available online at: http://journal.jptranstech.or.id/index.

php/ACHNR

Asian Community Health

Nursing Research
ACHNR
Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21

Effects of Physical Exercises on Peripheral

Neuropathy Sensation in Patients with Type 2
Diabetes: A Literature Review
Laode Saltar1* and Junaiti Sahar2
1Department of Community Health Nursing, School of Nursing, Mandala Waluya School of Health Sciences,
Indonesia;
[email protected]
2Department of Community Health Nursing, Faculty of Nursing, University of Indonesia
[email protected]
*Correspondence: [email protected]
Type of the Paper (Article)
Received: July 27, 2020; Accepted: August 17, 2020; Published: September 5, 2020
https://doi.org/10.29253/achnr.2020.21145

Abstract: Background - The most common complication in patients with type 2 diabetes is peripheral
neuropathy. Physical exercise is one of the effective Prevention and treatment strategies of peripheral
neuropathy in type 2 diabetes. Aims and objectives - The aim of this review articles is to describe the
effectiveness of physical exercise on peripheral neuropathy sensation in patients with type 2 diabetes.
Methods - A number of databases such as Science Direct, Springer Link, ProQuest, EBSCOhost, and
Google Scholar were searched for relevant articles using keywords such as “type 2 diabetes”, AND
“peripheral neuropathy sensation” OR “diabetes peripheral neuropathy" AND “physical exercises” OR
“aerobic exercises” OR “resistance exercise”. All types of articles were included for the study, such as
systematic reviews, randomized controlled trial, quasi-experiment, literature review, and pilot study
with the range 2015-2020. Only articles in English are included in this review. Results - Of the 11 articles
found, 9 articles showed that physical exercise had a direct effect on improving foot sensation in
diabetic peripheral neuropathy patients, while the other 2 articles had an indirect effect on improving
symptoms of peripheral neuropathy. Four types of physical exercise that are practiced in interventions
are: aerobic exercise, resistance exercise, balance and flexibility exercise and a combination of two or
more types of exercise. Physical exercise from low to moderate intensity has a positive effect on
increasing foot sensation in patients with type 2 diabetes peripheral neuropathy. Conclusions – This
review emphasizes the effect of physical exercise on peripheral neuropathic sensation in type 2 DM
patients and strengthens the evidence that low and moderate-intensity exercise are beneficial to reduce
peripheral neuropathy symptoms. Further research on the effectiveness of home and community-based
physical exercise to reduce symptoms of peripheral neuropathy is necessary.

Keywords: physical exercises; peripheral neuropathy sensation; type 2 diabetes; literature review

1. Introduction
The most common complication in diabetes mellitus (DM) patients is peripheral neuropathy
(Jember et al., 2017) and also become the main cause of ulceration and amputation of the foot

Copyright© 2020 by the authors. Submitted for open access publication under the terms and conditions of the Creative Commons
Attribution (CC BY) license.
12 Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21

(Seyedizadeh et al., 2020). Global estimates, the prevalence of peripheral diabetic neuropathy (DPN)
ranges from 9.6 - 88.7% of the DM population (Jember et al., 2017). It is known that the global prevalence
of DM cases at the age of 18 years and over increased from 4.7% in 1980 to 8.5% in 2014 (WHO, 2016).
As many as 30-50% of DM patients reported experiencing complications of DPN (Tesfaye, 2019; Hershey,
2016). The prevalence of DPN based on the Michigan Neuropathy Screening Instrument (MNSI)
measurement in Jordan is 39.5% (Khawaja et al., 2018), while in Ethiopia through a cross-sectional study
there were cases of peripheral neuropathy of 52.2% (192 of 368 DM patients) (Jember et al., 2017). In
Indonesia, information related to the risk of DM complications and DFU incidence is still inadequate. A
study states that the main complications of DM in Indonesia are neuropathy (13% - 78%), microvascular
complications (16% - 53%) and diabetic foot ulcer ranging from 7.3% - 24% (Abrar et al., 2019).
Neuropathy is the most complication of DM in RSUP Dr. Cipto Mangunkusumo (RSCM) amounted to 54%
in 2011 (Kemenkes RI, 2014).
Some studies have shown the benefits of physical exercise in preventing complications of DM,
improving glycemic control and reducing neuropathic pain (Hangping et al., 2019; Lee et al., 2017;
Kluding et al., 2012). Exercise and physical activity are non-pharmacological interventions to improve
peripheral sensory function and outcomes related to DM (Matos et al., 2018). A systematic review shows
that lifestyle interventions are effective in improving neuropathy symptoms (Zilliox & Russell, 2019).
Physical exercise is an effective modality therapy for type 2 DM patients (Balducci et al., 2006). Physical
exercise is physical activity that is carried out in a planned and structured manner with the aim of
improving health and or fitness (Sigal et al., 2018). This literature review aims to describe the
effectiveness of physical exercise in improving foot sensation for peripheral neuropathy in type 2 DM
patients.

2. Literature Review
Diabetic peripheral neuropathy is defined as the presence of symptoms and / or signs of peripheral
nerve damage after exclusion of other causes in DM patients (Hershey, 2016; Bruschi et al., 2017). The
main clinical symptoms of DPN are loss of sensation or numbness. Other signs and symptoms include
tingling, burning or stabbing pain, pain when walking, a hot or cold sensation in the legs (Tesfaye, 2019).
Factors that are significantly related to the incidence of DPN include: poor glycemic control,
unemployment (lack of physical activity), cardiovascular disease, duration of suffering from diabetes,
dyslipidemia, hypertension, smoking, and being overweight (Alramadan et al., 2019; Hershey, 2016;
Khawaja et al., 2018).
The cause of neuropathy cannot be explained with certainty (Hershey, 2016), but a prolonged
hyperglycemia condition that triggers an increase in the levels of Advanced Glycation End (AGE) and
Protein Kinase C (PKC) products is the main contributor to the metabolic changes that produce DPN
(Akter, 2019). Hyperglycemia causes a combination of axonal injury, insulin resistance, toxic adiposity,
endothelial injury, and microvascular dysfunction resulting in nerve ischemia which contributes to the
development of DPN. Progressive loss of nerve fibers results in the development of diabetic peripheral
neuropathy, with symptoms of paresthesia and pain. Loss of nerve fibers begins with small nerve fibers,
then involves large nerve fibers as the disease progresses. In addition, contributors to the development
of DPN come from changes in vascular factors, neurostructural mechanisms, and metabolic interactions
(Hershey, 2016).
Well-known instruments for measuring or evaluating the presence of peripheral neuropathy are
The Michigan Neuropathy Screening Instrument (MNSI), with a sensitivity of 80% and specificity of 95%
and the Semmes-Weinstein Monofilament Examination (SWME). Semmes-Weinstein monofilament
(SWME) examination as the cheapest and safest DPN screening method (Farhat & Yezback, 2016;
Navarro-peternella & Teston, 2019).

3. Methodology
The literature search focused on "physical exercise and sensation of peripheral neuropathy in type
2 DM patients". A number of databases such as Science Direct, Springer Link, ProQuest, EBSCOhost, and
Google Scholar were searched for relevant articles. Literature search using keywords such as “type 2
diabetes”, AND “peripheral neuropathy sensation” OR “diabetes peripheral neuropathy" AND “physical
exercises” OR “aerobic exercises” OR “resistance exercise”. All types of articles were included for the
Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21 13

study, such as systematic reviews, randomized controlled trial, quasi-experiment, literature review, and
pilot study with the range 2015-2020. Only articles in English are included in this review.

4. Results
Based on the keywords entered in the five databases, 1.262 articles appeared and then were
screened for titles, abstracts, repetition of articles and article content. The search results only found 11
articles discussing physical exercise in relation to sensation of peripheral neuropathy (Table 1). From
these 11 articles, analysis was carried out and it can be concluded that there are two effects that physical
exercise has on diabetic peripheral neuropathy, namely a direct positive effect on neuropathy (Dixit et
al., 2019; Kanchanasamut & Pensri, 2017; Matos et al., 2018; Nadi et al., 2017; Navarro-peternella &
Teston, 2019; Zilliox & Russell, 2019; Johnson & Takemoto, 2019; Stubbs Jr et al., 2019; Gholami et al.,
2020) and indirect effects on neuropathic sensation (Gholami et al., 2018; Seyedizadeh et al., 2020).
Types of Physical Exercise
Four types of physical exercise were practiced in the research intervention, such as: aerobic
exercise, resistance exercise, balance and flexibility training, and a combination of two or more types of
exercise. Aerobic exercise is physical activity that is carried out with rhythmic, structured and continuous
movements involving large muscles for at least 10 minutes per session. Examples of aerobic exercise are
walking, mini trampoline exercises, cycling, swimming and jogging (Sigal et al., 2018). Aerobic exercise
is divided into three levels, namely low, medium and high intensity. Low intensity ranges from 60-70%
Maximum Heart Rate (HRM) or 1.1 - 2.9 METs (Siomos et al., 2017). Medium intensity ranges from 70 -
80% HRM or 3 - 5.9 METs and high intensity ≥ 80% HRM or ≥ 6 METs (Johnson & Takemoto, 2019; Sigal
et al., 2018). Resistance training is repetitive exercise using additional weights, weight lifting machines,
resistance bands, or body weight alone to increase muscle strength and/ or endurance (Sigal et al., 2018).
Examples of resistance training are chest press, wide-grip lat pulldown, barbell curl, lying triceps press,
leg extension, lying leg curls, sit-up, and push-up using body building equipment. Examples of resistance
training are chest press, wide-grip lat pulldown, barbell curl, lying triceps press, leg extensions, lying leg
curls, sit-ups, and push-ups using bodybuilding equipment. Flexibility training is a form of activity, such
as stretching the lower back or hamstrings, that increases the ability of the joint to move through its
various movements. Balance exercises are exercises that are only intended to improve balance.
Combination exercises are combined movements that combine several exercises such as tai chi and yoga
(Sigal et al., 2018).
Measurement of Sensation of Diabetic Peripheral Neuropathy
Decreased sensory foot diabetic peripheral neuropathy is indicated by a decrease in the perception
of pressure and vibration in the feet (Kanchanasamut & Pensri, 2017). Measurements of peripheral
neuropathy that are frequently used are the Michigan Neuropathy Screening Instrument (MNSI) and the
Semmes-Weinstein monofilament Examination (SWME).
Michigan Neuropathy Screening Instrument (MNSI)
MNSI is a validated assessment instrument. This instrument has two components, namely a history
and examination questionnaire (Kanchanasamut & Pensri, 2017; Farhat & Yezback, 2016; Hershey,
2016). The component of the history questionnaire is about feelings in the feet which consists of 15
questions with a choice of "yes" and "no" answers. Each question is worth 1 point. A score >7 indicates
diabetic peripheral neuropathy (Hershey, 2016). The components of the examination include
appearance, ulceration, ankle reflexes, perception of vibrations in the big toe, and examination of the
monofilament. Score 1 if the appearance shows deformity, dry skin and / or calluses, infection and
fissure; the presence of ulceration; ankle reflex absent; vibration perception using a 128-Hz tuning fork
is absent; and the correct answer on the monofilament examination does not exist. Score 0.5 if on the
first test the ankle reflex is absent and the reflex appears when using the Jendrassic maneuver; on
vibration perception the examiner felt a vibration ≥ 10 seconds longer than the patient; on monofilament
examination, there are 1 to 7 correct answers. Positive for neuropathy if the score is> 2.5 (Hershey,
2016).
Semmes-Weinstein Monofilament Examination (SWME)
Another measurement of sensory function for peripheral neuropathy is to use the Semmes-
Weinstein monofilament (SWME) examination as the cheapest and safest DPN screening method (Farhat
14 Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21

& Yezback, 2016; Navarro-peternella & Teston, 2019). There are 10 measurement points on each of the
right and left feet covering the big toe; the plantar aspects of the 1st, 3rd and 5th metatarsal heads; and
six locations on the plantar base using 10 g monofilament. The measurement procedure is that the patient
is asked to sit or lie down, then the soles of his feet are straightened and given a touch of nylon
monofilament thread by being placed on the soles of the feet and bent slightly so that the nylon puts
pressure on the soles of the feet. The pressure is held for up to 2 seconds and then the examiner instructs
the patient to say "yes" if he has felt the monofilament sensation. The patient is asked to close his eyes
during the test. The examiner also needs to use a fake test, which is to ask the patient if he feels the
monofilament when it is not done. A decrease in perception is indicated by loss of sensation at least one
assessment site (Navarro-peternella & Teston, 2019; Ahn & Song, 2012; Feldman et al., 2020;
Kanchanasamut & Pensri, 2017).
Effect of Physical Exercise
Direct positive effect on sensation of diabetic peripheral neuropathy
Research on the effectiveness of aerobic exercise in increasing sensation of peripheral neuropathy
has shown strong evidence. A randomized controlled trial (RCT) study with a single blind parallel group
approach to 84 DM patients who were divided into a study group of 37 people and a control group of 47
people. The study was conducted at a tertiary university hospital in India which aims to determine the
effect of moderate intensity aerobic exercise for 8 weeks on the threshold of vibration sensation
perception (VPT) in peripheral neuropathy of type 2 diabetes. Vibration sensation in diabetic peripheral
neuropathy was measured using a Biothesiometer (QST Devices). In the study group, patients were given
education on the prevention and management of foot problems in type 2 diabetes through posters and
given diabetes diet instructions by nutritionists. Moderate intensity treadmill exercise is done 3 to 6 days
a week, with a duration of 150 minutes to a maximum of 360 minutes per week. Heart rate for sports
training is carried out in the range of 40% - 60% of the heart rate reserve (HRR). The results showed that
there was a significant difference in the vibration perception threshold (VPT) at 3 points (thumb, medial
malleoli, first metatarsal phalanx), for both lower limbs between the control and study groups (df1, df2
= 1.63; F = 8.56; p <0.001). This shows that moderate intensity aerobic exercise (treadmill) has a positive
effect in increasing the sensation of peripheral nerve vibrations in type 2 DM patients with peripheral
neuropathy (Dixit et al., 2019). The same study by Stubbs Jr et al (2019) to determine the effectiveness
of aerobic structured programs, isokinetic strength, or a combination of aerobic-isokinetic strength
training interventions in changing peripheral nerve function in diabetic patients who experience
glycemic controlled symmetric polyneuropathy. The study involved 38 DM patients, divided into 11
aerobic exercise patients, 10 isokinetic strength training patients, 8 aerobic-isokinetic strength patients
and 9 sedentary control patients. Exercises are performed 3 times a week for 12 weeks. A 10-minute
warm-up consisting of stretching and flexibility exercises starts all training sessions. The results show
that aerobic exercise improves peripheral sensory nerve function.
Other supporting research is the study of Kanchanasamut & Pensri (2017) on 21 DM neuropathy
patients. The intervention was divided into 11 patients in the exercise group and 10 patients in the
control group, which was carried out at home for 8 weeks with an intensity of 5 times a week. The
intervention was in the form of foot care education and resistance training with a mini-trampoline, which
is an activity in the form of a program containing a variety of strong weight-bearing activities such as
jumping and hopping. The results showed an increase in somatosensory perception in both legs, where
the number of subjects who experienced a decrease in pressure and vibration perceptions in the exercise
group significantly decreased at week 8 and 20 (p = 0.008-0.031). Apart from aerobic exercise, resistance
training has also been shown to improve peripheral neuropathy. A systematic review by Johnson &
Takemoto (2019) suggests that low-intensity resistance training reduces pain disruption in daily
activities, lowers pain thresholds, and reduces neuropathy symptoms.
Combination exercises, which are combinations of several types of exercise, have been shown to
increase the sensation of neuropathy. Clinical trial research with a sample of 30 DM patients in the form
of muscle stretching exercises that were carried out actively with 3 repetitions; muscle strengthening
performed passively by the therapist; and sensory exercise which is actively performed where, the
exercise is done twice a week for 12 weeks in 50minute sessions. The results showed an increase in
plantar skin sensibility in the exercise group compared to the control group on the right leg (3.46 points;
95% confidence interval CI, 3.85-9.80), left foot (3.46 points; 95% CI, 4.06-9.76). So it can be concluded
Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21 15

that cutaneous plantar sensory stimulation increases foot sensibility (Navarro-peternella & Teston,
2019). A systematic review by Matos et al. (2018) further strengthens the benefits of physical exercise in
improving peripheral neuropathy. This systematic review suggests that two studies used aerobic
exercise; two studies combined aerobic, resistance and balance exercise; and two combined studies of
aerobic exercise and balance using the Thai Chin Chuan method. The results of the review show that
physical activity and exercise significantly increase nerve conduction velocity, peripheral sensory
function and peak foot pressure distribution. Research by Gholami et al (2020) also provides evidence
that cycling exercise with 50% -70% of heart rate reserve, carried out for 30-45 minutes in 3 sessions /
week for 12 weeks, reduces symptoms of peripheral neuropathy.
Indirect effect on sensation of diabetic peripheral neuropathy
Another RCT study of 24 female DM patients, who were divided into an exercise group and a control
group in a combination aerobic and resistance exercise training program carried out for 3 sessions per
week for 8 weeks was not significant in increasing upper body strength, but it was significant in
increasing lower body strength. The progressive nature of peripheral neuropathy has slightly changed
(Seyedizadeh et al., 2020). With the same research method, research (Gholami et al., 2018) on 24 DM
peripheral neuropathies divided into 12 exercise groups, 12 control groups, where the experimental
group first conducted 3 socialization sessions a week before the main intervention, then the respondents
underwent aerobic exercise program for three months (walking, jogging or running on a treadmill, 3
sessions a week, 50-70% HRR, 20-45 minutes). The results showed that the sural sensory nerve
conduction velocity (NCV) in the exercise group significantly increased (from 35.2 ± 4.3 m / s to 37.3 ±
6.2 m / s) compared to the control group (P = 0.007). Aerobic exercise has the potential to inhibit the
development of PN diabetes by increasing NCV (Gholami et al., 2018).

5. Discussion
Physical exercise is an alternative non-pharmacological therapy that can improve glycemic control,
neuropathic sensation, pain, muscle strength and quality of life for DPN patients. Types of physical
exercise include aerobic, resistance, stretching, and balance exercises such as tai-chi (Ahn & Song, 2012).
Improved neuropathic sensation through an aerobic exercise program with a follow-up of 10 weeks has
shown strong evidence. By increasing the cutaneous nerve fibers, plantar numbness is reduced in
patients with DPN after physical exercise. This exercise can also increase the conduction velocity of the
sural sensory nerves and the peroneal motor nerves. In the mini trampoline exercise the muscles of the
body and lower extremities such as the knee and leg muscles are contracted, so that balance and stability
of the body can be controlled (Kanchanasamut & Pensri, 2017). Balance and resistance training in the
form of active muscle stretching with a therapist combined with electrical stimulation can also increase
the sensibility of the plantar skin in both feet and increase walking speed among older adults with DM2.
In addition to the effect of exercise, the effect of electrical stimulation is regenerating cell and nerve
function caused by hyperglycemia in diabetes (Navarro-peternella & Teston, 2019). Improvement of pain
felt in daily activities, pain threshold and neuropathic symptoms can be reduced through low intensity
resistance training. In addition, an increase in the patient's quality of life and an increase in lower leg
strength as a result of increased foot sensation and decreased pain and tingling symptoms can be
obtained through low-intensity aerobic exercise (Johnson & Takemoto, 2019).
Exercise has a number of beneficial effects on the body, including improving hypertension,
increasing organ perfusion, reducing lipid and protein oxidation and reducing humoral inflammation
(Zilliox & Russell, 2019). Exercise intervention reduces pain and symptoms of neuropathy (Kluding et al.,
2012). Systematic review by (Zilliox & Russell, 2019) concluded that physical exercise provides little
change in the progressive nature of peripheral neuropathy, therefore further research is needed
involving adequate samples (Seyedizadeh et al., 2020). In contrast to the case (Stubbs Jr et al ( 2019),
exercise is not statistically significant in improving nerve function, but exercise, regardless of type, does
not worsen peripheral sensory injury or motor nerve injury in diabetic neuropathic patients (Stubbs Jr
et al (2019).
16 Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21

Table 1. The effectiveness of physical exercise on sensation of peripheral neuropathy in type 2 DM patients.
Reference Participants Design Intervention and Exercise techniques Follow-up Outcome on neuropathy
type of exercise
(Kanchanasamut 21 patients with RCT - Foot care Powerful weight-bearing Five times a - Increase the perception
& Pensri, 2017) diabetic education and activities such as jumping week for of pressure on both feet
neuropathy mini-trampoline and hopping, spot walking eight weeks (p = 0.008-0.031).
exercises on mini trampolines, one- - Increase the perception
- Aerobic exercise leg jumps and two-leg of vibration (vibration
alternate hops with front pressure) for both feet
and rear displacement. (p = 0.004-0.016).
(Navarro- 30 DM patients Clinical trial Combination of Active muscle stretching; Twice a week Increases the sensibility of
peternella & aged ≥60 years balance and Passive muscle for 12 weeks the plantar skin on both
Teston, 2019) resistance training strengthening with in 50minute feet
therapists; Sensory sessions
exercise
(Dixit et al., 37 DM patients Single blind Moderate treadmill The heart rate for exercise 150 - 360 Increased vibration
2019) in the study parallel exercise training was carried out in minutes per perception threshold
group, 47 group RCT the range of 40% to 60% week, 3 days (VPT) at 3 points (thumb,
patients in the and heart rate reserve per week medial malleoli, first
control group. (HRR) as an adjunct to this metatarsal phalanx) (df1,
rating of perceived exertion df2 = 1, 63; F = 8.56; P
(RPE) (scale ranging from 6 <.001).
to 20) was carried out
before, during, and
postexercise.
Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21 17

Table 1. The effectiveness of physical exercise on sensation of peripheral neuropathy in type 2 DM patients. (continued)
(Seyedizadeh et 24 female DM RCT Combination of The resistance training: 3 sessions Increase lower body
al., 2020) patients aerobic and chest press, wide-grip lat per week for strength. And cause minor
resistance training pulldown, barbell curl, 8 weeks. changes in the progressive
lying triceps press, leg nature of diabetic
extension, lying leg curls, peripheral neuropathy
sit-up, and push-up using
bodybuilding equipment.
The aerobic training: the
interval running with 3-
minute repetitions and a
rest time of 30 seconds.
(Stubbs Jr et al., 38 DM patients RCT Combination of Warm-up, treadmill 3 times a Improve sensory nerve
2019) aerobic and waking, isokinetic leg week for 12 function
resistance training extensions weeks
(Zilliox & Russell, Twenty studies SR Diet and physical Prevents the development
2019) exercise of peripheral neuropathy
interventions
(Matos et al., Six studies Systematic Aerobic exercise; Physical activity and
2018) involved 418 DM review Combination of exercise improve
patients. aerobic, resistance peripheral sensory
and balance function
exercises;
Combination of
aerobic and balance
exercises (Thai Chin
Chuan)
18 Asian Comm. Health Nurs. Res. 2020, 2(2), 11–21

Table 1. The effectiveness of physical exercise on sensation of peripheral neuropathy in type 2 DM patients. (continued)
(C. Johnson & 10 articles Systematic Aerobic training, Aerobic: walking, Low intensity exercise
Takemoto, 2019) review resistance training, minitrampoline improves leg sensation in
balance training Resistance: weight peripheral neuropathy
machines
Balance: Tai-chi, yoga
(Gholami et al., 24 volunteers RCT Aerobic exercise Walk, jog or run on the 3 sessions a Aerobic exercise has the
2018) diagnosed with treadmill. week, 20-45 potential to inhibit the
diabetic PN minutes per development of PN
session for 3 diabetes by increasing
months NCV. More research is
needed on the mechanism
of exercise linking.
(Gholami et al., 31 respondents RCT Aerobic exercise Cycling 12 weeks Decreased neuropathic
2020) symptoms from 12.2 ± 3.9
at baseline to 7.9 ± 2.4 at
post-workout in the
experimental group (t =
4.346, P = 0.001)
(Nadi et al., 81 female RCT Combination of Light stretches to warm up, 12 weeks and Increased sensation in
2017) patients with aerobic and Simple aerobic exercise 3 sessions / numbness (P = 0.001), and
type 2 DM resistance exercise exercises, resistance week and 60 vibration perception (P =
and vitamin D training moves with minutes / 0.001)
supplements dumbbells and stretches for session.
cool down
Asian Comm. Health Nurs. Res. 2020, 2(2), 11—21 19

Physical exercise, either done alone or in combination, has a good effect on peripheral neuropathy
in type 2 DM patients. Further research is needed with methods of efficient physical exercise both at
home and involving groups and according to the age level of type 2 DM patients. more than 150 minutes
per week can reduce HbA1c with an average change of -0.89% compared to intervention of less than 150
minutes per week (Sigal et al., 2018). This is supported by a meta-analysis which found that supervised
exercise interventions lowered HbA1c in type 2 DM patients (Umpierre et al., 2016).
Glycemic control can be improved through resistance training. So far there has not been an optimal
endurance training program standard in terms of frequency, intensity, type and volume of training. The
benefits of physical activity in DM patients include improving cardiorespiratory fitness, increasing
strength, increasing glycemic control, lowering blood pressure and helping to lose weight (Sigal et al.,
2018). Low intensity resistance training decreases the threshold for pain and neuropathic symptoms.
Exercise of any kind does not worsen peripheral sensory or motor injury in patients with diabetic
peripheral neuropathy (Stubbs Jr et al ( 2019). Physical exercise, either alone or in combination, has a
good effect on peripheral neuropathy in type 2 diabetes patients. Resistance training in combination with
regular aerobic exercise twice a week is effective in reducing HbA1c and body fat. Increased glycemic
control prevents and reduces the development of peripheral neuropathy. However, there is no clear
standard in terms of frequency, intensity, type and volume in the resistance training program (Sigal et
al., 2018). After physical exercise intervention in type 2 DM patients with peripheral neuropathy, there
was an improvement in HbA1c levels and neuropathy symptoms assessed using MDNS (Gholami et al.,
2020). Increased glycemic control can reduce the development of nerve dysfunction and neuropathic
symptoms in type 2 DM patients. Nerve dysfunction in DM is not only caused by hyperglycemia, but
vascular factors are thought to be involved in the development of DPN, namely hypoxia due to blood flow
disorders (Gholami et al., 2020). Therefore, many studies have investigated the conduction velocity of
nerves, as they affect blood supply. This study shows that aerobic exercise has the potential to inhibit the
development of PN diabetes by increasing nerve conduction velocity (NCV). The increase in NCV sural
after local warming is directly related to local blood supply, but further research is needed to see the
long-term impact of exercise. Improved nerve conductive function through increased NCV, especially
sural sensory nerves can be achieved through 12 weeks of aerobic exercise. The sensory nerves in the
lower extremities are more sensitive to hyperglycemia, so they will be more sensitive to adaptation in
exercise (Gholami et al., 2020; Seyedizadeh et al., 2020).

6. Conclusion
This review emphasizes the effect of physical exercise on peripheral neuropathic sensation in type
2 DM patients and strengthens the evidence that low and moderate-intensity exercise are beneficial to
reduce peripheral neuropathy symptoms. Further research on the effectiveness of community-based
physical exercise to reduce symptoms of peripheral neuropathy is necessary.

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