Peripheral Arterial Disease, Peripheral Vascular Disease

P.A.D. Exercise Group Outcome Audit Pradeep Chockalingam Senior Physiotherapist

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Note

 This audit was presented in North-East

Regional Vascular Conference at Freeman Hospital, Newcastle upon Tyne, U.K on November 2006.

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Aim of this audit  To find out the feasibility & evidence behind

the new outcome measures.  To assess the effectiveness of the new

outcome measures.  To analyse the effectiveness of the exercise

group. www.pdfcoke.com/cpradheep

P.V.D or P.A.D ?  The Intermittent Claudication (I.C) is caused

by the atherosclerosis of the arteries of lower limbs. (Hiatt WR et al 1990)  Vascular is a global term which includes

arteries and veins.  As I.C is caused by the disease of the

arteries, Peripheral Arterial Disease (P.A.D) is the appropriate term. www.pdfcoke.com/cpradheep

Why Exercise group for P.A.D?  Regular exercises improves the walking

ability and delays the onset of claudication pain.  Exercise is an integral part of P.A.D

treatment.  Supervised exercise is superior than the

home based exercise programme. (Hirsch AT et al 2006, Leng GC et al 2000 & Bendermacher BLW et al 2006) www.pdfcoke.com/cpradheep

What participants do ?  It’s a seven week exercise programme, two

sessions per week  First and last classes dedicated for Pre &

Post rehab subjective & objective assessment/data collection.  12 different exercise stations. Participants

work at each station for five minutes for approx 45 minutes. www.pdfcoke.com/cpradheep

What’s New ?  Introduced new Evidence Based Objective &

Subjective outcome measures.  Objective: 6-Minute Walk Test.

 Subjective: Walking Impairment

Questionnaire.  New Database to collect and analyse data

quicker & accurate. www.pdfcoke.com/cpradheep

Why 6-MWT than Treadmill ?  Sensitive, Safe, Simple & Cost effective.  6 MWT is the best alternative to the Treadmill

Test & equally sensitive.  Treadmill test may not reflect daily activity.  More acceptable by Older people as walking

is a day to day activity.  Suitable for the community setup. (Enright PL et al 2003, Scherer SA 2004, Ohtake PJ 2005, Montgomery PS et al 1998) www.pdfcoke.com/cpradheep

Why W.I.Q than SF36 ?  Disease specific.  Simple and straight forward.  Easy to complete compared to SF-36.  Informative and able to assess the patients

point of view.  Able to assess other limiting factors. (Regensteiner JG et al 1990, Scherer SA 2004) www.pdfcoke.com/cpradheep

The Group  Number of groups included in this audit = 3  Total number of participants recruited to this

three groups = 32  Total number of participants completed the

seven week programme = 25  Total number of drop-outs = 7

78% 22% www.pdfcoke.com/cpradheep

The Group  Sex ratio: 2.5 Male:1 Female  Average age: 70 Years  Average height: 171 Centemeters  Average weight: 87 Kilogrames  Average 75% of predicted maximum

6-MWD: 332 Meters (Enright PL et al 2003) www.pdfcoke.com/cpradheep

Claudication Distance 185 180 Pre Post

175 170 165 Claudication Distance

Average Pre rehab (6MWT) : 172 Meters Average Post rehab (6MWT) : 184 Meters (Difference: +12 Meters OR +24%) www.pdfcoke.com/cpradheep

Pre & Post rehab Claudication Distance Difference by % Decline

3

7 No Change

10 5

Improvement Remakrable Improvement

< -9% -9% to +9% 10% to +99% > +99%

=7 =5 = 10 =3 www.pdfcoke.com/cpradheep

Total 6-Minute Walk Distance 310 305 300 Pre Post

295 290 285 280 Total 6-MWD

Average Pre rehab: 290 Meters Average Post rehab: 306 Meters (Difference: +16 Meters or +8%) www.pdfcoke.com/cpradheep

Pre & Post rehab Total 6-MWD Difference by % Decline

1

2

8

No Change

14 Improvement Remarkable Improvement

< -5 % -5 % to +5 % > +5 % to +49 % >+49 %

=2 = 14 =8 =1 www.pdfcoke.com/cpradheep

Total number of rest taken 20 15 Pre Post

10 5 0 Rest

Pre rehab: 18 Average: 0.7 Post rehab: 10 Average: 0.4 (Difference: -8 or +56%) www.pdfcoke.com/cpradheep

What’s the Standards ?  *Claudication distance improvement by 179%.

 *Total walking distance improvement by 122%. (For approx 36 sessions of supervised exercise)

 Similar reflection on the W.I.Q. questionnaire

compared to the 6-MWT results. (*Gardner AW et al 1995,*Schainfeld RM 2001 , Regensteiner JG et al 1990 & Tsai JC et al 2002) www.pdfcoke.com/cpradheep

What’s the Result ?  Claudication distance

improvement = 24%  Total walking distance

improvement = 8%

Predicted 36 sessions result  Claudication distance

improvement = 72 %

(For 12 sessions of supervised exercise)

 Total walking distance

 Similar reflection on the

improvement = 24 %

W.I.Q questionnaire compared to the 6MWT outcome = 50% www.pdfcoke.com/cpradheep

Analysis of Data 180 160 140 120 100

Standards Result Predicted

80 60 40 20 0 Claudication Total 6-MWD Distance

W.I.Q www.pdfcoke.com/cpradheep

Any Improvement ?  Yes, signs of improvement were noted as

Stewart KJ et al 2002 states “benefits have been observed as early as four weeks”.  But results were not up to the standards

mentioned. www.pdfcoke.com/cpradheep

Why Shortfall ? (Duration)  Duration: Very short duration, excluding the

first & the last sessions only six weeks of two sessions per week.  Evidence suggest minimum of three months

with three sessions per week. (Leng GC et al 2000, Hirsch AT et al 2006) www.pdfcoke.com/cpradheep

Why Shortfall ? (Level of Exercise)  Level of exercise: Mild level of exercise.  Papers used intermittent treadmill walking to

maximal tolerance level of pain for approx 30

to 45 minutes per session.

(Hiatt WR et al 1990 & 1994)

 The above is not practical, which may leads

to less compliant from the participants 1999)

(Hunt D et al

and high dropout rate. www.pdfcoke.com/cpradheep

Why Shortfall ? (Participants)  In most studies participants have had only mild

to moderate claudication only.

(Stewart KE et al 2002)

 Our participants were with moderate or severe

claudication and with multiple mobility limiting factors. www.pdfcoke.com/cpradheep

Why Shortfall ? (6-MWT)  Due to time factor unable to do Pre & Post

rehab assessment one person at a time as per the guideline.  Distraction of the examinee by the other

participants (mainly during Post rehab)  Unable to control environment factors of the

hall (Temperature & Humidity level).  Using lots of different examiners. (ATS Statement 2002) www.pdfcoke.com/cpradheep

Why Shortfall ? (Q.o.L)  No one walk with a yard stick

(Participants)

 Over or under predict their own performance

(mainly during Pre rehab)

(Enright PL 2003)

 U.S based Questionnaire. Therefore did few

modification to suite here.  Due to geography of Gateshead most of the

participants struggle to answer properly. www.pdfcoke.com/cpradheep

What we have achieved by the new Outcome Measures ?  Evidence based and most appropriate for this

group of patients.  Sensitive, Safe and Simple.  Well tolerated by the patients and cost effective.  Able to collect and analyse various data at one time.  Able to assess patients perception of other mobility limiting factors. www.pdfcoke.com/cpradheep

Suggestions / Recommendations  Increasing the duration of the group by three

months & three sessions per week.

(Gardner AW et al

1995, Leng GC et al 2000, Chockalingam P 2006)

 Replace the resistance exercise (Arm weights,

Teraband) stations with more functional exercise.

(Hiatt WR et al 1994 & Stewart KJ et al 2002)

 Minimising the examiners.

(ATS Statement 2002)

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Suggestions / Recommendations  Suggesting participants to work to the level 3

of pain & to the perceived exertion level of 4 to 5. (Gardner AW et al 1995 & Leng GC et al 2000)  Conceder altering the standard to local &

feasible level for further audit due to vast difference and limitations in practice compared to the evidence. www.pdfcoke.com/cpradheep

Reference 

ATS Statement 2002: Guidelines for the Six-Minute Walk Test: American Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117.



Bendermacher BLW et al 2006; Supervised Exercise Therapy versus NonSupervised Exercise Therapy for Intermittent Claudication; The Cochrane Database of Systematic Reviews; Iss-2, No CD005263.pub2



Chockalingam P 2006: P.A.D. Exercise Group Patient Questionnaire & Documentation Audit: Gateshead Health NHS Foundation Trust.



Enright PL et al 2003; The 6-min Walk Test: A Quick Measure of Functional Status in Elderly Adults. Chest; Vol 123; Page 387-398.



Enright PL 2003; The Six-Minute Walk Test: Resp Care; Vol-48,No-8, 783-785.



Gardner AW et al 1995; Exercise Rehabilitation Programs for the Treatment of Claudication Pain: A Meta-Analysis: JAMA; Vol-274, No-12, 975-980.



Hiatt WR et al 1990; Benefits of Exercise Conditioning for Patients with Peripheral Arterial Disease; Circulation; Vol-81, No-2;602-609.

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Reference 

Hiatt WR et al 1994; Superiority of treadmill walking exercise versus Strength training for patients with peripheral arterial disease. Implications for the mechanism of the training response: Circulation; Vol-90, 1866-1874.



Hiatt WR et al 1995; Clinical Trials for Claudication: Assessment of Exercise Performance, Functional Status, and Clinical End Points; Circulation; 92:614621.



Hirsch AT et al 2006; ACC/AHA Guidelines for the management of Patients with Peripheral Arterial Disease (Lower Extremity, Renal, Mesentric, and Abdominal Aortic): Journal of the American College of Cardiology; Vol-47, No-6, 1239-1312.



Hunt D et al 1999; Intermittent claudication: Implementation of an exercise programme. Treatment report; Physiotherapy; Vol-83, No-3, 149-153.



Leng GC et al 2000; Exercise for Intermittent Claudication; The Cochrane Database of Systematic Reviews; Iss-2, No: CD000990



Montgomery PS et al 1998: The Clinical utility of a Six-Minute Walk Test in Peripheral Arterial Occlusive Disease Patients; J Ame Geri Society; Vol- 46, No6, 706-711. www.pdfcoke.com/cpradheep

Reference 

Ohtake PJ 2005; Field Tests of Aerobic Capacity for Children and Older Adults; Cardiopulmonary Physical Therapy Journal; Vol 16, N23, Page 5-11&40



Regensteiner JG et al 1990; Evaluation of Walking Impairment by Questionnaire in Patients with Peripheral Arterial Disease; Journal of Vascular Medicine and Biology. Vol- 2, No-3, Page 142-152.



Schainfeld RM 2001: Management of Peripheral Arterial Disease and Intermittent Claudication; J Am Board Fam Pract; Vol-14. No-6, 443-445.



Scherer SA 2004; Research Corner: Functional Outcome Measurements for Patients with Peripheral Arterial Disease; Cardiopulmonary Physical Therapy Journal; Vol 15, No3, Page 23-28.



Stewart KJ et al 2002; Exercise Training for Claudication; The New England Journal of Medicine; Vol-347, Iss-24, Page 1941-1951.



Tsai JC et al 2002; The Effects of Exercise Training on Walking Function and Perception of Health status in Elderly Patients with Peripheral Arterial Occlusive Disease; Journal of Internal Medicine; Vol 252, Page 448-455

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