Peripheral Vascular / Arterial Disease

Peripheral Arterial Disease Pradeep Chockalingam Physiotherapist

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CONTENTS Introduction Nurse Led Claudication Clinic Role of Physiotherapy in PAD clinic Exercise Group Recruitment P.A.D. Exercise Group Class Six Minute Walk Test Walking Impairment Questionnaire P.A.D. Exercise Group Database Reference Appendices

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Appendicies 1, Physiotherapy Initial Assessment & Treatment Sheet 2, Physiotherapy Follow-Up Assessment & Treatment Sheet 3, PAD Exercise Group Registration/Information Sheet 4, 6-MWT Examiner Information Sheet 5, 6-MWT Patient Information Sheets 6, Walking Impairment Questionnaire 7, 6 MWT Lap Count Marking Sheet

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INTRODUCTION Peripheral arterial disease (PAD) is predominantly caused by atherosclerosis leading to reduced blood supply to the legs, which results in ischaemic muscular pain (usually in the calf). Stenosis of the proximal blood vessels means that during activities such as walking the lower limb muscles are starved of arterial blood supply and oxygen (William RH, et al 1995). The symptoms usually subside on cessation of walking and after a few minutes rest the patients are able to continue walking. This is the classic symptom of intermittent claudication and one of the easiest differential diagnoses from neurogenic claudication. The distance at which patients first experience the pain is called the claudication distance. The incidence of PAD and intermittent claudication increases with age. Diagnosis is based upon the symptoms described, history and consideration of risk factors. Many patients go on to have an angiogram to determine the presence and site of the disease. Surgical treatment options are considered if the site of the peripheral vascular disease is amenable to angioplasty or bypass grafting and if the patient is fit and well and wishes to undergo surgery. There is increasing evidence that exercise rehabilitation can be a suitable low cost alternative to surgery for those who are not fit enough or do not wish to undergo surgery. Various hypotheses are suggested to reason out the improvement gained by exercising but still the evidence is inconclusive (Kerry JW et al 2002). Bendermacher BLW et al (2006) and Kerry JW et al (2002) states centre based physical activity programmes are more effective for patients with PAD than home based exercise programmes. The aim of physiotherapy in this patient group is to limit progression, limit lifestyle impact and improve symptoms by risk factor reduction and exercise prescription. Physiotherapists are involved in both in the intermittent claudication clinic and running the exercise group.

NURSE LED CLAUDICATION CLINIC Recent literature is supportive of nurse-led clinics (rather than just consultant clinics) for assessment, monitoring and education of patients with intermittent claudication. It has been found that nurse-led clinics have more time to spend with patients in an educatory and assessment/reassessment role. The patients therefore have less frequent appointments with the vascular consultants, who are fed back information by the nurses as appropriate. The vascular nurse role includes:Initial Assessment    

Past Medical History – with respect to cardiovascular history, past vascular surgery and investigations Family History – with respect to cardiovascular history & diabetes Symptoms – where calf, buttock and thigh, which leg, severity, claudication distance & maximum walking distance Current medication

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 

Smoking status & history Lifestyle and exercise/activity level

Assessment    

Height/Weight/BMI Doppler of dorsalis pedis / tibialis posterior pulses Ankle Brachial Pressure Index (ABPI) – (Ankle systolic BP ÷ Brachial Systolic BP) if less than 0.9 is a sign of lack of blood supply to the particular lower limb. Cholesterol check (if not done recently)

Education for Risk Factor Reduction     

Smoking cessation advice & referral to clinic if patient wishes Diet – recommend reduced intake of saturated fats Exercise – helps promote new blood vessel pathways around blockages / blocked arteries. Where our role comes in Referral to diabetes nurse/chiropodist if appropriate Medications – see below

ROLE OF PHYSIOTHERAPY IN CLAUDICATION CLINIC Aims:    

Promote exercise in the patient group to help improve symptoms & encourage walking. Provide Home Exercise Programme for all patients, whether they are appropriate to attend exercise class or not. Each patient should be provided with a paper copy of their exercise programme. Mark appropriate exercises in the All about Intermittent Claudication (Pink) Booklet, Reference: OPUK/PLE/091 MAY 2004. (Vascular Nurses provide these booklets) Identify patients appropriate for exercise group & place on waiting list if patient willing to attend. Support Nursing staff through reinforcement of lifestyle/risk factor modification.

EXERCISE GROUP RECRUITMENT Usually patients are recruited from the PAD clinic. When ever a new patient fulfils the inclusion criteria, they will be offered the option of participating in the exercise group. If they are willing to attend their name will placed on the waiting list for the next available group. The vascular nurse will also forward a list of patients who have

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had arterial bypass surgery. The vascular consultants may occasionally refer specific patients for the exercise group.

Inclusion Criteria: 

Any Patient with Intermittent Claudication symptoms who are willing to attend. Patients who have had fem pop bypass surgery who have attended for their 6 week follow up appointment.

Exclusion Criteria:     

Low exercise tolerance and poor mobility Pain not resulting from claudication (such as diabetic neuropathy, symptoms from spine etc) Recent MI (check with cardiologists) Unhealed foot wounds as a result of vascular blisters Osteoporosis Attending other hospital rehab classes – eg Pulmonary Rehab, Cardiac Rehab. Need to wait until finished these.

P.A.D. EXERCISE GROUP CLASS Concept of Group Exercises The aim of the groups is to get the patients started on a form of exercise and for them to continue exercising after the classes finish. Ideally it is suggested that to gain significant improvement participants should exercise to achieve near maximal Claudication Pain Scale level-3 (Leng GC et al 2000) and perceived level of exertion to the Bourg Scale level- 4 (NNUH 2004), but practically it may be difficult to achieve or may lead to high numbers of „dropout‟. To avoid dropout and achieve significant outcome from the exercise class it is essential to talk with the participants and suggest they assess their own ability and work within their own limits, advising them to take rest periods when needed in order to allow blood or oxygen demands to be met. Emphasise the need for rests and for the patients not to feel embarrassed to rest as they will all be a different levels. The exercise group is conducted at Gateshead Leisure Centre, Monday and Thursday between 1pm and 2pm in the Sports Hall or Maple Hall. The exercise classes will be 7 week blocks. Patients who have already completed the seven week block may be invited to re-attend if there are spaces available in future classes. Currently patients will only be able to attend for two blocks. Inviting Dawn Harvey (Physical Activity Co-ordinatoer) to the penultimate session is a good idea as this will provide them with the necessary information to continue exercising independently in the community. There are some good articles about running claudication exercise classes in the vascular file. Basically we need as much activity as possible & the research shows

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that upper limb exercises are also beneficial. Laps bouncing balls, dribbling balls with hockey sticks or playing badminton are good ways of including walking without it being so boring. Exercise Sessions The first & final sessions will be 6MWT sessions; this will then give 6 weeks of exercise classes. Session One    

The first session is an introduction. Explain to the patients how the sessions will be run. Complete Pre rehab WIQ Complete a 6MWT for each patient to establish their pre rehab claudication distance & total walking distance (Pls. refer 6MWT protocol). Complete sheet “PVD Exercise Group Registration/Information sheet”, 6MWT scoring sheet, 6MWT patient information sheet which details name, address, GP details, dates of attendance, pre and post rehab 6MWT result and space to document any problems encountered over the course of the sessions.

Sessions 2 to 12  

 

 

Group warm up initially (approximately 5 minutes) Use exercise stations with the patients working in pairs. At each station there is an instruction sheet for the exercise. Where possible there are easier and harder versions for the exercises. Easier versions are printed on white paper and harder or standard versions are printed on blue paper. Patients are given 5 minutes per exercise station. In between circuits get the group to do a lap around the exercise hall, aiming by the end of the group to complete 1 lap of the hall between each exercise station, but at the initial classes maybe only completing a lap every 2-3 stations. Initially patients may spend 5 minutes at each exercise station but as they complete more laps of the hall towards the end the time spent at each station will have to be reduced. Group cool down to finish (approximately 5 minutes) At each session ask the patients individually if they have had any problems after the previous sessions and document if anyone has had any new health problems or exacerbations of existing conditions. Also document any advice you give to the patients regarding this. This information can be documented on the “PAD Exercise Group Registration/Information sheet” (Appendix-5) which will have been completed for each patient at session one. If there are no problems then make a note of this also.

Session 13 

Same format as sessions 2-12 but also at the penultimate session it is a good idea to ask Ms. Dragana Hanzen to come to speak to the group about exercise options available in the community for the patients to continue with after the

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groups are finished. She will advise of groups available and costs involved. You need to email her in as far advance as possible so she can timetable it into her diary. (Email: [email protected]) Provide the patients with theraband exercises and a piece of theraband to complete the exercises with. Agree with the patient the appropriate number of repetitions. This should be documented on the exercise sheet along with any specific instructions/modifications. The frequency of the exercises should also be documented eg 1 or 2 x daily along with the date the exercises are issued. There is a corresponding sheet with the same exercises on in smaller print and any specific instructions/modifications documented on the patient‟s copy of exercises should be duplicated onto this sheet along with the number of repetitions and frequency of exercise.



Session 14 (final session)  

Complete Post rehab WIQ Complete a 6MWT for each patient to establish their post rehab claudication distance & total walking distance (Pls. refer 6MWT protocol). Complete the result on the “PVD Exercise Group Registration/Information” sheet. Ask the patients to complete the evaluation questionnaire to give feedback/evaluate the sessions after the shuttle test. For patients who have only completed one seven week block of exercises ask them if they wish to return again in future should there be any spaces available. Currently patients who have completed two seven week blocks will be unable to return again.

 

SIX MINUTE WALK TEST (6-M.W.T.) William RH, et al 1995 and Susan AS 2004 suggests the Graded Treadmill Test is considered as the Gold Standard tool when assessing this group of patients. However, in a community setup and for practical reasons the 6 MWT is thought to be the best alternative to the Graded Treadmill Test (Paul LE et al 2003, Susan AS 2004, and Patricia JO 2005). Furthermore, the 6 MWT is as sensitive as treadmill test (Tsai et al JC 2002). We follow the ATS Statement 2002 for 6MWT. Modification of 6-MWT from ATS Statement 2002 Only a few modifications have been made to the ATS Statement 2002 guidelines to allow for the availability and time constrains. They are as follows 



The ATS Statement 2002 suggested using minimum of 30 meters distance between the cones, but as the halls length is just above 30 meters it is modified as 20 meters. A chair is provided at the 0 meter, 10 meters, 20 meters and the marking cones will be placed to mark 5 meters and 15 meters. The participants will walk around the 0 meter and the 20 meter chairs. The statement suggested testing one person at a time. Due to time constraints we have modified this to testing 3 or 4 persons at one time giving sufficient

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spacing between them. Explanation is given to the participants suggesting they walk at their on pace not comparing themselves with other participants. Points to consider before doing a 6 MWT    



Go through the Examiner Instruction (Appendix-6) and prepare yourself. All participants should read through the „Participants Information‟ (Appendix7) before undertaking the 6MWT. Keep examiners to a minimum number. Give them a copy of the Examiner Instruction and discuss with them what you are expecting and clarify any uncertainties well in advance. To avoid the lap counting error and for easily calculating the distance when ever the participants reach the 20th meter chair it is marked as participant completed one lap and when the participant reaches the starting point it is marked as second lap. Establish the classic symptom of claudication with the participants either when filling in the registration sheet or when filling in the WIQ form. (Some of the participants may have multiple limiting factors and may give unintentional calls for claudication pain symptoms during the 6 MWT).

6-MWT Compact Disc Audio The ATS Statement suggests using standardised encouragements at the completion of every minute. Due to time constraints (as we are testing more than one person at a time), to eliminate different examiners using different encouragements and to release the practitioner from time keeping, a C.D. has been produced. It goes through the instructions for participants, examiners and the 6-Minute Walk Test. To be on the safe side and to avoid any last minute technical errors it is wise to have a stop watch as a standby. Equipments required for 6MWT.    

6 MWT C.D and Stop watch Tape measure Marking cones 6 MWT Lap Count Marking Sheet (Appendix-9)

Calculating the Predicted 6 Minutes walking distance This is calculated based on a formula derived by Paul LE et al (2003). To calculate the predicted 6 MWD you need to have the following basic details    

Age in years Sex Height in Centimetres Weight in Kilograms

If this data is entered into the PAD Exercise Class Database it will automatically calculate and give the reading in column “I”.

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WALKING IMPAIRMENT QUESTIONNAIRE (WIQ) William RH, et al 1995, Susan AS 2004 and TASC suggest that subjective Quality of Life outcome assessment should also be assessed in this patient group. “SF-36” was tried in the P.A.D. clinic and it was dropped due to its lengthy, complex and time consuming factors. WIQ is a disease specific QoL outcome measure developed by Regensteiner JG et al 1990. During March 2006 WIQ was first introduced to the Exercise group at the QEH, Gateshead. It is still under trail so the full WIQ (Appendix-8) is at the moment only used in the exercise group and the symptoms associated with walking impairment section are used in the clinic. The advantages of this questionnaire are that it is:  Disease specific.  Simple and straight forward.  Easy to complete compared to SF-36.  Informative and able to assess the patient point of view.  Able to assess other limiting factors.

P.A.D. EXERCISE GROUP DATABASE For each group create a new database. It‟s a Pre-Programmed database which will do some automatic calculations if data is entered in the appropriate columns. As this database is a little complicated and in order to create a new one, the easiest way is to copy a blank pre-prepared database, then past it to the system and rename it with the next groups starting month and year. The following will explain the functions of each column and what data to enter in it. Information recorded:Column A: Column B: Column C: Column D: Column E: Column F: Column G: Column H: Column I: Column J: Column K: Column L: Column M:

Name Date of Birth Contact Number Note Age Sex (Use 17 for Male & 0 for Female patients) Height in Centimetres Weight in Kilograms Database will automatically calculate the 75% of the maximum 6MWD (Please do not enter any data here) Pre Rehab Claudication Distance (If no claudication distance is recorded enter the 6MWD) Pre Rehab 6MWD Database will automatically calculate the Pre rehab Walking Speed (Please do not enter any data here) Database will automatically calculate the Pre rehab Walking performance percentage compared to the 75% of max 6MWD (Please do not enter any data here)

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Column N: Column O: Column P: Column Q: Column R:

Column S: Column T:

Column U:

Column V:

Column W:

Column X: Column Y: Column Z: Column AA: Column AB: Column AC: Column AD: Column AE: Column AF: Column AG: Column AH:

Column AI:

Column AJ: & Further

Pre Rehab number of rest taken during 6MWT Post Rehab Claudication Distance (If no claudication distance is recorded enter the 6MWD) Post Rehab 6MWD Database will automatically calculate the Post rehab Walking Speed (Please do not enter any data here) Database will automatically calculate the Post rehab Walking performance percentage compared to the 75% of max 6MWD (Please do not enter any data here) Post Rehab number of rest taken during 6MWT Database will automatically calculate the difference between Pre & Post rehab Claudication distance. Positive figure is an improvement. (Please do not enter any data here) Database will automatically calculate the difference between Pre & Post rehab 6MWD. Positive figure is an improvement. (Please do not enter any data here) Database will automatically calculate the percentage of Post rehabe Claudication distance compared to Pre rehab performance. Above 100 is an improvement. (Please do not enter any data here) Database will automatically calculate the percentage of Post rehabe 6MWD compared to Pre rehab performance. Above 100 is an improvement. (Please do not enter any data here) Pre rehab WIQ Distance factor data Database will automatically calculate the percentage of Pre rehab WIQ Distance factor. (Please do not enter any data here) Pre rehab WIQ Speed factor data Database will automatically calculate the percentage of Pre rehab WIQ Speed factor. (Please do not enter any data here) Pre rehab number of factors affecting mobility Post rehab WIQ Distance factor data Database will automatically calculate the percentage of Post rehab WIQ Distance factor. (Please do not enter any data here) Post rehab WIQ Speed factor data Database will automatically calculate the percentage of Post rehab WIQ Speed factor. (Please do not enter any data here) Post rehab number of factors affecting mobility Database will automatically calculate the difference between Pre & Post rehab WIQ Distance factor Percentage. (Please do not enter any data here) Database will automatically calculate the difference between Pre & Post rehab WIQ Speed factor Percentage. (Please do not enter any data here) Class daily attendance

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REFERENCE ATS Statement (2002): Guidelines for the Six-Minute Walk Test: American Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117. (http://ajrccm.atsjournals.org/cgi/reprint/166/1/111) Bendermacher BLW et al 2006; Supervised Exercise Therapy versus Non-Supervised Exercise Therapy for Intermittent Claudication; The Cochrane Database of Systematic Reviews; Iss-2, No CD005263.pub2 Kerry JW et al 2002; Exercise Training for Claudication; The New England Journal of Medicine; Vol-347, Iss-24, Page 1941-1951 Leng GC 2000; Exercise for Intermittent Claudication; The Cochrane Database of Systematic Reviews; Iss-2, No: CD000990 Norfolk and Norwich University Hospital 2004; Patient Information: Exercise Classes for patient with Intermittent Claudication. Norfolk and Norwich University Hospital NHS Trust. Patricia JO 2005; Field Tests of Aerobic Capacity for Children and Older Adults; Cardiopulmonary Physical Therapy Journal; Vol 16, N23, Page 5-11&40. Free access from NHS Journal Database (Pro-Quest) Paul LE et al (2003); The 6-min Walk Test: A Quick Measure of Functional Status in Elderly Adults. Chest; Vol 123; Page 387-398. www.chestjournal.org/cgi/content/full/123/2/387 (free access). 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. Susan AS 2004; Research Corner: Functional Outcome Measurements for Patients with Peripheral Arterial Disease; Cardiopulmonary Physical Therapy Journal; Vol 15, No3, Page 23-28. Free access via NHS Journal Database (Pro-Quest) TransAtlantic Inter-Society Consensus (TASC); Management of Peripheral disease; The TransAtlantic Inter-Society Consensus; www.tasc-pad.org/html/index.htm; accessed between 05.02.2006 and 09.07.2006 Tsai et al JC 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 William RH et al 1995; Clinical Trials for Claudication: Assessment of Exercise Performance, Functional Status, and Clinical End Points; Circulation; 92:614-621; http://circ.ahajournals.org/cgi/content/full/92/3/614 free online access

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APPENDIX-1

PHYSIOTHERAPY P.A.D. CLINIC INITIAL ASSESSMENT & TREATMENT DATE: NAME:

HOSPITAL NUMBER:

DoB:

TELEPHONE:

ADDRESS:

Calves R/L

SYMPTOMS:

Buttock R/L

Thigh R/L

Others

CURRENT MOBILITY

:

CLAUDICATION DISTANCE

:

WIQ SCORE

:

PAST MEDICAL HISTORY:  MI

CABG

Heart Failure

Angina

 CVA/TIA O.A Hip/Knee

Osteoporosis

R.A

D.M

Anxiety /Depression

COPD/Asthma

Hypertension

TREATMENT / ADVICE / EXERCISES GIVEN:  Personal Exercise program High / Medium / Low issued & explained.  Issued All about Intermittent Claudication Booklet (OPUK/PLE/091 MAY 2004).  Walk as much as possible.  Continue your own Exercises / Activities as usual.  Others

WILLING / APPROPRIATE FOR EXERCISES GROUP:  Willing / Not Willing

NAME:

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 Yes / No

SIGNED:

APPENDIX - 2

PHYSIOTHERAPY P.A.D. CLINIC FOLLOW-UP ASSESSMENT & TREATMENT DATE: NAME:

HOSPITAL NUMBER:

DoB:

TELEPHONE:

ADDRESS:

SYMPTOMS:

Calves R/L

Buttock R/L

Thigh R/L

Others

CURRENT MOBILITY

:

CLAUDICATION DISTANCE

:

WIQ SCORE

:

TREATMENT / ADVICE / EXERCISES GIVEN:  Personal Exercise program progressed to High / Medium / Low issued & explained.  Walk as much as possible.  Continue your own Exercises / Activities as usual.  Others

FOLLOW-UP ASSESSMENT:  Improved

 Unchanged

Walking Distance & Claudication Pain Declined

FOLLOW-UP PLAN:  Review in NAME: Pradeep Chockalingam

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 Discharged SIGNED:

APPENDIX - 3

P.A.D. Exercise Group Registration & Information Sheet NAME: HOSPITAL NUMBER: DoB:

G.P. NAME & ADDRESS:

TELEPHONE: ADDRESS:

Height:

Cm.

Weight:

Kg.

PAST MEDICAL HISTORY:  MI

CABG

Heart Failure

Angina

 CVA/TIA O.A Hip/Knee

Osteoporosis

R.A

D.M

Anxiety /Depression

COPD/Asthma

Hypertension

MEDICATIONS:

PREDICTED 6MWD

:

PRE REHAB 6-MWT SCORE (CD: TD) SPEED

: :

, % of Pre 6MWD: Kms/H

%

POST REHAB 6-MWT SCORE (CD: TD) : SPEED :

, % of Pre 6MWD: Kms/H

%

(6-MWD/T: 6 Minute Walk Distance/Test, CD: Claudication Distance, TD: Total Distance)

CLAUDICATION DISTANCE IMPROVEMENT :

%

TOTAL DISTANCE IMPROVEMENT

%

:

(<90% = Decline, 91 to 105% = No change, >105% = Improvement)

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APPENDIX - 4 Six-Minute Walking Test Instructions To the examiner 

Stand near the starting line during the test.



Do not walk with the patient. Do not talk to anyone during the walk.



As soon as the patient starts to walk, start the timer.



Watch the patient. Do not get distracted and lose count of the laps.



Each time the participant completes a lap mark on the worksheet. Let the participant see you do it. Exaggerate the click using body language.



If the patient stops walking during the test and needs a rest, say this: "You can sit if you would like; then continue walking whenever you feel able." Do not stop the timer.



Please mark the time when participant complains of claudication pain symptom as well as the rest and restart time.



Inform the participant after completion of every minute and 15 seconds before end of the test. At the end of 6 minutes say this: "Stop!" and walk over to the patient and mark the spot where they stopped by placing a bean bag or a piece of tape on the floor.



Please use the standard phrases given below under the heading “Encouragement” when informing the participant after completion of every minute,15 seconds before end of the test and at the end of 6 minutes.



Record the additional distance covered (the number of meters in the final partial lap).



If the patient stops before the 6 minutes are up and refuses to continue (or if you decide that they should not continue), wheel the chair over for the patient to sit on, discontinue the walk, and note on the worksheet the distance, the time stopped, and the reason for stopping prematurely.



Reasons to immediately stop a 6MWT include the following:

chest pain,

intolerable dyspnea, leg cramps, exes of sweating, and pale appearance.

The above guidance is based on: ATS Statement: Guidelines for the Six-Minute Walk Test. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. American Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117, (2002)

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APPENDIX - 5 Six-Minute Walking Test Instructions To the participants 

The object of this test is to walk as far as possible for 6 minutes.



You will walk back and forth in this hallway around the marker cones (20 meters).



Pleas inform the examiner immediately when you start feeling the claudication pain on your legs.



Six minutes is a long time to walk, you will probably get claudication pain or out of breath or become exhausted.



Walk at your own pace. This test is to asses your progress. It’s not a competition or comparison with others performance, so please walk at your own pace and take rest if you required.



You are permitted to slow down, to stop, and to rest as necessary.



You may rest in the chair provided near the track, but resume walking as soon as you are able.



You will be walking back and forth around the cones.



You should pivot briskly around the cones and continue back the other way without hesitation.



I am going to use this chart to keep track of the number of laps you complete. I will tick it each time you turn around at this starting line.



I will inform you after completion of every minute and 15 seconds before end of the test. At the end of 6 minutes I will tell you to stop. When I do, just stop right where you are and I will come to you.



The object is to walk AS FAR AS POSSIBLE for 6 minutes, but don't run or jog.

Demonstrate:

(Walking one lap by the examiner.)

The above guidance is based on: ATS Statement: Guidelines for the Six-Minute Walk Test. ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. American Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117, (2002)

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APPENDIX - 6 Walking Impairment Questionnaire Name:

DoB:

Date:

1, Walking Distance: For each of the following distances, report the degree of difficulty that best describes how hard it was for you to walk WITHOUT stopping to rest. 3 2 1 Manage With some With much Difficulty walking a distance during the past well difficulty difficulty month / week Walking indoors (around the house)

Walking 17 yards / 50 feet

Walking 50 yards / 150 feet

Walking 100 yards / 300 feet

Walking 200 yards / 600 feet

Walking 300 yards / 900 feet

Walking 500 yards or more / ¼ mile (Distance Conversion table, 100 yards = 300 feet = 90meter) 2, Walking Speed: These questions refer to HOW FAST you were able to walk 100 yards. Tell us the degree of difficulty required for you to walk at each of these speeds WITHOUT stopping to rest. 3 2 1 0 Manage With some With much Difficulty walking at a certain well difficulty difficulty Unable to speed during the past month / do week Walking 100 yards/300 feet slowly?

Walking 100 yards/300 feet at an average speed?

Walking 100 yards/300 feet quickly?

Running or jogging 100 yards/300 feet? (Distance Conversion table, 100 yards = 300 feet = 90meter)

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0 Unable to do

3, Symptoms associated with walking impairment: To what extend do you think the following affects your walking.

Symptoms associated with walking impairment

3

2

1

0

No

Slight

Some

Much

Pain or aching in your calves?

Pain or aching in your thighs/buttocks?

Pain, stiffness or aching in your joints (knees or hips)?

Pain or discomfort in your chest?

Weakness in one or both of your legs?

Shortness of breath?

Heart palpitations?

Other problems? (please list)

Modified from: Regensteiner JG, Steiner JF, Panzer RJ and Hiatt WR: Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease. J Vas Med and Bio12:142-152, 1990

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APPENDIX - 7 Six-Minute Walking Test Name:

DoB:

Symptoms: Calves R/L

Date:

Buttock R/L

Thigh R/L

Others

1 Pain Rest

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

50

Claudication Distance

:

6 Minutes Distance

:

Reason for stopping the test:

Any comments:

Name of the examiner

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