Home-Based vs Supervised Exercise Program for PAD: What Works Best? - - PDF document

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Home-Based vs Supervised Exercise Program for PAD: What Works Best?

Andrew W. Gardner, Ph.D.

Professor and Vice Chair of Research

• Dept. of Physical Medicine & Rehabilitation

Penn State College of Medicine

Disclosures

• None

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Outline

• Describe supervised and home-based

exercise programs to treat claudication

• Review recent meta-analyses of both

programs

• Discuss head-to-head comparisons of the

programs

Peripheral Artery Disease (PAD)

• Caused by obstruction
• f the arterial supply to

the lower extremity

• Arterial lesions reduce

blood flow

• Mismatch between the

O2 supply & metabolic demands of muscle

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Intermittent Claudication

• Pain in one or both legs on walking,

primarily affecting the calves, that does not go away with continued walking, and is relieved by rest.

• Limits daily physical activities and

negatively affects quality of life in many

• lder adults.

Primary Goals in Ameliorating Claudication

• Improve ambulatory function
• Improve quality of life

Hiatt, WR, et al. Circulation. 2014;130:69-78.

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Supervised Exercise Program

In patients with claudication, a supervised exercise program is recommended to improve functional status and QoL and to reduce leg symptoms.

Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779.

Home-Based Exercise Program

In patients with PAD, a structured community- or home-based exercise program with behavioral change techniques can be beneficial to improve walking ability and functional status.

Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779.

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Structured Exercise Program: Supervised

• Program takes place in a hospital or outpatient facility.
• Program uses intermittent walking exercise as the treatment

modality.

• Program can be standalone or within a cardiac rehabilitation

program.

• Program is directly supervised by qualified healthcare

provider(s).

Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779.

Structured Exercise Program: Supervised

• Training is performed for a minimum of 30–45 min/session;

sessions are performed at least 3 times/wk for a minimum of 12 wk.

• Training involves intermittent bouts of walking to moderate-to-

maximum claudication, alternating with periods of rest.

• Warm-up and cool-down periods precede and follow each

session of walking.

Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779.

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Structured Exercise Program: Home-Based

• Program takes place in the personal setting of the patient rather

than in a clinical setting.

• Program is self-directed with guidance of healthcare providers.
• Healthcare providers prescribe an exercise regimen similar to

that of a supervised program.

Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779.

Structured Exercise Program: Home-Based

• Patient counseling ensures understanding of how to begin and

maintain the program and how to progress the difficulty of the walking (by increasing distance or speed).

• Program may incorporate behavioral change techniques, such

as health coaching or use of activity monitors.

Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779.

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Supervised and Home Exercise vs Non-Exercise Control Meta-Analyses Pain-Free Walking Distance

Fakhry F, et al. J Vasc Surg 2012;56:1132-1142.

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Maximum Walking Distance

Fakhry F, et al. J Vasc Surg 2012;56:1132-1142.

6-Minute Walk Distance

Parmenter BJ, et al. Sports Med 2015;45:231-244.

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Treadmill COD

Golledge, J, et al. Brit J Surg 2019;106:319-331.

Treadmill MWD

Golledge, J, et al. Brit J Surg 2019;106:319-331.

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6-Minute Walk Distance

Golledge, J, et al. Brit J Surg 2019;106:319-331.

Physical Activity

Golledge, J, et al. Brit J Surg 2019;106:319-331.

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Supervised vs Home Exercise Head to Head Comparison

• U. Oklahoma Health Sciences Center,

Oklahoma City R01-AG-24296; OCAST HR09-035

http://www.ClinicalTrial.Gov NCT00618670

Gardner, AW, et al. J Am Heart Assoc 2014;3:001107.

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Exercise Intervention Measures

Gardner, AW, et al. Circulation 2011;123:491-498.

• 100

100 200 300 C S H (sec)

P < 0.001

Change in COT

+ 88% * P < .001 + 53% * P < .001 + 8% P > .05

* P < .05 vs. Control

Gardner, AW, et al. J Am Heart Assoc 2014;3:001107.

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• 100

100 200 300 C S H (sec)

P < 0.001

Change in PWT

+ 54% * P < .001 + 29% * † P < .001 + 5% P > .05

* P < .05 vs. Control † P < .05 vs. Supervised

Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. 20 40 60 C S H (m)

P < 0.05

Change in 6-Min Walk Distance

+ 5% P < .05 + 14% * † P < .001 + 1% P > .05

* P < .05 vs. Control † P < .05 vs. Supervised

Gardner, AW, et al. J Am Heart Assoc 2014;3:001107.

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0.2 0.4 0.6 0.8 1 C S H (stride/min)

P < 0.05

Change in Average Daily Cadence

2 % P > .05 + 6 % P < .01 2 % P > .05 Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. 1 2 3 S H (ml/mmHg) x 10

P < 0.05

Change in Large Artery Elasticity Index

+ 6 % P > .05 + 16 % * P < .05 + 3 % P > .05

* P < .05 vs. Control

C Gardner, AW, et al. J Am Heart Assoc 2014;3:001107.

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• 2
• 1

H (mg/L)

P < 0.05

Change in C-Reactive Protein

• 6 %

P > .05

• 24 % *

P < .05

• 10 %

P > .05

* P < .05 vs. Control

C S H Gardner, AW, et al. J Am Heart Assoc 2014;3:001107.

Conclusions

• Both structured supervised and home-

based exercise programs are efficacious to improve ambulatory function.

• Changes in outcome measures are

specific to the intervention utilized.

• Combining both programs should be

considered to increase exercise volume and meet activity guidelines.

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