The impact of footwear and walking distance on gait stability in diabetic patients with peripheral neuropathy

Balance and gait in individuals with diabetic peripheral neuropathy

BACKGROUND

Diabetic Peripheral Neuropathy (DPN) causes various physical problems such as the increased risk of falling, loss of balance and coordination while standing or walking, susceptibility to injuries due to sensory loss.

AIMS

The aim of the study was to evaluate and compare the effects of neuropathic pain (NP) in individuals with DPN on balance and gait.

METHODS

This prospective controlled study was conducted on 42 adults aged between 40-65 years. The participants were divided into three groups; individuals with DPN and NP (DPN+NP/n = 14), individuals with DPN without NP (DPN-NP/n = 14), and the control group (n = 14), respectively. The Force Plate system and Core Balance System measured static and dynamic postural balance and stability limits. Gait and dynamic plantar pressure distribution analyses were performed with a computerized gait evaluation system.

RESULTS

The score of LANSS, and VAS during gait were higher in DPN+NP group than in DPN-NP (p < 0.05). No significant difference was observed between the groups in balance parameters (p > 0.05). The right-left heel maximum forces were lower in both groups with DPN compared to the control group (p < 0.05). In terms of spatiotemporal parameters of the gait, there was a difference between the groups only in step width and left single support line parameters (p < 0.05).

CONCLUSIONS

The results of this study indicate that the individuals with DPN have an increased step width, their left single support line was shortened, and the maximum force on the heel decreased. The NP did not cause any change in balance and gait parameters.

Objective assessment of mobility among adults with diabetes and end-stage renal disease using walking aid: A cross-sectional cohort study

BACKGROUND

This cross-sectional study aimed to compare physical activity levels, plantar sensation, and fear of falling between individuals with diabetes undergoing hemodialysis, with or without walking aids.

METHODS

Sixty-four participants were recruited, with 37 not using walking aids (age = 65.8 ± 0.7 years, 46% female) and 27 using walking aids (age = 69.2 ± 1.2 years, 63% female). Physical activity was measured using validated pendant sensors over two consecutive days. Concern for falling and plantar numbness were assessed using the Falls Efficacy Scale-International and vibration perception threshold test, respectively.

FINDINGS

Participants using walking aids exhibited a greater fear of falling (84% vs. 38%, p < 0.01) and fewer walking bouts (p < 0.01, d = 0.67) and stand-to-walk transitions (p < 0.01, d = 0.72) compared to those not using walking aids. The number of walking bouts was negatively correlated with concern for falling scores (ρ = -0.35, p = 0.034) and vibration perception threshold (R = -0.411, p = 0.012) among individuals not using walking aids. However, these correlations were not significant among those using the walking aid. There was no significant group difference in active behavior (walking + standing %) and sedentary behavior (sitting + lying %).

INTERPRETATION

Those undergoing hemodialysis often lead sedentary lives, with mobility affected by fear of falling and plantar numbness. Using walking aids can help, but it doesn't guarantee more walking. A combined psychosocial and physical therapy approach is key for managing fall concerns and improving mobility.

Using a contralateral shoe lift to reduce gait deterioration during an offloading fast-walk setting in diabetic peripheral neuropathy: A comparative feasibility study

AIMS

Diabetic peripheral neuropathy (DPN) is a predictor of foot ulcers and leads to sedentary behaviour. This comparative study evaluated gait and feasibility of a 20-minute fast walk, at 40-60% of cardiopulmonary capacity, in individuals with DPN wearing an offloading boot and a contralateral shoe balancer.

METHODS

Gait parameters were measured with inertial sensors on 32 individuals (group with DPN [n = 16], group with diabetes but without DPN [n = 9], and a group without diabetes/DPN [n = 7]). Feasibility was assessed by feedback on perceived effort and adverse events. Gait outcomes were compared between groups with or without a shoe balancer using one-way ANOVAs.

RESULTS

The three groups were equivalent in terms of activity level and age and gender except for the body mass index. Both groups with diabetes exhibited minimal decreased gait speed (p > 0.005) and the DPN group exhibited increased double-support percentage (+4.6%, p = 0.01) while walking with an offloading boot and contralateral shoe balancer. The use of a contralateral shoe balancer reduced gait asymmetry. Lower physical activity level was associated with further gait deterioration in all groups. Few adverse events were reported, and 91% of participants reported that the proposed activity would be feasible daily.

CONCLUSIONS

The offloading boot deteriorated gait function, but a contralateral shoe balancer minimized its impact, especially in the context of physical activity in people with diabetes and DPN.

Digital Biomarkers of Gait and Balance in Diabetic Foot, Measurable by Wearable Inertial Measurement Units: A Mini Review

People with diabetic foot frequently exhibit gait and balance dysfunction. Recent advances in wearable inertial measurement units (IMUs) enable to assess some of the gait and balance dysfunction associated with diabetic foot (i.e., digital biomarkers of gait and balance). However, there is no review to inform digital biomarkers of gait and balance dysfunction related to diabetic foot, measurable by wearable IMUs (e.g., what gait and balance parameters can wearable IMUs collect? Are the measurements repeatable?). Accordingly, we conducted a web-based, mini review using PubMed. Our search was limited to human subjects and English-written papers published in peer-reviewed journals. We identified 20 papers in this mini review. We found preliminary evidence of digital biomarkers of gait and balance dysfunction in people with diabetic foot, such as slow gait speed, large gait variability, unstable gait initiation, and large body sway. However, due to heterogeneities in included papers in terms of study design, movement tasks, and small sample size, more studies are recommended to confirm this preliminary evidence. Additionally, based on our mini review, we recommend establishing appropriate strategies to successfully incorporate wearable-based assessment into clinical practice for diabetic foot care.

Feet/Footwear-Related Fall Risk Screening Tool for Older Adults: Development and Content Validation

Background and Purpose

Screening for feet- and footwear-related influences on fall risk is an important component of multifactorial fall risk screenings, yet few evidence-based tools are available for this purpose. We developed the Screening Tool for Feet/Footwear-Related Influences on Fall Risk to support interprofessional health care providers in their efforts to screen for feet/footwear-related influences on fall risk among community-dwelling older adults identified at risk for falling.

Materials and Methods

The study consisted of two phases. During Phase 1, results of a systematic review of lower-limb factors associated with balance and falls informed tool development. The tool's initial draft was evaluated by an external group of nine interprofessional content experts. After incorporating changes recommended by Phase 1 participants, Phase 2 was initiated. During Phase 2, eight new interprofessional experts (19.3 average years of experience) completed the three rounds of a modified Delphi study.

Results

Phase 1 experts recommended modifying eight items and rated the tool's clarity, appeal and clinical feasibility as 81.2/100, 79.1/100, and 76.1/100, respectively. Phase 2 participants suggested combining items with similar recommended actions, adding a question about orthoses, and increasing the specificity of nine items. The refinements resulted in a 20-item screening tool. Each item was approved by the Phase 2 participants with > 80% agreement after two rounds of consensus voting, reflecting the tool's high face and content validity.

Conclusion

The new screening tool has high face and content validity and supports identification of feet- and footwear-related influences on fall risk among community-dwelling older adults. The tool can be used by interprofessional healthcare providers completing a multifactorial fall risk screening on community-dwelling adults identified as being at risk for falling.

Peripheral neuropathy in Parkinson's disease: prevalence and functional impact on gait and balance

Peripheral neuropathy is a common problem in patients with Parkinson's disease. Peripheral neuropathy's prevalence in Parkinson's disease varies between 4.8-55%, compared with 9% in the general population. It remains unclear whether peripheral neuropathy leads to decreased motor performance in Parkinson's disease, resulting in impaired mobility and increased balance deficits. We aimed to determine the prevalence and type of peripheral neuropathy in Parkinson's disease patients and evaluate its functional impact on gait and balance. A cohort of consecutive Parkinson's disease patients assessed by movement disorders specialists based on the UK Brain Bank criteria underwent clinical, neurophysiological (nerve conduction studies and quantitative sensory testing) and neuropathological (intraepidermal nerve fibre density in skin biopsy punches) evaluation to characterize the peripheral neuropathy type and aetiology using a cross-sectional design. Gait and balance were characterized using wearable health-technology in OFF and ON medication states, and the main parameters were extracted using validated algorithms. A total of 99 Parkinson's disease participants with a mean age of 67.2 (±10) years and mean disease duration of 6.5 (±5) years were assessed. Based on a comprehensive clinical, neurophysiological and neuropathological evaluation, we found that 40.4% of Parkinson's disease patients presented peripheral neuropathy, with a predominance of small fibre neuropathy (70% of the group). In the OFF state, the presence of peripheral neuropathy was significantly associated with shorter stride length (P = 0.029), slower gait speed (P = 0.005) and smaller toe-off angles (P = 0.002) during straight walking; significantly slower speed (P = 0.019) and smaller toe-off angles (P = 0.007) were also observed during circular walking. In the ON state, the above effects remained, albeit moderately reduced. With regard to balance, significant differences between Parkinson's disease patients with and without peripheral neuropathy were observed in the OFF medication state during stance with closed eyes on a foam surface. In the ON states, these differences were no longer observable. We showed that peripheral neuropathy is common in Parkinson's disease and influences gait and balance parameters, as measured with mobile health-technology. Our study supports that peripheral neuropathy recognition and directed treatment should be pursued in order to improve gait in Parkinson's disease patients and minimize balance-related disability, targeting individualized medical care.

Digital Biomarkers of Cognitive Frailty: The Value of Detailed Gait Assessment Beyond Gait Speed

BACKGROUND

Cognitive frailty (CF), defined as the simultaneous presence of cognitive impairment and physical frailty, is a clinical symptom in early-stage dementia with promise in assessing the risk of dementia. The purpose of this study was to use wearables to determine the most sensitive digital gait biomarkers to identify CF.

METHODS

Of 121 older adults (age = 78.9 ± 8.2 years, body mass index = 26.6 ± 5.5 kg/m2) who were evaluated with a comprehensive neurological exam and the Fried frailty criteria, 41 participants (34%) were identified with CF and 80 participants (66%) were identified without CF. Gait performance of participants was assessed under single task (walking without cognitive distraction) and dual task (walking while counting backward from a random number) using a validated wearable platform. Participants walked at habitual speed over a distance of 10 m. A validated algorithm was used to determine steady-state walking. Gait parameters of interest include steady-state gait speed, stride length, gait cycle time, double support, and gait unsteadiness. In addition, speed and stride length were normalized by height.

RESULTS

Our results suggest that compared to the group without CF, the CF group had deteriorated gait performances in both single-task and dual-task walking (Cohen's effect size d = 0.42-0.97, p < 0.050). The largest effect size was observed in normalized dual-task gait speed (d = 0.97, p < 0.001). The use of dual-task gait speed improved the area under the curve (AUC) to distinguish CF cases to 0.76 from 0.73 observed for the single-task gait speed. Adding both single-task and dual-task gait speeds did not noticeably change AUC. However, when additional gait parameters such as gait unsteadiness, stride length, and double support were included in the model, AUC was improved to 0.87.

CONCLUSIONS

This study suggests that gait performances measured by wearable sensors are potential digital biomarkers of CF among older adults. Dual-task gait and other detailed gait metrics provide value for identifying CF above gait speed alone. Future studies need to examine the potential benefits of gait performances for early diagnosis of CF and/or tracking its severity over time.

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

Background and Objectives: Diabetes mellitus is considered a serious public health problem due to its high prevalence and related complications, including gait and posture impairments due to neuropathy and vascular alterations and the subsequent increased risk of falls. The gait of patients with diabetes is characterized by alterations of the main spatiotemporal gait parameters such as gait velocity, cadence, stride time and length, which are also known to worsen with disease course. Wearable sensor systems can be used for gait analysis by providing spatiotemporal parameters and postural control (evaluated from the perspective of body sway), useful for investigating the disease progression. Thanks to their small size and low cost of their components, inertial measurement units (IMUs) are easy to wear and are cheap tools for movement analysis. Materials and Methods: The aim of this study is to review articles published in the last 21 years (from 2000 to 2021) concerning the application of wearable sensors to assess spatiotemporal parameters of gait and body postural alterations in patients with diabetes mellitus. Relevant articles were searched in the Medline database using PubMed, Ovid and Cochrane libraries. Results: One hundred and four articles were initially identified while searching the scientific literature on this topic. Thirteen were selected and analysed in this review. Wearable motion sensors are useful, noninvasive, low-cost, and objective tools for performing gait and posture analysis in diabetic patients. The IMUs can be worn at the lumber levels, tibias or feet, and different spatiotemporal parameters of movement and static posture can be assessed. Conclusions: Future research should focus on standardizing the measurement setup and selecting the most informative spatiotemporal parameters for gait and posture analysis.

Effects of offloading devices on static and dynamic balance in patients with diabetic peripheral neuropathy: A systematic review

Patients with diabetic peripheral neuropathy (DPN) usually have reduced somatosensory information and altered perception in feet and ankles. Somatosensory information acts as feedback for movement control and loss of somatosensation leads to altered plantar pressure patterns during gait and stance. Offloading devices are used to reduce peak plantar pressure and prevent diabetic foot ulcers. However, offloading devices can unfortunately have negative effects on static and dynamic balance. It is important to investigate these unwanted effects, since patient with DPN already are at high risk of falling and offloading devices could potentially increase this risk. The aim of this systematic review is to investigate the effects of plantar offloading devices used for ulcer prevention on their role in static and dynamic balance control in patients with DPN. PubMed and Embase were systematically searched using relevant search terms. After title selection, abstract selection, and full-text selection only five articles could be included for further analysis. Two articles included static balance measurements, two articles included dynamic balance measurements, and one article included both. Results suggested that static balance control is reduced when rocker bottom shoes and different insole configurations are used, however, toe-only rockers showed less evidence for reduced static balance control. There was no evidence for reduced dynamic balance control in combination with offloading devices. However, these results should be interpreted with care, since the number of studies was very small and the quality of the studies was moderate. Future research should evaluate balance in combination with different offloading devices, so that clinicians subscribing them are more aware of their potential unwanted consequences.

Wearable Health Technology to Quantify the Functional Impact of Peripheral Neuropathy on Mobility in Parkinson's Disease: A Systematic Review

The occurrence of peripheral neuropathy (PNP) is often observed in Parkinson’s disease (PD) patients with a prevalence up to 55%, leading to more prominent functional deficits. Motor assessment with mobile health technologies allows high sensitivity and accuracy and is widely adopted in PD, but scarcely used for PNP assessments. This review provides a comprehensive overview of the methodologies and the most relevant features to investigate PNP and PD motor deficits with wearables. Because of the lack of studies investigating motor impairments in this specific subset of PNP-PD patients, Pubmed, Scopus, and Web of Science electronic databases were used to summarize the state of the art on PNP motor assessment with wearable technology and compare it with the existing evidence on PD. A total of 24 papers on PNP and 13 on PD were selected for data extraction: The main characteristics were described, highlighting major findings, clinical applications, and the most relevant features. The information from both groups (PNP and PD) was merged for defining future directions for the assessment of PNP-PD patients with wearable technology. We established suggestions on the assessment protocol aiming at accurate patient monitoring, targeting personalized treatments and strategies to prevent falls and to investigate PD and PNP motor characteristics.

The impact of diabetic foot ulcers and unilateral offloading footwear on gait in people with diabetes

BACKGROUND

Unilateral offloading footwear prescribed to patients with diabetic foot ulcers elevates one limb relative to the other, which may lead to limp and abnormal gait. This study investigated whether the unilateral foot ulcer and offloading combination negatively impacts gait function beyond diabetic peripheral neuropathy.

METHODS

Eighty-six participants were recruited in 3 groups: 12 with diabetic peripheral neuropathy and unilateral foot ulcers wearing offloading footwear (offloading group, age = 55.6 ± 9.5 years, BMI = 30.9 ± 4.5 kg/m2), 27 with diabetic peripheral neuropathy (neuropathy group, age = 64.3 ± 7.7 years, BMI = 30.9 ± 5.4 kg/m2), and 47 non-diabetic controls (non-diabetic group, age = 62.9 ± 16.1 years, BMI = 29.0 ± 6.0 kg/m2). Gait function was quantified during a habitual speed walking test using a validated wearable platform.

FINDINGS

The offloading group exhibited deteriorated gait function compared to the non-diabetic group (p < 0.005, Cohen's effect size d = 0.90-2.61). They also had decreased gait speed (p < 0.001, d = 1.79) and stride length (p < 0.001, d = 1.76), as well as increased gait cycle time (p < 0.001, d = 1.67) and limp (p < 0.050, d = 0.72-1.49) compared to the neuropathy group. The offloading group showed increased gait unsteadiness compared to the neuropathy group, but the difference did not reach statistical significance in our samples.

INTERPRETATION

This study demonstrated that while diabetic peripheral neuropathy deteriorates gait function, including increasing gait unsteadiness and limp, the diabetic foot ulcer and offloading combination magnifies the deterioration beyond diabetic peripheral neuropathy. These findings promote caution of the current standards of care for treating diabetic foot ulcers with offloading footwear. However, it is possible that a contralateral shoe lift may remedy deteriorated gait function and improve quality of life for unilateral offloading users.

Characteristics of the gait initiation phase in older adults with diabetic peripheral neuropathy compared to control older adults

BACKGROUND

Gait is deteriorated in older adults with diabetic peripheral neuropathy; however, too little is known about the gait initiation phase. We aimed to determine if gait initiation variables are more sensitive in identifying the extent to which diabetic peripheral neuropathy impacts gait.

METHODS

We examined steps, distance, speed and dynamic balance in the gait initiation phase using a validated algorithm based on wearable sensors in 38 older adults with diabetic peripheral neuropathy and 33 non-diabetic, non-neurologic, non-orthopedic control older adults (≥65 years) under single-task and dual-task gait conditions.

FINDINGS

During the single-task gait condition, the largest differences between the two groups were found in gait initiation steps and dynamic balance (66.7% more steps and 57.2% poorer balance for the diabetic group; effect size = 1.08 and 1.11, respectively; all p < 0.05), while gait speed had a medium effect (10.9% slower for the diabetic group; effect size = 0.54; p < 0.05). Although gait deteriorated for both groups during the dual-task gait condition compared to the single-task gait condition, effect sizes of the between-group differences remained similar. The differences in gait initiation steps and dynamic balance between the two groups were independent of gait speed.

INTERPRETATION

Gait initiation steps and dynamic balance may be more sensitive than gait speed for detecting gait deterioration due to diabetic peripheral neuropathy. Given the association between gait initiation and risk for fall, our findings suggest that gait initiation variables may be important outcomes for clinical management of diabetic peripheral neuropathy.

The Biomechanics of Diabetes Mellitus and Limb Preservation

Biomechanical changes to the lower extremity in patients with diabetes mellitus are typically greatest with peripheral neuropathy, although peripheral arterial disease also impacts limb function. Changes to anatomic structures can impact daily function. These static changes, coupled with kinetic and kinematic changes of gait, lead to increased vertical and shear ground reactive forces, resulting in ulcerations. Unsteadiness secondary to diminished postural stability and increased sway increase fall risk. These clinical challenges and exacerbation of foot position and dynamic changes associated with limb salvage procedures, amputations, and prostheses are necessary and can impact daily function, independence, quality of life, and mortality.

The Effect of Daily Use of Plantar Mechanical Stimulation Through Micro-Mobile Foot Compression Device Installed in Shoe Insoles on Vibration Perception, Gait, and Balance in People With Diabetic Peripheral Neuropathy

OBJECTIVE

People with diabetic peripheral neuropathy (DPN) have impaired gait and balance performance. The aim of this study is to investigate therapeutic effectiveness of mechanical stimulation through a wearable foot compression device equipped in a shoe insole on vibration perception, balance control and gait performance in people with DPN.

METHODS

Using a single-arm 4-week intervention study design, we examined effectiveness of daily use of shoes equipped with the foot compression device (Footbeat™, AVEX, Grand Junction, CO, USA) on improving vibration perception threshold (VPT_max), skin perfusion pressure (SPP), ankle brachial index (ABI), lower extremities edema (circumferences in the calf and ankle), and motor performance (postural sway with eyes open and closed conditions, and gait performance during normal, dual-task and fast walking). Thirty people with type 2 diabetes and symptoms of PN completed the experimental protocol.

RESULTS

Improvements in VPT_max (before = 27.4 V, after = 23.3 V, P = .007, d = 0.33, where d denotes effect size), center-of-mass sway in the mediolateral direction with both eyes open and closed conditions (before = 0.94 cm, after = 0.76 cm, P = .020, d = 0.47; before = 1.10 cm, after = 0.83 cm, P = .033, d = 0.66, respectively), and stride velocity for normal walking, dual-task walking and fast walking tasks (before = 0.87 m/s, after = 0.96 m/s, P = .017, d = 0.41; before = 0.75 m/s, after = 0.91 m/s, P = .001, d = 0.77; before = 1.10 m/s, after = 1.20 m/s, P = .043, d = 0.33, respectively) were found post treatment. There was no significant improvement in SPP, ABI, and circumferences in the calf and ankle.

CONCLUSIONS

Our findings suggest the wearable foot compression device may be effective for reducing neuropathic symptoms and enhancing motor performances in people with DPN.

Using wearables to screen motor performance deterioration because of cancer and chemotherapy-induced peripheral neuropathy (CIPN) in adults - Toward an early diagnosis of CIPN

OBJECTIVE

An essential component for optimizing quality of life in adults with cancer is determining the degree to which therapy may negatively impact motor-performance, so that patients can maintain their quality of life and independence. This study examined whether instrumented gait and balance could determine the magnitude of deterioration in motor-performance from chemotherapy-induced peripheral neuropathy (CIPN).

METHODS

We recruited 84 adults with cancer (age = 71.1 ± 9.7 years old, BMI = 26.8 ± 6.2 kg/m², gender = 56%female) and 57 age-matched non-cancer patients (age = 69.5 ± 9.8 years old, BMI = 27.1 ± 6.0 kg/m², gender = 79%female). Based on clinical screening, the group with cancer was classified into two groups: participants with CIPN (CIPN+) and without CIPN (CIPN-). Gait and balance were quantified using validated wearables. The Vibration Perception Threshold (VPT) test was used to stratify the CIPN+ group into mild (Mild-CIPN) and severe (Severe-CIPN) subgroups.

RESULTS

All gait and balance parameters were deteriorated in the group with cancer compared to non-cancer group with the largest effects observed for stride-time (11%, Cohen's effect size d = 1.00, p < 0.001) and eyes-closed ankle sway (94%, d = 0.49, p = 0.001). The same trend was observed when the Severe-CIPN subgroup was compared to the Mild-CIPN. VPT correlates significantly with motor deterioration, with the largest correlation found in stride-time (Rho = 0.37, p = 0.007). Severe-CIPN subjects were significantly older and overall had more deterioration in the majority of motor-performance parameters after adjusting for age (p < 0.050).

CONCLUSION

These results confirmed the negative impact of CIPN on motor-performance with the largest effects on ankle stability and stride-time. VPT is a predictor of motor deterioration and may be used to determine the severity of CIPN symptom.

Instrumented Trail-Making Task: Application of Wearable Sensor to Determine Physical Frailty Phenotypes

BACKGROUND

The physical frailty assessment tools that are currently available are often time consuming to use with limited feasibility.

OBJECTIVE

To address these limitations, an instrumented trail-making task (iTMT) platform was developed using wearable technology to automate quantification of frailty phenotypes without the need of a frailty walking test.

METHODS

Sixty-one older adults (age = 72.8 ± 9.9 years, body mass index [BMI] = 27.4 ± 4.9 kg/m2) were recruited. According to the Fried Frailty Criteria, 39% of participants were determined as robust and 61% as non-robust (pre-frail or frail). In addition, 17 young subjects (age = 29.0 ± 7.2 years, BMI = 26.2 ± 4.6 kg/m2) were recruited to determine the healthy benchmark. The iTMT included reaching 5 indexed circles (including numbers 1-to-3 and letters A&amp;B placed in random orders), which virtually appeared on a computer-screen, by rotating one's ankle-joint while standing. By using an ankle-worn inertial sensor, 3D ankle-rotation was estimated and mapped into navigation of a computer-cursor in real-time (100 Hz), allowing subjects to navigate the computer-cursor to perform the iTMT. The ankle-sensor was also used for quantifying ankle-rotation velocity (representing slowness), its decline during the test (representing exhaustion), and ankle-velocity variability (representing movement inefficiency), as well as the power (representing weakness) generated during the test. Comparative assessments included Fried frailty phenotypes and gait assessment.

RESULTS

All subjects were able to complete the iTMT, with an average completion time of 125 ± 85 s. The iTMT-derived parameters were able to identify the presence and absence of slowness, exhaustion, weakness, and inactivity phenotypes (Cohen's d effect size = 0.90-1.40). The iTMT Velocity was significantly different between groups (d = 0.62-1.47). Significant correlation was observed between the iTMT Velocity and gait speed (r = 0.684 p < 0.001). The iTMT-derived parameters and age together enabled significant distinguishing of non-robust cases with area under curve of 0.834, sensitivity of 83%, and specificity of 67%.

CONCLUSION

This study demonstrated a non-gait-based wearable platform to objectively quantify frailty phenotypes and determine physical frailty, using a quick and practical test. This platform may address the hurdles of conventional physical frailty phenotypes methods by replacing the conventional frailty walking test with an automated and objective process that reduces the time of assessment and is more practical for those with mobility limitations.

Lace Up for Healthy Feet: The Impact of Shoe Closure on Plantar Stress Response

OBJECTIVE

This study examined the impact of shoe closure on plantar thermal stress response (TSR), which is known to be a surrogate of shear stress and skin perfusion. It is aimed to explore potential impact of shoe closure on increasing risk factors associated with plantar ulcers in people with diabetic peripheral neuropathy (DPN).

METHODS

Fifteen eligible subjects were enrolled. The left foot was used as a reference and fitted to a self-adjusted and habitual lace-tightening method by each subject. The right foot was used as a test closure and fitted into three lace closure conditions: loose, tight, and preset optimal closure (reel clutch, BOA technology). Thermal images were taken after 5 minutes of acclimatization (pre-trial) and immediately after 200 walking steps in each shoe closure condition (post-trial). TSR was calculated from the thermal images.

RESULTS

TSR was significantly higher in the test closure with loose (70.24%, P = .000) and tight (66.85%, P = .007) and lower (-206.53%, P = .000) in the preset optimal closure when compared to the reference closure. Only lace closure conditions affected TSR with no significant impact from age, BMI, and gender in our sample in a multivariable regression model.

CONCLUSION

The results from this study suggest that shoelace closure technique can have a profound effect on TSR. It therefore stands to reason that optimal lace closure may have an impact in reducing risk of plantar ulcers in people with DPN. Interestingly, results revealed that even a self-adjusted lace closure may not be necessarily optimal and a preset closure setting like reel clutch might ultimately be recommended to minimize risk. Further study is warranted to confirm or refute these interesting results.

Effects of foot and ankle devices on balance, gait and falls in adults with sensory perception loss: a systematic review

BACKGROUND

Foot and ankle devices are being developed as a method of preventing people with sensory perception loss sustaining a fall. Such devices are believed to work by reducing the likelihood of a fall by improving the balance and gait of the user.

OBJECTIVES

The objective of the review was to evaluate the effectiveness of foot and ankle devices for the prevention of falls and the improvement of balance and gait in adults with sensory perception loss.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Participants were community-dwelling adults with bilateral pathological sensory perception loss.

TYPES OF INTERVENTION(S)/PHENOMENA OF INTEREST

The current review evaluated any foot or ankle device, including but not restricted to, all types of footwear (therapeutic and retail), insoles (customized and prefabricated) and ankle-foot orthoses (AFOs).

TYPES OF STUDIES

In the absence of randomized controlled trials (RCT), the review considered experimental and epidemiological study designs, except case series, individual case reports and descriptive cross-sectional studies.

OUTCOMES

The primary outcome was number of falls. Secondary outcome measures were clinical or laboratory measures of balance or gait.

SEARCH STRATEGY

A search for published and unpublished literature from inception to March 2015 written in the English language was conducted across a number of major electronic databases. A three-step search strategy was developed using MeSH terminology and keywords to ensure all that relevant materials are captured.

METHODOLOGICAL QUALITY

Methodological quality of included studies was assessed by two reviewers, who appraised each study independently, using standardized Joanna Briggs Institute (JBI) critical appraisal tools.

DATA EXTRACTION

Quantitative data were extracted from the studies that were identified as meeting the criteria for methodological quality using the standardized JBI data extraction tools.

DATA SYNTHESIS

Due to the heterogeneity of populations, interventions and outcome measures, meta-analyses were not possible and results are presented in narrative form.

RESULTS

Nine trials (from 10 papers) involving 238 participants, (14 with multiple sclerosis and 16 with idiopathic peripheral neuropathy, 150 with diabetic neuropathy) and 58 controls were included in the review. No study reported falls as an outcome measure. The results of the included studies found that in people with sensory perception loss, postural sway improved with vibrating insoles and AFO, altering the softness and texture of the top cover had no effect on postural sway, wearing footwear over long distances or AFOs improved step-to-step consistency, and no foot and ankle device was reported to have a negative effect on the balance or gait of people with sensory perception loss. The methodological quality of the included studies was poor. No study used a randomized controlled trial (RCT) methodology. No study incorporated a follow-up period or tested the intervention within the context of the intended clinical environment.

CONCLUSION

There is limited evidence to suggest that footwear and insole devices can artificially alter postural stability and may reduce the step-to-step variability in adults with sensory perception loss. Varying the material properties of an insole does not notably affect static balance or gait.

Alterations in gait parameters with peripheral artery disease: The importance of pre-frailty as a confounding variable

Although poor walking is the most common symptom of peripheral artery disease (PAD), reported results are inconsistent when comparing gait parameters between PAD patients and healthy controls. This inconsistency may be due to frailty, which is highly prevalent among PAD patients. To address this hypothesis, 41 participants, 17 PAD (74±8 years) and 24 aged-matched controls (76±7 years), were recruited. Gait was objectively assessed using validated wearable sensors. Analysis of covariate (ANCOVA) tests were used to compare gait parameters between PAD and non-PAD groups, considering age, gender, and body mass index as covariates, while stratified based on frailty status. According to the Fried frailty index, 47% of PAD and 50% of control participants were non-frail and the rest were classified as pre-frail. Within non-frail participants, gait speed, body sway during walking, stride length, gait cycle time, double-support, knee range of motion, speed variability, mid-swing speed, and gait initiation were significantly different between PAD and control groups (effect size d = 0.75±0.43). In the pre-frail group, however, most of the gait differences were diminished except for gait initiation and gait variability. Results suggest that gait initiation is the most sensitive parameter for detecting gait impairment in PAD participants when compared to controls, regardless of frailty status (d = 1.30-1.41; p<0.050). The observed interaction effect between frailty and PAD on gait parameters confirms the importance of assessing functionality in addition to age to provide more consistency in detecting motor performance impairments due to PAD.

Postural Control and Gait Performance in the Diabetic Peripheral Neuropathy: A Systematic Review

Purpose. The aim of this paper is to review the published studies on the characteristics of impairments in the postural control and gait performance in diabetic peripheral neuropathy (DPN). Methods. A review was performed by obtaining publication of all papers reporting on the postural control and gait performance in DPN from Google Scholar, Ovid, SAGE, Springerlink, Science Direct (SD), EBSCO Discovery Service, and Web of Science databases. The keywords used for searching were “postural control,” “balance,” “gait performance,” “diabetes mellitus,” and “diabetic peripheral neuropathy.” Results. Total of 4,337 studies were hit in the search. 1,524 studies were screened on their titles and citations. Then, 79 studies were screened on their abstract. Only 38 studies were eligible to be selected: 17 studies on postural control and 21 studies on the gait performance. Most previous researches were found to have strong evidence of postural control impairments and noticeable gait deficits in DPN. Deterioration of somatosensory, visual, and vestibular systems with the pathologic condition of diabetes on cognitive impairment causes further instability of postural and gait performance in DPN. Conclusions. Postural instability and gait imbalance in DPN may contribute to high risk of fall incidence, especially in the geriatric population. Thus, further works are crucial to highlight this fact in the hospital based and community adults.

An immediate effect of custom-made ankle foot orthoses on postural stability in older adults

BACKGROUND

Foot and ankle problems are highly prevalent fall risks in the elderly. Ankle foot orthoses designed to stabilize the foot and ankles have been studied within specific patient groups, but their efficacy with a less restrictive elderly population is unknown. This study investigated if custom-made ankle foot orthoses improve postural stability in older adults.

METHODS

Thirty ambulatory older adults averaged 73 (standard deviation=6.5) years completed Romberg's balance (eyes-open/eyes-closed), functional reach, and Timed Up and Go tests while wearing validated kinematic sensors. Each test was completed in standardized shoes with and without bilateral orthoses. Additionally, barefoot trials were conducted for the Romberg's and functional reach tests.

FINDINGS

Compared to the barefoot and 'shoes alone' conditions, the orthoses reduced center of mass sway on average by 49.0% (P=0.087) and 40.7% (P=0.005) during eyes-open balance trials. The reduction was amplified during the eyes-closed trials with average reductions of 65.9% (P=0.000) and 47.8% (P=0.004), compared to barefoot and 'shoes alone' conditions. The orthoses did not limit functional reach distance nor timed-up and go completion times. However, the medial-lateral postural coordination while reaching was improved significantly with orthoses compared to barefoot (14.3%; P=0.030) and 'shoes alone' (13.5%; P=0.039) conditions.

INTERPRETATION

Ankle foot orthoses reduced postural sway and improved lower extremity coordination in the elderly participants without limiting their ability to perform a standard activity of daily living. Additional studies are required to determine if these benefits are retained and subsequently translate into fewer falls.

A novel shear reduction insole effect on the thermal response to walking stress, balance, and gait

Shear stresses have been implicated in the formation of diabetes-related foot ulcers. The aim of this study was to evaluate the effect of a novel shear-reducing insole on the thermal response to walking, balance, and gait. Twenty-seven diabetes peripheral neuropathy patients were enrolled and asked to take 200 steps in both intervention and standard insoles. Thermal foot images of the feet were taken at baseline (1) following a 5-minute temperature acclimatization and (2) after walking. Testing order was randomized, and a 5-minute washout period was used between testing each insole condition. Sudomotor function was also assessed. Gait and balance were measured under single and dual task conditions using a validated body worn sensor system. The mean age was 65.1 years, height was 67.3 inches, weight was 218 pounds, and body mass index was 33.9, 48% were female, and 82% had type 2 diabetes. After walking in both insole conditions, foot temperatures increased significantly in standard insoles. The intervention insole significantly reduced forefoot and midfoot temperature increases (64.1%, P = .008; 48%, P = .046) compared to standard insoles. There were significant negative correlations with sudomotor function and baseline temperatures (r = .53-.57). The intervention demonstrated 10.4% less gait initiation double support time compared to standard insoles (P = .05). There were no differences in static balance measures. We found significantly lower forefoot and midfoot temperature increases following walking with shear-reducing insoles compared to standard insoles. We also found improvements in gait. These findings merit future study for the prevention of foot ulcer.

Diabetic peripheral neuropathy and gait: does footwear modify this association?

BACKGROUND

Gait-related fall risk is the leading cause of mortality among patients with diabetes, especially those older than 65 years. Deterioration in balance and loss of protective sensation in lower extremities contribute significantly to fall risk in patients with diabetic peripheral neuropathy (DPN). This study aimed to explore the impact of neuropathy and foot ulcer on gait.

METHODS

We recruited 39 participants (age, 56.9 ± 8.2 years; body mass index, 29.6.3 ± 4.7 kg/m2), including 15 DPN patients without foot ulcers, 16 DPN patients with foot ulcers, and 8 healthy aged-matched controls. Patients with active foot ulcers wore an offloading device during gait examination, including removable cast walker.

RESULTS

Results suggest that neuropathy alters gait mainly by increasing gait initiation, gait variability (coefficient of variation of gait velocity), and double support (DS) time, while reducing knee range of motion and center of mass sway (p < .05). Interestingly, the presence of foot ulcer does not impact gait velocity (p > .1) but enhances some of the gait parameters such as gait variability and DS time.

CONCLUSIONS

This study demonstrates that neuropathy deteriorates gait, but the presence of foot ulcers does not alter gait parameters further than neuropathy. In addition, patients with foot ulcers demonstrated a better gait compared with DPN patients without ulcers. We speculate that offloading footwear may be enhancing the somatosensory feedback from sensate skin, thereby positively affecting gait parameters. A study with a larger sample is required to explore the effect of prescribed footwear in the DPN population in order to validate the findings of this research study.

Fear of falling is prevalent in older adults with diabetes mellitus but is unrelated to level of neuropathy

BACKGROUND

Patients with diabetic peripheral neuropathy (DPN) demonstrate gait alterations compared with their nonneuropathic counterparts, which may place them at increased risk for falling. However, it is uncertain whether patients with DPN also have a greater fear of falling.

METHODS

A voluntary group of older adults with diabetes was asked to complete a validated fear of falling questionnaire (Falls Efficacy Scale International [FES-I]) and instructed to walk 20 m in their habitual shoes at their habitual speed. Spatiotemporal parameters of gait (eg, stride velocity and gait speed variability) were collected using a validated body-worn sensor technology. Balance during walking was also assessed using sacral motion in the mediolateral and anteroposterior directions. The level of DPN was quantified using vibration perception threshold from the great toe.

RESULTS

Thirty-four diabetic patients (mean ± SD: age, 67.6 ± 9.2 years; body mass index, 30.9 ± 5.7; hemoglobin A1c, 7.9% ± 2.3%) with varying levels of neuropathy (mean ± SD vibration perception threshold, 34.6 ± 22.9 V) were recruited. Most participants (28 of 34, 82%) demonstrated moderate to high concern about falling based on their FES-I score. Age (r = 0.6), hemoglobin A1c level (r = 0.39), number of steps required to reach steady-state walking (ie, gait initiation) (r = 0.4), and duration of double support (r = 0.44) were each positively correlated with neuropathy severity (P < .05). Participants with a greater fear of falling also walked with slower stride velocities and shorter stride lengths (r = -0.3 for both, P < .05). However, no correlation was observed between level of DPN and the participant's actual concern about falling.

CONCLUSIONS

Fear of falling is prevalent in older adults with diabetes mellitus but is unrelated to level of neuropathy.