FOOTFIT Physical Activity mHealth Intervention for Minimally Ambulatory Individuals With Venous Leg Ulcers: A Randomized Controlled Trial

Use of a prescribed exercise intervention as an adjunct to improve venous leg ulcer healing

BACKGROUND

The complex healing process of venous leg ulcers (VLUs) is widely documented, yet wound healing outcomes continue to challenge community nurses. Compression therapy remains the 'gold standard' to improve healing outcomes. However, the complexities surrounding VLUs demand a holistic and unified approach. Advising patients with VLUs to perform exercises is a widely accepted practice based on the known benefits of lower leg mobility reducing venous hypertension. A lack of standardisation surrounding this subject has generated a rise in academic interest over the past decade, particularly in the benefit of a prescribed exercise intervention (PEI) as an adjunct to compression for VLU patients.

AIM

This review explored the use of an unsupervised PEI as an adjunct to improve VLU healing in housebound patients wearing compression therapy. The aim was to determine if a PEI is beneficial to VLU healing alongside compression therapy.

RESULTS

The review identified five randomised controlled trials (RCT) between 2009 and 2022. Although the evidence showed some limitations, statistically and clinically significant results were identified for VLU healing outcomes.

CONCLUSION

A PEI designed to engage the calf muscle pump is beneficial to improve VLU healing outcomes, alongside compression therapy, for housebound patients and should be included in the community nursing holistic model of care for VLU management.

Healthcare interventions to aid patient self-management of lower limb wounds: A systematic scoping review

Chronic lower limb wounds can be described as having the inability to progress through stages of wound healing. Although 80% of lower limb wounds develop as a result of venous insufficiency, other causes include arterial disease and diabetes. In addition to the sustained impact on quality of life, the chronicity of lower limb wounds presents a significant financial burden to healthcare systems. Self-management is a fundamental aspect of the long-term management of chronic illness and its relevance has intensified since the start of the global pandemic. The objective of this systematic scoping review was to define what the self-management of a lower limb wound entails and explore the interventions available to support patients to self-manage. A total of seven articles were evaluated. There was limited consensus regarding the definition and components of self-management in this area. Interventions involved patients participating in additional exercise, wound care, and lifestyle behaviours such as limb elevation and skin care. Only two studies applied theory and only one evaluated participant acceptability of interventions, making it difficult to assess the feasibility of implementation. Although the evidence reviewed provides some insight into the self-management of a lower limb wound, theoretically-guided research is needed in this area.

Smart Wearable Systems for the Remote Monitoring of Selected Vascular Disorders of the Lower Extremity: A Systematic Review

This systematic review aims at providing an overview of the state of the art regarding smart wearable systems (SWS) applications to monitor the status of patients suffering from vascular disorders of the lower extremity. Peer-reviewed literature has been analyzed to identify employed data collection methods, system characteristics, and functionalities, and research challenges and limitations to be addressed. The Medline (PubMed) and SCOPUS databases were considered to search for publications describing SWS for remote or continuous monitoring of patients suffering from intermittent claudication, venous ulcers, and diabetic foot ulcers. Publications were first screened based on whether they describe an SWS applicable to the three selected vascular disorders of the lower extremity, including data processing and output to users. Information extracted from publications included targeted disease, clinical parameters to be measured and wearable devices used; system outputs to the user; system characteristics, including capabilities of remote or continuous monitoring or functionalities resulting from advanced data analyses, such as coaching, recommendations, or alerts; challenges and limitations reported; and research outputs. A total of 128 publications were considered in the full-text analysis, and 54 were finally included after eligibility criteria assessment by four independent reviewers. Our results were structured and discussed according to three main topics consisting of data collection, system functionalities, and limitations and challenges.

The Effectiveness of Self-Guided Digital Interventions to Improve Physical Activity and Exercise Outcomes for People With Chronic Conditions: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review was to determine the effectiveness of self-guided digital physical activity (PA) and exercise interventions to improve physical activity and exercise (PA&E) outcomes for people living with chronic health conditions. Digital health interventions, especially those with minimal human contact, may offer a sustainable solution to accessing ongoing services and support for this population.

Methods

A comprehensive and systematic search was conducted up to December 2021, through seven databases, for randomized trials that evaluated the effect of self-guided web- or internet-based PA interventions on physical activity or exercise outcomes. Included studies had to have interventions with minimal human contact and interaction with participants needed to be automatically generated. All studies were screened for eligibility and relevant data were extracted. Two independent reviewers assessed the risk of bias using the Cochrane risk of bias tool. Standardized mean differences and 95% confidence intervals (CI) were calculated. PA data were pooled, and forest plots were generated.

Results

Sixteen studies met the eligibility criteria and included a total of 2,439 participants. There was wide variation in health conditions and intervention characteristics in mode and parameters of delivery, and in the application of theory and behavioral strategies. Self-reported PA in the intervention group was greater than controls at the end of the intervention [standardized mean difference (SMD) 0.2, 95% CI = 0.1, 0.3] and at follow up (SMD 0.3, 95% CI 0.2-0.5). The difference in objectively measured PA was small and non-significant (SMD 0.3, 95% CI -0.2 to 0.9). All interventions included behavioral strategies and ten of the sixteen were underpinned by theory.

Conclusions

Self-guided digital PA&E interventions provided a positive effect on PA immediately after the intervention. An unexpected and positive finding was a sustained increase in PA at follow-up, particularly for interventions where the behavioral strategies were underpinned by a theoretical framework. Interventions with minimal contact have the potential to support sustained PA engagement at least as well as interventions with supervision.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42019132464.

Effects of physical activity as an adjunct treatment on healing outcomes and recurrence of venous leg ulcers: A scoping review

Healing time is protracted and ulcer recurrence is common in patients with venous leg ulcers. Although compression is the mainstay treatment, many patients do not heal timely. Physical activity may be a clinically effective adjunct treatment to compression to improve healing outcomes. This scoping review provides a broad overview of the effect of physical activity as an adjunct treatment to compression on wound healing and recurrence. We followed the six-step framework developed by Arksey and O'Malley. We searched electronic databases and trial registration websites for relevant studies and ongoing trials. Two authors independently screened and selected articles. Findings were presented in a descriptive statistical narrative summary. We consulted and presented our findings to the wound consumer group to ensure the relevance of our study. Physical activity interventions in 12 out of the 16 eligible studies consisted of only one component, eight studies were resistance exercises, three studies reported ankle and/or foot range of motion exercises, and one study reported aerobic/walking exercises. The remaining four studies involved multicomponent exercise interventions. Resistance exercise combined with ankle and/or foot range of motion exercise minimised ulcer size on day 12 (intervention group: 4.55 ± 1.14 cm² vs. control group: 7.43 ± 0.56 cm² ) and improved calf muscle pump performance on day 8 (ejection fraction: 40%-65%; residual volume fraction: 56%-40%). We identified one study that reported ulcer recurrence rate with no clinical difference in the intervention group versus the control group (i.e., 12% in intervention vs. 5% in control). Our review identified that resistance exercise was the most common type of physical activity intervention trialled in the published literature. Resistance exercise combined with ankle and/or foot range of motion exercise appears to be effective adjunct treatments; however, the overall evidence is still relatively weak as most programmes had a short intervention period which limited clinical outcomes.