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Physical Therapy Implications For Cardiovascular And Pulmonary Complications
PULMONARY COMPLICATIONS IN
DIABETES MELLITUS (DM) IS A CHRONIC METABOLIC
DISORDER CHARACTERIZED BY HYPERGLYCEMIA AND CAUSED
BY INADEQUATE INSULIN PRODUCTION OR INEFFECTIVE
TYPE I: (IDDM)
Develops before adulthood.
Autoimmune destruction of
insulin producing pancreatic
beta cells occurs.
Result: Little or No insulin
Survival is dependent on
TYPE II: (NIDDM)
Heterogeneous disorder occurring in
later stages of life (rarely <40).
70 to 90% people have it because of
obesity, lack of exercises and familial
Patients are insulin resistant at the
cellular level because of receptor or
post receptor defects.
Hyperglycemia results from an
increased rate of hepatic glucose
production as a consequence of
hepatic insulin resistance.
Insulin causes the inhibition of
glucose production by the liver
and the promotion of glucose
transport across cell membrane
and its subsequent metabolism
within the cell.
Deficiency results in an inability
to utilize glucose as fuel,
impaired protein metabolism,
increased fat mobilization with
increased level of free fatty
Metabolism of free fatty acids in
the liver causes formation of
ketone bodies and ketoacidosis
Anti-insulin hormones like
Glucagon, Growth hormone,
Cortisol and Catecholamines
also participate in glucose
Insulin and Glucose
Microangiopathy with thickening or damage to the
capillary basement membrane (e.g., retinopathy,
nephropathy) and Macroangiopathy by
atherosclerosis (e.g., coronary artery,
cerebrovascular and peripheral vascular disease)
cause damage to organs like eyes, kidneys, heart
and peripheral nerves.
Combination of microangiopathy (peripheral
neuropathy) and macroangiopathy (arterial
insufficiency) leads to the frequent complications of
tissue necrosis and infection and sometimes
In diabetic patients atherosclerotic heart disease,
hypertension, defects in impulse conduction
through the heart, congestive heart failure,
autonomic neuropathy, cerebrovascular disease
and peripheral vascular diseases dominate.
Other cardiovascular abnormalities which are
particularly more common in DM are sinus node
dysfunction and AV node conduction
These are very common in long standing diabetics.
Individuals usually complain of postural hypotension.
Predominantly the parasympathetic nervous system (PNS) is involved.
Resting heart rate can determine the autonomic neuropathy.
In patients with PNS dysfunction HR is elevated at rest and during early
phase of exercise, but as the effort progresses, the normal activation of the
sympathetic nervous system allows virtually normal HR and BP responses.
In combined defects there is minimal response to stimuli such as valsalva
maneuver, standing up, and deep breathing, a fall in BP during standing
and blunted HR and BP responses to all phases of exercise.
Hyperglycemic patients have higher incidences of
pulmonary infections than non-diabetics.
Patients with autonomic neuropathy may have more sleep
related breathing problems.
PFTs show mild abnormalities in lung elastic recoil,
diffused capacity and pulmonary capillary blood volume,
which are directly related to the duration of DM.
Ketoacidosis causes hyperventillation,
pneumomidiastinum and mucus plugs in the major
IMPLICATIONS FOR PHYSICAL THERAPY
Adequate metabolic control should be established before an
exercise programme is initiated.
HR and BP evaluations should be incorporated in all physical
therapy evaluations as DM patients exhibit abnormal
hemodynamic responses to activities.
Self monitoring of blood glucose levels is essential.
Avoid vigorous and prolonged exercise if blood glucose levels are
250- 300 mg/dl and should not exercise at all if blood glucose
exceeds 300 mg/dl or if there is any ketosis. Likewise exercises
are contraindicated when blood glucose levels are 80-100 mg/dl
because of greater risk of hypoglycemia.
To minimize the risk of hypoglycemia, patients should
avoid exercising at the time of peak insulin effect.
Start with moderate workloads and increase intensity
Use a consistent pattern of exercises (time, duration and
Avoid injecting insulin into tissue near the exercising
muscle if patient will be exercising soon thereafter (
within 40 min after regular insulin or within 90 min after
Strenuous exercises should be avoided until reasonable
diabetic control is achieved.
AMPUTEE WITH DIABETES MELLITUS
Surgical healing following amputation is often delayed or
complicated due to the circulatory abnormalities, impaired
ability to fight infection, poor blood glucose control and
neuropathies associated with diabetics.
The energy demands for prosthetic gait are higher than
normal and increase the risk of cardiovascular
complications during rehabilitation.
Attention to wrist alignment when using assistive gait
devices is important because of the higher incidence of
carpal tunnel syndrome.
The Elderly Diabetic Patient: Special considerations
50 % of type II DM patients are above 60 years of age.
Depression, impaired cognitive function, and lack of recognition of
thirst and subsequent dehydration are important factors to be taken
into account in the management of older diabetic patients, who may
also have impaired physical function, an increased rate of injurious
falls, and increased prevalence of pressure ulcers, amputations and
Hyperglycemia can result in a decreased pain threshold and
Older diabetic patients report reduced physical function compared
with other older people as a result of multifactorial impairment that
includes visual deterioration, peripheral neuropathy and balance
Functional impairment is associated with increased falls.
UNIQUE ASPECTS OF DIABETES MELLITUS IN
Decreased pain threshold
Incontinence, tuberculosis and
Control hyperglycemia and provide
Screen using Geriatric Depression
Scale and Treat depression.
Pay special attention to foot care.
Balance exercises and monitoring of
orthostatic blood pressure.
Drink fluids regularly.
Numerous factors, such as decreased thirst perception,
decreased exercise tolerance, deteriorating vision, arthritis,
cognitive problems, depression and social problems, make
the management of older people with diabetes extremely
Exercise is the fundamental therapy for diabetes in older
people, but should be undertaken in moderation and not in
excess. Endurance exercises are only one component of
the complete exercise prescription; strengthening, posture,
flexibility and balance exercises are key to maintaining
function and preventing falls.
Cardiopulmonary implications of specific diseases :
The Elderly Type 2 Diabetic Patient: Special
Considerations John E. Morley* Geriatric Research, Education
and Clinical Center, St Louis VAMC, and Division of Geriatric Medicine, St Louis
University Medical School, St Louis, Missouri, USA.