Toe and ankle/brachial indices

NewsBot · Jul 14, 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 Jan-Feb;34(1):35-44.
Bonham PA, Cappuccio M, Hulsey T, Michel Y, Kelechi T, Jenkins C, Robison J.

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 · Jul 14, 2007

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Toe Brachial Index

NewsBot · Dec 15, 2015

Cross-sectional correlations between the toe brachial index and lower limb complications in older people
Jennifer A Sonter and Vivienne H Chuter
International Wound Journal; Early View

The aim of the study was to investigate the relationship between the toe brachial index (TBI) and foot ulceration and amputation in older people. Two hundred and sixty-one participants meeting guidelines for lower limb vascular assessment had their toe and brachial blood pressure measured, medical records audited and signs and symptoms of peripheral arterial disease (PAD) recorded. Pearson's correlation and linear regression analyses were performed to determine the strength of relationships between variables. Significant correlations were found between the TBI and painful symptoms (r = −0?35, P < 0?05) and foot complications (r = −0?31, P < 0?05). After adjusting for traditional risk factors for foot complications, participants with a TBI <0?70 were 19 times more likely to have a history of foot wounds or amputation (odds ratio = 19?20, 95% confidence interval (CI): 2?36–155?96, P < 0?001) than those with higher TBI values (>0?70). This preliminary study supports a TBI threshold of 0?70 for PAD diagnosis and indicates that lower values are associated with painful symptoms, history of ulceration and amputation. Future longitudinal investigation of the predictive capacity is now warranted.
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NewsBot · Mar 24, 2016

Associations between the toe brachial index and health-related quality of life in older people.
Sonter J, Chuter V
Health Qual Life Outcomes. 2016 Mar 22;14(1):50

BACKGROUND:
Peripheral arterial disease is responsible for impaired health-related quality of life as a consequence of associated morbidity and mortality. The toe brachial index (TBI) provides non-invasive assessment of peripheral arterial health. Lower TBI values have been associated with foot ulceration, amputation and impaired healing, however, the relationship with health-related quality of life has not yet been investigated. The aim of this study was to explore the relationship between the TBI and health-related quality of life.
METHODS:
This was a cross-sectional study of 100 participants aged over 50 years recruited from podiatry clinics in New South Wales, Australia. The TBI was calculated using automated equipment and quality of life was assessed using the Short Form 36 version 2 (SF-36v2). Strength of associations was determined using Pearson and Spearman correlation coefficients.
RESULTS:
Lower TBI values demonstrated modest significant associations with poorer scores for the SF-36v2 domains Role Physical (r s = 0.219, p > 0.05), Social Function (r s = 0.219, p < 0.05) and the Physical Component Summary score (r s = 0.203, p < 0.05).
CONCLUSIONS:
The toe brachial index demonstrates limited associations with physical and social aspects of health-related quality of life in older people.
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NewsBot · Aug 24, 2016

The effect of pretest rest time on automated measures of toe systolic blood pressure and the toe brachial index.
Sadler SG et al
Blood Press Monit. 2015 Oct;20(5):245-8

OBJECTIVES:
Evaluation of peripheral blood supply is fundamental to risk categorization and subsequent ongoing monitoring of patients with lower extremity peripheral arterial disease. Toe systolic blood pressure (TSBP) and the toe brachial index (TBI) are both valid and reliable vascular screening techniques that are commonly used in clinical practice. However, the effect of pretest rest duration on the magnitude of these measurements is unclear.
METHODS:
Eighty individuals meeting current guidelines for lower extremity peripheral arterial disease screening volunteered to participate. The Systoe and MicroLife automated devices were used to measure toe and brachial systolic blood pressures, respectively, following 5, 10 and 15 min of rest in a horizontal supine position. A ratio of TSBP to brachial pressure was used to calculate the TBI and change in TBI at each time interval was investigated.
RESULTS:
A significant increase in TSBP [3.66 mmHg; 95% confidence interval (CI): 1.44-5.89; P≤0.001] and the TBI (0.03; 95% CI: 0.01-0.05; P≤0.001) occurred between 5 and 10 min. Between 10 and 15 min, there was a nonsignificant decrease in TSBP (-0.73 mmHg; 95% CI: -1.48 to 2.93; P=1.000) and the TBI (0.00; 95% CI: -0.02 to 0.02; P=1.000).
CONCLUSION:
Ten minutes of pretest rest is recommended for measurement of TSBP and for both pressure measurements used in the calculation of a TBI to ensure that stable pressures are measured
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NewsBot · Dec 19, 2017

Diagnostic accuracy of resting systolic toe pressure for diagnosis of peripheral arterial disease in people with and without diabetes: a cross-sectional retrospective case-control study
Peta Ellen Tehan, Alex Louise Barwick, Mathew Sebastian and Vivienne Helaine Chuter
Journal of Foot and Ankle Research201710:58

Background
The resting systolic toe pressure (TP) is a measure of small arterial function in the periphery. TP is used in addition to the ankle-brachial index when screening for peripheral arterial disease (PAD) of the lower limb in those with diabetes, particularly in the presence of lower limb medial arterial calcification. It may be used as an adjunct assessment of lower limb vascular function and as a predictor of wound healing. The aim of this study was to determine the diagnostic accuracy of TP for detecting PAD in people with and without diabetes.

Methods
This was a retrospective case-control study. Two researchers extracted information from consecutive patient records, including TP measurements, colour Duplex ultrasound results, demographic information, and medical history. Measures of diagnostic accuracy were determined by receiver operating curve (ROC) analysis, and calculation of sensitivity, specificity, and positive and negative likelihood ratios.

Results
Three hundred and nintey-four participants with suspected PAD were included. In the diabetes group (n = 176), ROC analysis of TP for detecting PAD was 0.78 (95%CI: 0.69 to 0.84). In the control group (n = 218), the ROC of TP was 0.73 (95%CI: 0.70 to 0.80). TP had highest sensitivity when anatomical distribution of disease was both proximal and distal (diabetes group: 79.49%, the control group: 82.61%). TP yielded highest sensitivity in mild disease (50–75% stenosis) in diabetes group, (81.82%) and moderate disease (>75% stenosis) in control group (80.77%).

Conclusions
Our findings indicate that TPs are useful to assist in diagnosing PAD in clinical practice, however, results should be interpreted with caution due to the small probability of PAD being present with a negative test.
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NewsBot · Jun 7, 2019

Clinical Utility of the Ankle-Brachial Index and Toe Brachial Index in Patients with Diabetic Foot Ulcers.
Ababneh M et al
Current Diabetes Reviews [30 May 2019]

This cross sectional study investigated the clinical use of the ankle-brachial index (ABI) and toe brachial index (TBI) in 91 type 2 diabetic foot ulcer patients who visited the diabetic foot clinic, Prince Sultan Military Medical City, Saudi Arabia during July 2017 and January 2018. The ABI and TBI facilitated the detection of peripheral arterial disease (PAD) and the patients' medical records were used to collect the clinical and demographic variables. The variables of duration (p = 0.047) and treatment (p = 0.046) of the ABI showed significant differences. Age (p = 0.034) and duration (p = 0.001) were the factors related to the diagnosis of TBI by the "χ2" test. From the TBI 26.4% of the patients were found to have PAD, while the ABI showed that 21.8% patients had the condition. However, no statistical significance was noted. From the regression analysis the variable duration of diabetes (≥ 20 years of age) was recognized as an independent risk factor for TBI. In conclusion, it is recommend both the ABI and TBI to be used as screening tests for PAD in diabetic foot ulcer patients.
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NewsBot · Jun 7, 2019

Consistency of Toe Systolic Pressures, Brachial Systolic Pressures, and Toe-Brachial Indices in People with and without Diabetes.
Trevethan R
Curr Diabetes Rev. 2019;15(2):85-92

BACKGROUND & AIMS:
Toe Systolic Blood Pressures (TSPs) and Toe-Brachial Indices (TBIs) have been identified as useful adjuncts in the identification of pedal ischemia, peripheral artery occlusive diseases, and risk for either nonhealing of lower extremity wounds or for amputation. Valid measurement of TSPs and TBIs is therefore essential. However, it could be jeopardized by rater, instrument, and intratestee inconsistency. These three sources of inconsistency were examined in this research.

METHODS:
Five publications addressing TSP and TBI consistency were identified and their results were analyzed using intraclass correlation coefficients.

RESULTS:
Moderate variability in TSPs was found across all studies; greater variability was evidenced in brachial systolic pressure, particularly for people who had diabetes; and TBI values also exhibited considerable variability, but little difference between people who did and did not have diabetes.

CONCLUSION:
These findings provide qualified evidence of consistency regarding measurement of TSPs but challenge TBI as a valid and useful indicator in screening, prognostic, and monitoring contexts, particularly for people who have diabetes. However, there is a prospect that TBI assessment could be improved by adherence to standardized protocols and by obtaining multiple measurements from toes and arms on a single occasion as well as on different occasions.
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NewsBot · Jun 21, 2019

Toe Pressure in Predicting Diabetic Foot Ulcer Healing: A Systematic Review and Meta-Analysis.
Tay WL et al
Ann Vasc Surg. 2019 Jun 17

OBJECTIVES:
Foot ulceration is the most frequently recognised lower extremity complication in diabetic patients. Predicting wound healing is an essential step in the management of diabetic foot ulcers (DFU), as it is estimated that early detection and appropriate treatments may prevent up to 85% of amputations. Toe blood pressure (TBP) is a quick and portable bedside assessment and is less affected by medial sclerosis of arteries present in the diabetic population compared to other measurements like ankle-brachial index (ABI). This systematic review seeks to evaluate the sensitivity and specificity of toe pressure in prediction of DFU wound healing.

DESIGN, MATERIALS AND METHODS:
PubMed/ MEDLINE and Embase databases were systematically searched up to 20 September 2017 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All randomised control, prospective and retrospective trials were considered for inclusion if they reported healing rates of diabetic foot ulcers with respect to different TBP readings. Healing was defined to be intact skin for at least six months or at time of death. Quality assessment of articles was performed using the Revman Quality Assessment. Information on healing rates with respect to different TBP values was extracted. Summary estimates of sensitivity and specificity of TBP in predicting healing of DFU wounds were obtained using a bivariate model.

RESULTS:
A total of 580 articles were screened. Eight studies (six prospective and two retrospective) inclusive of 909 patients were eligible for inclusion. It was found that a TBP of more than 30mmHg is associated with a sensitivity and specificity of 0.86 and 0.58 respectively for healing of diabetic foot ulcers.

CONCLUSIONS:
A TBP of more than 30mmHg is sensitive but not specific in the prediction of healing of DFUs. Due to its portability and quick analysis, TBP may be used as a bedside assessment to complement current clinical parameters to aid in predicting the healing of diabetic foot ulcers.
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NewsBot · Aug 19, 2019

Toe Brachial Pressure Index as Alternative Method to Correlate Arteriosclerotic Disease in Type 2 Diabetes.
Martín-Fuentes M et al
J Assoc Physicians India. 2018 Oct;66(10):36-39.

AIM:
To investigate the association between the ankle brachial pressure index and toe brachial pressure index with the findings of carotid Doppler ultrasonography in patients with diabetes and coronary ischaemic disease.

METHODS AND RESULTS:
The objective was to evaluate the relationship between insulin resistance and serum homocysteine in subjects with polycystic ovarian syndrome (PCOS).

CONCLUSION:
We studied 81 type 2 diabetic patients, with established cardiovascular disease, consecutively admitted to our outpatient clinic in the Division of Diabetes of La Paz Hospital. We collected clinic and demographic data, ABI and TBI were measured and at the same time a carotid Doppler ultrasound was performed. Multiple linear regression analysis was used to investigate the association of ABI and TBI with carotid disease. We found a negative correlation between TBI and internal carotid artery peak systolic velocity (ICA PSV) (r = -0,300, p= 0,007), common carotid artery resistance index (CCA RI) (r = -0,232, p= 0,038) and intima-media thickness (IMT) (r -0,236, p=0,035). Toe blood pressure and ICA PSV showed an inverse association (r=- 0,226, p=0,042). Adjusting for clinical and demographic characteristic, only low TBI index is associated with a higher ICA PSV.
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NewsBot · Apr 5, 2022

Diagnostic thresholds for absolute systolic toe pressure and toe-brachial index in diabetic foot screening
Chuan Guan Ng, Cherry Ya Wen Cheong, Wan Chin Chan, Sean Wei Loong Ho, Melissa Susan Li Ann Phua, Khalid Anuar
Ann Acad Med Singap. 2022 Mar;51(3):143-148.

Introduction: Identifying peripheral arterial disease (PAD) during diabetic foot screening (DFS) is crucial in reducing the risk of diabetic foot ulcerations and lower limb amputations. Screening assessments commonly used include absolute systolic toe pressure (ASTP) and toe-brachial index (TBI). There is a lack of research defining the threshold values of both assessment methods. We aimed to compare the accuracy of ASTP and TBI and establish optimal threshold values of ASTP and TBI with reference to the internationally accepted ankle-brachial pressure index (ABPI) screening test, for a multiethnic diabetic population in Singapore.

Methods: A retrospective, observational study of DFS results from January 2017 to December 2017 was conducted. Receiver operating characteristic analysis was conducted for ASTP and TBI using the internationally accepted ABPI cut-off value of ≤0.9 to indicate PAD.

Results: A total of 1,454 patients with mean (standard deviation) age of 63.1 (12.4) years old were included. There were 50.8% men and 49.2% women, comprising 69.7% Chinese, 13.5% Indian, 10.1% Malay and 6.7% other ethnicities. Areas under the curve for ASTP and TBI were 0.89 (95% confidence interval [Cl] 0.85-0.94) and 0.94 (95% Cl 0.90-0.98), respectively, and the difference was statistically significant (P<0.001). Derived optimal threshold values to indicate ABPI≤0.9 for ASTP and TBI were <95.5mmHg (specificity 0.86, sensitivity 0.84) and <0.7 (specificity 0.89, sensitivity 0.95), respectively.

Conclusion: ASTP or TBI may be used to detect ABPI-determined PAD in DFS. The optimal threshold values derived from a multiethnic Asian diabetic population were <95.5mmHg for ASTP and <0.7 for TBI.
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