Intermittent Claudication

Definition

Intermittent claudicationis a pain in the leg that a person experiences when walking or exercising. The pain is intermittent and goes away when the person rests.

Description

Claudication comes from the Latin word that means "to limp," and the condition is characterized by intermittent pain in the leg muscles. Poor circulation produces the pain. The legs do not receive the oxygen-rich blood supply needed for activities like walking and exercising. The decreased blood flow is caused by the narrowing of arteries that bring blood to the leg and foot.

The leg pain produced by claudication is usually experienced as cramping in the thighs, calves, hips, and feet. The pain stops several minutes after the person rests, but returns when the person performs activities that use the leg muscles. If untreated, claudication is no longer intermittent and occurs when a person is resting.

People age 50 or older are at risk of intermittent claudication. The risk increases with age. Statistically, 5% of men and 2.5% of women experience symptoms of this condition, according to the Vascular Disease Foundation (VDF). Many people with this condition have cholesterol plaque build-up in the leg's arteries. Smoking raises the risk, as do high blood pressure, obesity, lack of exercise, and diabetes.

Intermittent claudication is the main symptom of peripheral arterial disease (PAD), which is also known as peripheral vascular disease, and or occlusive arterial disease. Intermittent claudication is an early symptom of the condition that affects peripheral arteries, those blood vessels located outside the heart. PAD is caused by arteriosclerosis, the narrowing and hardening of the arteries.

Women with diabetes are 7.6 times as likely to experience PAD as those without diabetes, according to the American Diabetes Association (ADA). Furthermore, intermittent claudication is related to a two to three times increased risk of coronary heart disease, stroke, or cardiac failure in men with diabetes, according to the association.

Causes & symptoms

Intermittent claudication is caused by poor circulation and is experienced in a person's muscle groups. It affects the peripheral arteries that convey oxygen-rich blood from the heart to the legs. A person with this condition feels pain shortly after beginning to exercise. Walking may trigger the pain in an inactive person. Activities such as climbing stairs, walking rapidly or dancing can cause the pain to increase.

The person feels the pain as tightness in the calf, thigh, or buttocks. The pain stops after the person rests for several minutes. However, it returns when the person reaches the exertion level that previously produced the pain.

Intermittent claudication is the primary symptom of PAD, the condition causing reduced flow of blood and oxygen to tissues. If the intermittent condition is not treated, the person will find that resting does not relieve pain. As arteries become more clogged, the person could feel pain even when not exercising. Symptoms include cold or numb feet and toes, poor balance when standing, a drop in leg strength, sores that heal slowly, and erectile dysfunction (impotence).

In the advanced stages of PAD, the person experiences pain when resting. This condition, ischemic rest pain, is characterized by symptoms visible on the feet and toes. These include ulcers, loss of hair, and the change to red color when feet are suspended. Other symptoms include blue or purple markings on the legs, feet and toes. The coloring is a sign that less oxygen is reaching these areas. Furthermore, black skin on the legs and feet is a sign of gangrene infection.

Diagnosis

People experiencing symptoms of intermittent claudication should contact their doctor immediately. The doctor will review the patient's medical history and examine the person for signs of the condition. This examination includes checking for a lower pulse or the absence of a pulse behind the knee, on the ankle, foot, and groin.

The doctor may order an ankle-brachial index (ABI) test to determine whether arteries are blocked. This procedure will verify if the person has PAD and provides information on the severity of the condition. The ABI measures blood pressure in the arms and ankle. Readings are taken when the person is at rest and after exercising lightly by walking on a treadmill. The ABI index is found by dividing the ankle blood pressure by the pressure for the arm. An ABI below 0.90 in a person at rest is a sign of PAD.

The physician may also order a Doppler ultrasound exam to measure the flow of blood through the arteries. Cuffs are placed on four places on each leg. The doctor then moves an ultrasound probe over arteries in the foot. The probe detects signals from the artery.

Testing can last from 20 minutes to an hour. Costs vary by location and facility. In March of 2005, the ABI test was priced from $45 to $150. Some facilities offered a package of tests for around $200. The procedures are usually covered by medical insurance.

Treatment

Lifestyle changes are the primary form of treating intermittent claudication. Physicians advise people to quit smoking, exercise, and to follow the American Heart Association's healthy diet guidelines. Diabetics need to control blood sugar levels. The patient may need to lower blood pressure and cholesterol levels. Those measurements should drop when a person makes lifestyle changes.

The goal of treatment is stop development of PAD. By exercising, eating a diet that includes fiber and low-fat foods, and not smoking, a person could also reverse the build-up that clogs arteries. After several months of this regimen, many people experience a lessening of leg pain. If pain continues, the doctor may prescribe medication. Furthermore, surgery may be needed in some cases.

Walking

Walking is frequently an important treatment for intermittent claudication. A person experiencing the pain of intermittent claudication may not feel like walking. However, walking can increase the capacity to exercise. Before starting an exercise program, the person should consult with consult with a doctor.

The physician reviews the patient's medical history, does a physical and may order an exercise stress test on a treadmill. The test shows how long a person walks before claudication starts. Information such as blood pressure is used to evaluate the person's ability to walk. The findings are also used to develop a medically supervised exercise program.

At the beginning, the treadmill is set to cause claudication symptoms in three to five minutes, according to the Vascular Disease Foundation. The person walks until pain is moderately severe. A rest period is scheduled after the person walks eight to 10 minutes.

The person walks and rests, with the goal of walking for a total of 35 minutes. The person walks at least three times weekly. If a treadmill is not available, VDF recommends that people walk on a track. Generally, a person walking three times weekly will be able to walk longer after three to 12 months.

Medications

People diagnosed with PAD are at a high risk for a stroke and heart attack. They should take aspirin to reduce this risk. Clopidogrel, a drug marketed as Plavix, worked even better than aspirin in a study. However, it was more costly, with 30 tablets selling for about $119 in 2005. The dosage is one tablet daily.

A doctor may also prescribe cilostazol—sold under the name Pletal—which extends the distance people can walk without pain. One tablet is taken twice daily. The medication cost around $112 for 60 tablets.

Surgical procedures

Surgical procedures may be necessary in cases where intermittent claudication is disabling. The person experiences pain when resting, has open sores that do not heal, or symptoms of gangrene like dying skin in the leg or foot.

Bypass surgery directs blood through a grafted blood vessel, bypassing the damaged artery. The grafted vessel is either a healthy artery or vein or an artificial vessel.

Angioplasty is a procedure to open blocked blood vessels. A catheter (tube) is inserted in the groin and moved to the artery. Then a tiny balloon is inflated to open the artery. Another angioplasty procedure involves the insertion of a stent, a metal device that keeps the vessel open.

Angioplasty is a minimally invasive procedure. Local anesthesia is used, and a person is able to resume normal activities within one to two days. The cost averaged $6,502, according to a 2001 Dartmouth Medical School study. Bypass surgery cost $12,422 on average, according to the study. A non-invasive procedure is not as risky as surgery. However, a bypass may be needed when multiple sections of blood vessels are blocked.

Once a person is diagnosed with intermittent claudication, health plans usually cover part of treatment costs. A study on the overall costs of this condition from diagnosis through treatment should be completed by the end of 2005, according to a Sheryl Benjamin, VDF executive director.

Alternative treatment

Ginkgo biloba extract, an herbal remedy, has been used by people with intermittent claudication. The extract made from the dried leaves of the Gingko tree is thought to improve blood flow, allowing people to walk longer without pain.

However, herbal remedies are not regulated the U.S. Food and Drug Administration, and people should consult with their doctors before taking Ginkgo. Furthermore, use of this remedy could interact adversely when taken with Vitamin E and some medications.

Prognosis

If untreated, intermittent claudication will advance and eventually restrict a person's mobility. In later stages, people feel pain when resting. The leg or foot may feel cold. In the extreme stage, the person might need a cane, walker, or wheelchair. There is more risk of gangrene developing, and amputation might be necessary. Diabetics face an increased risk of amputation.

PAD also increases the risk of heart attacks and strokes.

Prevention

A healthy lifestyle is the best method for preventing intermittent claudication. Cigarette smokers should quit smoking. Regular exercise and a healthy diet help reduce the risk of this condition. If necessary, people should work to lower cholesterol and blood pressure. Diabetics should strive to manage that condition, obese people should lose weight.

The methods of preventing intermittent claudication are also the means for managing the risks associated with a diagnosis of PAD.

People can learn more about peripheral vascular disease through public education programs like the free Legs for Life screenings held at sites across the nation. The program started the Society of Interventional Radiology features a free ABI testing.

Resources

PERIODICALS

"New Treatment for Leg Pain-Conference News Update." Clinician Reviews, April 2002 [cited March 25, 2005]. 〈http://www.findarticles.com/p/articles/mi_m0BUY/is_4_12/ai_86050499〉.

Warkentin, Donald L. "Intermittent Claudication." Clinical Reference Systems. January 1, 2004, 1813.

ORGANIZATIONS

American Diabetes Association. 1701 North Beauregard Street, Alexandria, VA 22311. 800-342-2383. 〈http://www.diabetes.org〉.

Society of Interventional Radiology. 10201 Lee Highway, Suite 500, Fairfax, VA 22030. 703-691-1805. 〈http://www.sirweb.org/index.shtml〉.

Vascular Disease Foundation. 1075 S. Yukon Street, Suite 320, Lakewood, CO 80226. 866-723-4636. 〈http://www.vdf.org/Contact_Frame.htm〉.

OTHER

"Intermittent Claudication: 8 Ways to Ease the Pain." The Doctors Book of Home Remedies, Rodale. [cited March 25, 2005]. 〈http://www.mothernature.com/Library/Bookshelf/Books/47/85.cfm〉.

"Peripheral Arterial Disease of the Legs." Kaiser Permanente. Updated November 3, 2003 [cited March 25, 2005]. 〈http://prospectivemembers.kaiserpermanente.org〉.

KEY TERMS

Arthrosclerosis— A condition where fatty deposits cause the arteries to narrow.

Gangrene— The decay of tissue in the body; it is caused by an obstruction to the blood supply.

intermittent claudication (inter-mit-ĕnt) n. see claudication.