Educators’ Perspectives on the Teaching and Learning of Type 2 Diabetes Content in Physiotherapy Programmes across Canada

Abstract

Purpose:

This qualitative descriptive study researched educators’ perspectives of type 2 diabetes (T2D) Teaching and learning, in physiotherapy (PT) programmes across Canada.

Methods:

Faculty members and clinical instructors from the 15 PT programmes in Canada were contacted. Online surveys collected data on the educators’ professional background and perspectives on T2D in the PT curriculum. One-on-one telephone interviews were conducted and thematic analysis was used to generate themes and codes from the interview transcripts.

Results:

Ten educators from 10 universities completed the survey. Seven of the 10 educators also participated in a telephone interview. Survey responses revealed that T2D content is taught predominantly through case studies and lectures. Of the 10 respondents, six reported that the curriculum does not devote adequate time to T2D content, and nine reported they “strongly agree” or “agree” that T2D is an essential component of the PT curriculum. The interviews revealed that T2D content varies across PT programmes. The educators agreed that T2D is a common condition seen in practice, there is a role for PT intervention, and T2D content is limited by classroom time.

Conclusions:

Educators noted challenges integrating more T2D content in the curriculum and said that PT clinical contributions for people living with T2D are underutilized. Additional evidence-informed rationale is needed to explore optimal integration of T2D content in PT programmes.

Diabetes affected 3.4 million Canadians in 2015 with the prevalence expected to increase to 5 million by 2025.¹ Type 2 diabetes (T2D), consisting of 90% of all diabetes cases, is characterized by hyperglycemia due to impaired insulin secretion or action.¹ People living with T2D are at risk of microvascular and macrovascular complications including peripheral neuropathy, retinopathy, nephropathy, cardiovascular disease, and stroke.^1,2 Poorly controlled diabetes is the leading cause of non-traumatic lower limb amputations and cardiovascular disease in Canada.¹ Health care professionals including physicians, nurses, and dietitians are trained to provide T2D care consisting of lifestyle counselling, medication adherence, and self-monitoring techniques.³ Counselling interventions (compared to usual care) have shown significant reductions in glycated hemoglobin (HbA1c),^4,5 but they do not address the decreased fitness and mobility in this population that can lead to disability, mortality, and a loss of independence.⁶ A prospective observational study reported an inverse relationship between aerobic fitness and risk of all-cause mortality in 1,263 men with T2D; compared to active men, sedentary men were at a 2.1 fold increased risk of all-cause mortality.⁷ However, each metabolic equivalent of tasks resulted in a 25% reduction in all-cause mortality (p < 0.001).⁷ As well, a randomized controlled trial (RCT) reported improved timed up-and-go scores (p = 0.032); ankle muscle strength (p = 0.031); and knee range of motion (p = 0.001) after the 143 participants with diabetic peripheral neuropathy completed a two-month physiotherapist-led strength and balance home exercise programme compared to standard medical care.⁸ Therefore, the literature suggests there is a role for physiotherapists in the management of T2D through exercise prescription.

A recent systematic review exploring the role of a mul-tidisciplinary team in managing T2D identified a gap in shared roles and suggested incorporating physiotherapists as a primary health care professional.⁹ Physiotherapists can contribute to the management of T2D through patient education, and the prescription and supervision of safe exercise. A 12-week community education and exercise programme for 36 adults with T2D supervised by a physiotherapist reported clinically significant improvements in the six-minute walk test (mean difference = 87m; p ≤ 0.01) and waist circumference (mean difference = −3 cm; p ≤ 0.05).¹⁰ As well, no intervention -related adverse events occurred, highlighting that supervised exercise is safe for people with T2D and physiotherapist-led exercise programmes can lead to improvements in function and mobility.¹⁰

Physiotherapists have the education and skills to treat patients with non-communicable diseases, such as T2D, as the primary condition. For referral through early non-pharmacological management in a holistic, individualized care approach.^11,12 Furthermore, a meta-analysis reported lifestyle modification through nutrition and exercise was the first line of defense for the prevention of T2D in high-risk individuals, with an odds ratio (OR) of 0.65 for developing T2D in the lifestyle group compared to standard care (95% CI: 0.56, 0.75).¹³ Exercise alone was also effective in preventing T2D compared to standard education interventions with an OR of 0.45 (95% CI: 0.24, 0.84).^{1 3}

The Canadian Council of Physiotherapy University Programs (CCPUP) classifies T2D as a level 1 metabolic condition, meaning entry-to-practice physiotherapists are expected to be knowledgeable about the aetiology, pathophysiology, clinical presentation, differential diagnoses, prognosis, medical or surgical management, and PT interventions for T2D.¹⁴ However, it is unknown how T2D content is currently being taught in entry-to-practice physiotherapy programmes in Canada.

A survey study explored the beliefs and practices of Canadian physiotherapists in the treatment and management of T2D.¹⁵ Physiotherapists were confident with exercise education; however, they lacked confidence providing education on secondary prevention, weight management, blood glucose control, and nutrition.¹⁵ Only 32.4% of the 401 physiotherapists who participated in the study provided T2D counselling.¹⁵ Furthermore, a recent survey study on physical activity and exercise counselling among physiotherapists in Nova Scotia reported that physiotherapists are most comfortable providing counselling for patients with musculoskeletal (MSK) injuries and least comfortable for other conditions including insulin-dependent diabetes.¹⁶

Research suggests physiotherapists can play a valuable role in the management of T2D through patient education, monitoring patient outcomes, and the prescription and supervision of safe exercise. However, despite T2D being a level 1 metabolic condition according to CCPUP, practising physiotherapists are not confident providing specific education and exercise prescription for their patients with T2D. To begin to address the gap between the expectations of physiotherapists and their knowledge of T2D, we sought to explore and describe the approaches to the teaching and learning, of T2D content in the entry-to-practice PT programs across Canada.

Methods

We employed a qualitative descriptive design using an online survey and telephone interviews. Email notification of an online survey in English was sent to the programme chairs of Canadian PT programmes (n = 15) with a request to distribute the survey link to faculty or clinical instructors responsible for teaching T2D content in the curriculum or who were knowledgeable about it. Western University’s Health Science Research Ethics Board approved the study. Providing consent to the online letter of information and consent triggered access to the survey. On completion of the survey, the respondents were asked to provide email contact information indicating permission to be contacted for a telephone interview.

Data collection

Online survey

We designed a 24-item online Qualtrics^XM (Qualtrics 2019, Provo, UT) survey to explore the educators’ experience with teaching T2D in the academic curriculum and their perspective on student preparedness for entry-to-practice. As a guide, we used an online survey designed by Bramley and colleagues¹⁷ addressing motor learning content in PT curriculum. We then created questions addressing T2D curriculum, educators’ opinions of the importance of teaching T2D, confidence teaching T2D content, and preparedness of students for assessment and treatment of people living with T2D. The survey included multiple choice, 5-point Likert scale (1 = not confident, 5 = very confident), level of agreement, and open response textbox questions.

Interviews

We conducted, audiotaped, and transcribed verbatim one-on-one semi-structured telephone interviews. The interview guide focused on T2D content in the curriculum, educators’ thoughts on T2D in the curriculum, and the role of physiotherapists in the management of T2D. Examples of an interview questions were: “Tell me about your experience treating patients with T2D.”“What aspects of T2D do you teach in your course?” We invited all of the educators to participate in a second interview to deepen our understanding of emerging themes. Examples of second interview questions were: “How do you prioritize T2D in your course?” “What are the skills and behaviours that students need to develop to address primary prevention of T2D?”

Data analysis

We downloaded the completed online Qualtrics^XM surveys to Microsoft Excel (Microsoft Corporation, Redmond, WA) and summarized the data using descriptive statistics. Then we read and reread the interview transcripts with the research question guiding what we wanted to know from the data. Thematic analysis¹⁸ was employed to analyze interview transcripts. We performed initial coding that was both descriptive and interpretive, and collected excerpts from the data for each initial code generated.¹⁸ Then we grouped similar codes together to generate broader themes and checked the themes against the initial codes to ensure coherency.¹⁸ We took an inductive approach to data analysis to develop participant experiences into representational themes.^19,20 We met repeatedly throughout the analysis of the interviews to compare identified patterns and work together to sort the patterns into themes. The meetings included discussion and collaboration in identifying the final themes, naming of the themes, and choosing representative quotations for themes. Throughout the interview analysis, the meetings served to ensure that the generated themes remained close to the data and were not guided by the researchers’ interests. It is important to note that the researchers analyzed the transcripts with different perspectives. Two authors are instructors in a master of PT programme, and the other is a student in a master of PT programme with an interest in T2D research.

We performed data collection and analysis concurrently, which modified the interview guide to focus on emerging themes. Second interviews allowed an opportunity for member checking and seeking clarification on emerging themes.²⁰ No new themes emerged from the second interviews. We discussed codes and themes and reached a consensus.

Results

Online survey

Ten participants from 10 PT programmes in Canada’s Atlantic, Central, Prairie, and West Coast regions completed the online survey. The respondents represented both English- and French-speaking schools. The participants were those who were assigned to teach T2D content or who served as the curriculum committee chair and were knowledgeable of the PT profession in Canada. Participant characteristics are summarized in Table 1. Table 2 provides a summary of T2D content and educators’ perspectives about T2D in their PT programme. All participants emphasized the incorporation of problem-or case-based learning in their programmes, with case studies and lecture content the most commonly reported methods of T2D content delivery.

Table 1.

Participant Characteristics (n = 10)

Characteristic	No. (%)
Highest level of education completed
Bachelor’s	2 (20)
Master’s	3 (30)
PhD	5 (50)
Highest level of PT education
Bachelor’s	7 (70)
Master’s	3 (30)
Clinical experience (y)
< 5	1 (10)
5–10	0 (0)
11–15	1 (10)
16–20	3 (30)
> 20	5 (50)
Main area of clinical practice
Cardiorespiratory	4 (40)
MSK	2 (20)
Geriatric	2 (20)
Sport	1 (10)
Multisystem	1 (10)
Years of teaching experience
< 1	1 (10)
1–5	3 (30)
6–10	2 (20)
> 10	4 (40)
Position at current institution
Part-time instructor	2 (20)
Lecturer	3 (30)
Assistant professor	2 (20)
Associate professor	2 (20)
Professor	1 (10)
Main teaching area
Cardiorespiratory	3 (30)
MSK	2 (20)
Orthopaedic	1 (10)
Geriatric	1 (10)
Chronic disease	1 (10)
Limb loss	1 (10)
Multisystem	1 (10)

MSK = musculoskeletal.

Table 2.

T2D Content and Educators’ Perspectives from the Online Survey (n = 10)

Question	No. (%) of responses
What year of the PT programme do you teach T2D content? (Select all that apply.)
1	6 (46)
2	7 (54)
How many total hours of T2D content do you teach?
< 5	7 (70)
5–10	2 (20)
> 10	1 (10)
What area of T2D do you teach in your course(s)? (Select all that apply.)
Rehabilitation	7 (29)
Cardiorespiratory	6 (25)
MSK	5 (21)
Neurological	5 (21)
Public health	1 (4)
Which of the following topics do you cover regarding T2D content? (Select all that apply.)
Exercise	8 (20)
Diabetes complications and comorbidities	8 (20)
Blood glucose control	7 (17)
Physiology	7 (17)
Weight management	6 (15)
Nutrition	3 (7)
Anatomy	2 (5)
Which methods do you use for the delivery of T2D content? (Select all that apply.)
Case studies	8 (31)
Lecture	7 (27)
Small group discussion	5 (19)
Clinical skills lab	3 (12)
Assignments	1 (4)
Presentations	1 (4)
Problem-based learning	1 (4)
Do you feel that adequate time is devoted to T2D in the PT programme?
No	6 (60)
Yes	4 (40)
How confident do you feel teaching T2D content to students? (1 = not confident, 5 = very confident)
1	0 (0)
2	0 (0)
3	1 (10)
4	8 (80)
5	1 (10)
How prepared do you think students are in applying T2D knowledge once they graduate? (1 = not prepared, 5 = very prepared)
1	0 (0)
2	3 (30)
3	7 (70)
4	0 (0)
5	0 (0)
T2D is an essential component of the PT programme:
Strongly agree	7 (70)
Agree	2 (20)
Somewhat agree	0 (0)
Neither agree nor disagree	1 (10)
Somewhat disagree	0 (0)
Disagree	0 (0)
Strongly disagree	0 (0)

T2D = type 2 diabetes.

T2D was interwoven within the MSK, neurological, and cardiorespiratory areas of PT curriculum. Nine participants reported that at least two of the following areas of course instruction included T2D-related content in PT curriculum: MSK, cardiorespiratory, neurological, rehabilitation, and public health.

The main T2D-related topics covered in the programmes were exercise and secondary complications; however, nutrition, weight management, blood glucose control, physiology, and anatomy were also covered. One participant reported that exercise was the only topic discussed when teaching T2D content.

Although educators were confident teaching T2D content, they did not feel students were prepared to adequately treat or address T2D as entry-to-practice physiotherapists. Seven of the 10 respondents reported less than five hours of T2D teaching in the curriculum. There were conflicting responses on whether adequate time was spent on T2D in the curriculum, with four of the 10 participants responding “yes,” and six of the 10 responding “no.” However, nine of the 10 participants “strongly agreed” or “agreed” that T2D was an essential condition taught in the curriculum.

Interviews

Seven of the 10 participants completed interviews lasting an average of 30 minutes. Of the seven participants, four had completed a Doctor of Philosophy degree, two had completed a master’s degree, and one had completed a bachelor’s degree as their highest level of education. Four participants were professors, two were full-time lecturers, and one was a part-time instructor. Teaching experience in a PT programme ranged from under one year to more than 10 years. Four participants taught a course or courses in cardiorespiratory, and three in MSK. Of these seven, three completed a second interview. We identified four themes relating to T2D content in PT curricula and perceptions of T2D in the field of PT held by educators. Figure 1 depicts our four main themes and codes.

Figure 1.

Thematic Map Showing the Four Main Themes (in Rectangles) with Associated Codes (in Ovals).

Theme 1: PT educators’ perceptions T2D

This theme describes educators’ perceptions on the prevalence of T2D and highlights the language used to describe T2D. All participants agreed that T2D is a common condition that is seen in all areas of practice. P4 stated, “I imagine that T2D is pretty prevalent in most populations so whether that’s in a private MSK clinic or acute-care hospital or rehab clinic.” Participants acknowledged the prevalence of T2D in PT settings but had varying perceptions of directly treating T2D in PT interventions. Perceptions could be, in part, related to the area of clinical practice. Two educators with experience in outpatient clinical settings described more time to treat “the whole” patient including concerns related to T2D, whereas three educators with experience working in acute-care settings with more complex patients described having less time and a perceived inability to treat T2D if it wasn’t the main concern.

Participants often used “risk factor” and “comorbid-ity” to describe T2D, providing insight into where T2D fits in the curriculum. P6 stated, “I mostly talk about [T2D] in cardioresp, obviously as a risk factor.” Participants often described T2D as a comorbidity and not the primary condition for treating patients. P3 discussed their clinical experience: “[T2D] was never the focus of my therapy, it would always come as a comorbidity.” Three of the seven participants described integrating a holistic approach to care and addressed T2D when treating patients for other conditions. P5 commented on their philosophy when treating patients with T2D in an outpatient setting: “You can’t just target your shoulder issue without targeting your glycemic control if I want to be a good clinician.”

Theme 2: T2D integrated into programme structure

This theme outlines how T2D is taught in PT programmes. Course coordinators often had guest lecturers with clinical experience working in a specific area of practice. P2 stated, “We hire specialists to go teach … some are physicians … when it comes to assessment, it’s mostly PTs who have clinical experience in that domain.”

PT programmes were often structured around the core systems of PT: MSK, neurological, and cardiorespiratory. T2D was often interwoven within different courses as T2D affects multiple systems. P7 talked about teaching T2D in a cardiorespiratory course: “We’re talking about what the disease is, we’re talking about diabetic medication, and we’re then talking about how those help to manage the disease.” Some but not all of the programmes taught T2D content from the perspective of the core PT systems. P6 stated, “We talk about neuropathy but not all the other systems that can be involved.” P7 discussed the importance of integrating T2D in all domains of PT: “until the students have education in all of the three main pillars of PT, they may not have a good enough understanding to really tackle the complexity of caring for people with diabetes.” Only P5 and P7 described integrating T2D into the three core systems. In addition, three participants stated that students received education on wound and foot care. P7 said, “We spend a reasonable amount of time on diabetic foot ulcers and foot care including a lecture from a pedorthist.” PT programmes can provide students with the foundational knowledge to treat patients with T2D, but it may not be fully implemented in the curriculum.

In terms of what T2D topics were taught in the curriculum, educators focused on the students’ ability to recognize the clinical presentation and exercise prescription. P2 stated, “we try to teach them to recognize the signs and symptoms of hypoglycemia and neurological changes, vascular changes.” P2 discussed that students are well prepared to assess patients with T2D, but the intervention piece was lacking: “the intervention part is much more softer.”

Aside from courses containing T2D content, participants discussed the concepts of behaviour change and how these strategies can be implemented when treating patients with T2D. P5 stated, “we have [students] identify facilitators and barriers and then try to either place them in a category in the transtheoretical model or see which of the behaviour change models might be most appropriate to apply.” In contrast, P6 said, “we don’t talk a lot about behavioural components … it’s not a huge component in our curriculum that’s for sure.”

Theme 3: pedagogical delivery of T2D in PT programmes

This theme described the delivery methods for T2D content and the knowledge, skills, and behaviours that are essential for PT practice. Case studies were the primary delivery method for T2D content. P4 noted, “we make [case studies] more realistic to what our patients present with by giving them some of these more common conditions.” However, despite the emphasis on problem- or case-based learning throughout the curriculum, P1 noted that students required prompts to identify the ways in which T2D may be impacting the patient presented in the case study, “they seem to be limited in their capacity without being prompted or taught of how diabetes affects things when they get to the second-year course.” Some participants discussed that although case studies are the primary delivery method, deeper learning happens when students are on clinical placements. P5 stated, “learning with a real-life patient in front of you is so much more valuable than the case studies.” Students’ clinical experiences regarding T2D, in part, depended on the clinical instructor. P5 suggested that some students don’t take full advantage of these learning opportunities: “sadly, physio students come in with preconceived ideas about where they’d like to work and sometimes don’t make the most of their clinical experiences to really learn as much as they can from that.” All seven educators agreed that students needed to take ownership of their learning experiences when out on placement.

Four educators emphasized the importance of students researching conditions independently. P6 explained, “I think that [students] need to be independent learners … when we don’t know the answer, what do we do? We ask our colleagues, we research.” However, P1 also reflected on the responsibilities of educators: “I think it’s on the instructors to help light the fire in the students that it’s not a chore. they’re going to go home and say, that was kind of cool what we talked about today, I want to find out more about that.”

Educators commented on the required skills that cannot be taught in lecture. P6 stated, “I think listening to their patients.” P1 reflected, “it’s the art of communication. If they came to you for plantar fasciitis, and now, you’re giving them a lecture on shedding a few pounds. Like, there’s an art to that.”

Theme 4: Challenges for integration of T2D in curriculum

This theme addresses the gaps in the PT curriculum regarding T2D content. P4 explained, “it’s not a huge focus as a condition on its own. we don’t perhaps highlight it as much as we need to.” When asked about barriers for T2D content in the curriculum, participants agreed that lack of time was a factor. P3 spoke about having to remove T2D content from the lecture material: “if I had more time and more resources maybe I would bring diabetes back to the normal schedule instead of just being included in the exam.”

Despite an already overcrowded curriculum, P5 elaborated on why T2D knowledge is essential and the impact physiotherapists can have on patients with T2D as a primary condition of referral:

If they are just diagnosed and they need some coaching and self-management assistance with optimizing exercise … be screened for complications … or if they’re living with a complication … there’s lots of good reasons where a person with diabetes could be referred to a physiotherapist.

More broadly speaking, P1 highlighted the role of physiotherapists from a general health promotion standpoint that can have an influence on patients with T2D: “empowering the merits of an active lifestyle and mobility and general fitness and cardiovascular fitness … I think, my role as a physiotherapist, that’s how I see where we make our biggest impact.” Although T2D content and perceptions of its importance differed among participants, five of the seven participants agreed that physiotherapists should assume a larger role in the management of T2D.

Discussion

This study described the approaches to teaching and learning of T2D content in the entry-to-practice PT programmes across Canada. In a survey of Canadian PT programmes, we gathered data regarding the timing, quantity, and aspects of T2D content in academic curricula from 10 of the 15 PT programmes. Previous studies explored physiotherapists’ experiences with prescribing safe exercise for T2D management¹⁰ and their perceived confidence in treating patients with T2D.¹⁵ Knowing the high prevalence of T2D in the general population, and the growing need for the PT profession to evolve as primary care providers as the population ages and the prevalence of chronic health conditions increases,²¹ it is important to understand the level of information and training included in the PT curriculum to align with this need for health care services.

The National Physiotherapy Entry-to-Practice Curriculum Guidelines (2019) developed by CCPUP the Canadian Alliance of Physiotherapy Regulators, and the Physiotherapy Education Accreditation Canada classifies T2D as a key indicator health condition that is prevalent among patients seen by physiotherapists working in cardiovascular-pulmonary, MSK, neurological, and other areas of PT practice.¹⁴ Although most programmes taught T2D from a multisystem perspective and covered a number of topics pertaining to lifestyle management, six of the 10 educators reported that not enough time is devoted to T2D content, and all educators believed students could better be prepared to treat T2D as entry-to-practice physiotherapists. This may be due to the level of awareness of T2D content in other courses in the curriculum among educators or how educators prioritize T2D compared to other conditions required to be taught in the programme. As well, T2D affects multiple body systems and leads to numerous complications. A lack of integration of T2D content throughout the core PT systems may contribute to educators’ responses in the survey pertaining to a lack of student preparedness on entry-to-practice. One potential solution that a participant presented was postgraduate training or education on T2D; however, the effectiveness of and interest in a continuing education course should be considered.

Theme 1 explored educators’ perspectives on the prioritization of T2D in PT interventions. Participants agreed that T2D was highly prevalent; 80% of patients in outpatient PT settings have T2D or are at high risk of developing T2D.²² Often, particularly in acute care settings, T2D is classified as a comorbidity and not addressed by physiotherapists. Although one participant discussed taking a holistic approach to care, this was not the norm. A mixed methods study of primary health care professionals including physiotherapists explored the effect of a lifestyle intervention consisting of motivational interviewing, and a physical activity and nutrition diary.²³ Apart from significant improvements in physical activity levels (p = 0.027), weight loss (p = 0.031) and HbA1c (p = 0.012), patients with T2D reported consultations with a physiotherapist and tracking physical activity through a diary useful.²³ Our findings suggest that there may be a missed opportunity for physiotherapists in the management of T2D in Canadian PT practice.

Theme 2 described integrating T2D content into physiotherapy curriculum, focusing on comprehension of the three pillars of physiotherapy: MSK, cardiorespiratory, and neurology. Additionally, T2D content was presented during the teaching of behaviour change, which varied across PT programmes. However, the CCPUP includes implementation of behaviour change strategies for patient-centered care.¹⁴ A content analysis of physical activity and exercise promotion across five undergraduate PT programmes also reported a lack of education or training on approaches for adopting physical activity and exercise into daily life for non-communicable diseases including obesity and T2D.²⁴

In theme 3, educators emphasized problem- or case-based learning and clinical placement opportunities as the primary methods for learning about T2D. A mixed methods study examined evidence-based practice through lecture- or problem-based learning in 109 PT students.²⁵ Evidence-based practice, which is part of the essential competencies,¹⁴ was best taught through problem-based learning, and students reported better understanding (p = 0.03), relevance (p = 0.02), and overall satisfaction (p < 0.001) compared to lecture-based learning.²⁵ However, the authors did not explore specific areas of interest; therefore, it is difficult to suggest that these findings would correlate with better comprehension of T2D content through case-based learning only. A qualitative study of a 12-week exercise and education programme for adults with T2D or at high risk for developing T2D was led by PT students as a clinical placement.²⁶ Focus groups and in-depth interviews revealed improved communication skills, building rapport with patients, and consolidation of T2D knowledge.²⁶ Similarly, participants in the current study acknowledged that richer learning, with T2D in particular, occurs while on clinical placement working with patients with T2D; however, student learning is limited by the clinical instructors’ perspectives and knowledge of T2D.

Despite challenges identified in theme 4, participants elaborated on the impact physiotherapists can play in the management of T2D. Participants acknowledged the role physiotherapists can play in T2D management through health promotion. A scoping systematic review explored health promotion in PT practice.²⁷ In this review, physiotherapists believed that health promotion practices were acceptable during interventions and part of their responsibility.²⁷ Although physiotherapists were confident in implementing health promotion practices, certain aspects did not always fall within the scope of practice and the patient’s expectations and goals.²⁷ Two of seven participants in the current study discussed the importance of promoting overall health in patients with T2D. Perhaps a greater emphasis on health promotion would benefit PT students in managing non-communicable diseases, as only one participant in the online survey reported a public health course containing T2D content. As exercise specialists, physiotherapists have the knowledge and skills to educate all patients on safe, effective exercise to improve overall health and aid in preventing non-communicable diseases. Behaviour change strategies and motivational interviewing, as mentioned in theme 2, are tools to promote overall health and can be effective for people with T2D. A meta-analysis revealed six months of motivational interviewing improved self-management strategies and significantly reduced HbAlc (p < 0.05) in patients with T2D.²⁸ As well, a qualitative study explored how patients with T2D felt about motivational interviewing and the following five themes were generated: nonjudgmental accountability, being heard and responded to as a person, encouragement and empowerment, collaborative action planning and goal setting, and coaching rather than cri-tiquing.²⁹ With behaviour change approaches incorporated into PT curriculum¹⁴ and accessible postgraduate training (https://opa.on.ca/professional-development/ course-listings/entry/81254/), physiotherapists are in a unique position to encourage lifestyle modifications through motivational interviewing for their patients with chronic health conditions, including T2D.

This study has limitations. First, it did not represent all 15 PT programmes across Canada. Only seven of the 15 PT programmes participated in the telephone interviews; therefore, our results may not represent all PT programmes. We were only able to recruit one educator from each university so we may not have fully captured T2D content in each PT programme. It is unclear whether programmes that did not participate had an instructor or faculty member that teaches T2D content or is knowledgeable about T2D in the curriculum. As well, although the analysis was data driven, the researchers remain to have epistemological values, and the data analysis is one interpretation of the findings.²⁶

Conclusion

This study provides insight into T2D content, student learning, and gaps in the PT entry-to-practice curriculum in Canada. As well, it explores educators’ perceptions of T2D in PT practice and the impact PT interventions can have in T2D management. In accordance with previous literature, educators acknowledged the importance of T2D knowledge but it was often referred to as a comorbid-ity and not addressed during PT intervention. Educators noted the complexity of T2D and often taught T2D content from a multisystem standpoint. Even though nine of the 10 participants “strongly agreed” or “agreed” that T2D was an essential component of the PT curriculum, most respondents also reported that there was not adequate time devoted to T2D in the curriculum. Lastly, educators reflected on the impact physiotherapists can have in terms of education, exercise prescription, and general health promotion for people living with T2D. Further research is needed to explore optimal integration of T2D in PT programmes.

Key Messages

What is already known on this topic

There is strong evidence that exercise prescription is safe and effective for the management of T2D. Although exercise specialists, physiotherapists are not part of the health care team for people living with T2D. Students acquire T2D knowledge in the curriculum, but entry-to-practice physiotherapists lack confidence educating patients with T2D on certain aspects of the disease.

What this study adds

Canadian PT programmes are teaching T2D from a multisystem perspective, and T2D knowledge is obtained mainly through case studies, lectures, and clinical placements. Educators agreed that T2D is an integral part of PT education and emphasized a need for physiotherapists to play a greater role in the management of T2D.