Exercise may benefit patients with leg ulcers

NewsBot · Nov 8, 2017

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PUBLIC RELEASE: 8-NOV-2017
Exercise may benefit patients with leg ulcers

A preliminary British Journal of Dermatology study suggests that ulcers in the legs may heal faster with exercise.

In the study of 39 patients with venous leg ulcers who were randomized to compression therapy plus supervised exercise (including aerobic, resistance and flexibility elements) or compression therapy only, ulcer healing time was lower in the exercise group (13 versus 35 weeks).

"Although this is a feasibility study and we can't draw any final conclusions from it, our findings suggest that people with ulcers not only enjoy taking part in a supervised exercise scheme, staying in the programme until the end, but may also draw multiple benefits from it, offering reduction in treatment costs as well," said chief investigator and lead author Dr. Markos Klonizakis, of Sheffield Hallam University, in the UK. "Having proven that such a programme is workable for everyone involved, we will now seek funding to test the main study hypothesis in seven regions across England."

NewsBot · Nov 8, 2017

Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomised controlled feasibility trial
M. Klonizakis, G. A. Tew, A. Gumber, H. Crank, B. King, G. Middleton and J. A. Michaels
BRITISH JOURNAL OF DERMATOLOGY 27 OCT 2017

Background
Almost 70% of all leg ulcers have a venous component. Venous leg ulcers (VLU's) are typically painful and heal slowly, resulting in an impaired quality of life (QoL), social isolation and reduced work productivity. Compression therapy offers high healing rates, however, improvements aren't usually sustained. Exercise is a low-cost, low-risk, and effective strategy for improving physical and mental health. However, little is currently known about the feasibility and efficacy of supervised exercise training used in combination with compression therapy in this patient group.
Objectives
To assess the feasibility of a 12-week supervised exercise programme combining aerobic, resistance and flexibility exercises as an adjunct therapy to compression in patients with VLU's.
Methods
This was a two-centre, two-arm, parallel-group, randomised feasibility trial. Thirty-nine patients with venous ulcers were recruited and randomised 1:1 either to exercise (3 sessions per week) and compression therapy or compression only. Progress/success criteria included exercise attendance rate, loss to follow-up and patients’ preference. Baseline assessments were repeated at 12 weeks, 6 months and 1 year following baseline, with healing rate and time, ulcer recurrence and infection incidents also being documented. Intervention and healthcare utilisation costs were calculated. Qualitative data was collected to assess participants’ experiences.
Results
Overall, 72% of the exercise group participants attended all scheduled exercise sessions. No serious adverse events, and only two exercise-related adverse events (e.g., increased ulcer discharge) were reported. Loss to follow-up was 5%. At 12-months median ulcer healing time was lower in the exercise group (13 vs 34.7 weeks). Total NHS costs were calculated as £813.27 for the exercise and £2,298.57 for the control group.
Conclusions
Our findings support the feasibility and acceptability of both the supervised exercise programme in conjunction with compression therapy and the study procedures. The next step will be the design and implementation of an appropriately-powered, multi-centre trial.
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NewsBot · Feb 15, 2018

What is the effect of exercise on wound healing in patients with venous leg ulcers? A systematic review
Daisy Smith, et al
International Wound Journal

Standard best practice for the treatment of venous leg ulcers (VLUs) is compression bandaging of the lower leg to reduce hydrostatic pressure. There is considerable variation in reported healing rates when using this gold-standard approach; therefore, a systematic and robust evaluation of other interventions is required. Exercise interventions, in addition to standard compression therapy, could improve wound-healing time and prevent their recurrence. We have conducted a systematic review to examine the effects of exercise on wound characteristics, including time to heal, size and recurrence, pain, quality of life, adverse events, and economic outcomes. This review was registered with PROSPERO 2016:CRD42016046407. A systematic search of Ovid Medline, Ovid EMBASE, Ovid CINAHL, The Cochrane Library, PsycINFO, Web of Science, and PEDro was conducted on January 30, 2017, for randomised control trials to examine the effects of exercise on time to heal, size and recurrence, pain, quality of life, adverse events, and economic outcomes. Six studies met the inclusion criteria, but all had design flaws leading to biases, most commonly performance and selective reporting bias. Three studies compared a progressive resistance exercise programme (PREG) plus compression with compression alone for a period of 12 weeks. Low-quality evidence indicates the following: possibly no difference in the proportion of ulcers healed (risk ratio [RR] 1.14, 95% CI 0.71 to 1.84, I2 36%; 3 trials, 116 participants); probably no difference in quality of life (mean difference [MD] 3 points better on 100 point scale with exercise, 95% CI −1.89 to 7.89, 1 trial, 59 participants); possible increase in the risk of adverse events with exercise (OR 1.32, 95% CI 0.95 to 1.85, 1 RCT, 40 participants); and no difference in ankle range of motion and calf muscle pump. Evidence was downgraded due to susceptibility to bias and imprecision. Recurrence, pain, and economic outcomes were not measured in these trials, and time to healing was measured but not fully reported in 1 trial. We are uncertain of the effects of other interventions (community-based exercise and behaviour modification, ten thousand steps, supervised vs unsupervised exercise) due to the availability of low- or very low-quality evidence only from single trials. The review highlights the need for further research, with larger sample sizes, to properly address the significance of the effect of exercise on VLU wound characteristics.
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NewsBot · Jun 13, 2018

Exercise fidelity and progression in a supervised exercise programme for adults with venous leg ulcers
Markos Klonizakis Anil Gumber Emma McIntosh Brenda King Geoff Middleton Jonathan A Michaels Garry A Tew
Int Wound Jnl : 06 June 2018 https://doi.org/10.1111/iwj.12933

Despite exercise being included in the recommended advice for patients with venous leg ulcers, there is a fear shared by clinicians and patients that exercise may be either inappropriate or harmful and actually delay rather than promote healing. Therefore, before implementing a larger‐scale study exploring the effects of a supervised exercise programme in patients with venous ulcers being treated with compression therapy, it is important to assess exercise safety as well as fidelity and progression in a feasibility study. Eighteen participants randomised in the exercise group were asked to undertake 36 (3 times/week for 12 weeks) 60‐min exercise sessions, each comprising moderate‐intensity aerobic, resistance, and flexibility exercise components. For the purposes of this paper, we analysed the data collected during the exercise sessions. The overall session attendance rate was 79%, with 13 of 18 participants completing all sessions. No in‐session adverse events were reported; 100% aerobic components and 91% of resistance components were completed within the desired moderate‐intensity target. Similarly, 81% of aerobic components and 93% of flexibility components were completed within the prescribed duration targets. Our data showed that patients with venous ulcers could safely follow a supervised exercise programme incorporating moderate‐intensity aerobic, resistance, and flexibility components.
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NewsBot · Mar 19, 2020

FOOTFIT Physical Activity mHealth Intervention for Minimally Ambulatory Individuals With Venous Leg Ulcers: A Randomized Controlled Trial.
Kelechi TJ et al
J Wound Ostomy Continence Nurs. 2020 Mar/Apr;47(2):173-181

PURPOSE:
The purpose of this study was to investigate the use of an mHealth application (app), self-management physical activity intervention FOOTFIT with an added patient-provider connectivity feature (FOOTFIT+), that was designed to strengthen the lower extremities of minimally ambulatory individuals with venous leg ulcers (VLUs).

DESIGN:
Randomized controlled trial.

SUBJECTS AND SETTING:
Twenty-four adults 18 years and older with VLUs being treated in 2 wound clinics in the Southeastern United States participated in this study.

METHODS:
Preliminary estimates and 95% confidence intervals for the medians of short-term functional impacts on foot function, strength, ankle range of motion, walking capacity, depression, and physical functioning were obtained pre- and postassessment after the 6-week intervention trial.

RESULTS:
There were negligible changes in either group for foot function. It is noted that both groups experienced substantial foot and ankle impairment at baseline. The greatest improvement in range of motion was noted in the FOOTFIT group for dorsiflexion of the right ankle (4.6 ± 5.22 lb/in over baseline) whereas strength decreased in both ankles for dorsiflexion and plantar flexion in the FOOTFIT+ group. No improvements were noted in walking distance or physical health for FOOTFIT (slight decrease -2.9 ± 5.6) and FOOTFIT+ (slight increase 3.0 ± 6.6) during the 6-week study period.

CONCLUSIONS:
In a minimally ambulatory population with VLUs, our mHealth FOOTFIT intervention composed of progressive exercise "boosts" demonstrated minimal short-term effects. We recommend engagement with the app for a longer period to determine longer-term outcomes of lower extremity function.
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NewsBot · Nov 26, 2020

Neuromuscular stimulation of the common peroneal nerve increases arterial and venous velocity in patients with venous leg ulcers
Saroj K. Das Luxmi Dhoonmoon Swati Chhabra
25 November 2020 https://doi.org/10.1111/iwj.13510

Activation of the venous muscle pumps by neuromuscular stimulation of the common peroneal nerve has been previously shown to increase venous and arterial flow in the legs of healthy subjects. The aim of this study is to determine whether a similar effect is observed in patients with chronic venous leg ulcers. 1 Hz intermittent electrostimulation of the common peroneal nerve was applied to 14 patients with ulcers between 1 and 10 cm in diameter, eliciting a small, painless, regular, muscular twitch of the leg. Flow was measured using Duplex ultrasound in the popliteal vein and the popliteal artery. Peak arterial velocity increased from 57 to 78 cm/s (P = .001) in sitting position, and from 79 to 98 cm/s in recumbent position (P = .001). Peak venous velocity increased from 10 to 33 cm/s (P = .001) sitting, and from 14 to 47 cm/s (P = .001) recumbent. Significant increases were observed in both venous and arterial blood flow in the lower limb. This suggestsed that activation of the venous muscle pump and improvement of arterial flow assisted oxygen delivery at the wound site. Moreover this may be a worthwhile intervention to assist in the healing of venous leg ulcers, and may provide a mechanistic explanation for the increased healing rates previously reported with neuromuscular stimulation of the common peroneal nerve.
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NewsBot · Jan 23, 2023

Effects of exercise in treating patients with venous leg ulcers: A systematic review and meta-analysis
Qianting Zhang, Ling Lu, Jia lin Song, Lu Wang
17 January 2023

To determine the effects of exercise on VLU healing and exercise adherence, and to provide evidence for clinical practice and scientific investigation. PubMed, Embase and Scopus were searched from inception to 31st March, 2022. Pooled relative risks (RRs), standardised mean differences (SMDs), adherence rate with respective 95% confidence intervals (CIs) were calculated. Quality assessment of included studies were performed using the Cochrane Collaboration risk of bias evaluation. Heterogeneity between enrolled studies was evaluated. We identified eight randomised control studies (RCTs) that met the inclusion criteria. The pooled RR for healing rate was 1.38 (95% CI: 1.14 to 1.66; P = 0.0008) with no significant heterogeneity between component studies (I2 = 0%, P = 0.96). SMD for differences of total range of ankle joint motion (ROAM) at the end and at the initiation of follow-up in the intervention and control groups was 0.87 (95% CI: 0.22, 1.52; P = 0.0091), no significant heterogeneity was detected (I2 = 59%, P = 0.0622). Pooled adherence rate was 64% (95% CI: 53%, 75%) with no significant heterogeneity. Exercise manifested positive effects on VLU healing, range of ankle mobility compared with the control group. Patients' adherence to the exercise regimens was favourable.
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NewsBot · Feb 11, 2024

Effects of exercise in treating patients with venous leg ulcers: An umbrella review
Min Shen, Mengzhen Xing, Hehe Jiang, Linlin Zhang, Chen Chen, Yuning Ma, Yuxia Ma
31 January 2024

Venous leg ulcers (VLUs) represent a substantial challenge within the healthcare landscape, thereby necessitating efficacious therapeutic strategies. Exercise has been investigated as a prospective intervention to bolster the management of VLUs. The objective of this comprehensive review is to systematically scrutinize and appraise the extant body of evidence pertaining to the impact of exercise on the treatment of patients diagnosed with VLUs. A comprehensive literature search was executed across multiple databases, encompassing PubMed, the Cochrane Library, Web of Science, Embase, and Google Scholar. The methodological rigour was evaluated utilizing the Assessment of Multiple Systematic Reviews 2 (AMSTAR-2) instrument, while the quality of the evidence was appraised via the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification system. The relative efficacy of exercise interventions on outcomes related to VLUs, including rates of wound healing, total range of motion in the ankle joint, and adherence rates, was synthesized. Data were consolidated employing fixed-effects models, and the impact of exercise on these outcomes was visually represented through the use of forest plots. The methodological foundation of this investigation comprised four systematic reviews and meta-analyses, each characterized by an intermediate level of methodological rigour and evidence quality. Subsequent analyses revealed that exercise interventions exert a multifaceted and favourable impact on the therapeutic landscape of VLUs. These interventions distinctly contribute to the enhancement of wound healing rates (risk difference 0.17, 95% confidence interval [CI]: 0.06–0.28) and the extension of ankle range of motion (mean difference [MD] 6.10, 95% CI: 4.61–7.59). Furthermore, Pooled adherence rate was 0.70 (95% CI: 0.20–2.45) with no significant heterogeneity. In conclusion, although existing evidence supports the positive impact of exercise training on VLUs, higher-quality research is still needed to deepen our understanding of its effects and provide more specific guidance for clinical practice.
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