Undiagnosed and Untreated Peripheral Complications of Diabetes: Findings from a Pilot Study on Diabetes-Related Foot Diseases (DFD) in Patients with Glycemic Disorders.

BACKGROUND Diabetes-related foot disease (DFD) is a serious complication of diabetes, increasing the risk of amputation. Coimplications are preventable, but most diabetics do not receive proper screening and treatment, despite indications. This study was a pilot screening of diabetes-related foot disease in a group of people with glycemic disorders. MATERIAL AND METHODS We recruited 143 volunteers over 40 years of age. In the final analysis, we included 85 people diagnosed with glycemic disorders (diabetes or prediabetes), for whom we performed a total of 170 foot measurements. We screened for peripheral artery disease using: foot pulse, ankle-brachial index (manual and automatic), toe-brachial index, and transcutaneous oxygen pressure (TcPO2). To screen for diabetic peripheral neuropathy, we used indicators of loss of protective sensation: pressure perception and temperature perception, and plantar pressure distribution. RESULTS A history of diabetes was reported by 26 (30.6%) of the subjects. Disorders of at least 1 foot occurred in 20 (66.7%) subjects with diagnosed diabetes and in 10 (17%) subjects declaring no diabetes. Higher risk and DFD category were correlated with duration of diabetes (r=0.68, p=0.007), glycemic levels (r=0.56, p=0.001), age (r=0.57, p=0.007), and the presence of other diabetes complications. The best predictor of risk in DFD was manual ABI, p=0.001; followed by automatic ABI, p=0.006. CONCLUSIONS Our results showed that peripheral complications of diabetes, such as DFD, often remain undiagnosed and untreated despite the high risk of developing ulcers. There is a need for multi-center screening studies.

Evaluation of factors affecting the healing process of venous ulcers: A 12-week longitudinal study.

The process of healing venous ulcers is complex and influenced by many factors. By identifying the risk factors that influence a slower healing process, it is possible to predict impending delays and plan an individualised care plan. We analysed our database of patients with venous ulcers and identified clinical and demographic factors that delay the healing process. The research analysed the medical records of 754 patients with VLUs at Chronic Wound Treatment Unit of the University Hospital treated between 2001 and 2019. In study, the majority (64.3%) were women, the mean age was 65.7 years. The median duration of Chronic Venous Insufficiency was 24 years, 52% patients had had the disease >20 years, and 296 (39.3%) had experienced ulceration >12 months. Most of the patients (85.8%) had comorbidities, 84% were obese. At 12-week follow-up, 432 of the 754 ulcers had healed. Identified independent predictors of slower ulcer healing rates: wound area greater than 8.25 cm2 , location of the ulceration other than the medial ankle area, underlying disease >20 years, the presence of multiple comorbidities, depth of the ulcer, the presence of an unpleasant smell and alert pathogens. The presence of redness resulted in faster healing of VLUc. Many factors influence the healing process of venous ulceration. The results of the study can help in planning patient care and implementing appropriate early strategies to promote healing.

Enhancing Functional Efficiency and Quality of Life through Revascularization Surgery in Peripheral Arterial Disease: A Comparative Analysis of Objective and Subjective Indicators.

BACKGROUND This study aimed to compare the ankle-brachial index (ABI), maximal claudication distance (MCD), pain-free walking distance (PFWD), claudication pain, and quality of life (intermittent claudication questionnaire [ICQ]) before and 3 months after revascularization surgery in 98 patients diagnosed with peripheral arterial disease (PAD) at a single center in Poland. MATERIAL AND METHODS Ninety-eight patients were examined (77% men, 23% women, 65.65±7.27 years old), diagnosed with PAD, and qualified for revascularization. The diagnosis of PAD was made on the basis of ABI ≤0.9 and medical records. The patients underwent a noninvasive examination, including measurement of ABI (by Doppler with the EZ8 probe), assessment of the quality of life by ICQ, distance of intermittent claudication on a treadmill using the Gardner-Skinner protocol (including PFWD and MCD), and pain intensity during walking (numeric rating scale [NRS11]). The assessment was carried out twice: 1 to 5 days before surgery and 3 months after surgery. RESULTS There was an increase of ABI (0.4 vs 0.62, P<0.001), PFWD (26.64 vs 80.21, P<0.001), MCD (60.08 vs 181.85, P<0.001), and ICQ (79.92 vs 60.23, P<0.001) and reduction of PFWD pain (7.26 vs 6.05, P<0.001) and MCD pain (9.24 vs 8.11, P<0.001). CONCLUSIONS Revascularization surgery improved the ABI and patients functional efficiency expressed in the improvement of subjective indicators PFWD, MCD, NRS11, and ICQ. Patients who had a longer duration of disease had worse outcomes after revascularization. More attention should be paid to increasing access to preventive examinations aimed at early detection of PAD and the possibility of implementing conservative treatment.

Fluorescence - modern method of the diagnosis of chronic wounds on the example of venous leg ulcer.

Introduction: Fluorescence imaging has become a method for bacterial visualisation in chronic wounds for the last few years. MolecuLight i:X (MolecuLight, Inc, ON, Canada) is a handheld device, which enables quick diagnostics to determine both the type and location of pathogens present in the wound and on the skin. By means of fluorescent light illumination the tissues populated by pathogenic bacteria emit red or cyan fluorescent signatures, depending on the type of the pathogen: red fluorescence signal is emitted by Staphylococcus and Escherichia coli among others, while Pseudomonas aeruginosa produce cyan fluorescence. The fluorescence image also presents the spatial pattern of bacterial load, which creates bacterial mapping of the wound and may be used by a clinician for targeted sampling or debridement, among others. Aim: This study presents the method of microbiological fluorescent imaging and two case studies of patients with venous leg ulcers. Material and methods: In both cases, the sample for microbiological testing was obtained by means of a swab stick. Results: The results obtained from fluorescent imaging showed moderate-to-heavy bacterial load, which corresponded with the results from microbiology laboratory. Thanks to quick diagnostics with the use of MolecuLight i:X device, instant implementation of targeted topical actions such as wound hygiene, skin disinfection, appropriate dressing choice and curative treatment among others was possible. Conclusions: Our observations are consistent with the reports from other facilities.

Venous leg ulcers treated with fish collagen gel in a 12-week randomized single-centre study.

Introduction: Venous ulcers are difficult to heal chronic wounds. Most challenging are the non-healing and recurrent ulcers, because of which we are seeking for therapies that stimulate and support their healing. Aim: To assess the efficacy of fish collagen and its impact on the process of healing of venous leg ulcers. Material and methods: This 12-week randomized single-centre study included a total of 97 adults with venous leg ulcer, randomized into two groups: the study group (n = 48) and the control group (n = 49). All patients received specialist medical care including skin and limb care, wound development according to the TIME scheme (tissue debridement, infection and inflammation control, moisture balance, edge) and short-stretch bandage compression (compression class II). In addition, the study group received tropocollagen gel applied to the skin around the wound. Every 2 weeks we evaluated the wound surface and temperature distribution on the shin (average temperature, median, minimum and maximum) - symmetrically on the sick and healthy limb. Results: We observed a greater number of complete ulcer healing in the study group (week 12: 29.2% vs. 22.4%; week 24: 52.1% vs. 36.7%). Faster healing time in the study group was observed in both big and small ulcers. The thermographic analysis showed statistically significant reduction in periwound inflammation among patients from the study group (p < 0.05). Statistically significant reduction in mean as well as maximum values of limb temperature occurred only in the study group (Tx: R = 0.37, p < 0.001; Tmax: R = 0.40, p < 0.001). Conclusions: Thermographic analysis showed better wound healing effects in the group using tropocollagen. Significant impact of collagen on the healing process was observed only after 8 weeks of application.

Complex treatment of venous leg ulcers including the use of oral nutritional supplementation: results of 12-week prospective study.

Introduction: Malnutrition is known to impair the wound healing process, contributing to wound chronicity. Venous leg ulcers (VLU) represent the most common chronic leg wounds and become epidemiologically relevant in an ageing society. Aim: This study investigated the effects of a complex treatment, including a specialized oral nutritional supplementation, on the dynamics of the VLU healing. Material and methods: This 12-week prospective study included 35 individuals with VLU. The patients received professional wound care including specialized dressings. To ensure an optimal nutritional status for wound healing, the patients were asked to drink three times per day 200 ml of an energy-dense protein-rich formula containing arginine, zinc, and vitamins. The healing dynamics were assessed by planimetry. Results: Complete wound healing was achieved in 6 patients, and the median ulcer area decreased from 26.5 cm2 to 14.8 cm2 (p = 0.0001). Both the highest healing rates and most marked increase in prealbumin levels were observed in the first 6-8 weeks. The progress in wound healing was associated with a decreased pain intensity and an improved quality of life. Supplementation was well accepted by the patients. Conclusions: This study shows that a complex intervention involving nutritional support contributes to a significant progress in VLU healing and promotes the well-being of affected individuals.

Healing Process, Pain, and Health-Related Quality of Life in Patients with Venous Leg Ulcers Treated with Fish Collagen Gel: A 12-Week Randomized Single-Center Study.

The aim of the study was to assess the effectiveness of fish skin collagen and its impact on healing, pain intensity, and quality of life in patients with venous leg ulcers (VLUs). This study included 100 adults with VLUs. Eligible patients were randomized to either tropocollagen gel treatment (group A, n = 47) or placebo alone (group B, n = 45). We applied the gel to the periwound skin for 12 weeks. All groups received standard wound care, including class 2 compression therapy and wound hygiene procedures. We assessed the healing rate (cm2/week) and quality of life (QoL) using the Skindex-29 and CIVIQ scales. In group A, more ulcers healed, and the healing rate was faster. In both study groups, patients showed a significant improvement in quality of life after the intervention, but there was a greater improvement in the tropocollagen group. In group A, the greatest improvement was related to physical symptoms and the pain dimension. This study showed that the application of fish collagen gel to the periwound skin improves the healing process and QoL in patients with VLUs. The 12-week treatment with collagen reduced the severity of physical complaints, pain, and local skin symptoms, which determined the quality of life in patients with VLUs to the greatest extent.

Antiseptics and antimicrobials for the treatment and management of chronic wounds: a systematic review of clinical trials.

Introduction: The development of the field related to the treatment of wounds has resulted in the appearance of new antimicrobial active ingredients. Aim: To analyse, evaluate and systematize the available scientific evidence of the effectiveness and safety of antiseptic preparations intended for the treatment of chronic wounds. Material and methods: We conducted a literature review using the advanced search engine in the PubMed database. We used a combination of two English keywords, i.e.: "antiseptic" and "chronic wound". We have selected only clinical, randomized controlled trials. Results: We obtained a total of 825 items (674 full-text works). We included 29 studies in the review. The most frequently evaluated preparation was octenidine dihydrochloride and povidone iodine (pharmacological drugs). Preparations containing polyhexanide, products based on hypochlorite, reactive oxygen species, 1% acetic acid, and specialized antibacterial dressings were also assessed. The new generation of antimicrobial preparations were highly effective, both in the prevention and treatment of infections, and were well tolerated by the tissues and do not interfere with the healing process. The best tolerated and most effective antiseptic was OCT/PE. For cleaning, we recommend OCT-based irrigation fluids, PHMB, or hypochlorite. The maintenance of the antimicrobial effect during the therapy was ensured by a compatible dressing. Conclusions: An antiseptic alone is not effective enough and the therapeutic effect depends to the greatest extent on properly selected causal therapy, preceded by thorough diagnostics.

Microbiological Status of Venous Leg Ulcers and Its Predictors: A Single-Center Cross-Sectional Study.

Venous leg ulcers are frequently colonized by microbes. This can be particularly devastating if the ulcer is infected with alert pathogens, i.e., highly virulent microorganisms with well-developed mechanisms of antibiotic resistance. We analyzed the microbiological status of venous leg ulcers and identified the clinicodemographic predictors of culture-positive ulcers, especially in ulcers with colonization by alert pathogens. METHODS: This study included 754 patients with chronic venous leg ulcers. Material for microbiological analysis was collected by swabbing only from patients who did not receive any antibiotic treatment. RESULTS: A total of 636 (84.3%) patients presented with culture-positive ulcers. Alert pathogens, primarily Pseudomonas aeruginosa, were detected in 28.6% of the positive cultures. In a logistic regression model, culture-positive ulcers were predicted independently by age > 65 years, current ulcer duration > 12 months, and ulceration area greater than 8.25 cm2. Two of these factors, duration of current ulcer > 12 months and ulceration area > 8.25 cm2, were also identified as the independent predictors of colonization by alert pathogens. CONCLUSIONS: Colonization/infection is particularly likely in older persons with chronic and/or large ulcers. Concomitant atherosclerosis was an independent predictor of culture-negative ulcers.

Occurrence and Severity of Pain in Patients with Venous Leg Ulcers: A 12-Week Longitudinal Study.

BACKGROUND: The aim of the study was to analyze the dynamics of pain severity and its predictors in a group of patients with chronic venous leg ulcers. METHODS: A 12-week longitudinal study included 754 patients with chronic venous leg ulcers. Subjective severity of pain was measured at weekly intervals with an 11-point visual analogue scale (VAS). RESULTS: A significant decrease in VAS scores has been observed throughout the entire analyzed period. Higher severity of pain during follow-up was independently predicted by the presence of pus and/or unpleasant smell from the ulceration during the first visit, as well as by the occurrence of posterior and/or circumferential ulcers. The presence of ulcer redness during the first visit was associated with lesser pain severity; also, a significant interaction effect between the ulceration redness and warmth was observed. CONCLUSIONS: Implementation of complex holistic care may contribute to a substantial decrease in the occurrence and severity of pain in a patient with venous leg ulcers. Pain control seems to depend primarily on clinical parameters and topography of venous ulcers. The predictors of pain severity identified in this study might be considered during the planning of tailored care for patients with venous leg ulcers.

Infrared thermography to prognose the venous leg ulcer healing process-preliminary results of a 12-week, prospective observational study.

Venous leg ulcers are complex, and their multifactorial etiology make successful treatment a difficult and long process. Nonhealing ulcers are the greatest challenge because they are resistant to standard therapies. In this study, we analyzed whether monitoring the temperature of the ulcered limb wound area could benefit the diagnosis of the wound's tendency to heal (estimating the presence of a healing or nonhealing wound) in patients with two-sided venous leg ulcers. This prospective, 12-week observational study included 57 adult individuals with chronic venous leg ulcers. The dynamics of wound healing was assessed by planimetry and infrared thermography every two weeks. We analyzed temperatures measured at three marked areas-the wound, the periwound skin, and the reference area. An initial wound area larger than 1 cm2 was associated with a temperature increase of 0.027 °C in the periwound skin. A 1-cm2 decrease in the wound area was associated with a 0.04 °C decrease in the temperature difference between the periwound skin and wound. A strong positive relationship was identified for both the bacteriology variables (the presence of bacteria: temperature increase in the periwound skin of 0.4 °C, p < 0.001; the number of bacterial species in a wound, temperature increase of 0.95 °C, p < 0.001). The temperature in the reference area was significantly correlated with the failure of the superficial and perforating veins (temperature increase of 0.69 °C, p = 0.04). This study reports that the assessment of the temperature a limb may be beneficial in predicting whether an ulcer is a healing or a nonhealing ulcer. The decrease in the temperature differences between the areas referred to as healing wounds was the only beneficial prognostic marker. Other temperature differences in the periwound skin were caused by disorders, such as multibacterial wound infections and superficial venous inflammation.

The role of compression therapy in the treatment of venous leg ulcers.

Epidemiological data regarding venous leg ulcers, specifically low healing rates and frequent recurrences (occurring in 20-70% of the cases), seems surprising regarding recent progress in the management of this complication. The aim of this review is to present the current state of knowledge on venous leg ulcer management, especially compression therapy. Treatment of venous ulcers should be comprehensive and wellorganized, based on modern standards and up-to-date, and should involve elaborated treatment strategies. A thorough diagnostic process followed by adequate treatment may result in marked improvement of the outcomes, with up to 67% healing rate at 12 weeks and up to 81% within 24 weeks. Continuation of therapeutic activities after the ulceration has been healed is reflected by a marked decrease in the recurrence rates, down to 16% whenever the patient is actively involved in the therapeutic process. Furthermore, early diagnosis and appropriate causal treatment may prevent progression of the illness.

Influence of ulceration etiology on the global quality of life and its specific dimensions, including the control of pain, in patients with lower limb vascular insufficiency.

INTRODUCTION: The results of previous studies suggest that the quality of life in patients with lower limb ulcerations is markedly poorer than in the general population - with regard to physical, mental and social spheres. This complex character of that parameter necessitates comprehensive analyses of its specific aspects, including the level of the acceptance of illness and associated pain symptoms. AIM: To compare the quality of life and its specific dimensions in patients with lower limb ulcerations of various etiology. MATERIAL AND METHODS: Patients with the ulcerations resulting from venous (n = 101) or arterial pathologies (n = 98), or having mixed etiology (n = 99) were examined with the: 1) Skindex-29 instrument, 2) Acceptance of Illness Scale, 3) Beliefs about Pain Control Questionnaire, and 4) Coping Strategy Questionnaire. RESULTS: The average quality of life related to physical symptoms was significantly higher in patients with venous ulcerations. Patients with ulcerations of arterial etiology more frequently used catastrophizing, and less often ignored pain sensations, used coping self-statements, and increased their activity levels; they were characterized by lower levels of control and poorer ability to decrease the pain. The internal locus of pain control increased proportionally to the global quality of life scores and levels of illness acceptance. Control over pain and ability to decrease the pain were more effective in individuals who used ignoring pain sensations, increasing the activity level, coping self-statements, and reinterpreting pain than in those using catastrophizing or praying and hoping strategies. CONCLUSIONS: Physical complaints seem to be the basic determinant of the quality of life in patients with the lower limb ulceration, irrespective of its etiology.

Subjective and objective assessment of patients' compression therapy skills as a predicator of ulcer recurrence.

AIMS AND OBJECTIVES: To verify whether the subjectively and objectively assessed patient's skills in applying compression therapy constitute a predicting factor of venous ulcer recurrence. BACKGROUND: Systematic implementation of compression therapy by the patient is a core of prophylaxis for recurrent ulcers. Therefore, patient education constitutes a significant element of care. However, controversies remain if all individuals benefit equally from education. DESIGN: A retrospective analysis. METHODS: The study included medical records of patients with venous ulcers (n = 351) treated between 2001 and 2011 at the Clinic for Chronic Wounds at Bydgoszcz Clinical Hospital. We compared two groups of patients, (1) with at least one episode of recurrent ulcer during the five-year observation period, and (2) without recurrences throughout the analysed period in terms of their theoretical skills and knowledge on compression therapy recorded at baseline and after one month. RESULTS: Very good self-assessment of a patient's compression therapy skills and weak assessment of these skills by a nurse proved significant risk factors for recurrence of the ulcers on univariate analysis. The significance of these variables as independent risk factors for recurrent ulcers has been also confirmed on multivariate analysis, which also took into account other clinical parameters. CONCLUSIONS: Building up proper compression therapy skills among the patients should be the key element of a properly construed nurse-based prophylactic program, as it is the most significant modifiable risk factor for recurrent ulcers. Although the development of compression skills is undeniably important, also other factors should be considered, e.g. surgical correction of superficial reflux. RELEVANCE TO CLINICAL PRACTICE: Instruction on compression therapy should be conducted by properly trained nursing personnel - the nurses should have received both content and psychological training. The compression therapy training should contain practical instruction with guided exercises and in-depth objective assessment of the effects of the training.

Quality of life in patients with leg ulcers or skin lesions - a pilot study.

INTRODUCTION: Attempts to determine the quality of life are advisable in patients with ulcers as the group affected with this problem is relatively large. According to one Polish randomized trial, approximately 0.3-2% of the adult population suffers from active or healed venous ulcers. AIM: To compare the quality of life of patients with leg ulcers of venous and arterial etiology and those with lower limb skin lesions due to chronic venous insufficiency. MATERIAL AND METHODS: This study included 90 consecutive patients with ulcers of venous (n = 30) or arterial etiology (n = 30), or patients with trophic disorders of the skin associated with chronic venous insufficiency (n = 30) treated at the Venous Ulceration Outpatient Clinic and at the Department and Clinic of General Surgery, Dr. J. Biziel Memorial University Hospital No. 2, in Bydgoszcz. This study was designed as a questionnaire survey and included the Skindex-29 instrument for the assessment of quality of life in patients with dermatological conditions. RESULTS: Overall, the global Skinndex-29 scores of all studied participants ranged between 37 and 136 points, 23.93 points on average. The analyzed groups of patients differed significantly with respect to the average level of the global quality of life determined using the Skindex-29 questionnaire. CONCLUSIONS: Significant differences were observed in the global quality of life of patients who suffered from venous or arterial leg ulcers or skin lesions resulting from chronic venous insufficiency.

The locus of pain control in patients with lower limb ulcerations.

AIMS AND OBJECTIVES: (1) To analyse the distribution of pain control profiles of individuals suffering from the lower limb ulcerations. (2) To identify sociodemographic and clinical factors determine the locus of pain control in this group of patients. BACKGROUND: The locus of pain control can play a critical role in determining the quality of life in patients with lower limb ulcerations, and identification of individuals with an unfavourable pain control profile would enable the opportunity of offering them dedicated psychological counselling. DESIGN: Quantitative survey. METHODS: This study included 298 patients with lower limb ulcerations resulting from chronic venous insufficiency (n = 101), lower limb atherosclerosis (n = 98), or having mixed arteriovenous aetiology (n = 99). The study included the completion of the Polish version of the Beliefs about Pain Control Questionnaire. RESULTS: The most important role in the control of pain was assigned to the powerful others locus. This locus correlated directly with poorer educational level and higher professional activity. Additionally, the intensity of usual pain correlated inversely with the powerful others locus. Respondents' age was the only sociodemographic variable decreasing the level of the internal locus. Moreover, the severity of usual and maximal pain and the area of ulceration correlated inversely with the internal locus of pain control. In contrast, the aetiology of lower limb ulceration did not affect significantly any of the dimensions of pain control. CONCLUSION: The control of pain in ulceration patients is mostly determined by the support of medical personnel, which generally should be considered a negative finding. Relevance to clinical practice. Determination of the locus of pain control should be included in the complex medical evaluation of individuals suffering from ulcerations.

Comparison of the effectiveness of compression stockings and layer compression systems in venous ulceration treatment.

INTRODUCTION: The aim of the research was to compare the dynamics of venous ulcer healing when treated with the use of compression stockings as well as original two- and four-layer bandage systems. MATERIAL AND METHODS: A group of 46 patients suffering from venous ulcers was studied. This group consisted of 36 (78.3%) women and 10 (21.70%) men aged between 41 and 88 years (the average age was 66.6 years and the median was 67). Patients were randomized into three groups, for treatment with the ProGuide two-layer system, Profore four-layer compression, and with the use of compression stockings class II. In the case of multi-layer compression, compression ensuring 40 mmHg blood pressure at ankle level was used. RESULTS: In all patients, independently of the type of compression therapy, a few significant statistical changes of ulceration area in time were observed (Student's t test for matched pairs, p < 0.05). The largest loss of ulceration area in each of the successive measurements was observed in patients treated with the four-layer system - on average 0.63 cm2/per week. The smallest loss of ulceration area was observed in patients using compression stockings - on average 0.44 cm(2)/per week. However, the observed differences were not statistically significant (Kruskal-Wallis test H = 4.45, p > 0.05). CONCLUSIONS: A systematic compression therapy, applied with preliminary blood pressure of 40 mmHg, is an effective method of conservative treatment of venous ulcers. Compression stockings and prepared systems of multi-layer compression were characterized by similar clinical effectiveness.

Randomized study assessing the influence of supervised exercises on ankle joint mobility in patients with venous leg ulcerations.

INTRODUCTION: The aim of the study was to assess the influence of a supervised programme of exercises on ankle joint mobility in patients with venous leg ulcerations. MATERIAL AND METHODS: The study was carried out between 2008 and 2009 at the Venous Ulcer Treatment Outpatient Clinic and Clinic of General and Vascular Surgery of the Dr Jan Biziel University Hospital no. 2 in Bydgoszcz. It was a randomized control study in which 32 patients with venous leg ulcerations were qualified. Patients with ulcerations were randomized to 2 groups - 16 patients were included in the group with a supervised programme of exercises and the other 16 patients were included in the control group performing physical exercises by themselves, without supervision. The ranges of ankle joint mobility were assessed before, during and after the end of the 9-week exercise programme. A 32 cm goniometer with a scale from 0° to 180° with accuracy to 1° was used for measurements. RESULTS: In both groups a substantial increase of ankle joint mobility (p < 0.05) was observed. The total ankle joint mobility after completion of the exercises was significantly higher in the group performing exercises under the supervision of a nurse. Having a significant effect on the mobility of the ankle were the ulceration area, the extent of lipodermatosclerosis, and the intensity of symptoms and signs of CVI (p < 0.05). CONCLUSIONS: Supervised physical exercises broaden the range of ankle joint mobility. They should constitute an integral part of a holistic model of care for patients with venous leg ulcerations.