| Intermittent claudication (Latin: claudicatio | | | | the symptoms will remain stable or improve. The |
| intermittens) is a clinical diagnosis given for muscle | | | | patients whose symptoms deteriorate tend to be |
| pain (ache, cramp, numbness or sense of fatigue), | | | | those who continue to smoke. |
| classically calf muscle, which occurs during | | | | Further improvements in walking can be made by |
| exercise and is relieved by a short period of rest. | | | | taking regular walks. This appears to develop |
| The term claudication comes from the Latin for | | | | fitness in the affected muscles (much as in an |
| 'to limp'. This is exactly what this condition forces | | | | athlete). A formal exercise programme can be a |
| someone to do: limp to a standstill. | | | | very effective way of improving walking distance. |
| People affected describe intermittent claudication | | | | Treatment-wise, the first step is to eliminate all |
| as an aching or cramping pain, accompanied by | | | | controllable risk factors; |
| tightness or fatigue in the leg muscles or buttocks. | | | | The major risk factors for intermittent |
| For some, this pain arises only during strenuous | | | | claudication include: diabetes, high cholesterol, |
| activity; for others, it comes on after walking a | | | | smoking, hypertension, lack of physical activity, |
| few metres. The key factor is that the pain | | | | high levels of a chemical called homocysteine , |
| stops within a few minutes of resting. | | | | family history of arterial disease. |
| Claudication affects those with peripheral arterial | | | | Without exception, numerous clinical studied have |
| disease (PAD), also known as peripheral vascular | | | | shown that exercise can prolong the pain-free |
| disease (PVD). In people with PAD the arteries of | | | | walking distance and total walking distance in |
| the extremities - the feet, legs, hands and arms - | | | | patients with intermittent claudication. Although |
| become hardened or furred up (a process called | | | | studies have demonstrated a wide range of |
| arteriosclerosis). This in turn obstructs blood flow. | | | | improvement (e.g. 88% to 190%), typically the |
| Peripheral arterial disease has, as its primary lesion, | | | | degree of improvement for pain-free walking |
| the same initial plaque which is responsible for | | | | distance is about 50% after 12 weeks and 100 % |
| other conditions associated with atherosclerosis, | | | | after 24 weeks. |
| e.g., coronary artery disease and cerebral vascular | | | | Despite the tremendous benefits of exercise in |
| insufficiency. In the lower limbs, the posterior tibial | | | | this condition, few physicians prescribe it. Walking |
| artery at the ankle and the anterior tibial artery at | | | | may be the best recommendations physicians can |
| its origin are the most commonly affected | | | | make to patients with peripheral arterial |
| arteries with atherosclerosis. | | | | insufficiency and intermittent claudication. Although |
| The arterial obstruction or narrowing causes a | | | | other activities have been recommended or |
| reduction in blood flow during exercise or at rest. | | | | incorporate into exercise programs for claudicants, |
| Clinical symptoms are caused by the consequent | | | | they have not been shown to produce the same |
| ischemia. The most common symptom of | | | | degree of benefits as walking. Strength training |
| peripheral arterial disease is a pain upon exertion - | | | | (weight lifting), bicycling, stair climbing, and other |
| intermittent claudication. The pain usually occurs in | | | | activities while beneficial for overall cardiovascular |
| the calf and is described as a cramp or tightness | | | | function do not appear to improve intermittent |
| or severe fatigue. The pain is usually bilateral. The | | | | claudication as well as a walking program. |
| cause of pain is not only reduced oxygen delivery, | | | | The optimal walking program should be |
| but also an increase in the production of toxic | | | | supervised, performed at least three times a |
| metabolites and cellular free radicals. These free | | | | week, and last a total of at least one hour. In a |
| radicals accumulate and react with the lipid | | | | supervised program, the patient typically walks on |
| constituents of the cell membrane. | | | | a treadmill at constant pace of about 1.5 to 2.0 |
| Pain at rest indicates serious reduction in resting | | | | miles per hour or a level just below the threshold |
| blood flow. It is obviously a sign of severe disease. | | | | of claudication. When pain occurs, the patient is |
| The pain may be localized to one or more toes, | | | | instructed to rest for a couple of minutes till the |
| or it may have a stocking-type distribution. The | | | | pain subsides and then resumes walking. |
| character of the pain is usually described as | | | | Patients can walk on-their-own, but according to |
| burning or gnawing and is generally worse at night. | | | | several trials appropriate steps to guarantee |
| Cyanosis or pallor of the extremity is usually | | | | patients compliance must be taken if unsupervised |
| apparent. In moderate to severe narrowing of the | | | | programs are to be successful. |
| artery, trophic changes occur, including dry, scaly, | | | | Pentoxifylline (trenal) has emerged as the "drug of |
| and shinny skin. The hair may disappear, and the | | | | choice" in the standard medical treatment of |
| toenails may become brittle, ridged, and | | | | intermittent claudication. Pentoxifylline was first |
| deformed. | | | | introduced in Germany twenty years ago. It is the |
| The standard medical approach to peripheral | | | | most thoroughly researched drug for intermittent |
| vascular disease and intermittent claudication | | | | claudication. A total of seventeen |
| includes avoidance to tobacco (which causes | | | | placebo-controlled trials could be retrieved from |
| vasoconstriction), a regular exercise program | | | | the world literature. The majority of these studies |
| consisting of walking, and/or a prescription for | | | | show that pentoxifylline will prolong the total and |
| pentoxifylline (Trenal). Surgery is also an | | | | pain-free walking distance in patients with |
| intermittent claudication need not take this risk. | | | | intermittent claudication. However, the level of |
| When walking/exercising, muscles demand more | | | | improvement (approximately 65% for pain-free |
| oxygen, when in fact in this cases less is | | | | walking distance) is less than that achieved with |
| distributed due to atherosclerosis restriction. | | | | exercise or with Ginkgo biloba extract. |
| Pain develops because there is a narrowing or | | | | Pentoxifylline is thought to work by reducing blood |
| blockage in the main artery taking blood to the leg | | | | viscosity: increasing the flexibility and distensibility |
| due to hardening of the arteries (atherosclerosis). | | | | of RBCs: and prevention of RBC and platelet |
| Over the years cholesterol and calcium build up | | | | aggregation. |
| inside the arteries. This occurs much earlier in | | | | Pentoxifyllline, in general is fairly well tolerated with |
| people who smoke and those who have diabetes | | | | the timed-released tablet being much better than |
| or high levels of cholesterol in the blood. | | | | the immediate release capsule. Minor side effects |
| The blockage in the arteries means that the blood | | | | include drowsiness, headache, dizziness, and |
| flow is reduced. At rest there is enough oxygen in | | | | gastrointestinal irritation. However, there are some |
| the blood reaching the muscles to prevent any | | | | major cautions with pentoxifylline. |
| symptoms. When walking the calf muscles need | | | | The natural choice and successful alternative is |
| more oxygen, but because the blood flow is | | | | Gingko biloba extract. |
| restricted the muscles cannot obtain enough | | | | The Gingko biloba extract (GBE) standardized to |
| oxygen from the blood and cramp occurs. This is | | | | contain 24% ginkoflavonglycosides may be the |
| made better by resting for a few minutes. If | | | | most important plant medicine in the world. GBE is |
| greater demands are made on the muscles, such | | | | now among the leading prescription medicines in |
| as walking uphill, the pain comes on more quickly. | | | | both Germany and France. The extracts account |
| Many patients also notice that if they are carrying | | | | for 1.0% and 1.5% of total prescription sales in |
| heavy bags the pain comes on sooner because | | | | Germany and France respectively. Although GBE |
| the leg muscles are having to work harder. | | | | has been most extensively studied and utilized in |
| In some patients the blood flow to the legs can | | | | the treatment of cerebral vascular insufficiency, it |
| be so restricted that there is barely sufficient | | | | is also of significant benefit in the treatment of |
| oxygen reaching the tissues even while resting. In | | | | peripheral vascular insufficiency. |
| these patients severe pain can develop particularly | | | | GBE has been extensively studied as it has been |
| at night and it is only eased when the leg is | | | | the subject of over 300 scientific papers. GBE |
| dangled down over the edge of the bed. When | | | | exerts profound, widespread tissue effects |
| this happens and tests show reduced blood flow, | | | | including membrane stabilizing, antioxidants, and |
| then critical limb ischaemia has developed and the | | | | free radical scavenging effects. Its vascular |
| leg is at risk of amputation. | | | | effects are primarily a result of direct stimulation |
| The blockages in the arteries never re-open | | | | of the release of endothelium-derived relaxing |
| spontaneously. Fortunately, the blockages | | | | factor (EDRF) and prostacyclin. In addition, GBE |
| themselves are not dangerous. It is only the | | | | inhibits enzymes in a way that leads to smooth |
| symptoms they cause that are important. Many | | | | muscle cell relaxation in the wall of the vessel. |
| people live for many years with blockages in the | | | | GBE also exerts a beneficial effect on platelet |
| arteries that never cause any serious problems. | | | | function including inhibition of platelet aggregation, |
| Often when patients develop claudication their | | | | adhesion, and degranulation. |
| symptoms can be worse in the first few months. | | | | GBE is extremely safe and side effects are |
| This is because it takes time for the body to | | | | uncommon. In 44 double-blind studies involving |
| adjust to the restricted blood flow. After 2-3 | | | | 9,772 patients taking GBE, the number of the side |
| months the situation can improve due to smaller | | | | effects was extremely small. The most common |
| arteries opening up (collateral circulation) and | | | | side effect, gastrointestinal discomfort occurred in |
| carrying more blood around any blockages. | | | | only 21 cases, followed by headache (seven |
| Smaller blood vessels, although not the major | | | | cases) and dizziness (six cases). |
| blood vessels to the leg, usually carry enough | | | | In this case, the natural choice is safer, effective |
| blood to prevent severe disability. Overall about | | | | and cheaper. Since pain is the greatest motivator, |
| one third of patients with claudication will improve, | | | | you should realize your body is telling you to take |
| one third will remain stable and one third will | | | | better care of yourself: it could also be a sign of |
| deteriorate. In the majority of patients (>65%) | | | | developing cardiovascular disease. |