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Exercise Therapy For Intermittent Claudication

Exercise Therapy For Intermittent Claudication. Wang Yan 王焱 Ph D. Xiamen Heart Center Zhongshan Hospital Xiamen University. Peripheral arterial disease. Carotid artery (Brain). Aorta (to body). Superior mesenteric artery & celiac artery (Intestines). Common iliac artery

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Exercise Therapy For Intermittent Claudication

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  1. Exercise Therapy For Intermittent Claudication Wang Yan 王焱 Ph D. Xiamen Heart Center Zhongshan Hospital Xiamen University

  2. Peripheral arterial disease Carotid artery (Brain) Aorta (to body) Superior mesenteric artery & celiac artery (Intestines) Common iliac artery (Legs) Narrowed artery Ischemia: decreased oxygen-rich blood to an area, which can cause pain and dysfunction • Peripheral arterial disease(PAD) Intermittent Claudication: A typical symptom of PAD, defined as walking induced pain in one or both legs that dose not go away with continued walking and is relieved only by rest.

  3. Am J Cardiol. 2001;87 (suppl):3D-13D

  4. Treatments For Claudication Be considered first N Engl J Med, Vol. 347, No. 24,1941

  5. Mosby Introduction of TASC SUPPLEMENT TO In order to ensure an appropriate management algorithms and to achieve the optimal outcome for PAD patients, a group of experts in managing these patients had formulated the TransAtlantic Inter-Society Consensus (TASC). The TASC Working Group consisted of 14 MD societies across United States & Europe who had formulated the TASC Guidelines in the management of PAD based in current evidence-based medicine. J O U R N A L O F VASCULAR SURGERY VOLUME 31NUMBER 1PART 2JANUARY2000 TASC Management of Peripheral Arterial Disease(PAD) TransAtlantic Inter-Society Consensus(TASC) Number 1, Part 2:S93 Section A: Introduction Section B:Intermittent Claudication Section C: Acute Limb Ischemia Section D: Critical Limb Ischemia • 107 Recommendations • 47 Critical Issues Developed by the TASC Working Group J Vasc Surg. 2000;31(1 Part 2):S1-S296

  6. Functional Benefits of Exercise Therapy • Potential Mechanisms of Improvement • Exercise Prescription

  7. Functional Benefits of Exercise Therapy • Meta-analysis*: Improved pain-free walking distance by an average of 179%, maximal walking distance of 122% • Cochrane Collaboration#: Improved maximal walking time by 150% (74~230%) * JAMA 1995;274:975-80 # Cochrane Database Syst Rev 2000 2 CD00990

  8. Effects of Exercise Training on Claudication Meta-analysis of 21 Studies 200 * Exercise Training 180 Control 160 140 * 120 Change in Treadmill Walking Distance (%) 100 80 60 40 20 * P < 0.05 0 Onset of Claudication Pain Maximal Claudication Pain Gardner AW, Poehlman ET. JAMA. 1995;274:975-980.

  9. Functional Benefits of Exercise Therapy • Meta-analysis*: Improved pain-free walking distance by an average of 179%, maximal walking distance of 122% • Cochrane Collaboration#: Improved maximal walking time by 150% (74~230%) * JAMA 1995;274:975-80 # Cochrane Database Syst Rev 2000 2 CD00990

  10. Potential Mechanisms of Improvement • Formation of Collateral Vessels and angiogenesis • Changes in Endothelial Function • The Hemorheologic Hypothesis • Increases in Muscle Metabolism and Oxygen Extration • Inflammation and Muscle Injury • Effects to Risk Factors of Atherosclerosis

  11. Formation of Collateral Vessels and angiogenesis In healthy subjects, exercise therapy up-regulated the expression of vascular endothelial growth factor (VEGF) messenger RNA (mRNA) in calf muscle, with the size of the increase related in a dose-dependent fashion to the degree of metabolic stress. Am J Pisol 1999,276 H679

  12. Formation of Collateral Vessels and angiogenesis (2) cardianet.org/images/resimg/za_1.jpg

  13. Changes in Endothelial Function • Endothelial vasodilator function was impaired in patients with claudication • Short term exercise stimulates endothelium-dependent vasolidatation by enhancing the release of nitric oxide and prostacyclin

  14. Changes in Endothelial Function Exercise improved endothelial-dependent dilation, and calf blood flow in older PAD patients with intermittent claudication. Am J Crdio 2001 87 324-9

  15. The Hemorheologic Hypothesis • Enhance collateral-dependent blood flow to the hind-muscles but in humans are moderately* or limited# • Redistribution of blood flow: from inactive to active muscles • improved blood and plasma-viscosity, filtered the ability of autologous red cells and red-cell aggregation * Circulation 1990;81:602-9. #J Am Geriatr Soc 2001;49:755-62

  16. 2 months of exercise therapy improved Plasma viscosity, blood cell filterability, and maximal walking distance significantly (Exercise vs.contrl, P<0.05) Circulation 1987:76:1110-4.

  17. Increases in Muscle Metabolism and Oxygen Extration • Patients with claudication have an imbalance between oxygen supply and demand lactate ↑ intermediates of oxidative metabolism ↑ (short-chain acylcarnitines) • Exercise Mitochondria ↑ the oxidative capacity of calf skeletal muscle ↑ Up-regulation of muscle enzyme activity ATP ↑ l.J A pplP hysiol, 1996;8 1:780-78

  18. Inflammation and Muscle Injury • Ischemia increases free-radical formation, neutrophil action, and systemic vascular endothelial damage • Exercise can lessen ischemia at any achieved workload and decrease markers of systemic inflammation: serum amyloid A protein C-reactive protein the urinary ratio of albumin to creatinine…

  19. Effects to Risk Factors of Atherosclerosis • Additional benefits that go beyond improvements in functional capacity and claudication • Exercise may also improve systemic cardiovascular health: reduce blood pressure improve lipid profile (↑HDL , ↓TG ) better glycemic control (in diabetic patients) reduce central obesity improve weight lose ……

  20. Conclusion of Mechanisms ↑Nitric oxide synthase Improved endothelial function ↑Prostacyclin Reduced inflammation ↓Free radicals Possible vascular angiogenesis ↑ VEGF Exercise therapy ↑ Muscle oxidative capacity Improved muscle metabolism ↑ Muscle enzyme activity ↑ Blood viscosity and filterability Improved hemorheology ↓ Red-cell aggregation

  21. Key Elements of an Effective PAD Therapeutic Claudication Exercise Program Primary clinician role: Establish the PAD diagnosis using the ABI measurement or other objective vascular laboratory evaluations Determine that claudication is the major symptom limiting exercise Discuss risk/benefit of claudication therapeutic alternatives, including pharmacological, percutaneous, and surgical interventions Initiate systemic atherosclerosis risk modification Perform treadmill stress testing Provide formal referral to a claudication exercise rehabilitation program Also see Table 18 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

  22. Exercise Prescription Supervised Exercise Rehabilitation A program of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication. Supervised exercise training should be performed for a minimum of 30 to 45 minutes, in sessions performed at least three times per week for a minimum of 12 weeks. - ACC/AHA 2005 Guidelines for the management of Patients with Peripheral Arterial Disease

  23. The PAD Exercise Training Prescription Warm-up: Approximately 5 minutes Repeated exercise periods: End at moderate claudication level Rest Periods: Until claudication abates Exercise Rest Exercise Exercise Cool Down Rest Warm-up This exercise interventional program has not been shown to be efficacious in a “home” setting. It requires a specific procedure and environment, much like invasive interventional procedures.

  24. Key Elements of an Effective PAD Therapeutic Claudication Exercise Program Exercise Guidelines for Claudication: Warm-up and cool-down period: 5 to 10 minutes each Types of exercise: Treadmill and track walking are the most effective exercise for claudication Resistance training has conferred benefit to individuals with other forms of cardiovascular disease, and its use, as tolerated, for general fitness is complementary to but not a substitute for walking Intensity: The initial workload of the treadmill is set to a speed and grade that elicit claudication symptoms within 3 to 5 minutes Patients walk at this workload until they achieve claudication of moderate severity, which is then followed by a brief period of standing or sitting rest to permit symptoms to resolve Also see Table 18 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

  25. Exercise Guidelines for Claudication: Duration: The exercise-rest-exercise pattern should be repeated throughout the exercise session The initial duration will usually include 35 minutes of intermittent walking and should be increased by 5 minutes each session until 50 minutes of intermittent walking can be accomplished Frequency Treadmill or track walking 3 to 5 times per week Key Elements of an Effective PAD Therapeutic Claudication Exercise Program Also see Table 18 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

  26. Role of Direct Supervision: As patients improve their walking ability, the exercise workload should be increased by modifying the treadmill grade or speed (or both) to ensure that there is always the stimulus of claudication pain during the workout As patients increase their walking ability, there is the possibility that cardiac signs and symptoms may appear (e.g., dysrhythmia, angina, or ST-segment depression). These events should prompt physician re-evaluation These general guidelines should be individualized and based on the results of treadmill stress testing and the clinical status of the patient. A full discussion of the exercise precautions for persons with concomitant diseases can be found elsewhere for diabetes * Key Elements of an Effective PAD Therapeutic Claudication Exercise Program *(Ruderman N, Devlin JT, Schneider S, Kriska A. Handbook of Exercise in Diabetes. Alexandria, Va: American Diabetes Association; 2002), (ACSM's Guidelines for Exercise Testing and Prescription. In: Franklin BA, ed. Baltimore, Md: Lippincott Williams & Wilkins; 2000), (Guidelines for Cardiac Rehabilitation and Secondary Prevention/American Association of Cardiovascular and Pulmonary Rehabilitation. Champaign, Ill: Human Kinetics; 1999). Also see Table 18 of Hirsch AT, et al. J Am Coll Cardiol. 2006;47:e1-e192.

  27. PAD Guideline-Based Care:Claudication Treatment via Home Exercise The usefulness of unsupervised exercise programs is not well established as an effective initial treatment modality for patients with intermittent claudication. IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I IIa IIa IIa IIa IIb IIb IIb IIb III III III III I I I B • The lack of proven efficacy for home-based, unsupervised exercise may be due to: • A lack of compliance with the minimum “exercise dose”; • A lack of progression of the workload in the absence of professional supervision; • A lack of confidence by the patient that it is safe to advance into moderate claudication discomfort severity. Hirsch AT, et al. J Am Col Cardiol. 2006;47:1239-1312.

  28. Exercise therapy may augment the effects of other treatments for claudication. The combination of revascularization procedures (bypass surgery and angioplasty)and exercise was more effective than either intervention alone. Patients may also benefit from the use of pharmacologic therapies Exercise combined with other treatments

  29. Conclusions • Exercise therapy is an effective treatment for claudication. • Increses in functional capacity and lessening of claudication symptoms may be explained by several mechanisms. • A supervised hospital- or clinic-based prescription, which ensures that patients are receiving a standardized exercise stimulus in a safe enviroment, is effective.

  30. Thanks for your attention!

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