Shared learning database

Physical activity and Referral Service. Manchester Health and Social Care Trust
Published date:
June 2012

The NICE clinical guideline on Lower Limb peripheral arterial disease recommends offering a supervised exercise programme to all people with intermittent claudication. This report and supporting appendices, documents the development of a new community supervised exercise programme (PADex) for patients with intermittent claudication in Manchester.

Guidance the shared learning relates to:
Does the example relate to a general implementation of all NICE guidance?
Does the example relate to a specific implementation of a specific piece of NICE guidance?


Aims and objectives

- To develop a new community supervised exercise programme (PADex) for patients with intermittent claudication (IC).
- To provide peer support for patients with IC
- To have a direct referral route from Leg Circulation Service (LCS) to the Physical Activity Referral Service's (PARS) Physical Activity Coordinator (PAC)
- To improve the patients knowledge on PAD and IC and the importance of lifestyle changes.
- To help increase patient compliance in exercise classes and reduce existing dropout rates
- To evaluate whether a PAD supervised exercise and education programme improves quality of life (QoL), cardiovascular health and walking distance.
- To provide the patients with reassurance and motivation throughout the exercise programme.
- Assess each patient for suitability for PADex and review their individualised goals - To provide a supervised exercise class for patients with PAD similar to cardiac rehabilitation (CR) and COPD supervised exercise classes.
- Provide PAD education for patients with IC as well as increasing the patient's awareness of cardiovascular risk factors and lifestyle interventions.
- For the PAC and Physical Activity Referral Officers (PARO) to develop in depth knowledge around PAD and IC so that they understand the disease process better, and the physical limitations that result from this.
- Collect primary and secondary outcome measurements at regular intervals.

Reasons for implementing your project

The NICE clinical guideline on Lower limb peripheral arterial disease recommends offering a supervised exercise programme to all people with intermittent claudication. NICE recommend the following components to the supervised exercise programme are considered; 2 hours of supervised exercise a week for a 3-month period and encouraging people to exercise to the point of maximal pain. In the full guideline (page 122) there is additional information about further features of a suitable exercise programme. These include; goal orientated with defined educational component, managed by an experienced and suitably qualified professional and location should be as close to the persons home as possible.

In Manchester, prior to PADex there was no disease specific supervised exercise programme for patients with IC. Patients with IC were referred from the LCS to PARS and then assessed by the PARO or PAC. From this assessment the patient would then be referred to the most suitable community exercise class, which would usually be the Phase IV CR class or generic gentle circuit class.
- The Vascular Nurse Specialist (VNS) from the LCS thought that the exercise classes needed to be more PAD specific.
- Patient education was a key component of PADex as there was an obvious lack of understanding amongst patients seen in LCS about the causes and treatment of their disease.
- More time was needed to educate the patient on the importance of lifestyle interventions (eg exercise, diet and smoking cessation) other than what is discussed in LCS (see LCS link). It was important to provide the patient education sessions directly after their exercise class so that the message about positive outcomes from lifestyle interventions are reinforced.

How did you implement the project

The VNS met several times with PARS Service Lead to discuss the above ideas and whether a new disease specific exercise class could be implemented in to the PARS service. No official barriers were experienced or additional project costs incurred as existing resources within the PARS service were adapted to develop PADex. However, there was a limitation on how many classes could be provided due to staff resource limitations.

A person within the PARS service needed to be identified to lead on implementing the exercise classes for PADex. A PAC was identified by the service lead as they were known to have existing specialist knowledge around exercise and cardiovascular disease as well as experience in developing and managing condition specific exercise classes.

The VNS provided education sessions to improve PAC's knowledge on PAD and IC, which was then disseminated to the rest of the PARS team. Subsequent meetings were arranged (between the VNS and PAC) to exchange ideas, discuss programme content and identify speakers for the patient education sessions (see appendix 1).

Meetings between VNS and PAC were held to discuss the referral process and patient pathway (see appendix 2). The outcome of this was that once the PAC received the referral from the LCS, direct contact was made with the patient via the phone to convey information about the programme. This helped to reassure the patient that the supervised exercise programme is designed to meet their specific needs.

An appointment for their initial assessment was booked at this time.

The supervised exercise class (see appendix 3, 4 and 5) was set up in an area of North Manchester known to have the greatest number of patients with intermittent claudication.

A patient information leaflet (see appendix 6) was designed outlining what the patients' involvement in the programme would be and what to expect, this was sent out with their appointment letter.

Key findings

Primary Outcome Data collected at week 1, 3, 6 and 12 months
Physical data:
- Blood pressure
- Heart rate
- Weight
- ABPI at week 1, week 12 and 6 months.
- 6 minute walk test (pain free walking distance and maximal walking distance).

Secondary Outcome measurements: at 3, 6, 12 months
- VascuQol (appendix 7), Walking Impairment Questionnaire and SF36 (see appendix 8) given to patients at initial assessment, 3, 6 and 12 months.
- Walking diary (appendix 9)

Medical therapy is reviewed in the patients LCS appointments and recorded in the PADex assessment form.

PADex has been an evolving initiative which has been regularly assessed and reviewed by the VNS and PAC. Subsequently, ongoing changes are made to adapt and improve areas where they are needed.

Comprehensive outcome data is pending and due for review in September and December 2012. Since the implementation of PADex there has been a noticeable increase in patient attendance and compliance.

Patient feedback so far has been very positive stating that they especially like the peer support they get from other people attending a class with the same condition.

Patients have reported positive feedback that their weekly education sessions have helped them to understand their condition better. Moreover it has increased their awareness of their own cardiovascular risk factors and how lifestyle changes can have a positive impact on their condition.

A service user evaluation form will be given out at 12 weeks to demonstrate this.

Key learning points

- Need a condition specific exercise class to cater for PAD patients
- Need to offer exercise classes in the patients locality
- Need regular communication between Vascular Nurse and Exercise specialist
- Need education sessions on PAD related health themes
- Need a direct and comprehensive referral process
- Ensure patient information handouts are clear about what to expect in the exercise programme (appendix 6).
- Aim to offer two one hour structured supervised exercise sessions per week as per NICE guidelines (PAD) recommendations. Currently PADex offers 1 hour supervised exercise and 1 hour education per week and patients are also encouraged to enter into other supervised exercise sessions run by PARS. It is hoped the 1 hours supervised exercise per week offered by PADex will be increased to 2 hours supervised exercise per week in the future.
- Patients need to understand and agree to individual exercise programme as set by exercise specialist.
- An exercise log for unsupervised exercise sessions needs to be provided (Although NICE do not make recommendations specifically about unsupervised exercise for people with PAD, NICE considered that simple advice to exercise should be seen as part of the lifestyle changes that the patient should be advised about when the diagnosis of PAD is first made)
- The programme should be goal orientated and clear individual goals should be set and regularly reviewed with each patient.
- Need to consider another location to maximise uptake and ensure equal access to this service.

Contact details

Serena Kent and Lisa Smith
Physical activity coordinator and Vascular Nurse Specialist
Physical activity and Referral Service. Manchester Health and Social Care Trust
Email: and

Primary care
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