Home-Based, Walking Exercise Behavior Change Intervention vs Usual Care for Adults With Peripheral Artery Disease—Reply

Abstract

To the Editor A recent study 1 demonstrated a greater improvement in 6-minute walk distance, self-reported walking ability, pain-free walking time, exercise-related behavior, and quality of life following 3 months of combined home-based, walking and exercise behavior counseling intervention compared with usual care in patients with peripheral artery disease (PAD). We have some concerns about this study's protocol.First, the patients' physical activity was subjectively assessed using the short form of the International Physical Activity Questionnaire, which was recently shown to overestimate physical activity and underestimate sedentary behavior compared with accelerometry in patients with coronary artery disease. 2 The same discrepancies between objectively and subjectively assessed physical activity have also been shown in patients with PAD. 3 Because greater than 40% of the patients in this study 1 had cardiovascular disease along with PAD, we believe that overestimation of physical activity could have occurred in this trial. This potential overestimation may have affected the enrollment process because all patients who walked more than 90 minutes per week, according to the brief physical activity questionnaire, were excluded from the study. In addition, the absence of posttraining improvement in physical activity may also have been influenced by an overestimation of self-reported physical activity at baseline.Second, the exercise adherence in this study 1 was monitored using pedometers, which have limited measurement characteristics (measuring only step count and distance) compared with triaxial accelerometry. Therefore, use of pedometers may have limited the optimal training adjustment of walking intensity, which is used to elicit greater improvements in maximal walking distance and pain-free walking, and is wellestablished to be associated with lower risk of cardiovascular and all-cause mortality. 4 With increasing use of accelerometers in cardiovascular rehabilitation, 5 we are proponents of objective assessment of daily sedentary behavior, walking, and different levels of physical activity to monitor and study the effects of home-based exercise training interventions. Accelerometer-or pedometerguided exercise therapy is established in patients with coronary artery disease. 5 Therefore, we believe that exercise therapy for PAD should follow in these footsteps to investigate whether the same principles can be applied.

Home-Based Walking Exercise for Peripheral Artery Disease

“…At 3-month follow-up, 6-minute walk distance changed from 352.9 m at baseline to 380.6 m in the intervention group and from 369.8 m to 372.1 m in the usual care group (adjusted mean between-group difference, 16.7 m [95% CI, 4.2 m to 29.2 m]; P = .009). This effect of the intervention was consistent with a statistically significant and modest but clinically meaningful improvement in 6-minute walk distance . In contrast with the RCTs that demonstrated larger effects of home-based walking exercise for people with PAD, the trial by Bearne et al included fewer in-person visits and did not objectively monitor intensity of walking exercise, which may have lessened the potency of the home-based exercise intervention …”

“…This effect of the intervention was consistent with a statistically significant and modest but clinically meaningful improvement in 6-minute walk distance . In contrast with the RCTs that demonstrated larger effects of home-based walking exercise for people with PAD, the trial by Bearne et al included fewer in-person visits and did not objectively monitor intensity of walking exercise, which may have lessened the potency of the home-based exercise intervention …”

“…In this issue of JAMA , Bearne et al report results of a multicenter RCT evaluating the effects of a home-based walking exercise behavior change intervention delivered by physical therapists, compared with usual care, on 6-minute walk distance at 3-month follow-up in 190 people with PAD. The 12-week intervention consisted of two 60-minute individual in-person sessions in weeks 1 and 2 of the intervention and two 20-minute telephone calls in weeks 6 and 12 of the intervention.…”

Long-Term Outcomes of Exercise Therapy Versus Revascularization in Patients With Intermittent Claudication

“…This kind of sustainable and effective approach is promising and deserves development. Moreover, recent studies contribute to understanding the potential benefits of home-based exercise regarding safety, optimal intensity, adjunct coaching, and feedback 41–43 . We must be cautious when considering generalizability of comparable limb-related outcomes shown in this meta-analysis.…”

“…Moreover, recent studies contribute to understanding the potential benefits of home-based exercise regarding safety, optimal intensity, adjunct coaching, and feedback. [41][42][43] We must be cautious when considering generalizability of comparable limb-related outcomes shown in this meta-analysis. In RCTs, follow-up visits are prespecified and patients have greater chances to be identified for failed EVT before the development of more severe ischemia.…”