Peripheral Vascular Disorder Therapy by Hemant Nandgaonkar

INTRODUCTION

Nandgaonkar Hemant P

causes  Occlusion  Inflammation  Vasomotor dysfunction  Neoplasm  Radiation therapy

Nandgaonkar Hemant P

Arterial disorders  Acute arterial occlusion  Thrombus, embolism, trauma  Loss of blood flow  Crush injuries  Viability of the tissue  Thromboembolectomy, bypass, anticoagulation therapy, CBR  Arteriosclerosis obliterans (ASO) (M>F)  Chronic occlusive arterial disease  Peripheral arterial occlusive disease  Lower extremities  Large & medium arteries Nandgaonkar Hemant P

Arterial disorders  Atherosclerotic occlusive disease

 Thromboanginitis obliterans (Buerger’s disease)  Smoking related  Distal small arteries – progresses proximally  Young males  Raynaud’s Disease (F>M)  Idiopathic Raynaud’s disease  Raynaud’s syndrome  Raynaud’s Phenomenon if secondary to RA, SLE, scleroderma  Vasospasm – exposure to cold, vibration, stress Nandgaonkar Hemant P

Nandgaonkar Hemant P

Critical Diameter

Adaptive arterial enlargement preserves luminal caliber until a critical plaque mass is reached

Nandgaonkar Hemant P

Diagnostic Modalities  Non-invasive  ABIs  Segmental limb pressures  Limb plethysmography  Exercise testing  Doppler & duplex ultrasound  MR angiography

 Invasive  Contrast arteriography  CT angiography Nandgaonkar Hemant P

Clinical manifestations  Diminished or absent arterial pulses  Integumentary changes  Skin discoloration, reactive hyperemia  Trophic changes – shiny, waxy appearance of the skin, dryness & loss of hair  Skin temperature  ulceration  Sensory disturbances  Intolerance to cold or heat & paesthesia (tingling, numbness)  Exercise pain & rest pain (IC)  Intermittent Claudication  Muscle weakness - atrophy Nandgaonkar Hemant P

Buerger’s Disease Thromboanginitis Obliterans

 Exclusively associated with cigarette smoking  More prevalent in Middle East and Asia  Occlusive lesions seen in muscular arteries, with a

predilection for tibial vessels  Presentation - rest pain, gangrene and ulceration

Nandgaonkar Hemant P

Buerger’s Disease  Recurrent superficial thrombophlebitis (“phlebitis

migrans”)  Young adults, heavy smokers, no other atherosclerotic

risk factors  Angiography - diffuse occlusion of distal extremity

vessels  Progression - distal to proximal

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Buerger’s Disease - Management  Revascularization options are limited  Clinical remission with smoking cessation  Sympathectomy has a limited role in patients with

ulcerations

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 Temperature

 Hair loss  Pallor  Nail hypertrophy

 Ulcer  Gangrene  Dry - non infected black eschar  Wet - tissue maceration and purulence

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Common sites associated with exercise pain & associated arterial artery Site of pain

Occluded artery

Chronic arterial insufficiency Calf

Femoral

Foot

Popliteal

Thigh

Illiac

Buttocks or low back..bilat

Aortic

Thromboangitis obliterance Arch of the foot

Plantar & tibial

Palm of the hand

Palmar & ulnar

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Examination & evaluation of arterial sufficiency  Palpation of pulses – normal, absent, diminished  Skin temperature - cool  Skin integrity & pigmentation – pallor, hair loss  Test for rubor/ reactive hyperemia –  Claudication time – treadmill (1-2 mph) - baseline  Doppler ultrasonography  Transcutaneous oximetry – pulse oximeter  Magnetic resonance angiography  arteriography Nandgaonkar Hemant P

Differential diagnosis of intermittent Claudication  Neurospinal disorders  Spinal stenosis  Herniated lumbar disc  Spinal Claudication/ pseudoclaudication  Neuropathic disorders  Diabetic  ischemic  Other peripheral entrapment (e.g. tarsal tunnel syndrome)  Plantar neuroma Nandgaonkar Hemant P

Beneficial effects of physical exercise in IC  Improvement in collateral circulation  Improvement in the redistribution of available blood    

flow Better utilization of oxygen by the muscle tissue through more efficient aerobic metabolism Change in walking technique Improvement in cardio respiratory endurance Increased pain tolerance & psychosocial confidence of the patient can lead to a considerable increase in work performance Nandgaonkar Hemant P

Ankle-Brachial Index  Comparison of ankle pressure to brachial SBP  Reproducible, useful for long term surveillance  Normal 0.85-1.2  Claudicants 0.5-0.7  Critical ischemia < 0.4  May be falsely elevated in calcified vessels (DM) Nandgaonkar Hemant P

ABI with corresponding indications ABI ranges

Possible indications

>1.2

Falsely elevated, arterial disease, diabetes

1.19 â&#x20AC;&#x201C; 0.95

Normal

0.94 â&#x20AC;&#x201C; 0.75

Mild arterial disease, + intermittent Claudication

0.74 â&#x20AC;&#x201C; 0.50

Moderate arterial disease, + rest pain

< 0.50

Severe arterial disease

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Management of acute arterial occlusion  Impairments  Severe ischemia  Severe pain  Potential for tissue necrosis & amputation  Risk of local or systemic infection

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Management guidelines Plan of care

Interventions

Decrease ischemia by restoration or improvements of blood flow

Medical: bed rest, complete systemic anticoagulation therapy Physical: reflex heating of the torso or opposite extremity Positioning the patient in bed, with head slightly raised, increase in blood flow to the distal portion of the extremity Note: thromboembolectomy & reconstructive arterial or bypass graft surgery are alternatives to nonoperative treatment.

Protect the limb

The limb must be protected from any trauma. Pressure on skin must be minimized by special mattress, implementation of a turning schedule, & periodic repositioning of the patient. Nandgaonkar Hemant P

Precautions / contraindications  Acute occlusion  No exercise  Local direct heat – burn the ischemic tissue  Support hose – may increase peripheral resistance to blood flow  Avoid restrictive clothing

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Chronic Arterial Insufficiency  Impairments  Decreased endurance & increase frequency of muscular fatigue with functional activities such as walking  Pain with exercise or at rest  Skin breakdown & ulcerations  Limitation of passive & active motion  Weakness & disuse atrophy

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Management guidelines Plan of care

Interventions

Teach the patient how to minimize or prevent potential impairments & correct impairments or functional limitations currently affecting functional capabilities

Self management of current impairments through patient education.

Communicate with health professionals from other disciplines appropriate for consultation with the patient

Medical & surgical management including medications; nutritional counseling for weight control & decrease salt, sucrose, cholesterol & caffeine intake; smoking cessation

Improve exercise tolerance

Regular graded aerobic conditioning program of walking or bicycling

Relieve pain at rest

Sleep with the legs in a dependent but supported position over the edge of the bed or with the head of the bed slightly elevated.

Prevent skin ulcerations

Proper care & protection of the skin, particularly the feet or hands Proper nail care Proper shoe selection & fit Avoid use of support hose & restrictive clothing Avoid exposure to extremes of temperature, both hot & cold. Nandgaonkar Hemant P

Management guidelines Plan of care

Interventions

Improve vasodilatation in affected arteries

Vasodilatation by iontophoresis Vasodilatation by reflex heating (questionable effectiveness)

Prevent or minimize joint contractures & muscle atrophy, if confined to bed

Repetitive, active ROM against low loads & /or gentle stretching exercises; proper positioning in bed to maintain joint & muscle extensibility

Promote healing of any skin ulcerations that develop

Wound management procedures for ischemic ulcers, electrical stimulation, oxygen therapy

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Exercise guidelines  Precautions  A maximum THR should be established  Avoid exercising outside during cold weather  Shoes with proper fit – NO skin irritations, blisters / sores  Cardiac disease – monitor closely  Contraindications  Graded ambulation / bicycling stopped if leg pain increases  Resting pain – NO ambulation/bicycle  Ulcerations of the feet & wound or fungal infections – No walking program Nandgaonkar Hemant P

Venous disorders ď&#x201A;&#x2014; Acute thrombophlebitis ď&#x201A;&#x2014; Chronic venous insufficiency

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Clinical manifestations  Acute deep vein thrombosis  Virchow’s triad  

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Venous stasis Hypercoagulability Primary intimal damage

 Chronic venous insufficiency

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Risk factors associated with thrombophlebitis          

Fracture or post operative immobilization Prolonged bed rest Trauma to venous vessels Advanced age Obesity Sedentary lifestyle Congestive heart failure Malignancy Use of oral contraceptives pregnancy Nandgaonkar Hemant P

Nandgaonkar Hemant P

Examination & evaluation of VI  Girth measurements  Competency of the greater saphenous vein (percussion

test)  Tests for deep vein thromboplebitis  Homan’s sign – poor sensitivity  Application of BP cuff around the calf

 Additional special tests  Doppler ultrasonography  Venous duplex scanning  Venography (phlebography) Nandgaonkar Hemant P

Prevention of DVT  Post operatively  Passive exercise  Elevation  Electrical stimulation  Segmental intermittent compression of calf muscle  Active movement (60-75 degrees)  Repeated deep breathing  Light sedation  Active / active resistive exercises  Isometrics if cast  Bed bicycle  Pedal home trainer (3-4/day)  Early ambulation - elevation Nandgaonkar Hemant P

Acute thrombophlebitis  Impairments  Dull ache or pain usually in the calf  Tenderness, warmth, & swelling with palpation

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Management guidelines Plan of care

Interventions

Relieve pain during the acute inflammatory period

Bed rest, pharmacologic management (systemic anticoagulant therapy); elevation of the affected LE, keeping the knee slightly flexed

As the acute symptoms subside, regain functional mobility

Graded ambulation with legs wrapped in elastic bandages or when pressure gradient support stockings are worn

Prevent recurrence of the acute disorder Continuation of appropriate medical & pharmacologic management Use strategies to prevent DVT

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contraindications  Passive or active motion  Application of moist heat  Use of sequential pneumatic compression pump

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Chronic venous insufficiency & varicose veins  Impairments  Edema  Increased risk of skin ulcerations & infections  Aching involved limb  Decreased functional mobility, strength & endurance

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Cascade of events of venous insufficiency

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tRaUmA Calf pump failure

Lipodermatosclerosis

Capillary & venular elongation & dilatation

Tissue anoxia & malnutrition

Increased production of tissue fluid with raised fibrinogen concentration & raised inhibitors of fibrinolysis

Interstitial (pericapillary) fibrin deposition

ULCERATION

Reduced tissue fibrinolysis Nandgaonkar Hemant P

Nandgaonkar Hemant P

Stages of venous insufficiency Stage

Symptoms

Physical findings

Pain Heaviness

Superficial varicosities Edema along perimalleolar area

Mild swelling Heaviness Varicosities Pigmentation Pruritis Moderate to severe swelling

Moderate varicosities Pigmentation Dermatitis Moderate to severe edema

Ulceration Severe swelling Calf pain with or without venous Claudication

Multiple varicosities Marked skin pigmentation Ulceration Severe edema

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Conservative therapy in VI Stage 1

Custom fitted elastic compression stockings Ace wrap/ variant Circ â&#x20AC;&#x201C; aid (leggings) Intermittent external pneumatic compression Skin care

Custom fitted elastic compression stockings Skin care with water based lotion Topical steroids for dermatitis Surgical consultation

Ulcer care Wet to dry saline dressings Duoderm Unna boot Four layer high compression bandage Custom fitted elastic compression stockings Nandgaonkar Hemant P

Management guidelines Plan of care

Interventions

Teach the patient

Patient education & self management skills for skin care, self massage for lymphedema, & 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 & worn every day Support garment worn during exercise & ambulation Light active exercise, such as walking, on a regular basis. Elevate LE after graded ambulation until the HR returns to normal. Avoid prolonged periods of standing still & sitting with legs dependent. Elevate involved limb above the level of the heart (about 30-45 degrees) when resting or sleeping) Nandgaonkar Hemant P 54

Management guidelines Plan of care

Interventions

Increase venous return & reduce Lymphedema if already present

Use intermittent mechanical compression pump & sleeve with involved limb elevated for several hours a day Manual massage to drain edema. Stroke in distal to proximal direction clearing the proximal nodes & areas of lymphedema first, then the middle, & finally the distal areas. Relaxation & active ROM, (pumping exercises) of the distal muscles while involved limb is elevated.

Prevent skin abrasions, Proper skin care ulcerations, & wound infections

Nandgaonkar Hemant P

function  To collect & clear excess tissue fluid from interstitial

spaces & return it to the venous system

 LYMPHEDEMA  An excessive & persistent accumulation of extra

vascular & extracellular fluid & proteins in tissue spaces  Not a disease..but a symptom Nandgaonkar Hemant P

Lymphatic disorders  Congenital malformation of the lymphatic system  Infection & inflammation  Lymphangitis –inflammation of lymph vessels  Lymphadenitis – inflammation of lymph nodes  Lymphadenopathy - enlargement of lymph nodes  Obstruction or fibrosis  Trauma, surgery & neoplasm, radiation therapy  Surgical dissection of lymph nodes  Lymphadenectomy  Chronic venous insufficiency  Secondary, associated with venous stasis & edema Nandgaonkar Hemant P

Lymphedema 59

Congenital – at birth • Praecox – presenting before age 35 • Tarda – after age 35

Aplasia – no formed lymph pathways, Milroy’s disease

Distal obliteration – 80% of primary, mild edema of both ankles & lower leg

• Hypoplasia – lymphatics +, but < normal • Hyperplasia – lymphatics larger & more numerous

• Proximal obliteration – 10%, usually entire limb, unilateral • Congenital - 10%, present at birth or an early age, either unilateral or bilateral

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Clinical manifestations  Lymphedema  Location – centrally – axilla, groin or trunk  Severity – mild (1-2), moderate (2-5), severe(>5cm)  Increased girth & weight of the limb  Volume…tautness… skin breakdown  Sensory disturbances  Itching, tingling, numbness, painless  Fine coordination  Stiffness & limited ROM  Decreased resistance to infection  Delayed wound healing Nandgaonkar Hemant P

Types of Lymphedema-severity Pitting edema

Pressure on edematous tissues with the fingertips causes an indentation of the skin that persists for several seconds after the pressure is removed. This reflects significant but short duration edema with little or no fibrotic changes in skin & subcutaneous tissues.

Brawny edema

Pressure on the edematous areas feels hard with palpation. This reflects a more severe for of interstitial swelling with progressive, fibrotic changes in subcutaneous tissues.

Weeping edema

This represents the most severe & long duration form of lymphedema. Fluids leak from cuts/ sores; wound healing is significantly impaired. Lymphedema of this severity occurs almost exclusively in the lower extremities

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Examination & evaluation  History & systems review  Skin integrity  Girth measurements  Volumetric measurements

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General considerations  Prevention of Lymphedema  Avoid static, dependent positioning of LE  Travelling – walk around, support extremity  Elevate & repetitive pumping exercises  Avoid repetitive & vigorous activities  Compression garments while exercising  Avoid wearing clothing that restricts circulation  Do not wear tight jewelry such as rings or watches  Monitor diet to maintain an ideal weight & maintain sodium intake  Avoid hot environments & use of local heat  If possible, avoid having BP taken on an involved UE or injections in either an involved extremity. Nandgaonkar Hemant P

General considerations  Prevention of Lymphedema  Skin care  Keep the skin clean & supple, use moisturizers, avoid perfumed lotions  Avoid infections; pay immediate attention to a skin abrasion or cut, an insect bite, a blister, or a burn  Protect hands & feet; wear socks or hose, properly fitting shoes, rubber gloves, oven mitts  Avoid contact with harsh detergents & chemicals  Use caution with cutting nails. Women need to use an electric razor when shaving legs or underarm area  Avoid hot baths, whirlpools, & saunas that elevate the body’s core temperature Nandgaonkar Hemant P

Components of decongestive lymphatic therapy program  Elevation  Manual lymphatic drainage  Direct intervention by a therapist  Self massage by the patient  Compression  Non elastic or low stretch bandages or custom fitted garments  Intermittent, sequential pneumatic compression pump

Nandgaonkar Hemant P

Components of decongestive lymphatic therapy program  Intermittent, sequential pneumatic compression pump

 Individualized exercise program  Active ROM (pumping exercises)  Flexibility exercises  Low intensity resistance exercises  Cardiovascular conditioning  Skin care & daily living precautions

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Specific guidelines  Precautions for prevention or self management  Use of community resources  Lymphnet.org  Lymphedema.org

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Lymphatic disorders associated with treatment of breast cancer  Surgical procedure  Radical mastectomy  Modified Radical mastectomy  simple mastectomy  Breast conservative surgery

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Post operative impairments  Postoperative pain  Incisional pain  Posterior cervical & shoulder girdle pain  Post operative thromboemboli & pulmonary

complications  lymph edema  chest wall adhesions  decreased shoulder mobility

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 weakness & impaired functional control of the

involved UE  weakness of the horizontal adductors of the shoulder  weakness of the Serratus anterior

 decreased grip strength

 postural malalignment  fatigue & decreased endurance

 psychological considerations

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management guidelines Plan of care

Interventions

Prepare the patient for post operative self management Prevent post operative pulmonary complications & thromboemboli Prevent or minimize post operative lymph edema Decrease lymph edema if & when it develops Prevent postural deformities Prevent muscle tension & guarding in cervical musculature Prevent restricted mobility of the UE Nandgaonkar Hemant P

management guidelines Plan of care

Interventions

Regain strength & functional use of the involved UE Improve exercise tolerance & sense of well being, & reduce fatigue Provide information about resources for patient & family support & ongoing patient education

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precautions

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exercise for Lymphedema ď&#x201A;&#x2014; rationale

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components of exercise regimens  deep breathing & relaxation exercises  flexibility exercises  strengthening & muscular endurance exercises  cardiovascular conditioning exercises  lymphatic drainage exercises

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Guidelines for lymphatic drainage exercises  Preparation for lymphatic drainage exercises  during lymphatic drainage exercises  after lymphatic drainage exercises

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Selected exercises for lymphatic drainage  sequence of exercises  exercises common to UE & LE  total body relaxation  posterior pelvic tilt & partial curl ups  unilateral knee to chest movements  cervical ROM  scapular exercises

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FOR UE          

Active circumduction of the arm Exercise on a foam roll bilateral hand press wand exercises, doorway or corner stretch & towel stretch unilateral arm exercises with arm elevated bilateral horizontal abduction & adduction overhead wall press wrist & finger exercises partial curl ups rest Nandgaonkar Hemant P

FOR LE            

Unilateral knee to chest movements bilateral knees to chest gluteal setting & posterior pelvic tilts ER of the hips knee flexion to clear the popliteal area active ankle movements wall slides in ER leg movements in the air hip abduction across the midline bilateral knee to chest partial curl ups rest Nandgaonkar Hemant P

VASCULAR/LYMPHEDEM COMPRESSION GARMENT CLASSIFICATION 82

CLASS

PRESSURE (mm Hg)

Indications

Class I

20-30

Varicose veins, phlebitis, edema during pregnancy

Class II

30 – 40

Venous insufficiency, mild Lymphedema

Class III

40 – 50

Lymphedema, post thrombotic syndrome

Class IV

>50

Severe Lymphedema

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WOUND MANAGEMENT

Physiology of wound healing 84

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A three phase process  Phase

I :inflammatory phase: days 0 to 10  Phase II :proliferative phase: days 3 to 20  Phase III : maturation phase: day 9 to 2 years

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Wound examination 85

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 

History Subjective examination Objective examination

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Types of CHRONIC WOUNDS 86

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    

Ischemic arterial ulcers Pressure ulcers Venous insufficiency ulcers Neuropathic ulcers Rheumatoid ulcers Vasculitis ulcers

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WOUND CLASSIFICATIONS 87

STAGE

DESCRIPTION

TISSUE INVOLVEMENT OR LOSS

Non blanchable erythema, epidermis & dermis intact

NONE

Complete loss of epidermis, partial disruption of dermis (blister)

Partial thickness wound

III

Complete loss of epidermis & dermis, extends down to but not through underlying fascia

Full thickness wound (superficial involvement)

Complete loss of epidermis & dermis with destruction of fascia with muscle, bone or joint involvement

Full thickness wound (deep involvement)

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Types of wound drainage 88

Type

Description

Wound state

Serous

Clear, shiny exudate; can have a slightly yellow appearance

HEALTHY

Sanguineous

Red, bloody drainage

HEALTHY

SEROSANGUINEOUS

Pinkish res colored exudate

HEALTHY

SEROPURULENT

Brighter yellow drainage, slightly thicker exudate than serous; slightly malodorous

Contaminated/ infected

Purulent/ pus

Thick, cloudy, or opaque exudate, malodorous

Infected

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Comparison of AI versus VI– wound characteristics 89

Characteristic

Arterial insufficiency

Venous insufficiency

Granulation tissue

Pale red

Bright red

Drainage

Minimal

Moderate to heavy

Location

Toes, feet, anterior tibial area

Medial malleolus

Pain

Moderate to severe

Minimal

Edema

+/_

Shape

Well circumscribed or “punched out” appearance

Irregular

Hemisiderin staining

(-)

(+)

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Benefits of moist wound healing environment 90

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 

  

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Facilitates autolysis or autolytic debridement Promotes angiogenesis Bathes cells in a naturally protein & enzyme rich environment Enhances epidermal cell migration Optimizes immune system function Increases patient comfort & compliance with dressing changes Decrease the number of dressing changes Nandgaonkar Hemant P

intervention 91

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MODALITIES  Hydrotherapy  Ultrasound  Compression

therapy  Electrical stimulation  Ultra violet radiation  Radiant heat  Vacuum assisted closure

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intervention 92

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WOUND DRESSINGS  Semi

permeable foams  Calcium alginate dressings  Hydrophilic fiber dressings  Absorbent antimicrobial dressings  Collagen dressings  Hydrocolloid dressing  Hydrogel dressing  Semipermeable film dressing Nandgaonkar Hemant P

Consideration for the insensate wound 93

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Total contact walking cost ADVANTAGES  Distribute

weight bearing stresses  Reduces focal areas of excessive pressure  Reduces pedal & lower leg edema  Protects foot from further trauma  Maintains weight bearing ambulation  Helps localize & prevent spread of infection  Minimum patient compliance needed 

DISADVANTAGES Nandgaonkar Hemant P

Consideration for the insensate wound 94

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Total contact walking cost DISADVANTAGES  Active

infection  Osteomyelitis  Excessively fragile skin  Excessive edema that is fluctuating  Non compliance with follow up visits for cast changes  Ischemic ulcer  Ulcer that is deeper than it is wide Nandgaonkar Hemant P

debridement 95

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Non selective Selective  Sharp  Autolytic

 enzymatic

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Foot care instructions 96

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Patient education skin care & footwear instructions 97

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Wound product names 98

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Dressing decision tree 99

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Risk factors for foot ulceration in diabetics 100

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Neuropathy  

 

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Sensorimotor (abnormal protective sensation ) Autonomic (dry, cracked skin)

Vascular disease Abnormal plantar pressure (elevated in neuropathy or in absence of deformity) Abnormal gait in elderly living alone     

Degenerative joint disease of hip & knee Muscle weakness Heel cord tightness Pronation, supination deformity of the foot Toe contractures Nandgaonkar Hemant P

Risk factors for foot ulceration in diabetics 101

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Thick mycotic nails Previous ulcer or amputation Soft tissue atrophy & fat pad displacement Poor hygiene Inappropriate footwear Blind / partially sighted Elevated activity profile Lack of education / poor Foot deformities 

 

Claw toes, hammer toes Hallux valgus & rigidus Deformities secondary to Charcot Arthropathy Nandgaonkar Hemant P

references 102

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Delisa Krusen – Physical Medicine & Rehabilitation O’Sullivan Therapeutic Exercise – Foundation & Techniques, 4th Edition, Carolyne Kisner Internet

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