can allow individual who are overweight or obese to participate in moderate and vigorous levels of exercise that can generate weight loss and achieve fitness levels that may be more difficult to access on land due to heavy joint loads (Devine et al., 2022). People with diabetes should be especially encouraged to participate in resistance training, aiming for at least 8–10 exercises with 1–3 sets of 10–15 repetitions to near fatigue per set early in training (Liguori & American College of Sports Medicine, 2020). They may also benefit from proprioceptive and balance training, which are described in the FITT recommendations in Table 16 (as suggested by Demir et al. (2022) in their randomized control trial) and which have been shown to increase balance ability and prevent falls and somatosensory loss.
for appropriate footwear to avoid foot ulcers. Peripheral neuropathy is nerve damage that may occur with prolonged exposure to high blood glucose levels. Individuals with peripheral neuropathy may complain of numbness, tingling, or pain in their hands and feet—or they may have no symptoms. Peripheral neuropathy puts individuals at an increased risk for developing foot ulcers and infections in the feet (but it does not preclude them from participating in weight-bearing exercise; American Diabetes Association, 2016). Because buoyancy reduces the risk of pain and injury, clients who experience too much discomfort with weight-bearing exercises can choose to engage in water- based exercise, which provides a safe and protective way to exercise (Devine et al., 2022). Water-based exercise
FITT for improving proprioception and balance for diabetes As it relates to optimizing proprioception and balance in patients with diabetes, the FITT principle exercise
prescription for proprioceptive balance exercises can be seen in Table 16.
Table 16: Aerobic Exercise Recommendations for Improving Proprioception and Balance Function FITT Recommendations F requency • 3 days a week. • 8 weeks. I ntensity • Progress from supported to unsupported exercises. T ime • 30–45 minutes. T ype • Proprioceptive activities: ○ Ball rolling under foot. • Balance activities: ○ Standing on one leg. ○ Taking steps on bosu ball. ○ Antero-posterior and medio-lateral weight transfer on bosu ball.
○ Star excursion gait and balance exercises such as walking without support on different grounds, heel to side walking, cross-walking exercises.
Note: Adapted from Demir et al. (2022). Osteoarthritis
Exercise should elicit only mild pain in the joint (less than 3 on a numeric scale of 10) or be modified to decrease pain (Vincent & Vincent, 2012). While ideally exercise should not cause any joint pain, many individuals with OA experience joint pain with daily physical activity and may experience some joint pain with exercise. When a joint is acutely inflamed, making weight-bearing exercises difficult, isometric strength training may be a beneficial form of resistance exercise. Performing isometric strength training will minimize the impact of movement but still allow for resistance training during times of acute inflammation. Isometric exercises are valuable because they produce low intra-articular pressures and can be done without increasing joint pain (Folland et al., 2005). However, strength is improved only at the angle at which the muscle is trained. Therefore, isometrics will need to be performed at multiple joint angles. It is generally recommended that the isometric strengthening exercise be performed every 10 to 30 degrees to cover the joint’s entire range of motion (Folland et al., 2005). The isometric contraction should be held for four to six seconds, and 8 to 10 repetitions at each joint angle should be performed (Folland et al., 2005). Reduced weight-bearing exercises such as pool walking, swimming, and biking may provide beneficial aerobic exercise during times of acute exacerbation. Tai chi has also been shown to decrease knee pain and to improve physical function and stiffness, and it may be a good resistance exercise option for those who are suffering from symptoms associated with OA (Brismee et al., 2007).
Osteoarthritis (OA) is characterized by pain and joint space narrowing (Vincent & Vincent, 2012). More than 60 million Americans currently suffer from OA (Vincent & Vincent, 2012). Patients with OA in weight-bearing joints, such as the knees and the hips, may have previously self-limited their exercise due to pain, but exercise is critical for older adults with OA. Quadriceps weakness contributes to an increase in symptoms, including pain and impaired proprioception in patients with hip and knee OA, making resistive exercise an important but sometimes difficult undertaking for this population (Alnahdi et al., 2012; Nguyen et al., 2016). Both aerobic and resistive exercise are known to decrease pain and increase function and mobility in older adults with OA and have been adopted as a core recommendation for adults with OA (Bennell et al., 2016; McAlindon et al., 2014). This means that exercise is generally recommended for all individuals with OA, but modifications may be needed in an exercise program for those who are experiencing pain associated with OA (Vincent & Vincent, 2012). A slower progression of exercise may be necessary for these older adults, and only one variable at a time should be changed for resistance exercise (i.e., frequency, resistance, or duration). For example, when progressing a leg press for someone with OA, the practitioner should either increase the weight or the repetitions, but not both, in the same training session. If joint pain is elicited as a result of the progression, the practitioner can determine which variable increased the joint pain.
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