Dear Readers: Physical exercise is important for healing chronic1 and acute2 wounds. Ambulation or calf muscle exercise is recommended for patients with venous insufficiency in addition to appropriate compression and elevation to prevent and manage venous ulcers.3 Modern approaches to pressure ulcer care recommend physical activity when feasible to reduce medical, physical, and psychological complications.4 Supplemental exercise is considered important in the recovery of patients with severe burns2 and is associated with earlier hospital discharge following hip replacement.5 The articles reviewed in this Evidence Corner illustrate precautions to consider in prescribing exercise during wound healing and affirm its benefits in acute wound care among healthy adults. Delaying Exercise After Breast Cancer Surgery Reduces SeromasReference: Shamley DR, Barker K, Simonite V, Beardshaw A. Delayed versus immediate exercises following surgery for breast cancer: a systematic review. Breast Cancer Res Treat. 2005;90(3):263–271.
Rationale: Postoperative exercises to maintain arm mobility after breast cancer surgery may have undesirable side effects by increasing fluid production at the surgical site. Resulting seroma formation may be associated with infection, fluid loss, and longer hospital stays.
Objective: This systematic review of randomized controlled trials (RCTs) determined whether a program of delayed versus immediate shoulder exercise reduces the risk of seroma formation and associated complications following breast cancer surgery in women without reducing beneficial effects on arm mobility.
Methods: The authors conducted a systematic review of RCTs comparing early versus delayed shoulder mobilization exercises in women after breast cancer surgery. Outcomes included one or more measurements of shoulder range of motion, wound complications, fluid drainage volumes, and incidence of seroma formation. Study validity was assessed for inclusion in a meta-analysis according to CONSORT criteria.6
Results: The meta-analysis included 6 of 12 RCTs reviewed. Delaying shoulder exercise significantly decreased the risk of seroma formation (P = 0.00001) but did not significantly affect arm movement ability, wound drainage volume, or length of hospital stay.
Conclusion: Current RCT evidence supports use of a delayed program of arm exercises to reduce seroma formation following breast cancer surgery in women. There was insufficient evidence to draw conclusions regarding effects of delayed exercise on immediate or long-term arm mobility, fluid drainage, or length of hospital stay.
Exercise Speeds Healing in Healthy Older Adults
Reference: Emery CF, Kiecolt-Glaser JK, Glaser R, Malarkey WB, Frid DJ. Exercise accelerates wound healing among healthy older adults: a preliminary investigation. J Gerontol A Biol Sci Med Sci. 2005;60(11):1432–1436. Rationale: Older adults are likely to experience slower wound healing. Physical exercise has a positive effect on physiological and psychological functioning among older adults, which may, in turn, benefit wound repair.
Objective: The objective of this study was to explore the effects of a 3-month exercise program on wound healing, neuroendocrine function, and perceived stress in healthy older adults.
Methods: On enrollment, healthy adults 55 to 77 years who had not exercised regularly for at least 6 months were randomly assigned to participate in an exercise program 3 times weekly for 3 months (n = 13) or were asked not to change their exercise habits for 3 months (n = 15). Each exercise session consisted of a 10-minute floor exercise warm-up followed by 30 minutes on a stationary bicycle, 15 minutes brisk walking or jogging on a treadmill, 15 minutes strength training, and a final 5 minute cool down. After 1 month of study acclimation, a 3-mm diameter punch wound 3 mm deep was made on the dorsal upper arm of each participant. Healing was measured from photographs 3 times weekly until the wound was no longer visible. Exercise endurance and oxygen consumption during a standardized stress test, self-reported stress, and salivary cortisol levels were measured on enrollment and at the study end.
Results: Time to complete wound healing was shorter (P = 0.012) for exercise participants (mean 29 days) than for control subjects (mean 39 days). Exercise participants significantly improved in cardio-respiratory fitness measures, experiencing increased oxygen consumption and longer exercise endurance with an increased salivary cortisol response to the stress test at the study end. No difference between the 2 groups was reported in the low levels of self-reported pre- and post-study stress.
Conclusions: Regular exercise over a 3-month period enhanced acute wound healing rates among healthy older adults and may be an important component of wound care to promote healing.
Clinical PerspectiveA growing body of pilot evidence supports the value of exercise in acute and chronic wound care and prevention protocols. Emery and colleagues suggest that healing benefits of exercise are related to increased cardiovascular or respiratory fitness and/or neuroendocrine responsiveness. They note that exercise is usually associated with lower levels of cortisol, not the higher levels observed in the exercise group in response to the exercise stress test. Earlier studies had shown that wound healing was delayed in stressed subjects with elevated cortisol. However, these studies differed in the conditions under which cortisol levels were measured. Further research will likely clarify the relationship between cortisol measures, exercise, and healing. The results summarized by Shamley and colleagues highlight the dangers of over exercising too soon after surgery. Surgical techniques, such as flap tacking,7 also significantly reduce seroma formation. These results remind wound care professionals to use good medical sense and consider related patient factors when prescribing any therapy aimed to improve wound outcomes. The take-home message is to apply therapeutic regimens, like exercise, with evidence of efficacy but apply them wisely with appropriate consideration of postoperative issues, such as circulatory disruption.
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References
1. Association for the Advancement of Wound Care. Summary algorithm for venous ulcer care with annotations of available evidence. Available at: http://www.guideline.gov/summary/summary.aspx?doc_id=7109&nbr=004280&string=aawc. Accessed February 16, 2006.
2. Pereira CT, Murphy KD, Herndon DN. Altering metabolism. J Burn Care Rehabil. 2005;26(3):194–199.
3. Kerstein MD. The non-healing leg ulcer: peripheral vascular disease, chronic venous insufficiency, and ischemic vasculitis. Ostomy Wound Manage. 1996;42(10A Suppl):19S–35S.
4. Norton L, Sibbald RG. Is bed rest an effective treatment modality for pressure ulcers? Ostomy Wound Manage. 2004;50(10):40–42, 44–52, discussion 53.
5. Whitney JD, Parkman S. The effect of early postoperative physical activity on tissue oxygen and wound healing. Biol Res Nurs. 2004;6(2):79–89.
6. Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet. 2001;357(9263):1191–1194.
7. Chilson TR, Chan FD, Lonser RR, Wu TM, Aitken DR. Seroma prevention after modified radical mastectomy. Am Surg. 1992;58(12):750–754.
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