Physical Therapy for Peripheral Artery Disease and Intermittent Claudication

Functional impairment in peripheral artery disease and how to improve it in 2013. Curr Cardiol Rep. 2013 Apr;15(4):347. McDermott MM.

Abstract
Lower extremity peripheral artery disease (PAD) affects 8 million men and women in the United States and will be increasingly common as the U.S. population lives longer with chronic disease. People with PAD have poorer walking endurance, slower walking velocity, and poorer balance, compared with individuals without PAD. People with PAD may reduce their walking activity to avoid leg symptoms. Thus, clinicians should not equate stabilization or improvement in exertional leg symptoms with stabilization or improvement in walking performance in PAD. In addition, even asymptomatic PAD patients have greater functional impairment and faster functional decline than individuals without PAD. Of the 2 FDA-approved medications for treating claudication symptoms, pentoxifylline may not be more efficacious than placebo, whereas cilostazol confers a modest improvement in treadmill walking performance. Supervised treadmill walking exercise is associated with substantial improvement in walking endurance, but many PAD patients do not have access to supervised exercise programs. Unsupervised walking exercise programs may be beneficial in PAD, but data are mixed.

My comments:

I took a 10 hour continuing education course last year on physical therapy for cardiovascular deficits. Most continuing education courses fall into one of two categories: 1) things you already know and you learned in school, or 2) pseudoscientific nonsense. This course, however, was different. It really got me thinking about use of the 6-minute walk test to determine deficits. I recollected back to the course when referred a patient for low back pain who just so happened to have intermittent claudication (intense calf pain while walking secondary to decreased blood flow to the working muscles). His back pain was relatively easy to treat, leaving intermittent claudication as his primary source of pain. It was preventing him from doing any cardiovascular exercise, and preventing him from playing golf, which was one of his favorite pastimes. I would have had no idea how to treat it if not for the continuing education course. The only problem was the course was written back in 2004, so I figured it best to do a current literature review to come up with what’s new and what I think is the best science-based protocol for intermittent claudication, and the above paper is the first one I read.

The gist is that people with peripheral artery disease (PAD) not only have lower levels of function (measured by walking speed and distance) than normal people of the same age, but they decline in function substantially faster than normal controls. This is thought to be due to the leg pain experienced when walking, such that they walk less and walk slower, to avoid the pain, which results in further downward spiral.

It turns out however that exercise (generally various treadmill programs, but also strengthening and cycle and upper body ergometry) seems to be very effective at improving walking speed, walking distance, and lessening or eliminating pain in the legs when walking. For some reason supervised exercise programs work, but unsupervised exercise programs, not as well, which is odd as you would think there isn’t a lot to walking on a treadmill. Unfortunately there was not a lot of detail with regards to any particular program in this paper, but having obtained a 3” thick pile of studies there seems to be considerable data to go off of. It should make for good blog fodder in the coming weeks, as well as what I hope to be a bang-up treatment protocol that I can alter or not depending on new research findings and as I gather more practical experience treating the condition.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

2 thoughts on “Physical Therapy for Peripheral Artery Disease and Intermittent Claudication

  1. Hi Chad,

    I have a patient with IC – I was wondering if you ever figured out an effective supervised exercise protocol, and if so, would you being willing to advise? Many thanks, L.

    • Unfortunately, since I did that series of blogs on intermittent claudication for physical therapy I haven’t had any additional referrals for the condition so I don’t have a lot of first hand experience to go with the research I was reading. With the patient I was treating the 30 minute intervals with active rest did seem to be helping. However, overall health that seemed cholesterol, type II diabetes related wasn’t very good so he would miss a lot of scheduled treatments. He really liked EMS and it was before I had optimized what I think is ideal EMS to increase circulation and I think might be a more tolerable way to go either instead of or in addition to “forced marches” on a treadmill.

      If I were to do it over again, I think I would maybe try 5 hz EMS at home every day (I’d say they really need to buy a good home EMS unit with large carbonized rubber electrodes) working up to maybe 30 minutes at a time. I would use the treadmill walking to supplement and gauge progress. I’d probably try a minimal pain/pain free approach blended with the use of intervals with active rest. I think it really takes a lot of motivation to push hard into the pain and maybe it’s not all that much better. I would also do weight training if needed. Last I would talk to them about diet, particularly if they were heavier. My patient wasn’t obese but he was definitely overweight and I think would have benefitted immensely, blood, circulation, and how much he had to lift when walking by losing weight. I’ve since become a BIG fan of intermittent fasting for weight loss and overall health. I’m happy to talk more and compare notes about any and all of this.

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