Clinically Relevant Anatomy and Pathophysiology
Diabetes Mellitus primarily affects the Islets of Langerhans of the pancreas, where glucagon (from the alpha cells) and insulin (from the beta cells) are produced. Glucagon raises the blood glucose level, while insulin lowers it. In Type 1 DM (Insulin Dependent), the loss of function of the beta cells leads to an absolute insulin deficiency. In Type 2 DM (Non-insulin Dependent), the impaired production and secretion of insulin by the beta cells is concommitant with the impaired ability of the tissues to utilize insulin (termed insulin resistance). The resulting accumulation of glucose in the blood is further elevated by the greater synthesis of glucose in the liver, which releases it to the general circulation.
Prevalence and Incidence
Diabetes Mellitus (both Type 1 and Type 2) is now a global epidemic. Usually correlated with being overweight and obese, a sedentary lifestyle and familial history are also being considered as risk factors.
According to the research entiltled “Global Prevalence of Diabetes” by Sarah Wild, MB, BCHIR, PhD and associates, “the total number of people with diabetes is projected to rise from 171 million in 2000 to 366 million in 2030. The prevalence of diabetes is higher in men than women, but there are more women with diabetes than men. The urban population in developing countries is projected to double between 2000 and 2030. The most important demographic change to diabetes prevalence across the world appears to be the increase in the proportion of people greater than 65 years of age.”
Diabetes can be categorized as acquired or hereditary. The lack or decrease in exercise, elevated stress levels, and unhealthy diet all predispose an individual to Type 2 Diabetes Mellitus even without a clear family history.
Considered an endocrine disorder, this could also occur in pregnant women during gestational stage. Susan Y. Chu, PhD, MSPH, and associates, in their research entitled “Maternal Obesity and Risk of Gestational Diabetes Mellitus”, concluded that “high maternal weight is associated with a substantially higher risk of GDM.”
In general, Diabetes Mellitus is a chronic disorder characterized by hyperglycemia or hypoglycemia (or impaired glucose tolerance), with subsequent disruption of the metabolism of carbohydrates, fats and proteins. Over time, it results in serious small and large vessel vascular complications and neuropathies.
Classic triad of Diabetes Mellitus are polydipsia (increased thirst), polyphagia (increased appetite and ingestion) and polyuria (increased urination caused by osmotic diuresis).
Amidst the increased appetite and craving for food, persons with DM (usually Type 1) may still experience weight loss because of the improper fat metabolism and breakdown of fat stores.
Diabetics are more prone to hypoglycemia than hyperglycemia during exercise. But physical therapists must be efficiently adept in distinguishing the differences of the signs and symptoms, including the dangerous Diabetic Ketoacidocis (DKA).
During Diabetic Ketoacidocis (DKA) the patient might experience abdominal pain, anorexia, nausea, vomitting or diarrhea. This occurs more in children. Patient will have confusion and dull mental state which can lead to coma. There is an increase in pulse rate, yet weak. There is an initial deep and rapid breathing which could lead to Kussmaul respiration. Cardinal sign is a fruity or acetone breath. Urine output is increased and the glucose level is extremely high (greater than 300 mg/dl). Ketones are high and pH is acidotic (less than 7.3). The skin is warm and dry. Onset is rapid, which is less than 24 hours.
While on hyperglycemia, there are no gastrointestinal symptoms, usually occur in adults with underlying chronic disease and the patient is also in a dull, confused mental state. Skin is warm and dry, pulse and respiratory rate are high, ketone and pH level are normal, relatively high glucose level and the onset is slow (may take days).
On the other hand, hypoglycemia can occur with all ages. The patient may feel hungry with difficulty in concentration and coordination which could eventually lead to coma. Skin is cold and clammy, there is profuse sweating, increased pulse rate, shallow respiration, considerably low glucose level, ketones and pH are normal and the onset is rapid.
Fasting glucose level of greater than 126 mg/dl on two separate occassions is considered positive.
The strictest criteria is according to the World Health Organization, which states that the diagnosis is positive if “ venous plasma glucose concentration is greater than 11.1 mmol/L 2 hours after a 75g glucose tolerance test.”
The following can be used:
- FOTO (Focus On Therapeutic Outcomes) under the Endocrine, Metabolic and Immunity Disorders of the Impairment Categories
- Foot and Ankle Ability Index
Management / Interventions
For Type 1 (Insulin Depentdent) Diabetes, intramuscular administration of insulin is needed. Dosage is always expressed in USP units. Humalog is the fastest acting insulin, acting within 15 minutes. The PZI has the longest peak of 8-20 hours and has the longest total duration of 36 hours. On the other hand, the Lantus is the only one “without peak” and lasts for 24 hours.
For Type 2 (Non-Insulin Dependent) Diabetes, popular oral hypoglycemics include Metformin and Sulfonylureas. Insulin sensitizers such as Rosiglitazone and Pioglitazone are also prescribed.
Weight management, nutritional and diet counselling combined with physical therapy / exercise prescription completes the wholistic treatment approach.
Physical Therapy Management
Patient education for proper foot care is an essential part of the physical therapy program for diabetic patients. Therapeutic exercises comprise the major aspect of the management.
A sound, individually tailored exercise prescription is a cornerstone in the management of Diabetes Mellitus.
The goal is to address the beyond normal BMI score (25 and above) for overweight and obese patients. Numerous studies show that a regular exercise program for diabetics has a profound effect on the regulation of their blood glucose levels.
From the archives of the Journal of the American Medical Association (JAMA), a research conducted by Daniel Umpierre, MSc and associates entitled “Physical Activity Advice Only or Structured Exercise Training and Association With HbA1C Levels in Type 2 Diabetes, A Systematic Review and Meta-analysis”, it was concluded that “structured exercise training that consists of aerobic exercise, resistance training, or both combined is associated with HbA1C reduction in patients with Type 2 diabetes. Structured exercise training of more than 150 minutes per week is associated with greater HbA1C declines than that of 150 minutes or less per week. Physical activity advice is associated with lower HbA1C, but only when combined with dietary advice.”
Similarly, a randomized controlled trial by Timothy S. Church, MD, MPH, PhD and associates which was entitled “Effects of Aerobic and Resistance Training on Hemoglobin A1C Levels in Patients With Type 2 Diabetes” made a conclusion that “among patients with Type 2 Diabetes Mellitus, a combination of aerobic and resistance training compared with the nonexercise control group improved HbA1C levels. This was not achieved by aerobic or resistance training alone.”
Guidelines for a sound exercise program are as follows:
- Do not exercise if the blood glucose level is less than 100 mg/dl or greater than 250 mg/dl.
- Preferably, exercise indoor instead of outdoor to minimize the risk of integumentary and musculoskeletal trauma, as well as for the patient to have an immediate access to necessary things to address hypoglycemia, hyperglycemia or diabetic ketoacidocis.
- Patients are highly advised to wear the medical tag for diabetics each time they come out of their house to go somewhere else.
- Always have a carbohydrate snack at hand every exercise session. A glass of orange juice or milk is a good pickup for a patient who is experiencing hypoglycemia.
- Exercise in a comfortable temperature. Never exercise in extreme temperatures.
- For Type 1 (Insulin Dependent) patients, never exercise during the peak times of insulin. Collaborate with the nurse in charge for the patient regarding the type of insulin administered.
- Type 2 diabetics are advised to have an average of 30 minutes of exercise duration per session.
- Always wear proper footwear and exercise in a safe environment.
- Type 1 diabetics may need to reduce insulin or increase food intake prior to the start of an exercise program. The physical therapist must coordinate with the referring physician in this case.
- During prolonged exercise duration, a 10-15 grams of carbohydrate snack is recommended for every 30 minutes.
- Clients who are on Sulfonylureas are red flags because it can cause an exercise-induced hypoglycemia. Closely coordinate with the referring physician if this was missed prior to referral.
- Menstruating women need to increase insulin during menses, especially if they’re not active.
- There should be no short-acting insulin injections close to the muscles to be exercised within one hour of exercise.
- Patients should eat 2 hours before exercising. If planning to exercise after meal, patients must wait 1 hour prior to start.
- Patients must always carry their own portable blood glucose monitor. They must check their glucose levels before and after exercise.
- Patients are advised to drink 17 oz. of fluid before exercise.
- If blood glucose is less than 100 mg/dl but not less than 70mg/dl, the physical therapist may provide carbohydrate snack and then recheck the glucose level after 15 minutes.
- Make sure that the type of exercise doesn’t contribute an unnecessary stress to the patient. Stress increases insulin requirements. A gradual progression from aerobic and resístance exercises is the key.
- Avoid exercising late at night.
- If faced with an unexpected and difficult situation wherein the physical therapist is in doubt whether the patient is experiencing hyperglycemia or hypoglycemia, always give a glass of orange juice or milk, or a carbohydrate snack. This is the safest action because this can relieve hypoglycemia (if it is indeed) and cannot harm if it is hyperglycemia.
- Exercise five times a week as a maintenance (or at least every other day) and at the same schedule / time, preferably.
- As much as possible, patient must not exercise alone, so that there will always be someone to help in unexpected situations.
- Good examples of carbohydrate snacks (10-15 grams of carbohydrates) are half a cup of fruit juice or cola, 8 oz. of milk, 2 packets of sugar, 2 oz. tube of honey or cake deco gel.
The physical therapist must screen for the following:
- Complex Regional Pain Syndrome
- Carpal Tunnel Syndrome
- Dupuytren’s Disease
- Flexor Tenosynovitis
- Adhesive Capsulitis
- “Physical Activity Advice Only or Structured Exercise Training and Association With HbA1C Levels in Type 2 Diabetes, A Systematic Review and Meta-analysis” by Daniel Umpierre, MSc and associates.
- “Effects of Aerobic and Resistance Training on Hemoglobin A1C Levels in Patients With Type 2 Diabetes” by Timothy S. Church, MD, MPH, PhD and associates.
1.↑ Sarah Wild,Gojka Roglic, Anders Green, Richard Sicree, and Hilary King. Global Prevalence of Diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care May 2004 vol. 27 no. 5 1047-1053
2.↑ Susan Y. Chu, William M. Callaghan, Shin Y. Kim, Christopher H. Schmid, Joseph Lau, Lucinda J. England,Patricia M. Dietz. Maternal Obesity and Risk of Gestational Diabetes Mellitus. Diabetes Care August 2007 vol. 30 no. 8 2070-2076
3.↑ Daniel Umpierre, Paula A. B. Ribeiro, Caroline K. Kramer, Cristiane B. Leitão, Alessandra T. N. Zucatti,Mirela J. Azevedo, Jorge L. Gross, Jorge P. Ribeiro, Beatriz D. Schaan. Physical Activity Advice Only or Structured Exercise Training and Association With HbA1c Levels in Type 2 Diabetes: A Systematic Review and Meta-analysis. JAMA. 2011;305(17):1790-1799.
4.↑ Timothy S. Church, Steven N. Blair, Shannon Cocreham, Neil Johannsen,William Johnson, Kimberly Kramer, Catherine R. Mikus,Valerie Myers, Melissa Nauta, Ruben Q. Rodarte, Lauren Sparks, Angela Thompson,Conrad P. Earnest. Effects of Aerobic and Resistance Training on Hemoglobin A1c Levels in Patients With Type 2 Diabetes: A Randomized Controlled Trial.JAMA. 2010;304(20):2253-2262.