Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication
Editorial Group: Cochrane Peripheral Vascular Diseases Group
Published Online: 23 AUG 2013
Assessed as up-to-date: 18 SEP 2012
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Fokkenrood HJP, Bendermacher BLW, Lauret GJ, Willigendael EM, Prins MH, Teijink JAW. Supervised exercise therapy versus non-supervised exercise therapy for intermittent claudication. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD005263. DOI: 10.1002/14651858.CD005263.pub3.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 23 AUG 2013
Although supervised exercise therapy is considered to be of significant benefit for people with leg pain (peripheral arterial disease (PAD)), implementing supervised exercise programs (SETs) in daily practice has limitations. This is an update of a review first published in 2006.
The main objective of this review was to provide an accurate overview of studies evaluating the effects of supervised versus non-supervised exercise therapy on maximal walking time or distance on a treadmill for people with intermittent claudication.
For this update, the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched September 2012) and CENTRAL (2012, Issue 9). In addition, we handsearched the reference lists of relevant articles for additional trials. No restriction was applied to language of publication.
Randomized clinical trials comparing supervised exercise programs with non-supervised exercise programs (defined as walking advice or a structural home-based exercise program) for people with intermittent claudication. Studies with control groups, which did not receive exercise or walking advice or received usual care (maintained normal physical activity), were excluded.
Data collection and analysis
Two review authors (HJPF and BLWB) independently selected trials and extracted data. Three review authors (HJPF, BLWB, and GJL) assessed trial quality, and this was confirmed by two other review authors (MHP and JAWT). For all continuous outcomes, we extracted the number of participants, the mean differences, and the standard deviation. The 36-Item Short Form Health Survey (SF-36) outcomes were extracted to assess quality of life. Effect sizes were calculated as the difference in treatment normalized with the standard deviation (standardized mean difference) using a fixed-effect model.
A total of 14 studies involving a total of 1002 male and female participants with PAD were included in this review. Follow-up ranged from six weeks to 12 months. In general, supervised exercise regimens consisted of three exercise sessions per week. All trials used a treadmill walking test as one of the outcome measures. The overall quality of the included trials was moderate to good, although some trials were small with respect to the number of participants, ranging from 20 to 304.
Supervised exercise therapy (SET) showed statistically significant improvement in maximal treadmill walking distance compared with non-supervised exercise therapy regimens, with an overall effect size of 0.69 (95% confidence interval (CI) 0.51 to 0.86) and 0.48 (95% CI 0.32 to 0.64) at three and six months, respectively. This translates to an increase in walking distance of approximately 180 meters that favored the supervised group. SET was still beneficial for maximal and pain-free walking distances at 12 months, but it did not have a significant effect on quality of life parameters.
SET has statistically significant benefit on treadmill walking distance (maximal and pain-free) compared with non-supervised regimens. However, the clinical relevance of this has not been demonstrated definitively; additional studies are required that focus on quality of life or other disease-specific functional outcomes, such as walking behavior, patient satisfaction, costs, and long-term follow-up. Professionals in the vascular field should make SET available for all patients with intermittent claudication.
Plain language summary
Supervised exercise versus non-supervised exercise for people with leg pain while walking (intermittent claudication)
Some people experience a type of leg pain in the calf of one or both legs that occurs during walking and is relieved only by rest. This is called intermittent claudication (IC), and it is the main symptom of peripheral arterial disease (PAD). PAD is characterized by reduced flow of blood in the leg due to hardening of the arteries, or blood vessels. Exercise is considered to provide significant benefit for people with this type of leg pain. People need to walk at least three times a week by themselves, or they can participate in a formal, supervised exercise program that involves walking on a treadmill. This review found that people in a supervised program improved their walking ability to a greater extent than those following an unsupervised walking program. After three months, people who followed the supervised treadmill program could walk 180 meters farther than those who did unsupervised exercise. Before participating in the program, they had walked around 300 meters, with a pain-free distance of 200 meters, so this improvement is likely to help with independence. These conclusions are drawn from the findings of 14 trials in which participants with PAD had been assigned to either supervised or unsupervised exercise. Altogether, 1002 participants with a mean age of 67 years were included. The overall quality of the included trials was moderate to good, although each had enrolled only a small number of participants. The trials lasted from six weeks to twelve months. Keeping to an exercise program is important because it leads to decreased leg pain and the likelihood of improving general physical condition, but it is not yet clear if it also improves quality of life.