乌鸦传媒

Patients with peripheral arterial disease (PAD) significantly improved their walking distance and time in 6 months after starting a home-based walking program, results of a randomized trial showed.

Distance on a 6-minute walk test increased by almost 140 feet in patients randomized to the walking program, whereas a control group's mean distance decreased by 35 to 40 feet, according to Mary M. McDermott, MD, of Northwestern University in Chicago, and co-authors.

Walking time, physical activity, impairment scores, and health-related quality of life all improved significantly in patients who participated in the walking program versus those who did not, they reported in the July 3 issue of JAMA.

"A home-based walking exercise program significantly improved walking endurance, physical activity, and patient-perceived walking endurance and speed in PAD participants with and without classic claudication symptoms," the researchers concluded. "These findings have implications for the large number of patients with PAD who are unable or unwilling to participate in supervised exercise programs."

Medical therapy has done little to improve functional impairment associated with lower-extremity PAD. Although supervised treadmill exercise has reportedly improved walking distance by as much as 200%, few insurers cover supervised exercise, and many patients face the additional obstacle of transportation to and from sessions.

McDermott and colleagues performed a randomized clinical trial to determine whether a home-based exercise program is feasible and can improve walking performance in patients with PAD. The program incorporated group support and self-regulatory skills to encourage adherence.

The primary inclusion criterion was an ankle-brachial index of 0.90 or lower in either leg. Leg symptoms were determined by the San Diego classification system, and patients with and without classic symptoms of intermittent claudication were eligible.

The primary outcome was the change in 6-minute walk performance on a treadmill. Secondary outcomes included change in maximal treadmill walking time, pain-free walking time, physical activity, scores on the Walking Impairment Questionnaire (WIQ), and the physical and mental composite scores from the 12-item Short-Form Health Survey (SF-12).

Patients were randomized to a group-mediated cognitive behavioral intervention or to an education group that consisted of weekly sessions led by physicians or other health professionals who discussed various health issues, including some unrelated to PAD. Participants randomized to the intervention group met weekly for 90-minute sessions that consisted of facilitated group discussions, followed by walking around an indoor track.

Participants randomized to the intervention also were instructed to engage in nontreadmill walking 5 days a week, escalating to a goal of 50 minutes per exercise session. Patients walked until leg pain reached a severity of 4 or 5 on a 0 to 5 scale and then rest until discomfort subsided enough to continue walking. Asymptomatic patients were instructed to walk until they reached a discomfort level of 12 to 14 on the Borg scale.

Data analysis included 194 patients. The results showed that 6-minute walk distance increased in the intervention group from an average of 357.4 to 399.8 meters. In the control group, average walk distance declined from a mean of 353.3 meters at baseline to a mean of 342.2 meters. The net difference of 53.5 meters between groups achieved statistical significance (P<0.001).

Analysis of secondary outcomes showed significant advantages for the intervention group with respect to:

• Mean maximal treadmill walking time: 7.91 minutes at baseline to 9.44 minutes at 6-month follow-up versus 7.56 to 8.09 (P=0.04)
• Mean accelerometer-measured physical activity over 7 days: 788.0 to 866.1 versus 671.6 to 645.0 (P=0.03)
• Average WIQ distance: 35.3 to 47.4 versus 33.3 to 34.4 (P=0.003)
• Average WIQ speed: 36.1 to 47.7 versus 35.3 to 36.6 (P=0.004)

A cardiovascular specialist who was not involved in the study found the results impressive.

"This type of intervention, with a little bit of upfront instruction and follow-up, is something that [patients with PAD] can do themselves," John Higgins, MD, of the University of Texas Health Science Center at Houston, told 乌鸦传媒. "It does not require the clinician to work out with them or supervise them. It's free. It works."

"While it might not be as good as a supervised intervention program in a full cardiac rehab facility, it still gave similar benefits," Higgins added. "It's definitely worth trying in these individuals."

From the American Heart Association:

Comment