title: Supervised vs unsupervised exercise for intermittent claudication: A systematic review and meta-analysis.
abstract: BACKGROUND
  Supervised exercise (SE) is widely accepted as an effective therapy for intermittent claudication (IC), but its use is limited by cost. Unsupervised exercise (UE) represents a less costly alternative. We assessed the comparative effectiveness of SE vs UE in patients with IC.
  
  
  RESULTS
  We searched PubMed, EMBASE, and the Cochrane Database of Systematic Reviews and identified 27 unique studies (24 randomized controlled trials, 4 observational studies) that evaluated the comparative effectiveness of SE vs UE in 2074 patients with IC. Compared with UE, SE was associated with a moderate improvement in maximal walking distance at 6 months (effect size 0.77, 95% CI 0.36-1.17, P < .001) and 12 months (effect size 0.56, 95% CI 0.34-0.77, P < .001). Supervised exercise also improved claudication distance to a moderate extent compared with UE at 6 months (effect size 0.63, 95% CI 0.40-0.85, P < .001) and 12 months (effect size 0.41, 95% CI 0.18-0.65, P = .001). There was no difference in the Short Form-36 quality of life at 6 months (effect size -0.05, 95% CI -0.50 to 0.41, P = .84) or walking impairment questionnaire distance (effect size 0.24, 95% CI -0.03 to 0.50, P = .08) or speed (effect size 0.26, 95% CI -0.06 to 0.59, P = .11).
  
  
  CONCLUSIONS
  In claudication patients, SE is more effective than UE at improving maximal walking and claudication distances, yet there is no difference in general quality of life or patient-reported community-based walking. Further studies are needed to investigate the relationship between functional gain and disease-specific quality of life.
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, NC. Electronic address: sreekanth.vemulapalli@dm.duke.edu.
authors.forename: Sreekanth
authors.initials: S
authors.lastname: Vemulapalli
authors.affiliation: Duke Clinical Research Institute, Duke University Medical Center, Durham, NC; Division of General Internal Medicine, Duke University Medical Center, Durham, NC; Duke Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University, Durham, NC.
authors.forename: Rowena J
authors.initials: RJ
authors.lastname: Dolor
authors.affiliation: Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC.
authors.forename: Vic
authors.initials: V
authors.lastname: Hasselblad
authors.affiliation: Department of Community and Family Medicine, Duke University School of Medicine, Durham, NC.
authors.forename: Kristine
authors.initials: K
authors.lastname: Schmit
authors.affiliation: Division of General Internal Medicine, Duke University Medical Center, Durham, NC.
authors.forename: Adam
authors.initials: A
authors.lastname: Banks
authors.affiliation: Duke Evidence-Based Practice Center, Duke Clinical Research Institute, Duke University, Durham, NC.
authors.forename: Brooke
authors.initials: B
authors.lastname: Heidenfelder
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors.forename: Manesh R
authors.initials: MR
authors.lastname: Patel
authors.affiliation: Division of Cardiology, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC.
authors.forename: W Schuyler
authors.initials: WS
authors.lastname: Jones
mesh_terms: D005081:Exercise Therapy / Q000379:methods*; D006801:Humans; D007383:Intermittent Claudication / Q000628:therapy*; D011788:Quality of Life; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D016138:Walking