Adaptive Gamified Sensory Training on Sensory Function and Limb-Specific Functional Performance in Patients With Diabetic Peripheral Neuropathy

The therapist will additionally record tactile discrimination accuracy, selected games, application settings, and progression between task levels.

Participants will receive a 6-week intervention consisting of three sessions per week (18 sessions total), with each session lasting 90 minutes. The intervention will include 30 minutes of conventional physical therapy, 30 minutes of upper-limb sensory training involving tactile sensory discrimination and interactive gamified hand exercises using a Bluetooth-connected ball, and 30 minutes of lower-limb sensory training involving progressive, task-oriented activities using visual targets, safe textured surfaces, texture matching, and controlled foot placement and weight shifting. Task difficulty will be progressively adjusted according to participants' performance and tolerance.

Device and tools:

Bluetooth-connected interactive squeeze ball Foam balance pad Textured sensory stimulation materials Visual floor targets

upper-limb conventional exercises

Lower-limb strengthening:

Conventional balance exercises:

Gait and functional mobility training:

Participants will receive a 6-week conventional rehabilitation program consisting of three sessions per week (18 sessions total), with each session lasting 90 minutes. The program will include 30 minutes of shared conventional physical therapy, 15 minutes of upper-limb range-of-motion and functional exercises, 15 minutes of lower-limb strengthening exercises, 15 minutes of balance training, and 15 minutes of gait and functional mobility training. Exercises will be adapted to participants' functional abilities and safety requirements.

devices and tools: Foam balance pad Textured sensory stimulation materials Visual floor targets

Change in sensory function from baseline to 6 weeks, assessed using the sensory subset of the Neuropathy Impairment Scale (NIS). Assessment includes touch pressure, pinprick, vibration, and joint position at the right and left index fingers and great toes. Higher scores indicate greater sensory impairment.

Grading: NIS Sensory Subset

• 0 = Normal sensation
• 1 = Decreased sensation
• 2 = Absent sensation Scale title: Neuropathy Impairment Scale - Sensory Subset (NIS Sensory Subset). Minimum value: 0 Maximum value: 32* Interpretation: Higher scores indicate worse sensory impairment; lower scores indicate better sensory function.

Change in hand functional performance from baseline to post-intervention at 6 weeks, assessed using the Jebsen-Taylor Hand Function Test.

Grading: Performance time in seconds for each subtest. Shorter completion times indicate better hand function.

• Unabbreviated scale title: Jebsen-Taylor Hand Function Test.
• Minimum value: 0 seconds (theoretical minimum).
• Maximum value: No fixed maximum; the score is recorded as the time required to complete each task.
• Interpretation: Higher scores (longer completion times) indicate worse hand function, whereas lower scores (shorter completion times) indicate better hand function.

Important: The JTHFT consists of seven timed subtests. Report the completion time in seconds for each subtest rather than treating it as a conventional 0-100 scale.

Condition 1: Eyes Open on a Firm Surface The participant stands on a firm, stable surface with eyes open. Visual, somatosensory, and vestibular information are available.

Condition 2: Eyes Closed on a Firm Surface The participant stands on a firm, stable surface with eyes closed. Visual input is removed, increasing reliance on somatosensory and vestibular information.

Condition 3: Eyes Open on a Foam Surface The participant stands on a foam surface with eyes open. The foam reduces the reliability of somatosensory information from the feet and ankles.

Condition 4: Eyes Closed on a Foam Surface The participant stands on a foam surface with eyes closed. Both visual input and reliable somatosensory information are reduced, increasing reliance on vestibular information.

Lower sway values generally indicate less postural sway and better postural stability.

Higher sway values: generally indicate greater postural sway and poorer postural stability.