Wound Care

J Wound Ostomy Continence Nurs. 2017;00(0):1-8.

Published by Lippincott Williams & Wilkins

The Effect of Foot Exercises on Wound Healing

in Type 2 Diabetic Patients With a Foot Ulcer
A Randomized Control Study
Şahizer Eraydin ¿ Gülçin Avşar

ABSTRACT
PURPOSE: The purpose of this study was to investigate the effect of foot exercises on wound healing in type 2 diabetic
patients with a diabetic foot ulcer.
DESIGN: Prospective, randomized controlled study.
SUBJECT AND SETTINGS: Sixty-five patients from an outpatient clinic with grade 1 or 2 ulcers (Wagner classification) who
met study criteria agreed to participate; 60 patients completed the study and were included in the final analysis. Subjects were
followed up between February 2014 and June 2015.
METHODS: Subjects were recruited by the researchers in the clinics where they received treatment. Subjects were randomly
allocated to either the control or intervention group. Data were collected using investigator-developed forms: patient information
form and the diabetic foot exercises log. Patients in the intervention group received standard wound care and performed daily
foot exercises for 12 weeks; the control group received standard wound care but no exercises. The ulcers of the patients in both
the intervention and control groups were examined and measured at the 4th, 8th, and 12th weeks. The groups were compared
in terms of the ulcer size and depth. To analyze and compare the data, frequency distribution, mean (standard deviation), variance
analysis, and the independent samples t test and the χ2 test were used.
RESULTS: The mean ulcer areas were 12.63 (14.43), 6.91 (5.44), 4.30 (3.70), and 3.29 (3.80) cm2 (P < .05) in the study
intervention group, and 24.67 (20.70), 24.75 (20.84), 20.33 (20.79), and 18.52 (21.49) cm2 in the control group in the 4th, 8th,
and 12th weeks, respectively. Significant differences were found between diabetic foot ulcer sizes in the study intervention
group in the 4th and 12th weeks compared to beginning baseline (P ≤ .05). However, only the 12th week was different from the
beginning in the control group (P = .000). The mean depths of the ulcers were 0.56 (0.85), 0.42 (0.68), 0.36 (0.50), and 0.28
(0.38) cm in the study intervention group (P < .05) and 0.61 (0.84), 0.82 (1.07), 0.83 (1.21), and 0.80 (1.26) cm in the control
group, respectively, at the baseline, and at the 4th, 8th, and 12th weeks, respectively (P = .000).
CONCLUSION: The ulcer areas decreased significantly in the study intervention group compared to the control group during the
3 follow-up measurements. An important finding in this study was the DFU area decreased more in those who exercised more.
Findings suggests foot exercises should be included in the treatment plan when managing patients with diabetic foot ulcers.
KEY WORDS: Diabetic foot exercises, Diabetic foot ulcers, Nursing, Randomized control trial, RCT, Wound healing.

INTRODUCTION is 70%. Incidence of DFU is 1% to 4% among patients with

Diabetic foot ulcers (DFUs) are a serious complication of di-
abetes mellitus (DM) that can be slow to heal, result in re-
peated hospitalizations, require intense and costly treatment,
and reduce the quality of life. There is a 12% to 25% risk
for patients with DM to develop DFU during their lifetime,
and DFUs constitute 40% to 60% of nontraumatic amputa-
tions.1-3 Also, when a DFU occurs once, the rate of possible
recurrence within 3 years is 35% to 40%, and within 5 years
Şahizer Eraydin, PhD, RN, Nursing Department, Faculty of Health Sciences,
Gaziosmanpaşa University, Tokat, Turkey.
Gülçin Avşar, PhD, RN, Faculty of Nursing, Atatürk University, Erzurum, Turkey.
The authors declare no conflicts of interests.
Correspondence: Şahizer Eraydin, PhD, RN, Nursing Department, Faculty of
Health Sciences, Gaziosmanpaşa University, Tokat, Turkey (sahizer.eraydin@
gop.edu.tr).
DOI: 10.1097/WON.0000000000000405
DM, with a prevalence of 3% to 10%.4-6
The main purpose of the treatment and care of DFU is to
prevent extremity loss and increase health-related quality of
life. Based on this, the aims of nursing care for patients with
DFU are promotion of health, protection from complications,
proper patient care, and encouraging treatment compliance.7-10
To achieve these aims, nurses take different roles in order to
become “a person who is responsible for patient care, an edu-
cator, counselor, leader, researcher, manager and a person who
protects patient rights.”5,9,11 Moreover, nurses provide patients
with the essential care necessary in preventing the occurrence
of DFU, in the treatment of wounds, in the development of
repetitive wounds and during infection, gangrene, and ampu-
tation.5,8,9,11 Therefore, preventing the development of DFU
in patients with DM is an important nursing function. In ad-
dition, if a DFU develops, nursing care includes appropriate
wound care to promote rapid healing, preventing amputation,
and preventing the ulcer from worsening.9,12

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2 JWOCN ¿ Month/Month 2017
The most common cause in the development of DFU is pe-
ripheral neuropathy, angiopathy, and immunopathy.2,7 More-
over, poor foot care and having foot deformities pose a risk for
DFU development. Many of these risk factors may combine
with a trauma that a patient suffers, cause the development of
DFU, and slow healing.2,7,13,14 Impaired wound healing also
increases the risk for serious complications. The amount of
blood flowing to the wound is highly important for wound
healing. A well-vascularized wound bed enables the formation
of new granulation tissue, and provides nutrition and oxygen,
which maintain an active immune response against micro-
organisms.1,15 It is recommended that patients with DM do
regular foot exercises to increase the blood flow to the lower
extremities, and to promote joint mobility.16-18 In Foot exercis-
es in patients with DFU may facilitate movement in joints and
muscles, increase blood flow to the area, and provide adequate
wound perfusion. These exercises may accelerate wound heal-
ing, prevent amputations, increase quality of life, and reduce
cost.19,20 Nursing care plays an important role in promoting
exercise in diabetic patients.
Many studies have emphasized the importance of perform-
ing daily foot exercises for patients with DM, according to
their age and health status. Most studies of foot exercises have
examined the effect of foot exercise on patients with DM who
do not have DFU. These studies have reported that diabetic
foot exercises have positive effects on neuropathy, vasculopa-
thy, standing and walking characteristics, body balance, foot
Figure 1. Research CONSORT schematic.
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pressure, and foot muscular force.16-18,21,22 However, other than
a small pilot study of 19 subjects conducted by Flahr,7 evidence
reporting the effect of exercise on wound healing in patients
with DFU is limited. The purpose of this study was to examine
the effect of foot exercises on wound healing in patients with
type 2 diabetes with a DFU.
METHODS
This study used a randomized controlled study design. The
target population were patients who had been hospitalized and
diagnosed with DFU in the 2 hospitals where the study was
conducted. The study subjects were recruited by the research-
ers in the clinics where they received treatment. The 2-group
simple parallel randomization started from the study interven-
tion group, and patients were prospectively allocated to the
control and study intervention groups. Randomization was
based on the order of patients’ referral to the clinic. Blinding
was not employed in this study (Figure 1). The study started
with 65 participants and was completed with 60 participants
(Figure 1).
Sample and Setting
The target population comprised 116 patients who sought
treatment at hospitals where this study was conducted be-
tween February 1, 2014, and June 1, 2015, and who were
diagnosed with type 2 DM, and classified as Wagner grade 1
JWOCN ¿ Volume 00 ¿ Number 0
or 2 DFU. Additional inclusion criteria were age between
20 and 80 years; not having dementia and mental problems;
having no systemic diseases such as musculoskeletal disorders,
heart diseases, or neurological diseases that can hinder ability
to participate in the study; undergoing the standard wound
care protocol (cleaning the wound with saline, covering it
with gauze dressing); not receiving other treatments that could
affect wound healing (negative-pressure wound treatment,
hyperbaric oxygen treatment, a special wound care product,
special wound dressing, or growth factor); and not using an-
other complementary treatment method (herbal wound care
products). Exclusion criteria were ulcer developed secondary
to acute trauma; ulcer developed secondary to burns; ulcer
advanced to Wagner grade 3, 4, or 5; a surgical operation
other than debridement was to be applied to the existing ul-
cer; impaired general health status; wound treatments other
than standard care deemed to be required by the physician for
wound care; and starting a complementary treatment method
such as a (herbal wound care product).
To initiate the study, an approval with the decision num-
ber “11.12.2013” was obtained from the Scientific Ethics
Committee of the Faculty of Nursing, Ataturk University. Re-
searchers obtained a written permission form the 2 hospitals
where the study was conducted, and written and verbal in-
formed consent was obtained from each participants.
Instruments
This form has 18 questions regarding the patients’ demograph-
ic characteristics, foot care, their general health status, and the
status of the ulcer. A test strip was used to measure the wound
depth in the deepest area of the wound. Wound size was mea-
sured in centimeters. Wound surface area was measured using
a scaled transparent measurement paper. The borders of the
wound were drawn on this paper. The wound size was calcu-
lated in squared centimeters.
An exercise log was prepared by the researchers based on the
literature7,23,24, and expert opinion. It included a schedule with
the pictures of the diabetic foot exercises that the patients were
taught; and the patients marked the schedule when they did
the exercises.
Diabetic Foot Exercises
Instructions to patients with DFU were provided that includ-
ed the following information: (1) avoid exercises that require
weight bearing,23; (2) complete the exercise program in a sit-
ting position at first and in a standing position after the wound
heals24; (3) exercises include range-of-motion movements of
plantar flexion, dorsiflexion, inversion, eversion, circumduc-
tion, and plantar and dorsal flexion of toes; (4) exercise series
should include, at minimum, 5 to 10 exercises with 10 to 15
repeats23.24; (5) exercise 1 hour after taking insulin and before
refreshments; (6) blood glucose level should be 100 to 125
mg/dL before the exercise; (7) defer exercises if the blood glu-
cose level is more than 300 mg/dL and the blood pressure is
more than 180 mm Hg before the exercise; and (8) discontin-
ue the exercise if the patient feels nausea, dizziness, or drowsi-
ness during the exercise.23 Participants completed 18 exercises
with 10 repeats.
Data Collection
Data were collected at 4 timepoints: at the beginning of the
study and at the 4th, 8th, and 12th weeks. After informed con-
sent, patients were asked to complete the patient information
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Eraydin and Avşar 3
form, and ulcer sizes were evaluated by the researcher nurse
(ŞE), using the wound measurement tools.
Patients in the study intervention group were taught the di-
abetic foot exercises over 20 to 30 minutes in the clinic setting
by the researcher without putting weight on the feet, includ-
ing the movements of plantar flexion, dorsiflexion, inversion,
eversion, circumduction, and plantar and dorsal flexion of toes
using a demonstration method. Subjects in the study interven-
tion group were asked to exercise twice daily for 12 weeks. The
patients were given the diabetic foot exercise log, including the
pictures of the exercises, to support the education. The patients
recorded the exercises they did on an exercise log. The markings
on the exercise logs and the DFU measurements were assessed
in the 4th, 8th, and 12th weeks. Patients in both groups re-
ceived standard wound care. The DFU measurements of the
control group were assessed in the beginning, in the 4th week,
the 8th week, and the 12th week. The researcher evaluated the
extent to which the patients remembered the foot exercise in-
formation twice during the course of the study.
Data Analysis
Data were analyzed using the SPSS 18.0 software (SPSS,
Chicago, Illinois). Between groups, independent sample t test
and the Mann-Whitney U test, analysis of variance, and the
Kruskal-Wallis test were performed. The χ2 and Fisher exact
tests were used to perform analysis between categorical vari-
ables. P values < .05 were deemed statistically significant.
RESULTS
Sixty-five patients were enrolled who met the inclusion crite-
ria and randomized to each group. Sixty subjects completed
all timepoints of the study (Figure 1). The average age of the
control group was 65.76 (8.57) years; the mean duration of
diabetes was 17.46 (8.79) years; the average body mass index
was 28.58 (4.66); and 73.3% were male and 66.7% were mar-
ried. The average age of the study intervention group was 61.03
(9.97) years; the mean duration of diabetes was 16.23 (8.57)
years; their average body mass index was 31.36 (7.62). Half
were male and 83.3% were married. No differences were found
between the demographic characteristics of the control and
study intervention groups when age, marital status, diabetes
onset, and laboratory results were compared (P > .05; Table 1).
The initial mean DFU area of the study intervention group
was 12.63 (14.43) cm2. The mean DFU areas in the 4th,
8th, and 12th weeks were 6.91 (5.44), 4.30 (3.70), and 3.29
(3.80)  cm2, respectively. Significant differences were found
between the study intervention group’s initial mean ulcer
sizes and mean ulcer sizes in the 4th, 8th, and 12th weeks,
and between the mean ulcer sizes in the 4th and 12th weeks
(P = .000; Table 2). The initial mean DFU area of the control
group was 24.67 (20.70) cm2. The mean DFU areas in the
4th, 8th, and 12th weeks were 24.75 (20.84), 20.339 (20.79),
and 18.52 (21.49) cm2, respectively. A significant difference
was found between the control group’s initial mean DFU area
and the mean DFU area in the 12th week (P = .000; Table 2).
Intragroup comparisons showed that, in the study interven-
tion group, while the mean ulcer areas significantly decreased
in all 3 follow-ups compared to the baseline findings, in the
control group, the mean decreased only in the last follow-up
(P < .05; Table 2).
The mean DFU areas were compared in this study. A sig-
nificant difference was found between the study and control
4 JWOCN ¿ Month/Month 2017 www.jwocnonline.com

TABLE 1.
Distribution of Demographic Characteristics of Patients
Control Group Study Group
Demographic Characteristics n (%) n (%) Test and P Value
Gender
Female 8 (26.7) 15 (50.0) χ2 = 3.455
Male 22 (73.3) 15 (50.0) P = .063
Marital status
Married 20 (66.7) 25 (83.3) χ2 = 2.222
Single 10 (33.3) 5 (16.7) P = .136
Education level
Uneducated 14 (46.7) 11 (36.7)
Primary school 12 (40.0) 11 (36.7) χ2 = 1.737
Middle school and above 4 (13.3) 8 (26.3) P = .420
Before foot care information
Informed 9 (30.0) 15 (50.0) χ2 = 2.500
Uninformed 21 (70.0) 15 (50.0) P = .114
Formation of a wound before
Yes 20 (66.7) 22 (73.3) χ2 = 0.317
No 10 (33.3) 8 (26.7) P = .573
Yearly average of diabetes 17.46 (8.79) 16.23 (8.57) t = 0.550
Min = 0.5; max =35 Min = 2; max=31 P = .584
Average age 65.76 (8.57) 61.03 (9.97) t = 1.970
Min = 49; max = 80 Min = 41; max = 80 P = .054
Average body mass ındex 28.58 (4.66) 31.36 (7.62) t = −1.703
min = 20.26; max = 39.62 Min = 20.06; max = 62.24 P = .094
HbA1c, % 10.02 (1.68) 10.36 (1.91) t = −0.599
Min = 7.71; max = 12.70 Min = 6.20; max = 14.22 P = .553
Hemoglobin, g/dL 11.90 (1.75) 12.17 (1.70) t = −0.588
Min = 8.10; max = 16.10 Min = 8.90; max = 15.70 P = .559
Leukocyte, mm3 9.93 (3.09) 9.60 (3.10) t = 0.410
Min = 5.25; Max = 17.00 Min = 5.62; max = 19.33 P = .683
Albumin, g/dL 3.48 (0.65) 3.70 (0.73) t = 1.190
Min = 1.99; Max = 4.70 Min = 1.45; max = 5.03 P = .239

groups’ beginning mean DFU areas and the mean DFU areas
in the 4th, 8th, and 12th weeks (P < .05; Table 2).
The mean ulcer depths were 0.56 (0.85), 0.42 (0.68), 0.36
(0.50), and 0.28 (0.38) cm in the study intervention group
(P < .05) and 0.61 (0.84), 0.82 (1.07), 0.83 (1.21), and 0.80
(1.26) cm in the control group at the baseline, and at the
4th, 8th, and 12th weeks, respectively (P  > .05). There were
differences in DFU depths. Intragroup comparisons showed
that, in the study intervention group, while there was a signif-
icant difference between the baseline and the third follow-up
findings (P = .014), in the control group, no difference was
found (P > .05; Table 3).
The number of the exercises marked by the study interven-
tion group on the exercise log was examined in this study. The
exercises were categorized into 3 groups. Of the patients in the
study group, 26.7% did the exercises for 0 to 30 days, 50% did
the exercises for 31 to 60 days, and 23.3% did the exercises for
61 to 90 days (Table 4).

TABLE 2.
Distribution of DFU Area Averages
Beginning 4th wk 8th wk 12th wk Test and
Group Mean (SD) Mean (SD) Mean (SD) Mean (SD) P value
Control 24.67 (20.70) 24.75 (20.84) 20.33 (20.79) 18.52 (21.49) P = .000a
Study 12.63 (14.43) 6.91 (5.44) 4.30 (3.70) 3.29 (3.80) P = .000b
Test and P value z = −2.647 z = −4.008 z = −4.156 z = −3.959
P = .008 P = .000 P = .000 P = .000
Abbreviations: DFU, diabetic foot ulcer; SD, standard deviation.
a
A difference was found between the beginning value and the value in the 12th week.
b
A difference was found between the beginning value and the values in the 4th, 8th, and 12th weeks; and between the values in the 4th and 12th weeks.

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JWOCN ¿ Volume 00 ¿ Number 0 Eraydin and Avşar 5

TABLE 3.
Distribution of DFU Total Depth
Beginning 4th wk 8th wk 12th wk Test and
Group Mean (SD) Mean (SD) Mean (SD) Mean (SD) P Value
Control 0.61 (0.84) 0.82 (1.07) 0.83 (1.21) 0.80 (1.26) P = .374
Study 0.56 (0.85) 0.42 (0.68) 0.36 (0.50) 0.28 (0.38) P = .014a
Test and p value P = .820 P = .150 P = .148 P = .125
Abbreviations: DFU, diabetic foot ulcer; SD, standard deviation.
a
A difference was found between the beginning value and the value in the 12th week.

In this study, an intragroup comparison was made between
the study intervention group DFU sizes and the number of ex-
ercises they performed. No difference was found between the
mean DFU areas on the total number of days patients based
the exercised (Table 4; Figure 2).
Follow-up assessments revealed a significant differences in
terms of the total DFU sizes between patients performing ex-
ercises for 0 to 30, 31 to 60, and 61 to 90 days (Table 4; P <
.05, and Figure 2). The comparison results in terms of DFU
sizes of patients in the study intervention group relating to the
number of exercises showed a difference between the baseline
and third follow-up findings of patients performing exercises
for 0 to 30 days (Table 4; P < .001), and between the baseline
and second and third follow-up findings of those performing
exercises for 31 to 60 days (Table 4; P < .001). This study also
determined a statistically significant difference in terms of the
DFU sizes between the baseline and first, second, and third
follow-up findings of patients performing exercises for 61 to
90 days (Table 4; P < .001).
The initial values in this study show that, of the control
group, 57% had Wagner grade 1 DFU, 53% had black ne-
crosis, and 23% underwent debridement; of the study group,
63% had Wagner grade 1 DFU, 47% had black necrosis, and
13% underwent debridement (Table 5; P > .05). In addition,
there is no difference in the distribution of ulcer properties
(Table 5; P > .05). This study found no difference between
the groups regarding the varied features of the patients’ DFU
in the distribution of the study and control groups at the be-
ginning and final follow-up (Table 5; P > .05). At the end of
this study, 20% of the study intervention group while only 3%
of the control group patients made a full recovery (Table 5).
DISCUSSION
Study findings suggest that regular foot exercises may reduce
the size and depth of the ulcers, accelerate wound healing, and
indicate a relationship between the exercise application time
and the speed of healing. While the first follow-up did not find
any change in the control group patients in terms of the mean
DFU size, there was a decrease of 50% in the study interven-
tion group. Patients in the control group experienced a decrease
in terms of the mean DFU size for the first time, according to
the measurements of the second follow-up. However, the third
follow-up found that both the control and study intervention
group patients continued to experience a decrease in the mean
DFU size. Moreover, while the DFU size in control group pa-
tients decreased 25% compared to baseline, the mean DFU
size decrease rose to 75% in the intervention group.
Slow and prolonged wound healing is common for a diabetic
patient receiving adequate care. In diabetic patients, inadequate
perfusion due to angiopathy and neuropathy causes the forma-
tion of hypoxia on tissues. Hypoxia prolongs and delays healing
by increasing the levels of oxygen radicals.1,25 In our study, the
control group began to experience a change in the wound size
after the 8th week, while the study intervention group began to
experience improvement after the 4th week. This can be inter-
preted as an encouraging finding. Wound healing started at the
4th week in the study intervention group and continued at the
8th and 12th weeks. We conclude that this was related to chang-
es occurring as the result of exercise (muscle activity, increase in
blood flow to the wound area, and decrease in hypoxia).
We also examined the mean DFU depth. While ulcer depths
were almost equal in the control and study intervention groups
at baseline, a significant decrease DFU depth was significant-
ly less in the intervention group on follow-up. According to
study results, it can be hypothesized that as ulcer depths of
patients in the control group increased, ulcers moved toward
inner tissues and negatively affected healing. Wound healing
process is prolonged with the spread of ulcer depth to inner
tissues, bone infection can develop, and it can even progress to
a depth requiring amputation.26,27 However, debridement in
the control group may have influenced this finding.

TABLE 4.
Distribution of the Total Ulcer Area Averages According to the Number of Days of Exercise in the Study Group
Number of Beginning 4th wk 8th wk 12th wk Test and
Exercises n (%) Mean (SD) Mean (SD) Mean (SD) Mean (SD) P Value
0-30 d 8 (26.7) 20.90 (19.88) 21.21 (19.95) 17.28 (19.47) 15.80 (19.90) <.001a
31-60 d 15 (50) 16.84 (19.14) 7.32 (5.80) 4.10 (3.59) 2.79 (2.84) <.001b
61-90 d 7 (23.3) 10.29 (5.28) 4.89 (0.96) 2.96 (1.73) 1.17 (2.10) <.001c
P value P = .480 P = .004 P = .001 P = .001
Abbreviation: SD, standard deviation.
aA
difference was found between the beginning value and the value in the 12th week.
b
A difference was found between the beginning value and the values in the 4th, 8th, and 12th weeks; and between the values in the 4th and 12th weeks.
c
A difference was found between the beginning value and the values in the 4th, 8th, and 12th weeks; and between the values in the 4th and 12th weeks.

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6 JWOCN ¿ Month/Month 2017 www.jwocnonline.com

Figure 2. The average diabetic foot ulcer area based on the number of exercises in the study group. Median values have been taken.

We also examined debridement as another factor related to
the depth of the wound. Debridement is often necessary in
chronic wounds for both diagnosis and treatment. Selection of
the methods for debridement should be determined by the con-
dition of the wound, presence or absence of infection, biofilms,
amount of necrotic tissue, vascularity of wound, and anticoag-
ulation medications. As a result of neuropathy, debridement is
usually painless.28 During our study, debridement was included
as a part of standard care and was applied only when deemed
necessary for treatment. Debridement was seen to be necessary
and applied more often for the control group, and this affected
the ulcer depth. However, debridement was not performed on
ulcers of patients in the study intervention group. The fact that
there was no need for debridement of ulcers of patients in the

TABLE 5.
Distribution of Ulcer-Related Features at the Beginning and Last Follow-up of Patients in the Study and Control Groups
Beginning 12th Week Last Follow-up
Control Group Study Group Control Group Study Group
N (%) N (%) Test and P Value N (%) N (%) Test and P Value
Ulcer classification
Wagner 1 17 (57) 19 (63) χ2 = 0.778 16 (54) 14 (47) χ2 = 0.278
Wagner 2 13 (43) 11 (37) P = .678 13 (43) 10 (33) P = .598
Improvement – (–) – (–) 1 (3) 6 (20)
Ulcer localization
Fingers 7 (23) 17 (57) 6 (21) 12 (50)
Bottom + heel 12 (40) 6 (20) χ2 = 7.056 12 (41) 6 (25) χ2 = 5.633
Other 11 (37) 7 (23) P = .129 11 (38) 6 (25) P = .060
Black necrosis
No 14 (47) 16 (53) χ2 = 2.324 21 (70) 28 (93) 0.706a
Yes 16 (53) 14 (47) P = .313 9 (30) 2 (7)
Yellow necrosis
No 23 (77) 26 (87) χ2 = .659 23 (77) 27 (90) χ2 = 0.111
Yes 7 (23) 4 (13) P = .417 7 (23) 3 (10) P = .739
Infection
Yes 8 (27) 2 (7) 1.00a 2 (7) – (–) 0.492a
No 22 (73) 28 (93) 28 (93) 30 (100)
Getting culture
Yes 8 (27) 6 (20) χ2 = 0.373 2 (7) – (–) NA
No 22 (73) 24 (80) P = .542 28 (93) 30 (100)
Reproduction in culture
Yes 7 (88) 5 (83) NA 1 (50) – (–) NA
No 1 (12) 1 (17) 1 (50) – (–)
Using antibiotics
Yes 30 (100) 30 (100) NA 2 (7) – (–) NA
No – (–) – (–) 28 (93) 30 (100)
Wound debridement
Yes 7 (23) 4 (13) χ2 = 0.617 3 (10) – (–) NA
No 23 (77) 26 (87) P = .432 27 (90) 30 (100)
Abbreviation: NA, cannot calculate because the number of samples is insufficient.
a
Fisher exact test.

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JWOCN ¿ Volume 00 ¿ Number 0
study intervention group may be regarded as a positive effect of
exercise on wound healing.
We found that half of the patients in the study intervention
group performed exercises for 31 to 60 days, 27% performed
exercises for less than 30 days, and 23% performed exercises
for more than 61 days. Moreover, the 1st, 2nd, and 3rd fol-
low-ups found a statistically significant difference between the
mean DFU areas of patients performing exercises for 0 to 30
days, 31 to 60 days, and 61 to 90 days. In this study, an im-
portant finding was that the study intervention group patients,
who performed exercises for a longer time, experienced more
of a decrease in the size of their ulcers, compared to those who
performed exercises for a shorter time. Oxygen ensures energy
production from adenosine triphosphate (ATP) and stimu-
lates cellular metabolism activity and angiogenesis. Moreover,
oxygen increases fibroblast proliferation, collagen synthesis,
and epithelization. In conclusion, wounds shrink in size and
wound infection is prevented.29-31 In addition to these effects,
the primary reason for the large increase in blood flow during
exercise is the decrease in oxygen in the tissues, which is one of
chemical factors found in diabetic patients. Oxygen decrease
causes dilatation because of its direct effect on muscle arte-
rioles. The muscles consume oxygen quickly during exercise,
and the amount of oxygen in tissues reduces. In the absence
of oxygen, the arteriole wall cannot continue contraction, and
oxygen deficiency leads to the release of vasodilator substances.
Therefore, it causes local arteriolar vasodilation. In conclusion,
all the capillaries open and the blood flow increases. However,
the blood flow in muscle capillaries is very low while resting.20
Because of such physiological effects of exercise, it is suggest-
ed that patients with DFU perform foot exercise for at least
8 weeks, without bearing weight on their feet.32-34 Our find-
ings support this recommendation.
Based on intensity, exercise can increase blood flow by 3 to 25
times. According to Keylock and colleagues,35 the reason why
exercise accelerates wound healing is associated with an increase
in circulation of the wound tissue, which stimulates the inflam-
matory response. Moreover, given that wound oxygenation di-
minishes and hypoxic perfusion occurs on the wound because
the blood flow decreases in diabetic patients, it is widely rec-
ognized that foot exercises are highly important for these pa-
tients.1,36 We found that, as the amount of exercise increased,
the wound area diminished. This suggests that exercise increases
blood flow and improves the flow of oxygen to the cells.
Studies examining the effect of exercise on patients with
DM not having DFU have reported that diabetic foot exercises
have positive effects on neuropathy, vasculopathy, standing
and walking characteristics, body balance, foot pressure, and
foot muscular force.16-18,21,22 Flahr7 examined the effect of exer-
cise on DFU and determined that participating patients per-
formed foot exercises at the rate of 70%. Flahr7 also reported
that 30% of the participants in both the study and control
groups made a full recovery. A study on the elderly by Emery
and colleagues37 also showed that exercises accelerate wound
healing. Our study’s findings confirm these studies and in-
dicate that regular foot exercises have positive effects on the
healing of DFU and that, as the number of daily exercises
performed without weight-bearing increases, the DFU healing
rate also increases.
Copyright © 2017 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
Eraydin and Avşar 7
Limitations
This study has several potential limitations. Some patients
were not able to fully follow the instructions. This may be
because they were elderly, forgetful, had vision problems, and
were illiterate. They often were not been able to fill out the pa-
pers for 12 weeks. In addition, this was a self-report of exercise
compliance. Participants may have overestimated or underesti-
mated their exercise activities. At times, participants expressed
they did the exercises, but forgot to fill out the paperwork.
Participants in this study were selected from 2 hospitals in the
Tokat province, which may not represent patients from other
locations, regions, or rural areas. Another limitation of this
study was the inclusion of wound debridement in standard
care. Debridement practice varied between the groups; wheth-
er this was due to the difference in ulcers between groups or
due to the benefit of exercise in the study intervention group
is unclear.
CONCLUSION
This study’s findings suggest that foot exercises influence
wound healing in the diabetic patient and should be consid-
ered as a part of the treatment plan. Diabetic foot exercises do
not require any equipment, there is no cost, and the exercises
can be performed at any time and at the convenience of the
patient. We recommended that foot exercises should take a
more prominent place in diabetic foot education and routinely
incorporated into the DFU wound treatment plan. Additional
research is needed to confirm these findings.
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