Concurrent Training on Patients With Type-II DM Associated PAD.

This clinical trial aims to analyze the effects of concurrent vs aerobic training on glycemic control, ABI, functional capacity and disease-specific QOL among patients with Type-II DM-associated PAD at baseline \& after 12 weeks of intervention. The main questions it aims to answer are:

1. Is concurrent training more effective than aerobic training in improving glycemic control among patients with Type-II DM-associated PAD?
2. Is concurrent training more effective than aerobic training in improving ABI among patients with Type-II DM-associated PAD?
3. Is concurrent training more effective than aerobic training in enhancing functional capacity among patients with Type-II DM-associated PAD?
4. Is concurrent training more effective than aerobic training in improving QOL among patients with Type-II DM-associated PAD? Signed informed consent will be taken before participation. For exercise training, Both will perform Warm up for 10 - 12 minutes, followed by 30 - 60 minutes of training protocol and then Cool down exercises for 10 - 12 minutes. Group A will perform concurrent training, whereas Group B will perform aerobic training.

DATA COLLECTION PROCEDURE;

Eighty patients will be referred from the OPD of Dr. Ziauddin Hospital Karachi, Pakistan. Signed informed consent will be obtained before participation. In the screening session, PAD by Fontaine's stage IIa, ABI (\<0.9), and an international Physical activity questionnaire (IPAQ) to assess sedentary behaviour will be collected. For IPAQ interpretation, \<600 MET Minutes will be considered category 1 (Lowest level of physical activity). In the next session, baseline measurements of all participants will be collected and documented, including HbA1C, ABI at rest, Functional Capacity, and QOL.

Moreover, Target heart rate (THR) and 1RM will be calculated for appropriate exercise intensity and BMI. Further, All patients will be randomly allocated into two groups. Group A (n=40) will perform concurrent training, whereas Group B will perform aerobic training (n=40). All patients will receive a brief explanation and demonstration of the exercise session during the familiarisation. Patients will perform 3 sessions weekly to improve their capability to do exercises and develop the exercise capacity needed to begin at the intensity of their allocated training protocol. Both groups will perform warm-up exercises for 10 - 12 minutes during the training session, followed by training protocol and then cool-down exercises for 10 - 12 minutes. Group A will perform concurrent training for 30 to 60 minutes, whereas Group B will perform aerobic training for 30 - 60 minutes. Both groups will perform warm-up and cool-down exercises for 10 - 12 minutes, including 5 minutes of static cycling followed by 5 reps. of static stretching of the hamstring, quadriceps, and calf muscles on each limb with the 10-second hold of each stretch (ACSM, 2018). During the intervention period, patients will be assessed for Heart rate, blood pressure, and random blood sugar before and after each session for 12 weeks duration, and perceived exertion status will be used during exercise for analyzing the exercise intensity.

Group A (Concurrent Training):

Concurrent training combines aerobic and resistance training within the same session. Patients in this group will perform aerobic exercises and resistance training for 30 - 60 minutes, comprising 3 sessions per week for 12 weeks under the supervision of a physical therapist. Aerobic training will be performed on a treadmill at an intensity of 40 - 60 % THR for 15 - 40 minutes, followed by resistance training using an elastic resistance band at 60 - 80% of 1 RM, following appropriate rest intervals. The patient will perform lower limb resistance exercises, including Quadriceps extension, leg curls, calf raises \& toe raises.

Group B (Aerobic Training):

Patients in this group will perform aerobic exercise for 12 weeks. All Patients will be assessed for HR, BP and RBS before and after each session. Patients in this group will perform aerobic exercises for 30 - 60 minutes, comprising 3 sessions per week for 12 weeks under the supervision of a physical therapist. Aerobic training will be performed on a treadmill at an intensity of 40 - 60 % THR.

After 12 weeks of intervention, all patients will be assessed for HbA1C, ABI, functional capacity, and QOL and documented for further data analysis.

SPECIAL CONSIDERATION FOR EXERCISE

* Educate the patient about the signs and symptoms of hypoglycemia.
* Hypoglycemia manifestations (particularly tachycardia) may mask due to Β-Blockers.
* Blood glucose level monitoring (before and after exercise).
* Carbohydrate intake (up to 15 g before exercise participation) to prevent hypoglycemia \*when starting RBS ≤100 mg/dL.
* Avoid head-down activities and the Valsalva manoeuvre.
* For peripheral neuropathy, closely examine feet regularly to detect sores or ulcers and incorporate proper foot care (dry feet, silica gel or air midsoles \& polyester socks).

EXERCISE TERMINATION CRITERIA The exercise will be terminated if the patient reports any following symptoms during exercise.

* The onset of Chest pain
* Shortness of breath (Borg's scale \>15)
* Hemodynamic imbalance during exercise is caused by limited perfusion (Pale appearance, cool skin, Diaphoresis (sweating), Physical exertion, altered pulse) and Low blood pressure (very late sign)
* On the patient's request to stop exercise
* Ischemic limb pain that is not alleviated after 10 minutes

Eligibility Criteria:
Inclusion Criteria:

* Age: 40 - 50 years
* Type-II DM
* Duration of DM: \> 10 years
* Baseline HbA1C (\> 6.6%)
* Intermittent claudication corresponding to Fontaine Stage IIa
* PAD by an ABI scale; \< 0.9 at rest
* Had \< 160 mmHg SBP and \< 105 mmHg DBP
* Sedentary lifestyle by IPAQ-SF

Exclusion Criteria:

* Smokers
* Insulin dependent individuals
* Patients with Complicated cardiovascular disease that might limit their ability to - participate in the intervention period physically (e.g. unstable cardiopulmonary symptoms, ischemic heart failure, or chronic kidney disease) and cancer
* Any major surgery or revascularization procedure within the previous 1 year
* In case of a history of severe arthritis that may limit exercise performance
* Diabetic foot (ulceration or gangrene)
* Patients with stroke
* BMI = \>30 classified by WHO-Asian as obesity class II
* Unable to follow the intervention protocol or visit three times per week for exercise
* Participation in any clinical trial during the past six months
* Revocation to consent