© Borgis - New Medicine 3/2013, s. 71-77
*Urszula E. Ulmer1, Leszek Czerwosz2, Rafał Ł. Leszcz1, Michał Bielwaski1, Maria M. Grochowska1, Katarzyna Wilczyńska1, Paweł Białek1, Robert Proczka1, Paweł Nitkowski1, Jerzy A. Polański1
Influence of surgical endarterectomy in the femoral-popliteal segment on gait pattern in a patient with peripheral arterial disease
1II-nd Department of General, Vascular and Oncological Surgery of Medical University of Warsaw
Head of Department: prof. Jerzy A. Polański, MD, PhD
2Bioinformatics Laboratory, Mossakowski Research Medical Centre, Polish Academy of Sciences,
Head of Laboratory: prof. Bogdan Lesyng
Aim. The aim of this study was to determine if surgical endarterectomy of the arteries of the lower limb affects in any way the gait pattern in patients diagnosed with PAD and if in a remote postoperative day, can be established improvement of the patient’s gait parameters relative to the values obtained in the test before surgery. The third objective was the verification of the suitability of the measurement method by measuring the gait parameters in a relatively small stretch, with the aid of the measuring system Ultraflex Computer Dyno Graphy (CDG) from Infotronic Medical Engineering (12).
Material and methods. In the study participated PAD 20 patients and 17 controls. Each patient was subjected to a surgical endarterectomy. Measurements of gait were performed in each patient three times: I one day before the endarterectomy procedure, II 1-3 days after surgery, and III 6 weeks later.
Results. Gait speed was lower in patients than in the control group by more than 1 km/h. In PAD patients, gait speed in series III was higher then speed in series II and very similar to series I. Mean cycle and mean frequency did not differ among series I, II, and III in patients, but there were a significant differences from control values – in patients cycle was longer and frequency smaller. Comparative analysis of three series showed no severe changes of speed or single or double support duration. The results of comparisons of single and double support times, calculated as percentage with respect to the duration of gait cycle, indicate however, that patients avoid single support in favour of double support. Gait measured in series II manifested an increased heterogeneity (inequality of steps) in relation to the other two series in PAD patients.
Conclusions. The performed study demonstrates that surgical endarterectomy procedure in the femoro-popliteal segment affected the PAD patient’s gait pattern, especially in the early days after surgery.
Peripheral arterial disease (PAD) is the artherosclerotic process, especially the lower limb arteries.
Anatomically, only about 30% of atherosclerotic lesions in the lower extremities concern iliac arteries. But as many as 70% of lesions are found within the vessels of femoro-popliteal and tibial segments (1).
PAD is found in almost 10% of people around the world (2), and PAD patients have a high risk factors of death from cardiovascular causes (3).
As the risk factors of the occurrence of PAD are recognized:
– Tobacco smoking. Most of the PAD patients (85-95%) are the current or former smokers (4),
– Lack of physical activity,
– Age, gender, ethnicity.
Men aged: 33-44 years old – an average of 6 PAD cases per 10,000 examined persons, 65-74 years old 61/10,000. Women aged 33-44 years old – 3/10,000, in 65-74 – 54/10,000 (5). The incidence of PAD depending on gender corresponds to the ratio 2:1 (male:female), whereas the incidence of critical limb ischemia is the ratio 3:1 (male:female). The studies also demonstrate that in terms of ethnicity, a black race bears the highest risk of PAD occurrence (6).
Intermittent claudication, rest pain and ulceration of the skin are the set of the most common symptoms of PAD. Generally accepted PAD classifications are based on two scales: Fontaine and Rutherford (7) (tab. 1, 2).
Table 1. Rutherford scale.
|II||4||Ischaemic rest pain|
|III||5||Small tissue defects|
|III||6||Large tissue defects|
Table 2. Fontaine scale.
|III||Ischaemic rest pain|
The types of surgical methods for endarterectomy of the femoral-popliteal segment
The primary purpose of each treatment of PAD is to minimize the risk of limb loss and reduce the symptoms associated with the presence of the disease, significantly impairing the quality of patient’s life (1).
Surgical treatments of peripheral ischemia, have long been the gold standard of treatment when symptoms cannot be controlled by diminishing the risk factors, physical therapy, or pharmacotherapy.
In the femoro-popliteal segment, the following treatment’s methods are used:
– PTA (percutaneous balloon angioplasty),
– stent implantation,
– laser endarterectomy.
A combination of these methods for the purposes of one procedure is also possible.
Another type of providing of the occlusion of the femoro-popliteal area is the procedure of implantation of femoro-popliteal bypass; from native vein, as well as artificial (7).
Intermittent claudication as the main symptom of PAD
Intermittent claudication as the primary symptom of peripheral arterial disease, is described as discomfort or pain in the lower extremities, thighs or buttocks, emerging during walking or other physical activity, and decreasing during the rest (2).
Statistically, the most common location of pain resulting from claudication caused by occlusion of superficial femoral artery are calf muscles.
Disorders of flow within the iliac, common femoral, tibial or peroneal artery result in pain around the buttocks, thighs, or feet.
The presence of symptoms of pain in both extremities, may indicate a disturbance in the flow within the aorta, iliac arteries on both sides or the non-vascular nature of the disease (8).
The majority of patients with intermittent claudication presents a stable course of PAD throughout life and in these patients is found ailments reduction as a result of the elimination of risk factors for PAD. 20-30% of patients are subjected to surgical treatment of arterial endarterectomy due to the deterioration of symptoms (9).
Intermittent claudication as a factor affecting the quality of gait
Intermittent claudication, defined as lower limbs pain emerging during gait and forcing the patient to stop and rest, is considered a classic symptom of peripheral arterial disease (10).
Quality of life in PAD patients who have intermittent claudication is deteriorating in many aspects. The pain resulting from claudication significantly effects on the degree of their independence – PAD patients have a higher susceptibility to fatigue as a result of reduced locomotion, they have difficulty in performing activities of daily living (11).
Purpose of the pilot study
To the II-nd Department of General, Vascular and Oncological Surgry of Medical University of Warsaw, per year are admitted about 400 patients with diagnosed peripheral arterial disease, in order to carry the procedure of endarterectomy of arteries of the lower limb. On average, 250 of the patients in this group are subjected to endarterectomy procedure in the femoro-popliteal region.
The objectives of this study is to determine:
1. If surgical endarterectomy of the arteries of the lower limb affects in any way the gait pattern in patients diagnosed with PAD.
2. If in a remote postoperative day, i.e. min 6 weeks after treatment, can be established improvement of the patient’s gait parameters relative to the values obtained in the test before surgery and thus recognize that the endarterectomy surgical procedure may significantly affect the quality improvement of the PAD patient’s gait
3. Verification of the suitability of the measurement method by measuring the gait parameters in a relatively small stretch, with the aid of the measuring system Ultraflex Computer Dyno Graphy (CDG) from Infotronic Medical Engineering (12).
MATERIAL AND METHODS
The research material
In the study participated 20 patients with diagnosed peripheral arterial disease (5 women, 15 men) and 17 healthy people as a control group. The average age of PAD patients participating in the study is 70 years old, the age range was 56-85 y.o. Each participating in the experiment patient was subjected to a surgical endarterectomy in the femoro-popliteal segment, of which nine treatments were related to endarterectomy in the right lower limb, and 11 in the left lower limb. PAD patients were admitted to the ward of II Department of General, Vascular and Oncological Surgery of Medical University in Warsaw in the period from VII.2011 to II.2012, in order to perform the endarterectomy procedure in the femoral-popliteal segment.
Into the study were enrolled PAD patients who have:
– A history of the occurrence of intermittent claudication;
– Ankle-brachial index did not exceed the value of 0.6;
– Occlusion of the carotid arteries on ultrasound did not exceed 4%;
– Occlusion of the lower limbs has been confirmed in angioTK study.
Measurement of the walking pattern and the gait analysis of each patient was performed by means of the CDG measurement system. Values and distribution of ground reaction forces were measured by means of eight tensometers embedded in each sole of measurement shoes.
The gait analysis was performed according to the method described in the Whittle’s book (13) „Gait Analysis: an Introduction” Whittle Michael, 2007, Butterworth-Heinemann. The author gives the gait structure in form of gait phases, which detection and the measurement provide parameters for gait evaluation Thus, main parameters are: duration of the support, including single and double support. The schedule is demonstrated on the figure 1 according to that described by Whittle.
Fig. 1. Gait phases (adapted from 13).
Method of measurement
In each patient qualified for the study three-fold measurement of gait were performed. All measurements were carried out within specified periods of time:
– I series – the day before the endarterectomy procedure,
– II series – 1-3 days after the endarterectomy procedure,
– III series – 6 weeks after the endarterectomy procedure.
In the control group only one measurement of gait was performed.
Each person taking part in the study walked distance of 24 meters, at a rate appropriate for his daily walk. Such a short distance was established for purpose for this study, so that no intermittent claudication in the patients occurred during the measurement , which could result in significant impairment of gait or stopping.
The essence of this study was in fact to determine, not a direct effect of claudication on patients’ gait, but the indirect effects in the form of gait adaptation to the current state of the disease and developing particular gait pattern, designed to minimize the risk of claudication during walking.
The following parameters of gait were subjected to the analysis of each measurement:
– walking speed (in km/h), the duration of the gait cycle (full cycle with both legs),
– the frequency of walking (in min-1),
– average time of single support and its standard deviation – heterogeneity (in seconds),average time of double-support and its standard deviation – heterogeneity (in seconds).
To avoid the ambiguity of application of the term standard deviation, two parameters require a comment: the standard deviation of times of a single and a double support.
An average value of single – or double-support time was calculated for each individual measurement within a set of steps that patient performed in while measuring. Within this set the standard deviation of a single or double-support time was also calculated. Average values represent approximately the typical times for a given set of steps, and standard deviations express their distribution, that is the heterogeneity of steps.
The standard deviation of a single-or double-support times calculated within a set of steps was then, as well as other parameters, averaged for group of patients. In the calculation appears therefore the standard deviation (within a set of measurements) of the standard deviation (within a set of steps for each measurement). For convenience, the standard deviation of times of a single/double support within a set of steps is referred to as, for the purposes of this study, the heterogeneity of time of a single/double support.
Velocity, cycle and frequency
As you can see from the table 3, gait speed was lower in patients than in the control group by more than 1 km/h, which is about 25%. All differences between measurements in patients (series: I, II, and III) and the measurements in the control group were statistically significant (p < 0.0001). If taking into account the comparison of successive series I, II and III in PAD patients, the gait speed in the III series differed from the speed obtained in the II series statistically significant (p < 0.01). Series I exhibited velocity similar to III, and yet, difference between series I and II was not statistically significant. Scattering the measurements of series I was, however, greater than of series III.
Table 3. Average values of parameters together with respective standard deviations of velocity, cycle time and frequency of gait in three consecutive measurements in the PAD patients, and the results for the same parameters acquired by control group.
| ||Velocity |
|Series I||3.5 ± 0.90||1.21 ± 0.20||101.2 ± 15.6|
|Series II ||3.18 ± 0.86||1.26 ± 0.21||97.6 ± 15.1|
|Series III ||3.63 ± 0.71||1.20 ± 0.17||101.4 ± 12.6|
|Control Group||5.13 ± 0.50||1.06 ± 0.07||114.4 ± 7.6|
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