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Therapeutics

Review: A long-term walking program is the optimal exercise for increasing endurance in claudication pain

ACP J Club. 1996 Mar-April;124:37. doi:10.7326/ACPJC-1996-124-2-037


Source Citation

Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995 Sep 27;274: 975-80. [PubMed ID: 7674529]


Abstract

Objective

To identify the exercise components of rehabilitation programs that provide optimal alleviation of claudication pain symptoms in peripheral arterial disease.

Data Sources

Studies of exercise rehabilitation programs for patients with claudication pain were identified in MEDLINE (1966 to 1993) and in bibliographies of review articles, textbooks, and published studies.

Study Selection

Studies were selected if claudication pain was assessed with a treadmill test before and after an exercise program. The exclusion criterion was the absence of reported mean or individual times or distances walked to the onset of claudication pain or to near-maximal claudication pain.

Data Extraction

Data were extracted on patient characteristics; rehabilitation program (duration of exercise sessions, length of program, weekly frequencies, mode of exercise, and level of supervision); endpoint assessment (onset and near-maximal pain); and treadmill speed, grade, and intensity.

Main Results

33 studies were identified, and 21 met the inclusion criteria (3 randomized controlled trials [RCTs]); 571 patients were studied. Patients exercised to onset or slightly beyond onset of pain in 15 studies and to near-maximal pain in 6 studies. 6 studies used only walking as the exercise program; 15 studies used a combination of exercises and sports. 7 studies had < 3 training sessions/wk; 11 studies had ≥ 3 sessions/wk. Exercise sessions lasted ≤ 30 min in 8 studies and > 30 min in 6 studies; 7 studies did not report duration. In 10 studies, the exercise program lasted < 6 months. In the non-RCT studies, exercise rehabilitation increased the mean distance to onset of claudication pain from 126 to 351 meters (P < 0.001) and increased the distance to near-maximal pain from 326 to 723 meters (P < 0.001). In the RCTs, the increase in distance to onset of pain was 107 meters greater (P = 0.02) and the increase in distance to maximal pain was 256 meters greater (P = 0.02) in the study groups compared with the control groups. Analysis of the components of the exercise programs showed that changes in distance both to onset of pain and to near-maximal pain were associated with exercise duration > 30 min/session, programs with ≥ 3 sessions/wk, program duration ≥ 6 months, and programs in which walking was the main exercise (P < 0.05 for each comparison).

Conclusions

The distances walked to onset of pain and to near-maximal pain increase after a program of exercise rehabilitation. The optimal program to increase the distances has individual sessions longer than 30 minutes, has 3 or more sessions/wk, lasts longer than 6 months, and has walking as the major component of the program.

Source of funding: Not stated.

For article reprint: Dr. A.W. Gardner, Baltimore Veterans Affairs Medical Center, Geriatrics Service/GRECC (18), 10 North Greene Street, Baltimore, MD 21201-1524, USA. FAX 410-605-7913.


Commentary

Intermittent claudication has an estimated prevalence of 4.5% in adults aged 55 to 74 years (1), and each year, approximately 1% of these patients require an amputation (2). Treatment for claudication should offer the maximal improvement in walking and the lowest risk. Exercise therapy has almost no risk. In their meta-analysis, Gardner and Poehlman convincingly show that exercise programs can double walking distance.

Angioplasty or arterial surgery are seldom appropriate for patients with mild-to-moderate claudication. Creasy and colleagues (3) randomly allocated patients with stable claudication to transluminal angioplasty or to an exercise program. The authors showed that angioplasty produced improvement in ankle brachial pressure indexes, whereas exercise did not. The functional outcome, however, was better in patients who received exercise therapy.

Why are exercise programs seldom provided for patients with intermittent claudication? It appears that most vascular surgeons do not view exercise programs as a medical treatment similar in importance to angioplasty or arterial bypass surgery. Advising patients to do more exercise simply does not seem to be good enough.

Does the site of the arterial stenosis affect the outcome? Recent work in Oxford suggests that exercise programs are more effective than angioplasty for treating atherosclerosis of the superficial femoral artery, but angioplasty is better for treating iliac artery stenosis. Given the current number of superficial femoral artery angioplasties, a definitive answer is required.

Jack Collin, MD
Nuffield Department of SurgeryOxford, England, UK


References

1. Fowkes FG, Housley E, Cawood EH, et al. Edinburgh Artery Study: prevalence of asymptomatic and symptomatic peripheral arterial disease in the general population. Int J Epidemiol. 1991;20:384-92.

2. Dormandy JA, Murray GD. The fate of the claudicant—a prospective study of 1969 claudicants. Eur J Vasc Surg. 1991;5:131-3.

3. Creasy TS, McMillan PJ, Fletcher EW, Collin J, Morris PJ. Is percutaneous transluminal angioplasty better than exercise for claudication? Preliminary results from a prospective randomised trial. Eur J Vasc Surg. 1990;4:135-40.