Exercise training and balance function in middle-aged and older adults with diabetic peripheral neuropathy: a GRADE-based systematic review and meta-analysis

Objective To systematically evaluate, using the GRADE framework, the effects of exercise training on static and dynamic balance function in middle-aged and older adults with DPN. Methods We systematically searched the Cochrane Library, EMBASE, PubMed, Web of Science, CNKI, and Scopus from inception to March 21, 2025, for randomized controlled trials (RCTs) investigating exercise interventions targeting balance in adults with DPN. Eligible studies enrolled middle-aged and older adults with DPN and reported at least one validated balance-related outcome. Risk of bias was assessed, and the certainty of evidence was rated using the GRADE approach. Meta-analyses were performed using R software and expressed as mean differences (MDs) with 95% confidence intervals (CIs). Results Sixteen RCTs involving 759 middle-aged and older adults with DPN were included. Low to very low certainty evidence indicated that exercise training significantly improved Berg Balance Scale scores [ MD = 2.14, 95% CI (1.57–2.73)], Functional Reach Test distance [ MD = 3.23, 95% CI (1.82–4.64)], and Timed Up and Go test performance [ MD = −1.65, 95% CI (−1.98–1.32)]. Exercise also increased One-Leg Stand Test duration with eyes open [ MD = 2.93, 95% CI (2.10–3.76)] and eyes closed [ MD = 1.37, 95% CI (0.55–2.19)]. After exclusion of a study contributing substantial heterogeneity, the Five-Times Sit-to-Stand Test showed significant improvement [ MD = −3.07, 95% CI (−4.87–1.28)]. No significant effect was observed for the Six-min Walk Test [ MD = 27.36, 95% CI (−18.43–73.14)]. Conclusion Exercise training may confer beneficial effects on both static and dynamic balance function in middle-aged and older adults with DPN, although the certainty of evidence is generally low to very low. No significant effect was found on six-min walking capacity. Larger, pragmatic trials are needed to confirm effects and to guide implementation in community and outpatient services, including monitoring of fall-related and longer-term functional outcomes. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420261305039 .