petrofsky2019

The Journal of Sports Medicine and Physical Fitness
EDIZIONI MINERVA MEDICA

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The influence of ageing and diabetic peripheral neuropathy

on posture sway, tremor, and the time to achieve balance
equilibrium
Jerrold PETROFSKY, Michael LAYMON, Haneul LEE
The Journal of Sports Medicine and Physical Fitness 2018 Oct 31

DOI: 10.23736/S0022-4707.18.08653-X
Article type: Original Article
© 2018 EDIZIONI MINERVA MEDICA
Article first published online: October 31, 2018

Manuscript accepted: October 5, 2018
Manuscript revised: September 26, 2018
Manuscript received: February 5, 2018
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The influence of ageing and diabetic peripheral neuropathy on posture sway,

tremor, and the time to achieve balance equilibrium
Jerrold Petrofsky1, Michael Laymon1, Haneul Lee, DSc2*
1
School of Physical Therapy, Touro University Nevada, Henderson, Nevada, USA
2
Department of Physical Therapy, College of Health Science, Gachon University, Incheon,
South Korea
Corresponding author:
Haneul Lee*
Department of Physical Therapy,
College of Health Science
Gachon University
191 Hambangmoe-ro, Yeonsu-gu,
Inchoen 406-799, South Korea
Email address: leehaneul84@gachon.ac.kr
Tel : +82-32-820-4335
1
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ABSTRACT
BACKGROUND: It is well recognized that ageing and diabetes are associated with reduced
balance and impaired gait. However, one important factor may be not just balance, but how long
it takes to achieve balance equilibrium after a balance challenge. This study examined the
relationship between balance, tremor, and time to achieve balance after a challenge to stability in
young and old individuals without and without diabetes.
METHODS: Twenty-four of the subjects were young controls, 22 were older controls, 23 were
individuals with diabetes, and 21 were young people with diabetes. Posture sway, tremor, and
time to achieve stability were assessed on a force plate during 8 progressively challenging
balance tasks.
RESULTS: For postural sway, tremor and time to reach postural stability, there was a
significant difference in all groups with the increased balance challenge of the 8 tests (p<0.01).
However, ageing and diabetes made balance, tremor and time to reach stability worse. In
general, the young group with diabetes, for example, had similar responses to the old group
without diabetes.
CONCLUSIONS: In the subjects with diabetes, balance was poorer than the non-diabetes groups.
The young subjects with diabetes showed similar results to the older subjects without diabetes.
Diabetes subjects had more muscle tremor and a slower response time of the body to a balance
challenge. This may account for increased falls in individuals with diabetes.
Keywords: balance; diabetes; fall; posture sway; tremor
2
Introduction
Balance is attained by the integration of the visual, vestibular, and somatosensory
systems. Ageing is associated with a natural senescence of these 3 systems resulting in
deteriorating balance with age(Puszczalowska-Lizis, Bujas et al. 2018). Damage to the visual,
vestibular, and somatosensory systems is even greater in individuals with diabetes, making
balance even more challenging(Alshammari, Petrofsky et al. 2014). The overall result of poor
balance is an increased risk of falls in older individuals, especially in those with diabetes, in
comparison to younger people. Falls are a major contributor to hospitalization and death(Gale,
Westbury et al. 2018).
Color sensitivity of the eye is reduced with ageing. Blue becomes more difficult to see and
visual acuity decreases (Moos, Faller et al. 2017). Common age-related eye diseases include
cataracts (Fragaki, Chaussenot et al. 2016), macular degeneration (Fu, Gong et al. 2016), diabetic
retinopathy (Fu, Gong et al. 2016), and optic nerve diseases (Gueven, Nadikudi et al. 2017), such
as glaucoma (Pelletier, Rojas-Roldan et al. 2016). Glaucoma is age-related progressive retinal
ganglion cell loss and visual field damage (Lopez Sanchez, Crowston et al. 2016). The most
severe disorders involve mitochondrial damage, since the eyes consume more ATP than almost
any tissue in the body (Gueven, Nadikudi et al. 2017). The overall result is that vision
degenerates with ageing, even more so in patients with diabetes since it is a metabolic disorder
(Jonas, Xu et al. 2015).
The vestibular system comprises the vestibular canals in the ear and the vestibular nuclei.
It is also located near the cerebellum for additional processing. This system is also responsible
for the perception of the body’s center of mass relative to gravity, head position, and
acceleration(Zalewski 2015). Balance relies heavily on the vestibular system when the visual
3
and vestibular systems are compromised (Peterka 2002). Ageing reduces vestibular function but
it is hard to detect in the early stages (Marchetti and Whitney 2005). A common dysfunction
seen in the elderly is dizziness. It is one of the 2 most common complaints in this patient
population (Cutson 1994). This, in turn, can lead to falls (Jacobson, McCaslin et al. 2008).
There are several causes of age related dizziness. First, an estimated 40% of vestibular neurons
are lost by the 9th decade of life (Matheson, Darlington et al. 1999). There is also loss of hair
cells (Rauch, Velazquez-Villasenor et al. 2001), saccular otoconia destruction, and vestibular
ganglion cells loss (Bergstrom 1973, Lopez, Honrubia et al. 1997, Alvarez, Diaz et al. 1998).
Likewise, diabetes accelerates the degeneration associated with ageing (D'Silva, Lin et al. 2016)
and increases benign positional paradoxical vertigo (D'Silva, Staecker et al. 2016).
Finally, the somatosensory system is impaired with ageing and diabetes (Walley,
Anderson et al. 2014). Impairment includes loss of peripheral sensation (Grewal, Bharara et al.
2013), reduction in nerve conduction velocity, and slowing of reflexes (Sohn, Song et al. 2017).
This is evidenced by impaired H reflexes with aging (Ryder, Kitano et al. 2016) and diabetes
(Petrofsky, Lee et al. 2005, Petrofsky, Lee et al. 2005, Petrofsky, Lee et al. 2005, Alsubiheen,
Petrofsky et al. 2017). Fine motor skills also decrease with aging, limiting motor control
(Hoogendam, van der Lijn et al. 2014).
While balance and gait have been evaluated with ageing and diabetes, it can be predicted
that with poor motor control and delayed reflexes, tremor will increase with diabetes and aging,
especially on difficult balance tasks. Further, the time it takes to become stable for a balance
task should also be longer with diabetes and ageing, but these have not been investigated.
Therefore, the purpose of this study was to examine posture sway, tremor, and time to stability in
young and old individuals without diabetes, and individuals with diabetes.
4
Materials and methods
Participants
One hundred and six individuals volunteered to participate in this study. All subjects
were divided into 4 groups: young controls (n=27), young individuals with diabetes (n=25), old
individuals without diabetes (n=28), and older individuals with diabetes (n=28). Older and
younger groups of subjects who did not have diabetes and were screened using blood tests within
the last year, and were not taking any medication that would alter balance or gait such as opioids,
barbiturates, antidepressants, anti- anxiety drugs, or antihistamines. Subjects with diabetes were
included if they had a history of type 2 diabetes for more than 2 years and had a hemoglobin
A1C (HbA1C) between 6 and 11. All subjects were screened by a physical therapist using
manual muscle testing. Sensory testing was also performed with Semmes-Winestein
monofilaments, which were placed at eight locations on the sole of the foot including each ray,
and bilaterally distal to the calcaneus. If sensory loss was established by monofilament testing (it
took more than 10 g of tension for subjects to detect the pressure of the monofilament), the
subject was excluded from the study. Subjects were also excluded if they had orthopedic injuries
to the lower back or lower extremities that would alter gait or balance. Finally, we excluded
subjects with body mass index (BMI) if it is either below 18.5 kg/m2 or above 35.0kg/m2.
Procedures
This study was approved by the Loma Linda Institutional review board (IRB) and the
Touro University IRB. All protocols and procedures were explained to each subject and the
subjects gave their written informed consent for the study.
5
After subjects were screened and signed a statement of informed consent, they rested
quietly for 30 minutes in a controlled temperature room (22 ˚C). Next, they were shown the
balance platform and how to accomplish each of the tasks. The subjects then waited for a visual
light cue and then stepped on the balance platform with the 8 tasks presented in random order.
The time from the time their feet were on the balance platform until they maintained steady state
weight distribution on the balance platform was measured. After they were steady, they
maintained posture for 6 seconds and then stepped off the platform. Data were collected at 2
Universities by the same investigators and using with the same equipment.
Measurements
Balance Tasks
Eight quiet standing balance tasks, each lasting for 10 seconds, were included in this
study. Sensory variables, such as the vision, base of surface, and surface compliance, were
altered individually or simultaneously in the balance tasks. Two levels of vision (eyes open and
closed) were used in the balance tasks to alter the visual input, and two different surface
compliances (firm and foam surface) were used to alter the somatosensory input. The aeromat
balance block, a PVC/NBR foam with size 16 × 19 × 2.5 inches and density around 0.04–0.06
g/cm3 (AGM Group, Fremont, CA), was placed on top of the balance platform as the foam
surface. Participants were asked to stand in two different stance positions with feet apart or in
tandem (feet in a heel-toe position with non-dominant foot in front). The eight balance tasks are
listed in Table 1.
6
Time to achieve stability
The time to achieve stability was measured by the time they placed their feet on the
balance platform to the time they maintained steady state weight distribution on the balance
platform.
Posture sway and tremor
Posture sway and tremor were assessed by a customized built force plate. It was built from
two aluminum plates. The balance platform was 1 m x 1 m x 0.1 m. The validity and reliability
of this force platform has been previously established (Petrofsky, Lohman et al. 2009). The plates
were separated by four metal bars connected to strain gauges. Four stainless steel bars, each with
four strain gauges, were mounted at the four corners under the platform (TML Strain Gauge FLA-
6, 350-17, Tokyo, Japan). The output of the 4 Wheatstone strain gauge bridges was amplified by
Biopac MP35 low-level bio-potential amplifiers, and was digitized through a 24-bit A/D converter.
The sampling rate was 1000 samples per second (Petrofsky, Lohman et al. 2009). Each bar was
positioned at 90° with reference to the other bar. As such, strain gauges were placed at 0°, 90°,
180°, and 270°. With the subject standing at the center of the platform, leaning in any direction
was then transduced through the strain gauges mounted on the metal bars to an electrical output,
so that the deviation and center of gravity could be assessed.
Previous studies used coefficient of variation (CV) of the weight displacement as a measure
of the postural sway (Usui, Maekawa et al. 1995, Clark and Riley 2007, Petrofsky, Lohman et al.
2009, Kouzaki and Shinohara 2010, Petrofsky, Focil et al. 2010). Petrofsky and colleagues
(Petrofsky and Lohman 2004, Petrofsky, Cuneo et al. 2006, Petrofsky and Khowailed 2014,
Petrofsky and Lee 2015) used the CV of the vector magnitude and angle of movement as measures
7
of the postural sway. CV of the polar vector of weight displacement was used to measure postural
sway in this experiment. It is a unit-less measure of the dispersion of the displacement of the
center of pressure.
The output of the four sensors was used to measure the X and Y coordinates of the center
of gravity of the subject to calculate the load and the center of pressure (CoP) of the force on the
platform. These data were converted to a movement vector giving a magnitude and angular
displacement. By averaging this movement vector over 10 seconds, mean and SD were obtained
for this measure. From this, the CV of the polar coordinate was calculated (SD ÷ Mean x 100%)
as a measure of the postural sway (Petrofsky, Lohman et al. 2009). The average CV for each task
was determined over a 5 second sample of the data.
Tremor was calculated using a digital filter which was flat from 6-10 Hz on the platform
sway. The tremor amplitude was calculated on the BioPac MP 35 system and software (Biopac
systems Inc., Goleta, CA). The time to balance was calculated by a marker, which was given when
they were told to stand on the platform, and then the duration of the time before they were steady
state in their balance.
Statistical Analysis
The SPSS 23.0 software (IBM, Armonk, NY) was used to analyze data, which were
summarized using means and SD. The assumption of normality of the continuous variables was
examined using the Kolmogorov-Smirnov test. One-way Analysis of variance (ANOVA) was
conducted for general characteristics and mean postural sway, tremor, and time to achieve
stability in each point of balance tasks among the 4 different groups. One-way repeated
8
ANOVA was conducted to see if there are any differences among 8 different balance tasks in
each group. The level of significance was set to α <.05.
Results
Ninety completed the study. We recruited 106 subjects, however, 8 withdrew due to
scheduling conflicts or fear of standing on the platform and 8 were excluded due to low or high
BMI. Finally, 24 young controls, 21 young with diabetes, 22 elder subjects without diabetes, and
23 elder subjects with diabetes completed the study. The general characteristics of subjects are
described in Table 2. The distribution of all quantitative variables was approximately normal and
height, weight, and BMI were not significantly different among the groups (p > 0.05). All
outcome results are presented in Table 3.
The coefficient of variance of posture sway
The result of the CV of posture sway for the 4 groups of subjects is shown in Figure 1. A
significant difference in mean CV of postural sway among 8 different balance tasks
(F(7,86)=10.05, p < .001) was found. When comparing groups to each other in each balance task,
significant differences were noted in all 8 different balance tasks between groups (p < .001)
except between the elderly and the young diabetes (p > .05)
Tremor
Figure 2 shows the tremor at a frequency of 8 ± 2 hertz recorded for the subjects in the 4
groups. A significant difference in tremor was seen among 8 different balance tasks
(F(7,86)=448.10, p < .001) was found. When comparing groups to each other in each balance task,
there was no significant difference in tremor among groups in the easiest task, FAEO-FIRM, but
significant differences were noted between the elderly diabetes subjects and young groups in all
9
balance tasks except FAEO-FIRM (p<.05). Also, there were significant differences between
young diabetes and young control in the 3 most difficult balance tasks (TEO-FOAM, FAEC-
FOAM, and TEC-FOAM, p=0.015, 0.002, 0.041, respectively).
Time to achieve stability
Figure 3 shows the time to achieve stability in the 4 groups of subjects. The greater the
measured time, the longer it took to become stable after changing to a new test on the balance
platform. A significant difference in the time to achieve postural stability was found comparing
each successive balance task (F(7,86)=2360.04, p < .001). When comparing groups to each other in
each balance task, similar to CV postural sway, significant differences were noted in all 8
different balance tasks between groups (p < .001) except between elderly and young diabetes (p
> .05) in all 8 balance tasks.
Discussion
Ageing and diabetes are associated with a senescence of the peripheral and central
nervous systems (Cutson 1994, Petrofsky, Lee et al. 2005). There is a reduction in reflex time
(Sohn, Song et al. 2017), slowing in nerve conduction speeds (Petrofsky, Lee et al. 2005), and H
reflex time decreases (D'Silva, Staecker et al. 2016, Alsubiheen, Petrofsky et al. 2017). Central
cognitive abilities are reduced, and vestibular nuclei data processing and the sensitivity of the
vestibular semicircular canals in the ear are reduced (Marchetti and Whitney 2005). Vision is
also impaired with ageing, more so in patients with diabetes (Moos, Faller et al. 2017).
Balance impairment in elderly individuals and those with diabetes has been reported
elsewhere (Cutson 1994, Arvanitakis, Wilson et al. 2007, Kotagal, Albin et al. 2013, D'Silva, Lin
10
et al. 2016). Few papers have examined tremor, and none have looked at the latency to achieve
stable balance in elderly individuals and those with diabetes. Diabetes in particular, has been
shown to cause Parkinson’s-like balance instability and tremor among the elderly (Arvanitakis,
Wilson et al. 2007). Here, tremor was increased with more difficult balance tasks. This is
probably due to the fact that in the most difficult balance tasks, somatosensory and visual inputs
were removed (Tse, Petrofsky et al. 2013). This would force the subjects to rely on their
vestibular systems, which, due to sensory and motor damage, would cause a greater error in
muscle activity, and therefore, increase tremor. The best evidence for this hypothesis is the
slowed H reflex latency and reduced H reflex with ageing and diabetes. This would reduce
damping in the spindle mono synaptic reflex causing more motor error. With more sensory
damage in the subjects with diabetes, it is not surprising that their tremor was even worse. We
agree with Louis et al (Louis, Wendt et al. 2000) that tremor is worse in the elderly. However, in
our study, we measured tremor with progressively reduced sensory inputs, and found that the
more sensation that was removed, the tremor was worsened.
If eyesight is impaired, the vestibular system is slowed, and peripheral reflexes are
diminished and slowed with ageing. It is then not surprising that the time to achieve balance
equilibrium is increased in older individuals. By removing visual and somatosensory inputs to
balance, the impaired data processing in the vestibular nuclei and cerebellum should account for
the even longer time delays to achieve balance equilibrium in the elderly. Since all of the
elements of balance equilibrium are even more impaired with diabetes, the longer time to
achieve balance also makes sense (Petrofsky, Lee et al. 2005).
Clinically, the incidence of falls increases in the elderly (Ko, Jerome et al. 2018). It is
even higher in patients with diabetes (Kotsani, Chatziadamidou et al. 2017). This has been
11
attributed to reduced vision and vestibular function, and an impaired somatosensory system
(Jacobson, McCaslin et al. 2008). However, the result of this impairment may be a slowing in
the time to achieve balance, which in turn, would create an impetus for falls. People rarely fall
when they are just standing (Petrofsky, Lee et al. 2005, Petrofsky, Cuneo et al. 2006). It is
during turns when the body’s center of gravity falls outside of the base of support, that the
balance system is challenged. If an older individual could not correct balance quickly, they
would be at risk for a fall. In our study, the more impaired the vestibular input (e.g. in low light
conditions or at night 0, the longer the time to achieve balance equilibrium and the more likely
the fall. Older individuals and those with diabetes widen their base of support to make it harder
to fall (Grewal, Bharara et al. 2013, Petrofsky and Lee 2015). However, our study shows that
when sensory or visual input is reduced, that simply is not enough.
In this study, subjects with diabetes were in good control of their glucose. Despite this,
the results still showed that balance was affected in these young and old patients with diabetes
and their response times were generally less than their age-matched counterparts were. Also,
there are several limitations. First of all, we could not control the subjects’ physical activity
level, lacking of exercise or physical activities might have poor balance ability and high risk of
suffering diabetes so that further study should control the exercise habit and control their
physical activity. In addition, it would be interesting to examine individuals with hemoglobin
A1c levels greater than 11 and diabetes for more than 10 years to determine whether their
balance is more impaired. In addition, young diabetes had a significant shorter duration of having
diabetes compared to elderly diabetes in this study, it might affect the matter of balance so if the
future study would match the duration it would be more accurate and powerful to compare
counterparts.
12
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15
NOTES
Conflict of Interest
The authors certify that there is no conflict of interest with any financial organization
regarding the material discussed in the manuscript
Author’s contributions
Jerrold Petrofsky and Michale Laymon make substantial contributions to conception and
design, and acquisition of data, and analysis and interpretation of data; Haneul Lee participate in
drafting the article or revising it critically for important intellectual content; and all authors give
final approval of the version to be submitted.
16
Legends of figures
Figure 1. Mean ± SD of the coefficient of variation (CV) of the postural sway with the balance
tasks.
Figure 2. Mean ± SD of the tremor at 8Hz during the balance tasks.
Figure 3. Mean ± SD of the time to reach stability on the balance platform.
17
Table 1. Eight balance tasks in the increasing order of tasks difficulty
Number of
Station Position Sensory Factor(s)
altered factor
Feet apart 0 Control task
Eyes open
FAEO-FIRM
Firm surface
Tandem standing 1 Base of support

Eyes open
TEO-FIRM
Firm surface
Feet apart 1 Surface compliance

Eyes open
FAEO-FOAM
Foam surface
Feet apart 1 Vision

Eyes closed
FAEC-FIRM
Firm surface

Eyes open Surface compliance
TEO-FOAM
Foam surface

TEC-FIRM Eyes closed Vision
Firm surface
Feet apart 2 Vision

Eyes closed Surface compliance
FAEC-FOAM
Foam surface

TEC-FOAM Eyes closed Vision
Foam surface Surface compliance
Note : Table is adapted from “Tse, Y.Y., et al., Postural sway and rhythmic electroencephalography
analysis of cortical activation during eight balance training tasks. Med Sci Monit, 2013. 19: p.
175-86.”
18
Table 2. General characteristic of subjects
Young Young diabetes Elderly Elderly Diabetes

(n=24) (n=21) (n=22) y(n=23)
Age (y) 24.19 ± 4.48 25.26 ± 2.72 58.14 ± 7.26 58.78 ± 7.15
Height (cm) 173.48 ± 13.26 173.75 ± 10.12 168.30 ± 10.41 169.41 ± 8.76
Weight (kg) 72.55 ± 9.95 76.26 ± 10.46 71.20 ± 11.02 74.21 ± 11.76
BMI (Kg/m2) 24.37 ± 4.39 25.22 ± 2.18 25.19 ± 3.12 25.86 ± 3.53
HbA1c - 7.74 ± 1.0. - 8.02 ± 1.11
Duration of - 3.24 ± 1.29 - 6.35 ± 2.74*
diabetes (y)
Abbreviations: BMI, body mass index.
*significant difference from young diabetes
19
Table 3. Mean (SD) of outcome variables in 8 balance tasks
Elderly Elderly Young Young p value d

diabetes Healthy diabetes Healthy
(n=23) (n=22) (n=21) (n=24)
CV postural sway a 12.05 ± 5.49 8.42 ± 2.07 8.49 ± 1.90 3.56 ± 0.86 < .001
FAEO- Tremor b 5.64 ± 1.98 6.02 ± 3.93 5.08 ± 2.34 4.03 ± 1.75 0.060
FIRM Time a 2.33 ± 0.26 1.90 ± 0.14 1.83 ± 0.14 1.11 ± 0.15 < .001
TEO- Tremor a 9.40 ± 3.31 7.55 ± 4.92 7.70 ± 3.43 5.40 ± 1.40 0.002
FIRM Time a 2.71 ± 0.19 2.10 ± 0.15 2.12 ± 0.17 1.10 ± 0.22 < .001
FAEO- Tremor a 14.12 ± 4.95 12.08 ± 7.86 13.73 ± 6.31 7.79 ± 2.11 0.001
FOAM Time a 3.07 ± 0.18 2.30 ± 0.17 2.37 ± 0.31 1.20 ± 0.22 < .001
FAEC- Tremor a 19.73 ± 6.95 18.11 ± 11.78 15.42 ± 6.75 9.69 ± 2.09 < .001
FIRM Time a 3.39 ± 0.20 2.45 ± 0.19 2.57 ± 0.37 1.28 ± 0.25 < .001
TEO- Tremor a 22.56 ± 7.94 18.71 ± 12.19 20.96 ± 8.52 14.56 ± 3.13 0.011
FOAM Time a 3.79 ± 0.24 2.69 ± 0.19 2.82 ± 0.23 1.77 ± 0.27 < .001
TEC-
Tremor C 29.13 ± 10.25 27.76 ± 18.06 30.17 ± 12.28 18.89 ± 4.08 0.007
FIRM
Time a 4.10 ± 0.27 2.89 ± 0.20 3.21 ± 0.26 2.10 ± 0.33 < .001
FAEC- Tremor C 47.00 ± 16.53 38.04 ± 24.75 44.00 ± 17.90 24.56 ± 5.30 < .001
FOAM Time a 4.57 ± 0.25 3.11 ± 0.18 3.37 ± 0.25 2.28 ± 0.42 < .001
TEC- CV postural sway a 40.06 ± 13.34 58.48 ± 17.35 38.60 ± 7.62 22.76 ± 5.67 < .001
C 65.80 ± 23.15 57.36 ± 37.32 62.87 ± 25.58 41.77 ± 9.02 .009
FOAM Tremor
a 7.31 ± 0.40 4.90 ± 0.36 5.30 ± 0.38 2.99 ± 0.39 < .001
Time
Abbreviations: SD, standard deviation; CV, coefficient of variance; FAEO, feet apart eyes open; TEO,
tandem standing eyes open; FAEC, feet apart eyes closed; TEC, tandem standing eyes closed
a
Significant difference between elderly diabetes and elderly healthy, and between elderly diabetes and
young diabetes, and elderly diabetes and young healthy, and between elderly healthy and young healthy;
No significant difference between elderly healthy and young diabetes
b
No significant difference between each groups
C
Significant differences between young diabetes and young control
d
One-way analysis of variance (ANOVA) among 4 different groups in each balance task
20

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The Journal of Sports Medicine and Physical Fitness

EDIZIONI MINERVA MEDICA

The influence of ageing and diabetic peripheral neuropathy

The Journal of Sports Medicine and Physical Fitness 2018 Oct 31

Article type: Original Article

© 2018 EDIZIONI MINERVA MEDICA

Article first published online: October 31, 2018

Subscription: Information about subscribing to Minerva Medica journals is online at:

EDIZIONI MINERVA MEDICA

The influence of ageing and diabetic peripheral neuropathy on posture sway,

Jerrold Petrofsky1, Michael Laymon1, Haneul Lee, DSc2*

Keywords: balance; diabetes; fall; posture sway; tremor

Balance is attained by the integration of the visual, vestibular, and somatosensory

systems. Ageing is associated with a natural senescence of these 3 systems resulting in

Westbury et al. 2018).

as glaucoma (Pelletier, Rojas-Roldan et al. 2016). Glaucoma is age-related progressive retinal

(Jonas, Xu et al. 2015).

(Hoogendam, van der Lijn et al. 2014).

Materials and methods

subjects gave their written informed consent for the study.

Time to achieve stability

Posture sway and tremor

so that the deviation and center of gravity could be assessed.

was determined over a 5 second sample of the data.

state in their balance.

each group. The level of significance was set to α <.05.

outcome results are presented in Table 3.

The coefficient of variance of posture sway

significant difference in mean CV of postural sway among 8 different balance tasks

FOAM, and TEC-FOAM, p=0.015, 0.002, 0.041, respectively).

Time to achieve stability

> .05) in all 8 balance tasks.

more sensation that was removed, the tremor was worsened.

equilibrium is increased in older individuals. By removing visual and somatosensory inputs to

achieve balance also makes sense (Petrofsky, Lee et al. 2005).

when sensory or visual input is reduced, that simply is not enough.

physical activity. In addition, it would be interesting to examine individuals with hemoglobin

Alshammari, F. S., J. S. Petrofsky, N. Daher, E. S. Alzoghbieh, S. O. Dehom and M. S. Laymon (2014).

regarding the material discussed in the manuscript

final approval of the version to be submitted.

Figure 2. Mean ± SD of the tremor at 8Hz during the balance tasks.

Figure 3. Mean ± SD of the time to reach stability on the balance platform.

Table 1. Eight balance tasks in the increasing order of tasks difficulty

Tandem standing 1 Base of support

Feet apart 1 Surface compliance

Feet apart 1 Vision

Tandem standing 2 Base of support

Tandem standing 2 Base of support

Feet apart 2 Vision

Tandem standing 3 Base of support

Table 2. General characteristic of subjects

Young Young diabetes Elderly Elderly Diabetes

Table 3. Mean (SD) of outcome variables in 8 balance tasks

Elderly Elderly Young Young p value d

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