P.A.D.

Exercise Group
Outcome Audit

Pradeep Chockalingam
Senior Physiotherapist

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Note

 This audit was presented in North-East

Regional Vascular Conference at Freeman
Hospital, Newcastle upon Tyne, U.K on
November 2006.

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Aim of this audit

 To find out the feasibility & evidence behind

the new outcome measures.

 To assess the effectiveness of the new

outcome measures.

 To analyse the effectiveness of the exercise

group.

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P.V.D or P.A.D ?

 The Intermittent Claudication (I.C) is caused

by the atherosclerosis of the arteries of lower
limbs. (Hiatt WR et al 1990)
 Vascular is a global term which includes
arteries and veins.
 As I.C is caused by the disease of the
arteries, Peripheral Arterial Disease (P.A.D) is
the appropriate term.

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Why Exercise group for P.A.D?
 Regular exercises improves the walking
ability and delays the onset of claudication
pain.
 Exercise is an integral part of P.A.D
treatment.
 Supervised exercise is superior than the
home based exercise programme.
(Hirsch AT et al 2006, Leng GC et al 2000 & Bendermacher BLW et al 2006)
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What participants do ?
 It’s a seven week exercise programme, two
sessions per week
 First and last classes dedicated for Pre &
Post rehab subjective & objective
assessment/data collection.
 12 different exercise stations. Participants
work at each station for five minutes for
approx 45 minutes.

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What’s New ?
 Introduced new Evidence Based Objective &
Subjective outcome measures.
 Objective: 6-Minute Walk Test.

 Subjective: Walking Impairment

Questionnaire.
 New Database to collect and analyse data
quicker & accurate.

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 Why 6-MWT than Treadmill ?
 Sensitive, Safe, Simple & Cost effective.

 6 MWT is the best alternative to the Treadmill

Test & equally sensitive.
 Treadmill test may not reflect daily activity.

 More acceptable by Older people as walking

is a day to day activity.
 Suitable for the community setup.

(Enright PL et al 2003, Scherer SA 2004, Ohtake PJ 2005, Montgomery PS et al 1998)

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Why W.I.Q than SF36 ?

 Disease specific.

 Simple and straight forward.

 Easy to complete compared to SF-36.

 Informative and able to assess the patients

point of view.

 Able to assess other limiting factors.

(Regensteiner JG et al 1990, Scherer SA 2004)

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The Group

 Number of groups included in this audit = 3

 Total number of participants recruited to this

three groups = 32

 Total number of participants completed the

seven week programme = 25 78%

 Total number of drop-outs = 7 22%

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The Group

 Sex ratio: 2.5 Male:1 Female

 Average age: 70 Years

 Average height: 171 Centemeters

 Average weight: 87 Kilogrames

 Average 75% of predicted maximum

6-MWD: 332 Meters (Enright PL et al 2003)

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Claudication Distance

185

180

175 Pre
Post
170

165
Claudication Distance

Average Pre rehab (6MWT) : 172 Meters

Average Post rehab (6MWT) : 184 Meters
(Difference: +12 Meters OR +24%)
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Pre & Post rehab Claudication
Distance Difference by %
Decline
3
7
No Change
10
5
Improvement

Remakrable
Improvement

< -9% =7
-9% to +9% =5
10% to +99% = 10
> +99% =3
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Total 6-Minute Walk Distance

310
305
300
Pre
295
Post
290
285
280
Total 6-MWD

Average Pre rehab: 290 Meters

Average Post rehab: 306 Meters
(Difference: +16 Meters or +8%)
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Pre & Post rehab Total 6-MWD
Difference by %
Decline
1 2
8 No Change
14
Improvement

Remarkable
Improvement

< -5 % =2
-5 % to +5 % = 14
> +5 % to +49 % =8
>+49 % =1
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Total number of rest taken

20

15
Pre
10
Post
5

0
Rest

Pre rehab: 18 Average: 0.7

Post rehab: 10 Average: 0.4
(Difference: -8 or +56%)
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 What’s the Standards ?

 *Claudication distance improvement by 179%.

 *Total walking distance improvement by 122%.

(For approx 36 sessions of supervised exercise)

 Similar reflection on the W.I.Q. questionnaire

compared to the 6-MWT results.

(*Gardner AW et al 1995,*Schainfeld RM 2001 , Regensteiner JG et al 1990 & Tsai JC et al 2002)

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What’s the Result ?
 Claudication distance Predicted 36 sessions
improvement = 24% result
 Total walking distance  Claudication distance
improvement = 8%
improvement = 72 %
(For 12 sessions of
supervised exercise)  Total walking distance

 Similar reflection on the improvement = 24 %

W.I.Q questionnaire
compared to the 6-
MWT outcome = 50%

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 Analysis of Data
180
160
140
120
100
Standards
80
Result
60 Predicted
40
20
0
Claudication Total 6-MWD W.I.Q
Distance
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Any Improvement ?

 Yes, signs of improvement were noted as

Stewart KJ et al 2002 states “benefits have

been observed as early as four weeks”.

 But results were not up to the standards

mentioned.

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Why Shortfall ? (Duration)

 Duration: Very short duration, excluding the

first & the last sessions only six weeks of two

sessions per week.

 Evidence suggest minimum of three months

with three sessions per week.

(Leng GC et al 2000, Hirsch AT et al 2006)
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Why Shortfall ? (Level of Exercise)

 Level of exercise: Mild level of exercise.

 Papers used intermittent treadmill walking to

maximal tolerance level of pain for approx 30
to 45 minutes per session. (Hiatt WR et al 1990 & 1994)

 The above is not practical, which may leads

to less compliant from the participants (Hunt D et al

1999) and high dropout rate.

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Why Shortfall ? (Participants)

 In most studies participants have had only mild

to moderate claudication only. (Stewart KE et al 2002)

 Our participants were with moderate or severe

claudication and with multiple mobility limiting

factors.

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Why Shortfall ? (6-MWT)
 Due to time factor unable to do Pre & Post
rehab assessment one person at a time as
per the guideline.
 Distraction of the examinee by the other
participants (mainly during Post rehab)
 Unable to control environment factors of the
hall (Temperature & Humidity level).
 Using lots of different examiners.

(ATS Statement 2002)

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Why Shortfall ? (Q.o.L)

 No one walk with a yard stick (Participants)

 Over or under predict their own performance

(mainly during Pre rehab) (Enright PL 2003)

 U.S based Questionnaire. Therefore did few

modification to suite here.
 Due to geography of Gateshead most of the
participants struggle to answer properly.

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What we have achieved by the new
Outcome Measures ?
 Evidence based and most appropriate for this
group of patients.
 Sensitive, Safe and Simple.
 Well tolerated by the patients and cost
effective.
 Able to collect and analyse various data at
one time.
 Able to assess patients perception of other
mobility limiting factors.

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Suggestions / Recommendations

 Increasing the duration of the group by three

months & three sessions per week. (Gardner AW et al

1995, Leng GC et al 2000, Chockalingam P 2006)

 Replace the resistance exercise (Arm weights,

Teraband) stations with more functional
exercise. (Hiatt WR et al 1994 & Stewart KJ et al 2002)

 Minimising the examiners. (ATS Statement 2002)

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Suggestions / Recommendations

 Suggesting participants to work to the level 3

of pain & to the perceived exertion level of 4
to 5. (Gardner AW et al 1995 & Leng GC et al 2000)
 Conceder altering the standard to local &
feasible level for further audit due to vast
difference and limitations in practice
compared to the evidence.

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Reference
 ATS Statement 2002: Guidelines for the Six-Minute Walk Test: American
Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117.
 Bendermacher BLW et al 2006; Supervised Exercise Therapy versus Non-
Supervised Exercise Therapy for Intermittent Claudication; The Cochrane
Database of Systematic Reviews; Iss-2, No CD005263.pub2
 Chockalingam P 2006: P.A.D. Exercise Group Patient Questionnaire &
Documentation Audit: Gateshead Health NHS Foundation Trust.
 Enright PL et al 2003; The 6-min Walk Test: A Quick Measure of Functional
Status in Elderly Adults. Chest; Vol 123; Page 387-398.
 Enright PL 2003; The Six-Minute Walk Test: Resp Care; Vol-48,No-8, 783-785.
 Gardner AW et al 1995; Exercise Rehabilitation Programs for the Treatment of
Claudication Pain: A Meta-Analysis: JAMA; Vol-274, No-12, 975-980.
 Hiatt WR et al 1990; Benefits of Exercise Conditioning for Patients with
Peripheral Arterial Disease; Circulation; Vol-81, No-2;602-609.

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Reference
 Hiatt WR et al 1994; Superiority of treadmill walking exercise versus Strength
training for patients with peripheral arterial disease. Implications for the
mechanism of the training response: Circulation; Vol-90, 1866-1874.
 Hiatt WR et al 1995; Clinical Trials for Claudication: Assessment of Exercise
Performance, Functional Status, and Clinical End Points; Circulation; 92:614-
621.
 Hirsch AT et al 2006; ACC/AHA Guidelines for the management of Patients with
Peripheral Arterial Disease (Lower Extremity, Renal, Mesentric, and Abdominal
Aortic): Journal of the American College of Cardiology; Vol-47, No-6, 1239-1312.
 Hunt D et al 1999; Intermittent claudication: Implementation of an exercise
programme. Treatment report; Physiotherapy; Vol-83, No-3, 149-153.
 Leng GC et al 2000; Exercise for Intermittent Claudication; The Cochrane
Database of Systematic Reviews; Iss-2, No: CD000990
 Montgomery PS et al 1998: The Clinical utility of a Six-Minute Walk Test in
Peripheral Arterial Occlusive Disease Patients; J Ame Geri Society; Vol- 46, No-
6, 706-711.

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Reference
 Ohtake PJ 2005; Field Tests of Aerobic Capacity for Children and Older Adults;
Cardiopulmonary Physical Therapy Journal; Vol 16, N23, Page 5-11&40
 Regensteiner JG et al 1990; Evaluation of Walking Impairment by Questionnaire
in Patients with Peripheral Arterial Disease; Journal of Vascular Medicine and
Biology. Vol- 2, No-3, Page 142-152.
 Schainfeld RM 2001: Management of Peripheral Arterial Disease and
Intermittent Claudication; J Am Board Fam Pract; Vol-14. No-6, 443-445.
 Scherer SA 2004; Research Corner: Functional Outcome Measurements for
Patients with Peripheral Arterial Disease; Cardiopulmonary Physical Therapy
Journal; Vol 15, No3, Page 23-28.
 Stewart KJ et al 2002; Exercise Training for Claudication; The New England
Journal of Medicine; Vol-347, Iss-24, Page 1941-1951.
 Tsai JC et al 2002; The Effects of Exercise Training on Walking Function and
Perception of Health status in Elderly Patients with Peripheral Arterial Occlusive
Disease; Journal of Internal Medicine; Vol 252, Page 448-455

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