Exercise Assessment and Prescription in Patients With Type 2 Diabetes in the Private and Home Care Setting: Clinical Recommendations From AXXON (Belgian Physical Therapy Association)

Type 2 diabetes mellitus (T2DM) is a disease associated with many complications: the likelihood for the development of heart disease or stroke is elevated twofold to fourfold, and the prevalence of hypertension, retinopathy, and neuropathy in patients with T2DM is approximately 70%, 28%, and 60% to 70%, respectively. Moreover, T2DM is the most important cause of kidney failure and need for nontraumatic lower-limb amputation.1 Eventually, life expectancy is reduced by about 8.2 and 7.5 years in men and women, respectively, when T2DM is diagnosed at the age of 50 years.2 In addition to the hazardous effects of T2DM on health, economic and financial consequences of this disease have been described: health care–related costs are approximately twofold to threefold higher in patients with T2DM, as opposed to their healthy counterparts, not taking into account the economic costs related to absenteeism and lowered economic productivity.3 Recent statistical models indicate that the prevalence of T2DM will increase exponentially in the next few decades.4 The total number of patients with diabetes is projected to rise from 171 million in the year 2000 to 366 million in the year 2030.4 As a result, it is important to prevent T2DM and optimize medical treatment of T2DM to prevent the development of diabetes-associated complications and health care–related and economic costs. In the care of people with T2DM, exercise intervention—besides pharmacologic treatment and caloric intake restriction—is considered a cornerstone. According to clinical guidelines, people with T2DM should permanently (lifelong) exercise 3 to 5 days a week, at a low to moderate intensity (40%–70% of maximum oxygen uptake [V̇o2max] or 50%–70% of maximal heart rate), achieving a minimal exercise duration of 150 minutes a week, and endurance exercises should be combined with resistance exercises (5–10 exercises per session, 3 series per exercise, 10–15 repetitions per series).5–7 Even though these guidelines are useful to physical therapists implementing exercise interventions in patients with T2DM, 2 major concerns still emerge. First, it remains to be described, in detail, what is the impact of a different selection of training modalities (exercise intensity, frequency, and duration; type of exercise; program duration) on the clinical effectiveness of exercise intervention in these patients.5,7 Second, and most importantly, it remains to be described how physical therapists, working in private and home care settings, need to implement these programs. More specifically, it remains to be described how to execute a preparticipation screening, how to screen for diabetes-associated complications, and how to increase the medical safety of exercise intervention, with the limited space and equipment that are available in private and home care physical therapy settings. It follows that guidelines for exercise therapy in T2DM5,7 need to be adapted to become applicable for physical therapists working in private and home care settings. Considering the exponential increase in prevalence of T2DM, it is very likely that physical therapists working in private and home care settings will be confronted more frequently with patients with this disease in the near future. Accordingly, approximately 80% of all patients visiting physical therapists in outpatient settings have diabetes, prediabetes, or risk factors associated with diabetes.8 These patients are at elevated risk for microvascular and macrovascular complications, retinopathy, nephropathy, and neuropathy.9 It follows that awareness of medical safety and knowledge of the impact of exercise modalities in these patients needs to be increased in physical therapists working in private and home care settings. The intention of this clinical recommendation is to describe a systematic, effective, and feasible approach for physical therapists, working in private and home care settings, who implement exercise interventions in patients with T2DM. With this approach, physical therapists are better capable to prescribe clinically effective and medically safe exercise interventions for these patients. The present recommendation consists of 4 main topics: (1) impact of exercise intervention in T2DM, (2) preparticipation screening, (3) increasing medical safety of exercise intervention, and (4) increasing the clinical benefits of exercise intervention. This recommendation has been developed within the Flemish Working Group of AXXON (Belgian Physical Therapy Association). AXXON is the only officially recognized trade union for Belgian physical therapists and is a member of the World Confederation for Physical Therapy (WCPT). AXXON aims to increase the quality of physical therapy in Belgium (stimulate evidence-based practice), to govern professional practice, and to provide education at the national level. The aim of the present recommendation is to increase medical safety and clinical effectiveness of exercise intervention in T2DM when implemented by physical therapists working in private and home care settings. Moreover, with this document, AXXON aims to stimulate physical therapists to implement evidence-based preparticipation tests and exercise interventions in the management of T2DM. To select proper preparticipation tests, it was first established which tests were necessary for physical therapists working in private and home care settings. In this selection, 2 criteria were handled: (1) tests should be feasible and (2) tests should be valid. Feasible tests were considered as those that could be executed in private and home care physical therapy settings, with minimum time investment and without need of expensive or large materials. Throughout this article, a difference between private and home care settings will be made in the selection of these tests. Valid tests were considered as those that actually measure what the physical therapist aims to measure. A preparticipation test was selected only when all members of the AXXON Working Group agreed. 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