Research ArticleTools for Practice

Exercise for peripheral artery disease

Arthur A. Qi and Christina S. Korownyk
Canadian Family Physician April 2022; 68 (4) 277; DOI: https://doi.org/10.46747/cfp.6804277

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

    • - Pain-free walking distance improvement: 23 m to 174 m over 2 to 78 weeks.

    • - Maximum walking distance improvement: 41 m to 218 m over 2 to 78 weeks.

      • —Improvement was likely clinically relevant.5,6

  • 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

  • Most common recommendations included supervised walking 2 to 3 times per week for 30 to 60 minutes.4,9

  • Patient understanding of physical activity for PAD should be explored: 63% identified walking as the primary cause of their pain and 90% thought walking would worsen their symptoms.10

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.

References

  1. 1.↵
    1. Lyu X,
    2. Li S,
    3. Peng S,
    4. Cai H,
    5. Liu G,
    6. Ran X
    . Intensive walking exercise for lower extremity peripheral arterial disease: a systematic review and meta-analysis. J Diabetes 2016;8(3):363-77. Epub 2015 Jul 21.
    OpenUrlCrossRefPubMed
  2. 2.
    1. Parmenter BJ,
    2. Dieberg G,
    3. Smart NA
    . Exercise training for management of peripheral arterial disease: a systematic review and meta-analysis. Sports Med 2015;45(2):231-44.
    OpenUrl
  3. 3.
    1. Vemulapalli S,
    2. Dolor RJ,
    3. Hasselblad V,
    4. Schmit K,
    5. Banks A,
    6. Heidenfelder B, et al.
    Supervised vs unsupervised exercise for intermittent claudication: a systematic review and meta-analysis. Am Heart J 2015;169(6):924-37.e3. Epub 2015 Mar 26.
    OpenUrlCrossRefPubMed
  4. 4.↵
    1. Lane R,
    2. Harwood A,
    3. Watson L,
    4. Leng GC
    . Exercise for intermittent claudication. Cochrane Database Syst Rev 2017(12):CD000990.
  5. 5.↵
    1. McDermott MM,
    2. Spring B,
    3. Tian L,
    4. Treat-Jacobson D,
    5. Ferrucci L,
    6. Lloyd-Jones D, et al.
    Effect of low-intensity vs high-intensity home-based walking exercise on walk distance in patients with peripheral artery disease: the LITE randomized clinical trial. JAMA 2021;325(13):1266-76.
    OpenUrl
  6. 6.↵
    1. Harwood AE,
    2. Pymer S,
    3. Ingle L,
    4. Doherty P,
    5. Chetter IC,
    6. Parmenter B, et al.
    Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners. BMJ Open Sport Exerc Med 2020;6(1):e000897.
    OpenUrlAbstract/FREE Full Text
  7. 7.↵
    1. Thanigaimani S,
    2. Phie J,
    3. Sharma C,
    4. Wong S,
    5. Ibrahim M,
    6. Huynh P, et al.
    Network meta-analysis comparing the outcomes of treatments for intermittent claudication tested in randomized controlled trials. J Am Heart Assoc 2021;10(9):e019672. Epub 2021 Apr 23.
    OpenUrl
  8. 8.↵
    1. Jansen SC,
    2. Abaraogu UO,
    3. Lauret GJ,
    4. Fakhry F,
    5. Fokkenrood HJ,
    6. Teijink JA
    . Modes of exercise training for intermittent claudication. Cochrane Database Syst Rev 2020(8):CD009638.
  9. 9.↵
    1. Hageman D,
    2. Fokkenrood HJ,
    3. Gommans LN,
    4. van den Houten MM,
    5. Teijink JA
    . Supervised exercise therapy versus home-based exercise therapy versus walking advice for intermittent claudication. Cochrane Database Syst Rev 2018(4):CD005263.
  10. 10.↵
    1. Sharath SE,
    2. Kougias P,
    3. Barshes NR
    . The influence of pain-related beliefs on physical activity and health attitudes in patients with claudication: a pilot study. Vasc Med 2017;22(5):378-84. Epub 2017 May 25.
    OpenUrl
  11. 11.↵
    1. Tew GA,
    2. Allen L,
    3. Askew CD,
    4. Chetter I,
    5. Cucato G,
    6. Doherty P, et al.
    Infographic. Exercise for intermittent claudication. Br J Sports Med 2020;54(23):1443-4. Epub 2020 Feb 12.
    OpenUrlFREE Full Text
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Exercise for peripheral artery disease
Arthur A. Qi, Christina S. Korownyk
Canadian Family Physician Apr 2022, 68 (4) 277; DOI: 10.46747/cfp.6804277
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