More on Innovations and Emerging Thinking in PAD

Editor's Note: The speaker acknowledges a verbal error in the video at minute 6:22, which should say "amount of time it takes ... from a sitting to standing position is increased with PAD," not decreased. 

There is a concept when we're trying to identify people who may be at risk of PAD. One of my recommendations to my colleagues is to look at the past medical history. And when you see that they've got a number of these different risk factors, diabetes, heart failure, hypertension, hyperlipidemia, smokers, age, because certainly really once you get above 50, the age goes up and certainly over 70, it's more probable these things could happen. And if they have any other atherosclerotic or atherothrombotic histories such as a stroke, TIA, things like this, renal insufficiency, at least my view is, I want to rule it out and I'm more comfortable proving that it's not there, that there's guessing that it might be.

And this opens up a whole new area into people who are at risk that have to do with health equity. Where we're looking at socioeconomic basis, we're looking at race, gender, ethnicity, education level, ability to obtain healthcare, nutrition, all these aspects that we didn't really look at until the last few years. Because most of the studies that were done, were done on white males. So it took us a while to realize maybe we should add some women to these groups.

And then some other people said, "Well, how come we see such a disparity in amputation rates between African Americans and Caucasians?" And then if we look at Hispanic or other groups, we realize that we're missing the boat on this, we're not even realizing how big the problem is until we start looking at the different tenets of health disparity. So now at least we're recognizing it and hopefully it seems at this point we're putting efforts into that, to be able to bring some of these areas that were hidden in the shadows before. They were there, we just weren't paying attention. So I think that'll be a big area that we'll be learning from over the next years.

Change your evaluation of the patient somewhat so that before you even sit down with the patient, you're looking at the medical history and saying where they may be. The next thing has to do with the examination. Pay close attention to the examination. I mean, we all know how to check pulses and we're looking for skin changes and such like that. But really look close, as I say, consider that they probably have PAD if they fall into these comorbidities, until you rule out otherwise. So look at that. Now, if you find your patients who do fall into that category, there is an incredibly appropriate treatment that we don't talk about very much. And I mean, besides proper diet, control of hypertension, diabetes, all those factors. But smoking cessation is key for almost all these and for most of the studies, unless smoking cessation is included, it's going to fail.

But there is a therapeutic modality that's been around for a long time. It's covered by Medicare and more and more research is coming out that structured exercise therapy is appropriate in almost all cases for this. And we've found that exercise therapy alone is good, but it really doesn't reach the same level as structured therapy does. Now, one of the problems we have is not every geographic area has the ability to provide structured therapy. So I'm sure this is going to be changing more as we do outreach and possibly some of these distant types of therapeutic issues can use that. But it seems that people do better if there's a coach or a monitor or somebody working with them. So for structured exercise therapy, it's extremely important and really should be initiated before any type of intervention, if that's possible. One of the newer thoughts has been that structured exercise therapy should be one of the mainstays, along with therapeutic, your pharmacologic control of these other aspects that we've spoken of. And I don't think that's happened as much.

Also, when you are with the patient, talking to them is key, developing a relationship that they're willing to tell you things because they probably don't tell many of their doctors really what's going on with them. A lot of them hold doctors in high esteem, a lot of people are afraid of doctors and they just don't want to tell them things because if they tell them, then the doctors are going to do something bad to them. Or they're just afraid, they're in denial, which we see a lot in patients with diabetes. But the idea is to try to develop some sort of a relationship with them. And during your examination, if you think this may be a patient with PAD, discussing their functional status is key. Because quite honestly, no matter what our treatments are, the goal is for them to be able to improve their function. And their function can be evaluated simply by asking them to stand up.

The amount of time it takes for them to come from a sitting to a standing position is increased in people who have PAD as it becomes advanced. And especially if you have a comparison of maybe what it was like six months ago, a year ago, and asking them. Watching them walk, we all should do it as podiatrists anyway, to get an idea of a gate pattern and what kind of problems this can lead to in the foot. But watching them walk can also tell they seem unbalanced, are they unsure? Is there a gate pattern quite slow?

And a lot of times they're not going to be able to tell you there's something wrong, but you examining them can or even better their family or friends come and tell you because all of a sudden somebody that used to bowl and go for walks in the park, stops. And the patient very well may say, "Well, I'm too busy." And the family says, "No, they're not." So functional status is important. And these are things that take a little bit of time sometimes to ascertain, but it has a lot to do with whether this person has reduced their ability to walk because of pain or inability, in which case we need to take that into consideration when we are coming up with different evaluations and treatments.

I'd also recommend that as podiatrists, we work on developing our referral net. As a podiatrist, you are the expert in a number of things, especially with the patient walking. So on your checking, you're going to be looking for the triad of things that commonly are said that lead to amputation. This is when we have diabetes, peripheral neuropathy and vascular insufficiency. Now, the nice thing about podiatry is there's a fourth leg that we don't talk about as much, and that's structural instability or biomechanical instability.

Because how many patients do we see that come in with wounds along the lateral column or under the fifth MPJ, and they get tested and they say, "Oh, it's a vascular problem." And so they do an intervention, they improve the circulation and it starts to get better. Because they've got a cavus foot and they're overloading the fifth ray and nobody else realized this, but you. So it's important for us to be able to share this, especially when you're referring patients for treatment. I've had a few patients who this is an issue we've run into, they go in, they do the testing, they find, "Oh, we have to improve the circulation for the lateral plantar artery." And they do and the ulcer doesn't go away because the biomechanical aspect wasn't looked at.

Because you're probably going to be the one person that picks that up. And so that's important. But developing a network, because the other issue is not all interventionists are of the same level of skill. And to be honest with you, it really doesn't matter whether a patient has a great SFA or popliteal, if the planter arch isn't getting revascularized. And it's not easy to perform vascular procedures that affect the foot directly. Now, fortunately, over the last five to seven years, a number of techniques have been developed and so it's much more common to see interventionists that have skills that can actually get into the pedal arch. But it's pretty much up to the podiatrist or primary care physician to understand the skills of the different interventionists and refer to the appropriate one.

So it's almost like you as a podiatrist or primary care physician has to be able to figure out where the problem is after the vascular testing is done as to where you send the patient. It's a lot of responsibility and unfortunately, within podiatry and primary care, we don't necessarily have the vascular acumen to be able to make these decisions. So it's important for organizations like ours in podiatry to increase the training to basically make podiatrists somewhat of vascular experts. Even though you are not the one who's able to fix the problem, you are the one who can find the person who can. And I think it's our responsibility to be able to do that.

I also think it's very important for us to educate the patient and their family and primary care when it comes to PAD. Because as we spoke of earlier, PAD does not go away, it continues throughout the patient's life. Even if an intervention's been done, even if they've been on medication, it's not like this cleans out the arteries because once the artery has undergone a certain amount of trauma and pathophysiology, you're cleaning it out, but it's going to be more prone to also accumulate the atherosclerotic plaques and deal with the microvascular problems that go along with it. So we need to educate the patients that, one, they're not fixed, but they have a leg, hopefully, and they're still functioning at a better level of activity. But for the rest of your life, this is something to deal with. And this is a problem because we run that risk of the patient tuning us out because they don't want to hear it.

We also need to educate their family because it's quite often that a patient's family, in a medical legal sense, will point the finger at the team that was treating the patient if it did not go well or if something future happens. Whereas on the medical end, we understand perfectly that PAD is progressive, but patients and their family often think, "No, you didn't fix me or you did something wrong or you didn't do a good enough job, you didn't clean it out enough." Whereas all of these things may have some degree in certain situations being appropriate, across the board, they're not going to get better from the state they were in after the intervention.

So we need to educate them and we need to educate primary care to the same thing because the majority of them did not train in an era that we have today where we understand a lot of this. Because a lot of this pathophysiology has been developed over the last 10 years. So unless you've really studied during that period of time, there's a lot of these things that we weren't aware of. I know that from firsthand evidence. I thought I knew a lot about PAD until I really started studying it and then found out I was off base a lot of the time. So I would encourage education as being part of the podiatrist and primary care's goal.