The correlation of the "Walking Estimated-Limitation Calculated by History" (WELCH) questionnaire with treadmill maximal walking time is not impaired by age, in patients with claudication.

PURPOSE: The "Walking Estimated-Limitation Calculated by History" (WELCH) questionnaire is a short four-item questionnaire that estimates the walking capacity of a patient in comparison with relatives, friends or people the same age. As such, it should be relatively insensitive to age, yet this has never been tested. METHODS: A prospective study was performed among 525 patients presenting vascular-type claudication. Patients were grouped into quintiles of age-from quintile 1 for the youngest patients to quintile 5 for the oldest ones. Patients completed a self-administered questionnaire and then had their maximal walking time (MWT) measured on a treadmill. We estimated the coefficient of correlation, the slope and the intercept of the relationship between the WELCH score and the MWT, then the accuracy of a WELCH score under 25 to predict the ability to walk for 5 min on a treadmill. RESULTS: The slopes of the relationships and the correlation coefficients were not significantly different in each quintile, but a significant shift in the intercept of regressing lines was found with age. Nevertheless, the accuracy in predicting treadmill results from the WELCH score with a cut-off point of 25 was, respectively, 68.6, 72.4, 80.0, 72.4 and 73.3 % in quintiles 1, 2, 3, 4 and 5 (p = 0.45). CONCLUSIONS: The relationship of MWT on a treadmill and the WELCH score is slightly influenced by age, but a score superior to 25 seems to be of equal discriminatory performance in different quintiles of age to predict the ability to walk for 5 min on a treadmill. This makes this cut-off limit of interest for routine use, regardless of age.

Validation of the English version of the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire in patients with intermittent claudication.

The Walking Estimated-Limitation Calculated by History (WELCH) questionnaire has recently been proposed as a valid and simple instrument for assessing walking limitation in patients with intermittent claudication. The aim of this study was to validate an English version of the WELCH questionnaire in an English native population. Thirty-nine patients (ankle-brachial index 0.59 ± 0.16, age 65 ± 11 years, 82% male) completed an English version of the WELCH questionnaire. Maximum walking distance was measured objectively using the Gardner-Skinner treadmill test and the 6-minute walk test. The median WELCH score was 24 (9-39). Maximum walking distances were 412 m (149-675 m) for the treadmill test and 381 ± 88 m for the 6-minute walking test. The Spearman's correlation coefficient was ρ = 0.59 between the WELCH score and treadmill distance (p < 0.001) and ρ = 0.82 between the WELCH score and 6-minute walk distance (p < 0.001). These findings suggest that the English version of the WELCH questionnaire is a valid instrument for assessing walking impairment in patients with intermittent claudication.

Calf muscle stimulation with the Veinoplus device results in a significant increase in lower limb inflow without generating limb ischemia or pain in patients with peripheral artery disease.

OBJECTIVE: Increase in arterial inflow to the lower limbs is important to obtain functional improvement in peripheral artery disease (PAD) patients with claudication. The aim of this study was to assess the effect of electrical stimulation of calf muscles on arterial inflow and tissue oxygen content in PAD in the area of stimulation. METHODS: Fifteen adult patients [mean (standard deviation) age, 62 (12 ) years; height, 165 (8)cm; weight, 76 (13) kg; lowest ankle-brachial index 0.66 (0.19)] with stable arterial claudication were recruited. All patients performed a treadmill test (3.2 km/h, 10% slope) associated with a transcutaneous oximetry test expressed as decrease from rest of oxygen pressure (DROP) index values (calf changes minus chest changes from rest) with a maximum walking distance (median [25th/75th percentiles]) of 295 [133-881] m. The DROP index on the symptomatic side was -25 [-18/-34] mm Hg. On another day the patients underwent electrical stimulation in the seated position on the leg that was the most symptomatic on the treadmill. After resting values were recorded, the gastrocnemius was stimulated for 20minutes at increasing contraction rates at 5-minute steps of 60, 75, 86, and 100bpm on the most symptomatic side. Arterial blood inflow with duplex Doppler ultrasound scanning of the femoral artery, DROP transcutaneous oxygen pressure value, and oxygen concentration (O2Hb) from the near-infrared spectroscopic signal of the calf were recorded on both sides. Patients were instructed to report eventual contraction-induced pain in the stimulated calf. Results are given as mean (standard deviation) or median [25th/75th percentiles] according to distribution, and the level of statistical significance was set at P < .05 on two-tailed tests. RESULTS: Lower limb inflow (mL/min) was 64 [48/86] vs 63 [57/81] (P> .05) before stimulation, 123 [75/156] vs 57 [44/92] (P < .01) at 60bpm, 127 [91/207] vs 49 [43/68] (P < .01) at 75bpm, 140 [84/200] vs 57 [45/71] (P < .01) at 86bpm, and 154 [86/185] vs 55 [46/94] (P < .01) at 100bpm on the stimulated vs nonstimulated limb, respectively. No apparent decrease or significant leg difference was observed in DROP index or O2Hb values. None of the patients reported contraction-induced pain in the leg. CONCLUSIONS: Electrical stimulation of calf muscle with the Veinoplus device results in a significant increase of arterial inflow without measurable muscle ischemia or pain. Potential use of this device as an adjuvant treatment to improve walking capacity in PAD patients remains to be evaluated.

Development and evaluation of the Walking Estimated-Limitation Calculated by History questionnaire in patients with claudication.

BACKGROUND: The Walking Impairment Questionnaire (WIQ) is used to estimate walking impairment in patients with peripheral artery disease; however, it faces frequent errors when self-completed and is complex to score. We aimed to validate an alternative, easily scored four-item tool, the Walking Estimated-Limitation Calculated by History (WELCH) questionnaire. METHODS: The WIQ and WELCH were prospectively tested in five centers. We studied 434 patients, among which 298 had a treadmill test (3.2 km/h; 10% slope) to determine their maximum walking time (MWT), and 30 were seen twice during the study period. RESULTS: After self-completion, we found at least one error in 177 WIQ (40.8%; 95% confidence interval [CI], 36.3%-45.5%) vs 56 WELCH (12.9%; 95% CI, 10.1%-16.4%) questionnaires (P < .0001). When scoring only questionnaires without missing or duplicate answers, 267 WIQ (61.5%; 95% CI, 56.9%-66.0%) vs 393 WELCH (90.6%; 95% CI, 87.4%-93.0%) questionnaires could be scored (P < .001). The median MWT was 233 seconds (interquartile range, 133-654 seconds) for the 298 patients who had a treadmill test. When the 296 patients who had both questionnaire scores available were studied, no difference was found between the Pearson r coefficient of correlation of the WIQ (r = 0.615) and the WELCH (r = 0.653) with MWT (P = .211). In the 30 patients who completed the WELCH twice, correlation was r = 0.839 (P < .001) between the two scores in 22 nonrevascularized patients, and the area under the receiver-operating characteristic curve was 0.830 ± 0.105 (P < .01) to discriminate the eight revascularized from the 22 nonrevascularized patients. CONCLUSIONS: The WELCH questionnaire is a simple tool to estimate walking limitation in patients with suspected peripheral artery disease. It is easily scored by mental calculation. It may help to standardize the estimation of walking limitation in routine clinical practice.

Aging reduces the accuracy of self-reported walking limitation in patients with vascular-type claudication.

BACKGROUND: The published correlations between treadmill performance and the Walking Impairment Questionnaire (WIQ) score are generally fair. We hypothesized that the slope of the relationship of maximal treadmill walking time to WIQ would be lower in older than in younger patients, resulting in (1) a fair correlation in the population considered as a whole and (2) different cutoff points of the WIQ score to predict the ability to complete 5 minutes of treadmill walking in different age groups. METHODS: A 9-month prospective study was performed among patients referred for vascular-type claudication. Patients were divided into three age groups by years: <60 (group 1, n = 91), 60 to 70 (group 2, n = 80), and >70 (group 3, n = 77). Patients self-completed the WIQ, which was corrected with a nurse, if necessary, and then completed a treadmill test. We calculated the correlation coefficient and slope of the relationship between the WIQ and maximal treadmill walking time. We used receiver operating characteristics curve analysis to estimate the accuracy of the WIQ score to determine the ability of the patients to complete 5 minutes of treadmill walking. RESULTS: Differences in slopes were significant between groups 1 vs 2 (P = .02), 2 vs 3 (P < .002), and 1 vs 3 (P < .001). The R(2) for the regression lines also tended to decrease but was only significant between two extremes (1 vs 2, P = .11; 2 vs 3, P = .07; 1 vs 3, P < .001). In patients aged <60 years (group 1), a WIQ score of 47 predicted the ability to complete a 5-minute test on treadmill with 86.8% accuracy (area under the receiver operating characteristics curve, 0.906; P < .001). The accuracy in predicting treadmill results from the WIQ score was fair in group 2 and nonsignificant in group 3. CONCLUSIONS: Prediction of treadmill walking capacity from the WIQ score should account for age. The TransAtlantic Inter-Society Consensus suggests that self-reported limitation has an equal weight as measured walking distance in the treatment choices and follow-up of patients with peripheral arterial disease. The WIQ should probably be used with caution in clinical routine, and constant-load treadmill testing is probably not the ideal candidate in elderly patients. New or adapted tools are likely needed in such patients but remain to be studied.

The "Walking Estimated Limitation Stated by History" (WELSH) visual tool is applicable and accurate to determine walking capacity, even in people with low literacy level.

Determination of the self-reported walking capacity by interview or standardized questionnaire is important. However, the existing questionnaires require the patient to be able to read and write in a specific language. We recently proposed the WELSH (Walking Estimated Limitation Stated by History) tool to be administrable to illiterate people. The main objective was to assess the applicability of WELSH tool in the community and in a large group. We performed a prospective study in the city of Bobo-Dioulasso in Burkina Faso during June 2020. We recruited 630 interviewers among medical students. They were trained to administer the WELSH, and to conduct a 6-minute walk test. We performed a Pearson's "r" correlation between the WELSH and maximal walking distance (MWD). Of the 1723 participants available for the analysis, 757 (43.9%: 41.6-46.3) never went to school or attended only elementary school. The percentage of questionnaires with participant filling-in errors corrected by the investigator decreased with the decrease in educational level (p<0.001). The average WELSH score was 53 ± 22 and the average MWD was 383 ±142 meters. The Spearman correlation coefficient between the WELSH score and the MWD was r = 0.567 (p<0.001). Correlations ranged from 0.291 to 0.576 in males and females, (all p values < 0.05) and in different levels of education, with the highest coefficients found in illiterate people. The WELSH is feasible on the community by a wide variety of interviewers. It correlates with the MWD estimated by the 6-minutes' walk test even for people with little or no schooling.

Validation of a new simple questionnaire to "estimate ambulation capacity by history" (EACH) in patients with claudication.

OBJECTIVES: The assessment of walking limitation is important in determining the severity of many diseases, including peripheral artery disease. Questionnaires exist for estimating walking capacity, but these have limited use in routine clinical practice. We sought to establish the feasibility and validity of the estimating ambulation capacity by history questionnaire (EACH-Q), a self-administered, four-item questionnaire that estimates walking capacity in patients reporting vascular-type claudication. BACKGROUND: The EACH-Q estimates the maximal duration that can be attained (eight possibilities: from impossible to 3 hours or more) at four different displacement speeds (from slow walking to running). Scores can be obtained easily by multiplying the rank of each possible answer (impossible being zero) by a speed factor. METHODS: The Walking Impairment Questionnaire (WIQ) and the EACH-Q were completed by 218 patients with vascular-type claudication, undergoing treadmill exercise testing. We hypothesized that less errors (ie, missing, duplicated, or paradoxical answers) and missing final scores would be observed for the EACH-Q than the WIQ. Validity was assessed by calculating correlation coefficients (r) between the questionnaire scores (both questionnaires, noncorrected and corrected) and treadmill maximal walking distance (MWD: 3.2 km/h, 10% slope, maximized to 15 minutes). RESULTS: Compared with the EACH-Qs, nearly twice as many WIQs had to be corrected for one or more errors (52% vs 28%; P < .0001). This resulted in 37 (17%) WIQ versus 18 (8%) EACH-Q scores being missing on noncorrected questionnaires (P < .0001). MWD was 162 m (25-75° percentiles: 91-390 m). The correlation coefficients of WIQ and EACH-Q to MWD were 0.59 and 0.52, respectively, before correction (P = .357) and 0.60 and 0.51, respectively, after correction (P = .185). CONCLUSIONS: The EACH-Q is a simple and valid questionnaire for estimating walking capacity in patients with vascular-type claudication. It is easily scored. It might help standardize the reporting of how patients feel about their walking limitation. Further research is needed to validate the EACH-Q in other patient groups and against other treadmill protocols and to assess its reliability and sensitivity.

Self-reported estimation of usual walking speed improves the performance of questionnaires estimating walking capacity in patients with vascular-type claudication.

OBJECTIVE: Most questionnaires do not estimate the usual walking speed of the patient, although it is well known that patients may experience apparently different walking capacities if walking slow or fast. We hypothesized that correcting the self-reported estimated walking capacity by a coefficient issued from the self-reported estimation of usual walking speed would significantly improve the correlation between questionnaire-estimated and treadmill-measured walking capacity. METHODS: Three hundred ten consecutive patients complaining of vascular-type claudication were asked to estimate their usual walking speed in comparison to people of their age (or friends or relatives) with ratings ranging from much slower (1 pt) to much faster (5 pts), in addition to the filling out of the walking impairment questionnaire (WIQ) and the estimated ambulatory capacity by history questionnaire (EACH-Q). Corrected WIQ (WIQc) and corrected EACH-Q (EACH-Qc) scores were obtained by multiplying the scores of each questionnaire by the "usual-speed" coefficient and dividing by 5. Results for questionnaire scores were compared to maximal walking time (MWT) on a treadmill. RESULTS: All but four patients self-completed the usual-speed question. Median scores (25-75 centiles) were 41% (26-59) for the WIQ and 24% (11-41) for the EACH-Q. Coefficients of correlation of the three WIQ subscales and of the EACH-Q with treadmill results were significantly improved after correction by the "usual-speed" question. Overall, WIQ (mean of the three WIQ subscales) tended to improve but did not reach significance. CONCLUSION: Correcting the self-reported estimation of walking capacity by a self-reported estimation of usual walking pace significantly improves the correlation of all WIQ subscale scores and of the EACH-Q score with treadmill measurements of capacity. This confirms the interest of speed estimation in patients with peripheral arterial occlusive disease and claudication.

Exercise-Induced Plasma Metabolomic Profiles in Patients With Peripheral Arterial Disease.

Aim: A better knowledge of the biological consequences in the blood of these exercise-induced ischemic events in lower extremity artery disease (LEAD) may improve the prospects of disease management. We explored the preminus postexercise metabolomic difference in 39 patients with LEAD referred for a treadmill oximetry test [transcutaneous oximetry (TcPO2)]. Methods: Ischemia was estimated through the sum of decrease from rest of oxygen pressure (DROPs) (limb TcPO2 changes minus chest TcPO2 changes) at buttocks, thighs, and calves regions. Targeted metabolomic analyses measuring 188 metabolites were performed on a few microliters blood samples taken at the earlobe at rest and 3 min after exercise. Results: Maximum walking distance (MWD) was 290 m (120-652 m) and ankle brachial index (ABI) was 0.67 ± 0.17. Supervised paired partial least squares discriminant analysis based on 23,345 models showed good predictive performance for test sets with a median area under the receiver operating characteristic (AUROC) curve value of 0.99 and a p-value of 0.00049. The best discriminant metabolites contributing to the model included a subset of 71 (47%) of the 150 accurately measured metabolites in the plasma, comprising 3 acylcarnitines, 3 amino acids, 5 biogenic amines, 9 sphingomyelin, 7 lysophosphatidylcholines, and 44 phosphatidylcholines. In addition, 16 of these metabolites were found to correlate with one or more severity scores of the LEAD. Conclusion: Our results provide new insights into the biological changes that accompany exercise in LEAD and contribute to a better understanding of walking impairment pathophysiology in LEAD, highlighting new candidate biomarkers.

The hidden side of calf claudication: Hemodynamic and clinical results of treadmill testing in 584 patients complaining of isolated exertional calf pain.

BACKGROUND AND AIMS: Calf pain is the most frequent symptom of arterial claudication. We hypothesized that patients with self-reported isolated calf claudication have frequent exertional non-calf symptoms during objective laboratory testing, and that many would show not only distal, but also proximal ischemia. METHODS: We retrospectively analyzed the patients referred since 2016 for exercise transcutaneous oxygen pressure (Ex-tcpO2). The Edinburgh Claudication Questionnaire (ECQ) was self-completed before and during a treadmill test. For calf and non-calf (buttock and thigh) Ex-tcpO2, a lowest decrease of rest of oxygen pressure (DROP) < -15 mmHg was indicative of ischemia. We selected the patients that reported calf claudication only and analyzed minimal DROP and per-test ECQ observations. RESULTS: Exertional symptoms on a treadmill occurred in 526 (90.1%) of the 584 patients analyzed (65.6 ± 11.4 years old), with 391 (74.3%) of these symptoms affecting only the calf. Isolated calf ischemia with or without symptoms was found in only 139 (23.8%) patients. Overall, among the 584 patients self-reporting isolated calf symptoms, a perfect concordance between symptoms on a treadmill and Ex-tcpO2 (i.e. calf symptoms associated to calf ischemia) was observed in only 114 (19.5%) cases. CONCLUSIONS: Our study demonstrated that patients self-reporting exertional limb pain strictly limited to the calf may also have non-calf claudication on a treadmill and frequently show not-only-calf ischemia. These observations are important when planning reeducation or when studying the tissue consequences of ischemia in patients with claudication.

The walking estimated limitation stated by history (WELSH): a visual tool to self-reported walking impairment in a predominantly illiterate population.

BACKGROUND: The prevalence of cardiovascular diseases is increasing in low-income countries. Various questionnaires to estimate walking capacity in patients are available in multiple languages but they are not suitable for illiterate patients. OBJECTIVE: The walking estimated limitation stated by history (WELSH) tool aims at rating individual walking disability using only drawings and four items. METHODS: A six-month prospective study was performed on new patients referred to the Department of Cardiology at the Centre Hospitalier Universitaire Sourô Sanou in Bobo-Dioulasso, Burkina Faso. We administered the WELSH tool after a short oral presentation in the patient's language or dialect. Thereafter, patients performed a six-minute walking test in the hospital corridor under the supervision of a nurse who was blinded to the results of the WELSH score. We performed a step-by-step multilinear regression analysis to determine the factors predicting maximal walking distance (MWD). RESULTS: There were 40 female and 10 male patients in this study. Their ages ranged from 54.8 ± 10.7 years. Only 32% of the patients had attended primary school. Most patients were classified as stage I to III of the New York Heart Association (NYHA) classification. The objective measurement of MWD during a six-minute walking test showed no association with the subjects' educational level, body mass index, NYHA stage or gender, but a significant correlation with the WELSH scores. The Spearman r-value for the WELSH score-to-MWD relationship was 0.605 (p < 0.001). CONCLUSIONS: The WELSH tool is feasible and correlated with measured MWD in a population of predominantly illiterate patients.

Clinical application of transcutaneous oxygen pressure measurements during exercise.

Exertional lower limb pain is a frequent diagnostic issue in elderly patients. Arterial claudication results from the mismatch between the oxygen requirement of, and oxygen delivery to the exercising muscles. Non-invasive vascular investigations (ultrasound imaging, plethysmography or segmental pressure) are used in routine at rest or following exercise, but none can be used during walking or to directly monitor cutaneous oxygen delivery to the limb. Here, we review the methods, tips and traps of the transcutaneous oxygen pressure measurement technique and potential applications. Transcutaneous oxygen pressure measurement is largely used in vascular medicine for patients with critical limb ischemia. It can also detect regional blood flow impairment at the proximal and distal limb simultaneously and bilaterally during exercise. Exercise-oximetry can also analyze systemic oxygen pressure changes on a reference area on the chest, to screen for occult pulmonary disease. As a surface technique, it does not directly measure muscle oxygen content but provides a reliable estimation of regional blood flow impairment. With the use of a recently reported index that is independent of the unknown transcutaneous gradient for oxygen, exercise-oximetry provides some accurate information compared to classical non-invasive vascular investigations to argue for a vascular or non-vascular origin of exertional lower limb pain during exercise. Although a time consuming technique, it is a simple test and it is progressively spreading among referral vascular centers as a useful non-invasive diagnostic tool for patients suspected of arterial claudication.

Multiprobe devices for exercise transcutaneous oxymetry in patients complaining claudication: interest and limits of unusual probe positions.

BACKGROUND: Exercise transcutaneous oximetry (PtcO2) can argue for a vascular origin of exercise-related pain in atypical unusual localizations, such as lumbar, thigh or foot pain. We used five probes as a standard for treadmill PtcO2 tests. Recent commercially available devices now include up to eight probes. We aimed at analyzing the potential interest of positioning a 6th probe on the area of unusual localization during exercise PtcO2 tests. METHODS: We retrospectively analyzed our data with a 6-probes device, using as a standard: one probe on the chest, one on each buttock and one on each calf. The sixth probe was positioned either: in the lumbar median position (N.=342), on the anterior lower part of the thigh (N.=391) or on the dorsum of the foot (N.=155) in patients complaining exercise-induced pain including the back, thigh or foot respectively. Results on the sixth probe at the limb were compared to result of the standard adjacent probe. A positive test (abnormal result) was defined as a minimal value of the DROP-index lower than minus 15 mmHg. RESULTS: Prevalence of positive results on the 6th probe with negative results on the adjacent standard probe was 2.3% at the lumbar site, 3.8% at the thigh and 12.3% at the foot level. CONCLUSIONS: Atypical localizations are rarely but sometimes associated to isolated positive exercise PtcO2 results and may justify the use of more than five probes in some patients, specifically for foot pain.

Proximal ischemia is a frequent cause of exercise-induced pain in patients with a normal ankle to brachial index at rest.

BACKGROUND: Excluding a vascular origin of exercise-related pain is often difficult in clinical practice. Recent papers have underlined the frequent association of concurrent lumbar spine degenerative disease and peripheral arterial disease. Furthermore, even when suspected, isolated exercise-induced proximal ischemia is difficult to diagnose. Measurement of transcutaneous oxygen pressure (tcpO2) is an interesting and accurate method to differentiate proximal (buttock) from distal (calf) regional blood flow impairment (RBFI) during exercise. OBJECTIVES: We searched for isolated proximal-without-distal RBFI as a possible cause of claudication, in patients with borderline (ABI-b: 0.91 - 0.99) or normal (ABI-n: 1.00 to 1.40) ankle to brachial index at rest. STUDY DESIGN: Retrospective cohort design study. We analyzed patients referred to our laboratory with symptom limiting claudication and an ankle brachial index within normal limits. SETTING: University-based exercise-investigation center. METHODS: Over a 12-year period, we identified 463 patients referred to our laboratory that had their lowest resting ABI between 0.90 and 1.40. The tcpO2 on chest, buttocks, and calves were recorded during treadmill walking tests (3.2 km/h, 10% slope) in 220 ABI-b and 243 ABI-n unique consecutive patients complaining of limiting claudication (each patient's ABI was the lowest of the 2 legs). Limiting claudication was defined as the reported inability to walk 1 kilometer without stopping. A DROP index (limb tcpO2-changes minus chest tcpO2-changes from rest) below -15 mmHg was used to indicate a positive result (i.e. exercise-induced RBFI). RESULTS: Treadmill exercise showed evidence for proximal or distal RBFI, of at least one side, in 128 out of 220 patients (58.2%) and in 86 out of 243 (35.4%) patients with ABI-b and ABI-n, respectively. Isolated proximal-without-distal RBFI was found in 32 out of the 128 (25.0 %) positive tests in ABI-b and 32 out of the 86 (37.2%) positive tests in ABI-n patients. LIMITATIONS: Study limitations include the absence of systematic follow-up of diagnosed patients and absence of systematic search for cardio-respiratory co-morbid conditions. CONCLUSION: Isolated proximal-without distal RBFI is found in approximately one out of 7 patients complaining of symptom limiting claudication with a borderline or normal resting ABI. Exercise-tcpO2 may help to discriminate patients with arterial claudication that could benefit from invasive vascular investigations and procedures.

Impaired somatosensation in patients with isolated proximal-without-distal exercise-related lower-limb ischemia.

OBJECTIVES: Isolated proximal-without-distal (buttock but not calf) exercise-related lower-limb ischemia (IPI) might develop in the presence of arterial lesions impairing the blood flow supply toward the hypogastric vascular bed. In IPI, lower-limb sensory nerve dysfunction might occur from the sacral nerve plexus becoming ischemic during exercise. The purpose of this study was to compare patients with IPI with healthy controls for the presence of sensory nerve dysfunction, as assessed using somatosensory testing (SST). METHODS: Seventeen nondiabetic patients with IPI and 17 age-matched and sex-matched healthy controls underwent SST of both the upper and lower limbs. RESULTS: The upper-limb SST data did not differ between groups (P>0.05). In contrast, lower-limb testing showed that patients with IPI had impaired warm (43.4±2.7 vs. 40.5±4.9°C) and vibration (5.0±2.3 vs. 6.4±1.4 arbitrary units) detection thresholds compared with healthy controls (P≤0.05). Furthermore, lower-limb mechanical detection threshold and Neuropathy Symptom and Disability Scores tended to be higher in the patients (P≤0.10). DISCUSSION: The SST data suggest that patients with IPI have abnormal functioning of Aß-fiber and C-fiber inputs in their affected limb(s). These sensory abnormalities might contribute to the exercise-induced ischemic symptoms experienced by these patients.

Heart rate recovery after constant-load exercise tests is decreased in proportion to the importance (severity and diffusion) of exercise-induced lower-limb ischaemia.

BACKGROUND: Conditions that may influence heart rate recovery at 1 min of recovery from exercise (HRR1: end-exercise heart rate minus heart rate 1 min after exercise) are not fully understood. We hypothesized that the 'importance' (both local severity and regional diffusion) of peripheral skeletal muscle ischaemia is associated with low HRR1. DESIGN AND METHODS: In 529 patients with suspected or confirmed peripheral vascular disease not receiving beta-blockers (61·4 ± 11·3 years old), we retrospectively studied the relationship of HRR1 to exercise-induced changes in transcutaneous oxygen DROP index (limb changes minus chest changes from rest). The sum of DROP indices observed on both calves and both buttocks (DROPtot) provides the unique opportunity to estimate both the severity and the diffusion of exercise-induced ischaemia on the right and left side simultaneously. It was used during a constant-load treadmill test (3·2 km h(-1) ; 10% grade) to classify patients in quartiles, the fourth quartile representing the more 'important' ischaemias. RESULTS: There was an inverse relationship between quartiles of DROPtot and HRR1, even after adjustment for heart rate reserve (Delta HR: end-exercise minus resting heart rate), age (≤ or >60 years), gender, body mass index, treadmill maximal walking distance and ankle brachial index: adjusted R = 0·629; P<0·0001. CONCLUSIONS: During constant-load treadmill testing, DROPtot, an index of the 'importance' of exercise-induced lower-limb ischaemia, correlates with HRR1. Whether HRR1 is improved in proportion of DROPtot improvement in patients undergoing surgery or rehabilitation for peripheral artery disease is a fascinating issue for future studies.