Supervised exercise needs to be defined more clearly

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Supervised exercise programmes have been proved to increase the walking distance of patients with intermittent claudication but how much and what kind of supervision is required?

At a session focusing on the exercise programme for intermittent claudication at the CX Symposium in London, UK, Andrew Gardner, Oklahoma, USA, said that a primary goal for peripheral arterial disease patients with intermittent claudication is to regain lost physical function through exercise rehabilitation. He also stated that medically supervised exercise programmes are efficacious to improve claudication onset time and peak walking time.

Gardner presented data of a study using a step activity monitor that quantifies daily ambulatory activity in claudicants. “We further explored its utility to address the primary flaw of home-based exercise programmes by directly measuring exercise adherence and exercise volume performed,” he said. “We compared changes in exercise performance and daily ambulatory activity in peripheral arterial disease patients with intermittent claudication following a home-based exercise rehabilitation programme, a supervised exercise programme, and a usual care control group.”

The control group, Gardner explained, was encouraged to walk more on their own but they did not receive specific recommendations regarding an exercise programme during the study.

Gardner told delegates that patients in home-based exercise completed 83% of their exercise sessions, averaging 42 minutes per session at a cadence of 37 strides per minute. Home-based exercise, he added, was efficacious for increasing claudication onset time, peak walking time, and daily ambulatory cadences. Increases in daily ambulatory cadences were also greatest following home-based exercise.

The results, Gardner said, showed that a home-based exercise programme, quantified with a step activity monitor, had high adherence and was efficacious in improving claudication measures, similar to that seen with a standard supervised exercise programme. “Home-based exercise appears more efficacious in increasing daily ambulatory activity in the community setting than supervised exercise,” he said.

Ian Chetter, Hull, UK, said that exercise programmes for claudication are effective with the correct programme and apt supervision. To the question does the exercise programme environment influence outcome? Chetter explained that there was conflicting evidence and vastly different levels of supervision in the community exercise programmes.

Jonathan Beard, Sheffield, UK, in the invited commentary, noted that current knowledge suggested that unsupervised exercise (advice) does not work; supervised exercise (classes) are effective, but expensive and unavailable for most patients and that home-based exercise with support seemed more cost-effective. Beard added that new terminology is needed with regard to location, class (whether group or individual), level of support, method of support, type of monitoring and type of trainer. He also highlighted that questions remain regarding the level and duration of support required and about which regime gave the best long-term compliance.

Roger Greenhalgh, London, UK, commented that supervised exercise is a blanket term that needed to be broken down.