PTH 121 Unit 6 Peripheral Vascular Disease (PVD) PDF

PTH 121- **[Unit 6 -- HO \#3 Peripheral Vascular Disease (PVD)]** References: ***O'Sullivan** 7^th^ ed, Ch14: Vascular, Lymphatic, and Integumentary Disorders.* ***Goodman** and Fuller's Pathology 5th Ed.Chap 1 Introduction to Concepts of Pathology* ***Paz**. Acute Care Handbook, 5th Ed. Chap 7,...

PTH 121- **[Unit 6 -- HO \#3 Peripheral Vascular Disease (PVD)]** References: ***O'Sullivan** 7^th^ ed, Ch14: Vascular, Lymphatic, and Integumentary Disorders.* ***Goodman** and Fuller's Pathology 5th Ed.Chap 1 Introduction to Concepts of Pathology* ***Paz**. Acute Care Handbook, 5th Ed. Chap 7, Vascular System and Hematology* **Learner Objectives:** Upon completion of this unit, including lecture and laboratory attendance, completion of reading assignments and review of handout materials, the student will be able to: D1.     Differentiate between arterial, venous, and lymphatic peripheral vascular disease (PVD). D2.     Identify the signs, symptoms, and treatment interventions for the following conditions:  thrombosis, atherosclerosis, Buerger's disease, Raynaud's Syndrome, deep vein thrombosis (DVT), and chronic venous insufficiency. D3. Demonstrate assessment methods for PVD including circumferential and volumetric measurements. **(7D24b, 7D24n)** Before we dive into peripheral vascular disease (PVD), we need to know the basics of \*pathology. ================================================================================================= Definitions (Disease, Illness, Heath, Pathology): ================================================= 1. [\*Pathology] -- the study of disease 2. [Disease] -- a biologic or psychological alteration that results in malfunction of a body organ or system 3. [Illness] -- (simply) deviation from a healthy state; a broader term than disease; the perception and response of a person to not being well 4. [Health] -- absence of disease; reflects a person's biologic, psychological, spiritual and sociologic state There is a continuum between [health] and [disease] -- most people fall somewhere in the middle. *Health \-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\--x\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-\-- Disease*  **[Psychological Aspects of Disease]** People react very differently to disease; the most important factor influencing how a person will react to a disease is [the premorbid psychological state of that person]. 1. Dependent personalities often become more dependent. 2. Narcissistic personalities will be hesitant to take meds that will alter their bodies. 3. Stoic personalities will have a difficult time admitting they are sick. Common reactions to disease are fear and denial. Understanding this process and having knowledge of a patient's premorbid personality will help physical therapy clinicians better help their patients achieve optimum health. Noncompliance during therapy may be the result of a patient's personality. **[Disease Classifications (5):]** 1. [Congenital/Hereditary] -- genetic; developmental abnormalities (CP, Down Syndrome/Trisomy 21) 2. [Inflammatory] -- body protects itself via inflammation (Allergies, Mosquito bites) 3. [Degenerative] -- degeneration of certain areas of the body (OA) 4. [Metabolic] -- disturbances of metabolic processes (DM, Alzheimer's disease) 5. [Neoplastic] -- abnormal cell growth leading to formation of benign or malignant tumors (Cancer: CA) Diseases can fall under more than one category. [For example,] rheumatoid arthritis (RA) -- metabolic (autoimmune) and inflammatory **[Disease Characteristics ~~(6):~~]** 1. [Symptoms] -- *subjective* complaints; diseases can be symptomatic or asymptomatic (Ex. Painful, stiff joints) 2. [Signs] -- *objective* manifestations; detected by tests, procedures and examination (Ex. x-ray reveals decreased joint spaces); can include lesions (structural changes found in tissues or organs -- CVA is a lesion in the brain) 3. [Etiology] -- cause of the disease; can be endogenous (occurs from within body- leukemia) or exogenous (occurs from outside the body -- West Nile virus); some diseases have an unknown etiology (idiopathic -- RA) 4. [Pathology] -- a branch of medicine that investigates the essential nature of the disease, changes in organs, tissues that cause or are caused by disease. 5. [Pathogenesis] -- manner in which a disease develops (whiplash injury from MVA leads to decreased joint motion and early DJD) 6. [Onset] -- can occur spontaneously (sudden, rapid) or insidiously (gradual, subtle) 7. [Duration] -- acute (rapid onset with short duration) vs. chronic (slow progression with long duration) **Principles of Diagnosis**: ---------------------------- [Diagnosis] -- identifying a disease based on its signs and symptoms [Prognosis] -- professional opinion regarding the outcome of the disease process Example: "Rehab prognosis is guarded" - means recovery with therapy (rehab) is limited/near plateau **[Diagnosis is based on an evaluation of]:** 1. Subjective complaints 2. Physical finding during physical examination 3. Test results 4. Diagnostic procedures 5. History of Present Illness (HPI), Past Medical History (PMH), Social History (SH) **[Diagnostic Tests and Procedures]:** [Test] -- analysis performed on specimen removed from patient 1. Lab tests -- example; CBC (Complete Blood Count), blood glucose level (BS); urinalysis (UA) 2. Cytological (cell) and histological (microscopic anatomy or microanatomy) tests -- biopsy (bx) [Procedures]-- invasive or noninvasive 1. Radiography: X-ray, Computerized Tomographic (CT) Scan, Mammography 2. MRI (Magnetic Resonance Imaging) 3. Endoscopy -- view inside the body with a tube with a light (example- Bronchoscopy, Colonoscopy, Cystoscopy, Laparoscopy, Laryngoscopy, Mediastinoscopy, Thoracoscopy, Upper Endoscopy) 4. Ultrasound -- high frequency sound waves (Doppler studies for blood vessels) 5. Phlebotomy -- needle is inserted to take the blood 6. Electrical activity tests -- EMG, EEG, EKG 7. Cardiac catheterization -- dye infected into arteries to check for blockages these are examples, not a list of conclusive tests and procedures **[Disease Treatment:]** 1. [Specific] -- target the disease; outcome is typically favorable (surgical removal of diseased colon; antibiotic for bacterial infection) 2. [Symptomatic, or palliative] -- treat the symptoms rather than the cause; not curative (use of morphine for pain control terminally ill CA patient) 3. [Prophylactic] -- preventative (vaccinations) **[Peripheral Vascular Disease (PVD) -- diseases of the 1) Arterial, 2) Venous and 3) lymphatic systems.]** 1. **[Arterial Insufficiency]** -- a lack of adequate blood flow to a region or regions of the body. Risk Factors: smoking, cardiac disease, diabetes, hypertension, renal disease, and/or elevated cholesterol and triglycerides. Examples of disorders (6) that occur with abnormal arterial blood flow. **Arterio**sclerosis: thickening, hardening, and loss of elasticity of arterial walls. **Athero**sclerosis: the most common form of arteriosclerosis, associated with damage to the endothelial lining of the vessels and the formation of lipid deposits, eventually leading to plaque formation. Arteriosclerosis obliterans: a peripheral manifestation of atherosclerosis characterized by intermittent claudication, rest pain, and trophic changes. This is the arterial disease most likely to lead to ulceration. Thromboangiitis \*obliterans (**Buerger's disease**): **inflammation** leads to arterial occlusion and tissue ischemia, especially in young men who smoke. \*Obliterans = obstruction due to inflammation and fibrosis **Raynaud's disease**: a vasomotor disease of small arteries and arterioles that is most often characterized by pallor and cyanosis of the fingers. In some cases, both the hands and feet may be affected. The cause of Raynaud's is unknown but attacks are usually triggered by cold or emotional upset. Ulceration: a peripheral sign of a long-standing disease process; by definition, [arterial ulcers] are associated with arterial insufficiency and ([venous ulcers] are associated with venous insufficiency.) **[Acute Arterial Occlusive Disease]** (arterial thrombosis or embolism) -- a sudden cessation of blood flow to an extremity requiring emergency treatment. Caused by a *thrombus* (blockage) or *embolus* (piece of thrombus that has broken away and eventually gets lodged) that can result in ischemia, necrosis and gangrene at the distal end. Thrombus vs Embolus [Signs and Symptoms ] 1\. Abrupt onset of pain 2\. Deathlike pallor 3\. Lack of pulses [PT Implications] -- often contraindicated, may undergo emergency surgery (bypass grafts for revascularization, endarterectomy) or begin on IV heparin; once stable -- restore mobility [**Chronic Arterial Insufficiency** (**atherosclerosis**)] -- (Peripheral Arterial Disease-PAD) fatty deposits (plaques) are formed on the wall of an artery. These plaques decrease the lumen size, impede blood flow and can eventually lead to complete blockage of the artery. As the disease progresses, the artery is no longer able to expand and contract, which can lead to rupture. *In general, do people with PAD have high blood pressure or low blood pressure?* [Signs and Symptoms:] 1. Intermittent claudication -- typically in the **calf** muscles (sudden muscle cramping, causes limping - relieved by rest; worsen with walking on/with hill/barefoot/flat shoes) 2. "rest pain" -- severe and unrelenting 3. Decreased or absent pulses 4. Rubor in dependent position (picture A) 5. Pallor on elevation (picture B) 6. Trophic changes-abnormal nail growth, dec hair, dry skin 7. Cool to touch 8. Possible presence of wound-ulcers (pictures below)     [Wounds Characteristics:] - **Dry**, punched out wounds most frequently located on/around lateral malleoli, dorsum of feet, toes (10-25% of all ulcers) - Frequently leads to loss of limb and death - Painful - Wound base -- necrotic, lacks granulation tissue, dry - Skin around the wound --can be black; gangrenous; mummifies (dry gangrene) - A nonhealing wound on an ischemic limb can lead to gangrene, amputation, further amputation, and/or loss of life [PT Implications] - **Pt education** (foot and skin care)- encourage to quit smoking, supervised exercise and walking. may need to sleep with BLE lower than head to relieve rest pain - If ulceration is present, intervention should enhance chemical and gaseous homeostasis in the wound bed, facilitate superficial blood flow to target tissues, and educate patients about the importance of facilitating blood flow to the extremities. - \*Ankle-Brachial Index (ABI) can help determine appropriate use of compression. - "The single most important intervention in PVD is prevention of smoking. - "The second most important intervention is exercise for weight control." Exercise will also improve collateral circulation, lipid profiles, and management of hypertension. A physical therapist plays a crucial role in wound care for arterial wounds and should address patient education and exercise in the intervention plan. [Medical/Surgical Interventions]: - Irrigation and Debridement (I&D) FYI- Incision and drainage (I&D) is for abscess - Vascular surgery (vascular bypass graft) - Amputation (last resort) **\*Ankle-Brachial Index -- ABI** -- a ratio of the LE pressure divided by the UE pressure, can be done with doppler or simple sphygmomanometer + stethoscope Fig 14.15 (O'Sullivan) -ABI test performed using a handheld Doppler ultrasound instrument. A blood pressure cuff is inflated to occlude blood flow temporarily and is then deflated as the examiner listens for the return of flow. Blood flow is observed on the upper extremity (UE) at the brachial artery and on the LE at the posterior tibial and the dorsalis pedis arteries  ABI= LEG/ARM In theory, ABI should be around 1. \