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Patient perspectives on claudication: An opportunity to improve the adoption and adherence of exercise therapy

The impact of exercise on perception of claudication among patients with peripheral artery disease (PAD) is a largely understudied area in vascular medicine. Studies that have examined assessments of leg pain among patients with PAD have highlighted claudication as a barrier to walking exercise.1–3 However, there is not a clear consensus as to why claudication is an impediment to ambulation, specifically when looking through the lens of the PAD patient. If patients are uninformed and believe that leg pain should not be provoked by physical activity, participation in and subsequent compliance with exercise programs will be poor. Thus, assessing how claudication affects a patient, particularly when linked to treatment options and outcomes, may be essential for ensuring optimal uptake and delivery of any PAD exercise program. In this issue of Vascular Medicine, Sharath and colleagues4 provide the results of a pilot study assessing the influence of fear-avoidance beliefs related to physical activity among patients with PAD and claudication (n=20) who were referred to a vascular surgery clinic. The fearavoidance model5 suggests that patients may fear a specific behavior due to negative beliefs and confusion, which ultimately leads to its corollary: avoidance of the behavior. Using this premise, a variety of questionnaires were used to better understand the patients’ physical activity levels and claudication experience. Most notably, patients were asked to complete a modified version of the Fear-Avoidance Beliefs Questionnaire5 to determine if they avoided physical activity because it was perceived to cause harm. Additionally, the Physical Activity Scale for the Elderly6 was used to assess whether fear of exercise was related to patient-reported daily activity. The study findings indicate that the majority of patients were misinformed, and lacked a thorough understanding of the relation between claudication and physical activity. A majority of patients feared exercise was the cause of claudication (n=12/19, 63%), and thought that physical activity would not only make their pain worse (n=18/20, 90%), but would also harm their legs (n=10/18, 56%).4 Conversely, patients with lower fearavoidance belief scores expected greater benefit from exercise, and were less likely to believe they should avoid physical activity due to their leg symptoms. While these results are intuitive, providing objective data of a potential psychological mechanism for why leg pain is a barrier to physical activity among patients with PAD is a key contribution of this study. The authors also conclude that there was no relation of patient-reported physical activity levels and fear-avoidance beliefs. Despite this, linking the etiology of pain from the patient’s perspective and to selfreported levels of physical activity is an important concept to explore.