Walking Impairment Questionnaire Distance Research Articles

Association of mental health with walking capacity in patients with claudication: a cross-sectional study

Objectives The purpose of this investigation was to verify the association between mental health (MH) indicators with walking capacity in patients with PAD. Methods Two hundred and forty-six patients with PAD and claudication symptoms participated in this study. Physical function was assessed objectively with the 6-min walk test (6MWT) and subjectively using the Walking Impairment Questionnaire (WIQ). MH was assessed by the World Health Organization Quality of Life-Bref (WHOQOL-Bref) (six questions were selected − 1, 2, 10, 16, 19, and 26). Patients were divided into tertile groups according to their composite z-score for mental health (Low MH, Middle MH, and High MH). Results The High MH group presented higher scores (p < 0.05) for the WIQ (distance = 26.8 ± 25.6, speed = 25.4 ± 17.3, and stairs = 33.6 ± 27.5), claudication onset distance (161.6 ± 83.6 m), and total walking distance (352.9 ± 79.6 m) compared to Low MH (WIQ distance = 14.8 ± 16.2, 17.7 ± 13.0, and stairs = 22.7 ± 20.7). Additionally, the High MH group presented a longer claudication onset distance (115.5 ± 70.5 m), and total walking distance in 6MWT (306.6 ± 83.2 m), and higher scores in the total walking distance compared to Middle MH (309.5 ± 93.6 m) (p < 0.05). Conclusion In patients with PAD, MH was positively associated with walking capacity. Based on these results, treatments that can improve mental health, through different mechanisms, can also positively influence the ability of these patients to walk.

Gujarati translation, validity and reliability of Walking Impairment Questionnaire in people with intermittent claudication due to peripheral artery disease

IntroductionThe Walking Impairment Questionnaire (WIQ) is a common and easy-to-use assessment of walking incapacity in people with claudication due to peripheral artery disease (PAD). It has four subscales: pain severity, walking distance, walking speed, and ability to climb stairs. It has not been translated into Gujarati, which limits its use in Indian subjects. AimThis study aims to translate and assess the validity and reliability of a Gujarati version of WIQ. Materials and MethodsThis study had three phases: 1. Forward and backward translation and Cultural adaptation of WIQ into the Gujarati language by two independent translators, 2. Face and content validation by six clinical reviewers and 10 participants with PAD and Type II diabetes, 3. Concurrent and construct validity, test-retest reliability, and internal consistency of Gujarati, the WIQ was assessed on 160 participants with PAD and Type II diabetes who had a mean Ankle Brachial Index (standard deviation) <0.40 (0.1). The concurrent and construct validity of the WIQ was analyzed by correlating the WIQ distance and speed score with 6-minute walk distance (6MWD) and speed and WIQ total score with the Medical Outcome Study Questionnaire Short Form 36 (SF-36) score using Pearson's correlation coefficient. Test-retest reliability was analyzed using an intraclass correlation coefficient (ICC) with a seven-day interval between two questionnaire applications. Internal consistency of the total WIQ score was determined using Cronbach's alpha. ResultsFollowing translation, the Gujarati WIQ was considered acceptable and understandable by people with PAD. There was excellent correlation between the WIQ distance score and 6-minute walk test distance (r = 0.95, P < .05)) , the WIQ speed score and 6-minute walk test speed score (r = 0.89, P < .05)) and the Gujarati WIQ total score and total score of physical functioning domain of SF- 36 (r = 0.99, P < .05). There was excellent test-retest reliability over 7 days for total WIQ score (ICC = 0.94). The Cronbach's alpha for internal consistency of 0.97 for total WIQ score were excellent. This demonstrates the sufficient homogeneity of the total questionnaire. ConclusionThe Gujarati version of the WIQ is reliable and valid and can be used to assess self-reported walking impairment in Gujarati-speaking people with PAD and Type II Diabetes.

Abstract 11123: Effects of Home-Based Ischemic Leg Symptom-Inducing Exercise on Simultaneous Improvement in Treadmill Walking Distance and Patient Reported Outcomes and in Peripheral Artery Disease: The LITE Randomized Clinical Trial

Introduction: An optimal exercise intervention for individuals with peripheral artery disease (PAD) should improve both objective measures of walking and patient reported outcomes (PROs). This study evaluated whether home-based walking exercise conducted at a pace that induced ischemic leg symptoms (high intensity) improved both treadmill walking distance and related PROs more often than walking exercise conducted at a pace that did not induce ischemic leg symptoms (low intensity) and a non-exercise control group (control), respectively. Methods: Post-hoc analysis of PAD patients who participated in the 12-month LITE Trial and were assessed at 12 months follow-up. The LITE Trial randomized people with PAD into home-based high intensity exercise, low intensity exercise, or control. Objective measures of walking were pain-free treadmill walking distance (PFWD) and maximal treadmill walking distance (MWD). PROs related to physical functioning consisted of Walking Impairment Questionnaire (WIQ) and the Short Form-36 (SF-36) physical function score. Participants were categorized into one of four groups at 12-month follow-up: 1) improved both treadmill outcome and PRO, 2) improved treadmill outcome but not PRO, 3) improved PRO but not treadmill outcome; and 4) improved neither treadmill outcome or PRO. Improvement was defined as follow-up score minus baseline &amp;gt0. Results: Of the 305 people with PAD randomized, 186 (61% Black, 46% female) had data for both treadmill testing and at least one PRO available at baseline and 12-month follow-up (age, sex, race). Participants randomized to high intensity exercise were significantly more likely to improve both MWD and WIQ distance and speed (Table), as well as both PFWD and WIQ speed, compared to the other groups. Conclusions: To improve both treadmill outcomes and PROs, patients with PAD should be encouraged to walk for exercise at a pace inducing ischemic leg symptoms, and not at a pace without ischemic leg symptoms.

Abstract 11480: Telmisartan to Improve Walking Performance in People With Lower Extremity Peripheral Artery Disease: The Telex Randomized Clinical Trial

BACKGROUND. People with lower extremity peripheral artery disease (PAD) have reduced lower extremity perfusion, impaired lower extremity skeletal muscle function, and poor walking performance. Telmisartan, an angiotensin receptor blocker (ARB), has properties that reverse these abnormalities. This randomized clinical trial tested whether telmisartan improved six-minute walk distance, compared to placebo, in people with PAD at 6-month follow-up. METHODS. This multi-centered randomized clinical trial was designed as a 2 x 2 factorial design, comparing the effects of telmisartan plus supervised exercise therapy (SET) to telmisartan alone and SET alone, respectively and comparing telmisartan alone to placebo. PAD participants were randomized to one of four groups: telmisartan+SET (N=30), telmisartan + attention control (N=29), placebo + SET (N=28), or placebo+ attention control (N=27) for six months. Due to slower than anticipated enrollment, the primary comparison was changed to a comparison of the two telmisartan groups combined to the two placebo groups combined. The primary outcome was 6-month change in 6-minute walk distance. Secondary outcomes were maximal treadmill walking distance, the Walking Impairment Questionnaire distance, speed, and stair climbing scores, and the short-form 36 physical functioning score. Results adjusted for site, baseline six-minute walk distance, randomization to SET vs. attention control, and group differences in the prevalence of sex and heart failure at baseline. RESULTS. Of 114 randomized patients (mean [SD] age, 67.3 [9.9] years, 46 (40.4%) female, 81 (71.1%) Black), 105 (92%) completed 6-month follow-up. See the Table for results. CONCLUSIONS. These results do not support telmisartan for improving objectively measured walking performance or patient reported outcomes in patients with PAD.

Ultrasound therapy for treatment of lower extremity intermittent claudication

BackgroundWhile often thought of as a diagnostic tool, ultrasound (US) can also potentially be used as a therapeutic modality. US applies mechanical stress on endothelial cells and induces nitric oxide synthase, which regulates the secretion of nitric oxide, a potent vasodilator. In animal ischemic models, US has been shown to improve hindlimb, myocardial, and cerebral perfusion. We performed a pilot trial of US therapy in the lower extremities of human subjects with intermittent claudication. Methods10 subjects (5 male, 5 female, mean age 69.7 ± 10.3) with intermittent claudication were recruited. Both legs were placed in a specially designed boot with a water interface between US transducers and the legs. Subjects underwent pulsed US therapy at 250 kHz frequency for 30 min for three treatments a week for six weeks. Pre and post treatment ankle:brachial index (ABI), 6-min walk (6 MW), Walking Impairment Questionnaire (WIQ), and Short Form 36 (SF36) were performed. Pre and post-treatment results were compared with paired t-test. ResultsSix minute walking distance at baseline was 352 ± 70 m, after one treatment session 353 ± 70 m (p = 0.99), and at completion 372 ± 71 m (p = 0.015). There was a trend toward improved ABI after 6 weeks of treatment (0.53 ± 0.17 vs 0.64 ± 0.12, p = 0.083). After six weeks, significant improvements were noted in overall WIQ score (2.00 ± 1.48 vs 2.63 ± 1.38, p = 0.0001), WIQ (distance) 2.07 ± 1.54 vs 2.73 ± 1.42 (p = 0.036), and WIQ (stair) 2.00 ± 1.67 vs 2.62 ± 1.24, p = 0.034, with a trend in WIQ (speed), 1.89 ± 1.26 vs 2.46 ± 1.43, p = 0.069. In the SF-36, significant improvements were noted in the domains of physical functioning (44.0 ± 41.6 vs 50.5 ± 41.1, p = 0.009) and role limitations – physical (35.0 ± 48.3 vs 60.0 ± 49.6, p = 0.006) after six weeks. ConclusionsTherapeutic US is a potential noninvasive treatment for intermittent claudication. Pilot study patients noted significant improvements in 6 MW and WIQ results after 6 weeks of treatment. A nonsignificant improvement in ABI was noted. Further research will be needed to clarify optimal treatment frequency and duration.

Association between meeting daily step count goals with ambulatory function and quality of life in patients with claudication

ObjectiveTo determine (a) whether patients with peripheral artery disease (PAD) who walked at least 7000 and 10,000 steps/day had better ambulatory function and health-related quality of life (HRQoL) than patients who walked less than 7000 steps/day, and (b) whether differences in ambulatory function and HRQoL in patients grouped according to these daily step count criteria persisted after adjusting for covariates. MethodsTwo hundred forty-eight patients were assessed on their daily ambulatory activity for 1 week with a step activity monitor, and were grouped according to daily step count targets. Patients who took fewer than 7000 steps/day were included in group 1 (n = 153), those who took 7000 to 9999 steps/day were included in group 2 (n = 57), and patients who took at least 10,000 steps/day were included in group 3 (n = 38). Primary outcomes were the 6-minute walk distance (6MWD) and Walking Impairment Questionnaire (WIQ) distance score, which is a disease-specific measurement of HRQoL. Patients were further characterized on demographic variables, comorbid conditions, and cardiovascular risk factors. ResultsThe groups were significantly different on ankle-brachial index (P = .02), and on the prevalence of hypertension (P = .04), diabetes (P < .01), abdominal obesity (P < .01), arthritis (P = .04), and chronic obstructive pulmonary disease (P < .01). Thus, these variables served as covariates in adjusted analyses, along with age, weight, and sex. The 6MWD (mean ± standard deviation) was significantly different among the groups in unadjusted (P < .01) and adjusted (P < .01) analyses (group 1, 313 ± 90 m; group 2, 378 ± 84 m; and group 3, 414 ± 77 m), with groups 2 and 3 having a higher 6MWD than group 1 (P < .01). The WIQ distance score was significantly different among the groups in unadjusted (P < .01) and adjusted (P < .01) analyses (group 1, 30 ± 30%; group 2, 45 ± 35%; and group 3, 47 ± 34%), with groups 2 and 3 having higher WIQ distance scores than group 1 (P < .01). ConclusionsPatients with PAD who walked more than 7000 and 10,000 steps/day had greater ambulatory function and HRQoL than patients who walked fewer than 7000 steps/day. Second, the greater ambulatory function and HRQoL associated with walking 7000 and 10,000 steps/day persisted after adjusting for covariates. This study provides preliminary evidence that patients with PAD who walk more than 7000 steps/day have better ambulatory function and HRQoL than patients below this threshold.

Abstract 14421: Association Between Meeting Daily Step Count Goals With Ambulatory Function and Quality of Life in Patients With Claudication

Introduction: The aims were to determine (a) whether patients with peripheral artery disease (PAD) who walked at least 7,000 and 10,000 steps/day had better ambulatory function and health-related quality of life (HRQoL) than patients who walked less than 7,000 steps/day, and (b) whether these group differences persisted after adjusting for covariates. Hypothesis: Patients who walk at least 7,000 steps/day have significantly better ambulatory function, as measured by greater 6-minute walk distance (6MWD), and better HRQoL, as measured by a higher distance score on the Walking Impairment Questionnaire (WIQ), than patients who walked less than 7,000 steps/day, and that patients who walked more than 10,000 steps/day would have the best values. Furthermore, group differences in the primary outcomes would persist after adjustment for covariates. Methods: Two hundred forty-eight patients were assessed on their daily activity for one week with a step activity monitor, and were grouped according to daily step counts as follows: Group 1 (&lt;7,000 steps/day; n=153), Group 2 (7,000-9,999 steps/day; n=57), Group 3 (&gt;10,000 steps/day; n=38). Primary outcomes were 6MWD and WIQ distance score, which is a disease-specific measurement of HRQoL. Results: Groups were different (p&lt;0.05) on ankle/brachial index, and on prevalence of hypertension, diabetes, abdominal obesity, arthritis, and chronic obstructive pulmonary disease. Thus, these variables served as covariates in adjusted analyses, along with age, weight, and sex. 6MWD (mean±SD) was significantly different among the groups in unadjusted (p&lt;0.01) and adjusted (p&lt;0.01) analyses (Group 1=313±90 m, Group 2=378±84 m, Group 3=414±77 m), with Groups 2 and 3 having higher 6MWD than Group 1 (p&lt;0.01). Similar results were found for the WIQ distance score (Group 1=30±30%, Group 2=45±35%, Group 3=47±34%; p&lt;0.01). Conclusions: PAD patients who walked more than 7,000 and 10,000 steps/day had greater ambulatory function and HRQoL than patients who walked fewer than 7,000 steps/day, and this finding persisted after adjusting for covariates. The clinical significance is that PAD patients should be encouraged to walk more than 7,000 steps/day because this target is associated with greater ambulatory function and HRQoL

Claudication Distances, the Walking Impairment Questionnaire, and Muscle Heme-Oxygen Saturation Best Describe the Home Daily Activity of Claudicating Patients With Peripheral Artery Disease

There is increasing interest in daily activity as a relevant index of impairment in patients with peripheral artery disease (PAD). However, correlations with other objective and subjective measures of function in PAD are not known. Ninety-six claudicating patients were recruited. Ankle-brachial index resting and with stress was determined, and patients completed the Walking Impairment Questionnaire (WIQ), a 6-minute walk test (6MWT), and a Gardner treadmill test (GTT) with concurrent near-infrared spectroscopy of gastrocnemius heme-oxygen saturation (Sto2). A wearable accelerometer was used to measure total daily steps. Mean daily activity was 4050 ± 2631 steps (n = 96). Peak walking time (r = 0.385), 6MWT (r = 0.53), and WIQ (speed r = 0.370 and distance r = 0.405) correlated with daily activity (P < .001), whereas resting and stress ankle-brachial index did not (P > .05). Three subanalyses were performed. For 6MWT, patients were grouped into those who stopped to rest and those who did not. For the GTT, fuzzy clustering analysis of time to minimum Sto2 of the more symptomatic leg grouped patients into those who reached an Sto2 minimum before (n = 44; 91 ± 12 seconds) and after (n = 12; 625 ± 76 seconds) 5 minutes. Finally, patients were grouped into those who reported bilateral or unilateral intermittent claudication. Our Results (Table) demonstrate less at-home daily activity and less walking distance on average among patients who stop to rest during the 6MWT, reach a minimum Sto2 before 5 minutes during GTT, or experience bilateral claudication. Furthermore, all patients with a time to minimum Sto2 >5 minutes had >5000 steps daily activity. Walking performance and the WIQ (distance and speed subscales) correlated with daily activity, whereas hemodynamics did not. Optimal measures of functional status in PAD need to be further explored so that PAD impairments can be better understood.TableDaily activity subanalysisCategorical groupsDaily activity, steps6-minute walk distance, metersGardner maximum walk time, secondsAnalysis based on 6MWT Rest(s) during 6MWT (n = 40)2490 ± 453237.8 ± 15211.6 ± 37 No rest during 6MWT (n = 52)4706 ± 372339.9 ± 12416.5 ± 28Analysis based on NIRS measurement during GTT Time to minimum Sto2 > 5 minutes (n = 12)7715 ± 1093367.4 ± 21735.2 ± 62 Time to minimum Sto2 < 5 minutes (n = 44)3286 ± 273256.8 ± 20251.0 ± 37Analysis based on claudication symptoms Unilateral symptoms (n = 42)5135 ± 359328.4 ± 12382.9 ± 28 Bilateral symptoms (n = 54)3341 ± 332297.3 ± 9a291.5 ± 22bGTT, Gardner treadmill test; NIRS, near-infrared spectroscopy; 6MWT, 6-minute walk test; Sto2, tissue heme-oxygen saturation.Group differences are significant at P < .001 in all comparisons except where noted.aP < .05.bP < .01. Open table in a new tab

Functional and Cardiovascular Parameters in Peripheral Artery Disease Patients with Interarm Blood Pressure Difference

To analyze the impact of interarm blood pressure difference (IAD) on functional and cardiovascular parameters in patients with peripheral artery disease (PAD). Ninety-eight patients with PAD were recruited in this cross-sectional study. Patients with differences between the right and left arms of systolic and/or diastolic blood pressure ≥10mm Hg were classified as IAD, whereas the remaining patients were classified as PAD control subjects. Functional parameters included were the 6-min walk test, short physical performance battery, walking impairment questionnaire (WIQ), and the walking estimated-limitation calculated by history. Systemic cardiovascular parameters included were arterial stiffness and heart rate variability. Local cardiovascular parameters assessed in both arms were brachial blood pressure and flow-mediated dilation. Patients with IAD presented higher systolic blood pressure and pulse pressure compared with control patients (P<0.01). The carotid femoral pulse wave velocity tended to be higher and flow-mediated dilation tended to be lower in PAD patients with IAD compared with control subjects (P<0.09). Patients with IAD presented lower scores in short physical performance battery (P=0.012), WIQ distance (P=0.003), WIQ speed (P=0.008), WIQ stair climbing (P=0.034), and walking estimated-limitation calculated by history (P=0.026) when compared with PAD control patients. In patients with PAD, IAD is associated with lower physical function and impairments in cardiovascular parameters compared with PAD patients without IAD.

Meaningful change in 6-minute walk in people with peripheral artery disease

ObjectiveThe 6-minute walk test is a common outcome measure in clinical trials of people with lower extremity peripheral artery disease (PAD). However, what constitutes a meaningful change in the 6-minute walk distance has not been well defined for people with PAD. The present study related the change in the 6-minute walk distance to the degree of participant-reported improvement or decline in the 6-minute walk distance to define a meaningful change in the 6-minute walk distance for those with PAD. MethodsParticipants with PAD from three observational longitudinal studies completed the walking impairment questionnaire (WIQ) distance score and 6-minute walk at baseline and 1 year later. The WIQ distance score measures participants' perceived difficulty walking seven different distances without stopping (ranging from walking around the home to walking 5 blocks) on a 0 to 4 Likert scale, with 0 representing an inability to walk the distance and 4 representing no difficulty. The mean changes in the 6-minute walk distance corresponding to the participants' report of no change, 1-unit change, or 2-unit change, respectively, in the Likert scale score between the baseline and 1-year follow-up measures were calculated for each WIQ distance. ResultsA total of 777 participants with PAD (mean age, 71.2 ± 8.8 years; mean baseline 6-minute walk distance, 350.1 ± 118.1 meters) completed 5439 questions about their difficulty walking each WIQ distance at baseline and follow-up. Participants with PAD who reported no change in their difficulty in walking each WIQ distance between baseline and follow-up had a decline of 7.2 meters (95% confidence interval [CI], −11.6 to −2.8 meters) in the 6-minute walk test. Relative to those reporting no change in difficulty walking, the participants reporting 1- and 2-point improvements in walking ability showed 6-minute walk distance improvements of 7.8 meters (95% CI, −0.3 to 15.9 meters) and 20.1 meters (95% CI, 1.1-39.2 meters), respectively. Relative to those reporting no change in walking difficulty, those reporting 1- and 2-point declines in perceived walking difficulty showed declines of −11.2 meters (95% CI, −19.0 to −3.4 meters) and −23.8 meters (95% CI, −37.4 to −10.3 meters) in the 6-minute walk distance. ConclusionsAmong people with PAD, ∼8- and ∼20-meter improvements in the 6-minute walk distance represent small and large improvements in walking ability, respectively. People with PAD who reported no change in their ability to walk distances over 1 year simultaneously declined by a mean of 7 meters in the 6-minute walk test. These findings will be useful for interpreting the results from randomized trials of interventions to improve the walking performance of people with PAD.

Diabetes Impairs Walking Capacity And Autonomic Function In Patients With Peripheral Artery Disease

Diabetes is a high prevalent comorbid condition in patients with peripheral arterial disease (PAD). Previous studies showed that diabetes impair physical function in PAD patients. However, whether cardiovascular function is also affected by diabetes is unknown. PURPOSE: To compare walking capacity and cardiovascular function in PAD patients with and without diabetes. A total of 80 patients (n=41 non-diabetic and n=39 diabetic) with PAD were recruited. Six-minute walk test (total walking capacity), 4-meter test, walking impairment questionnaire (WIQ) and the walking estimated-limitation calculated by history (WELCH) were used to assess walking capacity. Cardiovascular function was assessed by blood pressure, arterial stiffness, heart rate variability and flow-mediated dilation. Mann-Whitney U test were performed, and data are presented in median and interquartile range. RESULTS: Diabetic PAD patients presented lower total walking capacity (308 ± 120 m vs. 370 ± 125m, p=0.025), WIQ distance score (10 ±23 vs. 30 ±46, p=0.002), WIQ speed score (17 ± 21 vs. 28 ± 27, p=0.001), WIQ stairs score (21 ± 42 vs. 42 ± 42, p=0.024), WELCH total score (20 ± 26 vs. 40 ± 42, p=0.006) compared to non-diabetic PAD patients. In addition, diabetic PAD patients had lower SDNN (22 ± 21 vs. 29 ± 36, p=0.030), and a trend to have lower RMSSD (13 ± 19 vs. 19 ± 32, p=0.061), and PNN50 (0.4 ± 3.7 vs. 1.6 ±21.0, p=0.072). The remaining variables were similar between PAD patients with and without diabetes. CONCLUSION: Diabetes impairs walking capacity and cardiac autonomic modulation in patients with PAD. Therefore, interventions to improve these parameters should be emphasized in diabetic PAD patients. Supported by FAPESP (# 2016/16425-9) and CNPq (#310508/2017-7)

Predictors of Health-Related Quality of Life in Patients with Symptomatic Peripheral Arterial Disease

PURPOSE: To identify predictors of baseline measures of health-related quality of life (HRQoL) in symptomatic patients with peripheral artery disease (PAD) from objective markers of severity of PAD, clinical and demographic characteristics, comorbid conditions, cardiovascular risk factors, objectively measured physical activity, and patient-based measures of physical function. METHODS: HRQoL measurements of 216 symptomatic men and women with PAD were assessed with the Medical Outcomes Study Short-Form 36 survey. Patients were further characterized on demographic variables, comorbid conditions, cardiovascular risk factors, ankle/brachial index, peak walking time (PWT) during a maximal treadmill test, 6-minute walk distance (6MWD), gait speed, ambulatory activity monitored during one week, activities of daily living (ADL), mini-mental state examination questionnaire, and walking impairment questionnaire (WIQ). RESULTS: For the physical function HRQoL subscale, the significant predictors included WIQ speed score (p < 0.001), a history of stumbling (p < 0.001), WIQ stair climbing score (p < 0.001), the ADL associated with bathing (p = 0.001), 6MWD (p = 0.004), and daily walking cadence (p = 0.043). For the role emotional function HRQoL subscale, the significant predictors included a history of stumbling (p < 0.001), the ADL associated with transferring from a bed to a chair (p < 0.001), and the WIQ distance score (p = 0.022). CONCLUSIONS: Physical and mental subscales of HRQoL in symptomatic patients with PAD are primarily predicted by patient-based physical function, rather than by more specific markers of PAD severity and comorbid conditions. The clinical significance is that interventions designed to improve HRQoL should focus on improving the quality of executing functional tasks such as walking more steadily without stumbling, completing ADL’s that are not specific to walking, such as bathing and transferring, and improving patient-based ability to walk various distances, speeds, and to climb stairs.

Predictors of health-related quality of life in patients with symptomatic peripheral artery disease

ObjectiveThe aim of this study was to identify predictors of baseline measures of health-related quality of life (HRQoL) in symptomatic patients with peripheral artery disease (PAD) from objective markers of severity of PAD, clinical and demographic characteristics, comorbid conditions, cardiovascular risk factors, objectively measured physical activity, and patient-based measures of physical function. MethodsHRQoL measurements of 216 symptomatic men and women with PAD were assessed with the Medical Outcomes Study 36-Item Short Form Health Survey. Patients were further characterized on demographic variables, comorbid conditions, cardiovascular risk factors, ankle-brachial index, peak walking time during a maximal treadmill test, 6-minute walk distance, gait speed, ambulatory activity monitored during 1 week, activities of daily living (ADLs), Mini-Mental State Examination questionnaire, and Walking Impairment Questionnaire (WIQ). ResultsFor the physical function HRQoL subscale, the significant predictors included WIQ speed score (P < .001), history of stumbling (P < .001), WIQ stair climbing score (P < .001), ADL associated with bathing (P = .001), 6-minute walk distance (P = .004), and daily walking cadence (P = .043). For the role emotional function HRQoL subscale, the significant predictors included a history of stumbling (P < .001), the ADL associated with transferring from a bed to a chair (P < .001), and the WIQ distance score (P = .022). ConclusionsPhysical and mental subscales of HRQoL in symptomatic patients with PAD are primarily predicted by patient-based physical function rather than by more specific markers of PAD severity and comorbid conditions. The clinical significance is that interventions designed to improve HRQoL should focus on improving the quality of executing functional tasks, such as walking more steadily without stumbling; completing ADLs that are not specific to walking, such as bathing and transferring; and improving patient-based ability to walk various distances and speeds and to climb stairs.

Abstract 112: Exploring Sleep Disturbance Among Patients With Symptomatic Peripheral Artery Disease: Results From the Project Voice Pilot Study

Background: Sleep disturbance is an important determinant of both mental and physical health-related quality of life (QOL). Associations between sleep disturbance and subclinical cardiovascular disease have been described but little is known about it among patients with symptomatic PAD. We studied sleep disturbance in symptomatic PAD patients using a wearable device for 30 days. Methods: Patients with claudication confirmed by ABI&lt;0.9 were recruited to participate. Participants received walking exercise instruction, a wearable device to track walking activity and sleep, and an iPad with access to a PAD-specific digital health platform with educational materials and patient surveys. Participants set personal walking goals, received weekly telephone follow up, and completed quality of life instruments [Walking Impairment Questionnaire (WIQ) and VascuQol-6] at baseline and post-completion. Poisson regression was used to examine associations between number of nights with sleep interruption, patient characteristics and survey responses. Results: Twenty participants enrolled and completed the study; 35% were female; 30% were African American. Mean age was 69±9 years; mean ABI was 0.69±0.14. Over a mean study period of 34±6 days, sleep data were recorded an average of 28±6 days and walking activity on 12±10 days. Mean nights of interrupted sleep was 1.3±1.8; 8 participants (40%) had sleep interruption at least one night. No associations were observed between daily walking activity or VascuQol-6 scores and sleep disturbance. Increases in sleep disturbance were associated with higher (i.e., more severe) WIQ distance (P=0.02) and stair (P=0.03) scores at baseline, and WIQ distance (P=0.03), speed (P=0.002) and overall (P=0.009) scores at study completion. Conclusions: These observations suggest that sleep disturbance impacts walking, disability and QOL among people with symptomatic PAD. Further investigation is warranted to characterize sleep disturbance among patients with both claudication and critical limb ischemia, evaluate associations with disease severity, and explore utility as a treatment outcome.

Supervised vs unsupervised exercise for intermittent claudication: A systematic review and meta-analysis

Supervised exercise (SE) is widely accepted as an effective therapy for intermittent claudication (IC), but its use is limited by cost. Unsupervised exercise (UE) represents a less costly alternative. We assessed the comparative effectiveness of SE vs UE in patients with IC. We searched PubMed, EMBASE, and the Cochrane Database of Systematic Reviews and identified 27 unique studies (24 randomized controlled trials, 4 observational studies) that evaluated the comparative effectiveness of SE vs UE in 2074 patients with IC. Compared with UE, SE was associated with a moderate improvement in maximal walking distance at 6 months (effect size 0.77, 95% CI 0.36-1.17, P < .001) and 12 months (effect size 0.56, 95% CI 0.34-0.77, P < .001). Supervised exercise also improved claudication distance to a moderate extent compared with UE at 6 months (effect size 0.63, 95% CI 0.40-0.85, P < .001) and 12 months (effect size 0.41, 95% CI 0.18-0.65, P = .001). There was no difference in the Short Form-36 quality of life at 6 months (effect size -0.05, 95% CI -0.50 to 0.41, P = .84) or walking impairment questionnaire distance (effect size 0.24, 95% CI -0.03 to 0.50, P = .08) or speed (effect size 0.26, 95% CI -0.06 to 0.59, P = .11). In claudication patients, SE is more effective than UE at improving maximal walking and claudication distances, yet there is no difference in general quality of life or patient-reported community-based walking. Further studies are needed to investigate the relationship between functional gain and disease-specific quality of life.

Exercise training for health-related quality of life in peripheral artery disease: a systematic review and meta-analysis.

We sought to quantify whether health-related quality of life (HRQoL) is improved through exercise training in people with peripheral artery disease (PAD) and to clarify which prescriptions were optimal for improving HRQoL when compared to usual care. We conducted a systematic search (PubMed, CINAHL, Cochrane Central Register of Controlled Trials; 1966 - 31 August 2014). We only included randomized controlled trials (RCTs) of exercise training versus usual medical care in persons with PAD that included the Walking Impairment Questionnaire (WIQ) and Short-Form Health Survey component summary scores as outcomes. Of 15 RCTs, 1257 participants were studied: 543 participated in supervised exercise, with only 61 undertaking resistance training and 316 unsupervised exercise. When compared to controls, participants who completed any form of exercise training significantly improved their WIQ speed [mean difference (MD) 9.60 (95% CI 6.98 to 12.23, p<0.00001)]; WIQ distance [MD 7.41 (95% CI 4.49 to 10.33, p<0.00001)] and WIQ stair-climbing [MD 5.07 (95% CI 3.16 to 6.99, p<0.00001)]. Walking also significantly improved the Short-Form Physical Component Summary (SF-PCS) score when compared to controls [MD 1.24 (95% CI 0.48 to 2.01, p=0.001)], but not the Mental Component Summary (SF-MCS) score [MD -0.55 (95% CI -1.27 to 0.18, p=0.14)]. Exercise training improves the SF-PCS dimension, as well as perceived walking distance, speed and stair-climbing as measured by the WIQ, but not the SF-MCS score. Future studies should aim to blind assessors of such subjective measures, and study alternative modes and prescriptions of exercise alternative to walking.

Abstract 15110: Exercise Training for Management of Peripheral Arterial Disease: a Systematic Review and Meta-Analysis

Objective: To quantify expected benefits of exercise training in people with peripheral arterial disease (PAD). Hypothesis: Walking as a training modality and training to mild pain were optimal for improving peak VO 2 and symptoms. Methods: We conducted a systematic search (PubMed, CINAHL, Cochrane controlled trials registry; 1966-May 31, 2014).We included randomized controlled trials (RCT’s) of exercise training versus usual medical care in persons with PAD, 42 of 60 (70%) RCT’s met selection criteria. Results: Exercise training produced significant peak VO 2 improvements with Mean Difference (MD) 0.62 ml/kg/min (95% CI 0.47 to 0.77; p&lt;0.00001); 6 minute walk initial claudication MD 52.7m (95%CI 24.7 to 80.6m; p=0.0002); total walking distance MD 34.9m (95%CI 25.6 to 44.1m; p&lt;0.00001); graded treadmill initial claudication MD 68.8m (95%CI 54.4 to 83.2m; p&lt;0.00001); absolute claudication distance MD 41.0m (95%CI 28.8 to 53.2m; p&lt;0.00001)); but not ABI (p=0.12) or FMD (p=0.96). Sub-analyses of maximum change in Peak VO 2 showed arm cranking to be the superior modality MD 1.91 ml.kg -1 .min -1 (95% CI 1.28 to 2.54, p&lt;0.00001). Sub-analysis of peak VO 2 according to pain thresholds suggested that exercise training with no or mild pain may be superior MD 0.79 ml.kg -1 .min -1 (95% CI 0.45 to 1.14, p&lt;0.00001) to moderate/maximum pain MD 0.49 ml.kg -1 .min -1 (95% CI 0.31 to 0.66, p&lt;0.00001). Exercise training significantly improved Walking Impairment Questionnaire (WIQ) speed [MD 9.90 (95% CI 7.10 to 12.71, p&lt;0.00001)]; WIQ distance [MD 7.04 (95% CI 3.98 to 10.10, p&lt;0.00001)] and WIQ stair climbing [MD 4.99 (95% CI 3.03 to 6.69, p&lt;0.00001)]. Perceived symptoms were not improved. SF-36 physical score was significantly improved compared to control [MD 1.27 (95% CI 0.41 to 2.13, p=0.004)], but not SF-36 mental score. Conclusions and Relevance: Various modes of exercise improve cardio-respiratory fitness, pain free and total flat ground walking distances and graded treadmill performance in PAD. Alternative modes of exercise are understudied in terms of quality of life, however walking to some level of claudication pain improves WIQ speed, distance and stair climbing scores in PAD as well as SF-36 physical component score.

Home-based walking exercise in peripheral artery disease: 12-month follow-up of the GOALS randomized trial.

BackgroundWe studied whether a 6‐month group‐mediated cognitive behavioral (GMCB) intervention for peripheral artery disease (PAD) participants, which promoted home‐based walking exercise, improved 6‐minute walk and other outcomes at 12‐month follow‐up, 6 months after completing the intervention, compared to a control group.Methods and ResultsWe randomized PAD participants to a GMCB intervention or a control group. During phase I (months 1 to 6), the intervention used group support and self‐regulatory skills during weekly on‐site meetings to help participants adhere to home‐based exercise. The control group received weekly on‐site lectures on topics unrelated to exercise. Primary outcomes were measured at the end of phase I. During phase II (months 7 to 12), each group received telephone contact. Compared to controls, participants randomized to the intervention increased their 6‐minute walk distance from baseline to 12‐month follow‐up, (from 355.4 to 381.9 m in the intervention versus 353.1 to 345.6 m in the control group; mean difference=+34.1 m; 95% confidence interval [CI]=+14.6, +53.5; P<0.001) and their Walking Impairment Questionnaire (WIQ) speed score (from 36.1 to 46.5 in the intervention group versus 34.9 to 36.5 in the control group; mean difference =+8.8; 95% CI=+1.6, +16.1; P=0.018). Change in the WIQ distance score was not different between the 2 groups at 12‐month follow‐up (P=0.139).ConclusionsA weekly on‐site GMCB intervention that promoted home‐based walking exercise intervention for people with PAD demonstrated continued benefit at 12‐month follow‐up, 6 months after the GMCB intervention was completed.Clinical Trial RegistrationURL: ClinicalTrials.gov. Unique identifier: NCT00693940.

Clot strength is negatively associated with ambulatory function in patients with peripheral artery disease and intermittent claudication.

Peripheral artery disease (PAD) is associated with exercise impairment and greater thrombotic risk. We investigated whether clot formation and platelet aggregation assessed by thromboelastography and light-transmission aggregometry correlate with the severity of symptomatic PAD assessed by ambulatory function measures. We studied 40 symptomatic patients with PAD in whom severity of disease was assessed using ankle-brachial index, peak walking time (PWT), claudication onset time, peak oxygen uptake, daily ambulatory activity, and walking impairment questionnaire (WIQ) scores. Clot strength correlated negatively with peak oxygen uptake, PWT, WIQ distance, and stair-climbing scores. Time to clot formation did not correlate with exercise parameters. Platelet aggregation was negatively correlated with WIQ distance score and was positively correlated with PWT and peak oxygen uptake. In conclusion, clot strength and platelet aggregation correlated with objective and self-perceived ambulatory measures. Patients with PAD having more severe walking impairment may be likely to form stronger clots.

Declining Walking Impairment Questionnaire Scores Are Associated With Subsequent Increased Mortality in Peripheral Artery Disease

This study determined whether greater 2-year declines in Walking Impairment Questionnaire (WIQ) stair climbing, distance, or speed scores were associated with higher all-cause and cardiovascular disease (CVD) mortality among men and women with lower extremity peripheral artery disease (PAD). Associations of decline in the WIQ with mortality among people with PAD are unknown. Participants were 442 men and women with PAD identified from Chicago area medical centers. The WIQ was completed at baseline and at 2-year follow-up. Cox proportional hazard models were used to assess associations across categories of 2-year changes in WIQ stair climbing, WIQ distance, and WIQ speed scores with subsequent all-cause and CVD mortality, adjusting for age, sex, race, ankle-brachial index, body mass index, smoking, comorbidities, and other covariates. One hundred twenty-three participants (27.8%) died during a median follow-up of 4.7 years after the 2-year change in WIQ score measurements. Forty-five participants died from CVD. Adjusting for covariates, participants with WIQ score declines ≥20.0 points had higher all-cause mortality (hazard ratio [HR]: 1.93, 95% confidence interval [CI]: 1.01 to 3.68 for WIQ stair climbing; HR: 2.34, 95% CI: 1.15 to 4.75 for WIQ distance; and HR: 3.55, 95% CI: 1.57 to 8.04 for WIQ speed, respectively) compared with participants with ≥20.0 point improvement in each of the corresponding WIQ categories. Participants with ≥20.0 point declines in the WIQ distance score had higher CVD mortality (HR: 4.56, 95% CI: 1.30 to 16.01) compared with those with ≥20.0 point improvement in the WIQ distance score. Patients with PAD who experienced ≥20.0 point declines in the WIQ stair climbing, distance, and speed scores had a higher rate of all-cause mortality compared with those with less declines in each WIQ score.