A systematic review of randomized controlled trials: Walking versus alternative exercise prescription as treatment for intermittent claudication

Objective: There is a subset of older adults with peripheral arterial disease (PAD) who are unable to complete current walking exercise therapy guidelines due to the severity of claudication, presence of foot pathology, arthritis and/or other co-morbidities. Our aim was to therefore systematically review the evidence for the effectiveness of all forms of exercise on claudication in PAD, and subsequently compare walking to alternative modes. Methods: An electronic search of the literature was performed from earliest record until March 2011 using a variety of electronic databases. To be included trials must have been a randomized controlled trial of an exercise intervention for adults with intermittent claudication and have reported at least one claudication parameter such as initial (ICT/D) and/or absolute claudication time or distance (ACT/D) measured via a treadmill protocol. Assessment of study quality was performed using a modified version of the Physiotherapy Evidence Database Scale (PEDro). Mean difference and relative effect sizes (ESs) were calculated and adjusted via Hedges' bias-corrected for small sample sizes. Results: Thirty-six trials reported on walking distance in PAD: 32 aerobic (including 20 walking); 4 progressive resistance training (PRT) or graduated weight lifting exercise. In total 1644 subjects (73% male) were studied (1183 underwent exercise training); with few over 75. Most modes and intensities of exercise, irrespective of pain level, significantly improved walking capability (ACD/T Relative ES range 0.5-3.53). However, overall quality of the trials was only modest with on average 6 of the 11 PEDro quality criteria being present (mean 5.8 +/- 1.3), and on average sample sizes were small (mean 44 +/- 51). Conclusions: Modes of aerobic exercise other than walking appear equally beneficial for claudication and the benefits of PRT and upper body exercise appear promising, but little data are published on these modalities. Additional studies of high quality are required to validate these alternative prescriptions and their efficacy relative to walking. (C) 2011 Elsevier Ireland Ltd. All rights reserved.