**6. Interventions to improve balance in patients with peripheral neuropathy**

patients with diabetic peripheral neuropathy underwent a 3-week intervention to increase rapidly available distal strength and balance, showing improvement on unipedal stance time, functional reach, tandem stance time, but the score on the activities-specific balance and confidence scale [132]. To further increase physical activity and protocol adherence, a super‐ vised centre-based exercise program rather than a self-administered program may be recom‐ mended [130]. However, there is a need of studies examining the effect of physical training on the incidence of foot breakdown and fall risk in people with diabetes mellitus and peripheral

Postural Balance and Peripheral Neuropathy http://dx.doi.org/10.5772/55344 135

Postural control can be defined as the control of the body's position in space for the purposes of balance and orientation. Balance is the ability to maintain or return the body's centre of gravity within the limits of stability that are determined by the base of support. Spatial orientation defines our natural ability to maintain our body orientation in relation to the

The representation of the body's static and dynamic geometry may be largely based on muscle proprioceptive inputs that continuously inform the central nervous system about the position of each part of the body in relation to the others. Posture is built up by the sum of several basic mechanisms. First the tone of the muscles gives them a rigidity that helps to maintain the joints in a defined position; the postural tone is added to this basic tonus. Postural fixation maintains the position of one or several joints against an internal force. During movement of one segment of the body, other segments are disturbed, producing instability. Thus the precise movement of distal segments can be realized only

Postural balance is dependent upon integration of signals from the somatosensory, visual and vestibular systems, to generate motor responses, with cognitive demands that vary according to the task, the age of the individuals and their ability to balance. Descending postural commands are multivariate in nature, and the motion at each joint is affected uniquely by input

The proprioceptive system provides information on joint angles, changes in joint angles, joint position and muscle length and tension; while the tactile system is associated mainly with

Visual influence on postural control results from a complex synergy that receives multimodal inputs. Vestibular inputs tonically activate the anti-gravity leg muscles and, during dynamic tasks, vestibular information contributes to head stabilization to enable successful gaze control,

In order to assess instability or walking difficulty, it is essential to identify the affected movements and circumstances in which they occur (i.e. uneven surfaces, environmental light, activity) as well as any other associated clinical manifestation that could be related

providing a stable reference frame from which to generate postural responses.

surrounding environment, in static and dynamic conditions.

by stabilizing more proximal segments.

sensations of touch, pressure and vibration.

from multiple sensors.

neuropathy.

**7. Conclusions**

Richardson et al. (2004) [120], in patients with various forms of peripheral neuropathy, found that the use of a cane, ankle orthoses or touching a wall improved spatial and temporal measures of gait regularity while walking under challenging conditions. Evi‐ dence support that, additional hand contact of external objects may reduce postural instability caused by a deficiency of one or more senses. Contact with support of varying stability may reduce the destabilizing effect of a moving visual scene [121]. In patients with moderate to severe diabetic neuropathy, mechanical noise stimulation may improve vibration and tactile perception [122].

To improve stability in patients with decreased somatosensation, footwear may represent a modifiable factor. The efficacy of certain types of stabilizing reactions may be improved whether incorporating a pressure plantar-based biofeedback system in footwear [123], vibrating shoe insoles [38], or by mechanical facilitation of sensation from the boundaries of the plantar surface of the foot [124]. In patients with Charcot-Marie-Tooth, considering individual sensory and muscular deficits, ankle-foot orthosis prescription, appears relevant for improving balance and gait performance [125].

Exercise that improves lower-extremity balance and strength (force-generating capacity) has been shown to be effective in reducing falls in older adults [126]. In patients with clinically defined sensory ataxia due to bilateral chronic neuropathy compared to pa‐ tients with unilateral loss-related to multiple sclerosis, after a rehabilitation program including foot sensory stimulation, balance and gait training with limited vision, balance assessed on a static force platform remained similar in the open-eyes condition and improved in the closed-eyes condition only in patients with unilateral sensory loss, while dynamic balance improved in the two groups, suggesting that the relative contribution of proprioceptive and visual inputs may depend on the extent of somatosensory loss [127].

Guidelines for diabetes management recommend that patients perform at least 30 min of physical activity a day six times a week. Few studies on prevention of diabetic neuropathy through exercise have been reported, even if moderate intensity exercise in patients with type 2 diabetes mellitus has been associated with a decrease in blood glucose [128]. A preliminary controlled study has shown that a 12 week program of *tai chi chuan* exercises may improve peripheral nerve conduction velocities and fasting glucose levels [129].

Studies evaluating treatment strategies that could improve balance in diabetic patients with polyneuropathy are also scarce. Although, some interventions including leg strengthening and balance exercises to promote ambulatory physical activity may not decrease fall rates, but neither they increase them; suggesting that physical activity interventions that increase activity probably do not increase the risk of falling in patients with diabetic peripheral neu‐ ropathy [130]. In this group of patients, specific training may improve gait speed, balance, muscle strength and joint mobility [131].

To determine the effect of a specific exercise regimen on clinical measures of postural stability and confidence in a population with peripheral neuropathy, compared to a control group, ten patients with diabetic peripheral neuropathy underwent a 3-week intervention to increase rapidly available distal strength and balance, showing improvement on unipedal stance time, functional reach, tandem stance time, but the score on the activities-specific balance and confidence scale [132]. To further increase physical activity and protocol adherence, a super‐ vised centre-based exercise program rather than a self-administered program may be recom‐ mended [130]. However, there is a need of studies examining the effect of physical training on the incidence of foot breakdown and fall risk in people with diabetes mellitus and peripheral neuropathy.
