Under The Guidance of

“ASSOCIATION BETWEEN CENTER OF PRESSURE (COP)
DISPLACEMENT AND BERG BALANCE SCALE (BBS) ON RISK

OF FALLS IN ELDERLY DIABETICS”
By
Ms. SHREYA GIRISH SAOKAR

Dissertation Submitted to the
Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka,
In partial fulfillment
of the requirements for the degree of
MASTERS OF PHYSIOTHERAPY
IN
COMMUNITY PHYSIOTHERAPY
Under the guidance of
Dr. SALIMA MULLA

Associate professor and P.G. Guide
SDM COLLEGE OF PHYSIOTHERAPY

Manjushree Nagar, Sattur, Dharwad, Karnataka- 580009
2021-2022
i
Shri Dharmasthala Manjunatheshwara University, Dharwad, Karnataka.
DECLARATION BY THE CANDIDATE
I hereby declare that this dissertation/thesis entitled “ASSOCIATION BETWEEN
CENTER OF PRESSURE (COP) DISPLACEMENT AND BERG BALANCE
SCALE (BBS) ON RISK OF FALLS IN ELDERLY DIABETICS” is a bonafide
and genuine research work carried out by me under the guidance of Dr. SALIMA
MULLA, Associate Professor & P.G. Guide, S.D.M. College of Physiotherapy
Dharwad.
Date: Signature of the candidate
Place: Dharwad Ms. SHREYA GIRISH SAOKAR
MPT-2 Community Physiotherapy
ii
CERTIFICATE BY THE GUIDE
This is to certify that the dissertation entitled “ASSOCIATION BETWEEN
research work done by Ms. SHREYA GIRISH SAOKAR in partial fulfillment of the
requirement for the degree of Master of Physiotherapy (M.P.T.)
Date: Signature of the Guide
Place: Dharwad Dr. SALIMA MULLA
Associate professor and P.G Guide
Department of Community Physiotherapy
SDM College of Physiotherapy
iii
CERTIFICATE BY THE CO-GUIDE
research work done by Ms. SHREYA GIRISH SAOKAR in partial fulfillment of the
requirement for the of Master of Physiotherapy (M.P.T.)
Date: Signature of the Co-Guide
Place: Dharwad Dr. ANOOSHA BHANDARKAR
Assistant Professor of Diabetology
Department of Endocrinology
SDM College of Medical Sciences and Hospital
iv
ENDORSEMENT BY THE HOD, PRINCIPAL/HEAD OF THE
INSTITUTION
research work done by Ms. SHREYA GIRISH SAOKAR under the guidance of Dr.
SALIMA MULLA, Associate Professor & P.G. Guide, S.D.M. College of
Physiotherapy Dharwad.
Seal & Signature of the HOD Seal & Signature of the Principal
Name: Dr. SUNIL K.M. Name: Dr. SUNIL K.M.
Professor and Principal Professor and Principal
Date: Date:
Place: Dharwad Place: Dharwad
v
COPYRIGHT
Declaration by the Candidate
I hereby declare that the Shri Dharmasthala Manjunatheshwara University, Dharwad,
Karnataka shall have the rights to preserve, use and disseminate this dissertation / thesis
in print or electronic format for academic / research purpose.
Date: Signature of the Candidate
Place: Dharwad Ms. SHREYA GIRISH SAOKAR
© Shri Dharmasthala Manjunatheshwara University,

Dharwad, Karnataka
vi
ACKNOWLEDGMENT
First and foremost, I would like to thank GOD for his blessings and for all my
achievements in life.
I owe my gratitude to Dr. Niranjan Kumar, Vice chancellor, S.D.M university, for
permitting me to conduct the specified research work for my Post Graduate
Dissertation.
I sincerely thank Dr. Sunil K.M, Principal, S.D.M College of Physiotherapy, for his
support throughout the study duration.
I express my deepest appreciation to Dr. Salima Mulla, Associate Professor and P.G.
Guide, S.D.M College of Physiotherapy, for providing me with noble and generous
guidance.
I am extremely grateful to Dr. Anoosha Bhandarkar, Assistant Professor of
Diabetology, Department of Endocrinology, S.D.M. College of Medical Sciences and
Hospital, Dharwad, for providing me the Force Plate for my study and her constant
support,
I cannot begin to express my thanks to Dr. Bharati G. for timely referral of the out-
patients throughout the study
My sincere thanks to Dr. Shweta Bhatbolan, S.D.M. College of Physiotherapy,
Dharwad, for her patience, constant encouragement and support throughout the
academic year.
I would like to extend my sincere thanks to Dr. S.B. Javali and Dr. Ashwini for helping
with the statistical analysis work.
I also thank all the faculty members of S.D.M College of Physiotherapy and all library
staff for their support and help in fulfilling the work of dissertation.
vii
An honorable mention goes to my parents Mr. Girish N. Saokar & Mrs. Mangala G.
Saokar and sister Shruti Saokar for their unconditional love, support and for believing
in me.
Special thanks to my friends Ms. Sampada Nayak, Ms. Pooja Balyapelli, Ms.
Lakshada Nayak, Mr. Shubham Naroji and my co-PGs Ms. Aditi Prayag, Ms.
Suma Patil, Ms. Kavita Waddar for always boosting my morale and supporting me.
Well-deserved thanks to my seniors Ms. Navami Upadhyaya for her cooperation with
Kannada translation and Ms. Sailee Shetkar for solving my queries whenever needed.
I would like to acknowledge and thank my juniors and interns for assisting me with the
thesis work.
Lastly, I would like to offer my special thanks to all the participants who participated
in the study, without whom the task would not have been possible.
Date: Signature of the candidate
Place: Dharwad Name: SHREYA G. SAOKA
viii
LIST OF ABBREVIATIONS USED
Sr. Abbreviation Full Form

No.
1. ABC Activities-specific Balance

Confidence Scale
2. A-P Antero-Posterior
3. AUC Area under curve
4. BBS Berg Balance Scale
5. CVD Cardiovascular Diseases
6. COG Center Of Gravity
7. COM Center Of Mass
8. COP Center Of Pressure
9. DM Diabetes Mellitus
10. DPN Diabetic Peripheral Neuropathy
11. FT Field Test
12. FP Force Plate
13. FRT Functional Reach Test
viii
14. HMSE Hindi Mental State Examination
15. IDF International Diabetes Federation
16. M-L Medio-Lateral
17. MNSI Michigan Neuropathy Screening

Instrument
18. MMSE Mini Mental State Examination
19. NPV Negative Predictive Value
20. NCDs Non-Communicable Diseases
21. POMA Performance Oriented Mobility

Assessment
22. PPV Positive Predictive Value
23. ROC Receiver Operating Characteristic
24. ROF Risk of Falls
25. TUGT Timed Up and Go Test
26. WHO World Health Organization
ix
ABSTRACT
Background & Objectives:
The complications of diabetes especially peripheral neuropathy are major contributors
for fall risk which leads to increased Center of Pressure (COP) displacement and falls,
posing a serious threat to the independence of people aged 60 and older. Early detection
of falls can aid in the development of a holistic treatment plan. Objective assessments
of postural sway are recognized as key predictors of falls among community-dwelling
older people, along with impaired balance. Berg Balance Scale (BBS) is standardized
tool for fall risk assessment despite its drawbacks whereas the Force Plate (FP)
eliminates these constraints. Since no studies have identified correlation between field
tests and laboratory tests to determine Risk of Falls (ROF) in elderly diabetics, this
study aims at correlating COP displacement on FP (Laboratory Test) with BBS (Field
test).
Methods:
Participants who met the inclusion criteria were included. Their BBS scores and COP
displacement on force plate (AM3 FootWork Pro) were recorded.
Results:
Statistically significant negative correlation was found between COP displacement
(Antero-Posterior (A-P), Medio-Lateral (M-L) directions) on FP and BBS scores. The
cut-off values of ≥ 2.3 centimeters for A-P and ≥2.7 centimeters for M-L COP
displacements were found to be highly sensitive but less specific. Area under Curve
(AUC) was acceptable for both the cases with accuracy of 54.17%.
x
Interpretation & Conclusion:
Negative correlation between COP displacement on FP and BBS suggests that as the
BBS scores decreases, COP displacement increases, indicating higher ROF. COP
displacement on FP is sensitive but not specific to correctly identify ROF in elderly
diabetics with cut-off values ≥2.3 cms for A-P and ≥2.7cms for M-L COP displacement.
Thus, it can be used as a screening tool while BBS still remains the confirmatory test.
Keywords: Accidental Falls; Aged; Diabetes Complications; Independent Living;
Peripheral Nervous System Diseases; Postural Balance; Risk Assessment
xi
TABLE OF CONTENTS
Sr. CONTENTS Pg. No.

No.
1. Introduction 1-14
2. Research Question 15
3. Aim and Objectives 16
4. Review Of Literature 17-23
5. Methodology 24-31
6. Results 32-46
7. Discussion 47-61
8. Limitations 62
9. Future Scope of Study 62
10. Conclusion 63
11. Summary 64-65
12. Bibliography 66-73
13. Annexures 74-100
xii
LIST OF TABLES
Sr.No. Tables Pg.No.
1. Age wise distribution of participants 33
2. Gender wise distribution of participants 34
3. Distribution of participants according to the duration 34

of diabetes
4. BBS scores of participants 35
5. Comparison of age groups with mean duration of 37

diabetes by one-way ANOVA test
6. Comparison of males and females with mean 38
duration of diabetes by independent t test
7. Association between history of falls and BBS scores 38
by Chi-square test
8. Correlations between BBS scores and COP 39
displacement in A-P and M-L directions on Force
Plate using Karl Pearson’s correlation coefficient
method
9. Sensitivity and Specificity of A-P displacement of 44
COP on force plate over BBS
10. Sensitivity and Specificity of M-L displacement of 46
COP on force plate over BBS
11. Example of Sensitivity and Specificity in our study 55
xiii
LIST OF FIGURES
Sr.No. Figures Pg. No.
1. Schematic diagram showing the enrollment of the 28

participants and the study procedure
2. Graph showing BBS scores of participants 35
3. Graph of Screening of Diabetic Peripheral 36
Neuropathy using Michigan Neuropathy
Screening Instrument
4. Graph of Awareness of DPN among participants 36
5. Graph showing Comparison of age groups with 37
mean duration of diabetes by one-way ANOVA
test
6. Scatter plot showing the correlation between 40
BBS scores and COP displacement in A-P
direction on force plate
7. Scatter plot showing the correlation between 41
BBS scores and COP displacement in M-L
direction on force plate
8. Scatter plot showing the correlation between in 42
A-P and M-L directions on force plate
9. ROC curve of A-P displacement of COP on force 43
plate by BBS
10. ROC curve of M-L displacement of COP on 45
force plate by BBS
11. Pie- chart depicting the mean rate Plagiarism 93
xiv
report
12. Picture of Am3 FootWork Pro Force Plate 97
13. Figure showing measurement of COP 97
displacement of the participant by standing on the
force plate
14. Graph displayed by the Force plate (showing A-P 97
and M-L COP displacements)
15. Participant assessed for DPN using MNSI 98
16. Participant performing BBS component 4: 98
Standing to sitting
Reaching forward with outstretched arm while
standing
Placing alternate foot on step/ stool while
standing unsupported
Standing unsupported one foot in front
Standing on one leg
21. Educating participant on foot care 99
xv
INTRODUCTION
The World Health Organisation (WHO) defines health as “a state of complete physical,
mental and social well-being and not merely the absence of disease”. Health is the most
valuable asset a person may possess and a long, active, and pleasurable life requires
good health and fitness. Being healthy and fit implies taking proper care of one's body
which also includes a person's mental stability or inner peace. Protecting the body from
hazardous chemicals, exercising regularly, eating well, and getting enough sleep are just
a few examples of how to live a healthy lifestyle. A healthy and fit person is capable of
living the life to the most, without any major medical or physical issues. Cancer,
diabetes, and a variety of other physical and mental health disorders, such as depression,
a sluggish attitude, and so on, are all considered inadequacies in a person's fitness and
well-being by health specialists. Obesity and a lack of physical fitness among the
younger generation pave the way for diabetes, heart disease, and other significant health
issues.1
Chronic diseases, often known as Non-Communicable Diseases (NCDs), are medical
problems that last for a long time and advance slowly. They are the silent killers, posing
a health risk without causing any symptoms until the disease has progressed to an
advanced level. According to the WHO, NCDs are the main cause of death worldwide,
accounting for 71% of all deaths each year. Cardiovascular diseases (17.9 million deaths
per year), malignancies (9.0 million), respiratory illnesses (3.9 million), and diabetes
(1.6 million) are the four leading causes of death among NCDs. This could be due to
changes in dietary habits and lifestyle throughout time. Unhealthy diets, physical
inactivity, cigarette use, and alcohol abuse are the key risk factors for NCDs. As a result,
the majority of these diseases are preventable, as they proceed early in life due to
lifestyle factors.2
1
Diabetes is one of the fastest rising global health emergencies of the twenty-first
century, according to the International Diabetes Federation (IDF) Diabetes Atlas 2021-
10th edition. It is a serious health problem that has reached epidemic proportions.
Diabetes affects more than half a billion people globally today.3
Diabetes mellitus, or diabetes, is a threatening, long-term (or "chronic") disorder in
which the body cannot generate or efficiently utilise the hormone insulin, resulting in
elevated blood glucose levels. Insulin is an essential hormone that is generated by the
pancreas to allow glucose from the bloodstream to reach the cells of the body, where it
is either transformed to energy or stored and is also required for protein and fat
metabolism. Hyperglycemia (high blood glucose) is a clinical indicator of diabetes
caused by a shortage of insulin or the inability of cells to respond to it. If left untreated,
an insulin deficiency can damage many of the body's organs, resulting in disabling and
life-threatening health complications such as cardiovascular disease (CVD), nerve
damage (neuropathy), kidney damage (nephropathy), lower-limb amputation, and eye
disease (primarily affecting the retina), which can cause visual loss and even blindness.
However, if diabetes is properly managed, these dangerous problems can be postponed
or avoided completely.3
Type 2 diabetes is the most common type of diabetes, accounting for more than 90% of
all diabetes cases around the world. Hyperglycemia is the outcome of the body's cells'
inability to respond fully to insulin, a condition known as insulin resistance, in type 2
diabetes. Insulin resistance causes the hormone to become less effective, which leads to
an increase in insulin production. Inadequate insulin production can develop over time
as a result of the pancreatic beta cells' inability to keep up with demand. Type 2 diabetes
symptoms are far less severe as compared to type 1 diabetes, and the disease may go
2
unnoticed entirely. Furthermore, pinpointing the precise onset of type 2 diabetes is
nearly hard.3
As a result, there is typically a significant period of time between diagnosis and
treatment, and up to one-third to one-half of persons with type 2 diabetes may go
undetected. Complications such as vision impairment, poorly healing lower-limb ulcers,
heart disease, or stroke may occur if the diagnosis is delayed for an extended period of
time.3
The origins of type 2 diabetes are unknown, but there is a clear correlation with growing
age, ethnicity, and family history.3
Age distribution
Diabetes estimates for 2021 show increasing prevalence of diabetes by age. According
to IDF Diabetes Atlas 2021 – 10th edition, diabetes affects an estimated 537 million
persons between the ages of 20 and 79. This age group accounts for 10.5% of the
world's population. By 2030, the overall population is expected to reach 643 million
(11.3%), and by 2045, it will reach 783 million (12.2%).3
Gender distribution
Diabetes is significantly less common in women aged 20 to 79 years than it is in men
(10.2% vs. 10.8%). In 2021, there were 17.7 million more males with diabetes than
females.3
Country distribution
China, India, and Pakistan have the highest numbers of adults with diabetes aged 20–
79 years in 2021 and are expected to stay so in 2045.3 With 69.1 million people living
3
with diabetes, India is the country with the second-highest number of cases behind
China.4
Urban and rural distribution
Diabetes affects 12.1% of people in cities and 8.3% of people in rural regions.3Overall
prevalence in rural areas of Dharwad was found to be 49.1%.5
Undiagnosed diabetes affects an estimated 240 million individuals globally, which
means nearly one-in-two persons with diabetes are unaware of their condition. Nearly
90% of patients with diabetes who are undiagnosed live in low- and middle-income
nations.3
Polygenic and environmental factors are hypothesised to play a role in the development
of type 2 diabetes. Promoting a healthy lifestyle, which includes a nutritious diet,
frequent physical activity, quitting smoking, and maintaining a healthy body weight, is
the cornerstone of type 2 diabetes management. Regular screening for the onset of early
diabetes consequences such as kidney disease, retinopathy, neuropathy, peripheral
artery disease, and foot ulcers can enable preventive interventions to halt the
advancement of these issues. People with type 2 diabetes can live long and healthy lives
with regular check-ups and adequate lifestyle management, as well as medication if
necessary.3
Chronic hyperglycemia is a key player in the pathogenic pathways that lead to
microvascular (retinopathy, neuropathy, and nephropathy) and macrovascular
(peripheral vascular disease, cardiovascular disease, and cerebrovascular disease)
consequences in diabetes.6
The most prevalent type of diabetes-related neuropathy is peripheral neuropathy with a
prevalence of almost 60% with painful diabetes-related neuropathy being observed in
4
about 26% of adults with diabetes.7,8 Damage to the peripheral nerves can occur when
advanced glycation end products cause irreversible alterations to myelin protein,
resulting in segmental demyelination of the peripheral nerves. Furthermore, the
neuronal microvascular system is damaged, resulting in decreased nerve perfusion.
Diabetic peripheral neuropathy is characterised by pain, paraesthesia, and sensory loss
in up to two-thirds of persons with diabetes.6 It affects the limb’s distal nerves, notably
those in the feet and mostly affects symmetrical sensory function, resulting in unusual
sensations and gradual numbness. These factors make it easier for ulcers to form as a
result of external damage and/or an irregular distribution of internal bone pressure (the
dreaded "diabetic foot").8
Diabetic foot and lower limb problems, which affect 40 to 60 million people worldwide
with diabetes, are a major cause of morbidity. Chronic ulcers and amputations have a
major negative impact on quality of life and increase the risk of premature mortality.
Even when the patient is symptomatic, only about a third of doctors recognise the signs
and symptoms of diabetes-related peripheral neuropathy. Missed diagnosis are a major
contributor to these high rates of morbidity and mortality.8
Two management techniques should be prioritised:
• Increasing healthcare workers' awareness and knowledge of diabetic foot problems
management.
• Screening and risk classification for at-risk feet on a regular basis.
Foot complications and amputations are reduced by up to 85% with comprehensive
diabetic foot problems risk assessments and foot care based on prevention, education,
and support by a multidisciplinary team.8
5
Microvascular complications: peripheral neuropathy and retinopathy, are well known
contributors to instabilities, increased postural sway and falls among the various
consequences of diabetes.6,7 Diabetic Neuropathy (DN) might make it difficult to
maintain balance during daily activities and patients with DN are five times more likely
to fall. Mobility loss, activity avoidance, and institutionalization and mortality are some
of the effects.7
Balance is an important basic requirement in order to prevent falls, perform activities
of daily living and to lead an independent life. Human balance can be defined as the
ability to remain in an upright standing without falling. Through a mechanism known
as "postural sway", which takes place around a fixed postural position in the presence
of gravity, this crucial aspect of motor control is accomplished. Moritz Heinrich
Romberg, a neurologist, was the first to realise the clinical utility of monitoring postural
sway for assessing sensory feedback inadequacies in patients with balance disorders
over a century ago. Increased postural sway is now regularly assessed, based on
evidence, that it is linked to lower performance on activities of daily living, greater rates
of residential care, and an increased risk of falling.9
Balance requires the coordination of multiple sensory systems including vestibular,
somatosensory and visual systems.10 Also, there is contribution from the motor system.
In order to detect unstable conditions (i.e., perturbations to the system), sensory inputs
are necessary and in order to counteract these perturbations, it is necessary to initiate
timely and appropriate responses, which are motor contributors.11 Sensory systems
(visual, somatosensory, and vestibular systems), movement strategies, and cognitive
processing are required in order to maintain postural control.12
6
The centre of mass (COM) is a hypothetical place that represents a concentrated
expression of the overall weight and can be determined as the weighted average position
of each body segment in three-dimensional space. COG (centre of gravity) refers to the
vertical projection of COM on the ground. The centre of pressure (COP) is the place at
which the plantar ground reaction force is applied, and it reflects the complete pressure
in the foot–ground contact surface. In order to calculate the ground response force, a
force measurement platform is frequently employed. The posture control system
controls the passive variable COM, whereas the comprehensive control variable COP
is the sum of the inertia force of the sway body and the posture control system's restoring
equilibrium forces. Postural sway is the term for the movement of the COM while a
person is standing. 13
The functional linkage of a set of muscles such that they are forced to act as a single
unit is known as a synergy. One of the earliest patterns for regulating upright sway was
the ankle strategy and the muscular synergy that went along with it. The hip strategy
comes into play in order to restore equilibrium in response to faster, larger perturbations
14
or when the support surface is compliant or smaller. Antero-Posterior (AP)
displacements and Medio-Lateral (ML) displacements both show postural stability at
the ankle and hip levels, respectively.15 Postural stability during standing is mainly
controlled by a feedback loop and feedforward control is mainly responsible for postural
stability during walking.16
Many studies have reported higher instability while standing in diabetic patients with
peripheral neuropathy as compared to diabetic patients without peripheral neuropathy
and healthy people. Progression of neuropathy follows a distal-proximal slope so the
effects of diabetic peripheral neuropathy on strength and balance are most obvious at
the ankles and feet, sites of the distal endings of large, myelinated motor and sensory
7
fibers. The loss of nerve function can have dramatic consequences for both standing
and walking tasks.10 Reduction in ankle proprioception is caused due to reduction in
cutaneous and proprioceptive sensations in diabetic people.15 Also, there is decreased
proprioceptive feedback during walking. This leads to increased risk of falls.
Additionally, it has been discovered that recurring falls are related to diminished
vibration sensitivity and loss of pressure sensitivity. 6Also, there is a shift from ankle to
15
hip strategy in older individuals with DPN due to diminished peripheral sensation.
Older individuals having type 2 diabetes have several subtle deficits related to balance,
mobility and sensory functions even in the absence of DPN. This may contribute to
decline in balance and physical function in diabetics without DPN.17 Postural stability
may influence falls risk. Previous research has shown that in older persons, a decline in
postural stability might raise the chance of falling by 75% - 90%. 18 In a previous study
it was shown that people with DPN had 66 percent more sway than people of a similar
age and health when standing quietly with their eyes open.6
Falls among elderly are a major health concern that affects people all around the world.
It may be associated with significant health care costs.19 A fall can be defined as an
event resulting in a person coming to rest inadvertently on the floor, often caused by
multifactorial risk factors including intrinsic and extrinsic factors. The WHO, global
study on falls prevention, states that 28 -35 percent of people of 65 years of age and
older fall each year .In India, the fall prevalence rate in above 60 years age group ranges
from 14%-53%.20 Elderly adults with diabetes exhibit greater impairments in gait and
posture and have a higher incidence of falls along with a higher risk of falling.21Brain
trauma and hip fractures are the most serious injuries caused by falls, with the former
accounting for 46 percent of fatalities among the elderly. Falls are significantly linked
8
to balance issues and aberrant gait, according to extensive and in-depth study on the
processes and risk factors of falls.13
Since DPN is one of the factors, for increasing falls risk in elderly diabetics and most
of the people are unaware of this complication, it is necessary to screen all the
diabetics.3,6,8,10 Because nerve or skin biopsy, as a gold standard diagnostic test is
difficult to execute and analyse, electrophysiological testing is considered as the best
alternative diagnostic approach. Nerve conduction investigations are a gold standard
diagnostic tool that can reveal minor abnormalities such as alterations in sensory nerve
characteristics. Various clinical scoring systems have recently been created as
quantitative tools to document the presence and severity of DPN. 22 MNSI is a validated
score tool for diabetic distal symmetrical peripheral neuropathy that is frequently used
for diagnosis and quantification.7 The test is simple to administer and interpret,
particularly for internists and general practitioners.22 The MNSI is made up of two parts:
a 15-item self-administered questionnaire that is scored by adding abnormal answers
provided by the patient, and a lower extremity examination performed by a healthcare
professional, which includes inspection, evaluation of ankle reflexes, and vibration
perception at the great toe, with abnormal findings being scored. 7 The MNSI technique
has a high diagnostic impact due to its high specificity, likelihood ratio > 5, and
moderate to good post-test probability, and a cut-off value of 2 is indicated. Since the
MNSI is still only a screening test, electrophysiological investigations should be
considered, if the patient exhibits indications and symptoms that are not graded by the
MNSI, indicating peripheral nerve involvement. 22
It is also suggested that type 2 diabetes and defects in glucose metabolism might
predispose to poorer cognitive performances and more rapid decline in old age.
Numerous research has suggested that vascular pathophysiological pathways
9
underlying T2DM may be causally related to cognitive deficits, and longitudinal data
has shown that T2DM may contribute to accelerated cognitive ageing. 23 A well-known
and frequently used test for evaluating older individuals' cognitive abilities is the Mini
Mental State Examination (MMSE). Hindi Mental State Examination (HMSE) is a
modified version of MMSE developed specifically to overcome educational bias when
screening rural illiterate elderly people for cognitive impairment. HMSE has a high
sensitivity (0.81) and specificity (0.60) and is an effective and relevant screening tool
for the rural community with a cut-off score of 23.24
Balance tests are commonly used to assess balance ability, track changes, assess fall
risk, and diagnose different types of balance dysfunction. A psychometrically sound
balance measure should have adequate reliability, validity, and measurement breadth;
minimal floor and ceiling effects for the intended purpose and population; adequate
sensitivity and specificity for diagnosis; and adequate sensitivity to change and
responsiveness for change assessment. A balancing test would need to include tasks of
changing difficulty to cover the complete spectrum of ability from low to high in order
to attain precision and sensitivity to change equally across people of various balance
ability. 25
The three main approaches into which clinical balance assessment can be divided are:
functional assessments, a systems/physiological assessment, and quantitative
assessments. Functional balance tests are useful for documenting balance state and
changes as a result of intervention. They commonly utilise a stopwatch to time how
long the participant can maintain balance in a given posture or rate performance on a
set of motor tasks on a three to five point scale. Examples: Activities of Balance
Confidence (ABC), Tinetti Balance and Gait Test, Berg Balance Scale (BBS), Timed
“Up and Go Test” (TUG), Functional Reach Test (FRT). 26
10
Berg Balance Scale (BBS) is a standard outcome measure to check functional balance
specifically in elderly population.27 Despite its drawbacks, BBS has been recognized as
a "gold standard" for measuring balance since its introduction.28 The 14- item scale
contains both static and dynamic activities which are related to our everyday life. It
assesses balance and falls risk by directly observing the participant’s performance in a
variety of settings. The maximum score is 56 which indicates good balance19. Score
<45 indicates individuals maybe at greater risk of falling29. Meanwhile, BBS adheres to
certain limitations. Firstly, the BBS pays insufficient attention to gait and the dynamic
component of balance. As a result, additional balancing tests are required for a thorough
balance assessment, adding to the clinician’s workload. Secondly, for community-
dwelling older persons, the ceiling effect i.e. the high number of individuals who
achieve the highest attainable score of the measure (the upper limit), was reported as
22.5 percent. A large ceiling effect prevents the instrument from being used in a group
of more proficient participants and/or when significant improvement is demonstrated
between the first and subsequent tests.28 Third, is the subjectivity of scores. Subjective
scores depend on the scorer’s opinion/interpretation of participant’s responses to items.
Also, BBS requires a larger space, more manpower, repeated instructions and is more
time-consuming.28
A Systematic Review was done to find out the use of Berg Balance Scale as a clinical
screening tool to predict fall risk in elderly. The study showed that BBS has a ceiling
effect (showing high BBS scores for elderly) and that the BBS scores were high
irrespective of their fall history. The Review concluded that the evidence for using BBS
to predict falls is weak, and it should not be used alone to estimate the risk of falling in
older persons.30
11
When the goal of the evaluation is to determine the underlying reasons of the balance
deficit so that it can be effectively treated, a system approach is beneficial such as the
Balance Evaluation Systems Test (BESTest) and The Physiological Balance Profile
(PPA). 26
Unfortunately, all balance rating scales are coarse measures of complicated motor
action, and all subjective assessments are susceptible to tester bias. The ideal assessment
approach would be to include objective, measurable measurements that can be quickly
turned into simple and useful data. Thanks to advances in computerised technology;
objective balance examinations are becoming more and more realistic in clinical
settings.
Objective assessments include Static and Dynamic Posturography, Wearable Inertial
Sensors 26
Quantitative/ Objective assessments of postural sway during standing have been
available as therapeutic tools in the last decade, and an increasing number of physical
therapists and physicians are personalising therapies for their patients based on
posturography data. The displacements of the centre of foot pressure from a force plate
are commonly used to quantify postural sway.26
In a clinical environment, force plate technology is one of the most sensitive and
objective ways to assess postural sway9. Postural sway tests using a force platform have
been shown to be accurate and reliable measurements of balance in health and sickness,
and are regarded the gold standard. Force platforms, however, can be prohibitively
expensive, immobile, and impractical for clinical and at-home evaluations. 31 They use
a metric called centre of pressure (COP), which is the weighted average of forces
exerted when standing on a force plate, to evaluate postural sway.9
12
Objective measures of posturography are preferred to measure postural instability, the
advantages of this method over regular clinical assessments being- test performance
variability reduction and avoidance of subjective scoring systems32. Objective
(instrumental) measures will score a test by means of a number, so that different scorers
will arrive at the same score for the same set of responses. The best way to detect fall
risk is on the force plate.33 It is based on the determination of variables associated with
center of pressure displacement which is the point of application of the result of the
vertical forces which act on the base of support. 34 They quantify the center of pressure
excursion in AP and ML directions during quiet stance in varying conditions.35 It is best
suited for fall prevention studies as it shows subtle and small changes in millimeter and
centimeter.33Also force plates provide visual feedback to the patient which can be used
for balance training.36
Despite this, force plate usage in clinical settings has remained relatively low. Owing
to the high cost and lack of portability of most classical force plates; they may not be
appropriate for clinical or home examinations.9,31
Studies have shown that with regards to body sway measures, the center-of-pressure
area can be most consistently associated with falls.37 Another study done compared a
number of field tests (Berg Balance Scale (BBS), Performance Oriented Mobility
Assessment (POMA), Functional Reach (FR) and Timed Up and Go Test (TUGT) with
stabilometric tests using Force Platforms (FP) to determine whether these tests are
capable of distinguishing the differences in balance between the young and older adults
and results of the study demonstrated that both field and force platform tests are able
to differentiate the balance in young and elderly subjects. The elderly consistently
presented lower performance in the balance tests and greater oscillations of the center
of pressure in the force platform test when compared to young subjects and were
13
negatively correlated. 34 A study on evaluation of standing balance of the elderly with
different balance abilities by using Kinect and Wii Balance Board showed strong
negative correlations with Berg Balance Scale scores.38
Previous research showed a correlation between field tests (BBS) and laboratory tests
(Force Plate) along with the capability of differentiating the balance between the young
34
and elderly. However, no studies have been done to determine whether Field tests
and laboratory tests can be correlated to identify elderly diabetics at a ROF, or if they
can, what the cut-off values on the force plate will be in order to do so. Therefore, in
this study we aimed to correlate BBS (Field test) with Force Plate (Laboratory test) to
identify ROF in elderly diabetics. Additionally, this study will pinpoint the Force Plate
cut-off values, which are an objective way to identify ROF.
14
RESEARCH QUESTION
• Can Center Of Pressure (COP) displacement on Force Plate (Laboratory Test) be
associated/ correlated with Berg Balance Scale (Field Test) to identify risk of falls
in elderly diabetics?
Null Hypothesis (H0):
• There will be no statistically significant correlation between COP displacement on
Force Plate (Laboratory Test) and BBS (Field Test) to identify ROF in elderly
diabetics.
Alternative Hypothesis (H1):
• There will be statistically significant correlation between COP displacement on
Force Plate (Laboratory Test) and BBS (Field Test) to identify ROF in elderly
diabetics.
15
AIM AND OBJECTIVES
1. To determine the correlation between COP displacement on Force Plate (Laboratory
Test) and Berg Balance Scale (Field Test) to identify risk of falls in elderly diabetics.
2. To identify the test performance characteristics of the COP displacement on the
force plate (sensitivity, specificity, positive and negative predictive values,
accuracy).
3. To detect the cut-off values for Antero-Posterior and Medio-Lateral COP
displacement on force plate for the elderly diabetics.
16
REVIEW OF LITERATURE
• According to International Diabetes Federation (IDF) Diabetes Atlas 2021 – 10th
edition, diabetes affects an estimated 537 million persons between the ages of 20
and 79. This age group accounts for 10.5 percent of the world's population. IDF
Diabetes Atlas, Ninth Edition 2019, explained the various complications of diabetes
like: cardiovascular disease, damage to nerve (neuropathy), damage to kidney
(nephropathy), and eye disease such as retinopathy, visual loss and even blindness
and stated that peripheral neuropathy was the most common type of diabetes-related
neuropathy with a prevalence of 16%-87%. Studies have shown that the overall
prevalence of diabetes is 8.3% and that of prediabetics is 6.3%. The incidence and
falls risk increase in elderly people with diabetics and the prevalence of falls in older
adults of India ranges from 14%-53% 3,8,20,5,21
• A brief report done on Sensory functions, Balance and Mobility in older adults with
type 2 diabetes without overt diabetic peripheral neuropathy (Southern
Gerontological Society) by Nandini Deshpande, Patricia Hewston, et al. in 2015
confirms that Subtle but clear degradation of sensory functions is found in elderly
people suffering from type 2 diabetes much before the development of diabetic
peripheral neuropathy. Thus, proactive monitoring of elderly people with type 2
diabetes should begin way before the development of overt complications for
designing rehabilitation and prehabilitation interventions to delay or prevent
limitations in physical function.17
• Various systematic reviews are done on the impact of Diabetic Peripheral
Neuropathy on the fall risk in elderly. Review done by Amirah Mustapa, Maria
Justine, et al. in 2016 concluded that postural instability and imbalance in gait in
DPN may contribute to high risk of fall incidence, especially in the geriatric
17
population. Along with the pathologic condition of diabetes on cognitive
impairment; deterioration of somatosensory, visual, and vestibular systems may
cause further instability of postural and gait performance in DPN. Another review
by Karolina Snopek Khan and Henning Andersen in 2021 concluded that diabetic
neuropathy has a negative impact on postural balance and kinematics of gait along
with an increased risk of falls. Further, a study on postural sway in diabetic
peripheral neuropathy among Indian elderly by Snehil Dixit, Arun Maiya et al.
showed balance impairments on either firm and foam surfaces, with the likelihood
of falls being greater on foam (deformable) surfaces among elderly adults with
neuropathy. Also, higher mean values for mediolateral (M-L) displacements from
Eyes Open on firm surface (EO) to Eyes Closed on foam surface (ECF) was seen.
A cross-sectional study done on the impact of Diabetic Neuropathy on Balance and
on the risk of falls in patients with type 2 diabetes in the year 2018 by Bogdan Timar,
Romulus Timar, Laura Gaita, et al. concluded that the presence of diabetic
neuropathy in diabetic patients is associated with impairment in balance and
consecutively increased fall risk.39,40, 15,7
• A systemic literature review on clinical measures of balance in people with type 2
diabetes (Gait and Posture) by C.J. Dixon, T. Knight, et al. enumerated various
measures that could assess the different systems of balance. Eight studies
incorporated from MEDLINE, Dentistry and Oral Sciences Source, CINAHL plus,
SPORTDiscus and SCOPUS encompassed a total of ten different clinical balance
measures: Dynamic Balance Test, tandem and unipedal stance, balance walk, Berg
Balance Scale, Functional Reach Test, Clinical Test of Sensory Interaction, Tinetti
Performance- Oriented Mobility Assessment, Timed Up and Go Test, Dynamic Gait
Index and Activity-Specific Balance Confidence Scale.41
18
• Further, a review on the relevance of clinical balance assessment tools by Martina
Mancini and Fay B Horak to differentiate balance deficits concluded that most
functional balance evaluation tools (Activities of Balance Confidence, Tinetti
Balance and Gait Test, Berg Balance Scale Timed “Up and Go Test”, Functional
Reach Test) do not distinguish between different types of balance deficiencies, but
rather evaluate fall risk and the requirement for balance rehabilitation. Different
types of balance disorders can be distinguished using a system approach to clinical
balance assessment, and underlying sensorimotor mechanisms causing balance
disorders can be identified using a physiological approach (Balance Evaluation
Systems Test and The Physiological Balance Profile). Clinical balance testing can
become more sensitive, specific, and responsive with the use of objective measures
of balance employing computerised systems and wearable inertial sensors with
dynamic posturography being the most frequently used objective measurement in
order to discriminate between sensory and motor impairments that underlie postural
control.26
• Study done in Taiwan by Chiang-Yi Wang, Chiang-Lin Hsien, et al. to investigate
the psychometric properties of the Berg Balance Scale (BBS) in a community-
dwelling Elderly Resident Population showed that the internal consistency
reliability, interrater reliability and construct validity of the BBS are appropriate for
measuring balance in community-dwelling older adults. It also recognized tandem
stance and one-legged stance as the most challenging items in BBS for the above
population. Further, a Systematic Review by C.A. Lima, N.A. Ricci done on the use
of BBS as a clinical screening tool to predict fall risk in elderly concluded that there
is insufficient evidence to support the use of BBS to predict falls, and thus should
not be used alone to determine the risk of falling in older adults. The cut-off scores
19
for BBS were presented in three studies, ranging from 45-51 points and only two
studies reported a difference in the scoring of BBS between the fallers and non-
fallers. Another study with similar objective by Linda D Bogle Thorbahn et al.
showed that decreased scores (<45/56) were not a predictor of increased frequency
of falls. It also showed a difference between the subjects who were prone to falling
and those who were not, but it demonstrated poor sensitivity (53%) for predicting
who would fall, though the specificity of the test was very strong (96%). A
comparative study by Barbara Ban, France Sevšek et al. examined the ceiling effect
of Berg Balance Scale (BBS) and Mini-BESTest (MBT) in 26 community-dwelling
older adults and showed the ceiling effect difference between the two to be
statistically significant (p < 0.001). As many as 73.1% of participants obtained the
highest score on BBS indicating a very high ceiling effect whereas, only 3.8%
reached the highest score of the scale, when tested by MBT.42,30,29,28
• A study on increased postural sway during quiet stance as a risk factor for
prospective falls in community-dwelling elderly individuals (Age and Ageing) by
Jonas Johansson, Anna Nordstrom, et al. concluded that objective measures of
postural sway are independent predictors of incident falls in community-dwelling
older men and women. This risk was increased by 75%-90% for fallers as compared
to the non-fallers in the highest quintile of center of pressure sway length. A
Systematic Review with Meta-analysis done with the purpose of providing a
comprehensive comparison of the diagnostic balance tests for predicting falls and
for distinguishing older adults with and without falls history found the single-leg
test (non-instrumented tests) to be the most promising to discriminate between
fallers and non-fallers and the center-of-pressure area to be most consistently
associated with falls, in terms of body sway measures. Thus, the single-leg test was
20
recommended for the assessment of the risk of falling, and the measurements of
body sway for a more comprehensive assessment.32,37
• The relationship between force platform and two functional tests for measuring
balance in the elderly was studied by Andre W. O. Gil, Marcio R. Oliveira, et al.
with the purpose of correlating the force platform measurements with two functional
tests (one-leg standing test and a functional agility/dynamic balance test). The study
showed a weak association between them and thus supported the notion that
functional tests do not necessarily provide the same information as force platforms
regarding balance mechanisms. But another study on the comparison of field
balance tests: - Berg Balance Scale (BBS), Performance Oriented Mobility
Assessment (POMA), Functional Reach (FR), and Timed Up and Go Test (TUGT)
and Force Platform (Locomotor Apparatus in Exercise and Sports) by Renata Alyne
Czajka Sabchuk, Paulo Cesar Barauce Bento, Andre Luiz Fellix Rodacki concluded
that BBS and TUGT tests are preferred for evaluation of capacity and balance as
they are simple, low-cost tests and more strongly associated to the results found on
the force platform. Here, the variables analyzed in the force platform were: - center
of pressure displacement in the antero-posterior (AMP-AP) and medio-lateral
direction (AMP-ML) and total sway of the center of pressure (TRAJ-CP).34, 43
• Study on evaluation of standing balance of the elderly with different balance
abilities by using Kinect and Wii Balance Board (Korean Journal of Sport
Biomechanics) by Seung Tae Yang, Jung Woo Seo, et al. concluded that simple
standing balance of the elderly can be measured using Kinect and Wii Balance
Board which are easy to carry out, low-cost and easy to use. It was found that root
mean square (RMS), mean distance (MDIST) and range of distance (ROD) in the
Medio-Lateral direction had strong negative correlations with Berg Balance Scale
21
scores and are appropriate parameters for quantitatively assessing standing balance
of the elderly using Kinect and Wii Balance Board. Another study on the correlation
between center of pressure (COP) measures driven from Wii Balance Board and
Force Platform (Asian Journal of Sports Medicine) by Ladan Zakeri, Ali Asghar
Jamebozorgi and Amir Hossein Kahlaee showed both these devices to be having
acceptable reliability. Also, the difference between the measurements of the two
devices was found to be highly variable without any significant systematic bias.38,44
• A study done by A. K. Topper, B. E. Maki et al. achieved a 65 percent accuracy, 78
percent sensitivity, and 46 percent specificity by using posturography and logistic
regression to distinguish between fallers and non-fallers. The study also concluded
that a static posturography test may be helpful as a quick and easy screening
technique to help identify those who are at high risk of falling and may offer
improved overall prediction of the various kinds of falls. Sandra G. Brauer, Yvonne
R. Burns et al. in their study, used posturography and logistic regression to
differentiate between fallers and non-fallers with a sensitivity of 29% and specificity
of 88%. This study examined the ability of various clinical and laboratory measures
of postural stability to predict falls in community-dwelling older women, and it
found that the laboratory variables were better at predicting non-fallers than
fallers.45,46
• Various studies have shown the use of force platform as a therapeutic rehabilitation
tool. It can be used to improve motor skills and balance along with mobility and
quality of life in stroke patients. Balance training on force platform with visual
feedback improved balance control in aged population. It also showed significant
improvements when used along with functional electric stimulation. In older
women, balance training using visual feedback on force plate (lateral, forward, and
22
backward exercises) along with strength training improved static balance to a
greater extent.47,48,49,50
23
METHODOLOGY
Ethical clearance was obtained from the Institutional Ethical Committee of SDM
College of Medical Sciences and Hospital, before commencement of the study.
Study subjects:
Diabetic elderly visiting the Departments of Medicine and Endocrinology, SDM
Medical College and Hospital, Dharwad, Karnataka
Inclusion criteria:
• Community dwelling individuals
• Age group 60-75 years
• Participants with either gender
• Individuals diagnosed with diabetes by certified medical practitioners (with and
without diabetic peripheral neuropathy)
• Minimum 5 years duration of diabetes17
• Able to follow commands
• Normal cognition (HMSE- 23 points)24
Exclusion criteria:
• Uncorrected visual/ hearing impairment
• Neurologic pathology (e. g. Parkinson’s disease, stroke)
• Orthopaedic surgery to lower limbs (e. g amputations, total hip and knee
surgeries, fractures) in past 6 months
• Advanced stages of osteoarthritis, rheumatoid arthritis, gout
• Foot ulcers, cellulitis
24
• Medications that could influence posture and/or gait
• H/O vertigo
• Terminal disease (e. g. cancer)
Study area:
Departments of Medicine and Endocrinology of SDM College of Medical Sciences and
Hospital, Dharwad, Karnataka
Study period:
1-year duration
Study design:
Cross- sectional study
Sampling procedure:
Due to the COVID-19 pandemic, patients visiting the Medicine and Endocrinology
Departments of SDM Medical College and Hospital were restricted. As a result,
calculating the sample size using the prevalence rate method or utilizing the data from
the past 3 years hospital records was not applicable. Thus, a Convenient Sampling
method wherein patients visiting the departments of Medicine and Endocrinology
(Diabetic Clinic) for any emergency and even those accompanying them were included.
By the end of 1 year, approximately 92 patients were convinced to participate, out of
which only 72 met the inclusion criteria and gave consent to participate in the study.
25
Study methodology:
Patients visiting the Medicine and Endocrinology Department (Diabetic Clinic) of SDM
Medical College and Hospital meeting the inclusion criteria were approached for the
study. Each participant was briefed about the study and consent was obtained from them
before commencement of the procedure.
Basic demographic data (including medical, drug and falls history) was noted. HMSE
scale was used to screen participants for cognitive impairment (23/31)24 and MNSI to
screen for diabetic peripheral neuropathy (2/10)15,22. Orientation of the study procedure
was given to the participants along with a detailed explanation of both the outcome
measures i.e., the Force plate (AM3 FootWork Pro) and items included in Berg Balance
Scale (BBS).
Participants were instructed to properly clean and wipe their feet with tissue and
sterillium before standing barefoot on the force plate as even minute particles of mud
can lead to errors in the measurements. Also, they were told to remove any metallic
items (including toe rings) and any heavy items like phones, coins etc. before standing
on the force plate which could add up to the weight. Additionally, participants were
instructed to maintain an upright position throughout the test, stand relaxed and avoid
any arm or head movement, and not to unnecessarily shift their weight until the trial
completes.
Following the instructions, the participants were asked to stand still for 30 seconds on
the force plate with their eyes open, both feet in a static stance, and their feet hip-width
apart as measurements of the COP displacement values (centimeters) of (A-P) in the
sagittal plane and (M-L) in the frontal plane of the body were taken. Static
posturography was carried out with the participant positioned in a standing position on
26
a fixed instrumented platform (AM3 FootWork Pro) that was connected to force and
movement transducers, which are sensitive detectors that can pick up on the tiniest body
oscillations. On the monitor, stabilometric graphs for the right and left feet separately
as well as the entire body were displayed. For convenience, only the total body
displacement was taken into account. An average of 3 values was taken with a rest
period of 1 minute in between. After each trial, the system was upgraded to avoid any
technical errors.
After this, the participants were asked to stepdown from the force plate and BBS was
performed. Rest period of 2 minutes was given before commencement of BBS. Certain
items on BBS (Transfers, Forward reach, turning to look behind, placing alternate foot
on step) were demonstrated for better understanding by the participants. All the safety
and hygienic precautions were taken care of.
The entire procedure took 20-30 minutes for the explanation and demonstration of BBS.
27
Figure 1: Schematic diagram showing the enrollment of participants and study
procedure
Total no. of individuals approached (n= 92)
n=8 (H/O
ulcers)
n= 6 (cognitive
issues)
Procedure of the study explained to the
n= 2 (did not
participants (n=72) and written informed
give consent)
consent obtained prior to the study
n=4 (<5 years
duration of
DM)
Included = 72
HMSE to screen cognitive impairment and
MNSI to screen diabetic peripheral neuropathy
Posturography on force plate performed Participants

in double limb support static stance with stood in a
eyes open quiet static
stance on the
force platform
and feet at
pelvis width
while
Variables used for interpretation were measurements
Antero-posterior (A-P) and Medio- were recorded
lateral (M-L) COP displacements
Each
condition
Berg Balance Scale done after rest performed
period of 2 mins (with necessary for 30 secs
demonstrations) for 3 trials
with rest
period of 1
minute in
between
28
Study instruments:
1. Data collection sheet
2. Consent form
3. Stadiometer
4. Weighing machine
5. Berg Balance Scale
6. Michigan Neuropathy Screening Instrument
7. Hindi Mental State Examination Scale
8. Force plate (AM3 FootWork Pro)
9. Stopwatch
10. Ruler of 2, 5 and 10 inches
11. Chair (with and without armrests) of reasonable height
12. Step or stool of average step height
13. Knee hammer
14. Tuning fork (128 Hz)
15. Monofilament
16. Stationary
29
Hindi Mental State Examination (HMSE)
HMSE is a 31 item- scale used to screen participants for cognitive impairment which is
a modified version of Mini Mental State Examination (MMSE) developed primarily to
overcome educational bias for cognitive impairment evaluation in rural illiterate elderly
individuals. The cut-off score is 23/31 and it has a high sensitivity (0.81) and specificity
(0.60).24
Michigan Neuropathy Screening Instrument (MNSI)
MNSI is used to screen for Diabetic Peripheral Neuropathy.
Description of MNSI:
The first part of screening instrument comprises of 15 self-administered “yes or
no” questions on foot sensation including pain, numbness and temperature
sensitivity. A score of ≥ 7 is considered abnormal. 7
A brief physical examination constitutes the second part of the MNSI which
involves:
1) Inspection of both feet for any kind of deformities, dry skin, callus, any
infection, fissures or any other abnormalities
2) Presence of any ulceration
3) Ankle reflex grading
4) Vibration perception at great toe with a 128Hz tuning fork
5) Monofilament testing
A cut-off score of 2/10 indicates the presence of DPN.
30
The MNSI technique has a high diagnostic impact due to its high specificity,
likelihood ratio > 5, and moderate to good post-test probability, sensitivity 65%
and specificity 83%.22
Berg Balance Scale (BBS)
BBS is a standard outcome measure designed specifically for the elderly population to
check their functional balance. The scale consists of 14 items which contains both static
and dynamic activities which are related to our everyday life, scored from 0 to 4, which
are added to make a total score between 0 and 56; a higher score indicates better balance.
Score <45 indicates individuals maybe at greater risk of falling. The items vary in
difficulty – from sitting in a chair to standing on one leg. It takes approximately 10 to
15 minutes to complete the test. It assesses balance and falls risk by directly observing
the participant’s performance in a variety of settings and has a high relative reliability
with inter-rater reliability estimated at 0.97 (95% CI 0.96 to 0.98) and intra-rater
reliability estimated at 0.98 (95% CI 0.97 to 0.99) 19,51
The AM3 FootWork Pro
It is a plantar pressure measurement device which records all the relevant information
needed to analyse the foot’s behaviour. It is uniquely able to capture a multitude of
pressure samples (from either direction) before displaying the average. It has got both
static and dynamic features like Center of Pressure (COP) and maximum pressure of
each foot, centre of force and quadrant pressure distribution, Stabilometry: Quantifies
sway in anterior/posterior and sagittal perspectives and General Pressure Overview:
Mean, Maximum and Pressure/Time Integral, Cop and its velocity – foot timing and
muscle function respectively.52
31
RESULTS
Statistical analysis was done using SPSS 20.00 version. The descriptive analysis was
done and presented as numbers, means, percentages and standard deviation (SD) of age,
gender and duration of diabetes (Tables 1,2,3), BBS scores (Table 4, Figure 2) and
Screening for and awareness of DPN in the participants (Figures 3 and 4). Further,
comparison of age groups with mean duration of diabetes was done using one way
ANOVA test and Pair wise comparisons by Tukeys multiple posthoc procedures (Table
5, Figure 5). Comparison of males and females with mean duration of diabetes was
done by independent t- test (Table 6). Chi-square test was done to find the association
between history of falls and BBS scores (Table 7). Correlations between BBS scores
and COP displacement in A-P and M-L directions on the force plate was performed
using Karl Pearson’s correlation coefficient method (Table 8) and the same data were
presented in the form of Scatter plots (Figures 6,7,8). Receiver Operating Characteristic
(ROC) curve was used to find the cut-off values of COP displacement in both A-P and
M-L directions on Am3 force plate (Figures 9, 10). Further sensitivity and specificity
of COP displacement in A-P and M-L directions on force plate was found keeping BBS
as standard measure (Tables 9,10).
All calculations were performed at 95% Confidence Interval with p<0.05 being
considered as statistically significant.
32
Table 1: Age wise distribution of participants
Age groups No. of participants Percentage of participants
60-64yrs 42 58.33
65-70yrs 25 34.72
≥71yrs 5 6.94
Total 72 100.00
Mean age 63.86
SD age 4.47
Most of the participants were in the 60-64 years age group (58.33%), followed by
participants in the 65-70 years age group (34.72%), with least number of participants in
the age group of ≥71 years (6.94%). The mean age was found out to be 63.86 years,
with a Standard Deviation of 4.47 years.
33
Table 2: Gender wise distribution of participants
Gender No. of participants Percentage of participants
Male 41 56.94
Female 31 43.06
Total 72 100.00
Gender wise distribution of participants showed a greater number of males (56.94%) as
compared to females (43.06%)
Table 3: Distribution of participants according to the duration of diabetes
Duration of diabetes No. of participants Percentage of participants
5 yrs 29 40.28
6-10yrs 28 38.89
≥11yrs 15 20.83
Total 72 100.00
Mean 9.18
SD 6.21
Maximum participants had 5 years of diabetes duration (40.28%), followed by those in
6-10 years of duration (38.89%) and the least being with ≥11 years duration of diabetes
(20.83%). The mean duration of diabetes was 9.18 years, with a Standard Deviation of
6.21 years.
34
Table 4: Berg Balance Scale (BBS) scores of participants
BBS No. of participants Percentage of participants
<45 40 55.56
≥45 32 44.44
Total 72 100.00
Figure 2: Berg Balance Scale (BBS) scores of participants
A score of <45 indicates that individuals maybe at a higher risk of falls (ROF). In our
data, out of the total 72 participants, 40 participants were at a higher risk of falling
(55.56%) while 32 participants (44.44%) were at a lower risk.
35
Figure 3: Screening of Diabetic Peripheral Neuropathy using Michigan
Neuropathy Screening Instrument
Out of the total 72 participants screened for DPN using MNSI, 70 participants had DPN
while only 2 did not have this complication of diabetes.
Figure 4: Awareness of Diabetic Peripheral Neuropathy among participants
Our results showed that only 2 participants were aware of DPN among the 72
participants.
36
Table 5: Comparison of age groups with mean duration of diabetes by one way
ANOVA test
Age groups N Mean SD SE
60-64yrs 42 8.07 4.44 0.685
65-70yrs 25 10.00 6.83 1.365
≥71yrs 5 14.40 12.32 5.510
Total 72 9.18 6.21 0.732
F-value 2.7865
p-value 0.0686
Pair wise comparisons by Tukeys multiple posthoc procedures
60-64yrs vs 65-70yrs p=0.4227
60-64yrs vs ≥71yrs p=0.0771
65-70yrs vs ≥71yrs p=0.3059
Figure 5: Comparison of age groups with mean duration of diabetes by one way
ANOVA test
30.00
25.00
20.00
Mean+/-SD
14.40
15.00
10.00
10.00
8.07
5.00
0.00
60-64yrs 65-70yrs >=71yrs
37
The comparison of age groups with mean duration of diabetes was done by one way
ANOVA test. Results showed that there was no statistically significant difference (p
value = 0.0686) between the mean age and the mean duration of diabetes. F- value was
found out to be 2.7865.
Using Tukeys multiple posthoc procedures for pairwise comparisons, no statistically
significant differences were found; 60-64yrs vs 65-70 years (p=0.4227), 60-64 years vs
≥71 years (p=0.0771), 65-70 years vs ≥71 years (p= 0.3059).
Table 6: Comparison of males and females with mean duration of diabetes by
independent t test
Gender n Mean SD SE t-value p-value
Male 41 10.10 6.66 1.04 1.4520 0.1510
Female 31 7.97 5.43 0.97
Comparison of males and females with mean duration of diabetes done using
independent t test showed t-value of 1.4520 with p-value=0.1510 (no statistically
significant difference).
Table 7: Association between history of fall and Berg Balance Scale (BBS) scores
by Chi-square test
BBS No history of fall % History of fall % Total %
<45 23 57.50 17 42.50 40 55.56
≥45 24 75.00 8 25.00 32 44.44
Total 47 65.28 25 34.72 72 100.00
Chi-square= 2.4020, p=0.1210
38
Among the 40 participants, who had BBS score less than 45 (i.e., higher risk of falls),
17 participants already had history of falls.
32 participants were at a lower risk of falls (i.e., BBS score ≥45), but still out of them 8
participants had history of falls.
Thus, a total of 25 participants out of 72 had history of falls. The Chi-square value was
found to be 2.4020 with p-value =0.1210 (no statistically significant difference)
Table 8: Correlations between Berg Balance Scale (BBS) scores and Centre of
Pressure (COP) displacement in Antero-Posterior (A-P) and Medio-Lateral (M-P)
directions on force plate using Karl Pearson’s correlation coefficient method
Variables Correlations between
r-value t-value p-value
BBS with A-P -0.3686 -3.3171 0.0014*
BBS with M-L -0.4210 -3.8831 0.0002*
A-P with M-L 0.6011 6.2936 0.0001*
*p<0.05
Table 8. correlates BBS scores with COP displacement measures in A-P and M-L
directions on force plate by Karl Pearson’s correlation coefficient method.
Statistically significant Negative correlation was found when BBS score was
correlated with A-P (r-value= -0.3686, p-value=0.0014) and M-L (r-value= -0.4210,
p-value=0.0002) COP displacement scores separately. This indicates that as the BBS
scores decreases, the COP displacement in both A-P and M-L directions on the force
plate increases, indicating higher risk of falls. And as the BBS scores increases, the COP
displacement in both A-P and M-L directions on the force plate decreases, indicating
lower risk of falls.
39
Also, the A-P and M-L COP displacements showed statistically significant Positive
correlation (r-value=0.6011, p-value=0.0001) indicating that if the COP displacement
increases in the A-P direction, it also increases in the M-L direction.
The p-value was set at <0.05 and was found to be statistically significant in our
participants.
Figure 6: Scatter diagram showing the correlation between Berg Balance Scale
(BBS) scores and Center Of Pressure (COP) displacement in Antero-Posterior
(A-P) direction on force plate
The scatter plot depicting the correlation between BBS scores and A-P COP
displacement on force plate shows Negative correlation (i.e., as the BBS scores
40
decreases, the COP displacement in A-P direction increases and vice-versa). The points
in the scatter graph are falling while moving left to right.
Figure 7: Scatter diagram showing the correlation between Berg Balance Scale
(BBS) scores and Center of Pressure (COP) displacement in Medio- Lateral (M-
L) direction on force plate
The scatter plot representing the correlation between BBS scores and M-L COP
displacement on force plate shows Negative correlation (i.e., as the BBS scores
increases, the COP displacement in M-L direction decreases and vice-versa). A fall in
the points from left to right is noticed.
41
Figure 8: Scatter diagram showing the correlation between Center of Pressure
(COP) displacement in Antero-Posterior (A-P) and Medio-Lateral (M-L)
directions on force plate
Figure 8. illustrates the correlation between COP displacement on force plate in A-P
and M-L directions showing Positive correlation (i.e., as the A-P COP displacement
increases, COP displacement in M-L direction also increases). The points in the graph
are rising, moving from left to right.
42
Figure 9: Receiver Operating Characteristic (ROC) curve of Antero-Posterior (A-
P) displacement of Center of Pressure (COP) on force plate by Berg Balance Scale
(BBS)
AUC: 0.7500
The Area Under Curve (AUC) = 0.7500. This means that presented with a random
chosen pair of patients, one higher and one with lower Risk of Falls (ROF), the clinician
would correctly identify the patients 75% of the time.
In our study, the cut-off point for COP displacement in A-P direction using ROC curve
was found to be ≥2.3 centimeters.
43
Table 9: Sensitivity and specificity of Antero-Posterior (A-P) displacement of
Center of Pressure on force plate over Berg Balance Scale (BBS)
Statistic Value 95% CI
Sensitivity 96.88% 83.78% to 99.92%
Specificity 20.00% 9.05% to 35.65%
Positive Predictive Value 49.21% 45.05% to 53.38%
Negative Predictive Value 88.89% 51.33% to 98.38%
Accuracy 54.17% 42.00% to 65.98%
Using ≥2.3 cms as the cut-off point for A-P COP displacement on the force plate,
sensitivity was found to be 96.88%. Of the 40 participants identified as having higher
ROF on BBS, 39 participants were found to have larger COP displacement on the force
plate using this criterion.
The specificity of the test was found to be 20.00%. Of the 32 participants who were
identified as having low ROF on BBS, only 6 participants were found to have smaller
COP displacement on the force plate.
Positive Predictive Value (PPV) was 49.21% which means about half of the participants
who were identified as having larger COP displacement on the force plate with the cut-
off value of ≥2.3 cms in A-P direction, were actually at an increased ROF on BBS.
Negative Predictive Value (NPV) was 88.89% which means almost 89% of the
participants who were identified as having smaller COP displacement on the force plate,
were truly at a lower ROF on BBS.
The accuracy of the force platform for A-P COP displacement was found to be 54.17%.
44
Figure 10: Receiver Operating Characteristic (ROC) curve of Medio-Lateral (M-
L) displacement of Center of Pressure (COP) on force plate by Berg Balance Scale
(BBS)
The AUC = 0.6950. This means that presented with a random chosen pair of patients,
one higher and one with lower ROF, the clinician would correctly identify the patient
69% of the time and the cut-off point for COP displacement in M-L direction using
ROC curve was ≥2.7 centimeters.
45
Table 10: Sensitivity and specificity of Medio-Lateral (ML) displacement of Center
of Pressure on force plate over Berg Balance Scale (BBS)
Statistic Value 95% CI
Sensitivity 93.75% 79.19% to 99.23%
Specificity 22.50% 10.84% to 38.45%
Positive Predictive Value 49.18% 44.47% to 53.91%
Negative Predictive Value 81.82% 51.10% to 95.09%
Accuracy 54.17% 42.00% to 65.98%
Using ≥2.7 cms as the cut-off of the M-L displacement on the force plate, sensitivity
was found to be 93.75%. Of the 40 participants identified as having higher ROF on
BBS, 38 participants were found to have larger COP displacement on the force plate
using this criterion.
The specificity of the test was found to be 22.50%. Of the 32 participants who were
identified as having low ROF on BBS, only 7 participants were found to have smaller
COP displacement on the force plate.
PPV was 49.18 % which means about half of the participants who were identified as
having larger COP displacement on the force plate with cut-off value of ≥2.7 cms in the
M-L direction, were actually at an increased ROF on BBS.
NPV was 81.82 % which means almost 82% of the participants who were identified as
having smaller COP displacement on the force plate, were truly at a lower ROF on BBS.
The accuracy of force plate for M-L COP displacement was found to be 54.17%
46
DISCUSSION
This particular study as per the review of literature, the first of its kind to determine the
correlation between COP displacement on Force Plate (Laboratory Test) and Berg
Balance Scale (Field Test) to identify the risk of falls in elderly diabetics.
The study was conducted in SDM Medical Hospital, Dharwad, Karnataka and the force
plate used in the study is AM3 FootWork Pro which is available in the Endocrinology
Department (Diabetic Clinic). A total of 72 individuals participated till the end of the
study.
Our results showed a greater number of male participants (56.94%) with diabetes as
compared to females (43.06%) (Table 2). These findings are similar to a study done in
Sweden which concluded that men had a higher prevalence of type 2 diabetes than
women, which was linked to a higher proportion of visceral fat in men.53 Another study
done in India in the year 2021 showed higher prevalence of diabetes among men
(2.63%) than in women (2.35%). It concluded that females and males with identical
socioeconomic level, biological characteristics, dietary and smoking habits are affected
differently by diabetes depending among various other factors.54 The review on gender
differences in metabolic regulation and diabetes susceptibility has shown that diabetes
is more common in males than in females in most parts of the world, especially among
middle-aged people. Males are more likely than females to acquire fat, insulin
resistance, and hyperglycemia in response to nutritional challenges. Also, insulin
sensitivity is higher in women, who also have greater insulin secretion and incretin
response capacity than men. Endogenous oestrogens have been shown to have
protective effects in different organs, including the brain, liver, skeletal muscle, adipose
tissue, and pancreatic beta cells, primarily through oestrogen receptor alpha
activation.55
47
Majority of our participants were in the age group of 60-64 years (58.33%), followed
by 65-70 years age (34.72%), with least number of participants above the age of 71
years (6.94%) (Table 1). Less number of participants in the advancing age groups in
our study could be due to fewer hospital visits made by them either because of mobility
issues, other co-morbidities and the COVID-19 pandemic.
Literature shows that diabetes affects the majority of older persons due to a combination
of increasing insulin resistance and reduced insulin secretion. As age advances, insulin
resistance is thought to be caused by a combination of obesity, sarcopenia (loss of
muscle mass), and physical inactivity. Furthermore, as people get older, their pancreatic
islet function and proliferative ability deteriorate, potentially impairing insulin output.
In older adults compared to younger ones, increasing insulin resistance is likely a more
important cause of diabetes than decreased insulin production. Concomitant chronic
disorders (e.g., hypertension) can exacerbate the clinical course of older persons with
diabetes, which might interact with their condition and hasten the advancement of
diabetic complications.56
Hyperglycemia is caused by a lack of insulin secretion that develops with age, as well
as an increase in insulin resistance induced by a shift in body composition and
sarcopaenia. Clinically it is found that, as the age advances, prevalence and duration of
diabetes increases.57 Our results also proved the same i.e., the mean duration of diabetes
increased with advancing age, but it was not statistically significant (p-value= 0.0686)
(Table 5, Figure 5).Also the mean duration of diabetes was higher in males as compared
to females, but no statistically significant difference was found (p-value = 0.1510)
(Table 6).
48
Older persons with diabetes, are at an increased risk of an injurious fall that necessitates
hospitalisation than those without diabetes. Poor glycemic control in diabetics adds up
to this.58
With a prevalence of about 60%, diabetic peripheral neuropathies are one of the most
prevalent microvascular complications of diabetes among the various others.7
Studies have shown that the risk of falling and suffering injuries from falls is
considerably increased by diabetic peripheral neuropathy (DPN), which can include
muscle weakness, loss of ankle reflexes, and impairments in balance, coordination, and
gait control. However, regardless of the severity of their DPN, individuals show greater
fear of falling, which may cause them to avoid tasks within their capabilities; impairing
their mobility and further raising their risk of falling.59 It is known that increased
9
postural sway is associated with an increased risk of falls and several studies have
shown that people with diabetes and DPN have a greater postural sway as compared to
the healthy individuals.10,15,17
Since, presence of DPN is one of the factors for postural instability, loss of balance and
6,10,39,40
increased risk of falls, screening of all the participants was done using MNSI
which is a validated score tool for diabetic distal symmetrical peripheral neuropathy
that is frequently used for diagnosis and quantification and the test is simple to
administer and interpret, particularly for internists and general practitioners. The MNSI
technique has a high diagnostic impact due to its high specificity, likelihood ratio > 5,
and moderate to good post-test probability, with a cut-off score of 2 indicating presence
of DPN.7,22
One of the significant findings of this study was, out of the total 72 participants, only 2
participants did not show any symptoms of DPN (Figure. 3) and amongst all, only 2
were aware of having the complication of DPN (Figure 4). Our results were in line with
49
the study done in 2020 by Amnah Salem Basharheel et al. on the Awareness of diabetic
neuropathy in diabetic patients in Saudi Arabia which showed unsatisfactory response
for the level of knowledge towards diabetic neuropathy symptoms in their population.60
Thus, identification of DPN and the risk of falls in the elderly are crucial because the
majority of diabetics are unaware of this complication (i.e., DPN), which can lead to
falls.
In general, a number of field tests (FT) are used to assess balance. These FTs use various
protocols and approaches and can be divided into static, timed, functional,
observational, and subjective categories. The performance-oriented mobility
assessment (POMA), the timed up and go test (TUGT), the functional reach test (FRT),
and the Berg balance scale (BBS) are the tests that are most frequently employed.34
Out of these, the BBS is considered as the Gold Standard to assess balance and to
determine the risk of falls in the elderly. Although the Berg Balance Scale has a high
relative reliability with inter-rater reliability estimated at 0.97 and intra-rater reliability
estimated at 0.98, it has a large ceiling effect when used in people younger than 75 who
have an increased risk of falling even without a specific health condition likely to affect
balance. 51
Also, BBS is an assessment tool that can be performed by any qualified healthcare
provider with adequate training which also requires a larger space, more manpower,
demonstration of tasks along with repeated instructions and is time-consuming. It’s
commonly used by occupational therapists, physical therapists and clinical exercise
physiologists to determine a person’s functional mobility.61
On the other hand, the force platform has been considered as the gold standard for the
assessment of the postural control system.44 The centre of pressure (COP) displacement,
which is the application point of the result of the vertical forces acting on the base of
50
support, is the basis for the posturography tests used to evaluate posture control. Balance
measures on force plate have been reported as highly sensitive and are used as a
benchmark for determining changes in posture control. They enable the identification
of subtle posture changes.33,34
This method of posturography is basically used by physicians and diabetologists in the
absence of a trained physiotherapist which overcomes the requirements of BBS.
A Systematic Review done to find out the use of Berg Balance Scale as a clinical
screening tool to predict fall risk in older adults included 8 studies which showed that
the mean BBS score for older persons was generally high regardless of the history of
falls, indicating that the scale has a ceiling effect. Personal variables (gender, age), as
well as health state (visual and cognitive impairments, comorbidities, and
polypharmacy), have been shown to increase the risk of falls in older persons. The
Review concluded that the evidence for using BBS to predict falls is weak, and it should
not be used alone to estimate the risk of falling in older persons. 30
Furthermore, BBS is a subjective measure when compared to the force platform which
is a quick, accurate and objective method with least number of instructions to be given
to the participants. 9,32
Among community- dwelling older people, the objective measure of postural sway is
recognised as a significant predictor of falls, along with impaired balance. 32,62
Most of the field tests have been chosen for their easiness and low cost, but require a
larger space, manpower and are time-consuming and little is known about how well
they correlate with the objective measures provided by posturography testing using a
force platform.34
Thus, in the present study we aimed to correlate COP displacement on force plate
(Laboratory test) with BBS (Field test) to identify ROF in elderly diabetics.
51
Additionally, we tried to detect the cut-off values for A-P and M-L COP displacements
on force plate which can be used by physicians as a screening measure for further
evaluation and confirmation of ROF in elderly diabetics.
In our study, among the 40 participants, who had BBS score less than 45 (i.e., higher
risk of falls), 17 participants already had history of falls and among 32 participants who
were at a lower risk of falls (i.e., BBS score ≥ 45), 8 participants presented with previous
history of falls. No statistically significant association was found between history of
falls and BBS scores (p=0.1210) (Table 7).
In the study done by Linda Thorbahn to determine the use of BBS to predict falls in
elderly people, the BBS demonstrated high specificity (96%), but the sensitivity was
low (53%) with the cut-off score of 45. This finding indicates that people who score 45
and above on BBS, have a greater probability of not falling than those who scored less
than 45. However, decreased scores did not predict increased frequency of falls.
Evidence shows that falls are primarily multifactorial in nature. A thorough assessment
of a person's risk of falling must look at the environment in which they work, not just a
score on any balancing test.29 Our study showed statistically significant negative
correlation between Center of Pressure (COP) displacement in A-P direction (r-value=
-0.3686, p-value=0.0014) and M-L direction (r-value= -0.4210, p-value=0.0002) of
the elderly diabetics on Force Plate and Berg Balance Scale (BBS) for the assessment
of risk of falls, thus rejecting the null hypothesis and accepting alternative hypothesis.
Which means, as the BBS scores decreases, the COP displacement in both Antero-
Posterior (A-P) and Medio-Lateral (M-L) directions on the force plate increases,
indicating higher risk of falls and vice-versa (Table 8, Figures. 6 and 7).
52
A similar study was done in the year 2012, wherein a number of field tests (Berg
Balance Scale (BBS), Performance Oriented Mobility Assessment (POMA), Functional
Reach (FR) and Timed Up and Go Test (TUGT) were compared with stabilometric tests
using Force Platforms (FP) to determine whether these tests are capable of
distinguishing the differences in balance between the young and older adults and results
of the study demonstrated that both field and force platform tests were able to
differentiate the balance in young and elderly subjects. Alike our study, the elderly
consistently presented lower performance in the balance tests and greater oscillations
of the center of pressure in the force platform test.34
A Systematic Review and Meta-analysis published in the year 2020 with the purpose of
providing a comprehensive comparison of the diagnostic balance tests used to predict
falls and differentiate between older persons with and without a history of falls included
studies in which instrumented (force plate body sway assessment) or other non-
instrumented balance tests (functional reach, single-leg test, Romberg test) were used.
With regards to body sway measures, the center-of-pressure area was most consistently
associated with falls.37
A study on Elderly fall risk prediction using static posturography (Wii Balance Board)
done in Canada concluded that Romberg Quotients (the Ratio between Closed and Open
Eyes Values) calculations are particularly relevant for fall risk assessments in elderly.
For multi-faller classification, cut-off scores based on posturography measurements
were clinically viable and offered better accuracy than single-faller classification.
Romberg Quotients of center of pressure in Anterior- Posterior direction (RQ CoP AP)
range with cut-off score 1.64 could be used to screen for single-faller elderly and cut-
off score 0.541 achieved an accuracy of 84.9% and is viable to screen older people at
risk of multiple falls.63
53
A prospectively observational study done on community-dwelling individuals (70
years) to look into how incident falls (post 6 and 12 months of initial examination) can
be predicted by objective measures of postural sway concluded that objective measures
of postural sway are independent predictors of incident falls. Participants with COP
sway lengths ≥400 mm had a 75 percent higher fall risk during the Eyes open
experiment and it was almost doubled during the Eyes closed trial with sway length
≥920mm.32
In our study, the cut-off values found on the force plate (Am3 FootWork Pro) were ≥
2.3 cms for Antero-Posterior direction (A-P) and ≥ 2.7 cms for the Medio-Lateral (M-
L) direction (i.e., M-L displacement is larger than A-P displacement) (Figures. 9 and
10). A study done on postural sway in Diabetic Peripheral Neuropathy (DPN) among
elderly showed a significant increase for M-L displacement across firm surface and
foam surfaces. M-L displacements are known to indicate postural stability at the hip
level, while A-P displacements are known to represent postural stability at the ankle
level. This shift from ankle to hip strategy is thought to be linked to the neurological
deficits exhibited in DPN. Participants with neuropathy due to decreased peripheral
sensation mostly rely on hip strategy, which is one cause for the change in ankle to hip
strategy. As a result, they recruit their hip abductors and adductors first, resulting in
higher M-L displacement. This could potentially be a contributing reason to increased
M-L COP displacement mean values.15
However, the A-P and M-L COP displacements showed positive correlation indicating
that if the COP displacement increases in the A-P direction, it also increases in the M-
L direction (r-value=0.6011, p-value=0.0001) (Table 8, Figure. 8).
54
Also, we aimed to determine the test performance characteristics of the COP
displacement on the force plate (sensitivity, specificity, positive and negative predictive
values, accuracy).
Sensitivity and specificity are characteristics of a test and are independent of
prevalence whereas, Positive Predictive Value (PPV) and Negative Predictive Value
(NPV) are best thought of as the clinical relevance of a test and use the prevalence of
a condition.
Sensitivity, also known as true positive rate, is the test’s ability to obtain a positive
test when the target condition actually exists. Those who have the condition of interest
will be appropriately classified by a highly sensitive test.
Specificity i.e., the true negative rate, is the test’s ability to produce a negative test
when the condition is really absent. When a person does not have the condition, a highly
specific test will very seldom test positive.
In our study, the tool (instrument) used is the Force plate which detects the COP
displacement and the test condition is to identify the Risk of falls.
Table 11: Example of Sensitivity and Specificity in our study
COP displacement on Force Test Condition (ROF)
Plate on Berg Balance Scale
True Positives Increased COP displacement Increased ROF
True Negatives Decreased COP displacement Decreased ROF
False Positive Increased COP displacement Decreased ROF
False Negatives Decreased COP displacement Increased ROF
In addition to sensitivity and specificity, the usefulness of a diagnostic tool can be
assessed by its feasibility. A test must show that it makes effective use of the available
55
time and resources and that it produces enough accurate results to be clinically valuable.
The predictive value of the test is used to evaluate this attribute.
A positive predictive value (PV+) estimates the likelihood that a person who tests
positive actually has the disease (true positives). The actual number of patients who
have the target condition will be strongly estimated by a test with a high positive
predictive value.
Similar to that, the probability that a person who tests negative actually has no disease
is indicated by a negative predictive value (PV-) (true negatives). A test's negative
predictive value will give a reliable estimate of the people of not having the target
disease.
Predictive value may be of greatest importance in deciding whether to implement a
screening program to identify individuals who at risk for developing a disease or who
may be in an early stage. The utility of the test is based on how many cases are identified
as a result of early detection.
Accuracy is the proportion of true results, either true positive or true negative, in a
population. It measures the degree of veracity of a diagnostic test on a condition.
A Receiver Operating Characteristic (ROC) curve is a graphic depiction that can be
used to assess the relationship between sensitivity and specificity.
Setting many cut-off points for a test and computing sensitivity and specificity at each
one are the steps in the process of creating a ROC curve. The curve is then drawn by
plotting a point for each cut-off score that corresponds to the proportion of patients who
were correctly identified as having the condition (also known as true positives or
sensitivity) on the Y axis against those who were incorrectly identified (also known as
false positives or 1-specificity) on the X axis.
56
The curve is completed at the origin and the upper right-hand corners, reflecting cut-off
points above and below the highest and lowest scores.
Area Under the Curve
The ROC curve's quality is displayed by the area under the curve (AUC). The area
shows how well the test can distinguish between people who have the test condition and
those who don't. AUC = 1.00 indicates a flawless test, allowing for 100% identification
of those with the test condition.64
It accepts values between 0 and 1, where a value of 0 represents a test that is completely
inaccurate and a value of 1 represents a test that is completely accurate. Utilizing the
trapezoidal rule, AUC may be calculated. An AUC of 0.5 often indicates no
discrimination (the capacity to diagnose people with and without the disease or
condition based on the test), 0.7 to 0.8 is seen as acceptable, 0.8 to 0.9 is regarded as
excellent, and more than 0.9 is regarded as outstanding.65
Choosing a Cut-off Point
We can utilise the ROC curve to determine which cut-off point would be most helpful
in addition to comparisons or describing the relative efficacy of a test for diagnosing an
illness. The curve's turning point is often the optimal place to make a cutoff. The best
cut-off point will typically be at the point where the curve turns. This will be the point
at which there is a maximal difference between the true positive rate and the false
positive rate—the difference between sensitivity and 1– specificity, known as the
Youden index.
Setting the cut-off score low avoids false negatives, thereby increasing sensitivity and
setting the cut-off score high, avoid false positives, increasing specificity.64
57
In our study, the ROC curve of A-P displacement of COP on force plate by BBS showed
the Area Under Curve (AUC) = 0.7500 (Figure. 9). This means that presented with a
random chosen pair of patients, one with higher and one with lower Risk of Falls (ROF),
the clinician would correctly identify the patients 75% of the time and the ROC curve
of M-L displacement of COP on force plate shows AUC = 0.6950 (Figure. 10). This
means if presented with a random chosen pair of patients, one higher and one with lower
ROF, the clinician would 69% of the time correctly identify the patient truly presenting
with the condition. The AUC is acceptable for both the ROC curves. The cut-off point
for COP displacement in A-P direction is ≥2.3 cms and the cut-off point for COP
displacement in M-L direction is ≥2.7 cms (Figures. 9 and 10).
With ≥2.3 cms as the cut-off of the A-P displacement on the force plate, sensitivity
is found to be 96.88% (Table 9) which means, of the 40 participants identified as
having higher ROF on BBS, 39 participants were found to have larger COP
displacement on the force plate using this criterion.
The specificity of the test is found to be 20.00% (Table 9). Of the 32 participants who
were identified as having low ROF on BBS, only 6 participants were found to have
smaller COP displacement on the force plate.
Positive Predictive Value (PPV) is 49.21% (Table 9) which means about half of the
participants who were identified as having larger COP displacement on the force plate
with the cut-off value of ≥2.3 cms in A-P direction, were actually at an increased ROF
on BBS.
Negative Predictive value (NPV) is 88.89% (Table 9) which means almost 89% of
the participants who were identified as having smaller COP displacement on the force
plate, were truly at a lower ROF on BBS.
58
The accuracy of the force platform for A-P COP displacement is found to be 54.17%.
(Table 9).
With ≥ 2.7 cms as the cut-off of the M-L displacement on the force plate, sensitivity
is found to be 93.75% (Table 10). Of the 40 participants identified as having higher
ROF on BBS, 38 participants were found to have larger COP displacement on the force
plate using this criterion.
The specificity of the test is found to be 22.50% (Table 10). Of the 32 participants
who were identified as having low ROF on BBS, only 7 participants were found to have
smaller COP displacement on the force plate.PPV is 49.18 % (Table 10) which means
about half of the participants who were diagnosed as having larger COP displacement
on the force plate with cut-off value of ≥2.7 cms in the M-L direction, were actually at
an increased ROF on BBS.
NPV is 81.82 % (Table 10) which means almost 82% of the participants who were
diagnosed as having smaller COP displacement on the force plate, were truly at a lower
ROF on BBS.
The accuracy of force plate for M-L COP displacement is found to be 54.17% (Table
10).
Overall, our results show higher sensitivity and lower specificity for the COP
displacement on the force plate. Higher sensitivity means, that the instrument/ tool is a
good screening test.
Higher sensitivity in our results explains that the force plate can correctly identify the
participants who are at an increased risk of falls by showing larger COP displacement
(≥2.3 cms for A-P COP displacement and ≥2.7cms for M-L COP displacement).
59
Once we identify any patient showing larger COP displacement on the force plate, we
can use the Standard- Berg Balance Scale to confirm if the patient is truly at high ROF
(true positive) or no (false positives). Thus, all the patients with ≥2.3 cms (A-P) and
≥2.7 cms (M-L) COP displacement will be included for further confirmatory test.
Topper et al. used posturography and logistic regression to distinguish between fallers
and non-fallers, achieving a 65 percent accuracy, 78 percent sensitivity, and 46 percent
specificity. In this study they aimed to find whether an assessment that combined the
activity-based and posturography tests would yield improved predictions of falling
liability, compared with the use of either type of test alone and showed that a static
posturography test of medial-lateral spontaneous postural sway, done under blinded
settings, may provide a better overall prediction of the different kinds of falls and may
be beneficial as a quick and simple screening technique to help identify high-risk of fall
individuals. The findings also imply that activity-based testing of transfer, turning, and
reaching tasks could be effective in detecting the need for therapy or other intervention
in these areas to prevent falls during associated activities when used in conjunction with
the posturography tests.45Brauer et al. used posturography and logistic regression to
differentiate between fallers and non-fallers with a sensitivity of 29% and specificity of
88%. This study examined the potential of multiple laboratory and clinical
measurements of postural stability to predict fallers in community-dwelling older
women and showed that the laboratory variables were better able to predict non-fallers
than fallers.46
Further, it has been demonstrated that functional lower-extremity weakness has a
significant role in enhancing the probability of the transition from a non-faller to a faller.
Compared to hip extensor leg muscular strength, hip abductor muscle strength declines
more noticeably with age. Additionally, the hip abductor muscle group particularly is
60
perceived to be important for the elderly because of their significant role in maintaining
medio-lateral balance control and their relation with lateral and posterolateral falls.
Aditionally, the stability of the head, arms, and trunk over the support leg as well as the
strength of the muscles in the hip frontal plane are crucial factors in preventing
destabilisation in the mediolateral direction during single-leg support and preventing
the centre of mass from rapidly falling downward and lateral toward the unsupported
swing side. Hip abductors appear to operate as a protective mechanism against stress
placed on the femoral neck and the danger of a femoral fracture at the actual time of
impact of an acute fall.66 This shows the importance of hip muscle strengthening in the
balance rehabilitation and fall risk prevention in elderly.
A study done in the year 2020 on the use of force platform after stroke rehabilitation
concluded that using balancing platforms and training on a force platform as a part of
comprehensive physical rehabilitation in the early recovery period, helped to improve
motor skills and balance, as well as to improve the quality of life and mobility of stroke
patients.47
Study on the Effects of Combined Balance and Strength Training on Measures of
Balance and Muscle Strength in Older Women with a History of Falls in 2020 suggested
that balance training exercises including lateral, forward, and backward exercises using
visual feedback on force plate along with strength training improved static balance to a
greater extent in older women.50
Thus, force plate when used with visual feedback and other interventions can also serve
as therapeutic rehabilitation tool. Since hip abductor strengthening is important for
balance training and to prevent falls in elderly, hip strategies concentrating on M-L COP
displacement training can be done on the force plate.
61
LIMITATIONS
• The COVID-19 pandemic restricted hospital visits, making it difficult to determine
the sample size by using the prevalence rate or by gaining access to the previous
three years' hospital records. Hence, convenient sampling method was used and
only 72 individuals participated till the end of the study, making the sample size
small.
• Fewer individuals in the above 70 age group participated in the study; this could be
because less people in this age group visited hospitals due to co-morbid conditions,
mobility problems, and the COVID-19 epidemic.
• When analysing the fall history, the environment in which the person lives or works
was not taken into account.
• No control group was taken for comparison.
• Follow- up of the participants to confirm the risk of falls was not done
FUTURE SCOPE OF THE STUDY
• A study can be done to compare the cut-off values of COP displacement on Am3
FootWork Pro in the older population to those found in elderly diabetes.
• A larger sample size can be considered.
• A longitudinal prospective study (as a continuation of this study) can be done in the
elderly individuals to predict falls 6 and 12 months after the initial assessment by
using BBS and taking detailed falls history (taking into consideration the
environment in which the individual lives / works).
62
CONCLUSION
Our study concluded that COP displacement on force plate (A-P and M-L directions) is
negatively correlated with BBS scores and there is a positive correlation between A-P
and M-L COP displacements. Force plate is a sensitive measurement tool to identify
COP displacement in A-P and M-L directions which can be considered as a good
screening tool to identify ROF. This objective method is useful as it displays subtle
changes in centimeter and millimeter. However, as specificity of force plate is low, it
cannot be replaced with the BBS.
Thus, diabetic elderly patients identified with ≥2.3 cms COP displacement in A-P
direction and ≥2.7 cms COP displacement in M-L direction on the force plate, can be
further referred to a Physiotherapist to confirm ROF and plan a better rehabilitation
along with fall prevention strategies.
63
SUMMARY
This particular study as per the review of literature, is first of its kind to determine the
correlation between Force Plate (Laboratory Tests) and Berg Balance Scale (Field
Tests) to identify risk of falls in elderly diabetics.
According to the International Diabetes Federation (IDF) Diabetes Atlas 2021- 10th
edition Diabetes is one of the fastest rising global health emergencies of the twenty-first
century. It is a serious health problem that has reached epidemic proportions and today
it affects more than half a billion people globally. India is also known to be the diabetic
capital.
Older persons with diabetes, are at an increased risk of an injurious fall that necessitates
hospitalisation than those without diabetes. One of the major complications of diabetes
is Diabetic Peripheral Neuropathy (DPN) with a prevalence rate of 60%. Presence of
DPN is known to increase the postural sway, and lead to balance instability and falls.
Since falls can impair independent living in elderly thus leading to disability, early
detection and assessment of risk of falls is important.
Berg Balance Scale is considered as the gold standard for fall risk assessment, but it has
several limitations - subjective scoring, a need for large space, need for increased
manpower, more time, repeated instructions with demonstrations of certain tasks and a
skilled and competent physiotherapist to administer it. Contrarily, the force plate is
regarded as the gold standard for postural control systems as it is objective, detects
subtle changes and overcomes the limitations of BBS.
Among community- dwelling older people, the objective measures of postural sway are
recognised as a significant predictor of falls, along with impaired balance. Thus, we
aimed to correlate COP displacement on force plate with BBS.
64
A total of 72 participants were included using convenient sampling methods, fitting in
our inclusion criteria. Basic demographic data along with medical, drug and falls history
was taken after signing the consent form. After giving the necessary instructions,
participants were made to stand on force plate and COP displacement in A-P and M-L
directions was recorded and later their BBS scores were taken.
Karl Pearson’s correlation coefficient was used to find the correlation between COP
displacement on force plate and BBS. Our results found a negative correlation between
COP displacement (A-P and M-L directions) on force plate and BBS i.e., as the COP
displacement increases, the BBS scores decreases, indicating higher risk of falls and
vice-versa. Positive correlation was found between A-P and M-L COP displacement
i.e., as COP displacement in A-P direction increases, M-L displacement also increases.
ROC curve was used to find out the cut-off point for A-P and M-L displacement and
later the sensitivity and specificity at the particular cut-off points were found.
The cut-off point of ≥2.3 cms for A-P displacement showed sensitivity of 96.88% and
specificity of 20.00% and ≥2.7 cms for M-L displacement showed sensitivity of 93.75%
and specificity of 22.50%. The accuracy of force plate measures was 54.17% and the
area under curve was acceptable in both the cases (0.7500 for A-P displacement and
0.6950 for M-L displacement).
Thus, force plate is sensitive enough to correctly identify the participants (elderly
diabetics) with an increased ROF by showing larger COP displacement (≥2.3 cms for
A-P COP displacement and ≥2.7cms for M-L COP displacement). Hence, it can be used
as a screening tool for identifying the ROF. However, BBS will further confirm the
same.
65
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73
ANNEXURE: I
CONSENT FORM
O.P/I. P No:
Sr. No. of the study subject:
Title: “Association Between Center of Pressure (COP) Displacement and Berg Balance
Scale On Risk of Falls In Elderly Diabetics”.
Name of the Principal Investigator:
Contact No:
I Ms. /Mr., ______________ exercise my free power of choice, hereby giving my
consent to be included as a subject in the study mentioned above. I have been informed
to my satisfaction, the purpose, the importance and the method of the study in my own
language by the physiotherapist and a copy of information sheet has been given to me.
I have been explained in detail about the Scales and Tests which will be used in the
study. I confirm that I have understood the above study which will be conducted over a
period of 1 year, and I have the opportunity to ask questions. I am also aware about my
right to opt myself out of the study at any time during the course of the study without
having to give any reasons, without my medical care or legal rights being affected. I
agree to adhere to the physiotherapist’s instructions and to co-operate fully with those
conducting the study and inform them in case of any untoward experience. I agree to
restrict the use of any data or results that arise from the study provided and such a use
is only for scientific purpose(s) and publications. I fully consent to participate in the
above study.
Date:
Place:
________________________
(Signature/ Left thumb impression.)
Name of the Participant: ___________________.
Son/Daughter/Spouse of: ___________________.
Complete Postal Address:
______________________________________________________.
This is to certify that the above consent has been obtained in my presence.
________________________
74
Date:
(Signature of the Principal Investigator) Place:
1. Witness-1 2. Witness-2
Signature- Signature-
Name- Name-
Address- Address-
75
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76
ANNEXURE: II
INFORMATION FOR PARTICIPANTS OF THE STUDY
Dear volunteers,
We welcome you and thank you for your keen interest in participation in this research
project. Before you participate in this study, it is important for you to understand why
this research is being carried out. This form will provide you with all the relevant details
of this research. It will explain the nature, the purpose, the benefits, the risks,
discomforts, the precautions and the information about how this project will be carried
out. It is important that you read and understand the contents of the form carefully. This
form will contain certain scientific terms and hence, if you have any doubts or if you
want more information, you are free to ask the study personnel or the contact person
mentioned below before you give your consent and also at any time during the entire
course of the project.
1. Project Title: Association Between Center Of Pressure (COP) Displacement And

Berg Balance Scale (BBS) On Risk Of Falls In Elderly Diabetics
2. Department and Institute: S.D.M College of Physiotherapy, Sattur, Dharwad
3. Name of the investigator: Shreya Girish Saokar M.P.T. (Community Physiotherapy)
4. What is the purpose of this project/study?
To identify the association / correlation between center of pressure displacement
(Laboratory Tests) and Berg Balance Scale (Field Tests) on risk of falls in elderly
diabetics
5. What is the selection procedure of the participants? (Inclusion and Exclusion
criteria).
Participants will be those who are visiting the departments of Medicine and
Endocrinology of SDM Hospital.
Inclusion Criteria
➢ Community- dwelling individuals
➢ Age group 60-75 years
➢ Participants with either gender
➢ Individuals diagnosed with diabetes by certified medical practitioner (with and
without diabetic peripheral neuropathy)
➢ Minimum 5 years duration of diabetes
➢ Able to follow commands
➢ Normal cognition (HMSE-23 points)
Exclusion Criteria
➢ Uncorrected visual/ hearing impairment
➢ Neurologic pathology (e.g., Parkinson’s disease, stroke)
➢ Orthopedic surgery to lower limbs (e.g., amputations, total hip and knee
77
surgeries, fractures) past 6 months
➢ Advanced stages of osteoarthritis, rheumatoid arthritis, gout
➢ Foot ulcers, cellulitis
➢ Medications that could influence posture and/or gait
➢ H/O vertigo
➢ Terminal disease (e.g., cancer)
6. How will it be carried out? (Procedure of the study)
Participants will be briefed about the purpose of the study, the tests used and consent
form will be given to them. Before standing on the force plate, participants will be
instructed to clean their feet properly with sterillium and tissue and to remove any
metallic items (including toe rings) and any heavy items like phones, coins etc.
Participants will be told to stand with feet wide apart (hip width) with eyes open.
Participants will be told to look straight forward and breathe normally and not to
simply shift their weight till the trial completes.
7. What are the responsibilities of the participants?
Participants must agree to adhere to the principal investigator instructions and
cooperate fully with those conducting the study and inform the principal investigator
in case of any untoward experience.
8. What are the expected risks of the participants?
As such no risks are expected, but in case the patients feel exhausted while
performing the tests, the tests will be terminated and appropriate measures will be
taken care of by the principal investigator.
9. Whether my participation in this study be confidential?
Yes, the participant’s privacy and confidentiality will be maintained during and after
the completion of the study.
10. Can I withdraw from the study at any time during the study period?
Yes, the participants can opt out of the study at any given time during the course of
the study.
11. If there is any new findings/ information, will I be informed?
Yes, participants will be informed about new findings/information of the study.
12. What happens in case of study related injury?
In case of any study related injury, appropriate measures will be taken care of by the
principal investigator.
13. Whether my participation in the study will cause any additional financial
burden?
No additional financial burden will be borne by the participant.
14. Permission for publication?
Results obtained after a study may be published for scientific purpose. However,
identity is not disclosed even after the study or participation.
For any study related queries, you are free to contact,

1.Ms. Shreya Girish Saokar BPT, (M.P.T) (CBR),
SDM College of Physiotherapy,
78
Manjushri Nagar, Sattur,
Dharwad- 580009
Contact No: 9420026924
Email id: [email protected]
2.Dr. Salima Bijapuri BPT, MPT. (Ph.D.)
Associate Professor.
SDM College of Physiotherapy,
Manjushri Nagar, Sattur,
Dharwad- 580009
Karnataka, India
Contact No: 7760580737
Email id: [email protected]
Place: -
Signature of the Investigator: -
79
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EªÉÄÃ¯ï Lr- [email protected]
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82
ANNEXURE: III
DATA COLLECTION SHEET
Date:
IP/OP. No.
DEMOGRAPHIC DATA:
o Name -
o Age-
o Gender-
o Occupation-
o Educational level-
o Height (in cms)-
o Weight (in kgs)-
o BMI (kg/m2)-
o Address-
o Suburb-
o Postcode-
o Phone No-
PAST MEDICAL HISTORY:

o Diabetes since ---------- years
MEDICAL HISTORY:
o Other co-existing medical conditions:
o Whether on oral anti-diabetic drugs – YES/NO
o Whether insulin dependent – YES/NO
MEDICATION HISTORY:
o Please list any medications you are currently taking
MEDICATION DOSAGE REASON
COGNITIVE SCREENING:
o HMSE score-
FALLS HISTORY:
o Whether there was a fall- YES/NO
o Details-
SCREENING FOR DIABETIC NEUROPATHY:
83
o MNSI score
BALANCE ASSESSMENT:
o BBS score-
FORCE PLATE ANALYSIS:

Static double limb support (EO)
BODY –
AP displacement: Trial 1 (30 secs)- __________ (in cms)
: Trial 2 (30 secs)- __________ (in cms)
: Trial 3 (30 secs)- __________ (in cms)
AVERAGE- __________ (in cms)
-ML displacement: Trial 1 (30secs)- __________ (in cms)
: Trial 2 (30 secs)- __________ (in cms)
: Trial 3 (30 secs)- __________ (in cms)
AVERAGE- __________ (in cms)
84
ANNEXURE: IV
OUTCOME MEASURES
85
86
87
88
89
90
ANNEXURE: V
MASTER CHART
91
92
ANNEXURE: VI
PLAGIARISM REPORT
Plagiarism was checked by using Dupli Checker. At a time 1000 words were permitted
to check for plagiarism.
Hence, we divided the content and all the content was found to be unique which was
above 90%- 100%.
Introduction
1st part- 98% unique content, 2nd part- 100% unique content, 3rd part- 90% unique
content, 4th part- 100% unique content.
Review of Literature
content
Methodology
1st part- 100% unique, 2nd part- 93% unique
Discussion
content, 4th part- 94% unique content, 5th part- 100% unique content, 6th part- 100%
unique content
Using the software with default parameters, 9885 words were analysed. The mean rate
of plagiarism was 1.60%. Hence the originality of the text is 98.33%.
Plagiarism check was done in the presence of Dr. Salima Bijapuri, Associate Professor
and PG Guide, SDM College of Physiotherapy.
Figure 11: Pie- chart depicting the mean rate Plagiarism report
93
ANNEXURE: VII
ETHICS COMMITTEE CERTIFICATE
94
ANNEXURE: VIII
Reference Number: REF/2021/07/045709

Registration Number: CTRI/2021/08/035394
95
ANNEXURE: IX
GUIDE RECOGNITION LETTER:
96
ANNEXURE: X
PICTURES
Fig 12. Force Plate (AM3 FootWork Pro) Fig 13. COP displacement on Force
Plate
Fig 14. Graph displayed by the Force Plate
97
Fig 15. Assessing for DPN using MNSI
Fig 16. Standing to sitting (BBS: 4) Fig 17. Reaching forward (BBS: 8)
98
Fig 18. Placing alternate foot on step Fig 19. Tandem Standing (BBS: 13)
(BBS:12)
Fig 20. Standing on one leg (BBS:14) Fig 21. Education on foot care
99
ANNEXURE: XI
THESIS PAYMENT RECEIPT:
100

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“ASSOCIATION BETWEEN CENTER OF PRESSURE (COP)

DISPLACEMENT AND BERG BALANCE SCALE (BBS) ON RISK

Ms. SHREYA GIRISH SAOKAR

Under the guidance of

Dr. SALIMA MULLA

SDM COLLEGE OF PHYSIOTHERAPY

DECLARATION BY THE CANDIDATE

I hereby declare that this dissertation/thesis entitled “ASSOCIATION BETWEEN

CENTER OF PRESSURE (COP) DISPLACEMENT AND BERG BALANCE

SCALE (BBS) ON RISK OF FALLS IN ELDERLY DIABETICS” is a bonafide

MULLA, Associate Professor & P.G. Guide, S.D.M. College of Physiotherapy

Date: Signature of the candidate

Place: Dharwad Ms. SHREYA GIRISH SAOKAR

MPT-2 Community Physiotherapy

This is to certify that the dissertation entitled “ASSOCIATION BETWEEN

CENTER OF PRESSURE (COP) DISPLACEMENT AND BERG BALANCE

SCALE (BBS) ON RISK OF FALLS IN ELDERLY DIABETICS” is a bonafide

requirement for the degree of Master of Physiotherapy (M.P.T.)

Date: Signature of the Guide

Place: Dharwad Dr. SALIMA MULLA

Associate professor and P.G Guide

Department of Community Physiotherapy

SDM College of Physiotherapy

This is to certify that the dissertation entitled “ASSOCIATION BETWEEN

CENTER OF PRESSURE (COP) DISPLACEMENT AND BERG BALANCE

SCALE (BBS) ON RISK OF FALLS IN ELDERLY DIABETICS” is a bonafide

requirement for the of Master of Physiotherapy (M.P.T.)

Date: Signature of the Co-Guide

Place: Dharwad Dr. ANOOSHA BHANDARKAR

Assistant Professor of Diabetology

SDM College of Medical Sciences and Hospital

This is to certify that the dissertation entitled “ASSOCIATION BETWEEN

CENTER OF PRESSURE (COP) DISPLACEMENT AND BERG BALANCE

SCALE (BBS) ON RISK OF FALLS IN ELDERLY DIABETICS” is a bonafide

SALIMA MULLA, Associate Professor & P.G. Guide, S.D.M. College of

Name: Dr. SUNIL K.M. Name: Dr. SUNIL K.M.

Professor and Principal Professor and Principal

Place: Dharwad Place: Dharwad

Declaration by the Candidate

I hereby declare that the Shri Dharmasthala Manjunatheshwara University, Dharwad,

in print or electronic format for academic / research purpose.

Date: Signature of the Candidate

Place: Dharwad Ms. SHREYA GIRISH SAOKAR

© Shri Dharmasthala Manjunatheshwara University,

permitting me to conduct the specified research work for my Post Graduate

support throughout the study duration.

I am extremely grateful to Dr. Anoosha Bhandarkar, Assistant Professor of

Diabetology, Department of Endocrinology, S.D.M. College of Medical Sciences and

patients throughout the study

My sincere thanks to Dr. Shweta Bhatbolan, S.D.M. College of Physiotherapy,

with the statistical analysis work.

Date: Signature of the candidate

Place: Dharwad Name: SHREYA G. SAOKA

Sr. Abbreviation Full Form

1. ABC Activities-specific Balance

3. AUC Area under curve

4. BBS Berg Balance Scale