What is an appropriate physiotherapy regimen for a patient with type 1 diabetes mellitus to improve cardiovascular fitness, muscle strength, flexibility, and balance while preventing hypoglycemia or hyperglycemia and protecting the feet?

Physiotherapy Management of Type 1 Diabetes Mellitus

Adults with type 1 diabetes should engage in at least 150 minutes per week of moderate-to-vigorous aerobic exercise spread over at least 3 days (with no more than 2 consecutive rest days), combined with 2-3 sessions per week of resistance training on nonconsecutive days, while implementing specific glucose monitoring and carbohydrate/insulin adjustment protocols to prevent hypoglycemia. 1

Core Exercise Prescription

Aerobic Training

• Target 150 minutes weekly of moderate-to-vigorous intensity aerobic activity, distributed across at least 3 days with no more than 2 consecutive days without exercise to maintain insulin sensitivity 1
• For younger, physically fit individuals, a minimum of 75 minutes weekly of vigorous-intensity or interval training is sufficient 1
• Each aerobic session should last at least 10 minutes, building toward 30 minutes per session 2
• Daily exercise is optimal since insulin resistance benefits dissipate within 48-72 hours without activity 3

Resistance Training

• Perform 2-3 sessions weekly on nonconsecutive days 1
• Each session should include at least one set of five or more different exercises targeting large muscle groups 1
• Resistance training of any intensity improves strength, balance, and ability to perform daily activities 1
• Heavy resistance training with free weights or machines may provide additional glycemic control benefits 1

Flexibility and Balance Training

• Implement 2-3 sessions weekly of flexibility and balance exercises 1
• Yoga and tai chi are acceptable modalities that improve flexibility, muscle strength, and balance 1
• These exercises are particularly important for older adults to maintain range of motion and prevent falls 1

Sedentary Behavior Interruption

• Break up prolonged sitting every 30 minutes with brief standing, walking, or light physical activity for blood glucose benefits 1
• Encourage non-exercise physical activities including walking, yoga, housework, gardening, swimming, and dancing above baseline levels 1

Critical Safety Protocols for Hypoglycemia Prevention

Pre-Exercise Glucose Monitoring

• Check blood glucose before every exercise session 2, 4
• If pre-exercise glucose is <90 mg/dL (5.0 mmol/L), ingest additional carbohydrate before starting exercise 1
• The amount of carbohydrate needed depends on insulin dose adjustments, time of day, and exercise intensity/duration 1

Insulin Dose Adjustments

• Reduce insulin doses prior to exercise for those using insulin pumps or taking pre-exercise insulin injections 1
• Some insulin is typically still needed even with dose reductions 5
• Patients must be educated on specific insulin modification strategies based on their regimen 2

Post-Exercise Monitoring

• Monitor glucose frequently after exercise to detect delayed hypoglycemia, which can occur several hours post-exercise due to increased insulin sensitivity 1
• This prolonged monitoring is especially critical for those with hypoglycemia unawareness or after high-intensity exercise 5

Carbohydrate Adjustment Protocols

• Medication dose or carbohydrate consumption must be adjusted for each exercise bout and its post-bout impact 1
• Patients should carry glucose tablets or gel during exercise sessions 5
• Exercise with a partner who is aware of diabetes management needs 5

Exercise Contraindications and Precautions

Proliferative Retinopathy

• Vigorous-intensity aerobic or resistance exercise may be contraindicated if proliferative diabetic retinopathy or severe nonproliferative diabetic retinopathy is present due to risk of vitreous hemorrhage or retinal detachment 1
• Consultation with an ophthalmologist is appropriate before engaging in intense exercise regimens 1

Peripheral Neuropathy

• Decreased pain sensation and higher pain thresholds increase risk of skin breakdown, infection, and Charcot joint development 1
• Proper foot care is critical, including appropriate footwear selection, regular skin inspection, and evaluation/treatment of calluses and lesions 5
• Consider alternatives to weight-bearing exercises for those with severe neuropathy 5

Cardiovascular Assessment

• Perform careful history and assess cardiovascular risk factors before initiating moderate-to-vigorous exercise programs 1
• Those with high cardiovascular risk should start with short periods of low-intensity exercise and slowly increase intensity and duration as tolerated 1
• Exercise tolerance testing can identify anginal thresholds and asymptomatic ischemia 5

Special Considerations for Glycemic Response

Variable Individual Responses

• Each individual with type 1 diabetes has a variable glycemic response to exercise that must be taken into consideration when recommending exercise type and duration 1
• Intense activities may actually raise blood glucose levels instead of lowering them, especially if pre-exercise glucose levels are already elevated 1, 2
• This variability requires individualized education on glucose monitoring timing and adjustment protocols 2

Cardiovascular and Mortality Benefits

• Higher amounts of physical activity reduce cardiovascular mortality after mean follow-up of 11.4 years in patients with and without chronic kidney disease 1
• A dose-response inverse relationship exists between physical activity frequency and A1C, BMI, hypertension, dyslipidemia, and diabetes-related complications including retinopathy and microalbuminuria 1
• Regular exercise improves cardiovascular fitness, muscle strength, insulin sensitivity, triglyceride levels, LDL cholesterol, waist circumference, and body mass 1

Common Pitfalls to Avoid

• Never allow more than 2 consecutive days between exercise sessions, as insulin sensitivity benefits dissipate rapidly 1
• Do not assume exercise will always lower blood glucose—intense exercise can raise glucose if pre-exercise levels are elevated 1, 2
• Avoid inadequate post-exercise monitoring—hypoglycemia can occur hours after exercise completion 1
• Do not neglect foot inspection and proper footwear, especially in patients with peripheral neuropathy 1, 5
• Never initiate vigorous exercise without ophthalmology clearance in patients with known or suspected proliferative retinopathy 1