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Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial Neslihan Duruturk ∗ , Manolya Acar Özköslü Baskent University, Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ankara, Turkey
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aim: To determine the effect of a tele-rehabilitation (TR) program on glucose control, exercise
Received 14 January 2019
capacity, physical fitness, muscle strength and psychosocial status in patients with type 2
Received in revised form
diabetes mellitus (DM).
4 March 2019
Method: Fifty type 2 DM participants were enrolled in the study and divided randomly into
Accepted 25 March 2019
two groups; TR (n = 25, mean age: 52.82 ± 11.86) or control (n = 25, mean age: 53.04 ± 10.45)
Available online xxx
group. Participants in the TR group performed breathing and callisthenic exercises, three
Keywords:
including, HbA1c level, 6 min walk testing, physical fitness and muscle strength dynamome-
Tele-rehabilitation
ter measurement, Beck Depression Inventory were performed before and after the 6 weeks.
times a week, for 6 weeks, at home by internet based video conferences. Outcome measures
Type 2 diabetes mellitus
Results: HbA1c (p = 0.00), 6 min walking distance (p = 0.00), physical fitness subparameters;
Exercise training
sit-up (p = 0.00), sit-and-reach (p = 0.04), back scratch (p = 0.00), lateral flexion right (p = 0.04),
Physical fitness
left (p = 0.00) and time up go tests (p = 0.00), muscles strength (p = 0.00); deltoideus-anterior,
e-Health
middle, quadriceps femoris and gluteus maximus, and depression levels (p = 0.00) changed significantly (p = 0.00) in TR groups. There were no significant improvements in control group (p > 0.05). Conclusion: Our findings suggest that TR interventions found to be safe and effective, and may be an alternative treatment model for type 2 DM management. In addition to these health benefits, patients and rehabilitation team may save time, labor and treatment costs by using TR. © 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. E-mail address: [email protected] (N. Duruturk). https://doi.org/10.1016/j.pcd.2019.03.007 1751-9918/© 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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1.
Introduction
Diabetes mellitus (DM) is a chronic metabolic disorder in which the patients cannot sufficiently benefit from carbohydrates, fat and protein due to insulin deficiency or impaired insulin effect and which requires continuous patient care. Today, DM has become a health problem with gradually increasing importance worldwide due to its prevalence and related problems [1]. Type 2 DM is the most common form of DM [2,3]. Diabetes is among the most important cardiovascular risk factors and the underlying insulin resistance and decreased insulin secretion may lead to some symptoms like widespread fatigue, muscle weakness, sensory problems, dyspnea, dry mouth, nocturia, blurred vision, weight loss, infections, psychological problems and some comorbidity like dyslipidemia, hypertension, and some complications like myopathy, nephropathy, neuropathy, retinopathy and diabetic foot [4]. These symptoms, comorbidities and complications may impair quality of life, shorten lifespan and lead to psycho-social problems through influencing exercise capacity and physical capacity. Physical activity and regular exercise programs have suggested preventing or delaying symptoms and complications of type 2 DM besides pharmacological treatment and dietary approaches. Nevertheless, continuity of exercise programs is the leading problem for rehabilitation programs [5,6]. Computer-based technologies and the developments in communication facilities have led to innovative changes in health area. Tele-rehabilitation (TR) which carries health services distant through using electronic communication systems is an important treatment option for improving continuity for patient care and health care and for providing availability [7–9]. Awareness of exercise which is an important step for disease management besides follow up of complications, glycemic control, blood pressure, lipidemia, weight and diet may be achieved through TR procedures. Diabetes education is provided with interactive seminars, video-conferences and phone calls and the patients are encouraged for doing exercises. Patients may debate with their physiotherapists about exercises and rehabilitation programs. TR enables the patients to take part in their follow up and treatment, thereby adaptation to exercise through taking responsibility [10–12]. Tele-diabetes applications in which many systems like computer, analogue telephones, network systems, cell phones, video-conference system, satellite technologies, electrocardiography tele-transmission devices are used for yearly controls and complication follow-ups of type 2 DM patients whose health expenditures are two-fold of the patients without type 2 DM [13,14]. Previous tele-medicine and TR studies in type 2 DM patients are seen to investigate glycemic control, complications and quality of life of diabetic patients. These studies have indicated that tele-medicine applications have improved glycemic control, quality of life and reduced hemoglobin (Hb) A1c values [15–19]. However TR studies about exercise education in type 2 DM patients are not available in literature despite the presence of TR studies in musculoskeletal system, neurologic, cardio-pulmonary, orthopedic diseases [20–23].
Based on these opinions, the purpose of our study was to determine the effects of TR on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 DM.
2.
Material and methods
2.1.
Subjects
Fifty subjects with type 2 DM were selected from Baskent University Hospital between September 2017 and January 2018. Inclusion criteria were ages between 18–65 years and diagnose of type 2 DM at least 6 months. Participants who is clinically unstable or who have neuromuscular disease, unstable cardiovascular diseases, musculoskeletal disease, pregnancy, lactation, and inability or unwillingness to comply with the required exercise were excluded from the study. All parameters were assessed before and after 6 weeks the intervention period in all groups. This study was approved by the Medical Ethics Committee of Baskent University. Written informed consents were obtained from all of the participants.
2.2.
Study design-intervention
A double blind randomized controlled trial was performed to investigate the effectiveness of TR intervention for patients of type 2 DM. The subjects were randomized in to either a TR intervention group (n = 25) or a control group (n = 25). An independent therapist randomly picked up an envelope that contained patient information, in a blinded fashion, for allocating each patient to either of the two groups. Subsequently, clinical assessments were carried out by a physiotherapist, followed by interventions that were administered by a different physiotherapist assigned to the treatment arm of the study. The subjects in the control group just received the education session, continued their current medical therapies and evaluated at the beginning of the study and after the 6-weeks period. All subjects in the TR group trained three times a week, for 6 weeks, lasted 40 min at home by internet based video conferences with the supervision of a physiotherapist. Only the first session of the training was performed at the clinic to precept the exercises. The TR group performed breathing exercises and callisthenic exercise that consist of 16 different, rhythmical exercises of strengthening and stretching of the lower and upper extremity muscles (Appendix A). Before the callisthenic exercises, warm-up exercises involving lower and upper extremity joint movements were repeated 10 times each. During the first and second weeks, the third and fourth weeks and the fifth and sixth weeks, the exercises were performed 10–15, 15–20 and 25–30 times per session, respectively. The duration of the exercise sessions was between 20 and 45 min. All subjects in the TR group measured their heart rate and SpO2 with a pulse oximeter and blood pressure with a digital sphygmomanometer themselves during the all exercises for safety after they had been taught by physiotherapist at the beginning of the TR intervention. The exercise intensity was adjusted based on the subjects’ Modified Borg Scale [24]
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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rated dyspnea or fatigue. We advised subjects resting if the perceived exertion rated was >7 obtained by Borg Scale.
2.3.
Outcome measurements
The socio-demographic characteristics, disease duration and HbA1c level of all subjects were recorded at admission. The health-related physical fitness domains were flexibility, muscular endurance, cardiorespiratory fitness (6MWT) and balance measurements [25]. The instructions about the test were given to the TR and control groups during the fitness tests. The physical fitness test consists of 6 measures as follows; 30-second chair stand test; used to assess lower extremity endurance. The number of full stands that could be completed in 30 s with the arms folded across the chest. The sit-up test; used to assess the endurance of abdominal muscles. The subjects were lying in the supine position with their knees flexed at 90◦ . The subjects performed trunk flexion at this position for 30 s. The number of trunk flexion repetitions was recorded. Sit-and-reach test; used to assess lower body flexibility. The test was performed by sit and reach box with a measuring scale. The test involved sitting on the floor with legs stretched out straight ahead. The soles of the feet were placed flat against the box. Both knees were locked and pressed flat to the floor. With the palms facing downward and the hands on top of each other, the subjects reached forward along the measuring line as far as possible. The subjects performed the test 3 times and reached the most distant point on the scale with fingertips. Back scratch test; used to assess upper body (shoulder) flexibility. One hand reached over the shoulder and one up the middle of the back; the number of inches (or cm) between the extended middle fingers (+ or −) were measured. Lateral flexion test; used to evaluate trunk flexibility. The subjects were asked to reach laterally while standing for the body lateral flexion test. The longest distance of the 3-time reach was noted. The number of inches (or cm) between the extended middle fingers (+ or −) and ground were measured. Time up go test; used to evaluate balance (mobility). The subjects were asked to stand-up from a chair, walk with their assistive devices at a comfortable pace to a marked line 3 m away and return to the chair to sit-down. Time taken to complete the test was recorded with a stopwatch. Two trials were administered, and the average was used for the analysis [27]. Six minute walk test (6MWT); was used to determine functional exercise capacity of the participants. The 6MWT was applied in a 30-m flat corridor. The subjects were instructed to walk with their own walking speed in 6 min. The 6MWT was administered twice in the same day with a 30-min interval and the longest 6MWT walking distance was recorded. The distance covered was measured in meters [26]. Muscle strength was evaluated with an objective measurement which is digital dynamometer (JTECH, Medical Commander Powertrack II, ABD) for deltoideus-anterior, deltoideus-middle, bicepsbrachii, iliopsoas and quadriceps femoris muscles. Tests were repeated for each muscle three times to the right and left sides and were recorded in Newton (N). The best value was used for analysis [27].
3
Beck Depression Scale (BDI) that has 21-item was applied to assess depression levels. According to BDI, if the total value ¨ ¨ depression¨, 10–16 is mild ¨ is 9 or less, no ¨, 17–23 Moderate¨, 24 ¨ considered [28]. and more is s¨ evere depressionare
2.4.
Statistical analysis
Statistical analysis was performed using SPSS 22 (IBM Corp. Armonk, NY, USA). The data from participants who completed the trial were only considered. The data were reported as mean ± standard deviation. Homogeneity and normality tests helped guide the actual statistical methods that were used. When data were normally distributed, paired t-tests were employed. Otherwise, comparisons of the difference between pre- and post-intervention values were made using the Mann–Whitney U test, and the comparisons between baseline and post-training were made using the non-parametric Wilcoxon test for each group. The primary outcome measure for this study was the change in HbA1c values. We found that group sample size of 17 achieved 80% power to show an improvement in primary outcome measurement and having a significance level (alpha) of 0.05 [29,30].
3.
Results
Fifty patients who fulfilled the selection criteria were randomly assigned to one of the two groups and 44 subjects participated in the last study measurements (Fig. 1). There were no baseline demographic differences between the groups (Table 1).
3.1.
Change in marker of glucose control
Relative to baseline values, HbA1c (p < 0.05) value was significantly decreased in the TR group at the end of the training period. There was no significant change in the control group over the 6-week study period (p > 0.05). When the differences between the baseline and 6-week values were compared, the magnitude of the change over the study period did not significantly differ between two groups (p > 0.05) (Table 2).
3.2.
Changes in physical fitness
From the parameters of physical fitness evaluation, sit-up, sitand-reach test, back scratch, lateral flexion and time up go tests were significantly improved in the TR group at the end of the study (p < 0.00). There was no significant change in the control group over the 6-week study period (p > 0.05). The changes in sit-up, back scratch (left), lateral flexion and time up go tests parameters over the 6-week intervention period significantly differ between the two groups (p < 0.00) (Table 2).
3.3.
Change in exercise capacity
6MWD in the TR group was significantly increased after the training intervention (p < 0.05). Conversely, in the control group 6MWD were significantly diminished after the 6-week experimental period (p < 0.05). The change in this value over
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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Fig. 1 – Study flow diagram.
Table 1 – Baseline characteristics of the subjects.
Female/male (number) Age (years) Body mass index (kg/m2 ) HbA1c (%) Disease duration (years)
TR group (mean ± SD)
Control group (mean ± SD)
p
11/12 52.82 ± 11.86 32.07 ± 6.51 7.14 ± 0.91 4.89 ± 3.86
7/14 53.04 ± 10.45 29.90 ± 4.63 7.57 ± 0.99 5.23 ± 3.36
0.91 0.13 0.15 0.57
SD: standard deviation. There were no statistical differences among the groups (p > 0.05) (Mann–Whitney U test).
the 6-week intervention period significantly differ between the two exercise groups (p < 0.00) (Table 2).
3.4.
Changes in muscle strength
Deltoideus-anterior, deltoideus-middle, quadriceps femoris and gluteus maximus muscles strength were significantly improved in the TR group at the end of the study (p < 0.00). However, there were no statistically significant changes in any muscle strength variables in the control group over the study period (p > 0.00). The magnitude of the changes in deltoideusanterior, deltoideus-middle, quadriceps femoris and gluteus maximus muscles strength from baseline to after the 6-week intervention significantly differed between two groups in favor of TR group (p < 0.00) (Table 2).
3.5.
Change in psychosocial status
Back Depression scale scores were significantly improved in TR groups after the 6-week training period (p > 0.00). None of
this improvement was observed in the control group over the same period (p > 0.00). The magnitude of the changes between the baseline and 6-week values for measures of psychosocial status significantly differed between the two groups (p < 0.00) (Table 2).
4.
Discussion
The main finding of this randomized controlled study was that TR intervention in patients with type 2 DM was effective in improving exercise capacity, physical fitness, muscle strength, psychosocial status and in controlling glucose. Patient feedback gave the physiotherapist the perception that three times weekly provided the greatest motivation for patient to exercise in TR group. As well compliance with the intervention was very good; the TR group attended an average of 16 out of the 18 (89%) exercise sessions. The reason for not attending at those sessions was mostly the problem with the internet connection. Our findings also suggest that type 2 DM patients were able to tolerate the calisthenics, which consisted of increas-
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Table 2 – Marker of glucose control, physical fitness, exercise capacity, muscle strength and depression scores between TR and control groups. TR group
Measurements
HbA1c Physical fitness 30-second chair stand test Sit-up test Sit-and-reach test (cm) Back scratch test (right) (cm) Back scratch test (left) (cm) Lateral flexion test (right) (cm) Lateral flexion test (left) (cm) Time up go test (sn) Exercise capacity 6MWD (m) Muscle strength Deltoideus-anterior (right) (N) Deltoideus-anterior (left) (N) Deltoideus-middle (right) (N) Deltoideus-middle (left) (N) Bicepsbrachii (right) (N) Bicepsbrachii (left) (N) Quadriceps femoris (right) (N) Quadriceps femoris (left) (N) Gluteus maximus (right) (N) Gluteus maximus (left) (N) Depression Beck depression scale
Control group
Pˇ
Baseline (mean ± SD)
6 weeks (mean ± SD)
P˛
Baseline (mean ± SD)
6 weeks (mean ± SD)
P˛
7.14 ± 0.91
5.93 ± 1.46
0.00*
7.57 ± 0.99
7.92 ± 2.82
0.23
0.42
10.23 ± 6.16 13.91 ± 5.31 6.95 ± 10.60 9.52 ± 10.02 9.86 ± 6.49 10.56 ± 3.27 11.54 ± 6.18 9.92 ± 4.96
10.82 ± 8.00 17.17 ± 4.82 8.73 ± 10.28 10.50 ± 9.60 6.76 ± 5.04 14.60 ± 4.39 17.26 ± 4.80 6.74 ± 2.10
0.34 0.00* 0.04* 0.04* 0.00* 0.00* 0.00* 0.00*
11.83 ± 5.14 12.19 ± 5.62 −2.61 ± 9.34 8.52 ± 6.82 11.50 ± 4.58 12.47 ± 4.28 11.64 ± 6.76 7.44 ± 2.50
11.85 ± 6.10 13.09 ± 6.36 −1.80 ± 9.41 8.50 ± 7.09 11.76 ± 4.88 11.19 ± 5.10 11.47 ± 6.32 7.59 ± 1.22
0.58 0.53 0.94 0.52 0.25 0.43 0.60 0.32
0.11 0.01* 0.21 0.28 0.00* 0.00* 0.00* 0.00*
489.00 ± 143.76
554.39 ± 139.00
0.00*
458.15 ± 168.87
450.90 ± 165.81
0.03*
0.00*
61.62 ± 17.66 64.09 ± 18.96 78.13 ± 20.70 80.06 ± 22.45 85.80 ± 22.81 83.02 ± 21.38 70.73 ± 16.80 68.90 ± 19.53 74.69 ± 23.74 74.62 ± 28.10
66.33 ± 17.51 68.54 ± 18.29 84.28 ± 21.50 84.54 ± 22.63 79.55 ± 20.36 86.03 ± 21.83 74.38 ± 18.26 71.89 ± 20.35 78.50 ± 24.15 77.92 ± 26.81
0.00* 0.00* 0.00* 0.00* 0.37 0.24 0.00* 0.00* 0.00* 0.00*
68.88 ± 24.80 68.04 ± 26.70 75.33 ± 28.30 74.22 ± 30.05 80.13 ± 30.63 80.87 ± 37.02 64.82 ± 27.28 63.17 ± 25.38 76.27 ± 27.92 72.85 ± 28. 31
69.20 ± 25.10 68.11 ± 26.99 75.49 ± 28.19 75.13 ± 31.14 75.95 ± 30.27 80.39 ± 36.01 66.43 ± 26.77 64.91 ± 25.82 75.46 ± 27.56 72.59 ± 28.42
0.50 0.82 0.57 0.22 0.06 0.60 0.19 0.33 0.15 0.32
0.00* 0.00* 0.00* 0.00* 0.29 0.14 0.00* 0.00* 0.00* 0.00*
13.08 ± 9.50
9.95 ± 8.08
0.00*
11.38 ± 8.18
11.33 ± 8.23
0.91
0.00*
6MWD: six minute walk test distance, SD: standard deviation, N: newton p < 0.05 P˛ : baseline and after 6 week in training and control groups difference p values. Pˇ : two groups difference p-values. a: Wilcoxon testi ˇ: Mann–Whitney U test, significant difference from baseline. ∗ p < 0.05.
ing sets of specific extremity exercises. Extra loads were not used in the isotonic exercises, so that it was the patient’s own weight, the number of repetitions, and the speed of the exercise that affected the exercise resistance. Therefore, very little equipment was needed for the patients to perform the callisthenic exercises. A Cochrane systematic review of exercise interventions in people with diabetes does not include a tele-monitored exercise training study [31]. TR based exercise training in patients with type 2 DM is a novel approach. To the best of our knowledge, this is the first study to evaluate the influence of TR in type 2 DM patients. Klonoff had concluded at his review that telemedicine promises to become a novel 21st century tool for diabetes health care providers to communicate with patients to improve the quality and lower the costs of health care [32]. Most studies of telemedicine programs for type 2 DM have shown improved HbA1c outcomes [33]. The largest telemedicine study ever performed compared the outcomes of a combined web and video telemedicine system against therapy without a telemedicine system with 1665 DM patients. As a result telemedicine participants achieved an improvement in glycemic control [34]. The telephone-based physical activity counseling has been shown to be effective in increasing physical activity in older adults [35] and in improving glycemic control in patients with type 1 DM [36]. Similar to these results
obtained, our TR group participants have already achieved improvement in HbA1c after the exercise training. Exercise capacity is a strong predictor of all-cause mortality in type 2 diabetes [37]. Due to, exercise training has become an important integral therapy for the management of type 2 DM. Our TR regime was successful in terms of maintaining a reduction of about 65 m in 6MWD. Previous work has shown that tele-monitoring regime was modestly effective in increasing peak VO2 in DM [38]. In the literature, there were conflicting results regarding the effects of TR on 6MWD in chronic diseases. At a study, there was no significant difference in post program 6MWD between TR and the no intervention group in patients with chronic heart failure [39]. Another study by Piotrowicz et al., the amount of 6MWD improvement compared with baseline was significantly greater in the center based group than in TR group in heart failure patients [40]. There is very limited evidence about the effects of TR on muscle strength. In one study, muscle strength and endurance were even improved or maintained with TR in patients with chronic heart failure [41]. To our knowledge there is no study that investigate the effects of TR on muscle strength or any physical fitness sub parameters in patients with DM. Thereby our study is the first that shown improvements in muscle strength and physical fitness after TR intervention in type 2 DM patients.
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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In recent years, tele-monitoring has been shown to improve health outcomes in patients with chronic diseases [42]. It is also possible that TR may benefit people with DM in similar ways to tele-monitoring. Results of this investigation also provide evidence of significant improvements in psychosocial status through TR. The Smart Care-CAD Study [43] which investigated in 2017 concluded that, despite the benefits proven effectiveness and cost-effectiveness of telerehabilitation, patients still do not elect to participate in TR. Patients who are depressed are less willing to participate in TR than patients who are not depressed. Our study had some limitations. Exercise programs over a longer time period might better determine these effects. The other limitation of this study was that, although we had a supervised TR exercise group and a control group, we did not include a clinic based supervised exercised group, this might have provided further insights into the effects of the TR interventions in type 2 DM patients. The key element to reduce medical costs is engaging patients in chronic diseases with self-management. While research on TR is limited, there is increasing evidence supporting the need for TR services, the progress of TR interventions and support for people with disabling conditions that potentially limit access to rehabilitation services. A review of TR for cardiac patients concluded that TR appears to be a feasible and effective additional and alternative form of rehabilitation, compared to conventional forms in rehabilitation. Evaluations of TR programs taking into account patient safety and health economics are now required [44]. Some barriers currently limit the perception of telemedicine applications. These barriers are mostly arising from health care providers’ technical barriers, such as a fear of computers, poor access to computers, or a lack of training in computers. The rapid development and increasing speed of telecommunication technologies requires continuous study in order to demonstrate the efficacy of such technologies. By technologic improvements and advance interest in TR applications will provide more beneficial diabetes care. In conclusion, TR intervention in type 2 DM patients can lead to improvements in glucose control, exercise capacity, physical fitness and a further decline in depression. Therefore, in addition to existing pharmacological and non-pharmacological treatment modalities, our studies demonstrate that TR can be an additional therapeutic modality offering benefits to type 2 DM patients especially who could not participate to the clinic based rehabilitation programs. Callisthenic exercises could be considered as an alternative comprehensive exercise program for DM to improve overall health status. Because of the ease with which they can be performed and the minimal requirement for equipment, callisthenic exercise can be suit patient-specific needs, and is suitable for home exercise programs as long as appropriate assessment and regular monitoring are undertaken. Future studies should examine TR interventions in more DM patients and over a longer period of time.
Conflict of interest The authors state that they have no conflict of interest.
Appendix A.
Calisthenic exercises Supine position 1. Reciprocal straight leg raise 2. Reciprocal hip flexion and extension Side-lying position 3. Hip abduction Prone position 4. Trunk flexion Sitting with legs outstretched position 5. Hamstring muscle stretch Chair exercises 6. Shoulder/chest stretching (with hands on waist) 7. Shoulder/chest stretching (with hands clenched behind back) 8. Shoulder elevation 9. Shoulder circles 10. Shoulder circles (arms over side of chair, circle shoulders front and back) Standing exercises 11. Shoulder flexion and extension 12. Shoulder abduction and adduction 13. Reciprocal lateral trunk flexion and extension 14. Reciprocal hip and knee flexion and extension 15. Quarter knee bends 16. Reciprocal reach upwards with hands
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial Neslihan Duruturk ∗ , Manolya Acar Özköslü Baskent University, Faculty of Health Sciences, Department of Physical Therapy and Rehabilitation, Ankara, Turkey
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aim: To determine the effect of a tele-rehabilitation (TR) program on glucose control, exercise
Received 14 January 2019
capacity, physical fitness, muscle strength and psychosocial status in patients with type 2
Received in revised form
diabetes mellitus (DM).
4 March 2019
Method: Fifty type 2 DM participants were enrolled in the study and divided randomly into
Accepted 25 March 2019
two groups; TR (n = 25, mean age: 52.82 ± 11.86) or control (n = 25, mean age: 53.04 ± 10.45)
Available online xxx
group. Participants in the TR group performed breathing and callisthenic exercises, three
Keywords:
including, HbA1c level, 6 min walk testing, physical fitness and muscle strength dynamome-
Tele-rehabilitation
ter measurement, Beck Depression Inventory were performed before and after the 6 weeks.
times a week, for 6 weeks, at home by internet based video conferences. Outcome measures
Type 2 diabetes mellitus
Results: HbA1c (p = 0.00), 6 min walking distance (p = 0.00), physical fitness subparameters;
Exercise training
sit-up (p = 0.00), sit-and-reach (p = 0.04), back scratch (p = 0.00), lateral flexion right (p = 0.04),
Physical fitness
left (p = 0.00) and time up go tests (p = 0.00), muscles strength (p = 0.00); deltoideus-anterior,
e-Health
middle, quadriceps femoris and gluteus maximus, and depression levels (p = 0.00) changed significantly (p = 0.00) in TR groups. There were no significant improvements in control group (p > 0.05). Conclusion: Our findings suggest that TR interventions found to be safe and effective, and may be an alternative treatment model for type 2 DM management. In addition to these health benefits, patients and rehabilitation team may save time, labor and treatment costs by using TR. © 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
∗
Corresponding author. E-mail address: [email protected] (N. Duruturk). https://doi.org/10.1016/j.pcd.2019.03.007 1751-9918/© 2019 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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1.
Introduction
Diabetes mellitus (DM) is a chronic metabolic disorder in which the patients cannot sufficiently benefit from carbohydrates, fat and protein due to insulin deficiency or impaired insulin effect and which requires continuous patient care. Today, DM has become a health problem with gradually increasing importance worldwide due to its prevalence and related problems [1]. Type 2 DM is the most common form of DM [2,3]. Diabetes is among the most important cardiovascular risk factors and the underlying insulin resistance and decreased insulin secretion may lead to some symptoms like widespread fatigue, muscle weakness, sensory problems, dyspnea, dry mouth, nocturia, blurred vision, weight loss, infections, psychological problems and some comorbidity like dyslipidemia, hypertension, and some complications like myopathy, nephropathy, neuropathy, retinopathy and diabetic foot [4]. These symptoms, comorbidities and complications may impair quality of life, shorten lifespan and lead to psycho-social problems through influencing exercise capacity and physical capacity. Physical activity and regular exercise programs have suggested preventing or delaying symptoms and complications of type 2 DM besides pharmacological treatment and dietary approaches. Nevertheless, continuity of exercise programs is the leading problem for rehabilitation programs [5,6]. Computer-based technologies and the developments in communication facilities have led to innovative changes in health area. Tele-rehabilitation (TR) which carries health services distant through using electronic communication systems is an important treatment option for improving continuity for patient care and health care and for providing availability [7–9]. Awareness of exercise which is an important step for disease management besides follow up of complications, glycemic control, blood pressure, lipidemia, weight and diet may be achieved through TR procedures. Diabetes education is provided with interactive seminars, video-conferences and phone calls and the patients are encouraged for doing exercises. Patients may debate with their physiotherapists about exercises and rehabilitation programs. TR enables the patients to take part in their follow up and treatment, thereby adaptation to exercise through taking responsibility [10–12]. Tele-diabetes applications in which many systems like computer, analogue telephones, network systems, cell phones, video-conference system, satellite technologies, electrocardiography tele-transmission devices are used for yearly controls and complication follow-ups of type 2 DM patients whose health expenditures are two-fold of the patients without type 2 DM [13,14]. Previous tele-medicine and TR studies in type 2 DM patients are seen to investigate glycemic control, complications and quality of life of diabetic patients. These studies have indicated that tele-medicine applications have improved glycemic control, quality of life and reduced hemoglobin (Hb) A1c values [15–19]. However TR studies about exercise education in type 2 DM patients are not available in literature despite the presence of TR studies in musculoskeletal system, neurologic, cardio-pulmonary, orthopedic diseases [20–23].
Based on these opinions, the purpose of our study was to determine the effects of TR on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 DM.
2.
Material and methods
2.1.
Subjects
Fifty subjects with type 2 DM were selected from Baskent University Hospital between September 2017 and January 2018. Inclusion criteria were ages between 18–65 years and diagnose of type 2 DM at least 6 months. Participants who is clinically unstable or who have neuromuscular disease, unstable cardiovascular diseases, musculoskeletal disease, pregnancy, lactation, and inability or unwillingness to comply with the required exercise were excluded from the study. All parameters were assessed before and after 6 weeks the intervention period in all groups. This study was approved by the Medical Ethics Committee of Baskent University. Written informed consents were obtained from all of the participants.
2.2.
Study design-intervention
A double blind randomized controlled trial was performed to investigate the effectiveness of TR intervention for patients of type 2 DM. The subjects were randomized in to either a TR intervention group (n = 25) or a control group (n = 25). An independent therapist randomly picked up an envelope that contained patient information, in a blinded fashion, for allocating each patient to either of the two groups. Subsequently, clinical assessments were carried out by a physiotherapist, followed by interventions that were administered by a different physiotherapist assigned to the treatment arm of the study. The subjects in the control group just received the education session, continued their current medical therapies and evaluated at the beginning of the study and after the 6-weeks period. All subjects in the TR group trained three times a week, for 6 weeks, lasted 40 min at home by internet based video conferences with the supervision of a physiotherapist. Only the first session of the training was performed at the clinic to precept the exercises. The TR group performed breathing exercises and callisthenic exercise that consist of 16 different, rhythmical exercises of strengthening and stretching of the lower and upper extremity muscles (Appendix A). Before the callisthenic exercises, warm-up exercises involving lower and upper extremity joint movements were repeated 10 times each. During the first and second weeks, the third and fourth weeks and the fifth and sixth weeks, the exercises were performed 10–15, 15–20 and 25–30 times per session, respectively. The duration of the exercise sessions was between 20 and 45 min. All subjects in the TR group measured their heart rate and SpO2 with a pulse oximeter and blood pressure with a digital sphygmomanometer themselves during the all exercises for safety after they had been taught by physiotherapist at the beginning of the TR intervention. The exercise intensity was adjusted based on the subjects’ Modified Borg Scale [24]
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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rated dyspnea or fatigue. We advised subjects resting if the perceived exertion rated was >7 obtained by Borg Scale.
2.3.
Outcome measurements
The socio-demographic characteristics, disease duration and HbA1c level of all subjects were recorded at admission. The health-related physical fitness domains were flexibility, muscular endurance, cardiorespiratory fitness (6MWT) and balance measurements [25]. The instructions about the test were given to the TR and control groups during the fitness tests. The physical fitness test consists of 6 measures as follows; 30-second chair stand test; used to assess lower extremity endurance. The number of full stands that could be completed in 30 s with the arms folded across the chest. The sit-up test; used to assess the endurance of abdominal muscles. The subjects were lying in the supine position with their knees flexed at 90◦ . The subjects performed trunk flexion at this position for 30 s. The number of trunk flexion repetitions was recorded. Sit-and-reach test; used to assess lower body flexibility. The test was performed by sit and reach box with a measuring scale. The test involved sitting on the floor with legs stretched out straight ahead. The soles of the feet were placed flat against the box. Both knees were locked and pressed flat to the floor. With the palms facing downward and the hands on top of each other, the subjects reached forward along the measuring line as far as possible. The subjects performed the test 3 times and reached the most distant point on the scale with fingertips. Back scratch test; used to assess upper body (shoulder) flexibility. One hand reached over the shoulder and one up the middle of the back; the number of inches (or cm) between the extended middle fingers (+ or −) were measured. Lateral flexion test; used to evaluate trunk flexibility. The subjects were asked to reach laterally while standing for the body lateral flexion test. The longest distance of the 3-time reach was noted. The number of inches (or cm) between the extended middle fingers (+ or −) and ground were measured. Time up go test; used to evaluate balance (mobility). The subjects were asked to stand-up from a chair, walk with their assistive devices at a comfortable pace to a marked line 3 m away and return to the chair to sit-down. Time taken to complete the test was recorded with a stopwatch. Two trials were administered, and the average was used for the analysis [27]. Six minute walk test (6MWT); was used to determine functional exercise capacity of the participants. The 6MWT was applied in a 30-m flat corridor. The subjects were instructed to walk with their own walking speed in 6 min. The 6MWT was administered twice in the same day with a 30-min interval and the longest 6MWT walking distance was recorded. The distance covered was measured in meters [26]. Muscle strength was evaluated with an objective measurement which is digital dynamometer (JTECH, Medical Commander Powertrack II, ABD) for deltoideus-anterior, deltoideus-middle, bicepsbrachii, iliopsoas and quadriceps femoris muscles. Tests were repeated for each muscle three times to the right and left sides and were recorded in Newton (N). The best value was used for analysis [27].
3
Beck Depression Scale (BDI) that has 21-item was applied to assess depression levels. According to BDI, if the total value ¨ ¨ depression¨, 10–16 is mild ¨ is 9 or less, no ¨, 17–23 Moderate¨, 24 ¨ considered [28]. and more is s¨ evere depressionare
2.4.
Statistical analysis
Statistical analysis was performed using SPSS 22 (IBM Corp. Armonk, NY, USA). The data from participants who completed the trial were only considered. The data were reported as mean ± standard deviation. Homogeneity and normality tests helped guide the actual statistical methods that were used. When data were normally distributed, paired t-tests were employed. Otherwise, comparisons of the difference between pre- and post-intervention values were made using the Mann–Whitney U test, and the comparisons between baseline and post-training were made using the non-parametric Wilcoxon test for each group. The primary outcome measure for this study was the change in HbA1c values. We found that group sample size of 17 achieved 80% power to show an improvement in primary outcome measurement and having a significance level (alpha) of 0.05 [29,30].
3.
Results
Fifty patients who fulfilled the selection criteria were randomly assigned to one of the two groups and 44 subjects participated in the last study measurements (Fig. 1). There were no baseline demographic differences between the groups (Table 1).
3.1.
Change in marker of glucose control
Relative to baseline values, HbA1c (p < 0.05) value was significantly decreased in the TR group at the end of the training period. There was no significant change in the control group over the 6-week study period (p > 0.05). When the differences between the baseline and 6-week values were compared, the magnitude of the change over the study period did not significantly differ between two groups (p > 0.05) (Table 2).
3.2.
Changes in physical fitness
From the parameters of physical fitness evaluation, sit-up, sitand-reach test, back scratch, lateral flexion and time up go tests were significantly improved in the TR group at the end of the study (p < 0.00). There was no significant change in the control group over the 6-week study period (p > 0.05). The changes in sit-up, back scratch (left), lateral flexion and time up go tests parameters over the 6-week intervention period significantly differ between the two groups (p < 0.00) (Table 2).
3.3.
Change in exercise capacity
6MWD in the TR group was significantly increased after the training intervention (p < 0.05). Conversely, in the control group 6MWD were significantly diminished after the 6-week experimental period (p < 0.05). The change in this value over
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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Fig. 1 – Study flow diagram.
Table 1 – Baseline characteristics of the subjects.
Female/male (number) Age (years) Body mass index (kg/m2 ) HbA1c (%) Disease duration (years)
TR group (mean ± SD)
Control group (mean ± SD)
p
11/12 52.82 ± 11.86 32.07 ± 6.51 7.14 ± 0.91 4.89 ± 3.86
7/14 53.04 ± 10.45 29.90 ± 4.63 7.57 ± 0.99 5.23 ± 3.36
0.91 0.13 0.15 0.57
SD: standard deviation. There were no statistical differences among the groups (p > 0.05) (Mann–Whitney U test).
the 6-week intervention period significantly differ between the two exercise groups (p < 0.00) (Table 2).
3.4.
Changes in muscle strength
Deltoideus-anterior, deltoideus-middle, quadriceps femoris and gluteus maximus muscles strength were significantly improved in the TR group at the end of the study (p < 0.00). However, there were no statistically significant changes in any muscle strength variables in the control group over the study period (p > 0.00). The magnitude of the changes in deltoideusanterior, deltoideus-middle, quadriceps femoris and gluteus maximus muscles strength from baseline to after the 6-week intervention significantly differed between two groups in favor of TR group (p < 0.00) (Table 2).
3.5.
Change in psychosocial status
Back Depression scale scores were significantly improved in TR groups after the 6-week training period (p > 0.00). None of
this improvement was observed in the control group over the same period (p > 0.00). The magnitude of the changes between the baseline and 6-week values for measures of psychosocial status significantly differed between the two groups (p < 0.00) (Table 2).
4.
Discussion
The main finding of this randomized controlled study was that TR intervention in patients with type 2 DM was effective in improving exercise capacity, physical fitness, muscle strength, psychosocial status and in controlling glucose. Patient feedback gave the physiotherapist the perception that three times weekly provided the greatest motivation for patient to exercise in TR group. As well compliance with the intervention was very good; the TR group attended an average of 16 out of the 18 (89%) exercise sessions. The reason for not attending at those sessions was mostly the problem with the internet connection. Our findings also suggest that type 2 DM patients were able to tolerate the calisthenics, which consisted of increas-
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Table 2 – Marker of glucose control, physical fitness, exercise capacity, muscle strength and depression scores between TR and control groups. TR group
Measurements
HbA1c Physical fitness 30-second chair stand test Sit-up test Sit-and-reach test (cm) Back scratch test (right) (cm) Back scratch test (left) (cm) Lateral flexion test (right) (cm) Lateral flexion test (left) (cm) Time up go test (sn) Exercise capacity 6MWD (m) Muscle strength Deltoideus-anterior (right) (N) Deltoideus-anterior (left) (N) Deltoideus-middle (right) (N) Deltoideus-middle (left) (N) Bicepsbrachii (right) (N) Bicepsbrachii (left) (N) Quadriceps femoris (right) (N) Quadriceps femoris (left) (N) Gluteus maximus (right) (N) Gluteus maximus (left) (N) Depression Beck depression scale
Control group
Pˇ
Baseline (mean ± SD)
6 weeks (mean ± SD)
P˛
Baseline (mean ± SD)
6 weeks (mean ± SD)
P˛
7.14 ± 0.91
5.93 ± 1.46
0.00*
7.57 ± 0.99
7.92 ± 2.82
0.23
0.42
10.23 ± 6.16 13.91 ± 5.31 6.95 ± 10.60 9.52 ± 10.02 9.86 ± 6.49 10.56 ± 3.27 11.54 ± 6.18 9.92 ± 4.96
10.82 ± 8.00 17.17 ± 4.82 8.73 ± 10.28 10.50 ± 9.60 6.76 ± 5.04 14.60 ± 4.39 17.26 ± 4.80 6.74 ± 2.10
0.34 0.00* 0.04* 0.04* 0.00* 0.00* 0.00* 0.00*
11.83 ± 5.14 12.19 ± 5.62 −2.61 ± 9.34 8.52 ± 6.82 11.50 ± 4.58 12.47 ± 4.28 11.64 ± 6.76 7.44 ± 2.50
11.85 ± 6.10 13.09 ± 6.36 −1.80 ± 9.41 8.50 ± 7.09 11.76 ± 4.88 11.19 ± 5.10 11.47 ± 6.32 7.59 ± 1.22
0.58 0.53 0.94 0.52 0.25 0.43 0.60 0.32
0.11 0.01* 0.21 0.28 0.00* 0.00* 0.00* 0.00*
489.00 ± 143.76
554.39 ± 139.00
0.00*
458.15 ± 168.87
450.90 ± 165.81
0.03*
0.00*
61.62 ± 17.66 64.09 ± 18.96 78.13 ± 20.70 80.06 ± 22.45 85.80 ± 22.81 83.02 ± 21.38 70.73 ± 16.80 68.90 ± 19.53 74.69 ± 23.74 74.62 ± 28.10
66.33 ± 17.51 68.54 ± 18.29 84.28 ± 21.50 84.54 ± 22.63 79.55 ± 20.36 86.03 ± 21.83 74.38 ± 18.26 71.89 ± 20.35 78.50 ± 24.15 77.92 ± 26.81
0.00* 0.00* 0.00* 0.00* 0.37 0.24 0.00* 0.00* 0.00* 0.00*
68.88 ± 24.80 68.04 ± 26.70 75.33 ± 28.30 74.22 ± 30.05 80.13 ± 30.63 80.87 ± 37.02 64.82 ± 27.28 63.17 ± 25.38 76.27 ± 27.92 72.85 ± 28. 31
69.20 ± 25.10 68.11 ± 26.99 75.49 ± 28.19 75.13 ± 31.14 75.95 ± 30.27 80.39 ± 36.01 66.43 ± 26.77 64.91 ± 25.82 75.46 ± 27.56 72.59 ± 28.42
0.50 0.82 0.57 0.22 0.06 0.60 0.19 0.33 0.15 0.32
0.00* 0.00* 0.00* 0.00* 0.29 0.14 0.00* 0.00* 0.00* 0.00*
13.08 ± 9.50
9.95 ± 8.08
0.00*
11.38 ± 8.18
11.33 ± 8.23
0.91
0.00*
6MWD: six minute walk test distance, SD: standard deviation, N: newton p < 0.05 P˛ : baseline and after 6 week in training and control groups difference p values. Pˇ : two groups difference p-values. a: Wilcoxon testi ˇ: Mann–Whitney U test, significant difference from baseline. ∗ p < 0.05.
ing sets of specific extremity exercises. Extra loads were not used in the isotonic exercises, so that it was the patient’s own weight, the number of repetitions, and the speed of the exercise that affected the exercise resistance. Therefore, very little equipment was needed for the patients to perform the callisthenic exercises. A Cochrane systematic review of exercise interventions in people with diabetes does not include a tele-monitored exercise training study [31]. TR based exercise training in patients with type 2 DM is a novel approach. To the best of our knowledge, this is the first study to evaluate the influence of TR in type 2 DM patients. Klonoff had concluded at his review that telemedicine promises to become a novel 21st century tool for diabetes health care providers to communicate with patients to improve the quality and lower the costs of health care [32]. Most studies of telemedicine programs for type 2 DM have shown improved HbA1c outcomes [33]. The largest telemedicine study ever performed compared the outcomes of a combined web and video telemedicine system against therapy without a telemedicine system with 1665 DM patients. As a result telemedicine participants achieved an improvement in glycemic control [34]. The telephone-based physical activity counseling has been shown to be effective in increasing physical activity in older adults [35] and in improving glycemic control in patients with type 1 DM [36]. Similar to these results
obtained, our TR group participants have already achieved improvement in HbA1c after the exercise training. Exercise capacity is a strong predictor of all-cause mortality in type 2 diabetes [37]. Due to, exercise training has become an important integral therapy for the management of type 2 DM. Our TR regime was successful in terms of maintaining a reduction of about 65 m in 6MWD. Previous work has shown that tele-monitoring regime was modestly effective in increasing peak VO2 in DM [38]. In the literature, there were conflicting results regarding the effects of TR on 6MWD in chronic diseases. At a study, there was no significant difference in post program 6MWD between TR and the no intervention group in patients with chronic heart failure [39]. Another study by Piotrowicz et al., the amount of 6MWD improvement compared with baseline was significantly greater in the center based group than in TR group in heart failure patients [40]. There is very limited evidence about the effects of TR on muscle strength. In one study, muscle strength and endurance were even improved or maintained with TR in patients with chronic heart failure [41]. To our knowledge there is no study that investigate the effects of TR on muscle strength or any physical fitness sub parameters in patients with DM. Thereby our study is the first that shown improvements in muscle strength and physical fitness after TR intervention in type 2 DM patients.
Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007
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In recent years, tele-monitoring has been shown to improve health outcomes in patients with chronic diseases [42]. It is also possible that TR may benefit people with DM in similar ways to tele-monitoring. Results of this investigation also provide evidence of significant improvements in psychosocial status through TR. The Smart Care-CAD Study [43] which investigated in 2017 concluded that, despite the benefits proven effectiveness and cost-effectiveness of telerehabilitation, patients still do not elect to participate in TR. Patients who are depressed are less willing to participate in TR than patients who are not depressed. Our study had some limitations. Exercise programs over a longer time period might better determine these effects. The other limitation of this study was that, although we had a supervised TR exercise group and a control group, we did not include a clinic based supervised exercised group, this might have provided further insights into the effects of the TR interventions in type 2 DM patients. The key element to reduce medical costs is engaging patients in chronic diseases with self-management. While research on TR is limited, there is increasing evidence supporting the need for TR services, the progress of TR interventions and support for people with disabling conditions that potentially limit access to rehabilitation services. A review of TR for cardiac patients concluded that TR appears to be a feasible and effective additional and alternative form of rehabilitation, compared to conventional forms in rehabilitation. Evaluations of TR programs taking into account patient safety and health economics are now required [44]. Some barriers currently limit the perception of telemedicine applications. These barriers are mostly arising from health care providers’ technical barriers, such as a fear of computers, poor access to computers, or a lack of training in computers. The rapid development and increasing speed of telecommunication technologies requires continuous study in order to demonstrate the efficacy of such technologies. By technologic improvements and advance interest in TR applications will provide more beneficial diabetes care. In conclusion, TR intervention in type 2 DM patients can lead to improvements in glucose control, exercise capacity, physical fitness and a further decline in depression. Therefore, in addition to existing pharmacological and non-pharmacological treatment modalities, our studies demonstrate that TR can be an additional therapeutic modality offering benefits to type 2 DM patients especially who could not participate to the clinic based rehabilitation programs. Callisthenic exercises could be considered as an alternative comprehensive exercise program for DM to improve overall health status. Because of the ease with which they can be performed and the minimal requirement for equipment, callisthenic exercise can be suit patient-specific needs, and is suitable for home exercise programs as long as appropriate assessment and regular monitoring are undertaken. Future studies should examine TR interventions in more DM patients and over a longer period of time.
Conflict of interest The authors state that they have no conflict of interest.
Appendix A.
Calisthenic exercises Supine position 1. Reciprocal straight leg raise 2. Reciprocal hip flexion and extension Side-lying position 3. Hip abduction Prone position 4. Trunk flexion Sitting with legs outstretched position 5. Hamstring muscle stretch Chair exercises 6. Shoulder/chest stretching (with hands on waist) 7. Shoulder/chest stretching (with hands clenched behind back) 8. Shoulder elevation 9. Shoulder circles 10. Shoulder circles (arms over side of chair, circle shoulders front and back) Standing exercises 11. Shoulder flexion and extension 12. Shoulder abduction and adduction 13. Reciprocal lateral trunk flexion and extension 14. Reciprocal hip and knee flexion and extension 15. Quarter knee bends 16. Reciprocal reach upwards with hands
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Please cite this article in press as: N. Duruturk, M.A. Özköslü, Effect of tele-rehabilitation on glucose control, exercise capacity, physical fitness, muscle strength and psychosocial status in patients with type 2 diabetes: A double blind randomized controlled trial, Prim. Care Diab. (2019), https://doi.org/10.1016/j.pcd.2019.03.007