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Exercising with Autonomic Neuropathy

Altered Hormonal Responses

Of interest, in individuals with type 1 diabetes, autonomic neuropathy further reduces counterregulatory catecholamine responses, which increases the risk for severe hypoglycemia associated with exercise11. Intensive therapy, however, with an emphasis on preventing hypoglycemia reverses hypoglycemia unawareness in individuals with autonomic dysfunction despite marginal improvement in adrenaline responses; prevention of hypoglycemia also results in a lower occurrence despite impaired counterregulation12. Thus, autonomic neuropathy, long diabetes duration, and antecedent recent hypoglycemia contribute to different extents to impaired adrenaline responses and hypoglycemia unawareness (which is largely a reversible condition with prevention of hypoglycemia)13

In conclusion, many individuals with diabetes develop some autonomic nerve dysfunction as a result of diabetes and its associated hyperglycemia and oxidative stress. Any type of autonomic neuropathy potentially can affect the ability to exercise and alter normal exercise responses (such as heart rate and blood pressure). Once autonomic neuropathy has been diagnosed, individuals should take these alterations into account to be able to exercise safely and effectively with this diabetic complication.

References:

  1. Maser, R. E., and M. J. Lenhard: Cardiovascular autonomic neuropathy due to diabetes mellitus: clinical manifestations, consequences, and treatment. J Clin Endocrinol Metab 90 (10):5896–5903, 2005
  2. Vinik, A. I., R. E. Maser, and D. Ziegler: Autonomic imbalance: prophet of doom or scope for hope? Diabet Med 28 (6):643–651, 2011
  3. Parkman, H. P., R. Fass, and A. E. Foxx-Orenstein: Treatment of patients with diabetic gastroparesis. Gastroenterol Hepatol (N Y) 6 (6):1–16, 2010
  4. Vinik, A. I., and D. Ziegler: Diabetic cardiovascular autonomic neuropathy. Circulation 115 (3):387–397, 2007
  5. Loimaala, A., H. V. Huikuri, T. Koobi, M. Rinne, A. Nenonen, and I. Vuori: Exercise training improves baroreflex sensitivity in type 2 diabetes. Diabetes 52 (7):1837–1842, 2003
  6. Pagkalos, M., N. Koutlianos, E. Kouidi, E. Pagkalos, K. Mandroukas, and A. Deligiannis: Heart rate variability modifications following exercise training in type 2 diabetic patients with definite cardiac autonomic neuropathy. Br J Sports Med 42 (1):47–54, 2008
  7. Figueroa, A., T. Baynard, B. Fernhall, R. Carhart, and J. A. Kanaley: Endurance training improves post-exercise cardiac autonomic modulation in obese women with and without type 2 diabetes. Eur J Appl Physiol 100 (4):437–444, 2007
  8. Colberg, S. R., D. P. Swain, and A. I. Vinik: Use of heart rate reserve and rating of perceived exertion to prescribe exercise intensity in diabetic autonomic neuropathy. Diabetes Care 26 (4):986–990, 2003
  9. Figueroa, J. J., J. R. Basford, and P. A. Low: Preventing and treating orthostatic hypotension: As easy as A, B, C. Cleve Clin J Med 77 (5):298–306, 2010
  10. Ma, J., C. K. Rayner, K. L. Jones, and M. Horowitz: Diabetic gastroparesis: diagnosis and management. Drugs 69 (8):971–986, 2009
  11. Meyer, C., R. Grossmann, A. Mitrakou, R. Mahler, T. Veneman, J. Gerich, and R. G. Bretzel: Effects of autonomic neuropathy on counterregulation and awareness of hypoglycemia in type 1 diabetic patients. Diabetes Care 21 (11):1960–1966, 1998
  12. Fanelli, C., S. Pampanelli, C. Lalli, P. Del Sindaco, M. Ciofetta, M. Lepore, F. Porcellati, P. Bottini, A. Di Vincenzo, P. Brunetti, and G. B. Bolli: Long-term intensive therapy of IDDM patients with clinically overt autonomic neuropathy: effects on hypoglycemia awareness and counterregulation. Diabetes 46 (7):1172–1181, 1997
  13. Realsen, J. M., and H. P. Chase: Recent advances in the prevention of hypoglycemia in type 1 diabetes. Diabetes Technol Ther 13 (12):1177–1186, 2011

This article is excerpted from Chapter 19 of Exercise and Diabetes: A Clinician’s Guide to Prescribing Physical Activity, a case-study based book available through the American Diabetes Association in June 2013 and written by Dr. Sheri Colberg (find more information about the book online at www.shericolberg.com/exercise-diabetes.asp).  

In addition, anyone wishing to earn free CME credits through the ADA for completing a new self-assessment program on exercise and diabetes may do so now through the ADA’s web site at http://professional.diabetes.org/ce.

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