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Screening for Cardiovascular Disease Risk Factors in a Physical Therapist Wound Care Practice: A Retrospective, Observational Study

Empirical Studies

Screening for Cardiovascular Disease Risk Factors in a Physical Therapist Wound Care Practice: A Retrospective, Observational Study

Index: Wound Management & Prevention 2019;65(8):20–28 doi: 10.25270/wmp.2019.8.2028

Abstract

Understanding the prevalence of cardiovascular risk factors among individuals seeking physical therapist services in a wound care center is important, especially if aerobic exercise or other physical activity is recommended. PURPOSE: This study assessed the prevalence of cardiovascular risk factors in individuals seeking physical therapist services for an integumentary disorder in an outpatient wound care center. METHODS: Using a retrospective, observational study design, records from patients who were screened upon initial evaluation by a physical therapist for cardiovascular risk according to the American College of Sports Medicine (ACSM) guidelines were abstracted. The screening process entailed assessment of current signs and symptoms of cardiovascular, pulmonary, or metabolic disease; an individual or family history of cardiovascular disease; whether the patient was considered obese; and whether the patient was a current smoker, had a sedentary lifestyle, dyslipidemia, elevated glucose, or blood pressure >140/90 mm Hg. Patient demographics and wound history also were summarized and described, including wound type and duration and pain associated with the wound. Wounds then were classified by the physical therapist as either venous leg ulcers or nonvenous leg ulcers based upon the referring physician’s diagnosis. Descriptive statistics and frequency distributions were calculated to assess the prevalence of individual cardiovascular risk factors, total number of cardiovascular risk factors, cardiovascular risk stratification, and patient disposition. Frequencies of individual cardiovascular risk factors, total number of cardiovascular risk factors, and cardiovascular risk stratification also were assessed between patients with venous leg ulcers and nonvenous leg ulcers using chi-square tests for categorical data and t tests for continuous data. The alpha level was set at P <.05. RESULTS: Among the 70 study participants (41 male, 29 female; mean age 63.5 ± 15.1 years), 38 were treated for venous leg ulcers and 32 were treated for nonvenous leg ulcers. Overall, 38 patients (54%) had a history of cardiovascular disease and 29 (41%) had current signs and symptoms of cardiovascular disease. Patients with nonvenous leg ulcers had a significantly higher frequency of having a family history of cardiovascular disease than patients with venous leg ulcers (28% vs. 8%; P = .03).  According to the ACSM guidelines, 5 patients (7%) were considered low risk, 22 (31%) were moderate risk, and 43 (62%) were at high risk for experiencing a future cardiovascular event. Cardiovascular risk did not vary significantly according to wound type. CONCLUSION: The patient risk-stratification profile in this study strongly suggested physical therapists should screen for cardiovascular risk factors before prescribing aerobic exercise or other physical activity for all patients being seen for an integumentary disorder in an outpatient wound care practice. 

Introduction

Patients often seek medical management for wounds. In older individuals, especially persons with medical comorbidities, wound healing may be delayed, increasing the potential risk for infection.1 Exercise is one of many interventions that may be used for wound healing and may be associated with enhanced rates of wound healing.1-3 In a randomized controlled trial, Emery et al1 described high-intensity exercise in relation to wound healing among 28 older, healthy, sedentary adults (mean age 61.0 ± 5.5 [range 55–77] years; 68% women) who underwent an experimental wound procedure to their nondominant arm. To be deemed healthy, participants could not have any signs or symptoms of cardiovascular disease, hypertension, or abnormal findings on electrocardiograms. To be considered sedentary, participants could not have participated in regular exercise within the past 6 months. Patients were asked to exercise 3 times per week for 1 hour, maintaining 70% of their maximum heart rate. During each treatment session, the exercise activity (study) group (n = 13) completed 10 minutes of warm up, 30 minutes of continuous lower extremity ergometry, 15 minutes of brisk walking or jogging, 15 minutes of upper extremity ergometry, and 5 minutes of cool down. Participants in the nonexercise (control) group (n = 15) were asked not to change their lifestyle in any way. Wounds in the treatment group healed after an average of 29.2 days, compared with control group wounds that healed after an average of 38.9 days.1  

In a randomized controlled trial, Meagher et al2 investigated the effect of low-intensity exercise on wound healing among 35 persons with venous leg ulcers. Participants were divided into a walking group (n = 18) and a control group (n = 17). Patients with diabetes were excluded due to the association between diabetes and slower healing, as were pregnant women. Although risk factors for venous leg ulcers were assessed, cardiovascular risk factors were not formally evaluated. Daily stepping rate was recorded at initial assessment and after 4 weeks of treatment. Participants in the exercise group (mean age 66 [range 32–84] years; 67% women; 78% with a body mass index [BMI] >25 kg/m2) were encouraged to increase their daily steps with a target of 10 000 steps per day; patients in the control group (mean age 78 [range 55–91] years; 76% women; 59% with a BMI >25 kg/m2) were not asked to change their daily steps. Positive risk factors for venous leg ulcers were found in 78% and 71% of individuals in the exercise and control groups, respectively; 33% of exercise group participants achieved an average of 10 000 steps per day. Persons who took more steps at both the baseline and 4-week assessment healed more quickly than those who took fewer steps. More specifically, 67% of the participants who increased their daily steps achieved venous ulcer healing by 8 weeks, compared with 35% of persons who did not increase their step count. The researchers2 concluded that people who walked more steps showed faster venous ulcer healing when compared with those who took fewer steps, demonstrating the benefit of walking in this patient group. 

In a randomized controlled trial, O’Brien et al4 assessed the impact of a home-based progressive resistance exercise program for calf musculature in addition to routine evidence-based care on the healing rates of adults with venous leg ulcers. This study included 62 patients with venous leg ulcers (32 men, 30 women; mean age 71.5 ± 14.6 years; mean ulcer duration 16 [range 2–416] weeks). Medical comorbidities and cardiovascular risk factors were not formally evaluated in this study. Patients were randomized to receive either a 12-week progressive resistance exercise program for calf musculature with a telephone coaching component or usual care plus telephone calls. The primary outcome evaluated the effectiveness of the intervention in relation to wound healing. Intention-to-treat analyses for the primary outcome showed 77% of persons in the intervention group healed by 12 weeks compared with 53% of person receiving usual care. The authors concluded people who adhered to the exercise program as an adjunctive treatment to routine, evidence-based care were more likely to heal and have better functional outcomes than persons who did not adhere to the exercises in conjunction with usual care.

Exercise is a relatively low-cost intervention strategy that may be used clinically to treat relevant impairments in the wound healing process and facilitate healing. Unfortunately, although moderate- to high-intensity exercise may be beneficial for individuals receiving wound care,1-4 it is not clear how commonly exercise is prescribed in routine clinical practice for patients receiving treatment for wounds. Additionally, some patients receiving wound care have medical comorbidities, such as cardiovascular disease, diabetes, or obesity, that may influence safe exercise prescription. Fife et al5 retrospectively evaluated electronic health records for the medical comorbidities of 5240 patients (mean age 61.7 years; 52% male) originating from 1 of 59 hospital-based outpatient wound centers in 18 states. The most common comorbid conditions were diabetes (47%), being obese or overweight (71%), and cardiovascular disease (51%). Of note, 2% of patients died during their episode of care or within 4 weeks of their last clinic visit; however, causes of death were not provided. Considering these findings, exercising at the aforementioned intensities described by Emery et al,1 Meagher et al,2 or O’Brien et al4 or even performing physical activity associated with work or other activities of daily living might raise safety concerns and be contraindicated until patients are medically cleared. Therefore, it is recommended that clinicians thoroughly screen for cardiovascular risk factors before prescribing aerobic exercise or other physical activity.6,7 By identifying the level of cardiovascular risk for each patient, the clinician can determine whether medical clearance or additional consultation is necessary. 

Physical therapy practitioners have been involved in wound management almost since the field’s inception.8 Although physical therapists are less likely to be directly involved in wound care than in other specialties that require patient rehabilitation (eg, orthopedics, neurology, pediatrics), and this involvement may be influenced regionally, the American Physical Therapy Association’s Academy of Clinical Electrophysiology and Wound Management (ACEWM) Special Interest Group’s vision for the future is that physical therapists will continue to be recognized as vital members of the multidisciplinary wound management team.9 Although physical therapists can provide a wide variety of interventions for patients with wounds, it has been recommended by the ACEWM’s Wound Management Special Interest Group that physical therapists evaluate all patients for an individualized, progressive, monitored exercise program.9 Thus, cardiovascular risk assessment before prescribing aerobic exercise or other physical activity would be indicated.6,7 However, literature describing the prevalence of cardiovascular risk assessment performed by physical therapists generally is lacking. Frese et al10 surveyed physical therapy clinical instructors about measuring heart rate and blood pressure, which is one component of screening for cardiovascular disease. Only 45% of clinical instructors agreed that measuring heart rate and blood pressure is essential; 38% and 43% of the respondents reported never measuring heart rate or blood pressure, respectively, in the week before the survey as part of their examination of new patients; and only 4% of respondents reported they always measure the blood pressure of a new client. When given a list of reasons why heart rate and blood pressure were not routinely measured, the most frequently chosen answer was ‘‘not important for my patient population.’’ 

More recently, Arena et al11 described the practice patterns of physical therapists in outpatient settings with regard to blood pressure assessment. The authors determined that 51.8% of respondents did not believe measuring blood pressure during initial patient evaluation was important. Furthermore, 85% of respondents did not routinely measure blood pressure during initial patient evaluations. Although Frese et al10 and Arena et al11 addressed only one aspect of cardiovascular risk factor screening, their results suggest physical therapists infrequently assess baseline cardiovascular status as part of a plan of care. These findings are extremely concerning, especially if the patient is performing aerobic exercise or other physical activity as part of their treatment plan.12

Scant evidence is available that describes the prevalence of cardiovascular risk factors among individuals seeking physical therapist services in a wound care center. Therefore, the primary purpose of this study was to assess the prevalence of cardiovascular risk factors in individuals seeking physical therapist services for the treatment of an integumentary disorder in an outpatient wound care center. A secondary purpose was to determine if the prevalence of cardiovascular risk factors varied according to type of wound.

Materials and Methods

Clinical setting. This retrospective, observational study was performed at the Daemen College Physical Therapy Wound Care Clinic (Cheektowaga, NY). The study protocol was approved with an exemption by the Daemen College Institutional Review Board. Established in 2012 as a result of grants from private philanthropic organizations, this clinic has been operating as an outpatient physical therapy clinic specializing in wound care and serving the western New York community. The clinic is located with a physician’s office (operating as separate entities), and physical therapists consult with the physician when needed during wound care. All patients with a few exceptions are referred from and follow up with this physician who is an infectious disease expert. In addition to routine physical therapy wound care (ie, wound debridement, infection control, dressing application, electric stimulation, ultrasound, ultraviolet therapy), various forms of exercise are routinely prescribed for all patients, including range of motion, strengthening exercises, and endurance activities (eg, walking, stationary cycling, upper body ergometry). Physical therapists and researchers at the clinic have been tracking patient demographics and wound-related history using a deidentified electronic medical database since the opening of the clinic. Starting in August 2016, in addition to routine evaluation measures, each patient was screened upon initial evaluation by a physical therapist for cardiovascular risk according to the American College of Sports Medicine (ACSM) guidelines.12 

Screening procedure. At the time of initial physical therapy evaluation, patient demographics and wound history were summarized and described, including the type of wound, duration of the wound, and whether pain was associated with the wound. Pain was assessed on an 11-point numeric pain rating scale, where 0 = no pain and 10 = worst possible pain. Patients reporting 0 were deemed to have no pain associated with the wound; patients reporting between 1 and 10 were deemed to have pain associated with the wound. Pain scores were not tracked; they were used only to determine if the patient had pain associated with the wound. As such, pain severity results were not reported. 

Wounds then were classified by the physical therapist as either venous leg ulcers or nonvenous leg ulcers, based upon the referring physician’s diagnosis.13,14 After the physical therapist was trained and appropriately familiarized with the protocol, each patient was screened upon initial evaluation by a single physical therapist for cardiovascular risk according to the ACSM guidelines.12 The screening process entails assessment of current signs and symptoms of cardiovascular, pulmonary, or metabolic disease; an individual or family history of cardiovascular disease; whether the patient is considered obese; and whether the patient is a current smoker or has a sedentary lifestyle, dyslipidemia, elevated glucose, or blood pressure >140/90 mm Hg. Operational definitions for each of the risk factors are presented in Table 1.6,7,12

Methods. Study participants had been referred to a physical therapist at the Daemen College Physical Therapy Wound Care Clinic for the treatment of an integumentary disorder over a 9-month period (August 1, 2016, to May 1, 2017). In this study, all patients at least 21 years of age with wounds who had patient demographic, wound history, and ACSM variables appropriately recorded in the electronic medical database were eligible for study inclusion. Exclusion criteria included patients <21 years of age and a sufficient lack of variables recorded in the electronic medical database. 

Data collection. Data were anonymously entered on a standardized         paper-and-pencil data collection sheet from the deidentified patient electronic medical database and subsequently entered into a password-protected electronic spreadsheet. Patients then were stratified as being at low risk, moderate risk, or high risk for experiencing a future cardiovascular event according to the ACSM guidelines.12 More specifically, low risk is described as men <45 years old, women <55 years old, and only 1 risk factor and no symptoms; moderate risk is described as men >45 years old, women >55 years old, or 2 or more risk factors; and high risk is described as known cardiovascular, pulmonary, or metabolic disease or signs and symptoms of cardiovascular disease, including chest pain, shortness of breath at rest or mild exertion, syncope, ankle edema, and palpitations. Medical clearance is recommended for individuals who will be performing exercise if they are stratified as moderate or high risk of experiencing a future cardiovascular event. 

The ACSM guidelines12 for establishing cardiovascular risk have previously been recommended and utilized as a pragmatic method for exercise decision making and medical clearance in outpatient or community-based physical therapy settings6,7; these guidelines12 have been reported on extensively in various populations and appear generally to have face validity.15-18 Additionally, although the components that are evaluated in the ACSM guidelines are generally consistent with other cardiovascular risk guidelines and calculators and a part of sound, routine history and physical examination procedures (eg, evaluating smoking status, diabetic status, exercise habits, blood pressure measures, lipid profile, and BMI), the authors were unable to find research that has formally studied the reliability and validity of the guidelines. However, several studies that have evaluated other similar cardiovascular risk guidelines and calculators (eg, Framingham Risk Score,19-22 American College of Cardiology/American Heart Association Guidelines,23 algorithm for calculating cardiovascular disease risk [QRISK],24 and Reynolds Risk Score25) have demonstrated good construct validity and internal consistency, as well as high levels of reliability and responsiveness. Thus, in accordance with other authors, the current authors concluded ACSM guidelines for establishing cardiovascular risk are appropriate for clinical and research purposes.6,7,15-18

Data analysis. Statistical analyses were performed using SPSS, version 23.0 (IBM Corporation, Armonk, NY), including calculation of descriptive statistics (ie, means, standard deviations, ranges) and frequency distributions to assess the prevalence of individual cardiovascular risk factors, total number of cardiovascular risk factors, cardiovascular risk stratification, and patient disposition. Frequencies of individual cardiovascular risk factors, total number of cardiovascular risk factors, and cardiovascular risk stratification also were assessed between patients with venous leg ulcers and nonvenous leg ulcers using chi-square tests for categorical data and t tests for continuous data. The alpha level was set at P <.05.

Results

Seventy-five (75) consecutive patients initially were evaluated between August 1, 2016, and May 1, 2017; 5 did not meet the inclusion criteria (ie, 1 was <21 years of age and 4 had a sufficient lack of variables recorded in the electronic medical database). Thus, this retrospective observational study included 70 patients (41 male, 29 female; mean age 63.5 ± 15.1 years; BMI 33.6 ± 10.3 kg/m2).  

Types of wounds. Thirty-eight (38) patients (25 men, 13 women; mean age 64.8 ± 15.2 years; BMI 36.2 ± 11.3 kg/m2) were treated for venous leg ulcers, and 32 (16 men, 16 women; mean age 62.0 ± 15.1 years; BMI 30.4 ± 8.0 kg/m2) were treated for nonvenous leg ulcers (19 surgical/traumatic wounds, 5 pressure ulcers, 4 diabetic ulcers, 2 peripheral arterial disease wounds, and 2 pilonidal cysts). Patients with venous leg ulcers had a mean wound duration of 105.1 ± 122.7 days, and 20 patients (53%) had pain associated with their wound. Patients with nonvenous leg ulcers had a mean wound duration of 157.5 ± 186.5 days, and 15 (47%) had pain associated with their wound.

Prevalence of cardiovascular risk factors. The prevalence of cardiovascular risk factors for the entire sample is presented in Table 2. A history of cardiovascular disease was reported in 38 patients (54%); 29 (41%) had current signs and symptoms of cardiovascular disease. Additionally, 12 patients (17%) had a family history of cardiovascular disease, 35 (50%) were obese, 8 (11%) were current smokers, and 44 (63%) had a sedentary lifestyle. Dyslipidemia and elevated glucose were previously diagnosed in 30 (43%) and 23 patients  (33%), respectively; 42 (60%) were taking antihypertensive medications or had blood pressure measures >140/90 mm Hg. When totaled, participants had 4.6 ± 2.3 (range 0–9) cardiovascular risk factors. According to the ACSM guidelines,12 5 patients (7%) were considered low risk, 22 (31%) were moderate risk, and 43 (62%) were high risk for experiencing a future cardiovascular event (see Table 3). Eight (8) patients (11%) were referred to their physician after cardiovascular risk factors were assessed; 62 (89%) did not require a physician referral (5 [7%] were considered low risk and 57 [82%], despite being stratified as either moderate or high risk for experiencing a future cardiovascular event, were already being adequately managed by their physician). 

The prevalence of cardiovascular risk factors stratified by different wound types (venous leg ulcers versus nonvenous leg ulcers) is presented in Table 2. For individuals with venous leg ulcers, a history of cardiovascular disease was reported in 20 patients (53%); 18 (47%) had current signs and symptoms of cardiovascular disease. Additionally, 3 (8%) had a family history of cardiovascular disease, 22 (58%) were considered obese, 4 (11%) were current smokers, and 24 (63%) had a sedentary lifestyle. Dyslipidemia and elevated glucose were previously diagnosed in 14 (37%) and 11 (29%), respectively; and 20 (53%) were taking antihypertensive medications or had blood pressure >140/90 mm Hg. Participants with venous leg ulcers had a total of 4.4 ± 2.5 (range 0–8) cardiovascular risk factors. According to the ACSM guidelines, 3 patients (8%) were considered low risk, 11 (29%) were moderate risk, and 24 (63%) were high risk for experiencing a future cardiovascular event (see Table 3). For individuals with nonvenous leg ulcers, a history of cardiovascular disease was reported in 18 (56%), with 11 (34%) having current signs and symptoms of cardiovascular disease. Additionally, 9 patients (28%) had a family history of cardiovascular disease, 13 (41%) were considered obese, 4 (13%) were current smokers, and 20 (63%) had a sedentary lifestyle. Dyslipidemia and elevated glucose were previously diagnosed in 16 (50%) and 12 patients (38%), respectively; 22 (69%) were taking antihypertensive medications or had blood pressure >140/90 mm Hg. Participants with nonvenous leg ulcers had a total of 4.8 ± 2.2 (range 0–9) cardiovascular risk factors. According to the ACSM guidelines,12 2 (6%) were considered low risk, 11 (34%) were moderate risk, and 19 (60%) were high risk for experiencing a future cardiovascular event (see Table 3). Patients with nonvenous leg ulcers had a significantly higher frequency of having a family history of cardiovascular disease compared with patients with venous leg ulcers (28% vs. 8%; P = .03). Otherwise, frequencies of individual cardiovascular risk factors, total number of cardiovascular risk factors, and cardiovascular risk stratification did not vary significantly according to wound type. 

Discussion

The primary purpose of this study was to assess the prevalence of cardiovascular risk factors in individuals seeking physical therapist services for the treatment of a lower extremity integumentary disorder in an outpatient wound care center. A secondary purpose was to determine if the prevalence of cardiovascular risk factors varied according to type of wound. According to ACSM guidelines,12 the majority of patients in this study (65, 93%) were at either moderate or high risk for experiencing a future cardiovascular event and would potentially require medical clearance before aerobic exercise or physical activity could be added as a physical therapy intervention. The frequencies of individual cardiovascular risk factors, total number of cardiovascular risk factors, and cardiovascular risk stratification did not vary significantly according to wound type. These findings provide important and timely information for physical therapists and other health care professionals to facilitate effective preparticipation health clearance to optimize the safety and benefits of exercise for patients with integumentary disorders. Furthermore, the patient risk-stratification profile seen in this study strongly suggests that physical therapists screen all patients for cardiovascular risk factors, because this may inform patient education strategies regarding risk factor modification, which can positively influence disease management and guide appropriate and safe exercise prescription. 

A key general wound management principle is to treat underlying conditions such as diabetes mellitus and cardiovascular disease by providing appropriate patient education regarding lifestyle changes (eg, smoking cessation, exercise, dietary modifications) to help manage these conditions.26 Berry et al27 conducted a meta-analysis assessing risk factors for cardiovascular disease and their relationship to morbidity and mortality that involved 257 384 individuals. Blood pressure, cholesterol level, smoking status, and diabetes status were used to stratify participants according to risk factors. Among participants who were at minimum 55 years of age, persons with an optimal risk-factor profile (blood pressure <120 mm Hg systolic and 80 mm Hg diastolic, total cholesterol level <180 mg per deciliter [4.7 mmoL per liter], nonsmoking status, and nondiabetic status) had substantially lower risk of death from cardiovascular disease through the age of 80 years than participants with 2 or more major risk factors (4.7% vs. 29.6% among men, 6.4% vs. 20.5% among women). Persons with an optimal risk-factor profile also had lower lifetime risks of fatal coronary heart disease or nonfatal myocardial infarction (3.6% vs. 37.5% among men, <1% vs. 18.3% among women) and fatal or nonfatal stroke (2.3% vs. 8.3% among men, 5.3% vs. 10.7% among women). In the current study, 60% of patients were taking antihypertensive medications or had blood pressure >140/90 mm Hg, 43% had dyslipidemia, 11% were current smokers, and 33% had elevated glucose levels. Additionally, patients in the current study had 4.6 ± 2.3 cardiovascular risk factors. Even though no specific mention of wound presence was made for the patients in the Berry et al27 report, their results have important implications for wound management as well as clinical disease prevention and sound public health practice. First, in patients requiring wound care, as the number of comorbid conditions increases, the likelihood of achieving complete wound closure decreases and the cost associated with achieving complete wound closure increases.5 Second, consistent effort is necessary to manage modifiable risk factors to decrease the morbidity and mortality associated with cardiovascular disease in the general population. Third, efforts to lower the burden of cardiovascular disease will require prevention efforts to avoid the development of risk factors rather than solely relying on the treatment of existing risk factors.

The annual costs associated with venous leg ulcers and diabetic foot ulcers in the United States are approximately $14.9 billion28 and $9 billion,29 respectively. In a study that retrospectively evaluated administrative claims from 2 deidentified insurance databases, patients with venous leg ulcers were found to require more medical resources than patients in a demographically matched control population.28 Persons with venous leg ulcers also missed more days of work due to ulcer-related complications or the need for medical care, which resulted in costs from the loss of work that were nearly one third higher than persons in a matched population. Furthermore, about one third of patients will not achieve full wound closure.5 In the current study, the frequencies of individual cardiovascular risk factors, total number of cardiovascular risk factors, and cardiovascular risk stratification did not vary significantly according to wound type. Nonetheless, given the burden of lower extremity ulcers, physical therapists and other health care practitioners should focus not only on early intervention, but also on prevention in patients at risk for lower extremity ulcers.26 Lifestyle changes such as smoking cessation, exercise, and dietary modifications also should be encouraged to help manage underlying diseases such as hypertension, diabetes, and dyslipidemia; doing so also may have a positive effect on wound healing and disease management.26 Additionally, recent evidence suggests exercise intervention also may be associated with enhanced wound healing rates,1-4 which would likely greatly improve the prognosis for many of the patients with recalcitrant wounds.5

Unfortunately, it is not clear how commonly exercise is prescribed in routine clinical practice for patients receiving treatment for wounds. Despite the fact that ideal parameters for exercise prescription within a wound care population are also currently not known, several studies have shown exercise intervention may be associated with enhanced rates of wound healing.1-4 Emery et al,1 Meagher et al,2 and O’Brien et al4 have demonstrated that moderate- to high-intensity exercise may expedite the wound healing process; however, the presence of cardiovascular disease may influence safe exercise prescription, especially when practitioners would consider moderate-to high-intensity exercise a means of intervention.6,7 Therefore, it is important to thoroughly assess cardiovascular risk, especially in patients who are potentially at moderate or high risk for experiencing a future cardiovascular event, because moderate- to high- intensity exercise intervention may be contraindicated in those patients until they are medically cleared.1,2,6,7 

The prevalence of selected medical comorbidities in the current study is generally consistent with Fife et al.5 The mean patient age in their study was 61.7 years, and 52% of the patients in their study were male.5 In the current study, the mean patient age 63.5 years, and 59% of patients were male. The most common comorbid conditions reported by Fife et al5 included diabetes (33.1% of patients who had ulcers not identified as diabetic foot ulcers), 57 (82%) being obese or overweight (71%, defined as BMI >25 kg/m2), and having cardiovascular disease (51%). By comparison, 29% of patients in the current study who had ulcers not identified as diabetic foot ulcers were diabetic, 79% were obese or overweight, and 54% patients had cardiovascular disease. Although the current study authors did not track the long-term morbidity and mortality of participating patients, Fife et al5 noted that 2% of patients died during their episode of care or within 4 weeks of their last clinic visit. 

Limitations

There are some limitations to this study. First, the patients from this study were from a single wound care center. Further study on larger patient populations from multiple centers is necessary to increase understanding about cardiovascular risk in patients seeking physical therapist services for the treatment of an integumentary disorder. Second, although it is not completely clear how the data from this study informed decisions on intervention, 62 patients (89%) did not require a physician referral despite 57 (82%) being stratified as at either moderate or high risk for experiencing a future cardiovascular event, because these patients were already being adequately managed by their physician. Further study is necessary to determine how data pertaining to cardiovascular risk may inform clinical decision making. Third, it is not completely understood how various degrees of cardiovascular risk influenced patient outcomes and patient quality of life in this study. For example, did patients who were at higher risk for a cardiovascular event have poorer outcomes and poorer quality of life than patients who were at a lower risk for a cardiovascular event?  Future studies should assess the influence of cardiovascular risk on patient outcomes and factors related to patient quality of life. Fourth, it is not clear how commonly exercise is prescribed in routine clinical practice for patients receiving treatment for wounds; the ideal parameters for exercise prescription within a wound care population also are not currently known. Additionally, some of the research on the effects of exercise in patients with wounds is more than 10 years old. Thus, there is a need for further contemporary research on understanding the effects of exercise on outcomes in patients with wounds and multiple comorbidities, the ideal parameters for exercise prescription within a wound care population, and how commonly exercise is prescribed in routine clinical practice for patients receiving treatment for wounds.

Conclusion

This retrospective, observational study assessed the prevalence of cardiovascular risk factors among 70 individuals with an integumentary disorder seeking physical therapist services in a wound care center. According to the ACSM guidelines12 for establishing cardiovascular risk, 7% of patients were stratified as low risk, 31% were moderate risk, and 62% were high risk for experiencing a future cardiovascular event. Cardiovascular risk did not vary significantly according to wound type. Physical therapists and other health care professionals should become familiar with and implement appropriate methods to identify cardiovascular risk in their patients because these findings could potentially influence choice of interventions and treatment outcomes. Furthermore, these data would provide an important opportunity to assist in managing modifiable cardiovascular risk factors in an effort to decrease the morbidity and mortality associated with cardiovascular disease. The authors believe their findings provide important and timely information for physical therapists and other health care professionals to facilitate effective preparticipation health clearance to optimize the safety and benefits of exercise for patients with integumentary disorders. In addition, the patient risk-stratification profile seen in this study exemplifies the importance of thoroughly assessing cardiovascular risk for all patients, because this may inform patient education strategies for risk factor modification, which can positively influence disease management and guide appropriate and safe exercise prescription. 

Acknowledgment

The authors thank Michael Brogan, DPT, PhD, and Corstiaan Brass, MD, for their leadership and guidance during this project.  

Affiliations

Dr. Ross is an assistant professor, Department of Physical Therapy, Daemen College, Amherst, NY. Dr. Zhou is a third year internal medicine resident, Catholic Health Internal Medicine Training Program, University at Buffalo, Buffalo, NY. Dr. Perilli is a physical therapist, Buffalo Rehab Group, Hamburg, NY. Dr. Van Gorder is a physical therapist, Department of Physical Therapy, Daemen College. Dr. Pace is staff physical therapist, Craven Physical Therapy, New Bern, NC. Dr. Melendez is a physical therapist, FOX Rehabilitation, New York, NY. Dr. Doherty is a physical therapist, St. James Mercy Hospital, Hornell, NY. Dr. Hornung is an acute care physical therapist, UPMC Chautauqua, Jamestown, NY. Dr. Carroll is a physical therapist and director, Advanced Care Physical Therapy, Williamsville, NY.

Correspondence

Please address correspondence to: Michael Ross, PT, DHSc, Daemen College, 4380 Main Street, Amherst, NY, 14226; email: mross@daemen.edu.