JMV—Journal de Médecine Vasculaire 49 (2024) 90—97

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ORIGINAL ARTICLE

Feasibility of performing treadmill walking

test for patients with peripheral arterial
occlusive disease by the advanced practice
nurses
G. Dumas a, A. Danjou b,c, C. Richaud a, R. Spear d, M. Joly a,
S. Blaise a,e,∗

a
Service de Médecine Vasculaire, department of Vascular Medicine, Grenoble University Hospital, BP 217,
38043 Grenoble cedex 09, France
b
Grenoble Alpes Data Institute, TIMC, UMR 5525 CNRS, University Grenoble Alpes, Grenoble, France
c
IFSI, CHU de Grenoble Alpes, CS10217, 38043 Grenoble cedex 9, France
d
Service de Chirurgie Vasculaire, department of Vascular Surgery, Grenoble University Hospital, BP 217,
38043 Grenoble cedex 09, France
e
Inserm U1300, HP2, University Grenoble Alpes, Grenoble, France

Reçu le 7 décembre 2023 ; accepté le 22 mars 2024

Disponible sur Internet le 16 April 2024

KEYWORDS
Advanced practice
nurses (APNs) ;
Vascular medicine ;
Treadmill walking
test ;
Peripheral arterial
occlusive disease
Summary
Aim. — The treadmill walking test with post-exercise pressure measurement can be used as a
diagnostic test and could classify peripheral arterial disease of the lower limbs. It can also
exclude the diagnosis allowing to raise the possibility of differential diagnoses. In this study,
we assessed the feasibility of performing treadmill test by advanced practice nurse to assess
suspected lower extremity peripheral artery disease patients.
Design and method. — This is a longitudinal monocentric study to assess the feasibility of a
treadmill walking test performed by an advanced practice nurse. The primary endpoint was the
number of tests performed during this period. The secondary objectives were to evaluate the
reasons for requesting the test, the main results obtained in terms of the test’s contribution
and diagnoses, and patients’ clinical characteristics.
Results. — From February to May 2023, amongst 31 patients who underwent the treadmill wal-
king test, 4 tests were able to rule out peripheral arterial disease and to detect differential
diagnoses. For the remaining 27 patients, 4 had stage IIa of the Leriche classification, 23 had
stage IIb, 2 of which were associated with a narrow lumbar spine. In contrast to the usual report,
the APN’s report on the walking test included an identification of cardiovascular risk factors, as
well as a possible medical reorientation linked to the correction of a detected cardiovascular
risk factor.

∗ Corresponding author. Vascular Medicine Service, Grenoble University Hospital, BP 217, 38043 Grenoble cedex 09, France.
Adresse e-mail : SBlaise@chu-grenoble.fr (S. Blaise).

https://doi.org/10.1016/j.jdmv.2024.03.005
2542-4513/© 2024 The Author(s). Published by Elsevier Masson SAS. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
 JMV—Journal de Médecine Vasculaire 49 (2024) 90—97

Conclusion. — The treadmill walking test can be performed by an advanced practice nurse.
He/She added a comprehensive/global patient management, with the detection of cardiovas-
cular risk factors. This new profession led to an increase in the number of tests performed of
more than 50% over the period and reduced the time to access the test.
© 2024 L’Auteur(s). Publié par Elsevier Masson SAS. Cet article est publié en Open Access sous
licence CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction A declaration to the register of data processing activi-

The treadmill walking test is a non-invasive dynamic test
generally performed in France by a physician or physiothe-
rapist. It is used to make a positive diagnosis of peripheral
arterial disease (PAD) when this cannot be done using res-
ting systolic pressure indices, and to classify so-called PAD
according to the Leriche and Fontaine classification into
IIa (maximum walking distance greater than 200 m) or IIb
(maximum walking distance less than 200 m) [1], but also
to suggest a differential diagnosis to walking claudication.
Maximum walking distance can be used to assess and quan-
tify the stage of exertional PAD or masked PAD. It can also
be used to assess the results of rehabilitation, medical or
surgical treatments.
Of the 6 French university vascular centers surveyed
that perform treadmill walking tests in France, three have
the tests performed by qualified physicians, interns in trai-
ning or even externs, and only one by a physiotherapist.
We were unable to find any protocols for cooperation
between healthcare professionals in carrying out the tread-
mill walking test declared on the websites of the Agences
Régionales de Santé (French regional health agencies)
(https://coopps.ars.sante.fr/coopps/init/index.jsp).
The aim of this study is to assess the feasibility of car-
pet testing by an advanced practice nurse (APN) in Vascular
Medicine through an observational study.
Methods
A prospective observational monocentric study was carried
out from February 08 to May 05, 2023 in the Vascular Medi-
cine Department at the Grenoble Alpes University Hospital.
The primary objective was to evaluate the feasibility of
treadmill walking tests performed by an APN under the res-
ponsibility of a vascular physician. The assessment criterion
was the number of treadmill walking tests carried out by the
APN.
Secondary objective 1 was the description of the popula-
tion of patients referred for the examination, with patient’s
demographics and cardiovascular history.
Secondary objective 2 was to determine the proportion
of patients with or without PAD, confirmed by resting and
exercise systolic pressure indices, the stage of PAD according
to the Leriche and Fontaine classification and the number of
differential diagnoses made.
Secondary objective 3 was to evaluate compliance with
the conditions for performing the treadmill walking test,
including any modifications to the parameters of the tread-
mill walking test, i.e. percentage of slope, speed, as well as
maximum walking distance.
ties was made on May 15, 2023 with the « Délégation à la
Recherche Clinique et à l’Innovation » from the Grenoble
Alpes University Hospital.
Study population
All patients referred for a treadmill walking test in the vas-
cular medicine department were included. Patients had to
be able to walk barefoot on a treadmill. They had to have
an ECG within the month before the test and an arterial
Doppler ultrasound prior to the test.
Exclusion criteria were the presence of an acute car-
diovascular event within a month, a contraindication to
exercise, an amputation limiting walking capacity, a large
vascular wound localized to one of the lower limbs hindering
walking or ankle pressure measurement, as well as visually
impaired patients or patients with cognitive disorders pre-
venting proper performance of the test.
Treadmill walking test procedure
The procedure used was that of the rectangular method
treadmill walk known as Strandness or modified Strandness
test (objective method with constant workload, difficulty
and regular walking speed). The test was carried out in a
dedicated room with a treadmill, an ECG machine and an
automatic brachial tensiometer. Patients were required not
to have smoked 1 h before the test. If the ECG was not
available, it was performed by the APN with validation by
a vascular physician. Brachial and tibial arterial pressures
were measured in the supine position, after at least 15 mins’
rest. At the ankle, a cuff adapted to the limb circumfe-
rence and a continuous 8 MHz pocket Doppler was placed
over the malleoli. Brachial blood pressure was measured
with an oscillometric tensiometer [2].
The posterior and/or anterior tibial arteries were identi-
fied using the pocket Doppler, and the cuff inflated until
disappearance of the acoustic signal (approx. 20 mmHg
above). The reappearance of the signal on slow deflation
indicated the systolic pressure retained. To calculate the
ankle-brachial index (ABI), the highest arterial pressure
values (brachial and ankle) were used. Arteries were consi-
dered incompressible if ABI ≥ 1.4.
The patient then began the walking test on the mat.
Walking was performed barefoot, without pants or wearing
loose-fitting shorts. The osteoarticular behavior of the foot
and ankle, as well as deformities of the foot(s), were recor-
ded. During the test, patients were asked to describe their
discomfort, the type of pain and its location(s). The semio-
logical elements (intensity, location, irradiation) of the pain

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 G. Dumas, A. Danjou, C. Richaud et al.

Figure 1 Flow chart of selection of patients and results until treadmill walking test. PAD: peripheral arterial disease; APN:
advanced practice nurse; ECG: electrocardiogram.

were recorded. Walking distance and walking time were
recorded.
At the onset of identified maximum pain, walking was
stopped, with notification of maximum walking distance
and elapsed time. Post-exercise tibial and brachial pres-
sures were measured one minute after walking was stopped.
Posterior tibial pressures on the symptomatic side were
measured first, followed by anterior tibial pressures on the
contralateral side [2]. Brachial and distal pressures were
repeated until flow signals identical to those taken at rest
were restored, approximately every 1—2 mins until recovery.
A test was considered in favor of PAD when there was a
decrease in ankle pressures of more than 30 mmHg post-
exercise compared to the value at rest (reference) or when
the decrease in post-exercise systolic pressure indices was
more than 18.5% according to the consensus of the French
National Vascular Medicine Society (SFMV) and the French-
language Surgical and Endosurgical Society (SCVE) of 2021
[1,3]. Patients were considered not to have PAD if the pres-
sure drop was not within the above-mentioned criteria.
Results
Analysis of treadmill walking test requests
From February 8th to May 5th 2023, 37 requests for treadmill
walking tests were received. Only 31 patients completed the
test out of the 32 who visited the department (1 test not
completed due to the patient’s balance disorders) (Fig. 1).
Concerning ECGs, only 23 patients came with an interpre-
ted ECG, 14 of which were less than a month ago. Eight
patients presented without an ECG, which was performed
on the same day by the APN (Fig. 1). With regard to additio-
nal examinations requested prior to the walking test, all but
3 patients (including 1 who did not attend) had an arterial

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 JMV—Journal de Médecine Vasculaire 49 (2024) 90—97
Table 1 Characteristics data of the patients performing the treadmill walking test.
Risk factors
Non-modifiable risk factors
Age in years (M > 50, F > 60)
Male gender
Family history of cardiovascular risk factors
Modifiables risk factors
Active smoking
Smoking cessation
Toxics (drugs and alcohol)
Diabetic type 2
Diabetic type 1
Dyslipidemia
High blood pressure> 140 mmHg
Overweight, BMI > 25 kg/m2
Sedentary lifestyle (no physical activity)
Others events
Personal history of cardiovascular events
History of peripheral vascular disease without surgery
History of surgery in peripheral vascular disease
No history peripheral vascular disease
DM: missing data; BMI: body mass index.
Doppler ultrasound report for the lower limbs, even though
nine have been realized more than 3 months prior to the test
(Fig. 1). Of the 31 tests carried out, 12 were performed by
the APN alone and 19 by the APN accompanied by the phy-
siotherapist. The physiotherapist carried out 2 tests without
the presence of the APN during this period (which were not
included in the study).
Concerning the reasons for requesting an examination
(n = 37), requests for diagnostic confirmation of PAD were
the most frequent (n = 18) (bilateral pain or pain of atypical
topography on the buttocks, hips, etc., or possible neuro-
logical claudication), followed by requests for assessment
of known PAD (n = 9) prior to medical or surgical treatment,
and finally requests for help in classifying PAD II (n = 5), most
often when PAD is newly diagnosed.
Of the 37 requests, 21 came from within the university
hospital (14 from vascular physicians, 4 from vascular sur-
geons, and 3 from joint medical-surgical requests), 16 from
physicians outside the hospital (8 from independent vascular
physicians, 6 from independent vascular surgeons, 2 from a
neurosurgeon) (Fig. 1).
Description of the population undergoing the
treadmill walking test
Of the 32 patients who took part in the treadmill wal-
king test, 16 had a history of vascular surgery of the lower
limbs (stented or non-stented angioplasty, endarterectomy
or bypass), 15 had a medical history of vascular disease
without surgery (Table 1). Only one 17-year-old patient
had no history of cardiovascular risk factors. Among the 31
patients who performed the test, 22 were men and 9 women,
with a median age for men of 69 [17—86] years and for
women of 72 [43—79] years. The APN consultation enabled
us to assess all cardiovascular risk factors for each patient
93
Numbers (n = 32) (%)
26 (81.25%)
23 (71.87%)
9 (28.12%)
12 (37.50%)
11 (34.37%)
7 (21.87%)
10 (31.25%)
1 (3.12%)
22 (68.75%)
20 (62.50%)
16 (50%)
10 (31.25%)
25 (78.12%)
15 (46.87%)
16 (50%)
1 (3.12%)
of the cohort (Table 1). An average of seven cardiovascular
risk factors were found in men and five in women. The most
common were non-modifiable (age and male sex). The defi-
nition of a sedentary lifestyle was the absence of regular
physical activity for at least 30 mins 5 times a week.
Treadmill walking test results
Resting ABIs were 0.89 (0.41—1.46) on the right and 0.88
(0.34—1.33) on the left lower limb. Fig. 2 shows the ove-
rall distribution of resting and post-exercise ankle pressures
at the level of the right and left posterior tibial arteries
(Fig. 2). The posterior tibial artery is the artery most fre-
quently used for pressure measurement, as it vascularizes
the muscles of the posterior aspect of the leg.
Of the 31 patients referred for pain on walking, 14 des-
cribed unilateral pain (n = 9 on the left and n = 5 on the right
lower limb) and 15 described bilateral, symmetrical pain
of the lower limbs. On the other hand, 2 patients reported
pain in both legs, but not symmetrically. Eight complained
of pain located in the thighs and calves, n = 4 unilaterally
(n = 3 on the left and one on the right) and n = 4 bilate-
rally. The second most frequently mentioned pain (n = 7),
was located in the calves, bilaterally. The third pain descri-
bed by patients (n = 4) was pain in the ‘‘whole’’ lower limb,
without being able to give a precise description (n = 2 in one
leg and n = 2 in both lower limbs). Six patients had pain in
anatomical sites that were not very suggestive of an arte-
rial lesion, notably the ankle, the arches of the feet or the
toes, whether or not associated with the pain already men-
tioned. Other sites were also described, such as the hips,
groin, scarpa and buttocks, always in association with other
sites.
Among the 31 patients in whom the test was performed,
9 men had a brachial systolic pressure > 140 mmHg, including
 G. Dumas, A. Danjou, C. Richaud et al.
Figure 2 Differences in the right and left posterior tibial pressure arteries at rest and after exercise.
4 patients with a systolic pressure > 160 mmHg and 1with a
systolic pressure > 180 mmHg at rest at the start of the test.
Four women had a brachial systolic pressure > 140 mmHg,
including 3 patients with a systolic pressure > 160 mmHg.
Among the 21 patients with a history of hypertension, 9
had a systolic pressure > 140 mmHg, including 4 patients
with a systolic pressure > 160 mmHg. Among the 12 patients
with no known history of hypertension, 5 had systolic blood
pressure > 140 mmHg, including 3 patients with a systolic
pressure > 150 mmHg.
Treadmill walking test parameters
During the 31 tests performed, 26 (81.25%) patients had
a walking speed below the 3.2 km/h recommended in the
Strandness walking test (n = 10, < 2 km/h). In 11 patients,
walking speed was adapted because of dyspnea. The adapta-
tion affected speed and not the percentage of slope, which
was never modified. Despite these adaptations, 18 patients
(56.25% of the population) had a maximum walking distance
of less than 100 m (Figs. 3—4).
Conclusion of the tests
Out of 31 patients who completed the treadmill walking test,
4 tests were able to rule out PAD (3 patients with a very pro-
bable diagnosis of narrow lumbar spine and 1 with a strong
suspicion of narrow lumbar spine who was invited to investi-
gate for confirmation) (Fig. 1). Of the remaining 27 patients,
4 had stage IIa obliterative arteriopathy of the lower limbs
(walking distance greater than 200 m) and 23 had stage IIb
(walking distance under 200 m), 2 of which were associated
with a narrow lumbar spine. Four tests could be considered
non-contributory: 2 patients with known stage IIb PAD who
were unable to complete the test due to walking difficulties
(inability to walk barefoot and fatigue due to lack of sleep),
and 2 patients with stage IIb PAD with an associated neurolo-
gical deficit (significant decrease in distal arterial pressures
contralateral to leg pain).
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Discussion
This short-term study, corresponding to the APN’s internship
period, confirmed the feasibility of the treadmill walking
test being carried out by an APN under the supervision of
a physician or other experienced paramedic. As expected,
requests for examinations came mainly from vascular physi-
cians and surgeons. Coordination upstream of examinations,
to check prerequisites, may be one of the APN’s tasks. This
coordination appears necessary in order to reduce the num-
ber of cancelled or postponed examinations because of the
lack of ECG or arterial Doppler ultrasound of the lower limbs.
The APN can also perform ECG and interpret it under medi-
cal supervision. This approach also reduces the number of
referrals to cardiologists solely for ECGs. No abnormalities
on the ECG were found to indicate that the treadmill walking
test should not be carried out, after validation by the vas-
cular physicians present on those days. During the 3-month
period, the APN performed 12 tests independently, and the
physiotherapist performed 21. Over a 3-month period, the
number of treadmill walking tests carried out increased by
almost half, and this had an impact on reducing the time
taken to treat patients.
Article 1 on July 18, 2018 setting the list of stabilized
chronic pathologies provided for in article R. 4301-2 of the
public health code, confers on the APN the skills required
to care for patients with stabilized chronic arterial disease,
prevention and common polypathologies in primary care [4].
The use of a treadmill walking test is essential in certain
clinical situations to confirm the diagnosis of PAD [5,6]. It is
also very useful for classifying a PAD as stress ischemia or for
monitoring the pathology as part of a treatment evaluation,
for example [7,8]. In practice, examination requests are
sometimes not properly formulated, and the transmission
of medical and paramedical data is not always coordinated.
The diagnosis and, above all, the stage of PAD are often not
mentioned in examination requests. It seems important to
work on medical communication in order to better formulate
examination indications.
 JMV—Journal de Médecine Vasculaire 49 (2024) 90—97

Figure 3 Breakdown of patients by maximum walking distance.

Figure 4 Breakdown of walking speed in km/h for the cohort.

As expected, over 97% of the patient cohort had nume-
rous cardiovascular risk factors. Within the scope of his/her
field of action, APN could offer therapeutic education in
order to optimize the correction of vascular risk factors, and
even from a drug therapy point of view in association with
the delegating vascular physician. It would be wise to offer
these patients a reassessment of their blood pressure, given
the possible ‘‘white coat’’ effect of resting brachial systolic
blood pressure values. In addition to managing hypertension
by reminding patients of health and diet rules and other the-
rapeutic education measures, the APN could also play a role
in modifying hypertensive treatment. It should be remem-
bered that, in the case of PAD, it is nevertheless advisable to
avoid lowering blood pressure too much, in order to maintain
a minimum distal pressure [2]. The persistence in our cohort
of a high percentage of active smokers could also be one of
the APN’s actions in assisting smoking cessation (Table 1).
Beyond the technical feasibility of the test (ABI measure-
ment, supervision of treadmill walking test, etc.), we need
to think about the supervision of test interpretations and
conclusions. Indeed, prior to the test, the patient should be
asked about his or her pain symptoms, so that conclusions
can be drawn as to the coherence of the corresponding vas-
cular territory. The APN must be familiar with the clinical
pictures of differential diagnoses that may be encounte-
red, in particular venous and neurological claudications. The
conclusion of the test should include a clinical summary and
propose alternative diagnoses to PAD in the event that PAD
is not confirmed. In case of confirmed symptomatic PAD,
good knowledge of the APN of the vascular medical-surgical
pathway can improve the direction of patient care. In the
event of a newly detected PAD, the APN’s good knowledge
of the vascular medical-surgical pathway can improve the
orientation of the patient’s care.
It is surprising not to have found a protocol for coope-
ration between caregivers for the treadmill walking test
recorded on the websites of the French Regional Health
Agencies (‘‘Agences Régionales de Santé’’ [ARS]) web-
sites (https://coopps.ars.sante.fr/coopps/init/index.jsp).
The current interest is that with the arrival of APNs, the
performance of this procedure, even under supervision has
not been officially registered with an ARS. Nevertheless, it

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 G. Dumas, A. Danjou, C. Richaud et al.

does not seem superfluous to write a protocol that could be and therapeutic). Despite the autonomy of the APN, it
reproduced in different French teams at least, in order to remains under the supervision of the other physicians.
achieve a consensus on interpretation of measurements. The
recommendations of the American Heart Association (AHA), Conclusion
the European Society of Cardiology/European Society of Vas-
cular Surgery (ESC/ESVS), the European Society of Vascular
The treadmill walking test can be performed by an APN.
Medicine (ESVM) and the Society of Vascular Surgery (SVS) in
He/She added a comprehensive/global patient manage-
PAD are sometimes discordant [1]. The 2021 consensus of the
ment, with the detection of cardiovascular risk factors. This
French National Vascular Medicine Society (SFMV) and the
new profession led to an increase in the number of tests
French-language Surgical and Endosurgical Society (SCVE)
performed and reduced the time to access the test.
recommends measuring the post-exercise ABI for the diag-
nosis of PAD (Grade 1) [1]. A decrease is significant when
the post-exercise ABI decreases by at least 18.5% if PAD is Human and animal rights
known, or by 50% if the resting ABI is greater than 0.91, or if
a decrease in ankle arterial pressures of more than 30 mmHg The authors declare that the work described has involved
is observed [1]. In contrast, the international recommenda- humans as part of their standard care.
tions of the American Heart Association (AHA), the European
Society of Cardiology/European Society of Vascular Surgery Informed consent and patient details
(ESC-ESVS) and the Society of Vascular Surgery (SVS) pro-
pose the use of two thresholds: either a fall in post-effort
The authors declare that this report does not contain any
ABI > 20% of the resting ABI or a fall in ankle pressure in
personal information that could lead to the identification of
absolute value > 30 mmHg, whereas the European Society of
the patient(s).
Vascular Medicine (ESVM) only proposes a fall in post-effort
ABI > 20%. These criteria were validated without taking into
account resting ABI values and with carpet protocols not cur- Funding
rently used (i.e. 2.4 km/h and 7% gradient, 4 km/h and 10%
gradient, etc.). Whether or not the value of systolic brachial This work did not receive any grant from funding agencies
pressure is included appears to be very important (espe- in the public, commercial, or not-for-profit sectors.
cially if the interpretative criterion used is ABI). The value
of the resting brachial pressure is all the more important
Disclosure of interest
as some patients had a high value before the test. Inter-
pretating a decrease of the blood pressure and/or ABI is
not always straightforward, particularly in the event of a The authors declare that they have no competing interest.
mismatch.
The strandness or modified strandness test is an objec- Author contributions
tive, rectangular method based on constant workload,
difficulty and speed. It is opposed to the triangular method, All authors attest that they meet the current International
which is a protocol with increasing workload and difficulty Committee of Medical Journal Editors (ICMJE) criteria for
[9]. The Gardner protocol is the best-known example Authorship.
(generally 2% increase in slope and 2% increase in speed
every 2 mins). Given our patients’ vascular history and/or
the appearance of dyspnea during the walking test, the
Credit authorship contribution statement
modified strandness test seems more appropriate. The
speed is set in relation to the patient’s ability, without G. Dumas: conceptualization, investigation, methodology,
endangering him or her. The possible adaptations of the test resources, software, validation, writing & review.
in our series of patients, particularly in speed, demonstrates A. Danjou: validation, writing & review.
the difficulties of establishing a homogeneous and unique C. Richaud: conceptualization, investigation, methodo-
protocol for cooperation between health professionals. In logy, resources, writing & review.
the current context of medical demographic shortages, R. Spear: validation, writing & review.
the performance of a treadmill walking test by an APN M. Joly: validation, writing & review.
seems highly appropriate. In addition to the possibility of S. Blaise: conceptualization, formal analysis, inves-
a cooperation protocol between healthcare professionals, tigation, methodology, resources, software, validation,
the performance of this examination requires collaboration visualization, writing—original draft, review & editing.
between the APN and the delegate healthcare professional
(physician or experienced professional), during the learning Références
curve, particularly with regard to the interpretation of
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the management of PAD patients at different stages of the disease: Consensus of the French Society of Vascular Medicine
disease management process (diagnostic, such as during the (SFMV) and the French Society for Vascular and Endovascular
treadmill walking test, correction of vascular risk factors, Surgery (SCVE). Ann Vasc Surg 2021;72:1—56.

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