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Schmid R, Witzenhausen M, Engelhardt M, Palm HG, Beltzer C, Dallacker-Losensky K, Friemert B, Lang P. Improved gait parameters following surgical revascularization in patients with intermittent claudication. J Vasc Surg Cases Innov Tech 2024; 10:101466. [PMID: 38591017 PMCID: PMC11000169 DOI: 10.1016/j.jvscit.2024.101466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/21/2024] [Indexed: 04/10/2024] Open
Abstract
Objective Intermittent claudication (IC) is known to be associated with impaired gait parameters, with a higher incidence of falls and higher oxygen consumption due to uneconomic walking. However, the influence of arterial disobliteration in patients with IC on their gait pattern has rarely been investigated to date. The aim of this study was to examine the gait patterns before and after inflow revascularization by surgical disobliteration of pelvic and inguinal arteries (ie, common iliac artery, external iliac artery, common femoral artery, profound femoral artery, superficial femoral artery) in IC patients. Successful surgical disobliteration of inflow arteries (improvement of ankle brachial pressure index of ≥0.2 and patent common iliac, external iliac, common femoral, profound femoral, and superficial femoral arteries) is known to improve the painless walking distance for patients with IC due to peripheral arterial disease; however, its influence on gait parameters is unclear. We hypothesized that the gait parameters would also improve after surgery. Improved gait parameters can lead to a more economic walking process, lower oxygen consumption, a lower risk of falls, and a higher quality of life. Methods In a single-center, exploratory, longitudinal study, we examined the gait parameters of 20 IC inpatients of our hospital before and after surgical disobliteration of pelvic and inguinal arteries. Spatiotemporal parameters such as range of motion of the hip and knee joint, stance phase, cadence, and foot rotation were obtained using the Diers 4Dmotion Lab (Diers International). The gait parameters were obtained under painful walking conditions preoperatively and with the patients walking pain free at the same speed postoperatively. Results A total of 20 patients were examined. Surgical revascularization led to a higher walking cadence (mean, plus 7.88 steps; 95.5 steps/min vs 87.6 steps/min; P = .024), an increased range of motion of the hip joint (mean, plus 2.0°; 35.1° vs 33.1°; P = .038), and improved foot rotation (mean, plus 2.0°; 11.0° vs 9.0°; P = .02). Regarding other parameters such as step length, stance phase, and step duration, smaller differences were detected in this study. Conclusions In this exploratory study, we found that surgical revascularization of pelvic and inguinal arteries in IC patients improved certain gait parameters. Further studies with larger patient numbers are needed to confirm these data and provide more evidence on this subject.
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Affiliation(s)
- Robert Schmid
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Moritz Witzenhausen
- Klinik für Unfallchirurgie und Orthopädie, Septische und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Michael Engelhardt
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Hans-Georg Palm
- Zentrum für Orthopädie und Unfallchirurgie, Klinikum Ingolstadt, Ingolstadt, Germany
| | - Christian Beltzer
- Klinik für Allgemein-, Viszeral- und Thoraxchirurgie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Kevin Dallacker-Losensky
- Klinik für Unfallchirurgie und Orthopädie, Septische und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Benedikt Friemert
- Klinik für Unfallchirurgie und Orthopädie, Septische und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Germany
| | - Patricia Lang
- Zentrum für Integrative Rehabilitation, Universitäts- und Rehabilitationskliniken Ulm, Ulm, Germany
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Supervised Exercise Training Improves 6 min Walking Distance and Modifies Gait Pattern during Pain-Free Walking Condition in Patients with Symptomatic Lower Extremity Peripheral Artery Disease. SENSORS 2021; 21:s21237989. [PMID: 34883993 PMCID: PMC8659842 DOI: 10.3390/s21237989] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/17/2021] [Accepted: 11/26/2021] [Indexed: 12/24/2022]
Abstract
This study aimed to investigate the effects of supervised exercise training (SET) on spatiotemporal gait and foot kinematics parameters in patients with symptomatic lower extremity peripheral artery disease (PAD) during a 6 min walk test. Symptomatic patients with chronic PAD (Fontaine stage II) following a 3 month SET program were included. Prior to and following SET, a 6 min walk test was performed to assess the 6 min walking distance (6MWD) of each patient. During this test, spatiotemporal gait and foot kinematics parameters were assessed during pain-free and painful walking conditions. Twenty-nine patients with PAD (65.4 ± 9.9 years.) were included. The 6MWD was significantly increased following SET (+10%; p ≤ 0.001). The walking speed (+8%) and stride frequency (+5%) were significantly increased after SET (p ≤ 0.026). The stride length was only significantly increased during the pain-free walking condition (+4%, p = 0.001), whereas no significant differences were observed during the condition of painful walking. Similarly, following SET, the relative duration of the loading response increased (+12%), the relative duration of the foot-flat phase decreased (−3%), and the toe-off pitch angle significantly increased (+3%) during the pain-free walking condition alone (p ≤ 0.05). A significant positive correlation was found between changes in the stride length (r = 0.497, p = 0.007) and stride frequency (r = 0.786, p ≤ 0.001) during pain-free walking condition and changes in the 6MWD. A significant negative correlation was found between changes in the foot-flat phase during pain-free walking condition and changes in the 6MWD (r = −0.567, p = 0.002). SET was found to modify the gait pattern of patients with symptomatic PAD, and many of these changes were found to occur during pain-free walking. The improvement in individuals’ functional 6 min walk test was related to changes in their gait pattern.
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Lanzi S, Boichat J, Calanca L, Aubertin P, Malatesta D, Mazzolai L. Gait changes after supervised exercise training in patients with symptomatic lower extremity peripheral artery disease. Vasc Med 2021; 26:259-266. [PMID: 33571070 DOI: 10.1177/1358863x20984831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
This study aimed to investigate the effects of supervised exercise training (SET) on walking performance and spatiotemporal gait changes in patients with symptomatic lower extremity peripheral artery disease (PAD). In this single-arm prospective nonrandomized cohort study, patients with Fontaine stage II PAD following a 3-month SET program were included. Before and after SET, a constant-load treadmill test was performed to determine the pain-free and maximal walking distances (PFWD and MWD, respectively). During this test, spatiotemporal gait parameters were assessed. The ankle-brachial index (ABI) and toe-brachial index (TBI) were also measured. Twenty-seven patients with PAD (64.0 ± 1.9 y, 74% men) were included. Following SET, the PFWD (+68%; p = 0.001) and MWD (+79%; p ⩽ 0.001) significantly increased. The ABI and TBI did not change significantly. Following SET, the stride duration, stride frequency, stride length, and double support phase duration did not change significantly. In contrast, subphases of stance showed significant changes: the loading response (+8%; p = 0.03) and foot-flat (+2%; p = 0.01) phases were significantly longer, whereas the push-off phase (-7%; p = 0.002) was significantly shorter. A significant positive correlation was found between changes in the foot-flat phase and changes in PFWD (r = 0.43, p = 0.03). A significant negative correlation was found between changes in the push-off phase and changes in PFWD (r = -0.39, p = 0.05). No significant correlations were found between changes in relative durations of the subphases of stance and MWD. These results indicate that changes in temporal gait parameters during the foot contact phase potentially constitute an underlying mechanism of delayed claudication distance in patients with symptomatic PAD.
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Affiliation(s)
- Stefano Lanzi
- Heart and Vessel Department, Division of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Joël Boichat
- Heart and Vessel Department, Division of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Luca Calanca
- Heart and Vessel Department, Division of Angiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pauline Aubertin
- Heart and Vessel Department, Division of Angiology, Lausanne University Hospital, Lausanne, Switzerland.,Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Davide Malatesta
- Institute of Sport Sciences, University of Lausanne, Lausanne, Switzerland
| | - Lucia Mazzolai
- Heart and Vessel Department, Division of Angiology, Lausanne University Hospital, Lausanne, Switzerland
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Dziubek W, Stefańska M, Bulińska K, Barska K, Paszkowski R, Kropielnicka K, Jasiński R, Rachwalik A, Woźniewski M, Szuba A. Effects of Physical Rehabilitation on Spatiotemporal Gait Parameters and Ground Reaction Forces of Patients with Intermittent Claudication. J Clin Med 2020; 9:jcm9092826. [PMID: 32878323 PMCID: PMC7565509 DOI: 10.3390/jcm9092826] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 08/29/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic ischemia of the lower extremities often presents as intermittent claudication characterized by lower limb pain which subsides after a short break. This study aimed to provide an assessment of the spatiotemporal parameters of gait and ground reaction forces in patients with PAD participating in three forms of supervised physical training. A total of 80 subjects completed a three-month supervised physical rehabilitation program with three sessions per week. The subjects were assigned to one of three programs: group 1—standard walking training on a treadmill (TT); group 2—Nordic walking (NW) training; group 3—strength and endurance training comprised of NW with isokinetic resistance training (NW + ISO). Gait biomechanics tests (kinematic and kinetic parameters of gait) and a six-minute walk test were carried out before and after three months of physical training. Nordic walking training led to the greatest improvements in the gait pattern of patients with PAD and a significant increase in the absolute claudication distance and total gait distance. Combined training (NW + ISO) by strengthening the muscles of the lower extremities increased the amplitude of the general center of gravity oscillation to the greatest extent. Treadmill training had little effect on the gait pattern. Nordic walking training should be included in the rehabilitation of patients with PAD as a form of gait training, which can be conducted under supervised or unsupervised conditions.
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Affiliation(s)
- Wioletta Dziubek
- Department of Physiotherapy, University School of Physical Education, 35 Paderewskiego Street, 51-612 Wrocław, Poland; (W.D.); (K.B.); (R.J.); (M.W.)
| | - Małgorzata Stefańska
- Department of Physiotherapy, University School of Physical Education, 35 Paderewskiego Street, 51-612 Wrocław, Poland; (W.D.); (K.B.); (R.J.); (M.W.)
- Correspondence:
| | - Katarzyna Bulińska
- Department of Physiotherapy, University School of Physical Education, 35 Paderewskiego Street, 51-612 Wrocław, Poland; (W.D.); (K.B.); (R.J.); (M.W.)
| | - Katarzyna Barska
- Department of Cardiology, Jelenia Góra Valley Provincial Hospital Center, Ogińskiego 6, 58-501 Jelenia Góra, Poland;
| | - Rafał Paszkowski
- Department of Angiology, Diabetology and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland; (R.P.); (A.R.); (A.S.)
| | - Katarzyna Kropielnicka
- WROVASC—An Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, H. Kamieńskiego 73a, 51-124 Wroclaw, Poland;
| | - Ryszard Jasiński
- Department of Physiotherapy, University School of Physical Education, 35 Paderewskiego Street, 51-612 Wrocław, Poland; (W.D.); (K.B.); (R.J.); (M.W.)
| | - Anna Rachwalik
- Department of Angiology, Diabetology and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland; (R.P.); (A.R.); (A.S.)
| | - Marek Woźniewski
- Department of Physiotherapy, University School of Physical Education, 35 Paderewskiego Street, 51-612 Wrocław, Poland; (W.D.); (K.B.); (R.J.); (M.W.)
| | - Andrzej Szuba
- Department of Angiology, Diabetology and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wrocław, Poland; (R.P.); (A.R.); (A.S.)
- WROVASC—An Integrated Cardiovascular Centre, Specialist District Hospital in Wroclaw, Centre for Research and Development, H. Kamieńskiego 73a, 51-124 Wroclaw, Poland;
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Rodrigues E, Silva I. Supervised exercise therapy in intermittent claudication: a systematic review of clinical impact and limitations. INT ANGIOL 2020; 39:60-75. [DOI: 10.23736/s0392-9590.19.04159-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Haga M, Hoshina K, Koyama H, Miyata T, Ikegami Y, Murai A, Nakamura Y. Bicycle exercise training improves ambulation in patients with peripheral artery disease. J Vasc Surg 2019; 71:979-987. [PMID: 31495679 DOI: 10.1016/j.jvs.2019.06.188] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 06/04/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Exercise training has multiple beneficial effects in patients with arteriosclerotic diseases; however, the exact underlying mechanisms of the effects are not completely understood. This study aimed to evaluate the effectiveness of a supervised exercise program in improving gait parameters, including the variability and walking performance of lower limb movements, in patients with peripheral artery disease (PAD) and intermittent claudication (IC). METHODS Sixteen patients with a history of PAD and IC were recruited for this study, and they completed a 3-month supervised bicycle exercise program. The ankle-brachial index and responses to quality of life (QOL) questionnaires were evaluated. Near-infrared spectroscopy was also performed to determine the hemoglobin oxygen saturation in the calf. Patients' kinematics and dynamics, including joint range of motion and muscle tension, were evaluated using an optical motion capture system. Computed tomography images of each muscle were assessed by manual outlining. Data were collected before and after the supervised bicycle exercise program, and differences were analyzed. RESULTS Significant differences were not found in step length, ankle-brachial index, and hemoglobin oxygen saturation before and after the supervised bicycle exercise program; however, IC distance (P = .034), maximum walking distance (P = .006), and all QOL questionnaire scores (P < .001) showed significant improvement. Hip range of motion (P = .035), maximum hip joint torque (right, P = .031; left, P = .044), maximum tension of the gluteus maximus muscle (right, P = .044; left, P = .042), and maximum hip joint work (right, P = .048; left, P = .043) also significantly decreased bilaterally. Computed tomography images showed a significant increase in the cross-sectional area of the abdominal, trunk, and thigh muscles but not in that of the lower leg muscles after the supervised exercise program intervention. CONCLUSIONS In this study, bicycle exercise training improved the QOL and walking distance and decreased hip movement. The results showed that bicycling might be as useful as walking in patients with PAD.
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Affiliation(s)
- Makoto Haga
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Hiroyuki Koyama
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tetsuro Miyata
- Vascular Center, Sanno Hospital and Sanno Medical Center, Tokyo, Japan
| | - Yosuke Ikegami
- Department of Mechano-Informatics, The University of Tokyo, Tokyo, Japan
| | - Akihiko Murai
- Department of Mechano-Informatics, The University of Tokyo, Tokyo, Japan
| | - Yoshihiko Nakamura
- Department of Mechano-Informatics, The University of Tokyo, Tokyo, Japan
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Changes in Gait Variables in Patients with Intermittent Claudication. BIOMED RESEARCH INTERNATIONAL 2019; 2019:7276865. [PMID: 31263707 PMCID: PMC6556794 DOI: 10.1155/2019/7276865] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/29/2019] [Accepted: 05/19/2019] [Indexed: 11/22/2022]
Abstract
Objective Intermittent claudication (IC) is a pathological symptom with a particular effect on human gait patterns. Therefore, analyzing these patterns can facilitate rehabilitation or treatment through comparison of the values of kinematic and kinetic variables of patients with the normal values of healthy people. Therefore, the aim of this study was to find differences in the values of gait variables between patients with IC and healthy people. Methods The study included 98 patients diagnosed with peripheral arterial disease with IC. The patients traveled a distance of 6 m at a voluntary gait velocity. Ground reaction forces while the foot contacted the ground and kinematic variables of lower limb movements were recorded. The values of normal gait variables were computed based on the results obtained in a group of 30 healthy people. Results Patients used a gait velocity below the norm for healthy people. The velocity during the lower limb swing and the step and stride length in patients with IC were below the norm. Differences were also found in the ranges of motion between patients with IC and healthy people for the pelvic obliquity, pelvic rotation, hip flexion-extension, hip abduction-adduction, hip internal-external rotation, knee flexion-extension, ankle dorsi-plantar flexion, and foot progression angles. Conclusions The presented kinematic and kinetic characteristics measured by gait variables suggest differences between patients with IC and healthy people. Considering kinematic and kinetic gait variables during the rehabilitation process would facilitate the development of a more economic gait technique (with increased stride length and range of motion in the lower limb joints) to obtain the desired rehabilitation effects. Patients with IC should receive rehabilitation oriented towards improving mobility and increasing muscle strength in selected lower limb joints to increase gait velocity and stride length.
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other, more invasive therapies for treatment of leg pain on walking (intermittent claudication (IC)). This is the fourth update of a review first published in 1998. OBJECTIVES Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events, and improving quality of life. SEARCH METHODS For this update, the Cochrane Vascular Information Specialist searched the Specialised Register (last searched 15 November 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 10) via the Cochrane Register of Studies Online, along with trials registries. SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy for people with IC due to peripheral arterial disease (PAD). We included any exercise programme or regimen used for treatment of IC, such as walking, skipping, and running. Inclusion of trials was not affected by duration, frequency, or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximum walking distance), ankle brachial index (ABI), quality of life, morbidity, or amputation; if none of these was reported, we did not include the trial in this review. DATA COLLECTION AND ANALYSIS For this update (2017), RAL and AH selected trials and extracted data independently. We assessed study quality by using the Cochrane 'Risk of bias' tool. We analysed continuous data by determining mean differences (MDs) and 95% confidence intervals (CIs), and dichotomous data by determining risk ratios (RRs) and 95% CIs. We pooled data using a fixed-effect model unless we identified significant heterogeneity, in which case we used a random-effects model. We used the GRADE approach to assess the overall quality of evidence supporting the outcomes assessed in this review. MAIN RESULTS We included two new studies in this update and identified additional publications for previously included studies, bringing the total number of studies meeting the inclusion criteria to 32, and involving a total of 1835 participants with stable leg pain. The follow-up period ranged from two weeks to two years. Types of exercise varied from strength training to polestriding and upper or lower limb exercises; supervised sessions were generally held at least twice a week. Most trials used a treadmill walking test for one of the primary outcome measures. The methodological quality of included trials was moderate, mainly owing to absence of relevant information. Most trials were small and included 20 to 49 participants. Twenty-seven trials compared exercise versus usual care or placebo, and the five remaining trials compared exercise versus medication (pentoxifylline, iloprost, antiplatelet agents, and vitamin E) or pneumatic calf compression; we generally excluded people with various medical conditions or other pre-existing limitations to their exercise capacity.Meta-analysis from nine studies with 391 participants showed overall improvement in pain-free walking distance in the exercise group compared with the no exercise group (MD 82.11 m, 95% CI 71.73 to 92.48, P < 0.00001, high-quality evidence). Data also showed benefit from exercise in improved maximum walking distance (MD 120.36 m, 95% CI 50.79 to 189.92, P < 0.0007, high-quality evidence), as revealed by pooling data from 10 studies with 500 participants. Improvements were seen for up to two years.Exercise did not improve the ABI (MD 0.04, 95% CI 0.00 to 0.08, 13 trials, 570 participants, moderate-quality evidence). Limited data were available for the outcomes of mortality and amputation; trials provided no evidence of an effect of exercise, when compared with placebo or usual care, on mortality (RR 0.92, 95% CI 0.39 to 2.17, 5 trials, 540 participants, moderate-quality evidence) or amputation (RR 0.20, 95% CI 0.01 to 4.15, 1 trial, 177 participants, low-quality evidence).Researchers measured quality of life using Short Form (SF)-36 at three and six months. At three months, the domains 'physical function', 'vitality', and 'role physical' improved with exercise; however this was a limited finding, as it was reported by only two trials. At six months, meta-analysis showed improvement in 'physical summary score' (MD 2.15, 95% CI 1.26 to 3.04, P = 0.02, 5 trials, 429 participants, moderate-quality evidence) and in 'mental summary score' (MD 3.76, 95% CI 2.70 to 4.82, P < 0.01, 4 trials, 343 participants, moderate-quality evidence) secondary to exercise. Two trials reported the remaining domains of the SF-36. Data showed improvements secondary to exercise in 'physical function' and 'general health'. The other domains - 'role physical', 'bodily pain', 'vitality', 'social', 'role emotional', and 'mental health' - did not show improvement at six months.Evidence was generally limited in trials comparing exercise versus antiplatelet therapy, pentoxifylline, iloprost, vitamin E, and pneumatic foot and calf compression owing to small numbers of trials and participants.Review authors used GRADE to assess the evidence presented in this review and determined that quality was moderate to high. Although results showed significant heterogeneity between trials, populations and outcomes were comparable overall, with findings relevant to the claudicant population. Results were pooled for large sample sizes - over 300 participants for most outcomes - using reproducible methods. AUTHORS' CONCLUSIONS High-quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention. Exercise did not improve ABI, and we found no evidence of an effect of exercise on amputation or mortality. Exercise may improve quality of life when compared with placebo or usual care. As time has progressed, the trials undertaken have begun to include exercise versus exercise or other modalities; therefore we can include fewer of the new trials in this update.
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Affiliation(s)
- Risha Lane
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Amy Harwood
- Hull Royal InfirmaryVascular UnitAnlaby RoadHullUKHU3 2JZ
| | - Lorna Watson
- NHS FifeCameron House, Cameron BridgeWindygatesLevenUKKY8 5RG
| | - Gillian C Leng
- National Institute for Health and Care Excellence10 Spring GardensLondonUKSW1A 2BU
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Gommans LN, Smid AT, Scheltinga MR, Cancrinus E, Brooijmans FA, Meijer K, Teijink JA. Prolonged stance phase during walking in intermittent claudication. J Vasc Surg 2017; 66:515-522. [DOI: 10.1016/j.jvs.2017.02.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 02/10/2017] [Indexed: 11/24/2022]
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Harwood AE, Smith GE, Cayton T, Broadbent E, Chetter IC. A Systematic Review of the Uptake and Adherence Rates to Supervised Exercise Programs in Patients with Intermittent Claudication. Ann Vasc Surg 2016; 34:280-9. [PMID: 27126713 DOI: 10.1016/j.avsg.2016.02.009] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 02/15/2016] [Accepted: 02/17/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Intermittent claudication (IC) is a common and debilitating symptom of peripheral arterial disease and is associated with a significant reduction in a sufferer's quality of life. Guidelines recommend a supervised exercise program (SEP) as the primary treatment option; however, anecdotally there is a low participation rate for exercise in this group of patients. We undertook a systematic review of the uptake and adherence rates to SEPs for individuals with IC. METHODS The MEDLINE, Embase, and PubMed databases were searched up to January 2015 for terms related to supervised exercise in peripheral arterial disease. The review had 3 aims: first, to establish the rates of uptake to SEPs, second, the rates of adherence to programs, and finally to determine the reasons reported for poor uptake and adherence. Separate inclusion and/or exclusion criteria were applied in selecting reports for each aim of the review. RESULTS Only 23 of the 53 potentially eligible articles for uptake analysis identified on literature searches reported any details of screened patients (n = 7,517) with only 24.2% of patients subsequently recruited to SEPs. Forty-five percent of screen failures had no reason for exclusion reported. Sixty-seven articles with 4,012 patients were included for analysis of SEP adherence. Overall, 75.1% of patients reportedly completed an SEP; however, only one article defined a minimal attendance required for SEP completion. Overall, 54.1% of incomplete adherence was due to patient withdrawal and no reason for incomplete adherence was reported for 16% of cases. CONCLUSIONS Reporting of SEP trials was poor with regard to the numbers of subjects screened and reasons for exclusions. Only approximately 1 in 3 screened IC patients was suitable for and willing to undertake SEP. Levels of adherence to SEPs and definitions of satisfactory adherence were also lacking in most the current literature. Current clinical guidelines based on this evidence base may not be applicable to most IC patients and changes to SEPs may be needed to encourage and/or retain participants.
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Affiliation(s)
| | - George E Smith
- Academic Vascular Surgical Unit, Hull Royal Infirmary, Hull, UK
| | - Thomas Cayton
- Academic Vascular Surgical Unit, Hull Royal Infirmary, Hull, UK
| | | | - Ian C Chetter
- Academic Vascular Surgical Unit, Hull Royal Infirmary, Hull, UK
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Harwood AE, Cayton T, Sarvanandan R, Lane R, Chetter I. A Review of the Potential Local Mechanisms by Which Exercise Improves Functional Outcomes in Intermittent Claudication. Ann Vasc Surg 2016; 30:312-20. [DOI: 10.1016/j.avsg.2015.05.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 05/21/2015] [Accepted: 05/25/2015] [Indexed: 12/15/2022]
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King SL, Vanicek N, O'Brien TD. Gastrocnemius muscle architecture and achilles tendon properties influence walking distance in claudicants with peripheral arterial disease. Muscle Nerve 2015; 53:733-41. [PMID: 26427003 DOI: 10.1002/mus.24925] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/29/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The extent to which gastrocnemius muscle and Achilles tendon properties contribute to the impaired walking endurance of claudicants is not known. METHODS Ultrasound images quantified muscle architecture of the lateral and medial gastrocnemius (GL and GM) and were combined with dynamometry during plantarflexor contractions to calculate tendon stress, strain, stiffness, the Young modulus, and hysteresis. Key parameters were entered into multiple regression models to explain walking endurance. RESULTS Worse disease severity was significantly associated with longer fascicle: tendon length ratios (GL R = -0.789 and GM R = -0.828) and increased tendon hysteresis (R = -0.740). Walking endurance could be explained by GL and GM pennation angle, maximum tendon force, tendon hysteresis, and disease severity (R(2) = ∼0.6). CONCLUSIONS Peripheral arterial disease was associated with functionally important changes in muscle and tendon properties, including the usage of stored elastic energy. Interventions known to target these characteristics should be adopted as a means to improve walking endurance.
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Affiliation(s)
- Stephanie Louise King
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, L3 3AF, Liverpool, United Kingdom.,Department of Sport, Health and Exercise Science, University of Hull, Yorkshire, United Kingdom
| | - Natalie Vanicek
- Department of Sport, Health and Exercise Science, University of Hull, Yorkshire, United Kingdom.,Discipline of Exercise and Sport Science, University of Sydney, Sydney, Australia
| | - Thomas Daniel O'Brien
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Tom Reilly Building, Byrom Street, L3 3AF, Liverpool, United Kingdom.,School of Sport, Health and Exercise Science, Bangor University, Bangor, United Kingdom
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Konik A, Kuklewicz S, Rosłoniec E, Zając M, Spannbauer A, Nowobilski R, Mika P. Effects of 12-week supervised treadmill training on spatio-temporal gait parameters in patients with claudication. Disabil Rehabil 2015; 38:1157-62. [PMID: 26314413 DOI: 10.3109/09638288.2015.1075073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The purpose of the study was to evaluate selected temporal and spatial gait parameters in patients with intermittent claudication after completion of 12-week supervised treadmill walking training. The study included 36 patients (26 males and 10 females) aged: mean 64 (SD 7.7) with intermittent claudication. All patients were tested on treadmill (Gait Trainer, Biodex). Before the programme and after its completion, the following gait biomechanical parameters were tested: step length (cm), step cycle (cycle/s), leg support time (%), coefficient of step variation (%) as well as pain-free walking time (PFWT) and maximal walking time (MWT) were measured. Training was conducted in accordance with the current TASC II guidelines. After 12 weeks of training, patients showed significant change in gait biomechanics consisting in decreased frequency of step cycle (p < 0.05) and extended step length (p < 0.05). PFWT increased by 96% (p < 0.05). MWT increased by 100% (p < 0.05). After completing the training, patients' gait was more regular, which was expressed via statistically significant decrease of coefficient of variation (p < 0.05) for both legs. No statistically significant relation between the post-training improvement of PFWT and MWT and step length increase and decreased frequency of step cycle was observed (p > 0.05). IMPLICATIONS FOR REHABILITATION Twelve-week treadmill walking training programme may lead to significant improvement of temporal and spatial gait parameters in patients with intermittent claudication. Twelve-week treadmill walking training programme may lead to significant improvement of pain-free walking time and maximum walking time in patients with intermittent claudication.
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Affiliation(s)
- Anita Konik
- a Department of Clinical Rehabilitation , University School of Physical Education , Cracow , Poland .,b Department of Physiotherapy, Faculty of Physical Education in Gorzow Wielkopolski , University School of Physical Education in Poznan , Poland
| | - Stanisław Kuklewicz
- a Department of Clinical Rehabilitation , University School of Physical Education , Cracow , Poland
| | - Ewelina Rosłoniec
- a Department of Clinical Rehabilitation , University School of Physical Education , Cracow , Poland
| | - Marcin Zając
- a Department of Clinical Rehabilitation , University School of Physical Education , Cracow , Poland
| | - Anna Spannbauer
- c Department of Vascular Insufficiency , Collegium Medicum of Jagiellonian University , Cracow , Poland , and
| | - Roman Nowobilski
- d Faculty of Health Sciences , Institute of Physiotherapy, School of Medicine, Jagiellonian University , Cracow , Poland
| | - Piotr Mika
- a Department of Clinical Rehabilitation , University School of Physical Education , Cracow , Poland
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14
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Abstract
BACKGROUND Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)). This is an update of a review first published in 1998. OBJECTIVES The prime objective of this review was to determine whether an exercise programme in people with intermittent claudication was effective in alleviating symptoms and increasing walking treadmill distances and walking times. Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease, reducing cardiovascular events and improving quality of life. SEARCH METHODS For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2013) and CENTRAL (2013, Issue 8). SELECTION CRITERIA Randomised controlled trials of an exercise regimen versus control or versus medical therapy in people with IC due to peripheral arterial disease. Any exercise programme or regimen used in the treatment of intermittent claudication was included, such as walking, skipping and running. Inclusion of trials was not affected by the duration, frequency or intensity of the exercise programme. Outcome measures collected included treadmill walking distance (time to onset of pain or pain-free walking distance and maximum walking time or maximal walking distance), ankle brachial index (ABI), quality of life, morbidity or amputation; if none of these were reported the trial was not included in this review. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed trial quality. MAIN RESULTS Eleven additional studies were included in this update making a total of 30 trials which met the inclusion criteria, involving a total of 1816 participants with stable leg pain. The follow-up period ranged from two weeks to two years. The types of exercise varied from strength training to polestriding and upper or lower limb exercises; generally supervised sessions were at least twice a week. Most trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was moderate, mainly due to an absence of relevant information. The majority of trials were small with 20 to 49 participants. Twenty trials compared exercise with usual care or placebo, the remainder of the trials compared exercise to medication (pentoxifylline, iloprost, antiplatelet agents and vitamin E) or pneumatic calf compression; people with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.Overall, when taking the first time point reported in each of the studies, exercise significantly improved maximal walking time when compared with usual care or placebo: mean difference (MD) 4.51 minutes (95% confidence interval (CI) 3.11 to 5.92) with an overall improvement in walking ability of approximately 50% to 200%. Walking distances were also significantly improved: pain-free walking distance MD 82.29 metres (95% CI 71.86 to 92.72) and maximum walking distance MD 108.99 metres (95% CI 38.20 to 179.78). Improvements were seen for up to two years, and subgroup analyses were performed at three, six and 12 months where possible. Exercise did not improve the ABI (MD 0.05, 95% CI 0.00 to 0.09). The effect of exercise, when compared with placebo or usual care, was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data. No data were given on non-fatal cardiovascular events.Quality of life measured using the Short Form (SF)-36 was reported at three and six months. At three months, physical function, vitality and role physical all significantly improved with exercise, however this was a limited finding as this measure was only reported in two trials. At six months five trials reported outcomes of a significantly improved physical summary score and mental summary score secondary to exercise. Only two trials reported improvements in other domains, physical function and general health.Evidence was generally limited for exercise compared with antiplatelet therapy, pentoxifylline, iloprost, vitamin E and pneumatic foot and calf compression due to small numbers of trials and participants. AUTHORS' CONCLUSIONS Exercise programmes are of significant benefit compared with placebo or usual care in improving walking time and distance in people with leg pain from IC who were considered to be fit for exercise intervention.
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Affiliation(s)
- Risha Lane
- Vascular Unit, Hull Royal Infirmary, Anlaby Road, Hull, UK, HU3 2JZ
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Pilz M, Kandioler-Honetz E, Wenkstetten-Holub A, Doerrscheidt W, Mueller R, Kurz RW. Evaluation of 6- and 12-month supervised exercise training on strength and endurance parameters in patients with peripheral arterial disease. Wien Klin Wochenschr 2014; 126:383-9. [DOI: 10.1007/s00508-014-0548-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 04/13/2014] [Indexed: 01/08/2023]
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Vanicek N, King SA, Gohil R, Chetter IC, Coughlin PA. Computerized dynamic posturography for postural control assessment in patients with intermittent claudication. J Vis Exp 2013:e51077. [PMID: 24378378 PMCID: PMC4047968 DOI: 10.3791/51077] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Computerized dynamic posturography with the EquiTest is an objective technique for measuring postural strategies under challenging static and dynamic conditions. As part of a diagnostic assessment, the early detection of postural deficits is important so that appropriate and targeted interventions can be prescribed. The Sensory Organization Test (SOT) on the EquiTest determines an individual's use of the sensory systems (somatosensory, visual, and vestibular) that are responsible for postural control. Somatosensory and visual input are altered by the calibrated sway-referenced support surface and visual surround, which move in the anterior-posterior direction in response to the individual's postural sway. This creates a conflicting sensory experience. The Motor Control Test (MCT) challenges postural control by creating unexpected postural disturbances in the form of backwards and forwards translations. The translations are graded in magnitude and the time to recover from the perturbation is computed. Intermittent claudication, the most common symptom of peripheral arterial disease, is characterized by a cramping pain in the lower limbs and caused by muscle ischemia secondary to reduced blood flow to working muscles during physical exertion. Claudicants often display poor balance, making them susceptible to falls and activity avoidance. The Ankle Brachial Pressure Index (ABPI) is a noninvasive method for indicating the presence of peripheral arterial disease and intermittent claudication, a common symptom in the lower extremities. ABPI is measured as the highest systolic pressure from either the dorsalis pedis or posterior tibial artery divided by the highest brachial artery systolic pressure from either arm. This paper will focus on the use of computerized dynamic posturography in the assessment of balance in claudicants.
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Affiliation(s)
- Natalie Vanicek
- Discipline of Exercise and Sport Science, Faculty of Health Sciences, University of Sydney
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