Introduction
Diabetic polyneuropathy is one of the most problematic complications in patients with diabetes mellitus. In autonomic neuropathy, they suffered from various symptoms including dizziness, dyspepsia, urinary incontinence, etc. We experienced a rehabilitation case of diabetic autonomic neuropathy with uncontrolled orthostatic hypotension and report it.
Case
A 47-year-old man admitted for weakness in all 4 extremities. He was diagnosed diabetes, but he stopped medication against doctor’s recommendation for 5 years. One year ago, he slept down and got a temporal bone fracture, and aggravated to pterygomandibular abscess. After surgical treatment, he became quadriplegic and refused any treatment. He has lived for 6 months at home without any medicine and any rehabilitation with a bed-ridden state.
At administration, upper and lower limb muscle strength was measured at 3/5 grade.(Table 1) His sensation of all 4 extremities was decreased. His HbA1c was measured as 16.4%. The electrodiagnostic study showed peripheral polyneuropathy with autonomic neuropathy.(Table 2) He could not maintain sitting position more than 5 minutes because of symptomatic orthostatic hypotension.
We started diabetes medication. We applied elastic compression stocking and abdominal binder for severe orthostatic hypotension. But even at 40 degrees on the sloping bed, he could not tolerate only 5 to 10 minutes, and he could not use a wheelchair.
At the 7th day of hospitalization, Fludrocortisone 0.1mg was administered, and at the 14th-day midodrine 2.5mg was administered. However, he complained of dysuria, so midodrine was discontinued 4 days later. He showed poor response to these medications. We applied exercise therapy including motorized bicycle (Superdynamics), his symptoms were getting better. After 20 days of exercise, he could use a reclining wheelchair for ambulation. Finally, he was able to walk on a parallel bar with assistance and use a regular wheelchair in ordinary times.(Table 3)
Conclusion
We experienced a rehabilitation for severe orthostatic hypotension in a diabetic autonomic neuropathy patient. Comprehensive approach including pharmacologic, non-pharmacologic treatment, and rehabilitation exercise were applied. In our experience, the most effective modality was lower extremity exercise using a motorized stationery bicycle. It gave symptom relief and daily living improvement. In the future, larger sized study with comprehensive rehabilitation program would be required.
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