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202 MUSCULOSKELETAL FACTORS IN LEG ULCERS
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TABLE 4.3
Intrinsic Extrinsic
Sarcopenia Footwear and clothing
Age Home and outdoor lighting
Sex Flooring
Gait issues and balance Tripping hazards
Fitness Lack of xed grab bars
Strength and aerobic tness Unstable furniture
Vertigo
Impaired vision and hearing
Cognitive impairment
Cardiovascular disease
Medications
Depression
Source: Adapted from Ambrose etal. (2013).
Reasons forfalling.
decreased activity, which can have an adverse eect on a person’s
mobility (Hamilton etal.2020).
Knowledge of surgical procedures will inform the clinician of
any post- surgical trauma to the surrounding veins, tissues and lymphatics secondary to the surgery, which may cause the patient lower
limb problems that relate to CVD in the future.
Sitting andStanding Occupations
Although there is no denitive link between the development of
CVD and VLUs and certain occupations, there is evidence to suggest
that people in occupations who stand or sit in a static position for
long periods of time may be more at risk of developing CVD (de
Lima2019). Exploration of the patient’s occupation and determining
their activity at work can indicate how sedentary they are during the
day and provide insight into the possible risk of CVD or developing
VLUs (de Lima2019).
Occupations that involve long periods of prolonged static standing are associated with increased MSK disorders that aect the lower
back and the lower limbs (Anderson etal.2021). Such occupations
may increase the risk of developing a VLU (de Lima2019). Standing
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is known to be associated with prolonged discomfort and other
symptoms of venous diseases like varicose veins (Antle etal.2018).
Prolonged static standing leads to increased venous hydrostatic pressure and increased venous backow within the peripheral venous
system, which can lead to CVD and lymphoedema.
Conversely, occupations that are sedentary in nature or where
prolonged sitting is involved have been reported to be associated with
obesity, MSK pain and other chronic health conditions (Antle etal.
2018). Prolonged standing and sitting occupations are detrimental in
terms of impaired lower limb uid dynamics and the risk of increased
venous hypertension (Uhl and Gillot 2015; Horwood2019). Therefore, knowing a patient’s occupation will allow a more tailored approach
to giving advice on what can be done to improve VMP activity to help
reduce venous hypertension.
For example, if the person works in retail, then encouraging
them to spend less time in a static position by walking, stepping or
changing position will encourage lower limb muscle pump activity
and improve lower limb venous dynamics while enhancing VMP
activity. In terms of sitting, encouraging people to engage in chairbased exercises and regularly getting up from the chair will again
help with lower limb haemodynamics and reduce the risk of venous
pooling and peripheral oedema, which can lead to CVD.
Obesity
Obesity has an impact on gait, which can impair a person’s mobility and lead to a reduction in general activity; obesity is a known
risk factor for the development of VLUs (Davies et al. 2017).
These alterations in mobility or mobility impairment secondary
to obesity can lead to reduced CMP function, which has an impact
on ambulatory venous pressure (Davies et al. 2019). When
abdominal obesity is present this can obstruct venous outflow
and impair venous haemodynamics. Increased adipose tissue
results in augmented inflammatory cytokine activity that can
lead to chronic inflammation and increased endothelial permeability. This will affect microcirculatory function and can contribute to venous disease and ulceration (Meulendijks etal.2020a).
Addressing the causes and onward referral for the management
(Meulendijks et al. 2020a) of the obesity are key in helping to
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improve physical activity and reduce the risk of chronic venous
insufficiency (CVI).
Physical Activity
One of the responsibilities of healthcare practitioners is to oer lifestyle advice and discuss lifestyle modication in relation to physical
activity (Department of Health and Social Care2019). Physical activity is dened as any bodily movement produced by skeletal muscles
that requires energy (Langhammer etal.2018). It happens in many
forms, in dierent settings and has many purposes (Department of
Health and Social Care2019). Physical activity is not limited to exercise. Many patients with CVD or VLUs may not be able to ‘exercise’
due to their individual physical capabilities, therefore promoting
advice that is focused on being mobile and moving throughout the
day is important. Reinforcing these messages during appointments
may help reduce sedentary habits, which can have a positive impact
on a patient’s condition and quality of life.
Assessing the patient’s physical activity is important to identify if
they are meeting current physical activity guidelines, so that, if they
are not then the clinician is aware of this and can put in place a management plan to help them achieve this or move closer to reaching
activity levels within these guidelines (Knox etal.2013; Department of
Health and Social Care2019). The guidelines can be used as a guide in
terms of goals for patients to help improve mobility and activity.
They include:
150 minutes of moderate- intensity exercise per week.
75 minutes of vigorous activity.
Strength- building activities for muscles, bones and joints at least
two days a week. This could be carrying heavy bags, gym or yoga etc.
Reducing sedentary time.
Improving balance.
To determine a person’s activity, it is important to ask:
What types of physical activity do you do each day?
What levels of activity occur over a week? This would include
moderate or vigorous levels of activity over the week.
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What is your current physical ability? This would be a subjective
report of what the person feels they may be physically capable of
undertaking.
Are there any barriers to you undertaking more physical activity?
MANAGEMENT
Walking andMobility
Humans have evolved habitually to walk upright; this is called bipedalism (d’Août etal.2004). Habitual bipedalism that enables walking
is not only part of our physical evolution, walking is also engrained in
our psyche. The ability to walk is intimately linked to our identity
and emotional well- being (Hammarlund et al.2014). Being able to
walk independently is part of being autonomous in life (Pirker and
Katzenschlager2017).
Walking is an activity that people do in their everyday lives and
when promoted can be a way of helping to increase a person’s activity
and increase their mobility. The benet of walking is that it does
notrequire special skill, ability or specialised equipment (Lee and
Buchner 2008). Walking is accessible and is a universal form of
activity that can be advocated regardless of sex, age, ethnicity, education or socioeconomic background (Lee and Buchner2008).
Anecdotally, many patients who have VLUs state that their
mobility goals are focused on being able to ‘walk more’. In many
cases, patients will comment on how losing the ability to walk in the
way they did previously due to their lower limb condition is an issue
that they nd dicult to cope with and it impacts on their QoL.
Patients with CVI and VLUs report leg and foot pain and this has a
direct inuence on their levels of activity and a deleterious impact on
VMP function in the lower limb.
Active people may take thousands of steps per day. People who
are not experiencing walking and mobility issues will move pain free,
have adequate function and expend the least amount of energy possible to perform the task of walking, which is generally an automatic,
repetitive combination of movements grouped into what is termed
the gait cycle (Simonsen2014; Gardner etal.2016; Ricci2020).
It is important for healthcare professionals to watch the way
patients are moving and walking for the duration of their
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appointments to identify decits or impairments that may require
onward referral for in- depth assessment. Having a basic understanding of the concept of the gait cycle may clarify and help the clinician
articulate what is being observed and aid in documentation when
referring a patient to another healthcare professional.
The Gait Cycle
Complex gait analysis is beyond the scope of this book and requires
skills that are outside the nursing scope of practice. However,
understanding the rudiments of gait may help in recognising what
is sub- optimal and this may facilitate onward referral to an allied
health professional (AHP) who can undertake gait analysis and
commence appropriate management.
The gait cycle is the basic terminology used to describe human
locomotion. The process of walking is described in gait phases
(Figure4.3). Each gait cycle can be representative of how a person
walks and the comparison of several gait cycles can be indicative of
the variability of an individual’s gait pattern (Baker2013). Gait analysis
assumes that cyclic motion is an important indicator of locomotor
function (Baker 2013). Maintaining this optimal cyclical motion
(walking) is vital in enabling the lower limb joint ROM that will
enhance VMP function.
There are two main phases, the stance and swing phase, and
eight sub- phases, identied as initial contact, loading response, mid
stance, terminal stance, pre- swing, initial swing, mid swing and terminal swing.
The stance phase (when the foot is in contact with the ground) is
typically 60% of the gait cycle and the swing phase (when the foot is
o the ground) is typically 40% of the gait cycle. However, the gait
cycle is variable from person to person (Ricci2020). Typically gaitrelated issues occur within the stance phase of gait and this is where
podiatrists or therapists will focus their treatments, for example with
in- shoe foot orthoses (FO) or exercise therapy (Reina- bueno
etal.2020). However, not all gait- related issues occur in the stance
phase, for example a person with foot drop will have issues in
theswing phase and the stance phase due to lack of dorsiexion of
the foot and ankle, and treatments will need to be focused within the
stance and swing phases.
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FIGURE 4.3 The gait cycle.
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Source: Walha et al. (2020) / John Wiley & Sons / CC BY 4.0.
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Spatial andTemporal Parameters
When considering how a person is walking, there are known spatial
(space) and temporal (time) parameters that can be considered to
understand how a person is moving and walking. For example, a
nurse may adjust the speed at which they are walking with a patient
as the patient may be walking more slowly (a temporal parameter)
because they are taking shorter steps (a spatial parameter). This
slower speed, shorter step length and a wider base of gait may result
in a ‘shuing’ gait that is detrimental to VMP function, because the
sub- optimal movement of this gait pattern will result in a reduction
of joint ROM and thus VMP function. Other temporal and spatial
factors are listed in Table4.4.
The causes of gait disorders include neurological, nonneurological, orthopaedic, medical and other multifactorial aetiologies; that can become more common with increasing age. Given
that gait impairment is recognised as an issue for patients with
VLUs, when impairment is recognised patients should be referred
on for specialist gait assessment within a podiatry or physiotherapy
service (Clarke- Moloney etal.2007; Humphreys etal.2016; Guest
etal.2018).
TABLE 4.4
Spatial parameters
Step length The distance that one part of the foot travels
Stride length This is the distance between successive
Step width The measure of the mediolateral separation
Temporal parameters
Stride time The duration of one gait cycle
Cadence The number of steps per minute
Walking speed The distance travelled within a given time
Source: Adapted from Baker (2013).
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Spatial andtemporal parameters.
in front of the same part of the foot
during each step
points of initial contact of the same foot
with the ground
of the feet
(related to cadence and stride length)
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Mobility andExercise
As previously discussed, signicantly reduced ankle ROM and reductions in balance and strength are associated with the development of
CMP dysfunction and can also contribute to gait dysfunction
( Williams etal. 2014; de Souza et al.2022). Considering this evidence, activities and exercises that are focused on improving these
parameters would be of benet to patients with VLUs.
The evidence base reports that progressive and aerobic exercise
can be considered for those patients who have the capability of carrying out such activities (Davies etal.2008; Araujo etal.2016; Smith
et al. 2018). If a patient is capable then dynamic, aerobic exercise
would be appropriate, and encouraging walking or hobbies like tai chi
and dancing would be of benet, as these types of activities will all
promote active VMP function. If the patient has balance or strength
issues, then giving chair- based resistance exercises that mobilise the
ankle using a TheraBand (an elastic band that adds resistance to any
movement) is appropriate (Figure4.4). If the patient is not able to use
the TheraBand, then simple chair- based exercises that mobilise the
ankle in the sagittal plane in dorsiexion and plantarexion will again
help venous return and mobilise the ankle joint.
Foot Issues andMobility
Evidence suggests that foot problems have an impact on mobility and
are associated with reduced walking speeds, increased double limb
support, diculty in functional activities like rising from and sitting
in a chair and impaired balance (Menz2021). The foot is the interface
between the body and the ground when weight- bearing, thus footwear
can aect stability and balance in a positive or negative way, depending on the chosen footwear or how the footwear is worn (Menz2021).
Foot problems are common in older people and frequent foot pain
is reported in the forefoot and toes. The most common disorders
reported are:
Hyperkeratotic lesions (callus, corns).
Nail disorders.
Structural foot deformities like hallux valgus (bunions) and lesser
toe deformities (hammer, claw and mallet toe deformities)
(Menz2021).
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FIGURE 4.4 Seated ankle joint exercises with a TheraBand.
Identifying any foot pain or problems is important, as these
issues can result in reduced mobility that negatively impacts on VMP
activation.
Keeping patients walking, independently mobile and exploring
the barriers behind issues related to walking and foot problems are
important. Many of the issues explored and declared may be outside
of the nursing scope of practice and will be within the remit of an
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AHP. Therefore, it is important once these issues are identied that
the patient is referred to the appropriate practitioner, such as a podiatrist or physiotherapist for further assessment and management.
Footwear
Footwear protects the feet from the environment and enables a supporting surface between the foot and the ground (Barwick etal.2019).
Footwear is also seen as part of a person’s outward appearance and
plays a role in identity. Some patients will choose aesthetics over
comfort, t and safety, which can often lead to sub-
optimal footwear
choice (Davis etal.2013).
Similarly, shoe- wearing habits can be equally sub- optimal. Some
elderly people in the United Kingdom wear slippers 80% of the day,
indoors and outdoors; this can lead to a higher falls risk compared
with those who wear fastened footwear (Menant etal.2008). Walking
unshod (without footwear) or when wearing socks also increases an
elderly person’s falls risk compared to wearing trainers (athletic
shoes) or canvas- style shoes (Menant et al.2008; Menz 2021). The
heel height and design of footwear are also important factors (Menant
etal.2008). Footwear with a heel that is greater than 2.5 cm is linked
to a higher falls risk compared with canvas- style shoes or trainers
(Koepsell etal.2004).
Footwear has been shown to have an inuence on the haemodynamics in the lower limb in asymptomatic populations (Lerebourg
etal.2020). Unstable, rocker- soled, heelless (at) and athletic footwear has been shown to have a positive impact on the haemodynamics in the lower limb in asymptomatic, healthy populations
(Lerebourg etal.2020). Moreover, athletic shoes have been shown
to modify the spatial- temporal parameters in gait (increased step
frequency and speed), which will increase muscle activity in the
lower limb. This evidence suggests that unstable shoes cause instability, which increases ankle ROM during movement or gait (Lerebourg etal.2020).
The theory of ‘unstable’ shoes is that certain technologies (i.e. a
rocker sole) are built into the shoes that makes them unstable and
this helps to train and strengthen muscles in the human locomotor
system (Nigg etal.2010). These technologies built into the shoes are
reported to elicit an increase in muscle activity in approximately 80%
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