Skip to main content

Advertisement

SpringerLink
Log in

Impaired postural control in diabetes—a predictor of falls?

  • Original Article
  • Published:
Archives of Osteoporosis Aims and scope Submit manuscript

Abstract

Summary

New evidence points toward that impaired postural control judged by center of pressure measures during quiet stance is a predictor of falls in people with type 1 and type 2 diabetes—even in occurrence of well-known risk factors for falls.

Introduction/aim

People with type 1 diabetes (T1D) and type 2 diabetes (T2D) are at risk of falling, but the association with impaired postural control is unclear. Therefore, the aim was to investigate postural control by measuring the center of pressure (CoP) during quiet standing and to estimate the prevalence ratio (PR) of falls and the fear of falling among people with diabetes compared to controls.

Methods

In a cross-sectional study, participants with T1D (n = 111) and T2D (n = 106) and controls without diabetes (n = 328) were included. Study procedures consisted of handgrip strength (HGS), vibration perception threshold (VPT), orthostatism, visual acuity, and postural control during quiet stance measured by CoPArea (degree of body sway) and CoPVelocity (speed of the body sway) with “eyes open,” “eyes closed” in combination with executive function tasks. A history of previous falls and fear of falling was collected by a questionnaire. CoPArea and CoPVelocity measurements were analyzed by using a multiple linear regression model. The PR of falls and the fear of falling were estimated by a Poisson regression model. Age, sex, BMI, previous falls, alcohol use, drug, HGS, VPT, orthostatism, episodes of hypoglycemia, and visual acuity were covariates in multiple adjusted analyses.

Results

Significantly larger mean CoPArea measures were observed for participants with T1D (p = 0.022) and T2D (0.002), whereas mean CoPVelocity measures were only increased in participants with T2D (p = 0.027) vs. controls. Additionally, T1D and T2D participants had higher PRs for falls (p = 0.044, p = 0.014) and fear of falling (p = 0.006, p < 0.001) in the crude analyses, but the PRs reduced significantly when adjusted for mean CoPArea and mean CoPVelocity, respectively. Furthermore, multiple adjusted PRs were significantly higher than crude the analyses.   

Conclusion

Impaired postural control during quiet stance was seen in T1D and T2D compared with controls even in the occurrence of well-known risk factors. and correlated well with a higher prevalence of falls.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Data availability

All sensitive data were collected and secured in REDCap under “DIAFALL” in accordance with current legislation. Data was stored anonymized after termination of the project. Physical data achieved doing the study was stored in locked desks with locked doors. Computer equipment was borrowed by the North Jutland Region and was password protected in accordance with current guidelines. The data and study material are not available.

Code availability

The code is not available.

References

  1. Vos T, Barber RM, Bell B et al (2015) Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386:743–800

    Google Scholar 

  2. Falls. https://www.who.int/news-room/fact-sheets/detail/falls. Accessed 13 Mar 2020

  3. Toft AMH, Møller H, Laursen B (2010) The years after an injury: long-term consequences of injury on self-rated health. J Trauma - Inj Infect Crit Care 69:26–30

    Google Scholar 

  4. Laursen B, Møller H (2012) Long-term health effects of unintentional injuries in Danish adults. Dan Med J 59:A4423

    PubMed  Google Scholar 

  5. Cummings SR, Nevitt MC (1994) Non-skeletal determinants of fractures: the potential importance of the mechanics of falls. Osteoporos Int 4:67–70

    PubMed  Google Scholar 

  6. Kruisbrink M, Delbaere K, Kempen GIJM, Crutzen R, Ambergen T, Cheung KL, Kendrick D, Iliffe S, Zijlstra GAR (2021) Intervention characteristics associated with a reduction in fear of falling among community-dwelling older people: a systematic review and meta-analysis of randomized controlled trials. Gerontologist 61:E269–E282

    PubMed  Google Scholar 

  7. Florence CS, Bergen G, Atherly A, Burns E, Stevens J, Drake C (2018) Medical costs of fatal and nonfatal falls in older adults. J Am Geriatr Soc 66:693–698

    PubMed  PubMed Central  Google Scholar 

  8. Bergen G, Stevens MR, Burns ER (2016) Falls and fall injuries among adults aged ≥65 years—United States, 2014. MMWR Morb Mortal Wkly Rep 65:993–998

    PubMed  Google Scholar 

  9. Wang X, Chen Z, Li Z, Chen B, Qi Y, Li G, Adachi JD (2020) Association between frailty and risk of fall among diabetic patients. Endocr Connect 9:1057–1064

    PubMed  PubMed Central  Google Scholar 

  10. Vestergaard P (2007) Discrepancies in bone mineral density and fracture risk in patients with type 1 and type 2 diabetes - a meta-analysis. Osteoporos Int 18:427–444

    CAS  PubMed  Google Scholar 

  11. Yang Y, Hu X, Zhang Q, Zou R (2016) Diabetes mellitus and risk of falls in older adults: a systematic review and meta-analysis. Age Ageing 45:761–767

    PubMed  Google Scholar 

  12. Rasmussen NH, Dal J, Van den Bergh J, De Vries F, Jensen MH, Vestergaard P (2020) Increased risk of falls, fall-related injuries and fractures in people with type 1 and type 2 diabetes - a nationwide cohort study. Curr Drug Saf 16:52–61

    Google Scholar 

  13. Duthie EH (1989) Falls. Med Clin North Am 73:1321–1336

    PubMed  Google Scholar 

  14. Rasmussen NH, Dal J (2019) Falls and fractures in diabetes—more than bone fragility. Curr Osteoporos Rep 17:147–156

    PubMed  Google Scholar 

  15. Ivanenko Y, Gurfinkel VS (2018) Human postural control. Front Neurosci. https://doi.org/10.3389/fnins.2018.00171

    Article  PubMed  PubMed Central  Google Scholar 

  16. Alcock L, O’Brien TD, Vanicek N (2018) Association between somatosensory, visual and vestibular contributions to postural control, reactive balance capacity and healthy ageing in older women. Health Care Women Int 39:1366–1380

    PubMed  Google Scholar 

  17. Li Z, Liang YY, Wang L, Sheng J, Ma SJ (2016) Reliability and validity of center of pressure measures for balance assessment in older adults. J Phys Ther Sci 28:1364–1367

    PubMed  PubMed Central  Google Scholar 

  18. Palmieri RM, Ingersoll CD, Stone MB, Krause BA (2002) Center-of-pressure parameters used in the assessment of postural control. J Sport Rehabil 11:51–66

    Google Scholar 

  19. Hita-Contreras F, Martínez-Amat A, Lomas-Vega R, Álvarez P, Mendoza N, Romero-Franco N, Aránega A (2013) Relationship of body mass index and body fat distribution with postural balance and risk of falls in Spanish postmenopausal women. Menopause 20:202–208

    PubMed  Google Scholar 

  20. Quijoux F, Vienne-Jumeau A, Bertin-Hugault F, Zawieja P, Lefèvre M, Vidal PP, Ricard D (2020) Center of pressure displacement characteristics differentiate fall risk in older people: a systematic review with meta-analysis. Ageing Res Rev. https://doi.org/10.1016/j.arr.2020.101117

    Article  PubMed  Google Scholar 

  21. Leong D, Teo K, Rangarajan S, Lopez-Jaramillo P, Avezum A, Orlandini A, Yusuf S (2015) Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet (London, England) 386:266–273

    PubMed  Google Scholar 

  22. Quijoux F, Vienne-Jumeau A, Bertin-Hugault F, Lefèvre M, Zawieja P, Vidal PP, Ricard D (2019) Center of pressure characteristics from quiet standing measures to predict the risk of falling in older adults: a protocol for a systematic review and meta-analysis. Syst Rev 8:1–9

    Google Scholar 

  23. Brown SJ, Handsaker JC, Bowling FL, Boulton AJM, Reeves ND (2015) Diabetic peripheral neuropathy compromises balance during daily activities. Diabetes Care 38:1116–1122

    PubMed  Google Scholar 

  24. Thukral N, Kaur J, Malik M (2020) A systematic review and meta-analysis on efficacy of exercise on posture and balance in patients suffering from diabetic neuropathy. Curr Diabetes Rev 17:332–344

    Google Scholar 

  25. Brunzendorf J, Behrens R (2007) How to type test the coefficient of variation of an indication. Radiat Prot Dosimetry 123:21–31

    CAS  PubMed  Google Scholar 

  26. Pum J (2019) A practical guide to validation and verification of analytical methods in the clinical laboratory. Adv Clin Chem 90:215–281

    CAS  PubMed  Google Scholar 

  27. Jonsdottir SE, Brader L, Gunnarsdottir I et al (2013) Adherence to the Nordic Nutrition Recommendations in a Nordic population with metabolic syndrome: high salt consumption and low dietary fibre intake (The SYSDIET study). Food Nutr Res 57:21391

    Google Scholar 

  28. Uusitupa M, Hermansen K, Savolainen MJ et al (2013) Effects of an isocaloric healthy Nordic diet on insulin sensitivity, lipid profile and inflammation markers in metabolic syndrome - a randomized study (SYSDIET). J Intern Med 274:52–66

    CAS  PubMed  PubMed Central  Google Scholar 

  29. Sullivan PW, Ghushchyan VH (2016) EQ-5D Scores for diabetes-related comorbidities. Value Heal 19:1002–1008

    Google Scholar 

  30. National Institute for Health and Care Excellence (2013) Falls: assessment and prevention of falls in older people.  https://www.nice.org.uk/nicemedia/live/14181/64088/64088.pdf. Accessed 27 Sep 2022

  31. Falls defined by WHO. https://www.who.int/news-room/fact-sheets/detail/falls. Accessed 12 Dec 2021

  32. Eşer I, Khorshid L, Yapucu Güneş Ü, Demir Y (2007) The effect of different body positions on blood pressure. J Clin Nurs 16:137–140

    PubMed  Google Scholar 

  33. Darpo B (2015) Clinical ECG assessment. Handb Exp Pharmacol 229:435–468

    PubMed  Google Scholar 

  34. Wang F, Zhang J, Yu J, Liu S, Zhang R, Ma X, Yang Y, Wang P (2017) Diagnostic accuracy of monofilament tests for detecting diabetic peripheral neuropathy: a systematic review and meta-analysis. J Diabetes Res. https://doi.org/10.1155/2017/8787261

    Article  PubMed  PubMed Central  Google Scholar 

  35. Breda G, Xausa D, Giunta A, Tamai A, Silvestre P, Gherardi L (1991) Nomogram for penile biothesiometry. Eur Urol 20:67–69

    CAS  PubMed  Google Scholar 

  36. Leong DP, Teo KK, Rangarajan S et al (2016) Reference ranges of handgrip strength from 125,462 healthy adults in 21 countries: a prospective urban rural epidemiologic (PURE) study. J Cachexia Sarcopenia Muscle 7:535–546

    PubMed  PubMed Central  Google Scholar 

  37. Jenkins NDM, Buckner SL, Bergstrom HC, Cochrane KC, Goldsmith JA, Housh TJ, Johnson GO, Schmidt RJ, Cramer JT (2014) Reliability and relationships among handgrip strength, leg extensor strength and power, and balance in older men. Exp Gerontol 58:47–50

    PubMed  Google Scholar 

  38. Richardson S (1991) The timed “up & go”: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 39:142–148

    PubMed  Google Scholar 

  39. Colakoglu A, Colakoglu IE, Cosar CB (2021) Correlation between corneal thickness, keratometry, age, and differential pressure difference in healthy eyes. Sci Rep. https://doi.org/10.1038/s41598-021-83683-2

    Article  PubMed  PubMed Central  Google Scholar 

  40. McKendrick AM, Brennan NA (1995) Clinical evaluation of refractive techniques. J Am Optom Assoc 66:758–765

    CAS  PubMed  Google Scholar 

  41. Saling M, Koprdová I, Hrubý M, Hlavacka F (1991) Quantitative evaluation of disorders of upright posture using stabilometry. Cesk Neurol Neurochir 54:14–21

    CAS  PubMed  Google Scholar 

  42. Macedo Ribeiro AF, Bergmann A, Lemos T, Pacheco AG, Mello Russo M, Santos de Oliveira LA, de Carvalho RE (2017) Reference values for human posture measurements based on computerized photogrammetry: a systematic review. J Manipulative Physiol Ther 40:156–168

    PubMed  Google Scholar 

  43. Hlavacka F, Kundrát J, Krizková M, Bacová E (1990) Physiologic range of stabilometry values obtained in the upright posture using a computer. Cesk Neurol Neurochir 53:107–113

    CAS  PubMed  Google Scholar 

  44. Duarte M (2015) Comments on “ellipse area calculations and their applicability in posturography” (schubert and kirchner, vol.39, pages 518-522, 2014). Gait Posture 41:44–45

    PubMed  Google Scholar 

  45. Barros AJD, Hirakata VN (2003) Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol 3:1–13

    Google Scholar 

  46. Broadley MM, White MJ, Andrew B (2017) A systematic review and meta-analysis of executive function performance in type 1 diabetes mellitus. Psychosom Med 79:684–696

    PubMed  Google Scholar 

  47. Cumming RG, Klineberg RJ (1994) Fall frequency and characteristics and the risk of hip fractures. J Am Geriatr Soc 42:774–778

    CAS  PubMed  Google Scholar 

  48. Chisholm J (1990) The Read clinical classification. Br Med J 300:1092

    CAS  Google Scholar 

  49. Morrison S, Colberg SR, Parson HK, Vinik AI (2012) Relation between risk of falling and postural sway complexity in diabetes. Gait Posture 35:662–668

    CAS  PubMed  Google Scholar 

  50. Thompson LA, Badache M, Cale S, Behera L, Zhang N (2017) Balance performance as observed by center-of-pressure parameter characteristics in male soccer athletes and non-athletes. Sports. https://doi.org/10.3390/sports5040086

    Article  PubMed  PubMed Central  Google Scholar 

  51. Roman-Liu D (2018) Age-related changes in the range and velocity of postural sway. Arch Gerontol Geriatr 77:68–80

    PubMed  Google Scholar 

  52. Prado JM, Stoffregen TA, Duarte M (2007) Postural sway during dual tasks in young and elderly adults. Gerontology 53:274–281

    PubMed  Google Scholar 

  53. Schedler S, Kiss R, Muehlbauer T (2019) Age and sex differences in human balance performance from 6–18 years of age: a systematic review and meta-analysis. PLoS ONE. https://doi.org/10.1371/journal.pone.0214434

    Article  PubMed  PubMed Central  Google Scholar 

  54. Wolfson L, Whipple R, Derby CA, Amerman P, Nashner L (1994) Gender differences in the balance of healthy elderly as demonstrated by dynamic posturography. Journals Gerontol. https://doi.org/10.1093/geronj/49.4.M160

    Article  Google Scholar 

  55. Hill MW, Duncan MJ, Oxford SW, Kay AD, Price MJ (2018) Effects of external loads on postural sway during quiet stance in adults aged 20–80 years. Appl Ergon 66:64–69

    CAS  PubMed  Google Scholar 

  56. Sundhedsstyrelsen, Statens Serum Institut (2015) Alkoholstatistik 2015. Nationale data kilde 1:86

    Google Scholar 

  57. Berry SD, Zhang Y, Lipsitz LA, Mittleman MA, Solomon DH, Kiel DP (2011) Antidepressant prescriptions: an acute window for falls in the nursing home. Journals Gerontol-Ser A Biol Sci Med Sci 66A:1124–1130

    Google Scholar 

  58. Corona G, Norello D, Parenti G, Sforza A, Maggi M, Peri A (2018) Hyponatremia, falls and bone fractures: a systematic review and meta-analysis. Clin Endocrinol (Oxf) 89:505–513

    PubMed  Google Scholar 

  59. Khaledi M, Haghighatdoost F, Feizi A, Aminorroaya A (2019) The prevalence of comorbid depression in patients with type 2 diabetes: an updated systematic review and meta-analysis on huge number of observational studies. Acta Diabetol 56:631–650

    PubMed  Google Scholar 

  60. Machado-Duque ME, Castaño-Montoya JP, Medina-Morales DA, Castro-Rodríguez A, González-Montoya A, Machado-Alba JE (2018) Association between the use of benzodiazepines and opioids with the risk of falls and hip fractures in older adults. Int Psychogeriatrics 30:941–946

    Google Scholar 

  61. Jensen MH, Vestergaard P (2019) Hypoglycaemia and type 1 diabetes are associated with an increased risk of fractures. Osteoporos Int 30:1663–1670

    CAS  PubMed  Google Scholar 

  62. Huang ES, Karter AJ, Danielson KK, Warton EM, Ahmed AT (2010) The association between the number of prescription medications and incident falls in a multi-ethnic population of adult type-2 diabetes patients: the diabetes and aging study. J Gen Intern Med 25:141–146

    PubMed  Google Scholar 

  63. Leong DP, Teo KK, Rangarajan S et al (2015) Prognostic value of grip strength: findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 386:266–273

    PubMed  Google Scholar 

  64. Moreland JD, Richardson JA, Goldsmith CH, Clase CM (2004) Muscle weakness and falls in older adults: a systematic review and meta-analysis. J Am Geriatr Soc 52:1121–1129

    PubMed  Google Scholar 

  65. Feldman EL, Callaghan BC, Pop-Busui R, Zochodne DW, Wright DE, Bennett DL, Bril V, Russell JW, Viswanathan V (2019) Diabetic neuropathy. Nat Rev Dis Prim. https://doi.org/10.1038/s41572-019-0092-1

    Article  PubMed  Google Scholar 

  66. Mustapa A, Justine M, Mohd Mustafah N, Ami N, Manaf H (2016) Postural control and gait performance in the diabetic peripheral neuropathy: a systematic review. Biomed Res Int. https://doi.org/10.1155/2016/9305025

    Article  PubMed  PubMed Central  Google Scholar 

  67. Milos V, Bondesson Å, Magnusson M, Jakobsson U, Westerlund T, Midlöv P (2014) Fall risk-increasing drugs and falls: a cross-sectional study among elderly patients in primary care. BMC Geriatr 14:40

    PubMed  PubMed Central  Google Scholar 

  68. Lipsitz LA, Habtemariam D, Gagnon M, Iloputaife I, Sorond F, Tchalla AE, Dantoine TF, Travison TG (2015) Reexamining the effect of antihypertensive medications on falls in old age. Hypertension 66:183–189

    CAS  PubMed  Google Scholar 

  69. Wong TY, Sun J, Kawasaki R et al (2018) Guidelines on diabetic eye care: the international council of ophthalmology recommendations for screening, follow-up, referral, and treatment based on resource settings. Ophthalmology 125:1608–1622

  70. World Medical Association (2013) Declaration of Helsinki: ethical principles for medical research involving human subjects JAMA - J Am Med Assoc 310:2191–2194

  71. Dixon JR (1999) The International Conference on Harmonization Good Clinical Practice guideline. Qual Assur 6:65–74

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark

    Nicklas Højgaard-hessellund Rasmussen, Morten Hasselstrøm Jensen, Annika Vestergaard Kvist & Peter Vestergaard

  2. Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark

    Jakob Dal

  3. Department of Health Science and Technology, Aalborg University, Aalborg, Denmark

    Morten Hasselstrøm Jensen

  4. Department of Endocrinology and Metabolism, Molecular Endocrinology & Stem Cell Research Unit (KMEB), Odense University Hospital, Odense, Denmark

    Annika Vestergaard Kvist

  5. University of Southern Denmark, Odense, Denmark

    Annika Vestergaard Kvist

  6. Institute of Pharmaceutical Sciences, Department of Chemistry and Applied Biosciences, ETH-Zurich, Zurich, Switzerland

    Annika Vestergaard Kvist

  7. School for Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, The Netherlands

    Joop van den Bergh

  8. Division of Rheumatology, Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands

    Joop van den Bergh

  9. Department of Internal Medicine, VieCuri Medical Center, Venlo, The Netherlands

    Joop van den Bergh

  10. Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium

    Joop van den Bergh

  11. Faculty of Medicine, Department of Health Science and Technology, Aalborg University, Fredrik Bajers Vej 7, 9220, Aalborg East, Denmark

    Rogerio Pessoto Hirata

  12. Department of Clinical Medicine and Endocrinology, Aalborg University Hospital, Aalborg, Denmark

    Peter Vestergaard

Authors
  1. Nicklas Højgaard-hessellund Rasmussen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jakob Dal
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Morten Hasselstrøm Jensen
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Annika Vestergaard Kvist
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Joop van den Bergh
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Rogerio Pessoto Hirata
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Peter Vestergaard
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version.

Corresponding author

Correspondence to Nicklas Højgaard-hessellund Rasmussen.

Ethics declarations

Ethics approval

The methods used have been tested and performed in several studies both in Denmark and abroad, and no long-term side effects have been reported. The risks associated with the project are few, and the tests implied limited risks. The potential benefits in terms of well-being were large and estimated to outweigh the potential risks. The trial was reported to the local ethical committee in the North Jutland Region (N-2019–0004). The trial was conducted in compliance with Harmonized Tripartite Guideline for Good Clinical Practice (ICH GCP) and applicable regulatory requirements and in accordance with the Helsinki Declaration for biomedical research involving test participants [70, 71]. Finally, the project was reported to the North Jutland Research department (ID-number of 2018–174).

Consent to participate

Consent for each participant was achieved.

Consent for publication

Consent for each participant was achieved.

Conflicts of interest

Peter Vestergaard is head of research in the Steno Diabetes Center North Denmark sponsored by the Novo Nordisk Foundation. Joop van den Bergh is involved in research that is sponsored by Amgen, Eli Lilly, and UCB. Morten Hasselstrøm Jensen is a former employee of Novo Nordisk and holds shares in Novo Nordisk. Nicklas H. Rasmussen holds shares in Novo Nordisk. Jakob Dal: unrestricted research grants and lecture fee from Pfizer and IPSEN. The other authors Rogerio Pessoto Hirata and Annika Kvist declare that they have no conflict of interest.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rasmussen, N.Hh., Dal, J., Jensen, M.H. et al. Impaired postural control in diabetes—a predictor of falls?. Arch Osteoporos 18, 6 (2023). https://doi.org/10.1007/s11657-022-01188-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s11657-022-01188-5

Keywords

Search

Navigation