Med. J. Cairo Univ., Vol. 84, No.

2, September: 117-123, 2016

www.medicaljournalofcairouniversity.net

Center of Pressure Excursion and Stability in Diabetic Polyneuropathy

GEHAN MOSA, Ph.D.*; AMIRA ELGOHARI, M.D.**; BASSAM ELNASSAG, Ph.D.*;
MAHMOUD E. MIDAN, M.Sc.* and MOHAMMED ATTIA, M.Sc.***
The Departement of Physical Therapy for Neuromuscular Disorders and Its Surgery, Faculty of Physical Therapy*,
Department of Clinical Neurophysiology, Faculty of Medicine** and Department of Systems and Biomedical Engineering,
Faculty of Engineering***, Cairo University.

Introduction
CENTER of pressure (COP) is defined as the
projection of center of vertical force distribution
and thus the COP is an instantaneous point of
application of the resultant foot-floor reaction
vector. It has become a popular method of describ-
ing normal and abnormal foot movement during
gait [1,2] . COP trajectory during gait represents the
cumulative neuromuscular responses that control
the center of mass (COM) movement to help main-
tain forward progression and upright balance. COP
movement has been identified as a measure of
neuromuscular control during posture and gait [3] .
Diabetes mellitus is a group of metabolic dis-
orders sharing the common feature of hyperglyce-
mia which results from defects in insulin secretion,
insulin action, or, most commonly, both [4] . The
average percentage of Diabetic population increased
in Egypt over last decades to reach to average of
16.2% (18.2% females and 14.2% males) [5] . Dia-
betes can affect many different organs and systems
in the body and, over time, can lead to serious
complications. These Complications can be classi-
fied as microvascular or macrovascular complica-
tions. Microvascular complications include; neur-
opathy, nephropathy and Retinopathy. Macro-
vascular complications include cardiovascular
disease, stroke, and peripheral vascular disease
that may lead to bruises or injuries that do not heal,
gangrene, and, ultimately amputations. The prev-
alence of microvascular complications is generally
much higher than the prevalence of macrovascular
complications [6,7] .
Diabetic polyneuropathy (DPN) is one of the
most common diabetic complications and it affects
30% to 50% of individuals with diabetes [7] . Patho-
genesis of diabetic neuropathy is complicated and
still not identified completely. Metabolic and sec-

117
118 Center of Pressure Excursion & Stability in Diabetic Polyneuropathy
ondary vascular changes are believed to be the
main contributors to the damage of neurons and
Schwann cells. Hyperglycemia causes the non
enzymatic glycosylation of proteins, lipids, and
nucleic acids with the resulting advanced glycosy-
lation end products (AGEs) interfere with normal
protein function and activate inflammatory signal-
ing through the receptor for AGEs. Also, excess
glucose within cells is reduced to sorbitol, a process
that depletes Nicotinamide adenine dinucleotide
phosphate (NADPH) and increases intracellular
osmolarity. These and other metabolic disturbances
may predispose peripheral nerves to injury by
reactive oxygen species. On the other hand, the
vascular injuries that occur in chronic diabetes due
to hyperlipidemia and other metabolic alterations
may cause ischemic damage of the nerves [8] .
The neuropathies developing in patients with
diabetes are heterogenous by their symptoms,
pattern of neurologic involvement, course, risk
covariates, pathologic alterations and underlying
mechanisms [9] . The most common form of DPN
is the chronic sensorimotor distal symmetric poly-
neuropthy with the typical presentation of gradual
onset of sensory impairment, including burning
and numbness in the feet progress to loss of sen-
sation and progress from distal to proximal and
latterly may affect motor function [7,10] . Abnor-
mality of nerve conduction tests which is frequently
subclinical appears to be the first objective quan-
titative indication of the condition. The presence
of abnormalities of nerve conduction and a symp-
tom or a sign of neuropathy is needed to confirm
DSPN [11] .
DPN interferes with normal sensory function
and altered proprioception leads to abnormal weight
bearing aggravated with abnormal foot muscle
mechanism and structural changes caused by Motor
and sensory neuropathy in the foot [12] . DPN causes
diminished proprioceptive threshold both in foot
and ankle resulting in increased risk of tripping
and falls amongst these patients [13] . It is well
accepted that fall risk is increased amongst diabetic
patients and it was reported that an overall incidence
of falls of 1.25 falls per person-year in cohorts of
diabetic individuals which could be associated
with higher incidence of fracture, hence, under-
standing the nature and implications of gait and
balance and falling is important due its potential
long-term impact on health, such as reduced activity
levels and increased risk of musculoskeletal injury
[10,14] .
Patients with DPN often develop ulceration
due to altered walking pattern that are responsible
for the development of areas of high plantar pres-
sure [15,16] . In addition, patients with mild neurop-
athy have an increased pressure time integral at
the forefoot and a decreased peak pressure at the
heel. These findings aggravated in the later stage
of the disease [17] .
Meier et al. [18] studding gait termination,
reported that diabetic patients with neuropathy had
slower walking speed. In addition, they had in-
creased anteroposterior and mediolateral COP over
shooting which denoting poor postural mechanisms.
While Amemiya et al. [19] found that diabetic
neuropathic patient showed less mediolateral COP
excursion as compared to diabetic patients, more-
over, he found a negative correlation between COP
mediolateral excursion and elevated planter pres-
sure.
The current study focused on measuring spa-
tiotemporal parameters of the COP trajectory in
diabetic patients with and without DPN, and to
correlate them with balance represented by Berg
balance scale.
Patients and Methods
I- Population:
Thirty type II diabetic patients aged from 50
to 60 years with BMI from 30 to 35Kg/m 2 partic-
ipated in this study, fifteen patients with diabetic
neuropathy group (DN). The rest of the patients
without polyneuropathy. Each group consists of 4
males and 11 females. Patients were selected from
diabetes and endocrinology clinic at Kasr Al-Aini
hospital and outpatient clinic of National Diabetes
and Endocrinology Institute.
Inclusion criteria were as following:
Patients diagnosed with type II diabetes, ac-
companied by grad 0 (normal) of Dyck classifica-
tion for DPN (11) for group (D) and grad 2a for
group (DN) and both sexes were included.
Exclusion criteria were as following:
Patients with any foot deformities or other
musculoskeletal or neurological problems that may
affect gait and balance as advanced osteoarthritis,
leg length discrepancy, calcaneal spur, lumber
radiculopathy, nerve injury, stroke, patient with
previous or current foot ulceration. In addition,
patients with severe debilitating chronic illness
that interferes with gait and balance and patients
with symptoms of vertigo and Marked visual im-
pairment were excluded.
Gehan Mosa, et al.
II- Instruments:
Medilogic foot pressure measuring insoles sys-
tem (T&T medilogic Medizintechnik GmbH Mit-
telstr.9, D-12529 Schoenefeld).
It consist of different sizes pairs of insoles with
surface resistive pressure sensors that is connected
to patient modem on their waist and transmit re-
corded data to computer modem and through it to
computer that display a real time isobaric or 3D
color graphics. It gives information regarding
planter pressure distribution in average and maxi-
mum form, temporal gait parameter, and trajectory
of COP on each foot [20] .
Berg balance scale:
It is a 14 task scale developed and validated
for measuring balance among older people. Each
task has five point score from 0 to 4 with a maxi-
mum total score of 56 represent perfect balance
ability [21] .
III- Procedures:
Patients interviewed and supplied with infor-
mation about the study aim, procedures and poten-
tial benefits and filled the informed consent form.
Once patient signed the consent form, history
taking and BMI calculation e and a full clinical
assessment was done. The study was done at Rehab
and Bionics Lab at Systems and Biomedical Engi-
neering Department College of Engineering Cairo
University in the period between November 2015
and March 2016.
Nerve conduction study (NCS):
NCS were done for each patient for inclusion
and grouping of the patients. The patients with
NCS abnormality in lower limb together with
clinical symptoms and signs of diabetic neuropathy
were assigned in diabetic neuropathic group (DN)
and the patients without abnormality in NCS or
symptoms or signs of diabetic neuropathy were
assigned in diabetic control group (D).
Balance assessment:
All patients assessed for balance using BBS
through 14 task with final score of 56.
Assessment of foot pressure:
A foot print was drawn for each foot to measure
the foot length and width for data normalization.
Appropriate size insoles were selected and fixated
to the patients feet using socks instead of shoes to
avoid any effects of shoes model, size and, any
wear and tear of the shoe [17,22] . Insoles later
attached to the patient modem to start recording,
119
each patient was asked to walk in a walkway of
eight meters straight forward with their self-selected
speed. Three trials were collected. The trials were
recorded separately. Data were extracted as (CVS
format) file sheets for further analysis. Two of
these sheets describe the X and Y coordinate of
COP in respect to time for right and left legs.
IV- Data collection and analysis:
Average steps of each trial were analyzed using
matlab software to get measuring variables which
were:
• The anteroposterior COP displacement.
• The mediolateral COP displacement.
• The anteroposterior COP velocity.
• The mediolateral COP velocity.
Later, average of the three trials was calculated
for both right and left foot. These variables were
normalized through dividing the COP anteroposte-
rior displacement and COP anteroposterior velocity
by the foot length and the COP mediolateral dis-
placement and COP mediolateral velocity by foot
width to avoid the effect of anthropometric differ-
ences between patients.
V- Statistical procedure:
Statistical analysis was conducted using SPSS
for windows, version 18 (SPSS, Inc., Chicago, IL).
MANOVA was used to test data of COP parameters
of both groups. Moreover, non-parametric statistical
tests in the form of Mann-Whitney U-test was used
to compare between both groups for ordinal variable
(berg balance scale score). The Spearman product
moment correlation coefficient was used to deter-
mine the correlations among the berg balance scale
and COP mediolateral displacement, COP antero-
posterior displacement, velocity of COP mediolat-
eral displacement, and velocity of COP anteropos-
terior displacement. With the initial alpha level set
at 0.05.
Results
Both groups had 4 males and 11 females and
there were no statistically significant difference in
their age (Table 1).
Table (1): Physical characteristics of patients in both groups
(DN&D).
Group DN Group D Comparison
Items S
Mean ± SD Mean ± SD t-value p-value
Age (yrs) 55.06±3.05 55.4±2.91 –0.43 0.667 NS
*SD: Standard deviation. S : Significance.
P : Probability. NS: Non-significant.
120 Center of Pressure Excursion & Stability in Diabetic Polyneuropathy

Characteristics of COP parameters of the pa-
tient in both groups:
As presented in Table (2) Multiple pairwise
comparison tests (Post hoc tests) revealed that the
mean values between both groups showed no sig-
nificant differences in COP mediolateral displace-
ment (p=0.831) and velocity of COP mediolateral
displacement (p=0.546) between both groups. But
there were significant decrease in COP anteropos-
terior displacement (p=0.001 *) and velocity of
COP anteroposterior displacement ( p=0.019*) in
DN group compared with D group.
Berg balance scale between both groups:
Table (3) show median score, U, Z and p-values
of berg balance scale score in both groups. "Mann-
Whitney tests" revealed that there was significant
difference between both groups (U=114, Z=–5.197,
and p=0.0001 *) and this significant increase in
favor of group (D) than group (DN).
Correlations among the berg balance scale
score and COP parameters:
As presented at Table (4) Spearman product
moment correlation coefficient and revealed that
there was no significant correlation between berg
balance scale and COP mediolateral displacement
(p =0.155, p=0.237) or COP anteroposterior dis-
placement (p =0.209, p=0.110). While, there were
positive weak significant correlation between berg
balance scale and velocity of COP mediolateral
(p=0.377, p=0.003 *) and positive moderate signif-
icant correlation between berg balance scale and
Velocity of COP anteroposterior displacement
(p =0.51, p=0.0001).

Table (2): Mean ±SD and p-values of COP parametersat both groups.

Group DN Group D
Parameter MD % of change p-value
Mean ± SD Mean ± SD

COP mediolateral displacement (% of foot width) 0.219±0.06 0.216±0.05 0.003 1.36 0.831
Velocity of COP mediolateral displacement 0.32±0.11 0.34±0.08 –0.016 5 0.546
COP anteroposterior displacement 0.57±0.05 0.60±0.03 –0.03 8 6.66 0.001 *
Velocity of COP anteroposterior displacement 0.84±0.14 0.92±0.13 –0.08 9.52 0.019*
*Significant level is set at alpha level <0.05. SD : Standard deviation
MD: Mean difference. p-value: Probability value.

Table (3): Median score, U, Z, and p-values of the berg balance scale for both groups.

Median score
U-value Z-value p-value
Group DN Group D

Berg balance scale 52 56 114 –5.197 0.0001 *

*Significant level is set at alpha level <0.05.

Table (4): Bivariate correlations berg balance scale and COP parameters.

Velocity of COP Velocity of COP

COP mediolateral COP anteroposterior
mediolateral anteroposterior
displacement displacement
displacement displacement

Berg balance scale p =0.155 p =0.209 p =0.377 p =0.51

p=0.237 p=0.110 p=0.003 * p=0.0001 *

*Significant at alpha level 0.05.

Discussion This is consistent with Turcot et al. [23] who eval-

This study aims were to investigate the effect
of DPN on COP trajectory and stability in diabetic
patient. Regarding stability we found significantly
decreased stability in DPN patients compared to
diabetic group revealed with lower BBS score.
uated DPN instability using accelerometers and
reported that these patients have greater postural
instability with higher acceleration values than
normal subjects and diabetic patients without pe-
ripheral neuropathy. This instability may be attrib-
uted to impaired sensory feedback from distal
Gehan Mosa, et al.
structure as Lin et al. [24] reported that plantar
touch-pressure threshold was a significant predictor
for reach distance and COM displacement during
functional reaching test. Also decreased sensory
feedback put additional load on sensory cortical
centers involved in processing of this information;
hence, patients try to move more conservatively
[25] . This highlight the instability and increased
incidence of falling as a disabling problem so we
must start early detection and preventive measures
before reaching to the advanced stat of the disease.
There was significant decrease in anteroposte-
rior COP displacement in DN group (0.57+0.05)
compared to D group (0.60+0.03) with p=0.001 *
which denoting impairment of foot-floor interaction
and impaired foot and ankle mechanisms so putting
additional load on proximal strategies to maintain
balance and propulsion. This is consistent with
previous findings of Giacomozzi et al. [26] , who
hypothesized that Diabetic patients with neuropathy
approach the floor with the most anterior part of
the heel and perform their push off phase at the
metatarsals level, as proven by the reduction of
the COP progression along the longitudinal axis.
In other wards these patients develops impaired
rockers of the gait specially first and forth rockers
which normally acts for deceleration and acceler-
ation function respectively. This may cause the
variability in step time observed in those patients
[13] .
It was also reported that the push off time also
was drastically reduced with reduced moments
during sagittal plane at each joint and that diabetic
neuropathic patients adopted a hip pulling instead
of an ankle pushing walking strategy [27] . This
also speaks to the decreased rocking on foot and
lack of supporting function of the toes especially
the big toe [19] .
Another cause that may decrease ankle mobility
and so, lack of propulsion may be the co–contrac-
tion. This co-contraction enables these individuals
to adopt a safer, more stable gait pattern to com-
pensate for diminished sensory information [28] .
We found also significant decrease in antero-
posterior COP velocity in DN group (0.84+0.14)
compared to G group (0.92+0.13) with p=0.019*.
this may be caused by slower walking speed adopt-
ed with DPN patient to compensate for decreased
stability (25) in addition to impaired or lost first
and forth gait rocker as we mention before. This
may increases the pressure time integral on the
forefoot (amount of pressure and time of applica-
tion) and precipitating these patients to forefoot
121
ulcers [19] . Another factor that may participat in
slower COP velocity and also decreased stability
is that DPN patients have an increased reaction
time. And this instability and slowness increases
in turning [29] .
We also found that balance has a weak and
moderate positive correlation with mediolateral
and anteroposterior COP velocity respectively.
This is consistent with [28] who found that gait
speed is decreased in diabetic patients with neur-
opathy compared to normal subjects and this was
attributed to lack of sensory input that impair
stability and subsequent co-contraction around
ankle and knee.
This also may be discussed in closed loop in
which the instability causes increased incidence
of falling and falling incidence increases fear of
falling and so, the patient start to adopt more stable
walking patter with decreased speed, shorter steps
and increased width of steps and these factors over
time cause reconditioning that precipitates more
instability.
Conclusion:
DPN has a direct effect on foot rocking move-
ment and stability during walking, based on that,
DPN patients may have higher demand on proximal
strategies for acceleration and maintaining balance
and have increased incidence of fall. Instability
and gait alteration are of prym priority in dealing
with diabetic patients especially if with those with
DPN.
Acknowledgement:
Data acquisition was carried out in the Reha-
bilitation Engineering and Bionics Lab, Faculty of
Engineering, Cairo University, funded by the Sci-
ence and Technology Development Fund (STDF),
Egypt.
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