title: Investigation of standing balance in patients with diabetic neuropathy at different stages of foot complications.
abstract: BACKGROUND
  Diabetic peripheral neuropathy is known to cause postural instability. This study investigated standing balance in patients with diabetic neuropathy with secondary foot complications: foot ulceration, partial foot amputation and trans-tibial amputation, which are expected to pose further challenge to balance control.
  
  
  METHODS
  In this cross-sectional study, 23 patients with diabetic neuropathy alone (controls) were compared with 23 patients with diabetic foot ulceration, 16 patients with partial foot amputation and 22 patients with trans-tibial amputation. Posturography was used to determine the centre of pressure excursion during quiet standing. Differences between the 4 groups were tested using ANOVA and post-hoc comparisons.
  
  
  RESULTS
  The 4 groups varied in neuropathy score (P=0.001) and demonstrated significant decline in balance from neuropathy alone to foot ulceration, to partial foot amputation and trans-tibial amputation based on total excursion of centre of pressure (P<0.001) and centre of pressure excursion in antero-posterior direction (P<0.001). The excursion of centre of pressure in medio-lateral direction varied between 4 groups (P<0.05) however, there was no significant trend. The distance between ankles increased significantly from neuropathy to trans-tibial amputee group (P=0.001). Post-hoc comparison with controls revealed that each of three study groups demonstrated decreased balance (diabetic neuropathy vs. foot ulceration, P=0.001, diabetic neuropathy vs. partial foot amputation, P=0.002 and diabetic neuropathy vs. trans-tibial amputation, P=0.009).
  
  
  CONCLUSIONS
  Balance deterioration among patient groups from diabetic neuropathy alone to trans-tibial amputation appears to result from bio-mechanical impairment caused by progression of foot complications in addition to postural instability caused by diabetic neuropathy.
authors.affiliation: Physiotherapy Education, Clinical Sciences Building, Nottingham City Hospital, Hucknall Road, School of Community Health Sciences, University of Nottingham, Nottingham NG5 1PB, UK.
authors.forename: R V
authors.initials: RV
authors.lastname: Kanade
authors.forename: R W M
authors.initials: RW
authors.lastname: Van Deursen
authors.forename: K G
authors.initials: KG
authors.lastname: Harding
authors.forename: P E
authors.initials: PE
authors.lastname: Price
mesh_terms: D000328:Adult; D000368:Aged; D017719:Diabetic Foot / Q000503:physiopathology*; D018450:Disease Progression; D005260:Female; D005528:Foot / Q000503:physiopathology*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009038:Motion; D009119:Muscle Contraction; D018482:Muscle, Skeletal / Q000503:physiopathology*; D004856:Postural Balance; D011187:Posture; D011312:Pressure