Injection-related venous disease and walking mobility.

Injection users are at risk for vascular injuries resulting in chronic venous disease (CVD). The authors examined walking mobility in relation to CVD for 713 individuals in methadone treatment. The authors used a cross-sectional, comparative design that was stratified on age, sex, ethnicity, and drug use. CVD was present in 92.3% of participants. The structural equation model supported the causal link between leg injection and CVD (.40, P<.001). The worse the mobility, the greater was the CVD classification (-.21, P<.001). CVD had an indirect effect on mobility through pain. CVD and pain need to be considered when assessing mobility in illicit drug users.

The impact of vascular leg disorders on physical activity in methadone-maintained adults.

Chronic venous disorders (CVD) and peripheral arterial disease (PAD) may affect diverse physical activity domains. How CVD and PAD and other relevant variables affect physical activity was examined in 569 opioid-addicted adults. Both CVD and PAD were significantly inversely related to daily walking, sports, and active living. Effects remained significant in the latent variable regression after controlling covariates. Overall activity was very low; most participants walked less than a half mile daily and rarely engaged in sports. Motivation for physical activity was the strongest predictor (ß = .55) of daily physical activity. Health-care professionals promoting physical activity for injection users should consider the vascular health of their legs and motivational variables in addition to general health.

Impact of injection drug use on distribution and severity of chronic venous disorders.

We examined chronic venous disorders (CVD) in persons who injected illicit drugs. The study design was cross-sectional, comparative stratified by age, gender, ethnicity, as well as by three types of drug use (noninjection; arm or upper body injection only; and legs with or without upper body injection). Subjects completed demographic, health, and substances abuse questionnaires and were evaluated using the clinical component of the Clinical-Etiology-Anatomy-Pathophysiology Classification. Seven hundred and thirteen participants were evaluated. Those who injected in the legs +/- arms had significantly worse CVD. Thirty-nine percent of leg +/- arm injectors vs. 4.2% or noninjectors or arm only injectors had moderate to severe CVD. Persons who injected in the legs +/- arms were 9.14 times more likely to develop venous ulcers than those that injected in the arms and upper body only and 34.64 times more likely as those who never injected. CVD was associated with injecting in the groin, legs and feet as compared with other sites. The pattern of disorders associated with leg injection is consistent with the underlying pathology of chronic venous insufficiency.

Peripheral arterial disease among substance abusers in drug treatment.

OBJECTIVE: Examine the occurrence of and risk factors for peripheral arterial disease (PAD) in a sample in drug treatment. DESIGN: Cross-sectional/stratified design. SETTING: Ten methadone treatment centers in a large Midwestern metropolitan area in the United States. PARTICIPANTS: Six hundred forty participants (290 men [45.3%]; mean [SD] age, 46.54 years [8.85 years]) were included in the study. Sixty-one percent were African American, and 93.5% had a history of smoking cigarettes. MAIN OUTCOME MEASURES: PAD was defined as an ankle brachial index of less than 0.90 in at least 1 leg. Measures included demographic, health, and illicit drug use history questionnaires; the Walking Impairment Questionnaire; and body mass index. The Positive Attitude Toward Physical Activities/Exertion Questionnaire was added 9 months into the study; this decreased the sample size of the logistic regression for the predictors of PAD to 498. MAIN RESULTS: PAD was identified in 16.7% of the sample; the mean ankle brachial index value for persons with PAD was 0.84 (SD, 0.05). Multiple logistic regression analysis found that sex (women) (odds ratio [OR], 2.10), history of ever smoking cigarettes (OR, 5.16), years of smoking cigarettes (OR, 1.60 per 10 years' smoking), and having a positive attitude toward physical activities/exertion (OR, 0.63) made significant contributions to the predictors for PAD after controlling other background and risk variables. CONCLUSION: PAD is prevalent in persons undergoing drug treatment and is best accounted for by cigarette smoking, sex differences, and physical inactivity. PAD in drug abusers should be evaluated, and the current findings merit further investigation.

Venous ulcers: A reappraisal analyzing the effects of neuropathy, muscle involvement, and range of motion upon gait and calf muscle function.

Chronic venous insufficiency is a complex disease that can result in severe sequelae including venous ulceration. Though the exact progression from chronic venous insufficiency to venous ulcer remains unclear, the high cost and burden of this disease on patients and society is quite clear. Sustained ambulatory venous pressures or venous hypertension plays an integral role in the development of venous ulceration and involves the failure of the calf muscle pump system. Standard of care involves compression therapy to assist the calf muscle pump. However, several cofactors may contribute to or exacerbate this disease and understanding their impact may provide insight into new treatment modalities. Nerve involvement, which may result in neuropathic pain and muscle dysfunction, alterations in mobility and a decrease in range of motion may lead to gait alterations all affecting calf muscle pump function. In this paper, we analyze these cofactors and discuss possible treatment options to target them. Physicians treating this disease should be aware of the numerous factors involved in its development. Exploring new treatment options may 1 day lessen the burden and suffering caused by venous insufficiency.

The standing heel-rise test: relation to chronic venous disorders and balance, gait, and walk time in injection drug users.

Injection drug use can impair mobility. When mobility is impaired in combination with other potential pathologic changes to the veins, muscles, and joints of the lower legs, chronic venous disorders can develop. The heel-rise test, an assessment of eccentric-concentric muscle action of calf muscle function with regard to plantar flexion, can be used to measure ankle mobility. To examine the test-retest reliability and construct validity of the heel-rise test in relation to chronic venous disorders in persons with a history of injection drug use (N = 104), a test-retest study (M = 45.9+/-12.9 days from first to second test) was conducted. Participants were assessed for chronic venous disorders of the legs and walk time; they also completed the heel-rise and Tinetti Balance and Gait tests. Test-retest reliability was found to be good for full heel rise of right and left legs (ICC = .66 and .67, respectively). Heel-rise performance was positively correlated with balance (r = .38 to .47) and gait (r = .38 to .45) and negatively related to walk time (r = -.30 to -.35) (P <0.01). Participants who injected in the groin, legs, or feet performed fewer heel rises than those who injected in the arms and upper body only or those who did not inject drugs. Chronic venous disorders accounted for 7% to 17% of the variance in heel rise. The heel-rise test as a measure of calf muscle function is supported by these results, implicating the role of mobility restriction in the etiology of venous disease. Although more research is needed regarding its performance, the heel-rise test may be a low-cost, noninvasive screening or assessment tool in a variety of outpatient settings.

Chronic venous disorders and injection drug use: impact on balance, gait, and walk speed.

PURPOSE: Injection drug users are at high risk for chronic venous disorders (CVD), a condition resulting in a progressive deterioration of venous function of the legs. However, the effects of CVD on walking mobility in this population have not been studied. We examined a causal model of the relationship between injection drug use, CVD, and Walking Mobility. The validity of the Tinetti Balance and Gait scales and walk speed as a composite measure of Walking Mobility was also explored. SETTING AND SUBJECTS: The participants were 104 men and women from a methadone maintenance treatment center. Drug use included 18 persons who injected drugs only in the hands, arms, and above the waist; 70 who injected all over the body including the lower extremities; and 16 who never injected drugs but used illegal substances by other routes. Forty-nine percent of participants had moderate to severe CVD. DESIGN: Participants were classified into 2 groups according to their history of injection drug use: (a) those who injected in the lower extremities (n = 70) and (b) those who injected in the arms plus those who did not inject (n = 34). All measurements were obtained at baseline and again approximately 6.5 weeks later. Structural equation modeling was used to examine the causal effect of CVD on Walking Mobility. The validity of the Balance and Gait scales and the walk time variable as measures of a Walking Mobility factor was examined using a second-order confirmatory factor analysis. INSTRUMENTS: Questionnaires included the Demographic and Health History and Drug History. The lower extremities were evaluated with the clinical portion of the Clinical-Etiology-Anatomy-Pathophysiology classification. Participants completed the Tinetti Balance and Gait test. A timed 6-m walk at the person's normal pace was used to calculate walk speed. RESULTS: Test-retest reliability of the Tinetti Balance and Gait test and walk speed ranged from 0.79 to 0.86. Balance and gait scores were skewed toward the high end of the scale. Walking speed was slow. The leg-injecting group had lower Balance (P < .05) and Gait (P < .01) scores. A structural equation modeling showed that CVD was related to Walking Mobility after controlling for age, gender, body mass index, and comorbidities. Injection drug use and age were linked to Walking Mobility through CVD severity. Although fall information was not collected as part of our study, 15% of participants had a Tinetti score of less than 19, indicating a high risk for falls. CONCLUSIONS: Tinetti Balance and Gait scales and walking speed are reliable and valid measures for the evaluation of walking mobility among persons with a history of drug use. Further research is needed to alleviate the impact of venous disease on walking mobility.

Reliability and clinical validity of a technique to assess lifetime illicit injection drug use.

A lifetime injection drug history is necessary to examine the impact of injection drug use on a physical health problem but it may cover time periods for which information and/or data reported may not be reliable. A test-retest study design was used to examine a technique of questioning persons about lifetime illicit injection drug use history (the Lifetime Injection History Questionnaire), including its reliability and relation to chronic venous disorders as an assessment of validity. Study participants included 104 persons (60 men, 44 women, M age = 49.3 years) provided services at a methadone maintenance treatment center located in a large industrial city in the Midwest. Kappa values for "ever injected" drugs ranged from 1.00 for heroin to .50 for nonprescription methadone (median = .75). High interclass correlations were found for youngest and oldest ages of injecting, years not injecting, and total injecting years (.90 to .98). Interclass correlation values for years injecting in the upper body and lower body were .79 and .70, respectively. Interrater reliability for the clinical portion of the venous disease assessment tool (the Clinical-Etiology-Anatomy-Pathophysiology - CEAP - classification) was high: .97, right leg; .94, left leg. Controlling for age, gender, comorbidities, and body mass index, a classification of injection drug use based on the Lifetime Injection History scales accounted for 32% of the variance in the clinical CEAP scores. This is the first study to examine years of injection drug use that takes periods not injecting drugs into consideration. Focused substance abuse questioning (eg, drug, route, years of use) may help clinicians evaluate health problems related to drug use.

Effects of injection--drug injury on ankle mobility and chronic venous disorders.

PURPOSE: To identify potential confounders and test a causal model of injection-site risk, chronic venous disorders (CVD), and ankle mobility. The reliability and validity of goniometry measurements of ankle mobility were also of interest because they are seldom performed in people with a history of injection-drug use. DESIGN: The study was a test-retest design, consisting of 104 participants from a methadone maintenance treatment center. METHODS: Each participant provided demographic information, health and drug histories, and underwent bilateral ankle goniometric measures of dorsiflexion, plantar flexion, inversion, and eversion. The clinical portion of the Clinical-Etiology-Anatomy-Pathophysiology (CEAP)was used to classify CVD severity. FINDINGS: Reliability of goniometry measurements ranged from .70 to .90. Causal modeling supported hypotheses of increased risk from leg injection and reciprocal effects involving ankle mobility and disease progression. Ankle inversion mobility was the strongest indicator of ankle mobility. CONCLUSIONS: Injury to the lower extremities from IDU affected CVD and mobility. Further research should include assessment of comorbidity and other potential confounders. Ankle inversion should remain part of the goniometry assessment.

Injection drug use: an understudied cause of venous disease.

Injection drug use has devastating effects on the veins, skin, muscles, and joints of the lower extremities, thus increasing the risk of chronic venous disease (CVD). We examined the following risk factors for CVD in persons who injected drugs: health and drug use history, ankle mobility, pain, and skin and wound assessment. Because of deep venous thrombosis and injury and immobility to the calf muscle pump from injected drugs, CVD occurs at a young age. Decreased ankle joint movement, decreased walking, and increased pain are associated with worsening CVD clinical classification. Associated venous ulcers tend to be multiple and large by the time wound care is sought. Cellulitis and abscesses may also be present. Injection drug users serve as a model for the multifactorial nature of CVD including vein damage, diminished ankle range of motion, and decreased calf muscle strength. Persons who inject drugs need to have their lower extremities assessed for CVD on a routine basis.

Random control clinical trial on the effects of aerobic exercise training on erythrocyte levels during radiation treatment for breast cancer.

BACKGROUND: Erythrocyte changes from aerobic exercise training were examined during radiation treatment of breast cancer. METHODS: Twenty sedentary females with breast carcinoma who were ages 35 to 65 years were randomized to aerobic exercise (AE) of walking for 20 to 45 minutes, 3 to 5 times per week, at 50% to 70% of measured maximum heart rates or to placebo stretching (PS) activities 3 to 5 days per week during 7 weeks of radiation treatment. Measures were obtained 1 week before and after the radiation regimen. Serum blood analyses, through complete blood counts, measured red blood cell counts (RBC), hematocrit (HCT), and hemoglobin (HB). Peak aerobic capacity (peak VO(2)) was measured by exercise testing with oxygen uptake analysis to assess training. A Wilcoxon Mann-Whitney U test examined changes between groups (P < or = .05 for significance). RESULTS: AE peak VO(2) increased by 6.3% (P = .001) and PS decreased by 4.6% (P = .083). RBC increased in AE from 4.10 to 4.21 million cells/microL and declined in PS from 4.30 to 4.19 million cells/microL; the between-group differences were significant (P = .014). HCT increased in AE from 38.0% to 38.8% and declined in PS from 37.40% to 36.50%; the between-group differences were significant (P = .046). HB increased in AE from 12.3 to 12.4 g/dL and declined in PS from 12.25 to 11.77 g/dL; the between-group differences were significant (P = .009). CONCLUSIONS: The results of the current study suggest that moderate intensity aerobic exercise appears to maintain erythrocyte levels during radiation treatment of breast cancer compared with the declines observed in nontraining individuals. These findings suggest a safe, economical method to improve fitness and maintain erythrocytes in women during radiation treatment of breast cancer.

Double-blinded, placebo-controlled trial of midodrine for exercise performance enhancement in tetraplegia: a pilot study.

BACKGROUND/OBJECTIVE: Spinal cord injury (SCI) impairs cardiovascular autonomic responses to exercise and, depending on the level of injury, may result in hypotension and pathologic fatigue with exertion. Other clinical populations with sympathetic regulatory dysfunction, but without skeletal muscle paralysis, exhibit similar signs and symptoms. Their ability to engage in physical activity improves with elevation of blood pressure through pharmacologic treatment: Midodrine, an oral alpha-sympathomimetic agent, has been shown to be safe and efficacious for this purpose. Use of this medication in individuals with SCI merits investigation. METHODS: Double-blind, placebo-controlled, randomized, crossover, within-subjects protocol. Four participants with chronic, motor-complete injuries from C6 to C8 underwent 4 peak exercise tests (PXT) using a wheelchair ergometer, following administration of midodrine, 5 mg, 10 mg, and placebo, in random order. Heart rate, blood pressure, oxygen consumption (VO2), and perceived exertion were measured. RESULTS: Treatment with midodrine, 10 mg, was associated with elevated systolic blood pressure during peak exercise in 3 participants. Two participants showed a concurrent decrease in perceived exertion and increase in VO2. No adverse effects of midodrine were evident. CONCLUSION: Midodrine enhances exercise performance in some individuals with SCI, similar to other clinical populations with cardiovascular autonomic dysfunction.

Aerobic exercise training fails to lower hypertriglyceridemia levels in persons with advanced HIV-1 infection.

The purpose of this study was to determine whether blood lipid and lipoprotein concentrations varied in 5 men with advanced HIV-1 infection after 12 months of aerobic exercise training. Prior to exercise, the mean baseline cholesterol and high-density lipoprotein cholesterol (HDL-C) serum concentration were each lower, and mean baseline triglyceride concentration was higher compared to a healthy population norm. Consistent exercise training for 12 months failed to significantly (p > .05) alter cholesterol or HDL-C. Triglyceride concentration was significantly (p < .05) elevated above baseline (63 mg/dL) regardless of exercise compliance. The results suggest that long-term exercise training cannot correct lipid profile abnormality, particularly hypertriglyceridemia, common to individuals with advanced HIV-1 infection.