Effect of Supervised Exercise Therapy for Intermittent Claudication in Patients With Diabetes Mellitus

Socioeconomic factors predict successful supervised exercise therapy completion

OBJECTIVE

Supervised exercise therapy (SET) for patients with intermittent claudication (IC) can lower the risk of progression to chronic limb-threatening ischemia and amputation, while preserving and restoring functional status. Despite supporting evidence, it remains underutilized, and among those who initiate programs, attrition rates are extremely high. We hypothesize that socioeconomic factors may represent significant barriers to SET completion.

METHODS

Patients with IC referred to SET at a multi-hospital, single-institution health care system (2018-2022) from a prospectively maintained database were retrospectively analyzed. Our primary endpoint was SET program completion and graduation, defined as completion of 36 sessions. Our secondary endpoints were vascular intervention within 1 year of referral and change in ankle-brachial index (ABI). Baseline demographics were assessed using standard statistical methods. Predictors of SET graduation were analyzed using multivariable logistic regression generating adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Change in ABI was analyzed using t-test between subgroups. Reasons for attrition were tabulated. Patient Health Questionnaire-9 (PHQ-9), metabolic equivalent level, Vascular QOL, Duke Activity Status, and ABI were analyzed using paired t-tests across the entire cohort.

RESULTS

Fifty-two patients met inclusion criteria: mean age 67.85 ± 10.69 years, 19 females (36.54%), mean baseline ABI of 0.77 ± 0.16. The co-pays for 100% of patients were fully covered by primary and secondary insurance plans. Twenty-one patients (40.38%) completed SET. On multivariable analysis, residence in a ZIP code with median household income <$47,000 (aOR, 0.10; 95% CI, 0.01-0.76; P = .03) and higher body mass index (aOR, 0.81; 95% CI, 0.67-0.99; P = .04) were significant barriers to SET graduation. There were no differences in ABI change or vascular intervention within 1 year between graduates and non-graduates. Non-graduates reported transportation challenges (25.00%), lack of motivation (20.83%), and illness/functional limitation (20.83%) as primary reasons for SET attrition. Metabolic Equivalent Level (P ≤ .01) and Duke Activity Status scores (P = .04) were significantly greater after participating in a SET program.

CONCLUSIONS

Although SET participation improves lower extremity and functionality outcomes, only 40% of referred patients completed therapy in our cohort. Our findings suggest that both socioeconomic and functional factors influence the odds of completing SET programs, indicating a need for holistic pre-referral assessment to facilitate enhanced program accessibility for these populations.

Influence of Changes in Sedentary Time on Outcomes of Supervised Exercise Therapy in Individuals with Comorbid Peripheral Artery Disease and Type 2 Diabetes

BACKGROUND

Although supervised exercise therapy (SET) is effective in improving walking distance among adults with symptomatic peripheral artery disease (PAD), some research suggests that individuals with comorbid PAD and type 2 diabetes mellitus (T2DM) may experience a blunted response to SET. It is unknown whether free-living sedentary time changes during SET, and if increases in sedentary time could, in part, explain poor response to SET. The purposes of this pilot study were to (1) determine if older adults with PAD (with and without T2DM) engaging in SET change their sedentary behavior and (2) examine the relationship between changes in sedentary behavior and SET outcomes. We hypothesized that decreased sedentary time during SET would be associated with greater improvements in six-minute walk test (6MWT) total distance and other key SET outcomes.

METHODS

Participants (n = 44) initiating a 12-week SET program completed the 6MWT, Short Physical Performance Battery, Walking Impairment Questionnaire, and accelerometer-assessed sedentary behavior at SET initiation, 6 weeks, and 12 weeks.

RESULTS

Participants' mean age was 72.3 (7.1) years, mean ankle-brachial index was 0.71 (0.25), and 47.7% were female. On average, sedentary time did not change after SET, although there was substantial variability (-40% to +38% change in minutes of sedentary time/day). Participants with T2DM experienced greater improvements in claudication onset distance than participants without T2DM (mean = 35 m, P = 0.044, 95% confidence interval = 1.6 to 115.4 m). Neither changes in sedentary time from baseline to 6 weeks (P = 0.419) nor T2DM (P = 0.154) predicted changes in 6MWT total distance from baseline to 12 weeks.

CONCLUSIONS

As SET availability increases, further examination of factors that may influence SET outcomes will help maximize benefits of this proven therapy.

Effect of Supervised Exercise Program on Individuals in Peripheral Arterial Disease with Type 2 Diabetes Mellitus - A Systematic Review

BACKGROUND

Type 2 Diabetes Mellitus (T2DM) is usually accompanied by various micro and macro vascular complications. Peripheral Arterial Disease (PAD) is one of the major complications of diabetes which is accountable for morbidity and mortality throughout the world. The first line of treatment in these individuals is life style modification and exercise. There is a dearth of literature on effect of supervised exercise program in PAD with T2DM on quality of life, walking impairment, change in Ankle Brachial Index (ABI) values. So, we conducted a systematic review to explore the available literature on supervised exercise program in PAD with T2DM.

METHODS

We conducted a systematic review (PubMed, Web of Science, CINAHL and Cochrane) to summarise the evidence on a supervised exercise program in PAD with T2DM. Randomised and nonrandomised studies were included in the review.

RESULTS

Three studies met the inclusion criteria. The outcomes taken into accounts by the studies were the quality of life, walking impairment questionnaire, Ankle brachial index. Neither of the studies matched in their supervised exercise program nor in their outcome.

CONCLUSION

In conclusion, the data evaluating the supervised exercise program in PAD with T2DM is inadequate to determine its effect on this population. Future large-scale studies can be conducted on both subjective and objective outcomes of PAD with T2DM to have a better understanding of the condition and for a universally acceptable exercise program for these individuals which the healthcare practitioners can use in their practice. Prospero registration number: CRD42018112465.

Effect of diabetes mellitus on walking distance parameters after supervised exercise therapy for intermittent claudication: A systematic review

Some believe that certain patients with intermittent claudication may be unsuitable for supervised exercise therapy (SET), based on the presence of comorbidities and the possibly increased risks. We conducted a systematic review (MEDLINE, EMBASE and CENTRAL) to summarize evidence on the potential influence of diabetes mellitus (DM) on the response to SET. Randomized and nonrandomized studies that investigated the effect of DM on walking distance after SET in patients with IC were included. Considered outcome measures were maximal, pain-free and functional walking distance (MWD, PFWD and FWD). Three articles met the inclusion criteria ( n = 845). In one study, MWD was 111 meters (128%) longer in the non-DM group compared to the DM group after 3 months of follow-up ( p = 0.056). In a second study, the non-DM group demonstrated a significant increase in PFWD (114 meters, p ⩽ 0.05) after 3 months of follow-up, whereas there was no statistically significant increase for the DM group (54 meters). On the contrary, the largest study of this review did not demonstrate any adverse effect of DM on MWD and FWD after SET. In conclusion, the data evaluating the effects of DM on SET were inadequate to determine if DM impairs the exercise response. While trends in the data do not suggest an impairment, they are not conclusive. Practitioners should consider this limitation when making clinical decisions.

Intensive walking exercise for lower extremity peripheral arterial disease: A systematic review and meta-analysis

BACKGROUND

Supervised treadmill exercise is the recommended therapy for peripheral arterial disease (PAD) patients with intermittent claudication (IC). However, most PAD patients do not exhibit typical symptoms of IC. The aim of the present study was to explore the efficacy and safety of intensive walking exercise in PAD patients with and without IC.

METHODS

The PubMed, Embase and Cochrane Library databases were systematically searched. Randomized controlled trials comparing the effects of intensive walking exercise with usual care in patients with PAD were included for systematic review and meta-analysis.

RESULTS

Eighteen trials with 1200 patients were eligible for the present analysis. Compared with usual care, intensive walking exercise significantly improved the maximal walking distance (MWD), pain-free walking distance, and the 6-min walking distance in patients with PAD (P < 0.00001 for all). Subgroup analyses indicated that a lesser improvement in MWD was observed in the subgroup with more diabetes patients, and that the subgroup with better baseline walking ability exhibited greater improvement in walking performance. In addition, similar improvements in walking performance were observed for exercise programs of different durations and modalities. No significant difference was found in adverse events between the intensive walking and usual care groups (relative risk 0.84; 95% confidence interval 0.51, 1.39; P = 0.50).

CONCLUSIONS

Regardless of exercise length and modality, regularly intensive walking exercise improves walking ability in PAD patients more than usual care. The presence of diabetes may attenuate the improvements in walking performance in patients with PAD following exercise.

A Systematic Review of the Uptake and Adherence Rates to Supervised Exercise Programs in Patients with Intermittent Claudication

BACKGROUND

Intermittent claudication (IC) is a common and debilitating symptom of peripheral arterial disease and is associated with a significant reduction in a sufferer's quality of life. Guidelines recommend a supervised exercise program (SEP) as the primary treatment option; however, anecdotally there is a low participation rate for exercise in this group of patients. We undertook a systematic review of the uptake and adherence rates to SEPs for individuals with IC.

METHODS

The MEDLINE, Embase, and PubMed databases were searched up to January 2015 for terms related to supervised exercise in peripheral arterial disease. The review had 3 aims: first, to establish the rates of uptake to SEPs, second, the rates of adherence to programs, and finally to determine the reasons reported for poor uptake and adherence. Separate inclusion and/or exclusion criteria were applied in selecting reports for each aim of the review.

RESULTS

Only 23 of the 53 potentially eligible articles for uptake analysis identified on literature searches reported any details of screened patients (n = 7,517) with only 24.2% of patients subsequently recruited to SEPs. Forty-five percent of screen failures had no reason for exclusion reported. Sixty-seven articles with 4,012 patients were included for analysis of SEP adherence. Overall, 75.1% of patients reportedly completed an SEP; however, only one article defined a minimal attendance required for SEP completion. Overall, 54.1% of incomplete adherence was due to patient withdrawal and no reason for incomplete adherence was reported for 16% of cases.

CONCLUSIONS

Reporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in most the current literature. Current clinical guidelines based on this evidence base may not be applicable to most IC patients and changes to SEPs may be needed to encourage and/or retain participants.

Effect of structured home-based exercise on walking ability in patients with peripheral arterial disease: a meta-analysis

BACKGROUND

The present study is designed to investigate the effect of structured home-based exercise (SHE) programs on maximal walking time (MWT), pain-free walking time (PFWT), and self-reported walking ability in patients with peripheral arterial disease (PAD).

METHODS

We searched the databases including MEDLINE, EMBASE, ISI Web of Knowledge, and the Cochrane Library from inception to December 2013 for randomized controlled trials (RCTs) that assessed the effect of SHE programs on walking ability in patients with PAD. Meta-analysis was performed based on the searched results, moreover, we made a systemic review regarding the results along with our knowledge.

RESULTS

Of all the 348 publications we got from the databases, 5 RCTs covering 547 patients reached the inclusion criteria and were involved in the present study. Both inverse-variance fixed-effects and random-effects model were used to perform meta-analysis. SHE programs improved MWT by mean difference of 66.78 sec (95% confidence interval [CI], 5.15-128.41; P = 0.03), heterogeneity across studies was significant. When the trial accounting for significant heterogeneity was omitted, SHE programs improved MWT by mean difference of 91.21 sec (95% CI, 51.96-130.45; P < 0.0001). In contrast, there was no significant heterogeneity across the studies with regard to PFWT and Walking Impairment Questionnaire (WIQ) score. SHE programs improved both PFWT and WIQ scores (mean difference of PFWT, 57.76s; 95% CI, 20.42-95.10; P = 0.002; mean difference of WIQ distance score, 8.67; 95% CI, 3.86-13.49; P = 0.0004; mean difference of WIQ speed score, 8.05, 95% CI, 4.46-11.64; P < 0.0001; mean difference of WIQ stair-climbing score, 6.44; 95% CI, 2.55-10.34; P = 0.001).

CONCLUSIONS

SHE programs improve walking ability in patients with PAD.

Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication

BACKGROUND

It is not clear whether subgroups of patients with peripheral artery disease (PAD) and claudication respond more favorably to exercise rehabilitation than others. We determined whether sex and diabetes were factors associated with the response to exercise rehabilitation in patients with claudication.

METHODS

Eighty patients were randomized to home-based and supervised exercise programs, and 60 finished with complete exercise intervention data. Exercise consisted of intermittent walking to near maximal claudication pain for 3 months. Primary outcome measures included claudication onset time (COT) and peak walking time. Patients were partitioned into diabetic and nondiabetic groups and then further partitioned by sex to form four groups.

RESULTS

Overall, exercise adherence was high (84%), and there was no significant difference (P > .05) in the amount of exercise completed among the four groups. All groups had significant improvements (P < .05) in COT and peak walking time after exercise rehabilitation, except for diabetic women (P > .05). Only 37% of women with diabetes had an increase in COT compared with 100% of men with diabetes (P < .01), and their risk ratio for nonresponse was 9.2 (P < .0001).

CONCLUSIONS

Women with PAD and claudication, particularly those with diabetes, represent a vulnerable subgroup of patients who respond poorly to a program of exercise rehabilitation. Diabetic women with PAD and claudication may need a greater dose of exercise or another intervention separate from or in combination with exercise to elicit improvements in claudication measures that are similar to nondiabetic women and to diabetic and nondiabetic men.