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DIABETES MELLITUS


Diabetes mellitus is the clinical syndrome characterized by an increase in plasma blood glucose (hyperglycemia). Type 1 diabetes is generally considered to result from autoimmune destruction of insulin producing cells (β cells) in the pancreas, leading to marked insulin deficiency, whereas type 2 diabetes is characterized by sensitivity to the action of insulin and inability to produce sufficient insulin to overcome this ‘insulin resistance’.[1] Type 2 diabetes mellitus is associated with excess body fat. A common feature of type 2 diabetes is an upper-body fat distribution regardless of the amount of total body fat. Four types of diabetes are recognized based on etiologic origin: type 1, type 2, gestational (i.e., diagnosed during pregnancy), and other specific origins (i.e., genetic defects and drug induced); however, most patients have type 2, followed by type 1. Hyperglycemia causes both acute and long term problems. Acutely it can result in marked symptoms, metabolic decompensation and hospitalization. Chronic hyperglycemia is responsible for diabetes specific  ‘microvascular’ complications affecting the eyes (retinopathy), kidneys (neuropathy) and feet (neuropathy)[2]

 

IMPAIRMENTS


BODY STRUCTURES

  1. Destruction of β cells of islets of Langerhans ( in type 1)

  2. Hyperplasia and hypertrophy of β cells followed by atrophy and hypoplasia

  3. Hyaline arteriosclerosis

  4. Damage in medium and large arteries leading to arteriosclerosis.

  5. Retinopathy (cotton wool spots )

  6. Nephropathy – damage to glomerulus

  7. Neuropathy

  8. Ulcers

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BODY FUNCTIONS

  1. Impaired sensory functioning (gloves and stockings distribution)

  2. Polydypsia

  3. Polyphagia

  4. Polyuria

  5. Glycosuria

  6. Impaired healing of wounds

  7. Reduced Flexibility (calcification of arteries lead to reduced blood supply to the muscles)

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GOALS

 

  • Short term

  1. Patient and family awareness of disease

  2. Reduce risk of secondary impairments

  3. Aerobic exercises to Improve Cardiovascular fitness

  4. Improve muscle strength and endurance

  5. Improve flexibility

  6. Decrease symptoms of neuropathy

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  • Long Term

  1. ​Maintain all STG

 

MANAGEMENT

 

Patient and family education

  • To make patient aware of the condition.

  • Support risk factors modification techniques (for diabetes mellitus)

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Prevention of secondary complications

  • Preventive measures-

    • Diabetic control

    • Regular foot and leg self-examination

    • Use of proper foot wear

    • Regular exercise

    • Avoiding injury

    • Quit smoking     

 

Diabetes can be very dangerous to the patient’s feet—even a small cut could have serious consequenses. To avoid serious foot problems that could result in losing a toe, foot or leg, be sure your patient follow these guidelines-

DIABETIC FOOT CARE GUIDELINES
(By AMERICAN COLLEGE OF FOOT AND ANKLE SURGEONS)

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  • Inspect your feet daily

  • Wash your feet in lukewarm( not hot!) water

  • Be gentle while bathing your feet

  • Cut nails gently and straight across

  • Never trim corns and calluses

  • Wear clean, dry socks

  • Avoid wrong type of socks-

    • Tight elastic bands (they reduce circulation).

    • Thick or bulky socks (they can fit poorly and irritate the skin)

  • Wear sock to bed (if feet gets cold at night NEVER use a heating pad or hot water bottle)

  • Shake out your shoe and inspect the part before wearing.

  • Keep your feet warm and dry

  • Never walk barefoot

  • Take care of your diabetes

  • Don’t smoke

  • Get periodic foot exams

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Aerobic exercise training to improve cardiovascular fitness

  • Frequency : 3-7 days per week

  • Intensity : 50%–80% [V with dot above]O2R or HRR corresponding to a rating of perceived exertion (RPE) of 12 to 16 on a 6 to 20 scale 

  • Time : 20–60 min·d-1 continuous or accumulated in bouts of at least 10 minutes to total 150 minutes per week of moderate physical activity

  • Type : Emphasize activities that use large muscle groups in a rhythmic and continuous fashion. Personal interest and desired goals of the exercise program should be considered.[2]

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Improve muscle strength

  • Resistance training should be encouraged for people with diabetes mellitus in the absence of contraindications like retinopathy, and recent laser treatments.

    • Frequency: 2–3 d · wk-1 with at least 48 hours separating the exercise sessions

    • Intensity: 2 to 3 sets of 8 to 12 repetitions at 60% to 80% 1-RM

    • Time: 8 to 10 multijoint exercises of all major muscle groups in the same session (whole body) or sessions split into selected muscle groups

    • Type: Given that many patients may present with comorbidities, it may be necessary to tailor the resistance-exercise prescription accordingly. Emphasize proper technique, including minimizing sustained gripping, static work, and the Valsalva manuever to prevent an exacerbated BP response.[2] 

Strength training is effective in glycemic control and show added advantage in improving lipid profile. [3]

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Improve Flexibility

  • Passive static stretching[4]

 

Decrease symptoms of neuropathy

  • Neurodynamic Mobilization

    • Nerve sliders - nerve sliders performed for the positive tested nerve on neurodynamic testing

  • Transverse nerve massage along the nerve trunk found tender on manual palpation (sciatic, common peroneal and tibial nerves).[5]

 

REFERENCES

  1. Stuart H. Ralston, Ian D. Penman, et al, Davidson’s Principles and Practice of Medicine,23rd Edition, Page no-722.

  2. Walter R. Thompson, American College of Sports Medicine’s Guidelines for Exercise Testing and Prescription, 8th Edition, Page no-232 to 235.

  3. Edmund Cauza MD, Ursula Hanusch, et al, The Relative Benefits of Endurance and Strength Training on the Metabolic Factors and Muscle Function on People with Type 2 Diabetes Mellitus,Archives of Physical Medicine and Rehabilitation, Volume 86 Issue 8.

  4. Seong Hoon Park, MSc, PT, Effects of passive static stretching on blood glucose levels in patients with type 2 diabetes mellitus, J. Phys. Ther. Sci. 27: 1463–1465, 2015.

  5. Kumar P.S.,Adhikari P, et al, Immediate effects of nerve sliders and nerve massage on vibration and thermal perception thresholds in patients with painful diabetic peripheral neuropathy- a pilot randomized clinical trial, Physiotherapy and Occupational Therapy Journal Volume 3 Number 3, July - Sept 2010

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