Qualitative Research on Postoperative Exercise Rehabilitation Behavior of Patients With Peripheral Artery Disease (PAD)

Introduction

Peripheral arterial disease (PAD) is a chronic condition that significantly impacts the arteries of the lower extremities (Gornik & Beckman, 2005). With global aging and the rising prevalence of risk factors, including hypertension, diabetes, and smoking, the incidence of PAD has increased significantly (Fowkes et al., 2017). The prevalence of PAD ranges from 15% to 20% among individuals aged over 65 years (Fowkes et al., 2017). Atherosclerosis is the primary pathological mechanism of PAD, causing vascular stenosis or occlusion and subsequent limb ischemia. Patients commonly present with intermittent claudication, lower limb pain, and reduced skin temperature, among other symptoms (McDermott, 2015). Severe PAD may progress to limb ulcers, gangrene, and potential amputation, imposing significant physical, psychological, and socioeconomic burdens on patients, families, and society (Fowkes et al., 2017).

Surgical and endovascular interventions, including vascular bypass grafting, percutaneous transluminal angioplasty (PTA), and stent implantation, are vital for improving vascular patency and restoring limb perfusion in patients with PAD (Beckman et al., 2021). However, clinical evidence indicates that surgical interventions alone are insufficient to fully address postoperative rehabilitation challenges in patients with PAD (Vartanian & Conte, 2015). Patients with PAD post-surgery often experience impaired limb function recovery and an elevated risk of recurrent cardiovascular events (Smith et al., 2019). Studies indicate that, despite successful revascularization, some patients with PAD experience limited improvements in exercise capacity and quality of life (Vartanian & Conte, 2015).

Review of Literature

As a non-pharmacological intervention, exercise rehabilitation is pivotal in enhancing postoperative recovery for patients with PAD (Hamburg & Balady, 2011). Regular exercise promotes collateral circulation, enhances vascular endothelial function and muscle strength, alleviates intermittent claudication, and improves exercise endurance and self-care ability in patients (Gornik et al., 2024). Despite its benefits, postoperative exercise rehabilitation in patients with PAD exhibits low participation and adherence rates. International guidelines recommend exercise rehabilitation as the first-line treatment for PAD, with evidence demonstrating significant improvements in walking capacity and quality of life (Morcos et al., 2018). Despite the physiological benefits of exercise rehabilitation, long-term adherence among patients with PAD remains low, with information dropout rates exceeding 60% (McDermott, 2018). Current research on exercise rehabilitation for PAD primarily focuses on physiological outcomes, often overlooking patients' subjective experiences, psychological barriers, and social support needs (Signorelli et al., 2020).

This study aims to thoroughly investigate postoperative exercise rehabilitation behaviors in patients with PAD, identify influencing factors, and provide evidence for developing targeted intervention strategies. Nursing significantly influences postoperative mobility; thus, this study examines its impact on rehabilitation outcomes. By addressing rehabilitation barriers and optimizing a personalized rehabilitation navigation system, this research seeks to enhance recovery, improve quality of life, and advance intelligent, patient-centered rehabilitation medicine.

Methods

Results

Sample Characteristics

18 PAD patients comprised predominantly males (77.8%) with older age (mean age 63.1 ± 13.1 years), with most participants married (72.2%) and covered by urban medical insurance (61.1%). Among them, 66.7% were current smokers and 16.7% current drinkers, indicating health risks. Clinically, 44.4% exhibited severe lower limb ischemia​ (maximum walking distance < 300 m), underscoring significant disease burden, with moderate (33.3%) and mild (22.2%) cases less prevalent (Table 1).

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Table 1.

Demographic and Health Characteristics of the Sample.

Variable	Data
Sex
Male	14 (77.8%)
Female	4 (22.2%)
Age (years)	63.1 ± 13.1
Marital Status
Married	13 (72.2%)
Widowed	3 (16.6%)
Single	1 (5.6%)
Divorced	1 (5.6%)
Medical Insurance
Urban Insurance	11 (61.1%)
Rural Insurance	6 (33.3%)
Self-paid	1 (5.6%)
Smoking
Non-smoker	5 (27.8%)
Current smoker	12 (66.7%)
Ex-smoker	1 (5.5%)
Alcohol Use
Non-drinker	14 (77.8%)
Current drinker	3 (16.7%)
Ex-drinker	1 (5.5%)
Maximum Walking Distance (MWD)
>500 m (mild)	4 (22.2%)
300–500 m (moderate)	6 (33.3%)
<300 m (severe)	8 (44.5%)

Data shown as mean ± (standard deviation) (SD) for quantitative variables, and absolute frequency (percentage) for categorical variables.

Study Themes

Postoperative Rehabilitation Experience, Needs, and Changes in Patients With PAD

Based on in-depth interviews with 18 patients with PAD, the study revealed that the postoperative exercise rehabilitation behaviors of these patients exhibited multi-dimensional experience, which could be specifically divided into the following two sub-themes:

i. Postoperative Functional Recovery

Most patients (10 participants) reported a partial improvement in walking ability post-surgery, though recovery speed varied significantly by age, comorbidities, and compliance.

A patient who had undergone the surgery 1 year ago stated:

“Now I can walk around the community, much better than before the operation!.” (Male, 61 years old, underwent the surgery 1 year ago)

However, four patients were dissatisfied with the rehabilitation outcome due to the insignificant alleviation of limb ischemia symptoms (MWD < 300 m). They believed that the improvement in their quality of life after surgery was limited.

“The pain in my leg became unbearable when I walked less than 100 metres and was relieved only by painkillers.” (Female, 76 years old, underwent the surgery 1 year ago)

ii. Exercise Preferences and Adaptation

65% of patients prioritized safe, accessible exercises (for example: low-intensity Activities: walking), while only one participant engaged in resistance training.

"Walk slowly against the wall and feel more secure.” (Male, 79 years old, underwent the surgery 3 months ago) (Figure 1)

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Figure 1.

Categories and subcategories for the facilitators to exercise rehabilitation and the multifaceted nature of rehabilitation barriers.

Discussion

This study elucidates the postoperative exercise rehabilitation behaviors of patients with peripheral artery disease (PAD), highlighting facilitators and barriers that shape their experiences. The findings underscore the necessity of tailored exercise prescriptions and goal-setting, which provide clarity and motivation for patients. Nurses play a pivotal role in advocating for standardized, individualized rehabilitation protocols and ensuring continuity of care through regular follow-ups. However, modern healthcare increasingly relies on multidisciplinary teams to address the multifaceted barriers to rehabilitation, including physiological, psychological, and social challenges (Treat-Jacobson et al., 2019).

Physiological limitations, such as pain, lower limb weakness, and complications like ulcers, remain central challenges, consistent with PAD's pathophysiology (Hiatt et al., 2015). These barriers necessitate adaptive exercise protocols that balance intensity with symptom tolerance, such as interval walking programs to mitigate discomfort while maintaining therapeutic benefits. Kinesiologists and exercise specialists can contribute by designing evidence-based exercise regimens tailored to patients' physical capacities and symptom profiles, ensuring safe progression. Nurses, in collaboration with these specialists, can enhance patient education on exercise safety, self-monitoring techniques, and pain management strategies to address knowledge gaps that contribute to non-adherence.

Psychological barriers, including fear, anxiety, and social isolation, were reported by patients as significant obstacles to sustained engagement. Psychologists can play a critical role in addressing these barriers by providing cognitive-behavioral interventions, motivational interviewing, and coping strategies to build patients' confidence and resilience. For instance, addressing fear of pain or reinjury through psychological support can complement nursing-led education and encouragement. Social support deficits, such as lack of family supervision or community understanding, further highlight the need for rehabilitation professionals to facilitate peer support groups or community-based programs, fostering a sense of connection and accountability among patients.

The demand for digital rehabilitation tools, such as apps for remote monitoring and progress tracking, reflects a shift toward patient-centered, technology-driven care (Bull, 2023; Koebe et al., 2023). Nurses can lead the design and implementation of these tools, ensuring usability for older adults and incorporating features like real-time feedback, reminders, and virtual peer communities (Alruwaili et al., 2023). Collaboration with rehabilitation professionals and technology specialists is essential to integrate these tools into comprehensive care plans, ensuring they complement human interaction rather than replace it. Nurses remain central in interpreting data, adjusting plans, and providing empathetic support, while multidisciplinary input enhances the holistic nature of care.

The study's findings emphasize the need for a holistic assessment framework to address physiological and psychological barriers. Nurses, in partnership with psychologists, kinesiologists, exercise specialists, and rehabilitation professionals, can optimize pain management, adjust exercise intensity, and foster social support, thereby improving adherence (Tao et al., 2017). For example, integrating psychological counseling with tailored exercise plans can address both physical and emotional barriers, creating a synergistic effect.

While this study enriches understanding of PAD rehabilitation behaviors, its single-center design and small sample limit generalizability. Future research should explore diverse populations using longitudinal mixed-methods approaches to capture evolving patient needs. Testing the proposed rehabilitation navigation system in clinical settings, with input from multidisciplinary teams, will be crucial to validate its efficacy in improving adherence and outcomes.

Strengths and Limitations

This study provides valuable insights into the postoperative exercise rehabilitation behaviors of patients with PAD; however, several limitations must be acknowledged. The single-center design, conducted at from Shanghai Jiao Tong University School of Medicine, Shanghai Ninth People's Hospital, may limit the generalizability of findings to other healthcare settings with differing resources, patient demographics, or rehabilitation protocols. The small sample size of 18 participants, while sufficient for achieving data saturation in this qualitative study, restricts the ability to capture a broader range of experiences and may not fully represent the diversity of PAD patients. Additionally, the use of purposive sampling may introduce selection bias, as participants were required to have participated in a structured exercise rehabilitation program for at least two months, potentially excluding those with lower adherence or different rehabilitation experiences. The cross-sectional nature of the study limits insights into the long-term evolution of patients' rehabilitation behaviors and needs. Future research should address these limitations by incorporating multi-center designs, larger and more diverse samples, and longitudinal approaches to better understand the dynamic nature of postoperative rehabilitation in PAD patients.

Implication for Practice

Exercise rehabilitation in PAD patients is shaped by diverse facilitators and barriers. Addressing physiological and psychological barriers is essential for patient-centered rehabilitation. Future efforts should explore scalable, technology-driven solutions to optimize recovery.

Conclusion

This study highlights the critical role of nurses in developing personalized exercise programs and leveraging technology-based monitoring systems to enhance postoperative rehabilitation for PAD patients. By integrating comprehensive health education and tailored interventions, nurses can improve patient adherence and quality of life. However, large-scale, multi-center clinical trials are needed to validate the proposed intelligent rehabilitation navigation system and ensure its broader applicability in clinical practice. This research provides a foundation for advancing patient-centered, technology-driven rehabilitation in PAD care.

Supplemental Material

Supplemental Material