Vascular rehabilitation: Benefits of a structured exercise/risk modification program

Rehabilitation of patients with peripheral arterial disease

Vascular rehabilitation is an essential and effective treatment of peripheral arterial obstructive disease (PAOD). It is recommended in the first line by the European and American scientific societies. The rehabilitation to the walk remains the basic treatment of the arteriopathy of the lower limbs. Different walking protocols can be proposed. For similar effectiveness, vascular rehabilitation consists of an outpatient or specialized institution management program based on a comprehensive approach involving all or many of the following techniques: relaxation, active analytical exercises, gait rehabilitation, exercise re-entry, physical activities adapted to the patient's daily life and illness, respiratory physiotherapy, therapeutic education of the patient, smoking cessation aid. Vascular rehabilitation of arteritis requires a variety of skills but still faces a clear lack of suitable structures; it remains poorly prescribed and poorly known by usual prescribers (general practitioner, vascular surgeon).

[Follow-up of patients with chronic obstructive arterial disease, some months after their rehabilitation: Assessment of a therapeutic education program]

Vascular rehabilitation (VR) is becoming increasingly important in the management of the arterial patient. Therapeutic Patient Education (TPE) is an integral part of rehabilitation programs and aims to transform patients' lifestyle habits. The effectiveness of patient management at short-term no longer needs to be demonstrated, but we can question the effectiveness of education over the long term, some months following a rehabilitation program.

OBJECTIVE

This study aims to assess, in the long term, the effects of TPE in VR, and to observe the transformation of certain lifestyle habits of patients.

METHOD

We convened 68 patients (51 men and 17 women) 6 months and 1 year after VR treatment during which these patients participated in an TPE program. We assessed: knowledge by questionnaire, walking range, weight and body composition by impedimetric techniques.

RESULTS

We found that patients improved their knowledge at the end of rehabilitation 45.8 (±7.6) of good responses on average, compared to 36.2 (±8.6) at the beginning of rehabilitation and these results are consolidated 6 months after 43.4 (±7.5) and 1 year after 44.1 (±8.1). We also found that walking distances during treadmill testing and outdoor walking improved at the end of rehabilitation and were maintained at six months and one year. Finally, weight, fat mass and lean mass decreased slightly compared to the end of rehabilitation. Only 7 patients out of 22 gave up smoking.

CONCLUSION

An education program concerning risk factor management during vascular rehabilitation enables patients to acquire knowledge that can be used to maintain new lifestyle habits and stabilize their health status.

Initial Results of a 12-week, Institution-based, Supervised Exercise Rehabilitation Program for the Management of Peripheral Arterial Disease

This study assessed the effectiveness of a 12-week, institution-based, supervised exercise rehabilitation program with atherogenic risk factor modification in improving cardiovascular profile, ambulatory function, and quality of life of patients with peripheral arterial disease (PAD) by comparing pre- and postprogram measurements. Participants were prospectively enrolled. Cardiovascular profile variables, ambulatory function tests, and quality of life questionnaires were evaluated. Of 101 institution-based program participants, 69 completed the 12-session minimum and 47 completed a postprogram evaluation. Mean postprogram results were significantly different from preprogram results, corresponding to improvement, for the following variables: triglyceride levels ( p = .036), both function tests ( p < .001 for both), four of five Walking Impairment Questionnaire measurements, and Intermittent Claudication Questionnaire score ( p = .001). This supervised exercise program improved the cardiovascular profiles, ambulatory function, and quality of life of PAD patients completing the program and is a viable adjunct to drug therapy and surgical intervention.

Current literature for evidence-based infrainguinal endovascular treatment

With the proliferation of devices and techniques for lower extremity endovascular revascularization, treatment decisions become increasingly difficult as only limited experience with these new technologies is available for review. This monograph attempts to define the current state of the literature available to guide endovascular treatment of superficial artery disease, and to provide a baseline for future studies.

The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication

PURPOSE

The purpose of this randomized trial was to compare the efficacy of a low-intensity exercise rehabilitation program vs a high-intensity program in changing physical function, peripheral circulation, and health-related quality of life in peripheral arterial disease (PAD) patients limited by intermittent claudication.

METHODS

Thirty-one patients randomized to low-intensity exercise rehabilitation and 33 patients randomized to high-intensity exercise rehabilitation completed the study. The 6-month exercise rehabilitation programs consisted of intermittent treadmill walking to near maximal claudication pain 3 days per week at either 40% (low-intensity group) or 80% (high-intensity group) of maximal exercise capacity. Total work performed in the two training regimens was similar by having the patients in the low-intensity group exercise for a longer duration than patients in the high-intensity group. Measurements of physical function, peripheral circulation, and health-related quality of life were obtained on each patient before and after the rehabilitation programs.

RESULTS

After the exercise rehabilitation programs, patients in the two groups had similar improvements in these measures. Initial claudication distance increased by 109% in the low-intensity group (P < .01) and by 109% in the high-intensity group (P < .01), and absolute claudication distance increased by 61% (P < 0.01) and 63% (P < .01) in the low-intensity and high-intensity groups, respectively. Furthermore, both exercise programs elicited improvements (P < .05) in peak oxygen uptake, ischemic window, and health-related quality of life.

CONCLUSION

The efficacy of low-intensity exercise rehabilitation is similar to high-intensity rehabilitation in improving markers of functional independence in PAD patients limited by intermittent claudication, provided that a few additional minutes of walking is accomplished to elicit a similar volume of exercise.

Life-style Modification in Peripheral Arterial Disease

OBJECTIVE

To review the published evidence supporting the use of life-style modification in peripheral arterial disease (PAD).

DESIGN

A systematic search of the medical literature was performed for relevant studies.

MATERIALS

The publications obtained were then searched for randomised clinical trials which reported end-points of mortality or major cardiovascular event rates with various life-style modifications.

RESULTS

Only one randomised controlled trial was found reporting relevant end-points. Other trials were of other end-points such as walking distance or biochemical markers.

CONCLUSIONS

There is a lack of randomised controlled data proving the benefit of life-style modification in improving mortality and reducing cardiovascular events in patients with PAD. Despite this there is sufficient evidence to recommend some life-style modification as part of the overall approach to risk reduction in these patients. There is compelling evidence to support smoking cessation, increased exercise and improved diet.

Response to exercise rehabilitation in smoking and nonsmoking patients with intermittent claudication

BACKGROUND

The purpose was to compare the changes in claudication pain, ambulatory function, daily physical activity, peripheral circulation, and health-related quality of life following a program of exercise rehabilitation in smoking and nonsmoking patients with peripheral arterial disease (PAD) limited by intermittent claudication. Methods and results Thirty-nine smokers (63 +/- 4 pack-year smoking history; mean +/- SE) and 46 nonsmokers (former smokers who had a 51 +/- 7 pack-year smoking history who quit 14 +/- 2 years prior to investigation) completed the study. The 6-month exercise rehabilitation program consisted of intermittent treadmill walking to near maximal claudication pain 3 days per week, with progressive increases in walking duration and intensity during the program. Measurements were obtained on each patient before and after rehabilitation. Following exercise rehabilitation the smokers and nonsmokers had similar improvements in these measures, as initial claudication distance increased by 119% in the smokers (P <.001) and by 97% in the nonsmokers (P <.001), and absolute claudication distance increased by 82% (P <.001) and 59% (P <.001) in the smokers and nonsmokers, respectively. Furthermore, exercise rehabilitation improved (P <.05) ambulatory function, daily physical activity, peripheral circulation, and health-related quality of life in the smokers and nonsmokers.

CONCLUSION

Exercise rehabilitation is an effective therapy to improve functional independence in both smoking and nonsmoking patients with PAD limited by intermittent claudication. Therefore, smokers with intermittent claudication are prime candidates for exercise rehabilitation because their relatively low baseline physical function does not impair their ability to regain lost functional independence to levels similar to nonsmoking patients with PAD.

Outcome of Conservative Therapy of Patients with Severe Intermittent Claudication

BACKGROUND

Intermittent claudication due to peripheral artery disease (PAD) can be treated conservatively, or by revascularization.

OBJECTIVES

To assess the short-term outcome of conservatively-treated claudicants, and determine predictors for clinical improvement. Design. A retrospective cohort study.

METHODS

We evaluated Fontaine stage, walking distance and ankle brachial index (ABI) at baseline and after median 9 months (interquartile range (IQR) 6-24) in 181 patients with severe claudication.

RESULTS

We found clinical improvement by at least one Fontaine stage in 38 patients (21%) with an increased walking distance from baseline median 100 m (IQR 50-150) to follow-up median 650 m (IQR 300 to unlimited; p<0.001), but without changes in ABI (median 0.57, IQR 0.48-0.73 vs. median 0.54, IQR 0.45-0.81; p=0.10). One hundred and thirty-eight patients (76%) remained clinically and hemodynamically stable. A worsening of the clinical stage but without amputation was recorded in five patients (3%). Female gender (hazard ratio (HR) 0.51, p=0.052), diabetes (HR 0.35, p=0.020), and baseline ABI below 0.44 (HR 0.31, p=0.019) were associated with a reduced probability of clinical improvement.

CONCLUSION

Certain patients with intermittent claudication show substantial clinical improvement with conservative medical therapy, despite any lack of hemodynamic improvement. Given the low number of patients with clinical deterioration in the short term, primarily conservative therapy should be the preferred initial option for most claudicants.

Optimal therapeutic approaches to femoropopliteal artery intervention

Superficial femoral artery disease presents a complex challenge for therapy. The extent of vascular involvement may vary from focal disease with symptoms of intermittent claudication to long total occlusions manifest as critical limb ischemia. Optimal therapy requires understanding the available options including exercise programs, pharmacologic medical therapy, surgery and interventional endovascular therapy. Rapidly advancing endovascular technology for enabling safe intervention in complex, long occlusive segments of the superficial femoral artery continues to emerge. New devices like the SafeCross wire, Excimer laser, Silverhawk Atherectomy catheter, Cryoplasty catheter and new generations of bare metal and drug-eluting nitinol stents are shifting the paradigm for therapy from surgical to more endovascular treatment even for the most complex disease presentation.

Femoropopliteal occlusive disease: diagnosis, indications for treatment, and results of interventional therapy

The relative role of percutaneous therapy versus bypass surgery for femoropopliteal occlusive disease (FPD) represents an area of great controversy in the field of vascular medicine. This controversy is complicated by the very dynamic therapeutic options that continue to be introduced, particularly on the endovascular side. The purpose of this review is to provide an overview of the current diagnostic modalities available to characterize the level and degree of vascular insufficiency and summarize the currently available endovascular therapeutic options with their clinical role and outcomes. Finally, future therapeutic advances that will soon be evaluated in clinical trials will be discussed.

Clinical results for the training-phase roll-in patients in the Intracoil femoralpopliteal stent trial

The purpose of this study was to report the results of the roll-in patients for the multicenter IntraCoil trial in the femoropopliteal arteries at 9-month follow-up. Ninety-three roll-in patients (mean age, 67.8 +/- 10.5 years; 62.4% male gender) constituted the learning phase for the 22 clinical sites. Obstructive femoropopliteal artery disease up to 15 cm was treated with stenting. Clinical patency was measured over a 9-month period by clinical and hemodynamic data as well as the Rutherford scale. Diabetes mellitus was present in 35.5%. Twenty-nine percent of lesions treated were occlusions. The mean reference diameter for treated lesions was 4.27 +/- 1.11 mm, while the mean lesion length was 3.83 +/- 3.69 cm. Acute angiographic success by operator evaluation was obtained in 98.9% of patients. Major complications occurred in 3.2%. No patient experienced abrupt or subacute closure. There were two reports of failure to deliver assigned stent. In both incidences, the stent was removed without surgical intervention. There were also three reports of stent misplacement (moving during delivery), one report of stent migration, one report of delivery system failure. At 30-day and 9-month follow-up of successfully treated patients, 100%/77.9% remained free of major adverse clinical events (MACE) and 100%/81.8% target lesion revascularization (TLR), respectively. At 9-month follow-up, ankle-brachial index increased from 0.66 +/- 0.22 to 0.83 +/- 0.20 while mean maximum walking time increased form 4.47 +/- 3.02 to 5.91 +/- 3.97 min. The use of the IntraCoil stent appears to have a short learning curve. Excellent clinical and hemodynamic patency is seen at 9 months. The randomized comparison trial comparing the IntraCoil to angioplasty is pending.

Saving the diabetic foot with special reference to the patient with chronic renal failure

The chronic renal failure patient with diabetes has a lower limb amputation rate 10 times greater than the diabetic population at large. In studies of causal pathways leading to non-traumatic related lower extremity amputation, foot ulcers preceded approximately 84% of the amputations. Even though foot ulcers are more likely to develop in patients with diabetic nephropathy, they are no less likely to heal than are those in diabetic patients with normal renal function. Consequently, attempts to save the diabetic foot even in this high-risk population are justified. The pathogenesis of foot ulceration in the chronic renal failure patient with diabetes is primarily due to peripheral neuropathy. Loss of protective sensation due to sensory neuropathy combined with motor and autonomic neuropathy and macrovascular compromise result in increased risk for foot complications. Evaluation of the foot includes a selective history and a focused examination of skin integrity, presence of sensory neuropathy or vascular insufficiency, and biomechanical and footwear inspection. Effective treatment of diabetic foot complications include appropriate antibiotics (when indicated), meticulous wound care, off-loading, vascular surgery (when indicated), and selective/elective or prophylactic nonvascular surgery. Failure to heal an ulcer can often be traced to common pitfalls, which include: A "cavalier" attitude. W.N.L. exam (We Never Looked). Inadequate off-loading. Failure to establish depth of ulcer and miss "probe to bone." Non-healing means unrelieved pressure and/or no blood. Failure to correct edema. The multidisciplinary diabetic foot clinic model provides an ideal setting for early intervention, treatment, and assistance with preventive strategies.

Treatment efficacy of intermittent claudication by surgical intervention, supervised physical exercise training compared to no treatment in unselected randomised patients I: one year results of functional and physiological improvements

OBJECTIVES

to compare the effect of surgery, exercise and simple observation on maximum exercise power in claudicants.

DESIGN

prospective, randomised study.

METHODS

a total of 264 unselected claudicants were randomised to supervised exercise training, invasive treatment (open surgical or endovascular procedures) or observation. One year treatment outcomes were analysed on an intention to-treat basis.

RESULTS

invasively treated patients showed a significant improvement in maximum walking power, stopping distance, post-ischaemic blood flow and big toe pressure at one year. Patients randomised to physical exercise training or to the control group did not improve in any outcome measure.

CONCLUSION

invasive treatment increased walking capacity, leg blood pressure and flow. Supervised physical exercise training offered no therapeutic advantage compared to untreated controls.

Exercise training for claudicants: changes in blood flow, cardiorespiratory status, metabolic functions, blood rheology and lipid profile

OBJECTIVE

Exercise training improves the walking distance of claudicants. The aim of this study was to investigate factors associated with the improvement in the maximum walking distance (MWD) in respect to cardiovascular, respiratory and metabolic adaptations.

METHODS

Forty claudicants were studied. Common femoral artery blood flow (BF), heart rate (HR), oxygen consumption (VO(2)), respiratory exchange ratio (RER), lactate levels, blood rheology and lipid profiles were measured. Tests were repeated after 3 months of exercise training.

RESULTS

Fifteen patients did not complete the exercise program. For patients who did complete the program, MWD improved by 82%. A significant reduction in HR and VO(2)during exercise was demonstrated. No significant changes occurred in BF or RER. Although MWD increased significantly, there was no increase in recovery VO(2)(oxygen debt). A significant reduction in post-exercise lactate levels occurred. Blood rheology was unchanged, but an improvement in HDL levels was noted.

CONCLUSIONS

Many claudicants could not complete an exercise program, mainly due to osteoarthritis. Exercise training improved exercise tolerance significantly without any increase in BF. The HR and oxygen cost of similar exercise was reduced. An improved MWD did not correlate with a higher oxygen debt or lactate load. Favourable changes in lipid profiles occurred.

Exercise therapy or angioplasty? A summation analysis

OBJECTIVES

To compare the outcome of exercise therapy or angioplasty for the treatment of patients with intermittent claudication.

DESIGN

A summation analysis.

METHODS

A search using MEDLINE and PUBMED between 1966 and April 1999 followed by a review of the manuscripts yielded 54 studies involving angioplasty and 27 studies involving exercise therapy for intermittent claudication. Studies were only included (12 angioplasty and nine exercise series) when results were available for patients with intermittent claudication alone, and when outcome was assessed in terms of symptoms at a minimum of 6 months.

RESULTS

The total number of claudicants undergoing exercise therapy was 294 patients, with a mean symptomatic success rate of 38. 4% and a mean improvement in maximum walking distance of 189.7% at 6 months. The total number of claudicants undergoing angioplasty was 2071, with a mean overall symptomatic success rate of 76.6%. The mean overall complication rate was 9% and mean major complication rate was 2.7% for the angioplasty studies.

CONCLUSION

Although the result demonstrates an advantage of angioplasty over exercise therapy at 6 months, there is a small risk of major complications. However, comparison of studies was impaired due to disparity in patient numbers, limited follow-up time and lack of uniformity in outcome assessment. In order to achieve a valid comparison of these therapies in a future randomised study, a validated disease-specific instrument for the assessment of symptomatic outcome for claudicants is required.

Comorbidities and the entry of patients with peripheral arterial disease into an exercise rehabilitation program

BACKGROUND

Exercise rehabilitation is advocated to improve function in patients with peripheral arterial disease (PAD) who have intermittent claudication. Patients with PAD often have comorbid medical problems that may interfere with their ability to safely participate in exercise rehabilitation programs. There is a paucity of information regarding the medical comorbidities and the evaluation of PAD patients before their participation in exercise rehabilitation studies. The purpose of this study was to identify comorbidities that predicted exclusion of PAD patients from participation in an aerobic exercise rehabilitation clinical trial.

METHODS

This was a prospective cohort study of 225 consecutive outpatient volunteers (mean age 68 +/- 8 years, SD) with a history of Fontaine Stage II PAD recruited for exercise rehabilitation. Patient eligibility was determined by a history and physical exam, blood chemistries, measurement of ankle to brachial index (ABI), and an exercise treadmill test.

RESULTS

Seventy-nine volunteers (35%) were medically ineligible: 22 because of symptomatic coronary artery disease, 12 because of severe PAD, and the rest for a variety of medical problems. In stepwise logistic regression analyses, low ABI and use of insulin were predictors of exclusion, whereas peripheral revascularization was an indicator of inclusion. Age, a history of coronary artery disease, myocardial infarction, coronary bypass surgery, and hypertension were not independent determinants of eligibility.

CONCLUSIONS

Insulin-requiring diabetes and a low ABI increase the likelihood that older patients with PAD will be ineligible to participate in a research exercise rehabilitation program, whereas peripheral revascularization was associated with inclusion. Whether intensive medical management and peripheral revascularization would enable the claudicants deemed ineligible for entry into the exercise rehabilitation program to safely exercise remains to be determined.

Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease

OBJECTIVE

The purpose of this study was to determine whether a 6-month exercise rehabilitation program can improve cardiovascular risk factors in patients with peripheral arterial occlusive disease (PAOD).

METHODS

Thirty-four patients (mean age, 68 +/- 8 years; range 54-84 years) with PAOD with intermittent claudication (Fontaine stage II) and 14 longitudinal controls of comparable age with stage II PAOD enrolled in an exercise intervention at the University Medical Center and Veterans Affairs Medical Center at Baltimore, Maryland. The main outcome measures were lipid profile (total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol [LDL-C]), fasting glucose, blood pressure, body mass index, treadmill times to onset and maximal claudication pain, cardiopulmonary function (peak oxygen uptake), and ankle/brachial index.

RESULTS

With exercise rehabilitation, treadmill times to onset and maximal claudication pain increased by 106% and 64% (P <.0001), whereas peak oxygen uptake increased 7% (P <.05). Exercise rehabilitation lowered total cholesterol and LDL-C levels by 5.2% (P <.005) and 8% (P <.01), respectively. Systolic blood pressure declined by 5.7% (P <.05) with no change in diastolic blood pressure. These changes in cholesterol and LDL-C concentrations were related to their initial values. All other cardiovascular risk factors measured did not change. There was no correlation between improvement of cardiovascular risk factors and functional performance measurements. None of the variables measured changed significantly in the control group.

CONCLUSIONS

Exercise rehabilitation not only improves functional performance, but also results in favorable alterations in cardiovascular risk factor profile, which is an important element in the management of PAOD.

Effect of exercise on calf muscle pump function in patients with chronic venous disease

BACKGROUND

Musculoskeletal dysfunction may be associated with poor calf muscle pump function in patients with chronic venous ulceration. The aim of this study was to evaluate the effects of physical exercise on calf muscle pump function.

METHODS

Twenty patients were recruited into a 6-week intensive exercise programme. Calf muscle function and calf muscle pump function were assessed using an isokinetic device and air plethysmography respectively, before and after the exercise programme.

RESULTS

There was significant improvement in calf muscle pump function, measured as increased ejection fraction and decreased residual fraction (P < 0.05); however, venous reflux was not altered (P > 0.05). Calf muscle strength and endurance parameters all increased, but not significantly (P > 0.05).

CONCLUSION

Poor calf muscle pump function in patients with chronic venous ulceration can be improved by physical exercise.

Exercise therapy for intermittent claudication: a review of the quality of randomised clinical trials and evaluation of predictive factors

OBJECTIVE

To establish the effect of exercise therapy in patients with intermittent claudication and to identify outcome predictors for exercise training.

DESIGN

A methodological study of randomised clinical trials.

METHODS

A quality assessment of all eligible studies was performed, using a list of methodological criteria. A weighing scale for the criteria was developed, based on four main categories: study population, intervention, outcome variables and data presentation/analysis.

RESULTS

Ten studies were included in the analysis. Seven randomised clinical trials had a methodological score of 60 or more points (maximum 100), and were considered to be of good quality. The mean of the methodological score was 62.5 (S.D. 8.5). Improvement in pain-free/maximum walking distance/time ranged from 28-210% (mean 105, S.D. 55.8). Only one study evaluated outcome predictors for exercise therapy.

CONCLUSIONS

All studies reported a positive effect of exercise therapy on walking distance in patients with intermittent claudication, but no predictive factors were clearly identified. Future research efforts should focus on improving the quality of clinical research for patients with intermittent claudication and developing optimal rehabilitation programs.

Treatment of intermittent claudication: the impact on quality of life

OBJECTIVES

To measure changes in claudicant's quality of life after surgery, angioplasty or unsupervised exercise. To explore the relationship between clinical indicators of limb perfusion and patient's perception of health change.

DESIGN

Prospective study.

SETTING

University Hospital vascular outpatients.

MATERIALS AND METHODS

202 claudicants referred for Duplex of lower limb arterial disease over a 12 month period. The short form 36 questionnaire was used to determine quality of life. Ankle pressures and walking distances were determined.

MAIN RESULTS

The SF-36 was completed by 186 patients (92%) before and after treatment (34 operative patients, 74 angioplasty and 78 treated by exercise alone). Baseline quality of life was worse in surgical patients. Unsupervised exercise produced minimal changes in quality of life. Angioplasty and operation produced similar, significant improvements in physical functioning and pain. Changes in physical function or pain scores were unrelated to changes in ankle pressure.

CONCLUSIONS

Unsupervised exercise programs are unlikely to significantly improve patient's quality of life. The benefits of surgery and angioplasty support a relaxation in the indications for investigation and treatment of claudicants. Patients with impaired perceived health should not be denied treatment on the basis of preintervention ankle pressure or walking distance alone.

Vascular medicine: an alternative approach to arterial disease

The National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) is leading a nationwide initiative to develop comprehensive programs that integrate clinical care, education, and research in vascular disease by developing vascular centers designed to provide comprehensive patient care through a multidisciplinary approach. Only a few medical centers have a dedicated vascular medicine specialty. To date, 11 centers nationwide have received NIH support devoted to creating vascular centers and promoting vascular medicine as a specialty. In June 1992, Northwestern University/Northwestern Memorial Hospital received one of these awards. The NIH recognizes the complex medical problems in patients with vascular disease. The resulting necessity for care by multiple physicians has traditionally led to duplication and fragmentation of services. Until recently, vascular surgery programs have focused primarily on the surgical treatment of vascular disease. This approach does not address risk reduction and the diverse care needs of the population of patients with vascular disease.