Editing Intermittent claudication

{{short description|Muscle pain from mild exertion}}
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'''Intermittent claudication''', also known as '''vascular claudication''', is a [[symptom]] that describes [[muscle pain]] on mild exertion (ache, cramp, numbness or sense of fatigue),<ref>{{DorlandsDict|nine/000953879|intermittent claudication}}</ref> classically in the [[calf muscle]], which occurs during exercise, such as walking, and is relieved by a short period of rest. It is classically associated with early-stage [[peripheral artery disease]], and can progress to [[critical limb ischemia]] unless treated or [[peripheral artery disease#Risk factors|risk factors]] are modified and maintained.

Claudication derives {{ety|la|{{linktext|claudicare}}|to limp}}.

==Signs and symptoms==
One of the hallmarks of arterial claudication is that it occurs intermittently. It disappears after a very brief rest and the patient can start walking again until the pain recurs.
The following signs are general signs of atherosclerosis of the lower extremity arteries:<ref>{{cite web |url= https://www.lecturio.com/concepts/atherosclerosis/ | title= Atherosclerosis | website= The Lecturio Medical Concept Library |access-date= 2 July 2021}}</ref>
* [[cyanosis]]
* atrophic changes like loss of hair, shiny skin
* decreased [[temperature]]
* decreased [[pulse]]
* redness when limb is returned to a "dependent" position (part of Buerger's test)

The six "'''P'''"s of ischemia<ref>{{cite journal |url= https://www.ncbi.nlm.nih.gov/books/NBK441851/ | title= Acute Arterial Occlusion
| website= National Center for Biotechnology Information, U.S. National Library of Medicine | year= 2022
| pmid= 28722881
|access-date= 2 July 2021| last1= Smith
| first1= D. A.
| last2= Lilie
| first2= C. J.
}}</ref>
* '''P'''ain
* '''P'''allor (increased)
* '''P'''ulse (decreased)
* '''P'''erishing cold
* [[Paraesthesia|'''P'''araesthesia]]
* '''P'''aralysis

==Causes==
Most commonly, intermittent (or vascular or arterial) claudication is due to [[peripheral arterial disease]] which implies significant [[atherosclerosis|atherosclerotic blockages]] resulting in arterial insufficiency. Other uncommon causes are [[coarctation of the aorta]],<ref>{{cite journal |last1=Doshi |first1=Arpan R |last2=Chikkabyrappa |first2=Sathish |title=Coarctation of Aorta in Children |journal=Cureus |date=5 December 2018 |volume=10 |issue=12 |pages=e3690 |doi=10.7759/cureus.3690|doi-access=free |pmid=30761242 |pmc=6368362 }}</ref> [[Trousseau's syndrome|Trousseau disease]]{{Medical citation needed|date=October 2018}} and Buerger's disease ([[thromboangiitis obliterans]]),<ref>{{cite journal |last1=Qaja |first1=E |last2=Muco |first2=E |last3=Hashmi |first3=MF |title=Buerger Disease |date=January 2021 |pmid=28613608}}</ref> in which vasculitis occurs.

[[Raynaud's phenomenon]] functional vasospasm.{{clarify|date=October 2018}} It is distinct from [[neurogenic claudication]], which is associated with [[lumbar spinal stenosis]]. It is strongly associated with smoking, hypertension, and diabetes.<ref>{{cite web|last=Dr Hicks|first=Rob|title=Intermittent Claudication|url=https://www.bbc.co.uk/health/physical_health/conditions/intermittentclaudication1.shtml|publisher=BBC Health}}</ref>

==Diagnosis==
Intermittent claudication is a symptom and is by definition diagnosed by a patient reporting a history of leg pain with walking relieved by rest. However, as other conditions such as [[sciatica]] can mimic intermittent claudication, testing is often performed to confirm the diagnosis of [[peripheral artery disease]]. {{cn|date=February 2021}}

[[Magnetic resonance angiography]] and [[duplex ultrasonography]] appear to be slightly more cost-effective in diagnosing [[peripheral artery disease]] among people with intermittent claudication than projectional [[angiography]].<ref>{{cite journal |vauthors=Visser K, Kuntz KM, Donaldson MC, Gazelle GS, Hunink MG |title=Pretreatment imaging workup for patients with intermittent claudication: a cost-effectiveness analysis |journal=J Vasc Interv Radiol |volume=14 |issue=1 |pages=53–62 |year=2003 |pmid=12525586 }}</ref>

==Treatment==
Exercise can improve symptoms, as can [[revascularization]]. Both together may be better than one intervention of its own.<ref name="Review2012">{{cite journal |last=Frans |first=FA |author2=Bipat, S |author3=Reekers, JA |author4=Legemate, DA |author5=Koelemay, MJ |date=January 2012 |title=Systematic review of exercise training or percutaneous transluminal angioplasty for intermittent claudication. |journal=The British Journal of Surgery |volume=99 |issue=1 |pages=16–28 |doi=10.1002/bjs.7656 |pmid=21928409 |s2cid=205512324|doi-access=free }}</ref> 

Supervised exercise improves maximum walking distance and pain-free walking distance more than home based exercise. Although when monitoring is included in home based exercise programmes similar changes in pain-free walking distance are observed in both supervised and home based exercise.<ref name=":0">{{Cite journal |last=Pymer |first=Sean |title=An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication |journal=Journal of Vascular Surgery |date=2021 |volume=74 |issue=6 |pages=2076–2085 |doi=10.1016/j.jvs.2021.03.063 |pmid=34087396 |s2cid=235346102 |doi-access=free }}</ref> 

In people with stable leg pain, exercise, such as [[strength training]], pole-striding and upper or lower limb exercises, compared to usual care or placebo improves maximum walking time, pain-free walking distance and maximum walking distance.<ref>{{Cite journal|last1=Lane|first1=Risha|last2=Harwood|first2=Amy|last3=Watson|first3=Lorna|last4=Leng|first4=Gillian C.|date=26 December 2017|title=Exercise for intermittent claudication|journal=The Cochrane Database of Systematic Reviews|volume=2017|issue=12|pages=CD000990|doi=10.1002/14651858.CD000990.pub4|issn=1469-493X|pmc=6486315|pmid=29278423}}</ref> Alternative exercise modes, such as [[cycling]], [[strength training]] and upper-arm ergometry compared to supervised walking programmes showed no difference in maximum walking distance or pain-free walking distance for people with intermittent claudication.<ref>{{Cite journal |last1=Jansen |first1=Sandra Cp |last2=Abaraogu |first2=Ukachukwu Okoroafor |last3=Lauret |first3=Gert Jan |last4=Fakhry |first4=Farzin |last5=Fokkenrood |first5=Hugo Jp |last6=Teijink |first6=Joep Aw |date=2020-08-20 |title=Modes of exercise training for intermittent claudication |journal=The Cochrane Database of Systematic Reviews |volume=2020 |issue=8 |pages=CD009638 |doi=10.1002/14651858.CD009638.pub3 |issn=1469-493X |pmc=8092668 |pmid=32829481}}</ref> 

Pharmacological options exist, as well. Medicines that control lipid profile, [[diabetes]], and [[hypertension]] may increase blood flow to the affected muscles and allow for increased activity levels. [[Angiotensin converting enzyme]] <!-- (ACE) --> inhibitors, [[adrenergic agents]] such as [[adrenergic antagonist|alpha-1 blockers and beta-blockers]] and [[alpha-2 adrenergic receptor|alpha-2]] agonists, antiplatelet agents ([[aspirin]] and [[clopidogrel]]), [[naftidrofuryl]], [[pentoxifylline]], and [[cilostazol]] (selective PDE3 inhibitor) are used for the treatment of intermittent claudication.<ref>{{cite news|title=Intermittent Claudication Treatment India |url=http://www.vascularsurgerydelhi.com/intermittent-claudication.html | work=VascularSurgery | date=2015-01-31 |first=Team |last=Vascular}}</ref> However, medications will not remove the blockages from the body. Instead, they simply improve blood flow to the affected area.<ref>{{cite news|title="Cilostazol, naftidrofuryl oxalate, pentoxifylline and inositol nicotinate for the treatment of intermittent claudication in people with peripheral arterial disease".|url=https://www.nice.org.uk/guidance/ta223 | work=Retrieved July 28, 2016.|first=(Published date: 25 May 2011)|last=National Institute for Health and Care Excellence  }}</ref>

[[Catheter]]-based intervention is also an option. [[Atherectomy]], [[stent]]ing, and [[angioplasty]] to remove or push aside the arterial blockages are the most common procedures for catheter-based intervention. These procedures can be performed by interventional radiologists, interventional cardiologists, vascular surgeons, and thoracic surgeons, among others.{{cn|date=February 2021}}

Surgery is the last resort; [[vascular surgeon]]s can perform either [[endarterectomy|endarterectomies]] on arterial blockages or perform an [[vascular bypass|arterial bypass]]. However, [[Invasiveness of surgical procedures#Open surgery|open surgery]] poses a host of risks not present with catheter-based interventions.{{cn|date=February 2021}}

==Epidemiology==
Atherosclerosis affects up to 10% of the Western population older than 65 years and for intermittent claudication this number is around 5%. Intermittent claudication most commonly manifests in men older than 50 years.{{cn|date=February 2021}}

One in five of the middle-aged (65–75 years) population of the United Kingdom have evidence of peripheral arterial disease on clinical examination, although only a quarter of them have symptoms. The most common symptom is muscle pain in the lower limbs on exercise—intermittent claudication.<ref name="Edinburgh Artery Study">{{cite journal|title=Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population|pmid=1917239 | volume=20|issue=2|date=Jun 1991|journal=Int J Epidemiol|pages=384–92|doi=10.1093/ije/20.2.384|last1=Fowkes |first1=F G R. |last2=Housley |first2=E. |last3=Cawood |first3=E H H. |last4=MacIntyre |first4=C C A. |last5=Ruckley |first5=C. V. |last6=Prescott |first6=R. J. }}</ref>

==See also==
* [[Exercise intolerance]] 
* [[Peripheral artery disease]]
* [[Metabolic myopathy|Metabolic myopathies]]
* [[Second wind]]

==References==
{{Reflist}}

==Further reading==
* {{cite journal |vauthors=Burns P, Gough S, Bradbury AW |title=Management of peripheral arterial disease in primary care |journal=BMJ |volume=326 |issue=7389 |pages=584–8 |date=March 2003 |pmid=12637405 |pmc=1125476 |doi=10.1136/bmj.326.7389.584}}
* {{cite journal |doi=10.2147/vhrm.2007.3.2.229 |author=Shammas NW |title=Epidemiology, classification, and modifiable risk factors of peripheral arterial disease |journal=Vasc Health Risk Manag |volume=3 |issue=2 |pages=229–34 |year=2007 |pmid=17580733 |pmc=1994028 |doi-access=free }}

== External links ==
{{Medical resources
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|   ICD10       = {{ICD10|I|73|9|i|70}}
|   ICD9        = {{ICD9|440.21}}
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|   MeshID         = D007383
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* [http://pvd.cochrane.org/welcome Cochrane Peripheral Vascular Diseases Review Group] {{Webarchive|url=https://web.archive.org/web/20150223175035/http://pvd.cochrane.org/welcome |date=2015-02-23 }}

{{Vascular diseases}}{{Myopathy}}
{{DEFAULTSORT:Intermittent Claudication}}
[[Category:Symptoms and signs: Vascular]]
[[Category:Vascular diseases]]
[[Category:Diseases of arteries, arterioles and capillaries]]