Management of NCLI

• The management of non-critical limb ischaemia is largely two-fold:

  1. It is directed towards reducing cardiovascular risk factors in order to reduce risk or slow progression of peripheral artery disease and the incidence of myocardial infarction and stroke
  2. To reduce the severity and frequency of the main presenting symptom of noncritical limb ischaemia, which is of course intermittent claudication
• NICE Guidelines for Management of non-critical limb ischaemia:

  • diet - input from dietician
  • smoking cessation measures
  • control hypertension
  • regulate HDL to LDL (statins)
  • regulate blood glucose and Hb1Ac levels
  • aspirin or clopidogrel - antiplatelets
  • +/- use of peripheral vasodilators e.g. cilostazol
  • supervised exercise to include walk programme
• Exercise for Intermittent Claudication (non-critical limb ischaemia):

  • effects of exercise on claudication:
  • exercise can improve walking distance before onset of pain by 180%

  
• General exercise choices/decisions:

  • intensity: as tolerated, aim for moderate, guided by pain
  • exercising until onset of pain
  • supervised vs non-supervises
  • weightbearing vs non-weightbearing
• WB vs NWB:

  • McGregor et al
  • 2 days a week for 10 weeks
  • RPE of 12 to 14 (moderate intensity)
  • group A (treadmill and stepper) improved by 4.6 minutes
  • group B (cycling and rowing) improved by 2.4 minutes
  • both form of exercise showed added benefits of weightbearing compared to non-weightbearing, but progress can be made with non-weightbearing exercises as well
• Supervised or home alone exercise:

  • unsupervised programmes in US and K have failed to show significant improvements in intermittent claudication or quality of life
  • unsupervised = unsupported emotionally, psychologically as well as physically + for this group self directed exercise is particularly psychologically hard and time consuming
  • supervised exercise = significantly greater increase in distance of pain free walking compared with unsupervised programmes
  • a regular supervised measurable incremental walking programme can increase distances by 150% and improvement in health related quality of life measures
  • there is "overwhelming evidence that supervised exercise is of symptomatic benefit for intermittent claudication and little evidence that exercise done alone is an effective treatment"
• NICE recommendations:

  • supervised exercise programme for 2 hours per week for 3 months
  • patients are to walk to the point of moderate pain
• what a walk programme might look like:

  • aerobic exercise - free active exercise plus machines
  • strength/flexibility training as necessary
  • walking
• what a walk programme might look like:

  • pts walk at speed and gradient which induces intermittent claudication mild/moderate pain intensity within 3 to 5 minutes
  • rest + repeat
  • repeat sequence for 30 minutes if possible, increasing to 60 minutes over time
  • progress via small increases in speed, followed by alternating increase in incline as tolerated
  • claudication scale:
  • no higher than 4 (moderate pain) on the claudication scale
  • or keep pt below 4 on Borg CR-10 scale
  • do not use Borg RPE Scale

  
• Other exercise programmes are available:

  • alternatives to treadmill exercise consist of various forms of lower extremity aerobic exercise alone or in combination with brisk walking, bicycle ergometer and even strength training
  • however, the outcomes of treadmill exercise have so far been found to be superior to the outcomes of several other lower extremity exercises, namely cycling, stair climbing and static and dynamic leg exercises
• Home walking programme:

  • translate clinic to home for optimal outcomes
  • you know how long pts can walk before getting pain, so replicate in the streets
  • aim for 30 to 45 minutes, but starts as tolerated
  • record the number of breaks needed and duration - use a diary system
  • as breaks decrease in frequency/duration, increase duration of walking