Category Archives: Exercise Precautions

What Do We Really Know about Exercising with Complications?

Back injury

As a clinical exercise researcher, I frequently have found it difficult to study exercise effects in people with health complications, even though this is critical information to know in order to make appropriate exercise guidelines. Try convincing your university Institutional Research Board, or IRB, that it is advisable to exercise people with eye issues like unstable proliferative retinopathy to find out if breath-holding, jumping, jarring, or head-down activities cause them to experience retinal hemorrhages. Understandably, that is not going to happen, nor should it.

In some cases, I have not even been allowed to study relevant populations—like when we wanted to study older adults with type 2 diabetes and balance or gait issues related to peripheral neuropathy. Our IRB required so many exclusionary criteria that we were only able to recruit healthy, older subjects with diabetes, not the ones for whom an exercise training intervention to improve balance would be most relevant (i.e., those with actual balance issues).

It is still worth revisiting the latest recommendations for exercising safely and effectively with a variety of diabetes-related health complications. Most of these are derived from clinical observations and practical experience rather than clinical studies, though. The table that follows is a compilation of all these recommendations. (Please access the entire ADA Position Statement online, including redacted references, at http://care.diabetesjournals.org/content/39/11/2065).

Table 5: Physical activity consideration, precautions, and recommended activities for exercising with health-related complications (Modified from (1))

Health Complication Exercise Considerations Physical Activity Recommendations/Precautions
Cardiovascular Diseases
Coronary Artery Disease (heart disease) Coronary perfusion may actually be enhanced during higher intensity aerobic or resistance exercise All activities okay; consider exercising in a supervised cardiac rehabilitation program, at least initially
Exertional Angina (chest pain on exertion) Onset of chest pain on exertion, but exercise-induced ischemia may be silent in some with diabetes All activities okay, but heart rate should be kept 10 or more beats/min below onset of exercise-related angina
Hypertension (high blood pressure) Both aerobic and resistance training may lower resting blood pressure and should be encouraged; some blood pressure medications can cause exercise-related hypotension Ensure adequate hydration during exercise; avoid Valsalva maneuver during resistance training
Myocardial Infarction (heart attack) Stop exercise immediately should symptoms of myocardial infarction (such as chest pain, radiating pain, shortness of breath, and others) occur during physical activity and seek medical attention. Restart exercise post-MI in a supervised cardiac rehabilitation program; start at a low intensity and progress as able to more moderate activities; both aerobic and resistance exercise are okay
Stroke Diabetes increases the risk of ischemic stroke; stop exercise immediately if symptoms of a stroke (occurring suddenly and often affecting only one side of the body) during exercise Restart exercise post-stroke in a supervised cardiac rehabilitation program; start at a low intensity and progress as able to more moderate activities; both aerobic and resistance exercise are okay
Congestive Heart Failure Most common cause is coronary artery disease and frequently follows a myocardial infarction Avoid activities that cause an excessive rise in heart rate; focus more on doing low- or moderate-intensity activities
Peripheral Artery Disease Lower-extremity resistance training improves functional performance Low- or moderate-intensity walking, arm ergometer, and leg ergometer preferred as aerobic activities; all other activities okay
Nerve Disease
Peripheral Neuropathy Regular aerobic exercise may also prevent the onset or delay the progression of peripheral neuropathy in both type 1 and type 2 diabetes Proper care of the feet is needed to prevent foot ulcers and lower the risk of amputation; keep feet dry; use appropriate footwear, silica gel or air midsoles, and polyester or blend socks (not pure cotton); consider inclusion of more non-weight-bearing activities, particularly if gait altered
Local Foot Deformity Manage with appropriate footwear and choice of activities to reduce plantar pressure and ulcer risk Focus more on non-weight-bearing activities to reduce undue plantar pressures; examine feet daily to detect and treat blisters, sores, or ulcers early
Foot Ulcers/Amputations Moderate walking is not likely to increase risk of foot ulcers or re-ulceration with peripheral neuropathy Weight-bearing activity should be avoided with unhealed ulcers; examine feet daily to detect and treat blisters, sores, or ulcers early; amputation sites should be properly cared for daily; avoid jogging
Autonomic Neuropathy (central nerve damage) May cause postural hypotension, chronotropic incompetence, delayed gastric emptying, altered thermoregulation, and dehydration during exercise; exercise-related hypoglycemia may be harder to treat in those with gastroparesis With postural hypotension, avoid activities with rapid postural or directional changes to avoid fainting or falling. Those with cardiac autonomic neuropathy should have physician approval and possibly undergo symptom-limited exercise testing before commencing exercise. With blunted heart rate response, use heart rate reserve and ratings of perceived exertion (RPE) to monitor exercise intensity. With autonomic neuropathy, avoid exercise in hot environments and hydrate well.
Eye Diseases
Mild to Moderate Nonproliferative Retinopathy Individuals with mild to moderate nonproliferative changes have limited or no risk for eye damage from physical activity All activities okay with mild, but annual eye exam should be performed to monitor progression. With moderate non-proliferative retinopathy, avoid activities that dramatically elevate blood pressure, such as powerlifting
Severe Nonproliferative and Unstable Proliferative Retinopathy Individuals with unstable diabetic retinopathy are at risk for vitreous hemorrhage and retinal detachment Avoid activities that dramatically elevate blood pressure, such as vigorous activity of any type. Also avoid vigorous exercise, jumping, jarring, and head-down activities, and breath-holding. No exercise should be undertaken during a vitreous hemorrhage
Cataracts Cataracts do not impact the ability to exercise, only the safety of doing so due to loss of visual acuity Avoid activities that are more dangerous due to limited vision, such as outdoor cycling; consider supervision for certain activities
Kidney Disease
Microalbuminuria (micro bits of protein in urine) Exercise does not accelerate progression of kidney disease even though protein excretion acutely increases afterward. Greater participation in moderate-to-vigorous leisure time activity and higher physical activity levels may actually moderate the initiation and progression of diabetic nephropathy All activities okay, but vigorous exercise should be avoided the day before urine protein tests are performed to prevent false positive readings
Overt Nephropathy (protein in urine) Both aerobic and resistance training improve physical function and quality of life in individuals with kidney disease; individuals should be encouraged to be active All activities okay, but exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced
End-Stage Renal Disease (needing dialysis and/or kidney transplant) Doing supervised, moderate aerobic PA undertaken during dialysis sessions may be beneficial and increase compliance

 

Exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced; electrolytes should be monitored when activity done during dialysis sessions
Orthopedic Limitations
Structural Changes to Joints More prone to structural changes to joints that can limit movement, including shoulder adhesive capsulitis, carpal tunnel syndrome, metatarsal fractures, and neuropathy-related joint disorders (Charcot foot)

 

In addition to engaging in other activities (as able), do regular flexibility training to maintain greater joint range of motion; stretch within warm-ups or after an activity to increase joint range of motion best; strengthen muscles around affected joints with resistance training; avoid activities that increase plantar pressures with Charcot foot changes
Arthritis Common in lower extremity joints, particularly in older adults who are overweight or obese; participation in regular physical activity is possible and should be encouraged; moderate activity may improve joint symptoms and alleviate pain Most low- and moderate-intensity activities okay, but more non-weight-bearing or low- impact exercise may be undertaken to reduce stress on joints; do range of motion activities and light resistance exercise to increase strength of muscles surrounding affected joints; avoid activities with high risk of joint trauma, such as contact sports and ones with rapid directional changes

                                                                                                                                                            

Reference cited:

  1. Colberg SR, Sigal RJ, Yardley JE, Riddell MC, Dunstan DW, Dempsey PC, Horton ES, Castorino K, Tate DF: Physical activity/exercise and diabetes: a position statement of the American Diabetes Association. Diabetes Care 2016;39:2065-2079. http://care.diabetesjournals.org/content/39/11/2065
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When Do You Need a Checkup First Before Starting Exercise?

BP checkHow do you know if you need to get a checkup or medical clearance before you start any exercise training? You should have regular checkups at least annually with your doctor or another healthcare provider if you have any type of diabetes. This helps you keep on top of any problems that may pop up over time that have nothing to do with being physically active.

However, you probably don’t need to see a doctor before you start doing easy workouts or moderate activities like brisk walking. Requiring anyone with diabetes to get medical clearance before starting any type or intensity of exercise is recommended by the American College of Sports Medicine, but is not recommended by the American Diabetes Association because it sets too big of a barrier to participating in regular activities.

On the other hand, having a checkup before you begin more vigorous workouts is a good idea. It also depends on your age, your general health, and your physical activity level. If you’re already doing intense exercise, it’s not necessary, but it is advised for almost everyone with diabetes who is not already exercising at that level—just to be safe.

If/when you do have a checkup, get your blood pressure, heart rate, and body weight measured. If your doctor recommends that you do an exercise stress test, you’ll have to do walking on a treadmill or riding a stationary bike for around ten minutes. Your checkup may also include lab tests (urinalysis, kidney function testing, serum lipid evaluation, and electrolyte analysis) and screening for any diabetes-related complications (including heart, nerve, eye, and kidney disease). Most complications will not keep you from being active, but you may need to take precautions to exercise safely and effectively in certain cases.

For most people, getting a diagnostic graded exercise test is really going too far. Having one is only recommended by the American Diabetes Association if you’re over 40 and have diabetes; or if you’re over 30, have had diabetes for 10 or more years, smoke, have high blood pressure, have high cholesterol, or have eye or kidney problems related to diabetes. If you’re planning to do vigorous training that gets your heart rate up high, these criteria are relevant. If you’re just planning on doing mild or moderate aerobic activity or resistance training, such extensive (and often expensive) testing is unnecessary if you’re reasonably healthy or already fit and don’t have any symptoms of heart or vessel disease.

If you have any pre-existing health complications, you may need to take extra care to prevent problems during exercise. If your blood glucose has been in check, you’ve already been physically active, and you don’t have any serious diabetic complications, then go ahead and keep doing what you’re doing. If you’re very active, getting an extra checkup before you replace your current exercise regime with another exercise routine is neither necessary nor advised.

You still may need to take certain precautions when you exercise, particularly related to getting low blood glucose during and following the activity, going too high, and getting dehydrated. If you have any concerns, check with your healthcare provider at your next visit to discuss any precautions that may be important for your unique health circumstances when exercising.

Being Active and Getting Injured: How to Prevent This Conundrum

Back injury

You finally decide to get active to help manage your type 1 or type 2 diabetes better or to prevent type 2 altogether, and once you’ve hit your stride, you get an injury that puts you back on the couch! Getting injured from being active happens often enough that you need to know how to prevent and treat injuries so you can stay on track. The best medicine is prevention, so trying to prevent injuries before they happen is the best way to avoid having to take time off from exercising and sidetracking your fitness program. Here are some things you need to know:

The incidence of activity-related injuries, such as inflamed tendons (tendinitis) and stress fractures in bones, rises dramatically when people do more than 60 to 90 minutes of moderate or hard exercise daily. These types of overuse injury are nagging and persistently uncomfortable. Overuse injuries occur following excessive use the same joints and muscle in a similar way over an extended period of weeks or months. If you develop an overuse injury, it’s likely to be the result of excessive training, or doing too much too soon. In my own experience (since I’ve been regularly active for decades), they can also arise from doing something unusual, such as putting down a paver driveway, beating the yard into submission, or cleaning excessively prior to putting the house on the market.

Overuse injuries are more common in anyone with diabetes because elevated blood glucose can affect the health of your joints. Although everyone gets stiffer with age, diabetes accelerates the usual loss of flexibility especially when blood glucose is higher. Glucose “sticking” to joint surfaces makes people with diabetes more prone to overuse injuries like tendinitis and frozen shoulder (1; 2). It may also take longer for joint injuries to heal properly. The bones themselves can be thinned by exposure to elevated blood glucose levels, making fractures more common in people with any type of diabetes (3). The best prevention of any of these issues is optimal blood glucose control and regular stretching to maintain motion around joints.

You’ll likely benefit from doing a variety of activities on a weekly basis, an approach known as cross-training. Changing up your workouts is really they key to avoiding overuse injuries, keeping exercise fresh and fun, and getting more fit. Each activity a person does stresses muscles and joints differently, which lowers the risk of injury. It adds variety to an exercise program when you include activities like walking, cycling, rowing, swimming, arm biking, weight training, aerobic classes, and yoga, and it gives you the flexibility to choose different options based on your time constraints, the weather, and other factors. It also allows you to rest some muscles and joints without stopping exercising entirely. Alternating hard and easy days to lower the constant stress on muscles and joints is also a great idea.

To prevent overuse injuries, progress your exercise slowly (particularly the intensity), choose safe activities for you personally, always warm up and cool down, and make sure that you stretch your muscles regularly to stay more limber. For ongoing problems, treat affected areas with R.I.C.E. (rest, ice, compression, and elevation), combined with anti-inflammatory medications like ibuprofen (Advil or Nuprin) or naproxen sodium (found in Aleve), and avoid going back to normal activities or aggravating joints further until your symptoms resolve.

Finally, taking at least one day a week off from planned activities to rest allows your body time to recuperate and may prevent overuse injuries like tendinitis and stress fractures. It doesn’t mean that you have to stop moving, though, so keep your bodies in motion even on your days off for optimal blood glucose control.

References cited:

1. Abate M, Schiavone C, Pelotti P, Salini V: Limited joint mobility in diabetes and ageing: recent advances in pathogenesis and therapy. Int J Immunopathol Pharmacol 2011;23:997-1003

2. Ranger TA, Wong AM, Cook JL, Gaida JE: Is there an association between tendinopathy and diabetes mellitus? A systematic review with meta-analysis. Br J Sports Med 2015;

3. McCabe L, Zhang J, Raehtz S: Understanding the skeletal pathology of type 1 and 2 diabetes mellitus. Crit Rev Eukaryot Gene Expr 2011;21:187-206

Better Dehydrated than Overhydrated during Exercise

Jen Alexander (T1D)An updated position statement on the dangers of hyponatremia (also known as water intoxication) was just released (1). It once again highlights how drinking too much water or any fluids during physical activity in the hopes of preventing dehydration can be potentially fatal.

Taking in too much fluid dilutes the sodium levels in your blood, and severely low sodium levels can lead to brain swelling, seizures, coma, and death. Less severe, symptoms of hyponatremia include nausea and vomiting, headache, confusion, loss of energy and fatigue, restlessness and irritability, and muscle weakness, spasms or cramps.

Hyponatremia has become a problem in recent years following the push to stay hydrated during all exercise, but until recently has primarily been associated with marathon races and other prolonged endurance events, especially among slow participants. Their main problem is that they don’t sweat that much, but they drink at every opportunity, often to excess over many hours due to fear of getting dehydrated. More recently, though it has been reported as being a problem during half-marathons, sprint triathlons, long hikes, yoga classes, and team sport practices and games, particularly football at all levels.

Drinking sports drinks or other fluids with electrolytes in them instead of straight water can help a little bit, but hyponatremia appears to be more related to your total fluid intake, not whether or not the drinks contain some sodium in them (2). Sports drinks containing added sodium are still more dilute than what’s in your blood, and drinking any fluids in excess during exercise can lower your blood sodium levels.

This condition is almost completely preventable. The key is simply to drink only when you feel thirsty during exercise. It really isn’t necessary to stay ahead of your thirst. The small impact that slight dehydration is going to have on your performance is nothing compared to the medical emergency created by drinking too much. Listening to your “innate thirst mechanism” provides a safe and reliable guide to hydration (1).

Using thirst as your guide should not increase your risk for cramping either since dehydration may only contribute minimally to cramps, which are likely more associated with fatigue than dehydration/electrolyte losses (3). Even becoming severely dehydrated during exercise in the heat is not likely to cause muscle cramps (4).

Surprisingly, becoming dehydrated during exercise will not necessarily increase the risk of developing a heat-related illness like heat stroke either. A body mass loss of up to 3% (mostly fluid losses through sweating) was found to be tolerated by well-trained triathletes during an Ironman competition in warm conditions without any evidence of heat illnesses (5). In fact, athletes who collapse from heat illness often are quite well-hydrated, and it’s more likely that cramping and heat illnesses come from exercising too intensely. Muscles are more prone to spasms when fatigued, and heat illnesses generally occur in people who aren’t used to exercising in the heat and who continue to work out even when feeling unwell.

People with diabetes are also more likely to have electrolyte imbalances (e.g., sodium and potassium) to start with, including hyponatremia associated with extended hyperglycemia (6). As discussed in a recent article (7), an increased risk of electrolyte disturbances with diabetes can result from poorer blood glucose management, diabetes medications (some of which alter electrolyte balance), and organ damage associated with diabetes (such as nephropathy).

When it comes down to it, preventing overhydration during exercise is likely more important that worrying about the effects of dehydration.  Use thirst as your guide when you exercise, and avoid consuming excess fluids, especially during prolonged workouts or sporting events. Also, keep your blood glucose levels in better control overall prior to engaging in any activities to ensure that hyponatremia is not an issue.

References:

  1. Hew-Butler T, Rosner MH, Fowkes-Godek S, et al. Statement of the 3rd International Exercise-Associated Hyponatremia Consensus Development Conference, Carlsbad, California, 2015. Br J Sports Med. 2015 Jul 30. pii: bjsports-2015-095004. doi: 10.1136/bjsports-2015-095004. [Epub ahead of print] (http://www.ncbi.nlm.nih.gov/pubmed/26227507)
  2. Dugas J. Sodium ingestion and hyponatraemia: sports drinks do not prevent a fall in serum sodium concentration during exercise. Br J Sports Med. 2006 Apr; 40(4): 372. doi: 1136/bjsm.2005.022400 PMCID: PMC2577547 (http://www.ncbi.nlm.nih.gov/pubmed/16556798)
  3. Miller KC, Mack GW, Knight KL, et al. Three percent hypohydration does not affect threshold frequency of electrically induced cramps. Med Sci Sports Exerc. 2010 Nov;42(11):2056-63. doi: 10.1249/MSS.0b013e3181dd5e3a. (http://www.ncbi.nlm.nih.gov/pubmed/20351595)
  4. Braulick KW, Miller KC, Albrecht JM, Tucker JM, Deal JE. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2013 Jul;47(11):710-4. doi: 10.1136/bjsports-2012-091501. (http://www.ncbi.nlm.nih.gov/pubmed/23222192)
  5. Laursen PB, Suriano R, Quod MJ, et al. Core temperature and hydration status during an Ironman triathlon. Br J Sports Med. 2006 Apr;40(4):320-5; discussion 325. (http://www.ncbi.nlm.nih.gov/pubmed/16556786)
  6. Palmer BF, Clegg DJ. “Electrolyte and Acid-Base Disturbances in Patients with Diabetes Mellitus.” N Engl J Med. 2015;373(6):548-59. (http://www.ncbi.nlm.nih.gov/pubmed/26244308)
  7. Beware: Diabetes Results in Significant Electrolyte Disturbances, Diabetes In Control, Issue 798, September 11, 2015 (http://www.diabetesincontrol.com/articles/53-diabetes-news/18464-beware-diabetes-results-in-significant-electrolyte-disturbances#unused)