In the Journals

Panel identifies effective exercise programs for PAD

Supervised treadmill exercise therapy has the most evidence for effectiveness in patients with peripheral artery disease, but several other forms of exercise also appear to benefit this population, according to an American Heart Association scientific statement.

The panel also identified home-based walking exercise, arm ergonometry, leg cycling and resistance training as other methods that might improve walking performance and quality of life in patients with PAD.

As Cardiology Today’s Intervention previously reported, a 2016 AHA/American College of Cardiology guideline strongly recommended supervised exercise treadmill training to improve functional outcomes, and in 2017, CMS issued a national coverage decision in favor of supervised exercise therapy for patients with PAD.

Diane Treat-Jacobson, PhD, RN, FAHA, professor and associate dean for research at the University of Minnesota School of Nursing and chair of the writing committee, and colleagues reviewed the literature on exercise therapy for PAD to determine which methods are supported by evidence and what knowledge gaps remain.

Supervised programs beneficial

In the past 30 years, according to the panel, treadmill-based supervised exercise programs “have been shown to be consistently beneficial in improving walking ability as assessed by graded treadmill testing and to be effective in patients with PAD both with and without classic symptoms of claudication.”

The evidence suggests that “exercise sessions should progress up to a target goal of accumulating 30 to 45 minutes of treadmill walking per session” and “exercise should be carried out at an intensity that elicits mild claudication pain within 5 minutes and moderate to moderately severe claudication within 10 minutes followed by rest until claudication pain subsides,” the authors wrote.

A number of studies have compared supervised exercise therapy with revascularization, and the evidence suggests that both “improve functional outcomes in patients with aortoiliac and femoropopliteal arterial occlusive disease and claudication and that their effects appear to be additive,” Treat-Jacobson and colleagues wrote.

Alternative regimens

Most studies of structured home-based exercise interventions have found them to benefit patients with PAD, especially if occasional visits to meet with a coach are included, the panel wrote.

Advantages ... include that it is less burdensome and more convenient for people with PAD to walk in their neighborhood or even within their home environment than to travel to a supervised exercise center,” the authors wrote. “In addition, [home-based exercise] preferentially improves over-ground walking, which is more practical for navigating walking activity in daily life.”

Studies of pain-free treadmill training programs indicate they “improve walking ability in patients with claudication and that this improvement was similar to that seen with training that requires patients to walk to moderate claudication pain. Pain-free treadmill exercise might be more palatable to some patients for whom walking to pain is less well-tolerated, which could result in greater compliance with a walking program and better patient outcomes,” according to the authors.

Leg cycling exercise training appears to benefit some patients with PAD, although evidence that it may be preferable to other forms of exercise is lacking, they wrote.

There is evidence that arm cycling exercise training improves walking ability in PAD, possibly due to improved endothelial or cardiorespiratory function.

Studies of resistance training have shown “mixed results,” the panel wrote.

“Future studies should focus on identifying optimal exercise programs for patients with PAD and delineating biological pathways by which exercise improves walking performance in PAD,” Treat-Jacobson and colleagues wrote. “Given the magnitude of benefits and relative safety of exercise for patients with PAD, efforts should be made to make exercise accessible to all patients with PAD who are able to exercise.” – by Erik Swain

Disclosures: Treat-Jacobson reports no relevant financial disclosures. Please see the statement for all other authors’ relevant financial disclosures.

Supervised treadmill exercise therapy has the most evidence for effectiveness in patients with peripheral artery disease, but several other forms of exercise also appear to benefit this population, according to an American Heart Association scientific statement.

The panel also identified home-based walking exercise, arm ergonometry, leg cycling and resistance training as other methods that might improve walking performance and quality of life in patients with PAD.

As Cardiology Today’s Intervention previously reported, a 2016 AHA/American College of Cardiology guideline strongly recommended supervised exercise treadmill training to improve functional outcomes, and in 2017, CMS issued a national coverage decision in favor of supervised exercise therapy for patients with PAD.

Diane Treat-Jacobson, PhD, RN, FAHA, professor and associate dean for research at the University of Minnesota School of Nursing and chair of the writing committee, and colleagues reviewed the literature on exercise therapy for PAD to determine which methods are supported by evidence and what knowledge gaps remain.

Supervised programs beneficial

In the past 30 years, according to the panel, treadmill-based supervised exercise programs “have been shown to be consistently beneficial in improving walking ability as assessed by graded treadmill testing and to be effective in patients with PAD both with and without classic symptoms of claudication.”

The evidence suggests that “exercise sessions should progress up to a target goal of accumulating 30 to 45 minutes of treadmill walking per session” and “exercise should be carried out at an intensity that elicits mild claudication pain within 5 minutes and moderate to moderately severe claudication within 10 minutes followed by rest until claudication pain subsides,” the authors wrote.

A number of studies have compared supervised exercise therapy with revascularization, and the evidence suggests that both “improve functional outcomes in patients with aortoiliac and femoropopliteal arterial occlusive disease and claudication and that their effects appear to be additive,” Treat-Jacobson and colleagues wrote.

Alternative regimens

Most studies of structured home-based exercise interventions have found them to benefit patients with PAD, especially if occasional visits to meet with a coach are included, the panel wrote.

Advantages ... include that it is less burdensome and more convenient for people with PAD to walk in their neighborhood or even within their home environment than to travel to a supervised exercise center,” the authors wrote. “In addition, [home-based exercise] preferentially improves over-ground walking, which is more practical for navigating walking activity in daily life.”

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Studies of pain-free treadmill training programs indicate they “improve walking ability in patients with claudication and that this improvement was similar to that seen with training that requires patients to walk to moderate claudication pain. Pain-free treadmill exercise might be more palatable to some patients for whom walking to pain is less well-tolerated, which could result in greater compliance with a walking program and better patient outcomes,” according to the authors.

Leg cycling exercise training appears to benefit some patients with PAD, although evidence that it may be preferable to other forms of exercise is lacking, they wrote.

There is evidence that arm cycling exercise training improves walking ability in PAD, possibly due to improved endothelial or cardiorespiratory function.

Studies of resistance training have shown “mixed results,” the panel wrote.

“Future studies should focus on identifying optimal exercise programs for patients with PAD and delineating biological pathways by which exercise improves walking performance in PAD,” Treat-Jacobson and colleagues wrote. “Given the magnitude of benefits and relative safety of exercise for patients with PAD, efforts should be made to make exercise accessible to all patients with PAD who are able to exercise.” – by Erik Swain

Disclosures: Treat-Jacobson reports no relevant financial disclosures. Please see the statement for all other authors’ relevant financial disclosures.