I. Abstract
II. Description of PVD
Peripheral Vascular Disease (PVD) is defined as an atherosclerotic disease affecting blood vessels throughout the body. Most commonly the disease occurs in the arteries outside of the chest including the aortoiliac, carotid, axillary or femoral arteries (Venes, 2005). With an increase in severity of PVD, risks of myocardial infarctions, ischemic strokes and death from vascular causes also become greater. The relative risk of death due to cardiovascular disease in individuals with PVD is approximately the same as those who have history of coronary or cerebrovascular disease. Serious risks may also lead to claudication and amputation. Intermittent claudication occurs during activities such as walking and causes pain typically down the calf. This symptom does not decrease by continuing to walk; instead the pain subsides with rest (Hiatt, 2001). Claudication arises because of lack of blood flow to a muscle due to the narrowing of arteries (Judd, 2005).
PVD has a significant association with morbidity and mortality; however, with the identification and reduction of specific risk factors, the threat for these risks can be diminished (Hirsch, Criqui, Treat-Jacobson, Regensteiner, Creager, Olin, Krook, Hunninghake, Comerota, Walsh, McDermott, & Hiatt, 2001). Cigarette smoking, diabetes mellitus and age (above 40 years old) are the major risk factors of PVD (Hiatt, 2001). The risk factor with the highest correlation for the development of the disease is cigarette smoking. Cessation of this habit alone lowers the rates of amputation, resting ischemia, myocardial infarction and death. Reducing hyperglycemia, associated with diabetes, minimizes symptoms and outcomes of PVD such as claudication, peripheral revascularization, critical limb ischemia and amputation, as well as the risk for cardiovascular disease and myocardial infarction (Lesho, Manngolf, & Gey, 2004).
Additional risk factors for PVD include hypertension, hyperlipidemia and hyperhomocystinemia (Hiatt, 2001). Aggressive hypertension treatment studies suggest that PVD is positively affected by initializing such a treatment, but no data has been taken to determine antihypertensive therapy's role in PVD outcomes. The lack of data is due to low PVD-related events. However, hyperlipidemia has a relationship with the progression of PVD and increased symptoms of claudication, both of which can be minimized by reducing blood lipid levels (Lesho, Manngolf, & Gey, 2004). Additionally, evidence shows that increased levels of homocystine in the blood could be a risk factor associated with the development of atherosclerosis and therefore PVD (Venes, 2005).
PVD may also be determined by the ankle-brachial index (ABI) in which the blood pressure of an individual is taken at the brachial artery and the ankle on the same sides of the body (left ankle and left brachial artery; right ankle and right brachial artery). The systolic pressure determined at the ankle is then divided by the systolic pressure of the brachial artery. If the calculated value proves to be between 0.90 and 0.41, the individual has mild-to-moderate PVD. If he or she obtains a value below 0.40 then severe PVD may be assumed. Normal ABI values range from 0.91 to 1.30 (Hiatt, 2001). For a visual reference of risk factors see Figure 1.
Categories of PVD:
Grade 0 (asymptomatic), Grade 1 intermittent claudication, Grade 2 ischemic rest pain, Grade 3 minor or major tissue loss from the foot.
III. Benefits of Exercise for Individuals with PVD
One of the main purposes of including exercise to treatment patients with peripheral vascular disease (PVD) is to treat one of the major symptoms which is intermittent claudication of the lower extremities. The pain associated with this condition results in a moderate to severe impairment in walking ability (Haitt, Regensteiner, Wolfel, Carry, Brass, 1998). Intermittent claudication limits an individual's peak exercise performance and oxygen consumption, which is associated with a restricted range in one's ability to walk and perform daily routine activities (Stewart, Hiatt, Regensteiner, Hirsch, 2002). Exercise is prescribed in order to increase the amount of time and distance that the patient can walk without experiencing pain (Hiatt, 2001).
Many individuals with PVD resort to surgical or prescription drug use; however, these risky venues can be avoided via exercise...An exercise program of high intensity can help avoid revascularization procedures such as bypass surgery and angioplasty and may also be more beneficial to the patient's overall health (Hiatt, 2001). Walking exercise has been recommended as a nonsurgical treatment for claudication, because improvements have been shown to improve walking ability in patients with PVD (Haitt, Regensteiner, Wolfel, Carry, Brass, 1998). Exercise, when done properly, can condition the muscles to use oxygen effectively and may improve arterial blood flow to the affected limb. As blood flow improves, patients show an increase in tolerance to walking. Furthermore, as their tolerance for walking increases, there is an improvement in peak exercise performance and oxygen consumption. By treating the patient's claudication, not only will their walking capabilities improve, but an overall improvement in quality of life will be achieved (Hiatt, 2001).
Other signs and symptoms of PVD benefitted by exercise? Hypertension, diabetes, etc. How does exercise improve these and other conditions associated with PVD?
IV. Types of Exercise Recommended
As previously stated, the goal of exercise is to increase the distance that a patient can comfortably walk. Therefore, the recommended exercise for peripheral vascular disease would be a walking-based program under medical supervision (Hiatt, 2001). Studies have shown that treadmill training improves walking ability by enhancing peak exercise performance and delaying the onset of progression of intermittent claudication pain during exercise (Stewart, Hiatt, Regensteiner, Hirsch, 2002).
In the study, Effect of Exercise Training on Skeletal Muscle Histology and Metabolism in Peripheral Arterial Disease, the patients were in an exercise training program for twelve weeks, exercising two to three times each week. Initially, the patient was directed to walk on the treadmill at 2 mph, 0% grade until the pain from claudication became fairly severe. At that point, the patient stepped off the treadmill to rest until the pain subsided. After the patient could walk about ten minutes at the initial work load, the grade was increased by 1-2%, or the speed was increased by 0.5 mph.
In a different study, Exercise Training for Claudication, the patients were prescribed an exercise training program for twelve and 24 weeks. Were there two groups? One group trained for 12 weeks and the other for 24 weeks? Were both walking programs? Initially, the patient was directed to walk on the treadmill at 2 mph, 0% grade for three minutes. Stages increased 3.5% in grade every three minutes, with no change in speed until claudication pain was severe. If the patient did not experience maximal claudication pain, the test was stopped around 40 to 50 minutes. Both of these studies suggest that patients with peripheral vascular disease, characterized by moderate to severe impairment in walking ability, should engage in a treadmill training program to decrease claudication pain and increase walking distance.
Is walking the only exercise recommended?? Do some research on stair-climbing, elliptical or bicycle? See what more you can find.
V. Fitness Testing Procedures
Since there is an increased cardiovascular risk for those who suffer from PVD, following exercise testing procedures in a safe and effective manner is very important. The following are reasons for testing an individual who suffers from PVD.
• Measurement of the time it takes for claudication pain to occur.
• Measurement of the systolic blood pressure of the ankle following exercise.
• Determination of the effect coronary artery disease has on an individual.
• Collection of enough information on a subject to write an exercise prescription (Womack & Gardner, 2003). How do you determine how coronary artery disease affects the individual? Precautions to testing? Prediction formulas? These need to be in this introductory paragraph, as well as discussed in separate paragraphs in the body of this section.
The two most common methods used to test individuals who suffer from PVD are: claudication-free walking time or maximal claudication-limited walking time. Both of these tests measure for distance and the amount of time elapsed before claudication pain to occur (Hodges, Sandercock, Das, & Brodie, 2006). These tests are commonly done on a treadmill if it is tolerable to the subject.
Before implementing a treadmill exercise test with a patient with PVD, a measurement of the systolic blood pressure in the ankle and brachial artery must be taken. The patient should abstain from ingesting alcohol and caffeine for 12 hours prior to testing, and nicotine for 3 hours before the test (Hodges, Sandercock, Das, & Brodie, 2006). The ankle and brachial systolic blood pressures should be taken to calculate ABI (Ankle Brachial Index) after the subject has been lying in a supine position for at least 15 minutes (Womack & Gardner, 2003). Blood pressure is then taken in both arms and legs both in the posterior tibial and dorsalis pedis arteries using Doppler ultrasound. The artery with the highest systolic pressure for each ankle is used to determine ankle systolic pressure. Furthermore, the artery containing the highest blood pressure in the arm is then used to calculate the ABI. A normal score for an ABI is above one, and an abnormal level is below one (Womack, Gardner, & Nael, 2009). The further the ABI score falls below one, the more severe the symptoms of PVD get. For example, a score that's less than 0.95 indicates considerable narrowing of the blood vessels in the legs. A score that is less than 0.8 will most likely lead to claudication of the foot, leg, or buttock during exercise. If the score is below 0.4, the symptoms may even occur during rest as well. A score of 0.25 or below is an indicator of severe PVD, which in some cases can be hazardous to your arms or legs (Womack, Gardner, & Nael, 2009).
Once this is completed, an exercise test with graded increases is completed. A highly used treadmill protocol starts with an initial grade of 0% at a constant speed of 2 mph (Womack, Gardner, & Nael, 2009). At two minute intervals, there will be an increase in grade of 2%. A pain scale of 0 to 4 is used for the subject to identify claudication pain as it develops: starting at no pain and building up to a maximal pain threshold. Increasing the grade slowly allows for the claudication times of the subject to properly indicate how severe the disease is. The patient is discouraged from holding on to the handrails of the treadmill, since this could cause variations in claudication times. The heart rate of the subject is measured during the last minute of each two minute exercise interval.
After the test is complete, the patient then lies down in a supine position again to recover for 15 more minutes. The amount of time necessary for the claudication pain to subside is also measured during this time. Ankle and brachial blood pressures are also recorded throughout the recovery stage. If for some reason treadmill testing equipment is not readily available, a 6 minute walk test is also an acceptable alternative method. With a walking test, improvements are easier to see in regards to an increase in distance that a patient is capable of walking and a decrease in claudication (Womack & Gardner, 2003).
VO2 max tests and cardiac output are usually not measured with this population even though people suffering from PVD have a high risk of morbidity and mortality (Hodges, Sandercock, Das, & Brodie, 2006). This is due to VO2 max tests being very strenuous on the body, and the extreme unlikelihood of an individual with PVD being able to complete a max test without experiencing claudication. Why aren't VO2 max tests used?
VI. Demographics for Affected Population
Age, gender, medical history: diabetes, hypertension, cvd, race, diet
VII. Basic Exercise Prescription
The most effective, non-invasive treatment for individuals with peripheral vascular disease is exercise. There are many symptoms of PVD that can be treated by exercise; however, the two main symptoms benefitted by exercise are intermittent claudication and hyperlipidemia. To prescribe exercise to treat claudication and hyperlipidemia, a patient will need to know the type of exercise, frequency, intensity, and duration.
The type of exercise most recommended for intermittent claudication is walking on a track or treadmill. The frequency of exercise for individuals should be approximately three to five days each week. The patients should be walking on the treadmill at an intensity that induces claudication pain within three to five minutes of initiating exercise. At this point of moderate intensity of pain, the patient should stop walking and rest until the pain subsides at which point walking may continue. During exercise, the patient should follow this "exercise-rest-exercise" pattern throughout the duration of the session. Each exercise session should last approximately 35 minutes initially, and then increments of five minutes should be added each session until the patient can walk 50 minutes (Milani, 2007).
For hyperlipidemia, both resistance training and cardiovascular training are prescribed to reduce the risk for PVD. In Fahlman's study published in 2002, elderly women were prescribed aerobic and resistance training to determine the benefits to reduce LDL-C levels and increase HDL-C levels. The aerobic group exercised walked three days per week at an intensity of 70% heart rate reserve. The first exercise session lasted 20 minutes, and each additional session increased five minutes until the total walking time equaled 50 minutes. The resistance training consisted of three sets of 8RM, where "8RM" was defined as the amount of weight able to be lifted with good form for no more than eight repetitions (Fahlman, 2008). Resistance training has also been shown to benefit other signs of PVD such as cardiovascular disease (Milani, 2007).
VIII. Contraindications to Exercise
Exercise is a type of physical activity that should be scheduled into everyday life due to the health benefits received from it. Physical activity is especially beneficial to those who have or are at risk for cardiovascular disease. However, individuals who have peripheral vascular disease (PVD) must undergo medical examination before exercise is prescribed due to an unstable clinical status (Armen & Smith, 2003). Those diagnosed with PVD will most often have additional comorbid disorders such as neurologic, renal, retinal diseases, or symptoms such as intermittent claudication (Armen & Smith, 2003). Taking into consideration these and other factors that affect a patient's health is extremely critical when creating an exercise prescription, in order for the patient to experience maximal benefits and minimal risks.
** Instead elaborate on how these symptoms or diseases affect an individuals ability to exercise. Anything about blood pressure, glucose levels, etc? And I like that you mentioned drugs, but talk about if any drugs have bad side effects or CANNOT be taken at the same time with other medications. I put other parts in the "prescribed drugs" section.
The majority of the drugs prescribed to patients with PVD are drugs to relieve claudication. Several drugs have been discovered to have some type of positive effect on the treatment of claudication, unfortunately some cause undesirable side effects, while others such as Prostaglandins and Naftidrofuryl, and require more research (Hiatt, 2001). Pentoxifylline is another drug that has been used in the treatment of claudication. Although, Pentoxifylline has proven to cause a small increase in the distance of maximal treadmill walking, there is not enough data to allow for its widespread use.
IX. Safety Considerations
Due to the increased cardiovascular risk for those who suffer from PVD, it is essential to perform exercise testing procedures in the safest manner possible. It is also a prudent measure to keep in mind all other factors that could play a role in affecting the outcome of an exercise test. A few things that need an investigator needs to be aware of are as follows: the individual has a high risk of CAD, probably smokes or has a history of smoking, and may also have skin ulcers (Womack & Gardner, 2003). Since those with PVD are classified as high risk, exercise testing under the supervision of a doctor is necessary. It is also necessary to note the medications that the individual takes on a regular basis, and make sure there are no changes in medication before any following exercise tests (Womack & Gardner, 2003).
Additional precautions stem from the resemblance between diabetic neuropathy and claudication; therefore, diagnosticians must be sure the subject is indeed suffering from PVD and not another similar disease (Womack & Gardner, 2003). A person may also have other issues in addition to PVD such as, diabetes and hypertension, which could further complicate a fitness testing procedure.
Another safety consideration concerns individuals who have diabetes, in addition to PVD, typically have some type of vessel disease in the distal regions of the body, which makes them poor candidates for corrective surgeries (Serracino-Inglott et al., 2007). Nevertheless, individuals who have PVD coupled with diabetes can perform in exercise as well as patients without diabetes when prescribed an exercise program (Serracino-Inglott et al., 2007). Therefore, safe and supervised fitness testing is critically important to best meet the specific needs of the patient and effectively assist them in the recovery process.
The following are a few other special considerations and safety measures that need to be in the minds of fitness testers. An ideal "work-to-test ratio" has not yet been determined for those suffering from PVD; therefore, this ratio needs to be adjusted on an individual basis ("Prevention of cold," 2006). Also, an environment that is too cold can possibly exacerbate the symptoms of intermittent claudication, so a longer warm up may be crucial to a safe and proper testing procedure ("Prevention of cold," 2006). For the health and safety concern of the individual, they should be encouraged to discontinue smoking of they are presently smokers (Bulmer & Coombes, 2004). Finally, if any resistance exercise is to be performed, it is essential to closely monitor individuals with PVD, because if claudication occurs the pain could cause them to unintentionally drop the weight that is being lifted, which could obviously lead to bodily harm. In any type of exercise or testing situation, it is always vital to have safety at the forefront of every measure and procedure, especially when working with a special population such as this.
In the interest of safety, there are a few instances where exercise testing should cases be terminated. In an aerobic testing situation, exercise testing should be ended prematurely if one or more of the following occurs as noted on an ECG: major irregularities of heartbeat, an elevation or depression of greater than two mm in ST-segment, or an inversion of the T-wave wave (Womack, Gardner, & Nael, 2009). In endurance testing of individuals with PVD, a reason for halting exercise testing procedures would be an increase of systolic blood pressure that reaches levels of over 250 mmHg or diastolic blood pressure that is greater than 115 mmHg. Finally, testing measures should be discontinued if the individual being tested is incapable of standing up from a seated position (Womack, Gardner, & Nael, 2009).
X. Expected Outcomes from Training
Individuals that experience the most common symptom of peripheral vascular disease, intermittent claudication of the calf muscle, will greatly benefit from adopting a strict exercise program under the supervision of a physician and professional training staff (1). The physiological and metabolic impacts of physical training have been tested in multiple variations of studies that experimentally establish that exercise produces positive outcomes concerning physiologic responses of the body. During limited exertion, collateral blood flow, the identification marker for exercise tolerance and intensity of claudication symptoms, is slightly affected because increased blood flow to the ischemic muscle is improved (1). Metabolic components of the muscle also respond to exercise, in a way that the regulation of glucose and fatty acids is increased. Other identified improvements that are results of exercise are cardiac function and circulatory dynamics. In a recent study, the levels for peak oxygen uptake of claudicants increased by a considerable percentage amount, over an one year period of participating in a supervised exercise program (1). Additional metabolic components, such as, total and LDL cholesterol and systolic blood pressure showed a decrease, respectively, compared to a control group (1). The combination of these improving factors due to modest increase in physical training relieves the individual of claudication symptoms over a period of time. The individual will still experience cramping sensations in the ischemic calf muscle throughout the duration of exercise; intensity may or may not be heightened, but will soon subside after one or two minutes of rest (ASCM). The exercise protocol for claudication is not limited to treadmill walking and stair climbing because there may be situation where a participant may not be able to endure the intensity and duration period of the exercises due to painful tightness in the calf muscle (1). McCombs and Subramanian, (2002) as cited in Schwade et al., (1967), concluded that upper extremity exertion performed at a sub maximal intensity level can produce a higher level of cardiac function than a standard protocol of treadmill walking and stair climbing. Ergometry is a valid determinant of the effects the exercise has on circulatory dynamics of the body.
XI. Prescribed Drugs
Scientists have experimented with many drugs in the hopes of discovering which ones give the best results for improving the symptoms of peripheral vascular disease. Although, angiotensin-converting-enzyme inhibitors have been proven to decrease the possibility of ischemic events, antiplatelet drugs are stronger and have been proven effective in decreasing the possibility of fatal and nonfatal ischemic events in individuals diagnosed with peripheral vascular disease. Anti-platelet and anticoagulant drug therapy, are considered for patients that are forced to undergo surgical treatment, with the purpose of promoting graft patency.
Pentoxifylline is another drug that has been used in the treatment of claudication because of its ability to repair deformed red and white blood cells and also because of its antiplatelet effects.
The most recommended drug for the treatment of claudication is Cliostazol, which was approved by the FDA in 1999. Cliostazol has several affects on the body including inhibition of platelet aggregation and vasodilatation of blood vessels (Hiatt, 2001). All in all, Cliostazol is the most prescribed drug for peripheral vascular disease because it relieves claudication by allowing for maximal treadmill walking that is pain free and an overall improvement in quality of life (Hiatt, 2001).
Outline for other drugs prescribed:
Aspirin
Reduces the overall risk of ischemic events associated with peripheral vascular disease, affects the peripheral circulation, improve vascular-graft patency, inhibits the action of blood clotting element
81 to 325 mg per day orally
Acetylsalicylic acid
Clopidogrel
Block blood cells (platelets) and prevents them from forming harmful blood clots
75 mg per day orally
Plavix
Pentoxifyline
Improve the deformability of red cells and white cells, lowers plasma fibrinogen concentrations, has antiplatelet effects, increases maximal treadmill walking distance
1.2 g per day orally
Trental
Cilostazol
Inhibit phosphodiesterase type 3, increase intracellular concentrations of cyclic AMP, inhibit platelet aggregation, the formation of arterial thrombi, and vascular smooth-muscle proliferation, causes vasodilation
100 mg twice per day orally
Pletal
Niacin
Increase HDL levels, lower triglycerides, reduce cardiovascular morbidity and mortality, increase plasma glucose levels, affects glycemic control, decrease glucose tolerance, increase plasma insulin levels
Ticlopidine
Inhibits platelet activation by blocking platelet adenosine diphosphate receptors
500 mg per day orally
Ticlid
Antiplatelet-drug
Reduce the risks of nonfatal myocardial infarction, ischemic stroke, and death from vascular causes
* Picotamide
Inhibit thromboxane A2 synthase and blocks thromboxane A2 receptors
* Ketanserin
Antagonist of S2 serotonin receptors that has antiplatelet effects
Probucol
Lowers cholesterol concentrations (lowers serum low-density lipoprotein [LDL] and high-density lipoprotein [HDL] cholesterol concentrations, has antioxidant properties
Colestipol
Stabilize or regress femoral atherosclerosis
Vasodilator drugs
Decrease resistance in vessels that lead blood flow away from the underperfused muscle, lower systemic pressure, reduces perfusion pressure
Papaverine
Naftidrofuryl
Antagonist of 5-hydroxytrytamine receptors, improve pain-free treadmill walking distance, associated with fewer cardiovascular events than placebo
600 mg per day orally
Levocarnitine and Propionyl Levocarnitine
Improve metabolism and exercise performance of ischemic muscles, improve maximal treadmill walking distance
Propionyl levocarnitine is more effective than Levocarnitine in improving maximal treadmill walking distance
2 g per day orally
Prostaglandins
Relief of ischemic pain, heals ischemic ulcers, reduce the rate of amputation
120 mcg per day orally
* Beraprost, iloprost, prostaglandin E1 [Alprostadil]
XII. Glossary of Terms
XIII. References
American College of Sports Medicine. Position Stand. Prevention of cold injuries during exercise. Medicine & Science in Sports & Exercise. 2006;38:2012-2029.
Armen J, Smith BW. (2003). Exercise considerations in coronary artery disease, peripheral vascular disease, and diabetes mellitus. Clinical Sports medicine. Vol 22(1), 123-133.
Bulmer, A., & Coombes, J. (2004). Optimizing exercise training in peripheral arterial disease. Sports Medicine; 34:983-992.
Elam, M. B., Hunninghake, D. B., Davis, K. B., Garg, R., Johnson, C., Egan, D., et al. (2000). Effect of Niacin on Lipid and Lipoprotein Levels and Glycemic Control in Patients With Diabetes and Peripheral Arterial Disease. The Journal of the American Medical Association - JAMA , 1263-1270.
Hiatt, W. R. (2001). Medical Treatment of Peripheral Arterial Disease and Claudication. The new England Journal of Medicine, 344(21), 1608-1621.
Haitt, W.R., Regensteiner, J.G., Wolfel, E.E., Carry, M.R., Brass, E.E. (1998). Effect of exercise
training on skeletal muscle histology and metabolism in peripheral arterial disease.
Journal of Applied Physiology. (81): 780-788.
Hirsch, A. T., Criqui, M. H., Treat-Jacobson, D., Regensteiner, J. G., Creager, M. A., Olin, J. W., Krook, S. H., Hunninghake, D. B., Comerota, A. J., Walsh, M. E., McDermott, M. M., & Hiatt, W. R. (2001). Peripheral Arterial Disease Detection, Awareness, and Treatment in Primary Care. Journal of the American Medical Association, 286(11):1317-1324.
Hodges, L., Sandercock, G., Das, S., & Brodie, D. (2006). Cardiac pumping ability in patients with peripheral vascular disease. Clinical Physiology and Functional Imaging, 26:185-190.
Judd, S. J. (2005). Cardiovascular Diseases and Disorders Sourcebook: Basic Consumer Health Information about Heart and Vascular Diseases and Disorders (3rd ed.). Detroit: Omnigraphics.
Lesho, E. P., Manngolf, J., & Gey, D. C. (2004). Management of Peripheral Arterial Disease. American Family Physician, 69(3), 525-532.
Lesho, E. P., Gey, D. C., & Manngold, J. (2004). American Family Physician. Management of Peripheral Arterial Disease , 69 (3), 525-32,533.
Serracino-Inglott, F., Owen, G., Carter, A., Dix, F., Smyth, J. V., & Mohan, I. V. (2007). All patients benefit equally from a supervised exercise program for claudication. Vascular and Endovascular Surgery, 41(3):212-216.
Stewart, K.J., Hiatt, W.R., Regensteiner, J.G., Hirsch, A.T. (2002). Exercise training for claudication. The New England Journal of Medicine. (347): 1941-1951.
Womack, C., & Gardner, A. (2003). Peripheral arterial disease. In: Durstine J., editor. ACSM's Exercise Management for Persons with Chronic Diseases and Disabilities. 2nd ed. Champaign (IL): Human Kinetics:81-85.
XIV. Work Assignment Sheet
Caleb Ashmore: Fitness testing procedures and Safety Considerations
Keisha Bolds: Reason For Exercise and Types of Exercise Recommended
Michelle Brown: Basic Exercise Prescription, assisted in Demographics for Affected Population, and Project Manager (editing and compiling the resource manual)
Elizabeth Ironbar: Contraindications to Exercise and assisted Keisha in "Types of Exercise Recommended"
Jessica Meisner: Description of the disease, Causes and Risk Factors, and assisted in Demographics for Affected Population
Simone Molett: Expected Outcomes from Training, and Prescribed Drugs
