Exercise Training for Management of Peripheral Arterial Disease: A Systematic Review and Meta-Analysis

Improvement in 6-Minute Walking Distance after Supervised Exercise Training Is Related to Changes in Quality of Life in Patients with Lower Extremity Peripheral Artery Disease

This study aimed to investigate the relationship between supervised exercise training (SET)-induced changes in treadmill performance and 6 min walking distance, and changes in general (physical and mental) self-perceived health-related quality of life (HRQoL) in symptomatic patients with lower extremity peripheral artery disease (PAD). This is an observational study investigating Fontaine stage II PAD patients participating in 3-month SET. Before and following SET, treadmill performance (pain-free (PFWD) and maximal (MWD)), and 6 min walking distance (6MWD) were assessed. Self-perceived HRQoL was assessed with the Medical Outcomes Study Short-Form 36 (SF-36). Ankle- and toe-brachial indexes were also measured. One-hundred forty-seven patients with PAD were included (64.9 ± 9.6 y, 70% men). After SET, PFWD (+102%, p ≤ 0.001), MWD (+87%, p ≤ 0.001), and 6MWD (+14%, p ≤ 0.001) significantly increased. All eight SF-36 subscale scores significantly improved following SET (p ≤ 0.04). SET significantly improved physical and mental component summaries of the SF-36 (p ≤ 0.001). Larger increases in 6MWD were associated with greater improvements in physical (β = 0.19; p = 0.02) and mental (β = 0.24; p = 0.005) component summaries of the SF-36. No significant relationship was observed between changes in treadmill performance and changes in physical and mental component summaries of the SF-36. These results show that improvements in 6MWD following SET are related to improvements in general self-perceived HRQoL in patients with symptomatic lower extremity PAD. On the contrary, changes in treadmill performance were not related to improvements in HRQoL. These results suggest that the 6 min walking test is an essential outcome measure to assess overall patient functional status following interventions in patients with PAD.

Supervised Resistance Training on Functional Capacity, Muscle Strength and Vascular Function in Peripheral Artery Disease: An Updated Systematic Review and Meta-Analysis

Supervised resistance training appears to be a promising alternative exercise modality to supervised walking in patients with peripheral artery disease (PAD). This meta-analysis examined the efficacy of supervised RT for improving walking capacity, and whether adaptations occur at the vascular and/or skeletal muscle level in PAD patients. We searched Medline, CINAHL, Scopus, and Cochrane Central Register of Controlled Trials databases for randomized controlled trials (RCTs) in PAD patients testing the effects of supervised RT for ≥4 wk. on walking capacity, vascular function, and muscle strength. Pooled effect estimates were calculated and evaluated using conventional meta-analytic procedures. Six RCTs compared supervised RT to standard care. Overall, supervised RT prolonged claudication onset distance during a 6-min walk test (6-MWT) (101.7 m (59.6, 143.8), p < 0.001) and improved total walking distance during graded treadmill walking (SMD: 0.67 (0.33, 1.01), p < 0.001) and the 6-MWT (49.4 m (3.1, 95.6), p = 0.04). Five RCTS compared supervised RT and supervised intermittent walking, where the differences in functional capacity between the two exercise modalities appear to depend on the intensity of the exercise program. The insufficient evidence on the effects of RT on vascular function and muscle strength permitted only limited exploration. We conclude that RT is effective in prolonging walking performance in PAD patients. Whether RT exerts its influence on functional capacity by promoting blood flow and/or enhancing skeletal muscle strength remains unclear.

Effectiveness of Home-Based Pain-Free Exercise versus Walking Advice in Patients with Peripheral Artery Disease: A Randomized Controlled Trial

Exercise therapy in the intermediate stages of peripheral artery disease (PAD) represents an effective solution to improve mobility and quality of life (QoL). Home-based programs, although less effective than supervised programs, have been found to be successful when conducted at high intensity by walking near maximal pain. In this randomized trial, we aim to compare a low-intensity, pain-free structured home-based exercise (SHB) program to an active control group that will be advised to walk according to guidelines. Sixty PAD patients aged > 60 years with claudication will be randomized with a 1:1 ratio to SHB or Control. Patients in the training group will be prescribed an interval walking program at controlled speed to be performed at home; the speed will be increased weekly. At baseline and after 6 months, the following outcomes will be collected: pain-free walking distance and 6-min walking distance (primary outcome), ankle-brachial index, QoL by the VascuQoL-6 questionnaire, foot temperature by thermal camera, 5-time sit-to-stand test, and long-term clinical outcomes including revascularization rate and mortality. The home-based pain-free exercise program may represent a sustainable and cost effective option for patients and health services. The trial has been approved by the CE-AVEC Ethics Committee (898/20). Registration details: Clinicaltrials.gov NCT04751890 [Registered: 12 February 2021].

Satisfaction and Acceptability of Telemonitored Home-Based Exercise in Patients With Intermittent Claudication: Pragmatic Observational Pilot Study

BACKGROUND

Current guidelines recommend supervised exercise training (SET) as a first-line treatment in patients with intermittent claudication (IC). SET has been shown to be more effective than home-based exercise therapy (HBET). However, the lack of available SET programs hampers broad SET implementation in clinical practice.

OBJECTIVE

The aim of this study is to assess patient satisfaction and acceptability of a structured HBET program using wearable technology and elastic band resistance exercises.

METHODS

A total of 20 patients with IC (Rutherford 1-3) with internet access and currently not engaged in structured exercise training were recruited in a pragmatic observational pilot study. Participants were instructed to complete 3 walking sessions and 2 elastic band resistance exercise sessions per week in their home environment during a 4-week period. Patient satisfaction and acceptability were assessed using a 5-point Likert scale questionnaire (1-2=very unsatisfied, 3=neutral, and 4-5=very satisfied) evaluating the materials and intervention content. Secondary outcomes were evaluated at baseline and at completion of the 4-week intervention and included maximal walking distance (MWD) and pain-free walking distance (PFWD), physical fitness, and patient-reported outcomes on quality of life, walking capacity, levels of kinesiophobia, and self-efficacy. Statistically significant changes were tested using paired t tests or Wilcoxon signed-rank tests.

RESULTS

All patients (15 men, 5 women; mean age 64.6, SD 10.6 years; range 41-81 years) completed the 4-week intervention and were highly satisfied with the program (mean overall score 4.5, SD 0.5). Patients' questionnaire responses documented willingness to recommend the exercise program to other patients (mean 4.5, SD 0.5; median 4.5) and preference for continuing the intervention (mean 4.3, SD 0.5; median 4). Furthermore, participants endorsed the use of the sports watches to track walking sessions (mean 4.25, SD 0.6; median 4), felt safe (mean 4.4, SD 0.6; median 4), and appreciated personal feedback (mean 4.55, SD 0.5; median 5) and flexibility of training (mean 4.1, SD 0.7; median 4). Resistance training was not preferred over walking training (mean 2.65, SD 0.8; median 3). In addition, PFWD (+89 m; P=.001), MWD (+58 m; P=.03), Walking Impairment Questionnaire distance score (+0.18; P=.01), activity-related scores (+0.54; P<.001), and total quality of life (+0.36; P=.009) improved following the intervention. Other patient-related outcomes, physical fitness, and physical activity remained to be statistically unaltered.

CONCLUSIONS

Patients with IC were satisfied and accepted technology to monitor and guide HBET, with observed short-term effectiveness regarding walking capacity and quality of life. However, elastic band resistance exercises as a part of HBET were not preferred over progressive walking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04043546; https://clinicaltrials.gov/ct2/show/NCT04043546.

THE REFORM OF SUPPLY OF PUBLIC HEALTH SERVICES LEADING THE TRAINING OF SPORTS PROFESSIONALS IN LOCAL COLLEGES AND UNIVERSITIES IN THE BACKGROUND OF HEALTHY CHINA

ABSTRACT With the continuous expansion of public health services, the output of sports talents under the existing training mode of sports talents in Colleges and Universities has been unable to meet the market demand of social sports, so it is inevitable to optimize the existing talent training mode. Based on the original “dual system” teaching mode of college sports talents, this study incorporated the LDTA model to optimize and adjust it, so as to establish a new college sports talent training system. In order to prove the feasibility of the new sports talent training system, after analyzing the market economy of the local social sports industry and the basic situation of students, this paper studies the application of the new sports talent training system to the practical teaching of physical education students in 2017 in university X from 2019 to the first half of 2020, and compares the final scores of the students under the original teaching mode and the new sports talent training system. At present, the students' final scores under the new PE talent training system are generally higher than those under the original teaching mode. It is also found that for some practical skills courses, the students' performance under the new PE talent training system is obviously better than that under the original teaching mode. All these results show that the new sports talent training system established by the research is feasible, and has high practical value for promoting the reform of the supply of sports talents in Colleges and Universities and improving the professional skills and knowledge level of sports talents.

Gait changes after supervised exercise training in patients with symptomatic lower extremity peripheral artery disease

This study aimed to investigate the effects of supervised exercise training (SET) on walking performance and spatiotemporal gait changes in patients with symptomatic lower extremity peripheral artery disease (PAD). In this single-arm prospective nonrandomized cohort study, patients with Fontaine stage II PAD following a 3-month SET program were included. Before and after SET, a constant-load treadmill test was performed to determine the pain-free and maximal walking distances (PFWD and MWD, respectively). During this test, spatiotemporal gait parameters were assessed. The ankle-brachial index (ABI) and toe-brachial index (TBI) were also measured. Twenty-seven patients with PAD (64.0 ± 1.9 y, 74% men) were included. Following SET, the PFWD (+68%; p = 0.001) and MWD (+79%; p ⩽ 0.001) significantly increased. The ABI and TBI did not change significantly. Following SET, the stride duration, stride frequency, stride length, and double support phase duration did not change significantly. In contrast, subphases of stance showed significant changes: the loading response (+8%; p = 0.03) and foot-flat (+2%; p = 0.01) phases were significantly longer, whereas the push-off phase (-7%; p = 0.002) was significantly shorter. A significant positive correlation was found between changes in the foot-flat phase and changes in PFWD (r = 0.43, p = 0.03). A significant negative correlation was found between changes in the push-off phase and changes in PFWD (r = -0.39, p = 0.05). No significant correlations were found between changes in relative durations of the subphases of stance and MWD. These results indicate that changes in temporal gait parameters during the foot contact phase potentially constitute an underlying mechanism of delayed claudication distance in patients with symptomatic PAD.

Increased modifiable cardiovascular risk factors in patients with Takayasu arteritis: a multicenter cross-sectional study

BACKGROUND

Modifiable cardiovascular risk factors (MCRFs), such as those related to aerobic capacity, muscle strength, physical activity, and body composition, have been poorly studied in Takayasu arteritis (TAK). Therefore, the aim of the study was to investigate MCRFs and their relationships with disease status and comorbidities among patients with TAK.

METHODS

A multicenter cross-sectional study was conducted between 2019 and 2020, in which 20 adult women with TAK were compared with 16 healthy controls matched by gender, age, and body mass index. The following parameters were analyzed: aerobic capacity by cardiopulmonary test; muscle function by timed-stands test, timed up-and-go test, and handgrip test; muscle strength by one-repetition maximum test and handgrip test; body composition by densitometry; physical activity and metabolic equivalent by IPAQ, quality of life by HAQ and SF-36; disease activity by ITAS2010 and NIH score; and presence of comorbidities.

RESULTS

Patients with TAK had a mean age of 41.5 (38.0-46.3) years, disease duration of 16.0 (9.5-20.0) years, and a mean BMI of 27.7±4.5 kg/m². Three out of the 20 patients with TAK had active disease. Regarding comorbidities, 16 patients had systemic arterial hypertension, 11 had dyslipidemia, and two had type 2 diabetes mellitus, while the control group had no comorbidities. TAK had a significant reduction in aerobic capacity (absolute and relative VO₂ peak), muscle strength in the lower limbs, increased visceral adipose tissue, waist-to-hip ratio, reduced walking capacity, decreased weekly metabolic equivalent, and quality of life (P< 0.05) as compared to controls. However, there were no correlations between these MCRFs parameters and disease activity.

CONCLUSIONS

TAK show impairment in MCRFs; therefore, strategies able to improve MCRF should be considered in this disease.

Individual Differences in Response to Supervised Exercise Therapy for Peripheral Artery Disease

Nonresponse to exercise has been extensively examined in young athletes but is seldom reported in studies of aerobic exercise interventions in older adults. This study examined the prevalence of nonresponse and poor response to exercise in functional and quality of life outcomes and response patterns between and among older adults undergoing 12-weeks of supervised exercise therapy for the management of peripheral artery disease (N = 44, mean age 72.3 years, 47.7% female). The prevalence of nonresponse (no change/decline in performance) in walking distance was 31.8%. The prevalence of poor response (lack of a clinically meaningful improvement) was 43.2%. Similar patterns of response were observed in both objective and patient-reported measures of physical function. All participants improved in at least one outcome; only two participants improved in all measured outcomes. Additional research should examine modifiable predictors of response to inform programming and maximize an individual's potential benefit from exercise therapy.

Challenges in recruitment and adherence to a randomized clinical trial in Brazil on the effects of transcutaneous nervous electrical stimulation on individuals with peripheral arterial disease: A feasibility study

OBJECTIVE

Describe the feasibility, barriers during the recruitment and intervention period, recruitment rate (success and efficiency), and the level of participation and adherence in the randomized clinical trial to verify the effects of transcutaneous electrical nerve stimulation (TENS) for the symptoms of intermittent claudication (IC) and its repercussions on functional capacity, cardiorespiratory fitness and cardiovascular autonomic function in individuals with sta II Fontaine classification, residing in Brazil.

DESIGN

Prospective, double-blind, randomized clinical trial.

SETTING

Level secondary.

PARTICIPANTS

A total of 63 participants were screened, of which 12.6% were included. Eight individuals with peripheral arterial disease (PAD) and IC underwent a protocol that lasted 8 weeks.

INTERVENTIONS

The experimental group received 45 minutes TENS 10 Hz, followed by 30 minutes of aerobic exercise, and the control group received a placebo TENS also followed by 30 minutes of exercise. Incremental walking test, gait impairment questionnaire, treadmill test, heart rate variability, and 4-second test were applied, considering adherence, success, and efficiency.

RESULTS

The most efficient recruitment sources were as follows: 1) referral by physician and 2) referral by a physiotherapist. Out of 63 participants, 8 (12.6%) were included in the clinical trial. Participants were excluded due to the following reasons: not meeting the criteria (41 participants (65%)), locomotion (6 participants (9.5%)), transportation (5 participants (7.9%)), work release (1 participant (1.6%)), and interest (2 participants (3.2%)). The overall participation was 99 participants (51.6%) in a total of 192 sessions offered.

CONCLUSION

It was not possible to succeed in recruitment and adherence rates. The results of this clinical trial reinforce that PAD is neglected, and strategies including a multidisciplinary approach with the effective participation of nursing, physiotherapy, medicine, and nutrition professionals, are necessary to optimize care for individuals with PAD need to be strengthened. Brazilian Registry of Clinical Trials (RBR-8RTZFN).

Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners

Peripheral artery disease (PAD) is caused by atherosclerotic narrowing of the arteries supplying the lower limbs often resulting in intermittent claudication, evident as pain or cramping while walking. Supervised exercise training elicits clinically meaningful benefits in walking ability and quality of life. Walking is the modality of exercise with the strongest evidence and is recommended in several national and international guidelines. Alternate forms of exercise such as upper- or lower-body cycling may be used, if required by certain patients, although there is less evidence for these types of programmes. The evidence for progressive resistance training is growing and patients can also engage in strength-based training alongside a walking programme. For those unable to attend a supervised class (strongest evidence), home-based or 'self-facilitated' exercise programmes are known to improve walking distance when compared to simple advice. All exercise programmes, independent of the mode of delivery, should be progressive and individually prescribed where possible, considering disease severity, comorbidities and initial exercise capacity. All patients should aim to accumulate at least 30 min of aerobic activity, at least three times a week, for at least 3 months, ideally in the form of walking exercise to near-maximal claudication pain.

A Retrospective Comparison of Fitness and Exercise Progression in Patients With Coronary and Peripheral Artery Disease in Cardiac Rehabilitation

BACKGROUND

Cardiac rehabilitation (CR) is recommended for patients with coronary (CAD) and peripheral (PAD) artery disease. However, no study has compared changes in cardiorespiratory fitness (VO_2peak) or exercise prescription progression among PAD, CAD, and concomitant PAD and CAD (BOTH). The objectives of this study were to 1) compare change in VO_2peak among patients with PAD, CAD, and BOTH, and 2) examine progression in exercise prescription parameters in a comprehensive 6-month cardiac rehabilitation (CR) program.

METHODS

A retrospective analysis of patient data recorded from 2006 to 2017 from a large urban hospital was conducted. Patients with PAD (n = 63) and BOTH (n = 164) were included in the analyses. Patients with CAD (n = 63) were matched to PAD by sex (36.5% female), age (69 years), smoking status, diabetes, and year in program.

RESULTS

There were significant improvements in VO_2peak from baseline to 6 months in all groups (CAD +2.7 ± 3.4 mL⋅kg^-1⋅min^-1, PAD +2.4 ± 3.8 mL⋅kg^-1⋅min^-1, BOTH +1.8 ± 3.1 mL⋅kg^-1⋅min^-1; all P < 0.001). Between-group differences were significant between PAD and CAD as well as between CAD and BOTH (P = 0.001). Walking distance, duration, and pace increased for all groups over 6 months (P < 0.001), with a significant difference in pace between CAD and BOTH (P = 0.006).

CONCLUSIONS

Patients with PAD, CAD, and BOTH had significant improvements in VO_2peak following a 6-month CR program. However, despite similar prescribed walking distance and duration, improvements in VO_2peak were mitigated in PAD and BOTH compared with CAD. These results support benefits of CR for patients diagnosed with PAD, but alternate exercise strategies should be explored for patients with PAD.

Impact of aerobic exercise type on blood flow, muscle energy metabolism, and mitochondrial biogenesis in experimental lower extremity artery disease

Exercise training (ET) is recommended for lower extremity artery disease (LEAD) management. However, there is still little information on the hemodynamic and metabolic adaptations by skeletal muscle with ET. We examined whether hindlimb perfusion/vascularization and muscle energy metabolism are altered differently by three types of aerobic ET. ApoE^−/− mice with LEAD were assigned to one of four groups for 4 weeks: sedentary (SED), forced treadmill running (FTR), voluntary wheel running (VWR), or forced swimming (FS). Voluntary exercise capacity was improved and equally as efficient with FTR and VWR, but remained unchanged with FS. Neither ischemic hindlimb perfusion and oxygenation, nor arteriolar density and mRNA expression of arteriogenic-related genes differed between groups. ¹⁸FDG PET imaging revealed no difference in the steady-state levels of phosphorylated ¹⁸FDG in ischemic and non-ischemic hindlimb muscle between groups, nor was glycogen content or mRNA and protein expression of glucose metabolism-related genes in ischemic muscle modified. mRNA (but not protein) expression of lipid metabolism-related genes was upregulated across all exercise groups, particularly by non-ischemic muscle. Markers of mitochondrial content (mitochondrial DNA content and citrate synthase activity) as well as mRNA expression of mitochondrial biogenesis-related genes in muscle were not increased with ET. Contrary to FTR and VWR, swimming was ineffective in improving voluntary exercise capacity. The underlying hindlimb hemodynamics or muscle energy metabolism are unable to explain the benefits of running exercise.

Modes of exercise training for intermittent claudication

BACKGROUND

According to international guidelines and literature, all patients with intermittent claudication should receive an initial treatment of cardiovascular risk modification, lifestyle coaching, and supervised exercise therapy. In the literature, supervised exercise therapy often consists of treadmill or track walking. However, alternative modes of exercise therapy have been described and yielded similar results to walking. This raises the following question: which exercise mode produces the most favourable results? This is the first update of the original review published in 2014.

OBJECTIVES

To assess the effects of alternative modes of supervised exercise therapy compared to traditional walking exercise in patients with intermittent claudication.

SEARCH METHODS

The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 4 March 2019. We also undertook reference checking, citation searching and contact with study authors to identify additional studies. No language restriction was applied.

SELECTION CRITERIA

We included parallel-group randomised controlled trials comparing alternative modes of exercise training or combinations of exercise modes with a control group of supervised walking exercise in patients with clinically determined intermittent claudication. The supervised walking programme needed to be supervised at least twice a week for a consecutive six weeks of training.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, and assessed the risk of bias for each study. As we included studies with different treadmill test protocols and different measuring units (metres, minutes, or seconds), the standardised mean difference (SMD) approach was used for summary statistics of mean walking distance (MWD) and pain-free walking distance (PFWD). Summary estimates were obtained for all outcome measures using a random-effects model. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

For this update, five additional studies were included, making a total of 10 studies that randomised a total of 527 participants with intermittent claudication (IC). The alternative modes of exercise therapy included cycling, lower-extremity resistance training, upper-arm ergometry, Nordic walking, and combinations of exercise modes. Besides randomised controlled trials, two quasi-randomised trials were included. Overall risk of bias in included studies varied from high to low. According to GRADE criteria, the certainty of the evidence was downgraded to low, due to the relatively small sample sizes, clinical inconsistency, and inclusion of three studies with risk of bias concerns. Overall, comparing alternative exercise modes versus walking showed no clear differences for MWD at 12 weeks (standardised mean difference (SMD) -0.01, 95% confidence interval (CI) -0.29 to 0.27; P = 0.95; 6 studies; 274 participants; low-certainty evidence); or at the end of training (SMD -0.11, 95% CI -0.33 to 0.11; P = 0.32; 9 studies; 412 participants; low-certainty evidence). Similarly, no clear differences were detected in PFWD at 12 weeks (SMD -0.01, 95% CI -0.26 to 0.25; P = 0.97; 5 studies; 249 participants; low-certainty evidence); or at the end of training (SMD -0.06, 95% CI -0.30 to 0.17; P = 0.59; 8 studies, 382 participants; low-certainty evidence). Four studies reported on health-related quality of life (HR-QoL) and three studies reported on functional impairment. As the studies used different measurements, meta-analysis was only possible for the walking impairment questionnaire (WIQ) distance score, which demonstrated little or no difference between groups (MD -5.52, 95% CI -17.41 to 6.36; P = 0.36; 2 studies; 96 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

This review found no clear difference between alternative exercise modes and supervised walking exercise in improving the maximum and pain-free walking distance in patients with intermittent claudication. The certainty of this evidence was judged to be low, due to clinical inconsistency, small sample size and risk of bias concerns. The findings of this review indicate that alternative exercise modes may be useful when supervised walking exercise is not an option. More RCTs with adequate methodological quality and sufficient power are needed to provide solid evidence for comparisons between each alternative exercise mode and the current standard of supervised treadmill walking. Future RCTs should investigate outcome measures on walking behaviour, physical activity, cardiovascular risk, and HR-QoL, using standardised testing methods and reporting of outcomes to allow meaningful comparison across studies.

Expanding the Use of Six-Minute Walking Test in Patients with Intermittent Claudication

BACKGROUND

Six-min walking test (6MWT) has been widely in patients with symptomatic peripheral artery disease (PAD) to quantify the walking impairment and the efficacy of different therapeutic interventions. Despite the aforementioned usefulness of 6MWT for PAD, the information provided by this test goes beyond the meters walked. The aim of this study was to describe the relative values of 6MWT and body weight-walking distance product (DW) in patients with symptomatic PAD.

METHODS

Two hundred twenty-seven patients with symptomatic PAD participated in the study. The 6MWT was performed and absolute and claudication distances were obtained. The results of 6MWT were then relativized and expressed as a percentage of a healthy subject. DW was obtained by the product of 6MWT distance by weight. In both sexes, the relative 6MWT ranged from 57% to 64%.

RESULTS

Absolute 6MWT total distance (P < 0.001) was lower in women than in men, whereas the relative 6MWT total distance was similar between sexes (P = 0.398). The absolute and relative 6MWT total distance were similar among age categories (P > 0.072). The DW was higher in men than in women (P < 0.05). In addition, in women, DW was higher in younger group than in other age groups (P < 0.05).

CONCLUSIONS

Patients with symptomatic PAD achieve less than 70% of the distance achieved by an age-matched healthy subject. In patients with symptomatic PAD, the relative values of 6MWT total distance are similar between sexes and among different age groups, whereas DW are influenced by age and sex.

Cardiovascular Responses during and after Maximal Walking in Men and Women with Symptomatic Peripheral Artery Disease

BACKGROUND

Walking is recommended for patients with peripheral arterial disease (PAD). It has been shown that patients with PAD present sharper increases in blood pressure (BP) and heart rate (HR) during maximal walking when compared with healthy subjects. Additionally, women with PAD present a worse physiological profile, and it is possible that they may present higher cardiovascular load during and after a bout of maximal walking than men. Thus, the objective of this study was to compare cardiovascular and autonomic responses during and after maximal walking between men and women with PAD and intermittent claudication (IC).

METHODS

Forty patients with PAD and IC (20 men and 20 women) underwent, in random order, 2 sessions: control (standing on treadmill) and exercise (maximal treadmill walking test with Gardner's protocol). During the exercise, HR and BP were measured. Before and after the sessions, cardiovascular variables (BP HR, cardiac output, peripheral vascular resistance, and stroke volume) and autonomic modulation (HR and BP variabilities and baroreflex sensitivity) were assessed. In addition, an ambulatory BP monitoring was recorded after each session.

RESULTS

Men and women presented similar maximal walking capacity. During the walking test, HR and systolic BP increased similarly in men and women. After the maximal walking, cardiovascular and autonomic responses did not differ between the genders. In addition, postintervention ambulatory BP parameters were also similar in men and women. Therefore, in men and women, maximal walking similarly reduced clinic systolic BP and stroke volume, and increased HR and total power of HR variability during the recovery period.

CONCLUSIONS

Men and women with PAD and IC present similar cardiovascular and autonomic responses during and after maximal walking.

Asia-Pacific Consensus Statement on the Management of Peripheral Artery Disease: A Report from the Asian Pacific Society of Atherosclerosis and Vascular Disease Asia-Pacific Peripheral Artery Disease Consensus Statement Project Committee

BACKGROUND

Peripheral artery disease (PAD) is the most underdiagnosed, underestimated and undertreated of the atherosclerotic vascular diseases despite its poor prognosis. There may be racial or contextual differences in the Asia-Pacific region as to epidemiology, availability of diagnostic and therapeutic modalities, and even patient treatment response. The Asian Pacific Society of Atherosclerosis and Vascular Diseases (APSAVD) thus coordinated the development of an Asia-Pacific Consensus Statement (APCS) on the Management of PAD.

OBJECTIVES

The APSAVD aimed to accomplish the following: 1) determine the applicability of the 2016 AHA/ACC guidelines on the Management of Patients with Lower Extremity Peripheral Artery Disease to the Asia-Pacific region; 2) review Asia-Pacific literature; and 3) increase the awareness of PAD.

METHODOLOGY

A Steering Committee was organized to oversee development of the APCS, appoint a Technical Working Group (TWG) and Consensus Panel (CP). The TWG appraised the relevance of the 2016 AHA/ACC PAD Guideline and proposed recommendations which were reviewed by the CP using a modified Delphi technique.

RESULTS

A total of 91 recommendations were generated covering history and physical examination, diagnosis, and treatment of PAD-3 new recommendations, 31 adaptations and 57 adopted statements. This Asia-Pacific Consensus Statement on the Management of PAD constitutes the first for the Asia-Pacific Region. It is intended for use by health practitioners involved in preventing, diagnosing and treating patients with PAD and ultimately the patients and their families themselves.

Multimodal Supervised Exercise Significantly Improves Walking Performances Without Changing Hemodynamic Parameters in Patients With Symptomatic Lower Extremity Peripheral Artery Disease

We evaluated the outcome of multimodal supervised exercise training (SET) on walking performances and different hemodynamic parameters (ankle/toe-brachial index [ABI/TBI], and transcutaneous oxygen pressure [TcPO₂]) in patients with symptomatic lower extremity peripheral artery disease (PAD). Whether hemodynamic parameters predict walking performances at baseline and following SET was also investigated. Fontaine stage II PAD's patients following a 3-month SET were retrospectively included. Hemodynamic parameters and walking performances (pain-free [PFWD], maximal [MWD], and 6-minute [6MWD] walking distance) were measured in each patient. Eighty-five symptomatic PAD patients were included. Following SET, PFWD, MWD, and 6MWD significantly increased (+142%, +94%, +14%; respectively; P ≤ .001). Toe-brachial index significantly increased (MD: 0.04 ± 0.01; P = .02), whereas ABI and TcPO₂ did not change significantly. At baseline, patients with higher TBI and TcPO₂ performed significantly better (PFWD: β = 0.25, P = .01 for TBI; PFWD: β = 0.30, P = .005, and MWD: β = 0.22, P = .04, for TcPO₂). No significant relationship was observed at baseline between ABI and walking performances. Baseline values of hemodynamic parameters did not significantly correlate with changes in walking performances. Multimodal SET significantly improves walking performances. Following SET, no significant changes in ABI and TcPO₂ were observed. Toe-brachial index values significantly improved after SET. However, this increase was very modest and its clinical relevance remains questionable. Although baseline TBI and supine TcPO₂ values predict baseline walking performances, no association was found between baseline hemodynamic parameters and changes in walking performances following SET.

Telephone health coaching with exercise monitoring using wearable activity trackers (TeGeCoach) for improving walking impairment in peripheral artery disease: study protocol for a randomised controlled trial and economic evaluation

INTRODUCTION

Peripheral artery disease (PAD) is the third most prevalent cardiovascular disease worldwide, with smoking and diabetes being the strongest risk factors. The most prominent symptom is leg pain while walking, known as intermittent claudication. To improve mobility, first-line treatment for intermittent claudication is supervised exercise programmes, but these remain largely unavailable and economically impractical, which has led to the development of structured home-based exercise programmes. This trial aims to determine the effectiveness and cost advantage of TeGeCoach, a 12-month long home-based exercise programme, compared with usual care of PAD. It is hypothesised that TeGeCoach improves walking impairment and lowers the need of health care resources that are spent on patients with PAD.

METHODS AND ANALYSIS

The investigators conduct a prospective, pragmatic randomised controlled clinical trial in a health insurance setting. 1760 patients diagnosed with PAD at Fontaine stage II are randomly assigned to either TeGeCoach or care-as-usual. TeGeCoach consists of telemonitored intermittent walking exercise with medical supervision by a physician and telephone health coaching. Participants allocated to the usual care group receive information leaflets and can access supervised exercise programmes, physical therapy and a variety of programmes for promoting a healthy lifestyle. The primary outcome is patient reported walking ability based on the Walking Impairment Questionnaire. Secondary outcome measures include quality of life, health literacy and health behaviour. Claims data are used to collect total health care costs, healthcare resource use and (severe) adverse events. Outcomes are measured at baseline, 12 and 24 months.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Medical Association Hamburg. Findings are disseminated through peer-reviewed journals, reports to the funding body, conference presentations and media press releases. Data from this trial are made available to the public and researchers upon reasonable request.NCT03496948 (www.clinicaltrials.gov), Pre-results.

Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial

BACKGROUND

Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown.

METHODS

Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year.

RESULTS

A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants.

CONCLUSIONS

The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.

Sulodexide improves pain-free walking distance in patients with lower extremity peripheral arterial disease: A systematic review and meta-analysis

Peripheral arterial disease is associated with very high cardiovascular risk. The main symptom is intermittent claudication, which strongly affects the quality of life. Therefore, treatment goals in peripheral arterial disease consist of the reduction of cardiovascular events and the relief of symptoms. An increase in pain-free walking distance, evaluated based on the Initial Claudication Distance, was also a strong positive prognostic factor in patients with peripheral arterial disease. Our objective was to reassess whether sulodexide is effective in improving Initial Claudication Distance. For this, we searched the literature according to the PRISMA checklist for double blind clinical trials assessing the improvement in the Initial Claudication Distance after 90 days of standard therapeutic regimen with sulodexide in adult patients with peripheral arterial disease. We found and assessed for bias in 11 studies eligible for review and meta-analysis. Data extracted from those studies favoured the sulodexide group, showing an overall difference in Initial Claudication Distance of +68.9 (CI 95%; ± 11.9 m) at the end of treatment (p < 0.001). According to this review, sulodexide is effective in improving Initial Claudication Distance and consequently the quality of life in patients with peripheral arterial disease. Further studies are needed to assess the effects of this drug on disease progression in asymptomatic patients with peripheral arterial disease.

Entering Cardiac Rehabilitation With Peripheral Artery Disease: A RETROSPECTIVE COMPARISON TO CORONARY ARTERY DISEASE

PURPOSE

Supervised exercise is recommended for patients with peripheral artery disease (PAD) and patients with coronary artery disease (CAD). Both conditions share common etiology as atherosclerotic diseases. The clinical profile, cardiorespiratory fitness, and exercise prescriptions of PAD, CAD, and patients with concomitant PAD and CAD (BOTH) have yet to be compared upon entry into cardiac rehabilitation (CR).

METHODS

Cardiopulmonary, demographic, and anthropometric assessments were conducted at entry to CR between January 2006 and December 2017.

RESULTS

Among 9701 consecutively enrolled patients, there were 94.6% with CAD (n = 9179), 1.5% with PAD (n = 143), and 3.9% with BOTH (n = 379). Only 5.4% (n = 522) of all patients entering CR had a diagnosis of PAD. Compared with CAD, patients with PAD and BOTH were older (mean ± SD = 62.5 ± 11.1 vs 67.9 ± 11.4 and 69.2 ± 9.8 yr, P < .01), had higher resting systolic blood pressure (124 ± 17 vs 130 ± 17 and 133 ± 18 mm Hg, P < .01), had lower cardiorespiratory fitness (19.7 ± 6.3 vs 15.6 ± 4.8 and 15 ± 4.5 mL/kg/min, P < .01), and were more likely to have diabetes (25% vs 35% and 41%, P < .01), abdominal obesity (39% vs 54% and 51%, P < .01), and initially prescribed lower-intensity exercise (84.4 ± 14.1 vs 74.1 ± 15.7 and 70.0 ± 14.6 m/min exercise pace, P < .01), reflecting the complex nature of patients diagnosed with PAD.

CONCLUSIONS

Patients referred with PAD have a cardiovascular risk profile that places them at a greater risk for a repeat or first cardiac event compared with patients with CAD. Referral to structured exercise and risk factor modification programs should be considered to aid in the management of PAD.

Muscle-derived SDF-1α/CXCL12 modulates endothelial cell proliferation but not exercise training-induced angiogenesis

Chemokines are critical mediators of angiogenesis in several physiological and pathological conditions; however, a potential role for muscle-derived chemokines in exercise-stimulated angiogenesis in skeletal muscle remains poorly understood. Here, we postulated that the chemokine stromal cell-derived factor-1 (SDF-1α/C-X-C motif chemokine ligand 12: CXCL12), shown to promote neovascularization in several organs, contributes to angiogenesis in skeletal muscle. We found that CXCL12 is abundantly expressed in capillary-rich oxidative soleus and exercise-trained plantaris muscles. CXCL12 mRNA and protein were also abundantly expressed in muscle-specific peroxisome proliferator-activated receptor γ coactivator 1α transgenic mice, which have a high proportion of oxidative muscle fibers and capillaries when compared with wild-type littermates. We then generated CXCL12 muscle-specific knockout mice but observed normal baseline capillary density and normal angiogenesis in these mice when they were exercise trained. To get further insight into a potential CXCL12 role in a myofiber-endothelial cell crosstalk, we first mechanically stretched C2C12 myotubes, a model known to induce stretch-related chemokine release, and observed increased CXCL12 mRNA and protein. Human umbilical vein endothelial cells (HUVECs) exposed to conditioned medium from cyclically stretched C2C12 myotubes displayed increased proliferation, which was dependent on CXCL12-mediated signaling through the CXCR4 receptor. However, HUVEC migration and tube formation were unaltered under these conditions. Collectively, our findings indicate that increased muscle contractile activity enhances CXCL12 production and release from muscle, potentially contributing to endothelial cell proliferation. However, redundant signals from other angiogenic factors are likely sufficient to sustain normal endothelial cell migration and tube formation activity, thereby preserving baseline capillary density and exercise training-mediated angiogenesis in muscles lacking CXCL12.

Peripheral Arterial Disease: Supervised Exercise Therapy Through Cardiac Rehabilitation

Peripheral arterial disease (PAD) is frequently underdiagnosed and undertreated. This review identifies specific subgroups within older adults more likely to develop PAD, and describes methods to diagnose PAD and provide evidence in support of systematic referral to cardiac rehabilitation programs to enhance successful comprehensive management. Clear evidence and guidelines support the routine use of supervised exercise therapy to improve function, reduce risk of cardiovascular morbidity and mortality, and enhance the success of endovascular interventions.

Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association

Patients with lower-extremity peripheral artery disease (PAD) have greater functional impairment, faster functional decline, increased rates of mobility loss, and poorer quality of life than people without PAD. Supervised exercise therapy (SET) improves walking ability, overall functional status, and health-related quality of life in patients with symptomatic PAD. In 2017, the Centers for Medicare & Medicaid Services released a National Coverage Determination (CAG-00449N) for SET programs for patients with symptomatic PAD. This advisory provides a practical guide for delivering SET programs to patients with PAD according to Centers for Medicare & Medicaid Services criteria. It summarizes the Centers for Medicare & Medicaid Services process and requirements for referral and coverage of SET and provides guidance on how to implement SET for patients with PAD, including the SET protocol, options for outcome measurement, and transition to home-based exercise. This advisory is based on the guidelines established by the Centers for Medicare & Medicaid Services for Medicare beneficiaries in the United States and is intended to assist clinicians and administrators who are implementing SET programs for patients with PAD.

Tailoring Assessments and Prescription in Cardiac Rehabilitation for Older Adults: The Relevance of Geriatric Domains

Older adults have distinctive health challenges that are relevant to the prevention and treatment of cardiovascular diseases and are potentially modifiable by cardiac rehabilitation. Cardiac rehabilitation in older adults provides opportunity to assess sarcopenia, obesity, osteoporosis, frailty, falls risk, arthritis, cognition, special senses, self-efficacy, depression, social support, polypharmacy, and nutritional adequacy. Therefore, broadening standard assessments to include these domains can help detect modifiable vulnerabilities and inform therapeutic priorities.

Ankle-brachial index and peripheral arterial disease: An evaluation including a type 2 diabetes mellitus drug-naïve patients cohort

BACKGROUND

Peripheral arterial disease in patients with type 2 diabetes mellitus is an important risk factor for vascular events. Recommendations about whether ankle-brachial index should be performed differ depending on the source; therefore, it is necessary to re-evaluate the most important risk factors associated with peripheral arterial disease and whether it is useful to perform ankle-brachial index in newly diagnosed and drug-naïve patients with diabetes, independent of age or peripheral arterial disease symptoms.

METHODS

A total of 711 subjects were divided into groups: group 1, 600 type 2 diabetes mellitus patients, symptomatic or not for peripheral arterial disease; group 2, 61 type 2 diabetes mellitus patients newly diagnosed and drug naïve; and group 3, 50 subjects without diabetes. Ankle-brachial index, medical records and physical examination were performed in all patients, accessing cardiovascular risk factors.

RESULTS

Analysing group 1 asymptomatic patient to peripheral arterial disease, we found abnormal ankle-brachial index in 49% (77/156) ⩾50 years and 42% (16/38) <50 years (p = not significant). Considering drug-naïve patients, a peripheral arterial disease prevalence of 39% (24/61) was found; among these, 48% (13/27) were <50 years and 32% (11/34) were ⩾50 years (p = not significant). A forward stepwise regression model was developed, with type 2 diabetes mellitus duration (r² = 0.12) and sedentary lifestyle (r² = 0.14) found as independent variable predictors of severity of peripheral arterial disease, related to ankle-brachial index.

CONCLUSION

We suggest that, in type 2 diabetes mellitus, ankle-brachial index should be measured at diagnosis. In addition, sedentary lifestyle was strongly associated with presence and severity of peripheral arterial disease.

A mixed methods study of perceived barriers to physical activity, geriatric syndromes, and physical activity levels among older adults with peripheral artery disease and diabetes

Previous studies suggest a myriad of factors prevent individuals from engaging in physical activity; however, less is known about barriers faced by individuals with multiple chronic conditions, such as peripheral artery disease (PAD) and type 2 diabetes, and how these barriers may impact engagement in physical activity. To date, there are no studies that integrate simultaneous assessment of perceived barriers to physical activity and engagement in physical activity in older adults with PAD and diabetes. This integration is key to understanding the implications of barriers to physical activity and to developing strategies to address those barriers. Therefore, this study investigated the unique physical activity experiences of older adults with PAD and diabetes. This study used a concurrent mixed methods design. Ten adults aged 65 years and older with PAD and diabetes completed semistructured interviews about experiences with physical activity, self-reported questionnaires assessing quality of life and fear of falling, and measures of physical function (eg, 6-minute walk test, chair stand, gait speed). Physical activity was measured objectively with accelerometry. Inductive content analysis was used to identify themes, and integrated analysis was performed to evaluate patterns among qualitative and quantitative variables. On average, participants were 74 years old and spent 10% of their time in moderate or vigorous physical activity (range: 3%-18%); 80% of participants were men. Barriers to physical activity identified through qualitative interviews included lack of accessibility, lack of enjoyment of activity, lack of motivation, and pain and physical health. Facilitators to physical activity were social support, accessibility and convenience, and enjoyment of the activity. Participants with more sedentary time and less moderate or vigorous physical activity tended to report greater fear of falling and greater barriers to physical activity and achieved lower distances in 6-minute walk tests. This research provides insight into both the nature of perceived barriers to physical activity and engagement in physical activity among older adults with PAD and diabetes. The integration of self-reported measures and objective measures facilitates our understanding of the lived experiences of individuals with these conditions. Study findings can be used to support further investigation into factors that influence engagement in physical activity in individuals with PAD and diabetes and to assist in the development of strategies to address identified barriers.

Heat therapy vs. supervised exercise therapy for peripheral arterial disease: a 12-wk randomized, controlled trial

Peripheral arterial disease (PAD) is characterized by lower limb atherosclerosis impairing blood supply and causing walking-induced leg pain or claudication. Adherence to traditional exercise training programs is poor due to these symptoms despite exercise being a mainstay of conservative treatment. Heat therapy improves many cardiovascular health outcomes, so this study tested if this was a viable alternative cardiovascular therapy for PAD patients. Volunteers with PAD were randomized to 12 wk of heat ( n = 11; mean age 76 ± 8 yr, BMI 28.7 ± 3.5 kg/m2, 4 females) or exercise ( n = 11; 74 ± 10 yr, 28.5 ± 6.8 kg/m2, 3 females). Heat involved spa bathing at ∼39°C, 3–5 days/wk for ≤30 min, followed by ≤30 min of callisthenics. Exercise involved ≤90 min of supervised walking and gym-based exercise, 1–2 days/wk. Following the interventions, total walking distance during a 6-min walk test increased (from ∼350 m) by 41 m (95% CI: [13, 69], P = 0.006) regardless of group, and pain-free walking distance increased (from ∼170 m) by 43 m ([22, 63], P < 0.001). Systolic blood pressure was reduced more following heat (−7 mmHg, [−4, −10], P < 0.001) than following exercise (−3 mmHg, [0, −6], P = 0.078), and diastolic and mean arterial pressure decreased by 4 mmHg in both groups ( P = 0.002). There were no significant changes in blood volume, ankle-brachial index, or measures of vascular health. There were no differences in the improvement in functional or blood pressure outcomes between heat and exercise in individuals with PAD.

NEW & NOTEWORTHY Heat therapy via hot-water immersion and supervised exercise both improved walking distance and resting blood pressure in peripheral arterial disease (PAD) patients over 12 wk. Adherence to heat therapy was excellent, and the heat intervention was well tolerated. The results of the current study indicate that heat therapy can improve functional ability and has potential as an effective cardiovascular conditioning tool for individuals with PAD.

Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/heat-therapy-vs-exercise-in-peripheral-arterial-disease/ .

Beneficial Effect of Exercise on Cognitive Function during Peripheral Arterial Disease: Potential Involvement of Myokines and Microglial Anti-Inflammatory Phenotype Enhancement

Peripheral arterial disease (PAD), leading to intermittent claudication, critical ischemia with rest pain, and/or tissue damage, is a public health issue associated with significant morbidity and mortality. Little is known about the link between PAD, cognitive function, and whether exercise might reduce cognitive dysfunction in PAD patients, as previously observed concerning both quality of life and prognosis. This review highlights the fact that patients suffering from PAD often demonstrate cognitive dysfunction characterized by reduced performance in nonverbal reasoning, reduced verbal fluency, and decreased information processing speed and a greater risk for progression toward dementia. Further, the data presented support that physical exercise, likely through myokine secretion and microglial anti-inflammatory phenotype enhancement, might participate in the cognition protection in common clinical settings.

Acute cardiopulmonary responses to strength training, high-intensity interval training and moderate-intensity continuous training

PURPOSE

Long-term effects of exercise training are well studied. Acute hemodynamic responses to various training modalities, in particularly strength training (ST), have only been described in a few studies. This study examines the acute responses to ST, high-intensity interval training (HIIT) and moderate-intensity continuous training (MCT).

METHODS

Twelve young male subjects (age 23.4 ± 2.6 years; BMI 23.7 ± 1.5 kg/m²) performed an incremental exertion test and were randomized into HIIT (4 × 4-min intervals), MCT (continuous cycling) and ST (five body-weight exercises) which were matched for training duration. The cardiopulmonary (impedance cardiography, ergo-spirometry) and metabolic response were monitored.

RESULTS

Similar peak blood lactate responses were observed after HIIT and ST (8.5 ± 2.6 and 8.1 ± 1.2 mmol/l, respectively; p = 0.83). The training impact time was 90.7 ± 8.5% for HIIT and 68.2 ± 8.5% for MCT (p < 0.0001). The mean cardiac output was significantly higher for HIIT compared to that of MCT and ST (23.2 ± 4.1 vs. 20.9 ± 2.9 vs. 12.9 ± 2.9 l/min, respectively; p < 0.0001). VO_2max was twofold higher during HIIT compared to that observed during ST (2529 ± 310 vs. 1290 ± 156 ml; p = 0.0004). Among the components of ST, squats compared with push-ups resulted in different heart rate (111 ± 13.5 vs. 125 ± 15.7 bpm, respectively; p < 0.05) and stroke volume (125 ± 23.3 vs. 104 ± 19.8 ml, respectively; p < 0.05).

CONCLUSIONS

Despite an equal training duration and a similar acute metabolic response, large differences with regard to the training impact time and the cardiopulmonary response give evident. HIIT and MCT, but less ST, induced a sufficient cardiopulmonary response, which is important for the preventive effects of training; however, large differences in intensity were apparent for ST.

Experience Implementing Supervised Exercise Therapy for Peripheral Artery Disease

Background

Supervised exercise therapy (SET) is a cornerstone of treatment for improving walking distance for individuals with symptomatic peripheral artery disease and claudication. High quality randomized controlled trials have documented the efficacy of SET as a claudication treatment and led to the recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET). However, to date, the translation of highly controlled, laboratory based SET programs in real world cardiopulmonary rehabilitation settings has been unexplored.

Methods

In this article, we describe our experience integrating SET into existing cardiopulmonary rehabilitation programs, focusing on patient evaluation, exercise prescription, outcome assessments, strategies to maximize program adherence, and transitioning to home and community-based exercise training.

Results

Our team has over 3 years experience successfully implementing SET in cardiac rehabilitation settings. The experiences communicated within can serve as a model for rehabilitation therapists to follow as they begin to incorporate SET in their rehabilitation programs.

Conclusions

CMS reimbursement has the potential to change clinical practice and utilization of SET for patients with symptomatic peripheral artery disease. The experience we have gained through implementation of SET programs across the M Health and Fairview Health Systems and in other Minnesota communities, including specific elements in our programs and the lessons learned from our clinical experience, can inform and help to guide development of new programs.

Brief Abstract

The recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET) for beneficiaries with peripheral artery disease (PAD) has the potential to transform practice. In this article, we describe our experience integrating SET into existing cardiopulmonary rehabilitation programs, which could serve as a model for new programs.

Exercise Professionals with Advanced Clinical Training Should be Afforded Greater Responsibility in Pre-Participation Exercise Screening: A New Collaborative Model between Exercise Professionals and Physicians

Regular exercise improves health but can also induce adverse responses. Although such episodes are rare, many guidelines for pre-participation exercise screening have historically had a low threshold for recommending medical clearance prior to the commencement of exercise, placing the responsibility for decision making about exercise participation on physicians. The ‘clearance to exercise’ model still occurs widely in practice, but creates cost burdens and barriers to the uptake of exercise. Moreover, many physicians are not provided the training, nor time in a standard consultation, to be able to effectively perform this role. We present a model for pre-participation exercise screening and the initial assessment of clients wishing to commence an exercise programme. It is designed to guide professional practice for the referral, assessment and prescription of exercise for people across the health spectrum, from individuals who are apparently healthy, through to clients with pre-existing or occult chronic conditions. The model removes the request that physicians provide a ‘clearance’ for patients to engage in exercise programmes. Instead the role of physicians is identified as providing relevant clinical guidance to suitably qualified exercise professionals to allow them to use their knowledge, skills and expertise in exercise prescription to assess and manage any risks related to the prescription and delivery of appropriate exercise programmes. It is anticipated that removing unjustified barriers to exercise participation, such as mandated medical review, will improve the uptake of exercise by the unacceptably high proportion of the population who do not undertake sufficient physical activity for health benefit.

Inorganic nitrate supplementation enhances functional capacity and lower-limb microvascular reactivity in patients with peripheral artery disease

Peripheral artery disease (PAD) is characterized by functional and vascular impairments as well as elevated levels of inflammation which are associated with reduced nitric oxide (NO) bioavailability. Inorganic nitrate supplementation boosts NO bioavailability potentially improving functional and vasodilatory capacities and may reduce inflammation. Twenty-one patients with PAD were randomly assigned to sodium nitrate (NaNO₃) or placebo supplementation groups for eight-weeks. Outcome measures included a 6-min walk test (6 MWT), blood flow and vasodilator function in the forearm and calf, as well as plasma inflammatory and adhesion biomarker concentrations. NaNO₃ elevated plasma nitrate (32.3 ± 20.0 to 379.8 ± 204.6 μM) and nitrite (192.2 ± 51.8 to 353.1 ± 134.2 nM), improved 6 MWT performance (387 ± 90 to 425 ± 82 m), peak calf blood flow (BF_Peak; 11.6 ± 4.9 to 14.1 ± 5.1 mL/dL tissue/min), and peak calf vascular conductance (VC_Peak; 11.1 ± 4.3 to 14.2 ± 4.9 mL/dL tissue/min/mmHg) (p < 0.05 for all). Improvements in calf BF_Peak (r = 0.70, p < 0.05) and VC_Peak (r = 0.61, p < 0.05) correlated with changes in 6 MWT distance. Placebo supplementation did not change plasma nitrate or nitrite, 6 MWT, calf BF_Peak, or calf VC_Peak. Forearm vascular function nor inflammatory and adhesion biomarker concentrations changed in either group. Eight-weeks of NaNO₃ supplementation improves vasodilatory capacity in the lower-limbs of patients with PAD, which correlated with improvement in functional capacity.

Barriers and enablers to walking in individuals with intermittent claudication: A systematic review to conceptualize a relevant and patient-centered program

BACKGROUND

Walking limitation in patients with peripheral arterial disease (PAD) and intermittent claudication (IC) contributes to poorer disease outcomes. Identifying and examining barriers to walking may be an important step in developing a comprehensive patient-centered self-management intervention to promote walking in this population.

AIM

To systematically review the literature regarding barriers and enablers to walking exercise in individuals with IC.

METHODS

A systematic review was conducted utilizing integrative review methodology. Five electronic databases and the reference lists of relevant studies were searched. Findings were categorized into personal, walking activity related, and environmental barriers and enablers using a social cognitive framework.

RESULTS

Eighteen studies including quantitative (n = 12), qualitative (n = 5), and mixed method (n = 1) designs, and reporting data from a total of 4376 patients with IC, were included in the review. The most frequently reported barriers to engaging in walking were comorbid health concerns, walking induced pain, lack of knowledge (e.g. about the disease pathology and walking recommendations), and poor walking capacity. The most frequently reported enablers were cognitive coping strategies, good support systems, and receiving specific instructions to walk. Findings suggest additionally that wider behavioral and environmental obstacles should be addressed in a patient-centered self-management intervention.

CONCLUSIONS

This review has identified multidimensional factors influencing walking in patients with IC. Within the social cognitive framework, these factors fall within patient level factors (e.g. comorbid health concerns), walking related factors (e.g. claudication pain), and environmental factors (e.g. support systems). These factors are worth considering when developing self-management interventions to increase walking in patients with IC. Systematic review registration CRD42018070418.

Evolving Role of Exercise Testing in Contemporary Cardiac Rehabilitation

Symptom-limited (maximal) exercise testing before cardiac rehabilitation (CR) was once an unambiguous standard of care. In particular, it served as an important screen for residual ischemia and instability before initiating a progressive exercise training regimen. However, improved revascularization and therapy for coronary heart disease has led many clinicians to downplay this application of exercise testing, especially because such testing is also a potential encumbrance to CR enrollment (delaying ease and efficiency of enrollment after procedures and hospitalizations) and patient burden (eg, added costs, logistic hassle, and anxiety). Nonetheless, exercise testing has enduring value for CR, especially because it reveals dynamic physiological responses as well as ischemia, arrhythmias, and symptoms pertinent to exercise prescription and training and to overall stability and prognosis. Moreover, as indications for CR have expanded, the value of exercise testing and functional assessment is more relevant than ever in the growing population of eligible patients, including those with heart failure, valvular heart disease, and posttransplantation, especially as current patients also tend to be more clinically complex, with advanced ages, multimorbidity, frailty, and obesity. This review focuses on the appropriate use of exercise testing in the CR setting. Graded exercise tests, cardiopulmonary exercise tests, submaximal walking tests, and other functional assessments (strength, frailty) for CR are discussed.

The effect of exercise training on clinical outcomes in patients with the metabolic syndrome: a systematic review and meta-analysis

Background

Purpose: to establish if exercise training improves clinical outcomes in people with metabolic syndrome (MetS). Registered with PROSPERO international prospective register of systematic reviews (https://www.crd.york.ac.uk/PROSPERO/Identifier:CRD42017055491). Data sources: studies were identified through a MEDLINE search strategy (1985 to Jan 12, 2017), Cochrane controlled trials registry, CINAHL and SPORTDiscus. Study selection: prospective randomized or controlled trials of exercise training in humans with metabolic syndrome, lasting 12 weeks or more.

Results

We included 16 studies with 23 intervention groups; 77,000 patient-hours of exercise training. In analyses of aerobic exercise studies versus control: body mass index was significantly reduced, mean difference (MD) −0.29 (kg m⁻²) (95% CI −0.44, −0.15, p < 0.0001); body mass was significantly reduced, MD −1.16 kg (95% CI −1.83, −0.48, p = 0.0008); waist circumference was significantly reduced MD −1.37 cm (95% CI −2.02, −0.71, p < 0.0001), peak VO₂ was significantly improved MD 3.00 mL kg⁻¹ min⁻¹ (95% CI 1.92, 4.08, p < 0.000001); systolic blood pressure and diastolic blood pressure were significantly reduced, MD −2.54 mmHg (95% CI −4.34, −0.75, p = 0.006), and, MD −2.27 mmHg (95% CI −3.47, −1.06, p = 0.0002) respectively; fasting blood glucose was significantly reduced MD −0.16 mmol L⁻¹ (95% CI −0.32, −0.01, p = 0.04); triglycerides were significantly reduced MD −0.21 mmol L⁻¹ (95% CI −0.29, −0.13, p < 0.00001); and low density lipoprotein was significantly reduced MD −0.03 mmol L⁻¹ (95% CI −0.05, −0.00, p = 0.02). In analyses of combined exercise versus control: waist circumference, MD −3.80 cm (95% CI −5.65, −1.95, p < 0.0001); peak VO₂ MD 4.64 mL kg⁻¹ min⁻¹ (95% CI 2.42, 6.87, p < 0.0001); systolic blood pressure MD −3.79 mmHg (95% CI −6.18, −1.40, p = 0.002); and high density lipoprotein (HDL) MD 0.14 (95% CI 0.04, 0.25, p = 0.009) were all significantly improved. We found no significant differences between outcome measures between the two exercise interventions.

Conclusions

Exercise training improves body composition, cardiovascular, and, metabolic outcomes in people with metabolic syndrome. For some outcome measures, isolated aerobic exercise appears optimal.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-017-0590-y) contains supplementary material, which is available to authorized users.

Moderate Exercise Allows for shorter Recovery Time in Critical Limb Ischemia

Whether and how moderate exercise might allow for accelerated limb recovery in chronic critical limb ischemia (CLI) remains to be determined. Chronic CLI was surgically induced in mice, and the effect of moderate exercise (training five times per week over a 3-week period) was investigated. Tissue damages and functional scores were assessed on the 4th, 6th, 10th, 20th, and 30th day after surgery. Mice were sacrificed 48 h after the last exercise session in order to assess muscle structure, mitochondrial respiration, calcium retention capacity, oxidative stress and transcript levels of genes encoding proteins controlling mitochondrial functions (PGC1α, PGC1β, NRF1) and anti-oxidant defenses markers (SOD1, SOD2, catalase). CLI resulted in tissue damages and impaired functional scores. Mitochondrial respiration and calcium retention capacity were decreased in the ischemic limb of the non-exercised group (V_max = 7.11 ± 1.14 vs. 9.86 ± 0.86 mmol 02/min/g dw, p < 0.001; CRC = 7.01 ± 0.97 vs. 11.96 ± 0.92 microM/mg dw, p < 0.001, respectively). Moderate exercise reduced tissue damages, improved functional scores, and restored mitochondrial respiration and calcium retention capacity in the ischemic limb (V_max = 9.75 ± 1.00 vs. 9.82 ± 0.68 mmol 02/min/g dw; CRC = 11.36 ± 1.33 vs. 12.01 ± 1.24 microM/mg dw, respectively). Exercise also enhanced the transcript levels of PGC1α, PGC1β, NRF1, as well as SOD1, SOD2, and catalase. Moderate exercise restores mitochondrial respiration and calcium retention capacity, and it has beneficial functional effects in chronic CLI, likely by stimulating reactive oxygen species-induced biogenesis and anti-oxidant defenses. These data support further development of exercise therapy even in advanced peripheral arterial disease.

The Lactate Minimum Test: Concept, Methodological Aspects and Insights for Future Investigations in Human and Animal Models

In 1993, Uwe Tegtbur proposed a useful physiological protocol named the lactate minimum test (LMT). This test consists of three distinct phases. Firstly, subjects must perform high intensity efforts to induce hyperlactatemia (phase 1). Subsequently, 8 min of recovery are allowed for transposition of lactate from myocytes (for instance) to the bloodstream (phase 2). Right after the recovery, subjects are submitted to an incremental test until exhaustion (phase 3). The blood lactate concentration is expected to fall during the first stages of the incremental test and as the intensity increases in subsequent stages, to rise again forming a “U” shaped blood lactate kinetic. The minimum point of this curve, named the lactate minimum intensity (LMI), provides an estimation of the intensity that represents the balance between the appearance and clearance of arterial blood lactate, known as the maximal lactate steady state intensity (iMLSS). Furthermore, in addition to the iMLSS estimation, studies have also determined anaerobic parameters (e.g., peak, mean, and minimum force/power) during phase 1 and also the maximum oxygen consumption in phase 3; therefore, the LMT is considered a robust physiological protocol. Although, encouraging reports have been published in both human and animal models, there are still some controversies regarding three main factors: (1) the influence of methodological aspects on the LMT parameters; (2) LMT effectiveness for monitoring training effects; and (3) the LMI as a valid iMLSS estimator. Therefore, the aim of this review is to provide a balanced discussion between scientific evidence of the aforementioned issues, and insights for future investigations are suggested. In summary, further analyses is necessary to determine whether these factors are worthy, since the LMT is relevant in several contexts of health sciences.