3 Educational Expectations for this CEU article.
I . After finishing this article, the learner will be able to describe what PAD is.
2. After completing this article, the learner will be able to list 5 symptoms of claudication pain.
3. After completing this article, the learner will be able to summarize the focus of PAD Rehabilitation.

What is Peripheral Arterial Disease? PAD is an atherosclerotic process that causes gradual and progressive narrowing and sometimes-total occlusion of the arterial vessels. Many with PAD may remain asymptomatic for many years: others may more rapidly develop severe symptoms. The disease may deteriorate to a point where the limb has such poor blood supply that the leg or part of it may become ischemic.

The problem: Between 8 and 12 million Americans have PAD With up to 35% being asymptornatic. Too often, even mild claudication pain may be diagnosed as sciatica, arthritis, poor muscle strength or "just getting older."

Of the patients who are symptomatic, up to 80% are misdiagnosed even when exhibiting classic symptoms in the leg, thigh or buttocks: cramping pain, fatigue, burning, numbness, tightness or weakness.

Patients with even asymptomatic PAD are 5 to 7 times more likely to die from heart attack or stroke which is nearly equal for that of people who have already had a heart attack or stroke.

In 2001, a large study of PAD, called PARTNERS (PAD Awareness, Risk and Treatment) Medscape power point presentation regarding PARTNERS <http://www.medscape.com/viewarticle/424098_1> was published. 350 priniary care practices throughout the United States were involved with 6979 patients 70 years or older or 50 to 69 years of age with a history of smoking cigarettes or diabetes.

The results documented that PAD was detected in 29% (1865 patients) of all patients screened with about 16% of those patients having both PAD and CAD and 13% having PAD only. 24% (1527 patients) screened had CAD without evidence of PAD.

Another important finding of the study was that if a patient had known CAD, it was less likely that the diagnosis of PAD was a surprise. If the patient had PAD only, their diagnosis was less likely to be detected. Less than 50% of the physicians were aware of their patient's disease. Extrapolating the data further, the authors of the Study suggest that up to 75% of all people with PAD are not being treated.

Sharing the misconception that CAD affects mostly men, studies have shown that women share nearly equal diagnostic percentages as men. Studies do indicate that Blacks have a higher incidence of PAD than Caucasian, Hispanics and Asian.

Detection: As with CAD, symptoms of PAD are often the first reason that people seek help from their physician. Unfortunately, classic Claudication pain (angina of the lower limbs) manifests itself in only about 11% of all people with PAD. The entire limb, from the buttocks to the foot, may be affected by claudication. Most health care professionals recognize the classic complaints of pain, pressure, aching, cramping, fatigue, burning or weakness that occur from the buttock to the foot with exercise and dissipate with rest. Often overlooked are other symptoms of PAD: decreased warmth or color of the extremity; unequal hair distribution on legs, feet and toes; skin lesions; ulcers or wounds that do not heal; balance impairnent when standing on both feet: slow walking velocity: slower time to arise: low hip abduction force: poor leg strength: poor nail health or absence of a palpable pedal or posterior tibial pulse.
Confounding symptoms that may either mask or mimic claudication pain cause further complexity to a clear diagnosis: arthritis or injuries of the lower back, knees, hips, ankles, sciatica nerve problems, diabetic neuropathy, over-exertional muscular pain or other neurological problems can cause mis-diagnosis.

The Ankle Brachial Index: The most common and easiest to administer test for the detection of PAD is called the Ankle Brachial Index (ABI). Though easily done and at low cost, it is done by less than 8 % of primary care physicians. As 50 % to 65% of patients with PAD are initially asymptomatic, too often, the only clue to forging ahead with an ABI is a very thorough evaluation both, verbally and physically by the physician. When accurately performed, the ABI has a 90% sensitivity and 98% specificity for severity of PAD. Though the gold standard, there are limitations to the test. Failure to accurately administer the test is a main cause for faulty readings. Calcified arteries, found in elderly and diabetic patients may not be adequately compressible thus, preventing occlusion of the artery during the ABI.

The diagnosis of PAD is given when a patient had a ABI reading of <.90.

PAD and CAD Rehab- One in the Same?
Many similarities exist between the pathophysiology and the risk factors of PAD and CAD. Vessel narrowing by atherosclerotic disease creates similar occlusions of arteries with similar results. Smoking, diabetes, hyperlipidemia, hypertension, homocysteinemia, race and age are risk factors for both. Aggressive, multidisciplinary risk factor modification must be prescribed and supported by physicians and undertaken by patients with both diseases.

However, there is research that indicates a different approach for PAD Rehabilitation than what is done for Cardiac Rehabilitation.

The Focus of PAD Rehabilitation is predominately on a walking program. Following a brief warm up and stretching period, a sustained walking period of at least 30 minutes on a treadmill is prescribed. The initial settings for new patients should be based on their known limitations. The speed and elevation should be set to elicit claudication pain within the first five minutes. Patients are encouraged to walk to the point of moderately severe pain then pause until the pain subsides. When able, the patient returns to the treadmill and continues with the exercise, rest, exercise pattern for 30 minutes. If more than 5 minutes of rest is required for the pain to subside, the TM grade and speed should be reduced. When a patient is able to complete 30 minutes without stopping and with minimal pain, the grade and speed may be alternatively increased. With each increase of speed or grade, the patient should work up to his pain threshold, rest and return to walking. Specific realistic goals for each participant must be patient specific.

In addition to the walking portion of the PAD Rehabilitation process, other aerobic equipment and low-poundage weights should be employed for the benefit of a comprehensive exercise session. Stretching, balance enhancement and upper bodywork should not be ignored. However, studies have shown that resistive training does not directly improve claudication pain, while walking clearly has.

As with Cardiac Rehab, it is recommended that the exercise routine be carried out at least 5 days a week. Establishing a walking program in a supervised setting can be carried over to home programs. Patients must be aware of their responsibility for their own health.

Symptomatic Improvement: Exercise therapy has clearly shown an improvement of walking tolerance. Studies have shown improvement in claudication pain in as little as 4 weeks after the exercise program was initiated. An average increase of just under 180% was seen in initial walk to claudication pain. 122% improvement in maximal walk time was noted. Significant improvements in home walking, quality of life, activities of daily living and increased physical activity were also reported. The improvements were better than seen with just pharmaceutical administration and just as good, after 6 months for both surgery and percutaneous interventions.

The reasons for the improvements have little to do with any alteration in the arterial narrowing which defines the disease. Development of significant collateral circulation, often seen in the coronary artery system, is not seen to the same degree in the large peripheral arteries. Rarely, is an improvement noted in the ABI despite an improvement in functional capacity. The mechanisms for change are multi -factorial. Though studies are currently underway, exact mechanisms are still not fully understood.

Function does not necessary follow flow!

Summary: Though close cousins, PAD and CAD Rehabilitation have their own unique practices. Health care professionals may easily develop and monitor both programs, share common information with both groups and observe as patients in both groups make significant improvements in their daily life activities.

PAD Rehabilitation is challenging and important. As with PAD, PAD Rehabilitation is under-recognized and rarely offered. Cardiac Rehabilitation professionals are in a unique position to develop programs that will help patients with PAD to improve their health, reduce their risk of heart attack and stroke and assist physicians in providing optimal care for their patients.

Rehabilitation for Peripheral Arterial Disease Post- Test:

Write your answers on a piece of paper. Open your e-mail and send an e-mail message to Jane Hedgpeth CSCR Education Chairperson. jhedgpet_AT_pacbell_DOT_net Give her your name, title, e-mail address, license #, and phone #. Make a list 1-6 and indicate your answer to each question. Jane will e-mail your CEU certificate. This offer is free to CSCR members

1. The % of non-diagnosed PAD patients proposed to be in the United States.
A. 40%
B. 50%
C. 60%
D. 70%

2. Men with PAD outnumber women with PAD
True
False

3. The Ankle Brachial Index is done only by specialists.
True
False

4. The most common symptom of PAD is
A. Painful cramping when walking
B. Burning in the calf when walking
C. No pulses noted in the Dorsalis Pedis
D. No symptoms at all.

5. Which symptom is not consistent with the diagnosis of PAD
A. Cramping, burning in the leg with activity
B. Creaking / crackling of the knee with activity
C. Difficulty in maintaining balance while standing on both feet.
D. Shiny, smooth hairless leg with other leg appearing normal

6. The focus of PAD Rehabilitation is:
A. Improve the patient's ability to walk and function comfortably.
B. Improve the ABI results.
C. Increase the diameter of the large arterial vessels supplying the legs.
D. Prevent diabetes