# Home-Based Lower Limb Exercises for Individuals with Diabetes: A Scoping Review
## 4 Discussion
### Validation and Implementation of Remote Exercise Programs for Individuals with Diabetes  
The relatively narrow scope of included studies--9 out of more than 500 initially identified--may raise concerns regarding the perceived significance of home-based lower limb exercise programs within the broader context of diabetes research. This limitation is primarily a reflection of the current scarcity of high-quality, focused studies in this specific area, rather than an indication of the topic's lack of relevance. Although global diabetes management often emphasizes glycemic control and pharmacological interventions, diabetic foot ulcers remain a leading cause of morbidity, amputation, and healthcare burden. Consequently, the potential of low-cost, accessible strategies such as home-based exercise  
Figure 2: (**A**). Adherence rates (%) for home-based lower limb exercise interventions reported in the reviewed studies [16; 17; 18; 19; 20; 21] (**B**). Comparative effectiveness of interventions based on outcomes, including foot biomechanics, plantar pressure, gait/balance, and ulcer recurrence. Each intervention is scored on a 1–5 scale based on a qualitative synthesis of the results reported in the reviewed studies [13; 14; 15; 16; 17; 18; 19; 20; 21]. programs for secondary prevention should not be underestimated. Before introducing remote exercise programs for individuals with DM or DPN, researchers used the Delphi technique to validate these interventions among experts and patients. This method has supported the development and usability assessment of educational booklets and web-based software applications for desktop and mobile platforms [21]. Such studies offer valuable insights into ensuring the safety and acceptability of home-based exercise programs for both healthcare professionals and end-users. Some studies specifically focused on using the Delphi technique to establish a structured approach before clinical implementation. For instance, [PERSON] et al. [21] detailed the validation and usability evaluation of a web-based software [22] and an educational booklet [23]. These efforts highlight the importance of expert and patient involvement in refining home-based exercise programs. Several studies were excluded from this review, as they primarily described study protocols rather than the direct application of exercise interventions. These included research outlining the development of RCTs assessing the effects of an educational booklet [24] and the Diabetic Foot Guidance System (SOPeD) software [25]. One feasibility study, though not included, evaluated an internet-based foot-ankle exercise program using SOPeD [26], involving 14 participants to determine its scalability. Additionally, an economic evaluation of SOPeD [27] examined its cost-effectiveness in an RCT with 62 participants [21]. The results suggested that SOPeD could be a cost-effective tool for improving foot pain, foot function, and DPN symptoms, with cost-effectiveness probabilities of 98.7%, 82.5%, and 77.6%, respectively. However, no significant cost-utility benefit was observed for quality-adjusted life years (QALYs). These studies reinforce the necessity of validating remote exercise interventions while considering their economic viability. Other research, also not included in this review, explored hybrid exercise interventions that combined remote, unsupervised home-based exercises with in-person supervision. In some studies, participants engaged in twice-weekly supervised physiotherapy sessions alongside twice-weekly remote exercises using SOPeD [28; 29]. The findings indicated improvements in hip extension at push-off, plantar arch height, and plantar pressure distribution during gait, demonstrating the potential benefits of integrating supervised and remote exercise strategies for individuals with diabetes.