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<div class="noeditbox">Welcome to [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project]] This project is created by and for the students in the School of Physiotherapy at Glasgow Caledonian University. Please do not edit unless you are involved in this project, but please come back in the near future to check out new information!!</div><div class="editorbox">
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'''Original Editors '''- [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project|Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.]]  
'''Original Editors '''- [[Glasgow Caledonian University Cardiorespiratory Therapeutics Project|Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.]]  


'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}} &nbsp;  
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== Definition/Description  ==
== Introduction ==
[[File:Peripheral Arterial Disease.gif|right|frameless|435x435px]]Peripheral artery disease is a common type of [[Cardiovascular Disease|cardiovascular disease]], which affects 236 million people across the world. It happens when the arteries in the legs and feet become clogged with fatty plaques through a process known as [[atherosclerosis]].


Peripheral arterial disease (PAD) is known as a condition where by the blood flow in the limb arteries are obstructed <ref name="Henderson">Henderson, J, Pollack, A, Harrison, C, Miller, G. 2013, “Peripheral arterial disease”, Australian Family Physician, Vol. 42, no. 6, pp. 363.</ref>. Commonly, the legs are the most affected <ref name="Henderson" />. These arteries are obstructed due to plaque deposits that restrict blood flow through the peripheries <ref name="Warren">Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.</ref>. Although blood flow may be also restricted by deep vein thrombosis, which may be a blood clot that occurs in the periphery of the limbs <ref name="Warren" />. Common symptoms of PAD include pain during walking and rest, skin ulcers, cramping, aching, clubbing of the finger or toenails, cold skin, blue tinged skin, and slow blood refill <ref name="Mahameed" />. Thus there is a lack of blood flow to remove anaerobic metabolites that cause a pain sensation when built up&nbsp;<ref name="Warren" />.
While some people with this disease experience no symptoms, the most classic symptoms are [[Pain Assessment|pain]], cramps, numbness, weakness or tingling that occurs in the legs during walking – known as intermittent claudication. These problems affect around 30% of people with peripheral artery disease. Intermittent claudication is more common in adults over 50, men and people who smoke.<ref>The Conversation [https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240 Walking can relieve leg pain in people with peripheral artery disease] Available: https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240<nowiki/>(accessed 6.6.2021)</ref>
 
The management of PAD varies depending on the disease severity and symptom status. Treatment options for PAD include lifestyle changes, cardiovascular risk factor reduction, pharmacotherapy, endovascular intervention, and [[Surgery and General Anaesthetic|surgery]].<ref name=":1">Zemaitis MR, Boll JM, Dreyer MA. [https://www.ncbi.nlm.nih.gov/books/NBK430745/ Peripheral arterial disease.] StatPearls [Internet]. 2020 Jul 6.Available :https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)</ref>
 
The video below is a good summary of the basics of PAD 
{{#ev:youtube|https://www.youtube.com/watch?v=XTSgpiPqIbk|width}}<ref>American Heart Association PAD What is it? Available from: https://www.youtube.com/watch?v=XTSgpiPqIbk (last accessed 7.9.2019)</ref>  


== Epidemiology  ==
== Epidemiology  ==
[[File:Smoking-1026556 960 720-2.jpg|right|frameless]]
Prevalence: 12-14%,  20% of the over 70s in Western populations<ref name=":0">Radiopedia [https://www.ncbi.nlm.nih.gov/books/NBK430745/ PAD] Available:https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)</ref>.
Smoking increases the risk of developing PAD fourfold and has the greatest impact on disease severity. Compared to non-smokers, smokers with PAD have shorter life spans and progress more frequently to critical limb ischemia and amputation. Additional risk factors for PAD include diabetes, hyperlipidemia, hypertension, race, and ethnicity.
== Etiology ==
[[File:Diabetes-528678 960 720.jpg|right|frameless]]
Peripheral artery disease is usually caused by atherosclerosis. Other causes may be inflammation of the blood vessels, injury, or radiation exposure.<ref name=":1" />
Risk factors: Smoking, [[Hypertension]], [[Diabetes]], [[Hyperlipidemia|High cholesterol]], Increasing age (especially after reaching 50 years of age), Family history of peripheral artery disease, [[Coronary Artery Disease (CAD)|Heart disease]] or [[Stroke]], High levels of homocysteine (a protein component that helps build and maintain tissue).<ref name=":1" />
== History and Presentation ==
The most characteristic symptom of PAD is claudication which is a pain in the lower extremity muscles brought on by walking and relieved with rest. 
* Although claudication has traditionally been described as cramping pain, some patients report leg fatigue, weakness, pressure, or aching. 
* Symptoms during walking occur in the muscle group one level distal to the artery narrowed or blocked by PAD. eg Patients with aortoiliac artery occlusive disease have symptoms in the thigh and buttock muscles, patients with femoropopliteal PAD have symptoms in their calf muscles. 
* Some patients with mild or moderate PAD rarely sustain a walking pace that increases the blood flow requirement of the lower extremity muscles. By being physically inactive, these patients avoid the supply-demand mismatch that triggers claudication symptoms. 
* Other patients with PAD have muscle discomfort when they walk but fail to report these symptoms because they attribute them to the natural consequences of aging.


In the United Kingdom, an estimated 500-1000 new cases of PAD are diagnosed per million each year<ref name="Patient">Patient. Peripheral arterial disease. http://www.patient.co.uk/doctor/peripheral-arterial-disease (accessed 9 May 2015)</ref><ref name="Peach">Peach, G, Griffin, M, Jones, KG, Thompson MM, Hinchliffe, RJ. Diagnosis and management of peripheral arterial disease. BMJ 2012; 345: 1-8.  http://www.bmj.com/content/bmj/345/bmj.e5208.full.pdf (acccessed 9 May 2015)</ref>. Patients at high risk of PAD are those with cardiac disease, diabetes mellitus, older than 70 years or 50 years old with multiple cardiovascular factors<ref name="Mahameed">Mahameed, AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol, EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams &amp;amp;amp;amp;amp; Wilkins, 2007, p.1531-1537</ref>. These factors include smoking, dyslipedmia, dysglycemia, hypertension, family history of atherosclerotic vascular disease. In lower socioeconomic areas, PAD is more frequent as a result of increased incidence of smoking <ref name="Fowkes">Fowkes G. Peripheral vascular disease. 2010. http://www.birmingham.ac.uk/Documents/college-mds/haps/projects/HCNA/09HCNA3D2.pdf (accessed 9 May 2015)</ref>. Some studies report no difference in prevalence between the sexes <ref name="Mahameed" />, however, other studies have found a 3:1 ratio comparing men to women<ref name="Fowkes" /><ref name="Patient" />. A few studies have suggested that black non-Hispanics have an increased prevalence of PAD, with a reported 2.39 to 2.83 odd ratio. Although, a study that controlled for atherosclerotic risk factors found a small difference between whites and African Americans; 1.54 and 1.89, respectively<ref name="Collins">Collines, TC, Petersen, NJ, Suarez-Almazor, M, Ashton CM. Ethnicity and peripheral arterial disease. Mayo Clin Proc. 2005; 80(1): 48-54.</ref>.&nbsp;The majority of cases are asymptomatic..  
Patients with severe PAD can develop ischemic rest pain.  


== Aetiology  ==
* These patients do not walk enough to claudicate because of their severe disease. 
* They complain of burning pain in the soles of their feet that is worse at night. They cannot sleep due to the pain and often dangle their lower leg over the side of the bed in an attempt to relieve their discomfort. The slight increase in blood flow due to gravity temporarily diminishes the otherwise intractable pain. 


The most common cause of PAD is '''atherosclerosis''', similarly, they share the same risk factors: smoking, diabetes, age, hypertension, and hyperlipidemia. Uncommon vascular symptoms, such as vasculitis, thromboangiitis obliterans, popliteal entrapment syndrome, and fibromuscular dysplasis, account for less than 10% of cases <ref name="Mahameed" />. Atherosclerosis is the formation of lipid deposits in the tunica media and associated with damage to the endothelial lining <ref name="Martini">Martini, FH, Nath, JL, Bartholomew, EF. Fundamentals of anatomy and physiology. San Francisco: Pearson Education, 2015.</ref>.The endothelial cells become swollen with lipids and create a gap between in the linings. Platelets stick to the exposed collagen fibers, forming a localized clot that restricts arterial blood flow, leading to inadequate tissue perfusion. This and other complex interactions can lead to progression from asymptomatic PAD, Intermittent Claudication, Critical Limb Ischemia, Acute Limb Ischemia <ref name="Mahameed" />.  
=== Clinical Manifestations ===
[[File:Arterial ulcer peripheral vascular disease.jpeg|right|frameless]]Image: A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years.


Cigarette '''smoking '''increases the chance of having PAD by seven-fold <ref name="Price">Price, JF, Mowbray, PI, Lee, AJ, Rumley, A, Lowe, GDO, Fowkes, FGR. 1999, “Relationship between smoking and cardiovascular risk factors in the development of peripheral arterial disease and coronary artery disease”, European Heart Journal, Vol. 20, pp. 344-353.</ref>. Due to a change in the fibrin formation, endothelial cells, blood rheology, and lipoproteins decrease antioxidants in the blood <ref name="Price" />. Specifically, the change in endothelial cells that line the arterial walls is strongly associated with atherosclerosis <ref name="Hirsch">Hirsch, AT, et al. 2006, “Practice Guidelines for the Management of Patients With Peripheral Arterial Disease (Lower Extremity, Renal, Mesenteric, and Abdominal Aortic)”, Circulation, Vol. 113, pp. 463-654.</ref>. As the number of cigarettes smoked each day increase, so does the risk of PAD <ref name="Price" />.
* Non-healing wounds on legs or feet


'''[[Diabetes|Diabetes]]''', similarly to smoking causes abnormalities in endothelial cells and their function. The cells are unable to regulate the function and structure of the arterial walls<ref name="Creager">Creager, MA, Luscher, TF, Beckman, JA. Diabetes and vascular disease: Pathophysiology, clinical consquences and medical therapy. Circulation 2003;108:1527-1532.</ref>. Diabetes Mellitus leads to a two-to fourfold increase in risk of cardiovascular events <ref name="Mahameed" />.
* Unexplained leg pain


'''Age -&nbsp;'''The risk of PAD increases as the population approaches the age of 50. It has been reported that PAD affects 0.9% of 40-49 year olds and increases to 14.5% of 70 year olds and above <ref name="Mahameed" />.Studies also have shown that men are the target population of PAD <ref name="Mahameed" />.
*Pain on walking that resolves when stopped
*Pain in foot at rest made which worsens with elevation
*[[Chronic Leg Ulcers|Ulcers]]
*Gangrene
*Dry skin
*Cramping
*Aching<ref name="NICE">NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management, 2012. https://www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication (accessed 9 May 2015)</ref>


'''Hypertension -&nbsp;'''In a study conducted by Lewington et al. illustrated that for each 20-mmHg increase in systolic blood pressure or 10 mmHG in diastolic for people age 40-70 doubled the risk of cardiovascular disease and PAD <ref name="Mahameed" />.
== Evaluation ==
Making the diagnosis of PAD should factor in the patient’s history, physical exam, and objective test results. Key points in the history include an accurate assessment of:


'''Dyslipidemia -&nbsp;'''Developing PAD by 10% for every 10-mg/dL rise in total cholesterol<ref name="Mahameed" />. <br>  
* Patient’s walking ability<ref name=":1" />. For Objective Measures  see below, under physiotherapy
* [[File:Ankle-brachail index.png|right|frameless]]On physical exam, patients with PAD may have diminished or absent lower extremity pulses. This finding can be confirmed with the [[Ankle-Brachial Index|Ankle Brachial Pressure Index]] (ABI), a simple and inexpensive test that measures the ratio between blood pressure in the legs to the [[Blood Pressure|blood pressure]] in the arms.<ref name="Mahameed">Mahameed, AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol, EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams &amp; Wilkins, 2007, p.1531-1537</ref> An ABI of 0.9- 1.0 is '''normal''', 0.70-0.89 is a '''mild disease''', 0.40- 0.69 is a '''moderate disease''', and less than .40 is a '''severe PAD'''<ref name="Mahameed" />. When measuring for ABI, make sure the patient is calm and in a rested position <ref name="NICE" />.


== Investigations  ==
* Other investigations include:
** Doppler US: initial investigation; assess flow and atherosclerotic plaque
** Angiography (CT, MR, DSA): direct imaging of the vessels and runoff.<ref name=":0" />


A tool used to gain a diagnosis of PAD is Ankle Brachial Pressure Index (ABI), a simple and inexpensive test that measures the ratio between blood pressure in the legs to the blood pressure in the arms<ref name="Mahameed" />. The lower the pressure in the legs illustrates that PAD is present. An ABI of 0.9- 1.0 is normal, 0.70-0.89 is a mild disease, 0.40- 0.69 is a moderate disease, and less than .40 is a severe PAD<ref name="Mahameed" />. When measuring for ABI, make sure the patient is calm and in a rested position <ref name="NICE">NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management, 2012. https://www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication (accessed 9 May 2015)</ref>. It is also important to assess individuals if they have diabetes, non-healing wounds on their legs and feet, unexplained pain in their peripherals, and check for femoral and popliteal pulses<ref name="NICE" />.<br>
== Management ==
[[File:Dementia Walking Picture.jpg|right|frameless]]
Management strategies for PAD attempt to achieve two distinct goals: lower cardiovascular risk and improve walking ability. All patients with PAD, regardless of the presence or absence of symptoms, have an increased risk of stroke, myocardial infarction, and thrombosis compared to patients without arterial disease. These cardiovascular events probably account for the shorter life expectancy of patients with PAD. Therefore, all patients diagnosed with PAD should undertake lifestyle changes aimed at lowering their cardiovascular risk profile. Key targets for lifestyle changes include quitting smoking, lowering cholesterol, and controlling hypertension and diabetes.


== Clinical Manifestations  ==
Other treatment involves:


According to NICE:<ref name="NICE" /><br>  
Medical therapy: involves the use of cilostazol, a medication that promotes vasodilation and suppresses the proliferation of vascular smooth muscle cells; the use of statins to improve the atherosclerotic disease; [[Pharmacological Management of Hypertension|antihypertensives]].<ref name=":1" /><ref name=":0" />
[[File:3D Medical Animation Vascular Bypass Grafting.jpeg|right|frameless]]
Revascularisation


*non-healing wounds on legs or feet
* Balloon angioplasty or stent placement provides a minimally invasive, percutaneous treatment option for patients with PAD symptoms that do not respond to exercise or medical therapy
*unexplained leg pain
* Surgical options for PAD include bypass grafts to divert flow around the blockage or endarterectomy to segmentally remove the obstructive plaque.<ref name=":1" />
*pain on walking that resolves when stopped
*pain in foot at rest made which worsens with elevation
*ulcers
*gangrene
*dry skin
*cramping
*aching


== Physiotherapy and Other Management ==
=== Physiotherapy Management ===
The least invasive and most appropriate treatment for PAD conducted by Physiotherapists would be by prescribing an exercise program.  Exercise therapy involves walking until reaching pain tolerance, stopping for a brief rest, and walking again as soon as the pain resolves. These walking sessions should last 30 to 45 minutes, 3 to 4 times per week for at least 12 weeks. Despite being more effective, supervised exercise programs for PAD are not usually covered by insurance companies[[File:Treadmill walk.jpg|right|frameless]]
A 2018 review of the best exercise prescription for PAD summarised their findings thus
* Supervised treadmill exercise improves treadmill walking performance in patients with PAD.
* Supervised treadmill exercise has greater benefit on treadmill walking performance than home-based walking exercise.
* Home-based walking exercise interventions that involve behavioral techniques are effective for functional impairment in people with PAD and improve the 6-min walk distance more than supervised treadmill exercise.
* Upper and lower extremity ergometry improve walking performance in patients with PAD and improve peak oxygen uptake.


One method of treating PAD is to reduce cardiovascular risk factors by quitting smoking, managing diabetes mellitus, treating dyslipidemia and hypertension <ref name="Mahameed" />. Another method is to treat PAD symptoms to improve quality of life through pharmacotherapy, exercise rehabilitation program, revascularization, thrombolysis and surgical procedures <ref name="Mahameed" />. The least invasive and most appropriate treatment conducted by Physiotherapists would be by prescribing an exercise program. The recommended parameters of physical exercise are a 6 month program of 30-35 minutes walking sessions at a frequency of 3-5 times a week at near-maximal pain tolerant <ref name="Mahameed" />. NICE recommends PAD patients to exercise at near-maximal pain for a total of 2 hours per week for 3 months to improve quality of life <ref name="NICE" />. <br>  
* Lower extremity resistance training can improve treadmill walking performance in PAD, but is not as effective as supervised treadmill exercise.<ref>McDermott MM. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831500/ Exercise rehabilitation for peripheral artery disease: a review. Journal of cardiopulmonary rehabilitation and prevention]. 2018 Mar;38(2):63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831500/ (last accessed 6.9.2019)</ref>
The optimal exercise program for PAD recommended by the American Heart Association states the following : '''Exercise Prescription for Supervised Exercise Treadmill Training in Patients With Claudication'''
# Modality Supervised Treadmill Walking
# Intensity 40%–60% maximal workload based on baseline treadmill test or workload that brings on claudication within 3–5 min during a 6-MWT
# Session duration 30–50 min of intermittent exercise; goal is to accumulate at least 30 min of walking exercise
# Claudication intensity Moderate to moderate/severe claudication as tolerated
# Work-to-rest ratio Walking duration should be within 5–10 min to reach moderate to moderately severe claudication followed by rest until pain has dissipated (2–5 min)
# Frequency 3 times per week supervised
# Program duration At least 12 wk
# Progression Every 1–2 wk: increase duration of training session to achieve 50 min. As individuals can walk beyond 10 min without reaching prescribed claudication level, manipulate grade or speed of exercise prescription to keep the walking bouts within 5–10 min
# Maintenance Lifelong maintenance at least 2 times per week
Based on currently available evidence. Exercise prescription should be individualized to each patient as tolerated. 6-MWT indicates 6-minute walk test. <ref>Diane Treat-Jacobson, Mary M. McDermott, Ulf G. Bronas et al.[https://ahajournals.org/doi/10.1161/CIR.0000000000000623 Optimal Exercise Programs for Patients With Peripheral Artery Disease: A Scientific Statement From the American Heart Association.] AHA Journal Vol. Circulation.130 No.4 Available from: https://ahajournals.org/doi/10.1161/CIR.0000000000000623 (last accessed 7.9.2019)</ref>


== Prevention  ==
A recent research study showed that Nordic walking training improved the gait pattern of patients with PAD remarkably and caused a significant increase in the absolute claudication distance and total gait distance. The combined training of Nordic walking with the isokinetic resistance training of the lower extremities muscles (NW + ISO) increased the amplitude of the general center of gravity oscillation to the greatest extent. However, only treadmill training had little effect on the gait pattern. Hence, Nordic walking can be used to rehabilitate patients with PAD as a form of gait training<ref>W Dziubek, M Stefańska, K Bulińska, K Barska [https://pubmed.ncbi.nlm.nih.gov/32878323/ Journal of Clinical …, 2020 - mdpi.com]Effects of Physical Rehabilitation on Spatiotemporal Gait Parameters and Ground Reaction Forces of Patients with Intermittent Claudication
</ref>.


According to Warren<ref name="Warren" /> there are several methods one can prevent PAD. Firstly, help change the patient's lifestyle by educating them on the risk factors and the effects PAD. If the patient smokes cigarettes, it is important to address the issue and promote cessation. Those who consume a high fat diet have a higher chance of being diagnosed with PAD, thus one should encourage a reduced fat diet as a strong prevention method. Along with diet, it is important to live an active lifestyle. By being active and working up to the general standards of physical activity per week will allow a decrease in weight along with a decrease in risk of PAD.<br>  
== Outcome Measures ==
* [[Six Minute Walk Test / 6 Minute Walk Test|6 Minute Walk Test (MWT)]]
* [[Timed Up and Go Test (TUG)|Timed Up and Go Test (TUG)]]
* EQ-5D
* Incremental shuttle walk test (ISWT)<ref>Dixit S, Chakravarthy K, Reddy RS, Tedla JS. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513323/ Comparison of two walk tests in determining the claudication distance in patients suffering from peripheral arterial occlusive disease.] Advanced biomedical research. 2015;4.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513323/<nowiki/>(accessed 6.6.2021)</ref>


== Resources <br> ==
== Prevention ==
According to Warren<ref name="Warren">Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.</ref> there are several methods one can prevent PAD. Firstly, help change the patient's lifestyle by educating them on the risk factors and the effects PAD. If the patient smokes cigarettes, it is important to address the issue and promote cessation. Those who consume a high fat diet have a higher chance of being diagnosed with PAD, thus one should encourage a reduced fat diet as a strong prevention method. Along with diet, it is important to live an active lifestyle. By being active and working up to the general standards of physical activity per week will allow a decrease in weight along with a decrease in risk of PAD.


[http://www.nhs.uk/conditions/peripheralarterialdisease/Pages/Introduction.aspx Peripheral Vascular Disease], NHS Choices
== Prognosis ==
Even with treatment, the prognosis of PAD is generally guarded. If the patient does not change his/her lifestyle, the disease is progressive. In addition, most patients with PAD also have coexistence of cerebrovascular or coronary artery disease, which also increases the mortality rate. The outcomes in women tend to be worse than in men, chiefly because of the small diameter of the arteries. In addition, females are more likely to develop complications and embolic events.<ref name=":1" />


[http://www.circulationfoundation.org.uk/help-advice/peripheral-arterial-disease/ Peripheral Arterial Disease], Circulation Foundation&nbsp;
== Conclusions ==
Highlights  from the 2016  AHA advice regarding PAD management
* Patients with peripheral artery disease (PAD) should be on a program of guideline-directed medical therapy (including antiplatelet drugs that thin blood and statins to lower cholesterol) and should participate in a structured exercise program.


[http://www.mayoclinic.org/diseases-conditions/peripheral-artery-disease/basics/definition/con-20028731 Peripheral Artery Disease,] Mayo Clinic
* Restoring blood flow to the legs through vascular procedures is appropriate for many patients with severe symptoms due to PAD.
* Eliminating exposure to all tobacco – including second-hand smoke – is highly recommended for patients with PAD.<ref name=":3">Newsroom. [https://newsroom.heart.org/news/x-new-peripheral-artery-disease-guidelines-emphasize-medical-therapy-and-structured-exercise New peripheral artery disease guidelines emphasize medical therapy and structured exercise] 13.11. 2016 Available from: https://newsroom.heart.org/news/x-new-peripheral-artery-disease-guidelines-emphasize-medical-therapy-and-structured-exercise (last accessed 7.9.2019)</ref>


== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
<div class="researchbox">
<rss>http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1DAyVQqGr_VD40TNFES0RcPSSGJlm2wVXmvCm_ZQGLy6E3msSs|charset=UTF-8|short|max=10</rss>
</div>
== References  ==
== References  ==


<references />  
<references />  


[[Category:Glasgow_Caledonian_University_Project]]
[[Category:Glasgow_Caledonian_University_Project]] 
[[Category:Cardiopulmonary]]
[[Category:Cardiovascular Disease]]
[[Category:Cardiovascular Disease - Conditions]]
[[Category:Conditions]]
[[Category:Non Communicable Diseases]]

Latest revision as of 16:01, 14 June 2021

Original Editors - Students from Glasgow Caledonian University's Cardiorespiratory Therapeutics Project.

Top Contributors - Victoria Michaud, Lucinda hampton, Kim Jackson, Admin, Adam Vallely Farrell, Chris Seenan, Vidya Acharya, 127.0.0.1, Michelle Lee and WikiSysop  

Introduction[edit | edit source]

Peripheral Arterial Disease.gif

Peripheral artery disease is a common type of cardiovascular disease, which affects 236 million people across the world. It happens when the arteries in the legs and feet become clogged with fatty plaques through a process known as atherosclerosis.

While some people with this disease experience no symptoms, the most classic symptoms are pain, cramps, numbness, weakness or tingling that occurs in the legs during walking – known as intermittent claudication. These problems affect around 30% of people with peripheral artery disease. Intermittent claudication is more common in adults over 50, men and people who smoke.[1]

The management of PAD varies depending on the disease severity and symptom status. Treatment options for PAD include lifestyle changes, cardiovascular risk factor reduction, pharmacotherapy, endovascular intervention, and surgery.[2]

The video below is a good summary of the basics of PAD

[3]

Epidemiology[edit | edit source]

Smoking-1026556 960 720-2.jpg

Prevalence: 12-14%, 20% of the over 70s in Western populations[4].

Smoking increases the risk of developing PAD fourfold and has the greatest impact on disease severity. Compared to non-smokers, smokers with PAD have shorter life spans and progress more frequently to critical limb ischemia and amputation. Additional risk factors for PAD include diabetes, hyperlipidemia, hypertension, race, and ethnicity.

Etiology[edit | edit source]

Diabetes-528678 960 720.jpg

Peripheral artery disease is usually caused by atherosclerosis. Other causes may be inflammation of the blood vessels, injury, or radiation exposure.[2]

Risk factors: Smoking, Hypertension, Diabetes, High cholesterol, Increasing age (especially after reaching 50 years of age), Family history of peripheral artery disease, Heart disease or Stroke, High levels of homocysteine (a protein component that helps build and maintain tissue).[2]

History and Presentation[edit | edit source]

The most characteristic symptom of PAD is claudication which is a pain in the lower extremity muscles brought on by walking and relieved with rest.

  • Although claudication has traditionally been described as cramping pain, some patients report leg fatigue, weakness, pressure, or aching.
  • Symptoms during walking occur in the muscle group one level distal to the artery narrowed or blocked by PAD. eg Patients with aortoiliac artery occlusive disease have symptoms in the thigh and buttock muscles, patients with femoropopliteal PAD have symptoms in their calf muscles.
  • Some patients with mild or moderate PAD rarely sustain a walking pace that increases the blood flow requirement of the lower extremity muscles. By being physically inactive, these patients avoid the supply-demand mismatch that triggers claudication symptoms.
  • Other patients with PAD have muscle discomfort when they walk but fail to report these symptoms because they attribute them to the natural consequences of aging.

Patients with severe PAD can develop ischemic rest pain.

  • These patients do not walk enough to claudicate because of their severe disease.
  • They complain of burning pain in the soles of their feet that is worse at night. They cannot sleep due to the pain and often dangle their lower leg over the side of the bed in an attempt to relieve their discomfort. The slight increase in blood flow due to gravity temporarily diminishes the otherwise intractable pain.

Clinical Manifestations[edit | edit source]

Arterial ulcer peripheral vascular disease.jpeg

Image: A 71-year-old diabetic male smoker with severe peripheral arterial disease presented with a dorsal foot ulceration (2.5 cm X 2.4cm) that had been chronically open for nearly 2 years.

  • Non-healing wounds on legs or feet
  • Unexplained leg pain
  • Pain on walking that resolves when stopped
  • Pain in foot at rest made which worsens with elevation
  • Ulcers
  • Gangrene
  • Dry skin
  • Cramping
  • Aching[5]

Evaluation[edit | edit source]

Making the diagnosis of PAD should factor in the patient’s history, physical exam, and objective test results. Key points in the history include an accurate assessment of:

  • Patient’s walking ability[2]. For Objective Measures see below, under physiotherapy
  • Ankle-brachail index.png
    On physical exam, patients with PAD may have diminished or absent lower extremity pulses. This finding can be confirmed with the Ankle Brachial Pressure Index (ABI), a simple and inexpensive test that measures the ratio between blood pressure in the legs to the blood pressure in the arms.[6] An ABI of 0.9- 1.0 is normal, 0.70-0.89 is a mild disease, 0.40- 0.69 is a moderate disease, and less than .40 is a severe PAD[6]. When measuring for ABI, make sure the patient is calm and in a rested position [5].
  • Other investigations include:
    • Doppler US: initial investigation; assess flow and atherosclerotic plaque
    • Angiography (CT, MR, DSA): direct imaging of the vessels and runoff.[4]

Management[edit | edit source]

Dementia Walking Picture.jpg

Management strategies for PAD attempt to achieve two distinct goals: lower cardiovascular risk and improve walking ability. All patients with PAD, regardless of the presence or absence of symptoms, have an increased risk of stroke, myocardial infarction, and thrombosis compared to patients without arterial disease. These cardiovascular events probably account for the shorter life expectancy of patients with PAD. Therefore, all patients diagnosed with PAD should undertake lifestyle changes aimed at lowering their cardiovascular risk profile. Key targets for lifestyle changes include quitting smoking, lowering cholesterol, and controlling hypertension and diabetes.

Other treatment involves:

Medical therapy: involves the use of cilostazol, a medication that promotes vasodilation and suppresses the proliferation of vascular smooth muscle cells; the use of statins to improve the atherosclerotic disease; antihypertensives.[2][4]

3D Medical Animation Vascular Bypass Grafting.jpeg

Revascularisation

  • Balloon angioplasty or stent placement provides a minimally invasive, percutaneous treatment option for patients with PAD symptoms that do not respond to exercise or medical therapy
  • Surgical options for PAD include bypass grafts to divert flow around the blockage or endarterectomy to segmentally remove the obstructive plaque.[2]

Physiotherapy Management[edit | edit source]

The least invasive and most appropriate treatment for PAD conducted by Physiotherapists would be by prescribing an exercise program. Exercise therapy involves walking until reaching pain tolerance, stopping for a brief rest, and walking again as soon as the pain resolves. These walking sessions should last 30 to 45 minutes, 3 to 4 times per week for at least 12 weeks. Despite being more effective, supervised exercise programs for PAD are not usually covered by insurance companies

Treadmill walk.jpg

A 2018 review of the best exercise prescription for PAD summarised their findings thus

  • Supervised treadmill exercise improves treadmill walking performance in patients with PAD.
  • Supervised treadmill exercise has greater benefit on treadmill walking performance than home-based walking exercise.
  • Home-based walking exercise interventions that involve behavioral techniques are effective for functional impairment in people with PAD and improve the 6-min walk distance more than supervised treadmill exercise.
  • Upper and lower extremity ergometry improve walking performance in patients with PAD and improve peak oxygen uptake.
  • Lower extremity resistance training can improve treadmill walking performance in PAD, but is not as effective as supervised treadmill exercise.[7]

The optimal exercise program for PAD recommended by the American Heart Association states the following : Exercise Prescription for Supervised Exercise Treadmill Training in Patients With Claudication

  1. Modality Supervised Treadmill Walking
  2. Intensity 40%–60% maximal workload based on baseline treadmill test or workload that brings on claudication within 3–5 min during a 6-MWT
  3. Session duration 30–50 min of intermittent exercise; goal is to accumulate at least 30 min of walking exercise
  4. Claudication intensity Moderate to moderate/severe claudication as tolerated
  5. Work-to-rest ratio Walking duration should be within 5–10 min to reach moderate to moderately severe claudication followed by rest until pain has dissipated (2–5 min)
  6. Frequency 3 times per week supervised
  7. Program duration At least 12 wk
  8. Progression Every 1–2 wk: increase duration of training session to achieve 50 min. As individuals can walk beyond 10 min without reaching prescribed claudication level, manipulate grade or speed of exercise prescription to keep the walking bouts within 5–10 min
  9. Maintenance Lifelong maintenance at least 2 times per week

Based on currently available evidence. Exercise prescription should be individualized to each patient as tolerated. 6-MWT indicates 6-minute walk test. [8]

A recent research study showed that Nordic walking training improved the gait pattern of patients with PAD remarkably and caused a significant increase in the absolute claudication distance and total gait distance. The combined training of Nordic walking with the isokinetic resistance training of the lower extremities muscles (NW + ISO) increased the amplitude of the general center of gravity oscillation to the greatest extent. However, only treadmill training had little effect on the gait pattern. Hence, Nordic walking can be used to rehabilitate patients with PAD as a form of gait training[9].

Outcome Measures[edit | edit source]

Prevention[edit | edit source]

According to Warren[11] there are several methods one can prevent PAD. Firstly, help change the patient's lifestyle by educating them on the risk factors and the effects PAD. If the patient smokes cigarettes, it is important to address the issue and promote cessation. Those who consume a high fat diet have a higher chance of being diagnosed with PAD, thus one should encourage a reduced fat diet as a strong prevention method. Along with diet, it is important to live an active lifestyle. By being active and working up to the general standards of physical activity per week will allow a decrease in weight along with a decrease in risk of PAD.

Prognosis[edit | edit source]

Even with treatment, the prognosis of PAD is generally guarded. If the patient does not change his/her lifestyle, the disease is progressive. In addition, most patients with PAD also have coexistence of cerebrovascular or coronary artery disease, which also increases the mortality rate. The outcomes in women tend to be worse than in men, chiefly because of the small diameter of the arteries. In addition, females are more likely to develop complications and embolic events.[2]

Conclusions[edit | edit source]

Highlights from the 2016 AHA advice regarding PAD management

  • Patients with peripheral artery disease (PAD) should be on a program of guideline-directed medical therapy (including antiplatelet drugs that thin blood and statins to lower cholesterol) and should participate in a structured exercise program.
  • Restoring blood flow to the legs through vascular procedures is appropriate for many patients with severe symptoms due to PAD.
  • Eliminating exposure to all tobacco – including second-hand smoke – is highly recommended for patients with PAD.[12]

References[edit | edit source]

  1. ↑ The Conversation Walking can relieve leg pain in people with peripheral artery disease Available: https://theconversation.com/walking-can-relieve-leg-pain-in-people-with-peripheral-artery-disease-151240(accessed 6.6.2021)
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Zemaitis MR, Boll JM, Dreyer MA. Peripheral arterial disease. StatPearls [Internet]. 2020 Jul 6.Available :https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)
  3. ↑ American Heart Association PAD What is it? Available from: https://www.youtube.com/watch?v=XTSgpiPqIbk (last accessed 7.9.2019)
  4. ↑ 4.0 4.1 4.2 Radiopedia PAD Available:https://www.ncbi.nlm.nih.gov/books/NBK430745/ (accessed 6.6.2021)
  5. ↑ 5.0 5.1 NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management, 2012. https://www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication (accessed 9 May 2015)
  6. ↑ 6.0 6.1 Mahameed, AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol, EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams & Wilkins, 2007, p.1531-1537
  7. ↑ McDermott MM. Exercise rehabilitation for peripheral artery disease: a review. Journal of cardiopulmonary rehabilitation and prevention. 2018 Mar;38(2):63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5831500/ (last accessed 6.9.2019)
  8. ↑ Diane Treat-Jacobson, Mary M. McDermott, Ulf G. Bronas et al.Optimal Exercise Programs for Patients With Peripheral Artery Disease: A Scientific Statement From the American Heart Association. AHA Journal Vol. Circulation.130 No.4 Available from: https://ahajournals.org/doi/10.1161/CIR.0000000000000623 (last accessed 7.9.2019)
  9. ↑ W Dziubek, M Stefańska, K Bulińska, K Barska Journal of Clinical …, 2020 - mdpi.comEffects of Physical Rehabilitation on Spatiotemporal Gait Parameters and Ground Reaction Forces of Patients with Intermittent Claudication
  10. ↑ Dixit S, Chakravarthy K, Reddy RS, Tedla JS. Comparison of two walk tests in determining the claudication distance in patients suffering from peripheral arterial occlusive disease. Advanced biomedical research. 2015;4.Available: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4513323/(accessed 6.6.2021)
  11. ↑ Warren, E. Ten things the practice nurse can do about peripheral arterial disease. Practice Nurse 2013; 43; 12: 14-18.
  12. ↑ Newsroom. New peripheral artery disease guidelines emphasize medical therapy and structured exercise 13.11. 2016 Available from: https://newsroom.heart.org/news/x-new-peripheral-artery-disease-guidelines-emphasize-medical-therapy-and-structured-exercise (last accessed 7.9.2019)
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