Lower
extremity pain: a quantitative and qualitative analysis in a private
office of vascular surgery
(Portuguese
PDF version)
Jorge
R. Ribas Timi1
1.
MSc and Ph.D. in Surgical Clinic, Universidade Federal do Paraná
(UFPR). Associate professor of Vascular Surgery, UFPR. Vascular surgeon,
Serviço de Cirurgia Vascular Prof. Dr. Elias Abrão,
Curitiba, PR.
This
work was performed at Clínica da Circulação,
Curitiba, PR.
Correspondence:
Jorge R. Ribas Timi
Rua Padre Agostinho, 1923/2601
CEP 80710000 - Curitiba, PR
Brazil
Tel.: (41) 244.8787
E-mail: jorgetimi@terra.com.br
ABSTRACT
Objective:
The purpose of this study was to evaluate prevalence and profile
of patients presented with pain in the lower extremities at a private
office of vascular surgery.
Method: During one year, all new appointments were prospectively
evaluated. Patients presented with pain in the lower extremities
were asked several questions related to the following items: gender,
age, source of referral, indication of referral and diagnosis.
Results: Among 870 new appointments, 88.7% presented lower extremity
pain as a major complaint (772/870), being 78% female. The average
age was 47.4 years (ranging from 4 months to 93 years of age). Referral
was made by a physician for 46.4% of patients; 34% were referred
by other patients, 17.8% scheduled the appointment by themselves,
and 1.8% were referred by other health professionals. Vascular disease
was the main etiology in 93.4%. The number of patients incorrectly
referred was another source of "leg pain" complaint, besides
vascular disease, being 6.6% of cases of osteo origin (6.5% by physicians
and 6.8% by layman). In 10.3% of cases, "leg pain" complaints
were due to other causes rather than vascular disease, being osteomuscular
origin the most common. Venous disease was the major problem in
85.8%, arterial disease in 10.3% and lymphatic disease in 3.9% of
cases.
Conclusion: This analysis allowed us to conclude that: a) the
majority of patients seen by a vascular surgery presented lower
extremity pain as their main complaint; b) patient referral showed
minimal difference between laymen (patients and direct search) and
health care professionals; c) incorrect referral was low and equal
for the two groups; d) concomitant etiologies of "leg pain"
complaint were presented in 10% of cases; e) venous disease is the
most predominant etiology of "leg pain" complaint, which
leads patients to seek treatment with a vascular surgeon.
Key-words:
pain, lower extremities, surgery, physicians' offices.
Palavras-chave: dor, membros inferiores, cirurgia, consultórios
médicos.
J
Vasc Br 2004;3(2):123-6
Every time
our missed Professor Elias Abrão was asked about his speciality,
he answered with a smile on his face: "I am a 'leg-zoologist'".
Although vascular surgery is the speciality in charge of all anatomic
areas of the human body, the majority of patients who look for vascular
surgeons have the same complain: problems with their lower extremities.
Patients enter the physician's office and promptly complain about "leg
pain", regardless it is from vascular origin or not. These patients
are usually referred by physicians, by other patients, or they come
by themselves, through a direct search in the medical directory provided
by their health insurance company, increasing, therefore, the list of
wrongly referred patients. A vascular surgeon is not the suitable physician
to provide primary care, but a professional that should be referred
to provide specialized care to the population.
The national literature lacks an analysis of the medical care provided
at vascular surgery offices.
The data provided in this article present local validity. They must
solely serve as basis for comparison with other realities that exist
in a country of continental dimension and a rich cultural diversity
like Brazil
MATERIAL
AND METHOD
During
one-year period, the author evaluated all first appointments at his
office. In this office, the author attends private patients, as well
as patients with insurance.
For each of these appointments, an individual protocol was filled, including
the following items:
- Patient's data: gender and age;
- Patient's complaint: if it was related to lower extremities or
not. For patients whose complaint was related to lower extremities,
the remain sections of the protocol was filled. Patients, whose complaint
had no relation to lower extremities, were excluded from the study.
- Patient's referral: if it was performed by a health professional
or not. If performed by health professional, if it was a physician or
not; if a physician, which speciality. For patients not referred by
a health professional, if referral was performed by other patient or
by direct search in the medical directory of their insurance company.
- Initial diagnostic impression: it was initially registered whether
the patient presented a vascular or non-vascular cause, or an association
of vascular and non-vascular cause for "leg pain" complaint.
For patients with vascular cause, it was registered whether the cause
was venous, arterial or lymphatic. For those with non-vascular cause,
it was registered if the cause was of neurological or osteomuscular
origin, or other causes (for example, sickle cell anemia).
- Correct referral of the patient: It was considered correct the
patient who had been referred with "leg pain" of vascular
origin, or of mixed origin: vascular associated with non-vascular cause.
Patients who presented non-vascular cause were considered incorrectly
referred.
RESULTS
In one-year
period, 870 patients were attended in their first consultation. Among
those, 772 complained about "leg pain" (88.7%). The majority
of patients (603) were female (78%). The average age was 47.4 (ranging
from 4 months to 93 years of age).
Patients were referred by a physician in 46.4% of cases, by other patient
in 34%, direct search in 17.8% and other health care professionals in
1.8%. Table 1 shows the speciality of 358 physicians that referred the
patients who took part in the study. Table 2 shows the distribution
of health care professionals who referred 372 patients.
 Table
1 - Speciality of the physicians that referred patients who participated
in the study
 |
| Speciality
|
n |
% |
|
| Gynecology
|
86
|
24,0 |
| Orthopedy
|
83
|
23,2 |
| Cardiology
|
39
|
10,9 |
| General
Practice |
37
|
10,3 |
| Vascular
Surgery |
18 |
5,0 |
| Dermatology
|
13
|
3,6 |
| Urology |
11 |
3,0 |
| Nephrology |
9 |
2,5 |
| Rheumatology |
9 |
2,5 |
| Plastic
surgery |
7 |
2,0 |
| Endocrinology |
7 |
2,0 |
| Hematology |
6 |
1,6 |
| Neurology |
5 |
1,4 |
| Oncology |
5 |
1,4 |
| General
surgery |
4 |
1,1 |
| Pediatrics |
4 |
1,1 |
| Homeopathy |
3 |
0,8 |
| Gastroenterology |
2 |
0,6 |
| Occupational
medicine |
2 |
0,6 |
| Neurosurgery |
2 |
0,6 |
| Acupuncture |
1 |
0,3 |
| Anesthesiology |
1 |
0,3 |
| Infectology
|
1 |
0,3 |
| Otolaryngology |
1 |
0,3 |
| Pneumology |
1 |
0,3 |
| Radiology |
1 |
0,3 |
|
Table
2 - Health care professionals who referred patients to the vascular
surgeon
|
|
| Professional |
n |
% |
|
| Physician
|
358
|
96,2 |
| Physiotherapist |
9 |
2,5 |
| Nurse |
2 |
0,5 |
| Social
assistant |
2 |
0,5 |
| Psychologist |
1 |
0,3 |
| Total
|
372
|
100,0 |
|
Vascular
disease was the etiologic factor of "leg pain" complaint in
93.4% of patients. In 10.3% of the cases there was another cause for
"leg pain" complaint, besides vascular disease, being osteomuscular
origin the most common. Venous disease was present in 85.8% of cases,
arterial disease in 10.3% and lymphatic disease in 3.9% of cases.
Incorrect referral general rate was 6.6%, being 6.5% for patients referred
by health care professionals and 6.8% for patients referred by layman.
DISCUSSION
"Leg
pain" is the most common complaint that leads a patient to seek
treatment with a vascular surgeon. This the reason why a vascular surgeon
must understand all possible causes of lower limb pain, as well as arterial,
venous and lymphatic etiologies.1,2
Among 870 patients analyzed in their first consultation, 772, that is,
88.7% presented "leg pain" as complaint, being venous disease
responsible for 85.8% of cases, followed by arterial diseases 10.3%
and lymphatic disease 3.9% of cases. This is, in part, explained by
the fact that the great majority of patients were women, who are more
affected by varicose veins than men. In addition, women are more concerned
about the problem not only because of its symptomatology, but also due
to aesthetic matters.
"Leg pain" complaint was presented in all age groups, with
patients from 4 months up to 93 years of age. However, as the majority
of patients consisted of females presented with varicose veins, there
was age predominance between 30 and 50 years, which made the average
age group of this study to be 47.4 years.
Considering patients with "leg plain" complaint, health care
professionals almost equally share with layman the number of referrals
to vascular surgeon. The ideal vascular surgery office is the one where
every patient should de refereed by a physician in order to obtain a
specialized treatment. This is not the reality in Brazil however. More
than half of the patients (51.8%) search for a vascular surgeon without
having a previous medical consultation. These patients are referred
mostly by other patients or by direct search.
The majority of health care professionals who referred the patients
that participated in this study were physicians (96.2%). These physicians
belonged to 26 different specialities. Because they see more venous
problems, gynecologists and orthopedists are those who most refer patients
to vascular surgeon. Cardiologists, endocrinologists, nephrologists,
due to the profile of their patients, refer a larger number of patients
with arterial disease. However, the data shown on Table 1 is rather
variable, since they depend on the professional, or even the personal,
relationship of the vascular surgeon.
Vascular surgeons often hear from first time patients that they have
"circulatory problems" or "poor circulation" reflected
by "leg pain or any other pain in the lower extremities. Although
51.8% of patients were primarily attended by a vascular surgeon, that
is, they were not referred by a physician or by a health care professional,
only 6.8% of these patients did not present a vascular cause for their
complaint. This percentage brought two surprises. The first one is that
this percentage was lower than expected when the study was designed.
The second is that the rate was similar to the incorrect referral made
by physicians, which was 6.5% of cases.
It is also surprising the fact that 10.3% of patients presented a cause
that was associated with vascular cause. This is extremely important
since isolated treatment of non-vascular cause will not be sufficient
to solve the "leg pain" complaint. When there is a concomitant
cause for the complaint, the patient should be informed immediately,
avoiding, therefore, further dissatisfaction from a patient with a vascular
treatment with good results and a persistent painful symptom on the
lower extremities.
In conclusion, the vascular surgeon needs to understand the etiology
of lower extremity pain, in order to perform an accurate differential
diagnosis,1,2 since the majority of the
patients complain about "leg pain", but only 6.6% of these
patients do not present a vascular cause for their complaint and 10.3%
present a concomitant cause of lower extremity pain associated with
vascular disease. Ignoring other etiologies of lower extremity pain
lead us to a potential diagnostic error in 16.9% of the cases attended
in a vascular surgeon's office, which is an unacceptable rate.
REFERENCES
1.
Kauffman P. Dor nas pernas. Boletim Informativo SBACV 2001;8:4.
2. Moreira RCR, Timi JRR. Dor na perna: uma abordagem
multidisciplinar das dores dos membros inferiores. Curitiba; E@rt edições;
2000.
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