Diabetic Rehabilitation

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Introduction

Diabetes is a chronic metabolic disease in which the body is unable to appropriately regulate the level of sugar, specifically glucose, in the blood, either by poor sensitivity to the protein insulin, or due to inadequate production of insulin by the pancreas. It is characterised by hyperglcaemia following a disorder of insulin secretion, insulin action or both. A diagnosis of diabetes is made when Fasting Plasma Glucose (FPG) is ≥ 126 mg/dL (7.0 mmol/L) on two occasions of testing, with fasting referring to no caloric intake for at least 8 hours (ADA, 2021).

There are various forms of diabetes, with the most common being Type 2 Diabetes (T2D). Previously referred to as adult onset diabetes or noninsulin dependent diabetes, risk factors for T2D may include:

• Family History

• Obesity
• Sedentariness
• Increasing Age
• History of Gestational Diabetes
• Race (more common with African American, American Indian, Hispanics and Asian American) (ADA, 2021)

Classification of Diabetes

The American Diabetes Association (ADA) classifies diabetes into four categories namely:

1. Type 1 Diabetes which is an absolute deficiency of insulin due to an autoimmune destruction of β cells in the pancreas. This also includes latent autoimmune diabetes of adulthood.
2. Type 2 Diabetes occurs from insulin resistance and a progressive reduction in insulin secretion.
3. Specific type diabetes that are due to other causes such as monogenic diabetes syndromes, diseases of the exocrine pancreas, and drug or chemical induced.
4. Gestational Diabetes, which is diabetes that is often diagnosed in the second or third trimester of pregnancy and was not diagnosed prior to the pregnancy period.  

Classification of the disease is important to aid appropriate management of the condition. According to the ADA, previous assumptions of Type 1 Diabetes occurring in only children and Type 2 Diabetes in adults is now outdated as the two conditions can be expressed both in adults and children alike.

Complications of Diabetes

Over time, diabetes causes damage to the various systems of the body including: cardiovascular, neurological, musculoskeletal and integumentary systems with increased risk of developing comorbidities. It is known to affect specific organs such as the eyes, kidneys, nerves and heart.

Management of Diabetes

Management can either be pharmacological or non-pharmacological. To effectively tackle diabetes and its complications, lifestyle adjustments including diet and exercise are often recommended to ensure optimal health. Also patients are encouraged and educated on how to manage their conditions by themselves to achieve optimal results from the lifestyle modifications. Diabetes treatment is mainly aimed at glycaemic control, improving quality of life of patients, preventing complications and ultimately reducing mortality in this patient population.

Pharmacological Interventions

1. Insulin Therapy: This is an essential treatment in patients with type 1 diabetes as the condition is marked with a dysfunction in β cell function. To achieve best results and to prevent metabolic disturbances, the administration of insulin is recommended to be through injections given on a daily basis or via a continuous subcutaneous pump.
2. Pramlintide is an adjuvant glucose lowering medication that acts based on the naturally occurring β-cell peptide, amylin and is recommended for use in patients with type 1 diabetes.
3. Metformin is the preferred medication for the management of type 2 diabetes.
4. Sulfonylureas can either be used instead of metformin if the patient is not overweight or unable to tolerate metformin and it can be administered with metformin if glycaemic control is inadequate.

Non-pharmacological Interventions

The non-pharmacological management of diabetes is basically centred on lifestyle changes with exercise and diet being the main stay of the programme. Lifestyle modification is recommended to avoid infusion with insulin.

Nutritional Intake

Integrating an individualised meal plan is essential to achieving positive outcomes with these patients. The portion and types of food eaten may affect the balance of insulin and consequently, levels of blood glucose.

Physical Activity & Exercise

The exercise programmes are geared towards improving quality of movement, participation in activities of daily living, managing pain if any, lowering blood sugar and ultimately slowing the progression of the condition to multi systems complications. A combination of aerobic and resistance training exercises has been recommended in planning physical exercise for this population as it has been reported to produce positive effects on blood glucose levels.  

Rehabilitation as an Intervention in the Management of Diabetes

Diabetes, in all its forms can cause complications in many systems and parts of the body and even lead to untimely death hence, a need to employ rehabilitation in prevention of these deleterious complications. The prevalence of diabetes is projected to be on the rise and as such, the increasing demand on rehabilitation and its services. Management of diabetes requires a lifelong multi-faceted treatment approach to achieve set goals. Major goals of diabetic rehabilitation are to: attain glycaemic control, improve quality of life and prevent or delay complications. Educating patients on the need and importance of physical activity and exercise as well as encouraging active participation are tantamount in the rehabilitation of this population. As such, it is imperative to develop an individualised and structured physical activity/ exercise plan for each for each patient, while still taking their pharmacological management and dietary change into consideration.

Physical activity is known to help improve the uptake of glucose and improve the sensitivity of insulin to excess blood glucose. Physical activity helps to prevent cardiovascular complications in people with diabetes. In those with cardiovascular disease, it helps prolong survival and improve exercise capacity while postponing the occurrence of the condition and its complications in normal individuals. It also aids in the prevention of these complications such as: heart attack, stroke, kidney failure, lower limb amputation, loss of vision and nerve damage.

According to the American Diabetes Association recommendations, people with pre-diabetes should be enrolled in diabetes prevention programmes to gain and sustain a 7% loss of previous body weight and increase moderate-intensity physical activity to about 150 minutes per week.

Tele-rehabilitation should also be considered as an option for rehabilitation in individuals with diabetes. In a recent study tele-rehabilitation, which consisted of breathing exercises and calisthenics, three times a week over a six-week period showed improvement in the psychosocial status and exercise capacity of individuals with diabetes.

Rehabilitation of diabetes patients can take place in either an in-patient or out-patient setting.

Resources

References