Supervised exercise training in patients with lower extremity peripheral artery disease
A European overview
Abstract
Summary: 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.
References
1 Lower extremity peripheral artery disease: contemporary epidemiology, management gaps, and future directions: a scientific statement from the American Heart Association. Circulation. 2021;144:e171–e91.
2 . 5 Conservative treatment for PAD – Risk factor management. Vasa. 2019;48 Suppl 102 1–12.
3 Global, regional, and national prevalence and risk factors for peripheral artery disease in 2015: an updated systematic review and analysis. Lancet Glob Health. 2019;7:e1020–e30.
4 Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. 1992;326:381–6.
5 . Impaired balance and higher prevalence of falls in subjects with intermittent claudication. J Gerontol A Biol Sci Med Sci. 2001;56:M454–8.
6 Abnormal joint powers before and after the onset of claudication symptoms. J Vasc Surg. 2010;52:340–7.
7 . Quality of life and peripheral arterial disease. J Surg Res. 2006;136:294–301.
8 Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms. JAMA. 2004;292:453–61.
9 Muscle strength and control characteristics are altered by peripheral artery disease. J Vasc Surg. 2017;66:178–86.e12.
10 Optimal exercise programs for patients with peripheral artery disease: a scientific statement from the American Heart Association. Circulation. 2019;e10–e33.
11 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: the European Stroke Organization (ESO) The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J. 2018;39:763–816.
12 . Peripheral arterial disease: diagnosis and management (CG147). National Institute for Health and Care Excellence. 2012.
13 Management of chronic peripheral artery disease patients with indication for endovascular revascularization. Vasa. 2022;51(3):121–37.
14 . Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995;274:975–80.
15 . Exercise for intermittent claudication. Cochrane Database Syst Rev. 2017;12:CD000990.
16 . Exercise training for management of peripheral arterial disease: a systematic review and meta-analysis. Sports Med. 2015;45:231–44.
17 . Resistance training as a treatment for older persons with peripheral artery disease: a systematic review and meta-analysis. Br J Sports Med. 2020;54(8):452–61.
18 . Exercise-based interventions and health-related quality of life in intermittent claudication: a 20-year (1989–2008) review. Eur J Cardiovasc Prev Rehabil. 2010;17:140–54.
19 . Exercise training for health-related quality of life in peripheral artery disease: a systematic review and meta-analysis. Vasc Med. 2015;20:30–40.
20 Bicycle exercise training improves ambulation in patients with peripheral artery disease. J Vasc Surg. 2020;71:979–87.
21 . Gait changes after supervised exercise training in patients with symptomatic lower extremity peripheral artery disease. Vasc Med. 2021;26:259–66.
22 . 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. Sensors. 2021;21(23):7989.
23 Supervised walking exercise therapy improves gait biomechanics in patients with peripheral artery disease. J Vasc Surg. 2019;71:575–83.
24 . Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial. J Cardiopulm Rehabil. 2002;22:192–8.
25 Long-term effects of supervised exercise training on walking capacity and quality of life in patients with intermittent claudication. Vasa. 2008;37:250–6.
26 . Long-term results of peripheral arterial disease rehabilitation. J Vasc Surg. 2004;39:1186–92.
27 . Multimodal supervised exercise training is effective in improving long term walking performance in patients with symptomatic lower extremity peripheral artery disease. J Clin Med. 2021;10:2057.
28 National assessment of availability, awareness, and utilization of supervised exercise therapy for peripheral artery disease patients with intermittent claudication. J Vasc Surg. 2020;71:1702–7.
29 Exercise therapy referral and participation in patients with peripheral artery disease: Insights from the PORTRAIT registry. Vasc Med. 2021;26:654–6.
30 . Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit. Ann R Coll Surg Engl. 2021;104(2):130–7.
31 . Access to supervised exercise services for peripheral vascular disease patients. Bull R Coll Surgeons Engl. 2017;99:207–11.
32 . Provision of exercise services in patients with peripheral artery disease in the United Kingdom. Vascular. 2021;17085381211035259.
33 . A systematic review of the uptake and adherence rates to supervised exercise programs in patients with intermittent claudication. Ann Vasc Surg. 2016;34:280–9.
34 Adherence to guideline-recommended therapy-including supervised exercise therapy referral-across peripheral artery disease specialty clinics: insights from the international PORTRAIT registry. J Am Heart Assoc. 2020;9:e012541.
35 Editor’s choice – Randomised clinical trial of supervised exercise therapy vs. endovascular revascularisation for intermittent claudication caused by iliac artery obstruction: The SUPER study. Eur J Vasc Endovasc Surg. 2022;63:421–9.
36 Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularization (CLEVER) study. Circulation. 2012;125:130–9.
37 Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. J Am Coll Cardiol. 2015;65:999–1009.
38 Baseline functional performance predicts the rate of mobility loss in persons with peripheral arterial disease. J Am Coll Cardiol. 2007;50:974–82.
39 Prognostic value of functional performance for mortality in patients with peripheral artery disease. J Am Coll Cardiol. 2008;51:1482–9.
40 . Improvement in 6-minute walking distance after supervised exercise training is related to changes in quality of life in patients with lower extremity peripheral artery disease. J Clin Med. 2021;10(15):3330.
41 . Peripheral arterial disease – diagnosis and management in general practice. Aust Fam Physician. 2013;42:397–400.
42 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e686–e725.
43 Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45 Suppl S:S5–67.
44 Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners. BMJ Open Sport Exerc Med. 2020;6(1):e000897.
45 . 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. Vasc Med. 2021;1358863X211034577.
46 . What does the future hold for structured exercise training for people with PAD? Ideas from two Masters of the Society for Vascular Medicine. Vasc Med. 2022;27:116–9.
47 . Step-monitored home exercise improves ambulation, vascular function, and inflammation in symptomatic patients with peripheral artery disease: a randomized controlled trial. J Am Heart Assoc. 2014;3:e001107.
48 Meta-analysis of clinical trials examining the benefit of structured home exercise in patients with peripheral artery disease. Br J Surg. 2019;106:319–31.
49 An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication. J Vasc Surg. 2021;74:2076–85.e20.
50 . Safety of home-based exercise for people with intermittent claudication: A systematic review. Vasc Med. 2022;27:186–92.