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#307 Walking it off: How effective is exercise for management of peripheral artery disease?


CLINICAL QUESTION
What is the evidence for exercise in the management of patients with peripheral artery disease (PAD)?


BOTTOM LINE
In patients with PAD, exercise therapy improves maximum walking distance and pain-free walking distance by up to ~200 meters over 2 to 78 weeks compared to usual care. No benefit has been demonstrated for amputation or mortality. The most commonly studied exercise is supervised walking 2-3 times per week for 30-60 minutes, although other supervised activities (example resistance training) may be beneficial in those who cannot tolerate walking.



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EVIDENCE
  • Results statistically significant unless otherwise noted.
  • Exercise versus usual care +/- exercise advice in patients with PAD (mean age 67, 67% male, mean Ankle Brachial Index 0.67, pain free walking distance 110-266m):1
    • Four systematic reviews, 9-41 randomized controlled trials (RCTs), 391-1938 patients:1-4
      • Pain-free walking distance improvement: 23 to 174 meters over 2 to 78 weeks.
      • Maximum walking distance improvement: 41 to 218 meters over 2 to 78 weeks.
      • Improvement likely clinically relevant.5,6
    • Two systematic reviews, 1-8 RCTs, 177-937 patients:1,4
      • No difference in mortality,4 amputation, or adverse events (example cardiovascular events) at up to 78 weeks.
  • Different types of exercise:
    • Network Meta-analysis, 42 RCTs, 3515 patients:7
      • Maximum walking distance:
        • Improved with supervised and home-based exercise (187m and 89m respectively) at <1 year.
        • Only supervised programs continued to demonstrate benefit (201m) between 1-2 years.
    • Systematic review, 10 RCTs, 527 patients:
      • Supervised walking not superior to other supervised exercise (example resistance training, Nordic walking, combination exercises, arm ergometry, or cycling) for pain-free or maximum walking distance.8
      • Limitations: Based on small sample sizes, low quality evidence.
    • RCT, 305 patients: Home-based exercise inducing maximal pain superior to exercise inducing no pain (34.5m versus -6.4m).5
      • Limitations: Heterogeneous individual response.
      • Systematic reviews: No difference between exercising with no-to-mild pain versus moderate-to-maximal pain.1
CONTEXT
  • Most common recommendations included supervised walking 2-3 times per week for 30-60 minutes.4,9
  • Patient understanding of physical activity for PAD should be explored:
    • 63% identified walking as the primary etiology for their pain, 90% thought walking would worsen symptoms.10


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Authors do not have any conflicts of interest to declare.