“Intermittent claudication a real pain in the calf”—Patient experience of diagnosis and treatment with a supervised exercise program

doi:10.1016/j.jvn.2017.03.001

Journal of Vascular Nursing

Volume 35, Issue 3, September 2017, Pages 131-135

https://doi.org/10.1016/j.jvn.2017.03.001 Get rights and content

Intermittent claudication (IC) is a common condition which has severe impacts on quality of life, physical function, and mental health. Supervised exercise is the recommended first-line treatment for patients with this condition; however, these are not always feasible or accessible to patients. As the proportion of patients who have this treatment remains suboptimal, it is important to better understand the perception of exercise in this population. A gap in the literature exists about the barriers and facilitators to exercise in patients completing, dropping out of, or declining an exercise program. A qualitative analysis was undertaken to understand this further. Twenty-five patients were interviewed face to face, 10 who had completed exercise, 10 who had declined, and 5 who had dropped out of an exercise program.

Three major themes emerged from the data, IC, and perception to exercise and experience or beliefs of the exercise program.Addressing the barriers and facilitators to exercise in patients with IC is crucial in optimizing the delivery and uptake of exercise programs. More education or time investment is needed with these patients during initial diagnostic to help overcome perceived barriers and emphasis healthy behavioral changes.

Section snippets

Methods

This was a qualitative study, using semistructured interviews, conducted in a single vascular surgery unit of a tertiary teaching hospital. Ethical approval was granted by the Research Ethics Committee, and the study was conducted in accordance with the ethical standards of the Declaration of Helsinki, 1975. All participants provided informed written consent.

Participants and SEP

All patients had been reviewed by a consultant vascular surgeon and were documented to have stable yet persisting IC. Inclusion criteria included adults over the age of 45 years, and an ankle-brachial pressure index < 0.9. Exclusion criteria included severe cardiovascular or musculoskeletal illness precluding participation in SEP, critical limb ischemia, or active cancer treatments. All patients suitable for inclusion were offered the SEP provided in secondary care. The SEP was performed three

Interviews

Interviews were conducted using a topic guide to ensure consistency across participants; however, a flexible format was used to allow participants to generate naturalistic data. All interviews were conducted on a face-to-face basis at a place convenient for the patient, either in the home or a comfortable, accessible hospital setting. All interviews were audio recorded and transcribed verbatim.

Interviews were split into three groups:

•
Group A–exercise decliners
•
Group B–exercise completers
•
Group

Data analysis

Data were analyzed using thematic analysis. This approach is inductive (themes emerge from the data and are not imposed upon it by the researcher) and iterative (data collection and analysis occur simultaneously).⁹ Participants were also compared for commonality and differences.

Atypical cases were actively sought throughout the analysis and emerging ideas and themes modified in response. Data analysis involved a process of organizing the data, descriptive coding, thematic coding, writing, and

Results

In the recruitment between May 2015 and January 2017, a total of 547 patients were screened for the SEP. One hundred twenty-five patients were excluded based on the exclusion criteria, leaving a total of 422 eligible patients invited to participate. Ninety-two patients (22%) agreed to take part in the exercise program. Of the 92 patients who commenced on exercise only 38 fully completed (41%), 38 patients actively withdrew from the exercise program, and 2 patients died.

Understanding of the disease and risk factors

Many patients did not have a clear understanding of the disease process with only seven patients giving a clear description of a “blockage” or “furring” up of the arteries in their legs. Patients often used the terms “veins” and “arteries” interchangeably during the discussion. More men than woman responded with pathophysiological descriptions of the disease. In addition, a minority of patients discussed the potentially progressive nature of IC. “It is getting worse and I needed to do something

Previous exercise experience and current activity levels

Twenty-two patients had some level of exercise experience with most of them ending participation in sport at a school level. “I played netball at school but I didn't do anything after I left.” A minority of patients (14) continued with exercise in their adult life, mainly with activities such as walking. Only 9 patients out of the 25 interviewees were currently engaging in some form of physical activity which was mainly walking. “I try to walk every day; it's the only little bit of exercise I

Experience of the exercise program

Of the 14 patients who attended the class and were interviewed (four dropouts), 13 described it as “social” with the “instructors and other people who went making the class.” Only one patient (who had additional problems) said she “felt embarrassed because of her stomach.” Many patients described the class as “friendly,” “relaxing,” and a “feeling of all being in it together.” Although the 10 who completed the program did discuss the “commitment to coming three times a week,” they all said that

Discussion

This study aimed to examine the barriers and facilitators to exercise programs in patients with IC. Throughout the interviews, patients living with IC described significant symptoms with major functional reduction and impairment of daily activity levels. There were no discernible differences in symptoms or experiences between men and women and no difference between patients during the winter and summer months.

There were three major themes that emerged from the data including IC, perception to

Conclusion

This is the first study to assess the opinions of exercise programs in patients with IC using in-depth semistructured interviews. The first-line treatment for patients with IC is a SEP; however, a majority of patients either fail to engage or complete this treatment. The findings of this study identified four major themes including IC, perception to exercise, experience of exercise programs, and barriers to SEP participation. Although data suggest that SEP is still the most clinical and

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Cited by (23)

High INtensity Interval Training in pATiEnts with Intermittent Claudication: A Qualitative Acceptability Study
2024, Annals of Vascular Surgery
A novel high-intensity interval training (HIIT) program has demonstrated feasibility for patients with intermittent claudication (IC). The aim of this study was to explore patient perspectives of the HIIT program to inform refinement and future research.
All patients screened and eligible for the ‘high intensity interval training in patients with intermittent claudication (INITIATE)’ study were eligible to take part in a semistructured interview. A convenience subsample of patients was selected from 3 distinct groups: 1) those who completed the HIIT program, 2) those who prematurely discontinued the HIIT program, and 3) those who declined the HIIT program. Interviews considered patients views of the program and experiences of undertaking and/or being invited to undertake it. Interviews were audio recorded, transcribed verbatim, and analyzed via thematic analysis.
Eleven out of 31 participants who completed the program and 12 out of 38 decliners were interviewed. No participants who withdrew from the program agreed to interview. The 3 key themes were; personal reflections of the program; program facilitators and barriers; and perceived benefits. Completers enjoyed taking part, reported symptomatic improvement and would complete it again. Practical and psychological barriers exist, such as transport and motivation. Changes to the program were suggested.
Findings support the acceptability of this novel HIIT program, which in combination with the feasibility findings, suggest that a fully powered randomized controlled trial, comparing HIIT to usual-care supervised exercise programs is warranted.
Supervised Exercise Therapy for Intermittent Claudication: A Propensity Score Matched Analysis of Retrospective Data on Long Term Cardiovascular Outcomes
2024, European Journal of Vascular and Endovascular Surgery
This study aimed to explore the long term outcomes of patients with intermittent claudication (IC) who completed supervised exercise therapy (SET) vs. those who declined or prematurely discontinued SET, focusing on the incidence of chronic limb threatening ischaemia (CLTI), revascularisation, major adverse limb events (MALE), and major adverse cardiovascular events (MACE).
A retrospective registry analysis of consecutive patients with IC who were referred for SET between March 2015 and August 2016 and followed up for a minimum of five years. Serial univariable analysis and logistic regression were performed to identify the statistically significant clinical variables that were independent predictors of each outcome measure. The resulting statistically significant variables were used to guide 1:1 propensity score matching (PSM) using the nearest neighbour method with a calliper of 0.2. Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% confidence interval (CI) for the association between SET and the outcomes of interest.
Two hundred and sixty-six patients were referred to SET between March 2015 and August 2016. Of these, 64 patients completed SET and 202 patients did not. After PSM, 49 patients were analysed in each cohort. The Cox proportional hazards analysis revealed a significant association between completion of SET and revascularisation requirement (HR 0.46 95% CI 0.25 – 0.84; p = .011), completion of SET and progression to CLTI (HR 0.091, 95% CI 0.04 – 0.24; p < .001), completion of SET and MACE (HR 0.52; 95% CI 0.28 – 0.99; p = .05) and completion of SET and MALE (HR 0.28, 95% CI 0.13 – 0.65; p = .003). The Harrell’s C index for all of these models was greater than 0.75, indicating good predictive accuracy.
Completion of SET is associated with better outcomes in patients who completed SET compared with patients who declined or discontinued SET with respect to clinically important cardiovascular outcomes over seven years.
Association between home-based exercise using a pedometer and clinical prognosis after endovascular treatment in patients with peripheral artery disease
2023, Journal of Cardiology
Exercise therapy following endovascular treatment (EVT) is important for patients with peripheral artery disease (PAD); however, continuous exercise therapy is difficult to be performed in clinical practice. This study aimed to investigate the association between the implementation of home-based exercise using pedometers after EVT and 1-year clinical outcomes.
This multicenter observational prospective cohort registry included patients with PAD complaining of intermittent claudication who underwent EVT for aortoiliac and/or femoropopliteal artery lesions between January 2016 and March 2019. Patients were instructed to perform home-based exercises using a specific pedometer after EVT. The study population was divided into good and poor recording groups according to the frequency of the pedometer measurements. The good recording group was defined as those who completed ≥50 % of the prescribed daily pedometer recording during the follow-up period. The poor recording group was defined as those with an inability to use a pedometer and/or who completed <50 % of the prescribed daily pedometer recordings. The primary outcome was 1-year major adverse events (MAE), defined as a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, target vessel revascularization, and major amputation of the target limb.
The mean age was 74.4 years; 78 % were male. A total of 623 lesions were analyzed (58.7 % aortoiliac, 41.3 % femoropopliteal). At 1 year, a lower cumulative incidence of MAE was observed in the good recording group compared to that in the poor recording group [10/233 (4.3 %) vs. 35/267 (13.7 %) patients, respectively; p < 0.001]. Multivariate Cox regression analysis showed that patients in the good recording group had a lower hazard ratio for 1-year MAE (0.33; 95 % confidence interval, 0.16–0.68; p = 0.004) than that in the poor recording group.
Good self-recording of pedometer measurements was associated with favorable prognosis in patients with PAD following EVT.
An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication
2021, Journal of Vascular Surgery
Supervised exercise programs (SEP) are effective for improving walking distance in patients with intermittent claudication (IC) but provision and uptake rates are suboptimal. Access to such programs has also been halted by the Coronavirus pandemic. The aim of this review is to provide a comprehensive overview of the evidence for home-based exercise programs (HEP).
This review was conducted in according with the published protocol and PRISMA guidance. Medline, EMBASE, CINAHL, PEDro, and Cochrane CENTRAL were searched for terms relating to HEP and IC. Randomized and nonrandomized trials that compared HEP with SEP, basic exercise advice, or no exercise controls for IC were included. A narrative synthesis was provided for all studies and meta-analyses conducted using data from randomized trials. The primary outcome was maximal walking distance. Subgroup analyses were performed to consider the effect of monitoring. Risk of bias was assessed using the Cochrane tool and quality of evidence via GRADE.
We included 23 studies with 1907 participants. Considering the narrative review, HEPs were inferior to SEPs which was reflected in the meta-analysis (mean distance [MD], 139 m; 95% confidence interval [CI], 45-232 m; P = .004; very low quality of evidence). Monitoring was an important component, because HEPs adopting this strategy were equivalent to SEPs (MD, 8 m; 95% CI, –81 to 97; P = .86; moderate quality of evidence). For HEPs vs basic exercise advice, narrative review suggested HEPs can be superior, although not always significantly so. For HEPs vs no exercise controls, narrative review and meta-analysis suggested HEPs were potentially superior (MD, 136 m; 95% CI, –2 to 273 m; P = .05; very low quality of evidence). Monitoring was also a key element in these comparisons. Other elements such as appropriate frequency (≥3× a week), intensity (to moderate-maximum pain), duration (20 progressing to 60 minutes) and type (walking) of exercise were important, as was education, self-regulation, goal setting, feedback, and action planning.
When SEPs are unavailable, HEPs are recommended. However, to elicit maximum benefit they should be structured, incorporating all elements of our evidence-based recommendations.
Spurred by pedometers, unity and fun exercise: A qualitative study of participation in rehabilitation for patients with intermittent claudication (The CIPIC Rehab study)
2021, Journal of Vascular Nursing
Citation Excerpt :
see supplementary Table S1, interview guide). The research questions in the semi-structured interview guide drew on the conclusions from 26 out of 43 post-intervention evaluating surveys and systematic reviews on the conceptualization of a patient-centered program, as well as three qualitative studies that explore patient experiences of living with IC3,4,8,10,11. The model by Malterud et al. was used to suggest an adequate number of participants for the focus group interviews to demonstrate new knowledge referring to the aim of the study and to achieve “Information power”25[20, 25](p-70–75).
To explore how patients with intermittent claudication experiences participating in a community-based cardiovascular rehabilitation program and the various components of the rehabilitation program.
Intermittent claudication is a condition associated with progressive atherosclerosis that affects daily life. Most patients with intermittent claudication do not exercise even though exercise is essential in the treatment of this condition. Rehabilitation is reported to be effective in alleviating symptoms, increasing walking distance, reducing cardiovascular events, and improving quality of life. Patients’ perspectives are important when designing such programs, however, this aspect has not previously been investigated.
A qualitative study.
Patients with intermittent claudication (n=10) participating in a rehabilitation program were interviewed in two focus groups. Pragmatic philosophy inspired the approach. Data were analyzed using qualitative thematic analysis, and emerging themes were discussed according to self-efficacy theory.
Participants experienced social support from other patients, which motivated them to exercise. The intervention encouraged the patients’ management of leg pain, while a local setting and a pedometer were important motivational factors to keep adherence to the program. The participants’ experiences of the rehabilitation program are expressed in four themes revealed from the qualitative analysis: 1) the shared community, 2) pushing your own limits, 3) spurred by pedometers and health professionals, and 4) continuing new habits on your own. The participants found the components in the rehabilitation program meaningful, but encountered difficulties in continuing on their own after completion of the program.
A specialized community-based cardiovascular rehabilitation program for patients with intermittent claudication can be supportive for patients suffering from intermittent claudication.
The qualitative results can be used to guide development of existing cardiac rehabilitation programs targeted patients with intermittent claudication in a community setting.
Illness perceptions in patients with peripheral arterial disease: A systematic review of qualitative studies
2021, International Journal of Nursing Studies
Citation Excerpt :
However, other participants had no ideas about what caused their symptoms (Collins et al., 2006, Cunningham et al. 2014, Egberg et al., 2012, Gibson and Kendrick 1998, Gorely et al., 2015, Lokin et al., 2015), while others described beliefs that the symptoms could be explained by cramp or a sign of ageing (Egberg et al., 2012; Gorely et al., 2015; Harwood et al., 2017). These beliefs could result in delayed seeking of medical care (Gibson and Kendrick 1998; Gorely et al., 2015; Harwood et al., 2017). This component refers to individuals’ perceptions of the cause of the illness.
Patients with chronic diseases create their own subjective beliefs about their conditions based on their illness perceptions. In the common-sense model, illness perceptions constitute personal beliefs about illness with regard to five components: identity, timeline, cause, control/cure, and consequences. Patients’ illness perceptions affect both their management of their disease and their adherence to treatment. Since patients with peripheral arterial disease need life-long treatment for secondary prevention, generating knowledge about illness perceptions in patients with peripheral arterial disease is essential.
To systematically review and synthesise the literature on illness perceptions in patients with peripheral arterial disease.
A systematic review
PubMed, CINAHL, and PsycINFO.
A systematic search strategy was conducted in December 2017, with an update in July 2019. Two team members independently screened all titles and abstracts. A relevance and quality appraisal of the studies was performed. The references from the included studies were evaluated for additional studies. The data from 14 studies were extracted and synthesised using a “best-fit” approach to framework analysis. A deductive analysis was conducted using the common-sense model. The data not suitable for the framework were analysed separately using inductive conventional content analysis, yielding an additional component representing the retrospective consequences of peripheral arterial disease.
The findings showed diversity in illness perceptions in each of the five components of the framework as well as in the additional component. The findings showed participants’ lack of understanding of the chronic nature of the disease, i.e., about the timeline, the identity of the symptoms and the cause of the disease. The patients’ beliefs about control and cures varied from having high motivation to engage in physical activity to thinking that walking could make their situations worse. There was fear about the future, as patients perceived disease progression and decreasing control to be consequences of their illness. Living with the disease, the emphasis in the additional component, was a process for regaining control and adapting to their situations.
Patients with peripheral arterial disease shape their own understandings of their conditions. These beliefs may influence their management of their disease and adherence to treatment. Therefore, the current study suggests that illness perceptions should be addressed when planning secondary prevention for patients with peripheral arterial disease.

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: Conflicts of interest: The authors do not have any conflict of interest.

: Funding: Harwood is funded by a University of Hull PhD Scholarship.

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Article“Intermittent claudication a real pain in the calf”—Patient experience of diagnosis and treatment with a supervised exercise program

Section snippets

Methods

Participants and SEP

Interviews

Data analysis

Results

Understanding of the disease and risk factors

Previous exercise experience and current activity levels

Experience of the exercise program

Discussion

Conclusion

Eur J Vasc Endovasc Surg

Eur J Vasc Endovasc Surg

Ann Vasc Surg

Eur J Vasc Endovasc Surg

Ann Vasc Surg

J Vasc Nurs

J Vasc Surg

Low attendance of patients with intermittent claudication in a German community-based walking exercise program

Int Angiol

Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis

JAMA

Article
“Intermittent claudication a real pain in the calf”—Patient experience of diagnosis and treatment with a supervised exercise program