With Type 2 Diabetes in the Private and Home Care ... · Recommendations From AXXON (Belgian Physical Therapy Association) Dominique Hansen, Stefaan Peeters, Bruno Zwaenepoel, Dirk

doi: 10.2522/ptj.20120400Originally published online February 7, 2013

Published online February 7, 2013PHYS THER. Timmerman and Michel SchotteZwaenepoel, Dirk Verleyen, Carla Wittebrood, Nicole Dominique Hansen, Stefaan Peeters, Bruno(Belgian Physical Therapy Association)Setting: Clinical Recommendations From AXXONWith Type 2 Diabetes in the Private and Home Care Exercise Assessment and Prescription in Patients

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Exercise Assessment and Prescription inPatients With Type 2 Diabetes in the Privateand Home Care Setting: ClinicalRecommendations From AXXON (BelgianPhysical Therapy Association)Dominique Hansen, Stefaan Peeters, Bruno Zwaenepoel, Dirk Verleyen, Carla Wittebrood, Nicole Timmerman,Michel Schotte

In the management of type 2 dia-betes mellitus (T2DM), exercisetherapy is considered a corner-

stone. Official position statementsdescribe (1) the need for and effectof exercise therapy in patients withT2DM, (2) which training modalitiesto select, and (3) how to increasemedical safety. However, the appli-cation of these guidelines in privateand home care physical therapy set-tings might be difficult. Physical ther-apists working in private and homecare settings often are limited interms of equipment and space. Itthus remains to be described forthese physical therapists how to exe-cute a valid preparticipation screen-ing and how to increase the medicalsafety and clinical effectiveness ofexercise training in patients withT2DM in presence of these limita-tions. Physical therapists, however,will manage these patients moreoften in the near future because ofthe increasing prevalence of this dis-ease. In this clinical recommenda-tion, a systematic, effective, and fea-sible approach for preparticipationscreening and implementation ofexercise intervention in patientswith T2DM, specifically in privateand home care physical therapy set-tings, is provided. Hereby, physicaltherapists in private and home caresettings are better capable to pre-scribe clinically effective and medi-cally safe exercise interventions forthese patients.

Type 2 diabetes mellitus (T2DM) is adisease associated with many com-plications: the likelihood for thedevelopment of heart disease orstroke is elevated twofold to four-fold, and the prevalence of hyperten-sion, retinopathy, and neuropathy inpatients with T2DM is approxi-mately 70%, 28%, and 60% to 70%,respectively. Moreover, T2DM is themost important cause of kidney fail-ure and need for nontraumaticlower-limb amputation.1 Eventually,life expectancy is reduced by about8.2 and 7.5 years in men and women,respectively, when T2DM is diag-nosed at the age of 50 years.2 In addi-tion to the hazardous effects ofT2DM on health, economic andfinancial consequences of this dis-ease have been described: health car-e–related costs are approximatelytwofold to threefold higher inpatients with T2DM, as opposed totheir healthy counterparts, not tak-ing into account the economic costsrelated to absenteeism and loweredeconomic productivity.3

Recent statistical models indicatethat the prevalence of T2DM willincrease exponentially in the nextfew decades.4 The total number ofpatients with diabetes is projected torise from 171 million in the year2000 to 366 million in the year2030.4 As a result, it is important toprevent T2DM and optimize medicaltreatment of T2DM to prevent the

development of diabetes-associatedcomplications and health care–re-lated and economic costs.

In the care of people with T2DM,exercise intervention—besidespharmacologic treatment and caloricintake restriction—is considered acornerstone. According to clinicalguidelines, people with T2DMshould permanently (lifelong) exer-cise 3 to 5 days a week, at a low tomoderate intensity (40%–70% ofmaximum oxygen uptake [VO2max]or 50%–70% of maximal heart rate),achieving a minimal exercise dura-tion of 150 minutes a week, andendurance exercises should be com-bined with resistance exercises(5–10 exercises per session, 3 seriesper exercise, 10–15 repetitions perseries).5–7

Even though these guidelines areuseful to physical therapists imple-menting exercise interventions inpatients with T2DM, 2 major con-cerns still emerge. First, it remains tobe described, in detail, what is theimpact of a different selection oftraining modalities (exercise inten-sity, frequency, and duration; type ofexercise; program duration) on theclinical effectiveness of exerciseintervention in these patients.5,7 Sec-ond, and most importantly, itremains to be described how physi-cal therapists, working in private andhome care settings, need to imple-

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ment these programs. More specifi-cally, it remains to be described howto execute a preparticipation screen-ing, how to screen for diabetes-associated complications, and howto increase the medical safety ofexercise intervention, with the lim-ited space and equipment that areavailable in private and home carephysical therapy settings. It followsthat guidelines for exercise therapyin T2DM5,7 need to be adapted tobecome applicable for physical ther-apists working in private and homecare settings.

Considering the exponentialincrease in prevalence of T2DM, it isvery likely that physical therapistsworking in private and home caresettings will be confronted more fre-quently with patients with this dis-ease in the near future. Accordingly,approximately 80% of all patients vis-iting physical therapists in outpatientsettings have diabetes, prediabetes,or risk factors associated with diabe-tes.8 These patients are at elevatedrisk for microvascular and macrovas-cular complications, retinopathy,nephropathy, and neuropathy.9 Itfollows that awareness of medicalsafety and knowledge of the impactof exercise modalities in thesepatients needs to be increased inphysical therapists working in pri-vate and home care settings.

The intention of this clinical recom-mendation is to describe a system-atic, effective, and feasible approachfor physical therapists, working inprivate and home care settings, whoimplement exercise interventions inpatients with T2DM. With thisapproach, physical therapists arebetter capable to prescribe clinicallyeffective and medical safe exerciseinterventions for these patients. Thepresent recommendation consists of4 main topics: (1) impact of exerciseintervention in T2DM, (2) prepartici-pation screening, (3) increasing

medical safety of exercise interven-tion, and (4) increasing the clinicalbenefits of exercise intervention.

Method of Selection ofPreparticipation Tests andTraining ModalitiesThis recommendation has beendeveloped within the Flemish Work-ing Group of AXXON (Belgian Phys-ical Therapy Association). AXXON isthe only officially recognized tradeunion for Belgian physical therapistsand is a member of the World Con-federation for Physical Therapy(WCPT). AXXON aims to increasethe quality of physical therapy in Bel-gium (stimulate evidence-based prac-tice), to govern professional prac-tice, and to provide education at thenational level. The aim of the presentrecommendation is to increase med-ical safety and clinical effectivenessof exercise intervention in T2DMwhen implemented by physical ther-apists working in private and homecare settings. Moreover, with thisdocument, AXXON aims to stimulatephysical therapists to implementevidence-based preparticipationtests and exercise interventions inthe management of T2DM.

To select proper preparticipationtests, it was first established whichtests were necessary for physicaltherapists working in private andhome care settings. In this selection,2 criteria were handled: (1) testsshould be feasible and (2) testsshould be valid. Feasible tests wereconsidered as those that could beexecuted in private and home carephysical therapy settings, with mini-mum time investment and withoutneed of expensive or large materials.Throughout this article, a differencebetween private and home care set-tings will be made in the selection ofthese tests. Valid tests were consid-ered as those that actually measurewhat the physical therapist aims tomeasure. A preparticipation test was

selected only when all members ofthe AXXON Working Group agreed.From the first group discussion, itwas agreed that preparticipationtests should examine: medical safety,fall risk, physical activity, body com-position, endurance exercise capac-ity, and muscle strength. In prepara-tion for the subsequent meeting, theAXXON Working Group memberssearched for tests that could beimplemented in private and homecare physical therapy settings. Next,PubMed was consulted (up to Octo-ber 2012) for studies examining thevalidity of these selected tests,against gold standard tests, inpatients with T2DM. Data from thesestudies were discussed in theAXXON Working Group in the fol-lowing meeting, and it was decidedwhich tests were included in thepresent recommendation. Used keywords, total number of hits, andnumber of relevant hits (studiesexamining patients with T2DM) arementioned throughout the article foreach preparticipation test.

Tests found to be invalid in patientswith T2DM were not included. Teststhat remained to be examined forvalidity in patients with T2DM butthat did show sufficient validity inindividuals who were healthy wereincluded, but with the observationthat these tests remained to be vali-dated in patients with T2DM.

For the assessment of fall risk, thefollowing tests were examined forvalidity in patients with T2DM:Timed “Up & Go” Test (TUG), Func-tional Reach Test (FRT), Berg Bal-ance Scale (BBS), and Dynamic GaitIndex (DGI). For the assessment ofphysical activity, the followinginstruments were examined forvalidity in patients with T2DM: ques-tionnaires, pedometers, and acceler-ometers. For the assessment of bodycomposition, the following methodswere examined for validity in

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patients with T2DM: bioelectricalimpedance analysis (BIA), waist cir-cumference, and body mass index(BMI). For the assessment of endur-ance exercise capacity, the followingtests were examined for validity inpatients with T2DM: step test, single-stage treadmill walking test, Six-Minute Walk Test (6MWT), andAstrand-Rhyming cycling test. Forthe assessment of muscle strength,the following tests were examinedfor validity in patients with T2DM:handgrip strength test, arm curl test,sit-against-wall test, and sit-to-standtest.

For the selection of training modali-ties and how to increase medicalsafety of exercise training, the cur-rent clinical guidelines were used asthe starting point.5–7 However,based on recent studies,10 we furtherspecified the selection of trainingmodalities to optimize the clinicaleffectiveness of exercise interven-tion in T2DM. A summary of how toscreen patients with T2DM, how toincrease medical safety, and how tooptimize the clinical benefits of exer-cise intervention is shown inTable 1.

Impact of Exercise Therapyin T2DMExercise interventions improve gly-cemic control significantly inpatients with T2DM. Blood glycosy-lated hemoglobin (HbA1c) contenthas been reported to decrease by0.7% to 0.8% as result of �12 weeksof combined resistance and endur-ance exercise training in patientswith T2DM.11,12 Greater reductionsin blood HbA1c content are to beexpected in patients with T2DMwith higher baseline blood HbA1c

levels.12 Considering the significantrelationship between blood HbA1c

content and the risk of cardiovascu-lar disease and premature death,such a decline in blood HbA1c con-tent would lead to a reduction in risk

of microvascular and macrovasculardisease and premature death.13,14

Besides lowering blood HbA1c con-tent in these patients, exercise inter-ventions lead to improvements inexercise capacity, decreases in adi-pose tissue mass and increases inlean tissue mass, improvements inblood lipid profile and quality of life,and reductions in blood inflamma-tory markers and blood pres-sure.15–18 As a result, exercise inter-ventions substantially reducecardiovascular disease risk. Even anenhanced pancreatic �-cell functionhas been observed as result of exer-cise intervention in patients withT2DM, but only in those with mod-erate insulin-secretory capacity atentry of exercise intervention.19

Thus, exercise interventions arehighly effective in improving glyce-mic control and cardiovascular dis-ease risk profile and, therefore,should form a cornerstone in thecare of patients with T2DM.5,7

Preparticipation Screeningin T2DMFrom the previous paragraph, itbecomes evident that exercise inter-vention is important in the care ofpatients with T2DM. However,before initiating exercise interven-tions in these patients, a prepartici-pation screening that is feasible forphysical therapists working in pri-vate and home care settings has to beexecuted. Such screening will con-tribute to detection of potentialT2DM or exercise-related complica-tions, assessment of fall risk, andquantification of physical activity,body composition, endurance exer-cise capacity, and muscle strength.

Medical SafetyA preparticipation screening is initi-ated by a clinical examination of thepatient to detect potential complica-tions related to T2DM and exercise.Patients with T2DM may experiencethe following complications: micro-

vascular or macrovascular disease,retinopathy, nephropathy, periph-eral or autonomic neuropathy, ororthopedic injury.7 A detaileddescription of these pathologies ispresented in a previous review.9 Toassess the presence of cardiovasculardisease, retinopathy, nephropathy,or neuropathy, patients with T2DMshould be examined by a cardiologistor sports physician, ophthalmolo-gist, nephrologist, or neurologist,respectively. Obviously, mostpatients will be reluctant to visit allof these physicians at the start ofexercise intervention, so physicaltherapists should adequately exe-cute a preparticipation screening.

First, physical therapists should per-form a thorough medical historycheck (recording reports of previousdiseases, asking about current medi-cal problems, and analyzing medica-tion prescription). The followingmedications could be prescribed topatients with T2DM to lower bloodglucose level: metformin and thiazo-lidinedione (to increase insulin sen-sitivity), alpha-glucosidase inhibitor(to lower glucose uptake in the gas-trointestinal system), sulfonylurea,incretin, dipeptidyl peptidase 4(DPP-4) inhibitor, meglitinide (toincrease pancreatic insulin produc-tion), and exogenous insulin.20 InTable 2, the possible side effects ofthese blood glucose–lowering medi-cations, especially during exercisetraining, are displayed. Furthermore,patients with T2DM often are pre-scribed a variety of medications forthe control of blood pressure, lipidprofile, and coagulation. These med-ications include diuretics, beta-blockers, angiotensin-convertingenzyme (ACE) inhibitors, aspirin,and lipid-lowering medications. It isimportant to be aware that duringexercise beta-blockers reduce heartrate, diuretics can lead to dehydra-tion and electrolyte imbalances, and




Table 1.Preparticipation Screening and Exercise Intervention in Type 2 Diabetesa

Step Measures

Step 1: Preparticipation screening

General medical risk ● PAR-Q (further examination on positive outcomes)

Specific medical risk ● Cardiovascular, neurologic (peripheral and autonomic), and orthopedic screening: refer to physician in case ofsevere or previously undetected anomalies

● Screening of nephropathy and retinopathy is not feasible: medical history/records should be examined● Refer to physician in case of: untreated hypertension (blood pressure �140/90 mm Hg), angina pectoris,

previously undetected heart rhythm disturbances, untreated intermittent claudication, fasting hyperglycemia(blood glucose level �16.8 mmol/L, �300 mg/dL), frequent hypoglycemic episodes, untreated wounds inlower extremities, cachexia or sudden body weight loss, untreated autonomic or peripheral neuropathy, oruntreated vision disturbances

Glycemic control ● Laboratory values (glucose, HbA1c)● Medication treatment (biguanide, sulfonylurea, insulin, alfa-glucosidase inhibitor, bile acid sequestrant,

meglitinide, DDP-4 inhibitor, thiazolidinedione, dopamine agonist, GLP-1 receptor agonist, blood pressureand cholesterol lowering medication, and anticoagulation)

Health parameters ● Fall risk (TUG, DGI)● Physical activity level (pedometer/accelerometer)● Body composition (bioelectrical impedance, waist circumference)● Endurance exercise capacity (Astrand-Rhyming cycling test, 6MWT)● Muscle strength (handgrip strength test)

Consider patientmotivation toexercise

Step 2: Increase medical safety during exercise training

Take cardiovascular, neurologic, nephrologic, retinal, and orthopedic comorbidities into account before initiating exercise training

Optimize glycemiccontrol

● Check blood glucose level before and after exercise training (should be 4.2–16.7 mmol/L, 75–300 mg/dL)● Lower medication/insulin therapy in case of low blood glucose level (�4.2 mmol/L, �75 mg/dL) or symptoms

of hypoglycemia before exercise training● Elevate carbohydrate intake in case of low blood glucose level (�5.5 mmol/L, �100 mg/dL) or symptoms of

hypoglycemia before exercise training● Adjust training modalities (lower total exercise energy expenditure in case of low blood glucose level or

symptoms of hypoglycemia; do not execute high-intensity exercise in case of blood glucose level �16.7mmol/L, �300 mg/dL)

Optimize cardiovascularsafety

● Assess resting (60–100 bpm) and exercise (rate and rhythm) heart rate● Assess blood pressure at start and end of exercise session (�140/90 mm Hg)

Optimize generalmedical safety

● Retinopathy: avoid high-intensity exercise (�80% VO2max)● Nephropathy: avoid hypertension (systolic blood pressure �180 mm Hg) during exercise● Fever: postpone exercise training until body temperature is restored● Peripheral neuropathy (with foot wound): avoid weight-bearing exercises● Pregnancy: refer to gynecologist● Autonomic neuropathy: regularly check heart rate and blood pressure● Refer to physician when: development or worsening of hypertension, angina pectoris, heart rhythm

disturbances, development or worsening of resting tachycardia, development or worsening of intermittentclaudication, development or worsening of fasting hyperglycemia, frequent hypoglycemic episodes,development or worsening of wounds in lower extremities, cachexia, autonomic neuropathy, or developmentor worsening of vision disturbances

Step 3: Optimize exercise training intervention

● 3–5 days of exercise per week● Combine endurance training with strength training● Low to moderate endurance exercise intensities are effective (50%–75% VO2max)● Achieve a minimal exercise duration �150 minutes/week● Strength exercise modalities: 5–10 exercises/session, 3 series/exercise, 10–15 repetitions/series● Aim at permanent increase in physical activity level● In case of obesity: increase exercise volume or caloric expenditure (to 250 minutes/week)● In case of sarcopenia or low muscle strength: elevate strength training volume● Base exercise intensity on heart rate reserve● Evaluate blood HbA1c content (goal �6.5%) to assess impact of exercise intervention

a PAR-Q�Physical Activity Readiness Questionnaire, HbA1c�blood glycosylated hemoglobin, DPP-4�dipeptidyl peptidase 4, GLP-1�glucagon-like peptide 1,TUG�Timed “Up & Go” Test, DGI�Dynamic Gait Index, 6MWT�Six-Minute Walk Test, VO2max�maximum oxygen uptake.




statins can lead to myopathies (myal-gia, myositis).5

Next, the physical therapist shouldfill out, together with the patient, thePhysical Activity Readiness Ques-tionnaire (PAR-Q).21 In the PAR-Q,the patient responds to 7 simplequestions. In case of a positiveanswer, the physical therapistshould address this point in moredetail. When the physical therapistbelieves that the reported complaintneeds further examination or treat-ment, the patient should be referredto the appropriate medical specialist.A large body of evidence indicatesthat the PAR-Q is a sensitive tool forthe detection of significant anoma-lies that will increase the risk of med-ical complications during exercise.21

After a thorough interview andPAR-Q scoring, physical therapists

should perform a clinical examina-tion of the cardiovascular, neuro-logic, and orthopedic systems. First,the cardiovascular system is exam-ined. The therapist should measureresting blood pressure and heartrate. When assessing blood pressure,the following guidelines should beused: blood pressure should be mea-sured with a manual sphygmoma-nometer (with proper cuff) and astethoscope, the patient must be sit-ting down for at least 5 minutes on achair, the measured arm should be atthe level of the heart, blood pressurealways should be measured at thesame arm, the patient should notconsume caffeine-containing drinksor smoke cigarettes for at least 30minutes before assessment, no exer-cises should have been performedfor at least 30 minutes before assess-ment, and blood pressure should bemeasured at least twice (with aver-

aging of results).22 In the case ofhypertension (blood pressure�140/90 mm Hg), heart rhythm dis-turbances, tachycardia (heart rate�100 bpm), and bradycardia (heartrate �60 bpm) with clinical symp-toms, such patients should receivefurther attention and clinicalexamination.

To assess abnormalities in coronarycirculation and myocardial function,exercise testing with continuouselectrocardiographic (ECG) monitor-ing often is done. However, inpatients with T2DM, routine exer-cise testing with ergospirometry andECG monitoring is not advised.5 Thedecision when to perform ergospi-rometry testing with ECG monitor-ing depends on the intensity of exer-cise (this testing should be donewhen T2DM patients participate inexercise interventions that will elicit

Table 2.Commonly Used Glucose-Lowering Medications in Type 2 Diabetes and Interactions With Exercise Training21

Action Medication Interaction With Exercise Training

Increase in insulinsensitivity

Biguanide (metformin) No weight gain, no risk for hypoglycemia during exercisetraining

Gastrointestinal side effects possible

Thiazolidinedione (rosiglitazone,pioglitazone)

Restricted in use or prohibited because of increased riskfor acute myocardial infarction

No risk for hypoglycemia during exercise training

Dopamine agonist (bromocriptine) No risk for hypoglycemia during exercise trainingSide effects such as gastrointestinal complaints, nausea,

dizziness, and fatigue possible

Increase in blood insulinlevel

Injectable insulin● Short acting: human insulin

(aspart, lispro)● Long acting: neutral protamine

(hagedorn, detemir, glargine)

Significant weight gain might be expectedSignificant risk for hypoglycemia during exercise training

Sulfonylurea (glyburide, glipizide,gliclazide, glimepiride)

Modest weight gain might be expectedSignificant risk for hypoglycemia during exercise training

Meglitinide (nateglinide, repaglinide) Modest weight gain might be expectedSignificant risk for hypoglycemia during exercise training

Injectable glucagon-like peptide1 (GLP-1) receptor agonist(exetanide, liraglutide)

Significant weight loss because of appetite suppressionRisk for hypoglycemia rareSide effects such as nausea and vomiting possible

Dipeptidyl peptidase 4 inhibitor(saxagliptin, linagliptin,vildagliptin, sitagliptin)

No weight change expectedRisk for hypoglycemia during exercise rare

Decrease in carbohydrateabsorption

Alpha-glucosidase inhibitor (miglitol,voglibose, acarbose)

Frequent gastrointestinal complaintsNo risk for hypoglycemia during exercise training

Bile acid sequestrant (colesevelam) Frequent gastrointestinal complaintsNo risk for hypoglycemia during exercise training




exercise intensities above thoseachieved during brisk walking).5

Additionally, maximal ergospirom-etry testing with ECG monitoringshould be done in patients less than30 years or more than 40 years of ageand with the presence of one of thefollowing criteria: diabetes diag-nosed more than 10 years previ-ously, hypertension, cigarette smok-ing, dyslipidemia, retinopathy, ornephropathy. In the case of diag-nosed or suspected coronary arterydisease, peripheral arterial disease,cerebrovascular disease, autonomicneuropathy, or severe nephropathy(renal failure), such exercise testingalso is indicated.5 An evaluation ofperipheral vascular status shouldinclude assessment of pain, changesin extremity color, temperature, pul-sations of peripheral arteries (dorsa-lis pedis, tibialis posterior), andappearance of nails. When a patientcomplains of having peripheral mus-cle pain that is provoked by walkingand disappears during subsequentrecovery, this complaint might indi-cate intermittent claudication.

Second, the neurologic system isexamined. Peripheral neurologic sta-tus can be assessed by the combineduse of the DN4 questionnaire23,24

and monofilament testing.25 TheDN4 questionnaire is first filled outby the patient (first 7 questions),after which physical therapistsadminister simple tests to assess sen-sitivity at reported sites with sensi-tivity disorders (final 3 questions).When more than 3 out of 10 ques-tions of the DN4 questionnaire areanswered positively, this indicatesneuropathic pain (80% sensitivityand 92% specificity).23 A monofila-ment (Semmes-Weinstein) test willfurther establish the degree ofperipheral neuropathy (88% sensitiv-ity and 57% specificity when com-pared with the Neuropathy Disabil-ity Score).25 During this assessment,a 10-g monofilament for cutaneous

pressure assessment is used, and aneedle is used for pain sensationassessment. To assess pressure per-ception, the monofilament is pressedagainst the skin until it buckles andheld for 2 seconds. This test is per-formed twice on the plantar surfaceof each hallux and the 1st, 2nd, 3rd,and 5th metatarsal heads. Thepatient is asked to confirm whether astimulus is felt. The number of sitesat which the monofilament is felt isrecorded out of 10 for each foot,after which a categorization will fol-low: normal pressure perception(being able to feel �8/10 sites) orabnormal pressure perception(being able to feel �8/10 sites).

Next, the pinprick test (with needle)is used to assess pain sensation. Inrandom order, a sharp or blunt end ispressed against the plantar surface ofthe hallux until the guiding markersare aligned. The patient is asked todistinguish between painful and non-painful stimuli. The inability to dis-tinguish between painful and non-painful stimuli indicates sensitivitydisorder. An alternative to the DN4questionnaire and monofilament testis the Michigan Neuropathy Screen-ing Instrument (MNSI) (75% specific-ity and 79% sensitivity).26 The MNSIincludes inspection of the feet,examination of Achilles reflexes, andvibratory sensitivity. The vibratorysensitivity is tested with a 128-Hztuning fork with a damper on thebranches resulting in 64 Hz at thedorsum of the great toe. The vibra-tion sensitivity is considered reducedwhen the patient does not feel anyvibration, while the operator is per-ceiving the vibrations at the index ofhis or her own hand for another 10seconds.

To check for presence of autonomicneuropathy, heart rate and bloodpressure should be assessed, andsymptoms of orthostatic hypoten-sion also should be addressed.

Orthostatic hypotension is definedas a decrease in systolic blood pres-sure of greater than 30 mm Hg or adecrease in diastolic blood pressureof greater than 10 mm Hg whenchanging from a supine to standingposition. A slowed heart rate recov-ery after exercise also is typicallyassociated with autonomicneuropathy.

Within the neurologic assessment,the clinical investigation of the feet isimportant.27 During this assessment,the feet and shoes should beinspected. Shoes that are worn outor too narrow are inappropriate forwear. When examining the feet, der-matologic risk factors (eg, abnormalcolor, dryness, cracking, sweating,infection [mainly fungal infectionbetween toes], ulceration, blister-ing), musculoskeletal risk factors(eg, deformity, muscle wasting),neurologic risk factors (as men-tioned above), and cardiovascularrisk factors (eg, reduced peripheralpulsations) should be examined.27

Third, the orthopedic system isexamined for the following compli-cations: diabetic hand syndrome,Dupuytren contracture, trigger fin-ger, frozen shoulder, Charcot foot,diffuse idiopathic skeletal hyperosto-sis, osteoarthritis, and orthopedicmisalignment.

The presence of nephropathy is dif-ficult to assess without blood param-eters (urea nitrogen, creatinine, glo-merular filtration rate). Patients withchronic kidney disease typicallyreport polyuria, polydipsia, orperipheral edema. These symptoms,however, also could be present inpatients with T2DM withoutnephropathy. Retinopathy cannot bediagnosed by physical therapists.However, a worsening in vision indi-cates a progressive deterioration ofeye function as result of thisdiabetes-mediated retinopathy.




Based on such thorough clinicalexamination, physical therapistsshould be sufficiently aware of abso-lute or relative contraindications toexercise training, or anomalies thatrequire changes in the exercise pro-gram. Patients with T2DM should bereferred to a physician before initiat-ing the exercise intervention in thefollowing situations or conditions:untreated hypertension (blood pres-sure �140/90 mm Hg), angina pec-toris, previously undetected heartrhythm disturbances, untreatedintermittent claudication, fastinghyperglycemia (blood glucose level�16.8 mmol/L, �300 mg/dL), fre-quent hypoglycemic episodes,untreated wounds in the lowerextremities, cachexia or suddenbody weight loss, untreated auto-nomic or peripheral neuropathy, anduntreated vision disturbances.

In conclusion, during the first part ofthe preparticipation screening, phys-ical therapists screen patients for thegeneral risk for complications andexamine the cardiovascular, neuro-logic, and orthopedic systems andthe feet.

Fall RiskPatients with T2DM, especially thoseolder than 65 years, are at anincreased risk of falling or show anincreased fall rate.28–30 This condi-tion could lead to increased morbid-ity and mortality.28 It is important,therefore, to assess fall risk when ini-tiating an exercise intervention inthese patients (key words: fall risk,balance, assessment, diabetes; totalnumber of hits�379; relevanthits�reference 31). Recently, thevalidity of the TUG, FRT, BBS, andDGI has been compared in patientswith T2DM.31

When adjusting the cutoff scores,the TUG showed the greatest sensi-tivity (90%) and specificity (88%).31

In this test, the patient stands up

from a supine position, walks 3 m,turns around, walks back to thechair, and sits down.32 This testshould be completed within 10.6seconds; a longer duration predictsgreater risk for falling.

Another test with sufficient sensitiv-ity (90%) and specificity (85%) toassess fall risk in patients with T2DMis the DGI.31 The scoring of eachitem of the DGI ranges from 0 to 3. Ascore of 0 indicates that the individ-ual is unable to perform the walkingskill, and a score of 3 indicates theindividual can perform the skill nor-mally. A patient with a total score of22 or lower is prone to increased fallrisk.31 The great disadvantage of theDGI is the time needed for execution(approximately 15 minutes).

Both the TUG and DGI can be exe-cuted in private and home care phys-ical therapy settings. These tests arerecommended for the assessment offall risk in patients with T2DM,although with adjusted cutoffs.

Physical ActivityTypically, patients with T2DM aresedentary. It is important to assessphysical activity to understand theseverity of physical inactivity (keywords: physical activity, pedometer,accelerometer, step count, validity,diabetes; total number of hits�83;relevant hits�references 33–37).Moreover, it is advised to regularlyassess physical activity to understandthe impact of exercise interventionon home-based physical activity.

For the assessment of physicalactivity, specific questionnaires forT2DM patients have been developed(modified International PhysicalActivity Questionnaire and PhysicalActivity Questionnaire for DiabeticPatients).33,34,36 However, thesequestionnaires are prone to severeerror in estimation of physical activ-ity (r�.24–.62 between self-reported

physical activity and directlyassessed physical activity).33,34,36

Therefore, it is proposed to measurephysical activity directly with objec-tive techniques, as stated in clinicalguidelines.38

For physical therapists working inprivate and home care settings,accelerometers or pedometers couldbe used to assess physical activity inpatients with T2DM.37 The patientneeds to wear this monitor at the hiplevel for 3 to 5 consecutive days(except during sleeping), afterwhich the physical therapist candetermine the physical activitylevel.38 During such assessment, it isimportant that the patient is not ableto observe the registered physicalactivity level on this monitor andthat the patient does not suddenlychange his or her physical activityduring the assessment period.

An accelerometer is not sensitive tochanges in inclination during walk-ing or to carrying an extra load dur-ing walking, does not monitor upperbody activity, and is less applicablefor assessing cycling activity.38 More-over, an accelerometer is moreexpensive and requires more intensedata management. From the datagathered using this monitor, energyexpenditure related to physical activ-ity and exercise duration and inten-sity can be calculated. However,physical therapists should remaincautious with the registered exerciseintensity, as this parameter dependson what cutoff values are used todetermine different levels of exer-cise intensity.38

A pedometer also is a simple appara-tus that provides a valid estimation ofphysical activity, is less costly, anddata are easier to manage, but canonly be used to specifically assesswalking activities.38 Also, pedome-ters and accelerometers may be lim-ited by body size of patients and,




therefore, might not always provideaccurate information in thispopulation.

According to the observed stepcount, patients with T2DM could becategorized according to differentphysical activity levels: �5,000steps/day�inactive, 5,000–7,499steps/day�low active, 7,500–9,999steps/day�somewhat active,10,000–12,499 steps/day�active,and �12,500 steps/day�highlyactive.39 A step frequency of �100steps/minute is consideredmoderate-intensity to high-intensitywalking activity.39 In conclusion, forthe assessment of physical activity inpatients with T2DM, pedometers oraccelerometers are advised.

Body CompositionType 2 diabetes often is associatedwith excessive adipose tissue mass.It is important to obtain a properdetermination of adipose tissue massbecause visceral adipose tissue massis an important contributor to thedevelopment and maintenance ofT2DM and cardiovascular disease(key words: waist circumference,dexa, mri, bioelectrical impedanceanalysis, diabetes, validity; total num-ber of hits�103; relevanthits�references 40–46).

To assess adipose tissue mass, medi-cal imaging techniques such as x-raycomputed tomography (CT) scan,dual x-ray absorptiometry (DEXA)scan, and magnetic resonance imag-ing (MRI) scan are the gold standardtechniques. For obvious reasons(financial cost and technical com-plexity), these techniques are notavailable to physical therapists in pri-vate and home care settings. It fol-lows that feasible, but valid, tech-niques for the estimation of adiposetissue mass are needed.

Adipose tissue mass can be estimatedusing BIA.40,42,43,47 This technique

has been validated against DEXAscan (r�.89–.96) in patients withT2DM.41–43 In this regard, bipolar(feet) BIA scales can be used; tet-rapolar BIA weight scales do nothave a greater validity in adipose tis-sue mass assessment.47 However, ithas been shown that changes in adi-pose tissue mass as result of exerciseintervention is not always properlyestimated by BIA in patients withT2DM, even though high correla-tions have been reported with DEXAscan (r�.86).42 When conductingBIA, it is important to adhere to thefollowing guidelines: feet should beclean, the patient should abstainfrom exercise training during thepreceding 24 hours, dehydrationshould be absent, and excessive fluidintake should be avoided in the pre-ceding 24 hours.

As an addition to BIA, waist circum-ference should be assessed. By mea-suring waist circumference, a validestimation of abdominal adipose tis-sue mass can be obtained in T2DMpatients (r�0.53–0.83 with MRI andDEXA scan).44–46 The most validassessment location of the waist cir-cumference is right above the iliaccrest (r2�.85–.92 with DEXAscan).48 However, this assessmenttechnique is not always easy, espe-cially in patients who are obese,because the iliac crest needs to bedetermined accurately. The waist cir-cumference is measured with non-elastic tape with the patient in astanding position after full expira-tion.48 In men and women, a waistcircumference of �102 cm and �94cm, respectively, is considerednormal.

It might be proposed to calculateBMI. Even though this parameteroften is assessed for epidemiologicstudy or observation, at the individ-ual level, this parameter does notalways accurately reflect adipose tis-sue mass in patients with T2DM (cor-

relation between visceral adipose tis-sue mass measured by medicalimaging technique and BMI inpatients with T2DM: r�.71 inwomen and r�.56 in men).49 More-over, BMI provides a less valid esti-mation of adiposity in case ofstrength-trained athletes, older peo-ple, and people with fluid distur-bances (eg, heart failure, peripheraledema, ascites) and is differentbetween men and women and in dif-ferent ethnic groups. These limita-tions should be taken into accountwhen evaluating BMI.

In the home care setting, waist cir-cumference can be assessed; in theprivate setting, both waist circumfer-ence and adipose tissue mass (byBIA) can be assessed. In conclusion,in the evaluation of body composi-tion in patients with T2DM, theassessment of waist circumferenceand adipose tissue mass by BIA isrecommended.

Physical FitnessEndurance exercise capacity.The assessment of endurance exer-cise capacity is important. It pro-vides feedback to physical therapistsand patients about the clinical effec-tiveness of exercise intervention.Moreover, a higher endurance exer-cise capacity predicts greater sur-vival in patients with T2DM.50

According to clinical guidelines, thegold standard technique to assessendurance exercise capacity is a car-diopulmonary exercise test withergospirometry. During such testing,a direct assessment of VO2max canbe done, and medical safety of exer-cise can be checked.

In private and home care physicaltherapy settings, however, 2 prob-lems emerge with this assessmentmethod: (1) a maximal exercise testis required (which is not allowed tobe performed by physical therapistsin some countries), and (2) this




method requires the availability of anergospirometer (which is too expen-sive for many physical therapists)and high levels of technical skill.

For these reasons, for the prepartici-pation screening of patients withT2DM at low risk for cardiovascularcomplications, physical therapists inprivate and home care settings are inneed of submaximal exercise tests(with sufficient validity) withoutergospirometry.51 These submaxi-mal exercise tests are designed toestimate VO2max and use the heartrate in such estimations (key words:submaximal exercise, walking,cycling, Astrand, treadmill; totalnumber of hits�557, relevanthits�reference 51).

The Astrand-Rhyming cycling testcan be used to estimate VO2max.51 Inthis test, the patient cycles (at 50rpm) against a self-selected constantworkload (75–150 W), after whichthe corresponding steady-state heartrate (130–170 bpm) after at least 6minutes of exercise can be observed.It is very important that a steady-stateheart rate of at least 2 minutes ispresent. By using the Astrand-Rhyming nomogram, the predictedVO2max can be calculated by con-necting the selected workload withelicited heart rate. The validity of thistest has been examined,51 with verydifferent outcomes (from poor cor-relations to r�.98 with assessedVO2max). In patients with T2DM nottaking beta-blockers, it has beenfound that the actually achievedVO2max (as assessed by ergospirom-etry) is systematically different (27%lower) from the predicted VO2max(as assessed with the Astrand-Rhyming cycling test).52 Changes inVO2max during exercise interventionare different when using ergospirom-etry tests or submaximal tests withVO2max prediction. Resting heartrate and heart rate behavior duringexercise could be affected in

patients with T2DM, especially inthose with autonomic neuropathy.53

It should be mentioned that this find-ing is based on a single study exam-ining 27 women with T2DM52; stud-ies including large cohorts of malepatients with T2DM remain war-ranted. We conclude, therefore, thatthe Astrand-Rhyming cycling testcould be used to estimate VO2maxand changes in VO2max in patientswith T2DM, knowing that estimationerror could be present. In case ofbeta-blocker therapy, prediction ofVO2max is not feasible with theAstrand-Rhyming cycling test.

An alternative to the Astrand-Rhyming cycling test in case of beta-blocker intake is the 6MWT. This is apractical, simple submaximal testthat requires a 30-m corridor.54 Thepatient is instructed to walk as fast aspossible (verbal encouragementshould be given) for a total durationof 6 minutes and is allowed to usewalking aids.53 At the end of the test,total walking distance and Borg rat-ing of perceived exertion are noted.Normal walking distance is pre-dicted by the following formulas55:for male patients, 6-minute walkingdistance (m)�(7.57 � height [cm])–(5.02 � age)–(1.76 � weight [kg])–309; for female patients, 6-minutewalking distance (m)�(2.11 � height[cm])–(2.29 � weight [kg])–(5.78 �age)�667. By comparing the actu-ally achieved total walking distancewith this reference, level of physicalfitness level can be calculated. How-ever, the 6MWT does not estimateVO2max. Although walking capacityis significantly reduced in patientswith T2DM,56 validation studiesremain to be conducted in thesepatients. Moreover, the minimalimportant difference in walking dis-tance as a result of exercise interven-tion remains to be determined inpatients with T2DM; this measure-ment is 70 m and 43 m in patientswith chronic lung disease and

patients with heart failure, respec-tively.54 However, considering thegreat amount of literature about the6MWT,54 this test could be consid-ered in the private and home carephysical therapy settings. In thehome care physical therapy setting,the 6MWT could be used; in the pri-vate physical therapy setting, theAstrand-Rhyming cycling test isfeasible.

In conclusion, a maximal exercisetest with ergospirometry and ECGanalysis is indicated only in patientswith T2DM with greater risk of com-plications or when high-intensityexercise is prescribed. To estimateVO2max in patients with T2DM nottaking beta-blockers, the Astrand-Rhyming cycling test could be used,even though some level of error is tobe expected. To estimate functionalcapacity in patients with T2DM tak-ing beta-blockers, the 6MWT isrecommended.

Muscle strength. Muscle strengthtests should be implemented to iden-tify patients who are in need ofstrength training. In a study by Kimet al,57 a significant proportion ofpatients with T2DM (�16% preva-lence, n�414, mean age�58 years)were sarcopenic compared with age-matched individuals who werehealthy (�7% prevalence, n�446).In addition, in a study by IJzerman etal,58 muscle strength was reduced by30% to 50% in patients with T2DMcompared with their healthycounterparts.

To examine muscle strength, dyna-mometry is considered the gold stan-dard. However, considering thegreat financial cost of this device andthe required technical skills, this testis not feasible for physical therapistsworking in private and home caresettings. Feasible, low-cost, but validstrength tests are warranted for phys-ical therapists in private and home




care settings (key words: handgripstrength, sit-to-stand test, chair standtest, arm curl test, wall sit test, half-squat test, diabetes; total number ofhits�198, relevant hits�none).

The handgrip strength test showsmoderate to high correlations withextremity muscle strength asobserved during dynamometry test-ing (knee extensors, r�.43–.99),predicts prognosis, and is affected byexercise intervention, at least in indi-viduals who are healthy.59–61 How-ever, the validity of this test remainsto be examined in patients withT2DM. Therefore, we advise cautionregarding the results obtained withthis test. In this test, the patient sitson a chair with the elbow at 90degrees of flexion and with a hand-grip strength meter in the hand (thephysical therapist supports thelower arm of the patient). Next, thepatient squeezes the handgripstrength meter as hard as possible for3 seconds. This test is performed 3times, in both hands. Next, it can beobserved whether the handgripstrength is normal.61 In case of acuteor chronic injury of the arm or hand,the handgrip strength test is no lon-ger valid for estimating whole-bodymuscle strength.

Another strength test that might beconsidered to assess muscle strengthin patients with T2DM is the sit-to-stand test. Even though this testoften was used in previous stud-ies,62–64 recent data indicate that theoutcome of this test (sit-to-stand fre-quency) does not correlate withlower-extremity muscle strength, asassessed using a dynamometer, inindividuals who are healthy (whencontrolled for age: r��.02).65 Thevalidity of this test is currently underintense debate.

In elderly people, the arm curl testoften is assumed to have potentialfor assessing muscle strength in field

settings. However, a recent studyindicated that the outcome of thistest shows no correlation (r�.15)with maximal muscle strength mea-sured using a dynamometer.66 Thistest remains to be validated inpatients with T2DM. Also, the wallsit test, or half-squat test, remains tobe validated in individuals who arehealthy.67 It follows that the arm curltest and wall sit test are not pro-posed for muscle strength testing inpatients with T2DM until furthersupporting evidence is available. Inboth home care and private physicaltherapy setting, the handgripstrength test is feasible. In conclu-sion, the handgrip strength testseems to be the only applicable fieldmuscle strength test, even thoughthis test remains to be validated inpatients with T2DM.

Increasing the MedicalSafety of ExerciseIntervention in PatientsWith T2DMFrom a thorough preparticipationscreening, physical therapists areaware of conditions that mightincrease the risk of complicationsduring exercise. The exercise inter-vention should be adjusted accord-ing to these findings. However, evenafter such preparticipation screen-ing, the medical safety of exercisetraining could be further increasedby applying guidelines.5,68,69

Hyperglycemia during exercise isnot very common in stable patientswith T2DM. When a pre-exercise gly-cemia of �16.7 mmol/L (�300mg/dL) is detected, high-intensityexercise training should be post-poned until confirmation that keto-acidosis is absent. Ketone concentra-tions can be examined using urinesample strips. When concentrationsof ketones in urine samples that aretoo high are present, the patientshould be referred to a physician. Inthe absence of ketoacidosis, patients

with T2DM are allowed to performlow-intensity to moderate-intensityexercises. However, high-intensityexercise (�80% VO2max) is likely tofurther increase blood glucoselevel.69 It follows that such exerciseintensities should be avoided inpatients with T2DM who arehyperglycemic.

Hypoglycemia is a more commoncomplication during exercise train-ing in patients with T2DM. Severalrisk factors and situations should betaken into account when aiming tooptimize blood glucose levels duringexercise in patients with T2DM: typeof medication (exogenous insulintherapy and sulfonylurea intakeincrease the risk for hypoglycemia),volume of exercise and amount ofmuscle mass involved in exercisetraining (greater exercise volume ortotal muscle recruitment increasesthe risk for hypoglycemia), level ofphysical fitness, pre-exercise bloodglucose level (starting blood glucoselevel �5.5 mmol/L [�100 mg/dL]increases the risk for hypoglycemia),modalities of carbohydrate adminis-tration, nutritional status (training ina fasting condition or when skeletalmuscles are glycogen depletedincreases the risk for hypoglycemia),and patency of counter-regulatoryhormones. With regard to insulinintake, the type of insulin, timeelapsed since the last injection, formof administration, and injection site(proximity to exercising muscles)should be evaluated.68,69 Patientswith pre-exercise glycemia of �4.2mmol/L (�75 mg/dL) should con-sume monosaccharides (15 g) aheadof exercise. Those with pre-exerciseglycemia of �5.5 mmol/L (�100mg/dL) should be well aware of therisk of hypoglycemia during exer-cise. These patients should keepmonosaccharides nearby and con-sume them when symptoms of hypo-glycemia occur. Patients with T2DMreceiving exogenous insulin therapy




should adjust their insulin doseahead of exercise training to avoidhypoglycemia (Tab. 3).69 When fre-quent hypoglycemic episodes dooccur during exercise training, or indaily life, the exercise training pro-tocol, glucose intake, and medica-tion should be adjusted, in coopera-tion with a physician. It follows thatthe blood glucose content should beassessed regularly (immediatelybefore and after exercise training,and a few hours after exercise train-ing) to improve medical safety and toquantify the effect of exercise train-ing. In addition, monosaccharidesshould always be available topatients with T2DM during exercisetraining.

Patients with diagnosed retinopathyshould avoid high-intensity exercisetraining. Patients with diagnosednephropathy should be careful toavoid developing hypertension (sys-tolic blood pressure �180 mm Hg)during exercise training. In case offever or acute bacterial or viral infec-tion with clinical symptoms, exer-cise training should be postponeduntil full recovery from disease.Patients with peripheral neuropathyshould wear proper shoes. In case offoot wounds, no weight-bearingactivities should be performed. It isimportant that the feet are examinedevery week by the physical therapistto prevent development or worsen-

ing of food wounds. Patients withT2DM with autonomic neuropathytypically can develop blood pressuredisturbances (hypertension, hypo-tension) during exercise, and heartrate during exercise is significantlyaltered. In these patients, heart rateand blood pressure, at rest and dur-ing exercise, should be checked reg-ularly. Patients with T2DM who arepregnant should consult their gyne-cologist before proceeding with theexercise intervention. Exercise train-ing modalities should be adaptedaccording to findings from the ortho-pedic examination.

In the following situations and con-ditions during exercise training,patients with T2DM should bereferred to a physician: developmentor worsening of hypertension,angina pectoris, heart rhythm distur-bances, development or worseningof resting tachycardia, developmentor worsening of intermittent claudi-cation, development or worsening offasting hyperglycemia, frequenthypoglycemic episodes, develop-ment or worsening of wounds in thelower extremities, cachexia or sud-den body weight loss, developmentor worsening of autonomic neurop-athy, and development or worseningof vision disturbances.

In conclusion, medical safety of exer-cise training in patients with T2DM

can be improved when regularlyassessing blood glucose level, avoid-ing risk factors and situations forhypoglycemia, taking into accountthe presence of retinopathy ornephropathy, and referring back to aphysician in case of certain alarmingsigns.

Increasing the ClinicalBenefits of ExerciseTherapy in T2DMPhysical activity advice alone is farless effective when aiming toimprove glycemic control in patientswith T2DM, as opposed to super-vised exercise training.12 It followsthat in the treatment of T2DM,supervised exercise interventionsshould be set up. Physical therapistsare well capable of further optimiz-ing the clinical effectiveness of exer-cise intervention in patients withT2DM by adapting trainingmodalities.10

In this respect, studies indicate thatblood HbA1c content decreases orinsulin sensitivity increases with sig-nificantly greater magnitude whenincreasing exercise frequency, add-ing resistance exercises to endur-ance exercises, or prolonging exer-cise intervention.10,70 Meta-analysisindicates greater reductions in bloodHbA1c content when: increasingexercise frequency, prolonging par-

Table 3.Adjustments of Exogenous Insulin Therapy Dose Ahead of Exercise Training69

Duration and Type of Exercise Glycemia Pre-exerciseInsulin Adjustment

Pre-exercise

Extra GlucoseIntake During

Exercise

�30 min low-intensity exercise �5 mmol/L, �90 mg/dL Half dose 10–15 g

�5 mmol/L, �90 mg/dL Normal dose None

30–60 min moderate-intensity exercise �5 mmol/L, �90 mg/dL Skip 30–45 g

5–10 mmol/L, 90–180 mg/dL Half dose 15 g

�10 mmol/L, �180 mg/dL Normal dose None

�60 min moderate-intensity exercise �5 mmol/L, �90 mg/dL Skip 45 g/h

5–10 mmol/L, 90–180 mg/dL Half dose 30–45 g/h

�10 mmol/L, �180 mg/dL Half dose 15 g/h




ticipation to exercise intervention,and elevating exercise volume �150minutes/week.12

Because patients with T2DM shouldachieve a permanent increase inphysical activity, monitoring exer-cise motivation and barriers to exer-cise training is important. Physicaltherapists should regularly assess themotivation of the patient to exerciseand ask for any practical or medicalreasons that might complicate partic-ipation in an exercise intervention.Physical therapists, when possible,should intervene when barriers toexercise training emerge.

Continuous high-intensity endur-ance exercise interventions areequally effective, as opposed to con-tinuous low-intensity enduranceexercise interventions, to improveglycemic control in patients withT2DM (when matched for caloricexpenditure).10,71 It remains to beshown whether high-intensity inter-val exercise training would translateinto greater improvements in glyce-mic control in patients withT2DM.10,72 It should be mentionedthat exercise training at higher inten-sities contributes to orthopedic inju-ries and lower exercise adherence,at least in individuals who arehealthy.73 Therefore, physical thera-pists should be cautious when imple-menting high-intensity exerciseinterventions in patients with T2DM.

The addition of strength exerciseson top of endurance exercises con-tributes to a greater improvement inglycemic control in patients withT2DM.10 Recently, the impact of dif-ferent strength training modalities(intensity and volume), when com-bined with endurance exercise train-ing, was examined. The first dataindicate that high-intensity versuslow-intensity strength training con-tributes to greater improvements inmuscle strength, but does not affect

changes in muscle mass and glyce-mic control in patients with T2DM.74

Based on the recommendations fromclinical guidelines5–7 and data fromindividual relevant studies,10,70–74

the following recommendation forthe selection of training modalitiesemerges: exercise training shouldstart at a frequency of 3 days/weekand build up to 5 days/week withina few months, at a low to moderateexercise intensity (40%–70%VO2max), achieving a minimal exer-cise duration �150 minutes/week,in combination with resistance exer-cises (5–10 exercises/week, 3 series/session, 10–15 repetitions/session),and eventually leading to a perma-nently increased physical activitylevel. The required duration of anindividual exercise session, how-ever, remains unclear.10,75

Because most patients with T2DMare overweight or obese, trainingmodalities should be adapted to max-imize adipose tissue mass loss.Increasing exercise session volume(or greater total caloric expenditure)and prolonging the exercise inter-vention are effective modifica-tions.6,10,76 In addition, in thesepatients, a caloric intake restrictionintervention should be imple-mented.6,10 A greater visceral adi-pose tissue mass loss is instrumentalto augment improvements in glyce-mic control in patients with T2DM.77

In case of sarcopenia, the volume ofstrength training should be sufficientor elevated.

A great challenge in exercise inter-ventions for patients with T2DM ishow to properly determine endur-ance exercise intensity. Consideringthe potential prevalence of auto-nomic neuropathy and obesity andintake of beta-blockers, using heartrate for determining exercise inten-sity might be complicated in patientswith T2DM.53,78 It is advised, there-

fore, to take the resting heart rateinto account and to calculate theheart rate reserve for more accurateendurance training intensity determi-nation in patients with T2DM.79 Inthis method, the resting heart rate isassessed after the patient has beensitting for at least 5 minutes. Next,the target heart rate (HR) can be cal-culated with following formula:((maximum HR�resting HR) � %intensity))�resting HR. This methodshows a greater validity for the deter-mination of endurance exerciseintensity in patients with T2DM, asopposed to ratings of perceivedexertion.79,80

Blood HbA1c content should beassessed to determine the clinicaleffectiveness of exercise interven-tion in patients with T2DM. It is com-mon practice to assess fasting bloodglucose content in the follow-up ofthese patients. However, blood glu-cose level is affected by physicalactivity and food pattern during thepreceding 24 hours, hydration sta-tus, and even acute psychologicalstress. It follows that changes inblood glucose level are not necessar-ily related to the effects of exerciseintervention. Blood glycosylatedhemoglobin, on the other hand, isnot affected by these acute factors.

ConclusionsExercise interventions are highlyeffective in improving glycemic con-trol in patients with T2DM. In thisregard, clinical guidelines have beenpublished. However, these guide-lines are not always applicable tophysical therapists working in pri-vate and home care settings. In thepresent recommendation, a feasible,valid, and effective approach is for-mulated for physical therapists work-ing in private and home care settingsfor the implementation of exerciseintervention in patients with T2DM.By following these recommenda-tions, the clinical effectiveness and




medical safety of exercise trainingwill be improved.

D. Hansen, PT, PhD, Hasselt University, Fac-ulty of Medicine and Life Sciences, Agora-laan, Building A, 3590, Diepenbeek, Bel-gium; Heart Centre Hasselt, Jessa Hospital,Hasselt, Belgium; and Flemish WorkingGroup from AXXON (Belgian Physical Ther-apy Association), Antwerp, Belgium. Addressall correspondence to Dr Hansen at:[email protected].

S. Peeters, PT, Flemish Working Group fromAXXON.

B. Zwaenepoel, PT, Flemish Working Groupfrom AXXON; Ghent University, Faculty ofMedicine and Life Sciences, Ghent, Belgium;and Department of Cardiopulmonary Reha-bilitation, Algemeen Ziekenhuis Jan Palfijn,Ghent, Belgium.

D. Verleyen, PT, Flemish Working Groupfrom AXXON.

C. Wittebrood, PT, Flemish Working Groupfrom AXXON.

N. Timmerman, PT, MSc, Flemish WorkingGroup from AXXON

M. Schotte, PT, Flemish Working Groupfrom AXXON.

[Hansen D, Peeters S, Swaenepoel B, et al.Exercise assessment and prescription inpatients with type 2 diabetes in the private andhome care setting: clinical recommendationsfrom AXXON (Belgian Physical Therapy Asso-ciation). Phys Ther. 2013;93:xxx–xxx.]

© 2013 American Physical Therapy Association

All authors provided concept/idea/projectdesign. Dr Hansen, Mr Peeters, Mr Zwaene-poel, and Ms Wittebrood provided writing.Dr Hansen provided project management.Dr Hansen, Mr Peeters, Mr Zwaenepoel, MsWittebrood, Ms Timmerman, andMr Schotte provided consultation (includingreview of manuscript before submission).

The authors received financial support fromAXXON in the preparation of themanuscript.

Published Ahead of Print: February 7, 2013Accepted: February 4, 2013Submitted: October 2, 2012

DOI: 10.2522/ptj.20120400

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doi: 10.2522/ptj.20120400Originally published online February 7, 2013

Published online February 7, 2013PHYS THER. Timmerman and Michel SchotteZwaenepoel, Dirk Verleyen, Carla Wittebrood, Nicole Dominique Hansen, Stefaan Peeters, Bruno(Belgian Physical Therapy Association)Setting: Clinical Recommendations From AXXONWith Type 2 Diabetes in the Private and Home Care Exercise Assessment and Prescription in Patients

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With Type 2 Diabetes in the Private and Home Care ... · Recommendations From AXXON (Belgian Physical Therapy Association) Dominique Hansen, Stefaan Peeters, Bruno Zwaenepoel, Dirk