1. Exercise Management Peripheral Arterial Disease Chapter 15

2. Exercise Management Pathophysiology Peripheral arterial disease (PAD) results from stenoses and occlusions of the arteries of the lower extremities, causing a reduction in blood flow beyond the obstructions. The severity of PAD may be classified into the following categories according to recent guidelines: – –Grade 0 = asymptomatic – –Grade 1 = intermittent claudication – –Grade 2 = ischemic rest pain – –Grade 3 = minor or major tissue loss from the foot

3. Exercise Management The primary effect of PAD on a single exercise session is the development of claudication pain in the leg musculature during exercise because of insufficient blood flow.claudication The time and/or distance to onset and to maximal claudication pain during walking are used as criteria for assessing the functional severity of disease. One common diagnostic technique is the ABI (see p.114) VideoABIVideo FYI – review management and medications, p.115.

4. Exercise Management Effects of Exercise Training   intermittent claudication in clients with PAD is improved through physical conditioning. Proposed mechanisms for an increase in exercise tolerance   increase in leg blood flow;   more favorable redistribution of blood flow;   improved hemorheological and fibrinolytic properties   of blood (e.g., reduced viscosity);   greater reliance upon aerobic metabolism because of a higher concentration of oxidative enzymes;   less reliance upon anaerobic metabolism;   an improvement in the efficiency of waking   economy and oxygen uptake kinetics; and   increased free-living daily energy expenditure.

5. Exercise Management Recommendations for Exercise Testing The primary objectives of a treadmill test for clients with PAD are to:   obtain reliable measures of claudication pain times   obtain reliable measures of ankle pressure following exercise   assess whether coronary artery disease is present.

6. Exercise Management Recommendations for Exercise Testing (see recommendations p.116, next slide)   The treadmill test should have small incremental changes that will be sensitive to the onset of claudication   ABI index should be calculated, and noted for claudication scores   Claudication scale should be used, HR and Brachial BP are recorded during the last minute of each stage.   Recovery should be supine (15 min), Ankle and Brachial BP recorded.

7. Exercise Management

8. Recommendations for Exercise Programming (see Table 15.2, p 117, next slide)   Exercise programs for clients with PAD should be designed with a goal of improving claudication pain symptoms and reducing cardiovascular risk factors   Most patients should do interval walking or stair climbing three times a week, at an intensity that causes pain of a 3 score on a 4-point scale.   Program will promote claudication pain within 5 minutes, and allow for full recovery before the next exercise interval begins.

9. Exercise Management

10. Recommendations for Exercise Programming There are circumstances in which it is inappropriate for clients with PAD to exercise. – –Exercise training should not be performed until medical clearance, based on a physical exam, blood screening, and graded exercise test has been completed. – –Exercise should not be performed when there are concomitant comorbidities that may limit exercise tolerance.

11. Exercise Management Recommendations for Exercise Programming Special considerations for exercise programming include the following: Improvement in functional capacity may unmask coronary ischemia Changes in comorbidities should be monitored Cold weather may worsen symptoms, necessitating a longer warm-up.

12. Exercise Management End of Presentation