106
VOLUME 11 NUMBER 3 • SEPTEMBER 2014
REVIEW
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Physiotherapists frequently treat patients with diabetes-related
amputations. Rehabilitation may be challenging in the patient
with poor glycaemic control as wound healing may be delayed,
and vascular impairment, DN or ulceration of the intact limb affects
weight bearing and functional gait. The physiotherapist must be
aware of the condition of the wound and stump, as preparation of
the stump for prosthesis may damage fragile skin and subcutaneous
tissue. Resource limitations add to the challenges associated with
rehabilitation of amputees.
There are fewer than 800 medical orthotists and prosthetists
registered to practice in South Africa, of whom a minority practice in
the public health sector. Combined with financial restraints, this leads
to long waiting lists and delays in the provision of artificial limbs.
Considerations in the implementation of physical
activity and exercise
Barriers to participation in exercise are a factor in low activity levels.
Barriers to physical activity and exercise have been reported in
diabetic patients attending two urban clinics in Gauteng, including
both personal and environmental barriers such as health (e.g.
arthritis, foot problems, breathlessness, diabetes), laziness, socio-
economic circumstances (e.g. caring for dependants), perceived
adequate exercise (e.g. household chores, gardening), suitable
venue, safety, understanding the benefit of exercise.
20,21
The physiotherapy departments at public health institutions are
well positioned to promote exercise in communities with limited
resources. Establishment of a diabetes exercise group would
offer the diabetic patient a safe venue, access to regular exercise
and information sessions, and a supportive environment that
promotes self-management. Those unable to attend supervised
exercise groups can be prescribed an exercise programme that they
implement unsupervised in their home setting.
Mshuqane
et al
. undertook a study at Bethlehem regional
hospital in the Free State, which allocated diabetic patients to
one of three groups, namely walking under supervision, cycling
under supervision or walking unsupervised (at home). Although
the study groups were small, all groups showed improvement in
serum glucose levels and exercise capacity over the three-month
study period.
22
Patients who are unable or unwilling to take part in physical
activity of adequate duration, intensity and frequency may benefit
from participation in relaxation classes, which have been shown to
improve perception of health and general well-being, and reduce
stress and anxiety, which may have positive benefits for diabetes
self-management.
23
Guidelines for implementation of effective and safe
exercise programmes
Pre-exercise evaluation
For moderate-intensity aerobic or resistance exercise, stress testing
is not routinely necessary. Previously sedentary patients with
multiple CVD risk factors should be assessed before an exercise
programme is prescribed, and the patient’s age, activity levels and
the presence of other conditions should be noted and considered
when developing an exercise programme.
Objective measures such as the six-minute walk test, resting
and recovery pulse rates, body mass index and the Borg scale
score (perceived exertion) should be recorded during the initial
assessment. These measures should be considered when structuring
personalised programmes and rates of progression of activity.
These baseline scores may be useful to measure future progress
and motivate the patient to continue with the programme.
Exercise prescription: type, duration and frequency
To improve glycaemic control, assist with weight maintenance and
reduce risk of CVD, the physical activity should be distributed over
at least three days/week, with no more than two consecutive days
without physical activity.
17,18
At least 150 min/week of moderate-intensity aerobic physical
activity (50–70% of maximum heart rate) and/or at least 90 min/
week of vigorous aerobic exercise (70% of maximum heart rate)
should be done. Resistance exercise should be done three times a
week, targeting all major muscle groups, progressing to three sets
of eight to 10 repetitions at a weight that cannot be lifted more
than eight to 10 times.
17,18
Factors to consider during exercise prescription
Concerns have been expressed about the safety of high-intensity
resistance exercise in middle-aged and older people at risk of CVD.
The main concern is that the acute rise in blood pressure (BP)
associated with lifting a weight may provoke myocardial infarction,
stroke or retinal haemorrhage.
18
However, as an acute rise in BP can
also be associated with aerobic exercise and activities of daily living,
CVD risk should not be regarded as a contra-indication.
Until the insulin-dependent patient knows his/her usual
glycaemic response to the activity, blood glucose levels should
be determined before, after, and several hours after completing
a session of physical activity in order to prevent hypoglycaemia.
If pre-exercise glucose levels are less than 6.6 mmol/l, additional
carbohydrate can be ingested. Doses of insulin can be reduced
before exercise sessions of physical activity, or both strategies can
be implemented. However these strategies must be personalised
and blood glucose levels monitored.
17,18
Conclusion
Physiotherapists aim to restore normal function or minimise
dysfunction and pain and prevent recurring injuries and disabilities.
One of the core skills used by physiotherapists is exercise prescription,
which benefits many aspects of health. Physiotherapists are in a
position to impact on the prevention, control and management of
diabetes and diabetes-associated conditions.
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