Effect of Physical Therapy onWoundHealing and Quality of Life in PatientsWith Venous Leg Ulcers A Systematic Review

C hronicvenousinsufficiency(CVI)isadysfunctionofthevenous systemdue to sustainedambulatory venouspressure in the lower limbsthatoccursasaresultofanimpairmentofthecalf musclepump,whose components include theveins and their valves, the legandfootmuscles,andanklemobility.Venous legulcers (VLUs) are a severe consequence of CVI. They are themost common ulcers foundonthelegsandareoftenchronicandrecurrent.1Onecomponent ofthecalfmusclepump,anklerangeofmotion(ROM),decreaseswith increasingseverityofCVI,withpatientswithVLUshavingthemost impairedankleROM.2,3Anklemobility isneededforactivationof thecalf musclepump in returningblood to theheart. Calfmuscle contraction propelsbloodfromthesuperficialveinstothedeepvenoussystemsvia communicatingorperforatingveins.Severalfactorsmaylimitanklemobility, includingbutnot limitedtoedema,pain,neuropathy,andmuscle atrophyandweakness.Evidencesuggests thatdecreasedankleROM isassociatedwithdelayedhealing.Asanexample,Barwelletal4 found that13%of individualswithankleROMlessthan35°ofdorsiflexionand plantarflexioncomparedwith60%ofindividualswithtotalankleROM greaterthan35°healedat24weeks.PatientswithVLUsoftenhaveimpairedbalance, gait, andwalk speed5,6 and requiremorewalkingaids than patientswith healed ulcers.7 Evidence also suggests an associationbetweenexercisefrequencyandVLUreoccurrence.8Anargument couldbemadethatexercisesthattargetankleROMcould improvecalf musclepumpfunction,which in turnwouldhelp reducehealing time, diminishulcer size, and lessen the risk of recurrences. Physical therapy isan individualizedtreatmentregimenbasedon a patient’s comprehensive evaluative findings on measures such as strength,ROM,sensation,proprioception,circulation, functionalperformance, andmedical history. Individualizedphysical therapy interventionsare routinelyprescribed forpeoplewithperipheral vascular diseaseandarefrequentlystandardprotocol intherehabilitationofpatientsaftercardiacsurgery.However, littleevidenceexistswithregard to the effect of physical therapy interventions for peoplewithVLUs. In addition, quality of life (QOL) is increasingly being assessed as animportantoutcomemeasurewhencoupledwithobjectivemeasures, enablingamoreaccuraterepresentationof theglobaleffectaspecific interventionormodalityhasonaparticularpatientorapopulationwith thesamediagnosis.9,10Numeroushealth-relatedQOL(HRQoL) instruIMPORTANCE Patients with venous leg ulcers (VLUs) have calf muscle pump dysfunction, which is associated with reduced ankle range of motion (ROM). Physical therapy or exercise that targets ankle joint mobility may lead to improvement in calf muscle pump function and subsequent healing. However, little is known regarding the effect of physical therapy or exercise on healing and quality of life (QOL), which is impaired in patients with VLUs.