Abstract

Background: For patients with diabetic foot ulcers, offloading is one crucial aspect of treatment and aims to redistribute pressure away from the ulcer site. In addition to offloading strategies, patients are often advised to reduce their activity levels. Consequently, patients may avoid exercise altogether. However, it has been suggested that exercise induces an increase in vasodilation and tissue blood flow, which may potentially facilitate ulcer healing. The aim of this systematic review was to determine whether exercise improves healing of diabetic foot ulcers.

Review: We conducted a systematic search of MEDLINE, CINAHL and EMBASE between July 6, 2009 and July 6, 2019 using the key terms and subject headings diabetes, diabetic foot, physical activity, exercise, resistance training and wound healing. Randomised controlled trials were included in this review.

Three randomised controlled trials (139 participants) were included in this systematic review. All studies incorporated a form of non-weight bearing exercise as the intervention over a 12-week period. One study conducted the intervention in a supervised setting, while two studies conducted the intervention in an unsupervised setting. Two studies found greater improvement in percentage wound size reduction in the intervention group compared with the control group, with one of these studies achieving statistically significant findings (p < 0.05). The results of the third study demonstrated statistically significant findings for total wound size reduction (p < 0.05), however results were analysed within each treatment group and not between groups.

Conclusion: This systematic review found there is insufficient evidence to conclusively support non-weight bearing exercise as an intervention to improve healing of diabetic foot ulcers. Regardless, the results demonstrate some degree of wound size reduction and there were no negative consequences of the intervention for the participants. Given the potential benefits of exercise on patient health and wellbeing, non-weight bearing exercise should be encouraged as part of the management plan for treatment of diabetic foot ulcers. Further research is required to better understand the relationship between exercise and healing of diabetic foot ulcers.

Keywords: Diabetic foot ulcer, Exercise, Physical therapy, Wound healing.

Introduction: Pressure ulcer indicators are among the most frequently used performance measures in long-term care settings. However, measurement systems vary and there is limited knowledge about the international comparability of different measurement systems. The aim of this analysis was to identify possible avenues for international comparisons of data on pressure ulcer prevalence among residents of long-term care facilities. Material and methods: A descriptive analysis of the four point prevalence measurement systems programs used in 28 countries on three continents was performed. The criteria for the description and analysis were based on the scientific literature on criteria for indicator selection, on issues in international comparisons of data and on specific challenges of pressure ulcer measurements.

Results: The four measurement systems use a prevalence measure based on very similar numerator and denominator definitions. All four measurement systems also collect data on patient mobility. They differ in the pressure ulcer classifications used and the requirements for a head-to-toe resident examination. The regional or country representativeness of long-term care facilities also varies among the four measurement systems.

Conclusions: Methodological differences among the point prevalence measurement systems are an important barrier to reliable comparisons of pressure ulcer prevalence data. The alignment of the methodologies may be improved by implementing changes to the study protocols, such as aligning the classification of pressure ulcers and requirements for a head-to-toe resident skin assessment. The effort required for each change varies. All these elements need to be considered by any initiative to facilitate international comparison and learning.

Diabetic foot ulceration (DFU) is a devastating complication of diabetes whose pathogenesis remains incompletely understood. Here, we profifile 174,962 single cells from the foot, forearm, and peripheral blood mononuclear cells using single-cell RNA sequencing. Our analysis shows enrichment of a unique population of fifibroblasts overexpressing MMP1, MMP3, MMP11, HIF1A, CHI3L1, and TNFAIP6 and increased M1 macrophage polarization in the DFU patients with healing wounds. Further, analysis of spatially separated samples from the same patient and spatial transcriptomics reveal preferential localization of these healing associated fifibroblasts toward the wound bed as compared to the wound edge or unwounded skin. Spatial transcriptomics also validates our fifindings of higher abundance of M1 macrophages in healers and M2 macrophages in non-healers. Our analysis provides deep insights into the wound healing microenvironment, identifying cell types that could be critical in promoting DFU healing, and may inform novel therapeutic approaches for DFU treatment.