title: Increasing exercise tolerance of persons limited by claudication pain using polestriding. Incidence, natural history and cardiovascular events in symptomatic and asymptomatic peripheral arterial disease in the general population. Corridor-based functional performance measures correlate better with physical activity during daily life than treadmill measures in persons with peripheral arterial disease. The impact of short term supervised and home-based walking programmes on heart rate variability in patients with peripheral arterial disease. Hospital vs Home-Based Exercise Rehabilitation for Patients with Peripheral Arterial Occlusive Disease Efficacy of Quantified Home-Based Exercise and Supervised Exercise in Patients With Intermittent Claudication: A Randomized Controlled Trial Effects of a Home-Based Walking Intervention on Mobility and Quality of Life in People With Diabetes and Peripheral Arterial Disease Step‐Monitored Home Exercise Improves Ambulation, Vascular Function, and Inflammation in Symptomatic Patients With Peripheral Artery Disease: A Randomized Controlled Trial Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication. Quality of life in patients with intermittent claudication using the World Health Organisation (WHO) questionnaire. Value of a supervised exercise program for the therapy of arterial claudication. 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. Effects of home versus supervised exercise for 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. Exercise training increases endothelial progenitor cells and decreases asymmetric dimethylarginine in peripheral arterial disease: a randomized controlled trial. Training rather than walking: the test in -train out program for home-based rehabilitation in peripheral arteriopathy. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication. The relationship of walking distances estimated by the patient, on the corridor and on a treadmill, and the Walking Impairment Questionnaire in intermittent claudication. Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication. Six-minute walk test closely correlates to "real-life" outdoor walking capacity and quality of life in patients with intermittent claudication.
abstract: 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 BACKGROUND Intermittent claudication is associated with a poor prognosis , but less is known of the risks associated with asymptomatic peripheral arterial disease . The aims of this study were to determine the incidence and natural history of claudication , and the incidence of cardiovascular events in symptomatic and asymptomatic peripheral arterial disease . METHODS In 1988 , 1592 subjects aged 55 - 74 years were selected r and omly from the age-sex register of 10 general practice s in Edinburgh , Scotl and . The presence of peripheral arterial disease was determined by the World Health Organization question naire on intermittent claudication , the ankle brachial pressure index and a reactive hyperaemia test . This cohort was followed prospect ively over 5 years for subsequent cardiovascular events and death . RESULTS One hundred and sixteen new cases of claudication were identified ( incidence density 15.5 per 1000 person-years ) . Of those with claudication at baseline , 28.8 % and still had pain after 5 years , 8.2 % underwent  vascular surgery or amputation , and 1.4 % developed leg ulceration .  Claudicants had a significantly increased risk of developing angina compared with normals ( RR : 2.31 , 95 % CI : 1.04 - 5.10 ) , and asymptomatic subjects had a slightly increased risk of myocardial infa rct ion and stroke . Deaths from cardiovascular disease were more likely in both claudicants ( RR : 2.67 , 95 % CI : 1.34 - 5.29 ) and subjects with major ( RR : 2.08 , 95 % CI : 1.13 - 3.83 ) or minor asymptomatic disease ( RR : 1.74 , 95 % CI : 1.09 - 2.76 ) . Subjects with major asymptomatic disease also had an increased risk of non-cardiovascular death ( RR : 2.19 , 95 % CI : 1.33 - 3.59 ) , and therefore had the highest overall risk of death ( RR : 2.44 , 95 % CI : 1.59 - 3.74 ) . CONCLUSIONS Subjects with asymptomatic peripheral arterial disease appear to have the same increased risk of cardiovascular events and death found in claudicants OBJECTIVE To compare associations of physical activity during daily life with treadmill walking performance and corridor-based functional performance measures in persons with lower extremity peripheral arterial disease ( PAD ) . STUDY DESIGN Cross-sectional . SUBJECTS One hundred fifty-six men and women with PAD who completed baseline measurements and were r and omized into the study to improve leg circulation ( SILC ) exercise clinical trial . MAIN OUTCOME MEASURES Participants completed a  Gardner-Skinner treadmill protocol . Corridor-based functional performance measures were the 6-minute walk , walking velocity over four meters at usual and fastest pace , and the short physical performance battery ( SPPB ) ( 0 - 12 scale , 12 = best ) .  Physical activity during daily life was measured continuously over 7 days with a Caltrac ( Muscle Dynamics Fitness Network , Inc , Torrence , Calif ) accelerometer . RESULTS Adjusting for age , gender , and race , higher levels of physical activity during daily life were associated with greater distance achieved in the 6-minute walk ( P trend = .001 ) , faster fast-paced four-meter walking velocity ( P trend < .001 ) , faster usual-paced four-meter walking speed ( P trend = .027 ) and a higher SPPB ( P trend = .005 ) . The association of physical activity level with maximum treadmill walking distance did not reach statistical significance ( P trend = .083 ) . There were no associations of physical activity with treadmill distance to onset of leg symptoms ( P trend = .795 ) . CONCLUSION Functional performance measures are more strongly associated with physical activity levels during daily life than treadmill walking measures The aims of the study were to determine whether heart rate variability ( HRV ) measured at rest and during exercise could be altered by an exercise training programme design ed to increase walking performance in patients with peripheral arterial disease . Forty-four volunteers were r and omised into 12 weeks of either : supervised walking training twice weekly for 30 min at 75 % VO2peak ( SU ) , home-based walking training sessions : twice weekly , 30 min per week ( HB ) or no exercise ( CT ) .  HRV measures were calculated from a 5-min resting ECG . Each patient then underwent maximal , grade d exercise treadmill testing . All measures were repeated after 12 weeks . The SU group showed significantly ( p < 0.001 ) increased maximal walking time ( MWT ) but no change in VO2peak . There were no statistically significant changes in any of the measures of HRV in any group . Effect sizes for change in HRV measures were all very small and in some cases negative . Improved walking performance was not accompanied by central cardiorespiratory or neuroregulatory adaptations in the present study . The lack of any change in HRV was possibly due to either the low intensity or discontinuous nature of exercise undertaken . Key pointsIt is known that exercise can positively influence heart rate variability in some cardiac patients .It is known that exercise can increase walking performance in peripheral vascular disease patients .Exercise  training improved walking performance in peripheral vascular disease patients but HRV was unaltered . This may be due to low overall physiological dem and s on the cardiovascular system or the intermittent nature of the exercise Supervised , hospital-based exercise rehabilitation programs are effective for improving functional status for patients with claudication due to peripheral arterial occlusive disease . However , it has been suggested that unsupervised , home-based exercise programs , which have been relatively little evaluated , would be equally efficacious as compared with hospital-based programs . The authors tested the hypothesis that a hospital-based exercise rehabilitation program would improve treadmill exercise perfor mance more than a home-based program . Of 20 consecutively enrolled patients with claudication , 10 were r and omly placed into a supervised , hospital-based program and 10 into an unsupervised , home-based program for a three-month period .  Exercise perfor mance was evaluated by treadmill testing using a grade d protocol . In addition , func tional status was evaluated by the Walking Impairment Question naire ( WIQ ) and the Medical Outcomes Study SF-20 question naire ( MOS ) . Patients in the hospital-based program were treated with treadmill walking three times a week for one hour/visit . Patients in the home-based program were instructed to walk at least three times a week and were contacted weekly to provide encouragement and to record compliance with ( continued on next page ) the program . Patients in the hospital-based group improved peak walking time by 137 % , pain-free walking time by 150 % , and peak oxygen consumption by 19 % ( all P<0.05 ) . Patients reported an improved walking distance and speed according to WIQ data ( both P<0.05 ) . In addition , the MOS physical functioning score in the hospital-based group improved by 20 percentage points ( P<0.05 ) . In contrast , patients in the home-based program did not improve exercise performance measured on the treadmill . Improvement in the ability to walk on the treadmill was greater in the hospital-based than the home- based program ( P<0.05 ) . The ability to walk distances was the only question naire measure that improved in persons who received the home-based program ( P<0.05 ) . Preliminary results suggest that a supervised , hospital-based program is more effective for improving treadmill exercise performance than an unsupervised , home-based program 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 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 Background This prospect i ve , r and omized , controlled clinical trial compared changes in primary outcome measures of claudication onset time ( COT ) and peak walking time ( PWT ) , and secondary outcomes of submaximal exercise performance , daily ambulatory activity , vascular function , inflammation , and calf muscle hemoglobin oxygen saturation ( StO2 ) in patients with symptomatic peripheral artery disease ( PAD ) following new exercise training using a step watch ( NEXT Step ) home‐exercise program , a supervised exercise program , and an attention‐control group . Methods and Results One hundred eighty patients were r and omized . The NEXT Step program and the supervised exercise program consisted of intermittent walking to mild‐to‐moderate claudication pain for 12 weeks , whereas the controls performed light resistance training . Change scores for COT ( P<0.001 ) , PWT ( P<0.001 ) , 6‐minute walk distance ( P=0.028 ) , daily average cadence ( P=0.011 ) , time to minimum calf muscle StO2 during exercise ( P=0.025 ) , large‐artery elasticity index ( LAEI ) ( P=0.012 ) , and high‐sensitivity C‐reactive protein ( hsCRP ) ( P=0.041 ) were significantly different among the 3 groups . Both the NEXT Step home program and the supervised exercise program demonstrated a significant increase from baseline in COT , PWT , 6‐minute walk distance , daily average cadence , and time to minimum calf StO2 . Only the NEXT Step home group had improvements from baseline in LAEI , and hsCRP ( P<0.05 ) . Conclusions NEXT Step home exercise utilizing minimal staff supervision has low attrition , high adherence , and is efficacious in improving COT and PWT , as well as secondary outcomes of submaximal exercise performance , daily ambulatory activity , vascular function , inflammation , and calf muscle StO2 in symptomatic patients with PAD . Clinical Trial Registration URL : Clinical Trials.gov . Unique Identifier : NCT00618670 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 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 PURPOSE This study was performed to test the effectiveness of a formal supervised exercise program against a home-based exercise program for both walking ability and quality of life endpoints . METHODS Patients with arterial claudication were r and omized to either a 12-week supervised exercise program ( SUPEX ) with weekly lectures relating to peripheral vascular disease or to a home exercise group ( HOMEX ) who attended an identical lecture program and received weekly exercise instruction . The study population included 29 men and 26 women , with a mean age of 69.1 + /- 8.1 years . Forty-seven patients completed the 12-week program , 46 were available for testing at completion , and 38 for 6-month testing . Claudication pain time ( CPT ) and maximum walking time ( MWT ) on a progressive treadmill exercise test were assessed at baseline , program completion , and 6 months . The Medical Outcomes Study Short Form-36 ( SF-36 ) was administered at these intervals to assess effects on quality of life . RESULTS Each group improved ( p < 0.001 ) in both CPT and MWT at the completion of the 12-week program , which was sustained at the 6-month follow-up . Increase in HOMEX CPT from baseline ( 3.6 + /- 2.73 minutes ) to 6-month follow-up ( 6.6 + /- 3.17 minutes ) was less than for the SUPEX group ( 3.8 + /- 2.74 to 11.2 + /- 4.02 minutes , respectively ) ; similar results were obtained for MWT . At both completion and 6 months , there was a significant intergroup difference for CPT and MWT ( p < 0.004 ) favoring SUPEX . For both groups , measures of health perception based on the SF-36 demonstrated improvement ( p < 0.002 ) in Physical Function Subscale , Bodily Pain Subscale , and Physical Composite Score . There were no between-group differences on the subsets of the SF-36 at the three assessment intervals . CONCLUSIONS Supervised exercise programs provide superior increased walking ability in the noninterventional therapy of arterial claudication , and both supervised and home based exercise therapy result in improved SF-36 functional measures . The lack of intergroup differences in these measures may be a result of the high degree of interaction with healthcare providers in the HOMEX group . Although a supervised program results in optimal walking benefits , a highly structured home-based program provides similar functional improvement and may be a satisfactory alternative for patients with lesser walking requirements 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 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 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 BACKGROUND Supervised exercise training ( SET ) is recommended as initial treatment to improve walking capacity in peripheral arterial disease ( PAD ) patients with intermittent claudication . Various mechanisms by which SET yields beneficial effects are postulated , however data regarding its influence on angiogenesis are scarce . Thus , we design ed a prospect i ve r and omized controlled trial to study the impact of SET on markers of angiogenesis and endothelial function in PAD . METHODS Forty PAD patients were r and omized to SET on top of best medical treatment ( SET+BMT )  for 6 months versus  best medical treatment ( BMT ) only . Endothelial progenitor cells ( EPC ) were assessed by whole-blood flow cytometry ( co-expression of CD34 + CD133 + KDR+ ) and cell culture assays ( endothelial cell-colony forming units , circulating angiogenic cells , migration assay ) at baseline , 3 , 6 and 12-months after inclusion . Changes of plasma levels of asymmetric dimethylarginine ( ADMA ) , vascular endothelial growth factor ( VEGF ) , stromal cell-derived factor-1 ( SDF-1 ) and maximum walking distance were determined . RESULTS EPC - measured by flow cytometric and cell culture techniques - increased significantly upon training paralleled by a significant decrease of ADMA when compared to the BMT group ( p<0.05 ) . Six months after training cessation , the beneficial effect of  SET  on EPC diminished , but maximum walking distance was significantly improved compared to baseline and controls ( p<0.05 ) . No significant changes were observed for VEGF and SDF-1 plasma levels in time course . CONCLUSIONS SET increases circulating EPC counts and decreases ADMA levels reflecting enhanced angiogenesis and improved endothelial function , which might contribute to cardiovascular risk reduction BACKGROUND Exercise training reduces walking disability in peripheral arterial disease ( PAD ) . This non-r and omized study evaluates the effects on walking ability and hemodynamic parameters of a novel approach to home-based rehabilitation , the test in -train out program ( Ti-To ) , compared with the traditional home-based free walking exercise ( Tr-E ) . METHODS AND RESULTS A total of 143 patients with claudication ( 117 men , average age 68+/-10 years ) , were included in a Ti-To ( n=83 ) or Tr-E program ( n=60 ) . Evaluations , which were carried out upon entry and at 1 , 2 , 3 , 4 and 6 months , included : self-reported claudication , walking ability ( ie , absolute claudication distance , pain threshold speed ) , resting/exercise heart rates ( HR ) , systolic/diastolic brachial pressure ( SBP/DBP ) , ankle pressure ( AP ) , ankle-brachial index ( ABI ) . Ti-To involved 2 daily 10-min home walking sessions at maximal asymptomatic speed and the patient attending monthly check-ups at hospital . Tr-E involved 20 - 30 min of daily walking at self-selected speeds up to pain tolerance . A total of 126 patients ( Ti-To , n=74 ; Tr-E , n=52 ) completed the program . Ti-To induced better relief from claudication ( p=0.001 ) . Functional parameters improved significantly for both groups ( p<0.0001 ) with significant intergroup difference for Ti-To ( p<0.0001 ) . SBP and exercise HR decreased significantly in both groups , with Ti-To improving resting HR ( p=0.0002 ) , DBP ( p=0.003 ) , lowest AP worse limb ( p=0.004 ) and ABI worse limb ( p=0.0002 ) . CONCLUSIONS In patients with PAD , a Ti-To program had more positive effects on perceived claudication , and functional and hemodynamic parameters than did a Tr-E program 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 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 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 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
target: Based on a low quality of evidence , home-based supervised exercise may lead to less improvement in maximum and pain-free walking distance , and in more improvement in daily life walking capacity , compared with hospital-based supervised exercise .
  Home-based supervised exercise may improve maximum and pain-free walking distance compared with " go home and walk advice " and result in little or no difference in health-related quality of life and functional walking capacity compared with hospital-based supervised exercise or " go home and walk advice " .
background: OBJECTIVE To evaluate the effects of home-based supervised exercise vs hospital-based supervised exercise , and the effects of home-based supervised exercise vs unsupervised " go home and walk advice " on daily life and corridor-walking capacity , health-related quality of life and patient-reported functional walking capacity in patients with intermittent claudication .