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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. Eur Heart J 2024; 45:1303-1321. [PMID: 38461405 DOI: 10.1093/eurheartj/ehad734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2024] Open
Abstract
All guidelines worldwide strongly recommend exercise as a pillar of the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended for clinicians to promote and assist for the set-up of comprehensive exercise programmes to best advice in patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are narratively described based on the current best evidence. The document ends by highlighting disparities in access to supervised exercise programmes across Europe and the series of gaps for evidence requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Center of Cardiology, Department of Cardiology III-Angiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France
- INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. VASA 2024; 53:87-108. [PMID: 38461401 DOI: 10.1024/0301-1526/a001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Finland
- University of Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, France
- INSERM CIC 1414, Université de Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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Nascimento IDO, Geisel PP, de Faria VC, Ferreira AP, Passos BR, Prado D, Parreira VF, Gomes Pereira D. Comparison of home-based rehabilitation and a centre-based exercise in terms of functional capacity, muscle oxygenation and quality of life in people with peripheral arterial disease: a protocol for a randomised controlled trial. BMJ Open 2024; 14:e080071. [PMID: 38553076 PMCID: PMC10982778 DOI: 10.1136/bmjopen-2023-080071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/08/2024] [Indexed: 04/02/2024] Open
Abstract
INTRODUCTION Peripheral arterial disease (PAD) is increasingly prevalent, and supervised physical exercise programmes are recommended as the first-line treatment. However, these programmes are underused. Alternative delivery models may be able to expand treatment coverage. The objective of this study was to compare a home-based exercise programme (HBEP) and a centre-based exercise (CBE) in terms of their effects on functional capacity, peripheral muscle oxygenation and quality of life in individuals with PAD. METHODS AND ANALYSIS This single-blind, parallel randomised clinical trial will consist of two groups: HBEP and CBE. A qualitative analysis will be carried out to investigate acceptability and satisfaction. The primary outcome will be functional capacity, assessed by the incremental shuttle walk test. Secondary outcomes will include functional capacity, assessed by a treadmill walking test; peripheral muscle oxygenation and quality of life; and self-reported functional impairment, risk factors, morbidity, level of physical activity, adherence, acceptability and satisfaction. The intervention protocols will consist of 12 weeks of intermittent walking until claudication symptoms, three times a week. Participants randomly assigned to the CBE group will participate in supervised face-to-face sessions. The HBEP group will perform exercises at home with remote supervision, monitored by a pedometer and heart rate monitor, and subjective perception of effort during each session will be recorded by participants in a training diary; follow-up will be conducted by telephone calls. Statistical analyses will follow the intention-to-treat principle. Participants allocated to the HBEP group will be interviewed about their experience of remote treatment using a qualitative approach. ETHICS AND DISSEMINATION Ethics approval was obtained from the Ethics Committee of the Universidade Federal de Minas Gerais. The results will be disseminated in a peer-reviewed journal and presented at international congresses. This research has the potential to improve the care of people with PAD because if home-based rehabilitation demonstrates effectiveness, it could be considered an alternative or support resource to the usual centre-based treatment models, expanding access, coverage and participation in vascular physiotherapy TRIAL REGISTRATION: https://ensaiosclinicos.gov.br/rg/RBR-97vy9n7 on 14 April 2022.
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Affiliation(s)
| | - Patrícia Paulino Geisel
- Rehabilitation Sciences Program, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Valéria Cristina de Faria
- Marinha do Brasil, Belo Horizonte, Brazil
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ana Paula Ferreira
- Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Faculdade de Ciências Médicas e da Saúde de Juiz de Fora, Juiz de Fora, Brazil
| | - Bruno Rezende Passos
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Déborah Prado
- Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Danielle Gomes Pereira
- Rehabilitation Sciences Program, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Physical Therapy, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Peñín-Grandes S, López-Ortiz S, Maroto-Izquierdo S, Menéndez H, Pinto-Fraga J, Martín-Hernández J, Lista S, Lucia A, Santos-Lozano A. Winners do what they fear: exercise and peripheral arterial disease-an umbrella review. Eur J Prev Cardiol 2024; 31:380-388. [PMID: 37611200 DOI: 10.1093/eurjpc/zwad261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/02/2023] [Accepted: 08/06/2023] [Indexed: 08/25/2023]
Abstract
AIMS This systematic review aims to evaluate and summarize findings from published meta-analyses on the effects of regular exercise in patients with peripheral arterial disease (PAD). The review will assess the impact of exercise on functional parameters, health-related quality of life, haemodynamic parameters, physical activity levels, adverse events, and mortality. METHODS AND RESULTS A systematic search was performed in PubMed, Web of Science, Scopus, and Cochrane Library databases (up to May 2023) to identify meta-analyses including randomized controlled trials that examined the effects of regular exercise in patients with PAD. Sixteen studies, with a total of 198 meta-analyses, were identified. Results revealed with strong evidence that patients with PAD who exercised improved functional and health-related quality of life parameters. Specifically, supervised aerobic exercise (i.e. walking to moderate-maximum claudication pain) improves maximum walking distance [mean difference (MD): 177.94 m, 95% confidence interval (CI) 142.29-213.60; P < 0.00001; I2: 65%], pain-free walking distance (fixed MD: 68.78 m, 95% CI 54.35-83.21; P < 0.00001; I2: 67%), self-reported walking ability [i.e. distance score (MD: 9.22 points, 95% CI 5.74-12.70; P < 0.00001; I2: 0%), speed score (MD: 8.71 points, 95% CI 5.64-11.77; P < 0.00001, I2: 0%), stair-climbing score (MD: 8.02 points, 95% CI 4.84-11.21; P < 0.00001, I2: 0%), and combined score (MD: 8.76 points, 95% CI 2.78-14.74; P < 0.0001, I2: 0%)], aerobic capacity (fixed MD: 0.62 mL/kg/min, 95% CI 0.47-0.77, P < 0.00001, I2: 64%), and pain score (MD: 7.65, 95% CI 3.15-12.15; P = 0.0009; I2: 0%), while resistance exercise improves lower limb strength (standardized mean difference: 0.71, 95% CI 0.29-1.13, P = 0.0009; I2: 0%]. Regarding other outcomes, such as haemodynamic parameters, no significant evidence was found, while physical activity levels, adverse events, and mortality require further investigation. CONCLUSION Synthesis of the currently available meta-analyses suggests that regular exercise may be beneficial for a broad range of functional tasks improving health-related quality of life in patients with PAD. Supervised aerobic exercise is the best type of exercise to improve walking-related outcomes and pain, while resistance exercise is more effective to improve lower limb strength.
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Affiliation(s)
- Saúl Peñín-Grandes
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - Susana López-Ortiz
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - Sergio Maroto-Izquierdo
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - Héctor Menéndez
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - José Pinto-Fraga
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - Juan Martín-Hernández
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - Simone Lista
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
| | - Alejandro Lucia
- Research Institute of the Hospital 12 de Octubre ('imas12' and 'PaHerg group'), Madrid, Spain
- Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain
| | - Alejandro Santos-Lozano
- i+HeALTH Strategic Research Group, Department of Health Sciences, Miguel de Cervantes European University (UEMC), Padre Julio Chevalier Street, 2, 47012, Valladolid, Castilla y León, Spain
- Research Institute of the Hospital 12 de Octubre ('imas12' and 'PaHerg group'), Madrid, Spain
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Ravindhran B, Lim AJM, Kurian T, Walshaw J, Hitchman LH, Lathan R, Smith GE, Carradice D, Chetter IC, Pymer S. Supervised Exercise Therapy for Intermittent Claudication: A Propensity Score Matched Analysis of Retrospective Data on Long Term Cardiovascular Outcomes. Eur J Vasc Endovasc Surg 2024; 67:480-488. [PMID: 38040103 DOI: 10.1016/j.ejvs.2023.11.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/18/2023] [Accepted: 11/23/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE This study aimed to explore the long term outcomes of patients with intermittent claudication (IC) who completed supervised exercise therapy (SET) vs. those who declined or prematurely discontinued SET, focusing on the incidence of chronic limb threatening ischaemia (CLTI), revascularisation, major adverse limb events (MALE), and major adverse cardiovascular events (MACE). METHODS A retrospective registry analysis of consecutive patients with IC who were referred for SET between March 2015 and August 2016 and followed up for a minimum of five years. Serial univariable analysis and logistic regression were performed to identify the statistically significant clinical variables that were independent predictors of each outcome measure. The resulting statistically significant variables were used to guide 1:1 propensity score matching (PSM) using the nearest neighbour method with a calliper of 0.2. Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the association between SET and the outcomes of interest. RESULTS Two hundred and sixty-six patients were referred to SET between March 2015 and August 2016. Of these, 64 patients completed SET and 202 patients did not. After PSM, 49 patients were analysed in each cohort. The Cox proportional hazards analysis revealed a significant association between completion of SET and revascularisation requirement (HR 0.46 95% CI 0.25 - 0.84; p = .011), completion of SET and progression to CLTI (HR 0.091, 95% CI 0.04 - 0.24; p < .001), completion of SET and MACE (HR 0.52; 95% CI 0.28 - 0.99; p = .05) and completion of SET and MALE (HR 0.28, 95% CI 0.13 - 0.65; p = .003). The Harrell's C index for all of these models was greater than 0.75, indicating good predictive accuracy. CONCLUSION Completion of SET is associated with better outcomes in patients who completed SET compared with patients who declined or discontinued SET with respect to clinically important cardiovascular outcomes over seven years.
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Affiliation(s)
- Bharadhwaj Ravindhran
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK.
| | - Arthur J M Lim
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Thomas Kurian
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Josephine Walshaw
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Louise H Hitchman
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Ross Lathan
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - George E Smith
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Daniel Carradice
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Ian C Chetter
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
| | - Sean Pymer
- Academic Vascular Surgical Unit, Allam Diabetes Centre, Hull Royal Infirmary, Hull, UK
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Marcellis LHM, Sinnige A, Rutgers KM, Kittelson A, Spruijt S, Teijink JAW, van der Wees PJ, Hoogeboom TJ. Evaluating the implementation of personalised outcomes forecasts to optimise supervised exercise therapy in patients with intermittent claudication in the Netherlands: a multimethods study. BMJ Open Qual 2024; 13:e002594. [PMID: 38378615 PMCID: PMC10882410 DOI: 10.1136/bmjoq-2023-002594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 01/31/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND To support the optimisation of supervised exercise therapy (SET) in patients with intermittent claudication, we developed personalised outcomes forecasts (POFs), which visualise estimated walking distance and quality of life for individual patients. The POFs may enable healthcare professionals, such as physical and exercise therapists, to improve shared decision-making and patient outcomes. OBJECTIVES To assess differences in patient outcomes (functional walking distance, maximal walking distance and health-related quality of life) and the level of shared decision-making before and after the implementation of POFs in the conservative treatment of patients with intermittent claudication. METHODS An interrupted time series design was used to compare preimplementation and postimplementation differences on patient outcomes. Using routinely collected data, differences from baseline to 6 months were compared between patients before and patients after the implementation. To compare levels of shared decision-making, we conducted observations of initial consults within a sample of physical or exercise therapists both before and after the implementation. Audiorecords of observations were scored on shared decision-making using the OPTION-5 instrument. RESULTS Differences in improvements between patients with whom POFs were discussed (n=317) and patients before the implementation of POFs (n=721) did not reach statistical significance for both functional walking distance (experimental vs. control=+23%, p=0.11) and maximal walking distance (experimental vs. control=+21%, p=0.08). For health-related quality of life, the POFs-informed patients showed a statistically significant greater improvement of 4% (p=0.04). Increased levels of shared decision-making were observed in postimplementation consults (n=20) when compared with preimplementation consults (n=36), as the median OPTION-5 total score showed a statistically significant increase from 45 to 55 points (p=0.01). CONCLUSIONS Integrating POFs into daily practice of SET for patients with intermittent claudication could assist in improving health-related quality of life and enhancing patient involvement. Using POFs did not result in statistically significant different improvements between groups on walking distances. TRIAL REGISTRATION NUMBER NL8838.
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Affiliation(s)
- Laura H M Marcellis
- Radboud university medical center, IQ Health science department, Nijmegen, The Netherlands
- Chronisch ZorgNet, Eindhoven, The Netherlands
| | - Anneroos Sinnige
- Department of Surgery, Catharina Hospital, Eindhoven, The Netherlands
| | - Katrien M Rutgers
- Physique Preventiecentrum B.V, Arnhem, The Netherlands
- Physical Therapy Sciences, Program in Clinical Health Sciences, Utrecht University, Utrecht, The Netherlands
| | - Andrew Kittelson
- School of Physical Therapy and Rehabilitation Science, University of Montana, Missoula, Montana, USA
| | | | - Joep A W Teijink
- Department of Vascular Surgery, Catharina Hospital, Eindhoven, The Netherlands
- CAPHRI Research School, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Philip J van der Wees
- Radboud university medical center, IQ Health science department, Nijmegen, The Netherlands
- Clinical Research and Leadership, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Thomas J Hoogeboom
- Radboud university medical center, IQ Health science department, Nijmegen, The Netherlands
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7
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise Therapy for Chronic Symptomatic Peripheral Artery Disease: A Clinical Consensus Document of the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases in Collaboration With the European Society of Vascular Medicine and the European Society for Vascular Surgery. Eur J Vasc Endovasc Surg 2024; 67:S1078-5884(24)00011-X. [PMID: 38467522 DOI: 10.1016/j.ejvs.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland.
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Helsinki; Department of Vascular Surgery, University of Helsinki, Helsinki
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital; EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Lausanne Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University; National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France; INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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8
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Aronow WS, Avanesova AA, Frishman WH, Shamliyan TA. Inconsistent Benefits From Mobile Information Communication Technology in Adults With Peripheral Arterial Disease. Cardiol Rev 2024; 32:12-17. [PMID: 35674708 DOI: 10.1097/crd.0000000000000456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Quality of evidence regarding telemedicine in adults with peripheral arterial disease has not been systematically appraised. OBJECTIVES To explore benefits and harms from mobile information communication technology devices and applications in peripheral arterial disease. METHODS Systematic rapid evidence review and appraisal with the grading of recommendations assessment, development, and evaluation working group approach. RESULTS Sixteen randomized controlled clinical trials (RCT) examined various self-monitoring devices, telemedicine platforms, and individualized telephone counseling. Low-quality evidence suggested that the odds of treatment failure (pooled Peto odds ratio 0.8; 95% CI, 0.4-1.7; 5 RCTs), adverse effects (pooled Peto odds ratio 0.9; 95% CI, 0.5-1.5; 2 RCTs), and physical performance (standardized mean difference in 6-minute walking test 0.2; 95% CI, -0.3-0.7; 4 RCTs) did not differ between mobile interventions and usual care. Single RCTs suggested large but inconsistent improvement in the quality of life: EuroQol5D standardized mean difference = 5.0 (95% CI, 4.4-5.7; 1 RCT) after telehealth program for promoting patient self-management and standardized mean difference = 1.4 (95% CI, 0.4-2.3; 1 RCT) after structured rehabilitation with mobile self-monitoring. Inconsistent reporting of patient-centered outcomes and small sample sizes hampered the quality of evidence. CONCLUSIONS Improved quality of life after specific mobile applications should be confirmed in powered RCTs and large postmarketing studies.
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Affiliation(s)
- Wilbert S Aronow
- From the Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY
| | - Anna A Avanesova
- North-Caucasus Federal University, Stavropol, Russian Federation
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9
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Wang Y, Xia R, Pericic TP, Bekkering GE, Hou L, Bala MM, Gao Y, Wu M, Gloss D, Siemieniuk RA, Fei Y, Rochwerg B, Guyatt G, Brignardello-Petersen R. How do network meta-analyses address intransitivity when assessing certainty of evidence: a systematic survey. BMJ Open 2023; 13:e075212. [PMID: 38035750 PMCID: PMC10689416 DOI: 10.1136/bmjopen-2023-075212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 10/31/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVES To describe how systematic reviews with network meta-analyses (NMAs) that used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) NMA approach addressed intransitivity when assessing certainty of evidence. DESIGN Systematic survey. DATA SOURCES Medline, Embase and Cochrane Database of Systematic Reviews from September 2014 to October 2022. ELIGIBILITY CRITERIA Systematic reviews of randomised controlled trials with aggregate data NMAs that used the GRADE NMA approach for assessing certainty of evidence. DATA EXTRACTION AND SYNTHESIS We documented how reviewers described methods for addressing intransitivity when assessing certainty of evidence, how often they rated down for intransitivity and their explanations for rating down. RESULTS Of the 268 eligible systematic reviews, 44.8% (120/268) mentioned intransitivity when describing methods for assessing the certainty of evidence. Of these, 28.3% (34/120) considered effect modifiers and from this subset, 67.6% (23/34) specified the effect modifiers; however, no systematic review noted how they chose the effect modifiers. 15.0% (18/120) mentioned looking for differences between the direct comparisons that inform the indirect estimate. No review specified a threshold for difference in effect modifiers between the direct comparisons that would lead to rating down for intransitivity. Reviewers noted rating down indirect evidence for intransitivity in 33.1% of systematic reviews, and noted intransitivity for network estimates in 23.0% of reviews. Authors provided an explanation for rating down for intransitivity in 59.6% (31/52) of the cases in which they rated down. Of the 31 in which they provided an explanation, 74.2% (23/31) noted they detected differences in effect modifiers and 67.7% (21/31) specified in what effect modifiers they detected differences. CONCLUSIONS A third of systematic reviews with NMAs using the GRADE approach rated down for intransitivity. Limitations in reporting of methods to address intransitivity proved considerable. Whether the problem is that reviewers neglected to address rating down for transitivity at all, or whether they did consider but not report, is not clear. At minimum systematic reviews with NMAs need to improve their reporting practices regarding intransitivity; it may well be that they need to improve their practice in transitivity assessment. How to best address intransitivity may remain unclear for many reviewers thus additional GRADE guidance providing practical instructions for addressing intransitivity may be desirable.
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Affiliation(s)
- Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ruyu Xia
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | | | | | - Liangying Hou
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Chair of Epidemiology and Preventive Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Ya Gao
- Evidence Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, People's Republic of China
| | - Michael Wu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - David Gloss
- Charleston Area Medical Center, Charleston, West Virginia, USA
| | - Reed Alexander Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yutong Fei
- Centre for Evidence-Based Chinese Medicine, Beijing University of Chinese Medicine, Beijing, People's Republic of China
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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10
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Sandberg A, Nordanstig J, Cider Å, Jivegård L, Hagströmer M, Bäck M. The Impact of Nordic Pole Walk Advice Alone or in Combination With Exercise Strategies on Daily Physical Activity in Patients With Intermittent Claudication: A Randomized Clinical Trial. Phys Ther 2023; 103:pzad086. [PMID: 37459237 PMCID: PMC10630612 DOI: 10.1093/ptj/pzad086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 02/21/2023] [Accepted: 05/22/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE The impact of exercise interventions on physical activity (PA) remains undetermined in intermittent claudication, which is why it is important to include objectively measured PA as an additional endpoint. The aim of this prespecified secondary analysis of a randomized clinical trial was to investigate the impact of unsupervised Nordic pole walk advice (WA) alone or in combination with hospital-based supervised exercise (SEP) or home-based structured exercise (HSEP) on PA in patients with intermittent claudication. METHODS In total, 166 patients with intermittent claudication (mean age = 72 [SD = 7.4] y; 41% women) were randomized to 3 intermittent claudication-treatment strategies: WA, WA + SEP, or WA + HSEP. All patients received Nordic poles and standardized WA (≥30 min, 3 times weekly). Patients randomized to HSEP and SEP accepted participation in an additional 6-months exercise program. PA was measured with an accelerometer-based activPAL3 monitor for 7 days at baseline and at 3, 6, and 12 months. PA outcomes were steps per day, time spent within a stepping cadence ≥100 steps per minute, time spent upright, number of body transitions from sitting to standing, and number of sitting bouts of >30 minutes and >60 minutes. RESULTS At 1 year, no intergroup differences were observed in any of the PA variables, whereas significant intergroup differences were observed at 3 months regarding time spent within a stepping time cadence ≥100 steps per minute. The mean change for HSEP (2.47 [SD = 10.85] min) was significantly different from the mean change for WA (-3.20 [SD = 6.24] min). At 6 months, the number of sitting bouts (>60 min) for SEP was significantly different from WA (mean change = 0.24 [SD = 0.69] vs -0.23 [SD = 0.81]). CONCLUSION This study indicates that the addition of 6 months of HSEP or SEP does not improve PA at 1 year, as compared to unsupervised WA alone. Factors of importance for increasing PA in patients with intermittent claudication require further investigation. IMPACT At the 1-year follow-up, the addition of intermittent claudication-tailored additional exercise strategies did not improve daily PA in patients with intermittent claudication compared with unsupervised Nordic pole WA alone. Future studies may explore the role of behavior change techniques to increase PA in this patient group.
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Affiliation(s)
- Anna Sandberg
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Joakim Nordanstig
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Vascular Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Åsa Cider
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Health and Rehabilitation/Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Lennart Jivegård
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Health Technology Assessment Centre Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Hagströmer
- Division of Physiotherapy, Department of Neurobiology Care Sciences and Society, Karolinska Institute, Stockholm, Sweden
- Academic Primary Care Centre, Region Stockholm, Stockholm, Sweden
| | - Maria Bäck
- Department of Occupational Therapy and Physiotherapy, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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11
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Muacevic A, Adler JR, Stather PW. Patient and Healthcare Professional Priorities for a Mobile Phone Application for Patients With Peripheral Arterial Disease. Cureus 2023; 15:e33993. [PMID: 36824553 PMCID: PMC9941040 DOI: 10.7759/cureus.33993] [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: 01/20/2023] [Indexed: 01/21/2023] Open
Abstract
Introduction Supervised exercise therapy (SET) is the first-line treatment for the peripheral arterial disease (PAD), however, access and compliance are low. An alternative method of delivering this therapy is through mobile health applications, which can be more accessible and convenient for patients. The aim of this study is to evaluate patient, public and healthcare professional (HCP) priorities with regard to a dedicated mobile phone application to deliver remote SET. Methods Bespoke questionnaires were designed for patients and HCPs to assess app functionality and prioritisations for development. These were distributed through social media and the Norfolk and Norwich University Hospital. Results Functionality questionnaires were completed by 62 patients and 44 HCPs. Eighty-four per cent of patients wanted their therapy to be monitored by their vascular team with the majority (78%) interested in measuring walking distances. Most patients (76%) were interested in watching exercise videos. These views were shared by HCPs. A communication platform was prioritised for messaging and pictures by the patient (74% and 68% respectively), but not so by HCPs (40%). Documenting other forms of physical activity and the use of wearable technology was less valuable to patients but favoured by HCPs (50%). The ability to interact with other users was not prioritised by either group. Conclusion Delivery of a mobile phone application to deliver health programmes for SET in patients with PAD is an acceptable method for patients and HCPs. This data will enable the next stages of mobile phone application development to be appropriately prioritised, focusing on building exercise videos, a communication platform and further walking tests.
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12
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kobayashi T, Hamamoto M, Okazaki T, Tomota M, Fujiwara T, Honma T, Takahashi S. Effectiveness of Unsupervised Exercise Therapy After Endovascular Treatment for an Iliac Occlusive Lesion. Vasc Endovascular Surg 2022; 57:331-338. [PMID: 36525961 DOI: 10.1177/15385744221146669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective Exercise therapy has acceptable outcomes for patients with intermittent claudication (IC), but there are few reports on the results of continuous unsupervised exercise therapy after endovascular treatment (EVT) for an iliac lesion. The aim of this study is to analyze the long-term outcomes of unsupervised exercise therapy for patients after EVT. Material and Methods A retrospective analysis was performed in 76 patients (93 limbs) with IC who underwent iliac EVT from 2012 to 2020 at our hospital. Maintenance of unsupervised exercise therapy was evaluated at 6 months after EVT. Long-term outcomes such as primary patency, clinically driven target lesion revascularization (CD-TLR), survival, and major adverse cardiovascular events (MACE) were compared between patients who continued (cET group) or discontinued (dET group) unsupervised exercise therapy. Results A total of 28 patients (37%) continued unsupervised exercise therapy until 6 months after EVT for an iliac lesion. There were no differences in patient background and procedural details between the cET and dET groups. The follow-up rate was 96% in a median follow-up period of 35 [25 – 42] months. The mean exercise time in the cET group was 52 ± 18 minutes daily, with a mean frequency of 5.8 ± 1.1 days per week. The median step count in the cET group was 5559 ± 2908 steps daily. At 3 years, the cET group had significantly higher rates for primary patency (97% vs 71%, P = .002), and freedom from CD-TLR (97% vs 79%, P = .007); and a tendency for higher survival (100% vs 94%, P = .074), and higher freedom from MACE (89% vs 73%, P = .12). Conclusion The findings of this study suggested superior long-term outcomes, including primary patency, freedom from CD-TLR, survival, and freedom from MACE, in patients who maintained continuous unsupervised exercise therapy after EVT.
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Affiliation(s)
- Taira kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Mayu Tomota
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Takashi Fujiwara
- Department of Cardiology, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Tomoaki Honma
- Department of Rehabilitation, JA Hiroshima General Hospital, Hatsukaichi-shi, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Hiroshima University, Minami-ku, Hiroshima, Japan
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13
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Haile S, Lööf H, Johansson UB, Linné A, Joelsson-Alm E. Increasing patients’ awareness of their own health: Experiences of participating in follow-up programs after surgical treatment for intermittent claudication. JOURNAL OF VASCULAR NURSING 2022; 40:47-53. [DOI: 10.1016/j.jvn.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 06/23/2021] [Accepted: 11/29/2021] [Indexed: 01/10/2023]
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14
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Atkin L, Bullock L, Chadwick P, Elwell R, Gardner S, Goodwin T, Hopkins A, O'Connor C, Sneddon M, Wiles K, Williams K. Making Legs Matter: A Case for System Change and Transformation in Lower-Limb Management. J Wound Care 2021; 30:S1-S25. [PMID: 34756097 DOI: 10.12968/jowc.2021.30.sup11.s1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This consensus document is endorsed by The Queen's Nursing Institute (QNI) and The Queen's Nursing Institute Scotland (QNIS).
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Affiliation(s)
- Leanne Atkin
- Legs Matter Chair; Vascular Nurse Consultant, Mid Yorks NHS Trust/University of Huddersfield, UK
| | - Lynn Bullock
- PA to Ellie Lindsay, The Lindsay Leg Club Foundation, UK
| | - Paul Chadwick
- National Clinical Director, The College of Podiatry, UK
| | - Rebecca Elwell
- Macmillan Lymphoedema ANP and Team Leader, Lymphoedema Clinic, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, UK
| | | | | | | | | | - Margaret Sneddon
- Honorary Senior Research Fellow, University of Glasgow; Chair, British Lymphology Society, UK
| | | | - Kate Williams
- Tissue Viability Nurse, Leeds Community Health NHS Trust, UK
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15
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Jacobsen A, Houlind KC, Rai A. Life-style counseling program and supervised exercise improves walking distance and quality of life in patients with intermittent claudication. Physiother Theory Pract 2021; 38:2629-2639. [PMID: 34460344 DOI: 10.1080/09593985.2021.1970866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Asger Jacobsen
- Department of Vascular Surgery, Lillebælt Hospital, Kolding, DK, Denmark.,Rehabilitation Centre, Fredericia Municipality, Fredericia, Dk, Denmark
| | | | - Amrit Rai
- Department of Vascular Surgery, Lillebælt Hospital, Kolding, DK, Denmark
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16
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Aaij AGL, Wermelink B, Haalboom M, Vahl AC, Meerwaldt R, Geelkerken RH. Real World Practice Deviation from Nationwide Guidelines in Patients with Intermittent Claudication. Eur J Vasc Endovasc Surg 2021; 62:432-438. [PMID: 34217598 DOI: 10.1016/j.ejvs.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/19/2021] [Accepted: 05/02/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Patients with intermittent claudication (IC) are initially treated with supervised exercise therapy (SET), as advised by national and international guidelines. Dutch health insurance companies and the Dutch National Health Care Institute suggested an 87% compliance rate with these guidelines in the Netherlands in 2017 and judged this to be undesirably low. The aim of this study was to evaluate compliance with IC guidelines and to elaborate on the reasons for deviating from them (practice variation) in a large teaching hospital. METHODS A retrospective single centre cohort study was conducted at a large teaching hospital in the Netherlands. In total, 420 patients with newly diagnosed IC between 1 January 2017 and 31 December 2018 were analysed. Data included risk profiles and prescribed therapies. RESULTS For all 420 included patients, the compliance rate with the guidelines for SET was 80.5%. The rate of adequately motivated and defensible practice variation was 15.7%; the rate of unjustified practice variation was 3.8%. Meaningful care was seen in 96.2% of cases. CONCLUSION Deviation from IC guidelines was found in 19.5% of patients. Almost three quarters of this deviation can be explained by the decision to provide personalised, meaningful care.
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Affiliation(s)
- Anne G L Aaij
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands
| | - Bryan Wermelink
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands; University of Twente, Multi-Modality Medical Imaging group, TechMed Centre, Enschede, the Netherlands.
| | - Marieke Haalboom
- Medisch Spectrum Twente, Medical School Twente, Enschede, the Netherlands
| | | | - Robbert Meerwaldt
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands
| | - Robert H Geelkerken
- Medisch Spectrum Twente, Department of Vascular Surgery, Enschede, the Netherlands; University of Twente, Multi-Modality Medical Imaging group, TechMed Centre, Enschede, the Netherlands
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17
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Ney B, Lanzi S, Calanca L, Mazzolai L. Multimodal Supervised Exercise Training Is Effective in Improving Long Term Walking Performance in Patients with Symptomatic Lower Extremity Peripheral Artery Disease. J Clin Med 2021; 10:jcm10102057. [PMID: 34064875 PMCID: PMC8151788 DOI: 10.3390/jcm10102057] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 12/12/2022] Open
Abstract
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.
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Thanigaimani S, Phie J, Sharma C, Wong S, Ibrahim M, Huynh P, Moxon J, Jones R, Golledge J. Network Meta-Analysis Comparing the Outcomes of Treatments for Intermittent Claudication Tested in Randomized Controlled Trials. J Am Heart Assoc 2021; 10:e019672. [PMID: 33890475 PMCID: PMC8200724 DOI: 10.1161/jaha.120.019672] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background No network meta-analysis has considered the relative efficacy of cilostazol, home exercise therapy, supervised exercise therapy (SET), endovascular revascularization (ER), and ER plus SET (ER+SET) in improving maximum walking distance (MWD) over short- (<1 year), moderate- (1 to <2 years), and long-term (≥2 years) follow-up in people with intermittent claudication. Methods and Results A systematic literature search was performed to identify randomized controlled trials testing 1 or more of these 5 treatments according to Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. The primary outcome was improvement in MWD assessed by a standardized treadmill test. Secondary outcomes were adverse events and health-related quality of life. Network meta-analysis was performed using the gemtc R statistical package. The Cochrane collaborative tool was used to assess risk of bias. Forty-six trials involving 4256 patients were included. At short-term follow-up, home exercise therapy (mean difference [MD], 89.4 m; 95% credible interval [CrI], 20.9-157.7), SET (MD, 186.8 m; 95% CrI, 136.4-237.6), and ER+SET (MD, 326.3 m; 95% CrI, 222.6-430.6), but not ER (MD, 82.5 m; 95% CrI, -2.4 to 168.2) and cilostazol (MD, 71.1 m; 95% CrI, -24.6 to 167.9), significantly improved MWD (in meters) compared with controls. At moderate-term follow-up, SET (MD, 201.1; 95% CrI, 89.8-318.3) and ER+SET (MD, 368.5; 95% CrI, 195.3-546.9), but not home exercise therapy (MD, 99.4; 95% CrI, -174.0 to 374.9) or ER (MD, 84.2; 95% CrI, -35.3 to 206.4), significantly improved MWD (in meters) compared to controls. At long-term follow-up, none of the tested treatments significantly improved MWD compared to controls. Adverse events and quality of life were reported inconsistently and could not be meta-analyzed. Risk of bias was low, moderate, and high in 4, 24, and 18 trials respectively. Conclusions This network meta-analysis suggested that SET and ER+SET are effective at improving MWD over the moderate term (<2 year) but not beyond this. Durable treatments for intermittent claudication are needed.
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Affiliation(s)
- Shivshankar Thanigaimani
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - James Phie
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Chinmay Sharma
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Shannon Wong
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Muhammad Ibrahim
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Pacific Huynh
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Joseph Moxon
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Rhondda Jones
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia
| | - Jonathan Golledge
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD) College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,The Australian Institute of Tropical Health and Medicine James Cook University Townsville Queensland Australia.,The Department of Vascular and Endovascular Surgery Townsville University Hospital Townsville Queensland Australia
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19
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Kim M, Kim C, Kim E, Choi M. Effectiveness of Mobile Health-Based Exercise Interventions for Patients with Peripheral Artery Disease: Systematic Review and Meta-Analysis. JMIR Mhealth Uhealth 2021; 9:e24080. [PMID: 33587042 PMCID: PMC7920758 DOI: 10.2196/24080] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 12/14/2022] Open
Abstract
Background Peripheral artery disease (PAD) affects over 236 million people worldwide, and exercise interventions are commonly used to alleviate symptoms of this condition. However, no previous systematic review has evaluated the effects of mobile health (mHealth)–based exercise interventions for patients with PAD. Objective This study aimed to assess the effect of mHealth-based exercise interventions on walking performance, functional status, and quality of life in patients with PAD. Methods A systematic review and meta-analysis were conducted. We searched in seven databases to identify randomized controlled trials of patients with PAD published in English up to December 4, 2020. Studies were included if patients participated in mHealth-based exercise interventions and were assessed for walking performance. We analyzed pooled effect size on walking performance, functional status, and quality of life based on the standardized mean differences between groups. Results A total of seven studies were selected for the systematic review, and six studies were included in the meta-analysis. The duration of interventions in the included studies was 12 to 48 weeks. In the pooled analysis, when compared with the control groups, the mHealth-based exercise intervention groups were associated with significant improvements in pain-free walking (95% CI 0.13-0.88), maximal walking (95% CI 0.03-0.87), 6-minute walk test (6MWT) distance (95% CI 0.59-1.24), and walking distance (95% CI 0.02-0.49). However, benefits of the interventions on walking speed, stair-climbing ability, and quality of life were not observed. Conclusions mHealth-based exercise interventions for patients with PAD were beneficial for improving pain-free walking, maximal walking, and 6MWT distance. We found that exercise interventions using mHealth are an important strategy for improving the exercise effectiveness and adherence rate of patients with PAD. Future studies should consider the use of various and suitable functions of mHealth that can increase the adherence rates and improve the effectiveness of exercise.
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Affiliation(s)
- Mihui Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea
| | - Changhwan Kim
- Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
| | - Eunkyo Kim
- College of Nursing and Brain Korea 21 FOUR Project, Yonsei University, Seoul, Republic of Korea
| | - Mona Choi
- College of Nursing and Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea.,Yonsei Evidence Based Nursing Centre of Korea, A JBI Affiliated Group, Seoul, Republic of Korea
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Wearable Activity Monitors in Home Based Exercise Therapy for Patients with Intermittent Claudication: A Systematic Review. Eur J Vasc Endovasc Surg 2021; 61:676-687. [PMID: 33451865 DOI: 10.1016/j.ejvs.2020.11.044] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 11/09/2020] [Accepted: 11/25/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Intermittent claudication (IC) can severely limit functional capacity and quality of life. Supervised exercise therapy is the recommended first line management; however, this is often limited by accessibility, compliance and cost. As such, there has been an increased interest in the use of wearable activity monitors (WAMs) in home based telemonitoring exercise programmes for claudicants. This review aims to evaluate the efficacy of WAM as a feedback and monitoring tool in home based exercise programmes for patients with IC. DATA SOURCES A search strategy was devised. The databases MEDLINE, EMBASE, and Web of Science were searched through to April 2020. REVIEW METHODS Randomised trials and prospective trials were included. Eligible trials had to incorporate WAMs as a feedback tool to target walking/exercise behaviour. The primary outcome was the change in walking ability. Study quality was assessed with risk of bias tool. RESULTS A total of 1148 records were retrieved. Of these, eight randomised controlled trials and one prospective cohort study, all of which compared a WAM intervention against standard care and/or supervised exercise, met the inclusion criteria. Owing to heterogeneity between studies, no meta-analysis was conducted. WAM interventions improved measures of walking ability (heterogeneous outcomes such as maximum walking distance, claudication distance and six minute walk distance), increased daily walking activity (steps/day), cardiovascular metrics (maximum oxygen consumption), and quality of life. CONCLUSION There is some evidence that home based WAM interventions are beneficial for improving walking ability and quality of life in patients with IC. However, existing studies are limited by inadequate sample size, duration, and appropriate power. Achieving consensus on outcome reporting and study methods, as well as maximising device adherence, is needed.
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Kobayashi T, Hamamoto M, Okazaki T, Honma T, Iba K, Takakuwa T, Harada T, Takahashi S. Effectiveness of continuous unsupervised exercise therapy after above-knee femoropopliteal bypass. Vascular 2020; 29:387-395. [PMID: 32951562 DOI: 10.1177/1708538120957488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Exercise therapy has acceptable outcomes for patients with intermittent claudication, although few reports exist regarding the results of continuous exercise therapy after surgical reconstruction for intermittent claudication. This study aimed to analyze the long-term outcomes of unsupervised exercise therapy for patients after above-knee femoropopliteal bypass. MATERIAL AND METHODS We retrospectively analyzed 69 patients (69 limbs, 69 grafts) who underwent above-knee femoropopliteal bypass from April 2009 to March 2018 in our hospital. At six months after above-knee femoropopliteal bypass, we evaluated the maintenance of unsupervised exercise therapy. Patients who continued unsupervised exercise therapy or discontinued unsupervised exercise therapy were assessed via 1:1 propensity matching. Long-term outcomes such as patency, survival, and major adverse cardiovascular events were compared between the groups after matching. We also analyzed the maintaining rate of unsupervised exercise therapy in a study cohort. RESULTS Twenty-nine (42%) patients continued unsupervised exercise therapy until six months after above-knee femoropopliteal bypass. The discontinued unsupervised exercise therapy had higher proportions of female sex (p = 0.015) and cerebrovascular disease (p = 0.025) than did the continued unsupervised exercise therapy. The mean follow-up period was 65 ± 36 months. After propensity matching, the rates of the following factors were significantly higher in the continued unsupervised exercise therapy than in the discontinued unsupervised exercise therapy: primary patency (97% vs. 61%, p = 0.0041), secondary patency (100% vs. 69%, p = 0.0021), and freedom from major adverse cardiovascular events (61% vs. 24%, p = 0.0071) at five years. Both groups had a similar survival rate. The maintaining rate of unsupervised exercise therapy in the study cohort was 44% at six months, 41% at one year, 36% at three years, 25% at five years, and 25% at seven years. CONCLUSION The findings of this study suggested superior long-term outcomes, including graft patency and freedom from major adverse cardiovascular events, with unsupervised exercise therapy after open bypass than with the usual therapy. Unsupervised exercise therapy may be recommended for the patients after open bypass.
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Affiliation(s)
- Taira Kobayashi
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Masaki Hamamoto
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takanobu Okazaki
- Department of Cardiovascular Surgery, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Tomoaki Honma
- Department of Rehabilitation, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Kazutoshi Iba
- Department of Rehabilitation, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Tsubasa Takakuwa
- Department of Rehabilitation, JA Hiroshima General Hospital, Hiroshima, Japan
| | - Takumi Harada
- Department of Surgery, Institute of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Shinya Takahashi
- Department of Cardiovascular Surgery, Graduate School of Medicine, Hiroshima University, Hiroshima, Japan
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Midulla M, Loffroy R, Dake M. Commentary: Be Innovative, Stay Clinical! Time for a Patient-Specific SFA Treatment Algorithm? J Endovasc Ther 2020; 27:502-504. [PMID: 32517559 DOI: 10.1177/1526602820921405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marco Midulla
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Université de Bourgogne Franche-Compté, Centre Hospitalier Universitaire de Dijon, France
| | - Romaric Loffroy
- Department of Diagnostic and Therapeutic Radiology, Center for Mini-Invasive Image-Guided Therapies, Université de Bourgogne Franche-Compté, Centre Hospitalier Universitaire de Dijon, France
| | - Michael Dake
- Health Sciences, University of Arizona, Tucson, AZ, USA
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Oxidative Stress in Peripheral Arterial Disease (PAD) Mechanism and Biomarkers. Antioxidants (Basel) 2019; 8:antiox8090367. [PMID: 31480714 PMCID: PMC6770183 DOI: 10.3390/antiox8090367] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/29/2019] [Accepted: 08/30/2019] [Indexed: 12/13/2022] Open
Abstract
Hemodynamic dysfunction mainly characterizes pathophysiology of peripheral arterial disease (PAD) leading to chronic ischemia. Hemodynamic dysfunction is the origin of intermittent claudication (chronic PAD) or of critical limb ischemia (very severe PAD). Notably, it is well known that oxidative stress (OxS) plays a pathophysiological role in PAD. The higher production of reactive oxygen species (ROS) from OxS and reduced redox capability are two crucial players in initiating and progressing PAD. A number of biomarkers highlight OxS and monitor it in PAD. The present review summarizes data on OxS, on biomarkers available to mark OxS occurrence and to monitor on PAD progression, as well as to evaluate the effects treatments in PAD patients. In conclusion, by detailing OxS and its biomarkers, we hope to encourage more studies to focus on drugs which combat OxS and inflammation.
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