# Exercise and Manual Therapy for Diabetic Peripheral Neuropathy: A Systematic Review
###### Abstract  
(1) Background: Diabetic peripheral neuropathy (DPN) is one of the most common complications of diabetes mellitus (DM). Control of hyperglycaemia as well as surgical decompression are effective treatments for these patients. However, surgery is not indicated for all candidates. Manual therapy and physical exercise have been shown to be effective for peripheral neuropathies, and exercise for DM. The aim is to review the effectiveness of manual therapy and/or exercise in patients with DPN. (2) Methods: Randomised controlled clinical trials comparing the effects of manual therapy and/or exercise on pain, function and/or balance were selected. The search strategy was performed in PubMed, PEDro, Scopus, Cochrane and Web of Science databases. The PRISMA statement was followed. (3) Results: A total of 656 articles were registered, and 29 were selected. There was little consensus on DPN criteria selection. Aerobic, strength and balance exercises are beneficial for DPN. Sessions of 30-60 min, three times per week for 8 weeks seems to be the most used dose. Manual therapy is effective in the short term. A combination of both modalities was more beneficial than alone in one study. (4) Conclusions: Exercise and manual therapy are beneficial for patients with DPN. More studies should be carried out for analysing the potential effect of combining manual therapy and exercise. diabetes mellitus; diabetic neuropathies; exercise; manual therapy +
Footnote †: journal: Applied Sciences  
0000-0001-6000-0001-ischemia, cell signalling anomalies due to diacylglycerolglycerol and to protein kinase C, sodium channel deregulation and demyelination [8]. Hyperglycaemia is the main factor of risk in the various types of diabetes, provoking lesions by microvascular and metabolic alterations. These vascular changes damage the primary sensory nerves through neuronal hypoxia and nutrient deficits [8,9]. The neural lesion occurs in both long and short fibres indiscriminately, with a differentiated clinical presentation in both cases. The most frequent alterations are produced in short fibres. There is evidence that strict blood glucose control is effective in halting progression to diabetic neuropathy [10], as it controls the hyperglycaemic component of these patients. Invasive treatment, such as surgical decompression, can be useful for relieving neuropathic symptoms in some patients. However, not all diabetic patients with neuropathy are candidates for nerve decompression [4]. Conservative treatment such as exercising, receiving transcutaneous electrical nerve stimulation (TENS) and taking vitamin D supplements have been shown to be beneficial in reducing pain and improving function and balance in these patients [3,11,12]. During exercise, muscle contraction increases blood glucose capture to complement intramuscular glycogenolysis. To replenish glycogen stores, resting muscle captures glucose postprandially depending on circulating insulin. After exercise, both pathways increase glucose capture towards the muscle [13]. It has also been observed that exercise improves blood glucose control and quality of life, reduces cardiovascular risk and contributes to weight loss [14]. Consequently, exercise-based interventions are beneficial for patients with diabetic neuropathy. Various systematic revisions have indicated that manual therapy is beneficial in improving function and symptoms in patients with peripheral neuropathies [15, 16, 17]. In a study with rats, [PERSON] et al. [4] observed the impact of these oscillations on diabetic neuropathy using mobilisations of the sciatic nerve. The authors found an attenuation of allodynia in the treatment area and a reduction in pro-inflammatory mediator concentration in the sciatic nerve branches. In spite of the elevated prevalence of peripheral neuropathy and its major involvement in the morbidity of patients with diabetes, it is the chronic complication for which the least information is available about its pathogeny and epidemiology, and the one with the fewest standardised study methods.