Circulatory Exercises

• Circulatory exercises are a group of exercises used to prevent circulatory problems in prolonged bedridden patients.

Aims of Circulatory Exercises

• Prevent circulatory complications such as deep venous thrombosis (DVT)
• Facilitate venous return
• Prevent or reduce edema
• Prevent or minimize joint stiffness and muscle wasting due to immobility
• Facilitate early mobilization

Mechanism of Circulatory Complications

• Immobilization leads to venous stasis, injury to the intima of the vein which increases clotting factors, decreases fibrolytic enzymes, and forms blood clots, leading to DVT.
• Anesthesia and medication relaxes the smooth muscles of the vein and skeletal (calf) muscles, leading to a loss of muscle pumping action which can cause edema.
• Underlying diseases such as renal and hepatic diseases can also cause edema.

Principles of Circulatory Exercises

• Start from distal joints and move towards proximal joints
• Movement from distal to proximal facilitates gradual venous return
• Moving from proximal to distal can cause a sudden increase in venous return, increasing the load on the heart due to the increased action of large muscles located proximally.
• Exercises should be done in a rhythm of slow-fast-slow (3-4-3)
• Include a warm-up, active phase, and cool-down
• Exercises should be done in a full range of motion.
• Exercises can be performed on both upper and lower limbs.
• Exercises can be done unilaterally, then bilaterally, together, or alternatively.
• Perform 3 sets, with each set consisting of 10 repetitions.

Circulatory Exercises for Lower Limbs

• Patient position: Supine lying or long sitting with the ankle outside the bed.
• Therapist position: Standing in stride, facing the patient beside the bed.

Commands for Lower Limbs Exercises

• Flex and extend the toes on one foot, then the other, then both together, and finally alternating.
• Abduct the toes in the same manner.
• Perform all movements of the ankle joint (dorsiflexion & plantar flexion, eversion & inversion, circumduction, or figure of eight).
• Flex and extend the knee.
• Flex and extend the hip, abduct & adduct, internally & externally rotate, and perform circular movements with or without clockwise motion.
• In cases of upper & lower abdominal lesions or surgery, use static exercises for the hip & knee to prevent any stretch on the incision.
• Static exercises for the knee involve the therapist placing a hand below the knee and asking the patient to pull their patella up and press on the therapist's hand.
• Static exercises for the hip involve applying all hip movements.
• Squeeze the gluteal muscles and press on the bed.

Additional Commands

• Abdominal: Suck in your abdomen.
• Back: Press your back downward.
• Hip: Squeeze the gluteal muscles & press on the bed.
• Knee (Quadriceps): Therapist places a hand below the knee, asking the patient to pull the patella up & press on the therapist's hand.
• Hamstrings: Therapist places a hand below the ankle, asking the patient to press on the therapist's hand.

Circulatory Exercises for Upper Limbs

• Patient position: Supine lying or long sitting.
• Therapist position: Standing in stride, facing the patient beside the bed.

Command for Upper Limbs Exercises

• Flex and extend the fingers.
• Abduct and adduct the fingers.
• Flex and extend the wrist, perform radial & ulnar deviation of the wrist.
• Flex and extend the elbow, pronate & supinate the forearm.
• Flex and extend the shoulder girdle, abduct & adduct the arm, and perform internal & external rotation & circumduction.

Circulatory Complications

• Causes of circulatory complications:
  • Injury to the intima of vessels
  • Venous stasis
  • Tendency of blood to clot
  • Relaxation of the muscles of arms and legs

Assessment of Circulatory Complications

• DVT assessment: look for observation (redness), palpation (tenderness), Homan's sign ("sever pain in calf muscle with passive dorsiflexion the ankle and squeezing the muscle"), and swelling.
• Edema assessment: look for inspection (“color, shinny skin"), palpation ("Pitting or non-pitting", texture and temperature), tape measurement (round measurement), and tenderness (pain to palpation).