1 Professional articles

Intermittent Claudication: Implementation of an Exercise Programme Treatment report

Summary Peripheral vascular disease leading to intermittent claudication causes disability in a significant number of people. Exercise rehabilitation is of known benefit, and many centres provide such treatment. There is however no consensus on the most effective types of exercise. This report describes and discusses a specific programme which incorporates important factors identified from the literature. Suggestions are made for future research.

Hunt, K D, Leighton, M L and Reed, G M (1999). ‘Intermittment claudication: Implementation of an exercise programme’, PhysiolhmB, 85, 3, 149-153.

Introduction Peripheral vascular disease (PVD) is a common cause of morbidity, particularly in elderly people (Vogt et al, 1992). The predominant cause is arteriosclerosis obliterans leading to intermittent claudication (IC) , This results in ischaemic muscular pain (typically in the calf) due to an imbalance of nutrient blood supply and demand. During activities such as walking the muscles become starved of oxygen due to proximal stenosis of the arterial blood vessels. Symptoms are reduced on cessation of walking. In effect, patients walk painlessly for a certain distance and then stop as pain sets in and, after rest, start walking again. The distance at which patients first experience pain on walking is termed claudication distance (CD). The point at which pain requires patients to cease walking is their maximum walking distance (MWD) .

IC is a relatively benign condition: in approximately 80% of patients, their condition becomes stable in that claud- ication symptoms either improve or do not worsen (Imparato et aZ, 19’75). However, more recent studies indicate that 25% of patients have an ischaemic episode and 5% undergo amputation (Coffman, 1991).

Overall, significant functional disability results from PVD, particularly reduction of walking distance (Regensteiner et aZ, 1996), and reduction by approximately half of the normal exercise capacity (Hkatt et a~!, 1993).

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Key Words 149 Intermittent claudication, exercise, walking distance.

by Deborah Hunt Mary Leighton Geraldine Reed

Life expectancy is also significantly reduced (Coffman, 1991).

The annual incidence of IC in the USA is 20 per 1,000 men and women over 65 years of age (Kannel and McGee, 1985). UK figures indicate that 5% of people over 60 have IC. There are several risk factors involved in the development of PVD and therefore IC. These are hyperlipidaemia, diabetes mellitus, hypertension and cigarette smoking.

Treatment The standard treatment approach is an ..................................................................................................

angiogram to confirm presence and site of disease, followed by drug therapy and surgery consisting of angioplasty and/or bypass grafting. However several authors have questioned the efficacy of this approach, not only for reasons of cost and risks of surgery, but because the numbers of lower extremity amputations have not reduced significantly (Tunis et al, 1991; Hiatt et aZ, 1993; Coffman, 1991).

Reduction in risk factors may modify atherosclerotic disease, but may have no direct effect on claudication. Vasodilators do not increase peripheral blood flow or relieve claudication symptoms. The drug pentoxifylline, which decreases blood viscosity, delivers only a modest improvement in treadmill walking; angioplasty improves treadmill walking but patients still have IC (Hiatt et aZ, 1993). Since the 1960s there has been evidence that exercise rehabilitation can be a suitable low- cost alternative to surgery (Larsen and Lassen, 1966; Hayne, 1980; Hiatt et al, 1990; Ernst, 1992; Regensteiner et al, 1996).

However there is no consensus in the literature as to the type of exercise that gives the best results, though walking is a standard component of most programmes. Gardner

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Authors Deborah Hunt MCSP is a superiii tendent physiotherapist at the Oxfo1~1 RadclifI‘e Hospital.

Geraldine Reed MCSP is a senior I physiothcrapisl at the Oxford RadclifTe Hospital.

Mary Leighton MCSP was formcrly a senior I physiotlicrapist at Lhc Oxford Radclifk Iiospital.

This article was received on Febnrary 5, 1998 and accepted on September 10, 1998.

Address for Correspondence Mrs G M Recd, Physiotherapy Ikpartment, Oxford Kddcliffe Hospital, ‘The J o h n Kadcliffe, Headley WAY, Oxford OX3 9DU.

and Poehlman (1995) found that the three most important features were that: rn Exercise should continue until near

rn Exercise programmes should include

rn Programmes should last at least six

maximal claudication pain.

walking.

months. The authors of this treatment report have

ascertained informally (using question- naires) from physiotherapy colleagues around the country that many programmes are being developed using a variety of approaches and regimes. It is therefore important to stimulate discussion on this subject to ensure that programmes are effective and are based on the best available evidence.

Physiotherapists, as experts in the use of exercise, have an important contribution to make, both directly to patient care, and in the wider debate.

T h e Oxford Radcliffe Hospital prog- ramme began in 1995 following research there, which demonstrated a significant benefit of exercise over angioplasty (Creasey et a& 1990), confirmed at follow-up (Perkins et al, 1996).

The purpose of this report is to describe an effective regime of conservative treatment by supervised exercise therapy for IC and to identify some of the most important components of the exercise programme.

The Programme T h e programme consisted of patient education to increase understanding of the disease, self-management, dietary advice, advice o n cessation of smoking and a supervised twice-weekly group exercise programme, managed jointly b y the physiotherapist and a nurse practitioner, with the help of a physiotherapy assistant. Patients with stable IC, referred from the vascular surgeon, were assessed initially by the nurse practitioner, according to an agreed protocol. Conditions which excluded patients from the exercise group were : rn Uncontrolled angina. rn Disabling respiratory disorder. rn Joint pain/dysfunction which limits

patient before claudication occurs. rn Untreated proliferative retinopathy in

diabetic patients. The assessment included the following :

rn Full health history. rn Physicdl assessment: weight, height, blood

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pressure, condition of the feet.

rn Site of lesion, if known. rn Treadmill or walking distance test to

measure CD and MWD. MWD was measured by treadmill walking

at 3 km per hour (ie average normal walking speed) with no gradient. Some patients were unable to achieve treadmill walking at this speed and underwent a measured corridor walking test to determine their MWD. This would have been of greater value if it had been timed (Singh et al, 1992).

Any condition which might have required the exercises to be modified was also noted, but would not exclude the patient from participating. Some examples are :

Controlled angina. rn Breathlessness. rn Arthritis. rn History of injury. rn History ofjoint replacement.

Obesity. Patients judged suitable to attend the

exercise group agreed functional gods with the nurse. Those not suitable for the group received advice, education and support together with encouragement to exercise.

The physiotherapist reviewed patients’ assessments and proposed goals on their first exercise group attendance. Functional ability and individual exercise tolerance were noted and any physical problems such as arthrit is assessed in greater detail. Modifications required to the exercise programme, to take account of any other physical problem, were decided by the physiotherapist. Patients’ progress was monitored by ongoing assessment and by regular treadmill o r walking distance testing.

The group sessions, lasting one hour, took place in a local sports centre for disabled people. Patients were encouraged to attend for a six-month period, though facilities allowed graduates of the programme to continue attendance, although they exer- cised independently, with minimal input from staff. An added benefit was their support and motivation of new entrants to the programme.

Agreed protocols stated that both the nurse and the physiotherapist should be trained in cardiopulmonary resuscitation.

Exercises Routine non-weight-bearing warm-up/down, and stretching exercises for the lower quadrant were performed before and after the main session, which consisted of four basic exercises :

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1 . Alternate heel raising in standing. 2. Simultaneous heel raises in standing. 3. Step-ups on to a low bench, initially

leading with the worse leg and then repeating with the less affected leg.

4. Toe walking. Patients recorded the number of

repetitions achieved or length of time taken for each exercise at each session using a simple diary. They were encouraged to exercise up to and past the claudication point. Enough rest was allowed between exercises for the pain to subside. A range of gym equipment (eg step machine, static bicycle) was available for use also, but the four exercises stated above remained the 'core' of the programme. All patients were expected and encouraged to practise daily at least two of the exercises, plus a walk.

The exercises were increased in difficulty as patients improved; for example heel raising on the wall bars, double heel raises combined with squatting.

Results A total of 122 patients were referred to the vascular nurse practitioner and of these 42 were judged suitable to join the exercise group (see exclusion criteria above). The average age of patients was 65 years (range 39 to 86 years); 14 were women and 28 men. Comparison of the percentage change of the three-month and six-month repeat MWD with the initial MWD for each individual shows that over three-quarters of patients increased their MWD by 50% at three months, with more than half of these doubling their MWD after six months. The results were measured individually in this way to nullify some of the considerable variables (eg effects of lifestyle changes, lack of a control group, etc).

All patients who participated in the exercise class enjoyed working in a group. This provided peer support and en- couragement, thus enhancing motivation and compliance. This subjective response is confirmed by Ernst (IYYl), and Clifhrd el nl (1980). There was also the opportunity for staff to reinforce advice and for patients to discuss any problems.

The case study (top right) illustrates the effectiveness of the programme.

Mr S still attends the programme regularly and finds this provides the encouragement and discipline to continue exercising. His IC no longer restricts his daily activities and he is able to lead a full and active life in his local community.

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Case Study of 'Mr S' A 64-year-old man, 'Mr S', first pres- ented with left calf pain in 1991. He was referred to the exercise programme four years later in 1995.

He was an ex-smoker of 15 years. His height was 6 ft 1 in, weight 95 kg and blood pressure 135/70. He had an extensive vascular history:

1980 - Developed angina. 1992 - Repair of right popliteal

aneurysm. 1994 - Coronary artery bypass

grafting. Currently - Abdominal aortic

aneurysm of less than 5 cm (monitored). On examination before starting the

programme a treadmitl test at 3 km per hour showed a CD of 148 metres and a MWD of 148 metres.

The exercise programme began in May 1995 with attendance twice weekly. In addition to the class, 'Mr 5' undertook a home exercise programme including a daily walk. Progress was assessed at regular intervals: At 1 month: Subjective improvement

noted. Treadmill test showed CD of 175 m

and MWD of 250 m. At 3 months: Treadmill test showed CD

At 6 months: Treadmill test showed CD of 177 m and MWD of 1,014m.

of 273 m and MWD of 1,500 m.

Discussion Many studies have confirmed the value of exercise in the conservative management of IC (Coffman, 1991; Ernst, 1991, 1992; Hiatt et al, 1993; Regensteiner et al, 1996). The main component in all these regimes is the treadmill walking exercise (Ernst and Matrai, 1987; Hiatt et al, 1993). However, it is not practical to provide this at home, or for large numbers of patients in a supervised class.

Some of the most important factors to integrate into any exercise programme are outlined below: H Previous experience in Oxford (Creasey

et al, 1990) led us to believe that patients would be more compliant with a simpler regime, and would enjoy this form of exercise. This is supported by the literature (Gardiner, 1981; Clifford, 1980).

H Functional weight-bearing exercises were chosen. They were simple, few in number

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and could easily be incorporated into a daily routine. Patients were therefore more likely to take responsibility for and comply with such a regime at home (Walker, 1995).

rn The exercises were targeted at the calf and thigh muscles since these are usually the worst affected by IC (Gardner and Poehlman, 1995).

rn There is also evidence that exercising up to and beyond the claudication point is more effective than stopping short of pain (Lundgren et al, 1989; Gardner and Poehlman, 1995).

rn Warm-up and cool-down periods were included to prevent injury (Hiatt et al, 1993).

rn A progressive programme of walking was encouraged (Hiatt et al, 1990).

rn Patients were encouraged to record their exercise results as a visual reminder of their progress (Ernst and Fialka, 1993). The mechanisms involved in improving

MWD through exercise are still unclear, but haemodynamic, metabolic, structural and psychological factors have all been postulated as possible factors (Ernst, 1991; Hiatt et al, 1993; Ernst and Fialka, 1993). The site of lesion has not been shown to be of importance (Perkins et al, 1996). However, exercise-induced gain is lost if

References Clifford, P C, Davies, P W, Hayne, J A and Baird, R N (1980). ‘Intermittent ckaudication: Is a supervised exercise class worth while?’ Ijrilish Medical Journal, 280, 6320, 1503-05. Creasey, T S, McMillan, P J, Fletcher, E W L, Collin, J and Morris, P J (1990). ‘Is percutaneous transluminal angioplasty bctter than exercise for claudication? Prcliminary results from a prospective randomiscd trial’, hropean~fr,urnal of Vnscular Surfiery, 4, 135-140.

Coffman, J D (1991). ‘Intcrmittcnt claudication - Be conscrvativc’, New ICngland~Journal of Medicine, 325, 8, 577-578..

Ernst, E (1991). ‘l’eripheral vascular disease, bcrielits of exercise’, Sports Medicine, 12, 3, 1 49-1 5 1,

E r s t , E (1992). ‘Exercisc: Thc bcst thcrapy for in 1 errn i 1 tcn 1 claudicdlion?’ Rritish,Joumnl of Ho.spitn1 Medicine, 48, 6, 303-307. E r s t , E and Fialka, V (1993). ‘A review of the clinical efkctiveness of exercise therapy for intermittent ckdudication’, Archi7m of International Medicine, 153, 2357-60.

Emst, E and Matrai, A (1987). ‘Intermittent claudication, exercise, and blood rheology’, Circulation, 76, 11 10-14.

training is discontinued (Krause and Lehnert, 1991), hence. attendance for at least six months is encouraged with review of MWD at 12 months.

Furaer research is needed to demonstrate long-term benefit of particular exercise regimes. It is important to determine and validate the best method of measuring functional improvement (eg treadmill walk, timed shuttle walk or subjective/objective questionnaire), given the current lack of consensus nationally. Previous studies have not included the part played by risk factor modification in the analysis of their outcomes. The possible benefits of combining supervised exercise with surgical management could also be explored. Research should investigate methods of providing long-term support and encour- agement, since it is clearly impractical for patients to continue class attendance indefinitely.

Conclusion This particular supervised exercise regime has provided successful functional outcomes for patients with IC. We hope this report will stimulate further discussion and the wider development of such programmes for the treatment of this disabling condition.

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Gardiner, M D (1981). Prncipks of Exercise ’I’hajy, Uriwin Hyman, London, 4th edn, chap 20, page 264.

Gardner, A W and Poehlman. E T (1995). ‘Exercise rehabilitation programs for thc treatment of claudication pain: A meta analysis’, .Journal of the American Medical Association, 274, 12, 975-980. Hayne, J A (1980). ‘The effect of exercise with early cbaudication’, Physiotherapy, 66, 8, 260-261.

Hiatt, W R, Regensteiner, J G, Hargarten, M E, Wolfel, E E and Brass, E P (1990). ‘Rcncfit of exercisc conditioning for patients with pcriphcral vascular disease’, Circulation, 81, 2, 602-609.

Hiatt, W R, Regensteiner, J G and Wolfel, E E (1993). ‘Special populations in cardiovascular rehabilitation: Peripheral arterial disease, non-insulin-dependent diabetes rnellitus, heart failure’, Cnrrliology Clinics, 11, 2, 309-921.

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Krause, D and Lehnert, M (1991). ‘Iangxcitcrgcbnissc einund mehrmaliger

Professional articles 153

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Lundpn , F, Dahllof, A, Lundholm, K, Scherstcn, T and Volkmann, R (1989). ‘ I i i t ciwi t tent claudic:at.ioii - Surgical ~~.coiisl.rii(~t.i~)ri or physiml training?’ Annds o/

Perkins, J M , Collin, J, Creasey, T S, Fletcher, E W L and Morns, P J (1996). ‘l<xc:rc:isc training i m s u . s mgioplasty for stable c:laiidication: L.oiig and rnctlium terrri rcsdts of a prospcctivc, randorriiscd trial’, 1 C i i m p m . journal 01 Wisculnr and I+:nndovmcular

Regensteiner, J G, Stciner, J F and Hiatt, W R (1996). ‘Exercisc training improves funct.iona1 s t a t u s in pat.ieiits with periphcral artcrial diseasc’, journol o/ Vascular Si.irgmy, 23, 1 , 104-1 15.

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Tunis, S R, Bass, E B and Steinberg, E P (1991). ‘Thc 11s; of angioplasty, bypass surgcry, and ampuvation in thc mariagcmerit of periphcral vascular discase’, Nnu lhglund. Journal of Medicine, 325, 8, 556-562.

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