Intermittent claudication (Latin: claudicatio intermittens) is a clinical diagnosis that is given for muscle pain (pain, cramp, numbness or a feeling of fatigue), classically of the calf muscle, that occurs during exercise and is relieved with a short rest period.
The term claudication comes from the Latin “limp.” This is exactly what this condition forces someone to do: limp to a stop.
Affected people describe intermittent claudication as throbbing or cramping pain, accompanied by tension or fatigue in the muscles of the legs or buttocks. For some, this pain arises only during strenuous activity; for others, it lights up after walking a few meters. The key factor is that the pain disappears within a few 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 (feet, legs, hands, and arms) become hardened or tangled (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 cerebral vascular insufficiency. In the lower extremities, the posterior tibial artery at the ankle and the anterior tibial artery at its origin are the arteries most commonly affected with atherosclerosis.
The arterial blockage or narrowing causes a reduction in blood flow during exercise or at rest. The clinical symptoms are caused by the consequent ischemia. The most common symptom of PAD is pain with exercise – intermittent claudication. The pain usually occurs in the calf and is described as a cramp or tightness or severe fatigue. The pain is usually bilateral. The cause of pain is not only 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 components of the cell membrane.
Pain at rest indicates a significant reduction in blood flow at rest. Obviously, it is a sign of serious illness. The pain may be localized to one or more toes, or it may have a median distribution. The character of the pain is usually described as burning or gnawing and is usually worse at night. Cyanosis or paleness of the limb is usually evident. In moderate to severe narrowing of the artery, trophic changes occur, including dry, scaly, shiny skin. Hair can fade and toenails can 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 for pentoxifylline (Trenal). Surgery is also an intermittent claudication that you do not need to take this risk.
When walking / exercising, the muscles demand more oxygen, when in fact in these cases it is distributed less due to the restriction of atherosclerosis.
The pain develops because there is a narrowing or blockage in the main artery that carries blood to the leg due to hardening of the arteries (atherosclerosis). Over the years, cholesterol and calcium build up inside the arteries. This occurs much earlier in people who smoke and in 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 to reach the muscles to prevent any symptoms. When walking, the calf muscles need more oxygen, but because 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 higher demands are placed on the muscles, such as walking uphill, the pain appears more quickly. Many patients also note that if they carry heavy bags, the pain appears earlier 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 can develop especially at night and is only relieved when the leg is hanging 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 for amputation.
Blockages in the arteries never reopen spontaneously. Fortunately, the locks themselves are not dangerous. Only the symptoms they cause are important. Many people live for many years with blocked arteries that never cause serious problems.
Often when patients develop claudication, their symptoms may worsen in the first few months. This is because the body takes time to adjust to the restricted blood flow. After 2-3 months, the situation may improve as smaller arteries open (collateral circulation) 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 serious disability. In general, about a third of claudication patients will improve, a third will remain stable, and a third will deteriorate. In most patients (> 65%) the symptoms will remain stable or improve. Patients whose symptoms deteriorate are usually those who continue to smoke.
Further improvements in walking can be made by taking regular walks. This appears to develop the fitness of the affected muscles (as in an athlete). A formal exercise program can be a very effective way to improve walking distance.
Regarding treatment, the first step is to eliminate all controllable risk factors;
The main risk factors for intermittent claudication include: diabetes, high cholesterol, smoking, hypertension, lack of physical activity, high levels of a chemical called homocysteine, 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 for pain-free distance walked is approximately 50% after 12 weeks and 100% after 24 weeks.
Despite the tremendous benefits of exercise in this condition, few doctors prescribe it. Walking may be the best recommendation that doctors can make for 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), biking, 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 a 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 approximately 1.5 to 2.0 miles per hour or a level just below the threshold for claudication. When pain occurs, the patient is instructed to rest for a couple of minutes until the pain subsides and then resume walking.
Patients are able to 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 total and pain-free walking distance in patients with intermittent claudication. However, the level of improvement (approximately 65% for pain-free walking distance) is less than that achieved with exercise or Ginkgo biloba extract.
Pentoxifylline is believed to work by reducing the viscosity of the blood: increasing the flexibility and compliance of red blood cells and preventing the aggregation of red blood cells and platelets.
Pentoxifylline is generally fairly 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 and successful alternative choice is Gingko biloba extract.
Gingko biloba extract (GBE) standardized to contain 24% ginkoflavonglucosides may be the most important herbal medicine in the world. GBE is now among the leading prescription drugs in Germany and France. Extracts represent 1.0% and 1.5% of total prescription drug sales in Germany and France, respectively. Although GBE has been studied and used more extensively in the treatment of cerebral vascular insufficiency, it also presents significant benefit in the treatment of peripheral vascular insufficiency.
GBE has been extensively studied as it has been the subject of more than 300 scientific papers. GBE exerts pervasive and profound 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 way that leads to relaxation of 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 GBE, the number of side effects was extremely small. The most common side effect, gastrointestinal upset, occurred in just 21 cases, followed by headache (seven cases) and dizziness (six cases).
In this case, the natural choice is safer, more efficient and cheaper. Since pain is the biggest motivator, you need to realize that your body is telling you to take better care of itself – it could also be a sign that you are developing cardiovascular disease.