TY - JOUR
AU1 - Prévost, Alain
AU2 - on behalf the CEPTA educational team
AU3 - Lafitte, Marianne
AU4 - on behalf the CEPTA educational team
AU5 - Pucheu, Yann
AU6 - on behalf the CEPTA educational team
AU7 - Couffinhal, Thierry
AU8 - on behalf the CEPTA educational team
AB - Abstract Background Supervised exercise programs increase physical performance in patients with peripheral artery disease (PAD). However, there are a limited number of programs, and to date they have failed to provide evidence of long-term adherence to exercise or any meaningful effect on Quality of Life (QoL). We created a program of therapeutic education and a personalized program of reconditioning exercise for patients with PAD. Methods Patients with an ankle-brachial index (ABI) below 0.9 in at least one limb, and an absolute claudication distance (ACD) ≤500 meters, were included in the study. Quality of Life (QoL) as measured by SF-36, cardiovascular risk factors and functional parameters were evaluated at 0, 3, 6 and 12 months. Results Forty-six patients completed the program. Cardiovascular risks were controlled and stabilized over time. SF-36 scores improved significantly and remained stable. Initial and absolute claudication distance (ICD and ACD) as well as other functional parameters improved significantly (6 months: +138 m or +203% ICD and +139 m or +84% ACD). Ten patients (22%) did not show improvement in ICD or ACD within the first 3 months, but their SF-36 score did increase at subsequent visits. Interestingly, these patients had a significantly lower ACD at baseline. Conclusions This study measured beneficial effects of an educational therapeutic program for patients with PAD. The results demonstrate a significant improvement in functional and QoL parameters during the first 3 months of coaching, and long-term persistence of the results even when patients were no longer coached. Peripheral artery disease, therapeutic education, exercise programs, Quality of Life, (QoL), cardiovascular risks Introduction Approximately 10 to 20% of adults >55 years old have been diagnosed with peripheral artery disease (PAD), a percentage that is likely to increase as the population ages.1 PAD confers a heightened risk of cardiovascular morbidity and mortality.2 Patients with PAD, have classic claudication or atypical leg symptoms, which limits their mobility and hastens physical decline, leading to physical disability.3–6 These patients also have lower self-reported health related Quality of Life (QoL) along with a higher prevalence of depression.7,8 Treatment for PAD typically aims at improving walking performance and QoL.9 The accepted first-line treatment strategy is risk-factor management and exercise training. Exercise combined with comprehensive secondary prevention has the potential to benefit patients by reducing limb symptoms, improving exercise capacity, preventing or lessening physical disability, and decreasing the occurrence of cardiovascular events.10,11 Systematic reviews have shown that supervised exercise training (SET) programs produce clinically relevant increases in walking time (mean 5 min) and distance (mean 100 m).12–14 A number of barriers restrict patients with PAD from participating in SET programs, including a limited number of centers, limited capacity of each center, high transportation costs, lack of physician referral, patient willingness to participate, and medical comorbidities. Additionally, even SET programs that are able to demonstrate improvement in functional measures, have not yet provided evidence of long-term adherence to exercise or demonstrated a clear effect on long term QoL. Moreover, effects of supervision are unclear.15,16 In contrast, home-based programs are less effective at improving walking ability than SET programs, but may lead to higher long-term adherence to exercise, with lower cost to the healthcare system16 and increased daily physical activity which may have other health benefits.14,17 We hypothesized that a program focused on the needs of patients with PAD might lead to improved long-term progress in walking distance, QoL and adherence. We created a home-based program taking into account the patient’s social, familial and professional life. The program combined educational classes, implementation of secondary prevention18 and a personalized program of reconditioning exercise.19 Methods Patients Patients were recruited following a four-day cardiovascular check-up and completion of an initial educational program, previously described.20,21 Patients were included in the study if they had level II Leriche and Fontaine intermittent claudication or atypical symptoms, with an ankle-brachial index (ABI) below 0.9 in at least one limb, and an absolute claudication distance (ACD) ≤500 meters as assessed with a standardized treadmill test. At the time of enrollment all patients were receiving optimal medical treatment, and were not scheduled for peripheral surgery. Patients were excluded from the study if they had critical limb ischemia, foot ulcers, inability to walk on a treadmill, major surgery or an acute coronary syndrome within the past 3 months, significant cognitive impairment or psychiatric instability, or insufficient command of the French language. The Ethics Committee review board of the hospital (CPP SOOM III, Bordeaux) approved the study protocol, and all participants provided informed consent prior to participation. Educational workshops Educational workshops were designed with the aim of empowering patients. Individual empowerment reinforces health promoting behaviors and encourages the patient to take more control over events and important situations in their life.22 It also contributes to the development of problem-solving skills and increases both self-esteem and self-reliance.23 These workshops explored topics such as belief and representation of the illness, self-esteem, decision-making, developing relationships with support networks, and improvement in living conditions. Six discussion workshops plus monthly interviews and 10 telephone contacts were conducted over the first 3 months. The final workshop was designed to have patients summarize changes they experienced in managing their disease. Telephone coaching During the first 2 months patients benefited from weekly telephone contact designed to provide motivation, assist with problem solving, and help with adjusting to the home training objectives. During month 3 telephone contact was reduced to every 2 weeks, in preparation for the next 3 months during which no telephone contact was planned. Exercise regimen description Reconditioning to exercise, coupled with educational sessions, was based upon the Test-In/Train-out (TiTo) approach of Manfredini,19,24 although the walking program was less structured. During educational sessions we assisted each patient in defining their walking objectives with the overall goal of 30 to 40 minutes of effective walking time, at least every 2 days. Walking intensity was established at a speed corresponding to the individual’s maximal asymptomatic speed. Patients were instructed to keep the duration of each session constant during the study period, although they were encouraged to increase their walking intensity and frequency of exercise if possible. Follow-up The SF-36 outcome questionnaire, in its validated French language format,25 was administered to patients to assess QoL. Analysis was carried out utilizing the Physical and Mental Composite scores using the on-line algorithm (SF36.org). Functional testing was measured using one of 2 motorized treadmill testing protocols based upon patient capabilities: grade at 0% and speed at 2.4 km/hr or grade at 10% and speed at 3.2 km/hr. Two protocols were used to allow for enrollment of a wider group of patients, including those unable to tolerate the more challenging protocol. The same treadmill protocol chosen for a patient at baseline was used throughout the program for a given patient.26 The following parameters were calculated from the treadmill test (detailed protocol provided in supplementary material):26–28 Initial claudication distance (ICD), distance patient can walk on the treadmill without experiencing pain in the limb(s). Absolute claudication distance (ACD), maximal distance patient can walk on a treadmill. Percentage increase in ICD/baseline = (ICD at 3 months − ICD at baseline)/ICD at baseline *100. We then calculated the mean of each % increase in ICD and ACD. Intensity of pain, as rated on the Pain Numerical Scale. Time of pain release, measured using a stopwatch. Ankle-Brachial Index (ABI) calculation, as previously described.29 Patients were also evaluated on a 10-meter walk test and a 5-chair sit-up test, as previously described (detailed protocol provided in supplementary material).27,28 Program design The program was implemented over a 12-month period and divided into 3 phases: Phase I, month 0 to 3: QoL and functional endpoints evaluated at baseline and 3 months. Patients participated in educational workshops once a month, trained at home and had regular telephone contact. Phase II, month 3 to 6: patients trained at home without supervision. The final educational workshop and evaluation of function endpoints were conducted at 6 months. Phase III, month 6 to 12: patients trained at home without supervision, education or contact. The final evaluation of functional endpoints was conducted, and patient satisfaction questionnaires were administered at 12 months. Statistics Continuous variables are described as mean and standard deviation. Categorical variables are described as numbers and proportions. The percentage of ‘non-responders’ was estimated by the number of patients that did not show any improvement in ICD or ACD during the first 3 months, divided by the total number of patients. Ninety-five percent confidence intervals of proportions and incidence rates were calculated by the exact binomial method. All analyses were carried out using NCSS software. Results Study population Between February 2009 and May 2011 56 consecutive patients with intermittent claudication from our clinic were eligible for the study. Eight patients refused to be enrolled, 4 due to a lack of motivation, and 4 due to either distance from the clinic, or the onset of new medical problems. Two patients dropped out the program prematurely, with a diagnosis of major depressive disorder. The remaining 46 patients completed the 12-month follow-up period, and none of them had a cardiovascular event or underwent a peripheral vascular intervention. Patient characteristics and risk profile Baseline characteristics are summarized in Table 1 (and supplementary material Table 1). Most patients were retired, had experienced a myocardial infarction or stroke, and half had a history of peripheral revascularization. All patients had lesions in the superficial femoral, popliteal or infra popliteal artery. Half of the population had additional iliac artery lesions but without indication of revascularization. Most cardiovascular risks were controlled prior to initiation of the study and remained stabile throughout the course of the study, with the exception of cigarette consumption (supplementary material Table 1). Table 1. Baseline characteristics of patients enrolled in the study n = 46 . Age (years) 60.3 ± 8 Female gender (%) 13.0 Socio-economic status (%)  Retired 58.7  Working 19.5  Unemployed 6.5  Invalid 15.3 History of cardiovascular disease (%)  Myocardial infarction 60.8  Stroke 28.2 History of Peripheral Revascularization (%)  Stent 26.0  Bypass 26.0  Other 13.0 Positivity of Edinburgh  Claudication Questionnaire (%) 100 Significant lesion location (%)  Aorto-iliac 56.2  Femoral 89.1  Popliteal and infra popliteal 21.7 History of invalidating arthritis,  spinal stenosis, disk disease (%) 17.3 n = 46 . Age (years) 60.3 ± 8 Female gender (%) 13.0 Socio-economic status (%)  Retired 58.7  Working 19.5  Unemployed 6.5  Invalid 15.3 History of cardiovascular disease (%)  Myocardial infarction 60.8  Stroke 28.2 History of Peripheral Revascularization (%)  Stent 26.0  Bypass 26.0  Other 13.0 Positivity of Edinburgh  Claudication Questionnaire (%) 100 Significant lesion location (%)  Aorto-iliac 56.2  Femoral 89.1  Popliteal and infra popliteal 21.7 History of invalidating arthritis,  spinal stenosis, disk disease (%) 17.3 Open in new tab Table 1. Baseline characteristics of patients enrolled in the study n = 46 . Age (years) 60.3 ± 8 Female gender (%) 13.0 Socio-economic status (%)  Retired 58.7  Working 19.5  Unemployed 6.5  Invalid 15.3 History of cardiovascular disease (%)  Myocardial infarction 60.8  Stroke 28.2 History of Peripheral Revascularization (%)  Stent 26.0  Bypass 26.0  Other 13.0 Positivity of Edinburgh  Claudication Questionnaire (%) 100 Significant lesion location (%)  Aorto-iliac 56.2  Femoral 89.1  Popliteal and infra popliteal 21.7 History of invalidating arthritis,  spinal stenosis, disk disease (%) 17.3 n = 46 . Age (years) 60.3 ± 8 Female gender (%) 13.0 Socio-economic status (%)  Retired 58.7  Working 19.5  Unemployed 6.5  Invalid 15.3 History of cardiovascular disease (%)  Myocardial infarction 60.8  Stroke 28.2 History of Peripheral Revascularization (%)  Stent 26.0  Bypass 26.0  Other 13.0 Positivity of Edinburgh  Claudication Questionnaire (%) 100 Significant lesion location (%)  Aorto-iliac 56.2  Femoral 89.1  Popliteal and infra popliteal 21.7 History of invalidating arthritis,  spinal stenosis, disk disease (%) 17.3 Open in new tab Educational seminar compliance Each patient was offered 6 educational seminars over the course of the first 3 months of the study. A total of 93.4% of patients attended the recommended number of educational seminars. Patient satisfaction Patient satisfaction with the program was assessed through a questionnaire administrated at 12 months, completed by 95.6% of patients. Three main categories were assessed: Quality, duration, topics and benefit of the group educational sessions: 97.7% of the patients reported they were ‘very satisfied’. Scope, quality and benefits of individual discussion: 95.5% of the patients reported they were ‘very satisfied’. Attitude toward walking with their claudication and physical self-confidence: 52.2% of the patients reported they were ‘very satisfied’, while 36.3% reported they were ‘satisfied’. Quality of life (QoL) The SF-36 Physical Composite score improved significantly during the first 3 months, due to improvements in the subscales of physical functioning, role-physical, and pain. The Mental Composite score also improved significantly over the same period of time. These improvements remained stable over the 12-month follow-up period (Table 2). Table 2. Quality of life as expressed by SF-36 score SF-36 . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Physical composite score 36.0 ± 7 40.8 ± 9** 41.9 ± 7** 42.3 ± 9** Mental composite score 41.6 ± 12 45.2 ± 11* 44.7 ± 10* 44.2 ± 9 SF-36 . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Physical composite score 36.0 ± 7 40.8 ± 9** 41.9 ± 7** 42.3 ± 9** Mental composite score 41.6 ± 12 45.2 ± 11* 44.7 ± 10* 44.2 ± 9 * p < 0.05, **p < 0.01, compared to baseline. Open in new tab Table 2. Quality of life as expressed by SF-36 score SF-36 . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Physical composite score 36.0 ± 7 40.8 ± 9** 41.9 ± 7** 42.3 ± 9** Mental composite score 41.6 ± 12 45.2 ± 11* 44.7 ± 10* 44.2 ± 9 SF-36 . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Physical composite score 36.0 ± 7 40.8 ± 9** 41.9 ± 7** 42.3 ± 9** Mental composite score 41.6 ± 12 45.2 ± 11* 44.7 ± 10* 44.2 ± 9 * p < 0.05, **p < 0.01, compared to baseline. Open in new tab Hemodynamic and functional outcomes The mean ICD increased from 94 at baseline to 234 meters at 3 months and remained stable. The mean ACD showed a similar pattern, improving from 273 at baseline to 408 meters at 3 months. The percentage of progression for each patient (which is independent of the baseline level of ICD and ACD) showed a 277% and a 63% gain in ICD and ACD, respectively, as compared to baseline, during the first 3 months. At 12 months, the increase from the initial reading was 141% for ICD and 65% for ACD (Table 3). Table 3. Hemodynamic and functional outcome data . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Rest ABI  Worse lower limb 0.70 ± 0.1 0.71 ± 0.1 0.72 ± 0.1 0.70 ± 0.1  Better lower limb 0.89 ± 0.1 0.88 ± 0.1 0.88 ± 0.1 0.87 ± 0.1 Post-walk ABI  Worse lower limb 0.36 ± 0.1 0.38 ± 0.1 0.41 ± 0.1 0.42 ± 0.1  Better lower limb 0.59 ± 0.2 0.62 ± 0.2 0.64 ± 0.2 0.66 ± 0.2 Initial Claudication Distance (ICD) (m) 94 ± 83 234 ± 245** 234 ± 268** 286 ± 260** % increase in ICD/baseline 277 203 141 Absolute Claudication Distance (ACD) (m) 273 ± 227 408 ± 248** 443 ± 265** 460 ± 267** % increase in ACD/baseline 63 84 65 Intensity of pain 5.89 ± 2.4 4.73 ± 2.8* 4.34 ± 3.4** 4.53 ± 3.0* Time of pain release (min) 3.95 ± 2.5 3.11 ± 2.4 2.01 ± 1.5** 2.83 ± 2.7** 10-Meter walking velocity  Normal pace (cm/sec) 116 ± 16 120 ± 18 121 ± 17** 124 ± 17*  Fastest pace (cm/sec) 175 ± 34 172 ± 30 176 ± 36 181 ± 36  Repeated chair rises (sec) 9.04 ± 2.8 8.35 ± 2.0* 7.88 ± 2.0** 7.48 ± 1.7** . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Rest ABI  Worse lower limb 0.70 ± 0.1 0.71 ± 0.1 0.72 ± 0.1 0.70 ± 0.1  Better lower limb 0.89 ± 0.1 0.88 ± 0.1 0.88 ± 0.1 0.87 ± 0.1 Post-walk ABI  Worse lower limb 0.36 ± 0.1 0.38 ± 0.1 0.41 ± 0.1 0.42 ± 0.1  Better lower limb 0.59 ± 0.2 0.62 ± 0.2 0.64 ± 0.2 0.66 ± 0.2 Initial Claudication Distance (ICD) (m) 94 ± 83 234 ± 245** 234 ± 268** 286 ± 260** % increase in ICD/baseline 277 203 141 Absolute Claudication Distance (ACD) (m) 273 ± 227 408 ± 248** 443 ± 265** 460 ± 267** % increase in ACD/baseline 63 84 65 Intensity of pain 5.89 ± 2.4 4.73 ± 2.8* 4.34 ± 3.4** 4.53 ± 3.0* Time of pain release (min) 3.95 ± 2.5 3.11 ± 2.4 2.01 ± 1.5** 2.83 ± 2.7** 10-Meter walking velocity  Normal pace (cm/sec) 116 ± 16 120 ± 18 121 ± 17** 124 ± 17*  Fastest pace (cm/sec) 175 ± 34 172 ± 30 176 ± 36 181 ± 36  Repeated chair rises (sec) 9.04 ± 2.8 8.35 ± 2.0* 7.88 ± 2.0** 7.48 ± 1.7** * p < 0.05, **p < 0.01, compared to baseline. Open in new tab Table 3. Hemodynamic and functional outcome data . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Rest ABI  Worse lower limb 0.70 ± 0.1 0.71 ± 0.1 0.72 ± 0.1 0.70 ± 0.1  Better lower limb 0.89 ± 0.1 0.88 ± 0.1 0.88 ± 0.1 0.87 ± 0.1 Post-walk ABI  Worse lower limb 0.36 ± 0.1 0.38 ± 0.1 0.41 ± 0.1 0.42 ± 0.1  Better lower limb 0.59 ± 0.2 0.62 ± 0.2 0.64 ± 0.2 0.66 ± 0.2 Initial Claudication Distance (ICD) (m) 94 ± 83 234 ± 245** 234 ± 268** 286 ± 260** % increase in ICD/baseline 277 203 141 Absolute Claudication Distance (ACD) (m) 273 ± 227 408 ± 248** 443 ± 265** 460 ± 267** % increase in ACD/baseline 63 84 65 Intensity of pain 5.89 ± 2.4 4.73 ± 2.8* 4.34 ± 3.4** 4.53 ± 3.0* Time of pain release (min) 3.95 ± 2.5 3.11 ± 2.4 2.01 ± 1.5** 2.83 ± 2.7** 10-Meter walking velocity  Normal pace (cm/sec) 116 ± 16 120 ± 18 121 ± 17** 124 ± 17*  Fastest pace (cm/sec) 175 ± 34 172 ± 30 176 ± 36 181 ± 36  Repeated chair rises (sec) 9.04 ± 2.8 8.35 ± 2.0* 7.88 ± 2.0** 7.48 ± 1.7** . Baseline . 3 month . 6 month . 12 month . n = 46 . n = 46 . n = 46 . n = 46 . Rest ABI  Worse lower limb 0.70 ± 0.1 0.71 ± 0.1 0.72 ± 0.1 0.70 ± 0.1  Better lower limb 0.89 ± 0.1 0.88 ± 0.1 0.88 ± 0.1 0.87 ± 0.1 Post-walk ABI  Worse lower limb 0.36 ± 0.1 0.38 ± 0.1 0.41 ± 0.1 0.42 ± 0.1  Better lower limb 0.59 ± 0.2 0.62 ± 0.2 0.64 ± 0.2 0.66 ± 0.2 Initial Claudication Distance (ICD) (m) 94 ± 83 234 ± 245** 234 ± 268** 286 ± 260** % increase in ICD/baseline 277 203 141 Absolute Claudication Distance (ACD) (m) 273 ± 227 408 ± 248** 443 ± 265** 460 ± 267** % increase in ACD/baseline 63 84 65 Intensity of pain 5.89 ± 2.4 4.73 ± 2.8* 4.34 ± 3.4** 4.53 ± 3.0* Time of pain release (min) 3.95 ± 2.5 3.11 ± 2.4 2.01 ± 1.5** 2.83 ± 2.7** 10-Meter walking velocity  Normal pace (cm/sec) 116 ± 16 120 ± 18 121 ± 17** 124 ± 17*  Fastest pace (cm/sec) 175 ± 34 172 ± 30 176 ± 36 181 ± 36  Repeated chair rises (sec) 9.04 ± 2.8 8.35 ± 2.0* 7.88 ± 2.0** 7.48 ± 1.7** * p < 0.05, **p < 0.01, compared to baseline. Open in new tab Intensity and time of pain release improved significantly during the first 6 months, and remained stable during the last 6 months, over baseline values. The 10-meter walking velocity and repeated chair rises showed consistent and significant improvement over the 12 months follow-up period (Table 3). Responders versus non- responders Ten patients (22%) did not show improvement in their ICD or ACD within the first 3 months, and these patients were deemed ‘non-responders’. To identify prognostic factors of ‘non-responders’ we analyzed characteristics of these patients and compared them to ‘responders’, those patients that did improve their ICD and ACD in the first 3 months. The baseline socio-economic status, medical history, lesion location and risk profile characteristics of non-responders were not different from those in the responder group (supplementary material Table 2). It is important to note that there was an improvement in management of cardiovascular risks in the non-responder group (data not shown). The main difference between the 2 groups was that ACD was significantly lower at baseline in the non-responder group (supplementary material Table 3). Interestingly, the physical SF-36 scores that were lower in the non-responder group in the first 3 months increased in the following 3 months, and no difference was detected between the 2 groups at 6 months (supplementary material Table 4). In summary, patients that did not improve ACD during the first 3 months of the program still experienced an improvement in QoL and control of their risk factors at 6 and 12 months. Discussion In this study we measured potential beneficial effects of a 3-month educational therapeutic approach in patients with PAD. We enrolled patients who are traditionally excluded from such programs due to confounding factors including cardiac disease, diabetes, and smoking status. The issues evaluated in long-term follow-up were; QoL, control of risk factors, hemodynamic and functional parameters. The results showed a significant improvement in functional and QoL parameters during the first 3 months, and a long-term persistence of these results. Rationale We created a program based upon the needs of patients with PAD and addressed these in different educational sessions30. Coaching sessions constituted a distinctive feature of the program and allowed patients to stay in contact with the hospital while remaining in their home environment. Through these sessions individual patient challenges were identified and addressed, whether physical or psychological. A walking regimen was also included in our program based on each patient’s own objectives. Our hypothesis was that patients who choose to adopt health promoting behavior patterns would have better long-term adherence to regular walking activity, than those who participate in short-term trainings offered in a SET program.14,16 In a recent publication McDermott et al.31 reported the results of a home-based walking exercise program utilizing a group-mediated cognitive behavioral intervention, in a treatment naïve population of patients with PAD. Their results at 6-months showed a mild improvement in walking endurance, speed and physical activity. Quality of Life (QoL) autonomy In patients with PAD the predominant factors that affect QoL are fatigue, loss of activity, social and occupational limitations, associated body pain as well as the presence of mood disorders. Our study confirmed that PAD was associated with low global QoL. The educational program led to a significant improvement in physical and psychological QoL, autonomy and cardiovascular risk factor control. Our data indicate that this improvement can be obtained at minimal cost, even in patients who do not functionally improve due to exercise training.24,32 Functional Improvements Improvements observed in our program at 6 months (mean + 140 m/203% increase in ICD and mean +170 m/84% increase in ACD) were better or in the range of variations observed following the original TiTo program (59% increase in ICD, 62% increase in ACD).19 SET programs have been reported to be more efficient than home-based training programs however, the level of improvement is difficult to evaluate.12–14,16 In a 2008 analysis comparing randomized controlled trials of an exercise regimen versus control Watson showed that ICD was increased overall by mean 82 m (with an improvement of 75% to 200%,) and ACD by mean 113 m with a 100% improvement, in six trials.12 More recently analysis of a large SET program in the Netherlands reported an increase of mean 205 to 273 m of ACD after 3 months (with an improvement of 78 to 100%).33 Long-term effects While home-based programs have been reported to be less efficient than SET programs in terms of functional improvement, they may lead to a significantly higher long-term adherence rates.13,14,16,19 In the current report, during the 12-month follow-up, patients showed significant persistence in their functional improvement as well as control of their cardiovascular risk factors. The long-term improvement of QoL parameters observed in this population may help to explain these results. One risk factor that remained high in this population was cigarette consumption. It is important to note that prior to enrollment, 33% of patients had stopped smoking as a result of their first educational program in risk factor reduction. The remaining 46% who continued to smoke upon enrollment could be considered ‘resistant’ to modification in their smoking habit and may need more time to control their cigarette intake. Non-responders One out of 4 patients did not show a significant improvement in ICD and ACD during the first 3 months of the program. Importantly, QoL and risk factor control were significantly improved in this group, despite the lack of functional progress. We could reasonably conclude that there is a direct beneficial effect of the educational approach on these parameters. Even with limited improvement in physical limitations and pain, patients gained autonomy, and were empowered. A low ACD at baseline may be a predictor for the lack of functional improvement. Limits The limited number of patients precluded an extensive power correlation analysis. Important parameters are missing from our analysis: (1) evaluation of monthly average distance covered by patient’s at home (due to lack of objective measurement or self-reported distance) (2) evaluation of anxiety-depressive disorders, which are powerful limitation to training (3) the lack of a control group, although it should be noted that all patients had previously benefited from a prior therapeutic and educational program without improvement in physical limitation and QoL before entering this study. Conclusion The results of our study indicate that vascular specialists should develop therapeutic educational programs combined with home-based trainings for their patients with PAD, as these patients could benefit from such programs. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Conflict of interest The authors declare that there is no conflict of interest. References 1 Lloyd-Jones D , Adams R, Carnethon Met al. . Heart disease and stroke statistics 2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee . Circulation 2009 ; 119 : 480 – 486 . Google Scholar Crossref Search ADS PubMed WorldCat 2 Steg PG , Bhatt DL, Wilson PWet al. . One-year cardiovascular event rates in outpatients with atherothrombosis . JAMA 2007 ; 297 : 1197 – 1206 . Google Scholar Crossref Search ADS PubMed WorldCat 3 McDermott MM , Liu K, Greenland Pet al. . Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms . JAMA 2004 ; 292 : 453 – 461 . Google Scholar Crossref Search ADS PubMed WorldCat 4 Hirsch AT , Criqui MH, Treat-Jacobson Det al. . Peripheral arterial disease detection, awareness, and treatment in primary care . JAMA 2001 ; 286 : 131713 – 24 . Google Scholar Crossref Search ADS WorldCat 5 McDermott MM , Guralnik JM, Ferrucci Let al. . Asymptomatic peripheral arterial disease is associated with more adverse lower extremity characteristics than intermittent claudication . Circulation 2008 ; 117 : 2484 – 2491 . Google Scholar Crossref Search ADS PubMed WorldCat 6 McDermott MM , Ferrucci L, Simonsick EMet al. . The ankle brachial index and change in lower extremity functioning over time: the Women's Health and Aging Study . J Am Geriatr Soc 2002 ; 50 : 238 – 246 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Smolderen KG , Hoeks SE, Pedersen SSet al. . Lower-leg symptoms in peripheral arterial disease are associated with anxiety, depression, and anhedonia . Vasc Med 2009 ; 14 : 297 – 304 . Google Scholar Crossref Search ADS PubMed WorldCat 8 Regensteiner JG , Hiatt WR, Coll JRet al. . The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Program . Vasc Med 2008 ; 13 : 15 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat 9 Dormandy J , Heeck L, Vig S. The natural history of claudication: risk to life and limb . Semin Vasc Surg 1999 ; 12 : 123 – 137 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 10 Hamburg NM , Balady GJ. Exercise rehabilitation in peripheral artery disease: functional impact and mechanisms of benefits . Circulation 2011 ; 123 : 87 – 97 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Casillas JM , Troisgros O, Hannequin Aet al. . Rehabilitation in patients with peripheral arterial disease . Ann Phys Rehabil Med 2011 ; 54 : 443 – 461 . Google Scholar Crossref Search ADS PubMed WorldCat 12 Watson L , Ellis B, Leng GC. Exercise for intermittent claudication . Cochrane Database Syst Rev 2008 , pp. CD000990 – CD000990 . Google Scholar OpenURL Placeholder Text WorldCat 13 Guidon M , McGee H. One-year effect of a supervised exercise programme on functional capacity and quality of life in peripheral arterial disease . Disabil Rehabil 2013 ; 35 : 397 – 404 . Google Scholar Crossref Search ADS PubMed WorldCat 14 Fakhry F , Spronk S, de Ridder Met al. . Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication . Arch Phys Med Rehabil 2011 ; 92 : 1066 – 1073 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Wind J , Koelemay MJ. Exercise therapy and the additional effect of supervision on exercise therapy in patients with intermittent claudication. Systematic review of randomised controlled trials . Eur J Vasc Endovasc Surg 2007 ; 34 : 1 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat 16 Ashworth NL , Chad KE, Harrison ELet al. . Home versus center based physical activity programs in older adults . Cochrane Database Syst Rev. 2005 , pp. CD004017 – CD004017 . Google Scholar OpenURL Placeholder Text WorldCat 17 Thompson PD , Buchner D, Pina ILet al. . Exercise and physical activity in the prevention and treatment of atherosclerotic cardiovascular disease: a statement from the Council on Clinical Cardiology (Subcommittee on Exercise, Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity) . Circulation 2003 ; 107 : 3109 – 3116 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Hankey GJ , Norman PE, Eikelboom JW. Medical treatment of peripheral arterial disease . JAMA 2006 ; 295 : 547 – 553 . Google Scholar Crossref Search ADS PubMed WorldCat 19 Manfredini F , Malagoni AM, Mascoli Fet al. . Training rather than walking: the test in -train out program for home-based rehabilitation in peripheral arteriopathy . Circ J 2008 ; 72 : 946 – 952 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Lafitte M , Barandon L, Pucheu Yet al. . After acute coronary syndrome, diabetic patients with peripheral vascular disease remain at high risk of cardiovascular events despite secondary prevention measures . Arch Cardiovasc Dis 2010 ; 103 : 97 – 105 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Lafitte M , Pradeau V, Leroux Let al. . Efficacy over time of a short overall atherosclerosis management programme on the reduction of cardiovascular risk in patients after an acute coronary syndrome . Arch Cardiovasc Dis 2009 ; 102 : 51 – 58 . Google Scholar Crossref Search ADS PubMed WorldCat 22 St-Cyr Tribble D , Gallagher F, Bell Let al. . Empowerment interventions, knowledge translation and exchange: perspectives of home care professionals, clients and caregivers . BMC Health Serv Res 2008 ; 8 : 177 – 177 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Aujoulat I , Luminet O, Deccache A. The perspective of patients on their experience of powerlessness . Qual Health Res 2007 ; 17 : 772 – 785 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Malagoni AM , Vagnoni E, Felisatti Met al. . Evaluation of patient compliance, quality of life impact and cost-effectiveness of a ‘test in-train out' exercise-based rehabilitation program for patients with intermittent claudication . Circ J 2011 ; 75 : 2128 – 2134 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Ware JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection . Med Care 1992 ; 30 : 473 – 483 . Google Scholar Crossref Search ADS PubMed WorldCat 26 Duprez D , de Backer T, de Buyzere M, Clement DL. Estimation of walking distance in intermittent claudication: need for standardization . Eur Heart J 1999 ; 20 : 641 – 644 . Google Scholar Crossref Search ADS PubMed WorldCat 27 McDermott MM , Ades P, Guralnik JMet al. . Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: a randomized controlled trial . JAMA 2009 ; 301 : 165 – 174 . Google Scholar Crossref Search ADS PubMed WorldCat 28 McDermott MM , Greenland P, Liu Ket al. . The ankle brachial index is associated with leg function and physical activity: the Walking and Leg Circulation Study . Ann Intern Med 2002 ; 136 : 873 – 883 . Google Scholar Crossref Search ADS PubMed WorldCat 29 Lafitte M , Pucheu Y, Latry Ket al. . Predictors of cardiovascular prognosis in patients receiving optimized secondary prevention measures after acute coronary syndrome . Eur J Prev Cardiolo 2013 ; 20 : 283 – 290 . Google Scholar Crossref Search ADS WorldCat 30 Aujoulat I , Marcolongo R, Bonadiman Let al. . Reconsidering patient empowerment in chronic illness: a critique of models of self-efficacy and bodily control . Soc Sci Med 2008 ; 66 : 1228 – 1239 . Google Scholar Crossref Search ADS PubMed WorldCat 31 McDermott MM , Liu K, Guralnik JMet al. . Home-based walking exercise intervention in peripheral artery disease: a randomized clinical trial . JAMA 2013 ; 310 : 57 – 65 . Google Scholar Crossref Search ADS PubMed WorldCat 32 van Asselt AD , Nicolai SP, Joore MAet al. . Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a ‘go home and walk' advice . Eur J Vasc Endovasc Surg 2011 ; 41 : 97 – 103 . Google Scholar Crossref Search ADS PubMed WorldCat 33 Nicolai SP , Teijink JA, Prins MH. Multicenter randomized clinical trial of supervised exercise therapy with or without feedback versus walking advice for intermittent claudication . J Vasc Surg 2010 ; 52 : 348 – 355 . Google Scholar Crossref Search ADS PubMed WorldCat © The European Society of Cardiology 2015 This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © The European Society of Cardiology 2015
TI - Education and home based training for intermittent claudication: functional effects and quality of life
JF - European Journal of Preventive Cardiology
DO - 10.1177/2047487313512217
DA - 2015-03-01
UR - https://www.deepdyve.com/lp/oxford-university-press/education-and-home-based-training-for-intermittent-claudication-XY3moF8SlK
SP - 373
EP - 379
VL - 22
IS - 3
DP - DeepDyve
ER -