Patricia Kluding, PT, PhD, recently spoke with Physical Therapy Products about the prevalence of diabetes, and how PTs can be more involved in the care of patients suffering from this disease.

Have PTs taken an active role in establishing themselves as an integral part of the treatment program for people with diabetes?

Currently, I do not believe that PTs have taken an active role in the treatment of diabetes. I’m sure that there are individual therapists and individual hospitals who care for patients with diabetes very well. However, my sense is that most patients are referred to physical therapy for reasons other than diabetes. For example, patients with diabetes might be in physical therapy for a hip fracture, a stroke, or a musculoskeletal ailment. The fact that they have diabetes is noted. However, it does not really affect the treatment of the condition for which they are receiving physical therapy. This is probably the attitude that many therapists have.

What I want to try to get across to people is that we, as PTs, can actually treat the complications and symptoms of diabetes, and help prevent diabetes, and we can really play a much more active role than we have in the past. I think the present lack of involvement comes from the fact that in our curriculum and at conferences, diabetes does not fit nicely into a particular section, such as acute care, private practice, orthopedics, to cardiopulmonary—it does not really have a home. I’m sure in every curriculum, students are taught about diabetes, but it’s relatively broad and general information that’s provided. And when they talk about examination and treatment, I imagine that diabetes isn’t brought up again as a primary problem for which the patient is being treated. I think this is the reason why we do not have much of a role on the team in treating this problem.

What are some important developments in the medical treatment of people with diabetes that PTs need to be aware of?

Medicine is making huge progress with cancer and heart disease; however, we are just going the wrong direction with diabetes as the incidence continues to increase. The biggest medical treatment that many PTs may not be aware of is the importance of monitoring glycosylated hemoglobin—this is typically referred to as the HbA1C test or, sometimes, the A1C test. For years, the standard for monitoring diabetes has been the blood-glucose test, where you examine a drop of blood to measure the blood-sugar level for that moment. The glycosylated hemoglobin test gives you an indication of the blood-sugar level over the past 3 months and how well the glucose level has been controlled. The current standard of care is to keep the HbA1C values close to or below 7%—this is considered to be a well-controlled person with diabetes. Values above 10% are considered to be poorly controlled.

Speaking from my own perspective, I didn’t really know what HbA1C was after physical therapy school and even working in the clinic for so many years. It wasn’t until I really started to work within this population in more depth that I understood the importance of HbA1C. When PTs get a patient who says that they have diabetes in their history, their first question should be: “Do you know your A1C level?” Often, the patient might say, “I’ve had it tested, but I don’t remember what it is.” If the therapists can find out what it is through communication with the physician, this helps to educate the patient about the significance of this number. Explaining what this is, and using this as an indication of their control efficacies, will help reduce their risk for complications during physical therapy.

Very little research has looked at the effect of exercise and glycemic control; those that are out there have determined that one of the effects of exercise is improved HbA1C levels. So, a patient could come in and have an HbA1C level of nine, and through diet and exercise, the HbA1C level could go down to either an eight or seven over the course of a couple of months; this can possibly be attributed not to medication, but to exercise and lifestyle changes prescribed by the PTs.

The lack of studies goes back to the lack of physical-therapy involvement. When I go to the American Diabetes Association meetings, there are very few PTs, and a handful of exercise physiologists. Most of the people doing the research are physicians, nurses, and dieticians. The research findings include information on lifestyle changes, such as specific counseling, education, and changes in diet. Typically, the exercise “intervention” will include information by a research assistant about increasing physical activity. Perhaps there will be a handout of exercises, or patients may be told to exercise for 30 minutes, which is probably as specific as they get. However, these are patients with pain and other complications. If they have neuropathy, they cannot just start off walking for 30 minutes.

This is exactly where PTs need to be in terms of customizing an exercise program, helping people get started, and keeping them motivated to continue. I feel that there is a gap in the bridge between physical therapy and diabetes: PTs do not know much about diabetes, but the diabetes world needs PTs from not only the clinical level, but also the research level and public-policy level.

What are a few common conditions that people with diabetes display, which PTs may not always associate with diabetes?

Some common conditions that people do associate with diabetes are sensory neuropathy, retinopathy, nephropathy, and amputations. One of the conditions that we might not associate with diabetes are the changes in connective tissue that lead to a loss of range of motion. This occurs when collagen binds to glucose, resulting in glycosylated collagen fibers that act differently from regular collagen fibers. This causes a stiffness that is primarily manifested in the feet, atrophic changes in the skin, as well as loss of range of motion of the ankle and in the tarsal bones of the foot. Again, this is something that is so perfect for PTs to intervene in, but if we do not recognize or assess it, then we will not be able to treat it.

Sensory neuropathy is something we readily associate with diabetes. However, there is also a motor component to that neuropathy—it is subtle, and, certainly, sensory nerves are much more likely to be involved than the motor nerves. However, there is a weakness that tends to manifest itself more in the distal muscles of the foot and ankle. It is significant enough that patients have changes in gait and balance, which PTs can easily treat with exercise. However, there is limited research to show the effectiveness of exercise. The last thing that people might not associate with diabetes is the memory or cognitive changes that happen. These are also very subtle, and they tend to have more to do with the speed of processing information and with complex problem-solving.

Describe some unique conditions that people with diabetes present with, which PTs need to be aware of.

Increased incidence of carpal tunnel syndrome and other nerve impingements in people with diabetes are thought to be due to connective-tissue tightness. There is more likelihood that the soft tissue will be less mobile and will bind down or impinge on the nerves. Of course, anybody can have carpal tunnel syndrome. However, if you consider a person with diabetes who has limited motion of the wrist, and who has that tightness in collagen fibers, he or she may be more likely to develop carpal tunnel syndrome. Patients with diabetes may also have subtle neuropathy that exacerbates the symptoms of carpal tunnel or other nerve impingements. 

Why is autonomic neuropathy a “silent killer” that PTs may not know about?

This is neuropathy that affects the autonomic nervous system in the body. The autonomic nervous system is what regulates our heart, digestive track, and all of the things that we don’t think about—things that are automatic and do not require conscious effort on our part toward making them work. When we have a neuropathy of the autonomic nervous system, people do have adequate baseline functioning of those organs. However, there is no response to any stimulus that might cause a change in function. For example, when someone exercises, takes a deep breath, or holds their breath, you would expect there to be an increase or decrease in the heart rate. What happens in people who have autonomic cardiac neuropathy is that their heart rate just does not change. If they are exercising, breathing deeply, or holding their breath, or if they stand up suddenly, their heart rate stays very constant.

This is actually a problem, because our bodies are designed to respond to these stimuli; if we change our breathing, our heart rate responds accordingly. And when we do not have that change, it puts a lot of stress on the cardiac system. In addition, you can have underlying ischemia of the cardiac muscle that really has never been diagnosed. People may be less likely to have symptoms of chest pain or angina because of neuropathy. Diagnosing cardiac neuropathy requires that they have to get hooked up to an electrocardiogram (EKG) machine and go through a series of breathing or exercise tests; it is not an easy diagnosis and there is also very little information in the literature on what the standards are for diagnosis. If PTs are the ones saying, “Let’s start an exercise program,” we need to know that if the patient is diabetic, then there is a possibility that there is a neuropathy that affects the cardiac system. Therefore, we need to be more cautious than we would with someone who does not have diabetes.

Are there common diabetes drug effects that PTs need to know?

The drugs that are used to control glucose do not have any side effects that are severe enough that they would affect physical therapy. We do need to be concerned about the medications that are often taken to control conditions such as hypertension, because patients taking these medications may also have problems with their cardiac systems. Often, people with diabetes are on many different medications; and as PTs, we need to identify which ones are for what problem and identify how that might affect our therapy treatment.

Pharmacology treatment has changed a lot in the past 10 years. PT must keep going to continuing-education courses to keep learning about the different medications on the market.