Stepping up treatments for PAD

Proven therapies for this painful leg problem should soon be more accessible.

Published: March, 2018

Image: © stevecoleimages/Getty Images

When fatty deposits clog the arteries that supply blood to the legs, even a short walk can cause leg cramping and pain. This condition, called claudication, comes from the Latin word claudicatio, meaning "to limp." It's the hallmark of peripheral artery disease, or PAD, which affects roughly one in seven people over the age of 60.

People with PAD are also likely to have clogged arteries (atherosclerosis) in the heart. In fact, they may be even more prone to heart attacks and strokes than people with heart disease who have already had one of those problems.

"PAD is a particularly dangerous form of atherosclerosis," says Dr. Marc Bonaca, a vascular specialist at Harvard-affiliated Brigham and Women's Hospital. Doctors don't routinely screen people for PAD, but the test is easy and harmless (see "Detecting PAD"). Dr. Bonaca encourages people with risk factors for atherosclerosis, such as smoking, diabetes, and high blood pressure, to get screened for PAD — especially if they have leg pain when walking. The pain usually occurs in the calf but may also arise in the thighs or buttocks.

Detecting PAD

Illustration by Scott Leighton

A test called the ankle-brachial index can diagnose PAD. Using a special cuff, the doctor measures the blood pressure in your ankles and compares it with the blood pressure reading in your arms, at rest and sometimes after a brief period of exercise. When your blood vessels are healthy, the readings should closely match. A big difference between the arm and the ankle signals that blood isn't moving well through clogged vessels in your lower body.

Improved access to treatment

One of the most effective therapies for leg pain due to PAD — an approach called supervised exercise training — should soon become more widely available and affordable. Thanks to a policy approved last year, Medicare will now cover supervised exercise training for PAD, and other insurance companies will likely follow suit.

The therapy, which requires a doctor's referral, also includes counseling about healthy lifestyle habits. But the main focus is on the exercise, which is typically done on a treadmill with coaching from an exercise therapist.

Meeting with a trained therapist to exercise several times a week tends to be more effective than home exercise because people are more motivated and tend to work harder, says Dr. Bonaca. Medicare will cover up to 36 sessions of 30 to 60 minutes each over a 12-week period, with the possibility of approval for an additional 36 sessions over time.

Ask your doctor if you qualify for supervised exercise therapy, and get a referral. Academic medical centers with cardiac rehabilitation programs are likely your best bet. Attending one of these supervised programs may offer added advantages, such as better care coordination for drug therapy. This often includes cholesterol-lowering statins and aspirin. Recent research suggests that for some people with PAD, more potent therapies to lower cholesterol and prevent blood clots may be appropriate.

No pain, no gain?

Many people with PAD avoid walking, believing their leg pain is harmful. But the opposite is actually true, says Dr. Bonaca. "If you feel pain when you walk, you should rest, then walk again. You're helping — not hurting — yourself." The benefits people experience are likely due in part to a phenomenon known as ischemic preconditioning.

If you don't have access to supervised exercise training, start a home-based walking program with advice from your doctor. Most advise people to walk daily (even for just 10 minutes) and increase the duration gradually. When you feel discomfort, stop and rest for a few minutes, then resume walking. Your symptoms should improve over time, allowing you to walk farther and longer. As walking becomes easier, gradually increase the duration by five-minute increments until you have built up to 45 minutes. Consistency is important, because if you stop your routine, much of the benefit may disappear.

Although walking outside in a park or other natural setting may be appealing, you might want to walk in your local shopping mall (especially if the weather's bad) or another shopping area. In Italy, says Dr. Bonaca, doctors refer to PAD as "the window disease," because people with the disease who walk in towns or cities stop and look at store windows when their legs start to hurt.

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