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Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based. J Vasc Surg. 2007 Jun;45(6):1192-6.
Bendermacher BL, Willigendael EM, Nicolaï SP, Kruidenier LM, Welten RJ, Hendriks E, Prins MH, Teijink JA, de Bie RA.
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OBJECTIVE: This cohort study was conducted to determine the effect on walking distances of supervised exercise therapy provided in a community-based setting.
METHODS: The study included all consecutive patients presenting at the vascular outpatient clinic with intermittent claudication, diagnosed by a resting ankle brachial index<0.9, who had no previous peripheral vascular intervention for peripheral arterial disease, no major amputation, and sufficient command of the Dutch language. The exclusion criterion was the inability to walk the baseline treadmill test for a minimum of 10 m. The intervention was a supervised exercise therapy in a community-based setting. A progressive treadmill test at baseline and at 1, 3, and 6 months of follow-up measured initial claudication distance and absolute claudication distance. Changes were calculated using the mean percentages of change.
RESULTS: From January through October 2005, 93 consecutive patients with claudication were eligible. Overall, 37 patients discontinued the supervised exercise therapy program. Eleven stopped because of intercurrent diseases, whereas for 10, supervised exercise therapy did not lead to adequate improvement and they underwent a vascular intervention. Three patients quit the program, stating that they were satisfied with the regained walking distance and did not require further supervised exercise therapy. Ten patients were not motivated sufficiently to continue the program, and in three patients, a lack of adequate insurance coverage was the reason for dropping out. Data for 56 patients were used and showed a mean percentage increase in initial claudication distance of 187% after 3 months and 240% after 6 months. The mean percentage of the absolute claudication distance increased 142% after 3 months and 191% after 6 months.
CONCLUSION: Supervised exercise therapy in a community-based setting is a promising approach to providing conservative treatment for patients with intermittent claudication.
Exercise performance in patients with peripheral arterial disease who have different types of exertional leg pain.
Gardner AW, Montgomery PS, Afaq A. J Vasc Surg. 2007 Jul;46(1):79-86.
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OBJECTIVE: This study compared the exercise performance of patients with peripheral arterial disease (PAD) who have different types of exertional leg pain.
METHODS: Patients with PAD were classified into one of four groups according to the San Diego Claudication Questionnaire: intermittent claudication (n = 406), atypical exertional leg pain causing patients to stop (n = 125), atypical exertional leg pain in which patients were able to continue walking (n = 81), and leg pain on exertion and rest (n = 103). Patients were assessed on the primary outcome measures of ankle-brachial index (ABI), treadmill exercise measures, and ischemic window.
RESULTS: All patients experienced leg pain consistent with intermittent claudication during a standardized treadmill test. The mean (+/- SD) initial claudication distance (ICD) was similar (P = .642) among patients with intermittent claudication (168 +/- 160 meters), atypical exertional leg pain causing patients to stop (157 +/- 130 meters), atypical exertional leg pain in which patients were able to continue walking (180 +/- 149 meters), and leg pain on exertion and rest (151 +/- 136 meters). The absolute claudication distance (ACD) was similar (P = .648) in the four respective groups (382 +/- 232, 378 +/- 237, 400 +/- 245, and 369 +/- 236 meters). Similarly, the ischemic window, expressed as the area under the curve (AUC) after treadmill exercise, was similar (P = .863) in these groups (189 +/- 137, 208 +/- 183, 193 +/- 143, and 199 +/- 119 AUC).
CONCLUSION: PAD patients with different types of exertional leg pain, all limited by intermittent claudication during a standardized treadmill test, were remarkably similar in ICD, ACD, and ischemic window. Thus, the presence of ambulatory symptoms should be of primary clinical concern in evaluating PAD patients regardless of whether they are consistent with classic intermittent claudication.
Supervised exercise training for intermittent claudication: lasting benefit at three years.
Ratliff DA, Puttick M, Libertiny G, Hicks RC, Earby LE, Richards T. Eur J Vasc Endovasc Surg. 2007 Sep;34(3):322-6.
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OBJECTIVES: To assess the long-term outcome of supervised exercise training for intermittent claudication.
METHODS: A prospective study was undertaken of all patients referred to a single centre with intermittent claudication (>46 m). Patients underwent supervised exercise training twice weekly for 10 weeks, with regular follow-up to 3 years. Actual Claudication Distance (ACD), Maximum Walking Distance (MWD) and ankle-brachial pressure indices (ABPI) were measured.
RESULTS: In 202 patients the initial median ACD and MWD were 112 m and 197 m. Following exercise therapy both the median ACD and MWD increased to 266 m and 477 m at three months, increases of 237% and 242% respectively (p<0.001). At three years the median ACD and MWD were 250 m and 372 m, increases of 223% and 188% respectively (p<0.001). There was no significant change in ACD or MWD at 3 months compared to 1, 2 or 3 years. ABPI remained unchanged throughout.
CONCLUSIONS: Supervised exercise training has long term benefit in patients with intermittent claudication. Results seen at 12 weeks are sustained at three years.
Effects of a long-term exercise program on lower limb mobility, physiological responses, walking performance, and physical activity levels in patients with peripheral arterial disease.
Crowther RG, Spinks WL, Leicht AS, Sangla K, Quigley F, Golledge J. J Vasc Surg. 2008 Feb;47(2):303-9
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OBJECTIVE: The purpose of the study was to examine the effects of a 12-month exercise program on lower limb mobility (temporal-spatial gait parameters and gait kinematics), walking performance, peak physiological responses, and physical activity levels in individuals with symptoms of intermittent claudication due to peripheral arterial disease (PAD-IC).
METHODS: Participants (n = 21) with an appropriate history of PAD-IC, ankle-brachial pressure index (ABI) <0.9 in at least one leg and a positive Edinburgh claudication questionnaire response were prospectively recruited. Participants were randomly allocated to either a control PAD-IC group (CPAD-IC) (n = 11) that received standard medical therapy and a treatment PAD-IC group (TPAD-IC) (n = 10), which also took part in a 12-month supervised exercise program. A further group of participants (n = 11) free of PAD (ABI >0.9) and who were non-regular exercisers were recruited from the community to act as age and mass matched controls (CON). Lower limb mobility was determined via two-dimensional video motion analysis. A graded treadmill test was used to assess walking performance and peak physiological responses to exercise. Physical activity levels were measured via a 7-day pedometer recording. Differences between groups were analyzed via repeated measures analysis of variance (ANOVA).
RESULTS: The 12-month supervised exercise program had no significant effect on lower limb mobility, peak physiological responses, or physical activity levels in TPAD-IC compared with CPAD-IC participants. However, the TPAD-IC participants demonstrated significantly greater walking performance (171% improvement in pain free walking time and 120% improvement in maximal walking time compared with baseline).
CONCLUSION: The results of this study confirm that a 12-month supervised exercise program will result in improved walking performance, but does not have an impact on lower limb mobility, peak physiological responses, or physical activity levels of PAD-IC patients.
Background
Claudication secondary to peripheral arterial disease leads to reduced mobility, limited physical functioning, and poor health outcomes. Disease severity can be assessed with quantitative clinical methods and qualitative self-perceived measures of quality of life. Limited data exist to document the degree to which quantitative and qualitative measures correlate. The current study provides data on the relationship between quantitative and qualitative measures of symptomatic peripheral arterial disease.
Method
This descriptive case series was set in an academic vascular surgery unit and biomechanics laboratory. The subjects were symptomatic patients with peripheral arterial disease patients presenting with claudication. The quantitative evaluation outcome measures included measurement of ankle-brachial index, initial claudication distance, absolute claudication distance, and self-selected treadmill pace. Qualitative measurements included the Walking Impairment Questionnaire (WIQ) and the Medical Outcomes Study Short Form-36 (SF-36) Health Survey. Spearman rank correlations were performed to determine the relationship between each quantitative and qualitative measure and also between the WIQ and SF-36.
Results
Included were 48 patients (age, 62 ± 9.6 years; weight, 83.0 ± 15.4 kg) with claudication (ABI, 0.50 ± 0.20). Of the four WIQ subscales, the ankle-brachial index correlated with distance (r = 0.29) and speed (r = 0.32); and initial claudication distance and absolute claudication distance correlated with pain (r = 0.40 and 0.43, respectively), distance (r = 0.35 and 0.41, respectively), and speed (r = 0.39 and 0.39 respectively). Of the eight SF-36 subscales, no correlation was found for the ankle-brachial index, initial claudication distance correlated with Bodily Pain (r = 0.46) and Social Functioning (r = 0.30), and absolute claudication time correlated with Physical Function (r = 0.31) and Energy (r = 0.30). The results of both questionnaires showed reduced functional status in claudicating patients.
Conclusions
Initial and absolute claudication distances and WIQ pain, speed, and distance subscales are the measures that correlated the best with the ambulatory limitation of patients with symptomatic peripheral arterial disease. These results suggest the WIQ is the most specific questionnaire for documenting the qualitative deficits of the patient with claudication while providing strong relationships with the quantitative measures of arterial disease. Future studies of claudication patients should include both quantitative and qualitative assessments to adequately assess disease severity and functional status in peripheral arterial disease patients.
BACKGROUND: Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)).
OBJECTIVES: To determine the effects of exercise programmes on IC, particularly in respect of reduction of symptoms on walking and improvement in quality of life.
SEARCH STRATEGY: The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last search February 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2008, Issue 1.
SELECTION CRITERIA: Randomised controlled trials of exercise regimens in people with IC due to peripheral arterial disease.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed trial quality.
MAIN RESULTS: Twenty-two trials met the inclusion criteria involving a total of 1200 participants with stable leg pain. Follow-up period was from two weeks to two years. There was some variation in the exercise regimens used, all recommended at least two sessions weekly of mostly supervised exercise. All trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was good, though the majority of trials were small with 20 to 49 participants. Fourteen trials compared exercise with usual care or placebo; patients with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Compared with usual care or placebo, exercise significantly improved maximal walking time: mean difference (MD) 5.12 minutes (95% confidence interval (CI) 4.51 to 5.72 with an overall improvement in walking ability of approximately 50% to 200%; exercise did not affect the ankle brachial pressure index (ABPI) (MD -0.01, 95% CI -0.05 to 0.04). Walking distances were also significantly improved: pain-free walking distance MD 82.19 metres (95% CI 71.73 to 92.65) and maximum walking distance MD 113.20 metres (95% CI 94.96 to 131.43). Improvements were seen for up to two years. The effect of exercise compared with placebo or usual care was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data.Evidence was generally limited for exercise compared with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression due to small numbers of trials and participants. Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained.
AUTHORS' CONCLUSIONS: Exercise programmes were of significant benefit compared with placebo or usual care in improving walking time and distance in selected patients with leg pain from IC.
I have to ask " is it worth the effort"? statistically significant but is it realy clinically significant?
All the cited studies show improvement in walking distance post supervised exercise for a period of time. statistical percentages of 120% - 190% improvement are quoted, which didn't include those who dropped out fo various reasons. These figures appear significant but are they?
If the the average distance of painfree walking or distance to point where the subject had to stop and rest was say 500 metres then 20% improvement only = 600mtrs. a 90% improvement = 950mtrs. However most of these studies seem to indicate a much lower baseline than 500mtrs and overal improvement appear to be around the 100mtr mark ie 100mtrs further then 12 months ago.
Would thid be a significant improvement to the patient after 12 months of painful therapy?
Dave Smith
__________________
Descartes seems to consider here that beliefs formed by pure reasoning are less doubtful than those formed through perception.
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Adrenergic and neuropeptide Y Y1 receptor control of collateral circuit conductance: influence of exercise training
Jessica C. Taylor, H. T. Yang, M. Harold Laughlin, and Ronald L. Terjung J Physiol 2008 586: 5983-5998.
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This study evaluated the role of -adrenergic receptor- and neuropeptide Y (NPY) Y1 receptor-mediated vasoconstriction in the collateral circuit of the hind limb. Animals were evaluated either the same day (Acute) or 3 weeks following occlusion of the femoral artery; the 3-week animals were in turn limited to cage activity (Sed) or given daily exercise (Trained). Collateral-dependent blood flows (BFs) were measured during exercise with microspheres before and after -receptor inhibition (phentolamine) and then NPY Y1 receptor inhibition (BIBP 3226) at the same running speed. Blood pressures (BPs) were measured above (caudal artery) and below (distal femoral artery) the collateral circuit. Arterial BPs were reduced by -inhibition (50–60 mmHg) to 75 mmHg, but not further by NPY Y1 receptor inhibition. Effective experimental sympatholysis was verified by 50–100% increases (P < 0.001) in conductance of active muscles not affected by femoral occlusion with receptor inhibition. In the absence of receptor inhibition, vascular conductance of the collateral circuit was minimal in the Acute group (0.13 ± 0.02), increased over time in the Sed group (0.41 ± 0.03; P < 0.001), and increased further in the Trained group (0.53 ± 0.03; P < 0.02). Combined receptor inhibition increased collateral circuit conductances (P < 0.005), most in the Acute group (116 ± 37%; P < 0.02), as compared to the Sed (41 ± 6.6%; P < 0.001) and Trained (31 ± 5.6%; P < 0.001) groups. Thus, while the sympathetic influence of the collateral circuit remained in the Sed and Trained animals, it became less influential with time post-occlusion. Collateral conductances were collectively greater (P < 0.01) in the Trained as compared to Sed group, irrespective of the presence or absence of receptor inhibition. Conductances of the active ischaemic calf muscle, with combined receptor inhibition, were suboptimal in the Acute group, but increased in Sed and Trained animals to exceptionally high values (e.g. red fibre section of the gastrocnemius: 7 ml min–1 (100 g)–1 mmHg–1). Thus, occlusion of the femoral artery promulgated vascular adaptations, even in vessels that are not part of the collateral circuit. The presence of active sympathetic control of the collateral circuit, even with exercise training, raises the potential for reductions in collateral BF below that possible by the structure of the collateral circuit. However, even with release of this sympathetic vasoconstriction, conductance of the collateral circuit was significantly greater with exercise training, probably due to the network of structurally larger collateral vessels
Adrenergic inhibition increases collateral circuit conductance in rats following acute occlusion of the femoral artery
Jessica C. Taylor, Zeyi Li, H. T. Yang, M. Harold Laughlin, and Ronald L. Terjung J Physiol 2008 586: 1649-1667
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This study evaluated whether -adrenergic activation contributes to collateral circuit vascular resistance in the hindlimb following acute unilateral occlusion of the femoral artery in rats. Blood pressures (BPs) were measured above (caudal artery) and below (distal femoral artery) the collateral circuit. Arterial BPs were reduced (15–35 mmHg) with individual (prazosin, rauwolscine) or combined (phentolamine) -receptor inhibition. Blood flows (BFs) were measured using microspheres before and after inhibition during the same treadmill speed. 1 inhibition increased blood flow by 40% to active muscles that were not affected by femoral occlusion, whereas collateral-dependent BFs to the calf muscles were reduced by 29 ± 8.4% (P < 0.05), due to a decrease in muscle conductance with no change in collateral circuit conductance. 2 inhibition decreased both collateral circuit (39 ± 6.0%; P < 0.05) and calf muscle conductance (36 ± 7.3%; P < 0.05), probably due to residual 1 activation, since renal BF was markedly reduced with rauwolscine. Most importantly, inhibiting 2 receptors in the presence of 1 inhibition increased (43 ± 12%; P < 0.05) collateral circuit conductance. Similarly, non-selective inhibition with phentolamine increased collateral conductance (242 ± 59%; P < 0.05). We interpret these findings to indicate that both 1- and 2-receptor activation can influence collateral circuit resistance in vivo during the high flow demands caused by exercise. Furthermore, we observed a reduced maximal conductances of active muscles that were ischaemic. Our findings imply that in the presence of excessive sympathetic activation, which can occur in the condition of intermittent claudication during exertion, an exaggerated vasoconstriction of the existing collateral circuit and active muscle will occur.
Science Daily are reporting: Peripheral Artery Disease: Pain When Walking Can Be Reduced With Moderate Exercise, Study Suggests
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You probably know that poor diet and lack of exercise can lead to dangerous deposits of fatty plaques in arteries. But it is not just the heart that is affected – blood flow can be blocked to the legs too, leading to pain when walking, immobility and even in extreme cases, amputation.
Approximately 20% of us will suffer from this peripheral artery disease (PAD) once we are 65 or over, and with risk factors including smoking, diabetes, obesity and high blood pressure it is on the rise. Surgical intervention can sometimes help, but the prognosis is not good.
Encouragingly, new research by Ronald Terjung et al. published in The Journal of Physiology shows that regular, moderate exercise can go a long way to relieving the symptoms of PAD, and by some unexpected mechanisms.
When a major artery in the leg becomes blocked, the body naturally seeks another route for the blood to pass through by expanding and multiplying the surrounding smaller blood vessels in the area, called collateral blood flow.
The researchers studied rats with a blocked femoral artery and found that collateral blood flow was much more effective in restoring normal muscle function in rats that were put on regular exercise training.
The collateral vessels themselves were larger and less prone to constriction – a problem exacerbated with PAD – than in sedentary animals. Surprisingly, the function of blood vessels ‘downstream’ of the blockage also changed, making them more efficient.
The authors predict that a suitable exercise programme would delay the onset of pain and increase mobility for people suffering with PAD.
“Our findings raise the potential that new collateral vessels, that can develop in patients with PAD who are physically active, will function effectively to help minimize the consequences of the original vascular obstruction.” commented Dr Terjung.
This study examined whether a training intervention likely to elicit adaptations in the leg could result in reduced leg pain and increased whole body physical capacity. Twenty-seven peripheral arterial disease (PAD) patients were randomized to either an individual leg plantar flexion training group (TG) training 4 x 4 min intervals at 80% of maximal work rate three times per week for 8 weeks or a control group. The TG significantly increased plantar flexion peak oxygen uptake and power output by 23.5 and 43.9%, respectively. Treadmill peak oxygen uptake (VO(2peak)) significantly increased 12.3% in the TG and was associated with a significant increased time to exhaustion of 20.0% when treadmill walking. Eleven of 14 patients no longer reported leg pain limitations at VO(2peak). No differences in cardiac output measured at VO(2peak), or walking economy were observed. Plantar flexion training was effective in increasing VO(2peak) and walking performance, and may be a useful strategy in treatment of PAD.
OBJECTIVE: To determine the effects of exercise training on calf tissue oxygenation in men with peripheral arterial disease and intermittent calf claudication.
DESIGN: This pilot study was prospective and longitudinal and used a one-group, pretest-posttest design. SETTING: Tertiary care medical center for veterans. PARTICIPANTS: Fifteen male veterans (mean age 69 years) with Fontaine stage IIa peripheral arterial disease and classic intermittent claudication. MAIN OUTCOME MEASUREMENTS: Before and after intervention, participants performed graded treadmill exercise tests while medial calf tissue oxygenation (StO(2), % oxyhemoglobin saturation) was monitored continuously with near-infrared spectroscopy. INTERVENTION: The intervention consisted of a 3-month exercise training program involving 3 sessions per week at the clinic (treadmill walking, calf ergometry) and 2 sessions per week at home (free walking, standing heel raises).
RESULTS: After completion of the intervention, participants significantly increased their maximal treadmill exercise time from 7.19 to 11.27 minutes. Mean exercise StO(2) decreased from 29% to 19% saturation, StO(2) x time area increased from 421%.min to 730%.min StO(2) nadir, and StO(2) recovery time did not change significantly.
CONCLUSIONS: After the exercise intervention, the improved treadmill walking performance was accompanied by greater calf tissue deoxygenation during exercise. Given the continued presence of ischemia, this finding may represent increased capillarization and diffusion-based enhancement of arteriovenous O(2) extraction
Exercise for intermittent claudication
with an overall improvement in walking ability of approximately 50% to 200%; exercise did not affect the ankle brachial pressure index (ABPI) (MD -0.01, 95% CI -0.05 to 0.04). Walking distances were also significantly improved: pain-free walking distance MD 82.19 metres (95% CI 71.73 to 92.65) and maximum walking distance MD 113.20 metres (95% CI 94.96 to 131.43). Improvements were seen for up to two years. The effect of exercise compared with placebo or usual care was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data.Evidence was generally limited for exercise compared with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression due to small numbers of trials and participants. Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained. 
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