Sports Med 2004; 34 (14): 983-1003

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 983 1. Prevalence of Peripheral Arterial Disease (PAD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 984 2. Exercise Training for Patients with PAD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 984 2.1 Limitations of the Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985 2.1.1 Method of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 985 2.1.2 Exclusion Criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986 2.2 Frequency of Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 986 2.3 Duration of Training Sessions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 987 2.4 Work to Rest Ratios . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 987 2.5 Total Programme Duration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988 2.6 Training Volume . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988 2.7 Training Intensity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 988 2.8 Progression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 989 2.9 Detraining and Maintenance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 989 2.10 Mode of Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 990 2.10.1 Resistance Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 990 2.10.2 Stair-Climbing Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 990 2.10.3 Pole-Striding Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 990 2.10.4 Arm and Leg Ergometry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991 2.10.5 Further Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991 3. Supervision Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 991 4. Recommendations for Future Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 992 5. Conclusions and Recommended Training Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 992 Peripheral arterial disease (PAD) is an obstructive condition where the flow of Abstract blood through peripheral arteries is impeded. During periods of increased oxygen demand (e.g. during exercise), peripheral limb ischaemia occurs, resulting in the sensation of muscle pain termed ‘claudication’. As a result of claudication, subjects’ ability to exercise is greatly reduced affecting their quality of life. Although many treatment options for patients with PAD exist, exercise training is an effective and low-cost means of improving functional ability and quality of life. Currently, there are limited specific recommendations to assist the exercise prescription and programming of these individuals. This review summarises data from 28 exercise training studies conducted in patients with PAD and formulates recommendations based on their results. Exercise training for patients with PAD should involve three training sessions per week comprising 45 minutes of intermittent treadmill walking in a supervised environment for a time period of 20 984 Bulmer & Coombes weeks or more. Encouragement and direction is given to further research aimed at investigating the effectiveness of training programmes in these patients. Peripheral arterial disease (PAD) is characterised quality of life in diseased persons.[9] These treatby the development of obstructive atherosclerotic ments include pharmacotherapy,[10,11] surgery[12-14] plaques in the arteries of peripheral limbs. As these and behaviour change.[8] Participation in exercise plaques grow, they reduce blood flow through to programmes has consistently shown a significant tissues distal to the obstruction. Reduced blood flow improvement in functional ability, with exercise (ischaemia) to the muscles is accompanied by sensatraining described as one of the cornerstones of tions of local muscle pain and this is increased treatment for patients with PAD.[15] Exercise trainduring periods of increased oxygen consumption ing is generally viewed as an inexpensive, low-risk (V̇O2), such as during exercise. Limb pain upon option compared with other more invasive theraexertion is a symptom of PAD and is termed interpies.[16] mittent claudication (IC). As acute peripheral isRecently, some novel methods improving walkchaemia causes claudication, patients with PAD ening ability in patients with PAD have emerged, dure a chronic reduction in ambulatory ability and including the application of exercise-induced isquality of life.[1] Exercise training is established as chaemic preconditioning[17] and intermittent foot an effective therapy for patients with PAD who compression.[18] Furthermore, combining different experience IC; however, there are limited specific treatments such as surgery and exercise, and exerrecommendations in the literature regarding exercise with pharmacotherapy, appear effective in procise prescription and programming for these paviding additional benefits to patients over the use of tients. This review will discuss the results of 28 individual therapies.[13,19] studies (literature search concluded June, 2003) that Recently, a Cochrane Review supported the role have used exercise training in patients with PAD exercise training has in treating the symptoms of and will make recommendations based on an analyPAD.[20] When combining the findings of several sis of data from 22 of these studies. randomised, controlled exercise training trials, Leng et al.[20] concluded that exercise training was an 1. Prevalence of Peripheral Arterial effective method for improving walking ability in Disease (PAD) patients. However, this review did not attempt to devise an optimal exercise paradigm from the data. The prevalence of PAD has been assessed in In 1995, Gardner and Poehlman[21] published a numerous populations. The prevalence in Australian meta-analysis of training studies conducted in pamales aged 65 years and over was reported at 16% in tients with PAD. Their recommendations appear to 2002.[2] Investigations in other countries have found have formed the basis of exercise prescription for prevalence rates ranging from 3% to 12%.[3,4] The patients with PAD to date. They concluded that the prevalence of PAD appears similar between sexes;[5] most effective training programme included training however, increases with age reaching its peak in sessions >30 minutes in duration, at least three times persons >70 years of age.[6] As the greatest prevaa week, over a period of 27 weeks or more. On the lence of this disease occurs in the elderly, the strain important topic of exercise intensity, they stated that that PAD treatment will have on health services in the programme must include training to near maxithe years to come is raising concern.[7,8] Such conmal pain levels. Together, they believed that these cerns highlight the importance of cost-effective variables resulted in an optimal training response, treatment of this disease. maximising the improvement in walking ability. Although these findings are useful to the exercise 2. Exercise Training for Patients with PAD physiologist, several questions remain unanswered, Many treatment strategies for PAD exist, ultiparticularly in regard to duration, frequency and mately aimed at improving functional ability and type of exercise (continuous vs intermittent). Since  2004 Adis Data Information BV. All rights reserved. Sports Med 2004; 34 (14) Exercise Training in Peripheral Arterial Disease 985 this review, to our knowledge, additional PAD training studies have been published.[7,11,14,17,18,22-30] This review, based on the results of 22 studies,[13,14,17,19,22-28,30-40] will present relationships between training frequency (figure 1), training session duration (figure 2), total training duration (figure 3) and training volume (figure 4) on improvement in pain-free and absolute walking ability. The effect of training intensity, training mode, degree of supervision and the location of training (e.g. gymnasium or home-based) will also be discussed. 2.1 Limitations of the Review −50 50 100 150 200 250 300