No Pain, No Gain for Clogged Leg Arteries
WASHINGTON — For some exercisers, pain can lead to gain--but then, paradoxically, to less pain.
Many people with intermittent claudication, a form of arterial disease characterized by leg pains and weakness triggered by walking, can improve their ability to walk pain-free if they take part in a walking program, experts say. The catch is that the program makes them walk until they hurt.
“What I tell my patients is to try for four or five times a week to the point of pain--and a little farther--but stop before it gets excruciating,” said Dr. David L. Dawson, an Air Force lieutenant colonel who is an associate professor of surgery at the Uniformed Services University of the Health Sciences in Bethesda, Md.
Intermittent claudication is more than simply a debilitating condition, however. Clogs in the leg arteries are considered warning signs that the patient may have coronary artery disease as well, Dawson said. Up to 40% of patients with intermittent claudication are dead within five years, mostly from heart attacks and stroke, he said.
Intermittent claudication becomes more common as people grow old. And most patients with the condition don’t seek treatment, believing the pain and weakness to be just signs of aging, Dawson said.
Doctors tend to pay little attention to the claudication itself, focusing on the more severe problems underlying the leg pains, he said. Symptoms of intermittent claudication often do not worsen over time.
Intermittent claudication does not show itself when a person is inactive. But the condition can make it painful to walk a block, or even a half block, without resting. The ailment can interfere with activities of ordinary living, such as walking the aisles of a supermarket.
‘It’s like having a plugged fuel line in a car,” Dawson said. “You can idle OK, but when you step on the gas, it sputters and stalls.”
Clogs in the arteries reduce the ability of oxygen-carrying red blood cells to move to muscle cells. Exercise makes muscles more efficient in using the oxygen they can get.
Dawson is coauthor of an article in the journal Pharmacy and Therapeutics, which recommends exercise and drugs as a first-line therapy before doctors consider medical procedures to widen or replace damaged blood vessels. In the treatment options outlined in the paper, only patients with pain at rest--a sign of extensive artery problems--would be referred directly to a vascular surgeon.
Vascular surgeons also see the value of trying exercise first. A treadmill program can double or triple the time or distance a patient can walk, said Dr. William R. Hiatt of the University of Colorado Health Sciences Center in Denver.
An intermittent claudication patient may start the course of treatment at a very slow pace of 1 mile per hour, and wind up as fast as 3 miles an hour, which would count as a minimum brisk walk for a healthy person, Hiatt said.
The training program requires working into the point of pain and resting, repetitively, for up to 50 minutes. In his studies, 90% of people who start a three-month program stay with it until the end, Hiatt said. Others in less well monitored programs would probably do less well, he said.
Exercise has to be part of a monitored program, Hiatt said. “If you just tell a patient to go out and walk, it doesn’t happen,” he said. The pain puts off the unsupervised patients, he said.
Drugs can also fight intermittent claudication. Dawson and other researchers found that patients given a new drug, Pletal, increased their pain-free walking distance by 58%.
The drug seems to help the arteries widen, he said. “But it doesn’t work for everybody--probably about half--and it takes weeks to months for the effect to be seen,” he said.
More aggressive treatments than exercise have their place, said Dr. Gary J. Becker, assistant medical director for the Miami Cardiac and Vascular Institute.
“Intermittent claudication, when it is early and mild, tends to respond nicely to a monitored exercise program,” Becker said. As with other peripheral vascular problems, the patients also have to not smoke, and to control their cholesterol and blood pressure, he said.
Medical procedures are a logical next step for those in whom lifestyle changes have not worked and who still want active lives, such as letter carriers whose jobs depend on walking or exercisers who want to continue their sports, Becker said.
One option is a balloon angioplasty, in which a tiny balloon is threaded through an artery and expanded. Another is an artery bypass operation. But Becker said people who won’t give up smoking, for example, are not good candidates for these more aggressive treatments.
