On “Exercise assessment and prescription in patients with type 2 diabetes…” Hansen D, Peeters S, Zwaenepoel B, et al. Phys Ther. 2013;93:597–610.

Congratulations to Hansen and colleagues on a fine article on physical therapy and diabetes and to PTJ for publishing the article in the May 2013 issue.¹ The following observations are meant to supplement the information. They are not intended to be critical of the work.

Diabetes and the many other associated chronic diseases need to further emerge on the radar and practices of physical therapists should we continue on our path as doctors unbound by referral. It is still common to see statements such as, “Secondary conditions, such as diabetes, may be prevalent in this population, and physical therapists need to be aware of this to adjust interventions and treatment.”^2(p1408) Much worse positions often are encountered, such as, “Physical therapy does not treat diabetes. We do not prescribe medication.”

The terms “advanced glycation end-products (AGEs) or equivalent” and “chronic systemic inflammation (metaflammation) or equivalent” are absent from the Hansen et al article. Until physical therapy further translates the pathophysiology of this and related chronic diseases to our profession, we will remain practitioners following prescriptions and treating symptoms as opposed to addressing the origin of the maladies we treat. Exercise—one of the primary interventions for prevention, treatment, and recovery (PTR) in diabetes—places physical therapists as one of the most important practitioners in the PTR of diabetes and its many comorbid conditions. Physical therapists are positioned to be the lead practitioners in this and related diseases. We offer significant natural intervention approaches for PTR beyond the limitations and side effects of a “pill” or surgery. This potential will continue to be obfuscated by viewpoints and biases seen too often in our profession and certainly other professions we come into contact with. When 80% of the population is at direct risk,² the issue does not remain a casual footnote to our treatment plans.

With “diabesity”³ as a significant disease descriptor, it is time for the physical therapy profession to take a fresh look at diabetes and associated diseases in view of the mounting evidence emerging from the laboratories around the world. All are related to AGEs and metaflammation generated from our lifestyle that alters the cellular function of every system of the body. If physical therapy can shake the shackles of the virtual absence of evidence-based nutrition in its practice and further define its role in exercise and lifestyle modification, it can make the greatest contribution to the PTR of diabetes of any of the professions addressing the disease currently. Unfortunately, diabetes PTR is at present a very dark corner in the physical therapy profession.

The profession will benefit by observing information such as the meta-analysis by Umpierre et al⁴ making the association with exercise and glycemic control. Additionally, practicing professionals need to understand and expand their knowledge of DNA methylation and the resultant metaflammation⁵ as it relates to cellular dysfunction that begins in utero⁶ and progresses over the lifetime.^7–9 We must translate the importance of myokines¹⁰ and adipokines¹¹ from our musculoskeletal and adipose tissue endocrine systems into our practice.

Recent emerging evidence alters a physical therapist's focus past symptom treatment and toward the pathophysiological origin of the problem for treatment intervention strategies. Because Kirkness et al² included no mention of inflammation or AGEs in their article, it must be assumed that their “secondary” designation of diabetes is related to the other symptoms we are treating. Under present knowledge, diabetes appears to be secondary to the AGEs and resultant or accompanying metaflammation. It is likely one of many symptoms of this chronic long-term build-up that generally occurs covertly over many years mainly due to our lifestyle and nutritional practices. Diabetes becomes one of the comorbidities of this chronic degeneration and is not secondary to the other symptoms we treat so frequently. Although diabetes does create great damage, the most effective treatment strategy for PTR is to address the underlying pathophysiology of all of the symptoms. Perhaps the designation of “secondary” might have more accurately been termed “comorbid” or “accompanying”?

Kirkness et al make very important connections and points in their excellent article; perhaps my impression is not what the authors intended. But diabetes itself is not generally viewed as a disease we treat directly. How many physical therapist notes do you read that address “exercise for glycemic control” as one of the treatment goals? Hansen et al effectively push back against this too common omission. Still, we should be viewing this exercise intervention strategy at the cellular level, which puts us at DNA methylation,^12,13 AGEs,¹⁴ and metaflammation.¹⁵

Nonetheless, the articles by Hansen et al¹ and Kirkness et al² are fine offerings as the profession struggles to expand its horizons past symptom treatment toward addressing the basic pathophysiology of diabetes with all of its comorbid symptoms. PTJ is to be commended for recognizing their importance to the practice of physical therapy and publishing them.

• © 2013 American Physical Therapy Association