Anish,

Below is a position statement put out by the American Diabetes Association
and the American College of Sports Medicine that focuses on the exercise
aspect of Diabetes Mellitus management.
Hope you find it useful.

Regards,

Michael Warburton
Brisbane

Volume 29, Number 12
December 1997
JOINT POSITION STATEMENT
ADA/ACSM Joint Statement: Diabetes Mellitus and Exercise

INTRODUCTION
During exercise, whole-body oxygen consumption may increase by as much as
20-fold, and even greater increases may occur in the working muscles. To
meet its energy needs under these circumstances, skeletal muscle uses, at a
greatly increased rate, its own stores of glycogen and triglycerides, as
well as free fatty acids derived from the breakdown of adipose tissue
triglycerides and glucose released from the liver. To preserve central
nervous system function, blood glucose levels are remarkably well-maintained
during exercise. Hypoglycemia during exercise rarely occurs in nondiabetic
individuals. The metabolic adjustments that preserve normoglycemia during
exercise are in large part hormonally mediated. A decrease in plasma insulin
and the presence of glucagon appear to be necessary for the early increase
in hepatic glucose production during exercise, and during prolonged exercise
increases in plasma glucagon and catecholamines appear to play a key role.
These hormonal adaptations are essentially lost in insulin-deficient
patients with Type 1 diabetes. As a consequence, when such individuals have
too little insulin in their circulation due to inadequate therapy, an
excessive release of counter-insulin hormones during exercise may increase
already high levels of glucose and ketone bodies and can even precipitate
diabetic ketoacidosis. Conversely, the presence of high levels of insulin,
due to exogenous insulin administration, can attenuate or even prevent the
increased mobilization of glucose and other substrates induced by exercise
and hypoglycemia may ensue. Similar concerns exist in patients with type 2
diabetes on insulin or sulfonylurea therapy; however, in general
hypoglycemia during exercise tends to be less of a problem in this
population. Indeed, in patients with type 2 diabetes, exercise may improve
insulin sensitivity and assist in diminishing elevated blood glucose levels
into the normal range.
The purpose of this position paper is to update and crystallize current
thinking on the role of exercise in patients with types 1 and 2 diabetes.
With the publication of new clinical reviews, it is becoming increasingly
clear that exercise may be a therapeutic tool in a variety of patients with,
or at risk for diabetes, but that like any therapy its effects must be
thoroughly understood. From a practical point of view, this means that the
diabetes health-care team will be required to understand how to analyze the
risks and benefits of exercise in a given patient. Furthermore, the team,
consisting of, but not limited to, the physician, nurse, dietitian, mental
health professional, and the patient, will benefit from working with an
individual with knowledge and training in exercise physiology. Finally, it
has also become clear that it will be the role of this team to educate
primary care physicians and others involved in the care of a given patient.
EVALUATION OF THE PATIENT BEFORE EXERCISE
Before beginning an exercise program, the individual with diabetes mellitus
should undergo a detailed medical evaluation with appropriate diagnostic
studies. This examination should carefully screen for the presence of macro-
and microvascular complications which may be worsened by the exercise
program. Identification of areas of concern will allow the design of an
individualized exercise prescription which can minimize risk to the patient.
Most of the following recommendations are excerpted from the Health
Professional's Guide to Diabetes and Exercise (3).
A careful medical history and physical examination should focus on the
symptoms and signs of disease affecting the heart and blood vessels, eyes,
kidneys and nervous system.
Cardiovascular System
A graded exercise test may be helpful if a patient, about to embark on a
moderate- to high-intensity exercise program (see Table 1) (4-6), is at high
risk for underlying cardiovascular disease, based on one of the following
criteria:
? age > 35 years
? type 2 diabetes of >10 years duration
? type 1 diabetes of >15 years duration
? presence of any additional risk factor for coronary artery disease
? presence of microvascular disease (retinopathy or nephropathy, including
microalbuminuria)
? peripheral vascular disease
? autonomic neuropathy
In some patients who exhibit nonspecific electrocardiogram (ECG) changes in
response to exercise, or who have nonspecific ST and T wave changes on the
resting ECG, alternative tests such as radionuclide stress testing may be
performed. In patients with diabetes planning to participate in
low-intensity forms of exercise (<60% of maximal heart rate) such as
walking, the physician should use clinical judgment in deciding whether to
recommend an exercise stress test. Patients with known coronary artery
disease should undergo a supervised evaluation of the ischemic response to
exercise, ischemic threshold, and the propensity to arrhythmia during
exercise. In many cases, left ventricular systolic function at rest and
during its response to exercise should be assessed.
Peripheral Arterial Disease (PAD)
Evaluation of PAD is based on signs and symptoms, including intermittent
claudication, cold feet, decreased or absent pulses, atrophy of subcutaneous
tissues and hair loss. The basic treatment for intermittent claudication is
nonsmoking and a supervised exercise program. The presence of a dorsalis
pedis and posterior tibial pulse does not rule out ischemic changes in the
forefoot. If there is any question about blood flow to the forefoot and toes
on physical examination, toe pressures as well as Doppler pressures at the
ankle should be carried out.

Retinopathy
The eye examination schedule should follow the American Diabetes Association
's Clinical Practice Guidelines. For patients who have proliferative
diabetic retinopathy (PDR) that is active, strenuous activity may
precipitate vitreous hemorrhage or traction retinal detachment. These
individuals should avoid anaerobic exercise and exercise that involves
straining, jarring or Valsalva-like maneuvers.
On the basis of the Joslin Clinic experience, the degree of diabetic
retinopathy has been used to stratify the risk of exercise, and to
individually tailor the exercise prescription. Table 2 is reproduced, with
minor modifications, from The Health Professional's Guide to Diabetes and
Exercise (3).
Nephropathy
Specific exercise recommendations have not been developed for patients with
incipient (microalbuminuria >20 mg/min albumin excretion) or overt
nephropathy (>200 mg/min). Patients with overt nephropathy often have a
reduced capacity for exercise which leads to self-limitation in activity
level. Although there is no clear reason to limit low-to-moderate intensity
forms of activity, high-intensity or strenuous exercises should probably be
discouraged in these individuals.
Neuropathy: Peripheral (PN)
Peripheral neuropathy may result in loss of protective sensation in the
feet. Significant PN is an indication to limit weight-bearing exercise.
Repetitive exercise on insensitive feet can ultimately lead to ulceration
and fractures. Evaluation of PN can be made by checking the deep tendon
reflexes, vibratory sense and position sense. Touch sensation can best be
evaluated by using monofilaments. The inability to detect sensation using
the 5.07 (10 g) monofilament is indicative of the loss of protective
sensation. Table 3 lists contraindicated and recommended exercises for
patients with loss of protective sensation in the feet.

Neuropathy: Autonomic
The presence of autonomic neuropathy may limit an individual's exercise
capacity and increase the risk of an adverse cardiovascular event during
exercise. Cardiac autonomic neuropathy (CAN) may be indicated by resting
tachycardia (>100 beats per minute), orthostasis (a fall in systolic blood
pressure > 20 mm Hg upon standing), or other disturbances in autonomic
nervous system function involving the skin, pupils, gastrointestinal or
genitourinary systems. Sudden death and silent myocardial ischemia have been
attributed to CAN in diabetes. Resting or stress thallium myocardial
scintigraphy is an appropriate noninvasive test for the presence and extent
of macrovascular coronary artery disease in these individuals. Hypotension
and hypertension after vigorous exercise are more likely to develop in
patients with autonomic neuropathy, particularly when starting an exercise
program. Because these individuals may have difficulty with
thermoregulation, they should be advised to avoid exercise in hot or cold
environments and to be vigilant about adequate hydration.
PREPARING FOR EXERCISE
Preparing the individual with diabetes for a safe and enjoyable exercise
program is as important as exercise itself. The young individual in good
metabolic control can safely participate in most activities. The middle-aged
and older individual with diabetes should be encouraged to be physically
active. The aging process leads to a degeneration of muscles, ligaments,
bones, and joints, and disuse and diabetes may exacerbate the problem.
Before beginning any exercise program, the individual with diabetes should
be screened thoroughly for any underlying complications as described above.
A standard recommendation for diabetic patients, as for nondiabetic
individuals, is that exercise includes a proper warm-up and cool-down
period. A warm-up should consist of 5-10 minutes of aerobic activity
(walking, cycling, etc.) at low intensity level. The warm-up session is to
prepare the skeletal muscles, heart and lungs for a progressive increase in
exercise intensity. After a short warm-up muscles should be gently stretched
for another 5-10 minutes. Primarily the muscles used during the active
exercise session should be stretched, but warming up all muscle groups is
optimal. The active warm-up can either take place before or after
stretching. Following the activity session, a cool-down should be structured
similarly to the warm-up. The cool-down should last about 5-10 minutes and
gradually bring the heart rate down to its preexercise level.

There are several considerations that are particularly important and
specific for the individual with diabetes. Aerobic exercise should be
recommended but taking precautionary measures for exercise involving the
feet is essential for many patients with diabetes. The use of silica gel or
air mid-soles as well as polyester or blend (cotton-polyester) socks to
prevent blisters and keep the feet dry is important for minimizing trauma to
the feet. Proper footwear is essential and must be emphasized for
individuals with peripheral neuropathy. Individuals must be taught to
monitor closely for blisters and other potential damage to their feet, both
before and after exercise. A diabetes identification bracelet or shoe tag
should be clearly visible when exercising. Proper hydration is also
essential as dehydration can effect blood glucose levels and heart function
adversely. Exercise in heat requires special attention to maintaining
hydration. Adequate hydration prior to exercise is recommended (eg 17 ounces
of fluid consumed two hours before exercise). During exercise fluid should
be taken early and frequently in an amount sufficient to compensate for
losses in sweat reflected in body weight loss, or the maximal amount of
fluid tolerated. Precautions should be taken when exercising in extremely
hot or cold environments. High resistance exercise using weights may be
acceptable for young individuals with diabetes, but not for older
individuals or those with long standing diabetes. Moderate weight training
programs that utilize light weights and high repetitions can be used for
maintaining or enhancing upper body strength in nearly all patients with
diabetes.
EXERCISE AND TYPE 2 DIABETES
The possible benefits of exercise for the patient with type 2 diabetes are
substantial and recent studies strengthen the importance of long term
exercise programs for the treatment and prevention of this common metabolic
abnormality and its complications. Specific metabolic effects can be
highlighted as follows.
Glycemic Control
Several long term studies have demonstrated a consistent beneficial effect
of regular exercise training on carbohydrate metabolism and insulin
sensitivity which can be maintained for at least five years. These studies
used exercise regimens at an intensity of 50-80% VO2 max three to four times
a week for 30-60 minutes a session. Improvements in HbA1c were generally
10-20% of baseline and were most marked in patients with mild type 2
diabetes and those who are likely to be the most insulin resistant. It
remains true, unfortunately, that most of these studies suffer from
inadequate randomization and controls, and are confounded by associated
lifestyle changes. Data on the effects of resistance exercise are not
available for type 2 diabetes although early results in normals and patients
with type 1 disease suggest a beneficial effect.
It now appears that long term programs of regular exercise are indeed
feasible for patients with impaired glucose tolerance or uncomplicated type
2 diabetes with acceptable adherence rates. Those studies with the best
adherence have used an initial period of supervision followed by relatively
informal home exercise programs with regular frequent follow up assessments.
A number of such programs have demonstrated sustained relative improvements
in VO2 max over many years with little in the way of significant
complications.
Prevention of Cardiovascular Disease
In patients with type 2 diabetes, the Insulin Resistance Syndrome continues
to gain support as an important risk factor for premature coronary disease,
particularly with concomitant hypertension, hyperinsulinemia, central
obesity, and the overlap of metabolic abnormalities of hypertriglyceridemia,
low HDL, altered LDL, and elevated FFA. Most studies show that these
patients have a low level of fitness compared to controls even when matched
for levels of ambient activity and that the poor aerobic fitness is
associated with many of the cardiovascular risk factors. Improvement in many
of these risk factors has been linked to a decrease in plasma insulin levels
and it is likely that many of the beneficial effects of exercise on
cardiovascular risk are related to improvements in insulin sensitivity.
Hyperlipidemia
Regular exercise has consistently been shown to be effective in reducing
levels of triglyceride-rich very low density lipoprotein (VLDL). However,
effects of regular exercise on levels of LDL cholesterol have not been
consistently documented. With one major exception most studies have failed
to demonstrate a significant improvement in levels of HDL in patients with
type 2 diabetes, perhaps because of the relatively modest exercise
intensities used.
Hypertension
There is evidence linking insulin resistance to hypertension in patients.
Effects of exercise on reducing blood pressure levels have been demonstrated
most consistently in hyperinsulinemic subjects.
Fibrinolysis
Many patients with type 2 diabetes have impaired fibrinolytic activity
associated with elevated levels of Plasminogen Activator Inhibitor-I
(PAI-1), the major naturally occurring inhibitor of Tissue Plasminogen
Activator (TPA). Studies have demonstrated an association of aerobic fitness
and fibrinolysis. There is still no clear consensus on whether physical
training results in improved fibrinolytic activity in these patients.
Obesity
Data have accumulated suggesting that exercise may enhance weight loss and
in particular weight maintenance when used along with an appropriate
calorie-controlled meal plan. There are few studies specifically dealing
with this issue in type 2 diabetes and much of the available data is
complicated by the simultaneous use of unusual diets and other behavioral
interventions. Of particular interest are studies suggesting a
disproportionate effect of exercise on loss of intra-abdominal fat, the
presence of which has been associated most closely with metabolic
abnormalities. Data on the use of resistance exercise in weight reduction
are promising, but studies in patients with type 2 diabetes in particular
are lacking.
Prevention of Type 2 Diabetes
A great deal of evidence has been accumulated supporting the hypothesis that
exercise, among other therapies, may be useful in preventing or delaying the
onset of type 2 diabetes. Currently a large randomized prospective NIH study
is under way to clarify the feasibility of this approach.
EXERCISE AND TYPE 1 DIABETES
All levels of exercise, including leisure activities, recreational sports
and competitive professional performance, can be performed by people with
type 1 diabetes who do not have complications and are in good blood glucose
control (note previous section). The ability to adjust the therapeutic
regimen (insulin and diet) to allow safe participation and high performance
has recently been recognized as an important management strategy in these
individuals. In particular, the important role played by the patient in
collecting self-monitored blood glucose data of the response to exercise and
then using this information to improve performance and enhance safety is now
fully accepted.
Hypoglycemia which can occur during, immediately after, or many hours after
exercise can be avoided. This requires that the patient have both an
adequate knowledge of the metabolic and hormonal responses to exercise and
well-tuned self-management skills. The increasing use of intensive insulin
therapy has provided patients with the flexibility to make appropriate
insulin dose adjustments for various activities. The rigid recommendation to
use carbohydrate supplementation, calculated from the planned intensity and
duration of exercise, without regard to glycemic level at the start of
exercise, the previously measured metabolic response to exercise, and the
patient's insulin therapy, is no longer appropriate. Such an approach not
infrequently neutralizes the beneficial glycemic lowering effects of
exercise in patients with type 1 diabetes.
General guidelines that may prove helpful in regulating the glycemic
response to exercise can be summarized as follows:
1. Metabolic control before exercise
? Avoid exercise if fasting glucose levels are >250 mg/dl and ketosis is
present or if glucose levels are >300 mg/dl, irrespective of whether ketosis
is present
? Ingest added carbohydrate if glucose levels are <100 mg/dl.
2. Blood glucose monitoring before and after exercise
? Identify when changes in insulin or food intake are necessary
? Learn the glycemic response to different exercise conditions.
3. Food intake
? Consume added carbohydrate as needed to avoid hypoglycemia
? Carbohydrate-based foods should be readily available during and after
exercise.
Since diabetes is associated with an increased risk of macrovascular
disease, the benefit of exercise in improving known risk factors for
atherosclerosis is to be highly valued. This is particularly true in that
exercise can improve the lipoprotein profile, reduce blood pressure and
improve cardiovascular fitness. However, it must also be appreciated that
several studies have failed to show an independent effect of exercise
training on improving glycemic control as measured by HbA1c in patients with
type 1 diabetes. Indeed, these studies have been valuable in changing the
focus for exercise in diabetes from glucose control to that of an important
life behavior with multiple benefits. The challenge is to develop strategies
which allow individuals with type 1 diabetes to participate in activities
that are consistent with their lifestyle and culture in a safe and enjoyable
manner.
In general, the principles recommended for dealing with exercise in adults
with type 1 diabetes, free of complications, apply to children, with the
caveat that children may be prone to greater variability in blood glucose
levels. In children, particular attention needs to be paid to balancing
glycemic control with the normalcy of play, and for this the assistance of
parents, teachers, and athletic coaches may be necessary. In the case of
adolescents, hormonal changes can contribute to the difficulty in
controlling blood glucose levels. Despite these added problems, it is clear
that with careful instructions in self management and the treatment of
hypoglycemia, exercise can be a safe and rewarding experience for the great
majority of children and adolescents with insulin dependent diabetes
mellitus.
EXERCISE IN THE ELDERLY
Evidence has accumulated suggesting the progressive decrease in fitness and
muscle mass and strength with aging is in part preventable by maintaining
regular exercise. The decrease in insulin sensitivity with aging is also
partly due to a lack of physical activity. Lower levels of physical activity
are especially likely in the population at risk for type 2 diabetes. A
number of recent studies of exercise training have included significant
numbers of older patients. These patients have done well with good training
and metabolic responses, levels of adherence at least as good as the general
population, and an acceptable incidence of complications. It is likely that
maintaining better levels of fitness in this population will lead to less
chronic vascular disease and an improved quality of life.
CONCLUSIONS
The recent Surgeon General's Report on Physical Activity and Health
underscores the pivotal role physical activity plays in health promotion and
disease prevention. It recommends that individuals accumulate 30 minutes of
moderate physical activity on most days of the week. In the context of
diabetes, it is becoming increasingly clear that the epidemic of type 2
diabetes sweeping the globe is associated with decreasing levels of activity
and an increasing prevalence of obesity. Thus, the importance of promoting
exercise as a vital component of the prevention, as well as management of
type 2 diabetes must be viewed as a high priority. It must also be
recognized that the benefit of exercise in improving the metabolic
abnormalities of type 2 diabetes is probably greatest when it is used early
in its progression from insulin resistance to impaired glucose tolerance to
overt hyperglycemia requiring treatment with oral agents and finally to
insulin.
For people with type 1 diabetes, the emphasis must be on adjusting the
therapeutic regimen to allow safe participation in all forms of physical
activity consistent with an individual's desires and goals. Ultimately, all
patients with diabetes should have the opportunity to benefit from the many
valuable effects of exercise.
REFERENCES
1. Schneider, SH and RUDERMAN, NB. Exercise and NIDDM. Technical review.
Diabetes Care 13:785-789, 1990.
2. Wasserman, DH and ZINMAN, B. Exercise in individuals with IDDM. Technical
review. Diabetes Care 17:924-937, 1994.
3. Devlin, JT and RUDERMAN, N. Diabetes and exercise: In The Health
Professional's Guide to Diabetes and Exercise, ed. by N. Ruderman and JT
Devlin. Alexandria, VA, Am. Diabetes Association, 1995, pp. 3-4.
4. Physical Activity and Health: A Report of the Surgeon General. US
Department of Health and Human Service Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health
Promotion. 1996.
5. Physical Activity and Public Health. A Recommendation from the Centers
for Disease Control and Prevention and the American College of Sports
Medicine. JAMA 273:402-407, 1995.
6. American College of Sports Medicine (Position Statement). The Recommended
Quantity and Quality of Exercise for Developing and Maintaining
Cardiorespiratory and Muscular Fitness in Healthy Adults. Medicine and
Science in Sports and Exercise 22:265-274, 1990
Originally approved February 1990. Revised 1997. The initial draft of this
revision was prepared by Bernard Zinman, MD (Co-chair); Neil Ruderman, MD,
Phil (Co-chair); Barbara N. Campaigne, PhD; John T. Devlin, MD; and Stephen
H. Schneider, MD. The paper was peer-reviewed, modified, and approved by the
Professional Practice Committee and the Executive Committee, June 1997, as
well as by the ACSM Pronouncements Committee and Board of Trustees, July
1997. For technical reviews on this subject see Diabetes Care 13:785-789,
1990 and Diabetes Care 17:924-937, 1994. Guidelines of the American Diabetes
Association and the American College of Sports Medicine. This Position
Statement is being published simultaneously in the journal of Diabetes Care.

----- Original Message -----
From: "Anish m Thomas" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, January 23, 2001 7:13 PM
Subject: physiotherapy in diabetics


> hi list members
>     can any body give informations on physiotherapy
>    in diabetics
>         anish
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