i bc27f85be50b71b1 (211 page)

of insulin pump therapy at nighttimc only for children 7-10 years of age with rype 1

diabetes. Diabetes Care 2000; 123(5):579.

ENDOCRINE SYSTEM

677

Research directed at curing type I diabetes is aimed at specifically

idenrifying the causative genes, permanent replacement of lost betacell function, which could involve islet cell transplantation, regeneration of beta cells, or development of an immortalized insulin-secreting cell line.J1

Clinical Tip

•

Hypoglycemia may occur during exercise or up to 24

hours after exercise because of an inability to regulate

insulin levels. To help prevent this, the patient should con·

sume extra carbohydrates before and during exercise (e.g.,

JOg of carbohydrates per 30 minutes of activity), and the

nurse or patient may also decrease the dose or rate of insulin infusion, especially with CSII.

•

The physical therapist should be aware of the catheter

placement on the patient for CSII therapy so the catheter

will not be disrupted during intervention.

•

Circulation of insulin that is injected into an exercising

limb is enhanced as a result of increased blood flow and

temperature. The injection into the exercising limb may,

therefore, lead to hypoglycemia. Insulin can be injected

into the abdomen to help prevent this process.

•

Insulin is necessary to modulate lipolysis and hepatic

(liver) glucose production during exercise. Performing

exercise without adequate insulin can lead to hyperglycemia and ketogenesis.

•

The physical therapist should inquire about the

patient's blood glucose levels before and afrer exercise to

assist in physical therapy planning.

•

Coordinating physical therapy sessions with meals and

insulin injections may help optimize exercise tolerance.

•

Keeping graham crackers close by when working with

diabetic individuals is helpful in case hypoglycemia does

occur with activity.

Type 2 Diabetes

Type 2 diabetes is more common in the United States than type ·1

diabetes and generally occurs afrer 40 years of age. Type 2 diabetes is significantly linked to obesity, a sedentary lifestyle, and aging. Genetic predisposition has also been established.3o.JI.3J

678

AClJfE CARE HANDBOOK FOR PHYSICAL THERAPIST!,

The mechanism of type 2 diabetes involves increasing cellular resistance to insulin, which results in a compensatory hypersecretion of insulin from the pancreatic beta cells that ultimately leads to a failure

in insulin production.29-H Other etiologies for type 2 diabetes exist

but are nOt discussed in this text.

Signs and symptoms of type 2 diabetes may be similar to those of

type I diabetes but can also include the following:

•

Recurrent infections and prolonged wound healing

•

Genital pruritus

•

Visual changes

•

Paresthesias

Management of type 2 diabetes is similar to that of type 1 diabetes,

with an emphasis on medical nutritional therapy and exercise to control hyperglycemia. Oral hypoglycemic agents and actual insulin administration may also be used.J2,J4-J6 CSII has been shown to be as

effective as multiple do e injections of insulin in patients with type 2

diabetes.37 Clinical studies are also investigating the lise of inhaled

insulin for these patients, with preliminary results demonstrating

promising results.J8,J9

Listed below are oral hypoglycemic agents that help increase insulin production and belong to the drug class of slilfonyllireasJ2•1J: Tolbutamide (Orinase, Oramide)

Tolazamide (Tolinase, Ronase, Tolamide)

Chlorpropamide (Oiabinese)

Acetohexamide (Oymelor)

Glyburide (OiaBeta, Micronase)

Glipizide (Glucotrol)

An oral hypoglycemic agent that enhances glucose use in muscle is

metformin.33

Research direction for type 2 diabetes includes identifying the

genets) responsible for the predisposition to type 2 diabetes and the

mechanisms by which environmental factors trigger this predisposi-

ENDOCRINE SYSTEM

679

tion. Also, identification of the cellular defects responsible for insulin

resistance and impaired insulin secrerion in rype 2 diabetes will, it is

hoped, lead to the development of new medications that will be specific and relatively free of unwanted adverse effects.J1

Clinical Tip

•

Glycemic conrrol for patienrs with type 1 or type 2 diabetes may be altered significantly with the onset of new illnesses, such as systemic infection, because these new processes require added glucose metabolism. It is important for the therapist to carefully monitor the patient's blood glucose levels during therapeutic inrerventions,

because the symptoms of diabetes may be exacerbated in a

patient with significant comorbidities.

•

Blood glucose levels are denoted in the medical record

as BS levels.

•

Patients with diabetes present with a wide range of their

individual "normal" values. Therefore, establishing the

tolerable high or low value for each patient during the initial evaluation is very important in determining the parameters for physical therapy inrervenrion.

•

Patients with poor glycemic conrrol can have wide flucruations in rhe BS levels on a daily basis. Therefore, be

sure to always verify their BS level before physical therapy

intervention.

•

Consult with rhe nurse or physician regarding whether

therapy should be deferred for patienrs who were recently

placed on intravenous insulin to stabilize their glucose levels.

•

Patients who were following a regular exercise program

for glycemic control before hospital admission will require

education about how CO modify their exercise parameters

during the hospitalization and on discharge. Modification

of exercise parameters will be dependenr on the nature of

concurrent illnesses.

Complications of Diabetes Melli/us

Patients with diabetes mellitus, despite management, can still develop

organ and organ system damage linked to lesions of the small and

large blood vessels. Complications can manifest 2-15 years after diag-