Using Color Doppler Ultrasound to Promote Exercise in Adults with Peripheral Artery Disease

December 01, 2020

Information

Student Author: Sarah Fittro

“Sarah Fittro was a consummate professional right from our first meeting and had a keen sense of organization for the actual preparation of the thesis document. Sarah also chose a topic that has both research and clinical interest. It would be just perfect for a PA to perform professionally. All-in-all, Sarah performed at an exceptional level throughout the process.” – Dr. Yeckel

ID5946

To CiteDCA Citation Guide

00:00Hi bro, my name Sarah.
00:01I'm a third year PhD student here at
00:03Yale and today I'll be discussing with
00:06you my thesis entitled Using color
00:08Doppler ultrasound to promote exercise in
00:10adults with peripheral artery disease.
00:12Before I get started I want to
00:14give a big thank you to my advisor,
00:16Doctor Yakel who's a professor here
00:18in the public health Department.
00:20Here are a list of topics that
00:22I'll be discussing with you today.
00:24So what is peripheral artery
00:25disease and why does it matter?
00:28Peripheral artery disease is the
00:29condition where plaque buildup in
00:31the arteries and reduces oxygenated
00:33blood flow to your limbs and
00:35claudication is the first symptomatic
00:36phase of peripheral artery disease.
00:38Where you get leg pain when exercising
00:40due to reduced blood flow to your limb
00:43and eventually as the disease progresses,
00:45you get tissue necrosis due
00:47to lack of blood flow,
00:49which will eventually lead
00:50to amputation down the line.
00:52An unfortunately piedi comes with an
00:55increased cardiovascular event risk
00:57starting even in the asymptomatic stage,
00:59and this includes heart attacks, strokes,
01:02heart failure, and vascular desk.
01:05And these cardiovascular events
01:06have high mortality rates with up
01:09to 23% of people with PD dying from
01:12coronary or cerebral vascular disease.
01:14So PD prevalence and its impact on
01:17the economy so 202 million people
01:20worldwide have PhD with 70% coming
01:22from low and middle income countries
01:25and 30% from high income countries.
01:27And this is a 23.5% increase from
01:302000 due to our aging population
01:33and increased risk factors such
01:35as diabetes and obesity.
01:37There are currently 12 million
01:39people living with PD in the US an
01:42this hospitalization rate in 2014.
01:44Was 89.5 out of 100,000 people.
01:47This brings a total annual cost of
01:49these hospitalizations to be 6.31
01:51billion dollars and then more than
01:53half of these patients are discharged
01:56to skilled nursing facilities or
01:58need home health care.
02:00Bring additional costs.
02:01So what is PD treatment and why
02:04is it not working?
02:06First, there's medical management.
02:07There's currently only two
02:09medications approved for PAD and
02:11only one of these medications,
02:13Silas Diesel,
02:13has shown to improve walking distances.
02:16Unfortunately,
02:16after 36 months less than 40% of
02:19these people are adhering to the
02:21medication due to the side effects,
02:23so we don't have a good
02:26medical management for piedi.
02:27Next, there's surgical management,
02:29which includes revascularization,
02:30an amputation surgeries,
02:31which come with a whole host
02:33of complications.
02:35So really,
02:35behavioral management or exercise
02:37is the first line treatment.
02:39Exercise is known to improve
02:41claudication symptoms in piedi outcomes.
02:43However,
02:43this is very counter intuitive because
02:45if anyone is experiencing pain,
02:47the natural human responses
02:49to stop what you're doing.
02:51But we know that it continuing
02:54to exercise through this pain is
02:56really the best treatment for PAD.
02:59So people aren't really walking on their own,
03:01and that's led to the medical community
03:04creating things such as supervised
03:06exercise training programs where
03:07patients will go to a facility and
03:09their supervised as they walk on a
03:11treadmill by physicians
03:12and their support teams.
03:14And this is the gold standard,
03:16but unfortunately,
03:16a study found that 76% of screen
03:19people were not able or willing to
03:21participate due to barriers such as cost,
03:23travel time and access.
03:24So then this then led to structured
03:26home exercise programs to try to
03:29eliminate some of these barriers.
03:31However, the successful studies still
03:33have used things such as coaches,
03:35logs and psychiatrists which
03:36come with barriers in themselves.
03:38So this is the problem.
03:40Exercise is known to improve
03:42claudication symptoms in PD outcomes,
03:44but people aren't exercising these
03:46supervised and home exercise programs
03:48aren't working due to barriers,
03:50and we also know that additional barriers,
03:52such as poor understanding of how
03:55walking helps alleviate symptoms,
03:56fear of claudication, pain,
03:58and perceived lack of control
04:00over the disease. Also exist.
04:02So among a different patient population,
04:05coronary artery disease patients,
04:07they've used image Ng to positively
04:09change exercise behaviors,
04:11and so we're hoping to do a similar
04:14thing here with the padz population by
04:16using color Doppler ultrasound show
04:19patients their vasculature during
04:21exercise associated claudication in
04:23order to increase home exercise adherence.
04:27So the research question is,
04:29will using color Doppler ultrasonography
04:30during claudication pain increase
04:32exercise adherence among adults
04:33with intermittent claudication,
04:34peripheral artery disease?
04:36And you can see my hypothesis below.
04:38So the methods this will be a single
04:41blinded randomized control trial
04:42that will take about two years with
04:45two to three months for approval,
04:4716 months for recruitment in
04:49the initial appointments,
04:50five months for the home exercise portion
04:52and the post intervention appointment,
04:55and then about three months for data.
04:57Analysis it will include English
04:59speaking adults 45 to 7 years old with
05:02intermittent claudication PhD with the
05:04disease burden in the popliteal artery,
05:07and this is important because we want
05:09the disease burden to be Anna vessel
05:12that's near their claudication pain,
05:14which is typically in the calf.
05:17An it will include 50 subjects,
05:19so the control group will
05:21perform a graded treadmill test,
05:23which is basically when they're on
05:26the treadmill and overtime the grade.
05:28Over the steepness of the
05:30treadmill increases,
05:31making it more challenging and
05:33they won't see their images.
05:34And then the experimental group will
05:36look at their color Doppler ultrasound
05:39images taken during this graded treadmill
05:41test at different levels of pain.
05:43The primary dependent variable
05:45will be claudication onset time,
05:47in seconds,
05:48during the standard Yale graded
05:49treadmill tests,
05:50and then there's a whole host of
05:53secondary dependent variables including
05:54mean walking distances to mild,
05:56moderate and severe claudication pain.
05:586 minute walking test distances.
06:00Peak systolic velocity through
06:02the popliteal artery.
06:03Average steps per day during
06:05the 12 week home exercise.
06:07Component health related.
06:08Quality of life score.
06:09Walking impairments,
06:10Goran Fear avoidance score.
06:12So this is how it'll work
06:14during the screening.
06:15Visit an ABI.
06:16An ultrasound will be performed
06:18which is just confirming that
06:19they do have peripheral artery
06:21disease and it is in fact,
06:22within their popliteal artery.
06:24They'll fill out this claudication
06:25questionnaire to ensure that
06:27they have true claudication.
06:28Pain will do a history and physical exam,
06:30and then three participants will trial
06:32this graded treadmill test with the image
06:34Ng 'cause this has never been done before,
06:36and we want to make sure we have the proper
06:39technique to make sure it's successful
06:41with the rest of the participants.
06:43Then at this initial visit,
06:45after the screening,
06:46they'll perform this graded treadmill test.
06:48And those who are in the experimental
06:51group will be shown their images
06:54and they'll be explained.
06:56What is going on within their vasculature,
06:59why it's causing the pain and
07:02how exercise will improve their
07:04vasculature and their pain overtime.
07:07Also, fill out three questionnaires,
07:09both groups,
07:09and then they'll be told to go
07:11home and exercise to near maximal
07:13pain three times a week for 45
07:15minutes with increased frequency.
07:17Overtime they'll use a Fitbit only
07:19during exercise sessions to monitor
07:21the steps per day and they will do
07:23this for 12 weeks and then they'll
07:25come back in for a follow up visit.
07:28Well,
07:28they'll do the graded treadmill tests
07:30again and everyone will be showing
07:32their vasculature will repeat the three
07:34questionnaire and they'll be told,
07:35hopefully that they've had improvement
07:37overtime with both their distances.
07:38And within their images.
07:41So what are the strengths,
07:43novelty?
07:44This is the first time this has
07:46been done where we've used images to
07:49increase exercise adherence among the
07:51peripheral artery disease population.
07:53We believe that it addresses 6
07:55reasons for lack of adherence,
07:58which is much better than the than
08:00the supervised and the home exercise
08:03programs that currently exist.
08:04Ultrasound provides a noninvasive,
08:06inexpensive way to show patients the
08:09pathophysiology behind their disease
08:10and give them better understanding.
08:13Lastly,
08:13it allows them to see the impact of
08:15their home exercise at the follow up
08:18appointments and hopefully encourage
08:19them to continue to exercise at home.
08:21The limitations the novelty.
08:22Again anytime you try something new IT
08:25may come with unexpected challenges.
08:26It's not a double blinded study,
08:28but this would be impossible because
08:30we have to show the participants their
08:32images and someone has to do so.
08:34The recruitment process is on
08:36a volunteer basis,
08:37so there is a possibility that
08:38those enrolled in the study will
08:40be more motivated at baseline than
08:42those in the general population.
08:44Lastly,
08:44it may be challenging to motivate
08:46exercise in the winter months,
08:47especially among those who are
08:49low income and do not belong
08:51to exercise facilities.
08:52So what's the clinical significance of this?
08:55The medical community has not been
08:57successful in increasing exercise
08:58adherence among the PD population,
09:00and that's what this study is targeted to do.
09:03The PD prevalence is on the rise
09:05with increasing risk factors,
09:07so we need to find a solution now.
09:10If successful,
09:11this will provide an early intervention
09:13to decrease costly management such
09:15as surgery down the line is an easy
09:17intervention to incorporate into
09:19the diagnostic appointment here at
09:21Yale. They already had
09:22already performed the Abis.
09:23They already do the ultrasound.
09:25They have this graded treadmill
09:27machine within their practice,
09:28so it shouldn't be that big of a
09:30transition to implement this intervention
09:32into the diagnostic appointment.
09:34Ultrasound is cheap, so even outside
09:36the US where the PD prevalence is high,
09:39this may provide an option for them as.
09:42Well and then hopefully it could
09:44be a way to create sustained,
09:46change sustained change even after
09:48the study if they see improvement.
09:51Alright, so I'd like to thank Doctor
09:53Yakel who was the best possible
09:55advisor I could have asked for.
09:57Rosanna and Megan for their support
09:59throughout the entire recess.
10:00Search and thesis process of PA school.
10:03The librarians who answered numerous
10:05technology an resource questions for me.
10:07Throughout the way.
10:08Friends and family.
10:09The class of 2020,
10:10which you can see here an my
10:13big in the program,
10:14Libby has been supportive prior
10:16to PA School all the way through,
10:19even after she's graduated.
10:20So here are my references and thank you guys.