Physical Therapy Implications For Cardiovascular And Pulmonary Complications

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  • 1. PHYSICAL THERAPY IMPLICATIONS FOR CARDIOVASCULAR AND PULMONARY COMPLICATIONS IN DIABETES MELLITUS
  • 2. DIABETES MELLITUS DIABETES MELLITUS (DM) IS A CHRONIC METABOLIC DISORDER CHARACTERIZED BY HYPERGLYCEMIA AND CAUSED BY INADEQUATE INSULIN PRODUCTION OR INEFFECTIVE INSULIN ACTION. TYPE I: (IDDM)  Develops before adulthood.  Autoimmune destruction of insulin producing pancreatic beta cells occurs.  Result: Little or No insulin production.  Survival is dependent on insulin therapy. TYPE II: (NIDDM)  Heterogeneous disorder occurring in later stages of life (rarely <40).  70 to 90% people have it because of obesity, lack of exercises and familial tendencies.  Patients are insulin resistant at the cellular level because of receptor or post receptor defects.  Hyperglycemia results from an increased rate of hepatic glucose production as a consequence of hepatic insulin resistance.
  • 3. Insulin causes the inhibition of glucose production by the liver and the promotion of glucose transport across cell membrane and its subsequent metabolism within the cell. Deficiency results in an inability to utilize glucose as fuel, impaired protein metabolism, increased fat mobilization with increased level of free fatty acids. Metabolism of free fatty acids in the liver causes formation of ketone bodies and ketoacidosis develops. Anti-insulin hormones like Glucagon, Growth hormone, Cortisol and Catecholamines also participate in glucose metabolism. Insulin and Glucose Physiology
  • 4. COMPLICATIONS  Microangiopathy with thickening or damage to the capillary basement membrane (e.g., retinopathy, nephropathy) and Macroangiopathy by atherosclerosis (e.g., coronary artery, cerebrovascular and peripheral vascular disease) cause damage to organs like eyes, kidneys, heart and peripheral nerves.  Combination of microangiopathy (peripheral neuropathy) and macroangiopathy (arterial insufficiency) leads to the frequent complications of tissue necrosis and infection and sometimes amputation.
  • 5. CARDIOVASCULAR DISEASES  In diabetic patients atherosclerotic heart disease, hypertension, defects in impulse conduction through the heart, congestive heart failure, autonomic neuropathy, cerebrovascular disease and peripheral vascular diseases dominate.  Other cardiovascular abnormalities which are particularly more common in DM are sinus node dysfunction and AV node conduction abnormalities.
  • 6. AUTONOMIC DEFECTS  These are very common in long standing diabetics.  Individuals usually complain of postural hypotension.  Predominantly the parasympathetic nervous system (PNS) is involved.  Resting heart rate can determine the autonomic neuropathy.  In patients with PNS dysfunction HR is elevated at rest and during early phase of exercise, but as the effort progresses, the normal activation of the sympathetic nervous system allows virtually normal HR and BP responses.  In combined defects there is minimal response to stimuli such as valsalva maneuver, standing up, and deep breathing, a fall in BP during standing and blunted HR and BP responses to all phases of exercise.
  • 7. PULMONARY DISORDERS  Hyperglycemic patients have higher incidences of pulmonary infections than non-diabetics.  Patients with autonomic neuropathy may have more sleep related breathing problems.  PFTs show mild abnormalities in lung elastic recoil, diffused capacity and pulmonary capillary blood volume, which are directly related to the duration of DM.  Ketoacidosis causes hyperventillation, pneumomidiastinum and mucus plugs in the major airways.
  • 8. IMPLICATIONS FOR PHYSICAL THERAPY INTERVENTION  Adequate metabolic control should be established before an exercise programme is initiated.  HR and BP evaluations should be incorporated in all physical therapy evaluations as DM patients exhibit abnormal hemodynamic responses to activities.  Self monitoring of blood glucose levels is essential.  Avoid vigorous and prolonged exercise if blood glucose levels are 250- 300 mg/dl and should not exercise at all if blood glucose exceeds 300 mg/dl or if there is any ketosis. Likewise exercises are contraindicated when blood glucose levels are 80-100 mg/dl because of greater risk of hypoglycemia.
  • 9. SIGNS AND SYMPTOMS OF HYPOGLYCEMIA ADRENERGIC  Weakness  Sweating  Tachycardia  Palpitations  Tremors  Nervousness  Irritability  Tingling  Hunger  Nausea  Vomiting NEUROGLUCOPENI C  Headache  Hypothermia  Visual disturbances  Mental dullness  Confusion  Amnesia  Seizures  Coma
  • 10.  To minimize the risk of hypoglycemia, patients should avoid exercising at the time of peak insulin effect.  Start with moderate workloads and increase intensity gradually.  Use a consistent pattern of exercises (time, duration and intensity)  Avoid injecting insulin into tissue near the exercising muscle if patient will be exercising soon thereafter ( within 40 min after regular insulin or within 90 min after intermediate insulin).  Strenuous exercises should be avoided until reasonable diabetic control is achieved.
  • 11. AMPUTEE WITH DIABETES MELLITUS Additional considerations:  Surgical healing following amputation is often delayed or complicated due to the circulatory abnormalities, impaired ability to fight infection, poor blood glucose control and neuropathies associated with diabetics.  The energy demands for prosthetic gait are higher than normal and increase the risk of cardiovascular complications during rehabilitation.  Attention to wrist alignment when using assistive gait devices is important because of the higher incidence of carpal tunnel syndrome.
  • 12. The Elderly Diabetic Patient: Special considerations  50 % of type II DM patients are above 60 years of age.  Depression, impaired cognitive function, and lack of recognition of thirst and subsequent dehydration are important factors to be taken into account in the management of older diabetic patients, who may also have impaired physical function, an increased rate of injurious falls, and increased prevalence of pressure ulcers, amputations and tuberculosis.  Hyperglycemia can result in a decreased pain threshold and incontinence.  Older diabetic patients report reduced physical function compared with other older people as a result of multifactorial impairment that includes visual deterioration, peripheral neuropathy and balance problems.  Functional impairment is associated with increased falls.
  • 13. UNIQUE ASPECTS OF DIABETES MELLITUS IN ELDERLY Syndrome  Cognitive impairment.  Depression/suicide  Amputation  Decreased pain threshold  Functional impairement  Falls  Dehydration  Incontinence, tuberculosis and hypogonadism Preventive measures  Control hyperglycemia and provide written instructions.  Screen using Geriatric Depression Scale and Treat depression.  Pay special attention to foot care.  Control hyperglycemia.  Balance exercises and monitoring of orthostatic blood pressure.  Drink fluids regularly.  Control hyperglycemia.
  • 14.  Numerous factors, such as decreased thirst perception, decreased exercise tolerance, deteriorating vision, arthritis, cognitive problems, depression and social problems, make the management of older people with diabetes extremely difficult.  Exercise is the fundamental therapy for diabetes in older people, but should be undertaken in moderation and not in excess. Endurance exercises are only one component of the complete exercise prescription; strengthening, posture, flexibility and balance exercises are key to maintaining function and preventing falls.
  • 15. REFERRENCES  Cardiopulmonary implications of specific diseases : Joane Watchie.  The Elderly Type 2 Diabetic Patient: Special Considerations John E. Morley* Geriatric Research, Education and Clinical Center, St Louis VAMC, and Division of Geriatric Medicine, St Louis University Medical School, St Louis, Missouri, USA.  Google search.