Clinical practice guidelines for treatment of lower extremity peripheral artery disease (PAD) include a Class I recommendation for supervised exercise training for patients with intermittent claudication (IC). Prospective studies and meta-analyses have consistently shown that supervised exercise for patients with IC can increase their walking distances, quality of life, and function. Unfortunately, these programs are not available in all communities, and instructions from physicians to “get out and walk” are clearly not as effective as a supervised exercise program.

To help correct this treatment gap, the Vascular Disease Foundation and the American Association of Cardiovascular and Pulmonary Rehabilitation partnered to develop a PAD Exercise Training Toolkit. This toolkit is available in a free, downloadable format at http://www.vdf.org or http://www.aacvpr.org. It includes evidence-based and practical information for healthcare professionals to use to develop exercise programs specifically designed for patients with PAD.

Differences in Exercise for PAD Patients

Patients with lower extremity PAD often develop IC due to inadequate oxygenation of exercising muscles. These patients often self-regulate their activity level to avoid discomfort, which can lead to a downward spiral of worsened disability. Multiple studies have shown that supervised treadmill walking to the point of moderate claudication pain, interspersed with brief rest periods, with exercise sessions lasting 30 minutes or longer and occurring at least three times per week can double maximum walking distance and significantly reduce symptoms.

“Instructions from physicians to ‘get out and walk’ are clearly not as effective as a supervised exercise program.”

The mechanisms leading to improved symptoms and function have not been fully elucidated but include changes in the exercising muscle. This includes improved oxygen extraction and muscle metabolism; increased expression of vascular endothelial growth factor messenger RNA, circulating endothelial progenitor cells and angiogenic cells; and endothelial-dependent vasodilatation.  Improved gait efficiency and changes in hemorheology may also play a role. The stimulus for these changes is repeated ischemia, followed by exercise-induced hyperemia. Thus, exercising to the point of moderate claudication pain is necessary to improve symptoms and function.

Unfortunately, many physicians and exercise clinicians are not comfortable with encouraging patients to exercise to the point of moderate pain, despite evidence that this is effective. The PAD Exercise Toolkit reinforces these principles and includes chapters about medical clearance, pre- and post-exercise evaluation, and exercise programming to help clinicians develop individualized treatment plans and track functional improvement.

Practical Aspects to Consider

Unfortunately, many insurance companies, including Medicare, do not pay for supervised exercise for claudication, despite the level of evidence supporting its effectiveness.  However, many cardiac rehabilitation programs and hospital-based wellness programs have self-pay supervised exercise programs for people with coronary artery disease. These are perfect places for PAD patients to exercise and participate in educational programs about risk factors (eg, tobacco cessation and diabetes). Cardiologists are generally familiar with cardiac rehabilitation programs in their communities. For others, a directory for such programs can be found online at http://www.aacvpr.org. If local cardiac rehabilitation and wellness programs do not already work with PAD patients, it’s important to encourage them to read and use the toolkit.  If patients want additional information to raise awareness about the disease, the PAD Awareness Toolkit is available online at http://www.padcoalition.org.

Instead of just telling patients with claudication to “get out and walk,” healthcare providers should consider working with rehab and exercise clinicians in the community. This collaboration may lead to the promotion and development of high-quality PAD exercise programs.

References

The Vascular Disease Foundation’s PAD Exercise Training Toolkit is available at: http://www.vdf.org/professionals/exercisetoolkit.php.

Olin JW, Sealove BA. Peripheral artery disease: current insight into the disease and its diagnosis and management. Mayo Clin Proc. 2010;85:678-692.

Salmeh MJ, Ratchford EV. Update on peripheral arterial disease and claudication rehabilitation. Phys Med Rehabil Clin N Am. 2009;20:627-656.

Milani RV, Lavie CJ. The role of exercise training in peripheral arterial disease. Vascular Med. 2007;12:351-358.

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). J Am Coll Cardiol. 2006;47:1239-1312.