Experience Implementing Supervised Exercise Therapy for Peripheral Artery Disease

Abstract

Background: Supervised exercise therapy (SET) is a cornerstone of treatment for improving walking distance for individuals with symptomatic peripheral artery disease and claudication. High-quality randomized controlled trials have documented the efficacy of SET as a claudication treatment and led to the recent Centers for Medicare and Medicaid decision to cover supervised exercise therapy (SET). However, to date, the translation of highly controlled, laboratory-based SET programs in real-world cardiopulmonary rehabilitation settings has not been explored. Methods: In this article, we described our experience integrating SET into existing cardiopulmonary rehabilitation programs, focusing on patient evaluation, exercise prescription, outcome assessments, strategies to maximize program adherence, and transitioning to home and community-based exercise training. Results: Our team has over 3 years' experience successfully implementing SET in cardiac rehabilitation settings. The experiences communicated here can serve as a model for clinical exercise physiologists as they begin to incorporate SET in their rehabilitation programs. Conclusion: CMS reimbursement has the potential to change clinical practice and utilization of SET for patients with symptomatic peripheral artery disease. The experience we have gained through implementation of SET programs across the M Health and Fairview Health Systems and in other Minnesota communities—including specific elements in our programs and the lessons learned from our clinical experience—can inform and help guide development of new programs.

Individual Differences in Response to Supervised Exercise Therapy for Peripheral Artery Disease

“…The intensity of exercise via treadmill walking and other modes of exercise was individualized for each patient, with the goal of inducing self-reported moderate claudication of 3–4 (on a 0–5 scale) within 5–10 minutes. Exercise prescriptions were gradually progressed (via grade/speed or resistance) over the course of 12 weeks based on participant tolerance (Salisbury et al, 2019; Treat-Jacobson et al, 2019). The duration, intensity, and mode of exercise for each bout in each exercise session were recorded.…”

“…Finally, change in treadmill workload over the course of SET was assessed via changes in metabolic equivalent of task (METs) achieved during the exercise sessions. As the initial sessions typically involved individualization of the starting workload for each patient, the third session was used for calculation of baseline workload for comparison (Salisbury et al, 2019). Changes in METs from the third to the final exercise session were calculated using the treadmill speed and incline recorded for each bout.…”

Total body recumbent stepping vs treadmill walking in supervised exercise therapy: A pilot study

“…Exercise prescriptions differed depending on whether the exercise training modality induced claudication. 1,4 Participants were instructed to choose a comfortable pace (50-80 steps per minute [spm]) and a resistance that promoted 'moderate' effort. For participants who experienced claudication during TBRS, the exercise prescription mirrored that of the TM group and has been discussed previously.…”

“…1,3 However, TM is not feasible for some patients with PAD who enroll in SET due to foot ulcers, severe ischemia, gait instability, or other relative contraindications. 1,4 Another mode of exercise training commonly utilized in cardiac rehabilitation settings is total body recumbent stepping exercise training (TBRS). 5,6 TBRS is a seated, lowimpact training modality, which has been shown to significantly increase walking performance, aerobic fitness, and lower body strength in healthy adults and stroke survivors.…”

A Novel, Individualized Exercise Program for Patients with Peripheral Arterial Disease Recovering from Bypass Surgery

“…Exercise rehabilitation programs result in significant improvements in walking longer distances and are recommended as first-line therapies, but long-term effects of different rehabilitation programs are uncertain [5]. However, it is important to notice that a structured community- or home-based exercise program is recommended for these patients (a Class IIA level of evidence) [5,9,10]. The aim of this study was to compare an individual six-month-long physical exercise program for patients with PAD with a traditional exercise program and find the effect of these programs on HRQOL and PAD risk factors.…”