Wednesday, August 6, 2008

Stretching exercises for increasing muscle strength and quality in older adults with Type-2 Diabetes


Health status is an important factor that has a significant impact on the quality of life of an elderly population. The major elements of health status are perceived health, especially psychological well-being, chronic illnesses, and functional status. Various studies have shown that perceived health declines with age, and the effects of ill health impact on many areas of daily activity (Setiabudhi & Hardywinoto, 1999; Roman, Tatemichi, & Erkinjuntti, 1993; Boyle, Paul, Moser, Zawacki, Gordon & Cohen, 2003; Guralnik, La Croix & Abbott, 1993; Harris, Kovar, Suzman, Kleinman, & Feldman, 1989). According to the statistics and uninfected diseases surveillance in 2002 at Depok (BAPPEDA & BPS Kota Depok, 2003, 2004, 2005), diabetes is becoming increasingly prevalent and undertreated in elderly people. Diabetes mellitus as a long-standing illness has been associated with limitations in activities of daily living among elderly people (Ayis, Gooberman-Hill, Ebrahim, MRC Health Services Research Collaboration, 2003; Parmet, 2004).

In older adults, diabetes has been associated with a two- to threefold increased risk of developing physical disability (Gregg, Beckles, Williamson, Leveille, Langlois, Engelgau, & Narayan, 2000; Gregg, Mangione, Cauley, Thompson, Schwartz, Ensrud, & Nevitt, 2002; Ryerson, Tierney, Thompson, Engelgau, Wang, Gregg, & Geiss, 2003; Von Korff, Katon, Lin, Simon, Ciechanowski, Ludman, Oliver, Rutter, & Young, 2005). The Health, Aging, and Body Composition (Health ABC) study has reported the association of diabetes with sub clinical functional limitation (De Rekeneire, Resnick, Schwartz, Shorr, Kuller, Simonsick, Vellas, & Harris, 2003). However, one of the most crucial factors determining functional capacity is mobility. As the musculoskeletal system deteriorates with increasing chronic conditions frequently combined with diabetes, such as coronary heart disease, peripheral artery disease, visual impairment, and depression, partially explained the association, but still 40% of excess risk for physical disability remained unexplained (Ciechanowski, Russo, Katon, Von Korff, Ludman, Lin, Simon, & Bush, 2004; Tanaka1 & Seals, 2003).

Low muscle strength, but not muscle mass, is associated with poor physical function in older men and women (Visser, Deeg, Lips, Harris, Bouter, 2000; Visser, Newman, Nevitt, Kritchevsky, Stamm, Goodpaster, & Harris, 2000. Muscle strength measured in midlife or old age is highly predictive of functional limitations and disability up to 25 years later (Rantanen, Guralnik, Foley, Masaki, Leveille, Curb, & White, 1999; Rantanen, Avlund, Suominen, Schroll, Frandin, & Pertti, 2002; Visser, Goodpaster, Kritchevsky, Newman, Nevitt, Rubin, Simonsick, & Harris, 2005). In the present study, diabetes is associated with lower skeletal muscle strength and quality. These characteristics may contribute to the development of physical disability in older adults with diabetes. The Health ABC Study evaluated hand grip and knee extensor strength and muscle quality in community-dwelling older adults with and without diabetes in. Older adults with diabetes had greater arm and leg muscle mass than those without diabetes because they were bigger in body size (Newman, Haggerty, Goodpaster, Harris, Kritchevsky, Nevitt, Miles, & Visser, 2003). Despite this, muscle strength was lower in men with diabetes and not higher in women with diabetes than corresponding counterparts. Muscle quality, defined as muscle strength per unit regional muscle mass, was significantly lower in men and women with diabetes than those without diabetes in both upper and lower extremities. Furthermore, longer duration of diabetes (>6 years) and poor glycemic control (HbA1c >8.0%) were associated with even poorer muscle quality (Park, Goodpaster, Strotmeyer, de Rekeneire, Harris, Schwartz, Tylavsky, & Newman, 2006).

Low muscle strength is one of the most significant changes that adversely affect the ability of older people to cope independently in their communities and to have contacts with other people. Impaired mobility also greatly increases the need for different kinds of services. Interventions at early stages to reduce dysfunctional capacity may preserve function in community-dwelling older adults with diabetes in (Figaro, Kritchevsky, Resnick, Shorr, Butler, Shintani, Penninx, Simonsick, Goodpaster, Newman, Schwartz, & Harris, 2006). Improved strength has been associated with improved muscle and bone mass, balance, and also mobility (Rhodes, Martin, Taunton, Donnelly, Warren, & Elliot, 2000). All of these factors are important in the prevention of fractures and improved quality of life. Studies have also demonstrated that exercise can delay the normal decline in physical performance associated with diabetes (Sriwijitkamol, Christ-Roberts, Berria, Eagan, Pratipanawatr , DeFronzo, Mandarino, & Musi1, 2006). A typical exercise program includes activities aimed at increasing musculoskeletal flexibility, strength, and quality. Exercise training also has favorable effects on the controlled blood sugar, the regulation of blood pressure, and the prevention of excessive weight gain (Fairey, Courneya, Field, Bell, Jones, & Mackey, 2003; Ciechanowski, Russo, Katon, Von Korff, Ludman, Lin, Simon, & Bush, 2004; Booth, Gordon, Carlson, & Hamilton, 2000).

Purpose of the paper

The purpose of this paper is to explain a promoting functional capacity through increasing muscle strength and quality in older adults with type-2 diabetes.

Objectives of the paper

The objectives of this paper are to:

  1. Describes the decreasing functional capacity especially strength and quality muscle in older adults with type 2 diabetes.
  2. Describes a stretching exercise aimed at increasing musculoskeletal strength and quality.
  3. Describes the implications on promoting functional capacity through increasing muscle strength and quality in older adults with type-2 diabetes exercise program for the community health nursing practice.
Literature Review

Functional capacity is defined here as the ability to perform the physical tasks of daily life and the ease with which these tasks can be performed. Functional capacity declines at older adults with type 2 diabetes, resulting in a reduced capacity to perform certain physical tasks. This can eventually result in increased incidence of functional disability, increased use of health care services, loss of independence, and reduced quality of life (
Tanaka & Seals, 2003). Moreover, the decline in functional capacity provides a serious threat to individuals engaging in physically demanding occupations (WHO Study Group, 1993).
The capacity of the human body to make use of muscle strength peaks between ages 20 and 30 and from there on steadily declines with age, most significantly between ages 50 and 60. Muscle strength and quality decline can be fasted by diabetes. These changes are the result of a related skeletal muscle with the insulin action. Skeletal muscle is the major site of insulin-mediated glucose disposal and is implicated in the pathogenesis of insulin resistance and diabetes. Several pieces of evidence suggest that insulin action may be related to the oxidative capacity of skeletal muscle (Short, Vittone, Bigelow, Proctor, Rizza, Coenen-Schimke, & Nair, 2003). First, aerobic exercise training improves both insulin sensitivity and activity of oxidative enzymes in muscle (Ryder, Chibalin, & Zierath, 2001). Second, people who are obese and insulin resistant or have type 2 diabetes tend to have lower activity of muscle oxidative enzymes (Simoneau, Veerkamp, Turcotte, & Kelley, 1999).Third, insulin infusion preferentially stimulates the synthesis rate of mitochondrial proteins in skeletal muscle and increases the mRNA abundance genes associated with mitochondria and glucose metabolism (Boirie, Short, Ahlman, Charlton, & Nair, 2001). Fourth, recent work has shown that genes for mitochondrial proteins and the primary glucose transporter in muscle, GLUT4, are regulated by common signals, including elevations in cytosolic calcium and the transcriptional coactivator PGC-1α (peroxisome proliferator–activated receptor [PPAR]-γ coactivator 1α). Muscle mitochondrial function and gene expression are reduced in aging muscle, but the underlying cause and the relationship to insulin action are not yet understood.(Huang, Eriksson, Vaag, Lehtovirta, Hansson, Laurila, Kanninen, Olesen, Kurucz, Koranyi, & Groop, 1999)

A typical exercise program includes activities aimed at increasing musculoskeletal strength and quality. All of these components are important, and different types of activity are required for each. Exercise objectives can be either therapeutic or preventive in nature. Accomplishing these objectives can be related to specific types of exercise, for examples stretching, strengthening, and endurance.(Burke & Laramie, 2000)­

In this paper, we suggested the stretching exercises for the older adults with type 2 diabetes. Stretching exercises are intended to maintain or improve joint range of motion (ROM) and flexibility and to prepare individuals for activity and function. It can also be used during an exercise cool-down period. In the older adult with type 2 diabetes lack of flexibility usually limits an activity, rather than decreases strength. The lack of flexibility imposed by years of inactivity can yield an enormous degree of joint and motor limitation. This physiological limitation can cause burdensome functional limitations and, in the extreme, serious subsequent dependency. Activities such as grooming, dressing, sitting at a standard-height toilet or in a straight-back chair, reaching, and even stair climbing can be impaired by the joint limitation caused by lack of flexibility.

Stretching exercise are the only exercises that will increase flexibility. Stretching exercises do not increase strength or cardiovascular fitness. Static stretching is generally recommended as the best way of maintaining muscle length and correcting muscle imbalance. The stretching action can be done at everywhere and should be performed slowly and carefully, maintaining tension on the muscle for 10 to 20 seconds and then slowly releasing the stretch. A stretching session usually centers around 15 to 20 minutes of stretching exercise per day. When used as the warm-up and cool down segments of an exercise program, the stretching session can be limited to 5 to 8 minutes. The optional duration and intensity of stretching and the effects of temperature are still being questioned in the literature.

Figure 1. Examples of stretching exercises
Gently pull chin in while lengthening back of neck. Hold 10 seconds.
Bring arms straight up over head and back as far as possible, causing back to arch gently. Hold 10 seconds.
Place hands behind your head and pull elbows back as far as possible. Hold 10 seconds.
With arms behind doorjamb, gently lean forward. Hold for 10 seconds. Stretch is felt across chest.

Figure 2. Functional solo exercise patterns.
Trunk flexion
Trunk rotation
Left sided modified lunge
Assisted forward modified lunge

Figure 3. Functional partnered exercise patterns
Resisted back extension
Resisted arm lifts
Resisted horizontal shoulder abduction/adduction
Resisted arm extension with modified lunge

Implications for the community health nursing practice

Ultimately the community health nurse has the potential to be cost effective as it encourages a more responsible and independent patient population. This may result in shorter lengths of stay, a reduction in unnecessary utilization of expensive hospital care and greater emphasis on home care with support systems.

The work group could be developed and implemented as a restorative model of care that integrates the medical treatments for acute disease processes and the personal care and rehabilitative interventions directed toward chronic disabilities, to improve the functional outcomes of older adults receiving home care.


Muscle strength and quality declines are significant problems for many older adults with type 2 diabetes. Although not all muscle strength and quality declines can be prevented, the stretching exercise program that target specific resident problems with activities of daily living have been shown to increasing musculoskeletal strength and quality related to the insulin action. The greatest contribution to the older adults with type 2 diabetes in functional abilities resulted from improved hand grip and knee extensor strength and muscle quality. This indicates the potential of this exercise program to improve functional abilities that may have implications for an older adults with type 2 diabetes’s ability to continue to live independently in the community.

In patients with less severe disability, rehabilitation may be conducted and supervised mainly by a single health professional, such as a physiotherapist, who consults with other health professionals about specific issues. An example may be a nurse assisting an older person to become more independent in self-care who consults a physiotherapist or rehabilitation physician for specific help with the patient's mobility retraining.

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