Factors influencing physical activity in patients with venous leg ulcer

Abstract

Background and Aim: Venous leg ulcer is a chronic condition characterized by a cyclical pattern of healing and recurrence leading to pain, disability, inactivity and reduced health. Physical activity is beneficial for venous circulation and general health, but knowledge is needed of determinants of physical activity and of possibilities for patients with leg ulcer to be physically active. The overall aim of the present work was, in terms of the International Classification of Functioning, Disability and Health (ICF), to identify and illuminate factors influencing patients possibilities to be physically active, and to gain deeper understanding of how physical activity is perceived and understood in patients with present or previous venous leg ulcer.

Patients and Methods: Thirty-four female patients aged 60 85 years and 27 agematched control subjects were recruited to Study I, which had a descriptive, crosssectional design. Clinical tests and structured interviews were used to collect the data. In Study II, a survey study with a descriptive, cross-sectional design, data were collected with a postal questionnaire from 98 patients, 62 women, aged 60 86 years. In Study III, an experimental, cross-sectional study, six patients and 22 control subjects, 2/12 women, aged 67 (58-83) years, were included. For data collection, clinical tests, structured interviews and treadmill walking were used. In Study IV, using a qualitative semistructured in-depth approach, interviews were conducted with 22 patients, 13 women, aged 75 (60-85) years.

Results: In Study I, leg ulcer patients showed reduced ankle range of motion, calfmuscle strength, walking speed, mobility, primary and extended ADL and physical activity as compared to control subjects. Pain and functional limitations seemed to persist despite wound healing. Patients suffering from active ulceration were more negatively affected than their post-ulcer fellows. By contrast, general health and global life satisfaction were rated similarly by the two groups. In Study II, fear-avoidance beliefs were present in 83% of the patients and 41% had strong fear-avoidance beliefs. Odds ratios (OR) for low physical activity was about three times higher for patients with strong fear-avoidance beliefs (OR 3.1, 95% confidence interval 1.1 8.3; p = 0.027) than for patients with weak fear-avoidance beliefs. Study III showed that total ankle range of motion was decreased by 3-4% with multi-layer high-compression bandaging. Walking with compression showed no change in oxygen cost as compared to walking at the same speed without bandaging. In Study IV, four categories of descriptions of physical activity were identified; (i) self-management, (ii) instructions and support, (iii) fear of injury and (iv) a wish to stay normal. Patients displayed poor understanding of the underlying pathology and chronicity of the disease. No or contradictory information regarding physical activity was given patients from caregivers.

Conclusions: Factors influencing physical activity were identified in most components of the ICF. Disabilities seemed to persist despite wound healing. Strong fear-avoidance beliefs were present and associated with low physical activity. Use of multi-layer highcompression bandaging decreased ankle range of motion but did not increase oxygen cost of walking. Whether or not the patients had understood the chronic nature of the underlying pathology was an important aspect of various ways of perceiving physical activity. Disabilities were found to impede, but not preclude physical activity. Certain environmental factors such as compression bandaging and inappropriate walking shoes and personal factors such as dysfunctional fear of movement and poor knowledge of the chronicity of the underlying disease were the greatest obstacles to physical activity.