Can Exercise Expedite Wound Healing In Older Patients?
The benefits of exercise in preventing diabetes and improving general health are well established. Can exercise also facilitate improved wound healing among older adults? A recent study in the Journal of Gerontology: Medical Sciences found that wounds healed faster for patients who exercised compared to those who engaged in no activity. The study involved 28 healthy adults with a mean age of 61. The patients were assigned either to an exercise or non-exercise group. Researchers created small wounds on patients and conducted wound measurement three times a week to calculate the healing rate. In the exercise group, wounds healed at a mean of 29.2 days as compared to a mean of 38.9 days in the group that did not exercise, according to the study. Nicholas Romansky, DPM, touts the benefits of cardiovascular exercise, noting that it increases blood flow, especially among patients with diabetes. He notes that exercise functions the same way as insulin by moving sugar from the blood into the muscles and lowered blood sugar will generally lead to less sugar and more endurance. “In the elderly and especially patients with diabetes, increasing blood flow to the foot is going to make them heal because it is going to drop the sugar,” says Dr. Romansky, a Fellow of the American College of Foot and Ankle Surgeons. “If you do not have blood flow, nothing is going to heal.” Emphasizing A Degree Of Caution With Exercise Recommendations When recommending exercise, Dr. Romansky cautions DPMs to beware if patients have had a previous ulcer, deformity (which one may have to offload) or other problem that patients may be sensitized to again if they exercise. Tamara Fishman, DPM, calls exercise a “catch-22” for patients with wounds. “To be honest, exercise is the last thing I think about with wound patients,” says Dr. Fishman, the Chairman of the Wound Care Institute in North Miami Beach, Fla. “Most of the time, the wound patient needs to be off his or her feet for a period of time.” However, some patients who have undergone heart surgery may need to exercise if advised to do by their cardiologist. In those cases, Dr. Fishman recommends specialized shoes with inserts. If patients can exercise, their routines should include cardiovascular activity, strength and flexibility, according to Dr. Romansky, who is in private practice in Media and Phoenixville, Pa. He notes that patients should exercise slowly and regularly, and that older people should not increase their exercise by more than 10 percent from one week to the next. For example, if they walk 20 minutes one week, they should only walk 22 minutes the next week. If patients do not recover from an exercise routine in 24 to 36 hours, he says they should reassess if the program is working and also should re-evaluate their exercise routines every six weeks. If patients do not want to exercise or can only participate in limited exercise, Dr. Romansky suggests blending exercise into life activities. For example, they could park in a spot farther from a store, take the stairs instead of an elevator, and do activities like household chores or gardening. If patients treat exercise like an appointment, Dr. Romansky says they are more likely to stick to a routine. Study Examines More Accurate Test For Autonomic Neuropathy By Brian McCurdy, Associate Editor It may be difficult to distinguish Charcot’s neuroarthropathy from other conditions but an emerging test may yield clearer results. A recent study in the Journal of the American Podiatric Medical Association examined the efficacy of using short-term power spectral analysis (PSA) of heart rate variability (HRV) to assess autonomic neuropathy. Researchers studied 17 patients with acute Charcot’s neuroarthropathy and compared PSA of HRV to standard Ewing’s cardiovascular reflex tests. Using the PSA of HRV test diagnosed 92 percent of patients with autonomic neuropathy while Ewing’s tests diagnosed 82 percent, according to the study. How does PSA of HRV work? As study co-author Stephanie Wu, DPM, explains, the HRV spectrum has two main spectral components, low frequency (0.03 and 0.15 Hz) and high frequency (0.18 and 0.40 Hz). In general, the high-frequency component is considered a marker for vagal activity although some have advocated a sympathetic influence as well, according to Dr. Wu, the American Podiatric Medical Association/American Diabetes Association Senior Fellow at the Scholl College of Podiatric Medicine’s Center for Lower Extremity Ambulatory Research. In contrast, she says the low-frequency component depends on more complex mechanisms and some researchers theorize it may be influenced by centrally generated brainstem rhythms, baroreceptor feedback influences, and both sympathetic and vagal input. Dr. Wu says there is some controversy in the use of the low-to-high frequency spectra ratio in PSA of HRV as an index of parasympathetic-sympathetic balance since the low frequency component is not completely understood. Will PSA of HRV Emerge As A More Mainstream Testing Technique? In comparison to Ewing’s tests, PSA of HRV is noninvasive and patients tolerate the testing better, according to Dr. Wu. She also points out that PSA of HRV requires less time of patients, noting that Ewing’s tests are time-consuming and require attentive collaboration from patients. Dr. Wu notes that PSA of HRV permits quantitative evaluation of both the sympathetic and parasympathetic components of the autonomic nervous system. She adds that power spectral analysis may have better reproducibility of its 24-hour HRV indexes compared to Ewing’s tests. One can measure HRV using only ECG equipment, which does not add additional cost to the facility, according to Dr. Wu. However, she cautions that the Fourier analyses used in the assessment of PSA of HRV do require microprocessors, relevant software and electrophysiologic expertise. While PSA of HRV is mostly utilized in research studies, Dr. Wu says the test is not widely used in the clinical setting since there is no current standardized set of optimal variables and reference values for PSA of HRV. However, measuring heart rate variability is becoming increasingly standardized and accepted, according to Dr. Wu, who advocates further investigation into establishing reference values for the optimal variables of PSA of HRV in the general population. Is MIRE Technology Effective For Diabetic Neuropathy? By Brian McCurdy, Associate Editor When treating diabetic patients for peripheral neuropathy, one has a choice of treatments including monochromatic infrared energy (MIRE). However, a recent study raises questions about the effectiveness of MIRE. The Diabetes Care study examined 39 people with diabetic peripheral neuropathy over eight weeks. The patients received 30 minutes of either active MIRE or a placebo three times a week for four weeks. Researchers used a 5.07 monofilament to test sensation and discovered that the number of patients who could sense the monofilament increased for both the MIRE and placebo groups with no significant differences between the two groups for any measurement. The study authors concluded that MIRE was no more effective than placebo in increasing sensation in those with diabetic neuropathy. One DPM questions the study’s conclusions. Although he praises the study’s methodology, Paul J. Kim, DPM, says the authors’ conclusion that MIRE is ineffective is “premature.” He cites recent studies in Diabetes Care, JAPMA and Endocrine Practice that support MIRE’s efficacy. Dr. Kim also advocates further study to understand the clinical implications of the infrared therapy. Dr. Kim, an Assistant Professor at the Arizona Podiatric Medicine Program at the Midwestern University College of Health Sciences, says monochromatic infrared energy (MIRE) technology is based on basic physiology, and the challenge is translating the physiology to clinical application. He notes there are few options in reversing or slowing peripheral neuropathy, and MIRE’s advantages include its noninvasive nature. Although there are surgical options such as nerve decompression surgery, Dr. Kim cautions that not every patient with neuropathy is a candidate for surgery.