ALG Head of Education Michelle Weddell considers the importance of vascular assessment in determining lower limb peripheral arterial disease before treating patients.
It is well published that a diabetic patient with poor glucose control and foot ulceration with or without infection has a high risk of amputation.
This risk of amputation is further increased with cardiovascular risk factors – hypertension and hypercholesterolemia.
Since the publication of the National Institute for Clinical Excellence (NICE) 2004 diabetic foot guidelines and the Scottish Intercollegiate Guidelines Network (SIGN) 116 guideline, diabetic foot screening has increased with the development of diabetic multi-disciplinary foot teams.
However, with the worldwide rise in obesity and age, there is another part of the world’s population that is suffering from limited mobility, pain and possibly amputation. We have patients in our clinical caseloads – whether podiatrists, physiotherapists, orthotists or prosthetists – who have peripheral arterial disease.
In 2012, NICE produced a document on lower limb peripheral arterial disease – diagnosis and management. This document gives evidence-based tests that clinicians should carry out to determine vascular status including pulse palpation, waveform analysis and Ankle Brachial Pressure Index (ABPI). ABPI should be carried out by a trained and competent practitioner.
Peripheral arterial disease has become a Government issue with the publication of the All Party Parliamentary Group (APPG) report on vascular disease in 2012. The Government is looking at lower limb vascular services throughout the United Kingdom according to the number of amputations and services provided. They have found a correlation between limited services and the number of amputations.
Lower limb peripheral arterial disease is caused by atherosclerosis, which not only affects the legs but has a major impact on the cardiovascular system (cardiovascular disease), the brain (cerebrovascular disease) and kidneys (renal disease).
Smoking, diabetes, obesity and increasing age also have effects on a person developing peripheral arterial disease.
Evidence has been gathered by the APPG showing that 20% of people over the age of 60 will have peripheral arterial disease. In 2012 this equated to 2.3 million people. In practice, when taking a medical history from a patient we need to be aware that if they have had heart surgery or carotid surgery then there is a high possibility that they may have lower limb peripheral arterial disease.
Peripheral arterial disease can be asymptomatic, meaning patients attending clinic may not complain of the typical cramp like leg pain that disappears after resting for less than 10 minutes.
Only 25% of people affected by lower limb peripheral arterial disease will have claudication symptoms. As people get older, they put the symptoms down to general wear and tear. With technology ever increasing in our lives, so we use other means to do every day jobs rather than walking – perhaps using to car to go to the local shop or ordering our shopping online. As a result, people with peripheral arterial disease do not cover a walking distance known as “march tolerance” to exhibit signs of leg pain.
Since the launch of the peripheral vascular disease guidelines, GPs have to keep a database of patients with lower limb peripheral arterial disease and are targeted on secondary management of these patients through the Quality of Outcomes Framework (QOF). This includes medication reviews to lower blood pressure and cholesterol, dietary advice, exercise and smoking cessation. In turn, this will lower a patient’s risk of a cardiovascular or cerebrovascular event or even death.
In podiatry, vascular assessment of a limb is essential before carrying out debridement of callus or corns in routine treatment. For physiotherapists, the knowledge of the vascular status of a limb could help in the diagnosis of a spinal canal stenosis and pain caused by spinal impingement could mimic intermittent claudication and vice versa. Meanwhile, orthotists and prothetists’ require a knowledge of vascular insufficiencies when choosing materials to be used for orthotic and prosthetic manufacture.
In clinical practice we need to screen for peripheral arterial disease to improve general well-being and early intervention with medication to prevent cardiovascular and cerebral vascular events.
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