Physical Therapy Management and Effectiveness of Patients

with DiabetesJ. Kyle Veazey, SPT

Rockhurst University

According to the World Health Organization (WHO), 366 million people are projected to have a form of diabetes by the year 2030.

Increased incidence among VA population

Nearly 4.5% of the world’s population◦ Prevalence: M > F◦ Greatest increase in people >65 y.o.

(Wild S, et al. 2004)

Incidence

Cade (2008) notes that:“As physical therapists increasingly become first-line providers of treatment for musculoskeletal and movement disorders in people with diabetes, it will be important for clinicians to be keenly aware of the underlying vascular deficits in their treatment programs, even if [diabetes] was not the reason for referral.”

Incidence

Impairment of glucose metabolism in which glucose is underutilized and blood glucose levels become abnormally elevated (hyperglycemia)

Complications: stroke, CVD, genitourinary dysfunction, neuropathy, diabetic coma, retinopathy, nephropathy, atherosclerosis, decreased wound healing/infection, osteoporosis (Goodman, 2004)

Diabetes Mellitus

Atherosclerosis CVA, heart attack, PVD Infection, neuropathy ulceration,

amputation Retinopathy blindness Nephropathy ESRD, dialysis dependence Osteoporosis spinal compression

fractures, hip fractures

Complications (cont’d)

Usually diagnosed in childhood (under 20 years). The body makes little or no insulin, and daily

injections of insulin are required to sustain life. Without proper daily management, medical emergencies can arise.

These patients are prone to ketoacidosis and disorders associated with hyperglycemia.

They comprise ~5-10% of all cases of diabetes mellitus. (Cade, 2008; Goodman, 2004)

Type 1 Diabetes

Makes up 90% or more of all cases of diabetes mellitus and historically occurs in adulthood (over 40 years).

The pancreas does not make enough insulin for normal blood glucose levels, often because the body does not respond well to the insulin.

Continuum with Metabolic Syndrome and Obesity

Type 2 Diabetes

S & S of Type 1 Diabetes:

Increased thirst Increased urination Weight loss in spite

of increased appetite

Fatigue Nausea Vomiting

S & S of Type 2 Diabetes:

Increased thirst Increased urination Increased appetite

Fatigue Blurred vision Slow-healing

infections Impotence in men

Type 1 vs Type 2

◦ Insulin not present at all, or in sufficient amounts◦ Glucose collects in bloodstream and can’t enter

cellsOR

◦ Insulin present but cell wall/transport proteins resistant to its action

◦ Glucose collects in bloodstream and can’t enter cells

ALL cells in the body require insulin for glucose to enter the cell, except:◦ Central nervous system tissue◦ Working (exercising) muscle tissue

Physiology of diabetes

Increases GLUT-4 transporters at cell membrane◦ Increases transport of glucose into cell◦ Does NOT require insulin during this time

(temporary; follows exercise)◦ DOES need some insulin in the system

Over time, increases sensitivity of cells to insulin (helpful in Type II DM)

Changes composition of lipids in bloodstream (Gulve, 2008)

Effect of Exercise on Diabetes Mellitus

Check blood glucose BEFORE AND AFTER exercise◦ Per Goodman: 100-150 mg/dL before◦ Per Gulve: >/= 110 mg/dL after

Do NOT exercise if BGL is:◦ < 100 mg/dL◦ > 250-300 mg/dL

Optimal timing for exercise is 2-3 hours after meal (between peaks of fast-acting and slower-acting components of insulin) (Goodman 2004)

Low to moderate intensity is best to prevent abrupt changes in BGL (Gulve 2008)

Exercise Considerations

Gibson, et al. (2013) found that predictors for acute glucose response to exercise included:

◦ Pre-exercise glucose◦ % age adjusted max HR◦ Duration of exercise◦ Minutes since eating◦ Hgb A1c◦ Age

Exercise Considerations

Aerobic Exercise: 150 min a week, spread over at least 3 days each week◦ “aerobic activity alone cannot deliver the full

benefits of exercise to individuals with Type 2 DM”

Resistance Exercise (strength training): 2 to 3 times a week◦ highly effective adjunct for weight loss◦ only type of exercise offering some protection

against sarcopenia and decreasing muscle strength/physical function occurring with age (agrees with findings by Gulve, 2008)

Exercise Guidelines: ACSM 2010

Exercise helps improve insulin sensitivity (DMII)

Exercise counteracts several negative outcomes of the disease process◦ Atherosclerosis (change in lipid concentrations)◦ Cardiovascular disease (improved CV function)◦ Poor wound healing (boosting immune system)◦ Neuropathy (increased VO2)

Exercise can improve weight-control efforts (DMII)

Timing of insulin and/or meds may be the most important self-controlled factor to tight glycemic control

Patient Education

Cade, TW. Diabetes-related microvascular and macrovascular diseases in the physical therapy setting. Phys Ther. 2008;88(11):1322-1335. doi:10.2522/ptj.20080008

Gibson BS, Colberg SR, Poirier P, et al. Development and validation of a predictive model of acute glucose response to exercise in individuals with type 2 diabetes. Diabetology & Metab Synd. 2013;5(33):1-9.

Goodman CC, Fuller KS, Boissonnault WG. Pathophysiology: implications for the physical therapist. 2003;2nd ed. pp. 350-1.

Gulve, EA. Exercise and glycemic control in diabetes: benefits, challenges, and adjustments to pharmacotherapy. Phys Ther. 2008;88(11):1297-1321. doi:10.2522/ptj.20080114

Wild S, Roglic, G, Green A, Sicree R, King H. Global prevalence of diabetes estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27(5):1047-1053. doi:10.2337/diacare.27.5.1047

References