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Regarding ‘Life-style Modification in Peripheral Arterial Disease’
Eur J Vasc Endovasc Surg 29, 654 (2005) doi:10.1053/ejvs.2000.1146, available online at http://www.sciencedirect.com on
CORRESPONDENCE
Regarding ‘Life-style Modification in Peripheral Arterial Disease’ Sir, We read with great interest the article by Dr Khan et al. ‘life-style modification in peripheral arterial disease’.1 In view of the current great appeal of pharmacological and surgical treatment for peripheral vascular diseases, we were pleased to see the concern that the EJEVS has with this topic. However, we would like to make some necessary comments regarding this comprehensive and competent review. The authors state that ‘regular exercise coupled with risk factor modification, especially smoking cessation, is the cornerstone of conservative therapy for intermittent claudication.’ Beyond doubts, we must emphasize the great importance of stopping smoking in the reduction of the cardiovascular risk of atherosclerotic patients. This is very well established and we believe that all patients must do so. Nevertheless, our experience has shown that stopping smoking does not have an influence on increasing the distances that patients with intermittent claudication are able to walk. From a study of the evolution of the maximum walking distance in 500 patients submitted to an unsupervised physical training program while abstaining from smoking,2 we observed that, although the prognosis was strongly influenced by the patient’s adherence to the physical training, stopping smoking had nearly no influence on the patients’ response to the treatment. The patients who accomplished the training program and stopped smoking had an increase of 33.70 m/month, a similar result to that of those who also achieved the training program but did not quit smoking (42.92 m/month). Another point which grows us serious concern is the statement by the authors that ‘exercise in PAD usually involves treadmill walking although other modalities including upper limb exercise and polestriding have been reported’. There is no doubt that supervised training in a well-equipped setting brings
about benefits to patients with claudication, since good results arise among patients who keep up the training. However, many patients abandon the training program and end up not being considered in several analyses, thus generating distorted results. The importance of unsupervised training needs to be reinforced, and this is very clear in our study. Disagreeing with the authors, we believe that this is the most frequently applied method of physical training in the doctor’s day-to-day, rather than treadmill training. It should always be done in association with supervised physical training. Moreover, walking on a treadmill may present difficulties and risks for older patients.3 Finally, we would like to underline the relevance of the study of gait patterns in claudication patients. Since their gait pattern is clearly different from the normal one,4 we believe that incorporating favorable changes in those patients’ gait patterns could bring them worthy benefits which would merge with those achieved with regular treatment. R. Rosoky, N. Wolosker Divison of Vascular Surgery, Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil E-mail address. [email protected]
References 1 Khan S, Cleanthis M, Smout J, Flather M, Stansby G. Lifestyle modification in peripheral arterial disease. Eur J Vasc Endovasc Surg 2005;29:2–9. 2 Wolosker N, Nakano L, Rosoky RA, Puech Leao P. Evaluation of walking capacity over time in 500 patients with intermittent claudication who underwent clinical treatment. Arch Intern Med 2003;163:2296–2300. 3 Simonsick EM, Gardner AW, Poehlman ET. Aging 2000;12:274– 280. 4 Ayzin Rosoky RM, Wolosker N, Muraco-Netto B, Puech Lea˜o P. Ground reaction force pattern in limbs with intermittent claudication. Eur J Vasc Endovasc Surg 2000;20:254–259.
Accepted 16 February 2005 Available online 26 March 2005
1078–5884/000654 + 01 $35.00/0 q 2005 Elsevier Ltd. All rights reserved.
CORRESPONDENCE
Regarding ‘Life-style Modification in Peripheral Arterial Disease’ Sir, We read with great interest the article by Dr Khan et al. ‘life-style modification in peripheral arterial disease’.1 In view of the current great appeal of pharmacological and surgical treatment for peripheral vascular diseases, we were pleased to see the concern that the EJEVS has with this topic. However, we would like to make some necessary comments regarding this comprehensive and competent review. The authors state that ‘regular exercise coupled with risk factor modification, especially smoking cessation, is the cornerstone of conservative therapy for intermittent claudication.’ Beyond doubts, we must emphasize the great importance of stopping smoking in the reduction of the cardiovascular risk of atherosclerotic patients. This is very well established and we believe that all patients must do so. Nevertheless, our experience has shown that stopping smoking does not have an influence on increasing the distances that patients with intermittent claudication are able to walk. From a study of the evolution of the maximum walking distance in 500 patients submitted to an unsupervised physical training program while abstaining from smoking,2 we observed that, although the prognosis was strongly influenced by the patient’s adherence to the physical training, stopping smoking had nearly no influence on the patients’ response to the treatment. The patients who accomplished the training program and stopped smoking had an increase of 33.70 m/month, a similar result to that of those who also achieved the training program but did not quit smoking (42.92 m/month). Another point which grows us serious concern is the statement by the authors that ‘exercise in PAD usually involves treadmill walking although other modalities including upper limb exercise and polestriding have been reported’. There is no doubt that supervised training in a well-equipped setting brings
about benefits to patients with claudication, since good results arise among patients who keep up the training. However, many patients abandon the training program and end up not being considered in several analyses, thus generating distorted results. The importance of unsupervised training needs to be reinforced, and this is very clear in our study. Disagreeing with the authors, we believe that this is the most frequently applied method of physical training in the doctor’s day-to-day, rather than treadmill training. It should always be done in association with supervised physical training. Moreover, walking on a treadmill may present difficulties and risks for older patients.3 Finally, we would like to underline the relevance of the study of gait patterns in claudication patients. Since their gait pattern is clearly different from the normal one,4 we believe that incorporating favorable changes in those patients’ gait patterns could bring them worthy benefits which would merge with those achieved with regular treatment. R. Rosoky, N. Wolosker Divison of Vascular Surgery, Hospital das Clinicas, Faculty of Medicine, University of Sao Paulo, Sao Paulo, Brazil E-mail address. [email protected]
References 1 Khan S, Cleanthis M, Smout J, Flather M, Stansby G. Lifestyle modification in peripheral arterial disease. Eur J Vasc Endovasc Surg 2005;29:2–9. 2 Wolosker N, Nakano L, Rosoky RA, Puech Leao P. Evaluation of walking capacity over time in 500 patients with intermittent claudication who underwent clinical treatment. Arch Intern Med 2003;163:2296–2300. 3 Simonsick EM, Gardner AW, Poehlman ET. Aging 2000;12:274– 280. 4 Ayzin Rosoky RM, Wolosker N, Muraco-Netto B, Puech Lea˜o P. Ground reaction force pattern in limbs with intermittent claudication. Eur J Vasc Endovasc Surg 2000;20:254–259.
Accepted 16 February 2005 Available online 26 March 2005
1078–5884/000654 + 01 $35.00/0 q 2005 Elsevier Ltd. All rights reserved.