Connecting the past to the present: A historical review of exercise training for peripheral artery disease

Abstract

Peripheral artery disease (PAD), a prevalent manifestation of atherosclerosis, is associated with increased cardiovascular morbidity and mortality as well as decreased functional ability. Exercise training for PAD is acknowledged to be a highly effective treatment, which improves walking ability and cardiovascular risk. The historical development of this treatment has not been the focus of a report. Therefore, we present a historical review of research on exercise training for PAD. Overall, this body of knowledge has provided strong evidence of the efficacy of supervised exercise training (SET) to improve walking ability for patients with claudication due to PAD. SET, using intermittent bouts of walking exercise to moderate claudication pain on a treadmill, is considered the most efficacious mode of exercise to improve walking ability in patients with claudication. This compelling evidence published over the past 60 years was evaluated by the Centers for Medicare & Medicaid Services in 2017, which culminated in a national coverage determination for SET to improve symptomatic PAD. Future directions include determining optimal delivery strategies for SET and further elucidation of the mechanisms of improvement in walking ability resulting from SET. In addition, alternative forms of exercise should be evaluated and effective home- and community-based exercise interventions should be assessed. There is an enormous need to increase the inclusion of women and racial and ethnic minority groups in studies. It is to be hoped that researchers will continue with new innovative research and persistence in the treatment of claudication due to PAD.

Exercise therapy for peripheral artery disease in 2022: Progress and a prediction

“…10 Thus, recommendations for medical therapies to improve disability in PAD have completely reversed course, from a bed rest prescription in the 1950s to randomized trial evidence 70 years later demonstrating that inducing ischemic leg symptoms during exercise is necessary to improve objectively measured walking performance in a home-based exercise intervention for PAD. 9,10 Bronas and Regensteiner's review emphasizes that future studies of exercise therapy for PAD should include adequate representation of women and minority populations. 9 Importantly, some recent randomized trials of exercise for PAD have successfully included large proportions of participants who were women or underrepresented minorities.…”

“…10 Thus, recommendations for medical therapies to improve disability in PAD have completely reversed course, from a bed rest prescription in the 1950s to randomized trial evidence 70 years later demonstrating that inducing ischemic leg symptoms during exercise is necessary to improve objectively measured walking performance in a home-based exercise intervention for PAD. 9,10…”

“…They review results of more recent randomized trials documenting that home-based exercise can meaningfully improve walking performance in PAD when programs incorporate behavioral change methods. 1,9 Progress in exercise therapy for PAD over the past 75 years may be best illustrated by contrasting the recommendation of ‘bed rest’ for treating disabling claudication in the 1950s to the recent findings from a multicentered randomized clinical trial of 305 participants, which demonstrated that inducing ischemic leg symptoms during walking exercise was necessary to achieve objective improvement in walking performance. 10 Specifically, the LITE multicentered randomized clinical trial of 305 participants with PAD demonstrated that, compared to a nonexercise control group, home-based exercise that induced ischemic leg symptoms significantly and meaningfully improved the 6-minute walk distance and maximal treadmill walking time, whereas home-based walking exercise conducted without ischemic leg symptoms had no effect on these outcomes.…”

“…Bronas and Regensteiner reviewed the history of scientific investigation of exercise training for people with PAD over an approximately 75-year period, beginning with the 1940s and 1950s. 9 They discuss that the earliest recommended therapies for PAD-related disability were bed rest and physical activity avoidance. Bronas and Regensteiner trace the history of exercise therapy for PAD through the late 20th and early 21st centuries, when initial small clinical trials, often with fewer than 40 PAD participants, first documented the functional benefits of supervised exercise but eschewed home-based exercise as ineffective.…”

“…9,10 Bronas and Regensteiner's review emphasizes that future studies of exercise therapy for PAD should include adequate representation of women and minority populations. 9 Importantly, some recent randomized trials of exercise for PAD have successfully included large proportions of participants who were women or underrepresented minorities. [10][11][12] For example, the LITE randomized trial of 305 participants with PAD included 146 (47.9%) women and 181 (59.3%) participants who were Black.…”