----- Original Message -----
From: "Michael Warburton" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Tuesday, January 23, 2001 12:33 PM
Subject: Re: physiotherapy in diabetics


> 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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