Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_782_Библиотеки_им_академика_М_И_Перельмана
.pdf
212 MUSCULOSKELETAL FACTORS IN LEG ULCERS
https://t.me/medicina_free
of the population, with the highest relative increase in the muscles
that cross the ankle joint (Nigg etal.2010). However, this is variable
among subjects. This contrasts to an ‘unstable’ shoe that is unsafe to
wear because it is ill tting, worn-out or not appropriate for the task
being undertaken, for example wearing high heels to run a marathon.
Although the evidence suggests that unstable shoes with builttechnologies can lead to a change in ‘venous parameters’ like blood
ow in healthy populations (Lerebourg etal.2020), it is important to
note that appropriate footwear should be carefully recommended
considering the patient’s mobility and balance, and with safety being
of paramount importance.
Fit andCondition ofFootwear
The t of footwear is important in helping a person to walk pain free
and to allow optimal function during gait. Incorrectly tting shoes
have been linked to foot pain and foot disorders (Buldt and
Menz2018). There is no international sizing convention for footwear
and shoe brands will use anatomical last shapes when making shoes.
The last is a 3D model of a human foot that is used to construct a
shoe. The last shape depends on the country the shoe is from and on
the model of a typical foot from that region of the world. The style
and shape of the shoe will then be determined by the footwear producer and most shoe lines are mass made. It is therefore imperative
that patients check shoe t before purchase. See Figure4.5 for helpful suggestions when choosing footwear.
Patients may also present in footwear that they deem appropriate
but are inappropriate, or may be struggling to nd footwear that ts
over bandaging. Due to socioeconomic factors, they may have wornout footwear or even have had to repair shoes themselves. If this is
the case and the footwear is putting the patient at risk of falling or
non- healing, then referring the patient on to surgical appliances or
supplying them with temporary footwear is an option.
in
Temporary Footwear
It is not uncommon for a patient to go into a temporary shoe, like a
Darco healing sandal, during an episode of ulceration, as these better
accommodate compression bandaging (Figure 4.6). However, it is
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 213
Top tips
Leave a thumb width gap at the end of the shoe to allow your toes to move
Shoes with a wide opening allow for easier access for your feet
https://t.me/medicina_free
Fastening
1.
(lace or Velcro)
Sturdy
2.
heel
counter
Rocker sole that bends
3.
where your foot bends
Choose a shoe with a removable insole for extra room
FIGURE 4.5 Tips on choosing footwear.
Source: Accelerate Footwear UK.
FIGURE 4.6 Darco healing sandal.
important to remember that these shoes are temporary and should be
checked and replaced on a regular basis.
When transitioning a patient from bandaging into compression
garments, it is important to ensure that they have a well- tting and
appropriate shoe to wear. Consider asking the patient to bring their
本书版权归John Wiley & Sons Inc.所有
214 MUSCULOSKELETAL FACTORS IN LEG ULCERS
(a) (b)
https://t.me/medicina_free
shoes and the slippers they would normally wear so that you can
assess the t and style to see if any changes need to be made or if new
footwear needs to be considered.
Bespoke or Semi-
bespoke Footwear andFootwear Modications
Some patients may have a foot shape or structure that does not t
into retail footwear, or they may require footwear modications.
Rocker- soled shoes are important for patients with CVI and VLUs, as
the rocker sole enables improved ankle movement and thus enhances
the action of the CMP (Figure4.7). There are many retail shoes
ranges that have rocker soles, but in some cases it may be necessary
for a patient to have their shoes modied and have a specialist rocker
sole added. There are other modications that can be made to shoes
to help improve gait and mobility. This requires assessment with a
footwear specialist or podiatrist to ascertain what would be the most
appropriate modication given the person’s underlying medical
issues and biomechanical function.
Advice andEducation
Patient education on the important features of footwear is essential, as footwear can enhance foot function and enable improved
FIGURE4.7 (a) O- the- shelf functional foot orthoses. (b) Fully custom-
made functional foot orthoses.
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 215
https://t.me/medicina_free
haemodynamics in the lower limb (Lerebourg etal.2020). Shoes
should have a fastening (this could be a lace or Velcro®) that
helps to secure the shoe to the foot to enable optimal gait.
Asturdy heel counter to hold the heel in place will provide stability in the rear foot during heel strike and a rocker sole will
bend where the foot bends. This will enhance sagittal plane
movement, aid in CMP function and ooad the forefoot. Suggesting
shoes with a wide opening and a removable insole will help provide
extra room for oedematous feet or feet in bandaging or compression garments.
Changing footwear can be seen as a lifestyle change and must
be considered among other important factors such as cost, purpose
and choosing the right shoe for the right activity or occasion. Being
aware of these barriers is important, as it will help identify potential issues behind why a patient is reticent to change their footwear
and guide in future management. When patients do not wish to
change their footwear after being given information on optimal
footwear and the reasons why, then they have made an informed
choice and this discussion can be revisited later when they may be
more open to change.
Foot Orthoses
An orthosis is dened as ‘an appliance to support, align, correct
deformity or motion of parts of the body’ (Mills etal.2010). Orthotic
provision in general has been reported to help people achieve optimal health and QoL, and enable them to work and live independently
(Chockalingam etal.2019).
Foot orthoses (Figure 4.7) are appliances that can be inserted
into footwear to manage a number of foot and ankle pathologies
(Mills etal.2010) and can help to improve symptoms in chronic
foot conditions like rheumatoid arthritis (Hennessy etal. 2012).
VMPs in the lower limb rely on optimal lower limb function, so
foot orthoses should be considered where lower limb function and
movement are sub-
Research has reported improvements in pedobarographic
examination (the study of pressure acting between the plantar
surface of the foot and a supporting surface) when using orthoses
(Saggini et al. 2009). Positive changes in biomechanics and the
本书版权归John Wiley & Sons Inc.所有
optimal.
216 MUSCULOSKELETAL FACTORS IN LEG ULCERS
https://t.me/medicina_free
redistribution of power loads on the plantar surface of the foot were
noted. This included greater activation of the external and internal
plantar veins when using viscofoot posture in patients with CVI (Saggini etal.2009). Custom foot
orthoses have been studied and, again, positive ndings have been
reported in terms of improved venous return in the lower limb
(López- López etal. 2018). These positive ndings in the biomechanical parameters, improved venous return and improved activation
of the VMP of the foot and calf substantiate the use of orthoses in
clinical practice.
elastic foot orthoses that corrected
REDUCING FALLS RISK
A fall is dened by Public Health England (Oce for Health Improvement and Disparities2022) as ‘an event which causes a person to,
unintentionally, rest on the ground or lower level and is not a
result of a major intrinsic event’. Research has shown that 75–80%
of falls where no injury was sustained are not reported (Fleming and
Brayne2008) and that there is a stigma associated with falls (Homan
etal.2018). This is why asking questions and screening for the risk of
falls are so important, as this may help to mitigate the incidence of
falls and thus the sequelae of a fall, which can have a negative impact
on a patient’s mobility and exacerbate CVD or VLUs in terms of
prolonged healing.
Screening andAssessment ofFalls
Screening will help determine if further assessment or onward referral is required. One of the simplest screening approaches is to ask if
the patient has fallen in the last 12 months and then enquire about
the frequency and nature of the fall(s). Observation of the patient
walking is also useful to obtain objective information on how the
patient is moving and if they are using walking aids, if these appear
appropriate in terms of wear and height, as this may cause instability
and possibly result in a fall.
It is reported in the literature that a proportion of patients with
VLUs have reduced ankle ROM (Back etal.1995; Davies etal.2007;
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 217
https://t.me/medicina_free
Atkin etal.2016; de Souza etal.2022). Studies have shown that
people with decreased ankle exibility fall more often than those
with adequate ankle exibility (Menz2021). Long-
term bandaging
for VLUs can alter gait by impairing the ankle ROM (Atkin
etal.2016). Therefore, patients with VLUs and a restricted ankle
joint ROM are more at risk of falls. Injuries resulting from falls can
lead to pain and immobility, which will have an impact on uid
dynamics in the lower limb and can result in a longer episode of
ulceration.
Screening Tools forFalls
There are many validated and reliable mobility screening and assessment tools available to the practitioner and these can be used in the
home or clinical setting (Table4.5) (Tinetti etal.1986; Podsiadlo and
Richardson1991; Bogle Thorbahn and Newton1996).
Falls are complex, and in-depth assessment should be undertaken
by a practitioner or a team to ensure the most appropriate interventions are in place to help reduce the risk of a fall. Patients who are at
high risk of falls or who have a fear of falling should be referred to the
appropriate service for assessment.
TABLE 4.5
Modied falls ecacy scale A 14- item patient- reported measure
Timed up and go test Assessing sitting to stand, walking two
Thirty- second chair stand Focused on functional ability in repeated
Tinetti balance tool Assessment of balance and gait focused on
Berg balance scale An objective tool to determine a patient’s
本书版权归John Wiley & Sons Inc.所有
Examples ofscreening tools forfalls.
assessing confidence and activities of
daily living
meters, turning and then sitting down.
Cut- o times indicate falls risk
sitting and standing from a chair
chronic disabilities
ability to safely balance during predetermined tasks
218 MUSCULOSKELETAL FACTORS IN LEG ULCERS
https://t.me/medicina_free
ALLIED HEALTH PROFESSIONALS ASPART
OFTHE MULTIDISCIPLINARY TEAM
Populations are ageing worldwide. People are living longer and this
leads to higher levels of chronic disease (Saxon etal.2014). This will
have a direct impact on the numbers within the population who have
CVI and VLUs in the future.
The standards of care for long- term management of wounds have
been debated within the evidence, consensus documents produced
and various recommendations made (Atkin etal.2019). The current
trend within the evidence is that VLUs, especially those that are
deemed long term, should be escalated to a specialist service or a multidisciplinary team (MDT) (Atkin etal.2019). This notion is associated
with the standards of best practice that are based on the UK national
diabetic foot ulcer guidelines for MDT referral (Atkin etal.2019). Recommendations for specialty skills to be integrated into best practice
include podiatry, endocrinology and nutrition. While these skills
within the MDT may help those who have long- term wounds, little
attention is paid to addressing the area of management that enhances
mobility and VMP function. This is where AHPs who have a musculoskeletal scope of practice at the core of their skill set can be used to
enhance best practices within current and future guidelines.
CONCLUSION
This chapter has examined the important factors that inuence
mobility, biomechanical function, gait assessment and management
of MSK factors within the population of people who have CVD and
VLUs. The evidence elucidates the decreased levels of mobility, CMP
dysfunction and physical impairments that are present within this
group of patients. It is important to address these underlying MSK
issues, which may be inuenced by social or patient- related factors
for a positive clinical outcome and may not always be within the
scope of practice of wound care nursing. If this is the case, then
onward referral is warranted. This ensures that the patient receives
thecare they need to address any underlying causes for musculoskeletal issues in order to enhance mobility, expedite wound healing and
prevent the occurrence of a venous leg ulcer in the future.
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 219
https://t.me/medicina_free
REFERENCES
Ambrose, A.F., Paul, G., and Hausdor, J.M. (2013). Risk factors for falls
among older adults: a review of the literature. Maturitas 75 (1): 51–61.
Anderson, J., Williams, A.E., and Nester, C. (2021). Musculoskeletal disor-
ders, foot health and footwear choice in occupations involving prolonged standing. International Journal of Industrial Ergonomics
81: 103079.
Antle, D.M., Cormier, L., Findlay, M. etal. (2018). Lower limb blood ow and
mean arterial pressure during standing and seated work: implications
for workplace posture recommendations. Preventive Medicine Reports
10: 117–122.
Araki, C.T., Back, T.L., Padberg, F.T. etal. (1994). The signicance of calf
muscle pump function in venous ulceration. Journal of Vascular Surgery
20 (6): 872–879.
Araujo, D.N., Ribeiro, C.D., Maciel, A.C. et al. (2016). Physical exercise for
the treatment of nonDatabase of Systematic Reviews 12 (12): CD010637.
Atkin, L., Búcko, Z., Montero, E.C. etal. (2019). Implementing TIMERS: the
race against hard28(Sup3a): S1–S50.
Atkin, L., Stephenson, J., Partt, G. etal. (2016). An investigation to assess
ankle mobility in healthy individuals from the application of multicomponent compression bandages and compression hosiery. Journal of
Foot and Ankle Research 9 (1): 18.
Back, T.L., Padberg, F.T. Jr., Araki, C.T. etal. (1995). Limited range of motion
is a signicant factor in venous ulceration. Journal of Vascular Surgery
22 (5): 519–523.
Baker, R. (2013). Measuring Walking: A Handbook of Clinical Gait Analysis.
Chichester: Wiley.
Barwell, J.R., Ghauri, A.S.K., Taylor, M. etal. (2000). Risk factors for healing
and recurrence of chronic venous leg ulcers. Phlebology 15(2): 49–52.
Barwick, A.L., van Netten, J.J., Hurn, S.E. et al. (2019). Factors associated
with type of footwear worn inside the house: a cross- sectional study.
Journal of Foot and Ankle Research 12: 1–9.
Bogle Thorbahn, L.D. and Newton, R.A. (1996). Use of the Berg balance test
to predict falls in elderly persons. Physical Therapy 76 (6): 576–583.
Brockett, C.L. and Chapman, G.J. (2016). Biomechanics of the ankle. Ortho-
paedics and Traumatology 30 (3): 232–238.
Buldt, A.K. and Menz, H.B. (2018). Incorrectly tted footwear, foot pain and
foot disorders: a systematic search and narrative review of the literature.
Journal of Foot and Ankle Research 11 (1): 1–11.
ulcerated chronic venous insuciency. Cochrane
to- heal wounds. Journal of Wound Care
本书版权归John Wiley & Sons Inc.所有
220 MUSCULOSKELETAL FACTORS IN LEG ULCERS
https://t.me/medicina_free
Chockalingam, N., Eddison, N., and Healy, A. (2019). Cross- sectional survey
of orthotic service provision in the UK: does where you live aect the
service you receive? BMJ Open 9 (10): e028186.
Moloney, M., Godfrey, A., O’Connor, V. et al. (2007). Mobility in
Clarke-
patients with venous leg ulceration. European Journal of Vascular and
Endovascular Surgery 33 (4): 488–493.
Corley, G.J., Broderick, B.J., Nestor, S.M. etal. (2010). The anatomy and phys-
iology of the venous foot pump. Anatomical Record: Advances in Integra-
tive Anatomy and Evolutionary Biology 293 (3): 370–378.
D’Août, K., Vereecke, E., Schoonaert, K. etal. (2004). Locomotion in bonobos
(Pan paniscus): dierences and similarities between bipedal and quad-
rupedal terrestrial walking, and a comparison with other locomotor
modes. Journal of Anatomy 204 (5): 353–361.
Davies, J.A., Bull, R.H., Farrelly, I.J., and Wakelin, M.J. (2007). A home-
exercise programme improves ankle range of motion in long-
venous ulcer patients. Phlebology 22 (2): 86–89.
Davies, J., Bull, R., Farrelly, I., and Wakelin, M. (2008). Improving the calf
pump using home-
ease. Wounds UK 4 (3): 48–57.
Davies, H.O., Popplewell, M., Bate, G. etal. (2019). Publication of UK NICE
Clinical Guidelines 168has not signicantly changed the management
of leg ulcers in primary care: an analysis of the health improvement
network database. Phlebology 34 (5): 311–316.
Davies, H.O.B., Popplewell, M., Singhal, R. etal. (2017). Obesity and lower
limb venous disease–the epidemic of phlebesity. Phlebology 32 (4):
227–233.
Davis, A., Murphy, A., and Haines, T.P. (2013). ’Good for older ladies, not
me’: how elderly women choose their shoes. Journal of the American
Podiatric Medical Association 103 (6): 465–470.
Day, J. (2015). Diagnosing and managing venous leg ulcers in patients
inthe community. British Journal of Community Nursing 20 (Sup12):
S22–S30.
de Lima, D.C. (2019). Varicose veins and occupational health: symptoms,
treatment and prevention. Revista Brasileira De Medicina do Trabalho
17 (4): 589.
Department of Health and Social Care (2019). Physical activity guidelines:
adults and older adults. https://www.gov.uk/government/publications/
physicalde Souza, I.N., de Oliveira, L.F.F., de Almeida, I.L.G.I. etal. (2022). Impair-
ments in ankle range of motion, dorsi and plantar exors muscle strength
and gait speed in patients with chronic venous disorders: a systematic
review and meta- analysis. Phlebology 37 (7): 496–506.
activity- guidelines- adults- and- older- adults
based exercises for patients with chronic venous dis-
based
term
本书版权归John Wiley & Sons Inc.所有
Musculoskeletal Factors in Leg Ulcers 221
https://t.me/medicina_free
Farrelly, I. (2018). The adversarial relationship between wounds and biome-
chanics in the lower limb. Wounds UK 14 (5): 70–76.
Fleming, J. and Brayne, C. (2008). Inability to get up after falling, subsequent
time on oor, and summoning help: prospective cohort study in people
over 90. BMJ 337: a2227.
Franks, P.J., Barker, J., Collier, M. etal. (2016). Management of patients with
venous leg ulcers: challenges and current best practice. Journal of
Wound Care 25 (Sup6): S1–S67.
Gardner, A.M.N., Ch, M., and Fox, R.H. (1983). Pump of the preliminary
report. Bristol Medico- Chirurgical Journal 98 (July): 109–112.
Gardner, A.W., Montgomery, P.S., Casanegra, A.I. etal. (2016). Association
between gait characteristics and endothelial oxidative stress and inammation in patients with symptomatic peripheral artery disease. Age
38 (3): 64.
Guest, J.F., Fuller, G.W., and Vowden, P. (2018). Venous leg ulcer manage-
ment in clinical practice in the UK: costs and outcomes. International
Wound Journal 15 (1): 29–37.
Halkar, M., Inojosa, J.M., Liedl, D. etal. (2020). Calf muscle pump func-
tion as a predictor of all- cause mortality. Vascular Medicine 25 (6):
519–526.
Hamilton, D.F., Beard, D.J., Barker, K.L. etal. (2020). Targeting rehabilitation
to improve outcomes after total knee arthroplasty in patients at risk of
poor outcomes: randomised controlled trial. BMJ 371: m3576.
Hennessy, K., Woodburn, J., and Steultjens, M.P.M. (2012). Custom foot
orthoses for rheumatoid arthritis: a systematic review. Arthritis Care &
Research 64 (3): 311–320.
Hoffman, G.J., Ha, J., Alexander, N.B. etal. (2018). Underreporting of
fall injuries of older adults: implications for wellness visit fall
risk screening. Journal of the American Geriatrics Society 66 (6):
1195–1200.
Horwood, A. (2019). The biomechanical function of the foot pump in
venous return from the lower extremity during the human gait cycle:
an expansion of the gait model of the foot pump. Medical Hypotheses
129(March): 109220.
Horwood, A. (2021). The venous foot pump: modelling its function in gait.
Podiatry Review 78 (3): 19–24.
Houghton, D.E., Ashrani, A., Liedl, D. et al. (2021). Reduced calf muscle
pump function is a risk factor for venous thromboembolism: a
population- based cohort study. Blood 137 (23): 3284–3290.
Humphreys, C., Moatt, C., and Hood, V. (2016). Risk of falling for people
with venous leg ulcers: a literature review. British Journal of Community
Nursing 21 (Sup3): S34–S38.
本书版权归John Wiley & Sons Inc.所有
Соседние файлы в папке Библиотека им академика М.И. Перельмана