International Journal of Diabetes Research

Online Submissions: http://www.ghrnet.org/index./ijdr/ Int. J. Diabetes Res 2019 May; 2(1): 40-45
doi: 10.17554/j.issn.2414-2409.2019.02.18 ISSN 2414-2409

ORIGINAL ARTICLE

Effect of Ankle Proprioceptive Training on Gait and Risk of

Fall in Patients With Diabetic Neuropathy: A Randomized
Controlled Trial

Nagwa Ibrahim Rehab1, Marwa Shafiek Mustafa Saleh2

1 Physical Therapy Department for Neuromuscular Disorders & its exercises, whereas the control group (n = 15) received traditional
Surgery, Faculty of Physical Therapy, Cairo University, Egypt physical therapy exercises only, three sessions a week for eight
2 Department of Basic Science for Physical Therapy, Faculty of weeks. Spatiotemporal gait parameters (Walking velocity (cm/sec),
Physical Therapy, Cairo University, Egypt step length of dominant limb (cm), step time (sec), cadence (step/
min) and double support time (sec) and risk of falling were assessed
Conflict-of-interest statement: The author(s) declare(s) that there for all patients in both groups before and after the treatment program.
is no conflict of interest regarding the publication of this paper. RESULTS: There was no significant difference between both
groups in the pre-treatment mean values of all measured variables.
Open-Access: This article is an open-access article which was Significant improvement was observed in the two groups between pre
selected by an in-house editor and fully peer-reviewed by external and post treatment measured outcomes. Furthermore, the study group
reviewers. It is distributed in accordance with the Creative Com- recorded significantly better improvement in all measured variables
mons Attribution Non Commercial (CC BY-NC 4.0) license, which compared with the control group.
permits others to distribute, remix, adapt, build upon this work non- CONCLUSION: Ankle proprioceptive training could be an
commercially, and license their derivative works on different terms, excellent supplement to traditional physical therapy exercises used
provided the original work is properly cited and the use is non- for improving gait and reducing risk of falling in patients with
commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ diabetic neuropathy.

Correspondence to: Marwa Shafiek Mustafa Saleh, Department Key words: Ankle proprioceptive training; Gait; Fall risk; Diabetic
of Basic Science for Physical Therapy, Faculty of Physical Therapy, neuropathy
Cairo University, Egypt
Email: Marwa_shafiek2000@yahoo.com © 2019 The Author(s). Published by ACT Publishing Group Ltd.
Telephone: +02 01008342466 All rights reserved.

Received: April 15, 2019 Rehab NI, Saleh MSM. Effect of Ankle Proprioceptive Training
Revised: April 20, 2019 on Gait and Risk of Fall in Patients With Diabetic Neuropathy: A
Accepted: April 24, 2019 Randomized Controlled Trial. International Journal of Diabetes Re-
Published online: May 12, 2019 search 2019; 2(1): 40-45 Available from: URL: http://www.ghrnet.
org/index.php/ijhr/article/view/2564
ABSTRACT
BACKGROUND: Alterations in gait characteristics and falls are
INTRODUCTION
common symptoms in patients with diabetic neuropathy. However, Diabetic peripheral neuropathy (DPN) is a common chronic
little is known about possible treatment strategies for improving gait complication of diabetes mellitus which results in high public
ability and reduce risk of fall in patients with diabetic neuropathy. health costs and has a huge impact on patients’ quality of life[1]. It
PURPOSE: This study was conducted to investigate the effect of leads to sensory and motor deficits, which often result in mobility-
ankle proprioceptive training on gait and risk of falling in patients related dysfunction, balance impairments[2], and alterations in gait
with diabetic neuropathy. characteristics [3]. These alternations in gait performance cause
METHODS: Thirty patients with diabetic neuropathy from both increase in the risk of fall, which has the strongest association with
sexes, their ages ranged from 50-65 years were randomly assigned symptoms of depression in patients with diabetes[4].
to study or a control group. The study group (n = 15) received ankle Gait in DPN is known as a conservative gait performance, that
proprioceptive training in addition to traditional physical therapy occurs with high double support time, slow speed, and shorter steps

40
 Rehab NI et al. Ankle proprioceptive training for patients with diabetic neuropathy

as an attempt to keep stability in walking[5,6]. It has been reported process 30 patients were eligible to participate in the study.
by Goldberg et al[7] that, 39 % of patients with DPN take more than Patients were randomly allocated into an intervention group or a
10 sec during unilateral leg stance. Also, Allet et al[8] showed that, control group using sealed envelope with 15 patients in each group.
diabetic patients with polyneuropathy have more gait alterations Study group take ankle proprioceptive training plus traditional
than diabetic patients without polyneuropathy. These alternation physical therapy exercises while control group take traditional
in gait characteristics is closely related to impairment in ankle physical therapy exercises only. During study period, both groups
proprioception[9]. continued to receive the usual recommended medical care.
Many authors have found that individuals with diabetes and
peripheral neuropathy demonstrate impaired ankle joint movement Examination
perception[10-12]. In the study conducted by Hsu et al[12] to compare All of the following assessments were done to all patients in both
the joint position sense of the lower limb in patients with diabetic groups before and after 8 weeks of treatment program.
neuropathy and normal controls, they found that distal joint Measurement of spatiotemporal gait parameters: Spatiotemporal
involvement precedes that of proximal joints. Also, Guney et gait parameters including: (Walking velocity (cm/sec), step length of
al [13] found decrease in ankle joint position sense in diabetic dominant limb (cm), step time (sec), cadence (step/min) and double
patients, which was measured as the ability to reproduce target support time (sec)) were measured using the Biodex Gait Trainer
ankle dorsiflexion and plantarflexion actively. Owing to impaired (Model 950-380, software version 2.6x, New York). The Biodex
proprioception, theses individuals are at higher risk for fall-related Gait Trainer is a special treadmill with an instrumented desk that
injuries, which leads to high financial costs[13,14]. designed to evalute and train walking ability in patients with gait
Proprioception was defined as “the perception of joint and body impairment[19]. For evaluations of gait parameters, each patient was
movement as well as position of the body, or body segments, in first allowed to be familiar with gait trainer set up before starting
space”[15]. In a study conducted by Park et al[16] to investigate the recording the selected gait parameters. This was achieved through
effectiveness of an ankle propriocetive control program on gait of instructing the patient to walk over the gait trainer and to follow the
patients with chronic stroke, the study results provide evidence in tread belt movement for three to five minutes. This might be repeated
support the effectiveness of ankle propriocetive control program in two or three times till the patient became adapted and familiar with
improving gait ability of patients with chronic stoke. Also, Isakov the apparatus. To start the evaluation process, the tread belt was
and Mizrahi[9], stated that, clinical training of proprioceptive sense is ramped up slowly to 0.3 meter∕hour. The speed setting was then
an important factor in treatment of patients with neurologic problems increased gradually to a comfortable pace for each patient. Once the
in order to increase gaiting ability. patient became comfortable, the data recording was started. Each
Despite the strong relationship between ankle proprioception patient was allowed to walk continuously for three minutes, then the
and gait ability which has been reported in the previous research evaluation session ended and the gait trainer slowed down gradually
studies, up till now, there is no study to assess to what extent ankle until it stopped and the results were displayed. These procedures
proprioceptive training can improve gait ability and decrease risk of were repeated three successive times with three minutes rest period in
falling in patient with diabetic neuropathy. So, the current study is between trials. For each patient, gait parameters were averaged over
the first randomized controlled study to investigate the effect of ankle the trials for further data analysis.
proprioceptive training on gait and risk of falling in patients with Assessment of risk of falling: Risk of falling was assessed with
diabetic neuropathy. Fall Efficiency Scale- International (FES-I). This is a self-reported
16-item scale of perceived confidence to complete physical daily
PATIENTS AND METHODS activities. It is administered to reflect the level of concern about
falling in activities inside and outside the home. Each item is scored
Patients’ selection
on a four-point scale (1 = not at all concerned, 2 = somewhat
In this randomized controlled study, thirty patients diagnosed as type
concerned, 3 = fairly concerned and 4 = very concerned). Possible
II diabetes were selected from the Out Patient Clinics of Neurology
total score is 64 in the worst case and 16 in the best condition to do
and Internal Medicine in Kasr Al- Aini Hospitals and Out Patient
Clinic of Department of Neurology, Faculty of Physical Therapy,
43 Patients screened for eligibility
Cairo University in the period from March 2018 to January 2019.
Not fulfilling inclusion
Patients were eligible to participate in the study if they had
Not eligible (N = 13) criteria (n=9)
peripheral neuropathy which has been previously diagnosed by a Refused (N=4)
physician and confirmed by electrodiagnostic tests, age ranged from Eligible (N= 30)
50 and 65 years[17], body mass index did not exceed 30 Kg/m2, type II
diabetes mellitus diagnosed for at least 7 years[1], able to walk without Agreed to participate and sign informed
assistance or assistive device, able to stand on both feet and on one consent statement (N = 30)
leg, and had controlled blood glucose level by the screening by
Glycated Haemoglobin test (9 % > HbA1c > 6.5 %)[18]. While, patients Random assignment (N = 30)

were excluded from the study if they had cognitive deficits, severe
Study group Control group
retinopathy, scares under their feet, hypo or hypertension, any medical
(n = 15) (n = 15)
conditions that would confound assessment of neuropathy such as
malignancy, active/untreated thyroid disease, other neurological or Received allocation Received allocation
orthopaedic impairments (such as stroke, poliomyelitis, rheumatoid intervention ( n= 15) intervention (n = 15)
arthritis, or severe osteoarthritis), and severe nephropathy that causes
edema or needs haemodialysis. A diagram of patients’ retention and Available for 8 weeks post- Available for 8 weeks post
randomization throughout the study is shown in Figure 1. The figure treatment assessment (n = 15) treatment assessment (n = 15)
shows that 43 patients were initially screened, after the screening Figure 1 Flow diagram for randomized patient's assignment.

41
Rehab NI et al. Ankle proprioceptive training for patients with diabetic neuropathy

all tasks without any concern of falling[20]. Some studies have been direction). (B) One legged stance with slight knee flexion of other
supported validity of the FES-I questionnaire[21]. leg for 15 seconds (5 times for each leg). (C) One legged stance
Intervention: The same physiotherapist was responsible for all with increasing knee flexion of the other leg for 15 seconds (5 times
training sessions. In order to avoid bias, another physiotherapist for each leg). (2) Training on balance pad for 20 min (1-4 week):
performed all measurements. Patients in both groups received the (A) Standing on a balance pad with shifting weight (anteriorly,
same traditional physical therapy exercises for 8 weeks, three times posteriorly and lateral side) 10 times on each direction. (B) From
a week, 30 min per session. The program included the following standing position, bending and stretching both knees by squatting as
exercises as described by Richardson et al[22]: (1) Active range of much as possible (10 times ). (C) Standing with widening each feet
motion exercises for ankle and subtalar joints were done for 5 min forward and backward, then putting the body weight forward with
including: ( dorsiflexion, planterflexion, eversion and enversion ) 10 bending and stretching knees (10 times ). (3) Training on rocked
repetition for each movement. (2) Functional balance training for 15 balance board for 20 min (5-8 week): (A) In standing position,
min involving: (A) Sit to stand ( 5 times). (B) Standing with shifting moving the weight left and right maximally (5 min). (B) In standing
weight anteriorly, posteriorly, and sideway (5 times for each direction). position, moving the weight forward and backward maximally (5
(C) Functional reach sideway and anterior for touching targets set by min). (C) In standing position, moving both heels of feet up and
the therapist (5 times for each direction). (D) Standing on heels for 20 down (5 min). (D) In standing position, bending and stretching both
seconds (5 times). (E) Standing on toes for 20 seconds (5 times). (3) knees by squatting as much as possible (5 min).
Gait training for 10 min including: (A) Spot marching (2 min). (B)
Walking over the heels, toes, lateral border of feet with the preferred DATA ANALYSIS
speed (6 min). (C) Tandem walking in a straight line (2 min). Statistical analysis was performed using statistical package for
The study group additionally received ankle proprioceptive social studies (SPSS) version 22. Data were expressed as mean and
training, 3 times a week for 8 weeks, 30 min per session. Rest breaks standard deviation. Chi- squared test was used for comparison of sex
were provided as needed, and the patients were instructed to tell the distribution between groups. Mean changes within groups (pre and
physiotherapist and stop the exercise immediately if they report any post) were analyzed using Paired t-test, while mean changes between
side effects such as fatigue or dizziness. The ankle proprioceptive groups were analyzed using unpaired t-test. The level of significance
training used in this study was implemented by correcting and was set at p < 0.05.
supplementing the training programs used by Karakaya et al[23],
Lee et al[24] and Singh et al[25], which included the following groups Subject characteristics:
of exercises: (1) Training on the floor for 10 min (1-8 week): (A) Table 1 showed the subject characteristics of both groups. There
Weight shifting on each direction (anteriorly, posteriorly and lateral was no significant difference between both groups in the mean age,
side) combining with side to side head movements (5 times for each BMI, HbA1c, and duration of illness (p < 0.05). Also, there was no
significant difference in sex distribution between groups (p = 0.71).
Table 1 General characteristics of subjects in the study and control
groups. Comparison of pre and post treatment for both study and control
Study group Control group t- value p- value groups
Age (yrs) 57.6 ± 4.96 59.13 ± 4.2 -0.86 0.39* As shown in tables 2 and 3, there were significant differences
BMI (kg/m²) 27.28 ± 1.6 26.68 ± 1.11 0.78 0.43* between pre and post treatment in all measured variables in both
HbA1c (%) 7.94 ± 0.52 7.71 ± 0.44 1.27 0.21* study and control groups. As, step length, velocity and cadence
Duration (yrs) 9.66 ± 3.01 10.8 ± 3 -1.55 0.12* showed significant increase post treatment compared with that pre
Males/Females 7/8 6/9 (χ2= 0.13) 0.71* treatment (p = 0.001). Also, there was a significant decrease in FES-I,
Data are expressed as mean ± SD; χ2:Chi squared value; * p value > 0.05= step time and double support time post treatment compared with that
non significant. pre treatment (p = 0.001).

Table 2 Comparison between pre and post treatment mean values of each measured variable of the study group.
Pre treatment Post treatment MD % change t-value p-value
FES-I 36.26 ± 4.44 27.13 ± 4.53 9.13 25.17 24.27 0.001
Step length (cm) 51.66 ± 2.87 59.86 ± 3.04 -8.2 15.87 -16.11 0.001
Step time (sec) 0.62 ± 0.05 0.48 ± 0.08 0.14 22.58 11.91 0.001
Double support time (sec) 0.33 ± 0.04 0.25 ± 0.05 0.08 24.24 19.62 0.001
Velocity (cm/sec) 71.8 ± 6.8 80.06 ± 6.8 -8.26 11.5 -5.55 0.001
Cadence (step/min) 82 ± 2.92 98.06± 5.29 -16.06 19.58 -10.08 0.001
Data are expressed as mean ± SD; MD: mean difference; p value > 0.05: significant; Fall Efficiency Scale- International (FES-I).

Table 3 Comparison between pre and post treatment mean values of each measured variable of the control group.
Pre treatment Post treatment MD % change t-value p-value
FES-I 34 ± 5.52 31.06 ± 4.93 2.94 8.64 9.29 0.001
Step length (cm) 52.06 ± 3.49 56.2 ± 3.21 -4.14 7.952 -12.29 0.001
Step time (sec) 0.63 ± 0.06 0.54 ± 0.07 0.09 14.28 5.49 0.001
Double support time (sec) 0.32 ± 0.03 0.29 ± 0.04 0.03 9.37 4.1 0.001
Velocity (cm/sec) 70.93 ± 8.06 74.13 ± 7.9 -3.2 4.51 -13.16 0.001
Cadence (step/min) 80 ± 5.65 88.06 ± 4.7 -8.06 10.07 -10.63 0.001
Data are expressed as mean ± SD; MD: mean difference; p value > 0.05: significant; Fall Efficiency Scale- International (FES-I).

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 Rehab NI et al. Ankle proprioceptive training for patients with diabetic neuropathy

Comparison of pre and post treatment between study and control Table 4 Comparison between study and control groups on each
groups measured variable before and after treatment.
As shown in table 4, there was no significant difference between the Study group Control group MD t-value p-value

study and control groups in all measured variables pre-treatment (p Pre treatment
> 0.05). While, post treatment there was a significant increase in step FES-1 36.26 ± 4.44 34 ± 5.52 2.26 1.23 0.22*
length, velocity and cadence of the study group compared with that Step length (cm) 51.66 ± 2.87 52.06 ± 3.49 -0.4 -0.34 0.73*
of control group (p > 0.01). Also, there was a significant decrease Step time (sec) 0.62 ± 0.05 0.63 ± 0.06 -0.01 -0.06 0.95*
in FES-I, step time and double support time of the study group Double support
0.33 ± 0.04 0.32 ± 0.03 0.01 0.65 0.501*
compared with that of control group (p = 0.001). time (sec)
Velocity (cm/sec) 71.8 ± 6.8 70.93 ± 8.06 0.87 0.31 0.75*

DISCUSSION Cadence (step/min) 82 ± 2.92 80 ± 5.65 2 1.21 0.23*

Post treatment
Patients with DPN often exhibit greater impairments in posture FES-1 27.13 ± 4.53 31.06 ± 4.93 -3.93 -2.27 0.03**
and gait and are typically at increased risk of falling[26]. These
Step length (cm) 59.86 ± 3.04 56.2 ± 3.21 3.66 3.2 0.003**
impairments in balance and gait result from a range of deficits,
Step time (sec) 0.48 ± 0.08 0.54 ± 0.07 -0.06 -2.32 0.02**
including proprioception and muscle strength[13,27]. So, this study was
Double support
conducted to determine the effect of ankle proprioceptive training on 0.25 ± 0.05 0.29 ± 0.04 -0.04 -2.16 0.03**
time (sec)
gait and risk of fall in patients with diabetic neuropathy. Velocity (cm/sec) 80.06 ± 6.8 74.13 ± 7.9 5.93 2.2 0.03**
The results of the current study showed that, the study group Cadence (step/min) 98.06 ± 5.29 88.06 ± 4.7 10 5.47 0.001**
who received ankle proprioceptive training in addition to traditional Data are expressed as mean ± SD; MD: mean difference; * p value >
physical therapy exercises has a significant improvement in 0.05= non significant; ** p value < 0.05: significant; Fall Efficiency Scale-
spatiotemporal parameters (walking velocity, step length of dominant International (FES-I).

limb, step time, cadence, and double support time) and a significant
reduction in the risk of falling than the control group who received decrease in the onset latency of anterior tibialis muscle after ankle
traditional physical therapy exercises only. This results comes disk training. Also, Clark and Burden[38] reported that, after 4-week
in agreement with the findings of Martínez-Amat et al [28] who wobble board training, there was a significant decrease in muscle
mentioned that, 12 weeks proprioception training program in older onset latency and a significant improvement in perceived stability in
adults is effective for improving gait, and decreasing the risk of individuals with a functionally unstable ankle.
falling in adults aged 65 years and older. In addition, training on a soft, unstable surface in the proprioceptive
The results of the current study regarding the significant group is more likely to increase the plantar cutaneous sensation
improvement of the gait parameters in the study group than the and joint position sensation, which are considered as an important
control group, might be explained by several mechanisms. This is factors in standing balance and ambulation[39,40]. This explanation was
because, walking is a highly integrated function that requires the confirmed by Shumway-Cook and Wool lacott[41], who reported that,
coordinated contribution of multiple physiological subsystems[29]. unstable surfaces were effective for improving foot proprioception.
The first explanation is related to the role of proprioceptive training in Also, McIlroy et al[40] reported that increased postural sway on an
improving muscle activity around the ankle joint[30], which consider unstable surface resulted in increasing the postural reflex activity
as a key factor influencing gait abnormalities in people with DPN. This which characterized by increased afferent input from the cutaneous
explanation was supported by Park et al[16] who mentioned that ankle receptors in the soles of the feet.
proprioceptive control program leads to significant improvements in Regarding the risk of fall, although both groups produced
ankle dorsiflexors strength and gait of patients with stroke. statistically significant reduction in the risk of fall at post-exercise
The ability to maintain balance in standing position is a compared with pre-exercise, statistically significant reduction was
fundamental factor of stable independent gait and sensitively affects detected in the ankle proprioceptive group compared with the
gait velocity[31,32]. Thus, the second explanation for the significant traditional exercises group. These findings might be attributed to
improvement of spatiotemporal gait parameter in the study group than the reported significant improvement of walking in the study group
the control group might be attributed to the role of proprioceptive than the control group. This explanation was supported by Allet
training in improving balance, which lead to improvement in gait et al[8] who mentioned that, difficulties in walking in patients with
ability[33]. This explanation was supported by Han et al[34] who diabetic neuropathy results in higher risk of falling and injuries. Also,
stated that, ankle proprioception training plays an essential role in Cavanagh et al[42] suggested that, fall in patients with DPN most
balance control. Also, El-wishy and ElSayed[35], concluded that, commonly occur during gait.
proprioceptive training was effective in improving functional balance Repeated falls lead to increase the person’s fear of falling even
and reducing balance indices in patients with diabetic neuropathy. more, which is accompanied by a loss of confidence or self-
During proprioceptive training, the gradual progression to more efficacy in one’s ability to perform routine activities associated with
unstable balance board could be used as a method to increase the daily life[43]. Several researchers stated that, promoting physical
level of difficulty. Training on unstable surfaces help in improving functioning lead to increased confidence and a reduced fear of
muscle activity around the ankle joint, and reducing the time falling[44,45]. In the current study, most of the patients in the study
to contract the calf muscle than stable surfaces[36]. So, the third group reported a reduced fear of falling as the training program
explanation regarding the results of spatio-temporal parameters of progressed, and patients stated that, they moved with greater ease and
gait, could be attributed to use of balance pad and balance board more confidence after their participation in the intervention program.
during the proprioceptive training. This explanation supported by Therefore, it was the psychological effects that led to the significant
Osborne et al[37] who conducted a study to investigate the effects of reduction in risk of fall in the study group than the control group.
ankle disk training on muscle reaction time in subjects with a history It is necessary to note the limitations of this study. First, the sample
of ankle sprain, and the results revealed a statistically significant size was small, which potentially limits the generalizability of these

43
Rehab NI et al. Ankle proprioceptive training for patients with diabetic neuropathy

findings. In addition, the study considered only the immediate effects diabetic patients without neuropathy? Isokinetics and Exercise
of ankle proprioceptive training on gait and risk of fall in patient Science. 2013; 21(4): 317-323. [DOI: 10.3233/IES-130503]
with diabetic neuropathy, and did not reflect the long term effects. 12. Hsu WC, Lu TW. Liu MW. Lower limb joint position sense in
Furthermore, it was not be possible to blind the physiotherapist due to patients with type II Diabetes Mellitus. Biomedical Engineering:
Applications, Basis and Communications. 2009; 21(4): 271-278.
the nature of the interventions which need the direct communication
[DOI: 10.4015/S1016237209001362]
between the physiotherapist and the patients.
13. Menz HB, Lord SR, St George R,  Fitzpatrich RC. Walking stabil-
ity and sensorimotor function in older people with diabetic periph-
CONCLUSION eral neuropathy. Arch Phys Med Rehab. 2004;  85(2):  245- 252.
[PMID: 14966709]; [DOI: 10.1016/j.apmr.2003.06.015]
The results of the present study showed that, the addition of ankle
14. Kars HJ, Hijmans JM, Geertzen JH, Zijlstra W. The Effect of re-
proprioceptive training to traditional physical therapy exercises duced somatosensation on standing balance: A systematic review.
could provide more improvement of gait ability and decreasing risk J Diabetes Sci Technol. 2009; 3(4): 931-943. [PMID: 20144343];
of falling in patient with diabetic neuropathy. [DOI: 10.1177/193229680900300441]
15. Shumway-Cook A, Brauer S, Woollacott M. Predicting the prob-
ACKNOWLEDGMENTS ability for falls in community-dwelling older adults using the
Timed up & Go Test. Phys Ther. 2000; 80(9): 896-903. [PMID:
The authors would like to thank all participants for their collaboration 10960937]; [DOI: 10.1093/ptj/80.9.896]
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