Supervised Treadmill Exercise Research Articles

Exercise Therapy for Peripheral Artery Disease.

To summarize evidence regarding exercise treatments for lower extremity peripheral artery disease (PAD). Supervised walking exercise is recommended by practice guidelines for PAD. Supervised treadmill exercise improves treadmill walking distance by approximately 180m and 6-min walk distance by 30-35m, compared to control. The Centers for Medicaid and Medicare Services covers 12weeks of supervised exercise, but most people with PAD do not participate. Home-based walking exercise may be more convenient and accessible than supervised exercise. In randomized clinical trials, home-based walking exercise interventions incorporating behavioral methods, such as accountability to a coach, goal-setting, and self-monitoring, improved 6-min walk distance by 40-54m, compared to control. Arm and leg ergometry also improved walking endurance for people with PAD, but efficacy compared to walking exercise remains unclear. Walking exercise is first-line therapy for PAD-related walking impairment and can be effective in either a supervised or a structured home-based setting.

Comparing high-intensity versus moderate-intensity exercise training in coronary artery disease patients: a randomized controlled trial with 6- and 12-month follow-up

Abstract Aim This study aimed to investigate the long-term effects of two exercise-based CR programs on physical activity (PA), sedentary behavior, physical fitness, quality of life (QoL), and mental health in coronary artery disease (CAD) patients. Subject and methods Seventy-two CAD participants were randomized (1:1:1) into HIIT, MICT, and control groups. Both training programs spanned 6 weeks with three supervised treadmill exercise sessions per week. MICT targeted ≈70–75% of peak heart rate (HR), while HIIT aimed for ≈85–95% of peak HR. The control group adhered to standard medical recommendations. Assessments at 6- and 12-months post-intervention included body composition, aerobic capacity, muscle strength, PA, SB, QoL, anxiety, and depression. Results Over the 6- and 12-month follow-up periods, both exercise groups maintained the levels of aerobic capacity (HIIT ≈ 19.6 ml kg−1 min−1, MICT ≈ 17.8 ml kg−1 min−1), QoL, and PA compared to baseline (p < .001). Symptoms of anxiety and depression remained lower than baseline (p < .001). The HIIT group demonstrated a significant decreasing trend in waist circumference (∆m3−m2% −2 cm, p = .033) compared to MICT (p = .016) and control (p = .001) at 6 months of follow-up. It was maintained at 12 months of follow-up with significant differences to MICT (p = .018) and control (p = .001). In contrast, the control group experienced deteriorations in body composition, SB, symptoms of anxiety, and depression, along with a decline in aerobic capacity over time. Conclusion Encouraging CAD patients to maintain elevated PA levels can promote cardiovascular, WC, and mental health. CR exercise programs can reduce cardiovascular risk factors and induce favorable lifestyle changes. Notably, HIIT demonstrated sustained improvements surpassing those of MICT. These findings underscore the importance of structured exercise-based CR programs in optimizing long-term outcomes for CAD patients. Trial Registration https://clinicaltrials.gov/ct2/show/NCT03538119 on May 25, 2018.

Abstract 14128: Walking Exercise for Peripheral Artery Disease: Effects in Women and Black Americans

Introduction: In people with lower extremity peripheral artery disease (PAD), rates of participation in supervised exercise therapy are lower in women and Black Americans, compared to men and White Americans, respectively. This study used data from randomized clinical trials in participants with PAD to assess whether walking exercise improved walking performance in women and Black Americans. Methods: Data were combined from three randomized clinical trials that compared supervised treadmill exercise (3 sessions/week) for six months to a non-exercise control group. Data were also combined from two randomized clinical trials that compared home-based walking exercise for six months to a non-exercise control group. The six-minute walk (6MW), treadmill walking performance, and the Walking Impairment Questionnaire (WIQ) were measured at baseline and six-month follow-up. In meta-analyses, the effects of supervised and home-based exercise were each compared to a non-exercise control group. The effects of supervised and home-based exercise were compared directly. Tests for interaction were used to compare effects of exercise in Black, compared to White participants and in women, compared to men. Results: A total of 370 participants (n=159 [43%] women, n=228 [62%] Black) completed a supervised exercise trial; 349 participants (n=175 [50%] women, n=187 [54%] Black) completed a home-based exercise trial. Supervised and home-based exercise significantly improved 6MW in Black Americans and women (Table). Compared to home-based exercise, supervised exercise was associated with greater improvements in treadmill outcomes, while home-based walking improved 6MW more than supervised exercise. There was no significant interaction of sex or race on exercise outcomes. Conclusions: Supervised and home-based exercise significantly improved 6MW and treadmill walking distance in women and Black Americans with PAD, respectively, compared to a non-exercise control.

Home-Based Walking Exercise and Supervised Treadmill Exercise in Patients With Peripheral Artery Disease

Few people with lower extremity peripheral artery disease (PAD) participate in supervised treadmill exercise covered by the Center for Medicare and Medicaid Services. In people with PAD, the benefits of home-based walking exercise, relative to supervised exercise, remain unclear. To study whether home-based walking exercise improves 6-minute walk (6MW) more than supervised treadmill exercise in people with PAD (defined as Ankle Brachial Index ≤0.90). Data were combined from 5 randomized clinical trials of exercise therapy for PAD using individual participant data meta-analyses, published from 2009 to 2022. Of the 5 clinical trials, 3 clinical trials compared supervised treadmill exercise to nonexercise control (N = 370) and 2 clinical trials compared an effective home-based walking exercise intervention to nonexercise control (N = 349). Individual participant-level data from 5 randomized clinical trials led by 1 investigative team were combined. The 5 randomized clinical trials included 3 clinical trials of supervised treadmill exercise and 2 effective home-based walking exercise interventions. Change in 6MW distance, maximum treadmill walking distance, and Walking Impairment Questionnaire at 6-month follow-up. The supervised treadmill exercise intervention consisted of treadmill exercise in the presence of an exercise physiologist, conducted 3 days weekly for up to 50 minutes per session. Home-based walking exercise consisted of a behavioral intervention in which a coach helped participants walk for exercise in or around home for up to 5 days per week for 50 minutes per session. A total of 719 participants with PAD (mean [SD] age, 68.8 [9.5] years; 46.5% female) were included (349 in a home-based exercise clinical trial and 370 in a supervised exercise trial). Compared with nonexercise control, supervised treadmill exercise was associated with significantly improved 6MW by 32.9 m (95% CI, 20.6-45.6; P < .001) and home-based walking exercise was associated with significantly improved 6MW by 50.7 m (95% CI, 34.8-66.7; P < .001). Compared with supervised treadmill exercise, home-based walking exercise was associated with significantly greater improvement in 6MW distance (between-group difference: 23.8 m [95% CI, 3.6, 44.0; P = .02]) but significantly less improvement in maximum treadmill walking distance (between-group difference:-132.5 m [95% CI, -192.9 to -72.1; P < .001]). In this individual participant data meta-analyses, compared with supervised exercise, home-based walking exercise was associated with greater improvement in 6MW in people with PAD. These findings support home-based walking exercise as a first-line therapy for walking limitations in PAD.

Attendance at Supervised Exercise Sessions and Walking Outcomes in Peripheral Artery Disease: Results From 2 Randomized Clinical Trials.

Background Supervised exercise therapy (SET) is the first-line therapy for walking impairment in peripheral artery disease (PAD). This study evaluated the association between attendance at SET and improved walking performance, compared with a control group, in PAD. Methods and Results Data from 2 randomized clinical trials of SET for PAD were combined. In each trial, participants were randomized to 3 times weekly supervised treadmill exercise or an attention control group for 6 months (maximum, 77 exercise sessions). Participants randomized to SET were categorized into tertiles, according to the proportion of exercise sessions they attended. Results adjusted for age, sex, race, baseline walking performance, comorbidities, and other potential confounders. A total of 272 participants with PAD (mean age, 67.9±9.3 years; 44% women; 61% Black race) were included. For participants randomized to SET, tertiles of attendance rates at exercise sessions were as follows: 11% to 68% (N=45), 69% to <85% (N=46), and ≥85% (N=46). Compared with control, mean improvement in 6-minute walk was significantly greater in each SET tertile: mean (95% CI) for tertile 1, 27.9 m (1.3-54.4 m; P=0.04), tertile 2, 38.2 m (12.2-64.2 m; P=0.001), and tertile 3, 56.9 m (29.9-83.8 m; P<0.0001). Among participants randomized to SET, greater SET attendance was associated with greater improvement in 6-minute walk distance (overall P for trend=0.025). Compared with control, improvement in maximal treadmill walking time was greater in each SET attendance tertile: tertile 1 (3.3 minutes [95% CI, 1.7-4.8 minutes]; P<0.0001), tertile 2 (3.8 minutes [95% CI, 2.3-5.3 minutes]; P<0.0001), and tertile 3 (5.4 minutes [95% CI, 3.9-7.0 minutes]; P:<0.0001). Among participants randomized to SET, greater attendance at SET was not significantly associated with greater improvement in maximal treadmill walking time (overall P for trend=0.064). Conclusions Among people with PAD randomized to SET, better attendance at exercise sessions was associated with significantly greater 6-minute walk improvement. Among all participants with PAD, even relatively low SET attendance was associated with significantly greater improvement in walking performance, compared with a control group who did not exercise. Registration URL: https://clinicaltrials.gov/ct2/show/NCT01408901. URL: https://clinicaltrials.gov/ct2/show/NCT00106327.

Walking Exercise Therapy Effects on Lower Extremity Skeletal Muscle in Peripheral Artery Disease.

Walking exercise is the most effective noninvasive therapy that improves walking ability in peripheral artery disease (PAD). Biologic mechanisms by which exercise improves walking in PAD are unclear. This review summarizes evidence regarding effects of walking exercise on lower extremity skeletal muscle in PAD. In older people without PAD, aerobic exercise improves mitochondrial activity, muscle mass, capillary density, and insulin sensitivity in skeletal muscle. However, walking exercise increases lower extremity ischemia in people with PAD, and therefore, mechanisms by which this exercise improves walking may differ between people with and without PAD. Compared with people without PAD, gastrocnemius muscle in people with PAD has greater mitochondrial impairment, increased reactive oxygen species, and increased fibrosis. In multiple small trials, walking exercise therapy did not consistently improve mitochondrial activity in people with PAD. In one 12-week randomized trial of people with PAD randomized to supervised exercise or control, supervised treadmill exercise increased treadmill walking time from 9.3 to 15.1 minutes, but simultaneously increased the proportion of angular muscle fibers, consistent with muscle denervation (from 7.6% to 15.6%), while angular myofibers did not change in the control group (from 9.1% to 9.1%). These findings suggest an adaptive response to exercise in PAD that includes denervation and reinnervation, an adaptive process observed in skeletal muscle of people without PAD during aging. Small studies have not shown significant effects of exercise on increased capillary density in lower extremity skeletal muscle of participants with PAD, and there are no data showing that exercise improves microcirculatory delivery of oxygen and nutrients in patients with PAD. However, the effects of supervised exercise on increased plasma nitrite abundance after a treadmill walking test in people with PAD may be associated with improved lower extremity skeletal muscle perfusion and may contribute to improved walking performance in response to exercise in people with PAD. Randomized trials with serial, comprehensive measures of muscle biology, and physiology are needed to clarify mechanisms by which walking exercise interventions improve mobility in PAD.

말초동맥질환 환자의 심장재활

Patients with peripheral artery disease (PAD) usually have functional impairment, faster functional decline, and poorer quality of life (QoL). It is important to treat PAD properly because it can cause of increasing risk of cardiovascular diseases and related mortality. In addition to anti-platelet agents and statins, cardiac rehabilitation including lifestyle modification and aerobic exercise therapy must be provided to these patients. The mechanism leading to exercise induced improvement may include changes in the way that oxygen is used by exercising the muscle, improved endothelial function, reduced cardiovascular disease risk factors and improved gait as well as increased blood supply. Prior to prescribing exercise, treadmill exercise teat may be given priority to assess functional status. Structured supervised treadmill exercise and home-based exercise each significantly improve functional status and QoL and reduce leg symptoms. In patients with claudication, alternative strategies of exercise, including upper-body ergometry, cycling, and pain-free walking can be beneficial to improve walking ability and functional status. Studies with long-term follow-up have demonstrated a persistent benefit of those exercises in patients with claudication. Furthermore, the risk-benefit ratio is favorable, with an excellent safety profile in patients screened for absolute contraindications to exercise. In order to increase the effectiveness of exercise therapy and prevent problems, it will be most important to fully evaluate the patient’s condition and prescribe appropriate exercise intensity, duration, and modalities.

Abstract 14290: Treadmill Exercise Training Reduces the Systolic Blood Pressure Response to Walk Exercise in Patients With Peripheral Artery Disease

Introduction: Supervised exercise therapy (SET) improves functional capacity in people with peripheral artery disease (PAD). However, the effects of SET on improving cardiovascular health remain unclear. This study investigated the effects of a 6-month SET intervention on the blood pressure (BP) response to walking exercise in patients with PAD. Methods: Participants with PAD randomized to either SET or control group in the NHLBI sponsored PROPEL clinical trial were included. The SET intervention consisted of 3X weekly supervised treadmill exercise for 6 months. Participants in the control group attended weekly education sessions for 6 months. A Gardner-Skinner treadmill test (GSTT) and six-minute walk (6MW) test were completed at baseline and 6-month follow-up. BP was measured at the end of each 2-min stage of the GSTT. Mixed-effects regression models compared the 6-month change in systolic BP (SBP) &amp; diastolic BP (DBP) between groups for each of the first 5 stages of the GSTT. Pearson correlation coefficients were used to relate the average 6-month change in DBP &amp; SBP for the first 5 stages of the GSTT with the 6-month change in 6MW distance. Results: Ninety-seven participants with PAD (67 ± 9 years, 39 (40%) female, 65 (67%) black) completed a 6-month GSTT. Compared to the control group, SET significantly decreased SBP at stage 1, stage 2, stage 3, and stage 4 of the GSTT (Table 1). There were no effects of SET on DBP (Table 1). A greater reduction in SBP during the first 5 stages the GSTT test was associated with significantly greater improvement in 6MW distance at 6-month follow-up of SET (Pearson’s r = -0.37; 95%CI: -0.52, -0.19; p &lt; 0.001). However, there were no associations of reduction in DBP with improvement in 6MW distance. Conclusions: These results show that SET improves cardiovascular health in people with PAD. Furthermore, results suggest that improved CV health in part explains the improved 6MW in response to SET in people with PAD.

Similar effects of three endurance exercise protocols in women with metabolic syndrome: Interest of moderate-intensity aerobic exercise training with a pedometer

The aim of this study was to show the effects of different intensities and durations of aerobic exercise on weight, abdominal obesity, metabolic, and hormonal responses in women with metabolic syndrome (MetS). Sixty women with MetS were randomly assigned to one of the three training groups: high-intensity exercise group (HIE) ( n = 20), moderate-intensity exercise group (MIE) ( n = 20) and moderate-intensity pedometer group (ECE PEDO) ( n = 20). HIE group exercised 20 minutes a day, 3 days a week at %70 VO 2 max, while MIE and ECE PEDO groups exercised 5 days a week, 30 minutes a day at %50 VO 2 max. The primary outcome measures were anthropometric measurements including abdominal fat, VO 2 max measurements, lipid profile, adrenaline, noradrenaline, free fatty acids (FFA), glycerol, and oxyntomodulin parameter. A total of 51 women completed the 12-week exercise program. Anthropometric measurements such as weight, BMI, waist circumference (WC), visceral fat (VF) and trunk fat percentage were all decreased significantly at week 12 in all groups ( P < 0.017). The median VF was decreased from 17 (14.9–20.05) to 15.1 (11.2–16.75), from 17.75 (15.5–21.87) to 16.65 (13.9–20.9) and from 18.5 (17.5–20.45) to 16.65 (15.25–18.5) for HIE, MIE and ECE PEDO groups respectively at 12th week ( P < 0.017). The median oxyntomodulin increased from 61.65 (48.32–70.50) to 120.11 (63.37–157.35) only in MIE group ( P < 0.017). No significant differences were seen between the groups for all outcome measures ( P > 0.05). Moderate aerobic exercises performed 5 days a week as supervised treadmill exercise or home-based pedometer walking were not significantly different from high-intensity supervised treadmill exercise made 3 days a week for weight, VF, exercise capacity and metabolic parameters in women with MetS. Increasing oxyntomodulin levels with moderate-intensity exercise may have beneficial metabolic effects in patients with MetS. NCT03445741 . L’objectif de cette étude était de montrer les effets de différentes intensités et durées d’exercices aérobies sur le poids, l’obésité abdominale, les réponses métaboliques et hormonales chez les femmes atteintes du syndrome métabolique (MetS). Soixante femmes atteintes de MetS ont été réparties au hasard dans l’un des trois groupes d’entraînement : groupe d’exercices à haute intensité (HIE) ( n = 20), groupe d’exercices à intensité modérée (MIE) ( n = 20) et groupe de podomètre à intensité modérée (ECE PEDO) ( n = 20). Le groupe HIE a fait 20 minutes d’exercice par jour, 3 jours par semaine à %70 VO 2 max, tandis que les groupes MIE et ECE PEDO ont fait de l’exercice 5 jours par semaine, 30 minutes par jour à %50 VO 2 max. Les principales mesures des résultats étaient des mesures anthropométriques, notamment la graisse abdominale, les mesures VO 2 max, le profil lipidique, l’adrénaline, la noradrénaline, les acides gras libres (AGL), le glycérol et le paramètre de l’oxyntomoduline. Au total, 51 femmes ont suivi le programme d’exercice de 12 semaines. Les mesures anthropométriques telles que le poids, l’IMC, le tour de taille (WC), la graisse viscérale (VF) et le pourcentage de graisse du tronc ont toutes diminué de manière significative à la semaine 12 dans tous les groupes ( p < 0,017). Le tour de taille médian a diminué de 17 (14,9–20,05) à 15,1 (11,2–16,75), de 17,75 (15,5–21,87) à 16,65 (13,9–20,9) et de 18,5 (17,5–20,45) à 16,65 (15,25–18,5) pour les groupes HIE, MIE et ECE PEDO respectivement à la 12 e semaine ( p < 0,017). L’oxyntomoduline médiane est passée de 61,65 (48,32–70,50) à 120,11 (63,37–157,35) uniquement dans le groupe MIE ( p < 0,017). Aucune différence significative n’a été observée entre les groupes pour toutes les mesures de résultats ( p > 0,05). Les exercices aérobies modérés effectués 5 jours par semaine, comme les exercices sur tapis roulant supervisés ou la marche sur podomètre à domicile, n’étaient pas significativement différents des exercices sur tapis roulant supervisés de haute intensité effectués 3 jours par semaine pour le poids, la FV, la capacité d’exercice et les paramètres métaboliques chez les femmes atteintes de MIE. L’augmentation des niveaux d’oxyntomoduline avec un exercice d’intensité modérée peut avoir des effets métaboliques bénéfiques chez les patients atteints de MetS. NCT03445741 .

T-cell Response To Exercise Training Among Women At Heightened Risk Of Breast Cancer.

Aging causes changes in the peripheral T-cell compartment that may increase susceptibility to cancer and lower immune responses. Fitness is associated with lower frequencies of highly differentiated T-cells, increased naïve T-cells, and elevations in myokines such as IL-7 that contribute to naïve T-cell output, indicating that exercise may help preserve immunity. PURPOSE: Examine the impact of exercise training on the differentiation status of CD4+ and CD8+ T-cells, recent thymic emigrants (RTE), and plasma levels of IL-7 in older women with an elevated risk of breast cancer (obesity status, postmenopausal, elevated Gail and/or lifetime risk score or history of non-invasive breast cancer). METHODS: 44 women (VO2=19.58±3.37 ml/kg/min) were randomized to: high-intensity interval training (HIIT; n=16; 63.73±6.86yrs); moderate continuous exercise (MCE; n=14.; 64.62±12.21yrs); or control (CNT; n=14; 63.35±6.99yrs). Participants completed clinically supervised treadmill exercise 3x/week for 12 weeks using heart rate training. Naive (NA), central memory (CM), effector memory (EM) and CD45RA+ effector memory (EMRA) CD4+ and CD8+ T-cells, and RTE (CD4NA or CD8NA CD31+CD103+) in blood were quantified before and after training. Fold changes (cells/μl) were calculated by (post-pre)/pre and compared across groups via ANOVA with p<0.05 considered significant. RESULTS: 11, 10, and 11 participants completed the HIIT, MCE, and CNT training, respectively. Compared to HIIT, MCE increased total lymphocytes (-0.05±0.13 vs. 0.12±0.12), CD4 (-0.29±0.24 vs. 0.21±0.30), CD4 CM (-0.23±0.20 vs. 0.36±0.27), CD4NA (-0.33±0.32 vs. 0.31±0.39), and CD8EM (-0.16±0.31 vs. 0.32±0.31). The change in number of CD4CM was higher in MCE compared to CNT (0.36±0.27 vs. -0.24±0.42). No changes were found for IL-7 or RTEs. CONCLUSION: Immune responses to exercise training in women with an elevated risk of breast cancer are likely to vary depending on the intensity of exercise. Future research should focus on investigating the potential that exercise may have on T-cell phenotypes and their relation to breast cancer risk. Funded by NCI R25 CA057730, the MD Anderson Cancer Center/Energy Balance Assessment Supplemental Funding, MD Anderson Cancer Center, Center for Energy Balance in Cancer Prevention and Survivorship, UA T32CA009213.

Clinical characteristics and response to supervised exercise therapy of people with lower extremity peripheral artery disease

BackgroundAmong people with lower extremity peripheral artery disease (PAD), little is known about variation in response to supervised exercise therapy (SET). Clinical characteristics associated with greater responsiveness to SET have not been identified. MethodsData from participants with PAD in two randomized clinical trials comparing SET vs nonexercising control were combined. The exercise intervention consisted of three times weekly supervised treadmill exercise. The control groups received lectures on health-related topics. ResultsOf 309 unique participants randomized (mean age, 67.9 years [standard deviation, 9.3 years]; 132 [42.7%] women; 185 [59.9%] black), 285 (92%) completed 6-month follow-up. Compared with control, those randomized to SET improved 6-minute walk distance by 35.6 meters (95% confidence interval, 21.4-49.8; P < .001). In the 95 (62.1%) participants who attended at least 70% of SET sessions, change in 6-minute walk distance varied from −149.4 to +356.0 meters. Thirty-four (35.8%) had no 6-minute walk distance improvement. Among all participants, age, sex, race, body mass index, prior lower extremity revascularization, and other clinical characteristics did not affect the degree of improvement in 6-minute walk distance after SET relative to the control group. Participants with 6-minute walk distance less than the median of 334 meters at baseline had greater percentage improvement in 6-minute walk distance compared with those with baseline 6-minute walk distance above the median (+20.5% vs +5.3%; P for interaction = .0107). ConclusionsAmong people with PAD, substantial variability exists in walking improvement after SET. Shorter 6-minute walk distance at baseline was associated with greater improvement after SET, but other clinical characteristics, including age, sex, prior lower extremity revascularization, and disease severity, did not affect responsiveness to exercise therapy.

Comparing 6-minute walk versus treadmill walking distance as outcomes in randomized trials of peripheral artery disease

BackgroundRandomized trials of people with peripheral artery disease (PAD) and intermittent claudication have traditionally used maximal treadmill walking distance as the primary outcome, but the 6-minute walk test is increasingly used as a primary outcome in randomized trials of PAD. This study compared relative changes in maximal treadmill walking distance versus 6-minute walk distance in response to a therapeutic intervention or control in randomized trials of participants with PAD. MethodsData from four randomized trials of therapeutic interventions in participants with PAD that measured both 6-minute walk and treadmill walking performance at baseline and the 6-month follow-up were combined. Two trials studied supervised treadmill exercise, one studied home-based walking exercise, and one studied resveratrol. ResultsOf 467 participants (mean age, 69.8; standard deviation, 9.7), the mean ankle-brachial index was 0.66 (standard deviation, 0.17). At the 6-month follow-up, participants with PAD randomized to control or placebo significantly declined in 6-minute walk distance (−10.2 m; 95% confidence interval, −18.2 to −2.2; P = .013), but improved maximal treadmill walking distance (+25.7 m; 95% CI, +6.0 to +45.3 m; P = .010; difference between change in 6-minute walk versus maximal treadmill walking distance: −37.3 m; 95% CI, −56.4 to −18.2; P < .001). Home-based exercise improved the 6-minute walk distance by 43.2 m (95% CI, +28.4 to +57.9), and supervised treadmill exercise improved the 6-minute walk distance by 25.0 m (95% CI, +14.7 to +35.2; mean difference, +18.2 m favoring home-based exercise [95% CI, +0.2 to +36.2 m; P = .048]). Among all participants, the presence (vs absence) of treadmill exercise training was associated with a 141.3-m greater improvement in maximal treadmill walking distance compared to 6-minute walk distance (95% CI, 88.2-194.4; P < .001), suggesting a benefit from treadmill training on the treadmill outcome. ConclusionsMaximal treadmill walking distance and the 6-minute walk distance are not interchangeable outcomes in participants with PAD. Participants with PAD randomized to control groups improved treadmill walking distance but simultaneously meaningfully declined in 6-minute walk distance. Supervised treadmill exercise training amplified improvement in treadmill walking distance because of a training to the outcome measure phenomenon.

Clinical efficiency of prehabilitation program in patients undergoing coronary artery bypass grafting

Aim.To evaluate clinical efficacy of high-intensity exercise training included in the prehabilitation program for elective coronary artery bypass grafting (CABG).Methods. 38 male patients were included in the study before on-pump CABG. After fulfilling the inclusion/exclusion criteria, patients were randomized into two groups: Group 1 patients (n = 20) underwent supervised treadmill exercise, and Group 2 patients (n = 18) were referred to surgery without any exercise training. Patients underwent a 7-day exercise training with daily measurements of hemodynamic parameters and electrocardiogram (ECG) monitoring. The load intensity was measured with cardiopulmonary exercise testing and accounted for 80% of the maximal oxygen uptake. Postoperative complications were recorded in the in-hospital period and analyzed. Quality of life indicators were measured by the SF-36 standard version 7–10 days prior to surgery and on days 7-10 of the postoperative period. Adherence to drug and non-drug therapy was assessed during the 6-month follow-up.Results.There was a significantly lower incidence of postoperative complications during the in-hospital period in patients undergoing prehabilitation program with supervised high-intensity exercise training, compared with patients without any exercise training (p = 0.002). Group 1 patients had reliably better mental health (MH) scores compared with Group 2 patients (48.9±7.60 vs. 39.1±6.80 scores, respectively; p = 0.03) on days 7–10 after CABG. Six months after the CABG, patients who underwent prehabilitation exercise training were less likely to resume smoking than patients without any exercise training (p = 0.04). The tendency towards improved adherence to drug therapy and compensation in arterial hypertension has been determined among Group 1 patients.Conclusion. Exercise training included in the prehabilitation program proved to be safe and effective in terms of improved clinical outcomes after CABG, quality of life and adherence to treatment in this group of patients.

Racial Differences in the Effect of Granulocyte Macrophage Colony-Stimulating Factor on Improved Walking Distance in Peripheral Artery Disease: The PROPEL Randomized Clinical Trial.

BackgroundThe effects of race on response to medical therapy in people with peripheral artery disease (PAD) are unknown.Methods and ResultsIn the PROPEL (Progenitor Cell Release Plus Exercise to Improve Functional Performance in PAD) Trial, PAD participants were randomized to 1 of 4 groups for 6 months: supervised treadmill exercise+granulocyte‐macrophage colony‐stimulating factor (GM‐CSF) (Group 1), exercise+placebo (Group 2), attention control+GM‐CSF (Group 3), or attention control+placebo (Group 4). Change in 6‐minute walk distance was measured at 12‐ and 26‐week follow‐up. In these exploratory analyses, groups receiving GM‐CSF (Groups 1 and 3), placebo (Groups 2 and 4), exercise (Groups 1 and 2), and attention control (Groups 2 and 4) were combined, maximizing statistical power for studying the effects of race on response to interventions. Of 210 PAD participants, 141 (67%) were black and 64 (30%) were white. Among whites, GM‐CSF improved 6‐minute walk distance by +22.0 m (95% CI: −4.5, +48.5, P=0.103) at 12 weeks and +44.4 m (95% CI: +6.9, +82.0, P=0.020) at 26 weeks, compared with placebo. Among black participants, there was no effect of GM‐CSF on 6‐minute walk distance at 12‐week (P=0.26) or 26‐week (−5.0 m [−27.5, +17.5, P=0.66]) follow‐up, compared with placebo. There was an interaction of race on the effect of GM‐CSF on 6‐minute walk change at 26‐week follow‐up (P=0.018). Exercise improved 6‐minute walk distance in black (P=0.006) and white (P=0.034) participants without interaction.Conclusions GM‐CSF improved 6‐minute walk distance in whites with PAD but had no effect in black participants. Further study is needed to confirm racial differences in GM‐CSF efficacy in PAD.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT01408901.

Durability of Benefits From Supervised Treadmill Exercise in People With Peripheral Artery Disease.

BackgroundIt is currently unknown whether 6 months of supervised treadmill exercise has a durable benefit on 6‐minute walk performance, even after exercise is completed, in people with peripheral artery disease.Methods and ResultsA total of 156 participants with peripheral artery disease were randomized to 1 of 3 groups: supervised treadmill exercise, supervised resistance training, or attention control. Participants received supervised sessions during months 1 to 6 and telephone contact during months 6 to 12. Primary outcomes were change in 6‐minute walk distance and short physical performance battery at 6‐month follow‐up and have been reported previously. Secondary outcomes were change in 6‐minute walk and short physical performance battery at 12‐month follow‐up and are reported here. A group of 134 participants (86%) completed the 12‐month follow‐up. At 6‐month follow‐up, compared with control, 6‐minute walk distance improved in the treadmill exercise group (+36.1 m, 95% CI=13.9‐58.3, P=0.001). Between 6‐ and 12‐month follow‐up, 6‐minute walk distance significantly declined (−28.6 m, 95% CI=−52.6 to −4.5, P=0.020) and physical activity declined −272 activity units (95% CI=−546 to +2, P=0.052) in the treadmill exercise group compared with controls. At 12‐month follow‐up, 6 months after completing supervised treadmill exercise, change in 6‐minute walk distance was not different between the treadmill exercise and control groups (+7.5, 95% CI=−17.5 to +32.6, P=0.56). There were no differences in short physical performance battery change between either exercise group and control at 6‐month or 12‐month follow‐up.ConclusionsA 6‐month supervised treadmill exercise intervention that improved 6‐minute walk distance at 6‐month follow‐up did not have persistent benefit at 12‐month follow‐up. These results do not support a durable benefit of supervised treadmill exercise in peripheral artery disease.Clinical Trial Registration URL: https://www.clinicaltrials.gov. Identifier: NCT00106327.

Exercise Rehabilitation for Peripheral Artery Disease: A REVIEW.

To summarize evidence regarding exercise therapy for people with lower extremity peripheral artery disease (PAD). Literature was reviewed regarding optimal strategies for delivering exercise interventions for people with PAD. Randomized trial evidence and recent studies were emphasized. Randomized clinical trial evidence consistently demonstrates that supervised treadmill exercise improves treadmill walking performance in people with PAD. A meta-analysis of 25 randomized trials (1054 participants) concluded that supervised treadmill exercise was associated with 180 m of improvement in maximal treadmill walking distance and 128 m of improvement in pain-free walking distance compared with a control group. Three randomized trials of 493 patients with PAD demonstrated that home-based walking exercise interventions that incorporate behavioral change techniques improve walking ability in patients with PAD. Furthermore, evidence suggests that home-based walking exercise improves the 6-min walk more than supervised treadmill exercise. Upper and lower extremity ergometry also significantly improved walking endurance in PAD. The Centers for Medicare & Medicaid Services recently determined that Medicare would cover 12 wk (36 sessions) of supervised treadmill exercise for patients with PAD. Supervised treadmill exercise and home-based walking exercise each improve walking ability in patients with PAD. The availability of insurance coverage for supervised treadmill exercise for patients with PAD will make supervised treadmill exercise more widely available and accessible. Home-based exercise that incorporates behavioral change technique is an effective alternative for patients unwilling or unable to attend 3 supervised exercise sessions per week.

Reversal of Lower-Extremity Intermittent Claudication and Rest Pain by Hydration

Medical treatment of disabling intermittent claudication or critical limb-threatening ischemia causing rest pain often fails or has partial response. In this pilot study, 36 patients (12 females) affected by disabling intermittent claudication or rest pain of the lower extremities were exposed to a daily 3-L water intake for up to 6 weeks. Cutaneous foot temperature, ankle/brachial index, time and distance of claudication, and pain intensity were recorded before and at the completion of the hydration period. Patients with a mean±SE age of 71±2years (range, 40-86) had disabling claudication (less than 100meters) for more than 5 months while 11% reported pain at rest. A 6-week water intake of more than 2,500mL/24hr was achieved in 35 of the 36 patients enrolled in the study. Increased water intake was associated with significant improvements in median ankle/brachial index (from 0.60 to 0.76; P < 0.0001) and skin temperature (first dorsal right toe, from 29.95°C to 30.0°C, P<0.001). Time and distance to report claudication of supervised treadmill exercise improved from 1.25 to 6.25min (P<0.0001) and from 100meters to 535meters (P<0.0001), respectively. This study suggests that hydration attained by daily water consumption of more than 2.5L has a robust impact on reducing the symptoms of disabling claudication and rest pain caused by peripheral vascular disease.

Oxidized Low-Density Lipoprotein and Cell Adhesion Molecules Following Exercise Training.

Elevated oxidized low-density lipoprotein (ox-LDL) and cell adhesion molecules are associated with inflammation and atherosclerosis. The role of exercise in circulating ox-LDL, enzyme mediators, and cell adhesion molecules are not clearly understood in obesity. As a randomized controlled design, 27 obese (BMI>30 kg/m2) sedentary men (N=13) and women (N=14) were randomly assigned to either an exercise (N=15) or a control (N=12) group. The exercise group performed a 60-min supervised treadmill exercise at moderate intensity (70% of HRmax) for 3 days per week for 4 weeks, while the control group did not exercise. Overnight fasting blood samples were collected before and after the study period to analyze serum lipids, lipoprotein-cholesterol, ox-LDL, 12- and 15-lipoxygenases, myeloperoxidase (MPO), and soluble vascular cell adhesion molecules-1 and intercellular adhesion molecule-1. Moderate-intensity exercise training lowered both ox-LDL (from 44.76±1.99 to 38.51±1.99 U/L, p=0.032) and MPO (from 31.48±2.20 to 23.09±2.20 ng/mL, p=0.010), without significantly altering body weight, other parameters of serum lipids and lipoproteins, or soluble cell adhesion molecules. Moderate intensity exercise training reduced the levels of ox-LDL and MPO, indicating a reduced risk for developing CVD and additional protection to the possible metabolic complications associated with obesity.

Effect of Granulocyte-Macrophage Colony-Stimulating Factor With or Without Supervised Exercise on Walking Performance in Patients With Peripheral Artery Disease

Benefits of granulocyte-macrophage colony-stimulating factor (GM-CSF) for improving walking ability in people with lower extremity peripheral artery disease (PAD) are unclear. Walking exercise may augment the effects of GM-CSF in PAD, since exercise-induced ischemia enhances progenitor cell release and may promote progenitor cell homing to ischemic calf muscle. To determine whether GM-CSF combined with supervised treadmill exercise improves 6-minute walk distance, compared with exercise alone and compared with GM-CSF alone; to determine whether GM-CSF alone improves 6-minute walk more than placebo and whether exercise improves 6-minute walk more than an attention control intervention. Randomized clinical trial with 2 × 2 factorial design. Participants were identified from the Chicago metropolitan area and randomized between January 6, 2012, and December 22, 2016, to 1 of 4 groups: supervised exercise + GM-CSF (exercise + GM-CSF) (n = 53), supervised exercise + placebo (exercise alone) (n = 53), attention control + GM-CSF (GM-CSF alone) (n = 53), attention control + placebo (n = 51). The final follow-up visit was on August 15, 2017. Supervised exercise consisted of treadmill exercise 3 times weekly for 6 months. The attention control consisted of weekly educational lectures by clinicians for 6 months. GM-CSF (250 μg/m2/d) or placebo were administered subcutaneously (double-blinded) 3 times/wk for the first 2 weeks of the intervention. The primary outcome was change in 6-minute walk distance at 12-week follow-up (minimum clinically important difference, 20 m). P values were adjusted based on the Hochberg step-up method. Of 827 persons evaluated, 210 participants with PAD were randomized (mean age, 67.0 [SD, 8.6] years; 141 [67%] black, 82 [39%] women). One hundred ninety-five (93%) completed 12-week follow-up. At 12-week follow-up, exercise + GM-CSF did not significantly improve 6-minute walk distance more than exercise alone (mean difference, -6.3 m [95% CI, -30.2 to +17.6]; P = .61) or more than GM-CSF alone (mean difference, +28.7 m [95% CI, +5.1 to +52.3]; Hochberg-adjusted P = .052). GM-CSF alone did not improve 6-minute walk more than attention control + placebo (mean difference, -1.4 m [95% CI, -25.2 to +22.4]; P = .91). Exercise alone improved 6-minute walk compared with attention control + placebo (mean difference, +33.6 m [95% CI, +9.4 to +57.7]; Hochberg-adjusted P = .02). Among patients with PAD, supervised treadmill exercise significantly improved 6-minute walk distance compared with attention control + placebo, whereas GM-CSF did not significantly improve walking performance, either when used alone or when combined with supervised treadmill exercise. These results confirm the benefits of exercise but do not support using GM-CSF to treat walking impairment in patients with PAD. clinicaltrials.gov Identifier: NCT01408901.

Exercise training for intermittent claudication

ObjectiveThe objective of this study was to provide an overview of evidence regarding exercise therapies for patients with lower extremity peripheral artery disease (PAD). MethodsThis manuscript summarizes the content of a lecture delivered as part of the 2016 Crawford Critical Issues Symposium. ResultsMultiple randomized clinical trials demonstrate that supervised treadmill exercise significantly improves treadmill walking performance in people with PAD and intermittent claudication symptoms. A meta-analysis of 25 randomized trials demonstrated a 180-meter increase in treadmill walking distance in response to supervised exercise interventions compared with a nonexercising control group. Supervised treadmill exercise has been inaccessible to many patients with PAD because of lack of medical insurance coverage. However, in 2017, the Centers for Medicare and Medicaid Services issued a decision memorandum to support health insurance coverage of 12 weeks of supervised treadmill exercise for patients with walking impairment due to PAD. Recent evidence also supports home-based walking exercise to improve walking performance in people with PAD. Effective home-exercise programs incorporate behavioral change interventions such as a remote coach, goal setting, and self-monitoring. Supervised treadmill exercise programs preferentially improve treadmill walking performance, whereas home-based walking exercise programs preferentially improve corridor walking, such as the 6-minute walk test. Clinical trial evidence also supports arm or leg ergometry exercise to improve walking endurance in people with PAD. Treadmill walking exercise appears superior to resistance training alone for improving walking endurance. ConclusionsSupervised treadmill exercise significantly improves treadmill walking performance in people with PAD by approximately 180 meters compared with no exercise. Recent evidence suggests that home-based exercise is also effective and preferentially improves over-ground walking performance, such as the 6-minute walk test.