DM
Type I Diabetes Mellitus (T1DM)
Pathology:
•Autoimmune disorder: the body attacks the insulin producing cells in the pancreas
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Risk factors:
•Infection with a virus (polio related) may trigger an autoimmune response
•Hereditary factors:
•10 times more likely to have T1DM if your sibling has it
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Characteristics:
•Onset usually before age of 30
•Body build is usually lean (but not always)
Associated with ketosis
Type II Diabetes Mellitus (T2DM)
Pathology:
•Disorder of insulin reception by peripheral target cells
•Decreased production of insulin by beta cells in the pancreas
Risk factors:
•Increasing age:
•Onset usually after age 40
•Significant increase in younger adult/adolescent pre-diabetic and type II diabetes in the past 10-20 years
•Obesity:
•Fat distribution: increased abdominal fat associated with increased incidence of diabetes mellitus
•Hypertension
•Decreased physical activity
•Poor nutrition
•Smoking
•Genetic predisposition
•Race: increased rates in African Americans and Native Americans
Conditions Associated with DM
Insulin resistance
Body’s cells do not respond to properly to insulin
Impaired glucose tolerance
When blood sugar levels are high, the pancreas releases insulin to help move sugar into cells. Over time, cells can become resistant to insulin, causing blood sugar levels to remain high
Presents when individuals have a plasma glucose level of 140-199 mg/dL 2hrs after oral load of 75 g of glucose
Can lead to T2DM, hypertension, high cholesterol, and other metabolic issues.
Risk factors:
Overweight
Over 45
Family history
Ethnicities
Insulin Deficiency
•In absence of insulin or its receptors sites, glucose cannot be utilized by skeletal muscle, cardiac muscles, and adipose tissue.
•Increased utilization of fats as energy sources
•Protein depletion in the tissues 2° increased protein catabolism
Symptoms:
ØShakiness
ØDizziness
ØSweating
ØHunger or nausea
ØIrregular or fast heartbeat
ØDifficulty concentrating
ØFatigue
No, insulin deficiency and insulin resistance are not the same thing:
Insulin deficiency
•Occurs when the body doesn't produce enough insulin or when the body's tissues don't respond properly to insulin. This can happen in new-onset diabetes, when insulin treatment isn't followed, or when an insulin pump fails.
Insulin resistance
•Occurs when the body's cells don't respond normally to insulin. This can happen when blood glucose levels are high for a long time, which causes the body to produce more insulin. Over time, the cells can lose their ability to respond to insulin.
Treatments:
Insulin deficiency:
•Insulin replacement therapy with basal and postprandial components
Insulin resistance:
•Medications like metformin and thiazolidinediones that reduce insulin resistance
Complications
•Neuropathy
•Connective tissue changes
•Osteoporosis
•Microangiopathy (small vessel disease)
•Nephropathy
•Large vessel disease
•Diabetic Ketoacidosis (Diabetic coma)
•Insulin Shock
Neuropathy
WHY?
•Hyperglycemia damages the Schwann cells (produce and maintain the myelin sheath around the axons of PNS)
•Small vessel disease 2° hypoxia to peripheral nerves
Results:
•Affects sensory and motor nerves, and ANS
Signs/Symptoms:
•Decrease or loss of deep tendon reflexes in ankle
•Loss of sensation, vibration, touch, pain and temp sensation in “stocking/glove distribution”
•Distal symmetrical motor weakness and atrophy
•Abnormal heart rate
•Loss of protective sensation (test with 5.07 level monofilament) on plantar foot
Connective tissue Changes
WHY?
Shorting and thickening of connective tissue 2° a variety of reasons
Symptoms:
Painful limited motion in joints
Osteoporosis
WHY?
DM can impair the function of mature bone cells, which can slow or reduce bone formation
DM can cause bone density loss by increasing blood sugar levels, which can lead to the excretion of calcium and phosphorus in urine.
Advanced glycation end products (AGEs)
AGEs are proteins or lipids that become glycated after exposure to sugars, like those in the bloodstream of people with diabetes. AGEs accumulate in bone collagen, which can weaken bones
Microangiopathy (small vessel disease)
Retinopathy:
Most Significant factor 2° poor blood sugar control
Inner wall of capillaries thickens
Increased inflammatory cell adhesion to vessels walls
Weakening of vessel walls leading to aneurysm formation
Signs and Symptoms:
Total or partial loss of vision
Central vision loss
Nephropathy
vThickening of the basement of the Kidney
vSclerosis of the Kidney
vChronic Kidney Disease (CKD)
Signs and Symptoms:
Abnormal glomerular filtrated rate
High blood creatinine level
High blood urea nitrogen level (BUN)
Low RBC count
Peripheral edema
SOB
Fatigue
Muscle twitches and cramps
Large vessel disease
Peripheral Arterial Disease
Cardiac Disease
CVA
Diabetic Ketoacidosis (DKA) (Diabetic Coma)
WHY?
•A life-threatening complication of diabetes that occurs when the body produces too many ketones
•When the body doesn't have enough insulin, it can't use blood sugar for energy. Instead, the liver breaks down fat for fuel, which produces ketones. If too many ketones are produced too quickly, they can build up to dangerous levels in the body. This can cause the blood to become acidic.
•Ketone bodies are acidic compounds which are byproducts of fat metabolism
Signs/Symptoms:
•Nausea/Vomiting
•Abdominal pain
•Air hunger with rapid respirations
•Dry, flushed skin
•Intense thirst
•Smell of acetone on breath
•Diabetic coma and death if untreated
Onset:
•Gradual over several days to sudden
•Symptoms resolve in 6-12 hours after treatment with insulin, electrolytes and fluids
Insulin Shock (Hypoglycemia)
WHY?
•Low circulating blood glucose levels may result form insufficient food or excessive insulin
Signs/Symptoms:
•Moist, pale skin
•Weakness or shakiness
•Normal or shallow breathing
•Tachycardia
•Headache
•Confusion
•Slurred speech
•Blurred vision
•Hunger
•Convulsions or coma
Resolve:
•Quickly with carbohydrates administration or glucagon injection
PT management Exercise
•Increases ability of skeletal muscle to take glucose from blood stream and use it for fuel
•Decreases insulin resistance
•Reduces risk for atherosclerosis
•Psychological and social enhancement
Risks:
§Exercise induced hypoglycemia can occur if exercising with circulating insulin at high levels
§Ketoacidosis if exercising with insulin at very low levels
Precautions:
§Avoid extreme temperatures
§Design exercise to minimize risks due to neuropathy, retinopathy and LE ulcers
Contraindications:
•Do not exercise if blood sugar is <70 or >240 mg/dL (Normal is 80-120 mg/d)
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Key take aways:
oAvoid exercise at peak insulin times
oAvoid exercise at insulin injection spots
oInsure adequate diet supplement before exercise
