This document summarizes an evidence-based seminar on peripheral arterial disease (PAD). It defines PAD as blocked arteries in the legs causing leg pain with walking. Early PAD symptoms include cramping and fatigue in the legs when walking. The document discusses identifying PAD using questionnaires and ankle-brachial indexes. Interventions discussed include exercise, smoking cessation, medications, and angioplasty/surgery. Evidence from randomized controlled trials shows supervised exercise improves walking ability in PAD patients more than usual care.

1. Evidence-based seminar
GUIDE: DR.MANOJ KUMAR (MPT)
PRESENTED BY: DR.SHILPA PRAJAPATI

2. CONTENTS
 INTRODUCTION
 EPIDIMIOLOGY
 IDENTIFICATION OF SUBECTS WITH
EARLY PERIPHERAL ARTERIAL DISEASE
 INTERVENTION
 EVIDENCES
 CONCLUSION

3. INTRODUCTION
Normal Blood Vessel
Atherosclerosis

4. INTRODUCTION
 When the arteries to the legs become blocked, the
muscles are deprived of oxygen and cause
significant symptoms, is called Peripheral Arterial
Disease or PAD.
 In its early stages, common symptoms of poor leg
circulation are cramping, fatigue, heaviness, pain or
discomfort in the legs and buttocks during activity.
 This usually subsides when the activity stops. It’s
called “intermittent claudication”.
 The natural history of this condition is uncertain.

5. INTRODUCTION
 Housley et al (1988) indicate that “stop smoking and keep
walking”, the standard first line of management.
 The risk of the disease progressing to the point where operative
intervention is required is very small.
 Over the five years of follow-up in the Edinburgh Artery
Study, fewer than 9% of affected individuals required surgical
intervention (Leng et al 1996).
 Candidate endpoints include the presence of intermittent
claudication, the maximum walking distance before onset of
intermittent claudication, and the ankle:brachial index of systolic
blood pressure.

6. INSIDENCE

7. INSIDENCE
 All epidemiologic cross-sectional studies show that in the
general population asymptomatic peripheral arterial
disease (PAD) is more common than symptomatic PAD.
 Less than half of all PAD patients have symptoms of
intermittent claudication.
 When the disease progresses to involve more arteries
farther down the leg, then the symptoms can be more
severe, such as pain in the foot, the development of
ulcerations, or advanced changes such as gangrene in
the toes.
 PAD is part of a systemic illness caused by

8. IDENTIFICATION OF
SUBJECTS

9. IDENTIFICATION OF
SUBJECTS
 Identifying PAD while asymptomatic or early stage may
be life-saving for patient
 A classification of either
definite intermittent claudication or
atypical intermittent claudication on the
Edinburgh Claudication Questionnaire
(Leng et al 1992).
or
 An ankle-brachial index of systolic blood pressure of 0.9
or less in either leg, indicating a reduced blood flow to
the lower limbs.

10. IDENTIFICATION OF
SUBJECTS
 EDINBURGH QUESTIONNAIRE‘S
(1) Do you get a pain or discomfort in your leg(s) when you walk?
Yes/No
I am unable to walk
If you answered "Yes" to question (1) - please answer the following
questions. Otherwise you need not continue.
(2) Does this pain ever begin when you are standing still or sitting?
Yes/No
(3) Do you get it if you walk uphill or hurry? Yes/No
(4) Do you get it when you walk at an ordinary pace on the level?
Yes/No
(5) What happens to it if you stand still?

11. IDENTIFICATION OF
SUBJECTS
(6) Where do you get this pain or discomfort? Mark the place(s) with "x"
on the diagram below
 Definition of positive classification requires all of the following
responses:
 'Yes' to (1), 'No' to (2), 'Yes' to (3),
 And 'Usually disappears in 10 minutes or less' to (5);
 'No' to (4) = grade 1 and 'Yes' to (4) = grade 2.
 If these criteria are fulfilled, a definite claudicant is one who indicates
pain in the calf, regardless of whether pain is also marked in other
sites.
 A diagnosis of atypical claudication is made if pain is indicated in the
thigh or buttock, in the absence of any calf pain. Subjects should not
be considered to have claudication if pain is indicated in the
hamstrings, feet, shins, joints or appears to radiate, in the absence of

12. IDENTIFICATION OF
SUBJECTS

Ankle : brachial index
 >1.2 Arterial disease
 1.19-0.95 Normal
 0.94-0.75 Mild arterial disease +
intermittent claudication
 0.74-0-50 Moderate arterial disease + rest pain
 <0.50 Severe arterial disease

13. INTERVENTION

14. INTERVENTION
 Considered outcome goals for peripheral artery
disease include:
 Relieve the pain of intermittent claudication.
 Improve exercise tolerance by increasing the walking
distance before the onset of claudication.
 Prevent critical artery occlusion that can lead to foot
ulcers, gangrene, and amputation.
 Treatments of peripheral artery disease include
lifestyle measures, supervised
exercises, medications, angioplasty, and surgery

15. INTERVENTION
 Information on cessation of smoking (where
applicable), because it is associated with reduction
of elevated serum cholesterol levels (Cahan MA et
al,1999).
 Lipid-lowering therapy can include
atherosclerotic regression in the
diseased arteries (Wittlinger,2004).
 Men were referred to hydrotherapy classes or
special exercise sessions (Bess Fowler).

16. INTERVENTION
 Walking Exercise:
 Exercise and walking regularly, at least 30 continuous
minutes three times per week, can help improve your
symptoms by encouraging your body to form new, collateral
blood vessels. With a structured walking program, many
patients experience a dramatic increase in the distance they
are able to walk without pain.
 Patient should also be introduce to a
vascular rehabilitation program, Involving a weekly
exercise group of 45 minutes supervised.
 The session included a warm-up phase of stretching the
calf, hamstring and upper limb muscles, followed by 20
minutes of fast walking and ending with a cool-down

17. INTERVENTION (Susan B O’Sullivan)
Weak Exercises Intensity Ambulation
1-3 Isometrics: quadriceps and 3 sets,15 reps, 1/8 or ½ or just
hamstrings 2-3times daily prior to point of
AROM: ankle pumps, heel claudication
slides, heel and toe raises in
sitting
4-6 3sets, 20reps, ½ - 1 mile or to
AROM and resistive exercise: 2-3times daily point of
Add to above exercises- claudication
standing toe raises, wall squats
7-10 3sets, 20reps,
Continue resistive exercises, 3times daily 1+ miles or
increase resistance as distance as
tolerated tolerated

18. EVIDENCES
 1. Leng GC, Fowler B, Ernst E, Cochrane Database
Syst Rev. 2008.
 Exercise for intermittent claudication
 Randomized trials of exercise regimens in almost 1200
male and female patients with leg pain on walking
(intermittent claudication). All recommended at least two
weekly sessions of supervised exercise.
 CONCLUSIONS:
 Exerciseprogrammes were of significant benefit compared
with placebo or usual care in improving walking time and
distance in patients with leg pain from IC.

19. EVIDENCES
 2. Mary M. et al, Northwestern University Feinberg
School of Medicine, Chicago (Jan. 20, 2009)
 Treadmill Exercise Improves Walking Endurance For
Patients With Peripheral Arterial Disease
 randomized controlled clinical trial included 156
patients, assigned to supervised treadmill exercise, to
lower extremity resistance training or to a control
group, for six months.
 CONCLUSIONS:
 Supervised treadmill training improved 6-minute walk
performance, treadmill walking performance, brachial artery
flow-mediated dilation, and quality of life but did not improve
the short physical performance battery scores of PAD.

20. EVIDENCES
 3. M.P. Mosti, E.Wang, Ø.N.
Wiggen, J.Helgerud, J.Hoff 16 MAR 2011
 Concurrent strength and endurance training
improves physical capacity in patients with
peripheral arterial disease
 Plantar flexion (PF) endurance training and maximal
strength training (MST) induce distinct types of
improvements in walking ability in PAD.
 Ten patients with PAD underwent 8 weeks of concurrent
leg press MST and PF training, three times a week. The
reference group (n=10) received recommended exercise
guidelines.
 Conclusion

21. EVIDENCES
 4. Maggie A Cunningham et al Department of
Psychology, University of Stirling, UK October
7, 2010.
 Increasing walking in patients with intermittent claudication:
Protocol for Randomized Control Trial
 This measure gives an accurate idea of how far a patient can walk
before they experience claudication pain, and before they have to
stop, it does not give any idea of how much walking the patient
does in their day to day life, and therefore lacks ecological validity.
For this reason, we have decided to measure day-to-day walking
using pedometers. Participants will be asked to wear a pedometer
for one week at each time point, and their mean daily steps will be
calculated by averaging the six days with the highest number of
steps.
 Conclusion
 psychological intervention increase walking in patients with intermittent

22. EVIDENCES
 5. J. Wind, M.J.W. Koelemay, 2007 Jul
 Exercise Therapy and the Additional Effect of
Supervision on Exercise Therapy in Patients with
Intermittent Claudication. Systematic Review of
Randomized Controlled Trials
 evaluating 761 patients. In the studies comparing
supervised exercise to standard care the weighted mean
difference in pain free walking distance (PWD) and
absolute walking distance (AWD).
 Conclusion:
 Exercise therapy increases the Pain free Walking Distance
and Absolute Walking Distance in patients with intermittent
claudication. Supervised exercise therapy increases the Pain
free Walking Distance and Absolute Walking Distance more

23. EVIDENCES
 6. McDermott MM et al , 2006 Jan
 Physical performance in peripheral arterial disease:
a slower rate of decline in patients who walk more.
Prospective cohort study with a median follow-up of 36
month
 patients with PAD, self-directed walking exercise
performed at least 3 times weekly
 CONCLUSION:
 significantlyless functional decline during the subsequent
year. Similar trends were observed in the subset of
asymptomatic patients with PAD. These findings may be
particularly important for the numerous patients with PAD who
do not have access to supervised walking exercise programs.

24. EVIDENCES
 7. Streminski JA, de la Haye R, Rettig K, Kuntz G 1992
 Comparison of the effectiveness of physical training with
parenteral drug therapy in Fontaine stage IIb peripheral
arterial occlusive disease.
 30 patients were included in each of the three therapy
groups. Over a period of four weeks each patient received
daily therapy.
 Patients of group I received a daily intravenous infusion of
250 ml Actovegin 20% p.i. the patients in group II received
this medication by the intraarterial route. The third patient
group received standardized vascular training
 The conclusion
 Of the present study are discussed having in mind physical therapy

25. EVIDENCES
 8. Tisi PV, Shearman CP. 1998 Jan.
 The evidence for exercise-induced inflammation in
intermittent claudication: should we encourage
patients to stop walking?
 Exercise to the onset of calf pain results in an
inflammatory response with free radical
formation, neutrophil activation and systemic vascular
endothelial damage.
 CONCLUSIONS:
 Further studies are needed to determine the effect of long-
term exercise training on exercise-induced inflammation in
claudication.
 Early work suggests that exercise attenuates this
inflammatory response. If this were confirmed then it would

26. CONCLUSION
 A combination of simple and safe interventions
that are readily available in the community
through physiotherapists and movement
practitioners has the potential to improve early
peripheral arterial disease dramatically.

27. THANK YOU
!