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The Standing Heel-Rise Test: Relation to Chronic Venous Disorders and Balance, Gait, and Walk Time in Injection Drug Users
Mobility impairment is an unintentional and largely unrecognized consequence of injection drug use (IDU). This impaired mobility in combination with other potential pathologic changes to the veins, muscles, and joints of the lower legs from IDU may lead to the development of chronic venous disorders (CVD). Chronic venous disorders of the lower extremities may cause swelling, varicose veins, skin damage, refractory ulcers, and pain1 — progressive and debilitating sequelae. Injection drug users with CVD often complain of mobility problems such as difficulty with walking, stair climbing, and working.2,3 Previous research4 found evidence of CVD in 87% of persons in a methadone maintenance treatment program; by contrast, additional research found CVD affects 7% to 9% of the general population and occurs late in life.3,4
The calf muscle pump is a critical component of the conceptual model describing the relationship between CVD and mobility impairments. In addition to its role in a functional venous system, the calf muscle pump is dependent on ankle joint flexion for the compression motion that leads to venous emptying by forcing venous return to the central circulation.5 Changes to the musculoskeletal system of the lower leg can adversely affect the dynamics of the calf muscle pump.
The standing heel-rise test (the ability to perform consecutive heel rises) is an easily administered, noninvasive measure of the calf muscle pump’s strength and endurance. As an extension of their previous work,6,7 the 
authors examined the heel-rise test as a measure of ankle mobility, test-retest reliability, and validity related to CVD and mobility in persons who injected in different sites. The test assesses the eccentric-concentric muscle action of plantar flexion.8 Ankle plantar flexion strength has an important role in standing balance, walking, and most activities of daily living.9 People with weak plantar flexors may have difficulty walking, running, and jumping and may exhibit fatigue – the inability to maintain the expected force and power output to perform consecutive heel rises.10 The heel-rise test may provide a method to explore potential muscular function and mobility problems in persons who inject drugs. The test has not been examined in persons who injected drugs; thus, this reliability/validity phase is important.
Literature Review
Two studies address the heel-rise test in persons with a history of deep vein thrombosis (DVT) and CVD. Haber et al11 examined test-retest reliability of the heel-rise test on one leg of 40 healthy persons (median age 24 years) and on the unaffected leg of 38 persons (median age 51 years) who were > 1 year post-DVT. The median number of heel lifts for the healthy group was 34 and the intraclass correlation coefficient (ICC) was 0.93 at both 30 minutes and 48 hours. Participants with a history of DVT performed slightly fewer heel rises (median of 27 heel rises) with a test-retest ICC for a minimum of 7 days of 0.88. The authors neither reported statistical testing on the heel-rise difference between the healthy and DVT groups nor gave an explanation for why the unaffected leg was used.
van Uden et al12 examined heel rise and gait in 19 healthy volunteers (M age = 51.4 years) and 15 persons with current or healed venous ulcers (M age = 59.9 years). Participants with venous disease performed significantly fewer heel rises (14.6±7.34) than the healthy controls (23.5±6.54). The authors also reported a 14% slower preferred walking speed, wider base of support, slower step time, and slower stride time in persons with severe CVD. The results of their study indicated reduced calf muscle endurance in patients with advanced CVD, leaving open the question of milder forms of CVD on heel-rise performance.
Injection drug users represent a population at risk for mobility problems that has not been examined using the heel-rise test. This study assesses heel-rise test performance in a drug treatment population to: 1) establish reliability; 2) understand the impact of demographic variables of this population; 3) correlate findings with injection drug use site; 4) determine if heel-rise test results bear any relation to mobility measures including balance, gait, and walk time; and 5) correlate these findings with severity of CVD.
Methods
Design. Because a test-retest design was used for this study and reliability is based on the correlation of two replications of the same test, the study's protocol, research location, research staff, research procedure, and other potential variables were kept as near alike as possible at both times of testing. Participants in a drug treatment population were chosen to facilitate access to persons with a history of drug use and, based on their availability for two research visits, to allow examination of reliability. In addition, examination of mobility as a mediator of CVD progression and of methods to assess mobility in terms of disablement is critical. A test-retest interval of at least 30 days was employed to minimize memorized recall of questionnaire items from a lesser interval and to avoid subject loss from the drug treatment program from a longer time interval. Data were collected to provide construct validity for the heel-rise test as a measure of calf muscle pump function. The same data (balance, gait, walk time, CVD clinical classification, and injection drug use history) were collected at Time 1 and Time 2. If heel rise is a measure of calf muscle strength and endurance, it should correlate with balance, gait, and walk time. These correlations would provide construct validity evidence. Calf muscle pump function is essential to normal performance of these activities and they are critical for mobility. The authors' research7 has shown that injection in the veins of the lower extremities is a risk factor for CVD and a well established physiological connection exists between calf muscle pump function and the development of CVD.
Participants. Participants were individually tested at a methadone maintenance treatment center located in a large industrial city in the United States. Inclusion criteria stipulated that participants must be 25 to 65 years of age, able to understand and respond in English, have both lower extremities intact, and be able to walk. Exclusion criteria included: too physically or mentally ill to participate and not a client of the drug treatment center at which data were collected. Participants learned of the study from signs posted in the clinic. Drug treatment counselors told their clients about the study as well. The first 113 persons (a convenience sample) were placed in the two-part, reliability phase of the study and were given an appointment to return for the study a second time. The second testing occurred a mean of 45.9±12.9 days from the first test. Of the first 113 participants, nine (7.9%) were no longer receiving care at the treatment center and could not be contacted; thus, 104 persons were tested twice.
Measures.
Demographic and Health History Questionnaires. The Demographic Questionnaire obtained information about gender, race, and age of each participant. The Health History Questionnaire asked the participant about his/her medical diagnoses (eg, hypertension, DVT, arthritis). Participants were measured and weighed on a standard scale. The questionnaire had been used in previous research.7 In the current study, the test-retest reliability values for the demographic and health history questionnaires were 0.99 and 0.86, respectively.
Drug History Questionnaire. The Drug History Questionnaire14 was used to obtain a detailed drug history from each participant and is described elsewhere.14 For this report, items regarding the number of years of injecting in the hands, arms, and above the waist and years injecting in the groin, legs, and feet were used. The Drug History Questionnaire had a median kappa value of 0.79.
Clinical-Etiology-Anatomy-Pathophysiology (CEAP) Classification. 1 The clinical portion of the CEAP is a descriptive leg assessment that comprises the following classes regarding CVD: Class 0 - no visible or palpable signs of venous disease; Class 1 - telangiectasias or reticular veins; Class 2 - varicose veins, distinguished from reticular veins by a diameter of 3 mm or more; Class 3 - edema; Class 4a - pigmentation or eczema; Class 4b - lipodermatosclerosis or atrophie blanche; Class 5 - healed venous ulcers; Class 6 - active venous ulcer.1 In the authors' previous work, the inter-rater reliability of the CEAP was kappa = 1.0.7 In the current study, the inter-rater reliability was 0.97 for the right leg and 0.94 for the left leg.
Heel-rise test.15-17 For the heel-rise test, the participant stood facing the physical therapist. A block of wood, cut to a height of 5 cm to determine the participant's heel-rise ability, was placed next to the foot that was to be tested. A floor mirror placed lateral to the feet allowed the therapist to view the heel rise. The therapist explained and demonstrated the heel-rise procedure to the participant. The participant was instructed to stand tall, raise one leg with a bend to the knee, and rise onto the ball of the foot to the height of the wooden block. The participant was allowed to lightly touch the therapist's hand with one hand for stability. The participant was afforded two false starts to provide an opportunity to learn the heel-rise procedure and then encouraged to perform the test in a continuous movement without gaps for rest and to do as many heel lifts as possible within his/her comfort and strength-endurance capacity. If the person placed too much pressure on the research assistant's hand, put the elevated leg down, said he/she could not continue, had to rest between heel rises, or lost his/her balance, the test for that leg was considered completed. Both extremities were tested. The test of the second leg was performed after a 5-minute rest and when the participant stated a willingness to continue. The therapist counted the number of times the heel elevated at or above the top of the 5-cm block of wood (full heel rise) and the number of times the heel elevated but was less than the height of the 5-cm block of wood (partial heel rise).
Tinetti Balance and Gait and walk time testing. The participant wore shoes to complete the Tinetti Balance and Gait and walk time testing. The participant sat in a hard, armless chair. For the balance portion, the participant's ability to sit in the chair, rise from the chair, stand while being nudged, balance with closed eyes for 15 seconds, turn in a circle, and sit down were assessed. For the gait portion, the participant was evaluated on initiation of gait, step length and height, step symmetry, step continuity, path, trunk, and walking stance. The balance and gait items each were scored on a scale of 0 to 2 and were summed for combined total balance and total gait scores with the higher number indicating the better performance. For the timed walk, the participant was instructed to walk a total of 6 meters at his/her normal pace and speed, turn around without touching anything, and walk back to the start. The distance was marked on the floor. The walk test was timed with a stopwatch. Tinetti15 reported inter-rater reliability of the balance and gait in the form of percentage agreement of 85%; others also have reported strong reliability.16-18 The Tinetti version used for this study can be found at www.sgim.org/userfiles/handout16TinettiAssessmentTool1.pdf.
Procedure. Participants first completed a questionnaire that provided demographic, health, and illicit drug use history. After completing the questionnaire, participants removed shoes, socks, and dressings below their knees, where appropriate. Body mass index (BMI) was calculated from measured height and weight. Each leg was assessed using the clinical portion of the CEAP classification for CVD. Following the leg assessment, the heel-rise test and Tinetti balance, gait, and walk time testing were administered. Participants were compensated $40 for their time. The study had the approval of the Institutional Review Board of the affiliated university and all participants provided informed consent.
Data analysis. Reliability of the heel-rise test was assessed using test-retest correlation coefficients (r) and intraclass correlations (ICC). Each of these measures computes reliability differently using different mathematical models for reliability measurement. From the standpoint of Classic Test Theory, the test-retest r estimates the proportion of true variance in the scale and the square root of r is an estimate of the correlation between the observed scale score and the true scale score.19,20 The r coefficient as a reliability estimate also is used for estimating the standard error of measurement.20 The r coefficient for reliability assessment is limited in that it is invariant up to a linear transformation of scale – ie, it is unaffected by a constant shift in scale. As a result, any tendency to report higher or lower scores at the second test administration or to report proportionally higher/lower scores would result in the same test-retest correlation. The ICC is sensitive to these kinds of shifts in responding and often is recommended when absolute agreement is of interest. Absolute agreement is important in assessing test-retest reliability of the heel rise because if repeated administrations increased or decreased numbers, assessment of calf muscle strength and endurance would be under- or overestimated on successive tests. Although a conceptually similar ratio of the true variance to total variance is involved, Shrout and Fleiss's21 report showed six different ways of computing the ICC that can give very different estimates. In their example, ICC ranged from 0.17 to 0.91 for the same data set. Advances in computing software technology (eg, SPSS, Chicago, Ill) have made it easy to report any one of six ICCs. The ICC of interest in the current study assumes: 1) random participants and fixed occasions of measurement, 2) absolute rather than relative agreement, and 3) reliability for a single test administration rather than an average of multiple administrations. Reliability calculations were performed on three different measures of heel-rise performance: full, partial, and full plus partial (full+partial) rises.
Validity of the heel-rise test was examined by correlating heel-rise performance with demographic variables, measures of leg functional health, and a clinical measure of CVD. Because site of injection drug use (upper versus lower body) is theoretically related to calf muscle pump function, a multivariate analysis of covariance (MANCOVA) was used to investigate the relationship between site of injection drug use and heel-rise performance. The functional relation between severity of CVD and number of heel rises was examined using polynomial trend analysis.
Results
Participants. The sample consisted of 60 men (57.7%) and 44 women who ranged in age from 30 to 60 years old, M = 49.3±6.5. Of these, 68 (66%) were African American, 46 (44.2%) were single, and 63 (60.6%) were not employed. A mean of 3.6±2.3 comorbid health conditions was reported – the most common were hypertension (n = 47), arthritis (n = 44), depression (n = 35), and hepatitis C (n = 30). Twenty-three persons (23.7%) reported a history of DVT. Participants' mean height and weight were 171.53±9.09 cm and 85.56±21.81 kg, respectively. Body mass index ranged from 16 to 50 (M = 28.56, SD = 6.82). Drug use questions indicated that 88 persons injected drugs (85%) in their arms and 16 (15%) never injected drugs. Among those who injected in their arms (M years = 12.68, SD = 9.09), 70 (67%) also injected in their groin, legs, or feet (M years = 8.89, SD = 7.37).
Heel-rise performance. Table 1 presents the number of full, partial, and combined full+partial heel rises for the right and left legs at both times of 
administration as well as the correlations between left and right leg for each measure. No significant differences were found between left and right legs or between Time 1 to Time 2 for any of these three measures (P > 0.05). The left leg and right leg heel rises were significantly correlated for each measure at both assessment times. The highest number of full heel rises regardless of leg was 27. Not apparent in these figures was that 42 (40%) of the participants could not perform a single full heel rise.
Heel-rise reliability. Table 2 shows the results of the test-retest reliability analysis. The two coefficients of test-retest reliability (r and ICC) were in the range of 
0.65 to 0.73 for full and full+partial measures but only in the range of 0.40 to 0.41 for the partial measure. The partial heel-rise measure on its own appeared to be unreliable and was dropped from subsequent analyses.
Heel rise and demographic variables. Table 3 shows the correlations between the full and full+partial measures of heel-rise performance and select demographic variables obtained at both times of testing. Correlations showed a similar pattern for the full and full+partial measures, with the full+partial measure exhibiting lower correlations. This was not unexpected given the lower reliability of the 
partial measure. Correlations involving other study variables were consistently lower for the full+partial measure; consequently, only full rise is discussed further.
The full heel rise was inversely correlated with age, weight, BMI, and years of injecting in the veins of the groin, legs or feet. The correlations ranged from -0.08 to -0.44. Correlations greater in absolute value than 0.18 were statistically significant (P < 0.05). Each of these measures was significantly correlated with heel-rise performance at Time 2, indicating that older heavier participants with a history of lower body injection use performed fewer heel rises. Gender and height were unrelated to heel-rise performance.
Heel rise and injection drug site. The relationship between heel-rise performance and site of injection drug use was examined using a one-way MANCOVA. Three levels of injection site were identified: no injection drug use (No-IDU), n = 16; arm/upper body injection only (Upper-IDU), n = 17; and groin, legs and/or feet plus or minus upper body injection sites (Lower-IDU), n = 70. Two orthogonal contrasts, C1 and C2, were defined as follows: the first contrast, C1, compared the No-IDU group to Upper-IDU group. The second contrast, C2, compared the average of the first two groups with the third. The contrast coefficients were 1, -1, 0, and 1, 1, -2, for C1 and C2, respectively. In SPSS, this set of contrasts is referred to as a difference contrast set. The dependent variables were the four measures of full heel-rise performance: right leg at Time 1 (Right-T1), left leg at Time 1 (Left-T1), right leg at Time 2 (Right-T2), and left leg at Time 2 (Left-T2). The covariates were age and BMI. The first MANCOVA contrast, C1, was not significant, indicating that heel-rise performance on average did not differ between noninjection drug users and the arm/upper body only injection drug users. The second contrast was significant (P = .026, one-tail), indicating that those who injected in their groin, legs, or feet performed fewer heel rises than those who injected in the arms only or those who did not use injection drugs.
Multivariate analysis was followed with tests of univariate contrasts in order to determine if the composite differences between injection site groups involving C2 were due to each of the measures or only specific measures — eg, right leg at Time 1. This analysis found two significant (P > 0.05, one tail) contrasts, indicating poorer performance in both right leg measures for those who injected in the 
veins of the groin, legs, or feet. Figure 1 (mean heel-rise performance for each injection site group by leg and time of testing) shows the poorest performance occurred in the Lower-IDU group for the right leg heel rise regardless of time of testing.
Heel rise with balance, gait, and walk time. Construct validity of the heel-rise test as a measure of calf muscle strength and endurance was supported by significant correlations (P > 0.01) between full heel rise and balance (r = .38 to .47), gait (r = .37 to .45), and walking time (r = -.30 to -.39) (see Table 4). Because age and weight were found to be significantly correlated with heel rise, the partial correlation coefficients for balance, gait, and walk time were examined, controlling for age and weight. The correlations remained significant and ranged in absolute value from 0.23 to 0.29. Lower balance and gait scores, as well as slower walking time, were associated with a lower number of heel rises.
Heel rise with CVD (clinical CEAP). The functional 
relationship between heel rise and CVD was investigated by examining polynomial trend components in a one-way analysis of variance; the clinical CEAP score served as the ordinal independent variable and the full heel-rise score as the dependent variable. Because heel rise and the clinical CEAP score were determined for each leg separately and at Time 1 and Time 2, four separate analyses were conducted. In each analysis, only the linear trend was significant, accounting for 7%, 17%, 8%, and 17% of the heel-rise variance in the right-Time 1, left-Time 1, right-Time 2, and left-Time 2 measures, respectively. These linear trends are evident in Figure 2, which shows the mean heel rise for each leg and time measurement as a function of the clinical CEAP score.
Discussion
Because this is the first study to use the heel-rise test in a drug treatment population, its reliability, validity, and relationship with CVD and mobility were assessed. Persons who have injected drugs – especially in the groin, legs, and feet – are at risk for lower extremity CVD and mobility problems affecting walking, standing, stair climbing, working, and the like. In addition, the heel-rise test was performed using a wooden block to measure height, making the test easily transferable to clinical and community sites. An available, simple test may help identify early lower 
extremity problems in injection drug users. Early assessment and treatment may lead to enhanced leg health and prevention of disability from leg problems.
Both legs were evaluated for full and partial heel rises. The partial heel-rise measure was not reliable (r > 0.5). The full heel rise had good reliability with ICC, ranging from 0.66 to 0.67 depending on which leg was being compared. The ICC and r reliability coefficients were nearly identical, indicating an absence of practice effects on performance.
Intraclass correlation coefficient values for the heel-rise test have been reported for healthy and ill persons. For persons with a history of DVT, Haber et al11 reported a test-retest ICC for a minimum of 7 days as 0.88. For 10 healthy men, Moller et al22 reported ICC values of 0.84 and 0.78 for right and left legs, respectively. Jan et al9 reported an ICC value of 0.89 for 180 sedentary volunteers. Cider et al23 reported ICC values of 0.98 and 0.94 (right and left legs, respectively) for 20 patients with chronic heart failure. Although reliability was lower in the current study than in others, sample size in general was larger and reflected more diverse patient age, general health, leg health, and illness status. In addition, the period between Time 1 to Time 2 was longer than in other reported studies.
Construct validity of the heel rise was underscored by significant relations between heel-rise performance and measures of mobility, balance, gait, and walk time. Heel-rise performance also was functionally related to severity of CVD across the full range of the clinical CEAP. Functional relations of this type provide observational evidence for a causal link in underlying mechanisms, but not of the direction of causation.24 Possibly the relationship is reciprocal, so interventions directly or indirectly purposed to the disease process have the potential to curtail the disease progression. Interventions that control CVD symptoms may result in fewer mobility restrictions/better pump function, while interventions to improve mobility/pump function may improve or better control the CVD symptoms. Further research is needed. Regardless, affected persons need to be taught self care for the legs such as leg elevation, use of support hose, and leg/ankle exercises.
The mean number of full heel rises for study participants (4.14 to 4.64) was similar across legs and time periods. Approximately 40% of participants could not perform even one full heel rise. Older, heavier participants with a history of lower body injection use performed the fewest heel rises. The most striking data, compared to others' findings, were the number of full heel rises completed. In studies with healthy volunteers, participants completed 25 to 36 heel rises.8,10,22,25,26 Subjects with congestive heart failure23 and CVD12 had considerably greater heel-rise numbers than what was found in this study. Even though the subjects in the van Uden's12 study had similar pathology, they performed nine more rises than current study participants.
Differences in the heel-rise procedure are unlikely to account for such a great variance between heel-rise numbers. More likely, greater debilitating pathological features are found in the legs of subjects who inject drugs into the lower extremities compared to subjects who do not inject drugs into the lower extremities. More prevalent debilitating features in lower extremities from drug injection apparently resulted in considerably more dysfunction of the calf musculature. One feature of note was the lack of 10-degree dorsiflexion of the ankle, the starting position for other heel-rise studies. A noteworthy number of current participants would not have been able to assume this position to begin heel rises due to limited dorsiflexion observed by one researcher. This limited dorsiflexion implies diminished posterior calf musculature extensibility; thus, resultant heel rises become more difficult.
No significant differences between men and women were found. Lunsford and Perry25 reported a difference in the number of heel rises performed between healthy men and women (N = 203); patients with any history of musculoskeletal or joint pathology involving the hip, knee, or ankle were excluded — ie, subjects were without known weaknesses. Jan et al9 reported men performed significantly more heel-rise repetitions than women (P > 0.039 regarding multiple regression analysis for age and gender. For all age groups, women accomplished fewer than men). They also reported lower numbers of heel rises with increasing age of sedentary participants – ie, 41 to 80 years of age with mean values of 2.7 to 12.1. Since 60.6% of current participants stated they did not work outside the home, fewer heel rises may reflect this sedentary lifestyle or may illustrate a lack of mobility that prevents obtaining some types of employment.
A consistent relationship was found between walking and heel rises. The faster the subject was able to walk, the greater number of full and full+partial heel rises completed. Similar results were found by van Uden et al12 for subjects with CVD. Among 11 subjects with CVD who completed the heel-rise test, the mean number of heel rises by the patient group was significantly less than the control group (P > 0.003). The patient group also had a significantly slower walking speed (P > 0.039). The average preferred walking speed of current participants was approximately 50% of van Uden's12 study subjects, lending further support to pathologic differences between injection drug users in the current study and other previous populations studied. Although walking step, stride length, and base of support were not measured in the current study, clinical gait observations of subjects indicated a lack of both dorsi and plantar flexion. This, in turn, reduces the efficacy and efficiency of heel-plant and toe-off portions of the gait cycle, which are important components of a faster walking speed.
Studies including the heel-rise test have used different populations and different methodologies, increasing the challenge of comparing this with other studies. A metronome was used in some studies11,12,23 to ensure subjects kept to a strict pace in an effort to specifically assess local muscular endurance of the calf. These same studies permitted the subject to touch an adjacent wall for balance during the heel rise. Some studies12,23 had subjects stand on a board that dorsiflexed the foot 10 degrees. In contrast, the heel-rise test administered in the current study was performed using only a 5-cm block of wood for height measurement. A metronome for self-timing or a device that their foot could feel when they reached a specific height was not used, although the participants could see the wooden block and were verbally encouraged throughout the test. It is possible the lack of a timed sound or touch for reinforcement affected their performance. The current study procedure emphasized calf muscle strength, balance, and muscle endurance. Calf muscle performance was isolated – the participant only could lightly touch the researcher's hand with one hand versus touching the wall or using two hands for balance. This approach allowed researchers to determine when the person was applying too much pressure or loosing his/her balance. Possibly allowing the person to touch the wall or use two hands provides greater stability to perform the heel-rise test and inflates the number completed. Despite methodologic differences, neither the heel-rise test at Time 1 nor the re-test was found to be significantly different. Thus, the heel-rise procedure and method of assessing calf muscle endurance were consistent for the pathology tested. Furthermore, the value of assessing and counting a partial heel rise was defined (ie, elevating the heel off the floor but not above 5 cm). Correlations showed a similar pattern for the full and full+partial measures, with the combined full+partial measure exhibiting lower correlations, not unexpected given the lower reliability of the partial measure. Correlations involving other study variables were consistently lower for the full+partial measure.
Limitations
The heel-rise test is not standardized and other studies report the use of a metronome, a tilt wedge, or other measuring and adjunct devices to count the heel rises. It is possible the sound of the metronome is a stimulus for the person to continue the test. Instead, participants in this study were given verbal reinforcement to perform as many rises as possible, in essence more approximating a clinical evaluation. All participants were in methadone treatment, delaying their doses until after participating so they would be alert to progress through the study. How persons with a history of drug use but not in drug treatment would respond to the test is not known. The reliability of the procedure used should be improved in future studies. Supplementing the current procedure with techniques (ie, using a device to provide positive feedback with appropriate heel rise) used by others may improve reliability. Deep vein thrombosis or other lower extremity venous change was not documented using ultrasound
Conclusions
An acceptable level of reliability and good validity were found to substantiate use of the heel-rise test among persons with a history of drug use in methadone treatment. Because changes to the legs from injection drug use may lead to movement dysfunction, it is critical that leg assessment tools be examined within this population. Leg assessment for mobility and CVD may help clinicians understand why these persons complain of difficulty walking, stair climbing, and standing. Heel-rise testing demonstrated impaired mobility of the lower leg in persons with a history of drug abuse. Heel-rise values were significantly related to gait, balance, walk time, chronic venous disorders, and injecting drugs in the lower extremities.
The heel-rise test is designed to enable the clinician to efficiently and accurately determine posterior lower leg flexibility, strength, and endurance without extra cost or technical expertise. The heel-rise test requires minimal set-up time and is a simple physical task that is quickly learned. Although further research is needed, it may be possible to use the heel-rise test as part of leg assessment in exploring mobility and CVD and planning treatment strategies for both.
Acknowledgment
This project was supported by the National Institute of Nursing Research/National Institute of Health (NINR/NIH), Effect of Drug Use on the Legs: Chronic Venous Insufficiency, Mobility and Pain, R01 NR009264. The authors thank Joyce Peck, BSN, RN; Terri Gibbons; and Cynthia Birk, BA, CET as research assistants; and Lucilla Ryder, Executive Director, and her staff at Star Center Inc. for their support and encouragement of research in addiction healthcare.
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