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Original Investigation
November 2018

Prescribed Exercise With Compression vs Compression Alone in Treating Patients With Venous Leg Ulcers: A Systematic Review and Meta-analysis

Author Affiliations
  • 1School of Nursing, University of Auckland, New Zealand
  • 2National Institute for Health Innovation, University of Auckland, New Zealand
JAMA Dermatol. 2018;154(11):1304-1311. doi:10.1001/jamadermatol.2018.3281
Key Points

Question  Is an exercise regimen adjuvant to compression associated with increased venous leg ulcer healing compared with compression alone?

Findings  In this systematic review and meta-analysis including 5 randomized clinical trials comprising 190 patients with venous leg ulceration, exercise was associated with increased healing rates by 14 additional cases per 100 patients in exercise groups compared with control groups. Progressive resistance exercise plus prescribed physical activity was associated with increased healing by 27 additional cases per 100 patients in exercise groups compared with control groups.

Meaning  Daily sets of heel raises plus physical activity (eg, walking at least 3 times per week) may be an effective adjuvant to compression for treating venous leg ulceration.


Importance  Exercise is recommended as an adjuvant treatment for venous leg ulceration (VLU) to improve calf muscle pump function. However, the association of exercise with VLU healing has not been properly aggregated, and the effectiveness of different exercise interventions has not been characterized.

Objective  To summarize the association of different exercise interventions with VLU healing when used as an adjuvant to any form of compression.

Data Sources  The Cochrane Controlled Trials Register, MEDLINE, Embase, CINAHL, PsycInfo, and SCOPUS databases were searched through October 9, 2017.

Study Selection  Randomized clinical trials (RCTs) of any exercise compared with no exercise in participants with VLU were included, where compression was used as standard therapy and a healing outcome was reported. Independent title screening and full text review by 2 authors (A.J., J.S.) with appeal to a third author (J.P.) if disagreement was unresolved. Of the 519 articles screened, a total of 6 (1.2%) studies met the inclusion criteria for systematic review, including 5 for meta-analysis.

Data Extraction and Synthesis  Independent quality assessment for Cochrane risk of bias and data extraction by 2 authors with appeal to third author if disagreement unresolved (PRISMA). Data pooled using fixed effects model.

Main Outcomes and Measures  The a priori primary outcome was any healing outcome (proportion healed, time to healing, or change in ulcer area). Secondary outcomes (adverse events, costs, and health-related quality of life) were only collected if a primary outcome was reported.

Results  Six RCTs were identified and 5 (190 participants) met inclusion criteria for meta-analysis. The exercise interventions were progressive resistance exercise alone (2 RCTs, 53 participants) or combined with prescribed physical activity (2 RCTs, 102 participants), walking only (1 RCT, 35 participants), or ankle exercises (1 RCT, 40 participants). Overall, exercise was associated with increased VLU healing at 12 weeks although the effect was imprecise (additional 14 cases healed per 100 patients; 95% CI, 1-27 cases per 100; P = .04). The combination of progressive resistance exercise plus prescribed physical activity appeared to be most effective, again with imprecision (additional 27 cases healed per 100 patients; 95% CI, 9-45 cases per 100; P = .004).

Conclusions and Relevance  The evidence base may now be sufficiently suggestive for clinicians to consider recommending simple progressive resistance and aerobic activity to suitable patients with VLU while further research is produced.