Vascular Rehabilitation: Difference between revisions

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== Introduction ==
== Background ==
[[File:Peripheral Arterial Disease.gif|thumb|Peripheral Arterial Disease ]]
[[File:Peripheral Arterial Disease.gif|thumb|Peripheral Arterial Disease ]]
[[Cardiovascular Disease|Peripheral Arterial Disease (]]PAD)is a degenerative vascular condition which results in inadequate blood flow leading to chronic narrowing of arteries typically in the lower limbs, which can result in acute thrombotic events.  
[[Cardiovascular Disease|Peripheral Arterial Disease (]]PAD)is a degenerative vascular condition which results in inadequate blood flow leading to chronic narrowing of arteries typically in the lower limbs, which can result in acute thrombotic events.  
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== Introduction ==
== Introduction ==
The VRP(vascular rehabilitation program) is an essential and effective exercise program designed to improve exercise tolerance and decrease the risk of progressive cardiovascular disease<ref name=":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. </ref>. It is a complex, interprofessional intervention aimed to improve physical reconditioning and risk factor modification<ref name=":2">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.</ref>.  Vascular rehabilitation programs aim to reduce the risk of  mortality secondary to CVD and to limit the psychological and physiological stresses of PAD, and enhance cardiovascular function to help patients achieve a better quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient's self-confidence through gradual conditioning.  
The VRP(vascular rehabilitation program) is an essential and effective exercise program designed to improve exercise tolerance and decrease the risk of progressive cardiovascular disease<ref name=":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. </ref>. It is a complex, interprofessional intervention aimed to improve physical reconditioning and risk factor modification<ref name=":2">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.</ref>.  Vascular rehabilitation programs aim to reduce the risk of  mortality secondary to CVD and to limit the psychological and physiological stresses of PAD, and enhance cardiovascular function to help patients achieve a better quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient's self-confidence and hence functional independence.


They require a team approach, including a multidisciplinary the multidisciplinary team including:  
They require a team approach, including a multidisciplinary the multidisciplinary team including:  


*'''Multi-Disciplinary Team'''
*'''Multi-Disciplinary Team'''<ref name=":3" />
** Vascular Consultant
** Vascular Consultant
** Clinical Nurse Specialist
** Clinical Nurse Specialist
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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. <ref name=":3">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,</ref>
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. <ref name=":3">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,</ref>


== Goals of Vascular Rehabilitation ==
== Goals of Vascular Rehabilitation ==
Comprehensive cardiac rehabilitation program should contain specific core components.
Comprehensive vascular rehabilitation program should contain specific core components.


These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on:
These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on<ref name=":3" />:


* Patient assessment [[Nutrition|nutritional]] counseling
* Patient assessment [[Nutrition|nutritional]] counseling
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* Psychosocial management
* Psychosocial management
* [[Physical Activity|Physical activity]] counseling
* [[Physical Activity|Physical activity]] counseling
* [[Therapeutic Exercise|Exercise training]]<span class="reference" id="cite_ref-:7_1-3"></span>
* [[Therapeutic Exercise|Exercise training]]<span class="reference" id="cite_ref-:7_1-3"></span>  


== Individual Risk Assessment ==
== Individual Risk Assessment ==


== Risk Factors<ref name=":0" /><ref name=":1" /><ref name=":3" /><ref name=":2" /> ==
=== History ===
 
* Claudication
* Other non–joint-related exertional lower extremity symptoms (not typical of claudication) n
* Impaired walking function
* Ischemic rest pain
 
==== Physical Examination ====
 
* Abnormal lower extremity pulse examination
* Vascular bruit
* Non-healing lower extremity wound
* Lower extremity gangrene
* Other suggestive lower extremity physical findings (e.g., elevation pallor/dependent rubor) <ref name=":3" />
 
== Risk Factors ==


* Smoking  (82%)  
* Smoking  (82%)  
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* Family Support
* Family Support
* Social History
* Social History
* Occupation
* Occupation <ref name=":0" /><ref name=":1" /><ref name=":2" /><ref name=":3" />


== Vascular Rehabilitation Participation<ref name=":3" /> ==
== Vascular Rehabilitation Participation ==
Inclusion in vascular rehabilitation programs should be available to all vascular patients who require it. Age is not and should not be a barrier  to exercise unless not cardiovascularly fit.  
Inclusion in vascular rehabilitation programs should be available to all vascular patients who require it. Age is not and should not be a barrier  to exercise unless not cardiovascularly fit.  


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


=== 1. Supervised exercise program<ref>Hiatt WR, Regensteiner JG, Hargarten ME, et al. Benefit of exercise conditioning for patients with peripheral arterial disease. Circulation. 1990;81:602–9.  </ref><ref>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.</ref><ref>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. </ref><ref>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. </ref><ref name=":5">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.</ref><ref name=":6">Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg. 1996;23: 104–15. </ref><ref>Stewart KJ, Hiatt WR, Regensteiner JG, et al. Exercise training for claudication. N Engl J Med. 2002; 347:1941–51. </ref> ===
=== 1. Supervised exercise program ===
* takes place in a hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality.
Supervised exercise program takes place in a hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality.<ref>Hiatt WR, Regensteiner JG, Hargarten ME, et al. Benefit of exercise conditioning for patients with peripheral arterial disease. Circulation. 1990;81:602–9.  </ref><ref>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.</ref><ref>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. </ref><ref>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. </ref><ref name=":5">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.</ref><ref name=":6">Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg. 1996;23: 104–15. </ref><ref>Stewart KJ, Hiatt WR, Regensteiner JG, et al. Exercise training for claudication. N Engl J Med. 2002; 347:1941–51. </ref>
* Program can be standalone or can be made available within a cardiac rehabilitation program.
* Program can be standalone or can be made available within a cardiac rehabilitation program.
* Program is directly supervised by qualified healthcare provider(s).
* Program is directly supervised by qualified healthcare provider(s).
* Training is performed for a minimum of 30 to 45 min per session, in sessions performed at least 3 times/wk for a minimum of 12 wk (36–46).
* Training is performed for a minimum of 30 to 45 min per session, in sessions performed at least 3 times/wk for a minimum of 12 wk. <ref name=":5" />
* Patients may not initially achieve these targets, and a treatment goal is to progress to these levels over time.
* Patients may not initially achieve these targets, and a treatment goal is to progress to these levels over time.
* Training involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest.<ref name=":5" /><ref name=":6" />
* Training involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest.<ref name=":5" /><ref name=":6" />
* Warm-up and cool-down periods precede and follow each session of walking.<ref name=":4" />
* Warm-up and cool-down periods precede and follow each session of walking.<ref name=":4" />


==== 2. Structured community- or home-based exercise program<ref>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.</ref><ref>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.</ref><ref>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.</ref><ref>Mays RJ, Rogers RK, Hiatt WR, et al. Community walking programs for treatment of peripheral artery disease. J Vasc Surg. 2013;58:1678–87. </ref><ref>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.</ref> ====
==== 2. Structured community- or home-based exercise program ====
Structured exercise program that takes place in the personal setting of the patient rather than in a clinical setting (41,47–51).
Structured exercise program that takes place in the personal setting of the patient rather than in a clinical setting. <ref>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.</ref><ref>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.</ref><ref>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.</ref><ref>Mays RJ, Rogers RK, Hiatt WR, et al. Community walking programs for treatment of peripheral artery disease. J Vasc Surg. 2013;58:1678–87. </ref><ref>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.</ref>


* Program is self-directed with the guidance of healthcare providers who prescribe an exercise regimen similar to that of a supervised program.  
* Program is self-directed with the guidance of healthcare providers who prescribe an exercise regimen similar to that of a supervised program.  

Revision as of 21:50, 15 November 2022

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Background[edit | edit source]

Peripheral Arterial Disease

Peripheral Arterial Disease (PAD)is a degenerative vascular condition which results in inadequate blood flow leading to chronic narrowing of arteries typically in the lower limbs, which can result in acute thrombotic events.

These vascular events often affects a large and multilevel arteries causing complications. The initial narrowing of an artery reduces the blood flow capacity to the limb which eventually limits the exercise tolerance. Patients exhibit pain on exertion with an altered gait typical of intermittent claudication, while ~50% describe atypical symptoms that limit exercise.

Usually, the vascular lesions often progress leading to even greater limitation to mobility. In its extreme, blood flow(BF) can become limiting at rest, leading to frank ischemia, ulcerations, pathological changes, gangrene, and, all too often,amputation of the distal tissues. [1].

Introduction[edit | edit source]

The VRP(vascular rehabilitation program) is an essential and effective exercise program designed to improve 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 reduce the risk of mortality secondary to CVD and to limit the psychological and physiological stresses of PAD, and enhance cardiovascular function to help patients achieve a better quality of life possible. Accomplishing these goals is the result of improving overall cardiac function and capacity, halting or reversing the progression of atherosclerotic disease, and increasing the patient's self-confidence and hence functional independence.

They require a team approach, including a multidisciplinary the multidisciplinary team including:

  • Multi-Disciplinary Team[4]
    • 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.

These components should optimize cardiovascular risk reduction, reduce disability, encourage active and healthy lifestyle changes, and help maintain those healthy habits after rehabilitation is complete. Cardiac rehabilitation programs should focus on[4]:

Individual Risk Assessment[edit | edit source]

History[edit | edit source]

  • Claudication
  • Other non–joint-related exertional lower extremity symptoms (not typical of claudication) n
  • 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
  • Other suggestive lower extremity physical findings (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 require it. 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

  • Planned program that provides individualized recommendations for type, frequency, intensity, and duration of exercise.
  • Program provides recommendations for exercise progression to assure that the body is consistently 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 hospital or outpatient facility in which intermittent walking exercise is used as the treatment modality.[6][7][8][9][10][11][12]

  • Program can be standalone or can be made available within a cardiac rehabilitation program.
  • Program is directly supervised by qualified healthcare provider(s).
  • Training is performed for a minimum of 30 to 45 min per session, in sessions performed at least 3 times/wk for a minimum of 12 wk. [10]
  • Patients may not initially achieve these targets, and a treatment goal is to progress to these levels over time.
  • Training involves intermittent bouts of walking to moderate-to-maximum claudication, alternating with periods of rest.[10][11]
  • Warm-up and cool-down periods precede and follow each session of walking.[5]

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

Structured exercise program that takes place in the personal setting of the patient rather than in a clinical setting. [13][14][15][16][17]

  • Program is self-directed with the guidance of healthcare providers who prescribe an exercise regimen similar to that of a supervised program.
  • Patient counseling ensures that patients understand how to begin the program, how to maintain the program, and how to progress the difficulty of the walking (by increasing distance or speed).
  • Program may incorporate behavioral change techniques, 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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