title: Muscle enzyme adaptation in patients with peripheral arterial insufficiency: spontaneous adaptation, effect of different treatments and consequences on walking performance. Extending the range of treadmill testing for patients with intermittent claudication. Cost-effectiveness of endovascular revascularization compared to supervised hospital-based exercise training in patients with intermittent claudication: a randomized controlled trial. Strength training increases walking tolerance in intermittent claudication patients: randomized trial. Treadmill versus shuttle walk tests of walking ability in intermittent claudication. The Birmingham rehabilitation uptake maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation
abstract: 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 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 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 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 PURPOSE To compare treadmill and shuttle walk tests for assessing functional capacity in patients with intermittent claudication , with respect to test-retest reliability , cardiovascular responses , and patient preferences . METHODS Patients with stable intermittent claudication ( N = 55 , ages 52 - 85 yr , median age 68 yr ) were recruited from the Sheffield Vascular Institute at the Northern General Hospital , Sheffield , UK . Each patient performed an incremental shuttle walk test , a constant-pace shuttle walk test , and a st and ardized treadmill test ( 3.2 km x h(-1 ) , 12 % gradient ) , each on three occasions . The incremental shuttle walk began at 3 km x h(-1 ) and increased by 0.5 km x h(-1 ) every minute , whereas the constant-pace shuttle walk was performed at the fixed pace of 4 km x h(-1 ) . Claudication distance ( CD ) , maximum walking distance ( MWD ) , heart rate ( HR ) , and blood pressure were assessed in each testing session . The patients also completed a test preference question naire . RESULTS CD and MWD for both shuttle walks were greater than the corresponding walking distances achieved in the treadmill test ( P < 0.001 ) . Average coefficients of variation for repeated incremental shuttle walk , constant-pace shuttle walk , and treadmill tests were 15.9 % , 21.1 % , and 18.7 % , respectively , for MWD , corresponding to average intraclass correlation coefficients of 0.87 , 0.82 , and 0.87 . Treadmill walking evoked greater increases in HR and blood pressure ( P < 0.001 ) , and fewer patients expressed a preference for it ( 24 vs 43 % for shuttle walking ) . CONCLUSION These findings indicated that shuttle walk testing exhibits similar test-retest reliability as treadmill testing , but that it evoked a lower level of cardiovascular stress and is preferred to treadmill testing by a large proportion of patients Objective : 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
target: The effect of exercise compared with placebo or usual care was inconclusive on mortality , amputation and peak exercise calf blood flow due to limited data .
  Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained .
  Exercise programmes were of significant benefit compared with placebo or usual care in improving walking time and distance in selected patients with leg pain from IC
background: BACKGROUND Exercise programmes are a relatively inexpensive , low-risk option compared with other more invasive therapies for leg pain on walking ( intermittent claudication ( IC ) ) .
  OBJECTIVES To determine the effects of exercise programmes on IC , particularly in respect of reduction of symptoms on walking and improvement in quality of life .