Table 4.

Special Considerations for Exercise in Aging, OA and T2DM. Data from references^73,83,92,105

GENERAL CONSIDERATIONS Drink plenty fluids before, during, and after exercise Extended exposure to high temperature increases susceptibility to adverse effects from heat - exercise should be performed in a cool environment Delayed onset muscle soreness is common in the days following exercise (when starting or progressing exercise) Physician assessment is required in case of development or worsening of hypertension, angina pectoris, arrhythmia, resting tachycardia, claudication, frequent oscillations on fasting glucose levels, wounds in lower extremities, muscle weakness, joint pain, and vision disturbances Use of diuretics and beta-blockers - high doses of diuretics can interfere with fluid and electrolyte balance whereas beta-blockers can increase risk of hypoglycemia unawareness. For patients who take regular joint pain medication (e.g., analgesics, NSAIDs) it is recommended to time the medication accordingly to decrease discomfort during exercise

EXERCISE PROGRESSION Progression should be gradual to improve safety and to facilitate adaptation Previously sedentary individuals have to gradually build up amount of exercise, starting with as little as 5 to 10 minutes per day From the OA standpoint, exercise should progress only if patients do not experience increased joint pain, effusion, sensations of instability, or decreased joint motion To reduce the likelihood of delayed onset muscle soreness exercise should be started at low intensity and gradually increased to the target level as tolerated The exercise program should be reviewed regularly and be progressed/adjusted as appropriate

T2DM-SPECIFIC CONSIDERATIONS Maintain good diabetes control (A1C generally below 7%) Carry fast acting carbohydrate at all times and ingest it if glucose levels drop Carry an ID at all times with indication of medical conditions Wear proper shoes and clothes according with the type of exercise Perform foot inspection often Insulin injection site should be rotated away from active muscles For those who take insulin or insulin secretagogues blood glucose should be checked before, after, and several hours after exercise, at least until they know their usual glycemic responses to exercise. For those with tendency to hypoglycemia reduce medication before exercise and/or consume extra carbohydrate before exercise

In presence of Nephropathy: Systolic BP should not rise above 180 mm/Hg Avoid weight lifting, breath holding, or high-intensity exercise In presence of Retinopathy: Avoid vigorous activities, head jarring activities, Valsalva, and position with the head below the waist - non-weight bearing exercise (biking, walking in the pool, ballroom dancing) Systolic BP should not rise above 20 mm/Hg of resting value In presence of Autonomic Neuropathy: Monitor signs of blood glucose and silent ischemia (e.g., dyspnea, diaphoresis, orthostatic hypotension) – BP and HR response to exercise may be blunted

In presence of Peripheral Neuropathy: Pain and burning can make it difficult to bear weight - do non-weight-bearing or reduced weightbearing exercises (e.g., aquatic exercises and bicycle) Balance and control of movement may be impaired and contribute to falls - incorporate balance exercises along with precautions to avoid falls during exercise In presence of Charcot foot: Use a stationary or arm bike or do chair exercises using free weights In presence of foot ulcer and/or deformity: If active foot ulcer is present, perform non weight-bearing exercise Avoid swimming, keep feet clean and dry