Table 5

Physical activity consideration, precautions, and recommended activities for exercising with health-related complications

Health complicationExercise considerationsPhysical activity recommendations/precautions
Cardiovascular diseases
 Coronary artery disease
  • Coronary perfusion may actually be enhanced during higher-intensity aerobic or resistance exercise.

  • All activities okay.

  • Consider exercising in a supervised cardiac rehabilitation program, at least initially.

 Exertional angina
  • Onset of chest pain on exertion, but exercise-induced ischemia may be silent in some with diabetes.

  • All activities okay, but heart rate should be kept ≥10 bpm below onset of exercise-related angina.

 Hypertension
  • Both aerobic and resistance training may lower resting blood pressure and should be encouraged.

  • Some blood pressure medications can cause exercise-related hypotension.

  • Ensure adequate hydration during exercise.

  • Avoid Valsalva maneuver during resistance training.

 Myocardial infarction
  • Stop exercise immediately should symptoms of myocardial infarction (such as chest pain, radiating pain, shortness of breath, and others) occur during physical activity and seek medical attention.

  • Restart exercise after myocardial infarction in a supervised cardiac rehabilitation program.

  • Start at a low intensity and progress as able to more moderate activities.

  • Both aerobic and resistance exercise are okay.

 Stroke
  • Diabetes increases the risk of ischemic stroke.

  • Stop exercise immediately if symptoms of a stroke (occurring suddenly and often affecting only one side of the body) happen during exercise.

  • Restart exercise after stroke in a supervised cardiac rehabilitation program.

  • Start at a low intensity and progress as able to more moderate activities.

  • Both aerobic and resistance exercise are okay.

 Congestive heart failure
  • Most common cause is coronary artery disease and frequently follows a myocardial infarction.

  • Avoid activities that cause an excessive rise in heart rate.

  • Focus more on doing low- or moderate-intensity activities.

 Peripheral artery disease
  • Lower-extremity resistance training improves functional performance (161).

  • Low- or moderate-intensity walking, arm ergometer, and leg ergometer preferred as aerobic activities (162).

  • All other activities okay.

Nerve disease
 Peripheral neuropathy
  • Regular aerobic exercise may also prevent the onset or delay the progression of peripheral neuropathy in both type 1 and type 2 diabetes (163).

  • Proper care of the feet is needed to prevent foot ulcers and lower the risk of amputation (6).

  • Keep feet dry and use appropriate footwear, silica gel or air midsoles, and polyester or blend socks (not pure cotton).

  • Consider inclusion of more non–weight-bearing activities, particularly if gait altered.

 Local foot deformity
  • Manage with appropriate footwear and choice of activities to reduce plantar pressure and ulcer risk (164).

  • Focus more on non–weight-bearing activities to reduce undue plantar pressures.

  • Examine feet daily to detect and treat blisters, sores, or ulcers early.

 Foot ulcers/amputations
  • Moderate walking is not likely to increase risk of foot ulcers or reulceration with peripheral neuropathy (165).

  • Weight-bearing activity should be avoided with unhealed ulcers.

  • Examine feet daily to detect and treat blisters, sores, or ulcers early.

  • Amputation sites should be properly cared for daily.

  • Avoid jogging.

 Autonomic neuropathy
  • May cause postural hypotension, chronotropic incompetence, delayed gastric emptying, altered thermoregulation, and dehydration during exercise (6).

  • Exercise-related hypoglycemia may be harder to treat in those with gastroparesis.

  • With postural hypotension, avoid activities with rapid postural or directional changes to avoid fainting or falling.

  • With cardiac autonomic neuropathy, obtain physician approval and possibly undergo symptom-limited exercise testing before commencing exercise (166).

  • With blunted heart rate response, use heart rate reserve and ratings of perceived exertion to monitor exercise intensity (167).

  • With autonomic neuropathy, avoid exercise in hot environments and hydrate well.

Eye diseases
 Mild to moderate nonproliferative retinopathy
  • Individuals with mild to moderate nonproliferative changes have limited or no risk for eye damage from physical activity.

  • All activities okay with mild, but annual eye exam should be performed to monitor progression.

  • With moderate nonproliferative retinopathy, avoid activities that dramatically elevate blood pressure, such as powerlifting.

 Severe nonproliferative and unstable proliferative retinopathy
  • Individuals with unstable diabetic retinopathy are at risk for vitreous hemorrhage and retinal detachment.

  • Avoid activities that dramatically elevate blood pressure, such as vigorous activity of any type.

  • Avoid vigorous exercise; jumping, jarring, and head-down activities; and breath holding (6).

  • No exercise should be undertaken during a vitreous hemorrhage.

 Cataracts
  • Cataracts do not impact the ability to exercise, only the safety of doing so due to loss of visual acuity.

  • Avoid activities that are more dangerous due to limited vision, such as outdoor cycling.

  • Consider supervision for certain activities.

Kidney diseases
 Microalbuminuria
  • Exercise does not accelerate progression of kidney disease even though protein excretion acutely increases afterward (6,159).

  • Greater participation in moderate-to-vigorous leisure time activity and higher physical activity levels may actually moderate the initiation and progression of diabetic nephropathy (168170).

  • All activities okay, but vigorous exercise should be avoided the day before urine protein tests are performed to prevent false positive readings.

 Overt nephropathy
  • Both aerobic and resistance training improve physical function and quality of life in individuals with kidney disease.

  • Individuals should be encouraged to be active.

  • All activities okay, but exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced.

 End-stage renal disease
  • Doing supervised, moderate aerobic physical activity undertaken during dialysis sessions may be beneficial and increase compliance (171).

  • Exercise should begin at a low intensity and volume if aerobic capacity and muscle function are substantially reduced.

  • Electrolytes should be monitored when activity done during dialysis sessions.

Orthopedic limitations
 Structural changes to joints
  • Individuals with diabetes are more prone to structural changes to joints that can limit movement, including shoulder adhesive capsulitis, carpal tunnel syndrome, metatarsal fractures, and neuropathy-related joint disorders (Charcot foot) (25).

  • In addition to engaging in other activities (as able), do regular flexibility training to maintain greater joint range of motion (10,12).

  • Stretch within warm-ups or after an activity to increase joint range of motion best (172).

  • Strengthen muscles around affected joints with resistance training.

  • Avoid activities that increase plantar pressures with Charcot foot changes.

 Arthritis
  • Common in lower-extremity joints, particularly in older adults who are overweight or obese.

  • Participation in regular physical activity is possible and should be encouraged.

  • Moderate activity may improve joint symptoms and alleviate pain.

  • Most low- and moderate-intensity activities okay, but more non–weight-bearing or low-impact exercise may be undertaken to reduce stress on joints.

  • Do range-of-motion activities and light resistance exercise to increase strength of muscles surrounding affected joints.

  • Avoid activities with high risk of joint trauma, such as contact sports and ones with rapid directional changes.