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

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.

Editor's Choice - Effect of Physical Activity and Tobacco Use on Mortality and Morbidity in Patients with Peripheral Arterial Disease After Revascularisation: A Korean Nationwide Population Based Cohort Study

OBJECTIVE

To investigate the effects of physical activity (PA) and tobacco use on adverse clinical outcomes after revascularisation for peripheral arterial disease (PAD) in the Western Pacific region, where PAD cases and tobacco use are among the highest in the world.

METHODS

This was a retrospective cohort study using the Korean National Health Insurance Service (NHIS) database and included patients who had received revascularisation for PAD between 2010 and 2015. They were categorised as active or inactive based on the number of days per week they engaged in PA and as current or non-tobacco users (self report). The primary outcome was all cause mortality. Secondary outcomes included major adverse outcome (a composite of all cause mortality, myocardial infarction, and stroke) and major adverse limb event (MALE, a composite of amputation and recurrent revascularisation).

RESULTS

The relatively healthy cohort comprised 8 324 patients (mean age 64.7 years; 76.9% male) following revascularisation for PAD. Among them, 32.7% were inactive and 26.4% were tobacco users. Active patients had better outcomes than inactive patients (all cause mortality adjusted hazard ratio [adjHR] 0.766; 95% CI 0.685 - 0.855, major adverse outcome adjHR 0.795; 95% CI 0.719 - 0.878, MALE adjHR 0.858; 95% CI 0.773 - 0.953). Tobacco users had poorer outcomes than non-users (all cause mortality adjHR 1.279; 95% CI 1.124 - 1.456, major adverse outcome adjHR 1.263; 95% CI 1.124 - 1.418, MALE adjHR 1.291; 95% CI 1.143 - 1.458).

CONCLUSION

Even after receiving revascularisation for PAD, a sizable proportion of patients were physically inactive and used tobacco, leading to adverse clinical outcomes such as death, cardiovascular morbidity, and amputation in Korea. These modifiable risk factors should be addressed systematically, and a comprehensive approach including supervised exercise programmes and tobacco cessation is needed in patients with PAD.

Peripheral Artery Disease: A comprehensive updated review

Peripheral arterial disease is estimated to affect more than 200 million people worldwide. Although more than 50% of those affected are asymptomatic, it accounts for 3-4% of amputations and a crude five-year death rate of 82.4 deaths per 1000 patient-years when adjusted for duration of follow-up. Additionally, peripheral artery disease is often an indicator of obstructive atherosclerotic disease involvement of cerebral and coronary vessels, consequently increasing the risk of stroke, cardiovascular death, and myocardial infarction in these patient populations. The management of peripheral arterial disease includes conservative therapies, pharmacological treatments, interventional and surgical revascularization of blood vessels. Percutaneous transluminal angioplasty with balloons and stents has improved clinical outcomes compared to medical treatment alone. Despite these advances, the prevalence of peripheral arterial disease remains high. This review article aims to provide focused, up-to-date information on the clinical course, diagnosis, medical and interventional approach of the management of peripheral artery disease.

Rehabilitation of patients with peripheral arterial disease

Vascular rehabilitation is an essential and effective treatment of peripheral arterial obstructive disease (PAOD). It is recommended in the first line by the European and American scientific societies. The rehabilitation to the walk remains the basic treatment of the arteriopathy of the lower limbs. Different walking protocols can be proposed. For similar effectiveness, vascular rehabilitation consists of an outpatient or specialized institution management program based on a comprehensive approach involving all or many of the following techniques: relaxation, active analytical exercises, gait rehabilitation, exercise re-entry, physical activities adapted to the patient's daily life and illness, respiratory physiotherapy, therapeutic education of the patient, smoking cessation aid. Vascular rehabilitation of arteritis requires a variety of skills but still faces a clear lack of suitable structures; it remains poorly prescribed and poorly known by usual prescribers (general practitioner, vascular surgeon).

[Vascular rehabilitation in lower-extremity artery diseasein 2018]

WHAT WE KNEW

The vascular rehabilitation is an effective treatment for patients with an intermittent claudication linked to lower-extremity artery disease. This treatment increases the claudication distance of 180% with the Gardner's protocol (30 to 60 minutes of walking at least 3 times a week, walking until appearance of a mild pain) and allows also to control the vascular risk factors. This treatment is not enough prescribed for many reasons and often requires a hospitalization in a rehabilitation centre.

WHAT WE KNOW NOW

Walking rehabilitation remains the base of the treatment of lower-extremity artery disease. Many walking protocols can be proposed. For a similar efficiency, patients are not obliged to walk until appearance of a pain but only until appearance of a discomfort. Exercises other than walking have been tested and can be used. Heart Rehabilitation Centres will propose more often vascular rehabilitation including hospitalisations for complex patients or out-management for non-complex patients. With a lower cost, the walking rehabilitation could be also realised at home by the patient himself with a certain degree of supervision with good results. Supervision means the use of a podometer, weekly advices given by phone by a Vascular Physician or a Physiotherapist, one walking session once a week in a rehabilitation centre. Connected devices could be also helpful allowing increasing of the patients' motivation. Simultaneously, it is necessary that the patients observe the recommendations of the World Health Organisation by performing weekly 150 minutes of mild-intensity endurance's activity in order to minimise their long-term vascular risk. Finally, the respective place of the revascularisations and walking rehabilitation remains to be clarify in case of intermittent claudication due to a superficial femoral artery lesion.

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Since 1980, the American College of Cardiology (ACC) and American Heart Association (AHA) have translated scientific evidence into clinical practice guidelines with recommendations to improve cardiovascular health. These guidelines, based on systematic methods to evaluate and classify evidence, provide a cornerstone of quality cardiovascular care.

In response to reports from the Institute of Medicine1 ,2 and a mandate to evaluate new knowledge and maintain relevance at the point of care, the ACC/AHA Task Force on Clinical Practice Guidelines (Task Force) modified its methodology.3 –5 The relationships among guidelines, data standards, appropriate use criteria, and performance measures are addressed elsewhere.5

Pain-free treadmill exercise for patients with intermittent claudication: Are there gender differences?

Intermittent claudication, a common symptom of peripheral arterial disease, results in insufficient blood flow and oxygen supply to lower extremity muscles. Compared to men, women with peripheral arterial disease have a higher rate of mobility loss with peripheral arterial disease due to poorer lower extremity functioning. This study evaluates the effect of supervised pain-free treadmill exercise on improving performance in women with intermittent claudication due to peripheral arterial disease in comparison to men. A total of 26 participants (women, n = 9, 34.62%; mean age = 67.58 ± 5.59 years; averaging 23.46 ± 3.91 visits and 10.46 ± 0.99 weeks in the program) diagnosed with peripheral arterial disease, with symptoms of intermittent claudication, partook in a 45 min treadmill walk, twice per week, below the participant's minimal pain threshold. Female participants' change scores showed 752%, 278% and 115% improvement in mean walking distance, duration and rate, respectively. Men improved 334%, 149% and 80%, respectively. Significant differences (p < 0.05) in pre and post measurements within each group support positive outcomes. No significant differences between groups were observed (Cohen's d effect size > 0.80). Our results suggest that women reap similar benefits from this low-intensity treadmill program in comparison to men.

The prevalence of peripheral arterial disease in middle-aged people with intellectual disabilities

Peripheral arterial disease (PAD) is a manifestation of atherosclerosis below the bifurcation of the abdominal aorta. PAD increases the risk of cardiovascular disease and associated mortality. Little is known about the prevalence of PAD in middle-aged persons with intellectual disabilities (ID). We determined the prevalence of PAD among people with ID aged 40-59 years. Independent associations between PAD and patient and care characteristics were explored. A multi-center cross-sectional observational study was conducted in four care providing agencies for people with ID in the Netherlands. We included 407 participants with mild to profound ID aged 40-59 years, receiving medical care from specialized ID physicians. The ankle-brachial index was used to diagnose PAD. The overall prevalence of PAD was 8.4% (95% CI=6.0-11.4%), with no significant differences between age groups 40-49 years (8.2%) and 50-59 years (8.5%). None of the participants had been diagnosed with PAD prior to this study and only one participant with PAD had PAD-related symptoms (1/34). Wheelchair dependence was independently associated with PAD (OR=5.43). Prevalence of PAD among people with ID is high, which is especially remarkable in age group 40-49 years. Physicians need to be aware of this high prevalence of PAD and the increased risk of cardiovascular disease in (young) people with ID.

Association of diabetic peripheral arterial disease and objectively-measured physical activity: NHANES 2003-2004

Background

Although much is known about the management of peripheral arterial disease among adults in the general population, the management of this disease among those with diabetes, and the effects of diabetic-induced peripheral arterial disease on objectively-measured physical activity, is unclear. Here, we examined the association between accelerometer-assessed physical activity and peripheral arterial disease among a national sample of U.S. adults with diabetes.

Methods

Data from the 2003–2004 National Health and Nutrition Examination Survey were used. Physical activity was measured using an accelerometer in 254 adults with diabetes. Peripheral arterial disease was assessed via ankle brachial index. Negative binomial regression analysis was used to examine the association between physical activity and peripheral arterial disease.

Results

Results were adjusted for age, gender, race-ethnicity, comorbidity index, smoking, HgbA1C, C-reactive protein, homocysteine, glomerular filtration rate, microalbuminuria, peripheral neuropathy, physical functioning, and medication use. After adjustments, participants with peripheral arterial disease engaged in 23% less physical activity (RR = 0.77, 95% CI: 0.62-0.96) than those without peripheral arterial disease.

Conclusions

These findings demonstrate an inverse association between accelerometer-assessed physical activity and peripheral arterial disease in a national sample of U.S adults with diabetes.

[Vascular rehabilitation in patients with peripheral arterial disease]

Lower limb peripheral arterial disease (PAD) is a frequent debilitating disease associated with a high morbidity and mortality rate. The benefit of rehabilitation in PAD patients has been largely demonstrated, both for patients that undergo amputation, and for patients with claudication. In these latter patients, rehabilitation programs rely on a variety of additional techniques or tools, among which: stretching, specific muscle proprioception, walking and a variety of other physical activities, exercise or situations adapted to community life, lower limb and respiratory physiotherapy, patient's education, support for smoking cessation and healthy nutrition, social support, etc. Whether rehabilitation is performed in specialised integrated structures or performed on a home-based basis, various clinicians are involved. Despite evidence-based proof of efficacy, rehabilitation of PAD patients with claudication is still under-used.