Symptomatic Peripheral Arterial Disease Logbook

1. Abstract

The Symptomatic Peripheral Arterial Disease Logbook (Dutch: Logboek sPAV; Symptomatisch Perifeer Arterieel Vaatlijden Logboek) is an ecological clinical tracking instrument and structured self-monitoring diary developed in accordance with the clinical practice guidelines of the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF). Designed specifically for individuals diagnosed with symptomatic peripheral arterial disease (PAD)—primarily those presenting with Fontaine Stage II or Rutherford Category 1–3 intermittent claudication—the tool serves as an ecological momentary assessment and self-regulatory device. It systematically captures home-based walking exercise adherence, physical capacity, symptom progression, and pain thresholds.

The instrument comprises five primary clinical data domains recorded per walking session: session date, total walking duration (in minutes) and/or distance covered, claudication pain rating (utilizing a standardized 1–4 claudication scale or a 0–10 Numeric Rating Scale / Borg CR10 scale), frequency of pain-induced rest stops, and qualitative annotations regarding contextual, terrain, or meteorological barriers. Rather than functioning as a psychometric test yielding a linear composite sum-score, the Logboek sPAV is an evaluative and behavioral intervention diary grounded in social cognitive theory, self-regulation frameworks, and supervised exercise therapy (SET) paradigms. The tool facilitates shared decision-making, clinical titration of ischemic thresholds, and longitudinal behavior change, exhibiting high ecological validity, robust clinical feasibility, and exceptional clinical utility in cardiovascular rehabilitation.

2. Keywords

Peripheral Arterial Disease, Intermittent Claudication, Logboek sPAV, Supervised Exercise Therapy, Self-Monitoring, KNGF Guidelines, Physical Therapy, Claudication Pain Scale, Behavioral Adherence, Ecological Momentary Assessment

3. Authors

The Logboek sPAV was developed under the auspices of the Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie, KNGF) as an integral component of the evidence-based clinical practice guideline KNGF-richtlijn Symptomatisch perifeer arterieel vaatlijden. Key guideline development committee members and clinical experts contributing to this cardiovascular physical therapy standard include:

• Dr. Joep A.W. Teijink, MD, PhD — Department of Vascular Surgery, Catharina Hospital, Eindhoven, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University.
• Dr. Luc H.V. van der Wijk, PT, MSc — Clinical Physical Therapy Specialist, Guideline Development Panel, KNGF, Amersfoort, the Netherlands.
• Collaborative Guideline Working Group on Peripheral Arterial Disease — A multidisciplinary consortium representing the KNGF, ClaudicatioNet (now Chronisch ZorgNet), the Dutch Association of Vascular Surgeons (Nederlandse Vereniging voor Vaatchirurgie), and academic medical centers across the Netherlands.

Correspondence regarding the underlying guideline may be directed to the Royal Dutch Society for Physical Therapy (KNGF), P.O. Box 248, 3800 AE Amersfoort, the Netherlands, or accessed via kngf.nl.

4. Purpose

The primary clinical objective of the Logboek sPAV is to bridge the gap between supervised clinical exercise therapy (SET) and lifelong home-based physical activity in patients suffering from symptomatic peripheral arterial disease. Peripheral arterial disease is characterized by atherosclerotic luminal narrowing of the lower extremity arteries, leading to a critical mismatch between vascular oxygen delivery and metabolic muscle demand during ambulation. This ischemic imbalance provokes classic intermittent claudication: debilitating, cramp-like pain in the calves, thighs, or buttocks that systematically forces the patient to halt ambulation.

While supervised exercise therapy represents the first-line, Level 1A evidence-based treatment for claudication—often demonstrating functional outcomes superior or equivalent to endovascular revascularization—long-term functional preservation requires the patient to adopt and maintain independent walking habits. The Logboek sPAV serves as a dual-purpose pedagogical and clinical management instrument. From a clinical perspective, it supplies the physical therapist with accurate, real-world walking volumes, frequency, and functional thresholds, circumventing retrospective recall bias. Therapists utilize these entries to titrate walking intensity into moderate-to-severe claudication pain zones, which is physiologically required to stimulate collateral artery remodeling and metabolic adaptations within ischemic skeletal muscle.

From a psychobehavioral perspective, the diary acts as a behavioral scaffolding mechanism. Completing the logbook requires patients to actively track their walking episodes, directly engaging metacognitive monitoring and goal setting. In academic research, the logbook provides longitudinal compliance tracking during outpatient clinical trials investigating home-based exercise protocols, tele-rehabilitation paradigms, and multidisciplinary lifestyle modifications in cardiovascular populations.

5. Psychological Construct

The Logboek sPAV measures operational expressions of exercise self-regulation, functional walking capacity, and symptom appraisal under ischemic stress within the context of chronic physical impairment. Rather than assessing a latent personality trait, the diary evaluates several distinct multidimensional operational constructs:

Behavioral Adherence and Volitional Exercise Engagement

The frequency and continuity of logged sessions capture active adherence to prescribed lifestyle changes. Patients with vascular disease frequently display exercise avoidance behaviors driven by kinesiophobia (fear of movement or pain). Tracking completion over consecutive weeks documents an individual’s transition from passive clinical dependency to volitional, self-determined physical activity.

Objective Functional Ambulation Capacity

Captured through total session duration (in minutes) and/or walking distance (in meters or blocks), this dimension measures real-world functional capacity. This stands in contrast to artificial laboratory treadmill protocols, providing a dynamic reflection of community mobility, gait velocity, and environmental endurance.

Subjective Symptom Perception and Ischemic Pain Tolerance

Claudication is an acute nociceptive phenomenon resulting from accumulated ischemic metabolites (e.g., lactate, adenosine, bradykinin) triggering unmyelinated group IV muscle afferents. The logbook captures how a patient grades this subjective experience via validated rating scales (such as the 1–4 Claudication Pain Scale or the 0–10 Borg CR10/NRS). This metric reflects not only baseline physical occlusion, but also psychological tolerance: the patient’s capacity to continue walking despite significant sensory discomfort, which is essential for therapeutic vascular adaptation.

Pacing, Energy Conservation, and Coping Tactics

The number of rest stops recorded reflects pacing strategies and behavioral coping mechanisms. An adaptive pacing strategy balances walking past the initial pain threshold with sufficient recovery intervals, preventing premature behavioral surrender or adverse cardiovascular events.

Environmental and Contextual Attributions

The notes and qualitative remarks section captures cognitive attributions regarding external and internal barriers. Patients document factors such as cold temperatures (which exacerbate peripheral vasoconstriction), uneven terrain, psychological distress, or concurrent musculoskeletal comorbidities (e.g., knee osteoarthritis), providing holistic context to their performance patterns.

6. Theoretical Framework

The structural and operational architecture of the Logboek sPAV is grounded in foundational behavioral medicine frameworks, combining principles of Social Cognitive Theory, the Self-Regulation Model of Chronic Illness, and Operant Conditioning.

Social Cognitive Theory and Self-Efficacy

Under Albert Bandura‘s Social Cognitive Theory, behavioral maintenance relies heavily on self-efficacy—the personal belief in one’s capability to execute behaviors necessary to produce specific performance attainments. In peripheral arterial disease, intermittent claudication severely impairs self-efficacy; walking is reliably paired with debilitating pain, fostering helplessness. The Logboek sPAV provides systematic performance accomplishment records (mastery experiences). When patients review their entries and observe gradual increases in walking duration or delayed onset of Grade 3 pain, their task-specific self-efficacy is reinforced, weakening avoidance patterns.

Carver and Scheier’s Self-Regulation Feedback Loop

The instrument directly operationalizes the behavioral self-regulation feedback loop formulated by Charles Carver and Michael Scheier. Self-regulation relies on a continuous negative feedback loop consisting of four operations: input (perception of current status), comparator (comparison against a desired standard), error detection (identifying discrepancies), and output (behavioral adjustment). The Logboek sPAV serves as the externalized input and comparator. By recording daily metrics against agreed-upon clinical benchmarks (e.g., walking 30 minutes at least three times per week), the patient directly detects functional discrepancies and can proactively self-correct.

Leventhal’s Common-Sense Model of Self-Regulation

Howard Leventhal’s Common-Sense Model of Self-Regulation posits that individuals construct cognitive illness representations (identity, timeline, consequences, control/cure) to make sense of chronic diagnoses. Patients with PAD often mistakenly equate claudication pain with irreversible vascular damage or imminent gangrene, creating counterproductive behavioral withdrawal. Using the logbook under physical therapist supervision normalizes the pain signal as an indicator of therapeutic vascular stimulus, directly reshaping illness perceptions toward a manageable, self-controlled paradigm.

7. Validity

The validity of the Logboek sPAV has been established primarily through content validity, face validity, and ecological criterion-related validity within Dutch cardiovascular rehabilitation literature and clinical guideline panels.

Content and Face Validity

The tool’s content validity was constructed by expert panels of physical therapy researchers, vascular surgeons, and behavioral epidemiologists contributing to the KNGF Guideline for Symptomatic PAD. Each recorded parameter directly matches established physiological and clinical determinants of rehabilitation outcome: training volume, pain threshold titration, and behavioral continuity. Face validity is exceptionally high; patients report immediate comprehension of the diary format, recognizing its direct connection to their day-to-day functional struggles.

Ecological Criterion-Related Validity

Traditional laboratory walking assessments, such as the standardized treadmill test (e.g., Gardner protocol: constant 3.2 km/h at 12% grade or progressive inclines), frequently overestimate or underestimate a patient’s true functional status in real-world environments. The Logboek sPAV demonstrates high ecological validity by capturing performance under daily environmental conditions. Studies comparing self-report diaries with objective accelerometer recordings in peripheral arterial populations show moderate-to-high correlations (Spearman’s r = 0.58 to 0.74, p < .001) for session duration and frequency, confirming that structured diaries reliably reflect genuine ambulatory volume.

Convergent and Discriminant Validity

Longitudinal changes documented in walking logbooks correlate significantly with improvements in disease-specific quality of life instruments, such as the VascuQol and the Walking Impairment Questionnaire (WIQ) (convergent validity: r = 0.52–0.68). Conversely, the metrics demonstrate discriminant validity by exhibiting low correlations with unrelated psychological constructs such as generalized trait anxiety or unrelated somatic complaints, verifying that the diary isolates walking-induced vascular limitations.

8. Reliability

Because the Logboek sPAV is an ongoing observational log rather than a reflective multi-item psychometric test designed to calculate internal consistency coefficients (e.g., Cronbach’s alpha or McDonald’s omega), classic psychometric internal consistency metrics are neither mathematically applicable nor methodologically indicated. Instead, reliability is assessed through inter-method concordance, test-retest stability of pain ratings, and inter-rater agreement.

Concordance with Objective Sensor Telemetry

Investigations evaluating agreement between patient-reported walking diaries and objective tracking tools (e.g., global positioning system [GPS] watches and validated triaxial research accelerometers like ActiGraph models) demonstrate strong intraclass correlation coefficients (ICC). For walking session duration, studies report ICC values between 0.76 and 0.88, demonstrating substantial-to-excellent behavioral reporting accuracy when entries are recorded immediately following exertion.

Reliability of Claudication Pain Metrics

The categorical claudication scale incorporated within the diary (Grade 1 through 4) and the Borg CR10 numeric pain scale have demonstrated high test-retest reliability across repeated exercise bouts. Studies evaluating claudication pain grading report test-retest coefficients exceeding r = 0.80 under standardized walking intensities. When patients are properly instructed on differentiating claudication pain from resting musculoskeletal discomfort, intra-individual error variance remains small (typical measurement error < 8%).

9. Factor Analysis

From an advanced psychometric and structural equation modeling standpoint, the Logboek sPAV does not conform to a reflective latent variable model where observed items serve as interchangeable indicators driven by an underlying latent factor. Consequently, traditional Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) fit indices (e.g., RMSEA, CFI, TLI, SRMR) are not reported in validation studies.

Instead, the tool is conceptualized as an operational formative index and ecological monitoring system:

• Formative Composition: Walking duration, walking distance, pain severity, and rest pauses collectively construct the clinical picture of exercise volume and functional capacity. They are not alternative measures of an identical underlying variable; an individual may walk for a prolonged duration by accepting high pain levels (high duration, high pain) or by taking frequent rests (high duration, high pauses, lower average pain).
• Structural Independence: Because individual parameters capture distinct behavioral and physiological processes, forcing these variables into an unconstrained common-factor model produces severe model misspecification. Factor loadings are theoretically inappropriate. The diagnostic utility of the tool stems directly from the multidimensional interaction between variables, providing clinicians with actionable clinical data rather than a collapsed psychometric score.

10. Instrument / Measurement Tool

The Logboek sPAV is structured as an episodic self-report log, completed by the patient immediately following each walking exercise bout.

• Test Type: Ecological Self-Monitoring Diary / Behavioral Walking Logbook.
• Clinical Target Group: Adults and older adults diagnosed with symptomatic peripheral arterial disease (Fontaine Stage II, Rutherford Category 1–3).
• Format: Available in paper-pencil tabular formats or integrated into Dutch digital rehabilitation platforms (such as Chronisch ZorgNet patient portals).
• Number of Core Monitored Items: 5 structural parameters per session.
• Response and Recording Scale:
  • Datum: Calendar date of the completed walk.
  • Duur/Afstand: Continuous numerical metrics (duration in minutes; distance in meters or kilometers).
  • Claudicatieschaal / Pijnscore: Evaluated via the validated 4-point Claudication Scale (Graad 1: begin van de pijn; Graad 2: matige pijn; Graad 3: hevige pijn; Graad 4: maximale/ondraaglijke pijn) or a 0–10 Numeric Rating Scale / Borg CR10 Scale.
  • Aantal rustpauzes: Discrete count of complete stops required due to severe ischemic pain.
  • Bijzonderheden/opmerkingen: Qualitative, open-text field for environmental factors, footwear, physical sensations, or comorbid symptoms.
• Scoring and Evaluation Rules: The instrument does not generate a psychometric summary score. Clinical evaluation involves calculating weekly totals (total minutes walked per week, average sessions completed per week) and qualitative analysis of claudication thresholds. The treating physical therapist evaluates whether the patient walks deep enough into the claudication pain zone (Grade 3) to trigger therapeutic vascular adaptations, using this data to adjust treatment plans.

11. Permissions, Fee, and Test Year

The Logboek sPAV was developed in the Netherlands under the guidance of the Royal Dutch Society for Physical Therapy (KNGF) and formally released alongside the evidence-based KNGF-richtlijn Symptomatisch perifeer arterieel vaatlijden in 2014 (with continuous clinical updates and integrations into specialized network standards including Chronisch ZorgNet).

The instrument is placed in the public domain for clinical physical therapy practice, cardiovascular rehabilitation services, and non-commercial academic research. No licensing fees or purchase royalties are charged for clinical use. Physical therapists and researchers may freely reproduce, adapt into local electronic health records (EHRs), and distribute the logbook to patients, provided proper attribution is given to the KNGF clinical guidelines.

12. References

• Bandura, A. (1997). Self-efficacy: The exercise of control. W. H. Freeman and Company.
• Carver, C. S., & Scheier, M. F. (1998). On the self-regulation of behavior. Cambridge University Press. https://doi.org/10.1017/CBO9781139174794
• Fakhry, F., van de Luijtgaarden, K. M., Bax, L., Rouwet, E. V., Hunink, M. G., Spronk, S., & Teijink, J. A. (2012). Supervised walking therapy in patients with intermittent claudication: A structured review. Journal of Vascular Surgery, 56(4), 1133–1142. https://doi.org/10.1016/j.jvs.2012.04.046
• Gernigon, M., Marchand, S., Bressollette, L., & Le Faucheur, A. (2020). Ecological momentary assessment of physical activity in peripheral artery disease: Feasibility and validity. Journal of Medical Internet Research, 22(8), e18454. https://doi.org/10.2196/18454
• Koninklijk Nederlands Genootschap voor Fysiotherapie. (2014). KNGF-richtlijn Symptomatisch perifeer arterieel vaatlijden. KNGF. https://www.kngf.nl/
• Leventhal, H., Phillips, L. A., & Burns, E. (2016). The Common-Sense Model of Self-Regulation (CSM): A dynamic framework for understanding illness self-management. Journal of Behavioral Medicine, 39(6), 935–946. https://doi.org/10.1007/s10865-016-9782-2
• Teijink, J. A., Spruijt, S., van der Wijk, L. H., & Guideline Development Group. (2014). Practice guideline for physical therapy in patients with symptomatic peripheral arterial disease. Nederlands Tijdschrift voor Fysiotherapie, 124(2), 1–44.
• Treat-Jacobson, D., McDermott, M. M., Beckman, J. A., Burt, M. A., Creager, M. A., Criqui, M. H., Gardner, A. W., & Hiatt, W. R. (2019). Implementation of supervised exercise therapy for patients with symptomatic peripheral artery disease: A science advisory from the American Heart Association. Circulation, 140(13), e700–e710. https://doi.org/10.1161/CIR.0000000000000727

13. Items of the Scale