# Home-Based Lower Limb Exercises for Individuals with Diabetes: A Scoping Review
## 1 Introduction  
Diabetic foot ulcers (DFUs) impact around 18.6 million individuals globally each year [1], and approximately 20% of those affected will require a lower extremity amputation [2]. The development of these ulcers is influenced by a combination of neurological, vascular, and biomechanical factors [1]. Peripheral neuropathy and peripheral vascular disease are the main primary contributors to developing foot ulcers, which often lead to additional complications, such as restricted joint mobility, muscular changes, and foot deformities [3]. DFUs are characterized by a slow healing process; data from the US Wound Registry indicate that only 30% to 40% of these ulcers heal within 12 weeks, while 23% remain unhealed after a year [4]. Additionally, people with DFUs are characterized by a higher mortality risk compared to those with diabetes mellitus (DM) who do not have ulcers, with rates of 231 deaths per 1000 person-years versus 182 deaths per 1000 person-years, respectively [1]. Furthermore, the presence of DFU also increases the likelihood of depression among patients and, finally, negatively affects health-related quality of life [3]. The likelihood of DFUs recurring after healing is significant, with estimates suggesting a 42% recurrence rate within one year and 65% within five years [1]. In their guidelines, the International Working Group on the Diabetic Foot (IWGDF) has emphasized several essential strategies for DFU prevention. These include the regular inspection and assessment of at-risk feet, providing education not only to individuals with DM but also to their families and healthcare providers--incorporating psychological support as needed. Additionally, ensuring the consistent use of appropriate footwear and addressing risk factors that could lead to ulceration are vital components of a comprehensive prevention approach [5]. This review focuses specifically on secondary prevention, which refers to interventions designed to prevent the recurrence of diabetic foot ulcers (DFUs) in individuals who have already experienced ulceration. In contrast, primary prevention targets individuals at risk but without a prior history of DFUs. Clarifying this distinction is essential for appropriately contextualizing the scope and findings of the review. As noticed in a systematic review and meta-analysis conducted by [PERSON] et al. [6] that analyzed 29 studies, detailed conventional interventions aimed at preventing diabetes-related foot ulcers include specialized footwear, insoles, pediatric care, and self-management strategies. However, although the above-mentioned interventions can reduce the risk of foot ulcers, they do not address the underlying causes contributing to ulcer formation, i.e., protective sensation, mechanical stress, range of motion, and foot strength and function. Consequently, the IWGDF [5] outlined the need for further research into foot-ankle exercise programs and emphasized that future studies must evaluate longer-term outcomes (typically programs lasting 8-12 weeks), with an assessment of the acceptability and feasibility of sustaining exercise routines after the initial supervised phase. Additionally, these studies should prioritize ulceration as a key outcome measure. Interestingly, a review by [PERSON] et al. [6] indicated that while foot-related exercises may not be effective in preventing the initial occurrence of foot ulcers, they could be helpful in the secondary prevention of DFUs. The need to introduce exercise to the prevention of diabetic foot ulcers has been discussed in previous studies conducted so far, highlighting the significant differences in kinetic and kinematic parameters among three groups: participants with type 2 diabetes mellitus (T2 DM) having peripheral neuropathy, those with T2 DM without neuropathy, and non-diabetic individuals, showed in a meta-analysis by [PERSON] et al. [7].