Utilizing the Ankle Brachial Index in Clinical Practice

  • Wed, 9/3/08 - 10:24am
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Author(s): 
Tom Holland, PT, PhD

L ower extremity vascular changes have been highly correlated with claudication pain, ischemic tissue loss, and functional limitations that include poor standing balance and mobility.1,2 A thorough peripheral vascular assessment is essential in the clinical management of individuals with peripheral arterial occlusive disease (PAOD). Intermittent claudication, diminished distal lower extremity pulses and skin temperature, texture, and color changes are common indicators of PAOD.3 Tests that provide more objective and quantifiable values should be used to monitor vascular disease progression, therapeutic interventions, and for screening purposes in those individuals with asymptomatic PAOD. The ankle brachial index (ABI), when used with pulse volume recordings (PVRs), segmental systolic limb pressures (SLPs), and transcutaneous oximetry mapping (TCOM) can provide an accurate assessment of an individual?s peripheral vascular status.

Technique and Interpretation
The ABI is a noninvasive test performed with a blood pressure cuff and a Doppler ultrasound that magnifies vascular sounds. Individuals are tested in the supine position following a 5-minute rest period. Initially, brachial systolic blood pressure is recorded by inflating the blood pressure cuff above the elbow. The Doppler probe is coupled to the skin over the brachial artery with ultrasound gel. The probe should be held at a 45-degree angle that opposes the direction of brachial artery blood flow. The cuff is slowly deflated after the brachial artery has been occluded and the pressure at which the pulse sound returns is recorded as a brachial systolic pressure. Systolic pressure is measured in each arm two times and the highest value is used in the ABI calculation. Following the brachial recording, ankle systolic pressure is recorded by inflating the cuff approximately 5 cm above the ankle's medial malleolus and listening for vascular occlusion with the Doppler probe placed over the posterior tibial or dorsalis pedis arteries (see Figure 1). The cuff is slowly deflated and the pressure at which the pulse sound reappears is recorded as an ankle systolic pressure. After two posterior tibial or dorsalis pedis measures on each side, the highest systolic value is used in the ABI calculation. The ABI is calculated by dividing ankle systolic pressure by brachial systolic pressure:
ABI = ankle systolic
brachial systolic
Investigators4,5 report improved reliability when using multiple measurements and consistent cuff size and placement through all measures. A low normalized ABI measure fluctuation (1.7%) was reported during repeated measures in a 6-week study of 15 individuals with intermittent claudication.6 In another ABI reliability study,7 intraclass correlation coefficients (ICC) were calculated for intraobserver and interobserver variability within the same day and after a 1-week period. Fifty-four patients with various stages of PAOD were evaluated; ICCs were as follows: 0.98 (same observer/same day measures), 0.89 (same observer/measures separated by 1 week), 0.92 (different observers/same day measures), and 0.87 (different observers/measures separated by 1 week).
Normally, ankle systolic pressure should be equal or slightly higher than brachial systolic pressure (see Table 1). An ABI > 1.0 to 1.2 is considered normal, while progressively low ABIs are indicative of arterial narrowing associated with PAOD.8 Recently, two research studies9,10 involved performing ABIs on sample populations with (n = 50) and without PAOD (n = 353). An average ABI of 0.68 (+ 0.12) was reported for the PAOD population, while the sampled population without PAOD had an average ABI of 1.16 (+0.13). When considering measurement error, most clinicians will use an index change of 0.15 as a significant difference either from disease progression or therapeutic intervention (ie, arterial bypass).

References: 

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  says:
  October 22.2009 at 01:59 am
  
Dear Prof. Holland:

I was in your class back in 1994 for PT modalities at Hunter. I am in the process of completing my tDPT at BU and came across this article doing research for my class. It is very helpful and great knowing that you are continuing helping students and clinicians with your expertise and knowledge.

Thank you for everything!

Lily Zhang

  

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