|5. Supervised Exercise|
|Supervised exercise training for patients with intermittent claudication|
|Numerator||Patients who were|
■ Offered a supervised exercise training program as an option (preferred) OR
■ Given explicit written or verbal instructions for unsupervised exercise (acceptable alternative if no supervised program is accessible*) AND had a medical, patient, or system reason documented by a physician, advanced practice nurse, or physician assistant that they could not be offered a supervised program.
Note: Exercise training should be performed for a minimum of 30 to 45 min, at least 3 times/wk, for a minimum of 12 wks. (70)
|Denominator||Patients age ≥18 y with intermittent claudication|
Medical reason(s) documented by a physician, advanced practice nurse, or physician assistant that patient was not offered a supervised exercise training program as an option, such as
■ Critical limb ischemia (ischemic rest pain, nonhealing ischemic ulcers, gangrene)
■ Unstable angina or recent myocardial infarction
■ Decompensated heart failure
■ Uncontrolled cardiac arrhythmias
■ Severe or symptomatic valvular disease
■ Other conditions that could be aggravated by exercise including, but not limited to, severe joint disease, uncontrolled diabetes, uncontrolled hypertension, or severe pulmonary disease.
|Period of Assessment||1-y measurement period|
|Sources of Data||Prospective flow sheet, retrospective medical record review, electronic medical record|
|A supervised claudication exercise program is known to result in an increase in the speed, distance, and duration walked in a high fraction of candidates, with decreased claudication symptoms at each workload or distance. In addition, exercise programs achieve significant systemic risk-reduction benefits (lowered blood pressure, improved glycemic control, and improved lipid profile). These functional and biochemical benefits accrue gradually and become evident over 4 to 8 wks and increase progressively over ≥12 wks. The biological mechanisms underlying the exercise improvements are complex, and there is inadequate evidence to attribute this functional benefit, as is often believed, to the growth of new collaterals (angiogenesis). Although the mechanism(s) by which exercise improves walking is unknown, studies have suggested that 1 or more of the following may play a role: alterations in skeletal muscle metabolism, reduced inflammation, improvement in endothelial function and hemorheology, carnitine metabolism, or altered gait. Adverse events, although possible, are rare, and the risk can be further reduced with appropriate medical screening before starting a program.|
|ACC/AHA 2005 Guidelines for the Management of Patients With Peripheral Arterial Disease (12)|
Individuals with intermittent claudication who are offered the option of endovascular or surgical therapies should be provided information regarding supervised claudication exercise therapy and pharmacotherapy.
1. A program of supervised exercise training is recommended as an initial treatment modality for patients with intermittent claudication. (Level of Evidence: A)
2. Supervised exercise training should be performed for a minimum of 30 to 45 minutes, in sessions performed at least 3 times per week, for a minimum of 12 weeks. (Level of Evidence: A)
The usefulness of unsupervised exercise programs is not well established as an effective initial treatment modality for patients with intermittent claudication. (Level of Evidence: B)
Exercise therapy in intermittent claudication:
■ Supervised exercise should be made available as part of the initial treatment for all patients with peripheral arterial disease [A].
■ The most effective programs employ treadmill or track walking that is of sufficient intensity to bring on claudication, followed by rest, over the course of a 30 to 60-min session. Exercise sessions are typically conducted 3 times a week for 3 months [A].
American College of Sports Medicine Guidelines for Exercise Testing and Prescription, 7th ed, 2006 (71)
Initial enrollment in a medically supervised program with ECG, heart rate, and BP monitoring is encouraged.
|This measure should be reported by all clinicians or practices managing patients with cardiovascular disease. The level of “aggregation” (clinician versus practice) will depend upon the availability of adequate sample sizes to provide stable estimates of performance.|
|Method of Reporting|
Whether patient was offered the option of a supervised exercise program, if accessible, or given explicit instructions for an unsupervised program if a supervised program is not accessible. Documentation should include whether a supervised exercise training program is available in the local community.
Per patient population:
Percentage of patients who were offered the option of an exercise program either supervised, if accessible, or given explicit instructions for an unsupervised program if a supervised program is not accessible. Documentation should include whether a supervised exercise training program is available in the local community.
|Challenges to Implementation|
|■ Locating information in the medical record.|
■ Access to supervised exercise training records if the program is located at another facility.
■ Sample size may preclude reporting of reliable performance estimates, particularly at the clinician level.
*Inaccessible means that no program is available in the patient's area, or is affordable by insurance or by pricing within the patient's economic means, or will accommodate the patient's work hours or other fixed schedule barriers (72).