# Exercise and Manual Therapy for Diabetic Peripheral Neuropathy: A Systematic Review
## 3 Results
### Exercise
These exercises were generally carried out at medium intensity using a treadmill or stationary bike. Lastly, four articles used strength exercises as the basis of their training [25; 26; 32; 33]. The strength exercises were differentiated between using body weight or not, or strength-resistance training. The variables used to analyse the results of this subgroup were mainly aimed at assessing balance. The assessments most used to analyse balance were as follows: postural sway was measured in seven articles [28; 29; 40; 41; 47; 49; 50]; the Berg Balance Test (BBT) was used in five articles [30; 37; 39; 47; 49]; the Timed Up and Go (TUG) test was used in five articles [26; 27; 30; 37; 47]; the Functional Reach Test (FRT), in four articles [36; 37; 39; 49]; and the Five-Times-Sit-to-Stand (FTSTS) test, in two articles [26; 37]. Other tests such as the ABC scale, the one-leg stance, the Tinnetti test and tandem test were also used to assess this outcome. Ten articles analysed function [23; 25; 26; 27; 29; 31; 32; 38; 46; 50], using the Short Form-12 Quality of Life (SF-12), the Neuropathy Total Symptom Score-6 (NTSS-6), health-related quality of life (EQ-5D) or the Functional Independence Measure (FIM) questionnaires, or tests such as quantitative sensory and range of movement tests. Pain was analysed in three studies using a visual analogue scale (VAS) [27; 34; 46]. Strength capacity was analysed in seven articles [23; 25; 29; 32; 42; 46; 49] by means of the 6-Minute Walk Test (6 MWT), the International Physical Activity Questionnaire (IPAQ), the maximum volume of oxygen consumption or the 10-Meter Walk Test. The programmes focused on balance were compared with control groups with patient education and/or routine care, and statistically significant intra- and intergroup improvements were shown. In addition, the training that included vibration showed statistically significant differences as compared with a strength programme [38] or programmes without vibration [37]. [PERSON] et al. [30] added the wobble board against a balance programme, but they did not find statistically significant improvements in that group. This study used physiotherapy in both interventions. Training with a mini trampoline also observed statistically significant differences compared with a control group [50]. Aerobic training was also compared mainly with control groups; statistically significant differences in favour of the intervention group were found [28; 42; 46; 49]. [PERSON] et al. [23] observed that an exercise programme of high-intensity interval training (HIIT) and moderate-intensity continuous training (MICT) showed improvement and significant differences in pain as compared with a control group. However, HIIT training might involve adverse effects if it exceeds 100 h of training. Turning to another focus, it seems that treadmill and stationary bike training is more effective than a balance training group [39]. Lastly, [PERSON] et al. [34] observed that both aerobic exercise and electotherapy improved pain significantly. Essentially, strength training was compared with a control group. [PERSON] et al. [32], however, compared body-weight strength training with another strength training group without body-weight strength. They found statistically significant differences in the variable HbA1c in favour of the group with body weight, in the distance covered in the 6 MWT test, and in favour of the group without body weight. The rest of the articles used various methodologies for strength training: isometrics [33], isokinetic exercises [25] and combined with balance [26]. All of these were effective in the balance and strength variables compared with the control group. Furthermore, the study that used isokinetic exercises (in addition) included a programme focused on stability and aerobic capacity. Only six articles included manual therapy as the intervention for patients with diabetic neuropathy. Once again, these studies compared manual therapy with control groups, which were defined as patient education, standard care or no intervention.