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Physiotherapy in Specific Groups > Diabetes > Flashcards

Diabetes Flashcards

1
Q

What is diabetes mellitus?

A

Diabetes mellitus describes a metabolic disorder of multiple aetiology characterised by chronic hyperglycaemia with disturbances of carbohydrate, fat, and protein metabolism, resulting from defects in insulin secretion, insulin action, or both

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2
Q

What processes occur when an individual has low blood glucose?

A
  • Glucagon released by alpha cells of pancreas

- Liver releases glucose levels

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3
Q

How can glycaemia be assessed?

A
  • Blood glucose level (BGL): immediate
  • Oral glucose tolerance test (OGTT): Glycaemic response over two hours to an oral glucose load
  • HbA1c: gold standard for assessing BGL control over the preceding 2-3 months
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4
Q

When is HbA1c usually used and when is it not?

A

Usually used to monitor the effectiveness of glycaemic therapy, rather than for acute diagnosis

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5
Q

How is plasma glucose tested?

A
  • Overnight fasting

- Two hour plasma glucose in oral glucose tolerance test

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6
Q

What factors can affect plasma glucose during the day?

A
  • Dietary intake and composition
  • Exercise
  • Illness
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7
Q

What are the current diagnostic criteria for disorders of glycaemia and diabetes mellitus?

A
  • HbA1c > 6.5%
  • Fasting blood glucose >126mg/dL (7.0 mmol/L)
  • 2hr plasma glucose >200mg/dL (11.1 mmol/L) during an OGTT
  • With symptoms, a random PG >200mg/dL (11.1 mmol/L)
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8
Q

How is diabetes mellitus diagnosed?

A
  • Fasting venous plasma glucose (FPG)

- 2hr plasma glucose in OGTT

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9
Q

What does IFG stand for?

A

Impaired fasting glucose

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10
Q

What does IGT stand for?

A

Impaired glucose tolerance

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11
Q

What is the diagnostic criteria for impaired fasting glucose?

A

Plasma glucose concentration 5.6 - 6.9 mmol/L after fasting

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12
Q

What is the diagnostic criteria for impaired glucose tolerance?

A

Plasma glucose concentration 7.8 - 11.0 mmol/L after two hours

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13
Q

What is 1 mmol/L in mg/dL?

A

18mg/dL

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14
Q

What is pre-diabetes?

A

Patients with either or both impaired fasting glucose or impaired glucose tolerance, but not in the diabetic range.

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15
Q

What percentage of Australians have pre-diabetes?

A

About 16%

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16
Q

What are you at greater risk of with pre-diabetes?

A

Macrovascular disease

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17
Q

What percentage of the Australian population have some form of disorder glycaemia?

A

25%

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18
Q

What are the four WHO classifications of diabetes?

A
  • Type 1 diabetes mellitus
  • Type 2 diabetes mellitus
  • Gestational diabetes
  • Other specific types
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19
Q

What does Type 1 diabetes mellitus involve?

A
  • Destruction of pancreatic islets

- Absolute deficiency of insulin

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20
Q

What treatment options are used for T1DM?

A
  • Insulin: lowers BGL

- Exercise: reduce CV risk

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21
Q

What does Type 2 diabetes mellitus involve?

A
  • Resistant to the action of insulin

- Fasting hyperglycaemia

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22
Q

What is the goal of treatment for T2DM?

A

To reduce HbA1c, hence limit/reduce diabetic complications

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23
Q

What treatment methods are used for T2DM?

A
  • Exercise
  • Diet: low GI
  • Oral hypoglycaemics (+/- insulin)
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24
Q

What percentage of pregnant women are affected by gestational diabetes? What percentage are then at greater risk of T2DM?

A

6-9%.

30-50% greater risk of developing T2DM

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25
Q

What are the risk factors of gestational diabetes?

A
  • Glycosuria
  • Age >30 years
  • Obesity
  • Family history
  • Past history of gestational diabetes or impaired glucose tolerance
  • High risk group (ATSI, Polynesian, Middle Eastern, Indian, Asian)
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26
Q

At what time is screening for gestational diabetes recommended?

A

26-28 weeks

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27
Q

How is gestational diabetes diagnosed?

A

Oral glucose tolerance test: 100g glucose drink after fast.
1 hr > 10 mmol/L
2 hr > 8.6 mmol/L
3 hr >7.8 mmol/L
Positive test if 2 or more of above readings are recorded

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28
Q

Management of gestational diabetes

A

Exercise is recommended

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29
Q

What are the short term complications of diabetes?

A
  • Hyperglycaemia and ketosis
  • Hypoglycaemia
  • Infection
30
Q

What are the symptoms of hyperglycaemia?

A
  • Severe thirst
  • Polyuria
  • Fatigue
  • Blurred vision
  • Delayed healing of infections
31
Q

What are the symptoms of hypoglycaemia?

A
  • Hunger
  • Anxiety
  • Trembling
  • Blurred vision
  • Confusion
32
Q

What are the long term complications of diabetes?

A
  • Macro/microvascular disease
33
Q

What are the components of macro vessel disease?

A
  • Cardiovascular disease: heart attacks, stroke

- Peripheral vascular disease: claudication , foot/leg ulcers, amputation

34
Q

What are the components of micro vessel disease?

A
  • Retinopathy: eye blood vessel damage
  • Neuropathy: damage to blood vessels supplying nerves to various organs
  • Nephropathy
  • Alveolar microangiopathy
35
Q

Which group has the highest mortality rate after five years?

A

Known diabetes, type 1 and 2 (11.8%)

36
Q

What percentage of diabetes-related deaths are due to cardiovascular disease?

37
Q

What treatment is most effective for microvascular disease in type 1 diabetics?

A

Intensive treatment (3-4 daily insulin injections, 4 x daily BGL monitoring)

38
Q

What effects occur as a result of an intensive treatment program for diabetes?

A

Significant decrease in HbA1c levels

  • Decreased risk of retinopathy
  • Decreased risk of nephropathy
  • Decreased neuropathy
39
Q

What were the long term effects of intensive treatment for type 1 diabetes found in the DDCT at the 7 year follow up?

A

Less progression of retinopathy and neuropathy

40
Q

In the UK Prospective Diabetes Study, what effects were found with a 1% decrease in HbA1c in type 2 diabetics?

A

Significant decrease in:

  • Diabetes related deaths
  • Microvascular disease
  • Myocardial infarction
  • Stroke
  • Peripheral vascular disease
41
Q

What is the target HbA1c set by the UK Prospective Diabetes Study?

42
Q

What effect does a 10mmHg SBP reduction have in type 2 diabetics?

A

Decreased:

  • risk of diabetic complication
  • diabetes related death
  • risk of MI
  • risk for microvascular complications
  • risk for peripheral vascular disease
43
Q

When is a graded exercise test and ECG monitoring recommended?

A

Recommended for patients who were previously sedentary with a 10 year risk of a coronary event >10%.

44
Q

What tool may be used to estimate an individuals risk of a coronary event?

A

UKPDS Risk Engine

45
Q

What risks factors must be considered before diabetics commence an exercise program?

A 
Age >40 years
Age >30 years and:
- Type 1 or 2 >10 years
- HTN
- Smoker
- Dyslipidaemia
- Proliferative retinopathy
- Nephropathy
or, any of the following:
- Known/suspected CAD, cerebrovascular disease and/or PVD
- Autonomic neuropathy
- Advanced nephropathy with renal failure
46
Q

What responses do non-diabetics have to low-to-moderate intensity exercise?

A
  • Decreased insulin, increased catechols, glucagon, therefore HGO
  • Increased MGU
  • Stable BGL (HGO=MGU)
47
Q

What factors affect exercise response in type 1 diabetics?

A
  • Timing/dosage of last injection
  • Prior metabolic control
  • Presence/absence of complications
  • Nutritional status
  • Fitness
  • Intensity and duration
48
Q

When does over-insulinisation occur in type 1 diabetics?

A

30-40 minutes post exercise:

- Decreased HGO + increased MGU = decreased BGL (hypoglycaemia)

49
Q

What strategies can type 1 diabetics use to prevent over-insulinisation post exercise?

A
  • Reduce insulin does 30-80% before exercise
  • Inject away from active muscles
  • Monitor BGL
  • Exercise on ‘downswing’ of insulin curve
  • Consume simple CHO during, complex after exercise
50
Q

When does under-insulinisation occur in type 1 diabetics?

A

Poor control at rest, worsened during exercise:

Increased HGO + decreased MGU = increased BGL

51
Q

What strategies can type 1 diabetics use to prevent under-insulinisation during exercise?

A
  • Insulin

- Delay exercise until metabolic control has improved

52
Q

What are the acute effects of exercise in type 2 diabetics?

A
  • Decrease in BGL, but may remain above normal
  • May improve insulin senstivity
  • Decrease in glucose area under curve in OGTT with resistance exercise
53
Q

What effect was found after 4 months of aerobic and resistance training in women with type 2 diabetes?

A
  • No micro or macrovascular complications
  • Decreased HbA1c
  • Decreased area under curve in OGTT (glucose and insulin)
  • Improved strength and exercise time to fatigue
54
Q

What effects were found after 2 x 60 min/week exercise sessions in the Malmo study?

A

After five years:

  • Reduced CV risk factors
  • Improved fitness
  • 55% of type 2 diabetics no longer reached diagnostic glucose levels
55
Q

What additional benefits may HIIT provide over moderate intensity continuous exercise?

A
  • More potent stimulus in enhancing vascular functioning

- Greater positive influence on cardiorespiratory fitness and biomarkers associated with vascular function

56
Q

What is the optimal HIIT prescription as suggested by Ramos et al 2015?

A

4 x four minutes, three times per week for at least 12 weeks

57
Q

What did the Diabetes Prevention Program Research Group conclude regarding the effects of exercise training + low fat diet in “pre-diabetes”?

A

If exercise training is introduced early enough, ‘remission’ (early type 2) or prevention (IGT/”pre-diabetes”) when combined with dietary modification.

58
Q

What effects may exercise training have in type 2 diabetics and “pre-diabetes”?

A
  • Reduced HbA1c
  • Reduced macro and microvascular complications
  • Reduce/abolish need for medication
  • Remission or prevention if started early enough
59
Q

What are the aerobic exercise recommendations for glycaemic control, weight maintenance and CVD risk reduction?

A

150 min/week of moderate intensity exercise, 40-60 of VO2 max or 50-70% of maxHR and/or at least 90 min/week of vigorous exercise >60% VO2 max or >70% maxHR
Three days/week, no more than 2 consecutive days without exercise.

60
Q

According to Sigal et al 2004, how many hours of moderate-vigorous aerobic and/or resistance exercise associated with greater CVD risk reduction?

61
Q

According to Sigal et al 2004, how many hours of moderate-vigorous aerobic and/or resistance exercise must be completed for long term weight loss?

A

7 hours/week

62
Q

According to Sigal et al 2004, what resistance training prescription is recommended in type 2 diabetes?

A
  • Three sessions/week
  • Progress to 3 x 8-10RM
  • Include all major muscle groups
63
Q

What are the metabolic precautions/contraindications for exercise in diabetes?

A
  • Hyperglycaemia, ketosis
  • Hypoglycaemia (especially children)
  • ‘False warnings’: perceive BGL to be lower than actual
  • Caution in hot weather
64
Q

What are the neurological precautions/contraindications for exercise in diabetes?

A
  • Autonomic neuropathy

- Peripheral neuropathy

65
Q

What are the vascular precautions/contraindications for exercise in diabetes?

A
  • Proliferative retinopathy
  • Nephropathy
  • Myocardial blood vessel changes
  • Careful with SBP increments during exercise
66
Q

What are the orthopaedic precautions/contraindications for exercise in diabetes?

A
  • Ulcers
  • Obesity
  • OA
67
Q

What is the role of the physiotherapist in the management of diabetes?

A
  • Monitor, advise and educate on safe exercise programs
  • Monitor BGL before commencing physio treatment
  • Refer to podiatrist if indicated
68
Q

What diabetes-associated problems can be managed with the help of physiotherapy?

A
  • Angiopathy (heart disease, PVD, amputations)
  • Osteoarthritis
  • Tissue stiffening effects of glycosylation: increased incidence of frozen shoulder
  • Education: exercise, weight control, foot care, MDT approach
69
Q

What is the incidence of amputations in diabetics compared to people without diabetes?

A

15 times more common.

70
Q

What percentage of total amputations involve diabetics?

71
Q

What are the major predisposing factors leading to ulceration or amputation in diabetics?

A
  • Peripheral neuropathy
  • Vascular disease
  • Infection
  • Deformity of the feet

Physiotherapy in Specific Groups (5 decks)

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