Balance, risk of falls, risk factors and fall-related costs in individuals with diabetes

Balance function in critical illness survivors and evaluation of psychometric properties of the Mini-BESTest

Critical illness survivors commonly face impairments, such as intensive care unit-acquired weakness (ICUAW) which is characterized by muscle weakness and sensory deficits. Despite these symptoms indicating potential balance deficits, systematic investigations and validated assessments are lacking. Therefore, we aimed to assess balance function using the Mini-BESTest, evaluate its psychometric properties, and identify associated variables. Balance was assessed post-ICU discharge (V1) and at discharge from inpatient neurorehabilitation (V2) in patients with ≥ 5 days of invasive ventilation. Mini-BESTest measurement characteristics were evaluated in an ambulatory subgroup. A multiple linear regression was conducted. The prospective cohort study comprised 250 patients (34% female, 62 ± 14 years, median ICU stay 55 days). Median Mini-BESTest scores improved significantly from V1 (5 (IQR 0-15)) to V2 (18.5 (10-23)) with a large effect size. Excellent inter-rater and test-retest reliabilities of the Mini-BESTest were observed (ICC = 0.981/0.950). Validity was demonstrated by a very high correlation with the Berg Balance Scale (ρ = 0.90). No floor or ceiling effects were detected. Muscle strength, cognitive function, cerebral disease, critical illness polyneuropathy/myopathy, and depression were significantly associated with balance. Despite significant improvements during the rehabilitation period, balance disorders were prevalent in critical illness survivors. Ongoing therapy is recommended. Due to its excellent psychometric properties, the Mini-BESTest is suitable for use in critical illness survivors.Registration: The study was registered at the German Clinical Trials Register (DRKS00021753, date of registration: 2020-09-03).

Balance Problems in the Elderly with Diabetes Mellitus: A Literature Review

Diabetes mellitus (DM) is a syndrome of chronic metabolic disease which leads to all kinds of complications. Elderly people with DM have significantly higher fear of falling and balance problem scores as compared to those who did not have DM. This literature review aims: (1) to determine the risk factors for balance disorders in the elderly population with DM, (2) to describe valid and reliable balance measurement tools in the elderly population with DM, and (3) to describe the nonpharmacological management in dealing with balance disorders in the elderly population with DM. Several risk factors that cause balance disorders in the elderly with DM are related to complications of the disease they suffer, such as diabetic peripheral neuropathy, decreased sensory abilities, decreased motor skills, and decreased cognitive condition of the elderly with DM. Measuring instruments that can be used in the elderly population with DM to assess balance include the Mini-Balance Evaluation Systems Test, the Berg Balance Scale, and computerized measuring instruments with center of pressure analysis. Several nonpharmacological interventions are suggested in overcoming balance problems in the elderly with DM, including a combination of balance exercise and gait training, strength or resistance training, aquatic exercise, tai chi, yoga, technology-based exercise, electrotherapy, use of insoles, and whole-body vibrations.

The association between dual sensory loss and healthcare expenditure: Mediating effect of depression

BACKGROUND

Previous studies have suggested the dual sensory loss (DSL) is linked to depression, and that they are associated with higher healthcare expenditures, respectively. However, the association between DSL, depression and healthcare expenditures remains ambiguous.

OBJECTIVES

The current study aims to examine the association between DSL, depression and healthcare expenditures as well as catastrophic health expenditures (CHE) among Chinese people aged 45 and above.

METHODS

We first utilized the China Health and Retirement Longitudinal Survey (CHARLS) 2018 to obtain data from a total of 13,412 Chinese individuals aged 45 and above to conduct a cross-sectional study. DSL was defined as a combined variable of self-reported vision loss and hearing loss. Depression was measured using The Center for Epidemiologic Studies Depression Scale (CESD-10). The healthcare expenditures, including outpatient out-of-pocket cost and inpatient out-of-pocket cost, were obtained from the Harmonized CHARLS section. CHE were defined as out-of-pocket (OOP) health spending equal to or higher than 40 % of a household's capacity to pay. A Tobit linear regression with three models and a path analysis were conducted to estimate the association between DSL, depression and healthcare expenditures and CHE. Then we utilized 2011CHARLS and 2018CHARLS to present a longitudinal analysis. A path analysis was conducted to estimate the association between 2011DSL, 2018depression and 2018healthcare expenditures and CHE.

RESULTS

Depression has a significant mediating effect between DSL and healthcare expenditures. (For outpatient OOP cost: a = 0.453, b = 23.559, c = 25.257, the proportion of mediating effect in total effect = 29.71 %; for inpatient OOP cost: a = 0.453, b = 13.606, c = 15.463, the proportion of mediating effect in total effect = 28.50 %; all P < 0.05). The mediating effect of depression also exists in the association between DSL and CHE (a = 0.453, b = 0.018, c = 0.043, the proportion of mediating effect in total effect = 15.90 %; P < 0.05). The mediation effect of depression on healthcare expenditures and CHE also exists in the longitudinal analysis using CHARLS 2011 and CHARLS 2018 (all P < 0.05).

LIMITATIONS

The DSL status were based on self-report and we used 2018CHARLS to conduct the study, which may cause some bias.

CONCLUSION

Significant mediating effect of depression exists between DSL and higher healthcare expenditures and CHE. The mental health of elder people with DSL should be focused on, and we should have an overall viewpoint on the topic of healthcare expenditures and CHE.

Factors associated with balance impairments in the community-dwelling elderly in urban China

BACKGROUND

Identification of factors relevant to balance performance impairments in the elderly population was critical for developing effective interventions and preventions. However, there have been very limited data available based on large scale studies. The present study identified factors that independently contributed to performance impairments in overall balance, domains of static balance, postural stability, and dynamic balance, and individual items.

METHODS

A total of 1984 community-dwelling Chinese elderly from urban areas of Shanghai were recruited. Information on demographic characteristic, exercise, and health status were collected with a face-to-face interview. Balance performances were assessed on site by trained investigators based on the X16 balance testing scale. To identify the effectors, ordinal logistic regression analysis was applied for overall balance, static balance, postural stability, and dynamic balance. Binary logistic regression analysis was used for 16 items.

RESULTS

The community-dwelling elderly residents were aged from 60 to 97 years old. With increases of age, risks of impairments in overall balance increased gradually (ORs from 1.26 to 3.20, all P < 0.01). In the elderly with overweight and obesity, there was higher proportion of balance impairments compared to the elderly with normal BMI (OR = 1.26, P < 0.001). Regular exercise every week was associated with reduced risks of balance impairments (ORs from 0.63 to 0.73, all P < 0.001). Presences with vision lesion (ORs from 1.28 to 1.59, all P < 0.001), moderate hearing impairment (OR = 1.54, P < 0.001), somesthesis dysfunction (ORs from 1.59 to 13.26, all P < 0.001), and cerebrovascular disease (OR = 1.45, P = 0.001) were related to increased risks of balance impairments. Likewise, age, exercise, vision, hearing, somesthesis, and cerebrovascular disease were significantly associated with static balance, postural stability, and dynamic balance. Both overweight and obesity and underweight were associated with higher proportions of dynamic balance impairments. Regular exercise was significantly related to reduced risks of impairments in 15 out of the 16 items.

CONCLUSIONS

In the elderly, age, overweight and obesity, exercise, vision, hearing, somesthesia, and cerebrovascular disease were dominant factors associated with impairments in overall balance, domains of static balance, postural stability, and dynamic balance, and most individual items.

TRIAL REGISTRATION

Not applicable.

Falls caused by balance disorders in the elderly with multiple systems involved: Pathogenic mechanisms and treatment strategies

Falls are the main contributor to both fatal and nonfatal injuries in elderly individuals as well as significant sources of morbidity and mortality, which are mostly induced by impaired balance control. The ability to keep balance is a remarkably complex process that allows for rapid and precise changes to prevent falls with multiple systems involved, such as musculoskeletal system, the central nervous system and sensory system. However, the exact pathogenesis of falls caused by balance disorders in the elderly has eluded researchers to date. In consideration of aging phenomenon aggravation and fall risks in the elderly, there is an urgent need to explore the pathogenesis and treatments of falls caused by balance disorders in the elderly. The present review discusses the epidemiology of falls in the elderly, potential pathogenic mechanisms underlying multiple systems involved in falls caused by balance disorders, including musculoskeletal system, the central nervous system and sensory system. Meanwhile, some common treatment strategies, such as physical exercise, new equipment based on artificial intelligence, pharmacologic treatments and fall prevention education are also reviewed. To fully understand the pathogenesis and treatment of falls caused by balance disorders, a need remains for future large-scale multi-center randomized controlled trials and in-depth mechanism studies.

Does Lower Extremity Nerve Decompression Surgery Improve Quality of Life?

BACKGROUND

Entrapment neuropathies are more prevalent in patients with diabetes than in healthy patients. The aim of this study was to assess the effects of lower extremity nerve decompression surgery on quality of life and clarify predictors of this surgical outcome and the incidence of surgical site problems.

METHODS

Patients who underwent lower extremity nerve decompression surgery between September of 2017 and March of 2019 were followed prospectively at the outpatient clinic of University Medical Center Utrecht. The common, superficial, and deep peroneal nerve and tibial nerve at the tarsal tunnel and soleal sling were decompressed if an entrapment was diagnosed. The primary study outcome was quality of life as measured by the Norfolk Quality of Life-Diabetic Neuropathy questionnaire. Secondary outcomes of interest were change in Michigan Neuropathy Screening Instrument score, predictors of the Norfolk score at follow-up, and the occurrence of complications.

RESULTS

Sixty patients underwent surgery (45 unilateral, 15 bilateral), with a median postoperative follow-up of 13.0 months (interquartile range, 7.3 to 18.0 months). Quality of life improved significantly in this period of observation [baseline median, 46.0 (34.0 to 62.0) versus follow-up median, 37.0 (20.0 to 60.0); p = 0.011], as did Michigan Neuropathy Screening Instrument scores [7.0 (5.0 to 9.0) versus 3.0 (0.0 to 6.5); p < 0.01]. Predictors of quality of life were a higher baseline quality of life score [β, 0.59 ( p = 0.001)], longer follow-up time [β, 2.34 ( p < 0.001)], and hypertension [β, 16.38 ( p = 0.03)]. A total of 26.7 percent of patients had surgical site problems, including wound infections (18.3 percent).

CONCLUSIONS

Lower extremity nerve decompression surgery significantly improves quality of life by reducing neuropathy symptoms in patients with lower extremity nerve compressions. Attention should be given to lowering the risk of wound complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effect of Foot Reflexology on Muscle Electrical Activity, Pressure, Plantar Distribution, and Body Sway in Patients with Type 2 Diabetes Mellitus: A Pilot Randomized Controlled Trial

OBJECTIVE

To verify the effect of foot reflexology on the electrical muscle activity of the lateral and medial gastrocnemius muscle, and to examine the distribution, plantar pressure, and body sway in patients with type 2 diabetes mellitus.

METHODS

This pilot randomized controlled trial enrolled 17 volunteers who were clinically diagnosed with diabetes mellitus. The sample was assigned to one of two groups: the control group (CG, n = 7), who received information on foot care and health, and the intervention group (IG, n = 10), who received the application of foot reflexology on specific areas of the feet, for 10 consecutive days. There was blinding of the evaluator and the therapist. Surface electromyography (EMG) was used to assess the electrical activity of the medial and lateral gastrocnemius muscles in maximum voluntary isometric contraction (MVIC) and isotonic contraction (IC); baropodometry and stabilometry were used to analyze unloading, plantar weight distribution, and body sway.

RESULTS

There was a statistically significant difference for the variables of maximum peak electrical activity of the left medial gastrocnemius (p = 0.03; effect size = 0.87 and power = 0.81) and left lateral gastrocnemius muscles (p = 0.04, effect size = 0.70 and power = 0.66) respectively, in the intragroup IC, and median frequency of the left medial gastrocnemius muscle in the intragroup MVIC (p = 0.03; effect size = 0.64 and power = 0.59), and in the variables intergroups of the total area on the right side (p = 0.04; effect size = 1.03 and power = 0.50) and forefoot area on the left side (p = 0.02; effect size = 0.51 and power = 0.16).

CONCLUSIONS

We conclude that foot reflexology influenced some variables of the intergroup plantar distribution and intragroup EMG in the sample studied. There is a need for a placebo group, a larger sample and a follow-up to strengthen the findings of these experiments.

Clinical Intervention Effect of a Predictive Model Constructed Based on Risk Factors for Falls in Elderly Patients during Hospitalization

Falls in elderly patients are an important cause of fractures, functional impairment, and mortality. In this paper, a questionnaire was used to collect information on fall history, balance function and sensory function from patients over 65 years of age. In the analysis, the presence or absence of falls was used as a factor, and a corresponding prediction model was constructed using methods such as univariate analysis and regression analysis. This survey found that in the past year, 60% of the patients had fallen, 16.67% had one fall, 33.33% had two falls, and 50% had three or more falls; model specificity is 61.54%, the sensitivity is 71.43%, and the misjudgment is 38.46%. The model has good specificity and sensitivity and a small misjudgment rate; so, the model is more reasonable. This paper selects several sensitivity indices that have a certain impact on the risk of falling and makes a satisfactory forecast, which can provide a theoretical basis for the prevention of the risk of falls in elderly patients during hospitalization.

Diabetes Distal Peripheral Neuropathy: Subtypes and Diagnostic and Screening Technologies

Diabetes distal symmetrical peripheral neuropathy (DSPN) is the most prevalent form of neuropathy in industrialized countries, substantially increasing risk for morbidity and pre-mature mortality. DSPN may manifest with small-fiber disease, large-fiber disease, or a combination of both. This review summarizes: (1) DSPN subtypes (small- and large-fiber disease) with attention to clinical signs and patient symptoms; and (2) technological diagnosis and screening for large- and small-fiber disease with inclusion of a comprehensive literature review of published studies from 2015-present (N = 66). Review findings, informed by the most up-to-date research, advance critical understanding of DSPN large- and small-fiber screening technologies, including those designed for point-of-care use in primary care and endocrinology practices.

Sections of the Brief-Balance Evaluation Systems Test Relevant for Discriminating Fast Versus Slow Walking Speeds in Community-Dwelling Older Women

BACKGROUND AND PURPOSE

Walking speed can be used to identify characteristics of frailty in older adults. It has a strong positive correlation with balance abilities. The Brief-Balance Evaluation Systems Test (Brief-BESTest) was developed to assess functions of the 6 balance control systems in a short time. However, for community-dwelling older adults, the relationship between walking speed and the Brief-BESTest needs to be clarified. Even the cutoff scores for each Brief-BESTest section should be indicated for physical therapists to effectively evaluate balance deficits. Our objective was to establish cutoff scores for individual Brief-BESTest sections, determine fast or slow walkers in community-dwelling older adults, and investigate the relationship between balance control systems and walking speed.

METHODS

In a cross-sectional study involving 55 participants 77 years and older, the Brief-BESTest was evaluated after grouping the participants based on their walking speeds in public community centers. We compared the age, history of falls, handgrip strength, quadriceps strength, appendicular skeletal muscle mass index, comfortable walking speeds, and the Brief-BESTest scores between the fast- and slow-walking groups by using the independent t test, Fisher exact test, or Mann-Whitney U test. We also determined the receiver operating characteristic curves, and calculated the cutoff, area under the curve (AUC), sensitivity, and specificity of each section.

RESULTS

All sections of the Brief-BESTest, except Section 1 (Biomechanical Constraints) were able to differentiate between fast and slow walkers in community-dwelling older women. Section VI (Stability in Gait) showed the highest AUC (0.83) and the cutoff score for the fast- and slow-walker groups was 3.0 points (sensitivity = 0.85, specificity = 0.81). Sections III, IV, and V (Anticipatory, Reactive, and Sensory Orientation, respectively) had moderate AUC (0.71-0.72). Sections I and II (Stability Limits) showed weak correlations with the walking speed.

CONCLUSIONS

Three sections (III, anticipatory postural adjustments; IV, reactive postural responses; and VI, stability in gait) could differentiate between fast and slow walkers. Section VI was a particularly important balance function measurement that differentiated the walking speed with the highest accuracy. Therefore, it should be a primary focus when physical therapists treat community-dwelling older adults.

Cost-Effectiveness of Lower Extremity Nerve Decompression Surgery in the Prevention of Ulcers and Amputations: A Markov Analysis

BACKGROUND

The costs and health effects associated with lower extremity complications in diabetes mellitus are an increasing burden to society. In selected patients, lower extremity nerve decompression is able to reduce symptoms of neuropathy and the concomitant risks of diabetic foot ulcers and amputations. To estimate the health and economic effects of this type of surgery, the cost-effectiveness of this intervention compared to current nonsurgical care was studied.

METHODS

To estimate the incremental cost-effectiveness of lower extremity nerve decompression over a 10-year period, a Markov model was developed to simulate the onset and progression of diabetic foot disease in patients with diabetes and neuropathy who underwent lower extremity nerve decompression surgery, compared to a group undergoing current nonsurgical care. Mean survival time, health-related quality of life, presence or risk of lower extremity complications, and in-hospital costs were the outcome measures assessed. Data from the Rotterdam Diabetic Foot Study were used as current care, complemented with information from international studies on the epidemiology of diabetic foot disease, resource use, and costs, to feed the model.

RESULTS

Lower extremity nerve decompression surgery resulted in improved life expectancy (88,369.5 life-years versus 86,513.6 life-years), gain of quality-adjusted life-years (67,652.5 versus 64,082.3), and reduced incidence of foot complications compared to current care (490 versus 1087). The incremental cost-effectiveness analysis was -€59,279.6 per quality-adjusted life-year gained, which is below the Dutch critical threshold of less than €80,000 per quality-adjusted life-year.

CONCLUSIONS

Decompression surgery of lower extremity nerves improves survival, reduces diabetic foot complications, and is cost saving and cost-effective compared with current care, suggesting considerable socioeconomic benefit for society.

Balance and motion coordination parameters can be improved in patients with type 2 diabetes with physical balance training: non-randomized controlled trial

BACKGROUND

Type 2 diabetes (T2D) is a cause of multiple complications, including retinopathy and peripheral neuropathy. These complications are well understood and believed to contribute to gait instability. Poor balance control and increased falling risk have also been reported in people with diabetic peripheral neuropathy (DPN). Patients with DPN have increased risk of falling due to decreased proprioceptive feedback. Effective balance training should improve postural control in patients with DPN. For this purpose further evaluation was conducted and balance training was designed.

METHODS

The goal of our study was to determine values of proprioception, balance, muscle coordination and strength in patients with T2D and analyze whether biofeedback balance training with use of the Biodex Balance System could improve these parameters. To assess the fall risk the general stability index (GSI), the index of frontal-posterior (FPI) and medial-lateral (MLI) stability were evaluated. 37 patients with diagnosed type 2 diabetes mellitus were recruited to this study. Their results were compared with control group consisting of 41 healthy participants who were homogenic to the study group in terms of age and body mass index (BMI).

RESULTS

There were statistically significant differences between patients with diabetes compared to healthy subjects in GSI (2.79 vs 1.1), FPI (1.66 vs 0.7), MLI (0.88 vs 0.52) and risk of falling (5.18 vs 2.72) p < 0.05. There were also statistically significant changes before and after training in all stability indices (GSI: 2.79 vs 1.26, FPI: 1.66 vs 0.77, MLI: 0.88 vs 0.54 accordingly) p < 0.05 and risk of falling (5.18 vs 3.87) p < 0.05 in the study group who had undergone training with biofeedback.

CONCLUSIONS

This study found that there is a decreased balance and motor coordination and an increased risk of falling in patients with type 2 diabetes. These parameters improved in patients who have undergone training programme with biofeedback. Furthermore, an age-dependent deprivation of static balance was observed along with an increased risk of falling as a result of increasing BMI.

A new application of the Rotterdam Diabetic Foot Study Test Battery: grading pedal sensory loss to predict the risk of foot ulceration

AIMS

To assess the relationship between the degree of loss of foot sensation at baseline and incidence of foot ulceration (DFU).

METHODS

Diabetic patients (n = 416) participating in the observational Rotterdam Diabetic Foot (RDF) Study were followed prospectively (median 955.5 days (IQR, 841.5-1121)). Subjects underwent sensory testing of the feet (39-item RDF Study Test Battery) at baseline and were assessed regarding incident DFU. Seven groups of incremental degree of sensory loss were distinguished, according to the RDF-39 sum score. Kaplan-Meier and regression analyses were used to determine the independent hazard of baseline variables for new DFU.

RESULTS

40 participants developed DFUs. The mean incident rate of new-onset ulceration from study start was 4.5 (95%CI: 3.3 to 6.1) per 100 person-years, which increased significantly from 0 to 67.70 in the seven groups (p < 0.0005). Predictors for DFUs were higher RDF-39 score (aHR: 1.173, p < 0.0005) and kidney function (aHR: 1.022, p = 0.016). Prior DFU suggests increased mortality risk.

CONCLUSIONS

The degree of sensory loss at baseline was associated with progression to DFU during follow-up. Grading the loss of sensation using the RDF Study Test Battery may result in a more precise risk stratification compared to the use of the 10 g monofilament according to current guidelines.

Item reduction of the 39-item Rotterdam Diabetic Foot Study Test Battery using decision tree modelling

AIMS

Pedal sensory loss due to diabetes-related neuropathy can be graded by testing static two-point discrimination (S2PD), moving two-point discrimination (M2PD), static one-point discrimination (S1PD; eg, 10-g monofilament), and vibration sense and is included in the Rotterdam Diabetic Foot (RDF) Study Test Battery. The aim of this study is to investigate if decision tree modelling is able to reduce the number of tests needed in estimating pedal sensation.

METHODS

The 39-item RDF Study Test Battery (RDF-39) scores were collected from the prospective RDF study and included baseline (n = 416), first follow-up (n = 364), and second follow-up (n = 135) measurements, supplemented with cross-sectional control data from a previous study (n = 196). Decision tree analysis was used to predict total RDF-39 scores using individual test item data. The tree was developed using baseline RDF study data and validated in follow-up and control data. Spearman correlation coefficients assessed the reliability between the decision tree and original RDF-39.

RESULTS

The tree reduced the number of items from 39 to 3 in estimating the RDF-39 sum score. M2PD (hallux), S2PD (first dorsal web, fifth toe), vibration sense (interphalangeal joint), and S1PD (first dorsal web, fifth toe) measurements proved to be predictive. The correlation coefficients to original scores were high (0.76 to 0.91).

CONCLUSIONS

The decision tree was successful at reducing the number of RDF Test Battery items to only 3, with high correlation coefficients to the scores of the full test battery. The findings of this study aids medical decision making by time efficiently estimating pedal sensory status with fewer tests needed.

The natural history of tarsal tunnel syndrome in diabetic subjects

INTRODUCTION

Tibial nerve entrapment is highly prevalent in diabetic subjects, resulting in significantly more neuropathic complaints and concomitant sensory disturbances. The study aim was to assess the impact of tarsal tunnel syndrome (TTS) and sensory loss at baseline on incident diabetic foot ulceration (DFU) in diabetic patients, since decompressing the tibial nerve might change the natural history of the disease.

METHODS

In this study, 113 subjects with TTS (69 bilateral, 23 left-sided and 21 right-sided) participating in the prospective Rotterdam Diabetic Foot Study were compared to 303 diabetic controls without TTS, regarding incident DFU. Kaplan-Meier analysis and Cox's regression analysis were used to determine the independent hazard of baseline variables for new DFU.

RESULTS

The median observation period was 836.5 days (IQR, 459-1077.8). In bilateral TTS, 17.4% (95% CI: 8.4-26.3%) of subjects experienced DFU versus 8.3% (95% CI: 5.1-11.6%) in controls (left or right) during follow-up (p = 0.0036). In left-sided TTS, no subjects versus 6.2% (95% CI: 3.4-9.0%) in controls had DFUs (p = 0.243). Incident ulceration was seen in 14.3% (95% CI: -0.7% to -29.3%) of right-sided TTS subjects versus 4.1% (95% CI: 1.5-6.3%) in controls (p = 0.034). Besides HbA1c, diminished sensation at the hallux independently increased the risk of ulceration, in patients with (HR: 4.692, p = 0.003) and without (HR: 2.307, p = 0.002) prior DFU.

DISCUSSION

Elevated sensory thresholds in TTS render diabetic patients at a higher risk for DFU. With effective surgery, TTS is likely to be an amenable factor to potentially prevent diabetic foot disease and thereby reduce amputation risk.

LEVEL OF EVIDENCE

II.