were found to co-vary with motor function. Increased body mass index in the diabetic group did not account for motor function deficit.

SIGNIFICANCE

Our data suggest that: (1) systemic deficit beyond tactile dysfunction and increased body mass index contribute to reduced motor function in diabetes, and (2) both balance and working memory functions are simultaneously impaired in patients with Type 2 diabetes.

Postural control in healthy adults: Determinants of trunk sway assessed with a chest-worn accelerometer in 12 quiet standing tasks

Many diseases and conditions decrease the ability to control balance. In clinical settings, there is therefore a major interest in the assessment of postural control. Trunk accelerometry is an easy, low-cost method used for balance testing and constitutes an alternative method to the posturography using force platforms. The objective was to assess the responsiveness of accelerometry in a battery of 12 quiet standing tasks. We evaluated the balance of 100 healthy adults with an accelerometer fixed onto the sternum. We used the average amplitude of acceleration as an indirect measure of postural sways. The tasks of increased difficulty were realized with or without vision. The battery of tasks was repeated four times on two different days to assess reliability. We analyzed the extent to which the task difficulty and the absence of vision affected the trunk sway. The influence of individual characteristics (age, height, mass, sex, and physical activity level) was also assessed. The reliability analysis revealed that four repetitions of the battery of tasks are needed to reach a high accuracy level (mean ICC = 0.85). The results showed that task difficulty had a very large effect on trunk sways and that the removal of vision further increased sways. Concerning the effects of individual characteristics, we observed that women tended to oscillate more than men did in tasks of low difficulty. Age and physical activity level also had significant effects, whereas height and mass did not. In conclusion, age, sex, and physical fitness are confounders that should be considered when assessing patients’ balance. A battery of simple postural tasks measured by upper-trunk accelerometry can be a useful method for simple balance evaluation in clinical settings.

Foot function and strength of patients with diabetes grouped by ulcer risk classification (IWGDF)

BACKGROUND

The stratification system from the International Working Group on the Diabetic Foot (IWGDF) was used to classify the participants as to the ulcer risk. However, it is not yet known what the classification groups' individual deficits are regarding sensitivity, function, and musculoskeletal properties and mechanics. This makes it difficult to design proper ulcer prevention strategies for patients. Thus, this study aimed to investigate the foot function, foot strength and health of people with diabetes mellitus (DM)-with or without DPN-while considering the different ulcer risk classifications determined by the IWGDF.

METHODS

The subject pool comprised 72 people with DM, with and without DPN. The patients were divided into three groups: Group 0 (G0), which comprised diabetic patients without DPN; Group 1 (G1), which comprised patients with DPN; and Group 2 (G2), which comprised patients with DPN who had foot deformities. The health and foot function of the subjects' feet were assessed using a foot health status questionnaire (FHSQ-BR) that investigated four domains: foot pain, foot function, footwear, and general foot health. The patients' foot strength was evaluated using the maximum force under each subject's hallux and toes on a pressure platform (emed q-100, Novel, Munich, Germany).

RESULTS

Moderate differences were found between G0 and G1 and G2 for the foot pain, foot function, general foot health, and footwear. There was also a small but significant difference between G0 and G2 in regards to hallux strength.

CONCLUSION

Foot health, foot function and strength levels of people with DM and DPN classified by the ulcer risk are different and this must be taken into account when evaluating and developing treatment strategies for these patients.

Quantification of Axial Abnormality Due to Cerebellar Ataxia with Inertial Measurements

Cerebellar Ataxia (CA) leads to deficiencies in muscle movement and lack of coordination that is often manifested as gait and balance disabilities. Conventional CA clinical assessments are subjective, cumbersome and provide less insight into the functional capabilities of patients. This cross-sectional study investigates the use of wearable inertial sensors strategically positioned on the front-chest and upper-back locations during the Romberg and Trunk tests for objective assessment of human postural balance due to CA. The primary aim of this paper is to quantify the performance of postural stability of 34 patients diagnosed with CA and 22 healthy subjects as controls. Several forms of entropy descriptions were considered to uncover characteristics of movements intrinsic to CA. Indeed, correlation with clinical observation is vital in ascertaining the validity of the inertial measurements in addition to capturing unique features of movements not typically observed by the practicing clinician. Both of these aspects form an integral part of the underlying objective assessment scheme. Uncertainty in the velocity contained a significant level of information with respect to truncal instability and, based on an extensive clustering and discrimination analysis, fuzzy entropy was identified as an effective measure in characterising the underlying disability. Front-chest measurements demonstrated a strong correlation with clinical assessments while the upper-back measurements performed better in classifying the two cohorts, inferring that the standard clinical assessments are relatively influenced by the frontal observations. The Romberg test was confirmed to be an effective test of neurological diagnosis as well as a potential candidate for objective assessment resulting in a significant correlation with the clinical assessments. In contrast, the Trunk test is observed to be relatively less informative.

Adaptation of perturbation to postural control in individuals with diabetic peripheral neuropathy

Loss of sensation in the feet due to diabetic peripheral neuropathy can cause deterioration of postural control and result in higher risk of trips, slips or falls. In the literature, many studies have reported that people with diabetic peripheral neuropathy tend to show greater displacement of body sway than normal people when the base of support is disrupted. But not much is known about postural characteristics of diabetics with peripheral neuropathy at the moment of postural stability disruptions and during the time span for recovering stability. The objective of this study was to analyze differences of postural characteristics between diabetics with peripheral neuropathy and diabetics without peripheral neuropathy. A learning effect of perturbation was found for the diabetic peripheral neuropathy group in the posterior direction of perturbation during the first phase, which may indicate that it could be possible to design a postural control program for those people.

Electrophysiological measurements of diabetic peripheral neuropathy: A systematic review

INTRODUCTION

Peripheral neuropathy is one of the main complications of diabetes mellitus. One of the features of diabetic nerve damage is abnormality of sensory and motor nerve conduction study. An electrophysiological examination can be reproduced and is also a non-invasive approach in the assessment of peripheral nerve function. Population-based and clinical studies have been conducted to validate the sensitivity of these methods. When the diagnosis was based on clinical electrophysiological examination, abnormalities were observed in all patients.

METHOD

In this research, using a review design, we reviewed the issue of clinical electrophysiological examination of diabetic peripheral neuropathy in articles from 2008 to 2017. For this purpose, PubMed, Scopus and Embase databases of journals were used for searching articles.

RESULTS/FINDINGS

The researchers indicated that diabetes (both types) is a very disturbing health issue in the modern world and should be given serious attention. Based on conducted studies, it was demonstrated that there are different procedures for prevention and treatment of diabetes-related health problems such as diabetic polyneuropathy (DPN). The first objective quantitative indication of the peripheral neuropathy is abnormality of sensory and motor nerve conduction tests. Electrophysiology is accurate, reliable and sensitive. It can be reproduced and also is a noninvasive approach in the assessment of peripheral nerve function.

CONCLUSION

The methodological review has found that the best method for quantitative indication of the peripheral neuropathy compared with all other methods is clinical electrophysiological examination. For best results, standard protocols such as temperature control and equipment calibration are recommended.

Impaired balance is related to the progression of diabetic complications in both young and older adults

AIMS

To investigate the balance ability in younger and older adults with diabetes and evaluate the associations between balance ability and microvascular complications.

METHODS

This cross-sectional observational study compared 162 participants and 177 controls with and without type 2 diabetes, respectively. Balance ability was assessed using two static (one-legged stance and postural sway area) and two dynamic (Timed Up and Go [TUG] and Functional Reach) tests. Diabetic microangiopathy was also evaluated.

RESULTS

Participants with diabetes, including both younger (<50years) and older (≥50years) participants, showed significantly worse balance ability in all four tests and were more likely to have a history of falls than the controls (all P<0.01). In all age groups, severe impairment of balance ability was associated with progression of diabetic microvascular complications. In all and older diabetic adults, a longer duration of diabetes (P=0.022) and higher TUG test score (P=0.004), and female sex (P=0.01) and higher TUG score (P=0.001), respectively, were related to a history of falls. On the other hand, among younger diabetic adults, only a non-significant association with longer duration of diabetes (P=0.066) was observed.

CONCLUSIONS

Impaired balance ability correlates with microvascular diabetic complications. Accurate assessment of balance ability in adults with diabetes could predict the risk of falls, particularly benefitting people with diabetic complications.

AGING, DIABETES, AND FALLS

KEY POINTS Falls are a major health issue for older adults, leading to adverse events and even death. Older persons with type 2 diabetes are at increased risk of falling compared to healthy adults of a similar age. Over 400 factors are associated with falls risk, making identification and targeting of key factors to prevent falls problematic. However, the major risk factors include hypertension, diabetes, pain, and polypharmacy. In addition to age and polypharmacy, diabetes-related loss of strength, sensory perception, and balance secondary to peripheral neuropathy along with decline in cognitive function lead to increased risk of falling. Designing specific interventions to target strength and balance training, reducing polypharmacy to improve cognitive function, relaxation of diabetes management to avoid hypoglycemia and hypotension, and relief of pain will produce the greatest benefit for reducing falls in older persons with diabetes. Abbreviation: DPN = diabetic polyneuropathy.

Postural sway in diabetic peripheral neuropathy among Indian elderly

Background & objectives:

Diabetic peripheral neuropathy (DPN) is a major complication of type 2 diabetes and have long term complications on the postural control of the affected population. The objectives of this study were to evaluate postural stability in patients with DPN and to examine correlation of Michigan Neuropathy Screening Instrument (MNSI) with duration of diabetes, age and postural stability measures.

Methods:

Participants were included if they had clinical neuropathy which was defined by MNSI. Sixty one patients gave their consent to participate in the study and were evaluated on posturography for postural stability measures in four conditions. Repeated measures of analysis of variance (RANOVA) was used to analyze the changes in postural stability measures in different conditions.

Results:

An increase in mean value of postural stability measures was observed for velocity moment 20.4±1.3, 24.3±2.2, 42.3±20.7, 59±43.03, mediolateral displacement 0.21±0.10, 0.22±0.18, 0.03±0.11, 0.34±0.18, and anteroposterior displacement 0.39 ± 0.09, 0.45±0.12, 0.47±0.13, 0.51±0.20 from EO to EC, EOF, and ECF, respectively. There was a significant difference (P<0.05) in participants with DPN, with greater sway amplitude on firm and foam surface in all the conditions. Moderate correlation of MNSI with age (r=0.43) and postural stability measures were also observed.

Interpretation & conclusions:

Evaluation of postural stability in Indian DPN population suggests balance impairments on either firm and foam surfaces, with greater likelihood of fall being on foam or deformable surfaces among elderly adults with neuropathy (CTRI/2011/07/001884).

Educational Level Is Related to Physical Fitness in Patients with Type 2 Diabetes - A Cross-Sectional Study

Introduction

Low educational level (EL) and low physical fitness are both predictors of increased morbidity and mortality in patients with type 2 diabetes. It is unknown if EL is related to physical fitness. This would have important implication for the treatment approach of patients of low EL.

Materials and Methods

In 2011/12, we invited participants of a new nationwide Swiss physical activity program for patients with type 2 diabetes to participate in this study. EL was defined by self-report and categorized as low (mandatory education), middle (professional education) or high (high school/university). Physical fitness was determined using 5 validated measures that assessed aerobic fitness, functional lower limb muscle strength, walking speed, balance and flexibility. Potential confounder variables such as other socio-cultural factors, physical activity level, body composition, diabetes-related parameters and complications/co-morbidities as well as well-being were assessed.

Results

All invited 185 participants (mean age 59.6 ±9.8 yrs, 76 women) agreed to be included. Of all patients, 23.1% had a low, 32.7% a middle and 44.2% a high EL; 41.8% were professionally active. The study population had a mean BMI of 32.4±5.2 kg/m² and an HbA1c of 7.3±1.3%. The mean diabetes duration was 8.8±7.4 years. In the baseline assessment, higher EL was associated with increased aerobic fitness, increased functional lower limb muscle strength, and increased walking speed using linear regression analysis (values for low, middle and high EL, respectively: 91.8 ± 27.9, 116.4 ± 49.7 and 134.9 ± 60.4 watts for aerobic fitness (p = 0.002), 15 ± 4.7, 13.9 ± 2.7, 12.6 ± 2.9 seconds for strength (p = 0.001) and 8.8 ± 1.6, 8.3 ± 1.4, 7.8 ± 1.4 seconds for walking speed (p = 0.004)). These associations were independent of potential confounders. Overall, aerobic fitness was 46%, functional limb muscle strength 16%, and walking speed 11% higher in patients of high compared to those of low EL. EL was not related to balance or flexibility.

Discussion

A main strength of the present study is that it addresses a population of importance and a factor (EL) whose understanding can influence future interventions. A second strength is its relatively large sample size of a high-risk population. Third, unlike studies that have shown an association between self-reported fitness and educational level we assessed physical fitness measures by a quantitative and validated test battery using assessors blinded to other data. Another novelty is the extensive evaluation of the role of many relevant confounder variables.

Conclusions

In conclusion, we show that in patients with type 2 diabetes EL correlates favorably and independently with important health-related physical fitness measures such as aerobic fitness, walking speed, and lower limb strength. Our findings underline that diabetic patients with low EL should be specifically encouraged to participate in physical activity intervention programs to further reduce social disparities in healthcare. Such programs should be structured and integrate the norms, needs and capacities (financial, time, physical capacities and self-efficacy) of this population, and their effectiveness should be tested in future studies.

Trial Registration

University of Lausanne clinicaltrials.gov NCT01289587

Postural Control and Gait Performance in the Diabetic Peripheral Neuropathy: A Systematic Review

Purpose. The aim of this paper is to review the published studies on the characteristics of impairments in the postural control and gait performance in diabetic peripheral neuropathy (DPN). Methods. A review was performed by obtaining publication of all papers reporting on the postural control and gait performance in DPN from Google Scholar, Ovid, SAGE, Springerlink, Science Direct (SD), EBSCO Discovery Service, and Web of Science databases. The keywords used for searching were “postural control,” “balance,” “gait performance,” “diabetes mellitus,” and “diabetic peripheral neuropathy.” Results. Total of 4,337 studies were hit in the search. 1,524 studies were screened on their titles and citations. Then, 79 studies were screened on their abstract. Only 38 studies were eligible to be selected: 17 studies on postural control and 21 studies on the gait performance. Most previous researches were found to have strong evidence of postural control impairments and noticeable gait deficits in DPN. Deterioration of somatosensory, visual, and vestibular systems with the pathologic condition of diabetes on cognitive impairment causes further instability of postural and gait performance in DPN. Conclusions. Postural instability and gait imbalance in DPN may contribute to high risk of fall incidence, especially in the geriatric population. Thus, further works are crucial to highlight this fact in the hospital based and community adults.

Alternative Quantitative Tools in the Assessment of Diabetic Peripheral and Autonomic Neuropathy

Here we review some seldom-discussed presentations of diabetic neuropathy, including large fiber dysfunction and peripheral autonomic dysfunction, emphasizing the impact of sympathetic/parasympathetic imbalance. Diabetic neuropathy is the most common complication of diabetes and contributes additional risks in the aging adult. Loss of sensory perception, loss of muscle strength, and ataxia or incoordination lead to a risk of falling that is 17-fold greater in the older diabetic compared to their young nondiabetic counterparts. A fall is accompanied by lacerations, tears, fractures, and worst of all, traumatic brain injury, from which more than 60% do not recover. Autonomic neuropathy has been hailed as the "Prophet of Doom" for good reason. It is conducive to increased risk of myocardial infarction and sudden death. An imbalance in the autonomic nervous system occurs early in the evolution of diabetes, at a stage when active intervention can abrogate the otherwise relentless progression. In addition to hypotension, many newly recognized syndromes can be attributed to cardiac autonomic neuropathy such as orthostatic tachycardia and bradycardia. Ultimately, this constellation of features of neuropathy conspire to impede activities of daily living, especially in the patient with pain, anxiety, depression, and sleep disorders. The resulting reduction in quality of life may worsen prognosis and should be routinely evaluated and addressed. Early neuropathy detection can only be achieved by assessment of both large and small- nerve fibers. New noninvasive sudomotor function technologies may play an increasing role in identifying early peripheral and autonomic neuropathy, allowing rapid intervention and potentially reversal of small-fiber loss.

Diabetic peripheral neuropathy compromises balance during daily activities

OBJECTIVE

Patients with diabetes with peripheral neuropathy have a well-recognized increased risk of falls that may result in hospitalization. Therefore this study aimed to assess balance during the dynamic daily activities of walking on level ground and stair negotiation, where falls are most likely to occur.

RESEARCH DESIGN AND METHODS

Gait analysis during level walking and stair negotiation was performed in 22 patients with diabetic neuropathy (DPN), 39 patients with diabetes without neuropathy (D), and 28 nondiabetic control subjects (C) using a motion analysis system and embedded force plates in a staircase and level walkway. Balance was assessed by measuring the separation between the body center of mass and center of pressure during level walking, stair ascent, and stair descent.

RESULTS

DPN patients demonstrated greater (P < 0.05) maximum and range of separations of their center of mass from their center of pressure in the medial-lateral plane during stair descent, stair ascent, and level walking compared with the C group, as well as increased (P < 0.05) mean separation during level walking and stair ascent. The same group also demonstrated greater (P < 0.05) maximum anterior separations (toward the staircase) during stair ascent. No differences were observed in D patients.

CONCLUSIONS

Greater separations of the center of mass from the center of pressure present a greater challenge to balance. Therefore, the higher medial-lateral separations found in patients with DPN will require greater muscular demands to control upright posture. This may contribute to explaining why patients with DPN are more likely to fall, with the higher separations placing them at a higher risk of experiencing a sideways fall than nondiabetic control subjects.

Tactile intervention as a novel technique in improving body stability in healthy elderly and elderly with diabetes

BACKGROUND

Body sway increases in the elderly because of normal aging and high incidence of disease such as diabetes. Prevalence of sway is greater in the elderly with diabetes because of damage to the central and peripheral nervous systems. Increase in body sway is associated with an elevated risk of falling. Falling is one of the major causes of morbidity and mortality in the elderly. The purpose of this study was to develop a new technique to improve body stability and decrease body sway in the elderly people with or without diabetes.

SUBJECTS AND METHODS

Twenty-two subjects--12 elderly (mean age, 75.5±7.3 years) and 10 age-matched elderly with diabetes (mean age, 72.5±5.3 years)--were recruited for this study. Subjects received tactile feedback as a tingling sensation resulting from electrical stimulation triggered by body sway.

RESULTS

The results showed a significant reduction in body sway in the elderly while standing on foam with eyes open (1.0±0.31 vs. 1.9±0.8; P=0.006) and eyes closed (1.8±0.7 vs. 3.3±1.5; P=0.001). In the group with diabetes, there was a significant reduction in body sway while standing on foam with eyes closed (1.4±0.5 vs. 2.3±0.8; P=0.045) but not with eyes open.

CONCLUSIONS

In this small study, this technique offers a new tool for training people with diabetes and elderly people to improve body stability and balance.

Static balance in patients presenting diabetes mellitus type 2 with and without diabetic polyneuropathy

OBJECTIVES

To contrast the static balance in patients presenting diabetes mellitus type 2 (DM2) with and without polyneuropathy (DPN); and to correlate the rates from the scale Diabetic Neuropathy Examination (DNE) with the mean ratio of the center of pressure (CoP).

SUBJECTS AND METHODS

Twenty patients, aged between 40 and 54, presenting DM2 and classified, according to DNE scale, in groups with (n = 10) and without (n = 10) DPN, were compared. Static balance was evaluated by means of the CoP mean ratio on a Wii Balance Board® under the conditions of open and closed eyes. After normality verification (Shapiro-Wilk), balance between both groups was compared by means of the Student t test and Mann-Whitney U test, as applicable. DNE rating was correlated with the mean ratio of CoP in the group with DPN, considering a significance level p < 0.05.

RESULTS

Significant differences (p = 0.049) were found under the condition of closed eyes, with greater CoP ratio in the group with DPN (0.548 cm vs. 0.442 cm). The group with DPN showed a tendency (p = 0.059) towards a greater CoP mean ratio under the open eyes condition (0.351 cm vs. 0.239 cm). There was a strong correlation (r = 0.751) between the DNE rating and the CoP mean ratio under the closed eyes condition (p = 0.012).

CONCLUSIONS

Patients showing DPN demonstrated worse static balance than patients without DPN in the closed eyes condition. Furthermore, the higher the rating in DNE, the stronger the displacement of CoP, which may be associated with higher risk of falls.

Motor neuropathy

In distal symmetric sensorimotor polyneuropathy (DSPN) in diabetes, involvement of the motor system is rarely seen. Using dynamometry, substantial weakness at the ankle and knee has been found in type 1 and type 2 diabetic patients. The muscle weakness is found only in diabetic patients with DSPN, and is closely related to signs and severity of DSPN. In long-term follow-up studies, neuropathic patients have accelerated loss of muscle strength. Studies using MRI have shown that muscle weakness is paralleled by muscular atrophy within the feet and lower legs and in follow-up studies this atrophy is accelerated compared to healthy controls and non-neuropathic patients. In large-scale studies of diabetic subjects, lower muscle quality has been found, which indicates that even with preserved muscle strength diabetes per se causes lower strength per unit striated muscle. Muscle weakness causes slower movements of the feet and legs, unstable gait, and more frequent falls. Furthermore, weakness is also an independent risk factor for the development of foot ulcers. Training may improve strength, postural stability, and walking performance; however, this still needs to be studied including patients with various degrees of DSPN.

Which lower limb frontal plane sensory and motor functions predict gait speed and efficiency on uneven surfaces in older persons with diabetic neuropathy?

OBJECTIVE

To identify which frontal plane lower limb sensorimotor functions predict gait speed and efficiency (step-width-to-step-length ratio) on an uneven surface.

DESIGN

Cross-sectional observational study.

SETTING

A biomechanics research laboratory.

PARTICIPANTS

Thirty-three subjects (14 women [42.4%]; 21 with diabetic distal symmetric peripheral neuropathy [63.6%]), with a spectrum of lower limb sensorimotor functions that ranged from normal to marked diabetic neuropathy.

METHODS

Independent variables included ankle inversion-eversion proprioceptive thresholds, and normalized measures of maximum voluntary strength and maximum rate of torque development (RTD) of hip abduction-adduction and ankle inversion-eversion. Kinematic data were obtained by using an optoelectronic system as subjects walked over an uneven 10-m surface.

MAIN OUTCOME MEASURES

Dependent variables included gait speed and efficiency (determined by step-width-to-step-length ratio) on an uneven surface.

RESULTS

Hip adduction RTD and ankle inversion RTD predicted 54% of gait speed, with the former predicting the majority (44%). Ankle inversion RTD was the only significant predictor of gait efficiency, which accounted for 46% of its variability. Age did not predict gait speed or efficiency.

CONCLUSIONS

The rapid generation of strength in the frontal plane at the hip and ankle is responsible for the successful negotiation of irregular surfaces in older persons. Age demonstrated no independent influence. Training regimens in older persons should include maneuvers that rapidly develop strength in hip adductors and ankle invertors if navigation of uneven surfaces is a functional goal.

Virtualizing the assessment: a novel pragmatic paradigm to evaluate lower extremity joint perception in diabetes

BACKGROUND

Individuals with diabetes have a higher risk of falls and fall-related injuries. People with diabetes often develop peripheral neuropathy (DPN) as well as nerve damage throughout the body. In particular, reduced lower extremity proprioception due to DPN may cause a misjudgment of foot position and thus increase the risk of fall.

OBJECTIVE

An innovative virtual obstacle-crossing paradigm using wearable sensors was developed in an attempt to assess lower extremity position perception damage due to DPN.

METHODS

67 participants (age 55.4 ± 8.9, BMI 28.1 ± 5.8) including diabetics with and without DPN as well as aged-matched healthy controls were recruited. Severity of neuropathy was quantified using a vibratory perception threshold (VPT) test. The ability of perception of lower extremity was quantified by measuring obstacle-crossing success rate (OCSR), toe-obstacle clearance (TOC), and reaction time (T(R)) while crossing a series of virtual obstacles with heights at 10% and 20% of the subject's leg length.

RESULTS

No significant difference was found between groups for age and BMI. The data revealed that DPN subjects had a significantly lower OCSR compared to diabetics with no neuropathy and controls at an obstacle size of 10% of leg length (p < 0.05). DPN subjects also demonstrated longer T(R) compared to other groups and for both obstacle sizes. In addition, TOC was reduced in neuropathy groups. Interestingly, a significant correlation between T(R) and VPT (r = 0.5, p < 10(-3)) was observed indicating a delay in reaction with increasing neuropathy severity. The delay becomes more pronounced by increasing the size of the obstacle. Using a regression model suggests that the change in T(R) between obstacle sizes of 10% and 20% of leg length is the most sensitive predictor for neuropathy severity with an odds ratio of 2.70 (p = 0.02).

CONCLUSION

The findings demonstrate proof of a concept of virtual-reality application as a promising method for objective assessment of neuropathy severity, however a further study is warranted to establish a stronger relationship between the measured parameters and neuropathy.

Postural strategies in diabetes patients with peripheral neuropathy determined using cross-correlation functions

BACKGROUND

Although postural control strategies have been largely explored in diabetes patients with peripheral neuropathy, the literature on their postural control strategies related to peripheral neuropathy level and task complexity is still limited. The aim of this study is then to investigate how balance task difficulty influences postural strategies in diabetes patients with peripheral neuropathy.

SUBJECTS AND METHODS

Postural strategies and instability were evaluated in 25 diabetes patients during four standing tasks. The root mean square value of the anterior-posterior angular velocity, measured at the trunk and the ankle, was investigated and analyzed using cross-correlation functions (CCFs). Correlations between balance and clinical variables were analyzed.

RESULTS

A significant decrease in CCFs between trunk and ankles was observed under dynamic balance conditions. Correlations were observed between postural strategies and balance instability with the level of peripheral neuropathy and with hip and ankle strength.

CONCLUSION

Postural strategies are influenced by more demanding standing tasks and correlated with the level of peripheral neuropathy and strength of muscles in diabetes patients.

Frontal plane hip and ankle sensorimotor function, not age, predicts unipedal stance time

INTRODUCTION

Changes occur in muscles and nerves with aging. In this study we explore the relationship between unipedal stance time (UST) and frontal plane hip and ankle sensorimotor function in subjects with diabetic neuropathy.

METHODS

UST, quantitative measures of frontal plane ankle proprioceptive thresholds, and ankle and hip motor function were tested in 41 subjects with a spectrum of lower limb sensorimotor function ranging from healthy to moderately severe diabetic neuropathy.

RESULTS

Frontal plane hip and ankle sensorimotor function demonstrated significant relationships with UST. Multivariate analysis identified only composite hip strength, ankle proprioceptive threshold, and age to be significant predictors of UST (R(2) = 0.73), explaining 46%, 24%, and 3% of the variance, respectively.

CONCLUSIONS

Frontal plane hip strength was the single best predictor of UST and appeared to compensate for less precise ankle proprioceptive thresholds. This finding is clinically relevant given the possibility of strengthening the hip, even in patients with significant peripheral neuropathy.

Peripheral neuropathy may not be the only fundamental reason explaining increased sway in diabetic individuals

BACKGROUND

Individuals with diabetic neuropathy sway more than control individuals while standing. This review specifically evaluated whether peripheral sensory neuropathy can be the only fundamental reason accounting for significant increased sway within this population.

METHODS

Twenty-six experimental articles were selected using MEDLINE and reference lists of relevant articles. The articles chosen investigated kinematic data of postural behaviour in controls and individuals with diabetic neuropathy during stance. Results of literature were compared with four expectations related to the peripheral sensory neuropathy fundamental hypothesis.

FINDINGS

Consistent with the peripheral sensory neuropathy hypothesis, the literature showed that individuals with diabetic neuropathy sway more than controls in quiet stance and even more so if their visual or vestibular systems were perturbed. Inconsistent with the hypothesis, individuals with diabetic neuropathy are more destabilised than controls in conditions altering sensation of the feet and legs (standing on a sway-referenced surface).

INTERPRETATION

The review showed that the peripheral sensory neuropathy hypothesis may not be the only fundamental cause accounting for significant increased postural sway in individuals with diabetic neuropathy. Visual impairments and changes in postural coordination may explain the divergence between expectations and results. In order to develop interventions aimed at improving postural control in individuals with diabetic neuropathy, scientific exploration of these new expectations should be detailed. Also at the practical level, the review discussed which additional sensory information - at the level of the hands and feet - may be more beneficial in individuals with diabetic neuropathy to reduce their postural sway.

The gait and balance of patients with diabetes can be improved: a randomised controlled trial

AIMS/HYPOTHESIS

Gait characteristics and balance are altered in diabetic patients. Little is known about possible treatment strategies. This study evaluates the effect of a specific training programme on gait and balance of diabetic patients.

METHODS

This was a randomised controlled trial (n=71) with an intervention (n=35) and control group (n=36). The intervention consisted of physiotherapeutic group training including gait and balance exercises with function-orientated strengthening (twice weekly over 12 weeks). Controls received no treatment. Individuals were allocated to the groups in a central office. Gait, balance, fear of falls, muscle strength and joint mobility were measured at baseline, after intervention and at 6-month follow-up.

RESULTS

The trial is closed to recruitment and follow-up. After training, the intervention group increased habitual walking speed by 0.149 m/s (p<0.001) compared with the control group. Patients in the intervention group also significantly improved their balance (time to walk over a beam, balance index recorded on Biodex balance system), their performance-oriented mobility, their degree of concern about falling, their hip and ankle plantar flexor strength, and their hip flexion mobility compared with the control group. After 6 months, all these variables remained significant except for the Biodex sway index and ankle plantar flexor strength. Two patients developed pain in their Achilles tendon: the progression for two related exercises was slowed down.

CONCLUSIONS/INTERPRETATION

Specific training can improve gait speed, balance, muscle strength and joint mobility in diabetic patients. Further studies are needed to explore the influence of these improvements on the number of reported falls, patients' physical activity levels and quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00637546

FUNDING

This work was supported by the Swiss National Foundation (SNF): PBSKP-123446/1/