If Supervised Exercise Is Better Than Unsupervised Exercise

for Intermittent Claudication, Why Are Quality of Life

Indicators Similar?
A new study on intermittent claudication (IC) says that when it comes to improvements in walking
distances and time before the onset of pain, supervised exercise (SE) is more effective than
unsupervised exercise (UE). When it comes to quality of life and increased community-based
walking, however, those differences aren't as clear--and teasing out exactly why isn't easy.
Researchers conducted a meta-analysis of 27 studies (24 randomized controlled trials and 4
observational studies) of 2,074 patients that compared SE and UE approaches for participants with
IC, a condition associated with peripheral artery disease that causes cramping and early fatigue
after walking even short distances. What they found is likely not surprising to physical therapists
(PTs) and physical therapist assistants (PTAs): SE resulted in a "moderate to large" improvement in
maximal walking distance (MWD) and a "moderate" improvement in claudication onset time (COT)
compared with unsupervised exercise.

The findings are important, authors write, because even though SE is widely recognized as the
preferred approach for treatment of IC, "given the lack of Medicare reimbursement, lack of
physician and patient awareness of the role of [SE], and patient transportation and time barriers,
[SE] is underused." The study was published in the American Heart Journal (abstract only available
for free).
Less definitive were differences in quality of life (QOL) and community-based walking as measured
by the walking impairment questionnaire (WIQ). Here, researchers found little difference between
the SE and UE groups--a result that seems to run counter to the assumption that if individuals with
IC are able to walk longer with a slower onset of IC thanks to SE, they'll report improvements in life
quality and more time spent walking at home.

Authors argue that part of the reason for the similarities may have to do with the effects of treadmill
walking versus overground walking on the 6-minute walk test used in some QOL assessments. "In
contrast to treadmill walking, 6-minute walk tests have been shown to correlate better with physical
activity in daily life," authors write. "In addition, the biomechanics of treadmill walking differ
substantially from overground walking ... providing for a potential physiologic basis for the
discrepancy between treadmill gains and QOL."

When it comes to similarities in community-based walking assessed through WIQ, authors urge
caution about drawing conclusions due to the fact that only a small number of studies included this
kind of analysis.
The study's authors offer still another explanation for the QOL similarities: the lack of diseasespecific QOL assessments used in some of the studies. More generic QOL assessments, they write,
"typically do not address the emotional and psychosocial impact of disease-specific physical
limitations and thus may not adequately assess therapy-related improvements in QOL."
And while the authors found SE "superior" to UE for improvement in maximal treadmill walking and
COT, they write that in the end, it could be this lack of solid disease-specific evidence on QOL
improvements that will hold up any significant changes in utilization.
"Given the current lack of evidence that [SE] improves QOL or community walking over [UE]," they

write, "further evidence may be needed before reimbursement policies for supervised exercise will
be reconsidered."
Research-related stories featured in PT in Motion News are intended to highlight a topic of interest
only and do not constitute an endorsement by APTA. For synthesized research and evidence-based
practice information, visit the association's PTNow website.
http://www.apta.org/PTinMotion/News/2015/4/30/IntermittentClaudication/?blogid=10737418615