Intermittent claudication (Latin: claudicatio intermittens) is a clinical diagnosis given by muscle pain (ache, cramp, numbness, or a feeling of fatigue), typically in the calf muscles, that occurs during exercise and is relieved by a brief rest period.
The term claudication comes from the Latin for ‘limping’. This is exactly what this condition forces someone to do: hobble to a stop.
Affected individuals describe intermittent claudication as throbbing or cramp-like pain, accompanied by tightness or fatigue in the leg or buttock muscles. For some, this pain arises only during strenuous activity; for others, it turns on after walking a few feet. The key factor is that the pain stops within minutes of resting.
Claudication affects people with peripheral arterial disease (PAD), also known as peripheral vascular disease (PVD). In people with PAD, the arteries in the extremities (the feet, legs, hands, and arms) become hard or hard (a process called arteriosclerosis). This in turn obstructs blood flow.
Peripheral arterial disease has, as its primary lesion, the same initial plaque that is responsible for other conditions associated with atherosclerosis, for example, coronary artery disease and cerebrovascular insufficiency. In the lower limbs, the posterior tibial artery at the ankle and the anterior tibial artery at its origin are the arteries most commonly affected with atherosclerosis.
Arterial obstruction or narrowing causes reduced blood flow during exercise or at rest. The clinical symptoms are caused by the consequent ischemia. The most common symptom of peripheral arterial disease is pain on exertion: intermittent claudication. The pain usually occurs in the calf and is described as cramping, tightness, or severe fatigue. The pain is usually bilateral. The cause of the pain is not only a reduced oxygen supply, but also an increase in the production of toxic metabolites and cellular free radicals. These free radicals accumulate and react with the lipid constituents of the cell membrane.
Rest pain indicates a severe reduction in resting blood flow. It is obviously a sign of serious illness. The pain may be localized to one or more toes, or it may have a sock-like distribution. The character of the pain is often described as burning or stabbing and is often worse at night. Cyanosis or paleness of the extremity is usually evident. In moderate to severe narrowing of the artery, trophic changes occur, including dry, scaly, and shiny skin. Hair may disappear, and toenails may become brittle, rough, and misshapen.
The standard medical approach for peripheral vascular disease and intermittent claudication includes avoiding tobacco (which causes vasoconstriction), a regular exercise program consisting of walking, and/or a prescription pentoxifylline (Trenal). Surgery is also an intermittent claudication, it is not necessary to take this risk.
When walking/exercising the muscles demand more oxygen, when in fact in this case less is distributed due to the restriction of atherosclerosis.
The pain develops because there is a narrowing or blockage in the main artery that supplies blood to the leg due to hardening of the arteries (atherosclerosis). Over the years, cholesterol and calcium build up inside the arteries. This happens much sooner in people who smoke and those with diabetes or high blood cholesterol levels.
Blockage in the arteries means that blood flow is reduced. At rest there is enough oxygen in the blood that reaches the muscles to prevent any symptoms. When walking, the calf muscles need more oxygen, but because the blood flow is restricted, the muscles cannot get enough oxygen from the blood and cramps occur. This is improved by resting for a few minutes. If the muscles are more demanding, such as walking uphill, the pain appears more quickly. Many patients also find that if they are carrying heavy bags, the pain comes on sooner because the leg muscles have to work harder.
In some patients, blood flow to the legs may be so restricted that hardly enough oxygen reaches the tissues, even at rest. In these patients, severe pain may develop particularly at night and is only relieved when the leg dangles over the edge of the bed. When this happens and tests show reduced blood flow, then critical limb ischemia has developed and the leg is at risk of amputation.
Blockages in the arteries never reopen spontaneously. Fortunately, the locks themselves are not dangerous. It is only the symptoms that they cause that are important. Many people live for many years with blocked arteries that never cause serious problems.
Often when patients develop claudication, their symptoms can worsen in the first few months. This is because the body needs time to adjust to the restricted blood flow. After 2-3 months, the situation may improve as smaller arteries (collateral circulation) open up and carry more blood around any blockage. The smaller blood vessels, although not the main blood vessels in the leg, usually carry enough blood to prevent severe disability. In general, about one third of patients with claudication will improve, one third will remain stable, and one third will deteriorate. In most patients (>65%) symptoms will remain stable or improve. Patients whose symptoms worsen are often those who continue to smoke.
Further improvements in gait can be achieved by taking regular walks. This seems to build fitness in the affected muscles (just like in an athlete). A formal exercise program can be a very effective way to improve distance covered.
Regarding treatment, the first step is to eliminate all controllable risk factors;
The main risk factors for intermittent claudication include: diabetes, high cholesterol, smoking, high blood pressure, lack of physical activity, high levels of a chemical called homocysteine, a family history of arterial disease.
Without exception, numerous clinical studies have shown that exercise can prolong pain-free walking distance and total walking distance in patients with intermittent claudication. Although studies have shown a wide range of improvements (eg, 88% to 190%), typically the degree of improvement in pain-free walking distance is around 50% after 12 weeks and 100% after of 24 weeks.
Despite the tremendous benefits of exercise in this condition, few doctors prescribe it. Walking may be the best recommendation doctors can make to patients with peripheral arterial insufficiency and intermittent claudication. Although other activities have been recommended or incorporated into exercise programs for the lame, they have not been shown to produce the same degree of benefit as walking. Strength training (weight lifting), bicycling, stair climbing, and other activities, while beneficial for overall cardiovascular function, do not appear to improve intermittent claudication as well as a walking program.
The optimal walking program should be supervised, performed at least three times per week, and last a total of at least one hour. In a supervised program, the patient typically walks on a treadmill at a steady pace of about 1.5 to 2.0 miles per hour or a level just below the claudication threshold. When pain occurs, the patient is instructed to rest for a couple of minutes until the pain subsides, and then resume walking.
Patients can walk on their own, but according to several trials, appropriate steps must be taken to ensure patient compliance if unsupervised programs are to be successful.
Pentoxifylline (trenal) has become the “drug of choice” in the standard medical treatment of intermittent claudication. Pentoxifylline was first introduced in Germany twenty years ago. It is the most researched drug for intermittent claudication. A total of seventeen placebo controlled trials could be retrieved from the world literature. Most of these studies show that pentoxifylline will prolong pain-free total walking distance in patients with intermittent claudication. However, the level of improvement (approximately 65% for pain-free distance walked) is less than that achieved with exercise or Ginkgo biloba extract.
Pentoxifylline is thought to work by reducing blood viscosity: increasing the flexibility and compliance of red blood cells and preventing red blood cell and platelet aggregation.
Pentoxifylline is generally quite well tolerated and the extended release tablet is much better than the immediate release capsule. Minor side effects include drowsiness, headache, dizziness, and gastrointestinal irritation. However, there are some important precautions with pentoxifylline.
The natural choice and the successful alternative is the Gingko biloba extract.
Gingko biloba extract (GBE) standardized to contain 24% ginkoflavon glycosides may be the world’s foremost plant medicine. GBE is now among the leading prescription drugs in both Germany and France. The extracts represent 1.0% and 1.5% of total prescription sales in Germany and France, respectively. Although GBE has been most extensively studied and used in the treatment of cerebrovascular insufficiency, it is also of great benefit in the treatment of peripheral vascular insufficiency.
GBE has been extensively studied as it has been the subject of more than 300 scientific articles. GBEs exert widespread and deep tissue effects, including membrane stabilizing, antioxidant, and free radical scavenging effects. Its vascular effects are primarily the result of direct stimulation of the release of endothelium-derived relaxing factor (EDRF) and prostacyclin. Furthermore, GBE inhibits enzymes in a manner that leads to relaxation of the smooth muscle cells in the vessel wall. GBE also exerts a beneficial effect on platelet function, including inhibition of platelet aggregation, adhesion, and degranulation.
GBE is extremely safe and side effects are rare. In 44 double-blind studies involving 9,772 patients taking EGB, the number of side effects was extremely small. The most common side effect, gastrointestinal upset, occurred in only 21 cases, followed by headache (seven cases) and dizziness (six cases).
In this case, the natural choice is safer, more effective and cheaper. Since pain is the biggest motivator, you need to realize that your body is telling you to take better care of yourself: it could also be a sign that you’re developing cardiovascular disease.