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Nervous System Health

Nervous System Health and Physical Activity

by Bob Gurney

During the months of November and December 2011, Kinesiology/Physical Education students – University of Alberta – PEDS 409 – Research Methodology, provided a presentation, as part of the course assignment requirements. The students are as follows: Lauren Glenister, Amy Heidebrecht, Claire Altares, Jaclyn Ellis, and Christopher Hills. This paper has been edited by Robert Gurney.

Diabetic neuropathy (DN) is the most common form of neuropathy in the western world and is the most prevalent complication currently affecting nearly 50 per cent of patients with diabetes mellitus (Dejgaard, 1997; Aring, Jones & Falko, 2005). Diabetic Neuropathy can develop in patients with type 1 or 2 diabetes and can occur at any stage, however, is more common in patients with Type 2 diabetes mellitus (T2DM) and, chronic poor glycemic control (Aring, et al., 2005). Type 2 diabetes mellitus has achieved proportions of a real epidemic and, according to the International Diabetes Federation (IDF) the disease now affects over 240 million people (Teixeira-Lemos, Nunes, Teixeira, & Reis, 2011). Studies have shown that the longer duration a person has T2DM the higher risk they are for DN (Edwards, Vincent, Cheng, & Feldman, 2008). Early detection and control of diabetes and co-existing risk factors for neuropathy can prevent or delay the progression of DN (Aring, et al., 2005). Symptoms depend on the part of the nervous system that is affected but are commonly associated with muscle weakness, pain, decreased motility, amputation and other co-morbid complications that has a detrimental effect on the quality of life, and has greatly increased the risk of mortality (Edwards, et al., 2008). Classifications of DN can be found in the research of Aring, et al., (2005). Insulin deficiency and hyperglycemia have been found to initiate progression of all types of DN (Tesfaye, Harris, Wilson, Ward, 1992). Therefore, glycemic control has been correlated to reduce both incidence and progression of DN (Edwards, et al. 2008).

Current information included in the National Diabetes Information Clearinghouse provides basic how-to- management information for individuals with Diabetes (National Diabetes Information Clearinghouse, 2009). The problem with the information provided is that the individual is required to seek out many additional sources of information on how they can improve their neural health and eliminate root causes. The goal for our how-to guide is to express specific measures through multiple disciplines. Compiling the information into one how-to guide, will create material that can be referenced to improve neural health and help in the prevention of neural damage.

This guide will be looking at the causes of DN and how it can be self-managed through changes in lifestyle, including physical activity and nutrition. Looking through the research there are no how-to guides, based on scientific evidence, to advise the diabetic population on how to effectively management the progression of their disease through an interdisciplinary approach.

Physiology

Chronic hyperglycemia leads to an inability to transmit signals through nerves, slowing nerve conduction velocity (NCV) and increasing vasoconstriction (Tesfaye, et al., 1992). Nerve conduction velocity is a non-invasive measure of nerve function (Said, 2007). In tissues where glucose is transported independently (nerve, eye and kidney), hyperglycemia causes higher concentrations of intracellular glucose, leading to functional impairment of nerves (Dejgaard, 1997). When high concentrations of glucose are converted to sorbitol within the cell, there is a reduction in myo-inositol, inhibiting ionic activity within the cell. Tesfaye et al. (1992) found that after direct warming of the limb, in subjects with DN and subjects without, NCV increased. This implies that warmer temperature, initiated by a warming modality or exercise can be a potential treatment for DN symptoms.

Balducci, et al. (2006) illustrated that long term aerobic exercise training can prevent the onset or progression of DN. Aerobic and resistive exercise improves sodium, potassium and ATPase concentrations; which are beneficial to NCV, nerve function, vasodilatation, blood flow, and improving oxygen utilization (Balducci, et al. 2006). Improving glucose metabolism through exercise training occurs primarily through 3 distinct mechanisms: 1) stimulation of glucose transport to muscle, 2) increased insulin action on cells of organs involved in exercise, 3) positive regulation of the signalling pathway stimulated by insulin as a result of regular exercise (Teixeira-lemos et. al, 2011). Resistance and aerobic exercise can improve insulin sensitivity to approximately the same extent, and therefore, should be implemented to manage the progression of DN (Signal, Kenny, Wassermam, Castaneda-Sceppa, White, 2006).

Nutrition

Individual nutrition plays a huge role in diabetic complications including DN. High blood glucose, the main risk factor for DN has been proven to be manageable through diet. Diet can improve glycemic control, even when selecting diets without professional help that are based on American Diabetes Association recommendations (Pi-Sunyer, Maggio, Mccarron, Reusser, Stern, Haynes & Mcmahon, 1999). Decreasing the overall amount of carbohydrate (CHO) intake, by eating low glycemic index foods (including fruits and vegetables, diary, legumes and whole grains), have proven to decrease blood glucose levels in diabetic patients (Gonçalves Reis & Dullius, 2011). Tight glycemic control, through diet, is one of the most effective ways of managing or preventing the progression of DN. However, changes to lifestyle and diet can be some of the hardest things to change. Some micronutrients have been found to decrease the oxidative stress levels, alleviating pain brought on by DN. Low levels of Vitamin B, E, C, and Magnesium are often diminished in patients with DN and can contribute to the development of DN. By supplementing daily diets with vitamin B, C, E and Magnesium, pain scores for patients with DN decrease significantly (Farvid, Homayouni, Amiri & Adelmanesh, 2011).

Physiotherapy

Physiotherapists play an important role in the management of DN, and preventing its progression. Physiotherapists provide essential information on exercise prescription, which is vital in managing blood glucose levels, and therefore, DN. Exercise is also associated with the prevention of T2DM becoming DN (Teixeira-lemos et. al, 2011). Patients with DN who regularly participate in physical activity improve their glycemic control (Teixeira-lemos et. al, 201). An effective exercise program ensures cardio respiratory and muscular fitness, as well as an effective tool to manage and prevent the progression of DN. Participation of regular moderate physical activity has the capacity to improve insulin sensitivity, increase high density lipoprotein, decrease triglyceride levels and normalize blood pressure (Kruse et. al, 2010). Therefore, exercise training contributes to the regulation of blood glucose levels, helping to prevent and manage DN.

Pharmacology

Diabetic neuropathy is best treated with a combination of pharmacological and non-pharmacological strategies (Mann, 2009). Therefore the best treatment of DN comes from an integrated approach of pharmaceutical drugs and daily life management, one method being physical activity. Engaging in daily physical activity can be challenging for an individual with DN. These challenges come from the side effects of the medications, which regulate DN. Most people with DN are placed on multiple drugs to help deal with the degeneration of the nerve as well as dealing with the pain (Mann, 2009; Wamboldt & Kapustin, 2006). Some of the common drugs administered for DN are anti-convulsants, tricyclic antidepressants and opioids. These all have common side effects such as drowsiness/ fatigue, low blood pressure, nausea, dizziness/ vertigo, gait disturbance and/or peripheral edema. These side effects and DN itself cause difficulties in performing physical activity because of disturbance to balance, ulcers on feet, added challenge to movement due to the swelling in limbs or inability to experience ones somatosensory system and/or general weakness. However, with this said, the importance of physical activity in one’s life is still essential in managing DN in a non-pharmaceutical manner. The how to guide we are proposing to create will provide physical activity that is appropriate to perform and engage in while under the influence of the DN medications.

Bibliography

Aring, A., Jones., Falko, J. (2005). Evaluation and prevention of Diabetic Neuropathy. American Family Physician, 71:2123-8.

Balducci, S., Lacobellis, G., Parisi, L., Di Biase, N., Calandriello, E., Leonetti, F., & Fallucca, F. (2006). Exercise training can modify the natural history of diabetic peripheral neuropathy. Journal of diabetes and its complications, 20(4): 216-223.

Dejgaard, A. (1998). Pathophysiology and Treatment of Diabetic Neuropathy. Diabetic Medicine, 15: 97-112.

Edwards, J. L., Vincent, A. M., Cheng, H. T., & Feldman, E. L. (2008). Diabetic neuropathy: Mechanisms to management. Pharmacology & Therapeutics, 120(1), 1-34.

Farvid, M., Homayouni, F., Amiri, Z., & Adelmanesh, F. (2011). Improving neuropathy scores in type 2 diabetic patients using micronutrients supplementation. Diabetes Research & Clinical Practice, 93(1), 86-94.

Gonçalves Reis, C. E., & Dullius, J. J. (2011). Glycemic acute changes in type 2 diabetics caused by low and high glycemic index diets. Nutricion Hospitalaria, 26(3), 546-552.

Kruse, R., LeMaster, J., & Madsen, R. (2010). Fall and balance outcomes after an intervention to promote leg strength, balance, and walking in people with diabetic peripheral neuropathy: “Feet First” randomized control trial. Physical Therapy, 90(11) 1568 – 1578.

Mann, E. (2009). Diabetic neuropathy, part 1: pharmacology. Practice Nursing, 20(5), 246.

Pi-Sunyer, F., Maggio, C. A., Mccarron, D. A., Reusser, M. E., Stern, J. S., Haynes, R., & Mcmahon, M. (1999). Multicenter Randomized Trial of a Comprehensive Prepared Meal Program in Type 2 Diabetes. Diabetes Care, 22(2), 191.

National Diabetes Information Clearinghouse. (2009). Diabetic Neuropathies: The Nerve Damage of Diabetes. NIH Publication No. 09–3185.

Said, G. (2007). Diagnosis of Diabetic Neuropathy: Nerve conduction studies. National Clinical Practical Neurology Journal, 3(6) 331-340.

Sigal, R., Kenny, G., Wasserman, D., Castaneda-Sceppa, C., White, R. (2006). Physical Activity/Exercise and type 2 diabetes. Diabetes care, 29(6) 1433-1438.

Teixeira-Lemos, E., Nunes, S., Teixeira, F., & Reis, F. (2011). Regular physical exercise training assists in preventing type 2 diabetes development on its antioxidant and anti-inflammatory properties. Cardiovascular Diabetology, 10(12) 1-15.

Tesfaye, S., Harris, N.D., Wilson, R.M. & Ward, J.D. (1992). Exercise-induced conduction velocity increment: a marker of impaired peripheral nerve blood flow in diabetic neuropathy. Diabetologia, 35(2) 155-159.

Wamboldt, C., & Kapustin, J. (2006). Continuing Education: Evidence-Based Treatment of Diabetic Peripheral Neuropathy. The Journal For Nurse Practitioners, 2370-378.

Author: Bob Gurney


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