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Combined Lower Limb Revascularisation and Supervised Exercise Training for Patients with Peripheral Arterial Disease: A Systematic Review of Randomised Controlled Trials

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Abstract

Background

Both revascularisation and supervised exercise training improve functional outcomes and quality of life in patients with peripheral arterial disease (PAD). However, the value of combined therapy, where exercise therapy is delivered as an adjunct to revascularisation, is less clear.

Objective

To systematically review evidence on the efficacy of lower limb revascularisation combined with supervised exercise training in patients with PAD.

Methods

Parallel-group randomised controlled trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, CINAHL, SPORTDiscus and Web of Science were searched (up to Jan 2016). Outcome measures were pain-free and maximum walking distances, ankle-brachial index (ABI), leg blood flow and quality of life. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale.

Result

Eight trials were included that enrolled a total of 726 patients (mean age 66 ± 3 years, ABI 0.66 ± 0.05). Combined therapy led to greater improvements in pain-free (mean difference [MD] range 38–408 m) and maximal walking distances (MD range 82–321 m) compared with revascularisation or supervised training alone. Combined therapy had no added effect on resting ABI over revascularisation (MD range −0.05 to 0.13), and had a significantly greater effect than supervised exercise training alone (MD range 0.13–0.31). Limited evidence (one to three trials) also suggested that combined therapy led to greater improvements in leg blood flow and physical domains of quality of life than supervised exercise training alone, and that improvements in leg blood flow, as well as the physical and mental domains of quality of life were not different to that achieved with revascularisation alone.

Conclusion

Current evidence suggests that PAD patients treated with combined therapy achieve greater functional benefits than those treated with revascularisation or supervised exercise training alone. Limited evidence also suggests that the effect of combined therapy on leg haemodynamics and quality of life may be superior to supervised exercise training alone, and similar to revascularisation alone.

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Acknowledgments

We acknowledge Assoc. Prof. Melainie Cameron for her contribution to the development of the search strategy, the Inter-Library Loans Service of the University of the Sunshine Coast for assistance with paper requests, and researchers Hugo Kerherve, Ph.D., Timo Klein, M.Sc and Andreas Mireau, Ph.D. for their assistance with study language translations. We would like to thank the trial authors who provided the additional requested data and study information.

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Authors and Affiliations

  1. School of Health and Sport Sciences, University of the Sunshine Coast, Sippy Downs, QLD, Australia

    Annelise L. Menêses & Christopher D. Askew

  2. Hospital Israelita Albert Einstein, São Paulo, SP, Brazil

    Raphael M. Ritti-Dias

  3. Department of Exercise Physiology, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia

    Belinda Parmenter

  4. The Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia

    Jonathan Golledge

  5. Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia

    Jonathan Golledge

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  1. Annelise L. Menêses
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  2. Raphael M. Ritti-Dias
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  4. Jonathan Golledge
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  5. Christopher D. Askew
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Corresponding author

Correspondence to Christopher D. Askew.

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Funding

Annelise Meneses is supported by an Australian government-funded International Postgraduate Research Scholarship (IPRS). This work is supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence (CRE) (Grant Number 1000967), Australia. Jonathan Golledge holds a Practitioner Fellowship from the NHMRC (1019921). No other sources of funding were used to assist in the conduct of this review or the preparation of the manuscript.

Conflict of interest

Annelise Meneses, Raphael Ritti-Dias, Belinda Parmenter, Jonathan Golledge and Christopher Askew declare that they have no conflicts of interest relevant to the content of this review.

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Menêses, A.L., Ritti-Dias, R.M., Parmenter, B. et al. Combined Lower Limb Revascularisation and Supervised Exercise Training for Patients with Peripheral Arterial Disease: A Systematic Review of Randomised Controlled Trials. Sports Med 47, 987–1002 (2017). https://doi.org/10.1007/s40279-016-0635-5

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