What is intermittent claudication? What is intermittent claudication? Symptoms and treatments Intermittent claudication is caused by

VASCULAR SURGERY - EURODOCTOR.RU - 2007

What is intermittent claudication?

Intermittent claudication is pain or a feeling of weakness and fatigue in the legs that occurs when walking. This symptom appears at the beginning of physical activity and goes away with rest. Intermittent claudication is a symptom inherent in diseases of the peripheral arteries of the lower extremities, for example, obliterating atherosclerosis.

The arteries carry blood enriched with oxygen and nutrients from the heart. Tissues receive oxygen and nutrients necessary for their activity and vital functions, and release metabolic products - “waste” - into the blood. However, when the lumen of the arteries narrows, blood flow in the tissues is disrupted. Tissues and cells receive to a lesser extent the necessary substances and oxygen. This tissue condition is called ischemia. Typically, ischemia manifests itself during physical activity, when tissues require a greater volume of oxygen, while at rest, ischemia may not occur.

During physical activity, for example, walking, running, narrowed arteries deliver less blood to the tissues, and therefore less oxygen and nutrients. This leads to the accumulation of metabolic products in the tissues, including lactic acid. It is the accumulation of this acid that causes pain. This mechanism is also true for coronary heart disease.

Intermittent claudication is one of the early signs of peripheral artery disease. Narrowing of the arteries occurs not only with atherosclerosis. With a disease such as obliterating endarteritis, narrowing of the arteries also occurs, however, unlike the narrowing in atherosclerosis, it is uniform, since with endarteritis atherosclerotic plaques do not form. This disease has a slightly different development mechanism. However, it is also characterized by ischemia of the tissues of the lower extremities when walking and the manifestation of such symptoms as intermittent claudication.

Manifestations of intermittent claudication

Intermittent claudication is manifested by the occurrence of pain, fatigue and discomfort in the legs when walking. Sometimes there may be no pain, but there are cramps in the calf muscles and weakness of the legs. The degree of manifestation of intermittent claudication depends on the degree of circulatory impairment in the tissues. In the initial stages, this symptom may occur when walking over distances of more than a kilometer. The more extensive the disruption of blood flow in the legs, which depends on the number and length of narrowing of the arteries, the stronger the manifestations of leg ischemia. In later stages, intermittent claudication occurs even after the patient has walked 100 meters. Intermittent claudication can be either unilateral (characteristic of atherosclerosis) or bilateral (characteristic of endarteritis).

Causes of intermittent claudication

As mentioned above, intermittent claudication is one of the signs of diseases of the peripheral arteries of the lower extremities, such as obliterating atherosclerosis and obliterating endarteritis. The main mechanism of pain in this condition is the accumulation of lactic acid in the tissues.

Risk factors for intermittent claudication

Risk factors for intermittent claudication include risk factors for atherosclerosis and other diseases of the arteries of the lower extremities:

Smoking
High blood cholesterol
High blood pressure
Obesity
Hereditary predisposition

Methods for diagnosing intermittent claudication

Diagnosis, as with all other diseases, begins with interviewing the patient, collecting and evaluating his complaints. Next, the doctor finds out the onset and course of the disease. After this, an inspection is carried out. Particular attention is paid to examining the lower extremities. The doctor may also perform certain tests to determine the state of the blood supply to your legs. However, the main diagnostic methods for diseases of peripheral vessels, including arteries, are:

Determination of the brachial-ankle index - blood pressure in the shoulder and ankle area is determined. Normally, these indicators should be the same. In peripheral arterial disease, pressure in the ankle area is lower than in the shoulder area.
Biochemical blood test to determine cholesterol and lipid levels.
Duplex scanning is an ultrasound examination method that combines conventional ultrasound and Doppler.
Magnetic resonance angiography is a method that uses the energy of electromagnetic waves in a strong magnetic field, allowing one to see the structure of tissues, including blood vessels.
Spiral computed tomography is a method of obtaining layer-by-layer images of tissue using x-rays and then processing it on a computer.
Angiography - this method also allows you to see the structure of blood vessels and their narrowing. To do this, a catheter is inserted through the femoral artery and led into the abdominal aorta, above the origin of the renal arteries. After this, a contrast agent is injected through the catheter and a series of x-rays are taken.

Typically, the study begins with non-invasive methods such as ultrasound, tomography, magnetic resonance angiography. For more serious cases of vascular disease, invasive techniques such as angiography are used.

Treatment of intermittent claudication

Treatment of intermittent claudication consists of treating the underlying cause of peripheral artery disease. Treatment includes lifestyle changes, diet, smoking cessation, exercise and weight loss, as well as certain medications and, if necessary, endovascular surgery.

Exercise to treat intermittent claudication

Exercise is the initial step in treating intermittent claudication. The doctor will develop a special training plan that is specific to your situation. He will explain to you the type of exercise, recommended intensity, duration, and frequency per week. The recommended form of exercise is normal walking, for 1 hour or more, 3 or more times a week, for a minimum of 3-6 months, best under medical supervision. The goal of this treatment is to increase walking time without developing intermittent claudication.

Walk until claudication occurs, usually within 3 to 5 minutes. Next, you should continue walking as long as you can still endure the pain, usually 8-10 minutes. After this, you need to stop and rest until the pain goes away completely, and then continue walking. You should repeat periods of walking and rest, gradually increasing the period of walking without pain from 30 minutes to 50. Thus, you are training the tissues for the existing blood flow, and in addition, new vessels appear in the muscles of the lower extremities - the so-called collaterals through which the blood flows. blood.

Drug treatment of intermittent claudication

Currently, the following drugs are used to treat diseases of the arteries of the lower extremities:

Drugs that lower blood cholesterol levels - statins
Vasodilators - nicotinic acid, no-spa, etc.
Vazaprostan is currently the main drug in the treatment of vascular diseases, which has a beneficial effect on the vascular wall.
Anticoagulants and antiplatelet agents are drugs that reduce blood clotting and its viscosity, thereby reducing the risk of blood clots and increasing the “fluidity” of blood in small vessels - capillaries. These include aspirin, clopidrogel, warfarin and others
If you have diabetes, take antidiabetic drugs, including insulin

Diet for the treatment of intermittent claudication

Diet is also one of the important points in the complex treatment of arterial diseases. The diet should be limited in cholesterol and saturated fatty acids. It is recommended to eat vegetable fats – oils. They contain so-called polyunsaturated acids. It is also recommended to eat fish: salmon, salmon, mackerel, sardines. Their meat contains a substance called omega-3 fatty acids. These acids help reduce triglyceride levels in the blood. Soybeans and many soy-based meat substitutes also reduce low-density lipoprotein levels in the blood.

This year, 2013, a new revision of the National Guidelines for the Management of Patients with Peripheral Artery Diseases was published. An important place in it is given to diseases of the blood vessels of the legs. Despite the lack of comprehensive statistical data, it can be stated that the estimated number of people suffering from this disease based on the prevalence (0.9-7% of the population depending on the age group) in Russia is at least 1.5 million, which means that 100,000 citizens are diagnosed with terminal (critical) form of the disease; which annually leads to 20,000-40,000 amputations for this indication alone.

Intermittent claudication (IC) is the main clinical syndrome of atherosclerotic lesions of the arteries of the lower extremities. Unfortunately, most specialists forget about the relevance of this disease; Perhaps, against the backdrop of the dramatic course of other manifestations of atherosclerosis, this form undeservedly does not attract close attention. However, the prevalence of PC, depending on age, ranges from 0.9% to 7.0%. According to authoritative publications and large population studies (SAGE Group, 2010; Russian Consensus Document, 2013; PANDORA Study, 2012), the prevalence of peripheral arterial disease is high, ranging from 5.8% in the USA and 7% in Russia to 12.2% and 22.9% in France and Italy respectively. It is important that up to 50% of patients with PC have never consulted a doctor about these symptoms, but they still experience discomfort due to leg pain. Medical specialists, when examining such patients if they go to medical institutions for other complaints, do not ask them for the presence of ischemic pain in the legs when walking.

It has been established that atherosclerosis is the cause of damage to peripheral arteries in 80-90% of cases, the rest is “pure” diabetic angiopathy (without background significant atherosclerosis of the vessels of the lower extremities) and vascular damage of autoimmune origin. It has long been known that patients with PC have a high risk of developing myocardial infarction (MI) and acute cerebrovascular accident. Thus, compared with the normal population, their risk of MI is increased from 20% to 60%, and the risk of death from coronary pathology is increased from 2 to 6 times. With PC, the risk of developing acute cerebrovascular accident increases by 40%.

In more than half of patients with peripheral artery diseases, already at the time of treatment, stage IIB (surgical) of the disease is registered according to the classification of A.V. Pokrovsky-Fontaine, which corresponds to intermittent claudication that occurs when walking 50-200 m. Such patients are candidates for endovascular open or hybrid surgical treatment. However, the high level of development of modern reconstructive surgery of the arteries of the lower extremities cannot solve all the problems in this group of patients. The success of reconstructive interventions directly depends on the condition of the so-called. outflow tracts - vessels located below the inguinal fold. According to some data, up to 40% of patients requiring surgical treatment cannot undergo arterial reconstruction due to distal or widespread multifocal lesions of the arterial bed.

The appearance of rest pain and ulcerative-necrotic changes in the skin up to gangrene in patients with PC indicates the development of critical lower limb ischemia (CLI), a state of decompensation of arterial blood flow. Treatment of CLI requires a more active approach in terms of both pharmacotherapy and surgical interventions. The dynamics and statistics of CLI are such that during the first 6 months after diagnosing CLI, the limb can be saved only in 40% of cases, since 20% of patients will die, and the rest will undergo major amputation. As a result, by the end of the first year after verification of the diagnosis, only 45% of patients have a chance of saving a limb, about 30% continue to live after amputation of the thigh or lower leg, and a quarter of patients will not survive this time period (Fig. 1).

It is recognized (A.V. Gavrilenko et al., 2010) that when a diagnosis of peripheral arterial disease is made in a patient with PC or CLI, conservative therapy is indicated regardless of the location and extent of the vascular lesion and is prescribed for life. After endovascular or surgical interventions on the arteries, the need for conservative treatment also remains. In cases where it is not possible to achieve adequate compensation of blood circulation by surgical methods, the isolated use of therapeutic treatment remains the only therapeutic tactic of the doctor.

Modern approaches to conservative therapy

According to the guidelines of the American Heart Association (2005), the main goal of conservative therapy in patients with PC and CLI is to improve quality of life and reduce the risk of fatal cardiovascular events. To achieve this, the doctor’s treatment tactics must include both the correction of risk factors and the prescription of effective medications. One of the leading areas of risk factor correction is smoking cessation, which includes behavior modification, nicotine replacement therapy, bupropion therapy) (evidence class I) (Fig. 2).

All patients with PC are shown effective physical activity - dosed walking, that is, walking until almost maximum ischemic pain appears (evidence class I). An exercise therapy program is recommended as the initial form of treatment for patients with intermittent claudication as the primary manifestation of chronic lower limb ischemia (CLI) (Evidence Level A). The duration of physical therapy classes is from 30 to 45 minutes minimum, classes are held 3 times a week, the minimum course is 12 weeks. The maximum effectiveness of dosed walking appears after 1-2 months and persists after 3 or more months. The beneficial effect is explained by an improvement in the metabolism of skeletal muscles, an increase in muscle mass, as well as an improvement in endothelial function and, to a lesser extent, the formation of collateral circulation.

In addition to the modification of risk factors and dosed walking, targeted conservative treatment has the following main vectors: prevention of thrombotic and cardiovascular complications (MI, stroke, death due to cardiovascular events) through long-term administration of antiplatelet agents, administration of pharmaceutical drugs with complex and metabolic effects . Long-term, often lifelong, use of medications requires strict adherence to the dosing and administration regimen, implementation of non-pharmacological treatment measures, as well as regular monitoring by a doctor. Patient adherence to therapy is a key factor in achieving high treatment effectiveness.

An important area is monitoring blood lipid levels. Treatment with hydroxymethylglutaryl-acetyl-coenzyme A reductase inhibitors (statins) is indicated in all patients with peripheral artery disease (PAD) to achieve a target low-density lipoprotein (LDL) level of less than 100 mg/dL (Class I evidence). Treatment of dyslipidemia reduces the risk of adverse cardiovascular events in patients with atherosclerosis. However, the clinical picture of severe damage to the arterial bed of the lower extremities does not always strictly correlate with changes in the lipid spectrum of the blood and the level of cholesterol and LDL.

All patients with PAD, both PC and CLI, are advised to control blood glucose levels (reducing the level of glycosylated hemoglobin to 7%), and in the presence of diabetes mellitus, intensive therapy with antihyperglycemic drugs or insulin, as well as careful care of the skin of the feet and legs (class of evidence I) .

In addition to glucose control, an important direction in the correction of risk factors for PAD is the control of blood pressure (BP) levels. In patients without concomitant pathology, a blood pressure level of less than 140/90 mm Hg should be considered optimal. Art., while the presence of conditions such as arterial hypertension, coronary heart disease, chronic heart failure, diabetes mellitus and renal failure necessitate maintaining blood pressure levels below 130/80 mm Hg. Art. (class of evidence I). The targeted drugs are angiotensin-converting enzyme (ACE) inhibitors, which significantly reduce the risk of MI, stroke, and death due to cardiovascular events in patients with PAD.

Antiplatelet (antiplatelet) therapy in the form of Aspirin at a dosage of 75-325 mg/day or clopidogrel 75 mg/day is indicated for patients with atherosclerosis of the arteries of the lower extremities to reduce the risk of cardiovascular events (evidence class I). The practitioner should remember that in patients with PAD, oral anticoagulants should not be used to prevent adverse cardiovascular ischemic events.

It is advisable to prescribe a phosphodiesterase III inhibitor, cilostazol, which has a vasodilating, metabolic and disaggregant effect to patients with HP (evidence class I). At a dosage of 100 mg twice daily, the drug increased pain-free walking distance (PDW) by 40-60% compared with placebo after 12-24 weeks of treatment. Cilostazol, however, is not registered in the Russian Federation. Another obstacle to its widespread use is the need for the patient to have no concomitant pathology in the form of chronic heart failure of any class according to the New York Heart Association (NYHA) classification, as well as restrictions imposed by the European Medicines Agency on its use in 2013 due to the high likelihood of side effects.

Pentoxifylline at a dose of 1200 mg per day can be considered as one of the main drugs for increasing the maximum walking distance (MTD) in patients with PC (evidence class IIB). Pentoxifylline improves microcirculation and rheological properties of blood, has a vasodilating effect, blocks phosphodiesterase and promotes the accumulation of cyclic adenosine monophosphate in cells, which leads to a minimal but statistically significant increase in DBC by 21-29 meters and the maximum distance traveled by 43-48 meters.

Sulodexide (250 LE orally 2 times a day), previously recommended for use in patients with CLI, is now recommended for patients with PC. In this cohort of patients, sulodexide increases DBC by up to 95% when used in a course in combination with parenteral administration (evidence class IIA). The effectiveness of the drug is explained by its complex effect on the main links in the pathogenesis of the disease: correction of endothelial dysfunction, normalization of blood rheology and microvasculature, increased fibrinolytic activity.

A promising direction in the complex treatment of patients with PC of atherosclerotic etiology is the correction of endothelial dysfunction, aimed at stimulating the synthesis of nitric oxide (NO) by endothelial cells. Endothelial dysfunction is expressed in increased permeability and adhesiveness, as well as in increased secretion of procoagulant and vasoconstrictor factors, which can be considered as an early stage in the development of vascular damage. NO is an important regulator of cell metabolism and plays an important role in the pathogenesis of endothelial dysfunction. Intermittent pneumocompression can have a positive effect aimed at correcting endothelial dysfunction, including in patients with critical ischemia of the lower extremities. Another vector for correcting endothelial dysfunction is the use of drugs from the group of angiotensin-converting enzyme inhibitors, mainly perindopril, angiotensin II receptor blockers, mainly losartan, as well as beta-blockers, mainly nebivolol. This is especially important given the high prevalence of arterial hypertension, as well as coronary heart disease and chronic heart failure in patients with CLI. Beta-blockers are effective antihypertensive drugs and are not contraindicated in patients with lower extremity arterial disease, as most practitioners believe.

Correction of endothelial dysfunction is also possible by stimulating NO secretion by exogenous factors of the L-arginine - NO - guanylate cyclase system, in particular, when using the nitric oxide precursor L-arginine. Therapy aimed at correcting endothelial dysfunction is extremely promising, but is currently mostly at the stage of clinical trials.

As stated in the National Guidelines (2013), high class of evidence IIA includes the use of gene therapy drugs. This group of drugs has been actively studied over the past two decades. They are agents of the so-called. “therapeutic angiogenesis” is a new therapeutic tactic designed to induce the development of a microvascular network by introducing gene therapeutic drugs encoding the synthesis of various short-lived and short-distance molecules (growth factors, transcription factors), and subsequently lead to the formation of collaterals. It is believed that the development of the microvasculature in the ischemic muscle mass of the lower extremities promotes tissue oxygenation, reduces overall peripheral vascular resistance, and new vessels formed at the level of occlusion are able to evolve into functional collaterals. Plasmid and adenoviral gene constructs that do not integrate into the genome are being tested as potential drugs. A large number of clinical studies have shown their safety, including oncological ones. At the level of phase II clinical trials, significant results in increasing pain-free walking distance were obtained with genes encoding vascular endothelial growth factor (VEGF165), basic fibroblast growth factor (bFGF), hepatocyte growth factor growth factor, HGF), etc. However, treatment efficacy was not established for all designs in phase III. In particular, the use of a drug based on the bFGF gene in patients with stage IV of the disease (according to A.V. Pokrovsky-Fontaine) did not affect life expectancy and limb safety. At the same time, a plasmid construct with the HGF gene, used for the same indications, significantly reduced the severity of pain, had a positive effect on the quality of life, and promoted the healing of ulcers, which was the basis for recognizing its effectiveness.

Currently, the gene therapy drug Neovasculgen, the active substance of which is a supercoiled plasmid with the VEGF165 gene, is included in the State Register of Medicines of Russia. Its safety and effectiveness were studied in multicenter controlled randomized studies, which showed a significant increase in pain-free walking distance, as well as a number of other effects, including an increase in tissue oxygen tension, to some extent, linear blood flow velocity, and ankle-brachial index. The drug is intended for inclusion in complex therapy of patients with IIa-III degrees of PH (according to Pokrovsky-Fontaine) of atherosclerotic origin. The drug is administered at a dose of 1.2 mg locally intramuscularly twice with an interval of 14 days. The capabilities of the drug are realized as part of complex therapy. As part of clinical studies, the effectiveness of the drug was assessed in patients who did not undergo surgical revascularization methods and who were not prescribed therapy with prostaglandin drugs. It was found that within six months, patients experienced an increase in pain-free walking distance by an average of 110.4%, and after a year by 167.2%. Patients with a more severe stage of the process - III - responded to therapy to a greater extent; for them, increases were established at 231.2 and 547.5%, respectively. Also, statistically significant shifts are recorded when monitoring transcutaneously determined oxygen tension. Indicators of macrohemodynamics—the ankle-brachial index and linear blood flow velocity—change to a lesser extent. It is important that when assessing the quality of life in such patients, a significant increase was established on the “physical component of health” scale (p = 0.001).

In the treatment of CLI, if it is impossible to perform endovascular or open arterial reconstruction, the therapeutic approach differs from the treatment of PC. Prostanoids, the drugs prostaglandin E1 (PGE1) and prostacyclin I2 (PGI2), have been the most studied in the treatment of CLI. Numerous studies have shown that their parenteral administration for 7-28 days can reduce rest pain and promote healing of trophic ulcers and, in some cases, avoid or delay limb amputation (class of evidence IIB, level of evidence A).

Gene therapeutic angiogenic drugs recommended for use in the treatment of PC are considered potentially effective in the treatment of patients with CLI. Their role in the complex treatment of patients with CLI is shown in terms of improving long-term results of reconstructive interventions. The first data are emerging (I. N. Brodsky, 2013) on the successful combination of prostacyclin drugs with the induction of microvascular development by Neovasculgen in severe patients with CLI.

Data on the effectiveness of hyperbaric oxygenation, spinal neurostimulation, as well as traditional types of physiotherapy (laser therapy, magnetic therapy) used in Russia in the treatment of CLI are contradictory, and therefore there are no clear recommendations regarding their use. Encouraging data have been obtained regarding the use of regional catheter thrombolysis in the complex therapy of CLI in diabetic angiopathy. The purpose of local thrombolysis in this cohort of patients is the treatment and prevention of microthrombosis, stabilization of blood coagulation properties.

Effective treatment of patients with intermittent claudication and its dangerous complication in the form of critical ischemia of the lower extremities is an urgent problem in practical medicine due to insufficient attention, high morbidity, and treatment difficulties. The authors of the article hope that the material presented in the work will be useful in the work of not only angiosurgeons, but also doctors of other medical specialties.

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R. E. Kalinin*, 1 , Doctor of Medical Sciences, Professor
N. D. Mzhavanadze*
R. V. Deev**, Candidate of Medical Sciences

Intermittent claudication is a complex of symptoms manifested by disturbances in the blood supply to the lower extremities. The condition is characterized by pain in the legs after exercise, especially when a person walks a lot.

The disease is caused mainly by pathologies of the vascular system, less often by previous infectious diseases, consequences of intoxication or injury. Lameness often threatens people suffering from diabetes and other conditions associated with metabolic disorders. A person suffers from spasm in the peripheral vessels, causing the muscles and nerves of the legs to be insufficiently supplied with blood, after which pain occurs.

Diagnosis of intermittent claudication is not difficult, since the disease can be identified by external signs. In addition to a change in the shade of the skin, the doctor detects an absent pulse in the leg. Additionally, angiography and Doppler studies are required for examination and accurate diagnosis. For treatment, special drugs are prescribed that improve blood circulation, normalize metabolism and strengthen the body as a whole.

Most often, intermittent claudication is caused by the presence of atherosclerosis, which, in turn, affects the vessels of the lower extremities.

Small plaques called atherosclerotic plaques form on the walls of blood vessels, which impair blood supply, and in some cases, even clog the blood vessels. Atherosclerosis is characterized by blockage of both small vessels and large arteries, and even the aorta is often affected.

In a normal state, that is, at rest, the vessels cope, and the required amount of blood flows to both the nerves and the muscles, which is why symptoms do not appear. But during exercise, the vessels begin to become clogged, blood flows in insufficient quantities, which causes a state of ischemia, which, in turn, is accompanied by pain. If intermittent claudication is not treated, then in the future the person will be at risk of developing ulcers on the legs, turning into gangrene, and this is fraught with amputation of the leg.

Other reasons leading to pathology include the following conditions:

infectious diseases such as syphilis, typhoid, influenza;
states of intoxication associated with smoking, drinking alcohol;
hypothermia;
lower limb injuries;
endocrine diseases, including diabetes and gout.

Smoking plays a significant role in the development of lameness. It is tar and tobacco that have a negative effect on the vessels that are damaged.

Due to the fact that the disease progresses slowly, symptoms do not appear immediately; a person may not be aware of the pathology for several years. Over time, the first symptoms will begin to appear.

The main symptom of intermittent claudication is pain in the legs after exercise, that is, walking or running, which begins suddenly and quickly goes away at rest.

If a person continues to endure pain and puts further strain on his legs, this leads to severe pain. The fact is that when under load, muscles require more blood flow, and narrowed arteries cannot provide it.

A person begins to pay attention to pathology at the moment of climbing stairs or when walking up. So, symptoms occur faster due to the fact that the muscles are in a tense state. In order for the pain symptoms to go away, you have to take breaks, and all this affects the patient’s activity. By the way, for pain in the legs to go away, sometimes literally one minute of rest is enough.

The nature of the pain varies from a dull attack of pain to acute pain. Sometimes there is a burning sensation in the limbs, pulsation in the vessels. It all depends on what causes the disease, on age and duration of the disease. The disease begins to manifest itself most often in the arteries that are farthest from the heart, which is why the fingers and ankles suffer first. Over time, the main symptom is pain, which also occurs in the groin, buttocks, and thighs, which indicates the neglect of the pathological process.

There are also external signs of the disease. These include trophic changes in the skin of the lower extremities, which is associated with deterioration of nutrition. The skin begins to peel off, its shade changes, and it becomes pale. As it progresses, hair loss, nail peeling, and ulceration occur.

If left untreated, a person's erectile function may decrease. Among the complications of intermittent claudication, one can also highlight the threat of the formation of collaterals - bypass vessels necessary to compensate for the reduced blood supply. When the vessels are completely blocked, gangrene begins to develop, in such cases surgical intervention is necessary, and on an emergency basis.

With this disease, taking medication alone will not be enough. First of all, it is necessary to rid a person of bad habits, that is, smoking, drinking alcohol. The diet is adjusted, the consumption of fatty, fried foods, smoked foods, and salt is limited. It is recommended to avoid hypothermia of the lower extremities and injuries. Shoes should be comfortable so that they do not squeeze your feet.

The main goal in the treatment of intermittent claudication is to eliminate the negative effects on blood vessels. If a person is diagnosed with diabetes, he needs to take medications and follow a diet to normalize glucose levels. For gout, medications are prescribed to normalize metabolic processes and remove urea from the body. For infections, it is necessary to take antibiotics and antimicrobial agents. And also, if necessary, treatment is prescribed for atherosclerosis of the lower extremities, varicose veins and other vascular pathologies.

As for medications, it is mandatory to take medications aimed at normalizing the blood supply to the legs: Aspirin, Trental (Oxopurine). It is recommended to take medications to lower cholesterol levels.

Physiotherapy treatment is used, the most popular methods of which are:

UHF procedures;
diathermy method;
use of a steam pressure chamber;
hydrogen sulfide baths.

In a running state, an operation may need to be performed. We must not forget about additional treatment with traditional medicine, which can be combined with traditional treatment.

Folk remedy

To alleviate the condition and improve blood supply to the lower extremities, contrast baths are popular, which should be done before bedtime. To prepare the bath you will need fresh pine needles or pine. About 2 liters of water are boiled, after which 2 cups of pine needles or pine are poured into it and infused to a warm solution. After this, you need to add 5 tablespoons of salt, preferably sea salt, to the infusion and strain. Now you need to take 2 basins, add boiling water and a liter of infusion to one of them so that the water becomes hot, and lower your legs one by one. First, into a bath with hot water, then with cold water, into which the infusion and water are also poured. The total procedure time is 15 minutes.

There are other traditional medicine recipes:

The recipe involves using horse chestnut, for which you take 2 tablespoons of crushed fruits, add 3 tablespoons of crushed safflower root and 4.5 tablespoons of hop cones. Take 1 tablespoon of the resulting mixture, pour it into a thermos, pour a glass of boiling water into it and leave the infusion for 4 hours, then filter and take 100 milliliters per day.
Unrefined olive and sea buckthorn oils are taken, mixed in equal proportions, and the resulting mixture is rubbed into the skin of the legs. The procedure is performed at night for a month.
For inflammation in the blood vessels, it is recommended to take decoctions of sweet clover, red clover, burdock and hawthorn, which should be taken alternately for 1 week. The course as a whole takes 1 month, after which there is a break for 3 months.
Another recipe involves using a decoction of 5 tablespoons of pine needles, 3 tablespoons of rose hips, 1 tablespoon of onion peel. The resulting mixture is poured with a liter of water and brought to a boil, after which it must be infused in a dark place for 12 hours and the decoction should be taken 3-4 times a day, drinking everything in one day. The course of treatment is 4 months.

We must not forget that before starting treatment with folk remedies, you need to consult with your doctor. Some recipes are contraindicated if you have diabetes or allergies that are associated with intermittent claudication.

As a result, we can say that to get rid of lameness you need not only to use medications and traditional methods of treatment, but also to adhere to a diet and eliminate negative factors. The treatment of acute and chronic conditions deserves special attention. And, of course, we must not forget about prevention in the future.

The main cause is circulatory disorders in the lower extremities, due to which there is a deficiency of cell nutrition and gas exchange. The pathological condition is dangerous and requires careful examination and correct therapeutic actions.

Pain may occur over the entire surface of the lower limb. The most common location is the calf muscles. This is explained by the fact that a venous “pump” is concentrated in the lower part of the leg, which pushes the blood to move through the veins back to the heart, delivering carbon dioxide.

The intensity of the pain syndrome is so great that the person cannot move independently. At the beginning of the disease, the pain goes away with prolonged rest. If the condition of the blood vessels worsens over time, the pain becomes constant.

The syndrome of intermittent claudication cannot be ignored; not only the vessels in the lower extremity girdle area are affected, the brain and heart muscles suffer from ischemic manifestations. Serious complications can include myocardial infarction, stroke, and amputation of a limb in critical condition.

Causes

Intermittent claudication appears in pathologies based on arterial insufficiency, which occurs for various reasons:

Atherosclerosis is a vascular pathology with a chronic course. The muscle tissue of blood vessels is affected due to impaired metabolic reactions involving fats and carbohydrates. On the inner surface of the vessel wall, accumulations form in the form of plaques, which close the lumen of the vessel, reducing its throughput.
Takayasu's disease is an inflammatory disease that affects the walls of large arterial vessels. The conflict of immune cells with their own healthy tissues causes an autoimmune process. The pathology leads to complete closure of the vessel with subsequent cessation of blood flow.
Endarteritis is a chronic disease leading to vascular gangrene, localized in the vascular system of the lower extremities.
Angiopathy in diabetes mellitus is a complication of endocrine disease. Vessels are affected when blood sugar levels are high.
Thromboangiitis obliterans - damage to small and medium-sized veins and arteries. Appears in immune disorders that cause pathological processes of self-destruction.
Raynaud's syndrome is impaired blood circulation in the peripheral parts. The main symptom is that during a spasm, the skin on the phalanges turns pale and then acquires a bluish tint. At this time, blood stops flowing through small capillaries; when blood flow is restored, the skin returns to its usual shade.
After trauma or frostbite of the lower extremities, blood circulation is disrupted.
Poisoning with manganese and arsenic contributes to the appearance of intermittent claudication.
Infections caused by streptococci, chlamydia, viruses.

Kinds

Depending on the nature of origin, the following forms are distinguished:

Caudogenic (peripheral), another name is neurogenic peripheral claudication, appears with atherosclerosis, endarteritis, diabetic angiopathy, is accompanied by pain on exertion, pale skin on the legs, decreased pulse in the arteries, and the appearance of non-healing ulcers;
Vascular (spinal), considered true - small vessels that provide nutrition to the spinal cord are affected, the cause of development is syphilis and myelitis.

Each of the forms is united by the presence of pain and discomfort while walking or running. Caudogenic intermittent claudication, in addition to the above symptoms, includes sensory disturbances in the form of numbness of the surface layers and the appearance of a slight tingling and burning sensation, reminiscent of goosebumps.

Symptoms

Intermittent claudication is a consequence of poor circulation. Therefore, there are several stages of the disease with symptoms characteristic of each period:

The first stage is characterized by the appearance of fatigue, a feeling of aching below the knee, burning and painful symptoms of intermittent claudication, having covered 1 km at a calm pace on level ground. During rest, the legs become cold to the touch, the pulse in the foot area is weakly determined.
Second stage: the pathology moves into the period of trophic disorders with the progression of pathological changes in the vessels. The skin becomes dry and flaky, areas of keratinized layers of skin appear on the soles of the feet, and nails and hair do not grow on the feet. The nail plate changes color to brown, small muscles atrophy. Intermittent claudication is a consequence of physical activity of no more than 200 meters.
Third stage: the skin on the legs becomes thin and sensitive, with the slightest damage, non-healing wounds and scratches appear. Intermittent claudication syndrome occurs at rest and is permanent.
In chronic ischemia of the lower extremities, when adequate therapy is not carried out and the process continues to progress, the stage of necrosis develops. The phalanges of the fingers are the first to suffer, with a transition to the overlying tissues. Ulcers with a dirty gray coating form, inflamed around the perimeter. These are signs of developing gangrene, the outcome of which will be high amputation of the limb.

Intermittent claudication is a consequence of narrowing of the lumen of the vessel. The degree of damage to the arteries varies:

high level in case of damage to the main main vessels - the aorta and arteries in the iliac region, while the pain is localized in the buttock and thigh;
the middle level is located on the femoral and popliteal arteries, pain occurs in the calves;
low level - blood flow to the lower leg is blocked, intermittent claudication affects the feet.

Lameness, additional characteristic symptoms:

The patient's leg is lame due to severe pain. In adults, the symptom appears quite often. If after vaccination a child limps and complains of pain, it is necessary to urgently show him to a doctor, as there may be a circulatory disorder due to improper manipulation technique or as a complication during vaccination.
Insufficient calcium in the bones causes the condition of osteoporosis, in which voids appear, and the property of increased bone fragility.
The consequence of impaired blood flow is a symptom such as alopecia. Areas appear on the legs where the skin falls out and no longer grows due to an acute lack of cell nutrition.
Atrophic changes in tissues are manifested by the complete disappearance of muscle tissue and subcutaneous fat. When you apply strong pressure to the toe or heel area, a dent is left that does not straighten out in a short period. This phenomenon is called an “empty” heel or toe.

Diagnostics

To determine the disease, you will need to conduct diagnostic tests prescribed by your doctor. Collecting an anamnesis and listening to complaints is carried out at the first examination. Visualization of the surface of the legs and feet will allow you to preliminarily determine the degree of damage: brittle nails, pale skin, lack of hair on the fingers and shins.

Carrying out specialized tests will help establish the diagnosis:

Opel test: in a lying position, raise both legs to a height of 30 cm and fix the position for 1.5 minutes, bluish areas will appear on the legs;
Burdenko's test: bend and straighten one leg at a fast pace 8 times; with poor blood circulation, the skin will turn pale and unevenly colored;
Palchenkov's test: sit on a chair with your legs crossed, after a quarter of an hour the leg turns blue.

Ultrasound examination of blood vessels will allow us to study changes in the vascular wall from the inside. Angiography is an X-ray examination of blood vessels. Doppler ultrasound evaluates the volume of blood passing through the vessels.

Treatment

How to get rid of intermittent claudication? It is impossible to recover from this condition; the modified vessels remain like this for the rest of your life. Treatment of intermittent claudication involves preventing the condition from progressing in order to prolong work capacity and the ability to move independently.

The process of conservative treatment accompanies a person throughout his life. With the active transition of the disease to the second and third stages, surgical treatment may be prescribed. The stage of formation of necrotic masses leads to their partial removal or amputation of the leg.

Medicines

Disaggregants (Aspirin, Prasugrel, Clopidogrel) prevent the formation of blood clots by thinning the blood.
Lipid-lowering drugs (Atorvastatin, Simvastatin) to regulate lipid metabolism.
You can influence the stabilization of metabolic processes with the help of fortified complexes and with the help of tissue regeneration stimulators Actovegin, Kudesan, Elkar.
Prostaglandins will help relieve inflammation in blood vessels - Alprostat, Thrombo Ass.
To improve immunity, Polyoxidonium, Panavir, Viferon are recommended.

Physiotherapy

Intermittent claudication is amenable to restorative treatment using modern physical therapy methods. In the absence of thrombus formation, massage courses can be carried out. Therapeutic sessions will improve blood circulation, raise the tone of skeletal muscles, and improve sensitivity in the legs.

Magnetic therapy is carried out by applying an electromagnetic field to diseased limbs. The therapeutic effect is achieved by the end of the full course and persists until the next hardware treatment.

Therapeutic gymnastics is carried out under the supervision of a physical therapy instructor. The set of exercises and technique are explained by a specialist. Exact adherence to the instructions and dosing of the therapeutic load will ensure a positive result.

Hydrogen sulfide baths will saturate sore legs with the necessary chemical elements that restore metabolism and trigger the natural course of biochemical reactions.

Operation

Surgical treatment is performed to improve blood flow in areas susceptible to ischemia. Surgical treatment of intermittent claudication is carried out in the following ways:

mechanical cleansing of the inside of the affected vessel to restore optimal lumen;
excision of the damaged segment with replacement with an artificial vessel or transplantation of part of one’s own vein;
creating a bypass section of blood circulation to bypass the damaged area;
stenting – the vessel is forcibly expanded with the introduction of an endoprosthesis.

Traditional methods

Traditional treatment involves using natural ingredients to prepare healing compounds. Before using grandma's recipes, you should consult your doctor to avoid unforeseen conditions that could worsen the condition.

Contrasting foot baths using pine decoction will improve the condition, have an analgesic and anti-inflammatory effect, and strengthen the walls of blood vessels. Brew the pine needles in hot water and let it brew for a couple of hours. Place two containers with hot and cool solution. Immerse your feet in turn in two baths. Keep in cool water for no more than 3 minutes, in warm water - 10 minutes.
Grind the horse chestnut fruits to a powder. Pour two tablespoons into a bowl, add three tablespoons of algae and 4 tablespoons of hop cones. Steam one spoonful of the mixture with a glass of boiling water and drink it throughout the day, dividing it into three doses.

Prevention

lead a healthy lifestyle, avoiding cigarettes and alcoholic beverages;
promptly treat chronic pathologies and infectious diseases;
dose physical activity;
maintain normal body weight;
See a doctor at the first sign of discomfort.

Intermittent claudication is a symptomatic complex, the characteristic manifestation of which is a violation of the blood supply to the vessels located in the lower extremities with manifestations of pain in the legs of a transient nature, as well as those arising during walking. Many vascular pathologies, intoxications, infections, and injuries are the causes of the development of this disease. As a result of the spasm that forms in the peripheral vessels, there is insufficient blood supply to the muscles and/or nerve endings in the lower extremities, and much less often in the upper extremities.

Intermittent claudication is usually chronic, but there is also an acute form of the disease. Medical sources describe two types of diagnosis of intermittent claudication, namely spinal according to Dejerine and peripheral according to Charcot.

Causes of intermittent claudication

This is a peculiar symptom that accompanies diseases such as Leriche syndrome, obliterating endarteritis, postthrombotic and postembolic occlusions. Intermittent claudication is a consequence of atherosclerosis, in which blockages and plaques form in blood vessels. With this disease, the appearance of plaques occurs in small arteries, as well as in medium ones and even in the aorta. This blockage causes insufficient oxygen supply with blood to the lower extremities. Thus, ischemia develops, which causes pain.

Other diseases of the vascular system, and sometimes infections, intoxication of the body and various injuries of the extremities may also be involved in the development of intermittent claudication.

The most important factor that provokes the formation of intermittent claudication is smoking. A number of studies have found that there is a direct relationship between smoking and vascular occlusion. Toxic carcinogens contained in cigarette smoke provoke premature damage to the structure of blood vessels, namely arteries, leading to the formation of atherosclerotic plaques in them and increasing the risk of blood clots.

Intermittent claudication of a neurogenic nature develops as a result of pathological processes in the spine, such as spinal stenosis, etc.

In addition, risk factors for intermittent claudication include alcohol abuse, physical inactivity, hereditary predisposition and high blood pressure.

Intermittent claudication symptoms

As a rule, intermittent claudication is characterized by pain in the lower extremities, which begins to develop during walking as a consequence of pathological blood circulation, but disappears when movements stop.

Much more often this symptom is observed among men in middle age. But recently, this syndrome has begun to appear in women. This can be explained by the increase in the number of women smoking and the negative effects of nicotine on the body of the fairer sex.

For a long time, intermittent claudication does not manifest itself in any way, that is, it proceeds absolutely without any symptoms. A patient with the symptom of intermittent claudication already at the very beginning experiences a certain weakness, quickly gets tired, and then the first signs of paresthesia in the lower extremities appear. Subsequently, with increasing physical activity, the deformed arteries do not allow normal blood circulation, so patients experience characteristic pain in the calf muscles. It is this symptom that is the main manifestation of intermittent claudication syndrome. In this case, the patient is forced to periodically make minor stops, and after the pain attack subsides, continue to make his movements.

As the disease progresses, the pain begins to intensify and then becomes quite persistent. Painful sensations can be completely different in nature. Sometimes they can be pulsating or burning, and at other times they can be aching and dull. As a rule, the pain characteristic of this pathology very often occurs when climbing upward, or when moving long distances, so the patient is forced to limp.

Pain may also appear in the thighs and legs, as well as on the toes. All this is due to where the blockage or narrowing of blood vessels occurred. In this case, it is not possible to palpate the pulse in the foot area, and it cannot be felt under the knee. There is also a change in the skin in the form of blanching, and in the active phase of progression of the pathological process it appears. In addition, the condition of the skin deteriorates and the skin becomes dry.

The symptoms of intermittent claudication consist of a decrease in the temperature of the feet, and subsequently the patient loses sensitivity in this part of the body. In addition to these symptoms, a painful sensation appears in the calf muscles, and discomfort occurs when there is pressure on the nerve trunks in the lower legs. In rare cases, trophic ulcers appear. A symptom such as intermittent claudication is characterized by a chronic course with periodic remissions of the disease.

Pain can bother the patient, both during periods of disease progression and in a state of complete rest. At the same time, painful attacks force a person to wake up even at night. And gradually the symptom complex of intermittent claudication worsens quite significantly, so the patient is forced to take various painkillers to alleviate his condition.

This syndrome may indicate the development of a serious arterial disease, such as obliterating endarteritis. The severe form of intermittent claudication is characterized by the appearance of ischemic ulcers on the lower extremities, and later gangrene forms, followed by amputation of the limb.

In the absence of appropriate treatment, this disease may develop collaterals that can partially or completely compensate for the disease. But if the blood vessels are completely blocked, urgent surgery is necessary.

Intermittent claudication is the main symptom

The main symptom of intermittent claudication, which accompanies many diseases, is pain in the muscles of the lower extremities. Painful sensations, as a rule, appear when walking and at the very beginning of the disease disappear during rest. A person with such a diagnosis has to stop so that the pain disappears for a while, and then return to normal movement.

Intermittent claudication develops in the presence of certain factors that contribute to the formation of this symptom. These include smoking, obesity, old age and diabetes.

The symptoms of this syndrome largely depend on the stage at which the intermittent claudication is at that moment. Typically, there are four stages of the disease.

At the very beginning, and this is the first stage of the pathological process, patients are unable to palpate the main vessels in the lower extremities, namely in the groin area, popliteal fossa and foot. The absence of a pulse in these areas will depend on the location of the arterial blockage.

The second stage is characterized by the appearance of pain in the buttocks, thighs and calf muscles. These painful attacks become so intense that they force the patient to walk even short distances (up to one hundred meters), with periodic stops to rest.

In the third stage, intermittent claudication occurs in the patient in the form of severe pain already at rest or at night, and its intensity increases each time. In addition, the patient experiences a feeling of coldness and numbness in the toes. The skin takes on a pale tint, hair growth slows down, and then it completely disappears. Also, my toenails begin to grow quite slowly.

The last stage, the fourth, is considered one of the most dangerous and serious stages of the disease. In this phase, the patient’s intermittent claudication is characterized by attacks of severe pain in the lower extremities, which are constantly present, both during movement and at absolute rest. Patients during this period of the disease are practically unable to perform any physical activity, because it is at this stage that the nutrition of soft tissues is disrupted, which causes the development of necrosis and gangrene.

Intermittent claudication treatment

If the patient complains of characteristic pain in the legs, the doctor can diagnose this disease during the initial examination and establish a diagnosis of intermittent claudication. This is confirmed by the characteristic symptoms of the disease and the absence of a pulse at the corresponding points on the lower extremities. If additional research is necessary, examinations using ultrasound to determine arterial patency and angiography are prescribed. This diagnosis allows you to determine the degree of circulatory disorders in the lower extremities. If arterial occlusion is suspected, X-ray contrast angiography is prescribed, which will fully determine the state of intermittent claudication.

Almost 20% of patients have a severe form of the disease, which develops quite rapidly and urgently requires hospitalization and surgical treatment. Depending on certain features of the course of the symptom of intermittent claudication, reconstruction or vascular plasty is performed. But in the most urgent cases, when the limb is gangrenous, amputation is performed.

Treatment with medications for intermittent claudication is the same as for many other vascular diseases. To do this, first of all, drugs are prescribed that improve blood flow processes. At the same time, medications are used that reduce cholesterol levels and improve fat processes in the body. In this case, intravenous administration of 10 ml of saline solution, a solution of Pilocarpine, Insulin, Padutin or Depo-Padutin, Nicotinic acid, Pachycarpine is recommended. Favorable results can be achieved by introducing a perinephric novocaine blockade. Sometimes canned blood is injected intra-arterially into those vessels that are localized on the affected limb.

Physiotherapeutic methods for the treatment of intermittent claudication are also widely used. Among them, they use a steam pressure chamber, UHF, diathermy, various therapeutic baths using radon and hydrogen sulfide, as well as mud therapy.

An important point in the treatment of intermittent claudication is the complete cessation of smoking and drinking alcohol. In addition, it is necessary to avoid hypothermia and wearing tight shoes. You also need to carefully observe foot hygiene, avoid cracks and scratches. And patients with underlying diabetes mellitus should adhere to an appropriate diet and monitor blood sugar levels.

Also, for the symptom of intermittent claudication, treatment is practiced in the form of dosed walking, which significantly improves blood circulation in the lower extremities. In this case, it is advisable to walk until pain in the legs appears. Then you need to rest and continue walking. Alternation should be carried out in several stages. Good dynamics are observed after physical therapy exercises, foot massage and contrast shower.

But as the symptom of intermittent claudication progresses, sometimes they resort to inserting a catheter into the arteries to dilate them in order to restore blood flow. Surgical treatment methods include periarterial sympathectomy, epinephrectomy, or limb amputation.

An important point in the treatment of the syndrome remains proper nutrition with a systematic distribution of work and rest, as well as mandatory monitoring of blood pressure fluctuations.

An effective treatment for intermittent claudication is herbal treatment in the form of foot baths before bed. In addition, it is recommended to brew and consume herbal infusions in the form of infusions of immortelle, birch buds, St. John's wort, and rose hips, which have an anti-inflammatory effect.