What is the appropriate physiotherapy management for a medically stable adult with type 2 diabetes mellitus?

Physiotherapy Management of Type 2 Diabetes Mellitus

Core Exercise Prescription

Adults with type 2 diabetes must engage in at least 150 minutes per week of moderate-to-vigorous aerobic exercise spread over a minimum of 3 days, with no more than 2 consecutive days without activity, combined with resistance training 2-3 times weekly on nonconsecutive days. 1, 2

Aerobic Exercise Protocol

• Frequency: Exercise most days of the week, never allowing more than 2 consecutive days between sessions to maintain insulin sensitivity 1
• Duration: Each aerobic bout should last at least 10 minutes, building toward 30 minutes per session 1, 2
• Intensity: Moderate intensity (40-60% VO2max), equivalent to brisk walking where conversation is possible but challenging 3, 4
• Modalities: Walking, cycling, swimming, dancing, yoga, housework, and gardening all count toward aerobic targets 1, 2

The 2-day maximum gap between sessions is critical because the acute insulin-sensitizing effects of exercise fade rapidly, typically within 48-72 hours 1, 4. Higher exercise intensities produce greater improvements in HbA1c and cardiorespiratory fitness 1.

Resistance Training Protocol

• Frequency: 2-3 sessions per week on nonconsecutive days 1, 2
• Exercises: Target major muscle groups including chest press, rows, squats, leg press, shoulder press, lat pulldown, leg curls, leg extensions, and core exercises 2
• Volume: At least 1 set of 5-10 different exercises, with 10-15 repetitions per set 3, 2
• Intensity: Start at moderate intensity (50% of 1-repetition maximum), progressing as tolerated 2

Resistance training of any intensity improves strength, balance, glycemic control, and ability to perform activities of daily living, even if patients cannot tolerate heavy weights 1.

Breaking Sedentary Behavior

Interrupt prolonged sitting every 30 minutes with brief standing, walking, or light physical activity. 1, 2

This strategy provides independent glycemic benefits beyond structured exercise sessions and helps prevent insulin resistance 1, 4. Reducing sedentary time (computer work, television watching) is as important as adding structured exercise 1.

High-Intensity Interval Training (HIIT)

For patients capable of vigorous exercise, HIIT involves short bursts (10 seconds to 4 minutes) at 65-90% VO2peak with recovery periods, requiring only 75 minutes weekly to achieve similar benefits as 150 minutes of moderate exercise 1. This time-efficient modality produces significant physiologic and metabolic adaptations 1.

Pre-Exercise Safety Assessment

Before initiating exercise programs, assess for:

• Cardiovascular risk: Uncontrolled hypertension, history of coronary artery disease, atypical chest symptoms 1
• Retinopathy: Proliferative or severe nonproliferative retinopathy contraindicates vigorous exercise due to vitreous hemorrhage or retinal detachment risk 1
• Neuropathy: Peripheral neuropathy requires proper footwear, daily foot examinations, and consideration of non-weight-bearing activities 2, 4
• Autonomic neuropathy: May affect cardiovascular response to exercise 1
• Foot complications: History of ulcers or Charcot foot requires modified exercise selection 1

Routine cardiac stress testing is not recommended for asymptomatic patients, but careful history and cardiovascular risk assessment are essential 1, 3.

Hypoglycemia Prevention

For patients on insulin or insulin secretagogues:

• Monitor glucose before, during, and after exercise 2
• Ingest carbohydrates if pre-exercise glucose is <90 mg/dL (5.0 mmol/L), unless insulin doses can be reduced 1, 4
• Adjust medication timing and dosing around exercise sessions 1, 2
• Recognize delayed hypoglycemia can occur hours after exercise due to increased insulin sensitivity 4

The medication dose or carbohydrate consumption must be altered to prevent exercise-induced hypoglycemia 1.

Special Considerations for Diabetic Complications

Peripheral Neuropathy

Integrated exercise combining massage, foam rolling, aerobic training, and resistance exercise improves glycemic control and peripheral sensation in diabetic neuropathy 5. Exercise programs reduce neuropathic pain scores (Michigan neuropathy score reduction: Standardized Mean Difference -2.92) 6. Massage and foam rolling before aerobic/resistance work may improve blood circulation and sensation in neuropathic areas 5.

Peripheral Artery Disease

Supervised exercise therapy is superior to unsupervised programs for diabetic patients with PAD 7, 8. When supervised settings are unavailable, combine supervised sessions with home-based regimens 7. Target more than 3 days per week, progressively extending duration weekly to improve walking function, exercise tolerance, pain, and quality of life 7, 8.

Expected Outcomes

• HbA1c reduction: Structured exercise of at least 8 weeks reduces HbA1c by an average of 0.66%, even without significant weight loss 2
• Cardiovascular benefits: Moderate to high volumes of aerobic activity substantially lower cardiovascular and overall mortality risks 2
• Insulin sensitivity: Exercise improves insulin action regardless of weight loss 2
• Additional benefits: Improvements in blood pressure, lipid profile, triglycerides, LDL, waist circumference, and overall well-being 1, 2

Critical Implementation Pitfalls to Avoid

• Underestimating intensity: Walking must be "brisk" to qualify as moderate intensity; casual strolling is insufficient 3, 4
• Omitting resistance training: This component provides substantial metabolic benefits independent of aerobic exercise 3, 2
• Excessive rest periods: More than 2 consecutive days without exercise eliminates acute insulin-sensitizing effects 1, 4
• Inadequate footwear: All patients with peripheral neuropathy must wear proper footwear and examine feet daily 2, 4
• Ignoring medication adjustment: Failure to adjust insulin or carbohydrate intake leads to exercise-induced hypoglycemia 1

Progression Strategy

Start with short periods of low-intensity exercise for previously sedentary patients, slowly increasing intensity and duration as tolerated 1. Progress stepwise toward meeting the 150 minutes/week target over time 1. Medical monitoring may be indicated as patients intensify their programs to ensure safety and evaluate effects on glucose management 1.