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5 Things You Should Know When Treating a Type 1 Diabetic

by Brian Connell, PT, DPT

Diabetes is one of those conditions you learn about at length in your DPT programs. This is for good reason! In 2015, it was reported that more than 30 million Americans have diabetes, which means there’s about a 99.999999% chance you will be treating patients with this diagnosis in the future.

However, a majority of this number pertains to patients with type 2 diabetes. Only about 1.25 million Americans had a diagnosis of type 1 diabetes in that same year. Although both conditions are obviously similar in many ways, there are some key things that a PT must keep in mind when treating patients with type 1 diabetes.

I was diagnosed with type 1 diabetes myself about 10 years ago when I was 16 years old. As someone who has been through the healthcare system with this condition and as a someone who spent a year and a half as a PT patient due to an ACL tear a few years after my diagnosis, I have some firsthand tips about some things that should always be considered during treatment, regardless of your patient’s chief complaint.

How to identify hypoglycemia and hyperglycemia

When treating patients with type 1 diabetes, it is essential to recognize the signs of both hypoglycemia and hyperglycemia. These conditions are common among patients with type 1 diabetes. Hypoglycemia is especially a concern for physical therapists, as physical activity is a potential cause of low blood sugar.

Below are some (but not all) of the signs of hypoglycemia and hyperglycemia.

Signs of Hypoglycemia (Low Blood Sugar)

  • Hunger
  • Lightheadedness
  • Dizziness
  • Becoming pale
  • Irritation/anger
  • Shakiness
  • Confusion
  • Sweating
  • Feeling of weakness

Signs of Hyperglycemia (High Blood Sugar)

  • Increased thirst
  • Increased frequency of urination
  • Lethargy
  • Irritation/anger

Hypoglycemia requires urgent treatment to avoid a possible loss of consciousness. If you know that you have a diabetic patient coming in, make sure to have glucose tablets, cake icing, or juice boxes on hand, all of which are easily transportable and fast-acting sources of sugar.

Your patients’ blood sugar trends

Although all type 1 diabetics experience fluctuations in their blood sugar levels throughout their days, those fluctuations are different for everyone. For example, my blood sugar runs high in the morning, and low in the evenings, however, it is common for many diabetics to wake up with low blood sugars.

Editors note

As a fellow type 1 diabetic, I can attest that I frequently wake up with my blood sugar low in the morning. -Dyllan Thweatt, Associate Editor

This can have a huge impact on when patients should schedule their appointments for physical therapy. If a patient is prone to going low in the evening, and this is the only time in which they can make their appointments after a busy workday, a PT should be diligent about looking for signs of low blood sugar.

Although it may be unrealistic to expect a patient to plan their appointments around their trends, it’s still a topic that should be approached. Consider asking them about their blood sugar trends during their evaluation.

How activity affects their blood sugar levels

Exercise and activity can have major effects on a patient’s blood sugar levels. Aerobic exercises tend to cause blood sugar to go low, whereas anaerobic exercise tends to cause increases in blood sugar.

However, like above, some type 1 diabetics can be more sensitive to activities than others. For examples, I tend to go lower during long walks, rather than more explosive aerobic exercises such as plyometrics. Again, asking your patients questions about their experiences can help you to create treatment plans that will have minimal effects on their blood sugar levels while still achieving your treatment goals.

Opening up a dialogue with your patients about their experiences is one of many steps you can take to achieve successful outcomes! Check out our top 10 ways to continue to improve their outcomes.

Some diabetics use insulin pumps that allow them to decrease their basal rate (the rate at which they receive their flow of background insulin) in order to decrease the likelihood of hypoglycemia during activity.

If this is an option, we would not recommend that they make dramatic changes to their basal rates without first consulting their endocrinologist.

I generally have to decrease my basal rate by 35% to 60% about an hour and a half before I plan to go for a run, or if I know I have an active day ahead; that can include something as simple as walking around a city or a long hike.

How and where they give themselves insulin

There are a myriad of options for diabetics to use when giving themselves insulin, although type 1 diabetics generally will either use an insulin pump or injections.

Insulin pumps

There are a variety of insulin pumps out there for diabetics. Some pumps utilize small machinery with tubing in order to deliver insulin. Tubeless insulin pumps are also becoming more popular, where a patient will use a programming device that communicates to their pump via Bluetooth.


Type 1 diabetics that are not using a pump may opt to use injections of both short-acting and long-acting insulin using either traditional vials and syringes or pre-filled pens.

As a PT it's important to know how your patient gives themselves insulin as well as where they inject it. With pump systems, there is always a risk of accidentally yanking at tubing or bumping implanted wireless pumps off of the patient’s injection site. This can be painful for the patient and can lead to early termination of a treatment session so that they can address the issue.

The location of the insulin pump injection site is also important when attempting to do manual therapy with a patient. Not only can these pumps get in the way of the your hands, but you also run the risk of disturbing the pump itself if it is in a region that you are trying to work on.

Pro tip:

A common infusion site that may interfere with treatment is the low back area. Be careful!

The last time they checked their blood sugar levels

As I mentioned, physical activity can have a dramatic effect on blood sugar levels, so it’s important that you have an idea of what your patient’s blood sugar is before beginning their therex.

“Type 1 diabetes is becoming increasingly common in the world we practice in today, and it has never been more important for physical therapists to know how to not only treat this population safely but how to approach the topic in general.”

You can even start the treatment session by simply asking them, “when was the last time you check your glucose levels?” Consider following up with “What was your blood sugar at when you tested?” Ideally, they’ll have checked not long before they walked in the door. However, if you find that it has been an hour or two, it would be a good idea to ask them to check before starting their treatment session.

As a diabetic myself, I would appreciate the reminder at the beginning of each treatment session from my healthcare provider. This simple question can not only help the patient avoid going hypoglycemic during the treatment session but it can also alert the patient to an incident of hyperglycemia if they weren't already aware.

Type 1 diabetes is becoming increasingly common in the world we practice in today, and it has never been more important for physical therapists to know how to not only treat this population safely but how to approach the topic in general.

As I underwent rehab for my ACL, there were multiple times where my blood sugar went low due when performing my exercise program, leading to wasted time and sometimes early termination of the treatment session. I believe that with a little more education and planning for both patient and PT, situations like mine can be avoided, leading to greater safety, better outcomes, and higher quality of care for our diabetic patients.


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