This is an excerpt from ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities-4th Edition.
Type 2 Diabetes and Obesity With Osteoarthrosis
Presenter: Geoffrey E. Moore, MD, FACSM
"I intend to live into my 90s but I can't get there unless I'm dancing."
A 52-year-old woman with type 2 diabetes was referred for help on lifestyle. She had a family history of diabetes and tended toward a centripetal/abdominal fat distribution pattern associated with high CV risk. Her recent A1c values had been 6.5-6.6, and her a.m. fasting glucose was recently 102. She qualified as T2DM by A1c criteria but wasn't working on her diet or weight and had refused to start taking metformin, and her primary care physician was increasingly concerned.
She expressed a desire to be more active through dance, which she had loved since childhood and felt was a part of her culture (having immigrated to the United States as a child). She expressed little concern about her weight and was more worried that the pain in her L shoulder kept her from dancing. She had first experienced the shoulder problem 10 years earlier while swimming backstroke. She had been to physical therapy (PT) twice, which made it worse. She also had received subacromial cortisone injections, but the relief didn't last. Her shoulder is worse at night (rolls over on her left side); the pain was rated 8/10 and was daily and constant except for sharp pain that radiated to the side of the neck when she moved the shoulder too much. She tried not to take pain or anti-inflammatory medications because she said they "wreck her stomach." Acupuncture (cupping) helped.
She also noted a history of her L knee "giving out," causing falls, and of having 2 knee arthroscopic surgeries (4 and 10 years earlier). When she overdoes weight-bearing activity, her left knee swells "like a watermelon." She did PT after the surgeries and gets to her normal daily activities but can't dance.
- Height: 5 ft 4¾ in. (1.65 m)
- Weight: 234.4 lb (106.3 kg)
- BMI: 39 kg/m2
- HR: 65 contractions/min
- BP: 188/98 mmHg
- General: normal development, good nutrition, obese body habitus, no deformities
- CV: regular rhythm with normal S1 and S2, without rubs, gallops, or murmurs; distal pulses/circulation normal; no edema
- Normal gait and station, muscular build especially of lower extremities
- Valgus alignment of both knees, no tenderness but the L knee has a small effusion
- Normal ROM without pain, substantial crepitus in both knees
- Left shoulder-specific tests:
- + Painful arc
- + Glenohumeral laxity, with crepitus
- + Neer test, +/- Hawkins test, +/- Speed's test
- + Painful with resisted external rotation, - pain with resisted internal rotation
- + AC joint tenderness
- Osteoarthrosis in the acromioclavicular joint; severe osteoarthrosis in the glenohumeral joint with advanced sclerosis, subchondral cysts, and spurring; subluxed position of the humeral head at rest
- Coreg 10 mg once daily
- Diovan HCT 320/12.5 once daily
- Multivitamin once daily
- Increased CV risk: HTN, hyperlipidemia, diabetes by A1c criteria, sleep apnea, obesity
- Advanced glenohumeral osteoarthrosis and reduced function due to pain, status post - bilateral partial meniscectomies
Her shoulder markedly diminishes quality of life, impairing her ability to sleep and to recreate. Dance is her preferred form of physical activity, which she wants to do as her approach to improve the blood glucose and reduce her CV risk profile.
- L shoulder OA: refer to PT shoulder specialist
- It was explained that her shoulder would take a long time to get better, but she was likely to have some gains in reduced pain and better function after 3-6 months of PT
- Ibuprofen 500 mg every 8-12 hours and prior to bedtime as needed for pain
- Dance for exercise, but any dances that cause pain should be avoided
- Review on the difference between pain and discomfort
- High cardiovascular risk: She was not interested in addressing her cardiometabolic risk at the time of the first visit.
- Pain-free near-normal physical functioning of L shoulder
- Dance, including tango, for recreation and physical activity
- Physical therapy focused on rotator cuff and scapular stabilizer strengthening, postural control, manual therapy, and education on pain avoidance
- Gentle dancing that avoids painful arm movements started, daily for 30 min
- Dancing and daily activities to be increased as tolerated (i.e., shoulder discomfort)
- Physical therapy twice weekly
- Home exercises daily, as advised by therapist
- Dancing that does not cause pain allowed as tolerated
- L shoulder OA
- Pain-avoidance techniques gave rapidly improved physical functioning of L upper extremity.
- Physical therapy made good progress over 3 months to near-normal physical functioning.
- Dance for aerobic exercise was very successful in getting her motivated.
- High cardiovascular risk
After 2 months of PT, she was motivated to work on weight management and diabetes prevention. She enrolled in a partial meal-replacement lifestyle intervention plan, lost 25 lb (11.3 kg) over the subsequent 3 months, and her fasting blood glucose/A1c returned to normal.
Senior Editor's Comment
This patient's story illustrates some of the art of exercise medicine, revealing the importance of working with patients to meet their emotional expectations and needs. Her primary care team was concerned about the diabetes and had been advising her about diet, weight loss, and taking metformin, but this was less important to the patient than the loss of her ability to dance. Dancing was the only type of physical exercise she enjoyed, so she needed to be able to dance as part of her pathway to improving insulin sensitivity. Close liaison with the physical therapist facilitated the process, because the therapist provided her with tips on how to avoid painful movements and begin to dance immediately. By accepting the need to dance as her top priority and then working to help overcome her barriers to dancing, the lifestyle intervention team gained her faith in them and she began to follow their advice on diet and weight. This approach seemed unusual to many who were involved in her care, as it appeared to put the diabetes problem on hold while focusing on a painful shoulder. But from another perspective, the painful shoulder was the most important problem to the patient and thus a significant barrier that needed to be overcome if exercise (in the form of dance) was to become her most important medicine.