Exercise for intermittent claudication Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication. Long‐term clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial The ischemic window: a method for the objective quantitation of the training effect in exercise therapy for intermittent claudication. Skeletal muscle adaptation in response to supervised exercise training for intermittent claudication. The adjuvant benefit of angioplasty in patients with mild to moderate intermittent claudication (MIMIC) managed by supervised exercise, smoking cessation advice and best medical therapy: results from two randomised trials for stenotic femoropopliteal and aortoiliac arterial disease. Endovascular Revascularization and Supervised Exercise for Peripheral Artery Disease and Intermittent Claudication: A Randomized Clinical Trial. Improvement of the walking ability in intermittent claudication due to superficial femoral artery occlusion with supervised exercise and pneumatic foot and calf compression: a randomised controlled trial. The effect of supervised exercise and cilostazol on coagulation and fibrinolysis in intermittent claudication: a randomized controlled trial. Local Versus Systemic Mechanisms Underlying Supervised Exercise Training for Intermittent Claudication Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a 'go home and walk' advice. Efficacy of Quantified Home-Based Exercise and Supervised Exercise in Patients With Intermittent Claudication: A Randomized Controlled Trial Intermittent claudication: clinical effectiveness of endovascular revascularization versus supervised hospital-based exercise training--randomized controlled trial. Treatment efficacy of intermittent claudication by invasive therapy, supervised physical exercise training compared to no treatment in unselected randomised patients II: one-year results of health-related quality of life. Supervised exercise therapy for intermittent claudication in daily practice. Design of the multicenter standardized supervised exercise training intervention for the ‘CLaudication: Exercise Vs Endoluminal Revascularization (CLEVER) study’ Exercise training in intermittent claudication. Increasing exercise tolerance of persons limited by claudication pain using polestriding. Exercise training for intermittent claudication: does it adversely affect biochemical markers of the exercise-induced inflammatory response? Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. A pilot exercise intervention to improve lower extremity functioning in peripheral arterial disease unaccompanied by intermittent claudication.
Intermittent claudication is a common condition leading to significant functional impairment and enhanced risk of cardiovascular morbidity and mortality . However , despite the functional impairment caused by intermittent claudication , the natural history in the affected limb is fairly benign . Only about 25 % of patients show symptomatic deterioration and only 2 % eventually lose the affected limb.1 This epidemiological evidence has led most clinicians in both primary and hospital care to manage intermittent claudication conservatively , addressing cardiovascular risk factors2 and giving advice on exercise . This may well be appropriate but merely giving advice about exercise is unlikley to be the most effective treatment . Exercise as a treatment for intermittent claudication is not new , with improvements in walking described from as early as 1898 . A recent Cochrane review of 10 r and omised trials of exercise therapy estimated an overall improvement in walking distance of about 150%.3 The exercise component in all but one of these OBJECTIVE This cohort study was conducted to determine the effect on walking distances of supervised exercise therapy provided in a community-based setting . METHODS The study included all consecutive patients presenting at the vascular outpatient clinic with intermittent claudication , diagnosed by a resting ankle brachial index<0.9 , who had no previous peripheral vascular intervention for peripheral arterial disease , no major amputation , and sufficient comm and of the Dutch language . The exclusion criterion was the inability to walk the baseline treadmill test for a minimum of 10 m. The intervention was a supervised exercise therapy in a community-based setting . A progressive treadmill test at baseline and at 1 , 3 , and 6 months of follow-up measured initial claudication distance and absolute claudication distance . Changes were calculated using the mean percentages of change . RESULTS From January through October 2005 , 93 consecutive patients with claudication were eligible . Overall , 37 patients discontinued the supervised exercise therapy program . Eleven stopped because of intercurrent diseases , whereas for 10 , supervised exercise therapy did not lead to adequate improvement and they underwent a vascular intervention . Three patients quit the program , stating that they were satisfied with the regained walking distance and did not require further supervised exercise therapy . Ten patients were not motivated sufficiently to continue the program , and in three patients , a lack of adequate insurance coverage was the reason for dropping out . Data for 56 patients were used and showed a mean percentage increase in initial claudication distance of 187 % after 3 months and 240 % after 6 months . The mean percentage of the absolute claudication distance increased 142 % after 3 months and 191 % after 6 months . CONCLUSION Supervised exercise therapy in a community-based setting is a promising approach to providing conservative treatment for patients with intermittent claudication OBJECTIVE The initial treatment for intermittent claudication is supervised exercise therapy ( SET ) . Owing to limited capacity and patient transports costs of clinic-based SET , a concept of SET provided by local physiotherapists was developed . We hypothesized that provision of daily feedback with an accelerometer in addition to SET would further increase walking distance . METHODS This multicenter r and omized trial was set in vascular surgery outpatient clinics and included 304 patients with intermittent claudication . Patients were r and omized to exercise therapy in the form of " go home and walk " advice ( WA ) , SET , or SET with feedback . Local physiotherapists provided SET . The primary outcome measure was the change in absolute claudication distance . Secondary outcomes were the change in functional claudication distance and results on the Walking Impairment Question naire ( WIQ ) and Short-Form 36 ( SF-36 ) Health Survey after 12 months . RESULTS In 11 centers , 102 , 109 , and 93 patients were included , respectively , in the WA , SET , and SET with feedback groups , and data for 83 , 93 , and 76 , respectively , could be analyzed . The median ( interquartile range ) change in walking distance between 12 months and baseline in meters was 110 ( 0 - 300 ) in the WA group , 310 ( 145 - 995 ) in the SET group , and 360 ( 173 - 697 ) in the SET with feedback group ( P < .001 WA vs SET ) . WIQ scores and relevant domains of the SF-36 improved statistically significantly in the SET groups . CONCLUSIONS SET is more effective than WA in improving walking distance , WIQ scores , and quality of life for patients with intermittent claudication . Additional feedback with an accelerometer did not result in further improvement . SET programs should be made available for all patients with intermittent claudication Long‐term comparisons of supervised exercise therapy ( SET ) and endovascular revascularization ( ER )  for patients with intermittent claudication are scarce . The long‐term clinical effectiveness of SET and ER  was assessed in patients from a r and omized trial Twenty-two patients with intermittent claudication were prospect ively enrolled in a 12-week program of supervised , grade d treadmill exercise therapy . Severity and distribution of arterial occlusive disease were ascertained by noninvasive determination of segmental lower extremity blood pressures and waveforms . No attempt was made to modify risk factors for atherosclerotic occlusive disease . The exercise-induced reduction of the ankle pressure and its recovery were recorded over time , and the area under this curve , the " ischemic window , " represents the severity of the ischemic deficit . Absolute systolic ankle pressure , ankle-brachial index , maximum walking time , claudication pain time , and the ischemic window were measured before and after exercise training in all subjects . Maximum walking time and claudication pain time increased 659 % and 846 % , respectively , among the 19 patients completing the 12-week program ( p = 0.001 ; p = 0.0002 ) . These patients underwent a mean reduction of 58.7 % in the ischemic window after a st and ardized workload ( p less than 0.05 ) , and this correlated with the degree of symptomatic improvement . Absolute ankle pressure and ankle-brachial index were unchanged after exercise training . This study confirms the utility of supervised exercise therapy in the treatment of intermittent claudication . The ischemic window is a useful method for quantifying the ischemic deficit produced by exercise and provides a reproducible means of documenting functional improvement in patients undergoing exercise training OBJECTIVES There is evidence that the improvement following supervised exercise for claudication results from skeletal muscle adaptation . The myosin heavy chain ( MHC ) determines muscle fibre type and therefore efficiency . Immunohistochemical analysis has failed to take account of hybrid MHC expression within myofibres . This study sought evidence of differential MHC protein expression following supervised exercise for claudication . DESIGN 38 claudicants were recruited . Subjects undertook a three-month supervised exercise programme .  Controls were patients awaiting angioplasty for claudication . MATERIAL S AND METHODS Subjects underwent paired gastrocnemius biopsy . Relative expression of MHC proteins was determined by SDS-PAGE electrophoresis . Non-parametric data is presented as median with the inter-quartile range and parametric as the mean ± st and ard deviation . RESULTS Upon completion of the exercise programme there was a 94 % increase ( 124 ( 106 - 145 ) to 241 ( 193 - 265 ) metres , p = 0.002 ) in maximum walking distance , which was not evident in the control group . An 11.1 % ( p = 0.02 ) increase in MHC I expression was observed in the exercise but not the control group ( 34.3 % ± 6.8 to 45.4 % ± 4.4 ) . There was a positive correlation between the change in MHC I expression and the improvement in claudication distance ( r = 0.69 , p < 0.05 ) . CONCLUSIONS Supervised exercise training for claudication results in an increase in the proportion of MHC type I expression within the symptomatic gastrocnemius muscle BACKGROUND Uncertainty exists on whether there is adjuvant benefit of percutaneous transluminal angioplasty ( PTA ) over supervised exercise and best medical therapy in the treatment of intermittent claudication . METHODS Patients with symptoms of stable mild to moderate intermittent claudication ( MIMIC ) were r and omised in two multi-centre trials , for femoropopliteal and aortoiliac arterial disease , to receive either PTA or no PTA against a background of supervised exercise and best medical therapy and followed up for 24 months . Initial claudication distance ( ICD ) and absolute walking distance ( AWD ) on treadmill were compared between r and omised groups adjusting for the corresponding measure at baseline . Secondary outcomes included ankle-brachial pressure index ( ABPI ) and quality of life . FINDINGS A total of 93 patients were r and omised into the femoropopliteal trial ( 48 into PTA ) and 34 into the aortoiliac trial ( 19 to PTA ) . The mean ( st and ard deviation , SD ) age was 66(9 ) years for the femoropopliteal trial ( 63 % male ) and 63(9 ) for the aortoiliac trial ( 65 % male ) . At 24 months , there were significant improvements in both AWD and ICD in the PTA groups for both trials . The adjusted AWD was 38 % greater in the PTA group for the femoropopliteal trial ( 95 % ; CI 1 - 90 ) ( p=0.04 ) and 78 % greater in the PTA group for the aortoiliac trial ( 95 % ; CI 0 - 216 ) ( p=0.05 ) . Further benefits were demonstrated for ABPI but not for quality of life . INTERPRETATION PTA confers adjuvant benefit over supervised exercise and best medical therapy in terms of walking distances and ABPI 24 months after PTA in patients with stable mild to moderate intermittent claudication IMPORTANCE Supervised exercise is recommended as a first-line treatment for intermittent claudication .  Combination therapy of endovascular revascularization plus supervised exercise may be more promising but few data comparing the 2 therapies are available . OBJECTIVE To assess the effectiveness of endovascular revascularization plus supervised exercise for intermittent claudication compared with supervised exercise only . DESIGN , SETTING , AND PARTICIPANTS R and omized clinical trial of 212 patients allocated to either endovascular revascularization plus supervised exercise or supervised exercise only . Data were collected between May 17 , 2010 , and February 16 , 2013 , in the Netherl and s at 10 sites . Patients were followed up for 12 months and the data were analyzed according to the intention-to-treat principle . INTERVENTIONS A combination of endovascular revascularization ( selective stenting ) plus supervised exercise ( n = 106 ) or supervised exercise only ( n = 106 ) . MAIN OUTCOMES AND MEASURES The primary end point was the difference in maximum treadmill walking distance at 12 months between the groups . Secondary end points included treadmill pain-free walking distance , vascular quality of life ( VascuQol ) score ( 1 [ worst outcome ] to 7 [ best outcome ] ) , and 36-item Short-Form Health Survey ( SF-36 ) domain scores for physical functioning , physical role functioning , bodily pain , and general health perceptions ( 0 [ severe limitation ] to 100 [ no limitation ] ) . RESULTS Endovascular revascularization plus supervised exercise ( combination therapy ) was associated with significantly greater improvement in maximum walking distance ( from 264 m to 1501 m for an improvement of 1237 m ) compared with the supervised exercise only group ( from 285 m to 1240 m for improvement of 955 m ) ( mean difference between groups , 282 m ; 99 % CI , 60 - 505 m ) and in pain-free walking distance ( from 117 m to 1237 m for an improvement of 1120 m vs from 135 m to 847 m for improvement of 712 m , respectively ) ( mean difference , 408 m ; 99 % CI , 195 - 622 m ) . Similarly , the combination therapy group demonstrated significantly greater improvement in the disease-specific VascuQol score ( 1.34 [ 99 % CI , 1.04 - 1.64 ] in the combination therapy group vs 0.73 [ 99 % CI , 0.43 - 1.03 ] in the exercise group ; mean difference , 0.62 [ 99 % CI , 0.20 - 1.03 ] ) and in the score for the SF-36 physical functioning ( 22.4 [ 99 % CI , 16.3 - 28.5 ] vs 12.6 [ 99 % CI , 6.3 - 18.9 ] , respectively ; mean difference , 9.8 [ 99 % CI , 1.4 - 18.2 ] ) . No significant differences were found for the SF-36 domains of physical role functioning , bodily pain , and general health perceptions . CONCLUSIONS AND RELEVANCE Among patients with intermittent claudication after 1 year of follow-up , a combination therapy of endovascular revascularization followed by supervised exercise result ed in significantly greater improvement in walking distances and health-related quality -of-life scores compared with supervised exercise only . TRIAL REGISTRATION Netherl and s Trial Registry Identifier : NTR2249 OBJECTIVES To compare the effect of unsupervised exercise , supervised exercise and intermittent pneumatic foot and calf compression ( IPC ) on the claudication distance , lower limb arterial haemodynamics and quality of life of patients with intermittent claudication . METHODS Thirty-four eligible patients with stable intermittent claudication were r and omised to IPC ( n = 13 , 3h/d for 6 months ) , supervised exercise ( n = 12 , three hourly sessions/week for 6 months ) or unsupervised exercise ( n = 9 ) . In each patient , initial claudication distance ( ICD ) , absolute claudication distance ( ACD ) , resting ankle brachial pressure index ( ABPI ) , and resting hyperaemic calf arterial inflow were measured before , 6 weeks , 6 months and 1 year after r and omisation . Quality of life was assessed with the short form (SF)-36 , walking impairment ( WIQ ) and intermittent claudication question naires ( ICQ ) . RESULTS Compared with unsupervised exercise , both IPC and supervised exercise , increased ICD and ACD , up to 2.83 times . IPC  increased arterial inflow ( p < 0.05 at 6 weeks ) and ABPI .  Supervised exercise decreased arterial inflow and increased ABPI ( p < 0.05 at 6 months ) . Unsupervised exercise had no effect on arterial inflow or ABPI . IPC improved significantly the ICQ score and the speed score of the WIQ , while supervised exercise improved the WIQ claudication severity score . At 1 year clinical effectiveness of supervised exercise and IPC was largely preserved . CONCLUSIONS IPC , by augmenting leg perfusion , achieved improvement in walking distance comparable with supervised exercise . Long-term results in a larger number of patients will provide valuable information on the optimal treatment modality of intermittent claudication BACKGROUND The prothrombotic , hypofibrinolytic state that develops in patients with intermittent claudication ( IC ) upon walking due to ischemia-reperfusion injury ( IRI ) of the leg muscles may contribute to the high incidence of life- and limb-threatening thrombotic events observed in this patient group . Treatments , such as angioplasty , that obtund the IRI also ameliorate the procoagulant diathesis . The effect on this diathesis of supervised exercise and cilostazol , both of which provide symptomatic benefit in IC , but without significantly obtunding IRI , is unknown . METHODS Thirty-four patients ( 27 men and 7 women ; median age , 67 years ; range , 63 - 72 years ) were r and omized to receive best medical therapy ( BMT ) plus supervised exercise ( n = 9 ) , BMT plus cilostazol ( n = 9 ) , BMT plus supervised exercise plus cilostazol ( n = 7 ) , or BMT alone ( n = 9 ) in a 2 x 2 factorial design . Thrombin-antithrombin complex and prothrombin fragments 1 and 2 , both markers of thrombin generation ; plasminogen activator inhibitor antigen and tissue plasminogen activator antigen , both markers of fibrinolysis ; ankle-brachial pressure index ( ABPI ) ; and initial and absolute claudication distance ( ACD ) were measured at baseline and then 3 and 6 months after r and omization . RESULTS At 6 months , when compared with receiving BMT only , supervised exercise and cilostazol result ed in improvements in ABPI of 18 % and 13 % and in ACD of 40 % and 64 % , respectively . The effects on ABPI and ACD of combining supervised exercise and cilostazol were additive . Supervised exercise , cilostazol , and supervised exercise combined with cilostazol had no significant effect on any of the four hemostatic markers . CONCLUSIONS Treatment of IC by supervised exercise or cilostazol results in significant improvements in ABPI and ACD but has no demonstrable effect on the prothrombotic diathesis . This suggests that supervised exercise and cilostazol , unlike angioplasty , are unlikely to have a long-term beneficial effect on the thrombotic risks faced by these patients The mechanisms by which exercise training improves intermittent claudication remain unclear . In this article , the effects of local and systemic physiological factors on improved exercise tolerance after a supervised exercise program in claudicants are investigated . A total of 60 patients were r and omized to 3 months of supervised exercise followed by 3 months of unsupervised exercise , or to exercise advice alone ( control ) . Supervised exercise increased both pain-free and maximal walking distances . Heart rate during submaximal exercise and resting mean arterial pressure were lower after supervised exercise at 6 months . Serum lactate at maximum claudication increased significantly after 3 months in the supervised exercise group but this change had resolved by 6 months . Symptomatic improvement was accompanied by modest reductions in mean arterial pressure and submaximal heart rate on exercise . Increased serum lactate at maximum claudication subsequently declined despite continued improvement in walking distance , suggesting local adaptations to improve efficiency of muscle oxygen delivery and /or utilization OBJECTIVES The Exercise Therapy in Peripheral Arterial Disease ( EXITPAD ) study has shown supervised exercise therapy ( SET ) to be more effective regarding walking distance and quality of life than a ' go home and walk ' advice ( WA ) for patients with intermittent claudication . The present study aims to assess the cost-effectiveness of SET versus WA . PATIENTS AND METHODS Data from the EXITPAD study , a 12-month r and omised controlled trial in 304 patients with claudication , was used to study the proportion of costs to walking distance and quality of life . Two different incremental cost-effectiveness ratios ( ICERs ) were calculated for SET versus WA : costs per extra metre on the treadmill test , and costs per quality -adjusted life year ( QALY ) . QALYs were based on utilities derived from the EuroQoL-5 dimensions ( EQ-5D ) . RESULTS Mean total costs were higher for SET than for WA ( 3407 versus 2304 Euros ) , mainly caused by the costs of exercise therapy . The median walking distance was 620 m for SET and 400 m for  WA . QALYs were 0.71 for SET and 0.67 for WA . All differences were statistically significant . The ICER for cost per extra metre on the 12-month treadmill test was € 4.08 . For cost per QALY , the ICER was € 28,693 . CONCLUSION At a willingness-to-pay threshold of € 40,000 per QALY , SET likely is a cost-effective therapeutic option for patients with claudication Background — This prospect i ve , r and omized , controlled clinical trial compared changes in exercise performance and daily ambulatory activity in peripheral artery disease patients with intermittent claudication after a home-based exercise program , a supervised exercise program , and usual-care control . Methods and Results — Of the 119 patients r and omized , 29 completed home-based exercise  , 33 completed  supervised exercise , and 30 completed usual-care control . Both exercise programs consisted of intermittent walking to nearly maximal claudication pain for 12 weeks . Patients wore a step activity monitor during each exercise session . Primary outcome measures included claudication onset time and peak walking time obtained from a treadmill exercise test ; secondary outcome measures included daily ambulatory cadences measured during a 7-day monitoring period . Adherence to home-based and supervised exercise was similar ( P=0.712 ) and exceeded 80 % . Both exercise programs increased claudication onset time ( P<0.001 ) and peak walking time ( P<0.01 ) , whereas only home-based exercise increased daily average cadence ( P<0.01 ) . No changes were seen in the control group ( P>0.05 ) . The changes in claudication onset time and peak walking time were similar between the 2 exercise groups ( P>0.05 ) , whereas the change in daily average cadence was greater with home-based exercise ( P<0.05 ) . Conclusions — A home-based exercise program , quantified with a step activity monitor , has high adherence and is efficacious in improving claudication measures similar to a st and ard supervised exercise program . Furthermore , home-based exercise appears more efficacious in increasing daily ambulatory activity in the community setting than supervised exercise . Clinical Trial Registration — URL : http://www . Clinical Trials . Gov . Unique identifier : NCT00618670 PURPOSE To compare clinical success , functional capacity , and quality of life during 12 months after revascularization or supervised exercise training in patients with intermittent claudication . MATERIAL S AND METHODS This study had institutional review board approval , and all patients gave written informed consent . Between September 2002 and September 2005 , 151 consecutive patients who presented with symptoms of intermittent claudication were r and omly assigned to undergo either endovascular revascularization ( angioplasty-first approach ) ( n = 76 ) or hospital-based supervised exercise ( n = 75 ) . The outcome measures were clinical success , functional capacity , and quality of life after 6 and 12 months . Clinical success was defined as improvement in at least one category in the Rutherford scale above the pretreatment level . Significance of differences between the groups was assessed with the unpaired t test , chi(2 ) test , or Mann-Whitney U test . To adjust outcomes for imbalances of baseline values , multivariable regression analysis was performed . RESULTS Immediately after the start of treatment , patients who underwent revascularization improved more than patients who performed exercise in terms of clinical success ( adjusted odds ratio [ OR ] , 39 ; 99 % confidence interval [ CI ] : 11 , 131 ; P < .001 ) , but this advantage was lost after 6 ( adjusted OR , 0.9 ; 99 % CI : 0.3 , 2.3 ; P = .70 ) and 12 ( adjusted OR , 1.1 ; 99 % CI : 0.5 , 2.8 ; P = .73 ) months . After revascularization , fewer patients showed signs of ipsilateral symptoms at 6 months compared with patients in the exercise group ( adjusted OR , 0.4 ; 99 % CI : 0.2 , 0.9 ; P < .001 ) , but no significant differences were demonstrated at 12 months . After both treatments , functional capacity and quality of life scores increased after 6 and 12 months , but no significant differences between the groups were demonstrated . CONCLUSION After 6 and 12 months , patients with intermittent claudication benefited equally from either endovascular revascularization or supervised exercise . Improvement was , however , more immediate after revascularization OBJECTIVE to compare the effectiveness of invasive therapy , supervised physical training and no treatment in terms of health-related quality of life ( HRQL ) in patients with intermittent claudication ( IC ) . DESIGN a prospect i ve , r and omised , controlled study . MATERIAL S a total of 253 unselected patients with stable IC were sequentially r and omised into 3 balanced treatment groups . At 1 year follow-up data from a battery of generic and disease specific HRQL question naires , and global indices of quality of life and physical condition were available in 171 patients . RESULTS compared with a non-diseased reference group , claudicants were substantially limited in daily physical functioning , but little affected regarding emotional , cognitive and social functioning , or well-being .  Invasive therapy yielded significantly greater improvements in some aspects of physical functioning and walk-related symptoms than training . Training was not superior to invasive therapy on any HRQL dimension and superior to no treatment on only one dimension . Treatment effects , however , were generally small-to-moderate and levels of physical dysfunction in all groups remained higher than reference values . CONCLUSIONS invasive therapy is more effective than supervised training in alleviating illness-specific symptoms and improving certain aspects of physical functioning - the primary HRQL domains impacted on by IC and the principal goals of its treatment . However , since treatment effect sizes were at most moderate and given that untreated claudicants reported at most small deterioration in HRQL , the level of evidence supporting invasive therapy is modest OBJECTIVE This study describes the results and functioning of community-based supervised exercise therapy ( SET ) at one year of follow-up . METHODS We conducted a prospect i ve cohort study of community-based SET in regional physiotherapeutic practice s. Consecutive patients with intermittent claudication referred for community-based SET were included . Exclusion criteria for SET were pain at rest or tissue loss . All patients received a diagnostic workup consisting of an ankle-brachial index at rest and after exercise . Interventions were exercise therapy according to the guidelines of the Royal Dutch Society for Physiotherapy . The primary outcome measurement was the increase in absolute claudication distance ( ACD ) , assessed using a st and ardized treadmill protocol by a physiotherapist at baseline and at four , 12 , 26 , and 52 weeks of SET . RESULTS From January 2005 through September 2006 , 349 patients were referred by vascular surgeons for community-based SET . A total of 272 patients with intermittent claudication began the program . Of the 349 initially referred patients , 52 could not perform a st and ard treadmill test but did start community-based SET at a lower level , and 25 patients never started the program . At one year , 129 of the original 272 patients who began community-based SET  ( 47.4 % ) were available for analysis of walking distance . In the interim , 143 patients discontinued the program for the following reasons : satisfaction with the acquired walking distance ( n = 19 ) ; unsatisfying results ( n = 26 ) ; not motivated ( n = 22 ) ; (non)vascular intercurrent disease ( n = 48 ) ; and other reasons ( n = 28 ) . ACD increased significantly from a median of 400 m at baseline to 1100 m after 12 months of follow-up ( P < .001 ) , corresponding to a median increase of 107.8 % . CONCLUSION Community-based SET seems as effective as SET in a hospital-based approach in improving walking distance , however , it has a high dropout rate Abstract The CLaudication :  Exercise Vs Endoluminal Revascularization ( CLEVER ) study is the first r and omized , controlled , clinical , multicenter trial that is evaluating a supervised exercise program compared with revascularization procedures to treat claudication . In this report , the methods and dissemination techniques of the supervised exercise training intervention are described . A total of 217 participants are being recruited and r and omized to one of three arms : ( 1 ) optimal medical care ; ( 2 ) aortoiliac revascularization with stent ; or ( 3 ) supervised exercise training .  Of the enrolled patients , 84 will receive supervised exercise therapy . Supervised exercise will be administered according to a protocol design ed by a central CLEVER exercise training committee based on vali date d methods previously used in single center r and omized control trials . The protocol will be implemented at each site by an exercise committee member using training methods developed and st and ardized by the exercise training committee . The exercise training committee review s progress and compliance with the protocol of each participant weekly . In conclusion , a multicenter approach to disseminate the supervised exercise training technique and to evaluate its efficacy , safety and cost-effectiveness for patients with claudication due to peripheral arterial disease ( PAD ) is being evaluated for the first time in CLEVER . The CLEVER study will further establish the role of supervised exercise training in the treatment of claudication result ing from PAD and provide st and ardized methods for use of supervised exercise training in future PAD clinical trials as well as in clinical practice BACKGROUND Peripheral arterial occlusive disease ( PAOD ) at II stage results in a moderate to severe impairment in walking ability . Aim of this study , controlled and r and omized , was to evaluate the efficacy of an intensive 4 weeks exercise training in PAOD followed by a six-month period and to analyse the risk factors for atherosclerosis and the site of the lesion for possible predictors of result outcome . METHODS Patients with PAOD were included in the study ( ankle/arm ratio < or = 0.7 and < or = 0.5 after exercise ) with initial claudication distance ( ICD ) < or = 200 m and absolute claudication distance ( ACD ) < or = 500 m evaluated on a constant-load treadmill test ( 3 km/hr , 0 % slope ) . Forty patients were r and omized ( all with antiplatelet therapy ) : 20 to a supervised walking exercise ( mean ICD 121.8 m , ACD 289.7 m ) and 20 to a non exercising control group ( ICD 111.6 m , ACD 230.1 m ) . Both groups were tested at 4 weeks ( T1 ) and 6 months ( T2 ) . Training group was enrolled in a 4-week supervised training program . RESULTS In the training group 10 % of patients became asymptomatic ( > 1000 m ) . At T1 ICD increased 141 % ( p<0.001 ) and ACD was with low-pain-claudication > 1000 m in 50 % , at T2 ICD was 200 % ( p<0.05 ) with 70 % of asymptomatic for ICD and ACD . Control group has a no significant increase of ICD and ACD at T1 and T2 . Only arterial hypertension and intermittent claudication severity emerged as negative predictive factors for the results of training . CONCLUSIONS Vascular training produces a significant and lasting improvement in walking distance in PAOD OBJECTIVE The efficacy of polestriding exercise ( walking with modified ski poles with a movement pattern similar to cross-country skiing ) to increase exercise tolerance of persons with intermittent claudication pain caused by peripheral arterial disease was tested in this 24-week prospect i ve r and omized clinical trial . METHODS The study was conducted in a Department of Veterans Affairs Hospital with 52 individuals who gave written informed consent and were r and omized into either a polestriding exercise ( n = 27 ; age , 65.5 + /- 7.0 years ; ankle brachial index , 0.64 + /- 0.25 ) or nonexercise control ( n = 25 ; age , 68.6 + /- 8.9 years ; ankle brachial index , 0.69 + /- 0.14 ) group ( P > .05 for all comparisons ) . The polestriding exercise program consisted of supervised training three times per week for 4 weeks , two times per week for 8 weeks , one time per week for 4 weeks , biweekly for 4 weeks and unsupervised training for 4 weeks . Starting in week 5 , subjects took their poles home with instructions to repeat the most recent supervised training walk at an appropriate and convenient location near their residence . This was referred to as unsupervised but directed exercise . Subjects were provided with a personal log book for documenting unsupervised exercise sessions . With both supervised and unsupervised exercise , subjects were expected to complete a total of four 30-minute to 45-minute polestriding exercise sessions per week . The main outcome measures were exercise duration on symptom-limited incremental treadmill test , Walking Impairment Question naire , rating of perceived leg pain at baseline , 4 , 8 , 12 , 16 , and 24 weeks , and constant work-rate treadmill exercise tests at baseline and at 4 , 12 , and 24 weeks . RESULTS Polestriding significantly ( P < .001 ) improved exercise tolerance on the constant work-rate and incremental treadmill tests . Ratings of perceived claudication pain were significantly less after the polestriding training program .  Subject perceived distance and walking speed scores on the Walking Impairment Question naire improved in the polestriding trained group only ( P < .001 and .022 , respectively ) . CONCLUSION This r and omized clinical trial provides empirical evidence that 24 weeks of polestriding training significantly improves quantitative and qualitative measures of the exercise tolerance of persons limited by intermittent claudication pain OBJECTIVES To identify a stable biochemical marker of disease severity in patients with intermittent claudication and to use these findings to assess the effect of therapeutic exercise training . DESIGN Case-control study : prospect i ve r and omised-controlled trial of exercise training . MATERIAL S AND METHODS Plasma fibrinogen , serum amyloid A protein ( SAA ) , C-reactive protein ( CRP ) and urinary albumin-creatinine ratio ( ACR ) were measured in 67 claudicants and 15 controls . Twenty-two patients were r and omised to supervised exercise training and 17 r and omised to observation .  Subjects were review ed at 3 , 6 and 12 months . RESULTS The median ( interquartile range ) baseline fibrinogen was 3.7 g/l ( 3.3 - 4.25 ) in claudicants and 3.5 g/l ( 2.9 - 3.95 ) in controls ( p = 0.045 ) ; CRP was 4.7 mg/l ( 2.2 - 9.0 ) and 2.1 mg/l ( 1.0 - 2.8 ) , respectively ( p < 0.0001 ) ; SAA was 72 mg/l ( 35 - 132 ) and 30 mg/l ( 20 - 89 ) ( p = 0.0009 ) . Claudicants showed an increased urinary ACR following treadmill exercise ( Wilcoxon , p < 0.0001 ) with no change in controls . Exercise training reduced SAA at 6 months , CRP at 3 months and progressively attenuated the post-exercise increase in ACR . No similar changes were found in controls . CONCLUSIONS Repetitive low- grade inflammatory events in claudicants lead to elevation of serum acute-phase proteins .  Exercise training is associated with symptomatic improvement and reduction inflammatory markers . The concern that exercise has adverse systemic effects therefore seems to be unjustified BACKGROUND In patients with intermittent claudication , a supervised walking exercise program increases peak exercise performance and community-based functional status .  Patients with peripheral arterial disease also have muscle weakness in the affected extremity that may contribute to the walking impairment . However , the potential benefits of training modalities other than walking exercise , such as strength training , have not been critically evaluated in this patient population . The present study tested the hypothesis that a strength training program would be as effective as treadmill walking exercise and that combinations of strengthening and walking exercise would be more effective than either alone in improving exercise performance . METHODS AND RESULTS Twenty-nine patients with disabling claudication were r and omized to 12 weeks of supervised walking exercise on a treadmill ( 3 h/wk at a work intensity sufficient to produce claudication ) , strength training ( 3 h/wk of resistive training of five muscle groups of each leg ) , or a nonexercising control group . Grade d treadmill testing was performed to maximally tolerated claudication pain to define changes in peak exercise performance . After 12 weeks , patients in the treadmill training program had a 74 + /- 58 % increase in peak walking time as well as improvements in peak oxygen consumption ( VO2 ) and the onset of claudication pain . Patients in the strength-trained group had a 36 + /- 48 % increase in peak walking time but no change in peak VO2 or claudication onset time . Control subjects had no changes in any of these measures over the 12-week period . After the first 12 weeks , patients in the initial walking exercise group continued for 12 more weeks of supervised treadmill training . This result ed in an additional 49 + /- 53 % increase in peak walking time ( total of 128 + /- 99 % increase over the 24 weeks ) . After the initial 12 weeks , patients in the strength-trained group began 12 weeks of supervised treadmill training , and patients in the control group participated in a 12-week combined program of strengthening and treadmill walking exercise . The combined strength and treadmill training program and treadmill training after 12 weeks of strength training result ed in increases in peak exercise performance similar to those observed with 12 weeks of treadmill training alone . CONCLUSIONS A supervised treadmill walking exercise program is an effective means to improve exercise performance in patients with intermittent claudication , with continued improvement over 24 weeks of training . In contrast , 12 weeks of strength training was less effective than 12 weeks of supervised treadmill walking exercise . Finally , strength training , whether sequential or concomitant , did not augment the response to a walking exercise program PURPOSE A pilot study was conducted to test the feasibility of supervised treadmill exercise training to improve functioning in study participants with peripheral arterial disease who did not have classical symptoms of intermittent claudication . METHODS For this study , 32 men and women with peripheral arterial disease but no symptoms of claudication were r and omized to exercise training or usual care .  The intervention was a 12-week supervised treadmill walking program . Outcomes included 6-minute walk distance , maximum treadmill walking distance , and 4-meter walking velocity . Participant-reported community walking ability was measured with the Walking Impairment Question naire ( WIQ ) . Inflammatory blood factor levels also were measured . RESULTS Altogether , 25 participants who completed follow-up testing were included in intention-to-treat analyses . Of 24 participants ( 58 % ) r and omized to exercise , 14 completed the entire exercise training program . The participants r and omized to the intervention showed greater improvement in their WIQ walking speed score than the control subjects ( P = .05 ) . The participants r and omized to the intervention showed improvements in their 6-minute walk distance ( 1134 + /- 347 vs 1266 + /- 295 feet ; P = .03 ) , maximal treadmill walking distance ( 389 + /- 248 vs 585 + /- 293 feet ; P < .001 ) , WIQ distance score ( 52.3 + /- 29.1 vs 63.1 + /- 25.1 ; P = .002 ) , and WIQ speed score ( 48.7 + /- 26.8 vs 59.7 + /- 22.7 ; P = .008 ) . The participants r and omized to the control condition showed improvements in maximal treadmill walking distance ( 362 + /- 180 vs 513 + /- 237 feet ; P = .014 ) . There were no significant changes in the inflammatory blood factors after exercise . CONCLUSIONS This pilot study demonstrated that a supervised treadmill walking program may be feasible and may improve functioning for individuals with peripheral arterial disease who do not have classical symptoms of intermittent claudication . Further study is needed with a larger sample to identify optimal exercise methods that improve lower extremity functioning in men and women with peripheral arterial disease who do not have intermittent claudication
CONCLUSION Exercise therapy increases the PWD and AWD  in patients with intermittent claudication .
Supervised exercise therapy increases the PWD and AWD more than st and ard care .
OBJECTIVE To review the evidence for the effectiveness of exercise therapy and to estimate the additional effect of supervision on exercise therapy in patients with intermittent claudication .