Effects of an exercise intervention (Tai Chi) on diabetic peripheral neuropathy in a mHealth model

doi:10.21203/rs.3.rs-5308058/v1

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Research Article

Effects of an exercise intervention (Tai Chi) on diabetic peripheral neuropathy in a mHealth model

https://doi.org/10.21203/rs.3.rs-5308058/v1

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Background: E-health interventions can promote physical activity among adults in the short term, but there is still a lack of evidence on long-term effects.We conducted a randomized controlled trial to assess the effectiveness as well as the sustainability of the intervention. Our primary aim of this exercise intervention was to improve overall health-related quality of life （HRQoL）, and our secondary aims were to improve nerve conduction indices and glycemia.

Material & methods: The study design was a parallel randomized controlled trial. The participants were randomly paired and assigned to control and intervention groups (each consisting of 50 members).

Patients assigned to the intervention group received online instruction in Tai Chi exercises three times a week for three months under the guidance of a physical therapist. The intervention group was asked to use the Tencent conference application, which provided online video instruction on Tai Chi exercises. Participants in the control group received a written Tai Chi exercise program and recommendations on a sheet of paper. The primary outcome was a Change in HRQoL in the intervention group over 6 months as measured by the PCS index score. Secondary outcomes included changes in SF-36v2, NRS, PSQI, motor nerve conduction index, blood glucose, and biochemical indices.

Results: When comparing the primary outcomes at 6 months, we found that there was a significant difference in PCS scores (mean difference 4.33 [95% CI 2.03,5.87]; p = 0.01).

Conclusion: Web-based exercise therapy for patients may help improve exercise therapy's effectiveness in treating DPN. In this exploratory study, the exercise group consistently trended better than the conventional group for most endpoints.

Type 2 diabetes mellitus (T2DM)

24-style Tai Chi

diabetic peripheral neuropathy (DPN)

mHealth model

Health-Related Quality of Life (HRQoL)

Diabetic peripheral neuropathy (DPN) is one of the long-term complications of diabetes[1]. It arises from peripheral sensory and motor nerve dysfunction as a result of the disease's sequela[2]. The most prevalent neuropathy linked to diabetes mellitus is distal symmetrical polyneuropathy, characterized by a sensory and motor loss pattern that resembles the coverage of a glove and stocking [3].

Exercise has been shown to modify the factors contributing to the onset and progression of DPN, as well as metabolic syndrome-related markers such as hyperglycemia, accumulation of advanced glycation end products (AGEs), dyslipidemia, and insulin resistance [4]. Exercise directly benefits sensory neurons and the expression of neurotrophin-3 (NT-3) and brain neurotrophic factor (BDNF) in muscle increases following exercise[5] [6]. NT-3 and BDNF are essential for the growth and maintenance of proprioceptive axons and are strongly associated with symptoms of DPN proprioception, altered gait, and balance difficulties [7].

Although the literature shows that exercise interventions can help improve mobility and balance in patients with DPN, these studies aimed to prevent falls in these patients, not to improve Health-Related Quality of Life (HRQoL). Even in the absence of pain, DPN decreases HRQoL [8] [9].

DPN mainly affects the physical domains of HRQoL, which include aspects such as mobility, self-care, and pain/discomfort [10]. This is likely due to nerve damage that can lead to symptoms such as numbness, tingling, pain, and muscle weakness in the feet and legs [11]. These symptoms can severely limit an individual's ability to perform daily activities and reduce their overall well-being.

It is worth noting that Tai Chi performs relatively mildly in terms of energy metabolism [12]. This means it does not place an excessive physical burden on patients, reducing the risk of injury [13]. For T2DM patients, this low-intensity form of exercise is more likely to be accepted and adhered to, resulting in a greater likelihood of long-term health benefits. Therefore, in diabetes management, it is crucial that we actively promote Tai Chi and encourage patients to incorporate it into their daily health management programs.

As a traditional form of health-improving exercise, 24-style Tai Chi nourishes the body in tranquility[14]. It realizes the effect of internal and external cultivation and the unity of body and mind through slow, coherent, round, and soft movements and the coordination of breathing and movements[15]. During the practice of Tai Chi, every move and every style contains a wealth of wisdom for health maintenance, in which lightness and calmness go hand in hand, and emptiness and realism are born together[16]. Such movement characteristics significantly mobilize many organs of the whole body, promote the circulation of qi and blood, and regulate and improve the function of the digestive and circulatory systems [17].

The transmission model of exercise intervention makes it difficult for patients to have frequent interactions with professionals, and coverage is limited. In addition, the cost of hiring professionals is substantial, and there are practical difficulties for long-term intervention and patient follow-up.

Currently, web-based technology allows for GPS monitoring, customized feedback, and round-the-clock reminders. In China, the elderly use smartphones extensively and are increasing their use.

Telemedicine is the use of web-based technology for health coaching and intervention. It is uniquely advantageous because it allows for continuous monitoring that provides the basis for personalized feedback and goal setting.E-health interventions can promote physical activity among adults over 55 in the short term, but there is still a lack of evidence on long-term effects [18] [19].

Based on this rationale, we conducted a randomized controlled trial to assess the effectiveness as well as the sustainability of the intervention. Our primary aim of this exercise intervention was to improve overall health-related quality of life (HRQoL), and our secondary aims were to improve nerve conduction indices and glycemia.

Study design

The study design was a parallel randomized controlled trial. Enrolled patients were given a 3-month intervention and an additional 3-month follow-up.

Participants

Recruitment for this study occurred between January 2023 and October 2024 and recruited inpatients from the Department of Endocrinology, Shidong Hospital, Yangpu District, Shanghai, China. The inclusion criteria of this study were: (1) diagnosis of T2DM with Diabetic peripheral neuropathy (Michigan Questionnaire and Monofilament 10-Point Test by Application)[20]. (2) HbA1c 6.5–13.0%. (3) the age range of 55–75 years.

The following exclusion criteria were used: amputations, plantar injuries, severe retinopathy, dialysis, neuropathy, malignant hypertension, or history of falls and gait instability.

Subjects were randomly assigned to either of the two groups. They were assessed at baseline and after the six-month trial.

Both groups received routine discharge education and outpatient follow-up, which included recommendations for regular exercise and were evaluated at the same intervals for follow-up.

Intervention

The participants were randomly paired and assigned to control and intervention groups (each consisting of 50 members).

Patients assigned to the intervention group received online instruction in Tai Chi exercises three times a week for three months under the guidance of a physical therapist. The intervention group was asked to use the Tencent conference application, which provided online video instruction on Tai Chi exercises. Patients in the intervention group were able to clearly see the physiotherapist's demonstrations and explanations and perform Tai Chi in synchronization with the physiotherapist.

The intervention group performed aerobic 24-style Simplified Tai Chi exercise three times a week, lasting 60–90 minutes. All classes begin with a 5-minute pre-workout warm-up and gentle stretching and end with a slow 5-minute cool-down. The 24-style Simplified Tai Chi Forms are based on Tai Chi's main styles and characteristics and the selection and simplifying of representative movements. Two professional Tai Chi instructors with over ten years of training experience conducted the training. They have mastered the profound theoretical knowledge of Tai Chi and accumulated rich practical experience.

Participants in the control group received medical care according to the recommended clinical regimen. These participants did not receive specific interventions from the research team, but the physical therapist provided a written Tai Chi exercise program and recommendations on a sheet of paper. They also received follow-up evaluations at the same intervals as participants in the control group. All the patients were asked to maintain their daily routines as much as possible.

Assessments

All participants were assessed at three points (baseline, 3 months after baseline, and 6 months). HRQoL was assessed at each time point using the SF-36v2. The SF-36v2, the 36-entry Short Form 36 Health Survey version 2, is a standardized scale for measuring health-related quality of life widely used internationally [21]. It contains 36 entries designed to comprehensively assess an individual's health status and quality of life. The Physical Component Summary(PCS)is a component of the SF-36 or SF-12 scales used to determine an individual's physical health [22]. Its scores correlate positively with physical functioning, physical role limitations, physical pain, and general health status and negatively with emotional role limitations and mental health scores. Assessment of pain perception with the Numerical Rating Scale༈NRS༉, is a quantitative tool for assessing pain intensity [23]. The Numerical Rating Scale consists of 11 numbers, 0 through 10, each representing a different pain level. Where 0 indicates no pain, and 10 indicates the most intense pain, the pain level increases as the number increases.

For motor nerve conduction assessment using the RMS Salus 2C EMG/NCV machine, targeting the deep peroneal nerve, an active surface electrode was placed on the bunion extensor digitorum brevis (EDB) muscle, which was designed to record the electrical activity generated by the muscle during motor nerve conduction. Distal stimulation is performed 7 to 8 centimeters from the active electrode (the electrode placed on the bunion abductor muscle). This was to measure the speed and amplitude of nerve conduction from distal to proximal. Proximal stimulation was performed just below the head of the fibula. Proximal stimulation compares the results with distal stimulation to calculate the nerve conduction rate. In tibial nerve studies, the reference electrode may be placed near the toe or metatarsal heads to record potential changes during nerve conduction. Distal stimulation is performed 9 cm from the active electrode proximally to the medial malleolus, and proximal stimulation is performed slightly lateral to the mid-metatarsal. Nerve conduction studies are considered the most accurate, reliable, and sensitive measure of peripheral nerve function.

Sleep quality and quantity were assessed using the Pittsburgh Sleep Quality Index (PSQI) scale and a sleep monitoring bracelet [24]. The PSQI is a widely used and well-validated instrument for assessing sleep quality. The self-rate questionnaire evaluates sleep quality and patterns over the past month.

Primary and secondary outcomes

The primary outcome was a Change in HRQoL in the intervention group over 6 months as measured by the PCS index score.

Secondary outcomes included changes in SF-36v2, NRS, PSQI, motor nerve conduction index, blood glucose, and biochemical indices.

Statistical analysis

IBM SPSS 26.0 was applied for data processing. Measurement data were described as the mean ± standard deviation. Counting data was represented by frequency and percentage. Paired t-test was used to compare the blood glucose levels before and after the intervention. Two independent sample t-tests were used to compare baseline and intervention data between groups. Multiple group comparisons were analyzed using Analysis of Covariance (ANCOVA). Changes in baseline were treated as dependent variables, while group, visit time, and the interaction of group and visit time (group × visit) were treated as independent effects. Differences were considered statistically significant at P < 0.05.

A total of 100 people participated in the study: 50 in the intervention group and 50 in the control group. The mean age of the participants was 62 years, and 48 (48%) were female. Table 1 shows the distribution of baseline key outcomes for the intervention and control groups, which were similar in both groups. No exercise-induced musculoskeletal or cardiovascular complications were identified during the 6-month home-based exercise program.

Table 1

Baseline Characteristics of the Participants
Characteristic	Control (n = 50)	Intervention (n = 50)
Age, years	64 ± 7	65 ± 8
Sex, number (%)
Male	22(44)	30(60)
Female	28(56)	20(40)
Educational background
Compulsory school	16	12
High school	25	27
Higher education	9	11

Table 2

Measures of nerve function before and after 8 weeks of intervention
Variables	Control (n = 50)	Intervention (n = 50)	Time (T) effect ηp² (p-value)	Group (G) effect ηp² (p-value)	T×G interaction ηp² (p-value)
Peroneal nerve
Latency (msec)
Baseline	4.15 ± 1.2	4.13 ± 1.31	0.069 (0.226)	0.009 (0.135)	0.088 (0.066)
6th month	4.09 ± 1.14	4.19 ± 1.22	0.069 (0.226)	0.009 (0.135)	0.088 (0.066)
Amplitude(mV)
Baseline	4.43 ± 2.31	4.45 ± 1.99	0.083 (0.145)	0.015 (0.203)	0.083 (0.071)
6th month	4.38 ± 2.06	4.34 ± 2.26	0.083 (0.145)	0.015 (0.203)	0.083 (0.071)
Duration (msec)
Baseline	10.37 ± 1.94	9.68 ± 2.11	0.015 (0.338)	0.022 (0.481)	0.025 (0.592)
6th month	10.55 ± 1.84	9.73 ± 2.03	0.015 (0.338)	0.022 (0.481)	0.025 (0.592)
NCV (m/sec)
Baseline	38.37 ± 6.62	37.99 ± 7.38	0.153 (0.006)*	0.067 (0.228)	0.187 (0.021)*
6th month	39.04 ± 6.51	42.37 ± 6.59	0.153 (0.006)*	0.067 (0.228)	0.187 (0.021)*
Tibial nerve
Latency (msec)
Baseline	4.61 ± 1.24	4.58 ± 0.98	0.013 (0.639)	0.011 (0.552)	0.115 (0.024)*
6th month	4.58 ± 1.13	4.34 ± 1.37	0.013 (0.639)	0.011 (0.552)	0.115 (0.024)*
Amplitude(mV)
Baseline	6.14 ± 2.72	6.22 ± 3.04	0.033 (0.251)	0.017 (0.629)	0.041 (0.228)
6th month	6.16 ± 3.31	6.19 ± 3.56	0.033 (0.251)	0.017 (0.629)	0.041 (0.228)
Duration (msec)
Baseline	7.99 ± 1.73	8.11 ± 1.85	0.015 (0.411)	0.005 (0.629)	0.022 (0.311)
6th month	8.05 ± 2.01	8.13 ± 1.94	0.015 (0.411)	0.005 (0.629)	0.022 (0.311)
NCV (m/sec)
Baseline	36.12 ± 10.13	37.54 ± 9.68	0.225 (0.002)*	0.003 (0.724)	0.055 (0.417)
6th month	42.37 ± 8.72	43.59 ± 10.83	0.225 (0.002)*	0.003 (0.724)	0.055 (0.417)
NCV: Nerve conduction velocity; *: significant difference.

Table 3

Comparison of biochemical parameters in the two groups before and after intervention
Characteristics	Control group	t-test	P value	Intervention group	t-test	P value
HbA1c (%)	Before intervention 8.09 ± 0.65	2.933	0.132	Before intervention 7.93 ± 0.72	1.832	0.018*
HbA1c (%)	After intervention 7.92 ± 0.50	2.933	0.132	After intervention 7.29 ± 0.88	1.832	0.018*
C-peptide (ng/ml)	Before intervention 2.93 ± 0.58	3.417	0.735	Before intervention 3.13 ± 0.92	1.254	0.568
C-peptide (ng/ml)	After intervention 3.07 ± 0.69	3.417	0.735	After intervention 3.03 ± 0.92	1.254	0.568
FBG (mmol/l)	Before intervention 8.67 ± 1.23	3.226	0.015*	Before intervention 9.01 ± 1.00	2.368	0.011*
FBG (mmol/l)	After intervention 6.31 ± 1.58	3.226	0.015*	After intervention 7.78 ± 0.73	2.368	0.011*
Notes: FBG = fasting blood glucose; HbA1C = glycated hemoglobin.

Primary outcomes

When comparing the primary outcomes at 6 months, we found that there was a significant difference in PCS scores (mean difference 4.33 [95% CI 2.03,5.87]; p = 0.01).

Secondary outcomes

We include changes in NRS as a secondary outcome. Physical pain significantly improved in the intervention group compared to the control group (mean difference 1.04 [95% CI 0.47, 3.51]; p = 0.001). PSQI also improved (mean difference 0.87 [95% CI 0.55, 1.79]; p = 0.032), reaching statistical significance.

The NRS in the intervention group decreased from 6.2 ± 0.4 at baseline to 5.8 ± 0.5 at 3 months and 5.5 ± 0.3 at 6 months. In contrast, the NRS results in the control group remained stable at 6.4 ± 0.4 at baseline, 6.1 ± 0.6 at 3 months, and 6.1 ± 0.5 at 6 months.

At baseline, the PSQI was 7.1 ± 0.6 in the intervention group and 6.9 ± 0.4 in the control group. At 3 months, it decreased to 6.1 ± 0.4 and 6.7 ± 0.5 in the intervention and control groups, respectively. At 6 months, it was 5.9 ± 0.6 in the intervention group and 6.6 ± 0.6 in the control group.

We also compared nerve conduction and blood glucose over 6 months.

The conduction velocity of the common peroneal nerve showed a significant difference in the time effect (p = 0.006) and the time × group interaction (p = 0.021), while the between-group impact was not significant (p > 0.05). Tibial nerve conduction velocity showed a significant time effect (p = 0.002), whereas the between-group implications and the time × group interaction were unimportant. In addition, the time × group interaction was also significant for tibial nerve latency (p = 0.024). The amplitude and duration of the common peroneal nerve did not differ significantly in time between the two groups.

Tai Chi intervention was effective in reducing HbA1c (p = 0.018)and FBG༈p = 0.011༉ levels, and there was no significant change in C-peptide。

Table 4 presents changes in patients’ exercise habits from baseline to 6 months. In the intervention group, 12 patients (24%) did not have exercise habits when enrolled but insisted on exercising after 6 months. 1 patient (2%) in the intervention group had exercise habits when enrolled but failed to keep them after 6 months. Other patients had no change in exercise habits. There was a statistically significant difference in changes in exercise habits between the two groups (P = 0.016).

Table 4

Changes of patients’ exercise habits before and after intervention in the two groups
Group	Whether patients have exercise habits before and after intervention				P
	No/no,number(%)	No/yes,number(%)	Yes/no,number(%)	Yes/yes,number(%)	0.016
Control	5 (10)	10 (20)	6 (12)	29 (58)
Intervention	4 (8)	12 (24)	1 (2)	23 (46)

We charted the raw values of selected outcomes over time for both groups to see how these selected variables changed in both groups during and after the intervention. Both groups improved their PCS scores by approximately 4 points throughout the study period. The intervention group improved from 33.7 ± 10.2 points at baseline to 37.9 ± 11.1 points at 3 months and 40.6 ± 9.5 points at 6 months. The control group had baseline values of 34.2 ± 9.9, 36.9 ± 12.2 at 3 months, and 38.1 ± 9.3 at 6 months.

We hypothesized that Tai Chi exercise intervention in a mHealth model positively affects quality-of-life improvement, glycemic control, and enhancement of life treatment in DPN patients. This study found significant HRQoL, NRS, and PSQI improvements in the intervention group at the end of 3 months and the 6-month follow-up.

Previous studies have found that exercise therapy is an essential modality for the treatment of diabetic peripheral neuropathy (DPN) [25]; however, up to 78% of patients do not adhere to self-directed home exercises prescribed by exercise therapists [26]. To address the treatment burden this poses, it is essential to promote self-management solutions to remove barriers to accessing treatment. In the mHealth model, exercise interventions can be more convenient without losing precision, and we make full use of widely used smartphones and intelligent wearable devices; patients can freely choose where to exercise, and for patients with DPN, exercise guidance can be realized at home, so this is a practical and valuable study [27] [28].

Improvement in HRQoL

This study found a significant difference in overall HRQoL scores between the intervention and control groups. These improvements were sustained 3 months after the end of the intervention. A 16-week supervised aerobic exercise program significantly reduced pain in patients with DPN [29]. This is thought to result from decreased levels of advanced glycation end products and protein kinase C, which are generally increased by prolonged hyperglycemia. After completing a 15-week high-intensity interval training intervention, Hazari observed an improvement in pain in patients with DPN via the Leeds Assessment of Pain (Leeds Assessment of DPN) [30]. These studies and our findings confirm that exercise improves pain symptoms.

Improvement in Sleeping

The Pittsburgh Sleep Quality Index (PSQI) improved with a mHealth intervention. These findings are consistent with a meta-analysis that showed that different types of exercise, including single and combined exercise, were associated with improvements in the Pittsburgh Sleep Quality Index (PSQI) [31]. Exercise's effectiveness in improving sleep may be related to its ability to reduce psychological stress (e.g., stress, anxiety, and depression) [32].

Improvement in nerve conduction velocity(NCV)

Our study found that the conduction velocities of the joint personnel and tibial nerves changed over time, but they differed in between-group effects and interactions. In addition, the latency of the tibial nerve was also affected by the time-group interaction. In contrast, the amplitude and duration of the common peroneal nerve remained stable across time points.

Few studies have examined tele-exercise interventions for DPN lower limb nerve conduction. Previous studies have shown that after aerobic exercise or aerobic exercise plus resistance exercise, the NCV improved, which is similar to our findings [33].

When NCV improves, it usually means that nerve function is recovering or regenerating. Exercise can increase microvascular circulation by promoting endothelial vasodilatation, thereby increasing endothelial blood flow. Reducing nitric oxide production also helps reduce its potential toxicity to nerve tissue. Exercise can protect nerve tissue from damage by reducing levels of oxidative stress, which in turn promotes recovery of nerve function [34].

In DPN, the opening of ATP-sensitive K + channels may be protective [35]. These channels help regulate neuronal excitability and energy metabolism, thereby potentially attenuating diabetic damage to neural tissue. Although the direct link between this mechanism and exercise's promotion of neurological recovery is not fully understood, it may indirectly promote neurological recovery by improving neuronal energy status and modulating excitability [36]. This may be the mechanism by which exercise improves NCV.

Improvement in Blood Glucose Management

The significant effect of Tai Chi in improving glycemic control may be related to its promotion of body metabolism, enhancement of insulin sensitivity, and reduction of stress response [37]. Aerobic exercise, a standard means of diabetes management, has also been found to reduce FBG levels [38]. This may be because aerobic exercise promotes blood glucose utilization primarily by increasing cardiorespiratory fitness and muscle metabolic rate [39]. In contrast, Tai Chi may work through a more comprehensive mind-body regulatory mechanism. Tsang et al. reported that insulin resistance and HbA1c did not significantly improve in patients with T2DM after practicing Tai Chi for 60 minutes daily [40]. This is slightly different from our current findings, where we found that the exercise intervention had a positive effect on FBG, which may be related to the fact that the current study enrolled a population of DPN. We believe that self-management is also enhanced when patients develop diabetic complications.

Improvement in Exercise Habits

The results showed a statistically significant difference in exercise habits between the two groups during the follow-up period (P = 0.016). Patients with DPN are often associated with neuropathic pain, such as tingling and burning pain, which can limit the patient's willingness to be active and lead to decreased exercise, making it an essential target for aerobic training interventions [41]. The use of mobile devices may improve exercise adherence. In this study, more than 90% of the participants adhered well to exercise therapy using a mobile messaging app-based program. Previous studies reported similar adherence rates for home exercise programs of approximately 50–70% [42]. We want to develop sustainable behavioral patterns for our patients to ensure they can incorporate these lifestyle changes into their daily routines. Studies have shown that remote monitoring improves patient adherence to exercise rehabilitation and that those patients whose patients were exercising before the intervention were more likely to maintain their exercise habits [43]. Similar results have been achieved in foreign studies.

Innovations in remote management of DPN

An essential component of designing an exercise program for patients with DPN is determining the intensity of the exercise. On the one hand, patients may be unsteady on their feet and at risk of falls due to abnormal sensations in the chivalry and even muscle atrophy [44]. On the other hand, this population has a higher risk of heart attack or stroke [45]. It is prone to resting tachycardia, decreased heart rate variability, exercise intolerance, and orthostatic hypotension due to cardiovascular autonomic neuropathy [46]. This autonomic dysfunction can increase the risk of cardiovascular events and death by several times [47].

Therefore, Tai Chi may be a more effective and safer option for people who are less physically able, older, or have more severe peripheral neuropathy.

These preliminary findings suggest that mobile health (mHealth) exercise interventions could be a practical and scalable solution for exercise therapy for people with diabetic peripheral neuropathy (DPN).

Limitations

First, the small sample size made it difficult to fully confirm our opinion. Second, we did not assess the severity of DPN because this study focused on improving the quality of life of DPN rather than reducing the development of neuropathy. Therefore, our findings may not apply to patients with early DPN.

Web-based exercise therapy for patients may help improve exercise therapy's effectiveness in treating DPN. In this exploratory study, the exercise group consistently trended better than the conventional group for most endpoints.

Ethics approval and consent to participate

Research was in accordance with Declaration of Helsinki. The study protocol was approved by the Ethics Committee of Shanghai Yangpu District Shidong Hospital. All participants signed an informed consent, and the Institutional Review Boards of all participating institutions approved the study (2024-013-01).

Human and animal rights

No animals were used for the study. All human procedures were followed in accordance with the Helsinki Declaration of 1975 as revised in 2013.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests

Acknowledgements

We acknowledge Dr QingSu for guidance in statistical analysis for English editing.

Author contributions

JXF and XSC conceived the study and wrote the manuscript. YH, JM and HMZ collected clinical data, analyzed and interpreted the data. XH, YXH, FH, QG and SJW made a revised version. All authors read and agreed to the final version of the manuscript.

Funding

This research did not receive any specific grant from any funding agency in the public, commercial or not profit sector.

Data availability

All data supporting the findings of this study are available within the paper and its Supplementary Information.

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No competing interests reported.

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Effects of an exercise intervention (Tai Chi) on diabetic peripheral neuropathy in a mHealth model

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