Clinical Review

Improving Functional Outcomes in Patients with Intermittent Claudication

Journal of Clinical Outcomes Management. 2014 November;21(11)

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Several tests have been used to assess other aspects of functional capacity in patients with PAD, such as 4-meter walking speed, time to rise from a seated position 5 times, and standing balance (23). Although the inclusion of such measures may provide a more complete picture of a patient’s functional status than by assessing walking capacity alone, given the important of walking impairment in these patients and the predominant focus on this in the literature, the following sections on different treatments will focus solely on walking outcomes.

Treatments

A summary of therapeutic strategies for functional impairment in PAD is shown in Table 1 .

Supervised Exercise Training

There is a considerable body of evidence to support a beneficial effect of supervised exercise training on walking performance in individuals with intermittent claudication. As such, supervised exercise training is recommended as a first-line therapy in clinical guidelines throughout the world [3,7,8]. Several systematic reviews and meta-analyses have attempted to quantify the effects of supervised exercise programs on walking performance [30–34]. For example, Fakhry et al [31] conducted a meta-analysis of 25 randomized controlled trials from 1966 to 2012,

demonstrating weighted mean differences of 128 m (95% confidence interval [CI], 92 to 165 m) and 180 m (95% CI, 130 to 230 m) for pain-free and maximum walking distance, respectively, in favor of exercise relative to control. These findings represent large improvements in walking distances, and this is supported by the more recent meta-analysis of Gommans et al [34], which reported large standardized effects sizes (calculated between pre- and post-training) of 0.89 (95% CI, 0.65 to 1.14) and 0.96 (95% CI, 0.76 to 1.16) for pain-free and maximum walking distance, respectively, at 6 months of follow-up. Potential mechanisms of the response to exercise training have been reviewed previously and include increased collateral blood flow resulting from training-induced collateral growth, skeletal muscle metabolic adaptations, and improvements in walking efﬁciency and endothelial function [35].

Exercise programs comprise several components, including the mode and intensity of exercise, the duration and frequency of exercise sessions, the length of the program, and the level of supervision. Although few studies have directly compared different exercise regimes, some meta-analyses and systematic reviews have been conducted in an attempt to identify the program components that are the best predictors of improvement in walking distances [31,34,36–39]. For example, the meta-analysis of Gardner and Poehlman [36], which synthesized data from 21 randomized and nonrandomized exercise studies conducted between 1966 and 1993, indicated that claudication pain endpoint, program length, and mode of exercise explained 87% of the variance in improvements in maximum walking distance. Specifically, walking exercise appeared about twice as effective compared with other exercise modalities, walking to near-maximal leg pain was about 3 times more effective than walking to the point of claudication onset, and programs of at least 6 months' duration were about twice as effective as shorter programs. In contrast, the more contemporary synthesis of Fakhry et al [31] found that none of their predefined exercise components were independently associated with improvements in walking distances. Although walking programs are beneficial and frequently recommended