Objectives. Criteria for Diagnosing Diabetes. Outline. Glycated Hemoglobin

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1 Rehabilitation Strategies for Patients With Diabetes Mellitus & Associated Complications Combined Sections Meeting 2012 Chicago, Ill February 9, 2012 Rick Black, PT, DPT, MS, GCS Corporate Rehabilitation Consultant HCR ManorCare Objectives Participants will be able to: 1. Provide a rationale for the prescription of therapeutic exercise with appropriate exercise parameters for individuals with diabetes 2. Discuss factors that cause hypoglycemia and how to prevent the development of hypoglycemia in individuals with diabetes Outline Criteria for Diagnosing Diabetes 1. Discuss HbA1c 2. Clinical Considerations 3. ADA recommendations for exercise 4. Exercise prescription a) Intensity b) Duration c) Frequency d) Type of muscle contraction e) Supervision 5. Managing hypo/hyperglycemia HbA1c 6.5% Fasting Plasma Glucose (FPG) 126mg/dl Two hour plasma glucose 200 mg/dl during an OGTT A random plasma glucose 200mg/dl HbA1c Non-Diabetic Range= % Glycated Hemoglobin Conversion of HbA1c to estimated Average Glucose (eag) Glucose Red Blood Cell Hemoglobin Glycated Hemoglobin HbA1c % eag (mg/dl) eag (mmol/l) Ref. not to be copied without permission 1

2 Effect of Reducing HbA1c Acute Adaptations with Exercise Acute Muscle Contractions- Insulin independent Glycogen depletion- stimulates glucose uptake Colberg, et al. Curr Sports Med Rep Vol 8(4) Chronic Adaptations with Exercise Enhanced responsiveness to insulin Increased expression/activity of proteins Increased insulin signal transduction such as adensosine monophosphate activated protein kinase Increased lipid oxidative capacity in s. muscle Improved muscle mitochondrial function Increased glucose effectiveness Clinical Considerations Thorough Medical History Cardiopulmonary Screening Diabetic Foot Exam Neuropathy Screening Peripheral Neuropathy Autonomic Neuropathy Peripheral Arterial Disease (PAD) Colberg, et al. Curr Sports Med Rep Vol 8(4) Medical History Key Components Hx of foot ulceration Amputation Neuropathic Symptoms Peripheral Vascular Symptoms Impaired Vision- Retinopathy Renal Replacement Therapy (i.e. dialysis, transplant) Cigarette Smoking Cardiopulmonary Screening PMHx Medications Vital Signs Heart Sounds Lung Sounds Peripheral pulses Note: At least 1/3 of patients with DM with coronary disease have no signs of angina or have atypical angina sx such as exertional dyspnea, rather than exertional chest pain. not to be copied without permission 2

3 Diabetic Foot Examination* Dermatologic Musculoskeletal Neurological Assessment Vascular Assessment Note: 15% of people with DM will have a foot ulcer in their lifetime.** *Boulton AJ, et al. Diabetes Care Aug: 31(8): **Diabetes Care Aug:22(8): Autonomic Neuropathy & Cardiac Autonomic Neuropathy (CAN) Symptoms- Resting tachycardia, exercise intolerance, orthostatic hypotension Key Points Related to Exercise Increased risk for silent MI Do not use HR to monitor exercise intensityuse Perceived Exertion or EKG Should have cardiac stress test prior to initiating exercise program Exercise Testing Monitoring Tolerance to Exercise EKG Stress Testing ADA Standards of Medical Care Guidelines for Physical Activity People with diabetes should be advised to perform at least 150 min/wk of moderateintensity aerobic physical activity (50-70% of max HR) In the absence of contraindications, people with type 2 diabetes should be encouraged to perform resistance training at least twice per wk. Diabetes Care, Jan, 2012, Vol35: S11-63 Physiological Response to Different Exercise Intensities in Healthy Adults Moderate Intensity High Intensity Plasma Glucose Stable Increases sharply, esp. in recovery period Insulin Slightly decreases, baseline at recovery Initially decreases, increases with recovery Norepinephrine 3 Fold increase >3 Fold increase Epinephrine 3 Fold Increase > 3 Fold increase Glucagon Stable Stable Glucose Production 2 Fold increase 7 Fold increase Glucose Utilization 2 fold increase 4 Fold increase Treatment Effect on HbA1c Treatment Reduction in HbA1C Reduction in BG (mg/dl) Exercise (DM2)* 0.67% 19 Insulin, sulfonylureas, & Metformin Α- glucosidase inhibitors, glitazones, eglitinides 1-2% % Exenatide ~1% 29 Pramlintide ~0.5% 14.5 Sitigliptin ~0.8%. 23 Gulve, Phys Ther Nov;88(11): *Umpierre, JAMA. May 4, 2011, Vol 305 (17): not to be copied without permission 3

4 Muscle Tissue Largest Glucose absorbing organ in the body. Accounts for ~80% of total body glucose disposal. Type 1 vs. Type 2 Effect of Exercise on Blood Glucose Strong evidence to show that exercise can lead to a reduction in blood glucose in patient with DM2. Evidence for exercise to lower HbA1c in DM1 is inconsistent and weak. DeFronzo, J Clin Invest, 1985 Jul:76(1): Effect of Initial HbA1c on Response to Exercise in DM2 Types of Exercise Shown to Effect Blood Glucose in DM2 The effect of exercise on blood glucose is greater when the HbA1c is more elevated to begin with. Aerobic Exercise Strength Training Review of Studies All involved adults & older adults with DM2 Randomized Control Trials Aerobic Training Author-Bjorgaas et al. (2004), n=29 Types of Exercise- light jogging, coordination exercises, knee bends, stretching. Monitored activity with pedometer on off days. Duration- 90 mins, 12 wks Frequency- 2x/wk Intensity- aimed to keep intensity to 50-85% of MaxHR. Results- HbA1c decreased by.5% in high attendance and.4% in low attendance. Bjorgass, Diabetes Obes Metab. 2005:7(6): not to be copied without permission 4

5 Strength Training Types of Exercise- PRT exercises focusing on large muscle groups, e.g. chest & hip & knee extensors, upper back, knee flex, lats, etc. Duration min sessions/16-26 wks Frequency- 3x/wk Intensity- Beginning 50-60% 1 RM, Progress to 70-85% 1RM, 3 x 8 reps, one study- 6 x reps to exhaustion Results- HbA1c decreased by % Castaneda, Diabetes Care Dec; 25(12): Cauza, Arch PM&R Aug; 86(8) Dunstan, Diabetes Care Oct; 25(10): Aerobic & Strength Training DARE Clinical Trial Diabetes Aerobic & Resistance Exercise Group Change in HbA1c Difference Aerobic 7.41 to 6.98% -0.43% Resistance 7.48 to 7.18% -0.3% Combined 7.46 to 6.56% -0.9% Control 7.44 to 7.51% +0.07% Effect of Aerobic & Strength Training is Additive Sigal, Annals of Int Med. 2007: n = 251 Groups Physical Activity Advice vs. Structured Exercise Program Meta-analysis Aerobic Exercise -.73% Structured Resistance Training -.57% Aerobic & Resistance Training -.51% Physical Activity Advice* Duration of Exercise Exercise > 150min/wk -.89% Exercise <150 min/wk -.36% Reduction in HbA1c -.43%- Not Significant Reduction in HbA1c Common Adverse Events Musculoskeletal complaints Hypoglycemia (usually resolved with medication adjustment) Chest pain (MI ruled out, subj returned to & finished study) Often none noted Umpierre, JAMA. May 4, 2011, Vol 305 (17): Exercise Parameters Intensity not to be copied without permission 5

6 High Intensity vs. Low Intensity Duration Data are conflicting- Some studies show that low intensity and higher intensity equally effective and that total energy expenditure is most important. Hansen (2009) found that continuous low to moderate intensity aerobic exercise (55 min duration) equally effective as continuous moderate to high intensity aerobic exercise (40 min duration) for lowering HbA1c in obese subj. with DM2. Duration Most studies duration of each exercise session ranged from 30 to 75 mins. Duration of the training programs ranged from 1 day to 2.8 years Meta-analysis by Umpierre et al. found that duration more important than intensity Exercise Prescription If patients can only tolerate low intensity aerobic exercise, try to increase duration. Frequency Frequency Effect of exercise on BG and insulin resistance can be seen after one session. Most studies report the effect disappears after 72 hours- some studies reported longer lasting effect, especially longer duration studies Need to repeat exercise at least every 48 hours to maintain effect not to be copied without permission 6

7 Frequency Type of Muscle Contraction 3 ten minute bouts of aerobic exercise improved fasting glucose levels more than 1 continuous 30 min session- (6d/wk). Total time 30 mins, intensity % maxvo2 Eriksen, Diabetologia Nov; 50(11): Concentric vs. Eccentric Supervision Results conflicting- Marcus et al. (2008) show eccentric + aerobic exercise decreased Hb A1c by.6% pts with DM2 Asp et al. (1996) found eccentric leg exercise in healthy individuals impaired whole body insulin action Recommendation- Use a combination of concentric & eccentric, as described in previous studies Supervision Supervision and adequate intensity of exercise is necessary to maintain the glycemic control obtained from a six month supervised gym based resistance exercise training program. Home based resistance training did not maintain reduction in HbA1c achieved with a six month supervised gym based resistance exercise training program. Dunstan, Diabetes Care, Jan, 2005, 28 (2):3-9 Contraindications to Intense Exercise BG > 300 mg/dl with presence of ketones BG < 100 mg/dl Proliferative diabetic retinopathy (PDR) Severe nonproliferative diabetic retinopathy (NPDR) Autonomic Neuropathy (should undergo cardiac investigation prior to beginning more intense exercise program) Uncontrolled HTN Standards of Medical Care-2012, Diabetes Care. 2012, Jan:35(Suppl 1)S11-S63. not to be copied without permission 7

8 Effect of Exercise on Blood Glucose is dependant on: Timing of antidiabetic medication Type of antidiabetic medication BG levels at start of exercise Type of exercise Intensity of exercise Monitoring Blood Glucose with Exercise When adjusting to a new exercise program a patient should test BG: Before During Immediately after 2-3 hours after Duration of exercise Managing Hyper & Hypoglycemia associated with exercise Desired outcome Long term- Decrease Hyperglycemia Short term- Avoid Hypoglycemia Hyperglycemia Not necessary to postpone exercise if blood glucose is high as long as: Pt feels well Blood and urine ketones are negative Exercise can worsen ketosis National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health Effect of Intense Exercise >80% max VO 2 on BG BG elevated during & after HI due to increased catecholamines May not be appropriate for patient with elevated BG Strategy of decreased insulin &/or increased CHO may not be appropriate May need small dose of fast acting insulin after exercise Marliss, Diabetes (Suppl.1):S Hypoglycemia Definition- Mild- Self-treatment is possible, regardless of the degree in drop Severe- Requires external assistance for recovery National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health not to be copied without permission 8

9 Counter Regulatory Response Why is Hypoglycemia a Problem? BG (mg/dl) Insuline Declines Glucagon & Epinephrine Increases Autonomic & Severe Hypoglycemia Neuroglycopenic Symptoms Appear Counter regulatory response is blunted Response occurs at lower threshold Hypoglycemic Associated Autonomic Failure (HAAF) leads to Hypoglycemic Unawareness Vicious cycle *Stringently avoiding hypoglycemia for several wks can improve counter regulatory response Younk, Expert Rev Endo Met. 2011, Jan 1: 6(1): Barriers to Physical Activity in Patients with DM1 1. Fear of Hypoglycemia 2. Work Schedule 3. Loss of Control over diabetes 4. Low Fitness Level Glucose Regulation The greater the duration, intensity or both, the more the baseline levels of insulin should be reduced. Patients taking full dosage of insulin prior to exercise are at increased risk for hypoglycemia. Brazeau, Diabetes Care. 2008, 31: Medication: Mechanism of Action Pts on insulin, sulfonylureas, insulin secretagogues at increased risk of hypoglycemia with exercise Physical Activity Glucose Disposal Glucose Disposal Glucose Production Insulin Hypoglycemia not to be copied without permission 9

10 Strategies for Avoiding Hypoglycemia Associated with Exercise Blood Glucose Pre-Exercise Carbohydrate Replacement Carbohydrate Recommendation < 80 mg/dl Hold physical activity & ingest 15g CHO (cereal bar, fruit, honey, etc) 80 to 140 mg/dl Ingest 1 to 2 g/kg of CHO prior to activity >140 mg/dl < 250 mg/dl Within safe range, ingest 15 to 30 g CHO after activity * >300 mg/dl, no ketonuria Begin activity. No CHO replacement necessary > 300 mg/dl, with ketonuria Postpone activity until ketone levels return to normal. Take fluids (water). No CHO replacement necessary. Miculis, J Pediatr (Rio J) 2010, 86(4): Insulin Regimes Typically patients take a long acting insulin in the morning and then bolus dosage of short or intermediate acting insulin prior to meals (preprandial). Type 1 DM- Preventing Hypoglycemia Adjustment of preprandial (fast acting insulin) based on intensity & duration of exercise Exercise Intensity (%VO2 Max) % Reduction in Insulin Dosage 30 Min Exercise 60 Min Exercise 25 25% 50% 50 50% 75% 75 75% - Rabasa-Lhoret, Diabetes Care, 24(4), April 2001 Intermittent High Intensity Exercise (IHE) 10s sprint before or after 20mins mod intensity exercise Decreases post exercise drop in glucose 4s sprint q 2 mins during 30 mins mod intensity exercise decreases drop in glucose for 60 mins after exercise Bussau, Diabetologia : Bussau, Diabetes Care (3): Guelfi, Diabetes Care (6): Symptoms of Hypoglycemia Initially Headache Fatigue Tremor Hunger Tachycardia Sweating Anxiety Confusion Severe Hypoglycemia Loss of consciousness Convulsions Death not to be copied without permission 10

11 Hypoglycemic Episode Provide 15 g of CHO, wait mins, recheck BS. Foods with 15 grams carbohydrates: 4 oz (1/2 cup) of juice or regular soda 2 tablespoons of raisins 4 or 5 saltine crackers 4 teaspoons of sugar 1 tablespoon of honey or corn syrup If patient passes out DO NOT inject insulin. DO NOT provide food or fluids. DO NOT put hands in patient s mouth. DO inject glucagon. DO call for emergency help. Recommendations for family, friends & co-workers from ADA, Strategies for Management of Blood Glucose during/after Exercise Reduce pre-exercise bolus insulin Reduce pre-exercise basal insulin Take extra CHO with exercise Pre-exercise or post exercise sprint Insulin pump therapy Reduce basal insulin post exercise Summary Diabetes is a worldwide problem Physical Therapists & Physical Therapist Assistants are well equipped to be part of team managing patients with diabetes Exercise is critical for controlling blood glucose Exercise type, frequency, intensity & duration are important. Multiple benefits from exercise Must be aware of strategies to prevent hypo & hyperglycemia Thank you Rick Black rblack@hcr-manorcare.com not to be copied without permission 11