Supervised Exercise Therapy Program Research Articles

Socioeconomic factors predict successful supervised exercise therapy completion

ObjectiveSupervised exercise therapy (SET) for patients with intermittent claudication (IC) can lower the risk of progression to chronic limb-threatening ischemia and amputation, while preserving and restoring functional status. Despite supporting evidence, it remains underutilized, and among those who initiate programs, attrition rates are extremely high. We hypothesize that socioeconomic factors may represent significant barriers to SET completion. MethodsPatients with IC referred to SET at a multi-hospital, single-institution health care system (2018-2022) from a prospectively maintained database were retrospectively analyzed. Our primary endpoint was SET program completion and graduation, defined as completion of 36 sessions. Our secondary endpoints were vascular intervention within 1 year of referral and change in ankle-brachial index (ABI). Baseline demographics were assessed using standard statistical methods. Predictors of SET graduation were analyzed using multivariable logistic regression generating adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Change in ABI was analyzed using t-test between subgroups. Reasons for attrition were tabulated. Patient Health Questionnaire-9 (PHQ-9), metabolic equivalent level, Vascular QOL, Duke Activity Status, and ABI were analyzed using paired t-tests across the entire cohort. ResultsFifty-two patients met inclusion criteria: mean age 67.85 ± 10.69 years, 19 females (36.54%), mean baseline ABI of 0.77 ± 0.16. The co-pays for 100% of patients were fully covered by primary and secondary insurance plans. Twenty-one patients (40.38%) completed SET. On multivariable analysis, residence in a ZIP code with median household income <$47,000 (aOR, 0.10; 95% CI, 0.01-0.76; P = .03) and higher body mass index (aOR, 0.81; 95% CI, 0.67-0.99; P = .04) were significant barriers to SET graduation. There were no differences in ABI change or vascular intervention within 1 year between graduates and non-graduates. Non-graduates reported transportation challenges (25.00%), lack of motivation (20.83%), and illness/functional limitation (20.83%) as primary reasons for SET attrition. Metabolic Equivalent Level (P ≤ .01) and Duke Activity Status scores (P = .04) were significantly greater after participating in a SET program. ConclusionsAlthough SET participation improves lower extremity and functionality outcomes, only 40% of referred patients completed therapy in our cohort. Our findings suggest that both socioeconomic and functional factors influence the odds of completing SET programs, indicating a need for holistic pre-referral assessment to facilitate enhanced program accessibility for these populations.

Supervised exercise therapy program vs non-supervised exercise therapy program after distal radius fracture: A systematic review and meta-analysis

BackgroundIt is an updated systematic review with meta-analysis that compared supervised exercise therapy (SET) vs non-supervised exercise therapy (NSET) programs for patients with distal radius fracture. PurposeThe purpose of this systematic review is to appraise the current literature to determine if SET program is more effective than a NSET program for pain relief, improvement of range of movement, function and grip strength, both in the short or medium term for patients following distal radius fractures. Study DesignSystematic review. MethodsThe following electronic databases were searched: Medline/Pubmed, PEDro, Cinahl, Embase, CENTRAL, and Lilacs. PICOT strategy was used for trial selection. The searches were conducted on August 22, 2021, and May 26, 2022. Two researchers performed an independent search for papers from the references of the chosen trials. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) was used for assessing the quality of evidence. ResultsThe search strategy identified 2786 potentially eligible studies and 15 studies met our inclusion criteria. The results did not show that the SET program was more effective than the NSET program for all outcomes, in both terms for patients after distal radius fractures. GRADE showed that all analyses presented very low-quality evidence. ConclusionsEven the results showing there was no difference between the two programs analyzed, the available evidence for randomized controlled trials was insufficient to support these results.

Influence of Self-Reported Knee Instability on Outcomes Following Education and Exercise: A Cohort Study of 2,466 Patients With Knee Osteoarthritis.

To study the influence of self-reported knee instability on changes in knee pain and gait speed following patient education and supervised exercise therapy in patients with knee osteoarthritis (OA). We included patients enrolled in the Good Life With Osteoarthritis in Denmark (GLA:D) program, an 8-week education and supervised neuromuscular exercise program. Patients were classified into 4 groups according to their level of self-reported knee instability (never; rarely; sometimes; most of the time or all the time). Knee pain intensity was evaluated on a 0-100 mm scale and gait speed from the 4 × 10 meters fast-paced walk test at baseline and after the program. Using linear regression, we examined the association between knee instability and the change in pain and gait speed, respectively. Sex, age, body mass index, physical activity level, and previous knee surgery were covariates in adjusted models. Among 2,466 patients with knee OA, mean baseline pain and gait speed varied between 38-59 mm and 1.39-1.56 meters/second in patients experiencing no instability and patients experiencing instability most or all the time, respectively. All instability groups improved in pain and gait speed. Compared to the no instability group, patients reporting instability most or all the time experienced larger improvements in pain (4.3 mm [95% confidence interval 1.2, 7.5]), while no difference between instability groups was found for gait speed. Knee OA patients with self-reported instability seem to benefit even more from a patient education and supervised exercise therapy program than OA patients without instability.

A 12-Week Supervised Exercise Therapy Program for Patients with Diabetic Foot Ulcers: Program Development and Preliminary Feasibility.

Exercise therapy helps improve glycaemic control and insulin sensitivity and may be relevant in treating patients with diabetic foot ulcers (DFUs). This study describes the development of a 12-week exercise therapy program for patients with DFUs and the preliminary feasibility of the program focusing on the program's inclusion, adherence, and safety. The development process is built on knowledge from a published systematic review on exercise for people with DFUs and a grounded theory study on the main concerns of people with DFUs regarding physical activity. The development involved doctors, wound care nurses, podiatrists, and feedback from patients and physical therapists using semi-structured interviews. The program was designed as a combination of aerobic and resistance training exercises. The aerobic exercise phase on the stationary bike of 30-minute duration was aimed at a moderate intensity. Resistance exercises were conducted with a 15-repetition maximum approach (four to five sets per trial) throughout the 12-week period. Three patients were included and received the exercise intervention. Except for recruitment and retention rates, acceptance levels were met for all other research progression criteria. Patients found the intervention relevant, wanted further guidance on continuing exercising, and would have liked the intervention closer to their home for example, a municipality setting. Although the exercise therapy program for patients with DFUs was developed in a thorough process with the inclusion of available evidence and the involvement of patients and other stakeholders conclusions on feasibility are limited due to the low recruitment rate. A reconsideration of the setting is needed in future exercise intervention studies.

Supervised exercise training in patients with lower extremity peripheral artery disease

Summary: The optimal first line management of patients with symptomatic chronic lower extremity peripheral artery disease (PAD) includes secondary prevention of cardiovascular risk factors, pharmacological treatment, and supervised exercise therapy (SET). SET programs have shown to be effective in improving walking performance, functional performance, and quality of life. However, despite a large body of evidence, and despite national and international guidelines recommending SET as first line therapy, SET remains largely underused in patients with chronic PAD. This position paper aims to describe how SET is perceived, its accessibility and structure through Europe. An anonymous web-based survey was used. It comprised 21 questions developed in conjunction with an angiologist and a clinical exercise physiologist specialist in vascular rehabilitation. We had 131 responders from 17 countries. For patients with PAD, SET programs exist only in 59% of European countries. SET reimbursement is available in 41% of countries. SET programs showed to be heterogeneous across countries. Thirty-four percent of the SET programs are PAD-dedicated, while 23% are part of a cardiac rehabilitation program. In addition, among existing SET programs, 65% are dedicated to symptomatic patients with PAD only, 9% to both asymptomatic and symptomatic, 8% to post-revascularized patients only, and 1% to asymptomatic patients with PAD only. Finally, 17% reported not knowing which patients are eligible for enrolment in a SET program. Duration, frequency, and modality of SET also varied from country to country. Overall, these data indicate that a large variability of SET availability and characteristics exists across Europe. Therefore, there is an urgent need to provide detailed guidance to deliver optimal exercise therapeutic care in patients with PAD.

IMPACT OF PRIOR KNEE SURGERY ON KNEE PAIN, QUALITY OF LIFE, AND WALKING SPEED FOLLOWING 8-WEEK EDUCATION AND SUPERVISED EXERCISE THERAPY: ANALYSIS OF 17,262 MEN AND WOMEN WITH KNEE OSTEOARTHRITIS

Purpose: Previous surgery may negatively influence the effect of treatments in patients with knee osteoarthritis (OA). We compared changes in knee pain, quality of life, and walking speed after participation in an 8-week combined patient education and supervised exercise therapy program in men and women with and without previous knee surgery.

Centers for Medicare and Medicaid Services Policy Regarding Supervised Exercise for Patients With Intermittent Claudication: The Good, the Bad, and the Ugly

On May 25, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a decision memo establishing coverage for supervised exercise therapy (SET) for Medicare beneficiaries experiencing intermittent claudication due to peripheral artery disease (PAD). A meaningful impact on population health is possible with greater freedom to participate in regular physical activity. The authors of this editorial explain the potential roles of physical therapists in the SET program and argue for further integration of physical therapists through collaborative practice. J Orthop Sports Phys Ther 2017;47(12):892-894. doi:10.2519/jospt.2017.0111.

A 12-week supervised exercise therapy program for young adults with a meniscal tear: Program development and feasibility study

ObjectiveTo describe the development and feasibility of an exercise therapy program for treatment of young adults (18–40 years of age) with a meniscal tear. MethodsResearchers and experienced physical therapists developed a 12-week supervised neuromuscular and strengthening exercise therapy program based on clinical expertise and available evidence. Six patients (age range 22–39 years) considered eligible for meniscal surgery by an orthopedic surgeon underwent the program. Patients completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and evaluated the program during a semi-structured qualitative interview. Feedback from patients was included to finalize the exercise therapy program. ResultsMedian improvements (Range) in KOOS subscales were 15 (0–33) for Pain, 11 (−11 to 50) for Symptoms, 16 (3–37) for Function in daily living, 23 (10–45) for Function in sport and recreation, and 9 (−6 to 31) for Quality of life. The patients found the program relevant and effective with only a few short-lasting adverse events and important clinical improvements after four to ten weeks. Physical therapist supervision was considered important. No patients wanted surgery up to 6 month after the exercise therapy program. ConclusionA neuromuscular and strengthening exercise therapy program was feasible and showed important improvement in a small group of young adults with meniscal tears.

Abstract 19190: Effectiveness of Supervised Exercise Therapy for the Treatment of Intermittent Claudication in Real-world Clinical Practice

Introduction: Guidelines recommend supervised exercise therapy (SET) as a first-line treatment for patients with intermittent claudication. In trials, SET has indeed been shown to be equally effective as endovascular revascularization in improving walking performance and quality of life. However, SET is an underutilized treatment and the effectiveness of a SET-first approach outside a trial setting is unknown. Hypothesis: We assessed the hypothesis that SET is an effective treatment for intermittent claudication in real-world clinical practice. Methods: In a single-center prospective cohort study, 204 patients with newly diagnosed intermittent claudication were referred to a physiotherapist for SET between August 2009 and December 2013. All patients underwent lower extremity CTA or MRA imaging. Significant stenosis was defined as ≥50% reduction in luminal diameter. Community-based SET was provided according to national guidelines. Freedom from endovascular or open surgical intervention at the last outpatient visit was considered as the primary outcome. Kaplan Meier estimate was used to determine freedom from intervention at 1 year. Results: Mean age was 70±10 years with 59% men and the common risk factors (77% hypertension, 31% diabetes, 46% smoking, 10% obesity) and comorbidities (32% and 23% history of ischemic heart or cerebrovascular disease, resp.). Median maximum walking distance on treadmill testing at baseline visit was 320 m (IQR 150-510 m). The majority (88%) of patients had significant femoropopliteal and/or crural disease. Only 4% had isolated aortoiliac and/or common femoral artery stenoses. Of the 204 referred patients, 84% followed the SET program. After 1 year follow up, 88% of patients were still free from endovascular or surgical intervention. Conclusions: In a real-world clinical setting, a SET-first approach is an effective treatment for intermittent claudication, preventing invasive treatment in most patients.

Gender differences following supervised exercise therapy in patients with intermittent claudication

Prevalence of peripheral arterial disease is equal in men and women. However, women seem to suffer more from the burden of disease. Current studies on gender-related outcomes following supervised exercise therapy (SET) for intermittent claudication (IC) yield conflicting results. A follow-up analysis was performed on data from the 2010 Exercise Therapy in Peripheral Arterial Disease (EXITPAD) study, a multicenter randomized controlled trial including IC patients receiving SET or a walking advice. The SET program was supervised by physiotherapists and included interval-based treadmill walking approximating maximal pain combined with activities such as cycling and rowing. Patients usually started with three 30-minute sessions a week. Training frequency was adapted during the following year on the basis of individual needs. The primary outcome was gender differences regarding the change in absolute claudication distance (ACD) after SET. ACD was defined as the number of meters that a patient had covered just before he or she was forced to stop walking because of intolerable pain. Secondary outcomes were gender differences in change of functional walking distance, quality of life, and walking (dis)ability after SET. Walking distances were obtained by standardized treadmill testing according to the Gardner-Skinner protocol. Quality of life was measured by the 36-Item Short Form Health Survey, and walking (dis)ability was determined by the Walking Impairment Questionnaire (WIQ). Measurements were performed at baseline and after 3, 6, 9, and 12 months. Only patients who met the 12-month follow-up measure were included in the analysis. A total of 113 men and 56 women were available for analysis. At baseline, groups were similar in terms of clinical characteristics and ACD walking distances (men, 250 meters; women, 270 meters; P = .45). ACD improved for both sexes. However, ACD increase was significantly lower for women than for men during the first 3 months of SET (Δ 280 meters for men vs Δ 220 meters for women; P = .04). Moreover, absolute walking distance was significantly shorter for women compared with men after 1 year (565 meters vs 660 meters; P = .032). Women also reported less on several WIQ subdomains, although total WIQ score was similar (0.69 for men vs 0.61 for women; P = .592). No differences in quality of life after SET were observed. Women with IC benefit less during the first 3 months of SET and have lower absolute walking distances after 12 months of follow-up compared with men. More research is needed to determine whether gender-based IC treatment strategies are required.

Effect of exercise therapy compared with arthroscopic surgery on knee muscle strength and functional performance in middle-aged patients with degenerative meniscus tears: a 3-mo follow-up of a randomized controlled trial.

The aim of this study was to compare the effect of a 12-wk exercise therapy program and arthroscopic partial meniscectomy on knee strength and functional performance in middle-aged patients with degenerative meniscus tears. A total of 82 patients (mean age, 49 yrs; 35% women) with a symptomatic, unilateral, magnetic resonance imaging-verified degenerative meniscus tear and no or mild radiographic osteoarthritis were randomly assigned to a supervised neuromuscular and strength exercise program or arthroscopic partial meniscectomy. Outcomes assessed 3 mos after intervention initiation were isokinetic knee muscle strength, lower extremity performance, and self-reported global rating of change. Mean difference in isokinetic knee extension peak torque between the two groups was 16% (95% confidence interval, 7.1-24.0) (P < 0.0001), favoring the exercise group. Patients in the exercise group improved isokinetic knee extension peak by a mean of 25 Nm (range, 18-33 Nm) from baseline to follow-up. Furthermore, patients assigned to exercise therapy showed statistically significant improvements (P ≤ 0.002) in all other measured variables, with moderate to large effect sizes (0.5-1.3). Patients reported a similar and positive effect of both interventions. A 12-wk supervised exercise therapy program yielded clinically relevant and statistically significant improvement in isokinetic quadriceps strength immediately after completion of the program, as compared with treatment with arthroscopic partial meniscectomy.

Gait biomechanics and functional outcomes as predictors of response to a hip strengthening exercise program in knee osteoarthritis patients

s / Osteoarthritis and Cartilage 23 (2015) A82eA416 A371 study were to evaluate the feasibility and outcome of the newly developed protocol. Methods: Forty-nine patients with knee osteoarthritis and severe knee pain (NRS 7) were included in this study. Analgesics were prescribed following an incremental protocol. The incremental steps were (1) acetaminophen, (2)NSAIDs, (3)weak opioids and (4) an intra-articular steroid injection. After six weeks a supervised exercise therapy program for 12 weeks was added, consisting of muscle strengthening exercises and training of daily activities. Feasibility was evaluated by information about analgesics, pain reduction, exercise therapy content and the opinion of patients, rheumatologists andphysical therapists. Knee painwas assessed with NRS-pain and activity limitations were assessed with WOMAC-PF. Data were collected at baseline, after six weeks, and after 18 weeks. Results: Eighty-two percent of the patients were able to exercise according to the protocol. In intention-to-treat analyses statistically significant and clinically relevant improvements in pain (mean change 30% from baseline, p<0.001) and activity limitations (mean change 15% from baseline, p<0.001) were found after the combined intervention protocol with analgesics and exercise therapy. Improvements in pain (p<0.001) and activity limitations (p1⁄40.002) were found after six weeks of analgesic use. Further improvements in pain (p<0.001) and activity limitations (p1⁄40.004) were found after twelve weeks of exercise therapy in per protocol analyses in patients who were able to exercise according to the protocol. Conclusions: The combined intervention of analgesics and exercise therapy allows most patients with knee osteoarthritis and severe pain to participate in exercise therapy, leading to reduction of pain and activity limitations. Although the results are promising, they need to be confirmed in a randomized controlled trial. 611 GAIT BIOMECHANICS AND FUNCTIONAL OUTCOMES AS PREDICTORS OF RESPONSE TO A HIP STRENGTHENING EXERCISE PROGRAM IN KNEE OSTEOARTHRITIS PATIENTS D. Kobsar, S.T. Osis, B.A. Hettinga, R. Ferber. Univ. of Calgary, Calgary, AB,

No effects of a 12-week supervised exercise therapy program on gait in patients with mild to moderate osteoarthritis: a secondary analysis of a randomized trial.

BackgroundIt is unknown whether gait biomechanics in hip osteoarthritis patients with mild to moderate symptoms change following exercise therapy interventions. The aim of the present study was to compare stance phase gait characteristics in hip osteoarthritis patients with mild to moderate symptoms participating in a randomized trial with two different interventions; patient education only or patient education followed by a 12-week supervised exercise therapy program.ResultsThe study was conducted as a secondary analysis of a single-blinded randomized controlled trial. Patients aged 40 to 80 years, with hip osteoarthritis verified from self-reported pain and radiographic changes, were included. The final material comprised 23 patients (10 males/13 females, mean (SD) age 58.2 (10.02) years) in the patient education only group, and 22 patients (9 males/13 females, mean (SD) age 60.2 (9.49) years) in the patient education + exercise therapy group. Three-dimensional gait analysis was conducted at baseline and at four month follow-up. Sagittal and frontal plane joint angle displacement and external joint moments of the hip, knee and ankle were compared from a one-way analysis of covariance between the groups at follow-up, with baseline values as covariates (p < 0.05). No group differences were observed at the four-month follow-up in gait velocity, joint angle displacement, or moments. As the compliance in the exercise therapy group was inadequate, we calculated possible associations between the number of completed exercise sessions and change in each of the kinematic or kinetic variables. Associations were weak to neglible. Thus, the negative findings in this study cannot be explained from inadequate compliance alone, but most likely also suggest the exercise therapy program itself to be insufficient to engender gait alterations.ConclusionsAdding a 12-week supervised exercise therapy program to patient education did not induce changes in our selected biomechanical variables during the stance phase of gait, even when adjusting for poor compliance. Thus, we did not find evidence to support our exercise therapy program to be an efficacious intervention to induce gait alterations in this population of hip osteoarthritis patients.Trial registrationNCT00319423 at ClinicalTrials.gov (registration date 2006-04-26).

Functional claudication distance: a reliable and valid measurement to assess functional limitation in patients with intermittent claudication

BackgroundDisease severity and functional impairment in patients with intermittent claudication is usually quantified by the measurement of pain-free walking distance (intermittent claudication distance, ICD) and maximal walking distance (absolute claudication distance, ACD). However, the distance at which a patient would prefer to stop because of claudication pain seems a definition that is more correspondent with the actual daily life walking distance. We conducted a study in which the distance a patient prefers to stop was defined as the functional claudication distance (FCD), and estimated the reliability and validity of this measurement.MethodsIn this clinical validity study we included patients with intermittent claudication, following a supervised exercise therapy program. The first study part consisted of two standardised treadmill tests. During each test ICD, FCD and ACD were determined. Primary endpoint was the reliability as represented by the calculated intra-class correlation coefficients. In the second study part patients performed a standardised treadmill test and filled out the Rand-36 questionnaire. Spearman's rho was calculated to assess validity.ResultsThe intra-class correlation coefficients of ICD, FCD and ACD were 0.940, 0.959, and 0.975 respectively. FCD correlated significantly with five out of nine domains, namely physical function (rho = 0.571), physical role (rho = 0.532), vitality (rho = 0.416), pain (rho = 0.416) and health change (rho = 0.414).ConclusionFCD is a reliable and valid measurement for determining functional capacity in trained patients with intermittent claudication. Furthermore it seems that FCD better reflects the actual functional impairment. In future studies, FCD could be used alongside ICD and ACD.

Supervised exercise therapy for intermittent claudication in a community-based setting is as effective as clinic-based

This cohort study was conducted to determine the effect on walking distances of supervised exercise therapy provided in a community-based setting. The study included all consecutive patients presenting at the vascular outpatient clinic with intermittent claudication, diagnosed by a resting ankle brachial index<0.9, who had no previous peripheral vascular intervention for peripheral arterial disease, no major amputation, and sufficient command of the Dutch language. The exclusion criterion was the inability to walk the baseline treadmill test for a minimum of 10 m. The intervention was a supervised exercise therapy in a community-based setting. A progressive treadmill test at baseline and at 1, 3, and 6 months of follow-up measured initial claudication distance and absolute claudication distance. Changes were calculated using the mean percentages of change. From January through October 2005, 93 consecutive patients with claudication were eligible. Overall, 37 patients discontinued the supervised exercise therapy program. Eleven stopped because of intercurrent diseases, whereas for 10, supervised exercise therapy did not lead to adequate improvement and they underwent a vascular intervention. Three patients quit the program, stating that they were satisfied with the regained walking distance and did not require further supervised exercise therapy. Ten patients were not motivated sufficiently to continue the program, and in three patients, a lack of adequate insurance coverage was the reason for dropping out. Data for 56 patients were used and showed a mean percentage increase in initial claudication distance of 187% after 3 months and 240% after 6 months. The mean percentage of the absolute claudication distance increased 142% after 3 months and 191% after 6 months. Supervised exercise therapy in a community-based setting is a promising approach to providing conservative treatment for patients with intermittent claudication.