Advice for Professionals

Exercise and microvascular complications.

In most people provided exercise is started at a low intensity and increased gradually then no harm will be done.

However there are some conditions where caution is required or action needs to be taken prior to starting exercise. The tables below summaries these in relation to microvascular diseases.

Complications	Advice
Eyes diseases
Mild to moderate non-proliferative retinopathy	Little risk of eye damage from physical activity Ensure annual eye exam
Severe non-proliferative and unstable proliferative retinopathy	Individuals with unstable diabetic retinopathy are at risk for vitreous haemorrhage and retinal detachment Avoid vigorous intense activity or doing powerlifting ( very heavy weights)
Vitreous haemorrhage	Do not exercise Only exercise when given clearance by ophthalmologist
Cataracts	Cataracts do not limit ability to exercise But may affect safety due to limited vision
*Nerve diseases*
Peripheral neuropathy	All forms of activity fine. Regular aerobic exercise may prevent the onset or delay the progression of peripheral neuropathy [1]. Check feet regularly Wear appropriate shoes and keep feet dry Do not do weight bearing exercises if have active Charcot
Local foot deformities	All forms of activity fine but focus more on non-weight bearing exercises to reduce plantar pressure Check feet regularly Wear appropriate shoes and keep feet dry
Foot ulcers/ amputations	All forms of activity fine Exercise does not increase risk of foot ulcers or reulceration with peripheral neuropathy [2]. Avoid weight-bearing activity with unhealed ulcer Check feet/amputation site regularly
Autonomic neuropathy	Cardiac investigations should be carried out before beginning exercise of greater intensity than normal Addition care taken as high risk of hypoglycaemia Avoid exercising in extreme heat With blunted heart rate response, use heart rate reserve and ratings of perceived exertion to monitor exercise intensity [3]. With postural hypotension, avoid activities with rapid postural or directional changes to avoid fainting or falling.
Kidney disease
Microalbuminuria	All forms of activities fine Regular aerobic exercise may also prevent the onset or delay the progression of diabetic nephropathy [4,5].
Overt nephropathy	All forms of activities fine Both aerobic and resistance training improve physical function and quality of life in individuals with kidney disease
End-stage renal disease	All forms of activities fine but start at low intensity Electrolytes should be monitored when activity done during dialysis sessions. Doing supervised, moderate aerobic physical activity undertaken during dialysis sessions may be beneﬁcial and increase compliance [5].

References

Balducci S, Iacobellis G, Parisi L, et al. Exercise training can modify the natural history of diabetic peripheral neuropathy. J Diabetes Complications 2006;20:216–22 - to go to this paper click here.
Lemaster JW, Mueller MJ, Reiber GE, Mehr DR, Madsen RW, Conn VS. Effect of weight-bearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet ﬁrst randomized controlled trial. Phys Ther 2008;88:1385–1398- to go to this paper click here.
Colberg SR, Swain DP, Vinik AI. Use of heart rate reserve and rating of perceived exertion to prescribe exercise intensity in diabetic autonomic neuropathy. Diabetes Care 2003;26:986–99 - to go to this paper click here.
Robinson-Cohen C, Littman AJ, Duncan GE, et al. Physical activity and change in estimated GFR among persons with CKD. J Am Soc Nephrol 2014;25:399–406- to go to this paper click here.
Waden J, Tikkanen HK, Forsblom C, et al.; FinnDiane Study Group. Leisure-time physical activity and development and progression of diabetic nephropathy in type1 diabetes: the Finn Diane Study. Diabetologia 2015;58:929–936 169 -to go to this paper click here.
Koh KP, Fassett RG, Sharman JE, Coombes JS, Williams AD. Effect of intradialytic versus home-based aerobic exercise training on physical function and vascular parameters in hemodialysis patients: a randomized pilot study. Am J Kidney Dis 2010;55:88–9 - to go to this paper click here.