Physiotherapy Protocal for Diabetes Mellitu Patients

Physiotherapy Protocal for Diabetes Mellitu Patients

What is Diabetes Mellitus?

It is a syndrome in which abnormality in insulin secretion, action or combination of both may produce disturbance in carbohydrate, fat and protein metabolism associated with increase glucose level in blood.

It is a major public health problem in globally fourth leading cause of death in United States and also a common disease of developing countries. It affects central nervous system, kidney, retina, musculo-skeletal system and primarily damage to the cardiovascular system.

Due to imbalance of insulin hampered transport mechanism of glucose in body cells and tissues. Excess amount of glucose secrete out with urine.

Changes in insulin secretion or action may be unhealthy food, sedentary life style, lack of exercise, excessive stress.

Insulin works as a key of glucose binding sites.

Basically how many types of DM occurs?

  

Type 1 diabetes:
It occurs because of destruction of insulin producing beta cells of pancreas by immune system. The term used for this condition is insulin dependent diabetes because amount of production of insulin may be stop by beta cells so there is no insulin to control blood glucose level must need to use insulin injection.

It may occur at any age but usually starts in people under the age of 20.

Type 2 Diabetes: '
The body continues to produce insulin but over time it may be significant reduction of insulin secretion. The beta cells of pancreas produce either not enough insulin or the receptors (insulin binding cells) not available to recognize the insulin properly.

When there is inadequate amount of insulin or the insulin cells binding site not able to bind insulin properly then cells cant able to use glucose properly for metabolic activity.

Gestational diabetes:
Due to reduce the sensitive to insulin women suffer during pregnancy. All women not suffered with Gestational diabetes after birth usually it is resolve.

What are the factor for diabetes Mellitus?

•       Positive Genetic history
•        Sedentary life style
•       Obesity
•      Excess Stress
•        Inadequate sleep
•        Unhealthy food
•        Ethnicity  and race
•      History of hypertension
•        Dyslipidemia
•      Positive family history (being more than 45 years of age)
•       Having gestational diabetes
•         Prediabetes

              How to recognize symptoms of diabetes?

                 Do you feel very hungry?

                 Do you feel feel more thirsty?

                 Do you feel early weakness and fatigue?

                 Do you feel the increase frequency of urination?

                 Do you feel sudden weight loss?

              Attention these all are the warning sing of diabetes:

• Feeling of hungry
• Increase frequency of urine
• Weakness, fatigue,
• Feeling of tired
• Blurred Vision
• Feeling of more thirsty
• Dryness
• Altered consciousness
• Sudden Weight loss
• Headache

How to diagnose diabetes?

Glycosylated hemoglobin (HbA1C) use as a diagnostic tool by WHO and American Diabetes Association. It reproduce the mean value of blood glucose over the past 2–3 month. It is a standard biochemistry test to diagnose the blood glucose level.

Prediabetes	Normal	Diabetes Mellitus
Impaired Fasting plasma glucose 100mg-125mg.dl	Fasting plasma glucose <100mg.dl	>=200mg symptomatic with casual glucose
Impaired glucose tolerance =2-h ,140-199 mg. dl		Fasting plasma glucose >=126mg -200mg 2-h

      What is Prediabetes?

      Prediabetes is a condition increase amount of blood glucose level in the fasting state, 

      called abnormality in fasting glucose known as glucose intolerance with the response          of dietary carbohydrate and fat.

      This is very high risky condition to develop diabetes because the capacity to secrete            more insulin is decrease over time and insufficient insulin to normalize the blood                glucose    level.

     How to manage or care of  diabetes?

    We can easily mange diabetes with Medicine, Diet, Exercise therapy 

 Medical management 
   

     Hyperglycemia or hyperglycemia may require medical management. It may be                   manage with oral or injectable (eg Insulin, sulfonylurea respectively) type of drugs             recommended by physicians.

     
     Diet for Diabetes-The people  should recommended proper diet which must not           increase to much glucose levele in blood. It may be some juice or semiliquid diet.
                

               Exercise for diabetic peoples to modify the symptoms.
               How we can manage diabetes with physiotherapy?

      Physiotherapy Goals for long term management of Diabetes Mellitus

• Maximize the patient quality of life, general health, and wellbeing through            maximizing physiological reverse capacity.
• Educate about DM, self-management, nutrition, weight control, blood sugar regulation and its management (diet exercise stress and insulin requirement) medications, smoking cessation, relaxation, stress-management, and foot care, hygiene, infection control.
•      Maximize aerobic capacity and efficiency of oxygen transport
•      Optimize physical endurance and exercise capacity
•      Optimize general muscle strength
•      Design comprehensive lifelong health and rehabilitation program with the patient.

    what are the exercise testingprocedure for diabetes Mellitus  patientsin                        physiotherapy rehabilitation ?

EXERCISE TESTING

     The following are special points to remember during exercise testing in individuals               with    DM;

 •     For light-to-moderate intensity exercise testing may not be necessary for individuals           with DM or prediabetes who are asymptomatic for cardiovascular disease (CVD)               and low risk (only 10% risk of cardiac event over a 10-yr period) but during                       vigorous intensity exercise program should undergo a medically supervised graded            exercise test (GXT) with electrographic (ECG) monitoring.

•      If positive or nonspecific ECG changes in response to exercise are noted or               nonspecific ST and T wave changes at rest are observed, follow-up testing may be         performed.

FITT recommendations for individuals with diabetes mellitus

•     The regular exercise produce beneficial effect for both type 2 DM and                          prediabetes 
•       Increase glucose tolerance
•        Increase insulin sensitivity, decrease insulin requirement and HbA1C.
•        Improved CVD risk factors
•         Prevent or delay the transition to Type2 DM from prediabetes
•         Provides health and wellbeing.

How to prescribe exercise for Diabetes Patients?

Ex Rx (exercise prescription) with all parameters frequency, intensity,time, type, progression of Aerobic, Resistance and Flexibility Exercisetraining are depends on exercise testing:

Components of the Exercise Training Session:

 Warm-up: Cardiorespiratory and muscular endurance activities (light-to-moderate intensity) at least 5–10 min.

Conditioning: Aerobic, resistance, neuromotor, and/ or sports activities at least 20–60 min/day with bouts according to individuals.

Cool-down: cardiorespiratory and muscular endurance activities at least 5–10 min with light-to-moderate intensity.

Stretching: After the warm-up or cool down phase at least 10 min of stretching exercises needed.

Aerobic Training 

Frequency: 3–7 dwk

Intensity: 40 %–< 60% VO2 R with RPE (rating of perceived exertion) 11-13 on a 6-20 scale. Better blood glucose control may be achieved at higher exercise intensities (>-60% VO2R).

Time: It should be minimum of 150 min /wk. of exercise with moderate intensity or greater and to achieve Additional benefits we can increase up to 300 min /wk. with moderate-to-vigorous intensity with Aerobic activity bouts of at least 10 mins.

Type: It includes activities that use large muscle groups in a rhythmic and continuous fashion eg. Treadmill, cycle ergometer, swimming.

 Progression: Because of adaptation progression should be needed, we can progress in duration, intensities, time, type of exercises and aerobic bouts according to patient.

Resistance Exercise Training

FITT-VP

Frequency-Each major muscle group should be trained on 2–3 dwk.

Intensity-

•         60%–70% 1-RM (moderate-to-vigorous intensity) to improve      strength.
•          >=80% 1-RM (vigorous-to-very vigorous intensity) for experienced   strength trainers to improve strength.
•         40%–50% RM (very light-to-light intensity) for older individuals to     improve strength in beginning of resistance exercise.
•       40%–50% 1-RM (very light-to-light intensity) may be beneficial for sedentary individuals to improve strength.
•       <50% 1-RM (light-to-moderate intensity) to improve muscular endurance.
•         20%–50% 1-RM in older adults to improve power.

Time: No specific duration known for effectiveness.

Type: It should be involve each major muscle group with multi joint or single joint exercises affecting more than one muscle group and targeting agonist and antagonist muscle groups are recommended for all adults.

     Repetitions:

• 8–12 repetitions is required to improve strength and power in most adults.
• 10–15 repetitions is required to improve strength in middle-aged and older individuals.
• 15–20 repetitions are recommended to improve muscular endurance.
• Sets:
•       2–4 sets are required to improve strength and power for most adults.
•    A single set is effective especially among older people.
•    2 sets are effective to increase muscular endurance.

   Pattern:

•       2–3 min rest intervals between each set of repetitions more effective.
•       A rest of >=48 h between sessions for any single muscle group is suggested.

Progression: A gradual progression of greater resistance, repetitions per set, or increasing frequency is suggested.

Flexibility Training

FITT-VP

Frequency: It should be >=2–3d/wk.

Intensity: Stretch the large group of muscle up to feeling of discomfort or tightness.

Time: Holding a static stretch for 10–30s is recommended for most adults and 30–60s for older individuals but it must be changed with stretching techniques.

Type: It may be Static flexibility (i.e., active or passive), dynamic flexibility, ballistic    flexibility, and PNF.

Volume: It should be 60 s of total stretching time for each flexibility exercise.

Pattern:

•      To produce more effect of stretching it may require warm up with actively or passively through light-to-moderate aerobic activity or application of externally moist heat packs respectively.
•      2–4 times repetition is recommended.

Progression:

Unknown

Care for DM individuals during exercise

•         Always monitor the symptoms of hypoglycemia because rapid drop of glucose during exercise may produce hypoglycemia.
•         Monitoring of glucose before and after several hours.
•         The timing of exercise should be considered in individuals taking insulin or hypoglycemic agents.
•          Exercise with supervision is recommend to prevent risk of hypoglycemia.
•         Always monitor Blood Pressure, Heart Rate, and glucose level.

 References:

1.     Linda S. et al: ACSM Guidelines for Exercise Testing and Prescription 9^th Edition Lippincott Williams and Wilkins 2013.

2.     Susanna C. et al: Type 1 and Type 2 diabetes mellitus and incidence of seven cardiovascular disease; International Journal of Cardiology; 262 (2018) 66–70.

3.     Kumar et al: Effects of aerobics programme on physiological profile of diabetic patients; International journal of physiology, nutrition and physical education 2018; 3 (1): 1534-1537.

4.     Rathore et al. Prevention and control of madhumeha through diet and lifestyle; World journal of pharmaceutical research; 8, 5; 2019; 805-810.    

5.     Teich et al: Advances in exercise, physical activity, and diabetes mellitus; Diabetes technology & therapeutics; 21, 1, 2019.

6.     Diagnosis and classification of diabetes mellitus diabetes care, 33, 1, 2010.

7.     Prevention or delay of type 2 diabetes: Standard medical care in diabetes; diabetes care; 42, 1, 2019.

8.     Lee et al. The effects of exercise on vascular endothelial function in type 2 diabetes mellitus: A systematic review and meta-analysis; Diabetol metab syndr (2018) 10:15.

9.     Kasper, Faust, Hauser; Harrison’s principle of internal medicine 19^th edition.