Summary of exercise prescription recommendations
| Exercise rationale | To improve walking capacity, claudication symptoms and quality of life, and for secondary prevention of cardiovascular disease |
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| Provider | The programme should have a designated clinical lead (eg, vascular surgeon, physician or nurse specialist). Exercise professionals who wish to work in this area should possess the essential competencies and minimum qualifications as per the country of work. Professional standards of accredited exercise physiologists should include detailed knowledge of pathophysiology, exercise physiology and exercise training for patients with IC. Some of these are specified in the following BACPR Position Statement (UK Based):http://www.bacpr.com/resources/51A_EPG_Position_Statement.pdf |
| Mode of delivery | The exercise should ideally be delivered through an on-site supervised programme. The exercise prescription should be individually tailored based on an initial assessment; however, several patients may be supervised at the same time. A facilitated, self-managed exercise programme with embedded behaviour change techniques is a reasonable alternative for people who prefer this approach or are unable to access an on-site programme, or for longer-term benefit after a supervised programme is completed. Details of a structured education programme that promotes self-managed walking exercise can be found here.24 Additional information for home-based exercises can be found here: (https://circulationfoundation.org.uk/news/COVID-19-special) Unstructured, unsupervised exercise approaches that consist solely of basic advice to walk or exercise more are not effective. |
| Setting | On-site programmes can be delivered in various settings including hospital- or community-based exercise physiology or physiotherapy clinics or community exercise facilities. Self-managed programmes can be conducted in a setting that suits the individual. |
| Materials |
Assessment tools: Motorised treadmill with adjustable incline to allow incremental exercise testing (eg, ‘Gardner’ protocol) to determine pain-free and maximum walking distances or, if unavailable, procedures and instructions for an alternative functional capacity test (eg, 30 m 6-min corridor walk test); questionnaires for assessing patient-perceived ambulatory function (eg, WELCH questionnaire), and generic and condition-specific quality of life (eg, SF-36, VascuQoL and Walking Impairment uestionnaires, respectively). Optional—equipment to assess vascular status (eg, ankle-brachial index) and cardiovascular disease risk (eg, blood pressure, lipid profile). Exercise equipment: Motorised treadmills with adjustable incline or space for over-ground walking (preferably indoor and air-conditioned). Optional for aerobic exercise—upper and lower limb ergometers. Optional for resistance exercise—weights machines, dumbbells. Intensity-monitoring equipment: Five-point claudication pain scale, exertion scale (eg, 6‒20point Borg Rating of Perceived Exertion Scale), heart rate monitors, manual sphygmomanometer and stethoscope. |
| Walking exercise guidelines |
Programme duration: At least 3 months Frequency: ≥3 times/week Claudication pain endpoint: Based on current evidence, patients should be advised to walk to the point of near-maximum leg pain (ie, 4–5 on claudication pain scale); however, preliminary evidence suggests that walking only to the onset of ischaemic leg pain may also be beneficial for patients reluctant to walk at higher levels of pain Pattern: Following a warm-up period, the patient should walk at a speed and grade that induces claudication pain within 3–5 min. The patient is instructed to stop walking and rest when his or her claudication pain reaches a moderate-to-strong level. When the claudication has abated, the patient resumes walking until a moderate-to-strong claudication pain recurs. This cycle of exercise and rest is ideally repeated for at least 30 min. In subsequent visits, the speed or grade of walking is increased if the patient is able to walk for ≥10 min without reaching moderate claudication pain. For those patients who start at a lower level of claudication pain (1–3/5), as the patient tolerates it, they should be encouraged to increase the intensity of pain achieved as a progression tool. Duration per session: Many patients with IC may need to start with just 10–15 min of walking exercise per session. In this situation, the duration of exercise should be increased by 5 min each week, until the patient is walking for at least 30 min per session. Patients who can walk for more than 30 min per session should be encouraged to increase the exercise duration to 45–60 min. They should also be encouraged to include other modes of exercise to work on improving cardiorespiratory fitness and muscular strength |
| Upper and lower limb ergometry | May be considered as alternative aerobic exercise strategies for improving walking ability and quality of life. May also have the potential to provide a greater cardiorespiratory stimulus than walking exercise in individuals with severe claudication. Example protocol: Ten sets of 2 min of upper or lower extremity ergometry conducted twice weekly for at least 3 months. Intensity should be moderate or Borg RPE 13–14 (6–20 scale) |
| Resistance exercise | Though evidence is increasing, resistance exercise is yet to be included in international guidelines as a sole therapy, it is purely recommended as an adjunct for now. It therefore should be considered as complementary (eg, for targeting improved strength or reduced falls risk), but not as a replacement for aerobic exercise because its impact on walking ability appears modest at best. Example protocol: Moderate-to-high intensity (Borg exertion rating of 14–16), 6–8 exercises (leg press, Knee flexion, knee extension, calf press, chest press, seated row) targeting the major muscle groups of the upper and lower body, 2–4 sets of 10–15 repetitions per set, 2–3 sessions per week. |
| Other | Circuit-based training may be a practical way of delivering a combination of aerobic and resistance exercises when circumstances necessitate group-based training and is an effective tool for improving both muscle strength and cardiorespiratory fitness, which are both related to reduced cardiovascular and all-cause mortality.25 |
| Safety issues | An initial risk assessment should occur as per Appendix E of the following ACPICR Standards document https://www.acpicr.com/data/Page_Downloads/ACPICRStandards.pdf . Exercise is contraindicated by foot ulcers and limb pain at rest (ie, critical limb ischaemia). As patients increase their walking ability, there is the possibility that cardiac signs and symptoms may appear (eg, dysrhythmia, angina). These events should prompt further clinical assessment to ensure safety continuing. Clinical assessment should also be considered when a patient undertakes a mode of exercise that is not limited by claudication pain. |
ACPICR; BACPR; IC; RPE; SE-36, Short-Form-36; VascuQoL; WELCH.