Site icon SEMS-journal

The therapeutic role of exercise training in vascular diseases

Lanzi Stefano, Pedrazzoli Kaliska, Mazzolai Lucia
Division of Angiology, Heart and Vessel Department, Lausanne University Hospital, UNIL, Switzerland


It is well known that regular exercise training reduces the risk of developing cardio-vascular diseases. Therefore, along with cardiovascular risk factor management and pharmacological treatment, exercise training is considered a cornerstone of therapeutic care in patients with cardio-vascular diseases. The role of supervised exercise training in improving walking performance and quality of life in patients with symptomatic chronic peripheral artery disease is well documented. On the other hand, the therapeutic role of exercise training in the management of patients with venous, lymphatic, or rare vascular diseases is still poorly investigated. Recent evidence highlighted the potential role of exercise training in improving general mobility and quality of life in patients with venous, lymphatic, or rare vascular diseases. This suggests that exercise training should be part of the overall management of patients with vascular disease. However, more research is needed to provide more solid evidence and to standardize practice.  


Il est bien connu que l’exercice physique régulier réduit le risque de développer des maladies cardiovasculaires. Avec un strict contrôle des facteurs de risque cardiovasculaire, l’exercice physique est considéré comme un élément capital de la prise en charge thérapeutique des patient.e.s atteints de maladies cardio-vasculaires. Chez les patient.e.s avec une maladie artérielle périphérique chronique des membres inférieurs, il est bien documenté que les programmes d’entraînement supervisés améliorent les capacités de marche et la qualité de vie. En revanche, le rôle thérapeutique de l’exercice physique dans la prise en charge des patient.e.s avec des maladies veineuses, lymphatiques ou des maladies vasculaires rares reste encore peu étudié. Des données récentes ont mis en évidence le rôle potentiel de l’exercice physique dans l’amélioration de la mobilité générale et de la qualité de vie des patient.e.s avec des maladies veineuses, lymphatiques ou des maladies vasculaires rares. Cela suggère que l’exercice physique devrait faire partie de la prise en charge globale des patient.e.s avec des maladies vasculaires. Cependant, des investigations supplémentaires sont nécessaires pour fournir des évidences plus solides et pour standardiser la pratique.


Cardio-vascular (CV) diseases (CVDs) include conditions affecting the heart and vessels. CVDs are the leading cause of death globally and therefore, management of CVDs is of major public health interest. Controlling CV risk factors is recommended including pharmacological treatment, lifestyle changes, and increasing regular physical activity.
In this article, we will focus on the therapeutic role of exercise training in the management of arterial, venous, and lymphatic vessel diseases. The role of exercise in rare vascular diseases will also be discussed.

Exercise training for patients with lower extremity ­peripheral artery disease 

Lower extremity peripheral artery disease (PAD) is a chronic atherosclerotic vascular disease characterized by a narrowing or occlusion of one or more arteries in the lower limbs [1,2]. The hallmark symptom of PAD is intermittent claudication (IC), defined as a discomfort, fatigue or cramping appearing in the lower limbs (calf, buttock, thigh or foot) during exercise and forcing the patient to stop [1,2]. IC symptoms are usually relieved within 5-10 min of rest. It has been well shown that patients with PAD have decreased walking abilities [3], impaired muscle strength and muscle power [4], gait abnormalities [5], and balance impairments [6]. As a consequence, patients with PAD show decreased functional performance (defined as the ability to perform daily life tasks) and quality of life [7,8].
Along with CV risk factor control and pharmacological treatment, supervised exercise training (SET) is the first-line therapeutic option in patients with symptomatic PAD [1,3,9]. The goal of SET is to improve walking performance, physical function, and quality of life. It has been shown that SET programs significantly improve treadmill pain-free and maximal walking distance in patients with symptomatic PAD [10]. The improved walking performance following SET are similar to those observed after endovascular revascularization [11]. SET programs also improve functional walking performance (assessed by a six-minute walking test) and quality of life (assessed by dedicated questionnaires) [3,12]. It is interesting to note that improvements in six-minute walking distance following SET are predictive of improvements in quality of life in patients with PAD [13]. Finally, SET programs also showed gait pattern changes during treadmill and overground walking in these patients [14,15]. Notably, the changes in gait pattern are significantly related to changes in walking distance [14,15]. 
Walking is the most common training mode in patients with PAD. However, some patients are unwilling/unable to perform walking sessions, especially because of high pain levels leading to short walking bouts and long resting periods during. In those cases, alternative training modalities should be proposed with regard to maximizing the dose of exercise accumulated during the training sessions [16]. The effectiveness of other training modalities (such as resistance training, cycling, arm-cranking) in improving walking performance has been recently observed in patients with PAD [17]. For optimal results, exercise training program duration should be at least three months, with at least three exercise sessions per week, with a duration between 30 to 60 min [3,9,12].
Although international guidelines clearly recommend exercise training among first line treating modality in symptomatic chronic PAD, SET programs remain underused and their availability and adherence is low [18-20]. It has recently been shown that SET programs exist only in 59% of the European countries and that costs of SET are covered by the health insurance only in 41% of the European countries [21]. In this context, home-based programs with remote observation (logbook, phone call, activity trackers) may be an effective alternative, especially if delivered in a structured manner and considering the FITT (Frequency, Intensity, Time, Type) principles of exercise training prescription [22].
Although the therapeutic role of exercise training in the management of PAD has been widely investigated for several decades, the recommendations for other vascular diseases are currently less well established.

Exercise training in patients with rare vascular diseases

Among rare vascular diseases the most frequently observed ones are: connective tissue disorders such as vascular Ehlers-Danlos syndrome, Marfan syndrome and Marfan-like syndromes; Buerger’s disease, primary lymphedema, autoimmune vasculitis, and some vascular malformations. The therapeutic management in these situations is multimodal and complex due to the generally multisystemic involvement. In addition to condition-specific drug or surgical treatments, the therapeutic management generally includes blood pressure control and early detection of vascular damage.
As for the general population, exercise training in patients with rare vascular disease is a key component to maintain physical and psychological well-being. However, particular attention should be given to some specific exercise training parameters, such as the modality and the intensity of exercise [23,24]. In patients with rare vascular diseases the risks of inadequate exercise training monitoring are vascular injuries such as dissections or ruptures. For these reasons, patients with some specific rare vascular diseases (such as connective tissue disorders) should not engage in high-intensity exercise activities or resistance training (especially if performed under isometric conditions), high-contact and competitive activities. Because of these cautionary recommendations, exercise training prescription for these patients is very difficult, especially in the absence of clearly established protocols [23,24]. 
However, the sedentary lifestyle and consequent physical inactivity usually observed in these patients increases the risk of further vascular complications, including the risk of developing/increasing hypertension, which may contribute to the increased risk of vascular lesions. Therefore, the sedentary lifestyle is one of the cardiovascular risk factors that must be actively addressed in patients with rare vascular diseases. The few studies (mostly performed on animals) on exercise and Marfan have recently shown the potential benefits of exercise training on cardiorespiratory and muscular capacity [23]. A recent study showed beneficial effects of low-to-moderate intensity (55-65% of the maximal oxygen uptake) exercise training on aortic wall structure and function, but also showed deleterious effects when exercise training was conducted at high intensity (75-85% of the maximal oxygen uptake) [25]. In the only study conducted in humans, the exercise training protocol consisted in a combination of daily 30-min ergometer training, gymnastics for 60 min four times per week, fitness training during 60 min three times per week, and Nordic walking 30 min three times per week [26]. In addition, patients were asked to participate twice weekly in a psychological group therapy and muscle relaxation [26]. The training duration was three weeks. The authors observed significant improvements in the exercise capacity assessed by the increased maximum power developed on an ergometer and increased walking performance [26]. Significant improvements in psychological wellbeing (assessed by questionnaires) were also observed [26]. Notably, these improvements persisted through one-year follow-up [26].

To date, exercise training modalities performed at low-to-moderate exercise intensity, such as walking, hiking, swimming or cycling should be recommended in patients with rare vascular diseases. A personalized approach should also be recommended for these patients. 

Exercise training in patients with venous diseases

The most common diseases affecting venous system are the venous insufficiency and venous thromboembolic diseases [27,28].
Venous insufficiency results in peripheral venous stasis and hyperpressure that causes trophic changes in the muscles, subcutaneous tissues, and skin, through a chronic inflammatory process. This has a considerable impact on functional capacities and quality of life. The spectrum of clinical manifestations is wide: heaviness, pain, cramps, stasis dermatitis and eczema, tissue atrophy and skin ulceration [27,28]. Elastic compression and classic lifestyle measures, including regular exercise training, are the most common conservative treatments for the management of venous insufficiency [27,28]. Drug or interventional treatments are also considered depending on the stage of the disease [27,28]. A 6-week exercise training program combined with compression therapy has been shown to be more effective in improving quality of life, muscular strength, pain perception and functional ability than compression therapy alone [29]. The exercise training program comprised twice weekly aerobic exercise with cycle ergometer followed by calf muscles strengthening and stretching exercises [29]. 
For venous thromboembolic disease, short- and medium-term complications include extension of thrombosis, pulmonary embolism and recurrence of thrombosis [27,28]. The most common long-term complication is post-thrombotic syndrome, defined as the appearance of chronic venous symptoms and/or signs secondary to thrombosis. Current evidence indicates that regular exercise training is not contraindicated in the management of acute thromboembolic disease. On the contrary, it has previously been shown that early walking was associated with reduced incidence and severity of post-thrombotic syndrome [30]. Also, treadmill exercise did not worsen venous symptoms (heaviness and swelling) and improved calf flexibility in patients with post-thrombotic syndrome [31]. In addition, it has been shown that a 6-month supervised training program significantly improved quality of life (assessed by the Venous Insufficiency Epidemiological and Economic Study Quality of Life questionnaire) and reduced (although not significantly) the severity of post-thrombotic syndrome (assessed by the Villalta scale) compared to standard of care [32]. Moreover, the physical component summary score of the SF-36 questionnaire, leg strength and quadriceps flexibility were significantly improved following the training program [32]. In that study [32] the supervised training program consisted of a combination of strengthening, stretching, and aerobic ­exercises. 
Taken together, these data indicate that early mobilization (endurance activities and lower limb strengthening) after an acute event should be considered in these patients.  

Exercise training in patients with lipedema

Lipedema is a chronic, progressive and under-diagnosed disease characterized by an abnormal distribution of adipose tissue resulting in a disproportionate increase in volume in both lower and upper limbs [33]. Lipedema mainly affects women [33]. Although the physiopathological mechanisms are not yet fully elucidated, studies suggest the involvement of a polygenic susceptibility associated with hormonal, microvascular and lymphatic disorders [33]. Lipedema is associated with chronic pain, functional limitation and psychosocial distress [33]. Body fat excess may also have a huge impact on walking pattern. The gait abnormalities and knee pain usually reported by these patients drastically reduce the desire and the ability to move and perform daily life tasks. This may lead to an increased sedentary behavior and/or physical inactivity and an associated risk of obesity. In the absence of etiological treatment, the current management of lipedema aims to reduce symptoms, improve functional limitations, and prevent disease progression. Therefore, a multidisciplinary approach is needed including patient education, weight control, exercise training, lymphatic drainage, elastic compression, psychological support and, in selected cases, surgical management [33].
Aquatic exercise interventions seem to be effective because of a draining effect induced by the water pressure and an unloading of the joints avoiding further orthopaedic complications. It is recommended that elastic compression should always be worn during and after exercise training sessions for activities such as walking or resistance training. Although rehabilitation programs are under-investigated in these patients, a recent study showed that a 6-week (nine training sessions) rehabilitation program combining manual therapy, tailored exercise guidance, education and compression improved lower limb pain perception and quality of life in patients with early stage lipedema [34]. 

Exercise training in patients with lymphatic diseases

Lymphedema is a vascular disease characterized by an accumulation of fluid in the subcutaneous soft tissues secondary to dysfunction of the lymphatic system [35,36]. The primary lymphoedema occurs as a result of a congenital malformation of the lymphatic vessels [35]. The secondary lymphoedema occurs as a result of damage or obstruction of the lymphatic vessels caused by venous stasis, surgery, trauma or infection. Lymphedema mainly affects the upper and lower limbs and one of the most frequent complication is infection. This may lead to heaviness and pain in the limbs and have a negative impact on daily life functional performance and quality of life. The current treatment of lymphedema consists of monitoring oedema to prevent infection and hypomobility through manual lymphatic drainage, elastic compression and exercise training. In selected cases, surgical management may also be considered.
Although the role of exercise training in patients with lymphoedema has been poorly investigated, recent evidence suggests that exercise training appears to be safe and effective in controlling oedema and disease-related symptoms. A recent review of the literature has shown the potential relevance of aquatic exercise interventions [37]. This training modality has been shown to improve general mobility, quality of life and pain perception in these patients [37]. In addition, some studies reported a reduction in limb volume, especially in the short term period [37]. Notably, a high degree of adherence is usually observed during water-based treatment [37]. However, the role of exercise training in the therapeutic care of patients with lymphedema remains to be confirmed by future investigations. Indeed, the existing protocols are very heterogeneous and usually combine lymphatic drainage, elastic compression, and aquatic exercise interventions [37].


Exercise training is effective in improving general mobility and quality of life and should therefore be part of the overall management of patients with vascular disease.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


The authors received no financial support for the research, authorship, and/or publication of this article.

Corresponding author

Stefano Lanzi, PhD
Division of Angiology, Heart and Vessel Department
Lausanne University Hospital (CHUV)
Ch. de Mont-Paisible 18, 1011 Lausanne, Switzerland
Tél. +41 079 556 49 11,


  1. Aboyans V, Ricco JB, Bartelink MEL, Bjorck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018;39:763-816.
  2. Criqui MH, Matsushita K, Aboyans V, Hess CN, Hicks CW, Kwan TW, et al. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2021;144:e171-e91.
  3. Treat-Jacobson D, McDermott MM, Bronas UG, Campia U, Collins TC, Criqui MH, et al. Optimal Exercise Programs for Patients With Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2019;e10-e33.
  4. Schieber MN, Hasenkamp RM, Pipinos, II, Johanning JM, Stergiou N, DeSpiegelaere HK, et al. Muscle strength and control characteristics are altered by peripheral artery disease. J Vasc Surg 2017;66:178-86 e12.
  5. Koutakis P, Johanning JM, Haynatzki GR, Myers SA, Stergiou N, Longo GM, et al. Abnormal joint powers before and after the onset of claudication symptoms. J Vasc Surg 2010;52:340-7.
  6. Gohil RA, Mockford KA, Mazari F, Khan J, Vanicek N, Chetter IC, et al. Balance impairment, physical ability, and its link with disease severity in patients with intermittent claudication. Ann Vasc Surg 2013;27:68-74.
  7. McDermott MM, Liu K, Greenland P, Guralnik JM, Criqui MH, Chan C, et al. Functional decline in peripheral arterial disease: associations with the ankle brachial index and leg symptoms. JAMA 2004;292:453-61.
  8. Regensteiner JG, Hiatt WR, Coll JR, Criqui MH, Treat-Jacobson D, McDermott MM, et al. The impact of peripheral arterial disease on health-related quality of life in the Peripheral Arterial Disease Awareness, Risk, and Treatment: New Resources for Survival (PARTNERS) Program. Vasc Med 2008;13:15-24.
  9. Harwood A, Pymer S, Ingle L, Doherty P, Chetter I, Parmenter B, et al. Exercise training for intermittent claudication: a narrative review and summary of guidelines for practitioners. BMJ Open Sport & Exercise Medicine 2020;0: e000897:
  10. Lane R, Harwood A, Watson L, Leng GC. Exercise for intermittent claudication. Cochrane Database Syst Rev 2017;12:CD000990.
  11. Koelemay MJW, van Reijen NS, van Dieren S, Frans FA, Vermeulen EJG, Buscher H, et al. Editor’s Choice – Randomised Clinical Trial of Supervised Exercise Therapy vs. Endovascular Revascularisation for Intermittent Claudication Caused by Iliac Artery Obstruction: The SUPER study. Eur J Vasc Endovasc Surg 2022;63:421-9.
  12. Treat-Jacobson D, McDermott MM, Beckman JA, Burt MA, Creager MA, Ehrman JK, et al. Implementation of Supervised Exercise Therapy for Patients With Symptomatic Peripheral Artery Disease: A Science Advisory From the American Heart Association. Circulation 2019;140:e700-e10.
  13. Lanzi S, Calanca L, Berchtold A, Mazzolai L. Improvement in 6-Minute Walking Distance after Supervised Exercise Training Is Related to Changes in Quality of Life in Patients with Lower Extremity Peripheral Artery Disease. J Clin Med 2021;10:
  14. Lanzi S, Boichat J, Calanca L, Aubertin P, Malatesta D, Mazzolai L. Gait changes after supervised exercise training in patients with symptomatic lower extremity peripheral artery disease. Vasc Med 2021;26:259-66.
  15.  Lanzi S, Boichat J, Calanca L, Mazzolai L, Malatesta D. Supervised Exercise Training Improves 6 min Walking Distance and Modifies Gait Pattern during Pain-Free Walking Condition in Patients with Symptomatic Lower Extremity Peripheral Artery Disease. Sensors (Basel) 2021;21.
  16. Ehrman JK, Gardner AW, Salisbury D, Lui K, Treat-Jacobson D. Supervised Exercise Therapy for Symptomatic Peripheral Artery ­Disease: A REVIEW OF CURRENT EXPERIENCE AND PRACTICE-BASED RECOMMENDATIONS. J Cardiopulm Rehabil Prev 2022.
  17. Jansen SC, Abaraogu UO, Lauret GJ, Fakhry F, Fokkenrood HJ, Teijink JA. Modes of exercise training for intermittent claudication. Cochrane Database Syst Rev 2020;8:CD009638.
  18. Dua A, Gologorsky R, Savage D, Rens N, Gandhi N, Brooke B, et al. National assessment of availability, awareness, and utilization of supervised exercise therapy for peripheral artery disease patients with intermittent claudication. J Vasc Surg 2020;71:1702-7.
  19.  Harwood AE, Pymer S, Ibeggazene S, Ingle L, Caldow E, Birkett ST. Provision of exercise services in patients with peripheral artery disease in the United Kingdom. Vascular 2021;17085381211035259.
  20. Harwood AE, Smith GE, Cayton T, Broadbent E, Chetter IC. A Systematic Review of the Uptake and Adherence Rates to Supervised Exercise Programs in Patients with Intermittent Claudication. Ann Vasc Surg 2016;34:280-9.
  21. Lanzi S, Belch J, Brodmann M, Madaric J, Bura-Riviere A, Visona A, et al. Supervised exercise training in patients with lower extremity peripheral artery disease. Vasa 2022;51:267-74.
  22. Pymer S, Ibeggazene S, Palmer J, Tew GA, Ingle L, Smith GE, et al. An updated systematic review and meta-analysis of home-based exercise programs for individuals with intermittent claudication. J Vasc Surg 2021;74:2076-85 e20.
  23. Jouini S, Milleron O, Eliahou L, Jondeau G, Vitiello D. Is physical activity a future therapy for patients with Marfan syndrome? Orphanet J Rare Dis 2022;17:46.
  24. Tweet MS, Olin JW, Bonikowske AR, Adlam D, Hayes SN. Physical activity and exercise in patients with spontaneous coronary artery dissection and fibromuscular dysplasia. Eur Heart J 2021;42:3825-8.
  25. Gibson C, Nielsen C, Alex R, Cooper K, Farney M, Gaufin D, et al. Mild aerobic exercise blocks elastin fiber fragmentation and aortic dilatation in a mouse model of Marfan syndrome associated aortic aneurysm. J Appl Physiol (1985) 2017;123:147-60.
  26. Benninghoven D, Hamann D, von Kodolitsch Y, Rybczynski M, Lechinger J, Schroeder F, et al. Inpatient rehabilitation for adult patients with Marfan syndrome: an observational pilot study. Orphanet J Rare Dis 2017;12:127.
  27. Mazzolai L, Aboyans V, Ageno W, Agnelli G, Alatri A, Bauersachs R, et al. Diagnosis and management of acute deep vein thrombosis: a joint consensus document from the European Society of Cardiology working groups of aorta and peripheral vascular diseases and pulmonary circulation and right ventricular function. Eur Heart J 2018;39:4208-18.
  28. Mazzolai L, Ageno W, Alatri A, Bauersachs R, Becattini C, Brodmann M, et al. Second consensus document on diagnosis and management of acute deep vein thrombosis: updated document elaborated by the ESC Working Group on aorta and peripheral vascular diseases and the ESC Working Group on pulmonary circulation and right ventricular function. Eur J Prev Cardiol 2022;29:1248-63.
  29. Gurdal Karakelle S, Ipek Y, Tulin O, Alpagut IU. The efficiency of exercise training in patients with venous insufficiency: A double blinded, randomized controlled trial. Phlebology 2021;36:440-9.
  30. Partsch H, Kaulich M, Mayer W. Immediate mobilisation in acute vein thrombosis reduces post-thrombotic syndrome. Int Angiol 2004; 23:206-12.
  31. Kahn SR, Azoulay L, Hirsch A, Haber M, Strulovitch C, Shrier I. Acute effects of exercise in patients with previous deep venous thrombosis: impact of the postthrombotic syndrome. Chest 2003;123:399-405.
  32. Kahn SR, Shrier I, Shapiro S, Houweling AH, Hirsch AM, Reid RD, et al. Six-month exercise training program to treat post-thrombotic syndrome: a randomized controlled two-centre trial. CMAJ 2011;183:37-44.
  33. Buso G, Depairon M, Tomson D, Raffoul W, Vettor R, Mazzolai L. Lipedema: A Call to Action! Obesity (Silver Spring) 2019;27:1567-76.
  34. Donahue PMC, Crescenzi R, Petersen KJ, Garza M, Patel N, Lee C, et al. Physical Therapy in Women with Early Stage Lipedema: Potential Impact of Multimodal Manual Therapy, Compression, Exercise, and Education Interventions. Lymphat Res Biol 2022;20:382-90.
  35. Lee BB, Andrade M, Antignani PL, Boccardo F, Bunke N, Campisi C, et al. Diagnosis and treatment of primary lymphedema. Consensus document of the International Union of Phlebology (IUP)-2013. Int Angiol 2013;32:541-74.
  36. Rockson SG, Rivera KK. Estimating the population burden of lymphedema. Ann N Y Acad Sci 2008;1131:147-54.
  37. Maccarone MC, Venturini E, Menegatti E, Gianesini S, Masiero S. Water-based exercise for upper and lower limb lymphedema treatment. J Vasc Surg Venous Lymphat Disord 2022.

Zur Werkzeugleiste springen