Keeping Active With Diabetes and Arthritis
Daily physical activity is essential for good health and blood glucose control in people with diabetes. But what if you also have arthritis? One in five American adults has been diagnosed with arthritis, and half of all adults with diagnosed diabetes also have arthritis. Symptoms of arthritis can make it difficult to be active. But don’t let that stop you in your efforts: Frequent physical activity can help reduce the pain and stiffness of arthritis by improving muscle strength, endurance, and flexibility. Routine exercise also increases energy levels and helps with weight control. Other benefits include lowered blood pressure, a lower risk of heart disease, and sometimes improved sleep patterns.
If you have arthritis as well as diabetes, it is important to keep your muscles as strong as possible, because the stronger the muscles and tissues are around the joints, the better they will support and protect those joints. When you don’t exercise, your muscles become weak and your bones become more brittle, which leads to a worsening of arthritis symptoms and to other health problems such as osteoporosis, the decrease in bone density that can lead to bone fractures.
The most common form of arthritis is osteoarthritis, in which cartilage in the joints deteriorates.
Cartilage is the tough but flexible tissue that normally covers the ends of bones where they meet in a joint, allowing for easy movement. Over time, as cartilage deteriorates in an affected joint, the space between the bone ends may narrow, extra bits of bone may develop on the bone ends, and the joint may change shape. These changes can lead to friction, pain, stiffness, and further joint damage. Osteoarthritis often affects more than one joint, and while it can affect any joint in the body, some joints are affected much more often than others. These include the knees, hips, and joints in the neck, lower back, and fingers.
The primary cause of osteoarthritis is unknown, but excess weight and a family history of arthritis raise the risk of developing it. So does aging. Osteoarthritis can also be a result of overuse, trauma, or injury.
Osteoarthritis of the hips and knees often causes people to limit their physical activity. However, regular moderate exercise does not make arthritis worse in these or other joints. In fact, regular moderate exercise such as walking, swimming, and biking can reduce pain and improve strength and flexibility in affected joints. Research shows that most people with osteoarthritis feel better and can do more when they exercise regularly.
Regular exercise can also be beneficial for people with rheumatoid arthritis, an autoimmune disease that is characterized by inflammation in the lining of the joint. The inflammation causes swelling and pain, and over time it can destroy the cartilage and bone within the joint. Eventually, the joint can lose its shape and become unstable and misaligned. Rheumatoid arthritis can affect just a few joints or many, and if it affects a joint on one side of the body, it usually affects the corresponding joint on the other side, too. Most often, rheumatoid arthritis begins in the hands and feet, but it can affect many other joints, including the hips, knees, elbows, and shoulders. People with rheumatoid arthritis also often have body-wide symptoms, such as fatigue. What causes rheumatoid arthritis is not known.
Contrary to what people may believe is the case, exercise does not make rheumatoid arthritis worse. Instead, it increases strength and flexibility and helps people feel better. It also decreases fatigue. However, caution and moderation when exercising are in order. This is particularly the case during flare-ups, or times of acute joint inflammation. For those with rheumatoid arthritis who plan to start exercising, it is best to ask a doctor or physical therapist for advice about what is appropriate first.
A comprehensive exercise program has three parts: flexibility training, aerobic exercise, and strength training.
Flexibility training, or stretching, helps to keep joints and muscles limber, make movement more comfortable, and may reduce the risk for strains and injury. A simple stretch for your shoulders and elbows is to raise both hands over your head and stretch your arms as far as you can. You will feel the stretch the most where you are least flexible.
Aerobic exercise improves your heart health and increases your endurance for daily activities. Any activity that requires the continuous movement of the large muscles of your body, such as walking, bicycling, swimming, or aerobics classes, is considered aerobic exercise. You can get the health benefits of aerobic exercise by doing 30 minutes of moderate-intensity activity on most days of the week. Benefits are the same whether you do the 30 minutes all at once or in two or three shorter sessions.
You are considered to be working at a moderate intensity when you are breathing a little harder than usual, your heart is beating a little faster, and you are warmer than usual. However, you should be able to carry on a normal conversation while you are exercising and feel that you could continue the activity for at least 30 minutes. On a scale of 1–10, you should feel you are working at about a 5 (somewhat hard).
If you have not been physically active for a while, it is best to start your aerobic activity at a low intensity and to do it for short periods. As your body adapts to being more active, you can increase both the intensity and the time you spend being active. A rule of thumb is to increase aerobic activity by 10% to 20% each week. For example, if you can do 10 minutes of activity, increasing to 12 minutes the next week is enough.
Strength training, which is often called resistance training, increases the strength in the muscles you exercise. For example, using a leg press machine strengthens your leg muscles. Strength exercises should be done no more than two or three days a week. A good rule of thumb when starting out is to use a weight or resistance band that you can lift (or push or pull) with good form for at least 12–15 repetitions. You want the weight to feel easy in the beginning in case you have any underlying injuries that you don’t know about; too tough a workout may make them worse. Once you know your joints and muscles are healthy, you can start gradually increasing the weight. When you can do an exercise easily for 12 or more repetitions, increase the weight or resistance of the band by 3–5 pounds. Remember to allow at least 48 hours of rest between strength-training sessions.
Making exercise a habit
Adopting any new healthy habit takes work, and regular exercise is no exception. Many people start with high expectations and overly ambitious plans, then quickly get discouraged and give up. Some ways to avoid this are the following:
* Think about which activities you like. What have you done in the past that you enjoyed? It may be a sport, walking with a friend or dog, taking a dance class, doing yard work, or volunteering for a job where you walk or are physically active. See if you can include these activities in your new exercise plan.
* Make a plan that makes sense for your life. Think about easy ways to work exercise into your current daily routine. Big plans to “turn over a new leaf” are often too much of a change to keep up.
* Make sure your plan is something you really believe you can do. Use the 0–10 confidence scale to check how sure you are that you can carry out your plan. On a confidence scale of 0–10, if you are not at least an 8, you are unlikely to follow through. Rework your plan to make it less difficult. For example, you may feel very little confidence in the likelihood that you’ll go to the gym for an hour before work every day. You may feel more confident that you’ll be able to walk for 30 minutes every day during lunch or after work. But if walking for 30 minutes a day still ranks below an 8 on your confidence scale, you need to come up with another plan. Perhaps walking for 30 minutes three times a week is a better place to start.
* Whatever you start with, try it for a couple of weeks and see how you do. You may decide to stick with your plan for a few more weeks, to add more time or other activities to it, or to scale back to something a little easier. (This action plan strategy is explained in the book Living a Healthy Life with Chronic Conditions; see “Exercise Resources”.)
* When you start an exercise program, try being active at different times of the day to determine what time works best for you. Pick a time that fits into your lifestyle and does not interfere with your diabetes control efforts. You may also find you have more or less pain and stiffness in your joints at certain times of day.
* Remember that your most important goal is developing the habit of being physically active on a regular basis, not running a particular distance or being able to lift a particular amount of weight.
Dealing with pain
It’s common to have some discomfort when you ask your body to do new activities. Signs that your workout is too strenuous include joint pain that lasts for more than an hour, increased joint swelling, or increased weakness or persistent fatigue.
Muscle pain following exercise is usually a sign that your muscles did more than they are used to doing. Muscles that feel sore or tight a day or two after exercise are telling you that they are responding to the training and will get stronger. Doing some gentle aerobic activity to warm up the muscles followed by some gentle stretching may help them feel better. However, if muscle pain following exercise is so severe that it prevents you from doing normal activities like brushing your hair, contact your health-care provider for advice.
Joint pain after exercise probably means that you overdid it and that you need to move less vigorously and for shorter periods in the future. If a particular activity seems to increase joint pain, try a different activity for a while to see if it helps. It usually takes some trial and error to figure out what works for you. To avoid injury, start slowly and don’t push yourself too hard.
If you have tried to exercise in the past and have stopped because of increased pain, if you have trouble standing or walking because of lower-body limitations, or if, as noted earlier, you have rheumatoid arthritis, it would be wise to consult your doctor or a physical therapist before starting an exercise program. One of these professionals may be able to help you select activities, exercises, or classes that would suit your abilities. Your doctor may also be able to refer you to an occupational therapist or sports medicine specialist for more help.
Some diabetes complications may be worsened by some types of physical activity. It is therefore recommended that people with diabetes have a medical exam that screens for the presence of any complications, including cardiovascular disease and diabetic retinopathy (eye disease), before beginning an exercise program. This is especially important for people over 35, those with Type 2 diabetes, and people who have had Type 1 diabetes for more than 15 years. People younger than 35 whose blood glucose levels are usually in their target range can safely take part in most moderate-intensity exercise programs. However, anyone who feels chest tightness, shortness of breath, or nausea during exercise, or who feels dizzy or likely to faint should stop exercising and seek medical help right away.
If you take insulin or oral pills that lower your blood glucose, be sure to check your blood glucose level before you exercise. If your blood glucose is less than 100 mg/dl, eat or drink something containing 15 grams of carbohydrate to raise your blood glucose to a safe range before exercising. Anticipate the need to consume at least 15 grams of carbohydrate for each 20–30 minutes of moderate-intensity activity to avoid hypoglycemia (low blood glucose) during exercise.
When you first start an exercise program, check your blood glucose before and after the activity to see what effect exercise has on your blood glucose level and to determine whether a change in your usual food intake or medication is needed. Be particularly careful if you exercise during the peak action time of your insulin. (The peak action time is when insulin lowers blood glucose the most, and it differs from one type of insulin to the next. Check the literature that comes with your insulin for information on how quickly it starts working and when it reaches its peak action.) Exercising around the same time each day may have a more predictable effect on your blood glucose than exercising at different times, but there may still be instances when your blood glucose does not respond the way you expect it to.
Avoid exercise if your blood glucose level is higher than 250 mg/dl and you have ketones in your blood or urine. Use caution if your blood glucose level is 300 mg/dl or higher and you have no ketones. A blood glucose level over 250 mg/dl means there may be a lack of available insulin in your system, which in turn means that some of the glucose in your bloodstream may not be available to be used as fuel by your muscles. In addition, exercising when your blood glucose level is this high can cause it to go even higher.
If you start exercising with a high blood glucose level, stop 15 minutes into the activity and check your level again. If it has gone up further, stop exercising and continue to check your blood glucose periodically for the next 90 minutes. If it has gone down from your pre-exercise level, it’s safe to continue exercising. Remember to watch for signs of hypoglycemia, as usual.
People with Type 2 diabetes who control their diabetes with diet and exercise are less likely to develop hypoglycemia during exercise or to experience large swings in blood glucose levels as a result of exercise. In fact, for these people, exercise has a predictable lowering effect on blood glucose level and is an important part of diabetes treatment.
Before you start any exercise program, you need a good pair of shoes that provide support and cushioning. For most activities, you’ll need some type of sneaker or walking shoe; for water aerobics or swimming, wearing water shoes is recommended to reduce the risk of injury. It’s important that the shoes you buy have adequate arch support and fit in both the heel and toe areas. Your heel should not be able to lift more than half an inch, and you should have wiggle room for your toes. These precautions are especially important for people with peripheral neuropathy who have lost feeling or sensation in their feet. Wearing socks is also important for foot protection.
The best time to purchase shoes is in the afternoon, when your feet are swollen and at their largest. To ensure you have a good fit, look for the shape of the shoe to match the shape of your foot. Make sure that you have at least one thumb’s width of space between your longest toe and the end of the shoe, and make sure the arch in the shoe matches the arch in your foot.
Shoes should fit comfortably when you buy them. However, you should start by wearing new shoes for no more than 30 minutes at a time. Gradually increase the time you wear your shoes by five minutes each day. Once they have conformed to the shape of your feet and the way you move, you can wear them for as long as eight hours at a time.
After each exercise session, check your feet for blisters, areas of redness, and callus buildup. Be sure to check the spaces between your toes for any redness or broken skin. Use a mirror to inspect the bottoms of your feet, or have someone else inspect them for you. You can avoid serious foot problems by inspecting your feet every day and reporting any unusual symptoms that don’t disappear in a day or two to your diabetes care provider.
Are you ready to start a physical activity routine? If so, take a minute to think about the specific, concrete actions you need to take — such as buying a good pair of walking shoes or signing up for an exercise class — to make your plans a reality.
Then write down an achievable goal for activity, such as, “I will attend a twice-weekly aerobics class,” or “I will stretch for 15 minutes every afternoon, then take a 2-mile walk.” Make sure you specify at what time you’ll do this, and where you’ll do it, and jot down some thoughts on what you’ll do if it’s raining or if the phone rings just as you’re about to start your stretching routine or head out the door to class or to take your walk.
When you exercise, remember to pace yourself, and stay tuned in to your body’s signals so you know when you need to slow down or take a break. Performing regular physical activity can help to relieve the pain and stiffness caused by arthritis and help you control your diabetes, but not if you overdo it and get injured or burned out.
In addition, find ways to vary your routine so you don’t get bored, but always include stretching, strengthening exercises, and aerobic activity in your plan. By keeping yourself active in a variety of ways, you’ll be on your way to greater mobility and better health. Best of all — you might even have fun doing it!
by Kristina Ernst, RN, CDE, and Marian A. Minor, PT, PhD
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