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Relação entre a mobilidade da articulação talocrural e a úlcera venosa
Abstract
BACKGROUND: This study assesses talocrural joint mobility considering the six stages of CEAP classification (clinical, etiologic, anatomic and pathophysiologic by the International Consensus Committee reporting standards on venous disease) for venous disease using goniometry, and detects reduction in joint mobility in more advanced stages of the disease, C5 and C6 (healed or active ulcer). OBJECTIVE: Investigate the existence of a relationship between clinical severity of chronic venous disease of the lower limbs and reduction in talocrural joint mobility. METHODS: A total of 120 limbs from 88 Caucasian patients were randomly selected. They were divided based on clinical presentation according to the C clinical category of CEAP, being distributed into six groups belonging to categories from C0-C1 (control group) to C6, with 20 limbs each and similar mean age for each group. Range of ankle mobility was assessed by goniometry in the supine position. RESULTS: C groups on the CEAP classification showed significant difference in relation to talocrural joint mobility measured by goniometry (p
... We have also observed that dorsiflexion and plantar flexion of the foot depend on the area of ulceration and the extent of lipodermatosclerosis. It is mentioned in the literature [4, 10] that lipodermatosclerosis, which is typical for the advanced stages of chronic venous insufficiency (CVI), often covers the structures of foot joints, particularly the ankle joint and the Achilles tendon. The stiffness of the ankle joint limits the physiological range of foot mobility and prevents patients from maintaining proper biomechanics of walking. ...
... First, limited ankle joint mobility intensifies haemodynamic disturbances [7]. They are associated with a greater risk of the development of venous ulcers [8, 10]. They affect their healing and increase the risk of recurrence [5]. ...
... These parameters were 40-50% lower than in healthy persons. Belczak et al. [10] showed that ankle joint mobility decreases according to the clinical severity of CVI. The largest limitations of foot joint mobility occurred in the course of active venous ulcers. ...
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.
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.
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).
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.
... Esse achado, corrobora com outros estudos que utilizam exercícios voltados para musculatura da panturrilha resultando em benefícios quanto a aspectos gerais da doença venosa como atenuação de sintomas e cicatrização de úlceras em pacientes mais graves (C. E. Q. Belczak, Cavalheri, De Godoy, Caffaro, & Belczak, 2007;Caggiati, De Maeseneer, Cavezzi, Mosti, & Morrison, 2018). ...
Esse estudo comparou o efeito de dois programas de treinamento sobre a aptidão física e qualidade de vida em mulheres com Varizes, sendo um programa de condicionamento físico geral (CFG) e o outro de fortalecimento de membros inferiores (MMII) aplicado a 2 grupos de voluntárias, praticantes regulares de exercício físico, por 12 semanas. Foram coletados, pré e pós treinamento, dados de qualidade de vida, perimetria de panturrilha, goniometria do tornozelo, teste de ponta de pé e degrau. Nove mulheres do programa CFG (54 ± 18 anos) e onze do programa MMII (58 ± 8 anos) concluíram a intervenção. Comparando a magnitude de variação nos resultados de cada teste e entre os programas por teste t independente, as participantes do programa MMII apresentaram melhor desempenho nos testes de aptidão física e qualidade de vida que as do programa CFG, com diferença significativa nos resultados de resistência muscular (p < 0,01 para repetições e p = 0,02 para tempo de execução no teste de ponta de pé) e flexibilidade (p < 0,01). Concluiu-se que um programa específico de fortalecimento de membros inferiores possibilita melhores resultados em aptidão física em relação a um programa de condicionamento geral.
... As feridas crônicas de causa venosa são as mais frequentes, atingindo índices de até 80% do total de feridas que afetam os membros inferiores e constituem um sério problema de saúde pública em função do grande número de indivíduos acometidos 1,2 . Úlceras venosas em membros inferiores afetam 1-3% da população com mais de 60 anos e a incidência aumenta com a idade. ...
Contexto
Pacientes com úlceras venosas reportam múltiplas comorbidades e são mais propensos a ser fisicamente inativos. A sarcopenia e a fragilidade aumentam a vulnerabilidade de um indivíduo para maior dependência e/ou morte.
Objetivos
Verificar presença da sarcopenia e fragilidade em pacientes portadores de úlceras venosas crônicas.
Métodos
Estudo observacional e transversal, realizado com 9 pacientes com idade média de 67,4 ± 8,42 anos e portadores de úlcera venosa nos membros inferiores classificadas no Consenso Internacional de Doenças Venosas Crônicas (CEAP) em estágio 6. Para identificação e classificação da sarcopenia, foi avaliada a força (dinamometria manual), a velocidade da marcha (teste de caminhada de 10 metros) e a massa muscular (circunferência da panturrilha). Para triagem de fragilidade, foram utilizados os critérios de Fried: perda de peso não intencional, fadiga, redução da força e da velocidade da caminhada e baixa atividade física.
Resultados
O fenótipo de fragilidade foi mais frequente (n = 9; 100%) em relação à sarcopenia (n = 1; 11,1%). Entre os critérios de Fried, os mais frequentes foram a exaustão (n = 9; 100%), seguida pela baixa atividade física (n = 8; 88,8%) e fraqueza muscular (n = 5; 55%). Por fim, o critério menos frequente foi a diminuição da velocidade da marcha (n = 2; 22,2%). No diagnóstico de sarcopenia, foi observada redução da força associada à redução da massa muscular (n = 1; 11,1%).
Conclusões
Pacientes com úlceras venosas crônicas apresentam condição de fragilidade ou pré-fragilidade, enquanto a condição de sarcopenia foi pouco frequente.
... A doença venosa, quando acomete a articulação talocrural, pode influenciar a bomba muscular da panturrilha e sabe-se que a disfunção dessa bomba em pacientes com úlcera ativa é fator determinante na gravidade do prognóstico. 8,10,11 Segundo Belczak et al. 12 , "a anquilose total e permanente do tornozelo torna os pacientes incuráveis ao limitar ou mesmo anular a ação da mais importante bomba impulso-aspirativa dos membros inferiores, que é a bomba muscular da panturrilha". ...
Introdução: A úlcera varicosa é uma ferida crônica, aberta entre o joelho e o tornozelo, com forma e tamanho variáveis. Geralmente, não cicatriza antes de decorridas quatro semanas, sendo a lesão mais grave da insuficiência venosa crônica. É um ciclo contínuo de rupturas da pele ao longo de décadas, com redução da qualidade de vida. Os efeitos psicossociais são muitas vezes esquecidos. Objetivos: Avaliar a qualidade de vida de pacientes com úlcera venosa (C6) de acordo com Clinical Manifestation, Etiologic Factors, Anatomic Distribution of Disease, Pathophysiologic Findings (CEAP). Métodos: Estudo transversal descritivo-analítico composto por 50 pacientes. Foi utilizado para avaliação o questionário específico de qualidade de vida na úlcera venosa crônica traduzido, adaptado e validado na língua portuguesa a partir do questionário “Charing Cross Venous Ulcer Questionnaire”. Resultados: Mulheres (60%) apresentaram média maior na pontuação total e nos domínios. Houve significância estatística (p<0,05) entre os domínios estética (p=0,0390) e estado emocional (p=0,0274). Na comparação dos domínios, interação social e atividades domésticas obtiveram menor pontuação, em ambos os gêneros. O domínio mais afetado foi o estado emocional, para ambos os gêneros. Pouca diferença na média de idade entre mulheres e homens. As queixas mais comuns foram dor, mau odor e a impossibilidade de permanecer muito tempo em pé. Conclusões: A úlcera venosa causou impacto leve a moderado na qualidade de vida, principalmente pelo baixo bem-estar psicossocial.
... 7 Measuring ROM with a standard plastic goniometer does not control the patient's ability to flex or extend the toes or control for the subtalar range of motion and its influence on ankle ROM. Belczak et al. 8 used a goniometer with a plantar support to eliminate the influence on ankle ROM of the other articulations of the foot on ankle ROM. Despite the assumption that the instrument may have been cumbersome to use in the field, the authors were unable to acquire it for testing. ...
A modified inclinometer was designed for measuring total ankle range of motion (ROM) in the standing position for a large future study. The purpose of this pilot study was to assess the intra-examiner reliability of this new device in order to see if the examiner would be able to produce equally reliable measurements with this instrument as with a routinely used goniometer. Nineteen young healthy individuals took part in the pilot. The same examiner took the ROM measurements using both devices twice on the same day and one further time 2 or 3 days later. Test-retest reliability was measured using the intraclass correlation coefficient (ICC). The ICC values were 0.86 (95% CI=[0.67; 0.94]) and 0.83 (95% CI=[0.61; 0.93]) for the measurements taken with the goniometer on the same day and for those on two different days. The corresponding values for the modified inclinometer were 0.88 (95% CI=[0.72;0.95]) and 0.81 (95% CI=[0.57; 0.92]). Both instruments were found to have very good test-retest reliability.
... It causes muscular compression of the sural pump, which is located in the calf, reducing venous stasis by increasing venous flow volumes and providing an average of 1,134.59 ml every time the pump is activated by plantar flexion movements and dorsiflexion of the ankle 22,23 . ...
OBJECTIVE:
Determine the prevalence of postural edema and investigate whether working posture - sitting down or standing up - affect its frequency.
METHODS:
Sixteen traffic control agents were assessed by water displacement volumetry and the results were analyzed in two groups, depending on working posture. Those who worked standing up for more than 4 hours were allocated to the SU group and those who worked sitting down for more than 4 hours were allocated to the SD group. Each worker was assessed before and after their working shift for three consecutive days. Data were analyzed using ANOVA and the test of equality of two proportions. The significance level was set at p ≤ 0.05. The assessment showed that members of both groups had postural edema of the lower extremities (p ≤ 0.001).
RESULTS:
When the frequency of postural edema was compared across groups, a trend was observed for greater edema formation in the SU group than in the SD group, although without statistically significant difference.
CONCLUSION:
It was concluded that traffic control agents suffer postural edema after 4 hours working in either of the postures investigated although with a predominance of edema formation among those who work standing up.
... A mobilidade da articulação do tornozelo depende da eficiência da contração do músculo tríceps sural 7,8 , que é considerado uma parte fundamental da mais importante bomba impulso-aspirativa 9 para o retorno venoso dos membros inferiores. Assim, a flexibilidade desta articulação tem papel importante na eficiência da bomba muscular da panturrilha para evitar a estase venosa e suas consequências 7 . ...
BACKGROUND: Development of ankylosis in patients with chronic venous insufficiency (CVI) can be observed in different stages of the disease as the ankle range of motion is measured by a goniometer. OBJECTIVE: To relate a reduced ankle range of motion in patients with CVI of the lower limbs measured by goniometry and the severity of CVI according to the CEAP classification. METHODS: From March 2003 to August 2004, 86 patients (67 females and 19 males) with a mean age of 50.6 years had their ankles assessed by a goniometer. Patients were classified into three groups according to the severity of the CVI of the lower limbs (121 were assessed) using the CEAP classification. There were 40 limbs classified as C0 (control group), 40 limbs as C3 and 41 limbs as C4. Measurements of all groups were compared. RESULTS: The average ankle range of motion was 42.4º (from 26º to 54º) in C0 group, 37.9º (from 10º to 61º) in C3 group and 24.5º (from 8º to 50º) in group C4. The difference between C4 and C3 average values was 36% and that between C3 and the control group (C0) was 11%; thus, the contrast between C3 and C4 was more significant. CONCLUSION: Ankle goniometry may be used to assess chronic venous hypertension, as it reveals a correlation between the severity of ankylosis and the severity of CVI.
... In its more severe forms, such as venous stasis ulcer, the ultimate expression of this disease, it can lead to disability and be a cause of high costs to public coffers. Comprehensive evaluation and therapeutic management of these patients are less than expected [12][13][14][15] . ...
Background: The chronic venous insufficiency (CVI) has a considerable socioeconomic impact in Western countries due to its high prevalence, research and treatment cost, and loss of workdays. The Short Form Health Survey (SF-36) questionnaire, the analysis of muscular activation and mobility of the tibiotarsal joint are instruments used for CVI evaluation. Objective: To assess osteomuscular limitations and changes in the quality of life of patients with venous ulcers in lower limbs. Methods: Ten patients with ulcers classified using CEAP (Clinical, Etiological, Anatomical, and Pathophysiological) classification were evaluated. Six of them answered the SF-36questionnaire and the pain analogue scale, and underwent goniometry, muscular strength evaluation and electromyography. Results: The mean age of studied subjects was 67.4 (±11.7), and 70% of them were female. Results showed no statistically significant correlation between pain, range of motion (ROM), muscular strength, electromyography (EMG), and the lesion size. However, results showed a correlation between the psychological profile on SF-36 questionnaire and the domain of motor activities, as well as between psychological profile and social activities, and between psychological profile and perception of itself. The electromyographic evaluation of studied muscles also showed a significant difference. Conclusion: The presence of venous ulcers in lower limbs can generate limitations and changes in these patients' quality of life. The psychosocial aspect showed preponderance over the motor one, increasing restrictions in daily activities.
... A mobilidade da articulação do tornozelo depende da eficiência da contração do músculo tríceps sural 7,8 , que é considerado uma parte fundamental da mais importante bomba impulso-aspirativa 9 para o retorno venoso dos membros inferiores. Assim, a flexibilidade desta articulação tem papel importante na eficiência da bomba muscular da panturrilha para evitar a estase venosa e suas consequências 7 . ...
CONTEXTO: O desenvolvimento de anquilose em pacientes com insuficiência venosa crônica (IVC) pode ser evidenciado em diversos estágios da patologia através de medidas da amplitude de movimento da articulação do tornozelo tomadas com a utilização de um goniômetro. OBJETIVO: Relacionar a diminuição da amplitude de movimento da articulação tíbio-társica na IVC dos membros inferiores (MMII) medida por goniometria com a gravidade da IVC, utilizando-se a classificação CEAP. MÉTODOS: No período de março de 2003 a agosto de 2004, 86 pacientes (67 mulheres e 19 homens) com média de idade de 50,6 anos foram submetidos à goniometria do tornozelo. Os indivíduos foram divididos conforme a gravidade da IVC de seus MMII (121 avaliados) de acordo com a classificação CEAP. Quarenta membros foram caracterizados como C0 (grupo-controle), 40 como C3, e 41 como C4. As medidas obtidas nos diferentes grupos foram comparadas entre si. RESULTADOS: A média da amplitude de movimento da articulação tíbio-társica do grupo C0 foi de 42,4º (variação de 26-54); a do grupo C3 foi de 37,9º (variação de 10-61); e a do grupo C4 foi de 24,5º (variação de 8-50). A diferença das médias de C4 e C3 foi de 36%, e a de C3 comparada com o grupo-controle (C0), de 11%, caracterizando a maior diferença entre C3 e C4. CONCLUSÃO: A goniometria do tornozelo auxilia a graduar a hipertensão venosa crônica, pois demonstra a existência de correlação entre a gravidade da anquilose e a severidade da IVC.
Objective
Chronic venous insufficiency (CVI) is a progressive disease, leading to calf muscle pump dysfunction and reduced range of ankle motion (ROAM). A full ROAM increases venous return decreasing venous hypertension. The dysfunction of foot pump in static foot disorder (SFD) further contributes to chronic venous insufficiency. In present study we studied the effect of ROAM and SFD on CVI.
Methods
A prospective observational study was conducted from July 2022 to June 2023, with Institute Ethical clearance (INT/2022/MS-533). A total of 402 legs were included, of which 368 legs of the study group had CVI and 34 legs were in control C0 group. Patients were divided into control C0, mild C1-C3 and advanced C4-C6 disease group based on the severity of CVI. SFD and ROAM were evaluated from X-rays by Djian-Annonier angle and goniometry respectively. The primary objective was to study, impairment of ROAM in patients from C1-C6 and its comparison with control C0 group and impact of static foot disorders on ROAM.
Results
ROAM was highest in controls and decreased towards the lowest value in progression to advanced stages of CEAP classification (87° in C0, 71° in mild CVI and 45° in advanced CVI, p < .001). Controls had just nine % legs afflicted with SFD whereas 62.3% and 68.6% with mild and advanced disease had SFD, p < .001 . ROAM was highest in those without SFD (68.9°) and least in hollow feet (58.3°), p < .001 . ROAM was lower in the symptomatic C2 disease (80°) than asymptomatic type (69°) ( p < .001).
Conclusion
This study showed that poor ROAM is associated with higher rate of advance CVI. In addition patients with SFD had advance CVI and poor ROAM. So, it is important to consider treatment of SFD and physical rehabilitation to improve ROAM and break vicious cycle of progression to severe CVI.
Background: In the work of a psychiatric nurse, stress is part and parcel of this profession. However, long-term stress burden and ineffective coping with it led to psychosomatic disorders, engaging in self-destructive behaviours, and deteriorating the quality of nursing and medical care.
Aim: The aim of the study was to determine the occurrence of stress and ways of coping with the intensification of suicidal thoughts among psychiatric nurses in Poland
Sample and methods: The study involved the participation of 190 psychiatric nurses working in Poland. An original questionnaire was sent out electronically to the management of psychiatric care facilities in the largest cities of Poland with a request to forward the link to the nurses. The replies of the respondents were subjected to statistical analysis using the StatSoft's Statistica v.13.1 PL pro-gram.
Results: Almost 60 % of the respondents complained of frequent stress at work and among them 17.76% declared suicidal thoughts (p=0.000, Cramér's V= 0.326). The most frequent causes of stress in the nurses' work were working with aggressive patients, excessive workload, and low remuneration. The surveyed nurses most often coped with stress by talking to family or friends (59.47%), using relaxation techniques, or doing hobbies (57.89%) and seeking support from colleagues (57.89%). Suicidal thoughts occurred the most frequently among the nurses who did not receive support at work (p=0.038, Cramér's V = 0.169), took sedatives or drank alcohol (p=0.000, Cramér's V =0.323), and the least frequently in those who used relaxation techniques, confided in friends and family (p=0.000, Cramér's V =0.323) and received psychological support (p=0.038, Cramér's V = 0.169).Coping with the situation by taking a sick leave or changing the workplace was negatively correlated with the intensity of suicidal thoughts (p=-1).
Conclusions: Stress and the ways of stress management have a significant impact on the occurrence of suicidal thoughts among the surveyed psychiatric nurses. The nurses displaying behaviours with active stress management admitted to having suicidal thoughts less often than those who exhibited evasive behaviours. Further studies on a larger group of psychiatric nurses are required. The results of the research may encourage management staff to implement training in workplaces to combat stress and provide support to their subordinates as a means of preventing the consequences of stress.
Key words: Stress. Coping. Psychiatric nurses. Suicidal thoughts.
link :https://fz.tnuni.sk/uploads/media/OSEaZdravie_XIII__zbornik_2022.pdf
Resumo O presente trabalho surgiu da necessidade de aprimorar o tratamento de pacientes com insuficiência venosa crônica (IVC) que apresentam úlcera venosa. Foram avaliados os 40 membros inferiores de 20 pacientes portadores de úlcera venosa cicatrizada (C5) ou ativa (C6) que foram submetidos ou não à cirurgia de varizes. Foi estabelecida a relação entre a amplitude de movimento da articulação talocrural e a presença de úlcera venosa C5 ou C6, sendo para isso utilizada a goniometria dessa articulação dentro da normalidade como preditor de cicatrização e tendo como desfecho a cicatrização ou não da úlcera venosa. Dessa forma, ao se identificar redução ou imobilidade talocrural em pacientes com úlcera venosa, poderão ser oferecidas novas formas terapêuticas, a fim de aumentar a mobilidade dessa articulação para prevenir ou retardar complicações da IVC.
CONTEXTO: A presença de edema vespertino nos membros inferiores de indivíduos normais, após jornada habitual de trabalho, foi demonstrada na literatura nacional e internacional. O ritmo de formação e o acúmulo desse edema variam de acordo com os distintos turnos laborais. OBJETIVO: O edema de membros inferiores tem sido descrito após jornadas habituais de trabalho e representa uma queixa freqüente na prática vascular. O objetivo deste estudo foi avaliar a evolução do edema em indivíduos normais durante os distintos turnos laborais. MÉTODO: Foram feitas avaliações volumétricas de ambos os membros inferiores em 20 profissionais da área da saúde do Hospital e Maternidade São Marcos de Maringá, no Paraná. A escolha dos participantes foi por ordem de chegada, e as volumetrias foram feitas por técnica de deslocamento de água às 7, 13 e 19 h. Para análise estatística foi utilizado o teste t de Student, considerando erro alfa de 5%. RESULTADO: Dos 20 participantes, 19 eram do sexo feminino e 1 do masculino, sem evidência de doença venosa nos membros inferiores e pertencentes a C0 e C1 da classificação CEAP (C = clínica, E = etiologia, A = segmento anatômico, P = fisiopatologia). As idades dos participantes variaram entre 20 e 53 anos. Detectou-se aumento significativo de volume nos membros inferiores entre os distintos períodos avaliados, com p = 0,0001 e 0,0001, respectivamente. A maior variação ocorreu no período da manhã, com média ± desvio padrão de 107,2±63,5 mL, enquanto que à tarde, a variação foi de 44,5±35,4 mL. CONCLUSÃO: O edema é uma constante durante atividades laborais, mesmo em pessoas sem doença venosa manifesta e sofre influência do turno laboral ao qual o trabalhador se encontra exposto.
Venous leg ulcers (VLUs) represent the most advanced stage of chronic venous insufficiency. Despite the large body of knowledge available regarding the risk factors and aetiopathogeny of the condition, patients referred to public health care systems in developing countries often do not receive adequate diagnosis or early treatment, leading to clinical evolution and disease recurrence. This review collates updated information about the epidemiology, risk factors, aetiopathogeny, diagnosis, ulcer healing methods and determinant factors of the pernicious cycle of VLUs in developing countries, with a focus on the Brazilian setting.
Studies of the normal range of joint motion in human adults are uncommon, and frequently used references are based on materials not immediately accessible. The present paper reports on ranges of motion in healthy male subjects, 30–40 years old, in a randomized sample from the population in the city of Göteborg. It is based on 210 hips, 180 knees and 192 ankle joints. Arcs of passive motion were measured by techniques suggested by the American Academy of Orthopaedic Surgeons. Significant differences were found between the obtained measurements and previous referenced studies. The differences can be due to the measurement procedure, difficulties in measurement technique, the patient material, and inter-individual variations. There was no statistically significant difference between the motions of the right and left side, and it is therefore suggested that a patient's healthy limb can be used for comparison with the affected side in the presence of disease or a lesion.
The purpose of this study was to determine whether gender- and age-related differences in ankle joint complex (AJC) range of motion (ROM) exist in children (range 9-13 years), adolescents (14-16 years), and young adults (17-20 years), and to compare these data with those published for older subjects (21-79 years) using the same protocol. A total of 120 subjects (58 males and 62 females) ranging in age from 9 to 20 years were tested for AJC ROM using a specifically designed 6 degrees of freedom fixture. All measurements were made with respect to a laboratory coordinate system, and represented assessment of active AJC ROM. Angular displacements for plantarflexion, dorsiflexion, inversion, eversion, abduction, and adduction were digitally recorded and compared. AJC ROMs of females aged 9 to 20 years were generally greater than those for males about all three orthogonal axes. Within each gender, there was a consistent trend for AJC ROM to decrease from a maximum at 14 to 16 or 17 to 20 years to a minimum after age 60 years. The average decrement was greater for females than for males. This study provided evidence to support the contention that age-related and gender differences in AJC ROM do exist. The possibility of minimizing the decline in AJC ROM with age requires further investigation.
Durch den 1980 von Krämer und Gudat beschriebenen talokruralen Winkel ist ein genaues Maß zur radiologischen Bestimmung der Talusstellung in der Sprunggelenksgabel sowie der Beweglichkeit des oberen Sprunggelenkes gegeben. Reihenuntersuchungen bei Deutschen ergaben eine größere Beweglichkeit bei weiblichen Probanden. Mit zunehmendem Alter nahm die Beweglichkeit des oberen Sprunggelenkes bei beiden Geschlechtern ab. Gleiche Untersuchungen bei Japanern sollten Rückschlüsse auf genetische Unterschiede sowie den Einfluß von Lebensgewohnheiten auf die Beweglichkeit des oberen Sprunggelenkes erlauben.
Movement of the foot is essential for human locomotion. The purpose of this paper was to quantify the range of motion of the foot as a function of age and to compare the rage of motion measurements for the foot in a laboratory coordinate system and a coordinate system fixed to the tibia. The measurements were taken in vivo using a range of motion instrument developed by Allinger (University of Calgary, Canada, 1990) from 121 subjects. The results suggest that: (1) the range of motion in general is greater for women than for men in the young adult group; (2) the range of motion in general is in the same order of magnitude for women and men in the oldest age group; and (3) the range of motion is about 8 degrees smaller in dorsiflexion and about 8 degrees higher in plantarflexion for women than for men in the oldest age group. It is speculated that physical activity and common shoe wear are factors influencing the age- and gender-dependent differences in range of motion. Furthermore, it has been shown that the range of motion values measured in a laboratory coordinate system and in a coordinate system fixed in the tibia are different in all directions except inversion. The differences in plantarflexion and dorsiflexion and inversion and eversion are relatively small. However, they are substantial for adduction and abduction. In all cases, the results were bigger for measurements in the laboratory coordinate system compared with the tibia coordinate system, because the movement of the lower leg was included in the measurements in the laboratory coordinate system.(ABSTRACT TRUNCATED AT 250 WORDS)
Clinical deterioration of patients with chronic venous disease (CVD) has been well described and a standardized classification has been proposed. The progressive hemodynamic deterioration producing these clinical findings is less well appreciated. This study examines and correlates venous hemodynamics with clinical severity in patients with CVD. Two hundred seventy-four extremities from 149 patients with varying degrees of CVD and 56 extremities from 28 symptom-free volunteers were evaluated clinically and hemodynamically. Each limb was assessed for functional venous volume, degree of valvular insufficiency, efficiency of the calf muscle pump, and noninvasive estimate of ambulatory venous pressure. In addition, exercise venous pressures were recorded in 56 extremities from 36 patients and 9 extremities from 6 volunteers. As CVD progresses from class 0 to class 2, venous volume expands, valvular function deteriorates, the calf muscle pump becomes inefficient, and ambulatory venous hypertension develops. However, once extremities develop brawny edema or hyperpigmentation, further deterioration of limb hemodynamics does not occur. Patients with deep venous obstruction have more severe valvular insufficiency, calf muscle pump dysfunction, and ambulatory venous hypertension than have patients without evidence of obstruction. Residual volume fraction offers a reliable noninvasive estimate of ambulatory venous pressure (r = 0.76), although its correlation was significantly better for patients without venous obstruction (r = 0.86) than for those with obstruction (r = 0.40; p < 0.05). Deterioration in venous hemodynamics parallels clinical severity through class 2. Once brawny edema and hyperpigmentation occur, ulceration develops without additional deterioration of venous hemodynamics.
Air plethysmography has been used to quantitate venous reflux by measuring the average filling rate of the veins (venous filling index; in milliliters per second) on standing from the supine position, the ejection fraction of the calf muscle pump as a result of one tip-toe movement, and the residual volume fraction after 10 tip-toe movements. Thirty normal limbs, 110 limbs with primary varicose veins, 34 limbs with reflux in the deep veins but without occlusion, and 31 limbs with deep venous occlusion, with or without reflux, have been studied. An increase in the incidence of ulceration occurred with increasing values of reflux and decreasing values of the calf muscle pump ejection fraction. A poor ejection fraction was the primary cause of venous ulceration in limbs with minimal reflux. A good ejection fraction, however, significantly reduced the incidence of ulceration in limbs with marked reflux (p less than 0.05). The residual volume fraction, which expresses the combined effect of venous reflux and ejection fraction with rhythmic exercise, showed a good correlation with the incidence of ulceration and the measurements of ambulatory venous pressure (r = 0.81). The air-plethysmographic measurements completely assess the calf muscle pump function and provide an accurate method to identify the predominant hemodynamic factor (ejection fraction, reflux, or both) responsible for the clinical picture of the patient.
Studies of the normal range of joint motion in human adults are uncommon, and frequently used references are based on materials not immediately accessible. The present paper reports on ranges of motion in healthy male subjects, 30-40 years old, in a randomized sample from the population in the city of Göteborg. It is based on 210 hips, 180 knees and 192 ankle joints. Arcs of passive motion were measured by techniques suggested by the American Academy of Orthopaedic Surgeons. Significant differences were found between the obtained measurements and previous referenced studies. The differences can be due to the measurement procedure, difficulties in measurement technique, the patient material, and inter-individual variations. There was no statistically significant differences between the motions of the right and left side, and its is therefore suggested that a patient's healthy limb can be used for comparison with the affected side in the presence of disease or a lesion.
Calf muscle pump dysfunction is a recognized factor in chronic venous insufficiency (CVI). We investigated the hypothesis that limbs with CVI have a reduced ankle range of motion (ROM) that may be responsible for the poor calf pump function associated with venous ulceration.
Ankle ROM and calf pump function were assessed in 32 limbs of 26 adult men. Limbs were selected on the basis of clinical presentation: normal (n = 6 limbs), class 1 or 2 CVI with no history of ulceration (n = 9 limbs), class 3 CVI with healed ulceration (n = 9 limbs), and class 3 CVI with active ulceration (n = 8 limbs). ROM was determined by goniometry during maximal plantar flexion and dorsiflexion of the ankle. Calf pump function was determined by air plethysmographic measurement of ejection fraction (EF) and residual volume fraction (RVF).
Ankle ROM was significantly (p < 0.05) reduced in each CVI group compared with age-matched control subjects, because of decreases in both plantar flexion and dorsiflexion. Calf pump function was significantly impaired (decreased EF and increased RVF) in ulcerated limbs. ROM was significantly correlated to EF and RVF. Impairment of ROM and calf pump function was associated with deterioration in the clinical classification of venous disease.
Limbs with CVI have a limited ankle ROM that decreases with increasing severity of clinical symptoms. This decreased ROM is associated with, and may contribute to, poor calf pump function.
At the request of the Ad Hoc Committee on Reporting Standards of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery, this report updates and modifies "Reporting standards in venous disease" (J Vasc Surg 1988;8:172-81). As in the initial document, reporting standards for publications dealing with (1) acute lower extremity venous thrombosis, (2) chronic lower extremity venous insufficiency, (3) upper extremity venous thrombosis, and (4) pulmonary embolism are presented. Numeric grading schemes for disease severity, risk factors, and outcome criteria present in the original document have been updated to reflect increased knowledge of venous disease and advances in diagnostic techniques. Certain recommendations of necessity remain arbitrary. These standards are offered as guidelines whose observance will in our opinion improve the clarity and precision of communications in the field of venous disorders.
Patients with clinically evident chronic venous insufficiency were evaluated to relate the degree of insufficiency and calf muscle pump dysfunction to venous ulceration.
Sixty-nine limbs in 55 patients with chronic venous insufficiency by Society for Vascular Surgery/International Society for Cardiovascular Surgery Classification were compared in three groups: classes 1 and 2 with no history of ulceration (19 limbs); class 3 with healed ulceration (20 limbs); and class 3 with active ulcers (30 limbs). Air plethysmography measurements of outflow fraction, venous volume, venous filling time, venous filling index, ejection fraction, ejection volume, residual volume fraction, and residual volume were made. In 62 of the 69 limbs, color-flow duplex ultrasonography was used to determine the pattern of reflux.
The outflow fraction was normal in 84%, 75%, and 77% of nonulcerated, healed, and ulcerated limbs. The venous filling index was abnormal in most limbs (nonulcerated 95%, healed 90%, ulcerated 98%) but not significantly different among groups. Differences in calf muscle pump function were significant. Ulcerated limbs had significantly poorer ejection fractions (p = 0.0002) and greater residual volume fractions (p = 0.0006) than nonulcerated or healed limbs. By ultrasonography, deep and superficial vein incompetence was present in most limbs and was not statistically different among groups. Although venous insufficiency was not measurably different among groups, limbs with active venous ulcers had significantly poorer calf muscle pump function than those with healed ulcers or with no history of ulceration.
Venous insufficiency is necessary but not sufficient to cause ulceration, and a deficiency of the calf muscle pump is significant to the severity of venous ulceration.
Leg swelling is a significant problem following ankle fracture. Venous pump function and femoral and popliteal venous patency were assessed prospectively in 26 patients with ankle fractures requiring open reduction, internal fixation and immobilization in plaster. Functional venous volume, venous filling index (VFI), ejection volume fraction (EVF) and residual volume fraction (RVF) were measured using air plethysmography at 5 days and at 6, 12 and 18 weeks after fracture. The uninjured leg was used as a control. Popliteal and femoral venous patency was determined using duplex ultrasonography. No patient developed deep vein thrombosis during the study. At 5 days after fracture there was a significant reduction in mean(s.d.) EVF, 18.2(12.1) versus 55.9(19.5) per cent, and increase in RVF, 87.0(14.3) versus 42.5(22.2) per cent (both P < 0.001). Analogous values were similar at 6 weeks, EVF 28.5(21.2) versus 55.6(21.9) per cent, RVF 82.2(16.8) versus 48.5(23.8) per cent (both P < 0.001), and at 12 weeks, EVF 39.1(16.0) versus 60.3(14.9) per cent, RVF 64.7(18.8) versus 38.8(13.2) per cent (both P < 0.001). However, by 18 weeks there was no significant difference in venous function between fractured and control limbs. It is concluded that there is a significant and prolonged impairment in venous pump function following ankle fracture.
Two hundred thirty-six limbs of 220 unselected patients who were admitted with venous problems (83 with ulcers) were studied with continuous-wave Doppler ultrasonography, duplex scanning, and ambulatory venous pressure measurements. Patients with evidence of deep venous disease because of reflux or obstruction in the deep veins on Doppler and duplex ultrasonic examination or with an ambulatory venous pressure greater than 45 mm Hg despite the ankle cuff had venography. One hundred fifty-three limbs had superficial venous disease (reflux in the superficial veins with competent popliteal valves), and 83 limbs had deep venous disease (popliteal reflux on duplex examination or deep venous obstruction on venography). No ulceration occurred in limbs with ambulatory venous pressure < 30 mm Hg, and there was a 100% incidence with ambulatory venous pressure > 90 mm Hg. A linear increase occurred from 14% in limbs with ambulatory venous pressure between 31 and 40 mm Hg to 100% in limbs with ambulatory venous pressure greater than 90 mm Hg (r = 0.79). In the groups studied, an increased incidence of ulceration was associated with an increase in ambulatory venous pressure irrespective of whether the venous problem was the result of superficial or deep venous disease. Ambulatory venous pressure has both diagnostic and prognostic significance in patients with venous disease.
Goniometric measurement of forefoot position relative to the rearfoot is a routine procedure used by rehabilitation specialists. This measurement is also frequently made by visual estimation. The influence of tester experience on the reliability of these two techniques at the forefoot is unknown. The purpose of this investigation was to directly examine the reliability of goniometric and visual estimation of forefoot position measurements when experienced and inexperienced testers perform the evaluation. Two clinicians (> or = 10 years experience) and two physical therapy students were recruited as testers. Ten subjects (20-31 years old), free from pathology, were measured. Each foot was evaluated twice with the goniometer and twice with visual estimation by each tester. Intraclass correlation coefficient (ICC) and coefficients of variation method error were used as estimates of reliability. There was no dramatic difference in the intratester or intertester reliability between experienced and inexperienced testers, regardless of the evaluation used. Estimates of intratester reliability (ICC 2,1), when using the goniometer, ranged from 0.08 to 0.78 for the experienced examiners and from 0.16 to 0.65 for the inexperienced examiners. When using visual estimation, ICC (2,1) values ranged from 0.51 to 0.76 for the experienced examiners and 0.53 to 0.57 for the inexperienced examiners. The estimate of intertester reliability [ICC (2,2)] for the goniometer was 0.38 for the experienced examiners and 0.42 for the inexperienced examiners. When using visual estimation, ICC (2,2) values were 0.81 for the experienced examiners and 0.72 for the inexperienced examiners. Although experience does not appear to influence forefoot position measurements, of the two evaluation techniques, visual estimation may be the more reliable.
Musculoskeletal dysfunction may be associated with poor calf muscle pump function in patients with chronic venous ulceration. The aim of this study was to evaluate the effects of physical exercise on calf muscle pump function.
Twenty patients were recruited into a 6-week intensive exercise programme. Calf muscle function and calf muscle pump function were assessed using an isokinetic device and air plethysmography respectively, before and after the exercise programme.
There was significant improvement in calf muscle pump function, measured as increased ejection fraction and decreased residual fraction (P < 0.05); however, venous reflux was not altered (P > 0.05). Calf muscle strength and endurance parameters all increased, but not significantly (P > 0.05).
Poor calf muscle pump function in patients with chronic venous ulceration can be improved by physical exercise.
Because more than two thirds of patients with venous ulcer have an impaired calf muscle pump, enhancement of its ejecting ability with physical training may generate an improved hemodynamic milieu sufficient to promoting ulcer healing. This study evaluated the effects of short-term supervised calf exercise on calf muscle pump function and venous hemodynamics in limbs with venous ulceration.
Prospective controlled study.
University-associated tertiary care hospital.
The study consisted of 2 groups. An exercise group comprised 10 patients (median age, 72 years) receiving supervised isotonic calf muscle exercise for 7 consecutive days. A control group comprised 11 patients matched with those in the exercise group for age, sex, ulcer size, and ulcer duration (all, P>.09). Patients in both groups had perimalleolar venous leg ulcers, impaired calf muscle function (ejection fraction, <60%), and full ankle joint movement.
After providing a complete clinical history, both groups underwent a physical examination, venous duplex scanning, and air plethysmography. The venous filling index, venous volume, residual venous volume, and residual volume fraction of the calf on standing were measured plethysmographically at baseline and on day 8, in addition to calf muscle endurance as determined by the maximal number of plantar flexions performed against a fixed 4-kg resistance during 6 minutes (1 flexion/s). Operators were blinded to the subject's group. Exercise in the first group entailed consecutive active plantar flexions using a standardized 4-kg resistance pedal ergometer. Subjects daily completed 3 sets of flexions of 6 minutes each. All patients had short-stretched compression bandaging.
The ejected venous volume and ejection fraction were evaluated in both groups at baseline and on day 8.
Both groups had a similar hemodynamic performance at baseline for all the variables evaluated (P>.10). After 7 days of exercise, patients in the exercise group improved their ejected venous volume by 67.5%, ejection fraction by 62.5%, residual venous volume by 25% (all 3, P =.006), and their residual volume fraction by 28.6% (P =.008). Changes in the control group within the same period were small (all, P>.10). By day 8, the exercise group had a significantly better ejected venous volume (P<.001) and ejection fraction (P<.001) than the control group. The venous filling index and the venous volume did not change (P>.50) in either study group. Calf muscular endurance in the exercise group increased 135%, from a median 153 plantar flexions at baseline to 360 on day 7 (P<.001).
By increasing the muscular endurance, efficacy, and power of the calf muscle, isotonic exercise improves its ejecting ability and the global hemodynamic status in limbs with venous ulceration. Prospective evaluations of the clinical effects of calf muscle pump strengthening for the treatment of venous leg ulceration are indicated by the results of this study.
Many articles have been published on assessing and treating chronic venous insufficiency and venous leg ulcers; most recommend correcting the underlying cause. These same articles often fail to examine and address a common factor or cofactor of venous hypertension--musculoskeletal changes. Frequently, these changes accompany major injuries, neurological disease, vascular insufficiency, debilitating diseases, myositis, and bone and joint pain and can adversely affect the dynamics of the calf muscle pump. The calf muscles rapidly waste and weaken with disuse--even a change in gait related to a painful ulcer can exacerbate venous hypertension and cause calf muscle disuse atrophy. This article reviews the cause and effect of musculoskeletal changes on the hemodynamics of the calf muscle pump. Recommendations for changes in practice will be based on the identification of the underlying cause of chronic venous insufficiency related to these musculoskeletal changes.
Thirty subjects with type 1 diabetes, 30 subjects with type 2 diabetes, and 30 age- and sex-matched controls were evaluated through clinical goniometry and two-dimensional motion analysis systems to determine the dynamic and static range of motion of the knee, ankle, and hallux joints. The purpose of this study was to determine if the knee and ankle joints of patients with diabetes mellitus are affected by limited joint mobility syndrome. The study results support previous medical literature showing significant reduction of range of motion of the hallux in subjects with type 1 diabetes. Significant differences were found between the range of motion of male and female subjects in all lower-limb joints for both subject groups with diabetes compared to the control group, and male subjects in all groups recorded less range of motion than female subjects.
to investigate the relationship between clinical severity of venous disease, calf muscle pump dysfunction and range of ankle movement (ROAM).
ROAM was assessed by goniometry in the supine, nonweightbearing position. Calf muscle pump function was assessed by ambulatory venous pressure (AVP), calculating the pressure relief index (PRI). Venous disease was classified according to the CEAP classification (International Consensus Committee reporting standards on venous disease). Forty seven limbs in 38 adults were recruited and matched for age: 11 normal controls CEAP(0), 12 varicose veins CEAP(2), 12 chronic venous insufficiency CEAP(4,5) and 12 active ulceration CEAP(6).
mean (S.E.M.) age was 60.7 (1.3) years. Mean (S.E.M.) PRI was 1959.6 (313.7) in CEAP(0), 905.3 (139.3) in CEAP(2), 596.5 (148.5) in CEAP(4,5) and 170.6 (69.0) in CEAP(6) (p < 0.001, ANOVA). Mean (S.E.M.) ROAM was 61.3 (2.0) degrees in CEAP(0), but significantly reduced to 49.7 (2.0) in CEAP(2), 42.1 (2.6) in CEAP(4,5) and 40.9 (2.7) in CEAP(6) (p < 0.004, ANOVA post hoc Tukey). PRI correlated with ROAM (p < 0.001, Pearson correlation coefficientr = 0.52).
limbs with venous hypertension have a reduced range of ankle movement related to the clinical severity of venous disease.
Tiradentes, 1081 CEP 87013-260 – Maringá, PR E-mail: cleusabelczak@yahoo.com.br Articulação talocrural na úlcera venosa – Belczak CE et al. J Vasc Bras
- Correspondência
Correspondência:
Cleusa Ema Quilici Belczak
Centro Vascular João Belczak
Av. Tiradentes, 1081
CEP 87013-260 – Maringá, PR
E-mail: cleusabelczak@yahoo.com.br
Articulação talocrural na úlcera venosa – Belczak CE et al.
J Vasc Bras 2007, Vol. 6, Nº 2
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