Conservative treatment for intermittent claudication

This paper discusses the issues emerging during the treatment of lower-limb arterial diseases and intermittent claudication. According to the international and Russian guidelines, the common management strategy for intermittent claudication is as follows: conservative treatment is recommended in patients without limiting intermittent claudication who can walk 30 m or more without pain. Drugs that are prescribed is these patients are addressed. No large well-designed studies on most of these drugs were conducted, therefore, it is challenging to assess their efficacy in patients with intermittent claudication. The authors focus on cilostazol that has the largest evidence base. This drug is included in the Russian and international clinical guidelines. Several students demonstrate that cilostazol provides antithrombotic effect, stabilizes atherosclerotic plaques, prevents hyperplasia of neointima and restenosis after vascular procedures, improves lipid metabolism, and significantly increases pain-free walking distance (intermittent claudication distance). Recent studies show that cilostazol can be used in the complex treatment for COVID-19 due to pleiotropic mechanism of action. KEYWORDS: lower-limb arterial diseases, intermittent claudication, conservative treatment, cilostazol, COVID-19, restenosis, antiplatelet therapy. FOR CITATION: Kuznetsov M.R., Reshetov I.V., Sapelkin S.V., Yasnopol’skaya N.V. Conservative treatment for intermittent claudication. Russian Medical Inquiry. 2021;5(4):212–217 (in Russ.). DOI: 10.32364/2587-6821-2021-5-4-212-217.

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Ventilatory threshold is related to walking tolerance in patients with intermittent claudication

VASA ◽

10.1024/0301-1526/a000203 ◽

2012 ◽

Vol 41 (4) ◽

pp. 275-281 ◽

Cited By ~ 3

Author(s):

da Rocha Chehuen ◽

G. Cucato ◽

P. dos Anjos Souza Barbosa ◽

A. R. Costa ◽

M. Ritti-Dias ◽

...

Keyword(s):

Blood Flow ◽

Oxygen Uptake ◽

Intermittent Claudication ◽

Lower Limb ◽

Ventilatory Threshold ◽

Reactive Hyperemia ◽

Ankle Brachial Index ◽

Metabolic Parameters ◽

Walking Distance ◽

The Relationship

Background: This study assessed the relationship between lower limb hemodynamics and metabolic parameters with walking tolerance in patients with intermittent claudication (IC). Patients and methods: Resting ankle-brachial index (ABI), baseline blood flow (BF), BF response to reactive hyperemia (BFRH), oxygen uptake (VO2), initial claudication distance (ICD) and total walking distance (TWD) were measured in 28 IC patients. Pearson and Spearman correlations were calculated. Results: ABI, baseline BF and BF response to RH did not correlate with ICD or TWD. VO2 at first ventilatory threshold and VO2peak were significantly and positively correlated with ICD (r = 0.41 and 0.54, respectively) and TWD (r = 0.65 and 0.71, respectively). Conclusions: VO2peak and VO2 at first ventilatory threshold, but not ABI, baseline BF and BFHR were associated with walking tolerance in IC patients. These results suggest that VO2 at first ventilatory threshold may be useful to evaluate walking tolerance and improvements in IC patients.

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The test to retest reproducibility of walking test for intermittent claudication associated with lumbar spinal stenosis

10.21203/rs.2.24326/v1 ◽

2020 ◽

Author(s):

Shinji Tanishima ◽

Hu Jianzhong ◽

Zhao Jie ◽

Yang Huilin ◽

Hideki Nagashima ◽

...

Keyword(s):

Intermittent Claudication ◽

Spinal Stenosis ◽

Lumbar Spinal Stenosis ◽

Lower Limb ◽

Cauda Equina ◽

Walking Distance ◽

Walking Test ◽

Lower Limb Pain ◽

Significant Difference ◽

Lumbar Spinal

Abstract Background The walking test is useful to evaluate leg numbness and pain caused by cauda equina symptoms in patients with lumbar spinal stenosis but there are few reports described about reproducibility. The study aim was to evaluate the reproducibility of the walking test for lumbar spinal stenosis Methods Seventy patients with lumbar spinal stenosis who had intermittent claudication symptoms at a multicenter outpatient clinic were examined prospectively. A walking test was performed at 0 and 4 weeks. We investigated walking distance and lower limb pain and numbness in this study. Pain and numbness were evaluated by using the Visual Analog Scale (VAS) immediately after the walking test for the hip and outside, inside, front, and posterior sides of the lower legs. Cohen’s kappa analysis and interphase correlation coefficients (ICCs) were used to evaluate reproducibility. The Swiss Spinal Stenosis Questionnaire (SSS) was used to evaluate stenosis severity. Results The mean SSS was 30.2 ± 5.5 initially and 29.2 ± 5.2 at week 4, with no significant difference in severity ( P = 0.10). The walking distance ICC between baseline and 4 weeks was 0.670. The interobserver reliabilities for lower limb ache and numbness in both legs were acceptable. The average VAS for lower leg pain was 23.2 ± 25.2 mm at baseline and 27.4 ± 28.8 mm at week 4. The ICC was 0.668. The average VAS for leg numbness was 23.4 ± 26.7 mm at baseline and 24.8 ± 25.2 mm at week 4. The ICC was 0.683. Conclusions The walking test walking distance and symptomatic site results were reproducible.

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Home-based exercise programmes for individuals with intermittent claudication: A protocol for an updated systematic review and meta-analysis

SAGE Open Medicine ◽

10.1177/2050312118818295 ◽

2018 ◽

Vol 6 ◽

pp. 205031211881829

Author(s):

Sean Pymer ◽

Garry A Tew ◽

Joanne Palmer ◽

Lee Ingle ◽

George E Smith ◽

...

Keyword(s):

Intermittent Claudication ◽

English Language ◽

Exercise Intervention ◽

Data Extraction ◽

Meta Analysis ◽

Evidence Base ◽

Walking Distance ◽

Secondary Outcome ◽

Home Based ◽

Exercise Programmes

Background: The aim of this updated review is to consider the evidence base for the effectiveness of home-based exercise programmes as a treatment option for improving walking distance in patients with intermittent claudication. Methods: The Medline, EMBASE, CINAHL, PEDro and Cochrane CENTRAL databases will be searched for terms including ‘intermittent claudication’, ‘peripheral arterial disease’, ‘home-based exercise’ and ‘home-based walking’. No date restrictions will be used but only articles in the English language will be included. Both randomised and non-randomised trials of home-based exercise programmes versus a comparator arm will be included, and a meta-analysis using only the randomised controlled trials will be attempted if the assumptions of heterogeneity are met. Data extraction will include study details, sample description, intervention description, length of follow-up and outcomes measures. The primary outcome measure is objectively measured maximal walking distance or time, with secondary outcome measures including pain-free walking distance or time, changes in physical activity and quality of life. We will also provide a narrative description of the effective components of a home-based exercise intervention which can aid future recommendations. Conclusion: Overall, this proposed review and meta-analysis aims provide a comprehensive and complete overview of the evidence base for home-based exercise programmes, which can aid clinicians in the management of their patients.

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Influence of the Physical Training on Muscle Function and Walking Distance in Symptomatic Peripheral Arterial Disease in Elderly

BioMed Research International ◽

10.1155/2018/1937527 ◽

2018 ◽

Vol 2018 ◽

pp. 1-16 ◽

Cited By ~ 6

Author(s):

Katarzyna Kropielnicka ◽

Wioletta Dziubek ◽

Katarzyna Bulińska ◽

Małgorzata Stefańska ◽

Joanna Wojcieszczyk-Latos ◽

...

Keyword(s):

Intermittent Claudication ◽

Physical Training ◽

Lower Limb ◽

Training Group ◽

Walking Distance ◽

Nordic Walking ◽

Group Iii ◽

Exercise Rehabilitation ◽

Force Velocity ◽

Group Ii

Introduction. A typical symptom of chronic lower-limb ischaemia is lower-limb pain, which occurs during walking forcing the patient to stop, intermittent claudication (IC). Exercise rehabilitation is the basic form of treatment for these patients. Aim. The aim of this study was to compare the effectiveness of three types of physical training programmes conducted over a 12-week period in patients with chronic lower-limb arterial insufficiency. Materials and Methods. Ninety-five people qualified for the 3-month supervised motor rehabilitation programme, conducted three times a week. The respondents were assigned to three types of rehabilitation programmes using a pseudo-randomization method: Group I (TW), subjects undertaking treadmill walking training; Group II (NW), subjects undertaking Nordic walking training; Group III (RES+NW), subjects undertaking resistance and Nordic walking training. Treadmill test, 6 Minute Walk Test (6MWT), and isokinetic test were repeated after 3 months of rehabilitation, which 80 people completed. Results. Combined training (RES+NW) is more effective than Nordic walking alone and supervised treadmill training alone for improving ankle force-velocity parameters (p<0.05) in patients with intermittent claudication. Each of the proposed exercise rehabilitation programmes increased walking distance of patients with intermittent claudication (p<0.05), especially in 6MWT (p=0.001). Significant relationships of force-velocity parameters are observed in the maximum distance obtained in 6MWT, both in Group III (RES + NW) and in Group II (NW) at the level of moderate and strong correlation strength, which indicates that if the lower limbs are stronger the walking distance achieved in 6MWT is longer. Conclusions. Given both the force-velocity parameters and the covered distance, the training RES + NW gives the most beneficial changes compared to training TW alone and NW alone. All types of training increased walking distance, which is an important aspect of the everyday functioning of people with IC.

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Randomized Controlled Trial of Antioxidants in Intermittent Claudication

Vascular Medicine ◽

10.1177/1358863x9700200401 ◽

1997 ◽

Vol 2 (4) ◽

pp. 279-285 ◽

Cited By ~ 15

Author(s):

Gillian C Leng ◽

Amanda J Lee ◽

F Gerald R Fowkes ◽

David Horrobin ◽

Ruth G Jepson ◽

...

Keyword(s):

Placebo Group ◽

Intermittent Claudication ◽

Lower Limb ◽

Cardiovascular Events ◽

Plasma Cholesterol ◽

Controlled Trial ◽

Low Density Lipoprotein ◽

Density Lipoprotein ◽

Walking Distance ◽

Serious Adverse Events

Epidemiological evidence suggests that antioxidants protect against the development of atherosclerosis. To determine the effectiveness of antioxidant therapy in patients with lower limb atherosclerosis, a randomized placebo-controlled trial was performed in 120 men and women with intermittent claudication and an ankle/brachial pressure index (ABPI) ≤0.9. The study was analysed on an intention-to-treat basis. After 2 years, there were no significant differences between antioxidant and placebo groups in plasma cholesterol, lipoproteins, haemostatic or rheological factors. However, after 6 months, low density lipoprotein cholesterol was significantly lower in those taking antioxidant (108.0 mg/dl compared with 120.1 mg/dl, p < 0.05). There were no differences in the ABPI or walking distance, although both groups improved slightly with time. The incidence of cardiovascular events and death was nonsignificantly lower in the antioxidant compared with the placebo group: event rates per year were 5.5% (95% Cl 2.4–8.6) in the first year and 9.6% (95% Cl 6.8–12.4) in the second year for those on antioxidants; and 7.7% (95% Cl 5.1–10.3) and 13.3% (95% Cl 8.9–17.7) respectively for those on placebo. Significantly fewer serious adverse events occurred in the antioxidant than the placebo group: 21.8% (95% Cl 16.2–27.4) compared with 40.0% (95% Cl 33.9–46.1). This study therefore suggests that although antioxidants may prevent cardiovascular events in patients with peripheral atherosclerosis, they do not improve lower limb function.

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Simple assessment of quality of life and lower limb functional capacity during cilostazol treatment – results of the SHort-tERm cIlostazol eFFicacy and quality of life (SHERIFF) study

VASA ◽

10.1024/0301-1526/a000845 ◽

2020 ◽

Vol 49 (3) ◽

pp. 235-242 ◽

Cited By ~ 1

Author(s):

Katalin Farkas ◽

Endre Kolossváry ◽

Zoltán Járai

Keyword(s):

Quality Of Life ◽

Clinical Practice ◽

Intermittent Claudication ◽

Functional Capacity ◽

Lower Limb ◽

Ankle Brachial Index ◽

Walking Distance ◽

Treatment Results ◽

Walking Capacity

Summary: Background: Symptomatic peripheral arterial disease (intermittent claudication) is a major cause of disability and mobility loss in older men and women and thus has a significant negative impact on the patients’ quality of life. Both surgical and endovascular revascularization procedures and noninvasive medical therapies, such as supervised training and drug treatment, can improve walking capacity. Cilostazol is the only drug having a class I (level of evidence A) recommendation for the treatment of intermittent claudication (IC). The aim of this study was to evaluate the effect of three-month cilostazol treatment on the health-related quality of life and on the lower limb functional capacity in patients with IC in the clinical practice. Patients and methods: The study was a multicenter, non-interventional trial, performed in Hungary in 2018. 812 PAD patients (Fontaine II stage, mean age: 67.17 years, male/female: 58.25/41.75 %) were enrolled, who received cilostazol (50 or 100 mg b.i.d.) for 3 months. 802 patients completed the study. Quality of life was evaluated with the EQ-5D-3L questionnaire functional capacity with the WELCH (Walking Estimated-Limitation Calculated by History) questionnaire. Pain-free and maximal walking distance, ankle-brachial index (ABI) were measured at baseline and after 3-month treatment. Results: Upon conclusion of the study, the EQ-5D-3L index improved (baseline: –0.46 ± 0.22, 3rd month: –0.26 ± 0.18; p < 0.0001) and there was a significant increase in the WELCH score as well (19 ± 14, 31 ± 18; respectively, p < 0.0001). Both pain-free and maximal walking distance improved significantly by 54.52 % (median: 53.85 %) and 42.5 % (median: 34.68 %); respectively (p < 0.001). Adverse events occurred in 10 patients, 1 patient stopped cilostazol treatment because of side effects. Conclusions: Three months cilostazol treatment significantly improved quality of life and lower limb functional capacity in patients with intermittent claudication. The WELCH questionnaire is a useful tool for the evaluation of intermittent claudication treatment in the clinical practice.

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SPOD.01A double-blind, placebo-controlled, randomised trial of extracorporeal shockwave therapy as a novel treatment for intermittent claudication

British Journal of Surgery ◽

10.1093/bjs/znab310.011 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Paris Cai ◽

Sean Pymer ◽

Ali Raza ◽

Said Ibeggazene ◽

Ian Chetter ◽

...

Keyword(s):

Intermittent Claudication ◽

Lower Limb ◽

Randomised Trial ◽

Walking Distance ◽

Invasive Treatment ◽

Double Blind ◽

Extracorporeal Shockwave Therapy ◽

Double Blind Placebo ◽

Extracorporeal Shockwave ◽

Shockwave Therapy

Abstract Aims Intermittent claudication (IC) is a prevalent manifestation of peripheral arterial disease. Pilot data has shown Extracorporeal ShockWave Therapy (ESWT) as a novel, non-invasive treatment for IC. We aim to compare the effects of ESWT on quality of life (QoL) and walking distances of patients with lower limb IC through a randomised trial. Methods A double-blind, placebo-controlled, randomised trial, where patients with lower limb IC were randomised at a 1:1 ratio to ESWT or placebo. Primary outcome was the physical functioning domain of the SF-36 QoL questionnaire at 12-week follow up. Secondary outcomes included claudication and maximum walking distances, and Ankle Brachial Pressure Index (ABPI). Results Full study power achieved with 138 patients randomised. The ESWT group had a significantly higher physical function score at 12 weeks (Mdn 41 vs 34, z=-2.1, p = 0.033). At 12 weeks the ESWT group had significantly longer claudication and maximum walking distances (Claudication Mdn 125 vs 88, z=-2.9, p = 0.004) (Maximum Mdn 179 vs 129, z=-2.4, p = 0.013). The increase in claudication and maximum walking distance at 12 weeks from baseline was also significantly higher in the ESWT group (Mdn 51 vs 24, z=-2.8, p < 0.01) (Mdn 63 vs 17, z=-4 p < 0.01). Conclusion This study demonstrates ESWT is clinically effective in improving QoL and walking distances in patients with lower limb IC.

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Integrative therapy in patients with intermittent claudication

VASA ◽

10.1024/0301-1526/a000413 ◽

2015 ◽

Vol 44 (2) ◽

pp. 85-91

Author(s):

Erich Minar

Keyword(s):

Intermittent Claudication ◽

Modern Technology ◽

Walking Distance ◽

Interventional Treatment ◽

Therapeutic Concept ◽

Integrative Therapy ◽

Risk Factor Modification ◽

Supervised Exercise ◽

Main Challenge ◽

Exercise Programmes

The generally accepted first-line treatment in patients with intermittent claudication is risk factor modification, medical treatment and exercise training. In an era of reduced resources, the benefit of any further invasive intervention must be weighted against best conservative therapy for patients with claudication. According to some recent trials an integrative therapeutic concept combining best conservative treatment - including (supervised) exercise therapy - with endovascular therapy gives the best midterm results concerning walking distance and health-related quality of life. The improved mid- and long-term patency rate with use of modern technology further supports this concept. The conservative and interventional treatment strategy are more complimentary than competitive. The current main challenge is to overcome the economic barriers concerning the availability of exercise programmes.

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