Diabetes, Arthritis, and the Dog

I left Arizona in mid-April and have spent the last month in Minnesota watching snow melt followed by grass turning green and trees getting leaves. For better or worse, medical stuff has taken a good chunk of my time in recent weeks. 

The Dog:  Abby the Black Lab is 12 years old which is old for a big dog. For the last 6 months her breathing has been loud with occasional gagging and coughing. It turns out that she has chronic bronchitis which is kind of like COPD for dogs. Her treatment? A steroid inhaler. The vet told me that I could check out prices locally but recommended that I buy the inhalers from Canada. Sounds familiar for those of us on insulin…. One inhaler at Costco. $369. One inhaler from Canada. $69. My understanding is that while it is illegal to import prescription drugs from Canada, the ban is not being enforced. I am not losing sleep over the threat that I could go to jail for importing medication for my dog. Dr. Google mentions that canine patients can be “uncooperative” when dealing with inhalers and the Aerodawg chamber. Well, duh.

Pump Supplies:  More than once I have written about my need to change infusion sets every two days. I had always received sufficient supplies with no problems until 2018. I recently criticized CCS Medical for being less than helpful in resolving the problem and switched to another supplier. Meanwhile reflecting the power of Social Media I received a call from a customer service supervisor at CCS and I suspect that she would have helped me to navigate the process. But I was several weeks into working with Solara Medica and it didn’t make sense to go back to CCS. I did eventually get my 45 infusion sets from Solara but it wouldn’t have happened without my bulldog sales rep Stephanie. My endo’s assistant had to submit, resubmit, and re-resubmit medical necessity forms and office notes. The normal 30-day BG log wasn’t enough and I had to provide a 60-day log. Ironically none of the ever-morphing requirements for 2-day site changes had anything to do with adhesive allergies and site infections. I am now good for 3 months and dread starting over again in July.

Fiasp:  At my April endo appointment, I was given a Fiasp sample. There were no vials available and I took home a yellow and blue 300ml pen with several pen needles. I didn’t do systematic testing to see if Fiasp injections brought down highs better than Novolog, but I assume it did. I filled a pump cartridge and started using it in my Tandem X2 pump. Immediately I seemed to have an easier time with my morning BG’s.  Unfortunately as others have reported Fiasp seemed to run out of steam on Day 3. By Day 4 my numbers were terrible and I switched back to Novolog.

Was this is a fair trial of Fiasp? Absolutely not and it doesn’t matter. Fiasp is not covered by Basic Medicare and I have no interest in paying out of pocket for it. I had to laugh because several times on my blog, I have mentioned that my sister is very adverse to changes in her diabetes care. After a few days of Fiasp I determined that I am entirely too lazy to figure out pump settings to be successful with a new insulin. Meanwhile my sister has switched her mealtime insulin from Regular to Humalog and will be starting Tresiba soon. She is actually considering ordering the Freestyle Libre! So who is adverse to change???

Arthritis:  A year ago I wrote that arthritis is the “health problem that most threatens my Pollyanna “Life is great!” philosophy.” My systemic arthritis is well-controlled with NSAIDs, but degenerative osteoarthritis in my hands and feet is relentless. Last week my foot doctor indicated that surgery is the only option for my left foot. I am not totally on board with cutting into my foot. It fixes one joint but I still have tendon and heel problems. And then I have my right foot. Psychologically I struggle with having this surgery because it opens the door to dealing with my other bad joints. There is something comforting with staying with the pain I know and avoiding the pain and unknown results of surgery. 

I will schedule surgery for mid-August with the option to cancel it. Two weeks on the couch with drugs will be followed by two months in a boot with a knee scooter. In the short run I have abandoned the close-by health club where I enjoy the fitness classes but know that they are not good for me. I have joined the YMCA which has an extensive schedule of fitness and water aerobics classes directed at various levels of senior fitness. Argh! I can’t even stand to write this but I know that I will feel better. 

Frozen Shoulder:  I think that I am in the early stages of frozen shoulder on the right side. I am unfortunately an expert on this condition and on the 4-year plan. I had my first FS in 2001 on the left side. Four years later my right shoulder was affected and four years later the left again. Now it’s back to the right. Only the first one was horrible. The rest have been annoying and long-lasting but not hugely debilitating. Don’t tell me to stretch the shoulder in the shower. As I wrote in 2013, “if you can get rid of your “frozen shoulder” by doing a week’s worth of exercises in the shower, you don’t have adhesive capsulitis.” My experience with frozen shoulder indicates that it is an inflammatory disease-driven condition that is more related to duration of diabetes than A1c levels. Whatever. If you want to learn more about frozen shoulder, check out my “Argh! Frozen Shoulder” blogpost.

Summary:  That’s it for today. The dog is old. I’m getting older and my feet hurt. So do my hands. I’m a chicken when it comes to surgery but hate the idea of quitting the activities that I love. I had diabetes yesterday and still will tomorrow. But the sky is blue and the grass is green. Life is good.

Happy spring to everyone! 🌷🌷🌷

Oh No, Not Again!

Laddie:  In last week’s post  about frozen shoulder, I mentioned that my story is almost identical to that of Sue from New York.  Similar age, same risk factors, and currently experiencing the condition for the third time.  I wouldn’t wish frozen shoulder on my worst enemy and I’m sorry that my friend’s story mirrors my own.


Sue May 2013_Head SquareMy first bout with frozen shoulder (adhesive capsulitis) began in 2002. I had noticed that it was becoming increasingly difficult to put my left arm behind my back and I couldn’t raise it very high. I tried not to use arm and shoulder thinking that rest would be the best medicine. Because it continued to get worse, I finally I went to my family doctor who told me I had frozen shoulder. I had never heard of frozen shoulder before.

The doctor suggested physical therapy, and I made an appointment to go. When I arrived I gave them my insurance card and was told my copay would be $20 a visit. I was set up to go three times a week. I remember on one of my first visits lying on my back while a strapping young man took hold of my arm and tried to move it up, all the while straining and exerting a great deal of pressure. I was amazed that my arm barely budged, and decided that the term frozen shoulder was very appropriate. I continued my daily walks with my husband. One day while walking I stepped into a crack in the sidewalk and the pain was excruciating. After that, I carefully watched where I walked. My physical therapy progressed as my shoulder gradually loosened, and I was given exercises to do at home with an arm band. I went to physical therapy from January until May, when I was told I could stop coming but continue my home exercises. My frozen shoulder gradually recovered almost completely.

In 2007 I once again got frozen shoulder, this time my right shoulder.  I didn’t have the degree of inertia that I previously had, so I decided to cope with it on my own. I did the exercises at home with the arm band, and a friend at work suggested some other things to try. Once again I gradually recovered from the frozen shoulder and moved on.  Slot Machine2I told myself that I was done with frozen shoulder since I’d had it in both shoulders already.

Now it is 2013 and once again my left shoulder is showing signs of freezing. I noticed it while descending the stairs and lifting my arm to turn off the light. I am being proactive and starting to exercise my arm, but I know that it will run its course in its own time, with or without any effort on my part. Because I was told during my first bout with frozen shoulder that it would get worse if I favored the arm and didn’t move it, I plan to keep using my arm and shoulder as much as possible.

And I will keep praying that number three is the lucky number that will end my story with frozen shoulder….

Argh! Frozen Shoulder

Laddie_Head SquareI am an expert on frozen shoulder.  Believe me, it is not something that you want to be an expert on.

Frozen shoulder is the layperson’s name for adhesive capsulitis and is a shoulder condition that results in stiffness, decreased ROM (range of motion), and often incredible pain. If you want medical jargon and links to a lot of the literature about frozen shoulder, I suggest you check out a 2008 article by Manske and Prohaska.  Or just Google the term and you’ll find tons of information.  Suffice it to say that if you get frozen shoulder, you can’t move your shoulder very well and it hurts a lot.

I will be using term “frozen shoulder” only to mean adhesive capsulitis.  Some people and even doctors describe any shoulder stiffness as frozen shoulder.  If you can get rid of your “frozen shoulder” by doing a week’s worth of exercises in the shower, you don’t have adhesive capsulitis.

Diabetes is a huge risk factor for joining the frozen shoulder club.  Other risk factors include hypothyroidism, hyperthyroidism, Parkinson’s disease, cardiovascular disease, being middle-aged, and being a woman.  I win on four accounts:  woman, middle-aged, Type 1 diabetes, and hypothyroidism.  You don’t need to be middle-aged to win the lottery because I have a young Type 1 friend Cynthia who suffers greatly with frozen shoulder.

Frozen Shoulder Carnival GameAdhesive capsulitis has 3 stages, each which can last 3-6 months or longer.  Following along with the “frozen” analogy, the first stage is called the “freezing stage” and may be excruciatingly painful as the ROM of the shoulder slowly decreases.  When I had my first frozen shoulder, I slept in a reclining chair alternating ice packs and a heating pad for a few weeks because it was painfully impossible to lay in bed.  My next two frozen shoulders were moderately painful, but very manageable.

The second stage is the called the “frozen stage”.  It is characterized by decreasing pain along with increasing stiffness.  My experience in this stage is that strengthening exercises may be helpful but any stretching beyond gentle is futile. With the shoulder capsule totally immobile and full of adhesions, it won’t stretch and you run the danger of injuring other parts of your shoulder and neck if you push it too hard.

The third stage is the “thawing stage” when your shoulder slowly returns to normal.  There is only minimal pain with the stretching exercises and you can feel the correct things stretching.  Most people eventually have a full recovery from adhesive capsulitis although people with diabetes are less apt to achieve total remission.  Some people end up having surgery to release the shoulder, but my doctors are very anti-surgery for the condition. The vast majority of people only get frozen shoulder once or at most once in each shoulder.  Unfortunately another prize for having diabetes is that you may get it repeatedly.

The exact causes of frozen shoulder are not known but terms like collagen fibers, platelet derived growth factor, glycosylation, poor circulation, inflammation, and fibrofatty infiltration are tossed around.  Like most things with diabetes, doctors are quick to blame poor blood glucose control for the condition.  Upon diagnosing my third frozen shoulder in May of this year, my rheumatologist immediately asked “What was your last A1c?”  Rightly or wrongly, I was somewhat offended by the question because my A1c’s are always quite low and within the lab normal range.  On the other hand, I have Type 1 diabetes and my blood sugars are miles away from being “normal.”  So maybe I shouldn’t get so huffy.

What most doctors don’t know is that recent studies, including those led by Thomas and Yian, indicate that A1c’s are not associated with the development of frozen shoulder.  These studies found that the strongest correlation for those with Type 1 was with duration of diabetes. Similarly in a Finnish study headed by Arkkila,  A1c levels for the previous five years had no correlation to the onset of frozen shoulder.  In fact, the Type 1 patients with frozen shoulder had a lower mean A1c than the Type 1’s without the condition.  Ironically for me, two of my three frozen shoulders have coincided with the lowest A1c’s that I have ever had.*

Akkila Chart Frozen Shoulder

Frozen shoulder used to be listed on the last page of diabetic complications and was considered to be somewhat unusual.  More and more it is now being highlighted as a common problem for people with diabetes and it is often listed on the front page of complications.

I am not going to give a blow-by-blow account of my frozen shoulder history.  A synopsis is that my first one occurred on the left side after a shoulder injury in 2001 and was incredibly painful.  Along with physical therapy, time was the biggest healer and I was about 90% healed within a year.  My second one occurred about four years later on the right side.  It was not nearly as painful or debilitating as the first one, but it took longer to resolve. Number three is back on the left side and I’ve had symptoms for about 6 months.  I am optimistic that I will achieve at least a 90% remission.

I am not so confident that this will be my last dance with frozen shoulder.

Sue from New York is a contributing author to my blog and we are very close in age.  She has written about her frozen shoulder experience in a post which will be published on Monday.  It is uncanny how similar our stories are.  When you read her story, you will be reading mine.


It’s Not My Fault?!

Laddie_Head SquareMy mother was not a hoarder.  In fact, if there is anything that is the opposite of a hoarder, that is what my mother was.  She threw away everything.  Therefore I don’t have much stuff from my childhood.

But I do have my report cards.  All of them starting in first grade.

So what does this have to do with Diabetes?

My 1st Grade teacher wrote a comment that I had a hard time accepting mistakes and always blamed them on someone or something else.

Fast forward to Type 1 Diabetes.  I do fine with comorbidities.  Those are the things that go along with Type 1 Diabetes but are not caused by diabetes.  I have hypothyroidism.  It is not a result of abnormal blood sugar, but rather the same autoimmune process that destroyed my beta cells.  It is something that I could have done nothing to avoid. It is not my fault and I accept it openly and without guilt.

Similarly I have an autoimmune form of arthritis.  No guilt.  You can’t blame me.  It’s a result of my rogue immune system.  Same with a skin condition I have that comes and goes.

I am on my third frozen shoulder and that enters the murky area between complication and comorbidity.  The exact cause of frozen shoulder is not known.  One theory for why people with diabetes get it at a higher rate than the rest of the population is that high blood glucose causes an abnormal thickening of the collagen and fibrous material in our tendons and ligaments.  But other conditions such as age, hypothyroidism, Parkinson’s disease, and having a recent shoulder injury are culprits in the onset of this painful condition.  Ironically two of my frozen shoulders have come during periods when I had extremely low A1c’s, so there is definitely more to it than BG levels.  But at the same time I could never argue that I have normal blood sugar so the collagen theory makes sense.

Currently I have none of the complications of Type 1 that are commonly considered to be the result of high blood sugar levels.   No kidney disease, no retinopathy, no neuropathy.  Ha!  I’m free of complications and nothing is my fault.

The problem with that logic is that if you turn it around, you point your finger at those Complications Manwith complications and say it was “their fault.”  We all know how hurtful and untrue that remark is.  And as hard as I work to control my diabetes, I don’t know that one of those things won’t be on my plate next week.

Diabetes does not play fair.  For whatever reason, some people get multiple complications and others seem to remain relatively unscathed.  Sure, studies show that lower A1c’s increase our odds of good health and that gives most of us motivation to fight the diabetes battle every day.  But good A1c’s are not a guarantee against complications and diabetes does not sign a contract promising good outcomes for every individual.

So where am I when it comes to blaming other things and other people?  I have come a long way since 1st Grade and work hard to accept responsibility where appropriate.  The idea that comorbidities are easier to accept than complications is still part of me even though intellectually I think it is mostly a meaningless distinction.  When my rheumatologist confirmed in May that I was indeed dealing with frozen shoulder again, his first question was “What is your A1c?”  I was surprised that my first reaction was being defensive that he thought it was “my fault.”

This post has become riddled with terms such as comorbidity, complication, fault, blame, responsibility.  Those are words that never leave our Type 1 brains.

One of the best discussions about the line between blame and responsibility was in a 2/25/13 post by George at Ninjabetic.com.  You should read the whole post, but what has stuck in my head are these words:

“Sometimes it is good to remember that this stuff is my responsibility but not all my fault. That is the difference. It’s not my fault that I have diabetes. It’s not my fault my body doesn’t do what it’s supposed to.

But to not take care of my responsibilities and to allow bad things to happen to my body because of negligence is my fault.

The line is thin but there is a difference between the two.”

Thanks to George, there is not much else to say on the subject.