Individual Exercise Programming for Claudication Due to PAD Mark A. Patterson, M.Ed., RCEP - Clinical Exercise Physiologist Kaiser Permanente Colorado Department of Cardiovascular Services
Medical History Minute Claudication: Where did the name come from? The word "claudication" comes from the Latin "claudicare" meaning to limp. The Roman emperor Claudius (who ruled from A.D. 41-54) was so named because he limped, probably because of a birth defect. (medterms.com). 3 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Prevalence? Peripheral Artery Disease PAD is a marker of systemic atherosclerosis. risk of coronary artery disease (CAD) and cardiovascular events Estimated 8 + million people in the United States have PAD. Approximately 12% of the adult population (Bulmer/Coombes), and about 20% of adults over the age of 70 years have PAD. Smokers over 70 and diabetics over 50-60 years of age significantly increase the prevalence. Under diagnosed because it often presents with atypical or even no symptoms at all. Olin et al, Performance Measures for Adults with PAD JACC Vol. 56, No. 25, 2010 Bulmer AC, Coombes JS, Optimising exercise training in peripheral artery disease. Sports Med. 2004; 34 (14); 983-1003 4 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only. Criqui MH. The ankle-brachial index and incident cardiovascular events in the MESA (Multi-Ethnic Study of Athlerosclerosis) J Am Coll Cardiol 2010; 56: 1506-12.
Claudication: Only from PAD? Other Types of Claudication Spinal Canal Stenosis Peripheral Nueropathy Neuromuscular Pain (i.e. herniated disks) 5 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How Do We Misinterpret?????????????????????? 1. Varying interpretations of pain. 2. Variations in definition of different walking speeds. 3. Participants have altered their speed and walking habits due to the pain over time. Gardner, AW. Exercise performance in patients with peripheral arterial disease who have different types of exertional leg pain; J Vasc Surg 2007; 46: 79-86 6 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Typical Symptoms During Exercise, Usually with Walking Cramping Tightness Pressure Charley Horse Origin of Charlie Horse Named after an old white horse by the name of Charley. While pulling heavy loads the animal s legs stiffened so that he walked as if troubled with strained tendons. 7 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Less Obvious Claudication Symptoms With Exercise, Usually Walking Ache Burning Fatigue Similar to angina from the heart, we have found over the years that this discomfort can come in various forms. When taking a history, it is important to establish a pattern of exertional symptoms that do not have another cause such as neuromuscular or musculoskeletal origins. 8 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Co-Morbidities / Limitations What is really the most limiting issue? Orthopedic / Arthritic Chronic Fatigue Fibromyalgia Depression Neuromuscular Limitations Cardiovascular Pulmonary Cancer 9 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
PAD and Decreased Activity Cycle Risk Factors: Smoking, Sedentary behavior, Cholesterol, blood pressure, diabetes, age, genetics, etc. EXERCISE? Progression of atherosclerotic lesions: ABI < 0.90 EXERCISE? Symptoms: Person may have typical symptoms, atypical symptoms or even remain asymptomatic. EXERCISE? Functional Limitations: Increased sedentary behavior decreased strength, endurance, joint and muscle stiffness, impaired gait, onset of joint injuries, etc. EXERCISE? Disease process flourishes: Cardiovascular events, Critical leg ischemia, increased risk of cancer and other potential life altering conditions. EXERCISE? EXERCISE! Referred for exercise, better late than never. But, is much harder to be an effective therapy when it referred this late. 10 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
PAD and Decreased Activity Cycle 100 80 60 40 20 Active Sedentary 0 0 yrs 2 yrs 4 yrs 6 yrs 8 yrs Approximate Survival Rates Between Active vs. Sedentary Patients with PAD Sedentary was described as scoring 0 or 1 on the Johnson Space Center Physical Activity Scale (0=avoid physical activities whenever possible, 1= light physical activities done occasionally) Active described as 2 or higher (2=moderate physical activities done regularly for less than 1 hour per week) Adapted in part from Gardner, AW, Physical activity is a predictor of all-cause mortality in patients with intermittent claudication. J Vasc Surg 2008; 47:117-22 11 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Possible mechanisms of functional impairment and benefits of exercise Adapted in part from Hamburg and Balady, Exercise rehabilitation in peripheral artery disease: Functional impact and mechanisms of benefits. Circulation. 2011;123:87-97 and Kerry, S., et al, Exercise Training for Claudication, N Engl J Med, VOl. 347, No 24. December 12, 2002 Mechanism of Impairment Arterial obstruction Endothelial dysfunction Impaired hyperemic response Increased inflammation Mitochondrial dysfunction-impaired energy production Decreased muscle metabolism, oxygen extraction, oxygen utilization increased lactate production Inflammatory activation adverse skeletal muscle remodeling Decreased walking economy decline in walking speed, increased energy cost Increased blood viscosity and red cell aggregation 12 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only. Benefit of Exercise Collateral flow Improved NO vasodilation, increased capillary density Improved hyperemic blood flow Ischemia at any given workload-evidence of decreased systemic inflammation Improved mitochondrial energetics In mitochondrial biogenesis, improved oxidative metabolism and oxygen extraction Decreased markers of systemic inflammation walking mechanics, reduction in O2 cost of exercise Improved blood viscosity-improved oxygen availability to muscles.
How Does Exercise Measure Up? Adapted in part from, Kerry, S., et al, Exercise Training for Claudication, N Engl J Med, VOl. 347, No 24. December 12, 2002, Gardner et al, Exercise Rehabilitation Programs for the Treatment of Claudication Pain JAMA. 1995;274: 975-980, Beebe et al, A new pharmacological treatment for intermittent claudication: Results of a randomized, multi-center trial Arch Internal Med. 1999:159: 2041-50, Dawson et al, A comparison of Cilostazol and Pentoxifylline for treating intermittent claudication, Am J Med. 2000; 109: 523-530, PAD Coalition Website (September 2011) www.padcoalition.org, Ratliff, D.A., Supervised Exercise Training for Intermittent Claudication: Lasting Benefit at Three Years; Eur J Vasc Endovasc Surg, 34, 322e-326, 2007, Bulmer AC, Coombes JS, Optimising exercise training in peripheral artery disease. Sports Med. 2004; 34 (14); 983-1003, Regensteiner JG; Exercise rehabilitation for the patient with intermittent claudication: A highly effective yet underutilized treatment; Current Drug Targets Cardiovascular and Haematological Disorders, 2004, 4, 233-239 Treatment Result Safety Comments Exercise 120% to 400% (depending on study) improvement in time to onset of pain and total exercise time. Percutaneous Intervention Immediate symptom relief (most of the time), improvement in maximal walking distance similar to that of walking. Safe, effective, cardiovascular morbidity-mortality is rare. <0.5% morbidity and mortality Direct impact on risk and issues of functional decline Higher re-stenosis rate than with coronary PCI / stenting, limited due to anatomy, does not correct underlying issues leading to progression of PAD and functional decline. 13 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How Does Exercise Measure Up? -Continued- Treatment Result Safety Comments Surgical Revascularization Medications Symptom relief, improvement in maximal walking distance of 75-100% Cilostazol appears to be superior to Pentoxifylline, results vary but up to 100% improvement in onset to symptoms and over 150% improvement in maximal walking distance. 2-3% mortality, 5-10% morbidity Cilastazol contraindicated in those with CHF, potential drug side effects, frequent GI upset with Pentoxifylline Considerably higher risk therapy, long recovery time, does not correct underlying issues leading to progression of PAD and functional decline Not consistently as effective as exercise, potential side effects undesirable, does not correct underlying issues leading to progression of PAD and functional decline 14 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Exercise Testing Usually Treadmill Testing Note onset of symptoms Note total walking time Strongly consider pain trajectory Heart Monitoring? 15 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Exercise Prescription-What is Considered Best? TOP 4! WALKING WALKING WALKING WALKING BUT, IS IT REALLY THE BEST? 16 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Walking Walk to pain tolerance, rest, repeat 100-250% improvements in onset of pain and total distance (Ratliff) Put in perspective? What about pain free, go slow and long? Can work Progress not as good as intervals (Barak) May be best place to start for some Ratliff, D.A., Supervised Exercise Training for Intermittent Claudication: Lasting Benefit at Three Years; Eur J Vasc Endovasc Surg, 34, 322e-326, 2007 Barak, S. Benefits of low-intensity pain-free treadmill exercise on functional capacity of individuals presenting with intermittent claudication due to peripheral arterial disease. Angiology / Vol 60, No 4, August/September 2009 17 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Bike Treadmill superior to bike (Sanderson) Walking may improve if can cycle at high enough intensities to elicit pain (Sanderson) May improve adherence to exercise if can perform with less pain (Turner) Might consider incorporating into multimode approach Sanderson B. Short-term effects of cycle and treadmill training on exercise tolerance in peripheral arterial disease. J Vasc Surg 2006; 44: 119-27 18 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only. Turner SL. Cardiopulmonary responses to treadmill and cycle erogometry exercise in patients with peripheral vascular disease. J Vasc Surg 2008; 47: 123-50.
Strength Exercises Generally, Walking Still Wins What about research? No consistency Rigid protocols No real individualization Weakness an Equal Partner? Specificity and Individuality is the Key Mary M. McDermott; Philip Ades; Jack M. Guralnik; et al. Treadmill exercise and resistance training in patients with peripheral artery disease with or without intermittent claudication: A randomized controlled trial. JAMA. 2009;301(2):165-174 Hiatt, WR. Peripheral arterial and aortic diseases: Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease: Implications for the mechanism of the training response. Circulation; Vol 90(4), October 1994, 1866-1874. Ritti-Dias, Strength training increases walking tolerance in intermittent claudication patients: Randomized trial. J Vasc Surg 2010; 51:89-95. 19 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Arm Cranking? Increase Maximal Walking Distance (MWD) Increase in time to onset symptoms Treadmill still better in MWD Specificity? Suggest general cardiovascular conditioning effect? Walker, RD. Influence of upper and lower limb exercise training on cardiovascular function and walking distances in patients with intermittent claudication. J Vasc Surg 2000;31:662-9 Treat-Jacobson, et al, Efficacy of arm-ergometry versus treadmill exercise training to improve walking distance in patients with claudication; Vasc Med 2009; 14; 203 Tew, Limb-specific and cross-transfer effects of arm-crank exercise training in patients with symptomatic peripheral artery disease; Clinical Science (2009) 117; 405-413 20 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Volume and Intensity Days Per Week 3 Minutes Per Session 30 to 60 Weeks of Training 12 to 24 Total Volume of Training 2000 to 3000 minutes Work to Rest Ratio? Ideal? Intensity? Ideal? Bulmer AC, Coombes JS, Optimising exercise training in peripheral artery disease. Sports Med. 2004; 34 (14); 983-1003 21 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Measure Progress Exercise Testing Objective Subjective Specificity (does their exercise regimen uses the same mode in which you test) 22 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Measure Progress Pain Trajectories Typical: onset of pain, then maximal exercise tolerance. Trajectory: Progression of the severity. Use to identify more subtle changes. Explaining changes in trajectories may help with demonstrating progress to patients. Treat-Jacobson, et al, The Pain Trajectory During Treadmill Testing in Peripheral Artery Disease, Nursing Research, May/June 2011, 60:3S:S38-S49 23 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Pain Trajectories What s The Profile? 5 4 3 2 1 0 Linear Slow But Sure Fast Rise Source: Text is 9pt Arial Narrow 24 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Measure Progress Careful documentation of their initial and subsequent descriptions Get accurate information on their claudication symptoms. Time to first onset, total time, how many stops What it feels like, how it progresses (trajectory) Activities of Daily Living vs. Exercise 25 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Home Vs. Clinic Lack of outpatient programs Supervised Programs Generally Superior to Home Based Key to any program Adherence The more support the better especially for home based programs VS. Roberts, AJ. Physiological and functional impact of an unsupervised but supported exercise programme for claudicants. Eur J Vasc Endovasc Surg (2008) 36; 319e 324 Patterson, RB. Value of a supervised exercise program for the therapy of arterial claudication. J Vasc Surg, Vol 25(2), February 1997: 312-319 Wullink, M. A primary care walking exercise program for patients with intermittent claudication. Med Sci Sports Exerc Vol 33 Ni10, 2001, pp 1629-1634 Gardner, AW. Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication. Circulation 2011; 123:491-498. 26 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Troubleshooting I am not getting better, my leg still hurts when I exercise One of the most common complaints Get details on how far they are going, how long it takes them, how often they are stopping Ask about pain trajectory (time to initial onset, time to 1 st stop) Have them discuss with you activities of daily living Set a bench mark day to better assess progress 27 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Troubleshooting I can stand to walk with pain anymore Hard to deal with, especially if you do not see them often Install days off Exchange a walking day(s) with less painful mode Try shorter, more intense intervals, but with longer rest periods 28 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Troubleshooting It hurts too much to walk more than 1-2 minutes Good chance they are severely deconditioned OK to start with any kind of exercise Low volume, low intensity lower body strengthening exercises Non-weight bearing cardiovascular Add in weight bearing exercise very slowly Go Alternative! Remember the study about arm cranking and time to onset of symptoms? 29 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Succeed Consider actual contact time you will have What does your follow up look like (visits, phone calls, emails). How long do you follow up 30 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Succeed Establish trust. Review as much of the patients history as possible before they arrive. Greet them by looking in their eye and shake their hand. Ask them how they are doing. Ask what questions and concerns they want to make sure get answered Talk to them, not the computer (easer said than done) Perform active listening and communication skills. At the end of the appointment do not assume that they heard everything. Even if they were taking notes, they need to have the plan in writing from you, diagrams of exercises when possible, and what the follow up will look like. 31 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Succeed What type of progress are they are going to consider success? Is it going faster/further overall regardless of pain? Is it going further before they start to feel the pain? Lowering the amount of pain overall? Do they expect you to find a way to eliminate the pain? 32 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Succeed Remember that a person s emotions can contribute greatly to their pain. Regardless if it is due to physiology or psychology, it is their reality. You have to gain an understanding of all the possible factors that may be leading to their pain and although you may not be able to address all of them, you will have to most likely deal with multiple contributors. Personal and financial stressors may worsen the situation as much as lack of blood flow, arthritis, neuropathies and any musculoskeletal or neuromuscular issue. 33 April 1, 2015 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
Get em Active, Any Way You Can!