Clinical question
What is the evidence for exercise in the management of patients with peripheral artery disease (PAD)?
Bottom line
Exercise therapy improves maximum and pain-free walking distance by up to 200 m over 2 to 78 weeks compared with usual care. No benefit has been demonstrated for amputation or mortality. The most commonly studied exercise is supervised walking 2 to 3 times per week for 30 to 60 minutes, although other supervised activities (eg, resistance training) may be beneficial for those who cannot tolerate walking.
Evidence
Results are statistically significant unless otherwise noted. Evidence for exercise versus usual care with or without exercise advice in patients with PAD (mean age of 67, 67% men, mean ankle-brachial index of 0.67, pain-free walking distance of 110 m to 266 m) is as follows.1
Four systematic reviews (9 to 41 RCTs, 391 to 1938 patients) found the following.1–4
Two systematic reviews (1 to 8 RCTs, 177 to 937 patients)1,4 found no difference in mortality,4 amputation, or adverse events (eg, cardiovascular events) at up to 78 weeks.
Different types of exercise have also been studied.
A network meta-analysis (42 RCTs, 3515 patients)7 found that maximum walking distance improved with supervised (187 m) and home-based (89 m) exercise at less than 1 year. Only supervised programs continued to demonstrate benefit (201 m) between 1 and 2 years.
In a systematic review (10 RCTs, 527 patients), supervised walking was not superior to other supervised exercise (eg, resistance training, Nordic walking, combination exercises, arm ergometry, or cycling) for pain-free or maximum walking distance.8
- Limitations: small sample sizes, low-quality evidence.
An RCT (305 patients) found home-based exercise inducing maximal pain superior to that inducing no pain (change in 6-minute walking distance 34.5 m vs -6.4 m).5
-Limitations: heterogeneous individual response.
-A systematic review found no difference in exercise with no-to-mild pain versus moderate-to-maximal pain.1
Context
Implementation
General advice to walk at home has limited evidence of benefit.6 If a patient cannot attend a supervised program, a structured home-based program is reasonable. This may include advice to walk at a pace they can maintain for 5 to 10 minutes (until moderate-strong claudication), to rest until the pain subsides, then to begin the cycle again for at least 30 minutes. Some may need to start with shorter durations (eg, 10 minutes) and increase by 5 minutes per week. Most guidelines suggest a minimum 3 months’ duration.6 Tew et al provide a patient infographic example.11
Notes
Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice{at}cfpc.ca.
Footnotes
Competing interests
None declared
The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the College of Family Physicians of Canada.
This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.
Cet article se trouve aussi en français à la page 278.
- Copyright © 2022 the College of Family Physicians of Canada