A patient with asthma, Type II diabetes, hypertension and obesity presented with right lower limb cellulitis. Multiple surgeries were performed and she was left with two large wounds medially and laterally extending from her ankle up to her mid-calf region, a stiff ankle and an oedematous foot. It was initially presumed that this was the type of patient that would not be very physically active and that she would be difficult to motivate to participate in regular exercise. This assumption was completely incorrect. Once this patient understood the clear health benefits of physical activity to each of her different conditions and realized that being healthy would keep her out of hospital and with her children, she did not need any other input and was able to successfully push herself to exercise harder as the program progressed with marked results.
First impressions and judgement of a patient’s motivation to exercise can often be incorrect. A patient’s internal motivation can come from many different areas rather than one specific source.
Mrs. X was a 46 year old female patient presenting with right lower limb cellulitis. She underwent four incision and drainage surgeries and was transferred for rehabilitation two weeks later. She had multiple co-morbidities such as obesity (BMI = 30), asthma, Type II diabetes and hypertension.
She used an inhaler as needed, was on a sliding scale for insulin injection and was on medical treatment for her blood pressure.
She had a myocardial infarction in 2011 but no complications or complaints since that time.
Tests and investigations:
Doppler of right lower limb – Nil of note
Mrs X was married with five children. She lived in a four room house with electricity and running water and a toilet outside the house. She was the sole breadwinner of the family and her work entailed walking to a school our hour from her home to sell food.
Mental state: Alert and responsive
Blood Pressure: 140/80, Pulse 90 and Respiratory rate: 20
Wound on medical and lateral side of ankle extending 15cm up leg
ROM: Full except for Right ankle 0° – 91°
Muscle strength: Grade V except for right ankle Grade III
Oedematous right foot – pitting
The patient was independently mobile with a pair of elbow crutches and also independent in all ADLs
Endurance was fair
Management and Outcomes:
The care plan was to increase Mrs X’s physical activity levels gradually, introduce strength exercises as well as endurance training.
Her fitness was assessed using a modified Two Minute Step in Place test as her ankle and mobility with elbow crutches made other tests difficult to implement. She was unable to reach the recommended tape height due to difficulty weight bearing on her right ankle so the height was lowered to a more comfortable level. She was able to achieve a score of 80.
A daily walking exercise program was introduced. The distance and speed of walking was adjusted over the 2.5 weeks of treatment  and stairs and ramps were included. By the end of the 2.5 weeks, Mrs X was exercising for 30 minutes five days per week.  She did a warm up of marching on the spot as comfort allowed.
Strengthening exercises of the upper limb were done using 2 kg then 3 kg weights.   Exercises included bicep curls and elbow extensions, 2 sets of 20 repetitions (increased from one set initially). The quads bench for quadriceps and hamstring strengthening exercises was used instead of squats and lunges due to the patient’s stiff ankle.   Hip abduction with ankle weights was done in side lying. She was given two 2 kg ankle weights to use at home. The strengthening program was done 2 – 3 times per week. All weights added were low so as not to add too much stress with regards to her blood pressure and were only added after her blood pressure was stable for 2-3 days.
A motivational interview was done with Mrs X during which she easily identified where exercise could be added to her day. She was even able to come up with a solution for making her own weights for her upper limb exercise program at home. She was determined to continue and was keen to include her husband and children in the program.
Before starting the exercise program, Mrs X’s systolic blood pressure would regularly spike to 140–150mmHg. After 3-4 days of the walking program her blood pressure stabilized and for two weeks, she maintained a systolic pressure of 110–120mmHg.
Her fasting blood sugar levels were initially spiking between 15 and 20 mmol/L. This was always corrected prior to exercise. Following exercise, her blood sugar levels were more stable, maintaining a level of between 7-10 mmol/L. Normal fasting blood sugar levels for a diabetic person are 5–7.2 mmol/L.
There was also a report from Mrs X regarding the fact that she hadn’t needed to use her insuin pump and that prior to this program, she usually needed to use it in the type of weather we had been having.
Her score for the modified Step in Place Test increased from 80 to 120 steps.
Her level of breathlessness went from a level two to a level one.
Mrs X was initially assumed to be a difficult patient to implement an exercise program with because she was obese and had more than two co-morbidities. However, once she started the program, she quickly responded to the exercise and the health benefits were clear. She was able to feel and see the benefits and became well-motivated internally. She had many reasons for changing her habits, including the fact that she needed to care for her family and was unable to do so in hospital. She also saw the need to include and motivate her family to participate in the exercises with her. Even in her low income setting, she easily came up with a solution for adding her own weights by taking empty 2-litre bottles of water or soda and filling them with sand. Thus, given the right motivation at the right time, patients may only need minimal advice and input to change their own lives.