PRE EXERCISE EVALUATION- TO WHOM? HOW?

PRE EXERCISE EVALUATION- TO WHOM? HOW?

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 micro-vascular complications that may be worsened by the exercise program. Identification of areas of an individualized exercise prescription that can minimize risk to the patient. Most of the following recommendations are excerpts from The Health Professionals Guide to Diabetes and Exercise.

            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, is at high risk for underlying cardiovascular disease, based on one of the following criteria:

·        Age > 35 years

·        Type II diabetes of >10 years duration

·        Type I diabetes of >15 years duration

·        Presence of any additional risk factor for coronary artery disease

·        Presence of microvascular disease (proliferative 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 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.

Classification of physical activity intensity, based on physical activity lasting up to 60min

Intensity	Relative intensity
	Vo2max (%)	Maximal heart rate (%)	Relative Perceive Exertion
Very light	<20	<35	<10
Light	20-39	35-54	10-11
Moderate	40-59	55-69	12-13
Hard	60-84	70-89	14-16
Very hard	>85	>90	17-19
Maximal	100	100	20

Peripheral arterial disease

            Evaluation of peripheral arterial disease (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

            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.

            The degree of diabetic retinopathy has been used to stratify the risk of exercise, and to individually tailor the exercise prescription.

Table – Considerations for activity limitation in diabetic retinopathy

Level of DR	Acceptable activities	Discouraged activities	Ocular reevaluation
No DR	Dictated by medical status	Dictated by medical status	12 months
Mild NPDR	Dictated by medical status	Dictated by medical status	6-12 months
Moderate NPDR	Dictated by medical status	Activities that dramatically elevate blood pressure Power lifting Heavy Valsalva	4-6 months
Severe NPDR	Dictated by medical status	Activities that substantially increase SBP, Valsalva maneuvers, and active jarring Boxing Heavy competitive sports	2-4 months (may require laser surgery)
PDR	Low impact, cardiovascular conditioning Swimming Walking Low impact aerobics Stationary cycling Endurance exercises	Strenuous activities, Valsalva maneuvers, pounding or jarring Weight lifting Jogging High impact aerobics Racquet sports Strenuous trumpet playing	1-2 months (may require laser surgery)

Nephropathy

            Specific exercise recommendations have not been developed for patients with incipient (microalbuminuria >20mg/min albumin excretion) or overt nephropathy (>200mg/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 exercise should probably be discouraged in these individuals.

Neuropathy: Peripheral

            Peripheral neuropathy (PN) 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 (10g) monofilament is indicative of the loss of protective sensation.

Table – Exercises for diabetic patients with loss of protective sensation

Contraindicated exercise	Recommended exercise
Treadmill	Swimming
Prolonged walking	Bicycling
Jogging	Rowing
Step exercises	Chair exercises Arm exercises Other non weight bearing exercise

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 mmHg 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.

NOTE: Individual with diabetes should be evaluated, before beginning of an exercise programe with appropriate diagnostic studies and screen for complications of diabtes which may worsen by exam program.

REFERENCE:

            Clinical Practice Recommendation, ADA