Physical activity and dietary interventions in diabetic neuropathy: a systematic review

  • Lindsay A. Zilliox
  • James W. RussellEmail author
Review Article



Diabetic neuropathy is a common and disabling disorder, and there are currently no proven effective disease-modifying treatments. Physical activity and dietary interventions in patients with diabetes and diabetic neuropathy have multiple beneficial effects and are generally low risk, which makes lifestyle interventions an attractive treatment option. We reviewed the literature on the effects of physical activity and dietary interventions on length-dependent peripheral neuropathy and cardiac autonomic neuropathy in diabetes.


The electronic database PubMed was systematically searched for original human and mouse model studies examining the effect of either dietary or physical activity interventions in subjects with diabetes, prediabetes, or metabolic syndrome.


Twenty studies are included in this review. Fourteen studies were human studies and six were in mice. Studies were generally small with few controlled trials, and there are no widely agreed upon outcome measures.


Recent research indicates that dietary interventions are effective in modifying diabetic neuropathy in animal models, and there are promising data that they may also ameliorate diabetic neuropathy in humans. It has been known for some time that lifestyle interventions can prevent the development of diabetic neuropathy in type 2 diabetes mellitus subjects. However, there is emerging evidence that lifestyle interventions are effective in individuals with established diabetic neuropathy. In addition to the observed clinical value of lifestyle interventions, there is emerging evidence of effects on biochemical pathways that improve muscle function and affect other organ systems, including the peripheral nerve. However, data from randomized controlled trials are needed.


Diabetic neuropathy Exercise Diet Dysautonomia Sirtuins 



Supported in part by the National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health 1R01DK107007-01A1, the Office of Research Development, Department of Veterans Affairs (Biomedical and Laboratory Research Service and Rehabilitation Research and Development, 101RX001030), the Diabetes Action Research and Education Foundation, and the Baltimore GRECC (JWR), 1K2RX001651 (LAZ).


  1. 1.
    Cho NH, Shaw JE, Karuranga S, Huang Y, da Rocha Fernandes JD, Ohlrogge AW, Malanda B (2018) IDF diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 138:271–281Google Scholar
  2. 2.
    Dyck PJ, Kratz KM, Karnes JL, Litchy WJ, Klein R, Pach JM, Wilson DM, O’Brien PC, Melton LJ III, Service FJ (1993) The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology 43:817–824CrossRefGoogle Scholar
  3. 3.
    Dyck PJB, Dyck PJ (1999) Diabetic polyneuropathy. In: Dyck PJ, Thomas PK (eds) Diabetic neuropathy. W.B. Saunders Company, Philadelphia, pp 255–278Google Scholar
  4. 4.
    Albers JW, Herman WH, Pop-Busui R, Martin CL, Cleary P, Waberski B (2007) Subclinical neuropathy among Diabetes Control and Complications Trial participants without diagnosable neuropathy at trial completion: possible predictors of incident neuropathy? Diabetes Care 30:2613–2618CrossRefGoogle Scholar
  5. 5.
    Zilliox L, Peltier AC, Wren PA, Anderson A, Smith AG, Singleton JR, Feldman EL, Alexander NB, Russell JW (2011) Assessing autonomic dysfunction in early diabetic neuropathy: the Survey of Autonomic Symptoms. Neurology 76:1099–1105CrossRefGoogle Scholar
  6. 6.
    Costa LA, Canani LH, Lisbôa HR, Tres GS, Gross JL (2004) Aggregation of features of the metabolic syndrome is associated with increased prevalence of chronic complications in type 2 diabetes. Diabet Med 21:252–255CrossRefGoogle Scholar
  7. 7.
    Smith AG, Rose K, Singleton JR (2008) Idiopathic neuropathy patients are at high risk for metabolic syndrome. J Neurol Sci 273:25–28CrossRefGoogle Scholar
  8. 8.
    Smith AG, Singleton JR (2013) Obesity and hyperlipidemia are risk factors for early diabetic neuropathy. J Diabetes Complications 27:436–442CrossRefGoogle Scholar
  9. 9.
    Bergström B, Lilja B, Osterlin S, Sundkvist G (1990) Autonomic neuropathy in non-insulin dependent (type II) diabetes mellitus. Possible influence of obesity. J Intern Med 227:57–63CrossRefGoogle Scholar
  10. 10.
    Emdin M, Gastaldelli A, Muscelli E, Macerata A, Natali A, Camastra S, Ferrannini E (2001) Hyperinsulinemia and autonomic nervous system dysfunction in obesity: effects of weight loss. Circulation 103:513–519CrossRefGoogle Scholar
  11. 11.
    Peterson HR, Rothschild M, Weinberg CR, Fell RD, McLeish KR, Pfeifer MA (1988) Body fat and the activity of the autonomic nervous system. N Engl J Med 318:1077–1083CrossRefGoogle Scholar
  12. 12.
    Sumner CJ, Sheth S, Griffin JW, Cornblath DR, Polydefkis M (2003) The spectrum of neuropathy in diabetes and impaired glucose tolerance. Neurology 60:108–111CrossRefGoogle Scholar
  13. 13.
    Polydefkis M, Hauer P, Sheth S, Sirdofsky M, Griffin JW, McArthur JC (2004) The time course of epidermal nerve fibre regeneration: studies in normal controls and in people with diabetes, with and without neuropathy. Brain 127:1606–1615CrossRefGoogle Scholar
  14. 14.
    Smith AG, Howard JR, Kroll R, Ramachandran P, Hauer P, Singleton JR, McArthur J (2005) The reliability of skin biopsy with measurement of intraepidermal nerve fiber density. J Neurol Sci 228:65–69CrossRefGoogle Scholar
  15. 15.
    Lauria G, Hsieh ST, Johansson O, Kennedy WR, Leger JM, Mellgren SI, Nolano M, Merkies IS, Polydefkis M, Smith AG, Sommer C, Valls-Sole J, European Federation of Neurological Societies, Peripheral Nerve Society (2010) European Federation of Neurological Societies/Peripheral Nerve Society guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Report of a joint task force of the European Federation of Neurological Societies and the Peripheral Nerve Society. Eur J Neurol 17:903–912 (e944–909) Google Scholar
  16. 16.
    Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM (2002) Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med 346:393–403CrossRefGoogle Scholar
  17. 17.
    Ametov AS, Barinov A, Dyck PJ, Hermann R, Kozlova N, Litchy WJ, Low PA, Nehrdich D, Novosadova M, O’Brien PC, Reljanovic M, Samigullin R, Schuette K, Strokov I, Tritschler HJ, Wessel K, Yakhno N, Ziegler D (2003) The sensory symptoms of diabetic polyneuropathy are improved with alpha-lipoic acid: the SYDNEY trial. Diabetes Care 26:770–776Google Scholar
  18. 18.
    Ziegler D, Ametov A, Barinov A, Dyck PJ, Gurieva I, Low PA, Munzel U, Yakhno N, Raz I, Novosadova M, Maus J, Samigullin R (2006) Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy: the SYDNEY 2 trial. Diabetes Care 29:2365–2370CrossRefGoogle Scholar
  19. 19.
    Ziegler D, Low PA, Freeman R, Tritschler H, Vinik AI (2016) Predictors of improvement and progression of diabetic polyneuropathy following treatment with alpha-lipoic acid for 4 years in the NATHAN 1 trial. J Diabetes Complications 30:350–356CrossRefGoogle Scholar
  20. 20.
    Ziegler D, Low PA, Litchy WJ, Boulton AJ, Vinik AI, Freeman R, Samigullin R, Tritschler H, Munzel U, Maus J, Schutte K, Dyck PJ (2011) Efficacy and safety of antioxidant treatment with alpha-lipoic acid over 4 years in diabetic polyneuropathy: the NATHAN 1 trial. Diabetes Care 34:2054–2060CrossRefGoogle Scholar
  21. 21.
    Chandrasekaran KCC, Sagi AR, Russell JW (2016) A nicotinamide adenine nucleotide (NAD+) precursor is a potential therapy for diabetic neuropathy (abstract). In: ICNMD 2016: abstract book for the 14th International Congress on Neuromuscular Diseases, July 5–9, 2016 Toronto, Canada. J Neuromuscul Dis 3:S86Google Scholar
  22. 22.
    Trammell SA, Weidemann BJ, Chadda A, Yorek MS, Holmes A, Coppey LJ, Obrosov A, Kardon RH, Yorek MA, Brenner C (2016) Nicotinamide riboside opposes type 2 diabetes and neuropathy in mice. Sci Rep 6:26933. CrossRefGoogle Scholar
  23. 23.
    Liu D, Gharavi R, Pitta M, Gleichmann M, Mattson MP (2009) Nicotinamide prevents NAD+ depletion and protects neurons against excitotoxicity and cerebral ischemia: NAD+ consumption by SIRT1 may endanger energetically compromised neurons. Neuromolecular Med 11:28–42Google Scholar
  24. 24.
    Min SW, Sohn PD, Cho SH, Swanson RA, Gan L (2013) Sirtuins in neurodegenerative diseases: an update on potential mechanisms. Front Aging Neurosci 5:53Google Scholar
  25. 25.
    Stevens MJ, Li F, Drel VR, Abatan OI, Kim H, Burnett D, Larkin D, Obrosova IG (2007) Nicotinamide reverses neurological and neurovascular deficits in streptozotocin diabetic rats. J Pharmacol Exp Ther 320:458–464CrossRefGoogle Scholar
  26. 26.
    Canto C, Houtkooper RH, Pirinen E, Youn DY, Oosterveer MH, Cen Y, Fernandez-Marcos PJ, Yamamoto H, Andreux PA, Cettour-Rose P, Gademann K, Rinsch C, Schoonjans K, Sauve AA, Auwerx J (2012) The NAD(+) precursor nicotinamide riboside enhances oxidative metabolism and protects against high-fat diet-induced obesity. Cell Metab 15:838–847CrossRefGoogle Scholar
  27. 27.
    Avinash Rao S, Priyanka S, Chen C, Chandrasekaran K, Russell JW (2015) Administration of either nicotinamide mononucleotide (NMN) or over expression of SIRT1 prevents and treats peripheral neuropathy in type 1 and type 2 diabetic mouse models (abstract). In: 3rd International Conference and Exhibition on Neurology and Therapeutics. J Neurol Neurophysiol 6:3Google Scholar
  28. 28.
    Zilliox LA, Chadrasekaran K, Kwan JY, Russell JW (2016) Diabetes and cognitive impairment. Curr Diabet Rep 16:87CrossRefGoogle Scholar
  29. 29.
    Russell JW, Chandrasekaran K, Choi J, Chen H (2013) Nicotinamide adenine nucleotide (NAD+) regulation of sirtuin 1 (SIRT1) in the treatment of diabetic neuropathy (abstract). Ann Neurol p S95Google Scholar
  30. 30.
    Yoshino J, Mills KF, Yoon MJ, Imai S (2011) Nicotinamide mononucleotide, a key NAD(+) intermediate, treats the pathophysiology of diet- and age-induced diabetes in mice. Cell Metab 14:528–536CrossRefGoogle Scholar
  31. 31.
    Kobilo T, Guerrieri D, Zhang Y, Collica SC, Becker KG, van Praag H (2014) AMPK agonist AICAR improves cognition and motor coordination in young and aged mice. Learn Mem 21:119–126CrossRefGoogle Scholar
  32. 32.
    Cooper MA, Menta BW, Perez-Sanchez C, Jack MM, Khan ZW, Ryals JM, Winter M, Wright DE (2018) A ketogenic diet reduces metabolic syndrome-induced allodynia and promotes peripheral nerve growth in mice. Exp Neurol 306:149–157CrossRefGoogle Scholar
  33. 33.
    Coppey L, Davidson E, Shevalye H, Torres ME, Yorek MA (2018) Effect of dietary oils on peripheral neuropathy-related endpoints in dietary obese rats. Diabetes Metab Syndr Obes 11:117–127CrossRefGoogle Scholar
  34. 34.
    Hinder LM, O’Brien PD, Hayes JM, Backus C, Solway AP, Sims-Robinson C, Feldman EL (2017) Dietary reversal of neuropathy in a murine model of prediabetes and metabolic syndrome. Dis Model Mech 10:717–725CrossRefGoogle Scholar
  35. 35.
    Lewis EJH, Perkins BA, Lovblom LE, Bazinet RP, Wolever TMS, Bril V (2017) Effect of omega-3 supplementation on neuropathy in type 1 diabetes: a 12-month pilot trial. Neurology 88:2294–2301CrossRefGoogle Scholar
  36. 36.
    Lewis EJ, Perkins BA, Lovblom LE, Bazinet RP, Wolever TM, Bril V (2017) Using in vivo corneal confocal microscopy to identify diabetic sensorimotor polyneuropathy risk profiles in patients with type 1 diabetes. BMJ Open Diabetes Res Care 5:e000251CrossRefGoogle Scholar
  37. 37.
    Pritchard N, Edwards K, Russell AW, Perkins BA, Malik RA, Efron N (2015) Corneal confocal microscopy predicts 4-year incident peripheral neuropathy in type 1 diabetes. Diabetes Care 38:671–675Google Scholar
  38. 38.
    Groover AL, Ryals JM, Guilford BL, Wilson NM, Christianson JA, Wright DE (2013) Exercise-mediated improvements in painful neuropathy associated with prediabetes in mice. Pain 154:2658–2667CrossRefGoogle Scholar
  39. 39.
    Simone DA, Nolano M, Johnson T, Wendelschafer-Crabb G, Kennedy WR (1998) Intradermal injection of capsaicin in humans produces degeneration and subsequent reinnervation of epidermal nerve fibers: correlation with sensory function. J Neurosci 18:8947–8959CrossRefGoogle Scholar
  40. 40.
    Singleton JR, Marcus RL, Lessard MK, Jackson JE, Smith AG (2015) Supervised exercise improves cutaneous reinnervation capacity in metabolic syndrome patients. Ann Neurol 77:146–153CrossRefGoogle Scholar
  41. 41.
    Singleton JR, Smith AG, Russell JW, Feldman EL (2003) Microvascular complications of impaired glucose tolerance. Diabetes 52:2867–2876CrossRefGoogle Scholar
  42. 42.
    Orchard TJ, Temprosa M, Goldberg R, Haffner S, Ratner R, Marcovina S, Fowler S, Group DPPR (2005) The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med 142:611–619CrossRefGoogle Scholar
  43. 43.
    Balducci S, Iacobellis G, Parisi L, Di Biase N, Calandriello E, Leonetti F, Fallucca F (2006) Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complications 20:216–223CrossRefGoogle Scholar
  44. 44.
    Singleton JR, Marcus RL, Jackson JE, Lessard K, Graham TE, Smith AG (2014) Exercise increases cutaneous nerve density in diabetic patients without neuropathy. Ann Clin Transl Neurol 1:844–849CrossRefGoogle Scholar
  45. 45.
    Smith AG, Russell JW, Feldman EL, Goldstein J, Peltier A, Smith S, Hamwi J, Pollari D, Bixby B, Howard J, Singleton JR (2006) Lifestyle intervention for prediabetic neuropathy. Diabetes Care 29:1294–1299CrossRefGoogle Scholar
  46. 46.
    Kluding PM, Pasnoor M, Singh R, Jernigan S, Farmer K, Rucker J, Sharma NK, Wright DE (2012) The effect of exercise on neuropathic symptoms, nerve function, and cutaneous innervation in people with diabetic peripheral neuropathy. J Diabetes Complications 26:424–429CrossRefGoogle Scholar
  47. 47.
    Müller-Stich BP, Fischer L, Kenngott HG, Gondan M, Senft J, Clemens G, Nickel F, Fleming T, Nawroth PP, Büchler MW (2013) Gastric bypass leads to improvement of diabetic neuropathy independent of glucose normalization—results of a prospective cohort study (DiaSurg 1 study). Ann Surg 258:760–765 (discussion 765–766) CrossRefGoogle Scholar
  48. 48.
    Dixit S, Maiya A, Shastry B (2014) Effect of aerobic exercise on quality of life in population with diabetic peripheral neuropathy in type 2 diabetes: a single blind, randomized controlled trial. Qual Life Res 23:1629–1640CrossRefGoogle Scholar
  49. 49.
    Handsaker JC, Brown SJ, Bowling FL, Cooper G, Maganaris CN, Boulton AJ, Reeves ND (2014) Contributory factors to unsteadiness during walking up and down stairs in patients with diabetic peripheral neuropathy. Diabetes Care 37:3047–3053CrossRefGoogle Scholar
  50. 50.
    Handsaker JC, Brown SJ, Bowling FL, Maganaris CN, Boulton AJ, Reeves ND (2016) Resistance exercise training increases lower limb speed of strength generation during stair ascent and descent in people with diabetic peripheral neuropathy. Diabet Med 33:97–104CrossRefGoogle Scholar
  51. 51.
    Morrison S, Colberg SR, Parson HK, Vinik AI (2014) Exercise improves gait, reaction time and postural stability in older adults with type 2 diabetes and neuropathy. J Diabetes Complications 28:715–722CrossRefGoogle Scholar
  52. 52.
    Mueller MJ, Tuttle LJ, Lemaster JW, Strube MJ, McGill JB, Hastings MK, Sinacore DR (2013) Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial. Arch Phys Med Rehabil 94:829–838CrossRefGoogle Scholar
  53. 53.
    Taveggia G, Villafane JH, Vavassori F, Lecchi C, Borboni A, Negrini S (2014) Multimodal treatment of distal sensorimotor polyneuropathy in diabetic patients: a randomized clinical trial. J Manip Physiol Ther 37:242–252CrossRefGoogle Scholar
  54. 54.
    Astrup AS, Tarnow L, Rossing P, Hansen BV, Hilsted J, Parving HH (2006) Cardiac autonomic neuropathy predicts cardiovascular morbidity and mortality in type 1 diabetic patients with diabetic nephropathy. Diabetes Care 29:334–339CrossRefGoogle Scholar
  55. 55.
    Spallone V, Ziegler D, Freeman R, Bernardi L, Frontoni S, Pop-Busui R, Stevens M, Kempler P, Hilsted J, Tesfaye S, Low P, Valensi P (2011) Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev 27:639–653Google Scholar
  56. 56.
    Grisé KN, Olver TD, McDonald MW, Dey A, Jiang M, Lacefield JC, Shoemaker JK, Noble EG, Melling CW (2016) High intensity aerobic exercise training improves deficits of cardiovascular autonomic function in a rat model of type 1 diabetes mellitus with moderate hyperglycemia. J Diabetes Res 2016:8164518CrossRefGoogle Scholar
  57. 57.
    Voulgari C, Pagoni S, Vinik A, Poirier P (2013) Exercise improves cardiac autonomic function in obesity and diabetes. Metabolism 62:609–621CrossRefGoogle Scholar
  58. 58.
    Facchini M, Malfatto G, Sala L, Silvestri G, Fontana P, Lafortuna C, Sartorio A (2003) Changes of autonomic cardiac profile after a 3-week integrated body weight reduction program in severely obese patients. J Endocrinol Invest 26:138–142CrossRefGoogle Scholar
  59. 59.
    Figueroa A, Baynard T, Fernhall B, Carhart R, Kanaley JA (2007) Endurance training improves post-exercise cardiac autonomic modulation in obese women with and without type 2 diabetes. Eur J Appl Physiol 100:437–444CrossRefGoogle Scholar
  60. 60.
    Ito H, Ohshima A, Tsuzuki M, Ohto N, Yanagawa M, Maruyama T, Kaji Y, Kanaya S, Nishioka K (2001) Effects of increased physical activity and mild calorie restriction on heart rate variability in obese women. Jpn Heart J 42:459–469CrossRefGoogle Scholar
  61. 61.
    The Diabetes Control and Complications Trial Research Group (1998) The effect of intensive diabetes therapy on measures of autonomic nervous system function in the Diabetes Control and Complications Trial (DCCT). Diabetologia 41:416–423Google Scholar
  62. 62.
    Pop-Busui R, Low PA, Waberski BH, Martin CL, Albers JW, Feldman EL, Sommer C, Cleary PA, Lachin JM, Herman WH (2009) Effects of prior intensive insulin therapy on cardiac autonomic nervous system function in type 1 diabetes mellitus: the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study (DCCT/EDIC). Circulation 119:2886–2893Google Scholar
  63. 63.
    UKPDS (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 352:837–853CrossRefGoogle Scholar
  64. 64.
    Holman RR, Paul SK, Bethel MA, Neil HA, Matthews DR (2008) Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med 359:1565–1576CrossRefGoogle Scholar
  65. 65.
    Gaede P, Vedel P, Larsen N, Jensen GV, Parving HH, Pedersen O (2003) Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. N Engl J Med 348:383–393CrossRefGoogle Scholar
  66. 66.
    Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA, Sosenko JM, Ziegler D (2017) Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care 40:136–154CrossRefGoogle Scholar
  67. 67.
    Bhagyalakshmi S, Nagaraja H, Anupama B, Ramesh B, Prabha A, Niranjan M, Shreedhara A (2007) Effect of supervised integrated exercise on heart rate variability in type 2 diabetes mellitus. Kardiol Pol 65:363–368 (discussion 369) Google Scholar
  68. 68.
    Goit RK, Pant BN, Shrewastwa MK (2018) Moderate intensity exercise improves heart rate variability in obese adults with type 2 diabetes. Indian Heart J 70:486–491CrossRefGoogle Scholar
  69. 69.
    Vanninen E, Uusitupa M, Länsimies E, Siitonen O, Laitinen J (1993) Effect of metabolic control on autonomic function in obese patients with newly diagnosed type 2 diabetes. Diabet Med 10:66–73CrossRefGoogle Scholar
  70. 70.
    Zoppini G, Cacciatori V, Gemma ML, Moghetti P, Targher G, Zamboni C, Thomaseth K, Bellavere F, Muggeo M (2007) Effect of moderate aerobic exercise on sympatho-vagal balance in type 2 diabetic patients. Diabet Med 24:370–376CrossRefGoogle Scholar
  71. 71.
    American Diabetes Association (2018) 2. Classification and diagnosis of diabetes: standards of medical care in diabetes—2018. Diabetes Care 41:S13–S27Google Scholar
  72. 72.
    Howorka K, Pumprla J, Haber P, Koller-Strametz J, Mondrzyk J, Schabmann A (1997) Effects of physical training on heart rate variability in diabetic patients with various degrees of cardiovascular autonomic neuropathy. Cardiovasc Res 34:206–214CrossRefGoogle Scholar
  73. 73.
    Pagkalos M, Koutlianos N, Kouidi E, Pagkalos E, Mandroukas K, Deligiannis A (2008) Heart rate variability modifications following exercise training in type 2 diabetic patients with definite cardiac autonomic neuropathy. Br J Sports Med 42:47–54CrossRefGoogle Scholar
  74. 74.
    Villafaina S, Collado-Mateo D, Fuentes JP, Merellano-Navarro E, Gusi N (2017) Physical exercise improves heart rate variability in patients with type 2 diabetes: a systematic review. Curr Diab Rep 17:110CrossRefGoogle Scholar
  75. 75.
    Burr JF, Shephard RJ, Riddell MC (2012) Physical activity in type 1 diabetes mellitus: assessing risks for physical activity clearance and prescription. Can Fam Physician 58:533–535Google Scholar
  76. 76.
    Vadstrup ES, Frølich A, Perrild H, Borg E, Røder M (2011) Health-related quality of life and self-related health in patients with type 2 diabetes: effects of group-based rehabilitation versus individual counselling. Health Qual Life Outcomes 9:110CrossRefGoogle Scholar
  77. 77.
    Gibbons CH, Freeman R (2010) Treatment-induced diabetic neuropathy: a reversible painful autonomic neuropathy. Ann Neurol 67:534–541CrossRefGoogle Scholar
  78. 78.
    Colberg SR, Sigal RJ, Fernhall B, Regensteiner JG, Blissmer BJ, Rubin RR, Chasan-Taber L, Albright AL, Braun B, American College of Sports Medicine, American Diabetes Association (2010) Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: joint position statement executive summary. Diabetes Care 33:2692–2696Google Scholar
  79. 79.
    Colberg SR, Vinik AI (2014) Exercising with peripheral or autonomic neuropathy: what health care providers and diabetic patients need to know. Physiol Sports Med 42:15–23CrossRefGoogle Scholar
  80. 80.
    Colberg SR, Swain DP, Vinik AI (2003) Use of heart rate reserve and rating of perceived exertion to prescribe exercise intensity in diabetic autonomic neuropathy. Diabetes Care 26:986–990CrossRefGoogle Scholar

Copyright information

© This is a U.S. government work and its text is not subject to copyright protection in the United States; however, its text may be subject to foreign copyright protection 2019

Authors and Affiliations

  1. 1.Department of Neurology, School of MedicineUniversity of MarylandBaltimoreUSA
  2. 2.Maryland VA Healthcare SystemBaltimoreUSA

Personalised recommendations