Prediction of the effect of training on the walking tolerance in patients with intermittent claudication

The possibility of predicting the effect of training on the walking tolerance in intermittent claudication has been studied. After three months of supervised training in 54 patients, the maximal walking distance (MWD) increased by 67% and the painfree walking distance (PFD) by 91%. The analysis of the relation between tested background variables and the effect of training showed covariation only in 14% of the increase in MWD and in 19% of the increase in PFD. The possibility of predicting the effect of training on the walking tolerance in the individual patient with intermittent claudication is limited.     

Poor reproducibility of exercise test in assessment of claudication

To assess reproducibility of the exercise test in intermittent claudication, a prospective, comparative, randomized study was undertaken. Ten patients with stable intermittent claudication of ischaemic origin were exercised on a flat surface (0-Ex), with 12% steady inclination (12-Ex) and with progressively increasing inclination (p-Ex) in a random order during three different sessions. The ankle–brachial index (ABI) at rest and after exercise (rABI, exABI), initial and maximum walking distance (IWD, MWD) and metabolic equivalent (MET) were obtained as the main outcome measures. The results were analysed using intraindividual coefficients of variation (CVs) and standard deviations (SDs). The ABI values of the worst extremity were used in evaluation of results. Reproducibility of the exercise ABI appeared to be good, especially during progressively increasing exercise, the mean CV being 9 ± 5%. The best mean CV was observed during p-Ex (16% ± 14%) for maximum walking distance. The mean CV for initial walking distances ranged from 30% to 54%. Treadmill exercise testing to measure walking distances is highly inaccurate and the value of exercise on the flat treadmill should be questioned. Graded exercise appeared to be the most reproducible in this respect. The ABI after exercise, however, was a reliable single parameter when assessing arterial insufficiency causing decreased walking capacity.     

Potential clinical utility of partial body weight support on treadmill walking time in persons with intermittent claudication: A single case report

Intermittent claudication can seriously limit an individual's walking capacity. Walking programs are known to improve this limitation but could be limited by a person's ability to carry his or her own full body weight to perform the walking. We theorized that decreasing body weight, through mechanical unloading, might allow longer pain-free walking, thus potentially accelerating exercise training. This case report describes the effect of partial body weight support (PBWS) on walking time in a patient with claudication. A 60-year-old male with calf pain that prevented him from walking long distances or walking quickly was studied. The patient completed three treadmill walking tests (0%, 25%, and 50% PBWS) until claudication pain stopped him or 15 minutes elapsed. The participant walked 4:31 minutes at 0% PBWS with a pain rating of 3/4. He walked the full 15 minutes under each support condition with the same or less claudication pain (3/4 for 25% PBWS, 2/4 for 50% PBWS). This case reports the successful use of PBWS treadmill training for increasing walking time in an individual with intermittent claudication. If this finding holds true for a larger sample, PBWS may be a way for these individuals to participate in exercise training programs with less pain.     

Effects of intermittent claudication due to arterial disease on pain-free gait

IntroductionStudies of intermittent claudication gait report inconsistent outcomes. Changes in gait are often attributed to degradation of calf muscles, but causation has not been proven through real-time electromyographic data. Neither have effects of walking speed been fully considered. This study aimed to investigate the effect of intermittent claudication on kinematics, kinetics and muscle activity during pain-free gait.Methods18 able bodied individuals and 18 with intermittent claudication walked at their preferred speed while lower limb kinematic, kinetic and electromyography data were collected.FindingsPeople with intermittent claudication walk slower and with reduced step length. Internal ankle plantarflexion moment (P = 0.004, effect size = 0.96) and ankle power generation (P < 0.001, effect size = 1.36) in late stance were significantly reduced for individuals with intermittent claudication. Significant moment and power reductions at the knee and power reduction at hip occurred in early stance, with similar reductions in early and late stance for ground reaction forces. Peak electromyography of soleus activity was significantly reduced in late stance (P = 0.01, effect size = 1.1, n = 13). Effects were independent of walking speed.InterpretationReductions in ankle plantarflexion moments and power generation were consistent with reduced soleus electromyography activity and reduced peak vertical ground reaction forces during late stance. These effects are not due to a reduced walking speed. Changes in knee and hip function are also unrelated to walking speed. These outcomes provide a platform for the design and evaluation of interventions that seek to restore normal walking and improve pain-free walking distances for people with intermittent claudication.     

Potential clinical utility of partial body weight support on treadmill walking time in persons with intermittent claudication: a single case report

Intermittent claudication can seriously limit an individual's walking capacity. Walking programs are known to improve this limitation but could be limited by a person's ability to carry his or her own full body weight to perform the walking. We theorized that decreasing body weight, through mechanical unloading, might allow longer pain-free walking, thus potentially accelerating exercise training. This case report describes the effect of partial body weight support (PBWS) on walking time in a patient with claudication. A 60-year-old male with calf pain that prevented him from walking long distances or walking quickly was studied. The patient completed three treadmill walking tests (0%, 25%, and 50% PBWS) until claudication pain stopped him or 15 minutes elapsed. The participant walked 4:31 minutes at 0% PBWS with a pain rating of 3/4. He walked the full 15 minutes under each support condition with the same or less claudication pain (3/4 for 25% PBWS, 2/4 for 50% PBWS). This case reports the successful use of PBWS treadmill training for increasing walking time in an individual with intermittent claudication. If this finding holds true for a larger sample, PBWS may be a way for these individuals to participate in exercise training programs with less pain.     

Nordic pole walking improves walking capacity in patients with intermittent claudication: a randomized controlled trial

Purpose: The aim of the study was to compare the efficacy of Nordic pole walking (NPW) training with traditional treadmill training (TT) on a claudication (CD) and maximum walking distance (MWD) in patients with peripheral arterial disease (PAD). Method: Patients with intermittent claudication (IC) (n?=?70; age=68.27) in the Fontaine class II were randomized into a two three-month rehabilitation programs performed three times per week. TT were finished by 31 patients, NPW by 21. Walking capacity was measured by an exercise treadmill test (ETT) with the Gardner–Skinner protocol (before and after the program) and six minute walk test (6MWT) (before, during and after the program). Results: In an ETT both groups reached significant increase in CD and MWD (p?≤?0.005). In 6MWT NPW group reached significant increase in both CD (p?=?0.001) and MWD (p?=?0.001), whereas the TT group only in MWD (p?=?0.001). Conclusions: NPW has been shown to be as effective as the standard TT and is much less expensive. It should be the preferred method of exercise for PAD patients with IC.

• Implications for Rehabilitation

• Nordic walking training is a valuable form of rehabilitation for peripheral arterial disease (PAD) patients with intermittent claudication (IC).

• Nordic walking has been shown to be as efficient as traditional treadmill training. It is however more cost-effective method of rehabilitation in PAD patients.

     

Cardiovascular training effect associated with polestriding exercise in patients with peripheral arterial disease

Because individuals with claudication pain secondary to peripheral arterial disease (PAD) are limited in both walking speed and duration, the benefits of walking exercise may be insufficient to yield a cardiovascular training effect. The objectives of this analysis were to determine whether polestriding exercise training, performed by persons with PAD, would improve exercise endurance, elicit a cardiovascular training benefit, and improve quality of life (QoL). Persons (n = 49) whose claudication pain limited their exercise capacity were randomized into a 24-week polestriding training program (n = 25, 65.8 +/- 7.1 years of age) or a nonexercise attention control group (n = 24, 68.0 +/- 8.6 years of age). Those assigned to the polestriding group trained 3 times weekly. Control group subjects came to the laboratory biweekly for ankle blood pressure measurements. A symptom-limited ramp treadmill test, ratings of perceived leg pain, and QoL data (using the Short Form-36) were obtained at baseline and upon completion of training. After 24 weeks of polestriding training, subjects increased their exercise endurance from 10.3 +/- 4.1 minute to 15.1 +/- 4.5 minute. This was significantly greater than control group subjects whose exercise endurance declined (from 11.2 +/- 4.7 to 10.3 +/- 4.7 minute; P < .001). Relationships between systolic blood pressure (P < .001), heart rate (P = .04), rate pressure product (P = .05), oxygen uptake (P = .016), and perceived leg pain (P = .02) and exercise time improved from the baseline symptom-limited treadmill test to the 6-month symptom-limited treadmill test in the polestriding group compared to the control group. The improvement in the physical component summary score of the Short Form-36 was also greater in the polestriding group (P = .031). Polestriding training significantly improved the clinical indicators of cardiovascular fitness and QoL, and decreased symptoms of claudication pain during exertion.     

Rocker-soled shoes and walking distance in patients with calf claudication

Calf claudication is the major clinical manifestation of peripheral vascular occlusive disease in a significant number of patients. Although claudication causes substantial patient disability, most patients are treated conservatively because of the risks of surgical therapy and the uncertain efficacy of drug therapy. It was hypothesized that rocker-soled shoes would decrease the work of the plantar flexors and therefore increase walking distance in patients with calf claudication. To test this hypothesis, walking distances in patients with calf claudication using rocker-soled shoes and a placebo shoe insert were compared. Rocker-soled shoes significantly increased both the total distance walked and the distance at which patients were initially bothered by symptoms by 77m (37%, p less than .0005) and 89m (91%, p = .003), respectively. It was concluded that rocker-soled shoes may reduce disability in patients with calf claudication by increasing walking distance.     

The case for intermittent pneumatic compression of the lower extremity as a novel treatment in arterial claudication

Appreciation of the physiologic role of the natural muscle pumps of the lower limb in enhancing the return of venous blood promoted the development of intermittent pneumatic limb compression (IPC) systems that could activate these pumps artificially. The application of IPC to the foot (IPC(foot)), calf (IPC(calf)) or both (IPC(foot + calf)) on dependency generates a significant acute arterial leg inflow enhancement in patients with intermittent claudication that is highest with IPC(foot + calf), followed by IPC(calf) and IPC(foot). This enhancement is attributable to the leg venous pressure decrease after venous expulsion with IPC, which results in arteriovenous pressure elevation, and a marked attenuation in peripheral resistance to flow due to a transient abolition of peripheral sympathetic autoregulation and the release of nitric oxide. Implementation of IPC(foot) and IPC(foot + calf) for 3 to 5 months (> or = 2.5 hours/day) has been shown to improve the walking capacity and the ankle pressure indices of patients with intermittent claudication, with a significant beneficial impact on the quality of life. As the prevalence of symptomatic peripheral arterial disease is projected to increase substantially over the next decades with the aging population in Western societies and in the absence of established, cost-effective methods of treatment for claudication, the reported efficacy of IPC in claudication certainly warrants clinical attention. Level-1 clinical evidence by three independent investigators supports the clinical role of IPC in arterial claudication, reinforced by its domiciliary applicability, the high patient compliance with which it is associated, and the modest cost. This review offers an insight into the hemodynamic and clinical effects of IPC in patients with claudication in relation to the physiologic mechanisms proposed in explanation of these effects.     

Effect of training on the post-exercise ankle blood pressure reaction in patients with intermittent claudication

Summary. The effect of physical training on the post-exercise blood pressure reaction in the ankle was studied in 63 patients with intermittent claudication but without angina pectoris. After three months of supervised training the maximal walking distance increased by 67% and the pain-free walking distance by 73%. Compared with that after the pre-training treadmill test, the ankle blood pressure was significantly higher 2–16 min after the post-training test and more rapidly returned to the initial resting value, both with similar work loads and with a higher post-training work load. Blood pressure measurement in the ankle after exercise is useful as an objective test of the circulatory effect of training in patients with intermittent claudication.     

Calf muscle adaptation in intermittent claudication. Side-differences in muscle metabolic characteristics in patients with unilateral arterial disease

Summary. The adaptation of enzyme activities, notably in the oxidative metabolism, and of prerequisites for tissue transport of oxygen in the claudication leg was evaluated by comparing muscle biopsies from the gastrocnemius muscle of the claudication and the symptom-free leg of seven patients with unilateral claudication. The claudication leg had higher activities of a marker enzyme for mitochondrial oxidative capacity, citrate synthase (CS), as well as of the MB and the mitochondrial isoenzyme of creatine kinase (CK), which are considered to be involved in the transfer of high energy phosphate from the mitochondria to the resynthesis of ATP in the cytoplasm. The difference between claudication and healthy leg in activities of these CK isoenzymes were well correlated with the corresponding side difference in CS activity. No significant differences between claudication and healthy leg were found in distribution of muscle fibre types or fibre dimension, capillary density or myoglobin content, nor was there any side difference in phosphofructokinase or lactate dehydrogenase. Side differences tended to be greater in those patients with the most advanced obstructive arterial disease as estimated from non-invasive pressure measurements. It is concluded that in reasonably physically-active patients, the mode of ischaemia to which the claudication leg is subjected leads to a metabolic adaptation characterized by increased activities of enzymes involved in the oxidative metabolism, but no significant adaptation of either the conditions for local oxygen transport, as estimated by myoglobin content, and capillary density, or capacity for anaerobic metabolism.     

Activities of key enzymes in the energy metabolism of human myocardial and skeletal muscle

Summary. Activities of total creatine kinase (CK), its isoenzyme MB (CK-MB), total lactate dehydrogenase (LD) and its isoenzyme LD₁, phosphofructokinase (PFK), asparate aminotransferase (ASAT) and citrate synthase (CS) were determined in skeletal muscle biopsies obtained from physically trained and untrained men and in myocardial biopsies from patients subjected to open heart surgery because of valve disease. The LD₁, ASAT and CS activities were higher in trained than in untrained skeletal muscle and still higher in heart muscle than in either trained or untrained skeletal muscle. The CK-MB activity was higher in trained than untrained skeletal muscle and the myocardial CK-MB activity was similar to that in trained skeletal muscle. Total CK activity was slightly lower in trained than in untrained skeletal muscle and the myocardial CK activity was approximately one third of the skeletal muscle CK. Both the PFK and the total LD activity was of similar magnitude in the different muscle types. In conclusion, as estimated by enzyme activities, the oxidative capacity is 2–3 times larger in myocardial than in skeletal muscle, while the glycolytic capacity as estimated by PFK appears to be the same.     

Effects of Vacusac in intermittent claudication: a controlled cross-over study

Summary. The effect of a new physical treatment modality, Vacusac, was tested on a group of patients with stable intermittent claudication. Twenty-two patients with a median age of 65 years and a median duration of intermittent claudication of 5 years were randomized to either active or placebo treatments. Seventeen patients completed the study. The effect of treatment was quantified by measurements of systemic -and peripheral systolic blood pressures and by measurements of the pain-free and the maximal walking distance on a treadmill. The ankle pressure index (ankle systolic pressure/arm systolic pressure) and toe pressure index (toe systolic pressure/arm systolic pressure) were calculated. After 25 active treatments, administered over a period of 2 months, the patients allocated to this group attained a significant increase in the pain-free walking distance from 54 m (24–107 m) to 99 m (30–420 m) (P < 0·05) and in the maximal walking distance from 99 m (36–182 m) to 185 m (68–591 m) (P < 0·05). The patient group receiving 25 placebo treatments did not show any significant changes in either the pain-free or the maximal walking distance. This group then received 25 active treatments over a period of 2 months. This active treatment resulted in a significant increase in the pain-free walking distance from 51 m (14–100 m) to 86 m (18–1000 m) (P < 0·05) and in the maximal walking distance from 98 m (40–199 m) to 175 m (51–1000 m) (P < 0·05). Ten out of the 17 patients who completed the study achieved a doubling of their maximal walking distance. The patients randomized to active treatment attained a significant increase in the ankle pressure index from 0–46 (0–39-0·67) to 0·58 (0·46-0·94) (P < 0·05) while the toe pressure index was unchanged. The patients randomized to placebo treatment did not show any significant changes in these ratios, either during the period of placebo treatment, or during the period of active treatment. In conclusion, our study has shown that physical treatment with the Vacusac equipment significantly increases the walking distance in patients with stable, intermittent claudication of long duration.     

Muscle strength,aerobic capacity and physical activity in independent ambulating children with lumbosacral spina bifida

Purpose. This cross-sectional study investigates deficits and associations in muscle strength, 6-minute walking distance (6MWD), aerobic capacity (VO_2peak), and physical activity (PA) in independent ambulatory children with lumbosacral spina bifida.

Method. Twenty-tree children participated (13 boys, 10 girls). Mean age (SD): 10.4 (±3.1) years. Muscle strength (manual muscle testing and hand-held dynamometry), 6MWD, VO_2peak (maximal exercise test on a treadmill), and PA (quantity and energy expenditure [EE]), were measured and compared with aged-matched reference values.

Results. Strength of upper and lower extremity muscles, and VO_2peak were significantly lower compared to reference values. Mean Z-scores ranged from ?1.2 to ?2.9 for muscle strength, and from ?1.7 to ?4.1 for VO2peak. EE ranged from 73 – 84% of predicted EE. 6MWD was significantly associated with muscle strength of hip abductors and foot dorsal flexors. VO_2peak was significantly associated with strength of hip flexors, hip abductors, knee extensors, foot dorsal flexors, and calf muscles.

Conclusions. These children have significantly reduced muscle strength, 6MWD, VO_2peak and lower levels of PA, compared to reference values. VO_2peak and 6MWD were significantly associated with muscle strength, especially with hip abductor and ankle muscles. Therefore, even in independent ambulating children training on endurance and muscle strength seems indicated.     

Relieving intermittent claudication: A nursing approach

Peripheral arterial disease affects at least 10% of adults older than 70 years. Risk factors such as diabetes, hypertension, hyperlipidemia, history of smoking, and genetics increase the incidence of the disease. Intermittent claudication, experienced as calf pain or cramping, is the primary symptom in patients with lower-extremity peripheral arterial disease. Patients with claudication are unable to walk even moderate distances. As a result, they often lead lives that are profoundly restricted. Medical therapeutic options available for patients with intermittent claudication are limited to a small number of medications and walking exercise rehabilitation. Walking exercise training can significantly increase ability and decrease calf discomfort for many patients. Nurses can have a major impact on improving the quality of life of patients with claudication, not only by seeking referrals to established institutional walking exercise programs, but also by helping patients in the community develop a personalized walking program. In this article, a nursing plan of care including short-term and long-term goals is addressed. A case study will illustrate the effectiveness and improved quality of life that an individualized program of walking exercise had for one community-based client.     

Physiological and symptomatic responses to cycling and walking in intermittent claudication

To shed light on the potential efficacy of cycling as a testing modality in the treatment of intermittent claudication (IC), this study compared physiological and symptomatic responses to graded walking and cycling tests in claudicants. Sixteen subjects with peripheral arterial disease (resting ankle: brachial index (ABI) < 0.9) and IC completed a maximal graded treadmill walking (T) and cycle (C) test after three familiarization tests on each mode. During each test, symptoms, oxygen uptake (VO2), minute ventilation (VE), respiratory exchange ratio (RER) and heart rate (HR) were measured, and for 10 min after each test the brachial and ankle systolic pressures were recorded. All but one subject experienced calf pain as the primary limiting symptom during T; whereas the symptoms were more varied during C and included thigh pain, calf pain and dyspnoea. Although maximal exercise time was significantly longer on C than T (690 +/- 67 vs. 495 +/- 57 s), peak VO2, peak VE and peak heart rate during C and T were not different; whereas peak RER was higher during C. These responses during C and T were also positively correlated (P < 0.05) with each other, with the exception of RER. The postexercise systolic pressures were also not different between C and T. However, the peak decline in ankle pressures from resting values after C and T were not correlated with each other. These data demonstrate that cycling and walking induce a similar level of metabolic and cardiovascular strain, but that the primary limiting symptoms and haemodynamic response in an individual's extremity, measured after exercise, can differ substantially between these two modes.     

Pain in chronic arterial occlusive disease--the effect of improved macrocirculation on pseudo-radicular irritation]

In chronic obliterating arteriopathy the maximum walking distance does not correlate well with the ankle arm index of arterial pressure measured by Doppler ultrasound. Beside reduced macrocirculation and microcirculatory maldistribution in skeletal muscle, pseudoradicular irritation was established as a relevant factor for the onset of pain during walking. The present study investigates the influence of the macrocirculation on hyperalgesia at rest in intermittent claudication. In 35 patients with chronic obliterating arteriopathy of the lower limbs (stage II according to Fontaine) the ankle/arm index of arterial pressure and the walking tolerance, as well as the pain at rest on applying pressure to the calf muscles were determined before and 3 weeks after percutaneous transluminar angioplasty (PTA). All 3 parameters improved after dilatation. Improved macrocirculation leads not only to a decreased production and improved clearance of pain-inducing metabolites in muscle tissue, but also--through a decrease of sympathetic stimulation of the muscle--to an elevation of the pain threshold. Apart from the reduction in pain-inducing metabolites, an absence of booster effects on pseudoradicular irritation and the regeneration of sensitive cutaneous afferents with resultant inhibition of reflex pain development are considered as possible factors in the achievement of pain relief following PTA.     

Metabolic Activity of Skeletal Muscle in Patients with Peripheral Arterial Insufficiency

Abstract. 18 patients with intermittent claudication were studied to find some explanation for the beneficial effect of physical training on their symptoms. The patients were randomly allocated to a training group and a placebo-treated control group. The effect of treatment on serum lipids, muscle lipids and glycogen, walking tolerance, calf blood flow, muscle succinic oxidase activity and the in vitro incorporation rate of glucose-carbon into various metabolites were studied.
In the control group none of these parameters were changed.
In the trained group the following significant changes were found: Walking tolerance improved; muscle contents of cholesterol and phospholipids increased, as did succinic oxidase activity and the incorporation rate of glucose-carbon into glycogen, lipids and carbon dioxide. Incorporation of glucose-carbon into lactate decreased.
The improvement in walking tolerance was correlated with the altered pattern of metabolic activity but was not associated with increased calf blood flow. It is concluded that metabolic changes in skeletal muscles may be important in explaining the beneficial effects of physical training in patients with peripheral arterial insufficiency.     

Improving maximum walking distance in early peripheral arterial disease: randomised controlled trial

The purpose of this study was to determine the impact of increased physical activity and cessation of smoking on the natural history of early peripheral arterial disease. We conducted a randomised controlled trial in Perth, Western Australia, involving 882 men with early peripheral arterial disease identified via population-based screening using the Edinburgh Claudication Questionnaire and the ankle:brachial index. Members of the control group (n = 441) received "usual care" from their general practitioner while members of the intervention group (n = 441) were allocated to a "stop smoking and keep walking" regime - a combined community-based intervention of cessation of smoking (where applicable) and increased physical activity. Postal follow-up occurred at two and 12 months post-entry into the trial. The main outcome of interest was maximum walking distance. There were no statistically significant differences in the characteristics of the "intervention" and "usual care" groups at recruitment. Follow-up information at two and 12 months was available for 85% and 84% of participants, respectively. At 12 months, more men allocated to the intervention group had improved their maximum walking distance (23% vs 15%; chi2 = 9.74, df = 2, p = 0.008). In addition, more men in the intervention group reported walking more than three times per week for recreation (34% vs 25%, p = 0.01). Although not statistically significant, more men in the intervention group who were smokers when enrolled in the trial had stopped smoking (12% vs 8%, p = 0.43). It is concluded that referral of older patients with intermittent claudication to established physiotherapy programs in the community can increase levels of physical activity and reduce disability related to peripheral arterial disease. A combination of simple and safe interventions that are readily available in the community through physiotherapists and general practitioners has the potential to improve early peripheral arterial disease.     

The effects of physical training and flunarizine on walking capacity in intermittent claudication

The clinical significance of drugs improving red cell deformability is not confirmed. We established the effect of physical training alone and combined with flunarizine on intermittent claudication. Twelve patients aged 48-73 years were included in the study. Pain-free walking distance on treadmill, ankle/arm pressure ratio and transcutaneous oxygen tension were measured. Walking distance increased significantly (p less than 0.05) by 130% from 75 m to 173 m during the first year when the patients were on programmed physical training. Ankle/arm pressure ratio also increased significantly (p less than 0.05) from 0.46 to 0.55 during this period. The increase in walking distance ceased when the programmed physical training was discontinued for 6 months. During the following double-blind, cross-over medication period the patients were given flunarizine 5 mg b.i.d. and placebos in randomized order for 3 months each. They also continued the same programmed physical training as during the first year. Walking distance increased, albeit not significantly, with time to 392 m after the second medication period. There was no difference, however, between flunarizine and placebo. Ankle/arm pressure ratio was of the same magnitude as at the beginning of the trial. Oxygen tension measurements did not give consistent results. We conclude that programmed physical training increased walking distance as a function of time. Flunarizine had no effect on the performance of patients with intermittent claudication.