peripheral vascular / arterial disease

www.scribd.com/cpradheep

Peripheral Arterial Disease

Pradeep Chockalingam

Physiotherapist


CONTENTS

Introduction

Nurse Led Claudication Clinic

Role of Physiotherapy in PAD clinic

Exercise Group Recruitment

P.A.D. Exercise Group Class

Six Minute Walk Test

Walking Impairment Questionnaire

P.A.D. Exercise Group Database

Reference

Appendices


Appendicies

1, Physiotherapy Initial Assessment & Treatment Sheet

2, Physiotherapy Follow-Up Assessment & Treatment Sheet

3, PAD Exercise Group Registration/Information Sheet

4, 6-MWT Examiner Information Sheet

5, 6-MWT Patient Information Sheets

6, Walking Impairment Questionnaire

7, 6 MWT Lap Count Marking Sheet


INTRODUCTION

Peripheral arterial disease (PAD) is predominantly caused by atherosclerosis leading

to reduced blood supply to the legs, which results in ischaemic muscular pain (usually

in the calf). Stenosis of the proximal blood vessels means that during activities such

as walking the lower limb muscles are starved of arterial blood supply and oxygen

(William RH, et al 1995). The symptoms usually subside on cessation of walking and

after a few minutes rest the patients are able to continue walking. This is the classic

symptom of intermittent claudication and one of the easiest differential diagnoses

from neurogenic claudication. The distance at which patients first experience the pain

is called the claudication distance. The incidence of PAD and intermittent

claudication increases with age. Diagnosis is based upon the symptoms described,

history and consideration of risk factors. Many patients go on to have an angiogram to

determine the presence and site of the disease. Surgical treatment options are

considered if the site of the peripheral vascular disease is amenable to angioplasty or

bypass grafting and if the patient is fit and well and wishes to undergo surgery. There

is increasing evidence that exercise rehabilitation can be a suitable low cost

alternative to surgery for those who are not fit enough or do not wish to undergo

surgery. Various hypotheses are suggested to reason out the improvement gained by

exercising but still the evidence is inconclusive (Kerry JW et al 2002). Bendermacher

BLW et al (2006) and Kerry JW et al (2002) states centre based physical activity

programmes are more effective for patients with PAD than home based exercise

programmes.

The aim of physiotherapy in this patient group is to limit progression, limit lifestyle

impact and improve symptoms by risk factor reduction and exercise prescription.

Physiotherapists are involved in both in the intermittent claudication clinic and

running the exercise group.

NURSE LED CLAUDICATION CLINIC

Recent literature is supportive of nurse-led clinics (rather than just consultant clinics)

for assessment, monitoring and education of patients with intermittent claudication. It

has been found that nurse-led clinics have more time to spend with patients in an

educatory and assessment/reassessment role. The patients therefore have less frequent

appointments with the vascular consultants, who are fed back information by the

nurses as appropriate.

The vascular nurse role includes:-

Initial Assessment

Past Medical History – with respect to cardiovascular history, past vascular

surgery and investigations

Family History – with respect to cardiovascular history & diabetes

Symptoms – where calf, buttock and thigh, which leg, severity, claudication

distance & maximum walking distance

Current medication


Smoking status & history

Lifestyle and exercise/activity level

Assessment

Height/Weight/BMI

Doppler of dorsalis pedis / tibialis posterior pulses

Ankle Brachial Pressure Index (ABPI) – (Ankle systolic BP ÷ Brachial

Systolic BP) if less than 0.9 is a sign of lack of blood supply to the particular

lower limb.

Cholesterol check (if not done recently)

Education for Risk Factor Reduction

Smoking cessation advice & referral to clinic if patient wishes

Diet – recommend reduced intake of saturated fats

Exercise – helps promote new blood vessel pathways around blockages /

blocked arteries. Where our role comes in

Referral to diabetes nurse/chiropodist if appropriate

Medications – see below

ROLE OF PHYSIOTHERAPY IN CLAUDICATION

CLINIC

Aims:-

Promote exercise in the patient group to help improve symptoms & encourage

walking.

Provide Home Exercise Programme for all patients, whether they are

appropriate to attend exercise class or not. Each patient should be provided

with a paper copy of their exercise programme.

Mark appropriate exercises in the All about Intermittent Claudication (Pink)

Booklet, Reference: OPUK/PLE/091 MAY 2004. (Vascular Nurses provide

these booklets)

Identify patients appropriate for exercise group & place on waiting list if

patient willing to attend.

Support Nursing staff through reinforcement of lifestyle/risk factor

modification.

EXERCISE GROUP RECRUITMENT

Usually patients are recruited from the PAD clinic. When ever a new patient fulfils

the inclusion criteria, they will be offered the option of participating in the exercise

group. If they are willing to attend their name will placed on the waiting list for the

next available group. The vascular nurse will also forward a list of patients who have


had arterial bypass surgery. The vascular consultants may occasionally refer specific

patients for the exercise group.

Inclusion Criteria:-

Any Patient with Intermittent Claudication symptoms who are willing to

attend.

Patients who have had fem pop bypass surgery who have attended for their 6

week follow up appointment.

Exclusion Criteria:-

Low exercise tolerance and poor mobility

Pain not resulting from claudication (such as diabetic neuropathy, symptoms

from spine etc)

Recent MI (check with cardiologists)

Unhealed foot wounds as a result of vascular blisters

Osteoporosis

Attending other hospital rehab classes – eg Pulmonary Rehab, Cardiac Rehab.

Need to wait until finished these.

P.A.D. EXERCISE GROUP CLASS

Concept of Group Exercises

The aim of the groups is to get the patients started on a form of exercise and for them

to continue exercising after the classes finish. Ideally it is suggested that to gain

significant improvement participants should exercise to achieve near maximal

Claudication Pain Scale level-3 (Leng GC et al 2000) and perceived level of exertion

to the Bourg Scale level- 4 (NNUH 2004), but practically it may be difficult to

achieve or may lead to high numbers of „dropout‟. To avoid dropout and achieve

significant outcome from the exercise class it is essential to talk with the participants

and suggest they assess their own ability and work within their own limits, advising

them to take rest periods when needed in order to allow blood or oxygen demands to

be met. Emphasise the need for rests and for the patients not to feel embarrassed to

rest as they will all be a different levels.

The exercise group is conducted at Gateshead Leisure Centre, Monday and Thursday

between 1pm and 2pm in the Sports Hall or Maple Hall. The exercise classes will be 7

week blocks. Patients who have already completed the seven week block may be

invited to re-attend if there are spaces available in future classes. Currently patients

will only be able to attend for two blocks. Inviting Dawn Harvey (Physical Activity

Co-ordinatoer) to the penultimate session is a good idea as this will provide them with

the necessary information to continue exercising independently in the community.

There are some good articles about running claudication exercise classes in the

vascular file. Basically we need as much activity as possible & the research shows


that upper limb exercises are also beneficial. Laps bouncing balls, dribbling balls with

hockey sticks or playing badminton are good ways of including walking without it

being so boring.

Exercise Sessions

The first & final sessions will be 6MWT sessions; this will then give 6 weeks of

exercise classes.

Session One

The first session is an introduction. Explain to the patients how the sessions

will be run.

Complete Pre rehab WIQ

Complete a 6MWT for each patient to establish their pre rehab claudication

distance & total walking distance (Pls. refer 6MWT protocol).

Complete sheet “PVD Exercise Group Registration/Information sheet”,

6MWT scoring sheet, 6MWT patient information sheet which details name,

address, GP details, dates of attendance, pre and post rehab 6MWT result and

space to document any problems encountered over the course of the sessions.

Sessions 2 to 12

Group warm up initially (approximately 5 minutes)

Use exercise stations with the patients working in pairs. At each station there

is an instruction sheet for the exercise. Where possible there are easier and

harder versions for the exercises. Easier versions are printed on white paper

and harder or standard versions are printed on blue paper.

Patients are given 5 minutes per exercise station.

In between circuits get the group to do a lap around the exercise hall, aiming

by the end of the group to complete 1 lap of the hall between each exercise

station, but at the initial classes maybe only completing a lap every 2-3

stations. Initially patients may spend 5 minutes at each exercise station but as

they complete more laps of the hall towards the end the time spent at each

station will have to be reduced.

Group cool down to finish (approximately 5 minutes)

At each session ask the patients individually if they have had any problems

after the previous sessions and document if anyone has had any new health

problems or exacerbations of existing conditions. Also document any advice

you give to the patients regarding this. This information can be documented on

the “PAD Exercise Group Registration/Information sheet” (Appendix-5)

which will have been completed for each patient at session one. If there are no

problems then make a note of this also.

Session 13

Same format as sessions 2-12 but also at the penultimate session it is a good

idea to ask Ms. Dragana Hanzen to come to speak to the group about exercise

options available in the community for the patients to continue with after the


groups are finished. She will advise of groups available and costs involved.

You need to email her in as far advance as possible so she can timetable it into

her diary. (Email: [email protected])

Provide the patients with theraband exercises and a piece of theraband to

complete the exercises with. Agree with the patient the appropriate number of

repetitions. This should be documented on the exercise sheet along with any

specific instructions/modifications. The frequency of the exercises should also

be documented eg 1 or 2 x daily along with the date the exercises are issued.

There is a corresponding sheet with the same exercises on in smaller print and

any specific instructions/modifications documented on the patient‟s copy of

exercises should be duplicated onto this sheet along with the number of

repetitions and frequency of exercise.

Session 14 (final session)

Complete Post rehab WIQ

Complete a 6MWT for each patient to establish their post rehab claudication

distance & total walking distance (Pls. refer 6MWT protocol). Complete the

result on the “PVD Exercise Group Registration/Information” sheet.

Ask the patients to complete the evaluation questionnaire to give

feedback/evaluate the sessions after the shuttle test.

For patients who have only completed one seven week block of exercises ask

them if they wish to return again in future should there be any spaces

available. Currently patients who have completed two seven week blocks will

be unable to return again.

SIX MINUTE WALK TEST (6-M.W.T.)

William RH, et al 1995 and Susan AS 2004 suggests the Graded Treadmill Test is

considered as the Gold Standard tool when assessing this group of patients. However,

in a community setup and for practical reasons the 6 MWT is thought to be the best

alternative to the Graded Treadmill Test (Paul LE et al 2003, Susan AS 2004, and

Patricia JO 2005). Furthermore, the 6 MWT is as sensitive as treadmill test (Tsai et al

JC 2002). We follow the ATS Statement 2002 for 6MWT.

Modification of 6-MWT from ATS Statement 2002

Only a few modifications have been made to the ATS Statement 2002 guidelines to

allow for the availability and time constrains. They are as follows

The ATS Statement 2002 suggested using minimum of 30 meters distance

between the cones, but as the halls length is just above 30 meters it is

modified as 20 meters. A chair is provided at the 0 meter, 10 meters, 20

meters and the marking cones will be placed to mark 5 meters and 15

meters. The participants will walk around the 0 meter and the 20 meter

chairs.

The statement suggested testing one person at a time. Due to time constraints

we have modified this to testing 3 or 4 persons at one time giving sufficient

mailto:[email protected]


spacing between them. Explanation is given to the participants suggesting

they walk at their on pace not comparing themselves with other participants.

Points to consider before doing a 6 MWT

Go through the Examiner Instruction (Appendix-6) and prepare yourself.

All participants should read through the „Participants Information‟ (Appendix-

7) before undertaking the 6MWT.

Keep examiners to a minimum number. Give them a copy of the Examiner

Instruction and discuss with them what you are expecting and clarify any

uncertainties well in advance.

To avoid the lap counting error and for easily calculating the distance when

ever the participants reach the 20th

meter chair it is marked as participant

completed one lap and when the participant reaches the starting point it is

marked as second lap.

Establish the classic symptom of claudication with the participants either when

filling in the registration sheet or when filling in the WIQ form. (Some of the

participants may have multiple limiting factors and may give unintentional

calls for claudication pain symptoms during the 6 MWT).

6-MWT Compact Disc Audio

The ATS Statement suggests using standardised encouragements at the completion of

every minute. Due to time constraints (as we are testing more than one person at a

time), to eliminate different examiners using different encouragements and to release

the practitioner from time keeping, a C.D. has been produced. It goes through the

instructions for participants, examiners and the 6-Minute Walk Test. To be on the safe

side and to avoid any last minute technical errors it is wise to have a stop watch as a

standby.

Equipments required for 6MWT.

6 MWT C.D and Stop watch

Tape measure

Marking cones

6 MWT Lap Count Marking Sheet (Appendix-9)

Calculating the Predicted 6 Minutes walking distance

This is calculated based on a formula derived by Paul LE et al (2003). To calculate

the predicted 6 MWD you need to have the following basic details

Age in years

Sex

Height in Centimetres

Weight in Kilograms

If this data is entered into the PAD Exercise Class Database it will automatically

calculate and give the reading in column “I”.


WALKING IMPAIRMENT QUESTIONNAIRE (WIQ)

William RH, et al 1995, Susan AS 2004 and TASC suggest that subjective Quality of

Life outcome assessment should also be assessed in this patient group. “SF-36” was

tried in the P.A.D. clinic and it was dropped due to its lengthy, complex and time

consuming factors.

WIQ is a disease specific QoL outcome measure developed by Regensteiner JG et al

1990. During March 2006 WIQ was first introduced to the Exercise group at the

QEH, Gateshead. It is still under trail so the full WIQ (Appendix-8) is at the moment

only used in the exercise group and the symptoms associated with walking

impairment section are used in the clinic.

The advantages of this questionnaire are that it is:

Disease specific.

Simple and straight forward.

Easy to complete compared to SF-36.

Informative and able to assess the patient point of view.

Able to assess other limiting factors.

P.A.D. EXERCISE GROUP DATABASE

For each group create a new database. It‟s a Pre-Programmed database which will do

some automatic calculations if data is entered in the appropriate columns. As this

database is a little complicated and in order to create a new one, the easiest way is to

copy a blank pre-prepared database, then past it to the system and rename it with the

next groups starting month and year. The following will explain the functions of each

column and what data to enter in it.

Information recorded:-

Column A: Name

Column B: Date of Birth

Column C: Contact Number

Column D: Note

Column E: Age

Column F: Sex (Use 17 for Male & 0 for Female patients)

Column G: Height in Centimetres

Column H: Weight in Kilograms

Column I: Database will automatically calculate the 75% of the maximum

6MWD (Please do not enter any data here)

Column J: Pre Rehab Claudication Distance (If no claudication distance is

recorded enter the 6MWD)

Column K: Pre Rehab 6MWD

Column L: Database will automatically calculate the Pre rehab Walking Speed

(Please do not enter any data here)

Column M: Database will automatically calculate the Pre rehab Walking

performance percentage compared to the 75% of max 6MWD (Please

do not enter any data here)


Column N: Pre Rehab number of rest taken during 6MWT

Column O: Post Rehab Claudication Distance (If no claudication distance is

recorded enter the 6MWD)

Column P: Post Rehab 6MWD

Column Q: Database will automatically calculate the Post rehab Walking Speed


Column R: Database will automatically calculate the Post rehab Walking

performance percentage compared to the 75% of max 6MWD (Please

do not enter any data here)

Column S: Post Rehab number of rest taken during 6MWT

Column T: Database will automatically calculate the difference between Pre &

Post rehab Claudication distance. Positive figure is an improvement.


Column U: Database will automatically calculate the difference between Pre &

Post rehab 6MWD. Positive figure is an improvement. (Please do not

enter any data here)

Column V: Database will automatically calculate the percentage of Post rehabe

Claudication distance compared to Pre rehab performance. Above 100

is an improvement. (Please do not enter any data here)

Column W: Database will automatically calculate the percentage of Post rehabe

6MWD compared to Pre rehab performance. Above 100 is an

improvement. (Please do not enter any data here)

Column X: Pre rehab WIQ Distance factor data

Column Y: Database will automatically calculate the percentage of Pre rehab WIQ

Distance factor. (Please do not enter any data here)

Column Z: Pre rehab WIQ Speed factor data

Column AA: Database will automatically calculate the percentage of Pre rehab WIQ

Speed factor. (Please do not enter any data here)

Column AB: Pre rehab number of factors affecting mobility

Column AC: Post rehab WIQ Distance factor data

Column AD: Database will automatically calculate the percentage of Post rehab

WIQ Distance factor. (Please do not enter any data here)

Column AE: Post rehab WIQ Speed factor data

Column AF: Database will automatically calculate the percentage of Post rehab

WIQ Speed factor. (Please do not enter any data here)

Column AG: Post rehab number of factors affecting mobility

Column AH: Database will automatically calculate the difference between Pre &

Post rehab WIQ Distance factor Percentage. (Please do not enter any

data here)

Column AI: Database will automatically calculate the difference between Pre &

Post rehab WIQ Speed factor Percentage. (Please do not enter any data

here)

Column AJ: Class daily attendance

& Further


REFERENCE

ATS Statement (2002): Guidelines for the Six-Minute Walk Test: American Journal

of Respiratory and Critical Care Medicine Vol 166. pp. 111-117.

(http://ajrccm.atsjournals.org/cgi/reprint/166/1/111)

Bendermacher BLW et al 2006; Supervised Exercise Therapy versus Non-Supervised

Exercise Therapy for Intermittent Claudication; The Cochrane Database of

Systematic Reviews; Iss-2, No CD005263.pub2

Kerry JW et al 2002; Exercise Training for Claudication; The New England Journal

of Medicine; Vol-347, Iss-24, Page 1941-1951

Leng GC 2000; Exercise for Intermittent Claudication; The Cochrane Database of

Systematic Reviews; Iss-2, No: CD000990

Norfolk and Norwich University Hospital 2004; Patient Information: Exercise Classes

for patient with Intermittent Claudication. Norfolk and Norwich University Hospital

NHS Trust.

Patricia JO 2005; Field Tests of Aerobic Capacity for Children and Older Adults;

Cardiopulmonary Physical Therapy Journal; Vol 16, N23, Page 5-11&40. Free

access from NHS Journal Database (Pro-Quest)

Paul LE et al (2003); The 6-min Walk Test: A Quick Measure of Functional Status in

Elderly Adults. Chest; Vol 123; Page 387-398.

www.chestjournal.org/cgi/content/full/123/2/387 (free access).

Regensteiner JG et al 1990; Evaluation of Walking Impairment by Questionnaire in

Patients with Peripheral Arterial Disease; Journal of Vascular Medicine and Biology.

Vol- 2, No-3, Page 142-152.

Susan AS 2004; Research Corner: Functional Outcome Measurements for Patients

with Peripheral Arterial Disease; Cardiopulmonary Physical Therapy Journal; Vol

15, No3, Page 23-28. Free access via NHS Journal Database (Pro-Quest)

TransAtlantic Inter-Society Consensus (TASC); Management of Peripheral disease;

The TransAtlantic Inter-Society Consensus;

www.tasc-pad.org/html/index.htm; accessed between 05.02.2006 and 09.07.2006

Tsai et al JC 2002; The Effects of Exercise Training on Walking Function and

Perception of Health status in Elderly Patients with Peripheral Arterial Occlusive

Disease; Journal of Internal Medicine; Vol 252, Page 448-455

William RH et al 1995; Clinical Trials for Claudication: Assessment of Exercise

Performance, Functional Status, and Clinical End Points; Circulation; 92:614-621;

http://circ.ahajournals.org/cgi/content/full/92/3/614 free online access

http://ajrccm.atsjournals.org/cgi/reprint/166/1/111

http://www.chestjournal.org/cgi/content/full/123/2/387

http://www.tasc-pad.org/html/index.htm

http://circ.ahajournals.org/cgi/content/full/92/3/614


APPENDIX-1

PHYSIOTHERAPY P.A.D. CLINIC INITIAL ASSESSMENT & TREATMENT

DATE:

NAME: HOSPITAL NUMBER:

DoB: TELEPHONE:

ADDRESS:

SYMPTOMS: Calves R/L Buttock R/L Thigh R/L

Others

CURRENT MOBILITY :

CLAUDICATION DISTANCE :

WIQ SCORE :

PAST MEDICAL HISTORY:

MI CABG Heart Failure Hypertension

Angina CVA/TIA O.A Hip/Knee Osteoporosis

R.A D.M COPD/Asthma Anxiety /Depression

TREATMENT / ADVICE / EXERCISES GIVEN:

Personal Exercise program High / Medium / Low issued & explained.

Issued All about Intermittent Claudication Booklet (OPUK/PLE/091 MAY 2004).

Walk as much as possible.

Continue your own Exercises / Activities as usual.

Others

WILLING / APPROPRIATE FOR EXERCISES GROUP:

Willing / Not Willing Yes / No

NAME: SIGNED:


APPENDIX - 2

PHYSIOTHERAPY P.A.D. CLINIC FOLLOW-UP ASSESSMENT & TREATMENT

DATE:

NAME: HOSPITAL NUMBER:

DoB: TELEPHONE:

ADDRESS:

SYMPTOMS: Calves R/L Buttock R/L Thigh R/L

Others

CURRENT MOBILITY :

CLAUDICATION DISTANCE :

WIQ SCORE :

TREATMENT / ADVICE / EXERCISES GIVEN:

Personal Exercise program progressed to High / Medium / Low issued & explained.

Walk as much as possible.

Continue your own Exercises / Activities as usual.

Others

FOLLOW-UP ASSESSMENT: Walking Distance & Claudication Pain

Improved Unchanged Declined

FOLLOW-UP PLAN:

Review in Discharged

NAME: Pradeep Chockalingam SIGNED:


APPENDIX - 3

P.A.D. Exercise Group

Registration & Information Sheet

NAME: G.P. NAME & ADDRESS:

HOSPITAL NUMBER:

DoB:

TELEPHONE:

ADDRESS:

Height: Cm. Weight: Kg.

PAST MEDICAL HISTORY:

MI CABG Heart Failure Hypertension

Angina CVA/TIA O.A Hip/Knee Osteoporosis

R.A D.M COPD/Asthma Anxiety /Depression

MEDICATIONS:

PREDICTED 6MWD :

PRE REHAB 6-MWT SCORE (CD: TD) : , % of Pre 6MWD: %

SPEED : Kms/H

POST REHAB 6-MWT SCORE (CD: TD) : , % of Pre 6MWD: %

SPEED : Kms/H

(6-MWD/T: 6 Minute Walk Distance/Test, CD: Claudication Distance, TD: Total Distance)

CLAUDICATION DISTANCE IMPROVEMENT : %

TOTAL DISTANCE IMPROVEMENT : %

(<90% = Decline, 91 to 105% = No change, >105% = Improvement)


APPENDIX - 4

Six-Minute Walking Test Instructions

To the examiner

Stand near the starting line during the test.

Do not walk with the patient. Do not talk to anyone during the walk.

As soon as the patient starts to walk, start the timer.

Watch the patient. Do not get distracted and lose count of the laps.

Each time the participant completes a lap mark on the worksheet. Let the

participant see you do it. Exaggerate the click using body language.

If the patient stops walking during the test and needs a rest, say this: "You

can sit if you would like; then continue walking whenever you feel able." Do

not stop the timer.

Please mark the time when participant complains of claudication pain

symptom as well as the rest and restart time.

Inform the participant after completion of every minute and 15 seconds before

end of the test. At the end of 6 minutes say this: "Stop!" and walk over to the

patient and mark the spot where they stopped by placing a bean bag or a

piece of tape on the floor.

Please use the standard phrases given below under the heading

“Encouragement” when informing the participant after completion of every

minute,15 seconds before end of the test and at the end of 6 minutes.

Record the additional distance covered (the number of meters in the final

partial lap).

If the patient stops before the 6 minutes are up and refuses to continue (or if

you decide that they should not continue), wheel the chair over for the patient

to sit on, discontinue the walk, and note on the worksheet the distance, the

time stopped, and the reason for stopping prematurely.

Reasons to immediately stop a 6MWT include the following: chest pain,

intolerable dyspnea, leg cramps, exes of sweating, and pale appearance.

The above guidance is based on: ATS Statement: Guidelines for the Six-Minute Walk Test. ATS Committee on

Proficiency Standards for Clinical Pulmonary Function Laboratories.

American Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117, (2002)


APPENDIX - 5

Six-Minute Walking Test Instructions

To the participants

The object of this test is to walk as far as possible for 6 minutes.

You will walk back and forth in this hallway around the marker cones

(20 meters).

Pleas inform the examiner immediately when you start feeling the

claudication pain on your legs.

Six minutes is a long time to walk, you will probably get claudication

pain or out of breath or become exhausted.

Walk at your own pace. This test is to asses your progress. It’s not a

competition or comparison with others performance, so please walk at

your own pace and take rest if you required.

You are permitted to slow down, to stop, and to rest as necessary.

You may rest in the chair provided near the track, but resume walking

as soon as you are able.

You will be walking back and forth around the cones.

You should pivot briskly around the cones and continue back the other

way without hesitation.

I am going to use this chart to keep track of the number of laps you

complete. I will tick it each time you turn around at this starting line.

I will inform you after completion of every minute and 15 seconds

before end of the test. At the end of 6 minutes I will tell you to stop.

When I do, just stop right where you are and I will come to you.

The object is to walk AS FAR AS POSSIBLE for 6 minutes, but don't

run or jog.

Demonstrate: (Walking one lap by the examiner.)

The above guidance is based on: ATS Statement: Guidelines for the Six-Minute Walk Test. ATS Committee on

Proficiency Standards for Clinical Pulmonary Function Laboratories.

American Journal of Respiratory and Critical Care Medicine Vol 166. pp. 111-117, (2002)


APPENDIX - 6 Walking Impairment Questionnaire

Name: DoB: Date: 1, Walking Distance: For each of the following distances, report the degree of difficulty that best describes how hard it was for you to walk WITHOUT stopping to rest.

Difficulty walking a distance during the past month / week

3 Manage

well

2 With some difficulty

1 With much difficulty

0

Unable to do

Walking indoors (around the house)

Walking 17 yards / 50 feet





Walking 500 yards or more / ¼ mile

(Distance Conversion table, 100 yards = 300 feet = 90meter) 2, Walking Speed: These questions refer to HOW FAST you were able to walk 100 yards. Tell us the degree of difficulty required for you to walk at each of these speeds WITHOUT stopping to rest.

Difficulty walking at a certain speed during the past month / week

3 Manage

well

2 With some difficulty

1 With much difficulty

0

Unable to do

Walking 100 yards/300 feet slowly?

Walking 100 yards/300 feet at an average speed?

Walking 100 yards/300 feet quickly?

Running or jogging 100 yards/300 feet?

(Distance Conversion table, 100 yards = 300 feet = 90meter)


3, Symptoms associated with walking impairment: To what extend do you think the following affects your walking.

Symptoms associated with walking impairment

3

No

2

Slight

1

Some

0

Much

Pain or aching in your calves?

Pain or aching in your thighs/buttocks?

Pain, stiffness or aching in your joints (knees or hips)?

Pain or discomfort in your chest?

Weakness in one or both of your legs?

Shortness of breath?

Heart palpitations?

Other problems? (please list)

Modified from: Regensteiner JG, Steiner JF, Panzer RJ and Hiatt WR: Evaluation of walking impairment by questionnaire in patients with peripheral arterial disease. J Vas Med and Bio12:142-152, 1990


APPENDIX - 7

Six-Minute Walking Test

Name: DoB: Date: Symptoms: Calves R/L Buttock R/L Thigh R/L

Others

1 2 3 4 5 6 7 8 9 10

Pain Rest

11 12 13 14 15 16 17 18 19 20

21 22 23 24 25 26 27 28 29 30

31 32 33 34 35 36 37 38 39 40

41 42 43 44 45 46 47 48 49 50

Claudication Distance :

6 Minutes Distance :

Reason for stopping the test:

Any comments:

Name of the examiner Signature

peripheral vascular / arterial disease

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