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Kumaran B, Targett D, Watson T. Benefits of home-based foot neuromuscular electrical stimulation on self-reported function, leg pain and other leg symptoms among community-dwelling older adults: a sham-controlled randomised clinical trial. BMC Geriatr 2024; 24:683. [PMID: 39143586 PMCID: PMC11323382 DOI: 10.1186/s12877-024-05271-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/01/2024] [Indexed: 08/16/2024] Open
Abstract
INTRODUCTION Lower leg pain and symptoms, and poor leg circulation are common in older adults. These can significantly affect their function and quality of life. Neuromuscular electrical stimulation (NMES) applied via the feet as 'foot NMES' activates the leg musculovenous pump. This study investigated the effects of foot NMES administered at home using Revitive® among community-dwelling older adults with lower leg pain and/or other lower leg symptoms such as cramps, or sensations of tired, aching, and heavy feeling legs. METHODS A randomised placebo-controlled study with three groups (2 NMES, 1 Sham) and three assessments (baseline, week 8, week 12 follow-up) was carried out. Self-reported function using Canadian occupational performance measure (COPM), leg pain, overall leg symptoms score (heaviness, tiredness, aching, or cramps), and ankle blood flow were assessed. Analysis of covariance (ANCOVA) and logistic regression were used to compare the groups. Statistical significance was set at p < 0.05 (two-sided 5%). RESULTS Out of 129 participants enrolled, 114 completed the study. The improvement in all outcomes were statistically significant for the NMES interventions compared to Sham at both week 8 (p < 0.01) and week 12 (p < 0.05). The improvement in COPM met the minimal clinically important difference (MCID) for the NMES interventions compared to Sham at both week 8 (p < 0.005) and week 12 (p < 0.05). Improvement in leg pain met MCID at week 8 compared to Sham (p < 0.05). Ankle blood flow increased approximately 3-fold during treatment compared to Sham. Compliance with the interventions was high and no device-related adverse events were reported. CONCLUSIONS The home-based foot NMES is safe, and significantly improved self-reported function, leg pain and overall leg symptoms, and increased ankle blood flow compared to a Sham among older adults. TRIAL REGISTRATION The trial was prospectively registered in ISRCTN on 17/06/2019 with registration number ISRCTN10576209. It can be accessed at https://www.isrctn.com/ISRCTN10576209 .
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Affiliation(s)
- Binoy Kumaran
- School of Health and Social Work, University of Hertfordshire, Hatfield, AL10 9AB, UK.
| | | | - Tim Watson
- School of Health and Social Work, University of Hertfordshire, Hatfield, AL10 9AB, UK
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Heider D, Rezvani F, Matschinger H, Dirmaier J, Härter M, Herbarth L, Steinisch P, Böbinger H, Schuhmann F, Krack G, Korth T, Thomsen L, Chase DP, Schreiber R, Alscher MD, Finger B, König HH. The effect of telephone health coaching and remote exercise monitoring for peripheral artery disease (TeGeCoach) on health care cost and utilization: results of a randomized controlled trial. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:615-629. [PMID: 37428355 PMCID: PMC11136827 DOI: 10.1007/s10198-023-01616-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 06/26/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) is the third most prevalent atherosclerotic cardiovascular disease. In 2016, costs per patient associated with PAD exceeded even the health-economic burden of coronary heart disease. Although affecting over 200 million people worldwide, a clear consensus on the most beneficial components to be included in home-based exercise programs for patients with peripheral artery disease is lacking. The aim of the study was to examine the health care use and costs caused by the 12-month patient-centered 'Telephone Health Coaching and Remote Exercise Monitoring for Peripheral Artery Disease' (TeGeCoach) program in a randomized controlled trial. METHODS This is a two-arm, parallel-group, open-label, pragmatic, randomized, controlled clinical trial (TeGeCoach) at three German statutory health insurance funds with follow-up assessments after 12 and 24-months. Study outcomes were medication use (daily defined doses), days in hospital, sick pay days and health care costs, from the health insurers' perspective. Claims data from the participating health insurers were used for analyses. The main analytic approach was an intention-to-treat (ITT) analysis. Other approaches (modified ITT, per protocol, and as treated) were executed additionally as sensitivity analysis. Random-effects regression models were calculated to determine difference-in-difference (DD) estimators for the first- and the second year of follow-up. Additionally, existing differences at baseline between both groups were treated with entropy balancing to check for the stability of the calculated estimators. RESULTS One thousand six hundred eighty-five patients (Intervention group (IG) = 806; Control group (CG) = 879) were finally included in ITT analyses. The analyses showed non-significant effects of the intervention on savings (first year: - 352€; second year: - 215€). Sensitivity analyses confirmed primary results and showed even larger savings. CONCLUSION Based on health insurance claims data, a significant reduction due to the home-based TeGeCoach program could not be found for health care use and costs in patients with PAD. Nevertheless, in all sensitivity analysis a tendency became apparent for a non-significant cost reducing effect. TRIAL REGISTRATION NCT03496948 (www. CLINICALTRIALS gov), initial release on 23 March 2018.
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Affiliation(s)
- Dirk Heider
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Farhad Rezvani
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Herbert Matschinger
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lutz Herbarth
- KKH Kaufmännische Krankenkasse Statutory Health Insurance, Hannover, Germany
| | - Patrick Steinisch
- KKH Kaufmännische Krankenkasse Statutory Health Insurance, Hannover, Germany
| | - Hannes Böbinger
- TK Techniker Krankenkasse Statutory Health Insurance, Hamburg, Germany
| | | | - Gundula Krack
- mhplus Krankenkasse Statutory Health Insurance, Ludwigsburg, Germany
| | | | | | | | | | - Mark-Dominik Alscher
- Robert Bosch Gesellschaft Für Medizinische Forschung mbH, Bosch-Institute of Clinical Pharmacology, Dr. Margarete Fischer, Stuttgart, Germany
| | - Benjamin Finger
- Robert Bosch Gesellschaft Für Medizinische Forschung mbH, Bosch-Institute of Clinical Pharmacology, Dr. Margarete Fischer, Stuttgart, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. Eur Heart J 2024; 45:1303-1321. [PMID: 38461405 DOI: 10.1093/eurheartj/ehad734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/11/2024] Open
Abstract
All guidelines worldwide strongly recommend exercise as a pillar of the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended for clinicians to promote and assist for the set-up of comprehensive exercise programmes to best advice in patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are narratively described based on the current best evidence. The document ends by highlighting disparities in access to supervised exercise programmes across Europe and the series of gaps for evidence requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Center, Helsinki University Hospital, Helsinki, Finland
- University of Helsinki, Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery-Angiology-Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Center of Cardiology, Department of Cardiology III-Angiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Ch. de Mont-Paisible 18, Lausanne 1011, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, Rennes, France
- INSERM CIC 1414, Université de Rennes, Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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Mazzolai L, Belch J, Venermo M, Aboyans V, Brodmann M, Bura-Rivière A, Debus S, Espinola-Klein C, Harwood AE, Hawley JA, Lanzi S, Madarič J, Mahé G, Malatesta D, Schlager O, Schmidt-Trucksäss A, Seenan C, Sillesen H, Tew GA, Visonà A. Exercise therapy for chronic symptomatic peripheral artery disease. VASA 2024; 53:87-108. [PMID: 38461401 DOI: 10.1024/0301-1526/a001112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2024]
Abstract
All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.
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Affiliation(s)
- Lucia Mazzolai
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Jill Belch
- Institute of Cardiovascular Research, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Maarit Venermo
- Department of Vascular Surgery, Abdominal Centre, Helsinki University Hospital, Finland
- University of Helsinki, Finland
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, France
- EpiMaCT, INSERM 1094/IRD270, Limoges University, Limoges, France
| | - Marianne Brodmann
- Division of Angiology, Department of Internal Medicine, Medical University, Graz, Austria
| | | | - Sebastien Debus
- Department of Vascular Medicine, Vascular Surgery - Angiology - Endovascular Therapy, University of Hamburg-Eppendorf, Hamburg, Germany
| | - Christine Espinola-Klein
- Centre of Cardiology, Department of Cardiology III-Angiology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Amy E Harwood
- Department for Sport and Exercise Sciences, Manchester Metropolitan University, Manchester, UK
| | - John A Hawley
- Exercise and Nutrition Research Programme, Mary MacKillop Institute for Health Research, Australian Catholic University, Melbourne, VIC, Australia
| | - Stefano Lanzi
- Angiology Department, Lausanne University Hospital, University of Lausanne, Switzerland
| | - Juraj Madarič
- Department of Angiology, Comenius University, Bratislava, Slovakia
- National Institute of Cardiovascular Diseases, Bratislava, Slovakia
| | - Guillaume Mahé
- Vascular Medicine Unit, Centre Hospitalier Universitaire de Rennes, France
- INSERM CIC 1414, Université de Rennes, France
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Switzerland
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria
| | - Arno Schmidt-Trucksäss
- Division of Sport and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Switzerland
| | - Chris Seenan
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Garry A Tew
- Institute for Health and Care Improvement, York St John University, York, UK
| | - Adriana Visonà
- Angiology Unit, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
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Manfredini F, Traina L, Ficarra V, Gandolfi G, Argentoni A, Straudi S, Gasbarro V, Lamberti N. A "test in-train out" program versus a "go home and walk" intervention for home-based exercise therapy in patients with peripheral artery disease: A randomized controlled trial. Scand J Med Sci Sports 2024; 34:e14584. [PMID: 38349067 DOI: 10.1111/sms.14584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 01/28/2024] [Accepted: 01/29/2024] [Indexed: 02/15/2024]
Abstract
OBJECTIVE In this single-blinded randomized controlled trial, we compared the "Test in-Train Out" structured home-based exercise program (TiTo-SHB) with the traditional "go home and walk" exercise intervention in people with peripheral artery disease (PAD). METHODS Peripheral artery disease patients at Leriche-Fontaine's stage II were randomized to receive TiTo-SHB or walking advice (C-WA). The TiTo-SHB group performed two daily 8-min sessions of pain-free interval walking at progressive low-to-moderate speed maintained with a metronome. The C-WA group was recommended to walk for 30 min at least three times per week and to endure claudication pain. Outcomes collected at baseline and at the end of the program (6 months) included: 6-min and pain-free walking distance (6MWD, PFWD), ankle-brachial index (ABI), 5-time sit-to-stand test (5STS), and health-related quality of life (HRQoL) by the VascuQoL-6 questionnaire. RESULTS A total of 68 patients were randomized (males n = 50; aged 73 ± 9; TiTo-SHB n = 34). At the end of the program, patients in the TiTo-SHB group compared with the C-WA group had significantly improved 6MWD (Δ + 60 ± 32 m vs. Δ - 5 ± 37 m; p < 0.001) and PFWD (Δ + 140 ± 92 m vs. Δ - 7 ± 87 m; p < 0.001). A significant between-group difference in favor of the TiTo-SHB group was also recorded for all the secondary outcomes, including 5STS (Δ - 2.6 ± 1.8 s vs. Δ + 0.8 ± 2.6 s; p < 0.001), ABI of the more impaired limb (Δ + 0.10 ± 0.11 vs. Δ + 0.02 ± 0.08; p = 0.003), and VascuQoL-6 score (Δ +2 ± 2 vs. -1 ± 4; p < 0.001). CONCLUSION In PAD patients with claudication, the pain-free in-home TiTo-SHB program was more effective in improving exercise capacity and HRQoL than the traditional walking advice recommendation.
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Affiliation(s)
- Fabio Manfredini
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Program of Vascular Rehabilitation and Exercise Medicine, University Hospital of Ferrara, Ferrara, Italy
| | - Luca Traina
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Valentina Ficarra
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Giorgio Gandolfi
- School of Sports and Exercise Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Argentoni
- School of Sports and Exercise Medicine, University of Ferrara, Ferrara, Italy
| | - Sofia Straudi
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - Vincenzo Gasbarro
- Unit of Vascular and Endovascular Surgery, University Hospital of Ferrara, Ferrara, Italy
| | - Nicola Lamberti
- Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
- Program of Vascular Rehabilitation and Exercise Medicine, University Hospital of Ferrara, Ferrara, Italy
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Ingwersen M, Kunstmann I, Oswald C, Best N, Weisser B, Teichgräber U. Exercise Training for Patients With Peripheral Arterial Occlusive Disease. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:879-885. [PMID: 38019155 PMCID: PMC10859744 DOI: 10.3238/arztebl.m2023.0231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND One-third of all persons with peripheral arterial occlusive disease (PAOD) suffer from intermittent claudication. Exercise training under appropriate supervision is recommended in the pertinent guidelines, but physicians order it too rarely, and so-called vascular exercise groups are not available everywhere. This situation needs improvement in view of the impor - tance of walking ability and cardiorespiratory fitness for patients' quality of life and long-term disease outcome. METHODS We review the scientific evidence on exercise training and on ways to lower barriers to the ordering of exercise training and to patient participation, on the basis of pertinent articles retrieved by a search of PubMed and in specialized sports science journals. RESULTS 10 meta-analyses, 12 randomized controlled trials (RCTs), and 7 cohort studies were considered for this review. Largescale cohort studies have shown that exercise is associated with a lower risk of death (relative risk 0.65-0.78 after 12 months of exercise training, compared to an inactive lifestyle). Exercise training also improves the maximal walking distance by a mean of 136 m (training at home) or 180-310 m (supervised training). An additional improvement by a mean of 282 m can be expected from a combination of exercise training and endovascular revascularization. Further behavior-modifying interventions, such as goal-setting, planning, and feedback, increase both the maximum walking distance and the weekly duration of exercise. CONCLUSION Exercise improves walking ability and lowers mortality. To attract patients with intermittent claudication to exercise training, a broad assortment of analog, digital and telemetric tools and a dense network of vascular exercise groups should be made available, along with regular contact between physicians and patients.
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Affiliation(s)
- Maja Ingwersen
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Jena, Germany
| | - Ina Kunstmann
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Jena, Germany
| | - Carolin Oswald
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Jena, Germany
| | - Norman Best
- Institute of Physical and Rehabilitation Medicine, Sophien and Hufeland Hospital Weimar, Academic Teaching Hospital, University of Jena, Jena, Germany
| | - Burkhard Weisser
- Institute of Sports Science, Department of Sports Medicine, Kiel University, Kiel, Germany
| | - Ulf Teichgräber
- Institute of Diagnostic and Interventional Radiology, Jena University Hospital, Jena, Germany
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Rotundu A, Oancea A, Maștaleru A, Costache AD, Cumpăt CM, Abdulan IM, Alexa AI, Chirica C, Russu M, Leon MM. Benefits of Integrating Technology into Home Exercise Therapy in Patients with Lower Extremity Peripheral Artery Disease. J Clin Med 2023; 12:7635. [PMID: 38137704 PMCID: PMC10744306 DOI: 10.3390/jcm12247635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/06/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
(1) Background: Telerehabilitation is an approach that uses digital technology to provide remote medical recovery services. It can be an option for cardiovascular recovery at home in patients with peripheral arterial disease (PAD) of the lower limbs. (2) Methods: We performed literature research through two databases: PubMed and Embase. We included randomized controlled trials and cohort studies that evaluated the effectiveness of a technology-assisted home exercise intervention compared with conventional rehabilitation or the usual care in patients with PAD. We analyzed population, intervention, and outcome data. (3) Results: We identified 2468 studies. After rigorous screening, we included 25 articles in the review. The following results were evaluated: dissemination and acceptance of digital technologies among these people, functional capacity, exercise intensity, patient motivation, sex-specific response differences in mortality and clinical outcomes, quality of life assessment, and changes in values of inflammatory biomarkers. All of these were correlated with the type of intervention and the dose of the exercise. (4) Conclusions: Home-based exercise therapy supervised with the help of specific devices could be successfully implemented in the therapeutic management of the PAD population. Health specialists should take into account the clinical-paraclinical profile and the emotional status of the patients. Such individualized interventions could bring significant benefits for the people with this disease and for the healthcare system, including increasing exercise adherence, engagement, self-care capacity, life expectancy, and quality of life for these patients, as well as reducing their symptoms, cardiovascular complications, and hospitalizations.
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Affiliation(s)
- Andreea Rotundu
- Doctoral School, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Str., 700115 Iasi, Romania; (A.R.); (C.C.); (M.R.)
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-D.C.); (I.M.A.); (M.M.L.)
| | - Andra Oancea
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-D.C.); (I.M.A.); (M.M.L.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania;
| | - Alexandra Maștaleru
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-D.C.); (I.M.A.); (M.M.L.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania;
| | - Alexandru-Dan Costache
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-D.C.); (I.M.A.); (M.M.L.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania;
| | - Carmen Marinela Cumpăt
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania;
- Department of Medical Specialties III, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Irina Mihaela Abdulan
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-D.C.); (I.M.A.); (M.M.L.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania;
| | - Anisia Iuliana Alexa
- Department of Surgery II, Discipline of Ophthalmology, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Costin Chirica
- Doctoral School, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Str., 700115 Iasi, Romania; (A.R.); (C.C.); (M.R.)
| | - Mara Russu
- Doctoral School, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universității Str., 700115 Iasi, Romania; (A.R.); (C.C.); (M.R.)
| | - Maria Magdalena Leon
- Department of Medical Specialties I, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.-D.C.); (I.M.A.); (M.M.L.)
- Clinical Rehabilitation Hospital, 700661 Iasi, Romania;
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Gardner AW, Montgomery PS, Wang M, Liang M. Effects of Long-Term Home Exercise in Participants With Peripheral Artery Disease. J Am Heart Assoc 2023; 12:e029755. [PMID: 37929770 PMCID: PMC10727372 DOI: 10.1161/jaha.122.029755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023]
Abstract
Background This randomized controlled trial compared long-term changes in peak walking time (PWT) and exercise time-to-minimum calf muscle oxygen saturation (StO2) in symptomatic participants with peripheral artery disease following a long-term home exercise program (HEP), a short-term supervised exercise therapy (SET) program that transitioned to a long-term HEP (SET/HEP), and a control intervention. Methods and Results For the first 3 months, HEP and SET/HEP groups performed intermittent walking to mild-to-moderate claudication pain, whereas the control group performed light resistance training. For the subsequent 15 months, the HEP group continued their exercise program, the SET/HEP group transitioned from SET to the HEP program, and the control group transitioned to only receive walking advice. PWT increased significantly from baseline to month 18 in the HEP group (408±279 meters to 814±393 meters, P<0.001) and in the SET/HEP group (457±288 meters to 818±313 meters, P<0.001). Exercise time-to-minimum calf muscle StO2 increased significantly from baseline to month 18 in the HEP group (238±241 seconds to 497±485 seconds, P<0.05) and in the SET/HEP group (296±289 seconds to 620±450 seconds, P<0.001). These changes in PWT and exercise time-to-minimum calf muscle StO2 were greater than in the control group (P<0.001 and P<0.01, respectively). Additionally, the change in exercise time-to-minimum calf muscle StO2 was correlated with the change in PWT in both exercise groups combined (r=0.601, P=0.0015). Conclusions Long-term HEP and SET/HEP were efficacious in improving PWT and exercise time-to-minimum calf muscle StO2 in symptomatic participants with peripheral artery disease, and these changes were correlated with each other. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00618670.
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Affiliation(s)
| | | | - Ming Wang
- Department of Population and Quantitative Health Sciences, School of MedicineCase Western Reserve UniversityClevelandOHUSA
| | - Menglu Liang
- Department of Epidemiology and Biostatistics, School of Public HealthUniversity of MarylandCollege ParkMDUSA
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10
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Shen R, Mulder H, Wruck L, Weissler EH, Robertson HR, Sharlow AG, Kripalani S, Muñoz D, Effron MB, Gupta K, Girotra S, Whittle J, Benziger CP, VanWormer JJ, Polonsky TS, Rothman RL, Harrington RA, Hernandez AF, Jones WS. Internet Versus Noninternet Participation in a Decentralized Clinical Trial: Lessons From the ADAPTABLE Study. J Am Heart Assoc 2023; 12:e027899. [PMID: 37345815 PMCID: PMC10356087 DOI: 10.1161/jaha.122.027899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 05/23/2023] [Indexed: 06/23/2023]
Abstract
Background Internet-based participation has the potential to enhance pragmatic and decentralized trials, where representative study populations and generalizability to clinical practice are key. We aimed to study the differences between internet and noninternet/telephone participants in a large remote, pragmatic trial. Methods and Results In a subanalysis of the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) study, we compared internet participants with those who opted for noninternet participation. Study process measures examined included participant characteristics at consent, study medication adherence, and study retention. The clinical outcome examined was a composite of all-cause mortality, hospitalization for myocardial infarction, or hospitalization for stroke. Noninternet participants were older (mean 69.4 versus 67.4 years), more likely to be female (38.9% versus 30.2%), more likely to be Black (27.3% versus 6.0%) or Hispanic (11.1% versus 2.0%), and had a higher number of comorbid conditions. The composite clinical outcome was more than twice as high in noninternet participants. The hazard of nonadherence to the assigned aspirin dosage was 46% higher in noninternet participants than internet participants. Conclusions Noninternet participants differed from internet participants in notable demographic characteristics while having poorer baseline health. Over the course of ADAPTABLE, they also had worse clinical outcomes and greater likelihood of study drug nonadherence. These results suggest that trials focused on internet participation select for younger, healthier participants with a higher proportion of traditionally overrepresented patients. Allowing noninternet participation enhances diversity; however, additional steps may be needed to promote study retention and study medication adherence. Registration Information clinicaltrials.gov. Identifier: NCT02697916.
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Affiliation(s)
| | | | - Lisa Wruck
- Duke Clinical Research InstituteDurhamNCUSA
| | - E. Hope Weissler
- Division of Vascular and Endovascular SurgeryDuke University School of MedicineDurhamNCUSA
| | | | | | | | - Daniel Muñoz
- Vanderbilt University Medical CenterNashvilleTNUSA
| | - Mark B. Effron
- University of Queensland‐Ochsner Clinical SchoolNew OrleansLAUSA
| | - Kamal Gupta
- University of Kansas Medical CenterKansas CityKAUSA
| | | | | | | | | | | | | | | | | | - W. Schuyler Jones
- Duke Clinical Research InstituteDurhamNCUSA
- Division of CardiologyDuke University Health SystemDurhamNCUSA
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11
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Mays RJ, Kahnke R, Schorr EN, Treat-Jacobson D. Relation of non-exercise walking activity with exercise performance in patients with peripheral artery disease: NEW activity for PAD. JOURNAL OF VASCULAR NURSING 2023; 41:1-5. [PMID: 36898798 PMCID: PMC10009898 DOI: 10.1016/j.jvn.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/30/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Community-based structured exercise training (CB-SET) programs are beneficial for patients with peripheral artery disease (PAD). However, the impact of lower levels of walking activity accumulated separately from formal exercise is unclear. The aim of this study was to determine the relation of non-exercise walking (NEW) activity with exercise performance in PAD. METHODS This was a post hoc analysis from twenty patients with PAD enrolled in a 12 week CB-SET program using diaries and accelerometry. Formal exercise (3 sessions·week-1) was detected using patient-reported diary entries that corresponded with accelerometer step data. NEW activity was characterized as steps completed over five days each week, excluding steps achieved during formal exercise sessions. The primary exercise performance outcome was peak walking time (PWT) assessed on a graded treadmill. Secondary performance outcomes included claudication onset time (COT) from the graded treadmill and peak walking distance (PWD) achieved during the six-minute walk test (6MWT). Partial Pearson correlations evaluated the relation of NEW activity (step·week-1) with exercise performance outcomes using exercise session intensity (step·week-1) and duration (min·week-1) as covariates. RESULTS NEW activity demonstrated a moderate, positive correlation with change in PWT (r=0.50, p=0.04). Other exercise performance outcomes were not significantly related to NEW activity (COT: r=0.14; 6MWT PWD: r=0.27). CONCLUSIONS A positive association was demonstrated between NEW activity and PWT following 12 weeks of CB-SET. Interventions to increase physical activity levels outside of formal exercise sessions may be beneficial for patients with PAD.
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Affiliation(s)
- Ryan J Mays
- Academic Health Center, School of Nursing, Adult and Gerontological Health Cooperative, University of Minnesota, Minneapolis, MN, USA.
| | - Rachel Kahnke
- Labor and Delivery/Pregnancy Unit, MHealth Fairview, University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Erica N Schorr
- Academic Health Center, School of Nursing, Adult and Gerontological Health Cooperative, University of Minnesota, Minneapolis, MN, USA
| | - Diane Treat-Jacobson
- Academic Health Center, School of Nursing, Adult and Gerontological Health Cooperative, University of Minnesota, Minneapolis, MN, USA
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12
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Franklin BA, Eijsvogels TM, Pandey A, Quindry J, Toth PP. Physical activity, cardiorespiratory fitness, and cardiovascular health: A clinical practice statement of the American Society for Preventive Cardiology Part II: Physical activity, cardiorespiratory fitness, minimum and goal intensities for exercise training, prescriptive methods, and special patient populations. Am J Prev Cardiol 2022; 12:100425. [PMID: 36281325 PMCID: PMC9586849 DOI: 10.1016/j.ajpc.2022.100425] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 09/05/2022] [Accepted: 10/06/2022] [Indexed: 11/11/2022] Open
Abstract
The prescription of exercise for individuals with and without cardiovascular disease (CVD) should be scientifically-based yet adapted to the patient. This scientific statement reviews the clinical and physiologic basis for the prescription of exercise, with specific reference to the volume of physical activity (PA) and level of cardiorespiratory fitness (CRF) that confer significant and optimal cardioprotective benefits. Recommendations are provided regarding the appropriate intensity, frequency, and duration of training; the concept of MET-minutes per week; critical components of the exercise session (warm-up, conditioning phase, cool-down); methodologies for establishing the training intensity, including oxygen uptake reserve (V̇O2R), target heart rate derivation and rating perceived exertion; minimum and goal intensities for exercise training; and, types of training activities, including resistance training, adjunctive lifestyle PA, marathon/triathlon training, and high-intensity interval training. In addition, we discuss the rationale for and value of exercise training programs for patients with peripheral artery disease, diabetes mellitus, and heart failure.
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Affiliation(s)
- Barry A. Franklin
- Preventive Cardiology and Cardiac Rehabilitation, Beaumont Health, Royal Oak, MI, USA
- Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Thijs M.H. Eijsvogels
- Radboud Institute for Health Sciences, Department of Physiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ambarish Pandey
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - John Quindry
- Integrative Physiology and Athletic Training, University of Montana, Missoula, MT, USA
- International Heart Institute – St. Patrick's Hospital, Providence Medical Center, Missoula, MT, USA
| | - Peter P. Toth
- CGH Medical Center, Sterling, IL, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Thanigaimani S, Jin H, Silva MT, Golledge J. Network Meta-Analysis of Trials Testing If Home Exercise Programs Informed by Wearables Measuring Activity Improve Peripheral Artery Disease Related Walking Impairment. SENSORS (BASEL, SWITZERLAND) 2022; 22:8070. [PMID: 36298419 PMCID: PMC9611238 DOI: 10.3390/s22208070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 10/18/2022] [Accepted: 10/18/2022] [Indexed: 06/16/2023]
Abstract
Background: This study aimed to investigate whether home exercise programs informed by wearable activity monitors improved walking ability of patients with peripheral artery disease (PAD). Methods: A systematic literature search was performed to identify randomised controlled trials (RCT) testing home exercise that were or were not informed by wearable activity monitors. The primary outcome was the change in walking distance measured by a six-minute walking test or treadmill test over the course of the trial. Network meta-analysis (NMA) was performed using the gemtc R statistical package. The risk of bias was assessed using Cochrane tool for assessing risk of bias in RCTs (RoB 2.0). Results: A total of 14 RCTs involving 1544 participants were included. Nine trials used wearable activity monitors to inform the home exercise program tested, while five trials did not use wearable activity monitors to inform the home exercise program tested. Overall quality assessment showed 12 trials to be at low risk of bias and two trials at high risk of bias. Home exercise programs informed by wearable activity monitors significantly improved walking distance compared to non-exercise controls (Mean difference, MD: 32.8 m [95% credible interval, CrI: 6.1, 71.0]) but not compared to home exercise programs not informed by wearable activity monitors (MD: 4.7 m [95% CrI: -38.5, 55.4]). Conclusions: Home exercise informed by wearable activity monitors improve walking ability of patients with PAD. It is, however, unclear if activity monitoring informed exercise programs are more effective than exercise programs not using activity monitors.
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Affiliation(s)
- Shivshankar Thanigaimani
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD 4811, Australia
| | - Harry Jin
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD 4814, Australia
| | - Munasinghe Tharindu Silva
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD 4814, Australia
| | - Jonathan Golledge
- The Queensland Research Centre for Peripheral Vascular Disease (QRC-PVD), College of Medicine and Dentistry, James Cook University, Townsville, QLD 4811, Australia
- The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD 4811, Australia
- The Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, QLD 4814, Australia
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14
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Rezvani F, Pelt M, Härter M, Dirmaier J. Effects of walking impairment on mental health burden, health risk behavior and quality of life in patients with intermittent claudication: A cross-sectional path analysis. PLoS One 2022; 17:e0273747. [PMID: 36048797 PMCID: PMC9436130 DOI: 10.1371/journal.pone.0273747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/16/2022] [Indexed: 12/24/2022] Open
Abstract
Introduction Intermittent claudication is the leading symptom of peripheral artery disease (leg pain when walking). The present study investigates the extent to which walking impairment is associated with health-related quality of life, mental health and health risk behavior. Methods A theory-based, cross-sectional path model was empirically examined using pre-intervention baseline data from a multicenter, randomized-controlled trial of patients with intermittent claudication (PAD-TeGeCoach). Data were available from 1 696 patients who completed a battery of questionnaires between April 14, 2018 and March 12, 2019, including measures of walking impairment (Walking Impairment Questionnaire), health-related quality of life (SF-12), mental burden (GAD-7, PHQ-9), nicotine- and alcohol-related risk behavior (Fagerström-Test, AUDIT-C). Sociodemographic characteristics and comorbid conditions were included in the postulated model a priori to minimize confounding effects. Results Walking impairment was associated with an increase in depressive (β = -.36, p < .001) and anxiety symptoms (β = -.24, p < .001). The prevalence of depressive and anxiety symptoms was 48.3% and 35.5%, respectively, with female patients and those of younger age being at greater risk. Depressive symptoms were predictive of an increased tobacco use (β = .21; p < .001). Walking impairment had adverse effects on physical quality of life, both directly (β = .60, p < .001) and indirectly mediated through depressive symptoms (β = -.16, p < .001); and indirectly on mental quality of life mediated through depressive (β = -.43, p < .001) and anxiety symptoms (β = -.35, p < .001). Discussion The findings underscore the need for a comprehensive treatment strategy in patients with intermittent claudication. Measures to improve walking impairment (e.g. exercise training) are key to enhance quality of life and should be the primary treatment. As a key mediator of mental quality of life, depressive and anxiety symptoms should be addressed by rigorously including mental health treatment. Risky health behaviors should be approached by promoting behavior change (e.g. smoking cessation) as a secondary prevention of peripheral artery disease.
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Affiliation(s)
- Farhad Rezvani
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- * E-mail:
| | - Mara Pelt
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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15
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Monroe JC, Pae BJ, Kargl C, Gavin TP, Parker J, Perkins SM, Han Y, Klein J, Motaganahalli RL, Roseguini BT. Effects of home-based leg heat therapy on walking performance in patients with symptomatic peripheral artery disease: a pilot randomized trial. J Appl Physiol (1985) 2022; 133:546-560. [PMID: 35771219 PMCID: PMC9448284 DOI: 10.1152/japplphysiol.00143.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/15/2022] [Accepted: 06/21/2022] [Indexed: 11/22/2022] Open
Abstract
Few noninvasive therapies currently exist to improve functional capacity in people with lower extremity peripheral artery disease (PAD). The goal of the present study was to test the hypothesis that unsupervised, home-based leg heat therapy (HT) using water-circulating trousers perfused with warm water would improve walking performance in patients with PAD. Patients with symptomatic PAD were randomized into either leg HT (n = 18) or a sham treatment (n = 16). Patients were provided with water-circulating trousers and a portable pump and were asked to apply the therapy daily (7 days/wk, 90 min/session) for 8 wk. The primary study outcome was the change from baseline in 6-min walk distance at 8-wk follow-up. Secondary outcomes included the claudication onset-time, peak walking time, peak pulmonary oxygen consumption and peak blood pressure during a graded treadmill test, resting blood pressure, the ankle-brachial index, postocclusive reactive hyperemia in the calf, cutaneous microvascular reactivity, and perceived quality of life. Of the 34 participants randomized, 29 completed the 8-wk follow-up. The change in 6-min walk distance at the 8-wk follow-up was significantly higher (P = 0.029) in the group exposed to HT than in the sham-treated group (Sham: median: -0.9; 25%, 75% percentiles: -5.8, 14.3; HT: median: 21.3; 25%, 75% percentiles: 10.1, 42.4, P = 0.029). There were no significant differences in secondary outcomes between the HT and sham group at 8-wk follow-up. The results of this pilot study indicate that unsupervised, home-based leg HT is safe, well-tolerated, and elicits a clinically meaningful improvement in walking tolerance in patients with symptomatic PAD.NEW & NOTEWORTHY This is the first sham-controlled trial to examine the effects of home-based leg heat therapy (HT) on walking performance in patients with peripheral artery disease (PAD). We demonstrate that unsupervised HT using water-circulating trousers is safe, well-tolerated, and elicits meaningful changes in walking ability in patients with symptomatic PAD. This home-based treatment option is practical, painless, and may be a feasible adjunctive therapy to counteract the decline in lower extremity physical function in patients with PAD.
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Affiliation(s)
- Jacob C Monroe
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
| | - Byung Joon Pae
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
| | - Christopher Kargl
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
| | - Timothy P Gavin
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
| | - Jason Parker
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, Indiana
| | - Susan M Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Yan Han
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana
| | - Janet Klein
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Raghu L Motaganahalli
- Division of Vascular Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Bruno T Roseguini
- Department of Health and Kinesiology, Purdue University, West Lafayette, Indiana
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16
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Won J, Nielson KA, Smith JC. Subjective Well-Being and Bilateral Anterior Insula Functional Connectivity After Exercise Intervention in Older Adults With Mild Cognitive Impairment. Front Neurosci 2022; 16:834816. [PMID: 35620672 PMCID: PMC9128803 DOI: 10.3389/fnins.2022.834816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/19/2022] [Indexed: 11/29/2022] Open
Abstract
While it is well known that exercise training is associated with improvement in subjective well-being among older adults, it is unclear if individuals with cognitive impairment experience the same effects elicited by exercise on subjective well-being. We further explored whether the bilateral anterior insula network may be an underlying neural mechanism for the exercise training-related improvements in subjective well-being. We investigated the effects of exercise training on subjective well-being in older adults (78.4 ± 7.1 years) with mild cognitive impairment (MCI; n = 14) and a cognitively normal (CN; n = 14) control group. We specifically assessed the relationship between changes in subjective well-being and changes in functional connectivity (FC) with the bilateral anterior insula from before to after exercise training. Cardiorespiratory fitness, subjective well-being, and resting-state fMRI were measured before and after a 12-week moderate-intensity walking intervention. A seed-based correlation analysis was conducted using the bilateral anterior insula as a priori seed regions of interest. The associations between bilateral anterior insula FC with other brain regions and subjective well-being were computed before and after exercise training, respectively, and the statistical difference between the correlations (before vs after exercise training) was evaluated. There was a significant Group (MCI vs CN) × Time (before vs after exercise training) interaction for subjective well-being, such that while those with MCI demonstrated significantly increased subjective well-being after exercise training, no changes in subjective well-being were observed in CN. Participants with MCI also showed an exercise training-related increase in the bilateral anterior insula FC. While there was no significant correlation between subjective well-being and bilateral anterior insula FC before exercise training, a positive association between subjective well-being and bilateral anterior insula FC was found in the MCI group after exercise training. Our findings indicate that 12 weeks of exercise training may enhance subjective well-being in older adults diagnosed with MCI and, further, suggest that increased bilateral anterior insula FC with other cortical regions may reflect neural network plasticity associated with exercise training-related improvements in subjective well-being.
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Affiliation(s)
- Junyeon Won
- Department of Kinesiology, University of Maryland, College Park, MD, United States
| | - Kristy A. Nielson
- Department of Psychology, Marquette University, Milwaukee, WI, United States
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - J. Carson Smith
- Department of Kinesiology, University of Maryland, College Park, MD, United States
- Program in Neuroscience and Cognitive Science, University of Maryland, College Park, MD, United States
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WalkingPad protocol: a randomized clinical trial of behavioral and motivational intervention added to smartphone-enabled supervised home-based exercise in patients with peripheral arterial disease and intermittent claudication. Trials 2022; 23:326. [PMID: 35436974 PMCID: PMC9014283 DOI: 10.1186/s13063-022-06279-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 04/04/2022] [Indexed: 12/24/2022] Open
Abstract
Background Physical exercise is a first-line treatment for peripheral arterial disease (PAD) and intermittent claudication (IC) reducing pain and increasing the distances walked. Home-based exercise therapy (HBET) has the advantage of reaching a higher number of patients and increasing adherence to physical exercise as it is performed in the patient’s residential area and does not have the time, cost, and access restrictions of supervised exercise therapy (SET) implemented in a clinical setting. Even so, rates of adherence to physical exercise are relatively low, and therefore, m-health tools are promising in increasing motivation to behavior change and adherence to physical exercise. A built-in virtual assistant is a patient-focused tool available in a mobile interface, providing a variety of functions including health education, motivation, and implementation of behavior change techniques. Methods This is a single-center, prospective, three-arm, single-blind, randomized, controlled, superior clinical trial with stratified and blocked random allocation. Three hundred participants with PAD and IC will be recruited from an Angiology and Vascular Surgery Department, Centro Hospitalar Universitário Porto (CHUPorto), Porto, Portugal. All patients will receive the same medical care recommended by current guidelines. Participants in all three groups will receive a personalized prescription for an HBET program and a behavioral change and motivational intervention. Participants in experimental groups 1 and 2 will receive a smartphone with the WalkingPad app to monitor exercise sessions. Experimental group 2 WalkingPad app will have a built-in virtual assistant that will promote behavioral change and provide motivational support. Participants allocated to the active control group will not receive the m-health tool, but a practice diary to encourage monitoring. The program will last for 6 months with three evaluation moments (baseline, 3, and 6 months). The primary outcome will be the change in distances walked (maximal and pain-free) from baseline to 3 and 6 months. Secondary outcomes will be changes in quality of life, patients’ perception of resistance, and walking speed. Discussion This study will allow measuring the effectiveness of an m-health tool in increasing motivation for behavior change and adherence to an HBET program in patients with PAD. The superiority of experimental group 2 in the primary and secondary outcomes will indicate that the virtual assistant is effective for motivating behavioral change and encouraging the practice and adherence to physical exercise. The use of m-health tools and virtual health assistants can potentially fill a gap in the access and quality of health services and information, reducing the burden on the health system and promoting self-management and self-care in chronic illness. Trial registration ClinicalTrials.govNCT04749732. Registered on 10 February 2021 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06279-9.
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18
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Walking Promotes Physical Fitness of Community-Dwelling Older Adults. TOPICS IN GERIATRIC REHABILITATION 2022. [DOI: 10.1097/tgr.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bronas UG, Regensteiner JG. Connecting the past to the present: A historical review of exercise training for peripheral artery disease. Vasc Med 2022; 27:174-185. [DOI: 10.1177/1358863x211073620] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Peripheral artery disease (PAD), a prevalent manifestation of atherosclerosis, is associated with increased cardiovascular morbidity and mortality as well as decreased functional ability. Exercise training for PAD is acknowledged to be a highly effective treatment, which improves walking ability and cardiovascular risk. The historical development of this treatment has not been the focus of a report. Therefore, we present a historical review of research on exercise training for PAD. Overall, this body of knowledge has provided strong evidence of the efficacy of supervised exercise training (SET) to improve walking ability for patients with claudication due to PAD. SET, using intermittent bouts of walking exercise to moderate claudication pain on a treadmill, is considered the most efficacious mode of exercise to improve walking ability in patients with claudication. This compelling evidence published over the past 60 years was evaluated by the Centers for Medicare & Medicaid Services in 2017, which culminated in a national coverage determination for SET to improve symptomatic PAD. Future directions include determining optimal delivery strategies for SET and further elucidation of the mechanisms of improvement in walking ability resulting from SET. In addition, alternative forms of exercise should be evaluated and effective home- and community-based exercise interventions should be assessed. There is an enormous need to increase the inclusion of women and racial and ethnic minority groups in studies. It is to be hoped that researchers will continue with new innovative research and persistence in the treatment of claudication due to PAD.
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Affiliation(s)
- Ulf G Bronas
- Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois – Chicago, Chicago, IL, USA
| | - Judith G Regensteiner
- Ludeman Family Center for Women’s Health Research; Divisions of General Internal Medicine and Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
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20
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Gardner AW, Montgomery PS, Wang M, Shen B. Minimal clinically important differences in daily physical activity outcomes following supervised and home-based exercise in peripheral artery disease. Vasc Med 2022; 27:142-149. [PMID: 35164605 DOI: 10.1177/1358863x211072913] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: We estimated minimal clinically important differences (MCID) for small, moderate, and large changes in daily step counts and time spent in moderate-to-vigorous physical activity (MVPA) following both supervised and home-based exercise programs in symptomatic patients with peripheral artery disease (PAD). Methods: Patients were randomized to either 12 weeks of a supervised exercise program (n = 60), a home-based exercise program (n = 60), or an attention-control group (n = 60). Results: Using the anchor-based method to determine MCID, the MCID value for a large change in health-related quality of life (HRQoL) was an increase of 1211 total daily steps and an increase in 11 minutes in the time spent in MVPA following 12 weeks of exercise intervention. Using the distribution-based method, the MCID values for small, moderate, and large changes in total daily steps in the home-based exercise group were 558, 1396, and 2233 steps/d, respectively, and the corresponding changes in the time spent in MVPA were 6, 15, and 23 minutes. Similar distribution-based MCID scores were noted for the supervised exercise group. Conclusion: Following 3 months of home-based and supervised exercise programs for patients with PAD and claudication, increases of 11 minutes in time spent in MVPA and 1211 total daily steps were associated with large anchor-based MCID increases in HRQoL. The clinical implication is that patients with PAD and claudication should be encouraged to increase daily steps, particularly by walking an additional 11 minutes each day in MVPA, which is associated with a large meaningful increase in HRQoL.
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Affiliation(s)
- Andrew W Gardner
- Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, PA, USA
| | - Polly S Montgomery
- Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, PA, USA
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
| | - Biyi Shen
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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21
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Anghel R, Adam CA, Marcu DTM, Mitu O, Mitu F. Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era. J Clin Med 2022; 11:416. [PMID: 35054109 PMCID: PMC8778009 DOI: 10.3390/jcm11020416] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 12/12/2022] Open
Abstract
Cardiac rehabilitation (CR) is an integral part of the management of various cardiovascular disease such as coronary artery disease (CAD), peripheral artery disease (PAD), or chronic heart failure (CHF), with proven morbidity and mortality benefits. This article aims to review and summarize the scientific literature related to cardiac rehabilitation programs for patients with PAD and how they were adapted during the COVID-19 pandemic. The implementation of CR programs has been problematic since the COVID-19 pandemic due to social distancing and work-related restrictions. One of the main challenges for physicians and health systems alike has been the management of PAD patients. COVID-19 predisposes to coagulation disorders that can lead to severe thrombotic events. Home-based walking exercises are more accessible and easier to accept than supervised exercise programs. Cycling or other forms of exercise are more entertaining or challenging alternatives to exercise therapy. Besides treadmill exercises, upper- and lower-extremity ergometry also has great functional benefits, especially regarding walking endurance. Supervised exercise therapy has a positive impact on both functional capacity and also on the quality of life of such patients. The most effective manner to acquire this seems to be by combining revascularization therapy and supervised exercise. Rehabilitation programs proved to be a mandatory part of the integrative approach in these cases, increasing quality of life, and decreasing stress levels, depression, and anxiety.
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Affiliation(s)
- Razvan Anghel
- Clinical Rehabilitation Hospital, Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania; (R.A.); (C.A.A.); (F.M.)
| | - Cristina Andreea Adam
- Clinical Rehabilitation Hospital, Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania; (R.A.); (C.A.A.); (F.M.)
| | - Dragos Traian Marius Marcu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street nr 16, 700115 Iasi, Romania;
| | - Ovidiu Mitu
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street nr 16, 700115 Iasi, Romania;
- “Sf. Spiridon” Clinical Emergency Hospital, Independence Boulevard nr 1, 700111 Iasi, Romania
| | - Florin Mitu
- Clinical Rehabilitation Hospital, Cardiovascular Rehabilitation Clinic, Pantelimon Halipa Street nr 14, 700661 Iasi, Romania; (R.A.); (C.A.A.); (F.M.)
- Department of Internal Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, University Street nr 16, 700115 Iasi, Romania;
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22
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Miller MJ, Morris MA, Magnusson DM, Putnam K, Cook PF, Schenkman ML, Christiansen CL. Psychosocial Factors Influence Physical Activity after Dysvascular Amputation: A Convergent Mixed-Methods Study. PM R 2021; 13:737-745. [PMID: 32936512 PMCID: PMC7873162 DOI: 10.1002/pmrj.12466] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Physical function is a common target of rehabilitation intervention to improve disability and physical activity after dysvascular lower-limb amputation (LLA); yet, the influence of psychosocial factors on physical activity is unclear. OBJECTIVE To identify psychosocial factors with potential to influence clinically relevant measures of physical activity, physical function, and disability in light of participants' narratives. DESIGN Convergent mixed-methods. SETTING General community. PARTICIPANTS Twenty participants with dysvascular LLA were enrolled if their most recent LLA was at least 1 year prior, they were ambulating independently with a prosthesis, and were between 45 and 88 years old. INTERVENTION Not applicable. MAIN OUTCOME MEASURES Quantitative data included physical activity (activPAL; steps/d), physical function (Timed Up-and-Go; TUG), and disability (World Health Organization Disability Assessment Schedule 2.0; WHODAS 2.0). Qualitative data were collected via semistructured interviews. RESULTS Higher steps/d was moderately correlated with better TUG time (r = -.58, P < .01), but was not correlated with WHODAS 2.0 score (r = -0.18; P > .10). Qualitative analysis of interviews, using an inductive, team-based, phenomenological approach, identified four themes: (1) perceptions of their prosthesis, (2) fear during mobility, (3) influence of LLA on life activities, and (4) positive outlook within social interactions. Mixed-methods analysis used an iterative approach to interpret and describe how psychosocial factors influence physical activity in four exemplar cases. CONCLUSIONS Physical activity in people with dysvascular LLA results from an interaction among perceptions of their prosthesis, fear during mobility, influence of LLA on life activities, and positive outlook within social interactions. The overlapping nature of these themes suggests that interventions targeting psychosocial factors may be associated with improved physical activity, physical function, and subsequent disability after dysvascular LLA.
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Affiliation(s)
- Matthew J Miller
- Department of Physical Therapy and Rehabilitation Science, University of California, San Francisco, San Francisco, CA, USA
- Division of Geriatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Megan A Morris
- Adult and Child Consortium of Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Dawn M Magnusson
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Kelly Putnam
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Paul F Cook
- College of Nursing, University of Colorado, Aurora, CO, USA
| | - Margaret L Schenkman
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
| | - Cory L Christiansen
- Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO, USA
- VA Eastern Colorado Geriatric Research, Education, and Clinical Center, Aurora, CO, USA
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23
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An Updated Systematic Review and Meta-Analysis of Home-based Exercise Programmes for Individuals with Intermittent Claudication. J Vasc Surg 2021; 74:2076-2085.e20. [PMID: 34087396 DOI: 10.1016/j.jvs.2021.03.063] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Supervised exercise programmes (SEP) are effective for improving walking distance in patients with intermittent claudication (IC) but provision and uptake rates are sub-optimal. Access to such programmes has also been halted by the Coronavirus pandemic. The aim of this review is to provide a comprehensive overview of the evidence for home-based exercise programmes (HEP). DATA SOURCES Medline, EMBASE, CINAHL, PEDro and Cochrane CENTRAL were searched for terms relating to HEP and IC. REVIEW METHODS This review was conducted in according with the published protocol and PRISMA guidance. Randomised and non-randomised trials that compared a HEP to SEP, basic exercise advice or no exercise controls for IC were included. A narrative synthesis was provided for all studies and meta-analyses conducted using data from randomised trials. The primary outcome was maximal walking distance. Sub-group analyses were performed to consider the effect of monitoring. Risk of bias was assessed using the Cochrane tool and quality of evidence via GRADE. RESULTS 23 studies with 1907 participants were included. Considering the narrative review, HEPs were inferior to SEPs which was reflected in the meta-analysis (MD 139m, 95% CI 45 to 232m, p = .004, very-low-quality evidence). Monitoring was an important component, as HEPs adopting this were equivalent to SEPs (MD: 8m, 95% CI -81 to 97, p = .86; moderate-quality evidence). For HEPs versus basic exercise advice, narrative review suggested HEPs can be superior, though not always significantly so. For HEPs versus no exercise controls, narrative review and meta-analysis suggested HEPs were potentially superior (MD: 136m, -2-273m p = .05, very-low-quality evidence). Monitoring was also a key element in these comparisons.Other elements such as appropriate frequency (≥3x a week), intensity (to moderate-maximum pain), duration (20 progressing to 60 minutes) and type (walking) of exercise were important, as was education, self-regulation, goal setting, feedback and action planning. CONCLUSION When SEPs are unavailable, HEPs are recommended. However, to elicit maximum benefit they should be structured, incorporating all elements of our evidence-based recommendations. PROSPERO REGISTRATION NUMBER CRD42018091248.
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24
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Fukaya E, Welden S, Bukari A, Khan Z, Leeper N, Mohler E. Incentivizing physical activity through activity monitoring interventions in PAD - a pilot study. VASA 2020; 50:145-150. [PMID: 33150850 DOI: 10.1024/0301-1526/a000924] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: There is ample evidence to show that supervised exercise is efficacious and cost effective for improving claudication symptoms in patients with peripheral artery disease (PAD). Home based exercise therapy can be an effective alternative to supervised exercise however, the results of this is variable depending on the level of motivation and engagement of the patient. Patients and methods: We performed a pilot study in 41 patients to determine whether a home based exercise program with the use of an activity tracking device with personalized feedback and financial incentives can increase daily activity, improve walking and sustain engagement in the exercise regimen in patients with PAD. In this randomized pilot study, the patients in the study group were fitted with an activity monitoring device and given behavioral monitoring, motivational updates and feedback regarding their exercise program. This study group was further divided in to two groups. One half of these patients in the study group were also given financial incentives if they reached their set targets. The control group wore the device with no feedback or ability to see their number of steps walked. Results: Results showed that at the end of the 12 week period, patients in the study groups walked more compared to the controls and the financial incentive structure resulted in an additional 38-63% increase in average daily steps. Conclusions: This pilot study revealed that a home-based exercise program with activity monitoring, feedback and financial incentives resulted increased daily steps, 6-minute walking distance and overall compliance with the program in PAD patients with claudication.
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Affiliation(s)
| | - Scott Welden
- University of Pennsylvania, Philadelphia, PA, USA
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25
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Rezvani F, Heider D, Härter M, König HH, Bienert F, Brinkmann J, Herbarth L, Kramer E, Steinisch P, Freudenstein F, Terhalle R, Grosse Y, Bock S, Posselt J, Beutel C, Reif F, Kirchhoff F, Neuschwander C, Löffler F, Brunner L, Dickmeis P, Heidenthal T, Schmitz L, Chase DP, Seelenmeyer C, Alscher MD, Tegtbur U, Dirmaier J. Telephone health coaching with exercise monitoring using wearable activity trackers (TeGeCoach) for improving walking impairment in peripheral artery disease: study protocol for a randomised controlled trial and economic evaluation. BMJ Open 2020; 10:e032146. [PMID: 32503866 PMCID: PMC7279623 DOI: 10.1136/bmjopen-2019-032146] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION Peripheral artery disease (PAD) is the third most prevalent cardiovascular disease worldwide, with smoking and diabetes being the strongest risk factors. The most prominent symptom is leg pain while walking, known as intermittent claudication. To improve mobility, first-line treatment for intermittent claudication is supervised exercise programmes, but these remain largely unavailable and economically impractical, which has led to the development of structured home-based exercise programmes. This trial aims to determine the effectiveness and cost advantage of TeGeCoach, a 12-month long home-based exercise programme, compared with usual care of PAD. It is hypothesised that TeGeCoach improves walking impairment and lowers the need of health care resources that are spent on patients with PAD. METHODS AND ANALYSIS The investigators conduct a prospective, pragmatic randomised controlled clinical trial in a health insurance setting. 1760 patients diagnosed with PAD at Fontaine stage II are randomly assigned to either TeGeCoach or care-as-usual. TeGeCoach consists of telemonitored intermittent walking exercise with medical supervision by a physician and telephone health coaching. Participants allocated to the usual care group receive information leaflets and can access supervised exercise programmes, physical therapy and a variety of programmes for promoting a healthy lifestyle. The primary outcome is patient reported walking ability based on the Walking Impairment Questionnaire. Secondary outcome measures include quality of life, health literacy and health behaviour. Claims data are used to collect total health care costs, healthcare resource use and (severe) adverse events. Outcomes are measured at baseline, 12 and 24 months. ETHICS AND DISSEMINATION Ethical approval has been obtained from the Medical Association Hamburg. Findings are disseminated through peer-reviewed journals, reports to the funding body, conference presentations and media press releases. Data from this trial are made available to the public and researchers upon reasonable request.NCT03496948 (www.clinicaltrials.gov), Pre-results.
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Affiliation(s)
- Farhad Rezvani
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Dirk Heider
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Frank Bienert
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | - Julia Brinkmann
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | - Lutz Herbarth
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | - Edith Kramer
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | | | | | - René Terhalle
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | - Yvonne Grosse
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | - Susanne Bock
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | | | - Corinna Beutel
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | - Franziska Reif
- Kaufmännische Krankenkasse, Hannover, Niedersachsen, Germany
| | | | | | | | | | | | | | | | | | - Claudia Seelenmeyer
- Dr Margarete Fischer Bosch Institute of Clinical Pharmacology, Stuttgart, Baden-Württemberg, Germany
| | - Mark Dominik Alscher
- Dr Margarete Fischer Bosch Institute of Clinical Pharmacology, Stuttgart, Baden-Württemberg, Germany
| | - Uwe Tegtbur
- Department of Sports Medicine, Hannover Medical School, Hannover, Niedersachsen, Germany
| | - Jörg Dirmaier
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
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26
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Harzand A, Vakili AA, Alrohaibani A, Abdelhamid SM, Gordon NF, Thiel J, Benarroch‐Gampel J, Teodorescu VJ, Minton K, Wenger NK, Rajani RR, Shah AJ. Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial. Clin Cardiol 2020; 43:537-545. [PMID: 32324307 PMCID: PMC7298994 DOI: 10.1002/clc.23362] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 03/17/2020] [Accepted: 03/19/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown. METHODS Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year. RESULTS A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants. CONCLUSIONS The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.
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Affiliation(s)
- Arash Harzand
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
| | | | - Alaaeddin Alrohaibani
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
| | - Smah M. Abdelhamid
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
| | - Neil F. Gordon
- INTERVENT InternationalSavannahGeorgiaUSA
- Centre for Exercise Science and Sports Medicine, School of Therapeutic SciencesUniversity of the WitwatersrandJohannesburgSouth Africa
| | - John Thiel
- INTERVENT InternationalSavannahGeorgiaUSA
| | - Jaime Benarroch‐Gampel
- Division of Vascular Surgery, Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | - Victoria J. Teodorescu
- Division of Vascular Surgery, Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | | | - Nanette K. Wenger
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | - Ravi R. Rajani
- Division of Vascular Surgery, Department of SurgeryEmory University School of MedicineAtlantaGeorgiaUSA
- Grady Memorial HospitalAtlantaGeorgiaUSA
| | - Amit J. Shah
- Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaGeorgiaUSA
- Atlanta Veterans Affairs Medical CenterDecaturGeorgia
- Department of Epidemiology, Rollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
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27
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McDermott MM, Kibbe MR, Guralnik JM, Ferrucci L, Criqui MH, Domanchuk K, Tian L, Zhao L, Li L, Patel K, Polonsky TS. Durability of Benefits From Supervised Treadmill Exercise in People With Peripheral Artery Disease. J Am Heart Assoc 2020; 8:e009380. [PMID: 30587066 PMCID: PMC6405705 DOI: 10.1161/jaha.118.009380] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background It is currently unknown whether 6 months of supervised treadmill exercise has a durable benefit on 6-minute walk performance, even after exercise is completed, in people with peripheral artery disease. Methods and Results A total of 156 participants with peripheral artery disease were randomized to 1 of 3 groups: supervised treadmill exercise, supervised resistance training, or attention control. Participants received supervised sessions during months 1 to 6 and telephone contact during months 6 to 12. Primary outcomes were change in 6-minute walk distance and short physical performance battery at 6-month follow-up and have been reported previously. Secondary outcomes were change in 6-minute walk and short physical performance battery at 12-month follow-up and are reported here. A group of 134 participants (86%) completed the 12-month follow-up. At 6-month follow-up, compared with control, 6-minute walk distance improved in the treadmill exercise group (+36.1 m, 95% CI =13.9-58.3, P=0.001). Between 6- and 12-month follow-up, 6-minute walk distance significantly declined (-28.6 m, 95% CI=-52.6 to -4.5, P=0.020) and physical activity declined -272 activity units (95% CI =-546 to +2, P=0.052) in the treadmill exercise group compared with controls. At 12-month follow-up, 6 months after completing supervised treadmill exercise, change in 6-minute walk distance was not different between the treadmill exercise and control groups (+7.5, 95% CI =-17.5 to +32.6, P=0.56). There were no differences in short physical performance battery change between either exercise group and control at 6-month or 12-month follow-up. Conclusions A 6-month supervised treadmill exercise intervention that improved 6-minute walk distance at 6-month follow-up did not have persistent benefit at 12-month follow-up. These results do not support a durable benefit of supervised treadmill exercise in peripheral artery disease. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Identifier: NCT 00106327.
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Affiliation(s)
- Mary M McDermott
- 1 Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL.,2 Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Melina R Kibbe
- 3 Department of Surgery University of North Carolina Chapel Hill NC
| | - Jack M Guralnik
- 4 Department of Epidemiology and Public Health University of Maryland School of Medicine Baltimore MD
| | - Luigi Ferrucci
- 5 Longitudinal Studies Section of the Translational Gerontology Branch National Institute on Aging Baltimore MD
| | - Michael H Criqui
- 6 Department of Family Medicine and Public Health University of California San Diego La Jolla CA
| | - Kathryn Domanchuk
- 1 Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Lu Tian
- 7 Department of Biomedical Data Science Stanford University Palo Alto CA
| | - Lihui Zhao
- 2 Department of Preventive Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Lingyu Li
- 1 Department of Medicine Northwestern University Feinberg School of Medicine Chicago IL
| | - Kruti Patel
- 8 University of Illinois College of Medicine at Chicago IL
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28
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Miller MJ, Jones J, Anderson CB, Christiansen CL. Factors influencing participation in physical activity after dysvascular amputation: a qualitative meta-synthesis. Disabil Rehabil 2019; 41:3141-3150. [PMID: 30261758 PMCID: PMC6437000 DOI: 10.1080/09638288.2018.1492031] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 05/21/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
Abstract
Purpose: Identifying factors associated with physical activity after dysvascular lower limb amputation (LLA) could provide targets for improving rehabilitation outcomes. The purpose of this meta-synthesis was to identify modifiable factors that may influence physical activity after LLA, a condition characterized by amputation in the setting of older age, diabetes mellitus (DM), and/or peripheral artery disease (PAD).Methods: A systematic search of the literature identified qualitative studies exploring the perceptions of physical activity in people with lower limb amputation, older age, DM, or PAD. Qualitative rigor was assessed using the McMaster University's Guidelines for Qualitative Review. Meta-synthesis was undertaken to analyze the findings of included studies.Results: Fourteen studies of variable methodological quality were included for analysis. Three overarching factors that may influence physical activity after LLA emerged: 1) educational experiences and motivation, 2) support and self-efficacy, and 3) special concerns after lower limb amputation (e.g., prosthesis, equipment, and environment).Conclusions: Physical activity after LLA is influenced by relationships among health understanding, motivation, support, and self-efficacy in the presence of disability. Themes from this meta-synthesis can be used to develop and test behavior-based interventions to improve physical activity after LLA.Implications for rehabilitationPhysical activity participation after dysvascular lower limb amputation is complicated by the presence of chronic conditions, severe disability, and unaddressed psychosocial factors.Addressing a patient's self-efficacy, social support, motivation, and understanding during physically focused rehabilitation may improve participation in physical activity after dysvascular lower limb amputation.Rehabilitation professionals can address self-efficacy, motivation, and understanding by using collaborative, empathetic communication strategies known to enhance a patient's sense of support.
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Affiliation(s)
- Matthew J Miller
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO, USA
| | | | - Chelsey B Anderson
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO, USA
| | - Cory L Christiansen
- Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO, USA
- Department of Physical Medicine and Rehabilitation, Physical Therapy Program, University of Colorado, Aurora, CO, USA
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Abstract
PURPOSE OF THE REVIEW Peripheral artery disease (PAD) affects close to 200 million people worldwide. Claudication is the most common presenting symptom for patients with PAD. This review summarizes the current diagnostic and treatment options for patients with claudication. Comprehensive history and physical examination in order to differentiate between claudication secondary to vascular disease vs. neurogenic causes is paramount for initial diagnosis. Ankle-brachial index is the most commonly used test for screening and diagnostic purposes. Treatment consists of four different approaches, which are best utilized in combination: non-pharmacological treatment for claudication improvement, pharmacological treatment for claudication improvement, pharmacological treatment for secondary risk reduction, and interventional treatment for claudication improvement. RECENT FINDINGS Cilostazol is the only Food and Drug Administration (FDA)-approved agent for symptomatic treatment of claudication. Supervised exercise programs provide the maximum benefit for claudication improvement, but home-based exercise programs are an alternative. High-intensity statins and an antiplatelet agent should be prescribed to all patients with PAD. Angiotensin-converting-enzyme inhibitors can provide additional risk reduction, especially in patients with diabetes or hypertension. Rivaroxaban of low dosage (2.5 mg twice daily) in combination with aspirin further decreases cardiovascular risk, but this reduction comes at the cost of higher bleeding risk. Peripheral artery disease (PAD) is a form of atherosclerotic disease that affects hundreds of millions of people worldwide-one of its most common manifestations is intermittent claudication (IC), which results from insufficient blood flow to meet the metabolic demands of an affected extremity. This paper reviews the current literature regarding the workup, diagnosis, diagnostic modalities, treatment options, and management of intermittent claudication.
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Affiliation(s)
- Prio Hossain
- UC Davis School of Medicine, Sacramento, CA, USA
| | - Damianos G Kokkinidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.,Division of Cardiology, Rocky Mountain VA Medical Center and University of Colorado, 1600 North Wheeling Street, Aurora, Denver, CO, 80045, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain VA Medical Center and University of Colorado, 1600 North Wheeling Street, Aurora, Denver, CO, 80045, USA.
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Morris DR, Skalina TA, Singh TP, Moxon JV, Golledge J. Association of Computed Tomographic Leg Muscle Characteristics With Lower Limb and Cardiovascular Events in Patients With Peripheral Artery Disease. J Am Heart Assoc 2019; 7:e009943. [PMID: 30371256 PMCID: PMC6474956 DOI: 10.1161/jaha.118.009943] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Poor lower extremity physical performance is an independent predictor of unfavorable outcome in patients with peripheral artery disease ( PAD ); however, few studies have assessed muscle characteristics on imaging directly. Method and Results A novel 3-dimensional semi-automated protocol was developed to estimate leg muscle volume and density (mean attenuation) from computed tomography images. Patients with PAD who underwent a lower extremity computed tomography scan at a tertiary vascular surgery center were included, and were followed up using hospital records and linked data as part of a retrospective cohort study. The primary outcomes were lower limb events (major amputation or peripheral revascularization) and cardiovascular events (myocardial infarction, stroke, or cardiovascular death). Two hundred and twenty-three patients with PAD were included (median age 69.0 years; 73% men) and followed for a median of 4.9 [2.6-7.0] years. During this time there were 99 index lower limb events and 97 cardiovascular events. Low leg muscle density was associated with increased risk of lower limb (rate ratio 1.41 [1.11-1.80] per SD reduction) and cardiovascular events (rate ratio 1.60 [1.29-1.99] per SD reduction). Low muscle density remained an independent predictor of cardiovascular (but not lower limb) events, after adjusting for age, sex, traditional cardiovascular risk factors, and angiographic PAD severity (rate ratio 1.39 [1.09-1.77] per lower SD ). In contrast, leg muscle volume was not associated with outcomes after adjusting for risk factors and PAD severity. Conclusions Low leg muscle density, but not volume, is a strong, independent predictor of major cardiovascular events among people with PAD . Further research is needed to understand the mechanisms underlying these associations.
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Affiliation(s)
- Dylan R Morris
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Tristan A Skalina
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Tejas P Singh
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Joseph V Moxon
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia
| | - Jonathan Golledge
- 1 Queensland Research Centre for Peripheral Vascular Disease College of Medicine and Dentistry James Cook University Townsville Queensland Australia.,2 Department of Vascular and Endovascular Surgery The Townsville Hospital Townsville Queensland Australia
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Treat-Jacobson D, McDermott MM, Beckman JA, Burt MA, Creager MA, Ehrman JK, Gardner AW, Mays RJ, Regensteiner JG, Salisbury DL, Schorr EN, Walsh ME. Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association. Circulation 2019; 140:e700-e710. [PMID: 31446770 DOI: 10.1161/cir.0000000000000727] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with lower-extremity peripheral artery disease (PAD) have greater functional impairment, faster functional decline, increased rates of mobility loss, and poorer quality of life than people without PAD. Supervised exercise therapy (SET) improves walking ability, overall functional status, and health-related quality of life in patients with symptomatic PAD. In 2017, the Centers for Medicare & Medicaid Services released a National Coverage Determination (CAG-00449N) for SET programs for patients with symptomatic PAD. This advisory provides a practical guide for delivering SET programs to patients with PAD according to Centers for Medicare & Medicaid Services criteria. It summarizes the Centers for Medicare & Medicaid Services process and requirements for referral and coverage of SET and provides guidance on how to implement SET for patients with PAD, including the SET protocol, options for outcome measurement, and transition to home-based exercise. This advisory is based on the guidelines established by the Centers for Medicare & Medicaid Services for Medicare beneficiaries in the United States and is intended to assist clinicians and administrators who are implementing SET programs for patients with PAD.
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Weinberg I, Parmar G. A Quick Fix for Better Walking? That’s Probably a Bit of a Stretch. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2019; 20:628-629. [DOI: 10.1016/j.carrev.2019.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2019; 69:e71-e126. [PMID: 27851992 DOI: 10.1016/j.jacc.2016.11.007] [Citation(s) in RCA: 438] [Impact Index Per Article: 87.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Gardner AW, Parker DE, Montgomery PS. Changes in vascular and inflammatory biomarkers after exercise rehabilitation in patients with symptomatic peripheral artery disease. J Vasc Surg 2019; 70:1280-1290. [PMID: 30922751 DOI: 10.1016/j.jvs.2018.12.056] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/26/2018] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Andrew W Gardner
- Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, Pa.
| | - Donald E Parker
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Polly S Montgomery
- Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, Pa
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Golledge J, Singh TP, Alahakoon C, Pinchbeck J, Yip L, Moxon JV, Morris DR. Meta-analysis of clinical trials examining the benefit of structured home exercise in patients with peripheral artery disease. Br J Surg 2019; 106:319-331. [DOI: 10.1002/bjs.11101] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/11/2018] [Accepted: 11/30/2018] [Indexed: 01/13/2023]
Abstract
Abstract
Background
Supervised exercise is recommended for the management of peripheral artery disease (PAD); however, the uptake is limited. Structured home exercise programmes may be more feasible, but their effectiveness is unclear. This systematic review and meta-analysis examined the benefit of structured home exercise programmes for treating PAD in comparison to controls not receiving an exercise programme.
Methods
A literature search was conducted to identify RCTs comparing structured home exercise with controls not receiving an exercise programme among patients with PAD. To be included, studies had to report outcomes from treadmill or corridor walking tests, or objective assessment of physical activity. Inverse variance-weighted meta-analysis was performed to compare changes in maximum walking distance and intermittent claudication onset distance in treadmill tests, walking distance during a 6-min walking test, and physical activity measured using a pedometer or accelerometer. Summarized results are presented in terms of standard deviation differences.
Results
Eleven randomized trials involving 807 patients were included. Follow-up ranged from 2 to 24 months; only one trial included follow-up beyond 12 months. Meta-analyses showed that structured home exercise programmes led to significant improvements in maximum walking distance (mean difference (MD) 0·32, 95 per cent c.i. 0·15 to 0·50; P < 0·001), intermittent claudication onset distance (MD 0·45, 0·27 to 0·62; P < 0·001), walking distance in a 6-min walking test (MD 0·28, 0·09 to 0·47; P = 0·004) and physical activity (MD 0·27, 0·11 to 0·43; P = 0·001).
Conclusion
This meta-analysis suggests that structured home exercise programmes are effective at improving walking performance and physical activity in the short term for patients with PAD.
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Affiliation(s)
- J Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
- Department of Vascular and Endovascular Surgery, Townsville Hospital, Townsville, Queensland, Australia
| | - T P Singh
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - C Alahakoon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - J Pinchbeck
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - L Yip
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - J V Moxon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - D R Morris
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
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Treat-Jacobson D, McDermott MM, Bronas UG, Campia U, Collins TC, Criqui MH, Gardner AW, Hiatt WR, Regensteiner JG, Rich K. Optimal Exercise Programs for Patients With Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2019; 139:e10-e33. [DOI: 10.1161/cir.0000000000000623] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Sawlani NN, Kinlay S. Claudication: Pay for Structured Exercise or Go Take a Hike. JACC Cardiovasc Interv 2019; 10:725-727. [PMID: 28385411 DOI: 10.1016/j.jcin.2017.02.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 02/23/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Neal N Sawlani
- Veterans Affairs Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Scott Kinlay
- Veterans Affairs Boston Healthcare System, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, Fleisher LA, Fowkes FGR, Hamburg NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel RAG, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ, Treat-Jacobson D, Walsh ME, Halperin JL, Levine GN, Al-Khatib SM, Birtcher KK, Bozkurt B, Brindis RG, Cigarroa JE, Curtis LH, Fleisher LA, Gentile F, Gidding S, Hlatky MA, Ikonomidis J, Joglar J, Pressler SJ, Wijeysundera DN. 2016 AHA/ACC Guideline on the Management of Patients with Lower Extremity Peripheral Artery Disease: Executive Summary. Vasc Med 2018; 22:NP1-NP43. [PMID: 28494710 DOI: 10.1177/1358863x17701592] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
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- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | | | - Heather L Gornik
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information
| | | | | | | | - Douglas E Drachman
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,5 Society for Cardiovascular Angiography and Interventions Representative
| | - Lee A Fleisher
- 6 ACC/AHA Task Force on Clinical Practice Guidelines Liaison
| | - Francis Gerry R Fowkes
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,7 Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative
| | | | - Scott Kinlay
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,8 Society for Vascular Medicine Representative
| | - Robert Lookstein
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Sanjay Misra
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,9 Society of Interventional Radiology Representative
| | - Leila Mureebe
- 10 Society for Clinical Vascular Surgery Representative
| | - Jeffrey W Olin
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Rajan A G Patel
- 7 Inter-Society Consensus for the Management of Peripheral Arterial Disease Representative
| | | | - Andres Schanzer
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,11 Society for Vascular Surgery Representative
| | - Mehdi H Shishehbor
- 1 Writing committee members are required to recuse themselves from voting on sections to which their specific relationships with industry and other entities may apply; see Appendix 1 for recusal information.,3 ACC/AHA Representative
| | - Kerry J Stewart
- 3 ACC/AHA Representative.,12 American Association of Cardiovascular and Pulmonary Rehabilitation Representative
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Mukherjee D, Contos B, Emery E, Collins DT, Black JH. High Reintervention and Amputation Rates After Outpatient Atherectomy for Claudication. Vasc Endovascular Surg 2018; 52:427-433. [DOI: 10.1177/1538574418772459] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Outpatient use of atherectomy for peripheral arterial disease has grown rapidly and outcomes are poorly understood. We analyzed outcomes of atherectomy done for claudication, comparing office and hospital outpatient settings. Analysis of Medicare Part B claims data was performed for incident femoral–popliteal or tibial–peroneal atherectomy from 2012 to 2014. Longitudinal analysis assessed services 18 months before, during, and up to 18 months after the incident peripheral vascular intervention (PVI). Differences between office-based and hospital outpatient-based settings were assessed using χ2 and Fisher exact tests. Comparing procedure settings, significant differences in race (femoral–popliteal: P = .04, tibial–peroneal: P = .001), chronic renal failure (femoral–popliteal: P = .002), and hypertension (femoral–popliteal: P = .01, tibial–peroneal: P = .006) were found. Nine hundred twenty-four patients undergoing femoral–popliteal atherectomy were analyzed (262 office based, 662 hospital outpatient based); 42.7% of office-based and 36.9% of hospital outpatient-based femoral–popliteal atherectomy patients had repeat PVI within 18 months ( P = .10). Major amputation was performed in 2.3% and 3.2% of patients in office and hospital outpatient settings, respectively ( P = .47). Four hundred twenty-three patients undergoing tibial–peroneal atherectomy were analyzed (202 office based, 221 hospital outpatient based); 46.5% of office-based and 38.9% of hospital outpatient-based tibial–peroneal atherectomy patients had repeat PVI within 1 year ( P = .11). Major amputation was performed in 5.0% and 8.1% of patients in office and hospital outpatient settings, respectively ( P = .19). Our study demonstrates higher than expected rates of major amputation for patients undergoing peripheral arterial atherectomy with regard to previously reported rates. Further studies may be required to prove the efficacy and safety of atherectomy for occlusive disease in the femoral–popliteal and tibial–peroneal segments to ensure outcomes are not worse than the natural history of medically managed claudicants.
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Affiliation(s)
| | | | - Erica Emery
- Inova Fairfax Medical Campus, Falls Church, VA, USA
| | - Devon T. Collins
- Inova Fairfax Medical Campus, Falls Church, VA, USA
- George Mason University, Fairfax, VA, USA
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McDermott MM, Spring B, Berger JS, Treat-Jacobson D, Conte MS, Creager MA, Criqui MH, Ferrucci L, Gornik HL, Guralnik JM, Hahn EA, Henke P, Kibbe MR, Kohlman-Trighoff D, Li L, Lloyd-Jones D, McCarthy W, Polonsky TS, Skelly C, Tian L, Zhao L, Zhang D, Rejeski WJ. Effect of a Home-Based Exercise Intervention of Wearable Technology and Telephone Coaching on Walking Performance in Peripheral Artery Disease: The HONOR Randomized Clinical Trial. JAMA 2018; 319:1665-1676. [PMID: 29710165 PMCID: PMC5933394 DOI: 10.1001/jama.2018.3275] [Citation(s) in RCA: 134] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
IMPORTANCE Clinical practice guidelines support home-based exercise for patients with peripheral artery disease (PAD), but no randomized trials have tested whether an exercise intervention without periodic medical center visits improves walking performance. OBJECTIVE To determine whether a home-based exercise intervention consisting of a wearable activity monitor and telephone coaching improves walking ability over 9 months in patients with PAD. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted at 3 US medical centers. Patients with PAD were randomized between June 18, 2015, and April 4, 2017, to home-based exercise vs usual care for 9 months. Final follow-up was on December 5, 2017. INTERVENTIONS The exercise intervention group (n = 99) received 4 weekly medical center visits during the first month followed by 8 months of a wearable activity monitor and telephone coaching. The usual care group (n = 101) received no onsite sessions, active exercise, or coaching intervention. MAIN OUTCOMES AND MEASURES The primary outcome was change in 6-minute walk distance at 9-month follow-up (minimal clinically important difference [MCID], 20 m). Secondary outcomes included 9-month change in subcomponents of the Walking Impairment Questionnaire (WIQ) (0-100 score; 100, best), SF-36 physical functioning score, Patient-Reported Outcomes Measurement Information System (PROMIS) mobility questionnaire (higher = better; MCID, 2 points), PROMIS satisfaction with social roles questionnaire, PROMIS pain interference questionnaire (lower = better; MCID range, 3.5-4.5 points), and objectively measured physical activity. RESULTS Among 200 randomized participants (mean [SD] age, 70.2 [10.4] years; 105 [52.5%] women), 182 (91%) completed 9-month follow-up. The mean change from baseline to 9-month follow-up in the 6-minute walk distance was 5.5 m in the intervention group vs 14.4 m in the usual care group (difference, -8.9 m; 95% CI, -26.0 to 8.2 m; P = .31). The exercise intervention worsened the PROMIS pain interference score, mean change from baseline to 9 months was 0.7 in the intervention group vs -2.8 in the usual care group (difference, 3.5; 95% CI, 1.3 to 5.8; P = .002). There were no significant between-group differences in the WIQ score, the SF-36 physical functioning score, or the PROMIS mobility or satisfaction with social roles scores. CONCLUSIONS AND RELEVANCE Among patients with PAD, a home-based exercise intervention consisting of a wearable activity monitor and telephone coaching, compared with usual care, did not improve walking performance at 9-month follow-up. These results do not support home-based exercise interventions of wearable devices and telephone counseling without periodic onsite visits to improve walking performance in patients with PAD. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02462824.
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Affiliation(s)
- Mary M. McDermott
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Bonnie Spring
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Weinberg College of Arts and Sciences, Northwestern University, Evanston, Illinois
| | - Jeffrey S. Berger
- Department of Preventative Cardiology, New York University School of Medicine, New York, New York
| | - Diane Treat-Jacobson
- Center for Aging Science and Care Innovation, University of Minnesota School of Nursing, Minneapolis
| | - Michael S. Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco
| | - Mark A. Creager
- Department of Vascular Medicine, Dartmouth-Hitchcock Medical Center, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Michael H. Criqui
- Division of Preventive Medicine, Department of Family Medicine and Public Health, University of California, San Diego
| | - Luigi Ferrucci
- Division of Intramural Research, National Institute on Aging, Baltimore, Maryland
| | - Heather L. Gornik
- Department of Cardiovascular Medicine, Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, Ohio
| | | | - Elizabeth A. Hahn
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Peter Henke
- Department of Surgery, University of Michigan, Ann Arbor
| | - Melina R. Kibbe
- Department of Surgery, University of North Carolina School of Medicine, Chapel Hill
| | - Debra Kohlman-Trighoff
- Department of Cardiology and Cardiovascular Medicine, Duke University, Durham, North Carolina
| | - Lingyu Li
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Donald Lloyd-Jones
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Walter McCarthy
- Department of Cardiovascular and Thoracic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Tamar S. Polonsky
- Department of Medicine, University of Chicago Medical School, Chicago, Illinois
| | - Christopher Skelly
- Department of Surgery, University of Chicago Medical School, Chicago, Illinois
| | - Lu Tian
- Department of Health Research and Policy, Stanford University, Stanford, California
| | - Lihui Zhao
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Dongxue Zhang
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - W. Jack Rejeski
- Department of Health and Exercise Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Gardner AW, Montgomery PS, Wang M. Minimal clinically important differences in treadmill, 6-minute walk, and patient-based outcomes following supervised and home-based exercise in peripheral artery disease. Vasc Med 2018; 23:349-357. [PMID: 29671381 DOI: 10.1177/1358863x18762599] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
We estimated minimal clinically important differences (MCIDs) for small, moderate, and large changes in measures obtained from a standardized treadmill test, a 6-minute walk test, and patient-based outcomes following supervised and home-based exercise programs in symptomatic patients with peripheral artery disease (PAD). Patients were randomized to either 12 weeks of a supervised exercise program ( n=60), a home-based exercise program ( n=60), or an attention-control group ( n=60). Using the distribution-based method to determine MCIDs, the MCIDs for small, moderate, and large changes in peak walking time (PWT) in the supervised exercise group were 38, 95, and 152 seconds, respectively, and the changes in claudication onset time (COT) were 35, 87, and 138 seconds. Similar MCID scores were noted for the home-based exercise group. An anchor-based method to determine MCIDs yielded similar patterns of small, moderate, and large change scores in PWT and COT, but values were 1-2 minutes longer than the distribution approach. In conclusion, 3 months of supervised and home-based exercise programs for symptomatic patients with PAD results in distribution-based MCID small, moderate, and large changes ranging from 0.5 and 2.5 minutes for PWT and COT. An anchor-based approach yields higher MCID values, ranging from a minimum of 73 seconds for COT to a maximum of 4 minutes for PWT. The clinical implication is that a goal for eliciting MCIDs in symptomatic PAD patients through a walking exercise intervention is to increase PWT and COT by up to 4 minutes, which corresponds to two work stages during the standardized progressive treadmill test.
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Affiliation(s)
- Andrew W Gardner
- 1 Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, PA, USA
| | - Polly S Montgomery
- 1 Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, PA, USA
| | - Ming Wang
- 2 Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA, USA
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Hageman D, Fokkenrood HJP, Gommans LNM, van den Houten MML, Teijink JAW. Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication. Cochrane Database Syst Rev 2018; 4:CD005263. [PMID: 29627967 PMCID: PMC6513337 DOI: 10.1002/14651858.cd005263.pub4] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although supervised exercise therapy (SET) provides significant symptomatic benefit for patients with intermittent claudication (IC), it remains an underutilized tool. Widespread implementation of SET is restricted by lack of facilities and funding. Structured home-based exercise therapy (HBET) with an observation component (e.g., exercise logbooks, pedometers) and just walking advice (WA) are alternatives to SET. This is the second update of a review first published in 2006. OBJECTIVES The primary objective was to provide an accurate overview of studies evaluating effects of SET programs, HBET programs, and WA on maximal treadmill walking distance or time (MWD/T) for patients with IC. Secondary objectives were to evaluate effects of SET, HBET, and WA on pain-free treadmill walking distance or time (PFWD/T), quality of life, and self-reported functional impairment. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (December 16, 2016) and the Cochrane Central Register of Controlled Trials (2016, Issue 11). We searched the reference lists of relevant studies identified through searches for other potential trials. We applied no restriction on language of publication. SELECTION CRITERIA We included parallel-group randomized controlled trials comparing SET programs with HBET programs and WA in participants with IC. We excluded studies in which control groups did not receive exercise or walking advice (maintained normal physical activity). We also excluded studies comparing exercise with percutaneous transluminal angioplasty, bypass surgery, or drug therapy. DATA COLLECTION AND ANALYSIS Three review authors (DH, HF, and LG) independently selected trials, extracted data, and assessed trials for risk of bias. Two other review authors (MvdH and JT) confirmed the suitability and methodological quality of trials. For all continuous outcomes, we extracted the number of participants, mean outcome, and standard deviation for each treatment group through the follow-up period, if available. We extracted Medical Outcomes Study Short Form 36 outcomes to assess quality of life, and Walking Impairment Questionnaire outcomes to assess self-reported functional impairment. As investigators used different scales to present results of walking distance and time, we standardized reported data to effect sizes to enable calculation of an overall standardized mean difference (SMD). We obtained summary estimates for all outcome measures using a random-effects model. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS For this update, we included seven additional studies, making a total of 21 included studies, which involved a total of 1400 participants: 635 received SET, 320 received HBET, and 445 received WA. In general, SET and HBET programs consisted of three exercise sessions per week. Follow-up ranged from six weeks to two years. Most trials used a treadmill walking test to investigate effects of exercise therapy on walking capacity. However, two trials assessed only quality of life, functional impairment, and/or walking behavior (i.e., daily steps measured by pedometer). The overall methodological quality of included trials was moderate to good. However, some trials were small with respect to numbers of participants, ranging from 20 to 304.SET groups showed clear improvement in MWD/T compared with HBET and WA groups, with overall SMDs at three months of 0.37 (95% confidence interval [CI] 0.12 to 0.62; P = 0.004; moderate-quality evidence) and 0.80 (95% CI 0.53 to 1.07; P < 0.00001; high-quality evidence), respectively. This translates to differences in increased MWD of approximately 120 and 210 meters in favor of SET groups. Data show improvements for up to six and 12 months, respectively. The HBET group did not show improvement in MWD/T compared with the WA group (SMD 0.30, 95% CI -0.45 to 1.05; P = 0.43; moderate-quality evidence).Compared with HBET, SET was more beneficial for PFWD/T but had no effect on quality of life parameters nor on self-reported functional impairment. Compared with WA, SET was more beneficial for PFWD/T and self-reported functional impairment, as well as for some quality of life parameters (e.g., physical functioning, pain, and physical component summary after 12 months), and HBET had no effect.Data show no obvious effects on mortality rates. Thirteen of the 1400 participants died, but no deaths were related to exercise therapy. Overall, adherence to SET was approximately 80%, which was similar to that reported with HBET. Only limited adherence data were available for WA groups. AUTHORS' CONCLUSIONS Evidence of moderate and high quality shows that SET provides an important benefit for treadmill-measured walking distance (MWD and PFWD) compared with HBET and WA, respectively. Although its clinical relevance has not been definitively demonstrated, this benefit translates to increased MWD of 120 and 210 meters after three months in SET groups. These increased walking distances are likely to have a positive impact on the lives of patients with IC. Data provide no clear evidence of a difference between HBET and WA. Trials show no clear differences in quality of life parameters nor in self-reported functional impairment between SET and HBET. However, evidence is of low and very low quality, respectively. Investigators detected some improvements in quality of life favoring SET over WA, but analyses were limited by small numbers of studies and participants. Future studies should focus on disease-specific quality of life and other functional outcomes, such as walking behavior and physical activity, as well as on long-term follow-up.
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Affiliation(s)
- David Hageman
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
| | | | - Lindy NM Gommans
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
| | - Marijn ML van den Houten
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
| | - Joep AW Teijink
- Catharina HospitalDepartment of Vascular SurgeryEindhovenNetherlands
- CAPHRI School for Public Health and Primary Care, Faculty of Health, Medicine and Life Sciences, Maastricht UniversityDepartment of EpidemiologyMaastrichtNetherlands
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Miller MJ, Magnusson DM, Lev G, Fields TT, Cook PF, Stevens-Lapsley JE, Christiansen CL. Relationships Among Perceived Functional Capacity, Self-Efficacy, and Disability After Dysvascular Amputation. PM R 2018; 10:1056-1061. [PMID: 29580940 DOI: 10.1016/j.pmrj.2018.03.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 03/10/2018] [Accepted: 03/18/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prosthesis rehabilitation after dysvascular transtibial amputation (TTA) is focused on optimizing functional capacity with limited emphasis on promoting health self-efficacy. Self-efficacy interventions decrease disability for people living with chronic disease, but the influence of self-efficacy on disability is unknown for people with dysvascular TTA. OBJECTIVES To identify if self-efficacy mediates the relationship between self-reported functional capacity and disability after dysvascular TTA. DESIGN Cross-sectional, secondary data analysis. SETTING Outpatient rehabilitation facilities. PARTICIPANTS Thirty-eight men (63.6 ± 9.1 years old) with dysvascular TTA. METHODS Participants had been living with an amputation for less than 6 months and using walking as their primary form of locomotion using a prosthesis. The independent variable, functional capacity, was measured using the Prosthesis Evaluation Questionnaire-Mobility Scale (PEQ-MS). The proposed mediator, self-efficacy, was measured with the Self-Efficacy of Managing Chronic Disease questionnaire (SEMCD). MAIN OUTCOME MEASURE Disability was measured using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) questionnaire. RESULTS The relationship between self-reported functional capacity and disability is partially mediated by self-efficacy. Relationships between WHODAS 2.0 and PEQ-MS (r = -0.61), WHODAS 2.0 and SEMCD (r = -0.51), and PEQ-MS and SEMCD (r = 0.44) were significant (P < .01). Controlling for SEMCD (P = .04), the relationship between PEQ-MS and WHODAS 2.0 remained significant (P < .01). Statistically significant mediation was determined by a bootstrap method for the product of coefficients (95% confidence interval: -2.23, -7.39). CONCLUSIONS This study provides initial evidence that the relationship between self-reported functional capacity and disability is partially mediated by self-efficacy after dysvascular TTA. The longitudinal effect of self-efficacy should be further examined to identify causal pathways of disability after dysvascular amputation. Furthermore, additional factors contributing to the relationship between self-reported functional capacity and disability need to be identified. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Matthew J Miller
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Anschutz Medical Campus, Mail Stop C244, 13121 East 17th Avenue, Aurora, CO 80045; Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO
| | - Dawn M Magnusson
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO
| | - Guy Lev
- University of Colorado Hospital, Aurora, CO
| | - Thomas T Fields
- Denver VA Medical Center, VA Eastern Colorado Healthcare System, Denver, CO
| | - Paul F Cook
- College of Nursing, University of Colorado, Aurora, CO
| | - Jennifer E Stevens-Lapsley
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO; Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO
| | - Cory L Christiansen
- Physical Therapy Program, Department of Physical Medicine and Rehabilitation, University of Colorado, Aurora, CO; Geriatric Research Education and Clinical Center, VA Eastern Colorado Healthcare System, Denver, CO
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McDermott MM. Medical Management of Functional Impairment in Peripheral Artery Disease: A Review. Prog Cardiovasc Dis 2018; 60:586-592. [PMID: 29727608 PMCID: PMC6690383 DOI: 10.1016/j.pcad.2018.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 03/17/2018] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Mary M McDermott
- Northwestern University Feinberg School of Medicine, United States.
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45
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed-effect model unless we identified significant heterogeneity, in which case we used a random-effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow-up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty-seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre-existing limitations to their exercise capacity.Meta-analysis from nine studies with 391 participants showed overall improvement in pain-free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high-quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high-quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years.Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate-quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate-quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low-quality evidence).Researchers measured quality of life using Short Form (SF)-36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta-analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate-quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate-quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF-36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains - 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' - did not show improvement at six months.Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants.Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes - over 300 participants for most outcomes - using reproducible methods. AUTHORS' CONCLUSIONS High-quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.
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Affiliation(s)
- Risha Lane
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Amy Harwood
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Lorna Watson
- NHS FifeCameron House, Cameron BridgeWindygatesLevenUKKY8 5RG
| | - Gillian C Leng
- National Institute for Health and Care Excellence10 Spring GardensLondonUKSW1A 2BU
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Pandey A, Banerjee S, Ngo C, Mody P, Marso SP, Brilakis ES, Armstrong EJ, Giri J, Bonaca MP, Pradhan A, Bavry AA, Kumbhani DJ. Comparative Efficacy of Endovascular Revascularization Versus Supervised Exercise Training in Patients With Intermittent Claudication: Meta-Analysis of Randomized Controlled Trials. JACC Cardiovasc Interv 2017; 10:712-724. [PMID: 28385410 DOI: 10.1016/j.jcin.2017.01.027] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 01/10/2017] [Accepted: 01/27/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The authors performed a meta-analysis of randomized controlled trials to compare the efficacy of initial endovascular treatment with or without supervised exercise training (SET) versus SET alone in patients with intermittent claudication. BACKGROUND Current guidelines recommend SET as the initial treatment modality for patients with intermittent claudication, in addition to optimal medical therapy. The role of endovascular therapy as primary treatment for claudication has been controversial. METHODS The primary outcome was treadmill-measured maximal walk distance at the end of follow-up. Secondary outcomes included resting ankle brachial index (ABI) and treadmill-measured ischemic claudication distance on follow-up. Risk of revascularization or amputations was also compared. Pooled estimates of the difference in outcomes between endovascular therapy with or without SET and SET-only groups were calculated using fixed and random effects models. RESULTS A total of 987 patients from 7 trials were included. In pooled analysis, compared with SET only (reference group), patients that underwent combined endovascular therapy and SET had significantly higher maximum walk distance (standardized mean difference 0.79 [95% confidence interval (CI): 0.18 to 1.39]; weighted mean difference 98.9 [95% CI: 31.4 to 166.4 feet], and lower risk of revascularization or amputation (odds ratio 0.19 [95% CI: (0.09 to 0.40]; p < 0.0001, number needed to treat = 8) over a median follow-up of 12.4 months. By contrast, revascularization was not associated with significant improvement in exercise capacity or risk of future revascularization or amputation, compared with SET alone. Follow-up ABI was significantly higher among patients that underwent endovascular therapy with or without SET as compared with SET alone. CONCLUSIONS Compared with initial SET only, endovascular therapy in combination with SET is associated with significant improvement in total walking distance, ABI, and risk of future revascularization or amputation. By contrast, endovascular therapy-only was not associated with any improvement in functional capacity or clinical outcomes over an intermediate duration of follow-up.
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Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Subhash Banerjee
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christian Ngo
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Purav Mody
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Steven P Marso
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Emmanouil S Brilakis
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ehrin J Armstrong
- Section of Cardiology, Denver VA Medical Center and University of Colorado School of Medicine, Denver, Colorado
| | - Jay Giri
- Cardiovascular Medicine Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marc P Bonaca
- Divsion of Cardiovasular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aruna Pradhan
- Divsion of Cardiovasular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Anthony A Bavry
- Department of Medicine, University of Florida, Gainesville, Florida
| | - Dharam J Kumbhani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
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47
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McDermott MM. Exercise training for intermittent claudication. J Vasc Surg 2017; 66:1612-1620. [PMID: 28874320 DOI: 10.1016/j.jvs.2017.05.111] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 05/15/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of this study was to provide an overview of evidence regarding exercise therapies for patients with lower extremity peripheral artery disease (PAD). METHODS This manuscript summarizes the content of a lecture delivered as part of the 2016 Crawford Critical Issues Symposium. RESULTS Multiple randomized clinical trials demonstrate that supervised treadmill exercise significantly improves treadmill walking performance in people with PAD and intermittent claudication symptoms. A meta-analysis of 25 randomized trials demonstrated a 180-meter increase in treadmill walking distance in response to supervised exercise interventions compared with a nonexercising control group. Supervised treadmill exercise has been inaccessible to many patients with PAD because of lack of medical insurance coverage. However, in 2017, the Centers for Medicare and Medicaid Services issued a decision memorandum to support health insurance coverage of 12 weeks of supervised treadmill exercise for patients with walking impairment due to PAD. Recent evidence also supports home-based walking exercise to improve walking performance in people with PAD. Effective home-exercise programs incorporate behavioral change interventions such as a remote coach, goal setting, and self-monitoring. Supervised treadmill exercise programs preferentially improve treadmill walking performance, whereas home-based walking exercise programs preferentially improve corridor walking, such as the 6-minute walk test. Clinical trial evidence also supports arm or leg ergometry exercise to improve walking endurance in people with PAD. Treadmill walking exercise appears superior to resistance training alone for improving walking endurance. CONCLUSIONS Supervised treadmill exercise significantly improves treadmill walking performance in people with PAD by approximately 180 meters compared with no exercise. Recent evidence suggests that home-based exercise is also effective and preferentially improves over-ground walking performance, such as the 6-minute walk test.
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Affiliation(s)
- Mary M McDermott
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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Riegel B, Moser DK, Buck HG, Dickson VV, Dunbar SB, Lee CS, Lennie TA, Lindenfeld J, Mitchell JE, Treat-Jacobson DJ, Webber DE. Self-Care for the Prevention and Management of Cardiovascular Disease and Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association. J Am Heart Assoc 2017; 6:e006997. [PMID: 28860232 PMCID: PMC5634314 DOI: 10.1161/jaha.117.006997] [Citation(s) in RCA: 273] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Self-care is defined as a naturalistic decision-making process addressing both the prevention and management of chronic illness, with core elements of self-care maintenance, self-care monitoring, and self-care management. In this scientific statement, we describe the importance of self-care in the American Heart Association mission and vision of building healthier lives, free of cardiovascular diseases and stroke. The evidence supporting specific self-care behaviors such as diet and exercise, barriers to self-care, and the effectiveness of self-care in improving outcomes is reviewed, as is the evidence supporting various individual, family-based, and community-based approaches to improving self-care. Although there are many nuances to the relationships between self-care and outcomes, there is strong evidence that self-care is effective in achieving the goals of the treatment plan and cannot be ignored. As such, greater emphasis should be placed on self-care in evidence-based guidelines.
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49
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Chen X, Stoner JA, Montgomery PS, Casanegra AI, Silva-Palacios F, Chen S, Janitz AE, Gardner AW. Prediction of 6-minute walk performance in patients with peripheral artery disease. J Vasc Surg 2017. [PMID: 28647194 DOI: 10.1016/j.jvs.2017.03.438] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) is a highly prevalent disease that impairs walking ability. Walking tests, such as the 6-minute walk test (6MWT) and 4-meter walk test, are commonly used to assess exercise endurance and ambulatory function over a short distance, respectively. The 6MWT performance is predictive of PAD severity and disease outcomes, but it is not feasible in many clinical settings because it requires a long walkway to serve as the test route and lengthens clinic visits. As an alternative, the 4-meter walk test is convenient, inexpensive, and repeatable, but whether it accurately predicts endurance performance in the long-distance 6MWT is not known. The goal of this study was to develop a statistical model to predict 6MWT gait speed from 4-meter walk test results and clinical characteristics among patients with PAD. METHODS Measures of 6MWT gait speed were derived from 183 patients with symptomatic PAD who were evaluated at the University of Oklahoma Health Sciences Center (2004-2012). The testing procedures and research personnel remained constant throughout the duration of the study. Independent variables included demographic and clinical information and 4-meter walk test gait speed. Fivefold cross validation and manual backward selection were used for model selection. Adjusted R2 and corrected Akaike information criterion were applied to quantify the predictive performance of the regression models. RESULTS A total of 183 people (54% male; mean age, 65 [standard deviation (SD), 10] years) with moderate PAD severity (ankle-brachial index [ABI]; mean, 0.72 [SD, 0.24]) performed the walking tests. Participants covered an average distance of 335 (SD, 97) m distance in the 6MWT. The 4-meter walk gait speed, ABI, and dyspnea were independent predictors of 6MWT speed in the multivariate model (adjusted R2 = 0.55). The model resulted in 95% prediction interval widths of 30 m for mean and 260 m for individual predicted 6MWT distance measures. CONCLUSIONS Slower 4-meter walking speed, lower ABI, and presence of dyspnea all predict slower 6MWT gait speed, which corresponds to shorter 6MWT distance. Prediction of group means is reasonably precise; however, prediction of individual patient 6MWT performance is imprecise relative to between-group differences that are clinically important.
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Affiliation(s)
- Xi Chen
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla.
| | - Julie A Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Polly S Montgomery
- Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Ana I Casanegra
- Cardiovascular Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Federico Silva-Palacios
- Cardiovascular Section, Department of Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Sixia Chen
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Amanda E Janitz
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, Okla
| | - Andrew W Gardner
- Department of Geriatric Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Okla; Department of Physical Medicine and Rehabilitation, Penn State College of Medicine, Hershey, Pa
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Valentine EA, Ochroch EA. 2016 American College of Cardiology/American Heart Association Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Perioperative Implications. J Cardiothorac Vasc Anesth 2017; 31:1543-1553. [PMID: 28826846 DOI: 10.1053/j.jvca.2017.04.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Elizabeth A Valentine
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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