(Dr. Kumar Mrityunjay, Dr. Deepak Chhabra)
Diabetes mellitus, often simply referred to as Diabetes—is a group of metabolic diseases in which a person has high blood sugar, either because the body does not produce enough insulin, or because cells do not respond to the insulin that is produced. This high blood sugar produces the classical symptoms of Polyuria (frequent urination), Polydipsia (increased thirst) and Polyphagia (increased hunger).
Diabetes causes damage to small blood vessels, which leads to a microangiopathy, which can cause one or more of the following complications.
- Diabetic neuropathy,
- Diabetic cardiomyopathy,
- Diabetic nephropathy,
- Diabetic retinopathy,
Diabetic Neuropathies are neuropathic disorders that are associated with diabetes mellitus. These conditions are thought to result from diabetic microvascular injury involving small blood vessels that supply nerves (vasa nervorum in addition to macrovascular conditions that can culminate in diabetic neuropathy. It is estimated that the prevalence of neuropathy in diabetes patients is approximately 20%. Diabetic neuropathy is implicated in 50–75% of non-traumatic amputations. A patient can have sensorimotor and autonomic neuropathy or any other combination. Symptoms vary depending on the nerve(s) affected and may include symptoms other than those listed. Symptoms usually develop gradually over years.
There are 4 known types of diabetic neuropathy:
- Diabetic Autonomic Neuropathy: It affects most often the digestive tract, as well as the urinary system, blood vessels, and sex organs.
- Diabetic proximal neuropathy: It causes pain usually on only one side. This usually happens in the hips, thighs, or buttocks. It can even sometimes lead to leg weaknesses.
- Diabetic Peripheral Neuropathy: This is the form of neuropathy which is most common for diabetics. It seems to affect the nerve ending first and usually starts with the nerves that are longest. This means that legs and feet are where the beginning of this neuropathy usually starts. Rarely, other areas of the body such as the abdomen, arms and back may be affected.
- Diabetic focal neuropathy: It can very often appear suddenly and effects very specific nerves, most often those in the torso, head, or leg. This causes muscle weakness or pain. Mostly affects older adults.
The four factors thought to be involved in the development of diabetic neuropathy are Microvascular Disease, Advanced Glycated End (AGE) Products, Protein Kinase C, Polyol Pathway.
Despite advances in the understanding of the metabolic causes of neuropathy, medical management aims at interrupting these pathological processes have been limited. Thus, with the exception of tight glucose control, treatments are for reducing pain and other symptoms.
Physical therapy is an effective and alternative treatment option for patients with diabetes. Transcutaneous electrical nerve stimulation (TENS) and Interferential Therapy (IFT) use a painless electric current to relieve stiffness, improve mobility, relieve neuropathic pain, reduce oedema. UVR & Laser therapy can be used to treat healing foot ulcers. Gait training, posture training, and teaching these patients the basic principles of off-loading can help prevent and/or stabilize foot complications such as foot ulcers. Exercise programs, along with manual therapy, prevent muscle contratures, spasms and atrophy. Aerobic exercise such as swimming and using a stationary bicycle can help peripheral neuropathy, but activities that place excessive pressure on the feet (e.g. walking long distances, running) may be contraindicated. Therapeutic ultrasound, paraffin wax bath and short wave diathermy are also useful for treating diabetic neuropathy. Pelvic floor muscle exercises can improve sexual dysfunction caused by neuropathy. Biofeedback teaches to control certain body responses that reduce pain. High power laser therapy has been demonstrated to accelerate nerve regeneration as well as vasodilatation of blood vessels and neo capillary formation. Whole body vibration treatment reduces neuropathic pain, and improves gait and balance in a patient with type II diabetic peripheral neuropathy.
Lifestyle and Home Remedies to be taken control of are:-
- Keeping blood pressure under control.
- Make healthy food choices. Eat a balanced diet that includes a variety of healthy foods — especially fruits, vegetables and whole grains — and limit portion sizes to help achieve or maintain a healthy weight.
- Be active every day. The American Diabetes Association generally recommends about 30 minutes of moderate exercise a day daily at least five times a week.
- Stop smoking.
- Blood sugar control. By medication with diet modifications and control
- Foot care. Check your feet every day for cuts or wounds; Keep your feet clean and dry; Trim your toenails carefully; Wear clean, dry socks; Wear cushioned shoes that fit well.
So, the treatment of diabetes is not just limited to blood glucose control. It encompasses a much wider perspective. Physiotherapy as a branch of science plays an important role in treatment of secondary complications as neuropathy, arthromyopathy etc. found commonly in diabetes patients. Thus, a diabetes care centre must have an adjoining physiotherapy set-up to ensure an integrated approach towards the patient. In this way not only would glycemic control be achieved, but the complications of the patients would also be dealt with in an appropriate & apt way.
Case Reports:
Case 1 – Vidhya Devi ( 54/F; DM-II; 12 years) was on OHA’s. C/O leg pains, especially at night. H/O Swelling on her legs, developed blisters on her feet a day after she had worn a pair of new sandals, blisters had burst revealing cuts over the feet. Tests showed elevated random blood sugar level of 15 mmol & an HbA of 11%. She was started on twice daily insulin, given some antibiotic, daily dressing & simple analgesics. Bedside physiotherapy included TENS, bedside mobility exercises, Static quadriceps & hamstrings exercises, ankle toe pumps with elevation for edema reduction & non-weight bearing ambulation was done. After a week wounds started healing, swelling & pain reduced & patient progressed to partial weight bearing with walker. 1 week later she was discharged after giving her home protocol of exercises, 2 pt weight bearing crutches. Follow up after 1 month she was made to walk independently after a review.
Case 2: Sardar Singh (71/M; DM-II; 5-year) C/O peripheral neuropathic pain in his both feet. H/O pain starting as an aching, partially numbness, and burning pain in his right foot, followed by similar pain and numbness in the left foot as well, Aggravated by walking. O/E 4/5- muscle strength in the both feet and ankles, VAS right foot 8 & left foot 6. Physiotherapy treatment included TENS, gentle bedside mobility exercises, ankle toe pumps & gait training with verbal feedback, 5/week for 8 weeks. After 8 weeks, VAS right foot1 and the left foot0. For the gait variables, after the vibration treatment, the patient’s step length, stride length, and cadence notably increased. demonstrable improvement in the postural sway testing. Patient was discharged after getting a home protocol & reviewed after 1 month.
Case 3: Rani Aggarwal (47/F; DM-II; 6 Years) C/O cramping, pain & Numbness in boyh feet. H/O inability to keep her feet warm even during the summer numbness, tingling and heaviness in both of her feet with an occasional burning sensation. EMG revealed diffuse peripheral neuropathy consistent with diabetes. hemoglobin 7 to 8%. Medically patient was started on gabapentin & ibuprofen (but no improvement) so, topiramate 25 mg BID for her neuropathy was started and also in patient physiotherapy was started which included nerve facilitation techniques, TENS, active bedside exercises, gait training BID. She had improvement of her symptoms like severe muscle cramps of her feet, cold sensation, the shooting pains, and numbness. 1 month later her physical examination was stable and her neuropathy did not progressed.
Case 4: Yusuf (60/M; DM-II; 6 Years) C/O pain & severe burning sensations in toes. H/O painful swelling of toes followed by ulceration which got infected and spread to the interdigital spaces. Admitted to Hospital for wound debridement and started with insulin, antibiotics, analgesics and tricyclic antidepressants. Physiotherapy Included TENS, gentle bedside mobility exercises, Static quadriceps & hamstrings exercises, ankle toe pumps with elevation for edema reduction & non-weight bearing ambulation was done. After a week wounds started healing, swelling & pain reduced & was progressed to partial weight bearing with walker for 1 month after that he was made to walk independently after a review.
Case 5: Shehnaaz Fatima (52/F; DM-II; 18 Years) C/O bilateral pedal edema since, burning pain, numbness & paresthesias in bilateral sole. Was admission ambulatory with a wheelchair, 30%-35% sensory loss over the soles, X-rays revealed hyperlordosis – Lx spine with degenerative changes & tenderness over SIJ & coccyx. Sugar monitoring & insulin was given. physiotherapy included IFT, UST, Gentle mobility exercises were done. Isometrics for back extensors, quadriceps & hamstrings, elevated ankle toe pumps followed by gait training with walker. After few days patient started feeling better medically and was discharged on oral medication. but she continued PT. after a week’s time patient regained lower limb control and was self ambulatory with tripod cane HEP was taught and was told to review 1 month later.
Conclusion: The treatment of diabetes is not just limited to blood glucose control. It encompasses a much wider perspective. Physiotherapy as a branch of science plays an important role in treatment of secondary complications as neuropathy, arthromyopathy etc. found commonly in diabetes patients.
Thus, a diabetes care centre must have an adjoining physiotherapy set-up to ensure an integrated approach towards the patient. In this way not only would glycemic control be achieved, but the complications of the patients would also be dealt with in an appropriate & apt way