Diabetes, Metabolic Syndrome, PAD

Question 1

How many people in the US are diagnosed with pre-diabetes?

Answer 1

96 million or 38% of the US population

Question 2

How does Type I & Type II DM differ?

Answer 2

DM: Chronic metabolic disorder characterized by high blood glucose (“hyperglycemia”)

TYPE 1:
-beta cells of pancreas (produce insulin) are destroyed
-insulin dependence –> need supplemental
-commonly dx before age 30

TYPE II
1) insulin resistance - insulin action is abnormal and cells become resistant to insulin (abnormal uptake of blood glucose)
2) pancreas continues to produce more insulin to counteract insulin resistance–> over time B cells burn out –> insulin production decreases –> need supplemental insulin (insulin dependence)
-commonly dx after 40 years
-effects >90% of DM population

Question 3

Can someone with Type II DM require insulin? Why?

Answer 3

-yes, transition from insulin resistance to insulin dependence

-diabetes is a combination of macrovascular and microvascular complications

Question 4

Common precautions of hypoglycemia for DM population. Why are these important?

Answer 4

DEFINITION: BG <60 mg/dL

EXERCISE:
-exercise increases the risk of hypoglycemia bc it accelerates glucose uptake into peripheral tissues
-monitor blood glucose before, during, and after exercise

NOCTURNAL:
-can happen at night too

-know/compare timing of tube feeding and insulin dosing

Question 5

What types of cells release glucagon?

Answer 5

pancreatic alpha cells

-glucagon stimulates gluconeogenesis and glycogenolysis in liver and release of glucose to plasma (more glucose in the blood stream)

** primary target organ for glucagon is the liver (because liver can help to breakdown the glycogen that it stores)

Question 6

What cell types are highly responsive to insulin (glucose uptake)?

Answer 6

liver, fat, muscle

Question 7

Explain how insulin and glucagon are “counter regulatory” hormones to each other.

Answer 7

Insulin increases blood glucose uptake into cells

Glucagon increases release of blood glucose into blood steam (stimulates hepatic glucose production)

Question 8

What are the common diagnostic tests for DM? What information is derived from each?

Answer 8

Fasting Plasma Glucose Test:
-cheap, fast
-normal: 70-100 mg/dL
-100-125 mg/dL- prediabetes
-> 125 mg/dl - diabetes

Glycosylated Hemoglobin tests: (Hb A1c)
-normal <5.7% of total Hb
-tells you your 90 day history of glucose levels in blood
-if you leave RBC in a sugary solution it will add glucose to its structure –> measure this
-how elevated has glucose been over the lifetime of the RBC (90 days)

Oral Glucose Tolerance Test (OGTT)
-tested 2 hours after glucose-rich drink
-140-199 mg/dl signals pre-diabetes
-> 200 mg/dl signals diabetes

Question 9

Criteria for the Diagnosis of Diabetes

Answer 9

Fasting plasma glucose (FPG) ≥126 mg/dL (7.0 mmol/L)

OR

2-h plasma glucose ≥200 mg/dL (11.1 mmol/L) during an OGTT

OR

A1C ≥6.5%
(5.7-6.5% is pre-diabetic)

OR

Classic diabetes symptoms + random plasma glucose ≥200 mg/dL (11.1 mmol/L)

Question 10

Clinical Manifestations of heart disease in patients with diabetes:

Answer 10

CAD:
-late dx atypical symptoms: silent ischemia or silent MI
-angina equivalents: SOB/DOE; GI symptoms

Heart Disease risk in patients with DM vs without:
-increased atherosclerosis throughout coronary arteries
-increased HTN, CHF, and CVA risk
-increased incidence of dysrhythmias post MI (lack of blood flow to conduction system)

** assume a patient with DM has heart disease until proven otherwise

Question 11

What are the common complications of DM?

Answer 11

-atherosclerosis
-hyperglycemia
-hypertension
-retinopathy: multiple fragile micro-aneurysms
-nephropathy
-neuropathy (DPN, CAN)
-diabetic ketoacidosis
-peripheral vascular disease/peripheral arterial occlusive disease
-osteopathy
-immune dysfunction (increased infection risk–> poor blood flow and lack of sensation)

WORST: blindness (caused by retinopathy), renal failure, CAD, MI, HF, amputation, CVA

Question 12

a. Why is the patient with DM at a greater risk of CV disease? CV-related mortality?

Answer 12

-greater risk for atherosclerosis and HTN

-oxidative stress

-microvascular and macrovascular changes

-poor glycemic control can cause vascular changes

Question 13

What are the multiple factors that increase the risk of wound development in the DM population?

Answer 13

-lack of sensation
-poor blood flow (occluded blood vessels)
-innate immunity is impaired –> decreased function of macrophages
-infections more rapidly enter the body
-hyperglycemia –> increased bacterial growth and proliferation glucose feeds the infection)

Question 14

What is DKA? Who is at risk of developing DKA? What are the medical consequences of DKA?

Answer 14

Definition:
- very high levels of blood glucose
-lack of insulin and increased glucagon (more glucose in blood)
-increased release of glucose by liver (gluconeogenesis and glycogenolysis)

Etiology:
-more in DM I > DM II
-release of free fatty acids from adipose tissue lipolysis) –> converted by liver into ketone bodies (ketogenesis)
-ketones lead to acidosis –> respiratory compensation (kussmaul breathing)
** OCCURS BECAUSE LACK OF INSULIN PREVENTS GLUCOSE FROM GETTING INTO CELLS FOR USE AS ENERGY SOURCE

Medical Consequences:
-acidosis –> respiratory compromise
–with a lot of glucose in the urine–> water follows urine –> increased urine output (9-10 L/hr)
-osmotic diuresis: blood volume and blood pressure decrease; loss of H2O and electrolytes; because serum glucose exceeds reabsorption capability of the kidneys
-if severe: hemodynamic compromise= medical emergency

Question 15

What is DKA commonly precipitated by?

Answer 15

acute illness (infection, pneumonia); MI, CVA, drug abuse (cocaine); poor DM management

Question 16

Signs and symptoms of DKA:

Answer 16

N/V
abdominal pain
polydipsia- excessive thirst
polyuria
-dehydration (hypotension)

Question 17

What are the benefits of tight glucose management in the DM population?

Answer 17

-decreases risk of medical complications associated with DM

Question 18

Treatment of hypoglycemia (ADA):

Answer 18

15-20 grams of fast acting carb

wait 15-20 minutes and check BG again

still low and symptoms don’t stop–> repeat treatment

eat regular meals and snacks after you feel better

Question 19

Diet and diabetes

Answer 19

-ensuring weight control
-providing nutritional requirements
-good glycemic control
-correcting associated blood lipid abnormalities

Question 20

5. What are the signs/ symptoms of hypoglycemia? a. How can this be avoided during exercise?

Answer 20

SYMPTOMS:
-headache, confusion, tachycardia, sweating, anxiety, fatigue, hunger
-severe: loss of consciousness/convulsions/death

AVOIDED DURING EXERCISE: lower insulin dose pre-activity or higher carb intake prior to or during activity

-monitor BG before, during, and after activity

Question 21

Lifestyle changes and prevention of diabetes (or delay):

Answer 21

Research studies have found that lifestyle changes can prevent or delay the onset of type 2 diabetes among high-risk adults.

Question 22

6. What is the role of exogenous insulin therapy?

Answer 22

TYPES:
-injectable –> different rates of action: rapid acting, short acting, intermediate acting, long acting

CONSIDER THESE THINGS
-type: onset of action and duration
-site of administration
-impact of exercise/activity
-diet/meals/snacks
-emergency preparedness (hypoglycemia)

-patients are often instructed to rotate injection sites

Question 23

Glucose monitoring and pumps:

Answer 23

Finger stick: point of care

Continuous monitoring of glucose

Pump- basal rate delivery of insulin with dose adjustment

Artificial pancreas: automated insulin delivery system
-combines continuuous glucose monitoring and infusion pump
-pump can provide insulin and glucagon

Question 24

What are the different preparations of insulin?

Answer 24

Rapid acting (quick onset time)
Short acting
Intermediate acting
Long acting (longer overall duration of action)

Question 25

What are common examination items included in the DM foot exam?

Answer 25

Look to previous slide deck

Question 26

Why is monofilament testing important? Vibration testing? Pulses? …etc.

Answer 26

Monofilament: A monofilament test is done to test for nerve damage (peripheral neuropathy), which may be caused by conditions such as diabetes.

Vibration: adds to the diagnosis of peripheral neuropathy

Pulses: any arterial occlusion/atherosclerosis?

Question 27

What is Metabolic Syndrome? Why is recognition of this condition important? Criteria for diagnosis?

Answer 27

DEFINITION:
-A disorder diagnosed by a co-
occurrence of 3 out of 5 of the
following medical conditions:
1) abdominal obesity (visceral adiposity)
2) elevated blood pressure
3) elevated fasting plasma glucose
4) high serum triglycerides
5) low HDL levels

DIAGNOSIS:
* TG ≥ 150 mg/dL
* HDL-C
– <50 mg/dL women;
– <40 mg/dL men
* Waist circumference:
– >35” women;
– >40” men
* Glucose ≥ 100 mg/dL
* BP ≥ 130/or ≥ 85 mm

IMPORTANCE:
-Increases the risk of
developing cardiovascular
disease, particularly heart
failure, and diabetes

Question 28

Role of the PT with metabolic syndrome

Answer 28

-physical therapy has a role in prevention

-education on smoking, exercise, managing their blood pressure and blood glucose effectively via exercise and diet

Question 29

What the similarities and differences between PAD & CAD?

Answer 29

PAD
-atherosclerotic changes leading to arterial stenosis
-intermittent claudication
-incidence of claudication increases over age 70
-RISKS: smoking, HTN, atherosclerosis, diabetes, hypercholesterolemia, age >60 years
-predominantly effects the legs
-affects arteries of the limbs and peripheral areas of the body

CAD
-The usual cause is the buildup of plaque in coronary arteries. This causes coronary arteries to narrow, limiting blood flow to the heart.
-Coronary artery disease can range from no symptoms, to chest pain, to a heart attack.

Question 30

What is meant by “intermittent claudication”?

Answer 30

reproducible ischemic muscle pain with activity; relieved by rest

Question 31

11. How is PAD diagnosed? What is the “gold standard”?

Answer 31

GOLD STANDARD: ABI
–> R leg SBP/max arms SBP
-normal: 0.91-1.30
-normally lower extremity BP greater than or equal to upper
-0.7-0.9: mild
-0.40-0.79: moderate
-<0.4 severe (greater blockage in lower limb)

-ultrasonography

-magnetic resonance angiography

-computed tomographic

Question 32

S/S of PAD

Answer 32

-intermittent claudication

-blanching with elevation

-rubor of dependency with dependent position after elevation

Question 33

Physical examination tests that may indicate an arterial disorder

Answer 33

-Buerger’s test

-Capillary refill

-ABI

-6MWT with claudication scale

Question 34

What is the exercise prescription for a patient with PAD?

Answer 34

WARM UP- 5 min
-FREQUENCY: 3-5 times/week
-TIME: 35-50 minutes of exercise/session (increase by 5 minutes each session)
-repeated exercise periods ending at (moderate to severe) 2-3/4 on claudication scale during aerobic exercise is allowed
-take rest until pain is gone –> begin again
TYPE: treadmill or track walking

Etiology of exercise impairment:
-muscle ischemia
-structural changes in skeletal muscle

• want them to exercise into pain

** exercise training can reduce intermittent claudication (greater distance before onset of claudication)

Question 35

NPDR vs PDR

Answer 35

NPDR
-increased vascular permeability: macula edema
–> may be asymptomatic
–blurry vision
–> microaneurysms +/- hemorrhages

PDR (contra to high int. work)
-neovascularization
–> risk of vitreous hemorrhage
-blurry vision
-floaters
-detached retina
-progression to blindness

Question 36

Diabetic peripheral neuropathy vs autonomic neuropathy

Answer 36

DPN:
-loss of protective sensation
-impacts longer nerve fibers: distal> proximal (dying back)
-decreased vibration + proprioception sense
-diminished reflexes
-neuropathic pain
-progressive weakness and atrophy (motor)

AN:
-heart and vasculature changes (OH, silent MI)
-GI tract changes (gastroparesis, diarrhea)

Question 37

Charcot’s disease vs UE MSK concerns vs Spinal changes DM

Answer 37

Charcot’s:
-progressive degen. of weight bearing joints
-increased skin breakdown risk
-varied pressure distribution
-increased wound risk if combined with DPN

UPPER EXTREMITY:
-frozen shoulder
-carpal tunnel syndrome
-flexor tenosynovitis (trigger finger)
-Dupuytren’s contracture (flexiion of 4th and 5th digit)

SPINE:
-OP
-diffuse idiopathic skeletal hyperostosis (DISH) - DISH refers to extensive ossification through the axial and appendicular skeleton

Question 38

Three major components of diabetes treatment:

Answer 38

1) diet and exercise
2) oral hypoglycemic medications
3) insulin therapy

Question 39

Exercise and diabetes

Answer 39

-PA promotes weight reduction and improves insulin sensitivity–> lowering blood glucose levels
-regular PA and exercise should be considered –> consider individual’s health status and fitness level
-**educate on risk of potential hypoglycemia and how to avoid

TYPE I
-increased fitness
-increased confidence
-increased CV function and decreased CV risk profile
-no direct effect on glucose control

TYPE II
-improves fitness, confidence
-increased CV function and decreased CV risk profile
-** improves glucose control –> increased insulin sensitivity and increases glucose transporters –> reduced plasma glucose

Question 40

Exercise guidelines for DM:

Answer 40

Postpone moderate to vigorous exercise if BG > 250 mg/dL (hyperglycemia)

-exercise induced hyperglycemia can lead to ketoacidosis

EXERCISE TYPE AND QUANTITY:

Children with diabetes: 60 min/day of physical activity

Adults with type I or type II diabetes:
-150 min/week moderate (4-6/10) to vigorous (>/=7) aerobic activity 3 days/week no more than 2 consecutive days without
-75 min/week of vigorous intensity for younger, more physically fit
-resistance training 2-3 sessions/week on nonconsecutive days; 10-15 reps of 50-69% 1 RM (moderate intensity
-flexibility exercises

Question 41

Exercise implications with various medical complications of DM

Answer 41

RETINOPATHY
-Avoid isometrics, head down positioning, Valsalva maneuvers
-Keep SBP ≤ 150 mmHg/100
w/ mod-severe NPDR

OSTEOPATHY AND LOSS OF PROTECTIVE SENSATION
-be aware of foot deformities with weight bearing exercises
-increased wound risk

CARDIAC AUTONOMIC NEUROPATHY
-resting tachy
-angina equivalents/blunted awareness of CP
-postural hypotension

DEHYDRATION
-polyuria, polydipsia
-encourage increased fluid intake t/o exercise

Question 42

3 types of oral hypoglycemic medications

Answer 42

Biguanides
-inhibits glucose production in liver

Sulfonylureas
-increases insulin secretion

GLP-1 receptor agonist
-increases insulin secretion; inhibits glucagon
-weight loss
*wegovy

Question 43

Surgical interventions for PAD

Answer 43

-angioplasty/stenting
-endarterectomy- remove plaque from vessel
-bypass grafting: much more aggressive–>A coronary artery bypass graft involves taking a blood vessel from another part of the body – usually the chest, leg or arm – and attaching it to the coronary artery above and below the narrowed area or blockage.