VOLUME 11 NUMBER 3 • SEPTEMBER 2014
105
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
improving grip strength and maintaining or improving function.
Occupational therapy intervention may also include splinting to
assist with maintenance of ROM. In diabetics, the contractures are
usually mild and rarely require surgery.
3
Flexor tenosynovitis
This has a higher incidence in diabetic patients and people with
impaired glucose tolerance. A corticosteroid injection into the
affected tendon sheath is often curative.
3
Ultrasound over the
affected tendon may help to ease the symptoms.
Diffuse idiopathic skeletal hyperostosis (DISH)
This is also known as ankylosing hyperostosis and is characterised
by new bone formation, particularly in the thoracolumbar spine.
It occurs with greater frequency in the diabetic population than
in non-diabetics, and has a higher prevalence in type 1 compared
with type 2 diabetes. DISH is often asymptomatic and diagnosed
as an incidental radiographic finding. Physiotherapy treatment
would be symptomatic and include electrotherapy and exercise
programmes.
3
Neuropathic (Charcot’s) joints
Limited joint mobility (diabetic cheiroarthropathy) and diabetic
amyotrophy are seen more often in type 1 diabetics. Charcot’s joints
occur as a result of diabetic peripheral neuropathy. The weight-
bearing joints are most commonly affected. The use of walking aids
and orthotics can reduce impact on the affected joints, assist with
reduction of pain when walking and improve mobility.
Diabetic cheiroarthropathy is characterised by thick, tight skin
mainly on the dorsum of the hand, and flexion deformities of the
metacarpophalangeal and interphalangeal joints. In the early stages,
slight pain and parasthesias develop, with pain increasing slowly.
3,9
Physiotherapy (and/or occupational therapy) intervention would
comprise a hand therapy programme with the aim of optimising
ROM, improving grip strength and maintaining or improving
function, as well as instruction on skin care.
Diabetic amyotrophy is characterised by muscle weakness and
wasting, and proximal lower limb muscle pain. The shoulder girdle
is less commonly affected. Most cases improve gradually with
stabilised glycaemic control.
3
Effects of micro- and macrovascular complications
Diabetic peripheral neuropathy (DPN)
This is associated with both vascular and non-vascular mechanisms
of diabetes. Altered lower limb sensation and pain may be
encountered in the evaluation and treatment of balance and
movement disorders. When associated with impaired vascular
function, peripheral neuropathy can contribute to the development
of lower limb ulceration.
2
Transcutaneous electrical nerve stimulation
(TENS), percutaneous electrical nerve stimulation (PENS) and
acupuncture have all been proposed as modalities that may relieve
the pain and discomfort associated with DPN.
10-13
Spinal cord involvement
This may occur at a subclinical stage of DPN, which suggests
that the metabolic insult of diabetes has a generalised effect
on the nervous system.
14
Spinal cord involvement may be a reason
for poor responses to treatment modalities for pain associated
with DPN.
Cardiac autonomic neuropathy
This can include clinical abnormalities such as resting tachycardia,
exercise intolerance and slow heart rate recovery after exercise.
2
The
patient’s perceived exertion should be used as a measure of effort for
exercise prescription, rather than relying on heart rate responses.
Diabetic retinopathy (DR)
DR is a leading cause of visual disability and blindness in people
with diabetes. The most significant factor in the development and
progression of DR appears to be hyperglycaemia.
2
Vision loss has a
psychological impact as well as negatively impacting on diabetes
self-management skills. An intensive multidisciplinary rehabilitation
programme offering exercise training, instruction in diabetes self-
management techniques for the visually impaired, and group
support early in the course of vision loss may be of clinical benefit.
15
Orientation and mobility (O&M) trainers are a scarce but valuable
resource for advising and training both the visually impaired patient
and their caregivers.
Diabetic nephropathy
This typically first manifests as microalbuminaria, which progresses
to renal failure and end-stage renal disease. Physiotherapy renal
rehabilitation programmes and exercise are recommended to
improve patient functional performance, exercise tolerance and
quality of life.
16
Cardiovascular disease (CVD)
CVD risk factors are common in diabetes, but diabetes appears to
be an independent risk factor for CVD. Insulin resistance is also
linked with increased risk for CVD. Increased physical activity and
moderate to high levels of cardiorespiratory fitness is generally
recommended as an intervention, which assists with reduction and
control of central adiposity, dyslipidaemia, hyperglycaemia and
hypertension, so benefitting cardiovascular health and reducing
mortality.
17,18
Cerebrovascular disease
Diabetes is an independent risk factor for stroke across all ages.
In the SASPI study of stroke prevalence in rural South Africans,
the risk factor associated with diabetes mellitus was 12%, after
hypertension (71%) and current alcohol use (20%).
19
Diabetes
affects the cerebrovascular circulation by increasing the risk of
intracranial and extracranial atherosclerosis.
The challenges of accessing physiotherapy and occupational
therapy rehabilitation in rural areas and the lack of resources impact
negatively on the level of independent function that is achieved by
the stroke patient. Decreased functional abilities compounded by
cognitive disabilities associated with stroke can negatively impact
on diabetes self-care.
Peripheral vascular disease (PVD)
PVD is characterised by occlusion of the lower limb arteries, which
causes intermittent claudication and pain, especially with exercise
and activity. Severe disability and functional impairment is associated
with PVD and diabetes.
Exercise training in people with PVD has been shown to
be beneficial to improving walking distance and time, time to
claudication and pain, and quality of life. In addition, a person who
has better exercise tolerance and muscle power will be more likely
to achieve good functional outcomes post amputation.
2
