Combined Lower Limb Revascularisation and Supervised Exercise Training for Patients with Peripheral Arterial Disease: A Systematic Review of Randomised Controlled Trials

Background Both revascularisation and supervised exercise training improve functional outcomes and quality of life in patients with peripheral arterial disease (PAD). However, the value of combined therapy, where exercise therapy is delivered as an adjunct to revascularisation, is less clear. Objective To systematically review evidence on the efficacy of lower limb revascularisation combined with supervised exercise training in patients with PAD. Methods Parallel-group randomised controlled trials indexed in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Scopus, CINAHL, SPORTDiscus and Web of Science were searched (up to Jan 2016). Outcome measures were pain-free and maximum walking distances, ankle-brachial index (ABI), leg blood flow and quality of life. Methodological quality was assessed using the Physiotherapy Evidence Database (PEDro) scale. Result Eight trials were included that enrolled a total of 726 patients (mean age 66 +/- 3 years, ABI 0.66 +/- 0.05). Combined therapy led to greater improvements in pain-free (mean difference [MD] range 38-408 m) and maximal walking distances (MD range 82-321 m) compared with revascularisation or supervised training alone. Combined therapy had no added effect on resting ABI over revascularisation (MD range -0.05 to 0.13), and had a significantly greater effect than supervised exercise training alone (MD range 0.13-0.31). Limited evidence (one to three trials) also suggested that combined therapy led to greater improvements in leg blood flow and physical domains of quality of life than supervised exercise training alone, and that improvements in leg blood flow, as well as the physical and mental domains of quality of life were not different to that achieved with revascularisation alone. Conclusion Current evidence suggests that PAD patients treated with combined therapy achieve greater functional benefits than those treated with revascularisation or supervised exercise training alone. Limited evidence also suggests that the effect of combined therapy on leg haemodynamics and quality of life may be superior to supervised exercise training alone, and similar to revascularisation alone.