Effects of Perturbation-Based Versus Conventional Balance Training on Reactive Stepping Ability in Patients With Diabetic Peripheral Neuropathy

Diabetic peripheral neuropathy (DPN) is one of the most prevalent complications of diabetes mellitus, contributing substantially to disability worldwide. As a progressive condition, DPN leads to peripheral sensory loss, proprioceptive deficits, and delayed neuromuscular responses, all of which compromise balance and postural control. Because reactive stepping depends on rapid, sensory-driven neuromuscular responses, this progressive sensory and motor decline delays the reactive stepping response required to arrest a fall, placing this population at significantly elevated risk of falls and fall-related injury. Current rehabilitation approaches have not adequately addressed this specific deficit. A review demonstrates that conventional balance training predominantly improves static and anticipatory balance, as it relies on predictable, self-initiated movements. However, these gains fail to transfer to the unpredictable, real-world balance challenges that precipitate most falls, since conventional protocols do not expose patients to the rapid, feedback-driven corrections that reactive stepping demands. This represents a critical limitation a need for an intervention that trains balance in controlled conditions. But it leaves the reflexive, protective response untrained while this mechanism is most directly implicated in fall prevention.

Perturbation-based balance training (PBBT) has emerged as a promising alternative, grounded in principles of neuroplasticity. It has shown effectiveness in retraining reactive postural responses across several neurological populations. Despite this, evidence evaluating its effectiveness specifically on reactive stepping in individuals with DPN remains limited.

Thus, the existing literature reveals a clear and clinically consequential gap as balance training interventions in DPN have been shown to improve anticipatory postural control and static balance. The reactive stepping, which is the last line of defense against falls during unexpected perturbations, remains largely untrained and underexplored. This study therefore aims to address this gap by evaluating the effectiveness of PBBT in enhancing reactive stepping ability in individuals with diabetic peripheral neuropathy. This study is designed as a two-arm, parallel-group randomized clinical trial to compare the effects of PBBT and CBT on reactive stepping ability, dynamic balance, and functional balance in individuals with DPN. A total of 40 participants will be recruited and randomly allocated into either the PBBT group or the CBT group in a 1:1 ratio using a computer-generated randomization sequence with allocation concealment through sequentially numbered, opaque, sealed envelopes (SNOSE). Participants in both groups will receive intervention for 8 weeks, with 3 supervised sessions per week, making a total of 24 sessions. Each 60-minute session will include 20 minutes of routine physical therapy (7 minutes of warm-up, 6 minutes of rest, and 7 minutes of cool-down) and a main intervention of 40 minutes. All participants will first receive an equal standardized baseline treatment for 2 weeks. Following this, from week 3 to week 8, the PBBT group will receive manually delivered repeated exposure to unexpected and externally imposed postural perturbations by a physical therapist in a standing position on stable and unstable surfaces, while the CBT group will receive balance training with eyes open and eyes closed in various conditions on stable and unstable surfaces, with no manual perturbations. Sessions will be delivered under safety procedures, including a support bar during perturbation tasks and pre-session blood glucose monitoring. Outcome measures will include reactive stepping ability assessed using the Lean-and-Release Test (primary outcome), dynamic balance assessed using the Mini-BESTest, and functional balance assessed using the Berg Balance Scale. Participants will be screened for DPN using the Michigan Neuropathy Screening Instrument (MNSI). Assessments will be conducted at baseline (Week 0), post-intervention (Week 8), and follow-up (Week 12) by a blinded outcome assessor. The findings of this study will provide comparative evidence regarding the effectiveness of PBBT and CBT in improving reactive stepping and balance in individuals with DPN. Because the proposed intervention requires only basic rehabilitation equipment, it may offer a practical, cost-effective, and scalable rehabilitation approach for reducing falls in resource-limited settings and may assist clinicians in selecting the most appropriate balance training approach for this patient population.