Home-Based Walking Exercise Intervention in Peripheral Artery Disease: A Randomized Clinical Trial
Can a home-based program of walking exercise, using group-mediated cognitive behavioral intervention, improve functional performance compared with health education alone, in patients with peripheral arterial disease (PAD) with and without intermittent claudication?
The authors reported the results of GOALS (Group Oriented Arterial Leg Study), a randomized controlled clinical trial comparing a home-based group-mediated cognitive behavioral walking intervention versus an attention/education control. Home-based group-mediated cognitive behavioral intervention was comprised of weekly 90-minute sessions with a trained facilitator for discussion and training, versus weekly 60-minute group lectures on other medical/health-related topics. The primary outcome was change in 6-minute walk performance at 6 months. Secondary outcomes included 6-month change in treadmill walking, physical activity, the Walking Impairment Questionnaire (WIQ), and Physical and Mental Health Composite Scores from the 12-item Short-Form Health Survey.
Of 194 subjects randomized between July 22, 2008, and December 14, 2012, 72.2% had classic symptoms of claudication. Home-based intervention was associated with an increase in 6-minute walk distance reported in meters (357.4-399.8 m vs. 353.3-342.2 m for intervention and control, respectively; mean difference, 53.5 [95% confidence interval (CI), 33.2-73.8]; p < 0.001); an increase in maximal treadmill walking time (7.91-9.44 minutes vs. 7.56-8.09 for intervention and control, respectively; mean difference, 1.01 minutes [95% CI, 0.07-1.95]; p = 0.04); an increase in accelerometer-measured physical activity over 7 days (778.0-866.1 vs. 671.6-645.0 for intervention and control, respectively; mean difference, 114.7 activity units [95% CI, 12.82-216.5]; p = 0.03); an increase in WIQ distance score (35.3-47.4 vs. 33.3-34.4 for intervention and control, respectively; mean difference, 11.1 [95% CI, 3.9-18.1]; p = 0.003); and an increase in WIQ speed score (36.1-47.7 vs. 35.3-36.6 for intervention and control, respectively; mean difference, 10.4 [95% CI, 3.4-17.4]; p = 0.004).
The authors concluded that a home-based walking exercise program significantly improved walking endurance, physical activity, and patient-perceived walking endurance and speed in PAD participants with and without classic claudication symptoms. The authors further opined that these findings have implications for the large number of patients with PAD who are unable or unwilling to participate in supervised exercise programs.
This extremely rigorous and scientifically valid study strongly suggests that we can successfully amplify the benefit of home-based exercise therapy for PAD to improve symptoms, walking, and quality of life. This research team has previously shown that although home-based exercise/rehab for PAD is effective, it lags behind supervised exercise/rehab in effectiveness for improving walking in patients with PAD. However, although supervised exercise/rehab is clearly the most effective treatment for patients with PAD, most insurance plans will not reimburse for this therapy—despite the fact that they will reimburse for many less effective, more expensive treatments. This and other factors make access to, and participation in, supervised exercise/rehab for PAD disappointingly poor, and therefore too often not an option for our patients. One obvious caveat to the generalizability of the results of this study is the potential expense. It remains to be seen if the level of intervention evaluated in this study can feasibly be economically realized. That being said, the current excellent study demonstrates that we can improve this situation, to the benefit of our patients.
Keywords: Intermittent Claudication, Walking, Exercise Therapy, Peripheral Arterial Disease
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