Falls are a recognized as an important cause of morbidity and mortality in the elderly – costing the health care system millions of dollars each year. Almost one-third of those over age 65 and not in a nursing home fall each year. Much work has been done to identify risk factors that contribute to falls. An important risk factor that has been identified and is increasingly more prevalent is diabetic peripheral neuropathy.
Diabetic peripheral neuropathy causes loss of distal strength and sensation with interruption of both afferent and efferent pathways. Research has shown that diabetics with peripheral neuropathy are 15 times more likely to report falling or stumbling in a one-year period. The postural instability associated with diabetic peripheral neuropathy is most apparent in unipedal stance and balance – both of which are critical in gait and activities of daily living such as changing clothes and climbing stairs.
One retrospective study by Cavanagh et. al. found that diabetic neuropathic subjects were 15 times more likely to report injury and felt significantly less safe during standing and walking than non-neuropathic subjects. Another study by Richardson et. al. found diabetics with EMG-confirmed peripheral neuropathy were 23 times more likely to report instability resulting in a fall or injury.
As specialists in gait and lower extremity biomechanics, can we do anything to prevent falls and improve gait in diabetics with peripheral neuropathy? Is it not our responsibility to do as much as we can to maintain quality of life in these patients?
As both a 3rd year podiatry student and exercise specialist, I feel that there is more we can do as lower extremity specialists. Can we not help teach these patients to incorporate balance training into their daily regimen if it will improve the stability of their gait? Can we not show these patients daily stretching exercises that can prevent lower leg contractures that limit foot and ankle motion?
To date, no research has been done showing the effectiveness of balance training for diabetic peripheral neuropathy, however; research has proven balance training to be an effective means of preventing falls in older women with osteoporosis, the elderly and chronic stroke patients.
The instability, muscle weakness and sensorimotor dysfunction clinically seen in diabetic peripheral neuropathy is also common in chronic stroke patients. A 2005 study by Marigold et. al. showed that 10 weeks of agility training including tandem walking, figure eights, stepping over obstacles, etc., improved mobility, functional stability and increased postural reflexes in older adults with chronic stroke.
All balance exercises can be done in a patient’s home with little or no equipment. By following protocols from previous research studies, a patient can incorporate unipedal stance, tandem walking, side-stepping and backward walking into their daily routine. If we can encourage our peripheral neuropathy patients to even do a couple exercises every day in their home, I believe we will start to see an increase in confidence with a concomitant reduction in falls and injuries.
By Emily Splichal, BS, CPT
Class of 2008 DPM – NYCPM
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