Supervised Exercise Training for Intermittent Claudication: Lasting Benefit at Three Years

Anatomic patterns in claudicants who fail supervised exercise therapy

OBJECTIVE

Patients with intermittent claudication (IC) from peripheral arterial disease (PAD) have significant improvement with supervised exercise therapy (SET). However, many patients have progressive disease that will ultimately require revascularization. We sought to determine whether the anatomic patterns of PAD were associated with response to SET.

METHODS

We prospectively enrolled patients with IC at the West Haven, Connecticut Veterans Health Administration between June 2019 and June 2022. Patients were classified based on the level of their arterial disease with >50% obstruction. SET failure was defined as progressive symptoms or development of critical limb-threatening ischemia (CLTI) requiring revascularization.

RESULTS

Thirty-eight patients with PAD were included. Thirteen patients (34.2%) had significant common femoral artery (CFA) disease, and 25 (65.8%) had non-CFA disease. Over a median follow-up of 1407 days, 11 patients (84.6%) with CFA disease failed SET as compared with three patients (12.0%) with non-CFA disease (P < .001). Patients with CFA disease were more likely to develop CLTI (46.2% vs 4.0%; P = .001) and have persistent symptoms (38.5% vs 8.0%; P = .02). Patients with CFA disease had significantly lower post-SET ankle-brachial index (0.58 ± 0.14 vs 0.77 ± 0.19; P = .03). In multivariate analysis, the only variable associated with SET failure was CFA disease location (odds ratio, 68.75; 95% confidence interval, 5.05-936.44; P = .001).

CONCLUSIONS

Patients with IC from high-grade CFA atherosclerosis are overwhelmingly likely to fail SET, potentially identifying a subset of patients who benefit from upfront revascularization.

Outcomes following supervised exercise and home-based exercise for patients with intermittent claudication

INTRODUCTION

Intermittent claudication (IC) is the most common symptom of peripheral arterial disease (PAD) which presents as a consequence of muscle ischaemia resulting from the atherosclerotic obstruction to arterial flow. High-quality evidence (Lane et al., 2017) shows that exercise programmes provide important benefits compared with usual care in improving pain-free and maximum walking distance in people with IC, but do not improve ankle-brachial pressure index (ABPI).

METHODS

Retrospective data were analysed to examine walking and ABPI outcomes for participants who completed a 12-week course of supervised or home-based exercise. All participants had a history of IC.

RESULTS

46 participants (mean age 69±11 years; 76% male; 29% current smokers) referred for exercise were assessed, completed a 12-week course of exercise (home-based or supervised) and subsequently attended for re-assessment. Claudication onset distance (COD) increased by 363% (mean improvement 344.7 ± 265.1m; p < .001) and peak walking distance (PWD) by 324.4% in the supervised exercise group; COD increased by 30.6% (mean improvement 32.8 ± 57.2 m; p = 0.026) and PWD by 31.5% in the home-based exercise group. Resting ABPI for the total cohort significantly improved from 0.82 ± 0.25 at A1 to 0.88 ± 0.25 at A2 (p = 0.027).

DISCUSSION

A 12-week course of supervised exercise results in significantly greater walking distance outcomes (COD and PWD) than unmonitored home-based exercise. In contrast with previous findings (Lane et al. 2017), this retrospective study demonstrated a significant improvement in resting ABPI with both supervised exercise as well as home-based exercise.

CONCLUSION

A 12-week programme of exercise favourably influenced walking and ABPI outcomes for patients with IC. Both home-based exercise and supervised individualised exercise increased walking distances, but the magnitude of the improvement in walking outcomes was greater in individuals who attended supervised exercise therapy.

Life-style counseling program and supervised exercise improves walking distance and quality of life in patients with intermittent claudication

INTRODUCTION

There are many barriers for patients with intermittent claudication (IC) to complete and maintain the supervised exercise therapy (SET) programs. SET combined with life-style counseling was, therefore, investigated.

OBJECTIVE

This study aimed to report the experience of a single center where SET and life-style counseling targeting the modification of risk factors to treat IC, improved walking distance and quality of life.

METHODS

Thirty-five patients out of 62 referred patients with IC completed the full program of 12 weeks SET and 12 weeks self-training combined with counseling focusing in modifying the risk factors. The pain free walking distance (PFWD) and maximum walking distance (MWD) were measured as primary outcomes. Vascular Quality of Life Questionnaire 6 (VascuQoL-6) and 6-min walk test (6-MWT) were measured as secondary outcomes. Analysis of variance and last value carried forward method was used to compare the outcomes.

RESULTS

Fifteen females and 20 males with mean age of 71.5 years completed the program. PFWD and MWD increased by 116% (P < .001) and 120% (P < .001), respectively, at 24 weeks follow-up. Similarly, there was 14% increase in 6-MWT and VascuQoL-6 overall score increased from 13.1 to 15.9 at 24 week follow-up (P < .001).

CONCLUSION

SET along with life-style counseling can be considered as a package in the treatment of patients with IC.

Multimodal Supervised Exercise Training Is Effective in Improving Long Term Walking Performance in Patients with Symptomatic Lower Extremity Peripheral Artery Disease

This study aimed to evaluate the effect of a multimodal supervised exercise training (SET) program on walking performance for 12 months in patients with symptomatic lower extremity peripheral artery disease (PAD). Consecutive patients with Fontaine stage II PAD participating in the SET program of our hospital were retrospectively investigated. Walking performance, assessed using a treadmill with measures of the pain-free and maximal walking distance (PFWD, MWD, respectively), and 6 min walking distance (6MWD), were tested before and following SET, as well as at 6 and 12 months after SET completion. Ninety-three symptomatic patients with PAD (65.0 ± 1.1 y) were included in the study. Following SET, the walking performance significantly improved (PFWD: +145%, p ≤ 0.001; MWD: +97%, p ≤ 0.001; 6MWD: +15%, p ≤ 0.001). At 6 months, PFWD (+257%, p ≤ 0.001), MWD (+132%, p ≤ 0.001), and 6MWD (+11%, p ≤ 0.001) remained significantly improved compared with the pre-SET condition. At 12 months, PFWD (+272%, p ≤ 0.001), MWD (+130%, p ≤ 0.001), and 6MWD (+11%, p ≤ 0.001) remained significantly improved compared with the pre-training condition. The walking performance remained significantly improved in both women and men for up to 12 months (p ≤ 0.001). Multimodal SET is effective at improving walking performance in symptomatic patients with PAD, with improvements lasting up to 12 months.

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

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

Supervised exercise therapy and revascularization: Single-center experience of intermittent claudication management

Guidelines recommend supervised exercise therapy (SET) as first-line treatment for intermittent claudication. However, the use of revascularization is widespread. We addressed the effectiveness of preventing (additional) invasive revascularization after primary SET or revascularization based on lesion and patient characteristics. In this single-center, retrospective, cohort study, 474 patients with intermittent claudication were included. Patients with occlusive disease of the aortoiliac tract and/or common femoral artery (inflow) were primarily considered for revascularization, while patients with more distal disease (outflow) were primarily considered for SET. In total, 232 patients were referred for SET and 242 patients received revascularization. The primary outcome was freedom from (additional) intervention, analyzed by Kaplan–Meier estimates. Secondary outcomes were survival, critical ischemia, freedom from target lesion revascularization (TLR), and an increase in maximum walking distance. In the SET-first strategy, 71% of patients had significant outflow lesions. Freedom from intervention was 0.90 ± 0.02 at 1-year and 0.82 ± 0.03 at 2-year follow-up. In the primary revascularization group, 90% of patients had inflow lesions. Freedom from additional intervention was 0.78 ± 0.03 at 1-year and only 0.65 ± 0.04 at 2-year follow-up, despite freedom from TLR of 0.91 ± 0.02 and 0.85 ± 0.03 at 1- and 2-year follow-up, respectively. In conclusion, SET was effective in preventing invasive treatment for patients with mainly outflow lesions. In contrast, secondary intervention rates following our strategy of primary revascularization for inflow lesions were unexpectedly high. These findings further support the guideline recommendations of SET as first-line treatment for all patients with intermittent claudication irrespective of level of disease.

Long-term outcomes of supervised exercise in peripheral artery disease: Impact of differing modes of exercise 1-4 years after intervention

The prevalence and debilitating nature of peripheral artery disease (PAD) mandate the development and aggressive implementation of the most efficacious treatment strategies available. Research has clearly demonstrated that supervised exercise in individuals with PAD and lifestyle-limiting claudication leads to improved outcomes in the short term. An important factor in determining the relative value of exercise training in PAD rehabilitation is the extent to which the benefits are sustained over time. The aim of this study was to examine the long-term outcome status of participants in the EXercise Training to Reduce Claudication: Arm ERgometry versus Treadmill Walking (EXERT) trial. Twenty-two participants agreed to attend a single data collection visit 1-4 years after their completion of the EXERT study. Objective and subjective measures of health status and physical function and a measure of quality of life were obtained and compared to performance at the end of the EXERT trial. Although analyses indicate that changes in health status and objective measures of physical function occurred in the long-term follow-up period, between-group differences were minimal and were limited to a statistically significant difference in the distance covered during the 6-minute walk test. Subjects' perceptions on change in physical function and quality of life were similarly stable over time although a statistically significant decrease in participant's confidence in managing their disease/symptoms was evident, suggesting the importance of ongoing support and symptom management strategies. This has significant implications for vascular nurses.

Clinical impact of exercise in patients with peripheral arterial disease

Increasing prevalence, high morbidity and mortality, and decreased health-related quality of life are hallmarks of peripheral arterial disease. About one-third of peripheral arterial disease patients have intermittent claudication with deleterious effects on everyday activities, such as walking. Exercise training improves peripheral arterial disease symptoms and is recommended as first line therapy for peripheral arterial disease. This review examines the effects of exercise training beyond improvements in walking distance, namely on vascular function, parameters of inflammation, activated hemostasis and oxidative stress, and quality of life. Exercise training not only increases walking distance and physiologic parameters in patients with peripheral arterial disease, but also improves the cardiovascular risk profile by helping patients achieve better control of hypertension, hyperglycemia, obesity and dyslipidemia, thus further reducing cardiovascular risk and the prevalence of coexistent atherosclerotic diseases. American guidelines suggest supervised exercise training, performed for a minimum of 30-45 min, at least three times per week, for at least 12 weeks. Walking is the most studied exercise modality and its efficacy in improving cardiovascular parameters in patients with peripheral arterial disease has been extensively proven. As studies have shown that supervised exercise training improves walking performance, cardiovascular parameters and quality of life in patients with peripheral arterial disease, it should be encouraged and more often prescribed.

Randomized clinical trial comparing Nordic pole walking and a standard home exercise programme in patients with intermittent claudication

BACKGROUND

This was a randomized clinical trial to determine whether Nordic pole walking (NPW) is more effective in improving walking distance than a standard home exercise programme (HEP) in patients with intermittent claudication.

METHODS

Fifty-two patients with stable claudication were allocated randomly to a standard HEP or NPW group, and asked to complete three 30-min walks per week for 12 weeks. Claudication distance (CD) and maximum walking distance (MWD) were measured at 0 (baseline), 4, 8 and 12 weeks. Patients in the NPW group were tested with (NPW+) and without (NPW-) poles.

RESULTS

For NPW+, CD increased immediately from a median (range) of 124 (71-248) m to 148 (116-426) m, and MWD from 248 (149-900) to 389 (194-1099) m (P = 0.004 and P < 0.001 respectively). By 12 weeks, CD had further increased to 199 (118-550) m and MWD had more than doubled to 538 (250-1750) m (P < 0.001 and P = 0.001). For NPW-, CD at 12 weeks had increased significantly to 151 (100-328) m and MWD to 400 (200-900) m (P < 0.001 and P = 0.006 respectively). At 12 weeks the changes in the standard HEP group were not significant, despite excellent compliance: CD from 107 (56-332) to 153 (59-321) m and MWD from 355 (92-600) to 334 (149-874) m (P = 0.030 and P = 0.260 respectively).

CONCLUSION

A 12-week exercise programme using Nordic poles significantly improved walking distance in claudicants compared with a standard HEP.

REGISTRATION NUMBER

ISRCTN78168304 (http://www.controlled-trials.com).

Long-term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial

BACKGROUND

Long-term comparisons of supervised exercise therapy (SET) and endovascular revascularization (ER) for patients with intermittent claudication are scarce. The long-term clinical effectiveness of SET and ER was assessed in patients from a randomized trial.

METHODS

Consenting patients with intermittent claudication were assigned randomly to either SET or ER. Outcome measures on functional performance (pain-free and maximum walking distance, ankle : brachial pressure index), quality of life (QoL) and number of secondary interventions were measured at baseline and after approximately 7 years of follow-up. Repeated-measurement and Kaplan-Meier methods were used to analyse the data on an intention-to treat-basis.

RESULTS

A total of 151 patients were randomized initially to either SET or ER. After 7 years, functional performance (P < 0.001) and QoL (P ≤ 0.005) had improved after both SET and ER. Long-term comparison showed no differences between the two treatments, except in the secondary intervention rate, which was significantly higher after SET (P = 0.001). Nevertheless, the total number of endovascular and surgical interventions (primary and secondary) remained higher after ER (P < 0.001).

CONCLUSION

In the longer term, SET-first or ER-first treatment strategies were equally effective in improving functional performance and QoL in patients with intermittent claudication. The substantially higher number of invasive interventions in the ER-first group supports a SET-first treatment strategy for intermittent claudication.

REGISTRATION NUMBER

NTR199 (http://www.trialregister.nl).

Supervised exercise therapy for intermittent claudication: current status and future perspectives

Intermittent claudication (IC) has a high prevalence in the older population and is closely associated with cardiovascular and cerebrovascular disease. High mortality rates are reported due to ongoing atherosclerotic disease. Because of these serious health risks, treatment of IC should address reduction of cardiovascular events (and related morbidity/mortality) and improvement of the poor health-related quality of life (QoL) and functional capacity. In several randomized clinical trials and systematic reviews, supervised exercise therapy (SET) is compared with non-supervised exercise, usual care, placebo, walking advice or vascular interventions. The current evidence supports SET as the primary treatment for IC. SET improves maximum walking distance and health-related QoL with a marginal risk of co-morbidity or mortality. This is also illustrated in contemporary international guidelines. Community-based SET appears to be at least as efficacious as programs provided in a clinical setting. In the Netherlands, a national integrated care network (ClaudicatioNet) providing specialized care for patients with IC is currently being implemented. Besides providing a standardized form of SET, the specialized physical therapists stimulate medication compliance and perform lifestyle coaching. Future research should focus on the influence of co-morbidities on prognosis and effect of SET outcome and the potential beneficial effects of SET combined with a vascular intervention.

Update on peripheral arterial disease and claudication rehabilitation

The prevalence of peripheral arterial disease is high and will continue to grow with our aging population. It is often under diagnosed and under treated due to a general lack of awareness on the part of the patient and the practitioner. The evidence-base is growing for the optimal medical management of the patient with peripheral arterial disease; in parallel, endovascular revascularization options continue to improve. Exercise training for claudication rehabilitation plays a critical role. Comprehensive care of the peripheral arterial disease patient focuses on the ultimate goals of improving quality of life and reducing cardiovascular morbidity and mortality.

Exercícios físicos na doença arterial obstrutiva periférica

A maioria dos pacientes portadores de claudicação intermitente, um aspecto clínico da doença arterial periférica, tem importante limitação nas atividades físicas e redução na qualidade de vida. O objetivo deste estudo foi realizar uma revisão da literatura sobre a intervenção através de exercícios em portadores de doença arterial obstrutiva periférica com claudicação intermitente. Trata-se de uma revisão de artigos científicos consultados nos bancos de dados da BIREME, PubMed e SciELO, através das fontes LILACS e MEDLINE e a partir dos descritores em Ciências da Saúde claudicação intermitente, doenças vasculares periféricas, reabilitação, exercício e terapia por exercício. Concluiu-se que, apesar da variabilidade dos regimes de caminhada identificados na literatura, o treino aeróbio, de uma forma geral, proporciona benefícios a pacientes portadores de doença arterial obstrutiva periférica com claudicação intermitente, principalmente na melhora do desempenho de caminhada, o que pode ter impacto significativo na qualidade de vida desses pacientes.

Supervised Exercise in Intermittent Claudication: A Sedentary Notion?

The benefit of exercise in the management of intermittent claudication has been explored through extensive research in the preceding decades. Within the clinical setting, there is often little differentiation between home-based and supervised exercise regimens. We examined the history and qualification of supervised exercise as a distinct treatment modality from nonsupervised exercise in intermittent claudication. A Medline, Embase, Ovid, Cochrane Database, and Google Scholar search was performed on all studies published until December 31, 2007, investigating the use of supervised exercise in peripheral arterial disease. Supervised exercise is well grounded in evidence to support its superiority over nonsupervised exercise in the management of intermittent claudication, conveying marked improvement in symptomatology, function, and quality of life. Further research is required to determine the nature of the advantage that supervision affords.

Cilostazol and peripheral arterial disease

Peripheral arterial disease is both common and disabling. Contemporary management of peripheral arterial disease is multimodal, encompassing both medical and interventional treatments. Cilostazol (Pletal), a 2-oxoquinolone derivative, is currently licensed in the UK for the treatment of patients with intermittent claudication to improve their walking distance in the absence of tissue necrosis or rest pain. The therapeutic effects of cilostazol are thought to be mediated through antiplatelet, antiproliferative and vasodilatory activities. This review aims to provide an overview of the management of peripheral arterial disease focusing upon cilostazol pharmacotherapy.

Nordic poles immediately improve walking distance in patients with intermittent claudication

OBJECTIVES

To investigate the immediate effects of Nordic pole walking (NPW) on walking distance and cardiopulmonary workload in patients with intermittent claudication.

METHODS

Using a standardised treadmill test (3.2 km h(-1) at 4% gradient), walking distance, cardiopulmonary responses, leg pain and perceived exertion during NPW were compared to responses evoked by normal walking in 20 patients with intermittent claudication. The distance to onset of claudication pain (claudication distance: CD) and to maximum walking distance (MWD), heart rate (HR), expired gas parameters, leg pain (Borg's CR-10 Scale) and perceived exertion (Borg's Rating of Perceived Exertion: RPE Scale) were compared.

RESULTS

CD increased significantly from a median (range) distance of 77 m (28-503) to 130 m (41-1080) and MWD increased significantly from 206 m (81-1078) to 285 m (107-1080) when patients used the Nordic poles (P=0.000). The level of leg pain at MWD was also significantly reduced during NPW (P=0.002). Perceived exertion at MWD did not increase despite an increase in cardiopulmonary work, as indicated by an increase in oxygen consumption (16.5%; P=0.000).

CONCLUSION

These results show that NPW immediately enables patients with intermittent claudication to walk further with less pain, despite a higher workload. NPW might also be a useful exercise strategy for improving the cardiovascular fitness of patients with intermittent claudication.