Diabetes Ther (2018) 9:1713–1718 https://doi.org/10.1007/s13300-018-0448-7 CASE REPORT Successful Management of Poorly Controlled Type 2 Diabetes with Multidisciplinary Neurobehavioral Rehabilitation: A Case Report and Review . . . Zhihui Deng John Davis Flor Muniz-Rodriguez Fran Richardson Received: April 4, 2018 / Published online: May 28, 2018 The Author(s) 2018 admitted to a neurobehavioral rehabilitation ABSTRACT unit subsequent to his brain injury. Following 3 months of multidisciplinary rehabilitation for Lifestyle modiﬁcation with healthy diet and his functional neurological symptom disorder, physical exercise is considered the basic strategy all his pharmacological agents were gradually of prevention and treatment of type 2 diabetes, discontinued and his diabetes was successfully a commonly seen comorbidity in patients with managed solely by lifestyle approaches. acquired brain injury. Additionally, emotional stress with anxiety and depression is suggested to play a role in type 2 diabetes. Research Keywords: Lifestyle intervention; Neuro- studies have demonstrated the efﬁcacy of mul- behavioral rehabilitation; Physical exercise; tidisciplinary lifestyle intervention in patients Type 2 diabetes mellitus with inadequate glycemic control. However, whether lifestyle approaches alone may be adequate for the management of poorly con- INTRODUCTION trolled type 2 diabetes is unknown. We report a 30-year-old male patient whose type 2 diabetes The World Health Organization (WHO) repor- was inadequately controlled by 50 units of ted 422 million diabetes patients globally in insulin glargine, 15 units of insulin aspart sup- 2014 and diabetes will be the seventh leading plement with meals plus a correctional scale as cause of death in 2030. Diabetes is a major cause well as multiple oral hypoglycemic drugs when of blindness, kidney failure, heart attacks, stroke, and lower limb amputation. Type 2 Enhanced digital features To view enhanced digital diabetes accounts for more than 90% of all features for this article go to https://doi.org/10.6084/ diabetes cases in the world with an increased m9.ﬁgshare.6275948. prevalence in developed countries due to obe- sity, physical inactivity, and the growing pop- Z. Deng (&) F. Muniz-Rodriguez ulation of older age individuals . Healthy Division of Physical Medicine and Rehabilitation, Department of Medicine, McMaster University, diet, regular physical activity, and maintaining Hamilton, Canada a normal body weight are believed to prevent or e-mail: email@example.com delay the onset of type 2 diabetes. These Z. Deng J. Davis F. Muniz-Rodriguez approaches are also beneﬁcial for patients with F. Richardson type 2 diabetes [2, 3]. Recent research has Hamilton Health Sciences Regional Rehabilitation demonstrated the particular importance of Centre, Hamilton, Canada 1714 Diabetes Ther (2018) 9:1713–1718 intensive lifestyle intervention in patients with to phobic anxiety, worry about somatic com- inadequate glycemic control . However, suc- plaints and cognitive impairments, and signiﬁ- cessful glycemic control by lifestyle interven- cant problems with sleep and pain. tion alone is rarely seen in patients whose In addition to medical care, the patient diabetes is poorly controlled by medications. received transdisciplinary rehabilitation from a We present one successful case that demon- team including rehabilitation therapist, occu- strates a signiﬁcantly beneﬁcial effect of physi- pational therapist, physiotherapist, speech-lan- cal exercise and lifestyle intervention in the guage pathologist, behavior therapist, and management of type 2 diabetes mellitus. neuropsychologist. Rehabilitation was carried out in a therapeutic milieu in which functional activities were presented individually and in groups, both on the unit and in the commu- CASE DESCRIPTION nity. Activities were organized in a daily schedule that interspersed rehabilitation with A 30-year-old man was admitted to a neurobe- rest throughout the day, with both staff and havioral rehabilitation unit as a result of the patient recording completion of activities. development of a functional neurological Activities included physical exercise, as well as symptom disorder following a concussion sus- personal care, social and recreational pursuits, tained in a motor vehicle accident 3 years ear- chores to care for his ADL apartment on the lier. The patient had a history of type 2 diabetes unit, and community-based tasks such as for 8 years, but managed this successfully with shopping and volunteering. Duration and only physical activities and no medication prior intensity of activities were gradually increased to the accident. Unfortunately, there is no during the course of admission, with goals available data of his glucose values or HbA1C adjusted collaboratively. level prior to his injury. Following the accident, Psychological treatment in the form of cog- he developed depression, anxiety with the fea- nitive behavior therapy was directed to reduc- tures of post-traumatic stress disorder, and ing phobic avoidance of proximity to motor functional neurological symptoms with gait vehicles. As the patient progressed successfully and speech dysfunction, with brain imaging through a hierarchy of phobic situations, his studies showing no intracranial pathology. mobility increased from using a walker to run- Further complicating the clinical presentation ning. Relaxation and mindfulness exercises were chronic pain, insomnia, and neurocogni- were also conducted, and self-directed practice tive impairments. Together, these impairments introduced. Relaxation skills were integrated and symptoms prevented the patient from with sleep hygiene methods. Psychoeducational engaging in his normal routine of activities of intervention was provided related to the daily living (ADL) and work. At the time of the expected process of return to health following admission, he had gained 14 kg (BMI 28.7) and concussion. required 50 units insulin glargine subcutaneous With the application of multidisciplinary at bedtime, 15 units of insulin aspart three approaches on the neurobehavioral rehabilita- times a day with meals, as well as a correctional tion unit, he gradually made functional gains scale. Furthermore, he took canagliﬂozin during a 4-month admission. Psychometric 300 mg daily and metformin/sitagliptin ﬁndings from readministration of standardized 50/1000 1 tablet twice a day. In addition, he measures shortly before discharge showed a took rosuvastatin 10 mg daily and fenoﬁbrate resolution of anxiety, worry, sleeping difﬁculty, 160 mg daily for dyslipidemia. and pain. Physically he discontinued the usage Psychological assessment included stan- of a rollator walker for ambulating and started dardized measures (Symptom Checklist 90 aerobic exercises and resistance training while Revised, Beck Depression Inventory Revised, his mood and behavior were improving. Beck Anxiety Inventory, Insomnia Severity Approximately 3 months after his admission, all Index, Brief Pain Inventory). Findings were his hypoglycemic agents, including insulin and valid and showed abnormal elevations related Diabetes Ther (2018) 9:1713–1718 1715 oral medications, had been gradually weaned Supervised structured training was shown to be off, and he had lost more than 10 kg (BMI 25.0). more effective for HbA1C reduction than His HbA1C dropped from 10.5% to 6.4% and unstructured exercise, so participating in a well- his blood glucose was well controlled without designed exercise program is recommended for any pharmacological agents (capillary blood type 2 diabetes patients . glucose (CBG) varied between 4.0 and Following a motor vehicle accident, the 8.0 mmol/L). Meanwhile, rosuvastatin and patient in this report developed signiﬁcant fenoﬁbrate were discontinued as his triglyceride behavioral disturbance in the form of func- reduced from 4.15 to 0.89 mmol/L, and non- tional neurological symptoms, stopped all HDL cholesterol from 3.50 to 3.16 mmol/L. physical exercise, and experienced the worsen- ing of his diabetes. Upon admission to the neurobehavioral rehabilitation unit, he pre- Compliance with Ethics Guidelines sented with a signiﬁcant balance impairment and ambulated with the aid of a rollator walker. The authors received consent from the patient With structured and supportive physical and included in this case report. behavioral rehabilitation, his abnormal gait resolved, and he gradually made functional gains seen in his successful self-management of DISCUSSION his ADL on the rehabilitation unit and in the community, as well as completion of a healthy Type 2 diabetes is a common metabolic disorder exercise routine with a combination of aerobic that affects more than one in every 10 adults in and resistance training. After 3 months of the USA and Canada who are 20 years or older, rehabilitation he no longer took medication and is associated with an increased risk of while continuing to participate in routine coronary heart disease and microvascular dis- physical activity, including daily community eases including retinopathy, nephropathy, and walking for 30 min at a time, running 1.5 km peripheral neuropathy. Diabetes is also among 3–4 times per week, and daily gym exercises for the common comorbidities in patients admitted strength training with rotating muscle groups. to the setting where the patient was seen, i.e., a Meanwhile, he played leisure sports such as neurobehavioral rehabilitation unit in this case. basketball. Progressing with physical gains was Multiple medications are often required for accompanied by a gradual improvement of his glycemic control. Poorly controlled diabetes is a glycemic control. frustrating but commonly seen phenomena for In addition to exercises, dietary approach has clinical health providers. Besides pharmacolog- been suggested to play an essential role in the ical intervention, there is growing evidence of lifestyle intervention for patients with type 2 the effectiveness of lifestyle modiﬁcation on diabetes . Following the motor vehicle glycemic control in patients with type 2 accident, this patient developed a pattern of diabetes. poor sleep habits characterized by often sleep- Clinical trials have demonstrated that phys- ing during the day and staying up through the ical exercise is an effective strategy for the night. At the same time, his eating schedule was management of type 2 diabetes. Both aerobic highly inconsistent and he did not observe the and resistance training are beneﬁcial for the diet restrictions for diabetes. During his stay on management of blood glucose, lipids, and blood the neurobehavioral rehabilitation unit, he ate pressure and thus reduce cardiovascular com- meals at regular times and established healthy plication and mortality [5, 6]. According to the sleep hygiene. Diabetic diet was provided under position statements published by the American the supervision of the registered dietitian College of Sports Medicine, the American Dia- (1600–1800 calories per day with 15–20% pro- betes Association, and the American Heart tein and 50% carbohydrates plus diet drink/ Association, lifestyle intervention with regular dessert). He was compliant with diabetic diet exercises should be the ﬁrst-line strategy for the during his rehabilitation. These lifestyle prevention and control of type 2 diabetes [7, 8]. 1716 Diabetes Ther (2018) 9:1713–1718 changes worked synergistically with physical a costly and comprehensive program for long. training contributing to his weight loss and Ongoing support for these diabetic patients to better glycemic control. maintain their functional gains is an important There is evidence that different types of public health and socioeconomic problem. In emotional stress, including depression and this case, the patient self-reported his mainte- anxiety, are associated with an increased risk for nance of lifestyle changes 6 months after dis- the development of type 2 diabetes [11, 12]. The charge, successful return to work, continuing mechanism underlying this could be associated follow-up by his family physician, and no fur- with unhealthy lifestyle behaviors, chronic ther use of medication to treat diabetes. activation of hypothalamic–pituitary–adrenal There may be factors other than neurobe- axis and sympathetic nervous system, and havioral approaches responsible for his good immune system dysfunction. Psychological clinical outcome. It is unclear whether there intervention has been shown to be effective in was any error in his injection techniques con- the management of type 2 diabetes [13, 14]. Our sidering his high dose of daily insulin use prior patient developed signiﬁcant mood and to the admission to our rehabilitation unit, behavioral disturbance following the motor although this was less likely as a family member vehicle accident. Multidisciplinary neurobe- who is a registered pharmacist was overseeing havioral rehabilitation with psychological and assisting. Therefore, we cannot conclude intervention led to a resolution of his anxiety, with certainty that the loss of body weight worry, sleeping difﬁculty, and pain. The effec- coupled with neurobehavioral interventions tive management of his emotional issues was was the sole cause for the successful control of likely a factor contributing to the successful his diabetes. control of his diabetes. Previous research studies have demonstrated the efﬁcacy of multidisciplinary approach in CONCLUSION patients with poorly controlled type 2 diabetes [3, 4]. This patient was likewise managed with Though lifestyle modiﬁcation is a well-known the aforementioned intensive lifestyle approa- approach for preventing and managing type 2 ches combined with the support of a multidis- diabetes, the effectiveness of lifestyle approa- ciplinary rehabilitation team. The success of ches may not be fully understood by clinical this case provides evidence for the importance physicians, care providers, or patients. In the and beneﬁt of multidisciplinary lifestyle inter- case reported here, a combination of dietary vention in inadequately controlled type 2 dia- advice, regular aerobic exercise and resistance betes. However, with only one case, we cannot training, as well as multidisciplinary neurobe- havioral intervention was organized and sys- identify the group of type 2 diabetes patients for whom lifestyle and behavioral intervention tematically implemented in a highly structured might be sufﬁcient treatment. approach to providing rehabilitation for a Nevertheless, compliance with medical complex group of comorbidities, with highly advice is a signiﬁcant issue in patients with type beneﬁcial results. The remarkable outcome of 2 diabetes, and it is challenging in the real his poorly controlled type 2 diabetes occurred world for patients to pursue lifestyle modiﬁca- incidentally with the rehabilitation of a com- tion without support. Diet modiﬁcation and plex set of comorbidities that followed a sig- intense physical training without professional niﬁcant personal injury which had disrupted his supervision could be detrimental for patients normal lifestyle. This case provides striking with poorly controlled type 2 diabetes, espe- evidence of the potential beneﬁt of lifestyle cially if they take statins and ﬁbrates for dys- intervention in the management of this disease. lipidemia. Short-term rehabilitation with While acknowledging the scientiﬁc limitations supportive service from a multidisciplinary of this case presentation, the patient’s success team can be beneﬁcial for those patients. likely resulted from the synergistic effects of the However, no patient will be able to stay in such multiple aforementioned interventions. Diabetes Ther (2018) 9:1713–1718 1717 Although it is not clear which components of REFERENCES his rehabilitation were essential, the present results support the use of intensive lifestyle 1. Deshpande AD, Harris-Hayes M, Schootman M. intervention for patients with inadequately Epidemiology of diabetes and diabetes-related complications. Phys Ther. 2008;88(11):1254–64. controlled type 2 diabetes in a structured reha- bilitation program. Ongoing support for these 2. Johansen MY, MacDonald CS, Hansen KB, et al. patients to maintain their functional gains Effect of an intensive lifestyle intervention on gly- remains an important public health issue. cemic control in patients with type 2 diabetes: a randomized clinical trial. JAMA. 2017;318(7):637–46. ACKNOWLEDGEMENTS 3. Maislos M, Weisman D. Multidisciplinary approach to patients with poorly controlled type 2 diabetes mellitus: a prospective, randomized study. Acta We thank the patient in the study and all the Diabetol. 2004;41(2):44–8. team members who provided care for him on the neurobehavioral rehabilitation unit. We are 4. Sbroma Tomaro E, Pippi R, Reqinato E, et al. Intensive lifestyle intervention is particularly grateful to Dr. Shanker Nesathurai for his com- advantageous in poorly controlled type 2 diabetes. ments on an earlier version of the manuscript. Nutr Metab Cardiovasc Dis. 2017;27(8):688–94. 5. De Feo P, Schwarz P. Is physical exercise a core Funding. No funding was received for this therapeutical element for most patients with type 2 study or the publication of this report. diabetes? Diabetes Care. 2013;36(Suppl 2):S149–54. Authorship. All named authors meet the 6. Umpierre D, Ribeiro PA, Kramer CK, et al. Physical activity advice only or structured exercise training International Committee of Medical Journal and association with HbA1c levels in type 2 dia- Editors (ICMJE) criteria for authorship of this betes: a systematic review and meta-analysis. JAMA. manuscript, take responsibility for the integrity 2011;305(17):1790–9. of the work as a whole, and have given their ﬁnal approval of the version to be published. 7. Colberg SR, Siqal RJ, Fernhall B, et al. Exercise and type 2 diabetes: the American College of Sports Medicine and the American Diabetes Association: Disclosures. Zhihui Deng, John Davis, Flor joint position statement executive summary. Dia- Muniz-Rodrigues, Fran Richardson have no betes Care. 2010;33(12):2692–6. conﬂicts to disclose. 8. Marwick TH, Hordern MD, Miller T, et al. Exercise training for type 2 diabetes mellitus: impact on Compliance with Ethics Guidelines. The cardiovascular risk: a scientiﬁc statement from the authors received consent from the patient American Heart Association. Circulation. included in this case report. 2009;119(25):3244–62. 9. Sanghani NB, Parchwani DN, Palandurkar KM, et al. Open Access. This article is distributed Impact of lifestyle modiﬁcation on glycemic con- under the terms of the Creative Commons trol in patients with type 2 diabetes mellitus. Indian Attribution-NonCommercial 4.0 International J Endocrinol Metab. 2013;17(6):1030–9. License (http://creativecommons.org/licenses/ 10. Vetter ML, Amaro A, Volger S. Nutritional man- by-nc/4.0/), which permits any non- agement of type 2 diabetes mellitus and obesity and commercial use, distribution, and reproduction pharmacologic therapies to facilitate weight loss. in any medium, provided you give appropriate Postgrad Med. 2014;126(1):139–52. credit to the original author(s) and the source, 11. Hackett RA, Steptoe A. Type 2 diabetes mellitus and provide a link to the Creative Commons license, psychological stress—a modiﬁable risk factor. Nat and indicate if changes were made. Rev Endocrinol. 2017;13(9):547–60. 1718 Diabetes Ther (2018) 9:1713–1718 12. Pouwer F, Kupper N, Adriaanse MC. Does emo- in China: a systematic review and meta-analyses of tional stress cause type 2 diabetes mellitus? A review randomized controlled trials. Front Public Health. from the European Depression in Diabetes (EDID) 2015;3:252. Research Consortium. Discov Med. 2010;9(45):112–8. 14. Sudhir PM. Advances in psychological interven- tions for lifestyle disorders: overview of interven- 13. Chapman A, Liu S, Merkouris S, et al. Psychological tions in cardiovascular disorder and type 2 diabetes interventions for the management of glycemic and mellitus. Curr Opin Psychiatry. 2017;30(5):346–51. psychological outcomes of type 2 diabetes mellitus
Diabetes Therapy – Springer Journals
Published: May 28, 2018
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