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Episode 6 : Exercise and Peripheral Arterial Disease

Release Date: November 6, 2006

Dr. David Meyerson:  Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for this week's edition of Vascular Disease Foundation's HealthCast.  We've been privileged to bring you wonderful information on all types of vascular diseases from the Vascular Disease Foundation and as we've mentioned in the past, the VDF, the Vascular Disease Foundation represents truly the leading health organizations in medicine, surgery, radiology, rehabilitation, nursing and ultrasound technology and we are privileged to be able to bring you some of the very best and current peer-reviewed science.  Peer-reviewed means that we have not only our opinions, but these opinions are reviewed by other organizations and they represent the standard of medicine throughout the country.  We are so pleased to be able to bring you this level, this quality of information.

With me today, a very special guest is perhaps one of the foremost authorities on exercise training for patients with peripheral vascular disease. That is Dr. Judith Regensteiner.  She is a Professor of Medicine.  She is Director of the Center for Women's Health Research at the University of Colorado Health Science Center.  Again, a true expert in her field. Also with me in studio is Dr. Kerry Stewart.  He is Professor of Medicine and Director of Clinical Research Exercise Physiology at Johns Hopkins.  He is a current member of the Board of Directors of the Vascular Disease Foundation.  Dr. Regensteiner is just finishing two whole terms as Board of Director member as well. Dr. Regensteiner, thank you so much for taking the opportunity to be with us today.  I really appreciate it.  How are you?

Dr. Judith Regensteiner:  Fine.  My pleasure to be here.

Dr. David Meyerson:  And Dr. Stewart, in studio with us, Kerry as always, thank you for being here as well.

Dr. Kerry Stewart:  Glad to be here.

Dr. David Meyerson:  There is, I understand that there may be a little bit of new data.  The American Heart Association meetings are some of the most important meetings that new information is shared at and if I could ask for just a moment, Dr. Stewart, is anything new that you would care to share with us, that just came back from the American Heart Association meetings and something that we might ask Dr. Regensteiner's opinion about?

Dr. Kerry Stewart:  There was some new data presented, but perhaps we'll hold that for a little bit later.  Just let maybe Dr. Regensteiner explain what the standardized guidelines are for exercise training and perhaps we'll ask her about some new approaches that seem to be novel in terms of how to best treat these patients.

Dr. David Meyerson:  All right, then we'll come back to Dr. Stewart a little bit later.  Dr. Regensteiner, again peripheral vascular disease.  We talked in past episodes about a seventy-year-old house and if the plumber told us that there was a blockage in a pipe on the second floor bathroom, we wouldn't be shocked for a moment if there was also some corrosion in one of the pipes in the basement and this is something that affects the whole body.  When people come to you with claudication, what are they complaining about generally?  What's the first thing they say?

Dr. Judith Regensteiner:  When people come to me with claudication?

Dr. David Meyerson:  Yes.

Dr. Judith Regensteiner:  The first thing they might say is that they get pain in their legs when they walk.  If they know what it is, then they understand.  If they don't know what it is, they'll tell me that they've had this pain in their legs when they walk and it's limiting what they want to do and they ask if there are any therapies.

Dr. David Meyerson:  Now you often have to participate in helping other doctors make the diagnosis or differentiate between pain in the legs that would come from somebody's low back problems perhaps and pain in the legs that comes from a limited blood vessel supply to the legs.  Is that right?

Dr. Judith Regensteiner:  Yes.  Making that diagnosis is critical and it's not hard to do at all, because as you mentioned, a history of leg pain is very nonspecific and even measuring pulses isn't always conclusive.  Or feeling, palpating the pulses is not always conclusive so sometimes if you have a suspicion that a patient might have claudication or peripheral arterial disease, you might want to do an ankle- brachial index.  Measure the blood pressure in their ankles and their arms and form a ratio which is very sensitive and specific for diagnosing peripheral arterial disease.

Dr. David Meyerson:  So for a patient, that's merely putting blood pressure cuffs on the arms and the legs and doing differential measurements?

Dr. Judith Regensteiner:  Right.  You have them [inaudible] measure blood pressure in the ankle and the arms and form a ratio of ankle over arm using two pulses in the leg, one dorsalis pedis and one posterior tibial and then the brachial artery.  And you have to use a doppler to do this because you can't measure the ankle pressures without a doppler.

Dr. David Meyerson:  Now a doppler, most of our listeners might not know what that is, but suffice it to say that when the policeman uses the radar gun or clocks us with how fast we're going, that device shoots out a beam at a certain radio frequency and it bounces back and that frequency changes a little bit depending upon how fast that's going.  And you have a device that shoots that same wave at the blood stream.  Is that correct?

Dr. Judith Regensteiner:  That's correct and you can measure how fast the -- how strong the blood flow to the ankles is and normally, you know, you get quite enough blood flow to your legs when  you walk, but when you have blockages in those arteries which happens when you have blockages and peripheral arterial disease, then enough blood flow does not get down to the legs when you're exercising, especially when you're walking and it can become very painful.

Dr. David Meyerson:  Now we, as a cardiologist, I've mentioned this before, I find that when I have a patient who begins to limit their activity because of either peripheral vascular disease or because of low back problems or an orthopedic injury, I find that their overall health seems to decline because they're not able to keep their lipid status good, they're not able to keep their blood pressure as nicely controlled and they're not able to keep their weight down and their breathing and their exercise capabilities all suffer.  So you probably, from your perspective, have as strong a vested interest in keeping your patients highly functional.

Dr. Judith Regensteiner:  Absolutely.  If our patients don't exercise, everything goes downhill.  You know, it's just really a case where these -- the people who get peripheral arterial disease, you know, are the same risk factors or perhaps even more so for smoking and diabetes as those who get heart disease.  And a lot of people who get peripheral arterial disease will also get heart disease and also stroke, so all the patients with atherosclerosis, and that's all people need to exercise regularly to keep themselves healthy and patients with peripheral arterial disease, when it hurts them to walk, naturally they tend to stop exercising as much.  And it becomes really a very serious health issue.

Dr. David Meyerson:  It's a downward spiral if you will.

Dr. Judith Regensteiner:  Absolutely.

Dr. David Meyerson:  Because then if we're not exercising, our breathing isn't as good, we're not burning as many calories, our cholesterol is not as -- the HDL doesn't stay as high, we don't keep the LDL cholesterol down, as low as we'd like it and there's a training affect as well and something you just said a moment ago, I think we should emphasize to our listeners and that is if the doctor has made a presumptive diagnosis of peripheral vascular disease, if a doctor says we're going to begin to treat you for this, then it would be reasonable, don't you think, for that same patient to turn around and talk to their cardiologist or internal medicine provider or whoever else is looking at the other aspects of their vascular disease and say, "Am I at risk for cerebral vascular disease?"  For example, disease involving the carotid arteries, the arteries that nourish the brain?  Or perhaps am I at risk for coronary artery disease? Again, it's that seventy-year-old house that we talked about.  Once you find that you have a problem in the plumbing in one part of the house, it should be no surprise at all that plumbing in all areas of the house could be affected.  Wouldn't you agree?

Dr. Judith Regensteiner:  I totally agree.  I see it, you know, all the time especially with peripheral arterial disease because it hurts to walk, people just stop and limit their activity.  To be perfectly fair, a lot of people who get peripheral arterial disease are partly may have gotten it because they were sedentary in part, but stopping exercise just makes things worse.

Dr. David Meyerson:  And let me not let our time with you get away without commenting about smoking.  Would you tell us how you might feel about smoking?

Dr. Judith Regensteiner:  Well, I'm not very fond of it, as you can imagine.  Smoking and diabetes - smoking is the strongest risk factor for peripheral arterial disease  and if you smoke, you're, you know, it's more of a risk than anything you can think of for peripheral arterial disease and it makes everything worse.  And if you keep smoking, the whole – your walking will even get worse.  It's really very, very bad for you.  It's bad for everyone, but especially linked to peripheral arterial disease and you know, there's nothing good about smoking that I know.

Dr. David Meyerson:  As I have mentioned to patients when they say, "Doctor, I'm cutting down."  I usually like to applaud the fact that they're trying to do something, but then I honestly go ahead and say that cutting down is a little bit like saying I only drive a hundred and thirty-five miles an hour two days a week, so something terrible is going to happen on a Tuesday or a Saturday, but really smoking cessation, total cessation is the smartest and best thing that you can do for your vascular health throughout your body and I think Dr. Regensteiner and I and Dr. Stewart would echo that several fold.

Dr. Judith Regensteiner:  I would just say if there's a safe dose of smoking, we don't know it.

Dr. David Meyerson:  That's exactly right.

Dr. Judith Regensteiner:  There's no amount of smoking that is safe that we know of and the body knows what you do to it, so you've got to be really careful.

Dr. David Meyerson:  Absolutely correct.  One of the things I'd like to talk about for a minute with you because you are a recognized expert in this area. If we have -- if I have a patient who gets angina and that is an area of a heart muscle gets too little blood supply and oxygen when they do certain activities. Until we get them their proper therapies, we actually ask that they not exercise until they get the pain and then we ahead, of course, work them up in greater detail and try to do whatever we can to give them better blood supply to that area of the heart muscle, however, when you Dr. Regensteiner, deal with patients with peripheral vascular disease, you don't exactly follow that do you?  You may actually ask them to exercise up to and including getting some pain, wouldn't you?

Dr. Judith Regensteiner:  Well, it's a little bit different.  The analogy between angina, the chest pain that people get who have heart disease and claudication, the leg pain that people get who have peripheral arterial disease is good because it suggests that enough blood isn't getting to those areas, but it isn't life threatening to get the pain in your leg when you walk whereas people get nervous when they get pain in their heart because it could mean, you know, a bad thing happening with their heart which I understand. Now, we don't teach people and we teach them to exercise, we don't teach them walk to severe pain.  We teach them to walk to moderate pain and then stop and rest and start again.

Dr. David Meyerson:  So you're not asking them to be miserable, but you do pick a thresh hold --

Dr. Judith Regensteiner:  Right.

Dr. David Meyerson:  -- whereby getting to a certain level is actually beneficial.

Dr. Judith Regensteiner:  Absolutely.  Just because -- we don't know why exactly.  We're looking at that right now, but those repeated bouts of exercise, they just seem to get longer and longer when you do the supervised exercise program and I've never seen it not work.

Dr. David Meyerson:  So let me ask you this, when you actually put someone through a specialized training program, someone that does have limited blood supply to the legs, does the training actually enhance the blood supply to the legs or does it teach the muscles how to do better with a limited blood supply or is it both?

Dr. Judith Regensteiner:  We think it might be a little bit of both.  We don't know for sure and we're doing a big grant right now progress a study to look at that, but we think that probably there's a metabolic muscle type  answer and a blood flow answer, both.  So we're looking at why it improves things. What we do know, very clearly, that exercise in the right setting does improve walking.  And by the right setting, I mean, it has to be a supervised exercise program so typically these are done in cardiac rehab settings where patients come in three times a week for three months and spend the better part of an hour walking.

Dr. David Meyerson:  So you're not suggesting that someone who has leg pain just adopt this policy themselves.  You're suggesting a full vascular evaluation and then once the doctor knows and can explain to them what level of function is a good level for them, then there is an exercise prescription and increasing exercise prescription written for them?

Dr. Judith Regensteiner:  Well, I don't think that patients have to get a full vascular work up unless they have serious peripheral arterial disease. I think that a patient should be able to go to their primary care doctor and get their ankle pressure measured right there.  Now, of course, that's the ideal.  The real right now is that a lot of doctors may not have that equipment, but we're encouraging people to be able to screen for this more readily.  So we're hoping that people who have risk factors for heart disease and get this leg pain, will go on and get checked with their doctor, but if it has to be through the vascular specialty lab, then we understand.  It's important to get checked, because if we know you have this problem, we can maybe try to prevent or you from getting worse problems.

Dr. David Meyerson:  What type of patient should not just begin a gentle, even gently graded exercise program?

Dr. Judith Regensteiner:  Well, all patients with peripheral arterial disease.  As soon as they get worked up.  Now nobody is going to get put in a supervised exercise program without some medical supervision, so --

Dr. David Meyerson:  I guess what I'm suggesting though is that if somebody has an open, non- healing ulcer on their foot or their leg, you would suggest that those people get a very detailed evaluation before they enroll or get involved in exercise training program to improve their capabilities, right?

Dr. Judith Regensteiner:  Absolutely.

Dr. David Meyerson:  And diabetics also especially because they don't feel -- they often don't have sensation in their lower extremities and wounds can get kind of out of hand, if you will in a diabetic leg.

Dr. Judith Regensteiner:  That's right.  I think that people you know, need to be sensible about it, but mostly you will have to go through your doctor to get one of these programs probably anyway.  The reason we say it has to be supervised as opposed to an unsupervised home type program is that unfortunately our patients tend to be sedentary and probably they just don't do it very faithfully.

Dr. David Meyerson:  Dr. Regensteiner, are there medicines that you have seen used clinically that really make a material difference in the ability of the person to walk a distance?

Dr. Judith Regensteiner:  Typically the improvement is between a hundred and a hundred and fifty percent, so yes.  And I have seen such extreme cases that when a patient started, they could hardly walk five minutes without stopping and then when they finished three months supervised exercise, they could walk for fifty minutes.

Dr. David Meyerson:  So that's --

Dr. Judith Regensteiner:  And I've also mostly seen more intermediate improvement, but I've seen pretty substantial improvements.  You never sort of have to figure out, am I seeing improvement.  It's quite clear in most cases.

Dr. David Meyerson:  So you would say that exercise training is a very strong -- I was impressed what you said early.  You said you almost never seen a patient who didn't benefit substantially from it.

Dr. Judith Regensteiner:  Now I have heard anecdotal evidence of patients who haven't benefitted. In our University, I have never seen a patient not benefit except for one patient and that was my patient who sat by the coffee pot repetitively throughout the class and he never improved because he didn't walk. But otherwise, anyone who's done it actively, has improved.

Dr. David Meyerson:  So in your area, really is no pain, no gain, as they say.

Dr. Judith Regensteiner:  Well, that's some extent true.  I mean, we look at it as no moderate pain, no gain.  We don't push people to severe pain, but we do see that people improve a lot and it's a very wonderful thing to see.  People are able to return to more normal activities.

Dr. David Meyerson:  You know, what is so impressive to me is your description of how many people benefit from this and what I hear as a cardiologist so often is, "Doctor, I don't want to take medicines.  What can you do for me without medicines to make things better?"  And here you are with a whole modality of therapy that is not medicine based.  It may be able to use medicines as an adjunct, but what you do does not require medications.

Dr. Judith Regensteiner:  Absolutely.  And actually, some people would rather it be medication. You get a lot of people would like, what they call a quick fix which there isn't a quick fix for this, you know, blocks in the arteries.  But we do have treatments, that's the good news and exercise rehab is the gold standard treatment for these patients who have blockage of the arteries.

Dr. David Meyerson:  It must be also of critical importance in people who have had vascular procedures to their legs and need to improve their function after a surgical procedure.

Dr. Judith Regensteiner:  Absolutely, it will help everyone.

Dr. David Meyerson:  This might be a good time to bring Dr. Stewart, Kerry Stewart back to the microphone.  I asked at the beginning of our cast was there anything new that you wanted to bring to the microphone, Kerry, that you might ask Dr. Regensteiner to comment on.

Dr. Kerry Stewart:  I was recently at the American Heart Association meeting and I can't remember if you were sitting next to me when this was presented, but a study showed that avoiding leg pain, but actually doing upper body exercise appear to be as beneficial as the type of exercise you just described.  I wonder if you have any comments.

 Dr. David Meyerson:  Before you answer that - I just need to clarify the question for our listeners because it really is fascinating.  For the whole program, so far we've been talking about doing exercise with your lower extremities, with your legs to improve how your legs function and to improve how far you can go.  And Dr. Stewart is now saying that he listened to the presentation of a research paper that suggested even if you did not exercise the legs, if you did upper body exercise, it still translated into the increased ability to doing work and exercise with your legs.  Is that your understanding?

Dr. Kerry Stewart:  Well, that's what was presented and it was a small study.  It certainly is not at the point where it will change our recommendations, but it certainly something that needs further research and I wonder if Dr. Regensteiner can give us her take on that.

Dr. Judith Regensteiner:  I'm familiar with that work and I think it's very interesting, but I would echo your words in saying that it's a small study and it's preliminary to say that we can go this way, but it's an interesting study and I would also add that it is a supervised exercise program again, not a home -

Dr. David Meyerson:  So let me ask you this question as a -- on behalf of the lay public.  If -- what would be the mechanism, if you're doing exercise with your arms and it makes it possible that you could go further by exercising your legs when you do use your legs, what would be the mechanism?  How would that improve blood supply or make it less likely to get pain from the legs?

Dr. Judith Regensteiner:  I can think of two possible answers to that.  One would be that there's metabolic affect on the muscles of the person so that there's changing in the muscles that make it easier to use fuel for muscles, essentially, so that people are, so their whole bodies benefit from it.

Dr. David Meyerson:  So there's some hormone or peptide or substance that's being produced by the activity that not only does it affect the upper body muscles, but it also has a beneficial effect on the lower extremities.  And what was the other thought?

Dr. Judith Regensteiner:  My other thought is that it could include or could improve what's called endothelial functions and that's a fancy way of saying blood flow regulation and it could improve the blood flow regulation through the whole body so that the body's better able to send blood where it needs to go and the muscle gets the blood it needs --

Dr. Kerry Stewart:  I think what you were describing is what we generally refer to as a systemic effect of that, even though you're exercising with your upper body, it's having benefits throughout the whole system, systemic effect.

Dr. David Meyerson:  Dr. Regensteiner, maybe I can also ask you this point.  In the minute or two that we have left, what are the other potential benefits of an exercise therapy program?

Dr. Judith Regensteiner:  In terms of cardiovascular risk, risk for heart disease and stroke, an exercise program we know will help prevent bad things like that happening.  So that's the most obvious one.  Exercise also has a benefit for psychological profile, for all kinds of physical ailments.

Dr. David Meyerson:  Even maintaining ideal body weight, for example, would be a big spin off, keeping your blood sugar well controlled if you're diabetic.  I think the more --

Dr. Judith Regensteiner:  Well, I want to say something about diet though because if you don't diet, you won't lose weight even with exercise because it's too easy to eat three hundred calories, that's one donut, and exercise for an hour burns three hundred calories.  So, it's not a good form of weight loss and I don't like to let people think it is because then they get disappointed and blame the exercise.  But the good news is that it's number one way to keep that weight off.

Dr. David Meyerson:  Wonderful.

Dr. Judith Regensteiner:  So exercise is good for weight maintenance.  It's good for just so many things.  I just -- we have a big presentation in Washington, D.C. and they're going to write some policy statements about exercise for the whole country because it's just so good and there's almost --

Dr. David Meyerson:  Let me ask you in closing, I saw the more commercial Richard Simmons on a television program recently and he's very upset because physical education has been taken out of the public schools as a mandatory program and as someone who is a foremost authority in exercise training and exercise physiology, would you want to see that adopted again in public schools as a mandatory program?

Dr. Judith Regensteiner:  Absolutely.  Not only am I passionate about it in my work, but I also have a twelve-year-old daughter and I think it's outrageous that kids don't get daily exercise.  I think growing kids need to get the -- because kids now are developing type II diabetes and other ailments that used to be associated with older people.  We need to get our kids exercising and keep them that way.

Dr. David Meyerson:  So for our children, for everybody, we can agree don't smoke, don't smoke, don't smoke, keep your weight normal and exercise, exercise, exercise.  Is that right Dr. Regensteiner?

Dr. Judith Regensteiner:  That's exactly the message.

Dr. David Meyerson:  I'd like to thank my very special guest, Dr. Judith Regensteiner.  She's Professor of Medicine of the section of Vascular Medicine and Director of the Center for Women's Health Research at the University of Colorado Health Science Center.  I'd also like to thank my in studio guest, Dr. Kerry Stewart.  He's Professor of Medicine, Direction of Clinical and Research Exercise Physiology at Johns Hopkins.  I am Dr. David Meyerson.  I am so proud to be able to bring you these special editions of the Vascular Disease Foundation's HealthCast.  For the Vascular Disease Foundation, again I'm David Meyerson, have a good night.

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