Effects of exercise prescribed at different levels of claudication pain on walking performance in patients with intermittent claudication: a protocol for a randomised controlled trial

Abstract

Background: Peripheral artery disease affects over 236 million people globally and the classic symptom is intermittent claudication (IC) which is associated with reduction in physical activity. The evidence that supervised exercise programmes (SEPs) improve pain-free and maximal walking distance is irrefutable. However, adherence rates are low with exercise-related pain cited as a contributing factor. National and international guidelines recommend exercising at a moderate to maximal level of claudication pain to improve walking ability; however, exercising pain-free or at mild claudication pain has been shown to achieve this outcome. There is limited evidence that compares the relative effects of exercise prescribed at different levels of claudication pain. Objective: The objective of this study is to directly compare the effects of exercise prescribed at three different levels of claudication pain on walking performance. Design: This study will be a single-centre randomised controlled trial. Methods: Based on an a priori power calculation, 51 patients with IC will be allocated to 24 weeks of twice-weekly pain-free (PF), moderate pain (MOD-P) or maximal pain (MAX-P) exercise. The PF group will cease exercise at the onset of claudication (1 on the 0–4 IC rating scale), the MOD-P group will stop once moderate pain is reached (2 on the rating scale) and the MAX-P group will stop once maximal pain is reached (4 on the rating scale). Analysis: Outcome measures will be assessed at baseline, 12 and 24 weeks adopting an analysis of covariance (ANCOVA) to compare MWD across three time points. The primary outcome for the trial will be change in maximal treadmill walking distance at 12 and 24 weeks. Registration: Trial registration number: NCT04370327.

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“…The number of patients who have sufficiently adhered to the treatment protocol, such as completing a minimum of 80% of sessions over 12 weeks (29 of 36 sessions), will be reported. A minimum of 80% completion rate is most frequently used as a surrogate of satisfactory adherence in patients with PAD and cardiovascular diseases 47 48…”

Exercise therapy for chronic symptomatic peripheral artery disease

“…This indicates that a more flexible approach to exercise prescription may therefore be required, considering the patient's needs and preferences, and what might achieve a high level of (long term) adherence. Larger studies with a higher number of cases and longer duration, taking compliance into account, are needed for a conclusive statement 113 .…”

What is the correct level of claudication pain to prescribe? Universal inconsistency within guidelines, a painful issue

“…No research has directly compared maximal, pain-free and moderate claudication pain; however, trials are underway. 18 …”