Peripheral arterial disease (PAD) is estimated to affect up to 12% of the general population [1
], and up to 14% of people with diabetes [2
]. Characterised by progressive stenosis of the lower limb arteries, the presence of PAD is strongly predictive of morbidity and mortality in people with diabetes [3
Due to the high risk of concurrent cardiovascular disease, and lower limb complications associated with PAD, and the rapid progression of atherosclerosis in people with diabetes, accurate and reliable diagnostic testing methods are necessary for early diagnosis and effective ongoing monitoring. Early detection of PAD allows for intervention and management of coexisting cardiovascular disease, including lifestyle advice and medication [4
], and prevention and management of lower limb complications such as foot ulceration and amputation [6
The ankle brachial index (ABI) is typically calculated as the ratio of the highest of the dorsalis pedis and posterior tibial artery systolic pressure to the highest of the left and right brachial systolic pressures [7
]. A normal value for ABI assessment within the general population is considered to be 1.00–1.40 [8
], with values 0.91–0.99 classed as ‘borderline’, while those below 0.91 represent likely PAD [9
]. The ABI is a widely used as a non-invasive method of conducting objective lower limb vascular assessment to monitor at risk patients for the development of PAD [9
]. Current international guidelines recommend the ABI be used routinely to monitor for PAD in older people, those with a smoking history and in people with diabetes [8
Due to the requirement for periodic assessments over the long term to identify development, and where relevant, progression of PAD, high reliability of the ABI is essential [7
]. There are a number of factors that are recognised to affect ABI measurement, and, subsequently, its reliability. These include recent caffeine ingestion [11
], tobacco use [12
] or exercise [13
], clinical experience [15
], as well as measurement procedure including lack of pre-test rest [17
] and body position [18
] during measurement. Existing studies of ABI reliability are inconclusive, with inconsistencies in methodology, statistical analysis and reporting making interpretation of the findings difficult, particularly when coupled with the lack of data for those without symptoms, but for whom screening is recommended [19
]. There are currently little available data quantifying the magnitude of error that occurs with the measurement and therefore the amount of change in ABI that represents a true change (over and above measurement error) [20
]. There has also been limited investigation of the intra-tester reliability of the ABI in people with diabetes, with only one previous study, which reported a coefficient of variation of 8% [21
]. In diabetes cohorts, PAD is known to have a more aggressive disease presentation [22
], to be more likely to affect infra-genicular arteries [23
] and to co-exist with medial arterial calcification which can prevent compression and pressure measurement of the lower leg arteries [24
]. Although there is significant evidence that these factors affect diagnostic accuracy of the ABI in this population, it is unknown the extent to which the presence of diabetes may affect ABI reliability [25
]. The primary aim of this study was to determine the intra-tester reliability of the ABI in adults with and without a diagnosis of type 1 or type 2 diabetes mellitus.
Ninety participants were recruited (44 male, 46 female), 45 with diabetes. Of those recruited 5 participants (4 males, 1 female, all with diabetes) were unable to attend follow-up testing on the correct day or time and were excluded from the analysis. Eighty-five participants attended both sessions (40 male, 45 female), 40 with diabetes. The mean age of participants with diabetes was 68 years (SD ±7.3 years), and 76.3 years (±7.4 years) for those without. Mean BMI for those with and without diabetes was 33.9 ± 5.4 and 29.4 ± 3.9 respectively. Participant characteristics are described in Table 1
. There was no significant difference between the number of participants with a history of smoking, or between the gender distribution in those with and without diabetes.
Males n (%)
Females n (%)
Age range (years)
Mean age (years)
Mean body mass index
Smoking history n (%)
Mean diabetes duration (years)
| || |
Oral hypoglycaemics n (%)
| || |
Insulin n (%)
| || |
Neuropathy n (%)
| || |
Mean ankle pressure 1 mmHg (SD)
Mean ankle pressure 2 mmHg (SD)
Mean brachial pressure 1 mmHg (SD)
Mean brachial pressure 2 mmHg (SD)
Mean ABI test 1 mmHg (SD)
Mean ABI test 2 mmHg (SD
Mean ABI ≤0.90 in both assessments
N = 3
N = 5
There was no statistically significant difference between mean ankle pressure, mean brachial pressure or mean ABI values for the two groups (Table 1
). The rates of abnormal ABI results across both testing sessions for both groups were low (diabetes n
= 3, no diabetes n
= 5). There were no ABI results in excess of 1.4 indicating clinically apparent medial arterial calcification in either group. The diabetes group were significantly younger and with a higher BMI than the group without diabetes. All ICCs were above the lowest acceptable ICC value as previously determined.
Intra-tester reliability results are presented in Table 2
. The intra-tester reliability of the ABI was found to be moderate to good, with an ICC value of 0.80 (95% CI 0.70 to 0.86). However, sub-group analysis of participants with and without diabetes found that ABI reliability was slightly lower in participants with diabetes (ICC 0.78, 95% CI 0.62 to 0.88) compared to those without (ICC 0.82, 95% CI 0.70 to 0.90).
Whole group (N = 85)
0.83 to 0.92
− 8.69 to 18.22
0.67 to 0.84
−12.27 to 19.12
0.70 to 0.86
−0.14 to 0.16
Diabetes (n = 40)
0.85 to 0.96
−15.07 to 10.12
0.72 to 0.91
−13.37 to 11.12
0.62 to 0.88
−0.16 to 0.14
No diabetes (n = 45)
0.80 to 0.93
−6.75 to 18.35
0.58 to 0.85
−11.31 to 11.12
0.70 to 0.90
−0.15 to 0.15
The intraclass correlation coefficient (ICC) values obtained suggest that the intra-tester reliability of the ABI is good, with values that are comparable to the findings of previous studies in mixed populations including those with risk factors for and/or suspected PAD [30
]. Similar values were obtained for the whole group (ICC 0.81) as well as for the group with (ICC 0.78) and without (ICC 0.82) diabetes for all analyses. The limits of agreement (LOA) that were obtained were quite large with upper and lower bounds ranging from − 0.16 to 0.16. The LOA value represents the values between which 95% of the differences between measurements fall, with differences outside of those values being more likely to represent an actual change (rather than measurement error). For this measurement, the LOA suggest that an ABI value of 1.0 could vary from 0.84 to 1.16, and not reflect an actual change in peripheral arterial supply.
Similarly, the standard error of measurement (SEM), is an estimate of how far the sample mean is likely to be from the population mean. A SEM of 0.03 demonstrates that the variability of the test means that a large change in ABI is required clinically for there to be certainty around it being a true change rather than variability of the measurement. This was supported by a large minimal detectable change (MDC), which reflects the amount of change required to indicate a valid change in the test result that is not due to chance [33
]. The MDC was found to be 0.08 for the ABI overall, and in participants without diabetes. For the diabetes group, the MDC was 0.11. In practice, this represents a large difference between measures being required to be indicative of clinical change rather than measurement. For example, a decrease of 0.10 in ABI between measurements may represent a change from a normal value of 1.00 to 0.90, indicating a pathological value, however where the MDC is 0.11 this change may occur as a result of measurement variability rather than disease. This finding highlights the need for the results of this test to be interpreted with caution, particularly in people with diabetes. A number of cross sectional studies have identified problems with diagnostic accuracy of the ABI in specific populations, particularly those with diabetes and in older age, and have identified the need for additional testing (e.g. continuous wave Doppler, toe pressures) to be used to provide a more comprehensive evaluation of lower limb status [27
]. Although reliability relates to the consistency of the measurement as opposed to the accuracy, our results substantiate the need for multifaceted testing to be used as the variability of the measurement of the ABI likely further affects its effectiveness for identifying and monitoring PAD.
Our sub-analysis by diabetes status demonstrated a small reduction in ABI reliability in those with diabetes. To the authors’ knowledge, there are no published studies that evaluate ABI reliability in people with diabetes using ICC, with which our findings could be compared. However, published studies evaluating the intra-tester reliability of toe brachial index report similar results in people with diabetes (ICC0.72–0.75) compared to those without (ICC 0.74–0.8) [35
]. The only previously published study evaluating ABI reliability in people with diabetes reported a coefficient of variation of 8% [21
], which is similar to the standard error measurement of ±0.04 found in this study. Diabetes has been associated with several complications that affect diagnostic accuracy of the ABI for PAD including medial arterial calcification (MAC). It is possible such complications could affect reliability, however to our knowledge this has not yet been established. The diabetes cohort recruited to our study, although having increased risk of PAD (e.g. higher BMI, diabetes, insulin use), did not demonstrate overt clinical signs or symptoms of PAD and MAC. This cohort also had a relatively short mean duration of diabetes (< 10 years), making them less likely to have developed related complications. Similarly, the no diabetes group were significantly older (mean age > 75 years) placing them at greater risk of age-related PAD and MAC but lack of abnormally low or high ABI results suggest this was not the case. This may have resulted in the similar reliability of the test in both groups.
Overall brachial pressure measurements were found to be less reliable than ankle pressure measurements in participants with and without diabetes, which is consistent with previous research using handheld Doppler in podiatry practice [35
]. The use of automated oscillometric systolic blood pressure measurement has been shown to be more reliable than manual Doppler method in people with diabetes [37
]. Given that ankle pressures were found to be highly reliable (ICC 0.88–0.92) improving the reliability of brachial pressure measurement is likely to improve reliability of the ABI overall. Furthermore, the use of automated pressure measurement may reduce the time taken to carry out ABI, which is one of the most frequently cited reasons not to perform vascular assessment [38
]. There was a statistically significant difference in ankle pressure and brachial pressure values obtained between the first and second visit, however this was not reflected in a significant difference in the ABI result obtained. This finding may result from variation in the exact timing of the second appointment compared to the first (e.g. early in the morning for visit 1, mid-morning for visit 2), or it may be due to familiarity with the procedure, location and researchers at the second visit.
The findings of this study should be considered in the light of the controlled conditions under which the ABI was performed, which may not reflect those under which the test is performed in clinical practice. Furthermore, all measurements were obtained manually using Doppler, and represent reliability in relation to that technique only. A further limitation is the lack of blinding of the clinician to the pressure values obtained. This study only established the intra-tester reliability of the ABI when assessed by an experienced podiatrist. In clinical practice, the ABI is used by a range of health professionals, and as such the findings of this study may not be generalisable to other clinicians. In addition, the inter-rater reliability of the ABI is of considerable importance, considering that it is often used by different personnel rather than always being repeated by the same clinician. It is also most commonly repeated at intervals of more than 1 week, and not necessarily at the same time of day, and with patients not necessarily having avoided factors that may affect their result.
The results of this study suggest that while intra class correlation coefficients for the reliability of the ABI are good for people with and without diabetes, measures of the variability of the measurement suggest a large difference between tests results is required to reflect a true change. Therefore, results of the ABI should be considered in the context of other assessment of lower limb vascular status rather than in isolation. As such, our findings support the use of ABI only as part of a comprehensive vascular assessment, with the use of other techniques to form a more complete clinical picture. Further research should evaluate the inter-tester reliability of the ABI and using automated pressure measurement techniques.
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