Diabetes Mellitus






























General Information


Case no.


8.A Diabetes Mellitus


Authors


Sheena MacFarlane, PT, DPT, Board Certified Clinical Specialist in Cardiovascular & Pulmonary Physical Therapy


Melissa Brown MSPAS, PA-C


Diagnosis


Type 2 diabetes mellitus (DM) with peripheral neuropathy


Setting


Outpatient clinic


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. Explain the pathophysiology of the patient’s diagnosis.



  2. Relate the pathophysiology and progression of pathology to clinical manifestations and activity/participation limitations seen in physical therapy practice.



  3. Select, implement, and interpret physical therapy interventions based on the medical examination findings.
































Medical


Chief complaint


Loss of balance and bilateral foot pain


History of present illness


The patient is a 68-year-old woman with a long-standing history of uncontrolled type 2 diabetes. She was referred to outpatient physical therapy for evaluation and treatment of balance deficits and bilateral foot pain. She has been experiencing bilateral foot pain for the past 5 years. She describes the pain as an intermittent burning sensation of both feet, which she rates as a 6/10. She also notes worsening left ankle pain over the past month. She describes the ankle pain as a “nagging” 4/10 pain. She has been feeling unsteady on her feet and fallen three times in the past 3 months. She fell once in the shower, outside on uneven surfaces, and when ascending stairs to enter the home. She is intermittently compliant with medications and does not follow a diabetic diet.


Past medical history


Type 2 DM—uncontrolled with peripheral neuropathy, nephropathy, and retinopathy; hypertension (HTN), hyperlipidemia, coronary artery disease (CAD) with a myocardial infarction (MI) 6 years ago.


Past surgical history


Coronary artery bypass grafting (CABG) × 4 vessels 6 years ago


Allergies


Penicillin: rash


Medications


Metformin, Sitagliptin, Glipizide, Dapagliflozin, Lisinopril, Amlodipine, Metoprolol, Simvastatin, Aspirin


Precautions/orders


Activity as tolerated























Social history


Home setup




  • Resides in a single-level home alone.



  • Two steps without handrail to enter.



  • Flight of stairs + one handrail to basement where laundry is located.



  • No grab bars in the bathroom.


Occupation




  • Part-time librarian, reduced hours from full time 6 years ago.


Prior level of function




  • Independent with functional mobility and activities of daily living (ADLs); however, he admits to being a “furniture walker.”



  • Modified independence for stairs, required increased time.



  • Leans on a shopping cart when grocery shopping.



  • (+) driver


Recreational activities




  • Primarily reading and knitting



  • Previously enjoyed shopping but fatigues quickly.


























































































Lab


Reference range


Results (from outpatient visits 2 weeks ago)


Complete blood count


Hemoglobin


14.0–17.4 d/dL


13.2 g/dL


Hematocrit


42–52%


41.8%


White blood cell


5.0–10.0 × 109/L


9,200/μL


Platelets


140,000–400,000/μL


284,000/μL


Electrolytes


Calcium


8.6–10.3 mg/dL


10.1


Chloride


98–108 mEq/L


104


Magnesium


1.2–1.9 mEq/L


1.4


Phosphate


2.3–4.1 mg/dL


3.8


Potassium


3.7–5.1 mEq/L


4.8


Sodium


134–142 mEq/L


141


Blood urea nitrogen


7–20 mg/d


20


Creatinine


0.5–1.4


1.8


Other


Glucose


60–110 mg/dL


268


Hemoglobin A1C


< 5.7%


8.9%


Total cholesterol


< 200 mg/dL


180


High-density lipoprotein (HDL)


> 35 mg/dL


32


Low-density lipoprotein (LDL)


< 130 mg/dL


128


Triglycerides


< 150 mg/dL


254












Pause points


Based on the above information, what are the priorities?




  • Lab values?



  • Outcome measures?



  • Treatment interventions?
































































































































Physical Therapy Examination


Subjective


“Can you help me with my feet? I don’t want to fall again.”


Objective


Vital signs


Pre-treatment


Post-treatment


Supine


Sitting


Standing


Sitting


Blood pressure (mmHg)


140/86


142/84


138/86


138/82


Heart rate (beats/min)


62


64


60


68


Respiratory rate (breaths/min)


16


18


16


18


Pulse oximetry on room air (SpO2)


100


97


98


99


Borg Scale


1/10


2/10


3/10


2/10


Pain


3/10 bilateral feet


4/10 bilateral feet


General




  • The patient is sitting comfortably in the waiting room.



  • The patient does not appear to be in distress.



  • Observations notable for obese body habitus.


Head, ears, eyes, nose, and throat (HEENT)




  • Normocephalic, atraumatic



  • Pupils equal, round, responsive to light



  • Mucous membranes are moist


Cardiovascular and pulmonary




  • Auscultation: normal heart rate. No murmurs, rubs, or gallops



  • Lungs clear to auscultation



  • Pulses: dorsalis pedis and posterior tibial: left: 1 + , right: 2 + 


Femoral: bilateral: 2 + 




  • Left foot and ankle appear pale, cool to touch


Gastrointestinal




  • Rounded, no hepatosplenomegaly


Musculoskeletal


Range of motion (ROM)




  • Bilateral upper extremity (BUE): within functional range



  • Bilateral lower extremity (BLE): within functional range except bilateral dorsiflexion: 5 degrees


Strength




  • Bilateral shoulder flexion: 4 + /5



  • Bilateral elbow flexion: 5/5



  • Bilateral wrist extension: 4/5



  • Bilateral hip flexion: 4 + /5



  • Bilateral knee extension: 5/5



  • Right ankle dorsiflexion: 4/5



  • Left ankle dorsiflexion: 3 + /5


Aerobic




  • 6-Minute Walk Test: 90 feet (27 m) in 2 minutes and 12 seconds.



  • Patient experienced two losses of balance with second loss of balance requiring a chair.


Flexibility




  • Not assessed


Other




  • Left forefoot collapse



  • 2-cm callus metatarsal head of left foot


Neurological


Balance




  • Timed Up and Go (TUG): 22.4 seconds



  • Five Times Sit-to-Stand Test: 12.2 seconds


Cognition




  • Alert and oriented × 4


Coordination




  • Finger to nose: intact bilaterally



  • Heel to shin: intact bilaterally


Cranial nerves




  • II–XII: intact


Reflexes




  • Patellar: 2 + bilaterally



  • Achilles: 1 + bilaterally


Sensation




  • Proximal L4: intact to vibratory sensation bilaterally (17 seconds)



  • Distal L4 and L5: decreased bilateral vibratory sensation at great toe (5 seconds) and medial malleolus (7 seconds) bilaterally



  • Distal L4/L5/S1: absent to crude touch bilaterally



  • Monofilament testing (Fig. 8.1a):




    • Intact at proximal L4 bilaterally; tested at patella



    • Absent at L4/L5/S1 bilaterally; tested at distal phalanges (1–5; Fig. 8.1b), hallux, navicular, and plantar aspect calcaneus


Tone




  • BUE and BLE: normal


Functional status


Bed mobility




  • Supine to/from sit: independent


Transfers




  • Sit to/from stand: modified independent with use of hands


Ambulation




  • Ambulates 50 feet with supervision with no assistive device.



  • Gait deviations notable for decreased cadence, decreased bilateral step length, (+) loss of balance using a stepping strategy to correct.


Stairs




  • Ascend/descend four steps with modified independence using one handrail.



  • Step-to pattern noted



No Image Available!




Fig. 8.1 (a,b) ADA diabetic foot screening test with 10 g monofilament.

























Assessment


☑ Physical therapist’s


Assessment left blank for learner to develop.


Goals


Patient’s


“I would like to never fall again.”


Short term


1.


Goals left blank for learner to develop.


2.


Long term


1.


Goals left blank for learner to develop.


2.














Plan


☐ Physician’s


☑ Physical therapist’s


☐ Other’s


Will treat patient thrice a week with balance and endurance interventions to progress functional mobility and safety.






























Bloom’s Taxonomy Level


Case 8.A Questions


Create


1. Synthesizing the medical data and physical examination findings, develop an appropriate physical therapy assessment of the patient.


2. Develop two short-term physical therapy goals, including an appropriate timeframe.


3. Develop two long-term physical therapy goals, including an appropriate timeframe.


Evaluate


4. For a patient with DM, what pathology contributes to gait dysfunction? Give specific gait deviations.


5. List at least three other health care providers that the patient should be referred to optimize management and the rationale.


Analyze


6. Explain the pathophysiology and clinical manifestations of decreased palpable dorsalis pedis and posterior tibial pulses.


7. Interpret the results of TUG, Five Times Sit-to-Stand Test, and 6-Minute Walk Test.


Apply


8. Design and implement two interventions to improve this patient’s balance and decrease her fall risk.


9. Design and implement an intervention to address this patient’s endurance deficits.


10. Based on lab values, pertinent past medical history, and physical therapy findings, what educational interventions should be provided to this patient?


Understand


11. What are the physical therapy implications of the above medications?


Remember


12. Which of the patient’s medication causes a low heart rate?


13. What is the difference between type 1 DM and type 2 DM?


14. What balance strategies are there (aside from the stepping strategy)?






























Bloom’s Taxonomy Level


Case 8.A Answers


Create


1. The patient is a 68-year-old woman with a past medical history of type 2 DM complicated by peripheral neuropathy, HTN, CAD with resultant MI, and CABG, presenting to the clinic today with bilateral foot pain described as “burning” and three falls in the past 3 months. She ambulates without an assistive device but reports using furniture/shopping carts to stabilize herself as needed. The patient presents with ankle weakness, limited ankle dorsiflexion ROM, decreased sensation in BLE, and impaired balance. All of these contribute to impaired functional mobility and decreased safety. The patient would benefit from physical therapy to address her ROM, strength, endurance, balance, function, and safety. Will continue to follow.


2. Short-term goals:




  • Patient will improve her dynamic standing balance as evident by a score of 15 seconds on the TUG within 8 sessions to improve safety.



  • Patient will ambulate 250 feet with a least restrictive assistive device independently without loss of balance within 8 sessions to improve functional mobility and safety.


3. Long-term goals:




  • Patient will ambulate 540 meters with least restrictive assistive device on the 6MWT without loss of balance within 16 sessions to demonstrate improved endurance.



  • Patient will independently ascend/descend 13 steps with a single handrail, demonstrating reciprocal step pattern, within 16 sessions to improve safety at home.


Evaluate


4. DM presents with various polyneuropathies, including autonomic nervous system neuropathies (vestibular and visual), diabetic peripheral neuropathy, affecting sensory and muscle strength. Diabetic peripheral neuropathy is the progressive loss of peripheral sensation in BUEs and BLEs, with a stocking glove presentation as the distal component most impaired. Individually or collectively, loss of peripheral sensation, limb proprioception, and/or vestibular and visual input can lead to gait deviations. Such gait deviations may include decreased speed, impaired swing phase with shorter step length, impaired terminal stance phase with decreased force production, and/or wide base of support.


5. Other health care providers that the patient should be referred to include, but not limited to, podiatrist, primary care physician, nutritionist, ophthalmologist, and/or diabetic educator. A podiatrist could address her pain and peripheral neuropathy via custom shoes and education, as well as provide proper nail care. Her primary care physician could address her uncontrolled HTN, her uncontrolled type 2 DM, and her undiagnosed decreased pulses, pain, and pale lower extremities. A nutritionist could address dietary intake for weight loss and improving her lab values (specifically fasting glucose, hemoglobin A1C, cholesterol, and triglycerides). An ophthalmologist screens annually for diabetic retinopathy. Diabetic educators are a great resource for overall education about the disease and appropriate self-care.


Analyze


6. The patient has bilateral + 1 dorsalis pedis and posterior tibial pulses. + 1 is defined as a “thready” pulse or easily obliterated with slight pressure. Individuals with DM tend to have earlier onset atherosclerotic changes effecting peripheral arteries. Atherosclerosis leads to peripheral arterial disease (PAD), which presents with decreased distal pulses, lower extremity pain that worsens with lower extremity elevation, and pale skin of the affected distal extremities. Lower extremity hair loss, claudication, and arterial ulcerations can also be seen with PAD.


7.




  • The patient’s TUG score of 22.4 seconds is slower than the age-based norm of 15 seconds for community-dwelling adults with comorbidities, indicating impaired balance, positive fall risk, and impaired walking ability.



  • The patient’s Five Times Sit-to-Stand Test score of 12.2 seconds is slower than the age-based norm of 11.4 seconds for community-dwelling geriatric adults, indicating impaired strength, transfer function, and increased fall risk.



  • The patient’s 6MWT of 27 meters prior to loss of balance and termination of the test is well below age-based normative data for geriatric women, 538 feet.


Apply


8. Since the patient is currently falling one time per month for the last 3 months, has balance deficits as identified on the TUG score and Five Times Sit-to-Stand Test, and ankle weakness, addressing lower extremity strength and balance should be prioritized. Two potential interventions are:




  • Standing heel raises while holding a stable object: This weight-bearing activity would focus on ankle strength and dynamic balance.



  • Single leg stance static balance: This would emphasize ankle muscle strengthening in weight-bearing position and assist in activation of ankle strategy for balance.


9. Since the patient is currently only ambulating household distances and endurance deficits as identified on the 6MWT, endurance interventions are indicated. Two potential interventions are:




  • Seated (recumbent or upright) bicycle 30 to 50% of peak work rates for 10 minutes with rest breaks as needed.



  • Upper body ergometer (UBE) 30 to 50% of peak work rates for 5 to 10 minutes with rest breaks as needed.


Both of these interventions have her in a seated position and therefore optimize safety until standing balance is improved.


10.




  • Due to physical therapy findings of fall risk TUG score and Five Times Sit-to-Stand Test score, physical therapy should educate on methods to decrease her risk of falls while she improves her balance via ongoing physical therapy: environmental modifications at home, benefits of a rollator for household ambulation to allow for seated rest breaks as needed, benefits of a commode to utilize at night next to the bed, and requesting family assistance with community-based ADL.



  • Due to past medical history of type 2 DM with hemoglobin A1C of 8.9%, the physical therapist should educate on methods to prevent skin breakdown on her feet: daily diabetic skin checks, diabetics socks, and appropriately fitted shoes.



  • Due to past medical history of CAD and MI with lab values of triglycerides 254 and LDL 128, and type 2 DM with correlating lab values, the physical therapist should educate on benefits of exercise to decrease cardiac risk factors (triglycerides, HDL, LDL, cholesterol, inactivity) and optimize her glucose metabolism, as well as timing exercise around meals and DM medication.


Understand


11.




  • Metformin, sitagliptin, glipizide, dapagliflozin are all medications for control of glucose in the bloodstream. Glipizide promotes glucose-independent insulin release, which places the patient at high risk of developing hypoglycemia. The physical therapy implications are timing meals, medication administration, and exercise to prevent hypoglycemia.



  • Lisinopril and amlodipine can cause orthostatic hypotension.



  • Metoprolol causes a blunted heart rate response to exercise or any activation of the sympathetic nervous system. The physical therapist should utilize rate of perceived exertion (Borg rating of perceived exertion) for exercise intensity assessment, instead of heart rate.



  • Simvastatin is to decrease LDL level in the bloodstream, which causes statin-induced myopathy (muscle weakness, muscle pain, and muscle inflammation) in 5 to 10% of patients taking statins. Screening for statin-induced myopathy is an important part of physical therapy evaluation and physical therapy treatment sessions. Progression of statin-induced myopathy to rhabdomyolysis is another adverse effect of statins.



  • Aspirin inhibits platelet aggregation and is utilized post-MI to maintain coronary artery perfusion but can cause hemorrhaging.


Remember


12. Metoprolol is a selective beta-blocker, and therefore can lower heart rate.


13. Type 1 DM is categorized by little to no endogenous insulin production requiring exogenous insulin to treat; onset is usually abrupt prior to 20 years of age and is most often associated with autoimmune destruction of pancreatic beta cells. Type 2 DM is categorized by varying insulin production linked to obesity-associated insulin resistance with a gradual onset. Incidence of type 2 DM increases with age. Type 2 DM can be treated with weight loss, lifestyle modifications, oral medications, and exogenous insulin. Type 2 DM is much more prevalent compared to type 1 DM.


14. The balance strategies utilized by the body to maintain the center of mass over the base of support are ankle, hip, and stepping strategies. Ankle strategy is movement occurring at the ankle joint with the gastrocnemius soleus and anterior tibialis muscles initially activated. The hip strategy is the movement occurring at the hip joint with abdominals, paraspinals, and hip musculature initially activated. Ankle strategy is typically utilized for low disturbances, then hip strategy is utilized for larger disturbances, and stepping strategy is utilized for fast and large disturbances.


















Key points


1. It is important for the physical therapist to synthesize all components of a physical therapy examination and physical therapy evaluation to determine how the primary diagnosis is affecting the patient’s overall function.


2. Consider the pathophysiology and progression of chronic disease (CAD and type 2 DM) to analyze the patient’s findings.


3. When prescribing the frequency, intensity, and duration of exercise, prioritize the patient’s overall safety but do not “under-dose” the exercise prescription.


4. Always remember as a physical therapist, you are an integral part of a patient’s interdisciplinary team, even if you are working alone in an outpatient physical therapy clinic.





























General Information


Case no.


8.B


Authors


Sheena MacFarlane, PT, DPT, Board Certified Clinical Specialist in Cardiovascular & Pulmonary physical therapy


Melissa Brown MSPAS, PA-C


Diagnosis


Type 2 diabetes mellitus (DM) with peripheral neuropathy, Charcot foot, and diabetic wound


Setting


Acute care hospital


Learner expectations


☑ Initial evaluation


☐ Re-evaluation


☐ Treatment session


Learner objectives




  1. Identify signs, symptoms, and complications of diabetic neuropathy.



  2. Develop an understanding of medical management of wounds and how it influences physical therapy plan of care.



  3. Relate progression of diabetes to clinical manifestations and activity limitations seen in physical therapy practice.
































Medical


Chief complaint


Wound healing and difficulty ambulating.


History of present illness


The patient is a 68-year-old woman with a long-standing history of uncontrolled type 2 DM who was admitted 2 days ago with osteomyelitis of the left foot. She had participated in physical therapy as an outpatient for signs and symptoms related to diabetic neuropathy, including balance training. She has fallen once in the past 2 months. At that time, she was also diagnosed with a Charcot foot (neuropathic arthropathy). Despite conservative management, the patient developed an ulceration of the left foot 1 month ago that has progressively worsened. She has completed two courses of oral antibiotics as well as received a heel off-loading shoe. She currently notes intermittent “burning” pain in bilateral feet, which she rates at a 4/10. In the emergency department, intravenous (IV) antibiotics, IV insulin, and IV fluids were started. Oral diabetic medications were discontinued.


Past medical history


Uncontrolled type 2 diabetes with peripheral neuropathy, nephropathy, and retinopathy, hypertension (HTN), hyperlipidemia, coronary artery disease (CAD) with a myocardial infarction 6 years ago.


Past surgical history


Coronary artery bypass grafting (CABG) × 4 vessels 6 years ago


Allergies


Penicillin: rash


Medications (home)


Metformin, Sitagliptin, Glipizide, Dapagliflozin, Lisinopril, Amlodipine, Metoprolol, Simvastatin, Aspirin, Vancomycin, Ceftriaxone


Precautions/orders


Non–weight bearing (NWB) on left lower extremity (LLE)


Activity as tolerated























Social history


Home setup




  • Resides in a single-level home alone.



  • Two steps without handrail to enter.



  • Flight of stairs + one handrail to basement where laundry is located.



  • No grab bars in the bathroom.


Occupation




  • Part-time librarian, reduced hours from full time 6 years ago.


Prior level of function




  • Independent with functional mobility and activities of daily living (ADLs), however, admits to being a “furniture walker.”



  • Modified independence for stairs, required increased time.



  • Leans on a shopping cart when grocery shopping.



  • (+) driver


Recreational activities




  • Primarily reading and knitting



  • Previously enjoyed shopping but fatigues quickly.

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Dec 11, 2021 | Posted by in MANUAL THERAPIST | Comments Off on Diabetes Mellitus
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