Influence of the Physical Training on Muscle Function and Walking Distance in Symptomatic Peripheral Arterial Disease in Elderly The effects of exercise training on walking function and perception of health status in elderly patients with peripheral arterial occlusive disease. Treatment of intermittent claudication with beraprost sodium, an orally active prostaglandin I2 analogue: a double-blinded, randomized, controlled trial. Gender differences following supervised exercise therapy in patients with intermittent claudication. The development and pilot randomised controlled trial of a group education programme for promoting walking in people with intermittent claudication SUPERvised exercise therapy or immediate PTA for intermittent claudication in patients with an iliac artery obstruction--a multicentre randomised controlled trial; SUPER study design and rationale. Cholesterol Reduction With Atorvastatin Improves Walking Distance in Patients With Peripheral Arterial Disease Changes in pain-free walking based on time in accommodating pain-free exercise therapy for peripheral arterial disease. Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial. Experimental Model of Pain-Free Treadmill Training in Patients with Claudication 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. Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a 'go home and walk' advice. Exercise for intermittent claudication Does supervised exercise offer adjuvant benefit over exercise advice alone for the treatment of intermittent claudication? A randomised trial. Peripheral arterial disease and intermittent claudication: efficacy of short-term upper body strength training, dynamic exercise training, and advice to exercise at home. Is intermittent claudication improved by percutaneous transluminal angioplasty? A randomized controlled trial. Physiological and functional impact of an unsupervised but supported exercise programme for claudicants. Randomized clinical trial comparing Nordic pole walking and a standard home exercise programme in patients with intermittent claudication A randomised controlled trial of supervised exercise regimens and their impact on walking performance, skeletal muscle mass and calpain activity in patients with intermittent claudication. Exercise prescription using the heart of claudication pain onset in patients with intermittent claudication Nordic pole walking improves walking capacity in patients with intermittent claudication: a randomized controlled trial Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial. A primary care walking exercise program for patients with intermittent claudication. Randomised controlled trial of percutaneous transluminal angioplasty for intermittent claudication. A pilot exercise intervention to improve lower extremity functioning in peripheral arterial disease unaccompanied by intermittent claudication. The effect of exercise intensity on the response to exercise rehabilitation in patients with intermittent claudication. Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based. 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. Strength training increases walking tolerance in intermittent claudication patients: randomized trial. A non-randomised controlled trial of the clinical and cost effectiveness of a Supervised Exercise Programme for claudication. Endovascular Revascularization and Supervised Exercise for Peripheral Artery Disease and Intermittent Claudication: A Randomized Clinical Trial. 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. A feasibility double-blind randomized placebo-controlled trial of extracorporeal shockwave therapy as a novel treatment for intermittent claudication. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. The Acute Effects of Cigarette Smoking on Treadmill Exercise Distances in Patients with Stable Intermittent Claudication Impact of a walking program in people with down syndrome. Influence of upper- and lower-limb exercise training on cardiovascular function and walking distances in patients with intermittent claudication. The Claudication: Exercise Vs. Endoluminal Revascularization (CLEVER) study: rationale and methods. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication. Improved Quality of Life After 1 Year With an Invasive Versus a Noninvasive Treatment Strategy in Claudicants: One-Year Results of the Invasive Revascularization or Not in Intermittent Claudication (IRONIC) Trial Increasing exercise tolerance of persons limited by claudication pain using polestriding. Limb-specific and cross-transfer effects of arm-crank exercise training in patients with symptomatic peripheral arterial disease. The vascular nurse in practice: Results of prescribed exercise training in patients with intermittent claudication. The ischemic window: a method for the objective quantitation of the training effect in exercise therapy for intermittent claudication. Short-term effects of cycle and treadmill training on exercise tolerance in peripheral arterial disease. Walking performance and health-related quality of life after surgical or endovascular invasive versus non-invasive treatment for intermittent claudication--a prospective randomised trial. Effects of a long-term exercise program on lower limb mobility, physiological responses, walking performance, and physical activity levels in patients with peripheral arterial disease. Effects of walking and strength training on resting and exercise cardiovascular responses in patients with intermittent claudication. A randomized trial of iloprost in patients with intermittent claudication Exercise training in intermittent claudication. Agreements and discrepancies between the estimated walking distance, nongraded and graded treadmill testing, and outside walking in patients with intermittent claudication. Comparison of two treadmill training programs on walking ability and endothelial function in intermittent claudication. Cardiovascular Training Effect Associated With Polestriding Exercise in Patients With Peripheral Arterial Disease Benefits of Low-Intensity Pain-Free Treadmill Exercise on Functional Capacity of Individuals Presenting With Intermittent Claudication Due to Peripheral Arterial Disease Effect of upper- and lower-limb exercise training on circulating soluble adhesion molecules, hs-CRP and stress proteins in patients with intermittent claudication. Supervised exercise therapy for intermittent claudication in daily practice. Evaluation of patient compliance, quality of life impact and cost-effectiveness of a "test in-train out" exercise-based rehabilitation program for patients with intermittent claudication. Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial. The relationship of walking distances estimated by the patient, on the corridor and on a treadmill, and the Walking Impairment Questionnaire in intermittent claudication. Local Versus Systemic Mechanisms Underlying Supervised Exercise Training for Intermittent Claudication Walking training at the heart rate of pain threshold improves cardiovascular function and autonomic regulation in intermittent claudication: A randomized controlled trial. A Randomized Controlled Trial of Allopurinol in Patients With Peripheral Arterial Disease Efficacy of arm-ergometry versus treadmill exercise training to improve walking distance in patients with claudication Brief Communication: Ramipril Markedly Improves Walking Ability in Patients with Peripheral Arterial Disease One-year effect of a supervised exercise programme on functional capacity and quality of life in peripheral arterial disease Efficacy of Quantified Home-Based Exercise and Supervised Exercise in Patients With Intermittent Claudication: A Randomized Controlled Trial Evaluation of walking capacity over time in 500 patients with intermittent claudication who underwent clinical treatment. [Double-blind study of the effect of dipyridamole in patients with intermittent claudication]. Treatment efficacy of intermittent claudication by surgical intervention, supervised physical exercise training compared to no treatment in unselected randomised patients I: one year results of functional and physiological improvements. Propionyl-L-Carnitine versus Pentoxifylline Skeletal muscle adaptation in response to supervised exercise training for intermittent claudication. Effect of cloricromene on intermittent claudication. A randomized, double-blind, placebo-controlled trial in patients treated with aspirin: effect on claudication distance and quality of life Exercise training improves functional status in patients with peripheral arterial disease. beta blockade and intermittent claudication: placebo controlled trial of atenolol and nifedipine and their combination. Long-Term Evaluation of Indobufen in Peripheral Vascular Disease The constitutive procoagulant and hypofibrinolytic state in patients with intermittent claudication due to infrainguinal disease significantly improves with percutaneous transluminal balloon angioplasty. Six-minute walk test closely correlates to "real-life" outdoor walking capacity and quality of life in patients with intermittent claudication. Is percutaneous transluminal angioplasty better than exercise for claudication? Preliminary results from a prospective randomised trial. Effect of ramipril on walking times and quality of life among patients with peripheral artery disease and intermittent claudication: a randomized controlled trial. Randomized, double-blind, placebo-controlled study evaluating the efficacy and safety of AS-013, a prostaglandin E1 prodrug, in patients with intermittent claudication. Early outcomes from a randomized, controlled trial of supervised exercise, angioplasty, and combined therapy in intermittent claudication. Optimal exercise program length for patients with claudication. A dose-effect study of beraprost sodium in intermittent claudication. Home-based walking exercise intervention in peripheral artery disease: a randomized clinical trial. Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication. The effect of supervised exercise and cilostazol on coagulation and fibrinolysis in intermittent claudication: a randomized controlled trial. Effect of exercise training on clot strength in patients with peripheral artery disease and intermittent claudication: An ancillary study Comparison of the effect of upper body-ergometry aerobic training vs treadmill training on central cardiorespiratory improvement and walking distance in patients with claudication. Differential lipogenic effects of cilostazol and pentoxifylline in patients with intermittent claudication: potential role for interleukin-6. Effects of home versus supervised exercise for patients with intermittent claudication. PoleStriding exercise and vitamin E for management of peripheral vascular disease. Minimally Invasive Decompression Versus X-Stop in Lumbar Spinal Stenosis: A Randomized Controlled Multicenter Study Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication. Restoring vascular nitric oxide formation by L-arginine improves the symptoms of intermittent claudication in patients with peripheral arterial occlusive disease. Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial. Benefit of exercise conditioning for patients with peripheral arterial disease. A plantar flexion device exercise programme for patients with peripheral arterial disease: a randomised prospective feasibility study. Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication. Treatment of intermittent claudication with pentoxifylline: a 12-month, randomized trial--walking distance and microcirculation. The novel phosphodiesterase inhibitor NM-702 improves claudication-limited exercise performance in patients with peripheral arterial disease. Effects of a 6-month exercise program pilot study on walking economy, peak physiological characteristics, and walking performance in patients with peripheral arterial disease Optimizing supervised exercise therapy for patients with intermittent claudication. The influence of chronic treatment with betablockade and angiotensin converting enzyme inhibition on the peripheral blood flow in hypertensive patients with and without concomitant intermittent claudication. A comparative cross-over trial. Another look at the pentoxifylline efficacy data for intermittent claudication. Impact of exercise training on inflammation and platelet activation in patients with intermittent claudication. Intermittent claudication: a double-blind crossover trial of pentoxifylline. Impact of a 4-Week Treatment with Prostaglandin E1 on Health-Related Quality of Life of Patients with Intermittent Claudication Exercise on a treadmill or walking outdoors? A randomized controlled trial comparing effectiveness of two walking exercise programmes late after stroke Clinical and microcirculatory effects of transcutaneous CO2 therapy in intermittent claudication. Randomized double-blind clinical trial with a parallel design. Effects of Pentoxifylline on Severe Intermittent Claudication Lack of influence of propranolol and metoprolol on walking distance in patients with chronic intermittent claudication. Treadmill versus shuttle walk tests of walking ability in intermittent claudication. Walking training for intermittent claudication in diabetes. Vitamin C prevents endothelial dysfunction induced by acute exercise in patients with intermittent claudication. Findings of the Naftidrofuryl in Quality of Life (NIQOL) European study program. Red Blood Cell Deformability in Patients With Claudication After Pain-free Treadmill Training Quality of life in patients with intermittent claudication using the World Health Organisation (WHO) questionnaire. Ticlopidine in the treatment of intermittent claudication: a 21-month double-blind trial. Upper- vs lower-limb aerobic exercise rehabilitation in patients with symptomatic peripheral arterial disease: a randomized controlled trial. Supervised Exercise Versus Primary Stenting for Claudication Resulting From Aortoiliac Peripheral Artery Disease: Six-Month Outcomes From the Claudication Exercise Versus Endoluminal Revascularization (CLEVER) Study The effects of physical training and flunarizine on walking capacity in intermittent claudication. Effect of training on the response of plasma vascular endothelial growth factor to exercise in patients with peripheral arterial disease. Claudication: exercise vs endoluminal revascularization (CLEVER) study update. The effect of supervised exercise therapy on physical activity and ambulatory activities in patients with intermittent claudication. Supervised exercise, stent revascularization, or medical therapy for claudication due to aortoiliac peripheral artery disease: the CLEVER study. Post-walking exercise hypotension in patients with intermittent claudication. Multicenter Double-Blind Study of Ticlopidine in the Treatment of Intermittent Claudication and the Prevention of its Complications Effective training for patients with intermittent claudication Beta blockade and intermittent claudication.
Introduction A typical symptom of chronic lower-limb ischaemia is lower-limb pain , which occurs during walking forcing the patient to stop , intermittent claudication ( IC ) .  Exercise rehabilitation is the basic form of treatment for these patients . Aim The aim of this study was to compare the effectiveness of three types of physical training programmes conducted over a 12-week period in patients with chronic lower-limb arterial insufficiency . Material s and Methods Ninety-five people qualified for the 3-month supervised motor rehabilitation programme , conducted three times a week . The respondents were assigned to three types of rehabilitation programmes using a pseudo-r and omization method : Group I ( TW ) , subjects undertaking treadmill walking training ; Group II ( NW ) , subjects undertaking Nordic walking training ; Group III ( RES+NW ) , subjects undertaking resistance and Nordic walking training . Treadmill test , 6 Minute Walk Test ( 6MWT ) , and  isokinetic test  were repeated after 3 months of rehabilitation , which 80 people completed . Results Combined training ( RES+NW ) is more effective than Nordic walking alone and supervised treadmill training alone for improving ankle force-velocity parameters ( p<0.05 ) in patients with intermittent claudication . Each of the proposed exercise rehabilitation programmes increased walking distance of patients with intermittent claudication ( p<0.05 ) , especially in 6MWT ( p=0.001 ) . Significant relationships of force-velocity parameters are observed in the maximum distance obtained in 6MWT , both in Group III ( RES + NW ) and in Group II ( NW ) at the level of moderate and strong correlation strength , which indicates that if the lower limbs are stronger the walking distance achieved in 6MWT is longer . Conclusions Given both the force-velocity parameters and the covered distance , the training RES + NW gives the most beneficial changes compared to training TW alone and NW alone . All types of training increased walking distance , which is an important aspect of the everyday functioning of people with IC OBJECTIVE To determine the effects of 12-week exercise programme on ambulatory function , free-living daily physical activity and health-related quality of life in disabled older patients with intermittent claudication . DESIGN Prospect i ve , r and omized controlled trial . SETTING University Medical Center and Veterans Affairs Medical Center , Taipei , Taiwan . SUBJECTS Thirty-two of 64 patients with Fontaine stage II peripheral arterial occlusive disease ( PAOD ) were r and omized to exercise training and 32 to usual care control .  Five patients from the exercise group and six patients from the control group dropped out , leaving 27 and 26 patients , respectively , completing the study in each group . INTERVENTIONS Twelve weeks of treadmill exercise training . MAIN OUTCOME MEASURES Treadmill walking time to onset of claudication pain and to maximal claudication pain , 6-min walk distance , self-reported ambulatory ability and perceived health-related quality of life ( QOL ) . RESULTS Compliance of exercise programme was 83 % of the possible sessions . Exercise training increased treadmill walking time to onset of claudication pain by 88 % ( P < 0.001 ) , time to maximal pain by 70 % ( P < 0.001 ) , and 6-min walk distance by 21 % ( P < 0.001 ) . SUBJECTS Perception of health-related QOL improved from 12 % to 178 % in the exercise group . These improvements were significantly better than the changes in the control group ( P < 0.05 ) . CONCLUSIONS Significant improvements in claudication following 12-week exercise training in elderly PAOD patients were observed . Increase in treadmill walking time to maximal claudication pain in these patients translated into the improvement of perceived physical health , which enabled the patients to become more functionally independent OBJECTIVES In the current study , we hypothesized that beraprost would : 1 ) improve treadmill exercise performance and quality of life ; and 2 ) decrease rates of ischemic events in patients with intermittent claudication . BACKGROUND Previous trials with beraprost sodium , an orally active prostagl and in I(2 ) analogue , in the treatment of claudication in patients with peripheral arterial disease ( PAD ) have been inconsistent . METHODS Patients with intermittent claudication ( n = 897 ) were r and omized to receive either 40 microg three times a day of beraprost with meals ( n = 385 ) or placebo ( n = 377 ) in a double-blinded manner for one year . The primary efficacy parameter was treadmill-measured maximum walking distance , as assessed at three and six months after r and omization . Secondary efficacy parameters included treadmill-measured pain-free walking distance and change in quality of life . RESULTS There was no significant improvement in maximum walking distance in the beraprost group ( 16.7 % ) as compared with the placebo group ( 14.6 % , p = NS ) . Administration of beraprost did not improve the pain-free walking distance ( p = NS between treatment groups ) , and there was no improvement in the quality -of-life measures between the treatment groups . The incidence of critical cardiovascular events was 7.3 % in the beraprost group and 11.4 % in the placebo group ( p = NS ) . There was a significant reduction in the combination of cardiovascular death and myocardial infa rct ion in the beraprost group ( p = 0.01 ) . CONCLUSIONS Despite previous investigations suggesting efficacy , these results indicate that beraprost is not an effective treatment to improve symptoms of intermittent claudication in patients with PAD . The potential benefit of beraprost on critical cardiovascular events would require confirmation in a larger prospect i ve investigation OBJECTIVE Prevalence of peripheral arterial disease is equal in men and women . However , women seem to suffer more from the burden of disease . Current studies on gender-related outcomes following supervised exercise therapy ( SET ) for intermittent claudication ( IC ) yield conflicting results . METHODS A follow-up analysis was performed on data from the 2010 Exercise Therapy in Peripheral Arterial Disease ( EXITPAD ) study , a multicenter r and omized controlled trial including IC patients receiving SET or a walking advice .  The SET program was supervised by physiotherapists and included interval-based treadmill walking approximating maximal pain combined with activities such as cycling and rowing . Patients usually started with three 30-minute sessions a week . Training frequency was adapted during the following year on the basis of individual needs . The primary outcome was gender differences regarding the change in absolute claudication distance ( ACD ) after SET . ACD was defined as the number of meters that a patient had covered just before he or she was forced to stop walking because of intolerable pain . Secondary outcomes were gender differences in change of functional walking distance , quality of life , and walking (dis)ability after SET . Walking distances were obtained by  st and ardized treadmill testing  according to the Gardner-Skinner protocol . Quality of life was measured by the 36-Item Short Form Health Survey , and walking (dis)ability was determined by the Walking Impairment Question naire ( WIQ ) . Measurements were performed at baseline and after 3 , 6 , 9 , and 12 months . Only patients who met the 12-month follow-up measure were included in the analysis . RESULTS A total of 113 men and 56 women were available for analysis . At baseline , groups were similar in terms of clinical characteristics and ACD walking distances ( men , 250 meters ; women , 270 meters ; P = .45 ) . ACD improved for both sexes . However , ACD increase was significantly lower for women than for men during the first 3 months of SET ( Δ 280 meters for men vs Δ 220 meters for women ; P = .04 ) . Moreover , absolute walking distance was significantly shorter for women compared with men after 1 year ( 565 meters vs 660 meters ; P = .032 ) . Women also reported less on several WIQ subdomains , although total WIQ score was similar ( 0.69 for men vs 0.61 for women ; P = .592 ) . No differences in quality of life  after SET were observed . CONCLUSIONS Women with IC benefit less during the first 3 months of SET and have lower absolute walking distances  after 12 months of follow-up compared with men . More research is needed to determine whether gender-based IC treatment strategies are required The aim of this study was to develop and pilot a group education programme for promoting walking in people with intermittent claudication . Patient focus groups ( n=24 ) and literature review s were conducted to inform the development of the education programme , which involves a three-hour group-based education workshop and follow-up telephone support . A pilot study was subsequently conducted in which 23 new patients ( Rutherford category 1–3 ) were r and omly assigned to usual care ( control ) or usual care plus the education programme . Outcomes were assessed at baseline and six weeks including daily steps ( tri-axial accelerometer ) , walking capacity ( six-minute walk test and Gardner treadmill test ) , and quality of life ( Intermittent Claudication Question naire [ ICQ ] ) . Exit interviews were conducted to assess the acceptability and usefulness of the programme . Compared with controls , the intervention group had superior walking capacity and quality of life at six weeks . Mean differences in six-minute walk distance , treadmill maximum walking distance and ICQ score were 44.9 m ( 95 % confidence interval [ CI ] , 6.9 to 82.9 ) , 173 m ( 95 % CI , 23 to 322 ) , and −10.6 ( 95 % CI , −18.9 to −2.3 ) , respectively . The daily step count did not differ between groups . The exit interviews indicated that participants valued attending the programme , that it gave them a greater underst and ing of their condition , and that they had been walking more for exercise since attending . The results suggest that the education programme is feasible , acceptable , and potentially useful for improving walking capacity and quality of life . A fully-powered trial exploring clinical and cost effectiveness is needed . TRIAL REGISTRATION NUMBER : IS RCT N06733130 ( http://www.controlled-trials.com ) INTRODUCTION Treatment of intermittent claudication ( IC ) due to peripheral arterial disease ( PAD ) is aim ed at improving walking distance and includes secondary prevention of cardiovascular disease . Both supervised exercise therapy ( SET ) and percutaneous transluminal angioplasty ( PTA ) have proven to be effective in increasing maximum and pain-free walking distance in IC . However , the optimal treatment strategy in patients with IC due to iliac artery stenosis or occlusion remains unclear . OBJECTIVE To compare the ( cost- ) effectiveness of initial PTA versus initial SET in patients with disabling IC due to an iliac artery obstruction . DESIGN In a multicentre r and omised controlled trial 400 consecutive patients with IC will be r and omly assigned to PTA ( with additional stent placement on indication ) or SET . Primary outcomes are maximum walking distance and health-related quality of life measured using the disease-specific VascuQol instrument after 1 year . Secondary outcomes are pain-free walking distance , functional status , generic quality of life , complications related to each of the interventions , additional interventions , treatment failures and costs ( cost-effectiveness and cost-utility ) after 1 year . CONCLUSION AND IMPLICATION S Based on the results of this proposed large study well-founded adjustments of existing guidelines on the treatment of iliac artery occlusive disease can be implemented ( Clinical Trials.gov NCT01385774 ; Nederl and s Trial Register NTR2776 ) Background —Cholesterol modification reduces cardiovascular events in patients with atherosclerosis , including those with peripheral arterial disease . The purpose of this study was to determine whether cholesterol lowering with atorvastatin improves walking performance in patients with intermittent claudication . Methods and Results —This r and omized , double-blind , parallel- design study included 354 persons with claudication attributable to peripheral arterial disease . Patients were treated with placebo , atorvastatin ( 10 mg per day ) , or atorvastatin ( 80 mg per day ) for 12 months . The outcome measures included change in treadmill exercise time and patient-reported measures of physical activity and quality of life based on question naires . Maximal walking time after 12 months of treatment with atorvastatin did not change significantly . However , there was improvement in pain-free walking time after 12 months of treatment for the 80-mg ( P = 0.025 ) group compared with placebo . A physical activity question naire demonstrated improvement in ambulatory ability for the 10- and 80-mg groups ( P = 0.011 ) , whereas 2 quality of life instruments , the Walking Impairment Question naire and Short Form 36 Question naire , did not show significant change . Conclusions —Atorvastatin improves pain-free walking distance and community-based physical activity in patients with intermittent claudication . When treated with atorvastatin , patients with peripheral arterial disease may experience improvement in symptoms to complement the anticipated reduction in cardiovascular events reported in other studies of statins Symptoms of intermittent claudication ( IC ) can be relieved by lifestyle modification , medications , and walking exercises . The intensity of the walking exercise is still debatable . The goal of this study was to determine the effects of accommodating pain-free walking exercise therapy program length on pain-free walking . A descriptive , longitudinal study with repeated measures of exercise capacity was conducted . An IC question naire was administered to assess IC signs , symptoms , and lifestyle . Walking was performed on a treadmill for 30 to 50 minutes below the participant 's individualized walking pain threshold . The study included patients diagnosed with IC due to peripheral arterial disease . All participants were r and omly assigned to three groups . Group A ( n = 28 ) participated in the walking program for 2 - 9 weeks , group B ( n = 30 ) for 10 - 14 weeks , and group C ( n = 26 ) for 15 - 94 weeks . The main outcome measure of the study was to determine changes in exercise capacity : walking distance ( miles ) , walking duration ( minutes ) , and walking speed ( mph ) . Group A increased the amount of distance , duration , and speed walked from pretest to posttest by 80 % ( P < .001 ) , 27 % ( P < .001 ) , and 37 % ( P < .001 ) , respectively . Group B increased the amount of distance , duration , and speed walked from pretest to posttest by 122 % ( P < .001 ) , 56 % ( P < .001 ) , and 43 % ( P < .001 ) , respectively . Group C increased the amount of distance , duration , and speed walked from pretest to posttest by 26 % ( P = .002 ) , 22 % ( P = .002 ) , and 5 % ( P = .541 ) respectively . We reached the conclusion that a walking program of 10 - 14 weeks is optimal for achieving the best improvements in walking distance , duration , and speed OBJECTIVE To determine the effects of a 6-month exercise program on ambulatory function , free-living daily physical activity , peripheral circulation , and health-related quality of life ( QOL ) in disabled older patients with intermittent claudication . DESIGN Prospect i ve , r and omized controlled trial . SETTING University Medical ( Center and Veterans Affairs Medical Center , Baltimore , Maryl and . PARTICIPANTS Thirty-one of 61 patients with Fontaine stage II peripheral arterial occlusive disease ( PAOD ) were r and omized to  exercise rehabilitation and 30 to  usual-care control . Three patients from the exercise group and six patients from the control group dropped out , leaving 28 and 24 patients , respectively , completing the study in each group . INTERVENTION Six months of exercise rehabilitation . MEASUREMENTS Treadmill distance walked to onset of claudication and to maximal claudication , ambulatory function , peripheral circulation , perceived QOL , and daily physical activity . RESULTS Compliance with the exercise program was 73 % of the possible sessions . Exercise rehabilitation increased treadmill distance walked to onset of claudication by 134 % ( P < .001 ) and to maximal claudication by 77 % ( P < .001 ) , walking economy by 12 % ( P = .003 ) , 6-minute walk distance by 12 % ( P < .001 ) , and maximal calf blood flow by 30 % ( P < .001 ) . Changes in distance walked to maximal pain correlated with changes in walking economy ( r = -.50 , P = .013 ) and changes in maximal calf blood flow ( r = .38 , P = .047 ) . Exercise rehabilitation increased accelerometer-derived daily physical activity by 38 % ( P < .001 ) ; this change correlated with the change in distance walked to maximal pain ( r = .45 , P = .020 ) . These improvements were significantly better than the changes in the control group ( P < .05 ) . CONCLUSION Improvements in claudication following exercise rehabilitation in older PAOD patients are dependent on improvements in peripheral circulation and walking economy . Improvement in treadmill claudication distances in these patients translated into increased accelerometer-derived physical activity in the community , which enabled the patients to become more functionally independent Mika P , Spodaryk K , Cencora A , Unnithan VB , Mika A : Experimental model of pain-free treadmill training in patients with claudication . Am J Phys Med Rehabil 2005;84:756–762 . 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 r and omized 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 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 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 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 Exercise advice is the main treatment for symptom relief in the UK for patients with mild to moderate Intermittent Claudication ( IC ) . Would a weekly exercise and motivation class for 6 months offer adjuvant benefit over written and verbal exercise advice alone ? PATIENTS AND METHODS Fifty-nine patients attending a regional vascular centre for whom IC was the main factor affecting mobility were r and omised to either exercise advice alone ( n=30 ) or exercise advice with a once a week 45 min supervised exercise/motivation class ( n=29 ) . The mean age was 68 years . Baseline and 6-month assessment included a Quality of Life Question naire -- the Short-Form-36 , the Charing Cross Symptom Specific Claudication Question naire ( CCCQ ) and treadmill walking distance ( 3.5 km/h 12 % ) . RESULTS At 6-month follow-up the supervised exercise group had improved their treadmill walking by 129 % compared to 69 % in the advice alone group ( p=0.001 ) . This significant improvement was maintained at the subsequent 9 and 12-month follow-up assessment s. By the 9-month stage the advice only group CCCQ score had improved 16 % from baseline , while the supervised exercise group had a significantly better 43 % improvement in base line score ( p<0.05 ) . Self reported frequency of walks was higher in the exercise class group being significant for improvement in CCCQ score . CONCLUSION A weekly , supervised exercise and motivation class for a 6-month period provides a significant improvement in patients ' symptoms , quality of life , and distance walked compared with advice alone and this improvement continues after attendance at class has ceased OBJECTIVE To compare the effect of two training programmes and advice to exercise at home on physiological adaptations in patients with peripheral arterial disease ( PAD ) . DESIGN 30 patients with a typical history of PAD and intermittent claudication were r and omised to either an upper body strength training programme ( UBST ) , a dynamic ( walking , cycling , circuit ) conventional exercise rehabilitation programme ( CER ) , or advice to ' walk as much as possible at home ' ( CONT ) . Before and after intervention groups performed a st and ard grade d treadmill exercise test ( GTET ) and a 6-minute walk test ( SMWT ) to determine peak physiological parameters and walking distances . Maximal walking distance ( MWD ) , pain-free walking distance ( PFWD ) , peak oxygen uptake ( VO2 ) , heart rate and perceived pain were measured . RESULTS MWD on the GTET increased significantly in the CER group compared with the CONT and UBST groups ( 93.9 + /- 79 % v. 7.0 + /- 19.8 % v. 7.3 + /- 46 % ; CER v. UBST v. CONT p = 0.003 ) . Similarly , peak VO2 increased with CER compared with the CONT and UBST groups ( 28.4 + /- 20 v. -6.2 + /- 15 v. -1.0 + /- 21 % ; CER v. UBST v. CONT p = 0.004 ) . During the SMWT the CER and UBST groups improved in PFWD compared with the CONT group ( 37 + /- 47 % v. 27 + /- 71 % v. -30 + /- 29 % ; CER v. UBST v. CONT p = 0.03 ) , and perceived pain decreased in the CER group compared with the UBST group ( -24 + /- 39 % v. 27 + /- 48 % ; CER v. UBST p = 0.01 ) . CONCLUSION CER improves physiological parameters and walking distances more than UBST does . CER is effective within 6 weeks . Verbal encouragement to exercise is an ineffective form of management PURPOSE Percutaneous transluminal angioplasty ( PTA ) is an increasingly popular invasive treatment for peripheral arterial disease , but there have been very few controlled trials to justify its use . This r and omized controlled clinical trial was performed to determine in patients with mild and moderate intermittent claudication differences in outcome between PTA and conventional medical treatment after 2 years . METHODS Six hundred patients with claudication were screened at the Peripheral Vascular Clinic , Royal Infirmary of Edinburgh . Sixty-two patients with short femoral artery stenoses or occlusions ( 47 patients ) and iliac stenoses ( 15 patients ) were r and omized to either PTA plus medical treatment ( PTA group , 30 patients ) or to medical treatment alone ( control group , 32 patients ) . Medical treatment consisted of daily low-dose aspirin and advice on smoking and exercise . Outcome measures studied were patient-reported maximum walking distance , exercise treadmill distance until onset of claudication , treadmill maximum walking distance , ankle-brachial pressure index ( ABPI ) , quality of life ( Nottingham Health Profile ) , and duplex ultrasound-measured extent of occlusive disease . RESULTS At 2 years of follow-up , the PTA group and control subjects did not differ significantly in patient-reported maximum walking , treadmill onset to claudication , treadmill maximum walking distances , or ABPI ( p > 0.05 ) . However , the PTA group had significantly fewer occluded arteries ( p = 0.003 ) and a lesser degree of stenosis ( expressed in terms of the velocity ratio ; p = 0.004 ) in patent arteries . Quality of life was not demonstrably different between the two groups ( p > 0.05 ) . CONCLUSIONS Two years after PTA , patients had less extensive disease than medically treated patients , but this did not translate into a significant advantage in terms of improved walking or quality of life . There are important implication s for patient management and future clinical research OBJECTIVES To evaluate an unsupervised home-based exercise programme for physiological , functional , and quality of life impact in patients with symptomatic peripheral arterial disease . DESIGN Prospect i ve cohort with exercise intervention . MATERIAL S Human performance laboratory with non-invasive haemodynamic assessment facilities . METHODS Forty-seven patients with symptomatic peripheral arterial disease ( mean age 67.6+/-7 years , 33 males ) participated in an unsupervised home-based exercise programme .  Heart rate ( HR ) , ankle brachial blood pressure index ( ABPI ) , leg blood flow ( BF ) , and blood lactate were measured before and after a grade d treadmill walk at baseline and after the 12-week exercise programme .  Maximum walking distance ( MWD ) during the treadmill walk was measured at baseline and 12 weeks . Exercise compliance , functional parameters , and quality of life ( VascuQoL ) were assessed by question naire . RESULTS MWD , leg BF , and VascuQoL scores increased significantly , while resting HR , exercise HR , and end of walk rate-pressure-product ( RPP ) decreased significantly after 12 weeks . Exercise compliance was significantly correlated with increase in MWD ( r=0.89 , p<0.001 ) and QOL score improvement ( r=0.61 , p<0.001 ) . CONCLUSIONS This supported but unsupervised exercise programme generated improvements in walking distance and leg blood flow without detectable increases in cardiorespiratory work . Exercise compliance is related to MWD and VascuQoL score in a dose-response manner This was a r and omized clinical trial to determine whether Nordic pole walking ( NPW ) is more effective in improving walking distance than a st and ard home exercise programme ( HEP ) in patients with intermittent claudication OBJECTIVES Supervised exercise training ( SET ) is recommended for patients with intermittent claudication ( IC ) . The optimal exercise programme has not been identified , and the potential adverse effects of exercise on these patients warrant consideration . Calpain proteases have been linked with tissue atrophy following ischaemia-reperfusion injury . High calpain activity may therefore cause muscle wasting in claudicants undergoing SET , and skeletal muscle mass ( SMM ) is integral to healthy ageing . This study assesses the impact of ( 1 ) treadmill-based SET alone ; and ( 2 ) treadmill-based SET combined with resistance training on pain-free walking distance ( PFWD ) , SMM , and calpain activity . METHODS Thirty-five patients with IC were r and omised to 12 weeks of treadmill only SET ( group A ) , or combined treadmill and lower-limb resistance SET ( group B ) . PFWD via a 6-minute walking test , SMM via dual energy X-ray absorptiometry , and calpain activity via biopsies of gastrocnemius muscles were analysed . RESULTS Intention-to-treat analyses revealed PFWD improved within group A ( 160 m to 204 m , p = .03 ) , but not group B ( 181 m to 188 m , p = .82 ) . There was no between group difference ( p = .42 ) . Calpain activity increased within group A ( 1.62 × 10(5 ) fluorescent units [ FU ] to 2.21 × 10(5 ) FU , p = .05 ) , but not group B. There was no between group difference ( p = .09 ) . SMM decreased within group A ( -250 g , p = .11 ) and increased in group B ( 210 g , p = .38 ) ( p = .10 between groups ) . Similar trends were evident for per protocol analyses , but , additionally , change in SMM was significantly different between groups ( p = .04 ) . CONCLUSIONS Neither exercise regimen was superior in terms of walking performance . Further work is required to investigate the impact of the calpain system on SMM in claudicants undertaking SET OBJECTIVE : To assess the acute metabolic and cardiovascular responses to walking exercise at an intensity corresponding to the heart rate of claudication pain onset and to investigate the effects of a 12-week walking training program at this intensity on walking capacity . METHODS : Twenty-nine patients with intermittent claudication were r and omly allocated to the  walking training  ( n = 17 ) or control ( CO , n = 12 ) group . The walking training group performed an acute exercise session comprising 15 × 2-min bouts of walking at the heart rate of claudication pain onset , with 2-min interpolated rest intervals . The claudication symptoms and cardiovascular and metabolic responses were evaluated . Walking training was then performed at the same intensity twice each week for 12 weeks , while the control group engaged in twice weekly stretching classes  . The claudication onset distance and total walking distance were evaluated before and after the interventions . Brazilian Registry Clinical Trials : RBR-7M3D8W . RESULTS : During the acute exercise session , the heart rate was maintained within tight limits . The exercise intensity was above the anaerobic threshold and > 80 % of the heart rate peak and VO2peak . After the exercise training period , the walking exercise group ( n = 13 ) showed increased claudication onset distance ( 309±153 vs. 413±201 m ) and total walking distance ( 784±182 vs. 1,100±236 m ) compared to the control group ( n = 12 ) ( p<0.05 ) . CONCLUSION : Walking exercise prescribed at the heart rate of claudication pain onset enables patients with intermittent claudication to exercise with tolerable levels of pain and improves walking performance Abstract Purpose : The aim of the study was to compare the efficacy of Nordic pole walking ( NPW ) training with traditional treadmill training ( TT ) on a claudication ( CD ) and maximum walking distance ( MWD ) in patients with peripheral arterial disease ( PAD ) . Method : Patients with intermittent claudication ( IC ) ( n = 70 ; age=68.27 ) in the Fontaine class II were r and omized into a two three-month rehabilitation programs performed three times per week . TT were finished by 31 patients , NPW by 21 . Walking capacity was measured by an  exercise treadmill test ( ETT ) with the Gardner – Skinner protocol ( before and after the program ) and  six minute walk test ( 6MWT ) ( before , during and after the program ) . Results : In an ETT both groups reached significant increase in CD and MWD ( p ≤ 0.005 ) . In 6MWT NPW group reached significant increase in both CD ( p = 0.001 ) and MWD ( p = 0.001 ) , whereas the TT group only in MWD ( p = 0.001 ) . Conclusions : NPW has been shown to be as effective as the st and ard TT and is much less expensive . It should be the preferred method of exercise for PAD patients with IC . Implication s for Rehabilitation Nordic walking training is a valuable form of rehabilitation for peripheral arterial disease ( PAD ) patients with intermittent claudication ( IC ) . Nordic walking has been shown to be as efficient as traditional treadmill training . It is however more cost-effective method of rehabilitation in PAD patients CONTEXT Neither supervised treadmill exercise nor strength training for patients with peripheral arterial disease ( PAD ) without intermittent claudication have been established as beneficial . OBJECTIVE To determine whether supervised treadmill exercise or lower extremity resistance training improve functional performance of patients with PAD with or without claudication . DESIGN , SETTING , AND PARTICIPANTS R and omized controlled clinical trial performed at an urban academic medical center between April 1 , 2004 , and August 8 , 2008 , involving 156 patients with PAD who were r and omly assigned to supervised treadmill exercise , to lower extremity resistance training , or to a control group .  MAIN OUTCOME MEASURES Six-minute walk performance and the short physical performance battery . Secondary outcomes were brachial artery flow-mediated dilation , treadmill walking performance , the Walking Impairment Question naire , and the 36-Item Short Form Health Survey physical functioning ( SF-36 PF ) score . RESULTS For the 6-minute walk , those in the supervised treadmill exercise group increased their distance walked by 35.9 m ( 95 % confidence interval [ CI ] , 15.3 - 56.5 m ; P < .001 ) compared with the control group , whereas those in the resistance training group increased their distance walked by 12.4 m ( 95 % CI , -8.42 to 33.3 m ; P = .24 ) compared with the control group . Neither exercise group improved its short physical performance battery scores . For brachial artery flow-mediated dilation , those in the treadmill group had a mean improvement of 1.53 % ( 95 % CI , 0.35%-2.70 % ; P = .02 ) compared with the control group . The treadmill group had greater increases in maximal treadmill walking time ( 3.44 minutes ; 95 % CI , 2.05 - 4.84 minutes ; P < .001 ) ; walking impairment distance score ( 10.7 ; 95 % CI , 1.56 - 19.9 ; P = .02 ) ; and SF-36 PF score ( 7.5 ; 95 % CI , 0.00 - 15.0 ; P = .02 ) than the control group . The resistance training group had greater increases in maximal treadmill walking time ( 1.90 minutes ; 95 % CI , 0.49 - 3.31 minutes ; P = .009 ) ; walking impairment scores for distance ( 6.92 ; 95 % CI , 1.07 - 12.8 ; P = .02 ) and stair climbing ( 10.4 ; 95 % CI , 0.00 - 20.8 ; P = .03 ) ; and SF-36 PF score ( 7.5 ; 95 % CI , 0.0 - 15.0 ; P = .04 ) than the control group . CONCLUSIONS Supervised treadmill training improved 6-minute walk performance , treadmill walking performance , brachial artery flow-mediated dilation , and quality of life but did not improve the short physical performance battery scores of PAD participants with and without intermittent claudication .  Lower extremity resistance training improved functional performance measured by treadmill walking , quality of life , and stair climbing ability . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00106327 PURPOSE In a pilot study , the hypothesis was tested that a home-based walking exercise program with structured coaching would improve walking performance and adherence in patients with intermittent claudication ( IC ) . METHODS Thirty-one IC patients with a rest ankle-brachial pressure index < 0.90 started a 24-wk walking program in the home environment . They were coached according to the Health Counseling Model ( HCM ) . Patients were instructed to walk at least 9 bouts.wk-1 and to walk through the pain . The main effect measures were pain-free ( initial claudication distance ( ICD ) ) and maximum walking distance ( absolute claudication distance ( ACD ) ) measured with a grade d treadmill test , a corridor exercise test , a  walking-diary  , and the score on the Walking Impairment Question naire ( WIQ ) . RESULTS Twenty-four participants completed the program . The reported walking frequency was 7.4 times.wk-1 . The average ICD improved from 289 m ( 95 % CI , 209 - 369 ) to 347 m ( 95 % CI , 244 - 449 ) ( P < 0.05 ) and from 241 m ( 95 % CI , 171 - 310 ) to 373 m ( 95 % CI , 273 - 472 ) on the treadmill and the corridor test , respectively . The average ACD improved from 490 m ( 95 % CI , 397 - 583 ) to 544 m ( 95 % CI , 438 - 650 ) and from 564 m ( 95 % CI , 412 - 717 ) to 726 m ( 95 % CI , 546 - 906 ) ( P < 0.01 ) on the treadmill and the corridor test , respectively . The average maximum distance reported in the walking-diary improved from 957 m ( 95 % CI , 291 - 1623 ) to 1294 m ( 95 % CI , 646 - 1941 ) . The score of the walking distance on the WIQ improved from 57 % ( 95 % CI , 42 - 71 % ) to 60 % ( 95 % CI , 46 - 74 % ) . CONCLUSION IC patients improved their average ICD and ACD . The walking exercise program in the home environment with coaching according to the HCM seems a promising intervention to be tested in a r and omized controlled trial OBJECTIVES To determine differences between PTA and conventional medical treatment in treadmill distance until onset of claudication , treadmill maximum walking distance , patient reported maximum walking distance , ankle brachial pressure index ( ABPI ) , quality of life ( Nottingham Health Profile , NHP ) and Duplex measured extent of occlusive disease . DESIGN R and omised controlled clinical trial . METHODS Six hundred claudicants were screened . Fifty-one men and 11 women with intermittent claudication due to short femoral stenoses or occlusions ( n = 47 ) and iliac stenoses ( n = 15 ) were r and omised to either PTA plus medical treatment ( PTA group , n = 30 ) or to medical treatment alone ( control group , n = 32 ) . Medical treatment consisted of daily low dose aspirin and advice on smoking and exercise . RESULTS At 6 month follow up : In the PTA group more patients reported no claudication ( p < or = 0.05 ) and were asymptomatic on the treadmill ( p < or = 0.01 ) compared to the control group . The ABPI was significantly higher in the PTA group . More of the PTA group reported lower NHP pain scores ( p < or = 0.05 ) . In the control group there were more occluded arteries ( p < or = 0.001 ) , and the stenosis velocity ratio of patient arteries was significantly higher ( p < or = 0.001 ) . CONCLUSIONS Only 10 % of claudicants had discrete lesions suitable for PTA . Treatment of these patients with PTA produces a greater short-term improvement in walking and quality of life than medical treatment alone and is associated with less progression of disease 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 PURPOSE The purpose of this r and omized 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 r and omized to low-intensity exercise rehabilitation and 33 patients r and omized 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 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 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 OBJECTIVE To analyze the effects of strength training ( ST ) in walking capacity in patients with intermittent claudication ( IC ) compared with walking training ( WT ) effects . METHODS Thirty patients with IC were r and omized into ST and WT . Both groups trained twice a week for 12 weeks at the same rate of perceived exertion . ST consisted of three sets of 10 repetitions of whole body exercises . WT consisted of 15 bouts of 2-minute walking . Before and after the training program walking capacity , peak VO(2 ) , VO(2 ) at the first stage of treadmill test , ankle brachial index , ischemic window , and knee extension strength were measured . RESULTS ST improved initial claudication distance ( 358 + /- 224 vs 504 + /- 276 meters ; P < .01 ) , total walking distance ( 618 + /- 282 to 775 + /- 334 meters ; P < .01 ) , VO(2 ) at the first stage of treadmill test ( 9.7 + /- 2.6 vs 8.1 + /- 1.7 mL.kg(-1).minute ; P < .01 ) , ischemic window ( 0.81 + /- 1.16 vs 0.43 + /- 0.47 mm Hg minute meters(-1 ) ; P = .04 ) , and knee extension strength ( 19 + /- 9 vs 21 + /- 8 kg and 21 + /- 9 vs 23 + /- 9 ; P < .01 ) . Strength increases correlated with the increase in initial claudication distance ( r = 0.64 ; P = .01 ) and with the decrease in VO(2 ) measured at the first stage of the treadmill test ( r = -0.52 ; P = .04 and r = -0.55 ; P = .03 ) . Adaptations following ST were similar to the ones observed after WT ; however , patients reported lower pain during ST than WT ( P < .01 ) . CONCLUSION ST improves functional limitation similarly to WT but it produces lower pain , suggesting that this type of exercise could be useful and should be considered in patients with IC OBJECTIVES The main aims of treatment in patients with intermittent claudication ( IC ) are to improve the clinical indicators of lower limb ischaemia and patients ' quality of life ( QoL ) . The aims of this study were assess the clinical and cost effectiveness of a supervised exercise programme ( SEP ) in patients with IC . DESIGN Non-r and omised , controlled trial . SETTING University teaching hospital . PATIENTS AND METHODS Two groups of patients with IC were studied . Seventy patients were sequentially recruited before and after the establishment of a Supervised Exercise Programme at our unit . Thirty-seven patients ( median age 69 years , 26 men ) received  conservative medical therapy ( CMT ) and 33 patients ( median age 67 years , 22 men ) received CMT plus a 3 month SEP of graduated physical exercise for sixty minutes , three times each week . Patients were assessed prior to and at 6 months following treatment . At each assessment patient reported walking distances ( PRWD ) , treadmill claudication and maximal distances ( ICD and MWD ) , ankle brachial pressure indices ( ABPI ) pre & post exercise and patient reported QoL using the SF36 question naire were assessed . RESULTS Prior to intervention the two groups were well matched . Following treatment , CMT patients demonstrated no significant change in PRWD or ICD but did record a small but significant improvement in MWD .  CMT was also associated with a negative effect size in the SF36 index and in 7 of the 8 SF36 QoL domains , effect size > -0.5 for the domains of Physical Function and Emotional Role . SEP patients demonstrated significant improvement in PRWD , ICD and MWD . SEP was associated with a positive effect size in the SF36 index and in 2 SF36 QoL domains but a negative effect size in a further 2 domains . However , all QoL effect sizes following SEP were < + /-0.5 . Intergroup differences in effect sizes were > 0.5 for the SF36 domains of Physical Function , Physical Role , Emotion Role and SF36 index . SEP result ed in a 0.027 quality adjusted life year ( QALY ) gain over CMT in the first year post-treatment thus the cost/QALY gained of SEP is pound1780 at 1 year . CONCLUSIONS Compared to CMT , SEP increases walking distances , improves QoL and is a highly cost-effective treatment for IC 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 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 BACKGROUND Intermittent claudication is the most common symptom of peripheral arterial disease . Previous research has suggested that extracorporeal shockwave therapy ( ESWT ) may induce angiogenesis in treated tissue . The objective of this feasibility pilot trial was to assess the safety , tolerability , and efficacy of ESWT as a novel treatment . METHODS Patients with unilateral claudication were r and omized to receive ESWT or sham treatment to the calf muscle three times per week for 3 weeks . Primary outcomes were pain-free walking distance ( PFWD ) and maximum walking distance ( MWD ) . Secondary outcomes included safety and tolerability of ESWT treatment , ankle-brachial index before and after exercise , and quality of life assessed using generic ( 36-Item Short Form Health Survey , EuroQol-5 Dimension 3-Level ) and disease-specific ( Vascular Quality of Life ) instruments . Participants were assessed at baseline and 4 , 8 , and 12 weeks after treatment . Feasibility outcomes included recruitment and attendance rates for treatment and follow-up . RESULTS Thirty patients were recruited in total . Statistically significant ( P < .05 ) improvements at all time points were observed in the active treatment group for both MWD and PFWD compared with the sham treatment group . PFWD improved by 276 % in the active group and MWD improved by 167 % in the active group at 12 weeks after treatment . There were no immediate or delayed treatment safety concerns or documented adverse effects of treatment with ESWT in this trial . CONCLUSIONS ESWT is safe and well tolerated when it is applied to the calf and demonstrated significant improvements in walking distances . Current conservative management of intermittent claudication includes supervised exercise . The early results with ESWT as an alternative , noninvasive treatment option show great potential . The mechanism of action , durability of the clinical effect , and cost-effectiveness of ESWT for claudication require further investigation 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 The hypothesis that smoking has an acute effect on treadmill exercise per formance in patients with peripheral vascular disease was investigated in a crossover trial . Twelve patients with stable intermittent claudication who were regular smokers attended on two occasions within one week and treadmill tests were performed after 1/2 , 1 , 1½ , and 2 hours . Immediately before the second exercise test , two st and ard cigarettes were smoked or an unlit cigarette was " sham-smoked . " Because participants could not be blinded , an attempt to con trol for patient bias was made . Half were told that we expected smoking to make no difference or possibly cause some improvement , and half were told that we expected it to make no difference or possibly cause some deterioration . These explanations and the order of study days were determined by balanced r and om ization . Suggestion had a significant influence on claudication distance immediately after smoking ( p < 0.01 ) but no significant effect on walking distance . Combin ing data from both groups assumes that no overall bias was introduced by the explanations given . Immediately after smoking , small , nonsignificant increases in claudication distance ( + 10 % , 95 % CI-7 % , + 27 % ) and walking distance ( + 9 % , 95 % CI-2 % , + 19 % ) were observed . Smoking caused a mean increase in heart rate of 9 beats per minute , which persisted for one hour , but no consistent change in blood pressure . The results show that suggestion may have a signifi ca nt influence on treadmill exercise distances . Smoking is unlikely to have an important acute effect on exercise performance in claudicants The purpose of this study was to evaluate the efficacy of a  pain-free treadmill walking program in intellectually disabled ( ID ) adults with arterial occlusive disease . Fourteen participants with mild ID participated in the walking program .  Six patients showed stable intermittent claudication . A control ( nontreadmill , n = 12 ) group consisted of 4 individuals with intermittent claudication . Noninvasive determinations of lower-limb hemodynamics included photoplethysmography and ankle-brachial pressure . Pain levels were measured according to a pain pathophysiology index . The treadmill program consisted of individually prescribed low-endurance walking at a 0 % incline done at a comfortable speed 3 times per week . All participants completed the 15-week walking program and showed significant improvements ( p < 0.05 ) in walking speed , distance , and duration . Pain levels were reduced in individuals suffering from intermittent claudication . Blood hemodynamic parameters also showed significant improvements . In conclusion , low-intensity treadmill walking significantly improved the functional capacities of adult individuals with mild ID with vascular occlusion and reduced pain levels PURPOSE The effects of upper-limb ( arm cranking ) and lower-limb ( leg cranking ) exercise training on walking distances in patients with intermittent claudication was assessed . METHODS Sixty-seven patients ( 33 to 82 years old ) with moderate to severe intermittent claudication were recruited , and the maximum power generated during incremental upper- and lower-limb ergometry tests was determined , as were pain-free and maximum walking distances ( by using a shuttle walk test ) . Patients were r and omly assigned to an upper-limb training group ( n = 26 ) or a lower-limb training group ( n = 26 ) . An additional  untrained group ( n = 15 ) was recruited on an ad hoc basis in parallel with the main trial by using identical inclusion criteria . This group was subsequently shown to possess a similar demographic distribution to the two exercise groups . Supervised training sessions were held twice weekly for 6 weeks . RESULTS Both training programs significantly improved the maximum power generated during the incremental upper- and lower-limb ergometry tests ( P < . 001 ) , which may reflect an increase in central cardiovascular function that was independent of the training mode . More importantly , pain-free and maximum walking distances also improved in both training groups ( P < .001 ) . The improvements in the training groups were similar ; there were no changes in the untrained control group . These findings suggest that the symptomatic improvement after upper-limb exercise training may result , in part , from systemic cardiovascular effects rather than localized metabolic or hemodynamic changes . CONCLUSION Carefully prescribed upper-limb exercise training can evoke a rapid symptomatic improvement in patients with claudication , while avoiding the physical discomfort experienced when performing lower-limb weight-bearing exercise Intermittent claudication is the primary symptom of peripheral arterial disease , affecting between 1 and 3 million Americans . Symptomatic improvement can be achieved by endovascular revascularization , but such procedures are invasive , expensive , and may be associated with procedural adverse events . Medical treatment options , including claudication medications and supervised exercise training , are also known to be effective , albeit also with associated limitations . The CLEVER ( Claudication : Exercise Vs . Endoluminal Revascularization ) study , funded by the Heart , Lung , and Blood Institute of the National Institutes of Health , is a prospect i ve , multicenter , r and omized , controlled clinical trial evaluating the relative efficacy , safety , and health economic impact of four treatment strategies for people with aortoiliac peripheral arterial disease and claudication . The treatment arms are : ( 1 ) optimal medical care ( claudication pharmacotherapy ) ; ( 2 ) primary stent placement ; ( 3 ) supervised exercise rehabilitation ; and ( 4 ) combined stenting with supervised exercise rehabilitation . The CLEVER study is a 5-year r and omized , controlled clinical trial to be conducted at approximately 25 centers in the United States that will monitor 252 patients and their responses to treatment during an 18-month follow-up period . The primary end point is change in maximum walking duration on a grade d treadmill test . Secondary end points include the change at 18 months in maximum walking duration from baseline , comparisons of free-living daily activity levels assessed by pedometer , health-related quality of life , and cost-effectiveness . Other analyses include the effect of these treatment strategies on anthropomorphic and physiologic variables , including body mass index , waist circumference , blood pressure , pulse pressure , and resting pulse as well as biochemical markers of cardiovascular health , including fasting lipids , fibrinogen , C-reactive protein , and hemoglobin A 1c values 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 Background — The quality of evidence for invasive revascularization in intermittent claudication is low or very low . This prospect i ve , r and omized , controlled study tested the hypothesis that an invasive treatment strategy versus continued noninvasive treatment improves health-related quality of life after 1 year in unselected patients with intermittent claudication . Methods and Results — After clinical and duplex ultrasound assessment , unselected patients with intermittent claudication requesting treatment for claudication were r and omly assigned to invasive  ( n=79 ) or noninvasive  ( n=79 ) treatment groups . Primary end point was health-related quality of life after 1 year , assessed with Medical Outcomes Study Short Form 36 version 1 and Vascular Quality of Life Question naire , and secondary end points included walking distances on a grade d treadmill . The Medical Outcomes Study Short Form 36 version 1 physical component summary ( P<0.001 ) and 2 Medical Outcomes Study Short Form 36 version 1 physical subscales improved significantly more in the invasive versus the noninvasive treatment group . Overall , Vascular Quality of Life Question naire score ( P<0.01 ) and 3 of 5 domain scores improved significantly more in the invasive versus the noninvasive treatment group . Intermittent claudication distance improved significantly in the invasive ( + 124 m ) versus the noninvasive ( + 50 m ) group ( P=0.003 ) , whereas the change in maximum walking distance was not significantly different between groups . Conclusions — An invasive treatment strategy improves health-related quality of life and intermittent claudication distance after 1 year in patients with stable lifestyle-limiting claudication receiving current medical management . Long-term follow-up data and health-economic assessment s are warranted to further establish the role for revascularization in intermittent claudication . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01219842 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 Arm cranking is a useful alternative exercise modality for improving walking performance in patients with intermittent claudication ; however , the mechanisms of such an improvement are poorly understood . The main aim of the present study was to investigate the effects of arm-crank exercise training on lower-limb O2 delivery in patients with intermittent claudication . A total of 57 patients with intermittent claudication ( age , 70+/-8 years ; mean+/-S.D. ) were r and omized to an arm-crank exercise group or a non-exercise control group . The exercise group trained twice weekly for 12 weeks . At baseline and 12 weeks , patients completed incremental tests to maximum exercise tolerance on both an arm-crank ergometer and a treadmill .  Respiratory variables were measured breath-by-breath to determine peak VO2 ( O2 uptake ) and ventilatory threshold . Near-IR spectroscopy was used in the treadmill test to determine changes in calf muscle StO2 ( tissue O2 saturation ) . Patients also completed a square-wave treadmill-walking protocol to determine VO2 kinetics . A total of 51 patients completed the study . In the exercise group , higher maximum walking distances ( from 496+/-250 to 661+/-324 m ) and peak VO2 values ( from 17.2+/-2.7 to 18.2+/-3.4 ml.kg-1 of body mass.min-1 ) were recorded in the incremental treadmill test ( P<0.05 ) . After training , there was also an increase in time to minimum StO2 ( from 268+/-305 s to 410+/-366 s ) , a speeding of VO2 kinetics ( from 44.7+/-10.4 to 41.3+/-14.4 s ) and an increase in submaximal StO2 during treadmill walking ( P<0.05 ) . There were no significant changes in the control group . The results suggest that the improvement in walking performance after arm-crank exercise training in patients with intermittent claudication is attributable , at least in part , to improved lower-limb O2 delivery Intermittent claudication ( IC ) is a mild stage of peripheral arterial disease that affects between 3 % and 7 % of the population and up to 1 in 5 patients over the age of 75 years . Risk factors such as hypertension , hyperlipidemia , diabetes , smoking , and genetics increase the incidence of peripheral arterial disease . Patients with IC have limitations in functional capacity and can benefit from regular exercise . Walking is the preferred mode of exercise and improves the symptoms of claudication in several ways . Vascular nurses can play an important role during exercise therapy . A personalized , home-based exercise program can be developed , and nurses can assist and motivate patients during follow-up periods . Helping patients to quit smoking and control other risk-factor modifications ( ie , high blood pressure and lipid levels ) also has high priority in daily practice of the vascular nurse . This prospect i ve study will illustrate the results of prescribed home-based exercise training by a vascular nurse on the maximum painless walking distance for patients with IC and will be applied to subgroups of vascular pathology 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 BACKGROUND To explore the efficacy of cycle training in the treatment of intermittent claudication , the present study compared performance and physiologic effects of cycle training with more conventional treadmill walking training in a group of patients with claudication . METHOD Forty-two individuals with peripheral arterial disease and intermittent claudication ( 24 men , 18 women ) were stratified by gender and the presence or absence of type 2 diabetes mellitus and then r and omized to a treadmill ( n = 13 ) , cycle ( n = 15 ) , or control group ( n = 14 ) . Treadmill and cycle groups trained three times a week for 6 weeks , whereas the control group did not train during this period .  Maximal and pain-free exercise times were measured on grade d treadmill and cycle tests before and after training . RESULTS Treadmill training significantly improved maximal and pain-free treadmill walking times but did not improve cycle performance .  Cycle training significantly improved maximal cycle time but did not improve treadmill performance . However , there was evidence of a stronger cross-transfer effect between the training modes for patients who reported a common limiting symptom during cycling and walking at baseline . There was also considerable variation in the training response to cycling , and a subgroup of responsive patients in the cycle group improved their walking performance by more than the average response observed in the treadmill group . CONCLUSION These findings suggest that cycle exercise is not effective in improving walking performance in all claudication patients but might be an effective alternative to walking in those who exhibit similar limiting symptoms during both types of exercise OBJECTIVES Despite limited scientific evidence for the effectiveness of invasive treatment for intermittent claudication ( IC ) , revascularisation procedures for IC are increasingly often performed in Sweden . This r and omised controlled trial compares the outcome after 2 years of primary invasive ( INV ) versus primary non-invasive ( NON ) treatment strategies in unselected IC patients . MATERIAL S/ METHODS Based on arterial duplex and clinical examination , IC patients were r and omised to INV ( endovascular and /or surgical , n = 100 ) or NON ( n = 101 ) . NON patients could request invasive treatment if they deteriorated during follow-up . Primary outcome was maximal walking performance ( MWP ) on grade d treadmill test at 2 years and secondary outcomes included health-related quality of life ( HRQL ) , assessed with Short Form ( 36 ) Health Survey ( SF-36 ) . RESULTS MWP was not significantly ( p = 0.104 ) improved in the INV versus the NON group . Two SF-36 physical subscales , Bodily Pain ( p < 0.01 ) and Role Physical ( p < 0.05 ) improved significantly more in the INV versus the NON group . There were 7 % crossovers against the study protocol in the INV group . CONCLUSIONS Although invasive treatment did not show any significant advantage regarding MWP , the HRQL improvements associated with invasive treatment tentatively suggest secondary benefits of this regimen . On the other h and , a primary non-invasive treatment strategy seems to be accepted by most IC patients OBJECTIVE The purpose of the study was to examine the effects of a 12-month exercise program on lower limb mobility ( temporal-spatial gait parameters and gait kinematics ) , walking performance , peak physiological responses , and physical activity levels in individuals with symptoms of intermittent claudication due to peripheral arterial disease ( PAD-IC ) . METHODS Participants ( n = 21 ) with an appropriate history of PAD-IC , ankle-brachial pressure index ( ABI ) < 0.9 in at least one leg and a positive Edinburgh claudication question naire response were prospect ively recruited . Participants were r and omly allocated to either a control PAD-IC group ( CPAD-IC )  ( n = 11 ) that received st and ard medical therapy and a treatment PAD-IC group ( TPAD-IC ) ( n = 10 ) , which also took part in a 12-month supervised exercise program . A further group of participants ( n = 11 ) free of PAD ( ABI > 0.9 ) and who were non-regular exercisers were recruited from the community to act as age and mass matched controls ( CON ) . Lower limb mobility was determined via two-dimensional video motion analysis . A grade d treadmill test was used to assess walking performance and peak physiological responses to exercise . Physical activity levels were measured via a 7-day pedometer recording . Differences between groups were analyzed via repeated measures analysis of variance ( ANOVA ) . RESULTS The 12-month supervised exercise program had no significant effect on lower limb mobility , peak physiological responses , or physical activity levels in TPAD-IC compared with CPAD-IC participants . However , the TPAD-IC participants demonstrated significantly greater walking performance ( 171 % improvement in pain free walking time and 120 % improvement in maximal walking time compared with baseline ) . CONCLUSION The results of this study confirm that a 12-month supervised exercise program will result in improved walking performance , but does not have an impact on lower limb mobility , peak physiological responses , or physical activity levels of PAD-IC patients BACKGROUND Exercise training is recommended as the first-line therapy for intermittent claudication patients . However , the effects of exercise therapy on cardiovascular function of these patients have been poorly studied . The aim of this study is to compare the effects of walking and strength training on cardiovascular responses assessed at rest and during exercise in patients with intermittent claudication . PATIENTS AND METHODS Thirty-four patients with stable symptoms of intermittent claudication were r and omized into two groups : strength training ( ST ) consisting of eight exercises , three sets of 10 repetitions , intensity of 11 - 13 on 15- grade Borg scale , 2-min interval between sets ; and walking training ( WT ) consisting of walking on a treadmill , 15 bouts of 2-min , intensity of 11 - 13 on 15- grade Borg scale , with a 2-min interval between bouts . Before and after 12 weeks , blood pressure , heart rate and rate pressure product were measured at rest and during a progressive treadmill test until maximal claudication pain . RESULTS Fifteen patients in each group completed the training program . After the training programs , resting systolic blood pressure ( ST:-6 ± 13 mmHg and WT:-3 ± 18 mmHg , P = .04 ) , heart rate ( ST : -6 ± 10 bpm and WT:-2 ± 9 bpm , P = .03 ) , and rate pressure product ( ST:-1485 ± 1442 mmHg*bpm and WT:- 605 ± 2145 mmHg*bpm , P = .01 ) decreased significantly and similarly in both groups . Submaximal systolic blood pressure ( ST : -14 ± 23 mmHg and WT:-6 ± 23 mmHg , P = .02 ) , and rate pressure product ( ST:-1579 ± 3444 mmHg*bpm and WT : -1264 ± 3005 mmHg*bpm , P = .04 ) decreased significantly and similarly in both groups . There were no changes in submaximal heart rate after ST and WT . Maximal systolic blood pressure , heart rate , and rate pressure product did not change in either group , although maximal exercise time increased similarly in the ST and WT groups ( + 31 ± 19 % , and + 31 ± 32 % , respectively , P < .01 ) . CONCLUSIONS Strength and walking trainings promoted similar increases in walking capacity and decreases in resting and submaximal exercise cardiovascular load Abstract Prostanoids , which promote vasodilation and reduce platelet aggregation , have been proposed as c and i date therapies for intermittent claudication due to peripheral arterial disease ( PAD ) . However , studies of these medications have yielded inconsistent results . This study tested the hypothesis that iloprost , an oral prostacyclin analogue , would improve walking distance and quality of life in patients with intermittent claudication . The study was a multi-center , r and omized , double-blind , placebo-controlled trial comparing three doses of oral iloprost ( 50 μg , 100 μg , or 150 μg twice daily ) , pentoxifylline , or placebo in 430 patients with intermittent claudication . The primary outcome measure was improvement in absolute claudication distance ( ACD ) after 6 months . Secondary outcomes included initial claudication distance and quality of life assessment . Placebo increased ACD by 3.3 % , and iloprost  increased peak ACD by 7.7 % , 8.8 % and 11.2 % at the 50 μg , 100 μg , and 150 μg twice-daily doses , respectively ( all insignificant relative to placebo ) . Pentoxifylline  increased ACD by 13.9 % relative to placebo ( p = 0.039 ) . Neither iloprost nor pentoxifylline enhanced quality of life . These results indicate that oral iloprost is not effective in improving exercise performance or quality of life in patients with PAD who have intermittent claudication 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 BACKGROUND Disease severity in patients with intermittent claudication ( IC ) is often assessed using walking distances and treadmill tests . The aim of this study was to determine the agreement between walking distance as estimated by the patient , as measured during outside walking , and as determined using a non grade d treadmill protocol ( NGTP ) , and an incremental grade d ( Gardner-Skinner ) treadmill protocol ( GSP ) . METHODS In this prospect i ve observational study , 30 patients with IC estimated their maximal walking distance ( MWD ) and completed a  " Walking Impairment Question naire " ( WIQ ) .  Outside walking was determined using a measuring wheel and a GSP controlled device . Primary outcomes were differences in MWD and variability ( coefficient of variation , COV ) . Secondary outcomes were results of WIQ and differences in walking speed . RESULTS Estimated walking distance was significantly higher than MWD as objective ly measured during outside walking ( 400 m vs. 309 m , respectively , P = 0.02 ) . A substantial variability ( COV = 55 % ) was found between both parameters . A small 35-m MWD difference between outside walking and GSP was found with a substantial scatter ( COV = 42 % ) . In contrast , a much larger 122-m MWD difference was present between outside walking and NGTP ( COV = 89 % ) . Patients walked significantly faster in the open air than on treadmills ( median outside walking speed = 3.8 km/hr , GSP = 3.2 km/hr , NGTP = 2.8 km/hr ; P < 0.001 ) . CONCLUSIONS An incremental grade d ( Gardner-Skinner ) treadmill protocol demonstrated the best agreement to outside walking . Discrepancies between treadmill tests and outside walking may be explained by a difference in walking speed . A single determination of a walking distance is a poor reflection of true walking capacity BACKGROUND In this r and omized trial we compared two treadmill trainings , based on exercises performed to moderate claudication pain vs pain-free training , with respect to their effects on walking ability and endothelial function . METHODS A total of sixty patients with stable intermittent claudication were r and omized to the pain-free treadmill training ( repetitive intervals to onset of claudication pain ) or moderate treadmill training ( repetitive intervals to moderate claudication pain ) . In both groups exercises were performed 3 times a week for 3 months . Changes in flow mediated dilatation ( FMD ) and treadmill walking performance as well as plasma levels of C-reactive protein ( hs-CRP ) and fibrinogen were assessed before and after the program . RESULTS Fifty-two patients completed the training program . Post-training maximal walking time was prolonged by 100 % ( p<0.001 ) vs 98 % ( p<0.001 ) , and pain-free walking time by 120 % ( p<0.001 ) vs 93 % ( p<0.001 ) in the moderate training group as compared to the pain-free training group , respectively . FMD increased by 56 % ( p<0.001 ) in the moderate training group and by 36 % ( p<0.01 ) in the pain-free training group . No significant changes in the levels of hs-CRP and fibrinogen were seen after treadmill program in either group . CONCLUSIONS Both pain-free treadmill training and the moderate treadmill training have similar efficacy on walking ability in patients with claudication . The improvement of post-training FMD indicates systemic effect of both treadmill programs on endothelial function . Both programs appear to be safe therapeutic modes , since none of them escalates the inflammation . Pain-free treadmill training seems useful and effective therapeutic option for patients with claudication Because individuals with claudication pain secondary to peripheral arterial disease ( PAD ) are limited in both walking speed and duration , the benefits of walking exercise may be insufficient to yield a cardiovascular training effect . The objectives of this analysis were to determine whether polestriding exercise training , performed by persons with PAD , would improve exercise endurance , elicit a cardiovascular training benefit , and improve quality of life ( QoL ) .  Persons ( n = 49 ) whose claudication pain limited their exercise capacity were r and omized into a 24-week polestriding training program ( n = 25 , 65.8 ± 7.1 years of age ) or a nonexercise attention control group ( n = 24 , 68.0 ± 8.6 years of age ) . Those assigned to the polestriding group trained 3 times weekly . Control group subjects came to the laboratory biweekly for ankle blood pressure measurements . A symptom-limited ramp treadmill test , ratings of perceived leg pain , and QoL data ( using the Short Form-36 ) were obtained at baseline and upon completion of training . After 24 weeks of polestriding training , subjects increased their exercise endurance from 10.3 ± 4.1 minute to 15.1 ± 4.5 minute . This was significantly greater than control group subjects whose exercise endurance declined ( from 11.2 ± 4.7 to 10.3 ± 4.7 minute ; P < .001 ) . Relationships between systolic blood pressure ( P < .001 ) , heart rate ( P = .04 ) , rate pressure product ( P = .05 ) , oxygen uptake ( P = .016 ) , and perceived leg pain ( P = .02 ) and exercise time improved from the baseline symptom-limited treadmill test to the 6-month symptom-limited treadmill test in the polestriding group compared to the control group . The improvement in the physical component summary score of the Short Form-36 was also greater in the polestriding group ( P = .031 ) . Polestriding training significantly improved the clinical indicators of cardiovascular fitness and QoL , and decreased symptoms of claudication pain during exertion Patients with intermittent claudication due to peripheral arterial disease ( PAD ) experience muscle aching during walking secondary to ischemia . The purpose of this study was to examine the effects of low-intensity pain-free exercise ( LIPFE ) on functional capacity of individuals with PAD . A total of 12 participants with PAD underwent training on treadmill for 6 weeks , twice a week , for about 45 minutes . Outcome measures included walking distance ( WDI ) , walking duration ( WDU ) , mean walking rate ( WR ) , estimated oxygen consumption ( EVO2 ) , metabolic equivalent ( MET ) , estimated total energy expenditure ( ETEE ) , and estimated rate of energy expenditure ( EREE ) . Mean improvement of WDI , WDU , and MWR were 104 % ( an addition of 1.0 km ) , 55 % ( an addition of 13.3 minutes ) , and 41 % ( 0.9 km/h faster ) , respectively . Mean improvement of EVO2 , MET , ETEE , and EREE , were 20 % , 20 % , 80 % , and 20 % , respectively . In conclusion , it appears that LIPFE training is an effective intervention for individuals presenting with PAD OBJECTIVES To investigate the effects of exercise training on levels of circulating biomarkers associated with the progression of atherosclerosis and risk of cardiovascular events in patients with intermittent claudication . METHODS Circulating levels of soluble adhesion molecules ( sVCAM-1 , sICAM-1 , sE-selectin ) , high sensitivity C-reactive protein ( hs-CRP ) and stress proteins ( Hsp60 and Hsp70 ) in patients r and omised to a 24-week programme of arm- or leg-cranking exercise were compared with those in usual care controls . RESULTS Arm and leg exercise similarly improved lower-limb aerobic exercise capacity ( 20 % vs 19 % , respectively ; P<0.001 ) and maximum walking distance ( 30 % vs 35 % , respectively ; P<0.001 ) . Improvements in training limb-specific peak oxygen consumption were attenuated for patients in the highest vs lowest quartile for circulating sVCAM-1 levels at baseline ( 3 % vs 25 % respectively , P<0.001 ) . Although circulating hs-CRP levels tended to be lower in the arm-cranking group ( -1.55 [ 95 % CI : -1.06 to -2.26]mgl(-1 ) ) , exercise training had no effect on circulating levels of soluble adhesion molecules or stress proteins . CONCLUSIONS These findings suggest that high levels of circulating sVCAM-1 are associated with an attenuated exercise training response and that arm-cranking exercise may provide an effective stimulus for evoking systemic anti-inflammatory adaptations in patients with intermittent claudication 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 BACKGROUND Patients with intermittent claudication ( IC ) could benefit from low-cost , effective rehabilitative programs . This retrospective study evaluates compliance , impact on Quality of Life ( QoL ) and cost-effectiveness of a hospital prescribed , at-home performed ( Test-in/Train-out ) rehabilitative program for patients with IC . METHODS AND RESULTS Two-hundred and eighty-nine patients with IC ( 71 ± 10.1 years , M = 210 ) were enrolled for a 2-year period .  Two daily 10-min home walking sessions at maximal asymptomatic speed were prescribed , with serial check-ups at the hospital . Compliance with the program was assessed by assigning a score of 1 ( lowest compliance ) to 4 ( highest compliance ) . The SF-36 question naire and a constant-load treadmill test  were used to evaluate QoL and Initial/Absolute Claudication Distance , respectively . Both direct and indirect costs of the program were considered for cost-effectiveness analysis . Two-hundred and fifty patients ( 70.5 ± 9.2 years , M = 191 ) , at Fontaine 's II-B stage ( 86 % ) , were included in the study . No adverse events were reported . The average compliance score was 3.1 . At discharge , both SF-36 domains and walking performance significantly increased ( P < 0.0001 ) . A total of 1,839 in-hospital check-ups ( 7.36 /patient ) were performed . Direct and indirect costs represented 93 % and 7 % of the total costs , respectively . The average costs of a visit and of a therapy cycle were C68.93 and C507.20 , respectively . The cost to walk an additional meter before stopping was C9.22 . CONCLUSIONS A Test-in/Train-out program provided favourable patient compliance , QoL impact and cost-effectiveness in patients with IC PURPOSE To determine if improvements in physical function and peripheral circulation after 6 months of exercise rehabilitation could be sustained over a subsequent 12-month maintenance exercise program in older patients with intermittent claudication . METHODS Seventeen patients r and omized to exercise rehabilitation and 14 patients r and omized to usual care control completed this 18-month study . Patients exercised three times per week during the first 6 months of a progressive exercise program , followed by two times per week during the final 12 months of a maintenance program . Patients were studied at baseline , 6 months , and 18 months during the study . RESULTS Eighteen months of exercise rehabilitation increased the initial claudication distance by 373 meters ( 189 % ) ( P < .001 ) , the absolute claudication distance by 358 meters ( 80 % ) ( P < .001 ) , walking economy by 11 % ( P < .001 ) , 6-minute walk distance by 10 % ( P < .001 ) , daily physical activity by 31 % , and maximal calf blood flow by 18 % ( P < .001 ) . These changes were similar to those found after 6 months of exercise rehabilitation ( P = NS ) , and were significantly greater than the changes in the control group throughout the study ( P < .05 ) . CONCLUSION Improvements in claudication distances , walking economy , 6-minute walk distance , physical activity level , and peripheral circulation after 6 months of exercise rehabilitation are sustained for an additional 12 months in older patients with intermittent claudication using a less frequent exercise maintenance program OBJECTIVE Physicians and patients consider the limited walking distance and perceived disability when they make decisions regarding ( invasive ) treatment of intermittent claudication ( IC ) . We investigated the relationship between walking distances estimated by the patient , on the corridor and on a treadmill , and the  Walking Impairment Question naire ( WIQ ) in patients with IC due to peripheral arterial disease . METHODS This was a single-center , prospect i ve observational cohort study at a vascular laboratory in a university hospital in the Netherl and s. The study consisted of 60 patients ( 41 male ) with a median age of 64 years ( range , 44 - 86 years ) with IC and a walking distance ≤ 250 m on a st and ardized treadmill test .  Main outcome measures were differences and Spearman rank correlations between pain-free walking distance , maximum walking distance ( MWD ) estimated by the patient , on the corridor and on a st and ardized treadmill test , and their correlation with the WIQ . RESULTS The median patients ' estimated , corridor , and treadmill MWD were 200 , 200 , and 123 , respectively ( P < .05 ) . Although the median patients ' estimated and corridor MWD were not significantly different , there was a difference on an individual basis . The correlation between the patients ' estimated and corridor MWD was moderate ( r = 0.61 ; 95 % confidence interval [ CI ] , 0.42 - 0.75 ) . The correlation between patients ' estimated and treadmill MWD was weak ( r = 0.39 ; 95 % , CI 0.15 - 0.58 ) . Respective correlations for the pain-free walking distance were comparable . The patients ' estimated MWD was moderately correlated with WIQ total score ( r = 0.63 ; 95 % , CI 0.45 - 0.76 ) and strongly correlated with WIQ distance score ( r = 0.81 ; 95 % CI , 0.69 - 0.88 ) . The correlation between the corridor MWD and WIQ distance score was moderate ( r = 0.59 ; 95 % CI , 0.40 - 0.74 ) . CONCLUSIONS Patients ' estimated walking distances and on a treadmill do not reflect walking distances in daily life . Instruments that take into account the perceived walking impairment , such as the WIQ , may help to better guide and evaluate treatment decisions 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 This study investigated the effects of walking training ( WT ) on cardiovascular function and autonomic regulation in patents with intermittent claudication ( IC ) . DESIGN R and omized controlled trial . METHODS Forty-two male patients with IC ( ≥50years ) were r and omly allocated into two groups : control ( CG , n=20 , 30min of stretching exercises ) and WT ( WTG , n=22 , 15 bouts of 2min of walking interpolated by 2min of upright rest-walking intensity was set at the heart rate of pain threshold ) . Both interventions were performed twice/week for 12 weeks . Walking capacity ( maximal treadmill test ) , blood pressure ( auscultatory ) , cardiac output ( CO2 rebreathing ) , heart rate ( ECG ) , stroke volume , systemic vascular resistance , forearm and calf vascular resistance ( plethysmography ) , and low ( LF ) and high frequency ( HF ) components of heart rate variability and spontaneous baroreflex sensitivity were measured at baseline and after 12 weeks of the study . RESULTS WT increased total walking distance ( + 302±85 m , p=0.001 ) and spontaneous baroreflex sensitivity ( + 2.13±1.07ms/mmHg , p=0.02 ) . Additionally , at rest , WT decreased systolic and mean blood pressures ( -10±3 and -5±2mmHg , p=0.001 and p=0.01 , respectively ) , cardiac output ( -0.37±0.24l/min , p=0.03 ) , heart rate ( -4±2bpm , p=0.001 ) , forearm vascular resistance ( -8.5±2.8U , p=0.02 ) and LF/HF ( -1.24±0.99 , p=0.001 ) . No change was observed in the CG . CONCLUSIONS In addition to increasing walking capacity , WT improved cardiovascular function and autonomic regulation in patients with IC Background Patients with peripheral arterial disease ( PAD ) are limited by intermittent claudication in the distance they can walk . Allopurinol has been shown in coronary arterial disease to prolong exercise before angina occurs , likely by prevention of oxygen wastage in tissues and reduction of harmful oxidative stress . Methods In this study we evaluated whether allopurinol could prolong the time to development of leg pain in participants with PAD . In a double-blind , r and omized controlled clinical trial participants were r and omized to receive either allopurinol 300 mg twice daily or placebo for 6 months . The primary outcome was change in exercise capacity on treadmill testing at 6 months . Secondary outcomes were 6-minute walking distance , Walking Impairment Question naire , SF-36 question naire , flow-mediated dilatation , and oxidized low-density lipoprotein . Outcome measures were repeated mid study and at the end of study . The mean age of the 50 participants was 68.4 ± 1.2 years with 39 of 50 ( 78 % ) male . Results Five participants withdrew during the study ( 2 active , 3 placebo ) . There was a significant reduction in uric acid levels in those who received active treatment of 52.1 % ( P < 0.001 ) , but no significant change in either the pain-free or the maximum walking distance . Other measures of exercise capacity , blood vessel function , and the participants ' own assessment of their health and walking ability also did not change during the course of the study . Conclusions Although allopurinol has been shown to be of benefit in a number of other diseases , in this study there was no evidence of any improvement after treatment in patients with PAD Abstract The efficacy of treadmill walking training to improve pain-free ( PFWD ) and maximal ( MWD ) walking distance in patients with claudication is well documented . The effects of aerobic arm-ergometry to improve PFWD and MWD compared to treadmill walking or usual care are not known . Forty-one participants ( 29 male , 12 female , mean age 67.7 years , 92.7 % smoking history , 36.6 % with diabetes ) with lifestyle-limiting claudication were r and omized to 12 weeks of 3 hours/week of supervised exercise training using either arm-ergometry , treadmill walking , or a combination , versus control .  PFWD and MWD were assessed before and after training , and after 12 weeks of follow-up . The 12-week MWD increased significantly in the arm-ergometry ( + 53 % ) , treadmill ( + 69 % ) , and combination ( + 68 % ) groups ( p < 0.002 versus control ) . The 24-week MWD was maintained in the arm-ergometry ( p = 0.009 ) and treadmill ( p = 0.019 ) groups , whereas the combination group declined ( p = 0.751 ) versus control . The 12-week PFWD increased significantly in the arm-ergometry group ( + 82 % ; p = 0.025 versus control ) . Change in PFWD in treadmill ( + 54 % ; p = 0.196 versus control ) and combination ( + 60 % ; p = 0.107 versus control ) groups did not reach statistical significance . PFWD improvement was maintained in the arm-ergometry group after a 12-week follow-up ( + 123 % ; p = 0.011 versus control ) . In conclusion , these pilot data demonstrate for the first time that dynamic arm exercise training can improve walking capability in people with peripheral arterial disease (PAD)-induced claudication compared to participants receiving usual care and that improvement was not different from that seen with treadmill walking exercise training . Dynamic arm exercise may be a therapeutic exercise option for patients with PAD Context Few therapies substantially reduce symptoms and improve exercise performance in patients with peripheral arterial disease ( PAD ) . Contribution In this double-blind trial , investigators r and omly assigned 40 older adults without diabetes and with symptomatic PAD to receive either ramipril or placebo , 10 mg once daily for 24 weeks . Compared with placebo , ramipril increased maximum and pain-free walking time and walking speed and distance . Caution s The trial was small and involved selected patients with limited mobility and exercise tolerance . Implication s Ramipril may improve symptoms in some patients with PAD . The Editors This article has been retracted . See Notice of Retraction . Peripheral arterial disease ( PAD ) is a common disorder , with 12 % of adults older than 50 years of age having an anklebrachial index ( ABI ) that is diagnostic of PAD ( < 0.9 ) ( 1 ) . Approximately one third of these patients experience intermittent claudication during walking , limiting normal activities . Medical treatments to improve walking distance are limited . The angiotensin-converting enzyme ( ACE ) inhibitor ramipril reduced cardiovascular morbidity and mortality compared with placebo in patients with established atherosclerotic disease , including PAD , in the Heart Outcomes Prevention Evaluation ( HOPE ) study ( 2 ) . This effect seemed to be independent of blood pressure reduction ( 3 ) and may relate to the known benefits of ACE inhibitors on both coronary and brachial endothelial function ( 4 ) . No previous controlled studies have investigated the effect of ACE inhibitors on symptoms of intermittent claudication . Given the positive effects of ramipril in the HOPE trial and its convenient once-daily dosing formulation , we hypothesized that therapy with ramipril would improve intermittent claudication symptoms . We aim ed to examine the effect of 6-month ramipril therapy on walking distance and claudication pain in a defined group of patients with claudication due to infrainguinal PAD by using a double-blind , r and omized , placebo-controlled design . Methods This article has been retracted . See Notice of Retraction . We screened 152 patients with PAD from general practice clinics in the Melbourne , Australia , metropolitan area ( Figure 1 ) . Of them , 40 patients ( mean age , 66 years [ SD , 4 ] ) were recruited and completed the trial . All patients gave written informed consent to participate in the study . The Ethics Committee of the Alfred Hospital , Melbourne , Australia , approved the study , and we performed the study in accordance with the Declaration of Helsinki 2000 . All participants had an ABI less than 0.9 at rest in at least 1 leg ; had a history of intermittent claudication ( unilateral or bilateral ) , which was stable for 6 months ; had evidence of superficial femoral artery stenosis or occlusion on duplex ultrasonography ; had blood pressure of 160/90 mm Hg or less ; had a stable medication regimen for at least 6 months ; and had not previously been treated with ACE inhibitors . We excluded patients with limiting coronary artery disease , renal failure , history of hypertension , or type 2 diabetes mellitus . Figure 1 . Flow of patients through the study . Computer-generated numbers specified the allocation sequence . A tamper-proof r and omization process generated by the hospital research center r and omly assigned participants into blocks of 10 to receive either ramipril ( Tritace , Aventis Pharma Pty . Ltd. , Macquarie Park , Australia , 10 mg once daily for 24 weeks ) or placebo ( 10 mg once daily for 24 weeks ) in a parallel-group , double-blind design . Both investigators and patients were blinded to drug assignment . Furthermore , investigators did not have access to baseline data when they performed follow-up measurements and patients were not asked which treatment they thought they were receiving . No patient assigned to placebo crossed over to ramipril during the trial or vice versa . We advised participants to maintain all aspects of their lifestyle throughout the trial and requested them to refrain from exercise , smoking , and caffeine for 24 hours before all testing . On the morning of testing , patients rested in a supine position for 15 minutes in a quiet room before the measurements . We assessed blood pressure , ABI , walking distance , duplex ultrasounds of leg arteries , and the Walking Impairment Question naire ( WIQ ) scores before and after both interventions . We advised patients about potential side effects and requested that they report any adverse event to the study coordinator . All patients performed a treadmill exercise test at a speed of 3.2 km/h and a grade of 12 % ( 5 ) , and we recorded pain-free walking time ( time to onset of claudication pain ) and maximum walking time . In our study , all patients reached a maximal level of claudication pain that limited exercise during the grade d treadmill test . The WIQ was developed and vali date d against treadmill walking and is used to evaluate limitations in community-based walking ability ( 6 ) . The WIQ assessed walking distance , speed , and stair-climbing ability , using a weighted st and ardized formula and returning a summary score between 0 % and 100 % ( 6 , 7 ) . Statistical Analyses All analysts were blinded to treatment assignment , and an independent investigator double-checked all measurement calculations and data base entries . The study was powered to detect a 180-second change in maximum walking time with ramipril , assuming a st and ard deviation of 250 seconds ( = 0.05 [ 2-sided ] ; power , 86 % ) . We compared 24-week changes from baseline in pain-free walking time , maximum walking time , and WIQ scores between treatments by using an analysis of covariance model with terms for treatment and baseline value as the analysis end points . We log-transformed the WIQ data to achieve a normal distribution before analysis . We conducted all statistical analyses by using Stata software , version 8.2 ( Stata Corp. , College Station , Texas ) . We expressed normally distributed data as means ( SDs ) or 95 % CIs and non-normally distributed data as medians ( ranges ) . A P value less 0.05 was deemed to be significant . No data were missing for any clinical variable measured in our study . Role of the Funding Sources This work was funded by the National Health and Medical Research Council of Australia . Aventis Pharma Pty . Ltd. provided ramipril ( Tritace ) and matching placebo capsules but provided no other funding for the study or to the investigators . The funding sources had no role in the design , conduct , or reporting of the study or in the decision to su bmi t the manuscript for publication . Results This article has been retracted . See Notice of Retraction . The ramipril and placebo groups were similar in age , other cardiovascular risk factors , medication use , and PAD severity , as evidence d by clinical symptoms ( walking times ) , WIQ scores , and resting ABI ( Table ) . No patient was taking cilostazol or pentoxifylline . On duplex ultrasonography , 6 of 40 patients had a superficial femoral artery occlusion ( 2 placebo patients and 4 ramipril patients ) , and the remaining patients had stenotic disease in the superficial femoral artery . Only 25 % of patients were taking antiplatelet or lipid-lowering therapy . No adverse events were reported . Table . Baseline Characteristics AnkleBrachial Index Ramipril  significantly increased ABI both at rest ( change with placebo , 0.05 mm Hg [ SD , 0.04 ] ; change with ramipril , 0.07 mm Hg [ SD , 0.08 ] ; P < 0.001 ) and after exercise ( change with placebo , 0.04 mm Hg [ SD , 0.05 ] ; change with ramipril , 0.08 mm Hg [ SD , 0.14 ] ; P < 0.001 ) . At rest , this increase was due to reduction in brachial systolic blood pressure with ramipril treatment ( 0.85 mm Hg [ SD , 1.57 ] vs. 5.05 mm Hg [ SD , 2.33 ] ; P < 0.001 ) rather than an increase in limiting leg pressure ( 0.75 mm Hg [ SD , 1.71 ] vs. 0.15 mm Hg [ SD , 1.27 ] ; P= 0.26 ) . After exercise , both a reduction in brachial pressure ( change with placebo , 0.30 mm Hg [ SD , 2.45 ] ; change with ramipril , 6.80 mm Hg [ SD , 6.07 ] ; P < 0.001 ) and an increase in limiting leg pressure ( change with placebo , 5.40 mm Hg [ SD , 7.56 ] ; change with ramipril , 7.10 mm Hg [ SD , 4.59 ] ; P < 0.001 ) contributed to the increase in ABI . Treadmill Test After adjustment for the baseline pain-free walking time , mean pain-free walking time after ramipril treatment was 227 seconds ( 95 % CI , 175 seconds to 278 seconds ; P < 0.001 ) longer than after placebo treatment ( Figure 2 ) . Similarly , maximum walking time significantly improved over the 24-week treatment period by 451 seconds ( CI , 367 seconds to 536 seconds ; P < 0.001 ) in the ramipril group after adjustment for baseline values ( Figure 2 ) . The lack of change observed over the 24-week treatment period in the placebo group ( change in mean walking time , 10 seconds [ SD , 9 ] [ CI , 14 seconds to 6 seconds ] ; P < 0.001 ) may reflect both the advanced age of participants and the fact that they all had limiting infrainguinal disease , which would probably give more reproducible treadmill data than aortoiliac disease . In addition , we asked patients to maintain all aspects of their lifestyle throughout the trial . Figure 2 . Effect of ramipril on maximum treadmill walking times . Walking Impairment Question naire Ramipril improved WIQ median distance score from 5 % ( range , 1 % to 39 % ) to 21 % ( range , 12 % to 58 % ) ( P < 0.001 ) , speed score from 3 % ( range , 3 % to 39 % ) to 18 % ( range , 8 % to 50 % ) ( P < 0.001 ) , and stair-climbing score from 17 % ( range , 4 % to 80 % ) to 67 % ( range , 38 % to 88 % ) ( P < 0.001 ) . Duplex Ultrasonography Volume flow was unaltered in the limiting leg at the stenotic site . However , ramipril significantly increased volume flow in the common femoral artery proximal to the site of stenosis in both the limiting leg ( change with placebo , 0.014 L/min [ SD , 0.022 ] ; change with ramipril , 0.017 L/min [ SD , 0.034 ] ; P= 0.008 ) and the nonlimiting leg ( change with placebo , 0.006 L/min [ SD , 0.041 ] ; change with ramipril , 0.019 L/min [ SD , 0.019 ] ; P= 0.035 ) . Discussion This article has been retracted . See Notice of Retraction . Our study shows that Purpose : Peripheral arterial disease ( PAD ) is a chronic , progressive disease with a significant cardiovascular and cerebrovascular risk burden and a considerable impact on functional capacity and quality of life ( QoL ) . Exercise programmes result in significant improvements in walking distances but long-term effects are uncertain . The aim of this study was to assess the one-year effects of participation in a 12-week supervised exercise programme on functional capacity and QoL for PAD patients . Methods : Patients were r and omly allocated to a control ( n = 16 ) or an exercise ( n = 28 ) group . Data regarding functional capacity ( Walking Impairment Question naire WIQ ) , disease-specific QoL ( Intermittent Claudication Question naire ICQ ) and generic QoL ( SF-36 ) were collected at baseline , 12 weeks and 1 year . Results : At 12 weeks , there was a trend towards improved QoL in both groups , with a tendency for greater improvement in the exercise group ( p = 0.066 ) and a trend towards improved functional capacity ( WIQ Stair-climbing p = 0.093 ) in the exercise group . At 1 year , ICQ scores in the exercise group were considerably better than those in the control group ( p = 0.058 ) , reflecting improved QoL and maintenance of benefits . Conclusions : Participation in a supervised exercise programme results in improvements in functional capacity and QoL at 1 year post-participation . Implication s for Rehabilitation Peripheral arterial disease has a considerable impact on functional capacity and quality of life Functional capacity and quality of life are improved in patients with peripheral arterial disease up to 1 year post-participation in supervised exercise Improvements at 1 year are reduced from those noted immediately following an exercise 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 BACKGROUND The use of physical training in the treatment of intermittent claudication is well established . However , current data do not provide enough information about the prognosis for each case , and there are no data on how walking distances evolve over time with conservative treatment . The goal of this study was to evaluate improvement in walking capacity among patients with intermittent claudication who underwent unsupervised clinical treatment , observing whether sustained treatment would increase or decrease maximum walking distance , whether after 6 months there was a change in the maximum distance , and whether abstinence from smoking and well-conducted walking exercise had independent effects on the outcome . METHODS Five hundred patients with intermittent claudication were surveyed in a prospect i ve , nonr and omized , and uncontrolled study . Maximum walking distance and treatment compliance over time were analyzed . RESULTS Nonsmoking patients who walked achieved a mean increase during the first 6 months of 33.70 m/mo and a mean increase thereafter of 4.24 m/mo . Smokers who walked achieved an increase during the first 6 months only ( mean , 42.92 m/mo ) . Patients who did not practice physical training exhibited no effect ( smokers ) or negligible effect ( nonsmokers ) from the treatment ( mean , 7.58 m/mo ) . CONCLUSIONS Patients who adhered to physical training exhibited a significant increase in maximum walking distance during the first 6 months of treatment only . Patients who did not practice physical training exhibited no effect ( smokers ) or negligible effect ( ex-smokers ) from the treatment 32 patients ( mean age 65 years , range 51 - 75 years ) were included in this controlled , double blind study to evaluate the effect of dipyridamole in patients with intermittent claudication . Following a run-in phase of one month , 15 patients received 400 mg dipyridamole per day and 17 patients placebo . Patient characteristics ( risk factors , age , clinical and apparative tests ) of both groups did not differ significantly before and during the study period . Mean pain free und absolute walking distance on the treadmill ( 3.2 km/h , 12.5 degrees gradient ) increased significantly in both groups during study period ( p < 0.001 and p < 0.01 ) . Explanations are more intensive physical activity and increasing adaptation to treadmill exercise . However , dipyridamole did not induce a significantly longer walking distance in comparison with placebo . The working hypothesis that the drug with inhibiting properties of thrombocyte function prolongs walking distance in intermittent claudication , could not be confirmed OBJECTIVES to compare the effect of surgery , exercise and simple observation on maximum exercise power in claudicants . DESIGN prospect i ve , r and omised study . METHODS a total of 264 unselected claudicants were r and omised to supervised exercise training , invasive treatment ( open surgical or endovascular procedures ) or observation . One year treatment outcomes were analysed on an intention to-treat basis . RESULTS invasively treated patients showed a significant improvement in maximum walking power , stopping distance , post-ischaemic blood flow and big toe pressure at one year . Patients r and omised to physical exercise training or to the control group did not improve in any outcome measure . CONCLUSION invasive treatment increased walking capacity , leg blood pressure and flow . Supervised physical exercise training offered no therapeutic advantage compared to untreated controls Abstract Objective : To compare the efficacy and tolerability of propionyl-1-carnitine with those of pentoxifylline in the treatment of intermittent claudication . Design : This study was a phase II multicentre ( n = 14 ) , r and omised , open trial . Patients : 114 patients were enrolled who had intermittent claudication [ as diagnosed by an ankle/brachial pressure index ( ABPI ) ≤0.8 that decreased by ≥20 % after exercise ] . Interventions : After a 6-week run-in phase , patients were r and omised to 12 months of treatment with propionyl-L-carnitine ( 500 mg orally , three times daily ) or pentoxifylline ( 400 mg orally , three times daily ) . Main outcome measures and results : Primary outcome measures included 12-month changes from baseline in claudication distance and maximal walking distance , as assessed by treadmill . Secondary outcome measures included ABPI and safety . Statistical analyses were performed in the per- protocol population ( 34 patients in each group ) . Compared with baseline , improvement in initial claudication distance was 174 % with propionyl-L-carnitine versus 67 % with pentoxifylline ( p = 0.020 ) . The improvement in maximal walking distance was 123 versus 54 % ( p = 0.004 ) . There were no changes in electrocardiographic and routine biochemical and haematological tests that would indicate an adverse effect of either drug . Adverse events requiring drug discontinuation were five in the propionyl-L-carnitine group and eight in the pentoxifylline group . Resting and postexercise ABPI was not modified by treatments . Conclusions : The findings of this study suggest that propionyl-L-carnitine , a safe and well tolerated drug , is more effective than pentoxifylline in improving walking capacity in patients with intermittent claudication 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 The main aim of medical treatment for intermittent claudication ( IC ) is the reduction of mortality and morbidity from ischemic cardiovascular disease . However , symptomatic treatment with the aim of improving exercise performance and the overall quality of life may also be an important target of the clinical management of patients with intermittent claudication .  Cloricromene , a drug with antithrombotic and anti-ischemic activities , has previously shown some promising results in patients with claudication . We have carried out a clinical trial to assess the effect of cloricromene on the claudication distance and on the quality of life of patients with IC chronically treated with aspirin . A total of 159 patients with IC , Stage II ( Fontaine ) , were enrolled in a double-blind , r and omized , prospect i ve , multicenter study comparing cloricromene ( 100 mg orally b.i.d . ) or an identical placebo for 6 months . All patients received 160 mg/day aspirin . The primary end-point was the improvement of initial claudication distance ( ICD ) at 6 months as measured by a st and ardized treadmill test . The secondary end-points were the absolute claudication distance ( ACD ) at 6 months , the percentage of patients defined as responders to treatment ( improvement of ICD of at least 40 % ) , changes in the ischemic window ( IW ) , quality of life as assessed by the SF-36 question naire , and the occurrence of major cardiovascular events . The ICD increased in both treatment groups , with a non-significant difference at 6 months in favor of cloricromene of + 12.3 m. The ACD , percentage of responders to treatment and ischemic window also improved in both groups with a slight , non-significant trend in favor of cloricromene . Pretreatment quality of life scores showed only a slight worsening compared with an age-matched , healthy population and did not change upon treatment . A post hoc subgroup analysis showed a significant benefit from cloricromene in patients with an ICD at enrollment higher than the median of the patient population . In conclusion , treatment with cloricromene for 6 months does not significantly improve  claudication in patients with Stage II Fontaine peripheral arteriopathy chronically treated with aspirin . An improvement of 40 - 60 m in the ICD on a st and ardized treadmill test does not translate into a self-perceived improvement in the quality of life as assessed by the SF-36 question naire PURPOSE In patients with intermittent claudication ( IC ) a structured walking exercise program improves exercise performance . However , few studies have evaluated the effects of exercise training on functional status during daily activities . We hypothesized that a supervised exercise training program would improve functional status in patients with IC , with 24 weeks of training more beneficial than 12 weeks . A secondary aim was to evaluate the effects of strength training and combinations of strength and treadmill training on functional status . METHODS Twenty-nine men with disabling IC were r and omized to 12 weeks of either supervised treadmill training ( 3 hr/wk at a work intensity sufficient to produce claudication ) , strength training ( 3 hr/wk of resistive training of six muscle groups of each leg ) , or to a nonexercising control group .  Functional status was assessed by question naires characterizing walking ability ( Walking Impairment Question naire , WIQ ) , habitual physical activity level ( Physical Activity Recall , PAR ) , and physical , social , and role functioning , well-being , and overall health ( Medical Outcomes Study SF-20 , MOS ) . Patients alos had their activity levels monitored with an activity monitor ( Vitalog ) . RESULTS After 12 weeks of treadmill training  PAR scores increased by 48 metabolic equivalent hr/wk , the MOS physical functioning score by 24 percentage points , and the number of bouts of walking activity measured by the Vitalog by 4.5 bouts/hr ( all p < 0.05 ) . No changes were seen in WIQ scores . After 12 additional weeks of treadmill training improvements initially observed in the PAR , MOS , and Vitalog scores were maintained , and in addition the ability to walk distances ( WIQ ) improved by 31 percentage points , and the IC severity score had improved by 29 percentage points ( both p < 0.05 ) . After 12 weeks of strength training patients improved their WIQ walking speed , stair climbing scores , and MOS well-being scores with no other changes in functional status . Subjects in the control group did not improve functional status by any measure . Twelve weeks of treadmill training after the strength training program maintained WIQ walking speed scores , and activity level defined by Vitalog improved . Twelve weeks of combined treadmill and strength training after the control period had no effect on functional status . CONCLUSIONS A supervised treadmill training program improved functional status during daily activities , with 24 weeks more effective than 12 . In addition , treadmill training alone was more effective in improving functional status in patients with IC than strength training or combinations of the training modalities OBJECTIVE --To determine the effects of the beta 1 selective adrenoceptor blocker atenolol , the dihydropyridine calcium antagonist nifedipine , and the combination of atenolol plus nifedipine on objective and subjective measures of walking performance and foot temperature in patients with intermittent claudication . DESIGN --R and omised controlled double blind four way crossover trial . SETTING --Royal Hallamshire Hospital , Sheffield . SUBJECTS--49 patients ( 40 men ) aged 39 - 70 with chronic stable intermittent claudication . INTERVENTIONS --Atenolol 50 mg twice daily ; slow release nifedipine 20 mg twice daily ; atenolol 50 mg plus slow release nifedipine 20 mg twice daily ; placebo . Each treatment was given for four weeks with no washout interval between treatments . MAIN OUTCOME MEASURES --Claudication and walking distances on treadmill ; skin temperature of feet as measured by thermistor and probe ; blood pressure before and after exercise ; subjective assessment s of walking difficulty and foot coldness with visual analogue scales . RESULTS --Atenolol did not significantly alter claudication distance ( mean change -6 % ; 95 % confidence interval 1 % to -13 % ) , walking distance ( -2 % ; 4 % to -8 % ) , or foot temperature .  Nifedipine did not alter claudication distance ( -4 % ; 3 % to -11 % ) , walking distance ( -4 % ; 3 % to -10 % ) , or foot temperature .  Atenolol plus nifedipine did not alter claudication distance but significantly reduced walking distance ( -9 % ; -3 % to -15 % ( p less than 0.003 ) ) and skin temperature of the more affected foot ( -1.1 degrees C ; 0 to -2.2 degrees C ( p = 0.05 ) ) . These effects on walking distance and foot temperature seemed unrelated to blood pressure changes . CONCLUSIONS --There was no evidence of adverse or beneficial effects of atenolol or nifedipine , when given singly , on peripheral vascular disease . The combined treatment , however , affected walking ability and foot temperature adversely . This may have been due to beta blockade plus reduced vascular resistance , which might also explain the reported adverse effects of pindolol and labetalol on claudication Indobufen — an inhibitor of platelets aggregation — has been used in 306 pa tients with intermittent claudication due to peripheral vascular disease . Patients were treated and followed up for one year . One patient of every 3 treated with indobufen was treated with ASA , and a control group of patients receiving no treatment was also followed up . The authors studied by means of a treadmill exercise test the  pain-free walking distance ( PFWD ) , the global walking distance ( GWD ) , and the recovery time after exercise . The treatment period was com pleted by 290 patients : 204 claudicants , 51 claudicants with diabetes , and 35 with a short PFWD and GWD ( > 150 m ) .  Indobufen was more effective than ASA in improving the PFWD and GWD in all groups . There were also fewer side effects with indobufen , and cardiac morbidity and mortality was also reduced . In conclusion indobufen showed its activity and safety in chronic treatment of patients with peripheral disease , and we suggest that it may be used for long periods without side effects BACKGROUND Patients with intermittent lower limb claudication ( IC ) exhibit a prothrombotic diathesis that is acutely exacerbated by exercise . This may occur because of ischemia/reperfusion injury within the leg muscles during walking and may contribute to the increased risk of thrombotic vascular events in this group of patients . This r and omized study compared the effect of lower limb revascularization by percutaneous transluminal balloon angioplasty ( PTA ) , supervised exercise , and best medical therapy ( BMT ) alone on this prothrombotic state . METHODS Twenty-three patients ( 16 men and 7 women ; median age , 67 years ; range , 57 - 77 years ) with IC due to infrainguinal disease were r and omized to receive BMT alone ( n = 7 ) , BMT plus PTA ( n = 9 ) , or BMT plus supervised exercise ( n = 7 ) as part of the Health Technology Assessment -funded EXercise vs Angioplasty in Claudication Trial ( EXACT ) . Patients were assessed at baseline and at 3 and 6 months . Thrombin-antithrombin complex ( TAT ) was determined as a marker of thrombin generation , and plasminogen activator inhibitor ( PAI ) antigen was determined as a marker of fibrinolysis . Increased TAT indicates a procoagulant state , and increased PAI antigen indicates a hypofibrinolytic state . RESULTS At 6 months , subjects r and omized to BMT plus PTA demonstrated a significant improvement in ankle-brachial pressure index ( P = .013 ) and maximal walking distance ( P = .008 ) , a significant decline in resting thrombin generation ( median [ interquartile range ] TAT , 6.4 microg/L [ 2.7 - 13.5 microg/L ] to 1.5 microg/L [ 0.3 - 2.9 microg/L ] ; P = .038 ) , and an improvement in resting fibrinolysis ( median [ interquartile range ] PAI-1 , 10.0 ng/mL [ 1.0 - 20.5 ng/mL ] to 1.0 ng/mL [ 1.0 - 14.8 ng/mL ] ; P = .043 ) . There was no significant change in any of these parameters in patients r and omized to BMT plus supervised exercise or to BMT alone . CONCLUSIONS The addition of lower limb revascularization by PTA to BMT in patients with IC due to infra-inguinal disease results in a medium-term improvement in the resting procoagulant and hypofibrinolytic state . This may translate into a reduction in morbidity and mortality from thrombotic vascular events in this group of patients OBJECTIVE We used outdoor walking distance measured during 40 minutes as " real-life " outdoor walking capacity in 49 patients with intermittent claudication ( IC ) . The outdoor walking distance was measured by a global positioning system application for a smartphone . The relationships of self-reported maximum walking distance ( SR-MWD ) , the MWD on a grade d treadmill test , and the 6-minute maximum walk distance ( 6MWD ) vs outdoors walking capacity were investigated . Also studied were the associations of SR-MWD , MWD , and 6MWD with health-related quality of life assessed with the disease-specific instrument the  Vascular Quality of Life Question naire ( VascuQoL ) . METHODS In this prospect i ve observational cohort study , 49 IC patients underwent an  outdoor walking capacity test for 40 minutes , and MWD and 6MWD were measured . SR-MWD was recorded , and all subjects completed the VascuQoL question naire . Associations between the different walk estimates and outdoor walking capacity and health-related quality of life were investigated by correlation analysis ( Spearman ρ ) . RESULTS Outdoor walking distance during 40 minutes was a median 2495 m ( range , 1110 - 3300 m ) . SR-MWD correlated moderately and MWD correlated strongly to outdoor walking capacity ( r = 0.56 and r = 0.65 ; P < .001 , respectively ) . The 6MWD test showed the largest correlation to the outdoor walking capacity ( r = 0.78 ; P < .001 ) . The 6MWD was the only test that showed correlations with the VascuQoL sum score ( r = 0.53 ; P < .01 ) and all of the domain scores , whereas SR-MWD and MWD showed weak correlations to the VascuQoL. CONCLUSIONS The distance walked during the 6-minute walk test is closely correlated to outdoor walking capacity and health-related quality of life in IC patients . Our data support the use of 6MWD for routine clinical evaluation of walking capacity in IC patients Percutaneous transluminal angioplasty ( PTA ) is a commonly performed procedure for the treatment of  intermittent claudication  despite the lack of controlled studies . The aim of this study was to compare PTA with supervised exercise therapy for patients with arterial occlusive disease judged suitable for PTA at angiography . Patients were assessed before treatment commenced and at three monthly intervals afterwards . Assessment included measurement of resting ankle brachial pressure indices ( ABPI ) , and claudicating and maximum walking distances on a treadmill up a 10 degrees incline .  Twenty patients were r and omised to receive PTA and 16 exercise .  The groups were similar in age , sex , smoking habits and arteriographic pattern of disease . In the PTA group two patients had angioplasties that were technically unsuccessful and two other patients subsequently required surgery . One patient in the exercise group subsequently had a PTA . After PTA , mean ABPI were significantly improved at 3 , 6 and 9 months ( P less than 0.01 ) without a corresponding significant increase in mean maximum walking distances . However in the exercise group despite no increase in mean ABPI , mean maximum walking distances increased progressively , with significant increases at 6 , 9 and 12 months ( P less than 0.01 ) IMPORTANCE Approximately one-third of patients with peripheral artery disease experience intermittent claudication , with consequent loss of quality of life . OBJECTIVE To determine the efficacy of ramipril for improving walking ability , patient-perceived walking performance , and quality of life in patients with claudication . DESIGN , SETTING , AND PATIENTS R and omized , double-blind , placebo-controlled trial conducted among 212 patients with peripheral artery disease ( mean age , 65.5 [ SD , 6.2 ] years ) , initiated in May 2008 and completed in August 2011 and conducted at 3 hospitals in Australia . INTERVENTION Patients were r and omized to receive 10 mg/d of ramipril ( n = 106 ) or matching placebo ( n = 106 ) for 24 weeks . MAIN OUTCOME MEASURES Maximum and pain-free walking times were recorded during a st and ard treadmill test . The Walking Impairment Question naire ( WIQ ) and Short-Form 36 Health Survey ( SF-36 ) were used to assess walking ability and quality of life , respectively . RESULTS At 6 months , relative to placebo , ramipril was associated with a 75-second ( 95 % CI , 60 - 89 seconds ) increase in mean pain-free walking time ( P < .001 ) and a 255-second ( 95 % CI , 215 - 295 seconds ) increase in maximum walking time ( P < .001 ) . Relative to placebo , ramipril improved the WIQ median distance score by 13.8 ( Hodges-Lehmann 95 % CI , 12.2 - 15.5 ) , speed score by 13.3 ( 95 % CI , 11.9 - 15.2 ) , and stair climbing score by 25.2 ( 95 % CI , 25.1 - 29.4 ) ( P < .001 for all ) . The overall SF-36 median Physical Component Summary score improved by 8.2 ( Hodges-Lehmann 95 % CI , 3.6 - 11.4 ; P = .02 ) in the ramipril group relative to placebo . Ramipril did not affect the overall SF-36 median Mental Component Summary score . CONCLUSIONS AND RELEVANCE Among patients with intermittent claudication , 24-week treatment with ramipril result ed in significant increases in pain-free and maximum treadmill walking times compared with placebo . This was associated with a significant increase in the physical functioning component of the SF-36 score . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00681226 BACKGROUND Intermittent claudication due to peripheral arterial occlusive disease ( PAOD ) is a common cause of pain and disability in the middle-aged . Clinical trials of the potent vasodilator prostagl and in E1 have been disappointing . This is the first report of a controlled clinical trial of AS-0:3 , a novel prodrug of prostagl and in E1 incorporated into lipid microspheres that has been developed to improve delivery of the active compound to blood vessel walls . METHODS AND RESULTS Eighty patients with stenosis or occlusion , symptoms of intermittent claudication , and maximum walking distance of > or = 30 and < or = 300 m on a st and ard treadmill test were r and omized to  placebo  or one of three dosage regimens of AS-013 .  Drug was administered by intravenous injection 5 d/wk for 4 weeks . Treadmill tests and other assessment s were completed at weeks 0 , 4 , and 8 . A statistically significant increase in maximum walking distance was observed at 4 weeks ( for placebo : median , 4.5 m ; interquartile range [ IQR ] , 20 ; for active treatment : median , 28.0 m ; IQR , 81 ; P < .01 , Mann-Whitney test ) . A similar response was seen at 8 weeks ( for placebo ; median , -11.2 m ; IQR , 35 ; for active treatment : median , 35 m ; IQR , 68 ; P < .01 , Mann-Whitney test ) . Dose-related improvements in pain-free walking distance and quality of life were observed . No serious safety issues were noted . CONCLUSIONS These promising clinical data indicate that AS-013 , a new prodrug of prostagl and in E1 , could provide an effective and acceptable treatment for patients with intermittent claudication . Studies to investigate the optimal dosing regimen , duration of clinical benefit , and effects in more severe forms of peripheral arterial disease are warranted BACKGROUND To compare angioplasty ( PTA ) , supervised exercise ( SEP ) and PTA + SEP in the treatment of intermittent claudication ( IC ) due to femoropopliteal disease . METHODS Over a 6-year period , 178 patients ( 108 men ; median age , 70 years ) with femoropopliteal lesions suitable for angioplasty  were r and omized to PTA , SEP , or PTA + SEP . Patients were assessed prior to and at 1 and 3 months post treatment . ISCVS outcome criteria ( ankle pressures , treadmill walking distances ) and quality of life ( QoL ) question naires ( SF-36 and VascuQoL ) were analyzed . RESULTS All groups were well matched at baseline . Twenty-one patients withdrew . Results are as follows : Intragroup analysis : All groups demonstrated significant clinical and QoL improvements ( Friedman test , p < 0.05 ) . SEP ( 60 patients , 8 withdrew)-62.7 % of patients ( n = 32 ) improved following treatment [ 20 mild , 9 moderate , 3 marked ] , 27.4 % ( n = 14 ) demonstrated no improvement , and 9.8 % ( n = 5 ) deteriorated . PTA  ( 60 patients , 3 withdrew)-66.6 % patients ( n = 38 ) improved following treatment [ 19 mild , 10 moderate , 9 marked ] , 22.8 % ( n = 13 ) demonstrated no improvement , and 10.5 % ( n = 6 ) deteriorated . PTA + SEP ( 58 patients , 10 withdrew)-81.6 % of patients ( n = 40 ) improved following treatment [ 10 mild , 17 moderate , 3 marked ] , 14.2 % ( n = 7 ) demonstrated no improvement , and 4.0 % ( n = 2 ) deteriorated . Intergroup analysis : PTA + SEP produce a much greater improvement in clinical outcome measures than PTA or SEP alone , but there was no significant QoL advantage ( Kruskal-Wallis test , p > 0.05 ) . CONCLUSION SEP should be the primary treatment for the patients with claudication and PTA should be supplemented by an SEP BACKGROUND This prospect i ve , r and omized controlled clinical trial determined whether an optimal exercise program length exists to efficaciously change claudication onset time ( COT ) and peak walking time ( PWT ) in patients with peripheral artery disease and claudication . METHODS The study r and omized 142 patients to supervised exercise ( n = 106 ) or a usual care control group ( n = 36 ) , with 80 completing the exercise program and 27 completing the control intervention .  The exercise program consisted of intermittent walking to nearly maximal claudication pain 3 days per week . COT and PWT were the primary outcomes obtained from a treadmill exercise test at baseline and bimonthly during the study . RESULTS After exercise , changes in COT ( P < .001 ) and PWT ( P < .001 ) were consistently greater than changes after the control intervention . In the exercise program , COT and PWT increased from baseline to month 2 ( P < .05 ) and from months 2 to 4 ( P < .05 ) but did not significantly change from months 4 to 6 ( P > .05 ) . When changes were expressed per mile walked during the first 2 months , middle 2 months , and final 2 months of exercise , COT and PWT only increased during the first 2 months ( P < .05 ) . CONCLUSIONS Exercise-mediated gains in COT and PWT occur rapidly within the first 2 months of exercise rehabilitation and are maintained with further training . The clinical significance is that a relatively short 2-month exercise program may be preferred to a longer program to treat claudication because adherence is higher , costs associated with personnel and use of facilities are lower per patient , and more patients can be trained for a given amount of personnel time and re source utilization We compared the efficacy and safety of three doses of beraprost sodium , an epoprostenol analogue , with placebo in the treatment of intermittent claudication ( Fontaine 's stage II ) . One hundred sixty-four patients were r and omized to receive either placebo , 20 micrograms beraprost sodium ( BPS60 group ) , 40 micrograms beraprost sodium ( BPS120 group ) , or 60 micrograms beraprost sodium ( BPS180 group ) three times daily administered orally in a double-blind manner for 12 weeks . Treadmill exercise tests were performed twice during an initial selection phase ( D-28 and D0 ) at week 10 ( at trough beraprost concentration ) and week 12 ( at peak beraprost concentration ) of the treatment phase . At week 10 , all groups showed an increase in pain-free walking distance , and this distance was greatest in the BPS60 and BPS120 groups ( p = 0.055 ) . At week 12 , a similar pattern was observed , and the difference was significant between the groups ( p = 0.023 ) . The most frequent adverse events reported were gastrointestinal disorders , headaches , skin disorders , and flushes . Patients who received either 60 or 120 micrograms of beraprost sodium daily had an increased pain-free walking distance . Further studies are required to investigate why the highest dose used ( 180 micrograms daily ) showed lower efficacy . Having both vasodilating and antiplatelet properties and being able to increase pain-free walking distance in the short term , beraprost sodium is a promising drug for the treatment of intermittent claudication IMPORTANCE Clinical practice guidelines state there is insufficient evidence to support advising patients with peripheral artery disease ( PAD ) to participate in a home-based walking exercise program . OBJECTIVE To determine whether a home-based walking exercise program that uses a group-mediated cognitive behavioral intervention , incorporating both group support and self-regulatory skills , can improve functional performance compared with a health education control group in patients with PAD with and without intermittent claudication . DESIGN , SETTING , AND PATIENTS R and omized controlled clinical trial of 194 patients with PAD , including 72.2 % without classic symptoms of intermittent claudication , performed in Chicago , Illinois between July 22 , 2008 , and December 14 , 2012 . INTERVENTIONS Participants were r and omized to 1 of 2 parallel groups : a home-based group-mediated cognitive behavioral walking intervention or an attention control condition . MAIN OUTCOMES AND MEASURES The primary outcome was 6-month change in 6-minute walk performance . Secondary outcomes included 6-month change in treadmill walking , physical activity , the Walking Impairment Question naire ( WIQ ) , and Physical and Mental Health Composite Scores from the 12-item Short-Form Health Survey . RESULTS Participants r and omized to the intervention group significantly increased their 6-minute walk distance ( [ reported in meters ] 357.4 to 399.8 vs 353.3 to 342.2 for those in the control group ; mean difference , 53.5 [ 95 % CI , 33.2 to 73.8 ] ; P < .001 ) , maximal treadmill walking time ( intervention , 7.91 to 9.44 minutes vs control , 7.56 to 8.09 ; mean difference , 1.01 minutes [ 95 % CI , 0.07 to 1.95 ] ; P = .04 ) , accelerometer-measured physical activity over 7 days ( intervention , 778.0 to 866.1 vs control , 671.6 to 645.0 ; mean difference , 114.7 activity units [ 95 % CI , 12.82 to 216.5 ] ; P = .03 ) , WIQ distance score ( intervention , 35.3 to 47.4 vs control , 33.3 to 34.4 ; mean difference , 11.1 [ 95 % CI , 3.9 to 18.1 ] ; P = .003 ) , and WIQ speed score ( intervention , 36.1 to 47.7 vs control , 35.3 - 36.6 ; mean difference , 10.4 [ 95 % CI , 3.4 to 17.4 ] ; P = .004 ) . CONCLUSION AND RELEVANCE A home-based walking exercise program significantly improved walking endurance , physical activity , and patient-perceived walking endurance and speed in PAD participants with and without classic claudication symptoms . These findings have implication s for the large number of patients with PAD who are unable or unwilling to participate in supervised exercise programs . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00693940 OBJECTIVES To evaluate effects of a structured home-based exercise program on functional capacity and quality of life ( QoL ) in patients with intermittent claudication ( IC ) after 1-year follow-up , and to compare these results with those from a concurrent control group who received supervised exercise training ( SET ) . DESIGN Comparative longitudinal cohort study . SETTING Referral center . PARTICIPANTS Patients ( N=142 ) with IC . INTERVENTIONS Structured home-based exercise training or SET . MAIN OUTCOME MEASURES The maximum ( pain-free ) walking distance and the ankle-brachial index ( ABI ) ( at rest and postexercise ) were measured at baseline and after 6 and 12 months ' follow-up . Additionally , QoL was evaluated using a self-administered question naire consisting of the Euroqol-5D ( scale 0 - 1 ) , rating scale ( scale 0 - 100 ) , Medical Outcomes Study 36-Item Short-Form Health Survey ( SF-36 ; scale 0 - 100 ) , and the Vascular Quality of Life Question naire ( VascuQol ; scale 1 - 7 ) . Comparison of the groups was performed with adjustment for the nonr and omized setting using propensity scoring . RESULTS One hundred forty-two patients with IC started the  structured home-based exercise program , of whom 95 ( 67 % ) completed 12 months ' follow-up . The mean relative improvement compared with baseline was statistically significant after 12 months ' follow-up for the maximum and pain-free walking distance ( 342 % , 95 % confidence interval [ CI ] , 169 - 516 ; P<.01 and 338 % , 95 % CI , 42 - 635 ; P=.03 , respectively ) and for the ABI postexercise ( mean change , .06 ; 95 % CI , .01-.10 ; P=.02 ) . For the QoL outcomes , the improvement compared with baseline was statistically significant after 12 months for the VascuQol ( mean change , .42 ; 95 % CI , .20-.65 ; P<.01 ) and for the SF-36 physical functioning ( mean change , 5.17 ; 95 % CI , .77 - 9.56 ; P=.02 ) . Compared with the structured home-based exercise program , patients in the control group showed significantly better results in the mean relative improvement of maximum and pain-free walking distance and change in the ABI at rest after 12 months ' follow-up . CONCLUSIONS Structured home-based exercise training is effective in improving both functional capacity and QoL in patients with IC and may be considered as a feasible and valuable alternative toSET , since supervised exercise programs are not often available 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 Objectives : Patients with peripheral artery disease have walking impairment , greater thrombotic risk , and are often treated with exercise training . We sought to determine the effect of a 3-month-long exercise program on clot strength among patients with peripheral artery disease and intermittent claudication . Methods : Twenty-three symptomatic peripheral artery disease patients were r and omly assigned to a walking exercise program or to an attention control group who performed light resistance exercise . We investigated the effect of exercise training on clot strength and time to clot formation was assessed by thromboelastography . Results : After 3 months of exercise , clot strength ( maximal amplitude ) and time to clot formation ( R ) did not change significantly from baseline , even after improvements in claudication onset time ( p < 0.01 ) and peak walking time ( p < 0.05 ) . Furthermore , changes in clot formation parameters were not significantly different between groups . Among the 10 individuals demonstrating a reduction in clot strength ( reduced maximal amplitude ) , one was a smoker ( 10 % ) compared to 9 of 13 non-responders ( 69 % ) whose maximal amplitude was unchanged or increased ( p = 0.0097 ) . Conclusion : In this ancillary study , a 12-week walking program improved ambulatory function in peripheral artery disease patients with claudication , but does not modify clot strength or time to clot formation . Larger studies are needed to confirm these hypothesis generating findings and to determine whether a different amount or type of exercise may induce a change in clotting in this patient population BACKGROUND Supervised treadmill-walking exercise programs have been proven to be a highly effective in improving walking distance in peripheral arterial disease ( PAD ) patients with lifestyle-limiting claudication . Limited information is available on the contributions of central cardiorespiratory functions for improving these patients ' walking capacity with exercise training . METHODS This study r and omized 28 participants ( 21 men ; age , 65.6 years ; 92.7 % smoking history , 36.6 % with diabetes ) with lifestyle-limiting PAD-related claudication to 3 hours/week of supervised exercise training for 12 weeks  , using arm-ergometry ( n = 10 ) or treadmill-walking ( n = 10 ) vs a usual-care control group ( n = 8) . Cardiorespiratory function measurements were assessed before and after training at a submaximal workload and at the onset of claudication ( pain-free walking distance [ PFWD ] ) and at maximal walking distance [ ( MWD ] ) . Changes in these functions from baseline were analyzed among the groups with analysis of covariance . Associations between variables were determined by Pearson 's partial correlations . RESULTS The mean baseline demographic , medical , and exercise variables were similar among the groups . There were similar significant differences in the submaximal double product ( heart rate × systolic blood pressure ) and at MWD , ventilatory threshold , ventilatory oxygen uptake ( VO(2 ) ) at onset of claudication , and VO(2 ) peak in response to training in both exercise groups vs the control group . Statistically significant , moderate correlations ( r = 0.60 - 0.68 ) were found between changes in all cardiorespiratory variables and changes in PFWD or MWD . CONCLUSION Improvements in cardiorespiratory function after arm-ergometry or treadmill-training were significantly associated with improvements in both PFWD and MWD , providing supporting evidence of systemic contributions to exercise training-related improvements in walking capacity seen in patients with claudication Cilostazol , a novel oral phosphodiesterase inhibitor , has shown consistent improvement in exercise tolerance in patients with intermittent claudication ( IC ) . In addition to this effect , cilostazol has previously been shown to have beneficial effects on the dyslipidemia , i.e. , combination of high triglycerides with low high-density-lipoprotein cholesterol ( HDL-C ) levels . Interleukin-6 ( IL-6 ) suppresses the activity of lipoprotein lipase , which modulates the metabolism of triglycerides and HDL-C. To determine whether a reduction of IL-6 contributes to the improvement of lipid profiles , we prospect ively investigated the effect of cilostazol ( n=16 , 100 mg , twice daily ) on the changes of lipid profiles and on the association with the changes of IL-6 compared with those of pentoxifylline ( n=16 , 400 mg , bid ) in patients with IC . After eight weeks of administration of cilostazol to patients with IC , walking distances were increased , associated with a 29 % decrease in plasma triglycerides and a 13 % increase in HDL-C. No significant changes of lipid profiles in the pentoxifylline and placebo groups were observed although a similar improvement in walking distances was achieved in the pentoxifylline group . IL-6 levels were significantly reduced in patients receiving cilostazol as compared with those receiving placebo or pentoxifylline . The cilostazol-induced  changes in the IL-6 were positively related to those of triglycerides in the cilostazol group ( r=0.63 , P<0.05 ) and negatively related to those of HDL-C ( r=-0.55 , P<0.05 ) . These findings suggest that in addition to consistent improvement of exercise tolerance , cilostazol may improve lipid profiles by reducing IL-6 release . However , pentoxifylline did not affect lipid profiles although a similar improvement of maximal walking distance ( MWD ) was achieved PURPOSE This study was performed to test the efficacy of a supervised , hospital-based exercise program compared with a home-based exercise program involving minimal supervision , for both walking ability and quality of life measures in patients with exercise-limiting intermittent leg claudication . METHODS Twenty-one patients were assigned r and omly to 12 weeks of supervised exercise or to a home-based exercise group . After 12 weeks the participants in the supervised group transitioned to a home-based program . Both groups were then reevaluated at the end of 24 weeks . The initial claudication distance ( ICD ) and absolute claudication distance ( ACD ) on progressive treadmill exercise was measured at baseline , 12 weeks , and 24 weeks . Additionally , self-reported quality of life status was evaluated using the MOS SF-36 question naire . RESULTS Each group improved ( P < 0.01 ) ACD from baseline to 12 weeks , which was sustained at the 24-week follow-up . Both groups experienced similar long-term improvements ( P < 0.05 ) in ACD ( 521.5 + /- 253.4 meters to 741.9 + /- 365.6 meters for the supervised group , 532.2 + /- 263.5 meters to 715.0 + /- 394.4 meters in the home group , P not significant , between groups ) . The supervised group experienced a greater improvement ( P < 0.01 ) in the ICD after 12 weeks than the home group but not at 24 weeks . The on-site group also experienced significant improvements in ICD after 24 weeks ( P < 0.05 ) . Neither group manifested an improvement in self-reported physical function or mental health as assessed by the MOS SF-36 . CONCLUSION A structured exercise program was more effective in improving the ICD over a 24-week period than a less formal , home-based program . However , if patients are screened properly and receive adequate instruction , a home-based program can be a safe , low-cost alternative providing similar long-term ( 24 weeks ) exercise benefits in ACD PURPOSE The purpose of this investigation was to evaluate the efficacy of PoleStriding exercise ( a form of walking that uses muscles of the upper and lower body in a continuous movement similar to cross-country skiing ) and vitamin E ( alpha-tocopherol ) to improve walking ability and perceived quality of life ( QOL ) of patients with claudication pain secondary to peripheral arterial disease ( PAD ) . METHODS Fifty-two subjects were r and omized into four groups : PoleStriding with vitamin E ( N = 13 ) , PoleStriding with placebo ( N= 14 ) , vitamin E without exercise ( N= 13 ) , and placebo without exercise ( N = 12 ) . The dose of vitamin E was 400 IU daily . Only the PoleStriding with vitamin E and PoleStriding with placebo groups received PoleStriding instruction and training . Assignment to vitamin E or placebo was double blind . Subjects trained three times weekly for 30 - 45 min ( rest time excluded ) . Individuals in vitamin E and placebo groups came to the laboratory biweekly for ankle blood-pressure measurements . RESULTS Results of this r and omized clinical trial provide strong evidence that PoleStriding significantly ( P < 0.001 ) 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 ( P= 0.02 ) . In contrast , vitamin E did not have a statistically significant effect on the subjects ' ratings of perceived leg pain ( P= 0.35 ) or treadmill walking duration ( P= 0.36 ) . Perceived distance and walking speed ( Walking Impairment Question naire ) and perceived physical function ( R and Short Form-36 ) improved in the PoleStriding trained group only ( P < 0.001 , 0.022 and 0.003 , respectively ) . CONCLUSION PoleStriding effectively improved the exercise tolerance and perceived QOL of patients with PAD . Little additional benefit to exercise capacity was realized from vitamin E supplementation Study Design . Prospect i ve r and omized controlled multicenter study . Objective . To compare the effect of X-Stop with minimally invasive decompression ( MID ) in patients with neurogenic intermittent claudication due to lumbar spinal stenosis . Summary of Background Data . Lumbar spinal stenosis is the most common indication for operative treatment in elderly .  Laminectomy has been the “ gold st and ard , ” but MID is now widely used . Another minimally invasive surgery option is X-Stop showing good result compared with nonoperative treatment , but showing higher reoperation rate than laminectomy . Methods . We enrolled 96 patients aged 50 to 85 years , with symptoms of neurogenic intermittent claudication within 250-m walking distance and 1- or 2-level lumbar spinal stenosis , r and omized to either MID or X-Stop .  Primary outcome was Zurich Claudication Question naire in this intention-to-treat analysis . Secondary outcome was Oswestry Disability Index , EuroQol 5-dimensional question naire , numerical rating scale 11 for lower back pain and leg pain , and risk for secondary surgery and complications . Results . No significant differences were found in Zurich Claudication Question naire between the groups at any follow-ups . Both groups had a statistical and clinical significant improvement at 6 weeks and throughout the 2-year observation period . The number of patients having secondary surgery due to persistent or recurrent symptoms was significantly higher in the X-Stop group , odds ratio ( 95 % confidence interval ) = 6.5 ( 1.3–31.9 ) . Complication rate was similar and low , but more severe for MID . Conclusion . Both MID and X-Stop led to significant symptom improvements . There were no significant clinical differences in effect between the methods at any of the follow-up time points . X-Stop had significant higher risk of secondary surgery . Complication was more severe for MID . Level of Evidence : BACKGROUND It is not clear whether subgroups of patients with peripheral artery disease ( PAD ) and claudication respond more favorably to exercise rehabilitation than others . We determined whether sex and diabetes were factors associated with the response to exercise rehabilitation in patients with claudication . METHODS Eighty patients were r and omized to home-based and supervised exercise programs , and 60 finished with complete exercise intervention data . Exercise consisted of intermittent walking to near maximal claudication pain for 3 months . Primary outcome measures included claudication onset time ( COT ) and peak walking time . Patients were partitioned into diabetic and nondiabetic groups and then further partitioned by sex to form four groups . RESULTS Overall ,  exercise adherence  was high ( 84 % ) , and there was no significant difference ( P > .05 ) in the amount of exercise completed among the four groups . All groups had significant improvements ( P < .05 ) in COT and peak walking time after exercise rehabilitation , except for diabetic women ( P > .05 ) . Only 37 % of women with diabetes had an increase in COT compared with 100 % of men with diabetes ( P < .01 ) , and their risk ratio for nonresponse was 9.2 ( P < .0001 ) . CONCLUSIONS Women with PAD and claudication , particularly those with diabetes , represent a vulnerable subgroup of patients who respond poorly to a program of exercise rehabilitation .  Diabetic women with PAD and claudication may need a greater dose of exercise or another intervention separate from or in combination with exercise to elicit improvements in claudication measures that are similar to nondiabetic women and to diabetic and nondiabetic men BACKGROUND Administration of L-arginine improves nitric oxide ( NO ) formation and endothelium-dependent vasodilation in atherosclerotic patients . OBJECTIVES We investigated in this double-blind , controlled study whether prolonged intermittent infusion therapy with L-arginine improves the clinical symptoms of patients with intermittent claudication , as compared with the endothelium-independent vasodilator prostagl and in E1 , and control patients . METHODS Thirty-nine patients with intermittent claudication were r and omly assigned to receive 2 x 8 g L-arginine/day , or 2 x 40 microg prostagl and in E1 (PGE1)/day or no hemodynamically active treatment , for 3 weeks . The pain-free and absolute walking distances were assessed on a walking treadmill at 3 km/h , 12 % slope , and NO-mediated , flow-induced vasodilation of the femoral artery was assessed by ultrasonography at baseline , at 1 , 2 and 3 weeks of therapy and 6 weeks after the end of treatment . Urinary nitrate and cyclic guanosine-3 ' , 5'-monophosphate ( GMP ) were assessed as indices of endogenous NO production . RESULTS L-Arginine improved the pain-free walking distance by 230+/-63 % and the absolute walking distance by 155+/-48 % ( each p < 0.05 ) . Prostagl and in E1 improved both parameters by 209+/-63 % and 144+/-28 % , respectively ( each p < 0.05 ) , whereas control patients experienced no significant change . L-Arginine therapy also improved endothelium-dependent vasodilation in the femoral artery , whereas PGE1 had no such effect . There was a significant linear correlation between the L-arginine/asymmetric dimethylarginine ( ADMA ) ratio and the pain-free walking distance at baseline ( r=0.359 , p < 0.03 ) . L-Arginine treatment elevated the plasma L-arginine/ADMA ratio and increased urinary nitrate and cyclic GMP excretion rates , indicating normalized endogenous NO formation . Prostagl and in E1 therapy had no significant effect on any of these parameters . Symptom scores assessed on a visual analog scale increased from 3.51+/-0.18 to 83+/-0.4 ( L-arginine ) and 7.0+/-0.5 ( PGE1 ; each p < 0.05 ) , but did not significantly change in the control group ( 4.3+/-0.4 ) . CONCLUSIONS Restoring NO formation and endothelium-dependent vasodilation by L-arginine improves the clinical symptoms of intermittent claudication in patients with peripheral arterial occlusive disease OBJECTIVES To compare percutaneous transluminal angioplasty ( PTA ) against exercise training in the treatment of stable claudication . DESIGN Prospect i ve , r and omised trial . MATERIAL S Fifty-six patients with unilateral , stable , lower limb claudication assessed prior to r and omisation , at 3 monthly intervals for 15 months , and at approximately 6 years follow-up . Thirty-seven patients were available for long term review . OUTCOME MEASURES Ankle/brachial pressure index ( ABPI ) , treadmill claudication and maximum walking distances , percentage fall in ankle systolic pressure after exercise .  RESULTS Significant increases were seen in ABPI in the patients treated with PTA at all assessment to 15 months . However in terms of improved walking performance , the most significant changes in claudication and maximum walking distance were seen in the exercise training group . At long term follow-up , there was no significant difference between the groups . Subgroup analysis by angiographic site of disease showed greater functional improvement in those patients with disease confined to the superficial femoral artery treated by exercise training . The overall prognosis for the whole group of patients was benign , with only two ( 4 % ) undergoing amputation . CONCLUSIONS Exercise training confers a greater improvement in claudication and maximum walking distance than PTA , especially in patients with disease confined to the superficial femoral artery Patients with atherosclerotic peripheral arterial disease ( PAD ) of the lower extremities have impaired walking ability due to exercise-induced muscle ischemia and the result ant pain of intermittent claudication . To evaluate the benefit of exercise training as a treatment for patients with PAD , as well as possible mechanisms associated with improvement , we r and omly assigned 19 men with disabling claudication to treated and control groups . Treatment consisted of supervised treadmill walking ( 1 hr/day , 3 days/wk , for 12 weeks ) with progressive increases in speed and grade as tolerated . Grade d treadmill testing was performed to maximal toleration of claudication pain on entry and after 12 weeks of training to define changes in peak exercise performance . After 12 weeks , treated subjects had increased their peak walking time 123 % , peak oxygen consumption 30 % , and pain-free walking time 165 % ( all p less than 0.05 ) . Control subjects had no change in peak oxygen consumption , but after 12 weeks , peak walking time increased 20 % ( p less than 0.05 ) . In treated subjects , maximal calf blood flow ( measured by a plethysmograph ) increased 38 + /- 45 % ( p less than 0.05 ) , but the change in flow was not correlated to the increase in peak walking time . Elevated plasma concentrations of acylcarnitines have been associated with the functional impairment of PAD and may reflect the metabolic state of ischemic skeletal muscle . In treated subjects , a 26 % decrease in resting plasma short-chain acylcarnitine concentration was correlated with improvement in peak walking time ( r = -0.78 , p less than 0.05 ) . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVES To determine if the use of a plantar flexion device ( Step It pedal ) in a newly developed exercise programme is of benefit to patients with peripheral arterial disease . DESIGN Prospect i ve feasibility trial with patients r and omised to either st and ard care or the Step It exercise programme plus st and ard care .  SETTING Physiotherapy Department at Cumberl and Infirmary , Carlisle , UK . PARTICIPANTS Patients were identified from the vascular team 's referral list . In total , 42 patients agreed to take part ; 18 in the control group and 24 in the intervention group . INTERVENTIONS Eligible participants were r and omised and received either st and ard care or took part in a plantar flexion resistance exercise programme , involving the Step It pedal , for a period of 12 weeks . MAIN OUTCOME MEASURES Maximum walking distance , claudication distance and ankle brachial pressure index . RESULTS Eighty-three percent of patients completed the study . Improvements in median distance to claudication symptoms and maximum walking distance were observed in the intervention group but not in the control group . Nine out of 15 ( 60 % ) participants in the control group and 14 out of 20 ( 70 % ) participants in the intervention group improved their walking distance . Ankle brachial pressure index remained virtually unchanged in both groups . CONCLUSIONS Due to the variability of patients ' fitness in the sample , it can not be concluded whether use of the Step It pedal has additional benefits to patients over st and ard care . However , the study completion rate implies that patients with peripheral arterial disease are receptive to undertaking exercise programmes OBJECTIVE The aim of this study was to identify whether revascularization by percutaneous transluminal angioplasty ( PTA ) for patients with intermittent claudication improved measures of functional performance including balance . METHODS A prospect i ve observational study was performed at a single tertiary vascular center . Patients with symptomatic intermittent claudication ( Rutherford grade s 1 - 3 ) were recruited to the study . Participants were assessed at baseline ( pre-PTA ) and then 3 , 6 , and 12 months post-PTA for markers of ( 1 ) lower limb ischemia ( treadmill walking distances and ankle-brachial pressure index ) , ( 2 ) physical function ( 6-minute walk , Timed Up and Go , and chair st and time ) , ( 3 ) balance impairment using computerized dynamic posturography with the Sensory Organization Test , and ( 4 ) quality of life ( VascuQoL and Short Form Health Survey [ SF-36 ] ) . RESULTS Forty-three participants underwent PTA .  Over 12 months , a significant improvement was demonstrated in initial ( P = .04 ) and maximum treadmill walking distance ( P = .019 ) . Physical functional ability improved across all outcome measures ( P < .02 ) , and some domains of both generic ( P < .03 ) and disease-specific quality of life ( P < .01 ) . No significant improvement in balance was demonstrated by the Sensory Organization Test ( P = .24 ) . CONCLUSIONS Balance impairment is common in claudicants and does not improve with revascularization . Further research regarding effective treatment of balance impairment is required in this specific group of patients The efficacy , safety and cost of pentoxifylline ( PXF ) in severe intermittent claudication was studied comparing PXF and placebo in a 12-month study . A treadmill test and microcirculatory evaluation with laser Doppler flowmetry were performed at inclusion and at the end of 6 and 12 months . A physical training plan ( based on walking ) and reduction in risk factor levels plan was used in both groups . Of the 120 included patients , 101 completed the study : 56 in the  PXF group and 45 in the  placebo group . There were 19 dropouts ( due to low compliance ) . The two groups were comparable for age , sex distribution , walking distance , and the presence of risk factors and smoking . Intention-to-treat analysis indicated a 268 % increase in walking distance in the PXF group ( vs 198 % in the placebo group ; p<0.05 ) at 6 months and an increase of 404 % ( vs 280 % in the placebo group ; p<0.02 ) at 12 months . The absolute and percent increase in pain-free walking distance ( PFWD ) was greater in the PXF group ( p<0.05 ) . Treatment was well tolerated . No serious drug-related side effects were observed . Microcirculatory evaluation indicated an increase in flux ( p < 0.05 ) in the PXF group ( not significant in the placebo group ) ; the after-exercise flux ( AEF ) was increased ( p<0.05 ) in both groups at 6 months but the increase in AEF was greater in the PXF group at 12 month . In conclusion , between-group analysis favors PXF considering walking distance and microcirculatory parameters . Results indicate good efficacy and tolerability OBJECTIVES The current study tested the hypothesis that NM-702 improves treadmill exercise performance in peripheral arterial disease patients with claudication-limited exercise performance . BACKGROUND Patients with claudication experience significant disability , owing to their exercise limitation . Therapeutic options to improve exercise performance in these patients are limited . NM-702 is a novel drug that inhibits phosphodiesterase as well as thromboxane A2 synthase . METHODS This study was a r and omized , multi-center , placebo-controlled , double-blind trial . Patients were r and omized to receive 24 weeks of twice-daily treatment with either placebo ( intent to treat population , n = 130 ) , 4 mg NM-702 ( n = 126 ) , or 8 mg NM-702 ( n = 130 ) . RESULTS After 24 weeks of treatment , 8 mg NM-702 was associated with a statistically significant increased peak walking time on a grade d treadmill as compared with placebo ( p = 0.004 ) . Peak walking time after 24 weeks was increased by 17.1 + /- 49.0 % in the placebo arm , 22.1 + /- 60.1 % in the 4-mg NM-702 arm , and 28.1 + /- 50.5 % in the 8-mg NM-702 arm . NM-702 at the 8-mg dose for 24 weeks was associated with statistically significant improvements in the treadmill claudication onset time as compared with placebo . In addition , as compared with placebo , NM-702 improved the physical component and physical functioning scores of the Medical Outcomes Study 36-Item Short Form and the walking distance and stair climbing domains of the Walking Impairment Question naire . NM-702 was generally well tolerated , but adverse events typical of vasodilators were common . CONCLUSIONS NM-702 used for 24 weeks by patients with claudication was associated with improvements in laboratory- and ambulatory-based exercise performance The purpose of this study was to examine the effects of a 6-month exercise program on submaximal walking economy in individuals with peripheral arterial disease and intermittent claudication ( PAD-IC ) . Participants ( n = 16 ) were r and omly allocated to either a control PAD-IC group ( CPAD-IC , n = 6 ) which received st and ard medical therapy , or a treatment PAD-IC group ( TPAD-IC ;  n = 10 ) which took part in a supervised exercise program . During a grade d treadmill test , physiological responses , including oxygen consumption , were assessed to calculate walking economy during submaximal and maximal walking performance . Differences between groups at baseline and post-intervention were analyzed via Kruskal – Wallis tests . At baseline , CPAD-IC and TPAD-IC groups demonstrated similar walking performance and physiological responses . Postintervention , TPAD-IC patients demonstrated significantly lower oxygen consumption during the grade d exercise test , and greater maximal walking performance compared to CPAD-IC . These preliminary results indicate that 6 months of regular exercise improves both submaximal walking economy and maximal walking performance , without significant changes in maximal walking economy . Enhanced walking economy may contribute to physiological efficiency , which in turn may improve walking performance as demonstrated by PAD-IC patients following regular exercise programs BACKGROUND The first-line intervention for intermittent claudication is usually supervised exercise therapy ( SET ) . The literature describes a range of exercise programs varying in setting , duration , and content . The purpose of the present study was to examine the exercise protocol s offered and to identify the impact of the intensity of the SET programs ( in terms of frequency , duration , and type of exercise ) on improvements in walking distance ( response ) in the first 3 months . The present study is part of the Exercise Therapy in Peripheral Arterial Disease ( EXITPAD ) study , a multicenter r and omized clinical trial comparing the effects of SET provided by regional physiotherapists , with or without daily feedback , on the level of activities with the effects of walking advice . METHODS The analysis included patients r and omized to receive SET with or without feedback . The physical therapists administering the SET were asked to fill out therapy evaluation sheets stating frequency , duration , and type of exercises . The relationship between training volume and the impact on walking distance was explored by dividing training volume data into tertiles and relating them to the median change in maximum walking distance at 3 and 12 months . RESULTS Data of 169 patients were included in the analysis . A SET program consisting of at least two training sessions per week each lasting over 30 minutes , during the first 3 months of a 1-year program tailored to individual patients ' needs led to better results in terms of walking distance after 3 and 12 months than the other variants . The results of our analysis dividing training volume into tertiles suggest that there is a relationship between training volume and improvement in walking distance and that at least 590 minutes of training should be offered in the first 3 months . No differences were found between program involving only walking and a combination of exercises , nor between individual and group training . CONCLUSION A SET programs consisting of at least two training sessions a week , each lasting over 30 minutes , should be offered during the first 3 months of the SET program to optimize improvement in terms of maximum walking distance In a comparative cross-over trial we examined the influence of the betablocker bisoprolol and the ACE-inhibitor lisinopril on the peripheral blood flow of 2 groups of hypertensive patients with and without concomitant intermittent claudication . In 11 patients with hypertension without peripheral arterial obstructive disease and 11 patients with hypertension and claudication we assessed the blood pressure , leg blood flow , vascular resistance , walking distance , transcutaneous oxygen consumption and Laser-Doppler flow after treatment of one month with 10 mg bisoprolol once daily or 20 mg lisinopril once daily . The walking distance of patients with claudication improved in all patients while participating in an exercise program . For both treatment groups this improvement was significant ( p < 0.05 ) compared to baseline , from 264 m at baseline to 313 m with bisoprolol and to 400 m with lisinopril . The difference was not significant between the both drugs . In patients without peripheral vascular obstructive disease we found a significant ( p < 0.05 ) reduction in blood flow for both drugs . The peripheral blood flow parameters of 38 legs showed no statistical significant effect of bisoprolol nor lisinopril on the local vascular resistance at rest , after occlusion or after exercise Porter et al have reported that pentoxifylline shows statistically significant superiority over placebo in a seven-center , double-blind , parallel group , r and omized trial of out patients with intermittent claudication secondary to chronic occlusive arterial disease . The objective of this report is convey results of the intention-to-treat population , paying careful attention to relevant method ologic issues relating to the analysis of clinical trials . At the same time , a new measure of clinical efficacy , minimum distance walked , is proposed . The rationale for this measure is discussed and results are compared with those for walking distances at each visit . The re analysis of the Porter et al data by " intention to treat " and by use of the minimum-distance-walked measure confirms the published findings of efficacy of pentoxifylline for treatment of intermittent claudication BACKGROUND Serum markers of inflammation and platelet activation are related to cardiovascular risk . Cardiovascular risk reduction is a major treatment goal in patients with peripheral arterial disease ( PAD ) . Although current guidelines recommend supervised exercise training ( SET ) for PAD patients with intermittent claudication , its contribution to risk reduction remains unclear . Aim of the present study was to assess the impact of SET on inflammation and platelet activation as surrogates for cardiovascular risk . METHODS Fifty-three patients with intermittent claudication were r and omly assigned to SET on top of best medical treatment ( BMT ) for 6 months ( SET-group ) or to BMT only ( BMT-group ) . High sensitivity C-reactive protein ( hs-CRP ) , interleukin-6 ( IL-6 ) and fibrinogen as well as soluble P-selectin ( sP-sel ) , prothrombin fragment 1 + 2 ( F1.2 ) and monocyte-platelet aggregates ( MPA ) were determined at study entry , after 3 , 6 and 12 months . RESULTS While clinical improvement , reflected by an increase of walking capacity , was observed upon SET , no lasting changes of markers of inflammation and platelet activation were found within the SET-group during the training period . Compared to the BMT-group no improvements of these markers were observed in response to training at any time point ( all p > 0.05 ) . CONCLUSION Regular SET added no further anti-inflammatory effect and had no effect on platelet activation when provided on top of BMT in PAD patients with intermittent claudication The influence of the xanthine derivative pentoxifylline ( ' Trental ' or BL191 ; Hoechst-Roussel ) on exercise tolerance was measured in 38 subjects with stable , severe to moderately severe , intermittent claudication who completed a r and omised , double-blind , placebo controlled , cross-over clinical trial . Patients received placebo tablets or 400 mg slow-release pentoxifylline tablets ( ' Trental 400 ' ) twice a day for one week , followed by three times daily for seven weeks , and then crossed over to receive the alternate preparation for another eight weeks . Claudication distance and walking distance were measured on a treadmill before starting treatment and again at four-week intervals during the trial . At the same times , red blood cell filterability , plasma fibrinogen concentration and blood viscosity , resting and post-ischemic calf muscle blood flow , and the resting and post-exercise ankle/brachial systolic pressure ratio were also measured . In this study , the observed effects of  pentoxifylline treatment were no greater than those of placebo , even though serum levels of pentoxifylline and its hydroxy-metabolite were within the anticipated range . This was shown by a ' therapeutic effect ratio ' of 0.98 for treadmill claudication distance and 0.96 for treadmill walking distance after within-patient analysis at the end of the cross-over ( where a ratio of 1.0 means the test drug and placebo effects are identical ) . These ratios have 95 % confidence limits of 0.72 - 1.34 and 0.74 - 1.25 , respectively Intermittent claudication impairs functional status and quality of life in many patients by limiting walking capacity . The aim of this study was to evaluate the effects of a 4-week treatment with prostagl and in E1 ( PGE1 ) , a drug inducing vasodilation and inhibiting platelet aggregation , on improving functional status and health-related quality of life in patients with disabling intermittent claudication . Forty-two untrained out patients ( 37 men and five women , mean age 64 ±8 years ) with intermittent claudication , and maximum walking distance ( MWD ) of at least 50 and no more than 200 m on treadmill test ( 5 % slope , 3 km/hr ) were r and omized to 4 weeks of double-blind treatment either with 60 mcg PGE1 daily given IV in 250 mL saline over a period of 2 hours ( 21 patients ) or placebo ( 250 mL saline , 21 patients ) . Treatment-free follow-up was completed 8 weeks after the final infusion . Pain free walking distance ( PFWD ) , MWD , and question naire evaluation were determined at baseline , after the 4-week treatment period , and at the end of the 8 weeks of the treatment-free follow-up period . After 4 weeks of treatment with PGE1 PFWD and MWD increased from 72 ±16 m to 135 ±33 m ( + 87 % , p<0.001 ) and from 140 ±30 m to 266 ±62 m ( + 90 % , p<0.001 ) , respectively . Analysis of the Walking Impairment Question naire responses in the PGE1 group at 4 weeks demonstrated significant improvements in the walking impairment score ( + 19 percentage points , p<0.001 ) , in the distance score ( + 25 percentage points , p<0.001 ) , in the speed score ( + 24 percentage points , p<0.001 ) , in the stair climbing score ( + 20 percentage points , p < 0.001 ) . The R AND survey responses showed improvements in physical function and bodily pain scores ( + 14 percentage points , p<0.001 , and + 15 percentage points , p<0.01 , respectively ) . After the treatment-free follow-up period of 8 weeks , increases in PFWD and MWD were maintained ( 113 ±26 m , + 57 % , p<0.001 , and 229 ±55 m , + 63 % , p<0.001 , respectively ) . Similarly , at the end of the treatment-free follow-up , the walking impairment score ( + 16 percentage points , p<0.001 ) , the distance score ( + 23 percentage points , p<0.001 ) , the speed score ( + 22 percentage points , p<0.001 ) , the stair climbing score ( + 18 percentage points , p<0.001 ) as well as the R AND physical function and bodily pain scores ( + 10 percentage points , p<0.001 , and + 13 percentage points , p<0.01 , respectively ) were still increased compared with baseline . No change from baseline was found in all the target parameters in the placebo group after 4 weeks of treatment and at the end of the treatment-free follow-up period . These data show that a 4-week treatment with PGE1 improves functional status and quality of life as well as treadmill performance in patients with disabling intermittent claudication as compared with placebo-treated patients . The improvements are also maintained for a period of 8 weeks beyond the end of the treatment . Additional studies are needed to determine the duration of functional benefits after the end of treatment Objective : To evaluate spatial and temporal gait characteristics and endurance late after stroke in people who had received two different walking exercises .  A secondary aim was to compare the outcomes in relation to length of time exercising and number of exercise occasions between the two . Design : A r and omized controlled trial . Setting : A private rehabilitation centre . Subjects : Thirty-nine people with stroke entered the study , and five dropped out . Interventions : Treadmill training versus walking outdoors . Main measures : Six-Minute Walk Test , a 10-metre walk test and pulse rates at rest and in activity . Results : There were significant differences in favour of the treadmill group in Six-Minute Walk Test distance ( P = 0.04 ) , Six-Minute Walk Test speed ( P = 0.03 ) , 10-m walking speed ( P = 0.03 ) , bilateral stride length ( right leg ; P = 0.009 , left leg ; P = 0.003 ) and step width ( P = 0.01 ) , indicating more symmetrical use of the legs in the treadmill group ( 1.02—1.10 m versus 0.97—0.92 m ) . There were no significant differences between groups in cadence ( P = 0.78 ) . All participants complied 100 % with their respective programmes . Exercise frequency did not differ between the groups but significantly less time was spent exercising on the treadmill compared with walking exercise outdoors ( 107 versus 316 minutes , P = 0.002 ) . There were no differences in use of assistive aids between the groups on arrival at the clinic or at departure . Conclusion : The results indicate that treadmill walking improves spatial and temporal gait characteristics more effectively than walking outdoors BACKGROUND This r and omized , double blind trial determined the short and long-term clinical and hemodynamic vasodilator effects induced by percutaneous applications of natural CO2 gas in patients with moderate Fontaine stage II . PATIENTS AND METHODS 62 patients with intermittent claudication ( 100 - 500 meters ) were r and omized to 18 consecutive days of CO2 treatment or placebo ( air ) . The gas fluids were applied at a constant temperature of 30 degrees C on pre-humidified skin . The effects of the treatment were evaluated by total distance walked ( primary criterion ) and hemodynamic and microcirculatory findings . Patients also answered a quality of life question naire . RESULTS The Str and ness test showed a significant increase in total distance walked ( + 131 meters , 66 % ; p = 0.001 ) and pain-free distance ( + 81 meters , 73 % ; p = 0.02 ) after 18 days of CO2 treatment . The improvement was maintained 3 and 12 months later . The systolic pressure index ( ABI ) increased by 37 % ( p = 0.001 ) 1 minute after treadmill walking and ABI recovery time decreased significantly by 38 % ( p = 0.002 ) . Microcirculatory findings showed an increase in systolic pressure of the great toe ( 13 % ; p < 0.0001 ) , in baseline pO2 ( 20 % ; p = 0.01 ) and in vasomotion ( 78 % ; p = 0.001 ) in the treatment group . The improvement in total walking distance was correlated with the increase in ABI and peripheral cutaneous oxygenation . Patients ' subjective assessment s corroborated the benefits . No significant change was observed in the placebo group . CONCLUSIONS This study demonstrates that 18 consecutive days of percutaneous CO2 treatment significantly increases walking distance in patients with moderate intermittent claudication . This effect , which was associated with an increase in peripheral systolic pressure and pO2 , is evidence of a better ability to withst and effort Pentoxifylline has been shown to improve treadmill walking distances under blinded , controlled conditions in patients with intermittent claudication . From the pooled data of a blinded , controlled , r and omized , multicenter trial , the data from all enrolled patients with severe claudication ( < 70 m on treadmill at base line ) were evaluated . The treadmill data from these more severely ill patients were analyzed separately as a " severe subset " ( placebo n = 17 ; pentoxifylline n=21 ) . No differences between the two treatment groups were observed in de mography , history , or baseline treadmill walking distances . The initial claudica tion distance ( ICD ) improved 68 % over baseline with pentoxifylline and 12 % with placebo ( p=.012 ) after twenty-four weeks of treatment . A new , derived efficacy variable was developed , " minimum distance walked , " which tended to minimize psychological effects on treadmill performance . Over sixteen to twenty-four weeks of treatment , the pentoxifylline group improved 49 % over baseline and the placebo group 3 % ( p=.019 ) , when the " minimum distance walked " measurement was used . In this controlled trial the subset of patients with severe intermittent claudication benefited from pentoxifylline therapy Ten patients with chronic intermittent claudication were included in a double-blind , r and omized cross-over study of placebo , propranolol 80 mg b.i.d . and metoprolol 100 mg b.i.d . , each given for two months . At the end of each treatment period , the patients were tested on a treadmill and the time to first claudication pain and to intolerable claudication pain was noted . There was no decrease in time to first claudication pain or to intolerable pain with either propranolol or metoprolol as compared to placebo PURPOSE To compare treadmill and shuttle walk tests for assessing functional capacity in patients with intermittent claudication , with respect to test-retest reliability , cardiovascular responses , and patient preferences . METHODS Patients with stable intermittent claudication ( N = 55 , ages 52 - 85 yr , median age 68 yr ) were recruited from the Sheffield Vascular Institute at the Northern General Hospital , Sheffield , UK . Each patient performed an incremental shuttle walk test , a constant-pace shuttle walk test , and a st and ardized treadmill test ( 3.2 km x h(-1 ) , 12 % gradient ) , each on three occasions . The incremental shuttle walk began at 3 km x h(-1 ) and increased by 0.5 km x h(-1 ) every minute , whereas the constant-pace shuttle walk was performed at the fixed pace of 4 km x h(-1 ) . Claudication distance ( CD ) , maximum walking distance ( MWD ) , heart rate ( HR ) , and blood pressure were assessed in each testing session . The patients also completed a test preference question naire . RESULTS CD and MWD for both shuttle walks were greater than the corresponding walking distances achieved in the treadmill test ( P < 0.001 ) . Average coefficients of variation for repeated incremental shuttle walk , constant-pace shuttle walk , and treadmill tests were 15.9 % , 21.1 % , and 18.7 % , respectively , for MWD , corresponding to average intraclass correlation coefficients of 0.87 , 0.82 , and 0.87 . Treadmill walking evoked greater increases in HR and blood pressure ( P < 0.001 ) , and fewer patients expressed a preference for it ( 24 vs 43 % for shuttle walking ) . CONCLUSION These findings indicated that shuttle walk testing exhibits similar test-retest reliability as treadmill testing , but that it evoked a lower level of cardiovascular stress and is preferred to treadmill testing by a large proportion of patients OBJECTIVE Walking training ( WT ) is an established treatment for patients with intermittent claudication ( IC ) . Abnormalities specific to diabetes , such as a relative preponderance of distal lesions and the contribution of microcirculatory disease , might well influence the results of WT . We compared changes in walking distance during WT in diabetic patients with those in nondiabetic control subjects . RESEARCH DESIGN AND METHODS In consecutive patients with limiting IC and proven peripheral vascular disease , 33 patients with diabetes were compared with 136 control subjects during a  half-year supervised WT program .  Walking parameters were determined every 2 months , while vascular parameters were obtained at the start and end of the program . RESULTS Of the 33 diabetic patients , 25 ( 76 % ) completed the program , as did 87 of the 136 ( 64 % ) control subjects . Thereafter , the symptom-free walking distance and the maximum walking distance ( MWD ) were significantly increased in diabetic patients from 142 + /- 30 to 339 + /- 57 m and from 266 + /- 39 to 603 + /- 52 m , respectively , and in control subjects from 126 + /- 8 to 400 + /- 39 m and from 292 + /- 18 to 628 + /- 36 m , respectively . The relative gain in MWD was 88 % greater in those with diabetes . The vascular parameters were comparable for both groups before and after WT . CONCLUSIONS WT is an effective treatment for IC , with a greater relative gain in diabetic patients In patients with intermittent claudication , exercise is associated with a marked increase in oxidative stress , likely responsible for systemic endothelial perturbation . In 31 claudicant patients , we assessed the effect of vitamin C administration on the acute changes induced by maximal and submaximal exercise in endothelium-dependent , flow-mediated dilation ( FMD ) , and in plasma levels of thiobarbituric acid-reactive substances ( TBARS ) and soluble intercellular adhesion molecule-1 ( sICAM-1 ) . In 16 claudicants , maximal exercise reduced FMD ( from 8.5+/-0.9 to 3.7+/-0.8 % , P<0.01 ) , and increased plasma levels of TBARS ( from 1.93+/-0.06 to 2.22+/-0.1 nmol/ml , P<0.02 ) and of sICAM-1 ( from 282+/-17 to 323+/-19 ng/ml , P<0.01 ) . In eight of these patients , r and omized to vitamin C ,  exercise-induced changes in FMD and biochemistry were abolished . This beneficial effect was not observed in the eight patients r and omized to saline . In 15 patients , who walked until the onset of claudication pain ( submaximal exercise ) , and in ten control subjects , who performed maximal exercise , no changes were observed with exercise . Thus , in claudicants , vitamin C prevents the acute , systemic impairment in endothelial function induced by maximal exercise . This finding provides a rationale for trials investigating antioxidant therapy and cardiovascular risk in patients with intermittent claudication BACKGROUND We report in this paper the findings of a pooled analysis of 3 previously published studies undertaken in Germany , France and Belgium to assess the effects of naftidrofuryl on the quality of life of patients with intermittent claudication . METHODS A total of 754 patients were r and omised in the 3 studies , 709 of whom ( 358  naftidrofuryl  , 351  placebo )  were available for the primary intention-to-treat analysis . The primary outcome variable was the change in the disease-related limitation of the quality of life as measured by the CLAU-S question naire . This instrument which has been vali date d in an international study , comprises 47 questions covering 5 dimensions : " daily living " , " pain " , " social life " , " disease specific anxiety " and " mood " . RESULTS A multivariate analysis of covariance adjusted for baseline values , study effect and first order study treatment interaction , demonstrated the global superiority of naftidrofuryl over placebo ( p<0.001 ) . A separate covariance analysis for the 5 dimensions showed highly significant differences for " daily living " , " pain " , " social life " and " mood " ( all p<0.01 ) . CONCLUSIONS In conclusion , this pooled analysis has shown that naftidrofuryl can significantly improve the quality of life of patients with intermittent claudication . These findings , taken together with evidence from previous studies that it improves treadmill walking distances , suggest that naftidrofuryl can play a useful role in the treatment of this condition Objectives To assess the effect of pain-free treadmill training on red blood cell deformability and walking distance in patients with claudication . Design R and omized-controlled trial of exercise training . Setting Patients were recruited from the primary care , vascular outpatient clinic . Patients A total of 60 patients with peripheral arterial occlusive disease ( stage II according to Leriche-Fontaine ) were r and omized into the treadmill program or a control group .  Fifty-five patients completed the study ( 27 in the exercising group and 28 in the control group ) . Interventions Patients in the exercising group were walking on the treadmill 3 times a week for 3 months . Each session consisted of 1 hour repetitive walking [ performed to 85 % of the pain-free walking time ( PFWT ) ] was supervised by a qualified physiotherapist . Main Outcome Measurements Changes in erythrocyte deformability and treadmill walking performance ( PFWT , maximal walking time ) were assessed in both groups before the study and after 3 months . Results After 3 months of treadmill training , red blood cell deformability in the exercising group significantly increased ( P<0.01 ) . No significant changes were seen in the erythrocyte deformability in the control group . PFWT was prolonged by 102 % from 191±34 to 386±60 seconds ( P<0.01 ) , and maximal walking time increased by 49 % from 438±62 to 656±79 seconds ( P<0.01 ) in the exercising group , whereas these changes were insignificant in the control group . Conclusions A significant improvement of walking ability over 3 months of pain-free treadmill training is associated with a significant increase in red cell deformability in patients with claudication OBJECTIVE to assess quality of life ( QOL ) in patients with intermittent claudication . DESIGN a prospect i ve , open study . MATERIAL AND METHOD one hundred and fifty-one consecutive claudicants ( 100 men , 51 women ) , and 161 healthy controls ( 70 men and 91 women ) completed an adapted version of the World  Health Organisation  Quality of Life Assessment Instrument-100  . RESULTS patients scored significantly worse on the domains Physical health and Level of independence , as well as on the facets Pain and discomfort , Energy and fatigue , Mobility , Activities of daily living , Dependence on medication and treatments , Working capacity , Negative feelings , Recreation and leisure and Overall QOL and general health . Increasing disease to incapacitating claudication affected only the facet Mobility and the domain Level of independence . CONCLUSION QOL in patients with intermittent claudication is reduced in many aspects . Where co-morbidity seems to affect QOL strongly , the effect of walking distance on QOL might be small . These findings may justify a reserved attitude towards invasive , even minimally invasive treatment of these patients After a 3-month , single-blind , run-in period , 151 patients with intermittent claudication were r and omly allocated to receive the antiplatelet agent ticlopidine ( 250 mg twice per day ) or an identical placebo .  One hundred and twenty patients completed the double-blind phase of the trial , which lasted 21 months . The primary analysis was performed according to the " intention-to-treat principle " in all 151 enrolled patients . There was , continuing on from the third month after r and omization , a progressive and sustained improvement of the pain-free and maximum walking distances in the two treatment groups that was significantly greater in the ticlopidine group . The ankle-arm systolic blood pressure ratio at rest and after exercise increased in a significant manner in the ticlopidine group only . In a secondary analysis , with exclusion of 25 patients because of protocol violations at selection , consistently significant differences in favor of the ticlopidine group were still observed for maximum walking distance and systolic ankle-arm blood pressure ratio , both at rest and after exercise . No major side effects were reported in the treated group . It is concluded that long-term treatment with ticlopidine improves walking ability and ankle systolic blood pressure in patients with claudication OBJECTIVES To investigate the effects of a 24-week program of upper- and lower-limb aerobic exercise training on walking performance in patients with symptomatic peripheral arterial disease ( PAD ) and to study the mechanisms that could influence symptomatic improvement . METHODS After approval from the North Sheffield Local Research Ethics Committee , 104 patients ( median age , 69 years ; range , 50 to 85 years ) with stable PAD were r and omized into an upper- or lower-limb aerobic exercise training group ( UL-Ex or LL-Ex ) , or to a nonexercise training control group . Training was performed twice weekly for 24 weeks at equivalent relative exercise intensities . An incremental arm- and leg-crank test ( ACT and LCT ) to maximum exercise tolerance was performed before and at 6 , 12 , 18 , and 24 weeks of the intervention to determine peak oxygen consumption ( VO(2 ) ) . Walking performance , defined as the claudicating distance ( CD ) and maximum walking distance ( MWD ) achieved before intolerable claudication pain , was assessed at the same time points by using a shuttle-walk protocol . Peak blood lactate concentration , Borg ratings of perceived exertion ( RPE ) and pain category ratio ( CR-10 ) were recorded during all assessment s. RESULTS CD and MWD increased over time ( P < .001 ) in both training groups . At 24 weeks , CD had improved by 51 % and 57 % , and MWD had improved by 29 % and 31 % ( all P < .001 ) in the UL-Ex and LL-Ex groups , respectively . An increase in peak heart rate at MWD in the UL-Ex group ( 109 + /- 4 vs 115 + /- 4 beats/min ; P < .01 ) and LL-Ex group ( 107 + /- 3 vs 118 + /- 3 beats/min ; P = .01 ) was accompanied by an increase in the amount of pain experienced in both groups ( P < .05 ) , suggesting that exercising patients could tolerate a higher level of cardiovascular stress and an increased intensity of claudication pain before test termination after training . Patients assigned to exercise training also showed an increase in LCT peak VO2 at the 24-week time point in relation to baseline ( P < .01 ) and control patients ( P < .01 ) , whereas ACT peak VO2 was only improved in the UL-Ex group ( P < .05 ) . CONCLUSIONS Our results suggest that a combination of physiologic adaptations and improved exercise pain tolerance account for the improvement in walking performance achieved through upper-limb aerobic exercise training in patients with PAD . Furthermore , that both arm- and leg-crank training could be useful exercise training modalities for improving cardiovascular function , walking performance , and exercise pain tolerance in patients with symptomatic PAD Background — Claudication is a common and disabling symptom of peripheral artery disease that can be treated with medication , supervised exercise ( SE ) , or stent revascularization ( ST ) . Methods and Results — We r and omly assigned 111 patients with aortoiliac peripheral artery disease to receive 1 of 3 treatments : optimal medical care ( OMC ) , OMC plus SE , or OMC plus ST . The primary end point was the change in peak walking time on a grade d treadmill test at 6 months compared with baseline . Secondary end points included free-living step activity , quality of life with the Walking Impairment Question naire , Peripheral Artery Question naire , Medical Outcomes Study 12-Item Short Form , and cardiovascular risk factors . At the 6-month follow-up , change in peak walking time ( the primary end point ) was greatest for SE , intermediate for ST , and least with OMC ( mean change versus baseline , 5.8±4.6 , 3.7±4.9 , and 1.2±2.6 minutes , respectively ; P<0.001 for the comparison of SE versus OMC , P=0.02 for ST versus OMC , and P=0.04 for SE versus ST ) . Although disease-specific quality of life as assessed by the Walking Impairment Question naire and Peripheral Artery Question naire also improved with both SE and ST compared with OMC , for most scales , the extent of improvement was greater with ST than SE . Free-living step activity increased more with ST than with either SE or OMC alone ( 114±274 versus 73±139 versus −6±109 steps per hour ) , but these differences were not statistically significant . Conclusions — SE results in superior treadmill walking performance than ST , even for those with aortoiliac peripheral artery disease . The contrast between better walking performance for SE and better patient-reported quality of life for ST warrants further study . Clinical Trial Registration — URL : http:// clinical trials.gov/ct/show/NCT00132743?order=1 . Unique identifier : NCT00132743 The clinical significance of drugs improving red cell deformability is not confirmed . We established the effect of physical training alone and combined with flunarizine on intermittent claudication . Twelve patients aged 48 - 73 years were included in the study .  Pain-free walking distance on treadmill , ankle/arm pressure ratio and transcutaneous oxygen tension were measured . Walking distance increased significantly ( p less than 0.05 ) by 130 % from 75 m to 173 m during the first year when the patients were on programmed physical training .  Ankle/arm pressure ratio also increased significantly ( p less than 0.05 ) from 0.46 to 0.55 during this period . The increase in walking distance ceased when the programmed physical training was discontinued for 6 months . During the following double-blind , cross-over medication period the patients were given flunarizine 5 mg b.i.d . and placebos in r and omized order for 3 months each . They also continued the same programmed physical training as during the first year . Walking distance increased , albeit not significantly , with time to 392 m after the second medication period . There was no difference , however , between flunarizine and placebo .  Ankle/arm pressure ratio was of the same magnitude as at the beginning of the trial . Oxygen tension measurements did not give consistent results . We conclude that programmed physical training increased walking distance as a function of time . Flunarizine had no effect on the performance of patients with intermittent claudication Expansion of the capillary network , or angiogenesis , occurs following endurance training . This process , which is reliant on the presence of VEGF ( vascular endothelial growth factor ) , is an adaptation to a chronic mismatch between oxygen dem and and supply . Patients with IC ( intermittent claudication ) experience pain during exercise associated with an inadequate oxygen delivery to the muscles . Therefore the aims of the present study were to examine the plasma VEGF response to acute exercise , and to establish whether exercise training alters this response in patients with IC . In Part A , blood was collected from patients with IC ( n=18 ) before and after ( + 20 and + 60 min post-exercise  ) a maximal walking test to determine the plasma VEGF response to acute exercise .  VEGF was present in the plasma of patients ( 45.11+/-29.96 pg/ml ) and was unchanged in response to acute exercise . Part B was a training study to determine whether exercise training altered the VEGF response to acute exercise . Patients were r and omly assigned to a treatment group ( TMT ; n=7 ) that completed 6 weeks of high-intensity treadmill training , or to a control group ( CON ; n=6 ) . All patients completed a maximal walking test before and after the intervention , with blood sample s drawn as for Part A. Training had no effect on plasma VEGF at rest or in response to acute exercise , despite a significant increase in maximal walking time in the TMT group ( 915+/-533 to 1206+/-500 s ; P=0.009 ) following the intervention . The absence of a change in plasma VEGF may reflect altered VEGF binding at the endothelium , although this can not be confirmed by the present data The Claudication :  Exercise vs Endoluminal Revascularization ( CLEVER ) Study is a prospect i ve multicenter r and omized clinical trial design ed to compare the relative clinical and cost-effectiveness of invasive revascularization with stents to supervised exercise rehabilitation in a cohort with moderate to severe claudication due to aortoiliac insufficiency . The study is currently enrolling at twenty-eight sites in the US and Canada . Enrollment of 217 participants is planned , with data collected at baseline , six months , and 18 months . The primary study endpoint is maximum walking duration ( MWD ) on a grade d treadmill test ; secondary endpoints include community-based walking , markers of cardiovascular disease risk ( body mass index , waist circumference , blood pressure , lipid profile , glucose tolerance , and plasma fibrinogen ) , health-related quality of life , and cost effectiveness . There are currently sixty r and omized participants ; recruitment is projected to end in July 2010 and final study results reported in June 2012 OBJECTIVE / BACKGROUND Intermittent claudication ( IC ) is associated with a reduction in physical activity ( PA ) and a more rapid functional decline leading to a higher mortality rate compared with healthy individuals . Supervised exercise therapy ( SET ) is known to increase the walking capacity of patients with IC . However , it is unclear whether SET increases PA . The aim of this study was to investigate the effect of SET on PA levels and ambulatory activities in patients with IC . METHODS Patients newly diagnosed with IC were requested to wear an activity monitor 1 week prior to and 1 week immediately after 3 months of SET . The primary outcome was the percentage of patients meeting the minimum recommendations of PA ( American College of Sports Medicine [ACSM]/American Heart Association [ AHA ] recommendation for public health of ≥ 67 metabolic equivalents [METs]/min/day , in bouts of ≥ 10 min ) at baseline and after 3 months of SET . Additionally , daily PA level ( METs/min ) , duration of ambulatory activities , daily number of steps , pain free walking distance ( PFWD ) , maximal walking distance ( MWD ) , and Short Form Health Survey ( SF-36 ) health surveys were compared before and after SET . RESULTS Data from 41 participants were available for analysis . A higher number of participants met the ACSM minimum recommendation for PA at the 3 month follow up ( baseline : 43 % ; 3 months : 63 % ; p = .003 ) . Despite significant increases in PFWD ( baseline : 210 m ; 3 months : 390 m ; p = .001 ) , MWD ( baseline : 373 m ; 3 months : 555 m ; p = .002 ) and physical functioning score ( SF-36 )  following SET , no increase in the mean daily PA level was found ( 395 ± 220 vs. 411 ± 228 METs/min ; p = .43 ) . Furthermore , the total number of steps and time spent in ambulatory activities did not change following SET . CONCLUSION Three months of SET for IC leads to more patients meeting the ACSM/AHA public health minimum recommendations for PA . Assessment of PA could be incorporated as an outcome parameter in future research comparing different treatment modalities for peripheral arterial disease BACKGROUND Treatment for claudication that is due to aortoiliac peripheral artery disease ( PAD ) often relies on stent revascularization ( ST ) . However , supervised exercise ( SE ) is known to provide comparable short-term ( 6-month ) improvements in functional status and quality of life . Longer-term outcomes are not known . OBJECTIVES The goal of this study was to report the longer-term ( 18-month ) efficacy of SE compared with ST and optimal medical care ( OMC ) . METHODS Of 111 patients with aortoiliac PAD r and omly assigned to receive OMC , OMC plus SE , or OMC plus ST , 79 completed the 18-month clinical and treadmill follow-up assessment . SE consisted of 6 months of SE and an additional year of telephone-based exercise counseling . Primary clinical outcomes included objective treadmill-based walking performance and subjective quality of life . RESULTS Peak walking time improved from baseline to 18 months for both SE ( 5.0 ± 5.4 min ) and ST ( 3.2 ± 4.7 min ) significantly more than for OMC ( 0.2 ± 2.1 min ; p < 0.001 and p = 0.04 , respectively ) . The difference between SE and ST was not significant ( p = 0.16 ) . Improvement in claudication onset time was greater for SE compared with OMC , but not for ST compared with OMC . Many disease-specific quality -of-life scales demonstrated durable improvements that were greater for ST compared with SE or OMC . CONCLUSIONS Both SE and ST had better 18-month outcomes than OMC . SE and ST provided comparable durable improvement in functional status and in quality of life up to 18 months . The durability of claudication exercise interventions merits its consideration as a primary PAD claudication treatment PURPOSE This study aim ed to investigate the acute effect of intermittent walking exercise ( WE ) on blood pressure ( BP ) responses in patients with intermittent claudication ( IC ) . Secondly , this study aim ed to gain improved insight into the physiological mechanisms controlling BP regulation after intermittent WE in this patient group . METHODS Twenty patients with IC participated in two experimental sessions in a r and om order , as follows : WE ( 15 × 2-min bouts of WE interpolated with 2-min rest intervals ) and control ( st and ing rest on a treadmill for 60 min ) . BP , cardiac output ( CO : CO2 rebreathing ) , and cardiovascular autonomic modulation ( spectral analysis of HR variability ) were assessed before and after both experimental sessions during supine rest , and stroke volume ( SV ) and systemic vascular resistance ( SVR ) were calculated . Data were analyzed using two-way ANOVA . RESULTS WE  decreased systolic , diastolic , and mean BP , with net effects of -13 ± 2 , -5 ± 2 , and -7 ± 2 mm Hg versus control , respectively ( all P < 0.05 ) . WE also decreased SV ( -5.62 ± 1.97 mL , P < 0.05 ) and CO ( -0.05 ± 0.13 L·min(-1 ) , P < 0.05 ) versus preintervention and prevented the observed increase in SVR in the control condition ( + 4.2 ± 1.4 U , P < 0.05 ) . HR showed a decrease ( P < 0.05 ) , consistent with evidence of increased vagal modulation , in the control condition . BP measurements over the subsequent 24 h were similar between experimental conditions . CONCLUSIONS In patients with IC , WE induced a postexercise hypotension response that had a significant magnitude versus control but was not maintained over the next 24 h of daily activities . The acute postexercise hypotension response was mediated by a decrease in CO and SV , which was not compensated by an augmentation of SVR , as observed in the control arm of the study In this multicenter trial 169 patients with chronic intermittent claudication due to obstructive peripheral vascular disease were r and omized in a double- blind fashion into two parallel groups receiving either 250 mg ticlopidine or placebo , twice daily . At entry , the two groups ( 83 ticlopidine , 86 placebo ) were well matched for the major clinical features apart from an excess of women in the ticlopidine group . At six months , 167 patients were alive , 2 having died of malignant disease ( 1 from each group ) . At this stage , 39 patients from the ticlo pidine group and 29 from the placebo group ( p = 0.04 ) had increased their walking distance by more than 50 % of baseline values . For the groups as a whole pain-free and total walking distance were greater in the ticlopidine group than in the placebo group ( 194 vs 124 meters , p = 0.03 and 236 vs 170 meters , p = 0.04 , respectively ) . Two patients from the ticlopidine group vs 9 patients from the placebo group ( p = 0.03 ) developed significant cardiovascular events during the study . These results indicate that ticlopidine has a beneficial effect both in the treatment of the symptoms and the prevention of vascular complica tions in patients with intermittent claudication Objective . Current guidelines for treatment of intermittent claudication ( IC ) do not include a specific recommendation for the intensity of exercise therapy . Thus , the purpose of this study was to determine the relative effectiveness of high versus low intensity exercise for patients with IC , and further to study the effect of such training on blood flow to the legs during exercise . Design . The effect of eight weeks of supervised endurance training was examined in 16 patients with IC . The patients were r and omly assigned to training at intensities corresponding to either 60 % or 80 % of their peak oxygen consumption ( VO2peak ) , respectively . Results . VO2peak and time to exhaustion increased significantly ( 9 % and 16 % , respectively ) more in the high intensity group ( p<0.05 ) . Blood flow to the legs did not change after training in any of the groups . Conclusion . High intensity training gave larger improvements in VO2peak and time to exhaustion than low intensity training . As blood flow did not change after the exercise program , it is likely that the observed different increase of VO2peak was due to changed mitochondrial oxidative capacity and /or skeletal muscle diffusive capacity The aim of the present study was to evaluate whether beta blockade presents a risk of intermittent claudication and how it affects the walking capacity and lower limb haemodynamics in patients with intermittent claudication . The study was divided into six parts : A case-control study with 55 pairs , cases with hypertension and intermittent claudication and controls with hypertension only , matched for age , sex , place of residence , and time of examination , all without coronary heart disease , which is a known confounding factor . An open controlled study on the effect of withdrawal of beta blockade on walking capacity of 28 patients with intermittent claudication . A placebo-controlled double-blind crossover study on the effect of antihypertensive treatment on the walking capacity of 14 patients with intermittent claudication . Three placebo-controlled double-blind crossover studies on the effect of propranolol , metoprolol , pindolol , labetalol , and /or methyldopa on calf blood flow in 34 hypertensive subjects without peripheral arterial disease and in altogether 21 patients with intermittent claudication .  Walking capacity was measured on a treadmill . Calf blood flow was measured with strain gauge plethysmography by the venous occlusion technique . The case-control comparison showed that beta blockers were used as often by patients with intermittent claudication as by controls . Walking capacity increased during the first month of the open controlled study irrespective of whether the beta blockade was withdrawn or continued . There was no difference in this respect between the various types of beta blockers . Antihypertensive treatment with metoprolol or methyldopa did not affect walking capacity . Resting calf blood flow was unaffected by propranolol or metoprolol , regardless of the presence or absence of peripheral arterial disease , as well as by pindolol , labetalol , or methyldopa in patients with intermittent claudication . During reactive hyperaemia , propranolol and metoprolol reduced flow in patients without peripheral arterial disease . Propranolol also reduced hyperaemic blood flow in the limb with less or no symptoms in patients with intermittent claudication . None of the active drugs decreased the hyperaemic flow consistently in the limb with the stronger symptoms . In a comparison of haemodynamic effects between the drugs , calf blood flow at rest was higher after pindolol than after propranolol and hyperaemic flow of the better limb was higher after pindolol than after propranolol and labetalol . ( ABSTRACT TRUNCATED AT 400 WORDS
Data showed improvements secondary to exercise in ' physical function ' and ' general health ' .
The other domains - ' role physical ' , ' bodily pain ' , ' vitality ' , ' social ' , ' role emotional ' , and ' mental health ' - did not show improvement at six months .
Although results showed significant heterogeneity between trials , population s and outcomes were comparable overall , with findings relevant to the claudicant population .
High- quality evidence shows that exercise programmes provided important benefit compared with placebo or usual care in improving both pain-free and maximum walking distance in people with leg pain from IC who were considered to be fit for exercise intervention .
Exercise did not improve ABI , and we found no evidence of an effect of exercise on amputation or mortality .
Exercise may improve quality of life when compared with placebo or usual care .
BACKGROUND Exercise programmes are a relatively inexpensive , low-risk option compared with other , more invasive therapies for treatment of leg pain on walking ( intermittent claudication ( IC ) ) .
This is the fourth up date of a review first published in 1998 .
OBJECTIVES Our goal was to determine whether an exercise programme was effective in alleviating symptoms and increasing walking treadmill distances and walking times in people with intermittent claudication .
Secondary objectives were to determine whether exercise was effective in preventing deterioration of underlying disease , reducing cardiovascular events , and improving quality of life .