# Home-Based Lower Limb Exercises for Individuals with Diabetes: A Scoping Review
## 4 Discussion
### Evaluation of the Effectiveness in Improving Foot Biomechanics and Reducing Ulcer Recurrence  
Hyperglycemia-induced oxidative stress, impaired nerve regeneration, and vascular complications significantly impact neuromuscular integrity, leading to muscle mass loss and increased susceptibility to sarcopenia. Studies have highlighted that individuals with T2 DM, regardless of age, experience muscle weakness and physical function decline, particularly in men [35; 36]. This muscle deterioration contributes to biomechanical alterations that increase the risk of DFUs. Diabetes and diabetic peripheral neuropathy result in reduced lower limb muscle strength. Research utilizing handheld dynamometry has demonstrated diminished strength in various foot and ankle movements in diabetic patients [37]. Additionally, LJM exacerbates DFU risk by increasing plantar pressure, prolonging the stance phase during gait, and altering joint kinematics [6; 38]. Exercise interventions targeting foot-ankle flexibility and resistance training have shown promising results in reducing DFU recurrence. A study assessing lower limb exercises for DFU secondary prevention demonstrated a 72% reduction in ulcer recurrence within 12 weeks and a 78% reduction within 24 weeks, with no reported adverse effects [17]. Similar findings were reported in an interventional exercise program, which improved muscle strength and body flexibility in diabetic patients in remission [39]. Furthermore, weight-bearing activities have been deemed safe for diabetic individuals with DPN with proper assessment and counseling [40]. High-intensity interval training (HIIT) has emerged as an effective intervention. Research analyzing one-legged HIIT found that it significantly improved skeletal muscle insulin sensitivity, with a ~30% increase in insulin-stimulated glucose clearance in the trained leg compared to the untrained leg [41]. This suggests that localized lower limb exercises can substantially enhance metabolic health in diabetes patients. Exercise training has also been recognized as a key strategy in counteracting the neuromuscular decline in DPN, effectively alleviating sensory-motor deficits [19; 38]. Despite these benefits, adherence to exercise programs remains a challenge. Structured interventions incorporating remote monitoring tools, such as exercise booklets, mobile applications, and phone follow-ups, have reported higher adherence rates [24; 25]. Conversely, interventions lacking reinforcement mechanisms showed lower adherence, underscoring the importance of continuous engagement strategies. Additionally, research indicates that self-reported activity logs and supervised initial training sessions lead to better adherence compared to written instructions alone [17; 18]. Only a few studies monitored ulcer recurrence as a primary clinical outcome, despite its critical relevance in evaluating long-term effectiveness. Future research should prioritize ulcer recurrence alongside functional metrics to improve clinical decision-making and risk stratification. Overall, structured exercise programs focusing on foot biomechanics and lower limb strength play a critical role in reducing DFU recurrence and improving functional outcomes. The integration of targeted resistance training, flexibility exercises, and HIIT into diabetes management strategies offers a promising approach to mitigating neuromuscular decline and enhancing quality of life for individuals with diabetes and DPN. In addition to standardizing exercise protocols and improving long-term adherence, future studies are needed to determine which specific types and intensities of exercise are most effective for the secondary prevention of diabetic foot ulcers. These investigations should aim to establish evidence-based guidelines for exercise timing, dosage, and intensity, enabling the development of personalized strategies tailored to individual patient needs.