Implications for practice
Supervised exercise therapy provides statistically significant benefits for treadmill walking distance when compared with non-supervised regimens. The clinical relevance of this difference requires additional studies with a focus on quality of life or other disease- specific functional outcomes, such as walking behavior, patient satisfaction, and costs. The results of this review are consistent with those of previously performed studies and meta-analyses. All indicate that SET is an effective treatment that should be available as part of the care of patients with intermittent claudication. How- ever, the availability of SET in clinical practice is far from optimal (Lauret 2012a; Makris 2012; Nicolai 2010; Shalhoub 2009). Professionals in the vascular field are obliged to take action to make supervised exercise therapy that is community or hospital based available for all patients with intermittent claudication.
Implications for research
Research to optimize exercise program components (eg, duration, exercise intensity, different modes of exercise, endurance training vs interval training, implementation of lifestyle interventions) is needed. Future research should include people who have a more severe stage of PAD and other comorbidities, as this is more representative of the PAD population.
Most of the included studies in this review have focused on tread- mill hospital- based exercise, although the effectiveness of community-based exercise programs is an interesting consideration for fu- ture research (Kruidenier 2009), particularly because some form of conservative treatment should be initiated before an invasive revascularization is performed (Hirsch 2006; Norgren 2007). Others have shown that access to a conservative supervised exercise pro- gram is low across Europe (UK: 36.4%; Germany: 46.7%; Greece: 10%) (Makris 2012). Research is needed to investigate the effects of community-based exercise programs on walking behavior, physical activity, and costs, and their long-term effects on morbidity, cardiovascular risk factors, and mortality (eg, the ClaudicatioNet concept, which was launched in The Netherlands; 100% SET access; Makris 2012). The concept aims to implement nationwide coverage of regional networks that provide quality care according to contemporary guidelines for patients with PAD (Fokkenrood 2012; Lauret 2012a).