An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication.

Pymer, Sean A., Ibeggazene, Saïd, Palmer, Joanne, Tew, Garry, Ingle, Lee, Smith, George E., Chetter, Ian C. and Harwood, Amy E. (2021) An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication. Journal of Vascular Surgery, 74 (6). 2076-2085.e20. ISSN 0741-5214

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Abstract

Supervised exercise programmes (SEP) are effective for improving walking distance in patients with intermittent claudication (IC) but provision and uptake rates are sub-optimal. Access to such programmes 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 programmes (HEP). Medline, EMBASE, CINAHL, PEDro and Cochrane CENTRAL were searched for terms relating to HEP and IC. This review was conducted in according with the published protocol and PRISMA guidance. Randomised and non-randomised trials that compared a HEP to 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 randomised trials. The primary outcome was maximal walking distance. Sub-group analyses were performed to consider the effect of monitoring. Risk of bias was assessed using the Cochrane tool and quality of evidence via GRADE. 23 studies with 1907 participants were included. Considering the narrative review, HEPs were inferior to SEPs which was reflected in the meta-analysis (MD 139m, 95% CI 45 to 232m, p = .004, very-low-quality evidence). Monitoring was an important component, as HEPs adopting this were equivalent to SEPs (MD: 8m, 95% CI -81 to 97, p = .86; moderate-quality evidence). For HEPs versus basic exercise advice, narrative review suggested HEPs can be superior, though not always significantly so. For HEPs versus no exercise controls, narrative review and meta-analysis suggested HEPs were potentially superior (MD: 136m, -2-273m p = .05, very-low-quality evidence). Monitoring was also a key element in these comparisons.Other elements such as appropriate frequency (≥3x 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.

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