Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial

BACKGROUND

Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown.

METHODS

Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year.

RESULTS

A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants.

CONCLUSIONS

The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.

Cross-sectoral rehabilitation intervention for patients with intermittent claudication versus usual care for patients in non-operative management - the CIPIC Rehab Study: study protocol for a randomised controlled trial

INTRODUCTION

Intermittent claudication (IC) caused by peripheral artery disease (PAD) is a common cardiovascular disease. Patients with IC have reduced walking capacity, restricted activity levels and mobility, and reduced health-related quality of life. The disease leads to social isolation, the risk of cardiovascular morbidity, and mortality. Non-operative management of IC requires exercise therapy and studies show that supervised exercise training is more effective than unsupervised training, yet many patients with IC lack motivation for changes in health behaviour. No studies investigating the effects of existing cardiac rehabilitation targeted patients with IC have been published. The aim of this article is to present the rationale and design of the CIPIC Rehab Study, which examines the effect of a cross-sectoral rehabilitation programme versus usual care for patients in non-operative management for IC.

METHODS AND ANALYSIS

A randomised clinical trial aims to investigate whether cardiac rehabilitation for patients with IC in non-operative management versus usual care is superior to treatment as usual. The trial will allocate 118 patients, with a 1:1 individual randomisation to either the intervention or control group. The primary outcome is maximal walking distance measured by the standardised treadmill walking test. The secondary outcome is pain-free walking distance measured by the standardised treadmill walking test, healthy diet measured by a fat-fish-fruit-green score, and level of physical activity measured by an activity score within official recommendations. Statistical analyses will be blinded. Several exploratory analyses will be performed. A mixed-method design is used to evaluate qualitative and quantitative findings. A qualitative and a survey-based complementary study will be undertaken to investigate patients' post-discharge experiences. A qualitative post-intervention study will explore experiences of participation in rehabilitation.

DISCUSSION

The study is the first to assess the effect of a cardiac rehabilitation programme designed for patients with IC. The study will describe how to monitor and improve rehabilitation programmes for patients with IC in a real-world setting. Mixed-method strategies can allow for both exploration and generalisation in the same study, but the research design is a complex intervention and any effects found cannot be awarded a specific component.

TRIAL REGISTRATION

Retrospectively registered in Clinicaltrials.gov identifier: NCT03730623.

Beet the Best?

RATIONALE

A primary goal of therapy for patients with peripheral artery disease (PAD) and intermittent claudication is increased ambulatory function. Supervised exercise rehabilitation was recently shown to confer superior walking benefits to pharmacological or surgical interventions. Increases in plasma inorganic nitrite, via oral nitrate, have been shown to increase exercise performance in both human and animal models, especially in hypoxic conditions.

OBJECTIVE

To determine whether a 36-session exercise rehabilitation program while consuming oral inorganic nitrate (4.2 mmol concentrated beetroot juice) would produce superior benefits over exercise plus placebo in pain-free walking and markers of increased skeletal muscle perfusion in patients with PAD and intermittent claudication.

METHODS AND RESULTS

This was a randomized, double-blind, per-protocol study design. After the 12-week protocol, claudication onset time on a maximal treadmill test increased by 59.2±57.3 s for the exercise plus placebo group (n=13) and by 180.3±46.6 s for the exercise plus beetroot juice group (n=11; P≤0.05). This produced a between treatment medium to large standardized effect size (Cohen d) of 0.62 (95% CI, -0.23 to +1.44). The data for 6-minute walk distance showed a similar pattern with increases of 24.6±12.1 and 53.3±19.6 m ( P≤0.05) in the exercise plus placebo and exercise plus beetroot juice groups, respectively. Measures of gastrocnemius perfusion, including ankle-brachial index, peak reactive hyperemic blood flow, and tissue deoxygenation characteristics, during exercise (assessed my near-infrared spectroscopy) all changed significantly for the exercise plus beetroot juice group with moderate-to-large effect sizes over exercise plus placebo changes.

CONCLUSIONS

Although it is premature to speculate on overall clinical utility of a nitrate-based therapy for PAD, this early pilot study evidence is encouraging. Specifically, our data suggests that increasing plasma nitrite before exercise may allow PAD subjects to train with less pain, at higher workloads for longer durations at each training session, thereby maximizing the beneficial peripheral vascular and skeletal muscle adaptations.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01684930 and NCT01785524.

Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association

Patients with lower-extremity peripheral artery disease (PAD) have greater functional impairment, faster functional decline, increased rates of mobility loss, and poorer quality of life than people without PAD. Supervised exercise therapy (SET) improves walking ability, overall functional status, and health-related quality of life in patients with symptomatic PAD. In 2017, the Centers for Medicare & Medicaid Services released a National Coverage Determination (CAG-00449N) for SET programs for patients with symptomatic PAD. This advisory provides a practical guide for delivering SET programs to patients with PAD according to Centers for Medicare & Medicaid Services criteria. It summarizes the Centers for Medicare & Medicaid Services process and requirements for referral and coverage of SET and provides guidance on how to implement SET for patients with PAD, including the SET protocol, options for outcome measurement, and transition to home-based exercise. This advisory is based on the guidelines established by the Centers for Medicare & Medicaid Services for Medicare beneficiaries in the United States and is intended to assist clinicians and administrators who are implementing SET programs for patients with PAD.

Role of structured and supervised exercise programmes in peripheral artery disease patients with and without claudication - A Systematic Review and Metaanalysis

OBJECTIVE

This review aimed to determine the impact of exercise protocol among peripheral artery disease patients. Literature search was done from 2005 to 2018.

METHODS

Databases such as Google Scholar, Medline and PubMed was reconnoitred for the purpose of research articles by using key words like exercise training, peripheral artery disease, ankle brachial index, haemodynamic and atherosclerosis. Studies fulfilling the inclusion criteria were retrieved and encompassed in the present study.

RESULTS

The heterogeneity of the studies included in the analysis and the impact of exercise programmes on outcome measures were assessed by using hedge gstatistical model.Of the54 studies found, 9(16.6%) were analysed that suggest supervised and structured exercises programmes significantly improved (p<0.05) outcome variables.

CONCLUSIONS

Future randomized controlled trials related to the duration of exercises regimes are required in order to tailor the training programmes according to the need of individuals.

Effect of a Home-Based Exercise Intervention of Wearable Technology and Telephone Coaching on Walking Performance in Peripheral Artery Disease: The HONOR Randomized Clinical Trial

IMPORTANCE

Clinical practice guidelines support home-based exercise for patients with peripheral artery disease (PAD), but no randomized trials have tested whether an exercise intervention without periodic medical center visits improves walking performance.

OBJECTIVE

To determine whether a home-based exercise intervention consisting of a wearable activity monitor and telephone coaching improves walking ability over 9 months in patients with PAD.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at 3 US medical centers. Patients with PAD were randomized between June 18, 2015, and April 4, 2017, to home-based exercise vs usual care for 9 months. Final follow-up was on December 5, 2017.

INTERVENTIONS

The exercise intervention group (n = 99) received 4 weekly medical center visits during the first month followed by 8 months of a wearable activity monitor and telephone coaching. The usual care group (n = 101) received no onsite sessions, active exercise, or coaching intervention.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in 6-minute walk distance at 9-month follow-up (minimal clinically important difference [MCID], 20 m). Secondary outcomes included 9-month change in subcomponents of the Walking Impairment Questionnaire (WIQ) (0-100 score; 100, best), SF-36 physical functioning score, Patient-Reported Outcomes Measurement Information System (PROMIS) mobility questionnaire (higher = better; MCID, 2 points), PROMIS satisfaction with social roles questionnaire, PROMIS pain interference questionnaire (lower = better; MCID range, 3.5-4.5 points), and objectively measured physical activity.

RESULTS

Among 200 randomized participants (mean [SD] age, 70.2 [10.4] years; 105 [52.5%] women), 182 (91%) completed 9-month follow-up. The mean change from baseline to 9-month follow-up in the 6-minute walk distance was 5.5 m in the intervention group vs 14.4 m in the usual care group (difference, -8.9 m; 95% CI, -26.0 to 8.2 m; P = .31). The exercise intervention worsened the PROMIS pain interference score, mean change from baseline to 9 months was 0.7 in the intervention group vs -2.8 in the usual care group (difference, 3.5; 95% CI, 1.3 to 5.8; P = .002). There were no significant between-group differences in the WIQ score, the SF-36 physical functioning score, or the PROMIS mobility or satisfaction with social roles scores.

CONCLUSIONS AND RELEVANCE

Among patients with PAD, a home-based exercise intervention consisting of a wearable activity monitor and telephone coaching, compared with usual care, did not improve walking performance at 9-month follow-up. These results do not support home-based exercise interventions of wearable devices and telephone counseling without periodic onsite visits to improve walking performance in patients with PAD.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02462824.

Total Contact Cast Use in Patients With Peripheral Arterial Disease: A Case Series and Systematic Review

INTRODUCTION

As the majority of diabetic foot ulcerations (DFUs) occur on the plantar foot, excessive pressure is a major contributing factor to delayed healing. The gold standard for offloading is the total contact cast (TCC); yet, TCC use is contraindicated in patients with ischemia. Lower extremity ischemia typically presents in the more severe end stages of peripheral arterial disease (PAD). As PAD exists on a severity spectrum from mild to severe, designation of a clear cutoff where TCC use is an absolute contraindication would assist those who treat DFUs on a daily basis.

OBJECTIVE

The aim of this study is to determine if a potential cutoff value for PAD where TCC use would be an absolute contraindication could be ascertained from a retrospective case series and a systematic literature review of patients with PAD in which treatment included TCC use.

MATERIALS AND METHODS

A retrospective cases series and systematic review of patients with mild to moderate PAD treated with a TCC was performed. All reports of TCC use in patients with PAD and a neuropathic ulceration that included results of noninvasive vascular studies were included.

RESULTS

Results suggested that TCC use is a viable treatment modality for pressure-related DFUs in patients with an ankle pressure ≥ 80 mm Hg, a toe pressure ≥ 74 mm Hg, an ankle-brachial index ≥ 0.55, or a toe-brachial index ≥ 0.55.

CONCLUSIONS

Vascular evaluation, individual risk/benefit analysis, close follow-up, and patient education are essential components of TCC use in these patients. Repeat vascular evaluation is recommended if the wound fails to progress towards resolution with TCC use.

The effects of Crenotherapy and exercise in peripheral arterial occlusive disease. A comparison with simple exercise training

BACKGROUND

Conservative therapies for patients affected by Peripheral Arterial Occlusive Disease (PAOD) aim first to correct the risk factors and to slow down the disease progression. Among these, exercise has positive effects on blood flow, muscle metabolism and well demonstrated systemic effects. These include reduction of chronic inflammation markers, improvement of walking mechanics and heart function. Controlled physical training increases the ability to perform the daily activities improving life expectancy of these patients. The aim of this study is to evaluate the effects and the effectiveness of physical training performed in thermal water compared to traditional treadmill walking exercise.

METHODS

98 patients affected by IIb stage PAOD, according to Leriche-Fontaine classification, were enrolled. Patients were randomized into two groups: the first arm carried out an intensive training program under medical supervision (group A); the second one carried out a rehabilitative exercise associated with crenotherapy (group B). The following parameters were detected: Ankle-Brachial pressure index (ABI), actual claudication distance (ACD), maximum walking distance (MWD), flow mediated dilatation (FMD) and the intima-media thickness (IMT). All patients underwent Doppler echocardiography and complete biochemical assay.

RESULTS

In both groups, there was a statistically significant improvement of lipidaemia compared to baseline. When compared with each other, the two groups did not show statistically significant differences. There were no significant differences between the two groups regarding echocardiographic findings. Vascular reactivity study showed a statistically significant improvement of FMD after 3 months of exercise in both groups. In crenotherapy group (B) FMD values were significantly higher than the treadmill ones (A). In both groups a statistically significant improvement in ACD was observed CONCLUSIONS: Our experience shows that crenotherapy has similar effects compared to traditional physical training in the treatment of PAOD, being equally well tolerated and safe; it gives an advantage over conventional physical training in terms of ACD and MWD improvement, although not statistically significant, and it is extremely welcome to patients compared to traditional physical training.

KEY WORDS

Arterioscleroses, Intermittent Claudicatio, Peripheral Arterial Diseasen, Physical Exercise, Rehabilitation.

Effect of peripheral arterial disease on the onset of lactate threshold during cardiopulmonary exercise test: study protocol

INTRODUCTION

Cardiopulmonary exercise test (CPET) is widely used in preoperative assessment and cardiopulmonary rehabilitation. The effect of peripheral arterial disease (PAD) on oxygen delivery (VO₂) measured by CPET is not known. The aim of this study was to investigate the effect of PAD on VO₂ measurements during CPET.

METHODS AND ANALYSIS

We designed a prospective cohort study, which will recruit 30 patients with PAD, who will undergo CPET before and after treatment of iliofemoral occlusive arterial disease. The main outcome measure is the difference in VO₂ at the lactate threshold (LT) between the 2 CPETs. The secondary outcome measure is the relationship between change in VO₂ at the LT and peak exercise pretreatment and post-treatment and haemodynamic measures of PAD improvement (ankle-brachial index differential). For VO₂ changes, only simple paired bivariate comparisons, not multivariate analyses, are planned, due to the small sample size. The correlation between ABI and VO₂ rise will be tested by linear regression.

ETHICS AND DISSEMINATION

The study was approved by the North West-Lancaster Research and Ethics committee (reference 15/NW/0801). Results will be disseminated through scientific journal and scientific conference presentation. Completion of recruitment is expected by the end of 2016, and submission for publication by March 2017.

TRIAL REGISTRATION NUMBER

NCT02657278.

Patient Characteristics and Comorbidities Influence Walking Distances in Symptomatic Peripheral Arterial Disease: A Large One-Year Physiotherapy Cohort Study

Objectives

The aim of this study is to investigate the association between age, gender, body-mass index, smoking behavior, orthopedic comorbidity, neurologic comorbidity, cardiac comorbidity, vascular comorbidity, pulmonic comorbidity, internal comorbidity and Initial Claudication Distance during and after Supervised Exercise Therapy at 1, 3, 6 and 12 months in a large sample of patients with Intermittent Claudication.

Methods

Data was prospectively collected in standard physiotherapy care. Patients received Supervised Exercise Therapy according to the guideline Intermittent Claudication of the Royal Dutch Society for Physiotherapy. Three-level mixed linear regression analysis was carried out to analyze the association between patient characteristics, comorbidities and Initial Claudication Distance at 1, 3, 6 and 12 months.

Results

Data from 2995 patients was analyzed. Results showed that being female, advanced age and a high body-mass index were associated with lower Initial Claudication Distance at all-time points (p = 0.000). Besides, a negative association between cardiac comorbidity and Initial Claudication Distance was revealed (p = 0.011). The interaction time by age, time by body-mass index and time by vascular comorbidity were significantly associated with Initial Claudication Distance (p≤ 0.05). Per year increase in age (range: 33–93 years), the reduction in Initial Claudication Distance was 8m after 12 months of Supervised Exercise Therapy. One unit increase in body-mass index (range: 16–44 kg/m²) led to 10m less improvement in Initial Claudication Distance after 12 months and for vascular comorbidity the reduction in improvement was 85m after 12 months.

Conclusions

This study reveals that females, patients at advanced age, patients with a high body-mass index and cardiac comorbidity are more likely to show less improvement in Initial Claudication Distances (ICD) after 1, 3, 6 and 12 months of Supervised Exercise Therapy. Further research should elucidate treatment adaptations that optimize treatment outcomes for these subgroups.

[Vascular rehabilitation of patients suffering from peripheral arterial disease]

Rehabilitation programs represent an important and valuable tool for patients suffering various diseases. Supervised exercise programs for patients with peripheral arterial diseases have been shown to be efficacious in ameliorating walking performances and quality of life of such patients. With this regards the angiology service of the CHUV in Lausanne has established a multidisciplinary supervised program of vascular rehabilitation. This article describes organisation and characteristics of such a program.

Rehabilitative treatment in peripheral artery disease: protocol application and follow-up

AIM

Peripheral arterial disease (PAD) is a chronic figure suitable to be treated at the II stage to prevent the extreme developments both of the critical limb ischemia and the amputation, as well. The aim of this study was to establish a rehabilitation program (pharmacological and physical) focused not only on the improvement of the flow but also on the metabolic rebalancing in the claudicant limb.

METHODS

The study enrolled 222 patients, (125 non-diabetics and 97 diabetics): 54 II A and 168 II B stage; 172 patients (131 II B and 41 II A; 104 non-diabetics and 68 diabetics) were submitted to iv. L-propionil carnytine (Lpc) and physical training on treadmill or exercise bike and 50 patients to iv. therapy alone. Instrumental (Rheoscreen, Oximetry, ABI, walking distance measurement) and clinical checks (questionnaire - Appendix 1) were performed at days: T0, T45,T 90,T180, T230 and during the follow up stated at T 90,T180,T360 from T 230 (end of DH).

RESULTS

A significant increasing of the walking distance has been reached in the group undergoing the rehabilitation program. Treadmill: non-diabetics +261.48% at 0% and +122.53% at slope 10% (T230) further increasing to +502.31% at 0% and +289.42% at slope 10% (T360); diabetics: + 158.49% at T0 and + 98.26% at slope 10% (T230) further increased to +287.74% at 0% and +197.39% at 10% (T360) in comparison with the group which had only iv. Lpc : non-diabetics +141.63% at 0% and +104.08% at slope 10% (T230) further increased to +202.064% at 0% and +155.10% at slope 10% (T360); diabetics: +109.124% at T0 and +100% at slop 10% (T230) further increased to +171.08% at 0% and +140% at 10% (T360) . Exercise bike: non-diabetics: +170.27% at T230 in comparison T0 increased to +305.4% at T360; diabetics: +166.66 at T230 reaching +288.88% at T 360.

CONCLUSION

Our rehabilitative program gives not only good results at the end of the treatment but mainly stable, with the chance to reach further improving of both walking distance and quality of life, particularly in those patients which observe constantly the physical training.