"Shoulder Musculoskeletal Disorders in Type 2 Diabetes Mellitus: Contributing Factors and Rehabilitation Protocol"

SRG Protocol: shoulder rehabilitation protocol The protocol will be performed on a group with a maximum of 5 participants. Exercises intensity and difficulty will progress after completing 1 month of assistance, by increasing range of motion and loads (dumbbells) or resistance (elastic bands) in the exercises that are convenient. Each session will consist of 6 stages: 1) Pendulum exercise (10 repetitions - maintenance for 20 seconds); 2) Slide in flexion of the arms on the table (2 sets of 10 repetitions, maintenance in maximum range for 20 seconds); 3) Abduction and adduction (2 sets of 10 repetitions, maintenance for 20 seconds); 4) Wall slide - sliding of the arms on the wall (2 series of 10 repetitions, maintenance of 20 seconds); 5) Internal and external rotation (2 sets of 10 repetitions, maintenance for 20 seconds); 6) Elongation of the posterior capsule (cross-body) and pectoralis minor (3 repetitions of 30 seconds each). Pain will be evaluated during the protocol using the visual analog scale (VAS). The exercises proposed in this protocol are those that have already demonstrated in the literature an improvement in the function, strength, range of motion, and pain of the shoulder complex of the general population (27, 58).

The intensity and duration of the resistance exercises will be monitored by the physical therapist using heart rate monitors and adjusted to follow the same heart rate progression as outlined below for the aerobic group (ARG). In this manner, the average energy expenditure for both exercise groups will be similar. The protocol duration will be between 30-35 minutes. All sessions will be supervised by a physiotherapist with experience in physical exercise.

ARG group: Shoulder rehabilitation protocol combined to aerobic exercise program The ARG group will perform the shoulder rehabilitation protocol presented above combined with the aerobic exercise program. The aerobic program will last 20 minutes per session at 40% of the reserve heart rate (HRC), progressing up to 40 minutes with a maximum of 60% of the HRC in the last two weeks, according to the recommendations for patients with type 2 DM proposed in the American College of Sports Medicine Guidelines (59). The program will be carried out in groups of 4 participants and each session will consist of 3 stages: 1) Warm-up (5 min): patients will perform stretches of the main muscle groups; 2) Aerobic exercise in the treadmill with continuous heart rate monitors (Polar Electro Oy, Kempele, Finland), which will be used to adjust workload to achieve the target heart rate (15-40 min); 3) Cooldown (5 min): Stretching of the main muscle groups worked during the sessions and relaxation. In this way, the rehabilitation protocol of ARG group will last a total of approximately 90 minutes maximum. Before and after each session, blood pressure, heart rate and subjective perception of effort will be measured. During sessions, heart rate will be monitored by a heart rate monitor (Polar Vantage, Finland), and perceived exertion will be measured using the Borg CR20 scale, which should remain approximately between 11-13 (59). All sessions will be supervised by a physiotherapist with experience in physical exercise.