Identifying the Most Clinically Effective Exercise Prescription for Improving Maximum Walking Distance in People with Intermittent Claudication: A Systematic Review with Network and Component Network Meta-analysis.

Abstract

Supervised exercise programmes are first line treatment for patients with intermittent claudication. Their prescription comprises a combination of components, namely frequency, intensity, time, and type of exercise. However, the optimal prescription (i.e., the most effective combination of these components) remains unknown. This leads to a paucity of comprehensive programme guidelines, poor programme provision, uptake, and completion rates and potentially ineffective programmes. The aim of this systematic review with network and component network meta-analyses was to identify evidence for the optimal supervised exercise prescription for patients with intermittent claudication. CENTRAL, MEDLINE, Embase, CINAHL, trial registries, and Web of Science. Randomised controlled trials of patients with intermittent claudication comparing a supervised exercise programme with an appropriate, non-invasive comparator group or another, alternative supervised exercise programme were included. The primary outcome was mean difference in maximum walking distance between the exercise and control groups. A component network meta-analysis was planned to identify the most effective combination of components. However, the assumption required for a valid component network meta-analysis was violated, requiring alternative primary analyses. This involved initially grouping trials by their common components and undertaking standard network meta-analyses for each group to identify the likely effective levels (e.g., once or twice per week). These results were supported by other analyses to identify a likely optimal prescription. Searches returned 13 714 unique results. Sixty four trials (n = 3 427) were included in the primary analysis. The likely optimal supervised exercise prescription is intermittent walking, performed three times a week, utilising a pain based prescription (ranging from pain free/pain onset to maximal pain) for 30 - 60 minutes per session, for a period of twelve weeks (moderate to high quality evidence). This study identified the likely optimal supervised exercise prescription for patients with intermittent claudication, which should inform future guidelines, clinical practice, and clinical trials.