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These exercises have previously been How much reduction in ankle joint exibility occurs
KEY WORDS discovered to be effective among this in CVI and venous ulceration?
Venous ulcer patient group (Davies et al, 2007). Back et al (1995) measured ankle range of
Exercise motion (plantar and dorsiexion) in four
The calf pump groups:
Pain The calf pump is the essential mechanism 8 Healthy volunteers
Calf pump by which blood is returned to the heart 8 People with CVI but no ulceration
Ankle mobility from the lower limbs, and is aided by the 8 People with CVI and a healed ulcer
Patient participation foot pump, thigh pump and respiratory 8 People with CVI and an active ulcer.
pump mechanisms. Araki et al (1994)
demonstrated the signicance of a The study showed that a decrease in
failing calf pump in patients with venous ankle range of motion occurred before
C
hronic venous ulcers pose a insufciency progressing to ulceration. any ulcer developed: a difference of an
continuing challenge to nursing and In comparing three groups of patients average of 57 in healthy volunteers to
interdisciplinary care.The visible active ulcers, healed ulcers and chronic 39 in patients with CVI but no ulcer. A
nature of the ulcer wound bed makes it all venous insufciency without ulceration steady worsening of exibility occurred in
too easy to focus on wound healing, while there was no signicant difference in the next two groups. Those with healed
losing sight of the underlying pathology of either the pattern or amount of reux.The ulceration had an average of 29 ROM
a dysfunctional calf pump which is a major active ulcer group was distinguished from while those with active ulceration had, on
contributor to the ulceration. the other two only by means of indicators average, only 21. They also demonstrated
of calf muscle pump function (poorer that functions of calf pump efciency
This article will rst focus on the ejection fraction and residual volume (ejection fraction and residual volume
literature addressing the calf pump fraction).They concluded that in patients fraction) correlated signicantly with ankle
mechanism and its inter-relationship with venous insufciency, an impaired calf ROM.
with venous disease. It will then describe pump is a key factor in the progression to
a series of exercises that patients with ulceration. Back et al (1995) also showed that
chronic venous ulcers can be encouraged dorsiexion, when measured separately,
to do in order to reduce pain and increase What biomechanical factor plays the central dropped from 10 in normal limbs to
their range of motion (ROM), which in role in the calf pump mechanism? -5 in those with active ulceration a
turn improves the calf-pump mechanism. Research over the past 1012 years total difference of 15.This means that
points to ankle joint movement as the key the average patient with an open ulcer
biomechanical element in a functioning would not be able to stand in a normal
Judy Davies is Senior Tissue Viability Research Coordinator,
calf pump. When articially restricting the position with their feet at on the ground
Richard Bull is Consultant Dermatologist and Ina Farrelly
is Senior Podiatrist at East London Wound Healing Centre, movement of the ankle joint in healthy when not wearing heels. Being unable
Mile End Hospital, Tower Hamlets Primary Care Trust, volunteers, Kugler et al (2001) showed to achieve a 90 angle between the foot
London and Melanie Wakelin is Statistician at the Centre that a signicant drop occurred in the and the ankle creates a pathological gait
for Health Sciences, Barts and the London Queen Marys efciency of the pump to affect a decrease pattern, as normal heel to toe walking is
School of Medicine and Dentistry, London in venous pressure during exercise. no longer possible.The duration of ulcer
has also been shown to correspond with atrophy as shown by Leivseth et al (1992) ankle ROM: Padberg et al (2004)
the loss of ankle joint exibility. Helliwell in their experiment on guinea pigs. When were unable to achieve any signicant
and Cheesebrough (1994) showed that in one of the legs of the guinea pigs was improvement after three months of
patients with chronic leg ulceration, there partially immobilised, signicant muscle supervised exercise followed by three
was a loss of 0.78 of movement for every atrophy occurred when compared with months of unsupervised exercise. Klyscz
year of active ulceration. the unrestrained leg. Immobilisation, itself, et al (1995) on the other hand, showed
therefore, also needs to be acknowledged a signicant improvement in patients
What effect does reduced ankle mobility, with its as a risk factor. with CVI who had moderate ankle
associated problems with gait and calf-pump activity ROM (average 34.4). The twice-weekly
have on venous ulcer wound healing? The fact that compression bandaging, intensive gym-based programme yielded
This is the most crucial question, and only while being absolutely necessary, can also a signicant increase in dorsiexion from
one study by Barwell et al (2001) has impinge on ankle mobility needs to be 7.7 to 11.5 and a statistically insignicant
focused on this specically although other recognised here. Lentner et al (1997) increase in plantar exion from 26.7
studies have looked at it more generally, demonstrated on healthy volunteers that to 29.
in terms of reduced mobility.The study compression bandaging of different types
showed an astonishing difference in healing all restrict ankle joint mobility, with thick A pilot study by the authors (Davies et
rates in patients who had less than 35 bandages having a greater restricting effect al, 2007) implemented a practical, home-
ankle ROM, compared with those with than thinner ones. based exercise programme that could be
more than 35. Only 13% of those with easily followed by patients unable to attend
less than 35 had healed at 24 weeks, What gait changes occur in patients with a intensive gym programs.Ten patients with
compared with 60% of those with more history of venous ulceration? open venous ulceration, and who all wore
than 35, despite all of them being treated Walking is the normal way the calf pump compression bandaging, participated in
with multilayer compression bandaging.The functions in everyday life, so gait patterns the study.The exercise programme was
difference in healing rates is so signicant are particularly important in patients done three times each week for 24 weeks,
that one would think it would have with a history of venous ulceration.This with monthly monitoring visits. Once the
spawned a great deal of research interest, has only recently been addressed in study was over, patients were encouraged
but little has been done in response. research studies.Van Uden et al (2005) to keep doing the exercises without
demonstrated that patients with active supervision and a follow-up visit was done
Are there other biomechanical factors affecting or healed ulcers had a slower preferred at the end of the year.The programme
the calf pump? walking speed as well as taking shorter consisted of gait improvement and 510
Calf muscle strength may also affect steps, though the latter did not reach minutes of ankle exercises carried out
the efciency of venous return, as statistical signicance. Roaldsen et al (2006) three times a week if possible when
improvement in calf muscle strength also demonstrated a slower walking speed the leg was unbandaged.
correlates with improved venous return, in active and healed ulcer patients and
as demonstrated by Kan et al (2001). Calf decreased walking endurance. Ten patients took part.The median age
muscle wasting is commonly found in was 73 years with a range of 6380 years.
patients with long-standing venous ulcers. What research has been undertaken to develop There were four men and six women, with
Taheri et al (1984) demonstrated that therapeutic measures to counteract musculoskeletal a median of 20 years of ulcer duration,
muscle biopsies of patients suffering from calf pump deciencies? ranging from six to 51 years.The median
venous insufciency showed three types There are ve studies into the effects of size of ulcer was 9.8cm2, with a range of
of atrophy occurring in the gastrocnemius exercise on calf pump deciencies that 1.5cm to 93cm.
muscle which suggests that disuse, involve patients with chronic venous
denervation and ischemia all have a role to disease (Klyscz et al, 1995; Hartmann Two patients dropped out very shortly
play in muscle breakdown. et al, 1997; Yang et al 1999, Kan et al after screening so they were not included
2001, Padberg et al, 2004). All ve in the 12-week analysis. Another two
How much calf muscle volume reported that exercise improved venous dropped out at 12 weeks or later, and
itself contributes to venous insufciency haemodynamics, with three demonstrating were therefore not included in the 24-
is unclear although a recent study by an improvement in calf muscle strength. week analysis.
Moloney et al (2007) of nine patients Two of the studies (Klyscz et al, 1995;
with venous ulceration did not show a Hartmann et al, 1997) reported an The baseline mean ankle ROM for
correlation between calf muscle volume improvement in the subjective experiences the eight patients included in the 12-
and venous return. of the patient linked to the exercise week analysis was 18.5 measured using
programme including a decrease in a bi-plane ankle goniometer (Figure 1)
Is loss of ankle mobility related pain, oedema, leg restlessness and cramps, slightly less than the average for ulcerated
to calf muscle atrophy? and itching. patients cited above by Back et al (1995).
Ankle ROM is closely linked to contraction This reected the long-term nature of the
of the calf muscles and loss of exibility Only two of the above studies ulcers for this patient group. By week 12,
may contribute substantially to disuse specically set out to achieve improved there was an average increase of 8.7 (P =
should be seen as the twin cornerstones Hartmann BR, Drews B, Kayser T (1997) talo-calcaneonavicular joints caused by
of therapy for this patient group. WUK Physical therapy improves venous compression bandages. Phlebology 12: 2530
hemodynamics in cases of primary varicosity:
Moloney MC, Lyons GM, Egan M, Wallis
results of a controlled study. Angiology 48(2):
Acknowledgements 15762
F, Burke PE, Kavanagh E, Grace PA (2007)
Thank you to the North East London Does size matter? The impact of calf muscle
Helliwell PS, Cheesebrough MJ (1994) volume on venous return in patients with
Consortium for Research and Development Arthropica Ulcerosa: A Study of Reduced venous leg ulcers. Phlebology 22(2): 659
for providing statistical support from Mrs Ankle Movement in Association with
M J Wakelin and to Phil Page and The Padberg FT, Johnston MV, Sisto SA
Chronic Leg Ulceration. J Rheumatol 21(8):
(2004) Structured exercise improves calf
Hygenic Corporation (Akron, Ohio) for 15124
muscle pump function in chronic venous
donating the Thera-BandsTM and handles. Kan YM, Konstantinos T, Delis T (2001) insufciency: A randomized trial. J Vasc Surg
Hemodynamic effects of supervised calf 39(1): 7987
Muscle Exercise in Patients With Venous Leg
Roaldsen KS, Rollman O, Torebjork E,
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Key Points