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Physical Therapy with Peripheral Vascular Disease (PVD) patients.

2012 Class Presentation - Rebecca Simpson, Amanda Daughrity, Stacey Luna, & Lisa Brown
by

Stacey Luna

on 9 January 2013

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Transcript of Physical Therapy with Peripheral Vascular Disease (PVD) patients.

References:

Rossi E, Biasucci LM, Citterio F, Pelliccioni S, al e. Risk of myocardial infarction and angina in patients with severe peripheral vascular disease: Predictive role of C-reactive protein. Circulation. 2002;105(7):800-3. http://search.proquest.com/docview/212767984?accountid=41004.

Kisner C, Colby LA. Therapeutic Exercise 5th Edition. Philadelphia: F.A. Davis Company; 2007.

Gautam A, Maiya A, Vidyasagar M. Effect of home-based exercise program on lymphedema and quality of life in female post-mastectomy patients: pre-post intervention study. Journal Of Rehabilitation Research And Development [serial online]. 2011; 48(10):1261-1268. Available from: MEDLINE, Ipswich, MA.

Cohen M. Case Reports: Complete Decongestive Physical Therapy in a Patient With Secondary Lymphedema Due to Orthopedic Trauma and Surgery of the Lower Extremity. PHYS THER. November 2011;91:1618-1626. doi:10.2522/ptj.20100101

O’Sullivan, SB,Schmitz TJ. Physical Rehabilitation Fifth Edition. Philadelphia: F.A. Davis Company; 2007.

Adams J, Ogola G, Stafford P, Koutras P, Hartman J. High-intensity interval training for intermittent claudication in a vascular rehabilitation program. J Vasc Nurs. 2006;24(2): 46-49.

Schmidt-Trucksass, A. Exercise as a treatment option in peripheral arterial disease. Cardiovascular Medicine. 2012; 15(3): 79-84. Amanda's section Stacey's section Lisa's section Mr. Kaiser is 75 year old college professor recently admitted to a nursing home. He has become depressed due to illness and being isolated from his peer group. Mr. Kaiser has peripheral vascular disease; more specifically arteriosclerosis obliterans. Arteriosclerosis obliterans aka peripheral arterial occlusive disease, chronic occlusive arterial disease, or atherosclerotic occlusive disease

accounts for 95% of all the arterial disorders affecting the lower extremities
more common in men
often seen in elderly

Risk factors: high cholesterol, smoking, high systolic blood pressure, obesity, and diabetes.
(Kisner) Mr. Kaiser was a smoker, but quit 5 years ago. He was diagnosed with arteriosclerosis obliterans by his primary care doctor who found the dry, shiny, pallor of the skin of his LE, the below- normal skin temperature, and absence of leg hair. Confirmation was made by an Ankle-Brachial Index. (O’Sullivan) On Mr. Kaiser’s first visit, he admitted to rarely exercising due to experiencing pain in his calves and from feeling blue about his new living situation. The pain associated with this arterial disorder occurs with exercise and can be in the calf, foot, thigh, buttocks, or low back. It is called intermittent claudication.
A more serious manifestation of ASO is rest pain, in which pain is felt in LEs at rest, usually at night. (Kisner) It was discovered that Mr. Kaiser did not have any ulcerations on his feet or bony prominences, which can occur.

Mr. Kaiser’s claudication time was assessed with a treadmill test. He walked level at 1-2 mph until he began to feel pain.
Mr. Kaiser felt pain after 8 minutes.

Mr. Kaiser’s THR was determined to be 118 using Karvonen’s formula at 60% A graded exercise program using aerobic activities of walking or bicycling, in interval training with rest relief, has been shown to benefit people with arterial disease.

The participants in a study in 2006 walked briskly enough or with a non-level grade on a treadmill to bring on claudication pain within 6 min. They then rested for 3 min and walked again until pain and did 6 intervals in a session. Once able to walk 6 min. without resting, the speed and grade were increased to bring them to pain more quickly. Thirty-five subjects, mean age of 68, had an increased tolerance for more strenuous activity in 12 weeks. (Adams) The physiology of this is that collateral vessels are formed due to shear stress in the arteries that happens because of the working muscles. More nitric oxide is produced, too, which is an anti-atherosclerotic substance. So repeated bouts of exercise stimulated new capillaries in the tissues where ischemia is taking place. (Schmidt) Do NOT exercise if you begin to experience leg pain at rest.
Do NOT exercise if you develop a wound, skin irritation, ulcer, or fungal infection on your feet.
Let us know if either of these occur.
DO exercise with a partner; talk while you walk; play upbeat, fun music. Mr. Kaiser’s Home Exercise Program Don’t exercise outdoors in very cold weather.
Always wear really good-fitting, well-padded shoes that don’t rub.
Always check your feet after exercising. CAUTIONS 3 to 5 times a week, 30 min. minimum, working toward goal of 60 min. Frequency Sitting – 25 toe raises
25 heel raise

Standing – deep breath, raise arms to sides and bring overhead,
release breath as you lower arms. 5 reps WARM UP You may use the treadmill or the track at your community rec center or the grounds of your facility.

Walk until you feel pain in your calf, rest until pain abates (2-3 min), resume walking, and continue this pattern for 20 min. Slow your pace if you exceed you max THR. AEROBIC/ENDURANCE Walk for 5 min at a very slow pace.
Repeat stretches from warm-up but do 3 sets, holding 30 sec. COOL DOWN Stretches: feet shoulder-width apart, bend toward left side, hold 20 sec.
Bend toward right and hold, then bend forward, reaching for toes and hold. One hand may be on a chair or railing for balance. Repeat. Rebecca's section Arterial Venous Lymphatic Peripheral Vascular Disease (PVD) Presentation by: Lisa Brown, Amanda Daughrity, Stacey Luna, & Rebecca Simpson Jay's decongestive exercises for the lower extremities include the following:

All from supine (laying on your back) position

Deep breathing:
take slow deep breaths for about a minute

One-leg knee-to-chest:
raise right knee to chest 15x, then left knee

Both-leg knee-to-chest:
raise both knees, wrapping your hands around your thighs and gently pull them into the check. Repeat 15x

Posterior pelvic tilts:
tighten gluteals and pull belly button in toward the spine. Release slowly. Repeat 5x

External rotation of the hips:
legs elevated and resting against a wall, press buttocks together and externally rotate the hips. Repeat 5x each side

Knee flexion to clear the popliteal area:
keep right leg straight, bend left leg & hip to clear foot from mat, actively flex knee as far as possible by quickly moving the heel to the buttocks. Repeat 15x

Active ankle movements:
with both legs elevated and propped against a wall, do 15 ankle pumps and foot circles (clockwise & counterclockwise)

Wall slides in external rotation:
with feet propped against the wall, legs externally rotated, and heels touching, slide both feet down the wall as far as possible. 15x

Leg movements in the air:
both hips flexed and back flat on the floor, move legs pointed toward the ceiling in a walking or cycling pattern

Hip adduction across the midline (clear inguinal nodes):
flex left hip and knee, grasp the knee with the right hand, pulling the knee repeatedly across the midline in a rocking motion

Bilateral knee to the chest: repeat

Partial curl-ups
lift shoulders from the floor, 5x

Rest:
with feet elevated and legs propped against the wall, rest for several minutes. lower legs to a wedge or pillow and rest several more minutes Jay is 23 year old construction worker, functionally illiterate but very active and enjoys basketball and swimming. Uses public transportation to get to job site and lives in apartment complex with his 2 brothers. Jay has been diagnosed via duplex ultrasound, with chronic venous insufficiency (CVI) five months after a severe episode of deep vein thrombosis (DVT). The DVT was most likely a result of post-fracture immobilization of the left fibula. He is still on an anticoagulant therapy from the DVT and has been prescribed compression stockings. As a construction worker, Jay spends most of his workday on his feet. Patient reports a “tight feeling” in his left foot and calf with a dull aching feeling in his left leg. Girth measurements show that there is some edema in the left leg beginning distal to the knee. Volumetric measurement of the feet also shows some edema in the left foot. No skin discoloration is noted at this time. Patient stated that he has not been wearing the compression stockings as prescribed when he plays basketball. He also states that he gets relief from symptoms when he elevates his leg. Jay has been informed that CIV can lead to serious complication such as venous ulcerations and infection if it is not managed properly. He has not been wearing the compression stocking during basketball because of what his friends might say. He now understands that his health is more important than fashion. Jay demonstrated how to put on the garment and has said he will do it each morning before getting out of bed. He was also encouraged to continue with swimming for his aerobic conditioning. The water provides some hydrostatic pressure on the leg while allowing him to exercise with his legs in a non-dependant position. Also, since his work requires long periods of standing, it has been recommended to Jay to take a break from basketball until his symptoms have resolved. Jay needs to take every opportunity to elevate his leg throughout the day and at night. Jay’s home exercise program includes picture diagrams for him to follow. He has also given permission for one of his brothers that lives with him to sit in on our therapy session as we go through all the exercises. Aside from Jay’s aerobic exercise, his HEP will mainly focus on reduction and prevention of lymphedema. In a recent article Cohen states, “Considering all of the treatment options available for lymphedema management, Complete decongestive physical therapy (CDP) is considered a treatment of choice because it is effective at reducing lymphedema without any known side effects. In addition, CDP is conservative, nonoperative/noninvasive, and cost-effective because the care is transferred from the health care professional to the patient and caregivers, especially for long-term management.” Complete decongestive physical therapy includes the use of compression garments, and decongestive exercises, as well as education in appropriate nail and skin care, and manual lymph drainage. Meet Jay The circulatory system consists of two types of blood vessels; arteries and veins. Arteries carry oxygen and nutrient-rich blood from the heart to the organs.
Veins carry oxygen-depleted blood and wastes through the kidneys, liver and lungs and then remove them from the body. The venous blood is filled with oxygen in the lungs and returned to the heart. PVD is any disease or disorder of the circulatory system outside of the brain and the heart. Acute arterial occlusion
Arteriosclerosis Obliterans
Thromboangiitis Obliterans (Buerger's Disease)
Raynaud's Disease Arterial Disorders Thrombophlebitis
Deep Vein Thrombosis
Chronic Venous Insufficiency
Varicose Veins Venous Disorders: Results from a malfunctioning lymphatic system
Excessive accumulation of fluids from the lymphatic vessels in tissue spaces Lymphedema PVD is caused by a build-up of fatty materials within the vessels known as atherosclerosis.
This process is gradual where the vessels eventually become blocked. Leading cause of disability in people over 50 and people with diabetes.
Occurs more often in smokers with diabetes and men more than women. Common pathology in U.S. affecting people who are
50 and older. people diagnosed with peripheral artery disease
blood clots
diabetes
inflammation
infection
structural defects
injury Causes of PVD Symptoms of PVD 50% of the people diagnosed have no symptoms pain in one or both calves, thighs, or hips.
pain while walking then resolves at rest. (pain at rest indicates a more severe form of PVD)
dull cramping pain in legs
heaviness or tightness in the muscles of the leg.
buttock pain
numbness or tingling in leg
burning or aching in feet and toes
sore on leg that does not heal
color changes in legs and feet
impotence family history of heart attacks or stroke
over age of 50
obesity
sedentary lifestyle
smoking
diabetes
high blood pressure
high cholesterol Risk Factors Tests to diagnosis PVD Ultrasonography
MRI
Rose Criteria Test (test to screen for PVD, consist of nine questions. The answers to the questions indicate whether you have PVD and how severe it is.) eating healthy
maintaining healthy weight
quit smoking
exercising
angioplasty
medications
bypass surgery Treatment depends on the severity of the disease and what initially caused it Refer to pg. 841 in Kisner book to review the management guidelines we used during her previous treatment.
She has returned to our clinic because she has developed lymphedema leading to decreased shoulder ROM.
According to Kisner, 15-20% or as many as 1 in 4 pts with invasive breast cancer develop upper extremity lymphedema during or sometime after the course of treatment.

Axillary dissection places a pt at risk not only for upper extremity lymphedema but also for loss of shoulder mobility and limited function of the hand.

Radiation therapy can cause fibrosis of tissues in the area of the axilla, which obstructs the lymphatic vessels and contributes to pooling of lymph in the arm and hand.
Breast cancer-related lymphedema not only has an impact on Maggie’s physical function but also has a significantly adverse effect on her health quality of life, making prevention of lymphedema and aggressive treatment high priorities for management.
Shoulder weakness
Decreased grip strength
Postural mal-alignment
Fatigue and decreased endurance
Psychological considerations Patient Education
•Precautions, Prevention, and Self-Management of Lymphedema

When traveling long distances support the involved upper extremity on the car’s window ledge or have it propped up on several pillows
Elevate involved limb and perform repetitive pumping exercises frequently during the day.
Avoid vigorous, repetitive activities with the involved limb.
Avoid carrying heavy loads, such as a suitcase, a heavy backpack, or shoulder bag
Avoid use of heavy weights when exercising.
Wear compressive garments while exercising.
Avoid wearing clothing that restricts circulation.
Do not wear tight jewelry, such as rings or watches. 32 female post-masectomy lymphedema pts participated in an individualized HEP for 8 weeks. Arm circumference, arm volume, and Quality of Life were measured before and after program.
Justifications can be given regarding the use of gradual, progressive upper-limb exercise training along with deep breathing in the rehab of lymphedema.
Gradually increasing the physiological stress to the affected upper limb through flexibility, resistance, and aerobic exercises has proven better than guarding the affected limb with inactivity in post-mastectomy pts.
Stretching exercises may help reduce the soft tissue contractures resulting in decrease blood and lymphatic obstruction.
Progressive resistance exercises may cause self contraction of the lymphatic vessels by regulating sympathetic nerves innervating these vessels.
As we know, skeletal muscle contraction is a primary force in propelling lymph fluid throughout the lymphatic system which helps enhance lymphatic clearance. Use in conjunction with HEP and implement prior to lymphatic drainage exercises.
Assume a comfortable supine position and begin deep breathing. Then isometrically contract and relax the muscles of the lower trunk (abdominal and erector spinae) followed by the hips, lower legs, feet, and toes.
Contract and relax the muscles of the upper back, shoulders, upper arms, forearms, wrist, and fingers.
Contract and relax the muscles of the neck and face.
Relax the whole body for at least a minute.
Perform diaphragmatic breathing throughout the entire sequence. HEP for lymphedema clearance for upper and lower extremity Patient: Maggie Lou Complications involved with Lymphedema Exercise
Post-operative exercise programs focus on three main areas:

Improving shoulder function, regaining an overall level of fitness, and preventing or managing lymphedema.

Exercises must be progressed gradually
Excessive fatigue must be avoided
Energy conservation must be emphasized, especially if pt is undergoing chemotherapy or radiation therapy. Special Considerations Monitor diet to maintain an ideal weight and minimize sodium intake
Avoid hot environments or use of local heat.
If possible, avoid having blood pressure taken or injections given on involved upper extremity Special Considerations continued Deep breathing is vital to ensure an adequate supply of oxygen to the tissues when the body is undergoing greater than usual exertion.
Deep breathing also creates pressure change in the abdomen, which acts like a vacuum in the thoracic cavity, helping to drain lymphatic vessels. (Gautam)
Results:
On average arm volume reduced by 122 mL.
Participants reported improvement in affected upper-limb health (ex. Decreased pain, heaviness, and discomfort along with softening of fibrotic areas during daily household work) due to the exercise program.
Results showed improved QOL scores in all aspects, including physical, social, and emotional well-being as well as general and mental health and vitality scores after completion of HEP.
Increase in physical functioning scores proved the fact that affected upper-limb progressive resistance exercise had a beneficial effect on post-mastectomy lymphedema. Total Body Relaxation combined with Deep Breathing Early, but protective, assisted or AROM of the shoulder is key to restoring shoulder mobility. Maggie Lou is a 43 year old married female who is also taking care of her terminally ill husband. She lives in a 2 story house in the suburbs. Her family members are spread across the country.
Maggie has Peripheral Vascular Disease; more specifically breast cancer-related lymphatic dysfunction. Maggie was diagnosed with Stage 1 breast cancer about a year and a half ago. Maggie’s tumor was located in her right breast and measured about 2 cm in diameter. In conjunction with her doctor, Maggie decided to undergo a mastectomy of her right breast and excision of her right axillary lymph nodes. Maggie also underwent radiation to completely wipe out the cancer and has been cancer free for 6 months now. Maggie previously visited our clinic after her mastectomy to address impairments and complications relating to her breast cancer treatment.
Plan on re-assessing after 3 weeks to decide if she needs to continue on the same regimen or progress to incorporating resistive exercises. Re-assessment •Less dedicated to HEP because she is worried about taking care of her terminally ill husband. Her family members are unable to help because they are spread across the country.
Provide her with a caregiver service where someone is always available to accommodate her needs.

•Depressed because she is confined to her home and needs reassurance and education about her diagnosis and treatment.
Provide her access to community resources such as Reach to Recovery and The National Lymphedema Network. Reach to Recovery is a one-to-one pt education program sponsored by the American Cancer Society. Representatives of the program, most of whom are breast cancer survivors, provide emotional support to the pt and family as well as current info on breast prostheses and reconstructive surgery. Possible Barriers
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