A meta-analysis of randomized controlled trials evaluating the efficacy of smoking cessation interventions in people with peripheral artery disease.

OBJECTIVE: This review aimed to systematically pool evidence from randomized clinical trials on the efficacy of interventions in assisting smoking cessation in participants with peripheral artery disease (PAD). METHODS: Publicly available databases were searched for randomized clinical trials testing the effect of interventional programs in achieving smoking cessation in participants with PAD who were current smokers. The primary outcome was smoking cessation at the end of follow-up. Meta-analyses were performed using random effect models and reported as risk ratios and 95% confidence intervals. Risk of bias and publication bias were assessed using a modified version of the Cochrane Collaboration's tool and funnel plots, respectively. RESULTS: Six randomized clinical trials testing smoking cessation programs comprising physician advice, behavioral counselling from an expert delivered in-person or over the telephone, and the provision of nicotine replacement therapy and/or varenicline in 558 smokers with PAD were included. A meta-analysis suggested that, overall, these interventions did not significantly increase the chance of quitting smoking (risk ratio, 1.48; 95% confidence interval, 0.84-2.61), with low heterogeneity between studies (I2 = 20%), which were robust in sensitivity analyses. Risk of bias was high, moderate, and low in one, three, and two studies respectively. A funnel plot suggested a low risk of publication bias. CONCLUSIONS: Overall, previously tested smoking cessation interventions have not been effective in achieving smoking cessation in people with PAD. Further research is needed to develop and test interventions that can effectively help current smokers with PAD to quit.

A Retrospective Comparison of Fitness and Exercise Progression in Patients With Coronary and Peripheral Artery Disease in Cardiac Rehabilitation.

BACKGROUND: Cardiac rehabilitation (CR) is recommended for patients with coronary (CAD) and peripheral (PAD) artery disease. However, no study has compared changes in cardiorespiratory fitness (VO2peak) or exercise prescription progression among PAD, CAD, and concomitant PAD and CAD (BOTH). The objectives of this study were to 1) compare change in VO2peak among patients with PAD, CAD, and BOTH, and 2) examine progression in exercise prescription parameters in a comprehensive 6-month cardiac rehabilitation (CR) program. METHODS: A retrospective analysis of patient data recorded from 2006 to 2017 from a large urban hospital was conducted. Patients with PAD (n = 63) and BOTH (n = 164) were included in the analyses. Patients with CAD (n = 63) were matched to PAD by sex (36.5% female), age (69 years), smoking status, diabetes, and year in program. RESULTS: There were significant improvements in VO2peak from baseline to 6 months in all groups (CAD +2.7 ± 3.4 mL⋅kg-1⋅min-1, PAD +2.4 ± 3.8 mL⋅kg-1⋅min-1, BOTH +1.8 ± 3.1 mL⋅kg-1⋅min-1; all P < 0.001). Between-group differences were significant between PAD and CAD as well as between CAD and BOTH (P = 0.001). Walking distance, duration, and pace increased for all groups over 6 months (P < 0.001), with a significant difference in pace between CAD and BOTH (P = 0.006). CONCLUSIONS: Patients with PAD, CAD, and BOTH had significant improvements in VO2peak following a 6-month CR program. However, despite similar prescribed walking distance and duration, improvements in VO2peak were mitigated in PAD and BOTH compared with CAD. These results support benefits of CR for patients diagnosed with PAD, but alternate exercise strategies should be explored for patients with PAD.

Rationale and design of a smartphone-enabled, home-based exercise program in patients with symptomatic peripheral arterial disease: The smart step randomized trial.

BACKGROUND: Supervised exercise therapy (SET) is recommended in patients with symptomatic peripheral arterial disease (PAD) as first-line therapy, although patient adoption remains low. Home-based exercise therapy (HBET) delivered through smartphones may expand access. The feasibility of such programs, especially in low-resource settings, remains unknown. METHODS: Smart Step is a pilot randomized trial of smartphone-enabled HBET vs walking advice in patients with symptomatic PAD in an inner-city hospital. Participants receive a smartphone app with daily exercise reminders and educational content. A trained coach performs weekly phone-based coaching sessions. All participants receive a Fitbit Charge HR 2 to measure physical activity. The primary outcome changes in 6-minute walking test (6MWT) distance at 12 weeks over baseline. Secondary outcomes are the degree of engagement with the smartphone app and changes in health behaviors and quality of life scores after 12 weeks and 1 year. RESULTS: A total of 15 patients are randomized as of December 15, 2019 with a mean (SD) age of 66.1 (5.8) years. The majority are female (60%) and black (87%). At baseline, the mean (SD) ABI and 6MWT were 0.86 (0.29) and 363.5 m, respectively. Enrollment is expected to continue until December 2020 to achieve a target size of 50 participants. CONCLUSIONS: The potential significance of this trial will be to provide preliminary evidence of a home-based, "mobile-first" approach for delivering a structured exercise rehabilitation program. Smartphone-enabled HBET can be potentially more accessible than center-based programs, and if proven effective, may have a potential widespread public health benefit.

Short interval or continuous training programs to improve walking distance for intermittent claudication: Pilot study.

OBJECTIVE: Supervised exercise training is part of first-line therapies for intermittent claudication. Short periods of intensive treadmill training have been found efficient; however, the optimal modalities remain to be determined, especially interval training with active recovery (ITAR). In this prospective assessor-blinded single-centre pilot study, we assessed the feasibility of a randomised controlled trial comparing parallel 4-week intensive rehabilitation programs comprising treadmill training performed as ITAR or conventional training with constant slope and speed interspersed with rest periods (CT). METHODS: A total of 38 in- or out-patients were randomised to the ITAR or CT program for 5 days/week for 4weeks. The primary outcome was change in maximum walking distance measured on a graded treadmill before and after the program. RESULTS: Adherence was high. All training sessions were completed in the ITAR program and only a few were not completed in the CT program (median 100% [Q1-Q3 96-100]). Tolerance was excellent (no adverse events). VO2peak was low in both groups, corresponding to moderate to severe exercise intolerance. The 2 groups did not differ in the primary outcome (median ITAR vs CT 480 [135-715] vs 315m [0-710]; p=0.62) or other walking distances (constant speed and gradient treadmill test). For all 38 participants, both programs greatly increased maximum walking distance in the graded treadmill test: median 415 [240-650] to 995m [410-1490], with a large effect size (p<10-4). CONCLUSION: A 4-week intensive rehabilitation program with ITAR or CT for intermittent claudication showed high adherence, was well tolerated, and improved walking distance as much as that reported for longer conventional programs. These findings prompt the design of a larger multicenter randomised controlled trial. TRIAL REGISTRATION: NCT01734603.

Cross-sectoral rehabilitation intervention for patients with intermittent claudication versus usual care for patients in non-operative management - the CIPIC Rehab Study: study protocol for a randomised controlled trial.

INTRODUCTION: Intermittent claudication (IC) caused by peripheral artery disease (PAD) is a common cardiovascular disease. Patients with IC have reduced walking capacity, restricted activity levels and mobility, and reduced health-related quality of life. The disease leads to social isolation, the risk of cardiovascular morbidity, and mortality. Non-operative management of IC requires exercise therapy and studies show that supervised exercise training is more effective than unsupervised training, yet many patients with IC lack motivation for changes in health behaviour. No studies investigating the effects of existing cardiac rehabilitation targeted patients with IC have been published. The aim of this article is to present the rationale and design of the CIPIC Rehab Study, which examines the effect of a cross-sectoral rehabilitation programme versus usual care for patients in non-operative management for IC. METHODS AND ANALYSIS: A randomised clinical trial aims to investigate whether cardiac rehabilitation for patients with IC in non-operative management versus usual care is superior to treatment as usual. The trial will allocate 118 patients, with a 1:1 individual randomisation to either the intervention or control group. The primary outcome is maximal walking distance measured by the standardised treadmill walking test. The secondary outcome is pain-free walking distance measured by the standardised treadmill walking test, healthy diet measured by a fat-fish-fruit-green score, and level of physical activity measured by an activity score within official recommendations. Statistical analyses will be blinded. Several exploratory analyses will be performed. A mixed-method design is used to evaluate qualitative and quantitative findings. A qualitative and a survey-based complementary study will be undertaken to investigate patients' post-discharge experiences. A qualitative post-intervention study will explore experiences of participation in rehabilitation. DISCUSSION: The study is the first to assess the effect of a cardiac rehabilitation programme designed for patients with IC. The study will describe how to monitor and improve rehabilitation programmes for patients with IC in a real-world setting. Mixed-method strategies can allow for both exploration and generalisation in the same study, but the research design is a complex intervention and any effects found cannot be awarded a specific component. TRIAL REGISTRATION: Retrospectively registered in Clinicaltrials.gov identifier: NCT03730623.

Entering Cardiac Rehabilitation With Peripheral Artery Disease: A RETROSPECTIVE COMPARISON TO CORONARY ARTERY DISEASE.

PURPOSE: Supervised exercise is recommended for patients with peripheral artery disease (PAD) and patients with coronary artery disease (CAD). Both conditions share common etiology as atherosclerotic diseases. The clinical profile, cardiorespiratory fitness, and exercise prescriptions of PAD, CAD, and patients with concomitant PAD and CAD (BOTH) have yet to be compared upon entry into cardiac rehabilitation (CR). METHODS: Cardiopulmonary, demographic, and anthropometric assessments were conducted at entry to CR between January 2006 and December 2017. RESULTS: Among 9701 consecutively enrolled patients, there were 94.6% with CAD (n = 9179), 1.5% with PAD (n = 143), and 3.9% with BOTH (n = 379). Only 5.4% (n = 522) of all patients entering CR had a diagnosis of PAD. Compared with CAD, patients with PAD and BOTH were older (mean ± SD = 62.5 ± 11.1 vs 67.9 ± 11.4 and 69.2 ± 9.8 yr, P < .01), had higher resting systolic blood pressure (124 ± 17 vs 130 ± 17 and 133 ± 18 mm Hg, P < .01), had lower cardiorespiratory fitness (19.7 ± 6.3 vs 15.6 ± 4.8 and 15 ± 4.5 mL/kg/min, P < .01), and were more likely to have diabetes (25% vs 35% and 41%, P < .01), abdominal obesity (39% vs 54% and 51%, P < .01), and initially prescribed lower-intensity exercise (84.4 ± 14.1 vs 74.1 ± 15.7 and 70.0 ± 14.6 m/min exercise pace, P < .01), reflecting the complex nature of patients diagnosed with PAD. CONCLUSIONS: Patients referred with PAD have a cardiovascular risk profile that places them at a greater risk for a repeat or first cardiac event compared with patients with CAD. Referral to structured exercise and risk factor modification programs should be considered to aid in the management of PAD.

Bicycle exercise training improves ambulation in patients with peripheral artery disease.

OBJECTIVE: Exercise training has multiple beneficial effects in patients with arteriosclerotic diseases; however, the exact underlying mechanisms of the effects are not completely understood. This study aimed to evaluate the effectiveness of a supervised exercise program in improving gait parameters, including the variability and walking performance of lower limb movements, in patients with peripheral artery disease (PAD) and intermittent claudication (IC). METHODS: Sixteen patients with a history of PAD and IC were recruited for this study, and they completed a 3-month supervised bicycle exercise program. The ankle-brachial index and responses to quality of life (QOL) questionnaires were evaluated. Near-infrared spectroscopy was also performed to determine the hemoglobin oxygen saturation in the calf. Patients' kinematics and dynamics, including joint range of motion and muscle tension, were evaluated using an optical motion capture system. Computed tomography images of each muscle were assessed by manual outlining. Data were collected before and after the supervised bicycle exercise program, and differences were analyzed. RESULTS: Significant differences were not found in step length, ankle-brachial index, and hemoglobin oxygen saturation before and after the supervised bicycle exercise program; however, IC distance (P = .034), maximum walking distance (P = .006), and all QOL questionnaire scores (P < .001) showed significant improvement. Hip range of motion (P = .035), maximum hip joint torque (right, P = .031; left, P = .044), maximum tension of the gluteus maximus muscle (right, P = .044; left, P = .042), and maximum hip joint work (right, P = .048; left, P = .043) also significantly decreased bilaterally. Computed tomography images showed a significant increase in the cross-sectional area of the abdominal, trunk, and thigh muscles but not in that of the lower leg muscles after the supervised exercise program intervention. CONCLUSIONS: In this study, bicycle exercise training improved the QOL and walking distance and decreased hip movement. The results showed that bicycling might be as useful as walking in patients with PAD.

Resistance training as a treatment for older persons with peripheral artery disease: a systematic review and meta-analysis.

OBJECTIVE: Resistance training (RT) improves walking ability in persons with peripheral artery disease. We conducted a meta-analysis of randomised controlled trials (RCTs) investigating the effect of RT on peripheral artery disease (as measured by walking ability). DESIGN: We included RCTs that investigated the effect of RT on treadmill and/or 6 min walk (6-MWT) distances. RT intensity was assessed according to the American College of Sports Medicine guidelines by 1 repetition maximum or rating of perceived exertion. Standardised mean (SMD) and mean differences (MD) were calculated using a random-effects inverse variance model. Heterogeneity and bias were assessed using RevMan V.5.3. Meta-regression and meta-analysis of variance were performed as moderator analyses. DATA SOURCES: Databases (Medline, Embase, Web of Science, Cinahl and Google Scholar) were searched until July 2018. RESULTS: Fifteen trials isolated RT; 7 trials compared RT with aerobic exercise. We analysed 826 patients (n=363 completing RT), with a mean age of 67.1±3.8 years. Training ranged from low-high intensity, 2-7 times per week for 17±7 weeks, with a mix of upper, lower or whole body training. Overall RT significantly improved constant load treadmill claudication onset (COD) (SMD 0.66 [0.40, 0.93], p<0.00001) and total walking distance (WD) (SMD 0.51 [0.23, 0.79], p=0.0003), progressive treadmill COD (SMD 0.56 [0.00, 1.13], p=0.05) and total WD (SMD 0.45 [0.08, 0.83], p=0.02), and 6-MWT COD (MD 82.23 m [40.91, 123.54], p<0.0001). Intensity played a role in improvement, with high-intensity training yielding the greatest improvement (p=0.02). CONCLUSIONS: RT clinically improved treadmill and flat ground walking ability in persons with peripheral artery disease. Higher intensity training was associated with better outcomes. Our study makes a case for clinicians to include high-intensity lower body RT in the treatment of peripheral artery disease. TRIAL REGISTRATION NUMBER: CRD42017081184.

Referral from vascular surgery to cardiovascular rehabilitation and related outcomes in patients with peripheral arterial disease: the THINKPAD-RELOADED survey.

The utilization of cardiovascular rehabilitation (CR) programmes in patients with Lower Extremity Peripheral Artery Disease (LEPAD) is generally poor, with limited evidence of current policies for referral. The aim of the study was to evaluate, within a cohesive network of CR and vascular surgery facilities with facilitated referral process, the clinical characteristic of LEPAD patients referred to CR and related outcomes, as compared to patients not referred. The present is an observational prospective study of consecutive patients recruited at vascular surgery facilities. Out of 329 patients observed, the average referral rate to CR was 34% (28% and 39% in patients with and without recent peripheral revascularization, p<0.05). LEPAD patients entering the CR programme were similar to those who did not according to sex, age, the vascular surgery setting of evaluation, and localization of arterial lesions. Patients with moderate intermittent claudication and patients with acute limb ischemia as index event were more represented among those who attended CR (41% vs 21% and 9% vs 2% respectively, p<0.05). Patients referred to CR had five times more episodes of acute coronary syndrome and heart failure as complication of the index event. The cardiovascular risk profile (obesity 29.5% vs 11%, p<0.05; hypercholesterolemia 80% vs 61%, p<0.05) was much worse in LEPAD patients referred to CR, but conversely, they better achieved secondary prevention targets, particularly for blood pressure control (97% vs 57%, p<0.05). All-cause 2-year mortality in the whole patients' population was 6%. Patients entering the CR programme displayed less events (13.5% vs 37.7%, p<0.05), mainly death (3.1% vs 11.3%, p<0.05) and limb-related events (4.2% vs 15.2%, p<0.05). The results of our study suggest that when a cohesive network of vascular surgery and CR facilities becomes available, the referral rate to rehabilitation may increase up to one third of eligible patients. Patients with higher comorbidity and cardiovascular risk seem to have priority in the referral process, nevertheless those with peripheral revascularization are still underestimated. Entering CR may ensure better cardiovascular risk profile and cardiovascular prognosis in LEPAD patients, and consequently the systematic adoption of this care model needs to be strongly recommended and facilitated.

Intermittent Claudication in Physiotherapists' Practice.

Intermittent claudication is a symptom of atherosclerosis of the lower limbs (peripheral arterial disease (PAD)) and is characterized by pain and cramps of lower limb muscles during exercise. Claudication leads to a reduction in physical activity of patients. PAD is a systemic disease. Atherosclerotic lesions located in the arteries of the lower limbs not only pose the risk of the ischemic limb loss, but above all, they are an important prognostic factor. Patients with claudication are at significant risk of cardiovascular complications such as infarcts or strokes. Comprehensive rehabilitation of patients with intermittent claudication based on the current TASC II (Inter-Society Consensus for the Management of Peripheral Arterial Disease) guidelines, ESC (European Society of Cardiology) guidelines, and AHA (American Heart Association) guidelines includes supervised treadmill training, training on a bicycle ergometer, Nordic Walking, resistance exercises of lower limb muscles, and exercises of upper limbs. A trained, educated, and motivated patient has a chance to improve life quality as well as life expectancy.

Peripheral Arterial Disease: Supervised Exercise Therapy Through Cardiac Rehabilitation.

Peripheral arterial disease (PAD) is frequently underdiagnosed and undertreated. This review identifies specific subgroups within older adults more likely to develop PAD, and describes methods to diagnose PAD and provide evidence in support of systematic referral to cardiac rehabilitation programs to enhance successful comprehensive management. Clear evidence and guidelines support the routine use of supervised exercise therapy to improve function, reduce risk of cardiovascular morbidity and mortality, and enhance the success of endovascular interventions.

Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association.

Patients with lower-extremity peripheral artery disease (PAD) have greater functional impairment, faster functional decline, increased rates of mobility loss, and poorer quality of life than people without PAD. Supervised exercise therapy (SET) improves walking ability, overall functional status, and health-related quality of life in patients with symptomatic PAD. In 2017, the Centers for Medicare & Medicaid Services released a National Coverage Determination (CAG-00449N) for SET programs for patients with symptomatic PAD. This advisory provides a practical guide for delivering SET programs to patients with PAD according to Centers for Medicare & Medicaid Services criteria. It summarizes the Centers for Medicare & Medicaid Services process and requirements for referral and coverage of SET and provides guidance on how to implement SET for patients with PAD, including the SET protocol, options for outcome measurement, and transition to home-based exercise. This advisory is based on the guidelines established by the Centers for Medicare & Medicaid Services for Medicare beneficiaries in the United States and is intended to assist clinicians and administrators who are implementing SET programs for patients with PAD.

A Novel, Individualized Exercise Program for Patients with Peripheral Arterial Disease Recovering from Bypass Surgery.

The effectiveness of an individual six-month-long physical exercise program in improving health-related quality of life (HRQOL) is unclear. There is some evidence that an individual exercise program can be effective for this aim. The goal of this study was to compare an individual six-month-long physical exercise program for patients with PAD (Peripheral Arterial Disease) with a traditional exercise program and find the effect of these programs on HRQOL and PAD risk factors. The study included patients who underwent femoral-popliteal artery bypass grafting surgery. Patients were divided into three groups: patients participating in an individual six-month-long physical exercise program (group I), in the standard physical activity program (group II), and in a control group (group III), with no subjects participating in rehabilitation II. Results: group I patients had a significantly (p < 0.001) higher HRQOL at 6 months after their surgery compared with groups II and III. The HRQOL scores were significantly (p < 0.05) lower after surgery among older (≥ 65), overweight participants, as well as among patients with diabetes mellitus and cardiovascular diseases when comparing study results with patients without these risk factors.

Role of structured and supervised exercise programmes in peripheral artery disease patients with and without claudication - A Systematic Review and Metaanalysis.

OBJECTIVE: This review aimed to determine the impact of exercise protocol among peripheral artery disease patients. Literature search was done from 2005 to 2018. METHODS: Databases such as Google Scholar, Medline and PubMed was reconnoitred for the purpose of research articles by using key words like exercise training, peripheral artery disease, ankle brachial index, haemodynamic and atherosclerosis. Studies fulfilling the inclusion criteria were retrieved and encompassed in the present study. RESULTS: The heterogeneity of the studies included in the analysis and the impact of exercise programmes on outcome measures were assessed by using hedge gstatistical model.Of the54 studies found, 9(16.6%) were analysed that suggest supervised and structured exercises programmes significantly improved (p<0.05) outcome variables. CONCLUSIONS: Future randomized controlled trials related to the duration of exercises regimes are required in order to tailor the training programmes according to the need of individuals.

Fisioterapia intra-hospitalar para pacientes com isquemia crítica de membro inferior: consenso de especialistas / Fisioterapia intrahospitalaria para pacientes con isquemia crítica de miembro inferior: consenso de especialistas / Intra-hospital physical therapy for patients with critical lower limb ischaemia: an expert consensus

RESUMO A isquemia crítica de membro inferior (ICMI) gera impacto nos sistemas de saúde, na qualidade de vida e funcionalidade dos indivíduos diagnosticados. Entretanto, há pouca evidência científica que permita fundamentar a intervenção fisioterapêutica para pacientes internados por ICMI. O objetivo desse estudo foi elaborar um consenso de especialistas sobre a fisioterapia intra-hospitalar para pacientes com ICMI. Para tal, foi utilizado o método Delphi. Um painel de especialistas foi formado por 18 fisioterapeutas que representavam 85,7% da equipe de um hospital de referência em cirurgia vascular. Foram consideradas, para o consenso, as respostas com valor mínimo de concordância de 70% e média ou mediana ≥3,1 na escala Likert. Os questionários abordaram itens da avaliação, objetivos e condutas fisioterapêuticas nas fases pré e pós-cirurgia de revascularização. Definiram-se como itens essenciais a avaliação de sintomas, função cognitiva, musculoesquelética e cardiorrespiratória. Controle da dor, redução de edemas, ganho de amplitude de movimento, deambulação e educação em saúde são objetivos no pré-operatório e o ganho de força muscular na fase pós-operatória. Exercícios passivo, assistido, ativo livre e circulatório, incluindo os membros superiores, estão indicados antes e após as cirurgias. Educação em saúde e deambulação com redução de peso em área de lesão plantar são essenciais em todo o período de internação. A eletroanalgesia foi preconizada no pré-operatório e a elevação do membro inferior e exercícios resistidos no pós-operatório.

RESUMEN La isquemia crítica de miembro inferior (ICMI) afecta a los sistemas de salud y la calidad de vida y funcionalidad de los individuos diagnosticados. Sin embargo, hay poca evidencia científica que fundamente la intervención fisioterapéutica para pacientes internados por ICMI. El objetivo de este estudio fue elaborar un consenso de especialistas sobre la fisioterapia intrahospitalaria para pacientes con ICMI. Para ello, se utilizó el método Delphi. Se formó un panel de expertos con 18 fisioterapeutas que representaban el 85,7% del equipo de un hospital de referencia en cirugía vascular. Se consideraron, para el consenso, las respuestas con un valor mínimo de concordancia del 70% y media o mediana ≥3,1 en la escala Likert. Los cuestionarios abordaron ítems de evaluación, objetivos y conductas fisioterapéuticas en las fases pre y poscirugía de revascularización. Se definieron como elementos esenciales la evaluación de síntomas y las funciones cognitiva, musculoesquelética y cardiorrespiratoria. En el preoperatorio, control del dolor, reducción de edemas, ganancia de amplitud de movimiento, deambulación y educación en salud son los objetivos; en la fase posoperatoria, la ganancia de fuerza muscular. Los ejercicios pasivos, asistidos, activos libres y circulatorios, incluidos los miembros superiores, se indican antes y después de las cirugías. La educación en salud y la deambulación con reducción de peso en el área de lesión plantar son esenciales en todo el período de internación. La electroanalgesia fue preconizada en el preoperatorio; y, en el postoperatorio, elevación del miembro inferior y ejercicios resistidos.

ABSTRACT Critical limb ischemia (CLI) is a disease with a great burden for the healthcare system, patient's functionality and quality of life. However, there is little evidence to guide intrahospital physical therapy programs for patients with CLI. Thus, this study aimed to provide an expert consensus on intrahospital physiotherapeutic care for CLI patients. An expert panel was made up with 18 experienced physical therapists, which represented 85.7% of physical therapists from a reference vascular surgery team in a university hospital. The Delphi method was used to produce a consensus, considering a minimum agreement of 70% and a mean or median score in the Likert scale ≥3.1. The questionnaires included items related to assessment, goals and physiotherapeutic interventions prior and after revascularization. A consensus was reached on assessing symptoms, cognitive, articular, musculoskeletal and cardiorespiratory functions. Pain control, edema drainage, range of motion gain, walking incentive and health education are goals in the pre-operatory and the muscular strengthening in postoperatory phase. In both phases there was a consensus on the use of passive, active-assisted and active exercises, including upper limb exercises. Walking and therapeutic education are essential during the hospitalization period with offloading practices in area of plantar ulcer. Electroanalgesia should be used in preoperative phase and resisted exercises and lower limb elevation at postoperatory.

Dynamic strength training intensity in cardiovascular rehabilitation: is it time to reconsider clinical practice? A systematic review.

When added to endurance training, dynamic strength training leads to significantly greater improvements in peripheral muscle strength and power output in patients with cardiovascular disease, which may be relevant to enhance the patient's prognosis. As a result, dynamic strength training is recommended in the rehabilitative treatment of many different cardiovascular diseases. However, what strength training intensity should be selected remains under intense debate. Evidence is nonetheless emerging that high-intensity strength training (≥70% of one-repetition maximum) is more effective to increase acutely myofibrillar protein synthesis, cause neural adaptations and, in the long term, increase muscle strength, when compared to low-intensity strength training. Moreover, multiple studies report that high-intensity strength training causes fewer increments in (intra-)arterial blood pressure and cardiac output, as opposed to low-intensity strength training, thus potentially pointing towards sufficient medical safety for the cardiovascular system. The aim of this systematic review is therefore to discuss this line of evidence, which is in contrast to current clinical practice, and to re-open the debate as to what dynamic strength training intensities should actually be applied.

Cardiac rehabilitation in people with peripheral arterial disease: A higher risk population that benefits from completion.

BACKGROUND: Peripheral arterial disease (PAD) is common in people referred for cardiac rehabilitation (CR). However, the associations between PAD diagnosis and CR attendance and mortality remain to be defined. METHODS: All patients referred to a 12-week exercise-based CR program were included. Associations between PAD diagnosis and starting CR as well as between PAD diagnosis and completing CR were measured using multivariable logistic regression. Associations between CR completion and mortality were measured using adjusted Cox proportional hazards models, and a propensity-based matching sensitivity analysis was performed. RESULTS: 23,215 patients (mean age 61.3 years; 21.6% female) were referred to CR; 1366 (5.9%) had PAD. Those with PAD were less likely to start CR (57.0% vs 68.2%, adjusted OR 0.81, 95%CI 0.72, 0.91) and complete CR if they started (70.6% vs 76.7%, adjusted OR 0.80, 95%CI 0.68, 0.94). Patients with PAD completing CR had lower exercise capacity at baseline (6.6 vs. 7.6 METs, p < 0.0001) and completion (7.5 vs 8.6 METs, p < 0.0001). There were 3510 deaths over follow-up; 10-year survival was lower in those with PAD (66.9 vs 84.5%; p < 0.0001). CR completion was associated with lower mortality for all (adjusted HR 0.62 (95%CI 0.57, 0.67)), and the magnitude of the association was independent of PAD status. CONCLUSIONS: Patients with PAD referred to CR had a higher mortality than those without, and were less likely to start and complete CR. Completion of CR was associated with improved fitness and survival for PAD patients. These data support broader use of CR by those with PAD.

Changes in vascular and inflammatory biomarkers after exercise rehabilitation in patients with symptomatic peripheral artery disease.

OBJECTIVE: Home-based exercise is an alternative exercise mode to a structured supervised program to improve symptoms in patients with peripheral artery disease (PAD), but little is known about whether the slow-paced and less intense home program also elicits changes in vascular and inflammatory biomarkers. In an exploratory analysis from a randomized controlled trial, we compared changes in vascular and inflammatory biomarkers in patients with symptomatic PAD (typical and atypical of claudication) after home-based exercise and supervised exercise programs and in an attention-control group. METHODS: A total of 114 patients were randomized into one of the three groups (n = 38 per group). Two groups performed exercise interventions, consisting of home-based and supervised programs of intermittent walking to mild to moderate claudication pain for 12 weeks; a third group performed light resistance training as a nonwalking attention-control group. Before and after intervention, patients were characterized on treadmill performance and endothelial effects of circulating factors present in sera by a cell culture-based bioassay on primary human arterial endothelial cells, and they were further evaluated on circulating vascular and inflammatory biomarkers. RESULTS: Treadmill peak walking time increased (P = .008) in the two exercise groups but not in the control group (P > .05). Cultured endothelial cell apoptosis decreased after home-based exercise (P < .001) and supervised exercise (P = .007), and the change in the exercise groups combined was different from that in the control group (P = .005). For circulating biomarkers, increases were found in hydroxyl radical antioxidant capacity (P = .003) and vascular endothelial growth factor A (P = .037), and decreases were observed in E-selectin (P = .007) and blood glucose concentration (P = .012) after home-based exercise only. The changes in hydroxyl radical antioxidant capacity (P = .005), vascular endothelial growth factor A (P = .008), and E-selectin (P = .034) in the exercise groups combined were different from those in the control group. CONCLUSIONS: This exploratory analysis found that both home-based and supervised exercise programs are efficacious to decrease cultured endothelial cell apoptosis in patients with symptomatic PAD. Furthermore, a monitored home-based exercise program elicits additional vascular benefits by improving circulating markers of endogenous antioxidant capacity, angiogenesis, endothelium-derived inflammation, and blood glucose concentration in patients with symptomatic PAD. The novel clinical significance is that important trends were found in this exploratory analysis that a contemporary home-based exercise program and a traditional supervised exercise program may favorably improve vascular and inflammatory biomarkers in addition to the well-described ambulatory improvements in symptomatic patients with PAD.