Diyabetik Hastalarda Postür, Denge ve Yürümenin Değerlendirilmesi

Year 2023, Volume: 17 Issue: 3 - Turkish Journal of Family Medicine and Primary Care, 444 - 450, 20.09.2023

Mehmet Taylan Peköz Yakup Sarıca

https://doi.org/10.21763/tjfmpc.1345491

Abstract

Giriş: Diabetes mellitus yaş ve cinsiyet ayırımı gözetmeksizin görülebilen kronik metabolik bir hastalıktır. En sık görülen komplikasyonlarından biri polinöropati (PNP) olup denge, postür ve yürüme bozukluklarına yol açabilmektedir. Diyabetik hastalarda nöropati varlığının postür, denge ve yürüme bozukluklarında olası rolünün belirlenmesi amaçlanmıştır.
Yöntem: Çalışmaya Çukurova Üniversitesi Tıp Fakültesi Dahiliye-Endokrinoloji Anabilim Dalı polikliniğinde diabetes mellitus tanısı ile izlenen olgular alınmıştır. Bu olgularda yürüme ve denge statik postürografi (göz açık, göz kapalı, baş sağa, baş sola ve tandem Romberg) ve Tinetti Denge ve Yürüme Skalası ile değerlendirilmiş olup eşlik eden otonomik ve periferik sinir tutulumunu belirlemek için elektronörografi (ENG) ve sempatik deri yanıtlarına (SDY) bakılmıştır. Elde edilen veriler kontrol grubu ile karşılaştırılmıştır.
Bulgular: Diabetes mellitus tanılı toplam 29 hasta ve 16 sağlıklı kontrol grubu çalışmaya dahil edilmiş olup ortalama yaş sırası ile 49,9±7,1 ve 47,7±6,6 yıldır. Diyabetiklerde median ve ulnar sinirlerde duyusal iletim hızları ve peroneal ve ulnar sinirlerde ise motor iletim hızları normal kotrollere göre yavaşlamış bulunmuştur. Bu değerler istatistiksel olarak anlamlıdır (p<0.001 ve p<0.003). Klinik tablo ile birlikte yorumlanacak olur ise diyabetiklerin ENG çalışması sonucunda 14’ünde PNP saptanmış, 15’inde ise polinöropatiyi telkin eden bulgular gözlenmemiştir. SDY bakıldığında diyabetiklerde 3 olguda ayakta, 2 olguda ise hem ayak hem de elde SDY’ları elde edilememiştir. Böylece 5 olguda (5/29; % 17,2) otonomik (sudomotor) lif tutuluşu görülmüştür. Bu 5 olguda ENG verileriyle polinöropati tanısı da konmuştur. Tinetti yürüme, denge ve total skor istatistiksel olarak anlamlı olacak şekilde normal kontrol olgularından daha düşük olarak elde edilmiştir (p<0.001). Postürografik çalışma platform üzerinde başın sağ veya sola dönük olduğu pozisyonda ve tandem Romberg testi ile diyabetiklerin normallere göre daha fazla salındığı ve istatistik olarak bu farkın anlamlı olduğu görülmüştür (sırası ile p=0,002; p=0,03 ve p=0,041).
Sonuç: Çalışmamız diyabetik hastalarda nöropati varlığı ile doğrudan ilişkili olmakla birlikte polinöropatisi olan ve olmayan olgularda postüral stabilite ve dengenin kontrol grubuna göre bozuk olduğunu ortaya koymuştur.

Keywords

Diyabet, postürografi, yürüme, denge

Supporting Institution

destekleyen kurum yok

Evaluation of Posture, Balance and Gait Disorders in Diabetic Patients

Abstract

Objective: Diabetes mellitus is a chronic metabolic disease that occurs regardless of age and gender. One of the most common complications is polyneuropathy (PNP), which may lead to balance, posture, and gait disorders. We aimed to determine the possible role of the presence of neuropathy in posture, balance, and gait disorders in diabetic patients.
Methods: Patients who were followed up with a diagnosis of diabetes mellitus in the outpatient clinic of the Department of Endocrinology, Çukurova University Faculty of Medicine were included in the study. Gait and balance were evaluated on a static posturography force platform performing four tasks (eyes open , eyes closed, head to the right, head to the left, and tandem Romberg), Tinetti Balance and Gait Scale and electroneurography (ENG) and sympathetic skin responses were evaluated to determine the accompanying autonomic and peripheral nerve involvement. The results were compared with the control group.
Results: A total of 29 patients with diabetes mellitus and 16 healthy controls were included in the study with a mean age of 49.9±7.1 and 47.7±6.6 years, respectively. Sensory conduction velocities in the median and ulnar nerves and motor conduction velocities in the peroneal and ulnar nerves were found to be slowed down in diabetics compared to normal controls (p<0.001 and p<0.003). When interpreted together with the clinical picture, 14 of the diabetics had PNP as a result of the ENG study and 15 of them did not have findings suggestive of polyneuropathy. Autonomic fiber involvement was observed in 5 (5/29; 17.2%) of diabetic patients. In diabetics, Tinetti gait, balance, and total score were statistically significantly lower than in normal control subjects (p<0.001). Posturographic study was performed on the platform with the head turned to the right or left and with the tandem Romberg test and it was observed that diabetics oscillated more than normal subjects and this difference was statistically significant (p=0.002; p=0.03, and p=0.041, respectively).
Conclusion: Our study revealed that although postural balance disorders are directly related to the presence of neuropathy in diabetic patients, diabetic patients without polyneuropathy also displayed problems with balance and postural stability compared to normal controls.

Keywords

Diabetes, posturography, gait, balance

References

• 1. Ong KL, Stafford LK, McLaughlin SA, Boyko EJ,Vollset SE,Smith AE, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2023 Jul 15;402(10397):203-234.
• 1. Ong KL, Stafford LK, McLaughlin SA, Boyko EJ,Vollset SE,Smith AE, et al. Global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the Global Burden of Disease Study 2021. Lancet 2023 Jul 15;402(10397):203-234.
• 2. Ülgü MM, Gülkesen KH, Akünal A, Ayvalı MO, Zayim N, Birinci Ş, et al. Characteristics of diabetes mellitus patients in Turkey: An analysis of national electronic health records. Turk J Med Sci. (2023) 53: 316-322.
• 2. Ülgü MM, Gülkesen KH, Akünal A, Ayvalı MO, Zayim N, Birinci Ş, et al. Characteristics of diabetes mellitus patients in Turkey: An analysis of national electronic health records. Turk J Med Sci. (2023) 53: 316-322.
• 3. Çalışkan SG, Hacıağaoğlu N,Tuzun S, Öner C, Şimşek EG, Çetin H. Diyabet merkezinden takipli tip 2 diabetes mellitus hastalarında hipoglisemi sıklığı ve hipoglisemi korkusu. TJFMPC, 2022;16(4): 681-689
• 3. Çalışkan SG, Hacıağaoğlu N,Tuzun S, Öner C, Şimşek EG, Çetin H. Diyabet merkezinden takipli tip 2 diabetes mellitus hastalarında hipoglisemi sıklığı ve hipoglisemi korkusu. TJFMPC, 2022;16(4): 681-689
• 4. Zakin E, Abrams R. Diabetic neuropathy. Semin Neurol. 2019;39:560–569.
• 4. Zakin E, Abrams R. Diabetic neuropathy. Semin Neurol. 2019;39:560–569.
• 5. Ziegler D. Diabetic polyneuropathy. Internist (Berl). 2020 Mar;61(3):243-253.
• 5. Ziegler D. Diabetic polyneuropathy. Internist (Berl). 2020 Mar;61(3):243-253.
• 6. Archer AG, Watkins PJ, Thomas PK, Sharma AK, Payan J. The natural history of acute painful neuropathy in diabetes mellitus. J Neurol Neurosurg Psychiatry 1983;46(06):491–499
• 6. Archer AG, Watkins PJ, Thomas PK, Sharma AK, Payan J. The natural history of acute painful neuropathy in diabetes mellitus. J Neurol Neurosurg Psychiatry 1983;46(06):491–499
• 7. Baragnora L, Mazzotti A, Di Martino A, Faldini C, Cauli O. Wearable sensor for assessing gait and postural alterations in patients with Diabetes: A Scoping Review. Medicina (Kaunas). 2021 Oct 22;57(11):1145.
• 7. Baragnora L, Mazzotti A, Di Martino A, Faldini C, Cauli O. Wearable sensor for assessing gait and postural alterations in patients with Diabetes: A Scoping Review. Medicina (Kaunas). 2021 Oct 22;57(11):1145.
• 8. Litzelman DK, Marriott DJ, et al. Independent physiological predictors of foot lesion in patients with NIDDM. Diabetes Care 1997; 20:1273-1278.
• 8. Litzelman DK, Marriott DJ, et al. Independent physiological predictors of foot lesion in patients with NIDDM. Diabetes Care 1997; 20:1273-1278.
• 9. Singh N, Armstrong DG, et al. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293:217-228.
• 9. Singh N, Armstrong DG, et al. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293:217-228.
• 10. Stino MA, Smith AG. Peripheral neuropathy in prediabetes and the metabolic syndrome. J Diabetes Investig. 2017 Sep;8(5):646-655.
• 10. Stino MA, Smith AG. Peripheral neuropathy in prediabetes and the metabolic syndrome. J Diabetes Investig. 2017 Sep;8(5):646-655.
• 11. Colombo P, Taveggia G, Chiesa D, Penati R, Tiboni M, De Armas L, et al. Tinetti scores can support an early diagnosis of spatial neglect in post-stroke patients. Eur. J. Phys. Rehabil. Med. 2019, 55, 722–727.
• 11. Colombo P, Taveggia G, Chiesa D, Penati R, Tiboni M, De Armas L, et al. Tinetti scores can support an early diagnosis of spatial neglect in post-stroke patients. Eur. J. Phys. Rehabil. Med. 2019, 55, 722–727.
• 12. Balal M, Demir T, Erdem M, Demirkıran M. Postural stability in blepharospasm: the effects of dual-tasking and botulinum toxin therapy. BMJ Neurol Open 2023;5:e000403.
• 12. Balal M, Demir T, Erdem M, Demirkıran M. Postural stability in blepharospasm: the effects of dual-tasking and botulinum toxin therapy. BMJ Neurol Open 2023;5:e000403.
• 13. Demir T, Balal M,Demirkıran M. The effect of cognitive task on postural stability in cervical dystonia. Arq Neuropsiquiatr. 2020 Sep;78(9):549-555.
• 13. Demir T, Balal M,Demirkıran M. The effect of cognitive task on postural stability in cervical dystonia. Arq Neuropsiquiatr. 2020 Sep;78(9):549-555.
• 14. Hatemi H. Diabetes Mellitus Tarihçesi. Aktüel Tıp Dergisi 1996; 7:497-499.
• 14. Hatemi H. Diabetes Mellitus Tarihçesi. Aktüel Tıp Dergisi 1996; 7:497-499.
• 15. Maksimoviç A, Hanewinckel R, Verlinden V,Ligthart S,Hoffman A,Franco O, et al. Gait characteristics in older adults with diabetes and impaired fasting glucose: The Rotterdam Study. J Diabetes Complications. 2016 Jan-Feb;30(1):61-6.
• 15. Maksimoviç A, Hanewinckel R, Verlinden V,Ligthart S,Hoffman A,Franco O, et al. Gait characteristics in older adults with diabetes and impaired fasting glucose: The Rotterdam Study. J Diabetes Complications. 2016 Jan-Feb;30(1):61-6.
• 16. Eils E, Behrens S, Mers O ve ark . Reduced plantar sensation causes a cautios walking pattern. Gait&Posture 2004; 20:54-60
• 16. Eils E, Behrens S, Mers O ve ark . Reduced plantar sensation causes a cautios walking pattern. Gait&Posture 2004; 20:54-60
• 17. Horak FB . Postural ataxia relarted to somatosensory loss. In : Advances in Neurology, Volo 87. 2001: 173-182.
• 17. Horak FB . Postural ataxia relarted to somatosensory loss. In : Advances in Neurology, Volo 87. 2001: 173-182.
• 18. Diener HC,Dichgans J, et al. The significance of proprioception on postural stalibization as assessed by ischemia. Brain Research 1984; 296:103.
• 18. Diener HC,Dichgans J, et al. The significance of proprioception on postural stalibization as assessed by ischemia. Brain Research 1984; 296:103.
• 19. Dietz V, Mauritz KH, et al. Bady oscilations in balancing due to segmental strech refleks activity. Exp Brain Research 1980; 40:89-95.
• 19. Dietz V, Mauritz KH, et al. Bady oscilations in balancing due to segmental strech refleks activity. Exp Brain Research 1980; 40:89-95.
• 20. Kwon OY, Minor SD, et al. Comparison of mucle activity during wolking in subjects with and without diabetic neuropathy. Gait and posture 2003; 18:102-11
• 20. Kwon OY, Minor SD, et al. Comparison of mucle activity during wolking in subjects with and without diabetic neuropathy. Gait and posture 2003; 18:102-11
• 21. Armstrong DM . The supraspinal control of mammalian locomotion. J Physiology (London) 1988; 405:1-37.
• 21. Armstrong DM . The supraspinal control of mammalian locomotion. J Physiology (London) 1988; 405:1-37.
• 22. Cavanagh P, Derr J, et al. Problems with gait and posture in neuropathic patient with insulin dependent diabetes mellitus. Diabet Med 1992; 9:469-474.
• 22. Cavanagh P, Derr J, et al. Problems with gait and posture in neuropathic patient with insulin dependent diabetes mellitus. Diabet Med 1992; 9:469-474.
• 23. Hylton B.M, Stephan R.L, et al. Walking stability and sensorimotor function in older people with diabetic peripheral neuropathy. Arch Phys Med Rehabil 2004; 85:245-252.
• 23. Hylton B.M, Stephan R.L, et al. Walking stability and sensorimotor function in older people with diabetic peripheral neuropathy. Arch Phys Med Rehabil 2004; 85:245-252.