This research study consisted of three parts.  In the first part two surveys were conducted, one among General Practitioners (GPs) in Grampian Area of Scotland and the second among Consultant Vascular Surgeons throughout the United Kingdom and Ireland, which aimed to explore the attitudes towards management of secondary risk factors in patients with intermittent claudication.  Postal questionnaires were used to determine how GPs and Consultant vascular surgeons screened for and controlled the major risk factors - cigarette smoking, hypertension, diabetes and hyperlipidaemia, whether and what anti-platelet treatment was prescribed, and the availability of facilities such as smoking cessation clinics and supervised exercise programmes for patients with intermittent claudication.  The findings from the GP survey were compared with the responses to a questionnaire of patients with intermittent claudication referred to the Vascular Clinic, Aberdeen Royal Infirmary and to the results of blood investigations. The results of the two surveys showed that a significant proportion of both GPs and Consultant Vascular Surgeons do not abide by current recommendations on management of major secondary risk factors.  This may be partly due to the lack of national guidelines and the paucity of local guidelines specifically on the management of secondary risk factors in intermittent claudication.  The surveys have also identified serious deficiencies in the availability of supervised exercise and smoking cessation programmes for this group of patients.  Only a very small minority of consultant vascular surgeons have access to a vascular physician.  Furthermore a wide discrepancy was noted between the claims made by GPs.

Thesis (M Nursing (Advanced Practice))--University of South Australia, 1995

Thesis (doctoral)--Turku, 1979. / "English summary: Intermittent claudication: noninvasive functional evaluation in diagnosis and follow-up of physical training."

After looking in the vault copies, the Digitization Centre has determined that page vi is a missing page and may be a printing error. -Digitization Centre / This study aimed to improve understanding of walking exercise among individuals with intermittent claudication. Using a prospective design, Ajzen's (1985, 1991) theory of planned behaviour was applied to examine psychosocial determinants of walking exercise. In addition, measures of barrier self-efficacy were explored as determinants of behaviour and perceived pain intensity was examined as a moderator of the intention-behaviour relationship. Ninety-four participants (n = 33 female) completed baseline measures of attitudes, subjective norms, perceived behavioural control, and intentions to engage in walking exercise. Additional measures of pain-related barrier self-efficacy and barrier self-efficacy regarding walking exercise were obtained and the Borg CR1 0 Pain Scale (Borg, 1998) was used to assess perceived pain intensity during walking. Participants were contacted weekly by telephone over four consecutive weeks and asked to recall their walking exercise and associated perceived pain intensity for the preceding seven-day period. Attitudes, subjective norms and perceived behavioural control contributed significantly to a multiple regression model predicting 67% of the variance in walking intentions. Intentions and perceived behavioural control explained 34% of the variance in walking exercise; however, pain-related barrier self-efficacy and barrier self-efficacy did not explain additional variance in behaviour and perceived pain intensity failed to moderate the intention-behaviour relationship. Findings support the theory of planned behaviour for predicting walking intentions and exercise among individuals with intermittent claudication, and suggest that pain cognitions as measured in this study do not play a role in determining walking. / Thesis / Master of Science (MS)

Diss. (sammanfattning) Linköping : Linköpings universitet, 2005. / Härtill 6 uppsatser.

Made available in DSpace on 2017-07-21T14:13:03Z (GMT). No. of bitstreams: 1 Mona Lisa S Gomes.pdf: 2596723 bytes, checksum: cad81f365e93a147f44fe76b57ed4640 (MD5) Previous issue date: 2015-02-24 / Cilostazol is a selective inhibitor of phosphodiesterase III. It acts as a vasodilator and antiplatelet agent. It is the main drug for the treatment of intermittent claudication related to peripheral arterial occlusive disease. This drug belongs to the class II of the Biopharmaceutical Classification System (BCS) and shows low solubility and high permeability in gastrointestinal tract. The usual oral dose is 100 mg twice a day, which represents a disadvantage in treatment compliance. Cilostazol is a lipophilic drug and the development of controlled drug delivery systems can improve its bioavailability. The aim this study was to obtain and characterize nanocapsules suspensions prepared from poly(caprolactone) (PCL), poly(D,L-lactic-co-glycolic acid) (PLGA) and blends using polyethylene glycol (PEG), PCL/PEG and PLGA/PEG containing 0 to 3.0 mg.mL-1cilostazol. The analytical method was developed and validated for the quantification of cilostazol into the nanocápsulas by high performance liquid chromatography. All formulations had suitable encapsulation efficiencies (≥99.6%). Nanocapsules showed pH values between 6.0 and 6.4, average size lower than 137 nm, polydispersity index lower than 0.22 and average negative zeta potential of -35.34 mV. The images observed by electron transmission microscopy and scanning electron microscopy, revealed spherical shape with smooth surface. The results achieved by X-ray diffraction demonstrated no crystallinity which indicated the drug amorphization compared to the raw materials. Analyses performed by Fourier transform infrared spectroscopy showed no chemical reactions between drug and polymers. The formulations prepared from blends of PCL/PEG showed the best stability parameters after 60 days of storage. The use of nanoparticles can be a promising strategy for increasing the apparent solubility of cilostazol leading to better dissolution profiles and therapeutical effect. / O cilostazol é um inibidor seletivo da fosfodiesterase III, atuando como antiagregante plaquetário e vasodilatador. É o medicamento de primeira escolha para o tratamento clínico da claudicação intermitente por doença arterial obstrutiva periférica. O fármaco pertence à classe II do Sistema de Classificação Biofarmacêutica, apresentando baixa solubilidade e alta permeabilidade no trato gastrointestinal. A dose usual é de 100 mg, via oral, duas vezes ao dia, o que representa uma desvantagem à adesão ao tratamento. O cilostazol tem característica lipofílica, podendo ser utilizado no desenvolvimento de sistemas de liberação modificada de fármaco, com a finalidade de melhorar sua biodisponibilidade. Assim, com o propósito de se elaborar sistemas de liberação modificada, o objetivo deste trabalho foi obter e caracterizar suspensões de nanocápsulas, a partir do uso dos polímeros poli(caprolactona) (PCL), poli(D,L-ácido lático-co-ácido glicólico) (PLGA) e de blendas com polietilenoglicol (PEG), PCL/PEG e PLGA/PEG, contendo concentrações de 0 a 3,0 mg.mL-1 de cilostazol. O método analítico por cromatografia líquida de alta eficiência foi desenvolvido e validado para a quantificação do cilostazol presente nas nanocápsulas. Todas as formulações apresentaram valores de eficiência de encapsulação adequados (≥99,6%). As nanocápsulas obtidas apresentaram valores de pH entre 6,0 e 6,4, com tamanho médio de partículas inferior a 137 nm, índice de polidispersão menor que 0,22 e potencial zeta negativo de -35,34 mV, devido aos polímeros aniônicos empregados. As imagens obtidas por microscopia eletrônica de transmissão e microscopia eletrônica de varredura revelaram formato esférico com superfície lisa e homogeneidade das nanocápsulas. Os resultados obtidos por difração de raios X revelaram a ausência de cristalinidade das nanocápsulas, evidenciando sua característica amorfa, em comparação aos polímeros e ao fármaco. As análises efetuadas por espectroscopia na região do infravermelho com transformada de Fourier demonstraram que não ocorreram reações químicas entre o fármaco e os polímeros. Em geral, as formulações de cilostazol obtidas a partir de blendas PCL/PEG foram as que apresentaram os melhores parâmetros de estabilidade após 60 dias de armazenamento. O uso de nanopartículas pode ser uma estratégia promissora na promoção do aumento da solubilização aparente do cilostazol melhorando seu perfil de dissolução e, consequentemente, sua ação farmacológica.

Objectives This thesis aimed to explore psychological factors associated with walking behaviour in patients with Peripheral Arterial Disease, within the framework of Leventhal et al’s (1998) Common-sense Model of Self-regulation of Health and Illness. The objective was to identify psychological factors which could be modified to increase walking behaviour in these patients. Method A series of three studies were conducted to achieve these aims. The first study was an exploratory qualitative study, to explore the illness and treatment beliefs and walking behaviour of patients with intermittent claudication. The second study was a cross-sectional postal questionnaire to a cohort of patients with intermittent claudication, which tested the influence of the psychological factors identified in the qualitative study, in a larger sample. The final study was a randomised controlled trial of a brief psychological intervention designed to modify the illness and walking beliefs of patients with intermittent claudication, in order to increase walking behaviour. Results Beliefs about intermittent claudication, and beliefs about walking were both found to be associated with walking behaviour in the qualitative study. The results from the cross-sectional postal questionnaire confirmed this relationship – taken as a set, illness and walking beliefs accurately predicted adherence to minimum walking levels for 93.4% of the sample. The brief psychological intervention successfully modified illness and treatment beliefs and increased walking behaviour in patients newly diagnosed with intermittent claudication. Conclusion This thesis highlights the importance of illness and walking beliefs to the walking behaviour of patients with intermittent claudication. The thesis has added to the body of knowledge about intermittent claudication, and the findings of this thesis have implications for the treatment of patients with intermittent claudication within the health service. Theoretical and clinical implications of this research are discussed.

Bakgrund: Claudicatio Intermittens är vanligt förekommande hos äldre personer och ger upphov till fysiska och psykiska besvär såsom försämrad gångförmåga och sämre livskvalite. Fysisk aktivitet är en viktig fysioterapeutisk behandlingsmetod som har visat goda resultat för patientgruppen. Därför är det viktigt att sammanställa aktuell evidens för att öka och tillgängliggöra ny kunskap. Syfte: Att undersöka det vetenskapliga underlaget för fysisk aktivitet som behandling och dess effekt på gångförmåga och livskvalitet hos patienter med claudicatio intermittens. Metod: Studiens design var litteraturstudie. En litteratursökning efter randomiserade kontrollerade studier genomfördes i databasen PubMed. De utvalda studiernas kvalitet granskades enligt PEDro-skalan och tillförlitligheten av resultatet bedömdes utifrån ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”. Resultat: Sex studier inkluderades i litteraturstudien. Bäst resultat gällande gångförmåga och livskvalitet fick grupperna som genomgick endovaskulär revaskularisering i kombination med en intervention som innehöll fysisk aktivitet. Samtliga studier fick hög kvalitet från granskningen enligt PEDro. Tillförlitligheten av det sammanvägda resultatet bedömdes enligt ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter” vara låg. Konklusion: Kombinationen av endovaskulär revaskularisering och fysisk aktivitet hade positiv effekt på utfallsmåttet gångförmåga och livskvalitét hos patienter med claudicatio intermittens, men ingen skillnad mellan olika sorters fysisk aktivitet framgick. Fler studier av hög kvalitet som jämför liknande interventioner behövs för att med hög tillförlitlighet kunna avgöra vilken behandling som ger bäst effekt. / Background: Intermittent claudication is common in the elderly population and causes physical and psychological problems such as impaired walking ability and poorer quality of life. Physical activity is an important physiotherapeutic method that has shown promising results for this population. Therefore, it is important to summarize current evidence in order to increase new knowledge and make it available. Purpose: The aim of this literature study was to examine the scientific evidence for physical activity as a treatment, and its effect on walking capacity and quality of life in patients with intermittent claudication  Method: The design of the study was literature study. A literature search for randomized controlled trials was conducted in the PubMed database. The quality of the included studies was examined by the PEDro scale, and the reliability of the results was assessed with ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”. Result:  Six studies were included in the literature study. The best results regarding walking ability and quality of life were obtained by the groups that underwent endovascular revascularization in combination with an intervention that included physical activity. All studies received high quality according to PEDro. According to with ”Bedömning av den sammanvägda tillförlitligheten i systematiska översikter”, the reliability of the combined results was considered low. Conclusion: The combination of endovascular revascularization and physical activity had a positive effect on the outcome measures walking ability and quality of life in patients with intermittent claudication. No difference between different types of physical activity could be seen. More studies of high quality comparing similar interventions are needed to be able to determine, with high reliability, which treatment produces the best effect.

Nine patients with intermittent claudication diagnosed at least 6 months before this investigation were evaluated to determine the effects of walking exercise on serum lactate accumulation (HLa, mmol⁻¹), ankle pressure index (API), total treadmill time (sec), and onset of leg pain (sec) in the most severely diseased limb. Subjects were evaluated via a functional walking tolerance test before participation in a thrice-weekly exercise program lasting 6 weeks. Post- treatment, the participants were re-evaluated on an identical walking test. Measurements of HLa accumulation and API were taken at rest and immediately following termination of the treadmill test. In the training sessions, body weight (kg), exercise heart rate (HR), systolic blood pressure (SBP), and distance traveled (m) were recorded daily. There were no significant changes (p<.05) after training in total time (mean increase = 23.7%) or time for onset of pain in the treadmill test (mean increase = 30.1%). Neither were there significant changes (p<.05) in API or HLa levels taken immediately after exercise, when pre- and post-training treadmill test data were compared. The weekly responses for exercise HR, and SBP, as well as body weight remained stable throughout. Mean distance walked by the subjects increased 203% (± 45%) across the 6 weeks. These data suggest that increases in total distance walked in an exercise program were apparently not related to HLa accumulation or API measurements in the working muscles, and that other mechanisms must be investigated in future studies to explain enhanced performance of such subjects. / Master of Science

Patients with Peripheral Arterial Disease have a reduced capacity for exercise, the exact causes of which are poorly understood. This thesis investigated alternative testing procedures that aim to provide a more complete and precise description of the exercise capacities of these patients. Furthermore, the potential roles of gastrocnemius muscle fibre morphometry, capillary supply and glycogen stores in the exercise tolerance of PAD patients were studied. Study one aimed to determine the effect of test repetition on maximal exercise performance and test-to-test variability in PAD patients using an incremental treadmill walking test (T) (n=5), an incremental cycle test (C) (n=5), and incremental endurance (PF-endurance) and maximal strength (PF-strength) plantar flexion tests (n=5). Tests were conducted once per week for eight weeks. Performance was stable on the T (~530 s) and C (~500 s) tests across the eight weeks. Test-to-test variance on T decreased from 16%CV (CV: coefficient of variation) to 6%CV (p=.21,NS), and from ~8%CV to 2%CV on C (p<.05) over the eight week period. Variance of peak gas exchange variables tended to decrease with performance variance on both tests; however, other physiological variables, and the associated variance levels, were stable throughout the study. PF strength (635-712N) gradually increased over the initial 2-3 weeks (p<.05) which was accompanied by a reduction in variance from ~8%CV to ~3%CV (p<.05). Similarly, PF endurance increased over the first two weeks (~32,000 to 41500 N.s-1) while variance of this measure fell from ~21%CV to ~10%CV (p<.05) over the study duration. It is concluded that the implementation of familiarisation sessions leads to a reduction in whole body and local calf muscular performance variance in patients with PAD. Using a randomised crossover design, study two aimed to compare performance and the physiological and symptomatic responses between a T test and a C test in 16 patients with PAD. Peak exercise time on C (690 s) was greater than that on T (495 s); however the two were significantly correlated (n=16, r=.69, p<.05). Peak HR (120 bpm), VO2 (~1.22 l.min-1) and rate pressure product (~20') did not differ between the two tests, nor did the post exercise ankle pressure (T: 56; C: 61 mmHg). In two subjects with lower back pain during C, the ankle pressure of their "worst" limbs failed to fall by >10mmHg. Performance on both the T and C tests was closely related to the onset of leg symptoms; however the site of pain during C was much more variable than during T. Incremental cycle testing would overcome some of the limitations of treadmill testing (e.g. measurement of mechanical work), and it appears to be an acceptable alternative for measuring the exercise capacity and physiological exercise responses in known claudicants. Use of cycle ergometry for the diagnosis of PAD requires testing in the general population. Study three aimed to compare whole body (T test and C test) and local calf muscular (PF strength and endurance) exercise performance between 16 PAD patients (age: 63 ± 2; BMI: 25.9 ± 1.1) and 13 healthy, sedentary control (CON) subjects (age: 62 ± 1; BMI: 25.9 ± 0.4), and to describe relationships between the whole body and local calf muscular exercise capacities within the two groups. Furthermore, this study aimed to compare several histochemical characteristics of the medial gastrocnemius muscle fibres between PAD and CON, and to establish whether these factors were related to the exercise capacities of both groups. Maximal performance on T was 59% lower in the PAD group compared with the CON group, as was performance on C (50%), PF strength (25%), and PF endurance (58%). Compared with CON, PAD patients had a lower estimated calf muscle mass and a slight reduction (10%) in muscle fibre size (p=.14, NS). They also had a lower proportion of type I fibres (PAD: 49%; CON: 62%) that was offset by a greater proportion of type IIA fibres (PAD: 27%; CON: 16%), and a reduction in the capillary contacts per muscle fibre (PAD: 1.63; CON: 2.12) compared with CON. When expressed relative to fibre area there were no differences in capillarisation between PAD and CON; however this index was significantly related to resting and post exercise ABI in the PAD patients. There were no differences in the mixed muscle [glycogen], nor the optical density of glycogen in the individual fibres, between the two groups. PF endurance was poorly predictive of walking performance, and did not correlate with any of the morphological variables in both groups. Calf muscle mass correlated with PF strength (r=.59 - .62), and strength was correlated with T performance (r= .61 - .63) in both groups. In the PAD patients, T performance was correlated with the cross sectional area (n=12, r=.72, p<.05), capillary contacts (n=10, r=.81, p<.05) and glycogen density (n=9, r=.81, p<.05) of type I fibres. This study confirms that a reduction in calf strength, which appears to be mediated through muscle atrophy, plays some role in the reduced exercise capacity of claudicants. While both fibre area and capillary supply seem to be of relevance to the exercise capacity of PAD patients, these two factors are closely linked and further research is required to establish the determinants, and relative importance of both. An important, and possibly limiting role of carbohydrate oxidisation in PAD patients is supported by the strong relationship between type I glycogen stores and whole body exercise capacity.