In peripheral artery disease, diabetes is associated with reduced physical activity level and physical function and impaired cardiac autonomic control: A cross-sectional study

Effects of exercise therapy on diabetic neuropathy: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effects of exercise therapy on neuropathic symptoms, signs, psychosocial aspects, and physical function in people with diabetic neuropathy (DN).

METHODS

A search in PubMed, Web of Science, Physiotherapy Evidence (PEDro), and Cochrane databases was performed from inception to Invalid Date NaN, . Randomized clinical trials (RCTs) were selected in patients with DN comparing exercise therapy with a control group. The studies' methodological quality was assessed with the PEDro scale. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess the overall quality.

RESULTS

Eleven RCTs (n = 517 participants) were included. Nine studies showed high methodological quality. Mean (MD) and standardized mean differences (SMD) were observed in favor of exercise therapy for symptoms (MD = -1.05; confidence interval 95% = -1.90 to -0.20), signs (SMD = -0.66; confidence interval 95%= -1 to -0.32), and physical function (SMD = -0.45; confidence interval 95% = -0.66 to -0.24). No changes were found in psychosocial aspects (SMD = -0.37; confidence interval 95% = -0.92 to 0.18). The overall quality of evidence was very low.

CONCLUSION

The quality of evidence suggesting that exercise therapy provides short-term benefits in neuropathic symptoms, signs, and physical function in patients with DN is very low. Furthermore, there were no effects found on psychosocial aspects.

The bodyweight walking distance product and its relationship with clinical markers in patients with symptomatic peripheral artery disease

PURPOSE

The six-minute walk test (6MWT) is extensively employed to evaluate gait impairment in patients with symptomatic peripheral artery disease (PAD) and has been associated with different health outcomes. However, various approaches exist for calculating and interpreting the six-minute test in order to address the needs of patients more effectively. Therefore, we investigated how these different approaches correlate with functional capacity and cardiovascular health in patients with symptomatic PAD.

METHODS

In total, 227 PAD patients [65.2% men and 67 (13) y.o.] were included in this cross-sectional study. The 6MWT was performed along a 30-meter corridor and the distance was expressed in three ways: absolute (described as the meters walked during the test), relativized (based on the results of the 6MWT in healthy individuals), and DW (multiplying the body weight in kilograms by the absolute distance in the 6MWT). A functional capacity z-score was calculated using the results of the handgrip strength test, 4-meter walking test, and sit-and-stand test. A cardiovascular parameter z-score was calculated with data on brachial and central blood pressure, the low-frequency component/high-frequency component ratio, and carotid-femoral pulse wave velocity.

RESULTS

The absolute (b = 0.30, 95%CI: 18-0.43, R² = 0.11, p < 0.001) and DW (b = 0.40, 95%CI: 27-0.53, R² = 0.17, p < 0.001) measures were related to functional capacity, independently of sex, age, and the ankle-arm index of the patients. Neither absolute nor DW were related to cardiovascular health. The relativized measure was not associated with either functional capacity or cardiovascular health.

CONCLUSION

In patients with symptomatic PAD, absolute and DW measures are related to functional capacity, but not cardiovascular function.

Peripheral artery disease causes consistent gait irregularities regardless of the location of leg claudication pain

BACKGROUND

The most common symptom of peripheral artery disease (PAD) is intermittent claudication that involves the calf, thigh, and/or buttock muscles. How the specific location of this leg pain is related to altered gait, however, is unknown.

OBJECTIVES

We hypothesized that because the location of claudication symptoms uniquely affects different leg muscle groups in people with PAD, this would produce distinctive walking patterns.

METHODS

A total of 105 participants with PAD and 35 age-matched older volunteers without PAD (CTRL) were recruited. Participants completed walking impairment questionnaires (WIQ), Gardner-Skinner progressive treadmill tests, the six-minute walk test, and we performed an advanced evaluation of the biomechanics of their overground walking. Participants with PAD were categorized into 4 groups according to their stated pain location(s): calf only (C, n = 43); thigh and calf (TC, n = 18); buttock and calf (BC, n = 15); or buttock, thigh, and calf (BTC, n = 29). Outcomes were compared between CTRL, C, TC, BC and BTC groups using a one-way ANOVA with post-hoc comparisons to identify and assess statistically significant differences.

RESULTS

There were no significant differences between CTRL, C, TC, BC and BTC groups in distances walked or walking speed when either pain-free or experiencing claudication pain. Each participant with PAD had significantly dysfunctional biomechanical gait parameters, even when pain-free, when compared to CTRL (pain-free) walking data. During pain-free walking, out of the 18 gait parameters evaluated, we only identified significant differences in hip power generation during push-off (in C and TC groups) and in knee power absorption during weight acceptance (in TC and BC groups). There were no between-group differences in gait parameters while people with PAD were walking with claudication pain.

CONCLUSIONS

Our data demonstrate that PAD affects the ischemic lower extremities in a diffuse manner irrespective of the location of claudication symptoms.

DATABASE REGISTRATION

ClinicalTrials.gov NCT01970332.

Objective assessment of functional capacity in patients with peripheral artery disease: a narrative review

INTRODUCTION

Peripheral artery disease (PAD) patients with claudication symptoms exhibit impaired functional capacity, which has been associated with disease severity, worse quality of life and higher risk of cardiovascular events. Different tests have been used to assess functional capacity in PAD patients. Therefore, understanding the characteristics, strengths and limitations of these tests are important to support the choice of tests to be used in clinical practice.

AREAS COVERED

This review summarizes the main methods to assess functional capacity in PAD patients, discussing their psychometric properties, applications, and limitations.

EXPERT OPINION

Robust evidence supports the use of treadmill and six-minute walk tests in PAD patients, as their results are associated with clinically meaningful outcomes, adequate psychometric properties and are sensitive to effects of interventions. On the other hand, other functional tests (Shuttle-walk test, outdoor walking capacity test, timed-up and go, four-meter walk test, heel-rise test, short physical performance battery and modified physical performance battery) are related to activities of daily living and do not require sophisticated equipment and can be easily used in clinical practice. However, these other tests still need evidence regarding their clinical relevance, reliability, and ability to detect long-term intervention changes, providing further investigation directions.

Device-measured physical activity behaviours, and physical function, in people with type 2 diabetes mellitus and peripheral artery disease: A cross-sectional study

AIM

To quantify differences in device-measured physical activity (PA) behaviours, and physical function (PF), in people with type 2 diabetes mellitus (T2DM) with and without peripheral artery disease (PAD).

MATERIALS AND METHODS

Participants from the Chronotype of Patients with T2DM and Effect on Glycaemic Control cross-sectional study wore accelerometers on their non-dominant wrist for up to 8-days to quantify: volume and intensity distribution of PA, time spent inactive, time in light PA, moderate-to-vigorous PA in at least 1-minute bouts (MVPA1min), and the average intensity achieved during the most active continuous 2, 5, 10, 30, and 60-minute periods of the 24-h day. PF was assessed using the short physical performance battery (SPPB), the Duke Activity Status Index (DASI), sit-to-stand repetitions in 60 s (STS-60); hand-grip strength was also assessed. Differences between subjects with and without PAD were estimated using regressions adjusted for possible confounders.

RESULTS

736 participants with T2DM (without diabetic foot ulcers) were included in the analysis, 689 had no PAD. People with T2DM and PAD undertake less PA (MVPA1min: -9.2 min [95 % CI: -15.3 to -3.0; p = 0.004]) (light intensity PA: -18.7 min [-36.4 to -1.0; p = 0.039]), spend more time inactive (49.2 min [12.1 to 86.2; p = 0.009]), and have reduced PF (SPPB score: -1.6 [-2.5 to -0.8; p = 0.001]) (DASI score: -14.8 [-19.8 to -9.8; p = 0.001]) (STS-60 repetitions: -7.1 [-10.5 to -3.8; p = 0.001]) compared to people without; some differences in PA were attenuated by confounders. Reduced intensity of activity for the most active continuous 2-30 min in the 24-h day, and reduced PF, persisted after accounting for confounders. There were no significant differences in hand-grip strength.

CONCLUSIONS

Findings from this cross-sectional study suggest that, the presence of PAD in T2DM may have been associated with lower PA levels and PF.

Diabetes Is Negatively Associated With Meeting Physical Activity Time-Intensity Guidelines in Patients With Claudication

PURPOSES

We determined the percentage of patients with peripheral artery disease (PAD) and claudication who meet the 2018 physical activity (PA) time-intensity guidelines, and we identified the clinical characteristics associated with the status of meeting the guidelines.

METHODS

Five hundred seventy-two patients were assessed on their daily ambulatory activity for 1 wk with a step activity monitor, and were evaluated on whether or not they achieved 150 min/wk of moderate-intensity PA.

RESULTS

Thirty-one percent (n = 175) of the patients with PAD met the PA time-intensity guidelines and 69% (n = 397) did not. In a final multivariable logistic regression model identifying the independent predictors of meeting the PA time-intensity guidelines from clinical characteristics, diabetes was the only significant variable entered (OR = 0.310: 95% CI, 0.175-0.538; P < .001) and was associated with a 69% lower chance of meeting the guidelines. Patients with diabetes spent less daily time in moderate-intensity ambulatory PA than patients without diabetes (15 ± 13 vs 23 ± 20 min/d; P < .001).

CONCLUSIONS

Thirty-one percent of patients with PAD and claudication met the PA time-intensity guidelines. Furthermore, patients with diabetes were least likely to meet the PA time-intensity guidelines, as they had a 69% lower chance than patients without diabetes. The clinical significance is that PAD patients who have diabetes are particularly susceptible to being physically sedentary, and are therefore prime patients who should be encouraged to increase their daily PA.

Detecting and treating the protean manifestations of diabetic autonomic neuropathy

The manifestations of diabetic autonomic neuropathy (DAN) are protean and clinically involve multiple systems, including the cardiovascular system, the gastrointestinal system, the genitourinary system as well as the sweat glands (sudomotor dysfunction) and the gallbladder. In addition, cardiac autonomic neuropathy (CAN) is associated with a correctible inability to appreciate and correct hypoglycaemia. While not a clinical problem, pupillary involvement should be the clue and the catalyst to investigate for other manifestations of DAN. This review outlines a practical approach to detecting and investigating the manifestations of DAN. Of particular importance is early detection of cardiovascular involvement where prompt therapy through glycaemic control can decrease the severity of CAN and decelerate the frequency and severity of retinopathy and nephropathy in addition to decreasing cardiovascular events and mortality. CAN also plays a role in accelerating other diabetic complications such as acute ischaemic stroke, heart failure, medial artery calcinosis, foot ulcers, peripheral artery disease and Charcot joints. Many therapies of DAN are available, which should not only decrease morbidity and mortality from DAN, but also improve the patient's quality of life. However, the therapies available are largely symptomatic.

Physical Activity Reduces the Risk of Developing Diabetes and Diabetes Medication Use

Diabetes is a global public health challenge, exerting a large socioeconomic burden on healthcare systems. This study aimed to explore Diabetes prevalence and Diabetes medication use in diabetics regarding sex, age group, Physical Activity Level (PAL) and Body Mass Index (BMI) by studying possible differences and calculating the risks of developing Diabetes and Diabetes medication use in the population according to their PAL. A cross-sectional study was conducted using data extracted from the Spanish National Health Survey (ENSE2017). The sample was finally composed of 17,710 participants. A descriptive analysis was performed to characterise Diabetes prevalence and Diabetes medication use (Chi-square test and a z-test for independent proportions). Odds Ratios (OR) and 95% Confidence Intervals (CI) were calculated for Diabetes prevalence and Diabetes medication use according to the participants’ PAL. Both the Diabetes and Diabetes medication use was higher in men than in women, increasing with age and BMI, and decreasing with increasing PAL (p < 0.001). Higher prevalence levels were observed in the inactive group versus very active or active people (p < 0.001). Inactive people had a higher risk of Diabetes and use of Diabetes medication risk compared to the very active and active groups. Prevalence decreased the higher the PAL both in men and women.

Objectively measured physical activity levels and adherence to physical activity guidelines in people with multimorbidity-A systematic review and meta-analysis

Objective

To determine levels of objectively measured physical activity (PA) and the proportion of adults with multimorbidity that adheres to PA guidelines.

Methods

All studies, where PA was measured at baseline using an activity monitor in an adult (≥18 years) multimorbid (≥80% of the population had ≥2 chronic conditions) population. A systematic literature search was performed in Medline, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov, opengrey.eu and google.com from inception up until 18^th of January 2022. Risk of bias was assessed with a modified version of the Quality Assessment Tool for Quantitative Studies. A random-effects meta-analyses was performed to estimate daily minutes of sedentary behavior (SB), light PA (LPA), moderate PA (MPA), moderate to vigorous PA (MVPA) and steps. Proportions adhering to PA guidelines was narratively synthesized. Certainty of evidence was determined using The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Results

Fifteen studies (2,172 participants) were included. The most frequent combination of conditions were type 2 diabetes and hypertension (six studies). Participants spent a daily average of 500.5 (95% CI: 407.1 to 593.9) minutes in SB, 325.6 (95% CI: 246.4 to 404.7 minutes in LPA and 32.7 (95% CI: 20.2 to 45.3) minutes in MVPA. The mean daily number of steps was 5,145 (95% CI: 4264 to 6026) for people in free-living conditions. The proportion adhering to PA guidelines ranged widely (7.4% to 43%). All studies were rated as at high risk of bias and the certainty of evidence was very low.

Conclusions

PA levels and adherence varied from low to above guideline recommended levels for adults with chronic conditions, depending on PA intensity. The very low certainty of evidence calls for high quality studies focusing on detailed descriptions of PA behavior in people with multimorbidity.

PROSPERO registration number

CRD42020172456.

Longitudinal Changes in Physical Activity Levels and Cardiovascular Risk Parameters in Patients with Symptomatic Peripheral Artery Disease

BACKGROUND

Previous cross-sectional studies have demonstrated that physical activity is associated with lower cardiovascular risk in patients with peripheral artery disease (PAD). However, it is not possible to establish causality, and longitudinal design studies are required.

OBJECTIVE

To analyze the changes in cardiovascular risk parameters and physical activity levels after a 2-year follow-up in patients with symptomatic PAD.

METHODS

This study started in 2015. In the first phase, 268 patients were included. In the second phase, after 2 years (median = 26 months), 72 patients were re-evaluated. Cardiovascular risk parameters, such as blood pressure, cardiac autonomic modulation, and arterial stiffness, and physical activity levels were measured at baseline and after 2 years of follow-up. Association among delta changes (values from follow-up - baseline) in physical activity and cardiovascular parameters were analyzed by multiple linear regression. The significance level was set at p < 0.05.

RESULTS

Patients reduced their total physical activity levels compared to baseline (baseline = 2257.6 ± 774.5 versus follow-up = 2041 ± 676.2 min/week, p = 0.001). After follow-up, ankle-brachial index (0.62 ± 0.20 versus 0.54 ± 0.20, p = 0.003), and standard deviation of all RR intervals (43.4 ± 27.0 versus 25.1 ± 13.4 ms, p < 0.001) were lower, whereas carotid-femoral pulse wave velocity was higher (9.0 ± 3.0 versus 10.7 ± 3.4 m/s, p = 0.002) compared to baseline values. We did not observe any association among delta values of physical activity levels and cardiovascular risk parameters.

CONCLUSION

Patients with PAD had reduced physical activity levels and impaired cardiovascular risk parameters during 2-year follow-up.

Are Vascular Parameters Associated with Walking Impairment in Patients with Claudication?

BACKGROUND

The mechanisms underlying functional impairments in symptomatic PAD patients are controversial and poorly understood. Endothelial dysfunction and arterial stiffness have been proposed as potential mechanisms related to functional impairment in symptomatic PAD patients, however, more studies are needed to confirm these associations.

OBJECTIVE

To analyze the association between vascular function and walking impairment in patients with peripheral arterial disease (PAD) and symptoms of claudication.

METHODS

This was a cross-sectional study that included 68 patients with symptomatic PAD. All patients underwent an objective (Six-minute walk test [6MWT], 4-meter walk test) and a subjective (Walking Impairment Questionnaire [WIQ]) measurement of walking impairment. Vascular parameters measured were pulse-wave velocity (PWV) and flow-mediated dilation (FMD). Multiple linear regression was performed to investigate the association among walking impairment variables with vascular function parameters.

RESULTS

No significant associations between the claudication onset distance (PWV: b=.060, P = 0.842; FMD: b=-.192, P = 0.456), 6MWT (PWV: b=.007, P = 0..975; FMD: b=.090, P = 0.725), WIQ distance (PWV: b=.337, P = 0.117; FMD: b=-.025, P = 0.895) WIQ speed (PWV: b=.320, P = 0.181; FMD: b=-.028, P = 0.497), WIQ stairs (PWV: b=.256, P = 0.204; FMD: b=-.228, P = 0.230), 4-meter usual walk (PWV: b=-.421, P = 0.107; FMD: b=-.338, P = 0.112), 4-meter fast walk (PWV: b=-.496, P = 0.063; FMD: b=-.371, P = 0.086) and vascular function were found.

CONCLUSIONS

In symptomatic PAD patients, vascular function is not associated to walking impairment, even when adjusting for comorbid conditions and diabetes.

Patients with Diabetes Complicated by Peripheral Artery Disease: the Current State of Knowledge on Physiotherapy Interventions

Diabetes mellitus (DM) is one of the major public health problems that account for morbidity, mortality, and disability worldwide. The presence of DM increases the risk of peripheral artery disease (PAD), as well as accelerates its course, making these patients more susceptible to ischemic events and impaired functional status. Unfortunately, alternative treatments for vascular complications in diabetes are poorly researched. Physiotherapy (kinesitherapy combined with different physical therapy agents) in individuals with DM and coexisting PAD may offer an important complementary therapy alternative. Early therapeutic measures can significantly improve patient outcomes, reduce cardiovascular risk, and improve daily life quality. The article provides an update on the current state of knowledge on physiotherapy interventions in the course of DM in patients with coexisting PAD.