Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a 'go home and walk' advice. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication. Gender differences following supervised exercise therapy in patients with intermittent claudication. Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication. The effect of supervised exercise therapy on physical activity and ambulatory activities in patients with intermittent claudication. A randomised controlled trial of supervised exercise regimens and their impact on walking performance, skeletal muscle mass and calpain activity in patients with intermittent claudication. SUPERvised exercise therapy or immediate PTA for intermittent claudication in patients with an iliac artery obstruction--a multicentre randomised controlled trial; SUPER study design and rationale. Comparison of the effect of upper body-ergometry aerobic training vs treadmill training on central cardiorespiratory improvement and walking distance in patients with claudication. A primary care walking exercise program for patients with intermittent claudication. Efficacy of arm-ergometry versus treadmill exercise training to improve walking distance in patients with claudication Does supervised exercise offer adjuvant benefit over exercise advice alone for the treatment of intermittent claudication? A randomised trial. Peripheral arterial disease and intermittent claudication: efficacy of short-term upper body strength training, dynamic exercise training, and advice to exercise at home. Supervised exercise therapy for intermittent claudication in daily practice. A non-randomised controlled trial of the clinical and cost effectiveness of a Supervised Exercise Programme for claudication. Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based. A feasibility double-blind randomized placebo-controlled trial of extracorporeal shockwave therapy as a novel treatment for intermittent claudication. The relationship of walking distances estimated by the patient, on the corridor and on a treadmill, and the Walking Impairment Questionnaire in intermittent claudication. Nordic pole walking improves walking capacity in patients with intermittent claudication: a randomized controlled trial The effects of exercise training on walking function and perception of health status in elderly patients with peripheral arterial occlusive disease. Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial. Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial. Agreements and discrepancies between the estimated walking distance, nongraded and graded treadmill testing, and outside walking in patients with intermittent claudication. Strength training increases walking tolerance in intermittent claudication patients: randomized trial.
OBJECTIVES The Exercise Therapy in Peripheral Arterial Disease ( EXITPAD ) study has shown supervised exercise therapy ( SET ) to be more effective regarding walking distance and quality of life than a ' go home and walk ' advice ( WA ) for patients with intermittent claudication . The present study aims to assess the cost-effectiveness of SET versus WA . PATIENTS AND METHODS Data from the EXITPAD study , a 12-month r and omised controlled trial in 304 patients with claudication , was used to study the proportion of costs to walking distance and quality of life . Two different incremental cost-effectiveness ratios ( ICERs ) were calculated for SET versus WA : costs per extra metre on the treadmill test , and costs per quality -adjusted life year ( QALY ) . QALYs were based on utilities derived from the EuroQoL-5 dimensions ( EQ-5D ) . RESULTS Mean total costs were higher for SET than for WA ( 3407 versus 2304 Euros ) , mainly caused by the costs of exercise therapy . The median walking distance was 620 m for SET and 400 m for  WA . QALYs were 0.71 for SET and 0.67 for WA . All differences were statistically significant . The ICER for cost per extra metre on the 12-month treadmill test was € 4.08 . For cost per QALY , the ICER was € 28,693 . CONCLUSION At a willingness-to-pay threshold of € 40,000 per QALY , SET likely is a cost-effective therapeutic option for patients with claudication OBJECTIVE The initial treatment for intermittent claudication is supervised exercise therapy ( SET ) . Owing to limited capacity and patient transports costs of clinic-based SET , a concept of SET provided by local physiotherapists was developed . We hypothesized that provision of daily feedback with an accelerometer in addition to SET would further increase walking distance . METHODS This multicenter r and omized trial was set in vascular surgery outpatient clinics and included 304 patients with intermittent claudication . Patients were r and omized to exercise therapy in the form of " go home and walk " advice ( WA ) , SET , or SET with feedback . Local physiotherapists provided SET . The primary outcome measure was the change in absolute claudication distance . Secondary outcomes were the change in functional claudication distance and results on the Walking Impairment Question naire ( WIQ ) and Short-Form 36 ( SF-36 ) Health Survey after 12 months . RESULTS In 11 centers , 102 , 109 , and 93 patients were included , respectively , in the WA , SET , and SET with feedback groups , and data for 83 , 93 , and 76 , respectively , could be analyzed . The median ( interquartile range ) change in walking distance between 12 months and baseline in meters was 110 ( 0 - 300 ) in the WA group , 310 ( 145 - 995 ) in the SET group , and 360 ( 173 - 697 ) in the SET with feedback group ( P < .001 WA vs SET ) . WIQ scores and relevant domains of the SF-36 improved statistically significantly in the SET groups . CONCLUSIONS SET is more effective than WA in improving walking distance , WIQ scores , and quality of life for patients with intermittent claudication . Additional feedback with an accelerometer did not result in further improvement . SET programs should be made available for all patients with intermittent claudication OBJECTIVE Prevalence of peripheral arterial disease is equal in men and women . However , women seem to suffer more from the burden of disease . Current studies on gender-related outcomes following supervised exercise therapy ( SET ) for intermittent claudication ( IC ) yield conflicting results . METHODS A follow-up analysis was performed on data from the 2010 Exercise Therapy in Peripheral Arterial Disease ( EXITPAD ) study , a multicenter r and omized controlled trial including IC patients receiving SET or a walking advice .  The SET program was supervised by physiotherapists and included interval-based treadmill walking approximating maximal pain combined with activities such as cycling and rowing . Patients usually started with three 30-minute sessions a week . Training frequency was adapted during the following year on the basis of individual needs . The primary outcome was gender differences regarding the change in absolute claudication distance ( ACD ) after SET . ACD was defined as the number of meters that a patient had covered just before he or she was forced to stop walking because of intolerable pain . Secondary outcomes were gender differences in change of functional walking distance , quality of life , and walking (dis)ability after SET . Walking distances were obtained by  st and ardized treadmill testing  according to the Gardner-Skinner protocol . Quality of life was measured by the 36-Item Short Form Health Survey , and walking (dis)ability was determined by the Walking Impairment Question naire ( WIQ ) . Measurements were performed at baseline and after 3 , 6 , 9 , and 12 months . Only patients who met the 12-month follow-up measure were included in the analysis . RESULTS A total of 113 men and 56 women were available for analysis . At baseline , groups were similar in terms of clinical characteristics and ACD walking distances ( men , 250 meters ; women , 270 meters ; P = .45 ) . ACD improved for both sexes . However , ACD increase was significantly lower for women than for men during the first 3 months of SET ( Δ 280 meters for men vs Δ 220 meters for women ; P = .04 ) . Moreover , absolute walking distance was significantly shorter for women compared with men after 1 year ( 565 meters vs 660 meters ; P = .032 ) . Women also reported less on several WIQ subdomains , although total WIQ score was similar ( 0.69 for men vs 0.61 for women ; P = .592 ) . No differences in quality of life  after SET were observed . CONCLUSIONS Women with IC benefit less during the first 3 months of SET and have lower absolute walking distances  after 12 months of follow-up compared with men . More research is needed to determine whether gender-based IC treatment strategies are required OBJECTIVES To evaluate effects of a structured home-based exercise program on functional capacity and quality of life ( QoL ) in patients with intermittent claudication ( IC ) after 1-year follow-up , and to compare these results with those from a concurrent control group who received supervised exercise training ( SET ) . DESIGN Comparative longitudinal cohort study . SETTING Referral center . PARTICIPANTS Patients ( N=142 ) with IC . INTERVENTIONS Structured home-based exercise training or SET . MAIN OUTCOME MEASURES The maximum ( pain-free ) walking distance and the ankle-brachial index ( ABI ) ( at rest and postexercise ) were measured at baseline and after 6 and 12 months ' follow-up . Additionally , QoL was evaluated using a self-administered question naire consisting of the Euroqol-5D ( scale 0 - 1 ) , rating scale ( scale 0 - 100 ) , Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ; scale 0 - 100 ) , and the Vascular Quality of Life Question naire ( VascuQol ; scale 1 - 7 ) . Comparison of the groups was performed with adjustment for the nonr and omized setting using propensity scoring . RESULTS One hundred forty-two patients with IC started the  structured home-based exercise program , of whom 95 ( 67 % ) completed 12 months ' follow-up . The mean relative improvement compared with baseline was statistically significant after 12 months ' follow-up for the maximum and pain-free walking distance ( 342 % , 95 % confidence interval [ CI ] , 169 - 516 ; P<.01 and 338 % , 95 % CI , 42 - 635 ; P=.03 , respectively ) and for the ABI postexercise ( mean change , .06 ; 95 % CI , .01-.10 ; P=.02 ) . For the QoL outcomes , the improvement compared with baseline was statistically significant after 12 months for the VascuQol ( mean change , .42 ; 95 % CI , .20-.65 ; P<.01 ) and for the SF-36 physical functioning ( mean change , 5.17 ; 95 % CI , .77 - 9.56 ; P=.02 ) . Compared with the structured home-based exercise program , patients in the control group showed significantly better results in the mean relative improvement of maximum and pain-free walking distance and change in the ABI at rest after 12 months ' follow-up . CONCLUSIONS Structured home-based exercise training is effective in improving both functional capacity and QoL in patients with IC and may be considered as a feasible and valuable alternative toSET , since supervised exercise programs are not often available OBJECTIVE / BACKGROUND Intermittent claudication ( IC ) is associated with a reduction in physical activity ( PA ) and a more rapid functional decline leading to a higher mortality rate compared with healthy individuals . Supervised exercise therapy ( SET ) is known to increase the walking capacity of patients with IC . However , it is unclear whether SET increases PA . The aim of this study was to investigate the effect of SET on PA levels and ambulatory activities in patients with IC . METHODS Patients newly diagnosed with IC were requested to wear an activity monitor 1 week prior to and 1 week immediately after 3 months of SET . The primary outcome was the percentage of patients meeting the minimum recommendations of PA ( American College of Sports Medicine [ACSM]/American Heart Association [ AHA ] recommendation for public health of ≥ 67 metabolic equivalents [METs]/min/day , in bouts of ≥ 10 min ) at baseline and after 3 months of SET . Additionally , daily PA level ( METs/min ) , duration of ambulatory activities , daily number of steps , pain free walking distance ( PFWD ) , maximal walking distance ( MWD ) , and Short Form Health Survey ( SF-36 ) health surveys were compared before and after SET . RESULTS Data from 41 participants were available for analysis . A higher number of participants met the ACSM minimum recommendation for PA at the 3 month follow up ( baseline : 43 % ; 3 months : 63 % ; p = .003 ) . Despite significant increases in PFWD ( baseline : 210 m ; 3 months : 390 m ; p = .001 ) , MWD ( baseline : 373 m ; 3 months : 555 m ; p = .002 ) and physical functioning score ( SF-36 )  following SET , no increase in the mean daily PA level was found ( 395 ± 220 vs. 411 ± 228 METs/min ; p = .43 ) . Furthermore , the total number of steps and time spent in ambulatory activities did not change following SET . CONCLUSION Three months of SET for IC leads to more patients meeting the ACSM/AHA public health minimum recommendations for PA . Assessment of PA could be incorporated as an outcome parameter in future research comparing different treatment modalities for peripheral arterial disease OBJECTIVES Supervised exercise training ( SET ) is recommended for patients with intermittent claudication ( IC ) . The optimal exercise programme has not been identified , and the potential adverse effects of exercise on these patients warrant consideration . Calpain proteases have been linked with tissue atrophy following ischaemia-reperfusion injury . High calpain activity may therefore cause muscle wasting in claudicants undergoing SET , and skeletal muscle mass ( SMM ) is integral to healthy ageing . This study assesses the impact of ( 1 ) treadmill-based SET alone ; and ( 2 ) treadmill-based SET combined with resistance training on pain-free walking distance ( PFWD ) , SMM , and calpain activity . METHODS Thirty-five patients with IC were r and omised to 12 weeks of treadmill only SET ( group A ) , or combined treadmill and lower-limb resistance SET ( group B ) . PFWD via a 6-minute walking test , SMM via dual energy X-ray absorptiometry , and calpain activity via biopsies of gastrocnemius muscles were analysed . RESULTS Intention-to-treat analyses revealed PFWD improved within group A ( 160 m to 204 m , p = .03 ) , but not group B ( 181 m to 188 m , p = .82 ) . There was no between group difference ( p = .42 ) . Calpain activity increased within group A ( 1.62 × 10(5 ) fluorescent units [ FU ] to 2.21 × 10(5 ) FU , p = .05 ) , but not group B. There was no between group difference ( p = .09 ) . SMM decreased within group A ( -250 g , p = .11 ) and increased in group B ( 210 g , p = .38 ) ( p = .10 between groups ) . Similar trends were evident for per protocol analyses , but , additionally , change in SMM was significantly different between groups ( p = .04 ) . CONCLUSIONS Neither exercise regimen was superior in terms of walking performance . Further work is required to investigate the impact of the calpain system on SMM in claudicants undertaking SET INTRODUCTION Treatment of intermittent claudication ( IC ) due to peripheral arterial disease ( PAD ) is aim ed at improving walking distance and includes secondary prevention of cardiovascular disease . Both supervised exercise therapy ( SET ) and percutaneous transluminal angioplasty ( PTA ) have proven to be effective in increasing maximum and pain-free walking distance in IC . However , the optimal treatment strategy in patients with IC due to iliac artery stenosis or occlusion remains unclear . OBJECTIVE To compare the ( cost- ) effectiveness of initial PTA versus initial SET in patients with disabling IC due to an iliac artery obstruction . DESIGN In a multicentre r and omised controlled trial 400 consecutive patients with IC will be r and omly assigned to PTA ( with additional stent placement on indication ) or SET . Primary outcomes are maximum walking distance and health-related quality of life measured using the disease-specific VascuQol instrument after 1 year . Secondary outcomes are pain-free walking distance , functional status , generic quality of life , complications related to each of the interventions , additional interventions , treatment failures and costs ( cost-effectiveness and cost-utility ) after 1 year . CONCLUSION AND IMPLICATION S Based on the results of this proposed large study well-founded adjustments of existing guidelines on the treatment of iliac artery occlusive disease can be implemented ( Clinical Trials.gov NCT01385774 ; Nederl and s Trial Register NTR2776 ) BACKGROUND Supervised treadmill-walking exercise programs have been proven to be a highly effective in improving walking distance in peripheral arterial disease ( PAD ) patients with lifestyle-limiting claudication . Limited information is available on the contributions of central cardiorespiratory functions for improving these patients ' walking capacity with exercise training . METHODS This study r and omized 28 participants ( 21 men ; age , 65.6 years ; 92.7 % smoking history , 36.6 % with diabetes ) with lifestyle-limiting PAD-related claudication to 3 hours/week of supervised exercise training for 12 weeks  , using arm-ergometry ( n = 10 ) or treadmill-walking ( n = 10 ) vs a usual-care control group ( n = 8) . Cardiorespiratory function measurements were assessed before and after training at a submaximal workload and at the onset of claudication ( pain-free walking distance [ PFWD ] ) and at maximal walking distance [ ( MWD ] ) . Changes in these functions from baseline were analyzed among the groups with analysis of covariance . Associations between variables were determined by Pearson 's partial correlations . RESULTS The mean baseline demographic , medical , and exercise variables were similar among the groups . There were similar significant differences in the submaximal double product ( heart rate × systolic blood pressure ) and at MWD , ventilatory threshold , ventilatory oxygen uptake ( VO(2 ) ) at onset of claudication , and VO(2 ) peak in response to training in both exercise groups vs the control group . Statistically significant , moderate correlations ( r = 0.60 - 0.68 ) were found between changes in all cardiorespiratory variables and changes in PFWD or MWD . CONCLUSION Improvements in cardiorespiratory function after arm-ergometry or treadmill-training were significantly associated with improvements in both PFWD and MWD , providing supporting evidence of systemic contributions to exercise training-related improvements in walking capacity seen in patients with claudication PURPOSE In a pilot study , the hypothesis was tested that a home-based walking exercise program with structured coaching would improve walking performance and adherence in patients with intermittent claudication ( IC ) . METHODS Thirty-one IC patients with a rest ankle-brachial pressure index < 0.90 started a 24-wk walking program in the home environment . They were coached according to the Health Counseling Model ( HCM ) . Patients were instructed to walk at least 9 bouts.wk-1 and to walk through the pain . The main effect measures were pain-free ( initial claudication distance ( ICD ) ) and maximum walking distance ( absolute claudication distance ( ACD ) ) measured with a grade d treadmill test , a corridor exercise test , a  walking-diary  , and the score on the Walking Impairment Question naire ( WIQ ) . RESULTS Twenty-four participants completed the program . The reported walking frequency was 7.4 times.wk-1 . The average ICD improved from 289 m ( 95 % CI , 209 - 369 ) to 347 m ( 95 % CI , 244 - 449 ) ( P < 0.05 ) and from 241 m ( 95 % CI , 171 - 310 ) to 373 m ( 95 % CI , 273 - 472 ) on the treadmill and the corridor test , respectively . The average ACD improved from 490 m ( 95 % CI , 397 - 583 ) to 544 m ( 95 % CI , 438 - 650 ) and from 564 m ( 95 % CI , 412 - 717 ) to 726 m ( 95 % CI , 546 - 906 ) ( P < 0.01 ) on the treadmill and the corridor test , respectively . The average maximum distance reported in the walking-diary improved from 957 m ( 95 % CI , 291 - 1623 ) to 1294 m ( 95 % CI , 646 - 1941 ) . The score of the walking distance on the WIQ improved from 57 % ( 95 % CI , 42 - 71 % ) to 60 % ( 95 % CI , 46 - 74 % ) . CONCLUSION IC patients improved their average ICD and ACD . The walking exercise program in the home environment with coaching according to the HCM seems a promising intervention to be tested in a r and omized controlled trial Abstract The efficacy of treadmill walking training to improve pain-free ( PFWD ) and maximal ( MWD ) walking distance in patients with claudication is well documented . The effects of aerobic arm-ergometry to improve PFWD and MWD compared to treadmill walking or usual care are not known . Forty-one participants ( 29 male , 12 female , mean age 67.7 years , 92.7 % smoking history , 36.6 % with diabetes ) with lifestyle-limiting claudication were r and omized to 12 weeks of 3 hours/week of supervised exercise training using either arm-ergometry , treadmill walking , or a combination , versus control .  PFWD and MWD were assessed before and after training , and after 12 weeks of follow-up . The 12-week MWD increased significantly in the arm-ergometry ( + 53 % ) , treadmill ( + 69 % ) , and combination ( + 68 % ) groups ( p < 0.002 versus control ) . The 24-week MWD was maintained in the arm-ergometry ( p = 0.009 ) and treadmill ( p = 0.019 ) groups , whereas the combination group declined ( p = 0.751 ) versus control . The 12-week PFWD increased significantly in the arm-ergometry group ( + 82 % ; p = 0.025 versus control ) . Change in PFWD in treadmill ( + 54 % ; p = 0.196 versus control ) and combination ( + 60 % ; p = 0.107 versus control ) groups did not reach statistical significance . PFWD improvement was maintained in the arm-ergometry group after a 12-week follow-up ( + 123 % ; p = 0.011 versus control ) . In conclusion , these pilot data demonstrate for the first time that dynamic arm exercise training can improve walking capability in people with peripheral arterial disease (PAD)-induced claudication compared to participants receiving usual care and that improvement was not different from that seen with treadmill walking exercise training . Dynamic arm exercise may be a therapeutic exercise option for patients with PAD OBJECTIVE Exercise advice is the main treatment for symptom relief in the UK for patients with mild to moderate Intermittent Claudication ( IC ) . Would a weekly exercise and motivation class for 6 months offer adjuvant benefit over written and verbal exercise advice alone ? PATIENTS AND METHODS Fifty-nine patients attending a regional vascular centre for whom IC was the main factor affecting mobility were r and omised to either exercise advice alone ( n=30 ) or exercise advice with a once a week 45 min supervised exercise/motivation class ( n=29 ) . The mean age was 68 years . Baseline and 6-month assessment included a Quality of Life Question naire -- the Short-Form-36 , the Charing Cross Symptom Specific Claudication Question naire ( CCCQ ) and treadmill walking distance ( 3.5 km/h 12 % ) . RESULTS At 6-month follow-up the supervised exercise group had improved their treadmill walking by 129 % compared to 69 % in the advice alone group ( p=0.001 ) . This significant improvement was maintained at the subsequent 9 and 12-month follow-up assessment s. By the 9-month stage the advice only group CCCQ score had improved 16 % from baseline , while the supervised exercise group had a significantly better 43 % improvement in base line score ( p<0.05 ) . Self reported frequency of walks was higher in the exercise class group being significant for improvement in CCCQ score . CONCLUSION A weekly , supervised exercise and motivation class for a 6-month period provides a significant improvement in patients ' symptoms , quality of life , and distance walked compared with advice alone and this improvement continues after attendance at class has ceased OBJECTIVE To compare the effect of two training programmes and advice to exercise at home on physiological adaptations in patients with peripheral arterial disease ( PAD ) . DESIGN 30 patients with a typical history of PAD and intermittent claudication were r and omised to either an upper body strength training programme ( UBST ) , a dynamic ( walking , cycling , circuit ) conventional exercise rehabilitation programme ( CER ) , or advice to ' walk as much as possible at home ' ( CONT ) . Before and after intervention groups performed a st and ard grade d treadmill exercise test ( GTET ) and a 6-minute walk test ( SMWT ) to determine peak physiological parameters and walking distances . Maximal walking distance ( MWD ) , pain-free walking distance ( PFWD ) , peak oxygen uptake ( VO2 ) , heart rate and perceived pain were measured . RESULTS MWD on the GTET increased significantly in the CER group compared with the CONT and UBST groups ( 93.9 + /- 79 % v. 7.0 + /- 19.8 % v. 7.3 + /- 46 % ; CER v. UBST v. CONT p = 0.003 ) . Similarly , peak VO2 increased with CER compared with the CONT and UBST groups ( 28.4 + /- 20 v. -6.2 + /- 15 v. -1.0 + /- 21 % ; CER v. UBST v. CONT p = 0.004 ) . During the SMWT the CER and UBST groups improved in PFWD compared with the CONT group ( 37 + /- 47 % v. 27 + /- 71 % v. -30 + /- 29 % ; CER v. UBST v. CONT p = 0.03 ) , and perceived pain decreased in the CER group compared with the UBST group ( -24 + /- 39 % v. 27 + /- 48 % ; CER v. UBST p = 0.01 ) . CONCLUSION CER improves physiological parameters and walking distances more than UBST does . CER is effective within 6 weeks . Verbal encouragement to exercise is an ineffective form of management OBJECTIVE This study describes the results and functioning of community-based supervised exercise therapy ( SET ) at one year of follow-up . METHODS We conducted a prospect i ve cohort study of community-based SET in regional physiotherapeutic practice s. Consecutive patients with intermittent claudication referred for community-based SET were included . Exclusion criteria for SET were pain at rest or tissue loss . All patients received a diagnostic workup consisting of an ankle-brachial index at rest and after exercise . Interventions were exercise therapy according to the guidelines of the Royal Dutch Society for Physiotherapy . The primary outcome measurement was the increase in absolute claudication distance ( ACD ) , assessed using a st and ardized treadmill protocol by a physiotherapist at baseline and at four , 12 , 26 , and 52 weeks of SET . RESULTS From January 2005 through September 2006 , 349 patients were referred by vascular surgeons for community-based SET . A total of 272 patients with intermittent claudication began the program . Of the 349 initially referred patients , 52 could not perform a st and ard treadmill test but did start community-based SET at a lower level , and 25 patients never started the program . At one year , 129 of the original 272 patients who began community-based SET  ( 47.4 % ) were available for analysis of walking distance . In the interim , 143 patients discontinued the program for the following reasons : satisfaction with the acquired walking distance ( n = 19 ) ; unsatisfying results ( n = 26 ) ; not motivated ( n = 22 ) ; (non)vascular intercurrent disease ( n = 48 ) ; and other reasons ( n = 28 ) . ACD increased significantly from a median of 400 m at baseline to 1100 m after 12 months of follow-up ( P < .001 ) , corresponding to a median increase of 107.8 % . CONCLUSION Community-based SET seems as effective as SET in a hospital-based approach in improving walking distance , however , it has a high dropout rate OBJECTIVES The main aims of treatment in patients with intermittent claudication ( IC ) are to improve the clinical indicators of lower limb ischaemia and patients ' quality of life ( QoL ) . The aims of this study were assess the clinical and cost effectiveness of a supervised exercise programme ( SEP ) in patients with IC . DESIGN Non-r and omised , controlled trial . SETTING University teaching hospital . PATIENTS AND METHODS Two groups of patients with IC were studied . Seventy patients were sequentially recruited before and after the establishment of a Supervised Exercise Programme at our unit . Thirty-seven patients ( median age 69 years , 26 men ) received  conservative medical therapy ( CMT ) and 33 patients ( median age 67 years , 22 men ) received CMT plus a 3 month SEP of graduated physical exercise for sixty minutes , three times each week . Patients were assessed prior to and at 6 months following treatment . At each assessment patient reported walking distances ( PRWD ) , treadmill claudication and maximal distances ( ICD and MWD ) , ankle brachial pressure indices ( ABPI ) pre & post exercise and patient reported QoL using the SF36 question naire were assessed . RESULTS Prior to intervention the two groups were well matched . Following treatment , CMT patients demonstrated no significant change in PRWD or ICD but did record a small but significant improvement in MWD .  CMT was also associated with a negative effect size in the SF36 index and in 7 of the 8 SF36 QoL domains , effect size > -0.5 for the domains of Physical Function and Emotional Role . SEP patients demonstrated significant improvement in PRWD , ICD and MWD . SEP was associated with a positive effect size in the SF36 index and in 2 SF36 QoL domains but a negative effect size in a further 2 domains . However , all QoL effect sizes following SEP were < + /-0.5 . Intergroup differences in effect sizes were > 0.5 for the SF36 domains of Physical Function , Physical Role , Emotion Role and SF36 index . SEP result ed in a 0.027 quality adjusted life year ( QALY ) gain over CMT in the first year post-treatment thus the cost/QALY gained of SEP is pound1780 at 1 year . CONCLUSIONS Compared to CMT , SEP increases walking distances , improves QoL and is a highly cost-effective treatment for IC OBJECTIVE This cohort study was conducted to determine the effect on walking distances of supervised exercise therapy provided in a community-based setting . METHODS The study included all consecutive patients presenting at the vascular outpatient clinic with intermittent claudication , diagnosed by a resting ankle brachial index<0.9 , who had no previous peripheral vascular intervention for peripheral arterial disease , no major amputation , and sufficient comm and of the Dutch language . The exclusion criterion was the inability to walk the baseline treadmill test for a minimum of 10 m. The intervention was a supervised exercise therapy in a community-based setting . A progressive treadmill test at baseline and at 1 , 3 , and 6 months of follow-up measured initial claudication distance and absolute claudication distance . Changes were calculated using the mean percentages of change . RESULTS From January through October 2005 , 93 consecutive patients with claudication were eligible . Overall , 37 patients discontinued the supervised exercise therapy program . Eleven stopped because of intercurrent diseases , whereas for 10 , supervised exercise therapy did not lead to adequate improvement and they underwent a vascular intervention . Three patients quit the program , stating that they were satisfied with the regained walking distance and did not require further supervised exercise therapy . Ten patients were not motivated sufficiently to continue the program , and in three patients , a lack of adequate insurance coverage was the reason for dropping out . Data for 56 patients were used and showed a mean percentage increase in initial claudication distance of 187 % after 3 months and 240 % after 6 months . The mean percentage of the absolute claudication distance increased 142 % after 3 months and 191 % after 6 months . CONCLUSION Supervised exercise therapy in a community-based setting is a promising approach to providing conservative treatment for patients with intermittent claudication BACKGROUND Intermittent claudication is the most common symptom of peripheral arterial disease . Previous research has suggested that extracorporeal shockwave therapy ( ESWT ) may induce angiogenesis in treated tissue . The objective of this feasibility pilot trial was to assess the safety , tolerability , and efficacy of ESWT as a novel treatment . METHODS Patients with unilateral claudication were r and omized to receive ESWT or sham treatment to the calf muscle three times per week for 3 weeks . Primary outcomes were pain-free walking distance ( PFWD ) and maximum walking distance ( MWD ) . Secondary outcomes included safety and tolerability of ESWT treatment , ankle-brachial index before and after exercise , and quality of life assessed using generic ( 36-Item Short Form Health Survey , EuroQol-5 Dimension 3-Level ) and disease-specific ( Vascular Quality of Life ) instruments . Participants were assessed at baseline and 4 , 8 , and 12 weeks after treatment . Feasibility outcomes included recruitment and attendance rates for treatment and follow-up . RESULTS Thirty patients were recruited in total . Statistically significant ( P < .05 ) improvements at all time points were observed in the active treatment group for both MWD and PFWD compared with the sham treatment group . PFWD improved by 276 % in the active group and MWD improved by 167 % in the active group at 12 weeks after treatment . There were no immediate or delayed treatment safety concerns or documented adverse effects of treatment with ESWT in this trial . CONCLUSIONS ESWT is safe and well tolerated when it is applied to the calf and demonstrated significant improvements in walking distances . Current conservative management of intermittent claudication includes supervised exercise . The early results with ESWT as an alternative , noninvasive treatment option show great potential . The mechanism of action , durability of the clinical effect , and cost-effectiveness of ESWT for claudication require further investigation OBJECTIVE Physicians and patients consider the limited walking distance and perceived disability when they make decisions regarding ( invasive ) treatment of intermittent claudication ( IC ) . We investigated the relationship between walking distances estimated by the patient , on the corridor and on a treadmill , and the  Walking Impairment Question naire ( WIQ ) in patients with IC due to peripheral arterial disease . METHODS This was a single-center , prospect i ve observational cohort study at a vascular laboratory in a university hospital in the Netherl and s. The study consisted of 60 patients ( 41 male ) with a median age of 64 years ( range , 44 - 86 years ) with IC and a walking distance ≤ 250 m on a st and ardized treadmill test .  Main outcome measures were differences and Spearman rank correlations between pain-free walking distance , maximum walking distance ( MWD ) estimated by the patient , on the corridor and on a st and ardized treadmill test , and their correlation with the WIQ . RESULTS The median patients ' estimated , corridor , and treadmill MWD were 200 , 200 , and 123 , respectively ( P < .05 ) . Although the median patients ' estimated and corridor MWD were not significantly different , there was a difference on an individual basis . The correlation between the patients ' estimated and corridor MWD was moderate ( r = 0.61 ; 95 % confidence interval [ CI ] , 0.42 - 0.75 ) . The correlation between patients ' estimated and treadmill MWD was weak ( r = 0.39 ; 95 % , CI 0.15 - 0.58 ) . Respective correlations for the pain-free walking distance were comparable . The patients ' estimated MWD was moderately correlated with WIQ total score ( r = 0.63 ; 95 % , CI 0.45 - 0.76 ) and strongly correlated with WIQ distance score ( r = 0.81 ; 95 % CI , 0.69 - 0.88 ) . The correlation between the corridor MWD and WIQ distance score was moderate ( r = 0.59 ; 95 % CI , 0.40 - 0.74 ) . CONCLUSIONS Patients ' estimated walking distances and on a treadmill do not reflect walking distances in daily life . Instruments that take into account the perceived walking impairment , such as the WIQ , may help to better guide and evaluate treatment decisions Abstract Purpose : The aim of the study was to compare the efficacy of Nordic pole walking ( NPW ) training with traditional treadmill training ( TT ) on a claudication ( CD ) and maximum walking distance ( MWD ) in patients with peripheral arterial disease ( PAD ) . Method : Patients with intermittent claudication ( IC ) ( n = 70 ; age=68.27 ) in the Fontaine class II were r and omized into a two three-month rehabilitation programs performed three times per week . TT were finished by 31 patients , NPW by 21 . Walking capacity was measured by an  exercise treadmill test ( ETT ) with the Gardner – Skinner protocol ( before and after the program ) and  six minute walk test ( 6MWT ) ( before , during and after the program ) . Results : In an ETT both groups reached significant increase in CD and MWD ( p ≤ 0.005 ) . In 6MWT NPW group reached significant increase in both CD ( p = 0.001 ) and MWD ( p = 0.001 ) , whereas the TT group only in MWD ( p = 0.001 ) . Conclusions : NPW has been shown to be as effective as the st and ard TT and is much less expensive . It should be the preferred method of exercise for PAD patients with IC . Implication s for Rehabilitation Nordic walking training is a valuable form of rehabilitation for peripheral arterial disease ( PAD ) patients with intermittent claudication ( IC ) . Nordic walking has been shown to be as efficient as traditional treadmill training . It is however more cost-effective method of rehabilitation in PAD patients OBJECTIVE To determine the effects of 12-week exercise programme on ambulatory function , free-living daily physical activity and health-related quality of life in disabled older patients with intermittent claudication . DESIGN Prospect i ve , r and omized controlled trial . SETTING University Medical Center and Veterans Affairs Medical Center , Taipei , Taiwan . SUBJECTS Thirty-two of 64 patients with Fontaine stage II peripheral arterial occlusive disease ( PAOD ) were r and omized to exercise training and 32 to usual care control .  Five patients from the exercise group and six patients from the control group dropped out , leaving 27 and 26 patients , respectively , completing the study in each group . INTERVENTIONS Twelve weeks of treadmill exercise training . MAIN OUTCOME MEASURES Treadmill walking time to onset of claudication pain and to maximal claudication pain , 6-min walk distance , self-reported ambulatory ability and perceived health-related quality of life ( QOL ) . RESULTS Compliance of exercise programme was 83 % of the possible sessions . Exercise training increased treadmill walking time to onset of claudication pain by 88 % ( P < 0.001 ) , time to maximal pain by 70 % ( P < 0.001 ) , and 6-min walk distance by 21 % ( P < 0.001 ) . SUBJECTS Perception of health-related QOL improved from 12 % to 178 % in the exercise group . These improvements were significantly better than the changes in the control group ( P < 0.05 ) . CONCLUSIONS Significant improvements in claudication following 12-week exercise training in elderly PAOD patients were observed . Increase in treadmill walking time to maximal claudication pain in these patients translated into the improvement of perceived physical health , which enabled the patients to become more functionally independent OBJECTIVE To determine the effects of a 6-month exercise program on ambulatory function , free-living daily physical activity , peripheral circulation , and health-related quality of life ( QOL ) in disabled older patients with intermittent claudication . DESIGN Prospect i ve , r and omized controlled trial . SETTING University Medical ( Center and Veterans Affairs Medical Center , Baltimore , Maryl and . PARTICIPANTS Thirty-one of 61 patients with Fontaine stage II peripheral arterial occlusive disease ( PAOD ) were r and omized to  exercise rehabilitation and 30 to  usual-care control . Three patients from the exercise group and six patients from the control group dropped out , leaving 28 and 24 patients , respectively , completing the study in each group . INTERVENTION Six months of exercise rehabilitation . MEASUREMENTS Treadmill distance walked to onset of claudication and to maximal claudication , ambulatory function , peripheral circulation , perceived QOL , and daily physical activity . RESULTS Compliance with the exercise program was 73 % of the possible sessions . Exercise rehabilitation increased treadmill distance walked to onset of claudication by 134 % ( P < .001 ) and to maximal claudication by 77 % ( P < .001 ) , walking economy by 12 % ( P = .003 ) , 6-minute walk distance by 12 % ( P < .001 ) , and maximal calf blood flow by 30 % ( P < .001 ) . Changes in distance walked to maximal pain correlated with changes in walking economy ( r = -.50 , P = .013 ) and changes in maximal calf blood flow ( r = .38 , P = .047 ) . Exercise rehabilitation increased accelerometer-derived daily physical activity by 38 % ( P < .001 ) ; this change correlated with the change in distance walked to maximal pain ( r = .45 , P = .020 ) . These improvements were significantly better than the changes in the control group ( P < .05 ) . CONCLUSION Improvements in claudication following exercise rehabilitation in older PAOD patients are dependent on improvements in peripheral circulation and walking economy . Improvement in treadmill claudication distances in these patients translated into increased accelerometer-derived physical activity in the community , which enabled the patients to become more functionally independent CONTEXT Neither supervised treadmill exercise nor strength training for patients with peripheral arterial disease ( PAD ) without intermittent claudication have been established as beneficial . OBJECTIVE To determine whether supervised treadmill exercise or lower extremity resistance training improve functional performance of patients with PAD with or without claudication . DESIGN , SETTING , AND PARTICIPANTS R and omized controlled clinical trial performed at an urban academic medical center between April 1 , 2004 , and August 8 , 2008 , involving 156 patients with PAD who were r and omly assigned to supervised treadmill exercise , to lower extremity resistance training , or to a control group .  MAIN OUTCOME MEASURES Six-minute walk performance and the short physical performance battery . Secondary outcomes were brachial artery flow-mediated dilation , treadmill walking performance , the Walking Impairment Question naire , and the 36-Item Short Form Health Survey physical functioning ( SF-36 PF ) score . RESULTS For the 6-minute walk , those in the supervised treadmill exercise group increased their distance walked by 35.9 m ( 95 % confidence interval [ CI ] , 15.3 - 56.5 m ; P < .001 ) compared with the control group , whereas those in the resistance training group increased their distance walked by 12.4 m ( 95 % CI , -8.42 to 33.3 m ; P = .24 ) compared with the control group . Neither exercise group improved its short physical performance battery scores . For brachial artery flow-mediated dilation , those in the treadmill group had a mean improvement of 1.53 % ( 95 % CI , 0.35%-2.70 % ; P = .02 ) compared with the control group . The treadmill group had greater increases in maximal treadmill walking time ( 3.44 minutes ; 95 % CI , 2.05 - 4.84 minutes ; P < .001 ) ; walking impairment distance score ( 10.7 ; 95 % CI , 1.56 - 19.9 ; P = .02 ) ; and SF-36 PF score ( 7.5 ; 95 % CI , 0.00 - 15.0 ; P = .02 ) than the control group . The resistance training group had greater increases in maximal treadmill walking time ( 1.90 minutes ; 95 % CI , 0.49 - 3.31 minutes ; P = .009 ) ; walking impairment scores for distance ( 6.92 ; 95 % CI , 1.07 - 12.8 ; P = .02 ) and stair climbing ( 10.4 ; 95 % CI , 0.00 - 20.8 ; P = .03 ) ; and SF-36 PF score ( 7.5 ; 95 % CI , 0.0 - 15.0 ; P = .04 ) than the control group . CONCLUSIONS Supervised treadmill training improved 6-minute walk performance , treadmill walking performance , brachial artery flow-mediated dilation , and quality of life but did not improve the short physical performance battery scores of PAD participants with and without intermittent claudication .  Lower extremity resistance training improved functional performance measured by treadmill walking , quality of life , and stair climbing ability . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00106327 BACKGROUND Disease severity in patients with intermittent claudication ( IC ) is often assessed using walking distances and treadmill tests . The aim of this study was to determine the agreement between walking distance as estimated by the patient , as measured during outside walking , and as determined using a non grade d treadmill protocol ( NGTP ) , and an incremental grade d ( Gardner-Skinner ) treadmill protocol ( GSP ) . METHODS In this prospect i ve observational study , 30 patients with IC estimated their maximal walking distance ( MWD ) and completed a  " Walking Impairment Question naire " ( WIQ ) .  Outside walking was determined using a measuring wheel and a GSP controlled device . Primary outcomes were differences in MWD and variability ( coefficient of variation , COV ) . Secondary outcomes were results of WIQ and differences in walking speed . RESULTS Estimated walking distance was significantly higher than MWD as objective ly measured during outside walking ( 400 m vs. 309 m , respectively , P = 0.02 ) . A substantial variability ( COV = 55 % ) was found between both parameters . A small 35-m MWD difference between outside walking and GSP was found with a substantial scatter ( COV = 42 % ) . In contrast , a much larger 122-m MWD difference was present between outside walking and NGTP ( COV = 89 % ) . Patients walked significantly faster in the open air than on treadmills ( median outside walking speed = 3.8 km/hr , GSP = 3.2 km/hr , NGTP = 2.8 km/hr ; P < 0.001 ) . CONCLUSIONS An incremental grade d ( Gardner-Skinner ) treadmill protocol demonstrated the best agreement to outside walking . Discrepancies between treadmill tests and outside walking may be explained by a difference in walking speed . A single determination of a walking distance is a poor reflection of true walking capacity OBJECTIVE To analyze the effects of strength training ( ST ) in walking capacity in patients with intermittent claudication ( IC ) compared with walking training ( WT ) effects . METHODS Thirty patients with IC were r and omized into ST and WT . Both groups trained twice a week for 12 weeks at the same rate of perceived exertion . ST consisted of three sets of 10 repetitions of whole body exercises . WT consisted of 15 bouts of 2-minute walking . Before and after the training program walking capacity , peak VO(2 ) , VO(2 ) at the first stage of treadmill test , ankle brachial index , ischemic window , and knee extension strength were measured . RESULTS ST improved initial claudication distance ( 358 + /- 224 vs 504 + /- 276 meters ; P < .01 ) , total walking distance ( 618 + /- 282 to 775 + /- 334 meters ; P < .01 ) , VO(2 ) at the first stage of treadmill test ( 9.7 + /- 2.6 vs 8.1 + /- 1.7 mL.kg(-1).minute ; P < .01 ) , ischemic window ( 0.81 + /- 1.16 vs 0.43 + /- 0.47 mm Hg minute meters(-1 ) ; P = .04 ) , and knee extension strength ( 19 + /- 9 vs 21 + /- 8 kg and 21 + /- 9 vs 23 + /- 9 ; P < .01 ) . Strength increases correlated with the increase in initial claudication distance ( r = 0.64 ; P = .01 ) and with the decrease in VO(2 ) measured at the first stage of the treadmill test ( r = -0.52 ; P = .04 and r = -0.55 ; P = .03 ) . Adaptations following ST were similar to the ones observed after WT ; however , patients reported lower pain during ST than WT ( P < .01 ) . CONCLUSION ST improves functional limitation similarly to WT but it produces lower pain , suggesting that this type of exercise could be useful and should be considered in patients with IC
The HBET group did not show improvement in MWD/T compared with the WA group ( SMD 0.30 , 95 % CI -0.45 to 1.05 ; P = 0.43 ; moderate- quality evidence ) .Compared with HBET , SET was more beneficial for PFWD/T but had no effect on quality of life parameters nor on self-reported functional impairment .
Compared with WA , SET was more beneficial for PFWD/T and self-reported functional impairment , as well as for some quality of life parameters ( e.g. , physical functioning , pain , and physical component summary after 12 months ) , and HBET had no effect .
Data show no obvious effects on mortality rates .
Evidence of moderate and high quality shows that SET provides an important benefit for treadmill-measured walking distance ( MWD and PFWD ) compared with HBET and WA , respectively .
Although its clinical relevance has not been definitively demonstrated , this benefit translates to increased MWD of 120 and 210 meters after three months in SET groups .
These increased walking distances are likely to have a positive impact on the lives of patients with IC .
Data provide no clear evidence of a difference between HBET and WA .
Trials show no clear differences in quality of life parameters nor in self-reported functional impairment between SET and HBET .
BACKGROUND Although supervised exercise therapy ( SET ) provides significant symptomatic benefit for patients with intermittent claudication ( IC ) , it remains an underutilized tool .
Widespread implementation of SET is restricted by lack of facilities and funding .
Structured home-based exercise therapy ( HBET ) with an observation component ( e.g. , exercise logbooks , pedometers ) and just walking advice ( WA ) are alternatives to SET .
This is the second up date of a review first published in 2006 .
OBJECTIVES The primary objective was to provide an accurate overview of studies evaluating effects of SET programs , HBET programs , and WA on maximal treadmill walking distance or time ( MWD/T ) for patients with IC .
Secondary objectives were to evaluate effects of SET , HBET , and WA on pain-free treadmill walking distance or time ( PFWD/T ) , quality of life , and self-reported functional impairment .