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A Systematic Review of Exercise Prescription in Patients with Intermittent Claudication: Does Pain Matter?

Seed, Sally; Harwood, Amy; Sinclair, Jonathan; Pymer, Sean; Caldow, Edward; Ingle, Lee; Egun, Anselm; Birkett, Stefan


Sally Seed

Amy Harwood

Jonathan Sinclair

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Mr Sean Pymer
Academic Clinical Exercise Physiologist

Edward Caldow

Anselm Egun

Stefan Birkett


Background: Current guidelines for intermittent claudication advocate exercise at moderate to maximal claudication pain. However, adherence rates to supervised exercise programmes (SEP) remain poor and claudication pain is a contributing factor. Limited evidence suggests that moderate or pain-free exercise may be just as beneficial and may be better tolerated. However, it remains unclear what ‘level’ of claudication pain is optimal for improving functional outcomes. We therefore conducted a systematic review to synthesise the evidence for exercise prescribed at different levels of claudication pain. Methods: The CENTRAL, MEDLINE, Embase and CINAHL databases were searched up to October 2020. Randomized controlled trials (RCTs) that directly compared at least 2 different intensities of claudication pain were included. Outcome measures included walking performance, adherence, quality of life and vascular function. Results: Of 1,543 search results, 2 studies were included. Maximal walking distance improved by 100–128% in the moderate-pain SEP groups, and by 77–90% in the pain-free SEP groups. Importantly, there were no significant differences between the moderate-pain and pain-free SEP groups in either study for improvements in walking performance, though comparison to a maximal-pain SEP group was not made. Conclusions: The efficacy of SEPs for patients with intermittent claudication is irrefutable, though there is no consensus on the optimal level of pain. Therefore, adequately powered RCTs are required to compare the effect of pain-free SEPs, moderate-pain SEPs and maximal-pain SEPs on functional outcomes. (PROSPERO ID: CRD42020213684).


Seed, S., Harwood, A., Sinclair, J., Pymer, S., Caldow, E., Ingle, L., …Birkett, S. (in press). A Systematic Review of Exercise Prescription in Patients with Intermittent Claudication: Does Pain Matter?. Annals of vascular surgery,

Journal Article Type Review
Acceptance Date Jun 17, 2021
Online Publication Date Aug 28, 2021
Deposit Date Jun 18, 2021
Publicly Available Date Aug 29, 2022
Journal Annals of Vascular Surgery
Print ISSN 0890-5096
Electronic ISSN 1615-5947
Publisher Elsevier
Peer Reviewed Peer Reviewed
Public URL


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