Effects of exercise rehabilitation on cardiovascular risk factors in older patients with peripheral arterial occlusive disease

Differential effects of exercise training protocols on blood pressures and lipid profiles in older adults patients with hypertension: A systematic review and meta-analysis

Decreased physical activity and high blood pressure are both risk factors for cardiovascular diseases. Controlling blood pressure within the normal range can prevent or delay these complications. This systematic review and meta-analysis analyzed the effects of different types of exercise training on the blood pressure and lipid profiles of older adults patients with hypertension. Five electronic databases (Web of Science, Cochrane, PubMed, Google Scholar, and Scopus) were searched from their inception until March 03, 2024. English publications and randomized controlled trials involving different types of exercise training treatments for hypertensive populations were included. Data were analyzed using a random-effects model to estimate weighted mean differences (WMD) and 95 % confidence intervals. The systematic search identified 1998 articles, of which 92 studies met the inclusion criteria and were deemed eligible for inclusion. The results of the meta-analysis indicated that reduced systolic (SBP) and diastolic blood pressures (DBP) after aerobic training (p < 0.01), resistance training (p < 0.01), combined (aerobic + resistance) exercise training (p < 0.01) and isometric handgrip training (p < 0.01). Significant reductions were also observed in low-density lipoprotein (LDL) and triglyceride (TG) levels following combined (aerobic + resistance) exercise training (p < 0.05 and p < 0.001), and resistance training (p < 0.01), respectively. High-density lipoprotein (HDL) levels were increased following aerobic training (p < 0.01), and combined (aerobic + resistance) exercise training (p < 0.01), but not after resistance and Tai chi training. Isometric handgrip training leads to greater reductions in blood pressure in hypertensive patients compared to the effects of aerobic, resistance, combined aerobic and resistance exercise, and tai chi training. Additional studies are needed to determine the exercise prescription protocols to maximize the health of older adults patients with hypertension.

Comparing arm-ergometry and treadmill exercise training on cardiovascular risk factors in peripheral artery disease: secondary analysis of the ARMEX trial

BACKGROUND

Peripheral artery disease (PAD), usually caused by atherosclerosis, is linked to high cardiovascular mortality. In this setting, a multidimensional cardiovascular rehabilitation program (CRP) comprising supervised exercise training can improve cardiovascular risk factors (CRF) control. This study compares the effects of an arm-ergometry supervised exercise training (AEx) with a standard treadmill protocol (TEx) on CRF.

METHODS

The ARMEX trial (ISRCTN54908548) was a single-center, single-blinded, parallel groups, noninferiority randomized clinical trial enrolling symptomatic PAD patients referred to a CRP. Participants were randomized (1:1) either to a 12-week AEx or TEx. Changes in blood pressure, lipid profile, glycated hemoglobin, body composition, physical activity levels, sedentary time and number of cigarettes smoked after the CRP were assessed.

RESULTS

Fifty-six patients (66±8.4 years; 87.5% male) were included: AEx (N.=28) and TEx (N.=28). Systolic and diastolic blood pressure decreased in both groups without significant between-group differences. Total cholesterol and low-density lipoprotein cholesterol decreased significantly only in the AEx group, without significant between-group differences. Weight, body mass index, waist circumference, waist/hip ratio and physical activity levels improved in both groups, without significant between-group differences. Smoking reduction was also similar between groups.

CONCLUSIONS

A multidimensional CRP, whether involving arm-ergometry or treadmill exercise, improved CRF control in symptomatic PAD patients. Both exercise modalities were equally effective, supporting their use as part of a comprehensive approach in this complex population.

Smart Anklet Use to Measure Vascular Health Benefits of Preventive Intervention in a Nature-Based Environment-A Pilot Study

The present study aimed to investigate the associations between nature-based intervention and peripheral pulse characteristics of patients with PAOD using new smart technology specifically designed for this purpose. A longitudinal panel study performed between 1 January 2022 and 31 December 2022 included 32 patients diagnosed with peripheral arterial occlusive disease (PAOD) who were treated in the vascular surgeons' hospital "Dobb" in Valjevo. These patients were exposed for six months to moderate-intensity physical activity (MPA) in a nature-based environment. They practiced 150 to 300 min of walking 6 km/h and cycling activities (16-20 km/h) weekly as recommended for patients with chronic conditions and those living with disability. Univariate logistic regression analysis was used to identify factors associated with major improvements in peripheral pulse characteristics of patients with PAOD. After six months of MPA, half of the patients (50%, 16/32) achieved minor, and half of them major improvements in peripheral pulse characteristics. The major improvements were associated with current smoking (OR = 9.53; 95%CI = 1.85-49.20), diabetes (OR = 4.84; 95%CI = 1.09-21.58) and cardiac failure, and concurrent pulmonary disease and diabetes (OR = 2.03; 95%CI = 1.01-4.11). Our pilot study showed that patients with PAOD along with other chronic conditions and risk factors benefited more from continuous physical activity in a nature-based environment.

Effect of supervised exercise training on cardiovascular function in patients with intermittent claudication: a systematic review and meta-analysis of randomized controlled trials

This study aimed to determine the effect of supervised exercise training (SET) on cardiovascular function in patients with intermittent claudication (IC). A systematic search in MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases was conducted. Primary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), rate pressure product (RPP), cardiac output (CO), peak oxygen consumption (VO2peak), and heart rate variability (HRV). Secondary outcomes were maximum walking distance (MWD) and pain-free walking distance (PFWD). Outcomes were reported as weighted mean difference (WMD) between the SET group and the control group and synthesized by using the random-effects model. Seventeen RCTs with a total of 936 patients were included in this review. SET resulted in significant improvements of SBP (WMD =  - 7.40, 95% CI - 10.69 ~  - 4.11, p < 0.001, I2 = 15.2%), DBP (WMD =  - 1.92, 95% CI - 3.82 ~  - 0.02, p = 0.048, I2 = 0.0%), HR (WMD =  - 3.38, 95% CI - 6.30 ~  - 0.46, p = 0.023, I2 = 0.0%), RPP (WMD =  - 1072.82, 95% CI - 1977.05 ~  - 168.59, p = 0.020, I2 = 42.7%), and VO2peak with plantar flexion ergometer exercise (WMD = 5.57, 95% CI 1.66 ~ 9.49, p = 0.005, I2 = 62.4%), whereas CO and HRV remained statistically unaltered. SET also improved MWD (WMD = 139.04, 95% CI 48.64 ~ 229.44, p = 0.003, I2 = 79.3%) and PFWD (WMD = 40.02, 95% CI 23.85 ~ 56.18, p < 0.001, I2 = 0.0%). In conclusion, SET is effective in improving cardiovascular function in patients with IC, which was confirmed on outcomes of cardiovascular function associated with exercise ability. The findings hold out that the standard therapy of SET can improve not only walking distance but also cardiovascular function in patients with IC.

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.

Wand Stretching Exercise Decreases Abdominal Obesity Among Adults With High Body Mass Index Without Altering Fat Oxidation

Rationale

We designed a wand-based muscle stretching (WE) exercise program, which has become increasingly popular in physical therapy and has been used for elderly patients with adhesive capsulitis. However, studies regarding the effects of WE training on abdominal obesity and measures of cardiovascular risk factors among overweight/obese adults aged ≥55 years are rare.

Purpose

The objective of this study is to evaluate the effects of a 15-week wand stretching exercise program on waist circumference and cardiovascular risk factors in sedentary adults aged 55–70 years.

Methods

A total of 124 participants were randomly assigned to either participate in wand stretching exercise (WE) over a 15-week period or a control group (n = 62 each). Sixty participants in the WE group (26 overweight and 34 obese) and 51 in the control group (29 overweight and 22 obese) completed the study. The WE program included wand-assisted muscle stretching exercise on both the upper body and lower body for 40 min per day, 5 days per week, whereas the control group maintained their sedentary lifestyle.

Results

No significant improvements were observed in plasma glucose, insulin, and the homeostatic model assessment of insulin resistance (HOMA-IR) after exercise training. Compared with the control group, the WE group had more significant reductions in waist circumference among participants with a body mass index (BMI) < 25 kg/m² (−2.6 cm, 95% CI: −4.19 to −0.97 cm, d = 0.48) and BMI > 25 kg/m² (−2.5 cm, 95% CI: −4.1 to −0.9 cm, d = 0.59) (both P < 0.01). Furthermore, within groups, a significant increase in % fat free mass was observed after WE training. The basal metabolic rate was slightly increased, but the fat oxidation rate remained unaltered in the WE group. Improvements in low-density lipoprotein cholesterol to high-density lipoprotein cholesterol were minimal after WE. Significant reductions in high-sensitivity C-reactive protein were observed after WE only for participants with a BMI <25 kg/m².

Conclusion

The results suggest redistribution of a carbon source from the abdominal region to challenged skeletal muscle, following prolonged WE training. This abdominal fat reducing outcome of the WE is unlikely to be associated with fatty acid oxidation.

Functional Improvement After Outpatient Cardiac Rehabilitation in Acute Coronary Syndrome Patients is Not Related to Improvement in Left Ventricular Ejection Fraction

INTRODUCTION

Cardiac rehabilitation (CR) improves the functional capacity and the prognosis of patients with coronary artery disease.

AIM

Our study was aimed at assessing the relationship between functional improvement (evaluated with 6-min Walk Test-6MWT) and the improvement in left ventricular ejection fraction (LVEF) after CR.

METHODS

We collected data from 249 patients (age 66.79 ± 11.06 years; males 81.52%) with a recent history of Acute Coronary Syndrome that performed CR. The functional improvement after CR was expressed as the Δ between distance covered at the final versus the initial 6-min Walking Test (6-MWT), while LVEF was calculated with transthoracic echocardiogram at the beginning and at the end of the CR.

RESULTS

Patients were divided accordingly to their pre-rehab LVEF (≥ 55% vs < 55%). With superimposable age and baseline 6MWT distance covered (434.58 vs 405.12 m, p = 0.08), the latter group presented higher Δ meter values at 6MWT (167.93 vs 193.97 m, p = 0.018). However, no statistically significant positive correlation between Δ meters and Δ LVEF was found. Moreover, linear regression analyses found that nor baseline LVEF nor Δ LVEF were significant determinants of Δ meters when considering the whole group, with age, basal 6MWT and peak CK-MB as additional covariates in the model.

CONCLUSION

Although it could be expected that an increase in LVEF is related to the functional improvement after CR, no significant correlation was found in our population.

Cardiac Autonomic Modulation Is Associated with Arterial Stiffness in Patients with Symptomatic Peripheral Artery Disease

BACKGROUND

The objective of this study was to analyze the association between cardiac autonomic modulation and arterial stiffness in patients with peripheral artery disease (PAD).

METHODS

This cross-sectional study included one hundred fourteen patients with symptomatic PAD (67.5% men; 65 ± 7 years; body mass index: 26.8 ± 4.5 kg/m²). Heart rate variability (HRV) was measured within time (standard deviation of all RR intervals [beat to beat heart interval] [SDNN], root mean square of the successive differences between adjacent normal RR intervals [RMSSD], and the proportion of successive RR intervals that differed by more than 50 msec [pNN50]) and frequency (low frequency [LF] and high frequency [HF]) domains. Arterial stiffness was assessed by carotid-femoral pulse wave velocity (cfPWV). Crude and adjusted linear regression analyses examined the relationship between HRV and cfPWV.

RESULTS

Nonsignificant crude associations were identified among cfPWV and RMSSD (P = 0.181), SDNN (P = 0.105), pNN50 (P = 0.087), LF (P = 0.376), HF (P = 0.175), and LF/HF ratio (P = 0.426). After adjustments for age, sex, smoking, body mass index, ankle-brachial index, and use of beta-blockers, significant associations were identified among cfPWV and RMSSD (P = 0.037), SDNN (P = 0.049), and pNN50 (P = 0.049).

CONCLUSIONS

Cardiac autonomic modulation was significantly associated with arterial stiffness in patients with PAD after adjustment for confounding factors. This relationship may contribute to the enhanced cardiovascular disease risk for PAD patients and provides a target for strategies to improve patient clinical outcomes.

The Impact of Supervised Exercise Training on Traditional Cardiovascular Risk Factors in Patients With Intermittent Claudication: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with intermittent claudication (IC) are at increased risk of cardiovascular (CV) morbidity and mortality. Whereas extensive evidence supports the beneficial effects of supervised exercise training (SET) on walking capacity, little is known about the effect of SET on the CV risk profile of IC patients. Therefore, the aim was to evaluate the effects of SET on CV risk factors in IC patients by using meta-analysis techniques.

METHODS

A systematic search in the electronic databases MEDLINE, EMBASE, CINAHL, and CENTRAL was conducted from the earliest date available until October 2, 2018. Randomised and non-randomised controlled trials lasting ≥ four weeks and investigating the effect of SET on CV risk factors in IC patients were included. Traditional CV risk factors were studied as primary outcomes; pain free walking distance (PFWD) and maximum walking distance (MWD) were included as secondary outcomes. Data were pooled using random effects models with summary data reported as weighted means and 95% confidence interval (CIs).

RESULTS

Fifteen trials were included, involving 18 study groups (nine walking, four resistance, two aerobic training, and three combined groups), totalling 725 patients (mean age 66.3 years; mean ankle brachial index, 0.64). Exercise reduced systolic blood pressure (-5.8 mmHg; CI -9.89 to 1.67, p < .01) whereas all other CV risk factors (i.e., body weight, body mass index, diastolic blood pressure, and blood lipids) remained statistically unaltered. Exercise also improved PFWD (+132 m; CI 70-194, p < .001) and MWD (+183 m; CI 98-268, p < .001).

CONCLUSION

This meta-analysis supports the beneficial effects of SET on walking capacity. Little evidence for an improvement of the CV risk profile was found following exercise in patients with IC. However, given the scarcity of data, high quality RCTs that include an assessment of CV risk factors are urgently required to determine the effect of exercise therapy in the secondary prevention of CV disease of IC patients.

Changes in vascular and inflammatory biomarkers after exercise rehabilitation in patients with symptomatic peripheral artery disease

OBJECTIVE

Home-based exercise is an alternative exercise mode to a structured supervised program to improve symptoms in patients with peripheral artery disease (PAD), but little is known about whether the slow-paced and less intense home program also elicits changes in vascular and inflammatory biomarkers. In an exploratory analysis from a randomized controlled trial, we compared changes in vascular and inflammatory biomarkers in patients with symptomatic PAD (typical and atypical of claudication) after home-based exercise and supervised exercise programs and in an attention-control group.

METHODS

A total of 114 patients were randomized into one of the three groups (n = 38 per group). Two groups performed exercise interventions, consisting of home-based and supervised programs of intermittent walking to mild to moderate claudication pain for 12 weeks; a third group performed light resistance training as a nonwalking attention-control group. Before and after intervention, patients were characterized on treadmill performance and endothelial effects of circulating factors present in sera by a cell culture-based bioassay on primary human arterial endothelial cells, and they were further evaluated on circulating vascular and inflammatory biomarkers.

RESULTS

Treadmill peak walking time increased (P = .008) in the two exercise groups but not in the control group (P > .05). Cultured endothelial cell apoptosis decreased after home-based exercise (P < .001) and supervised exercise (P = .007), and the change in the exercise groups combined was different from that in the control group (P = .005). For circulating biomarkers, increases were found in hydroxyl radical antioxidant capacity (P = .003) and vascular endothelial growth factor A (P = .037), and decreases were observed in E-selectin (P = .007) and blood glucose concentration (P = .012) after home-based exercise only. The changes in hydroxyl radical antioxidant capacity (P = .005), vascular endothelial growth factor A (P = .008), and E-selectin (P = .034) in the exercise groups combined were different from those in the control group.

CONCLUSIONS

This exploratory analysis found that both home-based and supervised exercise programs are efficacious to decrease cultured endothelial cell apoptosis in patients with symptomatic PAD. Furthermore, a monitored home-based exercise program elicits additional vascular benefits by improving circulating markers of endogenous antioxidant capacity, angiogenesis, endothelium-derived inflammation, and blood glucose concentration in patients with symptomatic PAD. The novel clinical significance is that important trends were found in this exploratory analysis that a contemporary home-based exercise program and a traditional supervised exercise program may favorably improve vascular and inflammatory biomarkers in addition to the well-described ambulatory improvements in symptomatic patients with PAD.

A systematic review and meta-analysis of the effects of supervised exercise therapy on modifiable cardiovascular risk factors in intermittent claudication

OBJECTIVE

Cardiovascular events, such as myocardial infarction and stroke, contribute significantly to the prognosis of patients with peripheral artery disease. Therefore cardiovascular risk reduction is a vital element of treatment in patients with intermittent claudication (IC). The cardiovascular risk is largely determined by modifiable risk factors, which can be treated with medical care and lifestyle adjustments, such as increasing physical activity. The objective of this study was to determine the effects of supervised exercise therapy (SET) on modifiable cardiovascular risk factors in IC patients.

METHODS

This is a systematic review and meta-analysis of prospective studies on the effects of SET on cardiovascular risk factors in symptomatic IC patients. Studies were eligible if they presented baseline and follow-up values for at least one of the following risk factors: blood pressure (systolic or diastolic), heart rate, lipid profile (total cholesterol, triglycerides, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol), glucose, glycated hemoglobin, body weight, body mass index, or cigarette smoking. Pooled mean differences between follow-up and baseline were analyzed using a random-effects model. Data were classified into short-term results (6 weeks-3 months) and midterm results (6-12 months). Statistical heterogeneity was presented as I² and Q statistic.

RESULTS

Twenty-seven studies with a total of 808 patients were included in this review. In the short term, SET resulted in significant improvements of systolic blood pressure (decrease of 4 mm Hg; 10 studies; 95% confidence interval [CI], -6.40 to -1.76; I², 0%) and diastolic blood pressure (decrease of 2 mm Hg; 8 studies; 95% CI, -3.64 to -0.22; I², 35%). In the midterm, SET contributed to significant lowering of levels of low-density lipoprotein cholesterol (decrease of 0.2 mmol/L; four studies; 95% CI, -0.30 to -0.12; I², 29%) and total cholesterol (decrease of 0.2 mmol/L, four studies; 95% CI, -0.38 to -0.10; I², 36%). No significant effects of SET were identified for heart rate, triglycerides, high-density lipoprotein cholesterol, glucose, glycated hemoglobin, body weight, body mass index, or cigarette smoking.

CONCLUSIONS

This systematic review and meta-analysis shows favorable effects of SET on modifiable cardiovascular risk factors, specifically blood pressure and cholesterol levels. Despite the moderate quality, small trial sample sizes, and study heterogeneity, these findings support the prescription of SET programs not only to increase walking distances but also for risk factor modification. Future studies should address the potential effectiveness of SET to promote a healthier lifestyle and to improve cardiovascular outcomes in patients with claudication.

Medical Management of Functional Impairment in Peripheral Artery Disease: A Review

Lower extremity peripheral artery disease (PAD) now affects 200 million people worldwide and is a major cause of disability. Cilostazol is the only Federal Drug Administration approved medication for PAD-related ischemic symptoms that is recommended by clinical practice guidelines. Supervised treadmill exercise significantly improves treadmill walking performance in PAD. Recent evidence shows that home-based exercise interventions that include occasional medical center visits and incorporate behavioral change techniques also significantly improve walking endurance in PAD. Upper and lower extremity ergometry (cycling) also improve walking ability in PAD. A recent decision by the Center for Medicaid and Medicare Services to cover supervised exercise for people with symptomatic PAD will increase access to exercise for the large number of people disabled by PAD.

Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial

OBJECTIVES

This study investigated the effects of walking training (WT) on cardiovascular function and autonomic regulation in patents with intermittent claudication (IC).

DESIGN

Randomized controlled trial.

METHODS

Forty-two male patients with IC (≥50years) were randomly allocated into two groups: control (CG, n=20, 30min of stretching exercises) and WT (WTG, n=22, 15 bouts of 2min of walking interpolated by 2min of upright rest-walking intensity was set at the heart rate of pain threshold). Both interventions were performed twice/week for 12 weeks. Walking capacity (maximal treadmill test), blood pressure (auscultatory), cardiac output (CO₂ rebreathing), heart rate (ECG), stroke volume, systemic vascular resistance, forearm and calf vascular resistance (plethysmography), and low (LF) and high frequency (HF) components of heart rate variability and spontaneous baroreflex sensitivity were measured at baseline and after 12 weeks of the study.

RESULTS

WT increased total walking distance (+302±85m, p=0.001) and spontaneous baroreflex sensitivity (+2.13±1.07ms/mmHg, p=0.02). Additionally, at rest, WT decreased systolic and mean blood pressures (-10±3 and -5±2mmHg, p=0.001 and p=0.01, respectively), cardiac output (-0.37±0.24l/min, p=0.03), heart rate (-4±2bpm, p=0.001), forearm vascular resistance (-8.5±2.8U, p=0.02) and LF/HF (-1.24±0.99, p=0.001). No change was observed in the CG.

CONCLUSIONS

In addition to increasing walking capacity, WT improved cardiovascular function and autonomic regulation in patients with IC.

Clinical impact of exercise in patients with peripheral arterial disease

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

Risk Modification in Patients with Peripheral Arterial Disease: A Retrospective Survey

Peripheral arterial disease (PAD) is underdiagnosed and undertreated. This is despite the high vascular morbidity and mortality rates associated with PAD. There is also evidence that quitting smoking, improving the lipid profile, lowering the blood pressure, and administering antiplatelet drugs reduce the risk of vascular events in these patients. Secondary prevention for patients with PAD is yet to meet the standard of care for those with ischemic heart disease. The authors surveyed 200 claudicants attending a vascular clinic with additional follow-up in a risk modification clinic. After a median follow-up of 28 months (range: 6-65) there was a significant (p=0.001) improvement in walking distance; 34 patients (17%) had a vascular ischemic event. Of those, 11 patients (5.5%) had worsening intermittent claudication and 9 had a stroke/transient ischemic attack; 9 events (4.5%) were fatal. The lipid targets were met in 76% the patients. Half the smokers quit smoking and 94% of the patients were taking antiplatelet drugs or anticoagulants. Blood pressure reached the accepted target in 87% of the patients. Secondary prevention in patients with PAD may reduce the risk of vascular events. Aggressive risk modification is therefore recommended.

The challenges of treating peripheral arterial disease

Today, peripheral arterial disease (PAD) patients need effective medical care for an extended period of their lifetime. Therefore, different treatment modalities have to be tied sequentially into an effective therapeutic chain. First, preventive measures have to be reinforced and risk factors tightly controlled. Furthermore, antiplatelet agents have to be applied in every PAD patient to reduce the risk of cardiac and cerebral ischemic events, restenosis or reocclusion after revascularization, and possibly also progression of the PAD itself. Angiotensin-converting enzyme (ACE) inhibitors should be entertained in high-risk groups such as PAD patients with diabetes. In the claudicant, exercise therapy should be strongly encouraged and vasoactive drugs considered for those who are not good candidates for either exercise training or revascularization. In patients with disabling claudication or critical limb ischemia, revascularization procedures are highly effective. Especially for high-grade stenoses or short arterial occlusions, percutaneous transluminal angioplasty (PTA) should be the method of fi rst choice followed by the best surgical procedure later on. To achieve good long-term effi cacy, a close follow-up including objective tests of both the arterial lesion and hemodynamic status, surveillance of secondary preventive measures and risk factor control is mandatory.

Functional status measured by walking impairment questionnaire and cardiovascular risk prediction in peripheral arterial disease: results of the Peripheral Arteriopathy and Cardiovascular Events (PACE) study

The prognostic impact of the functional status of patients with intermittent claudication is still obscure. From the lists of seven general practitioners, we identified all subjects aged 40-80 years (n = 4352). Of those reporting leg symptoms while walking on the Rose questionnaire (n = 760), 60 had a qualifying diagnosis of peripheral arterial disease (PAD). All of them received the Walking Impairment Questionnaire (WIQ). For each patient affected by PAD, three sex- and age-matched controls were selected randomly. After a 24-month follow-up, survival curves showed that PAD patients with WIQ scores > median had a higher cardiovascular risk than controls, and patients with WIQ scores < median had an even poorer prognosis (p < 0.001 for all WIQ domains). In PAD, after adjustment for age, sex, ankle-brachial index and comorbidity, two WIQ domains (ie walking speed and stairclimbing) were associated with cardiovascular events. The cardiovascular risk of claudicants who had a score > median for at least three WIQ domains was intermediate versus the risk of controls and PAD patients with a WIQ score < median, also when adjusted for the covariates indicated above (RR = 3.26, p = 0.019). In intermittent claudication, a worse functional status entails a greater risk of ischemic events versus low functional impairment.

A single bout of resistance exercise does not modify cardiovascular responses during daily activities in patients with peripheral artery disease

OBJECTIVE

To analyze the posteffects of a single bout of resistance exercise on cardiovascular parameters in patients with peripheral artery disease (PAD).

DESIGN

Randomized cross-over.

MATERIALS AND METHODS

Seventeen PAD patients performed two experimental sessions: control (C) and resistance exercise (R). Both sessions were identical (eight exercises, 3×10 repetitions), except that the R session was performed with an intensity between 5 and 7 in the OMNI-RES scale and the C session was performed without any load. Systolic blood pressure (BP), diastolic BP, heart rate, and rate-pressure product (RPP) were measured for 1 h after the interventions in the laboratory and during 24-h using ambulatory BP monitoring.

RESULTS

After the R session, systolic BP (greatest reduction: -6±2 mmHg, P<0.01) and RPP (greatest reduction: -888±286 mmHg×bpm; P<0.01) decreased until 50 min after exercise. From the second hour until 23 h after exercise, BP, heart rate, and RPP product were similar (P>0.05) between R and C sessions. BP load, nocturnal BP fall, and morning surge were also similar between R and C sessions (P>0.05).

CONCLUSION

A single bout of resistance exercise decreased BP and cardiac work for 1 h after exercise under clinical conditions, and did not modify ambulatory cardiovascular variables during 24 h in patients with PAD.

Peripheral arterial occlusive disease (PAOD)

Leg pain on exertion is the cardinal symptom of both arterial occlusive disease. Patients with PAOD complain of cramping pain in the calf, which disappears after standing still with a straight back for a few minutes. The diagnostic and therapeutic options are discussed.

Comparison between subjective and objective methods to assess functional capacity during clinical treatment in patients with intermittent claudication

Objective

To analyze if there is any relation between functional capacity assessed by subjective and objective methods regarding the current state and after clinical treatment in patients with intermittent claudication.

Methods

A total of 500 patients with intermittent claudication were enrolled. All patients underwent clinical examination and a functional evaluation by subjective (clinical visit) and objective method (treadmill test). Additionally, 50 patients were selected to evaluate the effect of clinical treatment by subjective and objective methods in relation to functional capacity.

Results

Out of 500 patients, only 60 (12.0%) had similar results in both methods. The remaining, that is 440 patients (88.0%) had subject values in disagreement with stress test findings. Regarding the clinical effect of the treatment on the functional outcomes, results were similar in both methods (χ²=1.7; p=0.427).

Conclusion

Although the subjective method overestimates the functional capacity when compared to the objective method, no significant differences were observed between both methods when analyzing the effect of clinical treatment. Thus, the subjective method provides similar information as compared with objective method, in monitoring the clinical treatment of patients with intermittent claudication.

Walking disability in patients with peripheral artery disease is associated with arterial endothelial function

OBJECTIVE

Patients with peripheral artery disease (PAD) have varying degrees of walking disability that do not completely correlate with ankle-brachial index (ABI) or angiographic anatomy. We hypothesized that endothelial function (EF) is an independent predictor of symptom severity in PAD patients.

METHODS

This was a cross-sectional study of 100 PAD patients presenting to a vascular surgery clinic. All patients received ABI testing and brachial artery flow-mediated, endothelium-dependent vasodilation (FMD) to assess arterial EF. Symptom severity and walking disability reported by Rutherford category was based on the patient's self-report during the clinic visit and recorded by the investigator-vascular surgeons. Demographic, biochemical, and physiologic parameters were entered into regression equations to determine association with symptom severity.

RESULTS

Patients were a mean age of 66 ± 8 years, and 43% had diabetes. Mean FMD was 7.4%, indicating impaired EF. EF progressively declined as Rutherford category increased (P = .01). Brachial artery FMD, ABI, systolic blood pressure, C-reactive protein, low-density lipoprotein, high-density lipoprotein, β-blocker use, and a history of diabetes or coronary artery disease were all associated with Rutherford category (all P < .05). Multivariable regression showed EF (P < .02) and ABI (P < .0001) were independently associated with walking disability. When the cohort was restricted to claudicant patients (n = 73), EF remained associated with walking disability after adjustment for other covariates (P = .0001).

CONCLUSIONS

Symptom severity in PAD is multifactorial, reflecting impaired hemodynamics and vascular dysfunction. This is the first report demonstrating that walking disability in PAD is associated with arterial EF. The mechanistic link underlying these observations remains to be defined.

Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication

BACKGROUND

Although supervised exercise therapy is considered to be of significant benefit for people with leg pain (peripheral arterial disease (PAD)), implementing supervised exercise programs (SETs) in daily practice has limitations. This is an update of a review first published in 2006.

OBJECTIVES

The main objective of this review was to provide an accurate overview of studies evaluating the effects of supervised versus non-supervised exercise therapy on maximal walking time or distance on a treadmill for people with intermittent claudication.

SEARCH METHODS

For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2012) and CENTRAL (2012, Issue 9). In addition, we handsearched the reference lists of relevant articles for additional trials. No restriction was applied to language of publication.

SELECTION CRITERIA

Randomized clinical trials comparing supervised exercise programs with non-supervised exercise programs (defined as walking advice or a structural home-based exercise program) for people with intermittent claudication. Studies with control groups, which did not receive exercise or walking advice or received usual care (maintained normal physical activity), were excluded.

DATA COLLECTION AND ANALYSIS

Two review authors (HJPF and BLWB) independently selected trials and extracted data. Three review authors (HJPF, BLWB, and GJL) assessed trial quality, and this was confirmed by two other review authors (MHP and JAWT). For all continuous outcomes, we extracted the number of participants, the mean differences, and the standard deviation. The 36-Item Short Form Health Survey (SF-36) outcomes were extracted to assess quality of life. Effect sizes were calculated as the difference in treatment normalized with the standard deviation (standardized mean difference) using a fixed-effect model.

MAIN RESULTS

A total of 14 studies involving a total of 1002 male and female participants with PAD were included in this review. Follow-up ranged from six weeks to 12 months. In general, supervised exercise regimens consisted of three exercise sessions per week. All trials used a treadmill walking test as one of the outcome measures. The overall quality of the included trials was moderate to good, although some trials were small with respect to the number of participants, ranging from 20 to 304.Supervised exercise therapy (SET) showed statistically significant improvement in maximal treadmill walking distance compared with non-supervised exercise therapy regimens, with an overall effect size of 0.69 (95% confidence interval (CI) 0.51 to 0.86) and 0.48 (95% CI 0.32 to 0.64) at three and six months, respectively. This translates to an increase in walking distance of approximately 180 meters that favored the supervised group. SET was still beneficial for maximal and pain-free walking distances at 12 months, but it did not have a significant effect on quality of life parameters.

AUTHORS' CONCLUSIONS

SET has statistically significant benefit on treadmill walking distance (maximal and pain-free) compared with non-supervised regimens. However, the clinical relevance of this has not been demonstrated definitively; additional studies are required that focus on quality of life or other disease-specific functional outcomes, such as walking behavior, patient satisfaction, costs, and long-term follow-up. Professionals in the vascular field should make SET available for all patients with intermittent claudication.

Functional pain severity and mobility in overweight older men and women with chronic low-back pain--part I

OBJECTIVE

This study determined whether mobility and functional pain were different among older men and women with chronic low-back pain and varying body mass index levels.

DESIGN

This was a comparative, descriptive study of older adults with obesity with low-back pain (N = 55; 60-85 yrs). The participants were stratified on the basis of body mass index: overweight (25-29.9 kg/m), obese (30-34.9 kg/m), and severely obese (35 kg/m). The participants completed a functional test battery (walking endurance, chair rise, stair climb, 7-day activity monitoring, and gait parameters) and pain ratings with activity ("functional pain").

RESULTS

The functional pain scores during walking and stair climb were highest in the severely obese group compared with the overweight group (P < 0.05), but the functional test scores were not found to be significantly different by body mass index. Gait base of support was 36% greater and single/double support times were 3.1%-6.1% greater in the severely obese group compared with the overweight group (P < 0.05). The women had slower chair rise and stair climb times and had slower walking velocity than did the men. Daily step numbers were lowest in the severely obese group compared with the obese and overweight groups (2971 vs. 3511 and 4421 steps per day; P < 0.05) but were not different by sex. Normalized lumbar extensor, abdominal curl, and leg press strength values were lowest in the severely obese group, and the women had 18%-34% lower strength values than did the men for all three exercises (P < 0.05). Lumbar strength was associated with stair climb, chair rise, and walking endurance times. Body mass index was an independent predictor of walking endurance time but not of steps taken per day.

CONCLUSIONS

In this study, the persons with obesity reported higher functional pain values during walking and stair climb and had lower lumbar strength compared with the overweight participants. Rehabilitation strategies that include lumbar extensor strengthening may help improve functional mobility and walking duration, both of which can help with weight management in older adults with obesity with chronic low-back pain.

A program of 3 physical therapy modalities improves peripheral arterial disease in diabetes type 2 patients: a randomized controlled trial

BACKGROUND AND OBJECTIVE

Type 2 diabetes is one of the main causes of peripheral vascular disease. The beneficial effects of exercise on glucose homeostasis include a marked stimulation of blood glucose utilization during and after its performance. The objective of this study was to determine the effects of a program of 3 physical therapy modalities on blood circulation in patients with type 2 diabetes with peripheral arterial disease.

SUBJECTS AND METHOD

A randomized controlled trial was undertaken. Sixty-eight patients with type 2 diabetes with Leriche-Fontaine stage I or IIa peripheral arterial disease were randomly assigned to an exercise or placebo group. For 20 weeks, the exercise group underwent treatment comprising 3 exercises at proximal, medium, and distal segments of the lower limbs, and the placebo group received sham treatment with disconnected ultrasound equipment. Peripheral arterial disease was determined by evaluating the ankle/brachial index (ABI), Doppler flow velocity, blood parameters, cardiovascular risk score, and heart rate during exercise test.

RESULTS

After 20 weeks of treatment, significant differences between groups were found in the following: right (P < .039) and left (P < .023) ABI; Doppler flow velocity (cm/s) in the right (P < .010) and left (P < .026) posterior tibial artery and in the right (P < .012) and left (P < .022) dorsalis pedis artery; and fibrinogen (P < .045), hemoglobin (P < .021), cholesterol (P < .012), high-density lipoprotein cholesterol (P < .031), and HbA1c (P < .034) values. There was no significant difference in low-density lipoprotein cholesterol values (P < .110) between the groups.

CONCLUSION

A program of these physical therapy modalities improves ABI, Doppler flow velocity, and blood parameters in patients with type 2 diabetes.

Exercise interventions for patients with peripheral arterial disease: a review of the literature

Peripheral arterial disease (PAD) is a common chronic cardiovascular condition that affects the lower extremities and can substantially limit daily activities and quality of life. Lifestyle interventions, including smoking cessation, diet modification, regular physical activity, and pharmacotherapy, are often prescribed to treat patients with PAD. Exercise interventions can be effective in increasing claudication onset time and maximal walking distance. Of the various types of exercise interventions available for patients with PAD, little is known about the differences that may exist between men and women in patient response to such interventions. The purpose of this literature review is to examine the current knowledge of exercise interventions for individuals with mild (Fontaine stages I-II) PAD and to consider any differences that may exist between men and women. Women with PAD present with a different clinical profile compared with men, but respond similarly to an acute bout of exercise and a training program. Patients with PAD should be encouraged to walk regularly; however, more research is needed to determine differences between men and women in their response to various exercise interventions.

Effects of a 6-month exercise program pilot study on walking economy, peak physiological characteristics, and walking performance in patients with peripheral arterial disease

The purpose of this study was to examine the effects of a 6-month exercise program on submaximal walking economy in individuals with peripheral arterial disease and intermittent claudication (PAD-IC). Participants (n = 16) were randomly allocated to either a control PAD-IC group (CPAD-IC, n = 6) which received standard medical therapy, or a treatment PAD-IC group (TPAD-IC; n = 10) which took part in a supervised exercise program. During a graded treadmill test, physiological responses, including oxygen consumption, were assessed to calculate walking economy during submaximal and maximal walking performance. Differences between groups at baseline and post-intervention were analyzed via Kruskal–Wallis tests. At baseline, CPAD-IC and TPAD-IC groups demonstrated similar walking performance and physiological responses. Postintervention, TPAD-IC patients demonstrated significantly lower oxygen consumption during the graded exercise test, and greater maximal walking performance compared to CPAD-IC. These preliminary results indicate that 6 months of regular exercise improves both submaximal walking economy and maximal walking performance, without significant changes in maximal walking economy. Enhanced walking economy may contribute to physiological efficiency, which in turn may improve walking performance as demonstrated by PAD-IC patients following regular exercise programs.

Treatment for intermittent claudication and the effects on walking distance and quality of life

The objective of the study was to provide an overview of the most common treatments for intermittent claudication and to determine the effectiveness in improving walking distance and quality of life based on a combination of direct and indirect evidence. We included trials that compared: angioplasty, surgery, exercise therapy or no treatment for intermittent claudication. Outcome measurements were walking distance (maximum, pain-free) and quality of life (physical, mental). We used a network meta-analysis model for the combination of direct and indirect evidence. We included 42 studies, presenting 3106 participants. The network meta-analysis showed that supervised exercise therapy (Δ = 1.62, P < 0.01), angioplasty (Δ = 1.89, P < 0.01) and surgery (Δ = 2.72, P = 0.02) increased walking distance significantly more than no treatment. Furthermore, supervised exercise therapy (Δ = 0.60, P < 0.01), angioplasty (Δ = 0.91, P = 0.01) and surgery (Δ = 1.07, P < 0.01) increased physical quality of life more than no treatment. However, in the sensitivity analysis, only supervised exercise therapy had additional value over no symptomatic treatment (Δ = 0.66, P < 0.01). In conclusion, this network meta-analysis indicates that supervised exercise therapy is more effective in both increasing walking distance and physical quality of life, compared with no treatment. Angioplasty and surgery also increase walking distance, compared with no treatment, but results for physical quality of life are less convincing.

Exercise Training Prevents Coronary Endothelial Dysfunction in Type 2 Diabetic Mice

Type 2 diabetes (T2D) is a leading risk factor for cardiovascular diseases including atherosclerosis and coronary heart disease. Exercise training (ET) is thought to have a beneficial effect on these disorders, but the basis for this effect is not fully understood. Because endothelial dysfunction plays a key role in the pathological events leading to cardiovascular complications in T2D, we hypothesized that the effects of ET will be evidenced by improvements in coronary endothelial function. To test this hypothesis, we assessed the effects of ET on vascular function of diabetic (db/db, Lepr(db)) mice by evaluating endothelial function of isolated coronary arterioles of wild-type (WT) and db/db mice with/without ET. Although dilation of vessels to the endothelial-independent vasodilator, sodium nitroprusside was not different between db/db and WT, dilation to the endothelial-dependent agonist, acetylcholine (ACh), was impaired in db/db compared to WT mice. Vasodilation to ACh was restored in db/db with ET and insulin sensitivity was improved in the db/db after ET. Exercise did not change body weight of db/db, but superoxide dismutase (SOD1 and SOD2) and phosphorylated- eNOS protein (Ser1177) expression in heart tissue was up-regulated whereas tumor necrosis factor-alpha (TNF-α) protein level was decreased by ET. Serum level of interleukin-6 (IL-6) was higher in db/db mice but ET decreased IL-6. This suggests that ET may improve endothelial function by increasing nitric oxide bioavailability as well as decreasing chronic inflammation. We suggest this connection may be the basis for the benefit of ET in T2D.

Relação entre aptidão física e os indicadores de qualidade de vida de indivíduos com claudicação intermitente

O objetivo deste estudo foi verificar a relação entre a aptidão física e os indicadores de qualidade de vida de indivíduos com claudicação intermitente (CI). Participaram do estudo 42 indivíduos (65,2 ± 8,3 anos) com CI, de ambos os gêneros. Para a avaliação da aptidão física, foram realizados teste de esforço em esteira, para obtenção da distância de claudicação (DC) e da distância total de marcha (DTM) e o teste de uma repetição máxima no exercício extensão de joelho. Os indicadores de qualidade de vida foram avaliados por meio do Medical Outcome Study Questionnaire Short Form 36, composto por oito domínios: capacidade funcional (CF), aspectos físicos (AF), dor, estado geral de saúde, vitalidade (VI), aspectos sociais (AS), aspectos emocionais (AE) e saúde mental. Para a análise estatística foi utilizado o coeficiente de correlação de Pearson, com p < 0,05. Foi observada correlação significante entre o domínio da CF com a DC e a DTM (r = 0,60, p < 0,01 e r = 0,49, p < 0,01, respectivamente), o domínio da AF com a DTM (r = 0,46, p < 0,01), o domínio da VI e dos AS com a DC (r = 0,34, p = 0,03 e r = 0,33, p = 0,04, respectivamente) e o domínio da AE com a DC e a DTM (r = 0,43, p = 0,01 e r = 0,44, p = 0,01, respectivamente). Como conclusão, os resultados deste estudo sugerem que os indicadores da qualidade de vida nos domínios da saúde física e da saúde emocional são relacionados com a capacidade de caminhada de indivíduos com CI

Quality of Life and Functional Status After Revascularization or Conservative Treatment in Patients With Intermittent Claudication

Revascularization of patients with intermittent claudication (IC) is recommended only for selected patients who have chronic pain or disabling disease. However, improvement in the quality of life (QoL) could justify more widespread use.

Objectives: To determine the effect of conservative treatment and revascularization on the QoL and physical performance of selected patients with IC.

Patients and Methods: This nonrandomized, parallel group, follow-up study included 83 patients with IC at Fontaine stage II. On the basis of interventional opportunities and the risks and benefits, combined with the preference of the patient, 47 patients were treated conservatively and 41 were revascularized. The patients were examined at inclusion and 3 months later. The evaluations included the QoL measure Short Form 36 (SF-36), the Walking Impairment Questionnaire (WIQ), pain-free and maximal walking distance (treadmill at 3 km/h, no incline), maximal isometric knee-extension strength and endurance, and ankle—brachial blood pressure index (ABI).

Results: At baseline, the SF-36 and WIQ scores and the ABI were significantly lower in the patients selected for revascularization. After revascularization, all dimensions of QoL and functional status increased significantly in the patients who underwent revascularisation compared with the patients treated conservatively. The difference in the change in the physical component summary of SF-36 was 29.4% (P < .001), in the total WIQ 63.6% (P = .0002), and in the pain-free and maximal walking distances 313% (P < .001) and 135% (P < .001), respectively. After adjustment for age, smoking, ABI, body mass index (BMI), and baseline values, the differences remained statistically significant.

Conclusion: Revascularization above the knee increased QoL, functional status, and walking distance significantly in patients with moderate IC.

Initial Results of a 12-week, Institution-based, Supervised Exercise Rehabilitation Program for the Management of Peripheral Arterial Disease

This study assessed the effectiveness of a 12-week, institution-based, supervised exercise rehabilitation program with atherogenic risk factor modification in improving cardiovascular profile, ambulatory function, and quality of life of patients with peripheral arterial disease (PAD) by comparing pre- and postprogram measurements. Participants were prospectively enrolled. Cardiovascular profile variables, ambulatory function tests, and quality of life questionnaires were evaluated. Of 101 institution-based program participants, 69 completed the 12-session minimum and 47 completed a postprogram evaluation. Mean postprogram results were significantly different from preprogram results, corresponding to improvement, for the following variables: triglyceride levels ( p = .036), both function tests ( p < .001 for both), four of five Walking Impairment Questionnaire measurements, and Intermittent Claudication Questionnaire score ( p = .001). This supervised exercise program improved the cardiovascular profiles, ambulatory function, and quality of life of PAD patients completing the program and is a viable adjunct to drug therapy and surgical intervention.

[Efficacy of a massage and exercise programme on the ankle-brachial index and blood pressure in patients with diabetes mellitus type 2 and peripheral arterial disease: a randomized clinical trial]

BACKGROUND AND OBJECTIVE

Type 2 diabetes mellitus is a highly prevalent disease that can favour the development of peripheral arterial disease. The objective of this study was to analyse the efficacy of a massage and exercise programme on the ankle-brachial index and arterial pressure of patients with diabetes mellitus type 2 and peripheral arterial disease.

MATERIAL AND METHODS

An experimental study with placebo control group was performed. Sixty-six type 2 diabetes patients with Leriche-Fontaine stage II peripheral arterial disease were randomly assigned to an intervention (exercise and massage) or placebo control (simulated magnetotherapy) group. Study variables were arterial pressure and ankle-brachial index.

RESULTS

After 10 weeks of treatment, significant (P<0.05) differences between the intervention and placebo groups were found in right and left ankle-brachial index values and in systolic and diastolic pressures in right and left lower extremities.

CONCLUSIONS

A combined programme of exercise and massage improves arterial blood pressure and ankle brachial index values in type 2 diabetics with peripheral arterial disease.

Effective training for patients with intermittent claudication

OBJECTIVE

Current guidelines for treatment of intermittent claudication (IC) do not include a specific recommendation for the intensity of exercise therapy. Thus, the purpose of this study was to determine the relative effectiveness of high versus low intensity exercise for patients with IC, and further to study the effect of such training on blood flow to the legs during exercise.

DESIGN

The effect of eight weeks of supervised endurance training was examined in 16 patients with IC. The patients were randomly assigned to training at intensities corresponding to either 60% or 80% of their peak oxygen consumption (VO2peak), respectively.

RESULTS

VO2peak and time to exhaustion increased significantly (9% and 16%, respectively) more in the high intensity group (p<0.05). Blood flow to the legs did not change after training in any of the groups.

CONCLUSION

High intensity training gave larger improvements in VO2peak and time to exhaustion than low intensity training. As blood flow did not change after the exercise program, it is likely that the observed different increase of VO2peak was due to changed mitochondrial oxidative capacity and/or skeletal muscle diffusive capacity.

Changes in pain-free walking based on time in accommodating pain-free exercise therapy for peripheral arterial disease

Symptoms of intermittent claudication (IC) can be relieved by lifestyle modification, medications, and walking exercises. The intensity of the walking exercise is still debatable. The goal of this study was to determine the effects of accommodating pain-free walking exercise therapy program length on pain-free walking. A descriptive, longitudinal study with repeated measures of exercise capacity was conducted. An IC questionnaire was administered to assess IC signs, symptoms, and lifestyle. Walking was performed on a treadmill for 30 to 50 minutes below the participant's individualized walking pain threshold. The study included patients diagnosed with IC due to peripheral arterial disease. All participants were randomly assigned to three groups. Group A (n = 28) participated in the walking program for 2-9 weeks, group B (n = 30) for 10-14 weeks, and group C (n = 26) for 15-94 weeks. The main outcome measure of the study was to determine changes in exercise capacity: walking distance (miles), walking duration (minutes), and walking speed (mph). Group A increased the amount of distance, duration, and speed walked from pretest to posttest by 80% (P < .001), 27% (P < .001), and 37% (P < .001), respectively. Group B increased the amount of distance, duration, and speed walked from pretest to posttest by 122% (P < .001), 56% (P < .001), and 43% (P < .001), respectively. Group C increased the amount of distance, duration, and speed walked from pretest to posttest by 26% (P = .002), 22% (P = .002), and 5% (P = .541) respectively. We reached the conclusion that a walking program of 10-14 weeks is optimal for achieving the best improvements in walking distance, duration, and speed.

The use of osteopathic manipulative treatment as adjuvant therapy in patients with peripheral arterial disease

Peripheral arterial disease (PAD) is a manifestation of systemic atherosclerosis associated with impaired endothelial function and intermittent claudication is the hallmark symptom. Hypothesizing that osteopathic manipulative treatment (OMT) may represent a non-pharmacological therapeutic option in PAD, we examined endothelial function and lifestyle modifications in 15 intermittent claudication patients receiving osteopathic treatment (OMT group) and 15 intermittent claudication patients matched for age, sex and medical treatment (control group). Compared to the control group, the OMT group had a significant increase in brachial flow-mediated vasodilation, ankle/brachial pressure index, treadmill testing and physical health component of life quality (all p<0.05) from the beginning to the end of the study. At univariate analysis in the OMT group there was a negative correlation between changes in brachial flow-mediated vasodilation and IL-6 levels (r=-0.30; p=0.04) and a positive one between claudication pain time and physical function score (r=0.50; p=0.05). In conclusion, despite the relatively few patients in our study, these results suggest that OMT significantly improves endothelial function and functional performance in intermittent claudication patients along with benefits in quality of life. This novel treatment combined with drug and lifestyle modification might be an effective alternative to traditional training based on exercise.

Benefits of low-intensity pain-free treadmill exercise on functional capacity of individuals presenting with intermittent claudication due to peripheral arterial disease

Patients with intermittent claudication due to peripheral arterial disease (PAD) experience muscle aching during walking secondary to ischemia. The purpose of this study was to examine the effects of low-intensity pain-free exercise (LIPFE) on functional capacity of individuals with PAD. A total of 12 participants with PAD underwent training on treadmill for 6 weeks, twice a week, for about 45 minutes. Outcome measures included walking distance (WDI), walking duration (WDU), mean walking rate (WR), estimated oxygen consumption (EVO(2)), metabolic equivalent (MET), estimated total energy expenditure (ETEE), and estimated rate of energy expenditure (EREE). Mean improvement of WDI, WDU, and MWR were 104% (an addition of 1.0 km), 55% (an addition of 13.3 minutes), and 41% (0.9 km/h faster), respectively. Mean improvement of EVO(2), MET, ETEE, and EREE, were 20%, 20%, 80%, and 20%, respectively. In conclusion, it appears that LIPFE training is an effective intervention for individuals presenting with PAD.

Estudo comparativo da evolução e sobrevida de pacientes com claudicação intermitente, com ou sem limitação para exercícios, acompanhados em ambulatório específico

CONTEXTO: Os fatores de risco para doença aterosclerótica, que influenciam na evolução natural dessa doença, estão bem estabelecidos, assim como o benefício do programa de exercícios para pacientes claudicantes. Entretanto, faltam informações sobre a relação entres limitações clínicas e fatores de risco, com desempenho do programa de caminhadas e suas implicações na evolução e mortalidade destes pacientes. OBJETIVO: Comparar, ao longo do tempo, a distância de claudicação e sobrevida de pacientes claudicantes em ambulatório específico, com ou sem limitação para exercícios. MÉTODOS: Foi feito um estudo tipo coorte retrospectivo de 185 pacientes e 469 retornos correspondentes, no período de 1999 a 2005, avaliando-se dados demográficos, distância média de claudicação (CI) e óbito. Os dados foram analisados nos programas Epi Info, versão 3.2, e SAS, versão 8.2. RESULTADOS: A idade média foi de 60,9±11,1 anos, sendo 61,1% do sexo masculino e 38,9% do sexo feminino. Oitenta e sete por cento eram brancos, e 13%, não-brancos. Os fatores de risco associados foram: hipertensão (69,7%), tabagismo (44,3%), dislipidemia (32,4%) e diabetes (28,6%). Nos claudicantes para menos de 500 m, a CI inicial em esteira foi de 154,0±107,6 m, e a CI final, de 199,8±120,5 m. Cerca de 45% dos pacientes tinham alguma limitação clínica para realizar o programa de exercícios preconizado, como: angina (26,0%), acidente vascular cerebral (4,3%), artropatia (3,8%), amputação menor ou maior com prótese (2,1%) ou doença pulmonar obstrutiva crônica (1,6%). Cerca de 11,4% dos pacientes tinham infarto do miocárdio prévio, e 5,4% deles usavam cardiotônico. O tempo de seguimento médio foi de 16,0±14,4 meses. A distância média de CI referida pelos pacientes aumentou 100% (de 418,47 m para 817,74 m) ao longo de 2 anos, nos grupos não-limitante (p < 0,001) e não-tabagista (p < 0,001). A sobrevida dos claudicantes foi significativamente menor no grupo com limitação. A análise de regressão logística mostrou que a limitação para realização de exercícios, isoladamente, influenciou significativamente na mortalidade (p < 0,001). CONCLUSÃO: A realização correta e regular dos exercícios e o abandono do fumo melhoram a distância de claudicação, além de reduzir a mortalidade nesses casos, seja por meio de efeitos positivos próprios do exercício, seja por meio de controle dos fatores de risco e de seus efeitos adversos.

Effects of Supervised Treadmill Walking Training on Calf Muscle Capillarization in Patients with Intermittent Claudication

The aim of this study was to evaluate the effects of supervised treadmill walking training on the calf muscle capillarization in patients with intermittent claudication. The first 12-week period was a nonexercise, within-subject control stage, and the second 12-week period was an exercise training stage. Calf muscle biopsy and functional capacity measurement were performed at baseline, preexercise and postexercise training. In all, 11 subjects completed all procedures. Their average age was (mean ± standard deviation) 73.9 ± 5.5 years and resting ankle-to-brachial systolic blood presure index was 0.57 ± 0.11. After exercise training, the difference between the pretraining and posttraining capillaries in contact with type IIx and IIa muscle fibers for each subject was significantly correlated with an improved pain-free walking time, r = 0.69 and r = 0.62 (both P < .05), respectively. This finding suggests that the change in calf muscle capillarization might contribute to the improved walking capacity following supervised treadmill walking training in patients with intermittent claudication.