Let me begin by stating that exercise and patients with diabetes are not mutually exclusive. This also holds true for a patient with diabetes who has a non-healing foot ulcer. Preliminary research suggests that exercise may work to increase the rate of wound healing in such patients.
That being said, many patients seeking treatment for diabetic foot ulcers are not the most disciplined when it comes to lifestyle choices. Exercise and the lack thereof is often a contributing factor to the declining quality of life that affects many patients with diabetes.
Over the years, I have recommended regular exercise to my patients. First, I am an advocate for my patients and want nothing more than for them to enjoy quality in their lives. Too often, patients with chronic ulcers experience a downward spiral of declining health and mental well-being that is marked by seemingly endless doctor appointments. How is it possible to encourage these patients to exercise when they may have never exercised before or simply do not see the potential benefits of getting off the couch?
Secondly, I also practice what I preach. I have exercised regularly since I was in grade school, whether it was via after school pick-up games, high school sports, or later in life as a fitness instructor in a commercial health club and as a competitive men’s softball player. Even now with a hectic daily schedule, I manage to get out and walk an hour and hit the gym at least three times per week.
Nothing clears your mind and helps you focus like a brisk walk or a 30-minute stretch and circuit in the gym. It does take some planning but as legendary basketball Coach John Wooden used to say, “Plan your work and work your plan.” Why shouldn’t we “plan our exercise and exercise our plan”?
Even when you start a career or a family, and you have seemingly little free time, it is worth the effort to take care of yourself first. What good are you to your family and patients if you have low energy and poor health?
Conversely, nothing diminishes your credibility among your patients more than if you espouse exercise but are 15, 25 or 50 pounds overweight yourself. New statistics reveal that as many as 39 percent of physicians are overweight or obese.1
How about the cardiologist who recommends smoking cessation to a patient but writes a prescription for Zyban or Chantix with nicotine stained fingers and reeking of his own smoke. “Do as I say, not as I do” is rarely the way to motivate others.
Todd Keylock, PhD, is the Assistant Professor of Exercise Science at Bowling Green State University in Ohio. He is researching the connection between exercise and the immune system, specifically whether exercise can improve wound healing in patients with diabetes.
Dr. Keylock is testing his wound theory in the laboratory. One indicator of inflammation is a high level of C-reactive protein (CRP) in the blood. He is measuring CRP in people with high and low levels of activity as well as inflammation levels in wounds in diabetic laboratory animals. He is comparing those levels in the inactive animals to the active animals.
“While the mechanism by which activity reduces inflammation is as yet unclear, there is a growing body of evidence that it does,” notes Dr. Keylock.2 “Although drugs can help reduce inflammation, pills are a less than ideal way of solving the problem. We think regular aerobic exercise can maintain and restore health by reducing chronic inflammation.”
It is already known that regular exercise can help keep blood glucose levels down, another indicator of its importance to health, adds Dr. Keylock. However, in the case of diabetes, exercise alone cannot solve all the problems.
“It has to be a combination of lowered calories and exercise to achieve weight loss. Exercise scientists know we can’t do this alone,” explains Dr. Keylock.2
Swimming. Swimming is great exercise that reduces pressure on the extremities. Immersing an open wound into any pool, public or private, lake or ocean, would certainly be contraindicated due to potential for further contamination of the wound by the water or contamination of the waters from the wound. However, once the wound is healed, a patient with diabetes can certainly begin or resume regular swimming, and reap its cardiovascular benefits.
Non-weightbearing exercise is the key challenge when managing a patient with a diabetic foot ulcer. Choosing which exercise program to recommend to a patient can be complicated by a number of issues, the most apparent being basic instruction.
The following list is nothing more than a way to spark some ideas and enhance your efforts. This is certainly not the only group of activities that is available. Nevertheless, here are some recommendations you can offer your patients.
Resistance bands. These are inexpensive and one can purchase them at any sporting goods store. They combine stretching and help increase cardiovascular output. Many patients are familiar with resistance bands if they have previously participated in a physical therapy rehabilitation program using the bands.
Total Gym. Despite the infomercial that is associated with the marketing of the Total Gym, this is an excellent piece of equipment. I have personally used my own Total Gym for approximately 10 years. I have recommended it to my patients for nearly the same amount of time. It is especially great when you do not have time to get to the gym or take a walk. Most importantly for the patients of concern, it is possible to get a great workout in without placing any weight on the lower extremity.
The cardiovascular benefits are apparent. As celebrity endorsers Chuck Norris and Christie Brinkley state, it uses your body weight and the resistance is adjustable. It is available online, via TV infomercials or in sporting goods chain stores.
Bowflex. The Bowflex has been around for at least 20 years and is another excellent piece of home equipment that allows for both upper and lower body exercise without the need for weightbearing. One of my elderly (now deceased) diabetic patients used his Bowflex into his 80s. Despite several diabetic foot ulcers, (all of which healed) over his years as my patient, this retired Army major was an advocate for the use and benefits of the Bowflex. I would certainly agree with his endorsement.
Upper body/arm ergometer. Upper body ergometers have been a staple of rotator cuff surgery rehabilitation for many years. If you have never experienced this type of workout, do not let the sitting aspect fool you. It can be intense.
Again, because the individual is seated during an upper body ergometer workout, there is no pressure on the feet or legs.
The device looks like bicycle pedals moved to a tabletop. The individual grips the device’s handles and begins pedaling with hands and arms. Resistance on the machine is adjustable. When patients use the upper body ergometer regularly, they can increase endurance along with strength.
These machines are commercially available for the home as well as rehab and health club settings. Prices vary. There are plenty of websites offering product reviews and explaining where to purchase these machines.
Pilates. Pilates utilizes a series of movements and exercises that emphasize core strength building, balance, stretching and flexibility. The Pilates method ranges from simple stretching to a series of machines that incorporate the aforementioned principles. DVDs and local Pilates instruction are available in most areas. For more information regarding the Pilates method, go to www.pilates.com  .
Sit and Be Fit. This is a series of videos produced with senior citizens as a target audience with a crossover to morbidly obese individuals and others limited by various afflictions. Creators of this video series included a video titled “Exercise and Diabetes” in the series. You can find more information regarding the series and how to purchase the videos on the Sit and Be Fit Web site: http://www.sitandbefit.org  .
Wii. The Wii system of interactive gaming is a fun way for anyone to exercise. It even monitors body mass index and weight loss if desired. One can personally customize a series of games to suit his or her particular fitness needs. It can be a great way for someone who has been inactive for an extended period to get back into exercise.
The system has been used by physical therapists in rehab and assisted living facilities. My own wheelchair-bound patients have benefitted from the Wii system and my family members and I have enjoyed a variety of the activities, making this suitable for a wide range of ages and activity levels.
Many of the patients in this population have documented or undiagnosed cardiac disease. Before recommending a specific exercise program for your patient, I advise you to consult with his or her cardiologist.
Chances are a number of your patients with diabetes have previously undergone a cardiac rehabilitation program. Research has shown supervised exercise to have the most benefit. A team approach here would be the most optimal and medically sound way for those ready to embrace a more active lifestyle.3
We all know the benefits of regular exercise. When it is not a priority, it is easy to see days turn into months and then years with diminished physical activity. None of us are 20 years old anymore but we should never resign ourselves to the idea that we have seen better days.
We must view our patients in the same light. Accepting the fact that they are chronically ill is not a reason to view them as having outlived their usefulness and chance at some quality during the rest of their lives.
Therefore, we should consider a holistic approach to wound healing that includes the benefits of exercise when possible, even when non-weightbearing status is required in the treatment of a diabetic foot ulcer.
1. Available at http://www.medscape.com/features/slideshow/lifestyle/2012/public?src=soc...  .
2. Available at http://www.bgsu.edu/offices/mc/news/2011/news94622.html  .
3. Hirsch AT, Haskal ZJ, Hetzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic). J Am Coll Cardiol. 2006; 47(6):1239-1312.