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Practical exercise considerations Practical exercise considerations for intermittent for intermittent claudicationclaudication

Dr John BuckleyDr John BuckleyBASES Accredited Exercise PhysiologistBASES Accredited Exercise Physiologist

BACRBACRBelfast, 2006Belfast, 2006

CENTRE FOR EXERCISE & NUTRITION SCIENCECENTRE FOR EXERCISE & NUTRITION SCIENCE

OutlineOutline

Brief review of intermittent Brief review of intermittent claudicationclaudication(IC) and evidence for exercise(IC) and evidence for exercisePotential mechanisms of why exercise worksPotential mechanisms of why exercise worksStudies on types of exercise in ICStudies on types of exercise in ICSimple practical exercise prescription Simple practical exercise prescription adaptations for the patient with adaptations for the patient with claudicationclaudication

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Tiberius Claudius Drusus Nero Germanicus(b. 10 BC; emperor, 41-54 A.D.)

Latin: claudicare or claud-us = to be lame or limp

Pearce Eur Neurol 2005; 54: 118 – 119

Ankle Ankle -- Brachial Brachial Pressure IndexPressure Index

<0.2Gangrene and ulceration0.5 - 0.3Rest pain0.95 - 0.5Intermittent claudication1 or moreSymptom freeABPIClinical status

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EpidemiologyEpidemiologyGeneral PrevalenceGeneral Prevalence

2 2 –– 6% population under 50 6% population under 50 -- 60 years of age60 years of ageRising to > 7% in those 70+ yearsRising to > 7% in those 70+ years

McDaniel and McDaniel and CronenwettCronenwett 1989 1989 Ann Ann VascVasc SurgSurg 3:2733:273

FoulkesFoulkes et alet al. . 19911991 IntInt J J EpidemiolEpidemiol 20:38420:384

StoffersStoffers et al. 1996et al. 1996 IntInt J J EpidemiolEpidemiol 25:28225:282

EpidemiologyEpidemiologyPrevalence with CHDPrevalence with CHD

40 40 –– 60% of individuals with IC have CHD60% of individuals with IC have CHDDormandyDormandy et al. 1999 et al. 1999 SeminSemin VascVasc SurgSurg 12: 11812: 118

SonechaSonecha and Delis 2003, and Delis 2003, EJVascEJVasc EnvascEnvasc SurgSurg 25: 51925: 519

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Physical Activity & PADPhysical Activity & PADGargGarg et al. 2006et al. 2006 CirculationCirculation 114: 242 114: 242 -- 248248

Mortality rates; obeservational design

00.5

11.5

22.5

33.5

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1st Q'tile 2nd Q'tile 3rd Q'tile 4th Q'tile

Physical Activity Level

Haz

ards

rat

io

~¾ mile/wk

~2.5 mile/wk

Physical Activity & PADPhysical Activity & PADGargGarg et al. 2006et al. 2006 CirculationCirculation 114: 242 114: 242 -- 248248

Further study is needed to determine whether Further study is needed to determine whether interventions that increase physical activity interventions that increase physical activity during daily life are associated with improved during daily life are associated with improved survivalsurvival

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Cochrane Review; Exercise & ICCochrane Review; Exercise & ICLengLeng et al. 2000et al. 2000

NOT ONLY a 150% increase in walking timeNOT ONLY a 150% increase in walking timeBUTBUT

Exercise is better, after 12 months, than Exercise is better, after 12 months, than angioplastyangioplastyExercise is better than Exercise is better than antiplateletantiplatelet therapytherapyAs good as PA bypass surgery (inc surgery + As good as PA bypass surgery (inc surgery + exercise)exercise)PentoxifyllinePentoxifylline (1 study): 82% increase walking (1 study): 82% increase walking time time vsvs 62% increase walking group62% increase walking group

Cochrane Review; Exercise & ICCochrane Review; Exercise & ICLengLeng et al. 2000et al. 2000

Suggests the walking improvement Suggests the walking improvement mechanism, not necessarily related to mechanism, not necessarily related to improved blood flow; improved blood flow;

improvement requires skeletal muscle improvement requires skeletal muscle histohisto--chemical (efficiency) changes through chemical (efficiency) changes through exercise trainingexercise training

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In other wordsIn other wordsImproving the fuel supply line (arterial flow) Improving the fuel supply line (arterial flow) is only of benefit if the engine (muscle) is is only of benefit if the engine (muscle) is also in good knickalso in good knick

Potential Mechanisms of Improved Potential Mechanisms of Improved Walking Performance from ExerciseWalking Performance from Exercise

Increased blood flowIncreased blood flowEnhanced Enhanced vasodilatoryvasodilatory/endothelial response (Nitric Oxide)/endothelial response (Nitric Oxide)Collateralisation (conduit Collateralisation (conduit vsvs microcirculation)microcirculation)

Improved muscle metabolismImproved muscle metabolismIncrease OIncrease O2 2 usage/efficiencyusage/efficiencyReduced lactic acid productionReduced lactic acid production

Enhanced pacing and walking performanceEnhanced pacing and walking performanceImproved pain tolerance/pain perceptionImproved pain tolerance/pain perceptionImproved tolerance to Improved tolerance to exertionalexertional cuescues

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Release of Nitric Oxide from blood flow Release of Nitric Oxide from blood flow shear stress improves with exerciseshear stress improves with exercise

De Groot et al 2006 Exer Sport Sci Rev 34: 65Arosio et al 1999 Life Sci 65:2815

Blood flowBlood flow

Jasperse and Laughlin 2006 Med Sci Sports Exerc 38: 445

Increased muscle blood flow (collaterals and NO induced vasodilation) conduit & micro-circulation

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Summary of conduit blood flowSummary of conduit blood flow

SurgerySurgery

AngioplastyAngioplasty

ExerciseExercise

Walking Walking PerformancePerformance

Change in conduit Change in conduit blood flowblood flow

ABPI or DopplerABPI or Doppler

InterventionIntervention

Creasy et al 1990 Creasy et al 1990 EurEur J J VascVasc SurgSurg 4: 1354: 135Tan et al Tan et al 2000 2000 EurEur J J VascVasc SurgSurg 20:72 20:72 LengLeng et al. 2000 et al. 2000 Cochrane ReviewCochrane ReviewBrendleBrendle et al 2001 Am J et al 2001 Am J CardiolCardiol 87: 32487: 324SpronkSpronk et al 2005 et al 2005 RadiologyRadiology 235: 833235: 833

Muscle metabolism Muscle metabolism –– VOVO22

White circles = preWhite circles = pre--trainingtrainingBlack squares = 3 months trainingBlack squares = 3 months training

Tan et al Tan et al 2000 2000 EurEur J J VascVasc SurgSurg 20:7220:72

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Barker et al 2004 Clin Sci 106: 241

VO2 kinetics is slowed in IC compared to age matched healthy controls

Muscle metabolismMuscle metabolism-- blood lactateblood lactateWhite bars = pre-trainingBlack bars = 3 months training

Tan et al Tan et al 2000 2000 EurEur J J VascVasc SurgSurg 20:7220:72

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Exercise Prescription Exercise Prescription Considerations and AdaptationsConsiderations and Adaptations

Rehab-therapy downfall; over-emphasis on specific condition in attempt to fix what is broken

Exercise Prescription Exercise Prescription Considerations and AdaptationsConsiderations and Adaptations

Rehab-therapy ideal;broaden focus to improve what is working well that will counteractlimitations of disease system

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Exercise Prescription Exercise Prescription Considerations and AdaptationsConsiderations and Adaptations

It’s not just about improving walking pain and distance –there is a whole CV system needing improvement

RPE and CRRPE and CR--10 Scales10 Scales

Need patients to differentiate between Need patients to differentiate between ““PainPain””symptoms an symptoms an ““ExertionalExertional”” symptomssymptoms

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Exercise choicesExercise choicesSupervised or nonSupervised or non--supervised (home)supervised (home)Low versus higher intensity activityLow versus higher intensity activityWeightWeight--bearing bearing vsvs nonnon--weight bearing activityweight bearing activityUpperUpper--body body vsvs lower body activitylower body activityBiBi--lateral lateral vsvs unilateral limb activityunilateral limb activityTo which activity is patient most likely to adhere To which activity is patient most likely to adhere (do you need to push into the pain?(do you need to push into the pain?……))

Painful but potentially more beneficialPainful but potentially more beneficialLess painful with some reduced benefitLess painful with some reduced benefit

Cochrane Review Cochrane Review Supervised Supervised vsvs NonNon--supervised Exercisesupervised Exercise

BendermarcherBendermarcher et al. 2006et al. 2006

150m > distance covered compared with non150m > distance covered compared with non--supervised walking group supervised walking group

Statistically and clinically significant improvements in Statistically and clinically significant improvements in maximal treadmill walking distancemaximal treadmill walking distance

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Low v higher intensityLow v higher intensity

Gardner et al. 2005 Gardner et al. 2005 J J VascVasc SurgSurg 42: 70242: 702

63%63%61%61%Max distanceMax distance

109%109%+109%+109%Onset Onset claudclaud’’distancedistance

High 80% High 80% max capacitymax capacity

Low 40% Low 40% max capacitymax capacity

In both groups VO2 peak and HRQOL increased

WeightWeight--bearing v Nonbearing v Non--weightweight--bearingbearing

McGregor et al. 2000 McGregor et al. 2000 J Sports J Sports SciSci 1919 (1) : 55(1) : 55Group A Cycling & Rowing Group A Cycling & Rowing Group B Treadmill & StepperGroup B Treadmill & StepperGroup C ControlGroup C Control

2x/ week x 10 weeksBorg RPE 12-14Borg CR-10 pain <4

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WeightWeight--bearing v Nonbearing v Non--weightweight--bearingbearing

McGregor et al. 2000 McGregor et al. 2000 J Sports J Sports SciSci 1919 (1) : 55(1) : 55Group A: Treadmill & Stepper: Group A: Treadmill & Stepper: +4.6 +4.6 minsminsGroup B: Cycling & Rowing: Group B: Cycling & Rowing: +2.4 +2.4 minsminsGroup C: Control:Group C: Control: +0.6 +0.6 minsmins

WeightWeight--bearing v Nonbearing v Non--weightweight--bearingbearing

McGregor et al. 2000 McGregor et al. 2000 J Sports J Sports SciSci 1919 (1) : 55(1) : 55Group A: Treadmill & Stepper: Group A: Treadmill & Stepper: +4.6 +4.6 minsminsGroup B: Cycling & Rowing: Group B: Cycling & Rowing: +2.4 +2.4 minsminsGroup C: Control:Group C: Control: +0.6 +0.6 minsmins

Weight bearing was better, including 1.9 minsincreased time before onset of claudication

However all forms of activity beneficial to CVhealth and fitness; non-weight bearing more bearable

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Upper Upper vsvs lowerlower--body exercisebody exercise

ZwierskaZwierska et al 2005 et al 2005 J J VascVasc SurgSurg 42:112242:1122

Group A LegGroup A Leg--Cycle: Cycle: Group B ArmGroup B Arm--Cycle:Cycle:Group C ControlGroup C Control

24 weeks training50% - 65% VO2peak

Upper Upper vsvs lowerlower--body exercisebody exercise

ZwierskaZwierska et al 2005 et al 2005 J J VascVasc SurgSurg 42:112242:1122

Group A LegGroup A Leg--Cycle: Cycle: Group B ArmGroup B Arm--Cycle:Cycle:Group C ControlGroup C Control

+31%+31%+57%+57%+29%+29%+51%+51%Max walk distMax walk distClaudClaud distancedistance

Upper limb exercise equal to lower limb exercise in improving walking distance Increased pain tolerance (Borg CR-10 scale)

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BACRBACR--EPGEPGUniversity of Chester University of Chester 1313thth April, 2007April, 2007

Programme includes: IC & Exercise SymposiumProgramme includes: IC & Exercise SymposiumSpeakers: Speakers: G. McGregor; I. G. McGregor; I. ZwierskaZwierska; P. Roberts; M. Morris; P. Roberts; M. Morris

Personal adaptationsPersonal adaptationsPresently being objectively assessedPresently being objectively assessed

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Bi-lateral vs unilateral activity

Limiting gastrocnemius (calf)usage

Un-strapped

Strapped

Arch of foot on pedal, un-strapped

Crank-leverage reduced with “UniCam”adjustable crank

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SummarySummary

Physical inactivity is a risk factor for IC Physical inactivity is a risk factor for IC morbidity & mortalitymorbidity & mortality

Need for studies on exercise training interventionsNeed for studies on exercise training interventionsExercise is as good as medical or surgical Exercise is as good as medical or surgical therapiestherapies

Improved Improved ““fuel supply linesfuel supply lines”” (arterial blood) are only (arterial blood) are only as good as the engine (muscle) using the fuelas good as the engine (muscle) using the fuelMuscle training needs to accompany Muscle training needs to accompany medical/surgical intervention medical/surgical intervention

SummarySummary

Lower intensity activity as beneficial as higher Lower intensity activity as beneficial as higher Upper body and nonUpper body and non--weight bearing activity weight bearing activity

Are effective in improving both general health Are effective in improving both general health related CV fitness and walking performancerelated CV fitness and walking performanceMay be more palatable for longMay be more palatable for long--term adherence to term adherence to activity compared with weightactivity compared with weight--bearing bearing execiseexecise(stepping & walking)(stepping & walking)