Exercise Physiology for Intermittent Claudication Reduce Mortality and Morbidity

 Therefore, guidelines call for cardiovascular risk reduction as a key component of PAD management. Moreover, guidelines recommend supervised exercise therapy such as walking or cycling (upper or lower body). Growing evidence also supports strength training. However, regardless of the mode of delivery, guidelines prefer individually prescribed, supervised, and progressive therapeutic exercise programs tailored to the needs and responses of individual patients.2

The strongest evidence shows how supervised, therapeutic exercise programs can mitigate cardiovascular risk factors among various chronic disease populations.3,4 Recently, a research team from the Netherlands performed a systematic review and meta-analysis to determine the effects of supervised exercise therapy on cardiovascular risk factors specifically for patients with intermittent claudication.

Intermittent claudication ranks as the most prevalent symptom of PAD. It involves cramping pain in the buttocks, thighs, and calves, which is brought on by walking and relieved by short rests. Guidelines accept supervised exercise therapy as the best primary treatment in terms of walking ability and quality of life.6,7 What’s more, the recent analysis of the Netherlands team finds the evidence specific to patients with intermittent claudication consistent with the other evidence supporting prescriptions for supervised exercise therapy.

Their study finds quick reductions in systolic blood pressure (-4 mm Hg) as well as diastolic blood pressure (-2 mm Hg). With time, supervised exercise therapy is associated with lower LDL cholesterol (-0.2 mmol/L) and lower total cholesterol (-0.2 mmol/L). While these mean reductions may appear slight, they are clinically significant. For instance, the reduction in systolic blood pressure alone suggests a cardiovascular risk reduced by 8% and an all-cause mortality risk reduced by 5%.8 The meta-analysis only reported improvements in risk factors. Other studies examining the overall risk reduction of supervised exercise therapy compared to usual care find improvements in hospitalisations, morbidity, and cardiovascular mortality ranging between 30% and 52%.9-11 It is important to note that these results are specific to supervised exercise therapy. In intermittent claudication, exercise advice alone proves helpful, but generally inferior to the results available through supervised exercise therapy.12

References

1. Lauret GJ, van Dalen DC, Willigendael EM, Hendriks EJ, de Bie RA, Spronk S, Teijink JA. Supervised exercise therapy for intermittent claudication: current status and future perspectives. Vascular. 2012 Feb;20 (1):12-9.

2. Harwood AE, Pymer S, Ingle L, Doherty P, Chetter IC, Parmenter B, Askew CD, Tew GA. Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners. BMJ Open Sport & Exercise Medicine. 2020 Nov 1;6(1):e000897.

3. Pedersen BK, Saltin B. Exercise as medicine–evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian Journal of Medicine & Science in Sports. 2015 Dec;25:1-72.

4. Kujala UM. Evidence on the effects of exercise therapy in the treatment of chronic disease. British Journal of Sports Medicine. 2009 Aug 1;43(8):550-5.

5. Jansen SC, Hoorweg BB, Hoeks SE, van den Houten MM, Scheltinga MR, Teijink JA, Rouwet EV. A systematic review and meta-analysis of the effects of supervised exercise therapy on modifiable cardiovascular risk factors in intermittent claudication. Journal of Vascular Surgery. 2019 Apr 1;69(4):1293-308.

6. V. Aboyans, J.B. Ricco, M.E. Bartelink, M. Bjorck, M. Brodmann, T. Cohnert, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 55 (2018), pp. 305-368.

7. M.D. Gerhard-Herman, H.L. Gornik, C. Barrett, N.R. Barshes, M.A. Corriere, D.E. Drachman, et al. 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 Circulation. 135 (2017), pp. e686-e725.

8. Ettehad D, Emdin CA, Kiran A, Anderson SG, Callender T, Emberson J, Chalmers J, Rodgers A, Rahimi K. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. The Lancet. 2016 Mar 5;387(10022):957-67.

9. Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database of Systematic Reviews. 2017(12).

10. Sakamoto S, Yokoyama N, Tamori Y, Akutsu K, Hashimoto H, Takeshita S. Patients with peripheral artery disease who complete 12-week supervised exercise training program show reduced cardiovascular mortality and morbidity. Circulation Journal. 2009;73(1):167-73.

11. Anderson L, Taylor RS. Cardiac rehabilitation for people with heart disease: an overview of Cochrane systematic reviews. Cochrane Database of Systematic Reviews. 2014(12).

12. Bäck M, Jivegård L, Johansson A, Nordanstig J, Svanberg T, Adania UW, Sjögren P. Home-based supervised exercise versus hospital-based supervised exercise or unsupervised walk advice as treatment for intermittent claudication: a systematic review. Journal of Rehabilitation Medicine. 2015 Oct 5;47(9):801-8.