"What exercises do you use with clients whose legs have been weakened by neuropathy caused by diabetes?"
This very specific problem should not be approached by the novice trainer. Any personal trainer who works with diabetic clients should have advanced education and/or certifications for training this special population.
Diabetes can cause damage to the nerves through their prolonged exposure to high glucose levels in the blood. Symptoms of this damage may include loss of strength, muscle wasting and numbness in the arms, hands, legs and/or feet.
To work with a client with neuropathy, the trainer should first assess the client’s footwear. The shoes should be stable and provide proper support. I recommend referring the client to a podiatrist or other qualified professional who can evaluate foot mechanics and the need for orthotics. Furthermore, the trainer should consult with the client’s doctor to see if any of the client’s medications are causing or contributing to the peripheral neuropathy.
A thorough neuromuscular and musculoskeletal assessment is also recommended. This assessment will help identify any imbalances that may be exacerbating the condition. For example, soft-tissue adhesions or restrictions in the fasciae or muscles might be placing further stress on the major nerve sites of the body, such as the brachial and lumbar plexus. Any lower-back, hip or neck-and-shoulder dysfunction should be evaluated to rule out the possibility that soft-tissue structures in these areas could be causing referred pain or dysfunction in the extremities.
Guided by the assessment results, the trainer should do specific muscle testing of all the major muscles, including (but not limited to) the flexors and extenders of the foot; the hip flexors; the gluteus maximus, minimus and medius; the tensor fascia latae; the adductors, quadriceps and hamstrings; the lats and pecs; the rotator cuff muscles (internal and external rotators); the flexors and extensors of the wrist and fingers; and the biceps and triceps. This muscle testing will help create an understanding of which specific muscle and/or nerves have been affected.
Guided further by these results, the trainer can develop a myofascial release program to help release and align the soft tissue. Then an isometric strengthening program can be added to help facilitate a “reawakening” of those muscles and nerves that have been damaged. As progress is made with single-joint movements, weight-bearing exercises that address the entire kinetic chain can be added.
The trainer must not overtax the client’s nervous system; that is the key. Constant trainer-client feedback is imperative to ensure that the right muscles are firing during movements and that the client does not become too fatigued.
The choice of specific exercises will depend entirely on the individual client and his degree of dysfunction and neuropathy.
Justin Price, MA
Owner, The BioMechanics
2006 IDEA Personal Trainer of the Year
San Diego, California
Diabetic neuropathies can impact multiple areas of normal functioning. Clients might suffer from orthostatic hypotension, vasomotor instability, bladder dysfunction and motor deficits, among other things (Aring, Jones & Falko 2005). For fitness professionals, the primary focus would be on preventing or reversing motor deficits. Walking is commonly recommended to improve fitness, but a 2006 study also noted that walking capacity and progression decrease with the progression of foot complications (Kanade et al. 2006). Walking should be supplemented by partial or non-weight-bearing exercise, such as biking and swimming. To curtail the impact of weight-bearing exercises, lower-extremity strengthening can also be done using machines that allow open-chain movement.
Promoting daily foot care is an essential component of working with clients with diabetic neuropathies. The concern is that these clients’ risk for ulceration is high because they usually have a loss of feeling in their feet that reduces their ability to notice blisters or sores. Blisters may develop into more serious ulcers, which can become infected. In the most severe cases, ulcers may result in foot amputation. Part of the foot care regimen includes wearing properly fitted footwear.
Researchers have also noted that diabetics with foot neuropathies have reduced joint mobility, which may contribute to foot ulcerations (Zimny, Schatz & Pfohl 2004). Mueller and colleagues found that limited ankle dorsiflexion contributes to ulcerations on the bottom of the feet in this population (Mueller et al. 2003). Consequently, as a fitness professional you can help your clients by keeping their calf muscles flexible and by having clients perform range-of-motion and stretching exercises for the lower extremities. These exercises can be done manually—for example, a manual hamstring stretch—to alleviate the pressure on the feet that occurs during weight-bearing stretches.
Share these tips on shoe wear and foot care with your clients:
- Wear socks with your shoes at all times, and change socks daily.
- Break in new shoes slowly; in some cases, start with just 1–2 hours per day.
- Shop for shoes at the end of the day when your feet tend to be more swollen.
- After washing your feet, hand-dry them well with a soft towel.
- Keep the skin of your feet smooth by applying creams or lotions.
- If you note skin cracking, speak with your physician about topical treatment options.
- Check the bottom of your feet daily; for some people this task may require a mirror.
- Don’t exercise barefoot or let your feet get too hot or too cold when exercising.
Certified Personal Trainer and Pilates Instructor
Co-Founder, Fit to Flawless LLC
At NutriFormance, we currently have two clients dealing with neuropathy. Our goal is to help them maintain as much function for as long as possible. Therefore, we do a majority of exercises standing, such as small step-ups (2–8 inches) and single-leg balance on foam or floor, depending on the client’s capability. We include dynamic flexibility, such as leg swings and hip abduction/adduction, and end with an assisted flexibility section. With the client on the table in a supine position, we might include some manual resistance exercises, including straight-leg raises, dorsiflexion and plantar flexion. While the client is prone, we could include a flexed-knee hip extension. All of these exercises would be contingent on the progression of the disease and the client’s capability.
Dale Huff, CSCS
Co-Owner, NutriFormance LLC
St. Louis, Missouri
When designing an exercise program for this population, you should consider strength training, balance retraining and cardio training.
Strength Training. Include strength training exercises that clients can do in front of a mirror. Neuropathy diminishes proprioception and sensation, and the mirror will give them visual feedback on their movements. Exercises can include the following:
- chair squats or squats using the wall or ball
- band walks to strengthen the gluteus medius
- heel raises
- toe curls
The following cues will prepare a client to work on balance:
Stand in stocking feet. Keep the arches of the feet dynamic and not flattened out. Keep knees over feet. Stand with ears, shoulders, hips and ankles all in alignment. Imagine tucking the bellybutton into the small of the back with the pelvis in a neutral position. Maintain this position whenever possible throughout the program.
Then have the client start by standing between two chairs, and guide her through this sequence:
1. Place feet together and hold both chairs. Let go of one chair and then the other. Hold this position for 20 seconds.
2. If you feel steady with feet close together, then do the following steps a–c with feet together. Otherwise, stand with feet shoulder width apart to do the following:
a. Sway body side to side; keep body straight and do not pick up feet or bend knees. Move as though you were a solid structure from ankles to top of head.
b. Sway body forward and backward (onto balls of feet, then onto heels).
c. Imagine your body is cone shaped, with point of cone at your feet and round part at your head. Keeping feet still, see how perfectly round you can make the circle. Circle in both directions.
3. Holding the top of each chair, transfer weight to one foot and pick up opposite foot. Don’t let raised foot rest on supporting leg.
When you feel confident, release chair with one hand and then the other, and hold this position for up to 30 seconds with eyes open. Repeat the exercise standing on opposite foot. If you are successful, go to exercise #7. If you cannot hold for 30 seconds, go to exercise #4.
4. Staying between the chairs, take a full step forward and hold that position. Repeat with other leg forward.
5. Step forward with feet in a line but several inches apart, as if walking a tightrope. Place one foot directly in front of the other. Repeat with other leg forward.
6. Now bring feet closer together so that heel of forward foot is touching toes on back foot. Repeat with other leg forward.
7. Keeping left foot in place during first half of exercise, step forward onto right leg as if to take a step, transfer weight onto right leg and then step backward onto right leg. Repeat this motion six times. Repeat on other side.
8. Repeat as in #7, but now step in line as if walking a tightrope.
9. Stand on one foot as in exercise #3. In slow, controlled movements, move opposite leg forward, return it to your side, move it sideways, return it and then move it backward and return it. Build up to repeating sequence six times on each leg.
To make the balance program more challenging for the client, you can modify any of the exercises in these ways:
- Work on a softer surface, such as thick carpet, an exercise mat, grass or sand!
- Keep arms crossed in front of you.
- Train with a partner, and toss a ball back and forth, underhand, overhead, from right and from left.
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Kanade, R.V., et al. 2006. Walking performance in people with diabetic neuropathy: Benefits and threats. Diabetologia, 49 (8), 1747–54.
Mueller, M.J., et al. 2003. Effect of Achilles tendon lengthening on neuropathic planter ulcers: A randomized clinical trial. The Journal of Bone & Joint Surgery, American Volume, 85-A (8), 1436–45.
Zimny, S., Schatz, H., & Pfohl, M. 2004. The role of limited joint mobility in diabetic patients with an at-risk foot. Diabetes Care, 27 (4), 942–46.
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