[Follow-up of patients with chronic obstructive arterial disease, some months after their rehabilitation: Assessment of a therapeutic education program]. / Suivi de patients atteints d'artériopathie oblitérante des membres inférieurs, à distance d'une rééducation : évaluation d'un programme d'éducation thérapeutique.

Vascular rehabilitation (VR) is becoming increasingly important in the management of the arterial patient. Therapeutic Patient Education (TPE) is an integral part of rehabilitation programs and aims to transform patients' lifestyle habits. The effectiveness of patient management at short-term no longer needs to be demonstrated, but we can question the effectiveness of education over the long term, some months following a rehabilitation program. OBJECTIVE: This study aims to assess, in the long term, the effects of TPE in VR, and to observe the transformation of certain lifestyle habits of patients. METHOD: We convened 68 patients (51 men and 17 women) 6 months and 1 year after VR treatment during which these patients participated in an TPE program. We assessed: knowledge by questionnaire, walking range, weight and body composition by impedimetric techniques. RESULTS: We found that patients improved their knowledge at the end of rehabilitation 45.8 (±7.6) of good responses on average, compared to 36.2 (±8.6) at the beginning of rehabilitation and these results are consolidated 6 months after 43.4 (±7.5) and 1 year after 44.1 (±8.1). We also found that walking distances during treadmill testing and outdoor walking improved at the end of rehabilitation and were maintained at six months and one year. Finally, weight, fat mass and lean mass decreased slightly compared to the end of rehabilitation. Only 7 patients out of 22 gave up smoking. CONCLUSION: An education program concerning risk factor management during vascular rehabilitation enables patients to acquire knowledge that can be used to maintain new lifestyle habits and stabilize their health status.

Nordic walking versus walking without poles for rehabilitation with cardiovascular disease: Randomized controlled trial.

BACKGROUND: With Nordic walking, or walking with poles, one can travel a greater distance and at a higher rate than with walking without poles, but whether the activity is beneficial for patients with cardiovascular disease is unknown. OBJECTIVE: This randomized controlled trial was undertaken to determine whether Nordic walking was more effective than walking without poles on walk distance to support rehabilitation training for patients with acute coronary syndrome (ACS) and peripheral arterial occlusive disease (PAOD). METHODS: Patients were recruited in a private specialized rehabilitation centre for cardiovascular diseases. The entire protocol, including patient recruitment, took place over 2 months, from September to October 2013. We divided patients into 2 groups: Nordic Walking Group (NWG, n=21) and Walking Group without poles (WG, n=21). All patients followed the same program over 4 weeks, except for the walk performed with or without poles. The main outcome was walk distance on the 6-min walk test. Secondary outcomes were maximum heart rate during exercise and walk distance and power output on a treadmill stress test. RESULTS: We included 42 patients (35 men; mean age 57.2±11 years and BMI 26.5±4.5kg/m2). At the end of the training period, both groups showed improved walk distance on the 6-min walk test and treatment stress test as well as power on the treadmill stress test (P<0.05). The NWG showed significantly greater walk distance than the WG (P<0.05). Both ACS and PAOD groups showed improvement, but improvement was significant for only PAOD patients. CONCLUSIONS: After a 4-week training period, Nordic walking training appeared more efficient than training without poles for increasing walk distance on the 6-min walk test for patients with ACS and PAOD.

The effects of Crenotherapy and exercise in peripheral arterial occlusive disease. A comparison with simple exercise training.

BACKGROUND: Conservative therapies for patients affected by Peripheral Arterial Occlusive Disease (PAOD) aim first to correct the risk factors and to slow down the disease progression. Among these, exercise has positive effects on blood flow, muscle metabolism and well demonstrated systemic effects. These include reduction of chronic inflammation markers, improvement of walking mechanics and heart function. Controlled physical training increases the ability to perform the daily activities improving life expectancy of these patients. The aim of this study is to evaluate the effects and the effectiveness of physical training performed in thermal water compared to traditional treadmill walking exercise. METHODS: 98 patients affected by IIb stage PAOD, according to Leriche-Fontaine classification, were enrolled. Patients were randomized into two groups: the first arm carried out an intensive training program under medical supervision (group A); the second one carried out a rehabilitative exercise associated with crenotherapy (group B). The following parameters were detected: Ankle-Brachial pressure index (ABI), actual claudication distance (ACD), maximum walking distance (MWD), flow mediated dilatation (FMD) and the intima-media thickness (IMT). All patients underwent Doppler echocardiography and complete biochemical assay. RESULTS: In both groups, there was a statistically significant improvement of lipidaemia compared to baseline. When compared with each other, the two groups did not show statistically significant differences. There were no significant differences between the two groups regarding echocardiographic findings. Vascular reactivity study showed a statistically significant improvement of FMD after 3 months of exercise in both groups. In crenotherapy group (B) FMD values were significantly higher than the treadmill ones (A). In both groups a statistically significant improvement in ACD was observed CONCLUSIONS: Our experience shows that crenotherapy has similar effects compared to traditional physical training in the treatment of PAOD, being equally well tolerated and safe; it gives an advantage over conventional physical training in terms of ACD and MWD improvement, although not statistically significant, and it is extremely welcome to patients compared to traditional physical training. KEY WORDS: Arterioscleroses, Intermittent Claudicatio, Peripheral Arterial Diseasen, Physical Exercise, Rehabilitation.

[FLIGHT CERTIFICATION OF CIVILIAN PILOTS FOLLOWING SURGERY OF BRACHIOCEPHALIC ATHEROSCLEROTIC STENOSES].

The paper presents cases of surgery of brachiocephalic atherosclerotic lesions with asymptomatic stenosis in civilian pilots reviewed by a Flight Certification Board. Cerebrovascular diseases varying in their clinical presentation (syncopes, transitory ischemic attacks or strokes) may culminate in acute conditions and, consequently, threaten flight safety. There is an exigent need of law-guided regulations for flight certification boards on how to manage cases of pilots with a history of cerebrovascular disease.

Effect of physical activity assessment on prognostication for peripheral artery disease and mortality.

OBJECTIVE: To examine whether a simple question about the performance of regular vigorous activity is associated with peripheral artery disease (PAD) and mortality. METHODS: A total of 1288 individuals undergoing nonemergency coronary angiography were assessed for participation in regular vigorous activity by questionnaire. Data on demographic characteristics, ankle-brachial indexes, and cardiovascular outcomes were prospectively collected. RESULTS: Compared with those who denied participation in regular vigorous activity, those who reported participation were less likely to have PAD (odds ratio, 0.58; 95% CI, 0.39-0.86), had higher ankle-brachial indexes, had better Walking Impairment Questionnaire scores (P<.001), and experienced reduced all-cause mortality rates (hazard ratio, 0.48; 95% CI, 0.31-0.74). When added to the Framingham Risk Score, the response improved the net reclassification index for all-cause (32.6%) and cardiovascular (32.0%) mortality. CONCLUSION: Among at-risk individuals, regular vigorous activity is associated with decreased PAD and all-cause mortality. Simple and readily available, a single yes/no query about participation in regular vigorous exercise could be used to improve risk stratification.

Recanalização da artéria tibial anterior via artéria pediosa: relato de caso / Anterior tibial artery recanalization through dorsalis pedis artery: a case report

Os autores relatam um caso de abordagem mista para o tratamento endovascular de doença oclusiva da artéria tibial anterior por acesso pedioso retrógrado, no qual a abordagem tradicional anterógrada foi inadequada em vencer uma oclusão. A técnica parece oferecer uma opção para procedimentos endovasculares, que objetivam o tratamento de lesões da artéria tibial anterior em que a via anterógrada convencional mostre-se inadequada.

The authors report the case of mixed approach for endovascular treatment of occlusive disease of the anterior tibial artery by retrograde pedal artery access where the traditional antegrade approach failed to overcome a segmental occlusion. The technique seems to offer an option for endovascular procedures aimed at treating occlusion of the anterior tibial artery in cases where the conventional antegrade approach demonstrates to be inappropriate.

[Effect of supervised exercise training on walking speed, claudication distance and quality of life in peripheral arterial disease]. / Einfluss eines überwachten Gefäßtrainings auf Gehgeschwindigkeit, Gehstrecke und Lebensqualität bei peripherer arterieller Verschlusskrankheit.

BACKGROUND: Aim of the study was to evaluate the effects of supervised exercise training for peripheral arterial disease (PAD) on walking speed, claudication distance and quality of life. METHODS AND RESULTS: Ninety-four patients in stage IIa/IIb according to Fontaine underwent a six-month exercise training at the Center for Outpatient Rehabilitation Vienna (ZAW). Walking speed and Absolute Claudication Distance (ACD) improved significantly (p < 0,001 and p = 0,007 respectively). Increase of the Initial Claudication Distance (ICD) did not reach statistical significance (p = 0,14). Quality of life, as assessed by the questionnaire "PLC" manifested no significant change. CONCLUSIONS: The exercise training achieved considerable effects on walking speed and claudication distance. Despite these improvements, patient's quality of life revealed no relevant change. This outcome could be explained by the fact that aspects of physical functioning relevant to patients with claudicatio intermittens may be underrepresented in the PLC-questionnaire core module.

When is supervised exercise therapy considered useful in peripheral arterial occlusive disease? A nationwide survey among vascular surgeons.

OBJECTIVES: Although international guidelines state that supervised exercise therapy (SET) should be offered to all patients with intermittent claudication (IC), SET appears to be underutilised in clinical practice. The aim of this study was to document current opinions of Dutch vascular surgeons on SET as treatment option for peripheral arterial occlusive disease (PAOD). MATERIALS AND METHODS: Vascular surgeons and fellows in vascular surgery were asked to complete a 24-question survey either at the 2011 Annual Meeting of the Dutch Society for Vascular Surgery or online. RESULTS: Ninety-one participants, including 83 vascular surgeons (51% of all Dutch vascular surgeons), completed the survey. The respondents would refer 75.4% of newly diagnosed patients with IC for SET. SET was considered less useful in patients with IC and major (cardiopulmonary) co-morbidity or a significant iliac artery stenosis. In critical limb ischaemia, the combination of SET and angioplasty was considered useful in 71.9%. Respondents regarded patient satisfaction (63.3%) and improvement in pain-free or maximal walking ability (26.6%) as clinically most relevant goals of SET. Most (84.4%) agreed that SET should also include lifestyle management. CONCLUSION: Although the vast majority of Dutch vascular surgeons consider SET as an important treatment option for PAOD, SET should receive more emphasis in clinical practice since arguments not to refer for SET are outdated. Furthermore, vascular surgeons agree that lifestyle management should be integrated in SET.

Impact of a rehabilitation program on muscular strength and endurance in peripheral arterial occlusive disease patients.

UNLABELLED: Rehabilitation care and physical exercise are known to constitute an effective treatment for chronic peripheral arterial occlusive disease (PAOD) at the intermittent claudication (IC) stage. Improvements in functional capacities and quality of life have been reported in the literature. We decided to assess the effects of hospital-based exercise training on muscle strength and endurance for the ankle plantar and dorsal flexors in this pathology. PATIENTS AND METHODS: This prospective study included 31 subjects with chronic peripheral arterial occlusive disease (PAOD) and IC who followed a 4-week rehabilitation program featuring walking sessions, selective muscle strengthening, general physical exercise and therapeutic patient education. An isokinetic assessment of ankle plantar and dorsal flexors strength was conducted on the first and last days of the program. We also studied the concentric contractions at the angular velocity of 30°/s and 120°/s for muscle strength and at 180°/s for muscle fatigue. We also measured the walking distance for each patient. RESULTS: Walking distance improved by 246%. At baseline, the isokinetic assessment revealed severe muscle weakness (mainly of the plantar flexors). The only isokinetic parameter that improved during the rehabilitation program was the peak torque for plantar flexors at 120°/s. CONCLUSION: All patients presented with severe weakness and fatigability of the ankle plantar and dorsal flexors. Our program dramatically improved walking distance but not muscle strength and endurance.

The effect of high tone power therapy on gait range in patients with chronic lower limb ischaemia.

BACKGROUND: Pain-related abnormalities of the economy of walking are the most important factor adversely affecting overall physical activity of patients with chronic lower limb ischaemia. These patients are routinely managed conservatively, with the aim of improving pain-free claudication distance. The aim of this study was to examine the impact of HiToP on the functional status of the lower limbs in such patients and look for possible flow dynamics correlates in peripheral microcirculation in the lower limbs. MATERIAL AND METHODS: The study involved 68 patients aged 40-70 years, who were randomly assigned to Group A (experimental) and Group B (control). Study procedures included a treadmill test to determine the claudication distance and the measurement of blood flow in lower limb peripheral microcirculation using laser Doppler flowmetry. The intensity of lower limb pain was also determined. Patients from the experimental group were subjected to a series of HiToP sessions. The control group received mock HiToP (placebo). RESULTS: The claudication distance and maximum walking distance were significantly prolonged only in the HiToP group. With regard to microcirculation flow dynamics, only mean flow values increased substantially, but this was again only observed in the group treated with HiToP. CONCLUSIONS: HiToP makes it possible to improve lower limb function, as evidenced primarily by improved claudication distance, maximum walking distance and improved blood flow parameters in cutaneous microcirculation.

[Unusually favorable recovery from locked-in syndrome after basilar artery occlusion]. / Evolution inhabituellement favorable d'un Locked-in syndrome secondaire a une thrombose basilaire.

Locked-in syndrome (LIS) after basilar artery occlusion is associated with poor prognosis. For a patient with LIS, rehabilitation aims to restore communication, avoid complications, and ensure a certain comfort. We describe a case with remarkable recovery. After 2 years the patient was independent for daily living activities, walks independently and has comprehensible speech.

[Physical activity and peripheral arterial obstructive disease]. / Exercice physique et artériopathie oblitérante des membres inférieurs.

Intermittent claudication (IC) is the most common clinical manifestation of atherosclerotic peripheral arterial disease. Exercise training plays a major role in treating patients with IC. Regular exercise increases functional walking capacity, reduces cardiovascular mortality and improves quality of life. This seems to be achieved by: favorable effect on cardiovascular risk factors, anti-inflammatory effect, increased collateral blood flux, improved rheology profile, endothelial function, fibrinolysis, and muscular metabolism. However, exact mechanisms underlying beneficial effect of exercise remain largely unknown. Exercise modalities will be discussed in this article.

A patient's experience as a research participant.

The author presents a brief synopsis of an interview with a research participant, highlighting the individual's insights and recommendations both for participants and for researchers.

The influence of a long term exercise program on lower limb movement variability and walking performance in patients with peripheral arterial disease.

The purpose of this study was to examine the effects of a 12month exercise program on lower limb movement variability in patients with peripheral arterial disease (PAD). Participants (n=21) with an appropriate history of PAD and intermittent claudication (IC) volunteered for this study and were randomly allocated to either a control group (CPAD-IC) (n=11), which received normal medical therapy and a treatment group (TPAD-IC) (n=10), which received normal medical therapy treatment and a 12month supervised exercise program. All participants underwent 2D joint angular kinematic analysis during normal walking to assess lower limb movement variability and walking speed. Between-group differences were analyzed via mixed measures ANOVA. The 12month supervised exercise program made no significant impact on the lower limb movement variability or walking speed of the TPAD-IC group as determined by either intralimb joint coordination or single joint analysis techniques. Long term supervised exercise programs do not appear to influence the lower limb movement variability of PAD-IC patients.

[Limb amputations on the vascular patient]. / Majoramputationen beim Gefässpatienten.

For the rehabilitation after limb amputation is an as possible long stump necessary including good wound healing. For the vascular patient are the following amputation levels suitable: syme amputation, amputation of the lower leg, knee exarticulation, above knee amputation and very seldom hip exarticulation. Indication, surgical technics and following treatment are demonstrated.

Outpatient rehabilitation in patients with coronary artery and peripheral arterial occlusive disease.

OBJECTIVE: To assess participation rates and outcome in outpatient cardiac rehabilitation (OCR) of patients with peripheral arterial occlusive disease (PAOD). DESIGN: Prospective cohort study. SETTING: Referral center, ambulatory care. PARTICIPANTS: All patients undergoing OCR at 2 university hospitals in Switzerland from March 1999 to August 2005. INTERVENTION: OCR during 3 months. MAIN OUTCOME MEASURES: Primary endpoints were workload during bicycle stress test and quality of life (QOL), both at the end of OCR. Secondary endpoints were complications during OCR and termination of OCR. RESULTS: Of 1508 patients, 99 (7%) had PAOD (27 with Fontaine stage I, 69 with stage II, 3 with stage III). Patients with PAOD were older, had more cardiovascular risk factors, and were more likely to have undergone cardiac bypass grafting than those without PAOD. PAOD patients at OCR entry achieved a lower exercise workload than non-PAOD patients (PAOD patients, 105+/-31W and 69%+/-17% of target vs non-PAOD patients, 125+/-38W and 79%+/-19%; P<.001) but both groups achieved similar gains in exercise capacity at the end of OCR (PAOD patients, 126+/-44W and 82%+/-25% vs non-PAOD patients, 153+/-48W and 98%+/-24%; P<.001). For both groups, QOL was similar at baseline and follow-up, and improved equally in most dimensions. OCR was discontinued more often in patients with PAOD than in those without (18% vs 10%, P=.018). Cardiac and noncardiac complication rates were similar. CONCLUSIONS: Patients with PAOD undergoing OCR have a similar benefit but higher dropout rates than other patients. Thus, PAOD patients should be encouraged to participate in OCR, possibly by creating specifically tailored concepts.

Periodic whole body acceleration: a novel therapy for cardiovascular disease.

BACKGROUND: Periodic whole body acceleration in the spinal axis (pGz) applied by a motion platform is a novel treatment modality that induced endothelial nitric oxide release into the circulation of animals, healthy subjects and patients with inflammatory diseases during single treatment sessions in previous studies. We hypothesized that patients with advanced arteriosclerotic diseases who are not candidates for a surgical intervention would clinically benefit from repeated pGz treatments over several weeks through improvement of endothelial function. PATIENTS AND METHODS: 11 patients, 5 men (37 to 71 y) with stable ischemic heart disease, LVEF < 35%, NYHA stage > II, and 6 patients (51 to 83 y, 1 woman) with intermittent leg claudication, Fontaine stage II, were enrolled after optimization of pharmacological therapy. PGz was applied for 40 min, 5 days/week during 5 weeks. Quality of life (SF-36 questionnaire), exercise performance, and endothelial function were assessed at baseline, during the treatment period, and 4 weeks after discontinuation of pGz. RESULTS: PGz was well tolerated. In heart failure paitents, pGz therapy improved quality of life, increased 6 min walking distance by a mean +/- SE of 105 +/- 24 m, and improved postischemic skin hyperemia (p < .05 in all instances). In 4 of 6 patients with intermittent claudication, quality of life, treadmill walking distance and post-ischemic skin hyperemia improved with pGz therapy (p < .05). Four weeks after discontinuation of pGz, most therapeutic effects had vanished in both patient groups. CONCLUSIONS: In patients with severe heart failure and with leg claudication who remain symptomatic despite maximal medical therapy and who were not candidates for surgery, periodic acceleration applied over several weeks improved quality of life and exercise capacity. The clinical benefits appear to be mediated through improved endothelial function.