Long walks around his hilly Pittsburgh neighborhood turned scary for Jagdish Bhatnagar when his left calf started hurting so badly, he had to rest on the side of the road. Diagnosed in early 2021 with peripheral artery disease (PAD), the 83-year-old retired medical physicist knew blocked blood vessels in his leg were causing his severe cramps.
But Bhatnagar didn’t have surgery or take medications for his condition. Instead, he takes part in a supervised exercise therapy (SET) program that helps him push past his pain on a treadmill three times a week while being monitored by a nurse or other medical professional.
Since Medicare’s 2017 decision to cover SET, this PAD treatment has slowly caught on across the U.S. Studies show SET can help people like him walk longer and more comfortably.
“I feel I’m getting rejuvenated with this exercise,” Bhatnagar says. “Before, I felt like a sick person. But now, I feel I’m becoming healthy.”
Treadmill walking, the main form of exercise therapy included in SET programs, is the gold standard for improving PAD’s main symptom, called claudication. Claudication is the pain and cramping in the calf, thigh, or buttocks that happens while you walk because too little oxygen reaches your leg muscles.
“Basically, walking improves the way muscles use oxygen or helps develop more blood vessels to increase the supply of oxygen,” says Mark Jordan, a senior clinical exercise physiologist who leads SET sessions at the University of Pittsburgh Medical Center in Pennsylvania. Translation: It improves circulation to the leg.
A typical SET program includes up to 36 sessions over 12 weeks, each lasting 30-60 minutes.
You first take a walking test to measure how long and fast you can walk until you feel pain in your leg. Your team will then tailor SET sessions to your abilities, blending periods of walking and resting based on your symptoms. As you improve, your therapist will adjust your treadmill settings to increase speed, steepness, and time walking, Jordan says.
“We use a 1 to 5 pain scale for patients to rate their pain while walking,” he says. “Once they reach 4, we have them stop and sit down. They wait for their pain to go away, then go again. They continue doing that several times until they’ve been walking for a total of 60 minutes.”
Some SET programs blend in other forms of exercise. These can include an ergometer — a bike you pedal with your arms — as well as a stationary bike, rowing machine, and arm and leg weights. SET programs also educate you about the disease itself and about healthy eating to improve your risks. (Some SET programs include a nutritionist on the medical team.)
“Really, any movement has been shown to be beneficial,” says vascular surgeon Oliver Aalami, MD, a clinical associate professor of surgery at Stanford University. “But, if you’re trying to improve your discomfort with walking, then walking is best. You do use different muscles when riding a bicycle, for instance, so it won’t always ‘translate’ into leg pain relief in PAD.”
Research shows that SET programs work just as well as more invasive PAD treatments, such as surgery to place a cage-like stent in your leg to prop open blood vessels. The program can also cut your risks of other major conditions, such as a heart attack or stroke. That’s why SET is one of four nonsurgical treatments for PAD recommended and used to measure quality of care by the American College of Cardiology and the American Heart Association.
Compared with exercising on your own, supervised exercise also offers several other advantages, Jordan says. For one, it holds you accountable, helping you stick to a walking plan even if you’re tempted to slack off. In-person exercise therapy also means a medical professional will monitor you for changes in your heart rate and blood pressure.
“We’re not only able to guide and educate patients, we can push them a bit beyond their comfort zone until they reach a mild to moderate level of pain, which is what they need to achieve a benefit,” Jordan says.
Indeed, though pain is normally the body’s signal to stop doing something, this symptom is expected and even necessary to successfully treat PAD through exercise.
“It’s OK to experience the calf pain,” says Aalami, who notes that it can understandably discourage people from doing what’s good for them. But education about the benefits — and knowing what to expect — can help you work through discomfort.
People with PAD “should expect pain in their leg,” Jordan agrees. “We always make sure they know that up front. We do have to sometimes coach them through it and reassure them they’re safe.”
One obstacle to taking part in a formal SET program is that you might have trouble finding it near you. Ask your doctor if SET treatment is available in your area.
“So far, private insurance seems to cover it,” Jordan says. “Most of our patients are on Medicare, but there are so many different plans. It’s always best to call and check with your insurance provider to see if it’s covered.”
Doug Giller of Lansing, MI, doesn’t have a SET program nearby. But the 63-year-old was able to take part in a pilot test of a new mobile phone app that will offer the option virtually. Developed by the Society for Vascular Surgery, the app also includes telephone consultations with a medical professional.
Giller, a grandfather of eight, was diagnosed with PAD in 2019 after he had pain “like someone kicked you” in his right calf while walking. The self-described “Type A personality” began an hourlong daily walking routine around his large house that he has kept up for more than 2 years with his app.
“I got new carpet last year, and I can almost see a path through it,” says Giller, a retired electrician. “It’s like a racetrack now.”
\Aalami, one of the app’s developers, says the Society for Vascular Surgery is enrolling its first 10,000 people with PAD on the SET app and then will seek insurance coverage.
Thanks to SET, Bhatnagar no longer feels pain in his leg while walking. He’s happily trekking the hills and valleys in his neighborhood. “I don’t have that fear anymore — I just go,” he says. “It’s fantastic.”
Giller, on the other hand, still feels pain. But he considers it a reminder to keep going.
“It’s nothing like the pain when I first started,” he says. “I’m making new paths for my blood to flow to my leg.”
Giller has avoided surgery, and his doctor says the blockage in his right leg has improved enough so that he wouldn’t recommend surgery for stents.