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Sports Medicine
Published in: Sports Medicine 2/2015

01-02-2015 | Systematic Review

Exercise Training for Management of Peripheral Arterial Disease: A Systematic Review and Meta-Analysis

Authors: Belinda J. Parmenter, Gudrun Dieberg, Neil A. Smart

Published in: Sports Medicine | Issue 2/2015

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Abstract

Background

Peripheral arterial disease (PAD), a chronic condition with debilitating clinical sequelae, leads to reduced walking activity and increased mortality risk.

Objective

We sought to quantify expected benefits elicited via exercise training in people with PAD and aimed to clarify which prescriptions were optimal.

Data sources

We conducted a systematic search (PubMed, CINAHL, Cochrane controlled trials registry; 1966–31 July 2013).

Study selection

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.

Results

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.
Appendix
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Literature
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).
2.
Hirsch AT, Criqui MH, Treat-Jacobson D, et al. Peripheral arterial disease detection, awareness, and treatment in primary care. JAMA. 2001;286(11):1317–24.PubMedCrossRef
3.
Mahoney EM, Wang K, Keo HH, et al. Vascular hospitalization rates and costs in patients with peripheral artery disease in the United States. Circ Cardiovasc Qual Outcomes. 2010;3(6):642–51.PubMedCrossRef
4.
Jancin B. Mean health care costs for PAD exceeds CAD. Vasc Spec Online. 2009.
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.PubMedCrossRef
6.
Leeper NJ, Myers J, Zhou M, et al. Exercise capacity is the strongest predictor of mortality in patients with peripheral arterial disease. J Vasc Surg. 2013;57(3):728–33.PubMedCentralPubMedCrossRef
7.
Parmenter BJ, Raymond J, Dinnen P, Singh MA. A systematic review of randomized controlled trials: Walking versus alternative exercise prescription as treatment for intermittent claudication. Atherosclerosis. 2011;218(1):1–12.PubMedCrossRef
8.
Parmenter BJ, Raymond J. Fiatarone Singh MA. The effect of exercise on fitness and performance-based tests of function in intermittent claudication: a systematic review. Sports Med. 2013;43(6):513–24.PubMedCrossRef
9.
Watson L, Ellis B, Leng GC. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2008(4):CD000990.
10.
Gardner AW, Montgomery PS, Parker DE. Physical activity is a predictor of all-cause mortality in patients with intermittent claudication. J Vasc Surg. 2008;47(1):117–22.PubMedCentralPubMedCrossRef
11.
Parmenter BJ, Raymond J. Fiatarone Singh MA. The effect of exercise on haemodynamics in intermittent claudication: a systematic review of randomized controlled trials. Sports Med. 2010;40(5):433–47.PubMedCrossRef
12.
Leng GC, Fowler B, Ernst E. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2000(2):CD000990.
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).
14.
15.
Maher CG, Sherrington C, Herbert RD, Moseley AM, Elkins M. Reliability of the PEDro scale for rating quality of randomized controlled trials. Phys Ther. 2003;83(8):713–21.PubMed
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.
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.
18.
Gardner AW, Skinner JS, Cantwell BW, Smith LK. Progressive vs single-stage treadmill tests for evaluation of claudication. Med Sci Sports Exerc. 1991;23(4):402–8.PubMedCrossRef
19.
Hiatt WR, Regensteiner JG, Hargarten ME, Wolfel EE, Brass EP. Benefit of exercise conditioning for patients with peripheral arterial disease. Circulation. 1990;81(2):602–9.PubMedCrossRef
20.
Hiatt WR, Wolfel EE, Meier RH, Regensteiner JG. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. Circulation. 1994;90(4):1866–74.PubMedCrossRef
21.
Mika P, Spodaryk K, Cencora A, Mika A. Red blood cell deformability in patients with claudication after pain-free treadmill training. Clin J Sport Med. 2006;16(4):335–40.PubMedCrossRef
22.
Mosti MP, Wang E, Wiggen ON, Helgerud J, Hoff J. Concurrent strength and endurance training improves physical capacity in patients with peripheral arterial disease. Scand J Med Sci Sports. 2011;21(6):e308–14.PubMedCrossRef
23.
Regensteiner JG, Meyer TJ, Krupski WC, Cranford LS, Hiatt WR. Hospital vs home-based exercise rehabilitation for patients with peripheral arterial occlusive disease. Angiology. 1997;48(4):291–300.PubMedCrossRef
24.
Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg. 1996;23(1):104–15.PubMedCrossRef
25.
Treat-Jacobson D, Bronas UG, Leon AS. Efficacy of arm-ergometry versus treadmill exercise training to improve walking distance in patients with claudication. Vasc Med. 2009;14(3):203–13.PubMedCrossRef
26.
Wang E, Hoff J, Loe H, Kaehler N, Helgerud J. Plantar flexion: an effective training for peripheral arterial disease. Eur J Appl Physiol. 2008;104(4):749–56.PubMedCrossRef
27.
28.
29.
Norton K, Norton L, Sadgrove D. Position statement on physical activity and exercise intensity terminology. J Sci Med Sport. 2010;13(5):496–502.PubMedCrossRef
30.
Medicine ACoS. Guidelines for exercise testing and prescription, 9th edn. Baltimore: Lippincott Williams & Wilkins; 2014.
31.
Allen JD, Stabler T, Kenjale A, et al. Plasma nitrite flux predicts exercise performance in peripheral arterial disease after 3 months of exercise training. Free Radical Biol Med. 2010;49(6):1138–44.CrossRef
32.
Bronas UG, Treat-Jacobson D, Leon AS. Comparison of the effect of upper body-ergometry aerobic training vs treadmill training on central cardiorespiratory improvement and walking distance in patients with claudication. J Vasc Surg. 2011;53(6):1557–64.PubMedCrossRef
33.
Cheetham DR, Burgess L, Ellis M, Williams A, Greenhalgh RM, Davies AH. Does supervised exercise offer adjuvant benefit over exercise advice alone for the treatment of intermittent claudication? A randomised trial. Eur J Vasc Endovasc Surg. 2004;27(1):17–23.PubMedCrossRef
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.
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.PubMedCentralPubMedCrossRef
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.PubMedCrossRef
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.
38.
Gardner AW, Katzel LI, Sorkin JD, et al. Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial. J Am Geriatr Soc. 2001;49(6):755–62.PubMedCrossRef
39.
40.
Gardner AW, Parker DE, Montgomery PS, Scott KJ, Blevins SM. Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication: a randomized controlled trial. Circulation. 2011;123(5):491–8.PubMedCentralPubMedCrossRef
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.PubMedCrossRef
42.
Gibellini R, Fanello M, Bardile AF, Salerno M, Aloi T. Exercise training in intermittent claudication. Int Angiol. 2000;19(1):8–13.PubMed
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.PubMedCrossRef
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).
45.
Hodges LD, Sandercock GR, Das SK, Brodie DA. Randomized controlled trial of supervised exercise to evaluate changes in cardiac function in patients with peripheral atherosclerotic disease. Clin Physiol Funct Imaging. 2008;28(1):32–7.PubMed
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.PubMedCrossRef
47.
Larsen OA, Lassen NA. Effect of daily muscular exercise in patients with intermittent claudication. Lancet. 1966;2(7473):1093–6.PubMedCrossRef
48.
Mannarino E, Pasqualini L, Innocente S, Scricciolo V, Rignanese A, Ciuffetti G. Physical training and antiplatelet treatment in stage II peripheral arterial occlusive disease: alone or combined? Angiology. 1991;42(7):513–21.PubMedCrossRef
49.
McDermott MM, Ades P, Guralnik JM, et al. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial. JAMA. 2009;301(2):165–74.PubMedCentralPubMedCrossRef
50.
McDermott MM, Criqui MH, Greenland P, et al. Leg strength in peripheral arterial disease: associations with disease severity and lower-extremity performance. J Vasc Surg. 2004;39(3):523–30.PubMedCrossRef
51.
McDermott MM, Liu K, Guralnik JM, et al. Home-based walking exercise intervention in peripheral artery disease: a randomized clinical trial. JAMA. 2013;310(1):57–65.PubMedCrossRef
52.
McGuigan MR, Bronks R, Newton RU, et al. Resistance training in patients with peripheral arterial disease: effects on myosin isoforms, fiber type distribution, and capillary supply to skeletal muscle. J Gerontol A Biol Sci Med Sci. 2001;56(7):B302–10.PubMedCrossRef
53.
Nicolai SP, Teijink JA, Prins MH. Exercise Therapy in peripheral arterial disease study G. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication. J Vasc Surg. 2010;52(2):348–55.PubMedCrossRef
54.
Parmenter BJ, Raymond J, Dinnen P, Lusby RJ. Fiatarone Singh MA. High-intensity progressive resistance training improves flat-ground walking in older adults with symptomatic peripheral arterial disease. J Am Geriatr Soc. 2013;61(11):1964–70.PubMedCrossRef
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.
56.
Sanderson B, Askew C, Stewart I, Walker P, Gibbs H, Green S. Short-term effects of cycle and treadmill training on exercise tolerance in peripheral arterial disease. J Vasc Surg. 2006;44(1):119–27.PubMedCrossRef
57.
Sandri M, Adams V, Gielen S, et al. Effects of exercise and ischemia on mobilization and functional activation of blood-derived progenitor cells in patients with ischemic syndromes: results of 3 randomized studies. Circulation. 2005;111(25):3391–9.PubMedCrossRef
58.
Savage P, Ricci MA, Lynn M, et al. Effects of home versus supervised exercise for patients with intermittent claudication. J Cardiopulm Rehabil. 2001;21(3):152–7.PubMedCrossRef
59.
Stewart AH, Smith FC, Baird RN, Lamont PM. Local versus systemic mechanisms underlying supervised exercise training for intermittent claudication. Vasc Endovasc Surg. 2008;42(4):314–20.CrossRef
60.
Tebbutt N, Robinson L, Todhunter J, Jonker L. A plantar flexion device exercise programme for patients with peripheral arterial disease: a randomised prospective feasibility study. Physiotherapy. 2011;97(3):244–9.PubMedCrossRef
61.
Tew G, Nawaz S, Zwierska I, Saxton JM. Limb-specific and cross-transfer effects of arm-crank exercise training in patients with symptomatic peripheral arterial disease. Clin Sci (Lond). 2009;117(12):405–13.PubMedCrossRef
62.
Tisi PV, Hulse M, Chulakadabba A, Gosling P, Shearman CP. Exercise training for intermittent claudication: does it adversely affect biochemical markers of the exercise-induced inflammatory response? Eur J Vasc Endovasc Surg. 1997;14(5):344–50.PubMedCrossRef
63.
Tsai JC, Chan P, Wang CH, et al. The effects of exercise training on walking function and perception of health status in elderly patients with peripheral arterial occlusive disease. J Intern Med. 2002;252(5):448–55.PubMedCrossRef
64.
Wood RE, Sanderson BE, Askew CD, Walker PJ, Green S, Stewart IB. Effect of training on the response of plasma vascular endothelial growth factor to exercise in patients with peripheral arterial disease. Clin Sci (Lond). 2006;111(6):401–9.PubMedCrossRef
65.
Zwierska I, Walker RD, Choksy SA, Male JS, Pockley AG, Saxton JM. Upper- vs lower-limb aerobic exercise rehabilitation in patients with symptomatic peripheral arterial disease: a randomized controlled trial. J Vasc Surg. 2005;42(6):1122–30.PubMedCrossRef
66.
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.PubMedCentralPubMedCrossRef
68.
Cress ME, Meyer M. Maximal voluntary and functional performance levels needed for independence in adults aged 65 to 97 years. Phys Ther. 2003;83(1):37–48.PubMed
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).
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).
71.
Wisloff U, Stoylen A, Loennechen JP, et al. Superior cardiovascular effect of aerobic interval training versus moderate continuous training in heart failure patients: a randomized study. Circulation. 2007;115(24):3086–94.PubMedCrossRef
72.
Hirsch AT, Haskal ZJ, Hertzer NR, et al. ACC/AHA 2005 guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): executive summary. J Am Coll Cardiol. 2006;47(6):1239–312.PubMedCrossRef
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.
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.
75.
Gardner AW, Katzel LI, Sorkin JD, Goldberg AP. Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial. J Cardiopulm Rehabil. 2002;22(3):192–8.PubMedCrossRef
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).
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.
78.
Collins EG, Langbein WE, Orebaugh C, et al. Cardiovascular training effect associated with polestriding exercise in patients with peripheral arterial disease. J Cardiovasc Nurs. 2005;20(3):177–85.PubMedCrossRef
79.
Langbein WE, Collins EG, Orebaugh C, et al. Increasing exercise tolerance of persons limited by claudication pain using polestriding. J Vasc Surg. 2002;35(5):887–93.PubMedCrossRef
80.
Ekroth R, Dahllof AG, Gundevall B, Holm J, Schersten T. Physical training of patients with intermittent claudication: indications, methods, and results. Surgery. 1978;84(5):640–3.PubMed
Metadata
Title
Exercise Training for Management of Peripheral Arterial Disease: A Systematic Review and Meta-Analysis
Authors
Belinda J. Parmenter
Gudrun Dieberg
Neil A. Smart
Publication date
01-02-2015
Publisher
Springer International Publishing
Published in
Sports Medicine / Issue 2/2015
Print ISSN: 0112-1642
Electronic ISSN: 1179-2035
DOI
https://doi.org/10.1007/s40279-014-0261-z

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