1 Measuring the Effect of an Inpatient Amputee Rehabilitation Program on the Control of Diabetes Mellitus Dr. Sharon Grad 1, Dr. Tania Henriques 2, & Ashi Jain 3 1 Hamilton Health Science Physiatry, Ontario, Canada; 2 PM&R Residency Program, McMaster University, Ontario, Canada, 3 Chedoke HHS, Amputee Rehabilitation Program, Ontario, Canada,
2 Introduction Noticed a reduction in insulin dosing during in-patient amputee rehabilitation Literature search showed that insulin requirements decreased with increased activity in the diabetic population No research done specifically with amputee population
3 Hypothesis A significant reduction occurs in the total daily insulin requirement of the IDDM inpatient participating in amputee rehabilitation.
4 Method Retrospective chart review 84 charts of the patients admitted to the Chedoke Amputee Rehabilitation program in the year 2008 were reviewed 39 patients were included in the sample population after exclusion criteria were applied
5 Exclusions No DM 21 Unable to Participate Non-Insulin Dependent Insulin Independent Diabetics (NIDDM) Insulin pump (unrecorded) Combo trmt w Change to OHA(s) 39 6 Remaining IDDM (on insulin only or combo trmt w/o change to OHA)
6 Method Variables collected: - age - gender - level of amputation - length of stay - discharge mobility status - body weight - fasting blood glucose - HbA1c - total daily insulin
7 Statistical Analysis Daily requirements of insulin at admission were compared to those at discharge using a paired t-test Pearson s tests were used to uncover correlations between various variables including the difference in insulin, age, HbA1c and body weight ANOVA tests were used to look for correlations between the difference in insulin and the level of discharge mobility, as well as the correlation between insulin and gender
8 Population Characteristics Men outnumbered women almost 3:1 (10F, 29M) Average age: 59yo Mostly unilateral transtibial level Average LOS: 5.7wks (range 29 85, median 62) (2 Bilat TTs & 3 Symes) (range 2 8.5, median 6)
9 Admission vs. Discharge Insulin Variable ADM D/C Mean Diff (SD) p* Mean insulin dose (U/d) (12.96) 0.072
10 Correlations between Insulin Diff, Age, HbA1c & Wt Insulin Dec. (U/d) Age (yrs) HbA1c (mmol/l) Body Wt (kg) Insulin Dec (U/d) Age (yrs) HbA1c (mmol/l) Body Wt (kg)
11 Age vs HbA1c* Correlational (Pearson s test) p value of *HbA1c value at admission (N=36)
12 Insulin Difference vs HbA1c* Correlational (Pearson s test) p value of *HbA1c value at admission (N=36)
13 Discharge Mobility Status vs Insulin Requirement Mobility Categories W/o aid or occas cane N Mean Insulin Difference (SD) (9.21) One to two canes (12.80) Rollator / Walker (5.91) p* Supervision / Transfers (22.85) * Determined by ANOVA test
14 Gender vs Insulin Requirements N Mean Std. Dev. p* Male Female
15 Discussion No preadmission insulin values to know how controlled they were prior to admission. We did have HbA1c levels on admission. Self medication recording by patients Although on diabetic diet, no control over snacking while in program Skin breakdown was recorded in charts but not collected in this study
16 Summary A statistically significant tendency for IDDM amputee rehabilitation inpatients to require less insulin with participation in the program was not shown by this retrospective chart review although 82% of our sample either had no change or a decreased need for insulin The p value of 0.072, came close to the significance level of 0.05, suggesting that a larger sample size would be required Also revealed by this study was that more complete records on measures of diabetes management in this patient population are needed.
17 Future Work Assess fasting lipid profiles to determine if there is a correlation with insulin requirements or if there is any improvements in lipid profiles with an increase in level of activity Document admission and discharge height and weight for purposes of measuring BMI Use 2 minute walk test as an indicator for activity Prospective study
18 References 1. Joslin EP. The treatment of diabetes mellitus. 5 th edition. Philadelphia: Lea and Febiger, 1935; Mosher PE, Nash MS, Perry AC, LaPerriere AR, Goldberg RB. Aerobic circuit exercise training: effect on adolescents with well-controlled insulindependent diabetes mellitus. Arch Phys Med Rehabil 1998;79: Campaigne BN, Gilliam TB, Spencer ML, Lampan RM, Schork MA. Effects of a physical activity program on metabolic control and cardiovascular fitness in children with insulin dependent diabetes mellitus. Diabetes Care 1984;7: Dahl-Jorgensen K, Meen H. The effect of exercise on diabetic control and hemoglobin A 1 in children. Acta Paediatr Scand Suppl 1980;283: Horder MD, Cooney LM, Beller EM, Prins JB, Marwick TH, Coombes JS. Determinants of changes in blood glucose response to short-term exercise training in patients with Type 2 diabetes. Clinical Science. 2008;115(9):
19 Acknowledgments Support, encouragement and editing assistance was provided by prosthetist, Karen Litman of the Chedoke Prosthetic & Orthotic Department. Assistance in statistical analysis of the data was generously provided by Meghan McConnell. Guidance was provided by the Research Coordinator of the PM&R Undergraduate Program of McMaster University, Dr. Steve Baker.
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