Study demonstrates feasibility, effectiveness of at-home exercise therapy plus cognitive behavior therapy for IC

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Oliver Aalami

A mobile phone-administered, home-based exercise therapy program for patients with intermittent claudication (IC) incorporating cognitive behavior therapy (CBT) was found to be feasible, with 78% of participants completing the whole course, the 2022 Vascular Annual Meeting (VAM) heard.

The findings were part of a study delivered by Oliver Aalami, MD, from the Stanford University School of Medicine, Stanford, during VAM 2022’s William J. von Liebig Forum on the opening day of the meeting in Boston (June 15–18). 

Previous studies have shown “a trend towards improved outcomes with greater patient engagement and higher intensity and duration walking session recommendations,” Aalami explained. 

Aalami reported having chosen patients whose peripheral arterial disease (PAD) had been confirmed by abnormal ankle-brachial or toe-brachial index, or who had IC. The program they participated in was 12 weeks of home-based, mobile phone-delivered, exercise therapy, Aalami elaborated. Participants were tasked with performing phone-based, six-minute walk tests and completing mini-WIQ QOL [Walking Impairment Questionnaire and Quality of Life] surveys. They were also asked to complete three health education courses (What is peripheral arterial disease?; Exercise; and Nutrition) and were asked to record at least three 30-minute exercise therapy walks a week using their personal mobile phones. Participants also received daily “doses” of health education via text message. 

Alongside this, participants had regular weekly check-ins with health coaches trained in CBT techniques such as motivational interviewing. They also spoke with a health coach at the beginning, middle and end of the program to discuss their progress. Aalami stated that his reasoning for wanting to include CBT techniques in the program was that it is linked to immediate and lasting behavior change. 

Of the 145 patients (40% women; mean age=65) onboarded across 18 institutions (of which 44% did not offer in-person exercise therapy), 78% of patients completed the program, Aalami told VAM delegates. In total, patients recorded having spent 149,135 minutes walking 5,205,943 steps as part of the exercise therapy program. Aalami added that 19 of those initially enrolled paused, withdrew or were non-responsive due to medical issues, technical difficulties or privacy concerns. Ninety-two percent of patients achieved the CBT S.M.A.R.T goals (specific; measurable; achievable; realistic; timely) they had set prior to beginning the program, Aalami then acknowledged. 

Regarding freedom from intervention, at six months, the figure was 92%, and at 12 months, 69%. This, Aalami told Vascular [email protected], is promising, as it goes some way to mirroring the five-year results observed in an in-person supervised exercise therapy study in the Netherlands. 

He also spoke to the challenges of implementing exercise therapy for IC and PAD patients in the U.S. Among the obstacles, he cited poor program availability, the requirement for patients to travel to a facility for in-person therapy, and the low rate of reimbursement. While the Centers for Medicare and Medicaid Services granted National Coverage Determination for Medicare beneficiaries with IC in 2017, the reimbursement only includes facility costs, leaving physician fees uncovered. Aalami asserted that “the biggest challenge is not the tech or the patients or the providers, it is reimbursement.” 

Aalami underscored to the VAM audience that he and his team found a mobile phone-administered, home-based exercise therapy program incorporating CBT to be feasible, adding how it could be deemed effective since 92% of patients achieved their CBT S.M.A.R.T goals. He explained that engagement rose as a result of the home-based exercise therapy being offered where it had not been previously in the traditional format. 

Aalami concluded that “accessible and lower-cost digital health approaches to exercise therapy for patients with PAD and intermittent claudication could play a role in addressing the wide supervised exercise therapy utilization gap faced today.” 

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