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Differences in Physical Activity between Patients with Peripheral Artery Disease and Healthy Subjects

Differences in Physical Activity between Patients with Peripheral Artery Disease and Healthy... Hindawi Journal of Aging Research Volume 2020, Article ID 5093528, 6 pages https://doi.org/10.1155/2020/5093528 Research Article Differences in Physical Activity between Patients with Peripheral Artery Disease and Healthy Subjects 1 2 3 Sumiko Shiba , Akiko Shiba, and Atsutoshi Hatada Department of Physical erapy, Konan Women’s University, Kobe City 658-0001, Japan Department of Nursing, Akisaki Clinic, Wakayama City 640-0002, Japan Department of Cardiovascular Surgery, Saiseikai Wakayama Hospital, Wakayama City 640-8518, Japan Correspondence should be addressed to Sumiko Shiba; s.shiba@konan-wu.ac.jp Received 27 May 2020; Accepted 7 October 2020; Published 21 October 2020 Academic Editor: Carmela R. Balistreri Copyright © 2020 Sumiko Shiba et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. Peripheral artery disease (PAD) is a significant prognostic marker of poor long-term survival due to limited physical activity associated with various functional problems, such as intermittent claudication. A physically active lifestyle has the potential to modify peripheral artery risk factors and promote general health. While low daily physical activity levels have been recognized in the population of PAD, the exact level has yet to be quantified due to lack of research. (e aim of the present study was to compare physical activity level (PAL) and time spent at activities of different intensity levels between patients with PAD and healthy individuals. (e study subjects were 10 patients with PAD and 10 age-matched healthy control subjects. We measured the time spent at light, moderate, or vigorous physical activity using triaxial accelerometer and calculated PAL. Intermittent claudication onset distance and maximum walking distance were defined as the distance walked at which the subject first reported leg pain and the distance at which the subject was unable to continue walking because of leg pain, respectively. Results. Our results showed (i) lower PAL in patients with PAD compared with the controls; (ii) while there was no significant difference in the high- intensity activity between the two groups, the light- and moderate-intensity activities of the PAD group were significantly lower than the controls, the time spent at moderate-intensity activity was approximately 50% less; and (iii) among patients with PAD, low PAL did not correlate directly with intermittent claudication. Conclusions. PAD patients limit the amount of their physical activity, especially light and moderate intensities. Our study highlights the importance of spending more time walking in daily life. associated with enhanced health and quality of life, and 1. Introduction even small improvement in fitness correlates with re- Peripheral artery disease (PAD) is an atherosclerotic duced cardiovascular and all-cause mortality [4–8]. disease known to lead to narrowing of the lower limb (erefore, it is important to encourage physical activity arteries. Previous studies reported that PAD is associated to improve health status. While low daily physical activity with significant risk of cardiovascular disease morbidity levels have been recognized in this population, the exact and mortality [1–3]. As the primary symptom of PAD, level has yet to be quantified due to lack of research. (erefore, it is not clear how much physical activity intermittent claudication (IC) appears during physical activity when the blood and oxygen demands of the patients with PAD lack compared to healthy people. In working skeletal muscle exceed supply. Patients with IC other words, the minimum daily physical activity re- experience functional decline due to the limitation in quired by patients with PAD remains undetermined. We physical activity, further raising the risk of cardiovascular hypothesized that patients with PAD spend almost all of events in a vascular system already compromised by the their time in a low-intensity state of physical activity and underlying atherosclerosis. On the contrary, physical thus are generally lacking in high-intensity physical ac- activity and cardiorespiratory fitness are known to be tivity levels compared to healthy people. 2 Journal of Aging Research Since the methods for rehabilitation treatment for PAD combination with a gravity-removal physical activity clas- in Japan are less advanced compared to other developed sification algorithm, provides estimates of daily physical activity and classification of household and locomotive countries, these patients are not provided the appropriate treatment. We hope the present study will lead to insights activities. Data were summed and stored in 10 s epoch length into effective methods for improving daily physical activity within the range of acceleration data of ±6G and with a levels. (e aim of the present study was to compare the mean resolution of 3 mG. (e validity and reliability of the triaxial physical activity level and the time spent in activities of activity monitor in accurately capturing physical activity different intensity levels between PAD patients and healthy have been reported previously [11–13]. Metabolic equiva- controls. lents (METs) determined by the Active Style Pro correlated significantly with METs measured by indirect calorimetry 2. Materials and Methods [11, 12] and provide accurate estimate of energy expenditure under free-living conditions [13]. (is monitor provides 2.1. Subjects. Ten patients with PAD and ten healthy indi- information on METs, physical activity energy expenditure viduals of similar age (control group) participated in this (PAEE), total energy expenditure (TEE), the number of steps study. All patients with PAD were evaluated clinically by a taken, and the amount of time for physical activity. cardiovascular surgeon and underwent the ankle brachial Subjects were instructed to wear the accelerometer on index (ABI) test. We defined PAD as an ABI <0.90. Patients their waist, continuously throughout the day, removing it with clinically severe cardiac, pulmonary, musculoskeletal only for bathing or swimming and to wear them over eight disease that could alter gait, or severe risk of malnutrition days. To be included in the study, subjects had to have at least were excluded. (e control group consisted of subjects who seven valid days, including ≥5 valid weekdays and ≥2 valid reported no history of claudication and had no evidence of weekends. When the subjects forget to reattach the accel- cardiovascular or pulmonary disease or lower extremity erometer, they were asked to wear it for an extended period. musculoskeletal disease known to affect gait. None of the If that period included a weekday, they were asked to make participants performed the rehabilitation therapy for PAD. up for the lack of data on that day. When the participant (e Human Ethics Committee approved the present forgot to reattach the accelerometer on a weekend, and if the study and a written informed consent was obtained from all scheduled last next day was a weekday, she was asked to wear subjects. it continuously until the end of the next weekend in order to obtain valid data. We emphasized to the participants that they must not change anything in their lifestyle during the 2.2. Walking Test. All patients with PAD performed the experiment’s duration. (e screen on the triaxial acceler- walking test, which consisted of walking a route of 20 meters ometer was set to blank so that the participants could not with turns, delimited by two cones. (e subjects were check any indicators such as step count or the activity in- instructed to walk as 12 laps as they could at their com- tensity for themselves. fortable speed and to inform the evaluator of any sudden We calculate the average daily data from a seven-day onset of pain. Intermittent claudication onset distance (ICD) period, in which the following indices were examined (in and maximum walking distance (MWD) were defined as the minutes per day): 1 to<3 METs for low-intensity activity,≥3 distance walked when the subject first reported leg pain and to <6 METs for moderate-intensity activity, and ≥ 6 METs the distance at which the subject was unable to continue for high-intensity activity. Moreover, we also determined the walking due to leg pain, respectively [9, 10]. We asked the weekly number of steps and walking time. subjects to walk at a comfortable speed in order to determine the relationship in their daily walking. 2.4. Physical Activity Level. We calculated the physical ac- 2.3. Accelerometer-Measured Physical Activity. Physical ac- tivity level (PAL) as the TEE/basal metabolic rate (BMR). tivity over a 7-day interval was recorded using a triaxial TEE was assessed with the triaxial accelerometer. BMR was accelerometer (model: Active Style Pro HJA-750C, Omron calculated using the following equation for Japanese [14]: Healthcare, Japan). (is triaxial accelerometer, in males : {(0.1238 + (0.0481 × W) + (0.0234 × H) − (0.0138 × A) − 0.5473 × 1)} × , 4.186 (1) females : {(0.1238 + (0.0481 × W) + (0.0234 × H) − (0.0138 × A) − 0.5473 × 2)} × , 4.186 where W � body weight in kg, H � body height in cm, and the lifestyle patterns of subjects as very inactive [PAL <1.4], A � age in years. sedentary or lightly active [PAL ≥1.4 to <1.7], active or (e World Health Organization proposes that the BMR moderately active [PAL ≥1.7 to <2.0], or vigorous or vig- calculated using the above formulas can be used to classify orously active [PAL ≥2.00 to 2.40] [15]. Journal of Aging Research 3 Table 1: Subjects’ characteristics. PAD CON PAD Control P value n (women/men) 10 (2/8) 10 (6/4) 0.23 Age 76.7± 7.5 74.3± 5.8 0.42 800 ∗ Weight (kg) 64.4± 7.8 55.2± 8.8 0.02 Height (cm) 162.4± 7.1 161.9± 7.4 0.88 600 BMI (kg/m ) 24.4± 2.7 20.9± 1.8 0.03 Presence of IC (%) 80 — Resting ABI 0.68± 0.12 — ICD (m) 227.0± 157.8 — ∗ MWD (m) 296.0± 156.3 — CONUT score 0.9± 0.74 — BMI, body mass index; ABI, ankle brachial index; ICD, intermittent Figure 2: Box and whisker plots (median, quartile, and range) of claudication onset distance; MWD, maximum walking distance. Data are time spent at activities of light-, moderate-, and high-intensity in mean± SD. PAD patients (left) and healthy control subjects (right). P< 0.001 between PAD and CON at light- and moderate-intensity activities. PAD, peripheral artery disease patients; CON, healthy control Table 2: Average durations of different intensity levels and walking subjects. parameters. PAD Control determined using serum albumin, total cholesterol, and value total lymphocyte count [16]. Patients with CONUT scores of Light activity (min/day) 704.8± 158.4 976.9± 175.2 0.000 0-1 were considered to have a normal nutritional status; Moderate activity (min/ 38.5± 28.1 79.1± 25.5 0.003 those with a score of 2–4 are at mild risk; a score of 5–8 day) High activity (min/day) 0.4± 0.6 0.8± 0.6 0.089 indicates moderate risk; and a score of 9–12 reflected severe Total amount of activity risk of malnutrition. 743.7± 166.1 1004.2± 178.9 0.000 (min/day) Step counts (steps/day) 3250± 1989 6055± 2085 0.006 Data are mean± SD. 2.6. Statistical Analysis. All statistical analysis was con- ducted using the SPSS 20.0 for Windows (SPSS Inc., Chi- cago, IL). A P value <0.05 denoted the presence of a statistically significant difference. Descriptive statistics were 2.4 presented as mean±standard deviation. Normal distribution of data was assessed by the Shapiro–Wilk test (P> 0.05). 2.2 Mann–Whitney’s U test was used to identify significant Vigorous differences between two groups. (e Pearson correlation test was used to assess associations between PAL and age, BMI, ICD, MWD, ABI, and CONUT score in subjects with PAD and the Spearman correlation test was also used for the Moderate 1.8 association between PAL and gender. 1.6 3. Results Sedentary (e physical characteristics of the study participants are 1.4 shown in Table 1. PAD subjects had a higher BMI, compared with age- and sex-matched control subjects. Eight of the 10 1.2 subjects with PAD (80%) reported IC symptoms during the Very inactive PAD CON test, and six (70%) could not complete the walking test due to severe pain. One subject had undergone peripheral vascular surgery and did not report symptoms of IC. Table 1 also Figure 1: Classification and comparison of PAL between patients shows the values of ABI, ICD, MWD, and CONUT score for with PAD and control subjects (CON). ∗P< 0.001 between PAD the PAD group. and CON. PAL, physical activity level; PAD, patients with pe- (e values of PAL, step counts, and the walking time ripheral artery disease; CON, healthy control subjects. were lower in PAD subjects than the control (Table 2, Figure 1). Assessment of physical activity of patients with 2.5. Clinical Data Collection. Clinical data were collected PAL showed a mean PAL of 1.51± 0.97 and all subjects were from the hospital medical records. (e nutritional condition classified as physically very inactive and sedentary. For the was assessed using body mass index (BMI) and the con- control subjects, the mean PAL was 1.75± 0.14, 27.3% of trolling nutritional status (CONUT) score, which was subjects were classified as sedentary, and 72.7% were PAL 4 Journal of Aging Research Table 3: Correlation matrix of the variables in PAD patients. PAL Age Gender BMI ABI ICD MWD PAL Age − 0.689 Gender 0.087 0.306 BMI 0.382 − 0.109 0.174 ABI 0.268 − 0.118 0.696 0.185 ICD 0.104 − 0.266 0.000 0.339 0.484 MWD 0.21 − 0.458 − 0.443 0.195 0.116 0.836 ∗∗ CONUT score 0.539 − 426 0.283 0.800 ∗∗ 0.573 0.503 0.285 ∗ ∗∗ P< 0.05 (2 tailed). P< 0.01 (2 tailed). PAL, physical activity level; BMI, body mass index; ABI, ankle brachial index; ICD, intermittent claudication onset distance; MWD, maximum walking distance; CONUT, controlling nutritional status score. classified as active. In both group, none was classified with (us, the present study demonstrated reduced amount of vigorous activity (Figure 1). physical activity in patients with PAD. All subjects spent more time at low-intensity activities Subjects with PAD spent 40 fewer minutes walking each than moderate- or high-intensity activities. Figure 2 shows day (Table 2). (e lower PAL in the participants with PAD the time spent on activities with light-, moderate-, and high- was primarily due to these shorter walking times at light- intensity for PAD patients and healthy controls. PAD and moderate-intensity activities. Our results showed that subjects spent significantly less time in light- and moderate- the time spent at light- and moderate-intensity activities in intensity activity than the control subjects. However, there patients with PAD was approximately 30% and 50% less than that of the control, respectively. (e daily step count was also was no difference in the high-intensity activity (Figure 2). Furthermore, the total amount of time spent on all intensity approximately 50% less in the PAD group than the control. physical activity in subjects with PAD was 71.3% of that in Gardner et al. [18] compared patterns of physical activity healthy control. Especially, the time spent at moderate-in- between individuals with and without IC. (ey found that tensity activity was about 50% of that of healthy control. individuals with IC spent less time walking and took fewer Subjects with PAD spent 40 fewer minutes walking each day steps, particularly at medium to high cadence levels. A high (Table 2), with a daily step count that was also approximately cadence level of walking is equivalent to moderate-intensity 50% less compared to the control group. activity [19], and a moderate cadence level is considered to In PAD subjects, there was no significant association be equivalent to low-intensity activity. (us, it is considered between PAL and gender, ICD, MWD, ABI, and CONUT that their study supported our result. (e greater differences score, although a moderate correlation was identified be- in our present study are that our subjects are more than 10 years older and that we showed physical activity intensity. tween PAL and age (Table 3). Walking in daily life is considered to require 2–4 METs and to be a moderate-intensity activity [20, 21]. (erefore, the lower mean PAL in the PAD group could be explained by 4. Discussion spending less time in light- and moderate-intensity activities (is study investigated PAL of patients with PAD using in daily life. In particular, the reduced amount of time walking was the main contributor to the lower mean PAL. It triaxial accelerometer. (e main findings were as follows: (i) patients with PAD had lower PAL than the control; (ii) there has also been shown previously that the time spent at low- and moderate-intensity activities determines the PAL and was no significant difference in the high-intensity activity between the two groups; however, the light- and moderate- high-intensity activity does not have a significant impact on PAL [22–25]. Also, in view of the present result of the lack of intensity activities were significantly less in the PAD group difference in high-intensity activity, obtaining a higher PAL than the control, especially the time spent at moderate-in- in PAD patients does not necessarily require performance of tensity activity was approximately 50% less (40 minutes high-intensity activities such as sports. fewer); and (iii) among patients with PAD, low PAL did not directly correlate with IC. Differences exist among previous studies with regard to the relationship between IC and physical activity [26]. (is To investigate the cause of low physical activity in PAD patients, we selected PAL, which provides comprehensive could be due to differences in leg symptoms and/or walking test. Although IC has long been considered the hallmark evaluation of physical activities across all domains of daily life, as an exposure indicator. In this study, all participants symptom of PAD, several studies reported that more pa- tients with PAD are asymptomatic or have atypical leg with PAD were classified as very inactive or sedentary. As we expected, the mean PAL of subjects with PAD in the present symptoms than those with classic intermittent claudication [27–29]. We also expected that diminished physical activity study was significantly lower than that of the control in daily life was a consequence of IC, however it did not. For (1.51± 0.97 vs 1.75± 0.14). A previous study of 99 healthy our patients with PAD, the ICD as the walking parameters older men and women reported a mean PAL of 1.68± 0.28 were not associated with PAL (Table 3). (is finding suggests [17]. Compared with the healthy subjects of the above study, a low mean PAL was also observed in our PAD patients. inconsistent association between onset walking distance and Journal of Aging Research 5 PAL in PAD. It was reported that the limitation in exercise 6. Conclusions performance during standardized treadmill testing in PAD Our findings could help improve PAL in patients with PAD. patients with atypical leg pain is vascular-mediated, similar We demonstrated that PAD patients have limited amount of to patients with claudication [28]. In addition, the limited physical activity, especially in light and moderate intensity walking and exercise ability in PAD seems to depend on regardless of leg symptoms. Our results highlight the im- complex interaction of various pathological factors, in- portance of walking in the daily life of PAD patients. cluding arterial obstruction, endothelial dysfunction, and altered skeletal muscle phenotypes such as mitochondrial dysfunction and inflammation [29–31]. (erefore, ICD, as Data Availability the walking distance, might not be reflected in PAL (Table 3). (e data used to support the findings of this study are re- One important finding of this study is the fact that PAD stricted by the Ethics Committee in order to protect subjects’ limits the amount of physical activity regardless of leg privacy. Data are available from Sumiko Shiba, for re- symptoms. Some studies describe the relationship between searchers who meet the criteria to access confidential data. physical activity and the distance walked during the 6- minute walk test in IC patients [32, 33]. (is test is a Disclosure submaximal exercise test used to assess aerobic capacity and endurance. (erefore, we would expect that individuals with (e authors received no financial support for the research, higher levels of physical activity would be to cover longer authorship, and/or publication of this article. distances in this time interval. However, since we examined a route of 20 meters with turns for only 12 laps, MWB at the Conflicts of Interest present study did not reflect their aerobic capacity. For this reason, the present study did not show the relationship All authors declare no conflicts of interest. between physical activity and MWD. In patients with PAD, low daily PAL is a strong References predictor of mortality [34]. In this regard, a physically active lifestyle has the potential to modify peripheral [1] K. L. Piercy and R. P. Troiano, “Physical activity guidelines for artery risk factors and promote general health [5, 35, 36]. 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Differences in Physical Activity between Patients with Peripheral Artery Disease and Healthy Subjects

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Hindawi Journal of Aging Research Volume 2020, Article ID 5093528, 6 pages https://doi.org/10.1155/2020/5093528 Research Article Differences in Physical Activity between Patients with Peripheral Artery Disease and Healthy Subjects 1 2 3 Sumiko Shiba , Akiko Shiba, and Atsutoshi Hatada Department of Physical erapy, Konan Women’s University, Kobe City 658-0001, Japan Department of Nursing, Akisaki Clinic, Wakayama City 640-0002, Japan Department of Cardiovascular Surgery, Saiseikai Wakayama Hospital, Wakayama City 640-8518, Japan Correspondence should be addressed to Sumiko Shiba; s.shiba@konan-wu.ac.jp Received 27 May 2020; Accepted 7 October 2020; Published 21 October 2020 Academic Editor: Carmela R. Balistreri Copyright © 2020 Sumiko Shiba et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. Peripheral artery disease (PAD) is a significant prognostic marker of poor long-term survival due to limited physical activity associated with various functional problems, such as intermittent claudication. A physically active lifestyle has the potential to modify peripheral artery risk factors and promote general health. While low daily physical activity levels have been recognized in the population of PAD, the exact level has yet to be quantified due to lack of research. (e aim of the present study was to compare physical activity level (PAL) and time spent at activities of different intensity levels between patients with PAD and healthy individuals. (e study subjects were 10 patients with PAD and 10 age-matched healthy control subjects. We measured the time spent at light, moderate, or vigorous physical activity using triaxial accelerometer and calculated PAL. Intermittent claudication onset distance and maximum walking distance were defined as the distance walked at which the subject first reported leg pain and the distance at which the subject was unable to continue walking because of leg pain, respectively. Results. Our results showed (i) lower PAL in patients with PAD compared with the controls; (ii) while there was no significant difference in the high- intensity activity between the two groups, the light- and moderate-intensity activities of the PAD group were significantly lower than the controls, the time spent at moderate-intensity activity was approximately 50% less; and (iii) among patients with PAD, low PAL did not correlate directly with intermittent claudication. Conclusions. PAD patients limit the amount of their physical activity, especially light and moderate intensities. Our study highlights the importance of spending more time walking in daily life. associated with enhanced health and quality of life, and 1. Introduction even small improvement in fitness correlates with re- Peripheral artery disease (PAD) is an atherosclerotic duced cardiovascular and all-cause mortality [4–8]. disease known to lead to narrowing of the lower limb (erefore, it is important to encourage physical activity arteries. Previous studies reported that PAD is associated to improve health status. While low daily physical activity with significant risk of cardiovascular disease morbidity levels have been recognized in this population, the exact and mortality [1–3]. As the primary symptom of PAD, level has yet to be quantified due to lack of research. (erefore, it is not clear how much physical activity intermittent claudication (IC) appears during physical activity when the blood and oxygen demands of the patients with PAD lack compared to healthy people. In working skeletal muscle exceed supply. Patients with IC other words, the minimum daily physical activity re- experience functional decline due to the limitation in quired by patients with PAD remains undetermined. We physical activity, further raising the risk of cardiovascular hypothesized that patients with PAD spend almost all of events in a vascular system already compromised by the their time in a low-intensity state of physical activity and underlying atherosclerosis. On the contrary, physical thus are generally lacking in high-intensity physical ac- activity and cardiorespiratory fitness are known to be tivity levels compared to healthy people. 2 Journal of Aging Research Since the methods for rehabilitation treatment for PAD combination with a gravity-removal physical activity clas- in Japan are less advanced compared to other developed sification algorithm, provides estimates of daily physical activity and classification of household and locomotive countries, these patients are not provided the appropriate treatment. We hope the present study will lead to insights activities. Data were summed and stored in 10 s epoch length into effective methods for improving daily physical activity within the range of acceleration data of ±6G and with a levels. (e aim of the present study was to compare the mean resolution of 3 mG. (e validity and reliability of the triaxial physical activity level and the time spent in activities of activity monitor in accurately capturing physical activity different intensity levels between PAD patients and healthy have been reported previously [11–13]. Metabolic equiva- controls. lents (METs) determined by the Active Style Pro correlated significantly with METs measured by indirect calorimetry 2. Materials and Methods [11, 12] and provide accurate estimate of energy expenditure under free-living conditions [13]. (is monitor provides 2.1. Subjects. Ten patients with PAD and ten healthy indi- information on METs, physical activity energy expenditure viduals of similar age (control group) participated in this (PAEE), total energy expenditure (TEE), the number of steps study. All patients with PAD were evaluated clinically by a taken, and the amount of time for physical activity. cardiovascular surgeon and underwent the ankle brachial Subjects were instructed to wear the accelerometer on index (ABI) test. We defined PAD as an ABI <0.90. Patients their waist, continuously throughout the day, removing it with clinically severe cardiac, pulmonary, musculoskeletal only for bathing or swimming and to wear them over eight disease that could alter gait, or severe risk of malnutrition days. To be included in the study, subjects had to have at least were excluded. (e control group consisted of subjects who seven valid days, including ≥5 valid weekdays and ≥2 valid reported no history of claudication and had no evidence of weekends. When the subjects forget to reattach the accel- cardiovascular or pulmonary disease or lower extremity erometer, they were asked to wear it for an extended period. musculoskeletal disease known to affect gait. None of the If that period included a weekday, they were asked to make participants performed the rehabilitation therapy for PAD. up for the lack of data on that day. When the participant (e Human Ethics Committee approved the present forgot to reattach the accelerometer on a weekend, and if the study and a written informed consent was obtained from all scheduled last next day was a weekday, she was asked to wear subjects. it continuously until the end of the next weekend in order to obtain valid data. We emphasized to the participants that they must not change anything in their lifestyle during the 2.2. Walking Test. All patients with PAD performed the experiment’s duration. (e screen on the triaxial acceler- walking test, which consisted of walking a route of 20 meters ometer was set to blank so that the participants could not with turns, delimited by two cones. (e subjects were check any indicators such as step count or the activity in- instructed to walk as 12 laps as they could at their com- tensity for themselves. fortable speed and to inform the evaluator of any sudden We calculate the average daily data from a seven-day onset of pain. Intermittent claudication onset distance (ICD) period, in which the following indices were examined (in and maximum walking distance (MWD) were defined as the minutes per day): 1 to<3 METs for low-intensity activity,≥3 distance walked when the subject first reported leg pain and to <6 METs for moderate-intensity activity, and ≥ 6 METs the distance at which the subject was unable to continue for high-intensity activity. Moreover, we also determined the walking due to leg pain, respectively [9, 10]. We asked the weekly number of steps and walking time. subjects to walk at a comfortable speed in order to determine the relationship in their daily walking. 2.4. Physical Activity Level. We calculated the physical ac- 2.3. Accelerometer-Measured Physical Activity. Physical ac- tivity level (PAL) as the TEE/basal metabolic rate (BMR). tivity over a 7-day interval was recorded using a triaxial TEE was assessed with the triaxial accelerometer. BMR was accelerometer (model: Active Style Pro HJA-750C, Omron calculated using the following equation for Japanese [14]: Healthcare, Japan). (is triaxial accelerometer, in males : {(0.1238 + (0.0481 × W) + (0.0234 × H) − (0.0138 × A) − 0.5473 × 1)} × , 4.186 (1) females : {(0.1238 + (0.0481 × W) + (0.0234 × H) − (0.0138 × A) − 0.5473 × 2)} × , 4.186 where W � body weight in kg, H � body height in cm, and the lifestyle patterns of subjects as very inactive [PAL <1.4], A � age in years. sedentary or lightly active [PAL ≥1.4 to <1.7], active or (e World Health Organization proposes that the BMR moderately active [PAL ≥1.7 to <2.0], or vigorous or vig- calculated using the above formulas can be used to classify orously active [PAL ≥2.00 to 2.40] [15]. Journal of Aging Research 3 Table 1: Subjects’ characteristics. PAD CON PAD Control P value n (women/men) 10 (2/8) 10 (6/4) 0.23 Age 76.7± 7.5 74.3± 5.8 0.42 800 ∗ Weight (kg) 64.4± 7.8 55.2± 8.8 0.02 Height (cm) 162.4± 7.1 161.9± 7.4 0.88 600 BMI (kg/m ) 24.4± 2.7 20.9± 1.8 0.03 Presence of IC (%) 80 — Resting ABI 0.68± 0.12 — ICD (m) 227.0± 157.8 — ∗ MWD (m) 296.0± 156.3 — CONUT score 0.9± 0.74 — BMI, body mass index; ABI, ankle brachial index; ICD, intermittent Figure 2: Box and whisker plots (median, quartile, and range) of claudication onset distance; MWD, maximum walking distance. Data are time spent at activities of light-, moderate-, and high-intensity in mean± SD. PAD patients (left) and healthy control subjects (right). P< 0.001 between PAD and CON at light- and moderate-intensity activities. PAD, peripheral artery disease patients; CON, healthy control Table 2: Average durations of different intensity levels and walking subjects. parameters. PAD Control determined using serum albumin, total cholesterol, and value total lymphocyte count [16]. Patients with CONUT scores of Light activity (min/day) 704.8± 158.4 976.9± 175.2 0.000 0-1 were considered to have a normal nutritional status; Moderate activity (min/ 38.5± 28.1 79.1± 25.5 0.003 those with a score of 2–4 are at mild risk; a score of 5–8 day) High activity (min/day) 0.4± 0.6 0.8± 0.6 0.089 indicates moderate risk; and a score of 9–12 reflected severe Total amount of activity risk of malnutrition. 743.7± 166.1 1004.2± 178.9 0.000 (min/day) Step counts (steps/day) 3250± 1989 6055± 2085 0.006 Data are mean± SD. 2.6. Statistical Analysis. All statistical analysis was con- ducted using the SPSS 20.0 for Windows (SPSS Inc., Chi- cago, IL). A P value <0.05 denoted the presence of a statistically significant difference. Descriptive statistics were 2.4 presented as mean±standard deviation. Normal distribution of data was assessed by the Shapiro–Wilk test (P> 0.05). 2.2 Mann–Whitney’s U test was used to identify significant Vigorous differences between two groups. (e Pearson correlation test was used to assess associations between PAL and age, BMI, ICD, MWD, ABI, and CONUT score in subjects with PAD and the Spearman correlation test was also used for the Moderate 1.8 association between PAL and gender. 1.6 3. Results Sedentary (e physical characteristics of the study participants are 1.4 shown in Table 1. PAD subjects had a higher BMI, compared with age- and sex-matched control subjects. Eight of the 10 1.2 subjects with PAD (80%) reported IC symptoms during the Very inactive PAD CON test, and six (70%) could not complete the walking test due to severe pain. One subject had undergone peripheral vascular surgery and did not report symptoms of IC. Table 1 also Figure 1: Classification and comparison of PAL between patients shows the values of ABI, ICD, MWD, and CONUT score for with PAD and control subjects (CON). ∗P< 0.001 between PAD the PAD group. and CON. PAL, physical activity level; PAD, patients with pe- (e values of PAL, step counts, and the walking time ripheral artery disease; CON, healthy control subjects. were lower in PAD subjects than the control (Table 2, Figure 1). Assessment of physical activity of patients with 2.5. Clinical Data Collection. Clinical data were collected PAL showed a mean PAL of 1.51± 0.97 and all subjects were from the hospital medical records. (e nutritional condition classified as physically very inactive and sedentary. For the was assessed using body mass index (BMI) and the con- control subjects, the mean PAL was 1.75± 0.14, 27.3% of trolling nutritional status (CONUT) score, which was subjects were classified as sedentary, and 72.7% were PAL 4 Journal of Aging Research Table 3: Correlation matrix of the variables in PAD patients. PAL Age Gender BMI ABI ICD MWD PAL Age − 0.689 Gender 0.087 0.306 BMI 0.382 − 0.109 0.174 ABI 0.268 − 0.118 0.696 0.185 ICD 0.104 − 0.266 0.000 0.339 0.484 MWD 0.21 − 0.458 − 0.443 0.195 0.116 0.836 ∗∗ CONUT score 0.539 − 426 0.283 0.800 ∗∗ 0.573 0.503 0.285 ∗ ∗∗ P< 0.05 (2 tailed). P< 0.01 (2 tailed). PAL, physical activity level; BMI, body mass index; ABI, ankle brachial index; ICD, intermittent claudication onset distance; MWD, maximum walking distance; CONUT, controlling nutritional status score. classified as active. In both group, none was classified with (us, the present study demonstrated reduced amount of vigorous activity (Figure 1). physical activity in patients with PAD. All subjects spent more time at low-intensity activities Subjects with PAD spent 40 fewer minutes walking each than moderate- or high-intensity activities. Figure 2 shows day (Table 2). (e lower PAL in the participants with PAD the time spent on activities with light-, moderate-, and high- was primarily due to these shorter walking times at light- intensity for PAD patients and healthy controls. PAD and moderate-intensity activities. Our results showed that subjects spent significantly less time in light- and moderate- the time spent at light- and moderate-intensity activities in intensity activity than the control subjects. However, there patients with PAD was approximately 30% and 50% less than that of the control, respectively. (e daily step count was also was no difference in the high-intensity activity (Figure 2). Furthermore, the total amount of time spent on all intensity approximately 50% less in the PAD group than the control. physical activity in subjects with PAD was 71.3% of that in Gardner et al. [18] compared patterns of physical activity healthy control. Especially, the time spent at moderate-in- between individuals with and without IC. (ey found that tensity activity was about 50% of that of healthy control. individuals with IC spent less time walking and took fewer Subjects with PAD spent 40 fewer minutes walking each day steps, particularly at medium to high cadence levels. A high (Table 2), with a daily step count that was also approximately cadence level of walking is equivalent to moderate-intensity 50% less compared to the control group. activity [19], and a moderate cadence level is considered to In PAD subjects, there was no significant association be equivalent to low-intensity activity. (us, it is considered between PAL and gender, ICD, MWD, ABI, and CONUT that their study supported our result. (e greater differences score, although a moderate correlation was identified be- in our present study are that our subjects are more than 10 years older and that we showed physical activity intensity. tween PAL and age (Table 3). Walking in daily life is considered to require 2–4 METs and to be a moderate-intensity activity [20, 21]. (erefore, the lower mean PAL in the PAD group could be explained by 4. Discussion spending less time in light- and moderate-intensity activities (is study investigated PAL of patients with PAD using in daily life. In particular, the reduced amount of time walking was the main contributor to the lower mean PAL. It triaxial accelerometer. (e main findings were as follows: (i) patients with PAD had lower PAL than the control; (ii) there has also been shown previously that the time spent at low- and moderate-intensity activities determines the PAL and was no significant difference in the high-intensity activity between the two groups; however, the light- and moderate- high-intensity activity does not have a significant impact on PAL [22–25]. Also, in view of the present result of the lack of intensity activities were significantly less in the PAD group difference in high-intensity activity, obtaining a higher PAL than the control, especially the time spent at moderate-in- in PAD patients does not necessarily require performance of tensity activity was approximately 50% less (40 minutes high-intensity activities such as sports. fewer); and (iii) among patients with PAD, low PAL did not directly correlate with IC. Differences exist among previous studies with regard to the relationship between IC and physical activity [26]. (is To investigate the cause of low physical activity in PAD patients, we selected PAL, which provides comprehensive could be due to differences in leg symptoms and/or walking test. Although IC has long been considered the hallmark evaluation of physical activities across all domains of daily life, as an exposure indicator. In this study, all participants symptom of PAD, several studies reported that more pa- tients with PAD are asymptomatic or have atypical leg with PAD were classified as very inactive or sedentary. As we expected, the mean PAL of subjects with PAD in the present symptoms than those with classic intermittent claudication [27–29]. We also expected that diminished physical activity study was significantly lower than that of the control in daily life was a consequence of IC, however it did not. For (1.51± 0.97 vs 1.75± 0.14). A previous study of 99 healthy our patients with PAD, the ICD as the walking parameters older men and women reported a mean PAL of 1.68± 0.28 were not associated with PAL (Table 3). (is finding suggests [17]. Compared with the healthy subjects of the above study, a low mean PAL was also observed in our PAD patients. inconsistent association between onset walking distance and Journal of Aging Research 5 PAL in PAD. It was reported that the limitation in exercise 6. Conclusions performance during standardized treadmill testing in PAD Our findings could help improve PAL in patients with PAD. patients with atypical leg pain is vascular-mediated, similar We demonstrated that PAD patients have limited amount of to patients with claudication [28]. In addition, the limited physical activity, especially in light and moderate intensity walking and exercise ability in PAD seems to depend on regardless of leg symptoms. Our results highlight the im- complex interaction of various pathological factors, in- portance of walking in the daily life of PAD patients. cluding arterial obstruction, endothelial dysfunction, and altered skeletal muscle phenotypes such as mitochondrial dysfunction and inflammation [29–31]. (erefore, ICD, as Data Availability the walking distance, might not be reflected in PAL (Table 3). (e data used to support the findings of this study are re- One important finding of this study is the fact that PAD stricted by the Ethics Committee in order to protect subjects’ limits the amount of physical activity regardless of leg privacy. Data are available from Sumiko Shiba, for re- symptoms. Some studies describe the relationship between searchers who meet the criteria to access confidential data. physical activity and the distance walked during the 6- minute walk test in IC patients [32, 33]. (is test is a Disclosure submaximal exercise test used to assess aerobic capacity and endurance. (erefore, we would expect that individuals with (e authors received no financial support for the research, higher levels of physical activity would be to cover longer authorship, and/or publication of this article. distances in this time interval. However, since we examined a route of 20 meters with turns for only 12 laps, MWB at the Conflicts of Interest present study did not reflect their aerobic capacity. For this reason, the present study did not show the relationship All authors declare no conflicts of interest. between physical activity and MWD. In patients with PAD, low daily PAL is a strong References predictor of mortality [34]. In this regard, a physically active lifestyle has the potential to modify peripheral [1] K. L. Piercy and R. P. Troiano, “Physical activity guidelines for artery risk factors and promote general health [5, 35, 36]. 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Journal of Aging ResearchHindawi Publishing Corporation

Published: Oct 21, 2020

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