Category Archives: Diabetes

Acute Traumatic Brain Injury (TBI) Treatment

Acute TBI Treatment

By:  Helen Rousso

Acute treatment of a Traumatic Brain Injury (TBI) initiates several metabolic processes that can aggravate the injury. Therefore, management focuses on stabilizing and preventing a secondary injury. Ultimately, the goal is to assess and stabilize the airway and circulation, maintain sufficient blood and oxygen supply to the brain, stop intracranial bleeding and prevent an increase in pressure within the skull.

However, full neuro-monitoring including intracranial pressure measurement are rarely available before the patient’s arrival to the intensive care unit. Mechanical intervention (ventilation support) assists in breathing while alleviating pressure on the brain.  Traumatic brain injury (TBI) is a major health and socioeconomic problem that affects all societies. Research shows that worldwide, TBI is a leading cause of death and permanent disability.  In the United States alone, there are approximately 1.4 million reported cases of TBI each year.

Unfortunately, there is difficulty in recording the real incidence of TBI’s since many patients refuse to report the incident and seek medical care. Half of those who die from TBI do so within the first two hours of injury, it is now known, however, that all neurological damage does not occur at the moment of impact (primary injury) but rather evolves over the ensuing minutes, hours or days. This secondary brain injury can result in increased mortality and disability.

Consequently, the early and appropriate management of TBI is critical to the survival of these patients. Emergency Medical Services (EMS) personnel are often the first health care providers for patients with TBI. Thus, prehospital assessment and treatment is a critical link in providing appropriate care. Treatment begins in the field and continues during transport by EMS providers who have varied skills, backgrounds and qualifications.  Over the past 30 years, EMS has become progressively sophisticated, resulting in improved outcomes, particularly in cardiovascular and trauma resuscitations.

However, many challenges remain, especially in recognition and management of TBI in the prehospital setting.  There are three different stages of treatment for traumatic brain injuries. These include the acute phase where the patient is stabilized immediately after the injury; subacute phase, to rehabilitate the patient to their potential to return to the community and the chronic phase to continue rehabilitation and treat any long-term impairment.

Initial treatments will be provided at the scene of the accident by emergency personnel if they are summoned. Occasionally individuals in an accident or athletic injury may determine that it is quicker to transport themselves than it is to wait for an ambulance. However, more commonly an ambulance and paramedics are dispatched to treat the individual at the scene of the accident.

Treatments offered to the patient will vary with the type of injury. Commonly the head of the stretcher or bed will be slightly elevated, and the neck of the individual kept straight.  This position can help decrease any intracranial pressure by allowing blood and cerebral spinal fluid to drain using gravity. It is also imperative to maintain the neck and back straight to minimize the risk of further injury to the spinal column that may have been suffered during the trauma.

Paramedics will never give fluids by mouth to an individual who has undergone a dramatic events area. The brain is like a sponge and will absorb any extra fluid that is delivered. Limiting fluids can help control swelling. An IV is started at the scene of the accident to give the paramedics and doctors intravenous access for emergency medication. Emergency medical professionals will also assess the individual’s ability to breathe on their own. If the accident victim is unable to maintain oxygenation of their bodies, then medical professionals will assist until they reach the hospital.

Once admitted to the hospital, professionals will begin treatment of the brain injury. Using imaging studies and clinical assessments they will check for and surgically remove any life-threatening blood clots. Swelling in the brain (edema) is monitored and treated using either clinical evaluation or an intracranial monitor attached to the head.

This swelling can cause an increase in intracranial pressure (ICP) that will squeeze the soft tissue of the brain against the skull. This will damage the brain tissue and cause further harm.  A buildup of fluid can also occur within the ventricle of the brain. This is called hydrocephalus and is treated using a shunt. This too is placed within the ventricle and then allows the cerebral spinal fluid to drain in the ventricles to shrink stores normal functions of brain cells.

Seizures can also occur in a week or a month after a traumatic brain injury as the damaged brain cells begin to heal. These seizures can result in minor twitching of a finger or limb or lead to a complete loss of consciousness accompanied by involuntary movements of the entire body. Seizures are very dangerous during the acute treatment phase of a traumatic brain injury, so most patients who have experienced a moderate or severe injury will receive medications for the first few weeks prophylactically.

Another important aspect of the acute care of a traumatic injury is monitoring of other medical problems.  Abnormally high or low levels of sodium, calcium, sugar or other chemicals in the blood, which are released during a traumatic event can worsen confusion and precipitate seizures. Individuals who suffer from a traumatic brain injury are also at high risk for infection, such as ammonia, urinary tract infections, and sinusitis.

Medications which may be used to treat the brain injury can include diuretics to decrease the amount of water in the patient’s body, anticonvulsants to prevent seizures, and barbiturates to help control intracranial pressure. Surgeons may also choose to use a shunt or ventricular drain placed in the ventricle to help control cerebral spinal fluid. A ventilator, machine used to support the patient’s breathing, may be used to help control intracranial pressure.

Several surgeries may be required to assist in controlling the increased pressure within the brain. A craniotomy may be done to open the skull if there have been fractures in the bone, large blood clots or swollen brain tissue. Smaller blood clots will be removed to help relieve pressure or to place an intracranial pressure monitor. A bone flap removal is when a piece of bone is removed from the skull to make room and relieve tension that is caused by swollen brain tissue.

Once patients are stabilized in the acute setting, they will be transferred to a subacute dramatic brain injury treatment center where their rehabilitation will be initiated.  At the specialized care facilities, medical staff will fully evaluate the patient’s impairments, disabilities, and probability of recovery. Doctors will also outline a course of treatment, and healthy patients and their families build the right team of medical professionals necessary for successful rehabilitation.

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Did you say “Perfect Body”?

What would you consider to be the “perfect” female or male body? Instead of embracing diversity in all body types, shapes and sizes, we are often far more preoccupied with appearance. That is, how dissatisfied we’ve become with ourselves rather than appreciating our individual uniqueness. Far more emphasis is placed on how we appear to others, placing us at a much greater risk for engaging in dangerous behaviors to control weight and size.

We are constantly being bombarded with messages pertaining to body image and what the “perfect body” should be. Advertising and mass media have had such a great influence and are definitely amongst the biggest culprits. It should come as no big surprise then, that instead of our focus being placed on a healthy self, we worry about how we will appear to others. Our body image is often based on others looks, we examine how that relates to our own personal goals and aspirations for our bodies. These images become incorporated into our self-perception. Airbrush anyone?

Body image is not a concept that is static as there is constant change. It is not based on facts, but rather influenced by our self-esteem and psychological nature. Our body image is sensitive to our emotions and our moods. We learn how to perceive our body image to the interaction we have with our own families, friends, peers and coaches, but it is only a reinforcement of what is learned from the culture.

Receiving negative feedback as we age can give us a distorted perception of our body shape. One can perceive parts of their body to be unlike they really are. They are convinced that other people are attractive and that body size or shape is a sign of personal failure, which can lead to behaviors such as extreme dieting, exercise compulsion, laxative abuse, vomiting, smoking and use of anabolic steroids – These practices are associated with negative body image.

Many people can become so conscious of their body image they will go the extra mile to achieve the same sculptured body like those that are splashed in the pages of the magazines, billboards, TV, and movie screens. Others try to find sensible and sustainable ways to achieve and maintain a physically fit body, yet overlook another important aspect of their well-being: their emotional health.

If you’ve ever lost weight and managed to reach your dream goal, do you recall what your emotions were like? Were you as happy as you initially anticipated you would be? Although dieting in a manner which uses unhealthy practices such as starvation dieting may result in substantial weight loss, it will certainly affect your overall emotional well-being.

Not all experts agree that human beings are born with a full range of emotions. Instead, some theorize that people were born with instincts and urges, along with an innate capacity for feeling. As people grow older, they develop personalities and nurture relationships with others, which are valuable experiences that help them expand their feelings into full-fledged emotions. Having a complete range of emotion is important for overall health and well-being. We must be aware of our emotions.

Emotionally healthy people are in tune with their emotions and can identify and acknowledge them as experience. After connecting with your emotions, emotionally healthy people will typically develop appropriate ways of expressing them – we must be able to process our emotions. The ability to identify with one’s own emotions enables emotionally healthy people to identify emotions in others and to have an intuitive sense of what it feels like to experience them – showing sensitivity to others and to their emotional state while having the ability to empathize.

Emotionally healthy people honor their emotions which in return empower them to fulfill their goals. As the saying goes, a healthy body cannot be divorced from a healthy mind or a healthy spirit. Emotional health is considered an integral part of an individual’s overall wellness, if neglected, it can certainly cause damage to your physical health in the process. Research has shown that one of the leading contributing factors to illness is stress caused by unresolved emotional issues.

Emotions course through our conscious and unconscious mind at critical junctures or during seemingly inconsequential moments of our lives. Emotions such as grief and anger can be far more difficult to control or reason with. The interplay of various emotions makes that form of “reasoning” not an easy one. Just as emotional health can affect a person’s physical health, the same is true with one’s lifestyle making a direct impact on emotional health. It is important to take vitamins and minerals as they stimulate the production of chemicals in the brain. These are known as neurotransmitters that regulate our physical and mental health functions, including the way we process emotions. Minor deficiencies of these nutrients can lead to depression and irritability, as well as hamper our ability to concentrate and stay motivated.

Unhealthy foods can adversely affect emotional health. An excess amount of caffeine intake can demonstrate many of the same physiological and psychological symptoms as people suffering from anxiety, while a diet with high sugar content has been linked to depression, aggression, and impaired judgment. The real goal in altering your body image must always be health related. Whether an individual is trying to attempt to achieve a healthy weight or a healthy, toned body, the goal must be to achieve good health.

Individuals who desire to change their body image and self-perceptions do not need to change the way they look, feel, act, or live. Instead they must change the way they think about themselves and how attractive they believe themselves to be. Each of us are individuals. We cannot duplicate the current top model and they cannot duplicate us.

The first step for individuals who want to change their body image is to be sure that the weight is within healthy limits by checking with their primary care physician. We must learn to appreciate the diversity that we bring to the human race with our own individual interpretation of our bodies.

When you hear yourself, saying negative things – STOP!  You can be your own worst enemy or your own biggest fan. You need to be realistic about the size you are likely to be based on your genetic and environmental history. By staying active (biking, walking, dancing, yoga, etc.), regardless of your size, you can expect normal weekly and monthly changes in weight and shape. Work towards self-acceptance and self-forgiveness; be kind to yourself.

Make no mistake my friends, children are watching their parents or people dear to them very closely to learn what body image is and how to integrate it into their own lives. When children are learning from parents whose body image is tied to what they see as perfection, it results in raising a generation of children who aspire to perfection to the point that they become anorexic, starve themselves, are constantly dieting and never eat a nutritious well-balanced meal.

Do NOT be afraid to ask for support and encouragement from friends and family or a professional – especially when life is stressful. Most importantly, decide how you wish to spend your energy – do you spend it on making positive changes to yourself? Or, is it spent on focusing on a negative body image? Would you rather spend your valuable time pursuing the “perfect body” or enjoying family, friends, school and life? Clearly, the latter is the healthier choice that can and will lead to a happier and healthier you.

Diabetes and (Medical) Exercise

Perhaps the most distinguishing characteristic in the field of medical exercise is its application to patients with metabolic or cardiac abnormalities. The top three leading causes of premature death in the United States are heart disease, cancer and diabetes.

Despite their prevalence and economic burden, there should be more rehabilitation efforts directed to these conditions in terms of exercise prescription and post-rehabilitative care. There is a substantial amount of evidence that exercise may not only assist in the prevention of these disorders but that it also plays an intricate part of the treatment plan.

There are two types of Diabetes. Diabetes is defined as the body’s inability to metabolize carbohydrates. Insulin dependent diabetes mellitus [IDDM], in which the pancreas loses it’s ability to produce or secrete insulin. The second is non insulin dependent diabetes mellitus [NIDDM], where there is an inability of the muscle cell to uptake insulin from the blood stream making it necessary for the administration of medical intervention.

The medication used by many diabetics is insulin. Insulin is commonly injected under the skin into fatty tissue on the triceps region, abdomen, front of thigh and hip. The medical exercise specialist must inquire about the type of insulin(s) taken during the course of the day, number of injections per day, time of injections to determine appropriate time for exercise, body site preferred for injections (necessary for site specific exercises) while both the patient and fitness specialist must be aware of the times of peak insulin action.

Each type of insulin has an onset, a peak, and a duration time. The onset is how soon the insulin begins to lower your blood glucose once it has been administered. The peak is the time the insulin is working the hardest to lower your blood glucose. The duration is how long the insulin lasts (the length of time it keeps lowering your blood glucose).

For instance, long-acting/fast-acting forms are taken in the morning and evening to to cover the patients insulin requirements. Regular insulin (short acting type) is taken with meals covering glucose peaks which is dependent upon the carbohydrate content of the meal consumed. The correct combination of these types is necessary as it simulate’s the body’s response to a meal naturally. Since a person’s onset, peak, and duration times may vary, it is best to work with your health care team to come up with an insulin plan that works best for you.

The principle of individual differences must be applied when creating an exercise program for the client with special medical concerns and cannot be compared to that of the generally healthy individual. Specific guidelines must be adhered to, if overlooked, it can result in a serious medical emergency.

Studies show that long term physical conditioning lowers one’s blood glucose levels and makes the body more sensitive to insulin which then helps reduce overall resistance. When progress is monitored on a continual basis, the benefits will be noticeable. The main areas of focus with any conditioning program should include aerobic capacity, flexibility, muscular strength/endurance and motor skill development.[1]

Depending upon the type of exercise performed and the conditioning level of the participant, the blood glucose response will differ from one person to another. The diabetic client is constantly battling to avoid hypoglycemia on one hand and hyperglycemia on the other.

Hypoglycemia is a condition that occurs when the body’s blood sugar (glucose) falls below normal. Most healthy adults maintain fasting glucose levels above 4.0 mmol/L (72 mg/dl), and develop symptoms of hypoglycemia when the glucose falls below 4 mmol/L.[2]

Hypoglycemia is of great concern. One on one training is beneficial for all special medical population groups because the specialist can provide assistance in the event of a medical emergency. The client should carry some form of carbohydrate with them at all times to prevent low blood sugars when symptomatic.

Hyperglycemia, or high blood sugar (not to be confused with hypoglycemia) is a condition in which an excessive amount of glucose circulates in the blood. This is generally a glucose level higher than 11.1 mmol/l (200 mg/dl), but symptoms may not start to become noticeable until even higher values such as 15–20 mmol/l (~250–300 mg/dl). A subject with a consistent range between 100 and 126 (American Diabetes Association guidelines) is considered hyperglycemic, while above 126 mg/dl or 7 mmol/l is generally held to have diabetes. Chronic levels exceeding 7 mmol/l (125 mg/dl) can produce organ damage.[3]

There can be secondary abnormalities due to long standing high blood glucose levels (hyperglycemia). It can cause deterioration to tissues, becoming more severe around the ten year mark. These complications include retinopathy (eye disease), neuropathy (nerve disease commonly affecting the feet first), myopathy (muscle disease/stiffness), microvascular disease (increasing the risk of heart disease).[4]

Interestingly, exercise allows glucose to get in the cells having a glucose lowering effect. Secondly, stored glycogen* in the muscles and liver can be converted into glucose through what is called gluconeogenesis to provide fuel to muscles during low blood glucose periods. A conditioning effect is usually evident after approximately the first 6 or 7 sessions.

Exercise prescriptions created for the diabetic client must include two important elements, intensity and duration.  The intensity of the fitness routine will equal how fast your heart rate increases and for how long.  The amount of time (duration) which is chosen for the exercise program will relate to an individual’s lifestyle, overall health, amount of weight required for loss and motivation factor.

If the initial level of fitness doesn’t allow the individual to exercise for more than 10 minutes, then incorporating a 10 minute fitness plan three times throughout the day will give similar benefits to doing 30 minutes all at once.  Then, as your fitness level improves, you will be able to maintain a greater intensity for an extended length of time.

It has been my experience through various case studies that conditioning sessions should depend on blood glucose levels. In other words, the higher levels constitute a far more vigorous and longer training session (more sugar to burn). Lower levels constitute a less vigorous session for less time, thus, assisting in the prevention of medical emergencies – highly unlikely if guidelines are followed correctly.

Perhaps the two most fundamental aspects of an ideal weight management program are dietary modifications and regular exercise. When starting ANY weight loss and exercise program, one MUST address all aspects of a person’s physical makeup, lifestyle concerns and behavioral components. There are many factors in determining what will work for each person.

Exercise and weight management programs will improve the quality of your life, it will motivate you as you continue to see positive results.  Incorporating a fitness program into your lifestyle benefits all as there is a lower risk of heart attack, stroke, peripheral vascular disease, heart disease, vascular disease, inflammatory disease and cancer.

Special medical concerns require special attention, please take it seriously because your life can depend on it. Find a specialist that will develop a safe and effective program that does not require the supervision of a licensed medical professional for exercise, however utilizing the parameters that are established by a licensed physician would be highly recommended and the safest way to go.

*Glycogen: Most carbohydrates are broken down in the body to a type of sugar called glucose, which is the main source of fuel for our cells. When the body has extra glucose, it stores it in the liver and muscles. This stored form of glucose is called glycogen. Glycogen is like your backup fuel. It releases glucose into the bloodstream when the body needs a quick energy boost or when a person’s blood glucose level drops.

[1]Family Doctor: Diabetes and Exercise http://familydoctor.org/familydoctor/en/diseases-conditions/diabetes/treatment/diabetes-and-exercise.html
[2]Cryer, Philip E. (2001). “Hypoglycemia”. In Jefferson L, Cherrington A, Goodman H, eds. for the American Physiological Society. Handbook of Physiology; Section 7, The Endocrine System. II. The endocrine pancreas and regulation of metabolism. New York: Oxford University Press. pp. 1057–1092.
[3]http://www.diabetes.co.uk/Diabetes-and-Hyperglycaemia.html
[4]The science and practice of rehabilitative exercise FT/ISSA
http:// kidshealth.org/kid/word/g/word_glycogen.html

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