Objective
Treating the severely or mildly de-conditioned patient with diabetes requires a good assessment of their physical abilities and limitations as well as their psychological disposition for exercise.
Without this information, the typical exercise protocols presented to a patient, which are prevalent at most health clubs, will probably be too challenging. The predominant exercise protocols being taught to trainers in the general fitness market follow a rigid focus of stability, core, strength and power. Although this may be a good starting point for the generally fit patient I have found much of what is being presented to the very de-conditioned to be much too challenging.
Experience dealing with this segment of the population is crucial, otherwise you run the risk of injuring the patient and I have seen this first hand.
It should be noted here that improved athletic performance and health are distinct goals and that program design must reflect only health interests at this time.
Three concerns when evaluating and recommending an exercise program:
Safety - Safety should be a primary concern when developing an exercise program but is especially important with the very de-conditioned, diabetic population.
Mobility issues, circulatory, blood sugars, all have to be considered and addressed when developing an exercise protocol.
Optimal Clinical Outcomes- Results for this group refers to the health concerns of the client not sport specific.
Exercise in itself has short term benefits in handling sugars but long term benefits are achieved by challenging the larger muscles of the body in an exercise protocol, waking up the dormant muscle, and adding additional muscle.
Traditional protocols focus too much time on core and stability. This group needs simply to use the largest muscles as a means to an end, handling blood sugars more effectively. The basic exercise protocols that we have developed to engage the larger muscle groups, inherently have a positive affect on core and stability. Even when placed in very controlled stabilized positions such as variable resistance machines, there is a degree of stabilizer involvement for this very de-conditioned group. We have found that inexperienced trainers are overzealous in following the traditional protocols, overwhelming and frustrating patients.
Compliance - Your biggest issue I'm sure you will agree with will be compliance.
An effective protocol must be patient specific and based on the subjective answers a patient gives you. Your objective view that they need an aggressive protocol does not address the reality that most patients, even when threatened by the consequences of their illness, will not respond to a demand for big changes.
This approach will go a long way in stimulating compliance by your patient. By being real and understanding that your patient wants and needs help but probably won't make dramatic
changes in the short run, gives you a psychological advantage.
The following questions will help you determine your patients psychological predisposition for exercise. This will help you determine a realistic course of action for your patient, going a long way in gaining compliance.
• I don't know if I can find the time.
• I am only doing this for my health
• I don't find exercise enjoyable
• I believe exercise may be painful
• I get bored easily
• I get frustrated when I don't see results
• I feel intimidated or embarrassed in an exercise setting
• Work demands make it difficult to exercise
• Family obligations may make it difficult to exercise
• My family or friends may not support my attempts to exercise
• I may have to exercise alone
• I may lose track of my goal
• The exercise setting available to me does not meet my needs.
What to look for in a program.
Our experience has demonstrated a concern when acquiring supervision or recommending a program for this population. Overwhelming, complex, too challenging is the feedback we have been getting from patients subjected to inexperienced trainers or health club protocols.
The importance of the patients ability to tolerate the exercise stress, both physically and psychologically, cannot be overemphasized.
It is paramount that patients are presented undemanding exercises at the start of a program, transitioning to more challenging exercises only when they express and demonstrate comfort with their existing program. (example: standing core exercises as opposed to lying on the floor exercises).
It is better to start out conservatively than to overshoot the patients exercise tolerance, reducing the enjoyment.
Always err on the side of too little when applying loads.
Trainers must not fall into the trap of believing that more is better.
Even the Target Heart Rate Zone parameters may be too challenging for this population. A more prudent indicator would be perceived exertion.
Initial training should emphasize correct exercise technique and increasing the patients tolerance for exercise. As tolerance and technique allow... the focus will extend to increasing strength. Resistance loads in the 60% - 80% range of 1RM are essential to achieve goals. Determining 1RM will not be determined by testing 1RM, which would not be prudent for this population, but by trial and error, adjusting resistances that allow for a repetition range of 8 - 15 to exhaustion for their fitness level. Typically exercise alone will have a positive effect on stability and flexibility for this group.
As you know improving HA1C is paramount for optimal clinical outcomes. The result of this protocol is better glycemic control through a couple of mechanisms:
* Exercise in itself helps keep blood sugars under control.
* Protein synthesis as the result of challenging the largest muscles is very metabolically expensive, post exercise, utilizing thousands of calories.
* Adding muscle and recruiting dormant muscle allows for more active tissue into which sugars can be shuttled.
To insure that the special needs of this population are met look for an educational and nutritional system that addresses these concerns.
A well designed program will begin with an empowering psychological component addressing the "mind set" of what is really required to achieve glycemic control through proper eating habits and an effective exercise program.
A good program addresses the problem of compliance.
Look for an entry level program that strategically and safely addresses the needs of the very de-conditioned and overweight patient by transitioning from very comfortable non complex exercises to more challenging ones very gradually.
It should not be overwhelming or complex and the time requirement of only 2 days a week is the icing on the cake so to speak for those with time excuses.
As with any program an assessment of the patient must be performed first:
Assessment:
1. Age
2. Gender
3. Weight
4. Limitations - Orthopedic or Otherwise (Thrumbosis, Circulatory Concerns, Etc.)
5. Blood Pressure
6. Medications
7. How long since any structured exercise?
8. PAR-Q Test
We then place our patients into one of three classifications to ensure training protocols match patients fitness levels.
LEVEL 1: Very Obese Diabetic - Significantly De-conditioned - Very Limited Mobility
LEVEL 2: Overweight Diabetic - De-conditioned - Mobile
LEVEL 3: Active Overweight - Pre or Just Diagnosed Diabetic
Level 1 patients will require very low impact type of equipment that allow for stabilization and comfort such as a recumbent bike or mini tramp with safety handles. Exercise bands will probably be appropriate for this group.
Level 2 patients that are mobile allows for the use of more challenging exercise equipment in a health club setting that puts the patient in a comfortable, stabilized, seated position.
Level 3 patients will probably tolerate a more aggressive exercise protocol including free weight exercises
Based on this information patients should follow a system that addresses the following principles for a safe and effective workout.
1. The Foundation
A thorough warm-up, designed to be an integral part of the program not just an afterthought, making the transition to the challenging sets physiologically and psychologically more comfortable, reducing micro-trauma to the connective tissues reducing post exercise soreness, having a positive effect on adherence to the program. For the population with circulatory problems, a slow gradual warm up will help with circulation to the extremities.
2. Supersets
A challenging TOTAL BODY workout utilizing compound movements in a superset fashion based on the patients fitness level. Beginners find these compound movements to be inherently more comfortable to perform as they require less skill, coordination and balance. The emphasis on only using the largest muscles inherently burns plenty of calories during the workout but, more importantly, stimulates the endocrine system (hormone) and protein synthesis which is very metabolically expensive using the fat stores during the recovery process. (anabolic phase)
3. Intervals
Interval training taps into the fat burning mechanism effectively and immediately and as studies have proven, will burn 9 times the fat that aerobics can burn in the same time frame.
Intervals have a positive effect on "heart reserve" and circulation as opposed to traditional long duration, low intensity cardiovascular exercise.
These three cycles combine everything you need in an exercise program. Instead of splitting up body parts on different days and performing ineffective aerobics on the other days, you get the best of everything in one workout.
A minimum requirement of only 2 workouts a week goes a long way in promoting compliance.
This principle of 2 workouts a week has been backed by science. Using reverse psychology and positive reinforcement will guarantee success of the program.
If you can demonstrate a reasonable level of results for the time invested, it will result in an increase in compliance from your patients.
