Clinical Compendium

Perspective of the Primary-Care Provider
Perspective of the Nurse Practitioner
Perspective of the Community Pharmacist

Dr Doghramji is the Medical Director of Health Services at Ursinus College and a Family Physician at Collegeville Family Practice in Collegeville, Pennsylvania.

Dr Doghramji has indicated the following relevant financial relationships: consultant for Cephalon, Inc., Takeda Pharmaceuticals North America, Inc., and Sanofi-Aventis; speaker for Cephalon, Inc., Takeda Pharmaceuticals North America, Inc., Pfizer Inc, Wyeth, and Sanofi-Aventis; stockholder in Pfizer Inc and Wyeth.

On a daily basis, the primary-care provider (PCP) encounters a large number of patients either complaining of leg disorders or who need to be screened for leg disorders. Complaints can be varied and confusing, both to the patient and to the practitioner, resulting in misdiagnosis and/or unnecessary testing and treatment. Worse yet, if the condition is left unmanaged, valuable time is lost in preventing disease progression. Patients can have pains in both lower extremities or just the one, in similar locations or in varied places, or in joints, soft tissue, nerves, and/or skin. The complaints can be chronic or acute. Examination findings can be revealing or conflicting. All these issues result in leg complaints and findings that are challenging to diagnose and manage.

Not only are leg complaints very common, they also have a life-changing impact on the patient’s quality of life. With discomfort and dysfunction come disability and disuse. Patients in pain and with leg disturbances often move less, causing a decrease in their going from place to place.  Being stationary or dependent on others for locomotion is a major source of stress and mood disturbance.  These diseases affect ambulation, increasing the risk for falls and injuries.  Especially in the elderly, leg disorders can have a profound and prolonged impact on their health, leading to even further erosion of their quality of life. Aside from the discomfort, quality of life diminution, and increased healthcare costs that accompany leg disorders, there is also the burden to a patient’s family and friends, as well as the effect on his or her livelihood that can ensue. Decreased ambulation also affects one’s ability to exercise, which is so vital to maintaining not only optimal health but also to preserving one of the foundations of good health.  Exercise is the cornerstone in treating and/or preventing diabetes, hypertension, coronary artery disease, peripheral vascular disease, and numerous other diseases.

With increased index of suspicion, most leg disorders that result in morbidity and disability can be diagnosed early.  With greater attention to their presence, they can even be screened for. Early detection and early intervention can often result in a better outcome to a number of leg ailments. It is thus incumbent on the PCP to have a higher index of suspicion for certain ailments that present either silently or minimally. Moreover, one needs a fundamental knowledge of the different leg disorders that can occur, as well as the ability to identify patients at greatest risk. Finally, the PCP should possess an expeditious and efficient method of reaching the right diagnosis and then instituting optimal management.

It is with this in mind that this compendium has been constructed: to provide the PCP with a concise and methodical approach in diagnosing and treating patients with leg complaints, as well as patients at higher risk for leg diseases.

Proceed to the Table of Contents

Ms Counts is the Eloise Ross Eberly Professor at The Pennsylvania State University School of Nursing in Waynesburg and Clinical Director of the Primary Care Center of Mt. Morris, Inc. in Mount Morris, Pennsylvania.

Dr Counts has indicated that she has no relevant financial relationships with a commercial interest to disclose.

Leg disorders cross all lines of medicine and can present in patients throughout their lifespan: from childhood to old age. As new findings on cause, prevention, symptoms, prevalence, and treatment are revealed, it becomes increasingly important for primary-care providers to have a means to sort through the myriad available information to help them correctly identify the specific condition that must be addressed.

As identified by the American Academy of Nurse Practitioners (AANP), nurse practitioners combine the role of provider, mentor, educator, researcher, and administrator. As a rule, they focus on the whole patient and the impact of any condition on the patient’s lifestyle. Nurse practitioners are responsible for coordinating care with multiple specialists, and thus must be familiar with the multiple etiologies associated with leg disorders.

Leg disorders from any etiology have an impact on mobility, sleep patterns, general well-being, and overall lifestyle of the patient. Patients presenting with a leg disorder may complain of multiple, varying symptoms such as legs moving all the time, specific pain, numbness and tingling, swelling, or change in perceived temperature. When looking at the clinical presentation, identified symptoms, and results of the physical examination, the nurse practitioner needs to simultaneously consider the psychologic, neurologic, vascular, and musculoskeletal etiology of the disorder.

Nurse practitioners are acutely aware of the implication of misdiagnosis and its impact on patient outcomes. The spectrum of leg disorders can include diabetic peripheral neuropathy, restless legs syndrome, deep vein thrombosis, peripheral arterial disease, nocturnal leg cramps, shin splints, bowed legs, leg limb discrepancy, meralgia paresthetica, and osteoarthritis. When these conditions are not addressed or are misdiagnosed, it can lead to further complications and a decrease in patients’ ability to deal with comorbid conditions and life in general.

The nurse practitioner, as the primary care provider, needs to be able to quickly determine the differential diagnosis so that appropriate treatment methodologies can be implemented, thereby preserving the functional abilities of the individual. In addition to drugs, nurse practitioners may also implement nonpharmacologic treatment strategies with the goal of reducing morbidity and mortality, and improving the patient’s quality of life.

In looking at the multiple fields from which leg disorders can originate, evidence-based practice and guidelines from each field need to be accessed to assure the proper diagnosis. For primary-care providers, specifically nurse practitioners, it is important to be able to quickly and accurately determine—based on the spectrum of leg disorders—what they are dealing with and how best to treat the condition.

A compendium of leg disorders enhances the nurse practitioner’s ability to recognize and manage conditions by bringing information from all fields into a single resource. It is a valuable tool in the primary-care setting, reducing the need for a provider to investigate different resources, saving time, and allowing for more in-depth attention to the patient. If, as current data suggest, as much as 40% of the people in our population will experience some type of leg disorder in their lifetime, a compendium of medical literature and clinical evidence in one coherent resource would clearly augment both our understanding of disease differentiation and the impact of leg disorders on our patients and our society.

Proceed to the Table of Contents

Ms Binaso is the Director of Strategic Alliances and Business Development for the American Pharmacists Association in Washington, DC.

Ms Binaso has indicated that she has no financial relationships with a commercial interest to disclose.

Community pharmacists are one of the most accessible healthcare providers. Every day, they help patients live happier and healthier lives. They see a variety of patients, with various conditions or disease states, and develop relationships that last for generations. Because we have excelled in advancing medicine by earlier diagnosis and better treatments, patients are living longer. Many of the baby-boom generation remain active and continue to live life to the fullest. Viewed by patients as medication experts, community pharmacists are often sought out for advice on medications or possible treatment options available for various diseases. The role of pharmacists is also expanding outside of the dispensing arena and resulting in more patient-care–based services and medication therapy management.

Healthcare has made great strides over the past decade. In the realm of leg disorders, many medication treatment options have advanced into what has become known as the “biologics” age. Every year, we see new advances and revised guidelines on treatment options for conditions like rheumatoid arthritis, peripheral arterial disease, deep vein thrombosis (DVT), pulmonary embolism, osteoarthritis, and restless legs syndrome. The community pharmacist plays a key role in assisting patients in understanding how to properly use these therapies (injection devices, dosage forms) and why it is important that they continue to use them as prescribed. Helping patients stay adherent and compliant to medication is a key goal for successful treatment that also contributes to the patient’s quality of life. 

Contrary to popular belief, leg disorders, in general, are not restricted to the elderly. They can affect anyone at anytime. DVT is a perfect example of this. Over the past few years, its effect on airline passengers has gained wide attention, and DVT is not selective. Other patient populations at risk for leg disorders include pregnant women and women on medications for contraception. It is not uncommon for the community pharmacist to dispense more than one prescription a day for osteoarthritis or rheumatoid arthritis. Also, the rise in patients diagnosed with diabetes has made neuropathies (nerve damage) to the legs and feet even more common. Patients routinely ask pharmacists what therapies are safe and effective for leg cramps. The pharmacist, therefore, becomes a key player, especially when the patient is uncomfortable and in pain. 

A compendium is defined as a “brief summary of a larger work or of a field of knowledge.” This compendium covers 20 common and 16 rare vascular, neurologic, and musculoskeletal leg disorders in detail, including an overview of each disorder. The vast array of information that is available concerning leg disorders can be daunting to healthcare providers. They may, for instance, be unsure regarding where to find pertinent information or have limited resources available to them. It is not easy to keep hundreds of different documents at your fingertips at all times when you are answering patients’ questions. Hence, the availability of a single reference source is a welcome addition. 

Along with encouraging patients to list all of their medications on a single sheet of paper to create a personal medication record, it is also essential that pharmacists have tools available such as a compendium to provide a single source of vital information that can be easily accessed and give pharmacists what they need to help advance patient care.

Proceed to the Table of Contents