Type 2 diabetes is a common metabolic disorder that affects more than one in every 10 adults in the USA and Canada who are 20 years or older, and is associated with an increased risk of coronary heart disease and microvascular diseases including retinopathy, nephropathy, and peripheral neuropathy. Diabetes is also among the common comorbidities in patients admitted to the setting where the patient was seen, i.e., a neurobehavioral rehabilitation unit in this case. Multiple medications are often required for glycemic control. Poorly controlled diabetes is a frustrating but commonly seen phenomena for clinical health providers. Besides pharmacological intervention, there is growing evidence of the effectiveness of lifestyle modification on glycemic control in patients with type 2 diabetes.
Clinical trials have demonstrated that physical exercise is an effective strategy for the management of type 2 diabetes. Both aerobic and resistance training are beneficial for the management of blood glucose, lipids, and blood pressure and thus reduce cardiovascular complication and mortality [5, 6]. According to the position statements published by the American College of Sports Medicine, the American Diabetes Association, and the American Heart Association, lifestyle intervention with regular exercises should be the first-line strategy for the prevention and control of type 2 diabetes [7, 8]. Supervised structured training was shown to be more effective for HbA1C reduction than unstructured exercise, so participating in a well-designed exercise program is recommended for type 2 diabetes patients .
Following a motor vehicle accident, the patient in this report developed significant behavioral disturbance in the form of functional neurological symptoms, stopped all physical exercise, and experienced the worsening of his diabetes. Upon admission to the neurobehavioral rehabilitation unit, he presented with a significant balance impairment and ambulated with the aid of a rollator walker. With structured and supportive physical and behavioral rehabilitation, his abnormal gait resolved, and he gradually made functional gains seen in his successful self-management of his ADL on the rehabilitation unit and in the community, as well as completion of a healthy exercise routine with a combination of aerobic and resistance training. After 3 months of rehabilitation he no longer took medication while continuing to participate in routine physical activity, including daily community walking for 30 min at a time, running 1.5 km 3–4 times per week, and daily gym exercises for strength training with rotating muscle groups. Meanwhile, he played leisure sports such as basketball. Progressing with physical gains was accompanied by a gradual improvement of his glycemic control.
In addition to exercises, dietary approach has been suggested to play an essential role in the lifestyle intervention for patients with type 2 diabetes . Following the motor vehicle accident, this patient developed a pattern of poor sleep habits characterized by often sleeping during the day and staying up through the night. At the same time, his eating schedule was highly inconsistent and he did not observe the diet restrictions for diabetes. During his stay on the neurobehavioral rehabilitation unit, he ate meals at regular times and established healthy sleep hygiene. Diabetic diet was provided under the supervision of the registered dietitian (1600–1800 calories per day with 15–20% protein and 50% carbohydrates plus diet drink/dessert). He was compliant with diabetic diet during his rehabilitation. These lifestyle changes worked synergistically with physical training contributing to his weight loss and better glycemic control.
There is evidence that different types of emotional stress, including depression and anxiety, are associated with an increased risk for the development of type 2 diabetes [11, 12]. The mechanism underlying this could be associated with unhealthy lifestyle behaviors, chronic activation of hypothalamic–pituitary–adrenal axis and sympathetic nervous system, and immune system dysfunction. Psychological intervention has been shown to be effective in the management of type 2 diabetes [13, 14]. Our patient developed significant mood and behavioral disturbance following the motor vehicle accident. Multidisciplinary neurobehavioral rehabilitation with psychological intervention led to a resolution of his anxiety, worry, sleeping difficulty, and pain. The effective management of his emotional issues was likely a factor contributing to the successful control of his diabetes.
Previous research studies have demonstrated the efficacy of multidisciplinary approach in patients with poorly controlled type 2 diabetes [3, 4]. This patient was likewise managed with the aforementioned intensive lifestyle approaches combined with the support of a multidisciplinary rehabilitation team. The success of this case provides evidence for the importance and benefit of multidisciplinary lifestyle intervention in inadequately controlled type 2 diabetes. However, with only one case, we cannot identify the group of type 2 diabetes patients for whom lifestyle and behavioral intervention might be sufficient treatment.
Nevertheless, compliance with medical advice is a significant issue in patients with type 2 diabetes, and it is challenging in the real world for patients to pursue lifestyle modification without support. Diet modification and intense physical training without professional supervision could be detrimental for patients with poorly controlled type 2 diabetes, especially if they take statins and fibrates for dyslipidemia. Short-term rehabilitation with supportive service from a multidisciplinary team can be beneficial for those patients. However, no patient will be able to stay in such a costly and comprehensive program for long. Ongoing support for these diabetic patients to maintain their functional gains is an important public health and socioeconomic problem. In this case, the patient self-reported his maintenance of lifestyle changes 6 months after discharge, successful return to work, continuing follow-up by his family physician, and no further use of medication to treat diabetes.
There may be factors other than neurobehavioral approaches responsible for his good clinical outcome. It is unclear whether there was any error in his injection techniques considering his high dose of daily insulin use prior to the admission to our rehabilitation unit, although this was less likely as a family member who is a registered pharmacist was overseeing and assisting. Therefore, we cannot conclude with certainty that the loss of body weight coupled with neurobehavioral interventions was the sole cause for the successful control of his diabetes.