title: Exercise prescription using the heart of claudication pain onset in patients with intermittent claudication Plantar flexion: an effective training for peripheral arterial disease Comparison of two progressive treadmill tests in patients with peripheral arterial disease Optimal exercise program length for patients with claudication. Muscle enzyme adaptation in patients with peripheral arterial insufficiency: spontaneous adaptation, effect of different treatments and consequences on walking performance. Superiority of treadmill walking exercise versus strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response. Unsupervised Exercise and Mobility Loss in Peripheral Artery Disease: A Randomized Controlled Trial A pilot exercise intervention to improve lower extremity functioning in peripheral arterial disease unaccompanied by intermittent claudication. Ischemia-related changes in circulating stem and progenitor cells and associated clinical characteristics in peripheral artery disease The Claudication: Exercise Vs. Endoluminal Revascularization (CLEVER) study: rationale and methods. Benefit of exercise conditioning for patients with peripheral arterial disease. Does supervised exercise offer adjuvant benefit over exercise advice alone for the treatment of intermittent claudication? A randomised trial. Home-based walking exercise intervention in peripheral artery disease: a randomized clinical trial. The development and pilot randomised controlled trial of a group education programme for promoting walking in people with intermittent claudication Early outcomes from a randomized, controlled trial of supervised exercise, angioplasty, and combined therapy in intermittent claudication. A group-mediated, home-based physical activity intervention for patients with peripheral artery disease: effects on social and psychological function Is percutaneous transluminal angioplasty better than exercise for claudication? Preliminary results from a prospective randomised trial. Comparison of the effect of upper body-ergometry aerobic training vs treadmill training on central cardiorespiratory improvement and walking distance in patients with claudication. Increasing exercise tolerance of persons limited by claudication pain using polestriding. Corridor-based functional performance measures correlate better with physical activity during daily life than treadmill measures in persons with peripheral arterial disease. Predictors of treatment outcome in intermittent claudication. Extending the range of treadmill testing for patients with intermittent claudication. 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 Efficacy of Quantified Home-Based Exercise and Supervised Exercise in Patients With Intermittent Claudication: A Randomized Controlled Trial Comparison of Walking With Poles and Traditional Walking for Peripheral Arterial Disease Rehabilitation Influence of upper- and lower-limb exercise training on cardiovascular function and walking distances in patients with intermittent claudication. Effects of a Home-Based Walking Intervention on Mobility and Quality of Life in People With Diabetes and Peripheral Arterial Disease Impact of exercise training on inflammation and platelet activation in patients with intermittent claudication. Step‐Monitored Home Exercise Improves Ambulation, Vascular Function, and Inflammation in Symptomatic Patients With Peripheral Artery Disease: A Randomized Controlled Trial 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. A Program of 3 Physical Therapy Modalities Improves Peripheral Arterial Disease in Diabetes Type 2 Patients: A Randomized Controlled Trial Rocker-soled shoes and walking distance in patients with calf claudication. Effects of Physical Training on Peripheral Vascular Disease: A Controlled Study Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication. Effect of upper- and lower-limb exercise training on circulating soluble adhesion molecules, hs-CRP and stress proteins in patients with intermittent claudication. A non-randomised controlled trial of the clinical and cost effectiveness of a Supervised Exercise Programme for claudication. Impact of a walking program in people with down syndrome. Increased endogenous nitric oxide production induced by physical exercise in peripheral arterial occlusive disease patients. Effects of long-term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: a randomized controlled trial. Peripheral arterial disease and intermittent claudication: efficacy of short-term upper body strength training, dynamic exercise training, and advice to exercise at home. Efficacy and safety of oral porcine relaxin (pRLX) in adjunct to physical exercise in the treatment of peripheral arterial disease (PAD). Effects of a 6-month exercise program pilot study on walking economy, peak physiological characteristics, and walking performance in patients with peripheral arterial disease Post‐resistance exercise hypotension in patients with intermittent claudication Home‐Based Walking Exercise in Peripheral Artery Disease: 12‐Month Follow‐up of the Goals Randomized Trial The Effects of Walking or Walking-with-Poles Training on Tissue Oxygenation in Patients with Peripheral Arterial Disease [Experiences with the application of physiotherapy in peripheral arterial circulatory disorders of the lower extremities (stage I and IIa) under ambulatory conditions]. Optimizing supervised exercise therapy for patients with intermittent claudication. [Success of physiotherapeutic interval training combined with standardized hemoderivative in intermittent claudication (author's transl)]. 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Recruitment to clinical trials of exercise: challenges in the peripheral arterial disease population. Strength training increases walking tolerance in intermittent claudication patients: randomized trial. The Influence of Electrostimulation on the Circulation of the Remaining Leg in Patients with One-Sided Amputation The effect of pain-free treadmill training on fibrinogen, haematocrit, and lipid profile in patients with claudication Exercise training for intermittent claudication: does it adversely affect biochemical markers of the exercise-induced inflammatory response? Cardiovascular Training Effect Associated With Polestriding Exercise in Patients With Peripheral Arterial Disease The constitutive procoagulant and hypofibrinolytic state in patients with intermittent claudication due to infrainguinal disease significantly improves with percutaneous transluminal balloon angioplasty. Limb-specific and cross-transfer effects of arm-crank exercise training in patients with symptomatic peripheral arterial disease. Exercise rehabilitation improves functional outcomes and peripheral circulation in patients with intermittent claudication: a randomized controlled trial. Effects of walking and strength training on resting and exercise cardiovascular responses in patients with intermittent claudication. [Controlled vascular training in IIb peripheral arterial occlusive disease: additive effect of intravenous PGE1 versus intravenous pentoxifylline during training]. Upper- vs lower-limb aerobic exercise rehabilitation in patients with symptomatic peripheral arterial disease: a randomized controlled trial. Physical Training and Antiplatelet Treatment in Stage II Peripheral Arterial Occlusive Disease: Alone or Combined? Resistance training in patients with peripheral arterial disease: effects on myosin isoforms, fiber type distribution, and capillary supply to skeletal muscle. Red Blood Cell Deformability in Patients With Claudication After Pain-free Treadmill Training Peripheral arterial insufficiency, effect of physical training on walking tolerance, calf blood flow, and blood flow resistance. The inflammatory response to upper and lower limb exercise and the effects of exercise training in patients with claudication. Vitamin C prevents endothelial dysfunction induced by acute exercise in patients with intermittent claudication. Efficacy of arm-ergometry versus treadmill exercise training to improve walking distance in patients with claudication Treadmill versus shuttle walk tests of walking ability in intermittent claudication. Walking performance and health-related quality of life after surgical or endovascular invasive versus non-invasive treatment for intermittent claudication--a prospective randomised trial. Additional supervised exercise therapy after a percutaneous vascular intervention for peripheral arterial disease: a randomized clinical trial. 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Community-based walking exercise for peripheral artery disease: An exploratory pilot study Local Versus Systemic Mechanisms Underlying Supervised Exercise Training for Intermittent Claudication The effects of physical training and flunarizine on walking capacity in intermittent claudication. Percutaneous transluminal angioplasty results in improved physical function but not balance in patients with intermittent claudication. Effective training for patients with intermittent claudication [Combination of physiotherapeutic exercise therapy with bencyclane in intermittent claudication (author's transl)]. Intermittent Claudication—Surgical Reconstruction or Physical Training?: A Prospective Randomized Trial of Treatment Efficiency 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. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication. Changes in pain-free walking based on time in accommodating pain-free exercise therapy for peripheral arterial disease. Improving maximum walking distance in early peripheral arterial disease: randomised controlled trial. Exercise training versus angioplasty for stable claudication. Long and medium term results of a prospective, randomised trial. Effectiveness of Health Promotion Interventions Claudication: exercise vs endoluminal revascularization (CLEVER) study update. Exercise training in intermittent claudication. The influence of a long term exercise program on lower limb movement variability and walking performance in patients with peripheral arterial disease. The effect of exercise training on ankle-brachial index in type 2 diabetes. A single bout of resistance exercise does not modify cardiovascular responses during daily activities in patients with peripheral artery disease Impact of a supervised strength training or walking training over a subsequent unsupervised therapy period on walking capacity in patients with claudication. Diabetic women are poor responders to exercise rehabilitation in the treatment of claudication. Design of the multicenter standardized supervised exercise training intervention for the ‘CLaudication: Exercise Vs Endoluminal Revascularization (CLEVER) study’ The Birmingham rehabilitation uptake maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a 'go home and walk' advice.
abstract: 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 This study examined whether a training intervention likely to elicit adaptations in the leg could result in reduced leg pain and increased whole body physical capacity .  Twenty-seven peripheral arterial disease ( PAD ) patients were r and omized to either an individual leg plantar flexion training group ( TG ) training 4 × 4 min intervals at 80 % of maximal work rate three times per week for 8 weeks or a control group . The TG significantly increased plantar flexion peak oxygen uptake and power output by 23.5 and 43.9 % , respectively . Treadmill peak oxygen uptake ( VO2peak ) significantly increased 12.3 % in the TG and was associated with a significant increased time to exhaustion of 20.0 % when treadmill walking . Eleven of 14 patients no longer reported leg pain limitations at VO2peak . No differences in cardiac output measured at VO2peak , or walking economy were observed . Plantar flexion training was effective in increasing VO2peak and walking performance , and may be a useful strategy in treatment of PAD In a vascular rehabilitation program , 28 % of our frail elderly patients are unable to be tested with traditional progressive exercise protocol s at program entry due to the high ( 2.0 miles/h or 3.2 km/h ) initial treadmill speeds . The purpose of this investigation was to compare a new progressive treadmill protocol which has a reduced initial speed ( 1.0 mile/h or 1.6 km/h ) to an established protocol performed at 2.0 miles/h ( 3.2 km/h ) to determine the comparability and reproducibility of the new protocol . Eleven patients with arterial claudication performed three symptom-limited exercise tests in r and om order . Two tests used the new protocol while the remaining trial used the established protocol .  Claudication pain was measured using a 5-point scale . Oxygen consumption , heart rate , minute ventilation , respiratory exchange ratio and blood pressure at peak exercise were similar among the three trials . There were strong intra-class correlations for peak oxygen consumption ( r = 0.97 ) , onset of claudication ( r = 0.96 ) and maximum walking time ( r = 0.98 ) between the two trials using the new protocol . There was also a significant correlation between the new protocol and the established protocol for peak oxygen consumption ( r = 0.90 ) and maximum walking time ( r = 0.89 ) . The new progressive treadmill protocol represents a valid , reliable protocol for patients with arterial claudication . This protocol may be useful for testing patients with a low functional capacity so that clinical ly appropriate exercise prescriptions can be established and the efficacy of treatments can be determined 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 1 . The activities of  phosphofructokinase ( PFK ) , citrate synthetase ( CS ) , lactate dehydrogenase ( LDH ) , 3-hydroxyacyl-CoA dehydrogenase ( ACDH ) and cytochrome-c oxidase(Cyt-ox ) in the calf muscle tissue were compared in subjects with intermittent claudication ( n = 38 ) and controls ( n = 20 ) . The activities of CS , ACDH and Cyt-ox were increased and the activity of Cytox was positively correlated to the maximal walking distance ( MWD ) in the patients . 2 . Thirty-three patients with intermittent claudication were r and omized to three treatment groups : ( 1 ) operative surgery , ( 2 ) operative surgery supplemented with physical training and ( 3 ) physical training alone . Before and after 6 - 12 months of treatment , symptom-free walking distance ( SFWD ) , MWD , ankle-brachial blood pressure quotient ( ankle index ) , maximal plethysmographic calf blood flow ( MPBF ) and the activities of PFK , CS , LDH , ACDH and Cyt-ox were measured . 3 . SFWD and MWD increased in all three groups . Ankle index and MPBF increased in groups 1 and 2 , but were unchanged in group 3 . The activities of Cyt-ox and CS decreased with operation , but the activity of Cyt-ox was further augmented with training in group 3 . Overall , the change in ankle index explained 80 - 90 % of the variability in walking performance . In a separate analysis , the increased activity of Cyt-ox in group 3 was positively correlated to , and explained 31 % of the variability in , the improvement in SFWD . 4 . These findings indicate that both physical activity and a reduced calf blood flow are necessary conditions for the enzymatic adaptation to take place . A causal relationship between metabolic adaptation in the muscle tissue and walking performance is suggested . ( ABSTRACT TRUNCATED AT 250 WORDS 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 Background Few medical therapies improve lower extremity functioning in people with lower extremity peripheral artery disease ( PAD ) . Among people with PAD , we studied whether a group-mediated cognitive behavioral intervention promoting home-based unsupervised exercise prevented mobility loss and improved functional performance compared to control . Methods and Results One hundred ninety-four PAD participants were r and omized . During months 1 to 6 , the intervention group met weekly with other PAD participants and a facilitator . Group support and self-regulatory skills were used to help participants adhere to walking exercise . Ninety-percent of exercise was conducted at or near home . The control group attended weekly lectures . During months 6 to 12 , each group received telephone contact only . Primary outcomes have been reported . Here we compare changes in exploratory outcomes of mobility loss ( the inability to climb a flight of stairs or walk one-quarter mile without assistance ) , walking velocity , and the Short Physical Performance Battery . Compared to controls , fewer participants r and omized to the intervention experienced mobility loss at 6-month follow-up : 6.3 % versus 26.5 % , P=0.002 , odds ratio=0.19 ( 95 % CI=0.06 to 0.58 ) and at 12-month follow-up : 5.2 % versus 18.5 % , P=0.029 , odds ratio=0.24 ( 95 % CI=0.06 to 0.97 ) . The intervention improved fast-paced 4-m walking velocity at 6-month follow-up ( P=0.005 ) and the Short Physical Performance Battery at 12-month follow-up ( P=0.027 ) , compared to controls . Conclusions In exploratory analyses , a group-mediated cognitive behavioral intervention promoting unsupervised walking exercise prevented mobility loss and improved functioning at 6- and 12-month follow-up in PAD patients . Clinical Trial Registration URL : http:// clinical trials.gov . Unique identifier : NCT00693940 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 The extent and clinical significance of stem and progenitor cell ( SPC ) increases in response to lower-extremity ischemia in people with peripheral artery disease ( PAD ) are unclear . We compared changes in SPC levels immediately following a treadmill exercise test between individuals with and without PAD . Among participants with PAD , we determined whether more severe PAD was associated with greater increases in SPCs following treadmill exercise-induced lower-extremity ischemia . We measured SPC levels in 25 participants with PAD and 20 without PAD  before and immediately after a treadmill exercise test .  Participants with PAD , compared to participants without PAD , had greater increases in CD34+CD45dim ( + 0.08±0.03 vs −0.06±0.04 , p=0.008 ) , CD34+CD45dimCD133 + ( + 0.08±0.05 vs −0.08±0.04 , p=0.014 ) , CD34+CD45dimCD31 + ( + 0.10±0.03 vs −0.07±0.04 , p=0.002 ) , and CD34+CD45dimALDH+ SPCs ( + 0.18±0.07 vs −0.05±0.08 , p=0.054 ) measured as a percentage of all white blood cells . Among participants with PAD , those with any increases in the percent of SPCs immediately after the treadmill exercise test compared to those with no change or a decrease in SPCs had lower baseline ankle – brachial index values ( 0.65±0.17 vs 0.90±0.19 , p=0.004 ) and shorter treadmill times to onset of ischemic leg symptoms ( 2.17±1.54 vs 5.25±3.72 minutes , p=0.012 ) . In conclusion , treadmill exercise-induced lower-extremity ischemia is associated with acute increases in circulating SPCs among people with PAD . More severe PAD is associated with a higher prevalence of SPC increases in response to lower-extremity ischemia . Further prospect i ve study is needed to establish the prognostic significance of ischemia-related increases in SPCs among patients with PAD 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 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 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 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 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 ) 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 PAD is a disabling , chronic condition of the lower extremities that affects approximately 8 million people in the United States . The purpose of this study was to determine whether an innovative home-based walking exercise program for patients with peripheral artery disease ( PAD ) improves self-efficacy for walking , desire for physical competence , satisfaction for physical functioning , social functioning , and acceptance of PAD related pain and discomfort . Methods The design was a 6-month r and omized controlled clinical trial of 194 patients with PAD . 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 . Results Of the 194 participants r and omized , 178 completed the baseline and 6-month follow-up visit . The mean age was 70.66 ( ±9.44 ) and was equally represented by men and women . Close to half of the cohort was African American . Following 6-months of treatment , the intervention group experienced greater improvement on self-efficacy ( p = .0008 ) , satisfaction with functioning ( p = .0003 ) , pain acceptance ( p = .0002 ) , and social functioning ( p = .0008 ) than the control group ; the effects were consistent across a number of potential moderating variables . Change in these outcomes was essentially independent of change in 6-minute walk performance . Trial registration [ Clinical Trials.gov Identifier : NCT00693940 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 ) 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 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 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 OBJECTIVE To derive formulae to predict the likely 12-month health-related quality of life outcome following different treatments for intermittent claudication ( IC ) . DESIGN A prospect i ve , r and omized , controlled study . MATERIAL S One hundred and seventy-one unselected patients with stable IC were sequentially r and omized to invasive therapy , supervised physical training or observation . Hierarchical analysis was used to identify significant predictors of outcome . RESULTS The strongest outcome predictors were baseline values of the respective outcome variables in all groups . No more than two significant secondary predictors were identified for each outcome variable and no outcome variable was a predictor of any other outcome variable . Result ing prediction equations achieved between 61 and 90 % concordance with improvement ( 75 % considered adequate ) , with best prediction for invasive therapy and poorest for observation . Suggested cutpoints for the various endpoints in the three groups had sensitivities ranging between 65 and 100 % and false positive rates between 5 and 50 % . CONCLUSIONS The derived equations adequately predicted improvement on the various outcome variables in invasive therapy and supervised physical training , and may serve as aids in selecting patients likely to benefit most from a particular treatment strategy . The uniqueness of the outcome variables underscores the importance of implementing a comprehensive set of endpoints relevant to the impacts of the condition PURPOSE There is a need to evaluate patients with peripheral arterial disease ( PAD ) with a limited or extended walking distance . We aim ed to enable an estimation of walking distance as measured on a frequently used " st and ard " grade d ( 3.2 km·h(-1 ) , 2 % increase per 2 min ) protocol for walking distances measured on protocol s with a lower or higher workload . METHODS Patients with PAD and an absolute claudication distance ( ACD ) of < 500 or between 1000 and 1600 m as measured with the " st and ard " protocol were included . Four grade d study treadmill protocol s , two with lower and two with higher workload than the " st and ard " protocol , were developed . Two study protocol s ( low or high ) and the " st and ard " protocol were repeated in r and om order . Quality was determined with the intraclass correlation coefficient and the coefficient of variation . Orthogonal regression analysis was used to predict walking distances on the st and ard protocol on the basis of the study protocol s. RESULTS Forty-three patients with an ACD < 500 m and 23 patients with an ACD between 1000 and 1600 m were included . Because feasibility from the protocol s with 2.0 km·h(-1 ) and 2 % increase every 2 min and 4.4 km·h(-1 ) and 2 % increase every minute was highest , they were calibrated against the " st and ard " protocol , and reliability was comparable with the " st and ard " protocol . The coefficient of variation between the prediction of walking distance on the " st and ard " protocol on the basis of the new protocol s and the measured distances were in the same range ( 22%-25 % ) as the variation measured performing the same treadmill test twice . CONCLUSIONS An accurate estimate of walking distance as measured on a " st and ard " treadmill protocol can be derived from a protocol with a lower or higher workload 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 Background — This prospect i ve , r and omized , controlled clinical trial compared changes in exercise performance and daily ambulatory activity in peripheral artery disease patients with intermittent claudication after a home-based exercise program , a supervised exercise program , and usual-care control . Methods and Results — Of the 119 patients r and omized , 29 completed home-based exercise  , 33 completed  supervised exercise , and 30 completed usual-care control . Both exercise programs consisted of intermittent walking to nearly maximal claudication pain for 12 weeks . Patients wore a step activity monitor during each exercise session . Primary outcome measures included claudication onset time and peak walking time obtained from a treadmill exercise test ; secondary outcome measures included daily ambulatory cadences measured during a 7-day monitoring period . Adherence to home-based and supervised exercise was similar ( P=0.712 ) and exceeded 80 % . Both exercise programs increased claudication onset time ( P<0.001 ) and peak walking time ( P<0.01 ) , whereas only home-based exercise increased daily average cadence ( P<0.01 ) . No changes were seen in the control group ( P>0.05 ) . The changes in claudication onset time and peak walking time were similar between the 2 exercise groups ( P>0.05 ) , whereas the change in daily average cadence was greater with home-based exercise ( P<0.05 ) . Conclusions — A home-based exercise program , quantified with a step activity monitor , has high adherence and is efficacious in improving claudication measures similar to a st and ard supervised exercise program . Furthermore , home-based exercise appears more efficacious in increasing daily ambulatory activity in the community setting than supervised exercise . Clinical Trial Registration — URL : http://www . Clinical Trials . Gov . Unique identifier : NCT00618670 PURPOSE : The purpose of this study was to compare the effects of a 24-week walking with poles rehabilitation program with a traditional 24-week walking program on physical function in patients with peripheral arterial disease ( PAD ) . METHODS : Patients with PAD ( n = 103 , age = 69.7 ± 8.9 years , ankle-brachial index < 0.90 or evidence of calcified vessels ) were r and omized into a rehabilitation program of traditional walking ( n = 52 ) or walking with poles ( n = 51 ) . Patients exercised 3 times per week for 24 weeks . Exercise endurance was measured by time walked on a constant work rate treadmill test at 6 , 12 , and 24 weeks . Perceived physical function was measured by the Medical Outcomes Study Short Form-36 and Walking Impairment Question naire . Tissue oxygenation was measured using near-infrared spectroscopy . RESULTS : Patients assigned to the traditional walking group walked longer at 24 weeks than those assigned to the pole walking group ( 21.10 ± 17.07 minutes and 15.02 ± 12.32 minutes , respectively , P = .037 ) . There were no differences between the groups in tissue oxygenation . However , there was a significant lengthening of time for which it took to reach minimum tissue oxygenation values ( P < .001 ) within the groups on the constant work rate test . There were no differences between the groups in perceived physical function as measured by the Physical Function subscale on the Medical Outcomes Study Short Form-36 or perceived walking distance as measured by the Walking Distance subscale on the Walking Impairment Scale . CONCLUSIONS : Traditional walking was superior to walking with poles in increasing walking endurance on a constant work rate treadmill test for patients with PAD 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 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 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 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 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 Background and Objective : Type 2 diabetes is one of the main causes of peripheral vascular disease . The beneficial effects of exercise on glucose homeostasis include a marked stimulation of blood glucose utilization during and after its performance . The objective of this study was to determine the effects of a program of 3 physical therapy modalities on blood circulation in patients with type 2 diabetes with peripheral arterial disease . Subjects and Method : A r and omized controlled trial was undertaken . Sixty-eight patients with type 2 diabetes with Leriche-Fontaine stage I or IIa peripheral arterial disease were r and omly assigned to an exercise or placebo group . For 20 weeks , the exercise group underwent treatment comprising 3 exercises at proximal , medium , and distal segments of the lower limbs , and the placebo group received sham treatment with disconnected ultrasound equipment .  Peripheral arterial disease was determined by evaluating the ankle/brachial index ( ABI ) , Doppler flow velocity , blood parameters , cardiovascular risk score , and heart rate during exercise test . Results : After 20 weeks of treatment , significant differences between groups were found in the following : right ( P < .039 ) and left ( P < .023 ) ABI ; Doppler flow velocity ( cm/s ) in the right ( P < .010 ) and left ( P < .026 ) posterior tibial artery and in the right ( P < .012 ) and left ( P < .022 ) dorsalis pedis artery ; and fibrinogen ( P < .045 ) , hemoglobin ( P < .021 ) , cholesterol ( P < .012 ) , high-density lipoprotein cholesterol ( P < .031 ) , and HbA1c ( P < .034 ) values . There was no significant difference in low-density lipoprotein cholesterol values ( P < .110 ) between the groups . Conclusion : A program of these physical therapy modalities improves ABI , Doppler flow velocity , and blood parameters in patients with type 2 diabetes Calf claudication is the major clinical manifestation of peripheral vascular occlusive disease in a significant number of patients . Although claudication causes substantial patient disability , most patients are treated conservatively because of the risks of surgical therapy and the uncertain efficacy of drug therapy . It was hypothesized that rocker-soled shoes would decrease the work of the plantar flexors and therefore increase walking distance in patients with calf claudication . To test this hypothesis , walking distances in patients with calf claudication using rocker-soled shoes and a placebo shoe insert were compared . Rocker-soled shoes significantly increased both the total distance walked and the distance at which patients were initially bothered by symptoms by 77 m ( 37 % , p less than .0005 ) and 89 m ( 91 % , p = .003 ) , respectively . It was concluded that rocker-soled shoes may reduce disability in patients with calf claudication by increasing walking distance The effects of physical exercise on 8 stage II peripheral vascular disease ( PVD ) patients were observed after a six-month training program . Doppler velocimetry ( including the treadmill test ) , strain gauge plethysmography , and transcutaneous oxygen pressure were used to quantify the results , which were compared with those obtained in a control group of another 8 stage II PVD patients , under placebo therapy for six months . The results show physical exercise  increased the walking capacity , both the pain-free walking time and the maximum walking time . No significant difference was observed in the other parameters studied , in either the exercise patients or the control group 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 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 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 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 The effects of 14-day physical exercise or iloprost treatment ( 0.5 - 2 ng/Kg/min ) on endogenous nitric oxide production and neutrophil adhesion were evaluated in 20 patients with peripheral arterial occlusive disease ( Fontaine Stage II ) . Peripheral venous blood sample s and 4-h urine sample s were collected before , immediately after 14 days of therapy and 7 - 10 days after therapy in order to evaluate neutrophil adhesion , nitrite/nitrate and cGMP excretion rates . A longer pain free walking distance was observed after exercise , compared to iloprost ( > 500 m in 3/10 subjects ) . Urinary nitrite/nitrate , as well as cGMP concentrations , significantly increased after exercise . Nitrite/nitrate excretion rate inversely correlated to neutrophil adhesion . No variations were observed in these parameters in iloprost treated patients . The improvement in claudication and the transient increase in urinary nitrite/nitrate suggest a possible nitric oxide-dependent mechanism for the clinical efficacy of physical exercise . The results from the present and previous observations indicate that , besides pharmacological treatments , a regular aerobic exercise improves peripheral arterial occlusive disease 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 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 INTRODUCTION PAD medical therapy has a number of limitations . RLX showed promises in experimental model mainly through NO release . Our study is the first to evaluate the efficacy and safety of RLX in PAD . MATERIAL S- METHODS Eligible PAD La fontaine IIa-IIb patients were r and omized in 2 groups . Group A was treated with physical therapy plus oral pRLX , 20 ug b.i.d for 12 weeks , group B received physical therapy alone .  Pain Free Walking Distance ( PFWD ) and Maximum Walking Distance ( MWD ) at 3 and 12 wks and at follow up 3 months after treatment interruption were performed . RESULTS The percentage increases of PFWD in group B were 23 + /- 9 , 65 + /- 17 , and 35 + /- 4 respectively at 3 and at 12 weeks , and 3 months after termination . In Group A showed significantly higher percentage increases : 74 + /- 16 p < 0.01 , 168 + /- 28 p < 0.001 , and 122 + /- 15 p < 0.001 at the corresponding time points . The percentage increases of MWD in the B group were 29 + /- 7 , 55 + /- 10 and 54 + /- 8 at the above time points , while in the A group were 55 + /- 10 p < 0.001 , and 99 + /- 12 p < 0.001 . The RLX patients referred a better physical and mental status . No adverse events during or after the treatment were recorded . COMMENT RLX result ed very effective in PAD . Our results may suggest that the observed functional benefits should come not only from hemodynamic improvement but also from positive vascular remodeling 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 OBJECTIVE : To verify the acute effects of resistance exercise on post‐exercise blood pressure in patients with intermittent claudication . METHODS : Eight patients r and omly underwent two experimental sessions : a session of resistance exercise ( R : 6 exercises , 3 sets of 12 , 10 and 8 reps with a perceived exertion of 11 to 13 on the 15‐ grade Borg scale ) and a control session ( C : resting on exercise machines ) . RESULTS : Before and for 60 min following an intervention , auscultatory blood pressure was measured while subjects rested in a sitting position . After the C session , systolic , diastolic and mean blood pressures did not change from the pre‐intervention values , while these values decreased significantly after the R session throughout the entire recovery period ( greatest decreases = ‐14±5 , ‐6±5 , and ‐9±4 mmHg , respectively , P < 0.05 ) . CONCLUSION : After a single bout of resistance exercise  patients with intermittent claudication exhibited reduced systolic , diastolic and mean blood pressures , suggesting that acute resistance exercise may decrease cardiovascular load in these patients Background We studied whether a 6‐month group‐mediated cognitive behavioral ( GMCB ) intervention for peripheral artery disease ( PAD ) participants , which promoted home‐based walking exercise , improved 6‐minute walk and other outcomes at 12‐month follow‐up , 6 months after completing the intervention , compared to a control group . Methods and Results We r and omized PAD participants to a GMCB intervention or a  control group . During phase I ( months 1 to 6 ) , the intervention used group support and self‐regulatory skills during weekly on‐site meetings to help participants adhere to home‐based exercise . The control group received weekly on‐site lectures on topics unrelated to exercise . Primary outcomes were measured at the end of phase I. During phase II ( months 7 to 12 ) , each group received telephone contact . Compared to controls , participants r and omized to the intervention increased their 6‐minute walk distance from baseline to 12‐month follow‐up , ( from 355.4 to 381.9 m in the intervention versus 353.1 to 345.6 m in the control group ; mean difference=+34.1 m ; 95 % confidence interval [CI]=+14.6 , + 53.5 ; P<0.001 ) and their Walking Impairment Question naire ( WIQ ) speed score ( from 36.1 to 46.5 in the intervention group versus 34.9 to 36.5 in the control group ; mean difference = + 8.8 ; 95 % CI=+1.6 , + 16.1 ; P=0.018 ) . Change in the WIQ distance score was not different between the 2 groups at 12‐month follow‐up ( P=0.139 ) . Conclusions A weekly on‐site GMCB intervention that promoted home‐based walking exercise intervention for people with PAD demonstrated continued benefit at 12‐month follow‐up , 6 months after the GMCB intervention was completed . Clinical Trial Registration URL : Clinical Trials.gov . Unique identifier : NCT00693940 This r and omized trial proposed to determine if there were differences in calf muscle StO2 parameters in patients before and after 12 weeks of a traditional walking or walking-with-poles exercise program .  Data were collected on 85 patients who were r and omized to a traditional walking program ( n = 40 ) or walking-with-poles program ( n = 45 ) of exercise training .  Patients walked for 3 times weekly for 12 weeks . Seventy-one patients completed both the baseline and the 12-week follow-up progressive treadmill tests ( n = 36 traditional walking and n = 35 walking-with-poles ) . Using the near-infrared spectroscopy measures , StO2 was measured prior to , during , and after exercise . At baseline , calf muscle oxygenation decreased from 56 ± 17 % prior to the treadmill test to 16 ± 18 % at peak exercise . The time elapsed prior to reaching nadir StO2 values increased more in the traditional walking group when compared to the walking-with-poles group . Likewise , absolute walking time increased more in the traditional walking group than in the walking-with-poles  group . Tissue oxygenation decline during treadmill testing was less for patients assigned to a 12-week traditional walking program when compared to those assigned to a 12-week walking-with-poles program . In conclusion , the 12-week traditional walking program was superior to walking-with-poles in improving tissue deoxygenation in patients with PAD In a comparative study the authors report on results of series of physical therapy in disturbances of the peripheral arterial blood supply . Examined were the behaviour of blood pressure  , the  painless walking distance  and the peripheral microcirculation with the xenon-133-muscle clearance method before and after treatments lasting 10 to 12 weeks with combined exercises consisting of gymnastics and walking according to the interval principle ( twice a week ) , with sauna visits twice a week as well as before and after diadynamic series of the current . In all therapy groups an improvement of the peripheral haemodynamics could be statistically ascertained . The distance of the intermittent claudication  prolonged particularly in the group with interval walking . In the walking group and in the sauna group the values of the systolic blood pressure were significantly reduced . Side-effects were not observed . Therapy effects of the series of physical therapy described are best to be proved by the xenon-133 muscle clearance 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 cross-over trial with 114 patients , intravenous Actovegin or an oral placebo were administered in addition to basic physiotherapy . In the evaluation 105 of the subjects were taken into consideration . It was shown that the test group ( n = 53 ) achieved a 12 % increase in walking distance ( measured in the st and ardized walking distance test ) compared with the placebo group ( n = 52 ) . The therapeutic success rate , i.e. the evaluation base for the efficacy of basic physiotherapy was comparatively good and statistically confirmed at 69.8 % and 73.1 % for the two groups . From this it may be concluded that basic physiotherapy can be effectively supported by Actovegin 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 OBJECTIVE To examine the influence of peripheral arterial disease ( PAD ) on heart rate variability ( HRV ) in patients , and to examine the influence of an intense long-term ( 12 months ) exercise program on HRV in PAD patients . METHODS This study involved ambulatory patients attending a local hospital and university center . Participants were twenty-five patients with diagnosed PAD and intermittent claudication and 24 healthy , age-matched adults . Interventions involved r and om allocation of PAD patients to 12 months of conservative medical treatment ( Conservative ) or medical treatment with supervised treadmill walking ( Exercise ) . The main outcome measures were time- and frequency-domain , nonlinear HRV measures during supine rest , and maximal walking capacity prior to and following the intervention . RESULTS Despite significantly worse walking capacity ( 285 ± 190 m vs 941 ± 336 m ; P < .05 ) , PAD patients exhibited similar resting HRV to healthy adults . At the 12-month follow-up , Exercise patients exhibited a significantly greater improvement in walking capacity ( 183 % ± 185 % vs 57 % ± 135 % ; P = .03 ) with similar small nonsignificant changes in HRV compared with Conservative patients . CONCLUSIONS The current study demonstrated that PAD patients exhibited similar resting HRV to healthy adults with 12 months of intense supervised walking producing similar HRV changes to that of conservative medical treatment . The greater walking capacity of healthy adults and PAD patients following supervised exercise does not appear to be associated with enhanced HRV 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 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 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 BACKGROUND The optimal first-line treatment for intermittent claudication is currently unclear . OBJECTIVE To compare the cost-effectiveness of endovascular revascularization vs supervised hospital-based exercise in patients with intermittent claudication during a 12-month follow-up period . DESIGN R and omized controlled trial with patient recruitment between September 2002-September 2006 and a 12-month follow-up per patient . SETTING A large community hospital . PARTICIPANTS Patients with symptoms of intermittent claudication due to an iliac or femoro-popliteal arterial lesion ( 293 ) who fulfilled the inclusion criteria ( 151 ) were recruited . Excluded were , for example , patients with lesions unsuitable for revascularization ( iliac or femoropopliteal TASC-type D and some TASC type-B/C. INTERVENTION Participants were r and omly assigned to endovascular revascularization ( 76 patients ) or supervised hospital-based exercise ( 75 patients ) . MEASUREMENTS Mean improvement of health-related quality -of-life and functional capacity over a 12-month period , cumulative 12-month costs , and incremental costs per quality -adjusted life year ( QALY ) were assessed from the societal perspective . RESULTS In the endovascular revascularization group , 73 % ( 55 patients ) had iliac disease vs 27 % ( 20 patients ) femoral disease . Stents were used in 46/71 iliac lesions ( 34 patients ) and in 20/40 femoral lesions ( 16 patients ) . In the supervised hospital-based exercise group , 68 % ( 51 patients ) had iliac disease vs 32 % ( 24 patients ) with femoral disease . There was a non-significant difference in the adjusted 6- and 12-month EuroQol , rating scale , and SF36-physical functioning values between the treatment groups . The gain in total mean QALYs accumulated during 12 months , adjusted for baseline values , was not statistically different between the groups ( mean difference revascularization versus exercise 0.01 ; 99 % CI -0.05 , 0.07 ; P = .73 ) . The total mean cumulative costs per patient was significantly higher in the revascularization group ( mean difference euro2318 ; 99 % CI 2130 euros , 2506 euros ; P < .001 ) and the incremental cost per QALY was 231 800 euro/QALY adjusted for the baseline variables . One-way sensitivity analysis demonstrated improved effectiveness after revascularization ( mean difference 0.03 ; CI 0.02 , 0.05 ; P < .001 ) , making the incremental costs 75 208 euro/QALY . CONCLUSION In conclusion , there was no significant difference in effectiveness between endovascular revascularization compared to supervised hospital-based exercise during 12-months follow-up , any gains with endovascular revascularization found were non-significant , and endovascular revascularization costs more than the generally accepted threshold willingness-to-pay value , which favors exercise This study aims to evaluate the reliability of repeated grade d workload treadmill testing ( G-test ; 2 mph ; 0 % grade , increasing 2 % every 2 min ) and to compare the reliability of a constant workload treadmill protocol ( C-test ; 2 mph ; 12 % grade ) versus the grade d workload treadmill protocol in patients with intermittent claudication , studied longitudinally . A clinical trial investigating an orally stable prostacycline derivative that included 330 patients with intermittent claudication was performed . The trial employed three active treatment groups and one placebo group . Because there were no significant inter-group differences at baseline or after treatment , data from all groups were pooled for the evaluation of treadmill test reliability . Treadmill data were obtained from a 2-week run-in phase where three G-tests were performed , as well as from the beginning and the end of a 3-month double-blind phase where a G-test and a C-test were performed in r and om order . Treadmill test reliability was described through test process-related and between-subject variances and also using variance-derived parameters such as the reliability coefficient ( RC ) and the relative precision ( RP ) . A higher value for the RC and a lower value for the RP indicate that the test variability is predominantly due to between-subject variance and not to test process-related variance . Estimates of variance were described for both the maximal or absolute claudication distance ( ACD ) and the initial claudication distance ( ICD ) with each treadmill test . Reliability estimates are reported for the total study sample and for patients with baseline claudication distances < 300 feet and .300 feet ( approximately < 100 m ; .100 m ) , as measured with the C-test . The cut-off value was empirically chosen to separate severely diseased from mild to moderately diseased claudicants . Theoretical considerations suggest that reliability measures may differ in these subgroups . With repeated testing during the run-in phase for the measure of ACD , the G-test had an RC of 0.952 and an RP of 21.9 % . With the comparison of both test protocol s in the entire study population for the measurement of ACD , the G-test had an RC of 0.902 and an RP of 31.3 % , while the C-test had an RC of 0.876 and an RP of 35.2 % . The results for ICD on the G-test were an RC of 0.809 and an RP of 43.7 % , while the C-test had an RC of 0.737 and an RP of 51.3 % . The reliability of the ACD measurement for RC and RP was numerically superior to those for the ICD for both protocol s. In patients with a baseline ACD < 300 feet , the RC for ACD on the G-test was 0.827 and the RP was 41.4 % . In contrast , on the C-test the RC decreased to 0.250 and the RP increased to 86.6 % . These changes in RC and RP were due to a marked decrease in the between-subject variance , demonstrating the inability of the C-test to separate appropriately the different claudication distances in population s with highly limited baseline claudication distances . During a run-in phase , the G-test has excellent test characteristics . During the longitudinal phase of a trial , the reliability of G-tests and C-tests  are comparable in the entire study population . However , in patients with low claudication distances , the G-test should be given preference over the C-test 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 Functional impairment , functional decline , and mobility loss are major public health problems in people with lower extremity peripheral artery disease ( PAD ) . Few medical therapies significantly improve walking performance in PAD . We describe methods for the PROgenitor cell release Plus Exercise to improve functionaL performance in PAD ( PROPEL ) Study , a r and omized controlled clinical trial design ed to determine whether granulocyte-macrophage colony stimulating factor ( GM-CSF ) combined with supervised treadmill walking exercise improves six-minute walk distance more than GM-CSF alone , more than supervised treadmill exercise alone , and more than placebo plus attention control in participants with PAD , respectively . PROPEL Study participants are r and omized to one of four arms in a 2 by 2 factorial design . The four study arms are GM-CSF plus supervised treadmill exercise , GM-CSF plus attention control , placebo plus supervised exercise therapy , or placebo plus attention control . The primary outcome is change in six-minute walk distance at 12-week follow-up . Secondary outcomes include change in brachial artery flow-mediated dilation ( FMD ) , change in maximal treadmill walking time , and change in circulating CD34 + cells at 12-week follow-up . Outcomes are also measured at six-week and six-month follow-up . Results of the PROPEL Study will have important implication s for underst and ing mechanisms of improving walking performance and preventing mobility loss in the large and growing number of men and women with PAD 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 The aim of this r and omized study was to compare the reliability of the treadmill test at constant-load ( C-test , 3 km/hr ; fixed grade of 12 % ) recommended in Germany with that of the grade d-exercise test ( G-test , 3 km/hr ; increase in grade of 3.5 % every 3 minutes ) propagated in the United States . In 50 patients with an absolute claudication distance ( ACD ) in the C-test of between 50 and 400 m , the two treadmill tests were carried out in r and omized order on one and the same day , and repeated on 3 days within 1 week . For the initial claudication distance ( ICD ) , the intraclass correlation was 0.88 in the C-test and 0.87 in the G-test . For the ACD the coefficients were identical at 0.91 . The within-subject variation ( CVwithin ) in the C-test and G-test was 25 % and 27 % for the ICD and for the ACD 24 % and 21 % , respectively . The between-subject variation was very similar with 72 % and 73 % ( ICD ) and with 78 % and 68 % ( ACD ) . However , in ACDs below 100 m and between 100 to 150 m , the C-test showed significantly smaller coefficients of variation than the G-test : 13 % vs 81 % and 14 % vs 50 % , respectively . In conclusion , the results showed that both C-test and G-test are equally well reproducible In the treatment of peripheral obliterating arteriopathy ( POA ) physical training provides clear results in terms of increased walking autonomy ; it is still not fully clear whether the positive effects of physical training can be further improved by concomitant back-up drug therapy . For this purpose 374 patients of both sexes , with a mean age of 64 years , suffering from chronic peripheral obliterating arteriopathy of the lower limbs were enrolled in a controlled open clinical trial , instructed to follow a programme of physical training and r and omly allocated to low dose treatment with heparin calcium ( 12,500 IU/day ) for 6 months . An improvement in the claudicometric parameters ( free gait interval , absolute gait interval and recovery time ) measured at constant speed and in the resting Winsor ankle/arm index of the most severely damaged limb were observed in both groups . These improvements were significantly greater in the group receiving pharmacological treatment ( p < 0.01 ) and efficacy increased in line with basal deambulatory impairment . The results obtained and the good tolerance of the drug underline the clinical efficacy of heparin calcium at low doses in association with a physical training programme in patients suffering from Fontaine 's stage II peripheral obliterating arteriopathy 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 PURPOSE To compare clinical success , functional capacity , and quality of life during 12 months after revascularization or supervised exercise training in patients with intermittent claudication . MATERIAL S AND METHODS This study had institutional review board approval , and all patients gave written informed consent . Between September 2002 and September 2005 , 151 consecutive patients who presented with symptoms of intermittent claudication were r and omly assigned to undergo either endovascular revascularization ( angioplasty-first approach ) ( n = 76 ) or hospital-based supervised exercise ( n = 75 ) . The outcome measures were clinical success , functional capacity , and quality of life after 6 and 12 months . Clinical success was defined as improvement in at least one category in the Rutherford scale above the pretreatment level . Significance of differences between the groups was assessed with the unpaired t test , chi(2 ) test , or Mann-Whitney U test . To adjust outcomes for imbalances of baseline values , multivariable regression analysis was performed . RESULTS Immediately after the start of treatment , patients who underwent revascularization improved more than patients who performed exercise in terms of clinical success ( adjusted odds ratio [ OR ] , 39 ; 99 % confidence interval [ CI ] : 11 , 131 ; P < .001 ) , but this advantage was lost after 6 ( adjusted OR , 0.9 ; 99 % CI : 0.3 , 2.3 ; P = .70 ) and 12 ( adjusted OR , 1.1 ; 99 % CI : 0.5 , 2.8 ; P = .73 ) months . After revascularization , fewer patients showed signs of ipsilateral symptoms at 6 months compared with patients in the exercise group ( adjusted OR , 0.4 ; 99 % CI : 0.2 , 0.9 ; P < .001 ) , but no significant differences were demonstrated at 12 months . After both treatments , functional capacity and quality of life scores increased after 6 and 12 months , but no significant differences between the groups were demonstrated . CONCLUSION After 6 and 12 months , patients with intermittent claudication benefited equally from either endovascular revascularization or supervised exercise . Improvement was , however , more immediate after revascularization 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 In a non-r and omized , open-label study results after a structured  institution-based peripheral arterial occlusive disease ( PAD ) rehabilitation program  were compared with the results of training at home . Three groups were compared : group 1 ( n = 19 ) PAD rehabilitation ; group 2 ( n = 19 ) PAD rehabilitation + clopidogrel 75 mg once daily ; group 3 ( n = 21 ) home-based training .  The training period was 3 months for all groups , which was followed by a 3-month observation phase ( without prescribed training ) . The rehabilitation program consisted of 3 training hours per week . Background variables , demographics , and baseline claudication distances were comparable between groups . After 3 months of training the absolute claudication distances ( ACD ) improved by 82.7 % , 131.4 % , and 5.4 % for groups 1 , 2 and 3 . The initial claudication distances ( ICD ) changed by 163.8 % , 200.6 % , and 44.4 % , respectively . All changes , except the ACD result for group 3 , were statistically significant ( p 0.05 ) . Structured training groups ( 1 and 2 ) performed significantly better than group 3 ( p 0.05 ) . When results from groups 1 and 2 were pooled , ACDs changed from 493.3 218.1 to 1026.0 468.9 m , 546.0 378.8 m [ 95 % CI 417.8 - 674.2 m ] ; p 0.05 . ICDs improved from 175.3 110.8 m to 493.1 326.7 m , 320.8 315.9 m [ 95 % CI 213.9 - 427.7 m ] ; p 0.05 . The difference between the pooled mean results of the structured training groups and the results of group 3 amounted to 474.3 m [ 95 % CI 270.2 - 678.4 m ] and 242.4 m [ 95 % CI 99.0 - 385.7 m ] , for ACD and ICD , respectively . Structured , supervised PAD rehabilitation is a highly efficacious treatment for intermittent claudication and may be regarded as the present gold st and ard among conservative treatment options 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 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 Background : Lifestyle modification is associated with a substantially decreased risk of cardiovascular events . However , the role of lifestyle intervention for secondary prevention in patients with noncardioembolic ischemic stroke is inadequately defined . We assessed the hypothesis that lifestyle intervention can reduce the onset of new vascular events in patients with noncardioembolic mild ischemic stroke . Methods : We conducted an observer-blind r and omized controlled trial that enrolled 70 patients ( 48 men , mean age 63.5 years ) with acute noncardioembolic mild ischemic stroke . The patients were allocated in equal numbers to a lifestyle intervention group or a control group . We performed lifestyle interventions , which comprised exercise training , salt restriction and nutrition advice for 24 weeks . Then all patients were prospect ively followed up for occurrence of the primary endpoints , including hospitalization due to stroke recurrence and the onset of other vascular events . We also evaluated systolic blood pressure ( SBP ) at the clinic and at home , low-density lipoprotein cholesterol ( LDL-C ) , high-density lipoprotein cholesterol ( HDL-C ) , hemoglobin A1c ( HbA1c ) and high-sensitivity C-reactive protein ( hs-CRP ) to compare the efficacy of the lifestyle interventions . Results : This trial was terminated earlier than expected because of the prespecified early stopping rule for efficacy . After the 24-week intervention period , the intervention group showed a significant increase in daily physical activity and a significant decrease in salt intake ( physical activity , p = 0.012 ; salt intake , p < 0.001 ) , with a significant difference between the r and omized groups ( physical activity , p < 0.001 ; salt intake , p = 0.018 ) . Similarly , blood pressure was decreased and the HDL-C levels were increased in the intervention group ( SBP , p < 0.001 ; HDL-C , p = 0.018 ) , with significant differences between the r and omized groups ( SBP , p < 0.001 ; HDL-C , p = 0.022 ) . In contrast , LDL-C , HbA1c and hs-CRP tended to decrease in the intervention group , but this decrease did not achieve significance . After a median follow-up period of 2.9 years , 12 patients allocated to the control group and 1 patient in the lifestyle intervention group experienced at least 1 vascular event . A sequential plans analysis indicated the superiority of the lifestyle intervention in interim analysis . Kaplan-Meier survival curves after the log-rank test showed a significant prognostic difference between the r and omized groups ( p = 0.005 ) . Conclusions : Lifestyle intervention with appropriate medication is beneficial for reducing the incidence of new vascular events and improving vascular risk factors in patients with noncardioembolic mild ischemic stroke 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 Although there have been many studies showing that exercise training is beneficial for patients with peripheral vascular occlusive disease ( PVOD ) , there is little research comparing various modes of training . Previous studies showed that exercise tests performed on a StairMaster ( StairMaster Sports/Medical Products , Kirkl and , WA ) produce responses similar to those elicited by treadmill tests . The purpose of this study was to compare these modes of exercise in a training program for patients with PVOD . METHODS Of the 23 eligible individuals who began the exercise program  , 11 did not complete the regimen due to various complications . Thus , 12 patients were r and omly assigned to train for 12 weeks on either a StairMaster ( n = 6 ) or a treadmill ( n = 6 ) . Patients underwent progressive and single-stage exercise tests on both exercise modalities before and after training . RESULTS Mean exercise time before the onset of claudication pain for all tests rose significantly after training ( P < .01 ) , but greater improvements were seen on the specific training apparatus ( i.e. , treadmill training result ed in improvement in treadmill exercise performance with less improvement noted when tested on the StairMaster , and vice versa ) . Exercise time to maximal pain increased for the training apparatus only ( P < .01 ) . There were no changes in foot transcutaneous oxygen tension or the ankle-brachial blood pressure index . CONCLUSIONS Both StairMaster and treadmill training improve the exercise capacity of PVOD patients . The training effect is most apparent for the specific training apparatus , but there is some cross-over improvement to the other exercise modality . Thus , StairMaster training is appropriate and can be part of the exercise prescription for treatment of these patients 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 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 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 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 Platelet function and levels of vascular adhesion molecule-1 ( VCAM-1 ) were investigated in 24 patients with peripheral arterial disease at Fontaine stage II undergoing a 2 weeks treatment with iloprost ( 0.5 - 2 ng/kg/h i.v . infused , 6 h/day ) or a 2 weeks supervised physical training , r and omly assigned . Patients were studied before ( T0 ) and after ( T14 ) treatments and 10 days later ( T24 ) . The adhesion of washed platelets to fibrinogen coated microwells was reduced after treatment both with iloprost ( 1.9+/-0.4 vs 6.8+/-0.7 % ; T24 vs T0 ; M+/-SEM ; p<0.05 ) and physical exercise ( 3.0+/-1.0 vs 6.7+/-0.7 ; p<0.05 ) while adhesion to human plasma coated microwells was reduced only after treatment with iloprost ( 1.9+/-0.8 vs 5.8+/-0.9 ; p<0.05 ) . The expression of fibrinogen receptor ( glycoprotein IIb/IIIa ) on platelets , measured by flow-cytometry was also reduced after iloprost treatment ( 17.1+/-1.5 vs 31.8+/-4.8 AU ; p<0.05 ) and physical exercise ( 14.6+/-1.5 vs 34.0+/-3.3 ; p<0.05 ) . Theurinaryexcretion of platelet thromboxane A2 metabolite 2,3-dinor-thromboxane B2 decreased only in patients treated with iloprost ( 154.7+/-97.9 vs 256.2+/-106.4 pg mg creatinine(-1 ) ; p<0.05 ) . Similarly plasma VCAM-1 was lower in patients who were treated with iloprost ( 827.7+/-77.4 vs 999.0+/-83.8 ng ml(-1 ) ; p<0.05 ) . In conclusion , both iloprost and physical exercise seem to act on reversible phenomena such as the expression of adhesion molecules or ex vivo adhesion , whereas only iloprost reduces thromboxane A2 bio synthesis in vivo . This anti-platelet activity seems to be extended in time and to be associated with an improvement in vascular function 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 Introduction : Peripheral atherosclerotic disease ( PAD ) is a condition characterized by low functional capacity which is associated with impaired free living , ambulation and low exercise tolerance . The purpose of this r and omized controlled study was to evaluate whether changes in maximal walking time are associated with adaptations in cardiovascular function following supervised exercise OBJECTIVE This r and omized controlled trial investigated the effects of upper- and lower-limb aerobic exercise training on disease-specific functional status and generic health-related quality of life ( QOL ) in patients with intermittent claudication . METHODS The study recruited 104 patients ( mean age , 68 years ; range , 50 - 85 ) from the Sheffield Vascular Institute . Patients were r and omly allocated to groups that received upper-limb ( ULG ) or lower-limb ( LLG ) aerobic exercise training , or to a nonexercise control group . Exercise was performed twice weekly for 24 weeks at equivalent limb-specific relative exercise intensities . Main outcome measures were scores on the Walking Impairment Question naire ( WIQ ) for disease-specific functional status , the Medical Outcomes Study Short Form version 2 ( SF-36v2 ) , and European Quality of Life Visual Analog Scale ( EQ-VAS ) for health-related QOL . Outcomes were assessed at baseline , and at 6 , 24 , 48 , and 72 weeks . RESULTS After 6 weeks , improvements in the perceived severity of claudication ( P = .023 ) and stair climbing ability ( P = .011 ) vs controls were observed in the ULG , and an improvement in the general health domain of the SF-36v2 vs controls was observed in the LLG ( P = .010 ) . After 24 weeks , all four WIQ domains were improved in the ULG vs controls ( P ≤ .05 ) , and three of the four WIQ domains were improved in the LLG ( P < .05 ) . After 24 to 72 weeks of follow-up , more consistent changes in generic health-related QOL domains were apparent in the ULG . CONCLUSIONS These findings support the use of alternative , relatively pain-free forms of exercise in the clinical management 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 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 OBJECTIVES To describe recruitment to a r and omised controlled trial of a 12-week ( twice-weekly ) supervised exercise programme for patients with peripheral arterial disease ( PAD ) . PAD is a chronic , progressive disease with a significant cardiovascular and cerebrovascular risk burden , and exercise is an effective primary management approach . METHOD Potential patients were identified from the Non-Invasive Vascular Laboratory records and invited to participate in the study . On successful completion of an incremental treadmill exercise test , patients were allocated at r and om to a control ( usual care ) or an exercise group . RESULTS Between November 2006 and June 2009 , 548 patients were identified . Of the 156 patients who met the inclusion criteria , 40 ( 26 % ) declined to participate . Of the 71 patients who underwent exercise testing  , 23 ( 32 % ) did not complete the test . The final enrolment number was 44 ( 44/156 ; 28 % ) . Eleven patients ( 11/28 ; 39 % ) subsequently withdrew from the exercise programme . CONCLUSION Recruitment to clinical trials of exercise presents significant challenges in the PAD population due to the presence of co-existing cardiovascular and cerebrovascular disease , a reluctance to exercise due to leg pain , and an acceptance of reduced mobility as part of ageing . Early identification in primary care before the onset of significant comorbidity may ameliorate some of these issues 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 The aim of the authors ' study was to investigate , in patients with one leg amputated , the influence of electrostimulation on the arterial circulation of the other lower limb and on the ability of a leg with deteriorated blood flow to perform work . The study encompassed 50 patients who were admitted to the rehabilitation center to obtain a leg prosthesis and learn to walk after amputation of 1 lower limb because of severe circulatory disturbance . The patients were r and omly divided into 2 groups . The first group contained 25 patients treated with a st and ard exercise program for patients with limb amputation ( control group , C ) . In this control group , according to the Fontaine 's classification of peripheral arterial occlusive disease ( PAOD ) , 15 patients were in stage I and 10 patients were in stage II . In the second group , the electro stimulated ( ES ) group , there were also 25 patients that had the same rehabilitation program , to which electrostimulation of the gastrocnemius muscle of the remaining leg was added . In this group , 14 patients were in stage I , 10 patients were in stage II , and 1 patient was in stage III of PAOD . For electrostimulation , biphasic charge-balanced asymmetrical current stimuli with a pulse duration of 0.25 ms were used . The electrostimulation program consisted of 2 hours of electrostimulation per day for 8 weeks . Each patient was examined at the start of the rehabilitation program ( examination I ) , at the end of the 8-week program ( examination II ) and at the end of a 1-year follow-up period ( examination III ) . The effects of the treatment were followed using clinical examination , determination of the ankle-brachial index ( ABI ) , and by measuring the partial oxygen pressure ( TcPO2 ) on the skin surface of the diseased leg at rest and during exercise . After 8 weeks of treatment , in 3 patients of the ES group , claudica tion disappeared , and they thus moved from clinical stage II to stage I. In the control group , there were no changes in the clinical stages of PAOD . At the end of the observation period , 6 patients in group C and 5 patients in the ES group registered a progression of PAOD . During the observation period , 3 patients in group C and 1 patient in the ES group had below-knee amputations of the remaining leg ( p<0.01 ) . Perfusion pressures and ABI of investigated legs were comparable between groups and did not change during treatment . After 1 year of obser vation , there was a trend to ABI decrease in both groups . The capability of the diseased leg for performing work increased significantly during treatment only in the ES group . During treatment , TcPO2 at rest on the dorsum of the foot increased nonsignificantly in the ES group but in group C a trend of decrease in its value was indicated . After 8 weeks of treatment , total and partial oxygen drop during exercise significantly decreased in the ES group ; whereas , in group C , there was no significant change . During the 1-year observation period , these effects of electrostimulation disappeared ; however , fewer amputations in the ES group favor the presumption that this could be a positive effect of electrostimulation . The results of the authors ' study showed that electrostimulation improved oxygen delivery to a leg with disturbed arterial circulation and increased its work load capacity . The changes are probably caused by improvement of Objective : To assess the effect of pain-free treadmill training on changes of plasma fibrinogen , haematocrit , lipid profile , and walking ability in patients with claudication . Design : R and omized control trial . Methods : Sixty-eight patients with peripheral obstructive arterial disease and intermittent claudication ( Fontaine stage II ) were r and omly assigned into the treadmill training ( repetitive intervals to onset of claudication pain , three times a week ) or a control group ( no change in physical activity ) over 3 months . Both groups performed treadmill test to assess pain-free walking time ( PFWT ) and maximal walking time ( MWT ) and had blood analyses [ for haematocrit , fibrinogen , triglycerides , and cholesterol : total , high-density lipoprotein ( HDL ) and low-density lipoprotein ( LDL ) ] done at baseline and after 6 and 12 weeks of the study . Results : Total and LDL cholesterol levels in the training group decreased ( p < 0.05 ) by 14.8 % and 20,5 % , respectively . Significant ( p < 0.05 ) HDL cholesterol increased ( 14.6 % ) and triglycerides decreased ( 19 % ) in the training group but changes of all these lipids were insignificant in the control group over the 3 months . Haematocrit and fibrinogen changes were insignificant in both groups . PFWT was prolonged by 109 % and MWT increased by 54 % in the training group ( p < 0.01 ) , but not in the control group . Conclusion : The improvement in walking time over 3 months of pain-free treadmill training parallels with progressive normalization of lipid profiles in patients with claudication OBJECTIVES To identify a stable biochemical marker of disease severity in patients with intermittent claudication and to use these findings to assess the effect of therapeutic exercise training . DESIGN Case-control study : prospect i ve r and omised-controlled trial of exercise training . MATERIAL S AND METHODS Plasma fibrinogen , serum amyloid A protein ( SAA ) , C-reactive protein ( CRP ) and urinary albumin-creatinine ratio ( ACR ) were measured in 67 claudicants and 15 controls . Twenty-two patients were r and omised to supervised exercise training and 17 r and omised to observation .  Subjects were review ed at 3 , 6 and 12 months . RESULTS The median ( interquartile range ) baseline fibrinogen was 3.7 g/l ( 3.3 - 4.25 ) in claudicants and 3.5 g/l ( 2.9 - 3.95 ) in controls ( p = 0.045 ) ; CRP was 4.7 mg/l ( 2.2 - 9.0 ) and 2.1 mg/l ( 1.0 - 2.8 ) , respectively ( p < 0.0001 ) ; SAA was 72 mg/l ( 35 - 132 ) and 30 mg/l ( 20 - 89 ) ( p = 0.0009 ) . Claudicants showed an increased urinary ACR following treadmill exercise ( Wilcoxon , p < 0.0001 ) with no change in controls . Exercise training reduced SAA at 6 months , CRP at 3 months and progressively attenuated the post-exercise increase in ACR . No similar changes were found in controls . CONCLUSIONS Repetitive low- grade inflammatory events in claudicants lead to elevation of serum acute-phase proteins .  Exercise training is associated with symptomatic improvement and reduction inflammatory markers . The concern that exercise has adverse systemic effects therefore seems to be unjustified 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 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 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 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 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 An intensive 4-week vascular training ( patients with PAOD IIb ) leads to an effective amelioration of painfree walking distance ( + 120 % ) . Additive i.v . Pentoxifylline was not more effective ( + 105 % ) whereas PGE1 showed a remarkable increase ( + 605 % ) . After one year the results in all groups diminished : training group : + 30 % , Pentoxifylline group : + 30 % , PGE1 group : + 149 % 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 The efficacy of physical training alone or combined with antiplatelet thera py ( dipyridamole and aspirin ) was studied in 30 patients with stage II peripheral arterial occlusive disease ( PAOD ) . Patients were r and omly allocated to one of the following groups : Group A— dipyridamole 75 mg three times daily and aspirin 330 mg once daily : Group B— physical exercise ; Group C — physical exercise and dipyridamole 75 mg three time daily and aspirin 330 mg once daily . After six months ' treatment the pain-free walking time ( PFWT ) and the max imum walking time ( MWT ) improved significantly ( p < 0.05 ) in all three groups . In group A the PFWT lengthened by 35 % ( from 101.00 ± 34.56 to 137.32 ± 40.50 s ) and the MWT by 38 % ( from 150.34 ± 55.60 to 207.26 ± 60.67 s ) ; in group B the PFWT lengthened by 90 % ( from 90.65 ± 40.54 to 171.45 ± 55.60 s ) and the MWT by 86 % ( from 145.39 ± 60.50 to 270.63 ± 63.61 s ) . When physical exer cise was associated with drugs as in group C , the PFWT lengthened by 120 % ( from 89.51 ± 43.89 to 196.72 ±51.73 s ) and the MWT by 105 % ( from 160.43 ± 59.84 to 329.05 ± 63.96 s ) . No significant variations were observed at any stage of the study in the ankle/arm pressure ratio at rest and after st and ard treadmill exercise , in the plethysmographic rest and peak flows , or in the trans cutaneous oxygen pressure in basal conditions and in its half recovery time after an induced ischemia . The results confirm the benefits of regular exercise in stage II PAOD pa tients but suggest they may be enhanced by antiplatelet therapy The purpose of this study was to investigate the effects of a progressive resistance training program on myosin heavy chain isoform expression , fiber type , and capillarization in patients with symptomatic peripheral arterial disease . Patients were r and omized to either a training group ( n = 11 , mean + /- SD , 70 + /- 6 years , 4 men , 7 women ) or a control group ( n = 9 , 66 + /- 6 years , 5 men , 4 women ) . The training sessions were completed 3 times/week , using 2 sets of various exercises , each performed for 8 - 15 repetitions . Muscle biopsies were obtained before and after 24 weeks from the medial gastrocnemius . Following the 24-week training program , the training group had significantly decreased the percentage of myosin heavy chain type IIB . The proportion of type IIB/AB fibers as measured by using myosin adenosine triphosphatase histochemistry decreased significantly in the training group . There were significant increases in type I and type II fiber areas , and capillary density also increased significantly in the training group . There were significant increases in 10 repetition maximum leg press and calf press strengths in the trained subjects . There were no significant changes in any of the measurements in the control group . It is concluded that progressive resistance training results in significant increases in muscle strength and alters skeletal muscle composition of subjects with peripheral arterial disease 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 Twenty-three patients with intermittent claudication were su bmi tted to physical training during 4 - 6 months . Eleven other patients with intermittent claudication served as a control group and were given placebo tablets during the same period . The aim of the investigation was to study the influence of physical training on the blood flow conditions in the calf . The effect of treatment on walking tolerance , on calf blood flow , blood flow resistance , and systolic blood pressure graident between the systemic circulation and the vascular bed in the calf was studied . Half a year after the end of the treatment period the patients were reexamined . The walking tolerance increased in both groups but more in the trained group . The increase in walking tolerance even in the control group was caused by the fact that the control group began to train to some extent . In neither group the maximal calf blood flow changed significantly compared with the pretreatment values . The maximal blood flow showed an increasing trend in the training group after a period fo 4 months compared with the control goupr ( 2p greater than 0.10 ) . The blood flow resistance at maximal dilatation did not change significantly as compared with the initial values in any of the groups , but there was a significant difference ( 2p greater than 0.05 ) between the two groups with a decrease in the training group after 4 months . The changes in maximal calf blood flow and the changes in blood flow resistance at maximal dilatation were not related to the changes in walking tolerance . Half a year after the treatment period the walking tolerance had not decreased and there was no difference between the two groups . The maximal calf blood flow , the blood flow resistance , and the systolic pressure gradient were unchanged in comparison with the pretreatment values and there were no statistically significant differences between the two groups . The small changes in blood flow conditions observed after physical training can not be the only factor explaining the well known improvement in walking tolerance . However , training may cause a redistribution of the blood flow in the working muscle PURPOSE We have previously shown that a program of upper limb exercise training can induce significant improvements in walking distance in patients with claudication . This study assessed whether upper limb exercise avoids the systemic inflammatory responses associated with lower limb exercise and also whether the inflammatory response to acute lower limb exertion is modified by a program of supervised exercise training . METHODS Fifty-two patients with stable intermittent claudication were r and omized into two groups who underwent 6 weeks of supervised upper ( n = 26 ) or lower ( n = 26 ) limb cardiorespiratory exercise training . A parallel control group ( n = 15 ) was provided with lifestyle advice only . Neutrophil activation markers ( CD11b and CD66b ) and plasma levels of von Willebr and factor ( marker of endothelial damage ) in response to an acute bout of sustained upper and lower limb exercise were assessed before and after the period of training . Plasma levels of soluble E-selectin ( marker of endothelial activation ) were also determined before and after the training period . RESULTS An acute bout of sustained lower limb exercise significantly increased the intensity of CD11b and CD66b expression by peripheral blood neutrophils in all groups , whereas upper limb exercise had no effect . Resting neutrophil expression of CD11b and CD66b and circulating von Willebr and factor levels were unaffected by the training program , as were the inflammatory responses to an acute bout of sustained upper and lower limb muscular work , despite the fact that both training programs significantly increased walking distances . CONCLUSIONS These findings indicate that upper limb exercise training programs may offer certain advantages over currently prescribed lower limb programs . Our results show that exercising nonischemic muscles in a way that promotes improved cardiorespiratory function and walking capacity can avoid the potentially deleterious systemic inflammatory responses associated with lower limb exertion in patients with stable intermittent claudication 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 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 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 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 PURPOSE To determine whether a percutaneous vascular intervention ( PVI ) combined with supplemental supervised exercise therapy ( SET ) is more effective than a PVI alone in improving walking ability in patients with symptomatic peripheral arterial disease ( PAD ) . MATERIAL S AND METHODS In this prospect i ve r and omized trial , patients with PAD treated with a PVI were eligible . Exclusion criteria were major amputation or tissue loss , comorbidity preventing physical activity , insufficient knowledge of the Dutch language , no insurance for SET , and prior participation in a SET program . All patients received a PVI and subsequently were r and omly assigned to either the PVI alone group ( n = 35 ) or the PVI + SET group ( n = 35 ) . The primary outcome parameter was the absolute claudication distance ( ACD ) . This trial was registered at Clinical trials.gov , NCT00497445 . RESULTS The study included 70 patients , most of whom were treated for an aortoiliac lesion . The mean difference in ACD at 6 months of follow-up was 271.3 m ( 95 % confidence interval [ CI ] 64.0 - 478.6 , P = .011 ) in favor of additional SET . In the PVI alone group , 1 ( 3.7 % ) patient finished the complete treadmill test compared with 11 ( 32.4 % ) patients in the PVI + SET group ( P = .005 ) . Physical health-related quality -of-life score was 44.1 ± 7.8 in the PVI alone group compared with 41.9 ± 9.5 in the PVI + SET group , which was a nonsignificant difference ( P = .34 ) . CONCLUSIONS SET following a PVI is more effective in increasing walking distance compared with a PVI alone . These data indicate that SET is a useful adjunct to a PVI for the treatment of PAD 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 To compare the correlation and practicability of single-stage vs. grade d treadmill protocol s in the assessment of the  absolute claudication distance ( ACD ) .  DESIGN R and omized open study . MATERIAL AND METHODS In 52 patients with peripheral arterial occlusive disease , the ACD on treadmill at 3 km/h and 12 % grade ( constant-load test = C-test ) ranged form 50 to 400 m. The C-test and the grade d-exercise test ( walking on the treadmill at 3 km/h and 0 % gradient for 3 min , with subsequent increase in gradient of 3.5 % every 3 min = G-test ) were carried out at r and om on the same day under st and ardized conditions . RESULTS The ACD was higher in the G-test than in the C-test ( 360.4 + /- 208.8 m vs. 166.5 + /- 93.6 m ; p < 0.001 ) . The coefficients of variation were very similar ( 57.9 % and 56.2 % , respectively ) . In the subgroup of patients with an ACD of between 100 m and 150 m , a large difference was found both for the coefficient of variation ( 58.6 % G-test , 9.6 % C-test ) and for the st and ard deviation ( 339.8 + /- 199.0 m and 133.1 + /- 12.8 m , respectively ) . CONCLUSIONS For the assessment of the ACD in patients with severe claudication the C-test would seem to be more suitable than the G-test OBJECTIVE to compare the effectiveness of invasive therapy , supervised physical training and no treatment in terms of health-related quality of life ( HRQL ) in patients with intermittent claudication ( IC ) . DESIGN a prospect i ve , r and omised , controlled study . MATERIAL S a total of 253 unselected patients with stable IC were sequentially r and omised into 3 balanced treatment groups . At 1 year follow-up data from a battery of generic and disease specific HRQL question naires , and global indices of quality of life and physical condition were available in 171 patients . RESULTS compared with a non-diseased reference group , claudicants were substantially limited in daily physical functioning , but little affected regarding emotional , cognitive and social functioning , or well-being .  Invasive therapy yielded significantly greater improvements in some aspects of physical functioning and walk-related symptoms than training . Training was not superior to invasive therapy on any HRQL dimension and superior to no treatment on only one dimension . Treatment effects , however , were generally small-to-moderate and levels of physical dysfunction in all groups remained higher than reference values . CONCLUSIONS invasive therapy is more effective than supervised training in alleviating illness-specific symptoms and improving certain aspects of physical functioning - the primary HRQL domains impacted on by IC and the principal goals of its treatment . However , since treatment effect sizes were at most moderate and given that untreated claudicants reported at most small deterioration in HRQL , the level of evidence supporting invasive therapy is modest OBJECTIVE 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 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 Supervised walking exercise is an effective treatment to improve walking ability of patients with peripheral artery disease ( PAD ) , but few exercise programs in community setting s have been effective . The aim of this study was to determine the efficacy of a community-based walking exercise program with training , monitoring and coaching ( TMC ) components to improve exercise performance and patient-reported outcomes in PAD patients . This was a r and omized , controlled trial including PAD patients ( n=25 ) who previously received peripheral endovascular therapy or presented with stable claudication . Patients r and omized to the intervention group received a comprehensive community-based walking exercise program with elements of TMC over 14 weeks . Patients in the control group did not receive treatment beyond st and ard advice to walk . The primary outcome in the intent-to-treat ( ITT ) analyses was peak walking time ( PWT ) on a grade d treadmill . Secondary outcomes included claudication onset time ( COT ) and patient-reported outcomes assessed via the Walking Impairment Question naire ( WIQ ) . Intervention group patients ( n=10 ) did not significantly improve PWT when compared with the control group patients ( n=10 ) ( mean±st and ard error : + 2.1±0.7 versus 0.0±0.7 min , p=0.052 ) . Changes in COT and WIQ scores were greater for intervention patients compared with control patients ( COT : + 1.6±0.8 versus −0.6±0.7 min , p=0.045 ; WIQ : + 18.3±4.2 versus −4.6±4.2 % , p=0.001 ) . This pilot using a walking program with TMC and an ITT analysis did not improve the primary outcome in PAD patients . Other walking performance and patient self-reported outcomes were improved following exercise in community setting s. Further study is needed to determine whether this intervention improves outcomes in a trial employing a larger sample size 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 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 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 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 Earlier investigations had shown that an intensive physiotherapy program with 30 treatments in 6 weeks was the most rational therapy for intermittent claudication , but the question whether the therapeutic success could be improved by the addition of " vasoactive " substances remained open . For this reason , bencyclane was added to the basic physiotherapy in a double blind trial involving 109 ambulant patients . 91 or these were evaluated . The treatment group ( n = 45 ) showed a greater increase in walking distance of 21.7 % compared with the placebo group ( n = 46 ) . Also in the evaluation of the therapeutic success rate , the treatment group showed better results ( 84.4 % ) than the placebo group ( 71.7 % ) . From this it can be concluded that the basic physiotherapy can be effectively supported with bencyclane This study reports the initial evaluation of treatment efficiency in 75 patients with intermittent claudication who were r and omized to three treatment groups : 1 ) reconstructive surgery , 2 ) recon structive surgery with subsequent physical training , and 3 ) physical training alone . Before treatment , there were no statistically significant differences between the groups in age , sex , smoking habits , symptom duration of claudication , ankle-arm blood pressure quotient ( ankle-index ) , maximal plethysmographic calf blood flow , symptom-free and maximal walking distance , the history of other atherosclerotic manifestations or in the medical treatment . The walking performance was improved in all three groups at follow-up 13 ± 0.5 months after r and omization . Surgery was most effective , but the addition of training to surgery improved the symptom-free walking distance even further . In pooled observations of the three groups , age , symptom duration , and a history of myocardial ischemic disease correlated negatively with walking performance after treatment . In the operated group , the duration of claudication and a history of myocardial ischemic disease correlated negatively with the walking performance . This was not the case when patients were censored if limited by other symptoms than intermittent claudication after treatment . In the trained group , the duration of claudication correlated negatively to symptom-free and maximal walking distance . Ankle-index and maximal plethysmographic calf blood flow after treatment and the change of these variables with treatment correlated positively with both symptom-free and maximal walking distance when results were pooled for all patients . Although this mainly was a consequence of the improved blood flow after surgery , the change of maximal plethysmographic calf blood flow also correlated with symptom-free but not with maximal walking distance in the trained group . The results demonstrate that , compared with physical training alone , operation alone or in combination with subsequent training are superior treatment modalities in patients with intermittent claudication 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 ) 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 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 The purpose of this study was to determine the impact of increased physical activity and cessation of smoking on the natural history of early peripheral arterial disease . We conducted a r and omised controlled trial in Perth , Western Australia , involving 882 men with early peripheral arterial disease identified via population -based screening using the Edinburgh Claudication Question naire and the ankle : brachial index . Members of the control group ( n = 441 ) received " usual care " from their general practitioner while members of the intervention group ( n = 441 ) were allocated to a " stop smoking and keep walking " regime - a combined community-based intervention of cessation of smoking ( where applicable ) and increased physical activity . Postal follow-up occurred at two and 12 months post-entry into the trial . The main outcome of interest was maximum walking distance . There were no statistically significant differences in the characteristics of the " intervention " and " usual care " groups at recruitment . Follow-up information at two and 12 months was available for 85 % and 84 % of participants , respectively . At 12 months , more men allocated to the intervention group had improved their maximum walking distance ( 23 % vs 15 % ; chi2 = 9.74 , df = 2 , p = 0.008 ) . In addition , more men in the intervention group reported walking more than three times per week for recreation ( 34 % vs 25 % , p = 0.01 ) . Although not statistically significant , more men in the intervention group who were smokers when enrolled in the trial had stopped smoking ( 12 % vs 8 % , p = 0.43 ) . It is concluded that referral of older patients with intermittent claudication to established physiotherapy programs in the community can increase levels of physical activity and reduce disability related to peripheral arterial disease . A combination of simple and safe interventions that are readily available in the community through physiotherapists and general practitioners has the potential to improve early peripheral arterial 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 The purpose of the study was to determine whether patients who participated in an intervention program would improve exercise and foot-care habits , reduce smoking , and would , in turn , have fewer PVD-related illnesses than patients not exposed to the intervention . Eighty-six patients with ankle/ brachial pressure indices of less than 1.0 on one or both legs were r and omly assigned to a study ( N=42 ) or control  ( N=44 ) group . All patients were assessed on a variety of health-related and activity behaviors prior to and again 26 weeks after enrollment in the study . Study patients who participated in the intervention worked with professionals on selecting programs design ed to modify and improve their smoking , exercise , and / or foot-care habits . At the end of 26 weeks , chi-square analysis showed no significant differences between study and control groups on change in smoking and foot care , although the results were in the anticipated direction . Study patients who chose to increase their exercise showed greater increase than control patients in frequency ( p = .001 ) , distance ( p = .007 ) , and length ( p = .002 ) of walks . Although behaviors were modified , especially in the area of exercise , it was felt that longer interventions on a larger sample size are needed 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 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 The purpose of this study was to examine the effects of a 12month exercise program on lower limb movement variability in patients with peripheral arterial disease ( PAD ) . Participants ( n=21 ) with an appropriate history of PAD and intermittent claudication ( IC ) volunteered for this study and were r and omly allocated to either a control group ( CPAD-IC ) ( n=11 ) , which received normal medical therapy and a treatment group ( TPAD-IC ) ( n=10 ) , which received normal medical therapy treatment and a 12month supervised exercise program . All participants underwent 2D joint angular kinematic analysis during normal walking to assess lower limb movement variability and walking speed . Between-group differences were analyzed via mixed measures ANOVA . The 12month supervised exercise program made no significant impact on the lower limb movement variability or walking speed of the TPAD-IC group as determined by either intralimb joint coordination or single joint analysis techniques . Long term supervised exercise programs do not appear to influence the lower limb movement variability of PAD-IC patients INTRODUCTION Though being physically active has associated with a healthier ankle-brachial index ( ABI ) in observational studies , ABI usually does not change with exercise training in patients with peripheral artery disease ( PAD ) . Less is known about the effect of exercise training on ABI in patients without PAD but at high risk due to the presence of type 2 diabetes ( T2DM ) . METHODS Participants ( n = 140 ) with uncomplicated T2DM , and without known cardiovascular disease or PAD , aged 40 - 65 years , were r and omized to supervised aerobic and resistance training 3 times per week for 6 months or to a usual care control group . ABI was measured before and after the intervention . RESULTS Baseline ABI was 1.02 ± 0.02 in exercisers and 1.03 ± 0.01 in controls ( p = 0.57 ) . At 6 months , exercisers vs. controls improved ABI by 0.04 ± 0.02 vs. -0.03 ± 0.02 ( p = 0.001 ) . This change was driven by an increase in ankle pressures ( p < 0.01 ) with no change in brachial pressures ( p = 0.747 ) . In subgroup analysis , ABI increased in exercisers vs. controls among those with baseline ABI < 1.0 ( 0.14 ± 0.03 vs. 0.02 ± 0.02 , p = 0.004 ) , but not in those with a baseline ABI ≥1.0 ( p = 0.085 ) . The prevalence of ABI between 1.0 and 1.3 increased from 63 % to 78 % in exercisers and decreased from 62 % to 53 % in controls . Increased ABI correlated with decreased HbA1c , systolic and diastolic blood pressure , but the effect of  exercise on ABI change remained significant after adjustment for these changes ( β = 0.061 , p = 0.004 ) . CONCLUSION These data suggest a possible role for exercise training in the prevention or delay of PAD in T2DM , particularly among those starting with an ABI < 1.0 . Clinical trials.gov Registry Number : NCT00212303 Objective To analyze the posteffects of a single bout of resistance exercise on cardiovascular parameters in patients with peripheral artery disease ( PAD ) . Design R and omized cross-over . Material s and methods Seventeen PAD patients performed two experimental sessions : control ( C ) and resistance exercise ( R ) . Both sessions were identical ( eight exercises , 3 × 10 repetitions ) , except that the R session was performed with an intensity between 5 and 7 in the OMNI-RES scale and the C session was performed without any load . Systolic blood pressure ( BP ) , diastolic BP , heart rate , and rate – pressure product ( RPP ) were measured for 1 h after the interventions in the laboratory and during 24-h using ambulatory BP monitoring . Results After the R session , systolic BP ( greatest reduction : −6±2 mmHg , P<0.01 ) and RPP ( greatest reduction : −888±286 mmHg × bpm ; P<0.01 ) decreased until 50 min after exercise . From the second hour until 23 h after exercise , BP , heart rate , and RPP product were similar ( P>0.05 ) between R and C sessions . BP load , nocturnal BP fall , and morning surge were also similar between R and C sessions ( P>0.05 ) . Conclusion A single bout of resistance exercise  decreased BP and cardiac work for 1 h after exercise under clinical conditions , and did not modify ambulatory cardiovascular variables during 24 h in patients with PAD Previous studies have demonstrated that supervised strength training ( ST ) or walking training ( WT ) improve walking capacity in patients with claudication . However , it remains unknown whether these improvements would be sustained over a subsequent unsupervised period . This article reports the findings of a study to analyze whether the improvements in walking capacity , achieved with a supervised ST or WT , would be sustained over a subsequent unsupervised therapy period in patients with claudication . Patients were initially r and omized to supervised exercise consisting of ST  ( n = 15 ) or  WT  ( n = 15 ) for 12 weeks . After this period , 12 patients in each group consented to be followed for an additional 12 weeks of unsupervised therapy .  Initial claudication distance ( ICD ) and total walking distance ( TWD ) were measured at baseline , after the supervised period ( Week 12 ) and after the unsupervised period ( Week 24 ) . In comparison with baseline values , both groups similarly increased ICD and TWD at Week 12 . From Week 12 to Week 24 , both groups similarly decreased ICD ( ST : -55 ± 110 m and WT : -82 ± 142 m , P = .04 ) and TWD ( ST : -68 ± 186 m and WT : -128 ± 112 m , P < .01 ) . However , in both groups , ICD ( ST : + 126 ± 149 m and WT : + 50 ± 167 m , P = .01 ) and TWD ( ST : + 104 ± 162 m and WT : + 45 ± 139 m , P = .01 ) at Week 24 remained greater than baseline values . The conclusion is that supervised ST or WT followed by an unsupervised therapy period similarly decreased walking capacity in patients with claudication . However , after the unsupervised period , walking capacity remained at a higher level than before the onset of the supervised exercise-training period 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 Abstract The CLaudication :  Exercise Vs Endoluminal Revascularization ( CLEVER ) study is the first r and omized , controlled , clinical , multicenter trial that is evaluating a supervised exercise program compared with revascularization procedures to treat claudication . In this report , the methods and dissemination techniques of the supervised exercise training intervention are described . A total of 217 participants are being recruited and r and omized to one of three arms : ( 1 ) optimal medical care ; ( 2 ) aortoiliac revascularization with stent ; or ( 3 ) supervised exercise training .  Of the enrolled patients , 84 will receive supervised exercise therapy . Supervised exercise will be administered according to a protocol design ed by a central CLEVER exercise training committee based on vali date d methods previously used in single center r and omized control trials . The protocol will be implemented at each site by an exercise committee member using training methods developed and st and ardized by the exercise training committee . The exercise training committee review s progress and compliance with the protocol of each participant weekly . In conclusion , a multicenter approach to disseminate the supervised exercise training technique and to evaluate its efficacy , safety and cost-effectiveness for patients with claudication due to peripheral arterial disease ( PAD ) is being evaluated for the first time in CLEVER . The CLEVER study will further establish the role of supervised exercise training in the treatment of claudication result ing from PAD and provide st and ardized methods for use of supervised exercise training in future PAD clinical trials as well as in clinical practice Objective : To compare the outcomes of home-based ( using the Heart Manual ) and centre-based cardiac rehabilitation programmes . Design : R and omised controlled trial and parallel economic evaluation . Setting : Predominantly inner-city , multi-ethnic population in the West Midl and s , Engl and . Patients : 525 patients referred to four hospitals for cardiac rehabilitation following myocardial infa rct ion or coronary revascularisation . Interventions : A home-based cardiac rehabilitation programme compared with centre-based programmes . Main outcome measures : Smoking cessation , blood pressure ( systolic blood pressure ( SBP ) , diastolic blood pressure ( DBP ) ) , total cholesterol ( TC ) and high-density lipoprotein (HDL)-cholesterol , psychological status ( HADS anxiety and depression ) and exercise capacity ( incremental shuttle walking test , ISWT ) measured at 12 months . Health service re source use , quality of life utility and costs were quantified . Results : There were no significant differences in the main outcomes when the home-based was compared with the centre-based programme at 12 months . Adjusted mean difference ( 95 % CI ) for SBP was 1.94 mm Hg ( −1.1 to 5.0 ) ; DBP 0.42 mm Hg ( −1.25 to 2.1 ) ; TC 0.1 mmol/l ( −0.05 to 0.24 ) ; HADS anxiety −0.02 ( −0.69 to 0.65 ) ; HADS depression −0.35 ( −0.95 to 0.25 ) ; distance on ISWT −21.5 m ( −48.3 to 5.2 ) . The relative risk of being a smoker in the home arm was 0.90 . The cost per patient to the NHS was significantly higher in the home arm at £ 198 , ( 95 % CI 189 to 208 ) compared to £ 157 ( 95 % CI 139 to 175 ) in the centre-based arm . However when the patients ’ cost of travel was included , these differences were no longer significant . Conclusions A home-based cardiac rehabilitation programme does not produce inferior outcomes when compared to traditional centre-based programmes as provided in the United Kingdom 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
target: 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: 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 .