CHICAGO – Following a few simple steps can help patients with peripheral artery disease (PAD) get off on the right foot with a home-based exercise program.
“There is growing evidence that PAD patients can walk for exercise at home and improve their walking performance,” Dr. Mary McDermott said at a symposium on vascular surgery sponsored by Northwestern University.
Getting them to do so, however, can be challenging. Patients with peripheral artery disease have greater functional impairment and are at higher risk for cardiovascular disease than is the general population. They also frequently limit their activity to avoid leg problems, as their PAD progresses.
“It’s hard enough to get patients without peripheral artery disease to exercise. As a general internist, I’m well aware of that,” she said. “It’s even more difficult when walking is so painful and uncomfortable.”
At present, the American College of Cardiology/American Heart Association practice guidelines for the management of patients with PAD do not recommend advising patients with PAD to go home and walk.
The guidelines were published in 2005, however, and since 2011, three of four randomized clinical trials of home-based exercise programs have shown a significant gain in walking endurance in patients with PAD, Dr. McDermott of Northwestern University in Chicago, observed.
The most hands-off of these trials showed that patients with symptomatic PAD randomized to a supervised exercise program did the best at treadmill walking, but the home-exercise group who received a step monitor and in-person feedback just once per month did significantly better than did controls assigned light resistance training. Moreover, the home-exercise group had greater change in 6-minute walk distances than either of the other groups (J Am Heart Assoc. 2014 Oct;3:e001107).
“I think the reason for this is that the home-based group was walking outside or perhaps in a mall and getting better at walking over ground,” Dr. McDermott. “The treadmill group was walking only on the treadmill.”
Supervised treadmill exercise may seem like an easier prescription to write, but it faces two major barriers, she said. Most medical insurers, including Medicare, do not pay for supervised exercise for people with PAD and intermittent claudication, and most PAD patients don’t participate. The burden of traveling to an exercise center three times weekly, week after week, to participate can be overwhelming.
“For all of these reasons, we really need to develop home-based exercise programs that work,” Dr. McDermott said.
Based on the successful trials, home-based programs should include monitoring, group support, and goal setting. Dr. McDermott and her colleagues added cognitive-behavioral therapy to group support in the Group Oriented Arterial Leg Study (GOALS), resulting in significant improvement in 6-minute walk distance at 6 months, physical activity over 7 days, and self-perception of walking endurance and speed among home walkers (JAMA. 2013 Jul 3;310:57-65).
Before embarking on any home-exercise program, all patients with PAD should undergo a baseline cardiac stress test to rule out coronary artery ischemia, she cautioned. This also serves to identify any coronary ischemia that may develop during the new walking program.
Once this is performed, Dr. McDermott recommends clinicians:
• Advise patients to walk 5 days per week.
“This may seem like a lot, but it’s important to have them see this as part of their daily routine; just something they get in the habit of doing,” she said.
• Start with 10-15 minutes of walking per exercise session. Tailor the program to the individual patient.
• Walk to maximal leg pain or onset of ischemic pain. Stopping to rest is acceptable.
“A lot of patients, I find, have questions, “ ‘I can’t do this.’ ‘How can this be beneficial?’ So just letting them know that if they just walk and stop, walk and stop, and start with just 10 minutes of that and increase this over time, they really can see improvement,” Dr. McDermott said.
• Increase the walk time by 5 minutes each week.
Increase the duration until the patient is walking at least 30 minutes per session and preferably 45-50 minutes per session, excluding rest periods, she said.
• Advise patients to write down their walking goals.
Specify where they will walk, when they will walk, and the duration of walking to improve compliance, which can slip following hospitalizations or when patients experience acute illness.
• Have patients self-monitor, but also check in with someone for support.
“It doesn’t have to be a nurse,” Dr. McDermott said. “In our studies, we’ve used bachelor’s degree-level people, but told them what to look for. They can do this and the patient feels there is someone they’re accountable to.”