Functional Disorders As An
Impact of Diabetic
Neuropathy
Novitri Sumardi
KSM IKFR - RSUP Hasan Sadikin
Bandung Jawa Barat
THE GLOBAL BURDEN OF
DIABETES
• Diabetes is a leading cause of death in the world with 4.2
million deaths annually, equivalent to 1 death every 8
seconds
• The number of adults living with diabetes has > tripled over
the past 20 years, with serious health-related and
socioeconomic impacts on individuals and populations
• This escalation will be attributable to : type 2 diabetes, with
the greatest impact expected in low- and middle- income
countries due to rapid socioeconomic and lifestyle
transformations
THE GLOBAL BURDEN OF
DIABETES…
• Diabetes results in a range of distressing symptoms and can
impairs one’s ability to perform domestic and
occupational activities
• This can impede diabetes self-management and affect an
individual’s ability to integrate fully into society
THE GLOBAL BURDEN OF
DIABETES…
• ↓ mortality among people
with diabetes will ↑ the total
years of life spent living with
diabetes and → may drive the
emergence of new diabetes-
related complications (cancer,
mental disorders, cognitive
impairment, and disability)
•
DIABETES MELLITUS AT A GLANCE
• Diabetes mellitus (diabetes) is a chronic condition marked
by high levels of glucose in the blood.
• This condition is caused either by the inability to produce
insulin or by the body not being able to use insulin
effectively, or both
• People often develop diabetes some time before diagnosis.
It is therefore difficult to measure accurately the true
prevalence of DM
DIABETES MELLITUS AT A GLANCE…
• People with diabetes need to be aware of
eating habits, weight control and blood
glucose levels to prevent or reduce
complications of the disease
• Some people with diabetes need to take
insulin on a regular basis which can be
particularly challenging for people living with a
disability
DIABETES MELLITUS AT A GLANCE…
KEY POINTS :
• People with diabetes have a higher prevalence of disability
(rates of 39% compared with 17%) and are more likely to
have a severe or profound limitation (age-standardised
rates of 14% compared with 5%).
• The most common type of disability experienced → was
restriction in physical activities or work
DIABETIC NEUROPATHY
DIABETIC NEUROPATHY
• Diabetic neuropathy is a chronic complication with
high prevalence which affecting 60 - 70% of DM
patients
• It is considered the most important precursor to
plantar ulcers and amputations of feet
• 50% chance of losing a contralateral limb within 4
years after the first amputation
DIABETIC NEUROPATHY…
• Diabetic neuropathy is damage of the nerves that is caused
by diabetes
• This may deleteriously affect sensory, motor, and
autonomic nerve fibers
• Most common among diabetic neuropathies is chronic
distal symmetric polyneuropathy (DSPN), accounting for
about 75% of the diabetic neuropathies .
DIABETIC NEUROPATHY…
• The neurological peripheral dysfunction starts in the distal
portions of the peripheral nervous system (usually the feet)
and can extend to the upper limbs
• Measuring sensory loss, such as impaired vibration
perception, can identify significant risk factors for
amputation
DIABETIC NEUROPATHY…
Clinical Feature :
• Muscle weakness and atrophy
• Motor nerve conduction abnormalities
• Neuropathic pain and negative sensory symptoms
• Symmetrical reduction in distal sensation
• Positive neuropathic sensory symptoms which includes
burning pain in the distal lower extremities
• Decreased or absent ankle reflexes.
DIAGNOSTIC OF DIABETIC NEUROPATHY
• ITS DIFFICULT since the various pathophysiological
mechanisms that occur along with diabetes have a long
temporal span → more of diagnosis of exclusion
• DN develops slowly in which no sequence of which
disabilities of sensory or motor element will precede and
follow can be established → multiple clinical and then
laboratory testing becomes necessary
•
DIAGNOSTIC OF DIABETIC
NEUROPATHY…
• Therefore, DN remains a challenge for physicians to
screen, diagnose, follow-up, and evaluate for treatment
response
• But still, early diagnosis is recommended and is the key
factor for a better prognosis and preventing
complications such as diabetic foot ulcers, amputation,
and other disabilities
DIABETIC NEUROPATHY
ON POSTURAL CONTROL
DIABETIC NEUROPATHY ON POSTURAL
CONTROL
• Postural control is defined as the control of body’s
position in space for balance purpose
• Postural control is obtained from sensory feedbacks of the
body which are the vestibular, visual, and somatosensory
system
• Postural control in static conditions is known as postural
steadiness while in the dynamic volitional perturbations it is
noted as postural stability
• Postural sway is defined as the response of the postural
muscle activity in stimulating a continuous to-and-fro
move- ment of the body against the point of gravity while
standing
DIABETIC NEUROPATHY ON POSTURAL
CONTROL...
• Postural instability in DPN occurs due to deficits of systems
that work to control balance. Reducing accurate feed-back of
the proprioception sense along with the deterioration of
somatosensory, visual and vestibular systems causes larger
postural sway
• Interruption of the afferent and efferent neuron function
through the termination of the tibial, sural, and deep
peroneal nerves in the mechanoreceptors of the capsule and
ligaments at the ankle joint lead to diminishing function of
proprioceptive and tactile sensation in maintaining postural
stability
DIABETIC NEUROPATHY ON POSTURAL
CONTROL...
• Normal adult maintains their posture by ankle strategy,
DPN group exhibited reduced ability of the ankle strategy
to resist postural sway against gravity as proven by the
finding of larger trace surface of posturography in DPN
group compared to the control and diabetic without DPN
group
• Muscle strength reduction is associated with relatively high
glucose level and potentially less glucose uptake and
hyperglycemia in muscles, which can contribute to lower
capability in resisting postural sway
DIABETIC NEUROPATHY ON POSTURAL
CONTROL...
• Abnormality of the postural sway is recognized and expected if
there is any deterioration of one sensory input and/or motor
output. Evidently, postural sway requires high demands on the
peripheral nervous system. Therefore, impairments of the
afferent and the efferent pathways in DPN are suggested to
cause many considerable changes in postural sway reaction
• In spite of that, review by Bonnet and Ray (2011) partially agreed
with findings of DPN being the fundamental reason causing
larger postural sway in diabetic patients than controls in quiet
stance and affecting more if visual or vestibular systems are
deteriorated
DIABETIC NEUROPATHY ON POSTURAL
CONTROL...
• In addition, DPN also demonstrated significant high
reaction time and reduce movement velocity, which noted
slow sensory processing and motor planning deficits
DIABETIC NEUROPATHY
ON GAIT PERFORMANCE
DIABETIC NEUROPATHY ON GAIT
PERFORMANCE
• Normal walking is the end-product of a healthy neuro–musculo–skeletal
system, which requires both sensory input to modify learned motor
patterns and muscular output to execute the desired action
• Walking is a critical component of physical function. An intact central and
peripheral nervous system to initiate and control the movement, adequate
muscle strength and bones and joints moving in full range are essential
for normal locomotion, which is the most natural daily activity for humans.
Moreover, the majority of falls occur during situations in which the
individual is walking
• Abnormalities in gait have an effect on patients beyond simple functional
impairments. For example, Vileikyte et al. demonstrated that unsteadiness
in gait was the strongest association with symptoms of depression in
patients with diabetes
DIABETIC NEUROPATHY ON GAIT
PERFORMANCE
• Numerous abnormalities, including sensory loss (impaired
vibration and protective sensation), decreased lower-extremity
strength (force-producing capacity) and alterations in the central
nervous system contribute to impaired gait in diabetes
DIABETIC NEUROPATHY ON GAIT
PERFORMANCE
• Temporal-spatial parameters were significantly affected in
DPN group. There were smaller step length, reduced
duration of single support, higher duration of double
support, decreased gait velocity, lowered cadence,
increased step width-to-step length ratio, increased step
time and step time variability, and greater gait variability
• The changes in this gait parameter were concluded as the
factors of gait instability. Furthermore, DPN group
significantly walked slower with shorter steps than control
that causes increase in gait variability
DIABETIC NEUROPATHY ON GAIT
PERFORMANCE...
• In addition, lower ROM at the hips (frontal plane, by 25%),
hips and knees (transverse plane, 31% and 32%), ankles
(sagittal plane, 22%), and rst metatarsophalangeal joints
(sagittal plane, with less foot rotation (24%) identified gait
alterations in people with clinically severe peripheral
neuropathy and related plantar foot ulcer history.
• The maximum value of the vertical component of GRF was
found to be higher in the two control groups compared
with the DPN group
INTERVENTIONAL STUDIES ON GAIT
DISORDERS IN DIABETES
• The focus of interventional studies on patients DM with a gait
disorder : reducing the risk of falls and preventing diabetic foot
ulcer
• Allet et al showed that older individuals with diabetes had impaired
balance, slower reactions and, consequently, a higher risk of falling
than age-matched control subjects.
• With a view to diabetic ulcer prevention and treatment, a key in
addressing the detrimental effect of gait disorders in people with
diabetes is the reduction or redistribution of plantar pressure as
this is known to be a significant risk factor in ulcer formation
INTERVENTIONAL STUDIES ON GAIT
DISORDERS IN DIABETES…
• To redistribute the plantar pressure across a wider area and, as a
result, reduce the peak pressure in any one area
• This can be done through the application of various offloading
device : insole, brace or cast
• Another possible method of reducing plantar pressures is to
reduce gait speed; this strategy has been shown to reduce the
plantar pressures across the foot
CONCLUSION
• People with diabetes have a higher prevalence of disability
and are more likely to have a severe or profound limitation
• The most common type of disability experienced was
restriction in physical activities or work
• The most prominent complication of DM is diabetic
neuropathy which leads to diabetic foot that can progress to
limb amputation
• DPN patients have been demonstrated with postural instability
and gait imbalance that contribute to fall incidence
• Further works are crucial to provide evidence to support the
need for balance and gait training that can be used as one of
the primary strategies of rehabilitation in DN patients
•
REFERENCES
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