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The Effect of Structured Patient Education on Physical Activity in Patients with Peripheral Arterial Disease and Intermittent Claudication: A Systematic Review
Corresponding author. School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.
Affiliations
School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UKDepartment of Medical Rehabilitation, University of Nigeria Enugu Campus Enugu, Nigeria
The aim was review the components and effects of patient education interventions to improve physical activity (PA) in patients with peripheral arterial disease (PAD) and intermittent claudication (IC), and patients' experiences of these interventions.
Data sources
CINAHL, Cochrane Library, Ovid, ProQuest, AMED, MEDLINE, PsycINFO, Web of Science Core Collection, and PEDRO, and Trial registers and directory of Open Access repository websites and Web of science conference proceedings were searched. Hand searching of reference lists of identified studies was also performed to identify studies that reported the effect of patient education interventions on daily PA and/or walking capacity in individuals with PAD and IC, or studies investigating patients' experiences of such interventions.
Methods
A systematic search was conducted in June 2016 (updated in March 2017). Primary outcomes were daily step count and self reported PA; the secondary outcome was absolute claudication distance. There was substantial heterogeneity in terms of modalities of patient education in the included studies; hence a narrative synthesis was implemented.
Results
Six studies (1087 participants) were included in the review. Findings from a small number of high quality trials demonstrated potential for PA improvement with structured education interventions. Nevertheless, evidence is currently inconclusive regarding the effect on daily PA and walking capacity of patients with IC. Patients reported that they valued the interventions studied, finding them acceptable and important in improving their PA, motivating and empowering them to self manage their condition.
Conclusions
The evidence from the review is limited and inconclusive regarding the effectiveness of structured education for increasing PA in patients with PAD and IC. More rigorous trials are needed before recommendations can be made. Future interventions should consider the key criteria for a structured patient education programme, and also report patients' experiences and perceptions.
This article describes the first comprehensive systematic review of patient education interventions for physical activity (PA) improvement for individuals with intermittent claudication (IC). The current evidence is inconclusive regarding the effect of patients' education on PA of individuals with IC. Further research is warranted to establish the effects and optimal design of education interventions.
Introduction
Peripheral arterial disease (PAD) is a growing public health burden. PAD leads to arterial stenosis and consequently inadequate blood flow to the peripheries.
The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Program.
Reduced self efficacy, attributed to poor understanding of the disease and uncertainty regarding the importance of walking has been identified as a major barrier to exercise uptake in this population.
These findings suggest that a patient centred self management approach to improving PA, including structured patient education, may be beneficial in this population.
Although the current literature supports educating patients with IC about their disease pathology and the importance of walking,
neither evidence of effectiveness nor patients' perceptions of interventions have been established. The aim of this review was to examine the effect of patient education on improving PA in individuals with PAD and IC and the experiences and perceptions of patients of these interventions.
Methods
The protocol for this review was registered with the International Prospective Register of Systematic Reviews (CRD42015027314) and has been published elsewhere.
Studies reporting the effect of patient education interventions on daily PA and/or walking capacity in individuals with PAD and IC, or studies investigating patients' experiences of such interventions were included in this review. Diagnosis of PAD could be objective (e.g., an ankle brachial index (ABI) < 0.9), by questionnaire, or clinical diagnosis. Original English language research manuscripts in peer review journals and conference proceedings were included. Studies were included only if they reported on structured patient education interventions and/or components particularly related to PAD and IC. For the purposes of this review, the key criteria used to define structured education in diabetes were adopted.
To be included, a patient education intervention should (a) aim to empower and inform patients, and to support self management of their PAD/IC by building sufficient knowledge and skills to do so; (b) include topics about the nature of PAD/IC, and day to day living and management of PAD/IC including the importance of physical activity and walking; (c) have embedded quality assurance processes including having a structured curriculum, having trained educators, being quality assured, and being audited.
Outcomes
Daily PA (daily step count and self reported change in daily PA) was the primary outcome. Secondary outcomes included treadmill -measured walking capacity (absolute claudication distance [ACD]), pain intensity, quality of life (QoL), and qualitative data regarding patients' experiences with interventions.
Information sources, search strategy, study records, and data management
A systematic search was conducted in June 2016 (updated in March 2017). Nine databases (CINAHL, Cochrane Library, Ovid, ProQuest, AMED, MEDLINE, PsycINFO, Web of Science Core Collection, and PEDRO), trial registers, and directory of Open Access repository websites were searched by the first author (U.O.A.) using key words: patient education, lifestyle education, behaviour change intervention, peripheral arterial disease, intermittent claudication, physical activity, and home based exercise combined with specific search terms and strategies for each database.
Reference lists of identified studies were also searched. Titles, abstracts, and the full text of selected studies were independently screened by two authors from a pool of three (U.O.A., C.A.S., P.M.D.) using previously defined eligibility criteria.
Differences of opinion regarding inclusion or exclusion were resolved by discussion between authors and reflection in consultation with the second author (P.M.D.).
Data collection processes
The Cochrane Consumers and Communication Review Group Data Extraction Template
Cochrane Consumers and Communication Review Group. Communication review group: Data extraction template for Cochrane reviews. Cochrane Collaboration, 2007 (Updated Dec 2016). http://cccrg.cochrane.org/author-resources. [Accessed 10 May 2017].
Noyes J, Lewin S. Extracting qualitative evidence. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, Lockwood C (Eds.), Supplementary guidance for inclusion of qualitative research in Cochrane systematic reviews of interventions, Chapter 5. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. Retrieved April 27, 2017, from http://cqrmg.cochrane.org/supplemental-handbook-guidance.
were adapted to extract data from the included studies. The Cochrane Collaboration risk of bias tool was used to determine and summarise the risk of the included studies.
Studies were subsequently rated as low quality trials (i.e., having high risk of bias) or high quality trials (i.e., having low to moderate risk of bias) if there were three or more, or fewer than three identifiable sources of bias respectively (see Table 2). Two reviewers (U.O.A., C.S.) performed the data extraction and made judgements regarding the risk of bias independent of each other. Again any disagreement was resolved by discussion between the reviewers and consultation with the second author (P.D.).
Results
Study inclusion
The search initially identified 5707 studies (Fig. 1), of which six studies contributing data on 1087 participants were included in the final analysis. Meta-analysis was not possible due to wide variations in interventions and substantial methodological and clinical heterogeneity in the included studies. The results of this review are reported using narrative synthesis.
(Table 2). No study was assessed to have a risk of bias related to selective reporting. Sources of bias in the included studies included lack of blinding of outcome assessment (n = 5),
Total n = 58, IC in at least one leg Post-exercise ABI < 0.7
Intervention: Usual care + Information on PAD and walking, motivational interviewing, PA goal setting, action planning, self monitoring and feedback, barrier identification with problem solving. Delivered at patients' homes by via a trainee health psychologist 2 × 1 h sessions Control: Usual care (walking advice + consultation with vascular surgeon)
Daily steps (pedometer) Walking ability (patient report) ICQ (disease specific quality of life) Medical Outcome Study Short-Form (generic health related quality of life) Outcomes assessed at baseline and 4 months
Brief psychological intervention significantly improved walking behaviour in patients with IC in comparison with usual care
Total n = 23 Stable Rutherford IC Classification 1–3 for ≥ 3 months
Intervention: Usual care plus one off 3 h session of group patient centred structured education including patient story, PAD/IC and walking information provision, PA feedback, barrier identification with problem solving, goal setting, action planning, and self monitoring. Delivered at in clinical research facility followed by twice-weekly phone calls for 6 weeks. Control: Usual care
Daily step (accelerometer) ICD, 6 minute walk test WELCH questionnaire ICQ (disease specific quality of life) EQ-5D (generic health related quality of life) Self efficacy Acceptability (exit interview) Outcomes assessed at baseline and 6 weeks
Education programme is feasible, acceptable, and potentially useful for improving walking capacity and quality of life
Total n = 882 ABI ≤ 0.9 Clinical diagnosis of PAD Definite IC or atypical IC on Edinburgh Claudication Questionnaire
Intervention: Educational package + mobility program (supervised or home based) + smoking cessation where applicable Control: No intervention
ICD PA pattern (Patient report) Medical Outcome Study Short-Form (generic health related quality of life) Outcomes assessed at baseline, 2 months, and 12 months
Intervention for early PAD based on increased PA and smoking cessation results in a greater max walking distance 12 months later
Total n = 51, Diagnosis of PAD ABI > 0.5 and ≤ 0.955.
Intervention: Communication intervention beginning with completion of guide and followed by 15–20 minute of motivational interviewing, provision of information related to PAD/IC and walking, barrier identification and problem solving strategies, patient tailored walking prescription. Delivered by medical student Control: Video Intervention
PA pattern and time (patients report) ICD and ACD WIQ Outcomes assessed at baseline, and 12 weeks
Patients watching video on the use of PA in PAD improved participants walking speed
Total n = 48 Level II Leriche and Fontaine IC Atypical symptom ABI < 0.9
Intervention: Educational classes, implementation of secondary prevention, and a personalised program of reconditioning exercises Control: No intervention
ICD and ACD Medical Outcome Study Short-Form (generic health related quality of life) Pain intensity Patients experiences via exit questionnaire (12 months only) Outcomes assessed at baseline, 3 months and 12 months
Educational therapeutic program results in a significant improvement in functional and QoL parameters during the first 3 months in patients with IC and persists even patients are no longer coached
Total n = 25 Patients without walking limiting comorbidities except IC Severe cardiac ischaemia ≤ 3 months previous myocardia infarction TIA or stroke < 1 month treatment with cilostazol or penthoxifylline Endovascular therapy 4–6 weeks prior baseline or stable IC without revascularisation in the last 4–6 weeks (ABI ≤ 0.9)
Intervention: Initial in hospital walking exercise (2 weeks, 3 days/week) followed by community based walking exercise (12 weeks) with training, monitoring and coaching (TMC) components. Control: Usual care (standard advice to walk)
ICD and ACD WIQ Medical Outcome Study Short-Form (generic health related quality of life) Outcomes assessed at baseline and 14 weeks
Community based walking exercise with TMC improves ICD and walking performances other than ACD
ACD = absolute claudication distance; ABI = ankle brachial index; EQ-5D = EuroQoL EQ-5D-5L; IC = intermittent claudication; ICD = initial claudication distance; ICQ = intermittent claudication questionnaire; NS = not significant; PA = physical activity; RCT; randomised control trial; WIQ = walking impairment questionnaire; WELCH=Walking Estimated Limitation Calculated by History questionnaire.
Studies were subsequently rated as low quality trials (i.e. having high risk of bias) or high quality trials (i.e., having low to moderate risk of bias) if there was ≥3 or < 3 identifiable sources of bias respectively.
The Cochrane Collaboration tool for assessing risk of bias was used to determine and summarise possible sources of risk of bias in included studies (Cochrane 2011) (yes indicates the presence or potential presence of a source of bias).
a Summary risk of bias in included studies was presented.
b Studies were subsequently rated as low quality trials (i.e. having high risk of bias) or high quality trials (i.e., having low to moderate risk of bias) if there was ≥3 or < 3 identifiable sources of bias respectively.
Table 3Data extraction of finding from included studies (except where specified, results are presented as intervention group compared with control group).
Authors
Change in daily PA behaviour
PA capacity/ability measures
Pain, self efficacy, and perceived control over illness
At 14 weeks: Pain free walking time (p = NS); Greater increase in claudication onset time (5.8 ± 1.5 min to 7.4 ± 1.6 min vs. 4.7 ± 1.4 min →4.1 ± 1.5 min; p = 0.045); Greater improvement in walking impairment (42.3 ± 7.7 min →60.6 ± 7.2% vs. 49.1 ± 7.7 →44.6 ± 7.2%; p = 0.001)
) Improved from baseline in time of release of pain at 6 months, and 12months (3.95 →2.01** →2.83**)
Improvement from baseline in physical composite score of SF-36 at 3, 6, and 12 months (36.0→40.8→41.9→42.9; p < 0.01) Improvement from baseline in the mental composite of SF-36 at 3 and 6 months (41.6→45.5→44.7→44.2; p < 0.05)
At 6 weeks: Improvement in Six minute walk distance (44.9; CI 6.9 to 82.9); Greater increase in ACD (173; CI 23 to 322); ICD p=NS Greater improvement in self reported walking ability WELCH score (21.8; CI 8.6 to 35.0); WIQ Speed (21.0; CI 3.8 to 38.1), WIQ distance (30.7; CI 6.4 to 55.0), WIQ stair climbing (30.7; CI 6.4 to 55.0)
At 6 weeks: Improvement in walking performance efficacy (29.5; CI 12.6 to 46.4) Greater improvement in perceive control over illness (2.4; CI 0.0 to 4.7)
At 6 weeks: Greater improvement in disease specific QoL (−10.6; CI –18.9 to −2.3) General QoL (p = NS)
At 2 months: % of patients walking for recreation ≥ 3/week (p=NS); % of patients engaging in vigorous PA (p=NS); % of patient belonging to exercise group (p=NS) At 12th month: Greater % of patient walking for recreation ≥ 3/week (33.8 vs. 25; p = 0.01); % of patients engaging in vigorous PA (p = NS); Greater % of belonging to exercise group (16.5 vs. 1.8, p < 0.001)
At 2 months: Self report maximum walking distance before the onset of pain (p = NS) At 12th month: Improvement in self report maximum walking distance before the onset of pain (p = 0.04)
The included studies had wide variation in the intervention components used, but all included an education session, exercise prescription, and some behavioural change techniques (BCTs) (Table 1). Information provision, goal setting, action planning, and feedback were reported in all included studies. Other reported BCTs included motivational interviewing (n = 3), barrier identification/problem solving (n = 5), feedback on performance (n = 2), and prompting self monitoring of behavioural outcome (n = 4). Intervention duration ranged from 6 weeks
reported outcomes of daily PA. Walking capacity outcomes included treadmill walking distances and time, 6 minute walking distance, WELCH score, walking impairment questionnaire speed, distance, and stair climbing scores. Daily PA was assessed objectively in two studies: daily step counts using a pedometer
showed no difference between the percentage of participants who engaged in walking for recreation three or more times per week (36.8 vs. 31.4%; p = .14), engaged in more than usual activity (10.2 vs. 9.0%; p = 0.73), or belonged to an exercise group (14.0 vs. 10.1%) at 2 months. However, after 12 months follow-up, a greater percentage were walking three or more times per week (33.8 vs. 25.0%; p = 0.01), engaged in more activity than usual (11.1 vs. 5.9%; p = 0.03), or belonged to an exercise group (16.5 vs. 1.8%; p < .001). The other trial was of low quality
reported significant improvement in ACD: increases of 63% at 3 months, and 84% at 6 months compared with baseline. Similarly, one high quality pilot RCT
found no change in the number of people whose ACD improved, remained the same, or deteriorated at the 2 month follow-up. However, a significantly greater number of patients were found to have improved their maximum walking distance (p = 0.003) at 12 months.
reported outcomes related to QoL. Generally, outcomes of both general and disease specific QoL were mixed. One high quality trial showed improvement in SF-36 (0.40 vs. −0.30; p = 0.002) but no change in intermittent claudication questionnaire (ICQ) score (p > .05) at 4 months.
reported improvement in ICQ (−10.6; 95% CI –18.9 to −2.3) but not general QoL (EQ-5D utility score 0.05; 95% CI –0.09 to 0.19). Two high quality trials reported no change in health related QoL at 2 months (0.83 vs. 085; p = 0.33), and at the 12 month follow-up (0.83 vs. 0.84; p = 0.13),
A low quality trial, however, reported post-intervention improvement in the physical component of the SF-36 score at both 3 month (40.8 vs. 36.0; p < .01) and 12 month follow-up (42.3 vs. 36.0; p < .01) compared with baseline.
For this trial, there was also an improvement in the mental composite score at 3 months (45.2 vs. 41.6; p < .05) but not at 12 months (44.2 vs. 41.6; p > .05).
A high quality trial reported an improved walking performance self efficacy (mean adjusted difference 29.5; 95% CI 12.6–46.4) and perceived control over illness (mean adjusted difference 2.4 95% CI 0.0–4.7).
reported a decrease in pain intensity at 3 months compared with baseline (5.89 vs. 4.73, p < .05), which remained stable during the following 9 months (5.89 vs. 4.53; p < .05). Also, the time taken for claudication pain to disappear improved 6 months from the baseline (3.95 vs. 2.01; p < .05), and remained stable for the following 6 months (3.95 vs. 2.83; p < .05).
reported qualitative findings related to the experiences of patients with education interventions. Sixteen qualitative findings were extracted from the papers and grouped into eight categories. These categories were then merged to create three synthesised themes: acquiring knowledge; receiving pragmatic and tailored care; and gaining confidence and self monitoring (Table 4, Table 5). Although verbatim quotes were not available from the included papers, each synthesised theme is described below, with some examples that reflect the patients' experiences as reported in the included papers.
Table 4Category Label and description of patients' experiences with intervention.
Category label
Category description
Receiving information about disease
Participants valued participation in the intervention because it provided them with greater understanding of their condition (T); Patient valued intervention because it provided them with extra information about their illness(C). 97% were very satisfied with the topic discussed (P)
Receiving information about walking
Patients reported that they valued the intervention because it provided them with understanding of the importance of walking(C); Patients reported that they valued the intervention because it provided them with understanding of how walking will help(C); Patient said intervention were worthwhile and that they valued it because it provided them with extra information about walking (C)
Being motivation and empowered
Patients reported being satisfied with their improvement in attitude towards walking with their claudication and their physical self confidence (P); Patients reported being satisfied with their improvement in their physical self confidence (P); Participants valued participation because it enabled them to walk more (T); Patients said they valued intervention because it provided them with extra encouragement and motivation(C)
Benefit of group education session
97% reported that they were very satisfied with the benefit of group education session (P)
Self monitoring
The use of pedometer was valued as it was seen as useful tool for self monitoring (T)
Goal setting
Patient reported that intervention were worthwhile because it provided them clarity on what to do (C);
Pedometer as useful tool
Patients valued the pedometer and seen as a valuable tool for motivation, self monitoring, and goal setting (T)
Receiving personalised care
95.5% reported very satisfied with the scope, quality, and benefit of individual discussion (P); patients valued the intervention because it provided personalised plan(C)
Acquiring knowledge entails patients being provided information about their pathology and the systemic nature of IC, being informed of the importance of secondary prevention, and risk factor modification including the importance of PA. Tew et al.
reported that patients valued a 6 week programme of pragmatic group based structured patient education because it provided them with greater understanding of their condition, and empowered them to walk more.
Receiving pragmatic and tailored care
Patients valued the idea of a group based intervention that also gave the opportunity for individual attention. Prévost et al.
reported that 97% of the participants were satisfied with the quality, duration, topics discussed, and the group nature of the session. Similarly, 95% reported that they were satisfied with the scope, quality, and benefit of individual discussion.
Gaining confidence and self monitoring
Gaining confidence encompassed developing a positive self attitude, overcoming uncertainties, and feeling empowered; for example gaining confidence to self monitor their daily step counts with a pedometer: patients were presented with the opportunity to self monitor their progress and they considered this an important component for meeting their physical activity goal. Prévost et al.
reported that their participants were very satisfied with the improvement in their attitude towards walking with claudication and their physical self confidence and valued the use of a pedometer as a tool for motivation, self monitoring, and goal setting.
Discussion
Six trials evaluating a range of patient education interventions for improving PA in patients with PAD and IC were reviewed. The included studies were mostly of high methodological quality. The major sources of risks of bias were lack of blinding of outcome assessment, performance bias, and lack of allocation concealment. The combined evidence from four studies indicated that structured patient education intervention increased the maximum walking capacity
Generally, although the daily step count tended to improve only after longer periods of follow-up (4 months upwards), there was no such trend for the outcomes related to maximum walking distance. Evidence from five trials
showed marked variability regarding QoL measures. Useful interventions from the patients' perspective included those that provided them with information about their condition, were designed to enhance group interaction while maintaining individual discussion, and provided them with confidence and self monitoring.
Related reviews have been conducted on behaviour change techniques
reported limited evidence from one high quality RCT to support BCTs for improving maximum and pain free walking capacities, and for increasing daily PA among people with IC. Similarly, Al-Jundi et al.
reported that there is “low level” evidence that home based exercise programmes can improve walking capacity and QoL in patients with IC. However, the reviews were limited to RCTs of BCT,
No review has considered the qualitative experiences of patients with these interventions. Further, although these reviews include studies with patient education modalities, study eligibility did not specifically consider the key criteria for a structured patient education.
employed a pre-test–post-test design and therefore lacked a control group, and had high risk of bias including selection, detection, and performance bias. In another trial,
included patients who underwent vascular intervention in the weeks prior to the intervention and one patient who did not report claudication pain during treadmill testing. Furthermore, the large variations in patient education modalities and components warranted different contact time, duration of intervention, time point of outcome assessment, and intervention components, possibly resulting in wider outcome variability.
which applied a 6 week structured education intervention, demonstrated potential for increasing PA early in the programme, and was particularly rigorous with blinded outcome assessment, demonstrating improvement in walking capacity at 6 weeks. Although no change in daily step count was observed, it is possible that the effect of behaviour change interventions takes longer to be noticeable. There could be other factors that mediate a slow response to adapting PA change in patients with PAD and IC, even when the disease pathology is understood. One possible barrier is the claudication pain which these patients experience even when they are motivated to walk. Current NICE guidelines recommend “encouraging claudicants to exercise to the point of maximum pain.”
Perhaps for patients with IC to gain the benefit of secondary prevention, concomitant pain management may be desirable to delay the onset and reduce the intensity of pain. By delaying peak maximum pain and empowering patients through education, the potential therapeutic value of walking could not only be realised early in the programme, but may be sustained.
Structured exercise programmes are the recommended exercise therapy for IC; however, based on the small number of included trials, most exercise programmes either do not incorporate patient education, or do not typically comply with criteria definitions of a structured education programme.
Although “usual care” patient education is included in the NICE SEPs recommendations for secondary preventions in IC, the development and implementation of the education components in SEPs interventions are not sufficiently reported to allow a judgement of their fidelity. Therefore, it is often not known how education was delivered, whether educators were sufficiently trained, whether education interventions were delivered as intended, and/or whether sufficient topics were included to enhance patient self management skills. These elements are important as not only do they underpin the potential effectiveness of education programmes, they may be crucial in translating gains in a hospital based SEPs intervention to sustained improvement in daily physical activity at the end of the 3 month SEP, which is crucial in managing chronic diseases such as PAD/IC.
Only three of the included papers reported patient experience with interventions. In these trials, patients reported that they valued interventions that improved their understanding of the disease pathology of PAD and IC, and provided them with information of the importance of walking and how walking helped. For these patients, gaining confidence, self monitoring ability, and skills were key to their accepting and perhaps adhering to interventions. Other important components according to the patients were the benefits from socialising in a group session without losing the opportunity for individualise care. The interventions that included these components demonstrated improvement in both maximum walking capacity
Several limitations are recognised regarding the conclusions in this review. First, the planned meta-analysis could not be implemented because of heterogeneity in the included studies. Secondly, although four of the six included papers were of high quality, three were pilot trials assessing outcomes after a relatively short time. For instance, Tew et al.
only had 13 or nine participants in each group and assessed outcomes after just a 6 week intervention. This means that an inadequate sample and early assessment of outcome could limit the statistical power. Thirdly, the time point of outcome assessments were so varied that it was difficult to establish a reference time point to assess outcome performance even in a narrative synthesis. Fourthly, lack of a control group or use of an active control group meant that the specific efficacy of the intervention versus the usual care or nothing could not be clearly ascertained. In addition, the review design itself has inherent limitations: non-English language literature and unpublished literature were not searched or reviewed.
The limited evidence from four trials is inconclusive regarding the effect of structured patient education to improve daily PA and walking capacity of patients with IC. Interventions that provided patients with information about their disease pathology and walking, providing motivation and empowering patients, were valued and seen by patients as important in improving their PA. Structured education programmes may prove to be an essential part of exercise programmes for patients with IC, but rigorous trials are required before this can be recommended. Future interventions should consider the key criteria for a structured patient education programme. In addition, reporting on patient constructs of their experiences and perceptions to the interventions should always be factored in and reported so that holistic evaluation of effective components from the patients' perspective can be undertaken.
Funding
U.O.A. received funding from the University of Nigeria for a PhD at Glasgow Caledonian University, of which this work forms part.
Conflict of Interest
None.
References
McDermott M.M.
Lower extremity manifestations of peripheral artery disease: the pathophysiologic and functional implications of leg ischemia.
The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Program.
Cochrane Consumers and Communication Review Group. Communication review group: Data extraction template for Cochrane reviews. Cochrane Collaboration, 2007 (Updated Dec 2016). http://cccrg.cochrane.org/author-resources. [Accessed 10 May 2017].
Noyes J, Lewin S. Extracting qualitative evidence. In: Noyes J, Booth A, Hannes K, Harden A, Harris J, Lewin S, Lockwood C (Eds.), Supplementary guidance for inclusion of qualitative research in Cochrane systematic reviews of interventions, Chapter 5. Version 1 (updated August 2011). Cochrane Collaboration Qualitative Methods Group, 2011. Retrieved April 27, 2017, from http://cqrmg.cochrane.org/supplemental-handbook-guidance.
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