Peripheral arterial disease (PAD) is a condition resulting from atherosclerotic occlusive disease that leads to chronic, partial or total arterial occlusion in the legs. The consequences of PAD are variable, but the hallmark symptom is claudication. This is exercise-induced pain that is classically described as a cramp, ache, fatigue, or pain in the muscle group that is relieved by rest and reproducible with a similar degree of exercise. The pain in claudication is predictable based on the degree of arterial insufficiency and is reproducible in location based on the specific muscles that have perfusion defects. This symptom is what leads patients with PAD to diminished exercise tolerance and inactivity. Other symptoms of PAD include numbness, tingling, or a feeling of muscle fatigue in the lower extremity. Critical limb ischemia is the severe end of the PAD spectrum and can result in ulcers or sores on the feet or legs that do not heal or heal very slowly. If severe ischemia is present, there may be an associated pain at rest and the development of sores from minor trauma. In very severe cases, this can progress to frank gangrene. The diverse symptomatic presentation of PAD must be considered when classifying the functional limitations of affected patients.
Overview of Peripheral Arterial Disease (PAD)
PAD is a debilitating condition caused by occlusive atherosclerotic disease of the lower limb arteries. It is estimated to affect 20% of individuals over 55 years of age. PAD is often under-diagnosed with prevalence rates likely to be higher than that estimated. It is a major health concern with associated mortality and morbidity. PAD is an indicator of widespread atherosclerosis and is associated with a six-seven-fold increase in cardiovascular (CV) ischemic events. PAD patients also have a much higher incidence of death from CV events compared with the general population. Morbidity and mortality rates for PAD are at least as high as those of patients with coronary artery disease, and placed in the context that PAD patients are generally older and have greater co-morbid conditions, such as diabetes and hypertension, they have a poor long-term prognosis. This underlies the importance that PAD not be underestimated and to employ aggressive CV secondary prevention strategies. A cardinal symptom of lower limb PAD is intermittent claudication, described as a cramping leg pain induced by exercise and relieved by rest. This is a major cause of mobility limitation and is associated with a reduced quality of life. More severe limb ischemia leads to pain at rest and ulceration or gangrene, usually culminating in limb loss. CV events and intermittent claudication make up the most common manifestations of PAD. Over time it is likely that the number of patients with PAD will increase, it is a disease of aging and the life expectancy is rising in most developed and developing countries. PAD is an important disease with major implications for public health.
Importance of Exercise Rehabilitation for PAD Patients
Additionally, exercise rehabilitation is really safe to be done. This is because supervised exercise therapy has the capability to function as an initial diagnostic test and can potentially identify individuals with PAD who have a significant decrease in walking performance. Supervised exercise therapy also allows patients to exercise in a safe environment while their clinical signs and symptoms are being monitored by healthcare personnel. This is really important because complications may occur if the patients are unsupervised and doing unsupervised exercises. Exercise and supervised exercise therapy may prevent or delay PTA and/or amputation in patients with critical leg ischemia by improving walking distance and preventing deterioration of general fitness. And let’s not forget that exercise rehabilitation has a really good impact on their psychological well-being. By restoring the patients’ functional independence and ability to participate in normal or work activities, it may enhance their self-efficacy and reduce depression.
This section was a really important part of the book. Here, the author discusses the importance of exercise rehabilitation for PAD patients. In this chapter, he starts with the difficulties faced by PAD patients, mostly related to mobility. This disease has been really troublesome for the elderly. The quality of life for these patients is significantly decreased. One way to treat this disease is through bypass surgery. However, this kind of effort is considered heavy and the results are not really significant. The surgery mostly aims to increase the capability of these patients to walk. It is better for these patients to continue with conservative treatment. According to the study conducted by Zainah et al., exercise rehabilitation is more cost-effective and prolongs the walking distance compared to bypass surgery. This is the reason why the author believes that exercise rehabilitation is a priority in treating PAD patients.
Benefits of Exercise Rehabilitation for PAD Patients
The following conclusions reference the studies included in the previous text. Rehabilitation programs for individuals with PAD have been designed to optimize function and alleviate symptoms. This is accomplished by improving the patient’s ambulatory capability and cardiovascular function. Several medical organizations have recognized PAD as a significant impairment in quality of life and have supported the use of supervised exercise therapy for affected individuals. In 2002, the claudication guidelines working group, which was organized by the American Heart Association, recommended that a supervised exercise program be a primary therapy for patients limited by claudication. An updated and expanded version of this statement was published in 2005 by the American College of Cardiology Foundation and the American Heart Association Task Force on Practice Guidelines. These statements support the use of supervised exercise therapy for patients with PAD who have claudication or those with limitations in ambulation. The recently published systematic review and meta-analysis comparing supervised exercise therapy with revascularization or both showed that exercise therapy significantly increased pain-free walking time and patient-perceived quality of life and was found to be more effective than revascularization in these outcomes. In addition to the objective of the studies analyzed, the results provide evidence that any patient with claudication, intermittent or constant, will likely benefit from exercise therapy. This is of great importance since those with constant claudication have traditionally been considered poor candidates for revascularization and are often treated only with pharmaceutical therapy. Also, the finding that exercise therapy is more effective than revascularization in improving claudication symptoms may change the current treatment strategy for many patients with PAD. Finally, the increasing costs associated with the care of PAD patients must be considered. With the growing concern for the necessity to both control healthcare spending and deliver quality care, supervised exercise therapy may turn out to be a more cost-effective treatment strategy for many patients with PAD.
Improved Mobility and Walking Distance
Treadmill tests can be expensive and time-consuming. Typically, it is more suitable to evaluate a patient’s walking ability using the 6-minute walk test, which is a cheaper alternative and is also an effective measure of functional exercise capacity.
Measures of walking ability are reflected by the improvement in a patient’s ability to perform tasks of daily living, i.e., walking to the shops or climbing a flight of stairs. This is a vital outcome to patients and ultimately leads to an improved quality of life. This type of research generally quantifies a patient’s mobility using a treadmill test, and patients who have shown to improve during the exercise intervention can increase their walking distance before the onset of pain and can walk for longer periods of time.
Several systematic reviews have been conducted, and each has concluded that the optimal mode of exercise for PAD patients is supervised treadmill walking. In the latest Cochrane review, it was reported that treadmill training improves walking ability in patients with PAD and was associated with a fivefold increase in walking endurance time in comparison with control (non-exercising) participants. This will be a key finding for the majority of PAD exercise rehabilitation studies.
Despite the fact that many individuals with PAD experience leg pain that restrains their ability to walk, one of the primary reasons patients enter an exercise rehabilitation program is to improve their walking ability. Several decades of research have shown that structured home or community-based exercise is an effective treatment for symptomatic relief in PAD patients. This can result in improved mobility and an increased pain-free walking distance.
Enhanced Cardiovascular Health
Sudden damage to the blood vessel wall can be triggered by periods of heavy exercise or chronically by the repetitive stress of the pulse waves – caused by the narrowed arterial lumen because of arteriosclerosis – at locations predisposed to lesion formation. Stenosing atherosclerotic lesions decrease the lumen diameter by 15% to 20% before they become flow limiting and are often aggravated by vasospasm at their most stenosed segment. This reduces the distal supply of oxygen and nutrients to the muscles, which in peripheral artery disease patients results in intermittent claudication in the affected lower extremities. If ischaemia lasts longer or is more severe it can cause muscle damage, as manifested by increased serum creatine phosphokinase levels after exercise in PAD patients with claudication, and in some patients chronic limb pain at rest and/or ischaemic ulcers. Muscle damage and pain can result in an avoidance of exercise and further loss of fitness. This is of great consequence to cardiovascular health as a 4-year study showed that mortality in patients with intermittent claudication was as high as 26% and 24% had a non-fatal myocardial infarction. Therefore, exercise rehabilitation to increase walking distance and duration is an important strategy to improve cardiovascular outcomes in PAD patients. During periods of exercise, two major concerns for patients with cardiovascular disease are the risk of sudden cardiac death and myocardial events. High-intensity exercise increases the risk for sudden death or a myocardial infarction and may cause patients to feel vulnerable if not supervised in a setting where an emergency response is not possible. Progressive walking that goes to the point of induced leg pain but is not so intense that it causes cardiovascular events or serious injury to the limbs, supervised in a cardiac rehabilitation centre and with access to a treadmill if available, is a safe and ideal way for PAD patients to increase walking distance. Randomised trials have shown that such a regimen will increase pain-free walking duration and total walking duration to a greater extent than medications or angioplasty in limb intervention. Treadmill walking may also provide a cardiovascular training effect that has not been shown with other treatments for claudication. This is significant because a patient population with a mean age of 65 to 70 years has likely spent a lifetime accumulating inadequate cardiovascular training and often has other comorbid limitations to mobility. It has been suggested that poor functioning patients with limb claudication will benefit most from exercise training programmes but for this to be a viable option a safe and effective treatment for claudication must be found. High-intensity exercise provides a better systemic cardiovascular training effect and greater improvement in quality of life than lower intensity exercise but is unlikely to be a suitable option for patients who are at risk of cardiovascular events. High-intensity exercise would also not be an appropriate way to improve mobility in patients with leg ischaemia due to the risk of muscle damage, patients with CLI need interventions to improve limb blood flow and reduce the ischaemic pain that inhibits their mobility.
Increased Muscle Strength and Endurance
There are several studies that have shown significant increases in muscle strength and endurance following an exercise program. One study compared the effects of supervised treadmill exercise to strength training in patients with PAD. After 8 weeks of training, the patients who were in the treadmill group had significant increases in maximal walking time, claudication onset time, and peak VO2. Additionally, patients in the treadmill group had significant increases in calf muscle citrate synthase activity, a measure of mitochondrial content and function, suggesting that these outcomes were due to increased muscle aerobic capacity. Another study found that a combination of resistance training and treadmill walking improved walking performance on both the treadmill and a 6-minute walk test compared to supervised treadmill exercise alone. These data suggest that while supervised treadmill exercise improves walking ability in patients with PAD, the addition of resistance training can improve patient walking ability even further. Contributing to the overall increase in muscle strength and endurance in these patients are changes in morphology and biochemical function of muscle. In a recent strength training study, patients had significant increases in quadriceps muscle volume and strength. Finally, an observational study reported increased claudication-free walking distances in patients who were habitually active or began an exercise program after the onset of their symptoms compared to sedentary individuals.
Components of an Effective Exercise Rehabilitation Program
Aerobic exercise training does not adversely affect PAD symptoms and is considered safe at the proper intensity and duration. Assessment for the severity of PAD should be accomplished before prescribing an aerobic exercise program, including patients’ reported exercise capacity, testing their walking performance, and if possible, determining their functional impairment. The aerobic exercise prescription should progress from the initial exercise evaluation. The exercise mode, such as treadmill or cycle ergometry, must be consistent with the fitness objectives and functional limitations of the patient. Patients should exercise at a sufficient intensity to improve treadmill walking performance, but not so intense as to induce severe to moderate claudication. Patients with ABI levels ≤0.4 should not exercise at an intensity that induces moderate claudication or ischemia. A recent study has shown that in patients with ABI levels >0.9 and minimal functional limitations, supervised exercise at an ischemic basis in the form of treadmill walking actually shows improvement in the claudication. This form of exercise may also be used to try and strengthen a case for revascularization therapy in the future.
Aerobic exercise is an integral part of the rehabilitation process. PAD patients have a limited ability to walk because of claudication and an associated fear of bringing on ischemic pain. Supervised treadmill exercise improves pain-free walking time and standardizes the mode and intensity of exercise. Welcoming the standardization of the treadmill training protocol in the future, there is ample evidence to conclude that walking improves for these patients. But there are few data concerning the role of alternative aerobic exercise such as upper body ergometry or cycle training. High-intensity strength training or competitive sports are not normally prescribed for PAD patients, but for the few patients with milder disease in whom these activities are performed, supervised exercise on an ischemic basis may help alleviate the symptoms during the activity and strengthen a case for an invasive intervention.
There are four common components of an exercise rehabilitation program, each having a unique role in improving the patient’s ability to walk and function in their everyday environment. These four components are aerobic exercise, resistance training, flexibility and stretching exercises, and balance and coordination training.
Aerobic Exercise
Aerobic exercise is central to mobility and function, and is a primary modality for improving claudication. Treadmill walking is the most commonly studied aerobic exercise modality for PAD patients, while other forms of ambulatory exercise such as stationary cycling offer a low-impact alternative that may be more comfortable for some patients. A recent Cochrane review determined that structured exercise regimens can improve treadmill walking performance and quality of life for patients with intermittent claudication. Exercise has also been proven to increase pain-free walking distance by 50-200%, a finding which has been observed to endure for at least 1 year after the exercise program was completed. This is a particularly meaningful outcome given that it is directly correlated with an improved ability to function in daily life. Unfortunately, the benefits of supervised exercise are quickly lost if the patient does not continue to exercise on a regular basis. This underscores the importance of lifestyle modification and the adoption of a long-term exercise routine, which the rehabilitation program can help the patient to achieve. Consequently, patient education concerning the effect of exercise on PAD symptoms and prognosis is a key aspect of the exercise rehabilitation program.
Resistance Training
High intensity resistance training will provide optimal improved strength and function for PAD patients, and if used in conjunction with other exercise rehabilitation components, will improve overall mobility and independence.
Although the exercise program should focus on lower extremity resistance training, upper body exercises are also important to improve overall strength and function of the patient. High intensity upper extremity resistance exercises have shown to be beneficial for improving lower extremity function in people with PAD. For example, participants in the study by McDermott et al who did upper extremity resistance exercises improved their 6-minute walk performance and stair climbing ability. These patients also increased calf muscle cross-sectional area, an important outcome due to its strong association with lower extremity function in PAD patients.
High intensity lower extremity resistance training has been shown to improve walking duration on a treadmill for PAD patients. In the study by Regensteiner et al, twice-weekly strength training for 12 weeks improved pain-free walking distance and maximal walking duration for patients with PAD. These participants had improved walking performance compared with the control group that did lower intensity exercise. High intensity large muscle group lower extremity resistance training is safe and effective training and allows patients to perform exercises that are most specific to the objective of improving ambulatory function. High intensity resistance training may involve the use of weight machines, ankle weights, and light to moderate free weights. Exercises should be functional and specific to the task of improving walking ability. An example of functional exercise is a step up movement onto a block, that would be helpful to improve a patient’s ability to climb stairs.
Resistance training is an important component of exercise programs for PAD patients and is an essential part of improving strength, function, and mobility. If patients with PAD are able to improve the amount of weight they are able to lift in resistance training, it has been shown to improve strength and function in healthy elderly populations and those with chronic disease. The American College of Sports Medicine has stated that resistance training is crucial for all adults to maintain and improve physical function. Resistance training may be specific to certain muscle groups, or the exercises may be targeted to improve function and strength in a specific extremity.
Flexibility and Stretching Exercises
Static stretching is the most common method used to obtain flexibility. This form of flexibility exercise is performed by extending the targeted muscle group to its maximal point and holding it for 15-30 seconds. Individuals with PAD should perform static stretches immediately after the aerobic component of exercise, when the muscles are warm. A minimum of 4 days per week of static stretching is recommended in order to see improvements in flexibility. It is important that individuals stretch to the point of mild discomfort and not pain. Ballistic stretching is not recommended for individuals with PAD. This form of stretching uses the momentum of a moving body to stretch muscles and carries a high risk of muscle, tendon, and ligament damage in individuals with PAD. Yoga is an alternative form of flexibility exercise that combines many static stretches with breathing and meditation techniques. Yoga is an effective way to enhance flexibility; however, it is important to find a qualified instructor and a specific “gentle” yoga class. Many “power” or “Vinyasa” style yoga classes are too intense for individuals with PAD.
Balance and Coordination Training
The final issue to be addressed is the identification of the best method of increasing the engagement of PAD patients in exercise training. These individuals exhibit poor adherence to unsupervised exercise programs, with a lack of knowledge and supervision being two possible factors explaining this observation. Using the results from McDermott’s HOME-PAD trial, it may be suggested that task-specific training exercise provides a simple and more enjoyable alternative to standard treadmill exercise for improving lower limb muscle performance in PAD patients. By combining this with continued supervision from exercise professionals, there is a greater potential for inducing sustained lifestyle changes and an improved performance of self-directed exercise training. This area requires further research with an emphasis on finding cost-effective methods of community-based supervision to enhance the engagement of PAD patients in exercise rehabilitation.
To provide an effective means to improve muscle performance, task-specific training exercise must be of an intensity and duration sufficient to induce training effects. Training that progresses along the FITT principle for aerobic exercise (frequency, intensity, time, and type) has been shown to be effective for improving treadmill walking performance in PAD patients. The same principle has been applied to defined methods of task-specific training such as stair climbing, using a combination of stair exercise in a supervised exercise session and in the home environment, and lower limb strength and endurance exercise to improve isokinetic strength of the knee extensors and flexors.
Task-specific training involves repetition of a simple, often complex task, such as stair climbing exercise, to improve the performance of the task and a generalized effect on muscle performance. This is achieved through exercises that target coordination, by demanding the simultaneous and sequential activation of individual muscles and muscle groups to produce accurate and controlled movements; and balance, requiring limb positions that allow the maximum support of body loads in specific postures or activities with a minimum expenditure of energy.
In a study by McDermott et al. 2009, 41 PAD patients with a mean age of 69 were randomized to a 6-month supervised treadmill exercise (stepping) or a supervised home-based lower extremity exercise program. The home-based group completed a 6-month lower extremity exercise program, consisting of a series of exercise sessions in the home environment, using detailed instructions, photographs, and exercise equipment provided by a trainer. During the 6-month program, patients completed 3-4 sessions weekly.
Repeated and intensive muscle stimulation during walking – which is the most common form of exercise – is being proposed as an effective method for improving lower limb muscle performance in PAD patients. However, previous findings have shown that a supervised treadmill exercise program may not be effective in restoring normal gait and muscle performance due to the relatively high intensity and fast pace of the exercise. An alternative approach is to use task-specific training.
Considerations and Safety Precautions for Exercise Rehabilitation
Patients with PAD often experience leg pain, or intermittent claudication when walking. This occurs because the muscles are not receiving enough blood and oxygen to produce energy needed to keep moving. The discomfort stops after a short time of resting, due to lower levels of activity and oxygen requirements. The pain is located distal and unilateral, and its severity can be measured by the distance a patient is able to walk before the pain forces them to stop. Easing the pain of intermittent claudication is the primary goal of exercise rehabilitation in PAD patients, thus effective pain management and prevention of muscle ischemia during and after exercise is essential.
Monitoring exercise intensity and progression is important for safety and encouragement of results, however, this may be difficult to achieve in unsupervised unspecific exercise programs. Duration of walking has been used as a convenient measure of exercise intensity in specific research studies, and it has been suggested that an exercise program is more effective if there is a higher weekly duration of walking with a regiment of intermittent walking to moderate to strong ischemic leg pain. This progression will increase pain-free walking time in future exercise sessions. However, duration and intensity of walking may vary at different times, thus it is important to provide frequent instruction and patient monitoring to decide whether exercise should be progressed, maintained, or modified. Instructions should be clear, as it has been found that patients are more likely to walk to near-maximal claudication pain than healthy individuals if they have not been told otherwise.
Proper warm-up and cool-down techniques are often taken for granted, however, they prove to be highly effective in reducing symptoms during exercise therapy. It has been suggested that a well-planned warm-up and cool-down can extend pain-free walking distance in PAD sufferers. The warm-up should involve 5-10 minutes of walking at a slower pace than the main exercise session, thus gradually increasing blood flow to working muscles. Stretching exercises for major muscle-tendon units used in walking are appropriate if the patient has no discomfort. The main aim is to avoid aggravation of ischemic leg symptoms during the warm-up. The cool-down should involve cessation of exercise and immediate rest if claudication distances have been exceeded, or a gradual reduction in exercise intensity if claudication has been well tolerated. This is followed by 5-10 minutes of walking at the same or slightly slower pace than the main exercise session, and stretching exercises if there is no discomfort. This will reduce muscle ischemia.
Medical Evaluation and Supervision is highly important for exercise rehabilitation in PAD sufferers. A full history and physical examination should be done prior to commencement to identify the presence of peripheral neuropathy, and the patient should be educated on the importance of foot care and proper footwear. Exercise therapy may be contraindicated in PAD sufferers with active foot infection, and revascularization or surgical consultation may be required first. The presence and severity of intermittent claudication must also be established, as it’s the primary determining factor of ease for patients in PAD self-management and secondary prevention. This will assist in determining the type and level of exercise most suitable to the individual. Medical supervision by an expert and frequent patient monitoring is necessary to decide whether exercise therapy should be temporarily ceased or modified.
This component of the essay highlights the necessary considerations and safety precautions that should be taken when applying exercise rehabilitation on PAD patients. These steps should be followed to minimize adverse effects and maximize comfort, security, and benefits to the patient. They provide safety indicators as exercise rehabilitation may pose a higher risk of injury on PAD sufferers, largely due to their age and increased lack of condition. These steps are as follows:
Medical Evaluation and Supervision
Medical evaluation of the patient with PAD should begin with a thorough history and physical, paying special attention to claudication symptoms, presence of coronary or cerebrovascular disease, and functional status. A variety of questionnaires and objective functional measures have been validated to quantify functional status and track changes over time. Treadmill testing is a useful tool to objectively quantify functional impairment from claudication and to measure changes in treadmill walking performance in response to medical therapy or exercise training. It can also be useful to assess hemodynamic response to exercise in patients being considered for invasive revascularization procedures. An ankle-brachial index (ABI) is recommended to confirm the diagnosis of PAD in patients with exertional leg symptoms. Further non-invasive and invasive testing is generally only necessary to localize and determine the extent of disease in limbs with more severe or atypical symptoms, or in preparation for revascularization or other invasive procedures. Close communication between the exercise trainer and the patient’s physician is essential to ensure that exercise training is appropriate and safe, especially for individuals with significant cardiac disease or those with severe PAD in whom limb ischemia at rest or severe leg pain might make exercise training dangerous. This may require periodic updates on the patient’s exercise progress and symptom status, and occasional alterations in the exercise prescription. In some cases, supervision of exercise training in a medical facility-based program may be indicated, at least initially, for safe and effective implementation of exercise training in individuals with known or suspected high risk for exercise-induced cardiac events or severe ischemic complications. Finally, the possibility of exercise training as a therapeutic intervention for PAD patients with severe limb ischemia and those facing invasive revascularization procedures must be considered in the context of other medical and invasive therapies for which the risks and benefits are not the same for all patients.
Proper Warm-up and Cool-down Techniques
During the warm-up, the patient with intermittent claudication is required to walk to near maximal claudication pain. This is the pain threshold at which the patient will stop the activity. At this point, the muscles have reached a state of ischemia. If the patient stops at this point, there is a risk of further ischemic muscle damage and delayed onset muscle soreness. The optimum situation would be to commence the next exercise bout before the onset of ischemia. This could lead to improvement in pain-free walking time. It has been seen in the study of healthy subjects that the ischemic threshold of a muscle can be increased through exercise at an intensity of 70% VO2 max. This could be applied to PAD patients who are capable of several exercise intensities at the pain threshold. It may be possible to move the pain threshold to a greater exercise intensity, although this has yet to be researched for PAD patients. A suitable warm-up exercise intensity just below the pain threshold with gradual increase would simulate this training. This methodical warm-up of light intensity exercise just below the pain threshold and short rest periods may be beneficial for rehabilitation of PAD patients, but to our knowledge, this has yet to be researched.
Overview of the subject: Warm-up and cool-down are important parts of physical activity. In preparing for exercise, low-intensity aerobics, stretching, or calisthenics should be performed in a way that uses the muscles to be employed during the activity but in a less strenuous manner. After the main exercise period, cool-down exercise should be related to the warm-up activity and continue until the athlete’s heart rate has returned to near resting rate. These exercise rehabilitation techniques are important for patients’ safety and optimal response to exercise. It is the transition periods of warm-up and cool-down that require special consideration for PAD patients.
Monitoring Intensity and Progression
Exercise prescription is based around the overload principle, where the patient does regular, structured, and planned increases in exercise workloads in order to stimulate a positive adaptation. To do this, the exercise workload must be quantifiable; patient levels and progression are then based on this initial measurement. The primary method for this is walking velocity over a set distance. Treadmill walking tests can also be performed to measure claudication onset time, pain-free walking time, and maximum walking time. These tests should all be repeated at intervals throughout the program to assess the effectiveness of the exercise prescription. High exercise and increased walking capacity have been shown to cause greater improvements in walking ability. For this reason, it is important to be able to sufficiently induce claudication during supervised exercise. Altering walking speed and incline is the easiest method to achieve this. Other methods include the use of added weights, interval training, and pole walking. Completion of the session is the final method to ensure sufficient overload. It has been said that an exercise session has only been effective if the patient has experienced near maximal claudication during the session.
4.3. Monitoring Intensity and Progression
Proper warm-up and cool-down techniques are essential to patients with PAD due to the intermittent claudication and pain experienced with exertional activities. Warm-up should consist of 5-10 minutes of low-intensity exercise that does not induce claudication. Flexibility exercises and prolonged stretching should be avoided as it is difficult to distinguish between claudication pain and pain due to stretching. The cool-down, as with the warm-up, should be of low intensity and halted if pain occurs. The type and duration of exercise done post-rehabilitation program is subject to the patient’s goals, activity preferences, and available facilities. Supervised exercise programs have been shown to significantly increase the amount of supervised exercise and self-paced walking compared with unsupervised exercise. In order to maintain exercise levels achieved during rehabilitation, it may be beneficial for the patient to join a maintenance exercise program or graduate to a community-based exercise program.
4.2. Proper Warm-up and Cool-down Techniques
 Managing Pain and Discomfort
It is important to distinguish between muscle ischemia (an inadequate blood supply) during exercise and worsening of symptoms due to PVD progression. Muscle pain that lasts several hours after exercise and is disproportionate to the amount of exercise performed indicates exacerbation of the disease and cardiovascular risk, and the exercise program should be modified. Program modification can include shortening the duration of the exercise session, using intermittent rather than continuous exercise, or moving from lower to upper limb exercise. An exercise test using pulse oximetry and/or blood pressure determination can be used to measure the point of onset of ischemic symptoms and to determine the relative exercise intensities that produced subclass to verify content.
Exercise participation can be uncomfortable for many clients living with peripheral arterial disease. However, this pain is typically tolerated better than the intermittent claudication pain experienced during daily activities. The perception of leg pain intensity during exercise, in comparison to both intermittent claudication and pain-free walking, is likely due to the fact that the pain is somewhat expected during exercise and is associated with muscle fatigue or tightness rather than the characteristic cramping, aching, numbness, or heaviness feeling. Nevertheless, it is important that exercise-induced pain does not cause clients to adopt a sedentary lifestyle. Pain management is a useful strategy to improve tolerance to exercise; however, monitoring and modification of exercise programs can prevent exacerbation of the disease and increased cardiovascular risk.
