Teaching diabetics to exercise at home

Aim is to limit complications of the disease

A new diabetes fitness program at Bryn Mawr Rehab in Malvern, PA, combines education, an individual exercise program, and group aquatic fitness sessions to help diabetics learn to exercise safely on their own.

"Exercise can significantly improve the health of people with diabetes by limiting complications of the disease, lowering blood sugar, controlling obesity, and reducing the clotting factors responsible for heart attacks and strokes," says Martin M. Mandell, MD, director of the diabetic neuropathy and foot center at Bryn Mawr Rehab, who developed the diabetes fitness program.

The typical patient spends four hours a week for 12 weeks in the diabetes fitness program, which includes two hours a week in an individual exercise program, supervised by the physical therapy staff, an hour "Lunch and Learn" program led by a certified diabetes educator, and a one-hour aquatic exercise group session led by an exercise physiologist. During the last two weeks, family members attend the education sessions. (For topics covered in the sessions, see p. 143). "We take a team approach. Diabetes is too complicated to be treated by just one person," Mandell says.

The program is tailored specifically for diabetics and takes into consideration the effects and complications of the disease. Neuropathies, or loss of sensation, in the foot are of particular concern because patients can injure themselves and not feel it. This problem can lead to ulcers, infections, and, eventually, loss of a limb, he says.

For that reason, patients in the Bryn Mawr exercise on nonweight-bearing equipment, such as stationary bicycles and rowing machines, to avoid putting pressure on their feet. "If I put a diabetic patient on a treadmill, and he pounds his foot over and over, he could get ulcers," he says.

Because of the lack of sensation and poor circulation, diabetics are encouraged to check their feet frequently during the exercise program. They are told to look for irritation and blisters that could lead to complications.

Patients must wear special aquatic socks to protect their feet from injury when they are in the pool. "If they have poor sensation or lack of circulation, they won't feel it if they scrape their feet in the pool," says Shelley Epstein, PTA, who coordinates the program with Mazghan Hines, PTA.

Patients test their blood sugar levels before and after exercise and enter the figures on an exercise card. They are taught at what levels exercise is not advisable.

When diabetic patients are referred to the program, Mandell evaluates them for medical problems including neuropathies, eye or kidney problems, and foot ulcers.

Patients are referred to a physical therapist for evaluation. If they need individual therapy first, they go through outpatient physical therapy sessions. Later they join the diabetes fitness program. Based on the evaluations, the treatment team at Bryn Mawr develops an individual fitness program for each patient, depending on his or her physical condition.

"What one person needs is totally different from what the next person needs," Epstein says. For example, some patients have great upper-body strength but poor lower-body strength due to diminished capacity because of their neuropathies.

The Bryn Mawr fitness gym used for the diabetes program includes mostly cardiovascular equipment such as stationary bikes, an upper-body ergometer, free weights, ankle weights, and cuff weights. The program concentrates on building breathing capacity and increasing blood circulation to the brain. Exercises include stretching, warm-up exercises, a cardiovascular workout, and strength training.

At the end of the fitness program, the Bryn Mawr staff give the patients tips on how to continue the fitness program on their own. Epstein encourages patients to get involved in an individual walking program at local parks with walking trails. She suggests they check their heart rate before walking and bring a snack in case they become hypoglycemic.

Bryn Mawr staff encourage patients to join a local wellness facility and use the equipment, or if patients prefer exercising at home, they suggest inexpensive equipment patients can purchase.

Byrn Mawr advertises its program by direct mail to family physicians, internists, orthopedists, endocrinologists, and other referral sources. Bryn Mawr staff give community lectures, particularly during Diabetes Awareness Month in November and on Diabetes Alert Day in late March.

Bryn Mawr received a $25,000 grant from an anonymous donor that helps defray costs of the program because most insurance companies don't cover the wellness portion of the diabetes treatment, Mandell says. The hospital charges patients a small monthly fee to participate in the program.

When Mandell became a diabetes patient eight years ago, he became concerned that the disease and its complications were treated casually by patients and physicians alike. However, the cost of amputations and rehabilitation for amputees comes to $47 billion a year, Mandell says.

When he began working with amputees at Bryn Mawr Rehab, he realized they had no insight into why they lost their legs.

"They didn't realize that the higher their blood sugar ran, the more likely would be the possibility of getting a neuropathy," he says.

Neuropathies are the most common cause of amputation, Mandell says. "The foot becomes insensitive and has no feeling. If the shoe is too tight, the patient doesn't' feel it. It develops blisters. The wound doesn't heal. It becomes infected, and then the bone becomes infected," he says.

By educating all the diabetics who go through Bryn Mawr's amputee program, Mandell has succeeded in saving the other leg of 80% of patients.

[For more details, call Bryn Mawr Rehab Diabetic Neuropathy and Foot Center at (610) 640-3943]. n

· Fourth Annual Joint Conference - Oct. 10-13, 1998, San Diego. Sponsored by the American Hospital Association Section for Long Term Care and Rehabilitation and The American Medical Rehabilitation Providers Association. For more information, contact: American Hospi tal Association, P.O. Box 92247, Chicago, IL 60675-2247. Telephone: (312) 422-3302. Fax: (815) 753- 6900. n