Academy of Orthopaedic Physical Therapy

American Physical Therapy Association (APTA)

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20.1 Orthopaedic Implications for Patients With Diabetes
Table of Contents

THE ROLE OF OBESITY IN DIABETES

Abstract:

CONTENT: In the monograph, Dr. Stehno-Bittel thoroughly describes the spectrum of etiologies and symptoms that lead to an accurate classification of diabetes diagnoses. The identification and role of the inflammatory molecules released by adipose tissue and their interaction with the insulin receptor in skeletal muscle are then discussed. She then frames the current epidemic of obesity around a discussion on the thrifty gene theory and also correlates the impact of insulin resistance to obesity and sedentary lifestyles. The last portion of the monograph addresses the role of exercise in diabetes and how to adapt an exercise program using self-efficacy theory for a sedentary, unfit person and/or a person with Type 2 diabetes. This information provides the reader with an applied clinical perspective. CASE ANALYSES: Two cases appear in the monograph. The first is a 42-year-old elementary school teacher diagnosed with Type 2 diabetes who was referred to physical therapy with an exercise prescription to “lose weight.” The second case involves a 32-year-old man with a history of morbid obesity who had undergone a Roux-en-Y gastric bypass procedure.

Keywords:​

obesity, exercises, Type 2

References:

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DIABETES IN YOUTH: IMPACT OF DIABETES ON GROWTH,
DEVELOPMENT, AND MATURATION

Abstract:

CONTENT: In the monograph, Dr. Jesse first addresses the factors that affect bone structure and development in youth with diabetes. This section includes a detailed discussion of the metabolic and hormonal influences and provides a strong knowledge base with which to fully understand the far-reaching consequences of this disease on body growth and function. The following section reviews limited joint mobility and its relationship to diabetes in youth. Complications of foot pathology with a follow-up description of the effects of macrovascular and microvascular complications as a result of neuropathy are then highlighted. Dr. Jesse then discusses general guidelines for exercise in youth with diabetes. Dr. Jesse's work will allow the reader to gain a full appreciation of the metabolic consequences of diabetes on youth development and maturation. More specifically, readers will see why this disease is not solely a neurological and vascular affliction but a strong determinant in orthopaedic care and treatment when diagnosed at an early age. CASE ANALYSES: Two clinical cases complete the monograph. They take the reader through evaluation and treatment of a youth with Type 2 diabetes mellitus and a recent history of physical performance deficits and a young boy with Type 1 diabetes and a recent history of physical activity deficits.

Keywords:​

pediatrics, neuropathy, rehabilitation

References:

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METABOLIC AND CARDIOVASCULAR EFFECTS OF EXERCISE
IN THE ADULT WITH DIABETES

Abstract:

CONTENT: In this monograph, Dr. Cade thoroughly describes the etiology and pathophysiology of Type 1 and Type 2 diabetes and identifies the risk factors for each type. The clinical presentations of patients with diabetes are then presented, with an emphasis on how this pathology may affect treatment planning. Dr. Cade explores in detail the adverse effects of diabetes on skeletal muscle, the neurological system, and fat metabolism, and how each could contribute to exercise dysfunction. The treatment implications of exercise prescription for a patient with diabetes taking insulin-sensitizing medications, insulin medication, or both are also highlighted. The positive effects of exercise in reducing cardiovascular risk in patients with diabetes are clearly defined throughout the monograph. The effects of exercise on other diabetes-related complications (eg, peripheral arterial disease, diabetic peripheral neuropathy, and diabetic nephropathy) are also dealt with in separate sections of the monograph. Specific attention is given to addressing the role that physical therapists may play in the prevention and treatment of Type 2 diabetes. Dr. Cade offers the course participant a wealth of didactic and clinical information supported by a wealth of evidence-based literature. This provides the participant with a comprehensive resource that fits nicely with the other topics in this series or can even stand alone as a single reference. CASE ANALYSES: Two excellent case studies complete the monograph. The first presents a patient with adult-onset Type 1 diabetes experiencing fatigue and loss of endurance. The second describes a woman with Type 2 diabetes who is referred to physical therapy for balance, strength, and endurance training.

Keywords:​

physical activity, neuropathy, Type 2

References:

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WOUND MANAGEMENT AND THE DIABETIC FOOT

Abstract:

CONTENT: Written by a certified wound specialist Dr. Atkins first introduces the structure and function of skin, its layers, and influence of its composition in the wound healing process. This is followed by a detailed and phasic description of what occurs in normal wound healing. The local and systemic factors that affect wound healing are also identified. Dr. Atkins then integrates wound types, the causes, and classification categories with content included in the Integumentary section of the APTA Guide to Physical Therapist Practice. Treatment interventions such as the use of physical agents and dressings are then discussed. Specific emphasis is placed on the causal pathway to diabetic amputation and the role of diabetes in the pathway. Throughout the paper, evidence-based strategies for the care of a diabetic foot wound are emphasized. Finally, Dr. Atkins describes the critical role of the physical therapist in the care and the prevention of the diabetic foot. A thorough understanding of wound healing is critical in treating the patient with diabetes. When such knowledge is obtained, the focus then becomes intervention to achieve successful and optimal healing. Dr. Atkins provides the reader with both sides of the process; theory coupled with application. This combination will lead to best practice for the patient with diabetes. CASE ANALYSES: Application of the material is highlighted with the presentation of 2 case studies. The first describes a 51-year-old diabetic male with a right Charcot foot referred for care of a plantar heel ulcer. The second case is a 60-year-old morbidly obese white male who was referred for care of plantar ulcers on his right foot.

Keywords:​

ulcer, debridement, diabetes

References:

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ORTHOPAEDIC MANAGEMENT OF THE DIABETIC FOOT

Abstract:

CONTENT: Diabetes is a devastating systemic disease that can affect the foot and ankle complex in many ways. A systematic approach is needed to effectively manage and treat the patient with diabetes. A thorough examination process, appropriate testing, and a comprehensive understanding of the potential complications are essential for optimizing results in this patient population. In their monograph, Drs. McMillen, Lowery, and Wukich first discuss the main differences between patients with and patients without diabetes. The authors then highlight examination findings and comorbidities that require further work-up. There is also an emphasis on interpreting basic radiographic images and their implication in management of patients with diabetes. Through their writing the authors emphasize the complicated nature of managing foot and ankle deformities in patients with diabetes and also how a patient with diabetes would present if they were at risk for Charcot neuropathy. Distinctions are made in recognizing the differences between patients who have a foot and ankle complication directly resulting from diabetes as opposed to patients with diabetes who present with a separate problem unrelated to the disease. In addition, a detailed section is included on the classification, management, and treatment of Charcot neuroarthropathy. After reading the monograph, you will gain valuable insight into how to most effectively examine, treat, and manage patients with diabetes and foot complications. CASE ANALYSES: Two case studies conclude the paper. The first case discusses a 56-year-old man with Type 2 diabetes mellitus who presents with an ulcer on the bottom of his left foot. The second case describes a 30-year-old man with Type 1 diabetes mellitus who enters his local emergency department after sustaining an injury to his right ankle.

Keywords:​

Charcot, neuropathy, diabetes

References:

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COMPLICATIONS AND INTERVENTIONS FOR PATHOLOGIES
OF THE DIABETIC FOOT

Abstract:

CONTENT: Dr. Shipe provides a very useful work that will help the clinician conduct a thorough evaluation and formulate a treatment plan that will lead to quality care for the patient with diabetes. Dr. Shipe first introduces the reader to the metabolic, vascular, neurologic, and biomechanical risk factors associated with diabetic foot pathology. Specific pathologies are then discussed in detail with regard to their physiologic impact on foot integrity and function. Dr. Shipe then presents a comprehensive examination process for evaluation of the diabetic foot based on the APTA Guide to Physical Therapist Practice. There is a nice emphasis on linking examination findings related to structural changes of the foot and its effect on function. Balance and gait dysfunction are specifically addressed, along with the effect of plantar pressure changes. Dr. Shipe also cites some very useful Web-based resources that provide screening and patient education materials developed by government agencies as a result of key national initiatives. The results of the physical therapy examination and evaluation are then used to develop a comprehensive physical therapy intervention plan. This includes manual therapy, therapeutic exercise planning, balance and gait training, and pain control. Particular emphasis is also placed on the areas of patient education and prescribing protective footwear including custom orthotics. Outcomes measures are also discussed. CASE ANALYSES: Two relevant case studies complete the paper and apply theory into practice. The first case describes a 66-year-old male who is a retired coal miner with Type II diabetes and referred by his podiatrist with a diagnosis of right posterior tibial tendon tear and medial ankle sprain. The second case focuses on a patient with significant vascular occlusive disease and a prior history of foot ulceration. This patient is a 64-year-old male referred by his primary care physician for physical therapy with a diagnosis of a “frozen” right ankle.

Keywords:​

physical therapy, exercise, diabetes

References:

Click here.

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