Home-Based vs Supervised Exercise Program for PAD: What Works Best? - PDF document

4/8/19 Home-Based vs Supervised Exercise Program for PAD: What Works Best? Andrew W. Gardner, Ph.D. Professor and Vice Chair of Research Dept. of Physical Medicine & Rehabilitation Penn State College of Medicine Disclosures • None 1

4/8/19 Outline • Describe supervised and home-based exercise programs to treat claudication • Review recent meta-analyses of both programs • Discuss head-to-head comparisons of the programs Peripheral Artery Disease (PAD) Caused by obstruction • of the arterial supply to the lower extremity Arterial lesions reduce • blood flow Mismatch between the • O 2 supply & metabolic demands of muscle 2

4/8/19 Intermittent Claudication ● Pain in one or both legs on walking, primarily affecting the calves, that does not go away with continued walking, and is relieved by rest. ● Limits daily physical activities and negatively affects quality of life in many older adults. Primary Goals in Ameliorating Claudication ● Improve ambulatory function ● Improve quality of life Hiatt, WR, et al. Circulation. 2014;130:69-78. 3

4/8/19 Supervised Exercise Program In patients with claudication, a supervised exercise program is recommended to improve functional status and QoL and to reduce leg symptoms. Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779. Home-Based Exercise Program In patients with PAD, a structured community- or home-based exercise program with behavioral change techniques can be beneficial to improve walking ability and functional status. Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779. 4

4/8/19 Structured Exercise Program: Supervised Program takes place in a hospital or outpatient facility. ● Program uses intermittent walking exercise as the treatment ● modality. Program can be standalone or within a cardiac rehabilitation ● program. Program is directly supervised by qualified healthcare ● provider(s). Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779. Structured Exercise Program: Supervised Training is performed for a minimum of 30–45 min/session; ● sessions are performed at least 3 times/wk for a minimum of 12 wk. Training involves intermittent bouts of walking to moderate-to- ● maximum claudication, alternating with periods of rest. Warm-up and cool-down periods precede and follow each ● session of walking. Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779. 5

4/8/19 Structured Exercise Program: Home-Based Program takes place in the personal setting of the patient rather ● than in a clinical setting. Program is self-directed with guidance of healthcare providers. ● Healthcare providers prescribe an exercise regimen similar to ● that of a supervised program. Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779. Structured Exercise Program: Home-Based Patient counseling ensures understanding of how to begin and ● maintain the program and how to progress the difficulty of the walking (by increasing distance or speed). Program may incorporate behavioral change techniques, such ● as health coaching or use of activity monitors. Gerhard-Herman, MD, et al. Circulation 2017;135:e726-e779. 6

4/8/19 Supervised and Home Exercise vs Non-Exercise Control Meta-Analyses Pain-Free Walking Distance Fakhry F, et al. J Vasc Surg 2012;56:1132-1142. 7

4/8/19 Maximum Walking Distance Fakhry F, et al. J Vasc Surg 2012;56:1132-1142. 6-Minute Walk Distance Parmenter BJ, et al. Sports Med 2015;45:231-244. 8

4/8/19 Treadmill COD Golledge, J, et al. Brit J Surg 2019;106:319-331. Treadmill MWD Golledge, J, et al. Brit J Surg 2019;106:319-331. 9

4/8/19 6-Minute Walk Distance Golledge, J, et al. Brit J Surg 2019;106:319-331. Physical Activity Golledge, J, et al. Brit J Surg 2019;106:319-331. 10

4/8/19 Supervised vs Home Exercise Head to Head Comparison U. Oklahoma Health Sciences Center, Oklahoma City R01-AG-24296; OCAST HR09-035 http://www.ClinicalTrial.Gov NCT00618670 Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. 11

4/8/19 Exercise Intervention Measures Gardner, AW, et al. Circulation 2011;123:491-498. Change in COT P < 0.001 300 + 88% * 200 + 53% * P < .001 P < .001 (sec) 100 + 8% P > .05 0 C S H * P < .05 vs. Control -100 Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. 12

4/8/19 Change in PWT P < 0.001 300 + 54% * P < .001 200 + 29% * † P < .001 (sec) 100 + 5% P > .05 0 C S H * P < .05 vs. Control -100 † P < .05 vs. Supervised Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. Change in 6-Min Walk Distance P < 0.05 60 + 14% * † P < .001 40 (m) + 5% P < .05 * P < .05 vs. Control 20 + 1% † P < .05 vs. Supervised P > .05 0 C S H Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. 13

4/8/19 Change in Average Daily Cadence P < 0.05 1 + 6 % P < .01 0.8 (stride/min) 0.6 0.4 2 % 2 % P > .05 P > .05 0.2 0 C S H Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. Change in Large Artery Elasticity Index P < 0.05 3 + 16 % * P < .05 (ml/mmHg) x 10 2 + 6 % P > .05 * P < .05 vs. Control 1 + 3 % P > .05 0 S H C Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. 14

4/8/19 Change in C-Reactive Protein P < 0.05 0 H * P < .05 vs. Control - 6 % - 10 % (mg/L) P > .05 -1 P > .05 - 24 % * P < .05 -2 C S H Gardner, AW, et al. J Am Heart Assoc 2014;3:001107. Conclusions ● Both structured supervised and home- based exercise programs are efficacious to improve ambulatory function. ● Changes in outcome measures are specific to the intervention utilized. ● Combining both programs should be considered to increase exercise volume and meet activity guidelines. 15

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