Sweet Relief
Monday November 23, 2009
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As a result of these findings, experts now recognize that arthritis presents a significant barrier to increasing physical activity for people with diabetes.
The information that many adults with diabetes also have arthritis does not surprise Robin Marcus, PT, PhD, OCS, assistant professor in the department of physical therapy, University of Utah, Salt Lake City. Diabetes, according to Marcus, is more common than many know. In her general orthopedic practice, Marcus says that as many as half of her outpatient clients have either type 2 diabetes or at least one significant risk factor for the disease.
“I think that recognition that your patients have diabetes or potentially are at risk for diabetes is critical in anyone with whom you are going to start an exercise program,” Marcus says.
The American Diabetes Association and the American College of Sports Medicine agree that physical activity is vital for people with diabetes. Not only does exercise help reduce blood glucose and risk factors for complications such as obesity and hypertension, but it also improves cardiovascular disease outcomes. But there are potential exercise challenges when considering the joints of patients with diabetes.
“People with type 2 diabetes often have co-occurring overweight or obesity and when you start to exercise people who are obese, just by virtue of the forces that are applied to their joints, their chances of getting an injury are enhanced,” Marcus says. “So, we, as physical therapists, need to be aware of those and to devise our exercise programs to not worsen potential musculoskeletal problems, including those caused by degenerative joints.”
According to Marcus, PTs are experts at identifying and individualizing activities that are less jarring to the joints, such as swimming, aquatic exercise, and cycling.
Mary Jane Myslinski, PT, EdM, EdD, associate professor, University of Medicine and Dentistry of New Jersey, Newark, who once ran a diabetic rehabilitation center, says the clinic bike is an excellent start.
“The bike is a very good activity because your body weight is supported; it is 10% less V02w than walking, and it is rhythmical, as long as the bike is set correctly — so, you really do not get any increased knee pain,” Myslinski says.
Although the emphasis is on aerobic exercise for people with diabetes, there also is evidence that resistance exercises, or strength training, are good supplements to aerobic exercise. According to Marcus, strength training can help improve glucose control and the problems associated with diabetes. Resistance exercise, she says, is a good way to prepare people with diabetes who are intolerant to aerobic exercise initially (because of arthritis or lack of energy) for more intense aerobic challenges down the road.
“When aging is coupled with comorbid disease conditions like diabetes and/or arthritis, we see impaired muscle, with fat infiltrating the locomotor muscles,” says Paul LaStayo, PhD, PT, associate professor and director, Skeletal Muscle Exercise Research Facility at University of Utah. “At this juncture we cannot specifically parcel out the cause of this, i.e., age-induced or disease-induced, but it is probably safe to say it likely stems from these two factors and is compounded by decreased physical activity levels. The good news is that judicious use of resistance exercise appears to mitigate these adverse structural and functional changes we see in the Skeletal Muscle Exercise Research Facility,” he says.
PTs need to recognize that both musculoskeletal or degenerative problems, as well as diabetes or risk for diabetes, are occurring in many patients, Marcus says. They also need to realize that patients who have established diabetes and are starting exercise programs need to be monitored closely for their responses to prescribed exercises.
“When you have diabetes, your heart rate and blood pressure responses are different than someone without diabetes. And ... your sugar can go up or down, as a result of exercise,” Marcus says. “The timing of exercise, relative to when the patient has eaten and taken his or her medication, has a large impact on those glucose fluctuations.”
Exercising success, Myslinski says, requires that patients have a stress test before coming to their first PT appointment. This allows PTs to know what adverse effects those patients might have with exercise.
“Based on that stress test, we got the correct target heart rate. Then, based on their interviews, we found out about other comorbidities. And then based on the patients’ responses, they would either start on the bike or the treadmill,” she says. “After a few weeks, they were able to progress. If they had to start on the bike ... we still got them to the treadmill. They all did really well. But ... we paid attention to adverse signs and symptoms, their target heart rates and joint pain.”
Simply backing down on intensity for a day or applying a pain modality, such as ice, often is enough to address osteoarthritis flare-ups; conversely, patients with rheumatoid arthritis are less likely to be able to work through their bad days.
In any case, if a patient walks into a PT clinic with a joint problem, the PT should follow practice guidelines by clearing the four practice patterns: neuromuscular, musculoskeletal, integumentary, and cardiopulmonary.
“As I say to my students, you just do not treat the shoulder [or knee, etc.], you are also treating the heart, the lungs, and every other joint in that body. So, you need to have a really good idea of other impairments or pathologies going on that might affect your plan of care,” Myslinski says.
She recommends emphasizing education to help prevent future joint damage and health problems.
“Educate patients about how serious elevated blood sugars are; how important it is to take medications correctly; and how important it is to exercise based on what they are able to tolerate,” Myslinski says.
In general, even though many of the patients on Myslinski’s rehab unit had diabetes, arthritis, and even heart disease, they did amazingly well in physical therapy, given their prescriptions were correctly written.
“I had one patient who, at 65, went back to downhill skiing after the program,” Myslinski says. •
Lisette Hilton is a contributing writer for Today in PT.
To comment, e-mail pteditor@gannetthg.com.
