Adaptations in plantarflexor muscle-tendon properties and their impact on gait in claudicants with peripheral arterial disease

King, Stephanie (Stephanie L.)

Abstract

Peripheral arterial disease (PAD) is a chronic atherosclerotic disease, primarily affecting the lower limbs. The associated intermittent claudication (IC) is a muscle pain/cramping sensation in the legs, primarily brought on by physical activity, such as walking, which can negatively affect daily function and quality of life. Poorer levels of lower-limb muscle strength are strong predictors for mortality and the plantarflexor muscles in particular are a frequent site of claudication pain, with previous literature also indicating their dysfunction during level gait. However, little is known about the size and architecture of these muscles, the quality of the in-series Achilles tendon or the factors that contribute to voluntary joint moments and how these relate to physical function in this population. The aim of this thesis was to determine the functional properties of the gastrocnemii muscles and Achilles tendon in order to make evidence-based clinical recommendations for specific exercise interventions for claudicants.

A total of 23 participants (13 claudicants and 10 controls) took part in the study. Muscle-tendon dimensions and architecture, tendon properties, activation patterns and muscle strength, power and quality (specific tension) were assessed be integrating ultrasound imaging, electromyography and dynamometry. Stair gait biomechanics were analysed using 3D motion capture as indicators of whole body physical function. Within the claudicant cohort, disease severity was determined using the ankle brachial pressure index and walking performance assessed by a modified six-minute walk test. Average post-exercise ankle brachial pressure index of the claudicating-limbs were 0.55±0.21 with initial (onset of claudication pain) and absolute (maximal claudication pain) walking distances of 105±45m and 265±136m, respectively.

The first study investigated the relationships between the resting architecture of the gastrocnemii and functional properties of the Achilles tendon with disease severity and walking endurance. Worse disease severity was significantly associated with longer fascicle: tendon length ratios in both lateral (R=-.789, P=.001) and medial (R=-.828, P=<.001) gastrocnemius, and increased tendon hysteresis (R=-.740, P=.006). This suggests that the Achilles tendon has undergone deleterious changes and the muscle has adopted a structure designed to compensate for this. However, the concomitant associations with poorer walking endurance indicate this mechanism is not effective. Walking endurance could also be explained by lateral and medial gastrocnemius pennation angle, maximum tendon force, tendon hysteresis and disease severity (R2=~0.6). The direction of coefficients within these models suggests that improving tendon properties and increasing strength, but without increasing pennation angle, would be beneficial for walking endurance. Thus, eccentric resistance training may be an effective exercise intervention.

The second study investigated relationships between static and dynamic muscle quality with disease severity and walking endurance. The power-producing capabilities of claudicants’ plantarflexors (both the claudicating/painful limb and asymptomatic limb) were impaired compared to healthy controls, particularly at high contraction velocities (24% difference at 180°/s). This could be explained by some reduction in gastrocnemii muscle quality and a greater reliance on the prominently type I fibred soleus muscle. As reduced dynamic capability of the plantarflexor muscles was associated with disease severity (R=.541, P=.037) and walking endurance (R=.689, P=.006), high velocity resistance training of the plantarflexor muscles appears important to maintain functional performance.

The third and fourth studies investigated the functionally challenging daily tasks of stair ascent and stair descent, respectively. During stair ascent, plantarflexor moments were similar in claudicants compared to healthy controls, indicating the muscle could meet the strength demands of this task. We also observed that ankle angular velocity at the instant of peak moment, peak ankle power generation, as well as propulsive and vertical forces, were all reduced during forward continuance in the claudicating-limb group. It seems that claudicants possess adequate levels of strength when moving more slowly but are unable to remain strong when moving more quickly, therefore it could be suggested that the slower walking speed is a means to allow claudicants to operate within safer limits relative to their maximal strength capacity. This provides further evidence, in a functional context, of the velocity-dependent limitations of the plantarflexors detected in study two. During stair descent we hypothesised that the task demands would be redistributed away from the affected plantarflexors towards the muscles surrounding the hips and knees. Instead, the claudicants placed a greater reliance on the plantarflexors compared to healthy controls (40% vs 28% of plantarflexor contribution to peak support moment). Additionally, a unique hip extensor strategy was exposed during weight acceptance that was adopted by 73% of the claudicating-limb group, which was also associated with increased disease severity. However this was not a mechanism to reduce the functional demands on the plantarflexors but rather to reduce demands on the knee musculature. These data indicate the claudicants were relying heavily on the functionally limited plantarflexors to absorb the falling body mass during weight acceptance in stair descent, which may pose an increased risk of falling.

This thesis has identified important changes in the structure and quality of the gastrocnemii muscles and the properties and function of the Achilles tendon, that appear to influence whole body function during demanding and risky physical activities (stair negotiation) that necessitate alternate strategies. Taken as a whole, it is clear that high-velocity and eccentric resistance training would likely improve the musculoskeletal characteristics of claudicants, increase walking endurance and facilitate safe stair negotiation.

Citation

King, S. (. L. (2015). Adaptations in plantarflexor muscle-tendon properties and their impact on gait in claudicants with peripheral arterial disease. (Thesis). University of Hull. Retrieved from https://hull-repository.worktribe.com/output/4218349

• Thesis Type: Thesis
• Deposit Date: Aug 2, 2016
• Publicly Available Date: Feb 23, 2023
• Keywords: Sports sciences
• Public URL: https://hull-repository.worktribe.com/output/4218349
• Additional Information: Department of Sport, Health and Exercise Science, The University of Hull
• Award Date: May 1, 2015