Paul Sorace, MS, ACSM RCEP, CSCS*D
The Special Populations Column in this issue discusses the epidemiology, management, exercise benefits and risks, and exercise goals for persons with peripheral arterial disease (PAD). Because most individuals with PAD are classified as high risk for medical complications during exercise, a clinical exercise test with physician supervision should be performed prior to starting an exercise program (7). The personal trainer should obtain a copy of the exercise test results and medical clearance from their client. This can help with the initial program design (e.g., physician-prescribed exercise heart rate, and claudication times) (2). Claudication times include the onset of pain and times when the pain increased. For example, onset of pain, “1,” occurred at 3 minutes, the pain increased to “2” at 4 minutes, and so on (see Table 1 for the claudication scale).
Once a clinical exercise test has been performed and medical clearance has been obtained, a 6-minute walk test is a simple test the personal trainer can use during an initial health and fitness assessment to determine a client's current functional capabilities (e.g., current walking speed, distance, and duration and claudication times) and set an initial aerobic exercise prescription. It can also be used periodically to assess progress from regular exercise. The American Thoracic Society has established guidelines for performing the 6-minute walk test in a clinical environment (1). However, for clients with PAD who can safely exercise in the health and fitness setting, a variation of this test can be performed. Table 1 describes a protocol for performing a 6-minute walk test.
Retesting using the 6-minute walk test can show improvements through multiple variables:
- Greater distance walked in 6 minutes.
- Lower posttest heart rate.
- Lower posttest blood pressure.
- Lower posttest Borg score.
- Lower posttest claudication score.
- Higher posttest O2 saturation (if measurable).
- It is possible that the person may not finish the test the first time. If so, completing the test at a later time is an improvement.
It is important to understand that exercise performance (e.g., walking time and/or speed) can vary from one training session to the next. The exercise professional should look for overall improvements on a weekly or monthly basis and anticipate fluctuations in their client's performance. There are limited specific recommendations for exercise prescription and programming for PAD. However, walking and stair climbing are 2 very important activities that individuals with PAD should emphasize in their exercise program. Clients with PAD should be encouraged to gradually increase their daily walking. Evidence indicates that self-directed walking, performed at least 3 times weekly, is associated with significantly less functional decline (4).
Resistance training (RT) should be incorporated into the exercise program but should not take precedence over walking and/or stair climbing. However, because muscular strength and endurance decrease with age, RT has an important role in exercise training for persons with PAD. RT is a proven effective method to avoid age-related losses in skeletal muscle by increasing muscular strength, endurance, power, and muscle cross-sectional area (6). Walking speed can also be improved through RT (6). Along with these benefits, lower-body RT may improve pain-free walking distances (5). Because PAD most often affects the lower legs, exercises such as toe raises and heel raises should be performed. McGuigan et al (5) observed that these exercises improved strength and function in their patient's lower limb muscles and walking distances, while reversing negative skeletal muscle changes observed prior to the start of the exercise program. Table 2 provides general exercise training recommendations for individuals with PAD.
The personal trainer should obtain medical clearance prior to exercise testing and training a client with PAD. Persons with PAD may be taking any number of medications. Certain medications may affect exercise performance (e.g., beta blockers) and require exercise testing and training modifications. If the client had participated in a clinically supervised exercise program prior to working with you, contacting the clinical personnel they worked with is recommended.
The clinical exercise professional can provide exercise testing and training records and other information (e.g., how the person progressed and exercise likes/dislikes) that can be invaluable for the personal trainer. Because many individuals with PAD have existing comorbidities, a properly designed exercise program will likely help manage these conditions or risk factors as well. However, it is prudent to focus the exercise program design on PAD.
PAD significantly affects quality of life by limiting one's ability to walk. It also increases the risk for limb amputation, and most individuals with PAD have other forms of cardiovascular disease (e.g., hypertension), increasing risk for heart attack and stroke. Exercise, properly supervised and performed, is an effective treatment for PAD. After the individual has been medically cleared and preferably participated in a clinical exercise program, personal trainers can help continue facilitating the exercise program. Following proper guidelines/recommendations and regular follow-up with appropriate health care professionals will promote safe and effective exercise testing and training, resulting in enhanced functional ability, a possible reduction in cardiovascular disease risk factors, improved health, and quality of life.
1. ATS statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med
166: 111-117, 2002.
2. Durstine JL and GE Moore, eds. ACSM's Exercise Management for Persons With Chronic Diseases and Disabilities
(2nd ed). Champaign, IL: Human Kinetics, 2003. pp. 81-85.
3. Gardner AW, Katzel LI, Sorkin JD, and Goldberg AP. Effects of long term exercise rehabilitation on claudication distances in patients with peripheral arterial disease: A randomized controlled trial. J Cardiopulm Rehabil
22: 192-198, 2002.
4. McDermott MM, Liu K, Ferrucci L, Criqui MH, Greenland P, Guralnik JM, Tian L, Schneider JR, Pearce WH, Tan J, and Martin GJ. Physical performance in peripheral arterial disease: A slower rate of decline in patients who walk more. Ann Intern Med
144: 10-20, 2006.
5. McGuigan MR, Newton RU, and Bronks R. Resistance training for patients with peripheral arterial disease: A model of exercise rehabilitation. Strength Cond J
23(3): 26-32, 2001.
6. McGuigan MR, Newton RU, and Kraemer WJ. Resistance training for better health in older adults. Int J Sport Health Sci
4: 19-28, 2006.
7. Whaley MH, Brubaker PH, and Otto RM, eds. ACSM's Guidelines for Exercise Testing and Prescription
(7th ed). Baltimore, MD: Lippincott Williams & Wilkins, 2005. pp. 162, 225-227.
8. Williams MA, Haskell WL, Ades PA, Amsterdam EA, Bittner V, Franklin BA, Gulanik M, Laing ST, and Stewart KJ. Resistance exercise in individuals with and without cardiovascular disease: 2007 update. Circulation
116: 572-584, 2007.