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12 Articles in Volume 17, Issue #2
Chronic Pain and Bipolar Disorders: A Bridge Between Depression and Schizophrenia Spectrum
Differences in Pain Management of Peripheral Vascular Disease and Peripheral Artery Disease
Duloxetine and Liver Function Tests
How Well Do You Know Your Patient?
Insurers End Policies Requiring Prior Authorization for Opioid Use Disorder
Letters to the Editor: Initiating Hormones
Managing Opioid Use Disorders and Chronic Pain
Opportunities and Challenges of Pain Management: The Family Physician’s Perspective
Pathways to Recovery From Co-Occurring Chronic Pain and Addiction
Strategies for Weaning Opioids in Patients With an Opioid Use Disorder and Chronic Pain
Treating Multiple Pain Syndromes: A Case Series Using a Functional Medicine Model
Treatment of Chronic Exhaustion and Chronic Fatigue Syndrome

Differences in Pain Management of Peripheral Vascular Disease and Peripheral Artery Disease

When diagnosing peripheral artery disease, a common condition in people with diabetes, leg pain may arise from intermittent claudication and ischemia.
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Peripheral vascular disease (PVD) is a term that applies to a variety of vessel-occlusive conditions, which may develop within either the arterial or venous systems. When PVD develops, the condition is often seen concurrently with coronary artery disease, diabetes, and hypertension.1 However, PVD may arise from vasculitides (inflammation of multiple vasculitis) and other venous problems such as chronic venous insufficiency.

According to the American Heart Association, PVD is divided into 2 categories: organic and functional.2 Organic PVD is related to vessel blockage arising from inflammation, fatty infiltrates, or tissue damage. Functional PVD, which is not connected to structural problems within blood-vessel walls, arises from vessel compression or spasm. While PVD and peripheral artery disease (PAD) typically are used interchangeably, PAD has been classified as a subset of organic PVD.3

Diagnosing leg pain as peripheral artery disease in people with diabetes.

PAD is among the most common cardiovascular diseases, affecting more than 12 million men and women.4 As many as 1 in every 20 adults over the age of 50 years, and 1 in every 4 adults over the age of 70 years are likely to develop PAD. In addition to age, the risk of developing this condition rises in individuals who have diabetes, a history of current or past smoking, and the presence of other cardiovascular risk factors such as hypertension.

Development of PAD involves any artery except those supplying the heart directly. The term PAD broadly covers the vascular diseases, in which thromboembolic and atherosclerosis pathophysiologic processes occur, introducing changes to the normal function and structure of the aorta and its visceral arterial branches. Usually, PAD is indicative of a condition involving the main artery that supplies blood to the legs. Lower extremity PAD, or PVD, typically is caused by atherosclerosis due to obstruction of the internal lining of a blood vessel and leads to poor skin, limb, and muscle perfusion.5

PVD, or arteriosclerosis obliterans, is a condition manifesting from insufficient tissue perfusion that results in hardening of the arteries. When muscles fail to get sufficient nutrients and oxygen during exercise, a cramping discomfort referred to as claudication is likely to occur. This symptom may be referred to as intermittent claudication because the pain has a tendency to dissipate with rest. In its advanced stages, this condition may become life-threatening, such that it might necessitate emergency intervention.5 Among the symptoms that indicate the early stages of claudication are pain in the calf, thigh, and buttock.6 With these symptoms, ascertaining the onset of the disorder requires an ankle-arm index, imaging, or segmental blood procedures.6 The choice of procedure is dependent upon the symptoms evident.

Symptomatic PAD occurs in response to an imbalance in the nutrients available to skeletal muscles and an inability to meet the physiological demand for these substances. The normal nutrient balance is naturally lost in PAD once arterial stenosis occurs, leading to insufficient blood flow to the skeletal muscle. When the vessel lumen narrows, there is a pressure gradient that grows across the stenotic lesion, which is proportional to blood viscosity as well as the extent of stenosis. A stenosis that does not result in pressure gradient at rest, might cause a gradient when another stenosis develops during exercise. In a healthy person, a rise in cardiac output, as well as a decrease in regular vascular resistance is adequate to boost blood flow to skeletal muscles, which will recompensate for the increased demand. Nevertheless, an arterial stenosis, that is not apparent at rest, might become evident during exercise if augmented peripheral muscle demands do not match the augmented flow.  

It is easy to see how muscle discomfort, fatigue, and pain manifest as the primary symptoms of PAD. Having this condition will most likely result in blocked arteries. Usually, PAD is an indication that there are atherosclerotic changes elsewhere in the body, which may include the heart, brain, or kidneys. Patients with this condition have an increased risk of mortality, stroke, and myocardial infarction.7 For clinicians, the challenge in making a diagnosis is that most individuals may be asymptomatic.

Making a Differential Diagnosis of Leg Pain

The patient who presents with complaints of pain in the calves after exercising is likely to have advanced PAD. The calf muscles are usually the most common site for claudication, although it can also take place in the buttock or thigh muscles if there is sufficient proximal blockage. During exercise, a buildup of lactic acid may occur because of anaerobic respiration in which the oxygen demand is not fulfilled because of arterial blockage, initiating pain. Normally, this pain would dissipate in less than 5 minutes once the patient discontinues the exercise and returns to rest, only to return again when the patient begins to move again.

Making a differential diagnosis of PAD would require evaluating the leg for both musculoskeletal and neurological factors. The best way to achieve this is by making use of standardized monofilaments to assess light touch sensation.8 It is common for symptoms to be confused with those of spinal stenosis, but this pain most commonly radiates down both legs rather than just affecting 1 leg. In the case of spinal-cord claudication, the pain is localized to a specific muscle group, and upon walking there tends to be a history of recurring numbness, weakness, or heaviness instead of pain.6 In addition, clinicians will want to rule out other conditions with similar complaints of pain, including peripheral neuropathy, systemic vasculitides, and restless leg syndrome.  

Last updated on: March 17, 2017

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