Step-monitored home exercise improves ambulation, vascular function, and inflammation in symptomatic patients with peripheral artery disease: a randomized controlled trial

Home-based Circuit Training and Community Walking for Intermittent Claudication

BACKGROUND

Supervised exercise training is recommended for people with peripheral artery disease (PAD), yet it remains underutilized. Home-based exercise programs (HBEPs) are a potential alternative. The aim of this study was to assess the feasibility of conducting a full scale trial of a 12-week HBEP for people living with symptomatic PAD.

METHODS

In a randomized feasibility trial, patients with intermittent claudication were allocated to either an HBEP or a nonexercise control. The HBEP group was given a Fitbit to use during a 12-week exercise program comprising of personalized step goals and a resistance-based circuit to be undertaken at home twice weekly. The primary outcome was feasibility, assessed via eligibility, recruitment, attrition, tolerability, and adherence. Acceptability was assessed via semistructured interviews. Secondary analysis was undertaken to determine the feasibility of collecting clinical outcome data.

RESULTS

188 people were screened, 133 were eligible (70.7%), 30 were recruited (22.6%) and one withdrew (3.33%). Mean adherence to the daily step goal was 53.5% (range = 29.8-90.5%), and 58.6% of prescribed circuits were completed of which 56.4% were at the desired intensity. Six adverse events were recorded, 3 of which were related to study involvement. No significant differences were observed in exploratory outcomes. Small clinically important differences were seen in walking speed and pain-free treadmill walking distance which should be confirmed or refuted in a larger trial.

CONCLUSIONS

The HBEP was feasible and well tolerated, with successful recruitment and minimal attrition. The intervention was acceptable, with walking seen as more enjoyable than circuit exercise. The WALKSTRONG program may be suitable for those who will not, or cannot, take part in supervised exercise outside of the home.

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

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.

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

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.

Exercise Therapy for Peripheral Artery Disease

PURPOSE OF REVIEW

To summarize evidence regarding exercise treatments for lower extremity peripheral artery disease (PAD).

RECENT FINDINGS

Supervised walking exercise is recommended by practice guidelines for PAD. Supervised treadmill exercise improves treadmill walking distance by approximately 180 m and 6-min walk distance by 30-35 m, compared to control. The Centers for Medicaid and Medicare Services covers 12 weeks of supervised exercise, but most people with PAD do not participate. Home-based walking exercise may be more convenient and accessible than supervised exercise. In randomized clinical trials, home-based walking exercise interventions incorporating behavioral methods, such as accountability to a coach, goal-setting, and self-monitoring, improved 6-min walk distance by 40-54 m, compared to control. Arm and leg ergometry also improved walking endurance for people with PAD, but efficacy compared to walking exercise remains unclear. Walking exercise is first-line therapy for PAD-related walking impairment and can be effective in either a supervised or a structured home-based setting.

Supervised Versus Unsupervised Exercise for the Improvement of Physical Function and Well-Being Outcomes in Older Adults: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Unsupervised exercise intervention (UNSUP) appears to be a practical and beneficial strategy for older adults, although its feasibility and effectiveness compared to supervised exercise intervention (SUP) remains unknown. We aimed to compare the safety, attendance/adherence rates, and effectiveness of SUP versus UNSUP on physical function and well-being outcomes in older adults.

METHODS

A systematic search was conducted in PubMed, Web of Science, CINAHL, SPORTDiscus, and APA PsycINFO up to September 2022 for randomized controlled trials comparing SUP versus UNSUP in older adults (≥ 60 years). Safety and attendance/adherence rates were registered as indicators of feasibility, and meta-analyses were performed for physical function and well-being outcomes. Sub-analyses were performed for those studies that applied a similar intervention in both groups and for those studies where participants performed ≥ 66% of the sessions in the assigned condition.

RESULTS

Thirty-four studies were included (n = 2830). No serious adverse events were reported, with similar attendance rates (81%) for both SUP and UNSUP. Compared with UNSUP, SUP induced significant higher benefits on knee extension strength (standardized mean difference (SMD) = 0.18, p = 0.002), sit-to-stand test (STS, SMD = 0.25, p = 0.050), timed-up-and-go test (TUG, SMD = 0.21, p = 0.035), usual gait speed (SMD = 0.29, p = 0.026), lean mass (mean difference = 1.05 kg, p < 0.001) and health-related quality of life (HRQoL, SMD = 0.21, p = 0.035), albeit only knee extension strength remained significant in sensitivity analyses. Sub-analyses revealed superior benefits of SUP on knee extension strength when only considering those studies that applied a similar intervention in both SUP and UNSUP groups. However, no significant benefits were found for the remaining outcomes. Beneficial effects of SUP over UNSUP were also observed for knee extension strength, STS, functional reach test, TUG, usual gait speed, lean mass, and HRQoL when separately analyzing those studies in which participants performed ≥ 66% of the sessions in the assigned condition.

CONCLUSIONS

Current evidence suggests that both SUP and UNSUP programs are safe and could exert benefits on physical function and HRQoL. However, despite being associated with similar attendance rates, SUP might offer some additional benefits, although further high-quality research (i.e., accounting for confounding factors such as presence of supervised sessions in UNSUP or vice versa, as well as equating the exercise dose) is necessary to confirm these findings.

PROSPERO REGISTRATION NUMBER

CRD42022326420.

Gamification-augmented home-based exercise for peripheral artery disease: Rationale and design of the GAMEPAD Study

BACKGROUND

Supervised exercise therapy improves walking performance, functional capacity, and quality of life in patients with peripheral artery disease (PAD). However, few patients with PAD are enrolled in supervised exercise programs, and there are a number of logistical and financial barriers to their participation. A home-based walking intervention is likely to be more accessible to patients with PAD, but no fully home-based walking program has demonstrated efficacy. Concepts from behavioral economics have been used to design scalable interventions that increase daily physical activity in patients with atherosclerotic vascular disease, but whether a similar program would be effective in patients with PAD is uncertain.

STUDY DESIGN AND OBJECTIVES

GAMEPAD (NCT04536012) is a pragmatic, virtual, randomized controlled trial designed to evaluate the effectiveness of a gamification strategy informed by concepts from behavioral economics to increase daily physical activity in patients with PAD who are seen in cardiology and vascular surgery clinics affiliated with the University of Pennsylvania Health System. Patients are contacted by email or text message, and complete enrollment and informed consent on the Penn Way to Health online platform. A GAMEPAD substudy will evaluate the effectiveness of opt-in versus opt-out framing when approaching patients for study participation. Patients are then provided with a wearable fitness tracker, establish a baseline daily step count, set a goal to increase daily step count by 33%-50%, and are randomized 1:1 to the gamification or control arms. Interventions continue for 16 weeks, including a 4-week period during which goal step count is gradually increased in the gamification arm, with follow-up for an additional 8 weeks to evaluate the durability of behavior change. The trial has met its enrollment goal of 102 participants, with a primary endpoint of change from baseline in daily steps over the 16-week intervention period. Key secondary endpoints include change from baseline in daily steps over the 8-week postintervention follow-up period and changes in patient-reported measures of PAD symptoms and quality of life over the intervention and follow-up periods.

CONCLUSIONS

GAMEPAD is a virtual, pragmatic randomized clinical trial of a novel, fully home-based walking intervention informed by concepts from behavioral economics to increase physical activity and PAD-specific quality of life in patients with PAD. Its results will have important implications for the application of behavioral economic concepts to scalable home-based strategies to promote physical activity in patients with PAD and other disease processes where physical activity is limited by exertional symptoms.

CLINICAL TRIAL REGISTRATION

clinicaltrials.gov; NCT04536012.

Comparison of home-based rehabilitation and a centre-based exercise in terms of functional capacity, muscle oxygenation and quality of life in people with peripheral arterial disease: a protocol for a randomised controlled trial

INTRODUCTION

Peripheral arterial disease (PAD) is increasingly prevalent, and supervised physical exercise programmes are recommended as the first-line treatment. However, these programmes are underused. Alternative delivery models may be able to expand treatment coverage. The objective of this study was to compare a home-based exercise programme (HBEP) and a centre-based exercise (CBE) in terms of their effects on functional capacity, peripheral muscle oxygenation and quality of life in individuals with PAD.

METHODS AND ANALYSIS

This single-blind, parallel randomised clinical trial will consist of two groups: HBEP and CBE. A qualitative analysis will be carried out to investigate acceptability and satisfaction. The primary outcome will be functional capacity, assessed by the incremental shuttle walk test. Secondary outcomes will include functional capacity, assessed by a treadmill walking test; peripheral muscle oxygenation and quality of life; and self-reported functional impairment, risk factors, morbidity, level of physical activity, adherence, acceptability and satisfaction. The intervention protocols will consist of 12 weeks of intermittent walking until claudication symptoms, three times a week. Participants randomly assigned to the CBE group will participate in supervised face-to-face sessions. The HBEP group will perform exercises at home with remote supervision, monitored by a pedometer and heart rate monitor, and subjective perception of effort during each session will be recorded by participants in a training diary; follow-up will be conducted by telephone calls. Statistical analyses will follow the intention-to-treat principle. Participants allocated to the HBEP group will be interviewed about their experience of remote treatment using a qualitative approach.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Universidade Federal de Minas Gerais. The results will be disseminated in a peer-reviewed journal and presented at international congresses. This research has the potential to improve the care of people with PAD because if home-based rehabilitation demonstrates effectiveness, it could be considered an alternative or support resource to the usual centre-based treatment models, expanding access, coverage and participation in vascular physiotherapy TRIAL REGISTRATION: https://ensaiosclinicos.gov.br/rg/RBR-97vy9n7 on 14 April 2022.

Participants' experiences and acceptability of a home-based walking exercise behaviour-change intervention (MOtivating Structure walking Activity in people with Intermittent Claudication (MOSAIC))

OBJECTIVES

This study explored the experiences and acceptability of a novel, home-based, walking exercise behaviour-change intervention (MOtivating Structured walking Activity in people with Intermittent Claudication (MOSAIC)) in adults with Peripheral Arterial Disease (PAD).

DESIGN AND SETTING

Individual semi-structured audio-recorded interviews were conducted with adults with Peripheral Arterial Disease who had completed the MOSAIC intervention as part of a randomised clinical trial. Data were analysed using inductive reflexive thematic analysis and interpreted using the seven-construct theoretical framework of acceptability of healthcare interventions (TFA).

PARTICIPANTS

Twenty participants (mean age (range) 67(54-80) years, 70% male, 55% White British) were interviewed.

RESULTS

One central theme was identified: Acceptability of walking exercise as a treatment. This theme was explained by four linked themes: Exploring walking exercise with a knowledgeable professional, Building confidence with each step, Towards self-management-learning strategies to continue walking and The impact of walking exercise. These themes were interpreted using six of the seven TFA constructs: affective attitude, burden, perceived effectiveness, intervention coherence, opportunity costs, and self-efficacy.

CONCLUSIONS

Participants perceived MOSAIC as an effective, acceptable, and low burden intervention. Physiotherapists were regarded as knowledgeable and supportive professionals who helped participants understand PAD and walking exercise as a treatment. Participants developed confidence to self-manage their condition and their symptoms. As participants confidence and walking capacity improved, they expanded their activities and gained a more positive outlook on their future. MOSAIC is an acceptable intervention that may facilitate adoption of and access to exercise for people with PAD.

IMPLICATIONS FOR PRACTICE

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

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.

Inconsistent Benefits From Mobile Information Communication Technology in Adults With Peripheral Arterial Disease

INTRODUCTION

Quality of evidence regarding telemedicine in adults with peripheral arterial disease has not been systematically appraised.

OBJECTIVES

To explore benefits and harms from mobile information communication technology devices and applications in peripheral arterial disease.

METHODS

Systematic rapid evidence review and appraisal with the grading of recommendations assessment, development, and evaluation working group approach.

RESULTS

Sixteen randomized controlled clinical trials (RCT) examined various self-monitoring devices, telemedicine platforms, and individualized telephone counseling. Low-quality evidence suggested that the odds of treatment failure (pooled Peto odds ratio 0.8; 95% CI, 0.4-1.7; 5 RCTs), adverse effects (pooled Peto odds ratio 0.9; 95% CI, 0.5-1.5; 2 RCTs), and physical performance (standardized mean difference in 6-minute walking test 0.2; 95% CI, -0.3-0.7; 4 RCTs) did not differ between mobile interventions and usual care. Single RCTs suggested large but inconsistent improvement in the quality of life: EuroQol5D standardized mean difference = 5.0 (95% CI, 4.4-5.7; 1 RCT) after telehealth program for promoting patient self-management and standardized mean difference = 1.4 (95% CI, 0.4-2.3; 1 RCT) after structured rehabilitation with mobile self-monitoring. Inconsistent reporting of patient-centered outcomes and small sample sizes hampered the quality of evidence.

CONCLUSIONS

Improved quality of life after specific mobile applications should be confirmed in powered RCTs and large postmarketing studies.

Exercise Training for Patients With Peripheral Arterial Occlusive Disease

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.

Benefits of Integrating Technology into Home Exercise Therapy in Patients with Lower Extremity Peripheral Artery Disease

(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.

Sex differences in outcomes of exercise therapy for patients with intermittent claudication: A scoping review

Exercise therapy is first-line treatment for intermittent claudication due to peripheral artery disease. We sought to synthesize the literature on sex differences in response to exercise therapy for the treatment of intermittent claudication due to peripheral artery disease. A scoping review was performed (1997 to 2023) using Ovid MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Embase, SPORTDiscus, and Web of Science. Articles were included if they were a scientific report of any measures of health-related quality of life or walking performance after an intervention that included a structured walking program. Of the 13 studies, 11 included measures of walking distance; 7 included measures of walking time, 5 included measures of walking speed, and 4 included quality of life measures. Overall, exercise therapy resulted in significant improvements across most measures of walking performance for both men and females. When comparing magnitudes of outcome improvement by sex, results of walking-based measures were contradictory; some studies noted no difference and others found superior outcomes for men. Results of quality of life-based measures were also contradictory, with some finding no difference and others reporting substantially more improvement for females. Both men and females experienced considerable improvement in walking performance and quality of life with exercise therapy. Evidence regarding the differential effect of exercise therapy on outcomes by sex for intermittent claudication is limited and contradictory. Further efforts should be directed at using standardized interventions and metrics for measuring the outcomes that match the indications for intervention in these patients to better understand the expected benefits and any variance according to sex.

Effects of Long-Term Home Exercise in Participants With Peripheral Artery Disease

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.

Home-Based Walking Exercise and Supervised Treadmill Exercise in Patients With Peripheral Artery Disease: An Individual Participant Data Meta-Analysis

Importance

Few people with lower extremity peripheral artery disease (PAD) participate in supervised treadmill exercise covered by the Center for Medicare and Medicaid Services. In people with PAD, the benefits of home-based walking exercise, relative to supervised exercise, remain unclear.

Objective

To study whether home-based walking exercise improves 6-minute walk (6MW) more than supervised treadmill exercise in people with PAD (defined as Ankle Brachial Index ≤0.90).

Data Sources

Data were combined from 5 randomized clinical trials of exercise therapy for PAD using individual participant data meta-analyses, published from 2009 to 2022.

Study Selection

Of the 5 clinical trials, 3 clinical trials compared supervised treadmill exercise to nonexercise control (N = 370) and 2 clinical trials compared an effective home-based walking exercise intervention to nonexercise control (N = 349).

Data Extraction and Synthesis

Individual participant-level data from 5 randomized clinical trials led by 1 investigative team were combined. The 5 randomized clinical trials included 3 clinical trials of supervised treadmill exercise and 2 effective home-based walking exercise interventions.

Main Outcomes and Measures

Change in 6MW distance, maximum treadmill walking distance, and Walking Impairment Questionnaire at 6-month follow-up. The supervised treadmill exercise intervention consisted of treadmill exercise in the presence of an exercise physiologist, conducted 3 days weekly for up to 50 minutes per session. Home-based walking exercise consisted of a behavioral intervention in which a coach helped participants walk for exercise in or around home for up to 5 days per week for 50 minutes per session.

Results

A total of 719 participants with PAD (mean [SD] age, 68.8 [9.5] years; 46.5% female) were included (349 in a home-based exercise clinical trial and 370 in a supervised exercise trial). Compared with nonexercise control, supervised treadmill exercise was associated with significantly improved 6MW by 32.9 m (95% CI, 20.6-45.6; P < .001) and home-based walking exercise was associated with significantly improved 6MW by 50.7 m (95% CI, 34.8-66.7; P < .001). Compared with supervised treadmill exercise, home-based walking exercise was associated with significantly greater improvement in 6MW distance (between-group difference: 23.8 m [95% CI, 3.6, 44.0; P = .02]) but significantly less improvement in maximum treadmill walking distance (between-group difference:-132.5 m [95% CI, -192.9 to -72.1; P < .001]).

Conclusions and Relevance

In this individual participant data meta-analyses, compared with supervised exercise, home-based walking exercise was associated with greater improvement in 6MW in people with PAD. These findings support home-based walking exercise as a first-line therapy for walking limitations in PAD.

The Effect of Exercise Modalities on Walking Capacity in Patients With Intermittent Claudication: A NETWORK META-ANALYSIS

INTRODUCTION

Despite extensive research on the effect of supervised exercise therapy on walking performance in patients with symptomatic peripheral arterial disease (PAD), it remains unclear which training modality provides the greatest improvement in walking capacity. The objective of this study was to compare the effect of different types of supervised exercise therapy on walking capacity in individuals with symptomatic PAD.

METHODS

A random-effect network meta-analysis was performed. The following databases were searched from January 1966 to April 2021: SPORTDiscus, CINAHL, MEDLINE, AMED, Academic Search Complete and, Scopus. Trials had to include at least one type of supervised exercise therapy for patients with symptomatic PAD, with an intervention lasting ≥2 wk with ≥5 training sessions, and an objective measure of walking capacity.

RESULTS

Eighteen studies were included for a total sample of 1135 participants. Interventions duration ranged from 6-24 wk and included aerobic exercise (treadmill walking, ergometer, and Nordic walking), resistance training (lower and/or upper body), a combination of both, and underwater exercise. Results showed that combined training improved treadmill walking capacity to a comparable extent to aerobic walking (+122.0 [24.2-219.8] m vs +106.8 [34.2-179.4] m), but with a larger effect size (1.20 [0.50-1.90] vs 0.67 [0.22-1.11]). Similar results were observed for the 6-min walk distance, with combined training being the most promising modality (+57.3 [16.2-98.5] m), followed by underwater training (+56.5 [22.4-90.5] m) and aerobic walking (+39.0 [12.8-65.1] m).

CONCLUSION

While not statistically superior to aerobic walking, combined exercise seems to be the most promising training modality. Aerobic walking and underwater training also improved walking capacity for patients with symptomatic PAD.

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

PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Relation of non-exercise walking activity with exercise performance in patients with peripheral artery disease: NEW activity for PAD

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.

Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management

Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.

Maximal calf conductance is associated with 6-minute walk distance in participants with and without peripheral artery disease

INTRODUCTION

The aims were (a) to compare the maximal calf conductance and 6-minute walk distance of participants with and without peripheral artery disease (PAD) and claudication, (b) to determine whether maximal calf conductance was more strongly associated with 6-minute walk distance in participants with PAD than in the controls, and (c) to determine whether this association was significant in participants with PAD after adjusting for ABI, as well as for demographic, anthropometric, and comorbid variables.

METHODS

Participants with PAD (n = 633) and without PAD (n = 327) were assessed on maximal calf conductance using venous occlusion plethysmography, and on 6-minute walk distance. Participants were further characterized on ABI, and on demographic, anthropometric, and comorbid variables.

RESULTS

The PAD group had lower maximal calf conductance than the control group (0.136 ± 0.071 vs 0.201 ± 0.113 mL/100 mL/min/mmHg, p < 0.001). Additionally, the PAD group had a lower 6-minute walk distance (375 ± 98 m vs 480 ± 107 m, p < 0.001). Maximal calf conductance was positively associated with 6-minute walk distance in both groups (p < 0.001) and was more strongly associated in the PAD group (p < 0.001). In adjusted analyses, maximal calf conductance remained positively associated with 6-minute walk distance in the PAD group (p < 0.001) and in the control group (p < 0.001).

CONCLUSIONS

Participants with PAD and claudication had impaired maximal calf conductance and a lower 6-minute walk distance than those without PAD, and maximal calf conductance was positively and independently associated with 6-minute walk distance within each group before and after adjusting for ABI, and for demographic, anthropometric, and comorbid variables.

Association between home-based exercise using a pedometer and clinical prognosis after endovascular treatment in patients with peripheral artery disease

BACKGROUND

Exercise therapy following endovascular treatment (EVT) is important for patients with peripheral artery disease (PAD); however, continuous exercise therapy is difficult to be performed in clinical practice. This study aimed to investigate the association between the implementation of home-based exercise using pedometers after EVT and 1-year clinical outcomes.

METHODS

This multicenter observational prospective cohort registry included patients with PAD complaining of intermittent claudication who underwent EVT for aortoiliac and/or femoropopliteal artery lesions between January 2016 and March 2019. Patients were instructed to perform home-based exercises using a specific pedometer after EVT. The study population was divided into good and poor recording groups according to the frequency of the pedometer measurements. The good recording group was defined as those who completed ≥50 % of the prescribed daily pedometer recording during the follow-up period. The poor recording group was defined as those with an inability to use a pedometer and/or who completed <50 % of the prescribed daily pedometer recordings. The primary outcome was 1-year major adverse events (MAE), defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, target vessel revascularization, and major amputation of the target limb.

RESULTS

The mean age was 74.4 years; 78 % were male. A total of 623 lesions were analyzed (58.7 % aortoiliac, 41.3 % femoropopliteal). At 1 year, a lower cumulative incidence of MAE was observed in the good recording group compared to that in the poor recording group [10/233 (4.3 %) vs. 35/267 (13.7 %) patients, respectively; p < 0.001]. Multivariate Cox regression analysis showed that patients in the good recording group had a lower hazard ratio for 1-year MAE (0.33; 95 % confidence interval, 0.16-0.68; p = 0.004) than that in the poor recording group.

CONCLUSIONS

Good self-recording of pedometer measurements was associated with favorable prognosis in patients with PAD following EVT.

Barriers to participation in supervised exercise therapy reported by people with peripheral artery disease

OBJECTIVE

This study identified barriers to participation in supervised exercise therapy covered by the Centers for Medicare and Medicaid Services (CMS), reported by people with lower extremity peripheral artery disease (PAD).

METHODS

People with PAD participating in research studies of walking impairment due to PAD in the Chicagoland area were asked to complete a questionnaire between March 15, 2019, and July 12, 2022, assessing their experience and attitudes about supervised exercise therapy. Participants were identified using mailed postcards to people aged 50 and older in Chicagoland, from medical centers in Chicago, and using bus and train advertisements. The questionnaire was developed based on focus group feedback from people with PAD.

RESULTS

Of 516 participants with PAD approached, 489 (94.8%) completed the questionnaire (mean age: 71.0 years [standard deviation: 8.7], mean ankle-brachial index: 0.71 [standard deviation: 0.25]; 204 [41.7%] women and 261 [53.4%] Black). Of the 489 participants, 416 (85.1%) reported that their physician had never prescribed or recommended supervised exercise therapy. Overall, 357 (73.2%) reported willingness to travel three times weekly to the medical center for supervised exercise participation. However, of these, 214 (59.9%) reported that they were unwilling or unable to pay the $11 per exercise session copay required for supervised exercise covered by CMS. Of 51 people with PAD who reported prior participation in supervised exercise, only 5 (9.8%) completed the 12 weeks of supervised exercise therapy covered by CMS and 29 (56.9%) completed 6 or fewer weeks. Of 131 (26.8%) unwilling to travel three times weekly to a center for supervised exercise, the most common reasons for unwillingness to participate were "too time-consuming" (55.0%), "too inconvenient" (45.8%), and "lack of interest in treadmill exercise" (28.2%).

CONCLUSIONS

Approximately 2 to 4 years after CMS began covering supervised exercise for PAD, most people with PAD in this study from a large urban area had not participated in supervised exercise therapy. Of those who participated, most completed fewer than half of the sessions covered by CMS. The required CMS copayment was a common barrier to supervised exercise participation by people with PAD.

The Role of Neutrophils in Lower Limb Peripheral Artery Disease: State of the Art and Future Perspectives

In recent years, increasing attention has been paid to the role of neutrophils in cardiovascular (CV) disease (CVD) with evidence supporting their role in the initiation, progression, and rupture of atherosclerotic plaque. Although these cells have long been considered as terminally differentiated cells with a relatively limited spectrum of action, recent research has revealed intriguing novel cellular functions, including neutrophil extracellular trap (NET) generation and inflammasome activation, which have been linked to several human diseases, including CVD. While most research to date has focused on the role of neutrophils in coronary artery and cerebrovascular diseases, much less information is available on lower limb peripheral artery disease (PAD). PAD is a widespread condition associated with great morbidity and mortality, though physician and patient awareness of the disease remains low. To date, several studies have produced some evidence on the role of certain biomarkers of neutrophil activation in this clinical setting. However, the etiopathogenetic role of neutrophils, and in particular of some of the newly discovered mechanisms, has yet to be fully elucidated. In the future, complementary assessment of neutrophil activity should improve CV risk stratification and provide personalized treatments to patients with PAD. This review aims to summarize the basic principles and recent advances in the understanding of neutrophil biology, current knowledge about the role of neutrophils in atherosclerosis, as well as available evidence on their role of PAD.

Supervised Exercise Therapy for Symptomatic Peripheral Artery Disease: A REVIEW OF CURRENT EXPERIENCE AND PRACTICE-BASED RECOMMENDATIONS

PURPOSE

This review encompasses several practical components of supervised exercise therapy (SET) for patients with claudication including referral, exercise training, and billing issues. Real-life SET session examples are also provided. SET was approved for reimbursement by the Centers for Medicare & Medicaid Services (CMS) in 2017, and there is continual growth of programs offering SET and in participation. The purpose of this review is to provide useful information for the clinical exercise professionals working with these patients.

REVIEW METHODS

The 2016 ACC/AHA Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease (PAD) provided a class I (highest level) recommendation for the use of SET in those with symptomatic PAD. Since there has been much growth in the literature about the utility of SET, the literature was reviewed (PubMed) to provide information for this article. Topics reviewed include the benefits of exercise training, exercise prescription, billing, referral and participation, and best practices.

SUMMARY

SET should be offered to all patients with symptomatic PAD who are not at risk of acute limb ischemia. For optimal results, SET should be implemented several times per week and in a progressive process to increase exercise intensity as tolerated. For best results, programs should recommend patients supplement SET with home exercise. Considerations for utilizing reimbursed sessions should also be discussed because patients have a maximum of 72 sessions/lifetime. Referral practices need refinement, and participation rates remain extremely low and may be influenced by demographics. Research on best practices and home or hybrid training must continue to address issues related to common enrollment and participation barriers.

CONDENSED ABSTRACT

Supervised exercise training (SET) for symptomatic peripheral artery disease is a class IA recommendation and reimbursable by most insurances. Improvements in walking performance can be dramatic. However, referral and participation in SET remain very low and thus SET is vastly underutilized.

Increased pulse wave velocity is related to impaired working memory and executive function in older adults with metabolic syndrome

Age-related vascular alterations promote the pathogenesis of vascular cognitive impairment (VCI). Cardiovascular risk factors that accelerate vascular aging exacerbate VCI. Metabolic syndrome (MetS) constitutes a cluster of critical cardiovascular risk factors (abdominal obesity, hypertension, elevated triglycerides, elevated fasting glucose, reduced HDL cholesterol), which affects nearly 37% of the adult US population. The present study was designed to test the hypotheses that MetS exacerbates cognitive impairment and that arterial stiffening moderates the association between cognitive dysfunction and MetS in older adults. MetS was defined by the NCEP ATP III guidelines. Cognitive function (digit span and trail-making tests) and brachial-ankle pulse wave velocity (baPWV; a non-invasive clinical measurement of arterial stiffness) were assessed in older adults with MetS and age- and sex-matched controls. Multiple linear regression models were applied to test for the main effects of MetS, baPWV, and their interaction on cognitive performance. Fifty-three participants with MetS (age: 68 ± 8 years) and 39 age-matched individuals without MetS (age: 66 ± 9 years) were enrolled into the study. In adjusted multivariable regression analyses of the digit span backward length score, both MetS (ß = 1.97, p = 0.048) and MetS by baPWV interaction (ß =  - 0.001, p = 0.026) were significant predictors. In participants with MetS, higher baPWV was associated with poorer performance on digit span backward length score, a test of working memory (R =  - 0.44, p = 0.0012), but there was no association in those without MetS (R = 0.035, p = 0.83). MetS was negatively associated with performance on the digit span backward length score, baPWV was negatively associated with multiple neuropsychological outcomes, and baPWV moderated the association between digit span backward length score and MetS, as individuals with both MetS and higher baPWV had the most impaired cognitive function. Our findings add to the growing body of evidence that individuals with MetS and higher baPWV may be prone to VCI.

The effect of resistance training on functional capacity in middle-aged to elderly individuals with peripheral artery disease: a meta-analysis

INTRODUCTION

Peripheral artery disease (PAD) is an ischemic disease of the lower limbs, caused by atherosclerotic plaques, leading to impairments in functional capacity and reduced quality of life. This meta-analysis aimed to assess the effect of 12-week and 24-week resistance training (RT) interventions on 6-minute walking distance (6WMD) and initial claudication distance (ICD) measured during a 6-minute walk test (6MWT).

EVIDENCE ACQUISITION

A meta-analysis was conducted in accordance with PRISMA guidelines, with an electronic search conducted using the online database of PUBMED. Methodological quality of all included studies was completed using a modified version of the Newcastle Ottawa Scale (NOS). The effect sizes (ES) of 6MWD and ICD were calculated, with the 12-week and 24-week interventions analyzed separately.

EVIDENCE SYNTHESIS

An initial literature search yielded 1973 results that were consequently reduced to 7 studies to be included in the final meta-analysis. The pooled effect size for 6MWD for 12-week and 24-week interventions was ES=0.189 [95% CI: -0.074 to 0.451] P=0.159 and ES=0.298 [95% CI: -0.036 to 0.631] P=0.080 respectively. For ICD, ES=0.498 [95% CI: 0.000 to 0.995] P=0.050 and ES: 1.106 [95% CI: 0.120 to 0.428] P=0.001 respectively.

CONCLUSIONS

Short-term RT interventions have a positive effect on functional capacity in middle-aged to elderly individuals with PAD. There was a greater effect on ICD compared to 6MWD, with 24-week interventions showing larger effects for both measures. Improvements in functional capacity in such populations confers significant potential for positive health outcomes.

Smart Wearable Systems for the Remote Monitoring of Selected Vascular Disorders of the Lower Extremity: A Systematic Review

This systematic review aims at providing an overview of the state of the art regarding smart wearable systems (SWS) applications to monitor the status of patients suffering from vascular disorders of the lower extremity. Peer-reviewed literature has been analyzed to identify employed data collection methods, system characteristics, and functionalities, and research challenges and limitations to be addressed. The Medline (PubMed) and SCOPUS databases were considered to search for publications describing SWS for remote or continuous monitoring of patients suffering from intermittent claudication, venous ulcers, and diabetic foot ulcers. Publications were first screened based on whether they describe an SWS applicable to the three selected vascular disorders of the lower extremity, including data processing and output to users. Information extracted from publications included targeted disease, clinical parameters to be measured and wearable devices used; system outputs to the user; system characteristics, including capabilities of remote or continuous monitoring or functionalities resulting from advanced data analyses, such as coaching, recommendations, or alerts; challenges and limitations reported; and research outputs. A total of 128 publications were considered in the full-text analysis, and 54 were finally included after eligibility criteria assessment by four independent reviewers. Our results were structured and discussed according to three main topics consisting of data collection, system functionalities, and limitations and challenges.

Apple Watch-guided diagnosis of AVNRT in a pregnant woman—A case report and literature review

Cardiac arrhythmias occurring during pregnancy pose a therapeutic problem as antiarrhythmic drugs can be potentially harmful to the fetus. A 35-years-old woman in the 20th week of pregnancy was admitted to the Department of Cardiology due to the first episode of arrhythmia in her life. During the event, the patient was wearing an Apple Watch Series 6, which records a 30-sec single-channel ECG. The recording showed narrow QRS complex tachycardia of 216 bpm, and short RP interval and atrioventricular nodal reentrant tachycardia (AVNRT) was recognized. Due to the mild nature of the arrhythmia, antiarrhythmic pharmacotherapy was not initiated. The use of mobile health (mHealth) devices such as wearables and health monitoring applications is now a valuable addition to routine cardiac diagnostics for patients of all ages and levels of cardiovascular risk.

Association Between Meeting Physical Activity Time-Intensity Guidelines With Ambulation, Quality of Life, and Inflammation in Claudication

PURPOSE

The aim of this investigation was to determine if meeting the 2018 physical activity (PA) time-intensity guidelines was associated with better ambulatory function, health-related quality of life (HRQoL), vascular function, and inflammation than failing to meet the guidelines in patients with peripheral artery disease and claudication. Second, we determined the optimal number of total steps/d and steps taken at moderate cadence needed to meet the PA time-intensity guidelines.

METHODS

Five hundred seventy-two patients were assessed on daily ambulatory activity for 1 wk with a step activity monitor, and were grouped according to whether they achieved <150 min/wk of moderate-intensity PA (group 1 = do not meet guidelines; n = 397) or whether they were above this threshold (group 2 = meet guidelines; n = 175).

RESULTS

Treadmill peak walking time (mean ± SD) was higher ( P < .001) in group 2 (709 ± 359 sec) than in group 1 (427 ± 281 sec). The physical function HRQoL score was higher ( P < .001) in group 2 (61 ± 22%) than in group 1 (44 ± 21%). High-sensitivity C-reactive protein was lower ( P < .001) in group 2 (3.6 ± 4.5 mg/L) than in group 1 (5.9 ± 6.1 mg/L). Finally, ≥7675 total steps/d and ≥1660 steps/d at moderate cadence were optimal thresholds associated with meeting PA guidelines.

CONCLUSIONS

Patients with claudication who meet the 2018 PA time-intensity guidelines for US adults had better ambulation, HRQoL, and vascular outcomes than those who failed to meet the PA guidelines. Patients with claudication best achieved the PA time-intensity guidelines by taking ≥7675 total steps/d, and ≥1660 steps/d at a moderate cadence.

Network Meta-Analysis of Trials Testing If Home Exercise Programs Informed by Wearables Measuring Activity Improve Peripheral Artery Disease Related Walking Impairment

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.

Supervised exercise training in patients with lower extremity peripheral artery disease

Summary: The optimal first line management of patients with symptomatic chronic lower extremity peripheral artery disease (PAD) includes secondary prevention of cardiovascular risk factors, pharmacological treatment, and supervised exercise therapy (SET). SET programs have shown to be effective in improving walking performance, functional performance, and quality of life. However, despite a large body of evidence, and despite national and international guidelines recommending SET as first line therapy, SET remains largely underused in patients with chronic PAD. This position paper aims to describe how SET is perceived, its accessibility and structure through Europe. An anonymous web-based survey was used. It comprised 21 questions developed in conjunction with an angiologist and a clinical exercise physiologist specialist in vascular rehabilitation. We had 131 responders from 17 countries. For patients with PAD, SET programs exist only in 59% of European countries. SET reimbursement is available in 41% of countries. SET programs showed to be heterogeneous across countries. Thirty-four percent of the SET programs are PAD-dedicated, while 23% are part of a cardiac rehabilitation program. In addition, among existing SET programs, 65% are dedicated to symptomatic patients with PAD only, 9% to both asymptomatic and symptomatic, 8% to post-revascularized patients only, and 1% to asymptomatic patients with PAD only. Finally, 17% reported not knowing which patients are eligible for enrolment in a SET program. Duration, frequency, and modality of SET also varied from country to country. Overall, these data indicate that a large variability of SET availability and characteristics exists across Europe. Therefore, there is an urgent need to provide detailed guidance to deliver optimal exercise therapeutic care in patients with PAD.

Effects of home-based leg heat therapy on walking performance in patients with symptomatic peripheral artery disease: a pilot randomized trial

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.

Mobile health platform based on user-centered design to promote exercise for patients with peripheral artery disease

Background

Peripheral artery disease (PAD) is a cardiovascular disease that can be improved by risk factor modification. Mobile health (mHealth) intervention is an effective method of healthcare delivery to promote behavior changes. An mHealth platform can encourage consistent involvement of participants and healthcare providers for health promotion. This study aimed to develop an mHealth platform consisting of a smartphone application (app) synchronized with a wearable activity tracker and a web-based portal to support exercise intervention in patients with PAD.

Methods

This study was conducted based on an iterative development process, including analysis, design, and implementation. In the analysis phase, a literature review and needs assessment through semi-structured interviews (n = 15) and a questionnaire-based survey (n = 138) were performed. The initial prototype design and contents were developed based on the users’ requirements. In the implementation phase, multidisciplinary experts (n = 4) evaluated the heuristics, following which the mHealth platform was revised. User evaluation of the usability was performed by nurses (n = 4) and patients with PAD (n = 3).

Results

Through the development process, the functional requirements of the platform were represented through visual display, reminder, education, self-monitoring, goal setting, goal attainment, feedback, and recording. In-app videos of exercise and PAD management were produced to provide information and in-app automatic text messages were developed for user motivation. The final version of the platform was rated 67.86 out of 100, which indicated “good” usability.

Conclusions

The mHealth platform was designed and developed for patients with PAD and their healthcare providers. This platform can be used to educate and promote individualized exercise among patients with PAD.

Near-Infrared Spectroscopy Used to Assess Physiological Muscle Adaptations in Exercise Clinical Trials: A Systematic Review

Simple Summary

In recent years, physical exercise has been used as a therapeutic strategy in various clinical conditions, with pleiotropic benefits. Near-infrared spectroscopy (NIRS) has been positioned as a tool to analyze effects on muscle oxygenation, also allowing knowledge of adaptations on microvascular levels and muscle metabolism in subjects with central and peripheral vascular alterations, as well as cardiovascular, metabolic, and/or musculoskeletal diseases. This knowledge can help to guide therapeutic exercise specialists in decision making regarding the prescription and follow up of physical exercise as a therapeutic tool in the observation of acute or chronic adaptations to improve efficiency in the treatment and recovery of these patients. This review presents an overview of the effects of exercise clinical trials on muscle oxygenation in different pathologies and the technical characteristics related to the equipment used.

Abstract

Using muscle oxygenation to evaluate the therapeutic effects of physical exercise in pathologies through near-infrared spectroscopy (NIRS) is of great interest. The aim of this review was to highlight the use of muscle oxygenation in exercise interventions in clinical trials and to present the technological characteristics related to the equipment used in these studies. PubMed, WOS, and Scopus databases were reviewed up to December 2021. Scientific articles that evaluated muscle oxygenation after exercise interventions in the sick adult population were selected. The PEDro scale was used to analyze the risk of bias (internal validity). The results were presented grouped in tables considering the risk of bias scores, characteristics of the devices, and the effects of exercise on muscle oxygenation. All the stages were carried out using preferred reporting items for systematic reviews and meta-analyses (PRISMA). The search strategy yielded 820 clinical studies, of which 18 met the eligibility criteria. This review detailed the characteristics of 11 NIRS devices used in clinical trials that used physical exercise as an intervention. The use of this technology made it possible to observe changes in muscle oxygenation/deoxygenation parameters such as tissue saturation, oxyhemoglobin, total hemoglobin, and deoxyhemoglobin in clinical trials of patients with chronic disease. It was concluded that NIRS is a non-invasive method that can be used in clinical studies to detect the effects of physical exercise training on muscle oxygenation, hemodynamics, and metabolism. It will be necessary to unify criteria such as the measurement site, frequency, wavelength, and variables for analysis. This will make it possible to compare different models of exercise/training in terms of time, intensity, frequency, and type to obtain more precise conclusions about their benefits for patients.

A Systematic Review on Smartphone Use for Activity Monitoring During Exercise Therapy in Intermittent Claudication

OBJECTIVE

Supervised exercise therapy (SET) is recommended as first line in the management of intermittent claudication (IC). Its use is often limited by accessibility, compliance and cost. Home-based exercise therapy (HBET) programs emerged as an alternative solution, but have shown inferior results. Employment of structured monitoring with the use of external wearable activity monitors (WAM) has been shown to improve outcomes. Mobile applications can make use of built-in accelerometers of modern smartphones and become an alternative solution for monitoring patients during HBET, potentially providing wider accessibility. This review aims to assess current use of smartphone technology (i.e., mobile apps) for monitoring or tracking patients' activity in exercise therapy for peripheral arterial disease (PAD).

METHODS

The PubMed database was searched from January 2011 to September 2021. Eligible articles had to include a population of patients with PAD, conduct a mobile-health (m-health) exercise intervention and use smartphone technology for monitoring or tracking patients' activity. Randomized control trials (RCTs), prospective studies, and study protocols were included.

RESULTS

A total of seven articles met the selection criteria. These described six different studies and five different mobile applications. Three were fitness apps (FitBit, Nike+ FuelBand and Garmin Connect) that synchronized with commercially available WAMs to provide users with feedback. Two were PAD-specific apps (TrackPAD and Movn) developed specifically to assess patients' activity during exercise therapy. PAD-specific apps also incorporated coaching and educational elements such as weekly goal setting, claudication reminders, messaging, gamification, training advice and PAD education.

CONCLUSION

Current HBET programs use smartphone applications mainly via commercially available fitness apps that synchronize with WAM devices to register and access data. PAD-specific apps are scarce but show promising features that can be used to monitor, train, coach, and educate patients during HBET programs. Larger studies combining these elements into HBET programs should provide future direction.

Decision Aids for Determining Facility Versus Non-Facility-Based Exercise in Those with Symptomatic Peripheral Artery Disease

Purpose of Review

This paper sought to provide rationale for determining when a patient with symptomatic peripheral artery disease (PAD) might be referred for home-based versus facility-based exercise therapy.

Recent Findings

Multiple randomized controlled studies have embedded supervised, structured exercise therapy as a class IA recommended therapy for those with symptomatic PAD. More recently, there is interest in non-facility-based exercise training as an alternative. The current literature is mixed on the effectiveness of non-facility-based training and is influenced by the amount of contact with clinical staff providing some supervision (e.g., occasional facility-based exercise or coaching phone calls), and the intensity (e.g., performed intermittently by inducing pain or continually and not inducing pain) and frequency (e.g., 12-week common supervised exercise program or those longer than 24 weeks) of exercise. Certainly, the data suggests non-facility-based exercise, while possibly improving walking performance, is inferior to facility-based supervised exercise training. Comprehensive data is lacking on utilization of supervised exercise therapy in those with symptomatic PAD, but is likely <2% of those eligible who participate. This suggests a possible important role for alternatives including non-facility-based (e.g., home, fitness center).

Summary

Exercise training in the supervised, facility-based setting appears to be greatly underutilized. Non-facility-based exercise may help to overcome some of the most common barriers to participating in facility-based exercise including those related to motivation, transportation, and proximity. However, facility-based training is considered the gold standard so decisions about allowing a patient to exercise train at home must take into account issues including disease severity, patient motivation and available exercise resources, mobility and balance, cognitive function, and other medical concerns (e.g., symptomatic coronary artery disease or heart failure).

Major Adverse Events in Patients with Peripheral Artery Disease after Endovascular Revascularization: A Retrospective Study

OBJECTIVE

For peripheral artery disease (PAD) patients, after endovascular revascularization, it is crucial to manage associated factors that can affect the risk of major adverse events. We aimed to investigate the associated factors of major adverse events in these patients.

MATERIALS AND METHODS

We conducted a retrospective longitudinal analysis using the electronic medical records from a tertiary hospital in Korea and included the data of 1263 patients. Eligible patients were categorized into four groups based on diabetes mellitus (DM) and regular exercise. The major adverse events included major adverse limb events and major adverse cardiovascular events. Major adverse events-free survival was assessed using the Kaplan-Meier method, and associated factors of major adverse events were analyzed using Cox proportional hazards analyses.

RESULTS

Kaplan-Meier survival curves showed that patients with DM and non-regular exercise had a shorter major adverse events-free survival. The Cox regression analysis showed that for patients with critical limb ischemia or chronic kidney disease, the risk of major adverse events increased, while group variables were not significant.

CONCLUSION

Target management of patients with DM, critical limb ischemia, and chronic kidney disease is essential to reduce major adverse events after endovascular revascularization in patients with PAD.

Society for Vascular Surgery Appropriate Use Criteria for Management of Intermittent Claudication

The Society for Vascular Surgery (SVS) Appropriate Use Criteria (AUC) for Management of Intermittent Claudication were created using the RAND appropriateness method (RAM) which is a validated and standardized methodology that combines best-available evidence from medical literature with expert opinion, using a modified-Delphi process. These criteria serve as a framework upon which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition on treatments rated as inappropriate (risk outweighs benefit). There will be clinical situations in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC calls for a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with best available evidence should determine treatment strategy. Importantly, these are scenarios in need of mechanisms to track treatment decisions and outcomes. AUC should be revisited on a periodic basis to ensure that these criteria remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral and femoropopliteal segment in Round 2 rating. Of these, only 9 (0.4%) had disagreement according to the IPRAS formula, indicating an exceptionally high degree of consensus among the panelists. [Note, post-hoc, the term, "inappropriate," was replaced with the term "R>B" (risk outweighs benefit). The term "appropriate" was also replaced with "B>R" (benefit outweighs risk)]. The key principles for the management of intermittent claudication reflected within these AUC are: (1) Exercise therapy is a preferred initial management strategy for all patients with IC. (2) For patients who have not completed exercise therapy, invasive therapy may provide net benefit in selected patients with IC who are non-smokers, are taking optimal medical therapy, are considered low physiologic and technical risk, and who are experiencing severe lifestyle limitation and/or short walking distance. (3) Considering the long-term durability of currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitation and short walking distance. (4) In the common femoral segment, open common femoral endarterectomy provides greater net benefit than endovascular intervention for the treatment of IC. (5) In the infrapopliteal segment, invasive intervention for the treatment of intermittent claudication is of unclear benefit and may be harmful.

Primärtherapie der Claudicatio intermittens – Anspruch und Wirklichkeit

Die narrative Übersichtsarbeit fasst die Studienlage zum Thema Gehtraining bei Patienten mit Claudicatio intermittens (CI) zusammen. Eindringlich wird auf die evidenzbasierten Leitlinienempfehlungen und die dahinterstehenden Studien eingegangen. Aspekte zum angiomorphologischen Befund, zu Patientenadhärenz, Langzeitwirkung, Studienqualität und ihre Vergleichbarkeit werden diskutiert. Der Problematik in der Versorgungsrealität mit Abweichungen von den Leitlinien und der oftmals invasiven Erstlinientherapie des PAVK-IIb-Patienten werden besondere Bedeutung geschenkt. Dabei wird die Rolle des Rehasports und die gesundheitspolititsche Bedeutung von Gehtraining in Deutschland erörtert. Gründe für die fehlende Leitlinientreue und deren Umsetzung im Gesundheitssystem werden analysiert. Dementsprechend werden Handlungsempfehlungen, in Anlehnung an internationale Erfahrungen (Niederlande, Dänemark), zur Besserung der Situation in Deutschland formuliert.

Effect of a Home-Based, Walking Exercise Behavior Change Intervention vs Usual Care on Walking in Adults With Peripheral Artery Disease: The MOSAIC Randomized Clinical Trial

Importance

Home-based walking exercise interventions are recommended for people with peripheral artery disease (PAD), but evidence of their efficacy has been mixed.

Objective

To investigate the effect of a home-based, walking exercise behavior change intervention delivered by physical therapists in adults with PAD and intermittent claudication compared with usual care.

Design, Setting, and Participants

Multicenter randomized clinical trial including 190 adults with PAD and intermittent claudication in 6 hospitals in the United Kingdom between January 2018 and March 2020; final follow-up was September 8, 2020.

Interventions

Participants were randomized to receive a walking exercise behavior change intervention delivered by physical therapists trained to use a motivational approach (n = 95) or usual care (n = 95).

Main Outcomes and Measures

The primary outcome was 6-minute walking distance at 3-month follow-up (minimal clinically important difference, 8-20 m). There were 8 secondary outcomes, 3 of which were the Walking Estimated Limitation Calculated by History (WELCH) questionnaire (score range, 0 [best performance] to 100), the Brief Illness Perceptions Questionnaire (score range, 0 to 80 [80 indicates negative perception of illness]), and the Theory of Planned Behavior Questionnaire (score range, 3 to 21 [21 indicates best attitude, subjective norms, perceived behavioral control, or intentions]); a minimal clinically important difference was not defined for these instruments.

Results

Among 190 randomized participants (mean age 68 years, 30% women, 79% White race, mean baseline 6-minute walking distance, 361.0 m), 148 (78%) completed 3-month follow-up. The 6-minute walking distance changed from 352.9 m at baseline to 380.6 m at 3 months in the intervention group and from 369.8 m to 372.1 m in the usual care group (adjusted mean between-group difference, 16.7 m [95% CI, 4.2 m to 29.2 m]; P = .009). Of the 8 secondary outcomes, 5 were not statistically significant. At 6-month follow-up, baseline WELCH scores changed from 18.0 to 27.8 in the intervention group and from 20.7 to 20.7 in the usual care group (adjusted mean between-group difference, 7.4 [95% CI, 2.5 to 12.3]; P = .003), scores on the Brief Illness Perceptions Questionnaire changed from 45.7 to 38.9 in the intervention group and from 44.0 to 45.8 in the usual care group (adjusted mean between-group difference, -6.6 [95% CI, -9.9 to -3.4]; P < .001), and scores on the attitude component of the Theory of Planned Behavior Questionnaire changed from 14.7 to 15.4 in the intervention group and from 14.6 to 13.9 in the usual care group (adjusted mean between-group difference, 1.4 [95% CI, 0.3 to 2.5]; P = .02). Thirteen serious adverse events occurred in the intervention group, compared with 3 in the usual care group. All were determined to be unrelated or unlikely to be related to the study.

Conclusions and Relevance

Among adults with PAD and intermittent claudication, a home-based, walking exercise behavior change intervention, compared with usual care, resulted in improved walking distance at 3 months. Further research is needed to determine the durability of these findings.

Trial Registrations

ISRCTN Identifier: 14501418; ClinicalTrials.gov Identifier: NCT03238222.

Near infrared spectroscopy to evaluate the effect of a hybrid exercise programme on peripheral muscle metabolism in patients with intermittent claudication: an exploratory PROSECO-IC sub study

Intermittent claudication (IC) is characterized by decreased blood flow and oxygen delivery to the lower-limb muscles, resulting in pain and impaired functional capacity. This study evaluated the effects of a 12-week hybrid walking intervention on muscle oxygenation and functional capacity in 38 patients with IC (Rutherford I-III). Functional capacity was evaluated by means of two different treadmill test protocols and a six-minute walk test (6MWT). Muscle oxygenation was assessed during the treadmill tests using near-infrared spectroscopy. After the intervention, maximal walking distance was significantly increased (p < 0.001) during the progressive maximal treadmill test (mean (SD): +155 (SD 177) metres) and 6MWT (+18 (SD 29) metres) metres, with concomitant improvements in muscle oxygenation measures. Deoxygenation was slower during the progressive maximal test (p < 0.001) and reoxygenation was faster during recovery (p = 0.045). During the more submaximal test, oxygenated haemoglobin was better preserved (p = 0.040). Slower deoxygenation was more pronounced in the high responders of the progressive maximal treadmill test (p = 0.002). The findings suggest that preserved oxygen availability and slower deoxygenation during exercise could partly explain the improvements in functional capacity.

Connecting the past to the present: A historical review of exercise training for peripheral artery disease

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.

Minimal clinically important differences in daily physical activity outcomes following supervised and home-based exercise in peripheral artery disease

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.

A systematic review of exercise intervention reporting quality and dose in studies of intermittent claudication

BACKGROUND

Exercise therapy is an important treatment option for people with intermittent claudication (IC). Appropriate reporting of exercise interventions in populations with IC within randomised controlled trials (RCTs) is important to ensure that research can be translated into clinical practice. Therefore, the purpose of our review is to evaluate the reporting of exercise interventions in RCTs of exercise therapy in patients with IC.

METHODS

A systematic search was performed to identify relevant trials in patients with IC published until May 2020. Studies including only participants with critical limb ischaemia or asymptomatic peripheral artery disease were excluded. Each trial was scored using the recently developed 'Consensus on Exercise Reporting Template' (CERT) which has a maximum obtainable score of 19.

RESULTS

Of 1489 unique records identified from the search, 73 trials were included, reporting 107 exercise interventions. Overall, the average CERT score was 10/19. The exercise equipment used, the use of supervision and a description of whether the exercise prescription was tailored or generic were the most frequently reported intervention components. The motivational strategies used, intervention adherence and intervention fidelity were the most underreported CERT components. There was no trend indicating that CERT scores were higher in more recent publications.

CONCLUSIONS

We have identified that important details about exercise interventions are frequently missing from the published literature. These missing data hinder replication of research findings and limit the translation of evidence into clinical practice.

Supervised exercise therapy for patients with peripheral artery disease: Clinical update and pathways forward

Peripheral artery disease (PAD) is an atherosclerotic vascular disease resulting in widespread morbidity and mortality, particularly among older adults. One first-line therapy to improve symptoms, function, and clinical outcomes in PAD is supervised exercise therapy (SET), which is based primarily on a structured, start-and-stop walking protocol and is implemented in cardiac rehabilitation programs. SET is supported by a Class IA guideline for patients with symptomatic PAD; however, despite the effectiveness of SET and the 2017 CMS decision to cover SET for PAD, challenges of awareness, access, and implementation of SET persist. Recent efforts to address these challenges include digital health and hybrid approaches to SET that may minimize barriers to care by delivering SET in more innovative, flexible formats. Further study is needed to understand barriers, improve awareness, and implement SET in more equitable and accessible ways.

Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era

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.

LIGHT AND MODERATE INTENSITY PHYSICAL ACTIVITY ARE ASSOCIATED WITH BETTER AMBULATION, QUALITY OF LIFE, AND VASCULAR MEASUREMENTS IN PATIENTS WITH CLAUDICATION

OBJECTIVES

To determine whether patients with claudication who reported performing either light-intensity physical activity (LPA) or moderate-to-vigorous intensity physical activity (MVPA) had higher levels of objectively-determined physical activity, and better physical function, health-related quality of life (HRQoL), and vascular measures, consisting of exercise time to minimum calf muscle oxygen saturation (StO₂) and high-sensitivity C-reactive protein, than patients who reported being physically sedentary.

METHODS

Two hundred sixty-nine patients were assessed on the Johnson Space Center physical activity scale. Patients were grouped according to whether they performed no physical activities (n=75), LPA (n=140), or MVPA (n=54). Primary measurements were total daily steps obtained from a step activity monitor worn for one week, peak walking time obtained from a treadmill test, the physical function score on the Medical Outcomes Study Short-Form 36 survey to assess HRQoL, and high-sensitivity C-reactive protein.

RESULTS

Total daily steps (mean±SD) was significantly different among groups, as both the LPA group (7878±2808 steps/day) and the MVPA group (8551±3365 steps/day) took more daily steps (p<0.01) than the sedentary group (3323±986 steps/day). Treadmill peak walking time was significantly different among groups, as both the LPA group (433±296 sec) and the MVPA group (548±300 sec) had greater peak walking time (p<0.01) than the sedentary group (302±210 sec). Physical function score was significantly different among groups, as both the LPA group (44±20%) and the MVPA group (58±19%) had higher scores (p<0.01) than the sedentary group (36±20%). Exercise time to the minimum calf muscle StO₂ was significantly different among groups, as both the LPA group (215±238 sec) and the MVPA group (377±351 sec) had greater values (p<0.05 and p<0.01, respectively) than the sedentary group (147±172 sec). Finally, high-sensitivity C-reactive protein was significantly different among groups, as both the LPA group (4.8±5.5 mg/L) and the MVPA group (3.5±3.6 mg/L) had lower values (p<0.01) than the sedentary group (8.6±8.4 mg/L).

CONCLUSIONS

Patients with claudication who reported performing LPA had greater amounts of objectively-determined physical activity levels and better physical function, HRQoL, and vascular measures than those who reported being physically sedentary. Furthermore, these favorable results associated with LPA were even more pronounced in patients who performed MVPA than in patients who were sedentary. The clinical significance is that engaging in any physical activity, even at relatively light intensity, is associated with favorable health and vascular measures in patients with claudication.