Exercise Training for Patients With Peripheral Arterial Occlusive Disease

Efficacy and Adherence

Background: One-third of all persons with peripheral arterial occlusive disease (PAOD) suffer from intermittent claudication. Exercise training under appropriate supervision is recommended in the pertinent guidelines, but physicians order it too rarely, and so-called vascular exercise groups are not available everywhere. This situation needs improvement in view of the importance of walking ability and cardiorespiratory fitness for patients’ quality of life and long-term disease outcome.

Methods: We review the scientific evidence on exercise training and on ways to lower barriers to the ordering of exercise training and to patient participation, on the basis of pertinent articles retrieved by a search of PubMed and in specialized sports science journals.

Results: 10 meta-analyses, 12 randomized controlled trials (RCTs), and 7 cohort studies were considered for this review. Large-scale cohort studies have shown that exercise is associated with a lower risk of death (relative risk 0.65–0.78 after 12 months of exercise training, compared to an inactive lifestyle). Exercise training also improves the maximal walking distance by a mean of 136 m (training at home) or 180–310 m (supervised training). An additional improvement by a mean of 282 m can be expected from a combination of exercise training and endovascular revascularization. Further behavior-modifying interventions, such as goal-setting, planning, and feedback, increase both the maximum walking distance and the weekly duration of exercise.

Conclusion: Exercise improves walking ability and lowers mortality. To attract patients with intermittent claudication to exercise training, a broad assortment of analog, digital and telemetric tools and a dense network of vascular exercise groups should be made available, along with regular contact between physicians and patients.

About one-third of all persons with peripheral arterial occlusive disease (PAOD) suffer from intermittent claudication (1). Their quality of life is affected by calf pain (1). In addition, they are at high cardiovascular risk (amputation-free survival after five years ranges between 52% and 91%, depending on age and comorbidities) (2). Progression of the disease is to be expected in about one-quarter of patients (1).

Exercise can improve the symptoms, the quality of life and the prognosis of PAOD patients (3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19). A significant inverse dose-response relationship is found between exercise and all-cause mortality (7, 10, 11, 20). Despite the fact that, due to the significant evidence in support of this association, exercise training under appropriate supervision is clearly recommended in the pertinent guidelines as part of conservative treatment (level of evidence: 1; grade of recommendation: A) (21, 22, 23, 24, 25, 26), this recommendation is rarely followed in practice (27). Patients are often not informed about the risks and possibilities of influencing the disease and are not given much support in making the necessary behavioral changes. Until today, so-called vascular exercise groups are not available everywhere in Germany (28, 29, 30, 31).

The aim of this review is to provide an overview of the available research evidence on exercise training for patients with PAOD to shed light on the problem of treatment adherence and to propose motivation concepts.

Methods

We searched the PubMed database, using the following search terms: “peripheral artery disease“, “claudication”, “intermittent claudication”, “supervised exercise”, ”home-based exercise”, “exercise therapy”, “physical activity”, “walking training”, and “exercise program”. In addition, we considered references from the field of sports science as well as online documents of the German Federal Ministry of Health (BMG, Bundesgesundheitsministerium), the German Federal Joint Committee (G-BA, Gemeinsamer Bundesausschuss), the German Society for Angiology – Society for Vascular Medicine e.V. (DGA), the German Vascular League e.V. (Deutsche Gefäßliga e. V.), and the UK’s National Institute for Health and Care Excellence (NICE).

Management and secondary prevention of intermittent claudication

Exercise training is just as much an integral part of guideline-adherent therapy of PAOD as is the control of blood pressure and blood glucose levels and the use of statins and antiplatelet agents. It is also essential that smokers quit their nicotine habits (21, 22, 31). In addition, it is possible to address overweight and systemic inflammatory processes through diet. Fruit, vegetables, nuts, pulses, whole grains, and fish are considered healthy foods (32).

Ideally, exercise training is supervised by certified persons (German Society for the Prevention and Rehabilitation of Cardiovascular Diseases [DGPR, Deutsche Gesellschaft für Prävention und Rehabilitation von Herz-Kreislauferkrankungen e. V.]) (33, 34). Apart from a heart group leader’s license, those who take on the supervision of vascular exercise groups should also be qualified as vascular exercise coaches (“Gefäßsporttrainer“, DGPR). Home training is an alternative or complementary option (35, 36, 37, 38, 39). In severely impaired patients, endovascular revascularization should be considered as a supportive measure (40).

Efficacy of exercise training

There is a substantial body of evidence to support a reduction in risk through exercise (eTable 1) (4, 8, 9, 10, 11, 12, 13, 14). In addition, lack of exercise has been found to be an independent risk factor for mortality and morbidity (15, 16). Exercise training plays a significant role in increasing cardiorespiratory fitness (CRF), a factor which is strongly associated with both the risk of cardiovascular events, such as arrhythmia and thrombosis, and mortality.

eTable 1

Association between physical activity and mortality

CRF is in fact a stronger predictor of mortality than diabetes (e1, e2, e3). It describes the maximum performance, i.e. the aerobic capacity of the body (maximum oxygen uptake VO2-max in mL/kg/min). The resting oxygen uptake capacity corresponds to a metabolic equivalent of task (MET). A healthy middle-aged adult has a CRF of 8 to 12 MET. CRF declines with age and is lower in women. A meta-analysis of 33 cohort studies showed that an increase in CRF by 1 MET was associated with a decrease in mortality by 13% (pooled relative risk [RR] 0.87; follow-up: 1–26 years) (e4).

Furthermore, it is well supported by evidence that exercise training improves walking ability and quality of life in patients with PAOD (eTable 2) (17, 18, 19, 33, 34, 37, 38, 39, e5, e6, e7, e8). The exact mechanism is not yet fully understood. Improvements in endothelial function and increases in capillary density in muscle tissue have been described. Exercise training improves mitochondrial function in muscle cells, while inflammatory mediators decrease. Consequently, muscular microcirculation and metabolism are improved. In addition, there is an increase in cardiac stroke volume, oxygen transport and metabolism as well as insulin sensitivity (23, e9). After about four weeks of exercise training, an improvement in walking ability can be expected (e10).

eTable 2

Efficacy of exercise training in PAOD with regard to walking ability and quality of life

With regard to walking ability, combining exercise training and revascularization has been shown to be more effective overall than either measure alone (19, e5, e7, e8). In addition, patients who engaged in exercise training after a peripheral revascularization procedure required repeat revascularization less frequently (3, e11) (eTable 2).

The practice of exercise training

Classical walking training involves a minimum of three weekly sessions, each of 30 to 45 minutes of actual walking time. With treadmill training, patients start at a comfortable speed with no incline. A short break of about one minute is made each time a patient starts to experience moderate to severe calf pain. The intensity level should be chosen so that patients can walk for 5 to 10 minutes without stopping. Once they can walk for more than 10 minutes without stopping, the intensity (speed and incline) can be gradually increased. Ultimately, the success of walking training depends more on training intensity than on training duration and frequency. Later in the training program, walking training can be supplemented by resistance training. Possible alternatives to classical treadmill training include physical activities such as climbing stairs, pedaling in a lying position, upper-arm ergometry, cycling training or everyday activities. These are particularly useful in patients with severe intermittent claudication, previous falls and unsteady gait, or if patients are reluctant to commit to the training. Training should be ongoing and preferably be carried out at moderate to high intensity (7, 9, 10, 11, 12, 17, 23, 25, e1, e9, e10, e12, e13, e14) (Table 1).

Table 1

Recommendations for improving walking ability and cardiovascular fitness

Table 2 lists various examples of the intensity of physical activities (e2, e15, e16). A moderate to strong intensity corresponds to ≥ 3 MET. The exercise training program should consist of ≥ 500–1000 MET minutes per week (9, e10, e12, e13, e16, e17). This unit of measurement is based on the intensity (MET) and duration (in minutes) of the respective activity. Supervised exercise training for a minimum of twelve weeks is considered the gold standard. The training should then be continued independently as part of everyday life. If patients cannot or only for a limited time participate in a supervised exercise training program, training at home should be recommended as an alternative or in addition. This also leads to improvements in walking ability and CRF, depending on training duration and intensity (17, 38, 39) (eTable 2).

Table 2

Intensity of various physical activities

Overcoming personal barriers

With regard to the physical activity of PAOD patients, the current picture is one of missed opportunities. Presently, primary care physicians and hospital doctors discuss exercise training with only one in three patients with intermittent claudication (29, 30). A survey study on inpatients in German hospitals found that only 11% of the PAOD patient in this patient population had ever participated in an exercise training program. Only 26% felt appropriately informed about the advantage of exercise training by their GP practice and only 25% had access to information about local exercise training programs. Yet, a majority of these patients (65%) found it conceivable that supervised exercise training may improve their walking ability (28, 30). Physicians cited a lack of time, inadequate financial compensation and a lack of trust in patients‘ willingness to commit to exercise training as reasons for not devoting much time to this topic, as well as the lack of vascular exercise groups (39).

According to the transtheoretical model, the stages of change are pre-contemplation, contemplation, preparation, action, and maintenance (e18, e19). Based on this model, a phased approach to counseling is advisable. One example of this approach is described in the guideline on physical activity advice of the National Institute for Health and Care Excellence (NICE, Manchester, UK) (see Box) (25).

Box

Offerings and guides for physical activity

Identifying risk behavior

Given its prognostic significance, physicians should ask patients about their physical activity as a “vital parameter”: whether or not, what kind, for how long, how frequently (25, 29). During a routine visit, this should take no longer than three to four minutes..

Recommending action

Once the assessment has been completed, patients are informed about the health benefits of physical activity (e10, e20). However, appeals and general advice alone are usually ineffective (e21, e22).

Exploring willingness

Next, patients are asked whether they are willing to change their behavior. Are the patients willing to start exercise training? Are there any obstacles? How could they start?

Providing support

In order to reduce the burden on consultation hours, responsibilities in the provision of patient support should be allocated to the practice team and/or external service providers at the outset. Patients can be referred for further advice and examinations to outpatient vascular centers and/or for information about regional vascular exercise groups (Box). Physicians can prescribe vascular exercise by means of an application for coverage of the costs of sports rehabilitation. Guides in the form of brochures as well as exercise instructions are helpful. Further options include telemetric physical exercise programs and digital applications.

Giving feedback

The critical factor for success is not the length of the first consultation, but the regular feedback between the physician/health professional and the patient (18, 25, 28, 35, 36, e22, e23, e24, e25, e26, e27) (Table 3).

Table 3

Efficacy of behavioral interventions as a supplement to exercise training

Convincing patients to commit to more exercise

Physical inactivity is a risk factor that can be directly influenced by patients themselves. An improvement in CRF from a lower to a medium level is associated with a greater reduction in mortality risk than an increase from a medium to a higher level (e1, e2, e4, e15, e28). Consequently, the worse their status at baseline, the less effort patients have to make to improve their CRF. The prescription of patient-controlled training ideally includes the necessary concrete and individual recommendations (e9) as well as additional behavior change interventions (e29).

To date, only few randomized controlled trials have provided data on the effectiveness of supplementary behavioral interventions in patient with PAOD (Table 3). Based on these studies, it is not clear what contribution the respective interventions can actually make—a gap in research that needs to be filled in the future. Nevertheless, study results as well as insights especially from sport psychology (e30, e31, e32) and rehabilitation and nutritional medicine (e27, e33) suggest that recommendations should be made and underpinned with concrete goals, a plan and regular feedback.

Setting goals

The most promising approach is to encourage patients to image their personal goals (“imagery intervention” [e31]) and to formulate these themselves (e34). This approach strengths self-reflection and personal responsibility. Examples include: “I want to be able again to independently go shopping“, “. . . wander through town“, “. . . play with the grandchildren “, “. . . walk the dog“, “. . . live a long active life“. These overarching, long-term goals are usually more concrete than goals such as “I would like to exercise more“ and less abstract than an “increase in pain-free walking distance” (e21). In addition, subordinate, short-term goals are set. It has been shown that process goals, such as to go jogging every day during the next six weeks or to go swimming twice a week, are more effective than performance goals, such as step count and walking time, or outcome goals (e32). The short-term goals should be low-threshold, regularly adjusted and gradually increased as much as possible (e33).

Planning concrete actions

Next, the physician agrees concrete steps with the patient (e30) (medical prescription). What is realistic from a personal perspective? For example: “I will start with it . . . “. When, how and where the intention shall be implemented is best described by means of an If-Then plan: “If I have Friday off, I go jogging in the park.“ Furthermore, walking-free alternatives to classical treadmill training can be proposed on an individual basis. These activities not only improve cardiovascular fitness, but also the patient’s walking ability. Depending on the patient’s preferences, everyday activities, such as gardening, brisk walking and ascending or descending stairs quickly, are also options to consider (e21) (Table 1). It can be decided on a case-by-case basis whether the training is to be supervised by a professional or controlled by the patient. It is also possible to combine the two approaches. Generally, adherence to therapy is higher if the training is controlled by patients themselves; however, this advantage comes at the price of training intensity.

Conducting feedback discussions

For feedback, regular communication is advisable (25), including over the phone, if possible. In patients aged 60 years and older, however, a personal discussion is more effective than a phone conversation (e35). Feedback discussions are intended to encourage patients experiencing lethargy or facing obstacles. It is also part of the feedback discussion to ask the patient questions about their own perception of the training: Is the exercise plan realistic? Is the training perceived as pleasant and strengthening?

Technologies, such as pedometers or tracking the walking distance with Google Maps or smartphone applications (“remote supervision”), help with self-monitoring of physical activity. Applications with a fun factor (gamification, sports games) are now available too (36, e36, e37, e38). Alternatively or in addition, an activity diary can be kept. Adherence to therapy and any progress made should be rewarded with recognition in order to strengthen the patient’s belief in self-efficacy.

Involving the social environment to boost motivation

The involvement of the patient’s partner or family or the use of social media, online forums or a group provide a social component that helps to associate exercise training with positive emotions. This has a motivational effect and improves treatment adherence. By contrast, depression and chronic stress make the implementation of exercise training more challenging (e33, e39, e40). In patients with advanced intermittent claudication, a clinically indicated revascularization procedure can be a powerful cue to action that increases treatment adherence.

Closing gaps in routine care

The current situation is such that patients with PAOD are not informed about risk factors and supported in making behavioral changes in the best possible way (30). Furthermore, a denser network of vascular exercise groups would be desirable (22). In this context, incentives for providing low-threshold opportunities to establish training groups should be discussed. For this reason, we present two examples of projects here that still need to be evaluated with regard to their practical implementation in routine care: the project “Gesundheitscoaching und telemetrisch unterstütztes Gehtraining“ (pAVK-TeGeCoach, Health Coaching and Telemetrically Supported Walking Training) (36) and the project “Gefäß-Check der Beine“ (Vascular Check of the Legs).

pAVK-TeGeCoach

With this care model, training at home was supported by telephone coaching through physician-managed telemedicine centers. In a randomized study on 1982 patients with intermittent claudication, patients allocated to the intervention group received telephone feedback on a regular basis. This feedback was based on telemetrically transmitted data from fitness wristbands. In addition to routine care, patients in the control group only received information material on lifestyle changes. The results, which can be found on the G-BA-Innovationsfonds website, show a significantly larger improvement in walking ability in the intervention group at 12 months compared to the control group: improvement in Walking Impairment Questionnaire [WIQ] score by 6.3 points; p<0.001 [effect size is with d = 0.26 above the minimal clinically important difference of d>0.20]. At 24 months, the effect was no longer clinically important (36). A resolution passed by the Federal Joint Committee (G-BA) on 24 January 2023 provides for an assessment of a nationwide implementation of this care model into routine care.

Vascular Check of the Legs

The “Gefäß-Check der Beine” project is a regional pilot project at the Jena University Hospital. It enables community-based physicians to offer patients with suspected PAOD a low-threshold “vascular check of the legs”. Based on the walk-in clinic model, the “vascular check” is performed in a specialist outpatient clinic at short notice without waiting time. The check includes a structured sequence of tests, including walking test, ankle-brachial index (ABI) and vascular Doppler ultrasound. The results should typically be available on the same day as the examination, together with treatment recommendations. The aim is early detection of PAOD so that progression and hospitalization can be prevented. Digitally supported training at home is arranged with patients who are diagnosed with PAOD. Follow-up examinations and feedback discussions, complementing the consultations with the primary care physician, are an integral part of this project.

Conclusion

Despite the strong evidence supporting its efficacy in patients with intermittent claudication, exercise training has not yet been adopted in clinical practice everywhere. Given the great prognostic significance of physical activity, a stronger support of PAOD patients by their physicians is desirable. This in turn requires that more exercise training opportunities are offered.

Conflict of interest statement
The authors declare that no conflict of interest exists.

Manuscript received on 17 May 2023, revised version accepted on 18 October 2023.

Translated from the original German by Ralf Thoene, MD.

Corresponding author
Prof. Dr. med. Ulf Teichgräber
Institut für Diagnostische und Interventionelle Radiologie
Friedrich-Schiller-Universität Jena
Universitätsklinikum Jena,
Am Klinikum 1, 07747 Jena, Germany

Cite this as:
Ingwersen M, Kunstmann I, Oswald C, Best N, Weisser B, Teichgräber U: Exercise training for patients with peripheral arterial occlusive disease—
efficacy and adherence. Dtsch Arztebl Int 2023; 120: 879–85. DOI: 10.3238/arztebl.m2023.0231

►Supplementary material

eReferences, eTables:
www.aerzteblatt-international.de/m2023.0231

cme plus

This article has been certified by the North Rhine Academy for Continuing Medical Education. Participation in the CME certification program is possible only over the internet: cme.aerzteblatt.de. The deadline for submission is 26 December 2024.

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