Peripheral vascular disease,

Peripheral vascular disease,

1. JAMIA MILLIA ISLAMIA Topic: cardiac rehabilitation consideration for patient with PVD CENTER OF PHYSIOTHERAPY AND REHABILITATION SCIENCES Physiotherapy in cardiopulmonary conditions (402) Submitted to: DR. Jamal Ali Moiz Submitted by: Nada Zareen BPT 4 th year ROLL NO. : 17BPT042 1

2. Introduction Peripheral vascular disease (PVD) is a slow and progressive circulation disorder. Narrowing, blockage, or spasms in a blood vessel can cause PVD. It is characterised by a reduction in blood flow and hence oxygen through the peripheral vessels. When need of the tissues for oxygen exceeds the supply, areas of ischemia and necrosis is develops. PVD may affect any blood vessel outside of the heart including the arteries, veins, or lymphatic vessels. Organs supplied by these vessels, such as the brain, and legs, may not get enough blood flow for proper function. However, the legs and feet are most commonly affected. Peripheral vascular disease is also called peripheral arterial disease. PVD is also known as arteriosclerosis obliterans arterial insufficiency of the legs claudication intermittent claudication 2

3. Arterial insufficiency There decreased blood flow towards the tissues, producing ischemia Pulses are usually deminished or absent Sharp, stabbing pain occurs because of the ischemia, particulary with activity There is interference with nutrients and oxygen arriving to the tissues, leading to ischemic ulcers and changes in the skin. 3

4. 2. Venous insufficiency There is decreased return of blood from the tissues to the heart Leads to venous congestion and stasis of blood Pulses are present Lead to edema, skin changes and stasis ulcers 4

5. Comparison of characteristics of arterial and venous disease Arterial disease Venous disease skin Cool or cold, hairless, dry, shiny, pallor on elevation and rubor on dangling Warm, though, thickened, mottled, pigmented areas pain Sharp, stabbing, worsen with activity and walking, lowering feet may relief pain Aching, cramping activity and walking some time help, elevating feet help reduce pain ulcers Severely painful, pale, gray base, found on heel, toes, dorsum of foot Moderately painful, pink base, found on medial aspects of the ankle Pulse Often absent or dimineshed Usually present edema infrequent Frequent especially at the end of the day and in area of ulceration 5

6. Types of peripheral vascular disease There are two main types of PVD: Organic PVD  results from changes in the blood vessels caused by inflammation, plaque buildup, or tissue damage. Example atheroscelerosis . Functional PVD  happens when blood flow decreases in response to something that causes the blood vessels to vary in size, such as brain signals or changes in body temperature. In functional PVD, there is no physical damage to the blood vessels. Example Raynuad’s syndrome. 6

7. Causes 1. Organic PVD smoking high blood pressure diabetes high cholesterol Additional causes of organic PVD include extreme injuries, muscles or ligaments with abnormal structures, blood vessel inflammation, infection. 2. Functional PVD emotional stress cold temperatures operating vibrating machinery or tools Drugs 7

8. Risk factors NON MODIFIABLE Risk factors: Age (especially older than age 50) History of heart disease Male gender Postmenopausal women Family history of high cholesterol, high blood pressure, or peripheral vascular disease 8

9. MODIFIABLE Risk factors : Coronary artery disease Diabetes High cholesterol High blood pressure Overweight Physical inactivity Smoking or use of tobacco products 9

10. Clinical manifestation Intermitted claudication - most common Pain on the extremity that develops in the muscle that has an inadequate blood supply during exercise The cramping pain disappear within 1-2 minute after stopping the exercise or resting The femoral artery is often affected – pain the calf muscle- common symptom Pain at rest indicative of severe disease Gnawing, burning pain, occur more frequently at night Feeling of coldness Numbness Tingling sensation In Advanced aterioscelorosis oblitrans - ischemia may lead to necrosis, ulcerations and gangrene- toes and distal foot 10

11. Diagnosis Angiography Ankle- branchial index Doppler ultrasound MRA Treadmill exercise test PPG 11

12. Complications Amputation (loss of a limb) Poor wound healing Restricted mobility due to pain or discomfort Severe pain in the affected extremity Stroke (3 times more likely in people with PVD) 12

13. Management Medical management cilostazol or pentoxifylline to increase blood flow and relieve symptoms of claudication clopidogrel or daily aspirin to reduce blood clotting atorvastatin , simvastatin , or other statins to lower high cholesterol angiotensin -converting enzyme (ACE) inhibitors to lower high blood pressure 13

14. Surgical management Surgical management is used in case of advanced disease- ischemic changes and pain severely impairs activity Embolectomy Endarterectomy Arterial bypass surgery 14

15. Cardiac rehabilitation 15

16. Goals of cardiac rehabilitation 1) to reduce limb symptoms; 2) to improve exercise capacity and prevent or lessen physical disability; and 3) to decrease the occurrence of cardiovascular events. 16

17. Effects cardiac rehabilitation The improvement of the walking distance Improve muscular perfusion, by reduction of the endothelial dysfunction, contributes to the improvement of the oxidative metabolism improve daily activities reduction of cardiovascular risk factors, 30% mean decrease of mortality Improve quality of life Helps in mood disorder 17

18. Physical assessment Inspection: thick shiny skin Hair loss Expose the skin and look for: Brittle nails Colors changes Ulcers Muscle wasting Palpation: Temperature (cool, bilateral/unilateral) Pulses Capillary refill sensation/movement Auscultation: Femoral bruits Ankle brachial index: = systolic bp in ankle/systolic bp in brachial artery Burger’s test: Elevate the leg to 45 degree and look for palor Place the leg in dependent position 90 degree and look for red flushed foot before returning to normal Palor at <20 degree represents severe PAD 18

19. Evaluation of the aptitude to exercise The measurement of the walking distance on flat ground . 6-minute walking test Treadmill walking test Test on ergometric bicycle Stress test with the upper limbs 19

20. summarised findings of 2018 cocraine review of the best exercise prescription for PAD: Supervised treadmill exercise improves treadmill walking performance in patients with PAD. Supervised treadmill exercise has greater benefit on treadmill walking performance than home-based walking exercise. Home-based walking exercise interventions that involve behavioral techniques are effective for functional impairment in people with PAD and improve the 6-min walk distance more than supervised treadmill exercise. Upper and lower extremity ergometry improve walking performance in patients with PAD and improve peak oxygen uptake. Lower extremity resistance training can improve treadmill walking performance in PAD, but is not as effective as supervised treadmill exercise. 20

21. Modality Supervised :Treadmill Walking Intensity :40%–60% maximal workload based on baseline treadmill test or workload that brings on claudication within 3–5 min during a 6-MWT Session duration : 30–50 min of intermittent exercise; goal is to accumulate at least 30 min of walking exercise Claudication intensity :Moderate to moderate/severe claudication as tolerated Work-to-rest ratio :Walking duration should be within 5–10 min to reach moderate to moderately severe claudication followed by rest until pain has dissipated (2–5 min) Frequency :3 times per week supervised Program duration :At least 12 wk Progression :Every 1–2 wk increase duration of training session to achieve 50 min. As individuals can walk beyond 10 min without reaching prescribed claudication level, manipulate grade or speed of exercise prescription to keep the walking bouts within 5–10 min Maintenance: Lifelong maintenance at least 2 times per week Exercise Prescription for Supervised Exercise Treadmill Training in Patients With Claudication 21

22. Exercise prescription for PAD patient without claudication Endurance Training Frequency:3–5 d·wk −1 Modality: Stairclimber Stationary Cycle Arm Cycle Ergometry Rowing Swimming Intensity : 40 – <60% heart rate reserve + resting HR  or  40 – <60% VO 2  reserve + resting VO 2 Duration : 30–60 min·day −1 22

23. Resistance Training Frequency:≥2–3 d·wk −1 Intensity:1–3sets of 8–15 RM for muscle group All Major Muscle Groups 1. Arms/Shoulders: Biceps curls Triceps extension Overhead press Lateral raises 2. Chest/back: Bench press Lateral pull down /pull-ups Bent-over / Seated row 3. Legs: Leg extensions, curls, press Adductor / Abductor 23

24. Biceps curl Triceps extension Overhead press Lateral raises 24

25. Bench press Lateral pull up and pull down Bent over/seated row 25

26. Leg extension Leg curl Leg press 26

27. REFERENCES www.healthline.com www.hopkinsmedicine.org Physiopedia Casillas JM, Troisgros O, Hannequin A, Gremeaux V, Ader P, Rapin A, Laurent Y. Rehabilitation in patients with peripheral arterial disease. Ann Phys Rehabil Med. 2011 Oct;54(7):443-61. English, French. doi : 10.1016/j.rehab.2011.07.001. Epub 2011 Aug 5. PMID: 21917541. Hamburg NM, Balady GJ. Exercise rehabilitation in peripheral artery disease: functional impact and mechanisms of benefits.  Circulation . 2011;123(1):87-97. doi:10.1161/CIRCULATIONAHA.109.881888 27