Diabetes and the Need for Walking Canes

Table of Contents

1. Diabetic Neuropathies

2. Types of Diabetic Neuropathy

3. Disease Progression

4. Neuropathy Treatment

5. Gait Disturbance

6. Gait Complications

7. Mobility Aid for Balance

8. Mobility Aid Study

9. Conclusion

10. Expert Contributions

11. References


Diabetes is a metabolic disease state, whereby the body is unable to produce adequate amounts of insulin. Two types of Diabetes occur. Type 1 Diabetes is often seen in younger individuals who lack the ability to produce any insulin. Type 2 Diabetes is typically seen in middle age to older individuals, who are overweight and physically de-conditioned. Type 2 diabetes consists of a diminished ability to produce adequate levels of insulin in the bloodstream. The lack of insulin, in Type 1 and 2 Diabetes, results in elevated levels of blood glucose. As of 2007, there were 25.8 million adults and children in the United States that suffer from the disease, accounting for over 8% of the total population.

Diabetic Neuropathies

Diabetes can cause a family of disorders, known as diabetic neuropathies. These disorders are brought about because patients diagnosed with diabetes frequently develop nerve damage, over time. The nerve problems from this disorder occur throughout every organ system in the body, and about 60 to 70% of patients with diabetes suffer from some form of neuropathy. They can develop nerve problems at any given time, but the risk of nerve issues elevates with age and increased diagnosis time.

Types of Diabetic Neuropathy

There are four classifications of diabetic neuropathy, with the most common being peripheral neuropathy.

• Autonomic
• Peripheral
• Proximal
• Focal

Disease Progression

Peripheral neuropathy can cause nerve damage in the arms, hands, legs and feet. The hands and feet will most likely be affected in a patient before their arms and legs. Symptoms of peripheral neuropathy are worse at night and may present as:

• Insensitivity to temperature or pain and numbness
• Tingling, prickling, or burning sensation
• Cramps and stabbing pains
• An extreme sensitivity to touch
• A loss of coordination, position sense, and balance

People with peripheral neuropathy may also experience a loss in reflexes and muscle weakness, particularly at their ankles, that leads to a change in their gait. They sometimes experience the occurrence of foot deformities, such as a collapse of the mid-foot and hammertoes, as a result.

Neuropathy Treatment

The first thing a healthcare provider will want to do for a patient with diabetic neuropathy is to bring their blood glucose levels within a normal range, thereby preventing any further nerve damage. Actions that can be taken to regulate blood glucose levels include meal planning, monitoring blood glucose levels, exercise and insulin therapy. Patients may find their symptoms worsening when they initially stabilize their glucose levels. As time passes, the maintenance of stable, lower glucose levels may enable the neuropathic symptoms to lessen.

The key to delaying and preventing the onset of additional problems is tight blood glucose control. Researchers are learning more about the root causes of neuropathy, and new treatments are becoming available that can help prevent, slow, and even reverse a patient’s nerve damage.

Gait Disturbance

Diabetic patients often experience unusual and uncontrollable walking patterns, due to the progressive damage diabetes causes to the legs and feet. Patients with peripheral sensory neuropathy have a diminished ability to respond to potentially injurious stimuli, as well. They may also experience an atrophy of the intrinsic muscles of the foot, caused by motor neuropathy. This, in turn, causes instability of the anterior migration metatarsophalangeal joints and a gait shift to another area of the fat pad that is usually located right under the metatarsal heads. This anterior migration of the fat pad causes the forefoot to be more prone to injury when a patient is walking.

Gait Complications

Patients with diabetes often have trouble with foot ulcers. If they progress untreated, these ulcers can lead to permanent disabilities and complications. The role of exceeding, repetitive mechanical pressure, and decreased sensation to the plantar should be addressed, in order to prescribe specialized treatment. Very often high plantar pressures lead to the formation of ulcers and the breakdown of tissue. These lesions can be accompanied by infection and a progression to more severe problems such as gangrene and amputation.

As there is a tendency for patients with diabetic neuropathies to have abnormally increased plantar foot pressures, plantar pressure therapy has become a focal point in research and associated treatment recommendations. Healthcare providers must work with the patient to reduce peak plantar pressures on their forefoot while they walk, in order to effectively prevent and treat foot ulceration. Various strategies are used to reduce this type of pressures on the insensitive foot. Casts, therapeutic footwear, and accommodative orthotic devices have been used in treatment and stabilization of the plantar pressures. An alteration of gait can also be quite useful in lessening forefoot peak plantar pressures in some patients.

Mobility Aid for Balance

Therapy for people who have elevated plantar pressure can involve the use of a mobility aid such as a cane or other assistive device, to lessen forefoot plantar pressures while walking. Walking aides are commonly used for rehabilitation of neuromuscular or musculoskeletal disorders, to provide the unloading of forces on the affected extremity and to help improve balance. The primary function of an aid, such as this, is to decrease the risk of falls and load on limbs and joints that are recovering from injury. The cane also functions as a conduit for sensory information and subsequent feedback to the patient.

Mobility Aid Study

In the study titled, Walking Patterns Used to Reduce Forefoot Plantar Pressures in People With Diabetic Neuropathies published by Physical Therapy: Journal of the American Physical Therapy Association, researchers conducted studies on the effect of the cane on a patient’s gait. The studies indicated that the effect of using the cane in the ipsilateral hand vs. the contralateral hand when trying to offset pressures on the foot, may affect gait. Researchers used a portable in-shoe pressure system to measure plantar pressures at seven areas under each foot. The test subjects wound up decreasing the load on the plantar surface of their foot an average of 21.5% using a cane in the contralateral hand vs. 17% using a cane in the ipsilateral hand.

Using a cane in the contralateral hand led to the greatest unloading on the lateral side of the foot, at 35%, but the cane used in both hands only minimally unloaded the medial side of the foot at 14%. In addition, pressure was elevated on the big toe and metatarsals of the non-utilized foot at 21%.

The study suggested that the use of a cane in the contralateral hand, to offset a neurotrophic ulcer, has a bigger chance to be successful for fifth metatarsal ulcers than for first metatarsal ulcers. A cane’s use, to offset the load on one foot, stands a chance of putting the other foot at risk for developing an ulcer. It bears noting that the study was performed on test subjects who did not have impairments or known pathologies that would affect their gait. The conclusion of the study was that more studies were needed to determine whether the use of a cane would lessen forefoot plantar pressures for individuals with diabetic neuropathies.

Conclusion

The research regarding the use of a cane lessening forefront plantar pressure, for individuals with diabetes, remains inconclusive. It is recommended, however, that any patients having issues with their ambulation or balance use a walking cane or other mobility device. The healthcare provider, in order to avoid the associated dangers of falling, will commonly prescribe some variation of ambulatory assistance. Patients with diabetes that don’t perceive a dysfunctional gait, but have what is known as “foot drop,” are also candidates for ambulatory assist devices. In patients with foot drop, the toes of the foot may spontaneously drop forward and catch the floor, leading to the patient tripping or falling. Due to the unexpected nature of peripheral disease manifestation in patients with diabetic neuropathy, these patients should consider adding a mobility device to their treatment regimen.

Expert Contributions

References


1. American Diabetes Association. Statistics about Diabetes. http://www.diabetes.org/diabetes-basics/statistics/

2. National Diabetes Information Clearinghouse (NDIC). Diabetic Neuropathies: The Nerve Damage of Diabetes. http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/

3. National Diabetes Information Clearinghouse (NDIC). Diabetic Neuropathies: The Nerve Damage of Diabetes. http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/

4. National Diabetes Information Clearinghouse (NDIC). Diabetic Neuropathies: The Nerve Damage of Diabetes. http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/

5. National Diabetes Information Clearinghouse (NDIC). Diabetic Neuropathies: The Nerve Damage of Diabetes. http://diabetes.niddk.nih.gov/dm/pubs/neuropathies/

6. Kwon, Oh-Yun and Mueller, Michael J. Physical Therapy: Journal of the American Physical Therapy Association. Walking Patterns Used to Reduce Forefoot Plantar Pressures in People With Diabetic Neuropathies. https://academic.oup.com/ptj/article-abstract/81/2/828/2829552/Walking-Patterns-Used-to-Reduce-Forefoot-Plantar?redirectedFrom=fulltext . Accessed May 18, 2014.

7. Kwon, Oh-Yun and Mueller, Michael J. Physical Therapy: Journal of the American Physical Therapy Association. Walking Patterns Used to Reduce Forefoot Plantar Pressures in People With Diabetic Neuropathies. https://academic.oup.com/ptj/article-abstract/81/2/828/2829552/Walking-Patterns-Used-to-Reduce-Forefoot-Plantar?redirectedFrom=fulltext . Accessed May 18, 2014.

8. Kwon, Oh-Yun and Mueller, Michael J. Physical Therapy: Journal of the American Physical Therapy Association. Walking Patterns Used to Reduce Forefoot Plantar Pressures in People With Diabetic Neuropathies. https://academic.oup.com/ptj/article-abstract/81/2/828/2829552/Walking-Patterns-Used-to-Reduce-Forefoot-Plantar?redirectedFrom=fulltext. Accessed May 18, 2014.

9. Kwon, Oh-Yun and Mueller, Michael J. Physical Therapy: Journal of the American Physical Therapy Association. Walking Patterns Used to Reduce Forefoot Plantar Pressures in People With Diabetic Neuropathies. http://ptjournal.apta.org/content/81/2/828.full. Accessed May 18, 2014.

10. Neuropathy Support Network. Frequently Asked Questions About Neuropathy http://www.neuropathysupportnetwork.org/neuropathy-faq.htm. Accessed May 19, 2014.


Diabetes and the Need for a Walking Cane is Written by: Dr. Elizabeth Lewis

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