12 SECTION 3 Preventive medicine and public health Similarly, in patients with type 2 diabetes, UKPDS found progress back from an illness, but the initiation of rehabilita- that in general the lower the average glycemic level in tion should be incorporated into the patient's care from th patients, the fewer the complications Patients in the DCCT intervention group had to self monitor their blood glucose level, keep detailed records of sulin dosage and glucose level, regulate dietary intake and A. General Approach level of insulin based on self-monitoring results, and be Rehabilitation must begin in the early phases of treatment if actively involved in other aspects of their care. Although the it is to be maximally effective. In patients who have had a risk of hypoglycemic episodes was three times as high in the stroke, head injury, hip fracture, or other problem that tem intervention group as in the control group, no serious porarily immobilizes them, it is important to keep joints sequelae of hypoglycemia occurred in the intervention flexible from the beginning of the illness or injury, so that group. One death from hypoglycemia occurred in the control weakened but recovering muscles do not have to overcome betia p. Weight gain was a common side effect of tight dia stiffened joints. Beginning rehabilitation efforts early also tends to increase the cooperation of patients and family Based on the results of DCCT,"tight control"(defined as members by conveying to them that improvement is expected control as good as that obtained in DCCT) may benefit The most effective rehabilitation program is tailored to patients who are willing to participate actively in their own meet the physical, emotional, psychological, and occupa are. Currently, the most used definition of tight control is tional needs of the individual. As stated earlier, these pro hemoglobin Alc(glycohemoglobin, or sugar linked to Hb) grams also need to address pa values less than 7% of total hemoglobin. Many U.S. patients Often. a rehabilitation counselor coordinates the efforts of with diabetes may have glycohemoglobin above the recom- a team of specialists. Physical therapists work to strength mended level(57% with Hb Alc <7% in 2004). Tight weakened muscles, increase joint movement and flexibility, control should be supplemented with frequent examination and teach patients ways of accomplishing routine tasks of the retina and with laser treatment of microvascular despite their disabilities. These tasks, or activities of daily lesions when indicated. The use of ACE inhibitors has proved living(see Chapter 14), include feeding oneself, transferring valuable not only in controlling hypertension but also in from bed to chair and back, grooming, controlling reducing the incidence of microalbuminuria (albumin bladder and bowels, bathing, dressing, walking on a level protein in the urine)a sign of diabetic kidney damage, and surface, and going up and down stairs, Speech therapists seek delaying the onset of diabetes-induced renal failure. to improve the ability of patients to articulate their thoughts All patients with type I or type 2 diabetes should be after a stroke or head injury that produces aphasia, and they dvised of the need for moderate to high levels of physical may help to evaluate whether or not stroke patients can activity and should receive individual counseling about swallow food safely. Occupational therapists evaluate the nutrition. They should be informed of the common compli- occupational abilities of patients, counsel them regarding cations of diabetes and the importance of contacting their suitable types of work, provide them with job training or y note early ly symptoms of any of these retraining, and help them find a suitable job. Usually, the complications most cost-effective efforts are those designed to help a Many other hypoglycemic agents are being used to redr patient return to the previous place of employment. Some insulin resistance before it develops into frank type 2 diabe- patients may be able to resume their job, whereas others may tes. Current interest centers particularly on biguanides obtain a new or modified job there. Psychiatric or emotional metformin) and thiazolidinediones (glitazones ), which ounseling may be important, as may be spiritual counseling are more effective when used in combination than used by a member of the clergy. There also are specialists in alone. Oral hypoglycemic agents that act by stimulating the cardiac and pulmonary rehabilitation pancreas to produce more insulin(sulfonylureas, short- acting secretagogues)also are being used, but over time these B. Coronary Heart Disease ay exhaust the beta cells ability to make insulin. Oral hypoglycemics also tend to foster weight gain, which com Coronary heart disease (or CAD)was the first disease for pounds the problem of insulin resistance. The role, safety, which rehabilitation programs were developed, and these and impact on outcomes of newer agents such as glucago programs still provide the template for most rehabilitation. like peptide-1 analogs, incretins, amylin analogs, and di Most cardiac rehabilitation programs follow defined compo tidy peptidase-4 (DPP-4) inhibitors are not yet fully nents and stages"(Table 17-3). Core components of reha- established. For most patients, metformin should be the bilitation for all cardiac conditions include a comprehensive first-line agent assessment of the patient's clinical and functional status. This information provides the basis for a rigorous program aimed at gradually improving physical functioning, risk N. REHABILITATION factor profile, and psychosocial status Occurring after disease already has caused damage, rehabili tation may seem to take place when there is nothing left to BLOOD PRESSURE MONITORING prevent. However, the goal of rehabilitation is to reduce the If resting systolic BP is 130 to 139 mm Hg or diastolic BP social disability produced by a given level of impairment, both 85 to 89 mm Hg, recommend lifestyle modifications, by strengthening the patients remaining functions and by management,sodium restriction, and helping the patient learn to function in alternative ways moderation of alcohol intake(<30 g/day in men; <15 g/ Often, rehabilitation specialists can contribute to a patient's lay in women), according to DASH diet