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 Table of Contents  
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 39-42

Relation of glycated hemoglobin with nerve conduction study and proprioception in patients with type 2 diabetes mellitus

1 Department of Physiology, IGIMS, Patna, Bihar, India
2 Department of Neurology, IGIMS, Patna, Bihar, India

Date of Submission22-Jan-2021
Date of Decision12-Apr-2021
Date of Acceptance05-May-2021
Date of Web Publication28-Jun-2021

Correspondence Address:
Josni Khah
Department of Physiology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jigims.jigims_16_21

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Background and Aim: Diabetic peripheral neuropathy is a major complication of type 2 diabetes mellitus (T2DM). Association of elevated glycated hemoglobin (HbA1c) and nerve function is known, but its relationship with proprioception is still unknown. This study was conducted to find the correlation of HbA1c with nerve conduction study (NCS) and proprioception in T2DM patients.
Materials and Methods: 88 patients of T2DM of <5 years duration, between the age group 30 and 60 years, participated in the study. NCS of tibial motor, peroneal motor, and sural sensory nerves was done. Proprioception was assessed by testing the absolute error scores of knee joint position sense (JPS) with a digital inclinometer. Pearson correlation coefficient was used to analyze the relation of HbA1c with NCS parameters and the knee JPS errors.
Results: HbA1c showed a positive correlation with distal latency and a negative correlation with amplitude and conduction velocity. JPS errors showed a moderate positive correlation with HbA1c.
Conclusion: HbA1c values have a significant relation with the development of peripheral neuropathy in T2DM patients. This effect was observed on both nerve conduction studies as well as on proprioception test.

Keywords: Glycated hemoglobin, joint position sense, nerve conduction study, proprioception

How to cite this article:
Khah J, Kumar T, Sharan A, Kumar A. Relation of glycated hemoglobin with nerve conduction study and proprioception in patients with type 2 diabetes mellitus. J Indira Gandhi Inst Med Sci 2021;7:39-42

How to cite this URL:
Khah J, Kumar T, Sharan A, Kumar A. Relation of glycated hemoglobin with nerve conduction study and proprioception in patients with type 2 diabetes mellitus. J Indira Gandhi Inst Med Sci [serial online] 2021 [cited 2022 May 19];7:39-42. Available from: http://www.jigims.co.in/text.asp?2021/7/1/39/318922

  Introduction Top

Diabetes mellitus is a global problem with its prevalence increasing at an alarming rate.[1] There are an estimated 62 million diabetic persons in India, and this figure may increase to >79 million by 2030.[2],[3]

Diabetic peripheral neuropathy (DPN) is the most common and disabling complication and a major cause of morbidity due to diabetes.[4] It can even result in diabetic foot, and in its worst form, may lead to gangrene and amputations. DPN is associated with poor control of blood glucose level in chronic diabetic patients, although the exact pathogenesis of neuropathy is still unclear.[5] Glycemic control is measured with the help of a routinely used marker, glycated hemoglobin (HbA1c). It is considered as an important predictor of the development of complications in diabetic patients.[5]

Recent evidence shows that type 2 diabetes mellitus (T2DM) patients have greater risk of falls.[6],[7],[8] This may be due to decline in sensory function because of neuropathy.[8] Proprioception plays a major role in stabilizing body equilibrium and a decrease in proprioception increases the risk of falling. A recent study by Ettinger et al. tested the knee joint position sense (JPS) in T2DM patients and found that there was a significant loss of proprioception.[9]

Diabetic neuropathy is detected by the presence of symptoms and signs, electrodiagnostic testing, quantitative sensory testing, and autonomic testing.[10] Electrodiagnostic testing in the form of nerve conduction study (NCS) is considered the most sensitive and reliable tests for diagnosing peripheral neuropathy.[10],[11]

Proprioception testing is done using three commonly accepted subdivisions: (1) JPS, (2) sense of movement, and (3) dynamic position sense.[12] JPS tests are easy to perform, reproducible, and also have a good intratester and intertester reliability.[12] Instruments such as electronic goniometers, digital inclinometers, video-controlled environments, smartphone-based applications are valid, reliable, and sensitive to measure JPS.[12],[13] Relph and Herrington suggested that a method with patient seated and a measurement of absolute error scores, without considering the direction of error, showed highest reliability for testing knee JPS.[14] Moreover, collection of absolute error scores gives a consistent data.[14]

Good glycemic control has been shown to prevent the complications of diabetes, but it is still unclear whether it can affect proprioception in diabetic patients. Therefore, this study was conducted to test the association between glycemic control (HbA1c) and NCS and proprioception in T2DM patients.

  Materials and Methods Top

The study was conducted in the Department of Physiology and Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, from June 2019 to December 2020. This study was approved by the Institutional Ethics Committee vide letter no. 836/IEC/IGIMS/2019. The study sample consisted of 88 T2DM patients diagnosed at our institute. The patients were recruited from Endocrinology Department with duration of diabetes not >5 years. Procedure was explained to each participant, and written informed consent was obtained from them.

Inclusion criteria

88 T2DM patients of age group 30–60 years, with duration of diabetes up to 5 years, were included in the study.

Exclusion criteria

  • Patients with demyelinating polyneuropathies, lumbar radiculopathies
  • History of lower limbs injury or pain, knee osteoarthritis, which could affect knee joint motion or proprioception
  • Chronic alcoholics, smokers, history of occupational heavy metal exposure
  • History of thyroid disorders, Vitamin B12, B6 deficiency, and use of medications which could cause neuropathies (isoniazid, anticancer, and antiretroviral drugs).

Nerve conduction study

The nerve conduction tests were done on Medtronic NCV/electromyography machine with the following acquisition parameters: filter settings at 1 Hz, sweep speed of 2 ms, and gain of 50 microvolt/division. Ambient temperature of the electrophysiology laboratory was maintained at 25°C. All tests were done using the same standardized procedure. NCS of the T2DM patients' lower limb nerves was conducted. The nerves tested were tibial motor, peroneal motor, and sural sensory nerve. The parameters recorded were distal latency, amplitude, and conduction velocity [Figure 1].
Figure 1: Nerve conduction study graph

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Joint position sense test

Participant was seated on a high chair with eyes blindfolded to avoid any visual cues. Inclinometer was fixed on the patient's dominant leg with the help of straps.[14] Patient's leg was moved passively till the inclinometer showed a reading of 45°. This position was maintained for 5 s and the participant was told to memorize the position. Now, his leg was brought back to any other position of rest and he was then instructed to move his leg actively and try to stop at the same angle [Figure 2]. Reading on the inclinometer was noted. Mean of three trials was taken as the reading. This procedure of testing of JPS using a digital inclinometer is a valid method with excellent intertester and intratester reliability.[12],[13] Absolute error in reproducing desired joint position in degrees was recorded, which was calculated by the difference in the target angle and the angle reproduced by the participant.[14]
Figure 2: JPS test using Digital inclinometer

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All the resultant data were analyzed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp.

  Results Top

88 T2DM patients, 57 males and 31 females, in the age group of 30–60 years (mean age 47.98 ± 8.16 years) were studied. Pearson correlation coefficient was applied to analyze the relation of HbA1c with NCS parameters and the JPS absolute error scores. The results of this study are summarized in [Table 1], [Table 2], [Table 3].
Table 1: Descriptive statistics

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Table 2: Correlation of glycated hemoglobin and nerve conduction study

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Table 3: Correlation of glycated hemoglobin with proprioception

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The results of this study clearly show that the values of HbA1c show a correlation with all the parameters of the NCS [Table 2]. There was a positive correlation between HbA1c and distal latency, whereas the amplitude and conduction velocity showed a negative correlation with HbA1c. However, no statistically significant correlation was seen between HbA1c and tibial nerve latency.

On studying the relation between HbA1c and absolute error scores of JPS test, there was a moderate correlation (n = 88, r = 0.570, P < 0.001) [Table 3] and [Graph 1].

  Discussion Top

The present study shows a significant correlation between the HbA1c level and NCS parameters in a group of T2DM patients of duration not >5 years. The most important observation was that in all the motor and sensory nerves, there was increase in distal latencies, decrease in amplitudes, and slowing of conduction velocity as the value of HbA1c increased. Similar results have been observed by various investigators in different research studies. Lee et al. studied the various risk factors responsible for DPN, and they concluded that HbA1c was a significant predictive factor for early detection of DPN, which could increase the risk of peripheral neuropathy by about five-fold.[5] Bansal et al. also found a decrease in the amplitude and slowing of conduction velocity as the glycemic control became poorer.[10] Slowing of conduction velocity indicates that there may be damage to myelin sheaths, whereas amplitude reduction indicates the onset of axonopathy.[10],[15]

Another important observation of this study was the association of HbA1c with proprioception, as measured by the JPS test. This test measures the absolute error scores in reproducing a target angle of the knee joint with eyes blindfolded. This study showed a moderate correlation between HbA1c values and the JPS errors. Clinical trials have studied the relation between glycemic control and diabetes-related complications, including risk of falls. Miller et al. found that poor glycemic control was not associated with more risk of falls, whereas the study by Tilling et al. reported an increased risk of falls with poor glycemic control.[16],[17]

This is the first study aimed at observing the association between HbA1c and proprioception in diabetic patients. The findings of this study could be an important indicator regarding the role of proprioception testing as a routine test in diabetic patients. This is especially important because the incidence of falls and their recurrence can be prevented in diabetic patients by early detection and timely intervention. Since this is an observational study, so the ability to draw conclusions about the causal relations is limited.

One limitation of this study was that variability of glycemic control over a period of few years could have been a better indicator of changes in nerve function. Another limitation was that testing a distal joint such as great toe or ankle joint could be a better indicator of the proprioception ability in early stages, but with a small size of limb segment and a very small joint range of motion, we need sophisticated and highly sensitive computerized isokinetic equipment.

  Conclusion Top

The present study showed that HbA1c is associated with NCS and proprioception. Future studies to establish the role of proprioception tests at distal-most joints using sophisticated computer-based instruments should be carried out.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Sharma A, Deshpande AA, Brid S. Comparative analysis of electrophysiological changes in normal and Type 2 diabetic subjects. Int J Med Sci Educ 2016;3:360-6.  Back to cited text no. 1
Joshi SR, Parikh RM. India – Diabetes capital of the world: Now heading towards hypertension. J Assoc Physicians India 2007;55:323-4.  Back to cited text no. 2
Kumar A, Goel MK, Jain RB, Khanna P, Chaudhary V. India towards diabetes control: Key issues. Australas Med J 2013;6:524-31.  Back to cited text no. 3
Mayurasakorn K, Somthip N, Caengow S, Chulkarat N, Wanichsuwan M. Glycemic control and microvascular complications among type 2 diabetes at primary care units. J Med Assoc Thai 2009;92:1094-101.  Back to cited text no. 4
Lee WJ, Jang S, Lee SH, Lee HS. Correlation between the severity of diabetic peripheral polyneuropathy and glycosylated hemoglobin levels: A quantitative study. Ann Rehabil Med 2016;40:263-70.  Back to cited text no. 5
Yang Y, Hu X, Zhang Q, Zou R. Diabetes mellitus and risk of falls in older adults: A systematic review and meta-analysis. Age Ageing 2016;45:761-7.  Back to cited text no. 6
Pijpers E, Ferreira I, de Jongh RT, Deeg DJ, Lips P, Stehouwer CD, et al. Older individuals with diabetes have an increased risk of recurrent falls: Analysis of potential mediating factors: The Longitudinal Ageing Study Amsterdam. Age Ageing 2012;41:358-65.  Back to cited text no. 7
Hewston P, Deshpande N. Fall and balance impairments in older adults with type 2 diabetes: Thinking beyond diabetic peripheral neuropathy. Can J Diabetes 2016;40:6-9.  Back to cited text no. 8
Ettinger LR, Boucher A, Simonovich E. Patients with type 2 diabetes demonstrate proprioceptive deficit in the knee. World J Diabetes 2018;9:59-65.  Back to cited text no. 9
Bansal V, Kalita J, Misra UK. Diabetic neuropathy. Postgrad Med J 2006;82:95-100.  Back to cited text no. 10
Perkins BA, Olaleye D, Zinman B, Bril V. Simple screening tests for peripheral neuropathy in the diabetes clinic. Diabetes Care 2001;24:250-6.  Back to cited text no. 11
Romero-Franco N, Montaño-Munuera JA, Fernández-Domínguez JC, Jiménez-Reyes P. Validity and reliability of a digital inclinometer to assess knee joint position sense in an open kinetic chain. J Sport Rehabil 2019;28:332-8.  Back to cited text no. 12
Romero-Franco N, Montaño-Munuera JA, Jiménez-Reyes P. Validity and reliability of a digital inclinometer to assess knee joint-position sense in a closed kinetic chain. J Sport Rehabil 2017;26:jsr.2015-0138. doi: 10.1123/jsr.2015-0138.  Back to cited text no. 13
Relph N, Herrington L. Interexaminer, intraexaminer and test-retest reliability of clinical knee joint-position-sense measurements using an image-capture technique. J Sport Rehabil 2015;24:2013-0134. doi: 10.1123/jsr.2013-0134  Back to cited text no. 14
Lai YR, Chiu WC, Huang CC, Tsai NW, Wang HC, Lin WC, et al. HbA1C variability is strongly associated with the severity of peripheral neuropathy in patients with type 2 diabetes. Front Neurosci 2019;13:90.  Back to cited text no. 15
Miller DK, Lui LY, Perry HM 3rd, Kaiser FE, Morley JE. Reported and measured physical functioning in older inner-city diabetic African Americans. J Gerontol A Biol Sci Med Sci 1999;54:M230-6.  Back to cited text no. 16
Tilling LM, Darawil K, Britton M. Falls as a complication of diabetes mellitus in older people. J Diabetes Complications 2006;20:158-62.  Back to cited text no. 17


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


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