Exercise for claudication

[Owen Harris]

I am currently treating a patient with severe int. claudication of his leg (post DVT surgery 10 years ago) i have read that exercise is effective in causing improvements to function but i was wondering about intensity.
Some of the info i have read states only to exercise up to the onset of pain, and not past this point. Would you agree with this.

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[Physiobase]

Here's an abstract from a very useful article on exercise and claudication:

The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication.

Gardner AW, Montgomery PS, Flinn WR, Katzel LI.

CMRI Metabolic Research Center, University of Oklahoma Health Sciences Center, Oklahoma City 73117, USA. [email protected]

PURPOSE: The purpose of this randomized trial was to compare the efficacy of a low-intensity exercise rehabilitation program vs a high-intensity program in changing physical function, peripheral circulation, and health-related quality of life in peripheral arterial disease (PAD) patients limited by intermittent claudication. METHODS: Thirty-one patients randomized to low-intensity exercise rehabilitation and 33 patients randomized to high-intensity exercise rehabilitation completed the study. The 6-month exercise rehabilitation programs consisted of intermittent treadmill walking to near maximal claudication pain 3 days per week at either 40% (low-intensity group) or 80% (high-intensity group) of maximal exercise capacity. Total work performed in the two training regimens was similar by having the patients in the low-intensity group exercise for a longer duration than patients in the high-intensity group. Measurements of physical function, peripheral circulation, and health-related quality of life were obtained on each patient before and after the rehabilitation programs.

RESULTS: After the exercise rehabilitation programs, patients in the two groups had similar improvements in these measures. Initial claudication distance increased by 109% in the low-intensity group (P < .01) and by 109% in the high-intensity group (P < .01), and absolute claudication distance increased by 61% (P < 0.01) and 63% (P < .01) in the low-intensity and high-intensity groups, respectively. Furthermore, both exercise programs elicited improvements (P < .05) in peak oxygen uptake, ischemic window, and health-related quality of life.

CONCLUSION: The efficacy of low-intensity exercise rehabilitation is similar to high-intensity rehabilitation in improving markers of functional independence in PAD patients limited by intermittent claudication, provided that a few additional minutes of walking is accomplished to elicit a similar volume of exercise.

[Physiobase]

This one suggests you might be able to also get the result without taking them into pain at all. I would assume you need to do a baseline test first to see what their initial limit is and then do retesting after a period of time to reset that goal of pain free walking distance/time.

Experimental model of pain-free treadmill training in patients with claudication.

Mika P, Spodaryk K, Cencora A, Unnithan VB, Mika A.

Department of Rehabilitation, Academy of Physical Education, Krakow, Poland.

OBJECTIVE: Treadmill training in claudication is often based on walking exercise to a pain threshold or longer to the maximum muscle pain of the lower limbs. This kind of exercise may cause an inflammatory response. The purpose of this study was to determine whether pain-free treadmill training using walking exercise to 85% of the distance to onset of claudication pain can significantly improve pain-free walking distance in patients with intermittent claudication and to evaluate whether this kind of program may induce an inflammatory response leading to the progression of atherosclerosis.

DESIGN: A total of 98 patients aged 50-70 yrs with stable intermittent claudication were randomized into a supervised treadmill training program or a comparison group. Patients in the treatment group participated in 12 wks of supervised treadmill training. We examined the effects of 12 wks of pain-free treadmill training on pain-free walking distance, total leukocyte count, neutrophil count, and microalbuminuria in patients with claudication.

RESULTS: A total of 80 participants completed the program. Exercise rehabilitation increased the time to onset of claudication pain by 119.2%, from 87.4 +/- 38 m to 191.6 +/- 94.8 m (P < 0.001). There was no increase in total leukocyte count, neutrophil count, or microalbuminuria after 12 wks of treadmill exercise (P > 0.05)

CONCLUSION: A pain-free training program can be used in the treatment of claudication as a low-risk program, increasing walking ability without potential harmful effects of ischemia-reperfusion injury.

[MFSA21]

Exercise for intermittent claudication (Review)
Leng GC, Fowler B, Ernst E

A B S T R A C T
Background
Exercise is an inexpensive, low risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication).
Objectives
The objective of this review was to determine the effects of exercise for leg pain.
Search strategy
The reviewers searched the Cochrane Peripheral Vascular Diseases Group trials register, Embase, reference lists of relevant articles, and contacted principal investigators of trials.
Selection criteria
Randomised trials of exercise regimens in patients with leg pain on walking (intermittent claudication).
Data collection and analysis
At least two reviewers extracted and assessed data trial quality independently. The reviewers contacted investigators to obtain information or data needed for the review that could not be found in published reports.
Main results
Fifteen trials were identified that met the inclusion criteria, but five were subsequently excluded because of poor quality. The remaining ten trials involved a total of almost 250 male and female patients with stable leg pain. The follow-up ranged from 12 weeks to 15 months. There was also some variation in the exercise regimens used, although all recommended at least two weekly sessions of, mostly,
supervised exercise. All trials used a treadmill walking test as one of the outcome measures. The overall quality of the included trials was generally good, though the trials were all small (20-49 patients).
Exercise therapy signifcantly improved maximal walking time (minutes) (weighted mean difference 6.51, 95% confidence interval 4.36 to 8.66,Fixed effect model [FE]), with an overall improvement in walking ability of approximately 150% (range 74% to 230%).
Exercise produced significant improvements in walking time compared with both angioplasty at six months (weighted mean difference
3.30, 95% confidence interval 2.21 to 4.39, FE) and antiplatelet therapy (weighted mean difference 1.06, 95% confidence interval 0.15 to 1.97, FE), and did not differ significantly from surgical treatment. In one small trial, exercise was less effective than pentoxifylline (weighted mean difference -0.45, 95% confidence interval -0.66 to -0.24, FE).
Authors' conclusions
Exercise is of significant benefit to patients with leg pain.
S Y N O P S I S
Exercising three times a week can make a big difference to leg pain on walking (intermittent claudication) caused by blocked arteries. Intermittent claudication is a cramping pain, induced by exercise and relieved by rest. It is a symptom of atherosclerosis (fatty deposits blocking blood flow through the arteries), causing inadequate blood flow to the leg muscles. Treatments include stopping smoking, starting to exercise, drugs, heart bypass surgery or angioplasty (inserting 'balloons' to open up the arteries). This review of trials found that exercise (walking to the level that causes pain, three times a week) can relieve intermittent claudication for many people. Exercise may be better than angioplasty. Other forms of surgery may be more effective than exercise, but carry more risks.

[neurospast]

Doen't it sound strange to you that the amount of exercise as stated in the research, quoted by physiobase, has none what so ever effect on the improvement. It looks to me that since the ammount of exercise doesn't matter there is in that case there is no indication for physio treatment except the remark: walk every day.

[Physiobase]

Not coorect, re-read the text. This is all about the type of exercise, indicating that lower level is perhaps as effective as high level.

Neither study compared say one sessions for 5 minutes a week versus three sessions for 20 minutes each week. And interesting no study is looking at what is actually affected, only that the pain associated is reduced as any given work load.