TABLE 3.

Screening for Diabetes-Related Complications and Considerations for Patient Management^{4,9,27,66,84,105}

Screening Items Related to Diabetes and Diabetes-Related Complications	Physical Therapist Role and Responsibility
Psychosocial Factors*
Depression • The PHQ-2 may be used as a “first-step” screening. Patients who answer yes to either question should be further evaluated by a mental health provider108  - “During the last 2 weeks, have you been bothered by feeling down, depressed or hopeless?”  - “During the last 2 weeks, have you been bothered by little interest or pleasure in doing things?”	• Annual screening for depression among all patients diagnosed with diabetes. Screening should also be performed at any time depression is suspected • Assist patient in developing an appropriate program to increase physical activity
Anxiety disorder • Patients who exhibit anxiety or worries regarding their diabetes-related complications or ability to participate in a lifestyle management program	• Screen for anxiety disorder and refer for treatment if warranted
Disordered eating behaviors (binging, intentional omission of insulin) • Hyperglycemia • Unexplained weight loss	• Screen for disordered eating behavior, eating disorders, and disrupted eating and refer to appropriate health care providers if warranted
Cognitive impairment/dementia	• Screen for cognitive impairments and tailor management to improve understanding and optimize the patient’s ability to adhere to a lifestyle management program. All patients older than 65 y should be screened for cognitive impairments
Socioeconomic Factors
Lower social support Poor housing conditions	• Assess barriers to physical activity participation and problem solve with patient to address barriers • Customize the patient’s activity program based on the patient’s goals and preferred activities • Assist in accessing community resources
Diabetes: General
All diabetes-related complications	• Monitor blood pressure and glucose at the initial visit and as indicated at subsequent visits • Educate patient to monitor blood pressure and glucose daily, including response to exercise • Encourage lifestyle modifications to decrease caloric intake and increase physical activity for weight loss • Know medications, their side effects, and their effect on exercise response
Cardiovascular
Peripheral vascular disease • Absent dorsal pedis and/or posterior tibial pulse • Capillary refill: ≥4.5 s to refill the nail bed • Color of skin: pale	• Annual comprehensive foot examination by a diabetes specialist • Educate patient to perform daily foot examinations to look for unnoticed injury and determine need for nail care and moisturizer • If vascular screen is positive for any item, refer for a vascular assessment
Vision • Ask about  - Changes in vision  - Retina damage from microvascular disease  - Frequency of receiving an eye exam	• Refer to ophthalmologist for eye exam if the patient is not receiving annual eye exams and prior to initiating a vigorous exercise program
Cardiac autonomic neuropathy • Blood pressure response from supine to stand, drops ≥30 mmHg • Heart rate >100 beats/min after resting 15 min	• Refer to cardiologist prior to initiating a vigorous exercise program if abnormalities are measured6
Kidney
Ask about • Glomerular filtration rate • Frequency of kidney function assessment (urinary albumin and glomerular filtration rate)	• Refer to nephrologist or primary care physician if the patient is not receiving regular kidney function screening
Peripheral Neuropathy of Feet
Light touch (Semmes-Weinstein monofilaments) • Loss of protective sensation: can’t feel 5.07 monofilament • Absent: can’t feel 6.10 monofilament	• Annual comprehensive foot examination by diabetes specialist • Educate patient to perform daily foot examinations to look for unnoticed injury and determine need for nail care and moisturizer • If the patient lacks protective sensation, provide education about the need for wearing protective footwear when walking in the home or community and the lack of ability to detect damaging temperatures (cold and hot)
Tuning fork (128 Hz) on dorsal great toe interphalangeal joint: time between when the patient and examiner stop feeling vibration • Reduced: ≥10-s difference • Absent: the patient is unable to feel vibration
Biothesiometer • Unable to feel ≤25 V
Achilles reflex • Present with reinforcement: Jendrassik maneuver required • Absent: no reflex with Jendrassik maneuver
Muscle (see below)
Integumentary
Callus: indicator of high pressure and risk of injury Dry/cracked: indicator of autonomic neuropathy and increased risk of skin breakdown	• See recommendations above for peripheral neuropathy
Foot wounds • Neuropathic: plantar surface, area of high pressure, callus • Vascular: lateral surface, poorly perfused, absent pulse
Musculoskeletal
Joint • Deformity of toes (metatarsophalangeal joint hyperextension) and foot (midfoot collapse); palpation of plantar surface for bony prominences that can be a site of high pressure and skin breakdown24,25,48,49 • Range-of-motion limitations18,59,94  - Hands: prayer sign: the patient is unable to fully extend the fingers when placing the hands together in front of the chest in a prayer position  - Shoulders: limited active and passive shoulder flexion range of motion  - Ankle/foot: limited ankle dorsiflexion and plantar flexion, decreased extensor digitorum longus length • Ask about current or history of prevalent musculoskeletal injuries in diabetes (frozen shoulder, Dupuytren’s contracture, carpal tunnel, trigger finger)	• Determine whether the patient has any current pain or significant risk factors for musculoskeletal injury • Examine and address contributing factors to toe and foot deformity, including a short extensor digitorum longus and weak foot intrinsic muscles contributing to metatarsophalangeal joint hyperextension and limited ankle dorsiflexion contributing to foot and toe deformity • Develop regular stretching program to address limited joint mobility of the hands, shoulders, and ankles • Provide exercises specific to limitations in daily functional activities (sit-to-stand, stair and curb ascent and descent, walking speed and endurance) • Develop or connect the patient to community programs to increase physical activity that is appropriately dosed to reduce risk for injury and encourage participation
Muscle • Visible atrophy of the thenar/hypothenar eminence of the hand • Loss of muscle strength  - Calf and foot: decreased ability to complete full heel raise and lack of plantar flexion of the forefoot on the hindfoot during heel raise48,50  - Hands: decreased grip and/or pinch strength
Function • Slow gait speed (10-m walk time, <12.5 s39) • 2-minute walk test14 (see Bohannon et al14 for age- and sex-specific normative data) • Slow 5-times sit-to-stand (≥10 s70)

Abbreviation: PHQ, Patient Health Questionnaire.

^*A comprehensive list of measures to assess psychosocial factors is provided in a recent American Diabetes Association position statement¹¹¹