Exercise therapy for chronic symptomatic peripheral artery disease.

All guidelines worldwide strongly recommend exercise as a pillar of the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended for clinicians to promote and assist for the set-up of comprehensive exercise programmes to best advice in patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are narratively described based on the current best evidence. The document ends by highlighting disparities in access to supervised exercise programmes across Europe and the series of gaps for evidence requiring further research.

Exercise Therapy for Chronic Symptomatic Peripheral Artery Disease: A Clinical Consensus Document of the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases in Collaboration With the European Society of Vascular Medicine and the European Society for Vascular Surgery.

All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.

Exercise therapy for chronic symptomatic peripheral artery disease.

All guidelines worldwide strongly recommend exercise as a pillar in the management of patients affected by lower extremity peripheral artery disease (PAD). Exercise therapy in this setting presents different modalities, and a structured programme provides optimal results. This clinical consensus paper is intended to promote and assist the set up of comprehensive exercise programmes and best advice for patients with symptomatic chronic PAD. Different exercise training protocols specific for patients with PAD are presented. Data on patient assessment and outcome measures are described based on the current best evidence. The document ends by highlighting supervised exercise programme access disparities across Europe and the evidence gaps requiring further research.

Sit to Stand Muscle Power Is Related to Functional Performance at Baseline and After Supervised Exercise Training in Patients with Lower Extremity Peripheral Artery Disease.

OBJECTIVE: Patients with peripheral artery disease (PAD) have decreased muscle power, contributing to functional limitations. The sit to stand (STS) is a validated test to assess muscle power in older individuals; however, it has never been investigated in patients with PAD. The relationship between STS muscle power, and common disease related outcomes was evaluated at baseline and following supervised exercise training (SET) in patients with PAD. METHODS: This observational study investigated patients with Fontaine stage II. Before and after SET, maximum treadmill walking distance (MWD), functional performance tests (six minute walk, STS, stair climbing, habitual gait speed), and quality of life (Short Form 36 questionnaire) were assessed. Relative (W/kg) STS muscle power was calculated using a validated equation. Multiple regressions models were used. RESULTS: Ninety-five patients with PAD were included (63.1 ± 12.1 years, 67% male). Relative STS muscle power before: 2.7 W/kg, 95% confidence interval [CI] 2.5 - 2.9; after: 3.3, 95% CI 3.1 - 3.6, MWD before: 367.0 m, 95% CI 302.4 - 431.5; after: 598.4, 95% CI 515.6 - 681.3, six minute walking distance before: 418.3 metres; 95% CI 399.4 - 437.2; after: 468.8; 95% CI 452.7-484.9, stair climbing performance before: 6.8 seconds 95% CI 6.2 - 7.4); after: 5.3; 95% CI 4.9 - 5.7, habitual gait speed before: 1.10 m/s, 95% CI 1.05 - 1.14; after: 1.18, 95% CI 1.14 - 1.22 increased significantly following SET (p < .001). Similarly, physical before: 31.4, 95% CI 29.4 - 33.3; after: 35.8, 95% CI 33.9 - 37.7 and mental before: 39.5, 95% CI 37.0 - 42.0; after: 43.1, 95% CI 40.9 - 45.4 component summaries of the SF-36 also increased significantly (p < .001). Greater relative STS muscle power at baseline was significantly related to greater baseline treadmill (ß < .380; p < .002) and functional (ß < .597; p < .001) performance, and quality of life (ß < .291; p < .050). Larger increases in relative STS muscle power following SET were associated with greater improvements in functional performance (ß < .419; p < .009). CONCLUSION: The STS test is a valid clinical tool to monitor overall functional status in patients with symptomatic PAD.

Time-course evolution of functional performance during a 3-month supervised exercise training program in patients with symptomatic peripheral artery disease.

INTRODUCTION: Functional performance is impaired in patients with peripheral artery disease (PAD). The effects of a supervised exercise training (SET) program on functional performance have yet to be clearly determined. The aim was to investigate the time-course evolution of functional performance during a 3-month SET program. METHODS: Patients with chronic symptomatic PAD participating in a 3-month SET program were investigated. Six-minute walking distance (6MWD), the stair climbing test (SCT), and the Short Physical Performance Battery (SPPB) were assessed before SET, after the first and second months of SET, and following the SET program. The ankle- and toe-brachial indices were measured before and after the SET program. RESULTS: Ninety patients with PAD (age 65.4 ± 10.2 years) were analyzed. The 6MWD significantly improved after the first (+7%, p ⩽ 0.001) and second months (+13%, p ⩽ 0.001) and following SET (+14%, p ⩽ 0.001) compared to before the SET program. The 6MWD significantly improved after the 2nd month (+6%, p ⩽ 0.001) and following SET (+7%, p ⩽ 0.001) compared to after the first month of the SET program. The SPPB score and SCT performance significantly improved after the first (SPPB score: +9%, p ⩽ 0.001; SCT: +17%, p ⩽ 0.001) and second months (SPPB score: +11%, p ⩽ 0.001; SCT: +24%, p ⩽ 0.001) and following SET (SPPB score: +12%, p ⩽ 0.001; SCT: +25%, p ⩽ 0.001) compared to before the SET program. No significant differences were observed following SET compared to the second month of the SET program. Vascular parameters did not change significantly. CONCLUSIONS: A 3-month SET program improves several components of functional performance, and adaptations mainly occur during the 1st and 2nd months of the SET program.

Intensity-dependent effects of exercise therapy on walking performance and aerobic fitness in symptomatic patients with lower-extremity peripheral artery disease: A systematic review and meta-analysis.

We investigated how nonpain-based exercise therapy intensity (light-to-moderate or vigorous) affects improvements in walking performance and cardiorespiratory fitness of patients with symptomatic lower-extremity peripheral artery disease (PAD). We searched the Embase, MEDLINE, Cochrane, Web of Science, and Google Scholar databases up to April 2021 and included randomized controlled trials reporting training therapies targeting exercise intensity (heart rate, oxygen consumption, or perceived exertion). The main outcomes were walking performance (pain-free [PFWD] and maximal [MWD] walking distance) and cardiorespiratory fitness (V̇O2peak). Secondary subanalyses examined the training modality (walking or other modalities) and the approach (high-intensity interval or moderate-intensity training). A total of 1132 patients were included. Light-to-moderate was superior to vigorous exercise intensity in improving MWD (223 m [95% CI 174 to 271], p < 0.00001; 153 m [95% CI 113 to 193], p < 0.00001; respectively) and PFWD (130 m [95% CI 87 to 173], p < 0.00001; 83 m [95% CI 61 to 104], p < 0.00001; respectively). When training modalities were considered, walking at a vigorous intensity (272 m [95% CI 207 to 337], p < 0.00001) showed the largest improvement in MWD compared to other exercise modalities. A larger increase in V̇O2peak was observed following vigorous (3.0 mL O2·kg-1·min-1 [95% CI 2.4 to 3.6], p < 0.00001) compared to light-to-moderate (1.1 mL O2·kg-1·min-1 [95% CI 0.4 to 1.7], p = 0.001) exercise intensity. These results indicate that vigorous was less effective than light-to-moderate intensity in improving walking performance, whereas it was more effective in improving V̇O2peak. When the training modalities were considered, walking at a vigorous intensity showed the greatest improvement in MWD. (PROSPERO Registration No.: CRD42020199469).

Supervised exercise training in patients with lower extremity peripheral artery disease.

The optimal first line management of patients with symptomatic chronic lower extremity peripheral artery disease (PAD) includes secondary prevention of cardiovascular risk factors, pharmacological treatment, and supervised exercise therapy (SET). SET programs have shown to be effective in improving walking performance, functional performance, and quality of life. However, despite a large body of evidence, and despite national and international guidelines recommending SET as first line therapy, SET remains largely underused in patients with chronic PAD. This position paper aims to describe how SET is perceived, its accessibility and structure through Europe. An anonymous web-based survey was used. It comprised 21 questions developed in conjunction with an angiologist and a clinical exercise physiologist specialist in vascular rehabilitation. We had 131 responders from 17 countries. For patients with PAD, SET programs exist only in 59% of European countries. SET reimbursement is available in 41% of countries. SET programs showed to be heterogeneous across countries. Thirty-four percent of the SET programs are PAD-dedicated, while 23% are part of a cardiac rehabilitation program. In addition, among existing SET programs, 65% are dedicated to symptomatic patients with PAD only, 9% to both asymptomatic and symptomatic, 8% to post-revascularized patients only, and 1% to asymptomatic patients with PAD only. Finally, 17% reported not knowing which patients are eligible for enrolment in a SET program. Duration, frequency, and modality of SET also varied from country to country. Overall, these data indicate that a large variability of SET availability and characteristics exists across Europe. Therefore, there is an urgent need to provide detailed guidance to deliver optimal exercise therapeutic care in patients with PAD.

[Physical therapy in vascular diseases]. / L'exercice physique dans les maladies vasculaires.

Regular physical exercise reduces the risk of developing cardiovascular diseases. Along with cardiovascular risk factors management, physical exercise is considered as one of the main treatment components in people with cardiovascular diseases. The therapeutic role of physical exercise in patients with peripheral artery disease has been highlighted for decades. However, the role of physical exercise in the management of patients with venous, lymphatic, or rare vascular diseases remains poorly investigated. This article discuss the potential benefits of physical exercise in the therapeutic care of patients with vascular diseases.

Il est bien connu que l'exercice physique régulier diminue le risque de contracter une maladie cardiovasculaire. Chez les personnes avec une maladie cardiovasculaire, l'exercice physique est considéré, avec le contrôle strict des facteurs de risque cardiovasculaire, comme un élément capital de la prise en charge. Depuis des décennies, on met en évidence le rôle de l'exercice physique dans l'amélioration de la mobilité et de la qualité de vie des patient-e-s avec une maladie artérielle périphérique. Cependant, le rôle de l'exercice physique dans la prise en charge des patient-e-s avec des maladies veineuses, lymphatiques ou des maladies vasculaires rares demeure peu investigué. Cet article met en évidence les potentiels bénéfices de l'exercice physique dans la prise en charge des patient-e-s avec des maladies vasculaires.

Gait changes after supervised exercise training in patients with symptomatic lower extremity peripheral artery disease.

This study aimed to investigate the effects of supervised exercise training (SET) on walking performance and spatiotemporal gait changes in patients with symptomatic lower extremity peripheral artery disease (PAD). In this single-arm prospective nonrandomized cohort study, patients with Fontaine stage II PAD following a 3-month SET program were included. Before and after SET, a constant-load treadmill test was performed to determine the pain-free and maximal walking distances (PFWD and MWD, respectively). During this test, spatiotemporal gait parameters were assessed. The ankle-brachial index (ABI) and toe-brachial index (TBI) were also measured. Twenty-seven patients with PAD (64.0 ± 1.9 y, 74% men) were included. Following SET, the PFWD (+68%; p = 0.001) and MWD (+79%; p ⩽ 0.001) significantly increased. The ABI and TBI did not change significantly. Following SET, the stride duration, stride frequency, stride length, and double support phase duration did not change significantly. In contrast, subphases of stance showed significant changes: the loading response (+8%; p = 0.03) and foot-flat (+2%; p = 0.01) phases were significantly longer, whereas the push-off phase (-7%; p = 0.002) was significantly shorter. A significant positive correlation was found between changes in the foot-flat phase and changes in PFWD (r = 0.43, p = 0.03). A significant negative correlation was found between changes in the push-off phase and changes in PFWD (r = -0.39, p = 0.05). No significant correlations were found between changes in relative durations of the subphases of stance and MWD. These results indicate that changes in temporal gait parameters during the foot contact phase potentially constitute an underlying mechanism of delayed claudication distance in patients with symptomatic PAD.

Supervised Exercise Training Improves 6 min Walking Distance and Modifies Gait Pattern during Pain-Free Walking Condition in Patients with Symptomatic Lower Extremity Peripheral Artery Disease.

This study aimed to investigate the effects of supervised exercise training (SET) on spatiotemporal gait and foot kinematics parameters in patients with symptomatic lower extremity peripheral artery disease (PAD) during a 6 min walk test. Symptomatic patients with chronic PAD (Fontaine stage II) following a 3 month SET program were included. Prior to and following SET, a 6 min walk test was performed to assess the 6 min walking distance (6MWD) of each patient. During this test, spatiotemporal gait and foot kinematics parameters were assessed during pain-free and painful walking conditions. Twenty-nine patients with PAD (65.4 ± 9.9 years.) were included. The 6MWD was significantly increased following SET (+10%; p ≤ 0.001). The walking speed (+8%) and stride frequency (+5%) were significantly increased after SET (p ≤ 0.026). The stride length was only significantly increased during the pain-free walking condition (+4%, p = 0.001), whereas no significant differences were observed during the condition of painful walking. Similarly, following SET, the relative duration of the loading response increased (+12%), the relative duration of the foot-flat phase decreased (-3%), and the toe-off pitch angle significantly increased (+3%) during the pain-free walking condition alone (p ≤ 0.05). A significant positive correlation was found between changes in the stride length (r = 0.497, p = 0.007) and stride frequency (r = 0.786, p ≤ 0.001) during pain-free walking condition and changes in the 6MWD. A significant negative correlation was found between changes in the foot-flat phase during pain-free walking condition and changes in the 6MWD (r = -0.567, p = 0.002). SET was found to modify the gait pattern of patients with symptomatic PAD, and many of these changes were found to occur during pain-free walking. The improvement in individuals' functional 6 min walk test was related to changes in their gait pattern.

[Vascular passport : a tool for secondary prevention among patients with peripheral artery disease]. / Passeport vasculaire : un outil pour la prévention secondaire des patients avec maladie artérielle périphérique.

Peripheral arterial disease (PAD) is a major health problem in Switzerland, as myocardial infarction or stroke, all three sharing common cardiovascular (CV) risk factors and similar pathophysiological mechanisms (atherosclerosis). Unfortunately, PAD is still often overlooked, despite being fraught with significant morbidity/mortality and increasing the patient's overall CV risk. It is therefore essential to improve secondary prevention in order to decrease this burden and the overall CV risk of the patient. We will review the treatment targets for CV risk factors as secondary prevention in patients with PAD and see how the use of a vascular passport may improve management.

La maladie artérielle périphérique (MAP) est une problématique de santé majeure en Suisse, au même titre que l'infarctus du myocarde ou l'AVC, tous les trois partageant des facteurs de risque cardiovasculaire (FRCV) communs et des mécanismes physiopathologiques similaires (athérosclérose). Malheureusement, l'importance de la MAP est encore souvent sous-estimée, alors qu'elle est grevée d'une morbidité et d'une mortalité importantes et augmente le risque cardiovasculaire (CV) global du patient. Il est capital d'améliorer la prévention secondaire afin de diminuer ce fardeau et le risque CV global du patient. Nous allons passer en revue les cibles de traitement des FRCV en prévention secondaire chez les patients avec MAP et voir comment l'utilisation d'un passeport vasculaire permet d'améliorer la prise en charge.

How diet, physical activity and psychosocial well-being interact in women with gestational diabetes mellitus: an integrative review.

BACKGROUND: Gestational Diabetes Mellitus (GDM) is associated with future cardio-metabolic risks for the mother and her child. In addition, one-third of women with recent GDM develop postpartum depression. Given these adverse impacts of GDM on the health of the mother and her offspring, it is important to intervene on modifiable factors, such as diet, physical activity, and psychosocial well-being. This integrative review therefore explored evidence on how these modifiable factors interact in women with GDM and their offspring, and how effective combined interventions are on reducing adverse impacts of GDM. METHODS: A comprehensive search strategy included carefully selected terms that corresponded to the domains of interest (diet, physical activity and psychosocial well-being). The databases searched for articles published between 1980 and February 2018 were: CINAHL, PsycINFO, Embase, Pubmed and Cochrane. Studies that were included in this review were either observational or intervention studies that included at least two domains of interest. Articles had to at least report data on maternal outcomes of women with GDM. RESULTS: The search strategies identified 14'419 citations after excluding duplicates. After screening titles and then abstracts, 114 articles were selected for detailed evaluation of their full text, and 16 were included in this review: two observational and 14 intervention studies. Results from observational studies showed that psychosocial well-being (social support and self-efficacy) were positively associated with physical activity and dietary choice. Intervention studies always included diet and physical activity interventions, although none integrated psychosocial well-being in the intervention. These lifestyle interventions mostly led to increased physical activity, improved diet and lower stress perception. Many of these lifestyle interventions also reduced BMI and postpartum diabetes status, improved metabolic outcomes and reduced the risk of preterm deliveries and low birth weight. CONCLUSION: This integrative review showed that psychosocial well-being interacted with diet as well as with physical activity in women with GDM. We recommend that future studies consider integrating psychosocial well-being in their intervention, as observational studies demonstrated that social support and self-efficacy helped with adopting a healthy lifestyle following GDM diagnosis.

[Lower extremity peripheral artery disease†: local and systemic complications]. / Artériopathie oblitérante des membres inférieurs†: complications locales et systémiques.

Lower extremity peripheral artery disease can lead to local complications but also to complications in other vascular areas, stressing the systemic impact of the atheromatous disease. The current concepts of MALE (Major Adverse Limb Events) and MACE (Major Adverse Cardiac Events) encompass these risks. The systemic vascular complications, as well as the ones at lower extremities, are associated with significant morbidity and mortality. An optimal therapeutic management and healthy lifestyle, such as regular exercise, are crucial to limit the risk of unfavorable progression of the arterial disease. A close collaboration between the general practitioner and the angiologist is a key to adequate initial management and follow-up of the patients.

L'artériopathie oblitérante des membres inférieurs (AOMI) est associée à des complications locales et dans d'autres territoires vasculaires, témoignant du caractère généralisé de la pathologie athéromateuse. Les notions récentes de MALE (major adverse limb events) et MACE (major adverse cardiac events) reflètent cette approche conceptuelle de la maladie athéromateuse. Les complications vasculaires systémiques et spécifiques aux membres inférieurs sont à l'origine d'une morbi-mortalité significative. Une prise en charge optimale médicamenteuse et d'hygiène de vie, en particulier une activité physique régulière, sont fondamentales pour limiter les risques d'évolution défavorable de la pathologie artérielle. La collaboration étroite entre le médecin interniste-généraliste et l'angiologue est à la base de la prise en charge initiale et du suivi des patients.

[Exercise training therapy in patients with lower extremity peripheral artery disease]. / Traitement par l'exercice physique chez le patient avec une artériopathie oblitérante des membres inférieurs.

Patients with lower extremity peripheral artery disease (PAD) have decreased functional capacities leading to decreased quality of life and increased cardiovascular morbidity and mortality. Exercise therapy is recommended among first-choice therapeutic options and improves overall physical function and quality of life in symptomatic patients with PAD. Exercise therapy is also effective in patients with PAD following revascularization. Other than walking, different training modalities are safe, feasible and effective to induce clinical benefits for these patients. We present here the role of exercise therapy and its specificities in the management of PAD.

Les patients avec une artériopathie oblitérante des membres inférieurs (AOMI) présentent une diminution des capacités fonctionnelles qui conduit souvent à une baisse de la qualité de vie et une augmentation de la morbi-mortalité cardiovasculaire. L'exercice physique fait partie de la prise en charge optimale des patients avec AOMI et permet d'améliorer leur état fonctionnel général et leur qualité de vie. Les effets bénéfiques de l'exercice sont également présents après un geste de revascularisation. Plusieurs types et modalités d'entraînement sont efficaces afin d'obtenir des bénéfices cliniques pour ces patients. Nous présenterons ici le rôle de l'exercice physique et ses spécificités dans la prise en charge de l'AOMI.

Vascular Dynamics and Peripheral Oxygen Uptake in Obese Individuals during Progressive Physical Exercise.

BACKGROUND: Obese men show higher O2 consumption than lean men during physical exercise, with a trend toward higher peripheral O2 extraction; this is probably due to their larger muscle mass. OBJECTIVES: The aim of this study was to examine this phenomenon by measuring 2 vasoactive substances, endothelin-1 (ET-1) and nitric oxide (NO), during a progressive submaximal exercise. METHODS: Seventeen obese (body mass index [BMI] 38.6) and 15 lean (BMI 22.5) men performed a maximal progressive cycle ergometer exercise to determine peak power output (PPO) and peak O2 consumption (V∙O2peak); thereafter, they performed a submaximal cycle ergometer incremental test (every 6 min) at the same percentage of V∙O2peak until they reached 57.5% PPO. Blood samples were collected at rest and at the end of every step to measure ET-1 and NO concentrations. RESULTS: At rest, the ET-1 and NO concentrations in obese men and lean controls were the same. However, during exercise, the ET-1 concentration at each step was significantly lower (p < 0.05) in the obese group. There was no significant difference in NO concentration between the 2 groups, although the increase at the beginning of the exercise session was faster in obese individuals. During submaximal exercise, end-tidal O2 pressure (PETO2) was lower in the obese group, with a significant difference in the PETO2/fat-free mass ratio at each step. CONCLUSIONS: ET-1 and NO levels during physical exercise are different in obese versus lean men. This may support the notion that increased O2 consumption in obesity is due to different behaviors of the cardiorespiratory and circulatory systems.

[Gestational diabetes--what are the non-medical approaches?]. / Diabète gestationnel--quelles sont les approches non médicales?

Gestational diabetes is a multifactorial disease that increases the risk for complications for the mother and her child in the short and long term. The perinatal period represents an opportunity not only to assist the mother in improving her own health but also that of the future generation. This article focuses on lifestyle and psychological aspects that form the base for non-medical treatment approaches. Considering different risk factors separately is not sufficient for the improvement of the metabolic and mental health of women with gestational diabetes. With a multimodal interdisciplinary approach that includes physical activity, dietary advice and psychological support, an improvement of the health and well-being of both the mother and her child is expected. Future studies are necessary to confirm this proposed care approach.