Supervised exercise training as an adjunct therapy for venous leg ulcers: a randomized controlled feasibility trial

Background

Venous leg ulcers (VLUs) are typically painful and heal slowly. Compression therapy offers high healing rates; however, improvements are not usually sustained. Exercise is a low‐cost, low‐risk and effective strategy for improving physical and mental health. Little is known about the feasibility and efficacy of supervised exercise training used in combination with compression therapy patients with VLUs.

Objectives

To assess the feasibility of a 12‐week supervised exercise programme as an adjunct therapy to compression in patients with VLUs.

Methods

This was a two‐centre, two‐arm, parallel‐group, randomized feasibility trial. Thirty‐nine patients with venous ulcers were recruited and randomized 1 : 1 either to exercise (three sessions weekly) plus compression therapy or compression only. Progress/success criteria included exercise attendance rate, loss to follow‐up and patient preference. Baseline assessments were repeated at 12 weeks, 6 months and 1 year, with healing rate and time, ulcer recurrence and infection incidents documented. Intervention and healthcare utilization costs were calculated. Qualitative data were collected to assess participants’ experiences.

Results

Seventy‐two per cent of the exercise group participants attended all scheduled exercise sessions. No serious adverse events and only two exercise‐related adverse events (both increased ulcer discharge) were reported. Loss to follow‐up was 5%. At 12 months, median ulcer healing time was lower in the exercise group (13 vs. 34·7 weeks). Mean National Health Service costs were £813·27 for the exercise and £2298·57 for the control group.

Conclusions

The feasibility and acceptability of both the supervised exercise programme in conjunction with compression therapy and the study procedures is supported.

What's already known about this topic?

Almost 70% of all leg ulcers have a venous component.

Up to 30% of venous leg ulcers (VLUs) do not respond to compression alone, remain open after 1 year of treatment and need an average of 51 treatment visits to heal.

Adjunct therapies to compression are needed.

Exercise can form part of the therapeutic pathway, but evidence to determine whether exercise training has an effect on ulcer healing and quality of life is limited.

What does this study add?

The findings support the feasibility and acceptability of supervised exercise training as an adjunct therapy for adults with VLUs.

The preliminary data also support the potential effectiveness of exercise training in improving ulcer healing.

An appropriately powered, multicentre trial is required to confirm the clinical and cost‐effectiveness of the intervention.

Linked Comment: https://doi.org/10.1111/bjd.16523.

https://doi.org/10.1111/bjd.16618 available online

https://goo.gl/Uqv3dl

Clinical guideline and recommendations on pre-operative exercise training in patients awaiting major non-cardiac surgery

Despite calls for the routine implementation of pre-operative exercise programmes to optimise patient fitness before elective major surgery, there is no practical guidance for providing safe and effective exercise in this specific context. The following clinical guideline was developed following a review of the evidence on the effects of pre-operative exercise interventions. We developed a series of best-practice and, where possible, evidence-based statements to advise on patient care with respect to exercise training in the peri-operative period. These statements cover: patient selection for exercise training in surgical patients; integration of exercise training into multi-modal prehabilitation programmes; and advice on exercise prescription factors and follow-up. Although we acknowledge that further research is needed to identify the optimal exercise prescription in different clinical scenarios, we urge peri-operative teams to make use of these recommendations.

Randomized feasibility trial of high-intensity interval training before elective abdominal aortic aneurysm repair

Background

This study assessed the feasibility of a preoperative high-intensity interval training (HIT) programme in patients awaiting elective abdominal aortic aneurysm repair.

Methods

In this feasibility trial, participants were allocated by minimization to preoperative HIT or usual care. Patients in the HIT group were offered three exercise sessions per week for 4 weeks, and weekly maintenance sessions if surgery was delayed. Feasibility and acceptability outcomes were: rates of screening, eligibility, recruitment, retention, outcome completion, adverse events and adherence to exercise. Data on exercise enjoyment (Physical Activity Enjoyment Scale, PACES), cardiorespiratory fitness (anaerobic threshold and peak oxygen uptake), quality of life, postoperative morbidity and mortality, duration of hospital stay and healthcare utilization were also collected.

Results

Twenty-seven patients were allocated to HIT and 26 to usual care (controls). Screening, eligibility, recruitment, retention and outcome completion rates were 100 per cent (556 of 556), 43·2 per cent (240 of 556), 22·1 per cent (53 of 240), 91 per cent (48 of 53) and 79–92 per cent respectively. The overall exercise session attendance rate was 75·8 per cent (276 of 364), and the mean(s.d.) PACES score after the programme was 98(19) (‘enjoyable’); however, the intensity of exercise was generally lower than intended. The mean anaerobic threshold after exercise training (adjusted for baseline score and minimization variables) was 11·7 ml per kg per min in the exercise group and 11·4 ml per kg per min in controls (difference 0·3 (95 per cent c.i. –0·4 to 1·1) ml per kg per min). There were trivial-to-small differences in postoperative clinical and patient-reported outcomes between the exercise and control groups.

Conclusion

Despite the intensity of exercise being generally lower than intended, the findings support the feasibility and acceptability of both preoperative HIT and the trial procedures. A definitive trial is warranted. Registration number: ISRCTN09433624 (https://www.isrctn.com/).

Exercise training and the control of skin blood flow in older adults

The ability to control skin blood flow decreases with primary aging, making older adults less able to adequately thermoregulate and repair cutaneous wounds. Lifestyle factors such as physical activity, diet, and smoking might interact with the aging process to modulate "normal" age-associated changes in the cutaneous microcirculation. The main focus of this brief review is the effects of exercise training on the control of skin blood flow in older adults.