Exercise Training for Management of Peripheral Arterial Disease: A Systematic Review and Meta-Analysis
- 2.2k Downloads
Peripheral arterial disease (PAD), a chronic condition with debilitating clinical sequelae, leads to reduced walking activity and increased mortality risk.
We sought to quantify expected benefits elicited via exercise training in people with PAD and aimed to clarify which prescriptions were optimal.
We conducted a systematic search (PubMed, CINAHL, Cochrane controlled trials registry; 1966–31 July 2013).
We included randomized controlled trials (RCTs) of exercise training versus usual medical care in persons with PAD. Studies were assessed by two reviewers, 41 of 57 (72 %) of RCTs met selection criteria.
Data extraction and synthesis
Data extraction sheets were used to record data and two reviewers cross-checked data. Included study authors were asked for missing data.
Main outcomes and measures
Primary outcome: change in aerobic capacity (peak VO2). Secondary outcomes: ankle-brachial index (ABI), flow-mediated dilatation, 6-minute walk claudication distances (initial and absolute) and graded treadmill (initial and absolute) distances. The primary hypothesis was that peak VO2 would increase with exercise training. Using sub-analyses, we also aimed to clarify what types of exercise prescription would provide patients with most benefit; hypotheses were developed a priori.
Exercise training produced significant peak VO2 improvements with mean difference (MD) 0.62 ml·kg−1·min−1 (95 % CI 0.47–0.77; p < 0.00001); 6-minute walk initial claudication MD 52.7 m (95 % CI 24.7–80.6 m; p = 0.0002); total walking distance MD 34.9 m (95 % CI 25.6–44.1 m; p < 0.00001); graded treadmill initial claudication MD 68.8 m (95 % CI 54.4–83.2 m; p < 0.00001); absolute claudication distance MD 41.0 m (95 % CI 28.8–53.2 m; p < 0.00001)); but not ABI (p = 0.12) or flow mediated dilatation (FMD) (p = 0.96). Sub-analyses of change in peak VO2 after arm cranking showed a MD of 1.91 ml·kg−1·min−1 (95 % CI 1.28–2.54, p < 0.00001). Sub-analysis of peak VO2 according to exercise training pain thresholds suggested that no-to-mild pain may be superior (MD 0.79 ml·kg−1·min−1 [95 % CI 0.45–1.14, p < 0.00001]) to moderate-to-maximum training pain (MD 0.49 ml·kg−1·min−1 [95 % CI 0.31–0.66, p < 0.00001]).
Conclusions and relevance
Exercise training improves cardio-respiratory fitness, pain-free and total flat-ground walking distances, as well as graded treadmill performance in PAD. Exercise prescriptions for PAD may consider arm cranking as well as lower limb exercise, possibly at short vigorous intensity intervals, but only to a threshold of mild pain.
KeywordsElectronic Supplementary Material Exercise Training Peripheral Arterial Disease Mean Difference Aerobic Capacity
We acknowledge Mr Glenn Phipps for his assistance with literature searching, Glenn was not paid for this work.
The authors Neil Smart, Gudrun Dieberg, and Belinda Parmenter have no conflicts of interest to declare.
We would also like to thank included study authors who provided additional information.
There are no financial disclosures.
- 1.Berger JS, Hochman J, Lobach I, Adelman MA, Riles TS, Rockman CB. Modifiable risk factor burden and the prevalence of peripheral artery disease in different vascular territories. J Vasc Surg.2013;58(3):673–681 (e671).Google Scholar
- 4.Jancin B. Mean health care costs for PAD exceeds CAD. Vasc Spec Online. 2009.Google Scholar
- 5.Moussa ID, Jaff MR, Mehran R, et al. Prevalence and prediction of previously unrecognized peripheral arterial disease in patients with coronary artery disease: the Peripheral Arterial Disease in Interventional Patients Study. Catheter Cardiovasc Interv. 2009;73(6):719–24.PubMedCrossRefGoogle Scholar
- 9.Watson L, Ellis B, Leng GC. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2008(4):CD000990.Google Scholar
- 12.Leng GC, Fowler B, Ernst E. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2000(2):CD000990.Google Scholar
- 13.McDermott MM, Ades PA, Dyer A, Guralnik JM, Kibbe M, Criqui MH. Corridor-based functional performance measures correlate better with physical activity during daily life than treadmill measures in persons with peripheral arterial disease. J Vasc Surg. 2008;48(5):1231–1237 (1237 e1231).Google Scholar
- 16.Bendermacher BL, Willigendael EM, Teijink JA, Prins MH. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database Syst Rev. 2006(2):CD005263.Google Scholar
- 17.Fokkenrood HJ, Bendermacher BL, Lauret GJ, Willigendael EM, Prins MH, Teijink JA. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database Syst Rev. 2013;8:CD005263.Google Scholar
- 28.Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions. 2011. http://www.Cochrane-handbook.org. Accessed 29 March 2012.
- 30.Medicine ACoS. Guidelines for exercise testing and prescription, 9th edn. Baltimore: Lippincott Williams & Wilkins; 2014.Google Scholar
- 34.Collins EG, Edwin Langbein W, Orebaugh C, et al. PoleStriding exercise and vitamin E for management of peripheral vascular disease. Med Sci Sports Exerc. 2003;35(3):384–393.Google Scholar
- 35.Crowther RG, Leicht AS, Spinks WL, Sangla K, Quigley F, Golledge J. Effects of a 6-month exercise program pilot study on walking economy, peak physiological characteristics, and walking performance in patients with peripheral arterial disease. Vasc Health Risk Manag. 2012;8:225–32.PubMedCentralPubMedCrossRefGoogle Scholar
- 36.Crowther RG, Spinks WL, Leicht AS, Sangla K, Quigley F, Golledge J. 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. J Vasc Surg. 2008;47(2):303–9.PubMedCrossRefGoogle Scholar
- 37.Cucato GG, Chehuen Mda R, Costa LA, et al. Exercise prescription using the heart of claudication pain onset in patients with intermittent claudication. Clinics (Sao Paulo). 2013;68(7):974–978.Google Scholar
- 41.Gelin J, Jivegard L, Taft C, et al. Treatment efficacy of intermittent claudication by surgical intervention, supervised physical exercise training compared to no treatment in unselected randomised patients I: one year results of functional and physiological improvements. Eur J Vasc Endovasc Surg. 2001;22(2):107–13.PubMedCrossRefGoogle Scholar
- 43.Hobbs SD, Marshall T, Fegan C, Adam DJ, Bradbury AW. The constitutive procoagulant and hypofibrinolytic state in patients with intermittent claudication due to infrainguinal disease significantly improves with percutaneous transluminal balloon angioplasty. J Vasc Surg. 2006;43(1):40–6.PubMedCrossRefGoogle Scholar
- 44.Hobbs SD, Marshall T, Fegan C, Adam DJ, Bradbury AW. The effect of supervised exercise and cilostazol on coagulation and fibrinolysis in intermittent claudication: a randomized controlled trial. J Vasc Surg. 2007;45(1):65–70 (discussion 70).Google Scholar
- 46.Kakkos SK, Geroulakos G, Nicolaides AN. Improvement of the walking ability in intermittent claudication due to superficial femoral artery occlusion with supervised exercise and pneumatic foot and calf compression: a randomised controlled trial. Eur J Vasc Endovasc Surg. 2005;30(2):164–75.PubMedCrossRefGoogle Scholar
- 55.Pinto BMMB, Patterson RB, Roberts M, Colucci A, Braun C. On-site versus home exercise programs: psychological benefits for individuals with arterial claudication. J Aging Phys Act. 1997;5(4):311–28.Google Scholar
- 67.Swank AM, Horton J, Fleg JL, et al. Modest increase in peak VO2 is related to better clinical outcomes in chronic heart failure patients: results from heart failure and a controlled trial to investigate outcomes of exercise training. Circ Heart Fail. 2012;5(5):579–85.PubMedCentralPubMedCrossRefGoogle Scholar
- 69.Askew C. Exercise prescription for patients with peripheral arterial disease and intermittent claudication: A position statement from Exercise & Sports Science Australia. J Sci Med Sport. 2013 (in press, accepted for publication 24 October 2013).Google Scholar
- 70.Ismail H, McFarlane JR, Nojoumian AH, Dieberg G, Smart NA. Clinical outcomes and cardiovascular responses to different exercise training intensities in patients with heart failure: a systematic review and meta-analysis. J Am Coll Cardiol Heart Fail. 2013 (pii S2213-1779(2213)00316-00318).Google Scholar
- 73.Norgren L, Hiatt WR, Dormandy JA, et al. Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg. 2007;45 Suppl S:S5–67.Google Scholar
- 74.Smart NA, Ismail H. Is it safer and more beneficial to work heart failure patients harder? An editorial commentary. Clin Cardiol. 2013;36(10):638–639.Google Scholar
- 76.McDermott MM, Kibbe M, Guralnik JM, et al. Comparative effectiveness study of self-directed walking exercise, lower extremity revascularization, and functional decline in peripheral artery disease. J Vasc Surg. 2013;57(4):990–996 (e991).Google Scholar
- 77.Tisi PV Shearman CP. The impact of treatment of intermittent claudication on subjective health of the patient. Health Trends. 1998/9;30:109–114.Google Scholar