H.J.P Fokkenrood

Innovative strategies for
intermittent claudication

towards a stepped care approach and new outcome measures



 Unfortunately, only a minority of all newly diagnosed IC patients receives an efficient and structured treatment of their disease. We are convinced that the underlying contributing factors impeding full-scale implementation of SET & CVRM programs are:



  • Outdated national guidelines.

The guidelines of the Dutch Association of General Practitioners and the CBO guideline followed by Dutch vascular surgeons are at best ambiguous and do not mention the need of SET.14,15 In contrast, the contemporary international guidelines for PAOD explicitly state supervision as a necessary component in exercise therapy.


  •    Availability of a valid and established SET program

When medical specialists and General Practitioners (GP) have carried out the indication and initiated referral for SET correctly. Whom to refer to? Insights in PTs who provide qualitative SET programs were not available. Transparency and accessibility to quality SET programs are required.


The vast majority of the 23,000 Dutch PT's are not adequately trained according to the Royal Dutch Society for Physical Therapy guideline for IC. Those who are, do not always have sufficient experience to provide this form of therapy in a correct way. Moreover a SET program has a broader scope than physiotherapy alone. An essential feature of SET is that full attention is paid to existing comorbidities and modifiable lifestyle factors. If these aspects are not addressed appropriately, suboptimal results and loss of resources will occur. Adequately trained PT's should ideally be able to perform individual training, recognise symptoms, provide lifestyle counselling and monitor medication adherence.


  • Reimbursement issues

A major problem is the fact that the Dutch healthcare system does not stimulate the use of conservative treatment modalities for patients with IC. Cardiovascular risk management and invasive vascular interventions are fully compensated by the Dutch basic healthcare insurance. However, for patients with IC, the first 20 treatment sessions of a SET program are not covered in this basic health care insurance (since January 1st, 2012) and have to be paid for by the patient (either directly or through additional insurance). From the 21st session onwards all additional treatment sessions given in one year are covered by the basic health care insurance. This peculiar reimbursement policy results in a financially driven motivation to be treated by a vascular surgeon with a minimal invasive vascular intervention (e.g. angioplasty) or even bypass surgery (both fully reimbursed). This in spite of the associated risk of morbidity (<0,5 - 10%) and even mortality (2-3% for bypass surgery).


  • A knowledge gap
  •  In a recent nationwide survey among Dutch vascular surgeons, it appeared that around 70% of vascular surgeons believe that co-existing significant cardiopulmonary comorbidity and/or an aorta-iliac stenosis or occlusion are arguments not to refer for a SET program. Recent evidence shows that these arguments seem to be out-dated.
  • In severe or invalidating IC cases, as subjectively as these may be, invasive vascular interventions are performed without awaiting the possible positive effects of a SET program.