1. GOAL SETTING & TREATMENT PLANNING: C IRCULATORY C ASES Ms. Aila Nica J. Bandong, PTRP Unit presenter

2. Objectives At the end of the lecture, the students should be able to  Identify disorders of the arterial, venous, and lymphatic systems.  Describe clinical manifestations of vascular disorders of the extremities.  Identify pertinent assessment procedures to be performed in patients with vascular disorders.  Discuss factors that affect prognosis among patients with vascular disorders  Discuss considerations in setting goals for patients with vascular disorders.  Discuss treatment considerations in addressing vascular disorders.

3. Circulatory System Vascular Arteries Veins Lymphatic ANATOMY of the CIRCULATORY SYSTEM Let’s review your ANATOMY!!!

4. T HE V ASCULAR S YSTEM LEGEND: Arteries Veins

5. T HE L YMPHATIC S YSTEM  Protect the body from infection and disease  Facilitate movement of fluid back and forth between the bloodstream and interstitial fluid, removing excess fluid, blood waste, and protein molecules FUNCTIONS

6. TREATMENT PLANNING Thera Ex Assessment MRL

7. D ISORDERS OF THE C IRCULATORY S YSTEM  Can be classified into ACUTE and CHRONIC Peripheral Vascular Disease (PVD)  Caused by pathologies such as occlusion, inflammation, vasomotor dysfunction, or neoplasm

8. ARTERIAL INSUFFICIENCY

9.  Lack of adequate blood flow to a region of the body Acute arterial occlusion Arteriosclerosis obliterans Thromboangiitis obliterans Raynaud’s disease

10. Acute Arterial Occlusion  Acute loss of blood flow to peripheral arteries  Caused by:  Thrombus  Embolus  Trauma

11. Arteriosclerosis Obliterans (ASO)  Aka Chronic Occlusive Arterial Disease, Peripheral Arterial Occlusive Disease, Atherosclerotic Occlusive Disease  Arteriosclerosis vs Atherosclerosis  Peripheral manifestation of atherosclerosis characterized by chronic, progressive occlusion of the peripheral circulation, most often in the LARGE and MEDIUM arteries of the lower extremities

12. Arteriosclerosis Obliterans (ASO)  Epidemiology  Male > Female  Onset: >50 yrs  Risk factors  Elevated serum cholesterol (>200 mg/dL)  Smoking  High systolic BP  Obesity  Diabetes

13. Thromboangiitis Obliterans (TAO)  Aka Buerger’s Disease  A chronic disease characterized by an inflammatory reaction to nicotine resulting to vasoconstriction, decreased arterial circulation to the extremities, ischemia, and ulceration and necrosis of soft tissues  Affects the SMALL arteries of the hands and feet initially, then progresses proximally to include larger arteries

14. Thromboangiitis Obliterans (TAO)  Epidemiology  Male > Female  Onset: young (early adulthood)  Etiology  SMOKING!!!

15. Raynaud’s Disease  Aka Primary Raynaud’s Syndrome  Raynaud’s disease vs Raynaud’s phenomenon  Chronic, functional vasomotor disease characterized by temporary pallor then cyanosis and pain, followed by numbness and cold sensation of the digits  Affects the SMALL arteries and arterioles of the fingers most commonly and toes

16. Raynaud’s Disease  Epidemiology  Female > Male  Etiology  Sympathetic nervous system abnormality

17. C LINICAL M ANIFESTATIONS : P ERIPHERAL A RTERIAL D ISORDERS  Diminished or absent peripheral pulses  Integumentary changes  Skin discoloration  Trophic skin changes  Decreased skin temperature  Ulcerations  Sensory disturbances  Exercise and rest pain  Muscle weakness

18. Procedures that confirm Arterial Insufficiency  Ankle-brachial index  Doppler ultrasonography  Transcutaneous oximetry  Arteriography  Color duplex imaging  Magnetic resonance angiography

19. A SSESSMENT P ROCEDURES  Comprehensive history-taking and subjective assessment  Ancillary procedures  Ocular inspection  Palpation  Special Tests  Sensory Assessment  Manual Muscle Testing  Others

20. Ocular Inspection  Take note of the following:  Skin trophic changes  Skin discoloration  Wounds or ulcerations

21. Palpation  Peripheral pulses  Strength: normal, diminished, absent  LE: femoral, popliteal, dorsalis pedis, posterior tibial  UE: brachial, radial, ulnar  Skin temperature

22. Special Tests  Rubor of dependency  Reactive hyperemia  Claudication time  Functional treadmill exercise test

23. A NTICIPATED P ROBLEMS ???  Muscle atrophy  Contractures  Wounds/ulcerations  Myocardial infarction  Stroke * Especially if patient is on bed rest

24. predicts risk of future lower extremity ulcers, or need for vascular surgery or amputation asymptomatic and symptomatic PAD are consistent and powerful independent predictors of coronary artery disease and cerebrovascular disease events and mortality What does evidence say? PADPAD Golomb, BA, et al (2006). Peripheral arterial disease: Morbidity and mortality implications. Circulation. Retrieved on February 15, 2010 from http://circ.ahajournals.org/cgi/content/full/114/7/688

25. G OAL S ETTING C ONSIDERATIONS  Increase the exercise period or tolerance in performing activities before onset of pain (intermittent claudication)  Incorporate patient’s goals: what activities are meaningful to the patient

26. increase in claudication distances translated into increased free-living daily physical activity in the community setting enhanced ambulation improved peripheral circulation and cardiopulmonary function What does evidence say? Gardner, AW, et al. (2000). Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication. Journal of Gerontology. 55(10). M570-M577.

27. M ANAGEMENT G UIDELINES : Acute Arterial Occlusion  Therapeutic exercise  Direct heat application on the painful area  Prolonged positioning during bed rest  Restrictive clothing  Support hose

28. M ANAGEMENT G UIDELINES : Chronic Arterial Insufficiency  Graded exercise program to increase tolerance in activities  Improve vasodilation in affected arteries  Related medical problems must be identified and managed to control progression of the condition  Lifestyle modifications

29. exercise programmes clearly improve walking time and distance for people considered fit for exercise benefit lasted for up to two years types of exercise varied from strength training to upper or lower limb exercises, in generally supervised sessions, at least twice weekly What does evidence say? Watson, L., et al. (2008). Exercise for intermittent claudication. Retrieved on February 16, 2010 from http://www.thecochranelibrary.com.

30. Supervised treadmill training improved 6- minute walk performance, treadmill walking performance, brachial artery flow-mediated dilation, and quality of life of participants with and without intermittent claudication Lower extremity resistance training improved functional performance measured by treadmill walking, quality of life, and stair climbing ability What does evidence say? McDermott, MM., et al. (2009). Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: A randomized controlled trial. Retrieved on February 18, 2010 from http://jama.ama-assn.org/cgi/content/full/301/2/165.

31. a walking program will significantly improve walking distance of patients with intermittent claudication Limitations: statistical pooling of data was not performed; rather, a qualitative meta-analysis was performed What does evidence say? Brandsma, J. W., et al. (1998). The effect of exercises on walking distance of patients with intermittent claudication: A study of randomized clinical trials. Physical Therapy 78(3), 278-288.

32. Exercise Guidelines  Warm-up period of 10 minutes  Exercise proper within patient’s tolerance, above threshold level but not eliciting symptoms for 20 to 60 minutes, 3 to 5 days per week  Treadmill walking  Bicycle ergometer  Upper extremity ergometer  Cool-down period of 5 to 10 minutes

33. S PECIAL C ONSIDERATIONS : C HRONIC A RTERIAL I NSUFFICIENCY  Precautions  Avoid exercising outside during cold weather  Wear well-fitting shoes  Check feet for skin irritation after exercise  If leg pain increases after the program, discontinue  Contraindications  (+) skin irritation or wounds  Leg pain at rest

34. F ACTORS A FFECTING P ROGNOSIS  Co-morbidities: conditions associated with arterial insufficiency  Presence of leg pain at rest: denotes severe arterial disease  Presence of wounds and ulcerations: may lead to necrosis and amputation if not managed effectively; exercise programs are not advisable  Lifestyle of the patient

35. Age, ischaemic heart disease or cerebrovascular disease, and continued smoking were the principal factors associated with an adverse prognosis in patients with intermittent claudication What does evidence say? Hughson, W., Mann, J., Tibbs, D. Woods, H., and Walton, I. (1978). Intermittent claudication: Factors determining outcome. British Medical Journal. 1377-1379. PROGNOSISPROGNOSIS

36. Patients limited by intermittent claudication who engage in any amount of weekly physical activity beyond light intensity at baseline have a lower mortality rate than their sedentary counterparts who perform either no physical activity or only light- intensity activities What does evidence say? Gardner, A., Montgomery, P., and Parker, D. (2009). Physical activity is a predictor of all-cause mortality in patients with intermittent claudication. Journal of Vascular Surgery 47(1). 117-122. PROGNOSISPROGNOSIS

37. VENOUS INSUFFICIENCY

38.  Inadequate drainage of venous blood from a body part Thrombophlebitis Chronic venous insufficiency

39. Thrombophlebitis  Inflammation of the vein secondary to a thrombus/blood clot formation  Partial or complete occlusion of a superficial and deep vein Superficial thrombophlebitis Deep vein thrombosis

40. Superficial Thrombophlebitis  Thrombus formation at the superficial vein system  Small and resolves without serious complications

41. Deep Vein Thrombosis (DVT)  Thrombus formation at the deep veins  Larger and causes serious complications (embolism)

42. Deep Vein Thrombosis (DVT) VIRCHOW’s TRIAD (HIV) INTIMAL WALL DAMAGEHYPERCOAGULABILITY VENOUS STASIS

43. Deep Vein Thrombosis and Thrombophlebitis  Risk Factors  Prolonged immobilization  Trauma to vessels  Limb paralysis  Active malignancy within the past 6 months  History of DVT or pulmonary embolism  Risk Factors  Advanced age  Obesity  Sedentary lifestyle  Congestive heart failure  Use of oral contraceptives  Pregnancy

44. C LINICAL M ANIFESTATIONS : DVT AND T HROMBOPHLEBITIS  Swelling of the unilateral or bilateral extremities  Complaints of itching, fatigue, heaviness, dull aching or severe pain in the involved extremities  Increase in skin temperature  Redness of the skin

45. Chronic Venous Insufficiency  Venous insufficiency that persists over a long period of time  More common cause of leg ulcers than arterial insufficiency

46. C LINICAL M ANIFESTATIONS : C HRONIC V ENOUS I NSUFFICIENCY  Dependent edema of distal extremities that decreases with elevation  Dull, aching pain or tiredness in the affected extremity  If associated with varicosities, bulging of the vein (venous distention) is seen  Brownish pigmentation if edema persists

47. A SSESSMENT P ROCEDURES  Comprehensive subjective assessment  Ancillary procedures  Ocular inspection  Pain assessment  Palpation  Special tests  Anthropometric measurements  Range-of-motion  Manual muscle testing; Endurance

48. Special Tests  Percussion Test  Assess competency of the great saphenous vein  Used in the presence of varicosities  Homan’s Sign  Determines presence of deep vein thrombosis  Reliability: poor  Compression of limb with BP cuff  Intolerance to pressure above 40mmHg indicates acute thrombophlebitis

49. Ancillary Procedures  Doppler ultrasonography  Venous duplex screening/scanning  Venography (phlebography)

50. A NTICIPATED P ROBLEMS ???  DVT  Pulmonary embolism  Stroke  Recurrence of acute disorder  Chronic Venous Insufficiency  Lymphedema  Necrosis of tissues  Venous stasis ulcers

51. G OAL S ETTING C ONSIDERATIONS  DVT  Promote early ambulation  Chronic Venous Insufficiency  Return to function or activities with decreased occurrence of symptoms

52. M ANAGEMENT G UIDELINES : D EEP V EIN T HROMBOSIS  Medical intervention: anti-coagulants  Complete bed rest: 2 days to a week or more (7 to 10 days)  Extremity elevation: if LE involvement, knee should be slightly flexed  Use of graduated compression stockings  Graded ambulation using compression garments

53. initiating ambulation at 24 hours after pharmacologic management does not increase incidence of pulmonary embolism, and resolution of pain and swelling however, they also stressed that, due to limited evidence gathered, appropriate timing of initiating ambulation is dependent on PT and MD judgment, especially for patients with (+) pulmonary embolism What does evidence say? Aldrich, D., Hunt, D. P. (2000). When can the patient with deep venous thrombosis begin to ambulate? Physical Therapy 84(3), 268-273.

54. thigh-length GCS are not clinically effective at reducing the risk of proximal DVT after stroke and are associated with some adverse effects skin breaks, ulcers, blisters, and skin necrosis discomfort, inconvenience What does evidence say? The CLOTS Trials Collaboration. (2009). Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): A multicentre, randomised controlled trial. Retrieved on February 10, 2010 from http://thelancet.com.

55. M ANAGEMENT G UIDELINES : C HRONIC V ENOUS I NSUFFICIENCY  Patient education  Proper skin care  Compression garments  Decongestive therapy for management of lymphedema, if present  exercises

56. conservative treatment options for varicose veins include: avoidance of prolonged standing and straining elevation of the affected leg exercise external compression loosening of restrictive clothing medical therapy modification of cardiovascular risk factors reduction of peripheral edema weight loss What does evidence say? Jones, R. H. and Carek, P. J. (2008). Management of varicose veins. Retrieved on February 17, 2010 from http://www.aafp.org/afp.

57. LYMPHATIC DISORDERS

58. L YMPHATIC I NSUFFICIENCY  Disorders of the lymphatic transport system that may cause primary or secondary lymphedema (associated with another condition) Congenital malformation of the lymphatic system Infection and inflammation Obstruction or fibrosis Surgical dissection of lymph nodes Chronic venous insufficiency

59. C LINICAL M ANIFESTATIONS  Lymphedema  Increased size of limb  Sensory disturbance  Limited range-of-motion  Delayed wound healing

60. Lymphedema  Excessive and persistent accumulation of extracellular and extravascular fluids and proteins in tissue spaces due to compromised lymphatic system  Develops in the distal extremities  Pitting, brawny, weeping edema  Dependent edema

61. Lymphedema  Stage I lymphedema:  spontaneously reversible  Involves pitting edema, an increase in UE girth, and heaviness  Stage II lymphedema:  spongy consistency of the tissue  no signs of pitting edema  tissue fibrosis causes limbs to harden  increase in size  Stage III lymphedema:  advanced stage  lymphostatic elephantiasis Bicego D, Brown K, Ruddick M, et al. (2006). Exercise for women with or at risk for breast cancer– related lymphedema. Physical Therapy. 1398 –1405.

62. A SSESSMENT P ROCEDURES  Comprehensive history and systems review  Ocular inspection  Palpation  Anthropometric measurement  Range-of-motion  Manual muscle testing  Others

63. Grading of Edema  Pitting edema scale

64. A NTICIPATED P ROBLEMS ???  Wound infections  If associated with cancer:  Adhesions/contractures  Postural deviations  Decreased endurance

65. G OAL S ETTING C ONSIDERATIONS  Regain functional use of the involved extremity  Decreased occurrence of lymphedema  Consider task or activities of the patient  Requirements of the task

66. M ANAGEMENT G UIDELINES  Decongestive lymphatic therapy  Aka complex lymphedema therapy, complete or complex decongestive physical therapy  Includes the following: Elevation Manual lymphatic drainage Compression Active range-of-motion exercise Low-intensity resistance exercise Cardiopulmonary conditioning Skin care

67. consistent and long-term use of compression garments Recommended a range of 3 compression classes: 20 to SO mm Hg, 30 to 40 mm Hg, and 40 to 50 mm Hg.3g combined techniques, involving massage, sequential pneumatic compression, compression garments or compression bandaging, and exercise microwave therapy, used in conjunction with compression garments may be effective in reducing limb volume, but electrical stimulation, used in combination with compression garments, is no more effective than compression garments alone What does evidence say? Megens, A. and Harris, S. (1998). Physical therapist management of lymphedema following treatment for breast cancer: A critical review of its effectiveness. Physical Therapy 78(12). 1302-1311.

68. S PECIAL C ONSIDERATIONS  Wear compressive garments during exercise  Avoid wearing restrictive clothing  Avoid use of local heat or exercising in warm, humid environments  Avoid taking blood pressure on the involved extremity  Proper skin care

69. THANK YOU FOR LISTENING!!! Do you have any questions???

70. References Aldrich, D., Hunt, D. P. (2000). When can the patient with deep venous thrombosis begin to ambulate? Physical Therapy 84(3), 268-273. Bicego D, Brown K, Ruddick M, et al. (2006). Exercise for women with or at risk for breast cancer–related lymphedema. Physical Therapy. 1398 –1405. Braddom, R. L. (2007). Physical medicine and rehabilitation (3 rd ed). Philadelphia: Saunders Elsevier. Brandsma, J. W., Robeer, B. G., Van den Heuvel, S., Smit, B., Wittens, C., Oostendorp, R. (1998). The effect of exercises on walking distance of patients with intermittent claudication: A study of randomized clinical trials. Physical Therapy 78(3), 278-288. Gardner, A. W., Katzel, L. I., Sorkin, J. D., Killowich, L. A., Ryan, A., Flinn, W. R., and Goldberg, A. P. (2000). Improved functional outcomes following exercise rehabilitation in patients with intermittent claudication. Journal of Gerontology 55(10), 570-577. Gardner, A., Montgomery, P., and Parker, D. (2009). Physical activity is a predictor of all-cause mortality in patients with intermittent claudication. Journal of Vascular Surgery 47(1). 117-122. Golomb, BA, et al (2006). Peripheral arterial disease: Morbidity and mortality implications. Circulation. Retrieved on February 15, 2010 from http://circ.ahajournals.org/cgi/content/full/114/7/688. Hughson, W., Mann, J., Tibbs, D. Woods, H., and Walton, I. (1978). Intermittent claudication: Factors determining outcome. British Medical Journal. 1377- 1379. Jones, R. H. and Carek, P. J. (2008). Management of varicose veins. Retrieved on February 17, 2010 from http://www.aafp.org/afp. Kisner, C. and Colby, L. A. (2007). Therapeutic exercise: Foundations and techniques (5 th ed). Philadelphia: F. A. Davis Company. McDermott, MM., et al. (2009). Treadmill exercise and resistance training in patients with peripheral arterial disease with and without intermittent claudication: A randomized controlled trial. Retrieved on February 18, 2010 from http://jama.ama-assn.org/cgi/content/full/301/2/165. Megens, A. and Harris, S. (1998). Physical therapist management of lymphedema following treatment for breast cancer: A critical review of its effectiveness. Physical Therapy 78(12). 1302-1311. The CLOTS Trials Collaboration. (2009). Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): A multicentre, randomised controlled trial. Retrieved on February 10, 2010 from http://thelancet.com. Watson, L., et al. (2008). Exercise for intermittent claudication. Retrieved on February 16, 2010 from http://www.thecochranelibrary.com.