The SA Journal Diabetes & Vascular Disease Vol 11 No 3 (September 2014) - page 10

Correspondence to: Heidi Shanahan
Physiotherapy Department, Grey’s Hospital, Pietermaritzburg
S Afr J Diabetes Vasc Dis
: 104–107
An overview of the role of physiotherapy in managing
diabetes and diabetes-associated conditions
Heidi Shanahan
lthough physiotherapists usually encounter diabetes as a
secondary condition in patients during the evaluation and
treatment of movement, functional and musculoskeletal
disorders, physiotherapy is both a curative and preventative
discipline that employs a holistic approach to healthcare.
Physiotherapists in South Africa can utilise their knowledge
of therapeutic exercise and preventative care, so contributing to
addressing the challenges of non-communicable disease and
the increasing burden this is placing on healthcare resources.
Involvement in primary healthcare embraces health promotion,
which encourages the patient to share responsibility for optimal
health outcomes and adopt beneficial behavioural changes and a
healthy lifestyle, and to better self-manage his/her condition.
Physiotherapists may encounter patients with impaired glucose
tolerance or insulin resistance (pre-diabetes), early diabetes with
no or minimal vascular changes, and more advanced disease
with several vascular complications, as well as complications that
include involvement of the musculoskeletal system. Some of these
musculoskeletal conditions are commonly seen by physiotherapists,
who may not be aware of the impact of diabetes on the condition.
Micro- and macrovascular complications affect several organs
including the muscle, skin, heart, brain and kidneys.
Even though conditions such as diabetic neuropathy, retinopathy,
nephropathy and cardiovascular and peripheral vascular diseases
may not be the reason for the physiotherapy intervention, it is
important for the physiotherapist to be aware of the underlying
vascular deficits when providing treatment for musculoskeletal
and movement disorders. In addition, physiotherapists can play
an important role in the care of people with diabetes because
interventions such as exercise prescription and promoting increased
physical activity can assist in alleviating symptoms, slow metabolic
progression to overt type 2 diabetes and reduce morbidity and
mortality associated with these complications.
Musculoskeletal manifestations of diabetes
Assessment and management of the patient should include
questions regarding the presence of diabetes and glycaemic control,
and relevant patient education and exercise prescription, as well as
referral for review to other disciplines (e.g. dietitian, podiatrist) if
Adhesive capsulitis
This is alsoknownas frozen shoulder, andhas been reportedas having
greater incidence among patients with insulin-dependent diabetes,
with increased frequency of bilateral shoulder involvement.
The condition is characterised by three phases: painful (pain is
dominant), adhesive (stiffness dominates), and resolution, which
may take two to three years to complete. Adhesive capsulitis is
considered to be a self-limiting condition, but many patients never
regain normal shoulder mobility.
Physiotherapy treatment of adhesive capsulitis aims to relieve
pain, maintain or improve active and passive range of motion
(ROM) and restore function. The modalities include exercise,
electrotherapy, mobilisation techniques and hydrotherapy.
et al.
concluded that a single intra-articular injection
of corticosteroid administered under fluoroscopy combined with
a simple home exercise programme was effective in improving
shoulder pain and disability in patients with adhesive capsulitis.
Adding supervised physiotherapy provided faster improvement
in shoulder range of motion. When used alone, supervised
physiotherapy was of limited efficacy.
Patients with greater disability levels, more co-morbidities, high
fear and anxiety levels, lower educational levels, and those who
have less social support may benefit more from formal supervised
Patient education about the progression of
restricted motion and extended time to recovery is an important
aspect of treatment.
Carpal tunnel syndrome
The symptoms of parasthesia over the median nerve’s cutaneous
distribution may be caused by compression of the median nerve
in the carpal tunnel, by diabetic neuropathy, or a combination of
About 5–8% of patients with carpel tunnel syndrome have
diabetes, and it is more common in women than men.
Physiotherapy treatment of carpal tunnel syndrome with
ultrasound can provide satisfying short- to medium-term effects in
patients with mild to moderate idiopathic carpal tunnel syndrome.
Digital flexor tendon-mobilising techniques have been shown to be
helpful in the management of pre- and postoperative carpal tunnel
In addition, physiotherapists and occupational therapists can
offer advice on task modification and ergonomics, which will often
control mild or moderate symptoms of carpal tunnel syndrome.
The pressure in the carpal tunnel is lowest in neutral wrist flexion
extension range, with the pressure rising significantly as the wrist
is moved into flexion or extension. Splints that hold the wrist in the
neutral position are often helpful in controlling symptoms of mild
to moderate severity.
Depuytren’s contracture
This is palmar or digital thickening, tethering or contracture of
the hands. In patients with diabetes, the middle and ring finger
are more commonly affected, compared with the fifth finger in
patients without diabetes. Physiotherapy intervention comprises
a hand therapy programme with the aim of optimising ROM,
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