Virtualizing the assessment: A novel pragmatic paradigm to evaluate lower extremity joint perception in diabetes

Gurtej Grewal, Rashad Sayeed, Steve Yeschek, Robert Alexander Menzies, Talal K. Talal, Lawrence A. Lavery, David G. Armstrong, Bijan Najafi

Research output: Contribution to journalArticlepeer-review

25 Scopus citations


Background: Individuals with diabetes have a higher risk of falls and fall-related injuries. People with diabetes often develop peripheral neuropathy (DPN) as well as nerve damage throughout the body. In particular, reduced lower extremity proprioception due to DPN may cause a misjudgment of foot position and thus increase the risk of fall. Objective: An innovative virtual obstacle-crossing paradigm using wearable sensors was developed in an attempt to assess lower extremity position perception damage due to DPN. Methods: 67 participants (age 55.4 ± 8.9, BMI 28.1 ± 5.8) including diabetics with and without DPN as well as aged-matched healthy controls were recruited. Severity of neuropathy was quantified using a vibratory perception threshold (VPT) test. The ability of perception of lower extremity was quantified by measuring obstacle-crossing success rate (OCSR), toe-obstacle clearance (TOC), and reaction time (TR) while crossing a series of virtual obstacles with heights at 10% and 20% of the subject's leg length. Results: No significant difference was found between groups for age and BMI. The data revealed that DPN subjects had a significantly lower OCSR compared to diabetics with no neuropathy and controls at an obstacle size of 10% of leg length (p < 0.05). DPN subjects also demonstrated longer TR compared to other groups and for both obstacle sizes. In addition, TOC was reduced in neuropathy groups. Interestingly, a significant correlation between TR and VPT (r = 0.5, p < 10-3) was observed indicating a delay in reaction with increasing neuropathy severity. The delay becomes more pronounced by increasing the size of the obstacle. Using a regression model suggests that the change in TR between obstacle sizes of 10% and 20% of leg length is the most sensitive predictor for neuropathy severity with an odds ratio of 2.70 (p = 0.02). Conclusion: The findings demonstrate proof of a concept of virtual-reality application as a promising method for objective assessment of neuropathy severity, however a further study is warranted to establish a stronger relationship between the measured parameters and neuropathy.

Original languageEnglish (US)
Pages (from-to)463-471
Number of pages9
Issue number5
StatePublished - Aug 2012


  • Body-worn sensors
  • Diabetes peripheral neuropathy
  • Fall prevention
  • Lower extremity joint perception
  • Obstacle crossing
  • Virtual reality

ASJC Scopus subject areas

  • Aging
  • Geriatrics and Gerontology


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