Weightbearing Exercise for those with Diabetes

I don’t need to preach to the converted about the health benefits of running (or any form of exercise) for those with diabetes. Among other things its going to help general well-being; helps with weight control; and it has some specific benefits such as increasing insulin sensitivity. It is not without its dangers in terms of more careful diet planning and insulin dosing regime before, during and after exercise. A lot of my early research (eg) was on the foot complications in diabetes, so its a topic I still follow with interest.

I recall a conference around 15 years ago that I was a last minute replacement on a panel discussing exercise in diabetes. The panel consisted of a diabetes physician, diabetes nurse educator, physiotherapist, dietitian, exercise physiologist and me. All the others spoke about the wonderful benefits for exercise for those with diabetes (which I agreed with), but when it came to my turn (I was last), I was really negative! I pointed out that, for example, those with sensory neuropathy were at very high risk for stress fractures and other injuries (they can’t ‘listen to their body’, as they feel nothing – its not hard to imagine what would happen if you kept running on an injury you do not know is there!); as well as some other negative points such as the loads placed on the lower limb from the obesity associated with Type 2 diabetes. It was all around the negative aspects and risk of weightbearing (ie walking and running) exercises for those with diabetes and that they may want to consider some other form of non-weightbearing exercise. Maybe they weren’t really negative, but precautionary tales. It was quite a contrast to all the other positive presentations from the rest of the panel. I was even a little surprised at how many in the audience that had diabetes came up to me afterwards to say thank you!

In this context I was pleased to see this study from Michael Mueller et al published:

Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial.
Mueller MJ, Tuttle LJ, Lemaster JW, Strube MJ, McGill JB, Hastings MK, Sinacore DR.
Arch Phys Med Rehabil. 2013 May;94(5):829-38.
To determine the effects of weight-bearing (WB) versus nonweight-bearing (NWB) exercise for persons with diabetes mellitus (DM) and peripheral neuropathy (PN).
Randomized controlled trial with evaluations at baseline and after intervention.
University-based physical therapy research clinic.
Participants with DM and PN (N=29) (mean age ± SD, 64.5±12.5y; mean body mass index [kg/m(2)] ± SD, 35.5±7.3) were randomly assigned to WB (n=15) and NWB (n=14) exercise groups. All participants (100%) completed the intervention and follow-up evaluations.
Group-specific progressive balance, flexibility, strengthening, and aerobic exercise conducted sitting or lying (NWB) or standing and walking (WB) occurred 3 times a week for 12 weeks.
Measures included the 6-minute walk distance (6MWD) and daily step counts. Secondary outcome measures represented domains across the International Classification of Functioning, Disability and Health.
The WB group showed greater gains than the NWB group over time on the 6MWD and average daily step count (P<.05). The mean and 95% confidence intervals (CIs) between-group difference over time was 29m (95% CI, 6-51) for the 6MWD and 1178 (95% CI, 150-2205) steps for the average daily step count. The NWB group showed greater improvements than the WB group over time in hemoglobin A1c values (P<.05).
The results of this study indicate the ability of this population with chronic disease to increase 6MWD and daily step count with a WB exercise program compared with an NWB exercise program.

What did they find? They did sort of prove me wrong. Weightbearing exercise is good for those with diabetes. There were more musculoskeletal complaints in the weightbearing group and during the study, 4 diabetic foot ulcers developed, but 3 of them were in the nonweightbearing group. This lead the authors to say:

Those in the NWB group also had fewer complaints of lower-extremity musculoskeletal pain during aerobic exercise than the WB group. Consistent with other recent recommendations, we believe people with diabetes mellitus and peripheral neuropathy who do not have severe foot deformity or open ulcers should be given the choice to exercise in a WB or NWB capacity, and that exercise should be tailored to match their personal goals.

As always: I go where the evidence takes me until convinced otherwise and I don’t mind being proved wrong with good science.

Mueller MJ, Tuttle LJ, Lemaster JW, Strube MJ, McGill JB, Hastings MK, Sinacore DR (2013). Weight-bearing versus nonweight-bearing exercise for persons with diabetes and peripheral neuropathy: a randomized controlled trial Arch Phys Med Rehabil DOI: 10.1016/j.apmr.2012.12.015

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