Physiotherapy in the treatment of type 2 diabetes. Physiotherapy works

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1 Physiotherapy works Physiotherapy in the treatment of type 2 diabetes Physical training reduces the level of glucose in the blood and may reduce the need for antidiabetic drugs in patients with type 2 diabetes. As, besides diabe-tic symptoms, training instructors should manage muscular skeletal problems, neuropathy, heart and lung diseases and overweight, the training should be provided by physiotherapists at public and private clinics.

2 Physiotherapy in the treatment of type 2 diabetes What is Type 2 diabetes? Type 2 diabetes is characterised by high levels of glucose in the blood, due to insulin resistance and relative insulin deficiency. Physical inactivity and hyper-caloric food are the main contributors to type 2 diabetes. Poorly regulated blood glucose increases the patient s risk of developing medical complications related to diabetes (1). These complications include heart disease, stroke, neuropathy, foot ulcers, kidney failure and eye disease. Lower blood glucose values are associated with a lower risk of complications (1). Patients with type 2 diabetes often suffer from additional diseases that affect their health negatively. In addition, the patients physical performance is impaired by loss of muscle strength (2) and joint and muscle pain (3). In patients with type 2 diabetes, low back pain is reported twice as frequently as in an age and gender-matched general population. Effects of physiotherapy-led physical training Physiotherapists offer evidence-based training interventions encompassing aerobic training and/or resistance training. Three meta-analyses showed that both of these training modalities are effective in lowering the blood glucose by % in HbA1c (blood glucose control) (4-6). The training also impacts on other parameters associated with increased morbidity and mortality. Two meta-analyses have shown that training not only reduces the blood glucose but that it also has positive effects on high blood pressure, high cholesterol and overweight (6,7). Thus, the training affects several morbidity and mortality risk factors and is an essential component of type 2 diabetes treatment programs. Furthermore, physical training improves the patients physical capacity. In patients with type 2 diabetes aerobic training may increase aerobic capacity by 15% and resistance training may increase the muscle strength by 19% (8). Increased aerobic capacity and muscle strength is associated with improved physical performance which has great relevance to the increasing number of elderly patients with type 2 diabetes. Optimal training interventions may include training sessions three times a week for a minimum of 12 weeks. However, these interventions may be planned in different ways and include non-supervised training sessions. Physiotherapists may also deliver beneficial interventions with lower levels of physical activity. While not all patients are attracted to aerobic or resistance training, some may prefer physical activities outside the gym. Brisk walking is an alternative that has been shown to be effective in reducing blood glucose in patients with type 2 diabetes (9,10). There is strong evidence that physical training reduces the mortality risk in patients with type 2 diabetes. A recent meta-analysis showed that high levels of physical activity can potentially reduce the risk of mortality by 40% compared to physical inactivity (11). The same meta-analysis showed that not only rigorous training but also any amount of physical activity was beneficial compared to inactivity in reducing the mortality risk. Why should physiotherapists lead physical training? Physiotherapists play a crucial role in Danish type 2 diabetes treatment programs. These structured programs encompass supervised physical training, patient counselling and patient education. In the Danish Regional Authorities, physiotherapists have participated in the development of treatment programs in cooperation with other members of the health- 2 Physiotherapy in the treatment of type 2 diabetes

3 care system. These treatment programs have been implemented at the municipal level and patients are now referred to physical training programmes all over the country. The importance of physiotherapy-led training interventions is emphasised by the prevalence of arthritis, other joint pains, joint replacements, stroke and respiratory problems (12-14) among patients with Type 2 diabetes. Special attention should be paid to these nondiabetic conditions when conducting individually tailored training programs in terms of adjusting intensity and load as well as choosing exercises. Physiotherapists have a wealth of experience of training patients suffering from various symptoms and diagnoses. Once these are identified and the training programs adapted, the patients can engage safely in training sessions. Socio-economic impact The effect of long-term physical training on blood glucose is at the same level as anti-diabetic drug or insulin therapy in patients with type 2 diabetes (6). Thus, if physical activity interventions are accepted by the patients, training may reduce the use of medication and thereby become a cost-saving initiative (6). A 1% reduction in blood glucose control (HbA1c) is associated with a risk reduction of 21% of any complication related to diabetes (1). Physical training is recognised as a method of treatment to reduce the blood glucose. Furthermore, training also reduces other morbidity and mortality risk factors suggesting that such interventions save costs on a long term basis. This was shown to be true in a recent meta-analysis; training programs are cost-effective in terms of longer life expectancy with improved quality of life (Quality Adjusted Life Year) (15). Training interventions in patients with type 2 diabetes are offered as exercise on prescription in Denmark. Patients with type 2 diabetes may engage in training with patients who suffer from other chronic diseases, such as heart disease. When more patients with different chronic diseases can be included in training programs, it may be easier to implement the training in local communities. Previous results have shown that training interventions across diagnosis can be conducted with relevant reductions in the blood glucose leading to better prognoses (16,17). Physiotherapists work in multi-disciplinary teams that deliver patient education in the type 2 diabetes treatment programs. Patient education is an evidence-based intervention in type 2 diabetes (18). Physiotherapists are using empowerment-based patient education to help patients to make life style changes including engaging in enhanced physical activity (19). Finally, training given to patients with type 2 diabetes may also be effective in combating other pre-existing health problems, including loss of bone strength, musculoskeletal pain and reduced mental health. Conclusions Physical training is a cornerstone in the treatment of type 2 diabetes. Training programs are cost-effective; they prevent medical complications and reduce the mortality risk. Physiotherapists play an important role in the treatment of type 2 diabetes by leading evidence-based training programs. The importance of having physiotherapist-led training programs is emphasised by the patients individual impairments and other disorders. 3 Physiotherapy in the treatment of type 2 diabetes

4 Number of patients Recent data shows that more than 275,000 persons (~5%) have type 2 diabetes in Denmark (20). It has been suggested that more people have the disease without knowing it. More men than women have type 2 diabetes. The number of patients increased by more than 90% during the last decade and the number is expected to increase further in the coming years due to a larger number of elderly subjects, unhealthy food and physical inactivity. Disease severity In Denmark, the severity of type 2 diabetes is assessed according to a list of medical conditions. The severity is divided into three stages. The majority of patients (stages 1 and 2) are usually treated in local communities and in general practice. Patients with stage 3 diabetes are more often treated in hospital clinics. Physiotherapists are leading training intervention for patients with type 2 diabetes. The training: - Improves blood glucose control - Reduces the mortality risk - Is cost-effective - Also effects several comorbidities. The Association of Danish Physiotherapists has asked a group of experts to present a short summary of the latest evidence in a specific topic/area of physiotherapy. The summaries are ment to be used as tools to highlight and promote physiotherapy. This summary about type 2 diabetes is written in 2013 by physiotherapist, ph.d. Stig Mølsted. References (1) Stratton IM, Adler AI, Neil HA, Matthews DR, Manley SE, Cull CA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000 Aug 12;321(7258): (4) Umpierre D, Ribeiro PA, Kramer CK, Leitao CB, Zucatti AT, Azevedo MJ, et al. Physical activity advice only or structured exercise training and association with HbA1c levels in type 2 diabetes: a systematic review and meta-analysis. JAMA 2011 May 4;305(17): (5) Chudyk A, Petrella RJ. Effects of exercise on cardiovascular risk factors in type 2 diabetes: a meta-analysis. Diabetes Care 2011 May;34(5): (6) Snowling NJ, Hopkins WG. Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: a meta-analysis. Diabetes Care 2006 Nov;29(11): (9) Belli T, Ribeiro LF, Ackermann MA, Baldissera V, Gobatto CA, Galdino da Silva R. Effects of 12-week over- 4 Physiotherapy in the treatment of type 2 diabetes

5 ground walking training at ventilatory threshold velocity in type 2 diabetic women. Diabetes Res Clin Pract 2011 Sep;93(3): (10) Negri C, Bacchi E, Morgante S, Soave D, Marques A, Menghini E, et al. Supervised walking groups to increase physical activity in type 2 diabetic patients. Diabetes Care 2010 Nov;33(11): (11) Kodama S, Tanaka S, Heianza Y, Fujihara K, Horikawa C, Shimano H, et al. Association Between Physical Activity and Risk of All-Cause Mortality and Cardiovascular Disease in Patients With Diabetes: A metaanalysis. Diabetes Care 2013 Feb;36(2): (15) Coyle D, Coyle K, Kenny GP, Boule NG, Wells GA, Fortier M, et al. Cost-effectiveness of exercise programs in type 2 diabetes. Int J Technol Assess Health Care 2012 Jul;28(3): Download the complete list of references on fysio.dk/fagligstatus 5 Physiotherapy in the treatment of type 2 diabetes