Peripheral arterial disease (PAD) is largely asymptomatic but may manifest in a minority of patients as intermittent claudication, pain in the lower extremities on physical exertion that subsides when the individual is at rest again. This generally nearly completely nullifies already low rates of physical activity of afflicted patients, despite numerous well-researched benefits of regular physical exercise for improving functional status and general well-being. Clinicians should encourage and advise their patients on the best exercises to achieve pain relief and maximise their walking distance.
In this blog you will learn:
- What is intermittent claudication?
- Treatments beside exercise.
- Recommended exercise.
- Benefits of exercise.
- General guidance.
What is intermittent claudication?
It is estimated that there were almost 237 million adults with PAD in 2015 and today this number is even higher (1). Yet from a statistical standpoint, only a very few of those individuals will be symptomatic, i.e. have intermittent claudication. Studies have found that only 10% of all patients with PAD are symptomatic, 40% are entirely asymptomatic and the remaining 50% have atypical pain symptoms that could be attributed to other medical conditions (2, 3).
From a physiological standpoint, intermittent claudication is caused by a complex interaction of several mechanisms, including arterial obstruction, vascular dysfunction, inflammation, reduced microvascular flow, impaired angiogenesis, and altered skeletal muscle function (4). It is an intimidating mix of issues, but one that can initially be managed by conservative, non-surgical means, if the disease (PAD) is promptly diagnosed.
What are the treatment methods for intermittent claudication?
Regular exercise is or should be the main method in managing intermittent claudication, but let’s first take a look at other conservative treatment methods, which are primarily aimed at managing PAD and reducing the likelihood of incidence of other cardiovascular diseases (CVDs). Those benefits also translate to reducing leg pain on exertion. Smoking cessation is one such and the most prominent example. Besides improving intermittent claudication, it decreases the risk of amputation, graft failure, restenosis after endovascular revascularisation, myocardial infarction (MI), and death (5, 6, 7, 8, 9).
Other measures include the diligent management of hyperglycaemia, hypertension, and hyperlipidaemia (10, 11, 12, 13, 14). Use of statins in the latter case is particularly beneficial, however, in practice, many such patients are undertreated (15, 16, 17, 18, 19). Patients with PAD also benefit from antiplatelet medications like clopidogrel, which help reduce the risk of adverse outcomes (20). For intermittent claudication specifically, cilostazol may be used as it markedly improves treadmill walking performance, between 25% and up to 40% in selected patients (21, 22, 23). However, the benefits are greater in combination with physical exercise (24).
What is the recommended exercise for individuals with intermittent claudication?
Patients with PAD benefit from two types of physical exercises: supervised and unsupervised. In 2012, the National Institute for Health and Care Excellence in the UK published a clinical guideline on the diagnosis and management of PAD that recommends a three-month supervised exercise programme (SEP) as the first step in management of intermittent claudication (25). The use of vasodilators and revascularisation surgery should only be pursued when the exercise fails to alleviate the symptoms (25). Unsupervised exercise is the second-best option, despite it being less effective than SEP, and should be likewise pursued (25, 26). It is also more likely to benefit a larger number of patients as, for example, in the UK, only 38.5% of vascular units have access to an SEP (27).
Unsupervised exercise should simply consist of walking at a speed the patient can maintain for 3–10 minutes until moderate to strong pain develops and then rest until the pain subsides. The patient should repeat the entire process until he cumulatively walks at least for 30 to 60 minutes in one session (28). They should strive to do at least three to five sessions per week to obtain the maximum benefits (28).
What are the benefits of exercise?
The beneficial effects of exercise on intermittent claudication were known back in the 1960s when a study published in The Lancet reported improvements in pain relief and maximum walking distance following a six-month regime of interval walking (28). Since then, an even larger body of research has been gathered, supporting physical exercise for patients with intermittent claudication (29). In general terms, the patient should be informed that exercise reduces pain, improves cardiovascular health, reduces the need for vascular procedures, improves sleep and psychological well-being, and helps in maintaining a healthy weight (28). Still, some may need more persuasion, information, or guidance.
What general guidelines about exercise and intermittent claudication should clinicians know?
Patients should be given general guidelines for safe exercising, including the need to be adequately hydrated, wear appropriate clothing for the season, and plan the route with appropriate resting places (28). At the same time, they should be warned not to exercise if they are feeling unwell and seek immediate medical help if they are experiencing chest pain or dizziness (28). Additionally, assure them that walking with pain will not harm them, to take their time in gradually increasing walking time, and to be persistent since effects are usually noticeable only after several weeks (28). Lastly, patients can do additional muscle-strengthening and balance exercises and activities to maintain muscle strength and reduce the risk of falling (28).
Regular physical exercise, particularly if performed under professional supervision, is vital for the effective management of intermittent claudication, followed by unsupervised activity that should still be conducted within prescribed guidelines.