Identifying Peripheral Arterial Diseases or Flow Limitations of the Lower Limb +MP3
Research Review By Dr. Joshua Plener©
Audio:
Date Posted:
February 2023
Study Title:
Identifying peripheral arterial diseases or flow limitations of the lower limb: Important aspects for cardiovascular screening for referral in physiotherapy
Authors:
Feller D, Giudice A, Faletra A, et al.
Author's Affiliations:
Centre of Higher Education for Health Sciences, Trento, Italy; Department of Physical Therapy, Poliambulatorio Physio Power, Brescia, Italy; Queen Elizabeth Hospital, Clinical Support & Screening Services, Gateshead, United Kingdom
Publication Information:
Musculoskeletal Science and Practice 2022; 61: 102611.
Background Information:
Pain into the lower limbs can be caused by many conditions including peripheral arterial disease (PAD), which is a common and potentially serious condition of the lower limb. Despite its frequency in the population, the diagnosis of this condition can be challenging as it can mimic or present alongside other neuro-musculoskeletal conditions such as lumbar radiculopathy or lumbar spinal stenosis.
The purpose of this article is to provide an overview of peripheral arterial disease from the perspective of a musculoskeletal clinician.
The purpose of this article is to provide an overview of peripheral arterial disease from the perspective of a musculoskeletal clinician.
Summary:
Peripheral arterial disease is a result of total or partial blockage of the vessels that supply blood from the heart to the periphery, which is often caused by arteriosclerosis (1). Most commonly, this affects the lower limb with a prevalence of about 7% in individuals aged 55-59 years, and by age 95-99, the prevalence can reach almost 25% (2). In 20-50% of cases, peripheral arterial disease is asymptomatic, however once blood supply is insufficiently able to meet the metabolic demands of the tissues, symptoms occur (3).
Patient Interview:
During the patient interview, a clinician should consider this condition based on patient reported symptoms. Peripheral arterial disease is a progressive disorder and is associated with at least one cardiovascular risk factor (4, 5), most commonly atherosclerosis. Diabetes and smoking have also been identified to increase the likelihood of developing peripheral arterial disease (6). Other risk factors include male gender, hypertension, dyslipidemia, hyperhomocysteinemia, c-reactive protein levels, and renal insufficiency (3). The American College of Cardiology/American Heart Association guidelines consider the following individuals at risk for lower limb peripheral arterial disease: age 65 years and over, age 50 to 64 years with risk factors for atherosclerosis or a family history of peripheral arterial disease, age < 50 years with diabetes and another risk factor for atherosclerosis, and all individuals with known atherosclerotic disease in other sites (7).
When symptoms are present, the most common symptom is lower limb pain with three different patterns: 1) claudication; 2) ischemic; and 3) atypical pain. Claudication is reported in 10-35% of cases and is classified as unilateral or bilateral fatigue, aching, cramping, and burning pain in the lower limb muscles (this is similar to what lumbar spinal stenosis patients experience and must be differentially diagnosed in an older patient). The pain location depends on the site of occlusion, for example occlusion at the aorta will likely produce bilateral claudication, whereby occlusion at the common femoral artery would result in unilateral symptoms (8). Claudication is typically induced by exercise and relieved by rest within 10 minutes, but in the event of severe decrease in limb perfusion, patients may report ischemic pain that is continuous and present even at rest. Ischemic pain is typically localized at the forefoot and is worsened by elevation of the lower limb, making it difficult to distinguish from neuropathy (7). However, acute ischemia typically presents with sudden onset of one or more of the “6-Ps”, which are: pain, pallor, pulseless, paresthesia, paralysis, and “perishingly” cold, and are warning signs for the risk of limb amputation (8). Due to patient comorbidities, pain can also be atypical with mixed manifestations. Atypical symptoms differ from the classic descriptors of claudication as patients may describe and localize their symptoms differently.
During the patient interview, a clinician should consider this condition based on patient reported symptoms. Peripheral arterial disease is a progressive disorder and is associated with at least one cardiovascular risk factor (4, 5), most commonly atherosclerosis. Diabetes and smoking have also been identified to increase the likelihood of developing peripheral arterial disease (6). Other risk factors include male gender, hypertension, dyslipidemia, hyperhomocysteinemia, c-reactive protein levels, and renal insufficiency (3). The American College of Cardiology/American Heart Association guidelines consider the following individuals at risk for lower limb peripheral arterial disease: age 65 years and over, age 50 to 64 years with risk factors for atherosclerosis or a family history of peripheral arterial disease, age < 50 years with diabetes and another risk factor for atherosclerosis, and all individuals with known atherosclerotic disease in other sites (7).
When symptoms are present, the most common symptom is lower limb pain with three different patterns: 1) claudication; 2) ischemic; and 3) atypical pain. Claudication is reported in 10-35% of cases and is classified as unilateral or bilateral fatigue, aching, cramping, and burning pain in the lower limb muscles (this is similar to what lumbar spinal stenosis patients experience and must be differentially diagnosed in an older patient). The pain location depends on the site of occlusion, for example occlusion at the aorta will likely produce bilateral claudication, whereby occlusion at the common femoral artery would result in unilateral symptoms (8). Claudication is typically induced by exercise and relieved by rest within 10 minutes, but in the event of severe decrease in limb perfusion, patients may report ischemic pain that is continuous and present even at rest. Ischemic pain is typically localized at the forefoot and is worsened by elevation of the lower limb, making it difficult to distinguish from neuropathy (7). However, acute ischemia typically presents with sudden onset of one or more of the “6-Ps”, which are: pain, pallor, pulseless, paresthesia, paralysis, and “perishingly” cold, and are warning signs for the risk of limb amputation (8). Due to patient comorbidities, pain can also be atypical with mixed manifestations. Atypical symptoms differ from the classic descriptors of claudication as patients may describe and localize their symptoms differently.
Physical Examination:
A step-by-step guide was provided by the authors which further explains the components of the physical examination, as well as providing a visual representation of the exam (download the guide HERE).
The examination should include an inspection of the skin, nails and limb temperatures. Typically, patients with peripheral arterial disease have thinner skin, hypertrophic and ridged nails and reduced lower limb temperature (7). Discolouration and hair loss may also be observed. When arterial blood flow is insufficient to meet the metabolic demands of resting muscle or tissue, patients may have focal areas of ischemia, with full-thickness skin necrosis (9).
The examination should include blood pressure taken on both upper limbs, heart rate, screen of the patient’s cardiovascular profile, and measurement of Ankle Brachial Index at rest. The Ankle Brachial Index (ABI) is the ratio between the ankle systolic blood pressure divided by systolic brachial pressure and a ratio of < 0.90 has been demonstrated to have a higher degree of sensitivity and specificity for peripheral arterial disease. As well, this ratio has been associated with disease severity, as an ABI between 0.5 and 0.9 is correlated with claudication, between 0.2 and 0.5 is correlated with rest pain and between 0 and 0.2 is correlated with tissue loss (7). Although frequently performed, the capillary refill testing has limited diagnostic accuracy (10). The most sensitive sign that is used is pulse palpation of the femoral, popliteal, dorsalis pedis, and posterior tibial arteries.
A step-by-step guide was provided by the authors which further explains the components of the physical examination, as well as providing a visual representation of the exam (download the guide HERE).
The examination should include an inspection of the skin, nails and limb temperatures. Typically, patients with peripheral arterial disease have thinner skin, hypertrophic and ridged nails and reduced lower limb temperature (7). Discolouration and hair loss may also be observed. When arterial blood flow is insufficient to meet the metabolic demands of resting muscle or tissue, patients may have focal areas of ischemia, with full-thickness skin necrosis (9).
The examination should include blood pressure taken on both upper limbs, heart rate, screen of the patient’s cardiovascular profile, and measurement of Ankle Brachial Index at rest. The Ankle Brachial Index (ABI) is the ratio between the ankle systolic blood pressure divided by systolic brachial pressure and a ratio of < 0.90 has been demonstrated to have a higher degree of sensitivity and specificity for peripheral arterial disease. As well, this ratio has been associated with disease severity, as an ABI between 0.5 and 0.9 is correlated with claudication, between 0.2 and 0.5 is correlated with rest pain and between 0 and 0.2 is correlated with tissue loss (7). Although frequently performed, the capillary refill testing has limited diagnostic accuracy (10). The most sensitive sign that is used is pulse palpation of the femoral, popliteal, dorsalis pedis, and posterior tibial arteries.
Clinical Application & Conclusions:
Recognizing features that raise one’s suspicion of peripheral arterial disease is important to ensure patient safety and prompt, appropriate medical management (7). Patients presenting with known risk factors and one of the following: sudden onset of the “six-Ps” (pain, pallor, pulseless, paresthesia, paralysis, and “perishingly” cold), resting pain in the foot for more than 2 weeks, non-healing wounds and/or gangrene, should be urgently referred to a vascular specialist. Individuals presenting with a reduced pulse, atypical pain symptoms or claudication should be referred for primary/community care.
Addressing modifiable risk factors early, such as smoking cessation, blood pressure, glycated hemoglobin control, antiplatelet prescription and weight loss for overweight patients is a main component for the management of this condition. The initial management involves the prescription and implementation of exercise therapy for symptom reduction. Although supervised and unsupervised exercises have shown to improve symptoms, clinical practice guidelines recommend supervised exercise therapy as a first line treatment. A home-based program is also effective and is a safe alternative. Guidelines recommend that each session be performed for a minimum of 30-45 minutes, at least 3 times per week for a minimum of 12 weeks. A recent systematic review demonstrated that low to moderate exercise intensity provides more benefit on pain free walking distance (11). However, more vigorous exercise provides better results for improving maximal walking distance and cardiorespiratory fitness. Therefore, a personalized approach tailored to the patient’s characteristics and goals is advisable in order to determine which exercises are the best to do. When exercise management is ineffective for symptom control, vasoactive drugs are recommended. In worsening cases, seeking a vascular consultation is recommended for further investigation in case a revascularization procedure is required. There are currently no trials to determine the impact of prehabilitation for revascularization procedures (12).
All clinicians should be trained to identify symptoms of common neuromusculoskeletal conditions and peripheral arterial disease. Remaining vigilant and being aware of this condition is important to ensure that the appropriate management pathway is initiated in a timely manner.
Addressing modifiable risk factors early, such as smoking cessation, blood pressure, glycated hemoglobin control, antiplatelet prescription and weight loss for overweight patients is a main component for the management of this condition. The initial management involves the prescription and implementation of exercise therapy for symptom reduction. Although supervised and unsupervised exercises have shown to improve symptoms, clinical practice guidelines recommend supervised exercise therapy as a first line treatment. A home-based program is also effective and is a safe alternative. Guidelines recommend that each session be performed for a minimum of 30-45 minutes, at least 3 times per week for a minimum of 12 weeks. A recent systematic review demonstrated that low to moderate exercise intensity provides more benefit on pain free walking distance (11). However, more vigorous exercise provides better results for improving maximal walking distance and cardiorespiratory fitness. Therefore, a personalized approach tailored to the patient’s characteristics and goals is advisable in order to determine which exercises are the best to do. When exercise management is ineffective for symptom control, vasoactive drugs are recommended. In worsening cases, seeking a vascular consultation is recommended for further investigation in case a revascularization procedure is required. There are currently no trials to determine the impact of prehabilitation for revascularization procedures (12).
All clinicians should be trained to identify symptoms of common neuromusculoskeletal conditions and peripheral arterial disease. Remaining vigilant and being aware of this condition is important to ensure that the appropriate management pathway is initiated in a timely manner.
Study Methods:
This paper had no formal methods section.
Study Strengths / Weaknesses:
Strengths:
- This paper nicely summarizes what peripheral arterial disease is, signs and symptoms to look for, and the role of musculoskeletal clinicians for this condition.
- A step by step guide to assess peripheral arterial disease was also provided.
Weaknesses:
- Even though this type of paper doesn’t require any methodology to be described, understanding where the authors got their information from would have been helpful.
Additional References:
- Firnhaber JM, Powell CS, Lower Extremity Peripheral Artery Disease: Diagnosis and Treatment. AFP 2019; 99: 362–369.
- Fowkes FGR, Rudan D, Rudan I, et al. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: a systematic review and analysis. Lancet 2013; 382: 1329–1340.
- Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg 2007; 45 Suppl S: S5-67.
- Joosten MM, Pai JK, Bertoia ML, et al. Associations between conventional cardiovascular risk factors and risk of peripheral artery disease in men. JAMA 2012; 308: 1660–1667.
- Selvin E, Erlinger TP. Prevalence of and risk factors for peripheral arterial disease in the United States: results from the National Health and Nutrition Examination Survey, 1999-2000. Circulation 2004; 110: 738–743.
- Selvin E, Wattanakit K, Steffes MW, et al. HbA1c and peripheral arterial disease in diabetes: the Atherosclerosis Risk in Communities study. Diabetes Care 2006; 29: 877–882.
- Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease. Circulation 2017; 135: e726–e779.
- Morley RL, Sharma A, Horsch AD, et al. Peripheral artery disease. BMJ 2018; 360: j5842.
- Conte SM, Vale PR. Peripheral Arterial Disease. Heart Lung Circ 2018; 27: 427–432.
- Boyko EJ, Ahroni JH, Davignon D, et al. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. J Clin Epidemiol 1997; 50: 659–668.
- Fassora M, Calanca L, Jaques C, et al. Intensity-dependent effects of exercise therapy on walking performance and aerobic fitness in symptomatic patients with lower extremity peripheral artery disease: A systematic review and meta-analysis. Vasc Med 2021; 27(2):158-170.
- Palmer J, Pymer S, Smith GE, et al. Presurgery exercise-based conditioning interventions (prehabilitation) in adults undergoing lower limb surgery for peripheral arterial disease. Cochrane Database Syst Rev 2020.
