CLINICAL
REVIEW
Author
Rudy Dressendorfer, BScPT, PhD
Cinahl Information Systems, Glendale, CA
Reviewers
Brian Dy, PT, DPT, CKTP, CSCS
Cinahl Information Systems, Glendale, CA
Abigail Grover Snook, PT, MS, MEd
Cinahl Information Systems, Glendale, CA
Rehabilitation Operations Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Sharon Richman, MSPT
Cinahl Information Systems, Glendale, CA
September 22, 2017
Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights
reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by
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or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
Diabetes Mellitus, Type 1, and Exercise
Indexing Metadata/Description
› Title/condition: Diabetes Mellitus, Type 1, and Exercise
› Synonyms: Insulin-dependent diabetes mellitus and exercise; diabetes mellitus,
insulin-dependent, and exercise; type 1 diabetes mellitus and exercise; juvenile-onset
diabetes mellitus and exercise; diabetes mellitus, juvenile-onset, and exercise; IDDM and
exercise
› Anatomical location/body part affected: Islets of Langerhans of pancreas/microvascular
damage in numerous tissues (e.g., retinopathy, nephropathy, and neuropathy)
› Area(s) of specialty: Pediatric Rehabilitation, Cardiovascular Rehabilitation, Home
Health, Acute Care
› Description
• The hallmark of diabetes mellitus, type 1 (DM1), is the absence of endogenous insulin
production. Consequently, patients with DM1 must remain vigilant of their blood
glucose concentration and self-administer insulin to avoid the microvascular damaging
effects of abnormally high glucose levels (i.e., hyperglycemia)
• In addition to general health promotion, regular exercise increases insulin sensitivity and
reduces the daily amount of insulin needed for glycemic control. Exercise is, therefore,
an important component of DM1 management for preventing or at least delaying
complications of DM1(1)
• However, proper exercise prescription and monitoring is needed to maintain glycemic
control to reduce the risk of exercise-relatedhypoglycemia symptoms. Fear of
hypoglycemia during exercise is a major challenge for persons with DM1, especially
children, to participating in regular physical activity(34)
• It is important that persons with DM1 monitor their blood glucose during and after
exercise and adjust their insulin dose and carbohydrate intake, as needed, to avoid
becoming overinsulinized (i.e., excessive insulin production above that needed to
maintain normoglycemia) and hypoglycemic
• On the other hand, blood glucose may become elevated hours after exercise due to
counterregulatory glucose defense hormones that increase blood glucose and oppose
the effect of insulin.(35) Diabetic ketoacidosis is a potential acute emergency condition
caused by insulin deficiency and severe hyperglycemia. Persons with DM1 may have
increased risk of exercise-related ketoacidosis in high-intensity sports(2)
› ICD-9 codes
• 250.01 diabetes mellitus without mention of complication, type 1, not stated as
uncontrolled
• 250.03 diabetes mellitus without mention of complication, type 1, uncontrolled [i.e.,
blood glucose > 200 mg/dL]
• 250.1 diabetes with ketoacidosis
• 250.91 diabetes mellitus with unspecified complication, type 1, not stated as
uncontrolled
› ICD-10 codes
• E10 insulin-dependent diabetes mellitus type 1
• E10.1 insulin-dependent diabetes mellitus type 1 with ketoacidosis
(ICD codes are provided for the reader’s reference, not for billing purposes)
› G-Codes
• Mobility G-code set
–G8978, Mobility: walking & moving around functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8979, Mobility: walking & moving around functional limitation; projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8980, Mobility: walking & moving around functional limitation, discharge status, at discharge from therapy or to end
reporting
• Changing & Maintaining Body Position G-code set
–G8981, Changing & maintaining body position functional limitation, current status, at therapy episode outset and at
reporting intervals
–G8982, Changing & maintaining body position functional limitation, projected goal status, at therapy episode outset, at
reporting intervals, and at discharge or to end reporting
–G8983, Changing & maintaining body position functional limitation, discharge status, at discharge from therapy or to end
reporting
›.
G-code Modifier Impairment Limitation Restriction
CH 0 percent impaired, limited or restricted
CI At least 1 percent but less than 20 percent
impaired, limited or restricted
CJ At least 20 percent but less than 40 percent
impaired, limited or restricted
CK At least 40 percent but less than 60 percent
impaired, limited or restricted
CL At least 60 percent but less than 80 percent
impaired, limited or restricted
CM At least 80 percent but less than 100
percent impaired, limited or restricted
CN 100 percent impaired, limited or restricted
Source: https://www.cms.gov/

.
› Reimbursement: Reimbursement for exercise management in DM1 will depend on insurance contract coverage. No specific
issues or information regarding reimbursement have been identified
› Presentation/signs and symptoms
• Commonly, the patient is a recreationally active child, adolescent, or young adult. More research is needed on exercise for
older adults with DM1
• Signs and symptoms of hypoglycemia (blood glucose level less than 70 mg/dL)
–Inappropriate profuse sweating
–Rapid onset of fatigue, associated with loss of muscle tone or feeling weak(3)
–Confusion/impaired cognitive function(3)
–Dizziness(3)
–Hunger(3)
–Headache(3)
–Paleness of the skin(3)
–Alterations in behavior(3)
–Seizure(3)
–Area surrounding affected cutaneous nerves may tingle(3)
 –Shakiness/trembling
–Blurred vision
• Signs and symptoms of hyperglycemia
–Nausea
–Dehydration
–Frequent urination(3)
–Increased thirst(3)
• Signs and symptoms of ketoacidosis associated with hyperglycemia
–Distinctive fruity smell on patient’s breath
–Dehydration resulting from frequent urination
–Nausea and vomiting
–Shortness of breath
–Fatigue
–Muscle stiffness/aching
–Disorientation/stupor that can progress to coma
• Use of glucose sensor, subcutaneous insulin injections, or glucose pump
• Consumption of foods with high glycemic index to resolve symptoms of hypoglycemia

Causes, Pathophysiology, & Risk Factors

› Causes
• Diabetic hypoglycemia results from an imbalance in blood glucose homeostasis
–Glucose uptake in tissues greater than the arterial blood glucose supply
–Increased glucose uptake due to augmented muscle metabolism during physical activity/exercise and/or excessive insulin
dosing
–Failure to maintain blood glucose level because of insufficient glucose supplied by liver and/or consumption of
glucose-rich carbohydrate foods
• Chronic hyperglycemia in DM1 (blood glucose level routinely higher than 125 mg/dL) and acute hyperglycemia (higher
than 180 mg/dL) may result from:
–lack of insulin production
–resistance to insulin at the cellular level(4)
–intense or prolonged exercise, systemic infection, or inflammation that promotes the release of stress hormones (such as
glucagon and epinephrine) that stimulate glycogenolysis in liver
–certain medications used to treat comorbid conditions (e.g., beta-adrenergic blockers, thiazide diuretics, epinephrine,
corticosteroids, glucosamine)
• Diabetic ketoacidosis occurs with severe hyperglycemia due to insulin deficiency that results in rapid oxidation of lipids in
the liver. Blood pH falls as ketone bodies released from the liver accumulate in blood and urine
› Pathophysiology
• In nearly all persons with DM1, the pancreas is unable to produce insulin because beta cells in the islets of Langerhans
have been destroyed by autoimmune disease. Hyperglycemia develops since insulin inhibits glucose release from the liver
and stimulates the uptake of glucose
• Chronic hyperglycemia, which is clinically indicated by elevated glycosylated hemoglobin (HbA1c), generates oxidants
that promote cellular injury and also increase blood osmolarity with subsequent dehydration of the tissues. Chronic
hyperglycemia is the major initiator of diabetic microvascular and neural complications, such as retinopathy, neuropathy,
and nephropathy.(5) Aerobic or resistance exercise training performed at least twice weekly for a minimum of 2 months
may reduce HbA1c levels in adults with DM1(36)
–Low-intensity aerobic exercise performed 4 times per week for 12 weeks by patients with DM1 has been shown to induce
significant increases in microvascular density and endothelial-dependent capillary reactivity(39)
• Persons with DM1 should monitor their blood glucose concentration and receive insulin subcutaneously (usually
self-injection or glucose pump)and/or take oral antidiabetic medications to prevent hyperglycemia
–For some patients with DM1, insulin delivery through an insulin pump during exercise can be reduced or disconnected,
depending on the duration and intensity of the exercise(17)
 • The management of hyperglycemia in DM1 requires appropriate dosing of exogenous insulin. Achieving target levels
of blood glucose with therapeutic insulin involves a delicate balance between the current blood glucose level and the
insulin preparation used because overinsulinization can cause hypoglycemia. The use of combinations of short-acting and
long-acting insulin preparations has improved the hourly control of blood glucose levels(6)
• In addition to the health promotion benefits of regular physical activity, aerobic exercise improves insulin sensitivity and
thus enhances glucose uptake. However, this becomes an additional concern in the self-management of blood glucose
levels because excessive glucose uptake in muscle can cause hypoglycemia to develop during and/or after exercise.
Severe hypoglycemia is associated with reduced consciousness (which may cause accidents), coma, convulsions, transient
hemiparesis and stroke, cardiac arrhythmias, and myocardial ischemia
–The American Diabetes Association recommends that when symptoms of hypoglycemia occur (often suddenly), persons
with diabetes(3)
- consume 15-20 grams of glucose or simple carbohydrates
- Authors of a randomized crossover study conducted in New Zealand with 34 adults with frequent hypoglycemia
associated with DM1 found that a weight-based (0.3 g/kg) dosage was more effective than a standard dose of 15 g for
treating symptomatic hypoglycemia(40)
- recheck blood glucose after 15 minutes and if hypoglycemia continues, repeat
- once blood glucose returns to normal, eat a small snack if the next planned meal or snack is more than an hour or two
away
• Blood glucose supply and demand during physical activity is affected by several factors, including the type, intensity,
and duration of exercise as well as the amount of insulin and food in the body at the time of the activity. Low-intensity
and moderate-intensitycontinuous exercise increase insulin sensitivity and glucose uptake in muscle. When prolonged for
longer than 30 minutes, this type of exercise often lowers blood glucose in persons with DM1. The pre-exercise blood
glucose level, insulin dose, and carbohydrate intake should be appropriately managed in order to reduce the development of
hypoglycemia(7,8)
• Another problem in glycemic control during prolonged low- and moderate-intensity exercise is that the increased secretion
of counterregulatory glucose defense hormones (i.e., glucagon, epinephrine, and growth hormone) does not increase
hepatic glucose production enough to prevent a fall in blood glucose
• Also, patients with DM1 are often unaware of their falling blood glucose until symptoms occur during exercise.(17)
Typically, carbohydrate intake is needed during prolonged exercise to maintain blood glucose
• In contrast, short, intermittent, and high-intensity physical activity (e.g., resistance exercise/weight lifting, sprints, and
interval exercise) may counteract exercise-related hypoglycemia by raising blood glucose levels through the stimulation of
counterregulatory hormone secretion to promote hepatic glucose production.(9) However, moderate aerobic exercise may
blunt the effect of resistance exercise on increasing the growth hormone response
–Authors of a small study (n = 11 patients with DM1, mean age 33 years) in Canada found that weight lifting before
treadmill running exercise was more effective for increasing blood growth hormone levels compared to weight lifting
after treadmill exercise(37)
• Glycemic control in DM1 thus involves careful planning for exercise and monitoring of blood glucose levels before,
during, and sometimes for long periods after exercise. Post-exercise hypoglycemia may develop hours after exercise if a
sufficient amount of glucose-richfood is not eaten.(17) In one study, hypoglycemia occurred up to 31 hours after exercise(10)
• Target levels of blood glucose concentration in adults with diabetes(11)
–Before meals: 70–130 mg/dL
–One to two hours after starting a meal: < 180 mg/dL
› Risk factors for hypoglycemia
• Prolonged, continuous low- or moderate-intensity aerobic physical activity is associated with increased risk of
exercise-relatedhypoglycemia due to enhanced uptake of blood glucose(7)
–Authors of a study (n = 50 children and adolescents with DM1) in the United States found that a blood glucose
concentration under 120 mg/dL before starting treadmill walking exercise (target heart rate of 140 beats/min during four
15-minute periods with three 5-minute rest periods) increased the risk of hypoglycemia(12)
• Prolonged periods of not eating, including overnight fasting (leading to nocturnal hypoglycemia), can increase the risk
of severe hypoglycemia. Symptoms during sleep may go undetected. Patients with a history of profuse sweating at night
and morning headache or feeling weak and shaky in the morning are candidates for glucose monitoring during sleep and
 possible revision of their insulin regimen to compensate for extrinsic factors that can contribute to nocturnal hypoglycemia,
such as insulin dose, exercise, or fasting(13)
• Females may have poorer glycemic control, as indicated by their higher HbA1c levels. Further research is needed to
identify reasons for this gender difference(14)

Overall Contraindications/Precautions
› Exercise is contraindicated if the patient has unstable angina pectoris, uncontrolled hypertension, significant recent changes
in resting ECG, uncontrolled cardiac arrhythmias, severe heart failure, or acute conditions such as myocarditis, pericarditis,
thrombophlebitis, pulmonary embolus, or infection
› If ketoacidosis is suspected, ensure patient is taken immediately to emergency department
› Because of increased risk for dehydration and ketoacidosis, diabetic patients should not begin exercise if their blood glucose
level is over 250 mg/dL and/or ketones are found in the urine(11,30)
› These precautionary steps should be taken if blood glucose levels after exercise are regularly 100 mg/dL or less(15)
• Increase carbohydrate intake before exercise
• Decrease insulin dose before exercise
• Decrease insulin dose after exercise
› Glucose-rich snacks should be available for the patient in the event of hypoglycemic symptoms
› Patients over 30 years old with DM1 and/or who have had DM1 for more than 10 years should have a complete medical
examination prior to initiating a moderately intense physical activity program (i.e., more intense than walking).(30)
Patients over 35 with DM1 and/or who have had DM1 for more than 10 years should undergo general exercise testing with
electrocardiogram (ECG) monitoring prior to starting a moderate or intense exercise program(17)
› Vital signs should be monitored during exercise in patients with increased risk of cardiovascular disease
› Stop exercise if patient reports difficulty breathing, chest pain, unusual fatigue, weakness, dizziness, or nausea or shows
other signs/symptoms of exercise-related hypoglycemia or hyperglycemia
› Minimize patient discomfort throughout examination and treatment
› Encourage patient to wear shoes that fit well and have plenty of room for the toes, to always wear socks, and not to use
inserts or pads unless instructed by medical personnel. Inspect shoes for cracks in the soles, bunching of material, or
wrinkles in the lining. Patient should be taught to inspect his or her feet daily. Patients with peripheral neuropathy may need
to avoid exercise that stresses the feet
› Exercise-related abrasions and contusions (such as might occur during in falls or contact sports) should be prevented, if
possible, in patients with elevated risk for infection and poor healing
› See specific Contraindications/precautions to examination and Contraindications/precautions under Assessment/
Plan of Care

Examination
› Contraindications/precautions to examination
• Stop the exam if the patient reports shortness of breath, chest pain, abnormal fatigue, or dizziness; report symptoms to the
referring physician
• Monitor blood glucose to prevent or resolve symptoms of hypoglycemia
• Complications of DM1 (e.g., retinopathy, neuropathy, nephropathy, coronary artery disease, peripheral arterial disease, or
diabetic foot ulcers) may affect the examination findings as well as the mode and protocol that are suitable for testing each
patient’s exercise responses
› History
• History of present illness/injury
–Etiology of illness: Document date of diagnosis of DM1. Have there been any episodes of hypoglycemia that required
emergency treatment? Has the patient experienced severe exercise-related hypoglycemia? Is exercise prescription with
supervision the current reason for referral? Any episodes of hyperglycemia?
–Course of treatment
- Medical management: Review current prescription for monitoring of blood glucose, diet, exercise, and skin care
- Medications for current illness/injury: Determine what medications clinician has prescribed; are they being taken?
Does the patient feel the medications are effectively controlling his or her blood sugar?
 - Injectable insulin preparations: short-acting(e.g., Apidra – onset of action 15 minutes or less, peak 1 hour, duration 2-4
hours. Humulin R –onset of action 30 minutes, peak 2-4 hours, duration 6-8 hours); long-acting (Humulin N –onset
of action 1-2 hours, peak 6-12 hours, duration 18-24 hours. Humulin L – onset of action 1-3 hours, peak 6-15 hours,
duration 18-26 hours. Humulin U – onset of action 4-6 hours, peak 8-20hours, duration 24-48 hours)
- Does the patient use an insulin pump, artificial pancreas, or other "smart" insulin delivery system?
- Oral antidiabetic agents: metformin, rosiglitazone, sulfonylureas
- Angiotensin-converting enzyme (ACE) inhibitors such as ramipril are also prescribed to reduce progression of
cardiovascular disease
- Diagnostic tests usually completed
- Fasting and postprandial blood glucose tests
- Random capillary (fingerstick) blood glucose testing
- HbA1c
- Blood glucose protein and ketones
- Urine albumin, creatinine, and microalbumin
- BUN and blood creatinine
- Eye exam
- Foot exam
- Monofilament sensory testing
- Cardiovascular exam, including heart rate (HR), blood pressure (BP), and ECG
- Supervised exercise test with ECG monitoring if > 35 years old or if has had DM1 for > 10 years(17)
- Home remedies/alternative therapies: Document any use of self-administered remedies or alternative therapies and
whether they help or not
- Previous therapy: Document whether patient has had any occupational or physical therapy interventions for this or
other conditions and what specific treatments were helpful or not helpful
–Aggravating/easing factors (and length of time each item is performed before the symptoms come on or are eased): Is
the patient anxious of exercise-relatedhypoglycemia?
–Body chart: Use body chart to document location and nature of symptoms
–Nature of symptoms: Document nature of symptoms (e.g., constant vs. intermittent, sharp, dull, aching, burning,
numbness, tingling). In addition to those shown above (see Presentation/signs and symptoms), patient may report
polyuria, polydipsia, and/or pain
–Rating of symptoms: Use a visual analog scale (VAS) or 0-10 scale to assess symptoms at their best, at their worst, and
at the moment (specifically address if pain is present now and how much)
–Pattern of symptoms: Document changes in symptoms throughout the day and night, if any (A.M., mid-day, P.M.,
night); also document changes in symptoms due to weather or other external variables
–Sleep disturbance: Document number of wakings/night. Has the patient experienced symptoms of nocturnal
hypoglycemia?
- Symptoms during sleep may go undetected. Patients with a history of profuse sweating at night and morning headache
or feeling weak and shaky in the morning are candidates for glucose monitoring during sleep and possible revision of
their insulin regimen to compensate for extrinsic factors that can contribute to nocturnal hypoglycemia, such as insulin
dose, exercise, or fasting(13)
–Other symptoms: Document other symptoms patient may be experiencing which could exacerbate the condition and/
or symptoms that could be indicative of a need to refer to physician (e.g., dizziness, shortness of breath, bowel/bladder/
sexual dysfunction)
–Respiratory status: Does the patient have respiratory complications (e.g., asthma) that require monitoring during
exercise? Does the patient require supplemental oxygen or ventilatory support?
–Barriers to learning
- Are there any barriers to learning? Yes__ No__
- If Yes, describe _________________________
• Medical history
–Past medical history
- Previous history of same/similar diagnosis: Are there any medical reasons to exclude physical activity for this patient
due to a history of poor response to exercise?
 - Comorbid diagnoses: Ask patient about other medical problems, including cancer, heart disease, pregnancy, psychiatric
disorders, orthopedic disorders, or gastrointestinal disorders (such as celiac disease). Complications of DM1 may
include diabetic retinopathy, nephropathy and/or neuropathy, coronary artery disease, diabetic foot ulcers, and peripheral
arterial disease
- Authors of a 2015 systematic review and meta-analysis concluded that adults with DM1 are at increased risk of
fracture when compared to the general population(41)
- Based on 14 studies
- The relative risk for any type of fracture was 4 times greater for women and 2 times greater for men when compared
to adults without diabetes. The relative risk of hip fractures and spinal fractures was 3.78 times greater for women
and 2.88 times greater for men when compared to adults without diabetes
- Medications previously prescribed: Obtain a comprehensive list of medications prescribed and/or being taken
(including over-the-counter drugs)
- Other symptoms: Ask patient about other symptoms he/she may be experiencing
• Social/occupational history
–Patient’s goals: Document what the patient hopes to accomplish with therapy and in general activities of daily living
(ADLs)
–Vocation/avocation and associated repetitive behaviors, if any: Does the patient currently participate in recreational or
competitive sports? Is the patient in school? Is the patient sedentary? Ask about what physical activities the patient does
enjoy
–Functional limitations/assistance with ADLs/adaptive equipment: Are there any reported limitations?
–Living environment: Document if there are barriers to independent living in the home, such as stairs, or multiple floors.
Does patient live with caregivers? Identify if any modifications are needed in the home
› Relevant tests and measures: (While tests and measures are listed in alphabetical order, sequencing should be
appropriate to patient medical condition, functional status, and setting)
• Anthropometric characteristics: Determine height, weight, and body mass index (BMI).(16) Persons with DM1 are often
underweight, as compared to those with type 2 DM
• Arousal, attention, cognition (including memory, problem solving): Assess orientation to name, place, time, and reason
for hospital admission/outpatient visit. Is patient alert?
• Assistive and adaptive devices: Assess the fit and patient’s use of prescribed ambulatory assistive device or wheelchair,
as applicable. If indicated, evaluate for suitable ambulatory assistive device. Determine the need for supportive/protective
equipment/orthotics
• Balance: Assess balance while patient performs functional mobility. Assess standing balance on both feet (eyes open vs.
closed), also on toes and heels, as well as single-leg stance and tandem standing if appropriate. If the patient has impaired
balance due to the loss of sensation in the lower extremities, consider need to administer the Berg Balance Scale or another
formalized balance assessment tool
• Cardiorespiratory function and endurance: In compliance with medical guidelines, assess functional aerobic capacity or
peak oxygen uptake (VO2peak) using a progressive, incremental exercise test on treadmill or cycle ergometer(16,17)
–The 6-minute walk for distance test (6MWT) can also be used to assess aerobic fitness(16)
–Assess vital signs: HR, BP, and Borg’s Rating of Perceived Exertion (RPE) prior to, during, and after fitness testing(16)
–Impaired cardiorespiratory function and endurance are associated with poor glycemic control in patients with DM1(18)
- Authors of a cohort study (n = 35) in France found that persons with DM1 (n = 23), especially those with elevated
HbA1C (n = 11) had lower VO2peak and muscle deoxyhemoglobin increase during maximal aerobic exercise than
healthy controls(38)
• Circulation: Assess pedal pulses and lower extremity filling time
• Ergonomics/body mechanics: Assess if body mechanics are appropriate during functional mobility
• Functional mobility: Assess ability in transfers (e.g., sit to stand), stair climbing, and walking ability. Use Timed Up and
Go test (TUG), or FIM, as indicated. Functional sit-to-stand test may be used to assess mobility of lower extremities(16)
• Gait/locomotion: Observe for altered/antalgic gait pattern. Assess lower-extremity/rearfoot alignment and movement
of foot in barefooted walking, and width of stance. Assess walking ability, including synchrony of limb movements, gait
speed, and posture
• Joint integrity and mobility: Assess joint integrity and mobility, if applicable
 –Please see Clinical Review…Diabetic Foot Ulcer; Topic ID Number: T708727 for more details regarding integrity and
mobility of lower extremity joints
• Motor function (motor control/tone/learning): Are the patient’s dexterity and coordination within normal limits?
• Muscle strength: Assess strength of upper and lower extremities and trunk with manual muscle testing (MMT) or
1-repetition maximum (1RM) test(16)
• Observation/inspection/palpation (including skin assessment): Inspect skin integrity of upper and lower extremities. For
more details regarding inspection of feet, please see the Clinical Review referenced above
• Posture: Assess general posture and alignment of all major joints; document asymmetries and abnormalities
• Range of motion: Assess functional ROM of upper and lower extremities and trunk
• Reflex testing: Assess deep tendon reflexes (responses of the hamstrings, quadriceps, and plantar flexors may be
diminished)
• Self-care/activities of daily living: Assess independence in ADLs, as indicated
• Sensory testing: Sensation is commonly impaired in persons with DM1
–Use pinprick to assess pain in the lower extremities
–Assess proprioception of the feet and ankles
• Special tests specific to diagnosis:
–Capillary blood glucose level should be checked before, during, and after exercise
–Quality of life – SF-36, Diabetes Quality of Life Questionnaire (DQOL) questionnaire

Assessment/Plan of Care
› Contraindications/precautions
• Follow institution guidelines regarding exercise in persons with diabetes as well as the physician’s order
• Postpone exercise and consult with physician if patient’s blood glucose level is greater than 250 mg/dL or less than 100
mg/dL(19)
• Encourage patients prone to exercise-related hypoglycemia to monitor their blood glucose level before, during, and after
exercise sessions
• Patients with clinical retinopathy should avoid high-impact exercise or using the Valsalva maneuver(19)
• Patients with diagnosed hypertension should avoid heavy resistance exercise(19)
• Patients starting a new exercise program should be given extensive education on diet and insulin use(16,19)
• Avoid application of superficial heat or cold to areas with reduced sensation due to diabetic neuropathy
› Diagnosis/need for treatment: DM1/poor physical functioning related to sedentary lifestyle or fear of exercise. Supervised
aerobic and/or resistance exercise training program with patient education indicated for improving physical fitness
• Clinical and epidemiological studies indicate that in the long term, regular aerobic exercise, along with insulin control
and nutritional management, provides physiological health benefits in persons with DM1by helping to maintain
cardiorespiratory endurance fitness, lower HbA1c levels, and normalize BMI(20)
• Regular physical activity favorably influences glycemic control and glucose metabolism in DM1(21,37)
• Regular aerobic exercise improves the microvascular density and endothelial-dependent capillary reactivity(39)
› Prognosis: Research is lacking on whether exercise management in DM1 independently influences long-term prognosis or
disease outcomes beyond that of insulin and nutritional therapy
› Referral to other disciplines: Podiatrist for toenail clipping and fitting for therapeutic shoes or inserts; physician for
any medical concerns or new problems; nutritionist for dietary therapy; nursing for education, management, and testing
equipment; wound specialist, as indicated
› Other considerations
• Diabetic patients at risk for foot ulcers require extensive education on proper care and cleaning of the feet, inspection of the
skin, and choosing appropriate shoes
• Authors of a small study (n = 10) in the United Kingdom found that, along with a proper diet, pregnant women with DM1
maintained optimal glucose control with moderate levels of physical activity (three 20-minute self-paced walks per week
and two 25-minute brisk walks per week)(32)
• Authors of a small, repeated-measures study (n = 7 runners with DM1) in the United Kingdom found that consumption of
a low-glycemiccarbohydrate snack and 25% of usual insulin dose administered 30 minutes before running improved blood
glucose control during runs(22)
 › Treatment summary
• Prescribe components of aerobic exercise program according to general guidelines(17,19)
–Mode (walking, cycling, lap swimming, etc.) – individual preference
–Intensity – begin with “fairly light” or “moderate” exertion (i.e., 50% to 85% of age-predicted or observed HRpeak in
graded exercise test)
–Duration – begin with 15 to 20 minutes of exercise (allow short rest breaks as needed)
–Frequency – begin with 3 or 4 sessions per week, on alternate days
–Progression – increase to 7 days per week, as tolerated. Progress to at least 150 minutes a week of moderate intensity or
greater exercise. Additional benefits are seen with > 300 minutes per week of moderate to intense exercise(17)
• “Free-play” physical activity in children with DM1 may be as effective for glycemic control as structured exercise,
based on a study (n = 73, ages 8-14 years), conducted in the United States, showing that elevated blood glucose levels
significantly decreased an average of 19.4 mg/dL (197.18 mg/dL to 177.78 mg/dL) during 45 minutes of free-play
swimming(23)
• A moderate strengthening program should probably be included for general fitness in most patients with DM1. However,
heavy resistance exercise (80% of 1RM) and general weight lifting may not improve insulin sensitivity or long-term
glycemic control(24)
• Authors of a small randomized controlled trial (n = 16 persons with DM1) in Belgium found that combined aerobic
(cycling, running, and stepping) and resistance (weight machines) training twice a week for 20 weeks significantly lowered
daily insulin requirements while improving fitness and quality of life(16)
• Intermittent high-intensity “sprint” training appears to be well-tolerated in selected young adults with DM1. For example,
4-10bouts of “all-out” cycling sprints for 30 seconds each, 3 times per week for 7 weeks was found to improve blood
glucose and measures of acid-base and muscle oxidative metabolism responses to intense exercise(9,25)
• Sprint exercise also appears to be effective for improving counterregulatory hormone responses to subsequent moderate
aerobic exercise. For example, a 10-second maximal cycling sprint immediately before low-intensity exercise (40% of
estimated aerobic capacity) for 20 minutes was found to prevent a postexercise drop in blood glucose level(26)
• Authors of a literature review found that reduction of insulin dose and feeding 75 grams of low glycemic index
carbohydrates before running was the best strategy for preventing a postexercise drop in blood glucose level. The best
timing for carbohydrate ingestion was 30 minutes before exercise(27)
• Capillary blood glucose should be monitored before exercise, immediately after, and at 2-hour intervals at the beginning
of a new exercise program, until the patient is aware of predictable changes and, if indicated, can compensate by eating
glucose-richfoods(28)
• Individuals who exercise with a continuous subcutaneous insulin infusion may have less postexercise hyperglycemia and
stable interstitial glucose concentrations compared to individuals using multiple daily injection (MDI) therapy(31)
• Authors of a small study (n = 12) in Portugal found that exercise consisting of weight lifting at higher intensities (60%
and 80% of 1RM) was more effective for reducing before-exercise elevated blood glucose than lower intensities of
weightlifting(33)
–However, all intensities of weightlifting were effective in lowering before-exercise elevated blood glucose levels

.
Problem Goal Intervention Expected Progression Home Program
Minor soreness, Resolve exercise- Physical agents and The intensity and Provide the patient
tenderness, and related muscle soreness mechanical modalities duration of exercises with simple ROM and
swelling that may or injury _ should be gradually strengthening exercises
develop with new Cryotherapeutic agents progressed to avoid for minor strain/sprain
exercise program and the RICE approach overexertion
are indicated for acute
minor musculoskeletal
injuries
Reduced Normal age-related Therapeutic exercise Intensity of exercise Patient may progress
cardiorespiratory aerobic fitness _ based on the aerobic to performing
endurance fitness Aerobic exercises such fitness level (see aerobic exercise and
as walking, swimming, Treatment summary, simple therapeutic
or cycling (see above) exercise at home after
Treatment summary, _ mastering all necessary
above) _ precautions and self-
_ Target 30 minutes of monitoring(29)
_ exercise at least 3 days
Non-weight-bearing per week with possible
exercise (e.g., progression to 5-7 days
swimming or cycling) per week
is recommended for
those with severe
peripheral neuropathy
Reduced muscular Normal strength for age Functional training Intensity and number Provide patient and
strength Progressive resistance of repetitions and sets family/caregivers with
training performed 2 to dependent on patient’s written instructions
3 times per week ability regarding functional
activities that can be
performed at home
and correct use and/
or application of
equipment
Lack of appropriate Appropriate skin and Patient education See Clinical Review… See Clinical Review…
skin and foot care foot care See Clinical Review… Diabetic Foot Ulcer Diabetic Foot Ulcer
Diabetic Foot Ulcer referenced above referenced above
referenced above

Desired Outcomes/Outcome Measures

› Improved strength
• MMT
› Improved aerobic fitness
• Cycle ergometer, 6MWT, or treadmill exercise test
› Improved glycemic control during and after exercise
• Random capillary blood glucose
› Improved quality of life
• SF-36, DQOL questionnaire
› Increased physical activity with reduced episodes of hypoglycemia
• Activity diary, accelerometer device (e.g., Fitbit)

Maintenance or Prevention
› Participation in a home exercise program that includes aerobic and resistance exercise with monitoring of blood glucose
level and daily skin care

Patient Education
› American Diabetes Association website, “Exercise and Type 1 Diabetes,”
http://www.diabetes.org/food-and-fitness/fitness/exercise-and-type-1-diabetes.html
Note
› Recent review of the literature has found no updated research evidence on this topic since the previous publication of the
article

Coding Matrix
References are rated using the following codes, listed in order of strength:

M Published meta-analysis RV Published review of the literature PP Policies, procedures, protocols

SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation

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