Rivaroxaban with Aspirin Versus Aspirin for Peripheral Arterial Disease and Intermittent Claudication. Rationale and Design of the COMPASS CLAUDICATION Trial.

BACKGROUND: The COMPASS trial demonstrated that in patients with peripheral arterial disease, the combination of rivaroxaban and aspirin compared with aspirin reduces the risk of major adverse limb events, but it is not known whether this combination can also improve symptoms in patients with intermittent claudication. The primary objective of this study is to evaluate the effect of the combination on claudication distance. STUDY DESIGN: Eighty-eight patients with intermittent claudication will be randomized to receive rivaroxaban 2.5 mg twice daily plus aspirin 100 mg once daily or aspirin 100 mg once daily for 24 weeks. The primary outcome is the change in claudication distance from the baseline to 24 weeks, measured by 6 min walking test and treadmill test. The primary safety outcome is the incidence of major bleeding and clinically relevant non-major bleeding according to the International Society on Thrombosis and Hemostasis criteria. SUMMARY: The COMPASS CLAUDICATION trial will provide high-quality evidence regarding the effect of the combination of rivaroxaban and aspirin on claudication distance in patients with peripheral arterial disease.

New treatments for peripheral artery disease.

The stenosis or occlusion of extremities defining peripheral artery disease (PAD) is a risk factor for adverse cardiovascular events and adverse limb events including amputation. PAD is common, can occur without symptoms or with claudication, and is easily diagnosed. Proper diagnosis and adherence to guideline-directed therapy can reduce the morbidity and potential mortality associated with PAD.

Effects of Intermittent Calf Muscle Electrical Stimulation on Walking Capacity in Claudicants Living with Type 2 Diabetes.

BACKGROUND: First-line therapy for diabetic patients presenting with intermittent claudication includes supervised exercise programs to improve walking distance. However, exercise comes with a variety of barriers and may be contraindicated in certain conditions. The aim of this study was to evaluate whether calf muscle electrostimulation improves claudication distance. METHODS: A prospective, one-group, pretest-posttest study design was used on 40 participants living with type 2 diabetes mellitus, peripheral artery disease (ankle brachial pressure index, <0.90), and calf muscle claudication. Calf muscle electrostimulation of varying frequencies (1-250 Hz) was prescribed on both limbs for 1-hour daily sessions for 12 consecutive weeks. The absolute claudication distance (ACD) was measured at baseline and after the intervention. RESULTS: The recruited cohort (30 men and ten women; mean age, 71 years; mean ankle brachial pressure index, 0.70) registered a mean ± SD baseline ACD of 333.71 ± 208 m. After a mean ± SD of 91.68 ± 6.23 days of electrical stimulation, a significant mean ± SD increase of 137 ± 136 m in the ACD (P = .001, Wilcoxon signed rank test) was registered. Improvement was found to be sex independent, but age was negatively correlated with proportion of improvement (r = -0.361; P = .011, Pearson correlation test). CONCLUSIONS: Electrical stimulation of varying frequencies on ischemic calf muscles significantly increased the maximal walking capacity in claudicants with type 2 diabetes. This therapeutic approach should be considered in patients with impaired exercise tolerance or as an adjunct treatment modality.

Clinical Outcomes in Neurogenic Claudication Using a Multimodal Program for Lumbar Spinal Stenosis: A Study of 49 Patients With Prospective Long-term Follow-up.

OBJECTIVE: The purpose of this study was to assess long-term outcomes of a 6-week multimodal program (manual therapy, exercises, and self-management strategies) in patients with neurogenic claudication due to degenerative lumbar spinal stenosis. METHODS: This study evaluated 49 patients with neurogenic claudication who completed a 6-week multimodal program between 2010 and 2013. Outcomes included Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ), and Numeric Rating Scale. Mean differences, paired t tests, and the Wilcoxon rank-sum test were used to compare outcomes at baseline, 6 weeks, and long-term follow-up. RESULTS: Twenty-three patients completed the follow-up questionnaire (47% response rate). Median follow-up was 3.6 years (interquartile range: 3.3-4.6). The mean age was 73.5 years (standard deviation: 8.5). Between baseline and long-term follow-up, there were statistically significant and clinically important improvements in disability (ODI: -23.7 [95% confidence interval (CI): -15.7 to -31.6]; ODI walking item: -1.96 [95% CI: -1.34 to -2.57]; ZCQ function scale: -0.42 [95% CI: -0.10 to -0.70]) and pain (leg pain: -3.53 [95% CI: -1.80 to -5.20]; ZCQ symptom scale: -0.71 [95% CI: -0.30 to -1.10]), but not low back pain (Numeric Rating Scale: -1.03 [95% CI: -1.00 to 3.10]). There was no statistically significant change in any outcomes between 6 weeks and long-term follow-up. CONCLUSION: In a sample of patients with neurogenic claudication participating in a 6-week multimodal program, clinically important improvements in leg pain and disability, but not low back pain while walking, were maintained in the long term (median duration of 3.6 years) when compared to baseline.

Five-year results of a clinical pilot study utilizing a pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis.

OBJECTIVE Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic options have certain drawbacks. This study evaluates the 5-year clinical and radiographic results of a minimally invasive pedicle-lengthening osteotomy (PLO) for symptomatic LSS. METHODS A prospective, single-arm, clinical pilot study was conducted involving 20 patients (mean age 61.7 years) with symptomatic LSS treated by a PLO procedure at 1 or 2 lumbar levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS, and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index, Zürich Claudication Questionnaire, 12-Item Short Form Health Survey, and a visual analog scale for back and leg pain. Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, 12-, 24-, and 60-month time points. RESULTS The PLOs were performed through percutaneous incisions, with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Statistically significant improvement was observed in each of the outcome instruments and maintained over the 5-year follow-up period. Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT scans documented healing of the osteotomy site in all patients at the 6-month time point and an increase of 115% in the mean cross-sectional area of the spinal canal. CONCLUSIONS Treatment of patients with symptomatic LSS with a PLO procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non-disease-specific outcome measures at all follow-up time points out to 5 years. Future research is needed to compare this technique to alternative therapies for LSS.

Unilateral repetitive tibial nerve stimulation improves neurogenic claudication and bilateral F-wave conduction in central lumbar spinal stenosis.

BACKGROUND: Repetitive electrical nerve stimulation of the lower limb may improve neurogenic claudication in patients with lumbar spinal stenosis (LSS) as originally described by Tamaki et al. We tested if this neuromodulation technique affects the F-wave conduction on both sides to explore the underlying physiologic mechanisms. METHODS: We studied a total of 26 LSS patients, assigning 16 to a study group receiving repetitive tibial nerve stimulation at the ankle (RTNS) on one leg, and 10 to a group without RTNS. RTNS conditioning consisted of a 0.3-ms duration square-wave pulse with an intensity 20% above the motor threshold, delivered at a rate of 5 Hz for 5 min. All patients underwent the walking test and the F-wave and M-wave studies for the tibial nerve on both sides twice; once as the baseline, and once after either the 5-min RTNS or 5-min rest. RESULTS: Compared to the baselines, a 5-min RTNS increased claudication distance (176 ± 96 m vs 329 ± 133 m; p = 0.0004) and slightly but significantly shortened F-wave minimal onset latency (i.e., increased F-wave conduction velocity) not only on the side receiving RTNS (50.7 ± 4.0 ms vs 49.2 ± 4.2 ms; p = 0.00081) but also on the contralateral side (50.1 ± 4.6 ms vs 47.9 ± 4.2 ms; p = 0.011). A 5-min rest in the group not receiving RTNS neither had a significant change on claudication distance nor on any F-wave measurements. The M response remained unchanged in both groups. CONCLUSIONS: The present study verified a beneficial effect of unilaterally applied RTNS of a mild intensity on neurogenic claudication and bilateral F-wave conduction. Our F-wave data suggest that this type of neuromodulation could be best explained by an RTNS-induced widespread sympathetic tone reduction with vasodilation, which partially counters a walking-induced further decline in nerve blood flow in LSS patients who already have ischemic cauda equina.

Rhythmic Auditory Music Stimulation Enhances Walking Distance in Patients With Claudication: A FEASIBILITY STUDY.

PURPOSE: Patients with claudication have altered gait, characterized by slower pace and shorter stride length, compared with matched controls. Rhythmic auditory music stimulation has been used successfully to reduce symptoms of pain and improve walking ability in patients with neurological gait alterations. The purpose of this study was to test the hypothesis that rhythmic auditory music stimulation via increased tempo and bass would immediately increase total walking distance in patients with claudication compared with music-without rhythm-enhancement condition or a no-music condition (standard). METHODS: Fourteen patients with claudication (mean age = 66.1 ± 7.7 y; ankle-brachial index = 0.63 ± 17) underwent three 6-min walk tests on the same day in random order. One with music-without rhythm enhancement with the tempo set at the usual walking cadence of the patient, one without music, and one with rhythmically enhanced music with the tempo increased 10 to 15 beats/min above the usual walking cadence of the patient. This increase in tempo is considered imperceptible to the untrained ear. RESULTS: The paired t test indicated an increase in total walking distance by 22.1 ± 25.4 m (P = .006) during the rhythmic auditory stimulation condition compared with the no-music condition and by 20.7 ± 24.4 m compared with the music-without enhancement condition (P = .007). Functional claudication distance increased by 40.0 ± 49.0 m during the rhythmically enhanced music condition (P = .009) compared with the no-music condition. CONCLUSIONS: These results suggest that rhythmic auditory stimulation immediately increases total walking distance in patients with claudication due to peripheral artery disease. This technology may provide a tool for clinicians to use when prescribing exercise, improve motivation, and increase adherence to exercise rehabilitation programs.

The Effectiveness of Calf Muscle Electrostimulation on Vascular Perfusion and Walking Capacity in Patients Living With Type 2 Diabetes Mellitus and Peripheral Artery Disease.

The aim of the study was to explore calf muscle electrostimulation on arterial inflow and walking capacity in claudicants with peripheral artery disease and diabetes mellitus. A prospective, 1-group, pretest-posttest study design was used on 40 high-risk participants (n = 40) who exhibited bilateral limb ischemia (ankle brachial pressure index [ABPI] <0.90), diabetes mellitus, and calf muscle claudication. A program of calf muscle electrical stimulation with varying frequency (1-250 Hz) was prescribed for 1 hour per day for 12 weeks. Spectral waveforms analysis, ABPI, absolute claudication distance (ACD), and thermographic temperature patterns across 4 specified regions of interest (hallux, medial forefoot, lateral forefoot, heel) at rest and after exercise, were recorded at baseline and following intervention to evaluate for therapeutic outcomes. A significant improvement in ACD and ABPI was registered following the intervention ( P = .000 and P = .001, respectively). Resting foot temperatures increased significantly ( P = .000) while the postexercise temperature drops were halved across all regions at follow-up, with hallux ( P = .005) and lateral forefoot ( P = .038) reaching statistical significance. Spectral Doppler waveforms were comparable ( P = .304) between both serial assessments. Electrical stimulation of varying frequency for 1 hour per day for 12 consecutive weeks registered statistically significant improvement in outcome measures that assess arterial inflow and walking capacity in claudicants with diabetes mellitus. These results favor the use of electrostimulation as a therapeutic measure in this high-risk population.

The effects of Crenotherapy and exercise in peripheral arterial occlusive disease. A comparison with simple exercise training.

BACKGROUND: Conservative therapies for patients affected by Peripheral Arterial Occlusive Disease (PAOD) aim first to correct the risk factors and to slow down the disease progression. Among these, exercise has positive effects on blood flow, muscle metabolism and well demonstrated systemic effects. These include reduction of chronic inflammation markers, improvement of walking mechanics and heart function. Controlled physical training increases the ability to perform the daily activities improving life expectancy of these patients. The aim of this study is to evaluate the effects and the effectiveness of physical training performed in thermal water compared to traditional treadmill walking exercise. METHODS: 98 patients affected by IIb stage PAOD, according to Leriche-Fontaine classification, were enrolled. Patients were randomized into two groups: the first arm carried out an intensive training program under medical supervision (group A); the second one carried out a rehabilitative exercise associated with crenotherapy (group B). The following parameters were detected: Ankle-Brachial pressure index (ABI), actual claudication distance (ACD), maximum walking distance (MWD), flow mediated dilatation (FMD) and the intima-media thickness (IMT). All patients underwent Doppler echocardiography and complete biochemical assay. RESULTS: In both groups, there was a statistically significant improvement of lipidaemia compared to baseline. When compared with each other, the two groups did not show statistically significant differences. There were no significant differences between the two groups regarding echocardiographic findings. Vascular reactivity study showed a statistically significant improvement of FMD after 3 months of exercise in both groups. In crenotherapy group (B) FMD values were significantly higher than the treadmill ones (A). In both groups a statistically significant improvement in ACD was observed CONCLUSIONS: Our experience shows that crenotherapy has similar effects compared to traditional physical training in the treatment of PAOD, being equally well tolerated and safe; it gives an advantage over conventional physical training in terms of ACD and MWD improvement, although not statistically significant, and it is extremely welcome to patients compared to traditional physical training. KEY WORDS: Arterioscleroses, Intermittent Claudicatio, Peripheral Arterial Diseasen, Physical Exercise, Rehabilitation.

Clinical outcomes for neurogenic claudication using a multimodal program for lumbar spinal stenosis: a retrospective study.

OBJECTIVE: The purpose of this preliminary study was to assess the effectiveness of a 6-week, nonsurgical, multimodal program that addresses the multifaceted aspects of neurogenic claudication. METHODS: In this retrospective study, 2 researchers independently extracted data from the medical records from January 2010 to April 2013 of consecutive eligible patients who had completed the 6-week Boot Camp Program. The program consisted of manual therapy twice per week (eg, soft tissue and neural mobilization, chiropractic spinal manipulation, lumbar flexion-distraction, and muscle stretching), structured home-based exercises, and instruction of self-management strategies. A paired t test was used to compare differences in outcomes from baseline to 6-week follow-up. Outcomes included self-reported pain, disability, walking ability, and treatment satisfaction. RESULTS: A total of 49 patients were enrolled, with a mean age of 70 years. The mean difference in the Oswestry Disability Index was 15.2 (95% confidence interval [CI], 11.39-18.92), and that for the functional and symptoms scales of the Swiss Spinal Stenosis Questionnaire was 0.41 (95% CI, 0.26-0.56) and 0.74 (95% CI, 0.55-0.93), respectively. Numeric pain scores for both leg and back showed statistically significant improvements. Improvements in all outcomes were clinically important. CONCLUSIONS: This study showed preliminary evidence for improved outcomes in patients with neurogenic claudication participating in a 6-week nonsurgical multimodal Boot Camp Program.

[Physical trainings in peripheral atherosclerosis: problems and ways of solution].

Physical trainings (PT) in patients with peripheral atherosclerosis (PA) improve quality of life and the prognosis. They are accompanied and followed by favourable shifts in metabolism of peripheral tissues. The currently existing guidelines are unequivocally in favour of the necessity of physical trainings in patients with signs of intermittent claudication (class I, level A evidence). However, there is a considerable gap between efficacy of regular physical exercises and readiness of patients to participate in them, with only a sparse number of patients with PA actually performing these programmes. The review gives a detailed consideration of both subjective and objective factors limiting the participation of PA patients in PT programmes. New approaches for solving this problem have recently been proposed. In order to prevent the development of painful sensations during PT, they propose to use low-intensity loads, also performing training of other muscular groups, integral trainings, including those using electrostimulation of skeletal muscles. Mention should be made of the beginning of PT in patients with subclinical manifestations of PA, behavioural therapy in PA patients. Revealing early forms of PA and carrying out active rehabilitative measures are more convenient to be performed by physicians specializing in neurosurgery, thus requiring new organizational approaches.

[Effectiveness of pentoxifylline and of bio-electromagnetic therapy in lower limb obliterative arterial disease]. / A pentoxifillin és a bioelektromágnes-regulációs kezelés hatása alsó végtagi obliteratív veroérbetegségben.

INTRODUCTION: There are limited therapeutic options to improve microcirculation. AIM: The question of the study was to investigate any potential beneficial effect of bio-electro-magnetic-regulation therapy on microcirculation in patients suffering from obliterative peripheral arterial disease including the circulation of lower extremities, as well as intermittent claudication. METHOD: Thirty patients suffering from obliterative peripheral arterial disease (Fontaine IIa and IIb) were recruited. The first step of the study was to determine the pain free and maximal walking distance with a treadmill unit. After the placebo period patients received 8 and 20 minutes bio-electro-magnetic-regulation treatment 16 times. After the treatment the pain free and maximal walking distance were measured again. In the second stage of the study the patients were treated by pentoxifylline infusions. RESULTS: Bio-electro-magnetic-regulation treatment increased the pain free period by 57.4% (p = 0.005) and the maximal walking distance by 36.6% (p = 0.042). The two forms of therapy together increased the pain free and maximal walking distance by 81.9% and by 84.0%, respectively. The combined therapy was very effective in contrast to placebo and bio-electro-magnetic-regulation treatment (p = 0.000373 and p = 0.00741, respectively). CONCLUSIONS: The bio-electro-magnetic-regulation therapy mainly affected the microvessels and pentoxifylline therapy rather had beneficial effects on hemorheology. The clinical effectiveness of combined therapy was good or excellent in 70% of patients.

Nonoperative treatment for lumbar spinal stenosis with neurogenic claudication.

BACKGROUND: Lumbar spinal stenosis with neurogenic claudication is one of the most commonly diagnosed and treated pathological spinal conditions. It frequently afflicts the elderly population. OBJECTIVES: To systematically review the evidence for the effectiveness of nonoperative treatment of lumbar spinal stenosis with neurogenic claudication. SEARCH METHODS: CENTRAL, MEDLINE, CINAHL, and Index to Chiropractic Literature (ICL) databases were searched up to June 2012. SELECTION CRITERIA: Randomized controlled trials published in English, in which at least one arm provided data on nonoperative treatments DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. Risk of bias in each study was independently assessed by two review authors using the 12 criteria recommended by the Cochrane Back Review Group (Furlan 2009). Dichotomous outcomes were expressed as relative risk, continuous outcomes as mean difference or standardized mean difference; uncertainty was expressed with 95% confidence intervals. If possible a meta-analysis was performed, otherwise results were described qualitatively. GRADE was used to assess the quality of the evidence. MAIN RESULTS: From the 8635 citations screened, 56 full-text articles were assessed and 21 trials (1851 participants) were included. There was very low-quality evidence from six trials that calcitonin is no better than placebo or paracetamol, regardless of mode of administration or outcome assessed. From single small trials, there was low-quality evidence for prostaglandins, and very low-quality evidence for gabapentin or methylcobalamin that they improved walking distance. There was very low-quality evidence from a single trial that epidural steroid injections improved pain, function, and quality of life, up to two weeks, compared with home exercise or inpatient physical therapy. There was low-quality evidence from a single trial that exercise is of short-term benefit for leg pain and function compared with no treatment. There was low and very low-quality evidence from six trials that multimodal nonoperative treatment is less effective than indirect or direct surgical decompression with or without fusion. A meta-analysis of two trials comparing direct decompression with or without fusion to multimodal nonoperative care found no significant difference in function at six months (mean difference (MD) -3.66, 95% CI -10.12 to 2.80) and one year (MD -6.18, 95% CI -15.03 to 2.66), but at 24 months a significant difference was found favouring decompression (MD -4.43, 95% CI -7.91 to -0.96). AUTHORS' CONCLUSIONS: Moderate and high-quality evidence for nonoperative treatment is lacking and thus prohibits recommendations for guiding clinical practice. Given the expected exponential rise in the prevalence of lumbar spinal stenosis with neurogenic claudication, large high-quality trials are urgently needed.

An integrative review: application of self-efficacy instruments for walking in populations with peripheral arterial disease.

OBJECTIVE: The study objective was to identify which self-efficacy measurement instruments are being used for walking in patients with peripheral arterial disease (PAD), the psychometrics of these instruments, and recommendations for use in research on patients with PAD. BACKGROUND: PAD is a common problem for individuals with similar risk factors as cardiovascular disease (CVD). Experts recommend a supervised walking program with incremental increases in speed and distance as an initial treatment for patients with intermittent claudication. Because patients may experience pain while walking, there is a tendency to be nonadherent with exercise therapy, and many limit or avoid walking all together, resulting in a sedentary lifestyle. Self-efficacy plays a role in determining a person's confidence in his or her ability to participate in an exercise program. Data sources for this study were PubMed, Cumulative Index of Nursing and Allied Health Literature, PsycINFO, and the Cochrane database. METHODS: The integrative review method described by Wittemore and Knafl was used for this review (Wittemore R, Knafl K. The integrative review: updated methodology. J Adv Nurs 2005;52:546-53.). Publications were retrieved electronically and reviewed for inclusion on the basis of studies that measured self-efficacy for walking in populations with PAD, peripheral vascular disease, and CVD. The analysis consisted of 9 publications. RESULTS: Only 2 studies were specific to the population with PAD. The remaining studies addressed self-efficacy issues in CVD or congestive heart failure. The analysis identified 4 instruments based on Bandura's Social Cognitive Theory that were used to assess self-efficacy: (1) the Self-Efficacy Expectation Scale, (2) the Self-Efficacy for Managing Chronic Disease Scale, (3) the Performance-Based Efficacy Scale, and (4) the Barriers Self-Efficacy Scale. The Self-Efficacy Expectation Scale was most frequently used in these studies. CONCLUSIONS: The use of the Self-Efficacy Expectation Scale instruments for walking in patients with PAD is limited because reliability and validity have been demonstrated in an older, mostly white population with CVD and congestive heart failure. Instruments that encompass the key constructs of self-efficacy, including physical, personal, and environmental aspects, would allow full evaluation with identification of potential explanations for success or failure for the chosen outcome. This should be taken into consideration in future studies when using instruments of self-efficacy.

Living a demanding life--spouses' experiences of living with a person suffering from intermittent claudication.

AIM: To report a study of family members' experiences of living with a person suffering from intermittent claudication caused by peripheral arterial disease. BACKGROUND: Intermittent claudication is a symptom caused by peripheral arterial disease. Walking ability is reduced due to pain and this also affects the family members and leads to consequences such as isolation and a restricted life. DESIGN: This study has a qualitative descriptive design. METHODS: Ten spouses living with a person suffering from intermittent claudication were interviewed between December 2009-June 2010. The interviews were then analysed using qualitative thematic analysis. FINDINGS: Four themes were identified: 'Frustrating to not meet intentions', 'Undergoing changes in social life', 'Being a person on the side of things' and 'Intertwining of circumstances'. The overall theme 'Living a demanding life' illustrates that intermittent claudication has great impact on daily life among spouses. CONCLUSION: This study gives an insight into the complexities and the difficulties of living together with someone suffering from intermittent claudication, a symptom that has great impact on both the spouses' and the ill persons' lives. According to the findings in this study, it is important to gain knowledge about the spouses' experiences because an holistic perspective is essential to treat and support the ill persons and their spouses.

[Lumbar spinal stenosis: clinical course, pathophysiology and treatment]. / Canal lombaire étroit: clinique, physiopathologie et traitement.

The lumbar spinal stenosis is a radiological description of a pathology that can present clinically by a neurogenic intermittent claudication; its diagnosis is mainly clinical. After listing the main criteria allowing the clinician to make a diagnosis, a review of available treatments is proposed. There are few quality studies and an empirical approach is often necessary. In severe cases, very disabling despite correct treatment, a surgical approach may be considered and discussed with the patient to avoid failure, sometimes linked to excessive expectations.

Upper- versus lower-limb aerobic exercise training on health-related quality of life in patients with symptomatic peripheral arterial disease.

OBJECTIVE: This randomized controlled trial investigated the effects of upper- and lower-limb aerobic exercise training on disease-specific functional status and generic health-related quality of life (QOL) in patients with intermittent claudication. METHODS: The study recruited 104 patients (mean age, 68 years; range, 50-85) from the Sheffield Vascular Institute. Patients were randomly allocated to groups that received upper-limb (ULG) or lower-limb (LLG) aerobic exercise training, or to a nonexercise control group. Exercise was performed twice weekly for 24 weeks at equivalent limb-specific relative exercise intensities. Main outcome measures were scores on the Walking Impairment Questionnaire (WIQ) for disease-specific functional status, the Medical Outcomes Study Short Form version 2 (SF-36v2), and European Quality of Life Visual Analog Scale (EQ-VAS) for health-related QOL. Outcomes were assessed at baseline, and at 6, 24, 48, and 72 weeks. RESULTS: After 6 weeks, improvements in the perceived severity of claudication (P = .023) and stair climbing ability (P = .011) vs controls were observed in the ULG, and an improvement in the general health domain of the SF-36v2 vs controls was observed in the LLG (P = .010). After 24 weeks, all four WIQ domains were improved in the ULG vs controls (P ≤ .05), and three of the four WIQ domains were improved in the LLG (P < .05). After 24 to 72 weeks of follow-up, more consistent changes in generic health-related QOL domains were apparent in the ULG. CONCLUSIONS: These findings support the use of alternative, relatively pain-free forms of exercise in the clinical management of patients with intermittent claudication.

Lumbar spinal stenosis.

Lumbar spinal stenosis (LSS) is most commonly due to degenerative changes in older individuals. LSS is being more commonly diagnosed and may relate to better access to advanced imaging and to an ageing population. This review focusses on radicular symptoms related to degenerative central and lateral stenosis and updates knowledge of LSS pathophysiology, diagnosis and management. Since patients with anatomic LSS can range from asymptomatic to severely disabled, the clinical diagnosis focusses on symptoms and examination findings associated with LSS. Imaging findings are helpful for patients with persistent, bothersome symptoms in whom invasive treatments are being considered. There is limited information from high-quality studies about the relative merits and demerits of commonly used treatments. Interpreting and comparing results of available research are limited by a lack of consensus about the definition of LSS. Nevertheless, evidence supports decompressive laminectomy for patients with persistent and bothersome symptoms. Recommendations favour a shared decision-making approach due to important trade-offs between alternative therapies and differences among patients in their preferences and values.

Antioxidants attenuate oxidative damage in rat skeletal muscle during mild ischaemia.

We have previously shown oxidative stress and oedema, caused by both xanthine oxidase-derived oxidants and infiltrating neutrophils, within skeletal muscle after contractile-induced claudication. The purpose of this study was to determine whether supplementation with antioxidant vitamins attenuates the oxidative stress, neutrophil infiltration and oedema associated with an acute bout of contractile-induced claudication. Rats received vehicle, vitamin C, vitamin E or vitamin C + E for 5 days prior to contractile-induced claudication. Force production was significantly reduced in the claudicant limbs of all groups compared with the control (sham) limb of control animals. Contractile-induced claudication caused a significant increase in protein oxidation, lipid peroxidation, neutrophil infiltration and oedema compared with sham muscles. Supplementation with vitamin C, E or C + E prevented the increases in each of these, and there were no differences between groups. These findings suggest that, in an animal model of exercise-induced claudication, neutrophil chemotaxis is caused by oxidizing species and that antioxidant supplementation can prevent oxidative damage, neutrophil infiltration and oedema following an acute bout of contractile-induced claudication.

Management of peripheral arterial disease of the lower extremities.

Smoking should be stopped and hypertension, diabetes mellitus, dyslipidemia, and hypothyroidism treated in patients with peripheral arterial disease (PAD) of the lower extremities. Statins decrease the incidence of intermittent claudication and improve exercise duration until the onset of intermittent claudication in persons with PAD and hypercholesterolemia. Antiplatelet drugs such as aspirin or clopidogrel, especially clopidogrel, angiotensin-converting enzyme inhibitors, and statins should be given to all persons with PAD. Beta blockers should be given if coronary artery disease is present. Exercise rehabilitation programs and cilostazol increase exercise time until intermittent claudication develops. Chelation therapy should be avoided. Indications for lower extremity percutaneous transluminal angioplasty or bypass surgery are (1) incapacitating claudication in persons interfering with work or lifestyle, (2) limb salvage in persons with limb-threatening ischemia as manifested by rest pain, nonhealing ulcers, and/or infection or gangrene, and (3) vasculogenic impotence.