Effect of supervised exercise training on musculoskeletal symptoms and function in patients with type 2 diabetes: the Italian Diabetes Exercise Study (IDES)

Benefits and Harms of Exercise Therapy for Patients With Diabetic Foot Ulcers: A Systematic Review

AIM

Exercise therapy is a core element in the treatment of diabetes, but the benefits and harms for patients with a diabetic foot ulcer (DFU) are unknown. We therefore aimed to systematically review the benefits on health-related quality of life (HRQoL) and harms of exercise therapy for patients with DFU.

METHODS

We searched 6 major databases. We performed citation and reference searches of included studies and contacted authors of ongoing trials. We included randomized controlled trials (RCTs) to assess potential benefits on HRQoL and harms of exercise therapy. Observational studies were included to identify potential harms of exercise therapy.

RESULTS

We included 10 published publications of 9 trials and results from 2 unpublished trials including a total of 281 individuals with DFUs receiving various forms of exercise therapy. Due to lack of HRQoL measurements and high heterogeneity, it was not possible to perform meta-analyses. Results on HRQoL was present in one unpublished study. Harms reported ranged from musculoskeletal problems, increased wound size, to amputation; however, no safe conclusions could be drawn from the available data due to high heterogeneity and risk of bias in the trials.

CONCLUSIONS/INTERPRETATION

Protective strategies are often preferred over therapeutic exercise that might have unforeseen consequences for patients over time. Based on the current literature, no evidence-based recommendations can be provided on the benefits and harms of exercise therapy for patients with DFUs. Well-conducted RCTs are needed to guide rehabilitation including detailed description of adverse events and an exercise program in a semisupervised or fully supervised setting.

Potential efficacy of sensorimotor exercise program on pain, proprioception, mobility, and quality of life in diabetic patients with foot burns: A 12-week randomized control study

BACKGROUND

Both diabetes mellitus (DM) and burn injuries lead to physical and psychological impairments. Foot burns are still a challenging health condition because of its important sensory role. No previous studies have assessed the physical therapy intervention on diabetic patients with foot burns. Therefore, this study aimed to assess the potential efficacy of sensorimotor exercise on pain, proprioception, mobility, balance, and quality of life in diabetic patients with foot burns.

METHODS

Between July 2019 and February 2020, thirty-three diabetic patients with foot burns, aged 32 to 46yrs, were enrolled in this randomized control study, and randomized consecutively into two groups, study group (n=16) and control group (n=17). The study group underwent a sensorimotor exercise program thrice a week for 12 consecutive weeks, however the control group did not undergo the exercise intervention. Both groups were instructed to conduct home exercises. Visual analogue scale (VAS), proprioceptive responses, time-up and go (TUG) values, and short form-36 (SF-36) have been assessed prior and subsequent to the study intervention.

RESULTS

No significant differences were observed between groups regarding baseline data (p˃0.05). Subsequent to 12wk intervention, the study group showed significant improvements in outcome measures (proprioceptive responses, p˂0.05, VAS, p˂0.001, TUG, p=0.003, and SF-36, p˂0.001) and the control group exhibited significant changes in VAS and SF-36 (p=0.004, p=0.043 respectively) however, no significant changes were found in proprioceptive responses and TUG values (p˃0.05). Between groups, the post-intervention comparison demonstrated statistical differences with tending toward the study group (proprioceptive responses, p˂0.05, VAS, p˂0.001, TUG, p=0.013, and SF-36, p=0.046).

CONCLUSIONS

Sensorimotor exercise training may improve, pain, proprioceptive responses, mobility, balance, and quality of life in diabetic patients with foot burns. Physiotherapists and rehabilitation providers should include the sensorimotor exercise in their protocols in the treatment of diabetic patients with foot burns.

Effect of different exercise training intensities on musculoskeletal and neuropathic pain in inactive individuals with type 2 diabetes - Preliminary randomised controlled trial

AIMS

People with type 2 diabetes (T2D) have a greater prevalence of musculoskeletal and neuropathic pain. This exploratory analysis investigated whether exercise of different intensities leads to changes in self-reported musculoskeletal pain or symptoms of diabetic neuropathy in inactive individuals with type 2 diabetes.

METHODS

Thirty-two inactive adults with T2D (59% male, mean age 58.7 ± 9.1yrs, median HbA_1c 7.8%) were randomised to usual care (CON), supervised combined aerobic and resistance moderate-intensity continuous training (C-MICT), or supervised combined high-intensity interval training (C-HIIT). At baseline and 8-weeks, musculoskeletal and neuropathic pain were evaluated using a modified Nordic Musculoskeletal Questionnaire and the Neuropathy Total Symptom Score-6 respectively. Quantitative sensory testing was used to determine thermal, mechanical and vibration detection thresholds, as well as pain pressure thresholds. Adverse events were recorded throughout the intervention.

RESULTS

Compared to CON, reduction in musculoskeletal pain intensity was significantly greater for C-HIIT (MD -5.4, 95% CI [-10.6 to -0.2], p = 0.04) and non-significantly greater for C-MICT (MD -5.9 [-12.4 to 0.7], p = 0.08). Changes in neuropathy symptoms were not different between C-HIIT and CON (MD 1.0 [-0.9 to 2.8], p = 0.31), or C-MICT and CON (MD 0.2 [-3.1 to 3.6], p = 0.89). No differences in sensory function were observed between groups. Similar rates of adverse events were seen in both exercise interventions (19 C-HIIT; 17 C-MICT), all but one of which were mild.

CONCLUSIONS

Preliminary data suggests 8-weeks of high-intensity combined aerobic and resistance exercise may be safely prescribed for inactive individuals with T2D and may reduce musculoskeletal pain but not neuropathic symptoms.

TRIAL REGISTRATION

ACTRN12615000475549.

Effect of Tai Chi on Quality of Life, Body Mass Index, and Waist-Hip Ratio in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a worldwide public health concern with high morbidity and various progressive diabetes complications that result in serious economic expenditure and social burden. This systematic review aims to evaluate the effect of Tai Chi on improving quality of life (QoL), body mass index (BMI) and waist-hip ratio (WHR) in patients with T2DM.

METHOD

A systematic review and meta-analysis was performed following PRISMA recommendation. Four English databases and three Chinese databases were searched. The PEDro scale was used to assess the methodological quality of including studies. Study inclusion criteria: randomized controlled trials (RCTs) and quasi-experimental studies were included, patients with T2DM that adopted Tai Chi as intervention and QoL, BMI and/or WHR as outcome measurements.

RESULTS

Eighteen trials were included. The aggregated results of seven trials showed that Tai Chi statistically significantly improved QoL measured by the SF-36 on every domains (physical function: MD = 7.73, 95% confidence interval (CI) = 1.76 to 13.71, p = 0.01; role-physical function: MD = 9.76, 95% CI = 6.05 to 13.47, p < 0.001; body pain: MD = 8.49, 95% CI = 1.18 to 15.8, p = 0.02; general health: MD = 9.80, 95% CI = 5.77 to 13.82, p < 0.001; vitality: MD = 6.70, 95% CI = 0.45 to 12.94, p = 0.04; social function: MD = 9.1, 95% CI = 4.75 to 13.45, p < 0.001; role-emotional function: MD = 7.88, 95% CI = 4.03 to 11.72, p < 0.001; mental health: MD = 5.62, 95% CI = 1.57 to 9.67, p = 0.006) and BMI (MD = -1.53, 95% CI = -2.71 to -0.36, p < 0.001) compared with control group (wait list; no intervention; usual care; sham exercise).

CONCLUSION

Tai Chi could improve QoL and decrease BMI for patients with T2DM, more studies are needed to be conducted in accordance with suggestions mentioned in this review.

Not a Painless Condition: Rheumatological and Musculoskeletal Symptoms in Type 2 Diabetes, and the Implications for Exercise Participation

OBJECTIVES

People with type 2 diabetes (T2D) are more likely to develop a range of rheumatological and musculoskeletal symptoms (RMS), and experience both chronic and widespread pain, compared with the general population. However, these symptoms are not commonly acknowledged by researchers, which hampers our understanding of the impact on this population. Since exercise is a key lifestyle management strategy for T2D and participation levels are typically low, understanding the potential impact of RMS on exercise participation is critical. The aim of this review is to summarise the literature regarding the prevalence and pathophysiology of RMS in T2D, the evidence for the benefits and risks associated with exercise on RMS, and the currently available tools for the reporting of RMS in both research studies and community settings.

METHODS

A narrative review.

RESULTS

There are numerous exercise trials in T2D, but few have sufficiently reported pain-related adverse events and even fewer have investigated the effects of exercise on RMS and chronic pain.

DISCUSSION

Recommendations for future research are provided.

Study to Weigh the Effect of Exercise Training on BONE quality and strength (SWEET BONE) in type 2 diabetes: study protocol for a randomised clinical trial

INTRODUCTION

Type 2 diabetes (T2D) is associated with an increased fracture risk despite normal-to-increased bone mineral density, suggesting reduced bone quality. Exercise may be effective in reducing fracture risk by ameliorating muscle dysfunction and reducing risk of fall, though it is unclear whether it can improve bone quality.

METHODS AND ANALYSIS

The 'Study to Weigh the Effect of Exercise Training on BONE quality and strength (SWEET BONE) in T2D' is an open-label, assessor-blinded, randomised clinical trial comparing an exercise training programme of 2-year duration, specifically designed for improving bone quality and strength, with standard care in T2D individuals. Two hundred T2D patients aged 65-75 years will be randomised 1:1 to supervised exercise training or standard care, stratified by gender, age ≤ or >70 years and non-insulin or insulin treatment. The intervention consists of two weekly supervised sessions, each starting with 5 min of warm-up, followed by 20 min of aerobic training, 30 min of resistance training and 20 min of core stability, balance and flexibility training. Participants will wear weighted vests during aerobic and resistance training. The primary endpoint is baseline to end-of-study change in trabecular bone score, a parameter of bone quality consistently shown to be reduced in T2D. Secondary endpoints include changes in other potential measures of bone quality, as assessed by quantitative ultrasound and peripheral quantitative CT; bone mass; markers of bone turnover; muscle strength, mass and power; balance and gait. Falls and asymptomatic and symptomatic fractures will be evaluated over 7 years, including a 5-year post-trial follow-up. The superiority of the intervention will be assessed by comparing between-groups baseline to end-of-study changes.

ETHICS AND DISSEMINATION

This study was approved by the institutional ethics committee. Written informed consent will be obtained from all participants. The study results will be submitted for peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT02421393; Pre-results.

Physical activity and risk of diabetic retinopathy: a systematic review and meta-analysis

AIMS

Diabetic retinopathy (DR) is an important microvascular complication of diabetes mellitus (DM) and a leading cause of visual impairment and blindness among people of working age. Physical activity (PA) or exercise is critical and beneficial for DM patients, whereas studies evaluating the relationship between PA and DR have yielded inconsistent and inconclusive results. The American Diabetes Association's "Standards of Medical Care in Diabetes" has also pointed out the indeterminate roles of PA in DR prevention. The purpose of this systematic review and meta-analysis was to explore the association between PA and DR risk.

METHODS

Medline (accessed by PubMed), EmBase, and Cochrane Library were systematically searched for studies up to June 2018, and the reference lists of the published articles were searched manually. The association between PA and DR risk was assessed using random-effect meta-analysis.

RESULTS

Twenty-two studies were included in this meta-analysis. PA was found to have a protective association with DR [risk ratio (RR) = 0.94, 95% confidence interval (95% CI) 0.90-0.98, p = 0.005] in diabetic patients, and the impact was more pronounced on vision-threatening DR (RR = 0.89, 95% CI 0.80-0.98, p = 0.02). Sedentary behavior could increase the risk of DR (RR = 1.18, 95% CI 1.01-1.37, p = 0.04). Moderate-intensity PA was likely to have a slight protective effect (RR = 0.76, 95% CI 0.58-1.00, p = 0.05).

CONCLUSION

PA is associated with lower DR risk, and more studies should focus on the causality between them.

A systematic review and meta-analysis of adherence to physical activity interventions among three chronic conditions: cancer, cardiovascular disease, and diabetes

BACKGROUND

Physical activity is effective for the prevention and treatment of chronic disease, yet insufficient evidence is available to make comparisons regarding adherence to aerobic physical activity interventions among chronic disease populations, or across different settings. The purpose of this review is to investigate and provide a quantitative summary of adherence rates to the aerobic physical activity guidelines among people with chronic conditions, as physical activity is an effective form of treatment and prevention of chronic disease.

METHODS

Randomized controlled (RCTs) trials where aerobic physical activity was the primary intervention were selected from PsychInfo, PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Clinical Key, and SCOPUS from 2000 to 2018. Studies were included if the program prescription aligned with the 2008 aerobic physical activity guidelines, were at least 12 weeks in length, and included adult participants living with one of three chronic diseases. The data was extracted by hand and the PRISMA (preferred reporting items for systematic review and meta-analysis) guidelines were used to evaluate risk-of-bias and quality of evidence. Data were pooled using random-effect models. The primary outcome measure was program adherence and the secondary outcome measures were dropout and setting (e.g. home vs. clinic-based). Pooled effect sizes and 95% CiIs (confidence intervals) were calculated using random-effect models.

RESULTS

The literature search identified 1616 potentially eligible studies, of which 30 studies (published between 2000 and 2018, including 3,721 participants) met the inclusion criteria. Three clinical populations were targeted: cancer (n = 14), cardiovascular disease (n = 7), and diabetes (n = 9). Although not statistically significant, adherence rates varied across samples (65, 90, and 80%, respectively) whereas dropout rates were relatively low and consistent across samples (5, 4, and 3%). The average adherence rate, regardless of condition, is 77% (95% CI = 0.68, 0.84) of their prescribed physical activity treatment. The pooled adherence rates for clinic-based and home-based programs did not differ (74% [95% CI, 0.65, 0.82] and 80% [95% CI, 0.65, 0.91], respectively).

CONCLUSIONS

The current evidence suggests that people with chronic conditions are capable of sustaining aerobic physical activity for 3+ months, as a form of treatment. Moreover, home-based programs may be just as feasible as supervised, clinic-based physical activity programs.

Active Learning: Lessons From Women With Type 2 Diabetes in a Walking Program

PURPOSE

The purpose of this study was to explore the experiences and preferences of sedentary women with type 2 diabetes who had recently completed a pilot 12-week supervised treadmill walking study.

METHODS

A qualitative design was used. Content analysis was used to assess major themes and subthemes embedded within participants' responses to open-ended questions about their experiences of participating in a walking program. Women were recruited from a database of patients willing to be contacted for research studies.

RESULTS

Seven inner-city women with type 2 diabetes (71% African American, age 62 ± 4.2 years, A1C 6.8% ± 1.3, years since diagnosis 6.6 ± 3.4 years) completed the postprogram interview. Only 3 of the 7 women had ever received any diabetes education. Four major themes emerged: (1) supportive environment, (2) personal commitment: overcoming ambivalence, (3) learning, and (4) outcomes, and 8 subthemes emerged. A supportive environment (encouraging, person centered, social, and structured) in combination with actively learning about diabetes and self-monitoring the effects of exercise seemed to be associated with personal commitment and confidence in participating in a walking program.

CONCLUSIONS

Active/experiential learning in a supportive environment may enhance both personal diabetes knowledge and behaviors among women with little diabetes education and low activity levels.

Costs of diabetes medication among male former elite athletes in later life

AIMS

Regular physical activity plays a major role, in both prevention and treatment of type 2 diabetes. Less is known whether vigorous physical activity during young adulthood is associated with costs of diabetes medication in later life. The aim of this study is to evaluate this question.

METHODS

The study population consisted of 1314 former elite-class athletes and 860 matched controls. The former athletes were divided into three groups based on their active career sport: endurance, mixed and power sports. Information on purchases of diabetes medication between 1995 and 2009 was obtained from the drug purchase register of the Finnish Social Insurance Institution.

RESULTS

The total cost of diabetes medication per person year was significantly lower among the former endurance (mean 81 € [95% CI 33-151 €]) and mixed group athletes (mean 272 € [95% CI 181-388 €]) compared with the controls (mean 376 € [95% CI 284-485 €]), (p < 0.001 and p = 0.045, respectively). Of the former endurance athletes, 0.4% used insulin, while 5.2% of the controls used insulin (p = 0.018).

CONCLUSIONS

A career as former endurance, sprint, jumper or team game athlete seems to reduce the costs of diabetes medication in later life.

The Italian Diabetes and Exercise Study 2 (IDES-2): a long-term behavioral intervention for adoption and maintenance of a physically active lifestyle

BACKGROUND

Physical activity (PA)/exercise have become an integral part of the management of type 2 diabetes mellitus (T2DM). However, current guidelines are difficult to put into action in this population due to a number of barriers, especially the lack of acceptable, feasible, and validated behavioral intervention strategies. The present manuscript reports the rationale, study design and methods, and design considerations of the Italian Diabetes and Exercise Study (IDES)-2, a randomized controlled trial testing the efficacy of a behavior change strategy in increasing total daily PA and reducing sedentary time (SED-time) in patients with T2DM.

METHODS/DESIGN

Starting 7 January 2014, the IDES_2 began enrolling 300 patients with known T2DM of at least 1-year duration in three tertiary referral outpatient Diabetes Clinics in Rome. Additional requirements are age 40 to 80 years, body mass index 27 to 40 kg/m(2), sedentary lifestyle, and physically inactive for at least 6 months, ability to walk 1.6 km without assistance, and eligibility after cardiovascular evaluation. Patients are randomized by center and within each center, by age and type of diabetes treatment to either the intervention or the control group. Patients in the intervention (INT) group (n = 150) receive theoretical and practical exercise counseling consisting of aggregated behavior change techniques (one individual theoretical counseling session plus eight twice-a-week individual theoretical and practical exercise counseling sessions) once a year for 3 years. Patients in the control (CON) group (n = 150), receive standard care, including general physician recommendations for daily PA. The primary outcomes are total daily PA and SED-time, as measured objectively by the use of an accelerometer. Secondary outcomes include physical fitness, modifiable cardiovascular risk factors, musculoskeletal disturbances, well-being/depression, and health-related quality of life.

DISCUSSION

The behavioral intervention strategy tested in the IDES_2 is based on solid theoretical grounds and uses several behavioral change techniques, two factors which were found to improve effectiveness of behavioral intervention. In addition, physicians and exercise specialists have been specifically trained for counselling/prescribing and supervising PA/exercise, respectively, in subjects suffering from metabolic disorders. Finally, the large sample size, the long study duration, and the objective measurement of PA allow statistically significant and scientifically robust conclusions to be drawn on the feasibility and efficacy of this intervention in T2DM patients.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT01600937 ; 10 October 2012.