Exercise training for people with diabetes-related foot ulcers - a systematic review of glycaemia, fitness, and wound healing outcomes.

Background: Regular physical activity is a key, patient-centred therapy for people with diabetes to manage their glycaemia. The International Working Group on the Diabetic Foot (IWGDF) recommends optimisation of glycaemic control 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 glycaemia, fitness, and wound healing in people with active DFU are not clear.

Objective: To examine the effects of regular exercise (training) on glycaemia, cardiorespiratory fitness, and muscular strength, metabolic health, and ulcer healing in adults with diabetes and an active foot ulcer.

Method: 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 two reviewers.

Results: Of the 5,592 studies screened eight studies were included with a total of 213 participants. Exercise interventions involved foot range of movement exercises and/or aerobic and/or resistance type exercise. No studies reported on cardiorespiratory fitness or anthropometry and limited data were available for glycaemic 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 glycaemic) 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 focused to person-centred outcomes to better inform the implementation of exercise therapy for people with DFU.