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A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year
Eur J Vasc Endovasc Surg (2017)
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1e6
A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year C. Oakley a b
a,*
, C. Spafford a, J.D. Beard
b
Sheffield Nordic Walking Research, STEPS Physiotherapy and Circulation Clinics, 32 Southbourne Road, Sheffield S10 2QN, UK Sheffield Vascular Institute, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
WHAT THIS PAPER ADDS This paper confirms the long-term benefit of a three-month home exercise programme augmented with Nordic pole walking for patients with intermittent claudication. Weekly walking distance continued to improve out to one year and compliance was excellent. This is the first study to also show an increase in resting ABPIs after only three months. A large multicentre trial of an augmented Home Exercise Programme compared to existing (more expensive) Supervised Exercise Programmes is urgently required.
Objective/Background: The objective of this study was to collect 1 year follow-up information on walking distance, speed, compliance, and cost in patients with intermittent claudication who took part in a previously reported 12 week randomised clinical trial of a home exercise programme augmented with Nordic pole walking versus controls who walked normally. A second objective was to look at quality of life and ankle brachial pressure indices (ABPIs) after a 12 week augmented home exercise programme. Methods: Thirty-two of the 38 patients who completed the original trial were followed-up after 6 and 12 months. Frequency, duration, speed, and distance of walking were recorded using diaries and pedometers. A new observational cohort of 29 patients was recruited to the same augmented home exercise programme. ABPIs, walking improvement, and quality of life questionnaire were recorded at baseline and 12 weeks (end of the programme). Results: Both groups in the follow-up study continued to improve their walking distance and speed over the following year. Compliance was excellent: 98% of the augmented group were still walking with poles at both 6 and 12 months, while 74% of the control group were still walking at the same point. The augmented group increased their mean walking distance to 17.5 km by 12 months, with a mean speed of 4.2 km/hour. The control group only increased their mean walking distance from 4.2 km to 5.6 km, and speed to 3.3 km/hour. Repeated ANOVA showed the results to be highly significant (p ¼ .002). The 21/29 patients who completed the observational study showed a statistically significant increase in resting ABPIs from baseline (mean SD 0.75 0.12) to week 12 (mean SD 0.85 0.12) (t ¼ (20) 8.89, p ¼ .000 [two-tailed]). All their walking improvement and quality of life parameters improved significantly (p ¼ .002 or less in the six categories) over the same period and their mean health scores improved by 79%. Conclusions: Following a 12 week augmented home exercise programme, most patients with intermittent claudication continued to significantly improve their walking distance and walking speed at 1 year compared with normal walking. Quality of life and ABPIs improved significantly after only 12 weeks and it is postulated that the improvement in ABPI was due to collateral development. These results justify the belief that an augmented home exercise programme will be as clinically effective as existing supervised exercise programmes, with the added benefits of lower cost and better compliance. Funding for a multicentre trial comparing an augmented home exercise programme with existing supervised exercise programme is now urgently required. Ó 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 12 September 2016, Accepted 1 February 2017, Available online XXX Keywords: Ankle brachial pressure index, Exercise therapy, Home exercise programme, Intermittent claudication, Nordic pole walking, Nordic Poles, Peripheral arterial disease, Quality of life
* Corresponding author. STEPS Physiotherapy and Circulation Clinics, 32 Southbourne Road, Sheffield S10 2QN, UK. E-mail address: [email protected] (C. Oakley). 1078-5884/Ó 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2017.02.025
INTRODUCTION Nordic pole walking (NPW) has become an accepted form of exercise training for athletes, and is increasingly being used for patients with various conditions, including arthropathy and peripheral arterial disease (PAD). There is good
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
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evidence that NPW improves cardiovascular fitness in many patient groups, including those with intermittent claudication (IC),1 and is a suitable form of exercise for the older population.2 NPW results in an increase in oxygen use (23%) and calorific expenditure (22%) versus regular walking, without an increase in perceived exertion.3 It feels easier than normal walking (NW) but works the cardiovascular system up to 23% harder, as more muscles are used. NPW involves a significant contribution from the arm and shoulder muscles, which aids forward propulsion. It increases stability, and also reduces the load on the spine and lower limbs when walking uphill or on the flat, compared with ordinary walking.4 This may be an additional benefit as many patients with PAD are elderly and so have an increased incidence of arthritis.5 Psychological mood enhancement has also been attributed to NPW.6 Oakley et al. found that all patients with IC immediately walked further with poles.7 The immediate increase in walking distance with poles is probably due to the decreased level of leg pain caused by the reduction in lower limb loading stress.4 A previous randomised controlled trial (RCT) was carried out to compare the benefits of a 12 week home exercise programme (HEP) of NW with one augmented by NPW in patients with IC.8 Patients in the NPW group immediately walked further, both to claudication distance (CD) and maximum walking distance (MWD). CD and MWD continued to improve over the 12 weeks in both groups. Verbal feedback from participants indicated that the weekly telephone support, walking diaries, and pedometers helped considerably with self regulation and compliance during the study. The results showed that four weekly attendance for exercise testing was not required, as the telephone support was sufficient. Further investigation was needed to identify how significant these elements were to patient compliance in future studies and to investigate the impact on patient quality of life (QoL). Long-term compliance with home based exercise programmes in claudicants has been found to be low in previous studies.9 Two studies were therefore carried out. The follow-up study looked at walking data and compliance after 6 and 12 months for the patients who had completed the original RCT.8 The QoL study recruited a new observational cohort of 29 patients and compared resting ankle brachial pressure index (ABPI) and QoL before and after a 12 week HEP augmented with NPW. The first objective of this study was to collect long-term follow-up information on walking distance, speed, and compliance in patients with IC who took part in a previously reported 12 week RCT of a HEP augmented with NPW versus controls who walked normally.8 The second objective was to look at improvements in QoL and ABPIs in a new observational cohort of patients after the same 12 week NWP used in the original RCT. METHODS To be considered for the original RCT, patients were required to have had stable IC due to PAD (>6/12 duration
C. Oakley et al.
of symptoms and a resting ABPI of <0.9), and be unsuitable for revascularisation or had no revascularisation procedure in the last 6 months.8 The level of disease and unsuitability for revascularisation was determined by duplex ultrasound and/or magnetic resonance angiography. Patients were excluded if they had other conditions that could significantly compromise their walking distance (e.g., breathlessness or severe osteoarthrosis). Thirty-two of the 38 participants who had completed the previous RCT were successfully contacted via telephone 6 and then 12 months after the end of the original study. In the NPW group, 17/19 were contacted successfully and in the NW group 15/19 participants were contacted successfully. At the end of the original study, all participants had been asked to continue using diaries and pedometers. Based on this information, they were asked a series of questions about their walking habits, and their weekly duration, frequency, and distance walked were recorded. The NPW group had been encouraged to continue to use their poles when walking and the control (NW) group to walk normally. No further support was given after the end of the original 3 month exercise programme. A new observational cohort of 29 patients with IC were recruited for the QoL and ABPI study from the Sheffield Vascular Institute’s outpatient clinics, over a 9 month period. The inclusion and exclusion criteria were the same as for the previous RCT.8 The power calculation for the previous RCT indicated that 52 patients would be sufficient for a study involving two groups; therefore, for the QoL study it was deemed that more than 26 patients would give valid results. A proforma was used to record the demographic and clinical details, including age, sex, body mass index (BMI), duration of claudication, previous vascular interventions, level(s) of disease, and ABPI (Table 1). Patients attended Steps Clinic and were taught NPW by a physiotherapist. The patients were asked to use NPW for at least 30 min three times per week in the community. Patients were given a pedometer (Yamaxx Digiwalker CW-700/ 701; www.yamaxx.com), which could record up to 7 days of activity, and diaries to keep a record of the date, time, and duration of each period of exercise, together with the number of steps shown on the pedometer. Patients were asked to complete a walking impairment questionnaire (WIQ) and a quality of life (EQ-5D) questionnaire at 0 and 12 weeks. ABPI at rest was taken at baseline and again at 12 weeks. Compliance was monitored by using the patient diaries and by attaching a pedometer during exercise. Support was provided by weekly telephone calls (included in the budget for the study). The diary entries and activity data were discussed and relevant advice was given. BMI was measured at 0 and 12 weeks as an index of calorific expenditure. Data were analysed using IBM Statistics SPSS version 20 (IBM, Armonk, NY, USA). Descriptive statistics were obtained and tested for normal distribution using the KolmogoroveSmirnov test. The diary walking distance data (MWD) and the EQ-5D scores violated the assumption of normality and could not be normalised using data
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
An Augmented 3-month Home Exercise Programme Table 1. Demographics of the observational patient cohort. Variable Patients (n ¼ 29) Age (y) 66.8 1.66 Age range (y) 48e86 Sex (%) Male 55 Female 45 BMI (kg/m2) 28.26 1.02 Level of PAD (%) Calf 86 Thigh 10 Buttock 4 Resting ABPI 0.71 0.06 Smoking status (%) Current 17 Previous 62 Never smoked 21 Antihypertensive medication (%) 69 Beta blockers (%) 21 Previous operation (%) 10 COPD (%) 10 IHD (%) 24 Previous stroke (%) 10 Diabetes (%) 41 Arthritis (%) 31 Statins (%) 100 Antiplatelet agents (%) 100 Warfarin (%) 3 Note. Unless otherwise stated, values are means SE. Ankle brachial pressure indices (ABPI) data are presented for the most symptomatic limb. BMI ¼ body mass index; COPD ¼ chronic obstructive pulmonary disease; IHD ¼ ischaemic heart disease.
transformation techniques, so non-parametric tests had to be used. The Wilcoxon Signed Rank test was therefore used to analyse differences in walking distance and as multiple comparisons were being made, the alpha level was set to p < .017 using a Bonferroni correction to reduce the risk of type 1 errors. Friedman’s test (non-parametric ANOVA), was used to show differences between the groups across multiple tests. WIQ data, EQ-5D health scores and ABPI were analysed using paired-sample t tests. RESULTS Compliance with regular walking in both groups from the original RCT was excellent, with much higher values than the 20% predicted by the Bermingham model.9 Sixteen of 17 participants (94%) in the Nordic pole group were still walking regularly at both 6 and 12 months, while 11/15 (73%) of the control group were still walking regularly. A CONSORT diagram of the original RCT updated to include long-term follow-up and compliance is shown in Fig. 1.
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4.2 km/hour. The control group increased their weekly distance from 4.2 km to 5.6 km and speed to 3.3 km/hour (Fig. 2). Friedman’s test was used to show differences in WD between the groups and was highly significant (p ¼ .006). Repeated ANOVA test, which compares all possible means (with matched data within groups), was also highly significant (p ¼ .002). Twenty-one of the 29 patients in the observational study completed the 12 week augmented HEP. Eight patients withdrew from the study, owing to various health reasons. Walking diary distance data violated the assumption of normality; therefore, non-parametric tests were used for analysis. A Wilcoxon Signed Rank test revealed a statistically significant increase in walking distance (z ¼ 2.809; p ¼ .005), with a large effect size (r ¼ .66). The median weekly walking distance increased from 1.66 km at baseline to 2.06 km at 12 weeks. A paired-samples t test was used to analyse the ABPI data, as they were normally distributed. There was a statistically significant increase in resting ABPI from baseline (mean SD 0.75 0.12) to week 12 (mean SD 0.85 0.12; t ¼ (20) 8.89; p ¼ .000 [two-tailed]). The eta squared statistic (.80) indicated a large effect size, with an improvement in ABPI in all patients (Fig. 3) The WIQ data were normally distributed and therefore a paired-sample t test was used. There was a statistically significant increase in: (i) walking distance scores from baseline (mean SD 0.71 0.48) to week 12 (mean 1.02 0.48; t ¼ (18) 3.936; p ¼ .001 [two-tailed]) (the eta squared statistic [.46] indicated a large effect size); (ii) walking speed scores from baseline (mean SD 0.31 0.18) to week 12 (mean SD 0.52 0.16; t ¼ (18) 4.957; p ¼ .000 [two-tailed]) (the eta squared statistic [.58] indicated a large effect size); (iii) WIQ symptom scores from baseline (mean SD 0.61 0.19) to week 12 (mean SD 0.77 0.14; t ¼ (18) 3.725; p ¼ .002 [two-tailed]) (the eta squared statistic [.44] indicated a large effect size). The EQ-5D data violated the assumption of normality; therefore, non-parametric tests were used for analysis. A Wilcoxon Signed Rank test revealed a statistically significant increase in the EQ-5D scores (z ¼ 3.059, p ¼ .002), with a large effect size (r ¼ .7). The median scores increased from 0.68 at baseline to 0.80 at 12 weeks. The perceived health scores (as filled in by the patient), were much higher than the actual EQ-5D scores. As the data were normally distributed, a paired samples t test was used There was a statistically significant increase in scores from baseline (mean SD 56.32 16.98) to week 12 (mean SD 77.37 12.95; t ¼ (18) 6.601; p ¼ .000 [two tailed]). The eta squared statistic (.71) indicated a large effect size.
Distance, speed, and time One year later, both groups in the RCT follow-up study continued to improve their weekly walking distance, time, and speed. The NPW group increased their mean weekly distance to 17.5 km by 12 months, with a mean speed of
DISCUSSION Long-term compliance at both 6 and 12 months was much better than that predicted by the Bermingham model for both HEP and supervised exercise program (SEP).9 It was
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
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C. Oakley et al.
Referred from clinic (n = 86)
Excluded (n = 25) Did not meet inclusion criteria (n = 2) Declined to participate (n = 23)
Consented (n = 61)
Withdrawn after consent, prior to commencing study (n = 9)
Cancer n = 2 Cardiac n = 1 Back pain n = 1 Respiratory n = 1 General health deteriorated n = 1 Having surgery n = 1 No time n = 2
Randomised (n = 52)
Allocated to NPW group (n = 28)
Allocated to control (NW) group (n =24)
Withdrawn during study (n = 9)
Withdrawn during study (n = 5)
Too good with poles n = 2 Ill health n = 2 No time n = 5
Died (MI) n = 1 Had surgery n = 1 Ill health n = 1 No time n = 2
Analysed at end of 12/52 exercise programme (n = 19)
Analysed at end of 12/52 exercise programme (n = 19)
Contacted 1 year after end of programme (n = 17/19)
Contacted 1 year after end of programme (n = 15/19)
Still walking with Nordic poles (n = 16/17; 94%)
Still walking normally (n = 11/15; 73%)
Figure 1. CONSORT diagram for randomised controlled trial of 12/52 exercise programme, including follow-up 1 year after end of exercise programme. Note. NPW ¼ Nordic pole walking; NW ¼ normal walking; MI ¼ myocardial infarction.
Mean walking distance
Mean walking speed mean speed in Km/h
Distance in Km
20
15 10 5 0 Baseline
12 weeks
6 Months
1 Year
4.7 4.2 NPW 3.7 Control 3.2 2.7 12 weeks
6 months
1 year
Figure 2. Mean walking speed and distance. Note. NPW ¼ Nordic pole walking. Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
An Augmented 3-month Home Exercise Programme
Change in resng ABPI over 12 weeks 1.2
1
0.8
0.6
5
noted from the previous RCT that there was a trend towards improved ABPI in the NPW group, which merited further investigation, and it is believed that this is the first exercise study to show a significant increase in ABPIs in only 12 weeks. NPW enables patients with IC to reach their exercise threshold and therefore improves cardiac output and fitness. It is hypothesised that the improvement in resting ABPI is due to the development of increased collateral vessel development caused by this improved threshold.
0.4
CONCLUSIONS
0.2
0 week 1
week 12
Figure 3. Individual improvements in resting ankle brachial pressure indices over 12 weeks.
very encouraging to find that 94% of the NPW group and 73% of the NW group from the original RCT that were successfully contacted were still walking regularly. If it is assumed that all the participants that could not be contacted had stopped walking regularly, then 27/38 (71%) of all participants who completed the original study were still walking regularly. This high compliance demonstrates that a good walking habit had been formed. The patients all reported that the weekly telephone support for the first 12 weeks had a strong effect on them, as they developed a relationship with the research staff and did not want to “let them down”. This effect may be a “local” variant, but has been reproduced in other centres, and emphasises the benefit of such psychological support.10 One year later, the distance, speed and time were still rising in the NPW group, whereas they had plateaued in the NW group. This suggests that NPW may become even be more effective with time. Therefore, it is recommended that follow-up should be continued for even longer in subsequent studies. HEP, that is, a supported programme of home based exercise (using diaries, telephone support, and pedometers), has been shown to be superior to “go home and walk advice”, but inferior to SEP.11 WIQ pain, distance, and speed subscales and EQ-5D scores have been shown to correlate well with walking distance and to describe the ambulatory limitations of patients with intermittent claudication.12 QoL was not investigated in the previous RCT, owing to limited resources, but it was suggested by reviewers of the previously published paper that this should have been included. Improvements in QoL scores have been well documented in many studies for SEPs, unsupervised home exercise, and even “go home and walk” advice.11,13 Although QoL following a 12 week Nordic walking programme has never been studied, it was felt that it was unnecessary to have a control group. The present results demonstrate that a 12 week supported HEP augmented with NPW produced improvements in walking and QoL comparable with those achieved by SEP,11 at a lower cost, and with much better long-term compliance. The cost of SEP per patient has been estimated to be £288 versus costs of £87.50 per patient for HEP þ NPW.9 It was
There is considerable uncertainty concerning the long-term effectiveness of both conventional HEPs and SEPs. This may explain why they are poorly funded and therefore unavailable to the majority of claudicants, despite recommendations from the National Institute of Clinical Excellence and other similar bodies that a trial of exercise should be the first line treatment.13 Only six trials have compared a supported HEP with SEP. All showed that at 12 weeks SEP was superior in terms of improvement in walking distance.11 However, SEPs are more expensive and can be compromised by poor compliance because many patients dislike attending a gym. It has been convincingly demonstrated that a 12 week HEP, augmented by telephone support and Nordic walking poles, results in long-term benefits that match or exceed those of SEPs at lower cost and with much better compliance.9 Another recent RCT of 70 claudicants by Bulinska et al. confirms this conclusion.14 Bulinska et al. found that community based walking training using NPW was as clinically effective as a 3/12 SEP using treadmill training, and less expensive.14 Funding for a large, randomised, multicentre trial comparing an augmented HEP with existing SEPs is now urgently required. National and international societies such as the Vascular Society of Great Britain and Ireland and the European Society for Vascular Surgery must act as advocates for exercise therapy and lobby grant giving institutions to fund such a trial. Failure to do so will deprive many patients access to a simple, inexpensive and potentially highly effective treatment. Study limitations The main limitation of the follow-up study was the small sample size. This was due to the 14 patients that failed to complete from the original RCT after randomisation and a further six who could not be contacted for long-term followup. Eight patients also withdrew from the new QoL study. The most common reasons for withdrawal in both studies were lack of time and ill health. The problem of ill health is common in studies including patients with PAD, owing to their high incidence of comorbidities.15 Lack of time is a common “excuse” for patients who are not prepared to alter their lifestyle, as highlighted in the article by Popplewell and Bradbury.16 This reluctance shown by patients, who want a “quick fix” is reinforced by a lack of enthusiasm by many surgeons who have an affinity for their more familiar interventional techniques.
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
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CONFLICTS OF INTEREST None. FUNDING Sheffield Hospitals Charity. REFERENCES 1 Langbein WE, Collins EG, Orebaugh C, Maloney C, Williams KJ, Littooy FN, et al. Increasing exercise tolerance of persons limited by claudication pain using polestriding. J Vasc Surg 2002;35:887e93. 2 Skorkowska-Telichowska K, Kropielnicka K, Bulinska K, Pilch U, Wozniewski M, Szuba A, et al. Nordic walking in the second half of life. Ageing Clin Exp Res 2016;28:1035e46. 3 Church TS, Earnest CP, Morss GM. Field testing of physiological responses associated with Nordic walking. Res Q Exerc Sport 2002;73:296e300. 4 Willson J, Torry MR, Decker MJ, Kernozek T, Steadman JR. Effects of walking poles on lower extremity gait mechanics. Med Sci Sports Exerc 2001;33:142e7. 5 Centers for Disease Control and Prevention. Arthrtis. Available at: www.cdc.gov/arthritis/data_statistics/arthritis-related-stats. htm updated 5 October 2016. 6 Stoughton L. Psychological profiles before and after 12 weeks of walking or exerstrider training in adult women. MSc Thesis. University of Wisconsin La-Crosse; 1992. 7 Oakley C, Zwierska I, Tew G, Beard JD, Saxton JM. Nordic poles immediately improve walking distance in patients with intermittent claudication. Eur J Vasc Endovasc Surg 2008;36:689e94. 8 Spafford C, Oakley C, Beard J. Nordic pole walking is more effective than a standard home exercise programme in improving walking distance in patients with intermittent claudication: a prospective randomised study. Br J Surg 2014;101:760e7.
C. Oakley et al. 9 Bermingham SL, Sparrow K, Mullis R, Fox M, Shearman C, Bradbury A, et al. The cost-effectiveness of supervised exercise for the treatment of intermittent claudication. Eur J Vasc Endovasc Surg 2013;46:707e14. 10 Cunningham MA, Swanson V, O’Carroll RE, Holdsworth RJ. Randomized clinical trial of a brief psychological intervention to increase walking in patients with intermittent claudication. Br J Surg 2012;99:49e56. 11 Al-Jundi W, Madbak K, Beard JD, Nawaz S, Tew GA. Systematic review of home-based exercise programmes for individuals with intermittent claudication. Eur J Vasc Endovasc Surg 2013;46:690e706. 12 Myers SA, Johanning JM, Stergiou N, Lynch TG, Longo GM, Pipinos II. Claudication distances and the Walking Impairment Questionnaire best describe the ambulatory limitations in patients with symptomatic peripheral arterial disease. J Vasc Surg 2008;47:550e5. 13 Vemulapalli S, Dolor RJ, Hasselblad V, Schmit K, Banks A, Heidenfelder B, et al. Supervised vs unsupervised exercise for intermittent claudication: a systematic review and meta-analysis. Am Heart J 2015;169:924e37. 14 Bulinska K, Kropielnicka K, Jasinski T, Wojcieszczyk-Latos J, Picl L, Dabrowska G, et al. Nordic pole walking improves walking capacity in patients with intermittent claudication: a randomized controlled trial. Disabil Rehabil 2015;25:1e8. 15 Zeymer U, Parhofer KG, Pittrow D, Binz C, Schwertfeger M, Limbourg T, et al. Risk factor profile, management and prognosis of patients with peripheral arterial disease with or without coronary artery disease: results of the prospective German REACH registry cohort. Clin Res Cardiol 2009;98: 249e56. 16 Popplewell MA, Bradbury AW. Why do health systems not fund supervised exercise programmes for intermittent claudication? Eur J Vasc Endovasc Surg 2014;48:608e10.
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
-,
1e6
A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year C. Oakley a b
a,*
, C. Spafford a, J.D. Beard
b
Sheffield Nordic Walking Research, STEPS Physiotherapy and Circulation Clinics, 32 Southbourne Road, Sheffield S10 2QN, UK Sheffield Vascular Institute, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
WHAT THIS PAPER ADDS This paper confirms the long-term benefit of a three-month home exercise programme augmented with Nordic pole walking for patients with intermittent claudication. Weekly walking distance continued to improve out to one year and compliance was excellent. This is the first study to also show an increase in resting ABPIs after only three months. A large multicentre trial of an augmented Home Exercise Programme compared to existing (more expensive) Supervised Exercise Programmes is urgently required.
Objective/Background: The objective of this study was to collect 1 year follow-up information on walking distance, speed, compliance, and cost in patients with intermittent claudication who took part in a previously reported 12 week randomised clinical trial of a home exercise programme augmented with Nordic pole walking versus controls who walked normally. A second objective was to look at quality of life and ankle brachial pressure indices (ABPIs) after a 12 week augmented home exercise programme. Methods: Thirty-two of the 38 patients who completed the original trial were followed-up after 6 and 12 months. Frequency, duration, speed, and distance of walking were recorded using diaries and pedometers. A new observational cohort of 29 patients was recruited to the same augmented home exercise programme. ABPIs, walking improvement, and quality of life questionnaire were recorded at baseline and 12 weeks (end of the programme). Results: Both groups in the follow-up study continued to improve their walking distance and speed over the following year. Compliance was excellent: 98% of the augmented group were still walking with poles at both 6 and 12 months, while 74% of the control group were still walking at the same point. The augmented group increased their mean walking distance to 17.5 km by 12 months, with a mean speed of 4.2 km/hour. The control group only increased their mean walking distance from 4.2 km to 5.6 km, and speed to 3.3 km/hour. Repeated ANOVA showed the results to be highly significant (p ¼ .002). The 21/29 patients who completed the observational study showed a statistically significant increase in resting ABPIs from baseline (mean SD 0.75 0.12) to week 12 (mean SD 0.85 0.12) (t ¼ (20) 8.89, p ¼ .000 [two-tailed]). All their walking improvement and quality of life parameters improved significantly (p ¼ .002 or less in the six categories) over the same period and their mean health scores improved by 79%. Conclusions: Following a 12 week augmented home exercise programme, most patients with intermittent claudication continued to significantly improve their walking distance and walking speed at 1 year compared with normal walking. Quality of life and ABPIs improved significantly after only 12 weeks and it is postulated that the improvement in ABPI was due to collateral development. These results justify the belief that an augmented home exercise programme will be as clinically effective as existing supervised exercise programmes, with the added benefits of lower cost and better compliance. Funding for a multicentre trial comparing an augmented home exercise programme with existing supervised exercise programme is now urgently required. Ó 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. Article history: Received 12 September 2016, Accepted 1 February 2017, Available online XXX Keywords: Ankle brachial pressure index, Exercise therapy, Home exercise programme, Intermittent claudication, Nordic pole walking, Nordic Poles, Peripheral arterial disease, Quality of life
* Corresponding author. STEPS Physiotherapy and Circulation Clinics, 32 Southbourne Road, Sheffield S10 2QN, UK. E-mail address: [email protected] (C. Oakley). 1078-5884/Ó 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejvs.2017.02.025
INTRODUCTION Nordic pole walking (NPW) has become an accepted form of exercise training for athletes, and is increasingly being used for patients with various conditions, including arthropathy and peripheral arterial disease (PAD). There is good
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
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evidence that NPW improves cardiovascular fitness in many patient groups, including those with intermittent claudication (IC),1 and is a suitable form of exercise for the older population.2 NPW results in an increase in oxygen use (23%) and calorific expenditure (22%) versus regular walking, without an increase in perceived exertion.3 It feels easier than normal walking (NW) but works the cardiovascular system up to 23% harder, as more muscles are used. NPW involves a significant contribution from the arm and shoulder muscles, which aids forward propulsion. It increases stability, and also reduces the load on the spine and lower limbs when walking uphill or on the flat, compared with ordinary walking.4 This may be an additional benefit as many patients with PAD are elderly and so have an increased incidence of arthritis.5 Psychological mood enhancement has also been attributed to NPW.6 Oakley et al. found that all patients with IC immediately walked further with poles.7 The immediate increase in walking distance with poles is probably due to the decreased level of leg pain caused by the reduction in lower limb loading stress.4 A previous randomised controlled trial (RCT) was carried out to compare the benefits of a 12 week home exercise programme (HEP) of NW with one augmented by NPW in patients with IC.8 Patients in the NPW group immediately walked further, both to claudication distance (CD) and maximum walking distance (MWD). CD and MWD continued to improve over the 12 weeks in both groups. Verbal feedback from participants indicated that the weekly telephone support, walking diaries, and pedometers helped considerably with self regulation and compliance during the study. The results showed that four weekly attendance for exercise testing was not required, as the telephone support was sufficient. Further investigation was needed to identify how significant these elements were to patient compliance in future studies and to investigate the impact on patient quality of life (QoL). Long-term compliance with home based exercise programmes in claudicants has been found to be low in previous studies.9 Two studies were therefore carried out. The follow-up study looked at walking data and compliance after 6 and 12 months for the patients who had completed the original RCT.8 The QoL study recruited a new observational cohort of 29 patients and compared resting ankle brachial pressure index (ABPI) and QoL before and after a 12 week HEP augmented with NPW. The first objective of this study was to collect long-term follow-up information on walking distance, speed, and compliance in patients with IC who took part in a previously reported 12 week RCT of a HEP augmented with NPW versus controls who walked normally.8 The second objective was to look at improvements in QoL and ABPIs in a new observational cohort of patients after the same 12 week NWP used in the original RCT. METHODS To be considered for the original RCT, patients were required to have had stable IC due to PAD (>6/12 duration
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of symptoms and a resting ABPI of <0.9), and be unsuitable for revascularisation or had no revascularisation procedure in the last 6 months.8 The level of disease and unsuitability for revascularisation was determined by duplex ultrasound and/or magnetic resonance angiography. Patients were excluded if they had other conditions that could significantly compromise their walking distance (e.g., breathlessness or severe osteoarthrosis). Thirty-two of the 38 participants who had completed the previous RCT were successfully contacted via telephone 6 and then 12 months after the end of the original study. In the NPW group, 17/19 were contacted successfully and in the NW group 15/19 participants were contacted successfully. At the end of the original study, all participants had been asked to continue using diaries and pedometers. Based on this information, they were asked a series of questions about their walking habits, and their weekly duration, frequency, and distance walked were recorded. The NPW group had been encouraged to continue to use their poles when walking and the control (NW) group to walk normally. No further support was given after the end of the original 3 month exercise programme. A new observational cohort of 29 patients with IC were recruited for the QoL and ABPI study from the Sheffield Vascular Institute’s outpatient clinics, over a 9 month period. The inclusion and exclusion criteria were the same as for the previous RCT.8 The power calculation for the previous RCT indicated that 52 patients would be sufficient for a study involving two groups; therefore, for the QoL study it was deemed that more than 26 patients would give valid results. A proforma was used to record the demographic and clinical details, including age, sex, body mass index (BMI), duration of claudication, previous vascular interventions, level(s) of disease, and ABPI (Table 1). Patients attended Steps Clinic and were taught NPW by a physiotherapist. The patients were asked to use NPW for at least 30 min three times per week in the community. Patients were given a pedometer (Yamaxx Digiwalker CW-700/ 701; www.yamaxx.com), which could record up to 7 days of activity, and diaries to keep a record of the date, time, and duration of each period of exercise, together with the number of steps shown on the pedometer. Patients were asked to complete a walking impairment questionnaire (WIQ) and a quality of life (EQ-5D) questionnaire at 0 and 12 weeks. ABPI at rest was taken at baseline and again at 12 weeks. Compliance was monitored by using the patient diaries and by attaching a pedometer during exercise. Support was provided by weekly telephone calls (included in the budget for the study). The diary entries and activity data were discussed and relevant advice was given. BMI was measured at 0 and 12 weeks as an index of calorific expenditure. Data were analysed using IBM Statistics SPSS version 20 (IBM, Armonk, NY, USA). Descriptive statistics were obtained and tested for normal distribution using the KolmogoroveSmirnov test. The diary walking distance data (MWD) and the EQ-5D scores violated the assumption of normality and could not be normalised using data
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
An Augmented 3-month Home Exercise Programme Table 1. Demographics of the observational patient cohort. Variable Patients (n ¼ 29) Age (y) 66.8 1.66 Age range (y) 48e86 Sex (%) Male 55 Female 45 BMI (kg/m2) 28.26 1.02 Level of PAD (%) Calf 86 Thigh 10 Buttock 4 Resting ABPI 0.71 0.06 Smoking status (%) Current 17 Previous 62 Never smoked 21 Antihypertensive medication (%) 69 Beta blockers (%) 21 Previous operation (%) 10 COPD (%) 10 IHD (%) 24 Previous stroke (%) 10 Diabetes (%) 41 Arthritis (%) 31 Statins (%) 100 Antiplatelet agents (%) 100 Warfarin (%) 3 Note. Unless otherwise stated, values are means SE. Ankle brachial pressure indices (ABPI) data are presented for the most symptomatic limb. BMI ¼ body mass index; COPD ¼ chronic obstructive pulmonary disease; IHD ¼ ischaemic heart disease.
transformation techniques, so non-parametric tests had to be used. The Wilcoxon Signed Rank test was therefore used to analyse differences in walking distance and as multiple comparisons were being made, the alpha level was set to p < .017 using a Bonferroni correction to reduce the risk of type 1 errors. Friedman’s test (non-parametric ANOVA), was used to show differences between the groups across multiple tests. WIQ data, EQ-5D health scores and ABPI were analysed using paired-sample t tests. RESULTS Compliance with regular walking in both groups from the original RCT was excellent, with much higher values than the 20% predicted by the Bermingham model.9 Sixteen of 17 participants (94%) in the Nordic pole group were still walking regularly at both 6 and 12 months, while 11/15 (73%) of the control group were still walking regularly. A CONSORT diagram of the original RCT updated to include long-term follow-up and compliance is shown in Fig. 1.
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4.2 km/hour. The control group increased their weekly distance from 4.2 km to 5.6 km and speed to 3.3 km/hour (Fig. 2). Friedman’s test was used to show differences in WD between the groups and was highly significant (p ¼ .006). Repeated ANOVA test, which compares all possible means (with matched data within groups), was also highly significant (p ¼ .002). Twenty-one of the 29 patients in the observational study completed the 12 week augmented HEP. Eight patients withdrew from the study, owing to various health reasons. Walking diary distance data violated the assumption of normality; therefore, non-parametric tests were used for analysis. A Wilcoxon Signed Rank test revealed a statistically significant increase in walking distance (z ¼ 2.809; p ¼ .005), with a large effect size (r ¼ .66). The median weekly walking distance increased from 1.66 km at baseline to 2.06 km at 12 weeks. A paired-samples t test was used to analyse the ABPI data, as they were normally distributed. There was a statistically significant increase in resting ABPI from baseline (mean SD 0.75 0.12) to week 12 (mean SD 0.85 0.12; t ¼ (20) 8.89; p ¼ .000 [two-tailed]). The eta squared statistic (.80) indicated a large effect size, with an improvement in ABPI in all patients (Fig. 3) The WIQ data were normally distributed and therefore a paired-sample t test was used. There was a statistically significant increase in: (i) walking distance scores from baseline (mean SD 0.71 0.48) to week 12 (mean 1.02 0.48; t ¼ (18) 3.936; p ¼ .001 [two-tailed]) (the eta squared statistic [.46] indicated a large effect size); (ii) walking speed scores from baseline (mean SD 0.31 0.18) to week 12 (mean SD 0.52 0.16; t ¼ (18) 4.957; p ¼ .000 [two-tailed]) (the eta squared statistic [.58] indicated a large effect size); (iii) WIQ symptom scores from baseline (mean SD 0.61 0.19) to week 12 (mean SD 0.77 0.14; t ¼ (18) 3.725; p ¼ .002 [two-tailed]) (the eta squared statistic [.44] indicated a large effect size). The EQ-5D data violated the assumption of normality; therefore, non-parametric tests were used for analysis. A Wilcoxon Signed Rank test revealed a statistically significant increase in the EQ-5D scores (z ¼ 3.059, p ¼ .002), with a large effect size (r ¼ .7). The median scores increased from 0.68 at baseline to 0.80 at 12 weeks. The perceived health scores (as filled in by the patient), were much higher than the actual EQ-5D scores. As the data were normally distributed, a paired samples t test was used There was a statistically significant increase in scores from baseline (mean SD 56.32 16.98) to week 12 (mean SD 77.37 12.95; t ¼ (18) 6.601; p ¼ .000 [two tailed]). The eta squared statistic (.71) indicated a large effect size.
Distance, speed, and time One year later, both groups in the RCT follow-up study continued to improve their weekly walking distance, time, and speed. The NPW group increased their mean weekly distance to 17.5 km by 12 months, with a mean speed of
DISCUSSION Long-term compliance at both 6 and 12 months was much better than that predicted by the Bermingham model for both HEP and supervised exercise program (SEP).9 It was
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
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Referred from clinic (n = 86)
Excluded (n = 25) Did not meet inclusion criteria (n = 2) Declined to participate (n = 23)
Consented (n = 61)
Withdrawn after consent, prior to commencing study (n = 9)
Cancer n = 2 Cardiac n = 1 Back pain n = 1 Respiratory n = 1 General health deteriorated n = 1 Having surgery n = 1 No time n = 2
Randomised (n = 52)
Allocated to NPW group (n = 28)
Allocated to control (NW) group (n =24)
Withdrawn during study (n = 9)
Withdrawn during study (n = 5)
Too good with poles n = 2 Ill health n = 2 No time n = 5
Died (MI) n = 1 Had surgery n = 1 Ill health n = 1 No time n = 2
Analysed at end of 12/52 exercise programme (n = 19)
Analysed at end of 12/52 exercise programme (n = 19)
Contacted 1 year after end of programme (n = 17/19)
Contacted 1 year after end of programme (n = 15/19)
Still walking with Nordic poles (n = 16/17; 94%)
Still walking normally (n = 11/15; 73%)
Figure 1. CONSORT diagram for randomised controlled trial of 12/52 exercise programme, including follow-up 1 year after end of exercise programme. Note. NPW ¼ Nordic pole walking; NW ¼ normal walking; MI ¼ myocardial infarction.
Mean walking distance
Mean walking speed mean speed in Km/h
Distance in Km
20
15 10 5 0 Baseline
12 weeks
6 Months
1 Year
4.7 4.2 NPW 3.7 Control 3.2 2.7 12 weeks
6 months
1 year
Figure 2. Mean walking speed and distance. Note. NPW ¼ Nordic pole walking. Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
An Augmented 3-month Home Exercise Programme
Change in resng ABPI over 12 weeks 1.2
1
0.8
0.6
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noted from the previous RCT that there was a trend towards improved ABPI in the NPW group, which merited further investigation, and it is believed that this is the first exercise study to show a significant increase in ABPIs in only 12 weeks. NPW enables patients with IC to reach their exercise threshold and therefore improves cardiac output and fitness. It is hypothesised that the improvement in resting ABPI is due to the development of increased collateral vessel development caused by this improved threshold.
0.4
CONCLUSIONS
0.2
0 week 1
week 12
Figure 3. Individual improvements in resting ankle brachial pressure indices over 12 weeks.
very encouraging to find that 94% of the NPW group and 73% of the NW group from the original RCT that were successfully contacted were still walking regularly. If it is assumed that all the participants that could not be contacted had stopped walking regularly, then 27/38 (71%) of all participants who completed the original study were still walking regularly. This high compliance demonstrates that a good walking habit had been formed. The patients all reported that the weekly telephone support for the first 12 weeks had a strong effect on them, as they developed a relationship with the research staff and did not want to “let them down”. This effect may be a “local” variant, but has been reproduced in other centres, and emphasises the benefit of such psychological support.10 One year later, the distance, speed and time were still rising in the NPW group, whereas they had plateaued in the NW group. This suggests that NPW may become even be more effective with time. Therefore, it is recommended that follow-up should be continued for even longer in subsequent studies. HEP, that is, a supported programme of home based exercise (using diaries, telephone support, and pedometers), has been shown to be superior to “go home and walk advice”, but inferior to SEP.11 WIQ pain, distance, and speed subscales and EQ-5D scores have been shown to correlate well with walking distance and to describe the ambulatory limitations of patients with intermittent claudication.12 QoL was not investigated in the previous RCT, owing to limited resources, but it was suggested by reviewers of the previously published paper that this should have been included. Improvements in QoL scores have been well documented in many studies for SEPs, unsupervised home exercise, and even “go home and walk” advice.11,13 Although QoL following a 12 week Nordic walking programme has never been studied, it was felt that it was unnecessary to have a control group. The present results demonstrate that a 12 week supported HEP augmented with NPW produced improvements in walking and QoL comparable with those achieved by SEP,11 at a lower cost, and with much better long-term compliance. The cost of SEP per patient has been estimated to be £288 versus costs of £87.50 per patient for HEP þ NPW.9 It was
There is considerable uncertainty concerning the long-term effectiveness of both conventional HEPs and SEPs. This may explain why they are poorly funded and therefore unavailable to the majority of claudicants, despite recommendations from the National Institute of Clinical Excellence and other similar bodies that a trial of exercise should be the first line treatment.13 Only six trials have compared a supported HEP with SEP. All showed that at 12 weeks SEP was superior in terms of improvement in walking distance.11 However, SEPs are more expensive and can be compromised by poor compliance because many patients dislike attending a gym. It has been convincingly demonstrated that a 12 week HEP, augmented by telephone support and Nordic walking poles, results in long-term benefits that match or exceed those of SEPs at lower cost and with much better compliance.9 Another recent RCT of 70 claudicants by Bulinska et al. confirms this conclusion.14 Bulinska et al. found that community based walking training using NPW was as clinically effective as a 3/12 SEP using treadmill training, and less expensive.14 Funding for a large, randomised, multicentre trial comparing an augmented HEP with existing SEPs is now urgently required. National and international societies such as the Vascular Society of Great Britain and Ireland and the European Society for Vascular Surgery must act as advocates for exercise therapy and lobby grant giving institutions to fund such a trial. Failure to do so will deprive many patients access to a simple, inexpensive and potentially highly effective treatment. Study limitations The main limitation of the follow-up study was the small sample size. This was due to the 14 patients that failed to complete from the original RCT after randomisation and a further six who could not be contacted for long-term followup. Eight patients also withdrew from the new QoL study. The most common reasons for withdrawal in both studies were lack of time and ill health. The problem of ill health is common in studies including patients with PAD, owing to their high incidence of comorbidities.15 Lack of time is a common “excuse” for patients who are not prepared to alter their lifestyle, as highlighted in the article by Popplewell and Bradbury.16 This reluctance shown by patients, who want a “quick fix” is reinforced by a lack of enthusiasm by many surgeons who have an affinity for their more familiar interventional techniques.
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025
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CONFLICTS OF INTEREST None. FUNDING Sheffield Hospitals Charity. REFERENCES 1 Langbein WE, Collins EG, Orebaugh C, Maloney C, Williams KJ, Littooy FN, et al. Increasing exercise tolerance of persons limited by claudication pain using polestriding. J Vasc Surg 2002;35:887e93. 2 Skorkowska-Telichowska K, Kropielnicka K, Bulinska K, Pilch U, Wozniewski M, Szuba A, et al. Nordic walking in the second half of life. Ageing Clin Exp Res 2016;28:1035e46. 3 Church TS, Earnest CP, Morss GM. Field testing of physiological responses associated with Nordic walking. Res Q Exerc Sport 2002;73:296e300. 4 Willson J, Torry MR, Decker MJ, Kernozek T, Steadman JR. Effects of walking poles on lower extremity gait mechanics. Med Sci Sports Exerc 2001;33:142e7. 5 Centers for Disease Control and Prevention. Arthrtis. Available at: www.cdc.gov/arthritis/data_statistics/arthritis-related-stats. htm updated 5 October 2016. 6 Stoughton L. Psychological profiles before and after 12 weeks of walking or exerstrider training in adult women. MSc Thesis. University of Wisconsin La-Crosse; 1992. 7 Oakley C, Zwierska I, Tew G, Beard JD, Saxton JM. Nordic poles immediately improve walking distance in patients with intermittent claudication. Eur J Vasc Endovasc Surg 2008;36:689e94. 8 Spafford C, Oakley C, Beard J. Nordic pole walking is more effective than a standard home exercise programme in improving walking distance in patients with intermittent claudication: a prospective randomised study. Br J Surg 2014;101:760e7.
C. Oakley et al. 9 Bermingham SL, Sparrow K, Mullis R, Fox M, Shearman C, Bradbury A, et al. The cost-effectiveness of supervised exercise for the treatment of intermittent claudication. Eur J Vasc Endovasc Surg 2013;46:707e14. 10 Cunningham MA, Swanson V, O’Carroll RE, Holdsworth RJ. Randomized clinical trial of a brief psychological intervention to increase walking in patients with intermittent claudication. Br J Surg 2012;99:49e56. 11 Al-Jundi W, Madbak K, Beard JD, Nawaz S, Tew GA. Systematic review of home-based exercise programmes for individuals with intermittent claudication. Eur J Vasc Endovasc Surg 2013;46:690e706. 12 Myers SA, Johanning JM, Stergiou N, Lynch TG, Longo GM, Pipinos II. Claudication distances and the Walking Impairment Questionnaire best describe the ambulatory limitations in patients with symptomatic peripheral arterial disease. J Vasc Surg 2008;47:550e5. 13 Vemulapalli S, Dolor RJ, Hasselblad V, Schmit K, Banks A, Heidenfelder B, et al. Supervised vs unsupervised exercise for intermittent claudication: a systematic review and meta-analysis. Am Heart J 2015;169:924e37. 14 Bulinska K, Kropielnicka K, Jasinski T, Wojcieszczyk-Latos J, Picl L, Dabrowska G, et al. Nordic pole walking improves walking capacity in patients with intermittent claudication: a randomized controlled trial. Disabil Rehabil 2015;25:1e8. 15 Zeymer U, Parhofer KG, Pittrow D, Binz C, Schwertfeger M, Limbourg T, et al. Risk factor profile, management and prognosis of patients with peripheral arterial disease with or without coronary artery disease: results of the prospective German REACH registry cohort. Clin Res Cardiol 2009;98: 249e56. 16 Popplewell MA, Bradbury AW. Why do health systems not fund supervised exercise programmes for intermittent claudication? Eur J Vasc Endovasc Surg 2014;48:608e10.
Please cite this article in press as: Oakley C, et al., A Three Month Home Exercise Programme Augmented with Nordic Poles for Patients with Intermittent Claudication Enhances Quality of Life and Continues to Improve Walking Distance and Compliance After One Year, European Journal of Vascular and Endovascular Surgery (2017), http://dx.doi.org/10.1016/j.ejvs.2017.02.025