Ankle & Toe Brachial Indices vs Laboratory Standard

NewsBot · Jan 20, 2007

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Are Ankle and Toe Brachial Indices (ABI-TBI) Obtained by a Pocket Doppler Interchangeable With Those Obtained by Standard Laboratory Equipment?
J Wound Ostomy Continence Nurs. 2007 January/February;34(1):35-44.

PURPOSE: The aim of this study was to determine if the ankle and toe brachial indices obtained by an experienced registered nurse (RN) using a pocket Doppler were within acceptable levels of agreement with those obtained by a registered vascular technologist (RVT) using standard laboratory equipment.

DESIGN: A within-subjects comparative design was used.

SETTING AND SUBJECTS: Thirty subjects who were referred to a vascular laboratory for arterial studies were recruited. All tests were performed in the outpatient vascular laboratory of a large, urban medical center.

METHODOLOGY: Ankle and toe brachial indices were measured on each subject by the RN and the RVT during each visit. Data were analyzed using the Bland-Altman method to assess the level of agreement between the RN's pocket Doppler and the RVT's standard laboratory equipment.

RESULTS: Differences between each instrument's ankle brachial indices were within the a priori 15% limit of agreement. Differences between each instrument's toe brachial indices exceeded the a priori 15% limit of agreement.

CONCLUSION: The ankle brachial index obtained by using a pocket Doppler by an experienced RN is interchangeable with vascular laboratory testing for detection of lower extremity arterial disease (LEAD). The pocket Doppler-derived toe brachial index was not interchangeable with vascular laboratory testing for detection of LEAD.
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Admin2 · Jan 20, 2007

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Toe Brachial Index

NewsBot · Jun 8, 2012

Interrater and intrarater reliability of photoplethysmography for measuring toe blood pressure and toe-brachial index in people with diabetes mellitus
Christopher D Scanlon, Kris E Park, David Mapletoft, Lindy Begg and Joshua Burns
Journal of Foot and Ankle Research 2012, 5:13

Background
A reliable tool to measure arterial flow to the feet in people with diabetes is required given that they are particularly prone to peripheral arterial disease. Traditionally, the ankle brachial index (ABI) has been used to measure arterial circulation, but its application is limited due to calcification of larger arteries. More recently, toe pressure and the toe brachial index (TBI) has been suggested as superior to ABI measurements because they assess smaller digital arteries less prone to arterial calcification. However, reliability studies for the clinical use of photoplethysmography (PPG) in people with diabetes are lacking.

Methods
Sixty people with diabetes mellitus (35 males and 25 females, mean age 59.6 yrs) consented to take part in the study. The majority (92%) had type 2 diabetes and 8% had type 1 diabetes. Forty-three percent were diagnosed as having peripheral neuropathy when tested using a biothesiometer and 15% were current smokers (10 - 40/day). A podiatrist and a diabetes educator measured toe and brachial blood pressure independently and in a random order using PPG. These measurements were repeated again seven days later, and subsequently analysed with intraclass correlation coefficients (ICC), 95% confidence intervals (CI) and standard error of measurement (SEM).

Results
The intrarater reliability of measuring toe pressures was excellent (ICC3,1 =0.78-0.79, SEM 8mmHg) and interrater reliability was also excellent (ICC2,2=0.93, SEM 4mmHg). The intrarater reliability for measuring brachial pressures was generally poor (ICC3,1 = 0.40 - 0.42, SEM 19mmHg) and interrater reliability was fair-good (ICC2,2. 0.65, SEM 14mmHg). The TBI intrarater reliability was fair-good (ICC3,1= 0.51-0.72, SEM 0.08), whilst the interrater reliability of TBI was excellent (ICC2,2= 0.85, SEM 0.07).

Conclusion
Based on these results, interrater and intrarater reliability of PPG is excellent for measuring toe blood pressure, good for TBI and only fair for brachial pressures in people with diabetes mellitus.
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NewsBot · Aug 13, 2015

Use of hand-held Doppler ultrasound examination by podiatrists: a reliability study
Peta Ellen Tehan and Vivienne Helaine Chuter
Journal of Foot and Ankle Research 2015, 8:36 doi:10.1186/s13047-015-0097-2

Background
Hand held Doppler examination is a frequently used non-invasive vascular assessment utilised by podiatrists. Despite this, the reliability of hand-held Doppler has not been thoroughly investigated. Given the importance of Doppler in completing a vascular assessment of the lower limb, it is essential to determine the reliability of the interpretation of this testing method in practicing podiatrists.

Methods
This was a multi-centre inter and intra-rater reliability study. Four podiatrists (the raters) participated in this study, two public and two private practitioners. Three aspects of Doppler use were examined; (i) use of Doppler (i.e., technique and interpretation), (ii) interpretation of Doppler audio sounds, and (iii) interpretation of visual Doppler waveforms (i.e., tracings). Participants meeting current guidelines for vascular screening attended two testing sessions, 1 week apart at either the private practice (n = 32), or the public practice (n = 31). To assess use of Doppler, the raters evaluated the Doppler waveforms that they collected, rating them as mono-phasic or multi-phasic. To assess Doppler audio sounds and visual Doppler waveforms, raters were required to evaluate 30 audio recordings of Doppler sounds and 30 waveform tracings, respectively, that were previously recorded and chosen at random by the researchers. Cohen’s kappa (κ) statistics were used to calculate inter and intra-rater reliability using SPSS version 19.

Results
Use of Doppler demonstrated the lowest reliability for both pairs of clinicians (inter-rater reliability κ 0.20 to 0.24 and intra-rater reliability κ 0.27 to 0.42). The public podiatrists showed higher reliability in audio interpretation (inter-tester reliability κ 0.61, intra-tester reliability κ 1.00) compared to the private podiatrists (inter-tester reliability κ 0.31, intra-tester reliability κ 0.53). Evaluation of Doppler waveform tracings demonstrated highest reliability, with inter-rater reliability ranging from κ 0.77 to 0.90 and intra-rater reliability from κ 0.81 to 1.00.

Conclusions
There is a need for ongoing education for podiatrists using Doppler in clinical practice, as the reliability for the clinical use of the Doppler was low. This indicates that technique could be an issue. There is also a need to further evaluate if hand-held Doppler equipment, using the examinations that we evaluated, is suitable for use in the contexts examined in this study.
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NewsBot · Aug 20, 2015

Non-invasive vascular assessment in the foot with diabetes: sensitivity and specificity of the ankle brachial index, toe brachial index and continuous wave Doppler for detecting peripheral arterial disease.
Tehan PE, Bray A, Chuter VH
J Diabetes Complications. 2015 Jul 21

BACKGROUND & AIMS:
Non-invasive lower limb vascular assessment in people at risk of peripheral arterial disease (PAD) including those with diabetes is crucial. There is evidence that standard assessment techniques such as the ankle-brachial index (ABI) may be less effective in people with diabetes. However there is limited evidence for other frequently used tests including continuous wave Doppler (CWD), and the toe-brachial index (TBI). The aim of this study was to determine the sensitivity and specificity of, ABI, CWD and TBI in a population with, and without diabetes.
METHODS:
Participants with and without diabetes who met current guidelines for vascular screening were recruited, and CWD waveforms, an ABI and a TBI were obtained from the right lower limb. Diagnostic accuracy was determined using colour duplex ultrasound (CFDU). Receiver operating characteristic curves were calculated.
RESULTS:
117 participants were recruited, seventy-two with diabetes and forty-five without diabetes. CWD had the highest sensitivity in people with diabetes (74%) and without (84%). CWD also had the highest specificity in people with diabetes (74%) and without (84%) compared to both TBI and ABI. In participants with diabetes, the ABI was a poor test, area under the curve: 0.58 (p=0.27).
CONCLUSIONS:
CWD waveform is more likely to detect significant PAD compared to ABI and TBI in people with and without diabetes.
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NewsBot · Sep 2, 2015

Effect of patient positioning on toe pressure measurement using noninvasive vascular testing.
Sansosti LE, Berger MD, Gerrity MA, Kelly P, Meyr AJ
Br J Community Nurs. 2015 Sep;20(Sup9):S12-S16.

OBJECTIVE:
Interpretation of digital pressure in the assessment of healing potential for diabetic foot disease has become common because of the potential for false elevation with the ankle-brachial index. However, the specific testing protocol for segmental Doppler examinations and photoplethysmography require patients to be in the supine position, with the lower limbs at heart level, in order to minimise the effect of hydrostatic pressure. This may be difficult in many patients with lower extremity pathology, particularly those who are nonambulatory, with painful wounds, or with orthopnea. In these situations, the noninvasive vascular test may be performed with the patient in a more comfortable position, which may include sitting in a wheelchair with the leg in a dependent position. The objective of this investigation was to evaluate the effect of patient positioning on measurement of the digital pressure.
METHOD:
Hallux pressures were measured in 20 healthy volunteers in 3 variable positions of limb dependency.
RESULTS:
The mean?standard deviation of digital pressure for subjects while lying supine with the limb at heart level was 103.5?26.0 mmHg (the recommended position for performance of the test), while sitting upright with the limb level on the table was 130.6?27.9 mmHg (+26.2%, p<0.0001) and sitting upright with the limb in a dependent position was 169.8?30.8 mmHg (+64.1%, p<0.0001).
CONCLUSION:
On the basis of these results, we conclude that patient positioning has a significant effect on measurement of digital pressure.
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NewsBot · Sep 3, 2015

Ankle-Brachial Index, Toe-Brachial Index, and Pulse Volume Recording in Healthy Young Adults
Watanabe Yoshiko et al
Annals of Vascular Diseases

Objective: To clarify the characteristics of ankle-brachial index (ABI), toe-brachial index (TBI), and pulse volume recording (PVR) of the ankle with brachial-ankle pulse wave velocity (baPWV) in healthy young adults.Material and Methods: We analyzed ABI, TBI, baPWV, and PVR in the ankle of healthy adults aged 20 to 25 years (median, 20 years) using an automatic oscillometric device between 2002 and 2013. The ABI, baPWV, and PVR in 1282 legs of 641 subjects (301 men and 340 women) and the TBI in 474 toes of 237 subjects (117 men and 120 women) were evaluated.Results: The measured values showed no bilateral differences. ABI and baPWV were higher in men than in women, but TBI was similar in both sexes. ABI <1.0 was observed in 18.1% of the legs in men and in 25.6% in women. TBI <0.7 was observed in 16.2% of the toes in men and 19.1% in women. For ankle PVR, the % mean arterial pressure was higher in women than in men. The upstroke time was <180 ms in most subjects.Conclusions: For young people, ABI <1.0 or TBI <0.7 may not always indicate vascular abnormalities. When evaluating circulatory indexes, age and sex should be considered.
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NewsBot · Dec 8, 2017

Podiatry Ankle Duplex Scan: Readily Learned and Accurate in Diabetes.
Normahani P et al
Angiology. 2017 Jan 1:3319717695994. doi: 10.1177/0003319717695994

We aimed to train podiatrists to perform a focused duplex ultrasound scan (DUS) of the tibial vessels at the ankle in diabetic patients; podiatry ankle (PodAnk) duplex scan. Thirteen podiatrists underwent an intensive 3-hour long simulation training session. Participants were then assessed performing bilateral PodAnk duplex scans of 3 diabetic patients with peripheral arterial disease. Participants were assessed using the duplex ultrasound objective structured assessment of technical skills (DUOSATS) tool and an "Imaging Score". A total of 156 vessel assessments were performed. All patients had abnormal waveforms with a loss of triphasic flow. Loss of triphasic flow was accurately detected in 145 (92.9%) vessels; the correct waveform was identified in 139 (89.1%) cases. Participants achieved excellent DUOSATS scores (median 24 [interquartile range: 23-25], max attainable score of 26) as well as "Imaging Scores" (8 [8-8], max attainable score of 8) indicating proficiency in technical skills. The mean time taken for each bilateral ankle assessment was 20.4 minutes (standard deviation ±6.7). We have demonstrated that a focused DUS for the purpose of vascular assessment of the diabetic foot is readily learned using intensive simulation training.
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NewsBot · Dec 9, 2020

A systematic review and meta-analysis of the diagnostic accuracy of point-of-care tests used to establish the presence of peripheral arterial disease in people with diabetes
Pasha Normahani et al
J Vasc Surg. 2020 Dec 2;S0741-5214(20)32502-7

Objective: There is currently no agreement as to which bedside test is the most useful for the diagnosis of PAD in diabetes. The aim of this systematic review and meta-analysis was to evaluate the performance of bedside tests for the detection of PAD in individuals with diabetes.

Research design and methods: MEDLINE and EMBASE databases were systematically searched for studies providing data on diagnostic performance of bedside tests used for the detection of PAD in people with diabetes. A meta-analysis was performed to obtain pooled estimates of sensitivity and specificity for the diagnosis of PAD.

Results: A total of 18 studies, reporting on a total of 3016 limbs of diabetic patients, were included in our qualitative review. Of these, eleven studies (1543 limbs) were included in the meta-analysis of diagnostic accuracy: ankle-brachial pressure index (ABPI, 9 studies, 1368 limbs, sensitivity 63.5% [95% CI 51.7-73.9%], specificity 89.3% [95% CI 81.1-94.2%]); toe-brachial pressure index (TBPI, 3 studies, 221 limbs, sensitivity 83.0% [95% CI 59.1-94.3%], specificity 66.3% [95% CI 41.3-84.6%]); and tibial waveform assessment (4 studies, 397 limbs, sensitivity 82.8% [95% CI 73.3-89.4%], specificity 86.8% [95% CI 75.5-93.3%]). Overall, there was a high risk of bias across studies, most frequently relating to patient selection and lack of blinding.

Conclusions: TBPI, pulse oximetry and tibial arterial waveform assessment have demonstrated some promise, warranting further investigation.
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