# Exercise as it relates to Disease/Exercise management for peripheral artery disease

Exercise management for peripheral artery disease

### Prevalence

With the combination of systemic atherosclerosis, Peripheral arterial disease shows an increased risk of cardiovascular events in Older populations. The prevalence of Australians over the age of 55 is 20% with Asymptomatic and symptomatic Peripheral Arterial Disease, 11% increase between 60-65 and a 39% increase of prevalence in the 85 years and over category.

### What is Peripheral Arterial Disease(PAD)?

Peripheral arteriole disease, otherwise referred to as PAD is a vascular disease that mainly affects the peripheral arteries which carry blood to the legs, arms, head and stomach. PAD occurs when there is a large amount of plaque built up in the system,which accumulates within the artery walls. Plaque is made up of various fats, calcium, fibrous tissues and other waste substances that are carried in the blood. The condition Atherosclerosis is as a result of the plaque build up in the artery wall, preventing optimal blood flow and oxygen traveling to tissues effectively loosing there function, due to the hardening of the arteries. PAD commonly occurs in the lower extremity of the body causing stenosis(Abnormal narrowing of tissue) and occlusion (Blockage in a vessel), which on occasion leads to ischema (lack of blood to tissues) and gangrene in the distal tissues of the feet and legs. The Most common signs and symptoms of PAD involving the lower extremities include pain, tiredness or cramping up when walking, in the hips of the leg and leg muscles.
* Picture shows how PAD can affect the blood flow in the lower legs

## Diagnosis

* Clincal examination
* Assessment of PAD blood flow and pressure using the Doppler technique |
* Walking assessments.
Physiologists can diagnose the severity of PAD by following the Fontaine stages:
| Header text | Header text |
| I | Symptom Free |
| II | Intermediate Claudication |
| IIa | Pain free walking distance > 200m |
| IIb | Pain free walking distance < 200m |
| III | Pain at rest |
| IV | Necrosis (gangrene) |

## Causes of PAD preventable/non-preventable

Peripheral arteriole disease, can be considered a lifestyle disorder and can be prevented or delayed by changing habits to lower the risk of severe symptoms. Some of the changes that a person can make to there life style are:

##### Preventable Factors

* Cigarette Smoking- quit smoking. A major risk factor for PAD is smoking and by quiting the use of cigarettes you are lowering the risk of developing PAD and other diseases associated with it as smokers can have four times the risk of PAD than non-smokers.
* Obesity – PAD generally is scene in Adults with a BMI of 25 or higher. The literature has shown that being in this BMI category puts you at risk to develop Heart disease or a stroke even if you have no other risk factors in your profile.
* Diabetes mellitus – If the client has Diabetes then an effective management scheme is to make sure that you are managing sugar levels to control diabetes.
* Improper Diet- Making sure that a balanced diet is maintained with a lowered consumption of high fates, sugars and salts.
* Hypertension
* Lipid Metabolism Disorders.

##### Non-preventable Factors

* Genetic Dispossition
* Gender- males are 3 times more likely to develop PAD in early 50s.
* Age- 55 and over
* Environmental pollution.

## Current Rehabilitation methods

There are many methods which are currently used for managing the effects of PAD. The best method is early detection by knowing the signs and symptoms of the disease. Therapies that involve relieving symptoms of PAD aim to improve the functional capacity and quality of life in a person, by using conservative and interventional therapies. theses therapies can include:

### Medical therapies

* Stenting- is a type of splint which is used and placed temporarily inside a blood vessel to aid with the healing processes or relieve an obstruction which may be blocking the path.
* Percutaneous Transluminal Angioplasty - is a minimally invasive procedure which involves opening up blocked arteries using a mesh like balloon which forces the artery to stay open.
* Pharmaceutical drug use - Statins and Aspirin may improve treadmill walking performance. Cilostazol has been shown to improve walking by 40-60%

### Recommendations for Exercise management

The recommendations for the management of PAD include a mixture of Progressive resistance training and Moderate aerobic exercise. Many protocols have been performed to measure the effectiveness of therapies compared to invasive techniques. The Use of the Clever trail (Claudication Exercise versus Endoluminal revascularisation)is an example of one of those techniques(ref name=bronas/>. It aims to compare medical therapy such as 'stenting' and exercise training in patients with pad, so that patents can learn to relieve pain with other methods before resorting to surgeries.

#### Aerobic exercise

The Current Recommendations by the Journal of Science and Medicine in sport recommend moderate intensity sessions for 40 minutes at least 3 times per week for a 6 month period. These exercises should not be forced and if any discomfort occurs due to claudication factor, cease performing exercise.
Effective aerobic activities for the lower limb can include; Pole striding, Circuit aerobics, brisk walks and bike riding.

#### Progressive resistance training

The current recommendations for Progressive resistance training includes 2-3 sessions of PRT per week for 6months with a 60% load increasing it slightly as the months pass. Exercise specificity is important PRT exercises should focus mainly on the Calves, Tibialis anterior, Quadracepts, Hamstrings and the Gluteals.
Activities can include: lower limb weight lifting, thero-band exercises, swimming, Arm Crank(upper body)

## Further reading

* American Heart Association: PAD
* Heart Foundation: Physical Activity Guidelines

## References

* 1 2 3 Paulson, S., & Sanders, J. (2014). Peripheral Arterial Disease and Exercise for Older Adults. IDEA Fitness Journal, 11(4), 25-27.
* 1 2 3 4 5 6 7 8 9 10 11 National Heart, Lung and blood institute. (2014). What is peripheral arterial disease. Retrieved 20/9, 2014, from http://www.nhlbi.nih.gov/health/health-topics/topics/pad/
* ↑ A Calf Ergometer for Exercise Testing and Training of Patients with Peripheral Arterial Disease and Calf Claudication. (2009). Clinical Kinesiology (Online Edition), 23-29.
* ↑ Milani RV, Lavie CJ (2007)'The role of training in peripheral arterial disease',Society for Vascular Medicine, vol 12 pp 351-358
* 1 2 3 American Heart Association. (2014). Prevention and treatment of PAD. Retrieved 8/20, 2014, from http://www.heart.org/HEARTORG/Conditions/More/PeripheralArteryDisease/Prevention-and-Treatment-of-PAD_UCM_301308_Article.jsp
* ↑ American Heart Association. (2014). Atherosclerosis. Retrieved 19/8, 2014, from http://www.heart.org/HEARTORG/Conditions/Cholesterol/WhyCholesterolMatters/Atherosclerosis_UCM_305564_Article.jsp
* ↑ Hirsch, AT. et al (2005/2011) ACC/AHA Guidelines for the Management of patients withPeripheral Arterial Disease.
* 1 2 3 Schirmang, T. C., Ahn, S. H., Murphy, T. P., Dubel, G. J., & Soares, G. M. (2009). Peripheral Arterial Disease: Update of Overview and Treatment. Medicine & Health Rhode Island, 92(12), 398-402.
* 1 2 3 4 5 Schmidt-Trucks„ss, A. (2011). Exercise training in Peripheral Arterial Disease. International Sportmed Journal, 12(4), 150-155.
* 1 2 3 Bronas, U., Hirsch, A., Murphy, T., Badenhop, D., Collins, T., Ehrman, J., & ... Regensteiner, J. (2009). Design of the multicenter standardized supervised exercise training intervention for the claudication: exercise vs endoluminal revascularization (CLEVER) study. Vascular Medicine (London, England), 14(4), 313-321. doi:10.1177/1358863X09102295
* 1 2 3 4 Askew, C et al (2013) Exercise prescription for patients with peripheral arterial disease and intermittent claudication: A position statement from Exercise & Sports Science Australia. In Press. Journal of Science and Medicine in Sport
* ↑ Heart Foundation. (2014). Australian physical activity guidelines and policies. Retrieved 20/9, 2014, from http://www.heartfoundation.org.au/information-for-professionals/australian-physical-activity-network/Pages/guides-and-policies.aspx
* ↑ Guidon, M., & Mcgee, H. (2013). One-year effect of a supervised exercise programme on functional capacity and quality of life in peripheral arterial disease. Disability & Rehabilitation, 35(5), 397-404.
* 1 2 3 Mosti, M. P., Wang, E. E., Wiggen, Ø. N., Helgerud, J. J., & Hoff, J. J. (2011). Concurrent strength and endurance training improves physical capacity in patients with peripheral arterial disease. Scandinavian Journal Of Medicine & Science In Sports, 21(6), e308-e314.
* 1 2 Wang, E. E., Helgerud, J. J., Loe, H. H., Indseth, K. K., Kaehler, N. N., & Hoff, J. J. (2010). Maximal strength training improves walking performance in peripheral arterial disease patients. Scandinavian Journal Of Medicine & Science In Sports, 20(5), 764-770.