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Twomey A, Khan Z. Home-Based Exercise Therapy in the Management of Intermittent Claudication: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e39206. [PMID: 37384085 PMCID: PMC10294279 DOI: 10.7759/cureus.39206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2023] [Indexed: 06/30/2023] Open
Abstract
The current literature strongly supports the use of supervised exercise therapy (SET) as the first-line treatment for symptomatic peripheral arterial disease (PAD) such as intermittent claudication (IC). However, this form of treatment remains underutilised in clinical practice. The home-based exercise therapy (HBET), in which patients must conduct themselves unsupervised is generally less effective than SET in terms of improving functional walking capacity. Nevertheless, it may be a useful alternative where SET is unavailable. The objective of this systematic review is to determine the effectiveness of HBET in reducing symptoms of IC in patients with PAD. Studies eligible for inclusion in this systematic review were parallel-group randomised controlled trials (RCTs) published in the English language that compared the effect of HBET to a comparator arm (SET or no exercise/attention control) in adults with PAD and IC. Studies were eligible if outcome measures were available at baseline and at 12 weeks of follow-up or more. The electronic databases PubMed, Google Scholar, and the Cochrane Library were searched from the earliest records up to January 2021. The Cochrane Collaboration risk of bias tool for RCTs (RoB 2) was used to assess the risk of bias in individual studies, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) classification system was used to appraise the quality of evidence for each outcome across all studies. The primary investigator independently collected, pooled, and analysed the data. The data was then entered into the ReviewManager 5 (RevMan 5) software, and a meta-analysis was performed by using a fixed or random effects model depending on the presence or absence of statistical heterogeneity. The review author identified seven RCTs involving a total of 754 patients which were included in this study. Overall, the risk of bias in the included studies was moderate. Even though the results were variable, this analysis supported the ability of HBET to improve functional walking capacity and self-reported quality of life (QoL) to an extent. This review shows that a home-based exercise intervention with regular professional support and encouragement is beneficial in improving functional walking capacity as well as some aspects of QoL in patients with PAD and IC when compared to no exercise. However, when HBET is compared to hospital-based supervised exercise intervention, SET yields greater benefits.
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Affiliation(s)
- Alice Twomey
- Podiatry, Homerton University Hospital NHS Foundation Trust, London, GBR
| | - Zahid Khan
- Acute Medicine, Mid and South Essex NHS Foundation Trust, Southend on Sea, GBR
- Cardiology, Barts Heart Centre, London, GBR
- Cardiology and General Medicine, Barking, Havering and Redbridge University Hospitals NHS Trust, London, GBR
- Cardiology, Royal Free Hospital, London, GBR
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Anghel R, Adam CA, Marcu DTM, Mitu O, Mitu F. Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era. J Clin Med 2022; 11:416. [PMID: 35054109 PMCID: PMC8778009 DOI: 10.3390/jcm11020416] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/12/2022] Open
Abstract
Cardiac rehabilitation (CR) is an integral part of the management of various cardiovascular disease such as coronary artery disease (CAD), peripheral artery disease (PAD), or chronic heart failure (CHF), with proven morbidity and mortality benefits. This article aims to review and summarize the scientific literature related to cardiac rehabilitation programs for patients with PAD and how they were adapted during the COVID-19 pandemic. The implementation of CR programs has been problematic since the COVID-19 pandemic due to social distancing and work-related restrictions. One of the main challenges for physicians and health systems alike has been the management of PAD patients. COVID-19 predisposes to coagulation disorders that can lead to severe thrombotic events. Home-based walking exercises are more accessible and easier to accept than supervised exercise programs. Cycling or other forms of exercise are more entertaining or challenging alternatives to exercise therapy. Besides treadmill exercises, upper- and lower-extremity ergometry also has great functional benefits, especially regarding walking endurance. Supervised exercise therapy has a positive impact on both functional capacity and also on the quality of life of such patients. The most effective manner to acquire this seems to be by combining revascularization therapy and supervised exercise. Rehabilitation programs proved to be a mandatory part of the integrative approach in these cases, increasing quality of life, and decreasing stress levels, depression, and anxiety.
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Affiliation(s)
- Razvan Anghel
- Clinical Rehabilitation Hospital, Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania; (R.A.); (C.A.A.); (F.M.)
| | - Cristina Andreea Adam
- Clinical Rehabilitation Hospital, Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania; (R.A.); (C.A.A.); (F.M.)
| | - Dragos Traian Marius Marcu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street nr 16, 700115 Iasi, Romania;
| | - Ovidiu Mitu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street nr 16, 700115 Iasi, Romania;
- “Sf. Spiridon” Clinical Emergency Hospital, Independence Boulevard nr 1, 700111 Iasi, Romania
| | - Florin Mitu
- Clinical Rehabilitation Hospital, Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania; (R.A.); (C.A.A.); (F.M.)
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street nr 16, 700115 Iasi, Romania;
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Biswas MP, Capell WH, McDermott MM, Jacobs DL, Beckman JA, Bonaca MP, Hiatt WR. Exercise Training and Revascularization in the Management of Symptomatic Peripheral Artery Disease. JACC Basic Transl Sci 2021; 6:174-188. [PMID: 33665516 PMCID: PMC7907537 DOI: 10.1016/j.jacbts.2020.08.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 01/01/2023]
Abstract
In the management of symptomatic peripheral artery disease, aerobic exercise therapy and lower extremity revascularization are the mainstays of therapy. In this structured review, the most effective therapies, with 6 to 18 months of follow-up, indicated that exercise therapy and lower extremity revascularization each independently improve peak walking performance. The combination of therapies was superior to either therapy alone and may decrease the need for subsequent revascularization. Further research is needed to evaluate the long-term durability of these interventions, their impacts on subsequent invasive procedures, and predictors of response.
Exercise therapy and lower extremity revascularization both improve walking performance in symptomatic patients with peripheral artery disease. The combination of therapies provides greater benefit than either alone and may reduce the need for subsequent revascularization procedures, but further trials with longer follow-up are needed for the outcome of subsequent revascularization.
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Key Words
- 6MW, 6-minute walk
- CMS, Centers for Medicare and Medicaid Services
- ET, exercise therapy
- HBE, home-based exercise
- LER, lower extremity revascularization
- MCID, minimum clinically important difference
- PAD, peripheral artery disease
- PRO, patient-reported outcome
- PWD, peak walking distance
- PWT, peak walking time
- SET, supervised exercise training
- SF-36, Medical Outcomes Short Form–36
- VascuQOL, Vascular Quality of Life
- WIQ, Walking Impairment Questionnaire
- evidence
- exercise therapy (supervised exercise training, home-based exercise programs)
- lower extremity revascularization
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Affiliation(s)
- Minakshi P Biswas
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,CPC Clinical Research, Aurora, Colorado, USA
| | - Warren H Capell
- CPC Clinical Research, Aurora, Colorado, USA.,Division of Endocrinology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Mary M McDermott
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Donald L Jacobs
- Division of Vascular Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Joshua A Beckman
- Division of Cardiology, Department of Medicine, Vanderbilt University, Nashville, Tennessee, USA
| | - Marc P Bonaca
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,CPC Clinical Research, Aurora, Colorado, USA
| | - William R Hiatt
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.,CPC Clinical Research, Aurora, Colorado, USA
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Posadzki P, Pieper D, Bajpai R, Makaruk H, Könsgen N, Neuhaus AL, Semwal M. Exercise/physical activity and health outcomes: an overview of Cochrane systematic reviews. BMC Public Health 2020; 20:1724. [PMID: 33198717 PMCID: PMC7670795 DOI: 10.1186/s12889-020-09855-3] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 11/08/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sedentary lifestyle is a major risk factor for noncommunicable diseases such as cardiovascular diseases, cancer and diabetes. It has been estimated that approximately 3.2 million deaths each year are attributable to insufficient levels of physical activity. We evaluated the available evidence from Cochrane systematic reviews (CSRs) on the effectiveness of exercise/physical activity for various health outcomes. METHODS Overview and meta-analysis. The Cochrane Library was searched from 01.01.2000 to issue 1, 2019. No language restrictions were imposed. Only CSRs of randomised controlled trials (RCTs) were included. Both healthy individuals, those at risk of a disease, and medically compromised patients of any age and gender were eligible. We evaluated any type of exercise or physical activity interventions; against any types of controls; and measuring any type of health-related outcome measures. The AMSTAR-2 tool for assessing the methodological quality of the included studies was utilised. RESULTS Hundred and fifty CSRs met the inclusion criteria. There were 54 different conditions. Majority of CSRs were of high methodological quality. Hundred and thirty CSRs employed meta-analytic techniques and 20 did not. Limitations for studies were the most common reasons for downgrading the quality of the evidence. Based on 10 CSRs and 187 RCTs with 27,671 participants, there was a 13% reduction in mortality rates risk ratio (RR) 0.87 [95% confidence intervals (CI) 0.78 to 0.96]; I2 = 26.6%, [prediction interval (PI) 0.70, 1.07], median effect size (MES) = 0.93 [interquartile range (IQR) 0.81, 1.00]. Data from 15 CSRs and 408 RCTs with 32,984 participants showed a small improvement in quality of life (QOL) standardised mean difference (SMD) 0.18 [95% CI 0.08, 0.28]; I2 = 74.3%; PI -0.18, 0.53], MES = 0.20 [IQR 0.07, 0.39]. Subgroup analyses by the type of condition showed that the magnitude of effect size was the largest among patients with mental health conditions. CONCLUSION There is a plethora of CSRs evaluating the effectiveness of physical activity/exercise. The evidence suggests that physical activity/exercise reduces mortality rates and improves QOL with minimal or no safety concerns. TRIAL REGISTRATION Registered in PROSPERO ( CRD42019120295 ) on 10th January 2019.
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Affiliation(s)
- Pawel Posadzki
- Kleijnen Systematic Reviews Ltd., York, UK
- Nanyang Technological University, Singapore, Singapore
| | - Dawid Pieper
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany.
| | - Ram Bajpai
- School of Medicine, Keele University, Staffordshire, UK
| | - Hubert Makaruk
- Jozef Pilsudski University of Physical Education in Warsaw, Faculty Physical Education and Health, Biala Podlaska, Poland
| | - Nadja Könsgen
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Annika Lena Neuhaus
- Institute for Research in Operative Medicine, Witten/Herdecke University, Witten, Germany
| | - Monika Semwal
- Health Outcomes Division, University of Texas at Austin College of Pharmacy, Austin, USA
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Short interval or continuous training programs to improve walking distance for intermittent claudication: Pilot study. Ann Phys Rehabil Med 2020; 63:466-473. [DOI: 10.1016/j.rehab.2020.03.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 02/10/2020] [Accepted: 03/03/2020] [Indexed: 12/23/2022]
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Impact of aerobic exercise type on blood flow, muscle energy metabolism, and mitochondrial biogenesis in experimental lower extremity artery disease. Sci Rep 2020; 10:14048. [PMID: 32820213 PMCID: PMC7441153 DOI: 10.1038/s41598-020-70961-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 08/03/2020] [Indexed: 01/08/2023] Open
Abstract
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.
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Jansen SC, Abaraogu UO, Lauret GJ, Fakhry F, Fokkenrood HJ, Teijink JA. Modes of exercise training for intermittent claudication. Cochrane Database Syst Rev 2020; 8:CD009638. [PMID: 32829481 PMCID: PMC8092668 DOI: 10.1002/14651858.cd009638.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
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.
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Affiliation(s)
- Sandra Cp Jansen
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Ukachukwu Okoroafor Abaraogu
- Department of Physiotherapy and Paramedicine, School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
- Department of Medical Rehabilitation, University of Nigeria, Nsukka, Nigeria
| | - Gert Jan Lauret
- Department of Vascular Surgery, Slingeland Hospital, Doetinchem, Netherlands
| | - Farzin Fakhry
- Department of Cardiology, Haga Teaching Hospital, The Hague, Netherlands
| | - Hugo Jp Fokkenrood
- Department of Vascular Surgery, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, Netherlands
| | - Joep Aw Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, Netherlands
- CAPHRI School for Public Health and Primary Care, Maastricht University Medical Centre, Maastricht, Netherlands
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Rümenapf G, Morbach S, Schmidt A, Sigl M. Intermittent Claudication and Asymptomatic Peripheral Arterial Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:188-193. [PMID: 32327031 DOI: 10.3238/arztebl.2020.0188] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 09/10/2019] [Accepted: 12/20/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The conservative treatment of peripheral arterial disease (PAD), as recommended in current guidelines, encompasses measures such as lifestyle modification and risk-factor management. In addition, in patients with vasogenic intermittent claudication (IC), it is recommended that patients first be given drugs to improve perfusion and undergo supervised gait training. Revascularization is not recommended for asymptomatic persons, but it is considered mandatory for patients with critical ischemia. In this article on conservative and revascularizing treatment strategies for IC, we address the following questions: whether all treatment options are available, how effective they are, and whether the reality of treatment for IC in Germany corresponds to what is recommended in the guidelines. METHODS In 2014, the German Society for Angiology carried out a comprehensive literature search in order to prepare a new version of the S3 guideline on PAD. This literature search was updated up to 2018, with identical methods, for the present review. RESULTS The benefit of lifestyle modification and risk factor treatment is supported by high-level evidence ( evidence level I, recommendation grade A ). The distance patients are able to walk without pain is increased by drug therapy as well (evidence level IIb), but the therapeutic effect is only moderate. Supervised exercise training (SET), though supported by high-level evidence (I, A), is of limited efficacy, availability, and applicability, and patient compliance with it is also limited. In patients with IC, revascularization leads to complete relief of symptoms more rapidly than gait training, and its long-term benefit is steadily improving owing to advances in medical technology. A combination of arterial revascularization and gait training yields the best results. In a clinical trial, patients with IC who underwent combined therapy increased the distance they could walk without pain by 954 m in six months, compared to 407 m in a group that underwent gait training alone. CONCLUSION In the treatment of vasogenic IC, SET and drugs to increase perfusion are now giving way to revascularization, which is more effective. As far as can be determined, SET is not currently implemented at all in the German health care system. It would be desirable for SET to be more available and more widely used, both to sustain the benefit of revascularization over the long term and to lower the general cardiovascular risk.
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Affiliation(s)
- Gerhard Rümenapf
- Department of Angiology, Center of Vascular Medicine "Oberrhein" Speyer, Diakonissen-Stiftungs-Krankenhaus, Speyer; Department of Diabetology and Angiology, Marienkrankenhaus, Soest; Department of Angiology, University Hospital Leipzig; Department of Angiology, Department of Medicine 1, University Hospital Mannheim
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Carvalho TD, Milani M, Ferraz AS, Silveira ADD, Herdy AH, Hossri CAC, Silva CGSE, Araújo CGSD, Rocco EA, Teixeira JAC, Dourado LOC, Matos LDNJD, Emed LGM, Ritt LEF, Silva MGD, Santos MAD, Silva MMFD, Freitas OGAD, Nascimento PMC, Stein R, Meneghelo RS, Serra SM. Brazilian Cardiovascular Rehabilitation Guideline - 2020. Arq Bras Cardiol 2020; 114:943-987. [PMID: 32491079 PMCID: PMC8387006 DOI: 10.36660/abc.20200407] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Tales de Carvalho
- Clínica de Prevenção e Reabilitação Cardiosport , Florianópolis , SC - Brasil
- Universidade do Estado de Santa Catarina (Udesc), Florianópolis , SC - Brasil
| | | | | | - Anderson Donelli da Silveira
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre , RS - Brasil
- Hospital de Clínicas de Porto Alegre , Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre , RS - Brasil
- Vitta Centro de Bem Estar Físico , Porto Alegre , RS - Brasil
| | - Artur Haddad Herdy
- Clínica de Prevenção e Reabilitação Cardiosport , Florianópolis , SC - Brasil
- Instituto de Cardiologia de Santa Catarina , Florianópolis , SC - Brasil
- Unisul: Universidade do Sul de Santa Catarina (UNISUL), Florianópolis , SC - Brasil
| | | | | | | | | | | | - Luciana Oliveira Cascaes Dourado
- Instituto do Coração (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), Rio de Janeiro , RJ - Brasil
| | | | | | - Luiz Eduardo Fonteles Ritt
- Hospital Cárdio Pulmonar , Salvador , BA - Brasil
- Escola Bahiana de Medicina e Saúde Pública , Salvador , BA - Brasil
| | | | - Mauro Augusto Dos Santos
- ACE Cardiologia do Exercício , Rio de Janeiro , RJ - Brasil
- Instituto Nacional de Cardiologia , Rio de Janeiro , RJ - Brasil
| | | | | | - Pablo Marino Corrêa Nascimento
- Universidade Federal Fluminense (UFF), Rio de Janeiro , RJ - Brasil
- Instituto Nacional de Cardiologia , Rio de Janeiro , RJ - Brasil
| | - Ricardo Stein
- Programa de Pós-Graduação em Cardiologia e Ciências Cardiovasculares da Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre , RS - Brasil
- Hospital de Clínicas de Porto Alegre , Universidade Federal do Rio Grande do Sul (HCPA/UFRGS), Porto Alegre , RS - Brasil
- Vitta Centro de Bem Estar Físico , Porto Alegre , RS - Brasil
| | - Romeu Sergio Meneghelo
- Instituto Dante Pazzanese de Cardiologia , São Paulo , SP - Brasil
- Hospital Israelita Albert Einstein , São Paulo , SP - Brasil
| | - Salvador Manoel Serra
- Instituto Estadual de Cardiologia Aloysio de Castro (IECAC), Rio de Janeiro , RJ - Brasil
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Siercke M, Jørgensen LP, Missel M, Thygesen LC, Blach PP, Sillesen H, Berg SK. Cross-sectoral rehabilitation intervention for patients with intermittent claudication versus usual care for patients in non-operative management - the CIPIC Rehab Study: study protocol for a randomised controlled trial. Trials 2020; 21:105. [PMID: 31964402 PMCID: PMC6975054 DOI: 10.1186/s13063-019-4032-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 12/28/2019] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Intermittent claudication (IC) caused by peripheral artery disease (PAD) is a common cardiovascular disease. Patients with IC have reduced walking capacity, restricted activity levels and mobility, and reduced health-related quality of life. The disease leads to social isolation, the risk of cardiovascular morbidity, and mortality. Non-operative management of IC requires exercise therapy and studies show that supervised exercise training is more effective than unsupervised training, yet many patients with IC lack motivation for changes in health behaviour. No studies investigating the effects of existing cardiac rehabilitation targeted patients with IC have been published. The aim of this article is to present the rationale and design of the CIPIC Rehab Study, which examines the effect of a cross-sectoral rehabilitation programme versus usual care for patients in non-operative management for IC. METHODS AND ANALYSIS A randomised clinical trial aims to investigate whether cardiac rehabilitation for patients with IC in non-operative management versus usual care is superior to treatment as usual. The trial will allocate 118 patients, with a 1:1 individual randomisation to either the intervention or control group. The primary outcome is maximal walking distance measured by the standardised treadmill walking test. The secondary outcome is pain-free walking distance measured by the standardised treadmill walking test, healthy diet measured by a fat-fish-fruit-green score, and level of physical activity measured by an activity score within official recommendations. Statistical analyses will be blinded. Several exploratory analyses will be performed. A mixed-method design is used to evaluate qualitative and quantitative findings. A qualitative and a survey-based complementary study will be undertaken to investigate patients' post-discharge experiences. A qualitative post-intervention study will explore experiences of participation in rehabilitation. DISCUSSION The study is the first to assess the effect of a cardiac rehabilitation programme designed for patients with IC. The study will describe how to monitor and improve rehabilitation programmes for patients with IC in a real-world setting. Mixed-method strategies can allow for both exploration and generalisation in the same study, but the research design is a complex intervention and any effects found cannot be awarded a specific component. TRIAL REGISTRATION Retrospectively registered in Clinicaltrials.gov identifier: NCT03730623.
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Affiliation(s)
- Maj Siercke
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Lise Pyndt Jørgensen
- Department of Pathology, Herlev Hospital, Copenhagen University Hospital, Copenhagen, Denmark
| | - Malene Missel
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Selina Kikkenborg Berg
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- The Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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12
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Machado I, Sousa N, Paredes H, Ferreira J, Abrantes C. Combined Aerobic and Resistance Exercise in Walking Performance of Patients With Intermittent Claudication: Systematic Review. Front Physiol 2020; 10:1538. [PMID: 31969830 PMCID: PMC6960137 DOI: 10.3389/fphys.2019.01538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/05/2019] [Indexed: 01/19/2023] Open
Abstract
Background: The short-term benefits of aerobic and resistance exercise in subjects affected by Peripheral Arterial Disease (PAD) are scarcely examined in interaction. This study aimed to identify the effects of combined aerobic and resistance exercise programs on walking performance compared with isolated aerobic exercise or with the usual care in patients with intermittent claudication. Methods: A systematic review was conducted following the PRISMA statement. A total of five electronic databases were searched (until October 2019) for randomized and non-randomized controlled trials. The focus comprised PAD patients with intermittent claudication who performed a combined aerobic and resistance exercise program that assessed the walking performance. Results: Seven studies include combined aerobic and resistance exercise vs. isolated aerobic or vs. usual care. The studies represented a sample size of 337 participants. The follow-up ranged from 4 to 12 weeks, 2 to 5 times-per-week. The risk of bias in the trials was a deemed moderate-to-high risk. After the interventions, the percent change in walking performance outcomes had a large variation. In the combined and isolated aerobic programs, the walking performance always improved, while in the usual care group oscillates between the deterioration and the improvement in all outcomes. Combined exercise and isolated aerobic exercise improved the claudication onset distance from 11 to 396%, and 30 to 422%, the absolute claudication distance from 81 to 197%, and 53 to 121%, and the maximal walking distance around 23 and 10%, respectively. Conclusions: Currently, there is insufficient evidence about the effects of combined aerobic and resistance exercise compared to isolated aerobic exercise or usual care on walking performance. However, despite the low quality of evidence, the combined aerobic and resistance exercise seems to be an effective strategy to improve walking performance in patients with intermittent claudication. These combined exercise modes or isolated aerobic exercise produce positive and significant results on walking performance. The usual care approach has a trend to deteriorate the walking performance. Thus, given the scarcity of data, new randomized controlled trial studies that include assessments of cardiovascular risk factors are urgently required to better determine the effect of this exercise combination.
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Affiliation(s)
- Isabel Machado
- Department of Sports Science, Exercise and Health, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal.,Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal
| | - Nelson Sousa
- Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal.,Public Health Unit of Santo Tirso, ACES Grande Porto I-Santo Tirso/Trofa, Santo Tirso, Portugal
| | - Hugo Paredes
- Department of Engineering, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal.,Institute for Systems and Computer Engineering, Technology and Science (INESC TEC), Porto, Portugal
| | - Joana Ferreira
- Hospital of Senhora da Oliveira/EPE, Angiology and Vascular Surgery, Guimarães, Portugal.,Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal
| | - Catarina Abrantes
- Department of Sports Science, Exercise and Health, University of Trás-os-Montes e Alto Douro, Vila Real, Portugal.,Research Center in Sports Sciences, Health Sciences and Human Development (CIDESD), Vila Real, Portugal
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13
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Polaski AM, Phelps AL, Kostek MC, Szucs KA, Kolber BJ. Exercise-induced hypoalgesia: A meta-analysis of exercise dosing for the treatment of chronic pain. PLoS One 2019; 14:e0210418. [PMID: 30625201 PMCID: PMC6326521 DOI: 10.1371/journal.pone.0210418] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 12/21/2018] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Increasing evidence purports exercise as a first-line therapeutic for the treatment of nearly all forms of chronic pain. However, knowledge of efficacious dosing respective to treatment modality and pain condition is virtually absent in the literature. The purpose of this analysis was to calculate the extent to which exercise treatment shows dose-dependent effects similar to what is seen with pharmacological treatments. METHODS A recently published comprehensive review of exercise and physical activity for chronic pain in adults was identified in May 2017. This report reviewed different physical activity and exercise interventions and their effectiveness in reducing pain severity and found overall modest effects of exercise in the treatment of pain. We analyzed this existing data set, focusing specifically on the dose of exercise intervention in these studies. We re-analyzed data from 75 studies looking at benefits of time of exercising per week, frequency of exercise per week, duration of intervention (in weeks), and estimated intensity of exercise. RESULTS Analysis revealed a significant positive correlation with exercise duration and analgesic effect on neck pain. Multiple linear regression modeling of these data predicted that increasing the frequency of exercise sessions per week is most likely to have a positive effect on chronic pain patients. DISCUSSION Modest effects were observed with one significant correlation between duration and pain effect for neck pain. Overall, these results provide insufficient evidence to conclude the presence of a strong dose effect of exercise in pain, but our modeling data provide tes predictions that can be used to design future studies to explicitly test the question of dose in specific patient populations.
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Affiliation(s)
- Anna M. Polaski
- Department of Biological Sciences, Duquesne University, Pittsburgh, Pennsylvania, United States of America
- Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Amy L. Phelps
- Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
- Palumbo Donahue School of Business, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Matthew C. Kostek
- Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
- Department of Physical Therapy, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Kimberly A. Szucs
- Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
- Department of Occupational Therapy, Duquesne University, Pittsburgh, Pennsylvania, United States of America
| | - Benedict J. Kolber
- Department of Biological Sciences, Duquesne University, Pittsburgh, Pennsylvania, United States of America
- Chronic Pain Research Consortium, Duquesne University, Pittsburgh, Pennsylvania, United States of America
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14
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Pymer SA, Tew GA, Palmer J, Ingle L, Smith GE, Chetter IC, Harwood AE. Home-based exercise programmes for individuals with intermittent claudication: A protocol for an updated systematic review and meta-analysis. SAGE Open Med 2018; 6:2050312118818295. [PMID: 30574304 PMCID: PMC6295772 DOI: 10.1177/2050312118818295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 11/16/2018] [Indexed: 12/19/2022] Open
Abstract
Background The aim of this updated review is to consider the evidence base for the effectiveness of home-based exercise programmes as a treatment option for improving walking distance in patients with intermittent claudication. Methods The Medline, EMBASE, CINAHL, PEDro and Cochrane CENTRAL databases will be searched for terms including 'intermittent claudication', 'peripheral arterial disease', 'home-based exercise' and 'home-based walking'. No date restrictions will be used but only articles in the English language will be included. Both randomised and non-randomised trials of home-based exercise programmes versus a comparator arm will be included, and a meta-analysis using only the randomised controlled trials will be attempted if the assumptions of heterogeneity are met. Data extraction will include study details, sample description, intervention description, length of follow-up and outcomes measures. The primary outcome measure is objectively measured maximal walking distance or time, with secondary outcome measures including pain-free walking distance or time, changes in physical activity and quality of life. We will also provide a narrative description of the effective components of a home-based exercise intervention which can aid future recommendations. Conclusion Overall, this proposed review and meta-analysis aims provide a comprehensive and complete overview of the evidence base for home-based exercise programmes, which can aid clinicians in the management of their patients.
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Affiliation(s)
- Sean A Pymer
- Academic Vascular Surgical Unit, Hull, UK.,Hull York Medical School, Hull, UK
| | - Garry A Tew
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - Joanne Palmer
- Academic Vascular Surgical Unit, Hull, UK.,Hull York Medical School, Hull, UK
| | - Lee Ingle
- Department of Sport, Health and Exercise Science, University of Hull, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Hull, UK.,Hull York Medical School, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull, UK.,Hull York Medical School, Hull, UK
| | - Amy E Harwood
- Academic Vascular Surgical Unit, Hull, UK.,Hull York Medical School, Hull, UK
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15
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Hageman D, Fokkenrood HJP, Gommans LNM, van den Houten MML, Teijink JAW. Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication. Cochrane Database Syst Rev 2018; 4:CD005263. [PMID: 29627967 PMCID: PMC6513337 DOI: 10.1002/14651858.cd005263.pub4] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although supervised exercise therapy (SET) provides significant symptomatic benefit for patients with intermittent claudication (IC), it remains an underutilized tool. Widespread implementation of SET is restricted by lack of facilities and funding. Structured home-based exercise therapy (HBET) with an observation component (e.g., exercise logbooks, pedometers) and just walking advice (WA) are alternatives to SET. This is the second update of a review first published in 2006. OBJECTIVES The primary objective was to provide an accurate overview of studies evaluating effects of SET programs, HBET programs, and WA on maximal treadmill walking distance or time (MWD/T) for patients with IC. Secondary objectives were to evaluate effects of SET, HBET, and WA on pain-free treadmill walking distance or time (PFWD/T), quality of life, and self-reported functional impairment. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (December 16, 2016) and the Cochrane Central Register of Controlled Trials (2016, Issue 11). We searched the reference lists of relevant studies identified through searches for other potential trials. We applied no restriction on language of publication. SELECTION CRITERIA We included parallel-group randomized controlled trials comparing SET programs with HBET programs and WA in participants with IC. We excluded studies in which control groups did not receive exercise or walking advice (maintained normal physical activity). We also excluded studies comparing exercise with percutaneous transluminal angioplasty, bypass surgery, or drug therapy. DATA COLLECTION AND ANALYSIS Three review authors (DH, HF, and LG) independently selected trials, extracted data, and assessed trials for risk of bias. Two other review authors (MvdH and JT) confirmed the suitability and methodological quality of trials. For all continuous outcomes, we extracted the number of participants, mean outcome, and standard deviation for each treatment group through the follow-up period, if available. We extracted Medical Outcomes Study Short Form 36 outcomes to assess quality of life, and Walking Impairment Questionnaire outcomes to assess self-reported functional impairment. As investigators used different scales to present results of walking distance and time, we standardized reported data to effect sizes to enable calculation of an overall standardized mean difference (SMD). We obtained summary estimates for all outcome measures using a random-effects model. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS For this update, we included seven additional studies, making a total of 21 included studies, which involved a total of 1400 participants: 635 received SET, 320 received HBET, and 445 received WA. In general, SET and HBET programs consisted of three exercise sessions per week. Follow-up ranged from six weeks to two years. Most trials used a treadmill walking test to investigate effects of exercise therapy on walking capacity. However, two trials assessed only quality of life, functional impairment, and/or walking behavior (i.e., daily steps measured by pedometer). The overall methodological quality of included trials was moderate to good. However, some trials were small with respect to numbers of participants, ranging from 20 to 304.SET groups showed clear improvement in MWD/T compared with HBET and WA groups, with overall SMDs at three months of 0.37 (95% confidence interval [CI] 0.12 to 0.62; P = 0.004; moderate-quality evidence) and 0.80 (95% CI 0.53 to 1.07; P < 0.00001; high-quality evidence), respectively. This translates to differences in increased MWD of approximately 120 and 210 meters in favor of SET groups. Data show improvements for up to six and 12 months, respectively. The HBET group did not show improvement in MWD/T compared with the WA group (SMD 0.30, 95% CI -0.45 to 1.05; P = 0.43; moderate-quality evidence).Compared with HBET, SET was more beneficial for PFWD/T but had no effect on quality of life parameters nor on self-reported functional impairment. Compared with WA, SET was more beneficial for PFWD/T and self-reported functional impairment, as well as for some quality of life parameters (e.g., physical functioning, pain, and physical component summary after 12 months), and HBET had no effect.Data show no obvious effects on mortality rates. Thirteen of the 1400 participants died, but no deaths were related to exercise therapy. Overall, adherence to SET was approximately 80%, which was similar to that reported with HBET. Only limited adherence data were available for WA groups. AUTHORS' CONCLUSIONS Evidence of moderate and high quality shows that SET provides an important benefit for treadmill-measured walking distance (MWD and PFWD) compared with HBET and WA, respectively. Although its clinical relevance has not been definitively demonstrated, this benefit translates to increased MWD of 120 and 210 meters after three months in SET groups. These increased walking distances are likely to have a positive impact on the lives of patients with IC. Data provide no clear evidence of a difference between HBET and WA. Trials show no clear differences in quality of life parameters nor in self-reported functional impairment between SET and HBET. However, evidence is of low and very low quality, respectively. Investigators detected some improvements in quality of life favoring SET over WA, but analyses were limited by small numbers of studies and participants. Future studies should focus on disease-specific quality of life and other functional outcomes, such as walking behavior and physical activity, as well as on long-term follow-up.
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Affiliation(s)
- David Hageman
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
| | | | - Lindy NM Gommans
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
| | - Marijn ML van den Houten
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
| | - Joep AW Teijink
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
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Iso Y, Suzuki H, Kyuno E, Maeda A, Tsunoda F, Miyazawa R, Kowaita H, Kitai H, Takahashi T, Sambe T. Therapeutic potential of cycling high-intensity interval training in patients with peripheral artery disease: A pilot study. IJC HEART & VASCULATURE 2018; 18:30-32. [PMID: 29750181 PMCID: PMC5941238 DOI: 10.1016/j.ijcha.2018.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Revised: 02/07/2018] [Accepted: 02/12/2018] [Indexed: 01/02/2023]
Affiliation(s)
- Yoshitaka Iso
- Showa University Research Institute for Sport and Exercise Sciences, Yokohama, Japan
- Division of Cardiology, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Etsushi Kyuno
- Division of Cardiology, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Japan
| | - Atsuo Maeda
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Fumiyoshi Tsunoda
- Division of Cardiology, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Japan
| | - Ryo Miyazawa
- Cardiac Rehabilitation, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Japan
| | - Hitoshi Kowaita
- Cardiac Rehabilitation, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Japan
| | - Hitomi Kitai
- Cardiac Rehabilitation, Showa University Fujigaoka Rehabilitation Hospital, Yokohama, Japan
| | - Tetsuya Takahashi
- Department of Physical Therapy, School of Health Sciences, Tokyo University of Technology, Tokyo, Japan
| | - Takeyuki Sambe
- Showa University Research Institute for Sport and Exercise Sciences, Yokohama, Japan
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17
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Periphere arterielle Verschlusskrankheit und Diabetes mellitus. DIABETOLOGE 2017. [DOI: 10.1007/s11428-017-0283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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18
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Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; 4:CD011279. [PMID: 28436583 PMCID: PMC5461882 DOI: 10.1002/14651858.cd011279.pub3] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure. OBJECTIVES To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions. METHODS We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively. MAIN RESULTS We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance. AUTHORS' CONCLUSIONS The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.
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Affiliation(s)
| | | | - Clare Clarke
- Division of Population Health Sciences, University of DundeeNinewells Hospital & Medical SchoolKirsty Semple WayDundeeUKDD2 4DB
| | - Denis Martin
- Teesside UniversityInstitute of Health and Social CareParksideMiddlesbroughUKTS1 3BA
| | - Lesley A Colvin
- University of Edinburgh, Western General HospitalAnaesthesia & Pain MedicineEdinburghUK
| | - Blair H Smith
- University of DundeeDivision of Population Health SciencesDundeeUKDD2 4BF
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19
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Geneen LJ, Moore RA, Clarke C, Martin D, Colvin LA, Smith BH. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; 1:CD011279. [PMID: 28087891 PMCID: PMC6469540 DOI: 10.1002/14651858.cd011279.pub2] [Citation(s) in RCA: 355] [Impact Index Per Article: 50.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic pain is defined as pain lasting beyond normal tissue healing time, generally taken to be 12 weeks. It contributes to disability, anxiety, depression, sleep disturbances, poor quality of life, and healthcare costs. Chronic pain has a weighted mean prevalence in adults of 20%.For many years, the treatment choice for chronic pain included recommendations for rest and inactivity. However, exercise may have specific benefits in reducing the severity of chronic pain, as well as more general benefits associated with improved overall physical and mental health, and physical functioning.Physical activity and exercise programmes are increasingly being promoted and offered in various healthcare systems, and for a variety of chronic pain conditions. It is therefore important at this stage to establish the efficacy and safety of these programmes, and furthermore to address the critical factors that determine their success or failure. OBJECTIVES To provide an overview of Cochrane Reviews of adults with chronic pain to determine (1) the effectiveness of different physical activity and exercise interventions in reducing pain severity and its impact on function, quality of life, and healthcare use; and (2) the evidence for any adverse effects or harm associated with physical activity and exercise interventions. METHODS We searched theCochrane Database of Systematic Reviews (CDSR) on the Cochrane Library (CDSR 2016, Issue 1) for systematic reviews of randomised controlled trials (RCTs), after which we tracked any included reviews for updates, and tracked protocols in case of full review publication until an arbitrary cut-off date of 21 March 2016 (CDSR 2016, Issue 3). We assessed the methodological quality of the reviews using the AMSTAR tool, and also planned to analyse data for each painful condition based on quality of the evidence.We extracted data for (1) self-reported pain severity, (2) physical function (objectively or subjectively measured), (3) psychological function, (4) quality of life, (5) adherence to the prescribed intervention, (6) healthcare use/attendance, (7) adverse events, and (8) death.Due to the limited data available, we were unable to directly compare and analyse interventions, and have instead reported the evidence qualitatively. MAIN RESULTS We included 21 reviews with 381 included studies and 37,143 participants. Of these, 264 studies (19,642 participants) examined exercise versus no exercise/minimal intervention in adults with chronic pain and were used in the qualitative analysis.Pain conditions included rheumatoid arthritis, osteoarthritis, fibromyalgia, low back pain, intermittent claudication, dysmenorrhoea, mechanical neck disorder, spinal cord injury, postpolio syndrome, and patellofemoral pain. None of the reviews assessed 'chronic pain' or 'chronic widespread pain' as a general term or specific condition. Interventions included aerobic, strength, flexibility, range of motion, and core or balance training programmes, as well as yoga, Pilates, and tai chi.Reviews were well performed and reported (based on AMSTAR), and included studies had acceptable risk of bias (with inadequate reporting of attrition and reporting biases). However the quality of evidence was low due to participant numbers (most included studies had fewer than 50 participants in total), length of intervention and follow-up (rarely assessed beyond three to six months). We pooled the results from relevant reviews where appropriate, though results should be interpreted with caution due to the low quality evidence. Pain severity: several reviews noted favourable results from exercise: only three reviews that reported pain severity found no statistically significant changes in usual or mean pain from any intervention. However, results were inconsistent across interventions and follow-up, as exercise did not consistently bring about a change (positive or negative) in self-reported pain scores at any single point. Physical function: was the most commonly reported outcome measure. Physical function was significantly improved as a result of the intervention in 14 reviews, though even these statistically significant results had only small-to-moderate effect sizes (only one review reported large effect sizes). Psychological function and quality of life: had variable results: results were either favourable to exercise (generally small and moderate effect size, with two reviews reporting significant, large effect sizes for quality of life), or showed no difference between groups. There were no negative effects. Adherence to the prescribed intervention: could not be assessed in any review. However, risk of withdrawal/dropout was slightly higher in the exercising group (82.8/1000 participants versus 81/1000 participants), though the group difference was non-significant. Healthcare use/attendance: was not reported in any review. Adverse events, potential harm, and death: only 25% of included studies (across 18 reviews) actively reported adverse events. Based on the available evidence, most adverse events were increased soreness or muscle pain, which reportedly subsided after a few weeks of the intervention. Only one review reported death separately to other adverse events: the intervention was protective against death (based on the available evidence), though did not reach statistical significance. AUTHORS' CONCLUSIONS The quality of the evidence examining physical activity and exercise for chronic pain is low. This is largely due to small sample sizes and potentially underpowered studies. A number of studies had adequately long interventions, but planned follow-up was limited to less than one year in all but six reviews.There were some favourable effects in reduction in pain severity and improved physical function, though these were mostly of small-to-moderate effect, and were not consistent across the reviews. There were variable effects for psychological function and quality of life.The available evidence suggests physical activity and exercise is an intervention with few adverse events that may improve pain severity and physical function, and consequent quality of life. However, further research is required and should focus on increasing participant numbers, including participants with a broader spectrum of pain severity, and lengthening both the intervention itself, and the follow-up period.
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Affiliation(s)
- Louise J Geneen
- University of DundeeDivision of Population Health SciencesDundeeUK
| | - R Andrew Moore
- University of OxfordPain Research and Nuffield Department of Clinical Neurosciences (Nuffield Division of Anaesthetics)Pain Research UnitChurchill HospitalOxfordUKOX3 7LE
| | - Clare Clarke
- Division of Population Health Sciences, University of DundeeNinewells Hospital & Medical SchoolKirsty Semple WayDundeeUKDD2 4DB
| | - Denis Martin
- Teesside UniversityInstitute of Health and Social CareParksideMiddlesbroughUKTS1 3BA
| | - Lesley A Colvin
- University of Edinburgh, Western General HospitalAnaesthesia & Pain MedicineEdinburghUK
| | - Blair H Smith
- University of DundeeDivision of Population Health SciencesDundeeUK
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Patelis N, Karaolanis G, Kouvelos GN, Hart C, Metheiken S. The effect of exercise on coagulation and fibrinolysis factors in patients with peripheral arterial disease. Exp Biol Med (Maywood) 2016; 241:1699-707. [PMID: 27444152 DOI: 10.1177/1535370216660215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Peripheral arterial disease is a widely prevalent atherosclerotic occlusive disorder. Symptoms commence with exercise-induced pain in the lower extremities, known as claudication. Despite the fact that exercise has been shown to improve fibrinolytic profile some patients, the effect of exercise on coagulation and fibrinolysis cascades in claudicants has not been comprehensively defined. Literature search in English language yielded 13 studies of exercise on claudicants, including 420 patients. Claudicants tend to have a higher coagulation activity at rest compared to healthy individuals, a trend that persists even after exercise. Post-exercise coagulation activity of claudicants is increased when compared to their respective baseline levels, but it is so in a non-consistent manner. From the available data, it has been suggested that claudicants have a functional and effective fibrinolytic mechanism in place, operating continuously at a relatively higher activity level compared to healthy individuals. Fibrinolysis seems to be activated by exercise; a positive outcome with a prolonged effect as shown by a few of the studies. A final conclusion whether coagulation or fibrinolysis activity is affected mostly by exercise type and intensity in claudicants could not be answered. All conclusions regarding the effect of exercise on the coagulation and fibrinolysis mechanisms should be taken under cautious consideration, due to the limited number of studies, the small number of patients and the different exercise strategies employed in each study. Further randomized studies with similar exercise protocols could provide safer conclusions in the future.
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Affiliation(s)
- Nikolaos Patelis
- First Department of Surgery, Vascular Unit, Laiko General Hospital, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgios Karaolanis
- First Department of Surgery, Vascular Unit, Laiko General Hospital, National & Kapodistrian University of Athens, 11527 Athens, Greece
| | - Georgios N Kouvelos
- Vascular Unit, General University Hospital of Thessaly, 41110 Larisa, Greece
| | - Collin Hart
- Department of General Surgery, Royal Free Hospital, NW3 2QG London, UK
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Tew GA, Brabyn S, Cook L, Peckham E. The Completeness of Intervention Descriptions in Randomised Trials of Supervised Exercise Training in Peripheral Arterial Disease. PLoS One 2016; 11:e0150869. [PMID: 26938879 PMCID: PMC4777572 DOI: 10.1371/journal.pone.0150869] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/15/2016] [Indexed: 11/18/2022] Open
Abstract
Research supports the use of supervised exercise training as a primary therapy for improving the functional status of people with peripheral arterial disease (PAD). Several reviews have focused on reporting the outcomes of exercise interventions, but none have critically examined the quality of intervention reporting. Adequate reporting of the exercise protocols used in randomised controlled trials (RCTs) is central to interpreting study findings and translating effective interventions into practice. The purpose of this review was to evaluate the completeness of intervention descriptions in RCTs of supervised exercise training in people with PAD. A systematic search strategy was used to identify relevant trials published until June 2015. Intervention description completeness in the main trial publication was assessed using the Template for Intervention Description and Replication checklist. Missing intervention details were then sought from additional published material and by emailing authors. Fifty-eight trials were included, reporting on 76 interventions. Within publications, none of the interventions were sufficiently described for all of the items required for replication; this increased to 24 (32%) after contacting authors. Although programme duration, and session frequency and duration were well-reported in publications, complete descriptions of the equipment used, intervention provider, and number of participants per session were missing for three quarters or more of interventions (missing for 75%, 93% and 80% of interventions, respectively). Furthermore, 20%, 24% and 26% of interventions were not sufficiently described for the mode of exercise, intensity of exercise, and tailoring/progression, respectively. Information on intervention adherence/fidelity was also frequently missing: attendance rates were adequately described for 29 (38%) interventions, whereas sufficient detail about the intensity of exercise performed was presented for only 8 (11%) interventions. Important intervention details are commonly missing for supervised exercise programmes in the PAD trial literature. This has implications for the interpretation of outcome data, the investigation of dose-response effects, and the replication of protocols in future studies and clinical practice. Researchers should be mindful of intervention reporting guidelines when attempting to publish information about supervised exercise programmes, regardless of the population being studied.
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Affiliation(s)
- Garry A. Tew
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle Upon Tyne, United Kingdom
- * E-mail:
| | - Sally Brabyn
- Mental Health and Addiction Group, Department of Health Sciences, University of York, York, United Kingdom
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, York, United Kingdom
| | - Emily Peckham
- Mental Health and Addiction Group, Department of Health Sciences, University of York, York, United Kingdom
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González-Tapia D, Martínez-Torres NI, Hernández-González M, Guevara MA, González-Burgos I. Plastic changes to dendritic spines on layer V pyramidal neurons are involved in the rectifying role of the prefrontal cortex during the fast period of motor learning. Behav Brain Res 2016; 298:261-7. [DOI: 10.1016/j.bbr.2015.11.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 11/03/2015] [Accepted: 11/09/2015] [Indexed: 11/30/2022]
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Lindo FA. Exercise therapy for claudication: Should home-based exercise therapy be prescribed in clinical practice? JOURNAL OF VASCULAR NURSING 2015; 33:143-9. [DOI: 10.1016/j.jvn.2015.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 05/31/2015] [Accepted: 06/03/2015] [Indexed: 10/22/2022]
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Bø E, Hisdal J, Cvancarova M, Stranden E, Jørgensen JJ, Sandbæk G, Grøtta OJ, Bergland A. Twelve-months follow-up of supervised exercise after percutaneous transluminal angioplasty for intermittent claudication: a randomised clinical trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2013; 10:5998-6014. [PMID: 24284358 PMCID: PMC3863883 DOI: 10.3390/ijerph10115998] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 11/04/2013] [Accepted: 11/06/2013] [Indexed: 11/16/2022]
Abstract
UNLABELLED The aim of this study was to explore the effects during 12 months follow-up of 12 weeks of supervised exercise therapy (SET) after percutaneous transluminal angioplasty (PTA) compared to PTA alone on physical function, limb hemodynamics and health-related quality of life (HRQoL) in patients with intermittent claudication. Fifty patients were randomised to an intervention or a control group. Both groups received usual post-operative care and follow-up measurements at three, six and 12 months after PTA. The intervention group performed 12 weeks of SET after PTA. The control group did not receive any additional follow-up regarding exercise. During the 12 months' follow-up, the members of the intervention group had significantly better walking distance than the control group. The intervention group had a significantly higher HRQoL score in the physical component score of the SF-36, and the domains of physical function, bodily pain and vitality. For limb hemodynamics, there was a non-significant trend towards better results in the intervention group compared to the control group. CONCLUSION SET after PTA yielded statistically significantly better results for walking distance and HRQoL in the intervention group than the control group during the 12 months of follow-up.
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Affiliation(s)
- Elisabeth Bø
- Faculty of Health Sciences, Oslo and Akershus University, Pilestredet 46, 0130 Oslo, Norway; E-Mails: (M.C.); (A.B.)
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372 Oslo, Norway; E-Mails: (E.S.); (J.J.J.); (G.S.)
| | - Jonny Hisdal
- Section of Vascular Investigations, Oslo Vascular Centre, Oslo University Hospital Aker, Trondheimsveien 235, 0586 Oslo, Norway; E-Mail:
| | - Milada Cvancarova
- Faculty of Health Sciences, Oslo and Akershus University, Pilestredet 46, 0130 Oslo, Norway; E-Mails: (M.C.); (A.B.)
| | - Einar Stranden
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372 Oslo, Norway; E-Mails: (E.S.); (J.J.J.); (G.S.)
- Section of Vascular Investigations, Oslo Vascular Centre, Oslo University Hospital Aker, Trondheimsveien 235, 0586 Oslo, Norway; E-Mail:
| | - Jørgen J. Jørgensen
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372 Oslo, Norway; E-Mails: (E.S.); (J.J.J.); (G.S.)
- Department of Vascular Surgery, Oslo Vascular Centre, Oslo University Hospital Aker, Trondheimsveien 235, 0586 Oslo, Norway
| | - Gunnar Sandbæk
- Faculty of Medicine, University of Oslo, Klaus Torgårdsvei 3, 0372 Oslo, Norway; E-Mails: (E.S.); (J.J.J.); (G.S.)
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Aker, Trondheimsveien 235, 0586 Oslo, Norway; E-Mail:
| | - Ole J. Grøtta
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Aker, Trondheimsveien 235, 0586 Oslo, Norway; E-Mail:
| | - Astrid Bergland
- Faculty of Health Sciences, Oslo and Akershus University, Pilestredet 46, 0130 Oslo, Norway; E-Mails: (M.C.); (A.B.)
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