Relationship Between Glycemic Control, Psychological Health, and Lower Extremity Functional Impairments in Post-stroke Diabetic Patients

doi:10.21203/rs.3.rs-5254295/v1

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Relationship Between Glycemic Control, Psychological Health, and Lower Extremity Functional Impairments in Post-stroke Diabetic Patients

https://doi.org/10.21203/rs.3.rs-5254295/v1

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Background

Understanding the interplay of the psychological and physical challenges faced by post-stroke diabetic patients is essential for developing comprehensive treatment strategies to improve their overall well-being and quality of life. Limited studies examine the association between the variables hence, our study aims to determine the relationship between glycemic control, psychological health, and lower extremity functional impairments in post-stroke diabetic patients.

Methods

A correlational study was conducted involving 214 post-stroke diabetic participants including both genders aged 50 years and above, recruited in the rehabilitation department of hospitals in the twin cities of Islamabad and Rawalpindi. The data collected from the patients included glycemic control (HbA1c, BSR, and BSF), psychological health assessment using DASS-21, and lower extremity functionality assessment using FMA-LE. Correlation and multiple regression were performed between the variables using IBM Statistics SPSS v 25.0.

Results

Out of 214 participants, the frequency of males was n = 119 (55.6%), and females was n = 95 (44.5%). The mean HbA1c calculated was 10.88 ± 1.37 mmol/mol. A positive and significant (p < 0.05) correlation between glycemic control and psychological health was depicted except for BSR with stress. Similarly, a negative and significant (p < 0.05) correlation was found between glycemic control and lower extremity functionality except for BSF with sensation. The correlation between glycemic control and lower extremity functionality showed a negative and significant (p < 0.05) relationship except for anxiety with sensation and passive joint motion, and stress with motor function. Additionally, a strong association was observed between glycemic control with anxiety, stress, and sensation, and between depression and lower extremity.

Conclusion

This study reveals a complex interaction between glycemic control, lower extremity functionality, and psychological health. Findings indicate that poor glycemic control is associated with increased psychological distress and impaired lower extremity function. Lower extremity impairments can eventually lead to poor psychological health in post-stroke diabetic patients.

Blood Sugar Random

Depression

Fugl Meyer

HbA1c

Post-stroke diabetes

Diabetes Mellitus (DM) is the collection of heterogeneous metabolic disorders characterized by chronic hyperglycemia caused by defective insulin secretion, disturbed insulin effect, or both. [1] Higher HbA1c levels are linked to poorer recovery after a stroke. [2] Blood sugar random (BSR) levels were positively correlated with the risk of poor functional outcomes in stroke. [3] Similarly, blood sugar fasting (BSF) is an effective indicator for predicting poor neurological outcomes and increased risk of disability in stroke patients. [4] Globally, the prevalence of diabetes with stroke ranges between 8.2 and 50.2%. In Southeast Asia, it was reported as 33.5%. [5] In Pakistan, diabetic patients have a 52% risk of developing stroke. [6]

Diabetic patients have a higher risk of complications, such as stroke, which is a significant factor in affecting lower extremity function. [7] This is a crucial consideration since up to 80% of stroke survivors have either impaired glucose metabolism or diabetes. [8]

Post-stroke patients usually suffer from many mental health problems including depression, anxiety, and stress. [9] The relationship between depression and type 2 diabetes mellitus (T2DM) is substantial as glucose levels can predict late-onset post-stroke depression (PSD). [10] Hence, HbA1c and BSF are the prominent biomarkers for risk assessment as higher levels are associated with PSD. [11]

One study stated that somatosensory deficits lead to diminished proprioception and altered tactile sensations which impede the paretic lower limb's ability to execute essential functions, including initiating and controlling movement. [12] A study done by Yoon et al. showed that diabetes is associated with an increased risk of developing physical disabilities. [13] Similarly, research concludes that stroke survivors experience depression and anxiety during their recovery. [14] Furthermore, a study showed a clear association between higher levels of HbA1c and an increased risk of depression in post-stroke individuals. [15]

This study was planned to understand the relationship between glycemic control, psychological health, and lower extremity functional impairments in post-stroke diabetic patients which can help in designing effective interventions and addressing the complex needs of these patients.

Study design and population

A correlational study was conducted on post-stroke diabetic patients from July 2023 to September 2023 from PAF Hospital Islamabad, Islamabad Medical Complex NESCOM Islamabad, and AERO Hospital AWC Hasanabdal after approval from the ethical committee of Riphah College of Rehabilitation and Allied Health Sciences, Riphah International University, Islamabad. A sample size of 214 participants was calculated using a UCSF (University of California San Francisco) sample size calculator with r = 0.19. [16] The sample was raised using a non-probability purposive sampling technique.

Inclusion and exclusion criteria

The patients included were aged 50 years and above having at least 5 years of diagnosed chronic T2DM. All patients had lower extremity impairments and limited functional status but were actively participating in the rehabilitation program. The chronic stroke patients selected for this study had grade 4 and above in Brunnstrom stages of stroke recovery, grade 1 and 2 on the Modified Ashworth scale, and grade 1–3 on the Modified Rankin scale. The exclusion criteria involved individuals having any pending litigation, speech or hearing difficulty, and comorbidities including systemic illnesses like Alzheimer's, cancer, etc.

Data acquisition

Considering the ethical standards and ensuring confidentiality, informed consent was taken from all the participants. Their demographics were taken subjectively. HbA1c was obtained from their recent lab reports while BSR and BSF readings were taken using a glucometer.

The psychological health of the patients was assessed using the Depression, Anxiety, Stress Scale-21 (DASS-21), a self-reported questionnaire designed to measure the emotional states of depression, anxiety, and stress separately. [17]

Lower extremity functional impairments were measured using the Fugl-Meyer assessment of the lower extremity (FMA-LE). This tool assesses the lower limb's sensorimotor function, including motor function, sensory function, joint range of motion, and joint pain. [18]

Statistical Analysis

Statistical analysis was performed by using the IBM Statistics SPSS v 25.0. (IBM Corp. Armonk. NY, USA). The Shapiro Wilk test of normality was applied to all variables to assess the normality. The data was normally distributed as the p-value < 0.05. Based on the normality, non-parametric tests were applied to all variables. Multiple regression was performed to find the association between the variables.

Table 1 shows the demographics of the study participants. According to descriptive statistics, the mean age of the population was 70.00 ± 9.10 years where the minimum age was 57 years and maximum was 85 years. The frequency of males was n = 119 (55.6%), and females were n = 95 (44.5%). The mean HbA1c, BSR, and BSF were 10.88 ± 1.37 mmol/mol, 326.43 ± 84.71 mg/dl, and 181.00 ± 42.13 mg/dl respectively.

Table 1

Demographics of post-stroke diabetic patients
Characteristics		Mean ± SD or n (%)
Age		70.00 ± 9.10 years
Gender	Male	119 (55.6)
Gender	Female	95 (44.5)
BMI	Underweight	2 (9)
	Normal	18 (8.4)
	Overweight	139 (65)
	Obese	55 (25.7)
Mean HbA1c		10.88 ± 1.37 mmol/mol
Mean BSR		326.43 ± 84.71 mg/dl
Mean BSF		181.00 ± 42.13 mg/dl

Legends: BMI: Body mass index, Classification of BMI as underweight: <18.5, normal: 18.5–24.9, overweight: 25-29.9, obese: ≥ 30. HbA1c: Glycated hemoglobin, BSR: blood sugar random, BSF: blood sugar fasting.

Table 2 shows a positive and significant correlation between glycemic control and psychological health except for BSR with stress. A moderate relationship was observed between variables of glycemic control and psychological health except BSF and depression showing a negligible relationship. This can be interpreted as poor glycemic control may negatively affect psychological health.

Table 2

Correlation analysis between glycemic control, psychological health, and lower extremity functional impairments
Variables		p-value	r-value
Depression	HbA1c	< 0.01	0.40
	BSR	< 0.01	0.40
	BSF	< 0.01	0.23
Anxiety	HbA1c	< 0.01	0.41
	BSR	< 0.01	0.30
	BSF	< 0.01	0.34
Stress	HbA1c	< 0.01	0.34
	BSR	0.78	0.19
	BSF	< 0.01	0.40
Motor function	HbA1c	< 0.01	-0.44
	BSR	< 0.01	-0.54
	BSF	< 0.01	-0.20
Sensation	HbA1c	< 0.01	-0.80
	BSR	< 0.01	-0.81
	BSF	< 0.01	-0.08
PJM	HbA1c	< 0.01	-0.50
	BSR	< 0.01	-0.14
	BSF	< 0.01	-0.23
Joint pain	HbA1c	< 0.01	-0.33
	BSR	< 0.01	-0.33
	BSF	< 0.01	-0.21
Depression	Motor function	< 0.01	-0.31
	Sensation	< 0.01	-0.32
	PJM	< 0.01	-0.23
	Joint pain	< 0.01	-0.60
Anxiety	Motor function	< 0.01	-0.50
	Sensation	0.43	-0.05
	PJM	0.27	-0.08
	Joint pain	< 0.01	-0.50
Stress	Motor function	0.22	-0.10
	Sensation	0.05	-0.13
	PJM	< 0.01	-0.40
	Joint pain	< 0.01	-0.22
Legends: HbA1c: Glycated hemoglobin, BSR: blood sugar random, BSF: blood sugar fasting. PJM: Passive Joint Motion. p < 0.05 is statistically significant. Significant values are shown in bold.

Similarly, a negative and significant correlation was found between glycemic control and lower extremity functionality except for BSF with sensation. A strong relationship was observed between HbA1c, and BSR with sensation. HbA1c also showed a moderate relationship with motor function, passive joint motion, and joint pain while BSR depicted a moderate relationship with motor function and joint pain only. This concludes that poor glycemic control will contribute to lower extremity impairments.

Lastly, the correlation between glycemic control and lower extremity functionality showed a negative and significant relationship except for anxiety with sensation and passive joint motion and stress with motor function in Table 2. A moderate relationship was seen between depression and motor function, sensation, and joint pain. Similarly, a moderate relationship was also seen between anxiety with motor function and joint pain and stress with passive joint motion. This indicates lower extremity impairments can lead to poor psychological health.

Table 3 shows multiple regression analyses between glycemic control as an independent variable and psychological health as a dependent variable, where a positive and significant association was observed between all the variables except for HbA1c with depression and BSR with anxiety. A strong correlation between anxiety and stress with glycemic control was observed while depression showed a moderate relationship with glycemic control.

Table 3

Multiple regression analysis between glycemic control, psychological health, and lower extremity functional impairments
Dependent Variables	Independent Variables	Values
Dependent Variables	Independent Variables	β-coefficient	t-value	p-value	R-square	F-value	R-value
Depression	HbA1c	0.05	1.00	0.35	0.30	26.50	0.52
	BSR	0.01	6.50	< 0.01
	BSF	0.01	8.20	< 0.01
Anxiety	HbA1c	0.24	4.50	< 0.01	0.50	66.50	0.70
	BSR	0.00	1.60	0.11
	BSF	0.01	6.40	< 0.01
Stress	HbA1c	1.04	16.60	< 0.01	0.60	95.30	0.80
	BSR	0.02	14.14	< 0.01
	BSF	0.01	3.60	< 0.01
Motor Function	HbA1c	-0.06	-0.85	0.40	0.32	33.50	0.60
	BSR	-0.01	-6.02	< 0.01
	BSF	-0.01	-6.00	< 0.01
Sensation	HbA1c	-0.10	-1.04	0.30	0.50	62.10	0.70
	BSR	-0.01	-7.53	< 0.01
	BSF	-0.01	-5.50	< 0.01
PJM	HbA1c	-1.13	-9.20	< 0.01	0.30	30.30	0.60
	BSR	-0.01	-6.40	< 0.01
	BSF	0.00	-1.35	0.20
Joint Pain	HbA1c	-0.60	-0.60	0.60	0.20	15.13	0.42
	BSR	-0.01	-5.00	< 0.01
	BSF	-0.01	-3.45	< 0.01
Depression	MF	-0.10	-2.03	0.04	0.50	45.20	0.70
	Sensation	-0.10	-3.20	< 0.01
	PJM	-0.40	-10.53	< 0.01
	Joint Pain	-0.40	-10.73	< 0.01
Anxiety	MF	-0.22	-4.00	< 0.01	0.32	24.80	0.60
	Sensation	-0.03	-1.00	0.44
	PJM	-0.04	-1.21	0.23
	Joint Pain	-0.30	-8.00	< 0.01
Stress	MF	-0.04	-0.52	0.60	0.20	12.41	0.44
	Sensation	-0.06	-1.20	0.25
	PJM	-0.42	-5.40	< 0.01
	Joint Pain	-0.30	-4.60	< 0.01
Legends: HbA1c: Glycated hemoglobin, BSR: blood sugar random, BSF: blood sugar fasting, PJM: Passive joint motion, MF: Motor Function. p < 0.05 is statistically significant. Significant values are shown in bold.

In addition, multiple regression was run between glycemic control as an independent variable and lower extremity as a dependent variable. A negative association was seen between BSR and BSF with motor function, sensation, and joint pain, and between HbA1c and BSR with passive joint motion. A strong correlation between sensation and glycemic control was observed while motor function and passive joint motion showed a moderate relationship with glycemic control.

Lastly, Table 3 shows multiple regression performed between lower extremity functionality as an independent variable and psychological health as a dependent variable. A negatively significant association was seen with all the variables except sensation and passive joint motion with anxiety and motor function and sensation with stress. A strong correlation between lower extremity functionality and depression was observed while anxiety and stress showed a moderate relationship with lower extremity functionality.

This study highlights the intricate and interconnected relationship between glycemic control, psychological health, and lower extremity functional impairments in post-stroke diabetic patients.

The moderately significant correlation between glycemic control and psychological health indicates that poor glycemic control is strongly associated with deteriorating psychological health. This finding is consistent with previous studies showing a bidirectional relationship between diabetes and psychological health. A study done in 2023 found that HbA1c is associated with feelings of sadness and anxiety, as well as changes in mental well-being, such as unease and stress. [19] These results also corroborate the findings of Mushtaq et al. (2019), who reported a prevalence of depression in 40% of individuals with elevated BSR levels. [20] Notably, the negligible relationship between BSF and depression could imply that fasting blood sugar levels may not be as sensitive an indicator of psychological health. Existing literature reveals that the prevalence of anxiety (35.3%) is nearly three times greater than the rate of depression (13.6%). [21]

The negative and significant correlation between glycemic control and lower extremity functionality suggests that poor glycemic control exacerbated lower extremity impairments in our population. A moderate correlation was observed between HbA1c, BSR, and motor function. These results support existing literature suggesting that poor glycemic control negatively impacts lower extremity function in individuals with diabetes. [22] A strong correlation was found between HbA1c, BSR, and sensation. This supports the notion that sustained poor glycemic control contributes to the progression of reduced proprioception, and altered tactile sensations. [12] A moderate correlation was observed between the passive range of motion and HbA1c. Previous literature highlights that HbA1c levels were linked to an increased risk of developing limited joint mobility, providing supportive evidence that better long-term glycemic control reduces the frequency and severity of limited joint mobility. [23] Moreover, a moderate correlation was observed between joint pain and HbA1c, as well as BSR. Musculoskeletal pain was found to be more prevalent among people with DM compared to the general population in prior studies. [24]

The observed significant and negative correlation between lower extremity functionality and psychological health underscores the cyclical nature of disability and psychological health issues in post-stroke diabetic patients. The impaired motor function had a moderate correlation with depression and anxiety. Research shows that both anxiety and depression hinder motor function recovery. [25] Impaired sensations were found to have a moderate relationship with depression. The study of diabetic patients provides evidence that reduced sensation in the feet was linked to depressive symptoms. [26] Additionally, decreased passive range of motion also showed a moderate relationship with depression and stress. The physical limitations experienced in daily life and the necessary adjustments for mobility and self-care can elevate stress levels. [27] Joint pain was also found to have a moderate relationship with both depression and anxiety. Another study underscores that chronic pain, often accompanying lower extremity impairments, can often lead to clinical depression or anxiety disorders. [28] This correlation between lower extremity impairments and psychological health is particularly concerning, as it points to the heightened vulnerability of these patients to psychological distress, which can further impede rehabilitation efforts and quality of life.

The multiple regression analysis reinforces the significant associations between glycemic control, psychological health, and lower extremity functionality. The correlation between psychological health and glycemic control emphasizes the importance of maintaining optimal blood glucose levels to mitigate psychological distress. The findings that motor function, sensation, passive range of motion, and joint pain are influenced by glycemic control also suggest that interventions targeting glycemic control could benefit our population's physical outcomes. Moreover, the correlation between lower extremity impairments and psychological health highlights the need for comprehensive care targeting lower extremity function in post-stroke diabetic patients. Given the bidirectional relationships identified in this study, interventions aimed at improving one domain (e.g., glycemic control) may benefit others (e.g., psychological health and lower extremity functionality).

While the study provides valuable insights, it is not without limitations. A key limitation of this study was the homogeneity of the participant group. All post-stroke diabetic individuals exhibited good prognoses due to their active involvement in rehabilitation, resulting in little variability within the collected data. This restricted our ability to observe a wide range of outcomes. So, future studies should be conducted on post-stroke diabetic patients who are not actively involved in rehabilitation. Additionally, the results should be further confirmed in a larger prospective cohort of patients with post-stroke diabetes. Comparative analysis between diabetic and non-diabetic post-stroke patients can also provide valuable insights into the impact of diabetes on recovery. Additionally, examining the role of other factors such as socioeconomic status and social support could provide a more comprehensive understanding of the challenges faced by post-stroke diabetic patients and their psychological status.

DM: Diabetes Mellitus

HbA1c: Glycosylated Hemoglobin

BSR: Blood sugar random

BSF: Blood sugar fasting

DASS-21: Depression, anxiety, stress scale 21

FMA-LE: Fugl Meyer assessment of lower extremity

T2DM: Type 2 Diabetes Mellitus

PSD: Post-stroke Depression

PJM: Passive joint motion

MF: Motor function

Ethics approval and consent to participate

The study was approved by the ethical committee of Riphah College of Rehabilitation Sciences, Riphah International University, Islamabad with reference number Riphah/RCRAHS-ISB/REC/DPT-G/01563. Written informed consent was obtained from all participants included in the study. All procedures performed in the study involving human participants were under the ethical standards of the 1964 Declaration of Helsinki and its later amendments.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare no competing interests.

Funding

None

Authors' contributions

SJ: supervision, concept, study design, analysis, interpretation of results, manuscript review, and final approval for publication. MG: analysis, interpretation of results, manuscript review, and final approval for publication. TR, FS, AT, and KE: data collection, analysis, interpretation of results, writing, and manuscript review. TR and FS: editing, compilation, formatting, and manuscript drafting. All authors provided input, read, and approved the final manuscript

Acknowledgments

None

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No competing interests reported.

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Version 1

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You are reading this latest preprint version

Relationship Between Glycemic Control, Psychological Health, and Lower Extremity Functional Impairments in Post-stroke Diabetic Patients

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Background

Methods

Study design and population

Inclusion and exclusion criteria

Data acquisition

Statistical Analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

Version 1