How To Tell If You Have Claudication

Claudication is the medical term for limping that is usually caused by pain. Intermittent claudication is pain in the legs that is a symptom of arterial disease; the pain occurs during and after exercise. This pain usually occurs distal to the arterial narrowing or obstruction. Since the superficial femoral and popliteal arteries are the vessels most commonly affected by the atherosclerotic process, the pain of intermittent claudication is most often localized to the calf. The distal aorta and its bifurcation into the two iliac arteries are the next most frequent sites of involvement. Narrowing of these arteries may produce pain in the buttocks or the thighs as well as the legs.

Epidemiological studies indicate that up to 5% of men and 2.5% of women 60 years of age or older have symptoms of intermittent claudication. The prevalence is at least threefold higher when sensitive noninvasive tests are used to make the diagnosis of arterial insufficiency in asymptomatic and symptomatic individuals. The symptoms of chronic arterial insufficiency of the lower extremities progress rather slowly over time. Thus, after 5 to 10 years, more than 70% of patients report either no change or improvement in their symptoms, while 20% to 30% have progressive symptoms and require intervention, and less than 10% need amputation. Despite the relatively benign prognosis for the affected limb, however, symptoms of intermittent claudication should be viewed as a sign of systemic atherosclerosis. This explains why, compared with age-matched controls, patients with intermittent claudication have a threefold increase in cardiovascular mortality.

Physical training and exercise therapy for patients with intermittent claudication have been uniformly endorsed by experts in vascular disease. Regular exercise therapy coupled with risk factor modification, especially smoking cessation, is the mainstay of conservative therapy for intermittent claudication. In fact, critical review of the available literature suggests that exercise therapy is the most consistently effective medical treatment for this condition.

Smoking cessation is frequently combined with exercise therapy in patients with intermittent claudication. Cigarette smoking is the most significant independent risk factor for development of chronic peripheral arterial occlusive disease and is associated with progression of established disease and a higher likelihood of disabling claudication, limb-threatening ischemia, amputation, and the need for intervention. Because of the adverse general health effects of cigarette smoking and the marked increase in morbidity and mortality from cardiopulmonary causes among smokers, patients with intermittent claudication should be vigorously counseled to stop smoking.

In contrast to the uniform improvement with exercise therapy, drug treatment of intermittent claudication is much more variable. Many types of drugs have been used.

At present the best treatment for this indication appears to be aspirin, 75 to 325 mg daily. In addition, because these patients are at high risk of future cardiovascular events (ie, stroke, myocardial infarction, and vascular death), they should be treated with lifelong aspirin therapy unless there are contraindications. Ticlopidine is a reasonable alternative for patients who are intolerant of aspirin.

Taking folic acid and vitamin B6 supplements may help prevent fatty build-up in the arteries of those at high risk for arterial disease, researchers in the Netherlands report.

The findings come from a study involving siblings of patients with diseased heart arteries who have high levels of an amino acid called homocysteine. While the jury is still out on the effects of homocysteine, results from several studies suggest that high blood levels of this protein building-block damage the lining of blood vessels and may increase the risk of heart disease and stroke.

Studies have also found that treatment with folic acid and vitamin B6 lower homocysteine levels in the blood.

Supplementing carnitine, a naturally occurring amino acid, can lessen symptoms of claudication, or limping, in patients with peripheral arterial disease. A food bar enriched with assorted nutrients makes life easier for individuals who walk with a limp because of calf pain due to peripheral arterial disease, according to a study reported by Dr. Andrew J. Maxwell, of Cooke Pharma in Belmont, Calif. A cramp-like pain in one or both legs usually occurs when atherosclerosis narrows the arteries. The ingredients of the food bar, including four grams of the nutrient L-arginine, as well as antioxidant vitamins, niacin, and isoflavenoids, enhance the synthesis of nitric oxide, which in turn makes walking easier and less painful.

Surgery is associated with a higher initial success rate than other treatments, and this benefit is maintained in follow-up. However, because the complication rate of operative therapy is slightly higher than that of nonsurgical treatment, surgery should not be performed without an adequate trial of nonoperative therapy.

- Ernst E, Fialka V. A review of the clinical effectiveness of exercise therapy for intermittent claudication. Arch Intern Med. 1993;153:2357-2360

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