3.1. Physical activity for persons at higher risk of developing type 2 diabetes mellitus

Different clinical practice guidelines and systematic reviews agreed that participation in lifestyle therapy that includes regular physical activity should be the first line of defense against T2D development from a state of pre diabetes [23–26]. Both aerobic and anaerobic forms of physical activity have also various beneficial effects on metabolism in a number of tissues and organs, including skeletal muscle, adipose, liver, pancreas and even brain. Exercise may increase body's response to intrinsic insulin, by multiple mechanisms including [27, 28].

The American Diabetes Association states that simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. To help prevent type 2 diabetes and its complications, people should be physically active at least 30 minutes of regular, moderate-intensity activity on most days [16, 17, 29].

Several large-scale clinical trials have established that about 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity per week, such as brisk walking, with no more than 1 or 2 days off in a row, reduces the risk of developing type 2 diabetes regardless of the degree of adiposity [30–34].

People with prediabetes can be taught physical activities to use their body weight as resistance. They can also use mechanical devices like machines. Major muscle groups of both the upper and lower extremities such as the quadriceps, hamstrings, calves, abdominals, biceps, triceps and forearms should be trained to build their girth and strength. Physical activity guidelines vary on intensity and frequency of prescribing such exercises. The frequency and intensity of exercises should be designed based on an individual's observed capacity to continue the program [16, 35].

Resistance exercise can be performed 2 or 3 times per week for 30–60 min per session. It increases muscle mass, elevates resting metabolic rate, enhances muscular endurance, increases insulin sensitivity and attenuates muscle mass loss during caloric restriction and aging [31, 36].

A systematic review done on the effectiveness of combined diet and physical activity for the prevention of type 2 diabetes stated that combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardio metabolic risk factors in persons at increased risk. It stated that the more the intensive programs are the more effective will be [37].

Safety should be a major consideration for both health-care professionals and patients before initiating a new program of physical activity.

have less muscular strength than people without type 2 DM [42]. This further leads to reduced physical activity unless it is properly managed. However, physical activities in form of aerobic/ resistance or combination of both resulted in increase in strength in persons with diabetes

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Individuals with diabetic peripheral neuropathy (DPN) are 15 times more likely to experience fall compared to the healthy subjects. Falls are marked as a dangerous health issue in DPN especially in the geriatric population. Therefore, knowledge of the factors that influence falls such as postural control deficit and gait instability in DPN patients is essential. Tailored preventive programs including specific gait and balance exercises and cognitive training might

A growing number of studies have shown that exercises have some effect on gait and balance. Multisensory exercise and specific gait and balance training programs combined with functional orientated strengthening activities can improve gait speed and balance, and increase

Task-oriented motor gait training for DPN patients can be used to enhance performance during walking, balance and foot mechanics during walking. Changes in the provided sensorimotor information and enhanced muscle abilities can be regarded as reliable contributions

As evidenced by a review on the effectiveness of balance training in the intervention of fall risk in elderly with DPN, Proprioception training, vestibular training, lower limb strength training and mixed sports training enhance balance and reduce its risk of falling in elderly with DPN [45]. When the therapist applies the balance training to elderly patients with DPN, they should

Proprioceptive training can be applied to moderate to severe neuropathy in elderly patients due to the safety and its effectiveness. Vestibular training is more suitable for younger DPN patients. When we apply it to elderly patients, we should pay attention to their safety and should choose low-intensity training. Weight training could significantly improve the lower limbs of patients with DPN walking ability, and relatively more effective than non-weight

Peripheral neuropathy is the most common complication of diabetes mellitus (DM) both in developed and developing countries. It is found in about 10% of diabetic patients at diagnosis and in the majority of patients 25 years later on. In diabetic peripheral neuropathy peripheral nerves are unable to function optimally as a result of high blood sugar levels. This condition affects almost half of patients with type 1 and type 2 DM. It involves the presence of symptoms or signs of peripheral nerve dysfunction in people with diabetes after other possible causes have been excluded. Thus, decreasing blood glucose levels can help inhibit and possibly

3.2.3. Exercises can improve gait and balance of patients with diabetes mellitus

be beneficial in reducing fall risk in older adults suffering from diabetes.

both muscle strength and joint mobility of diabetic patients [43, 44].

focus on the features of different kinds of balance training.

3.3. Physical therapy for diabetic peripheral neuropathy

reverse some of the consequences of diabetic peripheral neuropathy.

for gait responses in DPN patients [44].

training [44].

mellitus.

Therefore physiotherapists should encourage patients who are at high risk of developing diabetes mellitus type 2 to do the following.

