People With Diabetes: A Population Desperate for Movement

“Good stories,” said APTA President Scott Ward, “contain complex situations and challenges.”^1(p1555) In that spirit, welcome to PTJ's special issue on diabetes and to the unfolding epic tale of a pervasive metabolic disease that has an impact on every cell and system in the body.

Diabetes affects approximately 24 million people in the United States, and the incidence is rising at an alarming rate. Importantly, the onset of type 2 diabetes is fostered by decreased physical activity. In addition, the progression and severity of complications in individuals with type 1 or type 2 diabetes are affected by a deficiency in the appropriate “dosage” of movement. This special issue shows that physical therapy interventions can have a dramatic and positive effect in fighting the local and systemic complications associated with diabetes. As the movement experts, physical therapists are ideally suited to help this population safely and effectively address their movement dysfunctions.

Each of the 15 papers contained in this special issue takes on at least one critical aspect of a disease that is currently considered to be pandemic. As a whole, the special issue presents a convincing narrative that should be a call to action for every clinician, educator, or scientist who reads it.

The story begins with an epidemiological overview of the diabetic complications that are most often encountered by physical therapists (Deshpande et al²). Although there are multiple forms and causes of diabetes, decreased movement and decreased activity—the antithesis of physical therapy—contribute to obesity and are a catalyst for type 2 diabetes. From epidemiology, the focus shifts to the underlying pathophysiology of the disease. Stehno-Bittel³ provides an in-depth characterization of the pathophysiology of fat—the proverbial “good guy” turned “bad.” The traditional view is that fat cells are good only for storing energy, but this article provides a fascinating description of how fat is the largest endocrine organ in the body, how it secretes multiple hormones essential for bodily functions, and how this process is sabotaged by obesity and diabetes.

Next, learn how fatty acids are metabolized, how diabetes affects this metabolism, and how exercise can play the hero and alleviate some of these damaging processes (Turcotte and Fisher⁴). Many people with diabetes take medications to treat the disease, and the article by Gulve⁵ provides detailed, cutting-edge information about the important role of pharmacological agents and exercise to facilitate glycemic control. In addition to serving as a guide for how you can help your patients with diabetes exercise safely and effectively, these articles will inspire you to strap on your exercise shoes, burn a few calories, and enhance your own insulin sensitivity before you read on.

The story continues by detailing the long-term, serious complications that some patients with diabetes experience. Every reader should understand that the #1 killer associated with diabetes is cardiovascular disease. Cade⁶ details numerous types of microvascular and macrovascular disease, including common mechanistic pathways, risk factors, and presentations of these pathologies. From blood vessels, the story moves to muscle—even this old friend has been infiltrated by neuropathy and by fat that has rendered it much less effective than healthy muscle (Hilton et al⁷). But there's good news for the management of muscle-related problems. Considerable evidence exists to show that aerobic and resistive exercise can have a very positive effect on muscle performance and overall disease control (Marcus et al⁸; Turcotte and Fisher⁴; Gulve⁵).

Chen et al⁹ provide interesting and useful data about factors that can predict insulin resistance, an important precursor of type 2 diabetes, and Brach et al¹⁰ address gait changes in elderly people with diabetes. Each of these articles helps the reader to better understand the complications of diabetes and how to manage them safely and effectively.

Next: the disasters that can befall the foot in diabetes. Although appropriate amounts of physical stresses are absolutely necessary to stimulate essentially all weight-bearing tissues in our body, excessive forms of physical stresses can contribute to skin breakdown on the insensitive, neuropathic foot (Mueller et al¹¹). Read further about a randomized controlled trial to investigate whether people with peripheral neuropathy who are at high risk for skin breakdown can tolerate and benefit from a progressive weight-bearing activity (LeMaster et al¹²). A number of negative factors can intersect to cause the bones of the neuropathic foot to basically self-destruct in a process called Charcot neuropathic arthropathy (Sinacore et al¹³). To help guard against these types of severe problems, guidelines¹⁴ for a comprehensive foot examination and risk assessment were published in the August 2008 issue of Diabetes Care (http://care.diabetesjournals.org); PTJ is reprinting these guidelines in this issue.

Every physical therapist, regardless of specialization, should be able to recognize and manage basic diabetes-related complications as part of patient care. This point is highlighted by Kirkness et al,¹⁵ who provide data that as many as 80% of the patients referred to physical therapy have diabetes or an associated risk factor for diabetes. Given the prevalence and magnitude of the problem, Cohn¹⁶ provides thoughtful perspectives on the financial implications for patients, payers, and physical therapists. Furthermore, we are reminded that movement—in the form of physical activity and exercise—is arguably the most effective tool to help prevent or manage this costly and pervasive disease, and the physical therapy profession is challenged to propose and support policy changes to facilitate physical activity on a large scale (Deshpande et al¹⁷).

This special issue is compelling reading about a clear match of needs and abilities, but the story is far from over.

Clinicians: Read this information tonight, and apply it to your patients tomorrow.

Educators: Use this issue to help train future clinicians and scientists. We need to develop a larger cadre of expert physical therapists to help ensure the well-being of the growing number of patients with diabetes.

Investigators: Important areas of study are not included in this special issue, most notably the effects of diabetes on collagen and joints (ie, limited joint mobility) and the psychosocial aspects of the disease. In particular, we know that exercise is useful to help prevent diabetes and its complications, but how do we better help our patients to perform this exercise? You might think of other critical areas not covered in this issue. Dr Craik and I hope that this special issue will stimulate authors to submit their research on the movement-related dysfunctions associated with diabetes to PTJ.

As you read this issue, I urge you to reflect on how you might use the information to help patients with diabetes move and exercise effectively and safely—so that they might be better able to participate in their own life story.

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Figure.

Permeability.

Mixed media

Artist: J Jacobs, www.type1diabetesart.com

The artist, who has diabetes, writes: “This piece is a commentary on the permeability of the human body. There are many hormonal fluctuations taking place within our bodies every second of the day— that we take for granted. However, people with type 1 diabetes are constantly reminded of the body's blood sugar and insulin levels because managing them requires bringing the inside out (testing your blood sugar) and putting the outside in (injecting insulin into your body).”

• American Physical Therapy Association