Physical Therapy and Diabetes PDF

PHYSICAL THERAPY AND Prof. Dr. Mahmoud Elshazly DIABETUS Introduction Diabetes mellitus has caught the attention of the world as a major public health problem due to the explosive increases in prevalence that have occurred, affecting virtually all regions of the world and, within area...

PHYSICAL THERAPY AND Prof. Dr. Mahmoud Elshazly DIABETUS Introduction Diabetes mellitus has caught the attention of the world as a major public health problem due to the explosive increases in prevalence that have occurred, affecting virtually all regions of the world and, within areas, affecting all age and demographic subgroups and across the full range of socioeconomic status. While the growth of diabetes is most apparent in prevalence trends, there are numerous dynamics in the epidemic underway, with important implications for the clinical and public health priorities that follow. We have synthesized primary findings from population studies of the burden and trends in prevalence, incidence, morbidity, and mortality, focusing on the status in North America and Latin America. CURRENT BURDEN OF PREVALENCE AND INCIDENCE In the USA, 11.2% of adults have been diagnosed with diabetes, and 3.4% have undiagnosed diabetes, for a total of 14.6%. The national prevalence in the USA conceals considerable geographic variation, ranging from less than 5% in low-prevalence areas of the USA to greater than 16% in high-prevalence areas, including areas of concentration in the Mississippi Valley and Deep South, the Appalachian Mountain chain, and selected areas of the West and Midwest corresponding to Native American lands. Prevalence is also notably high in areas corresponding to areas of high concentration of Native Americans and, in Canada, in areas with large populations of First Nations residents.  In the USA, diabetes prevalence is similar across genders but increases steeply with age, such that young adults (age 18-44), middle-aged (45-64), and older (≥65 years), have a prevalence of 2.4, 12.2, and 20.7, respectively. Prevalence also has a strong association with race and ethnicity in the USA, as compared to white women, American-Indians, Alaska Natives, and non-Hispanic blacks have a prevalence that is about twice that of whites, while Hispanics and Asians have a prevalence that is about 80% higher than whites. Education level is also a key factor, as adults with less than a high school education have a prevalence rate of 19.6% which is about 67% higher than that of those with a college or higher education (11.6%). Within Latin America, indigenous populations have historically had a low prevalence but now represent the populations with the greatest magnitude of recent increase, as evident in indigenous populations in Brazil and Chile. INCIDENCE Male 7 cases/1000/year Sex female 6 cases/1000/year Incidence 4/1000 In young adult (18- 44 years) 10/1000 Age In middle age (45- 64 years) 7 /1000 among persons aged ≥65 PREDIABETES Estimates of prediabetes vary considerably with the definition used, which remains an area of debate because of the high degree of discordance that exists across different glycemic markers, including fasting plasma glucose, post-challenge glucose response, and HbA1c. Using the American Diabetes Association-like prediabetes definition of fasting plasma glucose or elevated HbA1c, 35% of adult Americans have prediabetes, with estimates ranging from 24% among young adults (age 18-44) to 47% among adults aged ≥ 65 years. It is noteworthy that, while only about 15% of persons with prediabetes are aware of their risk status, this represents a 50% increase from the last estimates of 10%. Since the risk of progression from prediabetes to diabetes with the ADA definition is relatively low, the Center for Medicare and Medicaid Services (CMS) has adopted a definition of FPG > 110 mg/dl or HbA1c > 5.7% DIABETES AND MORTALITY Adults with diabetes in the USA, Canada, and several countries in Europe have been shown to have overall mortality rates that are approximately 60-80% higher than those of equivalent-aged adults without diabetes. However, data from a Mexico City cohort finding a considerably higher relative risk of death, ranging from 1.9 in persons aged 75-84, to 3.1 in those aged 60-74, to 5.4 for adults aged 35-59 years, serves as a reminder that there may be considerable variation across populations in excess mortality associated with diabetes. DEFINITION The word diabetes is derived from its Greek root, which means “to pass through,” referring to polyuria—the hallmark symptom of diabetes mellitus (DM). The word mellitus means “from honey,” denoting glycosuria, differentiating it from its close mimic, diabetes insipidus. ‫اﻟﺴﻜﺮي اﻟﻜﺎذب‬ DM is defined by the World Health Organization (WHO) as a metabolic syndrome characterized by chronic hyperglycemia resulting from any of the several conditions that cause defective insulin secretion and/or action. Prediabetes is a state characterized by metabolic abnormalities that increase the risk of developing DM and its complications. metabolism ‫ ف ﻟﻮ ﻣﻌﻨﺪﻳﺶ اﻧﺴﻮﻟﻴﻦ ﻳﺨﻠﻴﻨﻲ اﺳﺘﻔﺎد ﺑﻴﻪ ﻳﺒﻘﻲ ﻟﻴﻪ اﺗﻌﺐ ﻧﻔﺴﻲ ف‬by metabolic process ‫ ﻷﻧﻲ ﺑﺎﺧﺪ اﻟﺠﻠﻮﻛﻮز‬metabolic syndrome ‫ﻗﻮﻟﻨﺎ‬ metabolic syndrome ‫ف ﺑﻜﺪا دي‬ ‫‪CRITERIA FOR DIAGNOSIS‬‬ ‫ﺗﺮاﻛﻤﻲ‬ ‫ﺻﺎﻳﻢ‬ ‫ﺗﻘﺮﻳﺒﺎ اﺧﺮ ‪ ٣‬ﺷﻬﻮر‬ ‫ﻓﺎﻃﺮ‬ ‫ﻣﻦ ‪ ٨‬ل‪ ١٢‬ﺳﺎﻋﺔ‬ CLASSIFICATION OF DIABETES MELLITUS TYPE 1 DIABETES Type 1 DM is characterized by complete cellular-mediated destruction of the β-cells, resulting in insulinopenia and insulin replacement therapy for survival. Majority of patients present with the constitutional symptoms of DM, namely, polyuria, polydipsia, and polyphagia. One-third of the patients can present with diabetic ketoacidosis as the first manifestation. TYPE 2 DIABETES In contrast to type 1 diabetes, type 2 DM is characterized by relative insulin deficiency due to β-cell dysfunction and resistance to the action of insulin in target tissues. Unlike patients with type 1 DM, patients with type 2 DM, at least initially, are amenable to oral hypoglycemic agents. Beta cell loss occurs progressively and can result in treatment failure with oral hypoglycemic agents and the requirement of insulin for the control of hyperglycemia, especially in younger individuals. GESTATIONAL DIABETES MELLITUS GDM has traditionally been defined as any degree of glucose intolerance that is first detected during pregnancy, regardless of whether the condition may have predated the pregnancy or persisted after the pregnancy. This definition of GDM, which is based on the PG level alone, does not distinguish the underlying pathological process. SPECIFIC TYPES OF DIABETES DUE TO OTHER CAUSES Monogenic Diabetes Syndromes Single gene defects causing β-cell dysfunction constitute around 1–2% of all cases of DM. MODY is characterized by defective insulin secretion with intact insulin action. Thirteen different genetic loci have been identified so far and are inherited in an autosomal dominant fashion. The most commonly reported types include MODY 2, MODY 3, and MODY 1. There is wide variation in the severity and clinical course of the disease among the various types. Some forms show excellent response to sulfonylurea, and certain subtypes require insulin therapy for management. Identifying additional malformations or multisystem involvement helps in arriving at a diagnosis and also necessitates a multipronged approach to the management of these patients SPECIFIC TYPES OF DIABETES DUE TO OTHER CAUSES Neonatal Diabetes Infants developing DM within the first 6 months of life should undergo genetic testing to identify potential genetic defects. Neonatal diabetes can be transient or permanent, and patients who have an initial transient presentation can develop DM later in life. Making the correct diagnosis in these patients cannot be overemphasized, as switching to oral hypoglycemic agents is possible in a subset of them with potassium inwardly-rectifying channel, subfamily J, member 11 (KCNJ11), and ATP-binding cassette, subfamily C, member 8 (ABCC8) mutations, thus greatly reducing RISK FACTORS OF DIABETES reversible non-reversable Modifiable risk factors include higher body mass index, physical inactivity, poor nutrition, hypertension, smoking, and alcohol use, among others. Increased body mass index is consistently one of the strongest risk factors for the development of diabetes. Additionally, distribution of body fat, specifically an increased waist-to-hip ratio, increases the risk of diabetes. Lower levels of physical activity and more television viewing time increase the risk of type 2 diabetes. Smoking increases the risk of diabetes, regardless of age. Psychosocial factors such as depression, increased stress, lower social support, and poor mental health are also associated with an increased risk of developing diabetes. Different aspects of the environment have also been linked to type 2 diabetes development. Increased levels of noise, poor housing conditions, and air pollution were associated with increased risk.  RISK FACTORS OF DIABETES People who achieve recommended levels of moderate activity are about 30% less likely to develop diabetes than their inactive counterparts. walking for at least 2.5 hours per week was associated with reduced risk of type 2 diabetes compared to almost no walking, independent of body mass index. Higher levels of walkability and green space were associated with lower diabetes risk. person’s risk of diabetic complication can be reduced up to 12% with a 10-mmHg decrease in blood pressure. Diets favoring higher intake of whole grains, green, leafy vegetables, and coffee; lower intake of refined grains, red and processed meat, and sugar-sweetened beverages; and moderate intake of alcohol have been linked with reduced risk of type 2 diabetes. A healthier diet can help to reduce HbA1c levels. For each percentage-point reduction in HbA1c level, there can be a 40% reduction in risk of microvascular complications. A Mediterranean diet with extra-virgin olive oil supplementation reduced diabetes risk by 40% compared to a low-fat control diet COMPLICATIONS OF DIABETES HEART DISEASE AND STROKE Cardiovascular diseases account for up to 65% of all deaths in people with diabetes. According to the Centers for Disease Control and Prevention, people with diabetes are about twice as likely to die from heart disease or stroke compared to those without diabetes. Over 70% of people with diabetes, which is significantly higher than the rate in those without diabetes, have high blood pressure. While risk factors for cardiovascular disease development among people with diabetes are similar to those for people without diabetes (ie, hypertension, hypercholesterolemia, and smoking), the presence of just one of these risk factors leads to poorer outcomes among people with diabetes compared to those without diabetes. Over the past 20 years, preventive care (self-care management strategies, diet, and participation in physical activity) targeting diabetes and the risk factors that cause these complications has improved significantly in the United States. The rates of complications from heart disease and stroke declined in adults with diagnosed diabetes from 1990 to 2010, with myocardial infarction accounting for the greatest reduction (68%). PERIPHERAL ARTERY DISEASE Peripheral artery disease results from narrowing of peripheral arterial vasculature, affecting primarily the limbs, stomach, and kidneys. Early in the process, PAD may be asymptomatic and is often underdiagnosed. Once symptoms are present, they are of 2 types: (1) intermittent claudication, which presents as pain, ache, or discomfort occurring during physical activity, such as walking, but resolving with rest; and (2) pain at rest caused by limb ischemia, which indicates poor blood flow to the affected limb. During 1999 to 2004, prevalence of PAD was about 11%. The risk of PAD increases with older age, smoking, and longer duration of diabetes. People with PAD are at an increased risk of lower extremity amputation and mortality. Patients with intermittent claudication, considered to benefit from exercise, improved their walking time and distance after participation in exercise compared to placebo or usual care. PERIPHERAL NEUROPATHY Diabetic peripheral neuropathy, a neurodegenerative disease of the peripheral nervous system, is estimated to affect up to 75% of individuals with diabetes. Chronic sensorimotor distal symmetric polyneuropathy, the most common DPN,15 can lead to muscle weakness, sensory loss, and pain in the extremities. The predominant early manifestation of DPN is a gradual onset of sensory impairment, including burning and numbness in the feet. Diabetic peripheral neuropathy may go undetected for years due to its gradual progression. Neuropathic pain, present in 1 in 3 people with DPN, can be severe. Diabetic peripheral neuropathy is associated with substantial physical impairments, activity limitations, and reduced quality of life. The presence of DPN increases the risk of foot ulceration and lower extremity amputation and is associated with greater health care resource use, health care costs, and an inability to work due to physical limitations. Other potential complications of DPN, such as mobility impairments and falls, can result in significant limitations in activity and participation. Hyperglycemia is the primary risk factor for DPN. Additional risk factors include older age, longer duration of disease, cigarette smoking, hypertension, elevated triglycerides, higher body mass index, alcohol consumption, and taller height.  LOWER EXTREMITY AMPUTATIONS Nontraumatic lower extremity amputations are associated with high morbidity and mortality among people with diabetes. The 5-year mortality rate after NLEA ranges from 52% to 100%.103 The incidence of NLEA among people with diabetes is estimated to be as high as 704 per 100 000 person-years. Individuals with diabetes are 7.4 to 41.3 times more likely to have an NLEA compared to those without diabetes. With increased awareness of diabetes-related complications and subsequent implementation of preventive care strategies, the age-adjusted NLEA rates have decreased in the United States, from 70.4 per 10 000 adults with diagnosed diabetes in 1995 to 28.4 per 10 000 in 2010. Although overall NLEA rates have decreased, disparities between black and nonblack patients increased between 2007 and 2011, with the amputation-free survival rate being lower among black patients. Lower extremity amputation rates also differ significantly by the patient’s geographical location, highlighting the need to address both racial and regional disparities. Risk factors for NLEA include increasing age, being male, being African American or Hispanic, having peripheral neuropathy, and having chronic foot ulcers. Eighty-five percent of all NLEAs among people with diabetes were preceded by a chronic, nonhealing foot ulcer. Diabetic foot ulcers are common, with the lifetime risk of a person with diabetes developing an ulcer being as high as 1 in 4.96 Peripheral vascular disease underlies approximately half of all amputations in people with diabetes, and is associated with higher mortality after NLEA. MUSCULOSKELETAL COMPLICATIONS Musculoskeletal complications associated with diabetes are common. Yet, they may go undetected and impact the ability to participate in physical activity. Foot and ankle musculoskeletal complications related to diabetes place the foot at risk for ulceration and amputation. Intrinsic foot muscle deterioration, in the form of reduced muscle volume and increased fat volume, is associated with metatarsophalangeal hyperextension deformity, collapse of the midfoot, and decreased foot function during a heel-raise task. Metatarsophalangeal hyperextension deformity has a prevalence as high as 85% in those with diabetes and a history of ulcers and amputations. Extensive foot joint destruction associated with Charcot neuropathic osteoarthropathy is less common (approximately 1% of people with diabetes) but, when severe, prevents weight bearing. Early detection and treatment of musculoskeletal impairments of the foot and ankle may improve the patient’s current and future ability to participate in physical activity and should be addressed. Additionally, physical activity participation may need to be modified when diabetes-associated complications prevent or limit weight-bearing ability. Individuals with diabetes and a history of foot ulcers were found to be 46% less active than control participants matched by age, sex, and body mass index. Patients with diabetes are 4 times more likely to have musculoskeletal complications of the shoulder and hand (eg, adhesive capsulitis, Dupuytren’s contracture, and flexor tenosynovitis) compared to those without diabetes. PHYSICAL THERAPY ROLE Recommendations for Physical Therapists The standard for excellent physical therapist–led intervention care within our current model of practice must include screening patients for risk factors for diabetes and diabetes-related complications, and educating each patient about his or her specific risks. Modifiable risk factors such as physical inactivity, obesity, and hypertension can be directly addressed by physical therapists, by assisting the patient in developing and implementing programs to increase physical activity. The physical therapist should work with the patient to identify and address barriers to exercise. The barriers are often related to comorbidities that require specific accommodations or modifications to the exercise program. provides key assessment items and recommendations that physical therapists might consider when providing patient education about lifestyle management and physical activity. LIFESTYLE MANAGEMENT Lifestyle management may include diabetes self-management education and support, medical nutrition therapy, physical activity, smoking cessation counseling, and psychosocial care. Components of lifestyle management (eg, diet, physical activity, medication, invitation to smoking cessation courses) may reduce disease severity and improve self-assessed quality of life. People who receive diabetes self-management education and support (as a one-to-one interaction, in a group setting, or through internet-based interactions) may experience lower HbA1c, improved quality of life, and lower all-cause mortality risk. Substantial evidence exists of the benefits of physical activity, which we will discuss in the next section. Although there is clear benefit to preventive strategies, implementation in routine medical care is often lacking. In 2015, only 54% of people with diabetes attended a self-management class, 63% self-monitored their blood glucose, 62% received an annual eye exam, 72% received an annual foot examination from a professional, 55% performed daily foot self- exams, 71% had their HbA1c checked more than 2 times per year, and 66% participated in physical activity in addition to their daily and work activities.  Physical therapists can guide patients to implement an effective lifestyle management program. While interviewing the patient to gather the pertinent medical history, determine whether the patient with diabetes has a comprehensive lifestyle management program in place. If so, assess the patient’s ability to follow the program and address any perceived barriers to maintaining this program. If the patient does not have a program in place, communicate with the patient’s health care team and assist in the development of a program by providing appropriate referrals and guiding the development and implementation of physical activity participation PHYSICAL ACTIVITY AND EXERCISE PRESCRIPTION Physical activity is an effective “medicine” for diabetes and other chronic diseases. Given that patients likely have 2 or more comorbidities, the benefit of physical activity may go far beyond that of treating diabetes alone. Benefits of physical activity include improved glucose control, insulin sensitivity, maximum rate of oxygen consumption, and blood pressure. The improvements may require modifications to the patient’s pharmacologic management plan. Therefore, the physical therapist should facilitate patient follow-up visits with the primary care physician when needed. Important information to communicate with the physician includes glucose monitoring logs, resting and exercise blood pressure and heart rate, and key physical performance measures (eg, 6- or 2-minute walk test, 5- times sit-to-stand). A full review of the effects of physical activity on diabetes and other chronic diseases is available.  As a component of lifestyle management, physical therapists should assess the patient’s current level of physical activity and screen to determine the safest and most appropriate regimen for the patient. Recommendations by the ADA include 150 minutes per week of moderate- to vigorous-intensity aerobic activity. The activities should be spread over 3 days per week, with no more than 2 consecutive days without any activity. In addition, 2 to 3 sessions per week each of resistance exercise and flexibility/balance training are recommended. It is also important to decrease the time being sedentary; therefore, encourage physical activity throughout the day (eg, avoid sitting all day). Customize the physical activity program to the patient’s specific goals, preferred activities, comorbidities, and risk of complications