Cardiovascular Rehabilitation Increases Walking Distance in Patients With Intermittent Claudication. Results of the CIPIC Rehab Study: A Randomised Controlled Trial.

OBJECTIVE: To examine whether a cardiac rehabilitation programme in a community based setting for patients with intermittent claudication (IC) affects walking ability, quality of life, and changes in health behaviour. The trial investigated a cross sector cardiovascular rehabilitation programme compared with usual care for patients having non-operative management. METHODS: The trial allocated 118 patients, with 1:1 individual randomisation to either an intervention or control group. Data were collected at a department of vascular surgery and at a healthcare centre in Denmark. The rehabilitation intervention consisted of usual care plus 12 weeks of exercise training, pedometer, health education, and text messages. The primary outcome was maximum walking distance at six months measured by treadmill walking test. The secondary outcomes were maximum walking distance at 12 months and pain free walking distance measured by treadmill walking test, healthy diet, level of physical activity, and quality of life (QoL) at six and 12 months. RESULTS: In the intervention group, 46 participants were analysed, with 47 in the control group. Following three months of rehabilitation, a 37% difference (95% CI 1.10 - 1.70; p = .005) was found between groups in maximum walking distance at six and 12 months, in favour of the intervention group. The same positive effect was found in physical activity, QoL, and healthy diet, but was not statistically significant in pain free walking distance and smoking. CONCLUSION: A specialised community based cardiac rehabilitation programme for patients with IC showed statistically and clinically significant effects on maximum walking distance, physical activity, quality of life, and healthy diet, but not on pain free walking distance and smoking, compared with usual care without rehabilitation.

Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD.

Effective revascularization of the patient with peripheral artery disease is about more than the procedure. The approach to the patient with symptom-limiting intermittent claudication or limb-threatening ischemia begins with understanding the population at risk and variation in clinical presentation. The urgency of revascularization varies significantly by presentation; from patients with intermittent claudication who should undergo structured exercise rehabilitation before revascularization (if needed) to those with acute limb ischemia, a medical emergency, who require revascularization within hours. Recent years have seen the rapid development of new tools including wires, catheters, drug-eluting technology, specialized balloons, and biomimetic stents. Open surgical bypass remains an important option for those with advanced disease. The strategy and techniques employed vary by clinical presentation, lesion location, and lesion severity. There is limited level 1 evidence to guide practice, but factors that determine technical success and anatomic durability are largely understood and incorporated into decision-making. Following revascularization, medical therapy to reduce adverse limb outcomes and a surveillance plan should be put in place. There are many hurdles to overcome to improve the efficacy of lower extremity revascularization, such as restenosis, calcification, microvascular disease, silent embolization, and tools for perfusion assessment. This review highlights the current state of revascularization in peripheral artery disease with an eye toward technologies at the cusp, which may significantly impact current practice.

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.

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.

Revisión sistemática: costo-efectividad, acceso y adherencia a programas de ejercicio supervisado en pacientes con claudicación intermitente / Systematic review: cost-effectiveness, access and adherence to supervised exercise programs in patients with intermittent claudication

OBJETIVO: Determinar las razones de la escasa derivación, acceso, y adherencia a programas de ejercicio supervisado (PES) en pacientes con claudicación intermitente (CI) y la costo-efectividad de estos programas a nivel Internacional. MÉTODOS: Se utilizaron las fuentes de datos de PubMed y ScienceDirect. Se incluyeron revisiones con acceso completo, publicados desde el año 2010, que incluían como mínimo 3 artículos de tipo cuantitativo. RESULTADOS: Se incluyeron 5 Revisiones asociadas a los resultados del ejercicio supervisado, su costo-efectividad, la baja derivación y adherencia a PES de los pacientes con CI. En cuanto a la costo-efectividad los resultados indican que los PES fueron rentables con un ICER de £711 a £1.608 por QALY ganado al compararlos con ejercicio no supervisado, y al compararlos con la cirugía de revascularización (CR) no hay diferencia significativa en QALY ganados, sin embargo, el costo por QALY fue €381.694 más alto para la CR. Por otro lado, las principales razones de la subutilización de los PES, es que los pacientes se resisten a asistir, ya que involucra un esfuerzo y responsabilidad, además de tener problemas de reembolso, teniendo baja adherencia. Sumado a esto, el interés personal de los médicos por realizar intervenciones que involucran pago por servicio produce una baja derivación (45% de cirujanos en Europa refieren menos del 50% de sus pacientes). CONCLUSIÓN: Las principales dificultades para adoptar los PES serían una carencia en la destinación de recursos, falta de centros, dificultad de traslado, falta de tiempo, o de interés por parte de los pacientes, además de incentivos financieros a otras alternativas de tratamiento por sobre PES lo que limita su derivación.

OBJECTIVE: To determine the reasons for the limited derivation, access and adherence to supervised exercise programs (SEP) in patients with intermittent claudication (IC) and the cost-effectiveness of these programs internationally. METHODS: PubMed and ScienceDirect databases were searched. Revisions with full access, published since 2010, which included at least 3 quantitative type articles. RESULTS: 5 reviews were included, these were associated with the results of the supervised exercise, its cost-effectiveness, the low referral and adherence to programs of patients with IC. Regarding cost-effectiveness, the results indicated that SEP were more cost-effective with an ICER of £711 to £1.608 per QALY gained when compared with unsupervised exercise, and that when compared with revascularization surgery (RC) there was no significant difference in QALYs, however the cost per QALY was € 381.694 higher for the RC. On the other hand, the main reasons for the underutilization of SEP are that patients are reluctant to attend, since it involves effort and responsibility, in addition to having reimbursement problems, therefore having low adherence. Added to this, the personal interest of doctors in performing interventions that involve payment for service produce a low referral (45% of surgeons in Europe refer less than 50% of their patients) CONCLUSION: The main difficulties in adopting the SEP would be a lack in the allocation of resources, lack of centers, difficulty of transportation, lack of time or lack of interest from patients, in addition to financial incentives to other treatment alternatives over SEP, which limits their referral.

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.

National survey of current practice and opinions on rehabilitation for intermittent claudication in the Danish Public Healthcare System.

Objective. International guidelines recommend rehabilitation including supervised exercise therapy in patients with Intermittent Claudication (IC), but knowledge of the implementation in clinical practice is limited. This study aims to investigate current practice and opinions on rehabilitation for patients with IC among vascular surgeons and rehabilitation departments in the municipalities and hospitals. Design. Three electronic cross-sectional surveys were distributed nationally to the Danish vascular surgeons (n = 131) and to rehabilitation departments in the municipalities (n = 92) and hospitals (n = 33). Results. The response rates were 70% among the vascular surgeons, 98% among the municipalities and 94% among the hospitals. Vascular surgeons utilize oral advice to exercise by self-administered walking, pharmacological treatment, and revascularization to improve walking distance in patients with IC. Currently, only 12% of the vascular surgeons referred to rehabilitation to improve walking distance, while almost all vascular surgeons (96%) would refer their patients to IC rehabilitation, if it was available. Only 14% of municipalities and none of the hospitals, who treat patients with IC, have a rehabilitation program designed specifically for patients with IC. However, 59% of the rehabilitation departments in the municipalities and 26% in the hospitals included patients with IC in rehabilitation program designed for other patient groups - mostly cardiac patients. There was consensus among the groups of respondents that future IC specific rehabilitation should include an initial conversation, supervised exercise therapy, smoking cessation, and patient education according to guidelines. Conclusion. Vascular surgeons support referral and participation in IC rehabilitation to improve walking distance in patients with IC. Despite some hospitals and municipalities included patients with IC in rehabilitation nearly all services fail to meet current guideline as specific services tailored to patient with IC is almost non-existent in Denmark. Our findings call for action for services to comply with current recommendations of structured, systematic rehabilitation for patients with IC.

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.

Development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention for older adults with neurogenic claudication.

Neurogenic claudication due to spinal stenosis is a common cause of disability in older adults. Conservative treatments are a favourable treatment option. This paper describes the development and delivery of the BOOST (Better Outcomes for Older adults with Spinal Trouble) intervention, a physiotherapist-delivered physical and psychological intervention for the management of neurogenic claudication in older adults. The BOOST intervention is being tested in a multi-centre, randomised controlled trial in UK National Health Service Trusts; delivered by physiotherapists registered with the Health and Care Professionals Council. Participants are aged 65 years or older, registered with a primary care practice, and report symptoms consistent with neurogenic claudication. Intervention content and delivery was initially informed by clinical and patient experts, research evidence, and behaviour change guidelines; and refined following an intervention development day attended by researchers, health professionals, and Patient and Public Involvement representatives. The BOOST intervention comprises 12 group sessions, promoting sustained adherence with a long term home and physical activity programme. Each session includes education and group discussion, individually tailored exercises, and walking. Initial exercise levels are set at a one-to-one assessment. Continued home exercise adherence and increased physical activity following completion of the sessions is facilitated through support telephone calls. Trial registration ISRCTN12698674.

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.

Beet the Best?

RATIONALE: A primary goal of therapy for patients with peripheral artery disease (PAD) and intermittent claudication is increased ambulatory function. Supervised exercise rehabilitation was recently shown to confer superior walking benefits to pharmacological or surgical interventions. Increases in plasma inorganic nitrite, via oral nitrate, have been shown to increase exercise performance in both human and animal models, especially in hypoxic conditions. OBJECTIVE: To determine whether a 36-session exercise rehabilitation program while consuming oral inorganic nitrate (4.2 mmol concentrated beetroot juice) would produce superior benefits over exercise plus placebo in pain-free walking and markers of increased skeletal muscle perfusion in patients with PAD and intermittent claudication. METHODS AND RESULTS: This was a randomized, double-blind, per-protocol study design. After the 12-week protocol, claudication onset time on a maximal treadmill test increased by 59.2±57.3 s for the exercise plus placebo group (n=13) and by 180.3±46.6 s for the exercise plus beetroot juice group (n=11; P≤0.05). This produced a between treatment medium to large standardized effect size (Cohen d) of 0.62 (95% CI, -0.23 to +1.44). The data for 6-minute walk distance showed a similar pattern with increases of 24.6±12.1 and 53.3±19.6 m ( P≤0.05) in the exercise plus placebo and exercise plus beetroot juice groups, respectively. Measures of gastrocnemius perfusion, including ankle-brachial index, peak reactive hyperemic blood flow, and tissue deoxygenation characteristics, during exercise (assessed my near-infrared spectroscopy) all changed significantly for the exercise plus beetroot juice group with moderate-to-large effect sizes over exercise plus placebo changes. CONCLUSIONS: Although it is premature to speculate on overall clinical utility of a nitrate-based therapy for PAD, this early pilot study evidence is encouraging. Specifically, our data suggests that increasing plasma nitrite before exercise may allow PAD subjects to train with less pain, at higher workloads for longer durations at each training session, thereby maximizing the beneficial peripheral vascular and skeletal muscle adaptations. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov . Unique identifier: NCT01684930 and NCT01785524.

[Vascular rehabilitation in lower-extremity artery diseasein 2018]. / Réadaptation vasculaire de l'artériopathie oblitérante des membres inférieurs en 2018.

WHAT WE KNEW: The vascular rehabilitation is an effective treatment for patients with an intermittent claudication linked to lower-extremity artery disease. This treatment increases the claudication distance of 180% with the Gardner's protocol (30 to 60 minutes of walking at least 3 times a week, walking until appearance of a mild pain) and allows also to control the vascular risk factors. This treatment is not enough prescribed for many reasons and often requires a hospitalization in a rehabilitation centre. WHAT WE KNOW NOW: Walking rehabilitation remains the base of the treatment of lower-extremity artery disease. Many walking protocols can be proposed. For a similar efficiency, patients are not obliged to walk until appearance of a pain but only until appearance of a discomfort. Exercises other than walking have been tested and can be used. Heart Rehabilitation Centres will propose more often vascular rehabilitation including hospitalisations for complex patients or out-management for non-complex patients. With a lower cost, the walking rehabilitation could be also realised at home by the patient himself with a certain degree of supervision with good results. Supervision means the use of a podometer, weekly advices given by phone by a Vascular Physician or a Physiotherapist, one walking session once a week in a rehabilitation centre. Connected devices could be also helpful allowing increasing of the patients' motivation. Simultaneously, it is necessary that the patients observe the recommendations of the World Health Organisation by performing weekly 150 minutes of mild-intensity endurance's activity in order to minimise their long-term vascular risk. Finally, the respective place of the revascularisations and walking rehabilitation remains to be clarify in case of intermittent claudication due to a superficial femoral artery lesion.

Supervised Exercise Therapy for Intermittent Claudication Is Increasingly Endorsed by Dutch Vascular Surgeons.

BACKGROUND: Although supervised exercise therapy (SET) is generally accepted as an effective noninvasive treatment for intermittent claudication (IC), Dutch vascular surgeons were initially somewhat hesitant as reported by a 2011 questionnaire study. Later on, a nationwide multidisciplinary network for SET was introduced in the Netherlands. The aim of this questionnaire study was to determine possible trends in conceptions among Dutch vascular surgeons regarding the prescription of SET. METHODS: In the year of 2015, Dutch vascular surgeons, fellows, and senior residents were asked to complete a 26-item questionnaire including issues that were considered relevant for prescribing SET such as patient selection criteria and comorbidity. Outcome was compared to the 2011 survey. RESULTS: Data of 124 respondents (82% males; mean age 46 years; 64% response rate) were analyzed. SET referral rate of new IC patients was not different over time (2015: 81% vs. 2011: 75%; P = 0.295). However, respondents were more willing to prescribe SET in IC patients with chronic obstructive pulmonary disease (2015: 86% vs. 2011: 69%; P = 0.002). Nevertheless, a smaller portion of respondents found that SET was also indicated for aortoiliac disease (2015: 63% vs. 2011: 76%; P = 0.049). Insufficient health insurance coverage and/or personal financial resources were the most important presumed barriers preventing patients from initiating SET (80% of respondents). Moreover, 94% of respondents judged that SET should be fully reimbursed by all Dutch basic health insurances. CONCLUSIONS: The concept of SET for IC is nowadays generally embraced by the vast majority of Dutch vascular surgeons. SET may have gained in popularity in IC patients with cardiopulmonary comorbidity. However, SET remains underutilized for aortoiliac disease. Reimbursement is considered crucial for a successful SET implementation.

Centers for Medicare and Medicaid Services Policy Regarding Supervised Exercise for Patients With Intermittent Claudication: The Good, the Bad, and the Ugly.

On May 25, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a decision memo establishing coverage for supervised exercise therapy (SET) for Medicare beneficiaries experiencing intermittent claudication due to peripheral artery disease (PAD). A meaningful impact on population health is possible with greater freedom to participate in regular physical activity. The authors of this editorial explain the potential roles of physical therapists in the SET program and argue for further integration of physical therapists through collaborative practice. J Orthop Sports Phys Ther 2017;47(12):892-894. doi:10.2519/jospt.2017.0111.

Choosing the individual rehabilitation program for patients with intermittent claudication.

This study is aimed at identifying the collateral circulation in case of femoral-aorta-iliac axis obstruction, with the purpose of a more correct therapeutic indication being either medical or surgical or physiotherapeutic or combined.

Rehabilitación cardiovascular en pacientes con claudicación intermitente / Cardiovascular rehabilitation in patients with intermittent claudication

La claudicación intermitente constituye un problema en los pacientes con enfermedad arterial periférica. El objetivo de esta revisión bibliográfica fue describir los conocimientos sobre rehabilitación cardiovascular en este tipo de pacientes. Esta es una opción terapéutica que puede mejorar los síntomas, la limitación funcional y el pronóstico de los enfermos. El ejercicio físico supervisado es una terapia de primera línea, efectiva y segura, para los pacientes con claudicación de carácter leve a moderado, y el control de los factores de riesgo es esencial para mejorar su pronóstico. La rehabilitación es una terapia que incluye el entrenamiento físico y la prevención secundaria como perfiles importantes en el tratamiento de las enfermedades cardiovasculares. Logra incrementar la calidad de vida y reducir el riesgo de morbilidad y mortalidad. Sus complicaciones son escasas(AU)