Exercise improves gait, reaction time and postural stability in older adults with type 2 diabetes and 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.
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Conflicts of Interest: There are no conflicts of interest.