Exercises for diabetic neuropathy

Exercise Guidelines for Patients With Diabetes

Your patient is a middle-aged man with type 2 diabetes who wants to start a weight-training program. What recommendations would you offer him? Another patient with diabetes has peripheral neuropathy; which types of exercise are safest for her? Answers to these and other questions about physical activity by patients who have diabetes mellitus can be found in guidelines from the American Diabetes Association (ADA).1 Highlights of those recommendations are presented here.

Encourage your patients with diabetes to be as physically active as they are able. The goal is to follow the US Department of Health and Human Services’ Physical Activity Guidelines for Americans, which recommend that adults over age 18 years perform at least 150 minutes per week of moderate-intensity aerobic physical activity.2 In addition, encourage patients with type 2 diabetes to perform resistance training 3 times per week, unless they have diabetic complications that prohibit such exercise.

Strongly encourage patients with type 2 diabetes to exercise regularly. Among the specific benefits of a long-term exercise program for these patients are:
•Improved glycemic control.
•Reduced risk of cardiovascular disease.
•Improved lipid levels.
•Reduced blood pressure.
•Weight control.

A meta-analysis found that structured exercise interventions of at least 8 weeks’ duration lowered hemoglobin A1c levels by an average of 0.66% in persons with type 2 diabetes, even when there was no significant change in body mass index.3 In addition, regular exercise may help forestall the development of diabetes in persons who are at high risk for the disease.4

Exercise can worsen hyperglycemia and ketosis in persons with type 1 diabetes who have been deprived of insulin for 12 to 48 hours.1 Thus, caution patients to avoid vigorous activity if ketosis is present. However, it is not necessary to postpone exercise on the sole basis of hyperglycemia, provided the patient feels well and urine and blood tests are negative for ketones.

Previous guidelines had recommended assessment of patients with diabetes who have multiple cardiovascular risk factors for coronary artery disease (CAD). More recent guidelines, however, advise against routine screening of patients with diabetes who have no symptoms of CAD.5 Use your clinical judgment, and take into consideration the patient’s age and previous activity level. For example, it would be prudent to recommend that high-risk patients start with short periods of low-intensity exercise and then increase the duration and intensity slowly.

Focus the evaluation on identifying complications that might preclude certain activities or predispose the patient to injury, such as uncontrolled hypertension, severe autonomic neuropathy, severe peripheral neuropathy, a history of diabetic foot or leg ulcers, and unstable proliferative retinopathy.

Hypoglycemia. Physical activity can cause hypoglycemia in patients with diabetes who take insulin and/or insulin secretagogues if the medication dose or carbohydrate consumption is not adjusted to compensate. Advise patients who are receiving these therapies to consume additional carbohydrate if pre-exercise glucose levels are lower than 100 mg/dL.1 Hypoglycemia is rare in persons with diabetes who are not treated with insulin or insulin secretagogues.

Retinopathy. If the eye examination reveals proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy, vigorous aerobic or resistance exercise is contraindicated because it may cause vitreous hemorrhage or retinal detachment.1 Low-impact activities, such as swimming or stationary cycling, are acceptable, but running and weight lifting should be discouraged.

Peripheral neuropathy. Previous guidelines advised against weight-bearing exercise for patients with severe peripheral neuropathy; however, more recent studies have shown that moderate-intensity walking does not increase the risk of foot ulcers.6 Tell patients to wear proper footwear and to examine their feet for blisters and other injuries both before and after each exercise session. Those who have a foot injury or ulcer should avoid weight-bearing physical activity.

Autonomic neuropathy. Cardiac autonomic neuropathy associated with diabetes has been linked to sudden death and silent myocardial ischemia.1 Thus, a cardiac evaluation that includes appropriate noninvasive testing is recommended before patients with autonomic neuropathy increase their level of physical activity. These patients are also more likely to experience hypotension or hypertension at the start of an exercise program or after a vigorous session. Because these patients have difficulty with thermoregulation, they should not exercise in hot or cold environments and should drink plenty of fluids while working out.

Nephropathy. Because vigorous exercise does not increase the rate of progression of diabetic kidney disease, patients do not need to limit their physical activity.1

Training the Diabetic Client

The effects of diabetes may be ameliorated by a well-designed exercise program, giving personal trainers an opportunity to do more for these clients than improving their fitness. By learning how to tailor programs to meet a diabetic’s needs, we can enhance quality of life and help effect changes in various health outcomes.

Diabetes is a disease that affects the body’s ability to produce or use insulin, the hormone responsible for transferring glucose from the blood to the cells. In the absence of insulin, or in cases of insulin resistance, excess sugar builds up in the bloodstream, setting off a cascade of potentially life-threatening situations.

The term Type 1 diabetes is used to describe a condition in which one’s pancreas does not produce any insulin at all. Type 2 diabetes occurs when insufficient insulin is released, or when one’s cells are insulin resistant and therefore unable to turn food into a necessary energy source.

Exercise is Key

Studies of individuals with Type 2 diabetes indicate that only about 38% participate in regular physical activity, compared with 58 % of healthy Americans. Sheri Colberg-Ochs, Ph.D., founder of the Diabetes Motion Academy in Santa Barbara, California and professor emerita of Exercise Science at Old Dominion University in Norfolk, VA underscores the impact of exercise on the diabetic patient: engaging in regular moderate exercise can help increase the body’s insulin action and keep blood sugar levels steady.

Type 2 diabetes responds to exercise on more than the level of blood glucose regulation: it can mitigate comorbid ailments often found in diabetic patients–cardiovascular conditions and obesity being the most profound. The potential to delay or even prevent the occurrence of Type 2 diabetes with exercise has been promoted by the medical community for decades. Regular workouts also afford the opportunity for improved balance among those diagnosed with Type 2 diabetes who are often considered “fall risks”.

Notably, exercise has also shown to help those with Type 1 diabetes lead healthier and more productive lives. For this patient, exercise increases insulin sensitivity, meaning less is required post-workout to process carbohydrates. Less insulin required equals fewer injections and improved functionality.

How Exercise Affects Diabetes

Moderate exercise causes an elevation in heart rate and respiration. Throughout this process, muscles utilize more of the glucose circulating in the bloodstream. Over time, this can lower blood sugar levels. With consistent workouts, the body’s response to insulin becomes more adept. Such benefits may last as long as 24 hours after a workout has been completed.

Two randomized trials each found that lifestyle interventions of ∼150 min/week of physical activity, when coupled with calorie counting and weight loss, lowered the risk of progression from glucose resistance to Type 2 diabetes by ~58%. In addition, a cluster-randomized trial found that diet alone, exercise alone, and a combination were equally effective in reducing this progression. Researchers hence conclude that increased physical activity and modest weight loss decrease the likelihood of increased diabetic conditions.

The Fitness Professional’s Role

Before engaging in a program of activity more vigorous than brisk walking, clients with diabetes should be carefully assessed by the personal trainer, keeping in mind that diabetics live with an increased likelihood of cardiovascular disease.

Careful exercise selection is key since a significant number of diabetics have a predisposition to injury. Ailments such as severe autonomic neuropathy, severe peripheral neuropathy, and proliferative retinopathy are a few of the more common roadblocks to progress. Learning the client’s age and physical activity history will help when designing a safe and effective training protocol.

It is important to inform clients that any variety of exercise is beneficial, but most individuals will stick with activities that they find enjoyable.

Here are a few suggestions to present to new or deconditioned diabetic clients:

  • Walking, either outdoors or indoors on a track
  • Participating in a dance class
  • Cycling, outdoors or on a stationary bike
  • Swimming/ water aerobics
  • Stretch/balance classes
  • Pilates, yoga or tai chi
  • Tennis
  • Aerobics/fitness class
  • Engaging in household/ yard chores or gardening
  • Resistance training with light weights or elastic bands

Dangers of Hyperglycemia

When individuals with Type 1 diabetes are deprived of sufficient insulin for 12–48 hours and have entered into a ketotic state, exercise can actually aggravate high blood sugar, or hyperglycemia. There is delicate balance to be monitored so it is important for the trainer to inquire about insulin injections before exercising.

Low insulin levels coupled with strenuous physical activity, promotes secretion of other hormones such as norepinephrine, epinephrine, glucagon and cortisol. Together, these substances cause the liver to release more glucose into the blood, thereby elevating blood sugar rather than promoting the desired lowering. This is particularly the case after an intense workout.

In the past, the American Diabetes Association had suggested that physical activity be avoided at fasting glucose levels >13.9 mmol/l (>250 mg/dl) and ketosis is present. Today, the position has been revised to state that, in the absence of very severe insulin deficiency, light- or moderate-intensity exercise still has the potential to decrease blood glucose.

It becomes the trainer’s job to ascertain whether the client feels well, is adequately hydrated, and is not showing overt signs of ketoacidosis:

  • Excessive thirst
  • Frequent urination
  • Vomiting
  • Weakness
  • Shortness of breath
  • Fruity-smelling breath
  • Confusion

If the situation is deemed relatively safe enough for the client’s comfort level, it is not necessary to postpone exercise based solely on hyperglycemia.

Dangers of Hypoglycemia

The risk of potentially dangerous low blood sugar, or hypoglycemia, during or after exercise is elevated in the case of insulin deficiency. If a client is insulin-dependent, physical activity may lead to severe hypoglycemia if medication dosage or carbohydrate consumption is not altered in accordance with the intensity of exercise.

Type 2 diabetics run a slightly increased risk of developing hypoglycemia during or after exercise, although not to the extent of individuals reliant on insulin treatment. Since glucose is the body’s preferred energy source, a deficit of glucose renders the cells unable to function properly. For those diabetics on particular medications, even a short-term reduction in blood sugar can result in a cascade of complications. Blood sugar is considered low when it drops below 70 mg/dL. Immediate treatment for this situation will prevent more serious symptoms from developing.

Commonly exhibited symptoms of dangerously low blood sugar include the following:

  • Blurry vision
  • Rapid heartbeat
  • Sudden mood changes
  • Sudden nervousness
  • Unexplained fatigue
  • Pale skin
  • Headache
  • Hunger
  • Shaking
  • Dizziness
  • Sweating
  • Difficulty sleeping
  • Skin tingling
  • Trouble thinking clearly or concentrating
  • Loss of consciousness, seizure, coma

Skipping meals, eating less than normal, or taking medication on time but eating a meal later than usual often lead to a precipitous drop in blood sugar levels. Something as simple as engaging in unplanned physical activity without sufficient nutrient consumption can also cause blood sugar levels to dip below an acceptable range.

Trainers might consider sending a text or email reminding a diabetic client to assess his blood sugar one to two hours before exercise, ensuring that it is within his normal target range at the time of training. If the level is below normal, consuming a small meal or snack rich in carbohydrates prior to the gym can be all that is necessary.

If a training session has been designed to extend for an hour or more, the consumption of additional carbohydrates during the workout can help thwart any problems. Exercise gels, sports drinks, fresh fruit or granola bars can provide a quick burst of necessary glucose during exercise. Remind the client to monitor his blood sugar immediately after exercise and every 2-4 hours afterward up until bedtime. For this reason, intense physical exercise immediately prior to retiring for the night is never recommended for diabetic clients.

Impact of Aerobic Exercise on Diabetes

Aerobic training increases insulin sensitivity, lung function, immune function, and cardiac output. Moderate to high volumes of aerobic activity are associated with lower cardiovascular risks in the healthy population, and the same holds true for those living with diabetes. Type 1 diabetics typically react to aerobic training with an increase in cardiorespiratory fitness, decreased insulin resistance, improvement in lipid levels, reduction A1C, triglycerides, and blood pressure.

Research published in Diabetes Care suggests that aerobic activity between 30 and 90 minutes has a positive effect on blood sugar, with more benefit seen with longer exercise sessions. Start out slowly for new or deconditioned clients, with an initial goal of 10-30 minutes of moderate physical activity, 5-7 days/week. As endurance builds, workouts may be extended incrementally.

Resistance Training and Reduction in Hypoglycemia

Diabetes is an independent risk factor for low muscular strength and an accelerated decline in muscle function. The health benefits of resistance training include improvements in muscle mass, body composition, strength, mental health, bone density, blood pressure and cardiovascular health. “If you lose muscle mass, you have a lot harder time maintaining your blood sugar,” Colberg-Ochs says.

While the effect of resistance exercise on glycemic control in Type 1 diabetes is not yet fully understood, it may assist in minimizing the risk of exercise-induced hypoglycemia. When designing workouts, starting with resistance exercises results in fewer reported episodes of hypoglycemia than when aerobic exercise is performed first.

Each session should include 5-10 different types of lifts involving the major muscle groups. For optimal strength gains, encourage the client to work up to 3-4 sets of 10-15 reps for each exercise. Programs for these clients may include weight training at least twice a week as part of their management plan — 3x is ideal, but always include a rest day between weight workouts. This is the time when they can engage in the other activities listed above.

Addressing Fall Risks

Similar to their healthy counterparts, flexibility and balance exercises are important for older adults with diabetes. Limited joint mobility is frequently present resulting in part from the normal aging process, but accelerated by hyperglycemia.

“I fully recommend that anyone over 40 with diabetes include balance training as part of their weekly routine, at least 2- 3 days/week,” says Dr. Colberg-Ochs. “It can be as simple as practicing balancing on one leg at a time, or more complex like tai chi exercises. Lower body and core resistance exercises also double as balance training.”

Balance training can reduce falls by 28%−29% as well as fostering improvements in gait, even when peripheral neuropathy is present. Stretching increases range of motion and flexibility around joints. Yoga has the potential of improving glycemic control, lipid levels, and body composition in clients with Type 2 diabetes. Tai chi training eases balance and neuropathic symptoms in adults with diabetes and neuropathy. Additional studies on this training would prove helpful.

Helpful Hints for Diabetic Clients

Regardless of the type of training planned for a personal training session, remind clients of the following:

  • Wear well-fitting, comfortable shoes and cotton socks. Proper footwear can prevent blisters, which often lead to serious infections for many diabetics.
  • Carry a snack or glucose tablets in case blood sugar bottoms out.
  • Hydrate well before, during and after the workout.
  • Always wear a diabetes ID necklace or bracelet while exercising.

While some of the challenges related to blood glucose management are universal in terms of the type of exercise involved, medication prescribed, and the presence/absence of diabetes-related comorbidity, many will vary from person to person. Thus, as with any of our clients, physical activity and exercise recommendations should be tailored to meet the specific needs of each individual.

Our goal is to help diabetic clients understand and incorporate moderate mindful movement into their daily lives, and develop strategies to avoid the potential complications of exercise. With the client’s permission, work with his medical team to determine the right program for his specific needs. Keep these professionals posted periodically on the patient’s workout progress and corresponding blood glucose levels.

4 Great Exercises for People Managing Diabetes-Related Neuropathy

You know that exercise is vital to leading a healthy life with diabetes, to help boost your cardiovascular health, reduce body fat levels, and better manage blood sugar. But if you’re managing neuropathy, or nerve damage — which a report published in January 2017 in the journal Diabetes Care estimates half of people with type 2 diabetes are — is it even safe to break a sweat?

Short answer: Yes. You just have to take certain precautions when doing so.

What Is Neuropathy and What Causes It When You Have Diabetes?

First, know that neuropathy is nerve damage to cells that can occur anywhere in the body, though the condition often exhibits in feet and hands. In people with diabetes, high blood sugar levels, or persistent hyperglycemia, can cause neuropathy, not to mention a slew of other potential diabetes complications. Meanwhile, in those people with poor circulation — a common side effect of diabetes — a lack of blood flow and oxygen to hard-to-reach nerves can cause further damage and cell death.

What Are the Common Symptoms of Neuropathy?

The result of this damage includes everything from chronic pain to impaired digestive system, urinary tract, and cardiovascular function. But the most common signs of neuropathy include pain, tingling, and numbness in the extremities.

When such symptoms set in, the idea of exercising can become a bit scary. After all, sense of touch is your body’s built-in protective system, says Jason Machowsky, RD, CSCS, a sports dietitian and exercise physiologist at the Hospital for Special Surgery in New York City. So if that protective system isn’t running at top speed, and your hands and feet are tingling or even numb, how safe is your workout?

Before You Break a Sweat, Determine Whether You Need Neuropathy Treatment

If you feel tingling, numbness, loss of sensation, or pain from common clothing like socks or even bedsheets, that’s your cue to stop what you’re doing and potentially seek treatment for neuropathy. If you find from checking your feet daily that you have a blister or ulcer, be sure to notify your physician to help prevent infections.

“Loss of sensation in the foot or ankle can significantly increase the risk of getting infections in those areas from routine cuts or abrasions,” Machowsky says. “Since you may not feel the extent of the damage done and therefore not take action to treat it until it becomes a major medical emergency.”

Meanwhile, if you’re standing on the gym floor performing squats, it’s the nerves in your feet that help you gauge your body’s positioning (called proprioception) and maintain balance, he explains. Both are vital to performing your workouts safely and effectively.

Why You Still Need to Exercise if You Have Diabetes-Related Neuropathy

Despite all of the excuses you may come up with to skip the gym when you have neuropathy, you have even more reasons to make exercise a priority if you’re managing this complication. That’s because exercise is actually good for neuropathy.

“One of the best ways to prevent progression of diabetic neuropathy is to stay active,” Machowsky says. For instance, in one study published in September 2012 in the Journal of Diabetes and Its Complications, all it took was 10 weeks of exercise to significantly reduce pain and symptoms in men and women with diabetes-related neuropathy. In that time frame, the participants’ nerve health and function also improved.

That’s not exactly surprising when you consider what researchers already know about the benefits of exercise for diabetes. Physical activity is a great way to keep your blood sugar levels in check, improve insulin sensitivity, and reduce inflammation, Machowsky says. Plus, by undoing some of the blood vessel damage that can occur with diabetes, exercise can help increase the flow of blood, oxygen, and other nutrients to nerve cells, further helping to improve neuropathic symptoms.

The 4 Best Workouts for People With Diabetes Who Are Managing Neuropathy

To minimize the risks and amplify the possible rewards of exercising with neuropathy, prioritize these expert-approved workouts:

1. Low-Impact Cardiovascular Exercise

Cardio’s ability to improve vascular health in people with type 2 diabetes is well established, and a study published in January 2017 in the International Journal of Neuroscience suggests that aerobic exercise may also improve blood vessel health in those dealing with diabetes-related neuropathy. Aerobic exercise can also help reduce blood sugar and cholesterol levels, according to the American Diabetes Association (ADA), which helps to further improve blood flow to your hands and feet, and improve nerve health.

To boost your blood flow while preventing cuts, scrapes, and blisters, skip pounding the pavement in favor for gentler, low-impact activities, such as swimming and cycling, Machowsky recommends. If you aren’t the most balanced on a bike, stick with an indoor one. Whatever workout you choose, try to perform at least 30 minutes of aerobic exercise five times per week, the ADA recommends.

2. Strength Training (Seated)

Your muscle, insulin, and vascular health are tightly linked, with muscle acting as a sort of sugar-burning furnace that just so happens to help your blood vessels “pump” blood to and from your heart.

While weight-bearing exercises that keep you on your feet are great for helping you get the most out of every rep, if you’re not so steady on your feet, working out with a barbell across your back is probably not a great idea! Don’t worry. It’s impressive how many effective strength exercises you can perform from the seated position, Machowsky says.

Check out your gym’s seated leg-strengtheners, including the leg extension, hamstring curl, and glute kickback machines. Meanwhile, you can perform a vast array of upper-body exercises, from bicep curls to shoulder presses, while seated on a bench. The ADA recommends performing strength exercises at least twice per week, in addition to your cardio workouts.

3. Balance and Stability Work

By damaging nerve function and sensation in your feet, diabetes-related neuropathy greatly increases your risk of falls, according to a review published in December 2014 in the International Journal of Nursing Sciences. It notes that in one previous study of older adults, those with diabetes-related neuropathy were 23 times more likely to suffer a fall compared with those without. That’s where balance and stability work comes in: training your muscles and the neurons in charge of them to properly fire and work together, Machowsky says. The most important muscles for keeping you upright are found in your feet, legs, and core.

Try to integrate some sort of balance or stability work into every workout. Perform one-legged exercises (holding onto the wall or a sturdy object for balance), practice walking from heel to toe in a straight line, and complete core exercises, including planks, dead-bugs, bird-dogs, and cable chops, he says.

4. Mind-Body Exercise

Yoga, tai chi, and active meditation exercises may really be what your nervous system needs. After all, studies have repeatedly shown that yoga is beneficial in the management of various neurological disorders, diabetes-related neuropathy included, according to a review published in October 2012 in the journal Annals of Indian Academy of Neurology.

Researchers note that yoga is beneficial in reducing stress levels, blood pressure, and inflammation, all of which can affect the progression of diabetes-related neuropathy. And although yoga might feel less intense compared with cycling or strength training, it still gets your heart pumping and can build muscle.

Perform your mind-body method of choice in a way that meets your needs and augments your other workouts. For instance, you could consider a gentle flow yoga class as a way to recover after a more intense strength or cardio workout. Meanwhile, more advanced yoga classes (call your local studio for details) can function as a great cardio and strength workout in one.

Tip 1. Go for Low-Impact Exercise
Knowing you’re doing something safe — especially if you have painful neuropathy or loss of sensation removes one barrier to exercise: fear. Change to something that would be low-impact or even non-weight-bearing, says Trence, such as aerobic classes where you’re sitting in a chair or using an exercise ball. Other options:

  • Swimming . Water supports your muscles, bones, and joints as you swim, especially helpful if you’re overweight or have diabetic nerve pain in your feet. A longtime favorite of exercise experts over the years, swimming avoids the pounding on your feet, knees, and hips from a high-impact sport like jogging.
  • Yoga . “I think yoga is underutilized in people with diabetes,” says Trence. “It’s a wonderful exercise, particularly for people who need to be more controlled in their movements and not be pounding the pavement.”
  • Cycling. Biking is safely low-impact – as long as you stay safely aboard – and you can ride outside for a change of scenery, or ride with a friend on stationary bikes in a health club.

Tip 2. Shoot for 30 Minutes, 5 Days a Week.
The American Diabetes Association (ADA) advises being active for 30 minutes a day, five days a week. The good news? Vigorous yard work like raking leaves and housework like vacuuming count as “activity.”

  • Start with a short warm up period to help prepare your muscles, heart and lungs. Gentle stretches for five to 20 minutes help reduce injury.
  • Build slowly over time, so you keep feeling successful and having fun.
  • Don’t worry if, some days, you can’t do a full 30 minutes all at once. You can meet your daily goal of 30 minutes with 10 minutes of yard work in the morning, 10 minutes of vacuuming after lunch, and a brisk 10-minute walk after dinner.
  • Start with simple things, says Trence, like parking farther from the door or using the stairs when you can.

Tip 3. You Don’t Have to Sweat.
All exercise isn’t alike. Aerobic exercise raises your heart rate, helps you lose weight, and does make you sweat. But all your exercise doesn’t have to be so hard that you need to sweat to reap the benefits. Try strength training, like lifting weights, and working on your flexibility by stretching or taking a yoga class.

  • Mix it up. Try a combo of activities that build your aerobic fitness, strength, and flexibility. You’ll get more benefits – and be less prone to injury and boredom.
  • Modification is the key. If you can’t do a regular push-up, for instance, you can do a few push-ups against a wall, so it’s a lot less work for your arms and shoulders. Go for a sense of success: if you feel successful, you’re more likely to stay with it.
  • You don’t have to spend money for club dues. With so many exercise videos and DVDs out now, says Trence, people can exercise at home and try new things.

Tip 4. Make It Fun.
Choose activities you enjoy – or at least enjoy some aspects of. Otherwise, it’s a cinch you’ll back out when your commitment flags. So don’t join the dance workout at the Y just because your wife loves it – though if you’re a music lover, a dance class could be just your style. Bowling might be right up your alley. But if you’ve never had any hand-eye coordination or “ball sense,” then taking up tennis or volleyball may not be your thing.

  • Think back to high school or college: what did you love to do back then? Were you a great softball player, golfer – or love to shoot hoops? Look for a club, gym, or community center where you can join a pick-up league.
  • Find people at your fitness level, so you won’t feel overly frustrated.
  • Fun is unique to each person. For you, something may be fun because it’s new. For others, pleasure is something familiar and comfortable. Know thyself, and trust thyself.

Tip 5. Make It Social.
Behavioral medicine experts all agree: social support helps keep you going when the going gets tough. And what’s tougher than trying to make lifestyle changes?

  • Make regular weekly dates with a friend, neighbor, or family member to walk or exercise with you. You may be more likely to stay committed since you won’t want to let the other person down.
  • Consider joining a local walking or hiking club, so you get outside, get some fresh air, and meet new people. You may find it’s easier to exercise when you let others do the planning.
  • Check out groups like a softball team, volleyball team, or cycling club. Your local Y might have a swim team for adults. Or a local school may need a volunteer coach.

Tip 6. Try Something New
In the wake of the fitness boom, you have more choices than ever for new forms of exercise. Avoid boredom or feeling like exercise is a chore by trying something new.

  • Try a water aerobics class or other swim class at your local pool.
  • Take a class in a new sport or activity, like golf, badminton, kayaking, or ballroom dancing.
  • Try yoga, tai chi, and other exercise that enhances your mind/body connection, encourages relaxation, and brings on a sense of well-being.

The bottom line? The more fun you have with it, the more likely you’ll create a healthy, active lifestyle that invigorates you and helps you manage diabetes for a lifetime.

Diabetic Neuropathy

Original Editor – Wendy Walker

Top Contributors – Sheik Abdul Khadir, Lucinda hampton, Wendy Walker, Kim Jackson and Garima Gedamkar


Diabetic neuropathy is the most common complication of Diabetes Mellitus (DM), affecting as many as 50% of patients with type 1 and type 2 DM. A large American study estimated that 47% of patients with diabetes have some peripheral neuropathy. Diabetes increases the risk of foot ulceration and amputation more than 23-fold and neuropathy is the major contributory factor to this increased risk. Neuropathy presents as painful neuropathy in 20% of patients and it independently predicts all-cause and diabetes-related mortality. Neuropathies are characterized by a progressive loss of nerve fibre function.

Clinically Relevant Anatomy

Cutaneous and deep sensations are mediated by superficial and deep topically distributed receptors and nerve fibers. In most patients with peripheral neuropathy, loss of sensation is directly attributable to kind, severity, and distributed loss of these sensory receptors, nerve fibers, or neurons. There is a degree of functional specificity of cutaneous and deep receptors and of their sensory nerve fibers. Thus, touch-pressure sensation of non-hairy skin is mediated by Meissner corpuscles with small receptive fields, sharp borders, and low thresholds that accommodate rapidly. Pacinian corpuscles respond to vibratory stimuli and have large receptive fields with sloping borders and low thresholds that accommodate quickly. Cooling receptors are more widely distributed and more frequent than warm receptors.

Mechanism of Injury / Pathological Process


Current thinking on the causes of diabetic neuropathy is that it is likely to be multifactorial.

Contributory factors:

  • Hyperglycaemic exposure- causing increased levels of intracellular glucose in nerves, leading to saturation of the normal glycolytic pathway
  • Elevated lipids
  • Hypertension
  • Increased production of free radicals in diabetes – this may be detrimental via several mechanisms that are not fully understood

Development of symptoms depends on many factors, such as total hyperglycemic exposure and other risk factors such as elevated lipids, blood pressure, smoking, increased height, and high exposure to other potentially neurotoxic agents such as ethanol. Genetic factors may also play a role. Important contributing biochemical mechanisms in the development of the more common symmetrical forms of diabetic polyneuropathy likely include the polyol pathway, advanced glycation end products, and oxidative stress.

Risk Factors

Risk factors associated with more severe symptoms:

  • smoking
  • poor glycaemic control
  • advanced age
  • long duration of Diabetes disease
  • heavy alcohol intake
  • tall stature as it is thought that this may be because longer nerve fibres are more susceptible to injury.

Clinical Presentation

More than half of cases are distal symmetric polyneuropathy. Focal syndromes such as carpal tunnel syndrome (14-30%), radiculopathies/plexopathies, and cranial neuropathies account for the rest.

Motor Symptoms

Motor problems may include distal, proximal, or more focal weakness.

  1. In the upper limbs- distal motor symptoms often include impaired fine hand coordination.
  2. In the lower limbs – Mild foot drop or frequent tripping may be early symptoms of lower limb weakness. Symptoms of proximal limb weakness include difficulty climbing up and down stairs, difficulty getting up from a seated or supine position, falls due to the knees giving way, and difficulty raising the arms above the shoulders.

Sensory Symptoms

A slow, insidious onset sensory neuropathy typically shows a stocking-and-glove distribution in the distal extremities.

Sensory symptoms may be negative or positive, diffuse or focal.

  • Negative sensory symptoms include feelings of numbness or deadness, which patients may describe as being akin to wearing gloves or socks. Loss of balance, especially with the eyes closed, and painless injuries due to loss of sensation are common.
  • Positive symptoms may be described as burning, prickling pain, tingling, electric shock–like feelings, aching, tightness, or hypersensitivity to touch.

Diagnostic Procedures

Testing includes assessment of gross light touch and pinprick sensation. The first clinical sign that usually develops in diabetic symmetrical sensorimotor polyneuropathy is reduction of vibratory and pinprick sensation over the toes. As disease progresses, the level of decreased sensation may move upward into the legs and then from the hands into the arms, a pattern often referred to as “stocking and glove” sensory loss. Very severely affected patients may loose sensation in a “shield” distribution on the chest.

Vibratory sense in the feet is tested with a 128-Hz tuning fork placed at the base of the great toenail.
Deep tendon reflexes are commonly hypoactive or absent.

The latest recommendations continue to advocate a multimodal approach to assessing diabetic neuropathy. This should include symptoms and signs, quantitative sensory testing, and electrophysiology.


A classification system by Thomas combines anatomy and pathophysiology.

  • Hyperglycemic neuropathy (acute)
  • Generalised symmetrical polyneuropathies
  • Sensory neuropathy
  • Sensorimotor neuropathy (chronic, symmetric)
  • Autonomic neuropathy (cardiovascular, gastrointestinal, genitourinary, sudomotor)
  • Focal and multifocal neuropathies: this category includes cranial neuropathy, proximal motor neuropathy (amyotrophy), thoracic or lumbar radiculopathies, and focal limb neuropathies (entrapment neuropathies)
  • Superimposed chronic inflammatory demyelinating polyneuropathy (CIDP)

Another generally accepted classification of diabetic neuropathies divides them broadly into symmetrical and asymmetrical neuropathies.


A common staging scale of diabetic polyneuropathy is as follows:

  • NO – No neuropathy
  • N1a – Signs but no symptoms of neuropathy
  • N2a – Symptomatic mild diabetic polyneuropathy; sensory, motor, or autonomic symptoms; patient able to heel walk
  • N2b – Severe symptomatic diabetic polyneuropathy (as in N2a, but patient unable to heel walk)
  • N3 – Disabling diabetic polyneuropathy

Medical Management / Interventions

Anticonvulsants: Gabapentin; Pregabalin; Valproate

Antidepressants:Amitriptyline; Duloxetine; Venlafaxine

Opioids: Dextromethorphan; Morphine sustained release; Oxycodene; Tapentadol; Tramadol.

Others: Topical nitrate sprays; Capsaicin cream

Physiotherapy Management and Exercise

Research has shown that strength training can moderately improve muscle function in people with peripheral neuropathy (PN). Regular exercise can also help reduce neuropathic pain and help control blood sugar levels. Diabetic clients must tightly monitor their blood sugar levels during exercise to prevent major fluctuations. This may involve educating clients and monitoring blood sugars, ideally through a multi-disciplined approach in rehabilitation.

Specific exercise programs should include

  • Flexibility (progressive stretching and self stretches)
  • Muscle strengthening ( using a variety of modes as appropriate eg isometric, graded weight progression, open and close chain)
  • Aerobic activity ( aiming for 30 minutes 4 times a week)
  • Balance ( for falls prevention and stability)
  • Gait (can improve gait pattern or walking in patients with diabetic neuropathy) Evidence shows that resistant strengthening exercises lower blood glucose level

The youtube below shows some good exercises that a physiotherapist can employ to help manage the symptoms of diabetic neuropathy.

A 2014 review found that the biggest consequence of diabetic neuropathy was a increase in risk of falls. Therefore balance and falls prevention programs and or training, in the senior diabetic clientele in particular, by a physiotherapy is very beneficial.

Physiotherapy may also involve splinting for mononeuropathies eg. carpal tunnel or for muscle weakness eg Ankle foot orthoses.

As a consequence of diabetic neuropathy physiotherapist are involved in

The Diabetic Foot.

The Diabetic Amputee.

Physiotherapeutic Management of Pain in Diabetic Neuropathy

see also Nerve Injury Rehabilitation Physiotherapy

Evidence has been provided for:

  1. Transcutaneous Nerve Stimulation (TENS)
  2. Static magnetic field therapy
  3. Low-intensity laser therapy
  4. Monochromatic infrared light

Differential Diagnosis

Other possible causes of neuropathy include:

  • Toxins (eg, alcohol, occupational, vitamin B6)
  • medications (eg, amiodarone)
  • Hypothyroidism
  • Pernicious anaemia
  • Malignancies
  • Amyloidosis
  • Collagen vascular disease
  • Neurosarcoidosis.
  • Tabes dorsalis
  • AIDS.
  • Spinal cord disease
  • Cauda equina syndrome.
  • Autoimmune disorders (e.g. Guillain-Barré syndrome, systemic lupus erythematosus, and rheumatoid arthritis)

How Does Exercise Affect Nerve Pain?

The results support exercise as a potentially useful nondrug treatment for neuropathic pain, and suggest that it may work by reducing inflammation-promoting substances called cytokines. The lead author was Yu-Wen Chen, PhD, of China Medical University, Taichung, Taiwan.

Exercise Reduces Nerve Pain and Cytokine Expression in Rats Neuropathic pain is a common and difficult-to-treat type of pain caused by nerve damage, seen in patients with trauma, diabetes, and other conditions. Phantom limb pain after amputation is an example of neuropathic pain.

Dr Chen and colleagues examined the effects of exercise on neuropathic pain induced by sciatic nerve injury in rats. After nerve injury, some animals performed progressive exercise — either swimming or treadmill running — over a few weeks. The researchers assessed the effects of exercise on neuropathic pain severity by monitoring observable pain behaviors.

The results suggested significant reductions in neuropathic pain in rats assigned to swimming or treadmill running. Exercise reduced abnormal responses to temperature and pressure — both characteristic of neuropathic pain.

Exercise also led to reduced expression of inflammation-promoting cytokines in sciatic nerve tissue — specifically, tumor necrosis factor-alpha and interleukin-1-beta. That was consistent with previous studies suggesting that inflammation and pro-inflammatory cytokines play a role in the development of neuropathic pain in response to nerve injury.

Exercise also led to increased expression of a protein, called heat shock protein-27, which may have contributed to the reductions in cytokine expression.

Neuropathic pain causes burning pain and numbness that is not controlled by conventional pain medications. Antidepressant and antiepileptic drugs may be helpful, but have significant side effects. Exercise is commonly recommended for patients with various types of chronic pain, but there are conflicting data as to whether it is helpful in neuropathic pain.

The new results support the benefits of exercise in reducing neuropathic pain, though not eliminating it completely. In the experiments, exercise reduced abnormal pain responses by 30 to 50 percent.

The study also adds new evidence that inflammation contributes to the development of neuropathic pain, including the possible roles of pro-inflammatory cytokines. The results provide support for exercise as a helpful, nondrug therapy for neuropathic pain — potentially reducing the need for medications and resulting side effects.



Peripheral neuropathy is a progressive disease of the nerve endings most often occurring in people 50 years old and over.

Progressive nerve deterioration eventually leads to symptoms including numbness, loss of balance, tingling, pins and needles, burning sensations, and eventually unrelenting pain.

These symptoms get worse over a period of months to years and are different for every person. Over time, as the nerves get worse, the nerves of the hands can also become involved leading to problems with dropping objects, alteration of handwriting, numbness, tingling, and eventually chronic pain.

This progressive nerve disease is often caused by chronic diabetes (even if well managed), chemotherapy, vitamin imbalances, side effects from medications, chronic inflammation, and spinal stenosis. All of these factors can damage the delicate blood vessels that are responsible for feeding your nerves and keeping them healthy.

Medical help often begins and ends with a symptom cover-up approach. Medications like Gabapentin, Lyrica & Neurontin (if they work at all) cover-up pain but do not stop or reverse nerve damage. Antidepressants like Cymbalta may help one tolerate symptoms, but again, do not address the underlying condition…progressive nerve deterioration.

If medications DO NOT WORK, what about surgery or physical therapy?

Unfortunately, there isn’t a surgery to address this progressive nerve damage and physical therapy doesn’t work either. Now exercise (physical therapy) may help with balance but it cannot stop or reverse the nerve damage. If it could then walking around would do the trick. Plus, why work on balance training when the nerve damage is still present and is going to keep getting worse. Let’s not put the cart before the horse.

In order to effectively treat your neuropathy three factors must be determined.

1) What is the underlying cause?
2) How much nerve damage has been sustained.
*** Once you have sustained 85% nerve loss, there is likely nothing that we can do for you.
3) How much treatment will your condition require?


To heal damaged nerves, we use our State of the Art Multi-Spectrum Laser (MSL) . This laser is not like any other Laser you may have already seen or heard about. Why? Because those other Lasers were not designed specifically for neuropathy and typically produce only one or two small beams of Laser. While that may be good for pinpointing a very specific spot like a cavity in a tooth, it is not good for healing a large area of damage like a foot, a leg or a hand with neuropathy.

That’s why we use our Multi-Spectrum Laser (MSL). This Laser was designed specifically to treat neuropathy and uses 120 separate beams that surround your damaged body part and saturate your dying nerves with the blood, oxygen and nutrients they need to heal throughout the entire treatment session. Our laser even stimulates the growth of new blood vessels around the damaged nerves to better provide them with the proper nutrients to heal and repair. It’s like adding sunlight, water and Miracle Grow to a plant and seeing the roots grow deeper and deeper.

Now that probably sounds good to you, but you need to know more…

Laser treatments alone may not be enough to heal some advanced types of neuropathy. This is why we also use Deep Nerve Stimulation (DNP) to heal neuropathy.


With Deep Nerve Stimulation (DNS) we send a specific, pulsing wavelength of stimulation that penetrates deep down to where the damaged nerves are. The DNS treatment jump starts your damaged nerves. DNS retrains those sick nerves to transmit healthy signals instead of the bad, damaged neuropathy signals they are sending now.


The number of treatments needed to allow the nerves to fully recover varies from person to person and can only be determined after a detailed neurological and vascular evaluation. As long as you have not sustained at least 85% nerve damage there is hope! Nerve damage of 85% or beyond means we cannot help and will not accept the case.

Here is what some of our patients have said…

“I can sleep better, walk better and have much better balance. The thing I love about this program is they aren’t pushing pills at me. I’m very pleased with my progress and strongly recommend this program.” – Barbara H.

“I first noticed the tingling and numbness about eight years ago. Then my feet started to hurt and they always felt like they were swollen. My doctor put me on Gabapentin, Lyrica and then Cymbalta. Nothing worked and it was getting harder and harder to walk. We had to cancel a family vacation because of it. Three weeks into this treatment and my pain level was less than half of what it used to be. A few weeks later, I barely had any more pain, the numbness and tingling went away and I have much better balance. I’m very pleased.” – Charles S.

“I tried everything. My doctor had me on multiple drugs and they not only didn’t help my neuropathy, they made me dizzy, tired, made my heart race and left me with dry mouth. I wanted something that would actually work and without all the side effects. This program has been wonderful. I’ve had about 80% improvement. It’s been great!” – James W.

“My doctor told me nothing would help the pain in my feet and I’d just have to live with it. I knew there had to be something out there that could help. Thank you Dr. Rappaport for taking the pain away!” – Howard S.


The more people we treat, the more I see that this is the answer people with neuropathy have been waiting for. So now is the time to call us at 561-369-0808 to schedule your consultation.

Our office is called BODYWORKS WELLNESS. We are located at 7410 Boynton Beach Blvd (in the Flakowitz Shopping Center). Our phone number is 561-369-0808. Call Today for an appointment. We can help you.

-Dr. Brian Rappaport

7410 Boynton Beach Blvd, Suite B5

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