What is intermittent claudication?
It is estimated that there were 236.62 million adults with PAD (increasingly also referred to as lower extremity artery disease or LEAD) and today this number is even higher (a rising trend for the foreseeable future). Yet from a statistical standpoint, only a very few of those individuals will be symptomatic, i.e. have intermittent claudication. Studies have found that only 10% of all patients with PAD are symptomatic, 40% are entirely asymptomatic and the remaining 50% have atypical pain symptoms that could be attributed to other medical conditions.
From a physiological standpoint, intermittent claudication is caused by a complex interaction of several mechanisms, including arterial obstruction, vascular dysfunction, inflammation, reduced microvascular flow and impaired angiogenesis, and altered skeletal muscle function. It is a daunting array of issues, but one that can initially be managed by conservative, non-surgical means—if the disease (PAD) is promptly diagnosed.
What exercises to recommend for intermittent claudication?
Patients with PAD benefit from two types of physical exercises: supervised and unsupervised. In 2012, the National Institute for Health and Care Excellence in the UK published a clinical guideline on the diagnosis and management of PAD that recommends a three-month supervised exercise programme (SEP) as the first step in (conservative) management of intermittent claudication. The use of vasodilators and revascularisation surgery should only be pursued when the exercise fails to alleviate the symptoms. Unsupervised exercise is the second-best option, despite it being less effective than SEP, and should be likewise pursued. It is also more likely to benefit a larger number of patients as, for example, in the UK, only 38.5% of vascular units have access to an SEP.
Unsupervised exercise should simply consist of walking at a speed the patient can maintain for 3–10 minutes until moderate to strong pain develops and then rest until the pain subsides: the patient should repeat the entire process until he cumulatively walks at least for 30 to 60 minutes in one session (several intervals of walking/resting). The patient should strive to do at least three to five sessions per week to reap the maximum benefits.
What are the benefits of exercise?
The beneficial effects of exercise on PAD/intermittent claudication were known back in the 1960s when a study published in The Lancet reported improvements in pain relief and maximum walking distance following a six-month regime of interval walking. Since then, an even larger body of research has been gathered, supporting the rationale of physical exercise for patients with intermittent claudication. In general terms, the patient should be informed that exercise reduces pain, improves cardiovascular health, reduces the need for vascular procedures, improves sleep and psychological well-being (mood), and helps in maintaining a healthy weight. Still, some may need more persuasion, information, or guidance.
Regular physical exercise, particularly if performed under professional supervision, is paramount for the effective management of intermittent claudication, followed by unsupervised activity that should still be conducted within prescribed guidelines.
