Can’t feel the floor — neuropathy, foam and the Romberg

Diabetic peripheral neuropathy turns the balance examination into a sensory map. Richardson’s work established neuropathy as a true fall risk factor and tied the falls to the lost sensory channel, so the Romberg — markedly positive here — and the Shumway-Cook and Horak foam conditions are not formalities; they are the prescription, exposing exactly how much of him vision is carrying. The programme follows the map: perturbation and varied-surface training for the proprioception that survives, deliberate visual compensation for the dark and the kerbs, footwear that stops lying to the foot, and Charcot screening at every review because the complication is painless and the stakes are the foot itself. What you do with it: prove the sensory pattern at the bedside, train the surviving channels at a real dose, fix the shoes, check the feet every visit, and never let a normal strength grade talk you out of the diagnosis.

• A warm, red, painless, deforming foot — Charcot neuroarthropathy until proven otherwise; off-load and refer the same week
• Any ulcer or skin break under the neuropathy — podiatry and diabetes team before the next loaded session

• Three falls in six months — the multi-factorial work-upTier 4
• The wide-based gait — cerebellar ataxia, honestlyTier 3

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