|Year : 2022 | Volume
| Issue : 3 | Page : 210-226
Role of Physiotherapy in managing type 2 diabetes mellitus: A systematic review
Navjot Kaur1, Sandeep Singh2
1 College of Physiotherapy, Adesh Institute of Medical Sciences, Sri Muktsar Sahib, India
2 Department of Physiotherapy, Punjabi University, Patiala, Punjab, India
|Date of Submission||03-May-2022|
|Date of Decision||29-Jun-2022|
|Date of Acceptance||01-Jul-2022|
|Date of Web Publication||26-Sep-2022|
Dr. Navjot Kaur
Department of Physiotherapy, Guru Nanak Dev University, Amritsar 143001, Punjab
Source of Support: None, Conflict of Interest: None
Type 2 diabetes mellitus (T2DM) is the most widespread form of diabetes and is becoming a global burden. This disorder distresses almost all of body systems leading to a number of complications such as cardiovascular diseases, diabetic peripheral neuropathy, diabetic nephropathy, musculoskeletal disorders and lower limb amputations which in turn increase the rate of mortality and impoverished life’s quality. This beseeches for better treatment methods, but the pharmacological approaches are limited by their adverse effects. In that context physiotherapy is an emerging non-pharmacological approach. The objective of this review was to systematically review the current evidence on role of physiotherapy in type 2 diabetes patients. A comprehensive search of literature published between 2010 to 2021 was conducted using; PubMed, ScienceDirect and PEDro databeses. 34 RCTs determining the role of different physiotherapy interventions published in peer reviewed English language journal were included in this review. Studies with less than 20 participants and conducted in age less than 18 years were excluded. This review was conducted in compliance with PRISMA guidelines. Study quality was assessed using PEDro scale; data on participant and intervention characteristics, outcome measures and treatment outcomes were extracted based on PICO framework by one reviewer under the supervision of another reviewer. The quality of trials as per PEDro was a mean score of 6. Overall, these studies evaluated the role of physiotherapy interventions such as exercise therapy, electrotherapy and other new and uncommon interventions such as pilates, whole body vibration and mini-trampoline in improving T2DM patients. This was the first systematic review to gather the evidence related to role of physiotherapy as a non-pharmacological approach in managing T2DM. The findings of present review suggested that different physiotherapeutic interventions have a positive role to play in management of T2DM and its associated complications but the literature is mainly focused on exercise therapy although many other physiotherapy interventions also proved to be beneficial.
Keywords: Complications, electrotherapy, exercise, physiotherapy, type 2 diabetes mellitus
|How to cite this article:|
Kaur N, Singh S. Role of Physiotherapy in managing type 2 diabetes mellitus: A systematic review. J Diabetol 2022;13:210-26
| Key Messages:|| |
It is the first systematic review on the role of physiotherapy in type 2 diabetes mellitus and its complications. This systematic review includes thirty-four relevant publications from latest research of last 11 years. Main findings of this systematic review suggested that different physiotherapy interventions have a positive role to play in type 2 diabetes patients.
| Introduction|| |
Type 2 diabetes mellitus (T2DM) is the most widespread form of diabetes which accounts for almost 95% of total cases., The increased blood glucose levels in type 2 diabetes leads to a number of micro and macrovascular complications such as cardiovascular disease, kidney disease, vision loss and neuropathy. Additionally, causing feeling of sorrow, loneliness, anxiety and anger. These co-morbid conditions and complications affect multiple domains of overall health leading to worsening of quality of life.,,,, T2DM is a costly disease as it incurs 10-15% of total health cost in developed countries linked with outpatient and emergency care, medications, medical supplies and long-term care., This disease also affects the psychological health of caregivers/family members of diabetics as a few studies have found higher stress, proneness to depression and poorer quality of life of caregivers.,, The primary prevention and early treatment of T2DM is essential to avoid the financial burden and later complications. Overtime, constant attempts has been made to find the most effective treatment for diabetes, previously pharmacological treatment was considered first line of diabetes management,, however the adverse effects of drugs such as heart failure, increased fracture risk, bladder cancer and weight gain, often overweigh the benefits of pharmacological agents., Currently the importance of non-pharmacological treatment approaches is ever increasing and, in that context, physiotherapy is a rising field which provides cost effective, easy and tailor-based treatments to the one suffering from prediabetes, early T2DM and more advanced cases with number of complications. Physiotherapists are trained professionals that can provide a significant number of interventions such as exercise therapy, electrotherapy, strength training, hydrotherapy and balance training.,, American Diabetes Association and multiple other organizations such as The European Society of Cardiology and Belgium Physical Therapy Association also recommend physiotherapeutic exercise training for managing T2DM.,,
A number of systematic reviews have been conducted in this perspective, but the prior research was mainly focused on reviewing role of one physiotherapy intervention in T2DM and its related complications.,,,,,,,,, So the objective of present systematic review was to gather high level of evidence from published literature focusing on overall role of physiotherapy in T2DM and its complications. This review will provide an up to date and systematic summary of current evidence available and also helps to find the research gaps in this area.
| Materials and Methods|| |
This systematic review was conducted and reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
A systematic search was performed by using relevant keywords in the following databases: PubMed, ScienceDirect and PEDro for studies published from 2010 to 2021. Search terms used were a combination of key words “exercise” “electrotherapy” “electrical stimulation”, “physiotherapy” and “type 2 diabetes mellitus” “T2DM” “diabetic”. These search terms were combined with Boolean operators OR and AND to broaden or to narrow the search. The reference lists of included studies identified by the search were also examined manually for other potentially eligible studies.
The inclusion criteria were 1) Inclusion of both males and females (>18years) with T2DM. 2) Subjects having any one diabetes marker (HbA1c, fasting glucose or insulin, insulin sensitivity) assessed at baseline. 3) Studies having at least one physiotherapy intervention. 4) Full-length RCTs published in a peer-reviewed English language journal from 2010 to 2021. 5) Studies including comparisons of a physiotherapy intervention to placebo sham or no intervention or other physiotherapy interventions were included.
The exclusion criteria were 1) Observational studies, quasi, case-controlled studies, author manuscripts, conference abstracts were excluded. 2) Studies having less than 20 subjects. 3) Studies published in language other than English. 4) Clinical trials with no control group were also excluded.
One reviewer (NK) conducted the electronic database search in three different scientific databases PubMed, ScienceDirect and PEDro using relevant keywords. After the search was performed, the titles were screened to remove duplicity by one reviewer (NK). Thereafter the abstracts of remaining articles were further screened to retrieve the relevant articles that were related to the topic of present systematic review. Studies of potential relevance were retrieved for full text version and eligibility criteria was applied by one reviewer (NK) and supervised by the other reviewer (SS). Any trial that clearly did not fulfill the eligibility criteria was eliminated. Any disagreements were resolved by discussion without the need for a third reviewer.
For each selected article the data was extracted according to PICO approach. Data such as the study sample (size, mean age, gender), characteristics of the study (author name, year in which conducted, place, design, duration) participants in both experimental and control groups, the intervention (type duration and dose of interventions in both experimental and control groups), primary outcome measures, treatment outcomes (baseline, follow-up and end of treatment) results and conclusion were extracted by one of the reviewer (NK) and supervised by another reviewer (SS). Disagreements were discussed and solved.
Risk of bias of included studies
An 11-point PEDro scale was used for assessing methodological quality of retrieved studies. This scale is developed to rate the quality of RCT’s on the Physiotherapy Evidence Database., Retrieved studies were rated for quality by two reviewers independently. Any disagreement on any criterion between two reviewers was resolved by re-assessing by each reviewer independently.
| Results|| |
Combined search performed in three different scientific databases (PubMed, PEDro and ScienceDirect), identified a total of 3653 articles. No articles were found from other sources. From the total 3653 articles, 605 duplicated articles were excluded manually. After reviewing the title and abstract of 3048 articles, 2878 articles were excluded as they were found to be unrelated to the topic of present systematic review, leaving behind 170 abstracts for further full text review. Full text version of 14 abstracts could not be retrieved, thus, 156 articles were available for full text review that were then examined for their suitability to be included in systematic review. After full text review 122 articles could not match inclusion criteria owing to inappropriate study methodology, having no control group, sample size less than 20 and improper study design and publication language other than English. Hence 34 articles were finally were selected for present systematic review. The procedure of selection of articles is depicted in [Appendix 1].
|Appendix 1: PRISMA flow chart showing article search, inclusion criteria and selection process|
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Characteristics of included studies
The key characteristics of the included 34 randomized controlled trials are presented below according to PICO (population-intervention-comparison-outcomes) and the detailed summary is presented in [Table 1][Table 2][Table 3][Table 4][Table 5].
|Table 1: Studies (n = 12) related to the effect of different type of physiotherapy interventions on biochemical profiles|
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|Table 2: Studies (n = 10) related to the effect of different type of physiotherapy interventions on diabetic peripheral neuropathy, diabetic foot ulcer and gait-balance impairments|
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|Table 3: Studies (n=8) related to the effect of different type of physiotherapy interventions on cardiovascular risk factors and cardiovascular diseases|
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|Table 4: Studies (n = 3) related to the effect of different type of physiotherapy interventions on quality of life and mental health|
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|Table 5: Studies (n = 1) related to the effect of different type of physiotherapy interventions on musculoskeletal or neuropathic pain|
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34 RCTs with a total of 3546 participants were included – 2051 of which were allocated to intervention group and 1495 to the Control group. The number of drop outs across all studies was 313- A total of 164 participants dropped out from intervention group and 149 dropped out from control group. Out of total 34 studies, 5 studies were conducted only on women,,,, and 3 studies only on men,, and rest 26 studies included both men and women.,,,,,,,,,,,,,,,,,,,,,,,,,
Different physiotherapy interventions were administered to the participants of 34 RCTs. These interventions are detailed in [Tables 1]–. The frequency of physiotherapy sessions ranged between 2 to 6 sessions per week with 3 sessions/week as the most common. The overall duration of intervention ranged between 4 weeks to 1 year with most common of 12 week intervention.
In all trials (n = 34) the intervention group was compared to control group. The control group was administered a wide variety of interventions and care detailed in [Tables 1]–.
A wide variety of outcome measures were used in the included randomized controlled trials that were detailed in [Tables 1]–.
Quality and risk of bias
The quality and risk of bias was assessed by PEDro scale. The score ranged from 3/10 to 9/10. The most common score was 6 (11 studies), the maximum score was 9 (1 study) and the minimum score was 3 (1 study). A higher score represented lower risk of bias and higher quality of the studies. Sartor et al. scored the highest score of 9/10 among the included studies. Methodological quality of the included studies is depicted in the [Appendix 2].
|Appendix 2: PEDro scoring for methodological quality and risk of bias of the included studies (Y=1; n = 0)|
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| Discussion|| |
In present systematic review included RCTs (n = 34) have studied effect of physiotherapy interventions in management of T2DM and its complications. The main findings of this systematic review indicated that physiotherapy has a huge beneficial effect in patients with T2DM. In this systematic review trials mainly consisted of exercise therapy, electrotherapy and other interventions. The exercise therapy comprised of aerobic exercise, resistance exercise, endurance exercise, moderate intensity exercise, high intensity exercise, combined aerobic and resistance exercise, strengthening and stretching exercises. The electrotherapy comprised of percutaneous electrical nerve stimulation, Acupuncture-TENS and electrical nerve stimulation. The other physiotherapy interventions comprised of Pilates, hydrotherapy with massage, mini-trampoline and whole body vibration. The effects of these physiotherapy interventions were seen in glucose biomarkers, cardiovascular diseases, diabetic peripheral neuropathy, diabetic foot ulcer, gait and balance impairments, quality of life and psychological health.
Effect of physiotherapy interventions on biochemical profiles
In present review, 12 studies were found that have evaluated the direct effect of physiotherapy interventions on glucose metabolism, insulin resistance, hemoglobin A1c levels, fasting blood sugar levels, vaspin and lipid profiles.,,,,,,,,,,, The main findings from the studies suggest that various physiotherapy interventions such as aerobic exercise training, combined aerobic and resistance training, progressive resistance training, whole body vibration, Acupuncture-TENS, Pilates and mini-trampoline were helpful in improving blood glucose related outcomes. The mechanism postulated regarding the decrease of glucose parameters after exercise reveals that during exercise, insulin sensitivity increases which leads to surge in glucose uptake by contracting muscles and this shifts metabolism to favor using carbohydrates to utilize them for energy.,, Exercise also enhances metabolism of lipids and glucose, muscular and cardio respiratory fitness, with a decrease in blood pressure, obesity and fat level. The mechanism behind these new and uncommon interventions has been postulated by many authors. As it is suggested that Pilates works on the principle of increased muscle GLUT-4 expression which facilitate the use of glucose by skeletal muscle. Similarly mini-trampoline which is a new physiotherapy intervention also works on the basis of increased GLUT-4 expression due to loading and unloading of skeletal muscle achieved by repetitive acceleration and deceleration on mini-trampoline. Another intervention whole body vibration works on the theory that in response to vibration stimulus, more motor units are activated which leads to better muscle response and hence increased insulin sensitivity and glycemic control., One study evaluated use of acupuncture-TENS combining the effects of electrical stimulation and acupuncture therapy reported that HbA1c, 2h postprandial glucose, body mass index, total cholesterol, triglycerides and fasting serum insulin levels improved in T2DM. The theory behind Acupuncture-TENS suggests that it might activate larger axonal type 2 fibers in which glycogen is substantially used hence leading to more glucose uptake.
Effect of physiotherapy interventions on diabetic peripheral neuropathy, diabetic foot ulcers and gait-balance impairment
The main findings from the studies (n = 10) suggest that physiotherapy interventions such as aerobic exercise training,, specific gait and balance exercise training, combinations of stretching, strengthening and functional training, aquatic massage, plantar electrical stimulation,, whole body vibration training, and low intensity cathodal direct current were helpful in improving diabetic peripheral neuropathy symptoms and diabetic foot ulcers. Aerobic exercise training improved HbA1c levels, and nerve conduction velocity to hinder the progression of diabetic peripheral neuropathy. A combinations therapy of massage and hydrotherapy applied for 8 weeks improved nerve growth factor concentrations. Balance and gait were improved by the application of plantar stimulation in diabetic peripheral neuropathy individuals., Similarly specific gait and balance exercise training improved the gait velocity and gait cycle time.
Two studies evaluated the effect of whole body vibration, but the findings of these studies were contradictory to each other. One study indicated that a combination of whole body vibration therapy and balance training was beneficial in improving balance, muscle strength and HbA1c, in elderly patients with diabetic neuropathy who are at high risk for suffering falls, whereas other study indicated that 12 weeks whole body vibration training leads to increase vibration perception threshold (VPT) in patients with diabetic peripheral neuropathy. VPT is way of detecting nerve fibre dysfunction and its increase indicates the greater sensory impairment as well as chances of foot ulceration. The reason behind increased VPT has been contemplated, according to which the body adapts to vibratory stimulus causing worsening of performance followed by improvements to face a new stimulus in better conditions. Therefore this indicates that a higher level of evidence is required before recommending whole body vibration to diabetic peripheral neuropathy patients.
In present review two studies were found in relation to diabetic foot. A combinations of stretching, strengthening and functional training brought better functional condition of foot ankle complex and only modest changes in foot rollover. Author suggests that periodic repetition of this exercise protocol can bring positive changes in diabetic foot. Another study indicated that use of low intensity cathodal direct current (CDC) can decrease wound surface area in diabetic foot ulcers. CDC also has significant effects on improvements in amount of wound fluid release leading to better outcomes in diabetic foot healing.
Effect of physiotherapy interventions on cardiovascular risk factors and cardiovascular diseases
Cardiovascular diseases are the macrovascular complications of T2DM and these diseases can lead to high chances of morbidity and mortality. In present systematic review 8 studies were found related to physiotherapy role in cardiovascular risk factors and diseases. The main findings from the studies suggest that physiotherapy interventions such as endurance exercise training, high intensity intermittent training (HIIT),, and supervised aerobic and resistance training,,, were helpful in improving cardiovascular risk factors and health. Increased serum levels of surfactant protein D which are associated with cardiovascular related disease mortality were decreased after endurance exercise training on treadmill for 10 weeks. HIIT for 12 weeks was the potential therapy to improve cardiac structure and function along with liver fat reduction; HbA1c level reduction as compared to control group.This study was supported by another study in which the low volume HIIT improved fasting glucose, HbA1c levels, systolic blood pressure, lipid profile, body mass index and endurance performance. Along with this, the reduction in anti-hyperglycemic and antihypertensive medications was seen during follow up. HIIT applied for one year improved vascular complication of T2DM. Supervised aerobic and resistance training plus exercise counseling can improve HbA1c and cardiovascular risk factors such as BP, lipid profile, BMI and cardiovascular risk scores along with reductions in consumption of insulin therapy and oral agents. Ankle brachial index which is used to evaluate peripheral arterial disease was improved by supervised aerobic and resistance training. 6 weeks program of three physical therapy modalities at proximal, medial and distal segments of lower limb can improve peripheral arterial disease along with Hb, HbA1c and lipid profile in T2DM patients.
Effect of physiotherapy interventions on quality of life and mental health
T2DM can result in a number of associated complications that can affect the quality of life and psychosocial health of the one suffering. In this systematic review we found 2 studies related to role of physiotherapy in quality of life in patients with T2DM and its associated complications, and one study related to psychosocial health of diabetics. The main findings from the 3 studies suggest that physiotherapy interventions such as supervised aerobic and resistance training was useful in improving physical and mental health of individual along with life’s quality.
Effect of physiotherapy interventions on musculoskeletal or neuropathic pain
T2DM patients suffer from pain that can be due to both musculoskeletal and neuropathic reasons. In present systematic review only one study was found related to role of physiotherapy in musculoskeletal or neuropathic pain. Cox et al. (2020) indicated the effect of supervised combined aerobic and resistance moderate intensity continuous training or supervised combined HIIT on pain. In this study after 8 weeks the musculoskeletal pain reduced in both intervention groups compared to control, but no differences were seen in neuropathic pain.
Limitations of present review was heterogeneity among studies, in the duration of symptoms, interventions and reporting of outcome due to which results were difficult to compare and therefore meta-analysis was not carried out. Further, only English language published articles were included, so the articles published in the language other than English might have been missed. Also, the search was limited to most widely used databases that could be assessed for free, thus there are chances that articles from other databases had been left out.
| Conclusion|| |
The findings of present systematic review concluded that physiotherapy is a beneficial non-pharmacological treatment and it can improve optimal physical, psychological health of diabetic patients and can reduce the chances of morbidity and mortality by managing the complications of T2DM. Physiotherapy is also found to be beneficial in improving quality of life and mental health of diabetics when administered according to patient’s need condition and tolerability.
The main research gaps identified through this systematic review were:
The major research focus had been on effects of exercises, whereas electrotherapy and other related modalities have not been explored much for their role in management of diabetes.
The studies had mainly been conducted in old age population so the overall role of physiotherapy in gestational diabetes and type I diabetes is yet to be discovered.
In addition, advanced physiotherapy interventions are also advantageous in improving the overall health of diabetics and future research should be focused toward these interventions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]