Lower limb ischaemia in patients with diabetic foot ulcers and gangrene: recognition, anatomic patterns and revascularization strategies.

The confluence of several chronic conditions--in particular ageing, peripheral artery disease, diabetes, and chronic kidney disease--has created a global wave of lower limbs at risk for major amputation. While frequently asymptomatic or not lifestyle limiting, at least 1% of the population has peripheral artery disease of sufficient severity to be limb threatening. To avoid the critical error of failing to diagnose ischaemia, all patients with diabetic foot ulcers and gangrene should routinely undergo physiologic evaluation of foot perfusion. Ankle brachial index is useful when measurable, but may be falsely elevated or not obtainable in as many as 30% of patients with diabetic foot ulcers primarily because of medial calcinosis. Toe pressures and skin perfusion pressures are applicable to such patients.

[Physical activity and peripheral arterial obstructive disease]. / Exercice physique et artériopathie oblitérante des membres inférieurs.

Intermittent claudication (IC) is the most common clinical manifestation of atherosclerotic peripheral arterial disease. Exercise training plays a major role in treating patients with IC. Regular exercise increases functional walking capacity, reduces cardiovascular mortality and improves quality of life. This seems to be achieved by: favorable effect on cardiovascular risk factors, anti-inflammatory effect, increased collateral blood flux, improved rheology profile, endothelial function, fibrinolysis, and muscular metabolism. However, exact mechanisms underlying beneficial effect of exercise remain largely unknown. Exercise modalities will be discussed in this article.

[Current state-of-the-art of rehabilitative treatment of chronic obliterative arterial diseases of the lower extremities].

Up-to-date approaches and methods for balneotherapy of chronic obliterative arterial diseases of the lower extremities are discussed with special reference to their confirmed clinical efficiency. The necessity of differential application of physical agents to the treatment and rehabilitation of the patients with these diseases is substantiated.

Changes in the activities of daily living (ADL) in relation to the level of amputation of patients undergoing lower extremity amputation for arteriosclerosis obliterans (ASO).

BACKGROUND: The relationship between the level of amputation and the activities of daily living (ADL) in Japanese patients with arteriosclerosis obliterans (ASO) is unclear. METHODS AND RESULTS: In the present study 81 patients with ASO who underwent lower extremity amputation and were discharged from hospital after rehabilitation we evaluated. The patients were classified into 4 groups: toe amputation group (Toe), heel-preserving amputation group (Heel), below-knee amputation group (BK), and above-knee amputation group (AK). ADL at discharge and factors affecting the length of hospitalization were determined. Patients were walking at discharge in 94.5%, 94.0%, 59.0%, and 0.0% of the Toe, the Heel, BK, and AK group, respectively. However, the ratio of patients able to walk independently was 68% in the Toe group and 19% in the Heel group. In addition, the length of hospital stay was significant shorter in the Toe group than in the other groups. Factors affecting the length of hospital stay were the amputation level, cerebrovascular disease, reoperation, and diabetes. CONCLUSIONS: ADL are less affected and the length of hospital stay is shorter for patients undergoing toe amputation than other levels of lower extremity amputation. However, heel-preserving amputation maintains a comparable level of ADL in terms of ambulatory discharge.

[Study and evaluation of patients with obliterating arteriopathy of the lower limbs: use of isokinetics to analyze muscular strength and fatigue]. / Evaluation par isocinétisme de la force et de la fatigabilité musculaire chez les patients porteurs d'artériopathie oblitérante des membres inférieurs.

OBJECTIVES: The aim of the study was to evaluate strength of the dorsal and plantar flexors in patients with obliterating arteriopathy of the lower limbs (stage 2) and to evaluate fatigue. POPULATION AND METHODS: The comparison was based on two groups of ten patients: one with obliterating arteriopathy, and the second with healthy limbs as a control group. Each group of patients underwent bilateral plantar flexion and dorsiflexion of the ankle on an isokinetic machine, with the following movements: three series of five movements at 120 degrees/s, then three series of three movements at 30 degrees/s in a concentric mode to evaluate strength. The exercise was repeated 20 times at 180 degrees/s to evaluate fatigue. The isokinetic parameters selected were the couple peak and ratio of workload to total weight of the patient. Tests controlled for cardiac frequency, as measured by electrocardiography, and blood pressure. RESULTS: Patients with obliterating arteriopathy of the lower limbs were generally weaker in global strength of plantar and dorsal flexors and had greater muscular fatigue than the control group (P < 0.05). CONCLUSION: Decreased performance in the leg muscles in patients with obliterating arteriopathy of the lower limbs is likely due to arterial deficit. Muscular metabolism anomalies such dysfunction of the terminal stages of the oxidative phosphorylation could also affect strength. Use of isokinetics represents an interesting possibility for treatment of patients with multiple cardiovascular abnormalities.

Indications for and limitations of exercise training in patients with intermittent claudication.

BACKGROUND: The selection of candidates for exercise training among patients with intermittent claudication is still a matter of debate. PATIENTS AND METHODS: Forty-nine patients with intermittent claudication due to arteriosclerosis obliterans were tested. Forty-six patients were men and 3 were women, with an average age of 65 years (range, 46 to 76 years). The patients walked on a treadmill at 2.4 km/h on a 12% upgrade followed by an appropriate period of rest for 30 minutes twice a day during a 3-week hospitalization. Programs were individualized for each patient. Four parameters were assessed after exercise training: (1) Ankle-brachial index (ABI) at rest, (2) Fall in ABI after 40 m of treadmill walking (ABI Fall 40), (3) the recovery time (RT 40) required for the ABI to return to resting levels after 40 m of walking, and (4) the maximal walking distance (MWD) on the treadmill. RESULTS: The average ABI at rest before the 3-week training period was 0.60 +/- 0.02 (mean +/- SE), and after training it was 0.62 +/- 0.02. There was a small although not statistically significant increase in the ABI after training. This increase in the ABI did not exceed 0.21. The average ABI Fall 40 before training was 0.36 +/- 0.01, and after training it was 0.30 +/- 0.02. The average RT 40 before training was 9.9 +/- 0.8 min, and after training it was 6.2 +/- 0.6 min. There were significant decreases in the ABI Fall 40 and RT 40 after training (p < 0.01 and p < 0.001, respectively). The MWD increased after training in 48 of the 49 patients. The average MWD increased from 134 +/- 13 m to 226 +/- 32 m after training (p < 0.001). The occlusion levels did not influence the results as training effects and hemodynamic parameters. Fourteen of 49 patients desired arterial reconstruction after exercise training. CONCLUSIONS: Patients with shorter RT 40's before training achieved greater increases in the MWD after training. In patients with an RT 40 under 12 min, exercise training is indicated. However, there is some discrepancy between the increase in MWD and the degree of satisfaction in individual patients.

[Experience in using hyperthermia in combination with the radon pool in the combined treatment of patients with arteriosclerosis obliterans at the Belokurikha health resort]. / Opyt primeneniia gipertermii v sochetanii s radonovym basseinom v kompleksnom lechenii bol'nykh obliteriruiushchim aterosklerozom na kurorte Belokurikha.

The patients with atherosclerosis obliterans of the peripheral arteries received sanatorium treatment at Belokurikha health resort. The treatment (thermoradonotherapy) involved hyperthermia in sauna combined with radon pool. The above combination turned out superior to conventional radonotherapy provided the procedures were well tolerated and no balneoreactions arose.

[The autotransfusion of ultraviolet-irradiated blood in the rehabilitation of patients with ischemic heart disease at a sanatorium]. / Autotransfuziia ul'trafioletovom obluchennoi krovi pri reabilitatsii bol'nykh ishemicheskoi bolezn'iu serdtsa v sanatorii.

Autotransfusion of blood exposed to UV irradiation proved highly effective in multimodality rehabilitation treatment of coronary patients with the disease functional classes II and III. Short-term and long-term results indicate a positive effect on hyperlipoproteinemia, hyperglycosuria, hemodynamics, exercise tolerance. The method is recommended for use in sanatoria and outpatient clinics.

[Criteria of rehabilitation of patients and invalids operated on for arteriosclerosis obliterans of the blood vessels of the legs]. / Kriterii reabilitatsii bol'nykh i invalidov, operirovannykh po povodu obliteriruiushchego ateroskleroza sosudov nizhnikh konechnostei.

A complex clinico-functional examination of 103 patients and invalids operated for obliterating atherosclerosis of the lower extremity vessels was carried out. Clinico-functional criteria for the assessment of the degree of chronic arterial insufficiency are proposed. The leading criterion of rehabilitation is found to be the degree of compensation of circulation. Complex application of the above methods in combination with clinical findings helps to make an objective assessment of the peripheral circulation state and of efficiency of the operation in remote periods of time.

[Unresolved problems of the medical rehabilitation of arteriosclerosis obliterans patients]. / Nereshennye voprosy meditsinskoi reabilitatsii bol'nykh obliteriruiushchim aterosklerozom.

Remote results of the treatment of 51 patients of creative age are followed. Of 47 patients alive till the end of the observation period, blood circulation was compensated in 41 patients. Complete rehabilitation was obtained in 51,1% of the patients and partial rehabilitation--in 14,9%. The criteria of estimation of the working capacity of the patients are presented.