2.1. The diabetic care pathway

prevalence will likely to be twice as much as the current prevalence by the year 2030. The type 2 diabetes mellitus is the most common type of diabetes and accounts for 90–95% of overall diabetes cases [5, 6]. The number of adults with DM in the world elevated from 108 million to

As the diabetes epidemic grows in size and complexity, there is an increasing realization that physicians alone are unable to provide the care required by people with diabetes. To help them live life to the fullest, people with DM need to have an integrated and interdisciplinary rehabilitation team consisting a range of healthcare personnel, including physiotherapists, psychologists and eye specialists. Diet, medication, physical activity and education play a significant role

Most individuals with diabetes mellitus will visit a physical therapist in the multidisciplinary clinic where they receive care for their DM-related problems. Physical therapists are professionally allowed to exercise in several treatment settings including acute care, nursing home and inpatient and outpatient rehabilitation settings. Physical therapists also work in conjunction with the rehabilitation team to design components of community-based rehabilitation strategy so as to enhance physiological, anatomical and psychosocial outcomes [10] (Figure 1). Physical therapy is a thus corner stone of prevention and treatment of diabetes mellitus. Physical therapy-directed movement and exercise programs are clinically effective in helping diabetic patients to produce the desired health-related quality of life (HRQOL) outcomes [11].

for the prevention, rehabilitation and self-management of diabetes mellitus [5, 8, 9].

Figure 1. The multidisciplinary rehabilitation team approach centres on the patient and caregiver.

422 million between 1980 and 2014 [7].

168 Diabetes Food Plan

It is the right of people with diabetes mellitus to expect a timely, accessible and of uniformly high-quality care. However, diabetes care is complex and multidirectional due to their multifaceted needs [13–16]. It should be delivered in a wide range of clinical settings by healthcare professionals from diverse backgrounds and with diverse skills. The diabetic care pathway improves the delivery of effective care, facilitate critical evaluation of that care and strengthen multidisciplinary communication [17]. They promote a uniform standard of care delivery in a wide variety of clinical settings (Figure 2).

#### 2.2. General concept of physical therapy

Physical therapists must undergo assessment based on the International Classification of Functioning, Disability and Health (ICF) model before, during and after physical therapy for each diabetic patient (Figure 3). ICF enables physical therapists to identify and analyze problems to provide diabetic patients with therapy. Diabetic patients have many problems caused by diabetes itself and its associated complications. Physical therapy assessment should include

Figure 2. The integrated diabetes care pathway.

physical assessment findings, or objective data of diabetes mellitus patients can be obtained through the use of three specific diagnostic techniques: Observation, palpation and physical examination. An assessor physiotherapist has to quantify levels of impairment, physical activity limitation and participation restrictions of DM patients. The active and passive range of motion, the sensory integrity, the muscle power, balance, walking pattern and other gross motor activities

Exercise and Diabetes Mellitus

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http://dx.doi.org/10.5772/intechopen.71392

3.1. Physical activity for persons at higher risk of developing type 2 diabetes mellitus

Different clinical practice guidelines and systematic reviews agreed that participation in lifestyle therapy that includes regular physical activity should be the first line of defense against T2D development from a state of pre diabetes [23–26]. Both aerobic and anaerobic forms of physical activity have also various beneficial effects on metabolism in a number of tissues and organs, including skeletal muscle, adipose, liver, pancreas and even brain. Exercise may increase body's response to intrinsic insulin, by multiple mechanisms including [27, 28].

The American Diabetes Association states that simple lifestyle measures have been shown to be effective in preventing or delaying the onset of type 2 diabetes. To help prevent type 2 diabetes and its complications, people should be physically active at least 30 minutes of

Several large-scale clinical trials have established that about 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity per week, such as brisk walking, with no more than 1 or 2 days off in a row, reduces the risk of developing type 2 diabetes

People with prediabetes can be taught physical activities to use their body weight as resistance. They can also use mechanical devices like machines. Major muscle groups of both the upper and lower extremities such as the quadriceps, hamstrings, calves, abdominals, biceps, triceps and forearms should be trained to build their girth and strength. Physical activity guidelines vary on intensity and frequency of prescribing such exercises. The frequency and intensity of exercises should be designed based on an individual's observed capacity to continue the

Resistance exercise can be performed 2 or 3 times per week for 30–60 min per session. It increases muscle mass, elevates resting metabolic rate, enhances muscular endurance, increases insulin sensitivity and attenuates muscle mass loss during caloric restriction and

A systematic review done on the effectiveness of combined diet and physical activity for the prevention of type 2 diabetes stated that combined diet and physical activity promotion programs are effective at decreasing diabetes incidence and improving cardio metabolic risk factors in persons at increased risk. It stated that the more the intensive programs are the more

of diabetes mellitus patients should also be evaluated and objectified.

3. Physical rehabilitation in diabetes mellitus patients

regular, moderate-intensity activity on most days [16, 17, 29].

regardless of the degree of adiposity [30–34].

program [16, 35].

aging [31, 36].

effective will be [37].

Figure 3. International Classification of Functioning, Disability, and Health.

sensory integration, motor control and manual muscle testing (MMT), range of motion (ROM), balance test, endurance test, ADL test and participation in social affairs.

Physical therapists should be aware that diabetic patients are exposed to various risks such as infections and bedsores.

The importance of different modes of exercises in patients with type 2 diabetes is emphasized by increasing uptake of glucose by muscles, improving utilization, altering lipid levels, increasing high density lipoprotein and decreasing triglyceride and total cholesterol. Thus exercise helps people to overcome disability by preventing, treating and rehabilitating neuromuscular complications like neuropathies, skin break down, foot ulcers, arthritis, other joint pains, frozen shoulder, back pain and osteoarthritis associated with DM [17–20]. Moderate to high levels of different modes of exercises like cardio respiratory fitness exercises, aerobic exercise and progressive resistance exercises are also associated with substantially lower morbidity and mortality in men and women with diabetes. [11, 12, 15].

#### 2.2.1. Subjective assessment

An effective problem-solving approach exploits historical data and information gathered from a basic screening physical examination in a problem-oriented method to guide further investigation. Subjective assessment is an explanation which describes the patients self-report of their current status in terms of their function, disability, symptoms and history. Problem-oriented assessment forms should be used to record the relevant patient reported data, clinical investigation and physical examination results. Record-keeping is an essential component of patient management. It is used for follow-up and evaluation. Taking a full history of the present condition and its possible risk factors, such as smoking, hypertension, obesity, hyperlipidemia and family history is so imperious. Asking for the other symptoms of neuropathic complications such as numbness, joint pain and muscle weakness will also help to evaluate the biopsychosocial context, severity and nature of the patients' current DM state [21, 22].

#### 2.2.2. Objective measurement

Objective assessment should be done routinely to test and objectify the patient identified problems by using appropriate equipments and outcome measurement tools. In physiotherapy, physical assessment findings, or objective data of diabetes mellitus patients can be obtained through the use of three specific diagnostic techniques: Observation, palpation and physical examination. An assessor physiotherapist has to quantify levels of impairment, physical activity limitation and participation restrictions of DM patients. The active and passive range of motion, the sensory integrity, the muscle power, balance, walking pattern and other gross motor activities of diabetes mellitus patients should also be evaluated and objectified.
