The SA Journal Diabetes & Vascular Disease Volume 16 No 2 (November 2019)

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SA JOURNAL OF DIABETES & VASCULAR DISEASE RESEARCH ARTICLE
VOLUME 16 NUMBER 2 • NOVEMBER 2019 51
It is essential to note the risk of falls in patients with diabetes,
especially those with complications such as peripheral neuropathy,
as it predisposes them to fall-related injuries. Falls are ranked
among the 20 most expensive conditions to treat in general,
considering hospitalisation, possible need for surgery, and thereafter
implications for rehabilitation.3 Therefore, in a low socio-economic
context such as South Africa, prevention of falls through health
education and balance screening in patients with diabetes may
be a feasible strategy to minimise further strain on the healthcare
system.5
It was also found with the M-CTSIB in this study that more than
half (56%) of the participants with diabetes could not maintain
postural stability, especially under condition four (eyes closed on
foam). Postural instability and therefore a risk of falling in patients
with diabetes may be explained by the impact the disease has
on the eyes, ears and legs, which are integral in maintaining
proprioception and avoiding falls.13
Supporting the notion that complications of diabetes, such as
peripheral neuropathy and reduced visual acuity increase fall risk,
87% of participants with both conditions were unable to maintain
postural stability and therefore were at risk of falling. Fall risk in
patients with diabetes with sensory impairments such as peripheral
neuropathy is attributed to the lack of precise proprioceptive
response (sensory ataxia) from the lower limbs.21 It is also worth
noting that in another study,15 (n = 1 662) visual impairment was
reported to impact on the vestibulo-ocular reflex, an important
system that maintains balance and prevents falls. Consequently,
this study highlights that there is a crucial need to investigate fall
risk in order to prevent fall-related injuries, especially in patients
with diabetes and accompanying sensory impairments, such as low
vision.5,22
Of particular interest is the age of the participants (20–55 years).
Findings support other work that suggests that fall risk should be
explored in ever-younger populations, and challenges beliefs that
falls are a problem primarily of older adulthood. Multiple sensory
impairments, especially in an economically active age range, can
result in significant negative impacts on occupational productivity,
as well as cognitive and functional decline.23,24
This study represents one of the first studies that investigated fall
risk among young to middle-aged patients with diabetes in South
Africa. Its strength lies in its design, a matched control group to
ensure that the influence of confounding variables was minimised.
Our study design is in contrast to most of the previous studies,
which employed mostly retrospective reviews of records without
control groups. Also, participants were carefully selected to ensure
that only individuals under 55 years were selected, to minimise the
impact of age-related deterioration confounding findings.
However, the study also had some limitations. Because of its
descriptive nature, causal relationships could not be inferred. This
study investigated mainly fall risk and did not include a quality-
of-life aspect that may have enabled the researchers to have
more insight with regard to the impact of diabetes-related fall
risk particular to the age group included. Furthermore, history of
previous falls, which is in itself an important risk factor for future
falls, was not investigated.
One key clinical implication emerging from the current study
is that, in patients with diabetes, fall risk should be assessed and
rehabilitated early.24 Future research could add to the knowledge
base with studies focusing on incidence of fall risk and other balance
dysfunctions in patients with diabetes, through longitudinal,
prospective research, effective methods of fall prevention and
rehabilitation, and the impact of diabetes-related fall risk on quality
of life.25
Conclusion
Overall, participants with diabetes presented with a statistically
significantly higher risk of falls compared to those without diabetes.
Furthermore, those with possible complications (neuropathy and
vision difficulties), uncontrolled diabetes and longer diabetes
duration showed an even higher risk of falling. Therefore, the
study findings highlight the need to assess for fall risk in young to
middle-aged (20–55 years) patients with diabetes to enable early
identification and appropriate rehabilitation.
Acknowledgements
The authors acknowledge and thank the Polokwane Provincial
Hospital audiology staff as well as the Limpopo Provincial
Department of Health for their co-operation in the study, and the
University of Cape Town Human Research Ethics Committee for
granting approval for the study.
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