This document summarizes diabetic neuropathy and physical therapy interventions. It defines diabetic neuropathy as nerve damage caused by diabetes, affecting around 50% of type 2 diabetics. Symptoms vary but can impact mobility, sensation, and other body systems. The document outlines screening and assessment tools for neuropathy and recommends therapeutic exercises, neuromuscular re-education, pre-gait training, and modalities to improve sensation and functional mobility. The goal is to enhance somatosensory processing and reduce complications like foot ulcers.

1. Diabetic Neuropathy:
Background & PT Intervention
Kelsey Zane, SPT
University of St. Augustine
San Marcos, CA

2. Overview of Diabetes Mellitus
• Diabetes is a common co-
morbidity among many
Americans today.
• Definition: chronic disease
characterized by abnormal use
of insulin and elevated blood
glucose levels.8
• Associated complications:
hyper/hypoglycemia, glycosuria,
ketoacidosis, coma, ischemia,
atherosclerosis, amputation,
poor healing, HTN, MI, CVA,
kidney disease, peripheral
neuropathies and death.
Common Types of Diabetes Mellitus
Type I (Insulin Dependent) Type II (Non-insulin Dependent)
o severe deficiency of insulin
o usually present in youth
o without insulin, patients develop
ketoacidosis*
*definition: when sugar is not able
to utilized and instead the body
breaks down muscle and fat for
energy.
o presents later in life & usually
overweight
o glucose enters cell in adequate
amounts
o extracellular glucose is elevated
o do not usually become ketotic

3. A striking statistic:
"Diabetic polyneuropathy is one of the most common
long-term complications affecting around 50% of all
people [with type II diabetes mellitus].”8
Tesfaye, S., Boulton, A., Dyck, P. et al. Diabetes Care 2010.

5. Overview of Diabetic Neuropathy:
• Dependent Sensorimotor Polyneuropathy (DSPN): It is chronic, symmetrical and length
dependent.
• This most often develops with patients who has a background of long standing hyperglycemia, other
metabolic abnormalities and cardiovascular risk factors.8
• Diabetic Autonomic Neuropathy (DAN): disorder of the autonomic nervous system in the setting
of diabetes or pre-diabetic metabolic derangements (after the exclusion of other pathologies).
• Effect on body systems is variable, including the cardiovascular, gastrointestinal, urogenital and sudomotor
systems.
• What this means to healthcare professionals:8
• Cardiovascular system: unexplained tachycardia, orthostatic hypotension, poor exercise tolerance
Therapy: monitor vitals during treatment, setting realistic goals, breathing techniques
• Gastrointestinal system: Impaired oral drug absorption, malnutrition, poor quality of life
Therapy: timing of treatment to ensure participation
• Urogenital: Severe incontinence
Therapy: including pelvic floor exercises
• Sudomotor: Foot dryness increasing risk of foot ulceration
Therapy: foot hygiene instruction and proper footwear choice

7. Interdisciplinary communication
In order to provide comprehensive care for our patients other healthcare
providers on our team include:
• Physician
• Nursing
• Neurologist*
• Dietician/Nutritionist*
• Podiatrist*

8. Screening tools for sensation loss
• Semmes-Weinstein monofilament & tuning
fork testing:
• Study by Perkins et al: identified a baseline
for monofilament score that predicts the
probability of a patient developing diabetic
neuropathy in the next 4 years.
• Score: < 5/8
• Excellent inter- and intrarelater
reproducibility using specific protocol

9. Semmes-Weinstein protocol4
• 10 g Monofilament procedure:
• Apply a reference stimuli to the forehead or sternum.
• With patients eyes closed apply a stimuli to a non callused area of the
dorsum of the great toe just proximal to the nailbed in a smooth motion.
• The skin was touched and the monofilament bent for a full second then
lifted from the skin.
• This was repeated 4 times per foot in a random manner.
• Scoring: results are tallied and then applied to a 1-8 scale.
• Normal = 1 point assigned
• Decreased = 0.5 points assigned
• Absent = 0 points assigned

10. 128 Hz Tuning fork protocol4:
• Strike the tuning fork hard enough so it will vibrate for approximately 40
seconds.
• Apply base of tuning fork to the patients forehead or sternum and ensure
the vibration sensation is understood.
• Ask the patient to close their eyes then apply the tuning fork to the bony
prominence at the dorsum of the first toe just proximal to the nailbed.
• Ask if the vibration sensation is perceived. Then ask when the vibration
sensation has stopped.
• One point is given for if the vibration if the sensation is correctly perceived
as "on". Another point is assigned if the correct timing of dampening of the
vibration is perceived or "off".
• Repeat this procedure again on the same foot then twice on the other foot
in a random manner.

11. Neuromuscular
Re-education
Therapeutic
Exercise
Gait Training Modalities
Effective Interventions to Improve Functional Mobility in
Diabetic Neuropathy Patients

12. Therapeutic Exercises:
Sartor et al 2012:
• Focused on stretching, strengthening and functional foot/ankle exercise to improve foot
rollover.
• Prescription: 2x/wk for 12 wks at 40-60 min a session
• 4 areas that were included: increase in foot/ankle ROM, strengthen foot/ankle muscles,
functional exercises, walking skills & foot rollover training
• Outcome: Improvement was modest but plant pressure re-distribution did occur in
experimental group. Overall the patients demonstrated an improved dynamic loading pattern.7
• Application: Essential principles of therapeutic exercise including techniques to improve weight
bearing during mobility and exercises to increase strength can be beneficial for patients with
diabetic neuropathy. See attached example of the specific protocol used in this study.

13. Neuromuscular Re-education
• Various studies have focused on the importance of
balance training in this population:
• Progressive balance training in the anterior-posterior
direction and decreasing reliance on visual feedback
increased dynamic stability.1,6
• Furthermore other research supports training in ankle
strategies during standing dynamic balance to improve
functional mobility and reduce exploratory postural
sway.5,6

14. Pre gait & Gait Training:
• Amemiya et al identified a link between an increase in
plantar foot pressure and increased incidence in diabetic
foot ulcers.
• Outcome: Diabetic patients demonstrated decreased
motion during the mid-stance phase which could be
improved with increasing ankle ROM and sensory
feedback.
• Application: Joint mobilization and pre-gait training with
emphasis on ankle rollover are appropriate
interventions.

15. Modalities to Improve Sensation:
• Low level TENS can be used in
conjunction with other interventions to
increase sensory feedback3.
The protocol consisted of:
• 6 weeks of treatment at 5 times a week.
• patients sat for 30 min. in a foot bath
w/electrodes
• TENS delivered 120-Hz pulsed current
waveforms up to max of 50 mA at a 1:1
ratio.

16. Take Home Message:
Diabetic neuropathy is common among Type II DM patients and can lead to
serious consequences including amputation. As therapists we need to
improve their somatosensory processing in order to increase their functional
mobility. Interventions to improve ROM, sensation and dynamic balance are
examples of techniques to achieve that goal.

17. References:
1. Akbari, M., Jafari, H., Moshashaee, A., Forugh, B. "Do diabetic neuropathy patients benefit from balance
training?". JRRD. 2012; 49: 333-338.
2. Amemiya, A., Noguchi, H., Oe, M, et al. "Elevated plantar pressure in diabetic patients and its relationship
with their gait features". Gait & Posture. 2014; 40: 408-414.
3. Najafi, B., Crews, R., Wrobel, J. "A novel plantar stimulation technology for improving protective sensation
and postural control in patients with diabetic peripheral neuropathy: a double-blinded, randomized study".
Gerontology. 2013; 59: 473-480.
4. Perkins, B., Orszag, A., Ngo, M., Ng., E., New, P., Bril, V. "Prediction of incident diabetic neuropathy using the
monofilament examination." Diabetes Care. 2010; 33: 1549-1554.
5. Salsabili, H., Bahrpeyma, F., Forogh, B., Rajabali, S. "Dynamic stability training improves standing balance
control in neuropathic patients with type 2 diabetes". JRRD. 2011; 48: 775-786.
6. Salsabili, H., Bahrpeyma, F., Esteki, A., Karimzadeh, M., and Ghomashchi, H. "Spectral characteristics of
postural sway in diabetic neuropathy patients participating in balance training." Jour. Of Diabetes &
Metabolic Disorders. 2013; 12: 29-37.
7. Sartor, C., Hasue, R., Cacciari, L. et al. "Effects of strengthening, stretching and functional training on foot
function in patients with diabetic neuropathy: results of a randomized controlled trial." BMC
Musculoskeletal Disorders. 2014; 15: 137-150.
8. Tesfaye, S., Boulton, A., Dyck, P. et al. "Diabetic neuropathies: update on definitions, diagnostic criteria,
estimation of severity, and treatments." Diabetes Care. 2010; 33: 2285-2293.