Response to the letter to the editor regarding “Association between diabetic peripheral neuropathy and lower limb muscle strength in patients with type 2 diabetes mellitus: A systematic review and meta‐analysis”

Dear Editor, We appreciate the constructive comments provided by Sohaib and Ahmed et al.1 regarding our article entitled, “Association between Diabetic Peripheral Neuropathy and Lower Limb Muscle Strength in Patients with Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis”2. We address their points below. First, we acknowledge the variability in the diagnostic criteria for diabetic peripheral neuropathy (DPN) as a major limitation of our study. We conducted subgroup and sensitivity analyses based on sex, measurement site, use of nerve conduction studies for DPN assessment, and exclusion of studies with a high risk of bias to explore heterogeneity. Although these additional analyses contributed to interpreting our findings, we stated that the lack of standardized DPN diagnostic criteria may have influenced heterogeneity. Future research will benefit from further refinement and standardization of DPN diagnostic methods. Second, regarding the underlying pathophysiological mechanisms linking DPN and lower limb muscle weakness, we identified seven studies reporting skeletal muscle mass; four using magnetic resonance imaging, two using bioelectrical impedance analysis, and one using ultrasonography. Additionally, one study described motor unit characteristics, and no study has evaluated neuromuscular junction function. We agree that the neurophysiological mechanisms highlighted by the authors provide important insights. Further research that incorporates these mechanisms would advance our understanding of the relationship between DPN and muscle dysfunction. Finally, regarding the temporal relationship between neuropathy progression and muscle strength decline, only one included study was longitudinal. Therefore, drawing conclusions regarding causality remains difficult. As the authors noted, longitudinal studies are essential for elucidating causal pathways, and further research with repeated muscle strength assessments over time is strongly encouraged. We are grateful for the thoughtful and constructive comments regarding our work. Their insights provide valuable guidance for future research in this field. The authors declare no conflict of interest. Approval of the research protocol: Approval of the research protocol was not applicable. Informed consent: Informed consent was not applicable. Approval date of registry and the registration no. of the study/trial: The approval date of the registry and the registration number of the study/trial were not applicable. Animal studies: Animal studies were not applicable. Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.