Physical exercise in peripheral occlusive arterial disease

Abstracts

Most patients with intermittent claudication, a clinical aspect of peripheral arterial disease, have important limitations on physical activity and a reduced quality of life. The purpose of this study was to review literature on exercise intervention for patients with peripheral occlusive arterial disease and intermittent claudication. BIREME, PubMed (MEDLINE), SciELO and LILACS databases were searched for the terms intermittent claudication, peripheral vascular diseases, rehabilitation, exercise, exercise therapy, all of which were taken from the list of Health Science Descriptors (BIREME). It was concluded that, despite the variability of walking regimens identified in the literature, the aerobic training is of general benefit to patients with peripheral arterial disease and intermittent claudication, mainly improving their walking performance, which can have a significant impact on the quality of life of these patients.

Intermittent claudication; peripheral vascular diseases; rehabilitation; exercise; exercise therapy

A maioria dos pacientes portadores de claudicação intermitente, um aspecto clínico da doença arterial periférica, tem importante limitação nas atividades físicas e redução na qualidade de vida. O objetivo deste estudo foi realizar uma revisão da literatura sobre a intervenção através de exercícios em portadores de doença arterial obstrutiva periférica com claudicação intermitente. Trata-se de uma revisão de artigos científicos consultados nos bancos de dados da BIREME, PubMed e SciELO, através das fontes LILACS e MEDLINE e a partir dos descritores em Ciências da Saúde claudicação intermitente, doenças vasculares periféricas, reabilitação, exercício e terapia por exercício. Concluiu-se que, apesar da variabilidade dos regimes de caminhada identificados na literatura, o treino aeróbio, de uma forma geral, proporciona benefícios a pacientes portadores de doença arterial obstrutiva periférica com claudicação intermitente, principalmente na melhora do desempenho de caminhada, o que pode ter impacto significativo na qualidade de vida desses pacientes.

Claudicação intermitente; doenças vasculares periféricas; reabilitação; exercício; terapia por exercício

REVIEW ARTICLE

Physical exercise in peripheral occlusive arterial disease

Elenir Carlot Locatelli; Suélen Pelizzari; Kátia Bilhar Scapini; Camila Pereira Leguisamo; Alexandre Bueno da Silva^*

Correspondence

ABSTRACT

Most patients with intermittent claudication, a clinical aspect of peripheral arterial disease, have important limitations on physical activity and reduced quality of life. The purpose of this study was to review literature on exercise intervention for patients with peripheral occlusive arterial disease and intermittent claudication. BIREME, PubMed (MEDLINE), SciELO and LILACS databases were searched for the terms intermittent claudication, peripheral vascular diseases, rehabilitation, exercise, and exercise therapy, all of which were taken from the list of Health Science Descriptors (BIREME). The conclusion was that, despite the variability of walking regimens identified in the literature, aerobic training is of general benefit to patients with peripheral arterial disease and intermittent claudication, mainly improving their walking performance, which can have significant impact on the quality of life of these patients.

Keywords: Intermittent claudication, peripheral vascular diseases, rehabilitation, exercise, exercise therapy.

Introduction

The primary cause of peripheral occlusive atherosclerotic disease (POAD) is atherosclerosis, which, in progressive form, leads to obstructions in the arteries.¹ Intermittent claudication (IC), a part of the clinical spectrum of POAD, is characterized by patients feeling pain when walking, often restricting their daily activities.^2-4

It is estimated that the prevalence of peripheral arterial disease ranges from 3 to 10 percent of the population, climbing to 20 percent among those above the age of 70. Disease incidence is greater (2:1) among black males, Hispanics, and people with risk factors for atherosclerotic disease.⁵ Risk factors for atherosclerosis can be divided into those that can be changed (smoking, sedentary lifestyle, obesity, stress, hyperlipidemia, high blood pressure) and those that cannot (diabetes mellitus, familial hypertension, thrombophilias, gender, age, heredity).^2,6-11 Treatment for POAD includes changing risk factors, lifestyle changes,^8,11 and the use of certain drugs, usually associated with physical exercise; medications associated with rehabilitation with physical exercises decrease the need for surgical or endovascular interventions, reserving invasive procedures for patients whose symptoms become more severe.^3,9,12-15

Atherosclerotic disease is associated with high morbidity and mortality,^9,16 but the mortality rate can be reduced by regular physical activity.^17,18 The use of physical exercises as therapy has been proposed for patients suffering from IC.⁵ Physical therapy based on exercises can bring significant benefits to these patients, such as: improved walking,^18,19-23 improved quality of life and prognosis,^24,25 lower levels of stress, increased blood flow,^26,27 higher pain threshold, and improved physical functioning, making patients' private and professional lives much easier.²⁵ Rehabilitation through physical exercises, as well as effective and noninvasive, is also much cheaper than surgical intervention,²⁸ the treatment of choice when conservative treatments yield unsatisfactory results, and which should be recommended when the patient's walking distance is becoming increasingly affected.^29,30 Despite its numerous benefits, exercise interventions are not used routinely in clinical practice, possibly because the literature is still riddled with controversies about which exercise program would be the best fit for treating POAD. Therefore, this study sought to review studies about exercise intervention in POAD patients suffering from IC.

Method

This review of the literature involved searching the BIREME, LILACS, SciELO and PubMed (MEDLINE) databases for the terms intermittent claudication, peripheral vascular diseases, rehabilitation, exercise, and exercise therapy, both in English and in Portuguese (the corresponding terms in Portuguese are, respectively, claudicação intermitente, doenças vasculares periféricas, reabilitação, exercício, and terapia por exercício), all of which were taken from the list of Health Science Descriptors. Searches were restricted to articles published in English, Portuguese and Spanish between 2004 and 2008, and included studies that dealt with cases in which POAD and IC patients underwent interventions based exclusively on physical exercise programs. Once the search was complete, articles that dealt with upper limbs, venous or renal alterations, or surgical or pharmacological intervention or co-intervention were excluded. Thus, 42 articles were analyzed, but only 12 fit the study's inclusion criteria.

Results and discussion

Restricting the search to articles published between 2004 and 2008 in English, Portuguese and Spanish, despite the partial exclusion of global research, probably includes the most up-to-date and relevant evidences about the subject as discussed in Brazil and worldwide. Table 1 shows the data from the studies selected, only four (33.3%) of which, out of a total of twelve, were controlled clinical trials.^20,22,31,32 The twelve studies comprehended 790 patients (n = 790), with sample sizes ranging from 11 to 202 patients. Two studies^25,33 had samples with less than 20 patients; half the studies^{20,22,27,31,34,35} ranged from 20 to 75 patients; two^32,36 had from 75 to 100 patients; and two others^37,38 involved more than 100 patients. Most studies used supervised physical training (10 / 83.3%). In terms of duration of exercise intervention, they ranged from 10 weeks³⁸ to 1 year.²⁰. Five studies^{22,27,31,33,35} lasted 12 weeks, one²⁵ lasted 20 weeks and four lasted 24 weeks^32,34,36,37. It is well known that exercise programs lasting 3 months can benefit patients' lives, as found in most studies in this review; however, six or more months of training is considered a predictor of response to exercise training programs for POAD patients.⁵ In terms of exercise modality, most (8 / 66%) studies^{20,27,28,32,33,35-37} involved aerobic training with a single exercise modality, with walking as the most frequent activity. Walking exercise schemes varied from study to study, from unsupervised walking in community spaces^20,33 to formal supervised exercise programs involving walking on treadmills.^{22,25,27,34-38} The procedures adopted in each study are shown in Table 1. Four studies (44%) combined aerobic exercise training with some form of low-intensity resistance exercise.^25,31,34,38 No study used resistance exercises alone as intervention. Studies have found walking training, especially on treadmills, to be more effective than strength training or combinations of various modalities.⁵ However, few studies tried to assess the effects of resistance training on POAD patients. According to Câmara et al.,³⁹ patients suffering from POAD may benefit from the therapeutic effects of resistance training, thus recommending the modality be included in treatment for POAD. However, due to the patients presenting multiple diseases and risk factors, the authors recommend adopting special care when prescribing this exercise modality to this particular population. Training was usually prescribed at a frequency of three times per week,^{20,25,31,33,35,36} but three articles described the use of two sessions per week;^22,32,38 one study used six sessions per week;³⁷ only one study had exercise sessions every day²⁷, while one other recommended variable frequency, from two to three times per week.³⁴ Aerobic exercise training was usually of mild to moderate intensity, progressing according to patients' tolerance to pain and increased conditioning. Patients were encouraged to exercise close to maximum pain levels in three studies,^34,36,38 while three other used moderate intensity claudication as threshold.^20,22,33 According to Leng, Fowler and Ernst,⁴⁰ the best results come from walking exercise programs done three times per week, close to maximum pain levels. The Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II),⁵ on the other hand, recommends that patients stop walking when claudication pain is considered moderate, since less optimal training responses would be achieved if the patient stopped at the onset of claudication. Six studies reported initial walking speeds on the treadmill, five of which set it at 3.2 km/h.^{20,22,28,33,38} Two studies used high-intensity aerobic training with intervals. In one, aerobic exercise training was done on a cycloergometer and intensity was set according to VO₂ max; intensity tanged from 85 to 90% of VO₂, with patients exercising for 2 minutes and resting one until they totaled 40 minutes.³² In another study, this by Adams et al.,³⁵ training consisted of approximately 6 minutes of walking on a treadmill, followed by 3 minutes of rest, totaling six intervals per session. According to TASC II,⁵ patients should walk on treadmills at speeds and inclinations that induce claudication within 3 to 5 minutes, with the patient interrupting the walk when claudication pain becomes moderate, resting until claudication decreases, then walking again until reaching moderate discomfort levels from claudication once more. Also, treadmill speed and inclination should be increased when the patient is able to walk for 10 minutes or more at the lower workload without feeling moderate pain from claudication. Increased inclination is also recommended if the patient can already walk at 3.2 km/h. Overall, the duration of aerobic training exercises ranged from 20 to 40 minutes, with six studies reporting periods of rest during aerobic exercise training.^{20,22,27,32,33,35} According to TASC II,⁵ the exercise and rest cycle should total at least 35 minutes at the start of the program and reach 50 minutes as the patient starts feeling more comfortable at exercise sessions, but always avoid fatigue or excessive leg discomfort. As shown in Table 1, several benefits have been associated with physical training, some which are discussed below.

Improved walking

Despite the enormous variability of exercise programs, most studies show significant improvement in maximum walking distance for IC patients,^{25,27,31,32,34,36-38} with some reporting improvements of up to 191 percent after 24 weeks of aerobic training associated with resistance exercises.³⁴ Longer distances for onset of claudication were also reported,^{31,32,34,36-38} as well as increased maximum walking time,^20,22,25,33 pain-free walking time,^20,33 maximum walking speed, and pain-free speed.³⁷ The results show that a physical exercise program can significantly increase IC patients' walking capacity. Claudication patients also did not present any decrease in maximum walking distance in response to the development of new arterial lesions when submitted to physical exercise training, using 40-minute walking sessions, four times a week, even presenting worsening arterial disease of the lower limbs, characterized by new proximal stenoses in previously unaffected arterial segments.⁴¹

Increased maximum oxygen consumption

Five studies, all using aerobic training, assessed maximum oxygen consumption, with significant increases in three.^32,33,36 Two studies did not report significant increases in VO₂, possibly due to the low intensity and short duration of the session,^20,22 as well as the low frequency and short total duration of the training.²²

Improved quality of life

Quality of life improved significantly after physical exercise training in two studies.^25,27 Sudbrack and Sarmento-Leite²⁵ assessed quality of life using a WHOQOL quality of life questionnaire and found improvement in the physical and social relationships domains, as well as in total scores (p = 0.001). Roberts et al.²⁷ used a specific questionnaire for vascular disease patients (Vascular Quality of Life Survey – VascuQol) and found a 22.4 percent increase in total score (p < 0.001). Lee et al.,³¹ on the other hand, using the SF-36 generic quality of life assessment questionnaire, found no significant change in the group treated with physical exercises, but significant decrease in SF-36 total score for the control group.

Improved blood flow

Two studies assessed blood flow to the affected limb after the aerobic exercise program, both of which found significant increases.^27,36 Roberts et al.²⁷ measured blood flow by venous occlusion pletismography of the more symptomatic leg (PVL 50, SciMed, Bristol, UK) before and after the exercise test. Gardner et al.³⁶ assessed blood flow of the most affected limb under conditions of rest, reactive hyperemia, and maximum hyperemia through venous occlusion pletismography. The authors assessed the effects of aerobic exercise training on two groups, smoking and nonsmoking, finding similar results in both groups for all variables; however, blood flow after training was significantly lower for nonsmokers when comparing groups (p < 0.05). The fact shows that aerobic exercises can also lead to improvements for smoking patients, but also that blood flow in the affected limb, lower than for nonsmokers, despite improvements, will remain lower than that of nonsmokers.

Despite the many benefits from exercise interventions, the ankle-brachial index (ABI), the best predictor of the progression of peripheral arterial disease in patients with IC,⁵ showed no significant improvement in six^{27,31-33,36-38} of the seven studies which measured it. It's likely that no significant improvement in ABI was found because exercising improves blood flow in the affected limb by improving colateral circulation, which would not necessarily affect systolic pressure in the posterior tibial and dorsalis pedis arteries, since the mechanism seems to produce local redistribution of blood flow instead of increasing it in absolute terms. Therefore, this would explain why improved blood flow in the affected limb would not mean significant changes to ABI.²⁷ Of the studies analyzed, only two were unsupervised,^27,37 both of which had similar results to those from supervised studies. However, studies suggest supervised physical exercises produce more clinically relevant results than unsupervised ones, but the relevance has yet to be proven, showing the need for further studies to improve quality of life in POAD patients.²³

Conclusion

In the literature surveyed, there are still few studies about rehabilitation of POAD associated with IC through physical therapy. Studies using intervention through exercising are still limited and unstandardized, which might contribute to rehabilitation not being widely used in clinical practice. Aerobic exercises of the walking variety seem to be the activities used most often, with its effects primarily leading to improved walking and improved quality of life for people with IC. Interventions of this type also seem to be safe, effective, and low cost.

References

• 1. Garcia LA. Epidemiology and pathophysiology of lower extremity peripheral arterial disease. J Endovasc Ther. 2006;13(Suppl 2):3-9.
• 2. Medeiros AH, Chalegre ST, Carvalho CC. Eletroestimulação muscular: alternativa de tratamento coadjuvante para pacientes com doença arterial obstrutiva periférica. J Vasc Bras. 2007;6:156-62.
• 3. Pinto DM, Mandil A. Claudicação intermitente: do tratamento clínico ao intervencionista. Rev Bras Cardiol Invas. 2005;13:261-9.
• 4. Robless P, Mikhailidis DP, Stansby GP. Cilostazol for peripheral arterial disease. Cochrane Database Syst Rev. 2007;1:CD003748.
• 5. Norgren L, Hiatt WR, Dormandy JA, et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Vasc Surg. 2007;45 Suppl S:S5-S67.
• 6. Parry DJ, Grant PJ, Scott DJ. Atherothrombotic risk factor clustering in healthy male relatives of male patients with intermittent claudication. J Vasc Surg. 2004;40:891-8.
• 7. Makdisse M, Ramos LR, Moreira F, et al. Escore para rastrear idosos (= 75 anos) de alto risco para doença arterial periférica. Arq Bras Cardiol. 2007;88:630-6.
• 8. Yoshida RA, Matida CK, Sobreira ML, et al. Estudo comparativo da evolução e sobrevida de pacientes com claudicação intermitente, com ou sem limitação para exercícios, acompanhados em ambulatório específico. J Vasc Bras. 2008;7:112-22.
• 9. Chi YW, Jaff MR. Optimal risk factor modification and medical management of the patient with peripheral arterial disease. Catheter Cardiovasc Interv. 2008;71:475-89.
• 10. Gardner AW, Montgomery PS, Parker DE. Physical activity is a predictor of all-cause mortality in patients with intermittent claudication. J Vasc Surg. 2008;47:117-22.
• 11. Durazzo AE, Sitrângulo CD, Presti C, Silva ES, Luccia N. Doença arterial obstrutiva periférica: que atenção temos dispensado à abordagem clínica dos pacientes? J Vasc Bras. 2005;4:255-64.
• 12. Rice TW, Lumsden AB. Optimal medical management of peripheral arterial disease. Vasc Endovascular Surg. 2006;40:312-27.
• 13. Schaan B, Mandelli NC. Conduta na doença arterial periférica em pacientes diabéticos. Rev Soc Cardiol RS. 2004;XIII. http://sociedades.cardiol.br/sbc-rs/revista/2004/02/artigo02.pdf. Acessado: 25.09.2008.
• 14. Aronow WS. Management of peripheral arterial disease of the lower extremities. Compr Ther. 2007;33:247-56.
• 15. Hankey GJ, Norman PE, Eikelboom JW. Medical treatment of peripheral arterial disease. JAMA. 2006;295:547-53.
• 16. Neto SS, Nascimento JL. Doença arterial obstrutiva periférica: novas perspectivas de fatores de risco. Rev Para Med. 2007;21:35-9.
• 17. Garg PK, Tian L, Criqui MH, Liu K, Ferrucci L, Guralnik JM. Physical activity during daily life and mortality in patients with peripheral arterial disease. Circulation. 2006;114:242-8.
• 18. Askew CD, Green S, Walker PJ, et al. Skeletal muscle phenotype is associated with exercise tolerance in patients with peripheral arterial disease. J Vasc Surg. 2005;41:802-7.
• 19. Ambrosetti M, Salerno M, Boni S, Daniele G, Tramarin R, Pedretti RF. Economic evaluation of a short-course intensive rehabilitation program in patients with intermittent claudication. Int Angiol. 2004;23:108-13.
• 20. Crowther RG, Spinks WL, Leicht AS, Sangla K, Quigley F, Golledge J. Effects of a long-term exercise program on lower limb mobility, physiological responses, walking performance, and physical activity levels in patients with peripheral arterial disease. J Vasc Surg. 2008;47:303-9.
• 21. Wind J, Koelemay MJ. Exercise therapy and the additional effect of supervision on exercise therapy in patients with intermittent claudication. Systematic review of randomised controlled trials. Eur J Vasc Endovasc Surg. 2007;34:1-9.
• 22. Hodges LD, Sandercock GR, Das SK, Brodie DA. Randomized controlled trial of supervised exercise to evaluate changes in cardiac function in patients with peripheral atherosclerotic disease. Clin Physiol Funct Imaging. 2008;28:32-7.
• 23. Bendermacher BL, Willigendael EM, Teijink JA, Prins MH. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database Syst Rev. 2006;2:CD005263.
• 24. Murphy TP, Hirsch AT, Ricotta JJ, et al. CLEVER Steering Committee. The claudication: exercise vs. endoluminal revascularization (CLEVER) study: rationale and methods. J Vasc Surg. 2008;47:1356-63.
• 25. Sudbrack AC, Sarmento-Leite R. Efetividade do exercício na claudicação. Rev Bras Cardiol Invas. 2007;15:261-6.
• 26. Andreozzi GM, Leone A, Laudani R, Deinite G, Martini R. Acute impairment of the endothelial function by maximal treadmill exercise in patients with intermittent claudication, and its improvement after supervised physical training. Int Angiol. 2007;26:12-7.
• 27. Roberts AJ, Roberts EB, Sykes K, De Cossart L, Edwards P, Cotterrell D. Physiological and functional impact of an unsupervised but supported exercise programme for claudicants. Eur J Vasc Endovasc Surg. 2008;36:319-24.
• 28. Treesak C, Kasemsup V, Treat-Jacobson D, Nyman JA, Hirsch AT. Cost-effectiveness of exercise training to improve claudication symptoms in patients with peripheral arterial disease. Vasc Med. 2004;9:279-85.
• 29. Wolosker N, Munia MA, Rosoky R, et al. Tratamento cirúrgico para claudicação intermitente em pacientes que não melhoram com o tratamento clínico. Arq Bras Cardiol. 2004;82:445-9.
• 30. Aquarius AE, Denollet J, Hamming JF, Breek JC, De Vries J. Impaired health status and invasive treatment in peripheral arterial disease: a prospective 1-year follow-up study. J Vasc Surg. 2005;41:436-42.
• 31. Lee HL, Mehta T, Ray B, Heng MS, McCollum PT, Chetter IC. A non-randomised controlled trial of the clinical and cost effectiveness of a supervised exercise programme for claudication. Eur J Vasc Endovasc Surg. 2007;33:202-7.
• 32. Zwierska I, Walker RD, Choksy SA, Male JS, Pockley AG, Saxton JM. Upper-vs lower-limb aerobic exercise rehabilitation in patients with symptomatic peripheral arterial disease: a randomized controlled trial. J Vasc Surg. 2005;42:1122-30.
• 33. Wang J, Zhou S, Bronks R, Graham J, Myers S. Effects of supervised treadmill walking training on calf muscle capillarization in patients with intermittent claudication. Angiology. 2009;60:36-41.
• 34. Bendermacher BL, Willigendael EM, Nicolaï SP, et al. Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based. J Vasc Surg. 2007;45:1192-6.
• 35. Adams J, Ogola G, Stafford P, Koutras P, Hartman J. High-intensity interval training for intermittent claudication in a vascular rehabilitation program. J Vasc Nurs. 2006;24:46-9.
• 36. Gardner AW, Killewich Montgomery PS, Katzel LI. Response to exercise rehabilitation in smoking and nonsmoking patients with intermittent claudication. J Vasc Surg. 2004;39:531-8.
• 37. Manfredini F, Malagoni AM, Mascoli F, et al. Training rather than walking the test in-train out program for home-based rehabilitation in peripheral arteriopathy. Circ J. 2008;72:946-52.
• 38. Ratliff DA, Puttick M, Libertiny G, Hicks RC, Earby LE, Richard T. Supervised exercise training for intermittent claudication: lasting benefit at three years. Eur J Vasc Endovasc Surg. 2007;34:322-6.
• 39. Câmara LC, Santarém JM, Wolosker N, Dias RM. Exercícios resistidos terapêuticos para indivíduos com doença arterial obstrutiva periférica: evidências para a prescrição. J Vasc Bras. 2007;6:246-56.
• 40. Leng GC, Fowler B, Ernst E. Exercise for intermittent claudication. Cochrane Database Syst Rev. 2000;2:CD000990.
• 41. Rosoky RM, Wolosker N, Puech-Leao P. Performance of patients with intermittent claudication undergoing physical training, with or without an aggravation of arterial disease: retrospective cohort study. Clinics. 2006;61:535-8.

*

Faculdade de Educação Física e Fisioterapia, Universidade de Passo Fundo, Passo Fundo, RS.

Publication Dates

• Publication in this collection
  05 Jan 2010
• Date of issue
  Sept 2009

History

• Received
  14 Feb 2009
• Accepted
  01 July 2009