By Kym McNicholas, CEO of Global PAD Association
July 3, 2025
Join the Global PAD Association’s PAD walking support group HERE and its general PAD support group HERE.
“You need to walk through the pain.”
These words from Dr. Anahita Dua might sound counterintuitive, even cruel, to someone suffering from the leg pain of peripheral artery disease (PAD). But as I discovered during my recent conversation with this brilliant vascular surgeon from Massachusetts General Hospital, this seemingly tough-love approach is actually the key to freedom for millions of PAD patients. As an Assistant Professor of Surgery at Harvard Medical School and co-director of MGH’s Peripheral Artery Disease Center, she brings rare insight to a condition that affects millions yet remains woefully underdiagnosed and undertreated.
The Two Faces of PAD: Understanding What You’re Dealing With
“Peripheral artery disease is a misnomer,” Dr. Dua told me, leaning forward with the intensity I’ve come to recognize in physicians passionate about their specialty. “It’s this label we’ve stuck on a very wide variety of disease processes.”
She then broke PAD down into two distinct categories that immediately clarified the condition for me:
Intermittent Claudication:
The first is intermittent claudication—that cramping, aching pain that kicks in when you walk and disappears when you rest. If this describes your experience, I have encouraging news: Dr. Dua emphasized that while this form of PAD can be incredibly lifestyle-limiting (imagine not being able to make it to your mailbox without pain), it rarely leads to amputation. Only about 5% of patients with intermittent claudication end up facing that outcome.
Critical Limb Ischemia:
The second category is much more serious—critical limb ischemia. This involves either constant pain even at rest or actual wounds on your feet or legs. If you’re dealing with this form of PAD, walking therapy alone won’t be enough. You’ll need medical intervention, which we’ll discuss later.
For now, let’s focus on that first group—the much larger population dealing with intermittent claudication. Because here’s where Dr. Dua’s insights about walking become truly transformative.
Your Body’s Remarkable Ability to Build Its Own Bypasses
The pain you feel when walking with PAD is actually your body’s sophisticated warning system. “It’s your body telling you, ‘Stop it! You don’t have enough blood flow. You need to stop. You’re going to hurt yourself,’” explained Dr. Dua.
But here’s the fascinating twist—and why Dr. Dua’s approach turns conventional wisdom on its head: That pain is also an opportunity.
She made a comparison that stuck with me: “It’s very similar to if you were working out in the gym and doing a bunch of reps with your biceps. When you get that burning pain, what does your instructor tell you? ‘Give me one more! Give me one more!’ Why? Because it’s in those moments of severe pain when you’re actually building muscle.”
The same principle applies to PAD. When your leg muscles scream for oxygen that isn’t coming because of blocked arteries, that pain signal is actually triggering your body to develop new blood vessels around the blockages—your own natural bypass system.
Dr. Dua used a brilliant analogy about city councils and road construction that made this concept click for me. Imagine your body has a tribunal that decides where to invest resources like building new blood vessels. If your legs are screaming in pain from walking, they’re essentially telling this tribunal, “We need investment HERE, urgently!” But if you always stop at the first twinge of discomfort, your body never gets the message that this is a priority.
“It’s no different than if you live in a city with a crappy road outside your house,” Dr. Dua said. “The person who complains a thousand times, screaming and yelling and picketing and chaining themselves to the city council, is going to get money to fix that road. The person who stays quiet might see their road deteriorate even more.”
This is why so many PAD patients see their condition worsen over time—they’re inadvertently telling their bodies that the pain isn’t serious enough to warrant creating new blood vessels.
The Walking Protocol That Actually Works
So many of my readers and viewers have tried walking for PAD with limited success. After talking with Dr. Dua, I understand why—they’ve been doing it wrong. Here’s the protocol that actually works, based on the highest level of scientific evidence:
First, commit to 30 minutes of walking daily. This isn’t negotiable. But—and this is crucial—it must be continuous walking. As Dr. Dua emphasized, “It cannot be ‘I go for a walk with my spouse down a couple city blocks, stopping to pet someone’s dog, stopping to check if there are fresh avocados.’ No, no. Every time you stop, the clock restarts.”
Find a space where you can walk without interruption—a mall, a track, or even a treadmill at home. Start your timer and begin walking.
When the pain begins (whether that’s after seven steps or seven miles), don’t stop. This is the opposite of what most people do, and even what some well-meaning doctors might advise. Instead, push yourself to continue walking for another 5-10 minutes, even to the point where you’re limping.
This is where the magic happens—where your body gets the message to build those new blood vessels.
When the pain becomes truly unbearable, sit down (Dr. Dua recommends a portable folding chair if you’re walking outdoors). Wait until the pain subsides enough that you can walk again, then restart. Continue this cycle until you’ve completed 30 minutes total.
Most importantly, document two measurements each day:
How far you walked before the pain began
How far you continued walking with pain
“I guarantee you—I will give you this in blood writing,” Dr. Dua promised, “if you do that for six months, you will increase your walking distance and decrease the amount of time that you have to sit down.”
This approach is backed by solid research. A systematic review published earlier this year confirmed that structured exercise programs significantly improve walking ability and quality of life in PAD patients. What’s remarkable is that these improvements occur without any changes to the arterial blockages themselves—it’s all about creating new pathways around them.
Based on Dr. Dua’s expertise and current clinical evidence, here’s the precise walking protocol you should follow:
Step 1: Commit to Daily Walking
Dedicate 30 minutes every day to continuous walking. This is non-negotiable.
Step 2: Walk Continuously
Dr. Dua emphasized that stopping resets the clock. Choose a location where you can walk without interruption—a track, mall, or treadmill is ideal. This isn’t a casual stroll with friends where you stop to chat or window-shop.
Step 3: Document Your Pain-Free Distance
Record how far you can walk before pain begins. This is your baseline.
Step 4: Continue Walking Through Pain
This is critical: When pain begins, don’t stop. Continue walking for another 5-10 minutes, even to the point where you’re limping. This pain period is when your body receives the signal to build new blood vessels.
Step 5: Rest Only When Necessary
When the pain becomes unbearable, sit down using a portable chair if possible. Once the pain subsides, start walking again.
Step 6: Complete 30 Minutes Total
Maintain this cycle of walking, resting when absolutely necessary, and resuming for a total of 30 minutes.
Step 7: Track Your Progress
Document two measurements daily:
Distance walked before pain (pain-free walking distance)
Distance walked with pain (claudication time)
Dr. Dua guarantees that if you follow this protocol consistently for six months, you will increase your walking distance and decrease recovery time between walks.
The Smoking Gun: Why Lighting Up Destroys Your Progress
I’ve heard countless doctors advise against smoking, but Dr. Dua’s explanation for why it’s particularly devastating for PAD patients was eye-opening.
There’s a specific chemical in cigarettes that “actually murders the little new baby cells that are created to build those collaterals,” she explained. In other words, every time you smoke, you’re killing off the very blood vessel cells your body is trying to create through your walking therapy.
Dr. Dua put it memorably: “Every time you smoke a cigarette, a baby cell dies.”
No matter how diligently you follow the walking protocol, continuing to smoke will sabotage your progress. It’s like the city council finally agreeing to fix your road, only to have vandals destroy the new pavement every night.
I’ve spoken with hundreds of PAD patients who struggle with this addiction, and I know quitting isn’t easy. But understanding this direct connection between smoking and the destruction of your body’s healing process might provide the motivation needed to finally break free.
When Walking Isn’t Enough: Managing Critical Limb Ischemia
While my conversation with Dr. Dua focused heavily on walking therapy for intermittent claudication, she was clear that patients with wounds or rest pain (critical limb ischemia) need more immediate intervention.
In these cases, the blockages have reduced blood flow to the point where tissues are dying. Walking therapy alone won’t reverse this process quickly enough to save the limb.
If you’re dealing with foot wounds or pain even when resting, you need evaluation by a vascular specialist who can determine the right approach—which might include procedures to open blocked arteries or bypass surgeries to reroute blood flow.
Dr. Dua emphasized that proper wound care is also crucial, which led to an enlightening exchange with Kay Smith, a nurse practitioner who joined our conversation. Kay shared valuable insights about wound management, including the use of manuka honey for natural antimicrobial effects and the importance of proper offloading to relieve pressure on wounds.
What struck me about their discussion was the emphasis on comprehensive care. Kay pointed out a dangerous gap that exists between vascular procedures and proper follow-up wound care—a gap that costs too many patients their limbs. Dr. Dua agreed wholeheartedly, describing her hospital’s LEAP program (Limb Evaluation and Amputation Prevention), which brings together vascular specialists, wound care experts, and other professionals to provide coordinated care.
Promising New Developments: GLP-1 Medications Show Potential
While walking remains the gold standard therapy for intermittent claudication, exciting new research suggests that medications originally developed for diabetes may offer additional benefits for PAD patients.
The recently published STRIDE trial demonstrated that semaglutide (a GLP-1 receptor agonist) significantly improved walking distance and reduced pain in PAD patients. Even more promising, a large retrospective study of over 100,000 patients showed that those taking GLP-1 medications had lower rates of limb-threatening events and cardiovascular complications.
These medications appear to reduce inflammation in blood vessels and improve metabolic factors that contribute to PAD progression. While they’re not yet FDA-approved specifically for PAD, this research suggests they may become an important part of comprehensive treatment, especially for patients who also have diabetes.
I’ve interviewed several patients participating in these trials who reported dramatic improvements in their walking ability while taking these medications alongside their regular walking therapy.
The CHAT Approach: Protecting Your Whole Vascular System
One insight from our conversation that particularly resonated with me was Dr. Dua’s endorsement of our network’s “CHAT” approach to vascular health screening.
If you have PAD, it’s virtually certain that you have atherosclerosis (plaque buildup) elsewhere in your body as well. That’s why comprehensive vascular screening is so important.
When you visit your doctor, remember to ask about CHAT:
C: Carotids (checking for blockages that could cause stroke)
H: Heart (evaluating cardiac health and coronary artery disease)
A: Abdomen/Aorta (screening for aneurysms)
T: Toes (assessing peripheral circulation)
This simple acronym could literally save your life by identifying problems before they lead to catastrophic events like stroke or rupture of an aortic aneurysm.
Tools to Help You Implement Dr. Dua’s Protocol
After my conversation with Dr. Dua, I’m more convinced than ever that tracking your walking progress is essential to success. That’s why I’m excited to offer our free My Steps Walking Program, designed specifically to implement her protocol.
Unlike standard fitness apps that focus on step count, our program allows you to track both your pain-free walking distance and your claudication time (how long you continue walking with pain)—exactly what Dr. Dua emphasized as most important.
[SIGN-UP FOR MY STEPS WALKING PROGRAM HERE]
Additionally, if you’re struggling to find appropriate medical care for your PAD, our Leg Saver Hotline connects you with vascular specialists who understand the importance of comprehensive care, including supervised walking therapy.
LEG SAVER HOTLINE: 1-833-PAD-LEGS
A Path Forward Through the Pain
What struck me most about my conversation with Dr. Dua was the paradoxical nature of PAD treatment—the path to relief requires walking through pain rather than avoiding it. It’s counterintuitive, which perhaps explains why so many patients and even some healthcare providers miss this crucial approach.
I’ve interviewed countless PAD patients over the years, and those who’ve successfully implemented this walking protocol describe a transformation that goes beyond physical improvement. There’s a psychological liberation that comes from taking control of your condition rather than letting it control you.
One patient told me recently, “For years, I let my world shrink with each step that hurt. Now I see each painful step as building my future freedom.” That perspective shift can be as important as the physiological changes happening in your legs.
Dr. Dua’s evidence-based approach offers real hope—not just to manage PAD, but to actually improve it. The body’s remarkable ability to adapt and create new pathways is truly inspiring. All it needs is the right signals, consistently applied.
If you’re living with the limitations of PAD, I encourage you to begin this walking protocol today. Document your progress, celebrate small improvements, and keep pushing through the pain—knowing that each difficult step is actually creating your path to greater mobility and freedom.
This blog post is based on my interview with Dr. Anahita Dua and includes the latest research on PAD treatment. As always, consult your healthcare provider before beginning any new exercise regimen.
References
Naveh S, Thomas S, Abumoawad A, et al. Exercise Therapy in Symptomatic Peripheral Artery Disease. ACC Latest in Cardiology. 2025;Apr 02. Available at: https://www.acc.org/Latest-in-Cardiology/Articles/2025/04/02/13/44/Exercise-Therapy-in-Symptomatic-Peripheral-Artery-Disease.
Bonaca MP, et al. Semaglutide and walking capacity in people with symptomatic peripheral artery disease and type 2 diabetes (STRIDE): a randomised, double-blind, placebo-controlled, phase 3 trial. The Lancet. 2025. https://www.sciencedirect.com/science/article/abs/pii/S0140673625005094.
McKeown LA. GLP-1s Reduce Limb and Cardiac Events in Peripheral Artery Disease. TCTMD. June 12, 2025. https://www.tctmd.com/news/glp-1s-reduce-limb-and-cardiac-events-peripheral-artery-disease.
McDermott MM, Spring B, Tian L, et al. Effect of low-intensity vs high-intensity home-based walking exercise on walk distance in patients with peripheral artery disease: the LITE randomized clinical trial. JAMA. 2021;325:1266-76.
Mazzolai L, Belch J, Venermo M, et al. Exercise therapy for chronic symptomatic peripheral artery disease: a clinical consensus document of the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases. Eur J Vasc Endovasc Surg. 2024.
Share this post