SHREE B.G PATEL COLLEGE OF PHYSIOTHERAPY, ANAND

Improving maximum walking distance inearly peripheralarterial disease:Evidence-based seminarGUIDE: DR.MANOJ KUMAR (MPT)

PRESENTED BY: DR.SHILPA PRAJAPATI

CONTENTS

INTRODUCTION

EPIDIMIOLOGY

IDENTIFICATION OF SUBECTS WITH EARLY PERIPHERAL ARTERIAL DISEASE

INTERVENTION

EVIDENCES

CONCLUSION

INTRODUCTION

Normal Blood Vessel

Atherosclerosis

INTRODUCTION

When the arteries to the legs become blocked, the muscles are deprived of oxygen and cause significant symptoms, is called Peripheral Arterial Disease or PAD.

In its early stages, common symptoms of poor leg circulation are cramping, fatigue, heaviness, pain or discomfort in the legs and buttocks during activity.

This usually subsides when the activity stops. It’s called “intermittent claudication”.

The natural history of this condition is uncertain.

INTRODUCTION Housley et al (1988) indicate that “stop smoking and

keep walking”, the standard first line of management. The risk of the disease progressing to the point where

operative intervention is required is very small.

Over the five years of follow-up in the Edinburgh Artery Study, fewer than 9% of affected individuals required surgical intervention (Leng et al 1996).

Candidate endpoints include the presence of intermittent claudication, the maximum walking distance before onset of intermittent claudication, and the ankle:brachial index of systolic blood pressure.

INSIDENCE

INSIDENCE

All epidemiologic cross-sectional studies show that in the general population asymptomatic peripheral arterial disease (PAD) is more common than symptomatic PAD.

Less than half of all PAD patients have symptoms of intermittent claudication.

When the disease progresses to involve more arteries farther down the leg, then the symptoms can be more severe, such as pain in the foot, the development of ulcerations, or advanced changes such as gangrene in the toes.

PAD is part of a systemic illness caused by atherosclerosis, and its prevalence is associated with increasing age.

IDENTIFICATION OF SUBJECTS

IDENTIFICATION OF SUBJECTS

Identifying PAD while asymptomatic or early stage may be life-saving for patient

A classification of either definite intermittent claudication or atypical intermittent claudication on the Edinburgh Claudication Questionnaire (Leng et al 1992). or An ankle-brachial index of systolic blood pressure

of 0.9 or less in either leg, indicating a reduced blood flow to the lower limbs.

IDENTIFICATION OF SUBJECTS

EDINBURGH QUESTIONNAIRE‘S(1) Do you get a pain or discomfort in your leg(s) when you walk? Yes/No I am unable to walkIf you answered "Yes" to question (1) - please answer the following

questions. Otherwise you need not continue.

(2) Does this pain ever begin when you are standing still or sitting? Yes/No

(3) Do you get it if you walk uphill or hurry? Yes/No

(4) Do you get it when you walk at an ordinary pace on the level? Yes/No

(5) What happens to it if you stand still? Usually continues more than 10 minutes Usually disappears in 10 minutes or less

IDENTIFICATION OF SUBJECTS

(6) Where do you get this pain or discomfort? Mark the place(s) with "x" on the diagram below

Definition of positive classification requires all of the following responses: 'Yes' to (1), 'No' to (2), 'Yes' to (3), And 'Usually disappears in 10 minutes or less' to (5); 'No' to (4) = grade 1 and 'Yes' to (4) = grade 2.

If these criteria are fulfilled, a definite claudicant is one who indicates pain in the calf, regardless of whether pain is also marked in other sites.

A diagnosis of atypical claudication is made if pain is indicated in the thigh or buttock, in the absence of any calf pain. Subjects should not be considered to have claudication if pain is indicated in the hamstrings, feet, shins, joints or appears to radiate, in the absence of any pain in the calf.

IDENTIFICATION OF SUBJECTS

Ankle : brachial index

>1.2 Arterial disease

1.19-0.95 Normal

0.94-0.75 Mild arterial disease + intermittent claudication

0.74-0-50 Moderate arterial disease + rest pain

<0.50 Severe arterial disease

INTERVENTION

INTERVENTION

Considered outcome goals for peripheral artery disease include: Relieve the pain of intermittent claudication. Improve exercise tolerance by increasing the

walking distance before the onset of claudication. Prevent critical artery occlusion that can lead to

foot ulcers, gangrene, and amputation.

Treatments of peripheral artery disease include lifestyle measures, supervised exercises, medications, angioplasty, and surgery (Dennis Lee).

INTERVENTION

Information on cessation of smoking (where applicable), because it is associated with reduction of elevated serum cholesterol levels (Cahan MA et al,1999).

Lipid-lowering therapy can include atherosclerotic regression in the diseased arteries (Wittlinger,2004).

Men were referred to hydrotherapy classes or special exercise sessions (Bess Fowler).

INTERVENTION

Walking Exercise: Exercise and walking regularly, at least 30 continuous minutes

three times per week, can help improve your symptoms by encouraging your body to form new, collateral blood vessels. With a structured walking program, many patients experience a dramatic increase in the distance they are able to walk without pain.

Patient should also be introduce to a vascular rehabilitation program, Involving a weekly

exercise group of 45 minutes supervised. The session included a warm-up phase of stretching the

calf, hamstring and upper limb muscles, followed by 20 minutes of fast walking and ending with a cool-down period.

INTERVENTION (Susan B O’Sullivan)

Weak

1-3

4-6

7-10

Exercises

Isometrics: quadriceps and hamstringsAROM: ankle pumps, heel slides, heel and toe raises in sitting

AROM and resistive exercise:Add to above exercises- standing toe raises, wall squats

Continue resistive exercises, increase resistance as tolerated

Intensity

3 sets,15 reps, 2-3times daily

3sets, 20reps, 2-3times daily

3sets, 20reps, 3times daily

Ambulation

1/8 or ½ or just prior to point of claudication

½ - 1 mile or to point of claudication

1+ miles or distance as tolerated

EVIDENCES

1. Leng GC, Fowler B, Ernst E, Cochrane Database Syst Rev. 2008. Exercise for intermittent claudication Randomized trials of exercise regimens in almost

1200 male and female patients with leg pain on walking (intermittent claudication). All recommended at least two weekly sessions of supervised exercise.

CONCLUSIONS: Exercise programmes were of significant benefit

compared with placebo or usual care in improving walking time and distance in patients with leg pain from IC.

EVIDENCES

2. Mary M. et al, Northwestern University Feinberg School of Medicine, Chicago (Jan. 20, 2009) Treadmill Exercise Improves Walking Endurance

For Patients With Peripheral Arterial Disease randomized controlled clinical trial included 156

patients, assigned to supervised treadmill exercise, to lower extremity resistance training or to a control group, for six months.

CONCLUSIONS: Supervised treadmill training improved 6-minute walk

performance, treadmill walking performance, brachial artery flow-mediated dilation, and quality of life but did not improve the short physical performance battery scores of PAD.

EVIDENCES

3. M.P. Mosti, E.Wang, Ø.N. Wiggen, J.Helgerud, J.Hoff 16 MAR 2011 Concurrent strength and endurance training improves

physical capacity in patients with peripheral arterial disease

Plantar flexion (PF) endurance training and maximal strength training (MST) induce distinct types of improvements in walking ability in PAD.

Ten patients with PAD underwent 8 weeks of concurrent leg press MST and PF training, three times a week. The reference group (n=10) received recommended exercise guidelines.

Conclusion The training group improved treadmill peak oxygen consumption

and incremental protocol time and work economy improvement occur.

EVIDENCES 4. Maggie A Cunningham et al Department of

Psychology, University of Stirling, UK October 7, 2010. Increasing walking in patients with intermittent claudication:

Protocol for Randomized Control Trial This measure gives an accurate idea of how far a patient can walk

before they experience claudication pain, and before they have to stop, it does not give any idea of how much walking the patient does in their day to day life, and therefore lacks ecological validity. For this reason, we have decided to measure day-to-day walking using pedometers. Participants will be asked to wear a pedometer for one week at each time point, and their mean daily steps will be calculated by averaging the six days with the highest number of steps.

Conclusion psychological intervention increase walking in patients with intermittent

claudication, both in terms of the initiation, and maintenance of behaviourchange.

EVIDENCES

5. J. Wind, M.J.W. Koelemay, 2007 Jul Exercise Therapy and the Additional Effect of

Supervision on Exercise Therapy in Patients with Intermittent Claudication. Systematic Review of Randomized Controlled Trials

evaluating 761 patients. In the studies comparing supervised exercise to standard care the weighted mean difference in pain free walking distance (PWD) and absolute walking distance (AWD).

Conclusion: Exercise therapy increases the Pain free Walking Distance and

Absolute Walking Distance in patients with intermittent claudication. Supervised exercise therapy increases the Pain free Walking Distance and Absolute Walking Distance more than standard care.

EVIDENCES

6. McDermott MM et al , 2006 Jan Physical performance in peripheral arterial

disease: a slower rate of decline in patients who walk more. Prospective cohort study with a median follow-up of 36 month

patients with PAD, self-directed walking exercise performed at least 3 times weekly

CONCLUSION: significantly less functional decline during the

subsequent year. Similar trends were observed in the subset of asymptomatic patients with PAD. These findings may be particularly important for the numerous patients with PAD who do not have access to supervised walking exercise programs.

EVIDENCES

7. Streminski JA, de la Haye R, Rettig K, Kuntz G 1992 Comparison of the effectiveness of physical training

with parenteral drug therapy in Fontaine stage IIb peripheral arterial occlusive disease.

30 patients were included in each of the three therapy groups. Over a period of four weeks each patient received daily therapy.

Patients of group I received a daily intravenous infusion of 250 ml Actovegin 20% p.i. the patients in group II received this medication by the intraarterial route. The third patient group received standardized vascular training

The conclusion Of the present study are discussed having in mind physical

therapy being limited through contraindications and insufficient patient compliance.

EVIDENCES

8. Tisi PV, Shearman CP. 1998 Jan. The evidence for exercise-induced inflammation in

intermittent claudication: should we encourage patients to stop walking?

Exercise to the onset of calf pain results in an inflammatory response with free radical formation, neutrophil activation and systemic vascular endothelial damage.

CONCLUSIONS: Further studies are needed to determine the effect of long-term

exercise training on exercise-induced inflammation in claudication.

Early work suggests that exercise attenuates this inflammatory response. If this were confirmed then it would support the clinical impression that exercise training is beneficial in terms of symptomatic improvement in patients with intermittent claudication.

CONCLUSION

A combination of simple and safe interventions that are readily available in the community through physiotherapists and movement practitioners has the potential to improve early peripheral arterial disease dramatically.

THANK YOU !