Atherosclerosis is one of the most common causes of cardiovascular disease in the world, and the complications can be severe. The disease is characterized by the formation of atherosclerotic plaques, which narrow the lumen of the arteries. The symptoms depend on which arteries have been narrowed so that the manifestation of the disease can be very different in appearance and severity depending on the percentage of occlusion. When an artery supplying the extremities is occluded, it is called a peripheral arterial disease, and one of its manifestations is the so-called intermittent claudication.
Intermittent claudication (IC) is characterized by cramping and muscle pain with blocked vessels that normally occur during exercise and the pain intensifies until the person is forced to stop. Once the person stops blood flow and the lactic acid concentration is restored, ATP and phosphocreatine levels are reset, but isocemic damage over time. The disease is classified according to Fontaine's scale, where I is tingling and IV is critical limb ischemia.
The practical assessment for physiotherapists includes the scanning of periphalia pulses in the lower extremities and the maximum claudication distance, the maximum distance a person can walk before they have to stop because of their symptoms. An alternative to this is the painless, self-explanatory walk. At present, a limit of 100 meters means that surgical procedures must be considered.
What should a physiotherapeutic intervention be?
According to this review article, if you suspect IC, you should consult Vascular Surgery for proper diagnosis and initial treatment. If referred to you through vascular surgery / studies, you must ensure that the site of the stenosis has been identified, the stage of ischemia has been clarified, the initial and absolute distances to claudication, and the type of treatment (pharmacological or surgical). are determined; and concurrent diseases and contraindications for specific rehabilitation methods are known. Only then can an individual outpatient rehabilitation program be created for each patient.
The overall theme of the treatment is to improve the quality of life by alleviating body aches during walking, thereby increasing the distance of claudication and reducing the risk of cardiovascular complications. For this reason, supervised running training on a treadmill is considered the best initial treatment for patients with IC. The training should last 30 to 60 minutes and be performed three times a week for at least 3 months. The proposed belt speed is 3.2 km / h with increasing inclination of a treadmill. At the same time it is emphasized that the maximum pain of the ischemic muscles should always be avoided when walking. As the symptoms improve, the duration and speed of the sessions can be slowly increased. Outside the sessions, patients should be encouraged to "do a lot but not forcibly," as this should be a painless walk. It should be emphasized that severe pain and muscle cramping of the patient during walking as a result of ischemia – reperfusion injury (IRI) – have extremely adverse consequences.
When patients have difficulty walking due to competing comorbidities, cycling should be encouraged on a static bicycle with the forefoot on the pedals instead of the midfoot. This serves to ensure greater movement of the skull during exercise. Again, as with walking, it should be painless, and rest is imperative with the onset of pain, and once the exercise is done, the exercise can continue.
Flowchart of the PAD management – taken from the article discussed.
It goes without saying that educating patients about atherosclerosis is crucial, in addition to the absolute importance of smoking cessation and dietary change. Lifestyle advice should not be underestimated in these patients, and even in patients who do not yet have IC symptoms.
