Rehabilitation in patients with peripheral arterial disease

Rehabilitation contributes to lower readmission rates for individuals with peripheral arterial disease: A retrospective observational study

BACKGROUND

Non-pharmacological interventions, such as rehabilitation, are crucial for the treatment of people with peripheral arterial disease (PAD). Although several studies have shown rehabilitation is effective in improving the functional prognosis of PAD, there is currently insufficient evidence regarding its effect on readmission rates.

OBJECTIVES

To examine the impact of rehabilitation on readmission rates for people with PAD.

METHODS

A retrospective analysis of the JMDC hospital database was performed on data from two groups of people aged ≥20 years who were hospitalized between 2014 and 2020 with PAD, as based on a previous diagnosis. Participants were divided according to whether they did, or did not, receive any form of rehabilitation as part of their treatment in hospital. The primary outcome was readmission rates at 30, 60, 90, and 180 days after initial admission. A one-to-one propensity score matching was used to compare readmission rates between rehabilitation and non-rehabilitation groups.

RESULTS

We included 13,453 people with PAD, of whom 2701 pairs (5402 subjects) were selected after being matched in the rehabilitation and non-rehabilitation groups. The rehabilitation group participants had significantly lower mortality and readmission rates at 30, 60, 90, and 180 days. The odds ratios (95% confidence interval) for both groups were 0.79 (0.69-0.91; 30 days), 0.81 (0.71-0.91; 60 days), 0.78 (0.69-0.88; 90 days), and 0.79 (0.71-0.88; 180 days).

CONCLUSIONS

This large, nationwide study found that rehabilitation treatment during hospitalization was associated with lower readmission rates and mortality for people following hospitalization with PAD and supports its inclusion as a standard PAD treatment.

Risk Factors, Prevention, and Primary and Secondary Management of Sciatica: An Updated Overview

Sciatica is a chronic condition causing crippling low back pain radiating down to the sciatic nerve innervation area, which is the posterior thigh. It remains a major public health problem worldwide with significant socio-economic, physical, and psychological impacts. Studies suggested different diagnostic methods due to the lack of consensus on diagnostic and treatment guidelines. When it comes to the management and treatment, there is ambiguous evidence about the use of painkillers, surgical interventions, and alternative options and their effectiveness, with most studies contrasting one another in addition to the lack of high-quality trials. This review presents the available data on the current understanding of sciatica covering clinical manifestations, diagnosis and treatment modalities, prognosis, and complications since a disagreement is observed in the scientific community regarding sciatica, starting with a definition of sciatica, its epidemiological characteristics, to the management and treatment. Our review would help raise knowledge and awareness about sciatica in the health professional community and the general public since the prevalence of low back pain is high in most parts of the world and there is insufficient knowledge of sciatica in the literature.

Factors Associated With Change in Cardiovascular Fitness for Patients With Peripheral and Coronary Artery Disease in Cardiac Rehabilitation

PURPOSE

Cardiac rehabilitation (CR) yields improvements in cardiorespiratory fitness (peak oxygen uptake [V˙o2peak]). Predictors of change in V˙o2peak have been reported among patients with coronary artery disease (CAD) but have not been compared with peripheral artery disease (PAD). This study determined predictors of improved V˙o2peak among patients with PAD, CAD, and concomitant PAD and CAD (PAD/CAD) following a 6-mo home-based outpatient CR program (1supervised and 4 home weekly sessions).

METHODS

This study was a retrospective (2006-2017) multiple linear regression analysis of CR patients with PAD (n = 63), CAD (n = 63), and PAD/CAD (n = 164). Peripheral artery disease and CAD were matched for age, sex, smoking status, diabetes, and year in program.

RESULTS

Mean age of all patients was 68.9±10.1 yr, 72% were male, and mean improvement in V˙o2peak was 2.1 ± 3.3 mL/kg/min (14.5% improvement) following CR. In CAD, younger age (β = .30, P = .015), male sex (β = -.29, P = .019), and more recent year of entry (β = .26, P = .035) were predictors of improved V˙o2peak. In PAD, only male sex (β = -.36, P = .004) and in PAD/CAD, not having diabetes (β = -.24, P = .002), not smoking (β = -.25, P = .001), and shorter elapsed time from referring diagnosis to entry (β = -.19, P = .016) were predictors.

CONCLUSIONS

While younger age and male sex were predictors of improved V˙o2peak in CAD, age did not influence PAD, and neither age nor sex influenced PAD/CAD. Peripheral artery disease-related limitations may override some demographic factors, and strategies for improving V˙o2peak should be explored. Managing smoking and comorbid diagnoses including diabetes and a timely entry to CR may yield greater improvements in V˙o2peak among individuals with PAD.

[Basic principles and approaches to medical rehabilitation of patients with atherosclerosis obliterans of lower limb arteries]

The review presents current data on the management of patients with atherosclerosis obliterans of the lower extremities. The main approaches to medical rehabilitation of patients with diseases of the arteries of the lower extremities are considered, tools for determining the rehabilitation potential depending on the stage of lower limb ischemia are proposed. The programs of physical and psychological rehabilitation, as well as the methods of physical and balneotherapy in accordance with the stages of medical rehabilitation, are determined. Modern rehabilitation methods are presented.

Relationship Between Psychological Factors and Wound Occurrence in Patients With Peripheral Arterial Disease in the Leg

This prospective study investigated psychological factors affecting wound healing in patients with peripheral arterial disease (PAD). Fifty patients with PAD in a local hospital were enrolled. The Geriatric Depression Scale short version, Type-D scale 14, Medical Outcome Study 36-Item Short-Form Health Survey (SF-36), Functional Independence Measure, Self-efficacy for Managing Chronic Disease Scale, Barriers Self-Efficacy Scale, and Mini Nutritional Assessment were applied to assess physical and psychological factors. Wound occurrence and healing were evaluated at 6 months after discharge, and 34 and 30 patients could be followed, respectively. The patient group with wound occurrence showed poorer mental component score (MCS) and better role/social component score (RCS) category scores of SF-36, and a higher stage in the Fontaine classification, than those without wound occurrence. On comparing Fontaine classification-matched subgroups, patients with wound occurrence showed poorer general health factor and MCS and better RCS of SF-36 than those without wound occurrence. Logistic analysis showed that MCS and RCS predicted wound occurrence and needs for local medical treatment, respectively. Among the psychological factors tested, MCS was a major factor associated with wound occurrence in the present study, with wide variation in clinical conditions and factors associated with PAD. Psychological factors were important as biological, physical, and social factors for patients with PAD during the long-term follow-up period, and an appropriate battery to evaluate psychological factors focused on patients with PAD should be developed.

Entering Cardiac Rehabilitation With Peripheral Artery Disease: A RETROSPECTIVE COMPARISON TO CORONARY ARTERY DISEASE

PURPOSE

Supervised exercise is recommended for patients with peripheral artery disease (PAD) and patients with coronary artery disease (CAD). Both conditions share common etiology as atherosclerotic diseases. The clinical profile, cardiorespiratory fitness, and exercise prescriptions of PAD, CAD, and patients with concomitant PAD and CAD (BOTH) have yet to be compared upon entry into cardiac rehabilitation (CR).

METHODS

Cardiopulmonary, demographic, and anthropometric assessments were conducted at entry to CR between January 2006 and December 2017.

RESULTS

Among 9701 consecutively enrolled patients, there were 94.6% with CAD (n = 9179), 1.5% with PAD (n = 143), and 3.9% with BOTH (n = 379). Only 5.4% (n = 522) of all patients entering CR had a diagnosis of PAD. Compared with CAD, patients with PAD and BOTH were older (mean ± SD = 62.5 ± 11.1 vs 67.9 ± 11.4 and 69.2 ± 9.8 yr, P < .01), had higher resting systolic blood pressure (124 ± 17 vs 130 ± 17 and 133 ± 18 mm Hg, P < .01), had lower cardiorespiratory fitness (19.7 ± 6.3 vs 15.6 ± 4.8 and 15 ± 4.5 mL/kg/min, P < .01), and were more likely to have diabetes (25% vs 35% and 41%, P < .01), abdominal obesity (39% vs 54% and 51%, P < .01), and initially prescribed lower-intensity exercise (84.4 ± 14.1 vs 74.1 ± 15.7 and 70.0 ± 14.6 m/min exercise pace, P < .01), reflecting the complex nature of patients diagnosed with PAD.

CONCLUSIONS

Patients referred with PAD have a cardiovascular risk profile that places them at a greater risk for a repeat or first cardiac event compared with patients with CAD. Referral to structured exercise and risk factor modification programs should be considered to aid in the management of PAD.

Influence of the Physical Training on Muscle Function and Walking Distance in Symptomatic Peripheral Arterial Disease in Elderly

INTRODUCTION

A typical symptom of chronic lower-limb ischaemia is lower-limb pain, which occurs during walking forcing the patient to stop, intermittent claudication (IC). Exercise rehabilitation is the basic form of treatment for these patients.

AIM

The aim of this study was to compare the effectiveness of three types of physical training programmes conducted over a 12-week period in patients with chronic lower-limb arterial insufficiency.

MATERIALS AND METHODS

Ninety-five people qualified for the 3-month supervised motor rehabilitation programme, conducted three times a week. The respondents were assigned to three types of rehabilitation programmes using a pseudo-randomization method: Group I (TW), subjects undertaking treadmill walking training; Group II (NW), subjects undertaking Nordic walking training; Group III (RES+NW), subjects undertaking resistance and Nordic walking training. Treadmill test, 6 Minute Walk Test (6MWT), and isokinetic test were repeated after 3 months of rehabilitation, which 80 people completed.

RESULTS

Combined training (RES+NW) is more effective than Nordic walking alone and supervised treadmill training alone for improving ankle force-velocity parameters (p<0.05) in patients with intermittent claudication. Each of the proposed exercise rehabilitation programmes increased walking distance of patients with intermittent claudication (p<0.05), especially in 6MWT (p=0.001). Significant relationships of force-velocity parameters are observed in the maximum distance obtained in 6MWT, both in Group III (RES + NW) and in Group II (NW) at the level of moderate and strong correlation strength, which indicates that if the lower limbs are stronger the walking distance achieved in 6MWT is longer.

CONCLUSIONS

Given both the force-velocity parameters and the covered distance, the training RES + NW gives the most beneficial changes compared to training TW alone and NW alone. All types of training increased walking distance, which is an important aspect of the everyday functioning of people with IC.

Donor site morbidity after vascularized fibula free flap: gait analysis during prolonged walk conditions

The aim of this study was to determine the effect of vascularized fibula free flap (VFFF) harvest on gait variables during the six-minute walk test (6MWT). Eleven patients who had undergone VFFF harvest and 11 healthy peers participated in this case-control study. The main evaluation consisted of the collection of gait variables using the GAITRite system during three periods of the 6MWT: beginning (0-1min), middle (2:30-3:30min), and end (5-6min). The 6MWT was significantly shorter in the VFFF group than in the reference group (-31%, P<0.001). Most gait variables differed significantly between the groups for each period (P-value range 0.04-0.0004), including toe in/out on the operated side (P-value range 0.005-0.01). The increase in toe in/out on the operated side suggests a functional modification caused by an imbalance of the agonist-antagonist muscles. On comparison of the different periods, gait velocity decreased between the beginning and middle periods and increased between the middle and end periods in both groups. However, a significantly lower velocity between the beginning and end periods was found only for the VFFF group (P=0.026), suggesting an alteration in physical management. In conclusion, these results suggest that VFFF harvesting could alter gait and joint integrity.

Effectiveness of a new exercise program after lower limb arterial blood flow surgery in patients with peripheral arterial disease: a randomized clinical trial

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a supervised exercise program (SEP) plus at home nonsupervised exercise therapy (non-SET) on functional status, quality of life (QoL) and hemodynamic response in post-lower-limb bypass surgery patients.

RESULTS

One hundred and seventeen patients were randomized to an intervention (n = 57) or a control group (n = 60). A new individual SEP was designed for patients with peripheral arterial disease (PAD) and applied to the studied subjects of the intervention group who also continued non-SET at home, whereas those assigned to the control group received just usual SEP according to a common cardiovascular program. The participants of the study were assessed by a 6-min walking test (6 MWT), an ankle-brachial index (ABI), and the Medical Outcomes Study Short Form-36 (SF-36) of QoL at baseline, at 1 and 6 months after surgery. A significant improvement was observed in the walked distance in the intervention group after 6 months compared with the control group (p < 0.001). The intervention group had significantly higher QoL score in the physical and mental component of SF-36 (p < 0.05).

CONCLUSIONS

A 6-month application of the new SEP and non-SET at home has yielded significantly better results in walking distance and QoL in the intervention group than in the controls.

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).