Treating Impaired Gait Due to Diabetes
By David Yeager
Diabetes can cause a host of problems for older adults affected by the disease, but one related complication that receives less attention than increased insulin resistance, hypertension, or renal disease is muscle loss. A study published online May 17 in Diabetes Care found that diabetes was related to decreased muscle strength and worse muscle quality in older adults, which contributed to walking limitations in participants.
The study, conducted at the University of Ferrara in Italy, measured knee extension torque, plantar flexion and dorsiflexion strength, lower extremity muscle power, ankle muscle quality, and gait performance in 835 participants aged 65 and older. The prevalence of diabetes in the study group was 11.4% and after adjusting for age and sex, participants with diabetes were found to have lower muscle density, less knee and ankle strength, less muscle power, worse muscle quality, and slower walking speeds than nondiabetic participants.
When treating older patients who have diabetes, it’s important to consider the effects of muscle loss. John E. Morley, MD, a professor of internal medicine at the St Louis University School of Medicine, says diabetes accelerates the aging process by approximately 10 years, affecting muscles, tendons, and the peripheral nervous system. These changes contribute to a higher rate of falls in patients with diabetes.
Because of insulin resistance, fat deposits accumulate to a greater degree in the muscle tissues of patients with diabetes, reducing the muscles’ ability to contract. Collagen structures, particularly in tendons, are also altered, reducing flexibility in joints. Higher rates of peripheral neuropathy cause patients to not only have pain when they walk but also have difficulty recognizing where their feet are in space, causing balance problems. Additionally, neuropathies can cause a decrease in blood pressure when a patient stands up, which can cause dizziness.
“The data in diabetics is that they have many more falls, injurious falls, than does the general population; they have about a doubling of falls,” Morley says. “Particularly, injurious falls are very much more common in diabetics as they get older.”
When assessing patients, it’s important to consider how they walk. A person with a normal gait is able to stride so that, viewed from the side, there is space between the legs or between the leading foot and the trailing foot. Typically, people will land on the heel and roll forward onto the forefoot. The deterioration caused by diabetes alters a person’s gait. Morley says gait alterations can indicate different problems.
For example, a person who has lost muscle mass and strength will tend to take shorter, nonshuffling steps; shuffling may indicate a different problem, such as Parkinson’s disease. Over time, the weakness may reach a point where there is little space between the legs as the patient walks although the patient may still land on his or her heels. Patients with peripheral neuropathies will have a wider-based gait and tend to land flat-footed rather than on their heels.
Morley says the most effective way to address muscle loss in patients with diabetes is through diet and exercise. Because people with diabetes have somewhat larger bones on average, they also tend to have lower bone density and higher rates of osteoporosis; both factors can exacerbate the effects of falls. For this reason, Morley recommends approximately 1,000 IU of vitamin D per day, which can help improve bone density and maintain muscle mass. He says it’s also important for a patient’s diet to support muscle growth.
“The whole story of diet and diabetes is changing. You need to have adequate calories. To build muscle, you need protein, and you need a leucine-rich, balanced essential amino acid mix,” Morley says. “And many of these are available in the GNC stores for muscle builders. So you need the same sort of thing as a 20-year-old who wants to look good in the gym: leucine-enriched or whey protein extracts.”
Although a proper diet is important, Morley says exercise is even more vital to combating muscle loss. Resistance exercise, such as calisthenics or weight lifting, is the top priority because it will improve blood flow to the muscles. After that, a combination of balance exercises and aerobic activity will help maintain balance and walking speed, respectively. The appropriate amount and frequency of the exercise depends on the patient.
“The data varies from about 30 to 45 minutes twice a week to 30 minutes a day three to four times a week,” says Morley. “I tell all my patients to do 30 minutes a day, seven days a week because they always forget one or two, which means they come close to what they’re supposed to be getting.”
Along with diet and exercise, adequate diabetes control is important. Low levels of hemoglobin A1c can lead to hypoglycemia, which can cause weakness or fainting and increase the risk of falls. Also, men with diabetes often have low testosterone so they should be tested for hypogonadism to see whether they need testosterone replacement treatment. In addition, patients should be evaluated for cognitive difficulties, which may contribute to fall risk.
“The other piece that happens with diabetes is often you have some delay in cognition,” Morley says. “And those people, when they walk, basically can’t walk and talk at the same time, so asking them a question causes them to stop.”
Aside from that, Morley says it’s extremely important for diabetes patients to take care of their feet. Painful foot sores can cause people to change the way they walk, potentially leading to falls. Some people may need a cane or walking stick for added balance when they walk.
— David Yeager is a freelance writer and editor based in Royersford, Pennsylvania.