Low Back Pain and Somatic Referred Pain Concomitant with Intermittent Claudication in a Chiropractic Practice
The patient is a 56 year-old male who presented for chiropractic care in December 2011, complaining of low back pain, discomfort in the left hip and buttock area, occasional numbness in his distal thigh and calf, and tingling/numbness in the distal anterior thigh, and left knee weakness while walking. These symptoms were not unusual or unexpected for this patient due to prior care for spinal complaints.
The diagnosis of this presentation would be:
- Peripheral Artery Disease
- Low Back Pain
- Spinal Injury
Claudication is defined as pain caused by decrease blood flow within muscles of the lower extremity. The pain is frequently described as intermittent or "on and off".1-3 It frequently occurs in legs, but the arms can be affected.4 Claudication is a symptom of a disease, peripheral artery disease (PAD), which is a serious circulation problem. It is an atherosclerotic disease of the aorta and arteries of the lower extremities and states that the most frequent manifestations of ischemia occur in the lower extremity arteries, with intermittent claudication as the most common symptom 3
Approximately 12% of older patients in general population have atherosclerotic disease of the aorta and lower extremity arteries, i.e., peripheral artery disease (PAD). Intermittent claudication is the most common symptom. The diagnosis of PAD is considered to be a major risk factor for future cardiovascular events and increased mortality.1, 5
When a patient with low back pain complains of lower extremity pain that is worsened with mild exercise (e.g. walking), the etiology is often not clear. It can reduce the quality of life by limiting participation in social and leisure activities, interference with work, make exercise intolerable and may lead to potentially life-threatening complications if left untreated. Claudication isn't the only possible cause of leg pain. Other conditions associated with similar symptoms that need to be considered include spinal stenosis, peripheral neuropathy, certain musculoskeletal conditions and deep venous thrombosis. 6,7,8
A long case history of low back and leg injuries included hospitalization at age 21 with a disc herniation following a lifting injury, injections for low back pain at age 29, several occasions of pain due to yard work including an incident in which he fell backwards into a woodpile, and an episode of severe pain following a strained left hamstring muscle. He reported being a ‘light” cigarette smoker, “off and on” for many years and also being diligent about his nutritional and exercise habits.
Lumbar radiographic study was made at the sixth visit and the patient was referred for digital radiographic imaging. The Antero-Posterior (A-P), Lateral and L5 spot radiographic images were obtained which showed signs of degeneration at several levels of the lumbar spine including loss of disc heights, facet joint narrowing, bony proliferation, reactive sclerosis, and a degenerative retrolisthesis of L2. Significant calcification was noted within the abdominal aorta and common iliac arteries.
Lumbar and sacroiliac manipulations, along with flexion distraction were received at initial visit. The patient did not return until 6 weeks later, at which time he reported improvement for his low back complaint. He reported continued weakness in his left knee, and occasionally felt tired during long walks especially when he climbed up and down hills. Resting helped so that he could continue walking.
At the second visit, examination included palpation for the posterior tibial, dorsal pedal, and popliteal pulses. These pulses were found present bilaterally; however, examination of the femoral pulses was not done. Foot skin color appeared equal left to right, with neither side appearing pale. Although there were clues that he might have vascular intermittent claudication, he also had neuromusculoskeletal signs and symptoms. The patient also reported that he had described his symptoms to his internist, who examined him and did not think he had a serious problem; he had been instructed to return if the symptoms persisted or worsened.
The patient was seen for three additional chiropractic visits to manage neuro musculoskeletal dysfunction, and he received spinal manipulations, instruction on low back exercises, and transverse friction massage to muscles of the knee (popliteus, short head of the biceps femoris, gastrocnemius, and rectus femoris.) He felt improved and reported at the third visit he no longer needed to stop when he felt weakness, just to slow down. At the fourth visit, he complained of weakness in his left hip and buttock area, weakness and tiredness in his leg as before, and some burning in the bottom of his left foot. Upon examination, pulses were present bilaterally and foot coloration appeared bilaterally equal. The patient was sent for an ultrasound evaluation. The test showed signs of “hemodynamically significant occlusive disease” in the left leg, suggestive of “iliac or iliofemoral disease in a range consistent with claudication”
The patient had two stents inserted into the left external iliac/femoral artery, approximately four months after the office visit in which leg weakness was found. The surgeon reported a “significant amount” of blockage of the artery. After 6 weeks of surgical recovery, the leg weakness was resolved, though the patient complained of a discomfort in his groin from the stents. The patient began taking Plavix and various nutritional supplements that may prevent future vascular problems, and he quit smoking cigarettes. At 20 months after the surgery, the patient reported that he feels fine. He no longer has the groin discomfort or any other complications. He has not resumed smoking.
Claudication may go undiagnosed because many people consider the pain an unwelcome but certain consequence of aging, and some people just reduce their activity level to avoid the pain. Other conditions, such as spine, joint, or muscle problems can also cause pain in legs. The pain occurs intermittently because the leg muscles are not getting enough oxygenated blood to contract properly during exercise. PAD usually occurs as a result of atherosclerosis. Smoking increases the risk of PAD to 30%.9,10 Common tests that are widely used and are well described include pulses in the feet, ankle-brachial index (ABI), Doppler ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) angiography.5,9 ,11,12
The Ankle-Brachial Index has been established as an uncomplicated and inexpensive way to determine PAD. 13,14 It is highly specific (better than 90%) and has good sensitivity (less than 80%).15 The ABI is a ratio of the systolic blood pressure taken from the ankle to the systolic pressure taken from the brachial artery. ABI of less than 0.9 indicates the presence of PAD or other atherosclerotic conditions, whether or not the patient is symptomatic. 15,16 Treatment of claudication and peripheral artery disease can help prevent disease progression and reduce symptoms. Aggressive medical management incorporates risk factor modification and exercise therapy in addition to platelet inhibition and other pharmacotherapy. 3, 17, 18 Important in overall patient management are necessary lifestyle changes. Quitting smoking and participating in a regular exercise regimen are the first steps in treating claudication. If symptoms do not improve, then other options include medications, angioplasty and vascular surgery.
He has included various nutritional supplements, but it is unclear which nutritional supplements are helpful. The review suggested L-arginine may be helpful in relieving symptoms, but there were some questions about adverse reactions. 19 Vitamin E and omega-3 fatty acids have been suggested as treatments for claudication, but clinical trials demonstrating significant beneficial changes are needed.19
Patient management in the chiropractic clinical setting required appropriate medical referral in this case. Surgical implantation of stents in the left external iliac artery resolved the complaint of leg weakness. It is imperative for health care professionals to have awareness of the high occurrence of PAD in the general population.
- Alzamora MT, Baena-Díez JM, Sorribes M, Forés R, Toran P, Vicheto M, et al. Peripheral Arterial Disease Study (PERART): Prevalence and predictive values of asymptomatic peripheral arterial occlusive disease related to cardiovascular morbidity and mortality for the PERART study. BMC Public Health. 2007,7:348
- Hirsch AT, Criqui MH, Treat-Jacobson D, Regensteiner JG, Creager MA, Olin JW, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286:1317-24.
- Comerota AJ. The case for early detection and integrated intervention in patients with peripheral arterial disease and intermittent claudication. J Endovasc Ther 2003;10:601-13.
- Moritz G, Pollard H, Rigby S. Subclavian Steal Syndrome: a review. Chiropr Osteopat. 1998;7(1):20-8.
- Leng GC, Lee AJ, Fowkes FG, Whiteman M, Dunbar J, Housley E, et al. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1996;25:1172-81.
- Armstrong DWJ, Tobin C, Matangi MF. The accuracy of the physical examination for the detection of lower extremity peripheral arterial disease. Can J Cardiol. 2010;26(10):e346-50.
- Regensteiner JG, Hiatt WR, Coll JR, Criqui MH, Treat-Jacobson D, McDermott MM, et al. The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Program. Vasc Med. 2008;13:15-24.
- McDermott MMG, Greenland P, Guralnik JM, Liu K, Criqui MH, Pearce WH, et al. Depressive symptoms and lower extremity functioning in men and women with peripheral arterial disease. J Gen Intern Med. 2003;18:461-7.
- Mohler ER, Bundens W, Denenberg J, Medenilla E, Hiatt WR, Criqui MH. Progression of asymptomatic peripheral artery disease over 1 year. Vasc Med. 2012;17(1):10-6.
- Ain DL, Slovut DP, Kamath R, Jaff MR. The association between peripheral artery and lumbar spine disease: a single-center study. Am J Med. 2012;125(4):411-5.
- Wiles M, Blackmore T. Clinical diagnosis of peripheral vascular disease. J Canadian Chiropr Assoc. 1978;22(3):101-5.
- Terenzi T, Gallagher D, DeMeersman R, Beadle E, Muller D. The age-related advancement of arterial disease measured by Doppler ultrasound diastolic flow analysis. J Manipulative Physiol Ther. 1993;16(8):527-36.
- Collins TC, Suarez-Almazor M, Peterson NJ. An absent pulse is not sensitive for the early detection of peripheral arterial disease. Fam Med. 2006;38(1):38-42.
- Olin JW, Sealove BA. Peripheral artery disease: current insight into the disease and its diagnosis and management. Mayo Clin Proc. 2010;85(7):678-92.
- Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al. Measurement and interpretation of the Ankle-Brachial Index: a scientific statement from the American Heart Association. Circulation. 2012;126:2890-909.
- Fowkes FG, Murray GD, Butcher I, Heald CL, Lee RJ, Chambless LE, et al. Ankle brachial index combined with Framingham Risk Score to predict cardiovascular events and mortality: a meta-analysis. JAMA. 2008;300(2):197-208.
- Burns P, Lima E, Bradbury AW. What Constitutes Best Medical Therapy for Peripheral Arterial Disease? Eur J Vasc Endovasc Surg. 2002;24(6):12 pages.
- DeVries SO, Visser K, deVries JA, Wong JB, Donaldson MC, Hunink, MGM Intermittent claudication: cost-effectiveness of revascularization versus exercise therapy. Radiology. 2002;222:25-36
- Pittler MH, Ernst E. Complementary therapies for peripheral arterial disease: systematic review. Atherosclerosis. 2005;181(1):1-7.