Table 5.

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

Health complication	Exercise considerations	Physical 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 (168–170).	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.