What is the effect of exercise on wound healing in patients with venous leg ulcers? A systematic review

Smith D1, Lane R2, McGinnes R1, O’Brien J3, Johnston R4, Bugeja L1, Team V1, Weller C1. Int Wound J. 2018 Jun;15(3):441-453

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What is the effect of exercise on wound healing in patients with venous leg ulcers? A systematic review

Smith D1, Lane R2, McGinnes R1, O’Brien J3, Johnston R4, Bugeja L1, Team V1, Weller C1. Int Wound J. 2018 Jun;15(3):441-453

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.

Main findings

  • The aim of this study was to conduct a systematic review to examine the effects of exercise in addition to standard compression therapy on VLU characteristics, including time to heal, size and recurrence, pain, quality of life, adverse events, and economic outcomes.
  • Exercise included: – strength or resistance training and aerobic activity that involved the lower limb. – land- and water-based. – structured and not structured. – supervised and unsupervised (ie, undertaken at home).
  • This systematic review examined 6 RCTs published between 1990 and 2017 that measured the effects of exercise interventions on VLU healing rates, time to healing, recurrence, quality of life, pain, adverse events, and economic outcomes. The key findings are as follows: low quality evidence from 3 trials indicates there may be no difference in the proportion of ulcers healed after 12 weeks of a PREG plus compression compared with compression alone. Low-quality evidence from a single trial indicates there was probably no difference in quality of life and a possible increase in the risk of adverse events. Low-quality evidence from 2 trials also indicates that there was possibly no difference in ankle range of motion and CMP.
  • Recurrence, pain, and economic outcomes were not measured in these trials, and time to healing was measured only in a single trial but not fully reported.
  • There was no statistically or clinically significant change in wound-healing outcomes.
  • It is not known, however, whether the trend towards healing for those in exercise intervention groups occurred as a result of the exercise intervention because there was a lack of studies using direct measures of time to healing.
  • Direct comparisons of RCTs are not possible due to the lack of homogeneity.
  • The evidence suggests that exercise may improve wound healing, quality of life, and physical functioning in adults with VLUs. Although these preliminary results are promising, the findings are based on a relatively small number of trials with significant methodological weaknesses.