Physical Rehabilitation in Older Patients Hospitalized with Acute Heart Failure and Diabetes: Insights from REHAB-HF.

BACKGROUND: Prior studies showed an attenuated response to exercise training among patients with heart failure and type 2 diabetes mellitus. We explored the interaction between diabetes status and a novel, transitional, tailored, progressive rehabilitation intervention that improved physical function compared with usual care in the Rehabilitation Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial. METHODS: The effect of the intervention on 3-month Short Physical Performance Battery (SPPB) (primary endpoint), 6-minute walk distance (6MWD), modified Fried frailty criteria, and quality-of-life scores (Kansas City Cardiomyopathy Questionnaire [KCCQ] and EuroQoL Visual Analogue Scale [VAS]) was compared between participants with and without diabetes. Differences in 6-month clinical outcomes were also explored. RESULTS: Of the 349 participants enrolled in REHAB-HF, 186 (53%) had diabetes. The prevalence of diabetes was higher in the intervention group (59% vs 48%). Participants with diabetes had worse baseline physical function by the SPPB and 6MWD, but similar frailty and quality-of-life scores. There was a consistent improvement with the intervention for 3-month SPPB, 6MWD, and VAS regardless of diabetes status (all interaction P value > .6), but participants with diabetes had significantly less improvement for frailty (P = .021) and a trend toward lower improvement in KCCQ (P = .11). There was no significant interaction by diabetes status for 6-month clinical event outcomes (all interaction P value > .3). CONCLUSIONS: Participants with diabetes had worse baseline physical function but showed similar clinically meaningful improvements from the intervention. There was less benefit for frailty with the intervention in participants with diabetes.

Effectiveness of the pelvic floor muscle training on muscular dysfunction and pregnancy specific urinary incontinence in pregnant women with gestational diabetes mellitus: A systematic review protocol.

BACKGROUND: There is ample evidence that gestational diabetes mellitus has a direct influence on urinary incontinence and pelvic floor muscles. There are no standardized pelvic floor muscle exercise programs in the literature for the physiotherapy and differ in the type of exercise, intensity, type and duration of application, and the frequency and duration of treatment sessions. The aim of this systematic review will be to investigate that Pelvic Floor Muscle Training can prevent and/or decrease the pregnancy specific urinary incontinence in women with gestational diabetes mellitus or gestational hyperglycemia. METHODS: We will perform a systematic review according to the Cochrane methodology of Randomized Controlled Trials. An overall search strategy will be developed and adapted for Embase, MEDLINE, LILACS, and CENTRAL databases, with the date of consultation until June 2020. The MeSH terms used will be "Pregnancy", "Hyperglycemia", "Diabetes Mellitus, Type 2", "Diabetes Mellitus, Type 1", "Pregnancy in Diabetics", "Diabetes, Gestational", "Urinary Incontinence", "Pelvic Floor Muscle Strength". Primary outcomes: improvement or cure of pregnancy specific urinary incontinence (which can be assessed by questionnaires, and tools such as tampon test, voiding diary, urodynamic study). Secondary outcomes: improvement of pelvic floor muscle strength (pelvic floor functional assessment, perineometer, electromyography, functional ultrasonography), improved quality of life (questionnaires), presence or absence of postpartum Urinary Incontinence and adverse effects. Quality assessment by Cochrane instrument. Metanalysis if plausible, will be performed by the software Review Manager 5.3. DISCUSSION: The present study will be the first to analyze the effectiveness of pelvic floor exercises in pregnant women with Gestational Diabetes Mellitus or Hyperglycemia, who suffer from pregnancy specific urinary incontinence. Randomized Controlled Trials design will be chosen because they present the highest level of evidence. It is expected to obtain robust and conclusive evidence to support clinical practice, in addition to promoting studies on the theme and contributing to new studies. TRIAL REGISTRATION: Systematic review registration: PROSPERO CRD42017065281.

The Role of Physical Exercise in Obesity and Diabetes.

SUMMARY: The prevalence of obesity is increasing world-wide. Obesity is associated with a plethora of metabolic and clinical constraints, which result in a higher risk for the development of cardiovascular complications and metabolic disease, particularly insulin resistance and type 2 diabetes. Obesity is an acknowledged determinant of glycemic control in patients with type 1 diabetes and accounts for the majority of premature death due to cardiovascular events. Physical exercise is generally recommended in patients with diabetes in order to prevent the development of or reduce existing obesity, as adopted by every international treatment guideline so far. Regular physical exercise has a beneficial impact on body composition, cardiovascular integrity, insulin sensitivity and quality of life. However, only a minority of patients participates in regular physical exercise, due to individual or disease-related barriers. In type 2 diabetes, there is robust evidence for beneficial effects of physical exercise on glycemic control, cardiovascular health and the development of diabetes-related long-term complications. In type 1 diabetes and patients treated with insulin, a higher risk for exercise-related hypoglycemia has to be considered, which requires certain prerequisites and adequate adaptions of insulin dosing. Current treatment guidelines do only incompletely address the development of exercise-related hypoglycemia. However, every patient with diabetes should participate in regular physical exercise in order to support and enable sufficient treatment and optimal glycemic control.

Rehabilitation of Tendon Problems in Patients with Diabetes Mellitus.

Exercise is crucial in the management of diabetes mellitus and its associated complications. However, individuals with diabetes have a heightened risk of musculoskeletal problems, including tendon pathologies. Diabetes has a significant impact on the function of tendons due to the accumulation of advanced glycation end-products in the load-bearing collagen. In addition, tendon vascularity and healing may be reduced due to diabetes-induced changes in the peripheral vascular system, and impaired synthesis of collagen and glycosaminoglycan. The current chapter presents an evidence-based discussion of considerations for the rehabilitation of tendon problems in people with diabetes. The following conditions are discussed in detail - calcific tendinopathy, tenosynovitis, tendon rupture, and non-calcifying tendinopathy. Common diabetes-related findings are presented, along with their potential impact on tendinopathy management and suggested modifications to standard tendinopathy treatment protocols. A holistic approach should be used to optimize musculotendinous function, including a comprehensive exercise prescription addressing strength, flexibility, and aerobic fitness.

Physical Activity in Adults with Diabetes Following Prosthetic Rehabilitation.

OBJECTIVES: To determine whether adults with diabetes and with transtibial amputations (TTAs) are meeting the recommended guidelines for physical activity intensity and daily step counts. The secondary objectives were to 1) to explore whether physical activity levels are maintained following discharge from prosthetic rehabilitation and 2) to determine whether clinical measures of physical function are associated with physical activity. METHODS: Adults ≥40 years of age with TTAs secondary to diabetes were recruited following discharge from prosthetic rehabilitation. Outcomes included accelerometer-measured physical activity (worn on the ankle of the intact limb), the 2-minute walk test, gait speed, the L-test and balance confidence. Assessments were conducted at 3 months (baseline) and at 9 months following discharge from rehabilitation. Analyses included paired sample t tests and Pearson correlation coefficients. RESULTS: The mean age for all participants (n=22) was 63±12 years. Participants took 3809±2189 steps per day at follow up, markedly lower than the 6500 steps per day recommended for older adults with chronic illness. Participants accumulated 24±41 minutes per week of moderate to vigorous physical activity, falling well below the recommended total of 150 minutes per week. An improvement was observed for performance on the L-test of functional mobility at follow up (-8.7 s±11.4; p=0.008). All other outcomes remained stable over time. Physical activity exhibited a good to excellent correlation with the 2-minute walk test distance (r=0.753; p<0.001) and gait speed (r=0.752; p<0.001) at discharge from rehabilitation. CONCLUSIONS: Physical activity levels for adults with diabetes and TTAs remain stable following discharge from prosthetic rehabilitation but fall well below recommended guidelines of 6500 steps per day and 150 minutes of moderate to vigorous physical activity per week.

Assessment of the effects of rehabilitation after cerebrovascular accident in patients with diabetes mellitus and hypertension as risk factors.

AIM: The aim of this study is to evaluate the results of rehabilitation, to determine the prevalence of major risk factors in cerebrovascular accident and their consequences, as well as to propose measures and procedures that will affect the better rehabilitation. METHODS: The survey analyzed: age, sex, duration of rehabilitation, activities in daily life through the Barthel index at admission and at discharge, presence of risk factors HTA and DM. The study included a total of 116 patients, the majority of patients are older than 61 years. We had 49% of male patients and 51% of female patients and they spent 31-40 days at the rehabilitation. RESULTS: The most common risk factor is HTA (83%) and diabetes (33%). Most of the patients at admission had a BI from 0 to 4 (32.7%), and at discharge BI in the range 17-20 (36.2%). Statistical analysis shows that there is a statistically significant correlation between the BI at admission, BI at discharge and risk factors of HTA and diabetes mellitus. CONCLUSIONS: The rehabilitation results in most patients is good results of rehabilitation. The most important risk factors in patients are HTA, DM and directly affect on results of rehabilitation. For the better results we should have energetic fight against risk factors for HTA and DM through primary and secondary prevention and patient education about early detection and treatment of these risk factors.

Exercise intervention studies in patients with peripheral neuropathy: a systematic review.

INTRODUCTION: Peripheral neuropathies (PNPs) encompass a large group of disorders of heterogeneous origin which can manifest themselves with sensory and/or motor deficits depending on the predominantly affected nerve fiber modality. It represents a highly prevalent disease group which can be associated with significant disability and poor recovery. Exercise has the potential to improve side effects of PNP. OBJECTIVE: Our objective in this systematic review was to analyze exercise interventions for neuropathic patients in order to evaluate the possible benefits of exercise. METHODS: Three independent reviewers used PubMed, MEDPILOT (MEDLINE), Cochrane, and relevant reference lists to obtain the data. Relevant studies were graded according to the Oxford Levels of Evidence. RESULTS: Eighteen studies (ten randomized controlled trials and eight controlled clinical trials) met all inclusion criteria. Three (diabetic) studies were ranked very high quality [1b (A)], nine high quality (four diabetes, one cancer, four others) [2b (B)], while six (four diabetes, two others) showed low quality (4/C). Current data suggests that exercise is a feasible, safe, and promising supportive measure for neuropathic patients. This is best documented for patients with diabetic peripheral neuropathy (DPN), suggesting that endurance training has the potential to prevent the onset of and reduce the progression of DPN. In general, balance exercises showed the highest effect on the motor as well as sensory symptoms in all types of PNP. CONCLUSION: Overall, balance training appears to be the most effective exercise intervention. Studies focusing exclusively on strength, or a combination of endurance and strength, appear to have a lower impact. For metabolically-induced neuropathies, endurance training also plays an important role. Further research with high methodological quality needs to be conducted in order to establish evidence-based clinical recommendations for neuropathic patients.

Effects of cardiac rehabilitation in diabetic patients: both cardiac and noncardiac factors determine improvement in exercise capacity.

BACKGROUND: Diabetic patients have a worse prognosis than nondiabetic patients after myocardial infarction. Although exercise improves risk factors, exercise capacity, and mortality, it is still unclear if these benefits are the same as in nondiabetics. Furthermore, although exercise tolerance is predicted by systolic and diastolic dysfunction in nondiabetics, its role as a predictor of exercise capacity in diabetics remains unclear. HYPOTHESIS: Diabetics and nondiabetics see a similar improvement in their cardiac risk factors and exercise parameters from exercise-based cardiac rehabilitation (CR). METHODS: A series of 370 diabetics and 942 nondiabetics entered a 36-session outpatient CR program after interventions for coronary heart disease or after bypass or cardiac valve surgery. The program consisted of physical exercise, lifestyle modification, and pharmacotherapy. RESULTS: Quality of life, weight, blood pressure, and lipid profiles improved significantly in both groups during the 12-week program. Baseline metabolic equivalents (METs) were lower in diabetics vs nondiabetics at the start of CR (2.4 vs 2.7, P < 0.001). Although both groups increased their exercise capacity, diabetics had less improvement (change in METs 1.7 vs 2.6, P < 0.001). Significant predictors for improvement after CR included age, sex, and weight, as well as both systolic and diastolic function. After adjustment for these, diabetes remained a significant predictor of reduced improvement in exercise capacity. CONCLUSIONS: Diabetics saw a significant benefit in quality of life, weight, exercise tolerance, and cardiac risk factors, but to a lesser extent when compared with nondiabetics. The mechanisms for poorer improvement in diabetics following CR also include noncardiac factors and require further study.

Patients with diabetes in cardiac rehabilitation: attendance and exercise capacity.

PURPOSE: Diabetes increases mortality after myocardial infarction, but participation in cardiac rehabilitation (CR) reduces this risk. Our objectives were to examine whether attendance at CR and changes in cardiorespiratory fitness differed according to diabetic status and sex. METHODS: Retrospective cohort study of patients referred for CR in Calgary between 1996 and 2010. Cardiorespiratory fitness in metabolic equivalents (METs) was estimated by maximal exercise testing at baseline, at the end of the 12-wk CR program, and 1-yr after CR. RESULTS: Among 7036 nondiabetic and 1546 diabetic patients who started, 84.9% of nondiabetic versus 79.5% of diabetic patients completed CR (P < 0.0001). The difference between diabetic and nondiabetic patients was greater in women (81.7% vs 72.1%, P < 0.0001) than that in men (86.0% vs 82.5%, P = 0.004). Patients without diabetes were more likely to return for the 1-yr assessment (53.7% vs 42.7%, P < 0.0001), and nondiabetic women were more likely than diabetic women to attend the 1-yr follow-up (44.3% vs 31.7%, P < 0.0001). Change in cardiorespiratory fitness from baseline to 12 wk was +1.0 METs in nondiabetic men, +0.9 METS in diabetic men, +0.9 METs in nondiabetic women, and +0.7 METs in diabetic women (within-group change; P = 0.0009). Changes in cardiorespiratory fitness at 1 yr compared with baseline were +0.9, +0.6, +0.9, and +0.5 METS, respectively (within-group change, P = 0.0001). CONCLUSIONS: Patients with diabetes, especially females, were less likely than patients without diabetes to complete CR and attend follow-up. Among patients who attended 1-yr follow-up, changes in cardiorespiratory fitness were not as well maintained in diabetic patients as in nondiabetic patients. Identifying barriers and targeting CR adherence interventions to patients with diabetes may help improve outcomes.

[The epidemiologic characteristic of diabetes mellitus and its complications].

The article presents dynamics of prevalence, mortality and disability due to diabetes mellitus at the territory of Perm kraiy during last 10 years. The rate of diseases' complications and mean life interval are also considered. The materials of analysis made it possible to evaluate the epidemiological situation in kraiy and to develop activities to change it.

[Liveonline aftercare in patients with abdominal obesity in cardio-diabetological rehabilitation: findings of a randomized controlled study]. / Liveonline-Nachbetreuung bei Patienten mit abdominaler Adipositas in der kardio-diabetologischen Rehabilitation: Ergebnisse einer randomisierten, kontrollierten Studie.

Obese patients were coached after inpatient medical rehabilitation with a 6 units comprehensive multimodal Liveonline aftercare program. In the randomized controlled study design, significant improvements in all outcome criteria were found both in treatment and control group. The improvements in the treatment group, however, were only partially superior to the control group, especially in the area of food habits. A statistically significant superiority of the treatment group concerning the primary targets waist circumference and body mass index could not be determined. The Liveonline aftercare was evaluated positively by the participants. Future research is discussed.

Rehabilitation outcomes of stroke patients with and without diabetes.

OBJECTIVE: To investigate the relation of diabetes comorbidity and the rehabilitation outcomes of patients with stroke. DESIGN: Secondary data analysis. SETTING: Inpatient rehabilitation facilities. PARTICIPANTS: Patients with stroke (N=35,243) who received inpatient rehabilitation in 2004 through 2008. INTERVENTIONS: None. MAIN OUTCOME MEASURES: FIM, length of stay, and discharge destination. RESULTS: Mean age ± SD of the sample was 71.0 ± 13.2 years. The percent of the sample of Medicare beneficiaries was 53.8%, whereas 46.2% had other sources of funding. Of the patients in the sample, 34.5% had a comorbidity of diabetes, with 17.2% classified as tier-eligible and 82.8% as nontier eligible. Findings included that patients in this sample with diabetes were admitted for rehabilitation services at a younger age than those without diabetes and support previous studies in which tier-eligible diabetes comorbidities moderated by patient age were found to be significant predictors of stroke rehabilitation outcomes. Furthermore, similar findings remained regardless of payer source. CONCLUSIONS: This study provides additional evidence that diabetes as a comorbidity is significantly related to stroke rehabilitation outcome, but the relation is moderated by patient age.

[Diabetes mellitus in cardiac rehabilitation]. / Diabetes mellitus in der kardiologischen Rehabilitation.

Patients in cardiac rehabilitation suffering from diabetes mellitus belong to the group of patients at highest risk for new cardiovascular events and therefore require highly specialized rehabilitation programs. Changes in lifestyle are of great importance to control all relevant cardiovascular risk factors, and patients need to learn healthy lifestyle in special education programs. Furthermore, it is necessary to prepare patients for self-management of their disease in their daily life and work. Physicians should optimize pharmacological treatment in accordance with guidelines in order to minimize secondary end organ damage. To ensure long-term success of cardiac rehabilitation, reliable rehabilitation care should be initiated on discharge of the patient.

Síndrome de movilidad articular limitada (queiroartropatía) en niña diabética / Limited joint mobility syndrome (cheiroarthropathy) in the diabetic child

El término queiroartropatía diabética o síndrome de limitación de la movilidad articular se emplea para describir la limitación de la movilidad articular de la mano asociada a diabetes. Se caracteriza por contracturas de una o más articulaciones de los dedos, afectando principalmente a la extensión de las articulaciones metacarpofalángicas e interfalángicas. El objetivo ha sido revisar la bibliografía, en relación con las opciones terapéuticas y exponer un caso clínico con los resultados de la opción elegida. Niña de 12 años diabética con flexo indoloro de articulación interfalángica proximal del quinto dedo de ambas manos. Tratada con cinesiterapia y ortesis correctoras. A los 2 años de evolución se consiguió la reducción completa del flexo en la mano derecha y corrección parcial en la izquierda. El uso precoz y prolongado del tratamiento rehabilitador parece favorecer la ganancia articular (AU)

The term diabetic cheiroarthropathy or limited joint mobility syndrome is used to describe joint mobility limitation of the hand associated to diabetes. It is characterized by contractures of one or more joints of the fingers, particularly affecting extension of the metacarpophalangeal and interphalangeal joints. This study has aimed to review the bibliography related to the therapeutic options and to present a clinical case with the results of the chosen option. The case of a 12-year old girl with diabetes with painless contracture of proximal interphalangeal joint of the 5th finger in both hands is presented. She was treated with kinesitherapy and orthotic braces. At 2 years of evolution, complete reduction of the right hand contracture and partial correction in the left one was achieved. Early and prolonged use of rehabilitation treatment seems to help the joint improvement (AU)

[Physical activity and exercise for rehabilitation of type 2 diabetes]. / Körperliche Aktivität und körperliches Training in der Rehabilitation des Typ-2-Diabetes.

BACKGROUND: Along with diet and medication, exercise is the third cornerstone of type 2 diabetes treatment. However, current guidelines do not provide detailed information for designing effective exercise interventions. OBJECTIVE: Based on a review of the health-enhancing effects of endurance and resistance training, recommendations for exercise interventions for persons with type 2 diabetes and different comorbidities are derived to optimize the benefits of exercise. METHOD: A hierarchic, systematic literature analysis was conducted. The evidence is summarized, and evidence-based recommendations are given. RESULTS: Aerobic training, resistance training, and combined training programmes hold equal potential to reduce the HbA1c by about 0.5-0.8. Endurance training improves cardiorespiratory fitness and cardiovascular risk factors. Compared to resistance training it will lead to superior effects on hypertension and blood lipids. Combined training is generally a little superior to aerobic and resistance training showing greater improvements for body weight, HDL-cholesterol and blood pressure. Health-enhancing effects are found for a broad range of exercise types, intensities and scope. Persons with type 2 diabetes should perform at least 90 min per week of vigorous (> 65% of VO (2)max) aerobic exercise or 150 min per week of moderate-intensity (40-65% of VO (2)max) aerobic physical activity. Performing at least 240 min of physical activity per week is associated with greater cardiovascular disease risk reductions as well as with less cardioÂ-vascular events compared with lower volumes of activity. Optimizing therapeutic benefits with different types and doses of exercise in combination with dietary and drug treatments needs further research.

New rehabilitation program for intermittent claudication: Interval training with active recovery: pilot study.

BACKGROUND: Peripheral arterial disease (PAD) is one of the complications of atherosclerosis. Intermittent claudication is the second stage of PAD. In controlled studies on patients with Stage II PAD, intensive rehabilitation training has proved effective for improving the walking distance in this population. The objective of this prospective study was to determine the effects of treadmill interval training followed by active recovery (low-intensity exercise). METHODS AND RESULTS: Eleven patients with Stage II peripheral arterial disease were included in a rehabilitation program (mean age 68.3±10.3 years) for five days a week during two weeks including global exercises, exercises below and above the level of injury. The interval training program consisted of treadmill training for 30minutes twice a day (morning and evening) with a progressively increased intensity: the first week speed was increased and the second week slope was increased. Each session included five six-minute cycles. Each cycle was made of three minutes of active workout followed by three minutes of active recovery. RESULTS: All patients improved their walking distance, from a mean of 610 m (120-1930) at the beginning of the program to a mean of 1252 m (320-2870) at the end (P=0.003). All patients were very motivated by the rehabilitation training program No adverse event was reported. CONCLUSION: This study showed that an interval training program with active recovery was effective and safe for patients with Stage II peripheral arterial disease, the patients' motivation was high. This study must now be validated by a clinical trial.