Vascular Rehabilitation

Original Editor - Rochelle Dsouza

Top Contributors - Rochelle Dsouza and Chelsea Mclene  


Background[edit | edit source]

Peripheral Arterial Disease

Peripheral Arterial Disease (PAD) is a degenerative vascular condition which leads to acute thrombotic events due to chronic narrowing of the arteries which is caused by inadequate blood flow usually to the lower limbs.

Patients present with pain on exertion with an altered gait typical of intermittent claudication, while a majority of patients describe atypical symptoms that limit exercise. These vascular events affects a large and multilevel arteries causing complications. Exercise tolerance is initially limited due to narrowing of an artery as a result of reduced blood flow capacity to the limb.

Usually, the vascular lesions often progress leading to even greater limitation to mobility. In adverse cases, the blood flow cab (BF) can become restrictive at rest, leading to frank ischemia, ulcerations, and a series of pathological changes leading to gangrene, and after lack of success with the trial of antibiotics the MDT eventually consider, amputation of the distal tissues [1].

Introduction[edit | edit source]

The VRP (vascular rehabilitation program) is an essential and effective exercise program designed to ameliorate exercise tolerance and decrease the risk of progressive cardiovascular disease[2]. It is a complex, interprofessional intervention aimed to improve physical reconditioning and risk factor modification[3]. Vascular rehabilitation programs aim to minimize the risk of mortality secondary to CVD and to limit the psychological and physiological stresses of PAD, and optimize cardiovascular function to achieve more functional quality of life. They require a team approach, through a multidisciplinary team[4] including:

  • Vascular Consultant
  • Clinical Nurse Specialist
  • Physiotherapists
  • Clinical nutritionist/Dietitian
  • Occupational Therapist
  • Orthotist
  • Pharmacist
  • Psychologist
  • Smoking cessation counsellor/nurse
  • Social worker
  • Vocational counsellor
  • Clerical Administration

It is essential that all vascular rehabilitation staff have essential training, qualifications, skills, and competencies to practice within their scope of practice and recognise and respect the professional skills of all other disciplines involved in providing comprehensive vascular rehabilitation. [4]

Goals of Vascular Rehabilitation[edit | edit source]

Comprehensive vascular rehabilitation program should contain specific core components. The aim of these components is to enhance and minimize the cardiovascular risk, reduce the disability and hence optimize and promote active and healthy lifestyle changes, and to eventually integrate those core components as healthy habits after rehabilitation is complete. Vascular rehabilitation programs should focus on[4]:

Individual Risk Assessment[edit | edit source]

Individuals are screened by the members of the multidisciplinary team such as Diabetic nurses, Vascular nurses,vascular consultants, podiatrists, physiotherapists and other members of the team through a comprehensive assessment and evaluation.

History[edit | edit source]

  • Claudication
  • Lower extremity exertional symptoms (not typical of claudication)
  • Impaired walking function
  • Ischemic rest pain

Physical Examination[edit | edit source]

  • Abnormal lower extremity pulse examination
  • Vascular bruit
  • Non-healing lower extremity wound
  • Lower extremity gangrene
  • Objective lower extremity physical examination (e.g., elevation pallor/dependent rubor) [4]

Risk Factors[edit | edit source]

  • Smoking (82%)
  • Hypertension (50%)
  • Diabetes mellitus (26%)
  • Previous myocardial infarction (24%)
  • Hypercholesterolemia (18%)
  • Stroke (6%)
  • Obesity

Other factors to consider:

Vascular Rehabilitation Participation[edit | edit source]

Inclusion in vascular rehabilitation programs should be available to all vascular patients who will benefit and hence have a better quality of life. Age is not and should not be a barrier to exercise unless not cardiovascularly fit.

Inclusion:

  1. Acute limb ischemia
  2. Angioplasty
  3. Reduced ankle-brachial index
  4. Atypical leg symptoms
  5. Claudication/intermittent claudication[5]
  6. Critical limb ischemia/severe limb ischemia
  7. Foot wound/ulcer
  8. Peripheral arterial disease/peripheral vascular disease
  9. Lower extremity arterial disease
  10. Vascular surgery

Types of Rehabilitation[edit | edit source]

Structured exercise program comprises of planned programs that provides individualized recommendations for type, frequency, intensity, and duration of exercise. The main aim of the exercise program provides recommendations for exercise progression to ensure that the body is constantly challenged to increase exercise intensity and levels as functional status improves over time.

There are 2 types of structured exercise program for patients with PAD:

1. Supervised exercise program[edit | edit source]

Supervised exercise program takes place in a more controlled and clinical setting such as hospital or outpatient facility in which the treatment modality used is intermittent walking exercise.[6][7][8][9][10][11][12]

  • The program is carried out under the direct supervision of qualified healthcare professionals and this program a=can be an add-on to other known programs such as Cardiac Rehabilitation Program.
  • Patients are expected to gradually progress and achieve the treatment goals. Each session is conducted for a minimum of 30 to 45 min per session, and these sessions are held at least 3 times/wk for a minimum of 12 wk. [10]
  • Alternating with adequate periods of rest, followed by the warm-up and cool down periods[5] are included as a part of training involves intermittent bouts of walking to moderate-to-maximum claudication.[10][11]

2. Structured community- or home-based exercise program[edit | edit source]

Structured exercise program takes place within home environment or within the patient's personal set-up instead of a controlled clinical set-up. [13][14][15][16][17]

  • The program allows more patients to engage autonomously in a exercise program, prescribed by healthcare providers
  • Prior to the session, all patient are provided with adequate counselling sessions as how to go about the program, how to maintain consistency and how and when to progress the duration and difficulty of walking (by increasing distance or speed).
  • The program not only focuses on exercise program but also may incorporate behavioral change techniques to facilitate and enhance outcomes, such as health coaching and/or use of activity monitors.

References[edit | edit source]

  1. ↑ 1.0 1.1 Haas TL, Lloyd PG, Yang HT, Terjung RL. Exercise training and peripheral arterial disease. Compr Physiol. 2012;2(4):2933-3017.
  2. ↑ 2.0 2.1 Noumairi M, Bouallala A, El Mir S, Allam A, El Oumri AA. Rehabilitation of patients with peripheral arterial disease. Ann Med Surg (Lond). 2021 Sep 14;70:102864.
  3. ↑ 3.0 3.1 Wassel CL, Loomba R, Ix JH, et al. Family history of peripheral artery disease is associated with prevalence and severity of peripheral artery disease: the San Diego Population Study. J Am Coll Cardiol. 2011;58:1386–92.
  4. ↑ 4.0 4.1 4.2 4.3 4.4 Marie D. Gerhard-Herman, H L. Gornik, Coletta Barrett, Neal R. Barshes, Matthew A. Corriere, Douglas E. Drachman et al, 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, Journal of the American College of Cardiology,69:11,2017,e71-e126,
  5. ↑ 5.0 5.1 Murphy TP, Cutlip DE, Regensteiner JG, et al. Supervised exercise versus primary stenting for claudication resulting from aortoiliac peripheral artery disease: six-month outcomes from the claudication: exercise versus endoluminal revascularization (CLEVER) study. Circulation. 2012;125:130–9.
  6. ↑ Hiatt WR, Regensteiner JG, Hargarten ME, et al. Benefit of exercise conditioning for patients with peripheral arterial disease. Circulation. 1990;81:602–9.  
  7. ↑ Fakhry F, Rouwet EV, den Hoed PT, et al. Longterm clinical effectiveness of supervised exercise therapy versus endovascular revascularization for intermittent claudication from a randomized clinical trial. Br J Surg. 2013;100:1164–71.
  8. ↑ Parmenter BJ, Dieberg G, Smart NA. Exercise training for management of peripheral arterial disease: a systematic review and meta-analysis. Sports Med. 2015;45:231–44.
  9. ↑ Parmenter BJ, Dieberg G, Phipps G, et al. Exercise training for health-related quality of life in peripheral artery disease: a systematic review and meta-analysis. Vasc Med. 2015;20:30–40.
  10. ↑ 10.0 10.1 10.2 Pilz M, Kandioler-Honetz E, Wenkstetten-Holub A, et al. Evaluation of 6- and 12-month supervised exercise training on strength and endurance parameters in patients with peripheral arterial disease. Wien Klin Wochenschr. 2014;126:383–9.
  11. ↑ 11.0 11.1 Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg. 1996;23: 104–15.
  12. ↑ Stewart KJ, Hiatt WR, Regensteiner JG, et al. Exercise training for claudication. N Engl J Med. 2002; 347:1941–51.
  13. ↑ Fakhry F, Spronk S, de Ridder M, et al. Long-term effects of structured home-based exercise program on functional capacity and quality of life in patients with intermittent claudication. Arch Phys Med Rehabil. 2011;92:1066–73.
  14. ↑ Collins TC, Lunos S, Carlson T, et al. Effects of a home-based walking intervention on mobility and quality of life in people with diabetes and peripheral arterial disease: a randomized controlled trial. Diabetes Care. 2011;34:2174–9.
  15. ↑ Gardner AW, Parker DE, Montgomery PS, et al. Step-monitored home exercise improves ambulation, vascular function, and inflammation in symptomatic patients with peripheral artery disease: a randomized controlled trial. J Am Heart Assoc. 2014;3:e001107.
  16. ↑ Mays RJ, Rogers RK, Hiatt WR, et al. Community walking programs for treatment of peripheral artery disease. J Vasc Surg. 2013;58:1678–87.
  17. ↑ McDermott MM, Domanchuk K, Liu K, et al. The Group Oriented Arterial Leg Study (GOALS) to improve walking performance in patients with peripheral arterial disease. Contemp Clin Trials. 2012;33:1311–20.
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