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

Abstract

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.

Figure 1.. PRISMA Flow Diagram

Six randomized clinical trials were selected as meeting the inclusion criteria from the 853 citations identified.

Figure 2.. Risk of Bias Summary by Trial and Type of Bias

All trials were at low risk of bias for sequence generation (selection bias), attrition bias, and reporting bias. Two of 6 trials were at unclear risk of bias for allocation concealment (selection bias) whereas 4 of 6 trials were at high risk of detection bias.

Figure 3.. Forest Plot of the Association of Adjuvant Exercise vs No Exercise With Venous Leg Ulcer Healing

Overall the effect of adjuvant exercise is to increase healing rates at 12 weeks. Progressive resistance exercise plus physical activity had the strongest association with healing.