Comparison of Walking with Poles and Traditional Walking for Peripheral Arterial Disease(PAD) Rehabilitation 組別 : 第 5 組 組員 : 黃俊潔 CPT 湯季哲 CPT 李旻蓉 CPT 洪偉哲 CPT 洪白瑜雯 CPT 指導老師 : 李毓森老師 報告日期 :2015/12/29( 二 ) 組別 : 第 5 組 組員 : 黃俊潔 CPT 湯季哲 CPT 李旻蓉 CPT 洪偉哲 CPT 洪白瑜雯 CPT 指導老師 : 李毓森老師 報告日期 :2015/12/29( 二 ) 1

Purpose 24-week Compare Poles walking program Traditional walking program 24-week Compare Poles walking program Traditional walking program 2

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METHODS Randomized controlled clinical trial Appropriate institutional review boards & written informed consent Inclusion criteria Ankle-brachial index (ABI) in their most affected leg of ≤0.90 Documented calcification of vessels, were 21 years or older Positive response on the Edinburgh Claudication Questionnaire Excluded criteria Ischemic ulcerations in their legs or feet Frozen shoulder Unstable coronary arterial disease Amputation Unable to walk on a treadmill Randomized controlled clinical trial Appropriate institutional review boards & written informed consent Inclusion criteria Ankle-brachial index (ABI) in their most affected leg of ≤0.90 Documented calcification of vessels, were 21 years or older Positive response on the Edinburgh Claudication Questionnaire Excluded criteria Ischemic ulcerations in their legs or feet Frozen shoulder Unstable coronary arterial disease Amputation Unable to walk on a treadmill 4

METHODS-PAD test ABI baseline in both legs and in the more severely affected leg thereafter dorsalis pedis or posterior tibial arteries Doppler ultrasound measure the systolic pressure in the right and left arms and in the ankle of the most severely affected leg  For patients with an ABI ≥1.2,vessel calcification was confirmed by the vascular laboratory ABI baseline in both legs and in the more severely affected leg thereafter dorsalis pedis or posterior tibial arteries Doppler ultrasound measure the systolic pressure in the right and left arms and in the ankle of the most severely affected leg  For patients with an ABI ≥1.2,vessel calcification was confirmed by the vascular laboratory 5

METHODS-Exercise Test Symptom-limited treadmill test protocol Increases in percent grade occur every 30 seconds&after the first 6 minutes, speed increases every 3 minutes Electrocardiogram and tissue oxygenation (StO2) of the gastrocnemius muscle were monitored Constant work rate sub maximal treadmill test protocol 2-minute warm-up grade and speed of the treadmill were increased to the 85% of his/her peak oxygen uptake on the baseline progressive treadmill test  Two baseline CWR tests were completed and the best performance was used in the analysis Symptom-limited treadmill test protocol Increases in percent grade occur every 30 seconds&after the first 6 minutes, speed increases every 3 minutes Electrocardiogram and tissue oxygenation (StO2) of the gastrocnemius muscle were monitored Constant work rate sub maximal treadmill test protocol 2-minute warm-up grade and speed of the treadmill were increased to the 85% of his/her peak oxygen uptake on the baseline progressive treadmill test  Two baseline CWR tests were completed and the best performance was used in the analysis 6

Tissue oxygenation measured using near-infrared spectroscopy widest part of the gastrocnemius muscle of the leg with the lowest ABI most symptomatic for those subjects with stiff vessels Recorded 5 minutes of sitting pre-exercise & 2 minutes of standing pre-exercise & during exercise & 5 minutes post-exercise Measurements were also recorded for the time it took for the oxygen values to drop to their minimum level after initiation of exercise Tissue oxygenation measured using near-infrared spectroscopy widest part of the gastrocnemius muscle of the leg with the lowest ABI most symptomatic for those subjects with stiff vessels Recorded 5 minutes of sitting pre-exercise & 2 minutes of standing pre-exercise & during exercise & 5 minutes post-exercise Measurements were also recorded for the time it took for the oxygen values to drop to their minimum level after initiation of exercise 7

METHODS-Gait Analysis 8-camera motion capture system recording at 120 Hz 22 passive reflective markers 2 force plates baseline and 6 weeks 8-camera motion capture system recording at 120 Hz 22 passive reflective markers 2 force plates baseline and 6 weeks 8

METHODS-Quality of Life Short Form-36 v2 Physical and emotional function medically stable individuals Walking Impairment Questionnaire walking distance walking speed stair climbing  18 questions are ranked on a 0 – 3 Likert-like scale (0 = did not do, 3 = no difficulty)  0–100 scale (0 - extreme limitations, no limitations or difficulties) Short Form-36 v2 Physical and emotional function medically stable individuals Walking Impairment Questionnaire walking distance walking speed stair climbing  18 questions are ranked on a 0 – 3 Likert-like scale (0 = did not do, 3 = no difficulty)  0–100 scale (0 - extreme limitations, no limitations or difficulties) 9

METHODS-Comorbidities Index of Coexistent Diseases 9 physiologic severity of each chronic comorbid condition assessment of the impairment or disability caused by comorbidity at a specific point in time Index of Coexistent Diseases 9 physiologic severity of each chronic comorbid condition assessment of the impairment or disability caused by comorbidity at a specific point in time 10

METHODS-Study Intervention conducted 3 times weekly for 24 weeks Each 30 minutes (light - 20%, moderate - 60%, hard - 20%) week 24 goals : 60 minutes(light – 10%, moderate – 35%, hard – 50%, very hard – 5% ) Exercise training parameters identical conducted 3 times weekly for 24 weeks Each 30 minutes (light - 20%, moderate - 60%, hard - 20%) week 24 goals : 60 minutes(light – 10%, moderate – 35%, hard – 50%, very hard – 5% ) Exercise training parameters identical 11

METHODS-Statistical Analysis Variance (ANOVA) and covariance (ANCOVA) intent-to-treat procedures were used for the outcome variables Two tailed t-test 50 subjects needed in each group to achieve a power of 0.80 exercise endurance change on the CWR test Variance (ANOVA) and covariance (ANCOVA) intent-to-treat procedures were used for the outcome variables Two tailed t-test 50 subjects needed in each group to achieve a power of 0.80 exercise endurance change on the CWR test 12

RESULTS 13

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17 traditional walking group, 22.10±16.35 pole walking group, 17.06±13.57 traditional walking group, 22.10±16.35 pole walking group, 17.06±13.57

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DISCUSSION Exercise duration improving traditional walking program > poles walking program No differences claudication pain perceived physical function Exercise duration improving traditional walking program > poles walking program No differences claudication pain perceived physical function 22

Lengthening of the time calf muscle StO2 took to reach its minimal value progressive treadmill test Baseline : StO2 levels dropped within about 1 minute 24 weeks : StO2 levels dropped within about 2 minute Lengthening of the time calf muscle StO2 took to reach its minimal value progressive treadmill test Baseline : StO2 levels dropped within about 1 minute 24 weeks : StO2 levels dropped within about 2 minute 23

Walking exercise, with or without the use of walking poles significantly prolonged the deoxygenation of the exercising muscle Duscha et al have demonstrated that the patients with PAD occurs at 3 weeks postexercise training greatest increase in angiogenesis in the gastrocnemius muscle The study did not test patients at three weeks saw the greatest prolongation of muscle deoxygenation at the first followup exercise test at 6 weeks Walking exercise, with or without the use of walking poles significantly prolonged the deoxygenation of the exercising muscle Duscha et al have demonstrated that the patients with PAD occurs at 3 weeks postexercise training greatest increase in angiogenesis in the gastrocnemius muscle The study did not test patients at three weeks saw the greatest prolongation of muscle deoxygenation at the first followup exercise test at 6 weeks 24

Gardner et al have shown patients who have shorter times reaching minimal values in StO2 also experience shorter initial and absolute claudication distances Measured gait characteristics in a subset of patients at baseline and after 6-weeks of training with the walking poles, No differences Gardner et al have shown patients who have shorter times reaching minimal values in StO2 also experience shorter initial and absolute claudication distances Measured gait characteristics in a subset of patients at baseline and after 6-weeks of training with the walking poles, No differences 25

The study noted, Moderate correlation with force on the poles and improved exercise duration on the 6-week CWR treadmill test Short Form-36 Walking Impairment Questionnaire The study noted, Moderate correlation with force on the poles and improved exercise duration on the 6-week CWR treadmill test Short Form-36 Walking Impairment Questionnaire 26

Limitations The study sample was composed of primarily older men Sample size may not have been large The study sample was composed of primarily older men Sample size may not have been large 27

CONCLUSIONS Increasing walking endurance Traditional walking > poles walking Both training programs improved physical functioning prolonged calf muscle deoxygenation initial claudication pain Increasing walking endurance Traditional walking > poles walking Both training programs improved physical functioning prolonged calf muscle deoxygenation initial claudication pain 28

This study further supports the importance of walking exercise in patients with peripheral arterial disease 29

Thank you 30