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J Orthop Sports Phys Ther. Author manuscript; available in PMC 2021 January 01.
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Published in final edited form as:

J Orthop Sports Phys Ther. 2020 January ; 50(1): 5–16. doi:10.2519/jospt.2020.9154.

The Role of Physical Therapists in Fighting the Type 2 Diabetes

Epidemic
MARCIE HARRIS-HAYES, PT, DPT, MSCI1, MARIO SCHOOTMAN, PhD2, JEFFREY C.
SCHOOTMAN, BS3, MARY K. HASTINGS, PT, DPT, MSCI, ATC1
1Program in Physical Therapy and Department of Orthopaedic Surgery, Washington University
School of Medicine, St Louis, MO
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2Department of Clinical Analytics and Insights, Cente for Clinical Excellence, SSM Health, St
Louis, MO
3College for Public Health and Social Justice, Saint Louis University, St Louis, MO

Abstract
BACKGROUND—In 2014, the total prevalence of diabetes was estimated to be 422 million
people worldwide. Due to the aging population and continued increase in obesity rates, the
prevalence is expected to rise to 592 million by 2035. Diabetes can lead to several complications,
including cardiovascular disease, stroke, peripheral arterial disease, nephropathy, neuropathy,
retinopathy, lower extremity amputation, and musculoskeletal impairments.

CLINICAL QUESTION—Up to 80% of patients referred for outpatient physical therapy have
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diabetes or are at risk for diabetes, providing an opportunity for physical therapists to intervene.
Therefore, we asked, “What is the role of physical therapists in fighting the diabetes epidemic?”

KEY RESULTS—Physical therapists commonly prescribe physical activity for the treatment of
diabetes and other chronic diseases, such as cardiovascular disease and osteoarthritis. Physical
therapists may also screen for risk factors for diabetes and diabetes-related complications and
modify traditional musculoskeletal exercise prescription accordingly. Physical therapists must
advocate for regular physical activity as a key component of the treatment of chronic diseases in
all patient interactions.

CLINICAL APPLICATION—This commentary (1) describes the diabetes epidemic and the
health impact of diabetes and diabetes-related complications, (2) highlights the physical therapist’s
role as front-line provider, and (3) provides recommendations for physical therapists in screening
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for diabetes risk factors and diabetes-related complications and considerations for patient
management. We focus on type 2 diabetes.

Address correspondence to Dr Marcie Harris-Hayes, Program in Physical Therapy, Washington University School of Medicine, 4444
Forest Park Boulevard, St Louis, MO 63108. [email protected].
AUTHOR CONTRIBUTIONS
All authors contributed to the conception and design of the work, including preparation and final approval of the manuscript. The
corresponding author takes responsibility for the integrity of the work as a whole, from inception to the finished article.
DATA SHARING: There are no data available.
 HARRIS-HAYES et al. Page 2

Keywords
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complications; diabetes mellitus; disease management; epidemiology; physical therapist

Diabetes is a serious disease that has been identified by world leaders as 1 of 4

noncommunicable diseases to be targeted for action.110 Worldwide prevalence of diabetes
nearly quadrupled from 108 million persons in 1980 to 422 million in 2014, while the age-
adjusted prevalence nearly doubled from 4.7% to 8.5% during the same period.110 As it has
in the past 2 decades, the prevalence of diabetes is expected to rise further as the population
ages and adult obesity rates continue to increase.46,76 Implementation of effective
interventions to delay the onset of diabetes and reduce the effects of established diabetes is
desperately needed.

It is estimated that up to 80% of patients referred to outpatient physical therapy have

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diabetes, prediabetes, or diabetes risk factors,61 providing the perfect opportunity for
physical therapists to intervene. Diabetes has the potential to negatively impact every tissue
important for maintaining optimal function of the body’s systems required to produce
human movement, collectively known as the human movement system (eg, musculoskeletal,
nervous, endocrine, pulmonary, cardiovascular, integumentary). It is vital that physical
therapists assert their role as front-line providers for patients with or at risk for diabetes.

Given the impact of diabetes on health and well-being, it is vital that physical therapists
assert their role as front-line providers for patients with or at risk for diabetes. We therefore
asked, “What is the role of physical therapists in fighting the diabetes epidemic?”

We propose that physical therapists intervene in 3 important ways.

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Provide Guidance on Physical Activity Participation for Patients Who Have

or Are at Risk for Diabetes
Physical activity is an important component in the treatment of chronic diseases, including
diabetes, reducing morbidity and mortality.84 However, for patients with diabetes, physical
activity programs must be carefully prescribed, such that they account for diabetes-
associated pathophysiology and complications.

Regularly Screen Patients for Risk Factors for Diabetes and Diabetes-
Related Complications
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Once risk factors are identified, physical therapists can provide treatment that includes
education in self-management strategies and prescription of safe and rewarding physical
activity, an effective treatment for diabetes and associated comorbidities.

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Advocate Regular Physical Activity as a Key Component of the Treatment

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of Chronic Diseases in All Patient Interactions

In this clinical commentary, we highlight the diabetes epidemic and provide
recommendations for screening, examination, and preventive care practices that can be
immediately implemented by physical therapists to reduce the impact of diabetes and its
associated complications. Additionally, we highlight published, evidence-based
recommendations to promote physical activity among people with diabetes.

PATHOPHYSIOLOGY OF DIABETES MELLITUS

Diabetes mellitus is a group of chronic metabolic conditions all characterized by elevated
blood glucose levels resulting from the body’s inability to produce insulin, resistance to
insulin action, or both (TABLE 1).9 This group of conditions consists of 4 clinically distinct
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types: (1) type 1 diabetes, which results from autoimmune beta-cell destruction in the
pancreas and is characterized by a complete lack of insulin production; (2) type 2 diabetes,
which develops when there is increased resistance to the action of insulin and the body
cannot produce enough insulin to overcome the resistance; (3) gestational diabetes, which is
a form of glucose intolerance that affects some women during pregnancy; and (4) a group of
other types of diabetes caused by specific genetic defects of beta-cell function or insulin
action, diseases of the pancreas, drugs, or chemical toxicity.5 We focus on type 2 diabetes in
this commentary.

Type 2 diabetes accounts for 90% to 95% of all diagnosed diabetes cases.17 Type 2 diabetes
typically begins as insulin resistance. As the body is unable to produce enough insulin to
address the resistance, the pancreas may reduce or eventually stop the production of insulin.
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80 The term “prediabetes” is used to define individuals with a high risk of future diabetes.

However, not all individuals who meet the definition of prediabetes will develop diabetes.1
Prediabetes includes people with elevated but subdiabetic fasting glucose levels (ie,
“impaired fasting glucose”), impaired glucose tolerance, elevated glycated hemoglobin
(HbA1c), or a history of gestational diabetes. The diabetes epidemic has been attributed to
increasing sedentary behavior, a diet that provides excess energy (simple carbohydrates and
saturated fats), and obesity.113 Laboratory values used to diagnose diabetes and prediabetes
are provided in TABLE 1.

RISK FACTORS FOR TYPE 2 DIABETES MELLITUS

There are nonmodifiable and modifiable risk factors for development of type 2 diabetes
(TABLE 2). Nonmodifiable risk factors include age, sex, socioeconomic position, race/
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ethnicity, genetic predisposition, history of gestational diabetes, and low birth weight.36,113
While European studies show a higher risk of diabetes in men compared with women,53 this
was not consistently observed in the United States.68 In the United States, the risk of
developing type 2 diabetes was higher among those in lower socioeconomic positions,
including lower levels of education, occupation, and income.3 American Indians/Alaska
Natives have the highest prevalence of diabetes, followed by non-Hispanic blacks and
Hispanics. African Americans are more likely to develop diabetes than white and Asian

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individuals.36 For American Indians, the rates of diagnosed diabetes range from 5.5% to
33.5% in different tribes and population groups.22 Although genetic factors also play a role,
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primary risk factors appear to be those that are not genetic.93

Modifiable risk factors include higher body mass index, physical inactivity, poor nutrition,
hypertension, smoking, and alcohol use, among others.113 Increased body mass index is
consistently one of the strongest risk factors for the development of diabetes.52 Additionally,
distribution of body fat,88 specifically an increased waist-to-hip ratio, increases the risk of
diabetes.58 Lower levels of physical activity and more television viewing time increase the
risk of type 2 diabetes.45,55 Smoking increases the risk of diabetes, regardless of age.109
Psychosocial factors such as depression, increased stress, lower social support, and poor
mental health are also associated with an increased risk of developing diabetes.
11,33,35,42,72,100 Different aspects of the environment have also been linked to type 2 diabetes

development. Increased levels of noise, poor housing conditions, and air pollution were
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associated with increased risk.30,92

Identifying and addressing modifiable risk factors can reduce the risk of diabetes. People
who achieve recommended levels of moderate activity are about 30% less likely to develop
diabetes than their inactive counterparts.55 Brisk walking for at least 2.5 hours per week was
associated with reduced risk of type 2 diabetes compared to almost no walking, independent
of body mass index.55 Higher levels of walkability and green space were associated with
lower diabetes risk.30,92 A person’s risk of diabetic complication can be reduced up to 12%
with a 10-mmHg decrease in blood pressure.22 Diets favoring higher intake of whole grains,
green, leafy vegetables, and coffee; lower intake of refined grains, red and processed meat,
and sugar-sweetened beverages; and moderate intake of alcohol have been linked with
reduced risk of type 2 diabetes.68 A healthier diet can help to reduce HbA1c levels. For each
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percentage-point reduction in HbA1c level, there can be a 40% reduction in risk of

microvascular complications.22 A Mediterranean diet with extra-virgin olive oil
supplementation reduced diabetes risk by 40% compared to a low-fat control diet.91

HEALTH COMPLICATIONS
Diabetes may affect many different organ systems and can lead to serious microvascular and
macrovascular complications, such as (1) cardiovascular disease, (2) stroke, (3) peripheral
artery disease (PAD), also referred to as peripheral vascular disease, (4) nephropathy or
chronic kidney disease, (5) diabetic peripheral neuropathy (DPN), (6) nontraumatic lower
extremity amputations (NLEAs), and (7) retinopathy.31 The prevalence of the most common
diabetes complications among people with type 2 diabetes is shown in the FIGURE.82
Complications can be either episodic (eg, foot ulcers or infections), those that can be treated
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and may recur, or progressive (eg, nephropathy), those that result in further damage to the
organ and greater loss of functionality that are generally irreversible.

Heart Disease and Stroke

Cardiovascular diseases account for up to 65% of all deaths in people with diabetes.41
According to the Centers for Disease Control and Prevention, people with diabetes are about
twice as likely to die from heart disease or stroke compared to those without diabetes.20

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Over 70% of people with diabetes, which is significantly higher than the rate in those
without diabetes, have high blood pressure.82 While risk factors for cardiovascular disease
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development among people with diabetes are similar to those for people without diabetes (ie,
hypertension, hypercholesterolemia, and smoking), the presence of just one of these risk
factors leads to poorer outcomes among people with diabetes compared to those without
diabetes.99 Over the past 20 years, preventive care (self-care management strategies, diet,
and participation in physical activity) targeting diabetes and the risk factors that cause these
complications has improved significantly in the United States. The rates of complications
from heart disease and stroke declined in adults with diagnosed diabetes from 1990 to 2010,
with myocardial infarction accounting for the greatest reduction (68%).43

Peripheral Artery Disease

Peripheral artery disease results from narrowing of peripheral arterial vasculature, affecting
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primarily the limbs, stomach, and kidneys. Early in the process, PAD may be asymptomatic
and is often underdiagnosed.81 Once symptoms are present, they are of 2 types: (1)
intermittent claudication, which presents as pain, ache, or discomfort occurring during
physical activity, such as walking, but resolving with rest; and (2) pain at rest caused by limb
ischemia, which indicates poor blood flow to the affected limb.60 During 1999 to 2004,
prevalence of PAD was about 11%.16 The risk of PAD increases with older age, smoking,
and longer duration of diabetes.29,81 People with PAD are at an increased risk of lower
extremity amputation and mortality.75,81 Patients with intermittent claudication, considered
to benefit from exercise, improved their walking time and distance after participation in
exercise compared to placebo or usual care.67

Retinopathy (Vision Loss)

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Diabetic retinopathy is 1 of the 5 most common causes of severe visual impairment (visual
acuity of 20/200 or worse) in the United States—an estimated 286 000 people aged 40 years
or older had diabetic retinopathy during 2005 to 2008.62 As one of the longest-duration
prospective studies of the epidemiology of diabetic retinopathy, the Wisconsin
Epidemiologic Study of Diabetic Retinopathy reported a 10-year incidence of retinopathy of
74%.63 The 25-year follow-up of this cohort showed that 97% developed diabetic
retinopathy, with about half progressing to sight-threatening disease.64,65 Risk factors for
diabetic retinopathy include hyperglycemia, hypertension, dyslipidemia, longer duration of
diabetes, pregnancy, puberty, and cataract surgery.23 If detected early, diabetic retinopathy’s
progression can be slowed dramatically, and eyesight can be retained in many patients.57
The American Diabetes Association (ADA) recommends an eye exam every 2 years for
those who have no signs of diabetic retinopathy. If there is evidence of diabetic retinopathy,
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the ADA recommends annual exams.

Nephropathy (Renal Disease)

Nephropathy is a chronic condition characterized by a gradual increase in proteinuria in
patients without other conditions that directly cause proteinuria.69,89 Over time, nephropathy
may progress to the development of end-stage renal disease and renal transplant. Diabetes is
the leading cause of end-stage renal disease, accounting for 4 in every 10 new end-stage

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renal disease cases. Overall, the incidence and prevalence of end-stage renal disease have
increased in recent decades among people with diabetes.78
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Metabolic regulation, hypertension, cigarette smoking, obesity, and anemia are all
modifiable risk factors for nephropathy.56 Genetic factors also increase risk for diabetic
nephropathy.56 In persons with type 2 diabetes, strict metabolic control leads to a significant
reduction in the risk of developing microalbuminuria and the risk of progression to persistent
proteinuria.32,38,107

Peripheral Neuropathy
Diabetic peripheral neuropathy, a neurodegenerative disease of the peripheral nervous
system, is estimated to affect up to 75% of individuals with diabetes.2,19,44,86 Chronic
sensorimotor distal symmetric polyneuropathy, the most common DPN,15 can lead to muscle
weakness, sensory loss, and pain in the extremities. The predominant early manifestation of
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DPN is a gradual onset of sensory impairment, including burning and numbness in the feet.
Diabetic peripheral neuropathy may go undetected for years due to its gradual progression.
Neuropathic pain, present in 1 in 3 people with DPN, can be severe.34,97,106

Diabetic peripheral neuropathy is associated with substantial physical impairments, activity

limitations, and reduced quality of life. The presence of DPN increases the risk of foot
ulceration and lower extremity amputation10,83 and is associated with greater health care
resource use, health care costs, and an inability to work due to physical limitations.19,90
Other potential complications of DPN, such as mobility impairments and falls, can result in
significant limitations in activity and participation. Hyperglycemia is the primary risk factor
for DPN.86,95 Additional risk factors include older age, longer duration of disease, cigarette
smoking, hypertension, elevated triglycerides, higher body mass index, alcohol
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consumption, and taller height.2,85,95,101,102,112

Lower Extremity Amputations

Nontraumatic lower extremity amputations are associated with high morbidity and mortality
among people with diabetes. The 5-year mortality rate after NLEA ranges from 52% to
100%.103 The incidence of NLEA among people with diabetes is estimated to be as high as
704 per 100 000 person-years.77 Individuals with diabetes are 7.4 to 41.3 times more likely
to have an NLEA compared to those without diabetes.77

With increased awareness of diabetes-related complications and subsequent implementation

of preventive care strategies, the age-adjusted NLEA rates have decreased in the United
States, from 70.4 per 10 000 adults with diagnosed diabetes in 1995 to 28.4 per 10 000 in
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2010.43 Although overall NLEA rates have decreased, disparities between black and
nonblack patients increased between 2007 and 2011, with the amputation-free survival rate
being lower among black patients.79 Lower extremity amputation rates also differ
significantly by the patient’s geographical location, highlighting the need to address both
racial and regional disparities.79

Risk factors for NLEA include increasing age, being male, being African American or
Hispanic, having peripheral neuropathy, and having chronic foot ulcers.77 Eighty-five

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percent of all NLEAs among people with diabetes were preceded by a chronic, nonhealing
foot ulcer.83,87 Diabetic foot ulcers are common, with the lifetime risk of a person with
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diabetes developing an ulcer being as high as 1 in 4.96 Peripheral vascular disease underlies
approximately half of all amputations in people with diabetes,83 and is associated with
higher mortality after NLEA.103

Musculoskeletal Complications
Musculoskeletal complications associated with diabetes are common. Yet, they may go
undetected and impact the ability to participate in physical activity.94 Foot and ankle
musculoskeletal complications related to diabetes place the foot at risk for ulceration and
amputation. Intrinsic foot muscle deterioration, in the form of reduced muscle volume and
increased fat volume, is associated with metatarsophalangeal hyperextension deformity,25
collapse of the midfoot, and decreased foot function during a heel-raise task.48
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Metatarsophalangeal hyperextension deformity has a prevalence as high as 85% in those

with diabetes and a history of ulcers and amputations.51 Extensive foot joint destruction
associated with Charcot neuropathic osteoarthropathy is less common (approximately 1% of
people with diabetes) but, when severe, prevents weight bearing.51 Early detection and
treatment of musculoskeletal impairments of the foot and ankle may improve the patient’s
current and future ability to participate in physical activity and should be addressed.
Additionally, physical activity participation may need to be modified when diabetes-
associated complications prevent or limit weight-bearing ability. Individuals with diabetes
and a history of foot ulcers were found to be 46% less active than control participants
matched by age, sex, and body mass index.71

Patients with diabetes are 4 times more likely to have musculoskeletal complications of the
shoulder and hand (eg, adhesive capsulitis, Dupuytren’s contracture, and flexor
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tenosynovitis) compared to those without diabetes.18 There is also an increased prevalence

of low back pain in individuals with diabetes.37 Musculoskeletal impairments may be
associated with joint mobility limitation and tissue changes, due to the accumulation of
nonenzymatic advanced-glycation end products.73,94 Advanced-glycation end-product
accumulation results in thicker and stiffer collagen tissues, in particular those with low
turnover, such as tendons, skin, and discs,54 thus increasing the risk of contracture and
musculoskeletal injury.

TABLE 3 provides comprehensive information to screen for diabetes-associated

complications and highlights the physical therapist’s role in patient management. We also
provide recommendations that will assist the physical therapist in developing safe and
effective programs to promote physical activity and exercise among patients with diabetes
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and diabetes-associated complications.

THE PHYSICAL THERAPIST’S ROLE

As part of the multidisciplinary team, physical therapists should be front-line providers in
diabetes prevention and management. Physical therapists should be the provider of choice to
assist patients who have been diagnosed with diabetes or who are at risk for diabetes in
achieving their physical activity goals. Physical therapists’ education provides both broad

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and in-depth content covering the pathophysiology of diabetes and associated comorbidities,
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screening for and treatment of diabetes complications, and prescription of physical activity
for individuals with specific and important limitations of the human movement system that
moderate physical activity tolerance.

Patients may not be regularly referred to physical therapists for guidance on the development
of physical activity programs for chronic conditions, such as diabetes.61 Only 2% of
referrals to outpatient physical therapy in the United States were for diabetes as the primary
health condition to be treated.61 While it is true that the vast majority of patients seen in
outpatient settings have diabetes or are at risk of diabetes,61 these patients are often referred
for treatment of a specific impairment or limitation, such as pain or limited mobility. Patients
may not be referred to a physical therapist for management of diabetes. Physical therapist–
led intervention, including guidance on safe physical activity, should be a key component in
the treatment of diabetes. The fact that only 2% of referrals for physical therapy are for
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management of diabetes perhaps reflects the failure of medical providers to recognize

diabetes as an underlying mechanism contributing to many of the diagnosed conditions
physical therapists commonly examine and treat (eg, stroke, frozen shoulder, carpal tunnel
syndrome, myocardial infarction). Physical therapists have an opportunity to expand
practice, provide valuable contributions to the management of diabetes, and counter the
global burden of disease.

Physical therapists must consider the impact of diabetes and diabetes risk factors in patients
who are referred for other health conditions, such as musculoskeletal pain and mobility
limitations, that are frequent among persons with diabetes. Diabetes and associated
complications affect the type, duration, intensity, and precautions of physical activity that is
prescribed. Screening for diabetes and diabetes risk factors provides an opportunity to
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promote diabetes prevention and/or management through physical activity, and informs
treatment of musculoskeletal pain or mobility limitations. Physical therapists should
advocate for regular physical activity as a key component of the treatment of chronic
diseases in all patient interactions.98,105

Recommendations for Physical Therapists

The standard for excellent physical therapist–led intervention care within our current model
of practice must include screening patients for risk factors for diabetes and diabetes-related
complications, and educating each patient about his or her specific risks (TABLE 2).
Modifiable risk factors such as physical inactivity, obesity, and hypertension can be directly
addressed by physical therapists, by assisting the patient in developing and implementing
programs to increase physical activity. The physical therapist should work with the patient to
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identify and address barriers to exercise. The barriers are often related to comorbidities that
require specific accommodations or modifications to the exercise program. TABLE 3
provides key assessment items and recommendations that physical therapists might consider
when providing patient education about lifestyle management and physical activity.

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Lifestyle Management
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Lifestyle management may include diabetes self-management education and support,

medical nutrition therapy, physical activity, smoking cessation counseling, and psychosocial
care. Components of lifestyle management (eg, diet, physical activity, medication, invitation
to smoking cessation courses) may reduce disease severity and improve self-assessed quality
of life.40 People who receive diabetes self-management education and support (as a one-to-
one interaction, in a group setting, or through internet-based interactions) may experience
lower HbA1c, improved quality of life, and lower all-cause mortality risk.6,28 Substantial
evidence exists of the benefits of physical activity, which we will discuss in the next section.

Although there is clear benefit to preventive strategies, implementation in routine medical

care is often lacking. In 2015, only 54% of people with diabetes attended a self-management
class, 63% self-monitored their blood glucose, 62% received an annual eye exam, 72%
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received an annual foot examination from a professional, 55% performed daily foot self-
exams, 71% had their HbA1c checked more than 2 times per year, and 66% participated in
physical activity in addition to their daily and work activities.21 Physical therapists can guide
patients to implement an effective lifestyle management program. While interviewing the
patient to gather the pertinent medical history, determine whether the patient with diabetes
has a comprehensive lifestyle management program in place. If so, assess the patient’s
ability to follow the program and address any perceived barriers to maintaining this program.
If the patient does not have a program in place, communicate with the patient’s health care
team and assist in the development of a program by providing appropriate referrals and
guiding the development and implementation of physical activity participation. For more
information on lifestyle management programs, refer to the ADA6 and the Centers for
Disease Control and Prevention website (https://www.cdc.gov/diabetes/prevention/lifestyle-
program/experience/index.html).
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Physical Activity and Exercise Prescription

Physical activity is an effective “medicine” for diabetes and other chronic diseases.
12,28,84,104Given that patients likely have 2 or more comorbidities,13 the benefit of physical
activity may go far beyond that of treating diabetes alone. Benefits of physical activity
include improved glucose control, insulin sensitivity, maximum rate of oxygen consumption,
and blood pressure.84 The improvements may require modifications to the patient’s
pharmacologic management plan. Therefore, the physical therapist should facilitate patient
follow-up visits with the primary care physician when needed. Important information to
communicate with the physician includes glucose monitoring logs, resting and exercise
blood pressure and heart rate, and key physical performance measures (eg, 6- or 2-minute
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walk test, 5-times sit-to-stand). A full review of the effects of physical activity on diabetes
and other chronic diseases is available.84

As a component of lifestyle management, physical therapists should assess the patient’s

current level of physical activity and screen to determine the safest and most appropriate
regimen for the patient. Recommendations by the ADA include 150 minutes per week of
moderate- to vigorous-intensity aerobic activity.9,104 The activities should be spread over 3
days per week, with no more than 2 consecutive days without any activity. In addition, 2 to 3

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sessions per week each of resistance exercise and flexibility/balance training are
recommended.9 It is also important to decrease the time being sedentary47; therefore,
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encourage physical activity throughout the day (eg, avoid sitting all day).9,47 Customize the
physical activity program to the patient’s specific goals, preferred activities, comorbidities,
and risk of complications (TABLE 4).

Additional information regarding prescription of physical activity can be found in the

Standards of Medical Care in Diabetes published by the ADA,9 and in the joint position
statement from the ADA and the American College of Sports Medicine titled “Exercise and
Type 2 Diabetes.”26 The resources provided by the ADA and American College of Sports
Medicine are consistent with the recently updated Physical Activity Guidelines for
Americans105; however, they provide additional specificity for patients with diabetes.
Additionally, Kluding et al66 recently published specific recommendations for physical
training in people with DPN. An online tool developed by the US Department of Health and
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Human Services may assist patients to record and monitor their physical activity (https://
health.gov/moveyourway/).

The physical therapy profession should consider how we expand our professional reach
within our current and future health care system. There are many opportunities for
partnering and developing relationships with medical professionals within the established
health care system, including endocrinologists, diabetes clinicians, and diabetes educators.
There are also community partners and outreach opportunities that would benefit from the
skills and knowledge of physical therapists (eg, community-based exercise programs for
individuals with diabetes). Physical therapists have the expertise required to safely and
effectively prescribe physical activity and oversee exercise in medically complex
individuals.
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SUMMARY
Diabetes and its complications are major causes of morbidity and mortality and contribute
significantly to rising health care costs. The dramatic increase in diabetes, paired with high
rates of diabetes complications, will contribute to higher health care costs that are only made
worse by high rates of modifiable risk factors, such as obesity and physical inactivity.
Physical therapists play a central role in the multidisciplinary health care team in at least 3
ways: (1) providing guidance on physical activity participation that is safe and rewarding to
the patient, (2) assessing risk factors for diabetes and diabetes-related complications that
modify traditional musculoskeletal exercise prescription, and (3) advocating for regular
physical activity as a key component of the treatment of chronic diseases in all patient
interactions. ◉
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Acknowledgments
Research reported in this publication was, in part, supported by the National Institute of Diabetes and Digestive and
Kidney Diseases of the US National Institutes of Health under award number R01DK107809. The authors certify
that they have no affiliations with or financial involvement in any organization or entity with a direct financial
interest in the subject matter or materials discussed in the article.

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KEY POINTS
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FINDINGS
Physical therapists are key members of the health care team in the treatment of diabetes.
Physical therapists should screen for diabetes risk factors and diabetes-related
complications that modify traditional musculoskeletal exercise prescription. Physical
therapists must also advocate for regular physical activity as a key component in the
treatment of chronic diseases in all patient interactions.

IMPLICATIONS
This commentary highlights physical therapists’ role as front-line providers, and provides
recommendations for physical therapists in screening for diabetes risk factors and
diabetes-related complications, and considerations for patient management.
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CAUTION
Given the prevalence of diabetes and diabetes risk factors among patients seen in the
outpatient physical therapy setting, it is imperative that physical therapists screen patients
for diabetes risk factors and diabetes-related complications, and educate each patient
about his or her specific risks. Failure of physical therapists to recognize their role as
front-line providers in diabetes prevention and management increases the risk of injury
from inappropriate exercise prescription and limits the health potential of patients.
Author Manuscript
Author Manuscript

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FIGURE.
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Prevalence of complications and comorbidities among persons with diabetes in 2013. Data
source: Pantalone et al.82
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TABLE 1

Diagnosis of Prediabetes and Diabetes7,8

Normal Prediabetes Diabetes

Fasting plasma glucose, mg/dL <100 100–125 >126
2-h plasma glucose after 75-g OGTT, mg/dL <140 140–199 >200
Random plasma glucose, mg/dL ... 140–199 >200
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Glycated hemoglobin, % <5.7 57–6.4 ≥6.5

Abbreviation: OGTT, oral glucose tolerance test.

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TABLE 2

Risk Factors for Diabetes That Are Modifiable and Nonmodifiable With Physical Therapist–Led Intervention

Modifiable Nonmodifiable
Overweight/obesity Age
• Body mass index, ≥25 kg/m2 • >45 y
• Visceral fat Sex
• Waist circumference • Male
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- Female, >35 inches Socioeconomic

- Male, >40 inches • Lower level of education, occupation, housing conditions, and income
Inactivity Race/ethnicity
• <30 min of moderate to vigorous activity per day, 5 d/wk • American Indian, Alaska Native, African American, Hispanic, Asian American, Pacific Islander
Hypertension Family history/genetic predisposition
• Elevated, 120–129/<80 History of gestational diabetes
• Hypertension stage 1, 130–139/80–89 Low birth weight
• Hypertension stage 2, ≥140/≥90
• Hypertension stage 3, >180/>120 (requires emergency care)
Smoking
Diet
• Refined grains, red/processed meat, sugar-sweetened beverages, lack of moderate alcohol intake
Psychosocial
• Depression, increased stress, low social support, poor mental health
Abnormal fasting cholesterol
• Triglyceride, ≥150 mg/dL
• High-density lipoprotein
- Female, <50 mg/dL
- Male, <40 mg/dL

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TABLE 3

Screening for Diabetes-Related Complications and Considerations for Patient Management4,9,27,66,84,105

Screening Items Related to Diabetes and Diabetes-Related Complications Physical Therapist Role and Responsibility

Psychosocial Factors*

Depression • Annual screening for depression among all patients diagnosed with diabetes. Screening should also be
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• The PHQ-2 may be used as a “first-step” screening. Patients who answer yes to performed at any time depression is suspected
either question should be further evaluated by a mental health provider108 • Assist patient in developing an appropriate program to increase physical activity
- “During the last 2 weeks, have you been bothered by feeling down, depressed or
hopeless?”
- “During the last 2 weeks, have you been bothered by little interest or pleasure in
doing things?”
Anxiety disorder • Screen for anxiety disorder and refer for treatment if warranted
• Patients who exhibit anxiety or worries regarding their diabetes-related
complications or ability to participate in a lifestyle management program
Disordered eating behaviors (binging, intentional omission of insulin) • Screen for disordered eating behavior, eating disorders, and disrupted eating and refer to appropriate health care
• Hyperglycemia providers if warranted
• Unexplained weight loss
Cognitive impairment/dementia • Screen for cognitive impairments and tailor management to improve understanding and optimize the patient’s
ability to adhere to a lifestyle management program. All patients older than 65 y should be screened for cognitive
impairments

Socioeconomic Factors

Lower social support • Assess barriers to physical activity participation and problem solve with patient to address barriers
Poor housing conditions • Customize the patient’s activity program based on the patient’s goals and preferred activities
• Assist in accessing community resources

Diabetes: General

All diabetes-related complications • Monitor blood pressure and glucose at the initial visit and as indicated at subsequent visits
• Educate patient to monitor blood pressure and glucose daily, including response to exercise
• Encourage lifestyle modifications to decrease caloric intake and increase physical activity for weight loss
• Know medications, their side effects, and their effect on exercise response

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Cardiovascular

Peripheral vascular disease • Annual comprehensive foot examination by a diabetes specialist

• Absent dorsal pedis and/or posterior tibial pulse • Educate patient to perform daily foot examinations to look for unnoticed injury and determine need for nail care
• Capillary refill: ≥4.5 s to refill the nail bed and moisturizer
• Color of skin: pale • If vascular screen is positive for any item, refer for a vascular assessment
Vision • Refer to ophthalmologist for eye exam if the patient is not receiving annual eye exams and prior to initiating a
• Ask about vigorous exercise program
- Changes in vision
- Retina damage from microvascular disease
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Screening Items Related to Diabetes and Diabetes-Related Complications Physical Therapist Role and Responsibility
- Frequency of receiving an eye exam
Cardiac autonomic neuropathy • Refer to cardiologist prior to initiating a vigorous exercise program if abnormalities are measured6
• Blood pressure response from supine to stand, drops ≥30 mmHg
• Heart rate >100 beats/min after resting 15 min

Kidney

Ask about • Refer to nephrologist or primary care physician if the patient is not receiving regular kidney function screening
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• Glomerular filtration rate

• Frequency of kidney function assessment (urinary albumin and glomerular
filtration rate)

Peripheral Neuropathy of Feet

Light touch (Semmes-Weinstein monofilaments) • Annual comprehensive foot examination by diabetes specialist
• Loss of protective sensation: can’t feel 5.07 monofilament • Educate patient to perform daily foot examinations to look for unnoticed injury and determine need for nail care
• Absent: can’t feel 6.10 monofilament and moisturizer
• If the patient lacks protective sensation, provide education about the need for wearing protective footwear when
Tuning fork (128 Hz) on dorsal great toe interphalangeal joint: time between when walking in the home or community and the lack of ability to detect damaging temperatures (cold and hot)
the patient and examiner stop feeling vibration
• Reduced: ≥10-s difference
• Absent: the patient is unable to feel vibration
Biothesiometer
• Unable to feel ≤25 V
Achilles reflex
• Present with reinforcement: Jendrassik maneuver required
• Absent: no reflex with Jendrassik maneuver
Muscle (see below)

Integumentary

Callus: indicator of high pressure and risk of injury • See recommendations above for peripheral neuropathy
Dry/cracked: indicator of autonomic neuropathy and increased risk of skin
breakdown
Foot wounds

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• Neuropathic: plantar surface, area of high pressure, callus
• Vascular: lateral surface, poorly perfused, absent pulse

Musculoskeletal

Joint • Determine whether the patient has any current pain or significant risk factors for musculoskeletal injury
• Deformity of toes (metatarsophalangeal joint hyperextension) and foot (midfoot • Examine and address contributing factors to toe and foot deformity, including a short extensor digitorum longus
collapse); palpation of plantar surface for bony prominences that can be a site of and weak foot intrinsic muscles contributing to metatarsophalangeal joint hyperextension and limited ankle
high pressure and skin breakdown24,25,48,49 dorsiflexion contributing to foot and toe deformity
• Range-of-motion limitations18,59,94 • Develop regular stretching program to address limited joint mobility of the hands, shoulders, and ankles
• Provide exercises specific to limitations in daily functional activities (sit-to-stand, stair and curb ascent and
descent, walking speed and endurance)
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Screening Items Related to Diabetes and Diabetes-Related Complications Physical Therapist Role and Responsibility
- Hands: prayer sign: the patient is unable to fully extend the fingers when placing • Develop or connect the patient to community programs to increase physical activity that is appropriately dosed
the hands together in front of the chest in a prayer position to reduce risk for injury and encourage participation
- Shoulders: limited active and passive shoulder flexion range of motion
- Ankle/foot: limited ankle dorsiflexion and plantar flexion, decreased extensor
digitorum longus length
• Ask about current or history of prevalent musculoskeletal injuries in diabetes
(frozen shoulder, Dupuytren’s contracture, carpal tunnel, trigger finger)
Muscle
• Visible atrophy of the thenar/hypothenar eminence of the hand
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• Loss of muscle strength

- Calf and foot: decreased ability to complete full heel raise and lack of plantar
flexion of the forefoot on the hindfoot during heel raise48,50
- Hands: decreased grip and/or pinch strength
Function
• Slow gait speed (10-m walk time, <12.5 s39)
• 2-minute walk test14 (see Bohannon et al14 for age- and sex-specific normative
data)
• Slow 5-times sit-to-stand (≥10 s70)

Abbreviation: PHQ, Patient Health Questionnaire.

*
A comprehensive list of measures to assess psychosocial factors is provided in a recent American Diabetes Association position statement111

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TABLE 4

Key Recommendations for Physical Activity Prescription for People With Diabetes and Diabetes-Related Complications4,6,9,27,66,84,105

Patient Characteristic Recommendation for Physical Activity Prescription

Diabetes: general • Customize program for patient goals, comorbidities, and complication risk
• Prescription of physical activity must take into account baseline activity level in order to avoid injury and maximize long-term compliance
• Activity monitors are a useful tool to determine baseline activity and to monitor and encourage activity prescription compliance
• Physical activity should be progressed gradually, with the goal to achieve 150 min/wk of moderate- to vigorous-intensity aerobic activity6
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• Monitor blood pressure and glucose during and after performing new aerobic and/or resistance exercises
• Exercise equipment must accommodate the size and weight of the patient
• Decrease sedentary time by getting up and out of the chair every 30 min69
Lower extremity musculoskeletal • Weight-bearing exercise is not contraindicated; however, patients may be more at risk for skin breakdown when there is foot deformity or a history of foot
impairments, neuropathy, and/or a history wounds74
of foot ulcers/fractures • Select activities that minimize lower extremity load, including
- Pool-based exercise
- Stationary cycling
- Elliptical
- Seated aerobic activities
• If patients have an open sore or injury on their foot, non–weight-bearing exercise is preferred6
Autonomic neuropathy or medication (eg, • Use rate of perceived exertion in addition to heart rate and blood pressure to monitor exercise response
beta blockers, nitrates, calcium-channel
blockers, digoxin, diuretics, ACE
inhibitors) that blunts heart rate and blood
pressure response to physical activity
Proliferative and severe nonproliferative • High-intensity aerobic exercise may be contraindicated due to the potential to exacerbate eye damage6
diabetic retinopathy
Obesity • Resistance training has many of the same benefits as aerobic exercise84 and is often better tolerated by those who are obese or untrained

Abbreviation: ACE, angiotensin-converting enzyme.

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