Individual Exercise Programming for
Claudication Due to PAD
Mark A. Patterson, M.Ed., RCEP - Clinical Exercise Physiologist
Kaiser Permanente – Colorado
Department of Cardiovascular Services
Medical History Minute
Claudication: Where did the name
come from?
 The word "claudication" comes
from the Latin "claudicare"
meaning to limp. The Roman
emperor Claudius (who ruled
from A.D. 41-54) was so named
because he limped, probably
because of a birth defect.
(medterms.com).
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Prevalence?
Peripheral Artery Disease
 PAD is a marker of systemic atherosclerosis.
risk of coronary artery disease (CAD) and cardiovascular events

 Estimated 8 + million people in the United States have PAD.
 Approximately 12% of the adult population (Bulmer/Coombes), and about
20% of adults over the age of 70 years have PAD.
 Smokers over 70 and diabetics over 50-60 years of age significantly
increase the prevalence.
 Under diagnosed because it often presents with atypical or even no
symptoms at all.
Olin et al, Performance Measures for Adults with PAD
JACC Vol. 56, No. 25, 2010
Bulmer AC, Coombes JS, Optimising exercise training in peripheral artery
disease. Sports Med. 2004; 34 (14); 983-1003
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Criqui MH. The ankle-brachial index and incident cardiovascular
events in the MESA (Multi-Ethnic Study of Athlerosclerosis) J Am
Coll Cardiol 2010; 56: 1506-12.
Claudication: Only from PAD?
Other Types of Claudication
 Spinal Canal Stenosis
 Peripheral Nueropathy
 Neuromuscular Pain (i.e. herniated disks)
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How Do We Misinterpret?
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1. Varying interpretations of pain.
2. Variations in definition of different walking speeds.
3. Participants have altered their speed and walking habits due to the pain over time.
Gardner, AW. Exercise performance in patients with peripheral arterial disease who have
different types of exertional leg pain; J Vasc Surg 2007; 46: 79-86
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?
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Typical Symptoms
During Exercise, Usually with Walking
 Cramping
 Tightness
 Pressure
 “Charley Horse”
Origin of Charlie Horse – Named after an old white horse by the
name of Charley. While pulling heavy loads the animal’s legs
stiffened so that he walked as if troubled with strained tendons.
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Less Obvious Claudication Symptoms
With Exercise, Usually Walking
 Ache
 Burning
 Fatigue
Similar to angina from the heart, we have found over the years that this
discomfort can come in various forms. When taking a history, it is important
to establish a pattern of exertional symptoms that do not have another
cause such as neuromuscular or musculoskeletal origins.
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Co-Morbidities / Limitations
What is really the most limiting issue?
 Orthopedic / Arthritic
 Chronic Fatigue
 Fibromyalgia
 Depression
 Neuromuscular Limitations
 Cardiovascular
 Pulmonary
 Cancer
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PAD and Decreased Activity Cycle
Risk Factors: Smoking,
Sedentary behavior, Cholesterol,
blood pressure, diabetes, age,
genetics, etc.
EXERCISE?
Progression of atherosclerotic
lesions: ABI < 0.90
EXERCISE?
Symptoms: Person may have typical
symptoms, atypical symptoms or
even remain asymptomatic.
EXERCISE?
Functional Limitations: Increased
sedentary behavior decreased
strength, endurance, joint and
muscle stiffness, impaired gait,
onset of joint injuries, etc.
EXERCISE?
Disease process flourishes:
Cardiovascular events, Critical leg
ischemia, increased risk of cancer
and other potential life altering
conditions. EXERCISE?
EXERCISE!
Referred for exercise, better late than
never. But, is much harder to be an
effective therapy when it referred this
late.
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PAD and Decreased Activity Cycle
100
80
60
Active
40
Sedentary
20
0
0
2
4
6
8
yrs yrs yrs yrs yrs
Approximate Survival Rates Between Active vs. Sedentary Patients with PAD
Sedentary was described as scoring 0 or 1 on the Johnson Space Center Physical
Activity Scale (0=avoid physical activities whenever possible, 1= light physical activities
done occasionally) Active described as 2 or higher (2=moderate physical activities done
regularly for less than 1 hour per week)
Adapted in part from Gardner, AW, Physical activity is a predictor of all-cause mortality in patients with
intermittent claudication. J Vasc Surg 2008; 47:117-22
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Possible mechanisms of functional impairment and benefits of exercise
Adapted in part from Hamburg and Balady, Exercise rehabilitation in peripheral artery disease: Functional impact and mechanisms
of benefits. Circulation. 2011;123:87-97 and Kerry, S., et al, Exercise Training for Claudication, N Engl J Med, VOl. 347, No 24.
December 12, 2002
Mechanism of Impairment
Benefit of Exercise
Arterial obstruction
Collateral flow
Endothelial dysfunction
Improved NO vasodilation, increased
capillary density
Impaired hyperemic response
Improved hyperemic blood flow
Increased inflammation
Ischemia at any given workload-evidence of
decreased systemic inflammation
Mitochondrial dysfunction-impaired energy
production
Improved mitochondrial energetics
Decreased muscle metabolism, oxygen extraction,
oxygen utilization increased lactate production
In mitochondrial biogenesis, improved
oxidative metabolism and oxygen extraction
Inflammatory activation – adverse skeletal muscle
remodeling
Decreased markers of systemic
inflammation
Decreased walking economy – decline in walking
speed, increased energy cost
walking mechanics, reduction in O2 cost
of exercise
Increased blood viscosity and red cell aggregation
Improved blood viscosity-improved oxygen
availability to muscles.
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How Does Exercise Measure Up?
Adapted in part from , Kerry, S., et al, Exercise Training for Claudication, N Engl J Med, VOl. 347, No 24. December 12, 2002, Gardner et al, Exercise Rehabilitation Programs for the
Treatment of Claudication Pain JAMA. 1995;274: 975-980, Beebe et al, A new pharmacological treatment for intermittent claudication: Results of a randomized, multi-center trial Arch
Internal Med. 1999:159: 2041-50, Dawson et al, A comparison of Cilostazol and Pentoxifylline for treating intermittent claudication, Am J Med. 2000; 109: 523-530, PAD Coalition Website
(September 2011) www.padcoalition.org, Ratliff, D.A., Supervised Exercise Training for Intermittent Claudication: Lasting Benefit at Three Years; Eur J Vasc Endovasc Surg, 34, 322e-326,
2007, Bulmer AC, Coombes JS, Optimising exercise training in peripheral artery disease. Sports Med. 2004; 34 (14); 983-1003, Regensteiner JG; Exercise rehabilitation for the patient with
intermittent claudication: A highly effective yet underutilized treatment; Current Drug Targets – Cardiovascular and Haematological Disorders, 2004, 4, 233-239
Treatment
Result
Safety
Comments
Exercise
120% to 400%
(depending on study)
improvement in time to
onset of pain and total
exercise time.
Safe, effective,
cardiovascular
morbidity-mortality is
rare.
Direct impact on risk
and issues of functional
decline
Percutaneous
Intervention
Immediate symptom
<0.5% morbidity and
relief (most of the time), mortality
improvement in
maximal walking
distance similar to that
of walking.
Higher re-stenosis rate
than with coronary PCI /
stenting, limited due to
anatomy, does not
correct underlying
issues leading to
progression of PAD and
functional decline.
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How Does Exercise Measure Up?
-ContinuedTreatment
Result
Safety
Comments
Surgical
Revascularization
Symptom relief,
improvement in
maximal walking
distance of 75-100%
2-3% mortality, 5-10%
morbidity
Considerably higher
risk therapy, long
recovery time, does not
correct underlying
issues leading to
progression of PAD and
functional decline
Medications
Cilostazol appears to
be superior to
Pentoxifylline, results
vary but up to 100%
improvement in onset to
symptoms and over
150% improvement in
maximal walking
distance.
Cilastazol
contraindicated in those
with CHF, potential drug
side effects, frequent GI
upset with Pentoxifylline
Not consistently as
effective as exercise,
potential side effects
undesirable, does not
correct underlying
issues leading to
progression of PAD and
functional decline
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Exercise Testing
 Usually Treadmill Testing
 Note onset of symptoms
 Note total walking time
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 Strongly consider pain
trajectory
 Heart Monitoring?
Exercise Prescription-What is Considered Best?
TOP 4!
WALKING
WALKING
WALKING
WALKING
BUT, IS IT REALLY THE BEST?
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Walking
 Walk to pain tolerance, rest, repeat
– 100-250% improvements in onset of pain and
total distance (Ratliff)
– Put in perspective?
 What about pain free, go slow and long?
– Can work
– Progress not as good as intervals (Barak)
– May be best place to start for some
Ratliff, D.A., Supervised Exercise Training for Intermittent Claudication:
Lasting Benefit at Three Years; Eur J Vasc Endovasc Surg, 34, 322e-326,
2007
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Barak, S. Benefits of low-intensity pain-free treadmill exercise on functional
capacity of individuals presenting with intermittent claudication due to
peripheral arterial disease. Angiology / Vol 60, No 4, August/September 2009
Bike
 Treadmill superior to bike (Sanderson)
 Walking may improve if can cycle at high
enough intensities to elicit pain
(Sanderson)
 May improve adherence to exercise if can
perform with less pain (Turner)
 Might consider incorporating into multimode approach
Sanderson B. Short-term effects of cycle and treadmill training on exercise
tolerance in peripheral arterial disease. J Vasc Surg 2006; 44: 119-27
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Turner SL. Cardiopulmonary responses to treadmill and cycle erogometry
exercise in patients with peripheral vascular disease. J Vasc Surg 2008; 47:
123-50.
Strength Exercises
 Generally, Walking Still Wins
 What about research?
– No consistency
– Rigid protocols
– No real individualization
 Weakness an Equal Partner?
 Specificity and Individuality is the Key
Mary M. McDermott; Philip Ades; Jack M. Guralnik; et al. Treadmill exercise
and resistance training in patients with peripheral artery disease with or
without intermittent claudication: A randomized controlled trial. JAMA.
2009;301(2):165-174
Ritti-Dias, Strength training increases walking tolerance in intermittent
claudication patients: Randomized trial. J Vasc Surg 2010; 51:89-95.
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Hiatt, WR. Peripheral arterial and aortic diseases: 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(4), October 1994, 1866-1874.
Arm Cranking?
 Increase Maximal Walking Distance
(MWD)
 Increase in time to onset symptoms
 Treadmill still better in MWD – Specificity?
 Suggest general cardiovascular
conditioning effect?
Walker, RD. Influence of upper and lower limb exercise training on
cardiovascular function and walking distances in patients with intermittent
claudication. J Vasc Surg 2000;31:662-9
Tew, Limb-specific and cross-transfer effects of arm-crank exercise training in
patients with symptomatic peripheral artery disease; Clinical Science (2009)
117; 405-413
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Treat-Jacobson, et al, Efficacy of arm-ergometry versus treadmill exercise
training to improve walking distance in patients with claudication; Vasc Med
2009; 14; 203
Volume and Intensity
Days Per Week
3
Minutes Per Session
30 to 60
Weeks of Training
12 to 24
Total Volume of Training
2000 to 3000 minutes
Work to Rest Ratio
? Ideal ?
Intensity
? Ideal ?
Bulmer AC, Coombes JS, Optimising exercise training in peripheral artery
disease. Sports Med. 2004; 34 (14); 983-1003
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© 2011 Kaiser Foundation Health Plan, Inc. For internal use only.
How to Measure Progress
Exercise Testing
 Objective
 Subjective
 Specificity (does their exercise
regimen uses the same mode in
which you test)
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How to Measure Progress
Pain Trajectories
 Typical: onset of pain, then maximal
exercise tolerance.
 Trajectory: Progression of the severity.
 Use to identify more subtle changes.
 Explaining changes in trajectories may help
with demonstrating progress to patients.
Treat-Jacobson, et al, The Pain Trajectory During Treadmill Testing in
Peripheral Artery Disease, Nursing Research, May/June 2011, 60:3S:S38-S49
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Pain Trajectories
What’s The Profile?
5
4
3
2
1
0
Linear
Slow But Sure
Source: Text is 9pt Arial Narrow
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Fast Rise
How to Measure Progress
Careful documentation of their initial and subsequent descriptions
 Get accurate information on their claudication symptoms.
 Time to first onset, total time, how many stops
 What it feels like, how it progresses (trajectory)
 Activities of Daily Living vs. Exercise
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Home Vs. Clinic
 Lack of outpatient programs
 Supervised Programs Generally Superior to Home Based
 Key to any program – Adherence
 The more support the better – especially for home based programs
VS.
Roberts, AJ. Physiological and functional impact of an unsupervised but
supported exercise programme for claudicants. Eur J Vasc Endovasc Surg
(2008) 36; 319e – 324
Wullink, M. A primary care walking exercise program for patients with
intermittent claudication. Med Sci Sports Exerc Vol 33 Ni10, 2001, pp 16291634
Patterson, RB. Value of a supervised exercise program for the therapy of
arterial claudication. J Vasc Surg, Vol 25(2), February 1997: 312-319
Gardner, AW. Efficacy of quantified home-based exercise and supervised
exercise in patients with intermittent claudication. Circulation 2011; 123:491498.
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Troubleshooting
“I am not getting better, my leg still hurts when I exercise”
 One of the most common complaints
 Get details on how far they are going, how long it takes them,
how often they are stopping
 Ask about pain trajectory (time to initial onset, time to 1st stop)
 Have them discuss with you activities of daily living
 Set a “bench mark” day to better assess progress
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Troubleshooting
“I can stand to walk with pain anymore”
 Hard to deal with, especially if you do not see them often
 Install days off
 Exchange a walking day(s) with less painful mode
 Try shorter, more intense intervals, but with longer rest periods
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Troubleshooting
“It hurts too much to walk more than 1-2 minutes”
 Good chance they are severely deconditioned
 OK to start with any kind of exercise
 Low volume, low intensity lower body strengthening exercises
 Non-weight bearing cardiovascular
 Add in weight bearing exercise very slowly
 Go Alternative!
– “Remember the study about arm cranking and time to onset of
symptoms?”
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How to Succeed
 Consider actual contact time you will have
 What does your follow up look like (visits, phone calls,
emails).
 How long do you follow up
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How to Succeed
 Establish trust.
– Review as much of the patients history as possible before they arrive.
– Greet them by looking in their eye and shake their hand.
– Ask them how they are doing.
– Ask what questions and concerns they want to make sure get answered
– Talk to them, not the computer (easer said than done)
– Perform active listening and communication skills.
– At the end of the appointment do not assume that they heard everything.
– Even if they were taking notes, they need to have the plan in writing from you,
diagrams of exercises when possible, and what the follow up will look like.
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How to Succeed
 What type of progress are they are going to consider
success?
– Is it going faster/further overall regardless of pain?
– Is it going further before they start to feel the pain?
– Lowering the amount of pain overall?
– Do they expect you to find a way to eliminate the pain?
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How to Succeed
 Remember that a person’s emotions can contribute greatly to their
pain.
 Regardless if it is due to physiology or psychology, it is their reality.
 You have to gain an understanding of all the possible factors that may
be leading to their pain and although you may not be able to address
all of them, you will have to most likely deal with multiple contributors.
 Personal and financial stressors may worsen the situation as much as
lack of blood flow, arthritis, neuropathies and any musculoskeletal or
neuromuscular issue.
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Get em’ Active, Any Way You Can!