Exercise for intermittent claudication

  • Review
  • Intervention

Authors


Abstract

Background

Exercise programmes are a relatively inexpensive, low-risk option compared with other more invasive therapies for leg pain on walking (intermittent claudication (IC)).

Objectives

To determine the effects of exercise programmes on IC, particularly in respect of reduction of symptoms on walking and improvement in quality of life.

Search methods

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last search February 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library 2008, Issue 1.

Selection criteria

Randomised controlled trials of exercise regimens in people with IC due to peripheral arterial disease.

Data collection and analysis

Two authors independently extracted data and assessed trial quality.

Main results

Twenty-two trials met the inclusion criteria involving a total of 1200 participants with stable leg pain. Follow-up period was from two weeks to two years. There was some variation in the exercise regimens used, all recommended at least two sessions weekly of mostly supervised exercise. All trials used a treadmill walking test for one of the outcome measures. Quality of the included trials was good, though the majority of trials were small with 20 to 49 participants. Fourteen trials compared exercise with usual care or placebo; patients with various medical conditions or other pre-existing limitations to their exercise capacity were generally excluded.

Compared with usual care or placebo, exercise significantly improved maximal walking time: mean difference (MD) 5.12 minutes (95% confidence interval (CI) 4.51 to 5.72;) with an overall improvement in walking ability of approximately 50% to 200%; exercise did not affect the ankle brachial pressure index (ABPI) (MD -0.01, 95% CI -0.05 to 0.04). Walking distances were also significantly improved: pain-free walking distance MD 82.19 metres (95% CI 71.73 to 92.65) and maximum walking distance MD 113.20 metres (95% CI 94.96 to 131.43). Improvements were seen for up to two years. The effect of exercise compared with placebo or usual care was inconclusive on mortality, amputation and peak exercise calf blood flow due to limited data.

Evidence was generally limited for exercise compared with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression due to small numbers of trials and participants. Angioplasty may produce greater improvements than exercise in the short term but this effect may not be sustained.

Authors' conclusions

Exercise programmes were of significant benefit compared with placebo or usual care in improving walking time and distance in selected patients with leg pain from IC.

Plain language summary

Exercise for reducing intermittent claudication symptoms

Intermittent claudication is a cramping leg pain that develops when walking and is relieved with rest. It is caused by inadequate blood flow to the leg muscles because of atherosclerosis (fatty deposits blocking blood flow through the arteries). People with mild-to-moderate claudication are advised to keep walking, stop smoking and reduce cardiovascular risk factors. Other treatments include antiplatelet therapy and pentoxifylline, angioplasty (inserting a balloon into the artery to open it up) and bypass surgery.

The present review shows that exercise programmes clearly improve walking time and distance for people considered fit for exercise regimens. This benefit appears to be sustained over two years. The review authors identified 22 controlled trials that randomised some 1200 adults with stable leg pain to exercise, usual care or placebo, or the other interventions. Outcomes were measured at times ranging from 14 days to two years. The types of exercise varied from strength training to polestriding and upper or lower limb exercises, in generally supervised sessions, at least twice weekly. Compared with usual care, exercise therapy improved maximal walking time on a treadmill by some 5 minutes (range 4.5 to 5.7 minutes) in a total of 255 participants. Pain-free walking distance was increased overall by 82.2 metres (range 71.7 to 92.7) and the maximum distance participants could walk by 113.2 metres (range 95.0 to 131.4) in six trials. Exercise did not improve ankle to brachial blood pressure index. No data were given on non-fatal cardiovascular events; data on deaths and amputation were inconclusive.

Comparisons of exercise with surgical intervention, angioplasty, antiplatelet therapy, pentoxifylline, iloprost and pneumatic foot and calf compression were limited because of small numbers of trials and participants. Exercise programmes are relatively inexpensive and low risk compared with other more invasive therapies for improving leg pain on walking and related quality of life. People with intermittent claudication are often elderly and have other pre-existing medical conditions, which would compromise an exercise programme or make it impractical.

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