Working with Dutch Physiotherapy students in a first year module: Hanze University Trip

Heather Longbottom (BSc Hons Physiotherapy) and lecturer Larissa Kempenaar travelled to the Netherlands to meet with the Physiotherapy staff and students at Hanze University in Groningen. This is Heather’s account of the trip.

“When stepping out of the train station into Groningen the first thing you notice is bikes! Bikes are everywhere; you soon learn that you don’t look for cars when crossing roads but bikes instead! Bikes are nearly everyone’s main form of transport as the Netherlands are so flat and it’s a lot quicker to cycle than go by car or bus. From a physiotherapist’s perspective, this a really great thing to see and encourage as without realising many people are doing physical activity every day. This is the biggest contrast I observed when comparing the Netherlands to Scotland. The geography of the Scottish landscape plays a huge part in why so few people cycle on a daily basis because it is neither time efficient nor appealing to many people. Also, Scotland’s climate is less favourable for cycling in comparison to the Netherlands (where the temperature rarely goes below 3°). However, in some more major cities such as Glasgow or Edinburgh there may be more people who could easily incorporate cycling as an alternative mode of transport.

The majority of the students attending Hanze University of Applied Science use bikes to get to class – evident by the number of bikes outside the university buildings.

When arriving at the university it is also apparent that there is no physiotherapy dress code; rather than wearing leggings or navy trousers and a polo shirt like we do at GCU, both students and tutors wear casual clothing. After spending some time attending class and meeting both teachers and students I felt the lack of standard attire did not alter the professionalism they put across.

Whilst visiting the university I attended a practical first year physiotherapy class covering proprioception, which for my benefit was led in both Dutch and English. I also went to an international first year class (led in English) on massage. It was interesting to see the similar teaching style and set up –  a tutor at the front initially demonstrating a test followed by students in pairs at plinths mirroring the test and asking any questions they had.

Throughout my time in Groningen I was paired with a 1st year physiotherapist to welcome me and show me around, this was a really good experience as it enabled me to ask questions about their course and learn how they felt about their course from a student’s perspective. I learned there were some similarities such as using online blackboard for communicating to students, but also many differences, such as: their timetables changing every week, their academic year is a lot longer than ours and is split into 4, with more shorter holidays, when compared to GCU’s 2 semesters. In Scotland, we have 7 placements but at Hanze they only get 3 placements – however they are about 4 months each! In addition, due to the lack of the NHS in the Netherlands, Health Care is mostly private, therefore it is quite common to get all 3 placements in a private setting.

I really appreciated the opportunity to get a glimpse of a physiotherapy course in another country and found it interesting to see some of the similarities and differences. I also enjoyed the chance to learn more about the culture and lifestyle in the Netherlands, through both chatting to the physiotherapy students and being shown round some of the sights of Groningen by my buddy.”







Health Promotion with the elderly at the Glasgow Mosque

As part of the Health Promotion module on the MSc Physiotherapy pre-registration programme, some of our students visited the Glasgow Mosque in February to start working with a group of elderly women who come to the Mosque for day care to get a meal, social contact and to do activities. We were approached by the Mosque last year to find out if our students could develop some activities for this group.

This is a reflection written by the group on their experience of going into the Mosque to meet the women.

“When we initially found out that we were going to the mosque, we had mixed feelings on the idea as we were the only group who were unable to ‘bid’ for their desired community group.

However, this gave us a head start on our background research which we were keen to begin as our knowledge surrounding the community was limited. As time moved on, our nerves kicked in with fear of the unknown as we had never been immersed within the Muslim community, and it was the first time the university were working with this group, meaning we knew little about the situation. Thus, being coupled with the fact that they potentially spoke minimal English, we decided to attend an open day. We went on a tour of the mosque, which gave us a chance to view the prayer rooms and talk to some of the members, which was extremely interesting.

On route to the mosque on the day of the meeting with baked goods in hand, anxiety levels were still high. There had been a lot of backward and forward as to the age group we were dealing with, which was unknown. We had a presentation with information and questions that we knew could only be a guideline as we had no idea what to expect during the meeting. However, any lingering anxiety lifted almost instantaneously upon arrival to the group of women.

The women were very welcoming, and very willing to interact with us throughout. At first, they were struggling to understand us, however this was promptly acted on and as a result we were engaging effectively in an informal sense, whilst still collating the necessary information. Having attained background information helped, and as we got to know each other we moved closer to them as a group for a more intimate chat. They were very enthusiastic at how much we wanted to learn from them, and the idea that we could effectively help them too.

We feel strongly that they are looking forward to us coming back. Going forward, we are all equally excited to return to the mosque and work with them further in helping them produce a program that can hopefully be used long after completion of our module.

Having been taken out of our comfort zone and challenged to approach and communicate with a new community, and do so successfully, has given us a new confidence. It has also allowed us to build on our current skillset including adaptability, a skill that we can take forward through our physiotherapy careers.”

Katie, Julia, Kaylie, Kelly and Amy


Physical Activity And…Obesity

Scope of the Problem:

Obesity is a condition characterized by excessive body fat that can be stored around the waist. The BMI of 30 Kg/m2 in adults is classified as obese. However, BMI is not a suitable measure for children or athletes. It is usually an imbalance between exercise and food intake that usually results in obesity.

Scotland has one of the highest levels of obesity in; only the USA and Mexico having higher levels. In 2015, 28% of adults (16+) in Scotland were obese and 65.1% were overweight; 15.1% and 31.7% children.

Gender: Men are more likely to be more obese.

Age: Obesity peaks between the ages of;

  • Men: 55 and 64 years old
  • Women: 65 to 74 years old

Location: Lanarkshire, Scotland

  • More prevalent in deprived areas. (16.2% in Lanarkshire).
  • 65% of adults in Lanarkshire are overweight or obese.
  • 75 year old life expectancy for males and 79 year old life expectancy for females.


  • More common in smokers and people with drinking problems.

Increased risk of developing:

  • Diabetes
  • Hypertension
  • Heart disease
  • Some cancers
  • Cardiovascular disease
  • Hyperlipidemia

Future Challenge

  • Predicted that by 2030 adult obesity in Scotland could reach over 40%.
  • Total cost including both direct and indirect costs, up to 3 billion pounds.

Physiological Benefits of Exercise on Obesity:

  • Exercise triggers the release of IL-6:
    • Lipolysis
    • Decreases hypoxia with adipose tissue
    • Anti-inflammatory (adipose tissue, vascular epithelial cells and blood mononuclear cells)
    • May decrease insulin resistance

  • Aerobic exercise increases blood flow
  • Exercise increases mitochondria production which increases energy ATP production


  • Lipoprotein lipase (LPL) – released when smooth muscle contracts
  • Frees fatty acids from storage
  • Hydrolyzes the triglycerides that are in circulation for tissue uptake


  • Some studies show that moderate exercise does not have an effect on body composition but did promote beneficial effect on low grade inflammatory state
  • Balance of diet and exercise is crucial to improve the low grade inflammatory state and cardiovascular system

Evidence for the benefits of exercise for obesity

A systematic review from Miller et al (2013) showed that exercise training in addition to calorific restriction promoted increases in cardiovascular fitness (relative and absolute), muscular strength and had a positive impact on body composition in obese middle aged and older individuals. in addition, it was seen that the application of exercise training elicited greater fat mass loss and preserved lean mass more so than just calorific restriction weight loss programmes alone. Furthermore, it was found that energy restriction alone, had an undesirable effect on cardiorespiratory fitness, muscular strength and loss of lean muscle tissue.

A randomised controlled trial by Slentz et al (2004), studied the “Effects of the amount of exercise on body weight, body composition and measures of central obesity”. An eight-month exercise program was implemented with three groups participating in varying amounts of physical activity (high amount/vigorous, low amount/vigorous and low amount/moderate) and a control group. It was found that the non-dieting control group gained weight, meanwhile a dose response relationship was found with the exercise groups. From this it may be suggested that independent of diet modification a modest amount of exercise can lead to a reduction in body weight and a high amount of exercise will promote further benefits in initially obese individuals.

In a study done by Jakicic and colleagues comparing the effects of exercise duration and intensity over a 12-month period in sedentary, overweight women showed that duration of exercise had a greater impact on weight loss. Those in both the moderate and high intensity/high duration had a greater percentage weight loss than those in both the moderate and high intensity/low duration groups.

A study conducted by Barbara J Nicklas  (2009) and colleagues discussed the impact of diet and exercise on fat loss and cardiovascular health in postmenopausal obese women. The trial had three groups carrying out a 20-week intervention: one with calorie restrictions, one with calorie restrictions and moderate exercise and the last group having calorie restrictions and vigorous exercise. The results showed that diet restrictions were not enough to reduce fat and improve cardiovascular health, but there was no difference in the impact of intensity of exercise on the participants.

A meta-analysis by Wu et al. (2009) has shown that of the two most common therapies for obesity (diet and exercise) the combination of exercise and diet produced longer lasting benefits than diet alone. This is supported by Ozcelik et al. (2015) that found in women with obesity those that were treated with diet, drugs and exercise lost more weight and had better body composition with lower obesity-related CV risk factors than the group that were only treated with drugs and diet alone.


Australia Policy

– Display nutritional information on foods in vending machines and on outside of vending machine

– Main focus is on young children

– Implementation of APPs ; Traffic Light App –> The app gives a traffic light rating based on the amount of total fat, saturated fat, sugars and sodium per 100g – green for low, amber for medium and red for high.

– Effects of the environment: Access to fresh healthy foods, Density and placement of fast food outlets,

UK NICE guidelines

– Listed through prevention, identification and management

– Including guidelines for Adults, Young Adults and Children

– PREVENTION: Vending machines, Nutritional information at the point of choosing food and drink options, Prominent placement of healthy options, Maintaining details of local lifestyle weight management programmes, Publishing performance data on local lifestyle weight management programmes, Raising awareness of lifestyle weight management programmes, Referral to a lifestyle weight management programme for people with comorbidities, Preventing weigth regain, Reducing sedentary behaviour

– IDENTIFICATION : BMI – sometimes waist circumference

– Lowered BMI threshold for Black African + African Carribeans + Asia

– MANAGEMENT: Advice assessing lifestyle, willingness to change, referrals, drug treatment, surgery

National Institute for Health and Clinical Excellence (Great Britain), 2007. Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence. Vancouver


Sets out plans for involving the whole of society in reducing obesity states that obesity is everybody’s business and that it is the responsibility of individuals to change their behaviour to lose weight says that a range of partners, including government and business, have a responsibility to help people lose weight


A common barrier to exercise for the obese is the feeling that they are already too fat to participate in physical activity (Ball et al., 2000). This is particularly pronounced in the female population where an emphasis on body image is traditionally observed (Ball et al., 2000). Obesity has also been proven to be associated with fatigue, especially during the day. This has implications for exercise as it further reduces the desire of the obese patient to participate (Vgontzas et al., 2006). Furthermore, daytime sleepiness and fatigue may also be associated with insulin resistance, which may be a sign of other underlying conditions (Vgontzas et al., 2006.)

Comorbidities associated with obesity could also a barrier to these individuals:

  • Diabetes – barriers discussed yesterday
    • Lack of energy
    • Pain in knees and feet
    • Fear of hypoglycemia
  • Cardiovascular Disease
    • Increased risk of having cardiac complications
  • Mainly just a perceived limitation to exercise but actually exercise is very safe and good for them
  • Musculoskeletal conditions
  • Increased risk of having disabling musculoskeletal conditions, like osteoarthritis, low back pain, gait disturbance, soft tissue complaints.


GONDIM, O.S., DE CAMARGO, V.T.N., GUTIERREZ, F.A., DE OLIVEIRA MARTINS, P.F., PASSOS, M.E.P., MOMESSO, C.M., SANTOS, V.C., GORJÃO, R., PITHON-CURI, T.C. AND CURY-BOAVENTURA, M.F., 2015. Benefits of Regular Exercise on Inflammatory and Cardiovascular Risk Markers in Normal Weight, Overweight and Obese Adults. PloS one, 10(10), p.e0140596.


GRANT, I., FISCHBACHER, C. AND WHYTE, B. (2007). Obesity in Scotland An Epidemiology Briefing. Edinburgh: NHS National Services Scotland.

JAKICIC JM, MARCUS, GALLAGHER KL, NAPOLITANO M, LANG, W. (2003) Effect of Exercise Duration and Intensity on Weight Loss in Overweigh, Sedentary Women: A Randomized Trial. JAMA 290(10): 1323-1330 doi:10.1001/jama.290.10.1323


MILLER CT, FRASER SF, LEVINGER I, STRAZNICKY NE, DIXON JB, et al. (2013) The Effects of Exercise Training in Addition to Energy Restriction on Functional Capacities and Body Composition in Obese Adults during Weight Loss: A Systematic Review. PLoS ONE 8(11): e81692. doi: 10.1371/journal.pone.0081692.


NICKLAS BJ, WANG X, YOU T, LYLES MF, et al. (2009) Effect of exercise intensity on abdominal fat loss during calorie restriction in overweight and obese postmenopausal women: a randomized, controlled trial. Am J Clin Nutr 89: 1043-52


OZCELIK, O. OZKAN, Y. ALGUL, S. COLAK, R. (2015) Beneficial effects of training at the anaerobic threshold in addition to pharmacotherapy on weight loss, body composition, and exercise performance in women with obesity. Patient Preference and Adherence 9: 999-1004


PETERSON, A., & PEDERSEN, B., (2005) The anti-inflammatory effect of exercise. Journal of Applied Physiology. 98 (4), pp.1154-1162. Available from


SEIP, R.L. AND SEMENKOVICH, C.F., 1997. Skeletal muscle lipoprotein lipase: molecular regulation and physiological effects in relation to exercise. Exercise and sport sciences reviews, 26, pp.191-218


SLENTZ CA, DUSCHA BD, JOHNSON JL, et al. Effects of the Amount of Exercise on Body Weight, Body Composition, and Measures of Central Obesity: STRRIDE—A Randomized Controlled Study. Arch Intern Med. 2004;164(1):31-39. doi:10.1001/archinte.164.1.31.


The Scottish Government, (2010). Preventing Overweight and Obesity. Edinburgh: Scottish Government.

T, GAO. X, CHEN, M. AND VAN DAM, R.M. (2009) Long-term effectiveness of diet-plus-exercise interventions vs. diet-only interventions for weight loss: a meta-analysis. Obesity Reviews 10: 313-323


YOU, T., ARSENIS, N.C., DISANZO, B.L. AND LAMONTE, M.J., 2013. Effects of exercise training on chronic inflammation in obesity. Sports Medicine, 43(4), pp.243-256.


Statistics from:


Contributors: Mohamed Yusuf Admani, Stacey Ann Beierling, Elizabeth Ann Britton, Alastair Colin Callander, King Hong Chan, Jamie Lee Baker Conrick, Marissa Leanne Durnan, Ross Farro, Lynda Margaret Flaws, Paul Michael Fortin, Jayson Thomas Gallahue, Erik Peres Gouveia, Allison Claire Graham, Jenna Rae Holdham, Ning Lei, Lindsay Jane MacDonald, Ranvita Mahto, Kristina Mckeown, Mary Annette Naughton, Kulwinder Saggi, Jessica Ashley Swallow, Jonathan Wilson

Class Tutor: Kathryn Savage








Physical Activity and…Diabetes

Over the next few weeks we will be posting content created in class by our level one MSc (pre-reg) students. This first post looks at how physical activity can help those with type 2 diabetes and was produced by Group A.

What is the scope of the problem for this patient?

 Diabetes is becoming more prevalent all around the world, America being the most at risk country. Studies have shown that the lifetime risk in 2000 of developing diabetes is one in three in America, as well as being the 6th leading cause of death (Colberg et al., 2010). Of those ending in death, 65% are related to heart disease and stroke (National Health Interview Survey, 2000). The scope of the problem has become so severe that the prevalence is even increasing in children and young adolescents due to sedentary behaviour (American Diabetes Association, 2000). It is essential that this cycle is reversed in order to avoid difficulties in society. It has been shown that one major risk factor in diabetes in children is family history (close family) as it ranges from 74 – 100%. This may be due to a westernized lifestyle however there is a lack of research on this topic with regards to children.

It has been discovered that the cost of healthcare for those suffering with diabetes is four times greater than those without the disease (Harris, 1998). The main costs come from the complications of the disease ie amputation, blindness, kidney failure and stroke (Cost of Diabetes Report, 2014) With an increase in this epidemic, the strain on the NHS especially will increase.

The best course of action is a multidisciplinary lifestyle intervention targeting exercise, therapeutic education, nutrition and physiological counselling (De FeoF et al, 2013).


The Evidence for Physical Activity, in a Diabetes Population

Lifestyle interventions appear to be at least as effective as pharmacological interventions. However, exercise is associated with fewer side effects, and it also has a positive influence on cardiovascular events, quality of life, and mortality. One key issue is the need for compliance for exercise interventions as the effects of are not permanent, and therefore exercise needs to be reinforced on a regular basis. The more overweight someone is, the greater impact lifestyle interventions will have (Gillies et al., 2007).

Just 15 days of aerobic exercise is enough to have an impact on insulin sensitivity (Madden, K.M. (2013) ‘Evidence for the benefit of exercise therapy in patients with type 2 diabetes’, Diabetes Metab Syndr Obes, 6.)

150 mins per week of PA along with diet changes reduced the risk of progression from impaired glucose tolerance to T2 diabetes by 58% (Sigal, R.J., Kenny, G.P., Wasserman, D.H., Castaneda-Sceppa, C. and White, R.D. (2006) ‘Physical activity/exercise and type 2 diabetes’, Reviews/Commentaries/ADA Statements, 29(6), pp. 1433–1438. doi: 10.2337/dc06-9910)

Substantial reductions in mortality for  both men and women and in both T1 and T2 diabetes. Reductions overall mortality of 39-70% over 15 to 20 years. (Sigal, R.J., Armstrong, M.J., Colby, P., Kenny, G.P., Plotnikoff, R.C., Reichert, S.M. and Riddell, M.C. (2013) ‘Physical activity and diabetes’, Canadian Journal of Diabetes, 37, pp. 40–44. doi: 10.1016/j.jcjd.2013.01.018.)

Increased exercise aids in the effectiveness of pharmacological treatment by increasing the cardiovascular function and nutrient absorption.

Risk reductions are observed in as little as 30 minutes of moderate intensity exercise a day.


ACSM and ADA 2010

Increase in quality of studies establishing importance of fitness and exercise.

Physical Activity in prevention and management.

Regular Physical Activity increases blood glucose and prevent/delay type 2 diabetes.

Physical Activity and modest weight loss decreases risk of type 2 diabetes by 58% in high risk populations.

Acute and chronic improvements in insulin action for both aerobic and resistance training.


Policies for Type 2 Diabetes 

Global Guideline for Type 2 Diabetes Diagnosis/Screen


Each programme should decide whether to have a programme with undiagnosed diabetes. This decision should be based on prevalence and resources available.

Detection programmes should be based on:

  1. Identifying high risk individuals with questionnaire
  2. glycemic measure in high risk individuals

Diabetes can be diagnosed based on WHO criteria (numbers not disclosed)

People that are screened and diabetes detected should be given treatment and care.


Recommended care

Offer care to all people with diabetes, taking into account cultural wishes and desires.

Encourage a collaborative relationship by involving diabetes person in consultation. Ensure issues important to person are addressed.

Agree on a care plan, review it annually or more often, modify according to change in wishes

Use protocol-driven care to deliver care plan

Ensure each person with diabetes is recorder on list of people, to facilitate recall for annual surveillance.

Provide telephone contact between clinic visits.

Provide urgent access to diabetes health care advice for unforeseen consequences.

Use data gathered in routine care to support quality assurance and development activities.

International Guidelines Exercise Recommendation

Aerobic: either 150 minute minimum moderate intensity, 50-70% max HR/can continue conversation, 3 days week no more than 2 consc. days, brisk walk would be appropriate. Or 90 mins minimum vigorous if no CV C.I., 77-95% max HR progression/ca’t continue convo, brisk jogging recommended.

Resistance: in addition to aerobic recommended, min 2x week non-consec days, 1-4 sets 5-10 reps of mulit-joint, initially 50-69RM progressing to 70-84RM.

Combined aerobic + resistance had favourable impact of glyceamic control.


National strategy and policy to prevent type 2 Diabetes – NICE Guidelines/Pathways


  • Creating an integrated strategy for non-communicable diseases linked to diet, physical activity and being overweight or obese
  • Conveying healthier lifestyle messages to the whole population
  • Make sure these messages are clear and consistent
  • Make sure they address misconceptions about diabetes (e.g. fatalism, what actually is a healthy weight, stigma surrounding disease)
  • Make sure national media conveys correct and culturally appropriate information (given different target audiences)
  • Don’t reinvent the wheel – use existing materials, including those from other countries, when appropriate
    • Emphasize need to spend less time being sedentary, importance of being physically active and maintaining a healthy weight, increase awareness of healthier food choices.
  • Working with caterers, food manufacturers, food retailers and others to encourage people to eat more healthily – and monitoring and assessing the population’s diet
  • Make better quality food more available
  • Work to reduce the saturated fat and salt content, as well as the total amount of calories in the foods available.
  • Encourage the use of healthier cooking methods
  • Work to change pricing strategies to make healthier choices more affordable
  • Work to provide clear nutritional information on food
  • Encouraging people to be more physically active and monitoring and assessing physical activity levels
    • Improve knowledge of the national physical activity guidelines – make sure people know how active they are meant to be
    • Encourage even small changes towards being more active
    • Monitor the population’s physical activity levels to determine the success of the interventions
  • Management Advice
    • Key recommendations
      •   Evidence based education interventions around time of diagnosis with annual reinforcement and review
      • Dietary advice should be provided to all newly diagnosed people and reviewed annually with healthy balanced eating of high fibre, low glycaemic index sources of carbs and oily fish, control of intake containing free sugars and saturated and trans fatty acids
      • Self-monitoring of plasma glucose levels is only beneficial for a self-management education where education to understand the results should be provided
      •  Assess cardiovascular risk every year including full lipid profile
      • Check annually about development of neuropathic symptoms

Physiological Effects of Exercises on Type 2 Diabetes

Meta-analysis on different modes of exercise on type 2 diabetes by Snowling and Hopkins, 2006 (N=1003 using 27 studies)

  • Clear and small reductions in A1C (blood glucose test) were seen
  • This was done using a small to moderate intensity of exercise (aerobic only)
  • However, the use of combined exercise (aerobic & resistance) highlighted a large effect on insulin sensitivity.
  • Therefore the study concluded that aerobic, resistance and combined exercise had small to moderate benefits on glucose control in type 2 diabetic patients and small beneficial effects on some related risk factors for complications of diabetes. Furthermore, there is some evidence of small additional benefits resulting from combining aerobic and resistance exercise.
  • Structured exercise programs had a statistically and clinically significant beneficial effect on glycemic control (not primarily mediated by weight loss)? (Sigal et al., 2006)
  • Improves glycaemic control (Yang et al., 2014) → decreased glycated hemoglobin levels of 0.6% (Thomas et al., 2006).
  • No study reported adverse effects in the exercise group or diabetic complications (Thomas et al., 2006)
  • Improves blood lipid profiles (Yang et al., 2014)
  • Increased insulin response and decreased plasma triglycerides (-0.25mmol/L)
  • Effects of various types of exercise:
    • Aerobic exercise is the most extensively studied (Yang et al., 2014)
    • Decrease glycosylated hemoglobin of 0.46% (5.03 mmol/mol) in aerobic
    • Decrease glycosylated hemoglobin of 0.32% (3.50 mmol/mol) in resistance training
  • No evidence that resistance training differs from aerobic exercise in impact on cardiovascular risk markers or safety (Yang e al., 2014)

A study that compared the effects of 12 week progressive combined exercise (3min/week) on 18 diabetic subjects and 20 controls of similar age, bmi and aerobic capacity found that mitochondrial function was restored to control levels,  insulin sensitivity was significantly improved and metabolic flexibility was restored to control levels in type 2 diabetes individuals ( Meex et al 2010).

A combination of aerobic training and resistance training has benefits on the oxidative capacity of muscle. This improves skeletal muscle glucose disposal, reduces hepatic glucose production thereby improving glucose tolerance, insulin sensitivity and glycemic control.

Further benefits include an improvements in cognitive functioning. ( Cooper et al., 2011)

A study comparing groups being treated with medication (metaformin) versus those being treated with intensive exercise and nutrition counselling, demonstrated that the exercise group had a 58% reduction in the progression of T2DM after 2.8 year follow up.

Those who exercise regularly can reduce the dosage and even the need for insulin and oral agents while decreasing LDL cholesterol, triglycerides, and blood pressure in association with increasing HDL.

(Codario 2011)

Studies, and meta analysis based on these studies, have shown that exercise has beneficial physiological effects for people with Type 2 Diabetes Mellitus (T2DM). These include; body weight (adipose tissue ratio) reduction, blood glucose levels, insulin activation and resistance, rates of fat oxidation, blood cholesterol levels, and blood pressure (O’Hagan, De Vito, & Boreham, 2013). Although there are the typical limitations for studies including differentiation in participant group size, drop out rates, different measurement tools, and the fact that most of the participants have their symptoms under control; several meta analyses have manage to quantify these findings as statistically significant (O’Hagan, De Vito, & Boreham, 2013). These are exercise benefits for everyone however they are greater for people with T2DM because they have a greater risk to begin with (O’Hagan, De Vito, & Boreham, 2013).


  • Lack of time  
    • Younger patient more likely to report
  • Physical discomfort (34%)
    • Reports from older, with higher BMI
  • Access to facilities
  • Lack of motivation
  • Embarrassment of body image
    • Females and unmarried individuals more likely to report
  • Weather2,3
  • Diabetes specific management
    • Blood sugar management during exercise
    • No knowledge about why exercising is good to reduce blood sugar
  • Lack of social support
    • Family, friends
  • Fatigue
  • Past negative experiences, boredom, dislike of gym

(Dave et al 2015, Egan et al 2013, Lascar et al 2014)


Bassuk, S.S. and Manson, J.E., 2005. Epidemiological evidence for the role of physical activity in reducing risk of type 2 diabetes and cardiovascular disease. Journal of applied physiology, 99(3), pp.1193-1204.

Colberg, S.R., Sigal, R.J, Fernhall, B., Regensteiner, J. G., Blissmer, B.J, Rubin, R.R., Chasan-Taber, L., Albright, A.L. & Braun, B. (2010), ‘Excersise in Type II Diabetes”, Diabetes Care, 33(12), pp147-167

Dave, D., Soni, S. & Irani, A. 2015, “Identification of barriers for adherence to exercise in type 2 diabetes mellitus—a cross sectional observational study”, Physiotherapy, 101, pp. e297

De Feo et al. 2013. Diabetes and Exercise. 2nd ed. Endocrinology of Physical Activity. Springer Science and Business: New York

Egan, A.M., Mahmood, W.A.W., Fenton, R., Redziniak, N., Tun, T.K., Sreenan, S. and McDermott, J.H., 2013. Barriers to exercise in obese patients with type 2 diabetes. QJM, 106(7), pp.635-638

Gillies, C. L., Abrams, K. R., Lambert, P. C., Cooper, N. J., Sutton, A. J., Hsu, R. T., & Khunti, K. (2007). Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: A systematic review and meta-analysis. The British Medical Journal, 334. doi:

Harris, M.I. (1998), “Diabetes in America: Epidemiology and Scope of the Problem”, Diabetes Care, Vol. 21, pp. 11-15

Home, P., Mant, J., Diaz, J. and Turner, C., 2008. Management of type 2 diabetes: summary of updated NICE guidance. Bmj, 336(7656), pp.1306-1308.

Lascar, N., Kennedy, A., Hancock, B., Jenkins, D., Andrews, R. C., Greenfield, S. And Narendran, P. 2014. Attitudes and Barriers to Exercise in Adults with Type 1 Diabetes (T1DM) and How Best to Address Them: A Qualitative Study. Public Library of Science. 9 (9), pp. 1-8.

NICE Guidelines 2016 – National strategy and policy to prevent type 2 diabetes.

O’Hagan, C., De Vito, G., and Boreham, C.A.G., 2013. Exercise Prescription in the Treatment of Type 2 Diabetes. Current Practices, Existing Guidelines and Future Directions. Sports Medicine. 43. Pp. 39-49.

Sibal, L. and Home, P.D., 2009. Management of type 2 diabetes: NICE guidelines. Clinical medicine, 9(4), pp.353-357.

Sigal, R.J., Kenny, G.P., Wasserman, D.H. & Castaneda-Sceppa, C. 2004, “Physical activity/exercise and type 2 diabetes”, Diabetes care, vol. 27, no. 10, pp. 2518-2539.

Type II Diabetes in Children and Adolescents, Paediatrics, March 2000, 105(3)



Contributors: Greg Barnes, Alexander Benin, Ryan Bennett, Jessica Marie Buffam, Natalja Chorosajeva, Blair Colvin, Hugo David Curley, Claire Davidson,  Jason Freeman, Paul Griffin, David Monkman Hickey, Jackson Wyatt Hill, Caroline Elizabeth Johnston,Melissa Megan-Marie Leffelhoc, Orlaith Munnelly, Blaise Joseph Peters, Mitchell Eugene Petten, Aiste Pranciliauskaite, Claire Rankin, Heather Sabin Sauverwald, Frances Ann Young, Laura Anne Williamson, Chelsea Chrystal Windl.

Class Tutor: David Hegarty

Mechanisms of Action of Exercise Therapy for Knee OA

This week the GCU Physio Journal Club reviewed an article related to the benefits of exercise therapy for people with knee osteoarthritis (OA):

Improvement in upper leg muscle strength underlies beneficial effects of exercise therapy in knee osteoarthritis: secondary analysis from a randomised controlled trial.

Posted by Scott Rooney and Chris Seenan on behalf of the GCU Physio Journal Club

Scott Rooney 1  7fXZeBgCwUp5y8ZXODA1R4wwcoM7Vhvz3yhQikCTC2A

Here is what we thought:

Osteoarthritis is a common cause of knee pain which can impact a person’s ability to perform their normal daily tasks. Exercise therapy is proven to be effective in managing the symptoms of knee osteoarthritis. However, the underlying mechanism associated with these benefits is unknown.

A team of researchers sought to explore whether changes in muscle strength and proprioception were associated with improvement in knee osteoarthritis symptoms. This post explores what the researchers did and what they found.



Researchers analysed data from a randomised controlled trial which examined the effect of two exercise programmes. This trial included 159 participants with knee osteoarthritis who received strength training or strength training plus stabilisation exercises. Each group completed a 12-week exercise programme comprising of two 60 minute sessions each week at a rehabilitation centre in The Netherlands, and five days home-exercise.

Pain (numeric rating scale), activity limitations (WOMAC and get-up-and-go test), upper leg muscle strength (isokinetic dynamometer), and knee joint proprioception (detection of onset of passive movement) were measured at 6 weeks (mid-treatment), 12 weeks (post-treatment), and 38 weeks (6-month follow-up).

Results were combined and analysed to examine the relationships between changes in muscle strength and proprioception with pain and activity limitation while taking into account potential confounding factors (gender, age, duration of symptoms, use of pain medication, pain severity, BMI and knee malalignment).



At 6 months follow-up:

  • Pain
    • NRS scores improved by 34%
  • Activity limitation
    • WOMAC scores improved by 30%
    • Get-up-and-go test performance improved by 8%
  • Upper leg muscle strength improved by 23%
  • Knee joint proprioception improved by 36%
  • Significant association were found between change in upper leg strength and improvements in pain and activity limitations.
    • Change in muscle strength accounted for 7%, 6%, and 12% change in pain, WOMAC, and get-up-and-go test respectively.
  • No association was found between change in proprioception and any of the outcome measures


Authors conclusions: 

“this study provides evidence that upper leg muscle strengthening (of both quadriceps and hamstrings) is one of the mechanisms underlying the beneficial effects of exercise therapy in patients with knee osteoarthritis. Improved knee joint proprioception was not found to be related to the outcomes of exercise therapy.” 

Increases in strength of hamstrings and quadriceps muscle groups linked to reductions in pain and activity limitations.


GCU Physio’s opinion: 

We know that exercise therapy is effective for decreasing pain and increasing function in people with knee osteoarthritis. This high quality study provides an insight into the possible reasons for these effects and suggests that muscle strength is an important component. This has clinical implications in the planning and goal setting with of exercise interventions.

The main limitations of this study are the secondary nature of the analysis, the limited generalisation of the results due to specific knee OA sample studied and the possible limited validity of the proprioception outcome measure used.



KNOOP, J. et al, 2015. Improvement in upper leg muscle strength underlies beneficial effects of exercise therapy in knee osteoarthritis: secondary analysis from a randomised controlled trial. Physiotherapy. 101, pp. 171-177.

Exercise and Arthritis from the Arthritis Research UK

Health Promotion in real world settings: Meeting the stakeholders

Some exciting developments are happening within the MSc Physiotherapy pre-reg programme. This programme allows students with a relevant previous degree to train as physiotherapists in a 2-year taught programme. One of the first modules the students undertake is the Health Promotion module. The aim of this module is for students to understand the role of physiotherapists as agents for health promotion. In addition, they have the opportunity to carry out a health promotion session with members of the public with 3 different organisations. These organisations include the Glasgow Science Centre, ROAR Active for Life, and People Services at Glasgow Caledonian University (the external stakeholders).

Today we all met as a group for the first time to discuss the marking and assessment of the module. Invited were students who took part in the module last year, staff from GSC, ROAR and People Services and the module team. While development of modules is usually done by module teams, this module uses an engagement-through-partnership approach (Higher Education Academy, 2014). This means that we aim to have partnership between students, lecturers and stakeholders at various stages of teaching. This can be during the module when students work in groups, but also at the development stage, as we did today.

The meeting provided an opportunity to explain assessment procedures from a university perspective, but also meant that stakeholders could ask questions about the students’ involvement. The students shared their experiences from last year and for suggestions how assessment could be done better this year.

As we only had one hour, we got through a limited amount of the assessment. The assessment is a continuous summative assessment of the stages of project management. The component discussed today was the ‘scoping stage’. The main point that came out of the discussion was how important it is that we all understand the language of the assessment. For example, what it means when students must use demographic data to assess the needs of the target audience. While I didn’t question what this meant from an academic perspective, it should be clear to all involved what this means. We will therefore include definitions and descriptions about what we understand each term on the assessment form to mean.

Likewise, we agreed that the 3 sites will provide students with information about their organisations and their activities in the context of health promotion. This will help students to understand what the organisation is about. This also means they can ask more focussed questions in the scoping meeting with the organisation.

Best part of the meeting for me was having everyone in the room and having the opportunity to find out what the people around the table think of our ideas and jointly coming up with better ways of doing the assessment. It’s what I like about partnership working!