Elsevier

Journal of Diabetes and its Complications

Volume 28, Issue 5, September–October 2014, Pages 715-722
Journal of Diabetes and its Complications

Exercise improves gait, reaction time and postural stability in older adults with type 2 diabetes and neuropathy

https://doi.org/10.1016/j.jdiacomp.2014.04.007Get rights and content

Abstract

Aims

For older adults with type 2 diabetes (T2DM), declines in balance and walking ability are risk factors for falls, and peripheral neuropathy magnifies this risk. Exercise training may improve balance, gait and reduce the risk of falling. This study investigated the effects of 12 weeks of aerobic exercise training on walking, balance, reaction time and falls risk metrics in older T2DM individuals with/without peripheral neuropathy.

Methods

Adults with T2DM, 21 without (DM; age 58.7 ± 1.7 years) and 16 with neuropathy (DM-PN; age 58.9 ± 1.9 years), engaged in either moderate or intense supervised exercise training thrice-weekly for 12 weeks. Pre/post-training assessments included falls risk (using the physiological profile assessment), standing balance, walking ability and hand/foot simple reaction time.

Results

Pre-training, the DM-PN group had higher falls risk, slower (hand) reaction times (232 vs. 219 ms), walked at a slower speed (108 vs. 113 cm/s) with shorter strides compared to the DM group. Following training, improvements in hand/foot reaction times and faster walking speed were seen for both groups.

Conclusions

While falls risk was not significantly reduced, the observed changes in gait, reaction time and balance metrics suggest that aerobic exercise of varying intensities is beneficial for improving dynamic postural control in older T2DM adults with/without neuropathy.

Introduction

For many older adults with type 2 diabetes (T2DM), the risk of falling is a major concern (Crews et al., 2013, Richardson and Hurvitz, 1995). For this high-risk population group, a number of factors may predispose them to the likelihood of suffering such an adverse event. While some of these factors are generalizable to the older population, such as age-related declines in balance control, muscle strength, and walking ability (Morrison et al., 2010, Morrison et al., 2012, Schwartz et al., 2002, Schwartz et al., 2008, Wallace et al., 2002), others are specific to this disease process. These can include the development of neuropathy, retinopathy, poor glycemic control, diabetes medication and/or polypharmacy (Berlie and Garwood, 2010, Maurer et al., 2005, Richardson and Hurvitz, 1995, Tilling et al., 2006).

The combined contribution of these factors means that the risk of falling for an older person with T2DM is dramatically increased when compared to a healthy adult of similar age (Pijpers et al., 2012). Consequently, there is an urgent need to identify falls risk factors amenable to change and to design an appropriate intervention. One fall risk factor which is modifiable is muscle strength, which in turn influences balance and walking ability (American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention, 2001, Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society, 2011, Close et al., 2005, Lord and Clark, 1996, Peterson et al., 2009). While numerous studies have focused on implementing interventions for preventing falls in healthy older adults (Baker et al., 2007, Barnett et al., 2003, Buchner et al., 1997, Gardner et al., 2001, Nitz and Choy, 2004, Peterson et al., 2009), fewer examples of targeted interventions for reducing falls in T2DM individuals exist, despite the aforementioned heightened risk in this population (Cavanagh, Derr, Ulbrecht, Maser, & Orchard, 1992). Studies that have assessed the impact of training interventions for reducing falls and improving balance in persons with T2DM have produced encouraging results. The benefits reported to arise from structured balance training extend to general improvements in posture, reactions and/or gait function (Allet et al., 2010, Morrison et al., 2010, Morrison et al., 2012), although many of the changes reported do not reach the level of improvement seen in healthy adults of a similar age. Interestingly, exercise can lead to specific improvements in neuropathy symptoms, including increased nerve fiber branching (Kluding et al., 2012) and improved sensatory responses in the lower limbs (Balducci et al., 2006). These findings indicate that, in addition to the more general improvements seen in physiological function, exercise has the potential to induce structural changes in the nervous system which could also translate to functional benefits for balance and gait related activities.

However, fewer training studies have directly focused on changes in falls risk, gait, and balance issues in adults with T2DM, such as would be observed with different levels of neuropathy. Such studies may provide greater insight as to the effects of this disease process and whether they can be altered with structured interventions, especially given that specific health issues arising from the diabetes disease process (e.g., emergence of neuropathy, retinopathy, and poor glycemic control) are not commonly observed in healthy groups used for comparison. The decline of sensory function due to peripheral neuropathy can be particularly problematic since many everyday balance and walking activities require optimal sensory and proprioceptive input to be performed successfully (Lafond et al., 2004, Simoneau et al., 1995, Woolley et al., 1997). Consequently, the loss of appropriate sensory input related to neuropathy impacts everyday movements and has been directly linked to increased incidence of falls (Richardson and Hurvitz, 1995, Roman de Mettelinge et al., 2013, Schwartz et al., 2002, Schwartz et al., 2008, Wallace et al., 2002). Thus, the aims of the current study were to: 1) examine the differences in gait dynamics, reactions, falls risk (as measured by the Physiological Profile Assessment, PPA), and balance between T2DM individuals with and without peripheral neuropathy, and 2) determine the effect of 12 weeks of moderate or intense aerobic exercise training that was isocaloric on gait, balance and falls risk metrics.

Section snippets

Participants

Thirty seven individuals (age range 42–70 years) with T2DM participated in this study. Exclusion criteria included significant cardiovascular disease, unstable proliferative retinopathy, end-stage renal disease, and uncontrolled hypertension. Based upon peripheral neuropathy status, subjects were subdivided into two groups: no neuropathy (DM, n = 21, mean age 58.7 ± 1.7) or peripheral neuropathy (DM-PN, n = 16, mean age 58.9 ± 1.9). The presence of peripheral neuropathy for each person was based upon

Assessment of falls risk and neuropathy

At baseline, no significant group differences were observed (between DM and DM-PN) with regard to body mass index (BMI) or percent body fat. In addition, there was no difference in falls risk or number of previous falls (all p’s > 0.05), but the two groups exhibited significant differences in total neuropathy scores (F1,35 = 9.43; p < 0.05). No differences between groups based on aerobic exercise training intensity alone were evident; therefore, data from both intensities of training (moderate and

Discussion

The study was designed to assess the effects of 12 weeks of isocaloric aerobic training of two intensities on falls risk (as determined by the PPA), reaction time, balance and walking ability in a group of older T2DM adults with varying degrees of peripheral neuropathy. Significant differences in reaction time, walking and balance metrics were observed between the DM and DM-PN group at baseline with the neuropathy group exhibiting a slower walking speed with increased variability, decreased

Acknowledgments

This work was fully supported by a clinical research grant from the American Diabetes Association. We would also like to acknowledge the assistance of Samantha Hines Meier and Kathleen R. Thomas in supervising the exercise training and the collection of data.

References (55)

  • L.M. Tilling et al.

    Falls as a complication of diabetes mellitus in older people

    Journal of Diabetes and its Complications

    (2006)
  • T.T. van Sloten et al.

    Peripheral neuropathy, decreased muscle strength and obesity are strongly associated with walking in persons with type 2 diabetes without manifest mobility limitations

    Diabetes Research and Clinical Practice

    (2011)
  • N. Vuillerme et al.

    Effects of a reaction time task on postural control in humans

    Neuroscience Letters

    (2000)
  • L. Allet et al.

    The gait and balance of patients with diabetes can be improved: A randomised controlled trial

    Diabetologia

    (2010)
  • L. Allet et al.

    Clinical factors associated with gait alterations in diabetic patients

    Diabetic Medicine

    (2009)
  • L. Allet et al.

    Gait characteristics of diabetic patients: A systematic review

    Diabetes/Metabolism Research and Reviews

    (2008)
  • American Geriatrics Society, British Geriatrics Society, and American Academy of Orthopaedic Surgeons Panel on Falls Prevention

    Guideline for the prevention of falls in older persons

    Journal of the American Geriatrics Society

    (2001)
  • M.K. Baker et al.

    Multi-modal exercise programs for older adults

    Age and Ageing

    (2007)
  • A. Barnett et al.

    Community-based group exercise improves balance and reduces falls in at-risk older people: A randomised controlled trial

    Age and Ageing

    (2003)
  • H.D. Berlie et al.

    Diabetes medications related to an increased risk of falls and fall-related morbidity in the elderly

    Annals of Pharmacotherapy

    (2010)
  • D.M. Buchner et al.

    The effect of strength and endurance training on gait, balance, fall risk, and health services use in community-living older adults

    Journals of Gerontology. Series A, Biological Sciences and Medical Sciences

    (1997)
  • M.G. Carpenter et al.

    The influence of postural threat on the control of upright stance

    Experimental Brain Research

    (2001)
  • P. Cavanagh et al.

    Problems with gait and posture in neuropathic patients with insulin-dependent diabetes mellitus

    Diabetic Medicine

    (1992)
  • M. Cenciarini et al.

    Stiffness and damping in postural control increase with age

    Biomedical Engineering, IEEE Transactions on

    (2010)
  • R.T. Crews et al.

    A growing troubling triad: Diabetes, aging, and falls

    Journal of Aging Research

    (2013)
  • S.P. Cummings et al.

    Forgetting falls—the limited accuracy of recall of falls in the elderly

    Journal of the American Geriatric Society

    (1988)
  • K. Delbaere et al.

    Concern about falls elicits changes in gait parameters in conditions of postural threat in older people

    Journals of Gerontology. Series A, Biological Sciences and Medical Sciences

    (2009)
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    Conflicts of Interest: There are no conflicts of interest.

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