Relationship Between Loss of Pedal Sensibility, Balance, and Falls in Patients With Peripheral Neuropathy

Abstract

: The purpose of this study was to describe the relationship between balance and foot sensibility in a population of patients with impaired lower extremity sensation. The hypothesis was that increasing impairment of sensation correlates with impaired balance. To date, no report has investigated the relationship between loss of balance with the degree of sensibility in the foot in a population with neuropathy. Ten control subjects and 35 patients with sensory abnormalities and balance problems related to a neuropathy were evaluated. The MatScan Measurement System was used to measure their ability to stand still, maintaining their balance with their eyes open and then with their eyes shut. The degree to which the person moves while attempting to stand still is defined as "sway," which was recorded for normal and neuropathy patients. Sensibility of the foot was measured with the Pressure-Specified Sensory Device, which is noninvasive and nonpainful. The 1- and 2-point static touch thresholds are measured for the pulp of the big toe, medial heel, and the dorsum of the foot. Loss of 2- or 1-point sensation was recorded as sensibility score and compared with controls. Statistical analysis of data and their comparisons for the 2 groups was completed. There were 55% females in control and 64% in neuropathy patients, whereas average age was 50 and 62 years, respectively. Neuropathy was the result of diabetes in 64.5%, hypothyroidism in 19.3%, their combination in 13%, and of unknown etiology in the remaining 19% of patients. Controls had significantly lower mean sway than neuropathy patients (22.9 +/- 9% vs. 189.5 +/- 180%, P = 0.006). Likewise, sensibility score for normal and neuropathy patients was also significantly different (31.4 +/- 9% vs. 232.8 +/- 59%, P <0.0001). When compared with the controls, 99% upper limit of confidence, sensibility in the neuropathy group at the hallux pulp was abnormal at a level consistent with axonal loss in 52% and was completely absent in the remaining 48%. Similarly, at the heel, sensibility was normal in 6.5%, abnormal at a level consistent with axonal loss in 71%, and absent in the remaining 22.5%. The correlation coefficient between sway and sensibility score was 0.36. The results of this investigation for the first time document the intuitive relationship between increasing loss of foot sensibility and increasing loss of balance. These measurements can now be used prospectively to evaluate whether restoration of sensation to patients with neuropathy, through peripheral nerve decompression, can improve balance and reduce falls/fractures in this patient population.

The role of the great toe in balance performance

“…The same group also found great toe pressure in elderly subjects was significantly greater than in younger subjects. 4 Similar results were found by Ducic et al 5,6 in a group of patients with peripheral neuropathy. Significant changes in the plantar pressure distribution were measured in standing and walking within patients with great toe range of motion deficits.…”

The Effect of Reduced Somatosensation on Standing Balance: A Systematic Review

“…5,19,[23][24][25][26]32,[34][35][36]41,42,46,47,50 Thirteen of the 39 initially selected articles were excluded because no measures of somatosensation were presented. 1,22,[27][28][29][30]38,40,[43][44][45]48,51 Six of the selected articles 10,18,31,33,49,52 were excluded because the balance measurements did not refer to standing balance. Two articles 2,16 were excluded because there was no comparison with a control group or a standardized norm.…”

“…Based on title and abstract, 453 articles were excluded. Three articles 19,22,23 were added after examining the references of the 36 selected articles, resulting in 39 articles 1,2,5,10,15,16,18,19, to be assessed for detailed review. Before the consensus meeting, a disagreement originated from misreading sentences or misunderstanding the terminology used in the articles, between the two reviewers, about 14 articles.…”

“…The maintenance of balance requires the central integration of afferent information 1,2 and is highly dependent on vestibular, visual, and somatosensory information. [3][4][5] Healthy persons predominately rely on their somatosensory system when they are in a lightened environment with a solid base of support.…”

Reconsidering Nerve Decompression: An Overlooked Opportunity to Limit Diabetic Foot Ulcer Recurrence and Amputation

“…2,30,31 Objective outcome studies and prospective or randomized controlled trial protocols now report beneficial ND effects on balance, tunnel tissue pressures, ulceration risk, DFU recurrence risk, and electrophysiological parameters, as Figure 2 shows. [32][33][34][35][36][37][38][39] These often include and correlate common subjective measures of DSPN symptoms and signs. Aszmann and coauthors 32 first published the unanticipated finding that every ulceration and amputation in 50 DSPN cases that had unilateral ND surgeries for leg pain occurred in the contralateral, nonoperated legs.…”