Buergers disease by dr .ravinder narwal

PHYSIOTHERAPY IN BURGERS DISEASES

1. BUERGER’S DISEASE
OR
THROMBOANGITIS OBLITERANS
[TAO]
PRESENTED BY:
Dr. RAVINDER NARWAL
MPT- CARDIOLULMONARY
MPT- ORTHO
HIHT UNIVERSITY

2. PERIPHERAL ARTERIAL DISEASE
 ANY CONDITION THAT CAUSES PARTIAL OR
COMPLETE OBSTRUCTION OF THE FLOW OF BLOOD IN
ARTERIES.
Infective :-
 syphilitic
Non -syphilitic
Tuberculous
6.Non –infective :-
Collagen vascular disease
Wegner’s syndrome
Kwasaki syndrome
Buerger disease [ TAO ]
Raynauds disease
Takayasaku syndrome

3. BUERGERS DISEASE
It is an inflammatory occlusive vascular
disorder involving small and medium sized
arteries and veins in the distal upper and
lower extremities.
Cerebral , visceral and coronary vessels
may also be affected.
Buergers disease was first reported by Felix
von winiwarter in 1879 in Austria.

4. EPIDEMIOLOGY
Buergers disease is more common in men than
womens 3:1.
Most patients with buergers disease are aged 20
-45yrs.
It is more common in Israel , Japan , and India.The
disease is most common on among south asian.
Death from buergers disease is rare , but in patients
with the disease who continue to smoke ,43%
require 1 or more amputation in 7.6year.

5. ETIOLOGY
Mechanism of TAO remains unknown.
Several possible causes have been
propose.
2.Tobacco use.
3.Inherited factors
4.Immune response

6. PREDISPOSING FACTORS
1.Smoking [99.9 % ]
2.Hypertension
3.Diabetes
4.hyperlipidemia

7. Smoking –To Die For!
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Smoking –To Die For!
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11. Healthy Lungs
You can see how the
lung looks without the
effects of inhalation of
smoke.
 Note black specks
throughout indicative
of carbon deposits
from pollution.

12. Lung after smoking
Smokers lung with
cancer. White area
on top is the cancer,
this is what killed the
person. The
blackened area is just
the deposit of tars
that all smokers paint
into their lungs with
every puff they take.

13. PATHOLOGY
Inflammatory changes occur in the arteries and veins ,
involving small and medium sized vessels by a necrotising
panarteritis associated with prominent intra luminal thrombosis
characterised by an intensive inflammatory cell infilterate
consisting of neutrophils ,gaint cells and occasionally
granulomas.
LATER- intra luminal inflammatory infiltrate changes
from predominantly polymorphonuclear to
lymphocytic with occasionnal eosinophils.
FINALLY- In the chronic stage, reconalisation of the
thrombus occurs, and the pathological changes than
it produce are proliferation of endothelial
cells , infilteration of intimal layer with
lymphocytes , thickening of internal and
external elastic tissue and the lumen may be occluded
by the thrombus.

14. CLINICAL FEATURES
Pain and weakness in leg and feet or arms and hands.
Swelling in feet and hands.
Fingers and toes that turn pale when exposed to cold.
Open sores on fingers and toes.
skin changes or ulcers on hands or feet.
The pain typically begins in the extremities , but may radiate to
more central parts of the body.
Presence of distal extremity ischemia [ indicated by
claudication ,pain at rest , ischemic ulcers or gangrene ]
Paresthesias [ numbness, tingling, burning ] of the hands and
feet .

16. DIAGNOSIS
BLOOD TEST- can help to rule out scleroderma
,lupus ,blood clotting disorder and diabetes .
ANKLE BRACHIAL INDEX-
index=ankle/brachial…..normal value >1
PHOTO PHLE THESMOGRAPHY
LEG ELEVATION TEST
RUBBER DEPENDENCY TEST
ALLENS TEST

17. MEDICAL MANAGEMENT
FOR TREATMENT OF SMOKING –
2.First line :- 5 A’S
A – ask
A –advice
A – asses
A – assist
A – arrange
2. Second line :-
ANTI – NICOTINE REPLACEMENT DRUG :-
Nasal spray of nicotine – 8 to 40 doses/ day
Bupropion- 150mg
Nasal lotion of nicotine.

18. NICOTINIE ACID DERIVATIE :-
Insitol nicotinate :- 1g ,3-4 times daily orally
Nicotinyl alcohol :- 25 -50mg ,4 times daily
orally
3. Third line :-
Clonidine :- 0.15 -0.75mg/day
Refer to amputation.

19. Anti-platelat drug:-
Asprin – 75 to 325mg/day orally
Clopidrogrel -75mg/day orally
Ticlopidine – 500mg/day orally
Vasodilator drug :-
Cilastozol :- 100mg BD
Ca++ antagonist :-
Nifedipine :-10mg 3times daily orally.
Antihistamine :-
Cinnarizine – 75mg 3 times daily orally.
Vitamin E -300 to 600 mg daily orally.

20. Surgical management
Sympathectomy
Enarteratomy
Amputaion
PTCA
PABG

21. Complication of burgers disease
Embolisation
Gangrene
Ulcer formation
Amputation
Muscle weakness atrophy
Sensory and motor impairment.

22. REHABLITATION

23. TEAM
Medical director.
Medical co –director.
Cardio surgeon.
Cardiologist.
Cardio vascular pulmonary physiotherapist.
Physiotherapist.
Occupational therapist.
Psychologist.
Nurses.

24. PATIENTS PROBLEMS
Stress ,anexity.
Education about the exercise ,protocol.
Psychological problem.

25. AIMS AND GOALS
To improve patients physical condition
,mobility,functional condition.
Prevention of complication.
Prevention of sensory / motor impairment.
Prevention of skin.
Prevention of amputation
Prevention of risk factor
[ smoking,diabetes,hyperlipidemia ]

26. PATIENT EDUCATION
Stop smoking and amputation will be
avoided.
Bedridden patients should be educated
about the importance of protective heel pads
or foam boot.

27. STAGES
STAGE – 1 :-- [ 1 to 4 wks ]
SKIN CARE –use powder b/w the toes .
Wash gently every day.
To increase air circulation through the toes,cotton may be used
b/w toes.
Ulcer treatment – . positioning
. proper shoe fitting
. proper gait training
MOTOR WEAKNESS :- [1 TO 4WKS ]
Isometric exercise – quard. And hams.
AROM : Ankle pumps,heel slides,heel and toe raises in sitting
with 15 to 20 reps,3 sets,2-3 times daily.

28. Endurance excercises /aerobic ex.
Make pt. to walk ½ miles .
GANGRENE :-
Laser
Uv –rays
IRR
Proper care of skin
TO INCREASE CIRCULATION :-
Iontophoresis
Heat modalities
NEW MODALITIES – to increase peripheral circulation.
Vasotron
Curator
Artiassist
Ectera

29. BUERGER’S EXERCISES
Pt. in supine position ,legs elevated to 45
degree.
Observe time taken for blanching +2 min.
Made to sit in high sitting position + 3 min.
[ hyperemia ]
Pt. is made to lying supine for 3 – 5 min.
This sequence is repeated 4 – 5 times /
session , for 3 sessions a day.

30. Effects and uses
1.Improvement in collateral circulation.
2.Better utilization of oxygen by muscle
tissue.
3.Walking tech. improves.
4.Psychological confidence of the pt. can lead
to increase in work performance.

31. Stage – 2 [ wks ]
Isometric +strengthening ex.
Pt. is made to walk ½ - 1 miles.
Buergers ex.
STAGE :- 3 [ >8 wks ]
Pt. made to walk >1 miles
Cardiopulmonary endurance ex. [ tread mill ,
bicycle ]
Prevention of TAO.
Buergers disease ex.

32. PREVENTION
Smoking cessation –avoidance of 2
nd
hand smoke
& use of tobacco products.
Dietary modification –
 Reduced fat , cholesterol , sweets .
Increased amounts of fruits & veg.
5.Wt. reduction – maintains a healthy wt.
6.Moderation in alcohol intake.
7.Physical activity [brisk walking ]
8. Ex. plan of minimum 30 min daily.

33. REHABLITATION OF AMPUTATIONS
PRE – OPERATIVE PERIOD
Physical assessment of Pt. : --
3.Check MMT.
4.Joint mobility.
5.Cardio resp. function.
6.Functional abilities.
Ex. Management :--
8.Strengtheing ex.
9.Mobilization.
10.Bed mobility [ bridging ,rolling ]
11.Transfers from bed to chair & back.
12.Stabilization for the trunk in sitting & standing.

34. POST – OPERATIVE PERIOD
1.Aims of treatment :--
To prevent complication [ deformities , oedema ,
phantom pain ]
3.To maintain :--
Strength of whole body & muscles controlling the
stump.
Mobility.
Balance & transfers
To re –educate walking.
To restore functional independence.

35. THANK


YOU