Clinical Context
Diabetic foot ulcers (DFUs) are traditionally managed with wound care, offloading, infection control, and vascular optimization. Exercise is typically not emphasized during active DFU treatment—and may even be restricted due to concerns about offloading compliance, wound trauma, and energy expenditure diversion from healing. However, this paradigm may miss opportunities: exercise improves glycemic control, enhances circulation, reduces inflammation, and promotes tissue repair—all potentially beneficial for wound healing.
The challenge is designing exercise that doesn’t compromise the healing foot. Lower limb resistance training, when appropriately structured to avoid direct pressure on the wound and maintain offloading principles, could provide metabolic and circulatory benefits without mechanical harm. Adding breathing regulation (controlled breathing techniques) may reduce sympathetic tone, improve tissue oxygenation, and promote relaxation—additional factors that could support healing.
This RCT tested a novel approach: structured lower limb resistance training combined with breathing regulation in patients with active DFUs. The outcomes included both systemic markers (glycemic control) and wound-specific outcomes (healing rates).
Study Summary (PICO Framework)
Summary:
In patients with diabetic foot ulcers, 12-week lower limb resistance training + breathing regulation significantly improved glycemic control and enhanced wound healing compared to standard care alone, with only mild fatigue as adverse effect.
| PICO | Description |
|---|---|
| Population | Patients with diabetes-related foot ulcers. |
| Intervention | 12-week lower limb resistance training + breathing regulation. |
| Comparison | Standard wound care. |
| Outcome | Improved HbA1c, enhanced wound healing, improved physical well-being. Mild fatigue in some. |
Clinical Pearls
1. Exercise during active DFU healing is feasible and potentially beneficial—if designed appropriately. This challenges the assumption that patients with active ulcers should minimize activity. Structured resistance training that avoids wound trauma can be safely incorporated and may actually accelerate healing by improving systemic metabolic health.
2. Improved glycemic control directly supports wound healing. Hyperglycemia impairs neutrophil function, reduces angiogenesis, promotes infection, and delays collagen synthesis. The finding that resistance training improved glycemic control provides a clear mechanism for enhanced wound healing—better glucose means better immune function and tissue repair.
3. Lower limb resistance training preserves muscle mass during immobilization. Patients with DFUs often experience significant deconditioning during prolonged offloading and reduced mobility. Resistance training maintains muscle mass and strength, preserving functional capacity for when healing is complete. This may reduce fall risk and subsequent injury.
4. Breathing regulation adds a mind-body component that may enhance healing. Chronic wounds are associated with stress, anxiety, and depression. Breathing regulation techniques reduce sympathetic activation, lower cortisol, improve sleep, and may enhance immune function. The combination of physical exercise and stress-reduction techniques addresses multiple healing barriers.
Practical Application
Consider structured exercise programs for patients with DFUs: Work with physical therapists familiar with diabetic foot care to design safe exercise programs. Lower limb resistance exercises can be performed without weight-bearing on the affected foot. Upper body exercises are also beneficial for overall metabolic health.
Design programs that maintain offloading: Exercise shouldn’t compromise wound care fundamentals. Non-weight-bearing exercises, seated resistance training, and pool-based exercise (if wound is appropriately protected) can provide benefits without mechanical stress on healing tissue.
Incorporate breathing regulation or relaxation techniques: Simple diaphragmatic breathing, progressive muscle relaxation, or mindfulness practices can be taught alongside physical exercise. These address the psychological burden of chronic wounds and may have direct physiological benefits for healing.
Monitor for overexertion but don’t over-restrict: Mild fatigue is expected with exercise and shouldn’t prompt abandonment of the program. However, monitor for signs of overtraining, hypoglycemia (if on insulin or sulfonylureas), or wound complications. Adjust intensity as needed.
How This Study Fits Into the Broader Evidence
Exercise for diabetes management is well-established, but exercise specifically during active wound healing is less studied. The conventional approach has been to focus on wound care and defer exercise until healing is complete. Studies like this challenge that paradigm, suggesting that appropriately designed exercise is not just safe but actively beneficial during wound healing.
Mind-body interventions for wound healing have biological plausibility: stress reduction improves immune function, and relaxation techniques improve tissue oxygenation. Studies of guided imagery, relaxation, and stress management have shown accelerated surgical wound healing in other contexts.
Comprehensive DFU care increasingly recognizes that optimal healing requires addressing systemic factors (glycemic control, nutrition, circulation) alongside local wound care. Exercise fits into this comprehensive approach by addressing multiple systemic factors simultaneously.
Limitations to Consider
The specific exercise protocol (exercises, intensity, frequency) isn’t detailed—reproducibility depends on these specifics. Sample size and DFU characteristics (Wagner grade, location, duration) affect generalizability. Whether benefits persist after the 12-week program ends is unknown. The contribution of breathing regulation versus resistance training alone can’t be separated. Cost and resource requirements for supervised exercise programs may limit implementation.
Bottom Line
A 12-week program of lower limb resistance training combined with breathing regulation improved both glycemic control and wound healing in patients with diabetic foot ulcers compared to standard care alone, with only mild fatigue as an adverse effect. This study supports incorporating structured exercise into DFU management rather than restricting activity during healing. For patients with DFUs, appropriately designed exercise programs that maintain offloading principles can accelerate healing while improving overall metabolic health. Consider referral to physical therapy for individualized exercise prescription in this population.
Source: Jia-Ling Wu, et al. “Effects of a 12-week lower limb resistance training with breathing regulation in patients with diabetes-related foot ulcers: A randomized controlled trial.” Read article here.
