Intervention
BLOOD
Exercise was commenced during hospital admission. Where a participant required surgery for their DFU, clearance from the treating team was obtained for the patient to commence exercise. The treating team made weight bearing orders in relation to the DFU location for each participant to follow. Participants who were able to weight bear but in offloading footwear were prescribed this by the Podiatrist. These included removable ankle high and knee high devices. Otherwise, participants who were ordered to be non-weight bearing were able to participate in exercise whilst adhering to this restriction. Blood glucose levels (BGL) were assessed prior to and during exercise sessions. Exercise was not commenced, or was stopped, where BGL < 5 mmol/L.Supervised exercise sessions were comprised of both aerobic and strength training components. These exercises were individualised for each participant to maintain weight bearing orders given by the treating team. For example, participants who were ordered to be heel weight bearing undertook exercises weight bearing through the heel only. Participants ordered to be toe weight bearing completed exercises weight bearing through the toe only. Where a patient was strictly non-weight bearing on one leg, exercises were performed weight bearing on the opposite leg and non-weight bearing on the affected leg. Exercise selection was completed with respect to the participant’s ability to achieve the full range of movement of the selected exercises. This was assessed at the time of exercise by the supervising Physiotherapist.The mode of aerobic exercise was selected using a combination of patient preference and adherence to wound offloading requirements. Participants completed five to 20 min of upper limb ergometry (Monark Exercise AB, Dalarna, Sweden), single leg or two-legged cycling on an upright exercise bike (Monark Exercise AB, Dalarna, Sweden), or recumbent exercise bike (SportsArt, Washington, United States of America). The amount of time for the aerobic component was based on exercise tolerance. Participants were instructed to exercise at a moderate intensity using Borg’s Rating of Perceived Exertion Category-Ratio scale (CR-10) [Strength training exercises were completed as a circuit using body weight, resistance bands (Performance Health ANZ, Sydney, Australia), free weights and ankle weights, or pin-loaded cable weight machines (Cybex International, Illinois, USA). Exercises were selected based on weight bearing orders as described above. Participants were instructed to work to a moderate intensity on the CR-10 scale. Each participant completed a total of 2–3 sets of 8–15 repetitions of each exercise. Exercises targeted key muscles groups in both lower and upper limbs in standing, sitting or unilateral positions. Examples of some of the common exercises utilised were; bicep curl, shoulder press, deltoid fly, seated or bent over row, leg press, sit to stands, squats, bridging, heel raise, side lying or standing hip abduction and seated knee extensions. Participants were asked to rate the intensity of the full exercise session using the CR-10 scale at 10 min after their session.A home exercise programme was prescribed and consisted of a selection of pre-determined exercises similar to those utilised in the inpatient session (Additional file 