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 Table of Contents  
REVIEW ARTICLES
Year : 2022  |  Volume : 13  |  Issue : 3  |  Page : 210-226

Role of Physiotherapy in managing type 2 diabetes mellitus: A systematic review


1 College of Physiotherapy, Adesh Institute of Medical Sciences, Sri Muktsar Sahib, India
2 Department of Physiotherapy, Punjabi University, Patiala, Punjab, India

Date of Submission03-May-2022
Date of Decision29-Jun-2022
Date of Acceptance01-Jul-2022
Date of Web Publication26-Sep-2022

Correspondence Address:
Dr. Navjot Kaur
Department of Physiotherapy, Guru Nanak Dev University, Amritsar 143001, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jod.jod_48_22

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  Abstract 

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

How to cite this URL:
Kaur N, Singh S. Role of Physiotherapy in managing type 2 diabetes mellitus: A systematic review. J Diabetol [serial online] 2022 [cited 2022 Dec 7];13:210-26. Available from: https://www.journalofdiabetology.org/text.asp?2022/13/3/210/357130




  Key Messages: Top


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 Top


Type 2 diabetes mellitus (T2DM) is the most widespread form of diabetes which accounts for almost 95% of total cases.[1],[2] 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.[3] Additionally, causing feeling of sorrow, loneliness, anxiety and anger.[4] These co-morbid conditions and complications affect multiple domains of overall health leading to worsening of quality of life.[5],[6],[7],[8],[9] 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.[10],[11] This disease also affects the psychological health of caregivers/family members of diabetics as a few studies have found higher stress,[12] proneness to depression and poorer quality of life of caregivers.[13],[14],[15] The primary prevention and early treatment of T2DM is essential to avoid the financial burden and later complications.[16] Overtime, constant attempts has been made to find the most effective treatment for diabetes,[17] previously pharmacological treatment was considered first line of diabetes management,[18],[19] however the adverse effects of drugs such as heart failure,[20] increased fracture risk,[21] bladder cancer[22] and weight gain[4],[23] often overweigh the benefits of pharmacological agents.[24],[25] Currently the importance of non-pharmacological treatment approaches is ever increasing[26] and, in that context, physiotherapy is a rising field which provides cost effective, easy and tailor-based treatments[18] to the one suffering from prediabetes, early T2DM and more advanced cases with number of complications.[27] Physiotherapists are trained professionals that can provide a significant number of interventions such as exercise therapy, electrotherapy, strength training, hydrotherapy and balance training.[28],[29],[30] 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.[31],[32],[33]

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.[34],[35],[36],[37],[38],[39],[40],[41],[42],[43] 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 Top


Design

This systematic review was conducted and reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.[44]

Search strategy

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.

Eligibility criteria

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.

Selection process

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.

Data extraction

For each selected article the data was extracted according to PICO approach.[45] 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.[46],[47] 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 Top


Studies identified

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)[45] 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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Population/sample

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[48],[49],[50],[51],[52] and 3 studies only on men[53],[54],[55] and rest 26 studies included both men and women.[29],[30],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79]

Intervention

Different physiotherapy interventions were administered to the participants of 34 RCTs. These interventions are detailed in [Tables 1]–[5]. 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.

Comparison

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]–[5].

Outcome measures

A wide variety of outcome measures were used in the included randomized controlled trials that were detailed in [Tables 1]–[5].

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.[66] 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 Top


Main findings

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.[48],[51],[52],[56],[57],[58],[59],[60],[61],[62],[63],[79] 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.[18],[80],[81] Exercise also enhances metabolism of lipids and glucose, muscular and cardio respiratory fitness, with a decrease in blood pressure, obesity and fat level.[31] 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[18] 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.[82] 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.[83],[84] 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.[63] The theory behind Acupuncture-TENS suggests that it might activate larger axonal type 2 fibers in which glycogen is substantially used[85] 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,[55],[78] specific gait and balance exercise training,[65] combinations of stretching, strengthening and functional training,[56] aquatic massage,[30] plantar electrical stimulation,[29],[67] whole body vibration training[68],[69] and low intensity cathodal direct current[64] were helpful in improving diabetic peripheral neuropathy symptoms and diabetic foot ulcers. Aerobic exercise training improved HbA1c levels[55],[78] and nerve conduction velocity[55] to hinder the progression of diabetic peripheral neuropathy. A combinations therapy of massage and hydrotherapy applied for 8 weeks improved nerve growth factor concentrations.[30] Balance and gait were improved by the application of plantar stimulation in diabetic peripheral neuropathy individuals.[29],[67] Similarly specific gait and balance exercise training improved the gait velocity and gait cycle time.[65]

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,[68] whereas other study[69] 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.[66] 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.[64]

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,[50] high intensity intermittent training (HIIT)[49],[73],[74] and supervised aerobic and resistance training[54],[70],[71],[72] 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.[50] 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.[73]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.[49] HIIT applied for one year improved vascular complication of T2DM.[74] 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.[72] Ankle brachial index which is used to evaluate peripheral arterial disease was improved by supervised aerobic and resistance training.[70] 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.[71]

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[75],[76] and one study related to psychosocial health of diabetics.[53] 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.[77]

Limitations

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 Top


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.

Future implications

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

    Not applicable.

    Conflicts of interest

    There are no conflicts of interest.



     
      References Top

    1.
    Centers for Disease Control and Prevention. Natio nal Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2005. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2005.  Back to cited text no. 1
        
    2.
    Cho NH Q&A: Five questions on the 2015 IDF diabetes atlas. Diabetes Res Clin Pract 2016;115:157-9.  Back to cited text no. 2
        
    3.
    Zhao Y, Ye W, Boye KS, Holcombe JH, Hall JA, Swindle R Prevalence of other diabetes-associated complications and comorbidities and its impact on health care charges among patients with diabetic neuropathy. J Diabetes Complications 2010;24:9-19.  Back to cited text no. 3
        
    4.
    UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352:837-53.  Back to cited text no. 4
        
    5.
    Cukierman T, Gerstein HC, Williamson JD Cognitive decline and dementia in diabetes–systematic overview of prospective observational studies. Diabetologia 2005;48:2460-9.  Back to cited text no. 5
        
    6.
    Roriz-Filho JS, Sá-Roriz TM, Rosset I, Camozzato AL, Santos AC, Chaves ML, et al. (Pre)diabetes, brain aging, and cognition. Biochim Biophys Acta 2009;1792:432-43.  Back to cited text no. 6
        
    7.
    Cooray G, Nilsson E, Wahlin A, Laukka EJ, Brismar K, Brismar T Effects of intensified metabolic control on CNS function in type 2 diabetes. Psychoneuroendocrinology 2011;36:77-86.  Back to cited text no. 7
        
    8.
    Strachan MW, Reynolds RM, Marioni RE, Price JF Cognitive function, dementia and type 2 diabetes mellitus in the elderly. Nat Rev Endocrinol 2011;7:108-14.  Back to cited text no. 8
        
    9.
    Wändell PE Quality of life of patients with diabetes mellitus. An overview of research in primary health care in the Nordic countries. Scand J Prim Health Care 2005;23:68-74.  Back to cited text no. 9
        
    10.
    World Health Organization. Global Report on Diabetes. Geneva: World Health Organization; 2016.  Back to cited text no. 10
        
    11.
    Williams R, Van Gaal L, Lucioni C; CODE-2 Advisory Board. Assessing the impact of complications on the costs of type II diabetes. Diabetologia 2002;45:S13-7.  Back to cited text no. 11
        
    12.
    El-Mallakh P, Yates BE, Adkins S Family caregiving for adults with schizophrenia and diabetes mellitus. Issues Ment Health Nurs 2013;34:566-77.  Back to cited text no. 12
        
    13.
    Brod M Quality of life issues in patients with diabetes and lower extremity ulcers: Patients and care givers. Qual Life Res 1998;7:365-72.  Back to cited text no. 13
        
    14.
    Awadalla AW, Ohaeri JU, Al-Awadi SA, Tawfiq AM Diabetes mellitus patients’ family caregivers’ subjective quality of life. J Natl Med Assoc 2006;98:727-36.  Back to cited text no. 14
        
    15.
    Anaforoğlu I, Ramazanoğulları I, Algün E, Kutanis R Depression, anxiety and quality of life of family caregivers of patients with type 2 diabetes. Med Princ Pract 2012;21:360-5.  Back to cited text no. 15
        
    16.
    Nathan DM, Buse JB, Davidson MB, Ferrannini E, Holman RR, Sherwin R, et al; American Diabetes Association; European Association for the Study of Diabetes. Medical management of hyperglycaemia in type 2 diabetes mellitus: A consensus algorithm for the initiation and adjustment of therapy: A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes. Diabetologia 2009;52:17-30.  Back to cited text no. 16
        
    17.
    Khursheed R, Singh SK, Wadhwa S, Kapoor B, Gulati M, Kumar R, et al. Treatment strategies against diabetes: Success so far and challenges ahead. Eur J Pharmacol 2019;862:172625.  Back to cited text no. 17
        
    18.
    Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, et al; American College of Sports Medicine; American Diabetes Association. Exercise and type 2 diabetes: The American College of Sports Medicine and the American Diabetes Association: Joint position statement. Diabetes Care 2010;33:e147-67.  Back to cited text no. 18
        
    19.
    Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, Del Cañizo-Gómez FJ Update on the treatment of type 2 diabetes mellitus. World J Diabetes 2016;7:354-95.  Back to cited text no. 19
        
    20.
    Guan Y, Hao C, Cha DR, Rao R, Lu W, Kohan DE, et al. Thiazolidinediones expand body fluid volume through PPARgamma stimulation of ENaC-mediated renal salt absorption. Nat Med 2005;11:861-6.  Back to cited text no. 20
        
    21.
    Lecka-Czernik B, Ackert-Bicknell C, Adamo ML, Marmolejos V, Churchill GA, Shockley KR, et al. Activation of peroxisome proliferator-activated receptor gamma (PPARgamma) by rosiglitazone suppresses components of the insulin-like growth factor regulatory system in vitro and in vivo. Endocrinology 2007;148:903-11.  Back to cited text no. 21
        
    22.
    Piccinni C, Motola D, Marchesini G, Poluzzi E Assessing the association of pioglitazone use and bladder cancer through drug adverse event reporting. Diabetes Care 2011;34:1369-71.  Back to cited text no. 22
        
    23.
    McIntosh B, Cameron C, Singh SR, Yu C, Ahuja T, Welton NJ, et al. Second-line therapy in patients with type 2 diabetes inadequately controlled with metformin monotherapy: A systematic review and mixed-treatment comparison meta-analysis. Open Med 2011;5:e35-48.  Back to cited text no. 23
        
    24.
    Nissen SE, Wolski K Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes. N Engl J Med 2007;356:2457-71.  Back to cited text no. 24
        
    25.
    Pantalone KM, Kattan MW, Yu C, Wells BJ, Arrigain S, Jain A, et al. The risk of developing coronary artery disease or congestive heart failure, and overall mortality, in type 2 diabetic patients receiving rosiglitazone, pioglitazo ne, metformin, or sulfonylureas: A retrospective analysis. Acta Diabetol 2009;46:145-54.  Back to cited text no. 25
        
    26.
    Albano MG, Crozet C, d’Ivernois JF Analysis of the 2004-2007 literature on therapeutic patient education in diabetes: Results and trends. Acta Diabetol 2008;45:211-9.  Back to cited text no. 26
        
    27.
    Cade WT Diabetes-related microvascular and macrovascular diseases in the physical therapy setting. Phys Ther 2008;88:1322-35.  Back to cited text no. 27
        
    28.
    Stamatakis E, Straker L, Hamer M, Gebel K The 2018 physical activity guidelines for Americans: What’s new? Implications for clinicians and the public. J Orthop Sports Phys Ther 2019;49:487-90.  Back to cited text no. 28
        
    29.
    Navarro-Peternella FM, Teston EF, Dos Santos Santiago Ribeiro BM, Marcon SS Plantar cutaneous sensory stimulation improves foot sensibility and gait speed in older adults with diabetes: A clinical trial. Adv Skin Wound Care 2019;32:568-73.  Back to cited text no. 29
        
    30.
    Shourabi P, Bagheri R, Ashtary-Larky D, Wong A, Motevalli MS, Hedayati A, et al. Effects of hydrotherapy with massage on serum nerve growth factor concentrations and balance in middle aged diabetic neuropathy patients. Complement Ther Clin Pract 2020;39:101141.  Back to cited text no. 30
        
    31.
    American Diabetes Association. 2. Classification and diagnosis of diabetes: Standards of medical care in diabetes—2019. Diabetes Care 2019;42:S13-28.  Back to cited text no. 31
        
    32.
    Rydén L, Grant PJ, Anker SD, Berne C, Cosentino F, Xuereb RG ESC Guidelines on diabetes, pre-diabetes, and cardiovascular diseases developed in collaboration with the EASD: The Task Force on diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology (ESC) and developed in collaboration with the European Association for the Study of Diabetes (EASD). European Heart Journal 2013;34:3035-87.  Back to cited text no. 32
        
    33.
    Hansen D, Peeters S, Zwaenepoel B, Verleyen D, Wittebrood C, Timmerman N, et al. Exercise assessment and prescription in patients with type 2 diabetes in the private and home care setting: Clinical recommendations from AXXON (Belgian Physical Therapy Association). Phys Ther 2013;93:597-610.  Back to cited text no. 33
        
    34.
    Raghav A, Singh P, Ahmad J New insights into bioelectronic medicines: A new approach to tackle diabetic peripheral neuropathy pain in clinics. Diabetes Metab Syndr 2019;13:1011-4.  Back to cited text no. 34
        
    35.
    Hamasaki H Daily physical activity and type 2 diabetes: A review. World J Diabetes 2016;7:243-51.  Back to cited text no. 35
        
    36.
    Bhati P, Shenoy S, Hussain ME Exercise training and cardiac autonomic function in type 2 diabetes mellitus: A systematic review. Diabetes Metab Syndr 2018;12:69-78.  Back to cited text no. 36
        
    37.
    Melese H, Alamer A, Hailu Temesgen M, Kahsay G Effectiveness of exercise therapy on gait function in diabetic peripheral neuropathy patients: A systematic review of randomized controlled trials. Diabetes Metab Syndr Obes 2020;13:2753-64.  Back to cited text no. 37
        
    38.
    Matos M, Mendes R, Silva AB, Sousa N Physical activity and exercise on diabetic foot related outcomes: A systematic review. Diabetes Res Clin Pract 2018;139:81-90.  Back to cited text no. 38
        
    39.
    Jahantigh Akbari N, Hosseinifar M, Naimi SS, Mikaili S, Rahbar S The efficacy of physiotherapy interventions in mitigating the symptoms and complications of diabetic peripheral neuropathy: A systematic review. J Diabetes Metab Disord 2020;19:1995-2004.  Back to cited text no. 39
        
    40.
    Irvine C, Taylor NF Progressive resistance exercise improves glycaemic control in people with type 2 diabetes mellitus: A systematic review. Aust J Physiother 2009;55:237-46.  Back to cited text no. 40
        
    41.
    Zhao RR, O’Sullivan AJ, Fiatarone Singh MA Exercise or physical activity and cognitive function in adults with type 2 diabetes, insulin resistance or impaired glucose tolerance: A systematic review. Eur Rev Aging Phys Act 2018;15:1.  Back to cited text no. 41
        
    42.
    Robinson CC, Barreto RP, Sbruzzi G, Plentz RD The effects of whole body vibration in patients with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials. Braz J Phys Ther 2016;20:4-14.  Back to cited text no. 42
        
    43.
    Gu Y, Dennis SM, Kiernan MC, Harmer AR Aerobic exercise training may improve nerve function in type 2 diabetes and pre-diabetes: A systematic review. Diabetes Metab Res Rev 2019;35:e3099.  Back to cited text no. 43
        
    44.
    Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Ann Intern Med 2009;151:264-9, W64.  Back to cited text no. 44
        
    45.
    Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, et al(eds.). Cochrane Handbook for Systematic Reviews of Interventions. West Sussex: John Wiley & Sons; 2019.  Back to cited text no. 45
        
    46.
    Sherrington C, Herbert RD, Maher CG, Moseley AM Pedro. A database of randomized trials and systematic reviews in physiotherapy. Man Ther 2000;5:223-6.  Back to cited text no. 46
        
    47.
    Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M Reliability of the pedro scale for rating quality of randomized controlled trials. Phys Ther 2003;83:713-21.  Back to cited text no. 47
        
    48.
    Motahari-Tabari N, Ahmad Shirvani M, Shirzad-E-Ahoodashty M, Yousefi-Abdolmaleki E, Teimourzadeh M The effect of 8 weeks aerobic exercise on insulin resistance in type 2 diabetes: A randomized clinical trial. Glob J Health Sci 2015;7:115-21.  Back to cited text no. 48
        
    49.
    Alvarez C, Ramirez-Campillo R, Martinez-Salazar C, Mancilla R, Flores-Opazo M, Cano-Montoya J, et al. Low-volume high-intensity interval training as a therapy for type 2 diabetes. Int J Sports Med 2016;37:723-9.  Back to cited text no. 49
        
    50.
    Rezaei S, Shamsi MM, Mahdavi M, Jamali A, Prestes J, Tibana RA, et al. Endurance exercise training decreased serum levels of surfactant protein D and improved aerobic fitness of obese women with type-2 diabetes. Diabetol Metab Syndr 2017;9:74.  Back to cited text no. 50
        
    51.
    Melo KCB, Araújo FS, Cordeiro Júnior CCM, de Andrade KTP, Moreira SR Pilates method training: Functional and blood glucose responses of older women with type 2 diabetes. J Strength Cond Res 2020;34:1001-7.  Back to cited text no. 51
        
    52.
    Shahraki Z, Eftekhari E Impact of aerobic exercise on serum vaspin level in female patients with type 2 diabetes mellitus. Crescent Journal of Medical and Biological Sciences 2018;5:203-8.  Back to cited text no. 52
        
    53.
    Sardar MA, Boghrabadi V, Sohrabi M, Aminzadeh R, Jalalian M The effects of aerobic exercise training on psychosocial aspects of men with type 2 diabetes mellitus. Glob J Health Sci 2014;6:196-202.  Back to cited text no. 53
        
    54.
    Vinetti G, Mozzini C, Desenzani P, Boni E, Bulla L, Lorenzetti I, et al. Supervised exercise training reduces oxidative stress and cardiometabolic risk in adults with type 2 diabetes: A randomized controlled trial. Sci Rep 2015;5:9238.  Back to cited text no. 54
        
    55.
    Gholami F, Nikookheslat S, Salekzamani Y, Boule N, Jafari A Effect of aerobic training on nerve conduction in men with type 2 diabetes and peripheral neuropathy: A randomized controlled trial. Neurophysiol Clin 2018;48:195-202.  Back to cited text no. 55
        
    56.
    Church TS, Blair SN, Cocreham S, Johannsen N, Johnson W, Kramer K, et al. Effects of aerobic and resistance training on hemoglobin A1C levels in patients with type 2 diabetes: A randomized controlled trial. JAMA 2010;304:2253-62.  Back to cited text no. 56
        
    57.
    del Pozo-Cruz B, Alfonso-Rosa RM, del Pozo-Cruz J, Sañudo B, Rogers ME Effects of a 12-wk whole-body vibration based intervention to improve type 2 diabetes. Maturitas 2014;77:52-8.  Back to cited text no. 57
        
    58.
    Sanghani NB, Parchwani DN, Palandurkar KM, Shah AM, Dhanani JV Impact of lifestyle modification on glycemic control in patients with type 2 diabetes mellitus. Indian J Endocrinol Metab 2013;17:1030-9.  Back to cited text no. 58
        
    59.
    Hameed UA, Manzar D, Raza S, Shareef MY, Hussain ME Resistance training leads to clinically meaningful improvements in control of glycemia and muscular strength in untrained middle-aged patients with type 2 diabetes mellitus. N Am J Med Sci 2012;4:336-43.  Back to cited text no. 59
        
    60.
    Mitranun W, Deerochanawong C, Tanaka H, Suksom D Continuous vs. interval training on glycemic control and macro- and microvascular reactivity in type 2 diabetic patients. Scand J Med Sci Sports 2014;24:e69-76.  Back to cited text no. 60
        
    61.
    Lee SF, Pei D, Chi MJ, Jeng C An investigation and comparison of the effectiveness of different exercise programmes in improving glucose metabolism and pancreatic β cell function of type 2 diabetes patients. Int J Clin Pract 2015;69:1159-70.  Back to cited text no. 61
        
    62.
    Nuhu JM, Maharaj SS Influence of a mini-trampoline rebound exercise program on insulin resistance, lipid profile and central obesity in individuals with type 2 diabetes. J Sports Med Phys Fitness 2018;58:503-9.  Back to cited text no. 62
        
    63.
    Zhiyuan W, Ming Y, Jie J, Yi W, Tiansheng H, Mingfen L, et al. Effect of transcutaneous electrical nerve stimulation at acupoints on patients with type 2 diabetes mellitus: A randomized controlled trial. J Tradit Chin Med 2015;35:134-40.  Back to cited text no. 63
        
    64.
    Asadi MR, Torkaman G, Hedayati M, Mohajeri-Tehrani MR, Ahmadi M, Gohardani RF Angiogenic effects of low-intensity cathodal direct current on ischemic diabetic foot ulcers: A randomized controlled trial. Diabetes Res Clin Pract 2017;127:147-55.  Back to cited text no. 64
        
    65.
    Allet L, Armand S, Aminian K, Pataky Z, Golay A, de Bie RA, et al. An exercise intervention to improve diabetic patients’ gait in a real-life environment. Gait Posture 2010;32:185-90.  Back to cited text no. 65
        
    66.
    Sartor CD, Hasue RH, Cacciari LP, Butugan MK, Watari R, Pássaro AC, et al. Effects of strengthening, stretching and functional training on foot function in patients with diabetic neuropathy: Results of a randomized controlled trial. BMC Musculoskelet Disord 2014;15:137.  Back to cited text no. 66
        
    67.
    Najafi B, Talal TK, Grewal GS, Menzies R, Armstrong DG, Lavery LA Using plantar electrical stimulation to improve postural balance and plantar sensation among patients with diabetic peripheral neuropathy: A randomized double blinded study. J Diabetes Sci Technol 2017;11:693-701.  Back to cited text no. 67
        
    68.
    Lee K, Lee S, Song C Whole-body vibration training improves balance, muscle strength and glycosylated hemoglobin in elderly patients with diabetic neuropathy. Tohoku J Exp Med 2013;231:305-14.  Back to cited text no. 68
        
    69.
    Dominguez-Muñoz FJ, Hernandez-Mocholi MA, Villafaina S, García-Gordillo MA, Collado-Mateo D, Gusi N, et al. Acute effects of a whole body vibration session on the vibration perception threshold in patients with type 2 diabetes mellitus. Int J Environ Res Public Health 2020;17:4356.  Back to cited text no. 69
        
    70.
    Gibbs BB, Dobrosielski DA, Althouse AD, Stewart KJ The effect of exercise training on ankle-brachial index in type 2 diabetes. Atherosclerosis 2013;230:125-30.  Back to cited text no. 70
        
    71.
    Castro-Sánchez AM, Matarán-Peñarrocha GA, Feriche-Fernández-Castanys B, Fernández-Sola C, Sánchez-Labraca N, Moreno-Lorenzo C A program of 3 physical therapy modalities improves peripheral arterial disease in diabetes type 2 patients: A randomized controlled trial. J Cardiovas Nurs 2013;28:74-82.  Back to cited text no. 71
        
    72.
    Balducci S, Zanuso S, Nicolucci A, De Feo P, Cavallo S, Cardelli P, et al; Italian Diabetes Exercise Study (IDES) Investigators. Effect of an intensive exercise intervention strategy on modifiable cardiovascular risk factors in subjects with type 2 diabetes mellitus: A randomized controlled trial: The Italian diabetes and exercise study (IDES). Arch Intern Med 2010;170:1794-803.  Back to cited text no. 72
        
    73.
    Cassidy S, Thoma C, Hallsworth K, Parikh J, Hollingsworth KG, Taylor R, et al. High intensity intermittent exercise improves cardiac structure and function and reduces liver fat in patients with type 2 diabetes: A randomised controlled trial. Diabetologia 2016;59:56-66.  Back to cited text no. 73
        
    74.
    Magalhães JP, Melo X, Correia IR, Ribeiro RT, Raposo J, Dores H, et al. Effects of combined training with different intensities on vascular health in patients with type 2 diabetes: A 1-year randomized controlled trial. Cardiovas Diabetol 2019;18:1-13.  Back to cited text no. 74
        
    75.
    Nicolucci A, Balducci S, Cardelli P, Cavallo S, Fallucca S, Bazuro A, et al; Italian Diabetes Exercise Study Investigators. Relationship of exercise volume to improvements of quality of life with supervised exercise training in patients with type 2 diabetes in a randomised controlled trial: The Italian diabetes and exercise study (IDES). Diabetologia 2012;55:579-88.  Back to cited text no. 75
        
    76.
    Myers VH, McVay MA, Brashear MM, Johannsen NM, Swift DL, Kramer K, et al. Exercise training and quality of life in individuals with type 2 diabetes: A randomized controlled trial. Diabetes Care 2013;36:1884-90.  Back to cited text no. 76
        
    77.
    Cox ER, Gajanand T, Burton NW, Coombes JS, Coombes BK Effect of different exercise training intensities on musculoskeletal and neuropathic pain in inactive individuals with type 2 diabetes: Preliminary randomised controlled trial. Diabetes Res Clin Pract 2020;164:108168.  Back to cited text no. 77
        
    78.
    Dixit S, Maiya A, Shastry BA Effect of moderate-intensity aerobic exercise on glycosylated haemoglobin among elderly patients with type 2 diabetes & peripheral neuropathy. Indian J Med Res 2017;145:129-32.  Back to cited text no. 78
        
    79.
    Gouveia SSV, de Morais Gouveia GP, Souza LM, da Costa BC, Iles B, Pinho VA, et al. The effect of pilates on metabolic control and oxidative stress of diabetics type 2–A randomized controlled clinical trial. J Bodywork Movement Thera 2021;27:60-6.  Back to cited text no. 79
        
    80.
    Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C Physical activity/exercise and type 2 diabetes. Diabetes Care 2004;27:2518-39.  Back to cited text no. 80
        
    81.
    Cheng AY, Lau DC The Canadian diabetes association 2013 clinical practice guidelines-raising the bar and setting higher standards! Can J Diabetes 2013;37:137-8.  Back to cited text no. 81
        
    82.
    Riddell M, Perkins BA Exercise and glucose metabolism in persons with diabetes mellitus: Perspectives on the role for continuous glucose monitoring. J Diabetes Sci Technol 2009;3:914-23.  Back to cited text no. 82
        
    83.
    Cardinale M, Bosco C The use of vibration as an exercise intervention. Exerc Sport Sci Rev 2003;31:3-7.  Back to cited text no. 83
        
    84.
    Srikanthan P, Karlamangla AS Relative muscle mass is inversely associated with insulin resistance and prediabetes. Findings from the third national health and nutrition examination survey. J Clin Endocrinol Metab 2011;96:2898-903.  Back to cited text no. 84
        
    85.
    Sinacore DR, Delitto A, King DS, Rose SJ Type II fiber activation with electrical stimulation: A preliminary report. Phys Ther 1990;70:416-22.  Back to cited text no. 85
        


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