Scientific evidence for supervised exercise therapy


‘Stepped care’: supervised exercise therapy as primary treatment

The treatment of patients with peripheral artery disease (PAD) focuses on cardiovascular risk management and symptom relief. Extensive scientific research from the past decades has shown that supervised exercise therapy (SET) is an effective treatment. Logically, SET is recommended as primary treatment by international guidelines on PAD treatment. The physiotherapists of ClaudicatioNet provide therapy according to the symptomatic PAD guideline of the ‘Royal Dutch Society of Physiotherapists’, which is based on the latest scientific insights. Consistent with the ‘stepped care approach’, a vascular intervention is only considered if the results of supervised exercise therapy are insufficient or if symptoms are (severely) increasing.

Importance of supervision

The successful results of (unsupervised) walking therapy in PAD patients was initially described in 1898 by Wilhelm Erb (1).* The importance of supervision in walking therapy was first investigated in a Dutch multicenter randomized controlled trial, the EXITPAD-trial (2). In this trial, SET was compared to a simple walking advice. SET led to a significantly larger improvement in walking distance and quality of life compared to walking advice. As the study design provided the second highest ‘level of evidence’ (level Ib), this publication provided the proof that SET should be available worldwide. In a 2006 Cochrane review, Bendermacher et al. (3) concluded that three months of SET results in an additional increase in walking distance of 150 meters compared to non-supervised walking therapy. An update of this review by Hageman et al. (4) demonstrated that the additional increase even appears to be 210 meters. Moreover, this effect sustains up to at least one year after the start of treatment.

Hospital- versus community-based

Earlier studies on SET generally provided the treatment  in-hospital. Ideally, SET is delivered as close as possible to the patient’s home environment, as this is accompanied by higher compliance and lower costs (e.g. transport costs) for the patient (5). Research of Kruidenier et al. from 2009 (5) showed that the effect on walking distance is similar for community-based SET and in-hospital SET. Furthermore, in 2015, Gommans et al. (6) analyzed 82.725 hours of supervised training in which only eight non-fatal incidents occurred in total. Therefore, they concluded that community-based SET is safe and can be prescribed for PAD without prior cardiac screening. Based on these publications, ClaudicatioNet initiated a community-based SET program in the Netherlands.

SET versus invasive treatment

In the past, invasive treatment (i.e. percutaneous transluminal angioplasty or surgical bypass) was generally offered as primary treatment for PAD. According to current (inter)national guidelines, invasive treatment should be reserved for individuals in which the results of SET are insufficient. These guidelines are based on recent scientific insights.

In comparison with invasive treatment, SET leads to at least comparable results for increasing walking distance and quality of life (7). 19% of patients require invasive treatment (thus as secondary treatment) within two years after a SET program. Notably, of the patients who received primary invasive treatment, 19% needed a second intervention within two years (8)
 
With comparable effectiveness, factors such as costs play an important role in the choice of treatment. Spronk et al. (9) analyzed the cost-effectiveness of SET versus endovascular revascularization in PAD patients. One year after the start of treatment, no significant difference in walking distance and quality of life between the two groups exists. However, endovascular treatment is associated with significantly higher costs per patient. Fokkenrood et al. (10) demonstrated that the ‘stepped care model’ can lead to savings of 33 million euros on an annual basis in the Dutch healthcare system. These results have been confirmed for the longer term by means of a calculation model by Van den Houten et al. (11). A more detailed overview of the scientific evidence behind ClaudicatioNet can be found in an overview article of Hageman et al. (12)

Lifestyle

Atherosclerosis is a systemic disease that is strongly influenced by modifiable risk factors. Therefore, sustainable treatment results can only be achieved if the patient integrates physical activity into daily life. The same applies to other aspects of lifestyle, such as a healthy diet and smoking cessation (13). In addition to these ‘physical risk factors’, psychosocial risk factors (e.g. emotional disorders, depression, anxiety, pessimism, chronic stress) seem to have an equally large effect on the risk of developing cardiovascular diseases (14). For example, meditation seems effective in minimizing these risk factors. This is one of the reasons why the American Heart Association recommends meditation as an adjunct to current therapies in cardiovascular risk management (15).

* Erb W. [About intermittent walking and nerve disturbances due to vascular disease]. Deutsch Z Nervenheilk 1898;13:1-76. [Article in German]