Recommendations for Structured Exercise Therapy
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
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
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
		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
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