Modes of exercise training for intermittent claudication

Intermittent claudication is a cramping leg pain that develops during exercise and is relieved by a short period of rest. It is caused by inadequate blood flow to the muscles of the leg because of atherosclerosis (hardening and narrowing of the arteries). Intermittent claudication is closely associated with other vascular diseases, such as a heart attack or stroke. Therefore, all patients with intermittent claudication should receive cardiovascular risk management and lifestyle coaching to reduce cardiovascular risk factors.

To improve the walking capacity and quality of life, supervised exercise therapy is the primary treatment according to the current scientific evidence. Community-based supervised exercise appears to be at least as effective as programmes provided in a hospital setting. In the literature, supervised exercise therapy usually consists of treadmill walking. However, alternative modes of exercise therapy (e.g. cycling, strength training) have been described, with beneficial effects on walking capacity and quality of life. Therefore, the following question remains: Which exercise mode gives the most beneficial results?

The present review shows that there are few studies comparing alternative modes of exercise training to the standard of supervised walking exercise. The review authors identified five studies that randomised a total of 135 participants. The alternative modes of exercise therapy included cycling, strength training, and upper-arm ergometry. Comparing these alternative modes of exercise with supervised walking exercise showed no clear evidence of a difference in maximum or pain-free walking distance between the groups. Quality of life measures showed significant improvements in both groups; however, we could not make a direct comparison because of limited data.

This review shows that alternative modes of exercise therapy seem to yield similar results to supervised walking therapy. Therefore, they may be considered useful when supervised walking exercise is not an option for the patient. However, more randomised controlled trials are needed to make a meaningful comparison between the different modes of exercise therapy.

Authors' conclusions: 

There was no clear evidence of differences between supervised walking exercise and alternative exercise modes in improving the maximum and pain-free walking distance of patients with intermittent claudication. More studies with larger sample sizes are needed to make meaningful comparisons between each alternative exercise mode and the current standard of supervised treadmill walking. The results indicate that alternative exercise modes may be useful when supervised walking exercise is not an option for the patient.

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Background: 

According to international guidelines and literature, all patients with intermittent claudication should receive an initial treatment of cardiovascular risk modification, lifestyle coaching, and supervised exercise therapy. In most studies, supervised exercise therapy consists of treadmill or track walking. However, alternative modes of exercise therapy have been described and yielded similar results to walking. Therefore, the following question remains: Which exercise mode gives the most beneficial results?

Objectives: 

Primary objective: To assess the effects of different modes of supervised exercise therapy on the maximum walking distance (MWD) of patients with intermittent claudication.
Secondary objectives: To assess the effects of different modes of supervised exercise therapy on pain-free walking distance (PFWD) and health-related quality of life scores (HR-QoL) of patients with intermittent claudication.

Search strategy: 

The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Cochrane Peripheral Vascular Diseases Group Specialised Register (July 2013); CENTRAL (2013, Issue 6), in The Cochrane Lib rary; and clinical trials databases. The authors searched the MEDLINE (1946 to July 2013) and Embase (1973 to July 2013) databases and reviewed the reference lists of identified articles to detect other relevant citations.

Selection criteria: 

Randomised controlled trials of studies comparing alternative modes of exercise training or combinations of exercise modes with a control group of supervised walking exercise in patients with clinically determined intermittent claudication. The supervised walking programme needed to be supervised at least twice a week for a consecutive six weeks of training.

Data collection and analysis: 

Two authors independently selected studies, extracted data, and assessed the risk of bias for each study. Because of different treadmill test protocols to assess the maximum or pain-free walking distance, we converted all distances or walking times to total metabolic equivalents (METs) using the American College of Sports Medicine (ACSM) walking equation.

Main results: 

In this review, we included a total of five studies comparing supervised walking exercise and alternative modes of exercise. The alternative modes of exercise therapy included cycling, strength training, and upper-arm ergometry. The studies represented a sample size of 135 participants with a low risk of bias. Overall, there was no clear evidence of a difference between supervised walking exercise and alternative modes of exercise in maximum walking distance (8.15 METs, 95% confidence interval (CI) -2.63 to 18.94, P = 0.14, equivalent of an increase of 173 metres, 95% CI -56 to 401) on a treadmill with no incline and an average speed of 3.2 km/h, which is comparable with walking in daily life.

Similarly, there was no clear evidence of a difference between supervised walking exercise and alternative modes of exercise in pain-free walking distance (6.42 METs, 95% CI -1.52 to 14.36, P = 0.11, equivalent of an increase of 136 metres, 95% CI -32 to 304). Sensitivity analysis did not alter the results significantly. Quality of life measures showed significant improvements in both groups; however, because of skewed data and the very small sample size of the studies, we did not perform a meta-analysis for health-related quality of life and functional impairment.

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