Cold bluish legs and the Wounds that would not heal
Waqar A Shaikh (homeopath) Canada... (Reg with Homeopathic college of Ontario.....Canada)
M.D Alternative medicine (Colombo)
A 75 year old couch potato, after retirement decided to take charge of his health and changed his sedentary lifestyle for the better, more active one. He gave his refrigerator a complete makeover, healthy meals, regular morning walks, exercises were all on the way, however after some time, he started feeling mild, bearable pain in one of his legs, on and off, during the strolls. Initially, it was not much of a concern to him and this went on for months and months, but then the pain got worse to the point that he became more aware of it’s presence like an “unwelcome companion”. One obvious symptom he now noticed which he did not pay heed to before, was that the leg pain came only during walking and not at rest. His doctor did not notice any other signs or symptoms, so he put him on pain killers, but the pain only got worse day by day and he started feeling the pain even at rest also, and then came the days when he started spending most of his time on the bed. In the case of the above mentioned patient, with a little more investigation, the problem was found to be the of blockage of one of the arteries supplying blood to the affected leg. This blockage with cold bluish tint of the affected leg gave a reasonable clue to the doctors, this combination of leg pain with a lower temperature than the other leg with bluish color typically occurs in a disease called “Peripheral Vascular disease” or PVD. To take the guesswork out of this, they did some more tests, and this diagnosis was confirmed. Before further elaborating on this subject, it seems necessary to define some of the terminologies used relating to the subject in consideration, which will make it much easier to understand.
1-Peripheral: outer part of the body (mostly used for hands and legs), remote, outside of heart and brain.
2-Vascular: relating to blood vessels-consisting of arteries and veins a) arteries: carrying oxygen and nutrient rich blood, from the heart to all tissues of the body. b) veins: Bringing impure blood from all parts of the body back to heart.
3. Atherosclerosis: built up of abnormal material within the arteries called plaque which narrows the artery
4. Ischemia: reduction in blood supply to a part of the body due to atherosclerosis (blockage)
5. Intermittent Claudication (I.C): leg pain or discomfort that is worsened by walking.
6. Ischemic rest pain: stage after intermittent claudication, pain at rest.
7. Cyanosis : a bluish discoloration of the skin due to poor circulation of oxygenated blood
8. Sores: stubborn wounds
9.Homocysteine: a chemical in the blood that is produced when an amino acid (a building block of protein) called methionine is broken down in the body
10. Ankle-bracheal BP index( ABI): blood pressure in the ankle divided by blood pressure in the arm
11- Necrosis: Death of a tissue or organ due to complete Ischemia.
12- Collateral circulation: when abnormal material builds up slowly, sometimes but not always, a natural bypass circulation develops to supply to the tissues affected.
13. Differential diagnosis: the art of recognizing difference between two or more diseases having few similar sign and symptoms. People who have a disease first develop “sign and symptoms”, which of course are what actually bring them to see a doctor. These sign and symptoms are, through which their body talks to them, a language with two different dialects. Signs are physical manifestations of a disease like rashes, red watery eyes and discoloration (paleness of leg) which can be seen on the patient. Symptoms are which a patient only feels, like lethargy, headache and leg pain.
What is the other name for peripheral vascular disease: The name itself suggests that it is a disease of the vessels, as already described that vessels are composed of both arteries and veins, but this disease affects only the arteries of the legs, hence more appropriate name for this is “peripheral artery disease”.
How does Peripheral Artery Disease (PAD) show itself: the first noticeable symptom is the intermittent claudication (I.C), which means leg pain while walking and is relieved by rest, the cause of this pain is the “ischemia” due to “atherosclerosis”. This simply is because at rest there is less requirement for blood supply, but as the problem progresses, so is the ischemia, and the blood supply decreases so much that it is not sufficient even at rest and now the patient feels pain during rest also. This is called “Ischemic rest pain”, accompanying pain now are cyanosis, hair loss from affected area, stubborn ulcers, all because of the lack of blood supply which provides oxygen and nutrients, this pain sometimes wakes the patient from sleep at night. The stage is called “Critical limb ischemia (CLI)”. In the early stage and if blockage progresses slowly, sometimes ,within few weeks the condition improves on its own as a natural alternative circulation develops in the leg, this is called “Collateral Circulation. Types of PAD: There are two types of PAD:
1)Functional PAD: In functional PAD there is no change in the arteries, it is only functional changes such as “spasms” which cause temporary narrowing of the vessel, thus ischemia occurs.
2)Organic PAD: is caused by Atherosclerosis.
What are the main risk factors:
1. Atherosclerosis
(2)
2. History of smoking.
3. Diabetes: this is one of the most important causes of this condition. High sugar levels damage not only the blood vessels but the nerves also causing loss of sensations called “diabetic neuropathy” and because of this, when an ulcer appears, it is sometimes over looked and is grown bigger sometimes it gets infected also,, that is why it is also called “Diabetic foot”.
4. High blood pressure.
5. Advance age: normally, but because of other risk factors may appear at any age.
6. High Blood Homocysteine levels: this is the by product of proteins (such as chicken, fish, lentils) break down, and is utilized by body in the presence of folic Acid, vitamin B6 and B12, if there is a deficiency of these, the level of homocysteine is raised. According to Dr Koon Teo of McMaster university, Hamilton, Canada, raised level of this, damages the arteries( from inside) and plaque is formed .
Differential diagnosis: ( What are the other causes of leg pain ). Peripheral artery disease (PAD) is not the only disease which has limb pain, there are other conditions also like due to injury, sciatica or blood clot in deep-lying vein (Deep vein thrombosis), arthritis of back and few others. But this leg pain may be the only common symptom in all conditions, so totality of the symptoms has to be taken, e.g in injury there is always a clear history of accident, sciatica basically is a problem of lower back, which pinches the nerve. An Important point to remember here is that in all other conditions the pulses are normal, It is through the art of “differential diagnosis” that doctors can distinguish between conditions which have few common sign and symptoms. Like all other health problems this should always be left to the medical doctors to diagnose. What test are done: There are some invasive tests, but initially when PAD is suspected, two very simple and important tests are
1) Ankle Brachial Blood pressure Index or (ABI Index): This involves taking blood pressure in the ankle and in the arm in lying position, then dividing the ankle B.P by arm B.P. normally it is same so 1 or little greater is normal ,values less than 0.9 are considered abnormal.
2) Buerger’s Test: This test is done in lying position and the affected leg is raised to see if it gets pale or not, if it does, lowering it down to the side of the bed makes it red again, this is considered to be a positive test.
If not checked, this is how the disease progresses.
Stage 1 Ischemia (Intermittent claudication ) leg pain on walking, relieved by rest.. (ABI-Index 0.9 to 0.4)
Stage 2. Ischemic rest pain wakes from sleep Pain even at rest (ABI-index 0.4 to 0.2)
Stage 3. ( Cynosis ) Pale—blue—cold—leg
Stage 4. (also called Diabetic foot) Wounds ( ulcers ) appear-----slow or non healing
Stage 5 Critical Limb Ischemia ( Necrosis ) Gangrene or the death of part (ABI-index 0.4 t0 0.0)
In mainstream medical system, there may be many options, from lifestyle changes to medications and if patient seems fit for it, surgery may be the last resort. If those alone are not sufficient than a as complementary help, “Homeopathy” should always be thought of, before it gets into a incurable stage. “The earlier the better”.
This information only is for the public awareness. Remember, it is very important to tell exact symptoms to the physician. A lot depends on “History”, as it is rightly said “ A Good History Taken Is Half A Cure”.