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Physiotherapy approach in managing diabetic stroke patients.



ABSTRACT

The prevention and treatment of stroke in diabetic patients is regarded as a major challenge facing those in health planning. Stroke is by far the most common cause of neurological disability in adults. Of patients who suffer a stroke, about a third will die, a third will survive but with severe disability, and the remaining third will make a good recovery with functional independence. Diabetes is a strong modifiable risk factor for stroke and is recognized as an independent risk factor for ischaemic stroke. The presence of diabetes influences the incidence of stroke and its rehabilitation in several ways. These include age of occurrence, subtype, severity, prognosis, speed of recovery and modality. It is yet to be fully established, however, whether or not strict control of blood glucose prevents stroke.

Physiotherapy intervention in the rehabilitation of stroke patients who have diabetes mellitus as a co-morbid factor is multipurpose and encompassing. This is because the presence of diabetes, a metabolic disorder needs to be separately considered as the main neurological picture of stroke is being managed. This article delineates the relationship between stroke and the co-morbid effects of diabetes mellitus with specific reference to its effect on the physiotherapy approach in management and the overall prognosis.

Key words: stroke, diabetes and physiotherapy

INTRODUCTION

Diabetes mellitus refers to a spectrum of related disorders, characterized by one common factor; a deficiency in insulin or its metabolic effect. Diminished insulin effect, whether primary or secondary, results in a number of biochemical and physiological alterations. (1) Diabetes mellitus can also be described as a clinical syndrome characterized by hyperglycaemia hyperglycaemia or US hyperglycemia
Noun

Pathol an abnormally large amount of sugar in the blood [Greek huper over + glukus sweet]

Noun 1.
 caused by a relative or absolute deficiency of insulin or by a resistance to the action of insulin at the cellular level. It is classified into two types:

a. Insulin dependent diabetes mellitus (IDDM IDDM
abbr.
insulin-dependent diabetes mellitus



IDDM

insulin-dependent diabetes mellitus.

IDDM Insulin-dependent diabetes mellitus; now known as type 1 diabetes mellitus
) or Type 1 diabetes type 1 diabetes
n.
See diabetes mellitus.
 

b. Non-insulin dependent diabetes mellitus (NIDDM NIDDM
abbr.
non-insulin-dependent diabetes mellitus



NIDDM

non-insulin-dependent diabetes mellitus.

NIDDM Non-insulin-dependent diabetes mellitus. See Type 2 diabetes mellitus.
) or Type 2 diabetes type 2 diabetes
n.
See diabetes mellitus.
 (2)

In spite of the introduction of insulin therapy in the 1920s, which reduced the death rates in patients with diabetes mellitus, today, patients with the disease and their health care providers still face the challenge of chronic complications associated with the disease. (3,4) Some of these complications include macro-vascular disorders which manifest clinically as myocardial infarction, coronary artery disease coronary artery disease, condition that results when the coronary arteries are narrowed or occluded, most commonly by atherosclerotic deposits of fibrous and fatty tissue. , stroke, and vascular foot disease. (2) This has led to the increased risk of stroke in the diabetic patient, a fact that has been established in several studies to be a result of patho-physiological changes in the cerebral vessels of patients with diabetes. (5)

Diabetes affects more than 30 million people worldwide. The prevalence in persons aged 45-65 years is 7%, but the proportion increases significantly in persons aged 65 years and above. It is estimated that over 8 million people in the United States are unaware that they have the disease. (6) The number of individuals in the United States affected yearly by diabetes is expected to grow at an annual rate of 2.8% for the next twenty-five years. Consequently, more than 3.7 million additional individuals will require care for diabetes and diabetes-related complications by the year 2020.

Obesity contributes to the increased risk of diabetes among African-Americans, and the trend is such that even when adiposity adiposity /ad·i·pos·i·ty/ (ad?i-pos´i-te) obesity.

cerebral adiposity  fatness due to cerebral disease, especially of the hypothalamus.


adiposity

obesity.
 and socioeconomic status are normal, African-Americans are still more likely to have diabetes. (2) Whatever the age at which diabetes mellitus is diagnosed, the patient may live a reasonably normal life. Life expectancy is, however, reduced due to the chronic complications of the disorder, and quality of life is severely impaired. (7)

To the layman, stroke means either permanent or transient weakness of the limbs on one side of the body, often accompanied with loss or disturbance of speech. (8) The World Health Organization defines it as rapidly developed clinical signs of focal or global disturbance of cerebral function of presumed vascular origin, lasting more than 24 hours. (9) Stroke is not only considered a disease but also a syndrome caused by several common and uncommon disorders which cause the arteries to occlude or rupture. (10)

This article outlines the relationship between stroke and diabetes with specific reference to the effect on prognosis and physiotherapy management.

Relationship between Diabetes and Stroke

Pathologically, macro-vascular disease in diabetes mellitus is an indication of arteriosclerosis arteriosclerosis (ärtĭr'ēōsklərō`sis), general term for a condition characterized by thickening, hardening, and loss of elasticity of the walls of the blood vessels. , which is the deposit of materials within the inner layer in the intima intima /in·ti·ma/ (in´ti-mah)
1. innermost.

2. tunica intima vasorum.in´timal


in·ti·ma
n. pl.
 of the vessel walls. (3) Arteriosclerosis is a major predictor of stroke. Nine percent of type 2 diabetic patients were reported to develop micro-vascular disease after 9 years of follow-up, compared to 20% for macro-vascular complications. (3) In the United States, where diabetes is the fourth most common cause of death, arteriosclerotic ar·te·ri·o·scle·ro·sis  
n.
A chronic disease in which thickening, hardening, and loss of elasticity of the arterial walls result in impaired blood circulation. It develops with aging, and in hypertension, diabetes, hyperlipidemia, and other conditions.
 macro-vascular disease accounts for as much as 75% of mortality in type 2 diabetes. Researchers have 11 found that a drop in cholesterol level reduces the risk of haemorrhagic stroke, which accounts for 20% of stroke incidence. (12) This means that the relative risk of stroke in the diabetic patient is approximately doubled compared with persons without diabetes. (13) Patients with undiagnosed diabetes mellitus are at serious risk of developing coronary heart disease coronary heart disease: see coronary artery disease.
coronary heart disease
 or ischemic heart disease

Progressive reduction of blood supply to the heart muscle due to narrowing or blocking of a coronary artery (see atherosclerosis).
, stroke, or peripheral vascular disease Peripheral Vascular Disease Definition

Peripheral vascular disease is a narrowing of blood vessels that restricts blood flow. It mostly occurs in the legs, but is sometimes seen in the arms.
, and are likely to be hypertensive and obese. (6)

Cerebrovascular disease is the third leading cause of death in the United States in persons aged 65-84 years and the second leading cause in persons who are 85 years and older. (14) In black Africans, the prevalence of stroke is reported to range from 0.9% to 4.0%, accounting for 6.5% to 41.0% of neurological admissions and for about 4.0% to 9.0% of hospital deaths. (15) The risk of stroke essentially doubles with each successive decade after forty-five years. Several large population studies have reported that the blood pressure in diabetics is higher than in non-diabetics, the difference being more marked in women. (16)

Diabetes mellitus is associated with a marked increase in myocardial infarction and ischaemic stroke. Prospective data indicates that maturity onset clinical diabetes mellitus is a strong determinant of ischaemic stroke and cardiovascular mortality among middle aged women, and the adverse effect of diabetes is amplified in the presence of other cardiovascular risk factors. (17) In the non-diabetic patient, evidence shows a positive relationship between body mass index and blood pressure, (18) which makes hypertension more frequent in obese patients than in non obese patients. (19)

Studies have shown that patients diagnosed with diabetes before the age of 20 had only a 60-70% chance of living past the age of 50 years. In patients over 50 years, the major causes of death are heart disease, peripheral vascular disease and stroke. (8) In a retrospective study by Jorgensen et al., (13) it was reported that the neurological outcome of stroke was poorer in patients with diabetes than in non-diabetic patients. Forty percent of diabetic patients under 65 years have had stroke, using the WHO criteria (systolic blood pressure Systolic blood pressure
Blood pressure when the heart contracts (beats).

Mentioned in: Hypertension
 > 160mmHg and diastolic blood pressure Diastolic blood pressure
Blood pressure when the heart is resting between beats.

Mentioned in: Hypertension
 > 95mmHg). Also there was a higher prevalence of blacks (48.9%) than whites (37.5%) and Asians (35.4%). (18) The Framingham study revealed that female diabetic stroke patients have a 4-fold and males a 2-fold increased mortality compared to age and sex-matched non-diabetics. In 20 the same study, the risk of non-fatal and fatal stroke was 2.6-fold higher in men with NIDDM and 3.8-fold higher in women with NIDDM than in non-diabetics of the same sex. Stroke may trigger a 21 diabetic crisis which, even after prompt and appropriate therapy, can produce an increase in the cerebral damage and degree of handicap in the patient.

Physiotherapy Approach to Management of Diabetic Stroke Patients

The diabetic patient who has suffered a stroke may present with the same sensory, motor, mental, perceptual and language function impairments as a non-diabetic stroke patient. He/she may, however, have a greater degree of disability due to the existing clinical presentations in diabetes such as: staphylococcal skin infections, retinopathy, polyneuropathy polyneuropathy /poly·neu·rop·a·thy/ (-ndbobr-rop´ah-the) neuropathy of several peripheral nerves simultaneously.

amyloid polyneuropathy
 (which causes a tingling sensation and numbness in the feet), arterial diseases, lack of energy and weight loss or obesity. (8)

Proper assessment of the patient is an important aspect of management, since the ultimate goal of the treatment programme will depend on clinical findings. It is generally accepted that patients who have suffered a stroke need not spend the rest of their lives in bed. Physiotherapy, therefore, stresses the need to restore functional movement as soon as possible, in order to regain not only voluntary control of the muscles, reflexes and tone, but also to reduce abnormal movement. The same reasons apply to the stroke patient with diabetes mellitus.

The principal aim of physiotherapy management is to normalize tone and facilitate normal movement, thus providing sensorimotor sensorimotor /sen·so·ri·mo·tor/ (sen?sor-e-mo´ter) both sensory and motor.

sen·so·ri·mo·tor
adj.
Of, relating to, or combining the functions of the sensory and motor activities.
 experience on which all learning is based.

Re-education of bilateral righting reflexes and equilibrium reactions in the head, trunk and limbs are vital if independent balance is to be regained.

Movement is repeated to establish a memory of the feeling of normal movement (9) and assistance is gradually lessened until the patient performs the movement unaided.

Physiotherapy management involves 2 major stages:

Early Stage Treatment: The patient may be in the intensive care unit, and the physiotherapist will be concerned with three main aspects at this stage.

i. Respiratory Care--This involves the loosening of secretions through massage manipulations, which may involve vibrations, shaking and clapping for easy suctioning of secretions to maintain a clear airway. Intermittent positive pressure breathing intermittent positive pressure breathing
n. Abbr. IPPB
See controlled mechanical ventilation.
 machines, ultrasonic nebulizers and chest suction equipment should be available for the physiotherapist's use in case the patient has a chest infection.

ii. Positioning--Positioning of the limbs is vital where abnormal hemiplegic hem·i·ple·gia  
n.
Paralysis affecting only one side of the body.



[Late Greek hmipl
 motor patterns are present. The patient should be turned frequently to prevent pressure sores, especially as the patient is diabetic and has sensory impairment. Relatives must be educated in these techniques for home care.

iii. Passive Mobilization Exercise Therapy--These exercises should be carried out to maintain the range of movement in all joints, and maintain muscle length. It is important to remember that oedema oedema

see edema.
 of the hand is found in 16% of all stroke patients, due to insufficient drainage from the lymphatics; passive movement is essential for eliminating the oedema. (22)

Later Stage Treatment--The intensity of this treatment will depend on the response of the patient. In this case, the patient will usually be conscious and therefore requires careful explanation about the treatment. The emphasis should be on symmetrical positioning, while the physiotherapist facilitates movement, particularly those pertaining to function.

Mobilizing the affected arm--Although most hemiplegics with severe paralysis may never regain full functional use of the affected arm, it is important that the arm should remain fully mobile. A stiff painful arm impedes balance and movement of the body; therefore passive movement through the available range of the arm should be performed daily to prevent such complications. Other exercise techniques include elongation of the trunk, protraction protraction /pro·trac·tion/ (pro-trak´shun)
1. drawing out or lengthening.

2. extension or protrusion.

3.
 of the scapula scapula /scap·u·la/ (skap´u-lah) pl. scap´ulae   [L.] shoulder blade; the flat, triangular bone in the back of the shoulder. scap´ular

scap·u·la
n. pl.
, abduction and self-assisted arm movements, hip control movements, knee flexion with dorsiflexion dorsiflexion /dor·si·flex·ion/ (dor?si-flek´shun) flexion or bending toward the extensor aspect of a limb, as of the hand or foot.

dor·si·flex·ion
n.
The turning of the foot or the toes upward.
, bridging exercises, rolling exercises, weight transference with trunk control, weight bearing on affected side and active exercises for the unaffected limbs.

As motor movement gradually returns, facilitatory techniques can also be used to strengthen weak muscles. Mobilization exercises should be used to relieve pain in every joint that presents with pain. The use of any form of electrotherapy electrotherapy /elec·tro·ther·a·py/ (-ther´ah-pe) treatment of disease by means of electricity.

e·lec·tro·ther·a·py
n.
Medical therapy using electric currents.
 should be avoided due to the sensory impairment which is part of the pathology of diabetes mellitus. Constant and continuous passive movement should be maintained, especially for the lower limbs to facilitate circulation and adequate venous drainage. (9)

Foot Care--The foot and the skin in the diabetic stroke patient need special care. Studies on the aetiology of diabetic foot disease have identified inappropriate or ill-fitting footwear as a contributing factor. Ulcers on the plantar surface occur mostly at sites of high pressure due to repetitive loading during normal gait. (23) High-pressure areas stimulate the formation of callouses. (24) Education of the patient and health care staff to identify those at risk, the provision of measures designed to reduce the risk and the use of therapeutic footwear to prevent reoccurrence are sets of organized programmes for care of the foot to enable the diabetic stroke patient maintain a healthy lifestyle. (25) To allow for optimal use of this remarkable organized programme, a health care team including the physician, nurse educator, nutritionist, exercise physiologist, pharmacist, psychosocial professionals and the physiotherapist must interact with the patient for beneficial outcomes.

Weight Control--Management of obesity in the diabetic stroke patient depends on the severity of the stroke, but encompasses 3 basic areas: (i) diet control, (ii) appropriate exercise (this enables the obese to lose weight; improves circulation and prevents complications), and (iii) drug therapy. (26) As in other areas of diabetic stroke management, a team approach to exercise is essential, beginning with the physician who needs to refer the patient for further rehabilitation. Exercise has both benefits and risks. Today, the availability of more research has made it possible for health care providers to prepare guidelines to assist persons with diabetes to exercise safely.

Physical activity seems to be inversely related to the risk of stroke. Also, physical activity has a beneficial effect on body weight, blood pressure, and serum cholesterol and glucose tolerance. (27) The response to exercise is still highly variable and requires that the individual effect of exercise or metabolic parameters be monitored. The goal is to ensure that the benefits of exercise are maximized and the risks minimized. The expert on testing and prescribing appropriate exercise programmes ensures that the recommended exercise programme is safe for the individual.

Persons with diabetes derive the same benefits that person without diabetes gain from a regular exercise programme, namely: improved fitness and psychological state as evidenced in increased lean body mass, decreased adipose tissue store, weight control and improved physical work capacity. In addition, however, aerobic exercise has additional benefits for persons with diabetes. These include: increased insulin sensitivity, which results in a potential reduction in insulin dosage as well as a reduction in risk factors for arteriosclerosis. (28)

The exercise therapy in the diabetic stroke patient must be carefully prescribed, well monitored and must progress gradually. This is because like in every diabetic individual, there is the likelihood of the patient developing hypoglycaemic Adj. 1. hypoglycaemic - of or relating to hypoglycemia; "hypoglycemic agents"
hypoglycemic
 coma or ketoacidosis during exercise, especially in Type-2 diabetes mellitus.

CONCLUSION

Stroke in diabetic patients has a specific clinical pattern and a poor prognosis in terms of motor function, which emphasizes the need for early diagnosis and rapid treatment. Selecting patients for rehabilitation and the methods to be used in treatment must take into account any contraindications such as serious systemic disease in diabetes. There is evidence of an adverse relationship between diabetes and both disability and handicap in stroke patients. (5)

REFERENCES

(1.) Cahill GF. Foreword. In: Brownie M, ed. Diabetes Mellitus: Aetiology / Hormone Physiology. Chichester: Niley. 1981; ix.

(2.) Ratner RE. Review of diabetes mellitus. In: Haire-Joshu D (ed.) Management of Diabetes Mellitus 2nd edition. St. Louis: Mosby. 1996; 3-7.

(3.) Vinicor F. Features of macrovascular disease of diabetes. In: Haire-Joshu D (ed.) Management of Diabetes Mellitus 2nd edition. St Louis: Mosby. 1996. p. 281.

(4.) Reckless JPD JPD Just Plain Dumb
JPD Joint Probability Distribution
JPD Jackson Police Department
JPD Juvenile Periodontitis
JPD Joliet Police Department (Illinois, USA)
JPD Joint Planning Document
JPD Johnstown Police Department
. Epidemiology of heart disease in diabetes mellitus: In: Taylor K (ed.) Diabetes and the Heart 1st edition. Oxford: Oxford. 1992; 1-3.

(5.) Salah-Eddine Megherbi, Chantal Milan, Dominique Minier, Gregory Couvreur, Guy-Victor Osseby. Association between diabetic and stroke subtypes in survival and functional outcome 3 months after stroke: Stroke 2003; 34: 688.

(6.) Joe Florence and Bryan Yeager. Treatment of type-2 diabetes mellitus: Reports of the American Family Physician 1999.

(7.) Taylor K, ed. Diabetes and the Heart. 1st edition. Oxford: Oxford. 1992; ix.

(8.) Kumar P and Clark M (eds). Clinical Medicine 4th edition. Edinburgh: Saunders. 1999; 1046.

(9.) Todd JM and Davids PM. Hemiplegia--Assessments and approach. In: Downie PA, ed. Cash Textbook of Neurology for Physiotherapists. 4 edition. London: Wolfe. 1992; th 253-259.

(10.) Zaccagnino J. Stroke and Stroke Rehabilitation Outline. Berth Rodgers School of Continuing Education The School of Continuing Education is a part of the North Orange County Community College District, located in northern Orange County, California. The School of Continuing Education provides non-credit continuing adult education, English as a Second Language, vocational skills,  Publications: Florida 1: 2002.

(11.) Jeffery Wallace: Management of Diabetes in the Elderly. Clinical Diabetes 1999; 17(1).

(12.) http//www.diagnose-me.com//stroke: 2004

(13.) Jorgensen HS, Nakayama H, Raaschou HO, Olsen ST. Stroke in patients with diabetes (The Copenhagen Stroke Study). Stroke 1992; 25: 1977-1982.

(14.) Brodesick JP. Stroke and cerebrovascular disease S.N.. In: Barclay L (ed.) Clinical Geriatric Neurology 1st Edition. Philadephia: Lea and Febiger. 1993; 177-179.

(15.) Osuntokun, B.O. Epidemiology of stroke in blacks in Africa. Hypertension Research. 1994; 17: SI-S10.

(16.) Pacy PJ. Hypertension and diabetes mellitus. In: Tailor K (ed.) Diabetes and the Heart 1st edition; Oxford: Oxford. 1992; 42-44.

(17.) Winer D, Sowers J. Epidemiology of diabetes mellitus. Journal of Clinical Pharmacology 2004; 44: 397-405.

(18.) Boyle Jr. E. Biological patterns in hypertension by race, sex, body, weight and skin colour. JAMA 1970; 213: 1640.

(19.) Paffenbarger RS, Rhorna MC, and Wing SL. Chronic disease in former college students. VIII Characteristics in youth predisposing to hypertension in later years. American Journal of Epidemiology 1968; 88: 26-30.

(20.) Miller NE, Harmmett F, Saltissi et al. Relation of angiographically defined coronary artery disease to plasma lipoprotein subfractions and apolipoproteins. British Medical Journal The British Medical Journal, or BMJ, is one of the most popular and widely-read peer-reviewed general medical journals in the world.[2] It is published by the BMJ Publishing Group Ltd (owned by the British Medical Association), whose other  1981; 282: 1741.

(21.) Kuusisto J, Mykkanen L, Pyorala K, Laakso M. Non-insulin dependent diabetes and its metabolic control are important predictors of stroke in the elderly. Stroke 1994; 25: 1157-1163.

(22.) Thomson A, Skinner A, Pierce J, eds. Tidy's Physiotherapy 12th edition Scotland: Thomson 1991; 328-330.

(23.) Cavanagh PR, Ulbrecht JS. Biochemical aspects of foot problems in diabetes. In: Boulton AJ, Connor H, Canagh PR (eds.) The Foot in Diabetes 2nd edition. Chichester: Wiley. 1994; 29.

(24.) Hill RD. Diabetic foot disease. In: Hill RD. ed. Diabetes Health Care 1st edition. London: Chapman and Hall Chapman and Hall was a British publishing house, founded in the first half of the 19th century by Edward Chapman and William Hall. Upon Hall's death in 1847, Chapman's cousin Frederic Chapman became partner in the company, of which he became sole manager upon the retirement of , 1987.

(25.) Connor, H. Prevention of diabetic foot problem: Identification and Team Approach. In: Boulton AJ, Connor H, Cavanagh PR, eds. The Foot in Diabetes 2nd edition. Chichester: Wiley. 1994; 57.

(26.) http//www.info.gov.hk//health problems of the elderly. 2003.

(27.) Werner Hacke: Organisation of stroke care. European Stroke Initiative Reports (EUSI EUSI European Stroke Initiative ). 2004.

(28.) Farnz MJ, Exercise and diabetes. In: Haire-Joshu D, ed. Management of Diabetes Mellitus 2nd edition. Mosby: St Louis. 1996; p174.

OKESOLA, Yetunde A, B.Sc (Hons) Physiotherapy; MNSP

HAMZAT, TK, Ph.D (Neurophysiotherapy); MNSP

Physiotherapy Department, College of Medicine, University College Hospital, PMB 5017, GPO Dugbe, Ibadan, Nigeria

Correspondence: Okesola Yetunde A., Physiotherapy Department, College of Medicine, University of Ibadan The University of Ibadan is the oldest Nigerian university, and is located five miles (8 kilometres) from the centre of the major city of Ibadan in Western Nigeria. It has over 12,000 students.

The University was founded on its own site on 17 November 1948.
, PMB 5017, GPO Dugbe, Ibadan, Nigeria * E-mail: Yettykesh77@yahoo.com
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Author:Okesola, Yetunde A.; Hamzat, T.K.
Publication:Journal of the Nigeria Society of Physiotherapy
Geographic Code:6NIGR
Date:Jan 1, 2005
Words:3073
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