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What Do We Really Know About Exercising with Complications?

Oct 7, 2017

By Sheri R. Colberg, PhD

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 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 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 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 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 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 power lifting
Severe Nonproliferativeand 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 Exercise does not accelerate progression of kidney disease even though protein excretion acutely increases afterwards. 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 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 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