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Recommendations for
Structured Exercise Therapy |
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COR |
LOE |
Recommendations |
|
I |
A |
In patients with claudication, a
supervised exercise program is recommended to improve functional
status and QoL and to reduce leg symptoms.36–38,40–46,48,210,211
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See Online Data Supplement
32. |
The data supporting the efficacy of
supervised exercise training as an initial treatment for claudication
continue to develop and remain convincing, building on many earlier
RCTs.40–46,48,210,211 Trials with long-term follow-up
from 18 months37,38 to 7 years36 have demonstrated a
persistent benefit of supervised exercise in patients with claudication.
Data also support a benefit of supervised exercise for patients with
symptomatic PAD and diabetes mellitus.212 The risk–benefit ratio
for supervised exercise in PAD is favorable, with an excellent safety
profile in patients screened for absolute contraindications to exercise
such as exercise-limiting cardiovascular disease, amputation or
wheelchair confinement, and other major comorbidities that would
preclude exercise.36,39,49,213–216 Despite the health benefits associated with
supervised exercise in patients with PAD, initiating and maintaining a
high level of adherence remain challenging. Frequent contact with
patients both when performing exercise in the supervised setting and at
home has been somewhat effective in promoting retention.37,38
|
|
I |
B-R |
A supervised exercise program should
be discussed as a treatment option for claudication before possible
revascularization.36–38
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See Online Data Supplement
32. |
The CLEVER (Claudication: Exercise Versus
Endoluminal Revascularization) trial randomized patients with
symptomatic aortoiliac PAD and showed comparable benefits for supervised
exercise and stent revascularization at 6 and 18 months, with each
therapy being superior to optimal medical care.37,38 Overall, the safety profile for supervised
exercise was excellent. An RCT that compared 7-year effectiveness of
supervised exercise or endovascular revascularization in patients with
stable claudication with iliac or femoropopliteal disease found no
differences in improved walking and QoL outcomes.36 Although more secondary
interventions occurred in the exercise group, the total number of
interventions was greater in the endovascular revascularization group.
Collectively, these studies provide strong support for offering patients
a supervised exercise program for reducing claudication symptoms and for
improving functional status and QoL. |
|
A 3-month RCT that compared percutaneous
transluminal angioplasty (PTA), supervised exercise, and combined
treatment for claudication found that both supervised exercise and PTA
improved clinical and QoL outcomes, whereas PTA plus supervised exercise
produced greater benefits than either therapy alone.217 The ERASE
(Endovascular Revascularization and Supervised Exercise) study
randomized participants with claudication to endovascular
revascularization plus supervised exercise or supervised exercise alone.
After 1 year, patients in both groups had significant improvements in
walking distances and health-related QoL, with greater improvements in
the combined-therapy group.218 Collectively, these studies support the
continued provision of supervised exercise to patients with
claudication, whether as a monotherapy or combined with
revascularization. |
|
IIa |
A |
In patients with PAD, a structured
community- or home-based exercise program with behavioral change
techniques can be beneficial to improve walking ability and
functional status.49,88,94,213
|
|
See Online Data Supplement
32. |
Unstructured community-based or home-based
walking programs that consist of providing general recommendations to
patients with claudication to simply walk more are not
efficacious.50
Studies supporting structured community- or home-based programs for
patients with symptomatic PAD (claudication and/or leg symptoms atypical
for claudication) are more recent than studies supporting supervised
exercise programs, and have provided strong evidence in support of the
community- or home-based approach.47,49,51,88,94,213 For
example, the GOALS (Group Oriented Arterial Leg Study) trial94 included patients with
confirmed PAD with and without claudication (atypical lower extremity
symptoms or no symptoms) and showed increases in several parameters of
functional status for both of these patient cohort subgroups, versus
nonexercising controls, after 6 months,88 with improvement maintained at
12 months.94
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|
As with supervised exercise programs,
despite proven benefit, initiating and maintaining a high level of
adherence to community- or home-based exercise programs remains
challenging. Studies that have incorporated behavioral change
techniques, such as health coaching and activity tracking used in
supervised settings, appear to reduce attrition and promote higher
levels of adherence, thereby improving functional and QoL outcomes, both
short term and long term.49,88,94
|
|
IIa |
A |
In patients with claudication,
alternative strategies of exercise therapy, including upper-body
ergometry, cycling, and pain-free or low-intensity walking that
avoids moderate-to-maximum claudication while walking, can be
beneficial to improve walking ability and functional
status.39,215,219,220
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|
See Online Data Supplements 32 and
33. |
Protocols for exercise therapy for PAD
traditionally have recommended intermittent walking bouts to moderate or
higher pain levels interspersed with short periods of rest. Although
these protocols are efficacious, intolerance of pain may lead to poor
exercise adherence. An increasing number of studies have shown that
modalities of exercise that avoid claudication or walking performed at
intensities that are pain free or produce only mild levels of
claudication can achieve health benefits comparable to walking at
moderate or higher levels of claudication pain.39,41,215,219–221
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