Exercise Therapy Plus Intervention Improves Walking Ability in PAD Patients

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For patients with peripheral arterial disease (PAD), supplementing percutaneous intervention with supervised exercise therapy is more effective at improving walking ability than angioplasty alone, says a new randomized trial published in the July 2011 issue of the Journal of Vascular and Interventional Radiology.

The single-center trial led by Joep A. W. Teijink, MD, PhD, of Catharina Hospital (Eindhoven, The Netherlands), randomized 70 PAD patients who were slated for percutaneous vascular intervention to receive treatment with (n = 35) or without supervised exercise therapy (n = 35). Patients who underwent exercise therapy saw trained physiotherapists near their homes for 2 to 3 30-minute sessions a week and were also encouraged to walk every day.

To test if adding exercise improved walking ability in PAD patients, the researchers performed 30-minute treadmill tests on all study participants before intervention, within 3 weeks of treatment, and at 3- and 6-month follow-up. The study’s primary endpoint was absolute claudication distance, the point at which a patient had to stop walking to relieve leg pain.

Exercise Therapy Pushes Patients Further

Due to some participant withdrawal, the researchers were only able to analyze 27 patients in the angioplasty alone group and 34 patients in the exercise group. Of these patients, 61.4% were male. The mean age was 62.3 years, with a claudication distance before intervention of 318.4 ± 220.5 meters. There were no significant differences in baseline characteristics.

Immediately after intervention, claudication distance had improved over baseline in both groups; but by 6 months, walking distance had improved the most in patients who received exercise therapy. Functional claudication distance, the distance a patient would prefer to stop walking because of leg pain, also improved with exercise (table 1).

Table 1. Measures of Walking Distance


Intervention Alone
(n = 27)

Intervention + Exercise
(n = 34)

P Value

Absolute Distance, m
At 6 Months

343.3 ± 247.9
685.0 ± 313.5

186.1 ± 116.2
956.3 ± 490.4


Functional Distance, m
At 6 Months

282.2 ± 292.8
547.2 ± 263.5

186.1 ± 116.2
842.4 ± 478.3


Using the Medical Outcomes Study 36-item Short Form-36 Health Survey and the Euroqol-5D questionnaire, the researchers initially found no differences in physical health (P = 0.340) or mental health (P = 0.085) between the 2 study groups. However, after adjustment for baseline characteristics, patients who received exercise therapy had significantly better mental health scores (P = 0.035). The authors attribute this to a worsening of mental health in the angioplasty alone group rather than to the positive effects of exercise.

Confirming the Combination

In an e-mail communication with TCTMD, Dr. Teijink said his group’s results were in line with his original prediction that exercise would make a difference. “Our findings confirmed daily observations that [supervised exercise therapy] works in addition to revascularization for critical limb ischemia,” he noted.

Further verifying these findings, said Dr. Teijink, a paper published last week in the British Journal of Surgery demonstrated that a combination of balloon angioplasty and supervised exercise therapy may be superior to either treatment alone in patients with intermittent claudication. He said that 2 Dutch trials currently enrolling patients are also seeking to confirm the current findings.

Lifespan Over Lifestyle

While not surprised by the study results, William A. Gray, MD, of Columbia University Medical Center (New York, NY), told TCTMD in a telephone interview that the bigger question in exercise research concerns lengthening of lifespan, and not merely lifestyle improvement.

“We know that exercise when done correctly improves outcomes in patients with coronary disease. [But patients with claudication often] can’t participate in long-term activity. They have to stop and really get their heart rates up before they get the benefit of the exercise,” he said. Dr. Gray added that the key will be showing whether supervised exercise therapy can not only help these patients exercise more easily but also improve their clinical outcomes.

Since supervised exercise therapy is not currently reimbursed by the Centers for Medicare and Medicaid Services (CMS), many US patients do not have access to it.

This may be the root of the problem for many PAD patients, Dr. Gray asserted. “Many patients don’t have much of an athletic background so they don’t really understand what exercise is and what it means to exercise,” he said. “For those patients there can be an education component that can be very useful. For other patients who have been exercising their whole lives and then develop vascular disease, they may need less instruction.”

Dr. Gray theorized that if exercise therapy were proven to increase patient survival with cardiovascular disease, then it would be “politically hard” for CMS not to cover such treatment, allowing more patients to benefit.


Kruidenier LM, Nicolaï SP, Rouwet EV, et al. Additional supervised exercise therapy after a percutaneous vascular intervention for peripheral arterial disease: A randomized clinical trial. J Vasc Interv Radiol. 2011;22:961-968.



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  • Drs. Teijink and Gray report no relevant conflicts of interest.