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org/
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Short Communication:
Efficacy of Stability Trainer in Improving Balance in Type II
Diabetic Patients with Distal Sensory Neuropathy
*M.S Ajimsha
1,2
, J .K Paul
2
, S. Chithra
1,2

Abstract:
The loss of sensations associated with Diabetic Peripheral Neuropathy is thought to contribute to
impaired balance and increased risk of falling. If the measures of balance are improved, incidence of
sustaining falls and injuries can be reduced. Stability Trainers are oval shaped colour coded pads,
available in three densities for balance training. To find out the efficacy of Stability Trainer in improving
functional balance in Type II Diabetic patients, with Distal Sensory Neuropathy, a Randomized
controlled single blinded trial was conducted at the Physiotherapy Department of Kottayam Medical
College, Kerala, India. Thirty three patients with the diagnosis of Type 2 Diabetes with Distal Sensory
Neuropathy participated in the trial. The Control Group received relaxation exercises, range of motion
exercises, strengthening exercises and balance training. For Experimental Group, in addition to
conventional treatment, balance training on Stability Trainer was given and consisted of 16 sessions per
patient over 8 weeks. Main outcome measure: The outcome was measured using Berg Balance Scale
(BBS). The pre and post values were taken on the 1st and 8th week of treatment. Results: Both groups
showed significant improvement in functional balance performance. The Experimental Group showed
statistically significant improvement in functional balance when compared to Control Group. The
patients in the Experimental Group showed 28.2% improvement in their BBS scores; whereas Control
Group showed 17.4% improvement in their BBS scores, post week 8. Balance training on Stability Trainer
seems to be beneficial in improving functional balance in diabetic patients with distal sensory
neuropathy
Key words: Distal sensory neuropathy, Stability Trainer, functional balance
Introduction:
Diabetic neuropathy is a debilitating disorder
that occurs in nearly 50% of patients with
Diabetes (1). Distal symmetric poly neuropathy is
the commonest form of Diabetic neuropathy (2).
It affects men and women with equal frequency
(3). Most peripheral neuropathies damage
nerves of the limbs, especially the foot, on both
sides and thus lead to balance impairment (4).

1
Faculty of Allied Health & Medicine, AIMST
University, Kedah, Malaysia
2
Department of Physiotherapy, Mahatma Gandhi
University, Kottayam, Kerala, India
*Corresponding Author:
M.S. Ajimsha MPT, PhD
Lecturer
School of Physiotherapy, FAHP, AIMST University,
Kedah-08100, Malaysia
E-mail: ajimshaw.ms@gmail.com


The loss of sensations associated with diabetic
peripheral neuropathy is thought to contribute to
impaired balance, altered gait patterns, and
increased risk of falling, when performing a
challenging daily task (5). If the measures of
balance are improved, incidence of sustaining
falls and injuries can be reduced.
Stability Trainers are oval shaped colour coded
pads, available in three densities, Green with
smaller surface area and firm density, Blue with
larger surface area and soft density and Black
with air filled inflatable extra soft pad. Levels of
challenge were determined by an increasing
order of instability. A fixed set of exercises were
designed to perform on Stability Trainer.
Balancing on foam reduces the use of
somatosensory inputs of the ankles for controlling
balance, thereby challenging visual and
vestibular inputs for balance control (6,7). The
present study was conducted to investigate the
effectiveness of this concept in diabetic patients
with Distal Sensory Neuropathy (DSN). If found
effective, it can be used as a simple, cost
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effective training in improving the balance of
Diabetic DSN patients.
Methodology
This study was carried out in the Physiotherapy
Department of Kottayam Medical College,
Kerala, India. Population for the study was
patients with a diagnosis of Type 2 Diabetes with
DSN, based on nerve conduction studies.
Individuals aged 55-65 years, with moderate
neuropathy according to TORANTO clinical
neuropathy score (9-11 out of 19), bilaterally
positive Semmes Weinstein monofilament test,
ability to complete three minute walk test, ability
to make unipedal stance for 20 seconds,
duration of condition 4-8 years, fasting blood
sugar within 130 200 mg / dl consistently for at
least 6 months and those on insulin injection
(mixed plain 30:70 lente) 20 units/day and no
other diabetic medications for the last 6 months.
A special vestibular evaluation was conducted
to exclude any vestibular disorder with a view
that it can affect the study outcome. Those with
a history of any known cardiorespiratory,
orthopedic or neurologic conditions, peripheral
vascular complications, plantar ulcer and foot
problems, Body Mass Index above 30, and any
hearing and visual defects were excluded.
The study protocol was approved by the Ethics
Committee of Mahatma Gandhi University,
Kerala. Between September 2008 and April 2009,
46 patients were referred to physiotherapy
department, with a diagnosis of Type 2 Diabetes
with DSN. Out of these 33 individuals who met the
Inclusion Criteria and provided written informed
consent were randomized to an Experimental
and a Control Group. Participants were not
blinded to the intervention, they were
randomized to. Two examiners blinded to the
group to which the participants belonged
evaluated and analyzed the balance by using
Berg Balance Scale (BBS).
Interventions
All 2 interventions were provided twice weekly for
8 weeks (Weeks 1-8), with two days rest in
between each session.

Control Group
The technique used was same for all the patients
in Control Group. All techniques were proven as
conventional physiotherapy (7,8). Treatments
were given for 45 minutes with 1 minute rest for
every 5 minutes of exercise.
The Protocol was as follows

I. Relaxed deep breathing exercise (3 Minutes)
II. Range of motion exercises for bilateral ankle
joints (5 Minutes).
III. Functional Balance training (15 Minutes).
a) Sit to stand. (5 times)
b) Standing weight shift. (5 times each)
c) Functional reach- sidewards and anterior
for touching targets set by the therapist. (5
times each)
d) Bipedal heel raise for 20 seconds (5 times)
e) Unipedal standing; 15 seconds (5 times
each)
f) Unipedal standing with knee bending;15
second(5 times each)
IV. Wobble board training (6 Minutes).
V. Gait training.
a) Tandem walking (5 Minutes).
b) Spot marching (5 Minutes).

Experimental Group:
Received same conventional physiotherapy as in
Control Group, for 45 Minutes, and an additional
15 Minutes balance training on Stability Trainer,
with 1 minute rest for every 5 minutes of exercise.
Stability Trainers are oval shaped colour coded
pads, available in three densities;
a) Green with smaller surface area and firm
density,
b) Blue with larger surface area and soft
density
c) Black with air filled inflatable extra soft pad.
It provides two options for use. One surface
with rounded points provides tactile inputs
for sensorimotor training and opposite
surface with an anti skid bars that resist
slipping and is having highest instability.









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Levels of challenge were increased by increasing
the order of instability
1. Green,
2. Blue,
3. Black with rounded point surface
4. Black with antiskid surface.
Each levels of challenge practiced for 4 sessions.
The third and fourth sessions of each level of
challenge were practiced with a prism glass to
alter the visual inputs.
A fixed set of exercises were designed to perform
on Stability Trainer
a) Bipedal heel rise for 20 seconds (5 times).
b) One leg balance: balance on one leg over
the Stability Trainer; keep the posture for 15
seconds. Repeat the exercise over the other
leg (5 times each).
c) Hip flexion: balance on one leg, lift the other
leg to keep the hip at 90 degree flexion,
maintain for 15 seconds and repeat the
exercise over the other leg (5 times each).
d) Hip extension: balance on one leg, extend
the other leg behind the body, maintain the
posture for 15 seconds and repeat the
exercise over the other leg. (5 times each)
e) Knee bending: balance on one leg, bend the
other leg to keep the knee up to 90 degree
flexion, maintain the posture for 15 seconds
and repeat the exercise over the other leg (5
times each).
Patients in both groups were assessed with the
BBS before the treatment (Day 1, Week 1) and
following the treatment (Day 16, Week 8). The
BBS is an objective measure of balance abilities.
This tool relates to meaningful activities of daily
living like sit to stand, variations in standing
positions, transfer, turning and other balance
activities. The scale consists of 14 functional tasks
commonly performed in everyday life. Scoring
uses a five point ordinal scale, with scores
ranging from 0-4. Various studies have shown that
BBS has high Intra-rater, Inter-rater and test retest
reliability (9-11). It has a predictive validity in
identifying the risk of recurrent fall and a future
fall in elderly people (12).
Statistics
The two groups at baseline were compared using
unpaired-t test. The primary outcome measure
was the difference in BBS scores between Week 1
(Pre test score) and Week 8 (Post test score).
Statistical analysis of the data was done with
unpaired-t test and Mann-Whitney U test. Then, in
accordance with the primary objective of the
study, we compared the BBS scores of the
Experimental and Control Groups using Mann-
Whitney U test. A Z value less than 0.01 was
accepted as statistically significant.
Results
Of the 46 individuals recruited into this study, 33
participants (17 in Experimental Group and 16 in
Control Group) participated in the study
protocol. Two participants from the Experimental
Group and one from the Control Group dropped
out of the study without providing any specific
reason for it and their data were excluded from
the results presented below. Within the study
period, no serious adverse events occurred in
any of the groups. There were no statistically
significant differences between the groups for
any of the baseline characteristics (Table 1).
From Weeks 1 to Weeks 8, the difference
between pre and post test BBS readings were
increased by 11.5 (SD 1.5) in the Experimental
Group compared with 7.1 (SD 1.5) in the Control
Group. The patients in the Experimental Group
showed 28.2% improvement in their BBS scores;
whereas Control Group showed 17.4%
improvement in their BBS scores post Week 8.
Analysis of pre and post test BBS scores of
Experimental and Control Group using unpaired-t
test, showed statistically significant improvement
in functional balance of both groups post Week
8.
Data analysis of pre-tests (Week 1) BBS scores by
using Mann-Whitney U test revealed no
significant difference between the groups. Post-
test (Week 8) BBS score analysis proved that the
Experimental Group which received balance
training on Stability Trainer was improved
significantly in functional balance than the
Control Group who received conventional
training.
Component analysis of post test BBS scores of
Experimental and Control Group revealed
significant differences between the post test
scores of the Experimental and Control Groups
except in components such as sitting, sit to stand,
turning and reaching. The improvement in
components like standing, stepping and transfers
might be due to the added effect of balance
training on Stability Trainer, along with
conventional physiotherapy.

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BBS Berg Balance Scale score; data are the mean (SD) except for Gender, which is expressed as
ratio; for BBS readings (Week 1 & Week 8) the data are expressed as mean (SD), 95% confidence
interval of the mean.
Characteristic Experimental Group
(n=15)
Control Group
(n=15)
P value
Males: Females 7:8 8: 7 NS
Age (Yrs) 61.4 (2.4) 61.2 (2.3) 0.81
Body Mass Index (Kg / m
2
) 26.3 (1.6) 26.2 (2.0) 0.92
Duration of Condition, from
physicians reports (Yrs)
6.2 (1.2) 6.3 (1.2) 0.87
BBS reading Week 1, Mann-
Whitney U-test
40.8 (1.6), 39.9 41.7 40.9 (1.1), 40.3 41.5 0.8
BBS Reading Week 8
Mann-Whitney U-test
52.3 (1), 51.8 52.9 48 (1.6), 47.2 - 49 <0.0001
Change in BBS as a result of
the Intervention (unpaired-t
test)
11.5 (1.5) 7.1 (1.5) <0.0001

Discussion
The principal finding of this study is that balance
training on Stability Trainer along with
conventional physiotherapy was significantly
more effective than conventional physiotherapy
alone in improving functional balance in Type 2
Diabetic patients with moderate Distal Sensory
Neuropathy. The main limitation of the trial was
the small sample size which might have affected
the generalization of the results. Other limitations
were the absence of long-term follow up of study
participants and the inability to blind the trial
practitioners.
Diabetic patients with peripheral neuropathy
have significant loss of ankle movement
perception and have larger ranges of postural
sway (13). Prevention and treatment of the
complications of diabetes mellitus have the
potential to improve quality of life and to
increase the life expectancy (14). If the measures
of balance are improved, incidence of falls and
sustaining injuries can be reduced. Current
therapeutic approaches are mainly focusing on
it and people are encouraged to do balance
and strength training (15-17).
The better improvement in the Experimental
Group compared to Control Group might be
due to the fact that, practicing balance training


in progressive challenging levels can enhance
somatosensory integration with visual and
vestibular senses in CNS (7,18-20). Stability Trainer
provides an unsteady surface that challenges
the body to maintain balance. During the
exercise intervention with Stability Trainer, sensory
inputs were manipulated by altering the support
surface and environments. These manipulations
forced participants to effectively reweigh
remaining inputs within the CNS (21). Evidence of
similarly enhanced central integration, following
sensory training has been found in studies,
demonstrating improved stability during the
manipulation of proprioceptive, vestibular or all
of these, by use of Sensory Organization Test
(SOT) (18,22). Somatosensory training using
Stability Trainer can also augment increased
proprioceptive firing from the cutaneous
receptors from the feet and also from
mechanoreceptors of the muscle during co-
contraction produced by the swaying
movement, while standing on Stability Trainer
(23). It is also accountable that the new and
augmented feedback might have enhanced
motor learning which can also have an effect on
the balance. The exact mechanisms underlying
the effectiveness merit further investigation.
Based on the current study, further follow-up
studies can be performed. A larger study should
be counter plated to make the results more valid.
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Future studies can be undertaken with the
inclusion of more precise objective measurement
of functional performance using tools like
balance master, force platforms or with different
outcome measures like Dynamic Gait Index.
Conclusion
The balance training on Stability Trainer along
with conventional physiotherapy investigated in
this trial was more effective than a Control
Intervention consisting of conventional
physiotherapy alone, in improving functional
balance in Type 2 Diabetic patients with
moderate DSN. Balance training on Stability
Trainer can be used as a simple and cost
effective treatment program in improving
functional balance in Type 2 Diabetic patients
with DSN. This may help the patient with DSN to
improve their quality of life by reducing the risk of
falls when performing activities of daily living. The
exact mechanisms underlying these responses
merit further investigation.
Acknowledgement
This study was supported by a grant of the
Mahatma Gandhi University, Kottayam, Kerala.
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