Significant Improvement In Walking Distance Research Articles

Influence of the sagittal spinal profile type on the long-term outcome of patients with symptomatic lumbar spinal stenosis after microsurgical decompression

OBJECTIVE Microsurgical decompression for patients with symptomatic lumbar spinal stenosis (LSS) has demonstrated long-term improvement concerning pain and function. Nonetheless, a considerable proportion of these patients do not experience satisfactory alleviation of symptoms. Previous studies have not found a direct influence of single sagittal parameters on patient outcomes. However, recent research indicates that a composite of parameters, presented in specific sagittal profile types (SPTs) that were defined by Roussouly and colleagues, may affect these outcomes. This study aims to investigate the impact of SPT on long-term outcomes of patients with LSS following microsurgical decompression. METHODS This study is a prospective clinical observation. Patients with symptomatic LSS, who underwent microsurgical treatment and had long-term follow-up data for at least 36 months, were included. Patients with spinal deformity, fractures, or significant instability were excluded. Outcomes were measured using the numeric rating scale for pain, 36-Item Short Form Health Survey for quality of life, walking distance, Oswestry Disability Index, Roland-Morris Disability Questionnaire, and Odom’s criteria. SPT was determined in blinded fashion by using preoperative long standing radiographs. RESULTS The initial population of this observational study consisted of 128 patients, with long-term results available for 87 individuals, including 24 patients with SPT1, 20 with SPT2, 27 with SPT3, and 16 with SPT4. The average age was 70 years, with a slight male majority (56.3%) and a mean BMI of 27.9 kg/m2. After a median follow-up of 48 months, all groups showed significant improvement in walking distance, leg pain, and disability. Overall, 75% reported satisfaction with the surgery. However, patients with SPT1, which is characterized by low sacral slope and specific spinal curvatures, experienced significantly less improvement in back pain (p = 0.018) and related disability (p = 0.030), and lower satisfaction compared to other SPT groups (p = 0.008). CONCLUSIONS The sagittal spinal type is influencing the long-term outcome of patients suffering from symptomatic LSS. Patients with a combination of a flat sacral slope and a low overall lumbar lordosis with a high lordosis in the lower lumbar spine (i.e., spinal SPT1) showed worse outcome concerning back pain and had decreased satisfaction with surgery than comparable subjects from other SPT groups. Consequently, the authors recommend the assessment of sagittal spinal types in patients diagnosed with symptomatic spinal stenosis prior to decompression surgery. Inclusion of SPT in the preoperative consultation process can provide valuable insights, potentially guiding practitioners to more tailored patient counseling.

Improvement in functional gait parameters following corrective thoracolumbar surgery in children affected by Mucopolysaccharidosis 1 (Hurler syndrome)

ObjectiveThoracolumbar kyphosis is a common indication for spinal surgery in children with Mucopolysaccharidosis. Functional outcome of spinal surgical intervention has never been published in patients with this rare disease. We present a cohort of patients with Mucopolysaccharidosis 1(Hurler syndrome) who underwent thoraco-lumbar spinal deformity correction and functional outcome assessed by pre-operative and post-operative gait analysis. This study represents the first attempt at presenting a functional assessment of surgical outcome in any Mucopolysaccharidosis subtype.MethodsA retrospective analysis of prospectively collected data was carried out from 11 children diagnosed with this subtype of Mucopolysaccharidosis. All patients underwent thoracolumbar kyphosis correction between the years 2013 to 2016. Gait assessment was performed using GAITRite™ electronic walkway pre-operatively and post-operatively within 9 to 24 months from the index surgery. Walking distance, cadence and gait velocity were the three spatio-temporal parameters analysed. Wilcoxon signed rank test was used to analyse the data and P-Value ≤0.05 was deemed significant.ResultsThere was a statistically significant improvement in walking distance in 9 out of 11 patient post-operatively with a mean increase of 232.06 cms (P = 0.05). There was marginal improvement in cadence by 6.33 steps/min post-operatively (P-value 0.79). Gait velocity also showed a marginal increase by 8.73 cms/sec post-operatively (P-value 0.32).ConclusionThe results of our study suggest that correction of thoracolumbar kyphosis in children with Mucopolysaccharidosis 1 resulted in a significant improvement of walking distance with a trend towards improved gait in the other parameters. Post-operative change in cadence was not statistically significant suggesting that physiological maturation of gait had minimal effect in the specified post-operative assessment timeframe. This study emphasizes that outcomes of spinal surgery in children with Mucopolysaccharidosis 1 should be determined by functional measures aiming to maintain or improve quality of life.

Effect of active TENS versus de-tuned TENS on walking capacity in patients with lumbar spinal stenosis: a randomized controlled trial.

Background contextLumbar spinal stenosis (LSS) leads to diminished blood flow to the spinal nerves causing neurogenic claudication and impaired walking ability. Animal studies have demonstrated increased blood flow to the spinal nerves and spinal cord with superficial para-spinal electrical stimulation of the skin.PurposeThe aim of this study was to assess the effectiveness of active para-spinal transcutaneous electrical nerve stimulation (TENS) compared to de-tuned TENS applied while walking, on improving walking ability in LSS.Study designThis was a two-arm double-blinded (participant and assessor) randomized controlled trial.Patient sampleWe recruited 104 participants 50 years of age or older with neurogenic claudication, imaging confirmed LSS and limited walking ability.Outcome measuresThe primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals.MethodsThe active TENS group (n = 49) received para-spinal TENS from L3-S1 at a frequency of 65–100 Hz modulated over 3-s intervals with a pulse width of 100–200 usec, and turned on 2 min before the start and maintained during the SPWT. The de-tuned TENS group (n = 51) received similarly applied TENS for 30 s followed by ramping down to zero stimulus and turned off before the start and during the SPWT.Study funded by The Arthritis Society ($365,000 CAN) and salary support for Carlo Ammendolia funded by the Canadian Chiropractic Research Foundation ($500,000 CAN over 5 years).ResultsFrom August 2014 to January 2016 a total of 640 potential participants were screened for eligibility; 106 were eligible and 104 were randomly allocated to active TENS or de-tuned TENS. Both groups showed significant improvement in walking distance but there was no significant difference between groups. The mean difference between active and de-tuned TENS groups was 46.9 m; 95% CI (− 118.4 to 212.1); P = 0.57. A total of 71% (35/49) of active TENS and 74% (38/51) of de-tuned TENS participants achieved at least 30% improvement in walking distance; relative risk (RR), 0.96; 95% CI, (0.7 to 1.2) P = 0.77.ConclusionsActive TENS applied while walking is no better than de-tuned TENS for improving walking ability in patients with degenerative LSS and therefore should not be a recommended treatment in clinical practice.RegistrationClinicalTrials.gov ID: NCT02592642. Registration October 30, 2015.

Effect of a prototype lumbar spinal stenosis belt versus a lumbar support on walking capacity in lumbar spinal stenosis: a randomized controlled trial

BACKGROUND CONTEXTLumbar spinal stenosis (LSS) can impair blood flow to the spinal nerves giving rise to neurogenic claudication and limited walking ability. Reducing lumbar lordosis can increases the volume of the spinal canal and reduce neuroischemia. We developed a prototype LSS belt aimed at reducing lumbar lordosis while walking. PURPOSEThe aim of this study was to assess the short-term effectiveness of a prototype LSS belt compared to a lumbar support in improving walking ability in patients with degenerative LSS. STUDY DESIGNThis was a two-arm, double-blinded (participant and assessor) randomized controlled trial. PATIENT SAMPLEWe recruited 104 participants aged 50 years or older with neurogenic claudication, imaging confirmed degenerative LSS, and limited walking ability. OUTCOME MEASURESThe primary measure was walking distance measured by the self-paced walking test (SPWT) and the primary outcome was the difference in proportions among participants in both groups who achieved at least a 30% improvement in walking distance from baseline using relative risk with 95% confidence intervals. METHODSWithin 1 week of a baseline SPWT, participants randomized to the prototype LSS belt group (n=52) and those randomized to the lumbar support group (n=52) performed a SPWT that was conducted by a blinded assessor. The Arthritis Society funded this study ($365,000 CAN) with salary support for principal investigator funded by the Canadian Chiropractic Research Foundation ($500,000 CAN for 5 years). RESULTSBoth groups showed significant improvement in walking distance, but there was no significant difference between groups. The mean group difference in walking distance was −74 m (95% CI: −282.8 to 134.8, p=.49). In total, 62% of participants wearing the prototype LSS belt and 82% of participants wearing the lumbar support achieved at least 30% improvement in walking distance (relative risk, 0.7; 95% CI: 0.5–1.3, p=.43). CONCLUSIONSA prototype LSS belt demonstrated significant improvement in walking ability in degenerative LSS but was no better than a lumbar support.

Only walking matters-assessment following lumbar stenosis decompression.

Multiple outcome measures exist to evaluate the outcomes of spinal decompression surgery; however, these tend to be complex and are difficult to express to the patient pre-operatively to accurately guide their expectations. We present outcomes, in terms of walking distance measurement, of a prospective single surgeon series of 76 consecutive patients with spinal stenosis. 76 patients (mean age 68.8years; 48-91years) had decompression surgery using spinous process osteotomy. Accurate measurement of walking distance was used as an outcome measure, and factors that affect it were evaluated. Walking distance was measured pre-operatively, post-operatively and at 3months follow-up using a measuring wheel. The minimum follow-up was 5years. The mean distances walked were 78.1, 419.9 and 1285m, respectively. Pre-operative disc height (p=0.023) and male gender (p=0.039) predicted a significant improvement in walking distance, while age (p=0.23), ASA grade (p=0.39) and the number of levels operated on (p=0.89) did not significantly affect the increase in walking distance. 12 patients experienced post-operative complications (15.8%), and at last clinical follow-up (6.3years, 5.1-6.9years) 27 patients (35.5%) had residual leg symptoms and 8 had undergone further revision procedures (10.5%). This study demonstrates that walking distance is an accurate and accessible method of determining surgical outcomes.

Impact of traditional Greek dancing on jumping ability, muscular strength and lower limb endurance in cardiac rehabilitation programmes.

The objective of this study was to evaluate the effect of a training programme based on traditional Greek dance on the jumping ability, muscle strength and lower limb endurance in patients with chronic heart failure (CHF). Forty Greek patients with CHF graded as NYHA ⩽ II and aged 73.2±4.7 years were randomly divided into two groups. Group A ( n=20) participated in a three-month physical rehabilitation programme based on Greek traditional dances, whereas group B ( n=20) remained untrained and served as the control group. All patients were studied before and after the 12-week exercise training programme. At baseline and follow-up the exercise capacity of the patients was evaluated by the six-minute walking test, their lower extremity muscle strength was evaluated by an isokinetic dynamometer and their jumping ability by the Myotest-Pro test, which includes three types of jumps (plyometric, countermovement and squat jumps). No significant difference was observed between the two groups at the baseline evaluation. At follow-up, group A showed significant improvements in walking distance calculated from the six-minute walking test (10.0% improvement; p<0.05), in lower limb strength (10.32% improvement; p<0.05), and in countermovement jump speed (6.9%; p<0.05) and squat jump speed (5.8%; p<0.05). Group A also increased their jump plyometry height by 13.86% ( p<0.05), their counter jump height by 10.68% ( p<0.05) and their squat jump height by 10.45% ( p<0.05). Group A had a 6.85% ( p<0.05) increased force of counter jump compared with group B. The design and implementation of cardiac rehabilitation programmes using Greek traditional dances in patients with CHF are both safe and effective in improving lower limb function.

Long-term Outcome of Femoropopliteal Chronic Total Occlusion Percutaneous Treatment

Background: The endovascular approach of peripheral vascular disease is currently the treatment of choice in patients with severelylimited functional status. Chronic total occlusions (CTO) are lesions that pose a great challenge both for the clinician and the interventionist.Objective: The aim of this study was to analyze the feasibility and long-term outcome of CTO patients undergoing percutaneousintervention.Methods: From January 2008 to July 2013, consecutive patients with at least one chronic total occlusion of the femoropopliteal segment,undergoing elective or urgent percutaneous intervention, were included in the study. Demographic, angiographic and technicalaspects were analyzed and clinical long-term follow-up was performed by telephone or medical contact.Results: From a total of 431 treated patients, 129 presented with femoropopliteal CTO. TASC A-B lesions accounted for 62.8% ofcases and TASC C-D lesions for 37.2%. Stents were implanted in 62.7% of patients and complementary techniques were used in 22%(change of access, re-entry catheters, microdissection). Angiographic success of the procedure was 85.2%.Clinical improvement of 782.2 meters in the walking distance (25-75% interquartile range: 391-1,173) was obtained in the successfullytreated patients. In the multivariate analysis, run-off (OR 3.71, 95% CI 1.01-9.65; p=0.048) was the only independentsuccess variable. During the 623-day follow-up period (25-75% interquartile range: 430.7-1,292.2) 20 reinterventions (15.5%) and 3intervention-unrelated amputations were performed.Conclusions: Percutaneous CTO treatment in the femoropopliteal territory is feasible in a high proportion of patients, with significantimprovement in walking distance. The long-term outcome is associated with a significant rate of reinterventions.

Prospective, Systematic Observational Study on the Daily Use of Cilostazol (Pletal) in Clinical Vascular Surgical Practice - Significant Improvement of Walking Distance and Quality of Life for Patients with PAOD, Stage II b

Through a defined time period, all consecutive vascular surgical patients with indicated and initiated medication with cilostazol (PAOD, stage II b) were registered and controlled clinically within 3-month time intervals to investigate the therapeutic effect in a representative, specifically vascular surgical group of patients using a systematic prospective, unicentre clinical observational study. In particular, maximum walking distance, subjective (semiquantitative) assessment of the quality of life, impact of accompanying diseases as well as the occurrence of adverse effects and their impact onto the treatment were studied. Out of the 146 registered patients with initiated medication of cilostazol, 93 subjects were finally evaluated. Three months after initiation of cilostazol medication, maximum walking distance increased by 108 m (159.7 %) based on the initial 181 m. After 6 and 9 months, walking distance increased by 181 m (200 %) and 168 m (192.8 %), respectively. After 12 months, there was no further increase of the walking distance by 126 m (169.6 %) compared with months 6 and 9 but still with a significant difference to the initial distance. There was a trend of an improved walking distance from the 3rd to the 6th month (p = 0.1055) and a significant difference between the 3rd and the 9th month (p = 0.0094; no further significant differences between the time points 3rd/12th, 6th/9th, 6th/12th and 9th/12th month). While an improved quality of life was reported in 80.7 % of patients after 3 months, the rate varied between 82.6, 72.9 and 80.9 % at 6, 9 and 12 months, respectively, i.e., always in the majority of cases. There were no hints for safety concerns with regard to severe adverse effects, in particular, bleeding episodes. Subgroup analyses on accompanying diseases such as diabetes, hyperlipidemia or nicotine abuse did not reveal any impact on the improved walking distance (ABI - no feasible parameter). Medication with cilostazol led to a significant increase of the maximum walking distance (p < 0.0001) compared to the initial distance, which was further increased through one year (however, the effect became weaker) accompanied by a dominating improvement of the quality of life. The effects can be observed longer than 3-6 months.

Effects of treadmill training with the eyes closed on gait and balance ability of chronic stroke patients.

[Purpose] The purpose of this study was to compare the effect of treadmill walking with the eyes closed and open on the gait and balance abilities of chronic stroke patients. [Subjects and Methods] Thirty patients with chronic stroke participated in this study. The treadmill gait training for each group lasted 40 minutes, and sessions were held 3 times a week for 4 weeks. Gait ability was measured using a Biodex Gait Trainer Treadmill System. Balance ability was measured using a Biodex Balance System. [Results] After the treadmill training‚ the treadmill training with eyes closed (TEC) group showed significant improvements in walking distance‚ step length‚ coefficient of variation‚ and limit of stability (overall‚ lateral affected‚ forward lateral unaffected) compared to the treadmill training with eyes open (TEO) group. [Conclusion] The walking and balance abilities of the TEC participants showed more improvement after the treadmill walking sessions than those of the TEO participants. Therefore‚ treadmill walking with visual deprivation may be useful for the rehabilitation of patients with chronic stroke.

High‐Intensity Aerobic Interval Training for Patients 3–9 Months After Stroke. A Feasibility Study

High-intensity aerobic interval training (AIT) has shown to be beneficial in patients with cardiac and pulmonary diseases. Presumably, patients with stroke also benefit from such treatment. However, the feasibility and potential efficacy of high-intensity AIT should be investigated for patients early after stroke. This was a single-group, pre-test-post-test, intervention study. The intervention consisted of a 6-week high-intensity AIT programme, performed twice a week. The AIT comprised 4 × 4-minute intervals, at 85-95% of peak heart rate, interrupted by 3-minute active breaks. Adherence to the protocol, compliance and adverse events were registered to assess feasibility. Cardiorespiratory fitness and functional outcomes were assessed before and after the intervention and at 6 and 12 weeks follow-up. Ten men and five women (mean age 70.0 ± 7.7; range 61-85 years) with mild to moderate stroke were included, 3-9 months after onset. One patient was diagnosed with cancer during follow-up. There were three minor events, but no serious adverse events occurred. All patients accomplished all training sessions and reached the 85% intensity level, except one patient who discontinued the last session. The mean peak oxygen uptake showed no significant improvement from pre-treatment, 28.7 ± 3.8 ml kg(-1) min(-1), to post-treatment, 29.6 ± 3.6 ml kg(-1) min(-1), p = 0.189, whereas the mean 6-minute walk test improved from 410.7 ± 101.4 m to 461.0 ± 99.6 m, p = 0.001, and the median (interquartile range) Rivermead Motor Assessment Scale improved from 12.0 (11.0-13.0) to 13.0 (11.0-13.0) points, p = 0.100. These improvements continued after the intervention was concluded. This study has shown that high-intensity AIT is feasible for a selected group of stroke patients. However, the training should be accomplished in line with the American College of Sports Medicine guidelines for high-risk populations to ensure safety. The participants achieved a clinically highly significant improvement in walking distance. This intervention should be tested out in a randomized controlled trial to assess if it is superior to other interventions.

Six-minute walk test distance and resting oxygen saturations but not functional class predict outcome in adult patients with Eisenmenger syndrome

BackgroundEisenmenger syndrome (ES) represents the extreme manifestation of pulmonary arterial hypertension in patients with congenital heart disease, associated with significant exercise intolerance and mortality. Even though of six-minute-walk-test (6MWT) is routinely used in these patients, little is known about its prognostic value in comparison to functional class. Methods and resultsWe included 210 adult patients with ES who underwent a total of 822 6MWTs. Median walking distance (6MWD) was 330m [IQR 260–395], oxygen saturation (SO2) at baseline 86% [IQR 82–91%] and SO2 at peak-exercise 69% [IQR 60–80%]. In patients commenced on advanced therapy for pulmonary hypertension, but not in the reminder, there was a significant improvement in walking distance (297±97m vs. 325±87m,P=0.0019), SO2 at rest (84.9±7.1 vs. 86.8±5.9%,P=0.003), SO2 at peak exercise (69.1±12.7 vs. 72.3±12.2%,P=0.04) and NYHA functional class (P=0.0047).During a follow up of 3.3years, 29 patients died. On time-dependent Cox analysis, 6MWD (HR 0.94 per 10m, 95%CI: 0.91–0.97,P<0.001) and baseline SO2 (HR 0.90, 95%CI:0.86–0.94,P<0.0001) were predictors of death. In contrast, age, functional class, peak-exercise SO2 and SO2 change were not related to mortality. A three-fold increased risk of death was identified in patients not reaching a 6MWD of 350m or with baseline SO2 below 85%. ConclusionsThe 6MWD and resting SO2, but not functional class were predictive of outcome in this contemporary cohort of Eisenmenger patients and should be incorporated in both risk stratification and management algorithms for these patients.

Chronic thromboembolic pulmonary hypertension: role of medical therapy

Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease with poor prognosis if not treated. The treatment of choice is surgery with pulmonary endarterectomy. However, a significant percentage of patients are deemed non-operable due to distal distribution of the disease and arteriopathy in the non-occluded areas that is indistinguishable from pulmonary arterial hypertension (PAH). The overlap in clinical presentation, pathological features and pathogenesis between PAH and CTEPH provides a compelling rationale for exploring the efficacy of PAH-targeted therapies in CTEPH. These therapies are often considered for non-operable patients and are also used in operable patients as a bridge to surgery or as post-pulmonary endarterectomy therapy for persistent pulmonary hypertension, despite the fact they are not licensed for CTEPH. Two randomised clinical trials have been performed in non-operable CTEPH patients. The BENEFiT study, with the endothelin receptor antagonist bosentan, did not show improvement in walking distance. Recently, the CHEST-1 trial, with the soluble guanylate cyclase stimulator riociguat, met study end-point and demonstrated significant improvement in walking distance in patients with non-operable CTEPH. There is an urgent need for more randomised clinical trials designed to clarify whether administration of PAH-targeted therapies improves clinically meaningful end-points in various CTEPH populations.

A Randomized Trial Comparing 2 Types of In-Home Rehabilitation for Chronic Obstructive Pulmonary Disease

Pulmonary rehabilitation has been shown to be effective for improving quality of life and function in patients with chronic obstructive pulmonary disease (COPD) but has not been studied extensively in homebound patients. Furthermore, little is known about the effectiveness of specific types of home-based interventions. The purpose of this study was to examine the effectiveness of in-home rehabilitation programs for individuals with COPD considered homebound according to Medicare definition and to compare outcomes of 2 different rehabilitation interventions. Patients were randomly assigned to 2 home-based interventions including aerobic conditioning (group A) or functional strength training (group B), which were conducted over 8 weeks. In addition, all patients received COPD self-management education. Outcome measures were collected after completion of the intervention and after 16 weeks and included the Chronic Respiratory Questionnaire (CRQ), Geriatric Depression Scale, and 2-minute walk test. Of 41 patients enrolled, 24 completed the 8-week intervention. On average, all CRQ quality-of-life domains improved in both groups, with the largest improvements in the CRQ-dyspnea domain. Overall, at 16 weeks, 80% of group A and 71% of group B patients had clinically significant improvements in the CRQ-dyspnea domain. Furthermore, depression scores improved in both groups. Only group A had a clinically significant improvement in walking distance. The results of this pilot study suggest that both forms of home-based rehabilitation may improve disease-specific quality of life in homebound patients with COPD.

Six-Minute Walking Test to Assess Exercise Tolerance and Cardiorespiratory Responses During Training Program in Children With Congenital Heart Disease

This study assessed the exercise tolerance and the cardiorespiratory responses to a training program by the six-minute walk test (6'WT) in children with congenital heart disease (CHD). Seventeen cardiac and 14 healthy children performed maximal cardiopulmonary exercise test (CPET) and 6'WT. Reliability of 6'WT was assessed in all subjects (test-retest) by Bland-Altman plots. Cardiac subjects were randomly divided in training (T-CHD) and control groups (C-CHD). T-CHD underwent an individualized training exercise at the ventilatory threshold (VT) intensity during 12 weeks. We found that the 6'WT is a reliable and reproducible test. CHD children walked a lower distance than healthy children before training (472.5 +/- 18.1 vs. 548.8 +/- 7.7 m, respectively, p < 0.001). Likewise, power output, oxygen uptake (V.O (2)), and heart rate (HR) at the maximum and the VT levels, were significantly lower in patients (p < 0.001). After training, a significant improvement of walking distance (WD) was shown in T-CHD (529.6 +/- 15.3 vs. 467.7 +/- 17.1 m, p < 0.001). The power output, VO2, HR, and V.E increased slightly (6 to 10 %, p > 0.05) at peak exercise and significantly at ventilatory threshold level (p < 0.05) in T-CHD. Significant relationships between WD and VO2max as well as VO2 at VT were founded (p < 0.05). We concluded that the 6'WT is a useful and reliable tool in the assessment and follow-up of functional capacity during rehabilitation program in children with CHD.

The inflammatory response to upper and lower limb exercise and the effects of exercise training in patients with claudication

Purpose: We have previously shown that a program of upper limb exercise training can induce significant improvements in walking distance in patients with claudication. This study assessed whether upper limb exercise avoids the systemic inflammatory responses associated with lower limb exercise and also whether the inflammatory response to acute lower limb exertion is modified by a program of supervised exercise training. Methods: Fifty-two patients with stable intermittent claudication were randomized into two groups who underwent 6 weeks of supervised upper (n = 26) or lower (n = 26) limb cardiorespiratory exercise training. A parallel control group (n = 15) was provided with lifestyle advice only. Neutrophil activation markers (CD11b and CD66b) and plasma levels of von Willebrand factor (marker of endothelial damage) in response to an acute bout of sustained upper and lower limb exercise were assessed before and after the period of training. Plasma levels of soluble E-selectin (marker of endothelial activation) were also determined before and after the training period. Results: An acute bout of sustained lower limb exercise significantly increased the intensity of CD11b and CD66b expression by peripheral blood neutrophils in all groups, whereas upper limb exercise had no effect. Resting neutrophil expression of CD11b and CD66b and circulating von Willebrand factor levels were unaffected by the training program, as were the inflammatory responses to an acute bout of sustained upper and lower limb muscular work, despite the fact that both training programs significantly increased walking distances. Conclusions: These findings indicate that upper limb exercise training programs may offer certain advantages over currently prescribed lower limb programs. Our results show that exercising nonischemic muscles in a way that promotes improved cardiorespiratory function and walking capacity can avoid the potentially deleterious systemic inflammatory responses associated with lower limb exertion in patients with stable intermittent claudication. (J Vasc Surg 2001;33:392-9.)

The Effects of Sublingual Glyceryl Trinitrate on Walking Distance in Patients with Intermittent Claudication. A Randomised, Doubled-blind, Placebo-controlled, Crossover Study

SUMMARYBackground: Intermittent claudication (IC) is a common problem in older age. New work shows that the administration of glyceryl trinitrate (GTN) can reduce the fall in ankle brachial pressure index (ABPI) after exercise and can increase maximum walking distance by 19% on treadmill exercise. The aim of this study was to further define the clinical benefits of GTN in patients with PVD.Methods: The study is of a randomised, double-blind, placebo-controlled cross-over design. We studied 29 patients with intermittent claudication where the median age was 67.5 years (45-84). This included 20 males and nine females, and six of these patients were diabetics. To be selected, the patients had to have a history of IC with a resting ABPI of 1.0 or less, that fell by more than 0.1 on exercise. Patients were walked for 15 min on flat ground following GTN spray or placebo and total distances walked were measured. This was then followed by the crossover component of the trial.Results: Median walking distance with placebo was 825 m (100-1300 m) and with GTN was 900 m (240-1400 m). This is an increase of 9% (p = 0.02, using the Wilcoxon matched pairs signed ranks test).Conclusion: This study shows a statistically significant improvement in walking distance with GTN in patients with IC.

Quality of life changes after angioplasty for claudication: medium-term results affected by comorbid conditions

Rapid improvements in walking distance and quality of life have been identified in patients with intermittent claudication following percutaneous transluminal angioplasty, but the medium-term results are less well defined. The aim of this study was to assess quality of life and walking distance in the medium term. Walking distance was assessed before percutaneous transluminal angioplasty and at 6 weeks and 1 year after the procedure using a previously validated questionnaire. At the same time, quality of life was assessed using a EuroQol questionnaire and a visual analogue scoring system. Twenty-four patients (12 men, 12 women, mean age 65 years) underwent successful percutaneous transluminal angioplasty (five iliac, 17 femoropopliteal, two both). Significant improvements in walking distance and quality of life were demonstrated following percutaneous transluminal angioplasty. These were maintained at 1 year, although perceived health state deteriorated. During the study period, six patients developed other serious comorbidities. Development of comorbid conditions may affect the medium-term outcome of quality of life studies in patients treated for intermittent claudication. Data from such studies should therefore be interpreted with care.

Intermittent claudication

Twenty-one patients with intermittent claudication underwent a physical exercise program lasting 8 weeks. The patients were classified on the basis of maximal walking tolerance (MWT) and diagnosis at the initial examination. Seven of the patients had a MWT less than 1,000 m and no symptoms of chronic obstructive airways disease (COAD) or angina (group A), seven had a MWT less than 1,000 m plus angina and/or COAD (group B) and seven had an unlimited (greater than 1,250 m) MWT (group C). At the completion of the training program all three groups showed a significant improvement in walking distance to pain and stress test capacity. During the post-training walking tolerance test, the venous lactate concentrations in group A were lower after 2 min and 4 min of exercise, and at exhaustion (P less than 0.05). Group A patients showed a significant correlation between an increase in MWT after training and a decrease in maximum lactate concentration measured during walking. Although the patients in group B had a significant increase in MWT, blood lactate concentrations in this group were not always decreased by physical training. Group C lactate concentrations were lower after 8 min, 15 min, and 30 min of walking (P less than 0.05). It is concluded that a physical training program increases walking tolerance in different categories of claudicants, and possible mechanisms for the improvement are discussed.