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• W2077024333 abstract "To the Editor: We thank Dr. Dias for expressing interest in our article, published in the November 2013 issue of the Journal of the American Geriatrics Society.1 Resistance training is clearly understudied in peripheral arterial disease (PAD), and adaptation to resistance training is known to be intensity dependent for many outcomes. To the best of our knowledge, trials have been conducted investigating the effects of various intensities ranging from low- to moderate-intensity to moderate- to high-intensity resistance training2-6 with mixed results. However, it appears that true low- and high-intensity whole-body resistance training have never been studied in PAD, and no dose-response comparisons have been performed within trials. The low-intensity protocol used in this trial was chosen with the intention of mimicking current community resistance training intensities for older adults with chronic disease, which are typically low intensity and nonprogressive in nature. The low-intensity protocol itself has not been used in our clinical practice and, to our knowledge, has not been used in others. We have no intention of using it, because it has been shown to be ineffective and has also been shown to be ineffective for depression in our experience,7 but the high-intensity protocol has been used in our clinic and has been shown to be effective for a number of chronic diseases in older adults.8-11 We agree that workload was not equivalent between groups, precisely as intended. Our aim was to see whether higher-intensity progressive resistance training, which equates to more work performed, is superior to low-intensity training in this cohort. Strength training at a high intensity using this method will typically improve muscle strength and endurance12 without the need for adding “endurance muscle training.” With adherence to exercise programs being a problem for many populations, the authors feel that completing few sets and repetitions to achieve strength and endurance outcomes relevant to PAD is preferable because of its efficiency. With respect to the questions regarding statistical analyses, there was a significant difference in total 6-minute walk (6 MW) distance at baseline between the three groups, but this was acknowledged in the manuscript and adjusted for in relevant analysis of covariance models, as indicated in the Methods section. In addition, the high-intensity group was a potentially clinically meaningful 7 to 8 years older than the other two groups. Therefore, although this difference was not significant (P = .08), age was considered to be a potential confounder for all primary and secondary study outcomes, and all models were adjusted for age accordingly. When 6 MW distance and calf and hip extensor strength baseline values were adjusted for age, the clinically significant differences between groups at baseline were eliminated. This is outlined in the manuscript and in our opinion accounts for the large group differences in walking measures at baseline. Correlations with maximum muscle strength and endurance outcomes were performed and published in an earlier article,13 and results suggested that a low ankle–brachial index is related to poorer hip extensor strength, as well as poorer walking ability and functional performance in PAD. We combined the participants from the three groups because of the smaller numbers and to examine relationships over the broader spectrum of possible changes. If muscle endurance decreased or stayed the same, we wanted to see whether walking would be similarly affected. This strengthened the relationships and gave us a clearer idea of what was happening, adding to the rationale for strength training interventions. Figure 1 showed changes in muscular endurance, with Figure 1B specifically showing change in hip extensor endurance. Because of comorbidities such as chronic lower back pain, stroke, and amputation, only 10 subjects were able to complete the hip extension endurance testing. The relationship is highly significant despite the small number of subjects, highlighting the robustness of the association. The subject who experienced the adverse event was not excluded from the study; he continued the training protocol without the leg press exercise and completed the trial. The leg press exercise was subsequently excluded from the study protocol. The authors felt that the high intensity of the exercise on the leg press may have led to the problem and that the use of the leg press is clinically appropriate for most patients and is not contraindicated in future trials, although it should be avoided for individuals with heel cracks or fissures and poorer circulation, based on our single adverse event. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Belinda J. Parmenter is the primary author of this paper. All other authors approved of this paper. Sponsor's Role: None." @default.
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• W2077024333 date "2014-05-01" @default.
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• W2077024333 title "Response to Raphael Mendes Ritti Dias" @default.
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• W2077024333 doi "https://doi.org/10.1111/jgs.12803" @default.
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