REVIEWS
Rehabilitation in Diabetic Patients D. ZDRENGHEA, DANA POP, OANA PENCIU, V. ZDRENGHEA, M. ZDRENGHEA “Iuliu Haţieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania
Physical activity is very important for diabetic patients. In normal subjects physical activity postpones diabetes mellitus and in diabetic patients postpones the cardiovascular complications. In diabetic patients with cardiovascular disease, physical training increases exercise capacity, decreases complications and prolongs survival. Physical activity can be applied in diabetic patients as physical activity counseling or physical training, the second being recommended to be ambulatory and supervised but, sometimes, also home rehabilitation can be useful. Aerobic exercises, but also resistance exercises will be applied for a 30–60 min duration at least 3×/ week, recommended 5×/week, and optimal every day. Some specific aspects of diabetic patients as hyper or hypoglycemia, autonomic or peripheral neuropathy, retinopathy, have to be considered during physical rehabilitation and sometimes physical training has to be modulated according to them. In conclusion, physical activity and training represent a real chance for every diabetic patient and has to be recommended and applied in all of them. Key words: physical activity, diabetes mellitus.
Rehabilitation in diabetic patients has certain particularities derived first from the high individual cardiometabolic risk, and second, from the particularities of the diabetes mellitus as example hypoglycemia during physical exercise [1]. Rehabilitation in diabetic patients has two aspects: prevention and physical rehabilitation. Regarding the treatment of cardiovascular risk factors, this will generally have the same pathways like for the patients without diabetes mellitus, but the changing of lifestyle has to be more radical, and the drug therapy more aggressive than in nondiabetic subjects [2]. We discuss here mainly the aspects of physical rehabilitation in diabetic patients with associated cardiovascular diseases, according to current cardiovascular rehabilitation guidelines. When recommending and/or prescribing the prevention and rehabilitation procedures, we have to consider, as mentioned before, that the cardiovascular risk in diabetic patients without associated cardiovascular disease is similar to that of non-diabetic patients that already have a history of an acute coronary event [3]. Also, even if drug therapy used for the treatment of risk factors, for example statins, results in a similar or even better reduction of the associated risk in diabetic patients, in comparison with non-diabetic patients, the risk ROM. J. INTERN. MED., 2009, 47, 4, 309–317
still remains high for the first category. This implies the use of a more aggressive drug treatment, and also the inclusion in a greater percent, and in a more intense manner of diabetic patients in cardiovascular physical rehabilitation programmes. It is necessary to use all the resources, including physical activity, in order to reduce the high cardiometabolic risk in this category of patients [4]. Using physical rehabilitation in diabetic patients with or without cardiovascular disease raises two questions. First- is physical activity useful to these patients, and why?! The second question is how to apply physical activity during daily practice in diabetic patients? The answer for the first question is easy, for three reasons. First, physical activity prevents or postpones the onset of diabetes mellitus. Second, in patients that already have diabetes mellitus, physical activity prevents or postpones the onset of clinically manifest cardiovascular disease [5]. At last, but not least, physical activity increases the exercise capacity and improves the outcome in diabetic patients with overt cardiovascular disease [6]. Literature data offer arguments for the three beneficial effects of physical activity in diabetic patients. There are studies that demonstrate that diet, along with physical activity, or even physical
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activity alone, prevent the onset of diabetes mellitus, the risk reduction being as high as 25–50% [7]. A recent study regarding the risk of onset of diabetes mellitus, according to the level of physical activity proved that an intense occupational physical activity, reduces the risk of onset of diabetes mellitus to 0.74, that walking to or from work for more than 30 minutes a day reduces the risk with one third (RR 0.64), and leisure time activities can reduce the risk of onset of diabetes mellitus with 16% (RR 0.84%) [8]. When considering the risk of diabetes mellitus in patients with normal glucose tolerance and performing intense physical activity, the same study demonstrated that a low intensity physical activity together with decreased glucose tolerance increases the risk of diabetes mellitus by 13.6 fold. On the other hand, decreased glucose tolerance in physically active subjects increases the risk of diabetes mellitus by only 5.9 fold. Second, there are a lot of data confirming that physical activity in diabetic patients can prevent the onset of clinically manifest cardiovascular diseases. Studies demonstrate that the reduction of cardiovascular events is in direct correlation with the level of physical activity. Cardiovascular diseases, especially ischemic heart disease and cardiovascular mortality, can be decreased as much as 33–50% [9].
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A classic large trial demonstrated that in diabetic patients, the survival rates, no matter the mortality cause, are strictly dependent on the cardio-respiratory fitness, the lowest mortality rate being encountered in patients with an increased level of fitness [10]. More than that, a quantification regarding the average time of physical activity during a week has been made. Considering a duration of physical activity less than one hour per week as level of risk one, a total physical activity time more than seven hours per week reduced the risk of fatal cardiovascular events to 0.55, the risk of clinically manifest ischemic heart disease to 0.49, and the risk of stroke to 0.75 [11]. In the same way, the number hour-METs/week performed by the diabetic men influenced the cardiovascular diseases. In diabetic men with more than 37.2 hour-METs/week the total cardiovascular disease risk was reduced to 0.61–0.72, the risk of coronary artery disease to 0.79–0.82, and the risk of fatal cardiovascular disease to 0.45–0.62. The question that arises is, of course, which is the mechanism of improving the cardiovascular evolution in all patients, and especially the diabetic ones, with physical activity. There are few mechanisms involved, exposed in Fig. 1.
Increase of insulin sensitivity
Fig. 1. – The effect of physical training in diabetic patients.
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In diabetic patients, with or without heart failure, it has been proven that physical activity induces a decrease in insulin resistance, independent of the presence or absence of hypertension or dyslipidemia, every time the physical activity generates a significant increase in exercise capacity [12–13]. In the past years, it is well known that leptin and adiponectin have been involved in the cardiovascular risk in patiens with metabolic syndrome and diabetes mellitus, considered by some authors the most obvious form of metabolic syndrome [14]. A recent study demonstrated that a four week duration physical exercise increases adiponectin levels (protective cardiovascular role), and also increases the insulin sensitivity in 140 subjects having impaired or normal glucose tolerance, or type II diabetes mellitus [15]. No matter the methods used to demonstrate the insulin resistance or sensitivity (there were 18 methods described), the insulin resistance is decreased in diabetic patients with or without metabolic syndrome, that performed physical activity, even if low intensity in comparison with controls. At the same time, it has been noticed the decrease of lipid oxidation and improvement in body fat distribution [16][17]. Microcirculation is considered now more and more important in ensuring the normal blood perfusion in vital organs, including the heart. Microcirculation represents one of the most important “impact points” in diabetes mellitus. Considering all that, the finding that physical exercise significantly reduces the microvascular rarefaction in metabolic syndrome, is a very optimistic one [18]. In experimental studies on diabetic, hypertensive rats, the reduction in microvascular density is in direct correlation with the chronic decrease in nitric oxide concentration. In this category of animals, the physical training for 10 weeks, one hour/day, increased the nitric oxide concentration, and reduced the microvascular rarefaction [19]. Finally, it is important that in diabetic patients with associated cardiovascular diseases, the physical training and exercise not only increase the exercise capacity, but also improve the outcome. A 2005 study on 1505 diabetic and non-diabetic patients demonstrated that during a seven weeks cardiovascular rehabilitation training programme, the percent increase in exercise capacity evaluated in METs was very close in diabetics (26.3%) and non-
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diabetics (25.5%), the results being confirmed by another 2004 study when through rehabilitation the exercise capacity of patients with diabetes increased from 5.7 METs to 7.2 METs, and in nondiabetic patients from 7 to 8.9 METs [20, 21]. More, it has been demonstrated that an intense, comprehensive rehabilitation programme improves the control of cardiovascular risk factors in patients with type II diabetes mellitus, or altered glucose tolerance. There were considered patients with ischemic heart disease, heart failure or at least three risk factors with usual care, or included in a cardiovascular rehabilitation programme [22]. The results showed that patients with impaired glucose tolerance or type II diabetes mellitus addressed to cardiovascular rehabilitation, reached an effort capacity significantly higher in comparison to the patients with standard therapy, without physical rehabilitation. At the same time, in patients included in rehabilitation programmes the value of glycosylated hemoglobin was lower, and the percent of patients reaching the optimal blood pressure value (SBP=130mmHg, respectively DBP=80mmHg), or a value of LDL-C below 2.5mmol/dL was significantly higher. The percent of patients treated with aspirin, ACEI (ARBs) or statins was also increased, proving that physical rehabilitation programmes are beneficial, also, by increasing the adherence to secondary prevention measures [22]. All these studies demonstrate that physical training and cardiovascular rehabilitation represent a real chance of improving the outcome of diabetic patients. Next, we will consider the concrete mode of applying rehabilitation in cardiovascular patients. I. PRACTICAL ASPECTS OF PHYSICAL ACTIVITY AND TRAINING IN DIABETIC PATIENTS
There are a series of guidelines and consensus regarding the role of physical activity in diabetic patients. The comments referring to diabetes mellitus are parts of special recommendations, or are included in more general guidelines about physical activity in cardiovascular patients [23–25]. As example, the American Heart Association recommendations about the primary prevention of cardiovascular diseases in diabetic patients reinforce that the glycemic control, losing weight or maintaining a normal weight, with a consequent decrease in the cardiovascular risk can be a result
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of aerobic, moderate or intense physical activity, if it is performed for at least 150 minutes each week [24]. The physical activity must be distributed equally for at least three days/week, so there would not be more than two consecutive days without exercise. It is emphasized that for maintaining the weight loss for a long time, it is absolutely necessary to perform moderate or intense physical activity for at least 7 hours/ week [24][25]. Also, the diabetes and pre-diabetes guidelines of European Society of Cardiology, in 2007, recommend for diabetic patients (Class I, level of evidence A) lifestyle changing (non-pharmacological therapy), which alleviates the metabolic control [23]. There is a specific recommendation of 30 minutes physical activity, at least five times a week, along with the restriction of calories intake to 1500 kcal/day, and also of fat intake [23]. Regarding the modalities to apply the physical activity in diabetic patients, there are two major categories. The first one is represented by the physical activity counseling that is to advise the patients to perform physical activity, or promoting physical activity in diabetic patients, as daily or leisure time activity, including noncompetitive sports [26][27]. The second modality, and the most important one, from the point of view of this paper, is represented by the physical training conducted through specific cardiovascular rehabilitation programmes. The purpose of physical activity counseling is that of preventing the onset of diabetes mellitus, and in diabetic patients of preventing the onset of cardiovascular diseases [28–30]. Physical training is recommended in diabetes mellitus patients complicated, or associated especially with cardiovascular diseases being recommended that the patients perform supervised physical training, or at home rehabilitation, whenever the first choice is not possible [31][32]. Of course, more than in other patients, a complete evaluation before inclusion in exercise training programmes is necessary. This evaluation is made by exercise stress testing. This is not necessary in patients with uncomplicated diabetes, except over the age of 35, in those having at least one more additional risk factor for ischemic heart disease. In turn, exercise stress testing is recommended, even mandatory in patients with complicated diabetes mellitus or associated cardiovascular disease [1][33]. The training modalities are represented first by aerobic exercise. This is the best way of improving the peripheral uptake of the oxygen, preserving and even improving the cardiac hemodynamic, being
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indicated in all patients. The increase in maximal exercise capacity, around 25–30% is obtained through aerobic physical training [8][34]. The classical cardiovascular training protocol also contains resistance exercises. These are necessary because, during daily activity, the cardiovascular patients, including the diabetic ones, also perform resistance effort, with a significant isometric component, its efficacy and detrimental effects on cardiovascular system, being significantly improved, during the training. Resistance exercise is also important because it decreases insulin resistance, increases the muscular mass which is often reduced in this category of patients, especially in diabetic ones. It is well known that muscular atrophy contributes to the decrease in effort capacity [35]. Resistance exercises are also recommended for preventing the onset of diabetes mellitus (improving the insulin sensitivity), or in uncomplicated diabetes for delaying or preventing the onset of cardiovascular diseases [36]. In patients with complicated diabetes mellitus or associated cardiovascular diseases, diabetic neuropathy makes this type of exercises difficult to perform. In these cases, resistance exercises are relatively contraindicated [34]. Comparing the effects of endurance exercises with those of resistance exercise, the latter one has certain minor advantages regarding the increase in muscle force and non-fatty body mass [37]. At the same time, resistance training has certain disadvantages. It does not have the same beneficial effect as aerobic exercise on cardiovascular hemodynamics, because it does not decrease the rest heart rate, systolic or diastolic blood pressure does not increase the systolic or maximal stroke volume, etc. [38]. Both types of exercises significantly improve the quality of life in diabetic patients, and must be applied, especially the first one, in diabetic patients with associated cardiovascular disease [33]. At last, we must consider the flexibility or stretching exercises, usually used during fitness programs by healthy subjects. These do not have metabolic effects, being used as placebo exercises in comparison with aerobic or resistance exercises. They should not be neglected, and are recommended to be routinely included in physical rehabilitation training programmes, including in diabetic cardiovascular patients, because they increase, at least theoretically, the quality of life, but of course, their use remains optional [31].
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Table I Comparison of Effects of Aerobic Endurance Training with Strength Training on Health and Fitness Variables Variable
Aerobic Exercise
Resistance Exercise
Bone mineral density Body composition % Fat Lean Body Mass Strength Glucose metabolism Insulin response to glucose challenge Basal insulin levels Insulin sensitivity Serum lipids HDL LDL Resting heart rate Stroke volume, resting and maximal Blood pressure at rest Systolic Diastolic VO2max Submaximal and maximal endurance time Basal metabolism indicates values increase; , values decrease; , values remain unchanged; or , small effect; or , medium effect; or , large effect; LBM, lean body mass; HDL, high-density lipoprotein cholesterol; and LDL, low-density lipoprotein cholesterol [adapted from 37]
II. PRACTICAL ASPECTS OF PHYSICAL EXERCISE DURING TRAINING SESSIONS
Aerobic exercise optimal must be performed seven times a week, recommended five times a week, but the minimum number of necessary training sessions is three per week, for obtaining an increase in effort capacity, and all the pleiotropic effects of physical training [34]. We already discussed that there should not be more than two consecutive days without physical activity. Why? First, because a significant percent of the training effect is lost, and second the decrease in insulin resistance lasts no more than 72 hours [33]. The resistance exercises should be performed two-three times a week, even if the patients attend five to seven training sessions a week [36]. During aerobic exercise, there are two classical possibilities, when considering the intensity: moderate effort – 50–60% VO2max or 60–70% of maximal HR reached during pre-training stress test, or high intensity effort – 60–75% VO2max or 70–85% of
maximal HR. There will be performed 8–10 types of resistance exercises, 10–15 times/set, repeated in 1–3 sets [23][34]. The duration of exercise is the same as in nondiabetic patients, 30–60 minutes/ session [34]. The onset of certain complications related to diabetes that impair the patients’ ability to move, can prolong the duration of training sessions up to the maximal limit, that can sometimes be surpassed [36]. The physical training is also similar to that registered in non-diabetic patients, but it can be prolonged in diabetic patients with associated cardiac complications, in which the second phase can last for 8–12 weeks [31][36]. Also, in heart failure patients the second phase in rehabilitation is much prolonged, lasting 3–6 months, not only in non diabetic patients, but especially in diabetic ones [21]. Finally, in diabetic cardiovascular patients, there are a few specific aspects, that we have to remind here. First one is about weight loss and/or maintaining it. These are absolutely necessary and recommended in all diabetic patients, most of them having also a metabolic syndrome [36][39][40].
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From this point of view, physical training is important in maintaining a normal weight, but it is not very efficient if used alone without diet. For obtaining the best results in losing weight it is necessary to perform an intense physical activity for at least one hour/day, for a consumption of 700 kcal/day [21][40]. For maintaining the weight loss, seven hours of moderate or intense physical activity is recommended, this representing more, almost double, the time recommended in normal weight diabetic patients with or without associated cardiovascular diseases [18]. The second important aspect concerns hyperglycemia. It has been classically considered physical activity must be stopped when glycemia values are over 300 mg%, or 250mg%, but also associated with acidosis [20]. Nowadays, specialists consider that hyperglycemia is not a contraindication for physical activity, if the patient feels good and is well hydrated. Of course, even in this situation, the physical activity should be postponed if glycemia is over 400mg% [34]. On the other hand, it is recommended that in case of “hypoglycemia” below 100mg%, patients have some glucose before training [34]. We have to mention here that it is absolutely necessary to determine glycemia using a glucometer before each training session [36]. Now it is considered that glucose ingestion when glycemia is below 100mg% is recommended only in patients treated with insulin or insulin-secretagogues. In turn, for the other patients, physical activity can be carefully performed whenever glycemic values before the training are over 50mg% [34]. Retinopathy is another specific and severe complication of diabetes mellitus. It has been demonstrated that physical exercise and training generally have no adverse effects on nonproliferative retinopathy progression, although in medical practice, practitioners are a bit reserved. In turn, proliferative but also severe nonproliferative retinopathy represents a contraindication for intense aerobic physical exercise and for resistance training. In these patients the moderate aerobic exercise is recommended, if necessary of longer duration for compensating the lack of intensity. The patients that underwent laser photocoagulation have to postpone the physical training for 3–6 months [34]. Peripheral neuropathy can also significantly interfere with physical training because it increases the injury and accident risk, during training. Until now, there is not any study to certify these possible
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negative effects of physical training. This is the reason why peripheral neuropathy does not represent a contraindication for physical exercise, but caution is recommended and the type of training must be adapted according to the patient’s disability. In case a patient suffers with “diabetic foot”, arm exercises are recommended, or exercises that don’t cause injuries to the leg, such as swimming, etc. [34][36]. Autonomic neuropathy is also important because of its significant cardiac and peripheral effects. It increases the rest heart rate, reducing the heart rate reserve, and consequently the cardiac output reserve [34]. More than that, it reduces the maximal heart rate during effort, limiting the exercise capacity. The postural hypotension can cause dizziness and premature stop in exercise training, also bringing an additional risk of injury. Finally, the thermic adjustment can also be modified, and this is an aspect that must be considered during exercise. Beta-blockers have beneficial effects on autonomic neuropathy, being recommended once more especially since most of the diabetic patients also have associated ischemic heart disease. It is recommended physical training to be moderate in intensity, the vigorous one being not well tolerated in this category of patients. The training “with intervals” is preferred, giving the patients the possibility of “recovery”, between two exercise periods. These changes in the training technique, the reduced possibility of increasing the cardiac output and myocardial oxygen consumption, lead to prolonging of the second phase of rehabilitation in cardiovascular diabetic patients with autonomic neuropathy [21][41]. Finally, we have to consider the effect that microalbuminuria and nephropathy have on physical training [34]. The physical activity increases proteinuria, in direct correlation with the acute increase in blood pressure. Contrary to all that, experimental studies showed that physical activity has a beneficial effect by decreasing proteinuria in diabetic animals. This is the reason why, at this moment, proteinuria, and nephropathy do not represent a contraindication for physical activity. It is recommended though that the systolic blood pressure remains below 200 mmHg, for the whole duration of the exercise [36]. These were only a few aspects about the way diabetes mellitus modifies or modulates the physical training. We have to keep in mind that physical activity has a more beneficial role in
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diabetic patients, in comparison with nondiabetic patients with cardiovascular diseases. Physical training can prevent the onset of diabetes mellitus or can delay the onset of cardiovascular associated diseases [1][4][8]. There are a few “take away messages” about rehabilitation in diabetic patients that deserve to be mentioned: • Physical activity is essential in diabetic patients for preventing the onset of cardio-
• •
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vascular diseases, or improving their evolution. Physical activity will be promoted as physical counselling or physical training. Performing physical activity is similar to non-diabetic patients, but there are a few particularities. that must be considered, before starting, or during the training, in this category of patients.
Activitatea fizică este foarte importantă în cazul pacienţilor cu diabet zaharat. La subiecţii sănătoşi activitatea fizică previne (sau întârzie) apariţia diabetului zaharat. La bolnavii cu diabet deja constituit, cu boală cardiovasculară asociată, activitatea fizică creşte capacitatea de efort, reduce rata complicaţiilor şi ameliorează evoluţia bolii. Referitor la modalităţile de aplicare a activităţii fizice aceasta poate fi aplicată la pacienţii diabetici ca promovare a activităţii fizice (sfat medical) sau ca antrenament fizic. Antrenamentul fizic se poate face ambulator, sub supraveghere de specialitate, dar şi la domiciliu. Efortul aerob, dar şi exerciţiile de rezistenţă se prestează în mod ideal de şapte ori pe săptămână, de regulă, şi recomandat, de cinci ori pe săptămână, dar sunt necesare minimum trei şedinţe pe săptămână cu o durată de 30–60 min, pentru a asigura efectul de antrenament, creşterea capacităţii de efort şi efectele pleiotrope ale antrenamentului fizic. Prestarea activităţii fizice este similară cu aceea recomandată la bolnavii nondiabetici, dar există câteva particularităţi care trebuie luate în considerare înaintea recomandării sau pe parcursul aplicării antrenamentului fizic la această categorie de bolnavi, cum ar fi hiper- sau hipoglicemia, neuropatia periferica sau retinopatia. În concluzie, activitatea fizică şi antrenamentul fizic sunt esenţiale pentru diabetici, şi reprezintă o şansă pentru prevenirea complicaţiilor cardiovasculare sau pentru ameliorarea evoluţiei bolii, şi trebuie să fie aplicată în toate cazurile. Corresponding author: D. Zdrenghea University of Medicine and Pharmacy, Rehabilitation Hospital, Cardiology Department, 46–50 Viilor Str, Cluj-Napoca, Romania Tel +040 264438940; fax: +040264207035 E-mail address:
[email protected]
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