Exercise Training for People With Diabetes-related Foot Ulcers: A Systematic Review of Glycemia, Fitness, and Wound-healing Outcomes

Abstract

Objectives

Regular physical activity is a key, patient-centred therapy for people with diabetes to manage their glycemia. The International Working Group on the Diabetic Foot recommends optimization of glycemic management for people with/at risk of diabetes-related foot ulcer (DFU); however, people with DFU are commonly instructed by clinicians to avoid physical activity so as not to worsen the ulcer. The effects of exercise on glycemia, fitness, and wound healing in people with active DFU are not clear. In this study we examined the effects of regular exercise (training) on glycemia, cardiorespiratory fitness, muscular strength, metabolic health, and ulcer healing in adults with diabetes and an active foot ulcer.

Methods

Online databases and reference lists of included studies were searched from earliest records to December 2023. Studies involving adult populations with DFU and incorporating interventions of exercise training were included. Data were extracted independently by 2 reviewers.

Results

Of the 5,592 studies screened, 8 were included, with a total of 213 participants. Exercise interventions involved foot range-of-movement exercises and/or aerobic and/or resistance-type exercise. None of the studies reported on cardiorespiratory fitness or anthropometry and limited data were available for glycemic and muscular strength outcomes. Interpretation of data on safety, wound healing, and adherence to exercise were limited due to inconsistent reporting.

Conclusions

Despite some data that exercise may have a positive impact on wound healing, evidence regarding its benefits and safety is significantly lacking, despite metabolic (particularly glycemic) and fitness outcomes being core to the rationale for exercise therapy in diabetes. Given the importance of exercise in current management guidelines for diabetes, and the plausibility of positive health effects of exercise training for people with DFU, there is a need for research to move from foot-focussed to person-centred outcomes to better inform the implementation of exercise therapy for people with DFU.