title: Effects of a Home-Based Walking Intervention on Mobility and Quality of Life in People With Diabetes and Peripheral Arterial Disease Diabetes status differentiates endothelial function and plasma nitrite response to exercise stress in peripheral arterial disease following supervised training. Longitudinal predictors of reduced mobility and physical disability in patients with type 2 diabetes: the Fremantle Diabetes Study. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Effects of home versus supervised exercise for patients with intermittent claudication. Walking training for intermittent claudication in diabetes. Influence of diabetes on mortality in acute myocardial infarction: data from the GISSI-2 study. Peripheral arterial disease in diabetic and nondiabetic patients: a comparison of severity and outcome. Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication.
abstract: OBJECTIVE Determine the efficacy of a home-based walking intervention to improve walking ability and quality of life in people with diabetes and peripheral arterial disease ( PAD ) . RESEARCH DESIGN AND METHODS We conducted a r and omized , controlled , single-blind trial within university-affiliated clinics in our local community . We r and omized 145 participants ( 45 women ) with diabetes and PAD to our intervention — a 6-month behavioral intervention targeting levels of readiness to engage in routine walking for exercise — versus attention control . Our primary outcome was 6-month change in maximal treadmill walking distance . Secondary outcomes included 3-month change in maximal walking distance , lower limb function ( i.e. , walking impairment scores ) , quality of life ( Medical Outcomes Short Form Survey ) , exercise behaviors , depressive symptoms , and self-efficacy at 3 and 6 months . RESULTS The mean age of participants was 66.5 ( SD 10.1 ) years . Intervention and control groups did not differ significantly in 6-month change in maximal treadmill walking distance ( average [ SE ] 24.5 [ 19.6 ] meters vs. 39.2 [ 19.6 ] meters ; P = 0.60 ) . Among secondary outcomes , for the intervention and control groups , respectively , average walking speed scores increased by 5.7 [ 2.2 ] units and decreased by 1.9 [ 2.8 ] units ( P = 0.03 ) ; the mental health quality of life subscale score increased by 3.2 [ 1.5 ] and decreased by 2.4 [ 1.5 ] units ( P = 0.01 ) . CONCLUSIONS A home-based walking intervention did not improve walking distance but did improve walking speed and quality of life in people with diabetes and PAD . Clinicians should consider recommending home-based walking therapy for such patients AIMS To determine if type 2 diabetes mellitus ( T2D ) differentiates endothelial function and plasma nitrite response ( a marker of nitric oxide bioavailability ) during exercise in peripheral arterial disease ( PAD ) subjects prior to and following 3 months supervised exercise training ( SET ) . METHODS In subjects with T2D+PAD ( n = 13 ) and PAD-only ( n = 14 ) , endothelial function was measured using brachial artery flow-mediated dilation . On a separate day , venous blood draws were performed at rest and 10 min following a symptom-limited grade d treadmill test ( SL-GXT ) . Plasma sample s were snap-frozen for analysis of nitrite by reductive chemiluminescence . All testing was repeated following 3 months of SET . RESULTS Prior to training both groups demonstrated endothelial dysfunction , which was correlated with a net decrease in plasma nitrite following a SL-GXT ( p ≤ 0.05 ) . Following SET , the PAD-only group demonstrated an improvement in endothelial function ( p ≤ 0.05 ) and COT ( p ≤ 0.05 ) , which was related to a net increase in plasma nitrite following the SL-GXT ( both p ≤ 0.05 ) . The T2D+PAD group had none of these increases . CONCLUSIONS T2D in the presence of PAD attenuated improvements in endothelial function , net plasma nitrite , and COT following SET . This suggests that T2D maybe associated with an inability to endogenously increase vascular NO bioavailability to SET OBJECTIVE The purpose of this study was to determine longitudinal predictors of impaired mobility and physical disability in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS We studied patients with type 2 diabetes who participated in a prospect i ve , community-based study .  A wide range of baseline variables were examined to determine whether they predicted future difficulties with 1 ) mobility and 2 )  basic activities of daily living ( ADLs ) in patients free of ADLs difficulty at baseline . To study mobility impairment , subjects with baseline mobility problems were also excluded . RESULTS After an average 4.6 + /- 2.3 and 4.8 + /- 2.3 years of follow-up in 818 and 934 patients , respectively , 28.5 % of subjects had developed new mobility impairment and 18.1 % had developed new ADL disability . In Cox proportional hazards models , the risk of mobility impairment was significantly increased by older age ( 6%/year ) , peripheral neuropathy ( 40 % increase ) , stroke history ( 123 % ) , insulin treatment ( 117 % ) , albuminuria , and arthritis ( 82 % ) ; taking exercise and being married lowered the risk ( by 39 and 32 % , respectively ) . The risk of new ADL disability was increased by baseline mobility problems ( 222 % increase ) , stroke ( 92 % ) , claudication ( 67 % ) , and depression ( 41 % ) and was also influenced by age , smoking , lack of exercise , non-fluency in English , and indigenous Australian ethnicity . CONCLUSIONS Both mobility impairment and ADL disability in type 2 diabetes have multiple causes that are due to diabetes complications and common comorbidities . The specific causes of each functional problem are largely distinct , and different approaches may be required to prevent their onset or progression OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity 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 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 OBJECTIVES This study was conducted to determine the role of insulin-dependent and noninsulin-dependent diabetes in the prognosis of patients after myocardial infa rct ion and treatment with fibrinolytic agents .  BACKGROUND Several studies have shown that diabetic patients have a high mortality rate after acute myocardial infa rct ion . However , the impact of diabetes on survival in patients treated with fibrinolytic agents  is still undefined . It is also not known whether the type of diabetes or gender affects prognosis . METHODS We analyzed prevalence and prognostic significance of a history of diabetes in patients enrolled in the GISSI-2 study , all of whom received fibrinolytic agents .  The incidence of deaths in the hospital and at 6 months after study entry was computed for patients without diabetes and for insulin-dependent and noninsulin-dependent diabetic patients ; relative risks were evaluated by univariate and multivariate analysis . RESULTS Information on diabetic status was available for 11,667 patients , 94.2 % of those r and omized in the GISSI-2 study . The prevalence of diabetes was higher in women than in men ( 8.75 % vs. 1.85 % , p < 0.01 for insulin-dependent and 23.7 % vs. 13.8 % , p < 0.01 for noninsulin-dependent diabetic patients ) . The type of fibrinolytic agent did not affect mortality rates ; the increase in in-hospital mortality of diabetic patients was moderate and similar for men with insulin- and noninsulin-dependent diabetes ( 8.7 % and 10.1 % , respectively , vs. 5.8 % in nondiabetic patients ) ; in women , mortality was markedly higher for insulin-dependent and only slightly higher for noninsulin-dependent diabetic patients ( 24.0 % and 15.8 % , respectively , vs. 13.9 % for nondiabetic patients ) . The adjusted relative risks were 1.9 ( 95 % confidence interval 1.2 to 2.9 ) for insulin-dependent diabetic women and 1.4 ( 95 % confidence interval 1.1 to 1.8 ) for noninsulin-dependent diabetic men . The mortality rate after discharge showed a similar gender difference , and in insulin-dependent diabetic women , prognosis was ominous even in the absence of left ventricular damage before discharge . CONCLUSIONS A history of diabetes is associated with a worse prognosis after myocardial infa rct ion , even in patients treated with fibrinolytic agents . Gender and type of diabetes appear to be critical in affecting survival . In men , both insulin-dependent and noninsulin-dependent diabetes are associated with a moderately higher mortality rate ;  in women , insulin-dependent diabetes is , in itself , a strong risk factor for death after myocardial infa rct ion OBJECTIVE The aim of this study was to quantify the distribution of peripheral arterial disease in the diabetic and nondiabetic population attending for angiography and to compare severity and outcome between both groups of patients . RESEARCH DESIGN AND METHODS R  and omly selected lower-extremity angiograms were examined according to the Bollinger system . Patient demographics and medical history were recorded and case notes were examined to determine which patients later underwent a revascularization procedure or amputation and which patients had died . RESULTS A total of 136 arteriograms obtained between 1992 and 1996 were analyzed . The age ( mean + /- SD ) of the patients was 64.7 + /- 10.8 years . Diabetic patients ( 43 % ) and nondiabetic patients were of similar age ( 63.9 + /- 10.4 vs. 65.3 + /- 11.1 years , P = 0.43 ) , with a similar history of smoking ( 81.0 vs. 76.9 % , P = 0.26 ) , ischemic heart disease ( 41.4 vs. 37.2 % , P = 0.54 ) , and hypercholesterolemia ( 24.4 vs. 30.8 % , P = 0.48 ) . However , there were a greater proportion of hypertensive patients in the diabetic group ( 63.8 vs. 39.7 % , P = 0.006 ) . Diabetic patients had greater severity of arterial disease in the profunda femoris and all arterial segments below the knee ( P = 0.02 ) . A greater number of amputations occurred in the diabetic group : diabetic patients were five times more likely to have an amputation ( 41.4 vs. 11.5 % , odds ratio [ OR ] 5.4 , P < 0.0001 ) . Mortality was higher in the diabetic group ( 51.7 vs. 25.6 % , OR 3.1 , P = 0.002 ) , and diabetic patients who died were younger at presentation than nondiabetic patients ( 64.7 + /- 11.4 vs. 71.1 + /- 8.7 years , P = 0.04 ) . CONCLUSIONS In patients with peripheral arterial disease , diabetic patients have worse arterial disease and a poorer outcome than nondiabetic patients 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
target: On the contrary , the largest study of this review did not demonstrate any adverse effect of  DM on MWD and FWD after SET .
  In conclusion , the data evaluating the effects of DM on SET were inadequate to determine if DM impairs the exercise response .
background: Some believe that certain patients with intermittent claudication may be unsuitable for supervised exercise therapy ( SET ) , based on the presence of comorbidities and the possibly increased risks .
  We conducted a systematic review ( MEDLINE , EMBASE and CENTRAL ) to summarize evidence on the potential influence of diabetes mellitus ( DM ) on the response to SET .