Vascular disorders

physiotherapy in Vascular disorders

1. Physiotherapy in vascular disorders A. Thangamani ramalingam PT, MSc( psy ),PGDRM, ACspss MIAP

2. Management of vascular disease[8 Hours] : thrombosis, phlebitis and phlebothrombosis , burger’s disease, varicose veins, DVT, venous ulcers, lymphoedema & its PT management

3. Vascular disorders Atherosclerosis and Peripheral Artery Disease Aneurysm Raynaud's Phenomenon (Raynaud's Disease or Raynaud's Syndrome) Buerger's Disease(TAO) Peripheral Venous Disease and Varicose Veins Blood Clots in Veins/venous thromboembolisms (VTE ) Blood Clotting Disorders Lymphedema

4. Hemodynamics Decreases-thrombosis, ischemia &infarction Increases- hemorrhage, edema &hyperemia Causes: Traumatic Compressive Occlusive Tumours (growths) or malformations  Vessel spasms

5. Other factors not engaging in physical exercise poor eating habits smoking drug use over age 50 overweight abnormal cholesterol level history of cerebrovascular disease or stroke  heart disease diabetes family history of high cholesterol, high blood pressure, or PVD high blood pressure kidney disease on hemodialysis extreme injuries blood vessel inflammation infection.

6. symptoms Pain Decreased or no pulse Abnormal color changes in the fingertips( palor ) Ulcers or wounds that do not heal/gangrene Hand problems when in cold temperatures or locations Numbness or tingling of the fingertips Swelling R educed hair growth S evere burning of extremities Heavy limbs Cramps Claudication

7. Test Method interpretation Doppler ultrasound sound waves for imaging blood flow ankle-brachial index (ABI) ultrasound and blood pressure cuff around your ankle and arm, measured before and during exercise comparison of blood pressure readings in leg and arm - lower pressure in leg indicates a blockage angiography injected dye in a catheter that’s guided through the artery to diagnose the clogged artery magnetic resonance angiography (MRA) magnetic field imaging to diagnose blockage computerized tomography angiography (CTA) X-ray imaging to diagnose blockage

8. treatment Medications 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 diabetes medication to control blood sugar Surgery Phlebotomy Amputation

9. Phlebitis Phlebo thrombosis  occurs when a blood clot in a vein, forms independently from the presence of inflammation of the vein ( phlebitis ).  Thrombophlebitis  is phlebitis (vein inflammation) related to a thrombus (blood clot). These are conditions usually of the superficial venous system and generally mild and uncomplicated as opposed to deep vein thromboses  which can be life-threatening Phlebitis refers to inflammation of a vein Thrombophlebitis refers to the formation of a blood clot associated with phlebitis . Thrombophlebitis can be superficial (skin level) or deep (in deeper veins). F irst described by the Scottish surgeon John Hunter in 1784 . Treatment usually consists of  NSAIDs Pain Swelling Redness Tenderness Hard and cord like veins

10. Thrombosis/Greek-clot Increased temp Tender/swollen calf Red/shiny skin Homan’s test positive Engorged veins/edema Cord like veins Pain along the course of the vein

11. Deep vein thrombosis

12. Risk of DVT may begin during,in24-48hrs or late as 3 months of surgery

13. Homans ' sign  is a  sign of  deep vein thrombosis (DVT). A positive sign is present when there is pain in the calf or popliteal region with examiner's abrupt dorsiflexion of the patient's foot at the ankle while the knee is flexed to 90 degrees.

14. Pratt's sign  is an indication of femoral deep vein thrombosis. It is seen as the presence of dilated pretibial veins in the affected leg, which remain dilated on raising the leg. The sign was described by  American surgeon Gerald H. Pratt of St. Vincent's Hospital in 1949

15. Wells score or criteria: (Possible score -2 to 9) Active cancer (treatment within last 6 months or palliative) +1 point Calf swelling >3 cm compared to other calf (measured 10 cm below tibial tuberosity) +1 point Collateral superficial veins (non-varicose) +1 point Pitting edema (confined to symptomatic leg) +1 point Previous documented DVT +1 point. Swelling of entire leg +1 point Localized pain along distribution of deep venous system +1 point Paralysis, paresis, or recent cast immobilization of lower extremities +1 point Recently bedridden > 3 days, or major surgery requiring regional or general anesthetic in past 4 weeks +1 point Alternative diagnosis at least as likely -2 points

16. Interpretation: Score of 2 or higher — deep vein thrombosis is likely. Consider imaging the leg veins. Score of less than 2 — deep vein thrombosis is unlikely. Consider blood test such as  d-dimer test to further rule out deep vein thrombosis.

17. DVT complications(long term) Night pain Venous ulceration edema

18. Diagnostic tests Duplex ultra sound Venography Impedance plethysmography MRI D-dimer blood test

19. Prevention of DVT Heparin Warfarin Aspirin Dextran Compression devices

20. Burger’s disease/ thromboangiitis obliterans (TAO ) Medicines don’t usually work well to treat the disease. surgery may be effective stop using all tobacco products recurring progressive inflammation and thrombosis (clotting) of small and medium arteries and veins of the hands and feet. Pain Claudication at rest/walking ischemic ulcers or gangrene Cold hands or feet Skin changes

21. Burgers test- (assessment of arterial sufficiency ) With the patient supine, note the colour of the feet soles. They should be pink. Then elevate both legs to 45 degrees for more than 1 minute. Observe the soles. If there is marked pallor (whiteness), ischemia should be suspected. Capillary refill test Rubor of dependency: Sit the patient upright and observe the feet. In normal patients, the feet quickly turn pink. If, more slowly, they turn red like a cooked lobster, suspect ischemia.

22. Venous Filling Time Test Elevate leg to approximately 60for 1‐2 minutes • Allow gravity to drain distal veins • Quickly lower leg over edge of table/bed to dependent position (leg hanging perpendicular to floor) • Observe superficial veins and record amount of time required for them to refill and return to baseline appearance • Normal 5‐15 seconds • > 20 seconds indicative of moderate to sever arterial insufficiency • If refill < 5 seconds suspect venous insufficiency

23. ABPI The ankle pressure should be equal to or slightly higher than the arm pressure in the absence of arterial occlusive disease

24. Buerger -Allen exercise Buerger exercises is a system of exercises for arterial insufficiency of lower limbs, consisting of legs elevation, followed by dependency of the legs, and finally horizontal position of legs for rest. Published in 1924 by Leo Buerger (1879-1943), New York physician . Buerger exercises augmented by active exercises of the feet. These  exercises consist in flexion, extension, and circumduction of the ankles and are done during the phase of dependency of the legs, as suggested in 1931 by Arthur W. Allen (1887-1958). Buerger -Allen exercise  - Specific exercises intended to improve circulation to the feet and legs. The lower extremities are elevated to a 45 to 90 degree angle and supported in this position until the skin blanches (appears dead white). The feet and legs are then lowered below the level of the rest of the body until redness appears (care should be taken that there is no pressure against the back of the knees); finally, the legs are placed flat on the bed for a few minutes. The length of time for each position varies with the patient's tolerance and the speed with which color change occurs. Usually the exercises are prescribed so that the legs are elevated for 2 to 3 minutes, down 5 to 10 minutes, and then flat on the bed for 10 minutes.

25. Varicose veins Valvular insufficiency/ valvular incompetence visible, bulging, palpable (can be felt by touching), long, and dilated (greater than 4 millimeters in diameter ). retrograde flow or venous reflux leg swelling, stasis dermatitis/venous  eczema, skin thickening( lipodermatosclerosis ) and  ulceration Cramps telangiectasia/spider veins   sclerotherapy , elastic stockings, leg elevation and exercise . ultrasound-guided foam sclerotherapy , radiofrequency ablation and endovenous laser treatment. Cryotherapy

26. Trendelenburg Test  or  Brodie-Trendelenburg test patient in the supine position leg is flexed at the hip and raised  A tourniquet is applied around the upper thigh to compress the superficial veins The leg is then lowered by asking the patient to stand. Normally the superficial saphenous vein will fill from below within 30–35 seconds as blood from the capillary beds reaches the veins; if the superficial veins fill more rapidly with the tourniquet in place there is valvular incompetence below the level of the tourniquet in the "deep" or "communicating" veins. After 20 seconds, if there has been no rapid filling, the tourniquet is released. If there is sudden filling at this point, it indicates that the deep and communicating veins are competent but the superficial veins are incompetent The test can be repeated with the tourniquet at different levels above the knee - to assess the mid-thigh perforators below the knee - to assess incompetence between the short saphenous vein and the popliteal vein

27. commonly used as sclerosants are polidocanol , sodium tetradecyl sulphate (STS), Sclerodex , Hypertonic Saline, Glycerin and Chromated Glycerin . Flavonoids drug therapy.

28. Venous ulcers An ulcer is a shallow destruction of the skin tissues & mucous membrane which may occur at any part of the body. Various ulcers are the complication of various veinous problems Stasis and congestion both in veins & lymphatics Slight trauma – break down of skin – infected – ulcer – chronic inflammation –pain & stiffness – less usage – hypotonia of the muscle – decreased venous pumping –stasis & congestion – skin more prone for injuries(vicious cycle) Massage/pain relief/FUP/UVR/Laser Bisguard bandage method

29. Lymphoedema Primary Secondary

30. Causes of edema 1. Increased Hydro static Pressure of blood 2. Decreased Osmotic Pressure of blood 3. Increased Capillary permeability 4. Lymphatic obstruction 5. Slowed flow of blood and lymph

31. Direction and Amount of Pressure Gradient Arterial end: 30.3(Hydro)-22.= 8.3 out Venule end: 22(Net COP)- 15.3= 6.7 in

32. Measuring Edema 1+ - oedema barely there 2+ - oedema Significantly present 3+ - oedema is Very significant 4+ - The limb is 1.5-2.0 times more than the normal size

33. Lymphoedema grades

34. causes

35. Objectives of therapy Quitting smoking Lowering cholesterol Lower blood pressure Lower blood glucose Physical activity

36. physiotherapy The recommended parameters of physical exercise are a 6 month program of 30-35 minutes walking sessions at a frequency of 3-5 times a week at near-maximal pain tolerant  ( Mahameed , AA, Bartholomew, JR, Disease of Peripheral Vessels. In: Topol , EJ, editor. Textbook of Cardiovascular Medicine. 3rd ed. New York: Lippincott Williams & amp; Wilkins, 2007, p.1531-1537). NICE recommends PAD patients to exercise at near-maximal pain for a total of 2 hours per week for 3 months to improve quality of life  (NICE National Institute for Health and Care Excellence. Lower limb peripheral arterial disease: diagnosis and management,2012 . https:// www.nice.org.uk/guidance/cg147/chapter/guidance#management-of-intermittent-claudication )

37. Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. 1995;274:975-80. Lauret GJ, Fakhry F, Fokkenrood HJ, Hunink MG, Teijink JA, Spronk S. Modes of exercise training for intermittent claudication. Cochrane Database Syst Rev. 2014;7:CD009638 The duration and frequency of the exercise training sessions and duration of the exercise training program are important to achieve maximal benefit with training sessions: >30 minutes per session provides greater benefit than <30 minutes per session; >3 sessions per week is more effective than <3 sessions per week, and program lengths of >26 weeks are more effective than program lengths of <26 weeks . Alternatives to treadmill exercise potentially consist of various forms of lower extremity exercise alone or in combination (brisk walking, bicycle ergometer, and strength training). However, the outcomes of treadmill exercise have so far been found to be superior to the outcomes of several other lower extremity exercises, namely cycling, stair climbing, and static and dynamic leg exercises .

38. thank you