Diabetes and Postural Stability: Review and Hypotheses

Abstract

Among the complications associated with diabetes mellitus is postural control. The authors reviewed 28 studies in the literature that focused on the magnitudes of postural sway that people with and without diabetes exhibit. The general observation is that postural sway is greater for people with diabetes, especially if their condition includes neuropathy. Peripheral sensory neuropathy seems to be the primary factor, but the available evidence does not rule out diabetes per se, other neuropathies (central, autonomic, motor), or an inability to exploit fully optical and inertial information about posture. The authors' review raises the issue of foot disorders and the possibility of increased sway as a useful adaptation; it also calls for better neuropathy assessments, postural tasks, and measures.

Dynamic stability training improves standing balance control in neuropathic patients with type 2 diabetes

“…Clinical constraints in patients with DN are due to distinct, context-specific instabilities such as movement strategies (hip and ankle) [4] and sensory strategies (specifically somatosensory) [20]. Movement studies have shown that ankle strategy is responsible for slow and small movements of the COM at low velocities but that hip strategy controls larger movements of the COM at higher velocities [21].…”

“…This increased risk is presumably due to the well-documented balance problems attributed to neuropathy [1] and sensory ataxia, which is the lack of accurate proprioceptive feedback [2]. Sources of instability in patients with type 2 DN include the loss or reduction of peripheral sensory information in the feet [3][4], the inability of the central nervous system (CNS) to appropriately integrate available postural control information [2,[4][5], and a switch from an ankle-based to a hip-based balance strategy [6][7][8][9][10]. In addition, an increase in the use of vestibular information and dependence on visual information [11] alter the style of postural control in patients with DN.…”

“…Sources of sensory afferents that seem to contribute to postural control include (1) proprioception, (2) vestibular, and (3) visual systems [3]. Pathological or subclinical constraints in patients with DN are due to distinct, context-specific instabilities such as movement [4] and sensory (somatosensory) strategies [20]. Reactive movement strategies help patients develop coordinated multijoint movement, and sensory strategies help patients to select appropriate sensory information for postural control [21].…”

“…When persons stand on a firm surface, ankle strategy maintains balance with small movements of sway, like an inverted pendulum. Hip strategy controls the quick and narrow movements of the COM when a person stands on a narrow or compliant surface that allows inadequate ankle torque [4]. Retraining reactive movement strategies involves exposing the patients to external perturbations that vary in direction, speed, and amplitude [21].…”

“…In light of these concerns, a physical therapy team must encourage patients with DN to compensate by using the somatosensory system and ankle proprioception [4]. For instance, training with respect to sensory, ankle, and hip strategies appears to be useful for improving patients with DN impaired somatosensory subclinical constraints.…”