Treatment for intermittent claudication and the effects on walking distance and quality of life.

The objective of the study was to provide an overview of the most common treatments for intermittent claudication and to determine the effectiveness in improving walking distance and quality of life based on a combination of direct and indirect evidence. We included trials that compared: angioplasty, surgery, exercise therapy or no treatment for intermittent claudication. Outcome measurements were walking distance (maximum, pain-free) and quality of life (physical, mental). We used a network meta-analysis model for the combination of direct and indirect evidence. We included 42 studies, presenting 3106 participants. The network meta-analysis showed that supervised exercise therapy (Δ = 1.62, P < 0.01), angioplasty (Δ = 1.89, P < 0.01) and surgery (Δ = 2.72, P = 0.02) increased walking distance significantly more than no treatment. Furthermore, supervised exercise therapy (Δ = 0.60, P < 0.01), angioplasty (Δ = 0.91, P = 0.01) and surgery (Δ = 1.07, P < 0.01) increased physical quality of life more than no treatment. However, in the sensitivity analysis, only supervised exercise therapy had additional value over no symptomatic treatment (Δ = 0.66, P < 0.01). In conclusion, this network meta-analysis indicates that supervised exercise therapy is more effective in both increasing walking distance and physical quality of life, compared with no treatment. Angioplasty and surgery also increase walking distance, compared with no treatment, but results for physical quality of life are less convincing.

Cost-effectiveness of exercise therapy in patients with intermittent claudication: supervised exercise therapy versus a 'go home and walk' advice.

OBJECTIVES: The Exercise Therapy in Peripheral Arterial Disease (EXITPAD) study has shown supervised exercise therapy (SET) to be more effective regarding walking distance and quality of life than a 'go home and walk' advice (WA) for patients with intermittent claudication. The present study aims to assess the cost-effectiveness of SET versus WA. PATIENTS AND METHODS: Data from the EXITPAD study, a 12-month randomised controlled trial in 304 patients with claudication, was used to study the proportion of costs to walking distance and quality of life. Two different incremental cost-effectiveness ratios (ICERs) were calculated for SET versus WA: costs per extra metre on the treadmill test, and costs per quality-adjusted life year (QALY). QALYs were based on utilities derived from the EuroQoL-5 dimensions (EQ-5D). RESULTS: Mean total costs were higher for SET than for WA (3407 versus 2304 Euros), mainly caused by the costs of exercise therapy. The median walking distance was 620 m for SET and 400 m for WA. QALYs were 0.71 for SET and 0.67 for WA. All differences were statistically significant. The ICER for cost per extra metre on the 12-month treadmill test was € 4.08. For cost per QALY, the ICER was € 28,693. CONCLUSION: At a willingness-to-pay threshold of € 40,000 per QALY, SET likely is a cost-effective therapeutic option for patients with claudication.

From the Cochrane library: Ginkgo biloba for intermittent claudication.

BACKGROUND: Patients with intermittent claudication suffer from pain in the muscles of the legs during exercise that is relieved by a short rest. Ginkgo biloba extract is a vasoactive agent used for symptomatic relief in intermittent claudication. In this article a meta-analysis is discussed that assessed the effect of Ginkgo biloba on walking capacity in patients with intermittent claudication. PATIENTS AND METHODS: The Cochrane Peripheral Vascular Diseases Group searched their Trials Register and the Cochrane Central Register of Controlled Trials in The Cochrane Library. Furthermore MEDLINE/PUBMED (until May 2008) and EMBASE (until May 2008) were searched and manufacturers of Ginkgo biloba extract were contacted. Randomized controlled trials of Ginkgo biloba extract versus placebo in people with intermittent claudication were included. Two authors independently assessed trials for selection, assessed study quality and extracted data. To standardize walking distance or time, caloric expenditures were used to correct for the different treadmill protocols. RESULTS: Eleven trials involving 477 participants compared Ginkgo biloba with placebo and assessed the absolute claudication distance (maximal walking distance). At the end of the study the absolute claudication distance increased with an overall effect size of 3.57 kilocalories ( p = 0.06), for treatment with Ginkgo biloba, compared to placebo. This translates to an increase of 64.5 meters (confidence interval -1.8 to 130.7) on a flat treadmill with an average speed of 3.2 km/h. CONCLUSIONS: There is no evidence that Ginkgo biloba has a clinically significant benefit for patients with intermittent claudication.

To wear or not to wear compression stockings after varicose vein stripping: a randomised controlled trial.

OBJECTIVES: To assess the need to wear compression stockings for 4 weeks after inversion stripping of the great saphenous vein (GSV) from the groin to the level of the knee. DESIGN: Randomised controlled trial. PATIENTS: A total of 104 consecutive patients with primary complete incompetence of the GSV treated by inversion stripping of the GSV. METHODS: Postoperatively treated limbs underwent elastic bandaging for 3 days. Volunteers were randomised to wear a compression stocking for additional 4 weeks (intervention group) or no compression stocking (control group). The primary outcome was limb oedema as assessed by photoelectric leg volume measurement. Secondary outcome measures were pain scores, postoperative complications and return to full work. RESULTS: The control leg volume was 3657ml (standard deviation, SD 687) preoperatively and 3640ml (SD 540) 4 weeks postoperatively (non significant, N.S.). The stocking leg volume was 3629ml (SD 540) preoperatively, falling to 3534ml (SD 543) (P<0.01) 4 weeks postoperatively. The difference in leg volume between both the groups was not statistically significant. Patients in the control group resumed work earlier (control 11 days, stocking 15 days, P=0.02, Mann-Whitney test). No difference was observed in the number and type of complication and in pain scores during the 4-week follow-up period. CONCLUSIONS: Wearing an elastic compression stocking has no additional benefit following elastic bandaging for 3 days in postoperative care after stripping of the great saphenous vein as assessed by control of limb oedema, pain, complications and return to work.

Predictors of walking distance after supervised exercise therapy in patients with intermittent claudication.

OBJECTIVE: To identify predictor variables for results after supervised exercise therapy (SET), and to develop a clinical prediction model that aims to predict a target walking distance for individual patients. DESIGN: Retrospective analyses on prospectively collected data. MATERIALS: Patients with intermittent claudication who participated in a SET programme. METHODS: SET was conducted according to the guidelines of the Royal Dutch Society for Physiotherapy. The main outcome measurement was the absolute claudication distance (ACD) after 6 months of SET. Linear regression analyses were conducted to identify independent predictor variables for ACD. RESULTS: In this cohort, 437 patients were analysed. Independent predictor variables for post-treatment ACD were baseline ACD (P<0.001), smoking behaviour (P=0.012) and body-mass index (P=0.041). A better baseline ACD was associated with a longer post-treatment ACD whereas current smoking and a higher body-mass index were associated with a shorter post-treatment ACD. The final regression equation included baseline ACD, age, body-mass index, smoking and pulmonary disease, and was translated into several clinical prediction models. However, only 24.8-33.6% of the patients had an ACD within the calculated target range. CONCLUSIONS: Predictive variables for post-treatment ACD after SET are baseline ACD, age, body-mass index, pulmonary disease and smoking behaviour. However, translating the regression equation into a clinical prediction model did not lead to a valid model for use in clinical practice.

Supervised exercise versus non-supervised exercise for reducing weight in obese adults.

AIM: The prevalence of obesity is rising. Because obesity is positively associated with many health related risks and negatively associated with life expectancy this is a threat to public health. Physical exercise is a well known method to lose fat mass. Due to shame of their appearance, bad general condition and social isolation, starting and continuing physical exercise tends to be problematic for obese adults. A supervised training program could be useful to overcome such negative factors. In this study we hypothesized that offering a supervised exercise program for obese adults would lead to greater benefits in body fat and total body mass reduction than a non-specific oral advice to increase their physical activity. METHODS: Thirty-four participants were randomised to a supervised exercise program group (N.=17) and a control group (N.=17). Fifteen candidates in the intervention group and 12 in the control group appeared for baseline measurements and bought an all inclusive sports pass to a health club for Euro 10, per month. The control group just received the oral advice to increase their physical activity at their convenience. The supervised exercise group received biweekly exercise sessions of 2 hours with an estimated energy expenditure of 2 500 kJ per hour. Both groups received no dietary advice. RESULTS: After 4 months the overall decrease in body mass in the intervention group was 8.0 kg (SD 6.2) and the decrease in body fat was 6.2 kg (SD 4.5). The control group lost 2.8 kg overall (SD 4.2) and the decrease in body fat was 1.7 kg (SD 3.1). Correction for differences between groups in gender and age by multiple linear regression analysis showed significantly greater loss of total body mass (P = 0.001) and fat mass (P =0.002) in the intervention group compared with the control group. CONCLUSIONS: Stimulation of physical activity alone seems to result in a slight short term body mass and fat mass reduction in obese adults who are eager to lose weight. Supervised exercise under supervision of a qualified fitness instructor leads to a larger decrease.

Validation of the Dutch version of the Walking Impairment Questionnaire.

OBJECTIVES: The Walking Impairment Questionnaire (WIQ) is a frequently used questionnaire to evaluate patients with intermittent claudication (IC). The aim of this study is to validate the Dutch WIQ for the European situation using the metric system. DESIGN: Validation study. MATERIALS: After translation and cultural adaptation of the WIQ, 130 patients with IC completed the Dutch WIQ, the RAND-36, and the EuroQol questionnaire. Walking distances were determined by treadmill testing. METHODS: Correlations between the WIQ, the two quality of life questionnaires, and walking distances were calculated to determine validity. Reliability and internal consistency were determined using the intraclass correlation coefficient (ICC) and Cronbach's alpha, respectively. RESULTS: Significant correlations were found between the WIQ and the absolute claudication distance (ACD) (0.52), EuroQol (0.33) and seven domains of the RAND-36. Test-retest reliability expressed by the ICC was 0.89. The internal consistency determined by Cronbach's alpha was 0.92 for the total WIQ score. Furthermore, a lower WIQ score corresponds to a shorter ACD. CONCLUSIONS: This study shows that the Dutch version of the WIQ using the European metric system is a valid, reliable and clinically relevant instrument for assessing walking impairment in patients with intermittent claudication.

Supervised exercise therapy for intermittent claudication.

PURPOSE OF THE REVIEW: Although exercise therapy is considered to be of significant benefit to people with intermittent claudication, almost half of those affected do not undertake any exercise therapy. The purpose of this review is to evaluate the effects of supervised exercise therapy (SET) for people with intermittent claudication. MATERIALS AND METHODS: SET will be compared with non-supervised exercise therapy programs and the superiority of SET will be demonstrated. The development and implementation of a new community-based concept of SET will be addressed, whereas the first results of this new concept will be presented and compared with the results of SET programs provided in clinical settings, as described in literature. MAIN RESULTS: SET programs have significant benefits compared with non-supervised programs. Community-based SET has both economic and logistic advantages over clinic-based SET. Furthermore, community-based SET programs seems to be as effective as SET provided in a clinic-based setting and is a promising approach to providing conservative treatment for patients with intermittent claudication. CONCLUSIONS: SET in a community-based setting should ideally be the initial standard of care for patients with intermittent claudication. However, a study of the cost-effectiveness should be awaited.