SLR - June 2020 - Ricardo Navarrete Jr.

Supervised Walking Exercise Therapy Improves Gait Biomechanics in Patients with Peripheral Artery Disease

Reference: Schieber, M. N., Pipinos, I. I., Johanning, J. M., Casale, G. P., Williams, M. A., DeSpiegelaere, H. K. Myers, S. A. (2019). Supervised Walking Exercise Therapy Improves Gait Biomechanics in Patients with Peripheral Artery Disease. Journal of Vascular Surgery. doi:10.1016/j.jvs.2019.05.044

Scientific Literature Review

Reviewed By: Ricardo Navarrete Jr., DPM
Residency Program: Creighton University – Phoenix, AZ

Podiatric Relevance: Peripheral artery disease (PAD) is one of the most common complaints presented in a podiatric practice. One finding associated with this disease is the occurrence of an altered gait even before the onset of claudication pain. Supervised walking exercise therapy (SET) is a first line of treatment because it increases maximum walking distances comparable with surgical revascularization therapy. However, little has been studied regarding gait biomechanics after supervised exercise therapy. This study characterized the effects of supervised exercise therapy on gait biomechanics and walking distances in claudicating patients with PAD.

Methods: A prospective nonrandomized cohort of 47 patients with claudication symptoms, no previous history of revascularization and a Fontaine stage II in the leg underwent gait analysis before and immediately after 6 months of supervised exercise therapy. Exercise sessions consisted of a warmup of mild walking and stretching of upper and lower leg muscles, intermittent treadmill walking, and cool down three times per week. Measurements included self-perceived ambulatory limitations measured by questionnaire, the ankle-brachial index (ABI), walking distance measures, maximal plantar flexor strength measured by isometric dynamometry and gait biomechanics trials performed before and after the onset of claudication pain. Paired t-tests were used to test for differences in quality of life, walking distances, ABI and maximal strength. A two-factor repeated measures analysis of variance determined differences for intervention and condition for gait biomechanics dependent variables

Results: After SET, three of the four subcategories of the walking impairment questionnaire showed significant increases after SET, indicating less difficulty walking owing to pain and the perception that they walk farther. Both initial and absolute claudication distances on the standardized treadmill test significantly increased following SET. The area under the curve and peak torque/body weight increased after SET, indicating the increased capability of the ankle plantar flexors and posterior muscles to produce work and generate maximal force during an isometric contraction. Biomechanically, patients increased hip extensor weight acceptance, ankle power absorption, power generation at the ankle and hip. In all, quality of life, walking distances, and maximal plantar flexor strength improved, although body mass and ABI did not significantly change. 

Conclusions: This study suggests that six months of SET can produce significant increases in the walking distances and quality of life in patients with claudication. These increases were consistent with concurrent improvements in gait biomechanics at the level of the ankle and the hip. These improvements occurred even without improvement in ABI. Using SET, and or instructing patients to perform a walking program may provide lower extremity strengthening and neovascularization through collateralization while improving walking ability of patients with claudication.

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