Joined: May 11, 2004
I have a difficult time determining if symptoms are vascular in nature or neurogenic in nature especially if an elderly patient has bilateral lower extremity symptoms.
Can the ankle/brachial index be done without a doppler?
I am currently treating an 80+ year old woman. She's a rotten historian, anxious, a bit irritable and depressed combined with a lack of sleep. She is a nice lady though. Her complaint is tingling in her feet and in her ankles that comes and goes (she can't tell me when it comes or when it goes - I don't think she can remember specifics). It all started after she had an arthroscopy on her left knee in late November. She only complained of left foot/ankle tingling and now it is bilateral. I've treated her in the past for degenerative disc disease, so I know she has degenerative changes in the spine.
What I'm not able to determine is if she possibly has a lumbar stenosis causing her symptoms or if she has some vascular insufficiency causing her symptoms. Granted, I know I'm not a physician, but it would be helpful to determine what's what to have a more effective treatment plan, instead of feeling like I'm flying by the seat of my pants. I hate chasing symptoms. Oh, and in case Barrett is reading - when she lies supine her hips flop into an externally rotated position.
She doesn't tell me that she can only walk for so long and needs to sit. (So, I'm thinking less stenosis and more vascular)
She feels worse in sitting and tends to take off her shoes to make her ankles feel better. I'm not sure what that exactly means. I told her not to tie her shoes as tight and see if that made things better. She prior to her arthroscopy she wore orthotics and when I initially saw her she wasn't wearing orthotics and was wearing flimsy shoes - the shoes had no support and she walked with quite a bit of calcaneal valgus - so initially I was thinking along the lines of possible tarsal tunnel because of biomechanics. Her complaint hasn't changed with improved biomechanics.
Elevating her extremities does cause them to become quite pale but she doesn't have increased pain. Dependent position does cause kind of a darker reddish coloration in the toes, lateral foot and a bit into the lateral distal leg bilateral extremities.
Her skin really doesn't have any unusual appearance - it is thin, it is slightly dry (but so is mine - it's winter here).
I attempted to determine the ABI, but failed miserably. I've never attempted to hear the systolic pressure at the foot. My first attempt wasn't pretty.
Any ideas on how I can differentiate what might be going on with this patient?
If symptoms worsen while biking upright and do not improve with forward flexion, it leans you more toward vascular claudication. I'm not aware of this test being studied extensively for reliability/validity, as the article is from 1977, but it might be a good start for you.
Here's the abstract for it: Intermittent claudication (IC) is defined by leg muscle pain, cramping and fatigue brought on by ambulation/exercise; relieved on rest; and caused by inadequate blood supply and is the primary symptom of peripheral arterial disease (PAD). PAD has a detrimental effect on the quality of life. PAD is a debilitating atherosclerotic disease of the lower limbs and is associated with an increased risk of cardiovascular morbidity and mortality. IC is an extremely important marker of atheroma. Up to 60% patients with IC have significant underlying coronary and/or carotid disease and 40% of all patients suffering from IC die or suffer a stroke within 5 years of presentation. The therapeutic intervention of IC essentially aims at providing symptomatic relief and reducing the systemic cardiovascular complications. Although exercise therapy is one of the most efficacious conservative treatments for claudication, the pharmacotherapeutic goals can be best achieved through an increase in the walking capacity to improve quality of life and a decrease in rates of amputation. In the development of treatment for IC, an aggressive non-pharmacological intervention and pharmacological treatment of the risk factors associated with IC are considered. In the next 2 years, the results of major trials of drugs that stabilize and regress atherosclerosis such as statins and angiotensin converting enzyme inhibitors, and anti-platelet agents, recombinant growth factors and immune modulators will be available for IC. Levocarnitine (l-carnitine) and a derivative, propionyl levocarnitine, are emerging agents that increase the pain-free walking and improve the quality of life in IC patients by working at the metabolism and exercise performance of ischemic muscles. This article provides a comprehensive review of the pathophysiology involved, diagnosis of IC and existing and emerging pharmacotherapies with rationale for their use in its treatment.
Joined: May 11, 2004
I usually use the treadmill for claudication issues. The problem is that she really doesn't have the typical claudication complaints. She is quite deconditioned so yes, she does get fatigued with lower extremity exercise. With the exercise, I'm not able to differentiate the fatigue as a normal response to exercise or secondary to some vascular component. She doesn't complain of pain at all, she complains of tingling. She's very clear on that - "I don't have pain." LOL
She's more in the initial stages of something, I think. I just don't know what. Because of her history of osteoporosis, I don't believe that the bike would be the best option for assessing - flexing the spine isn't recommended. Meeks would reprimand me for that. But, I think I could have her on the treadmill and see if walking increased her symptoms and then incline it to see if anything changes. I guess I'll try that tomorrow and see if anything happens. A reduction in complaints could lead me to believe stenosis. And, no, I don't remember what literature I read that involved using the treadmill... but I did read it somewhere.
Joined: August 4, 2005
SJ, The doppler is the best and most reliable way to measure ABI, but if you have a BP cuff large enough to go around the patient's calf, you can get a pretty good idea by auscultating the dorsalis pedis or posterior tibial artery.
In my clinic, we use ABI mostly to differentiate venous stasis versus arterial insufficiency for lower extremity wound management.
As far as neuro vs. vascular, ditto the info Jason posted.
Joined: January 28, 2005
From: West Vancouver BC
Hi SJ, send your 80 year old back to see her physician as soon as you can. Look at the facts. 80 years old. Tingling but no pain in her feet and ankles. Bad historian. Depressed. Not sleeping well. She can't tell when it comes and goes. Have you noticed any hair loss on her lower leg? Is she using gastric acid blockers? Have you asked her children if granny is as with it as she was? Your patient may have low cobalamin having a b12 deficiency and she may have the beginnings of a neuropsychiatric disorder and time is of the essence. If she doesn't get the shots of "The Red stuff" early enough it can easily become permanent. Many years ago the American government had food suppliers add folates to food to stop neural tube defects. Unfortunately extra folates although necessary can skew the results of usual cobalamin and homocysteine level tests and give normal results. Tests should be given to measure the serum methymalonic acid and homocysteine evels.Perhaps all oldies should have a dose regularly, and the cost is minimal. Jim McGregor
You have a higher degree of confidence in the doctor to believe he will test for these things. If she has a history of osteoporosis he should have been monitoring homocysteine at least. B-12 is probably going to be a good route to go with her anyway, so a "suggestion" is in order.
As for the claudication test I would think with an 80-year old in the condition described it's going to be hard to conduct or evalutate the test in a meaningful way.
For treatment, can't you safely assume some degree of spinal stenosis and work from there?
Joined: January 25, 2003
Wow, there are some significant problems using the ABI index in anything but healthy patients...the ABI is fantastic on the healthy trauma subject, but really filled with poor sensitivity. It is an unreliable test. But I can understand your position, what are you to do?
Well, if you feel this is a vascular issue, a vascular specialist is the person to refer to. They will of course run arterial and venous dopplers, perhaps even arteriography via interventional radiology.
I must hand it to you for trying everything you can...but I think that even your best effort is crippled by a poor and rather nonspecific test.
I think in your case, the most sensitive test would be a provacative test regarding exercise.
Now, lets look at her case in particular.
You have a senior citizen (putting it nicely), the unddoubtedly has atherosclerotic disease. At the very least she has small vessel disease. The point is, does she have large vessel disease.
Further more, could this be sign of stenosis proximal to the lesion...ie initial signs of dissection or luminal sclerosis. Far more deadly concerns. I would bet if you look into the rest of her medical history or her medication list, you will likely find the answer.
As for the B12, look elsewhere first, the more deadly causes. B12 won't cause harm and is relatively cheap. I would certainly look at her CBC and smear first prior to making the diagnosis of B12 deficiency. It is relatively easy to diagnose.
Dr. Wagner DO Moderator of Medical Complexity Forum
Joined: May 11, 2004
Jim, she's taking very few medications. Can't remember what. She has some psychosocial issues that may be affecting her - some significant changes going on in her life. I talked to the nurse practitioner a couple days ago.
Wags, that's why I asked initially if the ABI had to be done with a doppler. I wasn't sure if that was gold standard or not. As Sean mentioned the ABI is used quite frequently in patients with wounds. I knew that part, but didn't know if it could be done on someone without wounds without a doppler.
This lady's pretty much been healthy. My gut thinks her complaint is more vascular in nature. I don't want to be treating her spine and I'm against flexion exercises for someone with osteoporosis... so I'm just trying to hammer down a more specific game plan. I'm going to attempt the treadmill as the exercise of choice today and hopefully get increased symptoms of some sort and then put the treadmill on incline. With the physicians, before I recommend referring her for a consult anywhere, I generally provide my rationale - I don't quite have a strong enough rationale yet... maybe after today, I can recommend a vascular consult and why. I had assumed the ABI would be my ticket, but I failed miserably on that deal. LOL (I can't even hear my systolic at my dorsalis pedis. LOL Never tried it before though, so maybe today I should practice until I can do it.)
Joined: January 25, 2003
Obviously you are a great disadvantage. The ABI is a poor test unless in the hands of an experienced person...with a doppler...a doppler that works (many times they gather dust). It really is no longer the gold standard for vascular insufficiency, but a screen...but once again only useful in the hands of someone who does them at the very least, monthly.
Regarding diabetes...well, lets look at her age. This would be pretty late onset. This would also be rather odd initial sign (peripheral neuropathy is LATE and generally from long standing poor control, NOT from new onset). Initial signs of diabetes (in the type II diabetic) may be the typical polyphagia, poly dipsia, polyuria. Or perhaps the most often finding...full DKA or nonketotic hyperosmolar syndrome causing acidosis...both really bad findings.
Dr. Wagner DO Moderator of Medical Complexity Forum
Joined: May 11, 2004
I'm at more of a disadvantage than anyone even knows. ;) Oh, I'm experienced, just not in the way of ABIs. LOL
The treadmill was a flop. She didn't sleep well last night. Mentally it was like she was in a zone and refused to focus. She got all anxious and couldn't move her feet. LOL Well, she did, but not effectively. Which then lead to more agitation on her part. LOL It wasn't funny, but it was.
So, anyways, I decided I'd try the bike. It went against my whole gut because I really didn't want her to flex her spine, but sometimes we gotta do things that we know aren't the recommended things. Forgive me, Meeks. So... I don't think her symptoms are related to spinal stenosis - no change in her increasing numbness with lumbar flexion. Her numbness moved proximally to just distal to her knees bilaterally and she had increased fatigue. The best speed she could maintain was between 6.5 and 7.5 mph. NOT a very good clip, but I took what I could. So, within 40 seconds of stopping the biking and letting her legs dangle, the numbness moved distally to her ankles. Then, after another 60 seconds, the numbness was just from the balls of her feet to her toes.
So... I got her doing 2 minute bouts of knee extension exercises at a moderate intensity. After 3 sets of that, her numbness had moved proximally to just distal to her knees bilaterally... within 60 seconds, the numbness was at the ankle region and within another 60 seconds the numbness was just at the balls of her feet and toes.
Oh, and she just remembered to tell me today that when she shops for food at the little local store that she has to sit in their lunch room because her legs get numb and tired. As I said, she's a poor historian.
So, I'm thinking it has got to be vascular in nature. I wasn't thinking diabetes - no history and no symptoms in that nature when I had her do a systems review.
Joined: October 21, 2005
I agree with Dr. Wagner - several studies show low sensitivity with the ABI for both identifying presence or, or progression of peripheral vascular diseease; and for identifying risk of general atherosclerosis risk (MI, Stroke). Doobay AV; Anand SS. Sensitivity and specificity of the ankle-brachial index to predict future cardiovascular outcomes: a systematic review. [Arterioscler Thromb Vasc Biol] 2005 Jul; Vol. 25 (7), pp. 1463-9. Wolosker N; Rosoky RA; Nakano L; Basyches M; Puech-Lećo P. Predictive value of the ankle-brachial index in the evaluation of intermittent claudication. [Rev Hosp Clin Fac Med Sao Paulo] 2000 Mar-Apr; Vol. 55 (2), pp. 61-4. McLafferty RB; Moneta GL; Taylor LM Jr; Porter JM. Ability of ankle-brachial index to detect lower-extremity atherosclerotic disease progression.[Arch Surg] 1997 Aug; Vol. 132 (8), pp. 836-40; discussion 840-1. There is a section on ABI in one of the newer cardiopulmonary PT textbooks - however - it is not clear how this should be used by therapists in clinical decision making.
Sean M. Collins, PT, ScD, CCS Associate Professor Research Coordinator Department of Physical Therapy Coordinator, Graduate Program in Disability Outcomes Adjunct Professor, Department of Work Environment School of Health &
I may have missed these pieces of information, but what about capillary refill? proximal LE pulses? and what was the answer regarding hair on her legs? Regarding spinal stenosis, any 'grocery cart' sign (ambulate in supported flexed position)? How about sidelying slump? What kind of meds is she taking (any insight into history)? I am also unsure how to interpret results from flexion on the bike: "...no change in her increasing numbness with lumbar/trunk flexion. Her numbness moved proximally to just distal to her knees bilaterally and she had increased fatigue."
Given an educated guesswork, I too put my bets on vascular (arterial insufficiency), and I question proximal large vessel 'impairment' given the bilateral nature :) That being said, I would be in contact with the referring provider.
Thanks for the interesting case.
ps. why such hesitation regarding stationary bike in the presence of osteoporosis?
Joined: May 11, 2004
Liz... the stationary bike wasn't the issue, it was the lumbar flexion to be performed while on the stationary bike for the testing that was the issue. (I tend to avoid flexion movements of the spine with folks that are osteoporetic.) If spinal stenosis were occurring, flexion would relieve the symptoms in the LE. Differentiates neurogenic claudication from vascular claudication.
I got an update on the patient. I forgot I had posted stuff on this lady.
I ended up referring her back to her primary care provider. Her last visit with me I didn't find any out of the ordinary objective findings that were measurable in nature(same old same old as I had posted above), except she was very irritable that day. Reported increased fatigue. She refused to see the physician that day.... anyways, she agreed to see the physician the next day. Her irritability just seemed like a red flag - and her report of increased fatigue just didn't sit well with me.
Long story short, I ran into her son at Mickey D's the other day. I hadn't heard anything on his mom and I wasn't going to call the patient because she's a poor historian and I know that if I called her up I'd put her into worry mode...
Anyways, the lady is now in an assisted living facility. Diagnoses: congestive heart failure and blood clots in the lung. She still has the darn leg pain... No one listens to the patient. She was put on meds for cramping... I told the family to ask the attending physician about intermittent claudication because of vascular issues and to see if an ABI could be performed. Hopefully, they can make her comfortable.