Diabetes Mellitus Type 1

 

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Definition/Description

Diabetes Mellitus (DM) Type 1 is a chronic disorder characterized by hyperglycemia (high blood sugar) and disruption in metabolism of carbohydrates, fats, and proteins. It occurs because of little or no insulin being produced by the pancreas. It occurs in children or young adults, usually before the age of 30. It typically has an abrupt onset, with most individuals having a thin or normal body weight at diagnosis. Type 1 Diabetes is managed by diet, exercise, and insulin injections. It can result in serious vascular complications and neuropathies and can be a major cause of cardiovascular disease and strokes. It is also the leading cause of end-stage renal (kidney) disease, non-traumatic amputations in the lower extremity, and new cases of blindness. Autoimmune, environmental, and genetic causes may put individuals at risk of developing Type 1 DM. 

Prevalence

• ~10% of all Diabetes cases are Type 1 DM
• 29.1 million Americans had Diabetes (2012)
• 1.25 million Americans had Type 1 DM (2012)
• 208,000 Americans under the age of 20 estimated to have Diabetes, which is 0.25% of the population
  

Characteristics/Clinical Presentation

• Polyuria (increased urination)
• Polydipsia (increased thirst)
• Polyphagia (Increased appetite)**
• Glycosuria (glucose in urine)
• Weight loss despite polyphagia**
• Hyperglycemia (increased blood glucose)
• Ketonuria (ketones in urine)
• Fatigue
• Generalized weakness
• Blurred vision
• Irritability
• Recurring skin, gum, bladder, vaginal, or other infections
• Numbness or tingling in hands or feet
• Cuts, scrapes, or bruises that are difficult or slow to heal
• Periarthritis (especially shoulder)**
• Hand stiffness
  

    **=Occurs primarily in Type 1 Diabetes

Associated Co-morbidities

• Hypoglycemia
• Hypertension
• Dislipidemia
• Cardiovascular Disease
• Blindness/Eye problems
• Kidney Disease
• Increased risk for cognitive decline/dementia (including Alzheimer’s disease)
• Sensory neuropathy, which can lead to trauma or ulceration, causing infection and ultimately may cause an amputation
• Charcot’s joint or neuropathic arthropathy (especially shoulder, hands, or feet)
• Diabetic Neuropathy
• Diabetic Ketoacidosis, resulting from high blood glucose levels that are not treated with increased insulin (usually in special circumstances of stress, trauma, surgery, pregnancy, puberty, or infectious states)
  

Medications

• Insulin Injections

       -Do not inject into site of active extremities within one hour of exercise because the insulin will be absorbed more quickly

• Insulin Pump
• If patient is on epinephrine, glucocorticoids, or growth hormone, there may be an increase in blood glucose levels
  

Diagnostic Tests/Lab Tests/Lab Values

Diagnostic Criteria:

• Fasting plasma glucose (FPG) ≥ 126 mg/dl on two different days
• A1C Levels≥ 6.5 % on two separate occasions (but must be confirmed by FPG)

Other Information:

• FPG >100mg/dl is a risk factor for future diabetes
• A1C is a measure of how diet, exercise, and/or medication/insulin have been controlling glucose over a period of time 
• Normal FPG= 80-120 mg/dl
• Want to keep A1C levels below 7%
• >10%=medical attention immediately

Etiology/Causes

Etiology: 

• An autoimmune destruction or absence of pancreatic islet cells (B-cells). Pancreatic islet cells secrete insulin, a hormone that stimulates the body to take up glucose from the bloodstream. 
• Impaired insulin: Glucose is increased in the circulating blood because it is not being taken up by the liver or other tissues, which causes a glusose accumulation. This leads to impaired protein synthesis because amino acids need insulin for transport through the body. It also leads to fat breakdown in order to free more glucose, which can lead to ketone formation. The accumulation of glucose in the blood can also lead to a hyper osmotic condition.  

Possible Cause:
The cause of the autoimmune destruction of pancreatic B-cells is still being researched, but genetics, viruses, allergens, and environmental exposures are all potential causes. It has been shown that all people with type 1 diabetes have at least one similar gene. Individuals who have a primary family member with type 1 diabetes have a 5-6% chance of developing the disease, while individuals with no family history of the disease only have a 0.4% chance of developing type 1 diabetes. 

Systemic Involvement

• Systemic Involvement is due to the effect on nerves and vessels.
• Infection and atherosclerosis are two long-term complications of DM, which are also usually the causes of severe illness or death of patients with DM

Atherosclerosis:

Large vessel (macro vascular) or small vessel (micro vascular)

• This occurs at an earlier age than usual in DM patients and it also progresses much faster too
• Can lead to coronary artery disease, peripheral vascular disease, cerebrovascular disease, renal artery stenosis, diabetic nephropathy (kidney disease), or diabetic retinopathy

Diabetic Neuropathy: the most common chronic long-term complication of DM 

• Thought to be from the accumulation of Sorbitol in nerve cells, which is a byproduct of improper glucose metabolism; this causes abnormal fluid/electrolyte shifts and nerve cell dysfunction; this along with poor vascular perfusion to nervous system tissue causes diabetic neuropathy 

Other Systemic Issues:

• Impaired wound healing
• Xanthomas (fat deposits on skin) can develop on skin due to high lipids in the blood; yellow patches on the eyelids may also occur due to the same reason
• Periarthritis 
  

Medical Management (current best evidence)

• Goal is to maintain blood glucose levels between 80 and 120 mg/do
• This is done through the modification of diet, exercise, and medication
• Insulin
• Yearly eye and feet exams
  
• Daily foot inspections by patient
• A1C (greater than or equal to ) 2 times a year
  
• With retinopathy or nephropathy, avoid high intensity exercise that will significantly increase BP
  
• EDUCATION! 

Physical Therapy Management (current best evidence)

• Screening examination: for type 1 DM, should be done five years post diagnosis and annually thereafter; this screening includes reflexes, sensation in feet, questions about neuropathic symptoms, ulcers, calluses, etc. 
• Foot inspections for skin integrity, color, calluses, beginning of ulcerations, etc.
• Exercise program 
  
• EDUCATION
  
• Educate on not exercising alone for type 1
  
• Type 1: may need to decrease insulin dose or increase food intake, especially with prolonged activities (10-15g CHO with every 30 min. of exercise)
  
• Exercise adds to insulin and can drop glucose levels to low dangerous ranges, especially with high intensity or prolonged duration exercise, so monitor levels before, during, and after exercise to be safe
  
• Watch for confused, lethargic state or change in mental status in DM patient..this is very concerning!! 
  

       -Have patient do finger stick check for glucose levels if available and immediately refer to physician

• If patient has an insulin pump, diabetic ketoacidosis (DK) can occur quicker if there is an interruption in insulin delivery so keep this in mind and consider excess perspiration, increased motion at pump site, and temperature during exercise. Monitor patient carefully.
  
• Watch for life threatening conditions and signs/symptoms of both of them:
        1. Hyperglycemia: HHNC (hyperglycemia hyperosmolar, nonnegotiable acidosis), which usually occurs in an older adult with type 2 DM; or DKA, which usually occurs in type 1 DM patients (usually occurs with undiagnosed DM or when insulin needs become greater such as stress, trauma, surgery, infection, etc. )
         2. Hypoglycemia: <70 mg/dl is considered hypoglycemia; This is a major complication with insulin users (type 1 DM mainly). It usually occurs from decreased food intake or an increase in physical activity. It interrupts oxygen consumption in nervous tissue, which is why it is a serious complication. Patients using beta blockers are at a higher risk for developing ypoglycemia. If hypoglycemia is suspected, 10-15 g of carbohydrte (CHO) should be given ( this equals a ½ cup of juice/cola, 8 oz. milk, 2 sugar packets, or 2 oz. honey) so keep these in the clinic but ask patients first if they have something due to food allergies because many diabetic patients will carry snacks with them. 

• Blood glucose levels in relation to exercise that a PT should be aware of: 

1. <100 mg/dL= give 10-15 g CHO snack and retest glucose levels 15 minutes later   
2. 100-250 mg/dL= safe exercise levels; proceed with treatment 
3. 250-300 mg/dL @ start of exercise="caution zone"; postpone exercise until stable levels are achieved; ketones in urine are checked for at these levels 
4. >300 mg/dL= stop exercise immediately!!!! (NOT SAFE)
   

Differential Diagnosis

-Type 2 diabetes 

-Cancer

-Diabetes Insipidus 

-Dehydration 

-Hypothyroidism 

Case Reports/ Case Studies

General Practitioner online. Case Study: Type 1 diabetes in a child. www.gponline.com/case-study-type-1-diabetes-child/diabetes/type-1-diabetes/article/1371101. Accessed 3 April 2016.

http://www.gponline.com/case-study-type-1-diabetes-child/diabetes/type-1-diabetes/article/1371101

Resources

American Diabetes Association: http://www.diabetes.org

Mayo Clinic on Type 1 Diabetes Mellitus: http://www.mayoclinic.org/diseases-conditions/type-1-diabetes/basics/definition/con-20019573

American Diabetes Association: <a href="http://www.diabetes.org">http://www.diabetes.org</a>

Recent Related Research (from http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])

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References

<references /> Goodman CC, Snyder TEK. Differential Diagnosis for Physical Therapists: Screening for Referral. 5th ed. St. Louis, MO: Saunders/Elsevier; 2013: 425-.