SLR - October 2016 - Paul Carroll
Reference: Yim E, Kisner RS, Gailey RS, Mandel DW, Chen SC, Tomic-Canic M. Effect of Physical Therapy on Wound Healing and Quality of Life in Patients with Venous Leg Ulcers: A Systematic Review. JAMA Dermatol. 2015 Mar; 151(3):320–327.Scientific Literature Review
Reviewed By: Paul Carroll, DPM
Residency Program: Medstar Washington Hospital Center
Podiatric Relevance: Chronic venous insufficiency is a dysfunction of the venous system due to impaired mobility of the calf muscle pumps but more specifically caused by malfunction of the valves. They are the most common type of ulcers of the legs, which can be recurrent and painful. One factor contributing to venous insufficiency is impaired ankle range of motion (ROM). Ankle range of motion is needed to activate the calf muscle pump. Patients with little ankle ROM tend to have worse venous insufficiency. Barwell et al found 13 percent of patients with ankle ROM with less than 35 degrees of dorsiflexion and plantarflexion compared to 60 percent of patients who had ROM greater than 35 degrees healed ulcers at 24 weeks of treatment. This article systematically reviews the current literature on the effect of physical therapy (PT) in ulcer healing and quality of life (QOL) outcomes in patients with venous leg ulcers and also demonstrates the need for further research on this subject.
Methods: A search of Pubmed (MEDLINE), CINAHL and Cochrane databases in April 2014 was performed using the keywords venous ulcer, venous leg ulcer, quality of life, health-related quality of life, physical therapy and exercise. Systematic literature reviews, observational studies and topics unrelated to venous ulcers were excluded. Expert opinion articles were also excluded from the study. The quality of evidence was assessed based on grading recommendations by Robinson et al. End points in the study included complete wound healing, reduction in wound size, improved quality of life and faster healing time.
Results: Forty-seven articles were screened, and 10 articles met inclusion criteria. Five articles were identified as randomized controlled trials (RCT), one as a non-RCT and four as single-arm cohort studies. The reported age ranged from 54 to 76 years old, and BMI was not reported in all studies. When reported, median or mean BMI was more than 33.9. Physical therapy in patients with VLUs was reported in all 10 studies. Seven discussed PT in patients with VLU, and three discussed the complete healing of ulcers. Exercises include the use of a treadmill, walking and heel raises. Most studies were home-based exercises without the supervision of a physical therapist or nurse. All studies had mixed outcomes in healing of venous ulcers. The subsequent portion of this review looked at calf muscle pump function and ankle ROM. It has been published that individuals with venous leg ulcers who underwent supervised exercises versus patients who were unsupervised reported increased mobility after nine weeks. Only three studies documented wound size during physical therapy. One article reported decreased wound size, but this was not significant. Two articles were found that measured QOL in individuals who took part in the study. They found no change in QOL in individuals after physical therapy in both studies. In one separate study that utilized the Short Form-36 Health Survey, there was no improvement in QOL or ankle ROM after physical therapy.
Conclusions: Currently, there is a lack of randomized studies investigating the role of physical therapy in increasing ankle ROM for the treatment of venous stasis ulcers. More studies are needed to evaluated physical therapy’s role in the treatment of venous ulcers.