Diabetes and physiotherapy

2. DIABETES MELLITUS
Submitted to: Dr. Nishant Tejwani Sir
Presented by: Nirshita Gandhi

3. Defination
● Diabetes mellitus(DM), is a group of
diseases characterized by high levels of
blood glucose resulting from defects in
insulin production, insulin action or both.
● The term diabetes mellitus describes a
metabolic disorder of multiple aetiology
characterized by chronic hyperglycemia
with disturbances of carbohydrate, fat
and protein metabolism resulting from
defects in insulin secretion, insulin action
or both.

4. Cont…..
• Normal Range of Blood Sugar is 70 – 99
mg/dl.
• Pre Diabetes Range is 100 – 124 mg/dl.
• ≥ 125 mg/dl is considered as Diabetes
Mellitus.
• The effects of diabetes mellitus include long-
term damage, dysfunction and failure of
various organs.
• Diabetes Mellitus may present with
characteristic symptoms such as frequent
urination, increased thirst, increase hunger,
blurring vision and weight loss.

5. Insulin action and
homeostasis
● Beta cell of islets of Langerhans secret
insulin when glucose level in blood is
high(normal:<126mg/dl).
● Insulin regulates glucose entry into all
tissues(primarily muscles and adipose
tissue except brain) by facilitation
diffusion mechanism.
● Following a meal, insulin mediated
glucose uptake by cell and
corresponding reduce hepatic glucose
output.

6. Cont…..
● Insulin exert hypoglycemic effect.
● Fat synthesis: increase glucose level
insulin secretion this facilitate glucose
uptake by fat cells for the triacylglycerol
synthesis.
● Insulin action also triggers intracellular
enzyme activity that facilitate protein
synthesis by:
1)increases amino acid transport
2)increases cellular level of RNA
3)increases protein formation by
ribosomes activation

8. Burden of Diabetes
 The development of diabetes is projected to
reach pandemic proportional over the next
10-20 years.
 International Diabetes Federation(IDF)
data indicate that by the year 2025, the
number of people affected will reach 333
million, in which 90% of these people will
have Type 2 diabetes.
 In most Western societies, the overall
prevalence has reached 4-6%, and is as
high as 10-12% among 60-70 year-old
people.

10. Types of Diabetes Mellitus
 1). Type 1 Diabetes Mellitus.
 2). Type 2 Diabetes Mellitus.
 3). Gestational Diabetes.
Other…
 Secondary Diabetes Mellitus.

11. Type 1 Diabetes Mellitus
 It is also known as Insulin-dependent Diabetes
Mellitus or Juvenile-onset diabetes.
● It is characterized by loss of insulin producing
beta cells of the Islet of Langerhans in the
pancreas, leading to insulin deficiency.
● So, little or no insulin production.
● So extreme hyperglycemia, ketosis occurs.
● Need insulin for survival.
● This form of diabetes usually strikes children
and young adults, although disease onset can
occur at any age.

12. Cont…..
 Type 1 Diabetes Mellitus may account
for 5% to 10% of all diagnosed cases
of diabetes.
 Risk factors for type 1 diabetes may
include autoimmune, genetic(impaired
glucose tolerance, defect in proper
development and growth of pancreas)
and environmental factors( Viral
Infection and Dietery factor).

13. Cont….
 Genetic Factors:-
Twin studies: Among
monozygotic twins, the concordance
rate is 30-70% i.e. if one twins gets
DM, the chances of second twin
getting are 30-70%.

14. Pathogenesis
 Normal Islets
 Viral infection in pancreatic cells secretion of
interferon α by β cells
 Hypersecretion of class 1MHC Ag
 Insulitis
 Selective destruction of cells
 Insulin deficit islet

16. Type 2 Diabetes Mellitus
 It is also known as non insulin-
dependent diabetes mellitus or adult-
onset diabetes.
 It usually begins as insulin resistance,
a disorder in which the cells do not
use insulin properly. As the need for
insulin rises, the pancreas gradually
loses its ability to produce insulin.
● Associated with obesity, lack of
exercise, familial tendency, older age,
impaired glucose metabolism.

17. Cont…..
 Type 2 diabetes is increasingly being
diagnosed in adolescents.
 Type 2 Diabetes Mellitus may account
for about 90-95% of all diagnosed
cases of diabetes.
 Risk factors for type 2 diabetes
includes genetic factors( mutation in
insulin receptor genes causes insulin
resistance) and environmental
factors(high calory food,less
excersie,stress).

18. Cont….
Other Risk Factors are:-
 Age more than or less than 45 years.
 Overweight.
 Family History of diabetes.
 History of GDM or deliver of a baby >
9 lbs.
 Hypertension.
 History of vascular disease.

19. Cont….
• Genetic Factors:-
Twin studies: Concordance in
monozygotic twins is 70-90%. If both parents
are diabetic, their off spring has 90% chance
of developing type 2 DM.
• The ‘thrifty phenotype’ hypothesis:-
Individuals with low birth weight appear
to have higher risk of type 2 DM, particularly
if they become obese in later life. This
hypothesis suggest that intra uterine
malnutrition leads to defective pancreatic
development. Such individuals may become
susceptible to diabetes, hypertension and
heart disease in later life.

20. Pathogenesis
 Insulin Resistance
 Increase hepatic glucose production
 Hyperglycemia.
Moderate reduction in pancreatic
islets tissues.

22. Comparison between Type 1 and
Type 2
Feature Type 1 DM Type 2 DM
Onset Sudden Gradual
Age of Onset Mostly in Children Mostly in adults
Body size Thin or Normal Often obese
Ketoacidosis Common Rare
Autoantibodies Usually Present Absent
Endogenous Insulin Low or absent Normal, decreased or
increased
Prevalence ~10 ~90

23. Gestational Diabetes
● It is due to when the body of a pregnant women
does not secret insulin require during pregnancy
leading to increase in blood sugar levels.
● Antagonization of peripheral actions of insulin
due to raised levels of oestrogens,
progesterone, corticosteroids and human
placental lactogen.
● Rapid insulin destruction due to high insulinase
activity of placenta.

24. Cont….
● Depletion of β cell insulin reserve. Increased
utilization of stored nutrients and glucose to
feed the foetus leads to fasting
hypoglycemia, ketonemia and elevated free
acids which leads to insulin release and
ultimately depletion of beta cell insulin
reserve.
● Occurs in about 2-10%of all pregnancies and
may improve or disappear after delivery.
● However, after pregnancy approximately 5-
10% of women with gestation diabetes are
found to have diabetes mellitus, most
commonly type 2.

25. Cont….
● Gestational diabetes is fully treatable,
but requires careful medical
supervision throughout the pregnancy.
● Management may be include dietary
change ( high protein intake and
restriction of salt if oedema), blood
glucose monitoring, exercise and in
some cases insulin may be required.

26. Cont….
 For fetal well being:-
- Maternal records of fetal
movements.
- Fetal heart rate patterns.
- Lecithin: Sphingomyelin ratio (for
lungs)

28. Adverse effects on Pregnancy
 Polyhydramnios
 Pre-eclampsia, eclampsia
 Recurrent abortions
 Premature labour
 Prolonged labour
 Hypoglycemia (first trimester)
 Hyperglycemia (third trimester)
 Postpartum Hemorrhage
 Retinopathy
 Nephropathy

29. Adverse effect on foetus
 Macrosomia (large babies) because of
foetus/hyperinsulinemia causing
excessive fat deposition and
visceromegaly.
 Prematurity.
 Post partum hypoglycemia from
persisting insulin secretion after birth in
absence of glucose supplied via
placenta.
 Intra-uterine death more common after
37th week, hence early termination of
pregnancy is advisable especially if she
has vascular complications.

30. Secondary DM
 Acromegaly.
 Cushing Syndrome.
 Thyrotoxicosis.
 Chronic Pancreatitis.
 Drug induced hyperglycemia:
- Beta-blockers- Inhibit insulin
secretion
-Calcium Channel Blockers- Inhibits
secretion of insulin by interfering with
cytosolic calcium release.
-Corticosteriods- Causes peripheral
insulin resistance and gluconeogensis.

31. Signs and Symptoms
● Polydipsia (Due to Lost blood volume will be
replaced osmotically from water held in body
cells and other body compartments, causing
dehydration and increased thirst.)
 Polyuria (Due to increase in the osmotic
pressure of the urine and inhibits reabsorption of
water by the kidney, resulting in increased urine
production.)
 Polyphagia (excessive hunger or increased
appetite and is one of the 3 main signs of
diabetes.)

32. Cont…..
 Glycosuria (When the glucose
concentration in the blood is raised beyond
its renal threshold, reabsorption of glucose
in the proximal renal tubuli is incomplete,
and part of the glucose remains in the
urine.)Normal:- 100mg/d is excreted.
 Tiredness (due to decrease glucose uptake
by body)
 Weight loss ( as the body can't utilize the
glucose in blood ,body starts breake down
fat storage)
 Blurred vision

33. Cont….
 Slow healing (more bacteria at fresh
wound as high sugar level in blood)
 Genital itching (as high sugar in urine
output)
 Stupor (lack of critical mental function)
 Leg Cramp (involuntary muscle
contraction of leg)
 Vomiting
 Nausea
 Abdominal Pain

34. Cont….
 Fatigability
 Irritability
 Numbness and tingling in extremeties
 High chances of infection
 Skin Rashes

37. Diagnosis

39. Diagnosis
● GLUCOSE TOLERANCE TEST
● DM is characterized by recurrent
persistent hyperglycemia and is
diagnosed by demonstrating any one of
following :-
● 1)Fasting Plasma Glucose level > 7.0
mmol/l
● 2)Plasma Glucose > 11.1 mmol/l
● 3)Glycated Hb > 6.5%
● 4)Symptoms of hyperglycemia and
causal plasma glucose >11.1 mmol/l.

40. Lab. Investigations
 Fasting glucose test.
 Post-pranidal blood glucose test.
 Lipid Profile.
 Urine Test.
 Micro-albuminuria.
 Glycated Haemoglobin.

41. Complications
Acute complications
1)Diabetic ketoacidosis
2)Hyperglycemia hyperosmolar state
3)Hypoglycemia

42. Diabetic ketoacidosis
 Low insulin levels cause the liver to turn to
fat for fuel ketone bodies.
 Elevated levels of ketone bodies in the blood
decrease the blood's pH, leading to DKA. On
presentation at hospital, the patient in DKA is
typically dehydrated and breathing rapidly and
deeply. This form of breathing referred to as
Kussmaul breathing. -Abdominal pain
 Ketoacidosis can easily become severe
enough to cause hypotension, shock, and
death. Ketoacidosis is much more common in
type 1 diabetes than type 2.

43. Hyperosmolar nonketotic state
 Hyperosmolar nonketotic state (HNS) is an
acute complication sharing many symptoms
with DKA.
 Water is osmotically drawn out of cells into
the blood and the kidneys eventually begin to
dump glucose into the urine. This results in
loss of water and an increase in blood
osmolarity. If fluid is not replaced (by mouth or
intravenously), the osmotic effect of high
glucose levels, combined with the loss of
water, will eventually lead to dehydration.
 Though this is more common in type 2
diabetes than type 1.

44. Hypoglycemia
 Hypoglycemia, or abnormally low blood
glucose, is an acute complication of several
diabetes treatments.
 Consciousness can be altered or even lost
in extreme cases, leading to coma, seizures,
or even brain damage and death.
 This may be caused by several factors, such
as too much or incorrectly timed insulin, too
much or incorrectly timed exercise.
 Intravenous infusion of dextrose is used for
treatment

45. Chronic complications
1)DIABETIC NEUROPATHY
2)DIABETIC NEPHROPATHY
3)DIABETIC RETINOPATHY
4)DIABETIC CARDIOMIOPATHY

46. 1)Diabetic Neuropathy
Somatic:
- Polyneuropathy
Symmetrical, mainly sensory
and distal
Asymmetrical, mainly motor
and proximal
- Mononeuropathy

47. Visceral:
Cardiovascular
Gastrointestinal
Genitourinary
Sudomotor
Vasomotor
Pupillary

48.  A diabetic foot is a foot that exhibits any
pathology that results directly from
diabetes mellitus.
 Presence of several characteristics
diabetic foot pathologies such as
infection and diabetic foot ulcer known
as diabetic foot syndrome.
 Due to the peripheral nerve dysfunction
associated with diabetes patient have a
reduced ability to feel his or her feet
properly.
 Normal sweat secretion and oil
production that lubricates the skin of the
foot is impaired.

49.  Most ulcers develop at the site of a
plaque of callus skin beneath which
the tissue necrosis occurs and
eventually breaks through to the
surface.
 In some cases, neuropathy or
ischaemia predominate.
 Ischaemia alone accounts for a
minority of foot ulcer in diabetic
patients, with most being either
neuropathic or neuro-ischaemic in
type.

50. Cont….
 These factors together can lead to
abnormal pressure on the skin, bones
and joints of the foot during walking and
can lead to breakdown of the skin of the
foot.
 Sores may develop.
 In diabetes, peripheral nerve
dysfunction can be combined with
peripheral artery disease causing poor
blood circulation to the extremities.
 As wound healing take a longer time
lower limb amputation may be
necessary.

52. Cont….
Treatment:
-systemic antibiotics.
Precautions:
Regular checking for foot for an scar,
inflammation, ulcer and injury.
Wear socks.
Never walk on bare foot.
Moisturize the feet but not toes.
Cut the nail carefully.

54. 2)Diabetic Nephropathy
 Damage to the kidney which can lead to
chronic renal failure, eventually requiring
dialysis.
 High blood glucose level damage to
kidney filtrate system allowing protein in
urine.
 Production of excessive reactive oxygen
and cytokinin leads to damage of
glomerular filtration barrier, which is
highly selective to pass only water.
 So we found albumin in Urine.

56. 3)Diabetic Retinopathy
 High blood sugar level damage to tiny
blood vessels in retina.
 Retina defects lights and convert into
signal for optic nerve.
 Blood vessels leaks fluid and blood,
distoring vision.
 In advance stage proliferation of new
blood vessels on retina, which cause
cell loss of retina.

58. 4)Diabetic Cardiomiopathy &
Stroke
 Normal blood vessels have endothelium,
that keeps blood flow smoothly by
producing nitrous oxide and prevent cell
from sticking on walls.
 Excessive blood sugar, elevated fatty
acid and triglycerides leads to sticky wall
and hardening wall.
 Due to atherosclerosis hardening and
narrowing of artery due to increase sugar
level.
 So patient are more prone to heart attack
and stroke.

59. Aims
● Control symptoms
● Prevent crises of ketoacidosis/
hypoglycemia
● Maintain normal growth
● Encourage self care
● Ensure optimal quality of life
● Obtain best glucose level
● Eliminate risk factors

60. Management
● Medical or pharmacological
management
● Surgical management
● Physiotherapy management
● Lifestyle modifications

61. (A) Pharmacological
management
● In presence of marked symptomatic
hyperglycemia along with dietary
modifications mainly 2 type drugs use:
● 1)Sulphonylureas(insulin secretion
by B cells)
● -tobutamine
● -metformin
● -acarbose
● -glipizide

62. Cont….
2). Biguanides (peripheral uptake of glucose)
- it is not causing hypoglycemia side
effect.
3). Thiazolidinediones(TZDs)
OTHER METHOD:-
1.open loop system
(without glucose sensor)
2.closed loop system
( with glucose sensor)
3.implantable insulin pump
4. insulin pens

63. Insulin
 Mostly used in type 1 diabetes and rarely in
type 2 if there is a failure of oral
hypoglycemic drugs.
 It includes:-
a. Short acting(10-20mins mostly used in
emergency)
b. Intermittent acting(12-20 hours) action
starts after 2.5 hours
c. Long acting (> 24 hours)

64. (B)Surgical management
 Transplantation of B cells of islets of
langerhans of pancreas.

65. (c) Physiotherapy
management
● The common complain of diabetic
patient are:
● Painful sensory neuropathy
● Weight gain
● General debility
● De Quervain disease
● Hip, Knee, wrist, hand stiffness
● Lateral epicondylitis
● Pedal oedema
● Mono/hemiparesis

66. Cont…..
 Facial/ bell's palsy
 Lower inter coastal pain
 Pectoral weakness
 Planter fascitis/calcaneal spur
 Headache
 Frozen shoulder
 Ankle sprain
 Carpal tunnel syndrome

67. Aims:
I. Relieve the symptoms according to the
patient’s complain
II. To correct associated problems to reduce
morbidity, mortality and economic costs of
diabetes.
III. To prevent as much as possible acute and
chronic long term complications.
IV. To improve the quality of life and productivity
of individual with diabetes.
V. The main role of us is mainly in TYPE 2 and little
in TYPE 1.

68. (D) Lifestyle modifications
● Take stairs
● Do chair exercise
● Park far from store door
● Ride a bicycle
● Get an exercise videotape
● Join an exercise class
● Walk every day

69. PT in diabetes
● Measure vitals -HR, BP, RR, PR, Temp,
Sugar
level
● Take appropriate carbohydrate snack
before exercise , to avoid hypoglycemia
● If exercise is prolonged then in between
fruit juice or soft drink 5-10gm every 30
min is taken.
● Start with moderate intensity exercise &
increase intensity gradually.
● Do not reach above 60%of predicted HR
max.

70. Cont….
● In type 1 DM= hypoglycemia develops at
5 to 15 hrs.
-sometimes it is up to 24 hrs also.
especially due to vigorous exercise.
- It can cause disturbance in sleep
pattern.
● In type 2 DM=it develops within 45 min of
moderate exercise.

71. Exercise prescription
● Exercise have more
beneficial effect to
prevent complications
& decrease dosage of
drugs.
● Also decrease
obesity and maintain
functional ability
because chances
hypoglycemia are
less as compared.

72. The exercise prescribed
are:
● Stretching
● Aerobic training
● Resistance training

73. Stretching
Stretching of major muscles groups like,
- Biceps
- Triceps
- Hamstring
- Quadriceps
- Calf muscles etc. are
done before the aerobic training for
relaxation.

74. Biceps Stretch

75. Triceps Stretch

76. Quadriceps Stretch

77. Hamstring Stretch

78. Calf Muscle Stretch

79. Aerobic training
Benefits are:-
- Better blood glucose level
- Weight loss
- Increase muscle mass
- Increase strength and endurance

80. Mode of Activity

81. Walking

82. Jogging

83. Cycling

84. Step Up Excersie

85. Treadmill Walking

86. Asanas

88. Resistance training:-
 Frequency:- twice a week on non-
consecutive days
 Warm up:- 5 minutes free hand exercises
 Exercises to be performed:- 8-10 exercises
involving major muscle groups
 Initial resistance:-40-60% of 1 RM

89. Cont….
 Repitions:- 10-15
 No of sets:- one for each exercise
 Rest of interval:- one minute after each set
 Cool down and stretching:- 5 mins
 Progression:-
- Intial condtioning phase
-Duration 6-8 weeks
-Frequency is increased to thrice a week

90. Cont….
 Improvement Conditiong Phase:-
-Duration:- 4-6 months
-Number of sets increased 2 to exercise
-Resistance increase to 50-70%1rm
 Maintance Phase :-
-Duration:-After 6 months of exercise
- To main the strength and endurance
regular training advised

91. Modalities
 The heat modalities like TENS(trans
cutaneous nerve stimulation),
IFT(interferential therapy) are
modalities that are used for relief of
pain
 Diabetic patients have altered
sensations and so the intensity of the
heating modalities should be kept
moderate so as to avoid burns.

94. Guidelines for exercise in DM
 Don’t exercise at less than 100mg/dl.
 Average 30 minutes exercise time is
adequate.
 Should eat before 2 hours of exercise.
 Moniter blood glucose level.
 Atleast 5 times a week exercise must
be carried out.
 Exercise should not be done alone.

96. Your own idea Get Moving
o Blood Glucose monitoring.
o Take stairs.
o Do chair exercises.
o Park far from store door.
o Stop smoking.
o Get an exercise videotape.
o Join an exercise class.
o Walk every day (home, mall).
o Foot care.
o Walk with your children, grandchildren or dog.