Diabetes-related microvascular and macrovascular diseases in the physical therapy setting

Abstract

Physical therapists commonly treat people with diabetes for a wide variety of diabetes-associated impairments, including those from diabetes-related vascular disease. Diabetes is associated with both microvascular and macrovascular diseases affecting several organs, including muscle, skin, heart, brain, and kidneys. A common etiology links the different types of diabetes-associated vascular disease. Common risk factors for vascular disease in people with diabetes, specifically type 2 diabetes, include hyperglycemia, insulin resistance, dyslipidemia, hypertension, tobacco use, and obesity. Mechanisms for vascular disease in diabetes include the pathologic effects of advanced glycation end product accumulation, impaired vasodilatory response attributable to nitric oxide inhibition, smooth muscle cell dysfunction, overproduction of endothelial growth factors, chronic inflammation, hemodynamic dysregulation, impaired fibrinolytic ability, and enhanced platelet aggregation. It is becoming increasingly important for physical therapists to be aware of diabetes-related vascular complications as more patients present with insulin resistance and diabetes. The opportunities for effective physical therapy interventions (such as exercise) are significant.

Figure 1.

Representative transmission electron micrographs of capillary basement membranes (opposing arrows) in tissues from 300- to 350-day-old normal mice (a) and age- and sex-matched transgenic diabetic mice (b). Capillary basement membranes are shown in renal glomerulus (1a, 1b), retina (2a, 2b), and peripheral nerve (6a, 6b). All micrographs: ×28,500. Reprinted with permission of Wiley-Liss Inc, a subsidiary of John Wiley & Sons Inc, from: Carlson EC, Audette JL, Veitenheimer NJ, et al. Ultrastructural morphometry of capillary basement membrane thickness in normal and transgenic diabetic mice. Anat Rec A Discov Mol Cell Evol Biol. 2003;271:332–341.

Figure 2.

Microaneurysms in diabetic retinopathy. From the Slice of Life collection, curated by Suzanne Stensaas, University of Utah.

Figure 3.

Potential mechanisms for diabetes-associated endothelial dysfunction. AGE=advanced glycation end products, RAGE=receptors for AGE, ROS=reactive oxygen species, PKC=protein kinase C, RAS=renin-angiotensin system, FFA=free fatty acid.

Figure 4.

Potential mechanisms for diabetes-associated vascular abnormalities. NO=nitric oxide, tPA-1=tissue plasminogen activator-1, PAI-1=plasminogen activator inhibitor-1.