Lower limb ischaemia and its treatment : the impact on physical function, balance and quality of life

Improving functional outcomes of elderly, high risk, populations is of enormous public health importance with both high social and economic value. Lower limb ischaemia is a chronic and disabling condition with increasing prevalence among elderly populations and has been shown to be associated with impaired physical function and balance. The aim of this study was to investigate the impact of standard treatment, through angioplasty or exercise therapy, on clinical indicators of lower limb ischaemia, physical function, balance, falls risk and quality of life in patients with lower limb ischaemia.Ankle brachial pressure index (ABPI) does not correlate with markers of physical function, balance and falls risk, whereas walking distances do correlate with physical function and falls. Angioplasty treatment leads to significant improvements in clinical indicators of lower limb ischaemia, markers of physical function that include an element of walking, history of falling or stumbling, fear of falling and quality of life. Balance is only slightly improved by angioplasty at 3 months following treatment. Supervised exercise programme treatment leads to significant improvements in walking distances but not ABPI, and physical function and a history of stumbles are improved. Balance is markedly improved at 3, 6 and 12 months from baseline. Quality of life improvements are seen at 3 and 6 months but not at 12 months from baseline.This study highlights the high frequency of balance abnormalities among claudicants and recognises the link between balance abnormalities and falls risk. Treatment with either angioplasty or exercise improves markers of physical function, balance, falls risk and quality of life but there are differences between the 2 treatment effects. It is important that patients are thoroughly assessed in the wider context of their presentation and that treatment is targeted to the individual

Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication

Objective The aim of this study was to identify whether revascularization by percutaneous transluminal angioplasty (PTA) for patients with intermittent claudication improved measures of functional performance including balance. Methods A prospective observational study was performed at a single tertiary vascular center. Patients with symptomatic intermittent claudication (Rutherford grades 1-3) were recruited to the study. Participants were assessed at baseline (pre-PTA) and then 3, 6, and 12 months post-PTA for markers of (1) lower limb ischemia (treadmill walking distances and ankle-brachial pressure index), (2) physical function (6-minute walk, Timed Up and Go, and chair stand time), (3) balance impairment using computerized dynamic posturography with the Sensory Organization Test, and (4) quality of life (VascuQoL and Short Form Health Survey [SF-36]). Results Forty-three participants underwent PTA. Over 12 months, a significant improvement was demonstrated in initial (P = .04) and maximum treadmill walking distance (P = .019). Physical functional ability improved across all outcome measures (P < .02), and some domains of both generic (P < .03) and disease-specific quality of life (P < .01). No significant improvement in balance was demonstrated by the Sensory Organization Test (P = .24). Conclusions Balance impairment is common in claudicants and does not improve with revascularization. Further research regarding effective treatment of balance impairment is required in this specific group of patients

Fear of falling in claudicants and its relationship to physical ability, balance, and quality of Life

Objectives: Intermittent claudication is associated with poor physical function, quality of life (QoL), and balance impairment. Fear of falling (FoF) is a recognized contributing factor to poor physical ability. Any link between claudication and FoF is yet to be determined. This study aimed to explore the prevalence of FoF in claudicants and its relationship with physical function and QoL. Methods: A prospective observational study was performed. Fear of falling was determined using the Activities-specific Balance Confidence (ABC) questionnaire and the categorical question “Are you afraid of falling?” Physical ability and QoL (Short Form 36 and Vascular QoL) were determined. Results: A total of 161 claudicants (118 men, median age of 69 years) were assessed; 83 answered the categorical question “Are you afraid of falling?” By receiver–operating characteristic curve analysis, an ABC threshol

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The effect of a 3-month supervised exercise programme on gait parameters of patients with peripheral arterial disease and intermittent claudication

BackgroundThe management of peripheral arterial disease with intermittent claudication includes angioplasty, pharmaceutical therapy, risk factor modification and exercise therapy. Supervised exercise programmes are used sporadically but may improve the distance that an individual with claudication can walk. The purpose of this study was to evaluate the effectiveness of a 3-month supervised exercise programme on improving gait parameters in patients with intermittent claudication.Methods12 participants were recruited (mean (SD) — age: 67.3 (6.8) years, height: 1.67 (0.09) m, mass: 79.4 (14.0) kg, ankle brachial pressure index: 0.73 (0.17)) from the local vascular unit and enrolled in a supervised exercise programme. Kinematic and kinetic data were collected at the following time points: pain-free walking, initial claudication pain, absolute claudication pain and after a patient-defined rest period. Data were collected before and after the 3-month supervised exercise programme.FindingsNo significant differences were found in any of the gait parameters post-intervention including pain-free walking speed (P=0.274), peak hip extension (P=0.125), peak ankle plantarflexion (P=0.254), or first vertical ground reaction force peak (P=0.654). No significant gait differences were found across different levels of pain pre- or post-intervention.InterpretationThe lack of improvement post-intervention observed suggests that the current exercise protocol was not tailored to elicit significant improvements in patients with intermittent claudication, specifically. The results indicate that exercise programmes may show improved results post-intervention if they are longer in duration and varied in intensity. Further research into more detailed muscle and biomechanical adaptations is needed to inform exercise programmes specific to this population

Kinematic adaptations to ischemic pain in claudicants during continuous walking

Intermittent claudication has been associated with impaired gait and balance. The study aim was to compare gait adaptations over time between claudicants classified with good versus poor balance. Kinematic data were collected from 24 claudicants during continuous walking. Balance was assessed using; Timed Up and Go test (TUG), and Sensory Organisation (SOT) and Motor Control (MCT) Tests using NeuroCom Equitest (R). 'Good balance' (GB) was operationally defined as those claudicants achieving normal scores on at least 2 of 3 tests whereas 'poor balance' (PB) claudicants achieved normal scores on 0 or 1 test. Temporal-spatial and sagittal plane joint kinematics were analysed at three time intervals; 'no pain' (prior to onset), 'initial pain' and 'maximal pain' (unable to continue walking). A two-way mixed design ANOVA was performed. Claudicants demonstrated a significant decrease in walking speed, step frequency and increased time in double support (p 0.05). There was no significant time and group interaction for any temporal-spatial or kinematic variable except hip flexion. GB claudicants demonstrated increased hip flexion as pain progressed but this adaptive strategy was not seen in PB claudicants. Claudicants make adaptations to walking by slowing (down) when in pain. Differences between GB and PB were not seen in temporal-spatial or ankle, knee and pelvic kinematic gait parameters. However adaptation to pain in GB claudicants involved a hip strategy, not seen in PB claudicants. (C) 2010 Elsevier B.V. All rights reserved

Balance impairment, physical ability, and its link with disease severity in patients with intermittent claudication

BackgroundTo determine whether increasing claudication severity is associated with impaired balance and physical functional ability.MethodsA prospective observational study in claudicants was performed. Disease severity was determined according to Rutherford's criteria. Patient's balance was assessed objectively using computerized dynamic posturography (CDP-Sensory Organization Test [SOT]; NeuroCom). "Bedside" assessment of balance was performed using the Timed Up and Go (TUG) test (dynamic balance) and the Full Tandem Stance test (static balance). Physical function was assessed using the Summary Physical Performance Battery (SPPB) score.Results185 claudicants were assessed (median age of 69 [IQR 63-74] years; 137 [74.1%] men). Fourteen claudicants were classified as Rutherford grade 0, 26 as grade I, 76 as grade II, and 69 as grade III. All Rutherford groups were comparable for age, gender, BMI, and comorbidities.Increasing Rutherford grade was associated with a significant deterioration in objective balance as determined by a failed SOT test: 3 (21.4%) in grade 0; 9 (34.6%) in grade I; 39 (52.7%) in grade II; and 41 (59.4%) in grade III (chi-squared 9.693, df 3, P = 0.021). A significant difference was also found with dynamic balance (TUG test), but not static balance (full tandem stance).Increasing claudication severity was also associated with significantly worse physical function: SPPB score.ConclusionsSpecific objective tests demonstrate impaired balance and physical function are common in claudicants and become more frequent with increasing severity of claudication. Simple "bedside" measures may be sufficiently sensitive to detect this

Patients' perspective of functional outcome after elective abdominal aortic aneurysm repair: a questionnaire survey

BackgroundTo evaluate patients' awareness, functional outcome, and satisfaction after abdominal aortic aneurysm (AAA) repair.MethodsA study-specific questionnaire was developed with collaboration of a multidisciplinary team. Lists of patients who underwent elective open AAA repair and endovascular aneurysm repair (EVAR) between January 2006 and December 2008 were obtained from the departmental database and cross-checked against hospital database for survival status. Emergency AAA repairs were excluded. Study questionnaires were posted to 138 patients (113 open, 25 EVAR) with self-addressed stamped return envelopes. Statistical analysis was performed using SPSS v16.0.ResultsResponse rate was 89% (n = 123; 102 open, 21 EVAR). Seventy-one percent (n = 88) were unaware of this condition before diagnosis. Ninety-seven percent (n = 120) indicated their understanding of the need for surgery. Ninety-two percent (n = 113) stated that the operation was adequately explained to them. Ninety percent (n = 111) reported full recovery after surgery, with 60% (n = 74) recovering within 6 months. Eighty-seven percent (n = 108) were satisfied with the overall experience, and 85% (n = 105) stated that they would recommend the operation to family and/or friends if required.ConclusionsThere is a lack of awareness regarding AAA in elderly population. However, after being diagnosed, patients understand the implications and are satisfied with the overall results and would recommend AAA repair to family and/or friends if required

Computerized dynamic posturography in the objective assessment of balance in patients with intermittent claudication

One-third of all elderly patients fall each year and impaired balance has been recognized as a specific risk factor. Intermittent claudication is common among the elderly population, affecting approximately 5% of the population over the age of 50. The aim of this proof-of-concept study was to assess the prevalence of impaired balance among elderly claudicants and to assess each patient's insight into their own risk of falling. A total of 58 claudicants (45 men), median age of 70 (interquartile range = 65-73) years, underwent objective balance assessment by using computerized dynamic posturography. As compared with 195 (5%) historic controls, 24 (41%) of the claudicants demonstrated abnormal balance when the Sensory Organization Test (SOT) was used. Vestibular dysfunction occurred in 52% of the claudicants. Abnormalities including somatosensory (22%), visual function (17%), and preferential reliance on inaccurate visual cues (17%) occurred less often. Prolonged Motor Control Test latency times were uncommon (n = 13) and were in most cases evenly distributed between those with normal (n= 7) and abnormal (n = 6) composite SOT scores. There was a significant difference in history of falling between claudicants with abnormal and normal SOT scores (p = 0.003), with a higher number of patients with abnormal SOT having experienced falling in the past year. However, no correlation between fear of falling and composite SOT score was found (Spearman rank correlation, r= 0.124; p = 0.381). Impaired balance, particularly secondary to vestibular problems, is very common among claudicants and may predispose to a high incidence of falls. Claudicants with abnormal balance are more likely to have a history of falls but not a fear of falling, thus potentially rendering these patients to be at a greater risk

An analysis of relationship between quality of life indices and clinical improvement following intervention in patients with intermittent claudication due to femoropopliteal disease

Objectives: To establish the relationship between quality of life (QOL) index scores and clinical indicators of lower limb ischemia. Methods: One hundred seventy-eight patients (108 men, median age 70 years) with femoropopliteal lesions suitable for angioplasty were recruited. Assessments were performed prior to and at 1, 3, 6, and 12 months following intervention (angioplasty and/or supervised exercise program). Clinical indicators of lower limb ischemia (treadmill walking distances, ankle pressures), generic (SF36, EuroQol), and disease-specific (Kings College VascuQol) quality of life questionnaires were analyzed. Correlation analysis was performed for index scores (SF-6D, EQ-5D, VascuQol) and individual domain scores using nonparametric tests. Results: All clinical indicators of lower limb ischemia and quality of life index scores showed a statistically significant improvement as result of intervention (Friedman test, P < .001). Both generic QOL index scores (SF-6D, EQ-5D) showed moderate but statistically significant correlation (Spearman’s rank correlation, P < .001) with treadmill walking distances (SF-6D r � 0.533, EQ-5D r�0.500) and weak but significant correlation to resting and postexercise ankle-brachial pressure index (SF-6D r�0.253, EuroQol r � 0.214). Disease-specific index scores (VascuQol) showed similar moderate correlation to treadmill walking distances (r � 0.584, P < .001) and weak but statistically significant correlation with resting and postexercise ABPI (r � 0.377, P < .001). All index scores showed strong and statistically significant (P<.001) correlation with patient-reported walking distance (SF-6D r� 0.604, EQ-5D r � 0.511, VascuQol r � 0.769). All domains of SF36 showed similar correlation with clinical indicators except general health. The strongest correlation was seen with treadmill walking distances in the domains of physical function (r�0.538) and bodily pain (r � 0.524). Conclusion: All generic and disease-specific QOL scores show statistically significant improvement with angioplasty and/or supervised exercise in patients with claudication due to femoropopliteal atherosclerosis. However, the degree of improvement seen in clinical indicators of lower limb ischemia is not reflected in these scores. These findings support the use of composite outcome measures with mandatory, independent assessment of QOL as an independent outcome measure in intervention studies in these patients