Setting Up a Vascular Collaboration Research Project

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Setting Up a Vascular Collaboration Research Project Sohail Choksy Consultant Surgeon, CHUFT Prof Ralph Beneke Essex University

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Atherosclerosis influences every single blood vessel bed Cerebrovascular infection Ischaemic stroke Transient Ischaemic Attack (TIA) Cardiovascular malady Myocardial Infarction (MI) Angina (stable/insecure) Peripheral blood vessel sickness (PAD) Intermittent claudication Pain on strolling Severe appendage ischaemia Rest torment Gangrene, putrefaction

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Prevalance and hazard elements 5% 55-74 y Claudication , promote 8% asymptomatic Risk variables Increasing age (>50 yrs old) Diabetes 2-3X Smoking 2X Hypertension 2.5-4X Hyperlipidaemia 2X Ethnicity, sex, homocysteinaemia , past MI Belch et al Arch Int Med . 2003;163: 884-892

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Peripheral Arterial Disease (PAD) Symptomatology Asymptomatic Intermittent claudication Critical appendage ischaemia

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Symptomatology Intermittent claudication "Claudere" to limp Pain is strong and spasm like Absent very still, brought on by practice Pain calmed inside a couple of minutes of ceasing activity Pain happens in muscle gather downstream to the sick corridor Affects strolling speed typical 3mph, claudicant 1-2mph

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Claudication blood supply

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ABPI Diagnosis of PAD Clinical history Physical examination Ankle Brachial Pressure Index (ABPI) Exercise test Duplex ultrasonography Angiography

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Natural History of claudication

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Symptomatology: Critical appendage ischaemia Definition Inadequate blood vessel blood stream for the metabolic needs of the tissues very still Symptoms Rest torment Ulcers/gangrene Doppler weights 50mm Hg at lower leg 30 mm Hg at toes Quality of life like terminal growth

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Reduce cardiovascular hazard Treating Peripheral blood vessel infection Reduce manifestations and enhance personal satisfaction Exercise Therapy Pharmacological treatment Radiological or surgical treatment Lifestyle change Smoking discontinuance Exercise Diet, weight diminishment Secondary counteractive action Antiplatelet Statins (lipid control) BP control, diabetic control

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Exercise Therapy Little confirmation that practice exhortation is compelling Supervised practice treatment is connected with Improvement in max strolling time (5.12 minutes (95% certainty interim (CI) 4.51 to 5.72;) torment free strolling separation 82.19 meters (95% CI 71.73 to 92.65) Max strolling separation of 113.20 meters (95% CI 94.96 to 131.43) No change in ABPI Cochrane Database Syst Rev. 2008 Oct 8;(4):CD000990. Practice for discontinuous claudication. Watson L, Ellis B, Leng GC.

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Mechanism of change in Claudication Mechanism of change of strolling separation in claudication obscure Local or systemic impact? Conceivable clarifications: Improved blood stream Altered stride Improved extraction of oxygen by muscles i.e. Metabolic Pain resilience Improved cardiovascular wellness

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Research Questions What is/are the prevailing mechanism(s) by which practice causes a change in strolling execution in claudicants? In what capacity would we be able to tailor practice to streamline change?

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What we require

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Setting up an examination joint effort Project in planning phase organize in "development" Collaborators: CHUNT: Sohail Choksy, Adam Howard, Chris Backhouse and Emma Raynar Essex University: R Beneke, C Cooper, A Wittekind, MJD Taylor, RM Leithäuser, T Cudmore Multidisciplinary extend consolidating abilities in Sports and Exercise Medicine, Vascular Surgery, Patho-and Exercise Physiology, Biomechanics, Biomedical Sciences and Sport Science Support

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Subjects Patients with stable irregular claudication whose side effects don't warrant surgical or radiological revascularisation Diagnosis in view of history and ABPI<0.9 Exclude patients on medications for claudication e.g. Cilostazol No other cause constraining effort e.g. COPD and CHD Patients enrolled into Colchester Vascular Rehabilitation Program

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Vascular Rehabilitation program Run by Vascular Nurse Specialist (Emma Rayner) and 2 physiotherapists Two one hour sessions for each week 8 week course with evaluations at starting and end obviously Brief warm up, general extend and shake! At that point turn around 10 stations which are gone for enhancing general wellness and working calf muscle. All stations planned for 3 minutes then on to next one.

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Exercise Regimen Stations are 1 Treadmill (speed and slope balanced by, mean to convey on claudication to level 3) 2 Trampette ( heel raises on trampette) 3 Toe strolling 4 Static bicycle 5 Round wobble board (move board in hover on floor) 6 Theraband ( around foot and move foot all over to practice calf) 7 Step ups 8 Square wobble board ( against bars, they need to wobble it back and advances) 9 Arm raises ( holding substantial ball) 10 Sitting and remaining from seat.

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Study Design: Pilot Study Initial pilot study to accumulate preparatory information to apply for an allow application Simple observational study utilizing current built up practice regimen Aim to reply: How is the degree of lower appendage ischemia connected with claudication agony and transient and spatial stride measures amid self-guided ambulation? How do resulting exercise mediations influence practice force and practice instigated exertion and torment sensations?

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Study Design: Pilot Study Assess greatest strolling separation on location at pattern and consummation of program Flat surface, not on treadmill Steps recorded on 2 cameras for stride examination Muscle ischaemia: Near infra red spectroscopy (NIRS) to survey oxygen immersion of calf musculature in influenced leg Effort checking and torment scale Heart rate and spirometry

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NIRS Gardner et al J Vasc Surg. 2008 Sep;48(3):644-9

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Study Design During activity preparing checking of: What was truly done Heart rate NIRS of influenced leg torment scale observing Overall exertion checking

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The Future Larger study looking at the impact of practice in claudicants Vs age coordinated controls on muscle ischaemia , stride examination, torment recognition and practice force Develop novel activities which streamline execution in claudicants Setting up an exploration foundation will make advance potential roads of research Monitoring the impact of pharmacological specialists on practice execution e.g. Cilostazol and Pentoxifylline Monitoring impact of novel strategies to enhance muscle perfusion e.g. Calf pressure and electrical muscle incitement

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