2009 - angiology care unit - padua - italy - aziendaospedalierauniversita’padova 1 university...

2009 - Angiology Care Unit - Padua - Italy - www.ANGIO-PD.it

AZIENDAOSPEDALIERA UNIVERSITA’PADOVA

1

University Hospital of Padua - Italy

Angiology Care Unit

G.M. Andreozzi

Physical Training in the Treatment of Peripheral

Arterial Disease(Intermittent Claudication)



Physical Training in Claudicants

Physical ExercisePhysiological Tool for Prevention and Treatment of Cardio – Vascular Diseaseseffective and cheapTask Force Multisocietaria (Fed. Medico Sportiva Italiana & Soc. It. Cardiologia dello Sport):Documento Cardiologico di Consenso su: La prescrizione dell’esercizio fisico in ambito cardiologico. (FMSI & SIC-sport Ed) Roma 9 maggio 2006

Physical Training effective mean for claudicant patients

Hirsch AT, Haskal ZJ, Hertzer NR: ACC/AHA Guidelines for the management of PAD. JACC 2006; 20 (10): 1-75

- low application- dyshomogenous procotols



Physical Training in Claudicants

The largest metanalysis on the results of Physical Training in Patients with Intermittent Claudication show and increase of ACDbetween 74 (a) and 230% (b)…

a) Girolami B et al: Arch Intern Med. 1999; 159:337-345 b) Leng GC et al: Exercise for intermittent claudication (Cochrane review). in: Cochrane library, 3, 2002. Oxford: Update Software.

0 50 100 150 200 250

m

Leng (b)

Girolami (a)

… unaccepatable for other therapeutic tools

… as pharmacological therapy



Physical Training Protocol (3 days weekly x 6 weeks = 18 days)

Int Angiol 2008 27(5):401-7



5

Management of Intermittent Claudication



Sub Maximal Test (speed 1,5 km/h slope 62%)

Single Exercise Load Patient walks until 60-70% of walking ability measured by sub

maximal test

Maximal Treadmill TestConstant Load (speed 3,2 km/h, slope 12-15%)Parameters: ICD, ACD, recovery time (rt)

Near maximal pain but without reaching it

Resting Restore (standing or sitting)until the patient can restart the walking(indicative setting could be a resting periodequal to recovery time measured during maximal test)

Daily Training SessionEXERCISE-REST-EXERCISE pattern should be repeated,

reaching at least 30 min of effective walking time

Single Exercise LoadPatient walks until 60-70% of new walking performance

(incremental protocol of the training programme)

Day 10 - New Assessment of Walking AbilitySub Maximal Treadmill (same speed and slope of the starting day)

Physical Training Protocol (3 days weekly x 6 weeks = 18 days)



Intermittent Claudication - Skeletal Muscle Pathophysiology

0

10

20

30

40

50

60

70%

F-1 F-2A F-2B

Histochemistry Prevalence of Muscle's Fibres

CONTROLS CLAUDICANTS

Askew CD et al: J Vasc Surg 2005 41:802-807

reduction of FAST 2B fibersincrease of INTERMEDIATE 2A fibers

SKELETAL MUSCLES

TWITCH

CHARACTERISTIC

METABOLIC

PROFILE

FUNCTION

TYPE 1 SLOW OXIDATIVE

high mitocondrial content adapted for

prolonged work

TYPE 2

(A)

INTERMEDIATE INTERMEDIATE

OXID - GLYCOL

INTERMEDIATE

TYPE 2

(B)

FAST GLYCOLYTIC more

rapidly fatigue

Steinacker JM et al: J Vasc Surg 2000 31:443-449

WEIGHTBEARING



8

Inflammatory Activation during Maximal Exercise Treadmill Test



9

Inflammatory Activation during Maximal Exercise Treadmill Test

IL-1 IL-6

Cordova R, Martini R, … Andreozzi GM: Flogistic arterial activity or own inflammatory attitude:what acts on PAD evolution? Int Angiol 2003 22 s1 21-22

Andreozzi GM et al: Circulating levels of Cytokines (IL-6 and IL-1),in patients with Intermittent Claudication, at rest, after maximal exercise treadmill test and during restore phase. Int Angiol 2007 26(3):245-52



10

FMD and Maximal Exercise

% F

MD



11

Physical Training Protocol (18 days) - Results

* p < 0,001** p < 0,0001

0

50

100

150

200

m.

before after

ICD

0

50

100

150

200

250

300

m.

before after

ACD

0

50

100

150

200

250

sec.

before after

recovery time

0,4

0,6

0,8

before after

ABI

** **

***

Moderate Claudication (33)

0102030405060708090

m.

before after

ICD

020406080

100120140160

m.

before after

ACD

0

50

100

150

200

250

sec.

before after

recovery time

0,6

0,8

before after

ABI

** **

***

Severe Claudication (41)



12

Physical Training and Endothelial Function

Before (-33,28%) After (-19,83) p<0,01

% F

MD



13

Paradoxical Effect of Physical Exercise on Endothelial Function

Murry CE, Jennings , Reimer KA: Preconditioning with ischemia: a delay oflethal cell injury in ischemic myocardium. Circulation 1986 74:1124-36Schott RJ, Rohamann S, Braun ER, Sharper W: Ischemic preconditioningreduces infarct size in swine myocardium. Circ Res 1990 66:1133-42

Ischemic Preconditioning: metabolic adaptationto low intensity repeated ischemia…

Di Perri T, Laghi Pasini F: Fisiopatologia e farmacologia del sistema adenosinico.Rel. 92° Congr SIMI Luigi Pozzi Ed. Roma 1981Di Perri T, Capecchi PL: Le arteriopatie obliteranti periferiche.In Allegra C, Andreozzi GM, Coccheri S, Di Perri T: Managementdel paziente arteriopatico. Excerpta Medica Milano 1999Capecchi PL, Laghi Pasini F, Cati G et al. Experimental model ofshort-time exercise-induced preconditioning in PAOD patients.Angiology 1997 48:469-480

… with ADP release, acting on specific receptorsof smooth muscle cells and endothelial cells

Acute Exercise: inflammatory, prothrombotic andvasoconstrictor activities

Chronic Exercise (training): improvement of physical efficiency,inflammatory reduction and enhancement of vasodilation and fibrinolysis



Training Effectiveness

The largest metanalysis on the results of Physical Training in Patients with Intermittent Claudication show and increase of ACDbetween 74 (a) and 230% (b)a) Girolami B et al: Arch Intern Med. 1999; 159:337-345

b) Leng GC et al: Exercise for intermittent claudication (Cochrane review). in: Cochrane library, 3, 2002. Oxford: Update Software.

0 50 100 150 200 250

m

Leng (b)

severe

moderate

Girolami (a)



Training Effectiveness

Andreozzi GM, et al: Effectiveness and costs of a short-course supervised training programin claudicants. Proposal for a shared protocol with aerobic working load. Int Angiol 2008 27(5):401-7



16

Physical Exercise and Physical Activity



17

Physical Exercise and Physical Activity

Effort (strain)

strenuous (agonistic activity)

physical and training activities, aimed at

competitive and extreme sport, which

reachs and overpass the maximal aerobic capacity

strong(occasinal

agonistic activity)

physical activity reaching the maximal aerobic

capcity

moderate(playful and

recreative activity)

regular or occasional physical activities which

does not reach the maximal aerobic capacity

Physical Activity

agonistic physical and training activities, aimed at competitive sport

playful and/or recreative

regular or occasional physical activities without maximal load



18

Cardiovascular Effects of Physical Training

[a] Cerneca F, Crocetti G, Gombacci A, at al:Variations in hemostatic parameters after near-maximum exercise andspecific tests in athletes. J Sports Med Phys Fitness 1999;39:31–6

[b] Abbot RD, Rodriguez BL, Burchfield CM, et al. Physical activity inolder middle-aged men and reduced risk of stroke: the Honolulu Heart Program.Am J Epidemiol 1994;139:881–93

[c] Contini M, Pacini S, et al: Modification of plasma glycosaminoglycans in long distance runners.Br J Sports Med 2004;38:134–137

Improvement of hemostatic pattern in athletesafter maximal aerobic exercise [a]

Improvement of hemostatic pattern in aged peopledoing regular physical activity [b]

These results are closely related withan improvement of the EFmediators: endothelial GAGs (glycocalix)[c]

EPCs [d]

[d] Shantsila E, Lip GY: Endothelial function and endothelial progenitors:possible mediators of the benefits from physical exercise?Eur J Cardiovasc Prev Rehabil 2009 in press



19

Clical Applications of Physical Exercise, Prevention and Therapy



20

Clinical Applications of Physical Exercise, Prevention and Therapy

SECONDARY

PREVENTION

PRIMARY PREVENTION

PRIMORDIAL PREVENTION

THERAPY

prevent the appearanceof risk factors



21


SECONDARY

PREVENTION

PRIMARY PREVENTION


THERAPY


prevent the clinical appearanceof the disease

prevent the appearance of new CV events

playful and/or recreative physical activityregular or occasional physical activities reaching the maximal aerobic capacity



22


SECONDARY PREVENTION

PRIMARY PREVENTION


THERAPY




the effort should be moderate and tailored on the own capacityof the patient, always avoiding

the maximal aerobic capacity, fatigue or discomfort!



23


SECONDARY PREVENTION

PRIMARY PREVENTION


THERAPY




treatment of intermittentclaudication to improve

the walking capacity

physical exercise should be moderate and well tailored on the own capacity of the patient



24

Indications for the Physical Activity and Exercise

Healthy People

The strenuous physical efforts are reserved to the athletes in the phase of full agonistic activity.

Healthy people, without ATS risk factors,to maintain a good physical efficiency,could be utilized also a strong effort,without overpass the own aerobic thresholds.

Cardio-Vascular Prevention and Treatment

In the primary cardiovascular prevention is indicated the moderate effort, with occasional sessions of strong effort, only if well tolerated!

In the secondary cardiovascular prevention, andin the treatment of intermittent claudication (or in the rehabilitation after AMI) the effort should be moderate and tailored on the own capacity of the patient, always avoiding fatigue or discomfort!



25

University Hospital of Padua - Italy

Angiology Care Unit

G.M. Andreozzi

Physical Training in the Treatment of Peripheral

Arterial Disease(Intermittent Claudication)

2009 - angiology care unit - padua - italy - aziendaospedalierauniversita’padova 1 university...

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