Physiotherapy Management of Vascular Disorders.pdf

PT MANAGEMENT OF VASCULAR DISORDERSOF THE EXTREMITIES ⯈Vascular disorders will cause ⯈insufficient circulation to the extremities, ⯈ can result in significant physical impairments and ⯈subsequent loss of function of either the upper or lower extremities. ⯈Disturbances of struc...

PT MANAGEMENT OF VASCULAR DISORDERSOF THE EXTREMITIES ⯈Vascular disorders will cause ⯈insufficient circulation to the extremities, ⯈ can result in significant physical impairments and ⯈subsequent loss of function of either the upper or lower extremities. ⯈Disturbances of structure or function of the circulatory systems are broadly classified as acute or chronic PERIPHERAL VASCULAR DISEASE (PVD) PVD CLASSIFICATION DISORDERS OF THE ARTERIAL SYSTEM DISORDERS OF THE VENOUS SYSTEM DISORDERS OF THE LYMPHATIC SYSTEM  DISORDERS OF THE ARTERIAL SYSTEM Types of Arterial Disorders 1. Acute Arterial Occlusion A thrombus (blood clot), embolism, or trauma can cause acute loss of blood flow to peripheral arteries. most common location of an arterial embolus is at the femoral popliteal bifurcation Management includes complete bed rest, systemic anti-coagulation therapy, thromboembolectomy, or reconstructive arterial bypass surgery With an acute occlusion therapeutic exercise is contraindicated. application of direct heat over painful areas also is contraindicated 2. Arteriosclerosis Obliterans Arteriosclerosis obliterans (ASO), also called chronic occlusive arterial disease, peripheral arterial occlusive disease, or atherosclerotic occlusive disease,  Accounts for 95% of all the arterial disorders affecting the lower extremities It is a chronic disorder seen in elderly patients risk factors that include elevated serum cholesterol ( 200 mg/dL), smoking, high systolic blood pressure, obesity, and diabetes 3. Thromboangitis Obliterans (Buerger’s Disease) chronic disease seen predominantly in young male patients who smoke Involves an inflammatory reaction of the arteries to nicotine Initially, it becomes evident in the small arteries of the feet and hands and progresses proximally It results in vasoconstriction, decreased arterial circulation to the extremities, ischemia, and eventual ulceration and necrosis of soft tissues 4. Raynaud’s Disease ⯈ also known as primary Raynaud’s syndrome, ⯈ isa chronic, functional arterial disorder that occurs more often in women than men. ⯈ caused by an abnormality of the sympathetic nervous system ⯈ characterized by digital vasospasm ⯈ Most often affecting the small arteries and arterioles of the fingers and sometimes the toes ⯈ Vasospasm is brought on by exposure to cold, vibration, or stress ⯈ response is characterized by temporary pallor (blanching), then cyanosis and pain, followed by numbness and a cold sensation of the digits Clinical Manifestations of Peripheral Arterial Disorders Signs and symptoms are 1.Diminished or Absent Peripheral Pulses more occluded or restricted the arterial blood flow the more diminished the peripheral pulses, the more severe or advanced is the arterial disease 2.Integumentary Changes Skin discoloration, including pallor at rest or with exercise Pallor is more evident when the extremity is elevated above the level of the heart for several minutes Trophic changes include a shiny, waxy appearance and dryness of the skin and loss of hair distal to the occlusion Skin temperature is decreased.  Ulcerations may develop, particularly at weight-bearing areas or over bony prominences Sensory Disturbances Intolerance to heat or cold and paresthesia 3. Exercise Pain and Rest Pain Pain during exercise and at rest is associated with progressive peripheral arterial disease Pain that occurs and gradually increases with exercise is referred to as intermittent claudication experienced most common in the lower extremities occurs more frequently and with greater intensity as the severity of chronic arterial insufficiency progresses During the early stages of arterial disease, intermittent claudication is characterized by a feeling of fatigue or weakness and, later, as cramping or aching in the muscles used during exercise. Rest pain When a burning, tingling sensation gradually becomes evident in the distal extremities at rest or with elevation, it may be indicative of severe ischemia With ischemia, pain frequently occurs at night because the heart rate and volume of blood flow to the extremities decreases with rest. 4. Muscle Weakness Loss of strength, muscle atrophy, and eventual loss of motor function, particularly in the hands and feet, occur with progressive arterial vascular disease EXAMINATION AND EVALUATION OF ARTERIAL SUFFICIENCY 1. Palpation of Pulses detection of pulses in the distal portion of the extremities Pulses are described as normal, diminished, or absent The strength of pulses also can be rated quantitatively from 0 to +3 The femoral, popliteal, dorsalis pedis, and posterior tibial pulses should be palpated in the lower extremities The radial, ulnar, and brachial pulses are palpated in the upper extremities 2. Skin Temperature A limb with diminished arterial blood flow is cool to the touch 3. Skin Integrity and Pigmentation trophic changes in the skin peripherally Dry skin, and diminished colour (pallor) Hair loss and a shiny appearance to the skin Skin ulcerations 4. Rubor Dependency Test—Reactive Hyperemia Changes in skin color that occur with elevation and dependency of the limb as the result of altered blood flow are determined 5. Claudication Time An objective assessment of exercise pain commonly used test is to have the patient walk at a slow, predetermined speed on a level treadmill The time that the patient is able to walk before the onset of pain is noted This measurement should be undertaken to determine a baseline for exercise tolerance before initiating a program to improve exercise tolerance 6. Doppler Ultrasonography Doppler measurement of blood flow with ultrasound imaging 7. Transcutaneous Oximetry provides information about the oxygen saturation of blood by means of a photoelectric device 8. Arteriography involves injecting a radiopaque dye (contrast medium) directly into an artery. The arteries are then radiographically visualized to detect any restriction of movement of the dye in arterial vessels indicating a partial or complete occlusion 9. Magnetic Resonance Angiography provides radiographic visualization of arteries without the use of a contrast medium PAD Classification  Neurogenic vs Vascular Claudication CHARACTERISTIC NEUROGENIC VASCULAR PAIN LOCATION Back, Buttocks, Thighs, Calves – Pain develops in calves – travels in Travels in a proximal to distal a distal to proximal direction direction PAIN QUALITY / Sharp or crampy may be Cramping ONSET associated with burning, Gradual Onset, consistent numbness, tingling Immediate onset PRECIPITATING / Pain occurs with standing and Pain occurs with walking AGGRAVATING walking Pain equally severe with flat or FACTORS Pain improves from flat to inclined treadmill walking. inclined treadmill walking Pain is equal in ascending & Pain is worse in descending descending stairs stairs Pain occurs during bicycle test. Pain does not occur during bicycle test.  CHARACTERISTIC NEUROGENIC VASCULAR RELIEVING FACTORS Pain is relieved with sitting or Relief with standing still bending forward and by lying, (Cessation of walking) particularly on side Shopping cart sign: Present Shopping cart sign : Absent LATERALITY Often Bilateral Usually unilateral if femoro- popliteal, bilateral if aortoiliac disease PHYSICAL FINDINGS Pulses: Present Pulses: Absent or Diminished Skin: Normal Skin: Pale/Shiny Hair loss Management of Acute Arterial Occlusion often a medical or surgical emergency. Medical or surgical measures must be taken to reduce ischemia and to restore circulation Medical management includes bed rest and complete systemic anticoagulation therapy physical interventions to improve peripheral blood flow while the patient is on bed rest may include warming the limb by reflex heating of the torso or opposite extremity or elevating the head of the bed Management of Chronic Arterial Insufficiency Impairments Decreased endurance and increased frequency of muscular fatigue with functional activities such as walking Pain with exercise or at rest Skin breakdown and ulcerations Limitation of passive and active motion Weakness and disuse atrophy REHABILITATION GUIDELINES Encourage risk factor modification: cessation of smoking, weight control, glucose and lipid control. Avoid excessive strain, protection of extremities from injury and extremes of temperature. Exercise training for patients with PVD: may result in improved functional capacity, improved peripheral blood flow and Improved muscle oxidative capacity EXERCISE TRAINING INCLUDES: I. Consider interval training (multistage discontinuous protocol) with frequent rests. II.Walking program, moderate intensity (40-70% V02 max) and duration, 2-3 times/day, 3-7 days/week. III.Exercise to the point of pain, not beyond. Use scale for subjective ratings for pain. Record time of pain onset. IV.Nonweight bearing exercise (cycle ergometry, arm ergometry) may be necessary in some patients V.perform mild warm-up and stretching activities prior to initiating walking or bicycling. I. Warmup activities could include active pumping exercises of the ankle and toes. Prevent skin ulcerations Proper care and protection of the skin, particularly the feet or hands. Proper nail care. Proper shoe selection and fit. Avoid use of support hose and restrictive clothing. Avoid exposure to extremes of temperature, both hot and cold Wound management procedures for treating ischemic ulcers, including electrical stimulation and oxygen therapy Improve vasodilation in affected arteries. Vasodilation by iontophoresis. Vasodilation by reflex heating.  DISORDERS OF THE VENOUS SYSTEM Types of Venous Disorders 1. Thrombophlebitis and Deep Vein Thrombosis Thrombophlebitis is a disorder typically affecting the lower extremities and caused by thrombosis (the development/formation of a blood clot—i.e., a thrombus). characterized by acute inflammation with partial or complete occlusion of a superficial or deep vein can occur in the superficial vein system (greater or small saphenous veins) or the deep vein system (popliteal, femoral, or iliac veins)  Thrombus formation in a deep vein in the calf or more proximally in the thigh or pelvic region, known as a deep vein thrombosis (DVT) cause serious complications When a clot breaks away from the wall of a vein and travels proximally, it is called an embolus When an embolus affects pulmonary circulation, it is called a pulmonary embolism, which is a potentially life- threatening disorder A lower extremity DVT is a common complication after musculoskeletal injury or surgery, prolonged immobilization, or bed rest 2. Chronic Venous Insufficiency Chronic venous insufficiency is defined as inadequate venous return over a prolonged period of time may begin after a severe episode of DVT, may be associated with varicose veins, or may be the result of trauma to the lower extremities or blockage of the venous system by a neoplasm. In all of these disorders damaged or incompetent valves in the veins prevent or compromise venous return, leading to venous hypertension and venous stasis in the lower extremities. Chronic pooling of blood in the veins causes inadequate oxygenation of cells and removal of waste products leads to necrosis of tissues and the development of venous stasis ulcers Clinical Presentation (General) Swelling of unilateral or bilateral LEs relieved in the early stages by elevation Complaints of itching, fatigue, aching, heaviness in involved limb(s) Skin changes including hemosiderin staining and lipodermato sclerosis Hemosiderin staining is the development of patches of brownish to yellow deposits just under the skin Lipodermatosclerosis refers to a skin change of the lower legs that often occurs in patients who have venous insufficiency. It is a type of panniculitis (inflammation of subcutaneous fat) Fibrosis of the dermis Increase in skin temperature of lower legs  Wounds: Most frequently located on the LEs: proximal to the medial malleolus although can occur anywhere (arterial wounds may also occur at this location). Not significantly painful; usually complaints of minor dull leg pain are relieved with elevation. Granulation tissue is usually present in the wound bed. Granulation tissue is new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process. Tissue is wet from a typically large amount of draining exudate. Pulmonary Embolism: Signs and Symptoms Vary considerably depending on the size of the embolus, The extent of lung involvement, and the presence of coexisting cardiopulmonary conditions The hallmark signs and symptoms are a sudden onset of shortness of breath (dyspnea), rapid and shallow breathing (tachypnea), and Chest pain located at the lateral aspect of the chest that intensifies with deep breathing and coughing  Other signs and symptoms include swelling in the lower extremities, anxiety, fever, excessive sweating (diaphoresis), a cough, and Blood in the sputum (hemoptysis)  Chronic Venous Insufficiency: Signs and Symptoms peripheral edema occurring with long periods of standing or sitting Edema decreases if the limb is elevated Patients often report dull aching or tiredness in the affected extremity If the insufficiency is associated with varicose veins, venous distention (bulging) also is notable. When edema persists, the skin becomes less supple over time and takes on a brownish pigmentation Examination and Evaluation of Venous Sufficiency Girth Measurements Circumferential measurements of the involved and uninvolved limbs are taken to determine the presence and extent of edema Competence of the Greater Saphenous Vein (Percussion Test) Procedure Ask the patient to stand until the veins in the legs appear to fill. While palpating a portion of the saphenous vein below the knee, sharply percuss a portion of the vein above the knee. If valves are not functioning adequately, the examiner feels a backflow of fluid distally under the palpating fingertips Tests for Deep Vein Thrombosis Homans’ Sign Procedure With the patient supine and the knee extended, passively dorsiflex the ankle and gently squeeze the calf muscles. If pain occurs in the calf, Homans’ sign is positive Application of a Blood Pressure Cuff Around the Calf Procedure Inflate the cuff gradually until the patient experiences calf pain. A patient with acute thrombophlebitis usually cannot tolerate pressures above 40 mm Hg Additional Special Tests Ultrasonographic Imaging, Doppler Measurement Of Blood Flow, And Venous Duplex And Venography  Rehabilitation Guidelines for Venous Disease Deep vein thrombophlebitis (DVT) & Thrombophlebitis Acute: patients on bedrest until signs of inflammation have subsided; elevation of involved leg. Elevation of the affected lower extremity, keeping the knee slightly flexed. Anticoagulation medications. Exercise therapy contraindicated during acute phase; increases pain, potential to dislodge clot, progress to pulmonary embolism, potentially fatal. Ambulation permitted (with elastic stockings) after local tenderness and swelling resolve. Ankle toe movements Prevention of Deep Vein Thrombosis and Thrombophlebitis Prophylactic use of anticoagulant therapy Initiation of ambulation as soon as possible after surgery Elevating the legs while lying supine and on a footstool No prolonged periods of sitting, especially for the patient with a long-leg cast Active “pumping” exercises (active dorsiflexion, plantarflexion, and circumduction of the ankle) regularly throughout the day while lying supine in bed Use of compression stockings to support the walls of the veins and minimize venous pooling For patients on bed rest, use of a sequential pneumatic compression unit Etiology of DVT  Comparison of characteristics of Arterial & Venous Disorders Arterial Disease Venous Disease Skin cool or cold, hairless, warm, tough, dry, shiny, pallor on thickened, elevation, rubor on mottled, pigmented dangling areas Pain sharp, stabbing, aching, cramping, worsens w/ activity and activity and walking walking, lowering feet sometimes help, may relieve pain elevating the feet relieves pain Ulcers severely painful, pale, moderately painful, pink grey base, found on base, found on medial heel, toes, dorsum of aspect of the ankle foot Pulse often absent or usually present diminished Oedema infrequent frequent, esp. at the end of the day and in areas of ulceration Management of Chronic Venous Insufficiency and Varicose Veins Impairments Edema Increased risk of skin ulcerations and infections Aching of involved limb Decreased functional mobility, strength, and endurance Patient must be advised on how to prevent dependent edema, skin ulceration, and infections Patient education and self-management skills for skin care, self-massage for lymphedema, and a home exercise program. Prevent lymphedema; minimize venous stasis. Use of individually tailored pressure-gradient support stockings donned before getting out of bed in the morning and worn every day. Support garment worn during exercise and ambulation. Light active exercise, such as walking, on a regular basis.  Elevate the lower extremities after graded ambulation until the heart rate returns to normal. Avoid prolonged periods of standing still and sitting with legs dependent. Elevate involved limb(s) above the level of the heart (about 30 to 45) when resting or sleeping Increase venous return and reduce lymphedema if already present Use intermittent mechanical compression pump and sleeve with involved limb elevated for several hours a day. Manual massage to drain edema Relaxation and active ROM (pumping exercises) of the distal muscles while involved limb is elevated.  Prevent skin abrasions, ulcerations, and wound infections Keep the skin clean and supple; use moisturizers Avoid infections; pay immediate attention to a skin abrasion or cut, an insect bite, a blister, or a burn. Protect hands and feet; wear socks, properly fitting shoes, rubber gloves etc. Avoid contact with harsh detergents and chemicals. Use caution when cutting nails Avoid hot baths, whirlpools, and saunas that elevate the body’s core temperature. DISORDERS OF THE LYMPHATIC SYSTEM PRIMARY FUNCTIONS To collect and clear excess tissue fluid from interstitial spaces and return it to the venous system Lymphedema is an excessive and persistent accumulation of extravascular and extracellular fluid and proteins in tissue spaces It occurs when lymph volume exceeds the capacity of the lymph transport system, and it is associated with a disturbance of the water and protein balance across the capillary membrane An increased concentration of proteins draws larger amounts of water into interstitial spaces, leading to lymphedema Conditions Leading to Insufficiency of the Lymphatic System Congenital Malformation of the Lymphatic System Infection and Inflammation Inflammation of the lymph vessels (lymphangitis) or lymph nodes (lymphadenitis) and enlargement of lymph nodes (lymphadenopathy) can occur as the result of a systemic infection or local trauma and lead to disruption of lymphatic system Obstruction or Fibrosis Trauma, surgery, and neoplasms can block or impair the lymphatic circulation Radiation therapy associated with treatment of malignant tumors also can cause fibrosis of vessels  Surgical Dissection of Lymph Nodes Lymph nodes and vessels often are surgically removed (lymphadenectomy) as an aspect of treatment of a primary malignancy or metastatic disease For example, axillary lymph node dissection is performed in most types of breast cancer surgeries pelvic or inguinal lymph node excision often is necessary for the treatment of pelvic or abdominal cancers Chronic Venous Insufficiency Clinical Presentation Swelling distal to or adjacent to the area where lymph system function has been impaired Swelling usually not relieved by elevation Pitting edema in the early stages of disease, nonpitting edema in later stages, as fibrotic changes occur Feelings of fatigue, heaviness, pressure, or tightness in the affected region Numbness and tingling Increased susceptibility to infection, at first local to the affected region but often becoming systemic Loss of mobility and ROM Impaired wound healing Discomfort varying from mild to intense Fibrotic changes of the dermis Dermal abnormalities such as cysts, fistulas Examination and Evaluation of Lymphatic Function History and Systems Review History of infection, trauma, surgery, or radiation therapy. The onset and duration of lymphedema, Delayed wound healing, or Previous treatment of lymphedema Examination of Skin Integrity Visual inspection and palpation of the skin The location of the edema When the limb is in a dependent position, palpate the skin to determine the type and severity of lymphedema Areas of pitting, brawny, or weeping edema should be noted When palpating the skin over lymph nodes, note any tenderness of the nodes Tenderness may indicate ongoing infection or serious disease Girth Measurements Circumferential measurements of the involved limb should be taken and compared with the noninvolved limb if the problem is unilateral Volumetric Measurements An alternative method of measuring limb size is to immerse the limb in a tank of water to a predetermined anatomical landmark and measure the volume of water displaced Prevention of Lymphedema  Elevation Manual lymphatic drainage (massage) Direct intervention by a therapist Self-massage by the patient Compression Nonelastic or low-stretch bandages or custom-fitted garments Intermittent, sequential pneumatic compression pump Individualized exercise program Active ROM (pumping exercises) Eg. Ankle Movements, speedy isometrics Flexibility exercises - Stretching Low-intensity resistance exercises Cardiovascular conditioning eg. Static cycling Skin care and daily living precautions Keep the skin clean and supple use moisturizers Avoid infections; pay immediate attention to a skin abrasion or cut, an insect bite, a blister, or a burn Protect hands and feet; wear socks or hose, properly fitting shoes, rubber gloves, Avoid contact with harsh detergents and chemicals Use caution when cutting nails Avoid hot baths, whirlpools, and saunas that elevate the body’s core temperature. THANK YOU