PHYSIOTHERAPY AND DIABETES March 2006 Executive Summary The Australian Physiotherapy Association (APA) strongly supports the use of multidisciplinary teams to provide evidence-based care to individuals with diabetes. Physiotherapy has a valuable role in the prevention and management of diabetes. Physiotherapists are experts in exercise prescription and are able to provide advice on physical activity and promote effective self-management practices. Physiotherapists also assist with the management of complications associated with diabetes. The APA contends that increased funding to support preventive and disease management interventions conducted by physiotherapists would decrease the cost burden of diabetes to the community. Introduction Diabetes is a chronic condition that imposes a significant burden on the Australian community. The disease can cause a number of long term complications, resulting in disability, reduced quality of life, and premature death. The Australian Physiotherapy Association (APA) believes that physiotherapy plays a vital role in the prevention and management of diabetes. Physiotherapists are experts in exercise prescription and are able to provide advice on physical activity and promote self management practices. Physiotherapists also assist with the management of complications associated with diabetes. The APA supports a multidisciplinary approach to diabetes management that focuses on person-centred care. All individuals with diabetes have the right to access diabetes management programs appropriate to their diagnosis, including physiotherapy. Regardless of financial status, cultural background, or geographical factors there should be sufficient services available to meet consumer need. There should be improved access to services for people living in regional, rural, and remote areas. The APA strongly supports preventive strategies to reduce the incidence of diabetes in Australia. The APA recommends that funding be made available to allow individuals who are at high risk of developing diabetes to access prevention programs such as physical activity interventions conducted by physiotherapists. Role of physiotherapy Physiotherapists have an essential role in all aspects of diabetes management, from prevention to rehabilitation following complications. Physiotherapists work with individuals and at risk groups who have any type of diabetes. Physiotherapists work as sole practitioners and also as part of multi-disciplinary teams in a variety of settings, including primary care and hospitals. APA Position Statement Page 1 of 6
Physiotherapists have the broad clinical knowledge and skills necessary for managing patients with diabetes. Common co-existing medical conditions for people with diabetes include heart disease, high blood pressure, and stroke (Shaw and Chisholm 2003). Physiotherapists are able to take into consideration these conditions and tailor treatment (including exercise programs) to the particular needs of the patient. Primary health and community care Primary health and community care encompasses an array of services and interventions spanning the disease continuum, from prevention through to management, rehabilitation, and maintenance. Physiotherapists are first contact practitioners and are well positioned to support health promotion strategies to encourage healthy lifestyle choices. Physiotherapists are suitably qualified and have the expertise to provide education and tailored physical activity programs to optimise the health and quality of life for those at risk of diabetes and those with the disease. Physiotherapists treat individuals who have complications that arise from diabetes. Vascular (circulatory system) complications result in visual disturbances, nephropathies and neuropathies. Peripheral neuropathies (disorders of the nerve endings) can result in disorders of sensation and balance and patients may need physiotherapy assistance to adjust to these changes. Hospitals Diabetes and its related complications are major causes of hospital utilisation in Australia. In 2001 02, diabetes was involved in 6.1% of all hospital separations (AIHW 2004). Hospital services (admitted and non-admitted) accounted for the largest proportion (36.9%) of overall direct health expenditure on diabetes (AIHW: Dixon 2005). Careful management of the individual by a multidisciplinary care team which includes the physiotherapist may prevent diabetic complications from arising. People with diabetes are at high risk of vascular complications such as cardiovascular disease and stroke. Early commencement of physiotherapy treatment after stroke has been shown to optimise recovery of movement and functional outcomes (Feys et al 2004). When circulatory system complications arise, there is also a risk of affected limbs requiring amputation. Physiotherapists play an important role in rehabilitating patients after amputation. Physiotherapy interventions Physiotherapy is a health profession concerned with maximising mobility and quality of life by using clinical reasoning to select and apply the appropriate treatment. Physiotherapy interventions are provided on the basis of scientific knowledge, evidence and clinical expert opinion, thorough assessment, diagnosis, and ongoing evaluation. Exercise and physical activity Exercise consists of both structured and incidental physical activity. Exercise plays an important role in the two primary types of diabetes Type 1 and Type 2. Physiotherapists have the skills to educate individuals on the benefits of regular physical activity and the knowledge to prescribe exercises most suited to an individual s medical condition. The APA has produced a number of position APA Position Statement Page 2 of 6
statements on physical activity which outline physiotherapists roles in a variety of areas (Exercise prescription 1995, Healthy participation of children in physical activity and sport 2004, and Physical activity and healthy weight in children 2004). Children and adolescents with Type 1 diabetes may develop complications such as limited joint mobility and impaired growth and delayed pubertal development (International Society for Paediatric and Adolescent Diabetes 2000). Regular physical activity is important to optimise the health and well being of all children and adolescents, including those with diabetes (Queensland Health 2003). Health professionals with an expertise in physical activity management should be involved in the care of children and adolescents with Type 1 diabetes (Queensland Health 2003). Physiotherapists have the skills and knowledge to develop appropriate physical activity and education programs for children and the community. Children and adolescents with Type 1 diabetes should be encouraged to participate in a variety of sport and physical activities (Commonwealth of Australia 2005). Physiotherapists are knowledgeable of the special precautions that need to be taken for children with Type 1 diabetes when participating in certain sports, along with other exercise considerations for healthy growth in children. They can also educate children and care givers on the monitoring of their blood glucose levels when participating in physical activity. Obesity and physical inactivity are key contributors to the development of Type 2 diabetes (AIHW 2002). Fat is thought to be involved in the development of diabetes by distending the receptor sites, and therefore, reducing the ability of the body to effectively uptake glucose (Boden and Shulman 2002). Other risk factors for type 2 diabetes include high blood pressure and inappropriate dietary intake (Shaw and Chisholm 2003). Strategies to reduce the incidence of Type 2 diabetes should address obesity and physical inactivity concurrently (NHMRC 2001). Exercise may play an important role in preventing or delaying the onset of Type 2 diabetes through its numerous modes of effect including improving blood sugar metabolism, reducing body fat, increasing muscle mass, and improving cardiovascular fitness (Aas et al 2005, McAuley et al 2003). Physiotherapists frequently design exercise programs to reduce sedentary behaviours and increase physical activity. With optimal design, these programs may contribute to the reduction of body fat levels and improve glucose metabolism both of which are important in the treatment of diabetes, particularly Type 2, as well as for general health. The APA recommends that funding be made available to provide access for individuals at risk of developing diabetes to risk prevention programs such as physical activity programs (whether individual or group focused) conducted by physiotherapists. The 1999 2000 Australian Diabetes, Obesity and Lifestyle Study reported that people with Type 2 diabetes were more likely to be physically inactive than the general population (AIHW 2002). Regular physical activity, combined with healthy eating can control Type 2 diabetes without the need for medication (AIHW 2002). Prescribing exercise for people with diabetes needs to be comprehensive, taking into APA Position Statement Page 3 of 6
consideration the complexities of the co-morbidities. Physiotherapists, working alongside the patient s physician and dietician, prescribe safe and effective exercise programs for patients with diabetes who also have other illnesses, and are an important part of the multidisciplinary care team. For people who are physically inactive and have Type 2 diabetes, best practice guidelines recommend that seeking the help of a physiotherapist may be of benefit (Diabetes Australia & Royal Australian College of General Practitioners 2005). As part of the management of gestational diabetes, it is recommended that women who are without medical or obstetrical contraindications commence or continue a program of moderate exercise (American Diabetes Association 2004). Physiotherapists have thorough knowledge of the recommended guidelines for exercise during pregnancy and are able to educate the patient about the benefits of physical activity to assist in managing blood sugar levels. Physiotherapists are also experts in managing the musculoskeletal problems associated with pregnancy such as back pain. Hence, they can tailor safe exercise programs appropriate to individual needs. Self management education Self-management is considered an essential component of diabetes care (American Diabetes Association 2006). Self management: involves (the person with the chronic disease) engaging in activities that protect and promote health, monitoring and managing of symptoms and signs of illness, managing the impacts of illness on functioning, emotions and interpersonal relationships and adhering to treatment regimes (Gruman & Von Korff 1996, p1). Physiotherapists are able to work in partnerships with their clients to support effective self-management. Gaps in research The APA strongly supports physiotherapy-specific and collaborative research with other health professionals to determine the most effective strategies for the prevention and treatment of diabetes. The APA believes that priorities for further research should include expanding the evidence base on effective means for changing behaviour in people at risk of developing diabetes and those with the condition, and addressing the needs of disadvantaged groups. Conclusion The APA supports the use of multidisciplinary teams to provide evidence-based care to individuals with diabetes. Physiotherapy has a valuable role in the prevention and management of diabetes. Physiotherapists are highly skilled in developing safe and effective exercise programs and promoting healthy lifestyle behaviours. Appropriate funding is needed to support preventive and disease management interventions conducted by physiotherapists. APA Position Statement Page 4 of 6
Glossary (Obtained from Diabetes Australia, www.diabetesaustralia.com.au/) Type 1 diabetes Occurs when the pancreas cannot produce insulin because the cells that actually make the insulin have been destroyed by the body s own immune system. This type of diabetes was formerly known as Insulin Dependant Diabetes or Juvenile Diabetes). Type 2 diabetes Unlike those with Type 1, people with Type 2 diabetes are always insulin resistant. This means that their pancreas is making insulin but the insulin is not working as well as it should, so it must make more. This type of diabetes was formerly known as noninsulin dependent diabetes or mature-age onset diabetes. Gestational diabetes Type of diabetes that occurs during pregnancy. References Aas AM, Bergstad I, Thorsby PM, Johannesen O et al (2005): An intensified lifestyle intervention programme may be superior to insulin treatment in poorly controlled Type 2 diabetic patients on oral hypoglycaemic agents: Results of a feasibility study. Diabetic Medicine 22: 316 322. American Diabetes Association (2004): Gestational diabetes mellitus. Diabetes Care 27: S88 S90. American Diabetes Association (2006): Standards of medical care in diabetes 2006. Diabetes Care 29: S4 S42. Australian Institute of Health and Welfare (2002): Diabetes: Australian Facts. National Centre for Monitoring Diabetes. Australian Institute of Health and Welfare (2004): Australia s Health 2004. Canberra: AIHW. AIHW: Dixon T (2005): Costs of Diabetes in Australia 2000 01. Bulletin No. 26. AIHW Cat. No. AUS 59. Canberra: AIHW. Boden G and Shulman GI (2002): Free fatty acids in obesity and type 2 diabetes: Defining their role in the development of insulin resistance and beta-cell dysfunction. European Journal of Clinical Investigation 32 Suppl 3: 14 23. Commonwealth of Australia (2005): Clinical practice guidelines: Type 1 diabetes in children and adolescents. Canberra: Department of Health and Ageing. Diabetes Australia and Royal Australian College of General Practitioners (2005): Diabetes management in general practice. New South Wales: Diabetes Australia. APA Position Statement Page 5 of 6
Feys H, De Weerdt W, Verbeke G, Steck G et al (2004): Early and repetitive simulation of the arm can substantially improve the long-term outcome after stroke: A 5 year follow-up study of a randomised trial. Stroke 35: 924 929. Gruman J and Von Korff M (1996): Indexed bibliography on Self-management for People with Chronic Disease. Washington DC: Centre for Advancement in Health. International Society of Paediatrics and Adolescent Diabetes (ISPAD) (2000): ISPAD Consensus Guidelines for the management of Type 1 diabetes mellitus in children and adolescents. Accessed 20 March 2006 on http://www.d4pro.com/diabetesguidelines/ NHMRC (2001): Evidence based guidelines for type 2 diabetes: Primary prevention, case detection and diagnosis. Canberra: NHMRC. McAuley KA, Murphy E, McLay RT, Chisholm A et al (2003): Implementation of a successful lifestyle intervention programme for New Zealand Maori to reduce the risk of type 2 diabetes and cardiovascular disease. Asia Pacific Journal of Clinical Nutrition 12: 423 426. Queensland Health (2003). The Best Practice Guidelines for the Management of Type 1 Diabetes in Children and Adolescent. Accessed 20 March 2006 http://www.health.qld.gov.au/publications Shaw JE and Chisholm DJ (2003): Epidemiology and prevention of type 2 diabetes and the metabolic syndrome. Medical Journal of Australia 179: 379 383. Disclaimer: This position statement has been prepared having regard to general circumstances, and it is the responsibility of the practitioner to have express regard to the particular circumstances of each case, and the application of this statement in each case. In particular, clinical management must always be responsive to the needs of individual patients, resources, and limitations unique to the institutions or type of practice. Position statements have been prepared having regard to the information available at the time of their preparation, and the practitioner should therefore have regard to any information, research or material which may have been published or become available subsequently. While the APA endeavours to ensure that statements are as current as possible at the time of their preparation, it takes no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently. Approved by National Advisory Council: April 2005 Approved by Board of Directors: April 2006 Due for review: April 2009 APA Position Statement Page 6 of 6