What is the recommended approach for a functional gait assessment in patients with diabetic neuropathy?

Functional Gait Assessment in Diabetic Neuropathy

All patients with diabetic peripheral neuropathy should undergo annual functional gait assessment that includes evaluation of kinesthetic and proprioceptive sensation, 10-g monofilament testing, and assessment of balance and mobility using validated tools such as the Timed "Up & Go" Test or Dynamic Gait Index. 1

Core Assessment Components

Neurological Examination

• Perform 10-g monofilament testing annually to identify loss of protective sensation (LOPS), which is the primary risk factor for foot ulceration and altered gait mechanics 1
• Assess vibration sensation using a 128-Hz tuning fork to evaluate large-fiber function, as this directly impacts proprioception during walking 1
• Test temperature or pinprick sensation to evaluate small-fiber function 1
• Evaluate kinesthetic and proprioceptive sensation specifically before recommending any physical activity program, particularly in patients with more severe neuropathy 1

Functional Mobility Testing

• Use the Timed "Up & Go" Test with a modified cutoff score of >13.5 seconds to identify elevated fall risk, as this demonstrated 88.9% diagnostic accuracy in diabetic neuropathy patients 2, 3
• Consider the Dynamic Gait Index as an alternative, which showed the highest overall diagnostic accuracy when using traditional cutoff scores 2
• The standard cutoff scores for these tests underperform in diabetic neuropathy populations; modified thresholds improve sensitivity from 30% to 80-90% 2

Gait Parameters to Document

• Measure stride length and velocity, as these are significantly reduced even in early diabetic neuropathy 4, 5
• Assess stance phase, swing phase, and double support time, which are abnormally prolonged in diabetic neuropathy patients 4
• Evaluate ankle and knee mobility and strength, as diabetic patients demonstrate reduced peak joint torques and operate at a higher percentage of their maximum strength capacity, leaving less reserve for balance perturbations 6, 5

Balance Assessment

Static Balance Testing

• Perform eyes-open standing balance assessment measuring center of mass sway in mediolateral (ML) and anteroposterior (AP) directions, as these parameters are significantly elevated even in subclinical diabetic neuropathy 4
• Conduct eyes-closed standing balance testing to evaluate AP range of center of mass sway, which reveals compensatory hip joint strategies in diabetic patients 4
• Document ankle and hip sway patterns, as diabetic patients rely more heavily on hip compensation strategies rather than normal ankle strategies for balance maintenance 4

Psychological Assessment

• Administer the Activities-Specific Balance Confidence (ABC) scale, as balance confidence is more strongly associated with fall risk than objective functional measures in diabetic neuropathy (each unit increase in balance confidence associated with 9% reduced odds of falling) 3

Risk Stratification

High-Risk Features Requiring Immediate Attention

• Previous amputation or foot ulcer history 1
• Visible foot deformities (hammertoes, prominent metatarsal heads, bunions, Charcot foot) 1
• Impaired visual acuity 1
• Concurrent autonomic neuropathy, which increases risk through postural hypotension, impaired thermoregulation, and decreased cardiac responsiveness 1
• Diabetic nephropathy, especially dialysis patients 1

Disability Assessment

• Evaluate activities of daily living (ADLs) and instrumental activities of daily living (IADLs) at each visit, as diabetes increases disability risk by 50-80%, with lower-body functional limitation being most prevalent (47-84%) 1
• Refer to physical therapy, occupational therapy, or physical medicine and rehabilitation when disability impacts functional ability or diabetes self-management capacity 1

Critical Clinical Caveats

Gait abnormalities occur before clinical neuropathy is evident. Patients with diabetes but without diagnosed peripheral neuropathy already demonstrate slower gait, shorter steps, limited knee and ankle mobility, and reduced ankle plantar flexor power compared to healthy controls 5. This means assessment should begin at diabetes diagnosis for type 2 diabetes and after 5 years for type 1 diabetes 1.

Hyperglycemia itself affects gait mechanics independent of neuropathy. HbA1c levels correlate significantly with ankle mobility and plantar flexion power, suggesting that metabolic control directly impacts biomechanical function 5.

Moderate-intensity walking is safe and beneficial when proper footwear is used, even in established peripheral neuropathy, and does not increase foot ulcer risk 1. However, anyone with an active foot injury or open sore must be restricted to non-weight-bearing activities 1.

Daily foot examination is mandatory for all patients with peripheral neuropathy to detect lesions early, as decreased pain sensation eliminates the normal warning system for tissue damage 1.