Evaluating the effectiveness of a self-management exercise intervention on wound healing, functional ability and health-related quality of life outcomes in adults with venous leg ulcers: a randomised controlled trial

Stasis Dermatitis: The Burden of Disease, Diagnosis, and Treatment

Stasis dermatitis (SD), an inflammatory dermatosis occurring on the lower extremities, is a cutaneous manifestation of chronic venous insufficiency (CVI). SD is associated with a significant burden of disease. Symptoms such as pain, swelling, and itching can be debilitating for patients, leading to poor sleep, loss of mobility, and the inability to perform daily activities, and can interfere with work and leisure activities. Moreover, SD is a progressive disease with serious secondary complications such as ulcerations, which increase the patients' morbidity, reduce their quality of life, and increase health care burden. Challenges in diagnosing patients may have both short- and long-term sequalae for the patients due to unnecessary treatment and management. In addition, misdiagnosis may result in hospitalizations, placing additional burden on health care professionals in terms of time and financial burden on the health care system. Compression therapy and leg elevation represent the mainstay of treatment for CVI; however, it is also difficult to self-manage, which places a substantial burden on patients and caregivers. Moreover, compression therapy may cause discomfort and exacerbate itching. Subsequent nonadherence may result in disease progression that places additional burden on the physicians who manage these patients and the health care system in terms of resources required and costs incurred. A large proportion of patients with SD develop allergic contact dermatitis because of innate immune signals and altered skin barrier predisposing to sensitization to topical prescriptions, over-the-counter medications, and compression devices used to treat SD. Other than topical corticosteroids, there are no approved pharmacological options to treat inflammation in SD.

Diagnosis and treatment of venous leg ulcers: S2k Guideline of the German Society of Phlebology and Lymphology (DGPL) e.V

This S2k guideline on venous leg ulcers was created on the initiative and under the leadership of the German Society of Phlebology and Lymphology (DGPL). The guideline group also consisted of representatives from the German Society for Phlebology and Lymphology, German Dermatological Society, German Society for General Medicine, German Society for Angiology, German Society for Vascular Surgery and Vascular Medicine, German Society for Surgery, German Society for Dermatosurgery, German Society for Wound Healing and Wound Treatment, Professional Association of Phlebologists and Lymphologists and Initiative Chronische Wunden. The aim of this guideline is to combine the different approaches and levels of knowledge of the respective professional groups on the basis of consensus, so that a basic concept for the best possible treatment of patients with venous leg ulcers can be provided. A total of 70 specific recommendations were formulated and agreed upon, divided into the subject areas of diagnostics, therapy, prevention of recurrences, and everyday challenges. The guideline thus reflects the current state of scientific knowledge and is intended to be widely used as the best available document for the treatment of patients with venous leg ulcers in everyday clinical practice.

A systematic review of the impact of compression therapy on quality of life and pain among people with a venous leg ulcer

AIM

To gain a greater understanding of how compression therapy affects quality of life, this systematic review appraised existing published studies measuring the impact of compression therapy on health quality of life (HRQoL), and pain, among people with venous leg ulcers (VLU).

METHOD

Five databases were searched, and two authors extracted data and appraised the quality of selected papers using the RevMan risk of bias tool. Due to heterogeneity in the types of compression and instruments used to evaluate HRQoL, meta-analysis was not appropriate; thus, a narrative synthesis of findings was undertaken.

RESULTS

Ten studies were included, 9 RCTs and one before-after study. The studies employed nine different HRQoL tools to measure the impact of a variety of compression therapy systems, with or without an additional exercise programme, versus other compression systems or usual care, and the results are mixed. With the use of the Cardiff Cardiff Wound Impact Schedule, the SF-8 and the SF-12, study authors found no differences in QoL scores between the study groups. This is similar to one study using QUALYs (Iglesias et al., 2004). Conversely, for studies using EuroQol-5D, VEINES-QOL, SF-36 and CIVIQ-20 differences in QoL scores between the study groups were noted, in favour of the study intervention groups. Two further studies using QUALYs found results that favoured a two-layer cohesive compression bandage and the TLCCB group, respectively. Results for the five studies that assessed pain are also mixed, with one study finding no difference between study groups, one finding that pain increased over the study period and three studies finding that pain reduced in the intervention groups. All studies were assessed as being at risk of bias in one or more domains.

CONCLUSION

Results were varied, reflecting uncertainty in determining the impact of compression therapy on quality of life and pain among people with a venous leg ulcer. The heterogeneity of the compression systems and the measures used to evaluate HRQoL make it a challenge to interpret the overall evidence. Further studies should strive for homogeneity in design, interventions and comparators to enhance both internal and external validity.

Association between physical activity levels and healing in people with venous leg ulcers: secondary analysis of prospective cohort data

Aim

To explore the relationship between physical activity levels and wound healing and recurrence in people with venous leg ulcers.

Methods

Questionnaires and medical records were used to collect data, with responses used to group participants into different physical activity groups. The differences in healing and recurrence outcomes of ulcers among different physical activity groups were compared using Chi-square, Kaplan Meier survival analysis, Cox proportional hazards regression analysis, and Kruskal-Wallis test. To measure the strength of the association between physical activity levels and patient outcomes, Spearman's Rho tests were used. We used descriptive analysis to examine how physical activity levels change over 24 weeks.

Results

Participants were classified into four distinct groups based on physical activity levels reported at baseline and week 12. The survival analysis showed higher physical activity level was associated with a shorter time to healing (log-rank test = 14.78, df = 3; p = 0.002). The persistently moderate-to-vigorous group had a 7.3-fold increased likelihood of healing compared to the persistently sedentary group. High levels of physical activity were also associated with a better quality of life score at baseline (ρ = 0.41, p < 0.000), week 12 (ρ = 0.36, p < 0.001), and week 24 (ρ = 0.49, p < 0.000). Most participants (48.5%) reported low levels of physical activity, which remained low for the entire study period.

Conclusion

An increased level of physical activity was linked to a shorter healing time and enhanced quality of life. Low levels of physical activity appeared common among people with venous leg ulcers.

Mobility range, level of pain and sleep quality of patients with venous leg ulcers

This study aimed to compare mobility range, level of pain and sleep quality in patients with venous leg ulcers to age- and gender-matched controls without ulcers. Twenty patients with venous leg ulceration and 20 matched controls each answered a questionnaire, completed the short-physical performance battery, filled in a subject diary and wore a smartwatch for 1 week. The median daily step counts of the ulcer group (3622 steps/day) and the control group (5133 steps/day) were significantly different (P = .017). Significant correlations between total step count and age, duration of physical outdoor activities and scores in the short-physical performance battery were observed in the ulcer group. The scores in the short-physical performance battery were significantly different in both groups (P = .005), indicating weaker physical performance in the ulcer group. The greatest difference in the self-reported level of pain between the two groups was stated during movement. On average, the ulcer group slept shorter by 1 h 38 min (P = .002) and had 0.7 wake phases per night (P = .019) more than the control group. Assessing mobility in patients with venous leg ulcers can be used to develop preventive and interventional concepts to improve and individualise physical therapies.

No More Venous Ulcers-What More Can We Do?

Venous leg ulcers (VLUs) are the most severe complication caused by the progression of chronic venous insufficiency. They account for approximately 70-90% of all chronic leg ulcers (CLUs). A total of 1% of the Western population will suffer at some time in their lives from a VLU. Furthermore, most CLUs are VLUs, defined as chronic leg wounds that show no tendency to heal after three months of appropriate treatment or are still not fully healed at 12 months. The essential feature of VLUs is their recurrence. VLUs also significantly impact quality of life and could cause social isolation and depression. They also have a significant avoidable economic burden. It is estimated that the treatment of venous ulceration accounts for around 3% of the total expenditure on healthcare. A VLU-free world is a highly desirable aim but could be challenging to achieve with the current knowledge of the pathophysiology and diagnostic and therapeutical protocols. To decrease the incidence of VLUs, the long-term goal must be to identify high-risk patients at an early stage of chronic venous disease and initiate appropriate preventive measures. This review discusses the epidemiology, socioeconomic burden, pathophysiology, diagnosis, modes of conservative and invasive treatment, and prevention of VLUs.

The co-design of an exercise-based, lifestyle intervention for people with venous leg ulcers; a self-care, expert-supported strategy for a chronic condition

Exercise is recommended as an adjunct treatment, alongside compression therapy to increase venous leg ulcer (VLU) wound healing times, however, there are no published programmes available that support patients to exercise at home on their own. To develop an exercise-based lifestyle intervention that is feasible and acceptable to people with VLUs, a participatory approach was utilised. Clinicians, researchers, and people living with VLUs collaborated in the design of "FISCU Home". Two focus groups and nine interviews were conducted with people living with a VLU. Tissue viability nurses provided clinical expertise. Data was analysed through thematic analysis. Ten key themes were identified and incorporated into FISCU Home: (I) a condition-specific flexible programme, (II) personal assessment and tailored exercises, (III) tapered individualised support, (IV) short lower-intensity sessions, (V) chair-based options, (VI) falls prevention, (VII) accessible resources, (VIII) functional, compact, self-managed exercises, (IX) a behaviour change strategy, and (X) education. FISCU Home has integrated patients' needs and preferences with evidence-based principles and theory to create an exercise-based lifestyle intervention for people with VLUs. FISCU Home could provide a mainstream adjunct therapy in wound care and support the movement towards self-management.

The Effect of Standard Compression Adjuvant with a Tailored Exercise Training Program on Health-Related Quality of Life Outcomes in Treating Adults with Venous Leg Ulcer: A Randomized Controlled Trial

Exercise training adjuvant to standard compression is considered to improve calf muscle pump dysfunction in venous leg ulcer (VLU) and subsequent healing. The objectives of this trial were to assess the effectiveness of a tailored exercise training intervention in addition to standard compression therapy on health-related quality of life and anticipating wound healing. Twenty-four VLU participants were recruited and randomly divided into 2 groups. The control group was prescribed conventional compression, and the intervention group received compression plus progressive tailored exercise training. The 14-item chronic venous disease quality of life questionnaire (CIVIQ-14) was used to assess improvement after treatment over time (0, 6, and 12 weeks). Intervention and control groups achieved wound closure for 11 (92%) and 7 (58%) patients. After adjusting for age, sex, and wound size at baseline, the exercise intervention group had 2 times the probability of complete wound healing in 12 weeks than those in the control group (risk ratio = 1.98, 95% CI= 1.01-3.72, P = .047). The primary outcome was the difference in CIVIQ-14 score in 3 dimensions and global index score per visit. The outcomes were evaluated by independent assessors. Demographic, comorbidities, and wound assessments were collected on enrollment. The overall adherence to exercise protocol was 71%. After adjusting age, sex, size of VLU, and CIVIQ score at baseline, the participants in the intervention group had the average global index scores and psychological scores increase at week 12 than those in the control group (21.2; 95% CI= 7.1-35.2, P = .005, and 13.5; 95% CI = 2.9-24.2, P = .044, respectively). Both groups showed similar improvement in the mean change in physical and pain scores within-group over time. Patients with combined conventional compression therapy with exercise training appeared to have a higher quality of life score in psychological and global scores than those with compression therapy alone.

Effects of exercise in treating patients with venous leg ulcers: A systematic review and meta-analysis

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.

Reducing Risks for Poor Surgical Wound Healing

This review summarizes common risk factors for poor surgical healing on the face and neck and a generalized approach to treating a delayed healing wound. During the preoperative evaluation patients should be screened for prior irradiation, cigarette or e-cigarette use, chronic steroid use, alcoholism, diabetes, malnutrition, and other chronic medical conditions and medications. Despite the surgeon's best efforts to prevent poor surgical healing, some wounds may display signs of persistent inflammation. The facial plastic surgeon should be astute in recognizing delayed healing and identifying intrinsic and extrinsic risk factors so that timely intervention can be performed.

Effect of educational interventions on wound healing in patients with venous leg ulceration: A systematic review and meta-analysis

Educational interventions for patients with venous leg ulceration (VLU) may promote adherence and self-management, however, their effect on wound healing is unclear. A systematic literature search was performed and randomised controlled trials with a focus on educational interventions were included. Wound healing was analysed by assessing wound healing rate, ulcer size, and the PUSH Score. Additional outcomes comprised pain, quality of life, and functional ability. The study protocol for this work is registered at PROSPERO 2020 (ID: CRD42021286152). Nine studies were included in this meta-analysis. The odds ratio for wound healing was 1.91 (95% CI, 0.99-3.67, P = .053) in favour of educational interventions compared to usual care. Ulcer size reduction was higher (MD: -7.22; 95% CI, -11.91 to -2.53, P = .003) in patients following educational interventions. Included studies also showed significant effects on pain, quality of life, and functional analysis, though no quantitative synthesis was feasible. The overall risk of bias showed some concerns. Educational interventions aim to actively involve patients in their treatment, thereby appearing to be able to have a positive impact on wound healing within 12 weeks. Consequently, integrating educational approaches to routine wound care may be a promising strategy to improve treatment of VLU.

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.

Active legs: Impact of physical activity as an adjuvant treatment in the healing of venous ulcers in primary care: a RCT protocol study

BACKGROUND

Venous ulcers usually present a torpid evolution with a negative impact on patients' quality of life. In primary care, they account for 2.5% of nursing consultations and their treatment represents high costs for national health systems. These patients usually have a low level of physical activity, with muscle pump dysfunction of the lower limbs, which may improve with increased physical activity. The purpose of this study is to analyse the effectiveness of a structured intervention involving physical activity and exercise (Active Legs) as an adjuvant treatment in improving healing of chronic venous ulcers at 3 months follow-up.

METHODS

A randomized, multicentre clinical trial. A total of 224 individuals receiving primary nursing care with a diagnosis of venous ulcer, with a diameter of 1 cm or greater and an ankle-brachial index between 0.8 and 1.3, able to comply with the study requirements and consenting to participate, will be sequentially included (112 per group). Both groups will receive the standard treatment in primary care, with cleansing, debridement and healing in a moist environment together with multilayer compression therapy. The intervention group will also receive a structured educational intervention involving lower limb physical exercise and daily ambulation guidelines. The primary response variables will be complete healing -understood as complete and sustained epithelialisation for at least 2 weeks- and time to healing. The secondary variables will be degree of healing, ulcer area, quality of life, pain and variables related to the healing process, prognosis, and recurrences. Sociodemographic variables, adherence to treatment and satisfaction variables will also be recorded. Data will be collected at baseline, at 3 months and at 6 months follow-up. Survival analysis (Kaplan-Meier and Cox) will be performed to measure primary effectiveness. Intention-to-treat analysis.

DISCUSSION

If the intervention is effective, a cost-effectiveness analysis could be conducted and implemented as an additional intervention in the usual venous ulcer treatment in primary care.

TRIAL REGISTRATION

NCT04039789. [ https://ClinicalTrials.gov ]. 07/11/2019.

Views of inpatients on the prevention of venous thrombosis with ankle pump exercise: A cross-sectional survey

INTRODUCTION

This study investigated the current status of patients' knowledge and clinical compliance with ankle pump exercises in order to better enhance patient education and improve patient compliance with ankle pump exercises.

METHODS

A cross-sectional survey of the current status of ankle pump exercise awareness and compliance was conducted using a self-designed questionnaire. The questionnaire consisted of a general demographic information questionnaire, a questionnaire on patients' perceptions of ankle pump exercise and a compliance questionnaire.

RESULTS

A total of 2,203 patients from 53 clinical departments participated in this survey. 87.8% of patients considered ankle pump exercise important, 92.1% could grasp the knowledge of ankle pump exercise, 48.5% could self-monitor and exercise daily as instructed, 81.5% of health care workers would often supervise patients to complete ankle pump exercise, poor self-control (34.6%), lack of physical strength (21.1%) and perceived hassle (18.9%) were the top 3 factors contributing to patients' inability to complete the ankle pump exercise. Regression analysis showed that the factors influencing patients' compliance with the ankle pump exercise were literacy, economic level, number of comorbidities and caprini risk class (p < .05).

CONCLUSION

The patient's cognition of ankle pump exercise is good, but the compliance needs to be improved. It is suggested that the compliance of ankle pump exercise in hospitalized patients should be improved in the future to reduce the incidence of Venous thromboembolism.

Venous leg ulcers and prevalence of surgically correctable reflux disease in a national registry

BACKGROUND

Chronic venous disorders are common, with varicose veins occurring in ∼40% of the population. Venous leg ulcers affect 1% to 2% of the population, with the prevalence increasing ≤4% for those aged >65 years. Both conditions are expensive and together are responsible for ≤2% of the annual healthcare budget expenditure of Western societies. The ESCHAR (effect of surgery and compression on healing and recurrence) and EVRA (early venous reflux ablation) trials demonstrated that surgical correction of superficial venous reflux reduced ulcer recurrence, resulted in faster healing times (EVRA), and was proved cost-effective. Largescale data regarding patients with chronic venous leg ulcers presenting to venous centers with treatable superficial venous insufficiency has not been previously reported. Our study was designed to evaluate the percentage of patients with leg ulcers presenting to dedicated vein centers who were found to have surgically correctable superficial venous insufficiency.

METHODS

The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry began collecting data in 2014 and is one of two national registries focused on chronic venous disorders. The database was queried first for the presence of an ulcer using the CEAP (clinical, etiologic, anatomic, pathophysiologic) classification (C6 status). These de-identified data were further correlated by crossing the number of ulcers for the same limb using the revised venous clinical severity score (rVCSS). The demographics, index duplex ultrasound details, and rVCSS features for ulcer duration and compression use were analyzed. Once the presence of an ulcer had been validated by CEAP and rVCSS, the population was divided into groups according to the ultrasound-reported anatomic pathology (eg, normal, reflux, obstruction, reflux plus obstruction). The query was directed toward all patients seeking a venous evaluation at participating centers from January 2018 through January 2022.

RESULTS

More than 270,000 unique patient records were reviewed. Of the 270,000 records, 163,027 (60%) had had duplex ultrasound scans available, for 1794 unique patients (1879 limbs), representing 1.1% with a leg wound. Of these patients, 55.4% were men and 44.6% were women. Group S included patients with isolated superficial pathology (n = 1291; 68.7%). Group M included patients with mixed superficial and deep pathology (n = 238; 12.7%). Group D included patients with isolated deep vein pathology (n = 58; 3.1%). Finally, group N included patients with leg wounds but no venous pathology (n = 292; 15.5%). The rVCSSs for groups S and M were significantly higher than those for group N. In group S, the dominant patterns involved the great saphenous vein (GSV) above the knee (54.8%), the small saphenous vein (30.7%), and the anterior accessory GSV (14.4%). The frequency of single, double, and triple axial vein reflux identified 1.45 vessels eligible for ablation treatment per limb. In group M, the dominant patterns involved the GSV above the knee (61.7%), the small saphenous vein (26.2%), and the anterior accessory GSV (12.1%), for 1.52 axial segments per limb. Of the 84.4% of venous ulcer patients, duplex ultrasound analysis revealed that 97% of this large subset had had surgically correctable disease.

CONCLUSIONS

The American Vein & Lymphatic Society Patient Reported Outcome Venous Registry demonstrated that 85% of the leg wounds in the present study were venous in origin and 97% possessed surgically correctable disease. Our findings support early referral to dedicated vein centers with appropriate venous reflux management as a part of the multidisciplinary team caring for patients with venous leg ulcers.

A 12-Week Supervised Exercise Therapy Program for Patients with Diabetic Foot Ulcers: Program Development and Preliminary Feasibility

Exercise therapy helps improve glycaemic control and insulin sensitivity and may be relevant in treating patients with diabetic foot ulcers (DFUs). This study describes the development of a 12-week exercise therapy program for patients with DFUs and the preliminary feasibility of the program focusing on the program's inclusion, adherence, and safety. The development process is built on knowledge from a published systematic review on exercise for people with DFUs and a grounded theory study on the main concerns of people with DFUs regarding physical activity. The development involved doctors, wound care nurses, podiatrists, and feedback from patients and physical therapists using semi-structured interviews. The program was designed as a combination of aerobic and resistance training exercises. The aerobic exercise phase on the stationary bike of 30-minute duration was aimed at a moderate intensity. Resistance exercises were conducted with a 15-repetition maximum approach (four to five sets per trial) throughout the 12-week period. Three patients were included and received the exercise intervention. Except for recruitment and retention rates, acceptance levels were met for all other research progression criteria. Patients found the intervention relevant, wanted further guidance on continuing exercising, and would have liked the intervention closer to their home for example, a municipality setting. Although the exercise therapy program for patients with DFUs was developed in a thorough process with the inclusion of available evidence and the involvement of patients and other stakeholders conclusions on feasibility are limited due to the low recruitment rate. A reconsideration of the setting is needed in future exercise intervention studies.

Systematic review and meta-analysis of exercise therapy for venous leg ulcer healing and recurrence

OBJECTIVE

National guidelines in the United Kingdom have recommended regular exercise for individuals with venous leg ulceration. However, data on the effects of exercise on ulcer healing and recurrence are sparse. In the present study, we aimed to quantify the evidence for exercise regarding venous ulcer healing with respect to the primary outcomes of the proportion of healed ulcers and rate of ulcer recurrence. The secondary outcomes were improvement in ulcer symptoms, ulcer healing time, quality of life, compliance, and adverse events reported.

METHODS

The review followed PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines using a registered protocol (CRD42021220925). The MEDLINE and Embase databases and Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, European Union Clinical Trials, and International Standard Randomised Controlled Trial Number registries were searched up to April 6, 2022 and included studies comparing exercise therapy and compression vs compression alone. Data for the proportion of healed ulcers were pooled using a fixed effects meta-analysis.

RESULTS

After screening 1046 reports, 7 were included, with 121 participants allocated to exercise therapy and 125 to compression alone. All the reports were of randomized controlled trials and had reported ulcer healing at 12 weeks, with a pooled relative risk of ulcer healing of 1.38 for exercise vs compression (95% confidence interval, 1.11-1.71). Only one study had reported on recurrence; thus, data pooling was not performed. No differences between exercise and usual care were demonstrated. Compliance with exercise ranged from 33% to 81%. The included studies demonstrated low enrollment and a high risk of bias. Also, most of the trials had failed to demonstrate any differences in activity completed between the intervention and control arms.

CONCLUSIONS

A paucity of studies has examined leg ulcer recurrence after exercise programs, with no evidence to show that exercise is beneficial. Furthermore, the quality of evidence supporting exercise as an adjunct to ulcer healing is very low, and the trials demonstrated serious methodologic flaws, chiefly in recording the activity undertaken by the participants in the intervention arm. Future randomized controlled trials should implement activity monitoring and standardize the reporting of key patient, ulcer, and reflux characteristics to enable future meaningful meta-analyses to determine the role of exercise as an adjunct to venous leg ulceration healing.

Exercise sustains the hallmarks of health

Exercise has long been known for its active role in improving physical fitness and sustaining health. Regular moderate-intensity exercise improves all aspects of human health and is widely accepted as a preventative and therapeutic strategy for various diseases. It is well-documented that exercise maintains and restores homeostasis at the organismal, tissue, cellular, and molecular levels to stimulate positive physiological adaptations that consequently protect against various pathological conditions. Here we mainly summarize how moderate-intensity exercise affects the major hallmarks of health, including the integrity of barriers, containment of local perturbations, recycling and turnover, integration of circuitries, rhythmic oscillations, homeostatic resilience, hormetic regulation, as well as repair and regeneration. Furthermore, we summarize the current understanding of the mechanisms responsible for beneficial adaptations in response to exercise. This review aimed at providing a comprehensive summary of the vital biological mechanisms through which moderate-intensity exercise maintains health and opens a window for its application in other health interventions. We hope that continuing investigation in this field will further increase our understanding of the processes involved in the positive role of moderate-intensity exercise and thus get us closer to the identification of new therapeutics that improve quality of life.

Effects of Oral Nutritional Supplementation on Patients with Venous Ulcers: A Clinical Trial

Background: The dosage and safety of nutritional supplements for patients with venous ulcers are still not well established. Aim: To evaluate the effects of a high calorie, high protein, arginine-, zinc-, and vitamins A, C, and E-enriched nutritional supplement on the biochemical profile, dietary intake, anthropometry, muscle strength, and characteristics of lesions of patients with venous ulcers. Methods: A controlled before−after clinical trial with a four-week follow-up involved 27 patients with venous ulcers under outpatient treatment in Brazil. It was administered in two to three doses per day (200 mL each) of a high-calorie and high-protein supplement enriched with arginine, zinc, and vitamins A, C, and E. Patients were assessed for anthropometric parameters, dietary intake, biochemical tests, and healing conditions according to the Pressure Ulcer Scale for Healing (PUSH). Results: It was observed that an increase in energy and protein supply led to an adequate intake of immunonutrients (zinc and vitamins A, C, and E), increased body weight, increased body mass index, and stronger handgrip strength. The injury area and the score on the PUSH notably decreased after the intervention (p < 0.001). Conclusions: The administered supplement, at the tested dosage, improved the nutritional status and characteristics of lesions in patients with venous ulcers.

At-home Topical Sevoflurane Added to the Conventional Analgesic Treatment for Painful leg Ulcers Greatly Improved the Analgesic Effectiveness and Reduced Opioid Consumption in a Single-Center Retrospective Comparative Study with one-Year Follow-up

The general anesthetic sevoflurane is being repurposed as a topical analgesic for painful chronic wounds. This study was aimed to compare the analgesic effectiveness and safety of systemic analgesics alone or plus at-home topical sevoflurane for the management of patients with painful nonrevascularizable leg ulcers who were referred to a Pain Clinic by their attending vascular surgeons. We reviewed charts of patients treated in a single Pain Clinic with analgesic Standard of Care either alone (group SoC) or plus at-home topical sevoflurane (group SoC + Sevo), according to safety criteria. The area under the curve of pain over a year (AUC-Pain) was the primary outcome for analgesic effectiveness. Opioids were converted into Oral Morphine Milligram Equivalents. Groups SoC (n = 26) and SoC + Sevo (n = 38) were similar in baseline characteristics. Compared to SoC, median values [interquartile range] of area under the curve of pain for one-year follow-up were markedly lower for SoC + Sevo (54 [35-65] vs. 15 [11-23]; p < 0.000001, U Mann-Whitney test). Oral Morphine Milligram Equivalents were similar at baseline (SoC: 78.5 [22.5-135] vs. SoC + Sevo: 101.3 [30-160]; p = 0.753), but significantly lower for SoC + Sevo at three (120 [22.5-202.5] vs. 30 [0-80]; p = 0.005), six (120 [11.3-160] vs. 20 [0-67.5]; p = 0.004), nine (114.4 [0-154] vs. 0 [0-37]; p = 0.018), and 12 months (114.4 [0-154] vs. 0 [0-20]; p = 0.001). Multiple linear regression analysis revealed the addition of sevoflurane to be the most likely variable to explain this difference in outcome (ß:-33.408; p < 0.000001). Nine patients (24%) in SoC + Sevo had adverse effects attributed to sevoflurane, but only one patient needed to stop using sevoflurane due severe dermatitis. In conclusion, the addition of topical sevoflurane to the analgesic standard of care in patients with painful nonrevascularizable leg ulcers was a well-tolerated therapy that significantly improved pain control and allowed for a significant reduction in opioid consumption.

Healing Process, Pain, and Health-Related Quality of Life in Patients with Venous Leg Ulcers Treated with Fish Collagen Gel: A 12-Week Randomized Single-Center Study

The aim of the study was to assess the effectiveness of fish skin collagen and its impact on healing, pain intensity, and quality of life in patients with venous leg ulcers (VLUs). This study included 100 adults with VLUs. Eligible patients were randomized to either tropocollagen gel treatment (group A, n = 47) or placebo alone (group B, n = 45). We applied the gel to the periwound skin for 12 weeks. All groups received standard wound care, including class 2 compression therapy and wound hygiene procedures. We assessed the healing rate (cm²/week) and quality of life (QoL) using the Skindex-29 and CIVIQ scales. In group A, more ulcers healed, and the healing rate was faster. In both study groups, patients showed a significant improvement in quality of life after the intervention, but there was a greater improvement in the tropocollagen group. In group A, the greatest improvement was related to physical symptoms and the pain dimension. This study showed that the application of fish collagen gel to the periwound skin improves the healing process and QoL in patients with VLUs. The 12-week treatment with collagen reduced the severity of physical complaints, pain, and local skin symptoms, which determined the quality of life in patients with VLUs to the greatest extent.

Impact of Educational Nursing Intervention on Compression Therapy Adherence and Recurrence of Venous Leg Ulcers: A Quasi-Experimental Study

Following the healing of venous leg ulcers, the primary problems for nursing and patients are adhering to compression therapy and preventing ulcer recurrence. As a result, it is important that patients comprehend their situation. The purpose of this study is to see how an educational nursing intervention affected compression therapy adherence and recurrence of venous leg ulcers in patients with chronic venous leg ulcers. A quasi-experimental design was used, including an intervention, a control group, and before and after assessments. This study was conducted in one of Egypt's largest teaching hospitals associated with Menoufia University. The 20-month study included 80 adult patients with healed venous leg ulcers. Each participant was randomized to either a control (got regular leg ulcer information) or study (received educational interventions) group. The following tools were used in the study: bio-sociodemographic variables, knowledge evaluation, compression therapy adherence scale, and recurrence follow-up, after 3, 6, and 12 months of implementation. Furthermore, there is a statistically significant difference between the study groups during the pretest (r = 0.885, 0.774, and 0.477, p = 0.002). The use of nursing education increased patients' understanding and adherence to compression treatment substantially. As a consequence, those with chronic venous leg ulcers may be able to avoid recurrent venous leg ulcers.

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.

Primary care disease management for venous leg ulceration—study protocol for the Ulcus Cruris Care [UCC] randomized controlled trial (DRKS00026126)

Background

Venous leg ulcers (VLU) have a prevalence of 1–2% in developed countries, and affected patients are severely and long-term impaired in daily activities, work, and social participation. Evidence-based outpatient treatment based on compression therapy is frequently not implemented. The “Ulcus Cruris Care” project was established to develop a disease management concept to improve outpatient treatment for patients with VLU in German primary care. For this purpose, a multifaceted intervention was conceived consisting of an online training for general practitioners and medical assistants, standardized treatment recommendations, e-learning and print-based information for patients, and a software support for case management. The main aims of the Ulcus Cruris Care intervention are to promote standardized treatment according to current scientific knowledge, to facilitate case management for VLU patients exerted by medical assistants, and to support patient education and participation in the treatment process. The UCC trial was designed to evaluate the effectiveness of the Ulcus Cruris Care intervention.

Methods

The UCC trial is a prospective cluster-randomized controlled multicenter trial. Fifty GP practices are intended to be recruited and randomized 1:1 to intervention or control arm. Patients with venous leg ulcers will be recruited by participating GP practices, to include a total of 63 patients in each arm. The primary outcome is time to ulcer healing. Secondary outcomes comprise number and sizes of ulcers, recurrence, pain intensity according to the visual analog scale, health-related quality of life according to EQ-5D-5L, depressiveness according to Patient Health Questionnaire (PHQ-9), patient satisfaction according to the Patient Assessment of Chronic Illness Care (PACIC-5A) query, and adherence to VLU treatment. The outcome analysis of the UCC trial is accompanied by a health economic analysis and a process evaluation.

Discussion

The UCC trial will evaluate whether the Ulcus Cruris Care intervention may lead to faster wound healing, higher health-related quality of life, and lower use of medical resources. If the intervention turns out to have a positive impact on assessed outcomes, comprehensive implementation in primary care may be considered.

Trial registration

The trial protocol (version 1 as of July 19, 2021) has been registered in the German Clinical Trials Register on August 30, 2021 (DRKS00026126).

Exercise Training as an Adjunctive Therapy for Chronic Venous Insufficiency Patients: Evidence from Research to Practice

Chronic venous insufficiency, which is defined as a condition relevant to persistent ambulatory venous hypertension, is a common cause of venous leg ulcers. Compression therapy is commonly used to relieve ambulatory venous hypertension and heal leg ulcers. Exercise is considered as adjunctive therapy, targeting calf muscle pump function, to additionally favor the compression treatment for facilitating the healing process. Different exercise training regimens for promoting wound healing and its relevant outcomes are reviewed and discussed in this study.

Physical Activity as an Adjunct to Compression Therapy on Healing Outcomes and Recurrence in Patients With Venous Leg Ulcers: A Scoping Review Protocol

Background: Chronic venous leg ulceration is a common and costly clinical issue across the world, affecting up to 3 in 1,000 people. Compression therapy is recommended as the gold standard treatment in clinical practice, although a large number of venous leg ulcers remain unhealed after several years. Physical activity may improve healing although there is limited evidence on the effects of physical activity as an adjuvant treatment to compression to improve venous leg ulcers healing and prevent recurrence. Objectives: This scoping review protocol aims to systematically search, appraise, and synthesize quantitative research evidence to assess the effect of physical activity interventions applied in conjunction with compression therapy on venous leg ulcer healing and recurrence. Methods and Analysis: We will use the methodology framework suggested by Arksey and O'Malley, Levac et al., the JBI as a guide. We will also follow the three-step search strategy recommended by the JBI to systematic search for relevant published research, ongoing clinical trials, and grey literature. Two review authors will independently screen titles and abstracts followed by full-text review to determine final eligibility for inclusion. The search process will be reported using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart. Characteristics of physical activity interventions, primary outcomes related to ulcer healing and recurrence, and secondary outcomes of interest included quality of life, pain level, adverse effects, and economic costs will be extracted and summarized. The review will provide a descriptive account of the findings from included studies. Where appropriate, data will be pooled for a meta-analysis using a random effects model. Discussion: Physical activity interventions represent a low-cost, potentially useful adjuvant treatment to compression therapy for the management of venous leg ulcers. Several gaps in knowledge remain that are answerable via a targeted scoping review. This protocol outlines the rationale, objectives, and the planned methodology for conducting the study. Ethics and Dissemination: The scoping review will use data from publicly available sources and ethical approval is not required. Findings from this review will be submitted to a peer-reviewed journal, presented at relevant conferences and disseminated via social media.

Effectiveness of combined conventional treatment with a tailored exercise training program on wound healing in patients with venous leg ulcer: A randomized controlled trial

INTRODUCTION

Venous leg ulcer (VLU) is a therapeutic challenge. The mainstay of care is compression therapy and wound care. Exercise is also recommended for facilitating wound healing. This study aimed to determine whether adding tailored exercise training to conventional treatment would be superior on wound healing, ankle mobility, calf muscle function, and functional ability compared to those with the conventional treatment alone.

METHODS

A randomized controlled trial, single-blinded was conducted. VLU patients were randomized to the conventional treatment plus tailored exercise training (intervention group) and the conventional treatment alone (control group) (12/group). The conventional treatment contained foam dressing and short-stretch bandage, while the tailored exercise training consisted of stretching, resistive, and aerobic exercise sessions (3-day/week, for 12-week). Primary outcomes included healing rate and wound size parameters. Secondary outcomes were ankle range of motion (ROM), calf circumference, calf muscle endurance and strength, and functional ability. All outcomes were assessed at baseline, 6-, and 12-week intervention.

RESULTS

The intervention group had a higher trend of healing rate after 12-week training than those in the control group, but this trend was not significantly different (92% versus 58%, p = 0.06). After training, the intervention group had significantly decreased wound size. The intervention group had significantly higher ankle ROM and dorsiflexor muscle strength after 6- and 12-week training than those in the control group.

CONCLUSION

Adding the tailored exercise training incorporated with the conventional treatment may provide a greater tendency on wound healing and have the potential to improve ankle mobility than the conventional treatment alone.

TRIAL REGISTRATION NUMBER

TCTR20170405002.

Effectiveness of therapeutic exercises for improving the quality of life of patients with chronic venous insufficiency: a systematic review

The main signs and symptoms of chronic venous insufficiency are pain, edema, varicose veins, and tissue changes; conditions that compromise functionality and quality of life. Management of the disease aims to mitigate these losses and involves a wide range of interventions, one of which is therapeutic exercise. This article presents the existing evidence on the effectiveness of therapeutic exercises for quality of life, pain, and functionality in chronic venous insufficiency. Searches were run on the databases CENTRAL, CINAHL, LILACS, MEDLINE, PEDro, SciELO, Science Direct, Scopus, and Web of Science. Four of the 2,961 results met the eligibility criteria. Only one of these studies showed benefits of exercise for improving quality of life and reducing pain. The others had low methodological quality. The existing evidence is therefore insufficient to indicate or contraindicate therapeutic exercises for improvement of quality of life, pain, and functionality in patients with chronic venous insufficiency.

Management of Lower Extremity Pain from Chronic Venous Insufficiency: A Comprehensive Review

PURPOSE OF REVIEW

Chronic venous insufficiency is found to some extent in a large proportion of the world's population, especially in the elderly and obese. Despite its prevalence, little research has been pursued into this pathology when compared to similarly common conditions. Pain is often the presenting symptom of chronic venous insufficiency and has significant deleterious effects on quality of life. This manuscript will describe the development of pain in chronic venous insufficiency, and will also review both traditional methods of pain management and novel advances in both medical and surgical therapy for this disease.

RECENT FINDINGS

Pain in chronic venous insufficiency is a common complication which remains poorly correlated in recent studies with the clinically observable extent of disease. Although lifestyle modification remains the foundation of treatment for pain associated with chronic venous sufficiency, compression devices and various pharmacologic agents have emerged as safe and effective treatments for pain in these patients. In patients for whom these measures are insufficient, recently developed minimally invasive vascular surgical techniques have been shown to reduce postsurgical complications and recovery time, although additional research is necessary to characterize long-term outcomes of these procedures. This review discusses the latest findings concerning the pathophysiology of pain in chronic venous insufficiency, conservative and medical management, and surgical strategies for pain relief, including minimally invasive treatment strategies.

Prescribed exercise regimen versus usual care and hypochlorous acid wound solution versus placebo for treating venous leg ulcers: study protocol for a randomised controlled trial (Factorial4VLU)

INTRODUCTION

Compression is the mainstay of treatment for venous leg ulcers (VLUs) and there are few effective adjuvant treatments. There is only observational evidence supporting the use of hypochlorous acid (HOCl) as a topical wound solution on VLU and some limited randomised evidence for the effect of a prescribed regimen of exercise.

METHODS AND ANALYSIS

The Factorial4VLU trial is a pragmatic, blinded, factorial randomised controlled trial, with 380 participants receiving either a prescribed exercise regimen compared with usual care and either active HOCl wound solution or placebo wound solution at each dressing change for up to 24 weeks. All participants will receive compression therapy. The primary outcome is the proportion of participants with healed VLU at 12 weeks after randomisation as adjudicated by blinded review of ulcer photographs. Secondary outcomes are proportion healed at 24 weeks, time to healing, estimated change in ulcer area, change in 2-Minute Walk Test, change in health-related quality of life, incidence of infection and incidence of all-cause adverse events. If either of the interventions shows a statistically significant positive difference on healing outcomes, cost-effectiveness will be modelled using a health service perspective.

ETHICS AND DISSEMINATION

The Factorial4VLU trial received ethical approval from the Northern B Health and Disability Ethics Committee. We plan to publish the results within 1 year of trial completion and will include the results on the trial registration page.

TRIAL REGISTRATION NUMBERS

Australia and New Zealand Clinical Trials Register (http://www.anzctr.org.au) (ACTRN12620000116921); Universal Trial Number (WHO) (U1111-1236-2997).

Experiences of Venous Leg Ulcer persons following an individualised nurse-led education: protocol for a qualitative study using a constructivist grounded theory approach

INTRODUCTION

Venous leg ulcers are slow-healing wounds with a high risk of recurrences. To prevent recurrences and promote healing, different nurse-led educational interventions have been developed. The impact of these interventions on self-management is ambiguous. Also, how persons with a venous leg ulcer experiences these educational sessions are poorly described.

AIM

This study protocol presents the methodology to provide a comprehensive explanation of participants' journeys-of how they experience their individualised education sessions concerning self-management.

METHODS AND ANALYSIS

A constructivist grounded theory approach according to Charmaz involving 30 participants will be used. Data will be collected through semistructured face-to-face interviews. Interviews will be transcribed verbatim and analysed with initial and focus coding using MAXQDA. Data collection and data analysis will occur iteratively, focusing on constant comparison to obtain well-developed categories. Categories will be reinforced using existent literature.

ETHICS AND DISSEMINATION

This pre-results study is embedded in a clinical trial (NCT04019340) and approved by ethical committee of the canton of Geneva (CCER: 2019-01964). A theory will emerge from participants' journeys informing future education sessions for patients with venous leg ulcers. The findings will be disseminated through peer-reviewed publications and communications.

Neuromuscular stimulation of the common peroneal nerve increases arterial and venous velocity in patients with venous leg ulcers

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.

Effectiveness of exercises by telerehabilitation on pain, physical function and quality of life in people with physical disabilities: a systematic review of randomised controlled trials with GRADE recommendations

OBJECTIVE

Investigate whether exercise-based telerehabilitation improves pain, physical function and quality of life in adults with physical disabilities.

DESIGN

Systematic review of randomised controlled trials.

DATA SOURCES

Searches were performed in AMED, MEDLINE, CINAHL, SPORTDiscus, Embase, PEDro, Cochrane Library and PsycINFO.

ELIGIBILITY CRITERIA

Trials were considered if they evaluated exercise by telerehabilitation. The population included adults with physical disability. Comparisons were control and other interventions. The outcomes were pain, physical function and quality of life. Study selection, data extraction and analysis followed the protocol registered in PROSPERO (CRD42019122824). GRADE determined the strength of evidence.

RESULTS

Forty-eight trials were included in the quantitative analysis. When compared with other interventions, there was high-quality evidence that telerehabilitation was not different to other interventions for pain (95% CI: -0.4 to 0.1), physical function (95% CI: -0.2 to 0.2) and quality of life (95% CI: -0.1 to 0.5) at long-term. There was moderate-quality evidence that telerehabilitation was not different to other interventions for physical function (95% CI: -0.1 to 0.5) and quality of life (95% CI: -0.2 to 0.5) at short-term. However, due to the low-quality evidence and the small number of trials comparing exercise protocols offered by telerehabilitation with control groups, it is still not possible to state the efficacy of telerehabilitation on pain, function and quality of life at short-term and long-term.

CONCLUSIONS

Exercise by telerehabilitation may be an alternative to treat pain, physical function and quality of life in adults with physical disabilities when compared with other intervention.

Benefits and Harms of Exercise Therapy for Patients With Diabetic Foot Ulcers: A Systematic Review

AIM

Exercise therapy is a core element in the treatment of diabetes, but the benefits and harms for patients with a diabetic foot ulcer (DFU) are unknown. We therefore aimed to systematically review the benefits on health-related quality of life (HRQoL) and harms of exercise therapy for patients with DFU.

METHODS

We searched 6 major databases. We performed citation and reference searches of included studies and contacted authors of ongoing trials. We included randomized controlled trials (RCTs) to assess potential benefits on HRQoL and harms of exercise therapy. Observational studies were included to identify potential harms of exercise therapy.

RESULTS

We included 10 published publications of 9 trials and results from 2 unpublished trials including a total of 281 individuals with DFUs receiving various forms of exercise therapy. Due to lack of HRQoL measurements and high heterogeneity, it was not possible to perform meta-analyses. Results on HRQoL was present in one unpublished study. Harms reported ranged from musculoskeletal problems, increased wound size, to amputation; however, no safe conclusions could be drawn from the available data due to high heterogeneity and risk of bias in the trials.

CONCLUSIONS/INTERPRETATION

Protective strategies are often preferred over therapeutic exercise that might have unforeseen consequences for patients over time. Based on the current literature, no evidence-based recommendations can be provided on the benefits and harms of exercise therapy for patients with DFUs. Well-conducted RCTs are needed to guide rehabilitation including detailed description of adverse events and an exercise program in a semisupervised or fully supervised setting.

Nurse-led patient education for persons suffering from a venous leg ulcer in outpatient's clinics and homecare settings: A scoping review

AIM OF THIS STUDY

To provide an overview of the available nurse-led individualized educational interventions, for persons with Venous Leg Ulcer (VLUs) in an outpatient or homecare settings.

MATERIALS AND METHODS

For this scoping review, a search was performed between December 2019 and January 2020. To identify sources of evidence a systematic search was conducted in PubMed, CINAHL, Embase, PsychINFO, Web of Science and LiSSa as well as in clinical trial registers to identify sources of evidence. All types of evidence associated with a nurse led-intervention were included.

RESULTS

Fifteen sources of evidence met the inclusion criteria. Educational sessions varied in modality, content and duration. Education sessions were face to face and supported by written materiel. The content focused on compression therapy and exercises. The duration and numbers of sessions varied. The most reported health related outcomes was wound healing.

CONCLUSION

This scoping review provides a broad overview of the available evidence and ongoing research for individualized nurse-led education persons with VLUs. Variability in the literature was found, which suggests that more intervention studies are needed to test and evaluate efficacy of nurse-led patient education.

Psychosocial factors of patients with venous leg ulcers and their association with healing

Objectives: To identify psychosocial factors present in patients with venous leg ulcers and the association that these factors have in the healing of venous leg ulcers. Methods: An integrative review of the quantitative studies in MEDLINE, Scielo and Cochrane Library databases, between 2008 and 2019, using the keywords, psychosocial factors, venous ulcer, wound healing, anxiety and depression in English, Spanish and Portuguese. Results: sixteen studies were included. The psychosocial factors present in patients with venous ulcers were depression, anxiety, feelings of helplessness, subjective well-being, self-esteem, loneliness and spirituality. Stress, a negative perception of venous ulcer, living alone and severe experience of symptoms such as pain and depression have statistically significant associations with longer periods of healing. Conclusions: Depression is one of the most frequently measured factors and present in this population. The available evidence on the association of psychosocial factors with the healing of venous ulcers is low.

Factores psicosociales en los pacientes con úlceras venosas y su asociación con la cicatrización

Objetivo: Identificar los factores psicosociales presentes en pacientes con úlceras venosas y la evidencia disponible sobre la asociación que estos factores tienen con la curación de este tipo de heridas. Métodos: Revisión integradora de la literatura de estudios cuantitativos en las bases de datos MEDLINE, Scielo y Cochrane Library entre los años 2008 y 2019, utilizando las palabras clave, factores psicosociales, úlcera venosa, cicatrización de heridas ansiedad y depresión en idioma inglés, español y portugués. Resultados: Dieciséis estudios fueron incluidos. Los factores psicosociales presentes en los pacientes con úlceras venosas fueron depresión, ansiedad, sentimientos de impotencia, bienestar subjetivo, autoestima, soledad y espiritualidad. El estrés, una percepción negativa de la úlcera venosa, vivir solo y la experiencia severa de síntomas como dolor y depresión tienen asociaciones estadísticamente significativas con periodos más prolongados de curación. Conclusión: La depresión es uno de los factores psicológicos medido y presente con mayor frecuencia en esta población. La evidencia disponible frente a la asociación de los factores psicosociales con la curación de úlceras venosas es escasa.

A Lower Leg Physical Activity Intervention for Individuals With Chronic Venous Leg Ulcers: Randomized Controlled Trial

BACKGROUND

Individuals with venous leg ulcers (VLUs) suffer disproportionately with multiple chronic conditions, are often physically deconditioned, and demonstrate high levels of physical inactivity.

OBJECTIVE

The primary objective of this randomized controlled trial was to establish the feasibility of a mobile health (mHealth) physical activity exercise app for individuals with VLUs to improve lower leg function.

METHODS

In a 6-week study, adults with VLUs were recruited from 2 wound centers in South Carolina, United States, and enrolled if they were aged 18 years or older with impaired functional mobility and an ankle-brachial index between 0.8 and 1.3. Participants were randomized 1:1 to receive evidence-based, phased, nonexertive physical conditioning activities for lower leg function (FOOTFIT) or FOOTFIT+ with an added patient-provider communication feature. The mHealth Conditioning Activities for Lower Leg Function app also provided automated educational and motivational messages and user reports. Foot movement on the VLU-affected leg was tracked by a Bluetooth-enabled triaxial accelerometer. The study was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to assess the feasibility of reach, adherence, acceptability, implementation, and maintenance.

RESULTS

A total of 24 patients were recruited, enrolled, and randomized in the study. Most patients reported difficulty following the protocol for exercising and using the accelerometer and mobile phone and did not use the provider contact feature. However, all patients were adherent to the 6-week exercise program more than 85% of the time for duration, whereas 33% (8/24) of patients adhered more than 85% for the frequency of performing the exercises. Across the three exercise levels, adherence did not differ between the two groups. Confidence limits around the difference in proportions ranged from -0.4 to 0.7. Providers in FOOTFIT+ were inconsistent in checking participant progress reports because of lack of time from competing work commitments. The technology became outdated quickly, making maintenance problematic. Participants said they would continue to exercise their foot and legs and liked being able to follow along with the demonstrations of each level of exercise provided through the app.

CONCLUSIONS

The findings of this study suggest that despite initial interest in using the app, several components of the program as originally designed had limited acceptability and feasibility. Future refinements should include the use of more modern technology including smaller wearable accelerometers, mobile phones or tablets with larger screens, an app designed with larger graphics, automated reporting for providers, and more engaging user features.

TRIAL REGISTRATION

ClinicalTrials.gov NTC02632695; https://clinicaltrials.gov/ct2/show/NCT02632695.

Nursing Interventions Aimed at Persons with Venous Ulcers: an Integrative Review

Objectives: This work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature. Materials and method: Integrative review between 2000 and 2018 in the Pubmed, Ovidnursing, and EBSCOhost electronic databases. Results: This review includes 16 articles. Most of the interventions were of educational nature; three were developed in the community (through the Leg Club model) and the other ones were delivered by a nursing professional, face to face. The minimum time of duration for these was eight weeks, with telephone follow up. The most-common result variables were venous ulcer healing and reduction of the wound area. Conclusions: Diversity existed in relation with the components of the interventions and the results expected. Report of the interventions must be reinforced, along with the use of nursing theories that support their design.

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

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.

Construção e validação de um folheto educativo para tratamento de úlcera venosa

Objective: To build and validate an educational leaflet for treatment of patients with ulcer of venous etiology. Methods: Methodological study, developed in two stages: construction of the educational leaflet by literature review and content validation of the material by judges specializing in the subject. Results: The instrument obtained a Content Validity Index (CVI) above 0.80; only one item was modified after the judges’ suggestion. Conclusion: The educational leaflet was presented to be understandable and comprehensive for the content.

Construction and validation of an educational leaflet for treatment of venous ulcer

Objective: To build and validate an educational leaflet for treatment of patients with ulcer of venous etiology. Methods: Methodological study, developed in two stages: construction of the educational leaflet by literature review and content validation of the material by judges specializing in the subject. Results: The instrument obtained a Content Validity Index (CVI) above 0.80; only one item was modified after the judges’ suggestion. Conclusion: The educational leaflet was presented to be understandable and comprehensive for the content.

Participant experiences in a feasibility trial of supervised exercise training in adults with venous leg ulcers: A qualitative study

Exercise training can improve lower-limb cutaneous microvascular reactivity in adults with venous leg ulceration; however, there is a lack of research on patients' views about the acceptability and feasibility of exercise interventions. The aim of this study was to explore participants' experiences of the trial "Exploring the Feasibility of Implementing a Supervised Exercise Training and Compression Hosiery Intervention in Patients with Venous Ulceration" (FISCU). Semi-structured face-to-face and telephone interviews were used to investigate participants' experiences (n = 16) of taking part in the FISCU trial. Data were analysed using thematic analysis. Three overarching themes were identified, along with 11 sub-themes: (a) sedentary cautious living (because of pain and reduced mobility, treatment and perceived control, and advice to rest and be careful), (b) key components of the exercise trial (including motivation, an individualised intervention supervised by a specialist exercise professional, and satisfaction with the intervention), and (c) benefits of exercise (physical benefits and healing, psychological well-being, positive impact on comorbidities, and an improved self-management strategy). This study found that an exercise intervention was viewed by participants as positive, acceptable, and feasible while living with a venous leg ulcer. An individualised and supervised exercise programme was key to build confidence to exercise.

Prescribed Exercise With Compression vs Compression Alone in Treating Patients With Venous Leg Ulcers: A Systematic Review and Meta-analysis

Importance

Exercise is recommended as an adjuvant treatment for venous leg ulceration (VLU) to improve calf muscle pump function. However, the association of exercise with VLU healing has not been properly aggregated, and the effectiveness of different exercise interventions has not been characterized.

Objective

To summarize the association of different exercise interventions with VLU healing when used as an adjuvant to any form of compression.

Data Sources

The Cochrane Controlled Trials Register, MEDLINE, Embase, CINAHL, PsycInfo, and SCOPUS databases were searched through October 9, 2017.

Study Selection

Randomized clinical trials (RCTs) of any exercise compared with no exercise in participants with VLU were included, where compression was used as standard therapy and a healing outcome was reported. Independent title screening and full text review by 2 authors (A.J., J.S.) with appeal to a third author (J.P.) if disagreement was unresolved. Of the 519 articles screened, a total of 6 (1.2%) studies met the inclusion criteria for systematic review, including 5 for meta-analysis.

Data Extraction and Synthesis

Independent quality assessment for Cochrane risk of bias and data extraction by 2 authors with appeal to third author if disagreement unresolved (PRISMA). Data pooled using fixed effects model.

Main Outcomes and Measures

The a priori primary outcome was any healing outcome (proportion healed, time to healing, or change in ulcer area). Secondary outcomes (adverse events, costs, and health-related quality of life) were only collected if a primary outcome was reported.

Results

Six RCTs were identified and 5 (190 participants) met inclusion criteria for meta-analysis. The exercise interventions were progressive resistance exercise alone (2 RCTs, 53 participants) or combined with prescribed physical activity (2 RCTs, 102 participants), walking only (1 RCT, 35 participants), or ankle exercises (1 RCT, 40 participants). Overall, exercise was associated with increased VLU healing at 12 weeks although the effect was imprecise (additional 14 cases healed per 100 patients; 95% CI, 1-27 cases per 100; P = .04). The combination of progressive resistance exercise plus prescribed physical activity appeared to be most effective, again with imprecision (additional 27 cases healed per 100 patients; 95% CI, 9-45 cases per 100; P = .004).

Conclusions and Relevance

The evidence base may now be sufficiently suggestive for clinicians to consider recommending simple progressive resistance and aerobic activity to suitable patients with VLU while further research is produced.

Experience of adults and older people with adherence to venous ulcer care

OBJECTIVE

To understand the experience of adults and older people with adherence to venous ulcer care.

METHOD

A qualitative study based on the concepts of Alfred Schütz's social phenomenology was carried out with 12 adults and older people undergoing venous ulcer treatment in a specialized service in the state of Minas Gerais. The interviews were carried out from October to November 2015, analyzed, categorized, and discussed based on the theoretical-philosophical framework adopted and on thematic literature.

RESULTS

The following thematic categories emerged from the interviews: "beliefs and personal and social activities hindering adherence to care"; "being protagonists in the care relationship with venous ulcers", and "motivation for adherence to care".

CONCLUSIONS

The intersubjective relationship established between patients with venous ulcers and healthcare professionals emerged as a driving force for adherence to care. Promoting the reciprocity relationship of perspectives between these social actors may promote greater adherence to venous ulcer care.

Adjuvant therapies in venous leg ulcer management: A scoping review

Compression therapy is the current evidence-based approach to manage venous leg ulcers (VLU); however, adherence is a major barrier to successful treatment. Combination approaches may relieve the burden of treatment by shortening the time to ulcer healing. This scoping review conducted by Australian researchers aimed to establish the evidence of effectiveness of various adjuvant methods on wound healing and recurrence. Randomized Controlled Trials (RCTs), and Systematic Reviews (SR) and Meta-Analyses (MA) on VLU management approaches published from January 2015 to December 2018 were included in this review. The articles included in the scoping review were grouped according to the management approaches, including (1) pharmaceutical interventions, (2) surgical interventions, (3) topical agents, (4) the use of devices, and (5) other, such as physiotherapy and psychological interventions. Results of this scoping review indicate that there is a limited high-quality evidence of effectiveness in most adjuvant therapies on wound healing and recurrence. Given the low-quality evidence observed in this scoping review for adjuvant treatments, the implication for practice is that current management guidelines be followed. Further rigorous studies have the potential to produce better quality evidence. Quality of evidence can be improved by ensuring large sample sizes of a single etiology wounds, standardizing reporting outcomes, and maintaining detailed and evidence-based protocols in physiological or psychological interventions.

Effectiveness of the strategies of an orientation programme for the lifestyle and wound-healing process in patients with venous ulcer: A randomised controlled trial

This study aimed to evaluate the effect of strategies of a lifestyle orientation programme on patients with venous ulcer in elastic compression therapy. This was a single-blind, 2-arm, randomised clinical controlled trial. The primary outcome included the reduction of the wound surface area. The secondary outcomes included the perception of pain, questionnaire of ulcer status, and quality of life. Seventy-one patients with ulcers of venous aetiology were randomised into 2 arms: control group (CG) and intervention group (IG), with a 12-week follow up. The CG was provided with the routine guidelines of the health services. Meanwhile, the IG was provided with lifestyle guidelines regarding the physiopathology of a venous ulcer, importance of compression therapy, physical exercises and rest in 4 face-to-face and 2 telephone interviews. The IG had significant improvement on the wound healing on 30, 60, and 90 days of follow up when compared with the CG (P = .0197; P = .0472; P = .0116). There were no statistical differences between groups; both had improvement in the quality of life and pain perception. Our results demonstrated that elastic compression therapy along with guidelines on lifestyle is effective adjunctive treatment to promote wound healing in patients with leg ulcers.