Physiotherapy approach in managing diabetic stroke patients.
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
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 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) or Type 1 diabetes
b. Non-insulin dependent diabetes mellitus (NIDDM) or Type 2 diabetes (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, 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 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, which is the deposit of materials within the inner layer in the intima 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 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, stroke, or peripheral vascular disease, 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 > 160mmHg and diastolic blood pressure > 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 (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 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 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 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 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 of the scapula, abduction and self-assisted arm movements, hip control movements, knee flexion with dorsiflexion, 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 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 coma or ketoacidosis during exercise, especially in Type-2 diabetes mellitus.
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)
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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, PMB 5017, GPO Dugbe, Ibadan, Nigeria * E-mail: Yettykesh77@yahoo.com