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  • 1. Physiotherapy for Patients With DiabetesPosted by Alice Martinez at 7:25 PMPhysical Therapy is a branch of medicine that uses the physiological effects of natural(water, air, solar heat and light) and artificial (electric current, magnetic field, etc.) ofphysical factors in the treatment of certain diseases .In the treatment of diabetes using a number of physiotherapy techniques. Very often,patients are electrophoresis. This method is based on the exposure of the body by directcurrent and medicinal materials. With the current medicines into the body throughmucous membranes or skin. When diabetes is used electrophoresis of zinc, copperelectrophoresis, electrophoresis of potassium. Electrophoresis of zinc has beneficialeffects on the state of the islets of Langerhans which produce insulin. Electrophoresis ofcopper improves the reduction-oxidation, reduces blood sugar levels. Diabetes is oftenaccompanied by polyuria, that is, the increased amount of urine separation. In this regard,the body loses potassium. That is why diabetes often prescribe electrophoresis ofpotassium to make up for the missing trace mineral.In addition, the use of magnesium electrophoresis in the general procedure for the neckarea or on Shcherbak, as well as on the liver area. Magnesium is very important for theorganism of the patient with diabetes mellitus. This trace mineral is involved in redoxprocesses, lowers cholesterol. Electrophoresis of the neck of calcium reduces bloodglucose levels. Electrophoresis of nicotinic acid on the epigastrium improves the functionof the pancreas. In diabetes often occur microangiopathy of the lower extremities, whichare accompanied by pain. In this case, patients administered iodine-novocaine-electrophoresis.This method is also used in the treatment of hypertonicity of the vessels. Whenangiopathies of the lower limbs with peripheral neuropathy are often assignedelectrophoresis of 5% sodium thiosulfate. He entered with a negative pole to the region of
  • 2. gastrocnemius muscle. When angiopathies of the lower extremities is also assigned toelectrophoresis with novocaine lumbar krestuovuyu area. It promotes the expansion oflower extremities, thereby decreasing pain. In the treatment of diabetic retinopathy iswidely used medicinal electrophoresis. It has a resolving, anti-inflammatory, anti-sclerotic action. If you are experiencing bleeding, the use of heparin electrophoresis. If apatient suffers from multiple sclerosis retinal vessels, using electrophoresis, a solution ofpotassium iodide. When angiospasm, degenerative changes of the retina usingelectrophoresis of nicotinic acid, a mixture of aloe with vitamin E, S. In the complextreatment of diabetes used a beneficial effect of magnetic field on the metabolic processesin the body. That is why diabetics assigned to the magnet projection area of the pancreas.Usually the course of treatment is 12 sessions. At the same after the first 3-5 sessions adecrease in blood sugar.Magnetic therapy is used in diabetic neuropathy and diabetic foot. The magnetic field hasangioprotective, analgesic, immunomodulating, trophico-regulatory effects. After anincrease in the magneto speed of about nerve impulse along the nerve fibers andperipheral blood flow. Markedly reduced pain in the extremities, less concerned aboutpatients cramps and paresthesia, increased muscular activity, there are beneficial changesin the sensitivity of the foot.For the treatment of neuropathies, used inductothermy angiopathies of the lowerextremities. Inductothermy - a method of electrotherapy, which uses a magnetic field ofhigh frequency. The duration of a procedure - 15 - 20 min. Sessions are held either everyday or every other day. The course of treatment consists of 10-12 procedures. The impactof an alternating magnetic field significantly improves blood and lymph circulation,therefore, is a very effective method of treatment. Also effective in hyperbaric oxygentherapy. This treatment with oxygen under high pressure. This method is capable ofeliminating all forms of hypoxia that occur in diabetes. That is why the hyperbaricoxygen therapy is a medical complex with various forms of diabetes. Observations showthat after the second session, patients feel much better. The general course of treatmentconsists of 10-12 sessions. Each session lasts 40-60 minutes. After about theirmanagement of patients are able to significantly reduce the dose of insulin and othermedications. When diabetes is usually oxygen-reduced function of the blood. Therefore,there is oxygen starvation of tissues and organs.Oxygen treatment reduces hypoxia in various organs and tissues, thus improving visionand hearing, as well as blood circulation in the limbs. It is also important that as a resultof the procedures activated the activity of cells of the pancreas. Keep in mind thathyperbaric oxygen therapy is contraindicated in those suffering from claustrophobia (fearof closed spaces), and epilepsy.Hyperbaric oxygen therapy as a form of oxygen treatment includes the use of oxygeninside the foam. This procedure is very useful for obesity, combined with diabetes
  • 3. mellitus. Ingestion of oxygen foam helps to reduce body weight. This is based on the factthat the foam expands the stomach, making the patient feel satiety and eating less. Foamtake 2 - 3 times a day for 1 hour before meals. Oxygen has beneficial effects on oxidativeprocesses in the body. Oxygen foam is made from infusions and decoctions of herbs withthe addition of whipped egg whites. The finished foam should foam, passing through heroxygen. This is done through a special apparatus. The course of treatment varies from 3to 6 months. During treatment, patients must be under medical supervision.When using acupuncture neuropathy. Special needles are inserted into the biologicallyactive points. Usually carried out 2 - 3 courses of treatment, each of which includesseveral sessions. The result of treatment is improvement of general condition. And mostimportantly, significantly improved nerve conduction, increases the sensitivity of thelower limbs, decrease pain. In addition to using acupressure, electroacupuncture and laseracupuncture.In the treatment of diabetes is used and plasmapheresis. The essence of this method isthat the plasma is removed and replaced with the patients blood plasma substitutes. Suchtreatment is usually given in renal failure and in septic complications. Very effective intreatment of diabetes is ozone therapy. The use of medical ozone increases thepermeability of cell membranes to glucose. Can achieve this effect by stimulating thepentose phosphate shunt, and aerobic glycolysis.As a result, glucose enters the tissue better, decreases hyperglycemia. Carried out theoxidation of glucose to the final products. Ozone affects the exchange of glucose inerythrocytes. Tissues receive more oxygen, hypoxia is eliminated. Ozone therapy canprevent development of pathological processes such as neuropathy, arthropathy,angiopathy. In addition, ozone has immunomodulatory effects. It is very important todiabetes type 1, because it increases the tendency to chronic infections and inflammationof the skin against the backdrop of a weakened immune system. The basis of ozonetherapy - intravenous administration of OS (ozonized physiological solution). Proceduresare carried out through the day. Total course of treatment is 10-14 procedures. Can alsobe rectal administration of ozone.During treatment, necessarily exercise control over blood glucose levels. If necessary,adjusted dose glucose-lowering drugs, the ozone-oxygen mixture because it has ahypoglycemic effect. Often in the course of therapy decreases the amount of glucose-lowering drugs.Ozone treatment significantly improves performance, normalizes sleep. The generalcondition of the patient improves. There was also a reduction in blood sugar levels,increases immunity. Repeated treatments are necessary after 3 - 6 months.In severe forms of diabetes treatment is carried out with great care. Can suddenly worsen,
  • 4. because the antioxidant defense system is broken.For physiotherapy and hydrotherapy methods include, or hydrotherapy. The essence ofthis method - in the external application of water. It could be pouring, wraps, shower,bath, wiping, etc. Various water treatment stimulates blood flow and lymph flow.As a result, water treatment increases lymph and blood flow to a particular area,improved nutrition and respiration of cells in this area. This is beneficial for tissue repairand for the whole body.Therapeutic effects of water based on the fact that by warming or cooling. Hot waterdilates blood vessels, thus increasing blood flow and lymph flow in a certain place. Coldwater, however, leads to a narrowing of veins and arteries. On this site reduces theamount of blood and lymph. The alternation of hot and cold water can bring freshportions of oxygen and nutrients in a particular area of the body. Hydrotherapy is used inthe complex sanatorium treatment, as well as in everyday life. Every patient with diabetesmay use a contrast shower, alternating hot and cold water. It has beneficial effects on thenervous system, blood circulation, has a tonic and invigorating action.Some caution should be exercised in a decreased sensitivity of limbs, which often occursin patients with diabetes mellitus. Using excessively hot water can cause burns becausethe patient does not always feel right temperature. It is undesirable to use and extremelycold water, so as not to catch cold. And the rest of hydrotherapy - an effective, affordableand secure method. However, preliminary medical consultation is still necessary.Balneotherapy (from Latin. Balnem - bath, bathing) for at least an effective treatment forpatients with diabetes. This method is based on the treatment of natural or artificiallyprepared mineral waters. Balneotherapy is used in complex sanatorium treatment. Formore information on it is written in the thematic section of the sanitary-health resorttreatment on an information portal on vital This BlogThis! Share to Twitter Share to Facebook Share to Google Buzz[Accept this article with precaution].
  • 5. Diabetes Chester Ryan AzurinContents • 1 Clinically Relevant Anatomy • 2 Prevalence, Incidence and Pathophysiology • 3 Clinical Presentation • 4 Diagnostic Procedures • 5 Outcome Measures • 6 Management / Interventions • 7 Physical Therapy Management o 7.1 Exercise Therapy • 8 Differential Diagnosis • 9 Key Evidences • 10 • 11 Recent Related Research (from Pubmed) • 12 ReferencesClinically Relevant AnatomyDiabetes Mellitus primarily affects the Islets of Langerhan cells of the pancreas, whereinsulin is produced. Insufficiency of these cells leads to impaired production andsecretion of insulin, which bears the purpose of regulation of blood sugar level.Prevalence, Incidence and PathophysiologyDiabetes Mellitus (both Type 1 and Type 2) is now a global epidemic. Usually correlatedwith being overweight and obese, a sedentary lifestyle and familial history are alsobeing considered as risk factors.According to the research entiltled "Global Prevalence of Diabetes" by Sarah Wild, MB,BCHIR, PhD and associates[1], "the total number of people with diabetes is projected torise from 171 million in 2000 to 366 million in 2030. The prevalence of diabetes ishigher in men than women, but there are more women with diabetes than men. Theurban population in developing countries is projected to double between 2000 and2030. The most important demographic change to diabetes prevalence across the worldappears to be the increase in the proportion of people greater than 65 years of age."
  • 6. 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 DiabetesMellitus even without a clear family history.Considered an endocrine disorder, this could also occur in pregnant women duringgestational stage. Susan Y. Chu, PhD, MSPH, and associates[2], in their research entitled"Maternal Obesity and Risk of Gestational Diabetes Mellitus", concluded that "highmaternal weight is associated with a substantially higher risk of GDM."In general, Diabetes Mellitus is a chronic disorder characterized by hyperglycemia orhypoglycemia (or impaired glucose tolerance), with subsequent disruption of themetabolism of carbohydrates, fats and proteins. Over time, it results in serious small andlarge vessel vascular complications and neuropathies.Clinical PresentationClassic triad of Diabetes Mellitus are polydipsia (increased thirst), polyphagia (increasedappetite and ingestion), and polyuria (increased urination caused by osmotic diuresis).Amidst the increased appetite and craving for food, persons with DM may stillexperience weight loss because of the improper fat metabolism and breakdown of fatstores.Other striking features include the presence of glucose and ketone bodies in the urine.Fatigue with weakness, irritability, blurred vision, numbness or tingling sensations in thehands and feet are also present.Diagnostic ProceduresFasting glucose level of greater than 126 mg/dl is considered positive.The strictest procedure is according to the World Health Organization, which states thatthe diagnosis is positive if "venous plasma glucose concentration is greater than 11.1mmol/L 2 hours after a 75g glucose tolerance test."Outcome MeasuresThe 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
  • 7. Management / InterventionsFor Type 1 (Insulin Depentdent) Diabetes, intramuscular administration of insulin isneeded. 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 longesttotal 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 includeMetformin and Sulfonylureas. Insulin sensitizers such as Rosiglitazone and Pioglitazoneare also prescribed.Weight management, nutritional and diet counselling combined with physical therapy /exercise prescription completes the wholistic treatment approach.Physical Therapy ManagementPatient education for proper foot care is an essential part of the physical therapy programfor diabetic patients. Therapeutic exercise program comprise the major aspect of themanagement.Exercise TherapyA sound, individually tailored exercise prescription is a cornerstone in the managementof Diabetes Mellitus.The goal is to address the beyond normal BMI score (25 and above) for overweight andobese patients. Numerous studies show that a regular exercise program for diabetics has aprofound effect on the regulation of their blood glucose levels.From the archives of the Journal of the American Medical Association (JAMA), aresearch conducted by Daniel Umpierre, MSc and associates[3] entitled "Physical ActivityAdvice Only or Structured Exercise Training and Association With HbA1C Levels inType 2 Diabetes, A Systematic Review and Meta-analysis", it was concluded that"structured exercise training that consists of aerobic exercise, resistance training, orboth combined is associated with HbA1C reduction in patients with Type 2 diabetes.Structured exercise training of more than 150 minutes per week is associated withgreater HbA1C declines than that of 150 minutes or less per week. Physical activityadvice is associated with lower HbA1C, but only when combined with dietary advice."
  • 8. Similarly, a randomized controlled trial by Timothy S. Church, MD, MPH, PhD andassociates[4] which was entitled "Effects of Aerobic and Resistance Training onHemoglobin A1C Levels in Patients With Type 2 Diabetes" made a conclusion that"among patients with Type 2 Diabetes Mellitus, a combination of aerobic andresistance training compared with the nonexercise control group improved HbA1Clevels. 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. Physical Therapist must coordinate with the referring physician for 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 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 theyre 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.
  • 9. • Make sure exercise doesnt 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.Diabetics are more prone to hypoglycemia than hyperglycemia during exercise. Butphysical therapists must be efficiently adept in distinguishing the differences in the signsand 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 haveconfusion and dull mental state which can lead to coma. There is an increase in pulserate, yet weak. There is an initial deep and rapid breathing which could lead to Kussmaulrespiration. Cardinal sign is a fruity or acetone breath. Urine output is increased and theglucose level is extremely high (greater than 300 mg/dl). Ketones are high and pH isacidotic (less than 7.3). The skin is warm and dry. Onset is rapid, which is less than 24hours.While on hyperglycemia, there are no gastrointestinal symptoms, usually occur in adultswith 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 arenormal, 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 hungrywith difficulty in concentration and coordination which could eventually lead to coma.Skin is cold and clammy, there is profuse sweating, increased pulse rate, shallowrespiration, considerably low glucose level, ketones and pH are normal and the onset israpid.Differential Diagnosis
  • 10. The physical therapist must screen for the following: • Complex Regional Pain Syndrome • Carpal Tunnel Syndrome • Dupuytrens Disease • Flexor Tenosynovitis • Adhesive CapsulitisKey Evidences • "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.References 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.
  • 11. A person with type 2 diabetes can use exercise to help control their blood sugar levels andprovide energy their muscles need to function throughout the day. By maintaining a healthy dietand sufficient exercise, a person with type 2 diabetes may be able to keep their blood sugar in thenormal non-diabetic range without medication.