PAD

The most common symptom of peripheral artery disease (PAD) in the lower extremities is intermittent claudication [1]. Patients with claudication experience reversible muscle ischemia characterized by persistent cramp-like pain and aching in the affected muscle while they walk. The symptoms severely limit both exercise performance and walking ability. As a consequence, PAD is associated with reduced physical functioning and quality of life [2].

Supervised exercise programs have been recommended as first-line therapies for the treatment of claudication in patients with PAD [3-5]. The treatment goals are: (1) to reduce limb symptoms, (2) to improve exercise capacity and prevent or lessen physical disability, and (3) to reduce the occurrence of cardiovascular events.

This article summarizes the current state of exercise therapy in patients with PAD and intermittent claudication.

Intermittent claudication

Intermittent claudication is a cardinal symptom in patients with PAD. The classic manifestation is muscle discomfort (patients may complain of muscle fatigue, aching, or persistent cramp-like pain) in the lower limb reproducibly produced by exercise and relieved by short-term rest.

PAD is caused by stenotic or occlusive atherosclerotic lesions in the major arteries supplying the lower extremities. Patients with intermittent claudication have normal blood flow at rest. With exercise, stenotic/occlusive lesions in the arterial supply of the leg muscles limit the increase in blood flow, causing a mismatch between oxygen supply and the metabolic demand of the muscle [1]. Patients with PAD shift more quickly to anaerobic metabolism, a less efficient means of energy production, during exercise, and have elevated lactate levels even at rest [6]. Acquired metabolic abnormalities of the muscles of the lower extremity also contribute to the reduced exercise performance and capacity of patients with PAD [2,6].

Claudication significantly affects quality of life and is associated with severe functional impairment that can be significantly improved by exercise intervention in properly selected patients [6].

Guidelines and indications for exercise therapy

The treatment of limb symptoms and exercise limitation should initially focus on structured, supervised exercise before any attempts are made to revascularize patients with claudication. A considerable body of evidence supports the clinical benefits of a supervised exercise program in improving exercise performance and quality of life [7].

The ESC [3], AHA/ACC [4], and Trans-Atlantic Inter-Society Consensus Document on Management of Peripheral Arterial Disease (TASC II) [5] have all declared that the evidence supporting exercise therapy in the treatment of claudication is sufficiently robust to merit a Level I recommendation. Table 1 shows the recommendation and evidence levels for exercise therapy in the recently published practice guidelines of the Society for Vascular Surgery [8].

Read more