• En

Claudication

Dr. Nabi Darya Vali (AIIMS)MBBS

December 05, 2020

December 05, 2020

Claudication
Claudication

The word claudication literally means the state of being lame or limping. In medicine, claudication refers to severe and debilitating pain in the legs, thighs, hips or buttocks because of less-than-adequate blood flow to the region. Claudication can also occur in the arms, though this is rare.

A major symptom of peripheral arterial disease (PAD), claudication affects almost 20% of PAD patients. PAD itself is emerging as the third biggest cause of vascular morbidity worldwide, debilitating 200 million people. 

Intermittent claudication occurs when a person walks or exercises - it subsides when they stop and the workload is taken off their lower extremities. However, as claudication progresses, the patient experiences pain and cramps in the peripheral limbs even during rest. Over time, the pain can become so bad that the person can’t even walk short distances. 

Claudication usually occurs when there’s a blockage in the peripheral blood vessels. This reduces both blood flow and oxygen supply to the patient’s legs. Our muscles require up to 30 times more oxygen during exercise. In the absence of oxygen, various inflammatory mediators accumulate distal to the narrowed blood vessels, resulting in weakness, fatigue, pain, cramping, and inability to walk, that is, claudication.

Symptoms of Claudication

Claudication itself is a symptom, not a diagnosis. However, a person suffering from claudication may feel a range of sensations because of the occluded blood vessel. These include: 

  • Fatigue in the legs while walking
  • Burning sensation in the legs while walking
  • Pain on continuous walking
  • Cold feet
  • Limited walking distance
  • Impaired balance
  • Substantial relief from pain upon resting 

Based on the onset and symptoms associated with it, claudication can be classified into three categories:

  • Mild claudication: When a person can walk up to 900 feet before cautiously stopping
  • Moderate claudication: When a person is able to walk 600 feet before being forced to take rest
  • Severe claudication: When a person can walk less than 300 feet before they have to stop because of the pain

Causes of Claudication

Any pathological condition which has the potential to impede the flow of blood to the lower extremities is a possible risk factor for claudication. Claudication is usually a sign of an underlying condition like:

  • Peripheral arterial disease: A circulatory disorder affecting blood flow to the peripheral arteries
  • Atherosclerosis: Restricting the blood flow through-hardened fatty deposits in the arterial wall
  • Thromboembolic obstruction: Formation of a blood clot in the blood vessels
  • Thromboangiitis obliterans (Buerger's disease): Long-standing inflammatory disease leads to the formation of blood clots in the peripheral vasculature
  • Polyarteritis nodosa: Inflammation of small- or medium-sized blood vessels, which obstructs blood flow to respective muscles or organs

The severity of claudication experienced by an individual depends directly on the location, extent and rate of development of arterial obstruction rather than the disease which causes it.

Other than the causative factor, there are various risk factors which aggravate the progression as well as the occurrence of claudication. The most significant among these are:

Diagnosis of Claudication

For making a diagnosis of claudication, the patient’s history is the first and foremost tool. The doctor will ask several questions regarding the onset, severity, location and, most importantly, the reproducibility of pain with exercise and the rest time required to get substantial relief.

In order to reach a definitive diagnosis, your doctor may advise tests like pulse reading through oscillometer and affirming blood supply by arteriography.

Pain Management for Claudication

Usually, if the blockage occurs slowly enough, the body creates microchannels to manage adequate blood flow to the leg. If, however, the condition develops very quickly or in multiple blood vessels, it leads to claudication which can be very painful.

Pain management is possible by numbing certain ganglia (collection of nerves) near the spine (paravertebral area), by injecting phenol, alcohol or procaine. Extirpation of lumbar ganglions at the nerve supply to the concerned muscle can also reduce the pain sensation arising from claudication. However, these techniques only serve to ease the pain and do not address the underlying problem, which is the blockage.

Treatment for Claudication

Management of claudication depends on the extent of the disease. In mild to moderate cases, certain exercises can improve function as well as the quality of life significantly. The gold standard in workouts for intermittent claudication is a programme of supervised walking exercise therapy. This three-month programme is performed under the guidance of a professional and includes episodes of walking and resting. Gradually, the patient is asked to increase the duration as well as the intensity of the walks. This exercise programme can improve the functional capability of a claudicated individual to a large extent. Other exercises which can be beneficial for claudication in the leg and arm are ergometry, pole striding and resistance training.

Medication and supplements like calcium and vitamin E tablets, theobromine, cytochrome C, depropanex, and intravenous hypertonic saline solution can also ease the symptoms. 

Mechanical aids can also help to improve vascular supply to the localised area. One such aid is mechanical compression device - it works by putting intermittent non-pneumatic pressure on the calf muscles, to stimulate blood circulation to the affected body part.

In severe cases of claudication, surgical interventions have shown promising results. Examples include femoral vein ligation (tying) followed by anastomosis (joining) with femoral artery - to bypass the blockage in the legs and restore circulation to the extremities. Nowadays, replacement of occluded blood vessel by grafts is also emerging as a remedy for claudication. 

Direct intervention at the site of obstruction can also prove beneficial. It is usually attempted by periarterial stripping (removing a thin layer of arterial wall circumferentially from inside using an operating microscope). 

Angioplasty can help to restore adequate blood supply to the vessels in the legs and hands. It is a percutaneous procedure where the cardiologist makes a small incision to insert a catheter, and then a balloon-like device into the vessel. “Inflating” this balloon slightly helps to push the plaque or cholesterol against the walls of the vessel and open up the passage for blood to flow. If necessary, the cardiologist may even suggest putting a stent in to prevent blockage in the same area again. It is a minimally invasive procedure where the patient can start walking after two days of stenting procedure or angioplasty and back to the normal life just after one or two weeks of the interventional procedure.



References

  1. Dr. Inger-Lise Aamot, Dr. Øivind Rognmo. Exercise therapy in intermittent claudication . e-Journal of Cardiology Practice; Vol. 16, 11 Apr 2018
  2. Smith RB III. Claudication.. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 13.
  3. Stanford Wessler. Intermittent Claudication. Clinical Progress; Circulatron, Volume XI, May, 1955
  4. Jefferson Health – Northeast. Peripheral Vascular Disease. Home of Sidney Kimmel Medical College; Philadelphia, Pennsylvania
  5. National Center for Advancing and Translational Sciences. Polyarteritis nodosa. Genetic and Rare Diseases Information Center
  6. Johns Hopkins Medicine [Internet]. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System; Claudication
  7. Bogdan Pietraszewski et al. Changes in Gait Variables in Patients with Intermittent Claudication. BioMed Research International Volume 2019, Article ID 7276865, 9 pages
  8. Mark Swerdlow. 4 years’ Pain Clinic experience . Anesthesia Vol 22 No. 4; October 1967
  9. Ryan J. Mays, Judith G. Regensteiner. Exercise Therapy for Claudication: Latest Advances. Curr Treat Options Cardiovasc Med. 2013 Apr; 15(2): 188–199. PMID: 23436041
  10. de Haro J, Acin F, Florez A, Bleda S, Fernandez JL . Management of claudication due to peripheral artery disease. J Vasc Surg. 2010;51(4):857.

Doctors for Claudication

Dr. Tushar Verma Dr. Tushar Verma Orthopedics
5 Years of Experience
Dr. Urmish Donga Dr. Urmish Donga Orthopedics
5 Years of Experience
Dr. Sunil Kumar Yadav Dr. Sunil Kumar Yadav Orthopedics
3 Years of Experience
Dr. Deep Chakraborty Dr. Deep Chakraborty Orthopedics
10 Years of Experience
Consult a Doctor
cross
Ask your health query now and get connected with a doctor within 10 minutes!