• 
• 

Three Part Question

In [patients who have had revascularisation surgery] does [post-operative exercise] reduce [the risk of further surgery/amputation and improve function]?

Clinical Scenario

A 75 year old man has a right fem-pop bypass to improve critical limb ischaemia, should he be referred to an exercise programme to reduce the risk of needing further surgery and improve his function?

Search Strategy

CINAHL, MEDLINE, PubMed, EMBASE and AHMED via the EBSCO interface Jan 2000-Nov 2018
({[exercise OR rehabilitation] AND [revascularisation surgery] AND [lower limb]} LIMIT to [english AND human])

Search Outcome

Altogether, 1,205 articles were found, 1,202 were irrelevant to the question. Therefore 1 systematic review and 2 randomised controlled trials (RCT's) were found. On review, the 2 RCT's were excluded as they were included in the systematic review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Meneses, A.L., Ritti-Dias, R.M., Parmenter, B., Golledge, J. and Askew, C.D. 2017 Switzerland	726 participants (8 trials included) who had peripheral arterial disease or intermittent claudication: 253 = underwent revascularisation therapy alone 145 = underwent supervised exercise training alone 328 = underwent combined therapy	Systematic Review	Pain-Free Walking Distance	Mean difference between combined therapy and revascularisation therapy alone ranged from 38-391m in favour of combined therapy	Only 1 reviewer completed the literature search and selected the studies. There was no attempt to find unpublished studies therefore there is a possibility of publication bias. Non-peer-reviewed publications such as conference abstracts, were excluded from the review. The protocols for the assessment of the primary outcomes were not uniform across the studies and the small number of trials within each outcome subgroup, meant a meta-analysis could not be performed.
			Maximal Walking Distance	Mean difference between combined therapy and revascularisation therapy alone ranged from 97-321m in favour of combined therapy. Effect size analysis revealed a large and significant effect size (p < 0.01) in favour of combined therapy over revascularisation in 2 trials.
			Six-min Walking Distance	Only 1 trial assessed. The between-group effect size was trivial with no significant difference between groups.
			Resting Ankle-Brachial Index	Between-group effect size was trivial with no significant difference between groups, with the exception of 1 trial; in which the between-group effect size was large and significant in favour of combined therapy (p<0.01)
			Health-Related Quality of Life	Between-group effect size were non-significant, except for 1 trial, which the effect size was large and significant in favour of combined therapy (p<0.01)

Comment(s)

This is a well-written systematic review that looks at the efficacy of lower limb revascularisation combined with supervised exercise training in patients with PAD. The authors concluded that current evidence suggests that PAD patients treated with combined therapy achieve greater functional benefits than those treated with revascularisation or supervised exercise training alone. There was no attempt to look at unpublished data in this paper and therefore, it is subject to publication bias. The current evidence suggests that exercise with revacularisation surgery does help to improve function, however, there is no evidence that it reduces the risk of further surgery or amputation. Further data collection and an RCT looking at exercise after revascularisation surgery and whether it reduces the risk of further operation is warranted

Clinical Bottom Line

Supervised exercise training combined with revascularisation surgery improves patients function, therefore, supervised exercise training should be implemented post surgery to provide functional benefits.

References

1. Meneses, A.L., Ritti-Dias, R.M., Parmenter, B., Golledge, J. and Askew, C.D. Combined Lower Limb Revascularisation and Supervised Exercise Training for Patients with Peripheral Arterial Disease: A Systematic review of Randomised Controlled Trials Sports Med Journal 2017; pp 987 - 1002