Sensory-Motor Mechanisms Increasing Falls Risk in Diabetic Peripheral Neuropathy

Abstract

Diabetic peripheral neuropathy (DPN) is associated with peripheral sensory and motor nerve damage that affects up to half of diabetes patients and is an independent risk factor for falls. Clinical implications of DPN-related falls include injury, psychological distress and physical activity curtailment. This review describes how the sensory and motor deficits associated with DPN underpin biomechanical alterations to the pattern of walking (gait), which contribute to balance impairments underpinning falls. Changes to gait with diabetes occur even before the onset of measurable DPN, but changes become much more marked with DPN. Gait impairments with diabetes and DPN include alterations to walking speed, step length, step width and joint ranges of motion. These alterations also impact the rotational forces around joints known as joint moments, which are reduced as part of a natural strategy to lower the muscular demands of gait to compensate for lower strength capacities due to diabetes and DPN. Muscle weakness and atrophy are most striking in patients with DPN, but also present in non-neuropathic diabetes patients, affecting not only distal muscles of the foot and ankle, but also proximal thigh muscles. Insensate feet with DPN cause a delayed neuromuscular response immediately following foot–ground contact during gait and this is a major factor contributing to increased falls risk. Pronounced balance impairments measured in the gait laboratory are only seen in DPN patients and not non-neuropathic diabetes patients. Self-perception of unsteadiness matches gait laboratory measures and can distinguish between patients with and without DPN. Diabetic foot ulcers and their associated risk factors including insensate feet with DPN and offloading devices further increase falls risk. Falls prevention strategies based on sensory and motor mechanisms should target those most at risk of falls with DPN, with further research needed to optimise interventions.

Wearable Sensor for Assessing Gait and Postural Alterations in Patients with Diabetes: A Scoping Review

“…Both nervous and vascular alterations are significant long-term complications in patients with diabetes, and they account for significant morbidity and mortality and the risk of falls, so the evaluation of gait and posture in patients with DPN and vascular problems in feet, leading to alterations in biomechanical spatiotemporal variables of gait, is clinically important to diagnose and tailor interventions to reduce the adverse outcomes [42][43][44][45][46]. Meta-analysis results suggest that DPN patients expended a longer period of time in the stance phase compared to patients with diabetes without DPN and healthy individuals [39].…”

Knee-High Devices Are Gold in Closing the Foot Ulcer Gap: A Review of Offloading Treatments to Heal Diabetic Foot Ulcers

“…Yet, in people with DPN, the sensory neuropathy results in a loss of sensation to pain, which usually means the person does not change their gait or seek treatment to offload [ 1 , 9 , 10 , 11 ]. The motor neuropathy from DPN can also lead to further detrimental gait, balance, and bony deformity changes, which can lead to even higher plantar tissue stress [ 1 , 9 , 10 , 11 , 12 , 13 , 14 ]. High plantar tissue stress, left untreated, often results in a breakdown of subcutaneous plantar tissue and a DFU develops, and if it remains untreated considerably prolongs DFU healing [ 1 , 9 , 10 , 11 ].…”

Efficacy and safety of the combined metabolic medication, containing inosine, nicotinamide, riboflavin and succinic acid, for the treatment of diabetic neuropathy: a multicenter randomized, double-blind, placebo-controlled parallel group clinical trial (CYLINDER)

“…The reported prevalence of diabetic polyneuropathy (DPN) varies from 6% to 51% in adult patients;1 its detection is increased to 90% with the use of electrophysiological methods 2 3. Symptoms of DPN, such as neuropathic pain and decreased sensation, can cause falls and fractures, impair quality of life, restrict activities of daily living, provoke depressive symptoms, and contribute to formation of foot complications 4–6. Treatment options for DPN which effectively target the underlying nerve damage are still lacking 5 7.…”