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    Move Forward Guide

    Physical Therapist's Guide to Diabetes

    According to the Centers for Disease Control, almost 26 million children and adults are living with diabetes (about 8% of the population). Of these, an estimated 19 million have been diagnosed, whereas 7 million are unaware that they have the disease. About 79 million people have "pre-diabetes," a condition in which blood sugar (glucose) levels are abnormal but are not yet considered diabetic.


     

    What Is Diabetes?

    In diabetes, the body does not produce or properly use insulin. Produced by the pancreas, insulin is a hormone needed to allow glucose (sugar) to enter the cell and provide the energy necessary for daily activities. When the pancreas doesn't produce adequate amounts of insulin, or when the muscle, fat and liver cells don't respond to insulin properly, glucose builds up in the blood (hyperglycemia). This can be toxic to your cells. In addition, because of the reduced glucose uptake into the cells, they can use an abnormal amount of fats for fuel (ketoacidosis) and may become undernourished.

    There are 3 main types of diabetes:

    • Type 1 diabetes – develops most often in children and young adults; the immune system destroys insulin-producing cells (beta cells) of the pancreas.
    • Type 2 diabetes – can develop at any age and can largely be preventable; the cells of the body become resistant to insulin, and the pancreas can't produce enough insulin to override the resistance.
    • Gestational diabetes – develops in women during pregnancy; it occurs more often in African Americans, American Indians, Hispanic Americans, and women with a family history of diabetes and also is associated with obesity and inactivity.

    Although the exact cause of diabetes is unknown, factors such as obesity and lack of exercise play important roles in type 2 diabetes. Diabetes can result in such conditions as:

    In a condition called "pre-diabetes" or "insulin resistance," blood sugar levels are normal or only moderately elevated and often are accompanied by elevated insulin levels but have not yet reached the diabetic stage. With pre-diabetes, you have a greater risk not only for diabetes but for heart attacks and strokes.

     

    Signs and Symptoms

    Diabetes symptoms include:

    • Increased thirst
    • Frequent urination
    • Constant or extreme hunger
    • Unexplained weight loss
    • Fatigue
    • Blurred vision
    • Slow-healing sores
    • High blood pressure
    • Frequent infections, such as gum or skin infections and vaginal or bladder infections

    The onset of type 1 diabetes can occur quickly. If you have ketoacidosis, your cells are using abnormal amount of fats for fuel and may become undernourished to the point where you could lapse into a diabetic coma unless you receive insulin. The onset of type 2 diabetes typically develops more slowly, and you might not have any symptoms at all.

    American Diabetes Association*

    Recommended Measurements for Adults With Diabetes

    Glycemic Control 
    AIC; <7.0%
    Preprandial plasma glucose (before a meal) 70-130 mg/dl (5.0-7.2 mmol/l)
    Postprandial plasma glucose (after a meal) <180 mg/dl (<10.0 mmol/l)
    Blood pressure <130/80 mmHg
    Lipids 
    LDL <100 mg/dl (<2.6 mmol/l)
    Triglycerides <150 mg/dl (<1.7 mmol/l)
    HDL >40 mg/dl (>1.1 mmol/l) for men, >50 for women
     

    How Can a Physical Therapist Help?

    Physical activity, along with diet and medication, is a cornerstone of treatment for diabetes—and physical activity is a cornerstone for prevention of diabetes. If you already have diabetes, you know that you need to control your blood glucose (sugar), lower your blood pressure and cholesterol, maintain a healthy weight, and exercise to reduce your risk of heart disease and stroke. Regular physical activity also can reduce your need for medications, particularly if you have pre-diabetes.

    The American Diabetes Association recommends 30 minutes of moderate exercise at least 5 days per week. Both aerobic and strength workouts are helpful. Your physical therapist will perform an evaluation, including a review of your medical history and medications, and develop an individualized exercise program.

    Improve Your Blood Sugar Levels, Manage Your Weight, and Reduce Your Risk of Heart Disease

    Based on your health status, your physical therapist will prescribe aerobic exercise tailored to your needs:

    • "Moderate intensity" aerobic exercise, where your heart rate and breathing rate increase. You might perspire, but you can engage in a conversation. Examples: brisk walking, swimming, gardening, ballroom dancing.
    • "Vigorous" aerobic exercise, where you breathe rapidly and are able to speak in short phrases. Your heart rate increases substantially, and you perspire. Examples include jogging, hiking uphill, fast dancing, martial arts.

    Your therapist likely will recommend physical activity at least 3 days per week, with no more than 2 days in a row without physical activity.

    If you have type 2 diabetes, your physical therapist will prescribe "resistance" exercises (exercises with weights or elastic therapy bands), unless you have another medical condition that makes them unsafe. The goal usually is to do them 3 days per week; your therapist will determine a safe beginning weight and number of repetitions.

    Your physical therapist also will help you manage exercise precautions:

    • If you have type 1 diabetes and high blood sugar levels ("hyperglycemia") and if your blood glucose is more than 250 mg/dl, you need to check your urine for ketones before exercising. Ketones are made when the body breaks down fat for energy ("ketoacidosis"). If there are no ketones, you can exercise with caution. If there are ketones, you should not exercise vigorously. If you have type 2 diabetes, it isn’t necessary to postpone exercise for high blood glucose if you feel well and are well hydrated.
    • If you take insulin or pills that help the body produce more insulin, you should eat carbohydrates before exercise if your blood sugar is less than 100 mg/dl. You also should talk to your physical therapist about the timing of medications in relation to when you exercise.
    • If you have diabetic eye disease (retinopathy), your physical therapist will prescribe an exercise routine that takes into account the activity limitations recommended by your eye doctor (for instance, do only exercises with light weights).
    • If you have an active foot ulcer from diabetes, your physical therapist may advise you to do exercises that don't require you to bear your own weight, such as bicycling.
    • If your sensation isn't as good as it should be in your feet or if you have peripheral neuropathy, you can still do weight-bearing exercise. Recent research has shown that these problems do not increase the risk of skin breakdown. Careful daily inspection of the feet in people with diabetes is always strongly recommended.
    • Other diabetes-related conditions may require that you undergo cardiac testing prior to increasing your physical activity. Your physical therapist can work with you to identify concerns and create exercise routines that are safe.

    Always see a physical therapist to help you with physical activity if you have:

    • Pain in your joints or muscles
    • Numbness or tingling in your feet
    • Calluses or sores on your feet
    • Pain or limping with walking
    • Used an assistive device such as a cane or crutches
    • Had a stroke
    • Questions about what type of exercise is best for you

    When You Have Complications

    If your diabetes isn't being managed well, it can lead to problems in blood vessels and nerves, often in the legs. Low blood flow to the legs can cause cramping pain when walking or lead to skin breakdown (ulcers, sores) on the legs or feet. Diabetes can affect the nerves, which can result in tingling in the feet and may progress to complete numbness. This numbness can mask any damage to the skin or joints because you don't feel pain in the normal way. These problems can lead to difficulty with daily activities, limit your ability to exercise, and also harm your overall health. If these problems occur, physical therapists can:

    • Use special tests to check the sensation in your feet
    • Help decrease your cramping pain during walking
    • Evaluate and care for skin ulcers and sores that are slow to heal
    • Improve your walking ability by adapting shoes or orthoses
    • Show you how to protect your feet if they have lost sensation
     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and experience to treat patients who have diabetes or pre-diabetes.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with diabetes or pre-diabetes.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and say what makes your symptoms worse.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapist management of diabetes. The articles report recent research and give an overview of the standards of practice for treatment of TMD both in the United States and internationally. The article titles are linked either to a PubMed abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Tuttle LJ, Sinacore DR, Cade WT, Mueller MJ. Lower physical activity isassociated with higher intermuscular adipose tissue in people with type 2 diabetes and peripheral neuropathy. Phys Ther. 2011 Apr 7 [Epub ahead of print]. Article Summary on PubMed

    Kruse RL, Lemaster JW, Madsen RW. Fall and balance outcomes after an intervention to promote leg strength, balance, and walking in people with diabetic peripheral neuropathy: "feet first" randomized controlled trial. PhysTher. 2010;90:1568–1579. Article Summary on PubMed.

    Taylor JD, Fletcher JP, Tiarks J. Impact of physical therapist-directed exercise counseling combined with fitness center-based exercise training onmuscular strength and exercise capacity in people with type 2 diabetes: arandomized clinical trial. Phys Ther. 2009;89:884–892. Free Article.

    Boulton AJ, Armstrong DG, Albert SF, et al. Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Phys Ther. 2008;88:1436–1443. Free Article.

    Cade WT. Diabetes-related microvascular and macrovascular diseases in the physical therapy setting. Phys Ther. 2008;88:1322–1335. Free Article.

    Mueller MJ, Zou D, Bohnert KL, et al. Plantar stresses on the neuropathic foot during barefoot walking. Phys Ther. 2008;88:1375–1384. Free Article.

    Turcotte LP, Fisher JS. Skeletal muscle insulin resistance: roles of fatty acid metabolism and exercise. Phys Ther. 2008;88:1279–1296. Free Article.

    Lemaster JW, Mueller MJ, Reiber GE, et al. Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. Phys Ther. 2008;88:1385–1398. Free Article.

    Deshpande AD, Harris-Hayes M, Schootman M. Epidemiology of diabetes and diabetes-related complications. Phys Ther. 2008;88:1254–1264. Free Article.

    Sinacore DR, Hastings MK, Bohnert KL, et al. Inflammatory osteolysis in diabetic neuropathic (charcot) arthropathies of the foot. Phys Ther. 2008;88:1399–1407. Free Article

    Deshpande AD, Dodson EA, Gorman I, Brownson RC. Physical activity and diabetes: opportunities for prevention through policy. Phys Ther. Free Article.

    Chen CN, Chuang LM, Wu YT. Clinical measures of physical fitness predictinsulin resistance in people at risk for diabetes. Phys Ther. 2008;88:1355–1364. Free Article.

    Hilton TN, Tuttle LJ, Bohnert KL, et al. Excessive adipose tissue infiltration in skeletal muscle in individuals with obesity, diabetes mellitus, and peripheral neuropathy: association with performance and function. Phys Ther. 2008;88:1336–1344. Free Article.

    Gulve EA. Exercise and glycemic control in diabetes: benefits, challenges,and adjustments to pharmacotherapy. Phys Ther. 2008;88:1297–1321. Free Article.

    Marcus RL, Smith S, Morrell G, et al. Comparison of combined aerobic and high-force eccentric resistance exercise with aerobic exercise only for people with type 2 diabetes mellitus [erratum in: Phys Ther. 2009;89:103]. Phys Ther. 2008;88:1345–1354.  Free Article.

    Centers for Disease Control and Prevention

    American Diabetes Association

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