Effects of offloading devices on static and dynamic balance in patients with diabetic peripheral neuropathy: A systematic review

Abstract

Patients with diabetic peripheral neuropathy (DPN) usually have reduced somatosensory information and altered perception in feet and ankles. Somatosensory information acts as feedback for movement control and loss of somatosensation leads to altered plantar pressure patterns during gait and stance. Offloading devices are used to reduce peak plantar pressure and prevent diabetic foot ulcers. However, offloading devices can unfortunately have negative effects on static and dynamic balance. It is important to investigate these unwanted effects, since patient with DPN already are at high risk of falling and offloading devices could potentially increase this risk. The aim of this systematic review is to investigate the effects of plantar offloading devices used for ulcer prevention on their role in static and dynamic balance control in patients with DPN. PubMed and Embase were systematically searched using relevant search terms. After title selection, abstract selection, and full-text selection only five articles could be included for further analysis. Two articles included static balance measurements, two articles included dynamic balance measurements, and one article included both. Results suggested that static balance control is reduced when rocker bottom shoes and different insole configurations are used, however, toe-only rockers showed less evidence for reduced static balance control. There was no evidence for reduced dynamic balance control in combination with offloading devices. However, these results should be interpreted with care, since the number of studies was very small and the quality of the studies was moderate. Future research should evaluate balance in combination with different offloading devices, so that clinicians subscribing them are more aware of their potential unwanted consequences.

Keywords: Balance; Neuropathy; Offloading.

Fig. 1

Quality assessment tool modified from van der Wilk et al. [19]. RT = randomized trial, COT = cross over trial, y = yes (low risk of bias), n = no (high risk of bias),? = unclear (uncertain risk of bias), NA = not applicable

Fig. 2

Flow-chart of the literature selection process, modified from the PRISMA statement [23]. The literature search was performed in PubMed and Embase

Fig. 3

Schematic overview of the rocker bottom shoes used by Albright et al. [26] and Ghomian et al. [24, 25]. Numbers 1–3 correspond to the conditions used by Albright et al. [26], numbers 4 and 5 correspond to the conditions used by Ghomian et al. [24], and numbers 6–8 correspond to the conditions used by Ghomian et al. [25]. (1) = Control shoe; (2) rocker bottom shoe with rocker apex positioned at 60–65% of the shoe length; (3) negative heel shoe with rocker apex at 60–65% of the shoe length and from rocker apex to heel the sole was reduced to zero thickness; (4) rocker bottom shoe with rocker apex position at 62.5% of the shoe length and a rocker angle of 23°; (5) baseline shoe; (6) Rocker bottom shoe with rocker angle of 10°, apex position at 60% of the shoe length, and apex angle of 80°; (7) rocker bottom shoe with rocker angle of 15°, apex position at 55% of the shoe length, and apex angle of 80°; (8) rocker bottom shoe with rocker angle of 20°, apex position at 60% of the shoe length, and apex angle of 95°